Friday, May 12, 2017

Evidence-based practice for juveniles in 2017

For those of us who treat juveniles with sustained sexual offenses (JWSSO) a challenge is to identify the best methods. One common approach is to develop your own curriculum through trial and error, and good judgment, and find out what works for your clients and setting. These types of curricula are often "one-of-a-kind" developed locally, not using an existing model. I know numerous examples of these "Homebrewed" models that appear to be successful, and staff and client friendly.
This "Homebrewed" approach now is operating in an environment where an alternative, and possibly competing approach is Evidence-based Practice (EBP). The logic of the EBP approach is that resources are finite, and treatment models which are validated by appropriate research methods are the best choice. As I noted in an article (Ralph, 2012), this approach was delineated by Cochran and others. It was adopted by national organizations such as the Institute of Medicine, the American Psychological Association, and the Association for the Treatment of Sexual Abusers. Many county probation departments now require the use of EBP for programs they will fund.
A significant issue is what constitutes EBP? And can EBP be reconciled with the "Homebrewed" approach that appears to produce good outcomes? I noted (Ralph, 2012) there are several approaches to defining EBP. The traditional approach classifies treatment methods in terms of their research basis. The California Evidence-based Clearinghouse for Child Welfare (CEB4CW, 2012) developed one definition derived from the Institute of Medicine (2001), who defined EBP as: (1) best research evidence, (2) best clinical experience, and (3) consistent with patient values. CEB4CW's highest level of evidence for programs was described as, "Well-Supported by Research Evidence" which involved in part at least two randomized controlled trials published in peer-reviewed journals, documented in manualized form, and effective beyond a year. Only one program met those criteria for JWSSO, Multisystemic Therapy (MST) (Borduin, Schaffer, and Heiblum, 2009). Practically it is viewed as not a viable option for many counties because of the expense, extensive staff training, and supervision required. Also it was designed for high risk populations, where most JWSSO youth now are viewed as having relatively low risk (Caldwell, 2016).
Are there viable alternatives to the CEB4CW model and similar approaches? The most comprehensive research is regarding the general juvenile probation population, of which JWSSO is a subset. Dr. Lipsey at Vanderbilt University, and his colleagues, have carried out research using meta-analytic procedures (Lipsey, 2009). Their approach identified several factors connected with positive outcomes for programming for juveniles on probation. Notably they found positive outcomes, not only in "Namebrand" programs like MST, but also "Homebrew" or generic programs. Lipsey's group believes that an exclusive focus on methods with randomized trials, or other approaches using "Namebrand" programs, may leave out consideration of "Homebrewed" programs which may be of good quality, effective, and low cost. The importance of implementing programs with fidelity has been subsequently validated (Goense, Assink, Stams, Boendermaker, and Hoeve, 2016). Using Lipsey's research, and other studies, a list of program characteristics associated with positive outcomes, can be delineated. I will refer to this approach as Evidence-based Program Characteristics (EBPC) which can be described as follows:
 1. The risk level and needs of the target population is assessed using reliable measures.
2. A treatment approach addresses the risk level and needs of the target population, and  includes a sufficient amount of treatment to be effective.
3. The treatment approach uses social skill building, problem-solving, and counseling approaches.
4. The treatment method is manualized to reliably administer it.
5. Training and supervision is given regarding fidelity to the method.
6. Fidelity checks are "baked in" in and part of implementation of the method.
7. Reliable outcome pre/post measures are used to assess treatment effectiveness.
The opinion of the Lipsey group is these types of criteria are associated with a positive treatment effect.
While Lipsey's (2009) research is on the general juvenile probation population, what is evidence for JWSSO treatment? The best summary of existing research is by Reitzel and Carbonnel (2006). Every study in their research had a positive effect. While it was expected from previous studies that cognitive-behavioral programs would be more effective, also many locally developed "Homebrew" models also were. Kim, Benekos and Merlo (2015) studied the effect size of treatments for juvenile and adult sexual offending for reducing recidivism using meta-analysis of meta-analysis studies. They identified a medium effect size for adolescent programs, -.51.
Given the above findings, what are rational choices for the average county? The Reitzel and Carbonnel (2006), and Kim, Benekos and Merlo (2015) studies gives us cautious confidence that well designed studies, can show good outcomes. Likewise, if programs are implemented consistent with the criteria described above, can they be considered comparable to "Name brand" programs? I would tentatively assert this is correct. If these local "Homebrewed" programs also had conducted simple pre/post test studies showing effectiveness, and demonstrated low levels of recidivism compared to baselines, this would further strengthen the case for their appropriateness. Further, if they could also use experimental or quasi-experimental designs to assess outcomes, this would also help validate effectiveness.
This model for EBP, EBPC, is a reasonable approach for decision-making regarding JWSSO programs. While EBP may be seen as a competitor to "Homebrew" programs, these approaches may in fact be complementary if the approach described above is used to design those programs.
Norbert Ralph, Ph.D.
California Evidence-based Clearinghouse for Child Welfare. (2012). Scientific Rating Scale. Retrieved 6/1/12 from
Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of multsystemic therapy with juvenile sexual offenders: Effects of youth social ecology and criminal activity. Journal of Consulting & Clinical Psychology, 77, 26 - 37.
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication.
Goense, P. B., Assink, M., Stams, G. J., Boendermaker, L., & Hoeve, M. (2016). Making ‘what works’ work: A meta-analytic study of the effect of treatment integrity on outcomes of evidence-based interventions for juveniles with antisocial behavior. Aggression and Violent Behavior, 31, 106-115.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Kim, B., Benekos, P., & Merlo, A. (2015). Sex offender Recidivism revisited: Review of recent Meta-analyses on the effects of sex offender treatment. Trauma, Violence & Abuse, 17(1), 105–17.
Lipsey, M. W. (2009). The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147.
Ralph, N. (2012). Evidence-based practice with juveniles. ATSA Forum, XXIV(3).
Reitzel, L.R., & Carbonell, J.L. (2006). The effectiveness of sexual offender treatment for juveniles as measured by recidivism: A meta-analysis. Sexual Abuse, 18, 401–421.

1 comment:

  1. Nicely said, Norbert. Thanks.
    I'm a little stuck with "the treatment method is manualized to reliably administer it," for a couple of reasons, and one is that manualized treatment can be stilted and is method driven rather than driven by individual needs, and secondly because manualized treatment is method- or model-driven it risks (or actually does) marginalize the role of the clinician in treatment and the need for individualized responses. I'm also a little stuck on the somewhat vague "includes a sufficient amount of treatment to be effective." What is the sufficient dose?