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Evidence Based Practice

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Naomi Weitz

on 6 October 2014

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Transcript of Evidence Based Practice

Social Phobia, Trauma Exposure & Anxiety
Behavioral Problems & Substance Abuse
Depression
Eating Disorders
References
American Psychological Association Task Force on Evidence-Based Practice for Children and Adolescents (2008). Disseminating evidence-based practice for children and adolescents: A systems approach to enhancing care. Washington , DC: American Psychological Association.
Evidence Based Practice
What is it?
Evidence Based Practice
www.coreims.co.uk
www.effectivechildtherapy.com
Journal of Clinical Child and Adolescent Psychology
, 37(1), 2008.
Naomi Leong, MS LMHC, MFT
2014
"The
integration
of the best available

research

with

clinical expertise

in the

context of

patient characteristics,

culture
,
and

preferences



Institute of Medicine
2 major elements of EBP:

1. Sound assessment
2. Evidence-based interventions
Accurate identification of disorders
Ongoing monitoring during care (even weekly)
Outcome evaluation at end of treatment
Longitudinal data for short
and
long term outcomes
Procedures shown to improve symptoms
Makes it possible to match the child's condition to the appropriate treatment
ACA Code of Ethics
Counselors have a responsibility to the public to engage in counseling practices that are based on rigorous
research
methodologies.
NASW Code of Ethics
American Counseling Association www.counseling.org
Social workers should base practice on recognized knowledge, including
empirically
based knowledge, relevant to social work and social work ethics.
Best practices mean adhering to ethical standards
National Association of Social Workers
www.socialworkers.org
For Children and Adolescents
Challenges to an Evidence-Based Practice
Children present with multiple
co-ocurring
problems,

complex
social and family problems and situations,
and
diverse
cultural contexts.
Most evidence-based treatments (EBTs) are designed for
single
conditions.
A scientifically minded approach
Evidence-based Practice (EBP)
Evidence-based Treatment (EBT)
Refers to either
intervention
or
prevention
programs for which there is a strong
scientific
base.
A framework for discussing the broader movement
prevention
assessment
treatment
access
engagement
retention
patient characteristics
clinical expertise
Criticism of EBP
Medical model origins
Neglects person variables
Individualized care
Cultural competencies
Strengths-based models
Types of evidence
Traditional psychometric and quantitative approaches rooted in Western European and North American cultures
Disease oriented approach
Prevention not emphasized
Scientific advances have been organized by
problems
due to prominence of the DSM and major funding organizations such as NIMH.
Efforts being made to use more diverse forms of research including qualitative methods.
Rather than focusing on particular theories, models, or treatments, EBP focuses on the
process
of assessment, treatment and ongoing monitoring in efforts to promote quality care.
Family centered care
EBP is about integrating
science
and
practice.
Using

clinical expertise
in initial assessment and diagnosis, case formulation, intervention procedures, clinical decision making, and monitoring of client progress.
"Psychological services are most likely beneficial when they are responsive to a
client's
specific problems, strengths, personality, sociocultural context, and preferences"
(Presidential Task Force on Evidence-Based Practice, 2006)
Criticism of EBP
Could lead to restriction of services
Recommendations may lead to the development of lists of
"approved"
treatments that could:
limit reimbursements by managed care companies
be applied to populations where there is no evidence of efficacy
Continuing research will lead to the development of
more
treatments that are
increasingly
culturally responsive.
Lillienfeld, S. (2014).
Evidence-Based Practice: The Misunderstandings Continue
. Retrieved 9-4-14 from www.psychologytoday.com
Why is EBP important?
Many practicioners are not using scientifically supported therapies for


Surveys show only 20% of people with Major Depressive DO receive effective treatment.

(Lilienfeld, 2014)
OCD
Autism
Eating Disorders
EBP reduces clinical error:
Decreases chances that clients will be exposed to interventions that:
Cause harm
Ineffective
Criticism of EBP
Mandates Cookie-Cutter Approach
Prevents clinicians from using unvalidated interventions
Does not take enough theoretical plausibility into account
EBP needs to be expanded to incorporate
theoretical plausibility
along with rigorous research evidence so
worthy
programs are not left out.
EBP relies too heavily on random controlled trials.
Only implies getting informed consent if using experimental interventions.
Treatments can be modified for individual clients.
Eliminates clinical judgment
Criticism of EBP
Client preferences and values
Clinical judgment and expertise
Research evidence on efficacy and effectiveness
EBP
Coping Cat
Coping Cat: Ages 7-13
C.A.T. Project: Adolescent
Evidence Based Treatments (EBT's)
And now...
Presented by diagnosis
http://www.workbookpublishing.com/fearplan.swf
&
Cognitive- Behavioral Treatment
Therapist manual and client workbook
Computer version: called Camp Cope-A-Lot
Cost:
Coping Cat Workbook $27, C.A.T. Project Workbook $27, Therapist Manual $24
Computer version $200 for individual use, $2000 for an institution
http://www.workbookpublishing.com/
Social Effectiveness Training for Children (SET-C)
For children and adolescents ages 7-17
Multi-component treatment program
Decrease social anxiety
Increase interpersonal skills
Expand range of enjoyable activities
Combines group social skills training, structured peer generalization sessions, and individualized behavioral exposure treatment.
One educational session with parents, 12 group sessions, and 12 in-vivo exposure sessions over a 12 week period.
Therapist's Guide, Parent's Guide, activity cards for group sessions and weekly contracts for setting behavioral goals.
Cost: $193

Adolescents Coping with Depression (CWD-A)
Ages 12-18
Cognitive-Behavioral Therapy
Sixteen 2-hour sessions over an 8 week period in small groups.
Self-monitoring mood
Increasing pleasant activities
Decreasing anxiety
Challenging unrealistic thinking that fosters depression
Social skills, improving communication, conflict resolution
Includes parallel parent course that addresses solutions to conflict with their teens.
Cost: FREE downloads at
http://www.kpchr.org/research/public/acwd/acwd.html
Brief, individual treatment program (5-9 sessions) for youth who are also receiving SSRI's.
InterPersonal Therapy for Depressed Adolescents (IPT-A)
Brief 12-16 session psychosocial intervention
Individual treatment
Goal: Decrease a client's depressive sx and improve social functioning within the context of his or her significant relationships.
Identify interpersonal competencies
Communication
Problem solving
Developmental: Addresses separation from parents, exploration of authority in relation to parents, development of sexual relationships, peer pressures. etc.
Cost: $25 from Guilford Press
Parental involvement: An individual tx but some degree of parent/guardian involvement helps with tx success.
Gately, G, (August 13, 2014). Evidence-based 'Gold Standard': Coveted Yet Controversial www.jjie.org
www.blueprintsprograms.com
The Incredible Years
Small Group Dinosaur
Parent and Teacher training programs
Ages 4-8 with disruptive bx
2-hour weekly small group sessions for 20 weeks
Cost: $1,300
Following rules
How to be successful in school
Problem solving
Communication
How to be friendly
Functional Family Therapy (FFT)
Multisystemic Therapy (MST)
www.fftllc.com
www.mstservices.com
Autism
Bipolar Disorder
Self-administered Treatment, plus Signal Seat
Ages 2-7
Time out chair that sounds an alarm whenever the child leaves the chair without permission.
Signal seat increases parental consistency, minimizes inconvenience.
Penn Prevention Program (PPP)
Manuals not available to the public yet!
Assessment
ACTION
Ages 9-14
Structured therapist's manual and workbook.
20 group and 2 individual sessions
Affective education
Coping Skills
Problem solving skills
Cognitive restructuring
Sense of self
Cost: Workbook $24 $Therapist Manual $21
Available: Amazon.com
The California Evidence-Based Clearinghouse for Child Welfare www.cebc4cw.org
Mentalization-Based Treatment (MBTA)
Ages 12-17
Training available at the Anne Freud Centre
LONDON
Self harm, trauma
Extensive training and funding
Self-Control Therapy
Primary and Secondary Control Enhancement Training (PASCET)
Stressbusters
Family Focused Treatment for Adolescents (FFT-A)
For adolescents with Bipolar Disorder and their families
Ages 9-17
21 session, 9 month intervention: 12 weekly, 6 biweekly, 3 monthly
Psychoeducation
Communication Enhancement Training
Problem-Solving Skills Training
Cost: $28 for paperback
Available: www.guildford.com
Individual-Family PsychoEducational Psychotherapy (IF-PEP)
Ages 8-12
Biopsychosocial approach based on cognitive-behavioral and family systems principles.
Cost: Therapist Manual $25, Parent Workbook
$25, Child Workbook $25
Learn about symptoms of mood disorders
Effectively manage the symptoms
Improve communication
Improve problem solving
Improve emotional regulation
Decrease family tension
Improve functioning
and more!
Applicable to an outpatient mental health setting
Accessible (doesn't require grants, funding, extensive certification process, treatment manuals available, etc.)
Sources
The California Evidence-Based Clearinghouse for Child Welfare
APA Journal Clinical Child and Adolescent Psychology, Special Issue: Evidence-based psychosocial treatments for children and adolescents: a ten year update, Vol 37, Issue 1 (2008)

Blueprints for Healthy Youth Development
ADHD
No treatments have been identified that supported
non-behavioral
psychotherapeutic or cognitive-behavioral treatments such as:
Individual therapy, Play therapy, Cognitive Therapy
Behavioral Parent Training (BPT)
No significant difference between those who were taking concurrent Rx and those who were not
Behavioral Classroom Management
Treatment manual not available but...
LifeSkills Training (LST)
Positive Action
School or institution based
Rational-Emotive Mental Health Program (REMH)
Helping the Noncompliant Child (HNC)
Ethnic Minorities
Trauma-Focused CBT
Ages 3-18
Free ten-hour basic web-based training www.musc.edu/tfcbt
Treatment Manual: Treating Trauma and
Traumatic Grief in Children and Adolescents $31 Available at www.guilford.com or www.amazon.com
Psychoeducation and parenting skills
Relaxation techniques
Affective expression and regulation
Cognitive Coping
P
R
A
C
T
I
C
E
Trauma narrative and processing
In vivo exposure
Conjoint parent/child sessions
Enhancing personal safety and future growth
Prolonged Exposure Therapy for Adolescents (PET-A)
Therapist guide available as ebook $20 books.google.com
For treatment of PTSD
Ages 12-18 but has been used with children 6-12
8-15 sessions or 2-4 months
Clients are encouraged to repeatedly approach situations or activities they are avoiding because they remind them of their trauma (
in vivo exposure
)
as well as revisit the traumatic memory several times through retelling it (
imaginal exposure
).
Building Confidence
Ages 7-11
GAD, Social Phobia, or SAD
Full package including manuals, books and 1 CEU available for $335 from www.socio.com
12-16 weekly sessions
Lots of parental involvement needed- home based exposure challenges.
Bridges gap between home, clinic and school goals.
Uses humor and rewards.
Eye Movement Desensitization and Reprocessing (EMDR)
PTSD
$210 for DVD course www.emdr.com
Information processing therapy
Involves simultaneously thinking of a negative belief, a positive belief and body sensations while moving their eyes back and forth for 20-30 seconds.
"Possibly efficacious" by APA
Adolescents with PTSD
(1) the past events that have laid the groundwork for dysfunction are processed, forging new associative links with adaptive information;

(2) the current circumstances that elicit distress are targeted, and internal and external triggers are desensitized;

(3) imaginal templates of future events are incorporated, to assist the client in acquiring the skills needed for adaptive functioning.
Treatment manual available for $30 from www.guilford.com
Ages 3-8 with disruptive bx
Addesses faulty parent-child interactions.
8-10 sessions are held in a playroom setting.
Phase I: Parents give increased attention to the child while ignoring minor inappropriate bx.
Phase II: Parents learn to provide direct, concise instructions to the child, allow the child sufficient time to comply, and provide appropriate consequences for compliance or noncompliance.
Triple P Positive Parenting Program
Multidimensional Family Therapy
Brief Strategic Family Therapy (BSFT)
Hispanic Families
Substance use
Conduct problems
Sexualy risky bx
School attendance
Improve family functioning
Parent leadership
Free manual available at:
http://effectivechildtherapy.com/sites/default/files/files/pro_BSFT_Manual.pdf
12-16 family sessions
Cash's Body Image Therapy, plus Virtual Reality
Free tx manual available at:
http://effectivechildtherapy.com/sites/default/files/files/pro_POP_VirtualBody_english.pdf
Psychotherapies
Cognitive Behavioral Therapy
(CBT)
Dialectic Behavioral Therapy
(DBT)
Interpersonal Therapy
Psychodynamic Therapy

A person is having emotional problems because of unresolved unconscious conflicts.
Focuses on the behaviors and interactions a client has with family and friends.
Helps people to identify and change inaccurate perceptions about themselves and the world.
Behavioral Therapy
Focuses on changing destructive behaviors, replacing bad habits with good ones.
Promotes acceptance and change simultaneously. Targets emotional dysregulation, suicidal bx, interpersonal deficits, and tx resistance.
Play Therapy


Expressive or Art Therapy
EBT's are based on one or more types of therapies.
Based on the idea that people can heal themselves through art, music, dance, writing, etc.
Involve using toys and games to help a child identify and talk about their feelings.
Cognitive-Behavioral approach
Virtual reality simulations are used as repeated exposures to represent the client's body in various significant contexts:
in the kitchen
in front of a mirror
in P.E.
Psychoeducation
Exposure
Safety behavior prevention
Cognitive restructuring
Body self-esteem building

Anorexia
Focusing on
(for the most part)
Cost $17 for paperback
DBT (Adolescents)
Modified for adolescents by incorporating illness-specific elements for this population.
Weekly Family Skills Training
Emotional Dysregulation
Interpersonal Effectiveness
Weekly Individual Therapy
Telephone Coaching
Essential element of traditional DBT. Clients are encouraged to call when they have the urge to engage in problem behaviors.
Free treatment manual available at:
https://www.starcenter.pitt.edu/Files/PDF/Manuals/Emotional_Regulation.pdf
Treatment resistance
Suicidal Bx
DBT and CBT complement and supplement each other well. DBT effective with
parasuicidal bx , emotional dysregulation,
and
interpersonal effectiveness
, CBT more appropriate for
chronic depression
. DBT concepts expands the range of self-talk options available to the teen. Use of imagery and other DBT techniques are
friendly ways
to bring
CBT to life
.
Services and Teens at Risk www.starcenter.pitt.edu
Psychoanalytic Therapy
(Self Psychology)
Based on the viewpoint that eating disorders areise from teen's inability to rely on other human beings for satisfy their emotional needs.
No treatment manual
Eating disorders lack a gold standard treatment but this one looks really hopeful and evidence is building:
The Maudsley Method
Avoiding hospitalization
Puts parents at the center of making sure their kids eat, rather than blaming them.
Treatment manual available: www.textbookrush.com $29
Conclusion
Standardized Program Evaluation Protocol (SPEP)
Looks at "generic" programs to see how close they come to evidence-based treatments.
Can be a bridge between EBT's and programs already in use.
Being used in the at-risk-youth field.

Recommendations
Potential Bridge
Use
psychometrically sound
assessments
frequently
to make sure your intervention is effective.
Be a wise consumer of research:
keep up to date on research
be open to other types of evidence than RCT's but proceed with caution
don't just read headlines
be aware that other treatments may be effective but lack studies.
Thank you!
Actually a combo of DBT and CBT
Antecedent Package
Antecedent Assessment & Intervention Strategies
Behavioral Package
Language and autism: Applied behavior analysis, evidence and practice
A treasure chest of behavioral strategies for individuals with autism
Joint Attention Intervention
Lesson ideas and activities for young children with autism and related special needs
Modeling
Seeing is believing: Video self-modeling for people with autism and other developmental disabilities
www.nationalautismcenter.org

Story-Based Intervention Package
The new social story
Schedules
Activity schedules for children with autism
Books
Cool Kids
Treatment package with Therapist Manual, Parent Workbook and Child Workbook available at www.centreforemotionalhealth.com.au
$60 per age group
Preschool 3-6 years
7-12 years
12-17 years
3 versions:
Cognitive-Behavioral treatment for Anxiety
12 weeks, 8 weekly individual sessions followed by 2 biweekly sessions.
Available in individual or group format
Essential components:
Psychoeducation
Cognitive Restructuring
Parent Skills
In-vivo exposure
Social Skills
Improved coping strategies
Attachment
Extremely important to adhere to evidence-based practice with this dx due to controversy surrounding harmful and sometimes fatal treatments.
"The most important intervention for young children dx with RAD and who lack attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure" (AACAP, 2014).
Schizophrenia
Few studies have been done on psychotherapies with youth, but current evidence shows including these
elements
leads to benefits:
(AACAP, 2013)
Psychoeducation about illness and tx options
Social skills training
Relapse prevention
Medication management
Basic life skills training
Problem solving strategies
Psychoeducation for family
www.cardinalinovations.org
1. Address child's needs for safe, dependable, predictable, responsive caregiving
The goal is for the child to gain new learning about relationships that can be generalized to other significant relationships- that relationships are not dangerous.
2. Address the child's traumatic history using EBT models such as TFCBT.
If the child does not have memory of their pathogenic care and/or does not have PTS sx then revisiting trauma directly is not indicated.
It is important for the clinician not to provide info about past trauma that the child is not already aware of.
Focusing on past trauma is important so that it is not confirmed for the child that certain things cannot be spoken.
3.Address unsafe or high risk bx immediately using EBT models.

Problem Solving Skills Training
Sexually inappropriate bx:
Suicidality:
Physical aggression:
Ongoing risk assessment and safety planning
4. There have been no psychopharmacologic trials for RAD.
Rx may be called for to treat co-morbid conditions or for symptom specific tx of emotional dysregulation.
(Potter, et al, 2009)
Center for Child & Family Health, Clinical Guildenlies Series, 2009: Reactive Attachment Disorder, Potter, et al.
There is not a specific EBT for RAD, but there are clinical guidelines for an EBP approach.
Problem Solving Skills Training (PSST)
Ages 7-13 with Disruptive Bx
20-25 sessions with the child
+ Practice version adds homework
+ Practice and Parent Managment version adds parent sessions
Unable to locate complete manual
but an overview of the knowledge and skils needed for a clinician is available for free at :
http://www.ucl.ac.uk/clinical-psychology/CORE/child-adolescent-competences/interventions/
Manual: Problem-solving Skills Training for Children and Adolescents with Oppositional, Aggressive, and Antisocial Behavior: Overview, (Kazdin, 2009)
Techniques used:
Modeling
Role Playing
Positive reinforcement of appropriate bx
Teaching alternate bx's
Managing thoughts and feelings
American Academy of Child and Adolescent Psychiatry
American Counseling Association
University of Pittsburg Medical Center, Western Psychiatric Institute and Clinic
University of Pittsburg Medical Center, Western Psychiatric Institute and Clinic
American Association of Child and Adolescent Psychiatry
www.aacap.com
For Substance Abuse & Behavioral Problems:
Children and adolescents with sexually inappropriate bx
and
hx of sexual abuse
Treatment Protocol based on research on EBT's, rather than single EBT
(Hof, et al, 2009)
Goals 1-3:
Goals 4-5:
Goals 6-8:
Goal 9:
Goal 10:
Goals 11-15:
Goals 17-18
Goals 19-22:
Goals 23-24:
Goals 25-26:
Goals 27-28:

Aftercare
Building rapport, safe environment
Sharing stories of offending bx and personal victimization
Ownership of bxs, understanding development of unhealthy patterns
Exploration of client's fantasies
Understanding bx cycle, thoughts, feelings, triggers, impact of victimization.
Teaching model of healthy sexuality
Goal 16:
Reexamine current relationships
Focusing on client's taking responsibility for their actions
Education on sex offender assault & lapse cycle, identifying realistic replacement bxs
Building client's support system
Development of relapse prevention plan
Treatment Protocol, not EBT
Typically includes:
Treatment protocol outlined earlier in presentation
Hof, D. D., Dinsmore, J. A., Hock, C. M., Bishop, M. A., & Scofield, T. R. (2009). Deviant sexuality in children and adolescents: A protocol for the concurrent treatment of sexual victimization and sex offending behaviors. In G. R. Walz, J. C. Bleuer, & R. KI. Yep (Eds.), Compelling counseling interventions: VISTAS 2009 (pp. 235-245). Alexandria, VA: American Counseling Association.
Assessment
VALID and RELIABLE!
At the beginning, during, and at the end of tx
Children's Depression Inventory (CDI)
$349 for online kit with 25 tests, 2.75 per additional test
Ages 7-17
Clinical Outcomes in Routine Evaluation (CORE)
34 item full outcome measure
CORE-10
CORE-5
CORE-YP
Valid and reliable across dx
Behavior and Assessment System for Children (BASC)
Assesses behavior in ages 2-21
$637 for starter set with computer entry and 25 tests
Designed for EBP
Quick to administer
Self-report takes 30 min
Free downloads of manuals and forms available at: http://www.coreims.co.uk/download-pdfs
Over the last week…
1. I’ve felt edgy or nervous
2. I haven’t felt like talking to anyone
3. I’ve felt able to cope when things go wrong
4. I’ve thought of hurting myself
5. There’s been someone I felt able to ask for help
6. My thoughts and feelings distressed me
7. My problems have felt too much for me
8. It’s been hard to go to sleep or stay asleep
9. I’ve felt unhappy
10. I’ve done all the things I wanted to
0- Not at all
1- Only occasionally
2- Sometimes
3- Often
4- Most
5- All the time
Short version of self reports takes 10 min
Screen for Child Anxiety Related Disorders (SCARED)Youth Version
41 items
10 min to administer
Ages 8-18
Child PTSD Symptom Scale (CPSS)
Free
Ages 8-18
Free
Further research needed on whether SCARED Brief Assessment is empirically supported
24 items
5-10 min to administer
http://www.childsworld.ca.gov/res/pdf/KatieA/ChildAdolescentTraumaScreenTools.pdf
Trauma Symptom Checklist for Children (TSCC)
$172 for intro kit
Ages 8-16
Mood and Feeling Questionnaire (MFQ)
Free
Ages 8-18
5-10 minutes to administer
Short version for both caregiver and child with only 13 items available
33 items
Depression
Trauma
Behavior
Eyeberg Child Behavior Inventory (ECBI)
Ages 2-16
Parent reports takes 5-10 min
36 items
$208 for kit including manual and 50 tests
General outcome assessment
Ohio Scales
Ages 5-18
Free
15 min to administer
Parent, child and provider versions
General outcome assessment
Looking to the future...
Anxiety
Any questions
Research will need to focus on increasing developmental, cultural, systemic, preventative, and humanistic considerations
Areas for growth
Types of Evidence
Random Controlled Trials (RCT's)
People are randomly assigned to treatment conditions, one of which is a control group.
2. Quasi-Experimental Design
People are not randomly assigned to groups.
i.e. Case Study
An in depth look at a particular situation
Whereas...
On the other hand...
Many of the EBT's recommended may be due to the fact that they have the most research behind them.
Research Designs 101
4. Observational Research
3. Correlational Research
1. True Experimental Design
Looks at the covariation of two variables
(APA, 2008)."
&
and keeping in mind...
Something can be considered credible based on appearances

Assessment
Using EBT's but also...
Well established
Probably efficacious
Possibly efficacious
Experimental
But first...
Guidelines:
Successful treatments typically involve intensive 40 hr/week interventions.

Assessment
One of the biggest...
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