A Common Elements Approach to Children's
Services
Presented to the
The Use of Evidence in Child Welfare Practice and Policy
An International Perspective on Future Directions
Haruv Institute, Bar-Ilan University, Israel
May 26, 2010
Richard P. Barth
ATLANTIC COAST CHILD WELFARE IMPLEMENTATION CENTER
School of Social Work
University of Maryland
Baltimore, MD 21201
rbarth@ssw.umaryland.edu
Summary
• Evidence based practices need to be based,
primarily, on practice principles and common
pracice elements, not on manuals
• Increasing the uptake of evidence based
methods will best be achieved by increasing
knowledge of common practice elements and
common factors
• Adapting evidence based practices to
international contexts will require emphasis
on common factors
The Alphabet of EBP
What is needed, it seems to me, is some
course of study where an intelligent young
person can ... be taught the alphabet of
charitable science.
Anna Dawes (1883)
From a paper given at the International Congress of Charities and
Correction at the Chicago World's Fair.
Source: Lehninger, L. (2000). Creating a new profession: The beginnings of
social work education in the United states. Washington, DC: Council on
Social Work Education.
The Language of Evidence Based
Practices
• Evidence Based Programs
– Multi-dimensional
• Evidence Supported Interventions
• Common (Practice) Elements
• Common Factors (CD OI)
– Client directed
– Outcome informed
– Coherent treatment strategy
• Practice Principles
• Practice (Policy) Framework
A Language for Evidence Supported
Interventions for Children and Families
• Specific Competence
– Needed to increase the acceptability of services and, possibly, to
improve interventions
• Evidence Supported Programs
– Multi-systemic Therapy (MST);
– “Wrap Around”
– Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A)
• Evidence Supported Manualized Interventions
– e.g., Cohen and Mannarino’s Trauma Focused-CBT
• Common (Practice) Elements Approach
– Chorpita and colleagues
• Common Factors Approach and Measurment Feedback Systems (MFS)
– Duncan, Lambert and Sparks (CDOI)
• Practice Principles
– Hurlburt & Barth Parent Training Programs
• Practice (Policy) Framework
– Commitment to “Place Matters” or “Family Focused Services” or “Safety
First”, or Safety, Permanency & Well-Being”
Specific
Knowledge of
Problem & Solutions
Not Drawn to Scale
Regarding the Number
in Each Set
Evidence Supported
Programs
(Manualized Interventions)
Common (Practice) Elements
Common Factors
Practice Principles
“Practice” (Policy) Framework
6
Specific Knowledge of Problems &
Solutions
•
•
•
•
•
•
Neglect
Adoption
Sexual Abuse
Trauma
Phobia
Running Away
Evidence Supported Programs and
Evidence Supported Interventions
PROGRAMS
• Multi-systemic Family Therapy (MST)
• Multi-Dimensional Treatment Foster CareAdolescent (MTFC-A) and MTFC-Pre
– KEEP
EVIDENCE SUPPORTED MANUALIZED
INTERVENTIONS
• Trauma Focused CBT
• Alternative Family-CBT
• Coping Cat
What Makes an Evidence Based
Program Work?
• We Really Do Not Know
– There has been very little deconstruction
• Multi-Dimensional Treatment Foster Care is
a LARGE Collection of Practice Elements
– Parent Daily Report
– Parent Management Training for Foster and
Biological Family
– Behavioral Group Work
– CBT for children
– Mentoring of Youth
What Makes a Manualized Evidence
Supported Intervention Work?
• Trauma Focused CBT is more tightly
manualized with a somewhat SMALLER
Collection of Practice Elements
–
–
–
–
–
–
Psycho-education
Stress-management
Narrative therapy
Exposure therapy
Cognitive restructuring
Parental treatment
How will I ever
master all these
ESI manuals
???
The Common Elements Approach
Step 1:
Emphasis on
evidencedbased
treatments
Step 2:
Development of
treatment
manuals
Step 3:
Information
overload: Too
many treatment
manuals to learn
and manuals
change as new
knowledge is
gained
The Common Elements Approach
• Using elements that are found across several evidencesupported, effective manualized interventions
• “Clinicians ‘borrow’ strategies and techniques from known
treatments, using their judgment and clinical theory to adapt
the strategies to fit new contexts and problems” (Chorpita,
Becker & Daleiden, 2007, 648-649)
• Actual treatment elements become unit of analysis rather
than the treatment manual
• Treatment elements are selected to match particular client
characteristics
Identifying the Practice Elements
 Trained coders reviewed 322 randomized
controlled trials for major mental health disorders
for children and teens;
 Over $500 million invested in these research
studies
 Studies conducted over a span of 40 years
 More than 30,000 youth cumulatively in the study
samples
 Approach:
 What features characterize successful treatments?
 What strategies are common across effective
interventions?
(Chorpita & Daleiden, 2009)
Coding Process for 322 RCTs:
 Frequencies of practice elements from
winning treatment groups were then tallied to
see what practice elements were most
commonly found in effective interventions
 41 practice elements identified that were
found in at least 3 of the 232 winning
treatment groups
Tools to Support the Common
Elements Approach
• www.practicewise.com
• Subscription-based resources:
– PracticeWise Practitioner Guides
– Modular Approach to Therapy for
Children (MATCH)
– PracticeWise Evidence-Based Services
Database (PWEBS)
– PracticeWise Clinical Dashboards
Common Elements Practitioner Guides
• Summarize the common elements of evidencebased treatments for youth;
• Handouts guide clinician in performing the main
steps of the technique
• Currently 29 Treatment elements, including:
– Response cost
– Modeling
– Social Skills
– Time out
– Engagement with caregiver
• Guide is searchable by: treatment, audience (child,
caregiver, family), purpose, objectives
Example
of
printable
PDF
describin
g practice
element:
Audience
Goals of this
practice
element
Steps
for
using
this
practi
ce
eleme
nt
MATCH Example: Putting Together
Practice Elements
Start
Clinical Dashboards
• Microsoft Excel based monitoring tool
– Tracks achievement of treatment goals or other
progress measures on a weekly/session basis
– Documents which practice elements were used when
• Dashboard can be customized:
– Display up to 5 progress measures;
– Write-in additional practice elements
• Potential uses:
– Documenting session activities
– Tracking client progress
– Clinical supervision
Docume
nt which
practice
element
was
used
when
Common Factors (Client Directed
Outcome Informed)
• Effective therapy arises from allegiance to a
treatment model, monitoring of change, and
creating a strong therapeutic alliance
– Feedback from clients on their level of functioning
– Feedback to therapists on the therapeutic alliance
– A coherent treatment approach that encourages
action to change
Duncan et al., (2010) Heart and Soul of Change: Delivering What
Works in Therapy (2nd Edition). Washington, DC: APA
22
Practice Based Evidence
“A continuous feedback or practice-based
evidence approach individualizes psychotherapy
based on treatment response and client
preference;
systematic feedback addresses the dropout
problem, as well as treatment and therapist
variability…” (p. 702).
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes:
A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704.
Client-Directed, Outcome-Informed
(CDOI) Treatment & Wrap Around
• Adapt to specific individual and family needs based on
client feedback
• Move from punitive and restrictive to optimistic and
responsive interventions
• Utilize brief and systemic client-report measures
throughout therapy
• Strengths-based and culturally responsive
“At its core, wraparound is flexible,
comprehensive, and team-based.” (p. 65)
Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community
collaboration. Journal of Systemic Therapies, 28, (3), 63-76.
Tools for Feedback: ORS and SRS
• Reliable and valid four-item, self-report
instruments used at each meeting
• Scored and interpreted in a collaborative
effort between client and therapist
• Rather than the therapist assigning meaning
to a client’s feedback, the client explains the
meaning behind the mark on the scale
• Help identify alliance strengths and
weaknesses in therapy
Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community
collaboration. Journal of Systemic Therapies, 28, (3), 63-76.
Outcome Rating Scale (ORS): Adults
Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have
been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high
levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.
Individually
(Personal well-being)
I ---------------------------------------------------------------------------------------------------- I
Interpersonally
(Family, close relationships)
I --------------------------------------------------------------------------------------------------- I
Socially
(Work, school, friendships)
I --------------------------------------------------------------------------------------------------- I
Overall
(General sense of well-being)
I --------------------------------------------------------------------------------------------------- I
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2000, Scott D. Miller & Barry L. Duncan
Session Rating Scale (SRS V.3.0): Adults
Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.
Relationship
I did not feel heard,
understood, and
I -------------------------------------------------------------------------------- I
I felt heard,
understood, and respected.
Goals and Topics
We did not work on
We worked on and
or talk about what I
wanted to work on
and talk about.
I ----------------------------------------------------------------------------------------- I
talked about what I
wanted to work on or talk about
Approach or Method
The therapist’s
approach is not a
good fit for me.
I ------------------------------------------------------------------------------------------- I
The therapist’s
approach is a good fit for me
Overall
Overall, today’s
session was right for I ------------------------------------------------------------------------------------------ I
me.
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson
There was something
missing in the session today.
Formatted for Children…
the CORS and CSRS
• Similar scales designed for use with children ages
6-12
• Written at a third grade reading level
• Used to track effectiveness and
therapeutic alliance as reported by children
and their parents or caretakers.
• CORS shows strong reliability (alpha=.84) and
validity as compared to a longer youth outcome
questionnaire (Pearson’s coefficient=.61)
• Gives youth a voice in their own therapy
Duncan, B. L., Sparks, J. A., Miller, S. D., Bohanske, R. T. & Claud, D. A. (2006) Giving youth a voice: A
preliminary study of the reliability and validity of a brief outcome Measure for children, adolescents, and
caretakers. Journal of Brief Therapy, 5, (2), 71-88.
Child Outcome Rating Scale (CORS)
How are you doing? How are things going in your life? Please make a mark on the scale to let us know. The closer to the smiley
face, the better things are. The closer to the frowny face, things are not so good. If you are a caretaker filling out this form, please
fill out according to how you think the child is doing.
Me
(How am I doing?)
I ---------------------------------------------------------------------------------------------------- I
Family
(How are things in my family?)
I --------------------------------------------------------------------------------------------------- I
School
(How am I doing at school?)
I --------------------------------------------------------------------------------------------------- I
Everything
(How is everything going?)
I --------------------------------------------------------------------------------------------------- I
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2003, Barry L. Duncan, Scott D. Miller & Jacqueline A. Sparks
Child Session Rating Scale (SRS V.3.0)
How was our time together today? Please put a mark on the lines below to let us know if how you feel.
Listening
Did not always
listen to me
I ---------------------------------------------------------------------------- I
Listened to me.
How Important
What we did and talked
What we did and
about was not
really that
important to me.
I --------------------------------------------------------------------------- I
talked about
were important
to me.
What We Did
I did not like
What we did
today.
I --------------------------------------------------------------------------- I
I liked what we
did today.
Overall
I wish we could
do something
different.
I --------------------------------------------------------------------------- I
I hope we do the
same kind of
things next time.
•
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2003, Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, and Lynn D. Johnson
Measurement Feedback Systems
• A MFS is a battery of comprehensive measures administered frequently
concurrent with treatment, providing timely feedback to clinicians and
supervisors to report on clinical processes and treatment adherence
(Bickman, 2008). A good MFS should have measures that are:
– short,
– Psychometrically sound, and
– useful in everyday practice by clinicians
• MFSs should assess several domains by multiple reporters that include
treatment progress (e.g. youth and family outcomes) and treatment
processes (e.g. therapeutic alliance and treatment activities).
• A MFS provides systematic feedback that can be used to enhance
clinical decision-making, improve accountability, drive program planning,
and inform treatment effectiveness (Chorpita et al. 2008; Kelley & Bickman 2009).
Client Feedback as a
Common Factor (or Element)?
• This study provides reliable support for alliance
building and monitoring treatment progress for
clients and therapists in couple therapy.
• Feedback tools (e.g., ORS and SRS) that are not
linked with a certain therapy or method can be
used in community settings more easily than
specific treatment packages.
• Further research may show the extent to which the
increased therapeutic engagement or allegiance effects can
influence the positive effect of the feedback tools.
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes:
A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704.
First CDOI/MFS RCT
• Couples using the feedback measure, ORS,
(N=103) at pre- and posttreatment and follow-up,
compared to couples receiving treatment as usual
(TAU) (N=102):
– Achieved almost 4 times the rate of clinically significant change
– Maintained a significant advantage on the ORS at 6-month
follow-up
– Showed greater marital satisfaction and lower rates of
separation or divorce
• The feedback condition showed a moderate to
large effect size (0.50)
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes:
A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704.
Other Common Elements/MFS: The
Parent Daily Report
Project KEEP: (MTFC-Lite)
• Foster Parent Groups
– Good behavioral group work a la Sheldon Rose
– Appreciate the foster parents efforts
– Reward their successes
– Demonstrate and role play skills
– Pre-teaching (shaping the antecedents)
• Parent Daily Report (PDR)
– Which of these problems occurred in the last 24 hours?
– How stressful did you find it?
Predicted Probability Of Negative Exits By
Prior Placements And Intervention Group
KEEP
MTFC and KEEP Implications
• We can change biological characteristics of
children—including stress hormones and executive
functioning—with consistent responsive social
interventions
• The use of the Parent Daily (or Weekly) Report
and Support Groups may be common elements of
benefit.
– Perhaps could also be used more in parent training (a la
PMTO) and post-adoption services
Practice Principles
• Example, Doug Kirby Pregnancy and STI
Practice Principles
• Hurlburt and Barth on parenting programs
• MORE ART THAN SCIENCE
– Most of these practices have not been
studied in isolation and we cannot tell what
their overlap might be—some may be inert.
Basic Components of Effective
Parent Training
•
•
•
•
•
Social learning framework
Strengthening parent-child relationship
Effectively use praise and reward
Sets clear and effective limits
Reserves most significant consequences for
targeted, limited behaviors
• Strictly limits negative consequences
• Parent Training + may have worse outcomes than
parent training alone (CDC)
• Addresses family as well as parent-child issues
Hurlburt, M., Barth, R.P., Leslie, L. & Landsverk, J. (in press). Haskins, R., Wulczyn, F., & Webb, M.
(Eds). Research on child protection: Findings from NSCAW. Washington, DC: Brookings.
Delivering Effective Parent Training Programs
• Detailed materials corresponding to specific, narrowly
focused parenting skills
• Specific means of monitoring changes in parenting
practices (e.g., homework)
• Parents take active, participatory role in learning and
practicing skills
• Minimum 15 hours of intervention and 25 hours for
group format
• Rigor of supervision processes to ensure program
delivery with fidelity
Practice Policy Framework
• Lack of clarity about the purposes of
societal efforts to protect children, promote
their well-being, and support families will
undermine the commitment to advance
new treatment approaches and handicap
efforts to generate measurement feedback
systems at the policy level—a crucial flaw.
Thank you for this opportunity
OR
‘S
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