To the Editor: The findings reported by Garland and colleagues (1) in the August 2010 issue advance our understanding of quality of care in children's mental health services by characterizing usual care for children with disruptive behavior problems in a public service system. In many cases, quality of care is assessed by determining whether service delivery is concordant with broad-sweeping evidence-based guidelines (2,3). Though this work is undoubtedly important, Garland and colleagues add value and nuance to the discussion of quality through their direct observation of the strategies and techniques that therapists employ to treat children and families.

Their analysis of 1,215 videotaped therapy sessions revealed that therapists use a wide range of therapeutic strategies, some of which are consistent with components of evidence-based treatments. However, the evidence-based components most frequently used were deployed at low levels of intensity, which would not be consistent with evidence-based treatment protocols. This is a sobering picture of the quality of mental health care for these vulnerable children and families, perhaps even more so when we consider that the sequencing of therapeutic strategies was not considered in this study. Indeed, the sequencing of therapeutic techniques may be critical to the effectiveness of evidence-based treatments. For example, in parent-child interaction therapy, it is important to enhance the parent-child relationship before the treatment shifts to teaching and rehearsing the principles and techniques of effective discipline (4). Although it was beyond the scope of this study to examine the sequencing of techniques and the decision-making processes of therapists, it is alarming that the mental health practitioners were not using “tried and true” techniques and more directive approaches in treating disruptive behavior problems. Frankly, children and families deserve better.

Garland and colleagues remind us of how critical it is to have a thorough understanding of systems of care before we attempt to change them and that despite the underutilization of evidence-based treatment approaches in usual care, there are also many strengths on which to build. As the empirical literature continues to highlight the research-practice gap, attention has shifted to developing the science of implementation. Given the exigencies of usual care settings and the barriers to evidence-based practice that seem so pervasive, it is imperative that we develop “empirically-supported strategies to integrate scientific knowledge and effective interventions into everyday use” (5). This requires that we carefully assess the state of usual care, including the potential barriers and facilitators to change, before attempting to design and test strategies to move evidence-based treatments (or treatment components) into real-world service systems.

I applaud Psychiatric Services for publishing rigorously conducted studies of quality of care, such as the report by Garland and colleagues, that set the foundation for implementation research in mental health and have the potential to facilitate the transformation of a system of care in dire need of change.