• By Sarah Blower
  • Posted on Tuesday 12th June, 2012

Systematic Concatenation

I have been reporting from the Society for Prevention Research (SPR)’s annual conference on Prevention Action this week. In one of my stories "State of the Art" program adaptation: SPR conference 2012 I featured the work of Naomi Goldstein, a US researcher who has come up with a new step-by-step guide for adapting evidence-based programs. Tom Dishion, Director of the University of Oregon’s Child and Family Center and a familiar name to many of us in the field, described Goldstein’s work as "State-of-the-Art." But he also asked an important question in the discussion following her presentation. He asked “how many manuals, for how many problems, with how many RCTs?”This resonated with many of us in the audience. The ad infinitum problem of where to step back. How much adaptation is too much and is it really a sustainable model if we want to take evidence-based programs to scale?It’s not so much the adaptation that is the problem - more the “programmism” says Dishion. EBPs have a narrow focus, the contexts in which they are tested are limited and they often overwhelm the staff involved in selecting and implementing the intervention. What is more, EBPs often fail to address co-morbid problems (and their causes), they are quickly abandoned and shelved when staff or implementers change. In the particular case of school-based interventions, Dishion also argues that EBPs frequently assume skill sets that schools may not have.Dishion remembers a pitch he made not so long ago to a school interested in the Family Check-Up (an intervention that he developed - see Family Check-Up ticks boxes at school). He was directed to the dark basement of an administration building to meet with the school principal. Looking around him at the stacks of books on the numerous shelves, he quickly realized that hundreds of program manuals lined the walls. He called it the “program cemetery.”Another of the schools Dishion visited ended up hiring a "Prevention Coordinator" because so many programs were being administered to its students. This can’t be sustainable.What is the solution? Dishion proposes "systemic concatenation." Systemic… what? According to the dictionary, concatenation means "a series of interconnected things or events."Dishion further explains that systematic concatenation is a radical approach to adaptation and integration, a method for linking (or concatenating) empirically based ideas into systems. His point is that we should be focusing on and seeking changes at a system level rather than looking to a suite of programs to address the needs of children and young people.Ultimately, this means taking the core components of a program - its mechanisms of action - and embedding them within an operating system - be it a school, hospital, or community. Dishion says that “effective school systems can be recreated and tailored by training administrative leaders and teachers in applying core behavior change processes within the overall school system.”It is vital, at this stage in the prevention research cycle, that prevention scientists willingly give up ownership (i.e. remove copyright) and get behind efforts to streamline the intervention so that the correct, active core components of the model are targeted. It’s a tall order. But Dishion thinks it is essential if prevention science is to scale "what works" so that it reaches more of the children and young people that need it.

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