Wednesday, January 27, 2010
Bruce Chorpita on Evidence Based Practice
Evidence Based Practice (EBP) in Children's Mental Health Services
How can we get more from what we already have?
In EBP, there is a knowledge management problem:
--One of his psychology graduate students entered the program wanting to become an evidence-based clinician, but after reading all the research, the proliferation of treatment protocols and EBP manuals, he wound up a professor!
--Community-based, Master's-level practitioners need to be generalists and yet read studies conducted at specialty research settings.
--There are 333 to 350 evidence-based protocols!
--Dissemination as usual is inadequate. Assuming a replacement approach is inefficient and may be insulting (what you are doing is wrong, now do this...)
--Assumes unlimited resources and learning capacity (this is not the case in community settings).
--Institutionalizes services -- when there is new information, then there will be a need to de-institutionalize services
Positive client outcomes is the goal (vs. fidelity).
Rather than merely install new programs in a system, improve the practices that are already there.
See evidence base as a source of knowledge and not a list of products (manuals).
There have been 413 to 450 randomized control trials (RCTs) to date. (RCTs are the gold standard in intervention research for making causal inferences).
Chorpita developed an automated/computerized review of child RCTs (see link below) - "cliff notes" of RCTs for kids where you may enter characteristics like presenting problem, age, setting (for example, school) and strength of evidence and get an aggregated list of EBPs, that is, the most common procedures. Individual procedures like cognitive coping, which is one of the most successful treatments for any age and problem!
What do the best treatments have in common?
Example - Parent Training EBPs and their Practice Elements:
Incredible Years: Commands*, Time Out, Rewards
Parent-Child Interaction Therapy (PCIT): Attending, Commands*
Defiant Children: Commands*, Time Out
(*"commands" refers to teaching parents not to say "let's" or "why don't you..." and to make eye contact and use proximity when making commands. Sounds like some of the elements of Parents in Control!)
What's common among all elements of research?
80% of EBP studies on anxiety use exposure (70 RCTs).
In their Hawaii study, only 6% of community-based Master's-level clinicians use exposure.
There are 31 practice elements needed to cover the maximum number of coverable CAMHD youth (address specific problems, age groups, ethnicity, and setting issues).
Only 12 practice elements are sufficient to cover 85% of the coverable youth.
Manuals can't be the only way of doing business. A coordinated library of 33 evidence-based procedures are available online and trained online.
Practitioner Guides available, one pagers (2-sided) per practice (for example, relaxation)
Clinical Dashboard (computer program) monitors client progress and practice elements being used by clinician and answers the all important question: Is the child your treating now getting better? There is something changing and what is helping to make that happen?
Chorpita did a study in Hawaii with community-based clinicians (no exclusion/inclusion criteria - all interested clinicians participated and those that initially refused were taken to lunch to get them to agree) and 203 youth ages 7 to 13 with anxiety, depression and conduct problems. Youth were part of the public mental health system and some were referred with IEP's and identified as SED (seriously emotionally disturbed). 50% had disruptive behavior disorders (ADHD, ODD, CD), 30% had anxiety disorders, and 20% had depressive disorders.
Clinicians were divided into 3 groups: 1) MATCH (clinicians were taught 33 EB procedures that they could use with flexibility - that is choose which elements to use and repeat elements as needed), 2) clinicians that provided the usual care, and 3) clinicians that were trained in using 3 EB manuals.
Clinicians were then asked about their satisfaction with training. The first group (modular) had the highest satisfaction. After tracking weekly total child problems, the modular group clients showed the least problems.
If they use it, it might work.
This study used the CAFAS (Child & Adolescent Functioning Assessment Score) - 8 scale total and the Achenbach to frequently monitor client progress (like periodic assessments). It took 10 months to decrease 10 points on the CAFAS, 20 months to decrease 20 points.
There is more in the evidence base than we are using (ignored/forgotten) :(
Exposure studies date back to the 70's and 80's! and are still not used widely.
We need to focus on how gold standard programs can inform all care, not just specialty care.
Inspect every case for outcomes (client improvements) and dig deeper when you're not getting them!
With modular treatment you can repeat certain practice elements or skip others depending on specific client needs. With manualized treatment, there is a set sequence and elements.
Flexibility in treatment vs. fidelity in manualized treatment.
Check out Chorpita's website http://www.practicewise.com/ for more information.