Children, Young People and Families

I think that in the community mental health sectors, so many of the clients we serve have multiple diagnoses, multiple problems, multiple risk factors and so much of the research seems focused on more single diagnoses, single risk factors, so I continue to think that it’s important for researchers to do what they’re doing but continue this trend of moving towards real-world situations and trying to find alternative methods of researching in real-world environments, or else the gulf between researchers and practitioners will continue. Practitioners will get research that is too removed from the clientele that they serve and just not be that impressed with it, and vice versa. I know researchers who view practitioners as not caring just one way or another about actual evidence will get frustrated. So I think there has been some great experience now with the federal system of care grants that have gone out and some of the other grant making processes where folks are learning more about how to do research and what outcomes are like and make it applicable to folks on the front line working in real community-based clinics. (Mental health services director)

Conceptual models of evidence use in policy and practice acknowledge that the URE to make or support decisions is often a collective and interactive endeavor rather than an activity performed by any one individual decision maker (Traynor et al, 2014; Edelstein, 2016). This collective endeavor involves the utilization of social capital (Spillane et al, 2001; Honig and Coburn, 2008), social networks (Foster-Fishman et al, 2001; Valente et al, 2015), a common language (Kothari et al, 2011), and the exchange of knowledge or information between researchers and practitioners and within networks of practitioners (Lomas, 2000; Mitton et al, 2007; Nutley et al, 2007).

There is a type of foster care that would like to contract through our county, to open up in this county, and it’s evidence-based practice that comes out of Oregon. And the Department of Children’s Services likes it, but in talking with other providers and looking at their materials, their costs for training are extraordinary and their fidelity requirements are extraordinary, and consequently, even if I had a grant to pay for it, I’d be less likely to support it than some models. (Mental health services director)

As noted in the last chapter, there are numerous theories, models and frameworks used in implementation science to understand the features of an intervention, an organization and its external environment believed to be associated with implementation outcomes, and to identify strategies designed to facilitate successful implementation (Nilsen, 2015). With all of these theories, models and frameworks to guide the selection of strategies for implementation, why is there a need for yet another theory, model or framework? The answer to this question lies in the emphasis that this model places on the transactions that occur in both social relations and cultural systems and the roles they play in implementation.

In this chapter, we introduce four major studies where the four pillars of implementation science were applied to identify barriers and facilitators to EBP implementation, evaluate strategies designed to overcome barriers and maximize facilitators, and employ innovative methods for examining the process and outcomes of EBP implementation. The lessons learned from each of these studies serve to build upon existing implementation theories, models and frameworks to highlight the roles of social networks, use of research evidence (URE), local models of implementation and evidence, research–practice–policy partnerships (RPPP), and cultural exchanges among implementation stakeholders in implementation processes and outcomes.

I think that we have to be careful about using the term evidence-based practice and really defining it in different ways. And I think of the three Ps, I think of evidence-based practices, I think of evidence-based programs, and I think of evidence-based principles. And I think principles are more interchangeable. But, the difference between a program that is a canned program that needs to be done just this way, versus having components of principles that people do. And so, for example, Motivational Interviewing is a skill that can be incorporated into many settings. It doesn’t have to be rolled out like a canned curriculum. So, like I said, we need to put that back out to think about evidence-based practices and principles as different things, or programs and principles as different things. And also, I think we need to be clear about what really has evidence behind it and what not, and what the quality of that evidence is. I think that we need to be careful, because I’m afraid everyone is going to say “Oh well, I do evidence-based practice,” but it doesn’t look like it when you break it down. That, again, is why I like principles. So, how are the staff delivering it? How are the kids receiving it, you know, or the adults? So, I guess I have a lot of concern about, you know, getting on the bandwagon with this and not being really thoughtful both from the practitioner’s side and the researcher’s side. (Chief probation officer)

Evidence provided by single studies, systematic reviews, and government statistics suggests that mental health problems affect up to one-quarter of all youths worldwide at any one point in time and about one-third across their lifetimes (Merikangas, 2009).

I’d say MST, Multi-Systemic Therapy by Scott Henggeler. Well promoted, good evidence-based practice, but their approach is very expensive, and in a civil service county environment…You know, some of the larger counties have been able to implement that, perhaps with the grant. We ended up choosing alternate, less expensive approaches that might serve a similar target population. So we use the public domain Intensive Case Management model based on the New York model to help treat many of our court wards at risk of group home placement. We might have done MST, but rather chose a less expensive model. (Mental health services director)

As we observed in the last chapter, the evidence used to support an EBP can come from a variety of sources. One often thinks of EBPs as being supported by rigorous scientific methods using data that is more often than not collected from populations and communities that are external to the community considering implementation. An agency in the United Kingdom considering the adoption and implementation of multisystemic therapy (MST) (Henggeler et al, 1998), for instance, may be asked to place their faith in the evidence-base of this EBP that was generated from a randomized controlled trial (RCT) conducted in the United States or Australia. To the degree that MST works in the U.K. in much the same manner that it does in the United States, the EBP and the evidence base for the EBP can be viewed as being global in nature. Global evidence is external (that is, originates outside of an agency or jurisdiction), scientifically rigorous (for example, RCTs), and generalizable or transferable from one setting to another. Global evidence is the foundation for EBP.

And I know that their interventions have been tested on populations similar to the populations that we’re working with. And so, and I have found that they’re good interventions for our clients, that they’re not rigid, that they have flexibility to them. That fidelity to the model is important. But that there’s sort of bobbing and weaving with clients, which is a really important thing when you’re working with folks that have multi-stressors and not a lot of supports. That being able to be responsive to the needs of clients and not having to have the sort of rigidity to a model is very useful. (Clinic director)

Evidence-based practices (EBPs) are designed to address specific needs. In many cases, the extent to which these practices successfully address those needs, as evidenced by improved and desired outcomes, determines whether or not they will be sustained. Often, programs will be sustained despite lack of evidence of positive outcomes. In either case, the decision whether or not to adopt a specific program or practice is determined by the availability or supply of services to address a specific need, the demand (that is, number of clients or patients) for that service, and the fit between the practice, the organization responsible for its use, and the patients or clients who are its intended beneficiaries.

In this chapter, we begin with an examination of the need for evidence-based mental health services among youth in general and child-welfare involved youth in particular. We begin with a review of the current state of our understanding of this need among youth in general, focusing on the prevalence of mental and behavioral health problems in this population and the risk of these problems associated with the experience of childhood adversities such as child maltreatment, poverty, racism and discrimination, and involvement in criminal justice systems.

It serves us because we understand the system better and make better policy decisions, and it helps them because they get to showcase their skills and publish things and get more grants and stuff. So it is a mutually beneficial process. I think what has happened with all of the systems change over the last year or two years is that the relationship has gone from mutually beneficial to symbiotic and absolutely positively critical for doing the work that we do. And the level of reliance is just skyrocketed exponentially and the partnership is more like closely intertwined than what it was previously…So people that you can rely on, that you can trust, that get it, that can be responsive to your needs real quickly and that can help you carry on the vision that you need to achieve in a short period of time, of having them as our partnership has been extremely beneficial, more so now than ever. (Policymaker, New York State)

In Chapter Five, the role of social influence networks in implementing EBPs was highlighted. These networks included staff members of one’s own organization as well as peers working in other organizations in the same jurisdiction (that is, county) or in other jurisdictions. In the case of the CAL-OH study, the networks also included researchers who developed the EBP (TFCO) and the implementation strategy (CDT) and who assessed the effectiveness of the implementation strategy in scaling up the EBP. However, the specific role of these researchers was not addressed in the CAL-OH study, but rather was viewed implicitly.

I go monthly to the Children’s System of Care meeting in Sacramento. And that’s where other people in similar administrative positions to myself who are responsible for children’s mental health services, we chew on these kinds of things. We discuss these kinds of things. And, you know, we have presentations, and so forth. So that is my peer group. And that, uhm, certainly provides a lot of information to me in making decisions. (Mental health services director)

In this chapter, we examine in detail the role of social networks in implementation process and outcomes. Beginning with a review of the importance of such networks in current implementation theories, models and frameworks, we focus on the Exploration, Preparation, Implementation and Sustainment (EPIS) framework developed by Aarons and colleagues (2011), and the Consolidated Framework for Implementation Research (CFIR) developed by Damschroder and colleagues (2009). The chapter then summarizes research on the influence of social networks and inter-organizational collaborations in implementing Treatment Foster Care Oregon (TFCO) (Chamberlain et al, 2007), an EBP designed to meet the behavioral health needs of youth in foster care, in California and Ohio. This research also demonstrates how community development teams, a continuous quality improvement strategy developed by the California Institute of Mental Health, can be used to build and sustain such networks.

Interpersonal contacts within and between organizations and communities are among the most important influences on the adoption of new behaviors. Interpersonal relations were given a prominent role in diffusion theory in explaining how new ideas and cultural practices expand within and between communities (Green et al, 2009).

We will use the results from the study, but it is not really about practice alone for us. The big benefit is that it begins to change the culture of the agency. It becomes a learning agency. We become an agency that has the wherewithal to develop new programs informed by research. We get to be a co-creator; we get to be an innovator. We get to be part of the group that advances the field. In addition, having your name on the research makes it easier to get funding to support the programs. It also has an impact on staff morale. Staff take pride when our own research demonstrates favorable results. (Program director)

Each of the previous five chapters focused on a specific component of EBP implementation, providing detail on how they manifest themselves in social and mental health services that target children and adolescents and their implications for the broader challenge of understanding and facilitating successful implementation of EBPs in any service setting. In Chapter Five, we examined social networks and inter-organizational collaboration and the role they played in the implementation of TFCO in California and Ohio. We then focused on URE as an illustration of both social interactions that facilitate URE and the shared understandings that comprise the organizational culture of URE. This was followed by another illustration of shared understandings, one that comprised the models of and for assessment of the barriers and facilitators of EBP implementation. We then returned to a focus on social relations and shared understandings that operate in the context of research–practice partnerships dedicated to the task of EBP implementation.

So, the key to these systems is not the clinical work, necessarily, it is the implementation process to make sure, first of all, that they are correctly diagnosed, and second of all, that the model is correctly implemented and people are well trained and they do it correctly, not doing part of it. Do part of it and you can’t measure it, and you don’t know why they got better. And so that is why I think we implement these models, when we’re doing it correctly, I see people get really excited and they get really good at doing it, and they start understanding why it has to be done correctly and people start getting better, and it’s an amazing thing to watch because you’re doing a particular model and the kid actually gets better, when you’re a probation officer or a social worker and you’ve done it for thirty years and you’ve never seen anybody get better because of something somebody did, it’s an amazing thing to watch. (Mental health services director)

As noted in the last chapter, despite the existence of numerous EBPs for prevention and treatment of mental and behavioral health problems in youth, fewer than one in five youth in need of such EBPs actually receive them. Given that one in every three to five youth are in need of such services at some point in their lives, the disconnect between supply of EBPs and demand for them is concerning. Identifying the barriers to successful EBP implementation and sustainment and application of evidence-based strategies to overcome these barriers are the aims of implementation science.