Evidence-Based Practice: Myths and Realities Bruce A. Thyer, Ph.D., - PowerPoint PPT Presentation

Evidence-Based Practice: Myths and Realities Bruce A. Thyer, Ph.D., LCSW, BCBA-D College of Social Work, Florida State University A Keynote Address Presented at the Michigan Autism Conference, 16 September 2016 Kalamazoo, MI 1

What is Evidence Based Practice? • “ Evidence-based practice requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances” From Strauss et al. (2011). Evidence-based medicine: How to practice and teach EBM (fourth edition, p. 1). New York: Elsevier. 2

Note the equivalent importance of ALL these factors in the EBP process • * 3

What is ‘Best Research Evidence’? • Clinically relevant research from basic and applied scientific investigations, especially drawing from intervention research evaluating the outcomes of social work services, and from studies on the reliability and validity of assessment measures. 4

Higher End of Internal Validity (in terms of causal inference) • Systematic Reviews (highest form of evidence) • Meta-analyses • Multi-site Randomized Clinical Trials • Individual RCTs • Quasi-experiments • Pre-experiments • Single Subject Studies • Correlational Studies/Epidemiological Studies • Qualitative Research • Narrative Case Studies • Basic Science Studies • Expert or consensus opinion, Theory (lowest form of evidence) Lower End of Internal Validity 5

‘Best Evidence’ Means Best Available • Look for relevant systematic reviews, then meta- analyses, then RCTs, then quasi-experiments, etc. Integrate this best available evidence into your decision-making practice. EBP does NOT depend on having a large body of RCT’s available to consult. It does depend on one examining the best available evidence. • There is ALWAYS evidence, even if it is of low quality. 6

What are Client Values? • The unique preferences, concerns and expectations each client brings to a clinical encounter with a social worker, and which must be integrated into practice decisions if they are to serve the client. • A thorough consideration of ethical considerations and client considerations is integral to the EBP model. 7

What is Clinical Expertise? • Our ability to use our education, interpersonal skills and past experience to assess client functioning, diagnose mental disorders and/or other relevant conditions, including environmental factors, and to understand client values and preferences. • Clinical expertise factors, costs, available resources, etc. are integral to the EBP model. • Research findings are NOT accorded greater weight. All are compellingly important. 8

Many Interventions Might Have Strong Research Support but Not be Acceptable • Client may not wish it • May be religiously objectionable (e.g., Jehovahs’ Witnesses may decline blood, or a Muslim may decline a pig valve implant) • May be illegal or unethical • Costs too much • So a lesser supported intervention may be provided, and still be consistent with EBP! 9

What are the Major Steps of Evidence-based Practice? 1. Convert the need for information into an answerable questions(s). 2 . Track down the best available evidence to answer each question. 3. Critically evaluate this evidence in terms of its validity, impact, and potential relevance to our client. 4. Integrate relevant evidence with our own clinical expertise and client values and circumstances. 5. Evaluate our expertise in conducting Steps 1-4 above, and evaluate the outcomes of our services to the client, especially focusing on an assessment of enhanced client functioning 10 and/or problem resolution.

What are ‘Answerable Questions’? 1. A question with a verb, as in • What has been shown to help ….? Or • What psychosocial treatments work ….? • What community-based interventions reduce ….? • What group therapies improve ….? 2. A question including some aspect of the client’s behavior or condition. As in • What psychosocial interventions reduce self-injurious behavior ? • What educational programs are the most successful in teaching children to read? • How can schools reduce the social isolation of students with autism? • What treatments are effective in improving social skills of youth with autism? 11

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How Can You Track Down the Best Available Evidence? There are LOTS of resources! • Practice-research journals, as in – Journal of Applied Behavior Analysis – Behavior Analysis in Practice – Behavior Analysis: Research and Practice – Journal of Autism and Developmental Disorders – Focus on Autism and other Developmental Disabilities 13

Science-based Textbooks, as in • Understanding Applied Behavior Analysis, Second Edition: An Introduction to ABA for Parents, Teachers, and other Professionals 2nd Edition • Applying Behavior Analysis Across the Autism Spectrum • The Parent's Guide to In-Home ABA Programs: Frequently Asked Questions about Applied Behavior Analysis for your Child with Autism • Applied Behavior Analysis for Children with Autism Spectrum Disorders 14

• Science-based Websites, as in: • Autism Speaks - https://www.autismspeaks.org/ • National Autism Center at the May Institute http://www.nationalautismcenter.org/about-nac/mission/ • Autism Consortium - http://www.autismconsortium.org/families/understanding- autism-and-treatments/ • The ABAI Learning Center - https://www.abainternational.org/learning-center.aspx • BE CAUTIOUS – There are many pseudoscientific websites promoting none-science-based treatments, such as this one promoting homeopathy as a treatment for autism: http://www.drhomeo.com/autism/autism-and- homeopathy-a-miraculus- cure/?gclid=CMyXsoXPiM8CFUM2gQodg5oNig 15

Science-based Professional Conferences, such as: • Association for Behavior Analysis International (ABAI) • Various state-chapter conferences of ABAI • Association of Professional Behavior Analysts • National Autism Conference • Autism Society National Conference Caveat – not all presentations will necessarily be science-based. 16

3. How Can You Critically Evaluate the Available Evidence? • Develop critical appraisal skills in evaluating research yourself. (a bottom-up search) • Seek out and rely on credible groups which have already done this (e.g. ABAI, Cochrane and Campbell Collaboration, APA’s Division 12’s lists of ESTs, SAMSHA, California Clearing House…etc.) (a top-down search) 17

Pros and Cons of Each Approach – Search Yourself • Searching yourself brings you into contact with the most current research. •Searching yourself can be difficult to do in a comprehensive manner. •Many stakeholders such as parents, may lack the scientific critical thinking skills needed to sort out legitimate research studies from poorly conducted one. • Many so-called “Systematic Reviews” are not of high quality and the term is promiscuously applied. Some interventions are designed as an ‘evidence-based practice’ for autism, when they are really not. The Cochrane and Campbell Collaborations provide access to the highest quality SRs. 18

Pros and Cons of Each Approach – Rely on Summaries of Research Prepared by Others •Locating a high quality systematic review dealing with a question important to you and your client is a tremendous time-saver. Others have done all the hard work for you! •Many so-called “Systematic Reviews” are not of high quality and the term is promiscuously applied. The Cochrane and Campbell Collaborations provide access to the highest quality SRs. •Getting access to the Cochrane and Campbell Libraries may be difficult for stakeholders not located in universities. •There may not be a systematic review relevant to your informational needs. 19

High Quality Systematic Reviews are: • Systematic, in that a replicable search strategy to locate relevant literature is clearly described and adhered to. •As unbiased as possible. Interrater reliability checks are used to evaluate potential papers. •Draw upon the international literature, not just English language journals and books and conference. •Make use of interdisciplinary teams of researchers, and non- professional stakeholders. These teams are often international in scope. •Follow previously published SR protocols. •Regularly updated. 20

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The Cochrane Collaboration has 23 systematic reviews dealing with the topic of AUTISM, including: • Early Intensive Behavioral Intervention (EIBI) for Increasing Functional behaviors and Skills in Young People with ASD. • Early Intervention Delivered by Parents for Young Children with ASD • Social Skills Groups for People Aged 6-21 with ASD • Auditory Integration Therapy for ASD • Intravenous Secretin for ASDAcupuncture for People with ASD • Chelation for ASD • Gluten and Casein-Free Diets for ASD • Omega-3 Fatty Acids for ASD • Using the Combined Vaccine for Protection of Children Against 22 Measles, Mumps and Rubella

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