Power Imbalances Undermine Evidence-Based Programs for Young People, Review Finds

When a therapy program proven to work in clinical trials fails to help children in the real world, the reason is often not the program itself but the people and structures charged with delivering it. A new systematic review published in the Journal of Child and Family Studies argues that leadership is one of the most decisive, and most frequently mishandled, ingredients in whether evidence-based interventions actually reach the young people they are designed to serve. The review, conducted by Charlotte Rose and Joel Harvey of Royal Holloway, University of London, synthesised 24 qualitative studies and found that the single most corrosive force undermining implementation was not a lack of funding or training, but the misuse of power within organisations.

The researchers set out to answer a deceptively simple question: which leadership components act as barriers or facilitators when evidence-based interventions are rolled out in services for children and adolescents? The distinction between efficacy and effectiveness sits at the heart of this question. An intervention may be efficacious, meaning it produces the intended outcomes under controlled research conditions, yet fail to be effective, meaning those outcomes are not achieved when frontline staff deliver it in routine services with real-world resource constraints and competing demands. Implementation science exists precisely to close that gap, and more than 60 frameworks have been developed to guide the process. Most converge on a small set of recurring domains, including intervention characteristics, the outer system context, the inner organisational context, individual provider characteristics, and the implementation process itself. Where frameworks diverge is in how they treat leadership: some position it as one factor among many within the organisational context, while others treat it as a cross-cutting mechanism that shapes multiple domains simultaneously.

Implementation leadership theory proposes that first-level leaders, the supervisors and managers with direct day-to-day oversight of frontline staff, shape what researchers call the implementation climate: the shared staff perceptions of what is expected, supported, and rewarded in relation to evidence-based practice. That climate, in turn, drives clinicians’ actual use of the intervention. Because first-level leaders sit closest to service delivery, they have been identified as key levers for improving the adoption, utilisation, and sustainment of evidence-based practice. Yet previous systematic reviews had concentrated almost exclusively on social care settings, leaving open whether the same leadership processes operate across the full range of contexts in which children receive interventions, from schools and community mental health clinics to residential units and child welfare agencies.

Child and adolescent services are structurally more complex than many adult-facing services in ways that plausibly change what leadership must do. Delivery typically involves multiple family members alongside the young person, meaning leaders must sustain buy-in across a wider and less stable set of stakeholders. Young people are frequently supported across several services simultaneously, including health, education, social care, and the justice system, requiring leaders to coordinate communication across organisational boundaries with different priorities, funding structures, and accountabilities. These services also often operate under statutory time limits, safeguarding obligations, and policy scrutiny that constrain the pace and manner in which change can be introduced.

To capture this complexity, Rose and Harvey conducted a systematic review in accordance with Cochrane guidelines and the PRISMA reporting standards, with the protocol registered on PROSPERO. They searched Scopus, PsycINFO, and Web of Science, complemented by hand-searching reference lists and grey literature, with no restrictions on publication date or geographic origin. Eligible studies had to be empirical, peer-reviewed, qualitative in design, and had to explicitly name the implemented intervention, which had to focus on mental health. Studies also had to investigate leadership directly or identify it as a major or subtheme. From 4,098 initial citations, 24 studies met the full criteria, published between 2014 and 2023 and encompassing 575 participants ranging from frontline practitioners and supervisors to organisational leaders and stakeholders. Seventeen studies were conducted in the United States, with the remainder from the United Kingdom, Canada, Norway, Australia, and Belgium, and settings spanned social care, education, community mental health, and inpatient and residential care.

The interventions under study were diverse, including SafeCare, the Strengthening Families Program, Parent Management Training Oregon Model, The Incredible Years Teacher Classroom Management Programme, Multisystemic Therapy, Trauma-Focused Cognitive-Behavioural Therapy, the Positive Parenting Program, the Olweus Bullying Prevention Program, and mindfulness-based approaches, among others. Methodological quality was assessed using the Critical Appraisal Skills Programme checklist, with all but one study rated as high or moderate quality, and interrater reliability reaching almost perfect agreement during screening. The synthesis itself followed Thomas and Harden’s three-step thematic synthesis: line-by-line coding, developing descriptive themes, and developing analytic themes.

The analysis produced one overarching theme, two themes, and six subthemes. The overarching theme, power imbalances, cut across everything else. A top-down approach, characterised by decisions made without consulting frontline staff, led to relationship breakdowns, inadequate implementation preparation, reduced engagement, and an absence of collaboration. The dynamic was compounded where oversight mechanisms intended to support fidelity instead reinforced a sense of surveillance and diminished autonomy. One caseworker described feeling unable to raise concerns about an intervention because doing so would be reported to senior leadership, admitting that ultimately, in their words, you do not want that because you want to keep your job. Power imbalances were thus sustained not only through exclusion from decision-making but through frontline staff’s fear of consequences for voicing disagreement. Conversely, involving individuals at all implementation levels fostered a sense of ownership and demonstrated the value of their contributions.

The first of the two main themes, developing a core purpose, captured the leadership tasks salient during the early adoption phase. It comprised creating a shared vision, obtaining staff buy-in, and demonstrating commitment to the intervention. Leaders who brought together staff from multiple levels and agencies, aligning the intervention’s vision with staff values and motivations, promoted engagement and commitment to change. Buy-in proved to be a recurring rather than one-off task: staff turnover meant leaders had to continuously re-engage successive cohorts, which in turn necessitated strategic recruitment practices such as screening for implementation willingness. Leaders who genuinely believed in an intervention’s effectiveness and appropriateness were more inclined to allocate resources and address staff needs, while disinterest and ambivalence at the top hindered support. Notably, in twelve studies, leaders’ physical presence, attending meetings, sending reminders, observing staff, and participating in training, reinforced commitment and priority, with staff describing leaders who were not just sitting in their offices but experiencing the work first-hand.

The second theme, maintaining implementation, reflected leadership tasks sustained throughout delivery and comprised effective communication, a collaborative approach, and holistic support. Clear communication structures prevented challenges from escalating, while their absence left staff feeling out of the loop and contributed to relationship breakdowns. Employing multiple communication methods, enabling staff to ask questions, sharing successes and concerns, and recognising staff efforts all enhanced engagement. Collaboration within leadership teams and with external agencies provided resources, knowledge, and expertise, and supported implementation even amid high staff turnover, with one participant noting that the show did not stop because one person did not show up. Yet collaboration was also described as complex, complicated by differing values and objectives between private and public services. Holistic support encompassed both instrumental support, such as supervision, training, and manageable workloads, and emotional support, including empathy and responsiveness to feedback, which together fostered motivation and reduced conflict.

The authors situate these findings within transformational leadership theory, mapping the identified components onto its classic dimensions: idealised influence through leaders’ commitment to the intervention, inspirational motivation through creating a shared vision, intellectual stimulation through vision-building, and individualised consideration through holistic support and communication. They also introduce resilience as an interpretive lens, suggesting that evidence-informed frameworks such as the Organizational Resiliency Model, developed in physical health and child protection contexts, could be applied in educational and mental health settings. The review is not without limitations: all included studies originated from high-income countries, restricting generalisability, and the breadth of sectors covered means setting-specific leadership components may have been obscured. The authors also note a striking absence of research on the psychological and interpersonal dimensions of leadership, particularly how interpersonal dynamics within collaboration shape implementation. Their conclusion is a call to action: organisations should not expect leadership skills to develop naturally but must actively upskill leaders through implementation models, ongoing training, and policy adjustments, because when leadership works, the ultimate beneficiaries are children, adolescents, and their families.

Subject of Research: The role of leadership in implementing evidence-based interventions in child and adolescent services

Article Title: Leadership in the Implementation of Evidence-Based Interventions in Child and Adolescent Services: A Systematic Review

Article References: Rose, C., & Harvey, J. (2026). Leadership in the Implementation of Evidence-Based Interventions in Child and Adolescent Services: A Systematic Review. Journal of Child and Family Studies. https://doi.org/10.1007/s10826-026-03378-y

Image Credits: AI Generated

DOI: 10.1007/s10826-026-03378-y

Keywords: leadership, implementation science, evidence-based interventions, child and adolescent mental health, systematic review, power imbalances, transformational leadership, staff buy-in, organisational climate, collaboration, qualitative synthesis, child welfare