Person:

Weisz, John

Improving outcomes for children and adolescents with mental health needs demands a broad meta-systemic orientation to overcome persistent problems in current service systems. Improving outcomes necessitates inclusion of current and emerging evidence about effective practices for the diverse population of youth and their families. Key components of the meta-system for children with emotional or behavioral needs include families, cultural norms and values, and service sectors such as schools, pediatric health centers, specialty mental health systems, juvenile justice systems, child protection services, and substance use treatment systems. We describe each component of the meta-system, noting challenges to the provision of evidence-based practice (EBP) and highlighting ways to optimize outcomes. Our focus is on the inclusion of evidence-based assessment and interventions, including prevention, within a developmentally driven and culturally responsive contextual model. Recommendations for addressing disparities in research funding and essential steps to foster communication and coordination of EBP across settings are provided.

Combining intervention diffusion with change in clinical practice and public policy is an ambitious agenda. The impressive effort in Hawaii can be instructive, highlighting questions for a science of treatment dissemination. Among these questions, some of the most important are the following: (a) Who should be targeted for change? (e.g., “downstream” clinicians in practice, “upstream” clinicians in training, consumers, “brokers,” policy makers, or payers?); (b) What should be disseminated? (e.g., full evidence-based protocols, specific treatment elements or “kernels”?); and (c) Which procedures maximize change? (e.g., what combination and duration of teaching, supervision, consultation, and other support?). Ultimately, change efforts need to assess what aspects of practice were actually altered, what measurable impact the changes had on clinical outcomes, and what changes in practices and outcomes can be sustained over time.

Psychotherapies for children and adolescents have been tested in hundreds of randomized controlled trials across five decades, and many of these youth therapies have now been classified as empirically supported treatments (ESTs). A burgeoning movement is underway to implement these ESTs in clinical practice settings, but questions arise as to whether the treatments are ready for practice and whether they will improve outcomes for clinically referred youths. Our data show ESTs to be more effective than usual care, on average, but only modestly so, and there are troubling exceptions. One reason may be that the design of most ESTs (e.g., single-disorder focus, linear session sequence) does not fit the characteristics of referred youths or clinical practice very well. Indeed, youth psychotherapy research has not focused much on the clients or contexts of actual clinical care. An alternative empirical approach, the deployment-focused model, proposes developing and testing interventions with the clients, clinicians, and contexts for which they are ultimately intended. Recent application of the model highlights its potential for stimulating robust treatments that are effective in clinical practice.

Comorbidity is common among youths referred for mental health treatment. Yet, the majority of evidence-based treatments (EBTs) for young people are focal, addressing one or a homogeneous cluster of disorders or problems. In addition, most of these EBTs have been developed and tested in research settings under controlled conditions that are useful experimentally but may limit the generalizability of findings to referred youths in clinical practice treated by real-world practitioners. Recently, researchers have begun to develop transdiagnostic treatments that may support implementation in everyday practice. Here, we describe a transdiagnostic program called MATCH (Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems; MATCH-ADTC), which employs a modular design to facilitate personalizing treatment to fit individual youths. We summarize evidence to date supporting the effectiveness of MATCH with youths treated by practitioners in community clinic and school settings. Directions for the future include replication of the effectiveness research, plus tests of adaptations designed for different populations and settings.