Abstract
Evidence-based practices are often discussed but less easily implemented. Almost all the existing manualized, diagnostic-specific evidence-based practices were neither designed for nor tested in residential programs. However, a recent survey of group care providers found great interest and some success in infusing evidence-based programs and practices in serving youth. This article described four possible pathways for group care programs to pursue to advance the use of evidence-based practices and programs. These examples include using the common elements approach, building a home-grown program and its evidence, adapting an existing manualized practice for a group care setting, and adapting a residential program to incorporate an evidence-based practice. An extended case study is provided to illustrate the process and potential challenges of creating an intervention and testing it in a group care setting.
Youth who are served in group care programs often experience behavioral or mental health needs. In a nationally representative sample of child welfare involved youth, almost 90% of youth in group care or residential treatment scored in the clinical range on the Child Behavior Checklist, but only about 60% were receiving mental health services (Burns et al., 2004). For those youth receiving mental health interventions, little is known about the quality of care provided. A recent Institute of Medicine (IOM;2015) report highlighted the gaps in access to care and quality of care in the adult mental health service system, where just more than half of individuals who needed care received it, but only about one third received treatment considered minimally adequate. A similar gap likely exists in the child-serving systems as well.
Evidence-based practice (EBP) has been proposed as a solution to the quality problem in youth mental health services (Weisz, Sandler, Durlak, & Anton, 2005). The term evidence-based practice is commonly used but not always well-defined. EBP was originally used to describe the process of using research evidence, along with clinician expertise and client preferences, to select and implement a specific technique or intervention (Gibbs & Gambrill, 2002; Sackett, Richardson, Rosenberg, & Haynes, 1997). However, it is also commonly used to designate manualized interventions that have a known evidence base (often meeting the criteria of two or more independent randomized controlled trials). Examples of manualized EBPs include Parent–Child Interaction Therapy (PCIT; Eyberg et al., 2001), Incredible Years (Reid & Webster-Stratton, 2001), or Multi-Dimensional Treatment Foster Care (Chamberlain & Mihalic, 1998), to name a few. Several websites identify these EBPs and classify the level of research supporting interventions (e.g., California Evidence-Based Clearinghouse for Child Welfare, National Registry of Evidence-Based Programs and Practices). National, state, and foundation efforts have been underway for more than a decade to promote knowledge building and application of evidence-informed interventions (Chambers, Ringeisen, & Hickman, 2005).
In general, manualized EBPs were not designed for and rarely tested with youth placed in group care settings. James (2011; James, Alemi, & Zepeda, 2013) identified some notable exceptions. First, she reviewed five milieu-wide evidence-based program models that have been implemented in residential settings (James, 2011). Their levels of evidence vary due to a limited number of empirical studies (many of which are dated) and research designs that often lack random assignment. In a later study, she conducted a systematic review to identify empirical studies of diagnostic-specific EBPs that were implemented in group care settings (James et al., 2013). She found that 10 different EBPs had been applied and tested to some degree in residential settings for youth, suggesting that EBPs can be successfully integrated and show positive effects in group care.
From the perspective of group care providers, attitudes toward EBP are generally positive and open to manualized EBPs. In a national survey of 75 agencies, James and colleagues (2015) found that about three fourths or more of all respondents endorsed the advantages of manualized treatments in providing structure, accountability, and consistency in practice as well as better outcomes for clients. The most commonly endorsed disadvantages noted by the sample were related to the “one size fits all” nature of some structured, manualized treatments that do not allow for flexibility or account for differences in client factors and preferences.
For group care programs, the path forward with EBP can be varied and circuitous. The Association of Children’s Residential Centers (ACRC) identified several ways that group care programs are “embracing the challenge” by engaging with EBPs, including implementing manualized EBPs in-house, infusing an evidence-based treatment model throughout the milieu, and making better-informed referrals to community clinicians who can provide specific EBPs to group care residents (American Association of Children’s Residential Centers [AACRC], 2009, p. 250). This article will outline four possible pathways to progress in the use of evidence-informed practices in residential settings for youth. These include (a) using the common elements of evidence-based interventions, (b) creating a home-grown intervention and its evidence base, (c) adapting an established EBP for use in a group care setting, and (d) adapting a group care setting to better facilitate the delivery of EBPs.
Using the “Common Elements” Approach
Instead of focusing on an evidence-based intervention’s treatment manual as the unit of analysis, the common elements approach unbundles manualized treatments into actual practice techniques or building blocks frequently found across interventions with known effectiveness (Chorpita, Daleiden, & Weisz, 2005). The common elements of child mental health practice were initially identified through a review of 322 randomized clinical trials of interventions to treat key child disorders (e.g., depression, anxiety, disruptive behavior, trauma). For each of these studies, the treatment conditions with significantly better outcomes were distilled to understand the components or practices embedded within (Chorpita & Daleiden, 2009). Then, across all the winning treatments, the most frequently included practices were labeled as common elements. For example, in managing disruptive behaviors of young children, several EBPs include teaching parents about time out, so time out is one of the common elements of effective practice. The process of reviewing 322 studies yielded approximately 41 practice elements (Chorpita & Daleiden, 2009).
The common elements approach is a method for summarizing the evidence base that has implications for designing and delivering treatment (Barth, Kolivoski, Lindsey, Lee, & Collins, 2014; Barth et al., 2012; Chorpita, Becker, & Daleiden, 2007). Unlike mastering a single manualized treatment, competence in the common elements of practice allows a practitioner to work with a larger proportion of youth. Relatedly, the training demands are minimized, as practitioners can be taught practice elements that can be applied across a number of clients. A commonly identified challenge of manualized EBPs is the cost in time and money to train and maintain certification for clinicians (Powers, Bowen, & Bowen, 2010). The practice elements have an inherent flexibility in the selection, sequencing, and pacing. This flexibility allows for greater customization to individualize treatment to a specific client’s needs and preferences as well as constraints of a system or setting (e.g., duration and structure of treatment). However, the flexibility is not mandated and a clinician could follow a modularized approach to delivering the practice elements in a sequenced order. This modularized framework, Managing and Adapting Practice (MAP), is an approach to treatment decision making based on research evidence, client characteristics, and ongoing outcomes monitoring (see more information at www.practicewise.com/Community/MAP).
Evidence for the effectiveness of the common elements approach is growing. The Child STEPS (System Treatment Enhancement Projects) Randomized Effectiveness Trial compared three groups of clinicians: those trained to use manualized EBPs; those trained to use the common elements packaged in a sequenced, modular approach; and clinicians following usual care (Weisz et al., 2012). Results over a 2-year period found that youth treated in the modular approach based on the common elements had a significantly greater improvement on internalizing and externalizing symptoms compared with usual care and a greater rate of improvement compared with both usual care and manualized EBPs (Chorpita et al., 2013). Therapists in the modular approach had the highest satisfaction and assessed the modular approach as being more effective and more responsive to a client’s needs than the therapists in the other two arms of the study (Chorpita et al., 2015).
The common elements approach could be a treatment model for delivering effective behavioral health services in group care settings. Mental health clinicians in group care settings could be trained in the common elements or modularized MAP framework. In their national survey of residential programs, James and colleagues (2015) found that six programs reported using MAP in their setting. MAP can be used with mental health issues that are commonly found in residential settings: anxiety, depression, trauma, and disruptive behaviors. Considering the empirical findings described above that demonstrate faster and greater youth behavior improvement as well as high rates of satisfaction by providers, MAP may be an appealing way for group care programs to infuse practices with evidence of positive outcomes for youth with mental health needs.
Although the inherent flexibility may raise concerns about maintaining fidelity to the model, the MAP resources and tools for outcome monitoring and benchmarking can provide some controls. A recent large-scale implementation study among Los Angeles County mental health providers found that MAP can be feasibly trained at acceptable competency and can produce medium-size positive effects for youth (Southam-Gerow et al., 2014). If MAP can be successfully implemented within a very large provider system, it certainly has potential for smaller systems or agencies that serve youth with diverse diagnoses or other behavioral health needs.
The common elements of child mental health emerged from empirical studies of diagnostic-specific evidence-based interventions tested in clinical trials. However, the methods used to identify these common elements could be more broadly applied to residential practices that are not particular to specific youth needs. The common elements of working with youth in group care settings could be discovered through a systematic review of the existing empirical literature on group care settings, using the common elements framework. These elements of group care could include milieu-wide interventions or practices that may be related to positive youth outcomes. For example, Thompson and colleagues (Thompson, Duppong Hurley, Trout, Huefner, & Daly, 2017) suggest that positive teaching and therapeutic alliance may be two of these common elements that are linked to improved outcomes in group care settings.
Researchers have demonstrated the feasibility of adapting the coding process to identify the common practice elements of client engagement (Lindsey et al., 2014) as well as the program and practice elements of placement prevention (Lee et al., 2014). The distillation and matching method that were used within the empirical literature for child behavior disorders could be implemented with empirical studies (albeit more limited in number and design) that test group care outcomes. Examining existing evidence through this lens could identify characteristics of group care staff training and staffing patterns, milieus, programmatic features, or practices that may be more commonly found in studies with positive outcomes for youth. These elements could then be considered to improve quality group care practice.
Building a Home-Grown Program and Its Evidence Base
In reviewing the five milieu group care models with some level of research evidence (James, 2011), they each began as an idea specific to a single agency. The teaching-family model started in Lawrence, Kansas, with a solitary group home and staff with some knowledge and interest in behavior modification techniques. The sanctuary model was developed by a team of mental health professionals working in a psychiatric unit of a hospital near Philadelphia. However, these very localized efforts were replicated and expanded, at least in some part due to their growing research base.
Not all evidence-based interventions are born in a research setting; interventions or techniques that have been designed and refined in real-world practice can grow into being evidence-based. Several steps are required to develop a home-grown practice and nurture it into an EBP. First, the theory and logic of the program would need to be developed, identifying the desired outcomes and the mechanisms that undergird achievement of these outcomes. Building a logic model or program theory may help explicate what to include.
Next, the practice would need to be sufficiently defined and described to both allow for clear fidelity measurement as well as replication. A treatment manual is often created to clearly prescribe what should happen when within the intervention. Next, the practice would need to be associated with a positive outcome that can be reliably measured, for example, improvements in youth behavior from pre- to postintervention, according to the Child Behavior Checklist or similar standardized measure. Positive change should be reported not just by individuals who are invested in the delivery of the intervention (i.e., group care staff or the intervention developer). Finally, the intervention would need to be tested against alternative treatments. Ideally, this would involve randomly assigning youth to receive the intervention of interest or some alternate condition. Many standards for defining the evidence for a practice give greater weight to independent evaluation, which suggests that some group care programs may benefit from partnering with university researchers or other evaluators outside of the agency to enhance credibility of findings.
With so many programs interested in demonstrating that their services are evidence-based, new resources are emerging to assist providers interested in this process. Child Trends has offered both webinars and a 5-week workshop series on becoming an evidence-based program. The Vera Institute for Justice developed a MacArthur Foundation-funded guide for providers to conduct process and outcome evaluations (Fratello, Kapur, & Chasan, 2013). The Children’s Bureau’s Child Welfare Information Gateway has cataloged about a dozen resources on their website about selecting and becoming an EBP (https://www.childwelfare.gov/topics/preventing/evidence/).
Although the process of becoming evidence-based is generally transparent, programs may be unable to allocate the time and talent required to complete it. Practitioners engaged in the practice may have the most institutional knowledge about the what, when, and why but may not have the skills or time to conduct a systematic evaluation. External partnerships with university researchers or other partners can facilitate this work (e.g., see the description of “On the Way Home” in Thompson et al., 2017). However, these partnerships may necessitate funding for large-scale projects or require sophisticated designs. In light of these obstacles, it is likely that effective practices may be incubating within group care programs and are in need of nurturing to move forward in becoming evidence-based.
The following case study traces the development of a new intervention and the quest to build its evidence base within a group care environment. It loosely follows the steps described above for developing and testing a home-grown intervention. However, it illustrates how real-world design and implementation can become messy, require significant resources and time, and involve aspects of each of the main strategies discussed in this article.
Case Study
A mid-size child and family service agency had been looking for an evidence-supported intervention for its residential programs to help deal with issues of explosive episodes, fighting, and runaway. Their staff identified a manualized intervention that had been subjected to one successful randomized trial in a psychiatric facility, but the required initial financial investment in training was beyond their reach. Around the same time, a social work professor had recently completed a small feasibility trial of a treatment foster care program for youth stepping down from residential programming and realized that the intervention needed additional components to better equip youth and foster parents to handle intense emotional episodes (McMillen et al., 2015). In 2011, the child and family service agency and the social work professor began collaborating on building a social-emotional intervention program for staff and child welfare that involved youth living in group homes, residential centers, and treatment foster care (http://www.handlingintenseemotions.com).
The agency’s clinical director and the professor developed a plan to proceed, using university’s resources to nominate appropriate theory and components for intervention development and the agency’s youth and staff to shape the intervention to assure its acceptability and feasibility. The first step in assessing stakeholder acceptability was to present this plan to the agency’s youth advisory council. They decided the plan was a worthy investment of youth time as long as the resulting intervention focused on social skill development.
From there, the faculty member hired a team of graduate students to explore the scientific literature on emotion regulation and identify promising intervention components. After input on proposed content from the agency’s clinical director, the university team began building an intervention based on the following components: (a) psychoeducation for youth and adult caregivers about emotion episodes (Stein, Hernandez, & Trabasso, 2008), beliefs about emotions (Leahy, Tirch, & Napolitano, 2011), and the development of emotion regulation capacities (e.g., Calkins & Hill, 2007); (b) skills components for youth to help de-escalate themselves when upset; and (c) skills for staff to help de-escalate youth. The skill-based elements derived mostly from existing interventions, especially dialectical behavior therapy (Linehan, 1993), acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 2003), and cognitive behavioral therapy. The university-based team advocated for a blended intervention that combined viewing online digitized content with facilitated group discussion and practice. The digitized content addressed three concerns related to the feasibility of delivering manualized interventions in group and residential care: (a) whether group care staff (clinicians or direct care staff) could reliably convey complex psychoeducation about emotions, (b) whether agencies could continually train new staff on the curriculum given high turnover, and (c) how to deliver intervention content to youth who miss group sessions or who are not appropriate for them due to their behavior in group. It was decided to build out the blended version of the intervention, despite realizing this would take substantially more time.
To develop the curriculum, the university team sought input from youth and staff in the agency’s residential program to gauge initial acceptability of the content domains and to identify real-world situations that could be used as case scenarios to teach the content. Using the suggestions from youth and staff, the university created roughly 5 hr of digitized content with scripted fictional scenes involving youth and staff characters, stock and original photos, stock and custom graphics, a limited number of video-recorded sequences, and both professional and amateur actors. This content is accessed online and plays as a series of animated slides. Introductory materials, logic models, hand outs, and several different manuals (for group facilitation, integrating content into individual therapy, and implementation) were created. This effort took just more than 1 year.
To solicit acceptability feedback from agency youth, a demonstration of a working model of the digitized content was presented to youth clients in a focus group format. From the university institutional review board’s (IRB) perspective, this activity was the start of the research to support the intervention. The focus group participants reacted to the curriculum content and rated its engagement and helpfulness. They appreciated the relevance of the depicted situations—such as moving from a residential center to a foster home. Based on their feedback, content on how people develop emotion regulation capacities was softened because youth found it too depressing; new youth characters and more youth narration were also added. The energy and attention of the focus group faded when an adult narrated the content. A new youth scenario was written and produced based on recommendations from an agency employee who was running a youth employment project. These revisions took several more months. The resulting intervention included 10 modules, designed to be delivered over approximately 16 group sessions to youth. The version of the curriculum for direct care staff could be delivered completely online, in a one-session training following online viewing, or over a longer time in shorter sessions, such as part of ongoing team meetings. The process included aspects of a common elements approach by compiling elements from several intervention packages and of an adaptation approach, making these intervention materials more acceptable, feasible, and scalable for a group care setting.
The revised version of the curriculum was implemented for the first time in 2014 in an agency group home. Youth were more receptive to the intervention program than staff. Program staff struggled with the suggestion that they access online material prior to an in-person training. Revisions from this initial implementation included programming in a “pause” button for the digitized content and financially incentivizing direct care staff to view the online content.
The fully developed curriculum and faculty–agency partnership were enough to attract foundation support for further development and pilot testing and testing of fidelity and other measurement tools. Subsequent implementations of the curriculum in the agency’s residential treatment programs included qualitative and quantitative evaluation of components. Minor revisions (content order, incentives for youth behavior) were added to the curriculum based on lessons learned from each cohort. The third implementation, with older youth who had more criminal involvement, went less well, with more problem behaviors within the group sessions and suggestions for even more youth narration. For the first time, youth complained that the characters in the curriculum were not enough like them.
After 5 years of collaborative development work, three cohorts of youth and staff have completed the intervention. Improvements to the curriculum and implementation protocol are ongoing, with a continued focus on ways to make the content more engaging for youth and direct care staff. Neither the agency nor faculty member considers the intervention to be fully ready for wider dissemination or a larger trial, although it is less clear whether small tweaks will make the needed differences or whether wholesale changes are needed. This example highlights that intervention development can become a long-term endeavor. Furthermore, the heterogeneous nature of the group care population may mean that an intervention developed for group care clients may be appropriate for only a segment of those clients.
Changing an EBP to Fit a Group Care Setting
Because of the unique and comprehensive nature of a group care setting, existing diagnostic-specific EBPs designed for nonresidential settings may not be a perfect fit. In their national survey, James and colleagues (2015) found that almost half of respondents were concerned that the positive outcomes for an EBP may not generalize to other settings, suggesting that manualized programs may need modifications to be feasible and effective in group care programs. There is some evidence that EBPs can be adapted to work in situations other than how they were designed. For example, foster parents in a group-based rather than the individual dyadic experience of PCIT still reported positive behavior gains for their foster youth (Mersky, Topitzes, Grant-Savela, Brondino, & McNeil, 2014). Revising the content to be presented in full-day, group-based trainings instead of weekly individual sessions accommodated the existing structure and format of other foster parent trainings in their locale and was less expensive than the original model.
In their review article on the use of EBPs in group care settings, James et al. (2013) identified the four types of implementation challenges described in the 10 empirical articles: client receptivity, staff receptivity, treatment setting factors, and structural/organizational barriers. They also described the needed intervention adaptions that were reported in empirical articles. These modifications focused primarily on changes in the length of time an intervention was delivered and change in content of curriculum that may not match the abilities or needs of the treatment population. For example, residential programs may be able to cover material more quickly than outpatient programs or may need to abbreviate content to accommodate unexpected discharge.
In making any modifications to a manualized intervention, ensuring there is no negative impact on the effectiveness of the intervention is essential. Identifying the fine line between adaptation and reinvention or “drift” requires a comprehensive understanding of the theoretical and conceptual framework from which the program operates as well as its key ingredients. As Aarons and colleagues (2012) warned, “intervention adaptation at its best is a cautious process . . .” (p. 2). Much of the existing research around adaptations of client-specific EBPs focuses on cultural adaptations for minority populations (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009), including a toolkit that provides guidance on modifying EBPs (Samuels, Schudrich, & Altschul, 2009). Similar caution should be used with adapting a manualized treatment for specific youth in a group care setting, with sufficient evaluation to insure consistency in achieving positive results.
Adapting a Group Care Model to Incorporate an EBP
The previous section “Changing an EBP to Fit a Group Care Setting” discussed the option of modifying a diagnostic-specific EBP to improve the fit within a residential program. This final section “Adapting a Group Care Model to Incorporate an EBP” proposes the opposite approach: changing the residential program to improve the capacity to deliver evidence-based interventions that are youth-specific or across the milieu. Specifically, this section will consider whether changes to the structure of a group care program can better facilitate EBPs or programs.
A challenge to implementing a diagnostic-specific EBP in a group care setting is that many EBPs require engagement of not just the target youth but also the family. Through family therapy or family interactions that focus on exchanges between the youth and caregivers, new patterns of relating and behavior can be built. For youth in a group care setting, the group care providers may be a proxy family to the youth, but as most youth will reunify with their family upon exit from placement (U.S. Administration for Children & Families, Office of Family Assistance, 2015), involving family members in the EBP would be advisable. However, for youth living in a group care setting away from family, engaging in family work can be a challenge.
One group care model that lends itself to increased family interaction is 5-day residential programs that incorporate weekly home visits. Project Re-ED or the Re-education of Emotionally Disturbed Children is a model that recognizes the importance of the family and social context in the youth’s well-being (Hobbs, 1966). Traditionally, Re-ED programs operated 5 days a week to insure weekly home visits where parents maintain emotional connections to the youth and work with youth on the same skills being taught in the residential setting. Several programs throughout the United States follow the Re-ED model and some residential programs offer weekly home visits or other unique program designs to maximize family involvement and transference of skills from the residential program to family life. However, the research base for this model is not as robust as other interventions, lacking any comparison studies (James, 2011).
In Norway, Tore Andreassen (2004) developed an intervention for residential and community settings called MultifunC (Multifunctional Treatment in Residential and Community Settings). The model was built from standards and content of interventions with established effectiveness, similar to a “common elements”-type approach. The model embeds several EBPs, including aggression replacement training, motivational interviewing, parent management training, and multisystemic therapy. The model is explicitly split into two equal-length phases, a residential stage and an aftercare stage, with each lasting 4 to 5 months (Andreassen, 2015). Through this staged approach, youth benefit from the milieu therapy and diagnostic-specific evidence-based interventions in the residential setting, but families also receive extended support and aftercare using evidence-based parent training models. Evaluations to assess the effectiveness of this model are underway in Norway and Sweden.
Another programmatic change that may better facilitate the delivery of EBPs is creating a family-like environment within the residential program. Jones, Landsverk, and Roberts (2007) found that youth in a program with live-in caregivers had better continuity of care and experienced less staff turnover than units with shift-care staffing. A recent study comparing eclectic group care models (with no primary or overarching model of treatment) with group homes following the teaching-family model (i.e., explicitly family-like, manualized, accredited) found that although youth in both settings improved during care, youth placed in teaching-family homes continued to report improvements and better outcomes even 8 months after program exit (Farmer, Seifert, Wagner, Burns, & Murray, 2016). Programmatic changes like staffing patterns or becoming family-like are presented as examples of how changing program structure may improve youth outcomes.
These programmatic or structural-level changes are not simple. They often require comprehensive changes to the philosophy and culture of the program. At times, they may also necessitate remodeling physical space, revising staffing roles and schedules, retraining staff, and other dramatic alterations. To successfully pursue a sweeping change, the effort required must be well-understood and sufficiently supported within the organization.
Conclusion
To remain a viable treatment setting, group care programs need to demonstrate evidence for their effectiveness. Developing and using interventions that are known to be effective with challenging youth can strengthen a group care program as well as the field of residential care as a whole. This article proposed four possible pathways for group care programs to move forward in embracing EBPs and programs.
Although these pathways exist, they are not easily traveled. As a recent survey of group care providers noted, many programs are engaging in using diagnostic-specific evidence-based interventions, but there are challenges to the process (James et al., 2015). Group care programs, like most social service providers, face financial constraints that can deter interest in new initiatives. Becoming trained and certified in an existing manualized practice can be expensive; building evidence for an intervention developed internally may also require funding as well as research skills or collaborations.
Staffing structures may also create a challenge. Many of the frontline providers in group care settings who have the most direct contact and time with youth are likely to have the least formal education in delivering clinical services. However, new studies offer promise that nonclinicians may be able to play a role in facilitating interventions. In health care studies, there is some evidence that task-shifting in primary care from physicians to nurses did not negatively affect patient outcomes (Martinez-Gonzalez, Tandjung, Djalali, & Rosemann, 2015). Implementation studies of EBPs are currently underway in child welfare to assess whether caseworkers can deliver a multiple family group intervention with the same positive results as clinicians. These inquiries suggest that frontline staff in group care settings may be able to be equipped to at least actively support if not primarily deliver EBPs and programs. Expanding the roles of workers or staff to include responsibilities for delivering intervention has been found to create resistance (Leathers et al., 2009). However, having the primary care staff serve as treatment agents can be a powerful way to expand clinical interventions to affect “the other 23 hours” in a day (Trieschman, Whittaker, & Brendtro, 1969).
Group care settings may also be uniquely challenged by physical plant limitations. The residential program’s physical structures (i.e., family home in a residential neighborhood, campus setting) may either facilitate or constrain the adoption of evidence-based interventions. Physical environments may not provide the space needed for delivering live coaching to families or group care providers. Youth are residing with other peers, which allows ample peer interactions, but securing individual time for youth to work on clinical “homework” with a care provider may be more challenging.
A subtle obstacle to advancing EBPs in residential settings is the lack of understanding for what constitutes an evidence-based intervention. According to James and colleagues (2015), many group care providers reported that they are using an EBP, but the practice they named is not supported by empirical research evidence. A first step programs may need is help in identifying whether they are using an EBP and then consider what path to pursue to move forward.
Several key partners can help residential programs and the field to take the next step in expanding the use of EBPs and programs. Existing membership organizations such as the ACRC can assist with sharing knowledge about how programs can be successful in these different endeavors and connect members following similar paths. Learning collaboratives or other peer learning opportunities may allow providers to learn from each other. Researchers can collaborate with provider agencies to design and conduct empirical studies to advance the evidence for home-grown programs as well as help identify and test adaptations of evidence-supported interventions being implemented in residential settings. Finally, intervention developers who have established EBPs should consider engaging group care programs to understand whether and how their intervention can be effective in a residential setting.
EBP in a group care setting can vary from adopting or adapting manualized, diagnostic-specific interventions provided by mental health clinicians to creating a milieu that emphasizes program characteristics associated with better outcomes for youth. Whether to incorporate client-specific treatments or program-wide efforts or both is a question of capacity as well as a question of science. Delivering a manualized or emergent EBP in a setting where supportive staff members surround the youth and can reinforce new skills may be especially powerful and optimize impact. More studies are needed to understand the potential synergistic effects of combining effective interventions with milieu-level supports.
The beginning of any journey begins with a small step and moving toward EBP is no different. Although much of the focus on evidence-supported interventions has emphasized using manualized, diagnostic-specific interventions, it is not the only option. This article described several possible steps that group care providers can follow to deliver services that are more likely to enhance youth outcomes.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for some aspects of the work described in this article was provided by Help for Children, a foundation supported by financial service industries. Special thanks to the staff and youth at Lawrence Hall, a community-based social service agency based in Chicago.