Bringing evidence-based practice to community settings
Author: Michael Southam-Gerow, PhD, Editor of Spring 2013 CYF News
Child and adolescent treatment research has made impressive strides in the past several decades. Given startling statistics about the prevalence of mental health problems in youth (e.g., Merikangas et al., 2010), the negative long-term outcomes of youth who do not receive treatment for these problems (e.g., Copeland, Shanahan, Costello & Angold, 2009) and the unacceptable levels of unmet need (e.g., Tang et al., 2008), the accumulation of knowledge on what may work to help specific child/adolescent mental health problems (e.g., Chorpita et al., 2011) — i.e., the identification of evidence based treatments–has been encouraging. The next challenge the field faces concerns translating the success of the development of these treatments into the diverse community settings in which mental health services are delivered.
This challenge has led to the explosion of studies and the rapid growth of dissemination and implementation science. Although definitions of these two terms remain a matter of scholarly debate, dissemination is generally conceived of as the directed and planned spread of an innovation (e.g., a treatment approach) or as Chambers et al. (2005) wrote, the “targeted distribution of a well-designed set of information” (p. 323). Implementation refers to the process of adapting the treatment to fit a specific context (cf. Fixsen, Naoom, Blasé, Friedman & Wallace, 2005; Proctor et al., 2009). Both of these definitions are consistent with the definitions of these terms offered by National Institutes of Health (Glasgow, Vinson, Chambers, Khoury, Kaplan & Hunter, 2012).
Dissemination and implementation are related processes, both with the end goal of maximizing the yield from clinical science by identifying how to move programs with a strong evidence base into as many settings as possible, to help improve the lives of as many youth and families as possible. Of course, these processes are easier said than done. Efforts to test EBTs outside of research clinics have not consistently supported the conclusion that the EBTs produce superior outcomes to usual clinical care (e.g., Clarke et al., 2005; Southam-Gerow et al., 2010; Weisz et al., 2012).
However, even when studies suggest that EBTs can improve usual care, there remains the larger problem of taking the EBTs to scale. That is, assuming we identify EBTs that can improve usual care, how can we implement them across broad and diverse mental health service systems? Also, and relatedly, how do we inform systems, providers, and families about these EBTs? These questions are central to the four papers that comprise the special feature of this issue of the CYF News. Four independent groups of scientists report on their work disseminating and/or implementing EBTs across diverse practice settings and across the United States. One hope is that these four papers will stimulate discussion and action among scientists, policymakers and other stakeholders in the children’s mental health system. Each paper represents what we deemed to be a model of how to leverage scientific evidence in collaboration with community stakeholders to improve the quality of services provided.
In the first paper, Bernstein and colleagues describe their efforts to help Los Angeles County (LAC) solve a too-common problem in many systems: how to meet the needs of clients not served by the array of EBTs the county offered. The authors describe how their solution to this problem, a system called Managing and Adapting Practices (see Southam-Gerow et al., 2013), not only filled the gap, but became a preferred program among providers in the system, accounting for nearly 25 percent of all billing in the county after one year. Further, the program led to improvements in youth functioning on standardized measures.
In the second paper, Saldana and Chamberlain describe their efforts to bring two different EBTs for youth in foster care to scale. Using an experimental design, they tested the efficacy of two different implementation strategies across more than fifty counties in California and Ohio. In the paper, they also describe the importance of working closely with stakeholders throughout the process. Indeed, one ingredient of success for their work appears related to how well their programs fit needs that youth and families in the foster care system have.
In the first paper, the focus was on youth treated in the mental health system. In the second, the focus was on youth in foster care. In the third paper, the focus was on yet another distinct population: children in the child welfare system. Here, Aarons and Chaffin describe their collaboration with stakeholders in a large county in the state of Oklahoma to identify and implement an EBT. The paper focuses on an instructive set of lessons learned.
Finally, in the fourth paper, Chang and Nakamura describe their efforts in the state of Hawai‘i to develop and implement an online resource designed to help guide caregivers’ choices about mental health services. Working closely with stakeholders, especially caregivers, they describe how the consumer-centric “Help Your Keiki” website was born.
All four papers focus on dissemination and implementation of science-based treatments for children, youth and families. In addition, all four papers demonstrate the importance of close and ongoing collaboration among stakeholders to enhance success of the efforts. However, each is distinguished by its focus on a distinct population and each project achieved its aims using some unique strategies. In the end, though, each paper demonstrates that well-designed dissemination and implementation efforts can produce positive outcomes for children, youth and families.
In closing, as noted at the outset, I hope that these four papers stimulate conversation and action among scientists, policymakers and other stakeholders. Each of the four papers describes a project that represents a model for how dissemination and implementation research can be used to improve the lives of children, youth and families.
Chambers, D. A., Ringeisen, H., & Hickman, E. E. (2005). Federal, state, and foundation initiatives around evidence-based practices for child and adolescent mental health. Child and Adolescent Psychiatric Clinics of North America, 14, 307-327.
Chorpita, B. F., Daleiden, E. L., Ebesutani, C., Young, J. Becker, K. D., Nakamura, B. J., . . . Starace, N. (2011). Evidence-based treatments for children and adolescents: An updated review of indicators of efficacy and effectiveness. Clinical Psychology: Science and Practice, 18, 153– 172. doi:10.1111/j.1468-2850.2011.01247.x
Clarke, G., Debar, L., Lynch, F., Powell, J., Gale, J., O’Connor, E., . . . Hertet, S. (2005). A randomized effectiveness trial of brief cognitive- behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 888–898. doi:10.1016/S0890-8567(09)62194-8
Copeland, W. E., Shanahan, L., Costello, E. J., & Angold, A. (2009). Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Archives of General Psychiatry, 66, 764–772. doi: 10.1001/archgenpsychiatry.2009.85
Fixsen, D. L., Naoom, S. F., Blase ́, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, Fla.: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).
Glasgow, R. E., Vinson, C., Chambers, D., Khoury, M. J., Kaplan, R. M., & Hunter, C. (2012). National Institutes of Health Approaches to Dissemination and Implementation Science: Current and Future Directions. American Journal of Public Health, 102(7), 1274–1281. doi:10.2105/AJPH.2012.300755
Merikangas, K. R., He, J., Brody, D., Fisher, P. W., Koretz, D. S., Kathleen, A., Merikangas, R., et al. (2010). Prevalence and Treatment of Mental Disorders Among US Children in the 2001 – 2004 NHANES. Pediatrics, 125, 75–81. doi:10.1542/peds.2008-2598
Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services : An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36, 24–34. doi:10.1007/s10488-008-0197-4
Southam-Gerow, M. A., Weisz, J. R., Chu, B. C., McLeod, B. D., Gordis, E. B., & Connor-Smith, J. K. (2010). Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1043–1052. doi:10.1016/j.jaac.2010.06.009
Tang, M., Hill, K., & Boudreau, A. (2008). Medicaid managed care and the unmet need for mental health care among children with special health care needs. Health Services Research, 43, 882–900. doi:10.1111/j.1475- 6773.2007.00811.x
Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., ... Research Network on Youth Mental Health. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69, 274–282. doi: 10.1001/archgenpsychiatry.2011.147
Michael Southam-Gerow, PhD, is an associate professor of psychology and pediatrics at Virginia Commonwealth University (VCU). His research focuses on the dissemination and implementation of evidence-based treatments (EBTs) for mental health problems in children and adolescents. Dr. Southam-Gerow’s other research interests include the study of emotion processes (e.g., emotion regulation) in children and adolescents and treatment integrity research. He is associate editor of the Journal of Clinical Child & Adolescent Psychology and author of dozens of scholarly papers.