Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.     

Future Issues in Pediatric Psychology: Delphic Survey

Using a Delphic poll procedure, we surveyed pediatric psychologists who were established in either clinical practice or empirical research in pediatric psychology. Three rounds of expert responses were logically combined in order to identify domains of importance to the future of pediatric psychology and to determine to what extent research and clinical aims concur. Overall, researchers and clinicians did not differ in the types of issues deemed important to the field. The top three domains for the next decade are concerned with pediatric psychology's ability to demonstrate viability, to integrate psychologists into primary care settings, and to demonstrate need for changes in reimbursement systems within managed care. Implications of the ten priority issues are discussed.     

Comparison of upright and flipped spoon presentations to guide treatment of food refusal

The current study examined the effects of bite placement with a flipped versus upright spoon on expulsion and mouth clean (product measure of swallowing) in the treatment of 3 children diagnosed with a pediatric feeding disorder and oral-motor deficits. For all 3 participants, extinction in the form of nonremoval of the spoon led to improvements in inappropriate mealtime behavior and acceptance of bites; however, re-presentation did not reduce expulsion or improve mouth clean. Results showed a lower level of expulsion and higher percentage of mouth clean during flipped spoon presentations and re-presentations for all participants. Findings from follow-up analyses supported transitioning back to an upright spoon in all 3 cases, although the time required for this to occur differed across participants.     

New Nomenclature for Sexually Abusive Youth: Naming and Assessing Sexually Violent and Predatory Offenders

New nomenclature is presented identifying two subsets of sexually abusive youths currently not defined in the literature or in existing models or risk assessment tools: sexually violent youth (YSV) and predatory sexually violent youth (YPSV). Distinctively and qualitatively different, these youths are more dangerous, manifest higher levels of coercion (e.g., threats of bodily injury, use of weapons), or are predatory sexually violent toward strangers or casual acquaintances. Discussed is the innovative, empirically guided risk assessment tool Multiplex Empirically Guided Inventory of Ecological Aggregates for Assessing Sexually Abusive Children and Adolescents (Ages 19 and Under) (MEGA) (Miccio-Fonseca, 2006a Miccio-Fonseca, L. C. August 2006a. Multiplex Empirically Guided Inventory of Ecological Aggregates for Assessing Sexually Abusive Children and Adolescents (Ages 19 and Under)—MEGA, August, San Diego, CA: Author.  [Google Scholar]) for assessing the level of risk for all youths (male and female) under the age of 19 years, including YSVs and YPSVs.     

On the Dissemination of Clinical Experiences in Using Empirically Supported Treatments

This article addresses the long-standing gap that has existed between psychotherapy research and practice and the efforts that have been made to bridge it. It also introduces one such effort, which has consisted of 3 clinical surveys on the experiences of practitioners in using empirically supported treatments for panic disorder, social anxiety, and OCD. In contrast to attempts to close the gap by disseminating research findings to the clinician, the clinical surveys are intended to allow for practitioners to disseminate their clinical experiences to the researcher—and also to other clinicians. What we view as a “two-way bridge” initiative is a collaboration between the Society of Clinical Psychology, Division 12 of the APA, and the Psychotherapy Division of the APA—Division 29. The mechanism that has been established provides a way for clinicians to be a part of the research process, which we hope will provide evidence that can help to enhance our clinical effectiveness.     

Clinical Experiences in Using Cognitive-Behavior Therapy to Treat Panic Disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.     

The Evidence-Based Practice of Applied Behavior Analysis

Evidence-based practice (EBP) is a model of professional decision-making in which practitioners integrate the best available evidence with client values/context and clinical expertise in order to provide services for their clients. This framework provides behavior analysts with a structure for pervasive use of the best available evidence in the complex settings in which they work. This structure recognizes the need for clear and explicit understanding of the strength of evidence supporting intervention options, the important contextual factors including client values that contribute to decision making, and the key role of clinical expertise in the conceptualization, intervention, and evaluation of cases. Opening the discussion of EBP in this journal, Smith (The Behavior Analyst, 36, 7–33, 2013) raised several key issues related to EBP and applied behavior analysis (ABA). The purpose of this paper is to respond to Smith’s arguments and extend the discussion of the relevant issues. Although we support many of Smith’s (The Behavior Analyst, 36, 7–33, 2013) points, we contend that Smith’s definition of EBP is significantly narrower than definitions that are used in professions with long histories of EBP and that this narrowness conflicts with the principles that drive applied behavior analytic practice. We offer a definition and framework for EBP that aligns with the foundations of ABA and is consistent with well-established definitions of EBP in medicine, psychology, and other professions. In addition to supporting the systematic use of research evidence in behavior analytic decision making, this definition can promote clear communication about treatment decisions across disciplines and with important outside institutions such as insurance companies and granting agencies.     

Satisfaction with therapist-delivered vs. self-administered online cognitive behavioural treatments for depression symptoms in college students

Participants with symptoms of depression received either eight sessions of therapist-delivered email cognitive behaviour therapy (eCBT; n=37), or eight sessions of computerised CBT self-administered treatment (cCBT; n=43). At post-treatment participants completed a questionnaire to determine what they found satisfying about their online treatment. Quantitative and qualitative analysis was employed to report outcomes. A sample of 25 participants(eCBT n=10; cCBT n=15) completed the satisfaction questionnaire. Both groups were satisfied with accessing and using an online treatment and that they had self-control over their treatment. Perceived anonymity was important for the eCBT group. For the cCBT group they found the treatment user-friendly, engaging and also a source of learning. Both groups disliked that the online treatment could at times be complicated and impersonal.     

呼吸机依赖患者撤机失败原因及对策

机械通气是近年来抢救呼吸衰竭患者的重要生命支持手段,但使用呼吸机的时间超过2周可导致撤机困难。本文详细分析了诸如心理障碍、营养不良、心肺功能不全以及撤机方法不当等各种可导致困难撤机的原因,并针对各个原因提出相应的治疗及护理对策,从而降低临床上困难撤机的发生率。