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Exploring the landscape of ‘evidence-based’ interventions for ‘deep-end’ children and their families: how do we know ‘what works’ and how do we make more of it available?

abstract

Plenary overview. Across many national boundaries and within multiple service contexts - juvenile justice, child mental and child welfare- there is a growing concern about a proportionately small number of multiply-challenged children and youth who consume a disproportionate share of service resources, professional time and public attention. While accurate, empirically validated population estimates and descriptions remain elusive, the consensus of international youth and family practitioners seems to be that some combination of externalizing, "acting-out" behavior, problems with substance abuse, identified and often untreated mental health problems, experience with trauma and challenging familial and neighborhood factors are often, and in various combinations, manifest in the population of children and youth most challenging to serve.

An additional sense of urgency is conveyed by the fact that many child and youth clients of "deep-end", restrictive services disproportionately represent underserved and often socially excluded families and communities of color. A basic concern with questions of equity and social justice coupled with a growing skepticism about the efficacy of traditional residential, "place-based" services has heightened the search for more preventive, family and community-based, culturally congruent service alternatives.

The primary purpose of this plenary paper, as indeed, the entire conference, is to begin the task of critically examining the existing cross-national research base of both child and family client characteristics and service outcomes to identify future directions for enlightened public policy, effective service programming and improved empirical outcome research. Emergent data bases on child and youth service populations and empirical research on promising treatment strategies offer, if not clear-cut prescriptions, then rich implications for future policy initiatives and service experiments.

As a closely related development, the pursuit of "evidence-based practice", in its many forms, increasingly attracts the attention of those who plan, deliver and evaluate critical treatment and rehabilitative services for vulnerable children and their families. While definitions of "evidence-based practice" emphasize different dimensions of that construct, the common themes of bringing "science-to-service" and its reciprocal are increasingly evident in the child, youth & family services systems in many European countries and North America as well as elsewhere. Simultaneously, reform efforts in many countries press for community-based, family oriented, non-residential alternatives to traditional institutional care and treatment programs for acting-out children & youth with identified mental health problems.

Our conviction is that this first joint conference of Eusarf & iaOBERfcs in Padova, Italy (2008) offers the hope of beginning cross-national dialogue designed to bridge some of the larger chasms in the larger child, youth & family services field:

  • the continuing tensions between "front-end", preventive services and "deep-end" highly intensive treatment services and the unhelpful dichotomies these tend to create and perpetuate.
  • the tensions between a widely shared desire to adopt more "evidence-based" practices and the genuinely felt resistances to these, particularly when they are employed in a "lock-step" or "cookie cutter" fashion requiring strict adherence to established protocols with little opportunity for experimentation or customization.
  • the tension as manifest in N. America and elsewehere between "evidence-based" and "culturally competent" practices reflecting, among other things, antagonism towards certain practice strategies based on perceptions of the representativeness of samples on which certain models have been validated.

We are in agreement with Munro, Stein & Ward (2005) that researchers, planners and youth & family practitioners are at a moment in time when cross-national perspectives are critical in helping identify new ways of both framing problems and shaping service solutions: identifying different formats for collecting, analyzing and utilizing routinely gathered client information, analyzing subtle local adaptations of internationally recognized evidence-based services and examining the effects of differing policy contexts on service outcomes.

Consequently, the bulk of this initial plenary session will be given over to defining key terms, highlighting core challenges in identifying and implementing promising and efficacious service strategies and practices and creating a supportive infra-structure for effective and humane child and family intervention:

  • Burns, B.J. & Hoagwood, K. (2002). Community Treatment for Youth: Evidence-Based Interventions for Severe Emotional and Behavioral Disorders. New York: Oxford University Press.
  • A good compendium on "evidence-based" models of contemporary youth mental health practice models [MST, MTFC, Wraparound] within a" systems of care" context.
  • Dishion, T.J., McCord, J. & Poulin, F. (1999). When interventions harm: peer groups and problem behaviour. American Psychologist, 54(9), 755-764.
  • Poulin, F., Dishion, T.J., & Burraston, B. (2001). 3 year iatrogenic effects associated with aggregating high risk adolescents in cognitive-behavioral preventive interventions. Applied Developmental Science, 5(4), 214-224.
  • Weiss, B.,Caron, A., Ball, S., Tapp, J., Johnson, M. and Weisz, J. (2005). Iatrogenic effects of group treatment for antisocial youth. Journal of Consulting and Clinical Psychology, 73(6), 1036-1044.

The papers by Dishion et. al. (1999) and Poulin et. al. (2001) lay out the case for the iatrogenic effects of negative peer influences in certain group treatment conditions through the mechanism of deviancy training. Weiss et. al. (2005: 1043) in a systematic review of research on group treatment conditions conclude that "the risk of iatrogenic effects may at present be overstated". While not an endorsement of residential treatment, or other forms of group intervention, this review appearing as it does in a top-tier journal and given the eminence of some on the author team (eg. John Weisz) at a minimum provides a more conducive environment for making the case for residential care as a treatment of first rather than last resort.

  • Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). For more information See the Web site http://nirn.fmhi.usf.edu
  • Key U.S. resource devoted to identifying factors associated with successful implementation of evidence-based practices and programs for troubled youth.
  • Jensen, P.J., Weersing, R., Hoagwood, K.E. & Goldman, E. (2005). What is the Evidence for Evidence-Based Treatments? A Hard Look at our Soft Underbelly. Mental Health Services Research, 7(1), 53-74.
  • Rauktis, M.E., Vides De Andrade, A.R., Doucette, A., McDonough, L. & Reinhart, S. (2005). Treatment foster care and relationships: Understanding the role of therapeutic alliance between youth and treatment parent. International Journal of Child & Family Welfare, 8(4), 146-163.
  • Weisz, J. (2006) Evidence-Based Practice in Child & Adolescent Mental Health: Recent News and My ESP on EBP. Keynote Address, CHARPP Conference [Children's Array of Psychiatric Programs], Portland, Oregon, September 11, 2006. Available on the CHARPP WebSite: http:www.charpp.org/index-2pr06.html

These three papers deal with various aspects of the current movement towards "evidence-based" practice in child mental health services. Jensen et. al. (2005) provide a detailed and thoughtful analysis on the difficulties involved in determin­ing the "active ingredients" in efficacious interventions. Rauktis et. al. (2005) report on empirical work in a youth-service setting focused on "therapeutic alliance"and the Weisz (2006) Powerpoint summary of his 2006 keynote address to CHARPP offers some useful, practical suggestions on introducing evidence-based practices in existing treatment settings.

  • Bullock, R., Courtney, M., Parker, R., Sinclair, I. and Thoburn, J. (2006). Can the Corporate State Parent. Children & Youth Services Review, 28(11), 1344-1358.
  • Munro, E., Stein, M., & Ward, H. (2005). Comparing how different social, political and legal frameworks support or inhibit transitions from public care to independence in Europe, Israel, Canada and the United States. International Journal of Child and Family Welfare, 8(4), 197-198.

These two papers deal with the relationship between state and family in carrying out parental responsibilities and about how varying socio-political-legal arrange­ments facilitate or impede positive developmental outcomes for certain children in care.

  •  Whittaker, J.K. (2004). The Re-Invention of Residential Treatment: An Agenda for Research & Practice. Child & Adolescent Psychiatric Clinics of North America: Special Issue on Residential Treatment (B.M. Leventhal, M.D., Editor). Elsevier Science, 13, 267-278.

A summary of issues and challenges facing contemporary residential treatment for children and youth.

  • Whittaker, J.K. (2005). Creating 'prosthetic environments' for vulnerable children: emergent cross-national challenges for traditional child & family services practice. In H. Grietens, W. Hellinckx & L. Vandemeulebroecke (Eds.), In the Best Interests of Children and Youth: International Perspectives (pp. 99-119). Leuven: Leuven University Press.

Makes the case for the "prosthetic environment" as a potential unifying construct in residential and non-residential child and youth mental health approaches.

  • Whittaker, J.K., Greene, K., Schubert, D., Blum,R., Cheng,K., Blum,K., Reed,N., Scott, K., Roy, R. and S.A. Savas (2006). Integrating evidence-based practice in the voluntary child mental health agency: a template for clinical and organizational change. American Journal of Orthopsychiatry, 76(2), 194-201.

Details a process of developing research capacity and integrating evidence-based practices in a multi-service child mental health agency.

  • Whittaker, J.K. & Maluccio, A.N. (2002). Re-thinking 'child placement': a reflective essay. Social Service Review, 76, 108-134.

A speculative, historical essay on the fixation in American child & family services policy and practice with "child placement" as a central, defining concept and the consequences thereof[1].

 

Contacts: James K. Whittaker, Ph.D., Charles O. Cressey Endowed Professor Emeritus, School of Social Work, University of Washington, 4101 15th Avenue N.E. Seattle, Washington 98105-6299, USA, jimw@u.washington.edu

 

[1]. Translated into Italian and published in Studi Zancan 6/2002.

 

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