Evidence-Based Evidence-Based Clinical Reasoning in Clinical Reasoning in Children's Mental Children's Mental Health Services Health Services Bruce F. Chorpita Bruce F. Chorpita Eric L. Daleiden Eric L. Daleiden CHARPP Conference: Real Data in Real Time CHARPP Conference: Real Data in Real Time September 10, 2007 September 10, 2007
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Evidence-Based Clinical Reasoning in Children's Mental Health Services Bruce F. Chorpita Eric L. Daleiden CHARPP Conference: Real Data in Real Time September.
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Evidence-Based Clinical Evidence-Based Clinical Reasoning in Children's Reasoning in Children's Mental Health ServicesMental Health Services
Bruce F. ChorpitaBruce F. Chorpita
Eric L. DaleidenEric L. Daleiden
CHARPP Conference: Real Data in Real TimeCHARPP Conference: Real Data in Real Time
September 10, 2007September 10, 2007
Acknowledgments
Acknowledgments
Acknowledgments
Acknowledgments
The Story of JohnThe Story of John
A Tale of Two CulturesA Tale of Two Cultures
This is John.
PremisePremise
As researchers attempt to As researchers attempt to implement multiple EBTs, they implement multiple EBTs, they come across the practitioner’s come across the practitioner’s realityreality
This was my experience with the This was my experience with the CAMHD Practice Development CAMHD Practice Development SectionSection
Practitioner ConcernsPractitioner Concerns
Fixed contentFixed content Fixed intensityFixed intensity Fixed lengthFixed length Single target Single target
Throw out the Bath Water:Throw out the Bath Water:Keep the BabyKeep the Baby
Move away from the idea that Move away from the idea that “Problem A gets Treatment B”“Problem A gets Treatment B”
We decided to map the decisions We decided to map the decisions made at the system level – not just made at the system level – not just the IF-THEN of treatment selectionthe IF-THEN of treatment selection
Goal: To build an Evidence Based Goal: To build an Evidence Based SystemSystem
Where should we treat the client?Where should we treat the client?
ServiceSetting
How should we treat the client?How should we treat the client?
TherapeuticPractices
ServiceSetting
Are we providing quality service to the Are we providing quality service to the client?client?
TherapeuticPractices
ServiceSetting
TreatmentIntegrity
Is the client getting better?Is the client getting better?
TherapeuticPractices
ServiceSetting
Who should treat the client?Who should treat the client?
TherapeuticPractices
ServiceSetting
How should we manage the treatment?How should we manage the treatment?
TherapeuticPractices
ServiceSetting
Treatment programs formalize these elementsTreatment programs formalize these elements
TherapeuticPractices
ServiceSetting
Selecting a program structures other Selecting a program structures other decisionsdecisions
Tx Program Selection
TherapeuticPractices
ServiceSetting
Selecting a program structures other Selecting a program structures other decisionsdecisions
Tx Program Selection
TherapeuticPractices
ServiceSetting
Multisystemic Therapy (MST) Example
Home & Community Based
TAMS & SAMS
Instrumental &Ultimate Outcomes
MST
4 – 5 Members
Team Supervisor
Cross-Team Supervisor
Family Therapy, etc.
Tx Program Selection
Valid alternatives to deciding by Valid alternatives to deciding by program?program?
TherapeuticPractices
ServiceSetting
How should we make decisions?How should we make decisions?
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
How should we make decisions?How should we make decisions?
GeneralServicesResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
Evidence-Based Services Model
How should we make decisions?How should we make decisions?
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
Individualized Case Conceptualization Model
How should we make decisions?How should we make decisions?
LocalAggregateEvidence
Case-SpecificHistorical
Information
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
Practice-Based Evidence Model
The Full System ModelThe Full System ModelGeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
The Phases of EvidenceThe Phases of Evidence
1.1. Data: Discretely identifiable unitsData: Discretely identifiable units
2.2. Information: Data in a context that provides it Information: Data in a context that provides it meaningmeaning
3.3. Knowledge: Information helpful to decision-Knowledge: Information helpful to decision-makingmaking
4.4. Wisdom: Knowing when to apply our Wisdom: Knowing when to apply our knowledgeknowledge
c.f., 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: The Phases of Evidence: ExampleExample1.1. Data: 70Data: 70
2.2. Information: 70Information: 70ºº F F
3.3. Knowledge: It is warm enough to wear shorts.Knowledge: It is warm enough to wear shorts.
4.4. Wisdom: I am giving a professional talk today, Wisdom: I am giving a professional talk today, so my knowledge that it is warm enough to so my knowledge that it is warm enough to wear shorts is irrelevant to my attire.wear shorts is irrelevant to my attire.
The Phases of Evidence: The Phases of Evidence: Managing Evidence BasesManaging Evidence Bases
1.1. Data: Define and capture relevant dataData: Define and capture relevant data
2.2. Information: Organize and analyze into Information: Organize and analyze into meaningful units for consumersmeaningful units for consumers
3.3. Knowledge: Deliver the information to the Knowledge: Deliver the information to the decision-making situationdecision-making situation
4.4. Wisdom: Prioritize use of the knowledge basesWisdom: Prioritize use of the knowledge bases
General Services Research:General Services Research:Turning Data into Knowledge ITurning Data into Knowledge I
Meta Analysis of Children’s Treatment Meta Analysis of Children’s Treatment ResearchResearch– Over 300 studies, 60 yearsOver 300 studies, 60 years– Largest meta-analysis to dateLargest meta-analysis to date– Made dynamic for providersMade dynamic for providers
Results: AnxietyResults: Anxiety
Best SupportBest Support CBTCBT EducationEducation ExposureExposure ModelingModeling
Good SupportGood Support Assertiveness TrainingAssertiveness Training Cognitive Behavior Cognitive Behavior
Therapy and Therapy and MedicationMedication
Cognitive Behavior Cognitive Behavior Therapy with ParentsTherapy with Parents
HypnosisHypnosis Play TherapyPlay Therapy RelaxationRelaxation
Results: TraumaResults: Trauma
Best SupportBest Support CBTCBT
Good SupportGood Support Cognitive Behavior Cognitive Behavior
Therapy with ParentsTherapy with Parents Play TherapyPlay Therapy
Good SupportGood Support Anger ControlAnger Control Client Centered TherapyClient Centered Therapy Communication SkillsCommunication Skills Functional Family TherapyFunctional Family Therapy Multidimensional Treatment Multidimensional Treatment
Foster CareFoster Care Multisystemic TherapyMultisystemic Therapy Parent Management Training and Parent Management Training and
Problem SolvingProblem Solving Physical ExercisePhysical Exercise Problem SolvingProblem Solving Rational Emotive TherapyRational Emotive Therapy RelaxationRelaxation Transactional Analysis Transactional Analysis
How do we get this knowledge to the How do we get this knowledge to the treatment team?treatment team?
GeneralServicesResearch
LocalAggregateEvidence
Case-SpecificHistorical
Information
CausalMechanismResearch
Tx Program Selection
TherapeuticPractices
ServiceSetting
Treatment Team
Supervision
ClientProgress
TreatmentIntegrity
General Services Research:General Services Research:Turning Data into Knowledge IITurning Data into Knowledge II
Common Elements approachCommon Elements approach– Identified components of evidence based Identified components of evidence based
practicespractices– Generated profiles using a decision tree Generated profiles using a decision tree
approachapproach
Is there a different Is there a different level of analysis?level of analysis?
Protocol Protocol Protocol
Family
Is there a different Is there a different level of analysis?level of analysis?
IncredibleYears
PCITDefiant Children
Parent Training
Is there a different Is there a different level of analysis?level of analysis?
Protocol Protocol Protocol
Family
PracticeElement
PracticeElement
PracticeElement
PracticeElement
PracticeElement
PracticeElement
Is there a different Is there a different level of analysis?level of analysis?
Incredible Years
PCITDefiant
Children
Parent Training
Commands CommandsAttending
Time Out
Rewards
Time Out
These are “practice elements.
”
ExampleExample
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
Exposure
Relaxation
Cognitive
Psychoeducational-Child
Modeling
Self-Monitoring
Therapist Praise/Rewards
Psychoeducational-Parent
Self-Reward/Self-Praise
Maintenance/Relapse Prevention
Problem Solving
Tangible Rewards
Relationship/Rapport Building
Assertiveness Training
Praise
Social Skills Training
Guided Imagery
Communication Skills
Educational Support
Response Prevention
Differential Reinforcement
Goal Setting
Play Therapy
Emotional Processing
Natural and Logical Consequences
Parent Coping
Monitoring
Peer Pairing
Stimulus Control or Antecedent Man.
Time Out
Behavioral Contracting
Activity Scheduling
Catharsis
Family Therapy
Hypnosis
Supportive Listening
Individual Therapy for Caretaker
PracticeWise Evidence Based Services Practice Element ProfileAnxiety Levels I and II –
September 05, 2007
0.0 0.2 0.4 0.6 0.8 1.0
Proportion of Studies (n = 91)
PracticeWise Evidence Based Services Practice Element ProfileTrauma Levels I and II –