Common Elements in Evidenced-Based Practice

(Originally published July 2014)

Decades before evidenced based practice became a hot topic in child welfare, a few theoretically minded scholars and practitioners engaged in speculation regarding the key elements of effective psychotherapies.  A number of comparative studies found that many seemingly dissimilar therapies helped approximately two-thirds of persons with “problems in daily living,” but not psychoses.  In the 1970’s, E. Fuller Torrey’s Witchdoctors and Psychiatrists: The Common Roots of Psychotherapy and Its Future identified four common features of effective therapeutic approaches around the world:  

                 

  • Naming the condition/ailment for which persons are seeking help

  • The personal characteristics of healers/ therapists that engender confidence in recipients regarding their healing powers

  • Creating an expectation that the therapeutic approach will be effective

  • Mastery of new skills that reduce or eliminate the condition/ailment

 

Careful consideration of Torrey’s list suggests the importance of a recipient’s confidence that (a) her condition/ailment has been accurately identified and is well understood, (b) the helper has an effective treatment and can be counted on to deliver it skillfully, (c) relief from the condition/ailment (perhaps affliction) is at hand and (d) the recipient of the “treatment” will develop skills that reduce suffering.

 

Torrey’s analysis provides a useful starting point for understanding the common elements of evidenced based practices (EBPs) utilized in child welfare settings, especially the dependence on mental health diagnoses widely accepted in Western societies, and in the emphasis on skill development that fosters a recipient’s sense of mastery in responding to his/her mental health conditions. There is, however, a notable difference between Torrey’s list and the standard features of programs that appear on authoritative lists of EBPs: the emphasis on program manuals that describe in detail the substance of EBPs and how they are to be delivered. The personal characteristics of therapists are given reduced importance in most EBPs except insofar as practitioners must develop therapeutic relationships with recipients of services that encourage and sustain program participation. The main source of confidence in delivering evidenced based practice is fidelity to a manualized program, not the personal characteristics of therapists.  

 

Given the insistence of developers on fidelity to detailed descriptions in program manuals, it is understandable that discussions of “active ingredients” of EBPs or evidenced based “kernels” has been met with resistance or silence in some quarters, or has led to an insistence that the “active ingredients” of EBPs are not well understood. Nevertheless, there continues to be a widespread interest in developing a better understanding of evidenced based practices that can be utilized independently of programs for reasons discussed by Embry and Biglan (2008):

 

  • EBPs are expensive to implement and sustain. Costs of training practitioners can amount to hundreds or thousands of dollars per person; and some developers charge large fees for consultation and/or fidelity monitoring. Furthermore, these are not one time costs either for training or fidelity monitoring.

  • Even if resources for EBPs were greatly increased, state child welfare systems would still have to add new programs gradually over a decade or two. In the meantime, child welfare practitioners, foster parents and others must respond to a wide range of urgent problems for which programs are lacking.  

  •  EBPs typically address a fairly narrow range of problems or conditions. Child welfare agencies that can only afford a handful of EBPs will continue to be challenged by numerous problems/conditions for which no EBP is available. Staff in child welfare agencies that lack programs for a wide range of urgent needs will be tempted to misuse EBPs for populations or problems for which they were not designed and for which they are not evidenced based.

  • Many problems – or behaviors – that affect child and family well-being “do not require lengthy or complex interventions involving consultations, workshops, training, or support,” Embry and Biglan assert. Delivering a costly program when a suggestion or two might suffice is foolish and wasteful.

  • If a child welfare agency delays adoption of EBPs, “thousands of individuals or families in geographic areas cannot avail themselves of strategies that might prevent school failure, substance abuse, mental illness, delinquency, or other ills.”

  • If, indeed, there are effective low cost prevention, intervention and treatment strategies that could be easily deployed and made available to large numbers of practitioners, foster parents and birth parents, it is of the utmost importance to make these strategies widely available, independent of program implementation.

 

Embry and Biglan also suggest the possibility of combining evidenced based practices (i.e., “kernels”) and programs in ways that can enable prevention initiatives to achieve population level effects. Triple P, the set of parenting interventions developed in Australia that is widely used around the world, disseminates information regarding specific evidenced based parenting practices to large numbers of parents and professionals using media campaigns, while also offering well developed intensive programs for higher need children and families. Triple P has demonstrated the capacity to reduce CPS reports, child injuries and out-of-home placements in a matched comparison study of counties in South Carolina. These encouraging results have recently been partially replicated in Ireland. Evidenced based “kernels” or “active ingredients” of EBPs have the potential to achieve population effects in child abuse prevention, something which dissemination of programs in and of itself is unlikely to ever achieve, in my view.

 

Common characteristics of evidenced based practices  

 

There are some common characteristics of EBPs that it would be misleading to describe as “active ingredients” or evidenced based “kernels” due to their generality. In 2001 Geraldine Macdonald commented regarding therapeutic interventions for child maltreatment that “Given the paucity of studies, and the methodological problems that accompany many of them … it is difficult to conclude anything other than that the available evidence base underpinning … therapeutic … interventions is wafer-thin. It is all the more serious that then that the evidence that is available is so rarely advocated, so rarely acted on, and the requisite practice skills so rarely taught on professional courses… One of the points of consensus in all the reviews to date is that behavioral and cognitive behavioral approaches have much to offer to the problems which need to be addressed if abuse and neglect are to be prevented from recurring …” Effective programs are usually concerned with both children’s and parents’ behavior and with their thinking, i.e., beliefs, attitudes and attributions of motives, that affect both behavior and parent-child relationships.

 

It would be a mistake to conclude that the limitations of research regarding EBPs are vastly different in 2014 than in 2001. In a 2013 article that summarized a review of almost 6,300 citations of research from 1990-2012, Fraser, et al, found only 17 randomized trials of interventions with children and families known to CPS systems that met their inclusion criteria. Some of these studies were of interventions designed to ameliorate the effects of child maltreatment on children, and some were studies of parenting interventions. Only a small number of studies met these authors’ rigorous methodological standards; and an even smaller number of programs were identified as evidenced based. These programs included CPC-CBT, TF-CBT and EMDR, trauma treatments that utilize a cognitive behavioral approach as well as other methods, along with two group treatments for sexually abused children/girls.  The authors conclude that “our review suggests that several interventions show promising child well-being comparative benefit.  However, our central finding was that comparative research remains relatively nascent in the child maltreatment arena, with striking substantive and methodological gaps in the literature.”

 

Parenting interventions on various lists of EBPs are delivered in a wide variety of ways, but they are all skill based and involve coaching and opportunities for parents to practice skills. The common belief among child welfare staff, scholars and advocates (until recently)  that parent education programs are an ineffective waste of time and resources may have been due to the basic error of assuming that information regarding positive parenting, absent practice of newly acquired parenting skills, would lead to improvements in parenting. Given the dramatic improvements in skill-based parenting programs, evidenced based parenting interventions may soon be recognized as among the most powerful time-limited interventions available in child welfare.

 

Evidenced Based Kernels / Active Ingredients

 

Embry and Biglan define evidenced based kernels as “any indivisible procedure shown through experimental evaluation to produce reliable effects on behavior,” a definition that resembles an ancient definition of atoms. These authors distinguish specific practices from nebulous “principles of effectiveness” along the lines discussed by Torrey. However, practices that consistently influence behavior may be different from elements of programs which, if removed, would render them ineffective, i.e., “active ingredients”.  For example, increased use of praise of children is such a common and fundamental part of evidenced based parenting interventions that dispensing with an emphasis on praise might render these programs inert; on the other hand, teaching parents to use “time out” for discipline may be an effective practice in some circumstances but not others.

 

Embry and Biglan acknowledge that many of the specific practices they identify as kernels “have more than a chance analogue in the wisdom traditions of cultures to influence the behavior of relatives, mates, and neighbors,” for example choral responding or recourse to breathing exercises (i.e.,  inhale through the nose, exhale through the mouth) to calm down. It is not the case that most EBPs have created methods of influencing behavior previously unknown; rather, developers have been adept at identifying kernels of behavioral influence and even active ingredients from a wide variety of sources including Buddhist meditation and mindfulness practices, as well as the vast literatures on parenting, trauma and attachment. One way of viewing EBPs is as clearly articulated bundles of kernels of behavior influence drawn from diverse sources, along with idiosyncratic approaches to program delivery.

 

Embry and Biglan list 52 kernels that involve use of consequences for behavior, for example increased use of praise and reduced use of punishment, practices that affect motivation, e.g., eliciting a public commitment to begin or stop behavior, or practices that alter biological functions in ways that affect behavior. Many of these kernels are educational strategies such as “beat the timer,” peer to peer tutoring, paragraph shrinking and team competitions. However, a number of these kernels can be used by parents, foster parents and adoptive parents: massage and other types of gentle touch, the “turtle” technique in which a child’s breathing through the nose, exhaling through the mouth is done with verbal or sub-verbal self-coaching and adult or peer reinforcement, “rough and tumble” free play with a higher status individual, nasal breathing as a means of calming down, use of non-verbal visual, auditory or kinesthetic  transition cues, aerobic play or exercise and several others.

 

Trauma-Informed Practice   

 

One of the most positive developments in child welfare during the past 10-15 years has been the increased interest in trauma as a framework for understanding both children and parents served by child welfare agencies, and dissemination of research on toxic stress, adverse childhood experiences and early brain development. The amount of useful information available to caregivers and professionals to help children with histories of trauma and other adversities far exceeds the capacity of agencies to deliver this information through foster parent training programs, evidenced based mental health programs and/or parenting education programs. In particular, foster parents and adoptive parents are hungry for information and guidance regarding how to overcome maltreated children’s resistance to developing new attachments, and how to help traumatized children feel safe and regulate their emotions.

 

The good news is that there are a large number of outstanding therapists, researchers, program developers and other experts who have translated lessons from trauma research into easily accessible books and articles: Judith Herman, Bessel van der Kolk, Bruce Perry, Deborah Gray, Ann Gearity, Glenn Saxe and many others. These authors combine a deep understanding of trauma and of its effects on both children and adults with a wealth of practical advice for caregivers and professionals. Some of this advice concerns attitudes and orientations that are helpful or unhelpful in working with traumatized persons, and some can be viewed as kernels of behavioral influence, for example:

 

  • Use of “patterned repetition” and reduced stimulation  to help children feel safe ( Bruce Perry and Maia Szalavitz)

  • Describing children’s intense emotional reactions to them as they occur or soon after as a means of developing children’s self-awareness and emotional vocabulary (Anne Gearity)

  • Staying close to children during  “meltdowns” rather than using time out (Anne Gearity)

  • Gradually increasing children’s exposure to new situations; expanding the comfort  zone of children who are afraid of exposure to trauma triggers (Deborah Gray)

  • Talking to school age children regarding their experiences prior to “meltdowns” and during the “revving” stage ( Glenn Saxe, et al)

 

Caregivers and professionals who work with children should apply these and other specific kernels with the understanding that “Coming back to arousal regulation must happen again and again … until the child expects that this is possible with adult help,” Anne Gearity states.

 

The main concern with widespread dissemination of kernels or “active ingredients” is not that to do so will undermine programs, or be viewed by agencies as a low cost alternatives to EBPs, but rather that it is often necessary to understand the rationale for practices and the context in which they are effective in order to use them wisely. The trauma experts listed above offer advice regarding specific practices and techniques as a part of a comprehensive in-depth discussion of child or adult reactions to trauma. How to combine explanations of conceptual frameworks with information regarding specific effective practices is an issue which all training programs must confront, and which proponents of the expanded use of evidenced based kernels and “active ingredients” have not yet adequately addressed.

 

References 

 

Embry, D. and Biglan, A., “Evidenced-based Kernels: Fundamental Units of Behavioral Influence,” Clinical Child and Family Psychological Review (2008),     

11, pp. 75-113.

 

Fraser,J., Lloyd, S., Murphy, R., Crowson, M, Zolotor, A., Coker- Schwimmer, E. & Viswanathan, M., “ A Comparative Effectiveness Review of Parenting and Trauma– Focused Interventions for Children Exposed to Maltreatment,” Journal of Developmental & Behavioral Pediatrics (2013), pp. 1-16.

 

Macdonald, G., Effective Interventions for Child Abuse and Neglect (2001), Wiley Publishers.

 

Torrey, E., Witchdoctors and Psychiatrists: The Common Roots of Psychotherapy and Its Future ( 1972, 1986), Jason Aronson.

  

Books or Articles on Trauma:

 

Gearity, Anne, Developmental Repair: A Training Manual (2009), Washburn Center for Children.

 

Gray, Deborah, Nurturing Adoptions (2007), Perspectives Press.

 

Herman, Judith, Trauma and Recovery (1997), Basic Books.

 

Perry, Bruce and Szalavitz, Maia, The Boy Who Was Raised As A Dog (2006), Basic Books.

 

Saxe, Glenn, Ellis, B. Heidi & Kaplow, Julie, Collaborative Treatment of Traumatized Children and Teens (2006), ISBN.

  

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