• By Laura Whybra
  • Posted on Thursday 05th September, 2013

Do young people’s multiple problems need modular solutions?

strong>Evidence-based programs capable of treating youth with multiple behavioral, emotional and social problems remain relatively scarce. Would a modular approach make it easier for practitioners to apply the core ingredients from effective interventions, adjusted to young people’s individual needs?The shortage of accessible, organized practice information for services that work with youth when mental disorders are compounded by psychosocial problems (such as drug misuse, homelessness and criminal behavior) is highlighted in an article by Penelope Fay Mitchell of the Youth Support and Advocacy Service in Melbourne, Australia.She notes how services providing emotional and behavioral health care for children and adolescents have been slow to implement evidence-based practice. Explanations, she suggests, include the practical difficulties of referring troubled young people to multiple, manualized interventions, even supposing that funding and training barriers can be overcome.Taking the example of a depressed or anxious teenager who is misusing drugs or alcohol, she argues that a practitioner would need to consult at least two manuals in order to deliver evidence-based care. However, if the young person also lives in a chaotic family home, is involved in criminal activity, experiences overwhelming emotions and engages in self-harming behaviors, then the manualized programs will not only risk being inadequate to the task, but also face frequent interruption by crises.A “modular practice elements” approachOne response to such problems has been the development of “integrative” treatment models such as Multisystemic Therapy (MST) Multidimensional Treatment Foster Care (MTFC), Multidimensional Family Therapy (MDFT) and the Adolescents Community Reinforcement Approach (ACRA). These evidence-based programs combine components from different areas of intervention and supporting theories. However, a second, more recent approach, described by Mitchell, is that of “modular practice elements”.The concept of practice elements suggests that the core ingredients of effective treatment models can be identified, specified, and then employed in different ways. For example, Bruce Chorpita and colleagues at the University of Hawaii identified 41 common practice elements out of 615 different treatment protocols for child and adolescent mental health problem. Ann Garland and colleagues at the University of California San Diego reviewed eight evidence-based programs targeting disruptive behavioural problems and identified 21 common elements. Other researchers have examined theory to think about how and why interventions work. For example, they have looked for the “active ingredients” in Social Control Theory, Social Learning Theory, Behavioral Choice theory and Stress and Coping Theory.Interest in a taking modular approach has, meanwhile, emerged from fields such as engineering where complex activities or structures have been being broken down into simpler parts that can function independently. In the context of helping youth with multiple psychosocial problems, a module “would contain practice elements that theory or practice wisdom suggests will add value to one another in achieving specific functions or therapeutic purposes”.Why use it?Mitchell argues that a modular practice elements approach would carry a number of advantages when treating young people will complex, multiple needs compared with conventional implementations of evidence-based practice:• Individual tailoring: with interventions broken into smaller parts, practitioners would find it easier to mix and match techniques best suited to the individual.• Integration with existing practice: instead of replacing what already exists, the new approach would build on its strengths.• Varied modalities: while many evidence-based programs run in a single, highly structured mode (e.g. a planned series of group-work sessions), a modular approach could combine a number of modes and timescales.• Cost efficiencies: training could concentrate on skills that are missing or underdeveloped among practitioners rather than training them in multiple, elaborate evidence-based programs. • Sensitivity to context: as the clients’ needs shift, practice elements could be added or subtracted.• Evaluation: research would improve knowledge about the effectiveness of “usual care” that has been poorly described and evaluated, as well as the overall modular approach.• Inter-agency collaboration: a common language about practice elements would help to form a shared understanding of interventions across different services.Early adopters Hawaii’s Child and Adolescent Mental Health Division took a modular practice elements approach to improve the effectiveness of its usual care services offered to young offenders who were not eligible for local MST and MTDC programs. Practitioners were equipped with a computerised database that enabled them to search for practice elements for depression, anxiety, and conduct disorder to match a particular client’s characteristics. The range of information offered has expanded as partner organizations have adopted the approach. The approach is now being privately marked as “PracticeWise” and its emerging applications include non-specialist mental health care provided in pediatric and school settings.Meanwhile, a three-way randomized-controlled trial conducted by Harvard psychologists in Massachusetts and Hawaii among 84 clinicians compared the success of those allocated to taking a modular approach to treating 7 to 13-year olds for anxiety, depression and conduct problems with those using a manualized program and those providing “usual care. Young people treated through the modular approach showed a faster rate of improvement on multiple clinical outcomes and better results at one-year follow-up. Further research is needed to discover whether the promise indicated by this single study can be confirmed. In principle, however, it already offers a practicable means of achieving better outcomes for particularly troubled children and young people whose complex problems are beyond the reach of a single intervention.Yet it would be unwise for service providers to imagine that modular practice elements delivers easy solutions, or tolerates a less rigorous approach to evaluation, evidence gathering or practice fidelity. Mitchell leaves no doubt that it requires a considerable investment of time and resources, including training and supervision.*********Reference: Mitchell, P. F. (2012). Designing evidence-based treatments for youth with multiple and complex needs: a modular practice elements approach. Advances in Dual Diagnosis, 5 (3), 122-136.

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