Evidence-based practice in real-world services for young people with complex needs: New opportunities suggested by recent implementation science

Abstract

There is growing agreement that child and youth services have been slow to implement evidence-based practice (EBP). A variety of interrelated barriers and facilitators of EBP implementation have been recognized and investigated. Key categories include the attitudes of providers, the characteristics of client populations, the characteristics of usual practice, organizational factors, and resource availability. Implementation scientists are investigating these factors, seeking to bridge the gap between clinical science and practice. Much of this work has been conducted in the context of behavioral health services for children and young people. This paper provides a purposeful review of this research from the perspective of decision-makers in agencies serving young people with multiple and complex psychosocial needs. It is argued that major barriers to EBP may be mitigated if ways can be found to transcend the oppositional construction that has characterized the discourses of EBP versus practice wisdom. A conceptual approach to such integration is offered. New lines of implementation research are offering opportunities for practical action by decision-makers consistent with this integrative approach.

Introduction

Health and social care policy in most developed countries is increasingly emphasizing evidence-based practice (EBP). Funding bodies are pressuring public, private for-profit and not-for-profit agencies to demonstrate that they are using EBP or to articulate the ways in which they are moving towards it. Despite this pressure, there is growing consensus among researchers and other commentators in the field of behavioral health care that EBP within usual care is being implemented at an unacceptably slow pace (Aarons et al., 2009, Garland et al., 2006, Godley et al., 2001, Liddle et al., 2006, Rosenberg, 2009, Stirman et al., 2004).

‘Implementation’ is the intentional use of strategies to introduce or adapt evidence-based interventions within real-world settings. Implementation must be distinguished from adoption, which is merely a formal decision to use an evidence-based intervention. Implementation usually aims to achieve regular use of evidence-based interventions.

Research investigating efforts to implement EBP in behavioral health care has identified several factors associated with adoption and/or implementation. Key categories of factors include: attitudes of practitioners; characteristics of client populations; characteristics of usual practice; organizational factors, and resource availability. These factors interact in complex ways, raising difficulties for practitioners and managers who must make decisions about what EBPs to use and how to design implementation processes with high odds of success.

Another trend coinciding with the increased emphasis on EBP is the growing recognition that there is a sizable population of young people who experience a combination of interrelated psychosocial difficulties. These include substance use problems, mental health problems, periods of homelessness, and offending behavior. There is an increasing convergence of understanding about the factors that contribute to the prevalence, exacerbation and amelioration of these problems and the interventions that can be effective in preventing and treating or moderating them.

This has implications for how EBP is conceptualized and implemented. Most evidence-based treatments developed and trialed in research settings focus on the amelioration of a single disorder or problem behavior, but many of the young people seen in real-world service settings experience multiple problems or disorders, or present with greater complexity than youth involved in clinical trials (Hawley and Weisz, 2002, Weisz et al., 2003). Increasing the applicability of EBP to realities such as clinical complexity may be an important strategy for enhancing adoption and implementation. While clinical evidence-based treatment research has recently extended to treatments for co-morbid disorders (e.g. depression or anxiety combined with substance use disorders) this extension still maintains a focus on discrete disorders (two rather than one) and rarely extends to embracing the construct of complexity in terms of dimensions beyond diagnostic categories. These dimensions include factors that are known to exacerbate emotional and behavioral problems for young people such as socio-economic hardship, learning difficulties, disconnection from core social institutions such as education, training and employment, family breakdown and homelessness, and lack of supportive relationships. There are also more neutral factors such as minority cultural background and minority sexual orientation which interact in complex ways with identity formation in adolescence. Adolescents with multiple and complex needs may be receiving services from multiple sectors, adding further complexity to the decision process for providers striving to deliver EBP. The lack of clinical research attention to this population is well recognized (Kazak et al., 2010).

The implementation science literature is moving beyond the siloed approach that has characterized treatment efficacy research. Implementation science has been open to conceptual frameworks and methods that embrace complexity, such as ecological systems theory, organizational theory, and qualitative and mixed-methods research. Some of the most insightful research on EBP implementation has been conducted in service systems (e.g. publicly funded child and adolescent mental health) with client populations containing large proportions of youth with multiple and complex needs. Implementation researchers are recognizing the special challenges involved in developing EBP for this population and calling for a multisystemic approach (Kazak et al., 2010).

The literature reviewed in this paper focuses on implementation research and some clinical intervention research that has been conducted in these settings, drawing out findings and practical implications of interest to decision-makers serving youth with multiple and complex needs. Several strands of implementation research are exploring particular types of barriers and facilitators, including interventions designed to address them. This research is yielding insights into approaches that have considerable potential to help bridge the gap between what is known about treatments that are supported in empirical research, and treatments that are used in real-world practice. There is a lack of literature that synthesizes insights emerging from the various lines of work.

Several major conceptual and practical issues need to be clarified before implementation research can provide comprehensive guidance to decision-makers in real-world service settings. A key conceptual challenge concerns the ways in which core concepts such as ‘practice’ and ‘treatment’ are understood and used in the ‘research’ literature—both clinical and implementation research—compared with the ‘practice wisdom’ literature. Although the need to integrate research with practice wisdom has been recognized in the EBP literature, there has been little analysis of the nature or content of the practice wisdom that needs to be integrated. While the field will hopefully debate and elaborate this over time, for the purpose of the current essay, practice wisdom is defined as practice-based knowledge that has emerged and evolved primarily on the basis of practical experience rather than from empirical research. This knowledge may be acquired directly by a practitioner through their personal experience, or it may be based on the personal experience of others and acquired through dissemination among practitioners. A well elaborated example is the kind of knowledge that is generated and acquired through the ‘situated learning’ that takes place in ‘communities of practice’ (Lave and Wenger, 1991, Wenger, 1998).

Much practice wisdom or practice-based knowledge remains tacit and undocumented. This knowledge may drive many decisions and actions without being articulated, but much has been explicated and documented. Key documentary sources include: the clinical practice literature or writing based on the reflections, opinions, and general knowledge including varied reading of the writer; and qualitative research investigating the views and experiences of practitioners. Much curriculum used in the education of human service professionals may be largely practice-wisdom based, as there is evidence of low dissemination of empirically supported treatments (ESTs) to graduate and internship training programs (McHugh and Barlow, 2010, Weissman et al., 2006).

The literatures based on empirical research versus practice wisdom can frequently appear to reflect contrasting world views. Some form of resolution or synthesis that incorporates the best knowledge from both would be of great benefit in increasing the quality and effectiveness of children and youth services (Aarons, 2004, Aarons et al., 2009). There is little analysis or commentary available in the research or practice literature to help decision-makers interpret and reconcile the apparent contradictions between these literatures or to select or design strategies that are consistent with both. Another challenge is to find ways of integrating findings from separate lines of research to distil feasible solutions for decision-makers. It would be helpful if the complexity inherent in these solutions could be reduced to a small number of simpler ideas. Is it possible, for example, that solutions for addressing barriers to EBP at the practice level could be based on the same principles as solutions for addressing barriers at the system level? At least one new approach to conceptualizing EBP offers this as a genuine possibility.