Evidence-Based Clinical Reasoning in Children's Mental Health Services

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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 10, 2007

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Acknowledgments
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Acknowledgments
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Acknowledgments
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Acknowledgments
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The Story of John

• A Tale of Two Cultures

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This is John.
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Premise

• As researchers attempt to implement multiple
  EBTs, they come across the practitioners reality
• This was my experience with the CAMHD Practice
  Development Section

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Practitioner Concerns

• Fixed content
• Fixed intensity
• Fixed length
• Single target approach
• Replacement

• Empty cell problem
• Crowded cell problem
• Expiration problem

Aarons (2004) Addis Krasnow (2000) Addis,
Wade, Hatgis (2004) Chorpita, Daleiden,
Weisz (2005) Kimhan Chorpita (2006) Persons
(1995)
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Throw out the Bath WaterKeep the Baby

• Move away from the idea that Problem A gets
  Treatment B
• We decided to map the decisions made at the
  system level not just the IF-THEN of treatment
  selection
• Goal To build an Evidence Based System

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Where should we treat the client?
Service Setting
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How should we treat the client?
Service Setting
Therapeutic Practices
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Are we providing quality service to the client?
Service Setting
Therapeutic Practices
Treatment Integrity
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Is the client getting better?
Service Setting
Therapeutic Practices
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Who should treat the client?
Service Setting
Therapeutic Practices
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How should we manage the treatment?
Service Setting
Therapeutic Practices
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Treatment programs formalize these elements
Service Setting
Therapeutic Practices
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Selecting a program structures other decisions
Service Setting
Tx Program Selection
Therapeutic Practices
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Selecting a program structures other decisions
Multisystemic Therapy (MST) Example
Service Setting
Home Community Based
Tx Program Selection
Therapeutic Practices
MST
Family Therapy, etc.
4 5 Members
Team Supervisor Cross-Team Supervisor
TAMS SAMS
Instrumental Ultimate Outcomes
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Valid alternatives to deciding by program?
Service Setting
Tx Program Selection
Therapeutic Practices
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How should we make decisions?
Service Setting
Tx Program Selection
Therapeutic Practices
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How should we make decisions?
General Services Research
Service Setting
Tx Program Selection
Therapeutic Practices
Evidence-Based Services Model
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How should we make decisions?
Causal Mechanism Research
Service Setting
Tx Program Selection
Therapeutic Practices
Case-Specific Historical Information
Individualized Case Conceptualization Model
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How should we make decisions?
Service Setting
Local Aggregate Evidence
Tx Program Selection
Therapeutic Practices
Case-Specific Historical Information
Practice-Based Evidence Model
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The Full System Model
General Services Research
Causal Mechanism Research
Service Setting
Local Aggregate Evidence
Tx Program Selection
Therapeutic Practices
Case-Specific Historical Information
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The Phases of Evidence

• Data Discretely identifiable units
• Information Data in a context that provides it
  meaning
• Knowledge Information helpful to decision-making
• Wisdom Knowing when to apply our knowledge

c.f., Speigler, I. (2000). Knowledge management
A new idea or a recycled concept? Communications
of the Association for Information Systems, 3, 1
23.
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The Phases of Evidence Example

• Data 70
• Information 70º F
• Knowledge It is warm enough to wear shorts.
• Wisdom I am giving a professional talk today, so
  my knowledge that it is warm enough to wear
  shorts is irrelevant to my attire.

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The Phases of Evidence Managing Evidence Bases

• Data Define and capture relevant data
• Information Organize and analyze into meaningful
  units for consumers
• Knowledge Deliver the information to the
  decision-making situation
• Wisdom Prioritize use of the knowledge bases

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General Services ResearchTurning Data into
Knowledge I

• Meta Analysis of Childrens Treatment Research
• Over 300 studies, 60 years
• Largest meta-analysis to date
• Made dynamic for providers

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Results Anxiety

• Best Support

• Good Support

• CBT
• Education
• Exposure
• Modeling

• Assertiveness Training
• Cognitive Behavior Therapy and Medication
• Cognitive Behavior Therapy with Parents
• Hypnosis
• Play Therapy
• Relaxation

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Results Trauma

• Best Support

• Good Support

• CBT

• Cognitive Behavior Therapy with Parents
• Play Therapy

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Results Attention

• Best Support

• Good Support

• Contingency Management
• Parent Management Training
• Self Verbalization
• Behavior Therapy and Medication

• Biofeedback
• Contingency Management
• Education
• Management Training and Problem Solving
• Physical Exercise
• Relaxation and Physical Exercise
• Social Skills and Medication

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Results Depression

• Best Support

• Good Support

• CBT
• CBT and Medication

• Client Centered Therapy
• Cognitive Behavior Therapy with Parents
• Interpersonal Therapy
• Play Therapy
• Relaxation

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Results Conduct

• Best Support

• Good Support

• Assertiveness Training
• Cognitive Behavior Therapy
• Contingency Management
• Exposure
• Modeling
• Parent Management Training
• Social Skills

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

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How do we get this knowledge to the treatment
team?
General Services Research
Causal Mechanism Research
Service Setting
Local Aggregate Evidence
Tx Program Selection
Therapeutic Practices
Case-Specific Historical Information
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General Services ResearchTurning Data into
Knowledge II

• Common Elements approach
• Identified components of evidence based practices
• Generated profiles using a decision tree approach

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Is there a different level of analysis?
Family
Protocol
Protocol
Protocol
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Is there a different level of analysis?
Parent Training
Incredible Years
PCIT
Defiant Children
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Is there a different level of analysis?
Family
Protocol
Protocol
Protocol
Practice Element
Practice Element
Practice Element
Practice Element
Practice Element
Practice Element
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Is there a different level of analysis?
Parent Training
Incredible Years
PCIT
Defiant Children
Commands
Commands
Attending
Time Out
Time Out
Rewards
These are practice elements.
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Example
Attending
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PracticeWise Evidence Based Services Practice
Element Profile Anxiety Levels I and II
September 05, 2007
Proportion of Studies (n 91)
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PracticeWise Evidence Based Services Practice
Element Profile Trauma Levels I and II
September 05, 2007
Proportion of Studies (n 10)
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PracticeWise Evidence Based Services Practice
Element Profile Attention Levels I and II
September 05, 2007
Proportion of Studies (n 25)
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PracticeWise Evidence Based Services Practice
Element Profile Depression Levels I and II
September 05, 2007
Proportion of Studies (n 24)
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PracticeWise Evidence Based Services Practice
Element Profile Conduct Levels I and II
September 05, 2007
Proportion of Studies (n 89)
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The Full System Model
General Services Research
Causal Mechanism Research
Service Setting
Local Aggregate Evidence
Tx Program Selection
Therapeutic Practices
Case-Specific Historical Information
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Case Specific HistoryTurning Data into
Knowledge III

• Clinical Dashboard
• Progress
• Practices

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A Foray into Wisdom
New Case?
EBS Database
Select Evidence- Based Service (EBS)
yes
Start
no
Critical Incidents Complaints Reports, etc.
Significant concerns?
Consult with specialists as needed
yes
no
Clinical Dashboard Progress Pane
Clinical Progress?
Continue plan until goals met
yes
EBS DB, Local Best Practices, Tx Team
no
Clinical Dashboard Practice Pane
Prob. w/ Tx Selection?
Identify barriers and revise plan
yes
no
Options 1. Increase supports 2. Change
Intervention 3. Further Consultation 4. Add
intervention
Therapy Protocols, Dashboards, EBS DB,
Consultation
Treatment Integrity?
yes
Consider adding consultation or training supports
no
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A Foray into Wisdom
New Case?
EBS Database
Select Evidence- Based Service (EBS)
yes
Start
no
Critical Incidents Complaints Reports, etc.
Significant concerns?
Consult with specialists as needed
yes
no
Clinical Dashboard Progress Pane
Clinical Progress?
Continue plan until goals met
yes
EBS DB, Local Best Practices, Tx Team
no
Clinical Dashboard Practice Pane, EBS DB
Prob. w/ Tx Selection?
Identify barriers and revise plan
yes
no
Options 1. Increase supports 2. Change
Intervention 3. Further Consultation 4. Add
intervention
Therapy Protocols, Dashboards, EBS DB,
Consultation
Treatment Integrity?
yes
Consider adding consultation or training supports
no
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A Foray into Wisdom
New Case?
EBS Database
Select Evidence- Based Service (EBS)
yes
Start
no
Critical Incidents Complaints Reports, etc.
Significant concerns?
Consult with specialists as needed
yes
no
Clinical Dashboard Progress Pane
Clinical Progress?
Continue plan until goals met
yes
EBS DB, Local Best Practices, Tx Team
no
Clinical Dashboard Practice Pane, EBS DB
Prob. w/ Tx Selection?
Identify barriers and revise plan
yes
no
Options 1. Increase supports 2. Change
Intervention 3. Further Consultation 4. Add
intervention
Therapy Protocols, Dashboards, EBS DB,
Consultation
Treatment Integrity?
yes
Consider adding consultation or training supports
no
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A Foray into Wisdom
New Case?
EBS Database
Select Evidence- Based Service (EBS)
yes
Start
no
Critical Incidents Complaints Reports, etc.
Significant concerns?
Consult with specialists as needed
yes
no
Clinical Dashboard Progress Pane
Clinical Progress?
Continue plan until goals met
yes
EBS DB, Local Best Practices, Tx Team
no
Clinical Dashboard Practice Pane, EBS DB
Prob. w/ Tx Selection?
Identify barriers and revise plan
yes
no
Options 1. Increase supports 2. Change
Intervention 3. Further Consultation 4. Add
intervention
Therapy Protocols, Dashboards, EBS DB,
Consultation
Treatment Integrity?
yes
Consider adding consultation or training supports
no
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This tells you the treatment types that work for
this problem.
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This tells you the practice elements associated
with those treatment types.
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Do the practices fit the problem?
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A Bit of Practice Wisdom
New Case?
PW Database
Select Evidence- Based Service (EBS)
yes
Start
no
Critical Incidents Complaints Reports, etc.
Significant concerns?
Consult with specialists as needed
yes
no
Clinical Dashboard Progress Pane
Clinical Progress?
Continue plan until goals met
yes
PW DB, Local Best Practices, Tx Team
no
Clinical Dashboard Practice Pane, PW DB
Prob. w/ Tx Selection?
Identify barriers and revise plan
yes
no
Options 1. Increase supports 2. Change
Intervention 3. Further Consultation 4. Add
intervention
Therapy Protocols, Dashboards, PW DB,
Consultation
Treatment Integrity?
yes
Consider adding consultation or training supports
no
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Select new practices?
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Seek Consultation?
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Results in HawaiiFrom Daleiden, Chorpita,
Arensdorf, Donkervoet, Brogan (2006)
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Avoid Hospital Residential Services for Conduct
Disorders MST Initiative
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Quality Reviews System Performance
Quality Dimension Examples Functional
Assessment Service Coordination Transition
Long-term view Caregiver Supports Service
Plan Implementation Effective Results
Service Array Integration Monitoring
Modification
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Quality Reviews Child Status
Quality Dimension Examples Learning
Progress Community Home Personal
Responsibility Caregiver Functioning
Safety/Personal Well-being Child/Family
Satisfaction Emotional/Behavioral Well-being
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Rate of Improvement?
Final Effect Size for Change .07/mo, .84/yr
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Getting Better at Getting Them Better
Start of 2002
End of 2004
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Greater Impairment Treated at Less Restrictive
Levels of Care
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Cost per Outcome
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This is John now.
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Thank You!

• Questions?