|
Many health care fields have adopted the core principles of evidence-based practice (EBP),
an approach to patient care that encourages clinicians to consider and synthesize empirical evidence, clinical expertise, and patient values in implementing treatments.
These principles of evidence-based practice also are very relevant to the practice of clinical psychology with children and adolescents, including the provision of psychological assessment and treatment.
Psychologists are uniquely skilled in conducting rigorous clinical research, and a large empirical base is available 1) to develop evidence-based assessment measures and treatments and 2)
to evaluate the efficacy and effectiveness of clinical practice techniques.
This article discusses:
For an in-depth description of EBP, please read this recent article from the Behavior Therapist, and also visit
this NIH Sponsored Site.
Why is EBP important in the practice of clinical psychology with children and adolescents?
Psychologists are ethically bound to "do no harm."
When empirical evidence exists demonstrating the efficacy of a specific assessment or treatment approach for a child or adolescent with a particular clinical presentation, it is ethically irresponsible not to discuss this approach and/or provide this option to the client and his/her caregiver. Such a discussion may include a review of the approach's applicability to this client, as well as its strengths and limitations.
To date, there is more empirical evidence available to support the efficacy
of cognitive and behavioral therapies
to treat children or adolescents with a wide range of psychological difficulties than for any other treatment approach.
Failure to discuss EBP options with the child/adolescent client and his/her caregiver may have several unintended harmful consequences:
- As compared to the provision of EBP (e.g., such as CBT), provision of therapy that is not based on empirical evidence presents a greater risk of treatment failure. A lack of progress in treatment is associated with a reduced likelihood of later efforts to seek psychological treatment throughout the lifespan.
- As compared to the provision of EBP, provision of therapy that is not based on empirical evidence has been associated with a longer course of symptoms and/or increases in symptom severity.
- In addition to protracted suffering from distressing clinical symptoms, ongoing psychopathology is associated with deteriorations in a child or adolescent's life circumstances (e.g., school failure, peer rejection).
EBP therapies are listed as 'Best Practice' Approaches for the Treatment of Children and Adolescents with Psychological Symptoms
As a form of EBP, CBT has been recommended by the American Psychiatric Association within the Practice Parameters for many pediatric psychological symptoms and disorders. The American Psychological Association also has adopted a policy statement on EBP as a preferred approach to psychological treatment for young people.
Reimbursement for non-EBP clinical services is less likely
Insurance companies increasingly demand evidence for the empirical basis underlying an assessment or treatment approach for children or adolescents before reimbursing for services. This is a policy consistent within medical and psychological treatment. For instance, insurance companies are less likely to reimburse medical treatments, at least as first-line options, when there are alternatives proven to be more effective. Moreover, medical practitioners who ignore current research evidence for practice are at risk of being found unethical or incompetent.
Balancing the Three-Legged Stool: Empirical Evidence, Clinical Expertise, and Patient/Parent Preferences
Empirical evidence is not always available to support the efficacy or effectiveness of every assessment or treatment approach for each of the complex and varied clinical presentations often encountered by clinicians. Until such empirical evidence is available, clinicians must provide EBP that best balances the most current empirical evidence, clinical expertise, as well as the preferences of the child or adolescent client and his/her guardian. Achieving this balance is difficult, but essential.
EBP theories offer guidance for achieving a balance in clinical decision-making. Importantly, EBP specifies that any positive evidence supporting a specific clinical approach is superior to a lack of evidence for an alternate treatment approach. In other words, the provision of services demonstrated to be efficacious or effective in any population is very often sufficient justification for the use of this approach with an untested population, and thus is preferable to the provision of untested services. EBP specifies that practitioners should learn to base treatment on the highest empirical grounds possible.
In addition, psychologists should recognize the limitations of clinical decision making. Considerable research across many fields suggests that people seek confirmatory evidence, fail to adequately consider evidence contrary to expectations, perceive correlations where there are none (or correlations in the opposite direction from the true association), and rely on numerous heuristics that can leave clinicians vulnerable to errors. The argument is not that clinicians are especially likely to make mistakes, but rather that clinical decision-making is extremely difficult for psychological disorders, and warrants an objective foundation.
For an in-depth description of EBP, please visit this NIH Sponsored Site.
What are Empirically Supported Treatments?
One implication of EBP is the fundamental necessity for treatment outcome research, the goal of which is to establish empirically which treatments are beneficial for different populations of people who suffer from specific disorders, syndromes, or symptoms. In psychology, this includes psychotherapy (and psychopathology) research. The movement toward EBP has been accompanied by a concomitant shift toward the identification of empirically-supported treatments (ESTs), or treatments whose demonstrated efficacy meets a standard of empirical investigation as gauged by various methodological criteria.
Although the movement toward formal identification of ESTs is at least 15 years old and has met with resistance from some quarters, a comprehensive discussion of these issues are beyond the scope of this primer. It is worthy of note in this context, however, that to some extent implementation of ESTs depends on the child or adolescent's presenting problem. ESTs are typically designed for, and targeted to particular psychological disorders. For example, there is no EST that has been developed and tested specifically for individuals who are struggling with questions about self-identity and personal meaning. At the risk of stating the obvious, reliance on ESTs is sensible for decision-making about interventions and disorders for which there is a research base.
The practice of cognitive behavior therapy (CBT) offers many advantages to clinicians interested in an evidence-based approach to their practice.
Several treatment manuals using CBT techniques are accessible from this site.
For further resources and recommended readings about EBP see the additional readings and resources below.
Recommended Reading and Resources
EBP and Identifying ESTs:
1. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.
2. Norcross, J. C., Beutler, L. E., & Levant, R. F. (Eds.). (2005). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association.
Utilizing ESTs and CBT:
1. Kazdin, A. E., & Weisz, J. R. (Eds.). (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford.
2. Barlow, D. H. (Ed.). (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). New York: Guilford.
3. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
4. Nathan, P. E., & Gorman, J. M. (Eds.) (2007). A guide to treatments that work (3rd Ed.). New York: Oxford University.
|
