doi:10.1111/j.1365-2206.2009.00621.x
Evidence-based intervention and services for high-risk
youth: a North American perspective on the challenges of
integration for policy, practice and research
James K. Whittaker
Charles O. Cressey Endowed Professor Emeritus, School of Social Work, University of Washington, Seattle,
Washington, USA
Correspondence:
James K. Whittaker,
School of Social Work,
University of Washington,
4101 Fifteenth Avenue NE,
Seattle, WA 98105-6299,
USA
E-mail: [email protected]
Keywords: children in need (services
for), evidence-based practice,
research in practice, therapeutic
social work
A B S T R AC T
This paper explores the cross-national challenges of integrating
evidence-based interventions into existing services for high-resourceusing children and youth. Using several North American model
programme exemplars that have demonstrated efficacy, the paper
explores multiple challenges confronting policy-makers, evaluation
researchers and practitioners who seek to enhance outcomes for
troubled children and youth and improve overall service effectiveness. The paper concludes with practical implications for youth and
family professionals, researchers, service agencies and policy–makers,
with particular emphasis on possibilities for cross-national
collaboration.
Accepted for publication: January
2009
INTRODUCTION
Across many national boundaries and within multiple
service contexts – juvenile justice, child mental and
child welfare – there is a growing concern about a
proportionately small number of multiply challenged
children and youth who consume a disproportionate
share of service resources, professional time and public
attention. While accurate, empirically validated population estimates and descriptions remain elusive. The
consensus of many international youth and family
researchers, including those reported by McAuley
and Davis (2009) (UK), Pecora et al. (2009a) (US)
and Egelund and Lausten (2009) (Denmark) in this
present volume seems to be that some combination of
externalizing, ‘acting-out’ behaviour, problems with
substance abuse, identified and often untreated mental
Author note: Portions of this paper in earlier form were
presented by the author at the 8th and 10th annual EUSARF
International Conferences at the University of Leuven,
Belgium, 9–11 April 2003 and the University of Padova,
Italy, 26–29 March 2008.
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Child and Family Social Work 2009, 14, pp 166–177
health problems, experience with trauma and challenging familial and neighbourhood factors are often, and
in various combinations, manifest in the population of
children and youth most challenging to serve. Many of
these find their way into intensive out-of-home care
services, and Thoburn (2007) provides a useful
window into the out-of-home care status of children in
14 countries and offers useful observations on
improvements in collecting administrative data for
child and family services to inform both policy and
practice. Others call for a critical re-examination of the
present status of ‘placement’ as a central fulcrum
in child and family services policy and practice
(Whittaker & Maluccio 2002).
A sense of urgency is conveyed by the fact that
many child and youth clients of ‘deep-end’, restrictive
(out-of-home) services disproportionately represent
underserved and often socially excluded families and
communities of colour, and pose additional challenges
in service planning around the cultural compatibility
of proffered interventions (Blasé & Fixsen 2003;
Barbarin et al. 2004; Miranda et al. 2005). Important
work in this area includes ethnic and cultural
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
variations on known effective practices. Lau (2006),
for example, offers a nuanced and sensitive treatment
of actual and potential adaptations in existing parent
training models. A basic concern with questions of
equity and social justice, coupled with a growing scepticism about the efficacy of traditional residential,
‘place-based’ services, has heightened the search for
more preventive, family- and community-based, culturally congruent service alternatives. All of this is set
against a backdrop of concern about the state’s ability
to provide effective parenting oversight and support
for children in care, as well as those who remain with
their families (Bullock et al. 2006). Fortunately, this
search is occurring at a time when researchers in many
countries are shedding light on mechanisms of risk
and resilience (Sameroff & Gutman 2004), change
processes involved in effective interventions (Biehal
2008) and the challenges faced by parents in multiply
stressed environments (Ghate & Hazel 2002; Ghate
et al. 2008) that are rich in their potential for contributions to intervention design and evidence-informed
practice.
The primary purpose of this paper is to examine
some of the challenges and opportunities in incorporating evidence-based strategies and interventions
into existing service systems to better meet the needs
of high-resource-using children and youth. The
growing corpus of empirical research on promising
treatment strategies offers, if not clear-cut prescriptions, then rich implications for future policy initiatives and service experiments.
Indeed, the pursuit of evidence-based practice, in
its many forms, increasingly attracts the attention of
those who plan, deliver and evaluate critical treatment
and rehabilitative services for vulnerable children and
their families across national boundaries and regions.
While definitions of ‘evidence-based practice’ emphasize different dimensions of that construct, the
common themes of bringing ‘science-to-service’, and
its reciprocal ‘service-to-science’, are increasingly
evident in the child, youth and family services systems
in many European countries and North America, as
well as elsewhere. Simultaneously, reform efforts in
the USA and many European countries press for
community-based, family-oriented, non-residential
alternatives to traditional residential care and treatment programmes for acting-out children and youth
with identified mental health problems (Chamberlain
2003; Weisz & Gray 2008). However, the impulse for
service reform and the availability of at least some
empirically validated model interventions do not of
themselves constitute a sufficient basis for system
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reform, but instead serve to illuminate some of the
many fault lines that exist in the child and family
services field:
• The continuing tensions between ‘front-end’, preventive services and ‘deep-end’ highly intensive
treatment services and the unhelpful dichotomies
these tend to create and perpetuate
• The tensions between a widely shared desire to
adopt more evidence-based practices and the genuinely felt resistances to these, particularly when they
are used in a rigid fashion that requires strict adherence to established protocols with little opportunity
for experimentation, customization or practitioner
discretion. For example, as one family support
researcher recently observed, we need much more
fine-grained analyses of the actual lived experience
of client families with the services offered to them
(S. P. Kemp 2008, personal communication). Such
analyses will almost certainly involved a ‘mixedmethods’ approach using qualitative measures and
methods to augment quantitative studies
• The tension, as manifested in North America and
elsewhere between evidence-based and culturally
competent practices, reflects, among other things,
antagonism towards certain practice strategies
based on perceptions of the under-representation of
ethnic minorities in the study samples on which
certain models have been validated
As model programmes proliferate and are increasingly removed from the particular political and cultural niches within which they were developed, we
would do well to heed the cautions offered by Munro
et al. (2005) that researchers, planners and youth and
family practitioners are at a moment in time when
cross-national perspectives are critical in helping identify new ways of both framing problems and shaping
service solutions. Cross-national dialogue can help in
identifying different formats for collecting, analysing
and utilizing routinely gathered client information,
analysing subtle local adaptations of internationally
recognized evidence-based services and examining
the effects of differing policy contexts on service
outcomes.
THE QUEST FOR MORE EFFECTIVE
INTERVENTIONS
For the remainder of this paper, I wish to do three
things: (1) briefly identify where we are in our search
for effective (evidence-based) interventions; (2) assess
how we are doing in increasing their availability to
high-resource-using troubled youth and their families;
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
and (3) identify some particular challenges faced by
the individual practitioner, the social agency and the
public policy context in furthering the shared goal of
improving outcomes, and thus life prospects for
troubled children. The author’s bias will soon be
readily apparent. First, as one who has spent a lifetime
trying to bring both the precision of research methods
and the richness of research findings to the ‘shop
floor’ of children’s agency practice, I am convinced
that the evidence-based practice movement will not
succeed until it is embraced by those closest to the
children: the child and youth care workers, the social
workers, teachers, family support workers and others
who, with parents, toil on the front lines of helping.
This is not in my view a one-way street – Science-toService – but presumes a vital feedback loop from
Service-to-Science where the insights and hypotheses
of those most directly involved in interventions
(including parent and child consumers) inform and
improve successive generations of applied research
studies. Second, I readily acknowledge the North
American bias apparent in many of my examples – I
write of what I know best – while recognizing a deeply
felt need in my country for European and other crossnational perspectives if we are ever to achieve success
with our internal efforts at improving outcomes.
The search for evidence-based practices with children and families is now well underway on both sides
of the Atlantic. Kazdin and Weisz (2003), Weisz
(2004), Burns and Hoagwood (2002), Macdonald
(2001), Pecora et al. (2009b) and McAuley et al.
(2006) survey effective interventions in child welfare
and child mental health services, as well as review
current research on service populations that will
inform the creation of novel interventions.
The simple, nominal definition of evidence-based
practice offered by Professor Geraldine MacDonald of
Queen’s University in Belfast provides a useful starting point:
competing definitions and nuances are, in toto, a sign
of health as they simply serve to underscore one or
another aspect of what is emerging as a more fulsome
understanding of what evidence-based practice consists of. These aspects include, but are not limited to:
• a dual focus on aetiology and outcomes
• the incorporation of ethics and values as key components
• the development of a collaborative process with
affected client groups
• a commitment to transparency in processes and
accountability
Many practitioners and practice researchers have
participated in the work of international groups such as
the Campbell and Cochrane Collaborations (Littell
2008) – originating in the health field – that attempt to
sift, sort and categorize the state of the evidence around
particular illnesses, socio-behavioural problems or
social welfare concerns. Many have also experienced –
closer to home – the increasing impact of national, state
and regional initiatives designed to increase the content
of proven, efficacious practices into child, youth and
family service systems. Such initiatives typically use
two strategies, often in combination:
Evidence-based practice indicates an approach to decisionmaking which is transparent, accountable and based on careful
consideration of the most compelling evidence we have about
the effects of particular interventions on the welfare of individuals, groups and communities. (MacDonald 2001, p. xviii)
In the USA at the moment, there is growing respect
for the complexities involved in moving from pilot
demonstrations of effective child, youth and family
interventions to broad-scale application: i.e. moving
from ‘efficacy’ to ‘effectiveness’ (Jensen et al. 2005;
Weisz & Gray 2008). What these terms signify are:
1. That individual investigators can demonstrate significant results for novel treatments over standard (or
traditional) services through carefully controlled, rigorously conducted studies often including randomized controlled trials: the ‘gold standard’ of clinical
research. That is, they can demonstrate efficacy.
It is clear that debates about what constitutes the
sufficiency and quality of evidence – where to set the
bar for rigour, how to distinguish evidence-based vs.
evidence-informed practice – continue apace both in
academic and practitioner discourse even as the
evidence-based practice movement as a whole continues to raise its profile in policy and services. These
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Positive Reinforcement: e.g. ‘Laying Flowers Along Certain
Pathways’ by encouraging adoption of selected efficacious
model interventions. (One notes in passing that ‘efficacy’ of a
given intervention often increases in proportion to the distance from its country of origin!)
Coercion: e.g. Penalizing a programme, agency or practitioner
whose interventions do not reflect a sufficient quantity of
evidence-based practice according to an agreed-upon time
schedule. In the USA, this typically means that a practitioner
or service agency follows a prescribed protocol for intervention or risks losing reimbursement for services rendered.
M OV I N G F R O M
‘ E F F I CAC Y- TO – E F F E C T I V E N E S S ’
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Evidence-based intervention for high-risk youth J K Whittaker
2. Yet, these impressive results do not, on close
examination, appear to influence what might be
thought of as routine, day-to-day practice as conducted in more familiar agency settings. Thus, the
evidence-based practice movement, while demonstrating efficacy, cannot as yet demonstrate overall
effectiveness.
What explains this disconnect? Lisbeth Schorr, an
astute analyst of child and family services innovation,
sums it up succinctly: ‘Successful programs’, she says,
‘do not contain the seeds of their own replication’
(Schorr 1993, quoted in Fixsen et al. 2005).
Thus, if we are truly interested in effectiveness – i.e.
achieving wide-scale adoption of proven efficacious
interventions, we need to look beyond efficacy studies:
(1) to those contextual elements that influence practice decisions and client outcomes (Kemp et al. 1997);
and (2) to a different kind of research undertaking
that focuses directly on the processes involved in successful adoption of proven efficacious interventions
(Weisz & Gray 2008).
John Weisz, one of the nation’s leading research
analysts in child mental health and a professor of
psychology at Harvard University as well as President
of the Judge Baker Children’s Center in Boston,
points the way forward on what is needed to ultimately
resolve the efficacy/effectiveness challenge:
A very important focus for the next stage of research on
interventions for children will be the effective implementation
of evidence-based practices by practitioners in service settings.
This will require an active collaboration between the researchers who develop and test interventions and the clinical, child
welfare, and education professionals who serve children and
families. (J.R. Weisz 2008, personal communication)
E X P L O R I N G T H E L A N D S CA P E O F
EVIDENCE-BASED SERVICES FOR
H I G H – R I S K YO U T H
Let us proceed, then, by exploring the context within
which evidence-based services are nested. Here, we
find some common and proximate elements familiar
to all who labour in the child and family services field,
as well as a few more distal forces that, nonetheless,
have a potential for considerable impact on the
identification, validation and eventual integration of
evidence-based practices. I will refer, briefly, to more
or less typical examples from within the US context.
Model intervention programmes
For purposes of illustration, I offer three interventions
that have received considerable attention in children’s
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mental health services in the USA, and which have
been the objects of numerous community replications
and research study both in North America and elsewhere (Whittaker 2005). These include:
• Multisystemic Therapy (MST), developed principally
by Dr Scott Henggeler, a psychologist now at the
Department of Psychiatry and Behavioral Sciences,
Medical University of South Carolina (Henggeler
et al. 1998; Schoenwald & Rowland 2002;
Henggeler & Lee 2003). http://www.mstservices.com
• Treatment Foster Care (MTFC), developed in several
clinical/research teams in the USA and represented
here by the model (Multi-dimensional Treatment
Foster Care) principally developed by Dr Patricia
Chamberlain and colleagues at the Oregon Social
Learning Center – a highly influential applied
behaviour analysis developmental research centre –
one of whose founding members is Dr Gerald
Patterson (Chamberlain & Reid 1998; Chamberlain
2002, 2003). http://www.MTFC.com
• Wraparound Treatment, a novel, team-oriented,
community-centred intervention developed by a
variety of individuals including the late Dr
John Burchard, formerly Professor of Clinical
Psychology at the University of Vermont, John Van
Den Berg, Carl Dennis and others beginning
in the early 1980s (Burns & Goldman 1999;
Burchard et al. 2002). http://www.rtc.pdx.edu/
PDF/PhaseActivWAProcess.pdf
[While space does not permit in depth analysis here,
the interested reader is directed to the previously cited
references, as well as to the web sites for each of these
three models that include multiple references to completed and in-progress research and demonstration
efforts, as well as specifics on programme principles
and components. A variation of the of the MTFC
model designed for younger children in regular foster
care is described in this present volume by Price et al.
(2009)].
These three interventions are specifically designed
to provide alternative pathways for children who
otherwise would be headed into more costly and
restrictive residential provision. Dr Barbara Burns,
Professor of Psychology at Duke University in North
Carolina and a principal author of the children’s
mental health section of our latest Surgeon General’s
Report on Mental Health (US Department of Health
and Human Services 1999) provides a succinct rationale for why this is warranted:
The most critical question for the future is, what will it take
to convince payers, public and private, to support the
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
interventions that are backed up by evidence about improved
outcomes? Assuming that the pool of dollars available for
mental health treatment will not increase, it will be necessary
to shift resources away from institutional care (which lacks
evidence of effectiveness) toward community alternatives.
This will require a reduction in funds allocated to institutional care, where a significant portion of the child mental
health money is still being spent. (Burns & Hoagwood 2002,
p. 13)
While reviews of residential care in both the UK
(Sinclair 2006) and the USA (Whittaker 2006)
confirm a move away from residential services,
recent comparative international contributions have
urged critical re-examination of the multiple varieties
of residential service (Courtney & Ivaniec 2009) to
meet the needs of at least some high-resourceusing youth. In part, this sentiment reflects the fact
that theory and model development, particularly in
the arena of intensive residential services has languished as development of comparable familycentred services has flourished. Some have urged the
development of a conceptual schema for intensive
services – e.g. the ‘prosthetic environment’ – which
transects more traditional residential, family and
community boundaries is strengths-oriented and
incorporates educational, socialization and family
support services along with intensive treatment
(Whittaker 2005).
In focusing here on a few programme models specifically designed to serve as alternatives to residential care and treatment, and other forms of intensive
out-of-home service, one must acknowledge omission of a great deal of promising, empirically based
work that is presently being done with a wide range
of family-, school- and community-centred interventions that is both more preventive in its focus and
appropriate for a much wider population of children
and families than space allows us to examine here.
See, for example, Carolyn Webster Stratton’s Incredible Years Program (Beauchaine et al. 2005) and the
work of many others whose contributions in such
areas as family support illuminates a segment of services more preventive in focus (Kemp et al. 2005;
Lightburn & Sessions 2006) and the contribution of
Jackson et al. (2009).
What, then, are the similarities and differences
of these three promising interventions? A recent
review (Burns & Hoagwood 2002) yields the
following:
1. All three interventions adhere to ‘systems of care’
values: The ‘systems of care’ framework derives from
both our National Institute of Mental Health and
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private foundation initiatives in the 1980s, and is
defined as:
A comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network
to meet the multiple and changing needs of children and
adolescents with severe emotional disturbances and their
families. (Stroul & Friedman 1986, p. xx)
The system of care thus defined is based on three main elements. First, the mental health service system efforts are
driven by the needs and preferences of the child & family and
are addressed by a strengths-based approach. Second, the
locus and management of services occur within a multiagency collaborative environment grounded in a strong community base. Third, the services offered, the agencies
participating and programs generated are responsive to cultural context and characteristics. [Though, as noted, this
remains a contested area with respect to some communities of
color.] (Burns & Hoagwood 2002, p. 19)
2. All three interventions are delivered in a community – home, school, neighbourhood – context as
opposed to an office
3. All have operated in multiple service sectors:
mental health, juvenile justice, child welfare
4. All were developed and evaluated in ‘real world’
community settings, thus enhancing external validity
5. All show preference for the model treatment condition in multiple randomized controlled trials
6. All lay claim to being less expensive to provide than
institutional care (Burns & Hoagwood 2002, p. 7).
Differences of course exist. For example, both MST
and MTFC possess a higher degree of specificity with
respect to intervention components than does wraparound. As of this writing, MST has perhaps the
strongest evidentiary base, particularly in clinical trials
showing positive effects, though some recent reviews,
including one by Prof. Julia Littell of Bryn Mawr
University in Pennsylvania conducted for the Campbell Collaboration, have raised critical questions about
the evidence base offered in support of MST (Littell
2005, 2008). Finally, from a staffing perspective, MST
appears to make higher use of master’s-level-trained
professionals in service delivery than either MTFC or
wraparound.
To these three model programmes, we must of
course add numerous other evidence-based treatment
techniques targeted to specific conditions and problems, as reflected in recent reviews by Kazdin and
Weisz (2003), Weisz (2004) and Chorpita et al.
(2007).These model intervention programmes do not
of course exist in a vacuum, but both influence and are
influenced by a host of other elements in a typical state
or regional context in the USA.
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
P U B L I C , VO L U N TA R Y A N D P R O P R I E TA R Y
S E R V I C E P R OV I D E R S
Model programmes such as MST, MTFC and wraparound are typically adopted by some segment of the
mixed system of service agencies (Public/Voluntary/
Proprietary) that make up the delivery system in a
given state, county or municipality. Public service providers are typically service funders as well, creating in
the view of some voluntary agencies an unequal influence in terms of what particular models are selected
for adoption, as well as on the masking of true administrative costs of programme implementation, given
the public sector’s economies of scale and presumed
ability to mask start-up costs. Given the wide variations in state and county service systems within the
USA, there are some anecdotal reports of the tendency of certain model programmes to bend and
shape themselves into a widely varying array of
funding arrangements (referred to as ‘pretzelling’) in
order to gain a foothold and a leverage in a given
public system (K. Blasé 2007, personal communication) with the result that local service providers may
be held to similar outcome and process standards
while enjoying widely varying reimbursements to
support their efforts.
N AT I O N A L , R E G I O N A L A N D L O CA L
RESEARCH CENTERS AND RESOURCE
NETWORKS
In addition to evidence-based programme models
that typically have their own internal capacity for programme development, marketing, training, evaluation
and dissemination, a wide variety of university and
institute-based resource networks and research centres
play an increasingly important role in the promotion
of evidence-based programmes and practices. For
example, the National Implementation Research
Network (NIRN) was begun at the University of South
Florida as part of a larger effort to bring science-based
information to the forefront of child mental health
practice. Recently relocated to the University of
North Carolina, NIRN has done significant work in
documenting national, state and regional capacity to
support model programme development, and has
provided consultation to individual states and organizations on effective strategies for integrating evidencebased practices into the fabric of existing services
(Fixsen et al. 2005). For more information, see: http://
www.fpg.unc.edu/~NIRN/. The California EvidenceBased Clearinghouse for Child Welfare Practice is
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funded by the California Department of Social Services, Office of Child Abuse Prevention and guided by
a state advisory committee and a National Scientific
Panel. The Clearinghouse provides guidance on
selected evidence-based practices in simple straightforward formats, reducing the consumer’s need to
conduct literature searches, review extensive literature
or understand and critique research methodology
(http://www.cachildwelfareclearinghouse.org/). The
Clearinghouse has developed a six-tiered schema for
sorting out promising programmes ranging from
‘Well-Supported – Effective Practice’ to ‘Concerning
Practice’ (e.g. shows negative effects on clients and/or
potential for harm).
A legislatively generated state institute, the
Washington State Institute on Public Policy (WSIP)
was created by the Washington state legislature to
conduct cost/benefit and a range of other studies on a
variety of classes of intervention, including child
welfare and early intervention (http://www.wsipp.
wa.gov/board.asp). Its generally thorough and wellexecuted analyses have achieved wide dissemination
beyond the region and are frequently cited by model
programme developers as confirmation of their effectiveness. Methodological concerns have recently been
raised about the general quality of intervention
research reviews (Littell 2005, 2008), including those
generated by WSIP, and within local practice communities, one hears anecdotally some concerns about the
potential for overly concrete inferences by legislative
bodies and funding sources whose attention may
extend only to the executive summary section of
detailed reviews of model programmes and not to the
caveats and nuances contained in their appendices
and footnotes.
Beyond these particular exemplars, there are a wide
variety of government-, university- and institutebased research centres and clearinghouses devoted to
the identification, review, evaluation and promotion
of evidence-based practices. Such centres are not
typically coordinated, resulting oftentimes in an overload of information for busy practitioners desirous of
identifying the most appropriate interventions for
troubled youth and their families. The problem is
intensified as estimates place the number of documented treatments for children and adolescents in
excess of 500 (Kazdin 2000). Here, the work of Dr
Bruce Chorpita at the University of Hawaii offers at
least a partial solution. For a number of years, Chorpita’s research team has been refining a ‘common
elements’ approach to identified evidence-based
treatments and then matching these with identified
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Evidence-based intervention for high-risk youth J K Whittaker
problem clusters and characteristics of youth and
families in service systems. The model’s particular
focus on the practitioner’s adoption of discrete strategies, as opposed to whole-cloth approaches, is
directly addressed to one of the major identified barriers to the implementation of evidence-based practice: the resistance to treatment manuals (Chorpita
et al. 2007). In a related area, the empirical research
of Professor Charles Glisson of the University of Tennessee and colleagues sheds important light on the
organizational factors that may impede or enhance
the uptake of evidence-based practices in service settings: e.g. organizational structure, organizational
culture and organizational climate (Glisson et al.
2008).
J U D I C I A L A N D L E G I S L AT I V E I N I T I AT I V E S
Vocal community advocacy calling attention to service
inadequacies and lacunae – for example, failure to
meet the mental health needs of children in the state
foster care system or excessive numbers of placement
changes – frequently end up in the court system. The
resultant settlements, or ‘consent decrees’, can exert
considerable direct and indirect pressure on the
service system to adopt particular models of evidencebased practice as a remedy to the perceived problem.
In addition, within an individual state or jurisdiction,
there are not infrequently legislative initiatives
designed to promote certain evidence-based practices,
as well as initiatives generated from within the public
service agency itself. Taken together with the already
identified promotional efforts of model programme
developers, sometimes augmented by the largesse of
voluntary foundations that seek to promote particular
strategies for service improvement, the resulting pressure for individual practitioners and voluntary service
agencies to follow certain prescribed pathways to
practice can be intense.
E V I D E N C E – B A S E D P R AC T I C E : M E E T I N G
T H E C H A L L E N G E O F I M P L E M E N TAT I O N
For each of the features of the evidence-based practice
landscape – model programmes, public and voluntary
service providers, individual youth and family practitioners, research centres and clearinghouses, legislative and judicial bodies and client communities – there
are challenges to achieving the generally agreed-upon
goal of improving outcomes for high-resource-using
youth and their families through the adoption of
proven, efficacious practices. While these challenges
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vary depending on the point one occupies in the
overall landscape of evidence-based practice, there
appears to be a growing consensus in the USA for a
far more intensive focus on what some have termed
‘implementation science’:
. . . the scientific study of methods to promote the systematic
uptake of clinical research findings and other evidence-based
practices into routine practice. (Implementation Science: UK:
on-line journal)
Thus, while different in their focus: (1) the previously cited efforts of NIRN to identify effective pathways for the integration of evidence-based practices
into existing service systems (Fixsen et al. 2005); (2)
the plea from research scholars like Julia Littell (2008)
and others to bring more rigour, precision and systematization to the scientific review processes for
evidence-based approaches; and (3) the numerous
contributions of senior research analysts like John
Weisz and others (Weisz & Gray 2008), directed
towards identifying pathways for bringing practitioners and researchers into a closer working relationship, are best viewed as part of a unified effort. There
is, I believe, a growing awareness that integration of
proven efficacious practices in youth and family work
will happen only when there is a fully functioning
infrastructure to support desired changes and various
individual actors see their ‘part’ in relational to the
‘whole’.
Thus, for model programme developers, there is the
critical task of identifying what are the active ingredients in their interventions. What are the necessary and
what are the sufficient components in a service unit of
MST, MTFC or wraparound? Despite the fact that
raising the question of ‘active ingredients’ leads one,
ineluctably, to what noted child psychiatry researcher
Peter Jensen calls ‘the soft underbelly’ of evidencebased treatment, it is an area of critical importance
for future research (Jensen et al. 2005). The costing
and ‘scaling-up’ implications alone of adding even a
modest increment of evidence-based practice to existing services warrants seeking answers to the question:
‘How much of what is enough’? There has been an
understandable resistance on the part of many model
programme developers to disaggregate their interventions for fear of compromising treatment integrity,
and thus weakening outcomes. That said, it is heartening to note the flexibility of some models to customize their interventions to fit the needs of particular
service populations and environmental niches. The
previously cited modification of the MTFC programme reported elsewhere in this volume offers one
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Evidence-based intervention for high-risk youth J K Whittaker
such excellent example (Price et al. 2009). We must
find ways to hold model programme developers harmless for their results if they are willing to experiment
with modifications of their ‘packages of service’ to
address particular needs.
From the perspective of the individual service
agency – whether it is a voluntary body, local authority
or a large, public bureaucracy – a key question vis-àvis the adoption of exemplary evidence-based programme models concerns the basic strategy for
implementation: is it to be additive or integrative?
The additive approach that appears to prevail in
many sectors of service in the present US context
means that service agencies adopt one model programme at a time, adhering strictly to the intervention, assessment, training and evaluation protocols of
the developer. This is meant to insure model fidelity
and programme (treatment) integrity and to prevent
what has been called ‘program contamination’. The
result, in the author’s view, can lead to an encapsulation of discrete programmes – each with its identified
staff and protocols for assessment and intervention –
within a single agency structure. This results in fewer
opportunities for cross-fertilization (e.g. common, or
cross-training) and is silent on the preferred order of
implementation: e.g. does it make a difference which
model is adopted first? Moreover, the administrative
complexities involved in managing multiple discrete
programmes in a single agency can be considerable,
particularly in smaller units with limited supervisory
resources.
An alternate, or what might be termed an integrative approach, would seek to identify common elements across successful model programmes and train
towards those. The previously cited work of Chorpita
et al. (2007) provides a potentially valuable foundation to such an approach. A slight variation on the
integrative approach would be to identify a common
platform of foundational knowledge and skill – e.g.
around client engagement – or ‘therapeutic alliance’,
the present legatee of the old concept of ‘relationship’ (Rauktis et al. 2005), and first establish that
core competency with all staff before moving to
incorporate the specific strategies and techniques
contained within successful model programmes. At
present, the enthusiasm for what might be called the
‘intervention-du-jour’ seems to suggest a continuation of the additive, seriatim, approach at the
expense of the integrative.
Behind the specific issue of the preferred method
for adopting efficacious model interventions lies the
broader question of the service agency’s capacity to
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Child and Family Social Work 2009, 14, pp 166–177
integrate, utilize and generate practice-focused
research. Weisz and others have proposed models for
closer integration of research and practice (Hoagwood
et al. 2002; Weisz & Gray 2008) within the service
agency, but at the moment these are not widely in
evidence. Whittaker et al. (2006) offer a five-stage
model template for integrating evidence-based practice in a child mental health agency, including logic
modelling of existing programmes as a means of
developing a common language of service, including
implicit theories of change, selected evaluation activities, strategic researcher–agency staff partnerships and
benchmarking against practice models of national significance. A barrier to building research capacity in
existing agencies is that present contracts are typically
tied to designated services, not to building an infrastructure supportive of research.
Challenges for the service agency include data
management where the adoption of electronic records
lags in certain sectors and where many agencies lack
the capacity to systematically analyse routinely gathered data at either the case or the aggregate level. As
noted, the proliferation of assessment and evaluation
measures – often tied to specific programmes – adds
complexity to the data management needs of the
service agency. In the critical arena of supervision, the
question arises of the adequacy of a single supervisor
to provide oversight and support to a staff operating
in widely disparate intervention models with their
differing change theories, assessment protocols,
outcome measures and time frames. In the related
arena of training, similar problems can be found,
including almost exclusive reliance on the use of
external (and often expensive) consultants during
the start-up phase of a model intervention with
unclear plans for transition of oversight to internal
agency staff. Moreover, the determinants for training
foci in some agencies remain strongly with worker
interests and are not necessarily related to client
characteristics. Of particular concern among many
smaller, voluntary service settings in the USA is the
factor of agency history. Many such agencies were
residential in their origins, typically following a
pathway from orphanage to treatment setting. Thus,
boards of governors and major donors may be more
oriented to place-based services and ‘bricks &
mortar’ than to community-based programme alternatives. A quote from a senior head in one such
agency captures the tension for those in leadership:
‘How do I insure that my program plan for the agency is
in synchrony with my business plan?’ (K. Scott 2002,
personal communication).
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
S U M M A R Y A N D TA K E – AWAY M E S S AG E S
The growing corpus of research on evidence-based
approaches to work with troubled youth and their
families offers both hope and challenge. In the area of
alternatives to residential services for high-resourceusing youth, model programmes like MST, MTFC
and wraparound appear to hold much promise, but
their full-scale adoption into existing service systems
will require addressing a series of complex implementation challenges. Public sector children’s services
often work with families who are challenging to
engage and for whom permanency and continued
child safety remain as core service objectives. The
sensitive application of evidence-based programmes
and practices into the real world of contemporary
child and family practice must necessarily involve
parents, social workers, model developers and
researchers in bidirectional communication. All of
these efforts will benefit greatly from sustained and
multilevel cross-national collaboration. Of the several
US originated programme models identified in this
brief review, virtually all are intruding to some degree
on the work-plans of service planners, evaluation
researchers, supervisors and practitioners in Europe,
Australia and elsewhere. Similarly, interventions or
intervention components as varied as ‘Patch’ (geographically centred, generalist services) (Adams &
Krauth 1995) and ‘Family Group Conferencing’
(Pennell & Anderson 2005) have come to the USA
from the UK, New Zealand and elsewhere in recent
years. Since all of these ‘imports’ will likely undergo
modification and appear again as ‘exports’, it behoves
staff at all of the above levels to carefully track how
these novel interventions are being incorporated into
widely differing political, geographic, cultural and
organizational contexts. Fortunately, the wide availability of instantaneous, direct, point-to-point electronic communication and the increasing prominence
of cross-national journals, networks and conferences
make such communication more possible than ever.
From a research perspective, the widely varying environments into which model programmes are being
introduced hold the distinct possibility for comparative research, including natural experiments.
For youth and family practitioners, service agencies
and researchers and policy-makers, some concrete
take-aways include:
1. For practitioners
• Challenge the ‘conventional wisdom’ of practice
wherever it resides – including in your own personal theories of change: for example, ‘insight is a
174
Child and Family Social Work 2009, 14, pp 166–177
requisite for behaviour change’; ‘longer service
produces better outcomes’.
• Seek out and read one up-to-date review of interventions most relevant to the children and youth
you presently work with. Discuss what you have
garnered with peers.
2. For researchers
• Focus on application to real-world practice in
your dissemination efforts: for example, ‘What are
the top five practice implications of your latest
study and where might these most usefully be disseminated?’
• Seek practice-partners for agency-centred
research projects specifically focused on issues of
implementation of evidence-based practices.
3. For child and family service agencies
• Discover first what is working within the agency
and build on that as a foundation before purchasing ‘off-the-shelf’ models.
• Develop an internal capacity to systematically
analyse routinely gathered data at the case level
and aggregate level and ‘mine’ this information to
inform practice.
4. For the service system/policy level
• Here, and speaking from a parochial perspective,
with all of our resources in the USA, we are sorely
in need of a new structure or body within a state or
authority that ‘connects-the-dots’ between relevant
service policy, research and practice in support of
enhancing the implementation of evidence-based
practices to improve outcomes. While the title and
organizational form for such a body proves elusive
– clearinghouse? executive steering committee for
evidence-based programme improvement? – its key
function should be to focus laser-like attention on
the question of what is most important in
evidence-based practice implementation in a state,
local authority or region:What do we need to learn
over the next 12 months? How will we learn it?
How will we decide ‘what-trumps-what’: Cost?
Urgent service need? Level of evidence? Cultural
relevancy? Organizational compatibility? Special
opportunity to experiment with proven efficacious
model programmes? While the fruits of such a new
body would be experienced locally, one hopes that
its field of vision and, eventually, its impact would
extend cross-nationally.
In sum, evidence-based practice has added greatly to
the ‘tool kit’ of social services in the identification of
proven efficacious models of intensive intervention
such as those referenced earlier in this paper.That said,
the task of scaling-up these exemplars is proving to be
© 2009 Blackwell Publishing Ltd
Evidence-based intervention for high-risk youth J K Whittaker
complex and challenging, and will require both
focused attention on the multiple contextual elements
that impede and enhance the adoption of evidencebased alternatives, as well as a critical re-examination
of existing biases – for example, the current and often
reflexive negative attitudes towards residential provision in any form – that underlay current services planning. Both of these conversations will be greatly
enhanced by multilevel, sustained and data-oriented
cross-national collaboration among practitioners,
service planners and researchers. Fortunately, through
technological innovations such as electronic communication, the means for such collaboration are close at
hand. High-resource-using youth and their families
presently in, or at risk of entering the intensive services
system, will be the ultimate beneficiaries of our efforts.
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