after integrated practices: complementary approaches to improving child services and outcomes bruce...
TRANSCRIPT
After Integrated Practices:Complementary Approaches to Improving Child
Services and Outcomes
Bruce F. Chorpita, Ph.D.Eric L. Daleiden, Ph.D.
March 18, 2008Burbank, CA
Agenda
Intros and acknowledgements
Background The “Evidence Based
System” The EBT Literature
PW EBS Database
Common elements The Clinical Dashboard Clinical Process
Modeling Modularity Results so far… Discussion
Traditional Approach to Evidence Based Practice
“Dissemination as Usual”
Assumes “replacement” approach Institutionalizes service programs Assumes an evidence base for all problems Assumes unlimited resources and learning
capacity
More Concerns
Fixed content Fixed intensity Fixed length Single target
approach
Too few choices Too many choices Expiration problem
Aarons (2004); Addis & Krasnow (2000); Addis, Wade, & Hatgis (2004); Chorpita, Daleiden, & Weisz (2005); Kimhan & Chorpita (2006); Persons (1995)
Throw out the Bath Water:Keep the Baby
Move away from the idea that “Problem A gets Treatment B”
We decided to map the decisions made at the service system level – not just the IF-THEN of treatment selection
Goal: To build an Evidence Based System
Alternative:The Evidence Based System
Selecting a program structures other decisions
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Selecting a program structures other decisions
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Multisystemic Therapy (MST) Example
Home & Community Based
TAMS & SAMS
Instrumental &Ultimate Outcomes
MST
4 – 5 Members
Team Supervisor
Cross-Team Supervisor
Family Therapy, etc.
How should we select a program?
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
How should we select a program?
GeneralServicesResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Evidence-Based Services Model
How should we select a program?
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Individualized Case Conceptualization Model
How should we select a program?
LocalAggregateEvidence
Case-SpecificHistorical
Information
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Practice-Based Evidence Model
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Traditional EBS ModelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Tx Program Selection
Valid alternatives to deciding by program?
GeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Common Elements Approach
Stay tuned…
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
A Brief Aside on Evidence Bases
The Phases of Evidence
1. Data: Discretely identifiable units
2. Information: Data in a context that provides it meaning
3. Knowledge: Information helpful to decision-making
4. Wisdom: Knowing when to apply our knowledge
Speigler, I. (2000). Knowledge management: A new idea or a recycled concept? Communications of the Association for Information Systems, 3, 1 – 23.
The Phases of Evidence: Example
1. Data: 65
2. Information: 65° F
3. Knowledge: It warm enough for me to wear a T-shirt.
4. Wisdom: I will be giving a professional talk, so the temperature outside is irrelevant to my attire.
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
General Services Research:Turning Data into Knowledge I
Meta Analysis of Children’s Treatment Research 322 studies 41 years 832 study groups 25,435 youth participants $407 million in today’s dollars Largest meta-analysis to date Automated for practitioners
ANXIETY145 protocols, 18 treatment families
Results: Anxiety
Best Support CBT (26) Exposure (24) Modeling (7) Education (2)
Good Support Cognitive Behavior Therapy
with Parents (2) Relaxation (2) Cognitive Behavior Therapy
and Meds (1) Hypnosis (1) Assertiveness Training (1)
Results: Anxiety
Attention Client Centered Therapy EMDR Relationship Counseling Teacher Psychoeducation
No Support
ATTENTION & HYPERACTIVITY67 protocols, 18 treatment families
Results: Attention & Hyperactivity
Best Support Self verbalization (4) Behavior Therapy and
Medication (2)
Good Support Parent Management Training (5) Contingency Management (4) Physical Exercise (3) Biofeedback (2) Social Skills and Meds (2) Relaxation and Exercise (1) Parent Management Training and
Problem Solving (1) Education (1)
Results: Attention & Hyperactivity
Client Centered Therapy Self-Control Training Skill Development Parent Management Training and
Self-Verbalization*
No Support
AUTISM SPECTRUM21 protocols, 3 treatment families
Results: Autism Spectrum
Intensive Behavioral Treatment (4) Intensive Communication Training (3)
Best Support
Results: Autism Spectrum
Auditory Integration Training
No Support
DEPRESSION39 protocols, 15 treatment families
Results: Depression
Best Support Cognitive Behavior Therapy
(12) Cognitive Behavior Therapy
and Medication (2)
Good Support Interpersonal Therapy (2) Relaxation (2) Cognitive Behavior Therapy with
Parents (2) Client Centered Therapy (1) Family Therapy (1)
Results: Depression
Attention Counselors Care Counselors Care plus Anger Management Life Skills Problem Solving Social Skills
No Support
DISRUPTIVE BEHAVIOR173 protocols, 34 treatment families
Results: Disruptive Behavior
Best Support Parent Management Training (26) Contingency Management (9) Multisystemic Therapy (9) Social Skills (6) Cognitive Behavior Therapy (6) Assertiveness Training (2)
Good Support Problem Solving (7) Communication Skills (3) Relaxation (2) Parent Management Training and Problem
Solving (2) Client Centered Therapy (2) Anger Control (2) Rational Emotive Therapy (1) Multidimensional Treatment Foster Care
(1) Functional Family Therapy (1) Transactional Analysis (1)
Results: Disruptive Behavior
Assertiveness Training Attention Catharsis Collaborative Problem Solving Education Exposure Family Empowerment Family Systems Therapy
Group Therapy (!!) Life Skills Project CARE (!!) Psychodynamic Self Verbalization Skill Development
No Support No Support
TRAUMATIC STRESS16 protocols, 7 treatment families
Results: Traumatic Stress
Best Support Cognitive Behavior Therapy with
Parents (5)
Good Support Cognitive Behavior Therapy (4)
Results: Traumatic Stress
Client Centered Therapy Cognitive Behavior Therapy with Parents Only EMDR
No Support No Support
BREAK
THE PW DATABASEHow do I keep track of all this information?
Live Demo Possible?
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Treatment Team
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Supervision
ClientProgress
TreatmentIntegrity
General Services Research:Turning Data into Knowledge II
Common Elements approach Identified components of evidence based
practices Complements integrated program
approach
Is there a different level of analysis?
Protocol Protocol Protocol
Family
Is there a different level of analysis?
IncredibleYears
PCITDefiant Children
Parent Training
Is there a different level of analysis?
Protocol Protocol Protocol
Family
PracticeElement
PracticeElement
PracticeElement
PracticeElement
PracticeElement
PracticeElement
Is there a different level of analysis?
Incredible Years
PCITDefiant
Children
Parent Training
Commands CommandsAttending
Time Out
Rewards
Time Out
These are “practice elements.
”
Example
Attending
Objectives: to increase the amount of positive attention provided to the child, even if the child has misbehaved
at other times during the day
to teach the caregiver to attend to positive behaviors
to promote the child’s sense of self-worth
Steps:
Provide rationale Emphasize the importance of providing positive attention to the child. Elicit the caregiver’s opinion about how attention affects behavior and
people’s motivation to do a good job. Have the caregiver describe his or her best and worst “managers”
and the caregiver’s motivation to work for each. Lead the caregiver to recognize that how he or she was treated
affected the caregiver’s desire to work. Discuss how the child’s behavior may be affected by the caregiver’s
behavior towards the child and how the child’s desire to behave can be increased by improving the caregiver-child relationship.
Set aside one-on-one time for caregiver and child
Encourage the caregiver to set aside a block of time (e.g., 10 minutes) each day devoted to joining the child in an activity the child has chosen.
Teach caregiver to provide positive and descriptive commentary
Show the caregiver how to demonstrate sincere interest in the child’s activities while they are playing.
Instruct the caregiver to provide enthusiastic descriptive (e.g., “You are drawing a tree”) and/or positive (e.g., “I like the way you stacked the blocks”) commentary and praise regarding the child’s behavior.
Encourage caregiver to engage in child’s activity
Suggest that the caregiver become actively involved in the play activity by imitating the child’s behavior in order to demonstrate approval.
Restrict criticism, questions, and commands
It is important that the child lead the activity; that is, the caregiver should refrain from making suggestions, asking questions, and criticizing the child.
Allow the child to use his or her imagination (e.g., coloring the green or making up new rules to a game) without caregiver input about the “correct” way to do things.
Anticipate difficulties When the procedure is initially implemented, the child may engage in negative behavior that characterizes the usual caregiver-child interaction. When this occurs, the caregiver should:
consistently ignore negative behavior by looking away; refrain from scolding the child so as to avoid providing negative
attention for misbehavior; end one-to-one time if disruptive behavior continues or is
dangerous. Over time, however, it is expected that consistent positive attending will result in decreased negative behavior and increased positive caregiver-child interactions.
Attending
Use This When:
To improve the quality of the caregiver-child relationship.
Practitioner Guide
For CaretakerFor Caretaker
Anxiety
ADHD
Autism
Depression
Disruptive Behavior
Disruptive Behavior
TraumaticStress
BREAK
The full system modelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
Case Specific History:Turning Data into Knowledge III
Clinical Dashboard Progress Practices
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child
Mother
Father
Other
Progress Measure:
Fear rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child
Mother
Father
Other
Progress Measure:
Fear rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
A Foray into Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, EBS DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
This tells you the treatment types that work for this problem.
This tells you the practice elements associated with those treatment types.
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child
Mother
Father
Other
Progress Measure:
Fear rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
Do the practices fit the problem?
A Bit of Practice Wisdom
ClinicalProgress?
Clinical Dashboard:Progress Pane
Continue plan until goals met
Significant concerns?
Critical Incidents & Complaints
Reports, etc.
Consult with specialists as
needed
yes
no
no
yes
no
yes
no
yes
Clinical Dashboard:Practice Pane, EBS DB
Prob. w/ TxSelection?
TreatmentIntegrity?
Therapy Protocols,Dashboards, PW DB,
ConsultationConsider adding consultation or
training supports
Identify barriers and revise plan
Options1. Increase supports2. Change Intervention3. Further Consultation4. Add intervention
EBS DB, Local Best Practices, Tx Team
New Case?
no
yes Select Evidence-Based Service (EBS)
EBSDatabaseStart
Individual Case Supervision Form Case Number: 6
Age: 12 Diagnosis: Generalized Anxiety Disorder Gender: M
Child
Mother
Father
Other
Progress Measure:
Fear rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
Days Since First Event
0 10 20 30 40 50 60 70 80 90 100
0
1
2
3
4
5
6
7
8
0 10 20 30 40 50 60 70 80 90 100
Select new practices?
Seek Consultation?
Handling Caseloads
Handling Caseloads
Handling Caseloads
Handling Caseloads
Handling Caseloads
Age: 14 Diagnosis: Depression Gender: M
Child
Mother
Father
Other
Progress Measure:
Mood Rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
0 10 20 30 40 50 60 70 80 90 100 110 120
0
1
2
3
4
5
6
7
8
9
0 10 20 30 40 50 60 70 80 90 100 110 120
Caseload Supervision Form Therapist Number: 15
Child
Mother
Father
Other
Progress Measure:
Mood Rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
0
1
2
3
4
5
6
7
8
9
Handling Caseloads
Caseload Supervision Form Therapist Number: 15
Child
Mother
Father
Other
Progress Measure:
Mood Rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
0
1
2
3
4
5
6
7
8
9
Caseload Supervision Form Therapist Number: 15
Child
Mother
Father
Other
Progress Measure:
Mood Rating
Rewards
Commands
Time Out
Praise
Problem Solving
Parent Monitoring
Response Cost
Ignoring/DRO
Stimulus Control/Antecedents
Attending/Directed Play
Modeling
Cognitive
Parent Psychoeducation
Self-Monitoring
Relaxation
Exposure
Maintenance
Psychoeducation
Activity Scheduling
Skill Building
Social Skills
Self Monitoring
Other
Other
Other
Other
Other
Other
Other
Other
0
1
2
3
4
5
6
7
8
9
BREAK
MODULARITY IN PRACTICE
Modular CBT for Anxiety
FearLadder
Social Skills
Rewards
LearningAbout
Anxiety
Practice
CognitiveRestructuring
Maintenance
Finish
FearLadder
Practice:In Vivo
LearningAbout
Anxiety
Practice:Imaginal
in vivo possible?
more items to practice?
Maintenance
yes
yes
yes
no
noFinish
no
FearLadder
In VivoExposure
LearningAbout
Anxiety
ImaginalExposure
child ready to practice?
in vivo possible?
more items to practice?
Maintenance
yes
yes
yes
no
noFinish
Interference
noyes
FearLadder
Social Skills:MeetingPeople
Time Out
ActiveIgnoring
Rewards
In VivoExposure
LearningAbout
Anxiety
ImaginalExposure
CognitiveRestructuring:
Probability
CognitiveRestructuring:
STOP
Social Skills:Nonverbals
child ready to practice?
mild disruptivebehavior?
lowmotivation?
parents rewardingavoidance?
negativebeliefs or
depression?
moderatedisruptivebehavior?
in vivo possible?
more items to practice?
Maintenance
social skillsdeficits?
other
CognitiveRestructuring:Catastrophic
bright, verbal, or older?
troubleshoot
yes
yes
yes
no
no
noFinish
Modular CBT Outcomes
Small N experimental design Better than monitoring control 7 of 7 diagnosis free at post 6 of 7 diagnosis free at follow-up
Modular CBT for Anxiety
Modular CBT for Anxiety
MATCH-ADC:Modular Approach to Therapy for Children
MATCH-ADC
M O D U L A R A P P R O A C H T O T H E R A P Y F O R C H I L D R E N
W I T H A N X I E T Y , DE P R E S S I O N O R C O N D U C T P R O B L E M S
THERAPIST MODULES
Bruce F. Chorpita, Ph.D. John R. Weisz, Ph.D.
Three Steps
Social Skills
Cognitive: BLUE
Skill Building
Relaxation
Activity Selection
Problem Solving
Psychoed Child
Psychoed - Parent
Covert Relaxation
Wrap up
Cognitive: FUN
Three Steps
Complete next in sequence
Interference
Evaluate & Triage
Yes
No
Able to proceed
Yes
No
Social Skills
Cognitive: BLUE
Skill Building
Relaxation
Activity Selection
Problem Solving
Psychoed Child
Psychoed - Parent
Covert Relaxation
Wrap up
Cognitive: FUN
GainsComplete
Three Steps
Complete next in sequence
Exposure
FearRelated
BehaviorRelated
Interference
OtherEvaluate &
Triage
Yes
No
Able to proceed
Yes
No
Commands
Active Ignoring
Time Out
Rewards
Anticipating Problems
Noncompliance
Specific Triggers
AttentionSeeking
LowMotivation
SeriousBehavior
Social Skills
Cognitive: BLUE
Skill Building
Relaxation
Activity Selection
Problem Solving
Psychoed Child
Psychoed - Parent
Covert Relaxation
Wrap up
Cognitive: FUN
GainsComplete
Child STEPs Treatment Project
Youth Network on Child Mental Health 5-Year, multisite randomized trial
Boston, Honolulu Anxiety, Depression, Conduct Problems Community therapists SMT, MMT, Usual Care 180 children enrolled so far
Training Results
p < .01
Treatment Results
Preliminary results look promising…
Other Efforts
Minnesota Department of Human Services Hawaii Child and Adolescent Mental Health
Division
Objectives: to educate the child about how anxiety works in order to build a rationale for activities to follow
to instill optimism about the child’s situation
to encourage participation in treatment
Steps:
Get a common vocabulary State that you will be talking about anxiety today, and begin by asking the child for his or her definition of anxiety. Elicit words that might mean the same thing as “anxiety.” Praise the child’s definitions and incorporate them into your own.
Explain the three parts to anxiety
Explain to the child that anxiety has three parts to it: What we THINK, what we FEEL, and what we DO.
Examples of thoughts Have the child come up with examples of thoughts the child has when feeling scared (e.g., write scared thoughts in cartoon thought bubbles).
Examples of feelings Come up with a list of feelings that the child has when feeling scared (e.g., make a drawing and label parts of the body that feel different when anxious).
Examples of behaviors Ask the child what kinds of things people do and what he or she does when scared. Go through several examples, if necessary.
Normalize the emotion of anxiety
Point out that anxiety is an emotion that all people experience. Ask the child whether he or she thinks anxiety is good or bad. Elicit the reasons why the child thinks this way about anxiety. Praise the response and indicate that the child is right, but then
ask whether anxiety could really be both good and bad. Make the point that anxiety can serve many functions, and that it
is often a good thing to have because it prevents us from getting into dangerous situations or getting hurt.
Introduce the alarm analogy
One way that we can think about anxiety is as an alarm. Ask the child if he or she can think of any other kinds of alarms (e.g., fire alarms, burglar alarms). Ask him or her what these alarms do (i.e., warn us that something bad or dangerous might be about to happen). Praise the child’s efforts to come up with examples of alarms and what they do.
Discuss different degrees or “stages” of anxiety
The first stage of the anxiety alarm is a warning that something bad might be about to happen. It can be just like a yellow light that says “watch out.” The second stage of our alarm system tells us that the danger is here right now. This stage would be like a red light, which tells us that there is real trouble.
Child Psychoeducation: Anxiety
Use This When:
To introduce a course of treatment for anxiety or phobias.
Practitioner Guide
For ChildFor ChildSample Practice
Element from Practitioner Guide
Sample Practice Element from
Practitioner Guide
Objectives: to educate the child about how anxiety works in order to build a rationale for activities to follow
to instill optimism about the child’s situation
to encourage participation in treatment
Steps:
Get a common vocabulary State that you will be talking about anxiety today, and begin by asking the child for his or her definition of anxiety. Elicit words that might mean the same thing as “anxiety.” Praise the child’s definitions and incorporate them into your own.
Explain the three parts to anxiety
Explain to the child that anxiety has three parts to it: What we THINK, what we FEEL, and what we DO.
Examples of thoughts Have the child come up with examples of thoughts the child has when feeling scared (e.g., write scared thoughts in cartoon thought bubbles).
Examples of feelings Come up with a list of feelings that the child has when feeling scared (e.g., make a drawing and label parts of the body that feel different when anxious).
Examples of behaviors Ask the child what kinds of things people do and what he or she does when scared. Go through several examples, if necessary.
Normalize the emotion of anxiety
Point out that anxiety is an emotion that all people experience. Ask the child whether he or she thinks anxiety is good or bad. Elicit the reasons why the child thinks this way about anxiety. Praise the response and indicate that the child is right, but then
ask whether anxiety could really be both good and bad. Make the point that anxiety can serve many functions, and that it
is often a good thing to have because it prevents us from getting into dangerous situations or getting hurt.
Introduce the alarm analogy
One way that we can think about anxiety is as an alarm. Ask the child if he or she can think of any other kinds of alarms (e.g., fire alarms, burglar alarms). Ask him or her what these alarms do (i.e., warn us that something bad or dangerous might be about to happen). Praise the child’s efforts to come up with examples of alarms and what they do.
Discuss different degrees or “stages” of anxiety
The first stage of the anxiety alarm is a warning that something bad might be about to happen. It can be just like a yellow light that says “watch out.” The second stage of our alarm system tells us that the danger is here right now. This stage would be like a red light, which tells us that there is real trouble.
Parent Psychoeducation
Use This When:
To introduce a course of treatment for anxiety or phobias.
Practitioner Guide
For CaretakerFor Caretaker
One Size Does Not Fit All
Dashboards Protocols Evidence Review
Hawaii CAMHD CAMHMIS PW Practitioner’s Guide; Integral protocols (e.g., MST)
EBS Biennial Report; Blue Menu
Minnesota DHS MS Office Version PW Practitioner’s Guide
PW EBS Website
Child STEPs STEPs MCTP MIS MATCH-ADC MacArthur Phase I
University of Hawaii
MS Office Version MATCH-ADCModular CBT
EBS Biennial Report; Blue Menu
Each also has unique decision model…
Results in HawaiiFrom Daleiden, Chorpita, Arensdorf, Donkervoet, & Brogan (2006)
Youth Receiving Hospital-Based Residential Services
96
80
56
30 28
37
0
20
40
60
80
100
FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005
Fiscal Year
Yo
uth
per
Qu
arte
r (M
ean
)
Avoid Hospital Residential Services for Conduct Disorders: MST Initiative
MSTBegan
EBS TaskForce Began
33
17
51
9587 90
0
20
40
60
80
100F
Y19
96
FY
1997
FY
1998
FY
1999
FY
2000
FY
2001
FY
2002
FY
2003
FY
2004
Fiscal Year
Acc
epta
ble
Rat
ing
(C
om
ple
x %
)
Complexes Meeting Quality Standards for System Performance
Quality Reviews: System Performance
Quality Dimension Examples: Functional Assessment Service Coordination & Transition Long-term view Caregiver Supports Service Plan & Implementation Effective Results Service Array & Integration Monitoring & Modification
48 48
61
8074
8589
94 94
0
20
40
60
80
100F
Y19
96
FY
1997
FY
1998
FY
1999
FY
2000
FY
2001
FY
2002
FY
2003
FY
2004
Fiscal Year
Acc
epta
ble
Rat
ing
(C
ase
%)
Cases Rated as Acceptable in Child Status
Quality Reviews: Child Status
Quality Dimension Examples: Learning Progress Community Home Personal Responsibility Caregiver Functioning Safety/Personal Well-being Child/Family Satisfaction Emotional/Behavioral Well-being
Rate of Improvement?
CAFAS 8-Scale Total
-1.1
-1.5-1.3 -1.3
-1.4-1.7 -1.8 -1.8
-2.3 -2.3-2.6 -2.6
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
2002.12002.22002.32002.4 2003.12003.22003.32003.4 2004.12004.22004.32004.4
Fiscal Quarter
Ch
ang
e p
er M
on
th(M
+/-
SE
)
Final Effect Size for Change = .07/mo, .84/yr
Getting Better at Getting Them Better
Expected Rate of Improvement Across Time
0
30
60
90
120
150
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Months Since Intake
CA
FA
S 8
-Sca
le T
ota
l (M
ean
)
End of2004
Start of2002
127
97 9991
149
119
0
20
40
60
80
100
120
140
160
2001
2002
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
2001
2002
2003
2004
Ave
rag
e S
core
HospitalResidential
CommunityResidential
TherapeuticGroupHome
TherapeuticFosterHome
CAFAS 8-Scale Total Scores within 45-days of Admission to Specific Service
MultisystemicTherapy
IntensiveIn-Home
Greater Impairment Treated at Less Restrictive Levels of Care
Cost per Outcome
$4,640$3,535
$2,087$1,080 $654 $564
$12,477
$9,325
$6,828
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,00020
02
2003
2004
2002
2003
2004
2002
2003
2004
Exp
en
dit
ure
s (U
S$)
CALOCUSLevel of Care
(0 - 5)
ASEBAParent CBCL
T-Score
CAFAS8-Scale Total
(0 - 240)
Service Expenditures per Unit of Improvement(Annual Cost per Youth / Average Annual Rate of Improvement)
On the Horizon…
Distillation tree
Relevance mapping
Better understanding of known risks
Summary
Modeling the clinical decision process Multiple evidence bases Dashboards Common elements Modularity Emphasis on the system, not just the
Treatment
Review and Discussion
Review and Discussion
What seems promising?
What doesn’t?
What are the primary current and future needs of agencies in CA?
Are there ways to structure practice development efforts across multiple agencies or counties?
Are there economies of scale for new initiatives?
Is there interest in research collaboratives or partnerships?
Thank you!
Contact Information
[email protected] [email protected] (after July 1) [email protected]
http://www.practicewise.com