Presenters: Alisha Pollastri, PhD Think:Kids at Massachusetts General Hospital, Boston, MA Natasha Tatartcheff‐Quesnel, MSA Ottawa Children’s Coordinated Access & Referral to Services, Ottawa, CA Michael Hone, MEd Crossroads Children's Centre, Ottawa, CA Discussant: Di t J. Stuart Ablon, PhD Think:Kids at Massachusetts General Hospital, Boston, MA Alisha Pollastri, PhD Director of Research & Evaluation Think:Kids J. Stuart Ablon, PhD Director Think:Kids What is Collaborative Problem Solving (CPS)? CPS is an approach for understanding and helping children with behavioral challenges i h b h i l h ll CPS is both a PHILOSOPHY and an INTERVENTION The PHILOSOPHY: Kids do well if they can. …If a child isn’t doing well, something is getting in the way. lagging critical neurocognitive skills Your understanding of the problem determines the solution! “Kids do well if they can.” Challenging behavior is the result of expectations outweighing a child’s skills Identify and build lagging neurocognitive skills so that they are no i i kill h h longer overwhelmed by demands The INTERVENTION: For each situation in which expectations are not being met, you have three options: ,y p Plan A: Impose adult will Plan B: Solve the problem collaboratively Plan C Drop it (for no at least) Plan C: Drop it (for now, at least) GoalsAchievedwithEachPlan GOALS Try to get your expectation met PLAN A PLAN B X X Reduce challenging behavior X Build skills and confidence X Solve chronic problems durably X Build relationship and confidence X PLAN C X CPS R hS CPS Research Summary All known published and unpublished All known published and unpublished studies of child and caregiver outcomes: studies of child and caregiver outcomes: Inpatient: Outpatient: Residential: Juv. Detention: Schools: number and disruptive restrictive restrictive teacher stress duration of restrictive interventions (i l d (includes restraints, i short holds, and seclusions) behaviors (e.g., symptoms of ODD and ADHD) interventions interventions aggression staff injuries discipline referrals staff turnover relationships parent stress social skills and parent‐child community participation restrictive t i ti interventions staff and student injury in‐school arrests, summonses, violent crimes committed Adapted from Pollastri, Epstein, Heath, & Ablon (2013), Harvard Review of Psychiatry Available at www.thinkkids.org Intervention to Implementation “Evidence on effectiveness helps us select what we might choose to implement. Evidence on outcomes does not help implement the program successfully. does not help implement the program successfully” ‐Fixsen 2005 Attention to good implementation must occur at: g p individual (clinician, educator, caregiver) level site level Think:Kids provides support at both levels Talking today about site‐level implementation Implementation Fact: Implementation Fact: Implementation of an EBP takes 2‐4 years. Year One Y O • • • • Introductory training for all staff (1 day) L d hi t i i f CPS l d ( d ) Leadership training for CPS leaders (1 day) Tier 1 Advanced training for CPS leaders/others Weekly coaching/consultation Year Two • • • • Intro training for new staff (if not revolving) Refresher training for all staff Weekly coaching/consultation Tier 2 Advanced training for CPS leaders/others Year Three Y F Year Four • Intro training for new staff • Refresher training for returning staff • Biweekly coaching/consultation • Certification of several staff, who then conduct trainings Certification of several staff who then conduct trainings • Biweekly coaching/consultation (as needed) Implementation Fact: There are four stages of implementation, each with its own tasks and challenges Exploration Installation I t ll ti Initial Implementation Full Implementation These are not necessarily linear. Stage 1: Exploration Effective implementation may require examination of, and changes to: Staff Behavior Climate Communication Structures Leadership Existing Models of Intervention R l Roles Goals Programming / Scheduling Policies and Procedures Physical Space Treatment Planning/Documentation Discharge and Aftercare Plans (That s all!) (That’s all!) Stage 1: Exploration Questions we ask: What is the baseline stress level of the system? Is the system ready for the discomfort of the change process? Who will lead the change process? Do they have the bandwidth? Is funding available to sustain the process? Begin staff discussion about mission and vision: What do you do well? What do you wish you did better? Tasks: Create a sense of urgency and collective buy‐in from staff Cultivate commitment, support and active engagement from leadership p Stage 2: Installation Get procedures and documentation in place Examine intervention procedures for consistency with approach Change documentation practices to be consistent with approach Plan evaluation system Consider how site will allocate resources Frequency of trainings Number of staff involved in trainings Tier 1 training for as many staff as possible g y p Tier 2 training for at least 15% of staff who will be core team Identify CPS leaders at site (these may change!) Full certification for select staff? Ongoing coaching and consultation for teams Implementation Fact: Follow up coaching is critical for implementation success. Follow‐up coaching is critical for implementation success. Training Component Knowledge Skill Transfer % of trainees who understand concept % of trainees who apply the concept % of trainees who make the concept part of repertoire Study of Theory 10% 5% 0% ... Plus Demonstration 30% 20% 0% ... Plus Practice 60% 60% 5% ... Plus Coaching Plus Coaching 95% 95% 95% Adapted from Joyce & Showers, 2002 Stage 3: Initial Implementation Collect baseline data for outcome measurement Begin training process Integrate CPS Assessment and Planning Tool into standard treatment planning procedures Start having and recording Plan B conversations Start coaching/consultation immediately after Tier 1 Advanced Training Test innovations or modifications in collaboration with us Be careful to maintain fidelity to the model while customizing to unique setting Stage 4: Full Implementation Begin certification training for core team Work toward consistently improving fidelity through training and coaching and internal monitoring/supervision Consider Site Certification if operating at highest fidelity Sample CPS site‐wide training schedule Year One Y O • • • • Introductory training for all staff (1 day) L d hi t i i f CPS l d ( d ) Leadership training for CPS leaders (1 day) Tier 1 Advanced training for CPS leaders/others Weekly coaching/consultation Year Two • • • • Intro training for new staff (if not revolving) Refresher training for all staff Weekly coaching/consultation Tier 2 Advanced training for CPS leaders/others Year Three Y F Year Four • Intro training for new staff • Refresher training for returning staff • Biweekly coaching/consultation • Certification of several staff, who then conduct trainings Certification of several staff who then conduct trainings • Biweekly coaching/consultation (as needed) Implementation Fact: Fidelity decreases over time due to turnover and drift. Fidelity decreases over time due to turnover and drift. Use internal CPS leaders to conduct trainings and supervision p Provide regular training for all new staff Provide periodic refresher training to re‐energize existing staff Monitor practitioner‐level fidelity l i Implementation Fact: Implementation requires a sustained effort in order to produce desired outcomes at each stage Watch for opportunities to adjust as tensions arise organically Create redundant processes to facilitate sustainability e.g., time and mechanisms for communication and to do Plan B Ensure CPS is embedded in all aspects of system documentation, job descriptions, supervision, hiring process, etc. Are there methods of regular communication between team members (e.g., a communication log, team meetings, shift-toshift reports)? Is CPS-oriented language used in mechanisms of team communication? Is there clear documentation of when TSIs are completed and reviewed for every child? Do intake forms use language consistent with CPS (e.g., problems to be solved, skills to be trained, plans used)? D treatment Do t t t planning l i documents d t use language l consistent i t t with ith CPS? E Communication E. C i i and Documentation Do discharge documents use language consistent with CPS? Do discharged children have a documented aftercare plan that Question includes CPS? Domain Self Study Is CPS CPS-consistent language in discussion communication with parents? Is used throughout the used organization, and isand its written use supported by the majority of staff? Is there system-wide use of CPS clear in external communications posters, with flyers, brochure, Is an organization-wide stance on critical incidents that(e.g., is consistent CPS (e.g., a website)? priority to reduce coercive and Is there a systematic data collection procedure in place to evaluate treatment outcomes related to CPS? physical intervention through proactive planning and problem solving)? A. Philosophy When CPS CPS-oriented oriented language appears in communication and documentation documentation, is it accurate and D Does administration d i i i actively i l support the h CPS philosophy hil h and d use off CPS in i the h organization? i i ? clear? If other treatment models are being implemented within the organization, is implementation consistent with the CPS Does new-staff orientation include initial training in the CPS model? philosophy? Are staff engaged in regular professional development opportunities related to CPS, including 6-month refreshers? Have received Tier 1 training? Is the all TSIstaff used for every child? Have at least 15% of staff received Tier 2within training? Does every child have a TSI completed 2 weeks of entry to program (or reasonable timeframe based on amount of Is there a core team of internal CPS coaches or CPS team leaders providing regular support within the organization? client contact)? Dothere staff aknow who the review CPS coaches the organization are?intervals and no less than every month? B. Assessment Is formal team of eachinchild’s TSI at regular Is thestaff administrator/administrative team actively participating in CPS-related in theonorganization? Can state primary problems and skill deficits for each child in their care,activities as reported their TSI? F. Professional Are there at least two certified trainers affiliated with the organization? Do the TSIs accurately identify problems to be solved (not maladaptive behaviors) and do they identify specific lagging Development Are several staff pursuing CPS professional certification? skills? Do staff performance evaluations include assessment of adherence to, and proficiency with, the CPS model (e.g., quizzes, review of audio or video recording of Plan B, B etc.)? etc )? Do TSIs show evidence of reasonable prioritization of problems for each child (e.g., which problems will be handled with Are there efforts to support parents/caregivers in learning/using CPS (e.g., treatment planning, structured activities, etc.)? Plans A, B, or C)? Is training and consultation provided to the organization’s community partners and referring agencies, if appropriate? Can staff state which problems will be handled with Plans A, B, or C for each child in their care, as reported on their TSI? C. Planning Are the professional development practices listed above of high quality? Can staff provide evidence of revision of this prioritization as problems and needs shift? Can staff members perform at or above 80% on the CPS Quiz? Do staff use Plan B Worksheets at least weekly? Is prioritization thoughtful and clinically appropriate? Are the written policies consistent with CPS (e.g., (e g in regard to restraints/seclusions, restraints/seclusions visitors, visitors family involvement, involvement home visits, debriefing of critical incidents, etc.)? Do staff have daily Plan B conversations (across clients)? Do the written job descriptions and job requirements reference the CPS model? G. Policies and Do children feel as if when they have a problem, the staff are likely to respond by talking about it, listening to their Does the organization have some system in place to monitor and recognize red flags/slippage (e.g., chaos due to too Procedures perspective,and collaborating on solutions? much Plan A or Plan C; increase in restraints, etc.) Do staffCPS-oriented use Plan B Tracking (orinpolicies a site-specific alternative)isatitleast weekly? When languageSheets appears and procedures, accurate and clear? D. Intervention Do staff initiate more proactive Plan B discussions than Emergency Plan B? Is there a LACK of motivational point and level systems? Does the organization budget contain allocated funding for implementation of CPS or is there other evidence of a plan for Are the Plan B conversations done well? ongoing financial support? H. Systems-Level Is audio or video recording used for supervision of Plan B conversations? Has the organization created partnerships with local agencies to share use of the model? Support Does the organization have, and know how and when to access, outside CPS support (e.g. Think:Kids at MGH)? Is the system-level support clear and consistent to organization staff? Site‐wide fidelity tool available at www.thinkkids.org/train/materials
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