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What are Clinical Evidence-based Practices?

Practitioners seldom have as much evidence as they would like about the best clinical approach to use in any given clinical situation. To choose the optimal approach for each client, clinicians must draw on research, theory, practical experience, and a consideration of client perspectives. Picking the best option at the moment using the best information available has been termed “evidence-based thinking”.  Evidence-based practices are approaches to prevention or treatments contrast to approaches that are based on tradition, convention, belief, or anecdotal evidence.

What is an Evidence-Based Practice?
by Teryn Mattox and M. Rebecca Kilburn                                                                                                 

Promising Practices Network on Children, Families and Community
Facing a growing emphasis on accountability for achieving results in the area of children and family services, decision makers such as funders and service providers are increasingly making programmatic choices based on the best research evidence. But what is the best available research evidence? And how can decision makers without research training make sense of that evidence?

Programs shown to be effective through rigorous research are known as evidence-based practices (EBPs). EBPs have garnered a new prominence in the field of child and family services in the past decade. Federal funding streams have increasingly been tied to research evidence, particularly around programming related to children and youth.   Concurrent with these trends, the field of child and family studies has become savvier in designing and publishing research studies, with the goal of establishing research evidence in support of programs and practices that improve outcomes for children and their families. However, the research evidence supporting these programs can be of varied quality. This can be problematic, because there is no single set of standards against which EBPs are evaluated in the field of child and family services.

Evidence-based Practices Resources

EBP resources vary according to the evidence required to accept a program or practice. For instance, some resources require a program or practice to offer replication materials or have demonstrated that replication is feasible. They can also differ on whether they admit practices or programs with evaluations that have any weaknesses. For example, some federal EBP resources, such as the What Works Clearinghouse and HomVEE, use a more rigid formula than other groups.  This exactitude is beneficial as a means of ensuring consistency, but in certain cases may also lead to rejection of high-quality studies on technicalities.

While the specifics may differ, substantial similarities remain across EBP resources in the requirements for a program to be labeled “evidence-based,” “proven,” a “model program,” etc. In Table 1, we identify the requirements for the top tier of evidence for each of the major EBP resources on a number of dimensions:

  • Topical focus — All EBP resources restrict the programs that they include to those that target a certain set of outcomes or target groups. Promising Practices Network, for example, includes only programs affecting children and families, while Office of Juvenile Justice and Delinquency Prevention includes only juvenile justice or delinquency programs.
  • Research design — A program evaluation’s design affects the legitimacy of its results. Randomized controlled trials are generally accepted as the research design that best minimizes threats to the validity of a study’s findings, but other designs may be acceptable, including quasi-experimental designs, nonrandomized controlled trials, prospective or retrospective cohort studies, cross-sectional studies, case control studies, case series and registries, and case reports.
  • Statistical significance — Statistical significance is a measure of how certain evaluators are that the effects observed for the group that received the treatment are different from those for a group that did not receive the treatment. The threshold for statistical significance is one area where most EBP definitions are in agreement.
  • Practical significance — It is possible for a measured outcome to be statistically significant but too small in size to actually matter in practical terms. For example, a preschool program may be shown to increase by one letter the number of letters a child can identify. While this may be statistically significant, knowing one more letter of the alphabet may not be practically significant given the costs of the program. Practical significance can be subjective, so “effect sizes,” a statistical measure of the size of a program impact, are typically used.
  • Attrition — Attrition occurs when study participants drop out of the research study over time. They might drop out of the treatment group, the nontreatment group, or both. Attrition can compromise a research study—for example, by changing the composition of the participants so that the individuals remaining in the study no longer represent the population that the intervention aims to affect.
  • Quality of outcome measures — Evaluated programs monitor changes in outcome measures to establish that the program is effective. Outcomes can be measured in various ways, such as child hospitalizations, teenage substance use, or family functioning. Some EBP resources require that the outcome measures used have been established in the academic literature as valid measures (that is, the measures assess what they say they do) and exhibit other desirable properties, such as consistency across repeated measurement. Additionally, some resources require that measures reflect a change in some outcome measure of real value rather than just participation in the intervention.
  • Publication or authorship requirements — Some EBP resources require that program evaluation findings be published in a peer-reviewed journal. Others require that the evaluation be independently conducted by individuals other than the program developers.
  • Replication — An initial program evaluation shows that a program is effective in that particular context, but a successful replication of the program shows that the program can be effective in other contexts. Some EBP resources require that evaluation findings have been replicated in order to achieve the highest tier of evidence.

Resources

 

Promising Practices Network (PPN) on Children, Families and Community                                            PPN is a group of individuals and organizations who are dedicated to providing quality evidence-based information about what works to improve the lives of children, families, and communities.  http://www.promisingpractices.net/

 

What Works Clearinghouse                                                                                                                        An initiative of the U.S. Department of Education’s Institute of Education Sciences, the What Works Clearinghouse was created in 2002 to be a central and trusted source of scientific evidence for what works in education.  http://ies.ed.gov/ncee/wwc/

 

Home Visiting Evidence of Effectiveness (HomVEE)

The Department of Health and Human Services launched Home Visiting Evidence of Effectiveness (HomVEE) to conduct a thorough and transparent review of the home visiting research literature and provide an assessment of the evidence of effectiveness for home visiting programs models that target families with pregnant women and children from birth to age 5.  http://homvee.acf.hhs.gov/

 

The Office of Juvenile Justice and Delinquency Prevention’s Model Programs Guide (MPG) is designed to assist practitioners and communities in implementing evidence-based prevention and intervention programs that can make a difference in the lives of children and communities. The MPG database of over 200 evidence-based programs covers the entire continuum of youth services from prevention through sanctions to reentry. The MPG can be used to assist juvenile justice practitioners, administrators, and researchers to enhance accountability, ensure public safety, and reduce recidivism. The MPG is an easy-to-use tool that offers a database of scientifically-proven programs that address a range of issues, including substance abuse, mental health, and education programs. http://www.ojjdp.gov/mpg/

 

California Evidence-Based Clearinghouse for Child Welfare (CEBC)                                                                     The California Evidence-Based Clearinghouse for Child Welfare (CEBC) provides child welfare professionals with easy access to vital information about selected child welfare related programs. The primary task of the CEBC is to inform the child welfare community about the research evidence for programs being used or marketed in California.* The CEBC also lists programs that may be less well-known in California, but were recommended by the Topic Expert for that Topic Area.  http://www.cebc4cw.org/

Center for the Study and Prevention of Violence Institute of Behavioral Sciences, University of Colorado Boulder                                                                                                                           The Blueprints mission is to identify truly outstanding violence and drug prevention programs that meet a high scientific standard of effectiveness.                                                                                                             http://www.blueprintsprograms.com/

Coalition for Evidence-Based Policy (CEBP)                                                                                         CEBP seeks to increase government effectiveness about what works in social interventions.  http://coalition4evidence.org/

United States Department of Health and Human Service Substance Abuse and Mental Health Services Administration (SAMSHA) 

SAMHSA’s National Registry of Evidence-based  Programs and Practices (NREPP)                                                       NREPP is a searchable database of interventions for the prevention and treatment of mental health and substance use disorders.  NREPP is a searchable online registry of more than 290 interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment.  The site additionally connects members of the public to intervention developers so they can learn how to implement these approaches.  NREPP is not an exhaustive list of interventions, and inclusion in the registry does not constitute an endorsement. http://nrepp.samhsa.gov/

SAMHSA’s Guide to Evidence Based Practices (EBP) on the Web                                                                                                                       This guide provides a list of Web sites with information about specific EBPs or reviews of research findings. It could be helpful to stakeholders seeking to promote awareness of current research and to increase the implementation and availability of evidence-based practices (EBPs).   SAMHSA provides this Web Guide to assist the public with simple and direct connections to Web sites that contain information about interventions to prevent and/or treat mental and substance use disorders.  The Web Guide provides a list of Web sites that contain information about specific evidence-based practices (EBPs) or provide comprehensive reviews of research findings.  The Web Guide can be used by stakeholders throughout the behavioral health field to promote awareness of current intervention research and to increase the implementation and availability of evidence-based practices (EBPs).  SAMHSA and the U.S. Department of Health and Human Services (HHS) do not necessarily endorse the programs and practices described on the featured Web sites, or promote the use of related materials. The views, policies, and opinions expressed on the featured Web sites are those of the organizations maintaining the Web site and/or the Web site authors and do not necessarily reflect those of SAMHSA or HHS.  You can either browse evidence-based practices by area or by age group using the links in the left navigation menu. http://www.samhsa.gov/ebp-web-guide

Choosing the Right Treatment- What Families Need to Know about Evidence-Based Practices (for children)                                                                                                                                                         This guide was designed by the National Alliance on Mental Illness (NAMI) to inform families on evidence-based practice (EBPs) in children’s mental health and to share information on an array of treatment and support options.  http://www.nami.org/Content/NavigationMenu/NAMILand/CAACebpguide.pdf

Autism Research and Evidence Based Practice

National Autism Center’s Evidence-Based Practice Autism in the Schools

A Guide to Providing Appropriate Interventions to Students with Autism Spectrum Disorders Eleven Established Treatments

 

Applies Behavior Analysis (ABA)                                                                                                                                 ABA is the design, implementation and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses antecedent, stimuli and consequences, based on the findings of descriptive and functional analysis, to produce practical change. Simply put, ABA is the application of behavioral principals to everyday situations which will, over time, increase or decrease a target behavior.  ABA providers are charged with the improvement of socially significant behaviors. Socially significant behaviors include communication, social skills, academics, reading and adaptive living skills such as gross and fine motor skills, toileting, dressing, eating, personal self-care, domestic skills, and work skills. ABA is a discipline that employs objective data to drive decision-making about an individual’s program. Data is collected on responses made by the individual to evaluate a particular intervention and determine its effectiveness.  Research demonstrates ABA is an effective treatment for those with Autism, developmental disabilities, mental illness including schizophrenia, ADHD and, traumatic brain injury.  In addition Behavior Analysts work in forensics, organizational management, and with individuals dealing with issues such as drug addiction.   Applied behavior analysis (ABA) is a science developed to the understanding and improvement of human behavior.  Behavior analysts focus on objectively defined and measured behaviors of socially significance (e.g., social, language, academic, daily living, vocational, and leisure skills).  ABA is a scientific approach for identifying variables that reliably influence socially significant behavior, which allows for the development of effective behavior change procedures.  ABA has more empirical evidence supporting its efficacy than any other approach in terms of teaching individuals with autism and related developmental disabilities.  http://www.abainternational.org/

 

Childhood Trauma Evidence Based Practices

Attachment, Self-Regulation and Competency (ARC)                                                                    ARC is a framework for intervention with youth and families who have experienced multiple and/or prolonged traumatic stress.   Recognized by the National Child Traumatic Stress Network (NCTSN) as a promising practice, ARC is a comprehensive framework for intervention with youth exposed to complex trauma. Intervention is tailored to each client’s needs and may include individual and group therapy for children, education for caregivers, parent-child sessions, and parent workshops.  ARC is a framework for intervention with youth and families who have experienced multiple and/or prolonged traumatic stress. ARC identifies three core domains that are frequently impacted among traumatized youth, and which are relevant to future resiliency. ARC provides a theoretical framework, core principles of intervention, and a guiding structure for providers working with these children and their caregivers, while recognizing that a one-size-model does not fit all. ARC is designed for youth from early childhood to adolescence and their caregivers or caregiving systems.         http://www.traumacenter.org/research/ascot.php

 

Applies Behavior Analysis (ABA)                                                                                                                                 ABA is the design, implementation and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses antecedent, stimuli and consequences, based on the findings of descriptive and functional analysis, to produce practical change. Simply put, ABA is the application of behavioral principals to everyday situations which will, over time, increase or decrease a target behavior.  ABA providers are charged with the improvement of socially significant behaviors. Socially significant behaviors include communication, social skills, academics, reading and adaptive living skills such as gross and fine motor skills, toileting, dressing, eating, personal self-care, domestic skills, and work skills. ABA is a discipline that employs objective data to drive decision-making about an individual’s program. Data is collected on responses made by the individual to evaluate a particular intervention and determine its effectiveness.  Research demonstrates ABA is an effective treatment for those with Autism, developmental disabilities, mental illness including schizophrenia, ADHD and, traumatic brain injury.  In addition Behavior Analysts work in forensics, organizational management, and with individuals dealing with issues such as drug addiction.   Applied behavior analysis (ABA) is a science developed to the understanding and improvement of human behavior.  Behavior analysts focus on objectively defined and measured behaviors of socially significance (e.g., social, language, academic, daily living, vocational, and leisure skills).  ABA is a scientific approach for identifying variables that reliably influence socially significant behavior, which allows for the development of effective behavior change procedures.  ABA has more empirical evidence supporting its efficacy than any other approach in terms of teaching individuals with autism and related developmental disabilities.  http://www.abainternational.org/

 

Cognitive Behavioral Therapy (CBT)                                                                                                                    CBT is an empirically grounded, evidence based therapy. CBT has been researched for treatment of a wide range of difficulties including Depression, Anxiety Disorders (such as Obsessive-Compulsive Disorder (OCD), Generalized Anxiety Disorder (GAD), Specific Phobias, Panic Disorder, Agoraphobia, Social Anxiety / Social Phobia), Eating Disorders (including Obesity, Binge-eating Disorder, Anorexia, and Bulimia), Insomnia, Attention Deficit Disorder (ADD), Health Behaviors, and Habit Disorders.  CBT has been demonstrated in hundreds of studies to be an effective treatment for a variety of disorders and problems for adults, older adults, children and adolescents. Below is a list of disorders for which CBT is effective, followed by sources. http://www.academyofct.org

Dialectical Behavior Therapy (DBT)                                                                           DBT is a cognitive-behavioral treatment approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. “Dialectical” refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual.  http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=36

Mindfulness program shows promise

A study of the Mindfulness in Schools Project (MiSP) has shown that it reduces depressive symptoms, lowers stress, and increases well-being in teenagers.

The MiSP program is a complex intervention that includes elements for young people who are stressed and experiencing mental health difficulties, for those in the normal range of mental health, and for those who are flourishing. It consists of nine lessons given weekly. A non-randomized controlled feasibility study matched six secondary schools teaching the MiSP program with similar schools. Students aged 12-16 took part in the program and were tested before the intervention, after the intervention (two months later), and at follow-up (three months later). After the intervention, there was strong evidence of lower depression scores for those receiving the MiSP program. At follow-up, there was evidence of increased well-being, lower stress, and lower depression scores.

The authors say that the next step should be a randomized control trial with longer follow-ups to examine key processes and outcomes, and pay close attention to generalizability.

 

Treatments that are used more than moderately by 50% or more of respondents:

  • CBT
  • DBT
  • Problem Solving Therapy for Depression
  • Psycho-education for Bipolar Disorder
  • Self Management for Depression
  • Social Learning /Token Economy
  • Family Behavior Therapy
  • Life Skills Training

 

 

Acceptance and Commitment Therapy for Depression
Applied Relaxation for Panic Disorder
Behavior Therapy/Behavioral Activation for Depression
Cognitive Behavioral Therapy
Dialectical Behavior Therapy
Emotion-Focused Therapy for Depression
Exposure and Response Prevention for Obsessive-Compulsive Disorder
Exposure Therapies for Specific Phobias
Eye Movement Desensitization and Reprocessing for Post-Traumatic Stress Disorder
Family Based Treatment for Eating Disorders
Healthy-Weight Program for Bulimia Nervosa
Interpersonal Therapy for Depression
Interpersonal Psychotherapy for Bulimia Nervosa
Interpersonal and Social Rhythm Therapy for Bipolar Disorder>
Problem-Solving Therapy for Depression
Prolonged Exposure for Post-Traumatic Stress Disorder
Psychoeducation for Bipolar Disorder
Self-Management/Self-Control Therapy for Depression
Self-System Therapy for Depression
Short-Term Psychodynamic Therapy for Depression
Social Learning/Token Economy Programs
Social Skills Training for Schizophrenia
Brief Strategic Family Therapy (BSFT)
Multidimensional Family Therapy (MDFT)
Psychoeducational Multifamily Groups (PMFG)
Adolescent Community Reinforcement Approach (A-CRA)
Family Behavior Therapy
LifeSkills Training (LST)
Motivational Enhancement Therapy (MET)
Motivational Interviewing
Multisystemic Therapy (MST) for juvenile offenders
Relapse Prevention Therapy (RPT)

 

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