Applying Evidence Based Practices

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Applying Evidence Based Practices

• Todd Sosna, Ph.D.

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Objectives

• Review research data on the effectiveness of
  corrections programs
• Review the scientific hierarchy that supports
  evidence based approaches
• Review data on the prevalence of emotional
  disorders among youth in the juvenile justice
  system
• Review assessments for juvenile justice youth
• Review specific evidence based programs and
  approaches
• Data cited in this presentation on the
  effectiveness of corrections programs is
  reproduced from Edward J. Latessa, Ph.D. at the
  University of Cincinnati

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Effectiveness of Corrections Programs

• Not a single reviewer of studies of the effects
  of official punishment (custody, mandatory
  arrests, probation, increased surveillance, etc.)
  has found consistent evidence of reduced
  recidivism
• At least 40 and up to 60 of the studies of
  correctional treatment services reported reduced
  recidivism rates relative to various comparison
  conditions, in every published review

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Criminal Sanctions versus Treatment
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Behavioral vs. Non-behavioral
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Major Set of Risk/Need Factors

• Antisocial/pro-criminal attitudes, values,
  beliefs and cognitive-emotional states
• Pro-criminal associates and isolation from
  anti-criminal others
• Temperamental and personality factors conducive
  to criminal activity including
• Psychopathy
• Weak Socialization
• Impulsivity
• Restless Aggressive Energy
• Egocentrism
• Below Average Verbal intelligence A Taste For
  Risk
• Weak Problem-Solving/Self-Regulation Skills

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Major Set of Risk/Need Factors

• A history of antisocial behavior
• Evident from a young age
• In a variety of settings
• Involving a number and variety of different acts
• Familiar factors that include criminality and a
  variety of psychological problems in the family
  of origin including
• Low levels of affection, caring and cohesiveness
• Poor parental supervision and discipline
  practices
• Out right neglect and abuse
• Low levels of personal educational, vocational or
  financial achievement.

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Minor Set of Risk/Need Factors

• 1. Lower class origins as a assessed by adverse
  neighborhood conditions and/or parental
  educational/vocational/economic achievement
• 2. Personal distress including
• Sociological constructs of anomie, strain and
  alienation
• Clinical psychological constructs of low
  self-esteem, anxiety, depression, worry, or
  officially labeled mentally disordered
• 3. A host of biological/neuropsychological
  indicators

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Principles of Effective Correctional Intervention

• Treatment interventions should be used primarily
  with higher risk offenders
• Target the known criminogenic predictors of crime
  recidivism
• Treatment services should be cognitive-behaviora
  l
• A range of other considerations, if addressed,
  will increase treatment effectiveness
• Responsivity targeting lack of offender
  motivation
• Interventions in community rather than
  institution
• Well trained, interpersonally sensitive staff
• Assist with other needs of offenders
• Close monitoring of offenders whereabouts
  associates
• Follow offenders after they have completed the
  program give structured relapse prevention
  aftercare

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What Doesnt Work With Offenders?

• Non-directive counseling
• Increasing cohesiveness of delinquent/criminal
  groups
• Targeting non-crime producing needs
• Vague unstructured rehabilitation programs
• Self-actualization through self-discovery
• Punishing smarter
• Military Style Boot camps
• Shaming Programs
• Scared Straight

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What Works

• Results from the Ohio Halfway House and CBCF
  Study Program Effects
• Edward J. Latessa, Ph.D.
• Chris Lowenkamp, M.S.
• Center for Criminal Justice Research
• Division of Criminal Justice
• University of Cincinnati
• Cincinnati, OH 45221
• www.uc.edu/criminaljustice

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Effective Programs Have Certain Characteristics

• Are based on research sound theory
• Have strong leadership
• Assess offenders using risk need assessment
  instruments
• Target crime producing behaviors
• Use effective treatment models
• Vary treatment services based on risk, needs,
  responsivity factors
• Disrupt criminal networks
• Have qualified, experienced, dedicated educated
  staff
• Provide after care
• Evaluate what they do
• Are stable have sufficient resources support

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Levels of Evidence

• Effective-achieves child/family outcomes in usual
  care settings
• Efficacious-achieves child/family outcomes under
  controlled conditions
• Promising-some positive evidence of success
  and/or expert consensus
• Not effective- significant evidence of a null,
  negative, or harmful effect
• Model Program-Structured or prescribed
  efficacious or effective intervention
• Proven Approach-General strategy common to a
  number of efficacious or effective programs

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Merits of Evidence-Based Practice

• Achieves outcomes sooner that last longer
• Avoids the adverse consequences of under or over
  serving
• Ethical
• Cost effective

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Multiple, Severe Needs
Goal(s) not achieved OVERSERIVCE UNDERSERVICE
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Consequences of Misfit

• UNDERSERVING
• Outcomes are not achieved
• Wasted expenditure of time and resources
• Unrealized hopes
• Loss of confidence in effectiveness of future
  interventions

• OVERSERVING
• Exposes child and family to overly intrusive and
  restrictive interventions
• Unnecessary costs
• Fosters dependence and undermines child/family
  autonomy

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Challenges of Evidence-Based Practice

• Evidence-based practices are based on sterile
  and limited research conditions that are not
  applicable to public mental health settings
  (efficacious)
• Often there are differences in key areas that
  influence effectiveness
• Clientele
• Practitioners
• Service delivery models
• Providers
• Financing

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Challenges of Evidence-Based Practice

• There are too few practices that have been
  researched
• Many good practices have not been rigorously
  studied
• Many current practices are the same or similar to
  evidence-based practices
• Evidence based practices are too prescribed
  restricting clinician and consumer preferences

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Implementing

• Adopting-Implementing with fidelity program
  principles and practices. Generally requires
  extensive training and supervision
• Adapting-Applying the key principles or practices
  of an evidence based program

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Application to Usual Care Settings

• Be aware of the effective and efficacious
  programs and approaches
• Be clear about adopting versus adapting issues
• When possible and appropriate use a model program
• Otherwise, use a proven approach
• Or, gather evidence on the approach that is
  selected and prove the approach used
• Stop using unsuccessful and harmful approaches

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Application to Usual Care Settings

• Assess risk and needs
• Match risk/needs with interventions
• Use cognitive and behavioral approaches
• Target factors that contribute to crime
• Probation staff need to model and reinforce
  pro-social behavior, in addition to safety and
  correction activities
• Mental health staff need to use proven approaches
  and model programs
• Program wide consistency and fidelity to
  assessment and treatment
• Do less really really well

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Californias Juvenile Justice Mental Health Needs

• 126,312 youth booked into juvenile halls
• 14,216 daily average detention
• 7,000 youth in the 11 Youth Authorities
• About 53,000 youth on probation and parole
• 1,097 youth in detention received psychiatric
  medications
• 19 have suicidal thoughts
• 73 of SED youth who dropped out of school were
  rearrested within 5 years

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Juvenile Justice Mental Health Needs

• 50-90 show conduct disorder
• 45 ADHD
• 6-40 anxiety disorders
• 30-80 mood disorders
• 1-6 psychotic disorders
• 25-50 substance use disorders
• 25-35 history of abuse
• 6-28 history of suicide attempts
• 12-26 history of psychiatric hospitalization
• 40-65 history of outpatient mental health
  treatment

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Assessment

• Risk
• Re-offendingYouth Level of Service (YLS)-Case
  Management Inventory
• Emotional disorderMassachusetts Youth Screening
  Instrument (MAYSI)-2nd Version
• SuicideSuicide Probability Scale
• Treatment (needs)
• Corrections interventionsYLS
• Mental health interventionsDiagnostic Interview
  Schedule for Children (DISC)-IV
• EffectivenessCDC Evaluation Framework
  (http//www.cdc.gov/eval/framework.htm)
• Fidelity to treatment model
• Reduction in crime
• Improvement in pro-social and well being outcomes

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Proven Programs

• Functional family therapy
• Multidimensional therapeutic foster care
• Multi-systemic therapy
• Fostering individualized assistance program
  (FIAP) wraparound

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Functional Family Therapy

• Targets at-risk and juvenile justice involved
  youth
• Based on theory, clinical experience and
  scientific research
• Builds on protective factors, and reduces risk
  factors
• Therapist assumes responsibility for
• Engagement
• Develops interventions that give family members
  hope even before behavior change occurs
• Work with families to develop a roadmap for
  change
• Provide them tools to be successful in the
  context of their own values and culture
• Treatment is conducted in phases
• Phases have specific goals, assessment foci,
  specific techniques of intervention, and clinical
  skills necessary for success
• Engage and motivate, change behavior, generalize

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Functional Family Therapy

• Wide range of interventionists
• Paraprofessionals, social workers, marriage and
  family therapists, psychologists, psychiatrists
  and nurses
• Full time therapist will serve 12-15 families at
  one time
• Average duration of service is 3-4 months
• Cost effective
• On average costs 2,100 per youth
• 8-30 sessions of direct service
• Site certification and training
• Teams of 3-8 interventionists

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Functional Family Therapy

• Demonstrates strong outcomes
• Reduces recidivism from 25-60
• Reduction in violent behavior
• Reduces siblings entry into high risk behaviors
• Low drop out from treatment
• Reduces family conflict
• Improves family communication
• Improves parenting
• Washington State Institute for Public Policy
• The average size of the crime reduction effect
  -.25
• Net direct cost of the program per client 2,161
• Net benefits per participant 14,149 to 59,067

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Engage and Motivate

• Engagement and motivation are essential and need
  to occur prior to initiating behavior change
  techniques
• Decreasing the intense negativity (Blaming,
  hopelessness)
• Therapist uses respect, sensitivity and
  reattribution techniques
• Therapists work to develop respect for each
  family member
• Therapist need to use relational skills including
• Sensitivity to personal and cultural issues and
  values
• Ability to link behavior to affect and to
  cognition
• Willingness to hear the pain of all family
  members without taking sides or balanced alliance
• Use of positive reframing is important
• NOTE Reframes and supportive interventions are
  associated with positive effects , as opposed to
  reflective, structuring, and acknowledging
  techniques

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Change Behavior

• Reduce and eliminate problem behaviors and
  accompanying family relational patterns through
  individualized behavior change interventions
• Therapists need to use structuring skills
• Ability and willingness to plan interventions
  that are individualized and respectful to all
  family members
• Match behavior change techniques to the
  interpersonal functions of all family members
• Cognitive/attributional component integrated into
  skill-training
• Communication training, Family-specific tasks,
  Technical aides, Basic parenting skills,
  Contracting and response-cost techniques, Problem
  solving, Conflict management

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Generalize

• Increase familys capacity to utilize community
  resources, across service systems
• Increase familys capacity to engage in relapse
  prevention
• Therapists will intervene directly into service
  systems, if needed, until family develops the
  ability to do so
• Therapists need to
• Know the community including have a current list
  of providers/agencies, know the transportation
  system, know the school system, know juvenile
  laws
• Develop contacts with specific individuals in
  each agency
• Be prepared to address release of information
  regulations and reporting laws
• Refer to follow-up services consistent with
  family members relational needs, culture and
  abilities

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Site Certification

• Submit application and discuss plans with FFT
  training committee
• Site prepares for FFT training
• Site purchases needed items (e.g. computer
  software)
• FFT site interviews and hires therapists
• Site schedules 2 day CSS Implementation 3 day
  Clinical training
• Site purchases FAM III YOQ, OQ-45, and POSIT
• New FFT therapists complete CSS Web Tutorial
• Site installs FFT Clinical Service System
  software
• One day FFT overview and site review two day
  FFT Clinical Service System
• Three day on-site clinical training for all FFT
  therapists
• Therapists begin to serve youth
• Weekly telephone supervision (one team member
  attends the externship), three 2-day follow-up
  visits
• Year end site assessment

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Multidimensional Therapeutic Foster Care

• Targets teenagers with delinquency histories
• Designed as an alternative to incarceration or
  group home care
• Youth is place in a Therapeutic Foster Home
• One youth per home
• 24/7 support for foster parent and natural
  parents
• Youth receive weekly individual therapy with
  focus on developing effective
• Problem solving skills
• Social skills
• Emotional regulation skills
• Parents attend weekly family therapy with focus
  on effective parenting and family management
• Youth attend public school, with daily monitoring
  of attendance and performance

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Multidimensional Therapeutic Foster Care

• Training and support for foster parents
• 20 hours of pre-service training based on social
  learning theory taught to use a daily behavior
  management program in their homes
• Foster parents attend a weekly group meeting run
  by a program case manager where ongoing
  supervision is provided
• Supervision and support through daily telephone
  calls
• Services for youth's family
• Family therapy for the youth's biological (or
  adoptive) family
• Intensive parent training--parents are taught to
  use the structured system that is being used in
  the foster home
• Supervised home visits
• Parents have frequent contact with the case
  manager

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Multidimensional Therapeutic Foster Care

• Coordination between the case manager and the
  youth's parole/probation officer, teachers, work
  supervisors, and other involved adults
• 12 month of follow up services following
  reunification
• Total ongoing program costs are about 120 per
  day
• Total training, consultation and clinical
  supervision costs for the first year are about
  40,000

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Multidimensional Therapeutic Foster Care

• Demonstrates strong outcomes
• Fewer arrests (less than half the rate of the
  control group)
• Fewer incarceration and group home placement days
• Greater completion of treatment and fewer AWOLs
• Improved school performance
• Less hard drug use
• Improved emotional well being
• Average length of stay is seven months
• Average costs 2,691 per month
• Washington State Institute for Public Policy
• The average size of the crime reduction effect
  -.37
• Net direct cost of the program per client 2,052
• Net benefits per participant 21,836 to 87,622

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Training and Supervision

• Initial two-day site visit with cross agency
  stakeholders focusing on program model and
  structural/staffing requirements
• Training at the Eugene, Oregon training site,
  three-days
• Foster parent recruitment consultation
• Second site visit, two-days training foster
  parents and starting the Parent Daily Report
• Weekly telephone consultation with case managers
• Three subsequent, follow-up visits, two-days each

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Staffing

• Program director to oversee the program
• One full time case manager for every 10 youth
• Masters level clinician with supervisor
  experience
• Supervises the treatment team, responsible for
  coordination
• Available 24/7
• One half-time individual therapist for every 10
  youth
• Masters level clinician
• One half-time family therapist for every 10 youth
• Masters level clinician
• Full time foster care recruiter/trainer Parent
  Daily Report caller
• Experienced with foster care and the program, may
  be a former foster parent
• Skills trainer, about 15 hours weekly for 10
  youth
• Bachelors education
• Often involving after-school activities

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Multisystemic Therapy

• Targets chronic, violent, or substance abusing
  offenders at high risk of out of home placements,
  and their families
• Demonstrates strong outcomes
• Fewer arrests
• Fewer days of incarceration
• Significantly less out of home placements
• Improved family functioning
• Less hard drug use
• Average costs 4,500 per youth
• Washington State Institute for Public Policy
• The average size of the crime reduction effect
  -.31
• Net direct cost of the program per client 4,743
• Net benefits per participant 31,661 to 131,918

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Multisystemic Therapy

• Home based model of service delivery
• Low caseloads (4-6 families per therapist)
• Time limited duration of treatment (typically 3-5
  months)
• Providers responsible for engaging the family in
  treatment
• Use cognitive-behavioral, behavioral , and family
  therapy interventions
• Provides intensive levels of flexible services
• Support available 24/7
• Build youth and parental skills
• Outcomes monitored continuously
• Supervision with clinicians focus on attaining
  outcomes
• Program fidelity is highly emphasized

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Staffing

• Two to four therapists and a supervisor
• Masters or highly skilled bachelors level
• Supervisor is typically doctoral level clinician
• Provide support 24/7 support
• Access to a small flexible fund
• 4-6 families per therapist

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Site Certification

• Pre-training site assessment, and assistance
  developing quality control and outcome tracking
  system
• Five days of intensive on-site orientation
  training
• Four, quarterly, 1.5 day booster trainings
• Ongoing, weekly telephone consultation
• Completion of MST treatment session logs
• Training and supervision costs range from 15,000
  to 24,000 per MST team

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Fostering Individualized Assistance
Program--Wraparound

• Targets youth 7-15 with history of out-of-home
  placements
• In one study, 2.6 years in placement and four
  placements per year on average
• Demonstrates Positive Outcomes
• Reduces delinquency
• Increases likelihood of permanent living
  arrangements

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Fostering Individualized Assistance
Program--Wraparound

• Strength-based child and family assessment
• Life domain area service planning to support and
  enhance permanency plans
• Clinical case management of individualized,
  wraparound service plans
• Follow-along supports and services
• Family specialist responsible for case
  management, collaborating with parents and
  providers, and home based counseling

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Recommendations

• Establish a wraparound team for each child
• Use a family specialist (clinical case manger)
  empowered to provide wraparound services
• Complete a comprehensive assessment
• Ensure unconditional commitment, not deny but
  adjust services
• Remove incentives for not providing effective,
  individualized family centered care
• Family specialist caseload not to exceed 10 youth
• Empower family specialist to broker and purchase
  services, monitor participation and outcomes, and
  make adjustments
• Protect against premature termination of parental
  rights
• Include natural parents in treatment planning and
  decision making
• Provide family specialist weekly clinical
  supervision
• Link permanent parents with naturally occurring
  supports
• Advocate with school staff to ensure each child
  receives appropriate educational services

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Resources

• Washington State Institute for Public Policy
• Surgeon Generals Report on Preventing Youth
  Violence
• Substance Abuse Mental Health Services
  Administration (SAMHSA) Model Program Matrix

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Application to Usual Care Settings

• Leadership
• Political support
• Resources
• Financing
• Staff time
• Interest
• Feasible
• Manager/supervisor driven
• Patience

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Application to Usual Care Settings

• Assess risk and needs
• Match risk/needs with interventions
• Use cognitive and behavioral approaches
• Target factors that contribute to crime
• Probation staff need to model and reinforce
  pro-social behavior, in addition to safety and
  correction activities
• Mental health staff need to use proven approaches
  and model programs
• Program wide consistency and fidelity to
  assessment and treatment
• Do less really really well

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Application to Usual Care Settings

• Strong interagency collaboration
• Clear philosophy
• Clear model
• Intensive training
• Booster training
• Daily/every contact data
• Weekly supervision
• Evaluation of fidelity
• Evaluation of outcomes

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Which Interventions

• Structured cognitive-behavioral approach
• Aggression replacement therapy (ART)
• Dialectical Behavior Therapy (DBT)
• Thinking for a Change (T4C)
• Model program for high-risk youth
• Functional Family Therapy (FFT)
• Multisystemic Therapy (MST)
• Multidimensional Therapeutic Foster Care (MTFC)
• Wraparound--Fostering Individualized Assistance
  Program (FIAP)