Evidence-based practice in child and adolescent mental health services.

The authors review the status, strength, and quality of evidence-based practice in child and adolescent mental health services. The definitional criteria that have been applied to the evidence base differ considerably across treatments, and these definitions circumscribe the range, depth, and extensionality of the evidence. The authors describe major dimensions that differentiate evidence-based practices for children from those for adults and summarize the status of the scientific literature on a range of service practices. The readiness of the child and adolescent evidence base for large-scale dissemination should be viewed with healthy skepticism until studies of the fit between empirically based treatments and the context of service delivery have been undertaken. Acceleration of the pace at which evidence-based practices can be more readily disseminated will require new models of development of clinical services that consider the practice setting in which the service is ultimately to be delivered.

Effectiveness, transportability, and dissemination of interventions: what matters when?

The authors identify and define key aspects of the progression from research on the efficacy of a new intervention to its dissemination. They highlight the role of transportability questions that arise in that progression and illustrate key conceptual and design features that differentiate efficacy, effectiveness, and dissemination research. An ongoing study of the transportability of multisystemic therapy is used to illustrate independent and interdependent aspects of effectiveness, transportability, and dissemination studies. Variables relevant to the progression from treatment efficacy to dissemination include features of the intervention itself as well as variables pertaining to the practitioner, client, model of service delivery, organization, and service system. The authors provide examples of how some of these variables are relevant to the transportability of different types of interventions. They also discuss sample research questions, study designs, and challenges to be anticipated in the arena of transportability research.

Multisystemic therapy: monitoring treatment fidelity.

The challenges of specifying a complex and individualized treatment model and measuring fidelity thereto are described, using multisystemic therapy (MST) as an example. Relations between therapist adherence to MST principles and instrumental and ultimate outcome variables are examined, as are relations between clinical supervision and therapist adherence. The findings provide modest support for the associations between MST adherence measures and instrumental and ultimate outcomes. Results also show that adherence can be altered when clinical supervision and adherence monitoring procedures are fortified. The modest associations between adherence measures and youth outcomes argue for further refinement and validation of the MST adherence measure, especially in light of the well-established effectiveness of MST with challenging clinical populations and the increasing dissemination of MST programs.

Multisystemic therapy versus hospitalization for crisis stabilization of youth: placement outcomes 4 months postreferral.

Hospitalization and out-of-home placement data for 113 youth participating in a randomized trial comparing home-based multisystemic therapy (MST; n = 57) with hospitalization (n = 56) for psychiatric crisis stabilization were analyzed following the completion of MST treatment--approximately 4 months post approval for emergency psychiatric hospitalization. Analyses showed that MST prevented any hospitalization for 57% of the participants in the MST condition and reduced the overall number of days hospitalized by 72%. Importantly, the reduction in use and length of hospitalization was not offset by increased use of other placement options, as MST reduced days in other out-of-home placements by 49%. The cost implications for the viability of MST as an alternative to hospitalization for youth presenting psychiatric emergencies are discussed.

Investigating family-based alternatives to institution-based mental health services for youth: lessons learned from the pilot study of a randomized field trial.

The development and validation of family-based alternatives to out-of-home placements for children is an important goal in the mental health services field. The rigorous evaluation of such alternatives, however, can be difficult to accomplish. The purpose of this article is to describe initial barriers experienced during the pilot study of a randomized trial, funded by the National Institute of Mental Health, conducted in a field setting, and the strategies that were used to overcome these barriers. The randomized trial is examining home-based multisystemic therapy as an alternative to the psychiatric hospitalization of youths presenting psychiatric emergencies. The pilot study illuminated the interface of treatment and services research issues, prompting significant changes in the project's clinical procedures, organization, and supervisory processes, as well as in the project's interface with existing community resources for serving youths with serious emotional disturbances.

Multisystemic treatment of violent and chronic juvenile offenders: bridging the gap between research and practice.

The lack of communication between researchers and practitioners has hindered the development of effective interventions for children and adolescents. Recently, however, significant headway in bridging this researcher-practitioner gap has been made due to the emergence of multisystemic therapy (MST) as a treatment approach that combines the rigor of science and the "real world" aspects of clinical practice in treating violent and chronic juvenile offenders and their families in community-based settings. MST addresses the multiple known determinants of delinquency and delivers services in the family's natural environment, with considerable emphasis on treatment fidelity. This article describes MST and provides a case example of how MST treatment principles are applied.

Multisystemic therapy: bridging the gap between university- and community-based treatment.

This article proposes, within the context of discouraging findings from child psychotherapy literatures, 2 theory- and empirically based explanations for the emergent success of multisystemic therapy (MST) when implemented in community settings as well as for MST's favorable long-term effects on serious antisocial behavior in adolescents. First, MST may have demonstrated success in community settings because it explicitly bridges the gap between university-based psychotherapy studies and their community-based counterparts (J. R. Weisz & B. Weiss, 1993). Second, although MST is based on a social-ecological model of behavior, its favorable cross-setting and temporal outcomes may exemplify the successful use of several active behavioral generalization strategies.

The contribution of treatment outcome research to the reform of children's mental health services: multisystemic therapy as an example.

Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation.