“There are guidelines for preparing manuals from scratch, but none to aid systematic adaptation of interventions for new contexts,” according to Naomi Goldstein, Associate Professor of Psychology at Drexel University.
This is a problem for researchers, implementers and providers. There is increasing demand for children’s services to be more evidence-based, but how can we be sure to give programs the best chance of working in a novel setting or with a new population? Goldstein offered a solution at this year’s Society for Prevention Research conference, held in Washington DC.
Faced with a juvenile justice system that does not traditionally incorporate evidence-based programs into its services, and a lack of evidence generally for intervening with female juvenile offenders to prevent aggression and mental health problems, Goldstein turned to a program that has been applied and tested in other contexts – Coping Power.
Coping Power is a preventive intervention for youth aged 9-11 at risk of developing substance abuse problems and conduct problems. It lasts 15-18 months and addresses key risk factors such as self-regulation and social competence. The model is based on cognitive behavior therapy, with highly structured sessions for young people and their parents that are supported by occasional home visits and individual contacts. Its goal is to help youth manage their anger, prevent physical and relational aggression, reduce recidivism rates, and improve the quality of youths’ relationships with friends and family.
A number of revisions were required in order to make the program appropriate for incarcerated young women who were court mandated to receive anger management treatment. Having had no success in finding guidelines for systematic program adaptation, Goldstein developed her own.
Her “9-stage model of manual adaptation” model involves gathering input from key stakeholders to guide revisions – community members, individuals from target treatment populations, and prospective treatment providers. The revised program is then tested in pilot studies and randomized controlled trials. Goldstein stressed the importance of protecting the underlying theory-of-change and core components of the intervention that are known to work.
The model has nine stages:
1. Choose a manual for adaptation (i.e. identify an empirically supported treatment; review the treatment’s theory and mechanisms of action; work out its adaptability for the new target population)
2. Conduct focus groups with new target populations (to reflect on the proposed content and structure)
3. Make initial revisions to the manual (based on feedback from target population)
4. Pilot initial revisions of the manualized intervention
5. Conduct focus groups with program facilitators
6. Acquire an expert review of the manual
7. Incorporate feedback from staff and experts
8. Conduct an initial open-trial of the revised intervention
9. Finalize the manual and conduct a randomized controlled trial
Having followed these nine steps, how successful was this variant of Coping Power with youth who were court mandated to receive anger management training?
According to Goldstein, female offenders in the intervention group experienced large and significant reductions in anger across several measures when compared with a control group who received services as usual. Moreover, the girls’ behavioral and mental health problems reduced from clinical levels before the intervention to more normal levels expected of girls of a similar age and stage of development by the end of the intervention.
It seems that this systematic nine-stage model resulted in a successful adaptation that replicated the positive benefits for outcomes demonstrated from the original version of Coping Power.
Tom Dishion, Director of the University of Oregon’s Child and Family Center, described Goldstein’s work as “state-of-the-art”. But, he asked, “How many manuals, for how many problems, with how many RCTs?” for more on this, see the following Prevention Action blog entry