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Co-Occurring Disorders Best Practices and Adolescent

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Co-Occurring Disorders Best Practices and Adolescent Powered By Docstoc
					            Understanding
       Evidence-Based Practices
Ventura County Behavioral Health
April 29, 2009

Presented by Todd Sosna, Ph.D.
                  Topics
•   MHSA Prevention and Early Intervention
•   Research Informed Practice
•   Levels of Effectiveness
•   Rating Criteria Examples
•   Implementation Considerations
•   Intervention Categories
•   Examples of EBPs


                                             2
MHSA Spectrum of Services

                  I                    Early Intervention
             PE




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                                                                                                        ov
                                               Early
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                                                                Extended




                                                                                                            er
                                           Intervention




                                                                                                              y
   ev




                                                               Treatment
 Pr




                           Selective                           for Known
                                                               Disorders

                                                                          Recovery
                  Universal                                             and Resilience
                                                                          Supports


            MENTAL HEALTH SERVICES ACT (MHSA) SPECTRUM OF SERVICES
             Source: Adapted from Mrazek & Haggerty (1994) and Commonwealth of Australia (2000)




                                                                                                                  3
                    Prevention
• Services provided to individuals who do not have any
  signs of a mental illness
    – Universal: Provided to the general public or a whole
      population group that has not been identified on the
      basis of individual risk.
    – Selective: Provided to individuals or subgroups
      whose risk of developing mental illness is
      significantly higher than average.
• Promotes and supports emotional well-being
• Prevents the development of mental illness
• No time limits imposed

                                                         4
          Early Intervention
• Services for individuals with minimal signs of
  mental illness
• Short duration (less than 1 year*) and low
  intensity
  * except services for treatment of early signs
  of severe mental illness
• Prevents mental health condition from
  worsening
• Supports return to well-being
• Avoids need for more costly services

                                                   5
    Research Informed Practice
• The effectiveness of a service is one important
  consideration in care planning, sometimes referred
  to as evidence-based practices--planning that
  integrates
  – Professional expertise and judgment
  – Consumer and family values and preferences
  – Best research evidence on the effectiveness of
    services

  – Based on the definition used in “Crossing the Quality Chasm: A
    New Health System for the 21st Century” (2001), by the Institute
    of Medicine


                                                                   6
Why is Research Informed Practice?
• Mental health disorders can be complicated,
  severe, and difficult to prevent and treat
• The causes of these disorders are not fully
  understood
• Prevention and early intervention models are
  not effective for all individuals in all situations
• However, some interventions are more
  successful than others


                                                   7
Why Research Informed Practices?
• Evidence-based practices result in more
  individualized and hopeful treatment
  decisions, and
  – Reduce adverse consequences of imprecise
    care
  – Are more likely to be effective
  – Achieve outcomes sooner
  – Outcomes that last longer
  – Are ethical and cost effective, allowing limited
    resources to be used to serve more children
    and their families

                                                       8
     Levels of Effectiveness
• The degree to which research indicates
  that a service is effective, or responsible
  for achievement of an outcome
• Levels of evidence are on a continuum
• Level of evidence is related to the
  quality of the research



                                                9
            Quality of Research
• There is a tendency to assume that if a treatment was
  provided and there is improvement then the treatment
  caused the improvement
• However, positive outcomes may be achieved as a result
  of a number of factors unrelated to treatment
   – Spontaneous recovery: Individuals naturally strive for
     health, try strategies and seek social support to reduce
     distress and achieve their goals; often this is
     successful!
   – Placebo effect: Improvement associated with non-
     specific aspects of treatment, for example, the
     expectation of improvement, that is independent of the
     unique characteristics of the specific practice; also can
     be successful!

                                                             10
      Other Unrelated Factors
• Non-specific factors
   – Treatment leads to outcomes but for reasons
     unrelated to the theory or active components
• Independent factors
   – Employment
   – Friends
• Bias
   – Selection bias
      • More hope and motivation
   – Consumers bias
      • Want to be helpful
   – Providers bias
      • Want to show success

                                                    11
         Quality of Research
• Research is helpful in clarifying the effect
  of a practice independent of other factors
  that promote health, and independent of a
  proponent’s bias in favor of the practice
• Quality of research studies vary
• The higher the quality of research, the
  greater the confidence in the conclusions
  of the study

                                                 12
          Quality of Research
• Qualitative studies
  – Anecdotal observations
  – Case studies
• Quasi- or partially controlled experimental
  studies
  – Within-subjects or longitudinal (pre and post
    comparison) studies
  – Between groups comparisons without assignment
• Controlled experimental studies
  – Random clinical trials (between groups)
  – Random clinical trial-longitudinal studies

                                                    13
             Quality of Research
• Qualitative studies are especially helpful in
  developing theories and practice elements
• Quasi-experimental studies provide support for the
  effectiveness of a practice but do not control for the
  influence of important factors
• Controlled studies provide the strongest evidence
  that the practice, and not other factors, is
  responsible for achievement of specific outcomes
• Studies vary in their ability to answer questions
  about if the intervention works (internal validity) and
  with whom (external validity) the intervention works


                                                        14
              Internal Validity
• Level of confidence that the practice is
  responsible for the outcome
• Answers the question “Does it work?”
  – Typically involves highly controlled research
    studies
  – Homogenous populations (for example, to
    diagnosis, gender, ethnicity)
  – Standard, verified application of the practice
    (for example, practitioner is highly trained and
    supervised by the developer)
                                                       15
            External Validity
• Level of confidence that the practice will be
  effective across diverse groups of individuals
• Answers the question “Will it work in my
  community?”
  – Also, involves highly controlled studies
  – Heterogeneous populations (for example, dual
    disorders, both genders and diverse ethnicities)
  – Replication in diverse (public mental health)
    usual care settings with diverse clients and
    practitioners
                                                   16
         Levels of Effectiveness
• Evidence-based practice
   – Clearly articulated model
   – Substantial and credible evidence of positive
     outcomes based upon experimental or equivalently
     strong research methods (replication)
• Promising practice
   – Clearly articulated model
   – Generally consistent evidence of positive outcomes
     based upon qualitative or quasi-experimental
     research methods (may have replications)
• Emerging
   – Clearly articulated model, sound theory, intention to
     evaluate

                                                         17
    Reviews of Effectiveness
• SAMHSA National Registry of Evidence Based
  Practices
                                  http://www.nre
  pp.samhsa.gov/index.htm
• SAMHSA--A Guide to EBPs on the Web
• http://www.samhsa.gov/ebpWebguide/index.asp




                                              18
     Confidence in a Practice
• No practice works with all individuals

• Confidence in achieving a positive
  outcome is increased when controlled
  research has demonstrated that the
  practice is effective, in real world settings
  and with individuals from diverse
  backgrounds


                                                  19
 Fidelity or Model Adherence
• Degree to which there is adherence to the
  model (high quality)
• Model adherent programs are most likely
  to result in achievement of similar
  outcomes to those reported in the
  research




                                              20
   Model Adherence or Fidelity
• Degree to which there is adherence to the
  model (high quality)
• Model adherent programs are most likely to
  result in achievement of similar outcomes to
  those reported in the research
• Drift from the model (poor fidelity) can
  jeopardize achievement of outcomes
• Achieving fidelity or model adherence is an
  important consideration
• Requires the practice be ready to disseminate


                                                  21
   Fidelity or Model Adherence
• Requires the community be ready to adopt
   – Consumer and family readiness
   – Staff readiness
   – Agency readiness
   – Service system readiness
• Implementing and sustaining an intervention with
  model adherence requires--
   – Training
   – Coaching (ongoing)
   – Monitoring and evaluation (ongoing)

                                                     22
       Causes of Program Drift
• Insufficient training or supervision
• Staff are not interested in or oppose the
  practice
• Practitioners with multiple or competing duties
• Failure to adhere to practice specific workload
  standards
• Insufficient intra- and inter-agency coordination
  around referrals, related services, and so forth



                                                  23
      Causes of Program Drift
• No administrative level champion
• Little or not attention to fidelity monitoring
• Increased scrutiny and accountability
• Interest in adapting the practice before it is
  well-established
• Attrition of practice-proficient practitioners
• Delays between training and service provision
• Competing initiatives


                                                   24
              Implementing
• Designate an administrator/manager lead to
  champion learning and using the model
• Develop a concrete intervention-specific
  implementation plan
• Select providers/staff based on a full
  understanding of the intervention requirements
  and commitment to achieving and maintaining
  fidelity
• Adhere to practice workloads and related
  intervention characteristics

                                              25
             Implementing
• Focus on fidelity from the outset
• Support fidelity thorough training, coaching,
  monitoring, and evaluation
• Maintain momentum
• Expect and plan for interrupted progression
• Expect and plan for staff turnover
  (replacement training)


                                              26
                     Selecting
• Fit with target population including cultural relevance
• Fit with intended outcome(s)
• Level of demonstrated effectiveness
   – Level of research support
   – Internal and external validity
• Readiness to be implemented and sustained with
  model adherence
   – Tried and proven training protocols
   – Tools for monitoring model adherence and
     outcomes

                                                            27
                     Selecting
• Select a practice with a high level of demonstrated
  evidence
• Select a practice that is valued by consumers,
  families and community
• Select a practice with a history of successful
  implementation across diverse communities
   – Relevant to MHSA PEI priority populations and
     intended outcomes
   – Suitable for use in Ventura County
   – Culturally sensitive and responsive to the diverse
     communities that comprise Ventura County


                                                          28
        Intervention Categories
• Education campaign --Universal Prevention
   – Triple P Parenting
   – Adolescent Transition Program
• Regular education curriculum --Universal Prevention
   – Incredible Years
   – Promoting Alternative Thinking Strategies
• Parenting program
   – Incredible Years
   – Triple P Parenting
   – Parent-Child Interaction Therapy
   – SafeCare


                                                        29
        Intervention Categories
• Family therapy
   – Functional Family Therapy
   – Multisystemic Therapy
   – Multidimensional Family Therapy
   – Brief Strategic Family Therapy
• School-based parent/child program
   – Family and Schools Together
   – Strengthening Families Program
   – Adolescent Transition Program
• Comprehensive
   – Nurse Family Partnership


                                       30
        Intervention Categories
• Disorder specific early intervention
   – Trauma
      • Trauma Focused Cognitive Behavior Therapy
      • Cognitive Behavioral Intervention for Trauma in
        Schools
   – Depression
      • Depression Treatment Quality Improvement
   – Psychosis
      • Early Detection and Intervention for the Prevention
        of Psychosis
• Foster Care
   – Multidimensional Treatment Foster Care


                                                          31
              Triple P Parenting
• Children 0-16 years of age
• Parenting program
• Five levels of intervention
• Universal prevention, early intervention, and treatment
• Individual and group modalities
• Numerous random clinical trials
• Real world (South Carolina) trial
   – Improves parenting skills
   – Decrease in parental stress and depression
   – Decrease in child behavior problems
   – Improves parent anger management skills
   – Decreases social isolation
• www.triplep.net/

                                                            32
                   Incredible Years
• Children 0-12 years of age
• Three sets of comprehensive developmentally based
  curriculums for parents, teachers and children to promote
  emotional and social competence
• Universal prevention, early intervention, and treatment
• Strengthens parents’ and teachers’ competence in
  communication, child directed play, clear limit setting, effective
  (nonviolent) discipline
• Numerous random clinical trials
• Use with diverse populations and settings
   – Less behavior problems
   – Increases in effective parenting
   – Less parental depression and increase in esteem
• www.incredibleyears.com/

                                                                   33
                        PATHS
• Children in elementary school
• Classroom curriculum to promote social-emotional
  competence and reduce behavior problems
• Self-control, feelings and relationships, interpersonal
  cognitive problem solving units
• Universal prevention
• Random clinical trials
• Use with diverse populations and settings
   – Improved self-control and ability to tolerate frustration
   – Use of more effective conflict resolution strategies
   – Decreased report of conduct problems and symptoms of
     depression and anxiety
• http://www.prevention.psu.edu/projects/PATHS.html

                                                            34
 Parent Child Interaction Therapy
• Children 2-8 years of age and their parents, at risk of or
  presenting conduct problems
• Parent guided (by therapist) in interacting with their child
• Early intervention and treatment
• Numerous random clinical trials
• Use with diverse populations and settings
   – Improved parenting skills
   – Improved child behavior
   – Improved quality of parent-child relationship
   – Improved parental affect and personal distress
• Developed by Eyberg at University of Florida
• UC Davis http://www.pcittraining.tv/Default.asp

                                                                 35
      Functional Family Therapy
• Youth 11-18 years of age, and their families, showing family
  conflict or serious delinquency, violence and/or substance
  use
• Strength-based, phasic family therapy involving 12-16
  sessions
• Numerous random clinical trials
• Use with diverse populations and settings
   – Low treatment drop out rate
   – Reduction in violent behavior and criminal activity
   – Improved family interactions
   – Reduced younger siblings’ high risk behaviors
• www.fftinc.com

                                                           36
   Strengthening Families Program
• Children 3-17 years of age
• Parent and family skills training program
• 14 weekly child and parent (individual and combined) skills
  building sessions
• Early intervention and treatment
• Random clinical trials
• Use with diverse populations and settings
   – Improved parenting skills
   – Improved child behavior
   – Improved family communication, and child problem
     solving and anger control
• http://www.strengtheningfamiliesprogram.org/


                                                           37
        Nurse-Family Partnership
• First time, low-income mothers (any age)
• Selective prevention involving home visitation, by public health
  nurses, intensively supporting maternal-prenatal and early
  childhood health, and well-being, over a 2 year period
• Focus on parental roles, family and friend support, physical
  and mental health, home and neighborhood environment, and
  major life events (e.g. pregnancy planning, education,
  employment)
• Random clinical trials
• Use with diverse populations and settings
   – Improved prenatal health
   – Increased maternal employment
   – Reduced childhood injuries
• www.nursefamilypartnership.org

                                                              38
•
                       TF-CBT symptoms
  Children 4-18 years of age with trauma
• Individual sessions (weekly) with the child, parent and joint
  child-parent (12-16 sessions)
• Therapeutic relationship, psycho-education, emotional
  regulation, stress management, connecting thoughts-feelings
  and behaviors, gradual in vivo exposure, cognitive and
  affective processing of trauma experiences, personal safety
  and skills training
• Numerous random clinical trials
• Use with diverse populations and settings
   – Decreases PTSD symptoms
   – Decreases negative attributes (self-blame)
   – Decreases externalizing problem behaviors
   – Improves parent-child relationship
• http://tfcbt.musc.edu/

                                                            39
                       DTQI
• Adolescents to young adults (ages 13-22) with depression
• Comprehensive approach to managing depression
• Screening and assessment, CBT psychosocial treatment,
  symptom monitoring and management, relapse prevention,
  individual and group formats
• Random clinical trials
• Use with diverse populations and settings
   – Improved mood
   – Decrease in depression symptoms
   – Decrease in suicide ideation and behaviors
• Developers Joan Asarnow (UCLA) & Maggie Rea,         (UC
  Davis)


                                                        40
                        EDIPP
• Teenagers to adults at-risk of psychosis
• Universal prevention, early intervention, and treatment
• Educational campaign to reduce stigma and barriers to
  treatment, and increase identification of individuals
  showing signs of psychotic disorders by community
  members (e.g teachers, doctors, nurses, police officers,
  parents), and use of assertive case management model
• Promising practice
• Several community-based trials in process
   – Delayed onset of psychotic disorders
   – Reduced symptoms
   – Improved functioning
• http://preventmentalillness.org/

                                                             41
                        MTFC
• In lieu of group home care for children ages 3-5
  (preschool), 6-11 (child), and 12-17 (adolescent)
• Multi-level child and family-focused behavioral foster care
  program
• Numerous random clinical trials
• Use with diverse populations and settings
   – Increase foster parent competencies
   – Decrease in child behavior problems
   – Improved parenting
   – Decreases parental stress and depression
   – Increase in social support
   – Promotes reunification and reduces juvenile crime
• http://www.mtfc.com/

                                                                42
      EBP Common Features
• Clearly articulated models
   – Curriculum or phases or strategies
   – Specific intervention goals
   – Defined start and end
   – Can be replicated
• Emphasis on engagement as an early goal of
  intervention and responsibility of practitioner
• Specific target populations
• Specific target outcomes
• Grounded in research-based theory

                                                    43
         Contact Information
• California Institute for Mental Health
  – web: www.cimh.org
  – Todd Sosna
  – email: tmq@verizon.net
  – Phone: (916) 549-5506




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