SOCW 6311 WK 1 Assignment: Accessing Information About Evidence-Based Practices

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Evidence-based intervention and services for high-risk youth: a North American perspective on the challenges of integration for policy, practice and research

James K. Whittaker Charles O. Cressey Endowed Professor Emeritus, School of Social Work, University of Washington, Seattle,

Washington, USA

A B S T R AC T

This paper explores the cross-national challenges of integrating evidence-based interventions into existing services for high-resource- using children and youth. Using several North American model programme exemplars that have demonstrated efficacy, the paper explores multiple challenges confronting policy-makers, evaluation researchers and practitioners who seek to enhance outcomes for troubled children and youth and improve overall service effective- ness. The paper concludes with practical implications for youth and family professionals, researchers, service agencies and policy–makers, with particular emphasis on possibilities for cross-national collaboration.

Correspondence: James K. Whittaker, School of Social Work, University of Washington, 4101 Fifteenth Avenue NE, Seattle, WA 98105-6299, USA E-mail: [email protected]

Keywords: children in need (services for), evidence-based practice, research in practice, therapeutic social work

Accepted for publication: January 2009

I N T R O D U C T I O N

Across many national boundaries and within multiple service contexts – juvenile justice, child mental and child welfare – there is a growing concern about a proportionately small number of multiply challenged children and youth who consume a disproportionate share of service resources, professional time and public attention. While accurate, empirically validated popu- lation estimates and descriptions remain elusive. The consensus of many international youth and family researchers, including those reported by McAuley and Davis (2009) (UK), Pecora et al. (2009a) (US) and Egelund and Lausten (2009) (Denmark) in this present volume seems to be that some combination of externalizing, ‘acting-out’ behaviour, problems with substance abuse, identified and often untreated mental

health problems, experience with trauma and challeng- ing familial and neighbourhood factors are often, and in various combinations, manifest in the population of children and youth most challenging to serve. Many of these find their way into intensive out-of-home care services, and Thoburn (2007) provides a useful window into the out-of-home care status of children in 14 countries and offers useful observations on improvements in collecting administrative data for child and family services to inform both policy and practice. Others call for a critical re-examination of the present status of ‘placement’ as a central fulcrum in child and family services policy and practice (Whittaker & Maluccio 2002).

A sense of urgency is conveyed by the fact that many child and youth clients of ‘deep-end’, restrictive (out-of-home) services disproportionately represent underserved and often socially excluded families and communities of colour, and pose additional challenges in service planning around the cultural compatibility of proffered interventions (Blasé & Fixsen 2003; Barbarin et al. 2004; Miranda et al. 2005). Important work in this area includes ethnic and cultural

Author note: Portions of this paper in earlier form were presented by the author at the 8th and 10th annual EUSARF International Conferences at the University of Leuven, Belgium, 9–11 April 2003 and the University of Padova, Italy, 26–29 March 2008.

doi:10.1111/j.1365-2206.2009.00621.x

mailto:[email protected]

variations on known effective practices. Lau (2006), for example, offers a nuanced and sensitive treatment of actual and potential adaptations in existing parent training models. A basic concern with questions of equity and social justice, coupled with a growing scep- ticism about the efficacy of traditional residential, ‘place-based’ services, has heightened the search for more preventive, family- and community-based, cul- turally congruent service alternatives. All of this is set against a backdrop of concern about the state’s ability to provide effective parenting oversight and support for children in care, as well as those who remain with their families (Bullock et al. 2006). Fortunately, this search is occurring at a time when researchers in many countries are shedding light on mechanisms of risk and resilience (Sameroff & Gutman 2004), change processes involved in effective interventions (Biehal 2008) and the challenges faced by parents in multiply stressed environments (Ghate & Hazel 2002; Ghate et al. 2008) that are rich in their potential for contri- butions to intervention design and evidence-informed practice.

The primary purpose of this paper is to examine some of the challenges and opportunities in incorpo- rating evidence-based strategies and interventions into existing service systems to better meet the needs of high-resource-using children and youth. The growing corpus of empirical research on promising treatment strategies offers, if not clear-cut prescrip- tions, then rich implications for future policy initia- tives and service experiments.

Indeed, the pursuit of evidence-based practice, in its many forms, increasingly attracts the attention of those who plan, deliver and evaluate critical treatment and rehabilitative services for vulnerable children and their families across national boundaries and regions. While definitions of ‘evidence-based practice’ empha- size different dimensions of that construct, the common themes of bringing ‘science-to-service’, and its reciprocal ‘service-to-science’, are increasingly evident in the child, youth and family services systems in many European countries and North America, as well as elsewhere. Simultaneously, reform efforts in the USA and many European countries press for community-based, family-oriented, non-residential alternatives to traditional residential care and treat- ment programmes for acting-out children and youth with identified mental health problems (Chamberlain 2003; Weisz & Gray 2008). However, the impulse for service reform and the availability of at least some empirically validated model interventions do not of themselves constitute a sufficient basis for system

reform, but instead serve to illuminate some of the many fault lines that exist in the child and family services field:

• The continuing tensions between ‘front-end’, pre- ventive services and ‘deep-end’ highly intensive treatment services and the unhelpful dichotomies these tend to create and perpetuate

• The tensions between a widely shared desire to adopt more evidence-based practices and the genu- inely felt resistances to these, particularly when they are used in a rigid fashion that requires strict adher- ence to established protocols with little opportunity for experimentation, customization or practitioner discretion. For example, as one family support researcher recently observed, we need much more fine-grained analyses of the actual lived experience of client families with the services offered to them (S. P. Kemp 2008, personal communication). Such analyses will almost certainly involved a ‘mixed- methods’ approach using qualitative measures and methods to augment quantitative studies

• The tension, as manifested in North America and elsewhere between evidence-based and culturally competent practices, reflects, among other things, antagonism towards certain practice strategies based on perceptions of the under-representation of ethnic minorities in the study samples on which certain models have been validated As model programmes proliferate and are increas-

ingly removed from the particular political and cul- tural niches within which they were developed, we would do well to heed the cautions offered by Munro et al. (2005) that researchers, planners and youth and family practitioners are at a moment in time when cross-national perspectives are critical in helping iden- tify new ways of both framing problems and shaping service solutions. Cross-national dialogue can help in identifying different formats for collecting, analysing and utilizing routinely gathered client information, analysing subtle local adaptations of internationally recognized evidence-based services and examining the effects of differing policy contexts on service outcomes.

T H E Q U E S T F O R M O R E E F F E C T I V E I N T E R V E N T I O N S

For the remainder of this paper, I wish to do three things: (1) briefly identify where we are in our search for effective (evidence-based) interventions; (2) assess how we are doing in increasing their availability to high-resource-using troubled youth and their families;

Evidence-based intervention for high-risk youth J K Whittaker

and (3) identify some particular challenges faced by the individual practitioner, the social agency and the public policy context in furthering the shared goal of improving outcomes, and thus life prospects for troubled children. The author’s bias will soon be readily apparent. First, as one who has spent a lifetime trying to bring both the precision of research methods and the richness of research findings to the ‘shop floor’ of children’s agency practice, I am convinced that the evidence-based practice movement will not succeed until it is embraced by those closest to the children: the child and youth care workers, the social workers, teachers, family support workers and others who, with parents, toil on the front lines of helping. This is not in my view a one-way street – Science-to- Service – but presumes a vital feedback loop from Service-to-Science where the insights and hypotheses of those most directly involved in interventions (including parent and child consumers) inform and improve successive generations of applied research studies. Second, I readily acknowledge the North American bias apparent in many of my examples – I write of what I know best – while recognizing a deeply felt need in my country for European and other cross- national perspectives if we are ever to achieve success with our internal efforts at improving outcomes.

The search for evidence-based practices with chil- dren and families is now well underway on both sides of the Atlantic. Kazdin and Weisz (2003), Weisz (2004), Burns and Hoagwood (2002), Macdonald (2001), Pecora et al. (2009b) and McAuley et al. (2006) survey effective interventions in child welfare and child mental health services, as well as review current research on service populations that will inform the creation of novel interventions.

The simple, nominal definition of evidence-based practice offered by Professor Geraldine MacDonald of Queen’s University in Belfast provides a useful start- ing point:

Evidence-based practice indicates an approach to decision-

making which is transparent, accountable and based on careful

consideration of the most compelling evidence we have about

the effects of particular interventions on the welfare of indi-

viduals, groups and communities. (MacDonald 2001, p. xviii)

It is clear that debates about what constitutes the sufficiency and quality of evidence – where to set the bar for rigour, how to distinguish evidence-based vs. evidence-informed practice – continue apace both in academic and practitioner discourse even as the evidence-based practice movement as a whole contin- ues to raise its profile in policy and services. These

competing definitions and nuances are, in toto, a sign of health as they simply serve to underscore one or another aspect of what is emerging as a more fulsome understanding of what evidence-based practice con- sists of. These aspects include, but are not limited to:

• a dual focus on aetiology and outcomes • the incorporation of ethics and values as key com-

ponents

• the development of a collaborative process with affected client groups

• a commitment to transparency in processes and accountability Many practitioners and practice researchers have

participated in the work of international groups such as the Campbell and Cochrane Collaborations (Littell 2008) – originating in the health field – that attempt to sift, sort and categorize the state of the evidence around particular illnesses, socio-behavioural problems or social welfare concerns. Many have also experienced – closer to home – the increasing impact of national, state and regional initiatives designed to increase the content of proven, efficacious practices into child, youth and family service systems. Such initiatives typically use two strategies, often in combination:

Positive Reinforcement: e.g. ‘Laying Flowers Along Certain

Pathways’ by encouraging adoption of selected efficacious

model interventions. (One notes in passing that ‘efficacy’ of a

given intervention often increases in proportion to the dis-

tance from its country of origin!)

Coercion: e.g. Penalizing a programme, agency or practitioner

whose interventions do not reflect a sufficient quantity of

evidence-based practice according to an agreed-upon time

schedule. In the USA, this typically means that a practitioner

or service agency follows a prescribed protocol for interven-

tion or risks losing reimbursement for services rendered.

M OV I N G F R O M ‘ E F F I C AC Y- T O - E F F E C T I V E N E S S ’

In the USA at the moment, there is growing respect for the complexities involved in moving from pilot demonstrations of effective child, youth and family interventions to broad-scale application: i.e. moving from ‘efficacy’ to ‘effectiveness’ (Jensen et al. 2005; Weisz & Gray 2008). What these terms signify are: 1. That individual investigators can demonstrate sig- nificant results for novel treatments over standard (or traditional) services through carefully controlled, rig- orously conducted studies often including random- ized controlled trials: the ‘gold standard’ of clinical research. That is, they can demonstrate efficacy.

Evidence-based intervention for high-risk youth J K Whittaker

2. Yet, these impressive results do not, on close examination, appear to influence what might be thought of as routine, day-to-day practice as con- ducted in more familiar agency settings. Thus, the evidence-based practice movement, while demon- strating efficacy, cannot as yet demonstrate overall effectiveness.

What explains this disconnect? Lisbeth Schorr, an astute analyst of child and family services innovation, sums it up succinctly: ‘Successful programs’, she says, ‘do not contain the seeds of their own replication’ (Schorr 1993, quoted in Fixsen et al. 2005).

Thus, if we are truly interested in effectiveness – i.e. achieving wide-scale adoption of proven efficacious interventions, we need to look beyond efficacy studies: (1) to those contextual elements that influence prac- tice decisions and client outcomes (Kemp et al. 1997); and (2) to a different kind of research undertaking that focuses directly on the processes involved in suc- cessful adoption of proven efficacious interventions (Weisz & Gray 2008).

John Weisz, one of the nation’s leading research analysts in child mental health and a professor of psychology at Harvard University as well as President of the Judge Baker Children’s Center in Boston, points the way forward on what is needed to ultimately resolve the efficacy/effectiveness challenge:

A very important focus for the next stage of research on

interventions for children will be the effective implementation

of evidence-based practices by practitioners in service settings.

This will require an active collaboration between the research-

ers who develop and test interventions and the clinical, child

welfare, and education professionals who serve children and

families. (J.R. Weisz 2008, personal communication)

E X P L O R I N G T H E L A N D S C A P E O F E V I D E N C E - B A S E D S E R V I C E S F O R H I G H - R I S K YO U T H

Let us proceed, then, by exploring the context within which evidence-based services are nested. Here, we find some common and proximate elements familiar to all who labour in the child and family services field, as well as a few more distal forces that, nonetheless, have a potential for considerable impact on the identification, validation and eventual integration of evidence-based practices. I will refer, briefly, to more or less typical examples from within the US context.

Model intervention programmes

For purposes of illustration, I offer three interventions that have received considerable attention in children’s

mental health services in the USA, and which have been the objects of numerous community replications and research study both in North America and else- where (Whittaker 2005). These include:

• Multisystemic Therapy (MST), developed principally by Dr Scott Henggeler, a psychologist now at the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina (Henggeler et al. 1998; Schoenwald & Rowland 2002; Henggeler & Lee 2003). http://www.mstservices.com

• Treatment Foster Care (MTFC), developed in several clinical/research teams in the USA and represented here by the model (Multi-dimensional Treatment Foster Care) principally developed by Dr Patricia Chamberlain and colleagues at the Oregon Social Learning Center – a highly influential applied behaviour analysis developmental research centre – one of whose founding members is Dr Gerald Patterson (Chamberlain & Reid 1998; Chamberlain 2002, 2003). http://www.MTFC.com

• Wraparound Treatment, a novel, team-oriented, community-centred intervention developed by a variety of individuals including the late Dr John Burchard, formerly Professor of Clinical Psychology at the University of Vermont, John Van Den Berg, Carl Dennis and others beginning in the early 1980s (Burns & Goldman 1999; Burchard et al. 2002). http://www.rtc.pdx.edu/ PDF/PhaseActivWAProcess.pdf [While space does not permit in depth analysis here,

the interested reader is directed to the previously cited references, as well as to the web sites for each of these three models that include multiple references to com- pleted and in-progress research and demonstration efforts, as well as specifics on programme principles and components. A variation of the of the MTFC model designed for younger children in regular foster care is described in this present volume by Price et al. (2009)].

These three interventions are specifically designed to provide alternative pathways for children who otherwise would be headed into more costly and restrictive residential provision. Dr Barbara Burns, Professor of Psychology at Duke University in North Carolina and a principal author of the children’s mental health section of our latest Surgeon General’s Report on Mental Health (US Department of Health and Human Services 1999) provides a succinct ratio- nale for why this is warranted:

The most critical question for the future is, what will it take

to convince payers, public and private, to support the

Evidence-based intervention for high-risk youth J K Whittaker

http://www.mstservices.com

http://www.MTFC.com

http://www.rtc.pdx.edu

interventions that are backed up by evidence about improved

outcomes? Assuming that the pool of dollars available for

mental health treatment will not increase, it will be necessary

to shift resources away from institutional care (which lacks

evidence of effectiveness) toward community alternatives.

This will require a reduction in funds allocated to institu-

tional care, where a significant portion of the child mental

health money is still being spent. (Burns & Hoagwood 2002,

p. 13)

While reviews of residential care in both the UK (Sinclair 2006) and the USA (Whittaker 2006) confirm a move away from residential services, recent comparative international contributions have urged critical re-examination of the multiple varieties of residential service (Courtney & Ivaniec 2009) to meet the needs of at least some high-resource- using youth. In part, this sentiment reflects the fact that theory and model development, particularly in the arena of intensive residential services has lan- guished as development of comparable family- centred services has flourished. Some have urged the development of a conceptual schema for intensive services – e.g. the ‘prosthetic environment’ – which transects more traditional residential, family and community boundaries is strengths-oriented and incorporates educational, socialization and family support services along with intensive treatment (Whittaker 2005).

In focusing here on a few programme models spe- cifically designed to serve as alternatives to residen- tial care and treatment, and other forms of intensive out-of-home service, one must acknowledge omis- sion of a great deal of promising, empirically based work that is presently being done with a wide range of family-, school- and community-centred interven- tions that is both more preventive in its focus and appropriate for a much wider population of children and families than space allows us to examine here. See, for example, Carolyn Webster Stratton’s Incred- ible Years Program (Beauchaine et al. 2005) and the work of many others whose contributions in such areas as family support illuminates a segment of ser- vices more preventive in focus (Kemp et al. 2005; Lightburn & Sessions 2006) and the contribution of Jackson et al. (2009).

What, then, are the similarities and differences of these three promising interventions? A recent review (Burns & Hoagwood 2002) yields the following: 1. All three interventions adhere to ‘systems of care’ values: The ‘systems of care’ framework derives from both our National Institute of Mental Health and

private foundation initiatives in the 1980s, and is defined as:

A comprehensive spectrum of mental health and other neces-

sary services which are organized into a coordinated network

to meet the multiple and changing needs of children and

adolescents with severe emotional disturbances and their

families. (Stroul & Friedman 1986, p. xx)

The system of care thus defined is based on three main ele-

ments. First, the mental health service system efforts are

driven by the needs and preferences of the child & family and

are addressed by a strengths-based approach. Second, the

locus and management of services occur within a multi-

agency collaborative environment grounded in a strong com-

munity base. Third, the services offered, the agencies

participating and programs generated are responsive to cul-

tural context and characteristics. [Though, as noted, this

remains a contested area with respect to some communities of

color.] (Burns & Hoagwood 2002, p. 19)

2. All three interventions are delivered in a commu- nity – home, school, neighbourhood – context as opposed to an office 3. All have operated in multiple service sectors: mental health, juvenile justice, child welfare 4. All were developed and evaluated in ‘real world’ community settings, thus enhancing external validity 5. All show preference for the model treatment con- dition in multiple randomized controlled trials 6. All lay claim to being less expensive to provide than institutional care (Burns & Hoagwood 2002, p. 7).

Differences of course exist. For example, both MST and MTFC possess a higher degree of specificity with respect to intervention components than does wrap- around. As of this writing, MST has perhaps the strongest evidentiary base, particularly in clinical trials showing positive effects, though some recent reviews, including one by Prof. Julia Littell of Bryn Mawr University in Pennsylvania conducted for the Camp- bell Collaboration, have raised critical questions about the evidence base offered in support of MST (Littell 2005, 2008). Finally, from a staffing perspective, MST appears to make higher use of master’s-level-trained professionals in service delivery than either MTFC or wraparound.

To these three model programmes, we must of course add numerous other evidence-based treatment techniques targeted to specific conditions and prob- lems, as reflected in recent reviews by Kazdin and Weisz (2003), Weisz (2004) and Chorpita et al. (2007). These model intervention programmes do not of course exist in a vacuum, but both influence and are influenced by a host of other elements in a typical state or regional context in the USA.

Evidence-based intervention for high-risk youth J K Whittaker

P U B L I C , V O L U N TA R Y A N D P R O P R I E TA R Y S E R V I C E P R OV I D E R S

Model programmes such as MST, MTFC and wrap- around are typically adopted by some segment of the mixed system of service agencies (Public/Voluntary/ Proprietary) that make up the delivery system in a given state, county or municipality. Public service pro- viders are typically service funders as well, creating in the view of some voluntary agencies an unequal influ- ence in terms of what particular models are selected for adoption, as well as on the masking of true admin- istrative costs of programme implementation, given the public sector’s economies of scale and presumed ability to mask start-up costs. Given the wide varia- tions in state and county service systems within the USA, there are some anecdotal reports of the ten- dency of certain model programmes to bend and shape themselves into a widely varying array of funding arrangements (referred to as ‘pretzelling’) in order to gain a foothold and a leverage in a given public system (K. Blasé 2007, personal communica- tion) with the result that local service providers may be held to similar outcome and process standards while enjoying widely varying reimbursements to support their efforts.

N AT I O N A L , R E G I O N A L A N D L O C A L R E S E A R C H C E N T E R S A N D R E S O U R C E N E T W O R K S

In addition to evidence-based programme models that typically have their own internal capacity for pro- gramme development, marketing, training, evaluation and dissemination, a wide variety of university and institute-based resource networks and research centres play an increasingly important role in the promotion of evidence-based programmes and practices. For example, the National Implementation Research Network (NIRN) was begun at the University of South Florida as part of a larger effort to bring science-based information to the forefront of child mental health practice. Recently relocated to the University of North Carolina, NIRN has done significant work in documenting national, state and regional capacity to support model programme development, and has provided consultation to individual states and organi- zations on effective strategies for integrating evidence- based practices into the fabric of existing services (Fixsen et al. 2005). For more information, see: http:// www.fpg.unc.edu/~NIRN/. The California Evidence- Based Clearinghouse for Child Welfare Practice is

funded by the California Department of Social Ser- vices, Office of Child Abuse Prevention and guided by a state advisory committee and a National Scientific Panel. The Clearinghouse provides guidance on selected evidence-based practices in simple straightfor- ward formats, reducing the consumer’s need to conduct literature searches, review extensive literature or understand and critique research methodology (http://www.cachildwelfareclearinghouse.org/). The Clearinghouse has developed a six-tiered schema for sorting out promising programmes ranging from ‘Well-Supported – Effective Practice’ to ‘Concerning Practice’ (e.g. shows negative effects on clients and/or potential for harm).

A legislatively generated state institute, the Washington State Institute on Public Policy (WSIP) was created by the Washington state legislature to conduct cost/benefit and a range of other studies on a variety of classes of intervention, including child welfare and early intervention (http://www.wsipp. wa.gov/board.asp). Its generally thorough and well- executed analyses have achieved wide dissemination beyond the region and are frequently cited by model programme developers as confirmation of their effec- tiveness. Methodological concerns have recently been raised about the general quality of intervention research reviews (Littell 2005, 2008), including those generated by WSIP, and within local practice commu- nities, one hears anecdotally some concerns about the potential for overly concrete inferences by legislative bodies and funding sources whose attention may extend only to the executive summary section of detailed reviews of model programmes and not to the caveats and nuances contained in their appendices and footnotes.

Beyond these particular exemplars, there are a wide variety of government-, university- and institute- based research centres and clearinghouses devoted to the identification, review, evaluation and promotion of evidence-based practices. Such centres are not typically coordinated, resulting oftentimes in an over- load of information for busy practitioners desirous of identifying the most appropriate interventions for troubled youth and their families. The problem is intensified as estimates place the number of docu- mented treatments for children and adolescents in excess of 500 (Kazdin 2000). Here, the work of Dr Bruce Chorpita at the University of Hawaii offers at least a partial solution. For a number of years, Chor- pita’s research team has been refining a ‘common elements’ approach to identified evidence-based treatments and then matching these with identified

Evidence-based intervention for high-risk youth J K Whittaker

http://www.fpg.unc.edu/~NIRN

http://www.cachildwelfareclearinghouse.org

http://www.wsipp.wa.gov/board.asp

problem clusters and characteristics of youth and families in service systems. The model’s particular focus on the practitioner’s adoption of discrete strat- egies, as opposed to whole-cloth approaches, is directly addressed to one of the major identified bar- riers to the implementation of evidence-based prac- tice: the resistance to treatment manuals (Chorpita et al. 2007). In a related area, the empirical research of Professor Charles Glisson of the University of Ten- nessee and colleagues sheds important light on the organizational factors that may impede or enhance the uptake of evidence-based practices in service set- tings: e.g. organizational structure, organizational culture and organizational climate (Glisson et al. 2008).

J U D I C I A L A N D L E G I S L AT I V E I N I T I AT I V E S

Vocal community advocacy calling attention to service inadequacies and lacunae – for example, failure to meet the mental health needs of children in the state foster care system or excessive numbers of placement changes – frequently end up in the court system. The resultant settlements, or ‘consent decrees’, can exert considerable direct and indirect pressure on the service system to adopt particular models of evidence- based practice as a remedy to the perceived problem. In addition, within an individual state or jurisdiction, there are not infrequently legislative initiatives designed to promote certain evidence-based practices, as well as initiatives generated from within the public service agency itself. Taken together with the already identified promotional efforts of model programme developers, sometimes augmented by the largesse of voluntary foundations that seek to promote particular strategies for service improvement, the resulting pres- sure for individual practitioners and voluntary service agencies to follow certain prescribed pathways to practice can be intense.

E V I D E N C E - B A S E D P R AC T I C E : M E E T I N G T H E C H A L L E N G E O F I M P L E M E N TAT I O N

For each of the features of the evidence-based practice landscape – model programmes, public and voluntary service providers, individual youth and family practi- tioners, research centres and clearinghouses, legisla- tive and judicial bodies and client communities – there are challenges to achieving the generally agreed-upon goal of improving outcomes for high-resource-using youth and their families through the adoption of proven, efficacious practices. While these challenges

vary depending on the point one occupies in the overall landscape of evidence-based practice, there appears to be a growing consensus in the USA for a far more intensive focus on what some have termed ‘implementation science’:

. . . the scientific study of methods to promote the systematic

uptake of clinical research findings and other evidence-based

practices into routine practice. (Implementation Science: UK:

on-line journal)

Thus, while different in their focus: (1) the previ- ously cited efforts of NIRN to identify effective path- ways for the integration of evidence-based practices into existing service systems (Fixsen et al. 2005); (2) the plea from research scholars like Julia Littell (2008) and others to bring more rigour, precision and sys- tematization to the scientific review processes for evidence-based approaches; and (3) the numerous contributions of senior research analysts like John Weisz and others (Weisz & Gray 2008), directed towards identifying pathways for bringing practitio- ners and researchers into a closer working relation- ship, are best viewed as part of a unified effort. There is, I believe, a growing awareness that integration of proven efficacious practices in youth and family work will happen only when there is a fully functioning infrastructure to support desired changes and various individual actors see their ‘part’ in relational to the ‘whole’.

Thus, for model programme developers, there is the critical task of identifying what are the active ingredi- ents in their interventions. What are the necessary and what are the sufficient components in a service unit of MST, MTFC or wraparound? Despite the fact that raising the question of ‘active ingredients’ leads one, ineluctably, to what noted child psychiatry researcher Peter Jensen calls ‘the soft underbelly’ of evidence- based treatment, it is an area of critical importance for future research (Jensen et al. 2005). The costing and ‘scaling-up’ implications alone of adding even a modest increment of evidence-based practice to exist- ing services warrants seeking answers to the question: ‘How much of what is enough’? There has been an understandable resistance on the part of many model programme developers to disaggregate their interven- tions for fear of compromising treatment integrity, and thus weakening outcomes. That said, it is heart- ening to note the flexibility of some models to cus- tomize their interventions to fit the needs of particular service populations and environmental niches. The previously cited modification of the MTFC pro- gramme reported elsewhere in this volume offers one

Evidence-based intervention for high-risk youth J K Whittaker

such excellent example (Price et al. 2009). We must find ways to hold model programme developers harm- less for their results if they are willing to experiment with modifications of their ‘packages of service’ to address particular needs.

From the perspective of the individual service agency – whether it is a voluntary body, local authority or a large, public bureaucracy – a key question vis-à- vis the adoption of exemplary evidence-based pro- gramme models concerns the basic strategy for implementation: is it to be additive or integrative?

The additive approach that appears to prevail in many sectors of service in the present US context means that service agencies adopt one model pro- gramme at a time, adhering strictly to the interven- tion, assessment, training and evaluation protocols of the developer. This is meant to insure model fidelity and programme (treatment) integrity and to prevent what has been called ‘program contamination’. The result, in the author’s view, can lead to an encapsula- tion of discrete programmes – each with its identified staff and protocols for assessment and intervention – within a single agency structure. This results in fewer opportunities for cross-fertilization (e.g. common, or cross-training) and is silent on the preferred order of implementation: e.g. does it make a difference which model is adopted first? Moreover, the administrative complexities involved in managing multiple discrete programmes in a single agency can be considerable, particularly in smaller units with limited supervisory resources.

An alternate, or what might be termed an integra- tive approach, would seek to identify common ele- ments across successful model programmes and train towards those. The previously cited work of Chorpita et al. (2007) provides a potentially valuable founda- tion to such an approach. A slight variation on the integrative approach would be to identify a common platform of foundational knowledge and skill – e.g. around client engagement – or ‘therapeutic alliance’, the present legatee of the old concept of ‘relation- ship’ (Rauktis et al. 2005), and first establish that core competency with all staff before moving to incorporate the specific strategies and techniques contained within successful model programmes. At present, the enthusiasm for what might be called the ‘intervention-du-jour’ seems to suggest a continua- tion of the additive, seriatim, approach at the expense of the integrative.

Behind the specific issue of the preferred method for adopting efficacious model interventions lies the broader question of the service agency’s capacity to

integrate, utilize and generate practice-focused research. Weisz and others have proposed models for closer integration of research and practice (Hoagwood et al. 2002; Weisz & Gray 2008) within the service agency, but at the moment these are not widely in evidence. Whittaker et al. (2006) offer a five-stage model template for integrating evidence-based prac- tice in a child mental health agency, including logic modelling of existing programmes as a means of developing a common language of service, including implicit theories of change, selected evaluation activi- ties, strategic researcher–agency staff partnerships and benchmarking against practice models of national sig- nificance. A barrier to building research capacity in existing agencies is that present contracts are typically tied to designated services, not to building an infra- structure supportive of research.

Challenges for the service agency include data management where the adoption of electronic records lags in certain sectors and where many agencies lack the capacity to systematically analyse routinely gath- ered data at either the case or the aggregate level. As noted, the proliferation of assessment and evaluation measures – often tied to specific programmes – adds complexity to the data management needs of the service agency. In the critical arena of supervision, the question arises of the adequacy of a single supervisor to provide oversight and support to a staff operating in widely disparate intervention models with their differing change theories, assessment protocols, outcome measures and time frames. In the related arena of training, similar problems can be found, including almost exclusive reliance on the use of external (and often expensive) consultants during the start-up phase of a model intervention with unclear plans for transition of oversight to internal agency staff. Moreover, the determinants for training foci in some agencies remain strongly with worker interests and are not necessarily related to client characteristics. Of particular concern among many smaller, voluntary service settings in the USA is the factor of agency history. Many such agencies were residential in their origins, typically following a pathway from orphanage to treatment setting. Thus, boards of governors and major donors may be more oriented to place-based services and ‘bricks & mortar’ than to community-based programme alter- natives. A quote from a senior head in one such agency captures the tension for those in leadership: ‘How do I insure that my program plan for the agency is in synchrony with my business plan?’ (K. Scott 2002, personal communication).

Evidence-based intervention for high-risk youth J K Whittaker

S U M M A R Y A N D TA K E - AWAY M E S S AG E S

The growing corpus of research on evidence-based approaches to work with troubled youth and their families offers both hope and challenge. In the area of alternatives to residential services for high-resource- using youth, model programmes like MST, MTFC and wraparound appear to hold much promise, but their full-scale adoption into existing service systems will require addressing a series of complex implemen- tation challenges. Public sector children’s services often work with families who are challenging to engage and for whom permanency and continued child safety remain as core service objectives. The sensitive application of evidence-based programmes and practices into the real world of contemporary child and family practice must necessarily involve parents, social workers, model developers and researchers in bidirectional communication. All of these efforts will benefit greatly from sustained and multilevel cross-national collaboration. Of the several US originated programme models identified in this brief review, virtually all are intruding to some degree on the work-plans of service planners, evaluation researchers, supervisors and practitioners in Europe, Australia and elsewhere. Similarly, interventions or intervention components as varied as ‘Patch’ (geo- graphically centred, generalist services) (Adams & Krauth 1995) and ‘Family Group Conferencing’ (Pennell & Anderson 2005) have come to the USA from the UK, New Zealand and elsewhere in recent years. Since all of these ‘imports’ will likely undergo modification and appear again as ‘exports’, it behoves staff at all of the above levels to carefully track how these novel interventions are being incorporated into widely differing political, geographic, cultural and organizational contexts. Fortunately, the wide avail- ability of instantaneous, direct, point-to-point elec- tronic communication and the increasing prominence of cross-national journals, networks and conferences make such communication more possible than ever. From a research perspective, the widely varying envi- ronments into which model programmes are being introduced hold the distinct possibility for compara- tive research, including natural experiments.

For youth and family practitioners, service agencies and researchers and policy-makers, some concrete take-aways include: 1. For practitioners

• Challenge the ‘conventional wisdom’ of practice wherever it resides – including in your own per- sonal theories of change: for example, ‘insight is a

requisite for behaviour change’; ‘longer service produces better outcomes’. • Seek out and read one up-to-date review of inter- ventions most relevant to the children and youth you presently work with. Discuss what you have garnered with peers.

2. For researchers • Focus on application to real-world practice in your dissemination efforts: for example, ‘What are the top five practice implications of your latest study and where might these most usefully be dis- seminated?’ • Seek practice-partners for agency-centred research projects specifically focused on issues of implementation of evidence-based practices.

3. For child and family service agencies • Discover first what is working within the agency and build on that as a foundation before purchas- ing ‘off-the-shelf ’ models. • Develop an internal capacity to systematically analyse routinely gathered data at the case level and aggregate level and ‘mine’ this information to inform practice.

4. For the service system/policy level • Here, and speaking from a parochial perspective, with all of our resources in the USA, we are sorely in need of a new structure or body within a state or authority that ‘connects-the-dots’ between relevant service policy, research and practice in support of enhancing the implementation of evidence-based practices to improve outcomes. While the title and organizational form for such a body proves elusive – clearinghouse? executive steering committee for evidence-based programme improvement? – its key function should be to focus laser-like attention on the question of what is most important in evidence-based practice implementation in a state, local authority or region: What do we need to learn over the next 12 months? How will we learn it? How will we decide ‘what-trumps-what’: Cost? Urgent service need? Level of evidence? Cultural relevancy? Organizational compatibility? Special opportunity to experiment with proven efficacious model programmes? While the fruits of such a new body would be experienced locally, one hopes that its field of vision and, eventually, its impact would extend cross-nationally.

In sum, evidence-based practice has added greatly to the ‘tool kit’ of social services in the identification of proven efficacious models of intensive intervention such as those referenced earlier in this paper.That said, the task of scaling-up these exemplars is proving to be

Evidence-based intervention for high-risk youth J K Whittaker

complex and challenging, and will require both focused attention on the multiple contextual elements that impede and enhance the adoption of evidence- based alternatives, as well as a critical re-examination of existing biases – for example, the current and often reflexive negative attitudes towards residential provi- sion in any form – that underlay current services plan- ning. Both of these conversations will be greatly enhanced by multilevel, sustained and data-oriented cross-national collaboration among practitioners, service planners and researchers. Fortunately, through technological innovations such as electronic commu- nication, the means for such collaboration are close at hand. High-resource-using youth and their families presently in, or at risk of entering the intensive services system, will be the ultimate beneficiaries of our efforts.

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