and Sustainability of EBPs in a Community Outpatient Clinic Implementing Organization Change to Provide Comprehensive Evidenced Based Protocols for Children Presenters Who Are These People ID: 575541
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Bridging the Science-Practice Gap – An Example of Successful Implementation and Sustainability of EBP’s in a Community Outpatient Clinic
Implementing Organization Change to Provide Comprehensive Evidenced Based Protocols for ChildrenSlide2Slide3
Presenters(Who Are These People??) Bridget DeFiccio LPCRobins’ Nest employee for 5 years
Business and Program DevelopmentOversight, Development and Expansion of Outpatient, School Based and Intensive In Community Clinical ServicesPractice Consultation
Jennifer Kugler LPC, ACSRobins’ Nest employee for 11 yearsDirector of Outpatient Centers and School Based Clinical ServicesTraumatic Loss Coalition Coordinator for Salem CountySlide4
CAUSE for AlarmSlide5
Choices, Choices!!
Take My Word For It:
Empirically Unsupported
Approaches to Treating Children
A Scientific Approach to Youth Mental Health:
Linking Science
and
Practice
Iam
Lucky, Ph.D.
Well Known, Ph.D.Slide6
Evidence-Based PracticeEvidence based practice is
the orchestration of:
1. best available research 2. clinical expertise
3.client characteristics,
culture
, and
preferencesSlide7
Empirically Supported Treatments
Laboratory Experiments
Show
Treatment is Effective
Specific client types
Outcome measurement
And
Replication
Treatment manuals
ResearchSlide8
RATINGs of Evidence-Based interventionsBest Support
Good SupportModerate Support
Minimal SupportNo SupportSlide9
California Evidenced Based Clearinghouse
Scientific Rating Scale
1 - 5 Well Supported Concerning 1 2 3 4 5
Child Welfare System Relevance LevelsHigh Medium LowSlide10
Can untested therapy do harm?Gluten free diets for autism – No evidence they work - Lead to some autism children with restricted dairy getting osteoporosis.
Seroquel also causes an extra seven or eight heart beats a minute in children. Weight gain and increased rate of diabetes.Rebirthing/compression therapy – child fatalities and traumaSlide11
If you are not doing EBT…Informed Consent:
You
should know that the intervention I propose to use has no credible research evidence that it works. I feel it works, I believe it works most of the time, but I have no objective evidence that it does. I do not use any standardized measures to help me determine whether it is working for your family. While I don’t believe this will be harmful to your family, I have no objective evidence this is true.
Please sign here….Slide12
Why We Don’t Love EBP’s
Feels restrictiveLimits ability to be creative
Feels “cold” to clients - disrupts connectionNo agency supportExpensiveI already AM effective!Slide13
Obstacles: clinician’s fearsTies me down: I can’t provide what my client needs
I can’t be creative or practice my “art”
I will get a bad reviewSlide14
ObstaclesTension arises betweenan organization’s
infrastructure and its
efforts to maintain program fidelity(Drake, Skinner and Goldman, 2008)Slide15
Obstacles: agency infrastructure“If you need the best
therapist to do it, then what good is it?”
Multi-problem familiesneed more than one EVBManagement aversion to
different approaches Slide16
Obstacles: Spending and fundingMedicaid/Insurance funding streams conflict with program processes
Definition of billable service
Definition of providerBillable timing (PCIT can sometimes run over)Slide17
SustainabilityLeadership Buy In
Essential from Top/DownInvestment in Training and Build Out costs (Funding through Development)
One Time and On-Going CostsCulture ChangeLanguageHiring
TrainingSupervisionPeer Learning CollaborativeSlide18
Assessment of NeedReview Data and DemographicsExecutive LeadershipDepartment Leadership
Line Staff
Search DatabasesReview OptionsDecision on EBP
Training and ImplementationLeadership support is crucial
Outcomes
SustainabilitySlide19
Most common diagnostic categories-Children
Oppositional Defiant DisorderConduct Disorder
ADHD (often combined with ODD)DepressionAnxietyTraumaSubstance abuseEating Disorder (pediatric obesity)Slide20
EBT relies on accurate assessmentsMultimodalMulti-method
Use of standardized scales (CBCL, BASC, Conners
, KSADs, KADI, Autism diagnostic interview, PTDS and trauma scales)If not sure – refer before treating Slide21
Robins’ NestSlide22
Promising EBTS with moderate training costsMotivational Interviewing
PCIT- Parent Child Interaction Therapy PMT- Parent Management Training
Social Skills/Problem solving skillsCoping CAT/CAT ProjectTrauma Focused CBTBrief Strategic TherapySlide23
ODD and Conduct Disorder
Parent child interaction therapy 2-7 (7-12 with contingency management extension)
Parent Management Training The Incredible YearsTriple P – Positive Parenting Program
MST
Functional Family Therapy
Brief strategic therapy
Oregon Multidimensional Treatment Foster Care ModelSlide24
ADHDBehavioral parent training: PCITBehavior contingency management in the classroom
PCIT and PMT – for impulsivity and disruptive behavior and to shape attention
Medication Management as an option after behavioral interventions are exhausted(Cognitive interventions do not work. Social skills training – poor evidence)Slide25
DepressionTaking ActionSelf-control therapy
Penn Prevention Program
Coping with Depression – AdolescentInterpersonal Therapy – AdolescentsParent components strengthen resultsSlide26
Anxiety DisordersGAS and Phobias– Coping CAT/CAT Project
– with parent component, Social Effectiveness training, systematic desensitization – with in vivo exposure
Social and school phobias – Parent/Teacher TrainingOCD – Exposure based CBT Trauma – PTSD – Trauma Focused CBTSlide27
Treatment for Substance UseMultidimensional family therapyFunctional Family Therapy
Group CBT
Brief Strategic Family Therapy Slide28
Autism and Eating disordersAutism – Applied Behavior Analysis
For ASD previously Asperger’s
- ABA and Social Skills Training Eating Disorders Anorexia –
Maudsley model of Family Therapy Bulimia – insufficient research for adolescents
For older adolescents- adult CBT approaches are recommended.
Pediatric Obesity Behavioral Modification (traffic light program) with parental involvementSlide29
Everyone should…Improve their diagnostic skills (what are we trying to treat?)Only provide services if there is something to treat
Use outcome measures and recognize things should change within 8 to 15 weeks for most
Get Better at Motivational InterviewingSlide30
Note the followingStrong theme of parental involvementMany alternatives to medications or psychosocial techniques that can be used with medications
Behavioral referrals to psych only after an attempt at EBP
Many useful and researched approaches to trySlide31
Approach versus TechniquesApproaches are broad conceptual views such as CBT, behavioral, psychodynamic, family
Research moving away from this – too broad a brush and difficult to measure
Treatments or techniques are specific programs design for specific problems. More appropriate for EBTMany hundreds of current treatments – less than 50 have any empirical evidence they workSlide32
Where do we go from here?General principlesImportance of accurate assessment
Understand the diagnostic categories
Specific approaches versus theoretical orientationsNo symptoms – no treatmentOutcome driver verse time limited – but changes should occur within 8-15 weeks Engagement of parents – focus on parent- child interactions- consider adult pathologySlide33
What to do next…TMI – too much information
Focus on high percentage diagnostic categories
Assess Agency Level of Change/CommitmentAssess Personnel (Who should be driving the bus?)Start with one EBP and build your EBP toolboxBuild in Sustainability Factors Slide34
What is the Cost of Not Doing EBT?Lack of consistency in treatment approaches across the system
Over use of medications Over use of crisis and mobile response
Revolving door treatmentFrustrated families and practitionersSlide35
Where To Find EBP’sYou Don’t Need To Recreate the Wheel!!California Evidenced Based Clearinghousehttp://www.cebc4cw.org/
SAMHSA National Registry of Evidenced Based Programs and Practiceshttps://www.samhsa.gov/capt/tools-learning-resources/national-registry-evidence-based-programs
Practice Wise (Free Searchable Database)**https://www.practicewise.com/Community/BlueMenuSlide36Slide37
ReferencesChambless
, D. L., & Holland, S. D. (1998). Defining empirically supported therapies.
Journal of Consulting and Clinical Psychology, 66(1), 7-18.Chadwick Center (2004). Closing the Quality Chasm in Child Abuse Treatment: Identifying and Disseminating Best Practices. The Findings of the Kauffman Best Practices Project to Help Children Heal. From Child Abuse. San Diego, CA: Children’s Hospital–San Diego, Chadwick Center for Children and Families.
Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC:
National
Academy
Press.
Kazdin
A. E., (2003). Psychotherapy for Children and Adolescents.
Annual Review of Psychology
, 54, 253-276.
Sackett, D. L., Straus, S. E., Richardson, W. C., Rosenberg, W.,
&
Haynes
, R. M. (2000).
Evidence-based medicine: How
to practice
and teach EBM (2nd ed.). New
York Churchill Livingstone
.
WHO, (2001). The World Health Report: 2001: Mental Health: New Understanding, New Hope, Geneva: WHOCahill, J. (2016), Evidence-Based Practice [Power-Point Slides]. Shared by presenter.Evidence-Based Psychotherapies for Children and Adolescents, Second Edition Edited by John R. Weisz and Alan E. KazdinMaterial/Image/Information obtained from the California Evidence-Based Clearinghouse for Child Welfare (CEBC) at www.cebc4cw.org.Handbook of Child and Adolescent Psychopathy Edited by Randall T. Salekin and Donald R.
Lynam Slide38
Many Thanks!!Slide39
Today’s ObjectivesObjective #1: Attendees will be able to identify EBPs relevant to their clients’ needs using the California Clearinghouse, SAMSHA, etc… Objective #2: Attendees will be able to understand how to change the culture of an agency to a learning organization that supports the use of multiple EBPs.
Objective #3: Attendees will be able to identify the administrative structure needed to sustain an EBP continuum.