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:
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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All known published and unpublished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and unpublished studies of child and caregiver outcomes: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:
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 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
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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
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 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
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


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