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Overview of Evidence Based Practice

Charles Wilson, MSSW, Executive Director of Chadwick Center The Sam and Rose Stein Chair on Child
Charles Wilson, MSSW, Executive Director of Chadwick Center
The Sam and Rose Stein Chair on Child Protection
Rady Children’s Hospital-San Diego
www.cachildwelfareclearinghouse.org
Overview of Evidence Based Practice Charles Wilson, MSSW, Executive Director of Chadwick Center The Sam and
How Things Change A Problem is Recognized Action­Any Action

How Things Change

A Problem is Recognized Action­Any Action
A Problem is
Recognized
Action­Any Action

Action­ Creation of Orphan Trains

• Between 1854 and 1929 100,000­200,000 children were placed in new families via the Orphan Trains.
Between 1854 and 1929 100,000­200,000
children were placed in new families via the
Orphan Trains.
http://www.orphantraindepot.com

•Children were taken in small groups of 10 to 40, under the supervision of at least one adult, and traveled on trains to selected stops along the way, where they were taken by families in that area.

http://www.pbs.org/wgbh/amex/orphan/teachers.html

How Things Change

A Problem is Recognized Action­Any Action Series of Trail and Errors Adjustments­ Some Better­ Some Worse
A Problem is
Recognized
Action­Any Action
Series of Trail
and Errors
Adjustments­
Some Better­
Some Worse
Informed Action
How Things Change A Problem is Recognized Action­Any Action Series of Trail and Errors Adjustments­ Some
Family Foster Care Trial and Error Orphanages and Boarding schools Tennessee Preparatory School for Dependent Children
Family Foster Care
Trial and Error
Orphanages and
Boarding schools
Tennessee Preparatory School for Dependent Children
How Things Change A Problem is Recognized Informed Action Informed Action­Based on Science

How Things Change

A Problem is Recognized Informed Action Informed Action­Based on Science
A Problem is
Recognized
Informed Action
Informed Action­Based on Science

So how do we know what works vs. mere marketing marketing hyperbole?

Let the Buyer Beware
Let the Buyer
Beware

Thought Field Therapy

“Thought field therapy with Callahan techniques® is a powerful therapy exerted through nature's healing system to
“Thought field therapy with Callahan techniques® is a powerful therapy
exerted through nature's healing system to balance the body's energy
system. This therapy promotes stress management and stress relief as
well as the reduction or elimination of anxiety and anxiety related
problems. This includes help for weight control and weight loss, trauma
Roger J. Callahan, PhD
or sleep difficulties, depression, addictions and the disorders
associated with past trauma including nightmares and post traumatic
stress disorder.”
(underlines added)
Thought Field Therapy “Thought field therapy with Callahan techniques® is a powerful therapy exerted through nature's

Retrieved from http://www.tftrx.com/, November 17, 2006

More Claims for TFT

Q. How Can TFT Benefit You? – What Kind of Problems Can Be Helped? • •
Q. How Can TFT Benefit You? – What Kind of Problems Can Be Helped?
Anxiety and Stress
Personal fears or your children’s fears
Anger and Frustration
Eating or smoking or drinking problems
Loss of loved ones
Social or public speaking fears
Sexual or intimacy problems
Travel anxiety including fear of flying or driving on the freeways
Nail biting
Cravings
Low moods and mood swings

Retrieved from http://www.tftrx.com/profaq.php?PHPSESSID= f4cf66c40b9678b742b82989fee7b377# on November 17, 2006

NPR All Things Considered, March 29, 2006

“According to psychologist Roger Callahan, the creator of thought field therapy, major problems like depression can
“According to psychologist Roger Callahan, the
creator of thought field therapy, major problems like
depression can be cured quickly with this method. He
says post­traumatic stress disorder is easily dispatched
in 15 minutes, and even the most serious cases of
anxiety, addiction and phobias are likewise subject to
quarter­hour cures.”

Research on TFT?

“Has any research been carried out on TFT? There have been no control (sic) studies on
“Has any research been carried out on TFT?
There have been no control (sic) studies on the
success of TFT”
From the Thought Field Therapy Training Center of La Jolla

Retrieved from http://thoughtfield.com/faqs.htm on November 17, 2006

Distinguishing groundless marketing claims from reality The The Problem Problem:: All All sorts sorts of of

Distinguishing groundless marketing claims from reality

The The Problem Problem:: All All sorts sorts of of “intervention “intervention s”s” are are available
The
The Problem
Problem::
All
All sorts
sorts of
of
“intervention “intervention
s”s” are
are
available
available out
out
there. there.

Waiting Room Sign

Waiting Room Sign Ben Saunders MUSC

Ben Saunders MUSC

Evidence Based Social Work “Professional judgments and behaviors should be guided by two interdependent principals: 1.
Evidence Based Social Work
“Professional judgments and behaviors should be guided
by two interdependent principals:
1.
When ever possible, practice should be grounded on
prior findings that demonstrate empirically…that they
are likely to produce predictable, beneficial, and
effective results.
2.
Every clients system, over time should be evaluated”
Evidence
Evidence Based
Based Practice
Practice Manual
Manual
Oxford
Oxford University
University Press
Press
2004
2004
Albert
Albert Roberts,
Roberts, PhD
PhD
Kenneth
Kenneth Yeager,
Yeager, PhD,
PhD, LISW
LISW

Global Definition of EBP

Including Both The best available clinical evidence from systematic research
Including Both
The best available clinical
evidence from systematic
research
The conscientious, explicit and judicious use of current best evidence in making decisions about the care
The conscientious, explicit and judicious use of current best
evidence in making decisions about the care of individual patients.
Global Definition of EBP Including Both The best available clinical evidence from systematic research The conscientious,
Individual clinical expertise
Individual clinical expertise

­David Sackett

Huge Policy Implications

• Should policy makers support adoption of EBP? – If so, which ones –When are they
Should policy makers support adoption of EBP?
If so, which ones –When are they “Ready for Prime time”
What is the standard of evidence?
If so, how best can they support adoption?
What are the pitfalls of a state or national policy
level adoption of EBP?
– Impact on Innovation
– Misapplication of good models?­One size does not fit all
– Watering down of empirically based practice­danger of
implementing in name only
– Ideology vs. Science­ who is the judge of the science?
Should we limit what we do to EBP?
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized
Parachute use to prevent death and
major trauma related to gravitational
challenge: systematic review of
randomized controlled trials
(Gordon C Smith, Jill P Pell, 2005)
The perception that parachutes are a successful intervention is based.
largely on anecdotal evidence
Observational data have shown that their use is associated with, morbidity and
mortality due to both failure of the intervention and mechanical complications. In
addition, “natural history" studies of free fall indicate that failure to take or
deploy a parachute does not inevitably result in an adverse outcome ...
The effectiveness of an intervention has to be judged relative to non­
intervention.
Understanding the natural history of free fall is therefore imperative.
If failure to use a parachute were associated with 100% mortality then any
survival associated with its use might be considered evidence of effectiveness.
Therefore, studies are required to calculate the balance of risks and

benefits of parachute use.

Why Evidence-Based Practice Now?

•A growing body of scientific knowledge •Increased interest in consistent application of quality services •Increased interest
•A growing body of scientific knowledge
•Increased interest in consistent application of
quality services
•Increased interest in outcomes and
accountability by funders
•Past missteps in spreading untested “best
practices” that turned out not to be as effective as
advertised

•Because they work !!

Problems in the Child Abuse Field in the U.S.

• Empirical evidence of efficacy has not been a common criteria for treatment selection in the
Empirical evidence of efficacy has not been a common criteria for treatment
selection in the child maltreatment field.
Lack of outcome research for many commonly used interventions.
Ready willingness among some to use, embrace, promote, and staunchly
defend practices that have no evidence for their efficacy and questionable
theoretical bases.
Poor dissemination of the significant clinical outcome research that has been
done.
Ineffective approaches to continuing education.
Poor adoption of empirically supported treatments in real world clinical
settings.
Disconnection between current scientific knowledge and practice in the field.

Scared Straight

Scared Straight

TF­CBT

TF­CBT

Reactive Attachment Disorder and Attachment Therapy

…pioneered by psychoanalyst Aaron Lederer, the RAD Consultancy’s creator and director. His methods yield remarkable results
…pioneered by psychoanalyst Aaron Lederer, the RAD
Consultancy’s creator and director. His methods yield
remarkable results within weeks.

Retrieved from http://www.radconsultancy.com/, November 17, 2006

Why Why should should wewe worry worry about about using using Evidence Evidence Supported Supported Treatments
Why
Why should
should wewe worry
worry
about
about using
using Evidence
Evidence
Supported
Supported Treatments
Treatments??
Why Why should should wewe worry worry about about using using Evidence Evidence Supported Supported Treatments

Institute of Medicine:

Apply the Principles and Methods of Evidence Based Practice

Integration of: • Best Research Evidence • Best Clinical Experience • Consistent with Client Values •http://www.shef.ac.uk/scharr/ir/netting/
Integration of:
• Best Research Evidence
• Best Clinical Experience
• Consistent with Client Values
•http://www.shef.ac.uk/scharr/ir/netting/
•http://ebmh.bmj.com/
•http://cebmh.com/

•http://www.cebm.utoronto.ca/

Understand Adoption of Innovation MTFC 1991 Innovators Early Late Majority Majority Early Traditionalists Adopters
Understand Adoption of Innovation
MTFC
1991
Innovators
Early
Late
Majority Majority
Early
Traditionalists
Adopters

Common Errors When Deciding about Intervention Effectiveness

• • • • • Reliance solely on individual anecdotes and remembered cases. – “That child
Reliance solely on individual anecdotes and remembered cases.
– “That child made such amazing changes during treatment.”
Confusing client satisfaction with clinical improvement.
– “The family just loved coming to therapy. Never missed a session
during their 3 years of therapy. Amazing. Too bad they had to move
away.”
Misattribution of the cause of change.
Failure to appreciate resilience and natural recovery.
– “The family got multiple services and wrap around care.”
– “With treatment her PTSD resolved in about 3 months after the rape.”
Guru effect in training and treatment adoption.
– “I heard Dr. McDreamy is doing a level II training. And, it’s in San
Diego in January!”

– “Those videos were just so amazing! I have got to try that.”

Ben Saunders

MUSC

What to look for in a Practice?

• Treatment or intervention protocol that has at least some scientific, empirical research evidence for its
Treatment or intervention protocol that has at least some scientific, empirical
research evidence for its efficacy with its intended target problems and
populations.
Evidence may be based on a variety of research designs.
Randomized Clinical Trial (RCT)
Controlled studies without randomization
Open trials, pre­ post­, or uncontrolled studies
– Multiple baseline, single case designs
The degree to which we are persuaded that the treatment is effective will vary by
the quality of empirical support.
– Number of RCT’s
– Replication by researchers other than the treatment developers
– Sampling, sample size used, comparison treatment, effect size
Various methods have been developed for classifying the level of empirical
support enjoyed by treatment approaches.

– Should be useful for front­line practitioners

CEBC Website: www.cachildwelfareclearinghouse.org
CEBC Website: www.cachildwelfareclearinghouse.org

Current Data on Visitors to the Website

Total Number of Visits to the Website 46,635 Percentage of Total Visitors from over 131 International
Total Number of Visits to the Website
46,635
Percentage of Total Visitors from over
131 International Countries
14%
Percentage of Total
Visitors from U.S.
86%
Current Data on Visitors to the Website Total Number of Visits to the Website 46,635 Percentage
Current Data on Visitors to the Website Total Number of Visits to the Website 46,635 Percentage
Percentage of Total Visitors from California 33%
Percentage of Total Visitors
from California
33%

Data based on numbers as of

September 1, 2007

CEBCs Definition

CEBC’s

Definition ofof Evidence-Based

Evidence-Based

Practice Practice for for Child Child Welfare Welfare  Best Research Evidence  Best Clinical Experience
Practice
Practice for
for Child
Child Welfare
Welfare
 Best Research Evidence
 Best Clinical Experience
 Consistent with Family/ Client Values
(modified from The Institute of Medicine)
http://www.iom.edu/
Definition CEBC’s of of Evidence-Based Practice Practice for for Child Child Welfare Welfare  Best

The California

The

California Evidence-Based

Evidence-Based

Clearinghouse

Clearinghouse

for for Child Child Welfare Welfare (CEBC) (CEBC) The CEBC was launched on 6/15/06.
for
for Child
Child Welfare
Welfare (CEBC)
(CEBC)
The CEBC was launched on 6/15/06.

In 2004, the California Department of Social Services, Office of Child Abuse Prevention contracted with the Chadwick Center for Children and Families, Rady Children’s Hospital-San Diego in cooperation with the Child and Adolescent Services Research Center to create the CEBC.

Advisory Advisory Committee Committee The Advisory Committee is composed of 15 members drawn from a broad
Advisory
Advisory Committee
Committee
The Advisory Committee is composed of 15 members drawn from a broad cross­
representation of communities and organizations.
There are representatives from:
California Department of Social Services
Child Welfare Departments from California Counties
Child Welfare Director’s Association (CWDA)
California Child Welfare Training Leaders
Public and Private Community Partners Within the State
The role of the Advisory Committee is to:
Determine the topical areas for the CEBC
Ensure the CEBC remains up­to­date with emerging evidence.
Assist in disseminating the products of the CEBC.
Provide feedback on the utility of the CEBC products.
National National
National
National
Scientific Scientific Panel Panel The National Scientific Panel is composed of five core members and up
Scientific
Scientific Panel
Panel
The National Scientific Panel is composed of five core
members and up to 10 selected Topical Experts.
The Panel is nationally recognized as leaders in child
welfare research and practice, and who are
knowledgeable about what constitutes best
practice/evidence-based practice.

The Panel assists in identifying relevant practices and research and provide guidance on the scientific integrity of the CEBC products.

Scientific Rating Scale and Relevance to Child Welfare Scale
Scientific Rating Scale
and
Relevance to Child Welfare Scale
Rating Scale Development • Goals: – Multiple categories – High standard for top ratings – Randomized
Rating Scale Development
Goals:
– Multiple categories
– High standard for top ratings – Randomized
Controlled Trials
– Clearly defined criteria
– Focus on peer-reviewed research and ability to
replicate program

Gold Standard for Evidence

• Randomized controlled trial (RCT) – Participants are randomly assigned to either an intervention or control
• Randomized controlled trial (RCT) –
Participants are randomly assigned to either an
intervention or control group. This allows the
effect of the intervention to be studied in
groups of people who are the same, except for
the intervention being studied.
– Any differences seen in the groups at the end can
be attributed to the difference in treatment alone,
and not to bias or chance.
Gold Standard for Evidence • Randomized controlled trial (RCT) – Participants are randomly assigned to either

Peer-Reviewed Research

• Peer review – A process used to check the quality and importance of research studies.
• Peer review – A process used to check the
quality and importance of research studies. It
aims to provide a wider check on the quality
and interpretation of a study by having other
experts in the field review the research and
conclusions.

Efficacy vs. Effectiveness

• Efficacy focuses on whether an intervention works under ideal circumstances and looks at whether the
• Efficacy focuses on whether an intervention
works under ideal circumstances and looks at
whether the intervention has any impact at all.
• Effectiveness focuses on whether a treatment
works when used in the real world.
– An effectiveness trial is done after the intervention
has been shown to have a positive effect in an
efficacy trial.
Efficacy vs. Effectiveness • Efficacy focuses on whether an intervention works under ideal circumstances and looks

Scientific Rating Scale

Scientific Rating Scale

6. Concerning Practice

• If multiple outcome studies have been conducted, the overall weight of evidence suggests the intervention
If multiple outcome studies have been conducted, the overall
weight of evidence suggests the intervention has a negative
effect upon clients served.
and/or
There is a reasonable theoretical, clinical, empirical, or
legal basis suggesting that, compared to its likely benefits,
the practice constitutes a risk of harm to those receiving it.

5. Evidence Fails to Demonstrate Effect

• Two or more randomized, controlled outcome studies (RCT's) have found that the practice has not
Two or more randomized, controlled outcome studies (RCT's)
have found that the practice has not resulted in improved
outcomes, when compared to usual care.
If multiple outcome studies have been conducted, the overall
weight of evidence does not support the efficacy of the
practice.

4. Acceptable/Emerging Practice­

Effectiveness is Unknown • There is no clinical or empirical evidence or theoretical basis indicating that
Effectiveness is Unknown
There is no clinical or empirical evidence or theoretical basis
indicating that the practice constitutes a substantial risk of
harm to those receiving it, compared to its likely benefits.
The practice has a book, manual, and/or other available
writings that specifies the components of the practice
protocol and describes how to administer it.
The practice is generally accepted in clinical practice as
appropriate for use with children receiving services from
child welfare or related systems and their parents/caregivers.
The
practice
lacks
adequate
research
to empirically
determine efficacy.
  • 3. Promising Practice

Same basic requirements as Level 4 plus: • . At least one study utilizing some form
Same basic requirements as Level 4 plus:
.
At least one study utilizing some form of control (e.g.,
untreated group, placebo group, matched wait list) has
established the practice’s efficacy over the placebo, or found it
to be comparable to or better than an appropriate comparison
practice. The study has been reported in published, peer-
reviewed literature.
Outcome measures must be reliable and valid, and
administered consistently and accurately across all subjects.
If multiple outcome studies have been conducted, the overall
weight of evidence supports the efficacy of the practice.

2.

Well Supported­Efficacious Practice

Same basic requirements as Level 3 plus: • Randomized controlled trials (RCTs): At least 2 rigorous
Same basic requirements as Level 3 plus:
Randomized controlled trials (RCTs): At least 2 rigorous
RCTs in highly controlled settings (e.g. University laboratory)
have found the practice to be superior to an appropriate
comparison practice.
-The RCTs have been reported in published, peer-reviewed
literature.
The practice has been shown to have a sustained effect at
least one year beyond the end of treatment, with no evidence
that the effect is lost after this time.

1. Well supported ­ Effective Practice

Multiple Site Replication: At least 2 rigorous randomized controlled trials (RCTs) in different usual care or
Multiple Site Replication: At least 2 rigorous randomized
controlled trials (RCTs) in different usual care or practice
settings have found the practice to be superior to an
appropriate comparison practice.
-
The RCTs have been reported in published, peer-
reviewed literature.
The practice has been shown to have a sustained effect
at least one year beyond the end of treatment, with no
evidence that the effect is lost after this time.

Same basic requirements as a Level 2 plus:

Child Welfare Ratings

• Not every program that is evidence-based will work in a Child Welfare setting… • We
• Not every program that is evidence-based will
work in a Child Welfare setting…
• We also examined each program’s experience
and fit with Child Welfare systems and
families

Relevance toto Child

Relevance

Child Welfare

Welfare Scale

Scale

1. High: The program was designed or is commonly used to meet the needs of children,
1.
High:
The program was designed or is commonly used to meet the needs of
children, youth, young adults, and/or families receiving child welfare
services.
2.
Medium:
The program was designed or is commonly used to serve children,
youth, young adults, and/or families who are similar to child welfare
populations (i.e. in history, demographics, or presenting problems) and
likely included current and former child welfare services recipients.
3.
Low:
The program was designed to serve children, youth, young adults,
and/or families with little apparent similarity to the child welfare
services population.

Child Welfare Outcomes

We also examined whether programs had included outcomes from the Child and Family Services Reviews in
We also examined whether programs had included outcomes
from the Child and Family Services Reviews in their peer-
reviewed evaluations:
Safety
Permanency
Well-being
Well-being
Common Continuing Education Dissemination Model One day workshop Therapist Use Tx with appropriate clients Book
Common Continuing Education
Dissemination Model
One day
workshop
Therapist
Use Tx with
appropriate
clients
Book
X Laying the Groundwork for Implementing Evidence Based Practice
X Laying the Groundwork for
Implementing
Evidence Based Practice

Levels of Implementation

Fixen et al • Paper Implementation • Process Implementation • Performance Implementation
Fixen et al
• Paper Implementation
• Process Implementation
• Performance Implementation

Fixsen, D., Naoosm, S., Blasé, K., Friedman, R., Wallace, F. (2005)

Institute for Healthcare

Improvement Model Environmental Environmental Context Context Community, Community, Government, Government, Funders Funders Organizational Organizational Context Context
Improvement Model
Environmental
Environmental Context
Context
Community,
Community, Government,
Government,
Funders
Funders
Organizational
Organizational Context
Context
Organizations
Organizations
Departments
Departments
Microsystem
Microsystem
and
and Programs
Programs
Within
Within
Organizations Organizations
Patient
Patient and
and
Community
Community
Social
Social Workers,
Workers, Therapists,
Therapists,
Medical
Medical Professionals
Professionals and
and
Families
Families

Transtheoretical Model of Change

5 Stages of Change

• Precontemplation • Compliant Status Quo • Contemplation • Changes in orientation • Preparation Self Efficacy
• Precontemplation
• Compliant Status Quo
• Contemplation
• Changes in orientation
• Preparation
Self Efficacy
&
• Planning for change
• Organizational and environmental
readiness
Decisional Balance
• Action
• Training

Driven at each stage by:

Maintenance

Monitoring/Institutionalization

Components of Implementation

Components of Implementation • Select a Solution that Fits a Problem • Prepare the internal and

• Select a Solution that Fits a Problem

• Prepare the internal and external environment

Supervision and Leadership Buy-in

• Acquire knowledge and skills

• Use practice with support, supervision and

consultation

• Adapt practice to environment

• Monitor fidelity

• Teach others

• Institutionalize Practice

Practice Selection

Attributes that can facilitate adoption

• Relative Advantage­ clear, unambiguous advantage in either effectiveness or cost effectiveness • Costs­ training/materials/on­going consultation­loss
Relative Advantage­ clear, unambiguous advantage in either
effectiveness or cost effectiveness
Costs­ training/materials/on­going consultation­loss productivity
during start up­ costs of delivery
Compatibility­How compatible is the practice with the organizational
and workforce’s values, norms, and clinical traditions and orientation
Complexity –perceived as more simple to use and to implement
Trialability­ able to experiment with in a limited basis
Observability of Benefits –outcomes or interim results/measures
Reinvention­ if can adapt, refine or otherwise modify it to meet own
needs
Risk­ if there is higher certainty of outcomes
Task Issues­ If relevant to performance of intended users work and
improved task performance
Knowledge­ if knowledge can be codified and transferred from one

context to another

Augmentation/Support­ if provided with training/consultation

From Greenhalgh et al

Organizational Readiness

• Organizational Culture/Traditions/History • Leadership • Supervision • Capacity to evaluate change­Know if it is working
Organizational Culture/Traditions/History
Leadership
Supervision
Capacity to evaluate change­Know if it is working
Support of Opinion Leaders
Connections with other supportive organizations/individuals
Does organization have the technology to support the change
Staff readiness

Staff Readiness

Staff Directly and Indirectly involved • Understand What Benefits Will the Adoption of the EBP Bring
Staff Directly and Indirectly involved
Understand What Benefits Will the Adoption of the EBP Bring
Meaning­What does the change mean to the staff?
What concerns will staff have about adoption
How congruent are the trainers in orientation and values with the
staff
Presence of Champions

Readiness of External Environment

• Congruence with Community/Cultural/Family Values • Referral Source Understanding and Support • Funding Source Support •
Congruence with Community/Cultural/Family Values
Referral Source Understanding and Support
Funding Source Support
Political Support
Role of Social Influence/Demand for Services
– Role Social Movement Theory

Supportive Implementation Model

Administrative Administrative Leadership Leadership and and Support Support for for EBT EBT Obtain Obtain Supervision Supervision
Administrative
Administrative Leadership
Leadership and
and Support
Support for
for EBT
EBT
Obtain
Obtain
Supervision
Supervision
client
client
feedback
feedback
Expert
Expert
Consultation
Consultation
Use
Use EST
EST with
with
Therapist
Therapist
appropriate
appropriate
clients
clients
Training
Training
Materials
Materials
Technical
Technical Assistance
Assistance

Community/Consumer Support

Community/Consumer

Support for

for EBT

EBT

Finding Evidence Supported Treatments on the Web

• • • www.nctsn.org www.cachildwelfareclearinghouse.org/ http://modelprograms.samhsa.gov/template.cfm? CFID=119292&CFTOKEN=55491051 • www.strengtheningfamilies.org/ • www.ncptsd.va.gov/topics/treatment.html • www.childtrends.org • www.wsipp.wa.gov •
www.nctsn.org
www.cachildwelfareclearinghouse.org/
http://modelprograms.samhsa.gov/template.cfm?
CFID=119292&CFTOKEN=55491051
www.strengtheningfamilies.org/
www.ncptsd.va.gov/topics/treatment.html
www.childtrends.org
www.wsipp.wa.gov
http://ebmh.bmjjournals.com/
www.cochrane.org
www.campbellcollaboration.org
www.colorado.edu/cspv/blueprints/model/overview.html

Contact Information

Download reports from: www.chadwickcenter.org www.chadwickcenter.org E-mail: cwilson@rchsd.org cwilson@rchsd.org
Download reports from:
www.chadwickcenter.org
www.chadwickcenter.org
E-mail:
cwilson@rchsd.org
cwilson@rchsd.org