Change Trajectories for the Youth Outcome Questionnaire Self-Report: Identifying Youth at Risk for Treatment Failure

Prediction of adolescent psychotherapy outcomes using youth- and caregiver-reported symptoms data

OBJECTIVE

We used longitudinal youth- and caregiver-reports of adolescent psychological symptoms from three samples of youth receiving mental health services in routine treatment settings to derive expected change trajectories and identify cases at risk for treatment failure.

METHOD

Participants were 1906 youth (1053 caregivers) receiving treatment in community mental health settings, merged across three samples. The Symptoms and Functioning Severity Scale (SFSS) was used as an indicator of weekly clinical change. Multilevel modeling methods were used to develop expected change trajectories and identify cases at risk for treatment failure (not on track; NOT). Logistic regression was used to predict client improvement as a function of NOT status.

RESULTS

The SFSS was a reliable indicator of therapeutic change according to youth-reported symptoms. Caregiver reports were not as robust. Whereas predictive accuracy of NOT status yielded moderately high sensitivity in detecting improvement according to youth report, caregiver reports were not as predictive.

CONCLUSIONS

The youth-reported version of the SFSS-based algorithm seems appropriate for implementation in clinical care. Future studies should search for similarly predictive measures for caregivers.

Consultation as an Implementation Strategy to Increase Fidelity of Measurement-Based Care Delivery in Community Mental Health Settings: An Observational Study

Regularly administering outcome measures to clients to inform clinical decision making, referred to as measurement-based care (MBC), has the potential to improve mental health treatment due to its applicability across disorders and treatment settings. Given the utility of MBC, understanding predictors of high-fidelity MBC implementation is important. Training and consultation are widely used implementation strategies to increase the fidelity of evidence-based practice delivery but have rarely been studied with MBC. The current study will examine the relationship between time clinicians spent discussing a case in consultation ("dosage") and MBC fidelity. Thirty clinicians and 56 youth were in the MBC condition of a randomized controlled trial and completed baseline questionnaires. Consultation dosage was extracted from call notes. MBC fidelity was measured using the implementation index, which combines rates of administering and viewing questionnaires, using objective data from the online MBC system. Multi-level modeling was used. Greater consultation dosage significantly predicted a higher implementation index (ß = 0.27, SE = 0.06, p < .001). For every 30 min spent discussing a case in consultation, the case's MBC fidelity increased by 8.1%. Greater consultation dosage significantly predicted higher rates of administration (ß = 0.07, SE = 0.03, p = 0.033) and feedback report viewing (ß = 0.24, SE = 0.06, p < .001). More consultation at the case level predicts greater MBC fidelity using objective measures. The greatest impact was increasing the clinician feedback report viewing rate. The results of this study can help inform future efforts to increase the fidelity with which MBC is delivered and to make consultation as efficient and effective as possible.

A Structural Model of Organization and Clinician Factors Associated with Standardized Measure Use in a National Survey of Youth Mental Health Providers

Standardized assessment measures are important for accurate diagnosis of mental health problems and for treatment planning and evaluation. However, little is known about youth mental health providers' typical use of standardized measures across disciplines and outside the context of evidence-based practice initiatives. A multidisciplinary national survey examined the frequency with which 674 youth mental health providers administer standardized and unstandardized measures, and the extent to which organizational (i.e., implementation climate, rigid hierarchical organizational structure) and provider (i.e., attitudes toward standardized assessment measures, highest degree, practice setting) characteristics are associated with standardized measure use. Providers used unstandardized measures far more frequently than standardized measures. Providers' perceptions (a) that standardized measures are practical or feasible, (b) that their organization supports and values evidence-based practices, and (c) that their organization has a rigid hierarchical structure predicted greater use of standardized measures. Working in schools predicted less frequent SMU, while working in higher education and other professional settings predicted more frequent SMU. Standardized measures were not routinely used in this community-based sample. A rigid hierarchical organizational structure may be conducive to more frequent administration of standardized measures, but it is unclear whether such providers actually utilize these measures for clinical decision-making. Alternative strategies to promote standardized measure use may include promoting organizational cultures that value empirical data and encouraging use of standardized measures and training providers to use pragmatic standardized measures for clinical decision making.

Overview of Ten Child Mental Health Clinical Outcome Measures: Testing of Psychometric Properties with Diverse Client Populations in the U.S

While many standardized assessment measures exist to track child mental health treatment outcomes, the degree to which such tools have been adequately tested for reliability and validity across race, ethnicity, and class is uneven. This paper examines the corpus of published tests of psychometric properties for the ten standardized measures used in U.S. child outpatient care, with focus on breadth of testing across these domains. Our goal is to assist care providers, researchers, and legislators in understanding how cultural mismatch impacts measurement accuracy and how to select tools appropriate to the characteristics of their client populations. We also highlight avenues of needed research for measures that are in common use. The list of measures was compiled from (1) U.S. state Department of Mental Health websites; (2) a survey of California county behavioral health agency directors; and (3) exploratory literature scans of published research. Ten measures met inclusion criteria; for each one a systematic review of psychometrics literature was conducted. Diversity of participant research samples was examined as well as differences in reliability and validity by gender, race or ethnicity, and socio-economic class. All measures showed adequate reliability and validity, however half lacked diverse testing across all three domains and all lacked testing with Asian American/Pacific Islander and Native American children. ASEBA, PSC, and SDQ had the broadest testing.

A routine outcome measure for youth mental health: Clinically interpreting MyLifeTracker

AIM

MyLifeTracker is a session-by-session mental health outcome measure for young people aged 12 to 25 years. The aim of this study was to determine clinically significant change indexes for this measure that would identify developmentally appropriate thresholds. The study also aimed to determine expected change trajectories to enable clinicians to compare a client's progress against average rates of change.

METHODS

Participants comprised young people aged 12 to 25 years from both a clinical and a community sample from Australia. The clinical sample was 63 840 young people that attended a headspace centre. The non-clinical group was an Australian representative community sample of 4034 young people.

RESULTS

Clinically significant change indexes were developed for MyLifeTracker specific for age and gender groups by comparing clinical and non-clinical samples. Males and young people aged 12 to 14 years needed to reach higher scores to achieve clinically significant change compared to females and other age groups, respectively. MyLifeTracker expected change trajectories followed a cubic pattern for those with lower baseline scores of 0 to 50, whereas those with baseline scores of 51 and above had varying patterns. For those with lower baseline scores, expected change trajectories showed that stronger change was evident early in treatment, which then tapered off before accelerating again later in treatment.

CONCLUSIONS

The development of MyLifeTracker benchmarks allows the measure to be used for Feedback Informed Treatment by supporting treatment planning and decision-making. This information can help clinicians to identify clients who are not on track or deteriorating and identify when clients are improving.

A systematic review of patient-reported outcome measurement (PROM) and provider assessment in mental health: goals, implementation, setting, measurement characteristics and barriers

PURPOSE

To review and integrate the literature on mental-health-related patient-reported outcome measures (PROMs) and routine outcome measures (ROMs), namely in the domains of goals, characteristics, implementation, settings, measurements and barriers. PROM/ROM aims mainly to ascertain treatment impact in routine clinical practice through systematic service users' health assessment using standardized self-report, caretaker and/or provider assessment.

DATA SOURCES

Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science's Direct.

STUDY SELECTION

Systemized review of literature (2000-2018) on implementation and sustainability of PROMs/ROMs in adult mental health settings (MHS).

DATA EXTRACTION AND SYNTHESIS

Systemized review of literature (2000-2018) on numerous aspects of PROM/ROM implementation and sustainability in adult MHS worldwide.

RESULTS

Based on 103 articles, PROMs/ROMs were implemented mostly in outpatient settings for people with assorted mental health disorders receiving a diversity of services. Frequency of assessments and completion rates varied: one-third of projects had provider assessments; about half had both provider and self-assessments. Barriers to implementation: perceptions that PROM/ROM is intrusive to clinical practice, lack of infrastructure, fear that results may be used for cost containment and service eligibility instead of service quality improvement, difficulties with measures, ethical and confidentiality regulations and web security data management regulations.

CONCLUSION

Improving data input systems, sufficient training, regular feedback, measures to increase administrative and logistic support to improve implementation, acceptability, feasibility and sustainability, follow-up assessments and client attrition rate reduction efforts are only some measures needed to enhance PROM/ROM efficiency and efficacy.

Factors affecting the implementation of an outcome measurement feedback system in youth mental health settings

Objective: Measurement feedback systems provide clinicians with regular snapshots of a client's mental health status, which can be used in treatment planning and client feedback. There are numerous barriers to clinicians using outcome measures routinely. This study aimed to investigate factors affecting the use of a measurement feedback system across youth mental health settings. Methods: The participants were 210 clinicians from headspace youth mental health services across Australia. They were surveyed on predictors and use of MyLifeTracker, a routine outcome measure. This was explored through three processes: looking at MyLifeTracker before session, using MyLifeTracker in treatment planning, and providing feedback of MyLifeTracker scores to clients. Results: Clinicians were more likely to look at MyLifeTracker before session, less likely to use it in treatment planning, and least likely to provide MyLifeTracker scores to clients. Each measurement feedback system process had a distinct group of predictors. Perceptions of MyLifeTracker's practicality was the only significant predictor of all three processes. Conclusion: Practically, organisations and supervisors can increase the use of measurement feedback systems through targeted supports.

Clinical Demonstration of the Potential of Parental Feedback in Reducing Deterioration During Group Psychotherapy With Children

In recent years, great efforts have been exerted to minimize the rates of deterioration in clinical practice, especially in child psychotherapy. The present study explored the potential effect of routine outcome monitoring (ROM) with parents as a preventive intervention to reduce deterioration in children. Twenty-five children receiving treatment for emotional problems were randomized to parent-based, ROM-assisted group psychotherapy or to treatment as usual (TAU). A mixed-methods approach was utilized, with the number of deteriorating cases compared at the group level and two case illustrations assessed at the individual level. At the group level, there were fewer cases of deterioration in child's anxiety, parental stress, and quality of parent's alliance in the ROM-assisted group, compared with TAU. Case studies illustrated how ROM can be used as a tool to communicate with parents to prevent deterioration. Routine outcome monitoring in child psychotherapy may thus benefit therapy process and outcome. Limitations and directions for future research are discussed.

Introducing a Measurement Feedback System for Youth Mental Health: Predictors and Impact of Implementation in a Community Agency

Measurement feedback systems (MFSs) that routinely collect and report client progress to mental health therapists have demonstrated beneficial impact on outcomes in numerous studies, with evidence that there is a dose-response relationship related to the implementation of the MFS. The current study examined the impact of MFS implementation (Implementation Index) on youth symptom outcomes separately by caregiver and youth self-report. Additionally, we tested the extent to which Implementation Index rates varied by individual therapists and clients, and whether therapist and client characteristics predicted MFS implementation. Methods: Administrative data (client charts, youth- and caregiver-reported Youth Outcome Questionnaires) for 229 youth (52.83% Latinx, 42.79% girls, M age = 10.33) treated during a 1-year period at a community mental health organization in Central Texas were analyzed using multi-level modeling. Caregiver-reported symptoms decreased faster for those with a higher MFS Implementation Index. Between-group differences among therapists accounted for a significant proportion of variance in the Implementation Index for caregiver report, whereas client differences accounted for most of the variance in the Implementation Index for youth self-report. Therapist trainee status predicted a significant increase in the Implementation Index for caregiver-report data. Youth symptom improvement as reported by caregivers varied with the extent of MFS implementation fidelity, and MFS implementation fidelity was higher for clients treated by trainees relative to staff therapists for caregiver report of symptoms.

Measurement-based care as a practice improvement tool: Clinical and organizational applications in youth mental health

Measurement-based care (MBC) is systematic, ongoing assessment to monitor treatment progress and inform clinical decision-making. MBC is considered an evidence-based practice, with extensive research support in adult clinical populations and emerging evidence in youth populations. This paper describes both clinical (e.g., enhancing therapy alliance, informing case conceptualization) and organizational (e.g., informing quality improvement efforts) applications of MBC, and illustrates the clinical applications through two case examples from publicly-funded mental health agency settings. The paper concludes by detailing future research needed to enhance the clinical and organizational utility of MBC.

Systematic Review and Meta-analysis: Outcomes of Routine Specialist Mental Health Care for Young People With Depression and/or Anxiety

OBJECTIVE

Depression and anxiety are the most prevalent mental health problems in youth, yet almost nothing is known about what outcomes are to be expected at the individual level following routine treatment. This paper sets out to address this gap by undertaking a systematic review of outcomes following treatment as usual (TAU) with a particular focus on individual-level outcomes.

METHOD

MEDLINE, Embase and PsycInfo were searched for articles published between 1980 and January 2019 that assessed TAU outcomes for youth depression and anxiety accessing specialist mental health care. Meta-analysis considered change at both group-level pre-post effect size (ES) and individual-level recovery, reliable change, and reliable recovery. Temporal analysis considered stability of primary and secondary outcomes over time. Subgroup analysis considered the moderating effect of informant; presenting problem; study design; study year; mean age of youth; use of medication; intervention dosage and type of treatment offered on outcomes. A protocol was preregistered on PROSPERO (CRD42017063914).

RESULTS

Initial screening of 6,350 publications resulted in 38 that met the inclusion criteria, and that were subsequently included in meta-analyses. This resulted in a final full pooled sample of 11,739 young people (61% of whom were female, mean age 13.8 years). The pre-post ES (Hedges' g) at first/final outcome (13/26 weeks) was -0.74/-0.87. The individual-level change on measures of self-report was 38% reliable improvement, 44% no reliable change, and 6% reliable deterioration. Outcomes varied according to moderators, informant, problem type and dosage.

CONCLUSION

Poor data quantity and quality are limitations, but this is the first study that indicates likely rates of reliable improvement for those accessing TAU. We propose the need for improved reporting of both individual-level metrics and details of TAU to enable greater understanding of likely current outcomes from routine care for youths with depression and anxiety in order to allow the potential for further improvement of impact.

Trajectories of change of youth depressive symptoms in routine care: shape, predictors, and service-use implications

Depression is one of the main reasons for youth accessing mental health services, yet we know little about how symptoms change once youth are in routine care. This study used multilevel modeling to examine the average trajectory of change and the factors associated with change in depressive symptoms in a large sample of youth seen in routine mental health care services in England. Participants were 2336 youth aged 8-18 (mean age 14.52; 77% females; 88% white ethnic background) who tracked depressive symptoms over a period of up to 32 weeks while in contact with mental health services. Explanatory variables were age, gender, whether the case was closed, total length of contact with services, and baseline severity in depression scores. Faster rates of improvement were found in older adolescents, males, those with shorter time in contact with services, closed cases, and those with more severe symptoms at baseline. This study demonstrates that when youth self-report their depressive symptoms during psychotherapy, symptoms decrease in a linear trajectory. Attention should be paid to younger people, females, and those with lower than average baseline scores, as their symptoms decrease at a slower pace compared to others.

Does feedback improve psychotherapy outcomes compared to treatment-as-usual for adults and youth?

Objective: Client-informed outcome feedback has consistently been shown to enhance psychotherapy outcomes for adults, particularly for clients at risk of treatment failure. However, there is a paucity of studies examining feedback in youth psychotherapy. Specifically, there is no research examining the feedback effect of the Youth-Outcome Questionnaire [Burlingame, G. M., Wells, M. G., & Lambert, M. J. (1996). The youth outcome questionnaire. Stevenson, MD: American Professional Credentialing Services.], despite the dominance of the adult version of the measure (Outcome Questionnaire-45 [Lambert, M. J., & Burlingame, G. M. (1996). Outcome questionnaire 45.2. Wilmington, DE: American Professional Credentialing Services.]) in adult feedback studies. Method: The effectiveness results for adult (N = 398) and youth clients (N = 397) attending psychotherapy at two psychology training clinics are presented and benchmarked against treatment-as-usual (for adults and youth) and feedback (for adults). Results: Psychotherapy with a feedback-informed approach was more effective than treatment-as-usual benchmarks, with 50% of adults and 64% of youth significantly improving after psychotherapy. Rates of adult improvement were similar to feedback-informed benchmarks, although the current sample had a higher rate of deterioration. There are no previously identified feedback-informed benchmarks for the Y-OQ, making this sample the first benchmark for future studies. Conclusions: Results support the benefits of feedback at enhancing psychotherapy outcomes for adults, and replicate this finding in a youth sample. Results also replicate that trainee psychotherapists can be as effective as licenced psychotherapists.

Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET): A comparative effectiveness trial of a transdiagnostic treatment and a measurement feedback system

Emotional disorders, encompassing a range of anxiety and depressive disorders, are the most prevalent and comorbid psychiatric disorders in adolescence. Unfortunately, evidence-based psychosocial therapies typically focus on single disorders, are rarely adopted by community mental health center clinicians, and effect sizes are modest. This article describes the protocol for a comparative effectiveness study of two novel interventions designed to address these challenges. The first intervention is a transdiagnostic treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A), a promising new approach that uses a small number of common strategies to treat a broad range of emotional disorders, and their underlying shared emotional vulnerabilities. The second intervention is a standardized measurement feedback system, the Youth Outcomes Questionnaire (YOQ), designed to improve clinical decision making using weekly symptom and relational data. The three study arms are treatment as usual (TAU), TAU plus the YOQ (TAU+), and UP-A (used in combination with the YOQ). The primary aims of the study are to [1] compare the effects of the UP-A and TAU+ to TAU in community mental health clinics, [2] to isolate the effects of measurement and feedback by comparing the UP-A and TAU+ condition, and [3] to examine the mechanisms of action of both interventions. Design considerations and study methods are provided to inform future effectiveness research.

Parent-youth informant disagreement: Implications for youth anxiety treatment

Greater parent-youth disagreement on youth symptomatology is associated with a host of factors (e.g., parental psychopathology, family functioning) that might impede treatment. Parent-youth disagreement may represent an indicator of treatment prognosis. Using data from the Child/Adolescent Anxiety Multimodal Study, this study used polynomial regression and longitudinal growth modeling to examine whether parent-youth agreement prior to and throughout treatment predicted treatment outcomes (anxiety severity, youth functioning, responder status, and diagnostic remission, rated by an independent evaluator). When parents reported more symptoms than youth prior to treatment, youth were less likely to be diagnosis-free post-treatment; this was only true if the youth received cognitive-behavioral therapy (CBT) alone, not if youth received medication, combination, or placebo treatment. Increasing concordance between parents and youth over the course of treatment was associated with better treatment outcomes across all outcome measures ( ps < .001). How parents and youth "co-report" appears to be an indicator of CBT outcome. Clinical implications and future directions are discussed.

Advancing the Scientific Foundation for Evidence-Based Practice in Clinical Child and Adolescent Psychology

Evidence-based practice (EBP) has become a central focus in clinical child and adolescent psychology. As originally defined, EBP in psychology is the integration of the best available research evidence, patient characteristics, and clinical expertise. Although evidence-based perspectives have garnered widespread acceptance in recent years, there has also been some confusion and disagreement about the 3-part definition of EBP, particularly the role of research. In this article, we first provide a brief review of the development of EBP in clinical child and adolescent psychology. Next, we outline the following 4 points to help clarify the understanding of EBP: (a) knowledge should not be confused with epistemic processes, (b) research on clinician and client factors is needed for EBP, (c) research on assessment is needed for EBP, and (d) the 3-part conceptualization of EBP can serve as a useful framework to guide research. Based on these principles, we put forth a slightly revised conceptualization of EBP, in which the role of research is expanded and more clearly operationalized. Finally, based on our review of the literature, we offer illustrative examples of specific directions for future research to advance the evidence base for EBP in clinical child and adolescent psychology.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

A systematic review of mental health outcome measures for young people aged 12 to 25 years

BACKGROUND

Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.

METHODS

MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.

RESULTS

A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.

CONCLUSIONS

With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.

Youth psychotherapy change trajectories and early warning system accuracy in a managed care setting

OBJECTIVES

To examine change trajectories in routine outpatient mental health services for children and adolescents in a managed care setting, and to use these trajectories to test the accuracy of two variations of an early warning system designed to identify cases at risk for deterioration.

METHOD

Multilevel modeling procedures were used to examine longitudinal Youth Outcome Questionnaire (YOQ) data for 16,091 youth aged 4-17 years (39% female, mean age 10.5) referred for treatment in a managed care system.

RESULTS

Clients with more frequent YOQ administrations had slightly lower baselines and faster rates of change. Both the traditional and simplified versions of the early warning system demonstrated good accuracy in identifying clients who deteriorated, with a sensitivity of .63, specificity of .83, and hit rate of .81.

CONCLUSIONS

Results provide further evidence that patient-focused early warning systems can accurately identify most youth who are at risk for negative outcomes in routine mental health services.

Trajectories of symptom reduction during treatment for behavior problems in pediatric primary-care settings

We examined trajectories of symptom reduction during the course of on-site treatment for behavior problems in pediatric primary-care settings for a subset of children from a larger clinical trial. Participants (N = 80) were children (ages 6-11) referred for treatment due to moderate elevations (≥75th percentile) on the externalizing subscale of the Pediatric Symptom Checklist (PSC-17). The sample was recruited from six pediatric practices in an urban setting. The treatment (Protocol for an Office-based Nurse-administered Intervention; PONI) was administered on-site by trained nurses over the course of 3-6 months. Overall, symptom reduction from the first session to last session was moderate (ES = 0.61) and gradual. Roughly two-thirds (72%) of symptom reduction took place over the first 8 weeks of treatment. The average trajectory of symptom reduction was characterized by a negative slope that flattened over time, consistent with a quadratic growth model. Initial symptom severity predicted final symptom severity (r = .36, P < .01), even though patients with greater initial symptom severity remained in treatment for a significantly greater number of sessions (r = .24, P < .05). The implications of these findings for enhancing the efficiency and effectiveness of treatment are discussed.

Predicting patient deterioration in youth mental health services: community mental health vs. managed care settings

OBJECTIVE

To examine differences across a community mental health system and a private managed care system in the accuracy of a warning system designed to identify youth at risk for deterioration in mental health services.

DESIGN

Longitudinal outcome data from the Youth Outcome Questionnaire (Y-OQ) were examined using multilevel modeling for 2,310 youth ages 4-17 who received outpatient treatment.

RESULTS

The warning system correctly identified 69% of cases that ultimately ended in deterioration in the community mental health setting, compared to 61% in the managed care setting. The overall hit rate (overall accuracy in classifying cases as deteriorators/non-deteriorators) was the same in the two settings (75%).

CONCLUSIONS

Results are consistent with previous research demonstrating that patient-focused warning systems can be reasonably accurate in identifying youth cases at risk for treatment failure.

Sensitivity to change of youth treatment outcome measures: a comparison of the CBCL, BASC-2, and Y-OQ

This study evaluated the relative sensitivity to change of the Child Behavior Checklist/6-18 (CBCL), the Behavior Assessment System for Children-2 (BASC-2), and the Youth Outcome Questionnaire 2.01 (Y-OQ). Participants were 134 parents and 44 adolescents receiving routine outpatient services in a community mental health system. Hierarchical linear modeling analyses were used to examine change trajectories for the 3 measures across 3 groups: parent informants, parent and adolescent dyads, and adolescent informants. Results indicated that for parent-report measures, the Y-OQ was most change sensitive; the BASC-2 and CBCL were not statistically different from each other. Significant differences in change sensitivity were not observed for youth self-report of symptoms. Results suggest that the Y-OQ may be particularly useful for evaluating change in overall psychosocial functioning in children and adolescents.