Evolution of the Revolution: How Can Evidence-Based Practice Work in the Real World? Bruce F. Chorpita Wing Institute Annual Summit on Evidence Based Special.

Evolution of the Revolution: Evolution of the Revolution: How Can Evidence-Based Practice How Can Evidence-Based Practice

Work in the Real World?Work in the Real World?

Bruce F. ChorpitaBruce F. ChorpitaWing Institute Annual Summit on Evidence Based Wing Institute Annual Summit on Evidence Based

Special EducationSpecial Education

April 24, 2008April 24, 2008

Acknowledgments

Acknowledgments

Acknowledgments

Acknowledgments

The Story of JohnThe Story of John

A Tale of Two CulturesA Tale of Two Cultures

This is John.

Evidence Based Practice:Evidence Based Practice:Not As Easy As It LooksNot As Easy As It Looks

Attributes of Innovations1. Relative Advantage2. Compatibility3. Complexity4. Observability

Diffusion of InnovationDiffusion of Innovation

Communication Channels1. Mass Media2. Interpersonal

Change Agent Properties1. Effort2. Homophily

Rate of Adoption

Adapted from Rogers (1995)

Diffusion CurveDiffusion Curve%

of

adop

ters

Adoption

Time

ATTRIBUTES OF THE ATTRIBUTES OF THE INNOVATIONINNOVATION

Practitioner ConcernsPractitioner Concerns

Fixed contentFixed content Fixed intensityFixed intensity Fixed lengthFixed length Single target Single target

approachapproach ReplacementReplacement

Empty cell Empty cell problemproblem

Crowded cell Crowded cell problemproblem

Expiration Expiration problemproblem

Aarons (2004); Addis & Krasnow (2000); Addis, Wade, & Hatgis (2004); Chorpita, Daleiden, & Weisz (2005); Kimhan & Chorpita (2006); Persons (1995)

Some EBS Effect SizesSome EBS Effect Sizes(Chorpita et al. 2002)(Chorpita et al. 2002)

CBT for anxiety: ES =1.05CBT for anxiety: ES =1.05 Exposure for anxiety: ES=2.02 Exposure for anxiety: ES=2.02 Modeling for anxiety: ES=0.55Modeling for anxiety: ES=0.55 CBT with Parent/Child for anxiety: ES=1.68CBT with Parent/Child for anxiety: ES=1.68 Behavior Therapy for ADHD: ES=1.24Behavior Therapy for ADHD: ES=1.24 CBT for depression: ES=1.74CBT for depression: ES=1.74 IPT for depression: ES=1.51IPT for depression: ES=1.51 Relaxation for depression: ES=1.48Relaxation for depression: ES=1.48 Parent training for ODD: ES=0.89Parent training for ODD: ES=0.89 MST for delinquency: ES=0.50MST for delinquency: ES=0.50

Diffusion strategies: Relative Advantage

Comparison with Usual CareComparison with Usual Care(Weisz et al. 1995)(Weisz et al. 1995)

-0.5-0.4-0.3-0.2-0.1

00.10.20.30.40.50.60.70.80.9

EBT Usual Care

Diffusion strategies: Relative Advantage

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?


ServiceSetting

TreatmentIntegrity

Is the client getting better?Is the client getting better?


ServiceSetting

Who should treat the client?Who should treat the client?


ServiceSetting

How should we manage the treatment?How should we manage the treatment?


ServiceSetting

Treatment programs formalize these elementsTreatment programs formalize these elements


ServiceSetting

Selecting a program structures other Selecting a program structures other decisionsdecisions

Tx Program Selection


ServiceSetting

Selecting a program structures other Selecting a program structures other decisionsdecisions



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.


Valid alternatives to deciding by Valid alternatives to deciding by program?program?


ServiceSetting

How should we make decisions?How should we make decisions?



ServiceSetting

Treatment Team

Supervision


GeneralServicesResearch



ServiceSetting

Treatment Team

Supervision

Evidence-Based Services Model


Case-SpecificHistorical

Information

CausalMechanismResearch



ServiceSetting

Treatment Team

Supervision

Individualized Case Conceptualization Model


LocalAggregateEvidence


Information



ServiceSetting

Treatment Team

Supervision

Practice-Based Evidence Model

The Full System ModelThe Full System ModelGeneralServicesResearch



Information




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.

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 350 studies, 40 yearsOver 350 studies, 40 years– Largest meta-analysis to dateLargest meta-analysis to date– Made dynamic for providersMade dynamic for providers

Diffusion strategies: Compatibility, Observability, Complexity

How do we get this knowledge to the How do we get this knowledge to the treatment team?treatment team?

GeneralServicesResearch



Information




ServiceSetting

Treatment Team

Supervision

ClientProgress

TreatmentIntegrity

Other OptionsOther Options

SAMHSA NREPSAMHSA NREP Published meta-analysesPublished meta-analyses Evidence based practice guidelinesEvidence based practice guidelines Paper/web reports Paper/web reports

– Hawaii CAMHD Biennial ReportHawaii CAMHD Biennial Report– Hawaii’s “Blue Menu”Hawaii’s “Blue Menu”

The Blue Menu is being substantially updated based on hundreds of additional studies. Some problem areas that are now omitted will reappear in updated form on future editions.

Problem Area Level 1-BEST SUPPORT

Level 2-GOOD SUPPORT

Level 3-MODERATE

SUPPORT

Level 4-MINIMAL SUPPORT

Level 5-NO SUPPORT

Anxious or Avoidant Behaviors

Cognitive Behavior Therapy, Education, Exposure, Modeling

Assertiveness Training, Cognitive Behavior Therapy and Medication, Cognitive Behavior Therapy with Parents, Hypnosis, Relaxation

None Biofeedback, Play Therapy, Psychodynamic Therapy, Rational Emotive Therapy

Client Centered Therapy, EMDR, Relationship Counseling, Teacher Psychoeducation [poorly tested: CBT with Parents Only; CBT with Child and CBT with Parent separately]

Attention and Hyperactivity Behaviors

Behavior Therapy and Medication, Self Verbalization

Biofeedback, Contingency Management, Education, Parent Management Training, Parent Management Training and Problem Solving, Physical Exercise, Relaxation and Physical Exercise, Relaxation and Physical Exercise, Social Skills and Medication, Working Memory Training

None Parent Management Training and Social Skills, Relaxation, Social Skills

Client Centered Therapy [poorly tested: Parent Management Training and Self-Verbalization, Self Control Training, Self Verbalization and Medication, Skill Development]

Autistic Spectrum Disorders

Intensive Behavior Therapy, Intensive Communication Training

None None None [poorly tested: Auditory Integration Training]

Delinquency and Disruptive Behavior

Assertiveness Training, Cognitive Behavior Therapy, Contingency Management, Multisystemic Therapy, Parent Management Training, Social Skills

Anger Control, Client Centered Therapy, Communication Skills, Functional Family Therapy, Multidimensional Treatment Foster Care, Parent Management Training and Problem Solving, Problem Solving, Rational Emotive Therapy, Relaxation, Transactional Analysis

Outreach Counseling, Peer Pairing, Self Control Training

Physical Exercise, Stress Inoculation

Education, Exposure, Family Systems Therapy, Group Therapy (!!), Life Skills, Project CARE (!!),Skill Development [poorly tested: Catharsis, Collaborative Problem Solving, Family Empowerment, Physical Exercise, Psychodynamic Therapy, Self Verbalization]

Depressive or Withdrawn Behaviors

Cognitive Behavior Therapy, Cognitive Behavior Therapy and Medication

Client Centered Therapy, Cognitive Behavior Therapy with Parents, Interpersonal Therapy, Family Therapy, Relaxation

None Self Control Training, Self Modeling

Attention, Counselors Care, Counselors Care and Anger Management, Life Skills[poorly tested: Problem Solving, Social Skills]

Eating Disorders None Family Therapy (anorexia only) None None None

Substance Use None Cognitive Behavior Therapy, Contingency Management, Purdue Brief Family Therapy, Family Therapy, Family Systems Therapy

None None Client Centered Therapy, Education, Group Therapy (!!), Project CARE (!!), Twelve Step Program

Traumatic Stress Cognitive Behavior Therapy with Parents Cognitive Behavior Therapy None Play Therapy, Psychodrama Client Centered Therapy, Cognitive Behavior Therapy with Parents Only[poorly tested: EMDR]

“Blue Menu” - Evidence-Based Child and Adolescent Psychosocial InterventionsThis tool has been developed to guide teams (inclusive of youth, family, educators and mental health practitioners) in developing appropriate plans using psychosocial interventions. Teams should use this information to prioritize promising options. For specific details about these interventions and their applications (e.g., age setting, gender) see the most recent Evidence Based Services Committee Biennial Report (http://www.hawaii.gov/health/mental-health/camhd/library/webs/ebs/ebs-index.html).<<NOTICE>>Note: Level 5 refers to treatments that were tested and found ineffective. Risk of harm is noted by the symbol (!!), which indicates that at least one study found negative effects on the main outcome measure. The risk of using such treatments should be weighed against potential benefits.

http://www.hawaii.gov/health/mental-health/camhd/library/webs/ebs/ebs-index.html

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– Complements integrated program Complements integrated program

approachapproach

Diffusion strategies: Compatibility, Complexity

Is there a different Is there a different level of analysis?level of analysis?

Protocol Protocol Protocol

Family


IncredibleYears

PCITDefiant Children

Parent Training


Protocol Protocol Protocol

Family

PracticeElement

PracticeElement

PracticeElement

PracticeElement

PracticeElement

PracticeElement


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

AnxietyAnxiety

ADHDADHD

AutismAutism

DepressionDepression

Disruptive Disruptive BehaviorBehavior

Disruptive Disruptive BehaviorBehavior

TraumaticTraumaticStressStress

The Full System ModelThe Full System ModelGeneralServicesResearch



Information




ServiceSetting

Case Specific History:Case Specific History:Turning Data into Knowledge IIITurning Data into Knowledge III

Clinical DashboardClinical Dashboard– ProgressProgress– PracticesPractices

Diffusion strategies: Compatibility, Observability

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

CLINICAL PROCESS CLINICAL PROCESS MODELINGMODELING

Now how do we put the evidence bases together…?Now how do we put the evidence bases together…?

A Foray into WisdomA 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


ClinicalProgress?





Reports, etc.


needed

yes

no

no

yes

no

yes

no

yes

Clinical Dashboard:Practice Pane, EBS DB


TreatmentIntegrity?



training supports




New Case?

no


EBSDatabaseStart


ClinicalProgress?





Reports, etc.


needed

yes

no

no

yes

no

yes

no

yes



TreatmentIntegrity?



training supports




New Case?

no


EBSDatabaseStart



Child

Mother

Father

Other

Progress Measure:

Fear rating

Rewards

Commands

Time Out

Praise

Problem Solving

Parent Monitoring

Response Cost

Ignoring/DRO



Modeling

Cognitive


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

0

1

2

3

4

5

6

7

8

0 10 20 30 40 50 60 70 80 90 100


ClinicalProgress?





Reports, etc.


needed

yes

no

no

yes

no

yes

no

yes



TreatmentIntegrity?



training supports




New Case?

no


EBSDatabaseStart

This tells you the treatment types that work for this problem.

This tells you the practice elements associated with those treatment types.



Child

Mother

Father

Other

Progress Measure:

Fear rating

Rewards

Commands

Time Out

Praise

Problem Solving

Parent Monitoring

Response Cost

Ignoring/DRO



Modeling

Cognitive


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

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 WisdomA Bit of Practice Wisdom

ClinicalProgress?





Reports, etc.


needed

yes

no

no

yes

no

yes

no

yes

Clinical Dashboard:Practice Pane, PW DB


TreatmentIntegrity?

Therapy Protocols,Dashboards, PW DB,


training supports



PW DB, Local Best Practices, Tx Team

New Case?

no


PWDatabaseStart



Child

Mother

Father

Other

Progress Measure:

Fear rating

Rewards

Commands

Time Out

Praise

Problem Solving

Parent Monitoring

Response Cost

Ignoring/DRO



Modeling

Cognitive


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

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?Seek Consultation?

MODULARITY IN PRACTICEMODULARITY IN PRACTICE

MATCH-ADC:MATCH-ADC:Modular Approach to Therapy Modular Approach to Therapy for Childrenfor 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.

Diffusion strategies: Compatibility

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 ProjectChild STEPs Treatment Projectwww.childsteps.orgwww.childsteps.org

Youth Network on Child Mental HealthYouth Network on Child Mental Health 5-Year, multisite randomized trial5-Year, multisite randomized trial

– Boston, HonoluluBoston, Honolulu Anxiety, Depression, Conduct Anxiety, Depression, Conduct

ProblemsProblems Community therapistsCommunity therapists SMT, MMT, Usual CareSMT, MMT, Usual Care 185 children enrolled so far185 children enrolled so far

Training ResultsTraining Results

p < .01





Rate of Adoption






Rate of Adoption


Diffusion CurveDiffusion Curve%

of

adop

ters

InterpersonalMass media

Time From Rogers (1995)

Why have a review Why have a review committeecommittee

Generates “buy-in” (homophily)Generates “buy-in” (homophily) Establishes an organizational Establishes an organizational

cultureculture Promotes relevancePromotes relevance Keeps evidence currentKeeps evidence current Activates interpersonal channelsActivates interpersonal channels

Diffusion strategies: Interpersonal, Homophily

Invite all stakeholders, Invite all stakeholders, (especially your “enemies”)(especially your “enemies”)

Maintains multiple Maintains multiple perspectivesperspectives

Coordinates opinion leaders Coordinates opinion leaders from various social circlesfrom various social circles

We can always agree on one We can always agree on one thing as a starting point…thing as a starting point…

Diffusion strategies: Interpersonal, Effort

Where The Rubber Meets Where The Rubber Meets the Roadthe Road

One-by-one supervision and One-by-one supervision and supportsupport

Respect for system Respect for system membersmembers– Pink spreadsheet story Pink spreadsheet story

Interpersonal critical massInterpersonal critical mass– Practice guidelines storyPractice guidelines story

Diffusion strategies: Effort, Interpersonal, Compatibility

Results in HawaiiResults in HawaiiFrom Daleiden, Chorpita, Arensdorf, Donkervoet, & Brogan (2006)From Daleiden, Chorpita, Arensdorf, Donkervoet, & Brogan (2006)

Rate of Improvement?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

Cost per OutcomeCost 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)

Innovation is as much a social process as a technological one.

Rogers (1995)

This is John now.

Thank You!Thank You!

Relevance MappingRelevance Mapping

How relevant is the evidence base How relevant is the evidence base to my service population?to my service population?

Under what assumptions?Under what assumptions? Where do we focus our efforts?Where do we focus our efforts?

ProcedureProcedure

Compare every member of a population Compare every member of a population to every study in the evidence baseto every study in the evidence base

Examine different inclusion Examine different inclusion assumptionsassumptions– ProblemProblem– AgeAge– GenderGender– EthnicityEthnicity

Aggregate the resultsAggregate the results

Initial Sample Initial Sample (N = 712)(N = 712)

34% Disruptive; 22% ADHD; 22% 34% Disruptive; 22% ADHD; 22% Anxiety; 6% DepressionAnxiety; 6% Depression

Age 4 to 18Age 4 to 18 68% boys, 32% girls68% boys, 32% girls 51% multiethnic, 16% white, 14% 51% multiethnic, 16% white, 14%

Asian, 8% Pacific IslanderAsian, 8% Pacific Islander

Who is covered?Who is covered?

Treatments P PAG PAGE

0 11.8% 18.7% 72.1%

1 or more 88.2% 81.3% 27.9%

How are they covered?How are they covered?

Treatment Family P PAG PAGE

Contingency Management 59.3% 18.1% 2.4%

Parent Management Training 58.4% 28.8% 2.8%

Parent Management Training and Problem Solving 56.7% 25.6% 2.4%

Cognitive Behavior Therapy 51.8% 45.5% 17.3%

Relaxation 50.1% 5.8% 1.1%

Education 48.9% 15.6% 2.5%

Assertiveness Training 46.2% 2.0% 0.0%

Client Centered Therapy 44.9% 22.6% 3.5%

Problem Solving 38.1% 35.3% 4.9%

Evolution of the Revolution: How Can Evidence-Based Practice Work in the Real World? Bruce F. Chorpita Wing Institute Annual Summit on Evidence Based Special.

Documents

innovation slide

system slide

treatment b n

relative advantage slide

n relaxation

n exposure

n modeling

baby n