Framework Guides Organization-wide Implementation of Intervention for Youth with Challenging Behaviors

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More than 15 years ago, psychologists in the program now called Think:Kids at Massachusetts General Hospital developed Collaborative Problem Solving (CPS), an approach to helping youth who exhibit challenging behaviors such as oppositionality, aggression or withdrawal. It emphasizes that such youth need help building neurocognitive skills.

As evidence grew for the effectiveness of CPS in outpatient therapy, residential treatment centers, hospitals, youth service agencies and schools began asking the Think:Kids program for organization-wide training. Over the same time period, a burgeoning number of papers were published in the medical literature about "frameworks" for implementing evidence-based practices.

In the Journal of Community Psychology, Alisha R. Pollastri, PhD, director of research and evaluation at Think:Kids, Luana Marques, PhD, director of the Community Psychiatry Program for Research in Implementation and Dissemination of Evidence-based Treatments (PRIDE) in the Department of Psychiatry, and colleagues describe the early implementation of CPS and how it changed once they applied an implementation framework called the active implementation frameworks (AIFs).

Components of the Framework

The group of Mass General interventionists and researchers selected the AIFs because this framework captures many aspects of what Think:Kids was already doing, while structuring the change needed in others. AIFs comprises of five components that are distinct but nonlinear and overlapping:

• Usable Innovation — The quality of the intervention depends on having a clear description of the program, a clear description of what features are essential, an operational definition of each essential feature and a system for assessing practitioners' adherence to the program
• Stages of Implementation — Implementation should occur in four stages that have distinct goals and tasks: the exploration of whether an organization is ready to adopt the evidence-based program, installation of necessary changes (to infrastructure, staff resources and a data collection plan), initial implementation (training, coaching and starting to use the intervention with clients) and full implementation (core components are integrated into the organization)
• Implementation Teams — Implementation of the change should be designed and led by teams whose members represent all levels of the organization
• Implementation Drivers — Nine factors in a system influence the success of an implementation project. These are divided into three categories:
  • Competency drivers (staff selection, training, coaching and fidelity assessment)
  • Organization drivers (a decision-support data system, management that facilitates implementation, strategies for working with external systems)
  • Leadership drivers (technical leaders overcome barriers, and adaptive leaders encourage change amid uncertainty and dissent)

• Improvement Cycles — Policies are needed to ensure regular, transparent communication from practitioners to leaders and back and encourage fast, data-driven decision-making

Aligning CPS with the AIFs

The authors report in detail how they used the AIFs to better understand what was already working well in helping other organizations implement CPS, standardize the implementation and overcome barriers. Some of the major changes they made were to:

• Coordinate implementation tasks with teams of staff members from all levels of the organization, rather than just the executive director or school principal
• Change from a time-based model of training and coaching (e.g., four to eight hours of introductory training, followed one month later by 16 hours) to a more flexible, customized stage-based model
• Provide better support for managers and adaptive leaders
• Standardize evaluations, rather than having organizations select their own outcomes, in order to drive greater improvement to the model

Besides AIFs, many other frameworks for implementing evidence-based practices have emerged. By following the example described in this paper, other groups can identify the framework that best fits their evidence-based program and use it to improve implementation by their organizational partners.

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Learn more about Think:Kids

Learn more about Community Psychiatry PRIDE