Skills-based interventions for children with externalizing concerns

Transcription

1 Evidence In-Sight request summary: Skills-based interventions for children with externalizing concerns Date: August

2 The following Evidence In-Sight report involved a non-systematic search and summary of the research and grey literature. These findings are intended to inform the requesting organization, in a timely fashion, rather than providing an exhaustive search or systematic review. This report reflects the literature and evidence available at the time of writing. As new evidence emerges, knowledge on evidence-informed practices can evolve. It may be useful to re-examine and update the evidence over time and/or as new findings emerge. Evidence In-Sight primarily presents research findings, along with consultations with experts where feasible and constructive. Since scientific research represents only one type of evidence, we encourage you to combine these findings with the expertise of practitioners and the experiences of children, youth and families to develop the best evidence-informed practices for your setting. While this report may describe best practices or models of evidence-informed programs, Evidence In-Sight does not include direct recommendations or endorsement of a particular practice or program. This report was researched and written to address the following question(s): What are evidence-informed treatment approaches for children with externalizing concerns? We prepared the report given the contextual information provided in our first communications (see Overview of inquiry). We are available at any time to discuss potential next steps. We appreciate your responding to a brief satisfaction survey that the Centre will to you within two weeks. We would also like to schedule a brief phone call to assess your satisfaction with the information provided in the report. Please let us know when you would be available to schedule a 15-minute phone conversation. Thank you for contacting Evidence In-Sight. Please do not hesitate to follow up or contact us at evidenceinsight@cheo.on.ca or by phone at Page 2

3 1. Overview of inquiry The requesting organization serves children, youth, and families in a small city and outlying communities. Their intensive child and family services division is considering new programming to work with children and youth with externalizing issues. There is variation in the type and severity of externalizing disorders, as well as the age ranges of clients, so they are interested in investigating service options to provide appropriate services for specific needs and groups. The agency has formed two working groups: one to consider evidence-informed options for their parent counseling and family treatment component, and the other for the child and youth component. They have asked Evidence In-Sight to provide a search of the literature for information on evidence-informed treatment options for children and youth with externalizing conditions. More specifically, they would like a selection of evidence-informed interventions that are skillsbased, provided in a group setting, and appropriate for children and youth at higher risk of dropping out of school, developing substance abuse issues, and continued anti-social behaviors in adulthood. Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are the most frequent presenting conditions. While more males than females present with externalizing conditions, programming for both genders is needed. Clients range in age from 6-18, so programs need to be available for both children and for adolescents. There are seven child and youth workers who provide services, with a Program Manager who leads this team. The agency is decentralized, with multiple locations, collects BCFPI and CAFAS data so the basic elements of data collection are already in place. 2. Summary of findings A 2011 review of findings from 69 studies that had achieved at least one positive outcome in programs with children and youth with externalizing issues identified six successful intervention strategies (Terzian et al, 2011): 1. Teaching at-risk children skills for managing strong emotions 2. Conducting family therapy with families of children exhibiting externalizing problems 3. Using a culturally appropriate approach 4. Teaching parents how to improve their family management skills 5. Teaching children how to interact well with others 6. Offering at least 30 sessions Since deficits in parenting is a robust predictor of negative long-term outcomes in children with behavioural problems, effectively moderating poor parenting practices is an important element in working with children and youth with externalizing problems (Chronis et al, 2004). Clinicians should consider parent training as the first-line approach for young children, and direct child-training approaches for older youth who could better benefit from the cognitive-behavioral therapy (CBT) approaches of skill-training programs (Eyberg et al, 2008). Parental involvement is encouraged for all ages (Chronis et al, 2004). Page 3

4 Cognitive and behavioral intervention strategies can significantly reduce children s externalizing behavior. Interventions are particularly effective when they are multimodal (include children, parents, other key figures) and focus on developing specific skills (Lochman et al, 2011). Of the programs we identified, these three might be the strongest in terms of outcomes research and applicability to the particular question. Implementation drivers, evaluation needs, local strengths, contextual factors, and available resources should go into the decision. o The Incredible Years (ages 6-12) o Coping Power (ages 8-14) o Parenting With Love and Limits (ages 9-18). Note that while the evidence of this program is not as strong as it is for the above two, it targets adolescents who are the most difficult and at greatest risk. The research evidence indicates that externalizing conditions are most effectively addressed when there is a parent component to the intervention. All of the programs we identified across the age spectrum include a parent counseling element, but for older children, it is increasingly important that there be a strong child counseling element. Although the request came from the child and youth side of the organization, we encourage the agency to bring their two working groups (child and parent) together to identify an evidence-informed course of action that considers both the parent and child treatment elements, in an integrative manner, with an even heavier emphasis on parent involvement for the younger children. 3. Answer search strategy Evidence In-Sight staff conducted a scan of the literature using a variety of search terms to identify treatment protocols. We also used PracticeWise software to identify high quality research articles and core intervention components. Furthermore, we searched the Cochrane Library, the National Guideline Clearinghouse, SAMHSA s National Registry of Evidence-based Programs and Practices, the California Evidence-based Clearinghouse for Child Welfare, the LINKS What Works Database, and Blueprints for Violence Prevention. 4. Findings Externalizing behaviors are overt, disruptive, and often involve the violation of societal norms, the destruction of property, and harm towards others (Keil and Price, 2006). Although internalizing problems also often accompany externalizing problems and need to be addressed, this paper only examines community-based treatment approaches for externalizing conditions. Children and youth present maladaptive conduct behavior in a range of ways, from relatively minor oppositional behaviors such as yelling or temper tantrums to more serious antisocial behavior such as aggression, stealing, and physical destructiveness (Lochman et al, 2011). Aggressive and uncooperative social behavior that begins in childhood has serious long-term consequences. Given that maladaptive behaviors are likely to become increasingly harmful and resistant to change as youth approach adulthood, it is important to intervene with children with externalizing conditions as early as possible (Lochman et al, 2011). Young children with maladaptive conduct issues such as disobedience, Page 4

5 tantrums, arguing, and aggression are at risk for poor school performance, peer rejection, and further escalation of aggressive behavior. They also face increased risk for failure in school, high-risk sexual behavior, association with deviant peers, and substance abuse problems. In adulthood, antisocial individuals have low educational attainment, poor occupational adjustment, marital problems, poor physical health, increased risk of psychiatric impairment, higher rates of violence against women, and a higher suicide rate (Barrera et al, 2002). Skills-based approaches to treatment use a doing element to help children and youth develop and practice strategies and abilities to work through challenging situations. Skills-based treatment is deliberate and aims to increase client capacity and competence. For instance, cognitive-behavioral based interventions such as Coping Power target emotion awareness, perspective taking, anger management, social problem solving, and goal setting (Lochman et al, 2011). These are discrete skills that practitioners can help children and youth learn and generalize from treatment into their day-today environment. There is a wealth of literature on treatment for externalizing conditions in children and youth, including a selection of manualized evidence-informed programs. However, many programs are school-based or meant for individual rather than group intervention. Our findings summarize core treatment components and then outline a selection of evidenceinformed programs. 4.1 Common practice elements and factors The PracticeWise resource provides a searchable list of the common elements from research literature on child and youth mental health problems ( subscription required). The modular approach is created by searching and listing all of the highest quality research papers on particular topics and summarizing the core treatment elements. We conducted a search of research papers and protocols related to youth with disruptive behavior who receive treatment in a community clinic setting. The most common treatment components are: Praise Tangible rewards Time-out Psychoeducation for parents Problem solving Differential reinforcement of other behavior Attending Commands Goal setting Maintenance/relapse prevention Monitoring Modeling Response cost Natural and logical consequences Stimulus control or antecedent management Communication skills The studies that PracticeWise reviewed fall under five distinct treatment modalities: Parent management training Anger control Parent management training plus problem solving Cognitive behavioral therapy (CBT) Social skills. Page 5

6 While these findings are drawn from research taking place with different target audiences (groups of parents, parent and child, individual parent, groups of children or youth, family, etc.), the requesting agency can consider these core components as potentially useful elements in any intervention. A 2011 review summarized lessons from 123 interventions listed in the LINKS database that are designed to address externalizing behavior in children and youth ( The review identified core strategies that appear to reduce externalizing or acting out behavior in children and adolescents (Terzian et al, 2011): 1. Teaching at-risk children skills for managing strong emotions 2. Conducting family therapy with families of children exhibiting externalizing problems 3. Using a culturally appropriate approach 4. Teaching parents how to improve their family management skills 5. Teaching children how to interact well with others 6. Offering at least 30 sessions Of the 123 evaluated programs, 69 were found to have a positive impact on at least one child or adolescent outcome. Outcomes of interest were: Decreased aggression or bullying (physical fighting or verbal threats of intimidation) 56 of 93 programs Decreased inattentive, impulsive, or hyperactive behavior that is associated with ADHD 2 out of 6 programs Decreased delinquency (antisocial or criminal acts) 12 out of 22 programs Decreased criminal offenses (intentional breaking of law, felony or misdemeanor) 4 out of 13 programs Decreased arrests for criminal and/or delinquent acts 9 out of 22 programs Only 20 programs measured longer-term outcomes, defined as an effect that is still measurable more than one year after program completion. Of these, eight were programs that specifically targeted children or youth with externalizing issues rather than being broader prevention efforts intended to reach a large population of children, such as an entire class in a school. For a complete listing of the reviewed programs, including links to the specific program, see the synthesis at Finally, the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, published a practice parameter for the assessment and treatment of children and adolescents with ODD, with these recommended practices (Steiner and Remsing, 2007): 1. Form therapeutic alliances with the child and family for assessment and treatment 2. Consider cultural issues in diagnosis and treatment 3. Use information from child and parents regarding symptoms 4. Consider comorbid psychiatric conditions in diagnosis and treatment 5. Use information from multiple outside informants for evaluation and treatment 6. Use questionnaires and rating scales for evaluation and in tracking progress 7. Develop individualized treatment plans 8. Use parent interventions 9. Use medications as adjuncts to treatment packages for symptomatic treatment and to treat comorbid conditions Page 6

7 10. Use intensive and prolonged treatment when oppositional defiant disorder (ODD) is severe and persistent 4.2 Effective interventions A 2008 review of evaluations of evidence-based psychosocial treatments for children and adolescents with disruptive behavior identified 16 evidence-based treatments categorized as probably efficacious and one that met criteria as a well-established treatment (see Appendix B for an explanation of criteria). No single intervention was the best. However, in general the review concluded that clinicians consider parent training as the first approach for young children, and view direct child-training approaches as appropriate for older youth who might benefit from the cognitivebehavioral approaches of skill-training programs (Eyberg et al, 2008). Graduate students and mental health counselors were the clinicians across all age groupings (ages 3-5, 6-11, 12-18), and there are programs that can be delivered in individual or group treatment settings. Further support for the importance of training for parents comes from a meta-analysis of 26 controlled studies of behavioral training programs for parents to modify child antisocial behavior. Results found that this training is effective (at least in the short-term) in decreasing children s aggressive or disruptive behavior (Serketich and Dumas, 1996). Social behavioral interventions work to modify social and cognitive behaviors in children and youth that are associated with aggressive behavior. These types of interventions aim to help children deal with social situations that might prompt aggressive behavior by teaching them an alternative problem-solving sequence, providing models of appropriate cognitive and social behavior and opportunities to practice these skills. The social behavioral interventions that produce the strongest results are those that use extensive modeling and role-playing (Barrera et al, 2002). There are a number of CBT-based programs specifically intended for adolescents with conduct disorder or oppositional defiant disorder. Meta-analyses of treatment outcome studies show that CBT can produce reduced externalizing behavior problems in both children and adolescents, although effect sizes are stronger in adolescents (Lochman et al, 2011). Youth-focused treatment components common in CBT-based programs include emotion awareness, perspective taking, anger management, social problem solving, and goal setting. Consistent with this, parent training sessions, such as those used in Coping Power, use behavioral training to help improve the parent-child bond and apply positive parenting skills. 4.3 Moderating factors Although there are a variety of programs for children and youth with externalizing disorders, there is little information on what predicts, moderates, or mediates treatment success in community agencies. Multiple and interacting factors such as child variables, family variables, and treatment variables (engagement process, therapist characteristics, therapist training) affect the course of treatment and determine whether outcomes are successful (Eyberg et al, 2008). These elements are important consideration, but there isn t a clear base of evidence on what particular factors determine whether or not an evidence-informed treatment will be successful in the practice setting. Agencies should consider contextual variables during the implementation planning phase, and tailor treatment to the individual adolescent so that personal and family preferences are acknowledged. Page 7

8 Intervention studies and program evaluations tend to have particular study populations, and given tight inclusion criteria it might not be possible to generalize findings beyond the strict study settings. For instance, in the 28 studies that Eyberg and colleagues (2008) looked at, three were conducted exclusively with males and one with females. Similarly, the racial or ethnic makeup of study populations tends to be very homogenous. In considering implementation planning it is important to know whether the findings of a study are representative of agency clientele and how confident one is that an evidence-informed treatment can be generalized to client needs. With that caveat, studies such as the SHIP intervention for Hispanic and non-hispanic children with aggressive behavior indicate that comprehensive interventions can be equally effective for different ethnic groups (Barrera et al, 2002). While intervention studies are usually conducted with certain populations, agencies should be able to adopt an intervention and satisfy the needs and preferences of diverse adolescents. 4.4 Attention deficit/hyperactivity disorder (ADHD) Psychopharmacologic medications are considered first-line therapy because they are effective in 70-80% of children with ADHD, although use can be limited by tolerability and acceptability (AAP, 2001). Augmenting medication treatment with psychosocial interventions does not appear to provide an advantage over medication alone for the core ADHD symptoms; it might, however, provide an advantage for associated problems such as internalizing disorders and social skills difficulties (MTA, 1999). In this light, non-pharmacological treatment of ADHD in childhood can be divided into parent or family focused strategies, child-specific interventions, and school-based interventions. Behavioral classroom management is an effective treatment strategy, and behavioral parent training (BPT) for ADHD has been shown to help improve both child behavior and maladaptive parent behavior. It may also be an important adjunct to medication treatment, as studies show that ADHD is associated with a host of family problems and stimulant medication alone will not result in improvements to parent mood and functioning. Poor parenting is a predictor of negative long-term outcomes in children with behavior problems, so moderating poor parenting practices is an important treatment consideration (Chronis et al, 2004). A 2004 review of 28 studies of behavioral parent training for children with ADHD found that BPT was effective in improving parent ratings of problem behavior and observed negative parent and child behaviors (Chronis et al, 2004). It also resulted in improvements in other domains including parental reports of stress and child social behavior and acceptance. Behavioral parent training received further support in a 2008 review of 22 studies (Pelham et al, 2008) that were all group-based, lasting from 8-16 sessions, and manualized with similar content. BPT as an intervention for ADHD appears to be a well-established treatment option. In terms of what does not work in treating ADHD, traditional social skills training groups are not a research supported approach (Toplak et al, 2008). Also, cognitive, cognitive-behavioral, and neural-based interventions do not appear to be effective interventions for children and youth with ADHD. 4.5 Evidence-informed Programs & Resources We searched several repositories of evidence-informed programs for existing programs intended to address children and youth with externalizing problems. Relevant programs include: 1. Equipping Youth to Help One Another (EQUIP) 2. Incredible Years Page 8

9 3. Montreal Prevention Experiment / Preventive Treatment Program (PTP) 4. Coping Power 5. Parenting With Love and Limits (PLL) Although other programs emerged based on the search criteria used, we excluded most of them because they did not fit the request. For instance, although Multi-Systemic Therapy and Functional Family Therapy are very strongly supported intervention models, they don t precisely fit the criteria laid out by the requesting agency. For a summary of the evidence-informed programs we included, see Appendix A. 5. Next steps and other resources This request pertained specifically to the youth and child side of the externalizing issue, not the parent and family side. However, the evidence strongly indicates that a parental component is critical to ensuring successful outcomes and an integrated child-parent/family approach is recommended. Most of the evidence-informed programs for externalizing conditions include a parent component, and programs for younger children will be predominantly parent-focused. For example, well-supported programs that might be worth consideration include: Helping the Non-compliant Child Triple P Positive Parenting Program Functional Family Therapy Knowing what works and receiving training on an evidence-informed practice or program is not sufficient to actually achieve the outcomes that previous evaluations indicate are possible. A program that has been shown to improve mental health outcomes for children and youth but that is poorly implemented will not achieve successful outcomes (Fixsen et al, 2005). In order for a program to be evidence-informed, it needs to be applied with fidelity to the design and it needs to be implemented using supportive drivers related to staff competency, organizational leadership and organizational capacity. These drivers include assessing and monitoring the outcomes of your practice using evaluation or performance measurement frameworks, which are particularly important when there is insufficient evidence in the literature to guide clinical decisions. Choosing a practice is an initial step toward implementation, but the implementation drivers are essential to ensure that the program reaches appropriate clients, that outcomes are successful and that clinical staff members are successful in their work. The Ontario Centre of Excellence for Child and Youth Mental Health has a number of resources and services available to support agencies with implementation, evaluation, knowledge mobilization, youth engagement and family engagement. For more information, visit: or check out the Centre s resource hub at For general mental health information, including links to resources for families: Page 9

10 References American Academy of Pediatrics. (2001). Clinical practice guideline: treatment of the school-aged child with attentiondeficit /hyperactivity disorder. Pediatrics,108,4, Barrera, M., Biglan, A., Taylor, T.K., Gunn, B.K., Smolkowski, K., Black, C., Ary, D.V., Fowler, R.C. (2002). Early Elementary School Intervention to Reduce Conduct Problems: A Randomized Trial With Hispanic and Non-Hispanic Children. Prevention Science, 3(2), Chronis, A.M., Chacko, A., Fabiano, G.A., Wymbs, B.T., Pelham, W.E. (2004). Enhancements to the Behavioral Parent Training Paradigm for Families of Children With ADHD: Review and Future Directions. Clinical Child and Family Psychology Review, 7, 1, Retrieved from: Eyberg, M.E., Nelson, M.M., Boggs, S.R. (2008). Evidence-Based Psychosocial Treatments for Children and Adolescents With Disruptive Behavior. Journal of Clinical Child and Adolescent Psychiatry, 37(1), Fixsen, D. L., Naoom, S.F., Blase, K.A., Friedman, R.M., & Wallace, F. (2005). Implementation research. A Synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHL Publication #231). Keil, P., Price, J.M. (2006). Externalizing behavior disorders in child welfare settings: Definition, prevalence, and implications for assessment and treatment. Children and Youth Service Review, 28, Krisanaprakornkit T, Ngamjarus C, Witoonchart C, Piyavhatkul N. Meditation therapies for attention-deficit/hyperactivity disorder (ADHD). Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD DOI: / CD pub2. Retrieved from: Lochman, J.E., Powell, N.P., Boxmeyer, C.L., Jimenez-Camargo, L. (2011). Cognitive-Behavioral Therapy for Externalizing Disorders in Children and Adolescents. Child and Adolescent Psychiatric Clinics of North America, 20, 2, Multimodal Treatment Study of ADHD Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 12, Serketich, W., Dumas, J.E. (1996). The Effectiveness of Behavioral Parent Training to Modify Antisocial Behavior in Children: A Meta-analysis. Behavior Therapy, 27, Steiner H, Remsing L, (2007). Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry,46, 1, Retrieved from: file:///v:/centre%20of%20excellence/transition%20projects/tp2-108%20evidence%20in- Sight/Articles/Externalizing%20-%20Skills%20Based/Practice%20guidelines.htm Page 10

11 Terzian, M., Hamilton, K., Ling, T., (2011). What Works for Acting-Out (Externalizing) Behavior: Lessons from Experimental Evaluations of Social Interventions. Child Trends Fact Sheet # Retrieved from: Toplak, M.E., Connors, L., Shuster, J., Knezevic, B., Parks, S. (2008). Review of cognitive, cognitive-behavioral, and neuralbased interventions for Attention-Deficit/Hyperactivity Disorder (ADHD). Clinical Psychology Review, 28, Page 11

12 Equipping Youth to Help One Another (EQUIP) Appendix A: Programs That Work Client Profile Juvenile delinquents and youth with antisocial conduct disorders between the ages of 12 and 17 Program overview EQUIP is a multi-component program to teach social skills, anger management, and moral reasoning to children with conduct disorders. It is a development from Aggression Replacement Training. Group size is 8-10 adolescents with one adult. Intensity is five days per week, at hours per session. Science base Cost and Training Staff and agency More information The program uses guided group interactions and skills training sessions to foster these positive behaviors and coping techniques. Guided group interactions are adult-led but youth-run. Social skills training sessions use modeling, imitation, feedback, and practice. The anger management component encourages cognitive-behavioral development in areas such as self-monitoring of emotions and thoughts, thinking ahead, and self-evaluation. The moral education component focuses on developmental delays with the intent of helping youth catch up to their age-group peers. EQUIP is only listed as an evidence-informed program by the LINKS database. The Blueprints database from the Center for the Study and Prevention of Violence ( has EQUIP in their database of violence related research, but the program does not meet their criteria as either a Model program or a Promising program. One evaluation study of 57 participants conducted in 1994 found that those receiving the EQUIP intervention had significantly greater decreases in self- and staff-reported misconduct and unexcused school absences. They also had lower rates of recidivism. However, this study was conducted in a juvenile corrections facility and the program might not be generalizable to community clinic settings, especially given the intensity (five times per week) of the program. Unknown Unknown whether program is applicable in community agency setting Contact: Dr. John C. Gibbs Professor of Psychology, The Ohio State University (614) gibbs.1@osu.edu

13 Incredible Years Client Profile Program overview Children, ages 0-5 and 6-12 presenting with or at risk of aggression, conduct problems, social competency problems, ADHD, and associated internalizing issues. The Incredible Years program has three separate, multifaceted, and developmentally based curricula for parents, children, and teachers. The program elements can be used separately or in combination, so the teacher piece is not required. The series is intended to promote emotional and social competence and to prevent, reduce, and treat behavior and emotional problems in young children. Parents learn a variety of interpersonal and parenting skills. Children learn skills in emotion management, social skills, problem solving, and classroom behavior. There is a homework component to apply skills in natural environments. Science base Cost and Training Staff and agency More information There are different protocols depending on child age. Implementation is in groups of for parents and 6 for children groups. Intensity is one 2-hour session per week for both children and parents, lasting weeks. The timeline is approximate though as the program can include Basic and Advanced levels, the length may vary, and child treatment may be spread over two years. CEBC rates Incredible Years as Well-supported by Research Evidence (see Appendix C). NREPP gave the Incredible Years consistently high ratings (3.7 out of 4) on the quality of research evidence and outcomes research. Readiness for implementation and implementation materials are very highly rated. The program is manualized and training is available. Program costs are substantial as training, material purchase, certification fee, and annual consultation are required. See the program website for most recent cost information. Training contact: Lisa St. George, Administrative Director (888) Appropriate in a community agency setting, or in schools. Minimum clinician certification is Master s level. Program website: CEBC overview: NREPP overview: Blueprints overview: Available in French and other languages. Contact: Lisa St. George incredibleyears@incredibleyears.com (888) Montreal Prevention Experiment / Preventive Treatment Program (PTP) Client Profile Boys ages 7-9 exhibiting disruptive behavior. They come from low socioeconomic home settings.

14 Program overview Science base Cost and Training Staff and agency More information PTP is a manualized program that targets elementary school aged boys identified in kindergarten by teachers as exhibiting disruptive behavior. Treatment is intended to prevent subsequent antisocial behaviors, including decreasing delinquency, substance abuse, and gang activity. It includes a parent and child component, with each family being assessed individually and the number of treatment sessions determined by severity of behavior. Parent sessions are less than an hour and teach skills to manage family crises, monitor behavior, discipline effectively, and reinforce positive behaviors. Children are invited to attend sessions but not required to attend. Treatment averaged 20 sessions over two years. Boys receiv small-group skills training sessions that included prosocial peers. Sessions incorporat role-playing, peer modeling, reinforcement techniques and coaching. Boys attend nine sessions the first year and ten the second year. Only one study population, although it is reinforced by the presence of a longitudinal component that found betterthan-comparison outcomes at 3 and 6 years after treatment completion. Blueprints rates PTP a Promising Program. LINKS does not formally rate programs. Evidence In-Sight suggests that while the findings are promising, more research is needed in order to determine if the program is effective. Unknown Unknown LINKS summary states intervention was conducted by case workers, and that it includes a clinic setting Blueprint overview : LINKS overview: Contact: Richard E. Tremblay, Ph.D. Université de Montréal (514) grip@umontreal.ca

15 Coping Power Client Profile Program overview Science base Cost and Training Staff and agency More information 8-14 year old children with aggression problems, and at risk for later delinquency. It addresses aggressive, disruptive, and non-compliant child behavior. Coping Power consists of separate child/adolescent and parent elements. It is CBT-based, and for high risk children it addresses deficits in social cognition, self-regulation, peer relations, and positive parental involvement. The child component is composed of 34 group sessions, while the parent component is 16 group sessions conducted concurrently. The child component focuses on anger management, social problem solving, and practicing skills to resist peer pressure. The parent component focuses on supporting involvement and consistency in parenting. Both parent and child components have homework elements. Recommended child group size is 4-6 children. Weekly sessions are 50 minutes. CEBC rates Incredible Years as Well-supported by Research Evidence (see Appendix C). LINKS does not rate programs. Coping Power is an NREPP Legacy Program with an Effective Rating. From our perspective, there is a good base of evidence in support of Coping Power as a candidate program for Pathways. It has a strong research base including outcomes studies, can be implemented in community settings, is group based, and focuses on skills development at a critical age during the transition to high school. Training is available. Contact: John E. Lochman, PhD, ABPP University of Alabama jlochman@ua.edu phone: (205) Community agencies are appropriate for Coping Power. Minimum provider qualifications are Master s or PhD level practitioners in psychology, social work, counseling, or related disciplines. CEBC overview at: LINKS overview at: See the training contact for further information.

16 Parenting With Love and Limits (PLL) Client Profile Program overview Children and adolescents ages with severe emotional and behavioral problems (conduct disorder, oppositional defiant disorder, ADHD) and frequently co-occurring problems such as depression, substance abuse, chronic truancy, destruction of property, domestic violence, or suicidal ideation. Also can be used with adolescents with less extreme externalizing concerns. PLL combines group and family therapy over six to seven weeks. Parents and teens learn specific skills in a group setting, then come together in facilitated family sessions. Recommended group size is 6-8 families, with two therapists, and no more than 15 people per group. Intensity is 2-hour weekly group sessions with 1 hour of parents and teens together and the second hour them meeting apart. A 1-2 hour weekly family session is optional, as needed. Duration is six weeks for group sessions, and 4-20 sessions for the family meetings depending on need. The program is fully manualized and there are four fidelity measures. Science base Cost and Training Staff and agency More information During the group sessions, two facilitators lead teens and parents together in skills development sessions. Extensive role-plays are used. CEBC and the Promising Practices Network have not yet thoroughly reviewed PLL, but they do list it as a highly regarded program. NREPP and the U.S. Office of Juvenile Justice and Delinquency Prevention list it as an evidence-based program. Although the CEBC ratings for Parenting With Love and Limits label the program Not able to be Rated, given the NREPP and OJDPP listings we are comfortable to list PLL as an evidence-informed practice. Training specifics are unclear but appear to be included in the annual licensing fee. The cost breakdown is available on the NREPP website: $1500 annually per family, which includes on-site training of facilitators; $55 for materials per family; $325 per kit per facilitator Community agency settings are appropriate, along with other settings. Minimum provider qualification is Master s level counselors. Program website at: CEBC overview at: NREPP overview at: OJJDP overview at: Contact: Scott P. Sells, PhD, LMFT, LCSW. spsells@gopll.com (800)

17 Appendix B: Defining Well-Conducted Studies and Evidence-informed Programs The Eyberg et al review (2008) provides a useful summary of criteria required for a study to be considered well-conducted. In order for a study to be well-conducted and included in the review of group-design interventions that are well-established or probably efficacious, it must have: Prospective study design Clear inclusion/exclusion criteria for the sample in question Appropriate control or comparison conditions Random assignment to conditions Reliable measures of disruptive behavior Clearly specified sample characteristics (child sex, age, race/ethnicity, and targeted behavior problem) Clearly described statistical procedures Document a clearly defined treatment protocol or manual and provide assurance of treatment fidelity Page 17

18 Appendix C: Scientific Rating Scale Directories of evidence-based programs use different rating scales. The California Evidence-Based Clearinghouse for Child Welfare uses a scale from 1-5, and NR for Not able to be Rated. Level 1: Well-supported by Research Evidence. No evidence that the practice poses a substantial risk. The practice has a book or manual to specify components and how to administer. At least two rigorous randomized controlled trials (RCTs) in different settings have found the practice to be better than an appropriate comparison practice, and the RCTs were reported in a peer-reviewed, published journal. In at least one RCT, positive effects were found beyond the first year after treatment. Valid and reliable outcome measures administered consistently. Overall weight of the evidence supports the practice. Level 2: Supported by Research Evidence No evidence that the practice poses a substantial risk. The practice has a book or manual to specify components and how to administer. At least one rigorous RCT in a different setting has found the practice to be better than an appropriate comparison practice, and the RCT was reported in a peer-reviewed, published journal. In at least one RCT, the practice showed a maintained effect of at least six months past the end of treatment. Valid and reliable outcome measures administered consistently. Overall weight of the evidence supports the practice. Level 3: Promising Research Evidence No evidence that the practice poses a substantial risk. The practice has a book or manual to specify components and how to administer. At least one study using some form of control (untreated group, placebo, matched wait list study) established the practice s benefit over the control, or found the practice to be as good as or better than an appropriate comparison practice. Study reported in a published peer-reviewed journal. Overall weight of the evidence supports the practice. Level 4: Evidence Fails to Demonstrate Effect Two or more RCTs found the practice did not result in improved outcomes compared to usual care. Studies were reported in published peer-reviewed journals. Overall weight of the evidence does not support the benefit of the practice. Overall weight is based on the preponderance of the published peer-reviewed studies, not a systematic review or meta-analysis. Level 5: Concerning Practice Overall weight of the evidence suggests the practice has a negative effect upon clients. There is reasonable theoretical, clinical, empirical, or legal basis suggesting that the practice constitutes a risk of harm compared to its likely benefits. Page 18

19 NR: Not able to be Rated: practices that are manualized, accepted in practice, and do not show risk of harm, but have not been rigorously evaluated for outcomes. Page 19