Tailoring interventions for groups that have been marginalized

In the past several decades, there has been a significant increase in the number of behavioral health interventions for children and adolescents with rigorous evidence to support their effectiveness. For example, the Results First Clearinghouse Database, compiled by the Pew-MacArthur Results First Initiative, currently includes information on nearly 3,000 interventions—over 70 percent of which have moderate or high evidence of effectiveness. Despite this abundance of evidence-based programs, many interventions do not have evidence of effectiveness for specific populations (Barrera et al., 2012). As a result, relying exclusively on rigorously evaluated interventions can further disadvantage groups that are often marginalized by the systems intended to support them—such as youth of color and youth involved in child welfare or juvenile justice systems—for whom few evidence-based interventions exist (Lorenc & Oliver, 2014; McNulty et al., 2019).

One potential solution to the scarcity of interventions with demonstrated success among groups that have been marginalized is to adapt interventions with proven track records to meet the needs of those groups. Some researchers refer to the process of leveraging well-established interventions to create versions better suited to underserved groups as “scaling out” (Aarons et al., 2017). Scaling out is defined as the process of adapting a well-established, effective intervention for a new setting, a new population, or—when there is particularly strong evidence about the core components of an intervention—for both a new population and a new setting.

Scaling out has the potential to address a disconnect between the typical methods of establishing evidence and the needs of practitioners working with communities that are often both marginalized by the systems intended to support them and absent from the literature. It does this by leveraging existing evidence to allow a greater focus on contextual factors that are particularly relevant to historically underserved populations through case studies and analysis of practice-based evidence (Alvidrez et al., 2019). Evaluations of scaled-out interventions are likely to be conducted in settings where program developers and evaluators must manage partnerships and establish buy-in; therefore, they must understand how stakeholders such as service providers and public agencies might respond to delivering, referring to, or paying for as-yet unproven services (Jaramillo et al., 2019).

Case study: Multisystemic Therapy for Emerging Adults (EA)

Behavioral health and judicial systems are generally divided into those that serve children and adolescents and those that serve adults. For this reason, youth enrolled in systems of care who are transitioning into adulthood—sometimes referred to as emerging adults—represent a particularly vulnerable group. Emerging adults are likely to have developmental needs that are not well-addressed by either of these systems. As a result, it can be challenging for service providers to identify interventions with strong evidence of effectiveness for youth who would benefit from additional supports to make a successful transition. Multisystemic Therapy for Emerging Adults (MST-EA) was developed to bridge the gap in behavioral health services that exists between the youth system and the adult system (Sheidow, McCart, & Davis, 2016).

To address the question of how service providers and public agencies might respond to a request to invest in an untested adaptation of an existing intervention, Child Trends conducted a series of interviews with stakeholders engaged in a process to establish evidence for MST-EA. This intervention is an adaptation of Multisystemic Therapy (MST), one of the most rigorously evaluated behavioral health interventions targeting youth and their families (Henggeler, 2016). MST-EA was first developed within juvenile justice settings, and the move to deliver it within child welfare is itself a scaling out (Aarons et al., 2017; Davis, Sheidow, & McCart, 2015). MST-EA had not yet been rigorously evaluated in a completed randomized controlled trial at the time of our interviews, although an open trial provided preliminary evidence on the effectiveness of the model (Davis, Sheidow, & McCart, 2015). Of note, two large-scale, federally funded randomized controlled trials of MST-EA are also in progress.

This brief summarizes the experiences of stakeholders involved in implementing MST-EA in two neighboring jurisdictions. Overall, the public officials and private service providers that participated in this initiative described a willingness to test an adaptation of a well-established intervention. Ultimately, only one of the two jurisdictions chose to fund MST-EA services over time. This case study suggests that— given the right circumstances—public officials are open to paying for services as a part of real-world evaluations of adaptations (i.e., those that require partnerships and community buy-in), particularly those with promise for meeting the needs of underserved populations.

Key findings

• Public officials and service providers were willing to refer youth to the adapted intervention for services, despite limited evidence of its effectiveness, because of the rigorous evidence behind the
  original intervention.
• Public officials and service providers were willing to refer youth to an adaptation with limited evidence because they viewed it as filling a critical gap in services for a historically underserved population.
• The strength of existing relationships between public officials and service providers helped them work together to address challenges.
• High-quality implementation on the part of the service provider—due in part to a strong track record implementing evidence-based programs, including MST—contributed to confidence among public officials.
• Addressing the unique needs and approaches of multiple jurisdictions can be a challenge when scaling out involves partners from several agencies and/or jurisdictions.
• While the partners ultimately obtained funding from multiple sources, a lack of ongoing, transparent communication about financing resulted in uncertainty and heightened concerns about the viability of the project.

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This video is a recording of a presentation that was prepared for the Society for Prevention Research 2020 Annual Meeting. The presentation summarizes findings from a study examining the potential interest of public agencies to fund unproven adaptations of well-established interventions in order to fill critical gaps in services and was based on this brief.