1. University of Maryland School of Social Work Common Elements and Parent Training in Child Welfare Services Richard P. Barth, PhD, MSW University of Maryland School of Social Work University of Maryland School of Social Work Presented at AHRC seminar, 28 May, 2012 London School of Economics

2. Evidence Based Practices at a Crossroads Evidence based practices for children (families) with behavior problems are often manualized—Manualized Evidence Supported Treatments (MESTS) This impairs dissemination and may, also, limit effectiveness because the exact setting and sample for the RCT testing the EBP is not the one in which the EBP is implemented Is a common elements approach a way forward?

3. Parent Training in CWS Today Effective parent training programs have been developing for 40 years –Just now being tested with child welfare populations –Evidence-based parenting programs are predominantly unused for CWS parent training in the US –QUESTION: Should we increase uptake of evidence based parenting programs by increasing uptake of name brand or commodity (common elements) programs?

4. Is Effective Parent Training a Specialty Good (Name Brand) or a Commodity? A commodity is a good or service where there are no special, distinguishing characteristics among individual units of the good or service. One grain of wheat, one barrel of oil, one lump of coal is indistinguishable from another of its kind. The opposite of a commodity is a specialty or “brand name” good or service. Evidence based practices are, generally, by virtue of how they are developed treated as brand names. Specialty goods and services command higher prices because of their distinguishing features of being in limited supply. Commodities are much cheaper because there is a much larger supply and many sellers. Can evidence based practices for parent training be a commodities?

5. Generic Parent Training to Reduce Conduct Problems Among Children Exposed to Intimate Partner Violence Jouriles and Colleagues (2009) in Texas developed a parent training intervention for mothers who had just left a DV Shelter. Treatment based on general text books: Dangel & Polster (1988) and Forehand and McMahon (1981). Included 12 child management skills (listening to your child, praising, reprimanding) presented in sequence: one family at a time. Pre-training of therapists and regular in-service supervision was provide.

6. Greater improvement during parent training and continued improvement well into the normal range from “generic” parent training

7. University of Maryland School of Social Work The Common Elements Approach Step 1: Emphasis on evidenced- based treatments Step 2: Development of treatment manuals Step 3: Information overload: Too many treatment manuals to learn and manuals change as new knowledge is gained

8. How will I ever master all these Manualized Evidence Supported Treatments???

9. Overview of the Common Elements Approach Developed by Bruce Chorpita & John Weisz and colleagues for child mental health practice; AKA “Distillation & Matching Method”; Alternative/complement to using only manualized evidence supported interventions; Premise: Apply elements that are found across several evidence-supported interventions to flexibly meet client needs 9

10. How Were The Practice Elements Identified?  Trained coders reviewed 322 RCTs for major mental health disorders for children and teens;  Over $500 million invested in these research studies  Studies conducted over a span of 40 years  More than 30,000 youth cumulatively in the study samples  Approach: What features characterize successful treatments? What strategies are common across effective interventions? 10

11. Possible Advantages of the Common Elements Approach Flexibility to adapt practice to client needs or practice setting/structure; Practice elements derived from interventions with known effectiveness; Training practitioners on practice elements may be less cumbersome and was found to improve attitudes towards EBP (Borntrager et al., 2009); Practicewise resources facilitates implementation of common elements approach. 11

12. University of Maryland School of Social Work 12

13. Example of printable PDF describing practice element: Audience Goals of this practice element Steps for using this practice element 13

14. What practice elements in what order could be used with treating a conduct disordered youth? 14

15. Identify The Common Practice Elements That Match Youth Characteristics Results summarize the research evidence: intervention settings, format, related practice elements and their prevalence. Option to view supporting papers or protocols. 15

16. Results summarize the research evidence: intervention settings, format, related practice elements and their prevalence. Option to view supporting papers or protocols. Identify The Common Practice Elements That Match Youth Characteristics 16

17. What Works for a 12-year Old Girl With Depression? Client Details Practice Elements Treatments Setting Format evidence 17

18. Copyright restrictions may apply. Weisz, J. R. et al. Arch Gen Psychiatry 2012;69:274-282. Weisz et al. RCT Shows that Modular Approach to MH Treatment Works

19. Weisz et al (2012) Results Youth in modular treatment showed significantly faster improvement than youths in usual care, on overall and parent-reported behavior problem measures Modular treatment also outperformed standard (manualized) treatment, on behavior problem score. Outcomes in the standard manual condition did not differ significantly from outcomes in usual care.

20. Weisz et al. (2012) Conclusions A modular design allows a balanced flexibility—including much more evidence based practice content (83% vs. 8%) than usual care but also contained somewhat more “other” content (17% vs 7%) than manualized sessions. This suggests the greater flexibility of the modular treatment approaches. “It may be wise to learn the priorities of patients and their families and to focus on these when developing and adjusting treatment plans.” For youth mental health in particular, the findings suggest that intervention procedures developed and tested over the decades in randomized controlled trials do have value for clinical practice but that a systematic restructuring of those procedures may enhance their benefits for clinically referred youths who are treated by practitioners in everyday treatment settings.

21. Modularized PT is Ready to Go Interventions for conduct problems for children 3-12 could be modularized –The common elements are known –The catalyzing ingredient may be the common factors of getting client feedback and using a measurement feedback system that generates information shared with the clinician, parents, and child

22. Policy Changes Needed Allow agencies to go beyond name brands Expectation of use of evidence based parent training –Assess whether components of effective parent training are present (even if name brands are not) –Assess whether the processes of effective treatment are present Expectation of developmentally appropriate parent training –Parenting programs should vary with the very different parent and child needs associated with the child’s age

23. Partial References Allen, B., Gharagozloo, L., & Johnson, J. C. (2012). Clinician Knowledge and Utilization of Empirically-Supported Treatments for Maltreated Children. [Article]. Child Maltreatment, 17(1), 11-21. doi: 10.1177/1077559511426333 Barth, R. P., Landsverk, J., Chamberlain, P., Reid, J., Rolls, J., Hurlburt, M., et al. (2006). Parent training in child welfare services: Planning for a more evidence based approach to serving biological parents. Research on Social Work Practice, 15, 353-371. Chaffin, M., Funderburk, B., Bard, D., Valle, L. A., & Gurwitch, R. (2011). A Combined Motivation and Parent-Child Interaction Therapy Package Reduces Child Welfare Recidivism in a Randomized Dismantling Field Trial. [Article]. Journal of Consulting and Clinical Psychology, 79(1), 84-95. doi: 10.1037/a0021227. Chaffin, M., Hecht, D., Bard, D., Silovsky, J.F., Beasley, W.H. (In press). A statewide trial of the SafeCare home-based services model with parents in Child Protective Services. Pediatrics Chorpita, B. F., & Daleiden, E. L. (2009). Mapping Evidence-Based Treatments for Children and Adolescents: Application of the Distillation and Matching Model to 615 Treatments From 322 Randomized Trials. Journal of Consulting and Clinical Psychology, 77(3), 566-579. Jouriles, E. N., McDonald, R., Rosenfield, D., Stephens, N., Corbitt-Shindler, D., & Miller, P. C. (2009). Reducing Conduct Problems Among Children Exposed to Intimate Partner Violence: A Randomized Clinical Trial Examining Effects of Project Support. [Article]. Journal of Consulting and Clinical Psychology, 77(4), 705-717. doi: 10.1037/a0015994 Keenan, H. T., & Leventhal, J. M. (2010). A Case-Control Study to Evaluate Utah's Shaken Baby Prevention Program. [Article]. Academic Pediatrics, 10(6), 389-394. doi: 10.1016/j.acap.2010.08.005 Kolko, D. J., Baumann, B. L., Herschell, A. D., Hart, J. A., Holden, E. A., & Wisniewski, S. R. (2012). Implementation of AF-CBT by Community Practitioners Serving Child Welfare and Mental Health: A Randomized Trial. [Article]. Child Maltreatment, 17(1), 32-46. doi: 10.1177/1077559511427346 Kolko, D. J., Iselin, A. M. R., & Gully, K. J. (2011). Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center. [Article]. Child Abuse & Neglect, 35(2), 105-116. doi: 10.1016/j.chiabu.2010.09.004 Nelson, M. M., Shanley, J. R., Funderburk, B. W., & Bard, E. (2012). Therapists' Attitudes Toward Evidence-Based Practices and Implementation of Parent-Child Interaction Therapy. [Article]. Child Maltreatment, 17(1), 47-55. doi: 10.1177/1077559512436674 Shapiro, C. J., Prinz, R. J., & Sanders, M. R. (2012). Facilitators and Barriers to Implementation of an Evidence-Based Parenting Intervention to Prevent Child Maltreatment: The Triple P-Positive Parenting Program. [Article]. Child Maltreatment, 17(1), 86-95. doi: 10.1177/1077559511424774 Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K.,... Res Network Youth, M. (2012). Testing Standard and Modular Designs for Psychotherapy Treating Depression, Anxiety, and Conduct Problems in Youth. [Article]. Archives of General Psychiatry, 69(3), 274-282. doi: 10.1001/archgenpsychiatry.2011.147 Whitaker, D. J., Ryan, K. A., Wild, R. C., Self-Brown, S., Lutzker, J. R., Shanley, J. R.,... Hodges, A. E. (2012). Initial Implementation Indicators From a Statewide Rollout of SafeCare Within a Child Welfare System. [Article]. Child Maltreatment, 17(1), 96-101. doi: 10.1177/1077559511430722

24. THANK YOU