Transcript Slide 1

Evidence-Based Practice and PracticeBased Evidence: Working the Best We
Can with Children/Adolescents and
their Families
Terri L. Shelton
University of North Carolina at Greensboro
North Carolina Practice Improvement
Collaborative
September 19, 2011
EBP/PBE
• What is it?
• Why do it?
• How do I learn about EBP’s?
• What should I consider when selecting?
• What should I consider when
implementing?
Definitional Considerations
• An evidence-based practice is considered to
be any practice that has been established as
effective through scientific research
according to a set of explicit criteria
(Drake et al., 2001)
• Evidence-based practice is the integration of
best research evidence with clinical expertise
and patient values (Institute of Medicine, 2001)
Definitional Considerations
 Approaches to prevention or treatment that are
validated by some form of documented scientific
evidence. What counts as "evidence" varies.
Evidence often is defined as findings established
through scientific research, such as controlled
clinical studies, but other methods of establishing
evidence are considered valid as well. Evidencebased practice stands in contrast to approaches that
are based on tradition, convention, belief, or
anecdotal evidence (SAMHSA, NREPP)
http://www.nrepp.samhsa.gov/about-evidence.htm
Definitional Considerations
• Empirically validated treatment - Coined by
APA Division 12 Task Force on Promotion
and Dissemination of Psychological
Procedures (1995)
• Empirically supported treatment – Preferred
by Chambless et al., 1996, 1998 (since
validated implies process complete)
• Evidence-based practice – broader category
that subsumes empirically supported
treatments and includes evidence from
sources other than RCT’s (Messer, 2004)
Definitional Considerations
• Hierarchy of evidence
– Randomized clinical trials
– Quasi experimental studies
– Correlational studies with systematic
observation across cases or programs
– Anecdotal case reports, professional opinion,
etc
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Why Should We Care?
• Gives guidance to better serve those seeking care
• Using scientific approach to evaluate treatment
is an effective way to advance knowledge that
improves quality of treatment in the future
• Helps to use resources wisely
• Increases utilization of effective treatments
• Ethical obligation
Where Do I Learn About EBP’s?
Lists/Registries
Government/Agency Sites
• SAMHSA Guide to Evidence-Based Practices on
the Web:
http://www.samhsa.gov/ebpWebguide/index.as
p
• SAMHSA’s NREPP: http://nrepp.samhsa.gov
• FindYouthInfo:
http://www.findyouthinfo.gov/ProgramSearch.a
spx
• OJJDP Model Programs Guide:
http://www.ojjdp.gov/mpg/
Lists/Registries
State Sites
• Hawaii Dept of Health EBP Services:
http://hawaii.gov/health/mentalhealth/camhd/library/webs/ebs/ebs-index.html
• Oregon Mental Health and Addiction Services:
http://www.oregon.gov/dhs
• University of Washington’s EBP Database:
http://www.adai.washington.edu/ebp/
• New York Evidence Based Treatment Dissemination
Center: http://www.omh.ny.gov/omhweb/ebt/
American Psychological Association
• Division 12:
http://www.apa.org/divisions/div12/cppi.html
• Division 53/Association for Behavioral and Cognitive
Therapies: http://www.abct.org/sccap/
Lists/Registries
Other Organizations
• RAND Corporation/Promising Practices Network:
http://www.promisingpractices.net
• The Campbell Collaboration:
http://www.campbellcollaboration.org/
• The Cochrane Collaboration:
http://www.cochrane.org/
• PracticeWise: http://www.practicewise.com
• CSAT: Treatment Improvement Protocols:
http://www.kap.samhsa.gov/products/manuals/tips/
numerical.htm
Lists/Registries
 Most contain a comprehensive set of criteria, that
together, present a consensus on how best to determine
whether or not a treatment is evidence based and
applicable in a community setting.
 Each database uses a slightly different set of criteria to
determine whether a treatment is “evidenced-based.”
 Some common criteria include:
 Positive outcomes - must demonstrate a reduction in
problem behaviors or risk factors
 Evaluation design - must be experimental and
published in peer-reviewed journals
 Fidelity - must demonstrate consistency between with
the experimental design and the actual intervention
 Conceptual framework and standardization – must
include a manual or materials are available to the
public
Selection Considerations
• Decision Making Model
• Distillation and Matching Model or
“Common Elements” Approach
Common Elements
• In response to the various challenges to
RCT’s and manuals, this approach codes and
identifies specific techniques and procedures
that make up evidence-based protocols
• A large number of evidence-based protocols
can be “distilled” to smaller number of
common elements
• Then, select those practice elements that
apply to client characteristics in the research
(e.g., diagnosis, age, gender, ethnicity)
Advantages: Common Elements
 Addresses reported negative reactions of clinicians to
treatment manuals
 More easily implemented if compatible with larger
context
 Addresses challenges that come with the complexity of
new practices can be overwhelming in terms of training
and workforce development, monitoring, and matching
payment systems
 Some EBP’s simply not available in some areas
 Better match with cultural competence/ community
defined principles
Chorpita, Becker, & Daleiden (2007)
Cautions: Common Elements
 Do not assume that protocols are just the sum of the
parts and that deconstructing them does not impact
outcome
 Does not mean that manuals are ignored or
theoretical underpinnings not considered
 Only allows for matching and does not
automatically result in success for a particular
person with a particular therapist
Chorpita, Becker, & Daleiden (2007). Understanding the common elements of evidence
based practice: Misconceptions and clinical examples. American Academy of Child and
Adolescent Psychiatry, 46(5), 647-652
Common Elements
• Anxiety: exposure, relaxation, cognitive,
modeling, and child psychoeducational
approaches for the child
• Depressed Mood: cognitive, child
psychoeducational, maintenance/relapse
prevention, activity scheduling, problem
solving, and self-monitoring
• Oppositional/Aggression: praise, time out,
tangible rewards, commands, problem solving,
and differential reinforcement
Chorpita & Daleiden, 2009
Common Elements
• Adolescent Substance Abuse
• Support adolescent development
(developmental tasks; adolescent brain)
• Motivational Interviewing
• Cognitive emotional decision making model
(CBT)
• Consideration of stages of change)
• Harm reduction (not strict abstinence)
Selecting a Treatment
Is Study Population Comparable to Yours?
Age
Gender
Race/Ethnicity
Clinical Profile
Are Outcomes Meaningful?
Do Monitoring and Reimbursement
Requirements Fit with Agency?
Fidelity Measure Available
Fidelity Required
Specification of an Outcome Measure
Medicaid Reimbursement
Do Intervention Characteristics Fit with
Agency and Community?
Setting: Clinic, School, Home
Length of Intervention
Family Component
Individual or Group
Level of Training Required
Does Intervention Fit with Agency Needs
and Resources?
Training Available
Location of Training
Length of Training
Cost
Follow-up Coaching/Consultation
Does Intervention Fit with Clinicians?
Openness to Evidence-Based
Practice
Compatibility with Theoretical
Orientation
Expectation of Parent Involvement
in Treatment
Does Intervention Fit with Youth and Family
Values and Preferences?
Individualized
Family-Centered
Choice
Flexibility
Culture
Lane, Rivard, Burns, & Fisher, 2007
What is the Fit with the Person Seeking
Services?
• Is the intervention palatable, feasible,
relevant, and helpful from their point of
view?
• What is the match with their values,
beliefs, preferences and priorities?
• What is the evidence on the best way to
engage this person?
Implementation Considerations
• Practice-Based Evidence
• System of Care
• Cultural Competence
• Community-Defined Evidence
• Best Practice in Implementation
Cultural Competence
• Cultural competence is a set of congruent behaviors,
attitudes, and policies that come together in a
system, agency or among professionals and enable
that system, agency or those professions to work
effectively in cross-cultural situations.
• The word culture is used because it implies the
integrated pattern of human behavior that includes
thoughts, communications, actions, customs, beliefs,
values and institutions of a racial, ethnic, religious
or social group. The word competence is used
because it implies having the capacity to function
effectively.
Cross et al. (1989)
Considerations in Delivering Culturally
Competent Services
Cultural Considerations:
• Ethnicity, age, gender, primary language, spiritual practices,
English proficiency, literacy levels, geographic location, sexual
orientation, education, employment, income, immigration status,
country of origin, physical limitations or disabilities, etc.
• What are the cultural norms, beliefs, and values of the person,
family and community who is being served?
• What is the social context/cultural process: what is at stake, what
matters most for individuals/groups (Lopez & Weisman, 2005)?
• What is the intended goal of the service?
• Is there evidence services are effective across cultural groups?
• What can be done differently to reach people based upon
information from and about the community?
• How can community data be utilized to plan for the future?
NY Office of Mental Health; Lopez & Weisman, 2005
Definition of Cultural
Adaptation
• The systematic modification of an
EBT or intervention protocol to
consider language, culture, and
context in such a way that it is
compatible with the client’s cultural
patterns, meanings, and values.
(Bernal, Jiménez-Chafey, & Domenech Rodríguez, in press)
Community-Defined Evidence
“ A set of practices that communities have used and
determined to yield positive results as determined by
community consensus over time and which may or
may not have been measured empirically but have
reached a level of acceptance by the community
(CDEP Working Group, 2007). CDE includes world
view, historical and contextual aspects and
transactional processes that are culturally rooted and
do not limit it to one manualized treatment. It is a
supplemental approach to ESTs.”
(Martinez, 2008).
Analytic Process to Select Best Fit Prevention
Interventions
McHale & Hennessy, 2007
Paradigm Shift: Defining and Selecting
Evidence-Based Interventions
… grounding in theory
Guideline 1: The prevention program,
practice, or strategy is based on a solid
theory or theoretical perspective that has
been validated by research, and
McHale & Hennessy, 2007
Paradigm Shift: Defining and Selecting
Evidence-Based Interventions
… empirical track record
Guideline 2: The prevention program,
practice, or strategy is supported by a
documented body of knowledge—a
converging of empirical evidence of
effectiveness—generated from similar or
related interventions that indicate
effectiveness, and
McHale & Hennessy, 2007
Paradigm Shift: Defining and Selecting
Evidence-Based Interventions
…consensus among informed experts including key
community prevention leaders, elders, or other
respected leaders within indigenous cultures
Guideline 3: The prevention program, practice,
or strategy is judged by a consensus among
informed experts to be effective based on a
combination of theory, research, and practice
experience.
McHale & Hennessy, 2007
Implementation Considerations
• The usability of a program has little to do with
the quality or weight of evidence regarding that
program
• Evidence of the effectiveness of the intervention
does not necessarily lead to the successful
implementation of that program
• Implementation is not an event
• Implementation is a mission oriented process
involving multiple decisions actions and
corrections
• Implementation occurs in stages
National Implementation Research Network (http://www.fpg.unc.edu/~nirn/)
Implementation Considerations
Effective intervention practices +
Effective implementation practices =
Good outcomes for consumers
Need to Consider the Fidelity of both the:
• Intervention Processes and
• Implementation Processes