Kimberly D. Becker

Evidence-based practice at a crossroads: The timely emergence of common elements and common factors

Social work is increasingly embracing evidence-based practice (EBP) as a decision-making process that incorporates the best available evidence about effective treatments given client values and preferences, in addition to social worker expertise. Yet, social work practitioners have typically encountered challenges with the application of manualized evidence-supported treatments. For social work, the path to implementing the delivery of science-informed practice remains at a crossroads. This article describes two emergent strategies that offer a plausible means by which many social workers can integrate an EBP model into their service delivery—common factors and common elements. Each strategy will be presented, and related evidence provided. Tools to implement a common elements approach and to incorporate client feedback consistent with a common factors perspective will also be described. These strategies will be placed in the broader context of the EBP framework to suggest possible advances in social work practice and research.

Evaluation of the Brief Problem Checklist: Child and caregiver interviews to measure clinical progress

OBJECTIVE To support ongoing monitoring of child response during treatment, we sought to develop a brief, easily administered, clinically relevant, and psychometrically sound measure. METHOD We first developed child and caregiver forms of a 12-item Brief Problem Checklist (BPC) interview by applying item response theory and factor analysis to Youth Self-Report (YSR; Achenbach & Rescorla, 2001) and Child Behavior Checklist (CBCL;Achenbach & Rescorla, 2001) data for a sample of 2,332 youths. These interviews were then administered weekly via telephone to an ethnically diverse clinical sample of 184 boys and girls 7-13 years of age and their caregivers participating in outpatient treatment, to examine psychometric properties and feasibility. RESULTS Internal consistency and test-retest reliability were excellent, and factor analysis yielded 1 internalizing and 1 externalizing factor. Validity tests showed large and significant correlations with corresponding scales on paper-and-pencil administrations of the CBCL and YSR as well as with diagnoses obtained from a structured diagnostic interview. Discriminant validity of the BPC interviews was supported by low correlations with divergent criteria. Longitudinal data for the initial 6 months of treatment demonstrated that the BPC significantly predicted change on related measures of child symptoms. Estimates obtained from random coefficient growth models showed generally higher slope reliabilities for the BPC given weekly relative to the CBCL and YSR given every 3 months. CONCLUSIONS Given their combination of brevity and psychometric strength, the child and caregiver BPC interviews appear to be a promising strategy for efficient, ongoing assessment of clinical progress during the course of treatment.

Traumatic Stress Symptoms of Women Exposed to Different Forms of Childhood Victimization and Intimate Partner Violence

Interviews of women with (n = 193) and without (n = 170) recent exposure to intimate partner violence (IPV) were used to examine how IPV and past exposure to child abuse influence self-reports of posttraumatic stress disorder (PTSD) symptoms. The measurement of IPV included assessing psychological, physical, escalated physical, and sexual abuse. Women’s retrospective accounts of childhood victimization included reports of physical abuse, sexual abuse, and witnessing domestic violence growing up. Each form of adult IPV showed an independent association with PTSD symptoms, as did each form of childhood victimization. In regression models including child and adult abuse together, adult IPV and childhood sexual abuse were related to PTSD symptoms, and adult IPV mediated the association between childhood physical abuse and adult PTSD. Tests of the interactions between childhood and adulthood victimization on PTSD symptoms were not significant. Findings are discussed within the context of a life-course perspective of trauma.

Improvement in Symptoms Versus Functioning: How Do Our Best Treatments Measure Up?

We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts.

Maternal control behavior and locus of control: examining mechanisms in the relation between maternal anxiety disorders and anxiety symptomatology in children.

This study tested components of a proposed model of child anxiety and examined the mediational roles of (1) maternal control behavior, (2) maternal external locus of control, and (3) child external locus of control in the association between maternal and child anxiety. Thirty-eight clinically anxious mothers and 37 nonanxious mothers participated along with one of their children aged 6 to 14 (52.0% female; 78.7% Caucasian). Path analysis indicated that the overall model fit the data very well. Analyses also indicated that child external locus of control mediated the associations between (1) maternal and child anxiety and (2) maternal control behavior and child anxiety. Maternal anxiety was not related to maternal control behavior and maternal external locus of control was not associated with child anxiety. Findings are discussed in the context of theoretical models (e.g., Chorpita and Barlow 1998) regarding the transmission of maternal anxiety to their children and the specific roles of maternal behavior and child locus of control.

Coaching Teachers to Improve Implementation of the Good Behavior Game

This study explored the association between coaching and the implementation of the Good Behavior Game (GBG) by 129 urban elementary school teachers. Analyses involving longitudinal data on coaching and teacher implementation quality indicated that coaches strategically varied their use of coaching strategies (e.g., modeling, delivery) based on teacher implementation quality and provided additional support to teachers with low implementation quality. Findings suggest that coaching was associated with improved implementation quality of the GBG. This work lays the foundation for future research examining ways to enhance coach decision-making about teacher implementation.

Individual and School Organizational Factors that Influence Implementation of the PAX Good Behavior Game Intervention

Evidence-based interventions are being disseminated broadly in schools across the USA, but the implementation levels achieved in community settings vary considerably. The current study examined the extent to which teacher and school factors were associated with implementation dosage and quality of the PAX Good Behavior Game (PAX GBG), a universal classroom-based preventive intervention designed to improve student social-emotional competence and behavior. Specifically, dosage (i.e., number of games and duration of games) across the school year and quality (i.e., how well the game is delivered) of PAX GBG implementation across four time points in a school year were examined. Hierarchical linear modeling was used to examine the association between teacher-level factors (e.g., demographics, self-reports of personal resources, attitudes toward the intervention, and workplace perceptions) and longitudinal implementation data. We also accounted for school-level factors, including demographic characteristics of the students and ratings of the schools’ organizational health. Findings indicated that only a few teacher-level factors were significantly related to variation in implementation. Teacher perceptions (e.g., fit with teaching style, emotional exhaustion) were generally related to dosage, whereas demographic factors (e.g., teachers’ age) were related to quality. These findings highlight the importance of school contextual and proximal teacher factors on the implementation of classroom-based programs.

The Science of Training in Evidence-Based Treatments in the Context of Implementation Programs: Current Status and Prospects for the Future

Training plays a critical role within the broader implementation research agenda involving evidence-based treatments (EBTs). EBTs, interventions that have demonstrated client improvement within the context of controlled trials (Kazdin 2008), tend to be complex, multisession treatment packages that hinge largely on the provider’s execution of a set of interventions with a satisfactory level of fidelity (Carroll et al. 2010; Chorpita and Regan 2009; Herschell et al. 2010). Although training alone is not sufficient to guarantee successful implementation, there is evidence that adequate training can reduce variations in provider behavior, improve fidelity, and ultimately, increase the quality of service delivery (Aarons et al. 2011; Feldstein et al. 2008; Fixsen et al. 2005; Stirman et al. 2004) above and beyond that provided by therapy as usual (Schoener et al. 2006; Simons et al. 2010). In light of the central role training plays in the implementation of EBTs in mental health service delivery settings (Karlin et al. 2010; McHugh and Barlow 2010), efforts to scientifically examine the impact of training and to establish best practices in training are essential (Herschell et al. 2010). Our field is fortunate to be at the point at which EBTs have been designed, tested, and refined with much success; however, dissemination and implementation initiatives are still in their relative infancy (Becker et al. 2009). This early stage of evidence-based training development renders the field at a crossroads. One possible path parallels the traditional stage model of EBT development (Onken et al. 1997), with training methods developed and tested in university-based settings with tightly controlled conditions to demonstrate efficacy prior to testing effectiveness. As demonstrated by highly controlled studies of training (Miller et al. 2004; Sholomskas et al. 2005), this approach has merit inasmuch as information regarding necessary and sufficient training components, and optimal dosage, sequencing, and spacing of training can be identified (see Rakovshik and McManus 2010 for a review of these factors in the training of cognitive behavioral therapy). However, as the stage model of psychotherapy development has demonstrated, the needs of the field, in terms of understanding effective, efficient treatment strategies that can be deployed in less tightly controlled settings, easily outpace the stages of research (Institute of Medicine 2001). Similarly, given that advances in EBTs have outpaced the development of implementation supports (i.e., evidencebased training) (Fixsen et al. 2005), the ‘‘research-topractice gap’’ (McHugh and Barlow 2010) is at risk of continuing to widen, leaving a workforce with insufficient training and support in the very treatments that may have the best chance of improving the conditions of patients in need. An alternative path to promoting the science of training involves fitting the training program into the existing mental health delivery system (Stirman et al. 2010) to K. D. Becker (&) Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD 21205, USA e-mail: kbecker@jhsph.edu

A review of educational outcomes in the children's mental health treatment literature

We examined the measurement of educational outcomes related to childrens mental health treatments. A total of 85 papers describing 88 randomized controlled trials that included at least one educational outcome and one mental health outcome were included in these analyses. Forty-five different measures were identified as the primary educational outcome of interest in these studies. Educational measures reflected academic achievement (64.2%), academic and behavioural skills (20.1%), attendance (11.2%), quality of the learning environment (3.4%) and academic self-efficacy (1.1%). Positive educational outcomes were demonstrated by treatments delivered in school and non-school settings. There was a significant association between improvement on educational and mental health outcomes. Within the literature of childrens mental health treatments, few studies (14.86%) measure educational outcomes. Of those that do, there is significant diversity in measurement methods. Nevertheless, these results offer promise that mental health treatments can succeed in improving both mental health symptoms and educational performance.

Using the Classroom Check-Up model to support implementation of PATHS to PAX

The purpose of this paper is to describe the process of adapting the Classroom Check-Up (CCU) coaching model to bolster teacher implementation of a universal evidence-based social–emotional and classroom management intervention, PATHS to PAX. This paper includes a description of the intervention and a rationale for supporting implementation with the CCU coaching model. Findings from a feasibility test and initial pilot study are provided. Implications for school-based intervention implementation are also discussed.