Evidence based interventions that work (EBI)

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EBI

Clinical practice that has been researched for efficacy and positive outcomes is not only important as we strive towards quality practice, but delivers tangible improvements in outcome for infants, children and young people experiencing mental health and addiction concerns. 

This resource has been designed to help you, as a busy health practitioner, to quickly establish if a particular intervention has a solid research basis, and whether it is likely to work for the child or young person you are working with and their family/whānau. 

Common presentations come with an information sheet summarising key elements, prevalence and the quality of evidence behind numerous interventions, helping you easily become familiar with a range of evidence bases for various approaches within child and adolescent mental health services.



Evidence-based intervention categories

  • Research-based, or evidence-based interventions (EBIs) have been shown to be more effective than usual care.
  • The strength of the research evidence for particular interventions has been summarised into “gold”, “silver” and “bronze” categories, allowing health professionals to see the evidence at a glance.  
Gold Strongly recommended by all recent effectiveness reviews in the group surveyed.
Silver Moderately recommended, based on the recommendation of several reviews, and/or weaker evidence.
Bronze Endorsed as an effective treatment, but with some caveats, or mixed results across studies.
Not recommended The intervention was designated as ‘not recommended’ by one or more reviews in the group. 
  • The most effective interventions are usually an integration of the health professional’s expertise and experience, the research evidence, and client preferences, goals and values. 
  • In Aotearoa-New Zealand there is a recognised need for EBIs to be developed by specific cultural groups (Māori and Pacific) in the first instance. As most evidence-based interventions have been developed and tested in North America and only a selection have been formally tested in New Zealand, where it is culturally appropriate partnering with Māori and Pacific people to adapt EBIs for the New Zealand context is required.
  • Therapy is both an art and a science.  It is well known that useful interventions almost always involve therapist intuition, insight, experience and a rich connection with the client and their family (the 'art').  It's also important that the therapy approach chosen is likely to be effective (the 'science').  In a busy working environment, the health practitioner needs to establish quickly and reliably that a particular intervention has a good, solid foundation of research, and is likely to work for this client and their family/whānau at this time. 

More about the EBI categories

The process of establishing an evidence-base for a particular therapy is complex. When a researcher designs an intervention, it is usually first tested with a small group of clients who have volunteered their time, often with a ‘mild’ presentation of (for here) a mental health or AOD concern, in what’s known as a pilot (or feasibility) study. If results are encouraging, a larger study is arranged. Over time, other researchers are likely to study the effectiveness of the intervention with different groups within the population. And eventually, groups of researchers pool together all the results from previous studies and explore the effectiveness of the intervention overall (a meta-analysis or review). The strongest evidence comes from these meta-analyses, but it can take many years to have a collection of studies to review. It follows that if an intervention doesn’t have an established evidence base, it does not necessarily mean that it’s not effective. Rather, it may be an emerging approach where an evidence base hasn’t yet been established. So, instead of the presence or absence of evidence it’s important to consider the level of evidence, or strength of the evidence. One small study showing weak positive effects of an intervention is not nearly as compelling as several large review studies with large effect sizes.

Many studies are designed with a group of people not receiving the intervention (for example a placebo medication), or having their intervention delayed. This study design can strengthen the conclusions that are able to be drawn. For obvious reasons, it is morally and ethically difficult to use a no-intervention or delayed-intervention condition when researching interventions for infants, children and adolescents with moderate to severe mental health and/or AOD issues. So researchers often test interventions on children and young people with less significant needs (subclinical populations) or with no co-morbidities, leading to concerns that interventions may not work as well with infants, children and young people presenting with more complex concerns in the ‘real world’  (Weisz et al., 2013).

It’s also been suggested that evidence-based approaches may not allow for the health professional to personalise the intervention to meet individual clients’ needs (Weisz et al., 2013). Many evidence-based interventions have been manualised (i.e. a manual has been written outlining how to deliver the intervention) to ensure that there is consistency in how they’re delivered. This can be reassuring for therapists (knowing that they’re providing the ‘science’), but can also diminish some of the ‘art’ of therapy.

Despite each of these concerns, evidence-based interventions have been shown to be more effective than usual care (Weisz et al., 2013). 

Gold Strongly recommended by all recent effectiveness reviews in the group surveyed.
Silver Moderately recommended, based on the recommendation of several reviews, and/or weaker evidence.
Bronze Endorsed as an effective treatment, but with some caveats, or mixed results across studies.
Not recommended The intervention was designated as ‘not recommended’ by one or more reviews in the group. 

The practice of evidence-based psychotherapy involves far more than simply selecting an intervention from a list of acceptable interventions (Fonagy et al., 2015). The evidence-base is only one of many factors that are considered. And even if an intervention has strong research support for a particular presentation, it can’t be applied in a ‘one size fits all’ fashion. Instead, research evidence is usually integrated with clinical expertise (Sackett et al., 1996), and client preferences, goals, values and expectations, to come up with “evidence informed practice”.

Evidence-informed practice

The notion that any one intervention is going to “fix” children and young people with multiple difficulties presenting to ICAMHS is likely to be incorrect and unhelpful (Fonagy et al., 2015). Instead, it’s probable that infants, children and young people with complex needs, and their families and whānau will require a lot of support over a considerable time period.

It should also be acknowledged that children’s brains are rapidly developing, so what the evidence suggests is best at one developmental stage may be different at another (Fonagy et al., 2015). Also a number of different sectors usually need to be involved for interventions to be successful, including school, family, and social/peer groups. 

The majority of evidence-based interventions are designed and tested in Western (usually North American) settings, and may not meet the needs of local cultures or communities (Weisz et al., 2013). In New Zealand it is particularly important to prioritise interventions developed by, and researched with, Māori and Pacific peoples. If this is not possible, an alternative is to incorporate Māori and Pacific perspectives or adaptations to existing evidence-based interventions in partnership.

Studies which have specifically investigated the effectiveness of interventions within New Zealand Māori populations are unfortunately rare, and particularly when it comes to infant, child and adolescent presentations. This is also the case with Pacific populations, and other minority ethnicities such as Asian children and families.

It has been suggested that each individual within a particular cultural group may have their own unique cultural beliefs, values, needs and opinions, and effective therapy is based on a comprehensive assessment of these needs and preferences (Te Pou o te Whakaaro Nui, 2016). It is also acknowledged that religious beliefs and practices are also likely to be integral to facilitating and maintaining mental health and wellbeing, and thorough assessment of this dimension is likely to add to the richness and effectiveness of a particular therapeutic approach. 

It is well known that useful interventions almost always involve therapist intuition, insight, experience and a rich connection with the client and their family (the 'art').  It's also important that the therapy approach chosen is likely to be effective (the 'science').  In a busy working environment, the health practitioner needs to establish quickly and reliably that a particular intervention has a good, solid foundation of research, and is likely to work for this client and their family/whānau at this time. 


References

  • American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association.
  • Dunnachie, B. (2007). Evidence-based Age-appropriate Interventions – A guide for child and adolescent mental health services (CAMHS). Auckland: The Werry Centre for Child and Adolescent Workforce Development.
  • Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What Works for Whom? A critical review of treatments for children and adolescents (2nd Ed). New York: Guilford.
  • Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. British Medical Journal 312, 71-72.
  • Te Pou o te Whakaaro Nui (2016). Therapy: A guide to evidence-based talking therapies. Auckland, New Zealand: Te Pou o te Whakaaro Nui.
  • The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.
  • Weisz, J. R., Kuppens, S., Eckshtain, D., Ugeto, A. M., Hawley, K. M., & Jensen-Doss, A. (2013). Performance of Evidence-Based Youth Psychotherapies Compared with Usual Clinical Care: A Multilevel Meta-analysis. JAMA Psychiatry 70 (7), 750-761