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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [545]-[549]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [545]-[549]
CHAPTER 28 The Research, Policy, and Practice Context for Delivery of Evidence-Based Mental Health Treatments for Adolescents: A Systems Perspective
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Research discoveries in the past 20 years have led to major breakthroughs in identifying treatments for adolescents that are most likely to improve their mental health functioning. Problems of attention, depression, and various forms of anxiety, including those related to traumatic abuse and obsessive-compulsive disorders, can now be treated and treated effectively through cognitive-behavioral, interpersonal, and medication therapies and, in some cases, a combination of these therapies (Lonigan, Elbert, & Johnson, 1998; March, Amaya, Jackson, Murray, & Schulte, 1998; March and the TADS Consortium, MTA Cooperative Group, 1999a; Mufson, Dorta, Olfson, Weissman, & Hoagwood, 2004; Silverman, Kurtines, & Hoagwood, 2004). A range of community-based services to support youth and families in accessing or continuing with treatments have also been examined rigorously. Some of this work is demonstrating how engagement techniques, particularly forms of intensive case management, in-home therapeutic services, and functional family therapies can help parents or caregivers care for their children (Alexander & Sexton, 2002; Burns, Costello, Angold, et al., 1995; Chamberlain & Reid, 1991; Evans, Banks, Huz, McNulty, 1994; Farmer, Dorsey & Mustillo, 2004; Henggeler & Schoenwald, 1998; McKay & Lynn, in press). Research progress in these areas has been of unprecedented proportions, in part because there was a tripling of funding at the National Institute of Mental Health (NIMH) between 1989 and 2001 for studies of children's mental health in general (National Advisory Mental Health Council, 2001). Although in general research on child and adolescent mental health has lagged far behind studies of adult mental illness, research on the efficacy of specific treatment and service models for youth is now in an era of expansion. The nexus for this progress has arisen because of the growing popularity of evidence-based practices (EBPs). At least 26 federal Web sites use this term to refer to their practices. A MEDLINE search from 1995 to 2002 found over 5,400 citations that included the terms evidence-based medicine, evidence-based treatment, or evidence-based practice. Between 1900 and 1995 there were only 70 such citations. The term evidence-based practice has captured the public imagination in
part because it provides what appears to be a scientific imprimatur upon a body of work whose application in real-world clinical practice is presumed to lead to improvements in children's emotional or behavioral functioning. Because the state of current mental health service de-livery has been widely criticized as being fragmented, ineffective, and insufficient (Bickman, 1996c; Stroul & Friedman, 1986), policymakers' hopes for improvements in service delivery and practices are now largely linked to delivery of EBPs. Logically, this is a reasonable assumption. However, the growth in empirical knowledge and focus on community-based care has drawn attention to the “different worlds of research and practice” (Ringeisen, Henderson, & Hoagwood, 2003). A series of influential reports, including the Institute of Medicine Report ( 1998), the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services [DHHS], 1999), and the Surgeon General's National Action Plan on Children's Mental Health (U.S. Public Health Service [USPHS] 2001b), have uniformly voiced a single theme: the gap between research and practice must be closed. Yet, despite this progress, there exist numerous challenges to providing quality care for youth and their families within the systems that serve these populations. These challenges are largely systemic and, unfortunately, have become endemic to the current structure of youth mental health care in this country. As Flynn points out in a recent special issue on EBP, “Many parents are frankly doubtful that grafting evidence based practices onto a failed and fragmented system will succeed” (Flynn, in press). Among the challenges to embedding effective treatments within the current system of mental health care for youth are a range of both research-based knowledge gaps and systemic barriers. Gaps in research knowledge exist in five major areas: treatment development for specific disorders; the comorbidities that exist among these disorders and psychiatric classification more generally; ways of bridging the gap between research and practice; the categorizations of EBPs; and means of implementing or disseminating effective practices. Systemic barriers exist
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in five areas: service fragmentation; access and use of services, which are especially relevant to ethnic and cultural variations; lack of sustained family involvement; regulatory practices; and fiscal disincentives. The purpose of this chapter is to outline these challenges to improving delivery of effective treatments for adolescents and their families and to define a set of research and policy directions that may help improve delivery. In particular, a number of major multisite studies supported by several foundations and federal agencies are currently under way to examine contextual influences on delivery of youth mental health services. These studies will very likely lead to new ways of thinking about implementation and dissemination of effective practices.
Gaps in Treatment Development
A recent report from the National Alliance for Mental Illness (NAMI, 2004) indicated that research on serious mental illness has been underfunded, compared to other chronic, disabling illnesses, and consequently is insufficiently prioritized. As a result, little is known about the safety, efficacy, or effectiveness of treatments for bipolar disorders, eating disorders, depression, and trauma. The placebo effect in medication research, particularly in studies of adolescent depression, can be higher than 50% (Emslie, Walkup, Pliska & Ernst, 1999), thus calling into serious question the mechanisms whereby treatment affects outcomes. Furthermore, when families of youth with these kinds of problems are seeking treatment, they are unlikely to be able to identify any providers sufficiently well informed to be able to diagnose and treat these disorders. In addition, despite progress in identifying the efficacy of certain medication treatments for certain conditions (e.g., attention-deficit hyperactivity disorder [ADHD], obsessive-compulsive disorder [OCD], aggression), no studies have yet been completed on the long-term safety and efficacy of these medications. Thus families do not know what the long-term effects may be of treating their children with medication therapies.
Gaps in Comorbidity and Issues in Psychiatric Diagnosis
The strength of the evidence in research-based knowledge centers largely on discrete treatments for discrete disorders (Weisz et al., 1995a; Weisz, Donenberg, Han, & Weiss, 1995b). Unfortunately, many children present with multiple, chronic, and severe problems. The strength of the evidence about mental health care for these youth is weak. This is a major problem because comorbidity of disorders among youth is relatively common. The Great Smoky Mountain Study (GSMS; Costello, Farmer, Angold, Burns, & Erkanli ( 1997) Costello et al., (1996a,b), conducted in North Carolina, found that while the prevalence of psychiatric disorders in an epidemiological sample among youth was 20%, a full third of the youth had more than one diagnosis. In addition, studies by Weisz and colleagues conducted within public mental health clinics in Los Angeles found that the modal number of diagnoses among youth presenting to these clinics was 5, and that youth with single disorders were extremely rare (Weisz et al., 1995a, 1995b). As a consequence, the lack of a developed research base on the effectiveness of treatments for youth with more than one problem presents serious problems for delivery of services within complex service systems that routinely are responsible for multiproblem youth. A more fundamental problem exists with respect to psychiatric classification itself, especially in the field of children's mental health. Diagnostic vicissitudes are the norm rather than the exception. This has given rise to a variety of perspectives, not to mention tensions, on what constitutes mental health, mental illness, or psychiatric impairments among children and on their etiology (Jensen & Hoagwood, 1997). The epistemological issues surrounding diagnostic classification and its nomenclature have been described elsewhere. Diagnostic criteria for children rely primarily on observational markers subject to clinical bias (Bickman, 1999), cultural inferences, and these problems are compounded by lack of reliability between research-based diagnoses and community-based diagnoses (Lewczyk, Garland, Hurlburt, Gearity, & Haugh, 2001). These issues raise questions about the na
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ture of psychiatric knowledge itself, and underscore the importance of inclusion and collaboration of family members, teachers, and other persons knowledgeable about the behavior of children prior to assigning a diagnosis. In short, the complexities surrounding psychiatric diagnosis for children push the notion of collaboration into a place of conceptual prominence with respect to children's mental health.
Lab-to-Clinic Translatability
Meta-analyses of psychosocial treatments for youth have indicated that psychosocial treatment appears to work equally well for internalizing conditions (which include depression and anxiety disorders) and externalizing disorders (those directed more outwardly, including disruptive behavior problems such as conduct disorder). However, most of these studies have been conducted in university or laboratory settings rather than in community clinics. Thus the degree of adaptation (either cultural, practical, or organizational) needed to translate a protocol from a laboratory setting into a community clinic is unknown and is not built into the design or methods for developing treatments in the first place, even though it is a critical ingredient for the ultimate fit of a treatment to a clinical context (Hoagwood, Jensen, Roper, Arnold, Odbert et al., in press). Studies by Weisz and colleagues have demonstrated that mental health interventions used to treat youth in everyday clinical practice are not only different from those studied in academic settings but also potentially less effective (Weisz et al., 1992; 1995b). Weisz et al. ( 1992) found that the vast majority of studies supporting the effectiveness of these models were conducted in either university, school, or laboratory settings. Under these conditions, the interventions improve the outcomes for the children. However, the dozen studies that investigated outcomes of these treatments in naturalistic (clinic) settings demonstrated a negative effect. The implications of these different outcomes are that the conditions of routine clinic care are vastly different from the conditions under which
most studies of treatment effectiveness have been conducted. Weisz and colleagues (Weisz, 2000; Weisz et al., 1992, 1995a, 1995b) also identified some possible explanations for the disparity between results in laboratory and clinic settings. One is that laboratory settings may be more conducive to therapeutic gain, simply because they have more resources. Providers may be better trained and have more modern equipment and intensive supervision, making it a better setting in which to deliver services. Another explanation is that psychosocial treatment provided in laboratory settings may result in better outcomes because it is more likely to use behavioral treatment methods, which are well established. Studies are currently under way to examine how and whether research-based treatment models can be delivered in clinic settings and whether these models actually improve clinical outcomes beyond treatments usually delivered within these settings (MacArthur Foundation Network on Youth Mental Health, 2004; J. Weisz, personal communication, March 2004). This study is described in greater detail below.
Limitations and Discrepancies in the Categorization of Evidence-Based Practices
Kazdin ( in press-a) suggests that an emphasis on the distinctions between evidence-based and not evidence-based is misguided and limits the potential of research studies to further the goal of improving practices. Instead, he suggests broadening the continuum of evidence to include a range of categories for differentiating studies about treatments. The categories he suggests are (1) not evaluated; (2) evaluated, but unclear, no, or possibly negative effects at this time; (3) promising (some evidence); (4) well-established (parallel to well-established in conventional schemes); and (5) better/best treatments (treatments shown to be more effective than other evidence-based treatments). He also points out that an exclusive focus on outcomes rather than on the reasons that treatments work—i.e., on the mechanisms or processes of change within therapies—is leading to a proliferation of treatments, many of which are likely to be similar. Attention
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© Copyright Oxford University Press, 2006. All Rights Reserved
to mechanisms of change can create better efficiencies of effort and improve treatments more generally (Kazdin, in press). In addition to these limitations, there is currently no consensus on how to define evidence-based, nor on when the evidence base, however it is defined, is ready to be deployed, moved out, or used in community settings. While the term is generally used to demarcate research-based, generally structured and manualized practices that have been examined with randomized trial designs from less rigorous or well-tested practices, no currently agreed-upon definition exists, and it is becoming a popular phrase with which to capture public attention and public funds (Tannenbaum, 2003). In this chapter I use the term evidence-based practices to refer to a set of research-based treatments, preventive interventions, services, or clinical practices (e.g., assessment, screening, referral). Evidence-based policies refer to local, state, or federal mandates or initiatives promoting the use or adoption of evidence-based practices. In fact, numerous and discrepant criteria are being used by professional associations and by the scientific community to differentiate evidence based from non–evidence based. The varying definitions make it difficult for policymakers or practitioners to decide which among the practices to adopt in any given circumstance. Currently foundations and federal agencies are attempting to create agreed-upon criteria and an archive of research-based practices that can be updated to assist field practitioners and the scientific community in evaluating the quality, strength, and fit of evidence for specific clinical practice. In addition, the standards for entry into the lists of EBPs vary widely. Operational criteria have been proposed by the Division of Clinical Psychology of the American Psychological Association (APA; Lonigan et al., 1998) and applied to studies of specific psychosocial treatments for childhood disorders. A similar process has been developed for evaluating the evidence for pharmacological treatments (Jensen, Bhatara, et al., 1999), preventive programs (Greenberg, Domitrovich, & Bumbarger et al., 2001), and school-based mental health services (Rones & Hoagwood, 2000). Yet, because inclusion criteria
vary, the ways in which delivery variables have been taken into account also vary. For example, the APA standards apply criteria that ignore parameters of effectiveness that would be likely to yield answers to questions about the readiness of a treatment model to be implemented. Such factors are often excluded from clinical trials of specific treatments for the very reason that they may create “noise” around the interpretation of treatment effects. Yet it is precisely these “nuisance” factors that are essential to understand if implementation of a treatment is likely to be successful. So the relevance of the applicability of most EBPs' integration into routine services is largely unknown (Mufson et al., in press). These different definitions make it difficult for policymakers, families, treatment developers, and consumer organizations to speak in a uniform voice or to learn from each other's lessons in the complex task of implementing these models.
Gaps in Knowledge About Implementation and Dissemination
Knowledge about ways in which to integrate evidence-based practices within complex, dynamic service systems is currently lacking. Challenges remain in “scaling up” interventions from local sites to states. The use of the term evidence-based practice is thus far associated with specific models of child or family interventions; it has not yet been applied to system-or organization-level interventions (e.g., quality assurance methods) (Chambers, Ringeisen, & Hickman, in press). Studies from outside of mental health (in AIDS or cancer trials, for example) have found that characteristics of the environment within which an intervention is placed influence the delivery of the model and the outcomes associated with it. Consequently, studies that examine how to build an infrastructure to support delivery of quality clinical care are greatly needed. As Ringeisen and colleagues ( 2003) point out, both content-specific and contextual factors influence the ability to disseminate services and treatments. For example, Kendall et al. ( 1997) examined specific mechanisms of action within a cognitive-behavioral intervention for childhood anxiety disorders and found that exposure ac
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doi:10.1093/9780195173642.003.0029
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