Developmental Psychology for the Helping Professions

Evidence-Based Practice in Health and Social Care

Brian Sheldon

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137321145
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This book offers a bio-psycho-social approach to evidence-based practice in health and social care. The book presents current evidence on the influence of genetic, epigenetic and environmental factors on behaviour, a survey of developmental factors from childhood to old age, and implications for practice at each stage.

1

Principles of Evidence-Based Practice

What is known depends upon how it is known.

—Francis Bacon, 1604

The phrase ‘evidence-based practice’ is in the title because a particular stance on questions of evidence is taken throughout this book. For me, this position is uncontroversial at the level of rationality and logic, but others may disagree, and in any case there are problems of interpretation and implementation that continue to pose difficulties. Therefore, rather than holding multiple (and probably tedious) discussions about study quality, unintended bias, validity and reliability throughout the text, it is better to get these out of the way in one go, or at least to establish some ‘Marquess of Queensberry rules’ for handling disputes (no spitting, gouging or hitting below the belt).

There are four types of research with which we are concerned in this book:

1. Empirical investigations into the nature of normal/average development and patterns within that. This to provide a template for making assessments and signalling exacerbations.

2. Investigations of the causes, epidemiology, courses and points of tractability of developmental problems and delays, conditions, syndromes and illnesses. The origins of these typically lie within a matrix of genetic, epigenetic, environmental, familial and sociocultural influences that interact together, their ‘skeins’ becoming ‘cable-knitted’.

3. Studies of the effectiveness of interventions, whether predominantly psychological, social, medical or, as is often the case, combinations of these.

4. Evaluations of the way (2) and (3) are combined into broader theories that attempt to ‘join the dots’ of empirical observations. Such theories, favoured approaches, plus a few selected studies are what practitioners tend to rely on to guide their behaviour.

Addressing the bias-reduction qualities in these different types of research and how we relate to them, and implement their findings, is the essence of evidence based-practice. Here is a working definition (freely adapted from the work of Sackett et al., 1996):

Evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of individuals in need.

Of course, some of our clients or patients have extant needs, and some have ‘needs’ thrust upon them, so we are dealing here with ethical as well as merely technical matters. Let us look further into this definition.

Conscientiousness

Obedient to conscience, (habitually) governed by a sense of duty: done according to conscience; scrupulous, painstaking. (Shorter Oxford English Dictionary)

The word conscientiousness reminds us of our ethical obligations to our clients/patients, not only regarding important areas such as confidentiality, a caring and kindly professional demeanour, technically astute and skilful actions, but also with implications for how habitually painstaking we are willing to be. Keeping abreast of current best evidence in various overlapping fields is no routine task, even in the age of the internet. This is particularly the case when we inherit a culture that tends to value hindsight, simplicity and individual professional responsibility (blameworthiness) over considerations of more complex political and organisational factors.

Some examples will clarify this. In the infamous case of Baby P (Peter Connelly), who matched known risk factor profiles quite closely, 60 contacts (medical, policing and social work) were recorded before his desperately sad death from abuse. Therefore, professional contact levels and the question of collaboration and information sharing (a reflex conclusion of all inquiry reports) were not really the issue. The problem was the quality of the information shared, and the degree to which it was acted on, and the quality of the paediatric examinations (or the lack of them if the child was fractious), not the lack of known risk indicators (see Haringey Local Safeguarding Children Board, 2010).

The point is that assessing the quality of interventions and the quality of evidence behind decisions to act or not to act requires careful judgement by expert people: the ‘judicious’ part of our working definition. This is time-consuming and distracts us from politically and managerially inspired target clusters made up of things that are easy to count, which at times amount to an unintentionally malign behaviour modification scheme. Such target-setting works rather well clinically (Emmelkamp, 2004; Sheldon, 2011), so why should we expect it not to be influential when applied to professionals for narrower, sometimes inappropriate purposes, such as managers at risk of career damage, or the government of the day needing to look more re-electable? Thus, social workers now spend 70–80% of their working week in the office carrying out administrative tasks. It has become more important that assessments are on file and that records match pro-formas than that a case file contains examples of well-monitored, evidentially based, good work. We might almost call this virtual reality social work (see Sheldon & Macdonald, 2009). The political action taken in the Peter Connelly case was to order the sacking of the Director of Children’s Services pour encourager les autres, but the question is what exactly it would encourage the others to do. Probably not to take better care regarding the professional calibre of the staff they employ (there are hundreds of unfilled vacancies, and no wonder); not to introduce better post-qualification training in risk assessment; not to take the long-promised ‘hard look’ at whether increased organisational accountability measures do more harm than good and result mainly in ‘frozen watchfulness’; and probably not to implement Eileen Munro’s excellent report on child safety and social work training (2011), but in fact to ‘tighten up’ all round (once again).

The point of this discussion is to urge on the reader the idea that a review of evidence prior to intervention is not merely a clinical responsibility, it should also weigh on policy makers and managers. They need to be just as aware of the omnipresence of side effects, which exist independently of good intentions (see the systematic reviews available at www.campbellcollaboration.org). All new schemes, reorganisations and ‘shake-ups’ are interventions and will very likely affect professional behaviour and thus patient/client care, and all involve opportunity costs. A good illustration of the latter is the recent writing-off, at a conservative cost of £12–30 billion, of (yet another) NHS computer scheme. Such wasted sums could have done a lot for home care or child-protection services, or funded 36 new general hospitals, as King and Crewe (2013: 199) highlight:

From its inception, the whole thing had been either, at best, a mess-in-waiting or, at worst, a mess already apparent. It began, more or less, at a meeting in Downing Street between a Prime Minister who knew next to nothing about computers and a clutch of computer enthusiasts. It was wildly ambitious. It was far from being essential. No one ever seems to have subjected it to a serious – or even a back-of-the envelope – cost–benefit analysis … No one ever thought to ask medical administrators and practioners whether it was a high-priority project from their own point of view, or how they expected this ambitious new programme to mesh with their existing IT arrangements, or whether they would want to opt into the new system, or, come to that, whether they believed that the new system could actually be made to work. The timescale proposed for the project was ludicrously short.

Not all calls for a stonger emphasis on evidence-based policy-making and practice involve increased expenditure. Indeed, sometimes the opposite is the case. For instance, the group controlled trial of clinical, quality-of-life and community tenure outcomes for frail, elderly people conducted by Trappes-Lomax et al. as part of the CEBSS project (2003) showed that these were as good or better if the patients/clients were in receipt of good, reliable, home care sevices immediately on discharge from hospital than if they went first to a bespoke residential rehabilitation centre with a £6.2 million per annum share of the local authority budget.

And it gets more difficult still. Were we prospectively to apply child-care risk factor schedules (see Macdonald, 1999) to all or most inner-city children, then the number of false positives and false negatives that would be thrown up would create a civil liberties outcry. Distinguishing the troubling from the desperate and the desperate from the dangerous should be a matter of cautious professional judgement, yet our services are driven more by ad hoc advice from journalists in air-conditioned offices in Wapping. The Daily Telegraph’s reaction to the Peter Connelly case was: ‘Social workers too slow to take children into care?’ After the inevitable increase in receptions (which always happens following an inquiry), the subsequent headline on 13 April 2010 was: ‘Social workers too quick to take children into care?’

Case study 1.1

From the early/middle part of the developmental spectrum is a (now) 17-year-old adopted boy diagnosed with moderate to severe attention deficit hyperactivity disorder (ADHD) plus oppositional disorder (see DSM-V [American Psychiatric Association, 2013] for both of these). He determinedly and persistently bends or breaks all rules. He has been expelled from both state, private and specialist schools, one toddler group, one play group and one day nursery – all for aggressive behaviour. He has had regular brushes with the police, chain smoked and drank under age, has tattoos and collects knives. At the same time, he is kind to his animals, helpful to his elderly neighbours and is loving towards his adoptive mother. As a result of her campaigns on his behalf, he has been assessed by three psychiatrists, multiple GPs and three psychologists (two educational, one clinical). Multiple referrals have been made to social services (more assessments but no action – his file is a foot thick), an adoption support unit (which offered none), an ‘attachment disorders clinic’ and so forth. Most of the psychological tests applied to him seem appropriate; his WISC results, with subtests, are just above average, except for general knowledge and short-term memory. His (generally cooperative) adoptive parents live on internet websites and are in regular contact with volunteer support groups. Nevertheless, at no time in 16 years have these parents been able to procure a single home visit, either for therapeutic or support purposes, or received a family assessment. They came close to a visit from social services until they confirmed that they had never hit the boy and would never contemplate doing so (one made-up story of a childhood shaking might well have changed things).

ADHD is a difficult condition to treat either psychologically or pharmacologically, but moderately effective or at least containing treatments do exist (see Moriyama et al., 2013 for a meta-analysis; Kazdin, 2004 on applicability). Medications such as Ritalin and later, more synthesized preparations are in common use; they have been prescribed, but this young man refuses to take them or takes them only intermittently. No visiting social worker or child psychiatric nurse has been available. Behaviour modification schemes based largely on rewards and cognitive behavioural therapy have both achieved mixed, but generally useful results for this condition (see Hollon & Beck, 2004), but they have never been tried in this case, nor has cognitive training, counselling or family therapy in support of the family. His adoptive parents (evidentially, his best hope) are divorcing and will have to sell their (his) home. We shall return to this case later.

What would conscientiousness have meant in this case? It would have led to much earlier interventions at the sites of the problems (home, school); much greater therapeutic support for the parents; nursing and social care in support of both medication compliance and to set up behavioural and cognitive training programmes; and an active, supportive link between school and home, instead of the parents’ evening denunciations and warnings sent in the post. The causes of this pattern of inaction were most probably high eligibility criteria concentrating help on those most in need; the preference of service managers for ‘battery’ rather than ‘free-range’ staff; lack of training in evidentially based interventions; and, of course, short-term cost worries. However, there is little doubt that what has been injudiciously not done will cost the agency, and ultimately all of us, a significant amount in the future.

Case study 1.2

At the other end of the developmental spectrum lies an 83-year-old, borderline depressed, recently bereaved, agoraphobic woman in poor physical health. She was admitted to hospital by a locum ‘out of hours’ doctor, and tests revealed that she had an aggressive form of lung cancer (she did not smoke, and neither did her late husband in case you are thinking passive thoughts). Relatives visited assiduously but lived a considerable distance away. She found the hospital food virtually uneatable: ‘I’m used to plain food and all this is spiced up and messed about.’ Visitors provided sandwiches, but she lost weight rapidly and was put on a ‘red tray scheme’ for food and drink. The result was a beautifully produced chart depicting her decline, but there was no coaxing to eat, and so the steady loss of weight continued. No ward round took place. Doctors visited the bedside unaccompanied by nurses and their recommendations went straight into the notes. She had several procedures for pneumonia, was on 11 different medications and the technical side of her treatment was intensively pursued. However, the basic nursing care left much to be desired. On one occasion she asked to go to the toilet, but was told that there were no assistants on hand to help because of recent cutbacks to the budget for agency staff, and that she should ‘go in the bed’ and get cleaned up later, which was not part of her definition of herself. She tried to make it to the lavatory unaided, drip and all, and fell. She was not physically hurt, but was distressed and fearful. Her wish was to die at home or with relatives, but the medical requirements of her treatment were apparently too much for the local home-nursing and care services, so she died in hospital, in her sleep, and was found only the next morning.

There is now widespread public concern about cases like this, with patients’ groups pushing for conscientious care alongside technical interventions: both, not one or the other. The Royal College of Nursing (RCN) shows concern, but tends to advance explanations focusing on ‘rogue nurses’, ‘rogue wards’ and ‘rogue hospitals’, pointing to its and the NHS’s (admittedly) admirable record overall. Nevertheless, an airline with three recent crashes to explain, which defended itself by saying that the majority of passengers landed safely, would be given short shrift. The government blames poor management, but routinely says that it cannot comment on ‘individual cases’. Case study 1.2 is the case of an individual who was rarely treated as such. The nurses rarely left their computer stations and, by repute and observation, rarely or never engaged in ordinary, morale-boosting conversations with patients. The woman’s relatives did make use of the complaints system, but the replies they received were so anodyne (‘We at the X-shire NHS Trust are committed to the highest standards of health care’ etc.) that they gave up after her death, since it was the standards of humanity that they were complaining about. The purpose of case illustrations such as this in a book stressing the need for methodological rigour is not to adduce them in general evidence, but to humanise and illustrate what lies behind figures on care standards (see Care Quality Commission 2013; Francis Report, 2013; Parlimentary and Health Service Ombudsman, 2015). And remember that this account would have constituted evidence for the patient.

Conscientious service provision is, therefore, not simply a matter of individual attitudes or skills. It is strongly influenced by policy and by the organisational milieu, and it is perfectly possible to be faithful to managerial priorities and end up doing the opposite of what evidence-based practice requires. The poor standards of care outlined in these case studies are not universal, but they occur more often than is comfortable and for reasons that are not beyond empirical investigation (see Care Quality Commission, 2013).

Leaving aside the lack of ethics in these cases, and the danger that health and local authority staff are induced into becoming the equivalent of insurance loss adjusters, the technical evidence for handing choice back to pat...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables and Figures
• Preface
• Acknowledgements
• About the Author
• 1. Principles of Evidence-Based Practice
• 2. What Comes with Us?
• 3. The Influence of Learning on Development
• 4. Stages and Dimensions of Psychological Development
• 5. Adolescence and Early Adulthood
• 6. Middle Life and the Transition to Old Age
• Bibiliography
• Index