Overview of Evidence
Based Practice
Charles Wilson, MSSW, Executive Director of Chadwick Center
The Sam and Rose Stein Chair on Child Protection
Rady Children’s Hospital-San Diego
www.cachildwelfareclearinghouse.org
How Things Change
A Problem is
Recognized
Action-Any Action
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
How Things Change
A Problem is
Recognized
Action-Any Action
Informed Action
Series of Trail
and Errors
AdjustmentsSome BetterSome Worse
Family
Foster
Care
Trial and Error
Orphanages and
Boarding schools
Tennessee Preparatory School for Dependent Children
How Things Change
A Problem is
Recognized
Informed Action
Informed Action-Based on Science
So how do we know what works
vs.
mere marketing marketing
hyperbole?
Let the Buyer
Beware
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
Roger
J. Callahan,
PhDincludes 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)
Retrieved from http://www.tftrx.com/, November 17, 2006
More Claims for TFT
Q. How Can TFT Benefit You? – What Kind of Problems Can Be Helped?
•
•
•
•
•
•
•
•
•
•
•
Anxiety and Stress
Personal fears or your children’s 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?PHPSESSID=
f4cf66c40b9678b742b82989fee7b377# on November 17, 2006
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.”
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
Distinguishing groundless
marketing claims from reality
The Problem:
All sorts of
“interventions”
are available
out there.
Waiting Room Sign
Ben Saunders
MUSC
Evidence Based Social Work
“Professional judgments and behaviors should be guided
by two interdependent principals:
1. When ever possible, practice should be grounded on
prior findings that demonstrate empirically…that they
are likely to produce predictable, beneficial, and
effective results.
2. Every clients system, over time should be evaluated”
Evidence Based Practice Manual
Oxford University Press
2004
Albert Roberts, PhD
Kenneth Yeager, PhD, LISW
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
Individual clinical expertise
The best available clinical
evidence from systematic
research
-David Sackett
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?
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 nonintervention.
• 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.
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 !!
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.
Scared Straight
TF-CBT
Reactive Attachment Disorder and
Attachment Therapy
…pioneered by psychoanalyst Aaron Lederer, the RAD
Consultancy’s creator and director. His methods yield
remarkable results within weeks.
Retrieved from http://www.radconsultancy.com/, November 17, 2006
Why should we worry
about using Evidence
Supported Treatments?
Institute of Medicine:
Apply 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/
Understand Adoption of Innovation
MTFC
1991
Innovators
Early
Late
Majority Majority
Early
Adopters
Traditionalists
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, it’s in San
Diego in January!”
– “Those videos were just so amazing! I have got to try that.”
Ben Saunders
MUSC
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 RCT’s
– 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
CEBC Website: www.cachildwelfareclearinghouse.org
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
Percentage of Total
Visitors from U.S.
14%
86%
Percentage of Total Visitors
from California
33%
Data based on numbers as of
September 1, 2007
CEBC’s 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/
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
Children’s 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.
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 Director’s 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.
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.
Scientific Rating Scale
and
Relevance to Child Welfare Scale
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
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.
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.
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.
Scientific Rating Scale
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.
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.
4. Acceptable/Emerging PracticeEffectiveness 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.
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 practice’s 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, peerreviewed 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.
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.
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, peerreviewed 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.
Child Welfare Ratings
• Not every program that is evidence-based will
work in a Child Welfare setting…
• We also examined each program’s experience
and fit with Child Welfare systems and
families
Relevance to Child Welfare Scale
1.
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.
2.
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.
3.
Low:
The program was designed to serve children, youth, young adults,
and/or families with little apparent similarity to the child welfare
services population.
Child Welfare Outcomes
• We also examined whether programs had included outcomes
from the Child and Family Services Reviews in their peerreviewed evaluations:
Safety
Permanency
Well-being
Common Continuing Education
Dissemination Model
One day
workshop
Book
Therapist
Use Tx with
appropriate
clients
X Laying the Groundwork for
Implementing
Evidence Based Practice
Levels of Implementation
Fixen et al
• Paper Implementation
• Process Implementation
• Performance Implementation
Fixsen, D., Naoosm, S., Blasé,
K., Friedman, R., Wallace, F. (2005)
Institute for Healthcare
Improvement Model
Environmental Context
Organizational Context
Microsystem
Community, Government,
Funders
Organizations
Departments
and Programs
Within
Organizations
Patient and
Community
Social Workers, Therapists,
Medical Professionals and
Families
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
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
Practice Selection
Attributes 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 workforce’s 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
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
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
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
Supportive Implementation Model
Administrative Leadership and Support for EBT
Obtain
client
feedback
Technical Assistance
Supervision
Expert
Consultation
Therapist
Training
Use EST with
appropriate
clients
Materials
Community/Consumer Support for EBT
Finding Evidence Supported
Treatments on the Web
• www.nctsn.org
• www.cachildwelfareclearinghouse.org/
• http://modelprograms.samhsa.gov/template.cfm?CFID=11
9292&CFTOKEN=55491051
• 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.html
Contact Information
Download reports from:
www.chadwickcenter.org
E-mail:
cwilson@rchsd.org
www.cachildwelfareclearinghouse.org