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Have a Challenging Child? Evidence-Based Therapy May Help You Cope

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by Stacey Burling, STAFF WRITER

Amy Herschell and Kristen Schaffner,  experts at taming particularly difficult children, described the kind of kid who gets referred to the treatment model they espouse, one that harnesses the power of parental attention:

He’s 5 and in danger of being thrown out of day care.  He’s mean to other kids in his class and his siblings.  He refuses to do what adults tell him to do.  He throws things or spits or bites or swears.  He has tantrums.  His problems are so consuming, his  parents’ jobs are at risk.  No one wants to be his babysitter. No one wants to be his friend.

It’s the kind of behavior that puts a kid on a bad path that some never get off. Herschell and Schaffner say a program that coaches parents to reward good behavior and ignore bad, to discipline consistently and effectively, can quickly transform even that hypothetical child into one whose behavior is better than average.

The duo, who both work at the University of Pittsburgh and West Virginia University, along with Sarah Taber-Thomas, clinical assistant professor at the University of Buffalo, spent three days in Philadelphia this month teaching therapists and managers at Community Behavioral Health about Parent-Child Interaction Therapy (PCIT). Though the program was developed in the 1970s, it has only recently begun spreading from universities to community treatment centers.   The approach has been shown to improve children’s behavior both at home and at school and to reduce parental depression and stress. Studies found that the results persisted for years.

CBH offered the training to seven agencies that provide services to its Medicaid clients (there were also a few trainees from Chester County) as part of its effort to expand access to treatments that are proven to work, said Ronnie Rubin, director of CBH’s Evidence-Based Practices and Innovation Center.  While translational medicine — the effort to move cutting-edge science more quickly from bench to bedside — has been trendy in the medical world for several years, Rubin said it has been slower to take off in mental health care.

Herschell said there has been widespread interest in PCIT in Pennsylvania. About 100 agencies have some workers who have  had training. Philadelphia, she said, has given an unusual amount of support at the county level.

PCIT consists of two parts delivered over 10 to 20 sessions  that last an hour or so.  In the first, a therapist helps a parent create a stronger, warmer bond with the child.

They focus on discipline in the second.  Most of the work is between the parent and child. They play — the child decides how — while a therapist watches behind a one-way mirror, coaching the parent, who wears a “bug” in the ear.

The goal is to praise the child for behaving well.  Maybe he sat still for a while or drew something creative.  If he has a tantrum, Mom can focus on drawing her own picture until he’s ready to interact nicely again.  The coach may suggest what to say and do with the child but also praises the parent. “Great labeled praise,” the coach might say, or “I like the way you’re following his lead.”  The coach, Schaffner said, is “working on shaping the parent behavior just like they’re trying to shape the child behavior.”

That voice in the ear is a key difference between PCIT and other efforts to help parents manage difficult children.

“Coaching is where the magic happens,” Schaffner said. “It’s amazing how powerful it is.”

Herschell said that children in PCIT programs typically start out doing what their parents ask only about 30 percent of the time.  Average kids have compliance rates of 60 to 70 percent.  By the time the program ends, PCIT graduates are doing what they’re asked 80 to 90 percent of the time, she said.

Some of this sounds like advice you’d get in any parenting program,  but the experts said children who need PCIT really are more challenging than other kids.

Rubin said that in PCIT, parents are taught the sorts of things therapists learn in advanced classes. “It’s like good parenting on steroids,” she said.

Some children truly are harder to parent, and a mismatch between parenting style and the child’s temperament can bring out the worst in both of them.

“Negative behaviors pull for negative attention,” Taber-Thomas said.  “Over time, that spirals.”

Parents sometimes have trouble seeing the good in a child who misbehaves a lot, Rubin said. The program helps parents reconnect with all the good things their child is doing and to appreciate them.  That helps the child relax and feel closer to the parent.

“We’re making the parent’s attention more powerful and more strategic,” Herschell said.

The beauty of PCIT, the trainers said, is that it “empowers” parents to change their children’s lives and, as a consequence, their own.

“The difference is those therapeutic skills are being given to the parents as an agent of change,” Rubin said.

The PCIT trainers will be back early next year to teach workers about the discipline phase, but Rubin hopes agencies will begin offering the program immediately to 2.5- to 7-year-olds and their parents.  People who are interested in participating in the program or referring patients to it can call 888-545-2600.   A brochure on PCIT can be found here.  And a link to a map of Philadelphia PCIT providers and their contact information is here.

EPIC Seminar Series: Making Your EBP Stick for the Long Haul!

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The 2016 EPIC Seminar Series is focused on the theme of implementing evidence-based practices (EBPs) in community behavioral health settings. These presentations are geared toward behavioral health administrators and clinicians who are interested in an exploration of the latest topics in the field of evidence-based practice and implementation science. Seminars will cover a range of issues that cut across EBPs, including organizational, cultural and practice change factors related to successful implementation of EBPs.

Torrey Creed, Ph.D. will join us to share concrete ideas about what it takes to keep your EBP or innovative practice going. Dr. Creed will share key insights into what sustainability is, why it doesn’t happen automatically, and how to make it more successful.

About our Presenter:
Torrey A. Creed, PhD. is an Assistant Professor in Psychiatry at the University of Pennsylvania’s Aaron T. Beck Psychopathology Research Center. As the director of The Beck Community Initiative at Penn, she leads a large-scale implementation program to increase community access to evidence-based cognitive behavioral therapy (CBT). This program implements CBT in community services with diverse populations, presenting problems, and levels of care. Dr. Creed has traveled nationally and internationally to deliver tailored training in CBT. Her co-authored book, Cognitive Therapy for Adolescents in School Settings, is used as a guide for mental health services in Philadelphia and other public schools. Dr. Creed’s primary research interests are the adaptation, implementation, and sustainment of CBT for community mental health settings, and the role of recovery and resilience in behavioral health.

Penn Study Finds Drawbacks to Cost-Saving Measures in Public Mental Health Clinics

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We would like to call your attention to recent research on the impact of staffing models on the delivery of behavioral health services. The study, conducted by partners at the University of Pennsylvania, Center for Mental Health Policy and Services Research, is one of the first to investigate the relation between independent contractor employment status and service quality, specifically attitudes and knowledge of Evidence-based Practices (EBPs). They found that independent contractors had less knowledge and more negative attitudes about the use of EBPs. In qualitative interviews, agency leadership indicated that there is less investment in training and professional development for contract employees due to concerns about turnover and contract employees’ reluctance to engage in non-billable activities.

While the research stops short of finding that the use of independent contractors results in lower quality of care, this is an area of significant concern for our system. We understand that providers are turning to this staffing model to address financial challenges; however, there are important clinical implications of this staffing model. Independent contractors, including non-licensed clinicians, are not afforded professional development, training, supervision and support to ensure the delivery of quality services.

This staffing model also impacts workforce turnover, stability and continuity of care for service recipients. As a system, our priority is effective and efficient service delivery, which includes incorporating evidence-based practices.

As you know, we have been discussing staffing models for quite some time and this study serves to reinforce this important point. We need to identify strategies to support the development of a highly skilled workforce and address this staffing trend. To that end, we will be taking a number of steps to address this issue, such as:

  • Looking to address financial challenges and concerns related to staffing
  • Engaging you, and other provider agencies, to solicit additional input and recommendations
  • Including expectations that all staff receive supervision and professional development throughout all of our policies

To learn more about the study, please take a look at a recent media article in the Philly Voice. Additionally, we encourage you to learn more about DBHIDS’ Evidence-based Practice and Innovation Center to better understand how we aim to work with you to further promote the delivery of behavioral health evidence-based practices throughout Philadelphia.

Frequently Asked Questions

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Frequently Asked Questions
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Frequently Asked Questions: Evidence-Based Practices

Please click through the questions below for answers to frequently asked questions. If you have a question that doesn’t appear below, please feel free to share at epic_dbhids@phila.gov.

You can learn more simply by clicking on each FAQ.

What is an evidence-based practice?

An evidence-based practice (EBP) is a specific treatment technique, model, or program that has been shown, through research, to improve outcomes.

The term, evidence-based practice, also refers to the process of integrating:

  • the best available research
  • with clinical expertise
  • in the context of patient characteristics, culture, and preferences

EBP_FAQ_1

A free downloadable handout is available providing more information on understanding EBPs.

(Definition from the American Psychological Association, 2006.)

What are the advantages to using EBPs?

There are many advantages to using EBPs. We have highlighted four key examples below.

  1. Help promote recovery and resilience. A recovery and resilience oriented system of care:
    • Supports people in achieving their goals to live, work, learn and participate in their communities.
    • Recognizes that services and supports should include multiple pathways to recovery based on an individual’s unique strengths as well as his or her needs, preferences, experiences, and cultural background.
    • Has the benefit of, and is grounded in, the best available science.
  2. Increase the likelihood of a program working by providing structure and a focus on services that achieve meaningful change.
  3. Support the development of competence and confidence among service providers by equipping them with tools that work.
  4. Provide hope to families by offering treatments that have been proven to work.

EBPs are tools that should be offered in the context of recovery frameworks and individualized treatment. Learn more about this perspective by checking out the DBHIDS Practice Guidelines.

What is the “evidence”?

The “evidence” that a particular practice is effective is collected through research studies that measure the outcomes of the practice. The most rigorous research studies are called Randomized Control Trials. When there is an accumulation of research evidence from several research studies showing that a specific practice helps people get better, it can be considered an evidence-based practice.

Are there different levels of evidence?

Yes, some practices have not been evaluated through multiple rigorous research studies, but have shown some success in helping people improve through other types of evaluations. As the research evidence for different practices is still being developed, DBHIDS recognizes that there is a continuum of research evidence.

EBP_FAQ_2

Evidence-Based Practice:
A practice that has been demonstrated to be effective through an accumulated body of well-designed research studies conducted by more than one research team in diverse settings and populations.

Evidence-Supported Practice:
A practice that has demonstrated positive outcomes in a limited number of research studies or in studies that use quasi-experimental designs. This could also include a practice that has a strong body of research support but is being delivered to different population or in a different setting.

Promising Practice:
A practice that has demonstrated some positive outcomes through evaluation or research but those studies are limited in their research methodology and the practice has not yet been evaluated through more rigorous or generalizable methods.

How do providers ensure that EBPs are delivered with quality?

While there are many factors to consider when thinking about the quality delivery of an EBP we have detailed three frequently used terms below.

Fidelity

An important feature of EBPs is that the elements of the practice are clearly articulated so that they can be delivered consistently. This is often done through specific training expectations and the use of a manual or protocol to guide treatment delivery. This is important because it allows a researcher to be sure that the outcomes achieved are due to the specific practice. It also provides a roadmap for how a treatment provider should deliver the practice in order to achieve similar outcomes. In other words, an EBP is delivered with “fidelity” when care is taken to ensure that it is delivered as it was designed in the research studies.

Fit

The success and sustainability of an EBP starts with selecting a practice or program that fits with your organization, population, or community. Fit impacts things like how well the innovation is adopted at an agency, and how effective it is for the intended population. Below are a few examples of the kinds of fit questions you may want to think about.
How does this program fit with:

  • The population that we serve
  • The mission, vision and values of my agency and community
  • Our organizational resources and readiness
  • Staff skills and structure
  • Existing initiatives

To read more about fit you can check out this ASPE Brief on contextual fit, this infographic that highlights fit and offers additional useful resources, or this hexagon tool created by the National Implementation Research Network (NIRN).

Adaptations

Adaptation is the process of making changes to an evidence-based practice or program in order to make it more suitable for a particular population, setting or structure without compromising or removing its core components. Adaptations to EBPs need to be done systematically and thoughtfully to ensure that the treatment isn’t compromised. Fortunately, some minor adaptations can be done without changing core elements.
Examples:

  • Adapting language/examples that are relevant to age or culture when teaching skills (e.g making the words, images, and scenarios inclusive of all participants).
  • Considering cultural norms when presenting coping methods or skills (e.g. faith or spiritual approaches, expressivity when communicating, respect for elders).

You can read more about making thoughtful adaptations by using this guide for adapting evidence-based programs or this tip sheet.

Are EBPs being developed in diverse communities such as ours?

Yes, in fact in recent decades research funders have begun to expect more culturally diverse samples. They have also begun to require that research be conducted in “real world” communities to ensure that the treatment and trainings developed are relevant and feasible. Here in Philadelphia we’ve seen more researchers interested in doing research in our community settings.

You can also learn more by visiting the general registries section on the EPIC Resources page. Many EBP registries provide descriptive information about where and with whom the practice or intervention has been researched. These categories include things like: age, race/ethnicity, geographic location, settings, gender, and many more.

What is implementation science? How does that relate to EBPs?

The definition of implementation is: “a specified set of activities designed to put into practice an activity or program of known dimensions.” Implementation Science is a field of research that aims to identify concrete strategies for how to implement and sustain a practice; these may include supports such as training, coaching, or infrastructure.

Implementation Science is important when talking about EBPs because evidence-based programs aren’t much help unless we can put them into everyday practice and produce the same positive results that they produced during the research process. Implementation Science helps us understand HOW to make use of the interventions and programs that have been identified as effective. Read more about implementation science, or watch this quick implementation overview for more information.

(Definition from the National Implementation Research Network, 2016.)

How does clinician expertise factor into the delivery of EBPs?

Clinician expertise isn’t just a factor in the delivery of EBPs – it’s an imperative. EBPs sometimes get unfairly judged as “cookbooks” because they provide written structures, but within those structures practitioner success depends on their own experience, judgment, and skills.

A clinician using an EBP is analogous to an architect building a house. The architect needs to follow formulas and plans regarding important structures like the foundation and weight bearing walls, but what the house looks like in the end is determined by the creativity and skill set of the architect.

Practitioner experience, knowledge and skill form the basis for: client engagement, assessment of contributing factors to behaviors of concern, delivery of intervention, and so forth. Clinician expertise is the foundation by which the successful delivery of EBPs is built.

I am seeking services for myself / my family, what do I need to know about seeking evidence-based practices?

You can find lots of useful resources under the family section of our resource section, but here are two resources that we find particularly useful.

  • The Parents Guide to Getting Good Care helps walk you through the steps of finding the best professional (or team) and the most appropriate treatment.
  • The Hawaii State Child and Mental Health Division’s Help Your Keiki site offers links to information about: choosing the right treatment, what to expect from a good therapist, and questions to ask your child’s therapist.

You can also find a listing of the available Evidence-based Practices in Philadelphia by visiting the EBPs in Philadelphia section of our website.

I’d like to learn more about EBP research, where can I find research articles?

This blog post from the Canadian Centre for Addiction and Mental Health offers some free resources and search tips for finding research articles.
In addition, the American Psychological Association has a nice resource that highlights the kinds of things to look for when reading research articles.

How does my organization take part in a DBHIDS-EBP training initiative?

All EBP training opportunities go through a formal procurement process. You can monitor the CBH website for new contracting opportunities, or sign up for CBH News to get email updates on things like upcoming procurement opportunities.

To learn more about the current department funded initiatives visit the Department Funded Initiatives section of our website.