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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2003, 36, 141–146 NUMBER 1 (SPRING 2003)

BRIDGING THE DISCONNECTION BETWEENAPPLIED RESEARCH AND PRACTICE:

A REVIEW OF TREATMENTS THAT WORK:EMPIRICALLY SUPPORTED STRATEGIES FORMANAGING CHILD BEHAVIOR PROBLEMS

BY ED CHRISTOPHERSEN AND SUSAN MORTWEET

KEITH D. ALLEN AND JODI POLAHA

MUNROE-MEYER INSTITUTE FOR GENETICS AND REHABILITATION

UNIVERSITY OF NEBRASKA MEDICAL CENTER

In recent years, behavior analysts have lamented a disconnection between applied researchand practice. In their book, Treatments That Work: Empirically Supported Strategies forManaging Child Behavior Problems, Christophersen and Mortweet (2001) have attemptedto bridge this gap for medical and behavioral health providers alike by describing empir-ically supported treatments, derived from behavior therapy and its application, that arespecifically designed for challenging problems commonly seen in typical children. Thebook is clearly intended for both primary care physicians and behavior therapists, and inthis article, we review the extent to which the book meets the needs of each. Discussioncenters on the extent to which the book can meet the need for both technical precisionand conceptual breadth in training of behavior therapists. We conclude that, in makingexplicit the connections between research and practice, the authors have provided a usefulclinical teaching tool and have also raised important questions about how best to establishcollaborative relationships with physicians and promote the use of behavioral technologyin primary care.

DESCRIPTORS: primary care, behavioral health, empirically supported treatments,dissemination, marketing

Over the past 20 years, behavior analystshave become increasingly interested in thedelivery of behavioral health services in pri-mary care settings, especially with pediatri-cians (Allen, Barone, & Kuhn, 1993; Arn-dorfer, Allen, & Aljazireh, 1999). A majorityof patients with behavioral health problemspresent them in primary care settings ratherthan in clinics that specialize in psychologi-cal services (Costello, 1986), and physiciansare expected to address and manage theseneeds in the context of a short office visit

Preparation of this review was supported in part byGrant MCJ 319152 from the Maternal and ChildHealth Bureau, Health Resources Services Administra-tion and by Grant 90 DD 032402 of the Adminis-tration on Developmental Disabilities.

Correspondence may be addressed to Keith D. Al-len, Munroe-Meyer Institute for Genetics and Reha-bilitation, 985450 Nebraska Medical Center, Omaha,Nebraska 68198-5450 (e-mail: kdallen@unmc.edu).

(Arndorfer et al., 1999). In fact, a numberof authors have proposed models of collab-orative care between psychologists and phy-sicians that are touted as having the advan-tage of increased continuity of care (deGruy,1997; Drotar, 1995; Schroeder & Gordon,1991). Behavior analysts are in a particularlystrong position in such a partnership, be-cause a majority of the empirically supportedtreatments for managing behavioral healthproblems presenting in primary care are de-rived from behavior theory and its applica-tion (Kazdin & Weisz, 1998).

Yet, behavior analysts have been in similarpositions before, and still some lament a dis-connection between applied research andpractice that has been described as being atleast as great as that between basic and ap-plied research (Critchfield, 2002; Neef,1995). Happily, at least one behavior analyst

142 KEITH D. ALLEN and JODI POLAHA

has a bridge underway. For much of the past20 years, Ed Christophersen has pioneeredthe application and dissemination of behav-ior analysis in pediatrics. Christophersen hasbeen able to bridge the often-worrisome dis-connection between applied research andpractice that has received considerable atten-tion in the Journal of Applied Behavior Anal-ysis (JABA), in part by using strategies de-scribed in this journal (e.g., Allen et al.,1993; Neef, 1995; Schwartz & Baer, 1991).He has published in major pediatric jour-nals, including Pediatrics, Pediatric Clinics ofNorth America, Journal of Developmental andBehavioral Pediatrics, and Pediatric Annals,demonstrating to pediatricians that behavioranalysts are empirically based. He has pub-lished on topics ranging from toilet trainingand injury prevention to medical adherenceand basic management of everyday prob-lems, demonstrating to pediatricians that be-havior analysts are interested in high-inci-dence, low-intensity problems that are rele-vant in primary care. Finally, he has provid-ed guidance to pediatricians in choosing,adapting, applying, and evaluating interven-tions, demonstrating to pediatricians thatbehavior analysts care about conditions thataffect the social validity of their interven-tions. His book, Treatments That Work: Em-pirically Supported Strategies for ManagingChild Behavior Problems (2001), coauthoredwith Susan Mortweet, is one of his most re-cent efforts to continue packaging and mar-keting behavioral technology to primary careproviders.

Christophersen and Mortweet make itclear from the outset that their book is notintended for primary care providers alone,but they are explicit in targeting this audi-ence. First, they hypothesize in the intro-duction that a book such as Treatments ThatWork may enhance the collaborative rela-tionship between behavior therapists andprimary care physicians by providing a re-source to help physicians ‘‘make decisions

about referring children on the basis ofwhether or not empirically supported treat-ments exist’’ (p. 10). This hypothesis has in-tuitive appeal because the medical commu-nity has expressed a preference for evidence-based medicine in their own practices.Moreover, there is a good fit between theneeds of primary care physicians and theempirically supported behavioral healthtreatments that have been derived. Five ofthe eight chapters included in the book (i.e.,those on disruptive behavior and attentiondeficit hyperactivity disorder, encopresis,pain, enuresis, and sleep disorders) corre-spond closely with pediatricians’ reports ofcommon and challenging problems encoun-tered in everyday primary care practice (Arn-dorfer et al., 1999). It is not hard to imaginethat chapters on habit disorders, anxiety, andmedical nonadherence could also be relevantand valuable to pediatricians.

Second, Christophersen and Mortweetwrote the book to provide primary care phy-sicians with a reference that would helpthem to stay current with the literature onbehavioral health care. To this end, the bookalso offers overviews of diagnostic criteria,causes and correlates, and assessment pro-cedures, as well as reviews of both medicaland behavioral interventions for each type ofproblem. Physician-friendly elements in-clude (a) excellent ‘‘Differential DiagnosisCriteria’’ tables in a checklist format (basedon the DSM-IV) that could serve as a handyclinical tool, (b) reviews of medication in-terventions preceding reviews of behavioralinterventions, a format likely to be valuedby individuals trained in a disease-centeredbiomedical model, and (c) concise summa-ries at the end of the chapters that providesuggestions about choosing among treat-ment options.

In spite of these strengths, the book’sgreatest contribution may be heuristic; infact, there has been little research on whatfuels a referral from primary care to a be-

143BOOK REVIEW

havioral health professional. Opinions are le-gion, but there does not yet exist an empir-ically derived technology of establishing andmaintaining collaborative relationships. Noris there any support for the notion that pri-mary care physicians would read or ‘‘keephandy’’ a reference book regarding behavior-al health assessment and treatment. In ad-dition, having and promoting empiricallyderived technology alone is not enough.Getting physicians to use behavioral tech-nology is likely to be at least as difficult asgetting parents to implement effective tech-nology (Allen & Warzak, 2000). If Treat-ments That Work inspires research designedto answer these questions, it has served avaluable function.

The amount of information provided inTreatments That Work also begs the questionof ‘‘How much is too much?’’ for primarycare physicians. The book includes relativelybrief reviews (compared to what psycholo-gists are used to) of diagnosis and assessmentprocedures, but one wonders how muchphysicians want to know about interviewprocedures, observational techniques, or self-report measures. Treatments That Work mayalso provide too much information abouttreatment. For example, several of the chap-ters (those on habits, enuresis, encopresis,and disruptive behaviors) provide enough in-formation in the form of protocols andhandouts to suggest that the reader couldimplement a given intervention based on theprotocol alone. Yet, the extent to which phy-sicians are interested in, or capable of, car-rying out behavioral interventions in thecontext of primary care is unknown.

A final concern centers on the fact thatmany of the chapters in Treatments ThatWork provide discussions of any interventionwith some supporting research, rather thanlimiting the book to descriptions of onlythose treatments that have been subjected torigorous (Chambless & Hollon, 1998) sci-entific investigation. For example, the chap-

ter on disruptive behavior disorders discussesbehavioral parent training, cognitive behav-ioral therapy, structural family therapy, psy-chodynamic therapy, and parenting groups.The chapter on enuresis reviews arousaltraining (a procedure with limited empiricalsupport) alongside the urine alarm (a pro-cedure with extensive empirical support).Chapters on habit disorders, sleep disorders,enuresis, and pain offer overviews of the en-tire treatment literature rather than specificguidance and direction toward treatmentsthat have undergone rigorous scientific in-vestigation. The implicit message in thesechapters is that the described interventionsare all ‘‘treatments that work,’’ althoughsome of the treatments have undergonemore rigorous scientific investigation thanothers. It is difficult to see how this type ofbroad overview would be of assistance to pri-mary care physicians, as a resource or as areferral guide.

One reason that Christophersen and Mor-tweet included more detail than might beneeded or desired by pediatricians may bethat the authors had a larger audience inmind. Indeed, Treatments That Work waswritten to be used not only by pediatriciansbut also by mental health practitioners, grad-uate students, and predoctoral interns. Writ-ing a book for such a wide audience is adifficult challenge because the needs of thesevarious groups are so different. Primary carephysicians, who have approximately 13 minwith each patient to deal with an average ofsix different problems (deGruy, 1997), areunlikely to be interested in the technical pre-cision necessary to treat some problems orthe conceptual breadth necessary to under-stand why a given treatment might work. Atthe same time, physicians have little trainingin the recognition of psychological disorders(Badger et al., 1994), and most feel insecurein managing problem behaviors and in pre-scribing psychoactive drugs (deGruy, 1997).Ultimately, the kind of information pedia-

144 KEITH D. ALLEN and JODI POLAHA

tricians need, how much they need, and inwhat format they need it are all empiricalquestions.

Behavioral health practitioners, on theother hand, need the sort of technical pre-cision offered in some of the chapters inTreatments That Work. Precision (i.e., the ex-tent to which our descriptions of our tech-nology tell us what to do) is important be-cause without it our science has no utility(Hayes, 1991). Chapters on habit disorders,encopresis, enuresis, and pain, in particular,provide user-friendly assessment forms andtreatment protocols that could be photocop-ied directly and used by a clinician. Al-though the chapters are not, nor were theymeant to be, treatment manuals or ‘‘how-to’’guides, they do provide enough informationto guide the clinical practice of doctoral-levelstudents and practitioners with advanced be-havioral clinical training. In addition, thebook does provide two appendixes with in-structions for implementing a token pro-gram and for conducting relaxation training.These chapters (and appendixes) could proveto be valuable resources in graduate-levelclasses or in clinics that focus on behavioralhealth service delivery in primary care set-tings. In addition, these chapters addresscommon problems that are not typically ad-dressed in traditional textbooks of childhoodclinical pathology (e.g., Mash & Barkley,1998) and provide precision that is not typ-ically offered in traditional textbooks of pe-diatric psychology (e.g., Roberts, 1995).

In contrast, chapters on disruptive behav-ior disorders, anxiety disorders, medical ad-herence and sleep problems offer less preci-sion and, therefore, less utility. Perhaps be-cause these chapters address diagnosticallyrelated groups of problems (e.g., disruptivebehavior disorders include attention deficithyperactivity disorder, oppositional behavior,and conduct disorder) rather than individualproblems (e.g., enuresis), there is simply lessprecise information about assessment and

treatment for any individual problem. Forexample, the chapter on disruptive behaviordisorders provides brief handouts and pro-tocols for ‘‘time-in’’ and problem solving butnothing similar on time-out and differentialattention, both of which are empirically sup-ported treatments for disruptive behaviorproblems. The tendency, exposed earlier, bythe authors to provide discussions of any in-tervention with some supporting research,rather than limiting the book to descriptionsof only those treatments that have been sub-jected to rigorous scientific investigation, ismagnified in these chapters. It appears thatthe authors had a difficult time deciding be-tween breadth of coverage and precision ofcoverage. The result is that some chaptersprobably offer more information than a typ-ical primary care physician would need orbe interested in and not enough informationto be immediately useful to a doctoral-levelclinical practitioner.

A final caution for trainers of doctoral-level students who might use this book. Thebook models a diagnosis-driven rather thanan assessment-driven approach to treatmentselection. This type of approach encouragesdisconnected, diagnosis-driven theorizingrather than integrative, process-oriented,functional thinking (Forsyth, 1997). In ad-dition, Treatments That Work rarely offers in-sight into why the technology being de-scribed works as it does. Yet, knowing howand why treatments work is important, be-cause such knowledge provides the concep-tual grounds to use a given treatment whenconfronted with a new problem (Hayes,1991). Without the conceptual grounds, thesource for new techniques may fall to ‘‘com-mon sense’’ or to unscientific theories (Haw-kins, 1997). The ‘‘why’’ is also important,because it allows tools and techniques tocomplement rather than supplant the appli-cation of basic principles derived from ex-perimental science (Forsyth, 1997). Finally,it is also difficult to teach what is known in

145BOOK REVIEW

an area without understanding why, becauseseemingly disconnected facts proliferate(Hayes, 1997).

Admittedly, in practice, it is almost im-possible to write a book that offers technicalprecision and conceptual breadth, becausewriting for one almost always comes at theexpense of the other. Textbooks that includeinteresting and advanced conceptual discus-sions are often introductory in their han-dling of applications and procedures, where-as textbooks that are technically sound oftenomit detailed discussions of important con-ceptual issues (Vollmer, 2001). We do notmean to suggest that Treatments That Workshould have included more conceptual dis-cussions about the how and why of the tech-nology being described, but neither shouldthe book be considered a substitute for text-books that do. Doctoral-level psychologistsshould be interested in both the technicalprecision necessary to implement empiricallyderived technology and the conceptual scopenecessary to talk about and describe thattechnology in a systematic fashion with re-spect to basic principles of our science.

In spite of these reservations, Christo-phersen and Mortweet’s effort to bridge ap-plied research and clinical practice in pri-mary care has made a contribution to be-havior analysis in general and to our practicein particular. In general, efforts to make ex-plicit the connections between research andpractice have received considerable supportin the JABA community (e.g., Mace &Wacker, 1994), and this book should receivethe same. For us, however, their effort is es-pecially propitious given that we regularlycollaborate with primary care physicians andtrain doctoral-level psychology students;both are target audiences of Treatments ThatWork. Foremost, the book has found a placein our teaching with both medical residentsand psychology interns, precisely becausesome of the chapters provide something forboth: simple diagnostic tables and brief over-

views of the treatment literature for medicalresidents and straightforward treatment pro-tocols for doctoral interns. But the book hasalso inspired us to begin our own researchto answer the questions posed earlier regard-ing the critical features related to the estab-lishment of referral and collaborative rela-tionships with primary care physicians andthe use of behavioral technology by pedia-tricians. This is not a small point, becausethe survival of our science may depend, atleast in part, on the answers.

REFERENCES

Allen, K. D., Barone, V. J., & Kuhn, B. (1993). Abehavioral prescription for promoting behavioranalysis within pediatrics. Journal of Applied Be-havior Analysis, 26, 493–502.

Allen, K. D., & Warzak, W. J. (2000). The problemof parental nonadherence in clinical behavior anal-ysis: Effective treatment is not enough. Journal ofApplied Behavior Analysis, 33, 373–391.

Arndorfer, R. E., Allen, K. D., & Aljazireh, L. (1999).Behavioral health needs in pediatric medicine andthe acceptability of behavioral solutions: Implica-tions for behavioral psychologists. Behavior Ther-apy, 30, 137–148.

Badger, L. W., DeGruy, F. V., Hartman, J., Plant, M.A., et al. (1994). Patient presentation, interviewcontent, and the detection of depression by pri-mary care physicians. Psychosomatic Medicine, 56,128–135.

Chambless, D. L., & Hollon, S. D. (1998). Definingempirically supported therapies. Journal of Con-sulting and Clinical Psychology, 66, 7–18.

Christophersen, E. R., & Mortweet, S. L. (2001).Treatments that work: Empirically supported strate-gies for managing child behavior problems. Wash-ington, DC: American Psychological Association.

Costello, E. J. (1986). Primary care pediatrics andchild psychopathology: A review of diagnostic,treatment, and referral practices. Pediatrics, 78,1044–1051.

Critchfield, T. S. (2002). Evaluating the function ofapplied behavior analysis: A bibliometric analysis.Journal of Applied Behavior Analysis, 35, 423–426.

deGruy, F. V. (1997). Mental health care in the pri-mary care setting: A paradigm problem. Families,Systems, & Health, 15(1), 3–26.

Drotar, D. (1995). Consulting with pediatricians: Psy-chological perspectives. New York: Plenum.

Forsyth, J. P. (1997). In the name of the ‘‘advance-ment’’ of behavior therapy: Is it all in a name?Behavior Therapy, 28, 615–627.

146 KEITH D. ALLEN and JODI POLAHA

Hawkins, R. P. (1997). Can behavior therapy besaved from triviality? Behavior Therapy, 28, 637–645.

Hayes, S. C. (1991). The limits of technological talk.Journal of Applied Behavior Analysis, 24, 417–420.

Hayes, S. C. (1997). Technology, theory, and the al-leviation of human suffering: We still have such along way to go. Behavior Therapy, 28, 517–525.

Kazdin, A. E., & Weisz, J. R. (1998). Identifying anddeveloping empirically supported child and ado-lescent treatments. Journal of Consulting and Clin-ical Psychology, 66, 19–36.

Mace, F. C., & Wacker, D. P. (1994). Toward a great-er integration of basic and applied behavioral re-search: An introduction. Journal of Applied Behav-ior Analysis, 27, 569–574.

Mash, E. J., & Barkley, R. A. (Eds.). (1998). Treat-ment of childhood disorders (2nd ed.). New York:Guilford.

Neef, N. A. (1995). Research on training trainers inprogram implementation: An introduction andfuture directions. Journal of Applied Behavior Anal-ysis, 28, 297–299.

Roberts, M. C. (Ed.). (1995). Handbook of pediatricpsychology (2nd ed.). New York: Guilford.

Schroeder, C. S., & Gordon, B. N. (1991). Assessmentand treatment of childhood problems. New York:Guilford.

Schwartz, I. S., & Baer, D. M. (1991). Social validityassessments: Is current practice state of the art?Journal of Applied Behavior Analysis, 24, 189–204.

Vollmer, T. R. (2001). Review of Miltenberger’s Be-havior Modification: Principles and Procedures (2nded.). Journal of Applied Behavior Analysis, 34, 551–557.

Received June 4, 2002Final acceptance November 7, 2002Action Editor, Patrick C. Friman