The mental health field is facing unprecedented challenges during the COVID-19 pandemic. Professional counselors who have worked with children and adolescents prior to the pandemic have found that some traditional personal techniques over virtual platforms are not appropriate.
These circumstances require that counselors consider selecting treatment approaches and interventions that can be tailored or created for the provision of telemental health. Today, counselors need to determine how Evidence-Based Practices (EBPs) should be selected and implemented when working with children and adolescents on telemental health in times of crisis.
History of the EBPs
In 1996, David L. Sackett and colleagues stated that evidence-based medicine is "the conscientious, explicit, and judicious use of the best evidence currently available in making decisions about individual patient care." In addition, Leslie Greenberg and Frederick Newman realized in 1996 that there were different types of study designs that led to the evidence base, each suitable for answering certain types of research questions. For example, according to a 2005 American Psychological Association task force, one of the following methods can be used to produce evidence: clinical observation, qualitative, systematic case studies, case-by-case design, ethnographic data, process outcomes, random control pathways, or meta-analyzes
EBPs and the terminology associated with them have gained popularity in all areas of health care over the past few decades. However, their exact origins are mixed. For example, parts of the nursing profession assume that EBP came from Florence Nightingale, while Lightner Witmer took a similar approach when he founded the first psychological clinic in 1896.
Regardless, the concept of EBP marked a paradigm shift among health professionals to consider data-based research rather than relying on the opinions of the authorities to guide clinical practice.
Levels of evidence
The accuracy or the level of scientific evidence is often presented in the form of an evidence pyramid that corresponds to the taxonomy of Benjamin Bloom's educational goals.
This evidence pyramid traditionally moves from expert opinions at the base to case series / case reports via case control studies, randomized control studies, systematic reviews and finally to meta-analyzes at the top.
Expert opinion
These sources of evidence range from editorials to book chapters. They are good resources for an early understanding of the clinical areas as they discuss definitions, ratings, and treatments. However, these sources lack statistical conclusions to reach scientific conclusions.
An expert opinion could be in the form of a textbook chapter in which a person who is generally very knowledgeable in this field comments on this topic without referring to a specific compilation of facts. While expert opinions can be very informative and insightful, they should only be viewed as a minimal form of scientific evidence. Few of these expert opinions speak for our currently dominant telemental health practice.
Case series / case reports
These are descriptive studies that could come from a single clinical case or from a number of clients with similar presentations. While inferential statistics are traditionally absent, individual experimental case-by-case designs are often implemented. However, control groups or conditions are clearly absent. Despite these limitations, case series / case reports are often advertised to highlight novel concerns that generate additional research.
Classical examples of case studies in the field of mental health seemed to start with Anna O. who received a psychoanalysis for the so-called "hysteria". Sigmund Freud wrote about her case and how the "speaking healing" caused her symptoms to fade. Biopsychologists often cite the case of Phineas Gage, who showed personality changes after a large iron rod was driven through his head in a railroad accident. Then there is the behaviorist account of Little Albert (by John Watson) in which conditioning was actually used to instill fear into a baby.
Case control studies
Case control studies are generally retrospective in nature and examine the risk of exposure to an event with a possible negative outcome – usually a disease or disorder. Comparison or control groups are then used with people who did not have the first experience or the disease / disorder. However, these studies can only declare relationships, not cause-effect relationships. Despite this limitation, evidence of cause and effect begins with a correlation.
A typical case control study in the field of mental health could investigate the connection between physical activity and depressive characteristics. To do this, the investigators would collect information from a previously administered questionnaire on patients receiving services in a mental health facility. Additionally, these investigators would use a coordinated control group of participants with no mental health issues who also completed the questionnaire. Although a control group or comparison group is part of the study, it lacks the characteristic that makes it a real experiment: randomization.
Randomized controlled studies
It has often been claimed that randomization turns an investigation from quasi-experimental to truly experimental. Randomized controlled trials assign patients with similar presentations to either the treatment group or the control group based on chance alone. This allows other mitigating factors to balance themselves out between the groups and the "treatment" itself to cause the scale to tilt. This strategy makes it possible to compare a treatment with no treatment, an alternative treatment or a waiting list controlled treatment.
A typical randomized controlled trial for a new treatment for depression would involve the random assignment of half of the participants to the new treatment, while the remaining half would be assigned to an existing treatment. Then pre-tests and post-tests for each group would be compared to assess the effectiveness of the new protocol.
While considered the gold standard for clinical research studies, the random assignment of patients to treatments may not reflect best ethical practice without considering other attenuating factors.
Systematic reviews
Systematic reviews evaluate and synthesize the results of similar studies in order to arrive at a higher order conclusion than would be possible with a single study alone. As a rule, the authors select a priori factors or topics for which the studies are to be assessed. Then all factors or issues are considered and tabulated to arrive at that conclusion.
Systematic reviews are often limited to studies that use randomized controlled trials. In this way, the results from the group of similar randomized controlled trials can be integrated for a truly convergent conclusion.
Building on our previous examples of possible depression studies, a systematic review could be used to determine the best treatment protocol for adolescent depression, including psychopharmacology, individual therapy, or both. In addition, investigators could limit the investigation to those studies that used random mapping. Rubrics can then be created to rate treatments based on topics such as symptom reduction, satisfaction with the approach, and time spent. Typical systematic reviews generally lack an objective measure with which the results of the various studies can be consistently assessed.
meta-analyzes
Meta-analyzes are often referred to as a type of systematic review that deserves the gold standard of clinical knowledge. Meta-analyzes, like all systematic reviews, evaluate similar studies on the basis of factors or topics that are selected a priori. However, these forms of evidence use a statistical technique – the effect size – to reduce sources of bias in the conclusions. This is the objective uniform measure that is missing in systematic reviews.
Effect sizes generally indicate the extent to which a treatment has progressed. It has often been found that the effect size actually indicates the importance of the results rather than the likelihood that the results are not random, as is the case with statistical significance.
In order to increase the accuracy of our previous example of a systematic check on that of a meta-analysis, effect sizes would therefore have to be used. Instead of building on the a priori comparison topics, this meta-analysis would calculate the effect sizes from the measures specified in each study. Average effect sizes would then be calculated from the selected studies for each treatment protocol, so that meaningful comparisons could be made and each protocol could be evaluated according to its effectiveness.
Beyond the Evidence
While the concept of EBP was originally based on the practitioner using only data-based research and not the opinions of authorities as a guide to clinical practice, the field of medicine built on it and included other parameters. In particular, this newer definition defines EBP as integrating the best of research with clinical expertise and patient values. The expansion of this definition clearly highlights the additional paradigm shifts that take into account cultural sensitivity and patient involvement in treatment decisions, while recognizing the advantages and disadvantages.
Advantages
EBP has advantages and disadvantages. The 2005 American Psychological Association Presidential Task Force on Evidence-Based Practice described EBP as the integration of science and practice. It has been recognized that much research is needed to determine whether a treatment is effective. However, the research to demonstrate an effective treatment protocol needs to become a practice offered by clinicians who treat patients on-site. So one has to consider both the effectiveness and the clinical benefit of the treatment.
The APA Task Force defined effectiveness as the way we evaluate the protocol and examine how strong the evidence is in that evaluation. The clinical benefit of the protocol must then examine whether the treatment is generalizable and feasible and what cost advantage the treatment offers. The combination of research and practice leads to better clinical outcomes for clients.
EBPs provide doctors and their clients with information about the effectiveness of a treatment. This research can inform the expected time frame and results of a particular treatment. It clearly shows what the EBP will treat and for which age groups evidence will be provided. It is then up to the counselor to determine whether the EBP is a good fit for the child and family. After all, most children in a research study do not present the exact parameters as a control group. The current COVID-19 pandemic also does not provide counselors with traditional clinical sessions or historical data to reflect the current situation.
Disadvantages
Not all individual differences can be taken into account in every EBP. For example, consideration should be given to how development, gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs, and sexual orientation play a role in treatment. Customers should also have entered their treatment protocol and received a consent form. This may lead to their desire or preference for one type of treatment over another.
As counselors, it is our duty to educate clients about the costs and benefits of treatment approaches, but ultimately it is clients who determine whether they will proceed with EBP. In our day and age, clients may agree to an approach to treatment, but have difficulty with technology or face other barriers that affect their comfort in telemental health.
Cognitive behavioral therapy (CBT) is an example of how EBP suitability is taken into account. Pamela Hayes discussed the specific challenges between CBT and multicultural therapy. She acknowledged that CBT is evidence-based for many disorders and populations, but may have limitations when applied to some cultures.
In particular, she named three main restrictions:
1) CBT has strong assertiveness aspects and overlooks cultures that prefer subtle communication.
2) CBT has present focus and neglects the past.
3) CBT findings focus on individualism, with less emphasis on environmental interventions.
The last restriction can be particularly problematic for people with physical disabilities, for whom the disregard of environmental barriers can be great. In response, Hayes recommended culturally appealing CBT modifications.
However, not all EBPs have recommendations on how to adapt them to specific customers or populations with whom the consultant may work. Therefore, while treatment may prove effective for a particular age or disorder, it may conflict with the client's values. In addition, there may be other obstacles to consider, such as: B. technology, data protection or logistics, as is currently the case with many practitioners.
COVID-19 forced many consultants to investigate their "practice as usual". Many sought telemental health certification in order to continue offering services to existing customers. This followed in many ways the best practices and guidelines of the 2014 ACA Code of Ethics, which prohibits leaving customers.
At the same time, this forced the clinicians to consider whether their treatment of choice was still possible via telemental health or whether another practice / protocol was more sensible. For example, in the field of child and youth counseling, many play therapists investigated the feasibility of child-centered play therapy (CCPT), which is an EBP, via telemental health. Dee Ray expressed the opinion that CCPT may not be the best treatment for telemental health, but acknowledged that a similar theoretically-oriented treatment for parents – branch therapy – might be accessible for telemental health.
Case study
Jane is a 7 year old girl who was scared, which has reportedly resulted in behavioral outbursts and refusals to comply. Jane was seen by her advisor about six sessions before the clinic was closing for COVID-19 and a nationwide stay at home order. Jane's advisor met the state board's requirements to provide telemental health services, but could not imagine how to work with Jane using CCPT as she had done at home prior to the order.
Jane's advisor researched the EBP literature and identified other options for treating anxiety in children. However, the counselor had limited training, which limited her ability to provide EBP services outside of her current role.
Jane's counselor discussed the options, including a referral, with Jane's parents in a planned telemental health consultation. At the consultation, the advisor discussed the benefits of branch therapy and the typical populations with which the modality is used in therapy. The counselor also stated that parents would be more involved in the session because branch therapy would use parents as change agents.
Jane's consultant stated that this type of therapy would lead to telemental health in a way that CCPT would not. For example, CCPT relies on the therapist-child relationship to enable change. This can be difficult to achieve through telemedicine because the therapist is not in the room. Branch therapy, on the other hand, is based more on the parents than means of change and can work well through telemental health, since the parents are in the room with the child. In addition, they will meet with the telemental health therapist to learn the techniques for their child. The weekly telemental health sessions allow parents to discuss challenges while receiving guidance and supervision, making this method more accessible to telehealth.
EBP databases and clearing houses
Psychiatrists have online access to multiple EBP databases and clearinghouses to accommodate different approaches to meet the unique needs of clients and cases. A wide range of techniques and programs are available and these clearinghouses provide practitioners with the ability to compare and learn about the reliability and evidence of the techniques and programs. We will highlight some examples of databases and clearinghouses that we use in our practice when working with children and adolescents.
The seventh edition of the Collection of Evidence-Based Practices for Children and Adolescents in Mental Health Needs is an educational resource that specifically highlights the mental health treatments available to non-clinicians. The guide breaks the treatments down into what works, what seems to work, what doesn't, and what hasn't been tested enough. It highlights disorders like adjustment disorders, autism, anxiety, depression, and more.
The Results First Clearinghouse database is powerful because it combines available EBPs from nine national clearinghouses covering the categories of crime and crime, child and family wellbeing, education, employment and professional training, mental health, public health, and sexual behavior Teenage pregnancy and substance use. Programs can be broken down by category, setting, clearinghouse, or rating. The rating scale divides programs according to highest rated, second highest rated, mixed effects, no effects, negative effects, and insufficient evidence. The following clearinghouses highlighted in this article are included in the Results First Clearinghouse.
Blueprints provides information on programs to promote healthy youth development and to reduce anti-social behavior in children and adolescents. The database is aimed at youth, families and their communities, from prevention to intervention programs. The database divides programs into three categories of research: model plus, model, and promising.
The California Evidence-Based Clearinghouse for the Welfare of Children provides information and resources that can be used by any professional who can work with children and families in the welfare system. The database breaks treatments down based on a scientific rating scale that includes well-researched, research-backed, promising research, evidence that has no effect on practice and cannot be rated.
Social Programs That Work provide information about social policy programs. The aim is to enable policy makers and other readers to easily distinguish these programs from other available programs for which there is no supporting evidence. The guide divides programs into top tier, near top tier, and suggestive tier. Of particular interest to practitioners, some programs for early childhood, parenting, substance abuse, and suicide prevention are highlighted.
The National Institute of Justice's CrimeSolutions provides information on criminal justice outcomes, juvenile justice, and crime victims to educate practitioners and policy makers about what works and what doesn't. The database divides programs and field results into effective, promising and no impact.
The Resource Center for Evidence-Based Drug Abuse and Mental Health Administration Practices provides clinicians, community members, and policy makers with resources and information on a variety of topics, including mental health services.
The United States Department of Health identifies programs with evidence of effectiveness in reducing teenage pregnancies, sexually transmitted infections, and associated sexual risk behavior. The database organizes studies based on a quality rating of high, medium, low or not applicable.
Additional resources
For practitioners interested in learning more about the EBP process, evidence-based behavioral practice is a useful online training resource.
"Evidence-Based Practice in Social Work: A Contemporary Perspective" by James W. Drisko and Melissa D. Grady, Journal of Clinical Social Work
"Evidence-Based Practice in Psychology" by the American Psychological Association's Presidential Task Force on Evidence-Based Practice, American psychologist
"Clinical Expertise in the Age of Evidence-Based Medicine and Patient Selection" by R. Brian Haynes, P.J. Devereaux, and Gordon H. Guyatt, BMJ Evidence-Based Medicine
Evidence-Based Practice for the National Association of Social Workers
"Evidence-Based Practice: A Common Definition Is Important" by Danielle E. Parrish, Journal of Social Work Education.
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Krystal Vaughn is a licensed professional counselor who specializes in children ages 2 to 12. As an Associate Professor at the Health Sciences Center at Louisiana State University in New Orleans, she enjoys teaching and providing clinical services. Her research interests include autism, supervision, play therapy, and parenting counseling. Contact her at [email protected].
Kellie Giorgio Camelford is a licensed professional counselor specializing in parenting, women's issues, children and adolescents. She has received specialized training in play therapy, school counseling, parenting, and perinatal mood disorders. As an assistant professor at the Health Sciences Center at Louisiana State University in New Orleans, she enjoys teaching, mentoring, and providing clinical and nonprofit services. Her research interests include ethical issues in counseling and supervision. Prior to teaching, she was a professional school counselor at a local parish college in New Orleans and a private practitioner.
George W. Hebert is a faculty member in both the Clinical Rehabilitation and Counseling Department and the Master of Physician Assistant Studies program at the Health Sciences Center at Louisiana State University in New Orleans. He is a licensed psychologist and has certificates as a school psychologist and head of school psychological services. He specializes in assessing and treating learning and behavioral problems for school-age children and their families, and supervises interns and interns at the University Clinic for Child and Family Counseling.
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It should not be assumed that opinions or statements in articles appearing on CT Online represent the opinions of the editors or guidelines of the American Counseling Association.
