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Sponsored by the California Evidence- Based Clearinghouse for Child Welfare

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Overview of Evidence Based Practice Charles Wilson, MSSW, Executive Director of Chadwick Center The Sam and Rose Stein Chair on Child Protection – PowerPoint PPT presentation

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Title: Sponsored by the California Evidence- Based Clearinghouse for Child Welfare


1
Overview of Evidence Based Practice
Charles Wilson, MSSW, Executive Director of
Chadwick Center The Sam and Rose Stein Chair on
Child Protection Rady Childrens Hospital-San
Diego
Sponsored by the California Evidence- Based
Clearinghouse for Child Welfare
www.cachildwelfareclearinghouse.org
2
How Things Change
A Problem is Recognized
Action-Any Action
3
Action- Creation of Orphan Trains
  • Between 1854 and 1929 100,000-200,000 children
    were placed in new families via the Orphan Trains.
  • http//www.orphantraindepot.com
  • Children were taken in small groups of 10 to 40,
    under the supervision of at least one adult, and
    traveled on trains to selected stops along the
    way, where they were taken by families in that
    area.

http//www.pbs.org/wgbh/amex/orphan/teachers.html
4
How Things Change
A Problem is Recognized
Series of Trail and Errors Adjustments-Some
Better-Some Worse
Action-Any Action
Informed Action
5
Trial and Error
Family Foster Care
Orphanages and Boarding schools
Tennessee Preparatory School for Dependent
Children
6
How Things Change
A Problem is Recognized
Informed Action
Informed Action-Based on Science
7
So how do we know what works vs. mere
marketing marketing hyperbole?
  • Let the Buyer Beware

8
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9
Thought Field Therapy
Thought field therapy with Callahan techniques
is a powerful therapy exerted through nature's
healing system to balance the body's energy
system. This therapy promotes stress management
and stress relief as well as the reduction or
elimination of anxiety and anxiety related
problems. This includes help for weight control
and weight loss, trauma or sleep difficulties,
depression, addictions and the disorders
associated with past trauma including nightmares
and post traumatic stress disorder.
(underlines added)
Roger J. Callahan, PhD
Retrieved from http//www.tftrx.com/, November
17, 2006
10
More Claims for TFT
  • Q. How Can TFT Benefit You? What Kind of
    Problems Can Be Helped?
  • Anxiety and Stress
  • Personal fears or your childrens fears
  • Anger and Frustration
  • Eating or smoking or drinking problems
  • Loss of loved ones
  • Social or public speaking fears
  • Sexual or intimacy problems
  • Travel anxiety including fear of flying or
    driving on the freeways
  • Nail biting
  • Cravings
  • Low moods and mood swings

Retrieved from http//www.tftrx.com/profaq.php?PHP
SESSID f4cf66c40b9678b742b82989fee7b377 on
November 17, 2006
11
NPR All Things Considered, March 29, 2006
According to psychologist Roger Callahan, the
creator of thought field therapy, major problems
like depression can be cured quickly with this
method. He says post-traumatic stress disorder is
easily dispatched in 15 minutes, and even the
most serious cases of anxiety, addiction and
phobias are likewise subject to quarter-hour
cures.
12
Research on TFT?
Has any research been carried out on TFT?
There have been no control (sic) studies on the
success of TFT
From the Thought Field Therapy Training Center of
La Jolla
Retrieved from http//thoughtfield.com/faqs.htm
on November 17, 2006
13
Distinguishing groundless marketing claims from
reality
The Problem All sorts of interventions are
available out there.
14
Waiting Room Sign
Ben Saunders MUSC
15
Evidence Based Social Work
  • Professional judgments and behaviors should be
    guided by two interdependent principals
  • When ever possible, practice should be grounded
    on prior findings that demonstrate
    empiricallythat they are likely to produce
    predictable, beneficial, and effective results.
  • Every clients system, over time should be
    evaluated

Evidence Based Practice Manual Oxford University
Press 2004 Albert Roberts, PhD Kenneth Yeager,
PhD, LISW
16
Global Definition of EBP
The conscientious, explicit and judicious use of
current best evidence in making decisions about
the care of individual patients.
Including Both
The best available clinical evidence from
systematic research
Individual clinical expertise
-David Sackett
17
Huge Policy Implications
  • Should policy makers support adoption of EBP?
  • If so, which ones When are they Ready for Prime
    time
  • What is the standard of evidence?
  • If so, how best can they support adoption?
  • What are the pitfalls of a state or national
    policy level adoption
    of EBP?
  • Impact on Innovation
  • Misapplication of good models?-One size does not
    fit all
  • Watering down of empirically based
    practice-danger of implementing in name only
  • Ideology vs. Science- who is the judge of the
    science?
  • Should we limit what we do to EBP?

18
Parachute use to prevent death and major
trauma related to gravitational challenge
systematic review of randomized controlled
trials (Gordon C Smith, Jill P Pell, 2005)
  • The perception that parachutes are a successful
    intervention is based. largely on anecdotal
    evidence
  • Observational data have shown that their use is
    associated with, morbidity and mortality due to
    both failure of the intervention and mechanical
    complications. In addition, natural history"
    studies of free fall indicate that failure to
    take or deploy a parachute does not inevitably
    result in an adverse outcome...
  • The effectiveness of an intervention has to be
    judged relative to non-intervention.
  • Understanding the natural history of free fall is
    therefore imperative.
  • If failure to use a parachute were associated
    with 100 mortality then any survival associated
    with its use might be considered evidence of
    effectiveness.
  • Therefore, studies are required to calculate the
    balance of risks and benefits of parachute use.

19
Why Evidence-Based Practice Now?
  • A growing body of scientific knowledge
  • Increased interest in consistent application of
    quality services
  • Increased interest in outcomes and accountability
    by funders
  • Past missteps in spreading untested best
    practices that turned out not to be as effective
    as advertised
  • Because they work !!

20
Problems in the Child Abuse Field in the U.S.
  • Empirical evidence of efficacy has not been a
    common criteria for treatment selection in the
    child maltreatment field.
  • Lack of outcome research for many commonly used
    interventions.
  • Ready willingness among some to use, embrace,
    promote, and staunchly defend practices that have
    no evidence for their efficacy and questionable
    theoretical bases.
  • Poor dissemination of the significant clinical
    outcome research that has been done.
  • Ineffective approaches to continuing education.
  • Poor adoption of empirically supported treatments
    in real world clinical settings.
  • Disconnection between current scientific
    knowledge and practice in the field.

21
Scared Straight
22
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23
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24
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25
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26
TF-CBT
27
Reactive Attachment Disorder and Attachment
Therapy
pioneered by psychoanalyst Aaron Lederer, the
RAD Consultancys creator and director. His
methods yield remarkable results within weeks.
Retrieved from http//www.radconsultancy.com/,
November 17, 2006
28
Why should we worry about using Evidence
Supported Treatments?
29
Institute of MedicineApply the Principles and
Methods of Evidence Based Practice
  • Integration of
  • Best Research Evidence
  • Best Clinical Experience
  • Consistent with Client Values
  • http//www.shef.ac.uk/scharr/ir/netting/
  • http//ebmh.bmj.com/
  • http//cebmh.com/
  • http//www.cebm.utoronto.ca/

30
Understand Adoption of Innovation
MTFC 1991
31
Common Errors When Deciding about Intervention
Effectiveness
  • Reliance solely on individual anecdotes and
    remembered cases.
  • That child made such amazing changes during
    treatment.
  • Confusing client satisfaction with clinical
    improvement.
  • The family just loved coming to therapy. Never
    missed a session during their 3 years of therapy.
    Amazing. Too bad they had to move away.
  • Misattribution of the cause of change.
  • Failure to appreciate resilience and natural
    recovery.
  • The family got multiple services and wrap around
    care.
  • With treatment her PTSD resolved in about 3
    months after the rape.
  • Guru effect in training and treatment adoption.
  • I heard Dr. McDreamy is doing a level II
    training. And, its in San Diego in January!
  • Those videos were just so amazing! I have got to
    try that.

Ben Saunders MUSC
32
What to look for in a Practice?
  • Treatment or intervention protocol that has at
    least some scientific, empirical research
    evidence for its efficacy with its intended
    target problems and populations.
  • Evidence may be based on a variety of research
    designs.
  • Randomized Clinical Trial (RCT)
  • Controlled studies without randomization
  • Open trials, pre- post-, or uncontrolled studies
  • Multiple baseline, single case designs
  • The degree to which we are persuaded that the
    treatment is effective will vary by the quality
    of empirical support.
  • Number of RCTs
  • Replication by researchers other than the
    treatment developers
  • Sampling, sample size used, comparison treatment,
    effect size
  • Various methods have been developed for
    classifying the level of empirical support
    enjoyed by treatment approaches.
  • Should be useful for front-line practitioners

33
CEBC Website www.cachildwelfareclearinghouse.org
34
Current Data on Visitors to the Website
  • Total Number of Visits to the Website
  • 46,635

Percentage of Total Visitors from over 131
International Countries 14
Percentage of Total Visitors from U.S. 86
Percentage of Total Visitors from California 33
Data based on numbers as of September 1, 2007
35
CEBCs Definition of Evidence-Based Practice for
Child Welfare
  • Best Research Evidence
  • Best Clinical Experience
  • Consistent with Family/ Client Values

  • (modified from The Institute of
    Medicine)

  • http//www.iom.edu/

36
The California Evidence-Based Clearinghouse for
Child Welfare (CEBC)
  • In 2004, the California Department of Social
    Services, Office of Child Abuse Prevention
    contracted with the Chadwick Center for Children
    and Families, Rady Childrens Hospital-San Diego
    in cooperation with the Child and Adolescent
    Services Research Center to create the CEBC.
  • The CEBC was launched on 6/15/06.

37
Advisory Committee
  • The Advisory Committee is composed of 15 members
    drawn from a broad cross-representation of
    communities and organizations.
  • There are representatives from
  • California Department of Social Services
  • Child Welfare Departments from California
    Counties
  • Child Welfare Directors Association (CWDA)
  • California Child Welfare Training Leaders
  • Public and Private Community Partners Within
    the State
  • The role of the Advisory Committee is to
  • Determine the topical areas for the CEBC
  • Ensure the CEBC remains up-to-date with
    emerging evidence.
  • Assist in disseminating the products of the
    CEBC.
  • Provide feedback on the utility of the CEBC
    products.

38
National Scientific Panel
  • The National Scientific Panel is composed of five
    core members and up to 10 selected Topical
    Experts.
  • The Panel is nationally recognized as leaders in
    child welfare research and practice, and who are
    knowledgeable about what constitutes best
    practice/evidence-based practice.
  • The Panel assists in identifying relevant
    practices and research and provide guidance on
    the scientific integrity of the CEBC products.

39
  • Scientific Rating Scale
  • and
  • Relevance to Child Welfare Scale

40
Rating Scale Development
  • Goals
  • Multiple categories
  • High standard for top ratings Randomized
    Controlled Trials
  • Clearly defined criteria
  • Focus on peer-reviewed research and ability to
    replicate program

41
Gold Standard for Evidence
  • Randomized controlled trial (RCT) Participants
    are randomly assigned to either an intervention
    or control group. This allows the effect of the
    intervention to be studied in groups of people
    who are the same, except for the intervention
    being studied.
  • Any differences seen in the groups at the end can
    be attributed to the difference in treatment
    alone, and not to bias or chance.

42
Peer-Reviewed Research
  • Peer review A process used to check the quality
    and importance of research studies. It aims to
    provide a wider check on the quality and
    interpretation of a study by having other experts
    in the field review the research and conclusions.

43
Efficacy vs. Effectiveness
  • Efficacy focuses on whether an intervention works
    under ideal circumstances and looks at whether
    the intervention has any impact at all.
  • Effectiveness focuses on whether a treatment
    works when used in the real world.
  • An effectiveness trial is done after the
    intervention has been shown to have a positive
    effect in an efficacy trial.

44
Scientific Rating Scale
45
6. Concerning Practice
  • If multiple outcome studies have been conducted,
    the overall weight of evidence suggests the
    intervention has a negative effect upon clients
    served.
  • and/or
  • There is a reasonable theoretical, clinical,
    empirical, or legal basis suggesting that,
    compared to its likely benefits, the practice
    constitutes a risk of harm to those receiving it.

46
5. Evidence Fails to Demonstrate Effect
  • Two or more randomized, controlled outcome
    studies (RCT's) have found that the practice has
    not resulted in improved outcomes, when compared
    to usual care.
  • If multiple outcome studies have been conducted,
    the overall weight of evidence does not support
    the efficacy of the practice.

47
4. Acceptable/Emerging Practice- Effectiveness
is Unknown
  • There is no clinical or empirical evidence or
    theoretical basis indicating that the practice
    constitutes a substantial risk of harm to those
    receiving it, compared to its likely benefits.
  • The practice has a book, manual, and/or other
    available writings that specifies the components
    of the practice protocol and describes how to
    administer it.
  • The practice is generally accepted in clinical
    practice as appropriate for use with children
    receiving services from child welfare or related
    systems and their parents/caregivers.
  • The practice lacks adequate research to
    empirically determine efficacy.

48
3. Promising Practice
  • Same basic requirements as Level 4 plus
  • At least one study utilizing some form of control
    (e.g., untreated group, placebo group, matched
    wait list) has established the practices
    efficacy over the placebo, or found it to be
    comparable to or better than an appropriate
    comparison practice. The study has been reported
    in published, peer-reviewed literature.
  • Outcome measures must be reliable and valid, and
    administered consistently and accurately across
    all subjects.
  • If multiple outcome studies have been conducted,
    the overall weight of evidence supports the
    efficacy of the practice.

.
49
2. Well Supported-Efficacious Practice
  • Same basic requirements as Level 3 plus
  • Randomized controlled trials (RCTs) At least 2
    rigorous RCTs in highly controlled settings (e.g.
    University laboratory) have found the practice to
    be superior to an appropriate comparison
    practice.
  • -The RCTs have been reported in published,
    peer-reviewed literature.
  • The practice has been shown to have a sustained
    effect at least one year beyond the end of
    treatment, with no evidence that the effect is
    lost after this time.

50
1. Well supported - Effective Practice
  • Same basic requirements as a Level 2 plus
  • Multiple Site Replication At least 2 rigorous
    randomized controlled trials (RCTs) in different
    usual care or practice settings have found the
    practice to be superior to an appropriate
    comparison practice.
  • The RCTs have been reported in published,
    peer-reviewed literature.
  • The practice has been shown to have a sustained
    effect at least one year beyond the end of
    treatment, with no evidence that the effect is
    lost after this time.

51
Child Welfare Ratings
  • Not every program that is evidence-based will
    work in a Child Welfare setting
  • We also examined each programs experience and
    fit with Child Welfare systems and families

52
Relevance to Child Welfare Scale
  • High
  • The program was designed or is commonly used to
    meet the needs of children, youth, young adults,
    and/or families receiving child welfare services.
  •   
  • Medium
  • The program was designed or is commonly used to
    serve children, youth, young adults, and/or
    families who are similar to child welfare
    populations (i.e. in history, demographics, or
    presenting problems) and likely included current
    and former child welfare services recipients.
  • Low
  • The program was designed to serve children,
    youth, young adults, and/or families with little
    apparent similarity to the child welfare services
    population.

53
Child Welfare Outcomes
  • We also examined whether programs had included
    outcomes from the Child and Family Services
    Reviews in their peer-reviewed evaluations
  • Safety
  • Permanency
  • Well-being

54
Common Continuing Education Dissemination Model
One day workshop
Use Tx with appropriate clients
Therapist
Book
55
X Laying the Groundwork for Implementing
Evidence Based Practice
56
Levels of ImplementationFixen et al
  • Paper Implementation
  • Process Implementation
  • Performance Implementation

Fixsen, D., Naoosm, S., Blasé, K., Friedman, R.,
Wallace, F. (2005)
57
Institute for Healthcare Improvement Model
Community, Government, Funders
Organizations
Departments and Programs Within Organizations
Social Workers, Therapists, Medical Professionals
and Families
58
Transtheoretical Model of Change 5 Stages of
Change
  • Precontemplation
  • Compliant Status Quo
  • Contemplation
  • Changes in orientation
  • Preparation
  • Planning for change
  • Organizational and environmental readiness
  • Action
  • Training
  • Maintenance
  • Monitoring/Institutionalization

Driven at each stage by Self Efficacy
Decisional Balance
59
Components of Implementation
  • Select a Solution that Fits a Problem
  • Prepare the internal and external environment
    Supervision and Leadership Buy-in
  • Acquire knowledge and skills
  • Use practice with support, supervision and
    consultation
  • Adapt practice to environment
  • Monitor fidelity
  • Teach others
  • Institutionalize Practice

60
Practice SelectionAttributes that can
facilitate adoption
  • Relative Advantage- clear, unambiguous advantage
    in either effectiveness or cost effectiveness
  • Costs- training/materials/on-going
    consultation-loss productivity during start up-
    costs of delivery
  • Compatibility-How compatible is the practice with
    the organizational and workforces values, norms,
    and clinical traditions and orientation
  • Complexity perceived as more simple to use and
    to implement
  • Trialability- able to experiment with in a
    limited basis
  • Observability of Benefits outcomes or interim
    results/measures
  • Reinvention- if can adapt, refine or otherwise
    modify it to meet own needs
  • Risk- if there is higher certainty of outcomes
  • Task Issues- If relevant to performance of
    intended users work and improved task performance
  • Knowledge- if knowledge can be codified and
    transferred from one context to another
  • Augmentation/Support- if provided with
    training/consultation

From Greenhalgh et al
61
Organizational Readiness
  • Organizational Culture/Traditions/History
  • Leadership
  • Supervision
  • Capacity to evaluate change-Know if it is working
  • Support of Opinion Leaders
  • Connections with other supportive
    organizations/individuals
  • Does organization have the technology to support
    the change
  • Staff readiness

62
Staff Readiness Staff Directly and Indirectly
involved
  • Understand What Benefits Will the Adoption of the
    EBP Bring
  • Meaning-What does the change mean to the staff?
  • What concerns will staff have about adoption
  • How congruent are the trainers in orientation and
    values with the staff
  • Presence of Champions

63
Readiness of External Environment
  • Congruence with Community/Cultural/Family Values
  • Referral Source Understanding and Support
  • Funding Source Support
  • Political Support
  • Role of Social Influence/Demand for Services
  • Role Social Movement Theory

64
Supportive Implementation Model
Administrative Leadership and Support for EBT
Obtain client feedback
Supervision
Technical Assistance
Expert Consultation
Use EST with appropriate clients
Therapist
Training
Materials
Community/Consumer Support for EBT
65
Finding Evidence Supported Treatments on the Web
  • www.nctsn.org
  • www.cachildwelfareclearinghouse.org/
  • http//modelprograms.samhsa.gov/template.cfm?CFID
    119292CFTOKEN55491051
  • www.strengtheningfamilies.org/
  • www.ncptsd.va.gov/topics/treatment.html
  • www.childtrends.org
  • www.wsipp.wa.gov
  • http//ebmh.bmjjournals.com/
  • www.cochrane.org
  • www.campbellcollaboration.org
  • www.colorado.edu/cspv/blueprints/model/overview.ht
    ml

66
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67
Contact Information
Download reports from www.chadwickcenter.org
E-mail cwilson_at_rchsd.org
www.cachildwelfareclearinghouse.org
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