Dose effect in child psychotherapy: outcomes associated with negligible treatment

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents

OBJECTIVE

Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents.

METHODS

Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit.

RESULTS

A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001).

CONCLUSIONS

These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

The Potential Emergence of "Education as Mental Health Therapy" as a Feasible Form of Teacher-Delivered Child Mental Health Care in a Low and Middle Income Country: A Mixed Methods Pragmatic Pilot Study

Objective: We assessed task-shifting children's mental health care to teachers as a potential approach to improving access to child mental health care. Methods: In Darjeeling, India, we conducted a single-arm, mixed-methods feasibility study with 19 teachers and 36 children in five rural primary schools to determine whether teachers can deliver transdiagnostic mental health care to select children-in-need with fidelity to protocol, to assess which therapeutic options teachers chose to use within the protocol, and to evaluate for a potential signal of efficacy. Results: Participation rates for intervention activities were >80%. A majority of teachers met or exceeded quality benchmarks for all intervention activities. Teachers chose to deliver teacher-centric techniques, i.e., techniques that only teachers could deliver given their role in the child's life, 80% of the time. Children improved in mental health score percentiles on the Achenbach Teacher Report Form. Key facilitators included the flexibility to adapt intervention activities to their needs, while identified barriers included limited time for care delivery. Conclusion: Findings support the feasibility of task-shifting children's mental health care to classroom teachers in resource-limited schools. Fidelity to protocol appeared feasible, though the freedom to choose and adapt therapeutic techniques may also have enhanced feasibility. Surprisingly, teachers consistently chose to deliver teacher-centric therapeutic techniques that resulted in a potential signal of efficacy. This finding supports the potential emergence of "education as mental health therapy" (Ed-MH) as a new therapy modality. Continued investigation is required to test and refine strategies for involving teachers in the delivery of transdiagnostic mental health care.

Implementing Evidence-Based Treatments for Youth in Acute and Intensive Treatment Settings

Evidence-based treatments (EBTs) have been well studied in outpatient and research settings to address a myriad of mental health concerns. Research studies have found benefits and challenges when implementing these interventions. However, less is known about the implementation of EBTs in acute and intensive treatment settings such as inpatient psychiatric hospitalization (IPH) units, partial hospitalization programs (PHPs), or intensive outpatient programs (IOPs). As a result, the specific benefits and challenges of providing EBTs in these settings are less clear. For example, challenges of implementing EBTs in IPHs, PHPs, and IOPs can include working within a multi-disciplinary team setting and sustaining trained staff. The current article provides an overview of implementing EBTs in IPHs PHPs, and IOPs. Current PHP, IOP, and IPH models of implementing evidence-based interventions along with strategies for engaging stakeholders, program development and implementation, and measurement are reviewed. Further considerations for sustainability and practice consideration are also provided.

Trajectories of care for children and adolescents with psychosocial problems: a 3-year prospective cohort study

BACKGROUND

Care for children and adolescents with psychosocial problems is aimed at reducing problems. There may be a relationship between the intensity and duration of care provision and improvement of these outcomes, but evidence on this issue is lacking. We therefore examined the association between care trajectories based on duration and intensity of care for children, and the reduction in psychosocial problems after 3 years.

METHODS

We obtained a cohort of all children entering psychosocial care in one region (n = 1,378), the TAKECARE cohort, and followed it for 3 years, with five assessment rounds. Retention in the final round was 85.8%. Psychosocial problems were measured using the parent report of the Total Difficulty Score of the Strength and Difficulties Questionnaire (SDQ-TDS). We constructed trajectories for intensity of care using growth mixture modelling and assessed the association between duration and intensity of care trajectories and SDQ-TDS after 3 years.

RESULTS

After 3 months 60.6% of children and adolescents were receiving care, after 1 year 38.7% were receiving care and after 3 years 26.0%. Regarding intensity of care, three trajectories were found: one with minimal intensity during all 3 years, a second with initially medium intensity and strong reduction within 1 year, and a third with high intensity and a reduction after 1 year. Although the psychosocial problems of children and adolescents were reduced during the 3-year period, the rate of decline was relatively less marked for children and adolescents with longer care trajectories.

CONCLUSION

Overall, children and adolescents with psychosocial problems who received care had improved outcomes at follow-up. However, increased provision of care does not automatically lead to reduction of problems, and although overall psychosocial problems are reduced, a substantial subgroup has longer lasting problems.

Turning Back to Treatment: The Effect of Attendance and Symptom Outcomes on Subsequent Service Use

This study explored whether post-treatment symptom severity moderated the association between session attendance during an initial treatment episode and subsequent mental health service use. Data on attendance, symptom severity, and service use were gathered from an effectiveness trial testing a modular treatment for youth anxiety, depression, disruptive behavior, and traumatic stress. Multilevel logistic regression analyses showed a significant interaction between attendance and post-treatment symptom severity on subsequent service use, such that attendance significantly predicted subsequent service use when post-treatment symptom severity was in the normal range. Implications regarding the influence of treatment engagement on future help-seeking are discussed.

Predicting patterns of service utilization within children's mental health agencies

BACKGROUND

Some children with mental health (MH) problems have been found to receive ongoing care, either continuously or episodically. We sought to replicate patterns of MH service use over extended time periods, and test predictors of these patterns.

METHODS

Latent class analyses were applied to 4 years of visit data from five MH agencies and nearly 6000 children, 4- to 13-years-old at their first visit.

RESULTS

Five patterns of service use were identified, replicating previous findings. Overall, 14% of cases had two or more episodes of care and 23% were involved for more than 2 years. Most children (53%) were seen for just a few visits within a few months. Two patterns represented cases with two or more episodes of care spanning multiple years. In the two remaining patterns, children tended to have just one episode of care, but the number of sessions and length of involvement varied. Using discriminant function analyses, we were able to predict with just over 50% accuracy children's pattern of service use. Severe externalizing behaviors, high impairment, and high family burden predicted service use patterns with long durations of involvement and frequent visits.

CONCLUSIONS

Optimal treatment approaches for children seen for repeated episodes of care or for care lasting multiple years need to be developed. Children with the highest level of need (severe pathology, impairment, and burden) are probably best served by providing high intensity services at the start of care.

Defining Episodes of Care in Children's Mental Health Using Administrative Data

Criteria to define an episode of care in children's mental health services are needed. Various criteria were applied to 5 years of visit data from children 4-11 years (N = 5,206) at their first visit to 1 of 3 children's mental health agencies. A minimum of 3 visits with 180 days between episodes optimized agreement with other dates (e.g., telephone intake assessment) marking the start and end of an episode, and clinician-rated number of episodes. Grouping visits into episodes provides a clearer representation of how services are distributed over extended periods of time, facilitating research and enhancing accuracy in service planning.

Reducing risk for anxiety and depression in adolescents: Effects of a single-session intervention teaching that personality can change

Efforts to reduce youth mental health problems have advanced greatly but have not lowered overall rates of youth mental illness. Thus, a need exists for disseminable, mechanism-targeted approaches to reducing risk of youth psychopathology. Accordingly, we conducted a randomized-controlled trial testing whether a single-session intervention teaching growth personality mindsets (the belief that personality is malleable) reduced known risk factors for anxiety and depression in adolescents experiencing or at risk for internalizing problems (N = 96, ages 12-15). Compared to a supportive-therapy control, a 30-min computer-guided mindset intervention strengthened adolescents' perceived control; this improvement was associated with increases in growth mindsets. Further, electrodermal activity recovery slopes showed that youths receiving the mindset intervention recovered from a lab-based social stressor over three times as fast as control group youths. Improvements in growth mindsets and perceived control were linked with faster stress recovery. Results suggest a disseminable strategy for reducing internalizing problem risk among adolescents.

Does psychotherapy work with school-aged youth? A meta-analytic examination of moderator variables that influence therapeutic outcomes

The present study is a quantitative synthesis of the available literature to investigate the efficacy of psychotherapy for children's mental health outcomes. In particular, this study focuses on potential moderating variables-study design, treatment, client, and therapist characteristics-that may influence therapeutic outcomes for youth but have not been thoroughly accounted for in prior meta-analytic studies. An electronic search of relevant databases resulted in 190 unpublished and published studies that met criteria for inclusion in the analysis. Effect sizes differed by study design. Pre-post-test designs resulted in absolute magnitudes of treatment effects ranging from |-0.02| to |-0.76| while treatment versus control group comparison designs resulted in absolute magnitudes of treatment effects ranging from |-0.14| to |-2.39|. Changes in youth outcomes larger than 20% were found, irrespective of study design, for outcomes focused on psychosomatization (29% reduction), school attendance (25% increase), and stress (48% reduction). The magnitude of changes after psychotherapy ranged from 6% (externalizing problems) to 48% (stress). Several moderator variables significantly influenced psychotherapy treatment effect sizes, including frequency and length of treatment as well as treatment format. However, results did not support the superiority of a single type of intervention for most outcomes. Implications for therapy with school-aged youth and future research are discussed.

Searching for elements of evidence-based practices in children's usual care and examining their impact

Most of the knowledge generated to bridge the research-practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.

Gender differences in trauma treatment: do boys and girls respond to evidence-based interventions in the same way?

This article investigates gender differences in trauma symptoms from baseline to end of treatment (trauma-focused cognitive behavioral therapy or parent-child interaction therapy) in children ages 7-18 years. Multivariate analysis of covariance (MANCOVA) and trend analysis using analysis of covariance (ANCOVA) were conducted on baseline and end of treatment University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) total scores. Results suggest that female children start at higher reported total posttraumatic stress disorder rates than males, but both groups experience significant symptom reduction during the course of treatment. At posttreatment, girls are still reporting higher symptom levels on the UCLA PTSD-RI than boys, suggesting that their clinical presentation at discharge may differ despite significant treatment gains. A full factorial model including the interaction of dose and gender was not significant. Identification of these gender-specific response patterns are an important consideration in treatment and discharge planning for children who have been trauma-exposed and are presenting for treatment with post trauma exposure disturbances.

Therapist, Parent, and Youth Perspectives of Treatment Barriers to Family-Focused Community Outpatient Mental Health Services

This exploratory qualitative study describes treatment barriers to receiving family-focused child mental health services for youths with disruptive behavior problems from multiple perspectives. Data were collected during a series of focus groups and interviews, including: 4 therapist focus groups, 3 parent focus groups, and 10 youth semi-structured interviews. Therapist, parent, and youth stakeholder participants discussed perceived barriers to effective treatment, the problems with current child outpatient therapy, and desired changes (i.e., policy, intervention, etc.) to improve mental health services. Results indicate similar themes around treatment barriers and dissatisfaction with services within and across multiple stakeholder groups, including inadequate support and lack of family involvement; however, parents and therapists, in particular, identified different contributing factors to these barriers. Overall, stakeholders reported much frustration and dissatisfaction with current community-based outpatient child therapy services. Study findings can inform service provision, intervention development, and future research.

Improving community-based mental health care for children: translating knowledge into action

There is urgent need for improvement in community-based mental health care for children and families. Multiple studies have documented serious limitations in the effectiveness of "usual care." Fortunately, many empirically-supported strategies to improve care have been developed, and thus there is now a great deal of knowledge available to address this significant public health problem. The goal of this selective review is to highlight and synthesize that empirically-supported knowledge to stimulate and facilitate the needed translation of knowledge into action. The review provides a sound foundation for constructing improved services by consolidating descriptive data on the status quo in children's mental health care, as well as evidence for an array of promising strategies to improve (a) Service access and engagement; (b) Delivery of evidence-based practices; and (c) Outcome accountability. A multi-level framework is used to highlight recommended care improvement targets.

Are children improving? Results from outcome measurement in a large mental health system

Standardized outcome assessment was implemented in a large county mental health system. This study examines changes in children's emotional and behavioral problems after 6 months of treatment and identifies factors associated with treatment improvement. Results from 3,215 youth indicated that externalizing and internalizing problems significantly decreased from intake to 6 months and that ethnicity, gender, and age were associated with caregiver-reported changes in symptomatology. While there was improvement associated with entry into treatment, the magnitude of symptom reduction was small to medium and not associated with amount of care, providing only limited support for the impact of routine out-patient care.

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.

Clinician and Parent Perspectives on Parent and Family Contextual Factors that Impact Community Mental Health Services for Children with Behavior Problems

The present study employed qualitative methods to examine multiple stakeholder perspectives regarding the role of parent and family contextual factors on community child mental health treatment for children with behavior problems. Findings suggest agreement between clinicians and parents on the number, types and importance of parent and family factors in children's mental health services; however, stakeholders differed in reports of which factors were most salient. Specifically, clinicians endorsed most factors as being equally salient, while parents described a few salient factors, with parental stress and inadequate social support being the most frequently discussed. These qualitative data further elucidate the context of community services and have implications for evidence-based practice implementation and improving community care.

A brief intervention is sufficient for many adolescents seeking help from low threshold adolescent psychiatric services

Background

There has been a considerable increase in the need for psychiatric services for adolescents. Primary health care practitioners have a major role in detecting, screening and helping these adolescents. An intervention entitled SCREEN is described in this article. The SCREEN intervention was developed to help practitioners to detect and screen adolescent needs, to care for adolescents at the primary health care level and to facilitate the referral of adolescents to secondary care services in collaboration between primary and secondary health care. Secondly, the article presents the background and clinical characteristics of youths seeking help from the SCREEN services, and compares the background factors and clinical characteristics of those patients referred and not referred to secondary care services.

Methods

The SCREEN intervention consisted of 1 to 5 sessions, including assessment by a semi-structured anamnesis interview, the structured Global Assessment Scale, and by a structured priority rating scale, as well as a brief intervention for each adolescent's chosen problem. Parents took part in the assessment in 39% of cases involving girls and 50% involving boys. During 34 months, 2071 adolescents (69% females) entered the intervention and 70% completed it. The mean age was 17.1 years for boys and 17.3 years for girls.

Results

For 69% of adolescents, this was the first contact with psychiatric services. The most common reasons for seeking services were depressive symptoms (31%). Self-harming behaviour had occurred in 25% of girls and 16% of boys. The intervention was sufficient for 37% of those who completed it. Psychosocial functioning improved during the intervention. Factors associated with referral for further treatment were female gender, anxiety as the main complaint, previous psychiatric treatment, self-harming behaviour, a previous need for child welfare services, poor psychosocial functioning and a high score in the priority rating scale.

Conclusions

A brief intervention carried out by a team including professionals from both primary and secondary level services was sufficient for a considerable proportion of adolescents seeking help for their psychiatric problems. Referral practices and counselling in special level services can be standardized. In the future, it will be important to develop and assess psychiatric services for adolescents using randomised controlled trials.

The effectiveness of child and adolescent psychiatric treatments in a naturalistic outpatient setting

Data concerning the effectiveness of naturalistic treatments (treatment-as-usual) in child and adolescent psychiatric (CAP) services are scarce. The purpose of this prospective observational study was to examine the effectiveness of CAP treatments in a naturalistic outpatient setting. Three hundred six patients (attention-deficit/hyperactivity disorder, ADHD, n=94; conduct disorder, CD, n=57; anxiety disorder, AD, n=53; depressive disorder, DD, n=38; other diagnostic categories, n=64), from nine child and adolescent psychiatric practices in Germany, were evaluated. Treatment effects were compared between patients who received frequent treatment and patients who only participated in diagnostics and short interventions. Since randomization was not feasible, propensity score analysis methods were used. Regarding the total sample, no significant treatment effects were found. However, a subgroup analysis of the four most frequent disorders (ADHD, CD, AD, DD) showed small to moderate treatment effects in patients with ADHD and AD. In CD and DD subgroups, no significant treatment effects could be found. "Real-world" CAP outpatient treatment seems to produce significant effects for ADHD and AD, but not for CD and DD. Compared to efficacy studies, our results show that naturalistic treatment might be better than expected.

Factors associated with use of evidence-based practice strategies in usual care youth psychotherapy

The purpose of this study was to gain an understanding of how therapists providing usual care (UC) psychotherapy are using elements of treatment common to evidence-based practices (EBPs) for children with disruptive behavior disorders (DBPs) and to identify client and therapist characteristics that may be associated with EBP strategies directed toward children and those directed to their caregivers. Results indicate that certain child, family, and therapist characteristics are associated with use of EBP strategies; however, much of the variability in practice was not explained by the variables examined. These findings highlight the complexity of UC psychotherapy and provide directions for future research on implementation of EBPs in UC.

Prevention of depression in at-risk adolescents: a randomized controlled trial

CONTEXT

Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings.

OBJECTIVE

To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase.

INTERVENTION

Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone.

MAIN OUTCOME MEASURE

Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers.

RESULTS

Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67).

CONCLUSION

The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00073671.

Accountability of specialist child and adolescent mental health services

Outcome auditing of specialist child and adolescent mental health services (CAMHS) is now well under way internationally. There is, however, debate about objectives and tools. A case is made for the achievable goal of enhancing service accountability through user satisfaction information and clinician-rated contextualised measures of improvements in symptoms and impairment.

Practitioner review: How can epidemiology help us plan and deliver effective child and adolescent mental health services?

This review focuses on ways in which epidemiological research can inform mental health service development and clinical practice. Data from epidemiological studies can provide cross-sectional and secular estimates of the prevalence of psychopathology to support rational service development. Epidemiological surveys have difficulties in finding large enough samples of children with rare disorders, although these disorders are often severely debilitating and require extensive service input. Systematic surveillance provides a rigorous method for studying rare disorders and events. Only a minority of children with impairing psychopathology reach mental health services, although a larger proportion have mental health related contacts with other services. The gap in provision is such that an expansion of mental health services is unlikely to reach all children who could benefit, suggesting that mental health professionals need to develop innovative strategies to increase the number of children seen and the effectiveness of interventions that they receive. Training and supervision of non-mental-health professionals working with children in the identification and management of mental health problems is also extremely important. Most studies suggest that the children with the severest problems are getting to specialist mental health services, and service contact is more likely if important adults can perceive the child's difficulty or find it to be burdensome. The latter suggests that education of key adults would improve detection if services had the capacity to cope. Studies consistently suggest that the region in which the child lives affects the likelihood of service contact, but studies of other characteristics predicting service contact are so contradictory that studies should only be (cautiously) applied to similar populations to assess which types of children may currently be falling through gaps in service provision. Academics are beginning to explore the use of structured measures developed for epidemiological studies in clinical assessment and outcome monitoring.

Variaciones del consumo de recursos ambulatorios en la atención especializada de salud mental a niños y adolescentes

OBJECTIVES

To assess possible variability in the therapeutic approaches provided to patients aged less than 18 years old in community mental health centres (CMHC) in terms of the number of visits and length of treatment.

METHOD

An observational, analytical, prospective, longitudinal study was performed in a clinical cohort of 298 subjects attending the CMHC of Leganés and Fuenlabrada (Madrid) for the first time.

RESULTS

The median number of visits per patient was six in Leganés and three in Fuenlabrada (p < 0.001). The mean length of treatment was more than twice as long in Leganés (276 days) than in Fuenlabrada (119 days) (p < 0.001). Stratified analysis showed that the treatments provided in Fuenlabrada involved fewer visits, irrespective of the health professional in charge (psychiatrist or psychologist), the treatment modality prescribed (individual psychotherapy, other psychotherapies or no explicit treatment prescribed), or whether the patient abandoned treatment or the discharge was agreed. Similar results were found for the length of treatment.

CONCLUSIONS

The different clinical styles illustrate the difficulty of developing useful risk adjustment systems in mental health. The differences in resource consumption and costs cannot easily be attributed to patient-related variables, but are due rather to the intervention provided, which depends on the staff.

Parent Management of Attendance and Adherence in Child and Adolescent Therapy: A Conceptual and Empirical Review

There have been impressive, recent advances in the development of efficacious treatments for child and adolescent behavior problems. However, specific methods for delivering these treatments in a way that amplifies their efficacy have not been well articulated. Although many factors may be involved, attendance and adherence to treatment are arguably the most basic necessities for effective treatment delivery. We provide a conceptual and empirical review of past research on attendance and adherence to child and adolescent therapy, with a special focus on the importance of parents/guardians in managing treatment participation. Our review demonstrates that attendance and adherence are associated with a range of significant methodological, clinical, and financial outcomes. Several pretreatment predictors of attendance and adherence have been identified; however, to date only 12 controlled, clinical trials have evaluated strategies for enhancing attendance and adherence to child therapy. We conclude with an agenda for advancing research on the prediction and enhancement of attendance and adherence to child therapy as a means of improving the efficiency and effectiveness of child treatments.

Jousting With Straw Men: Comment on Westen, Novotny, and Thompson-Brenner (2004)

Empirically supported treatments (ESTs) do not cure every patient, and the randomized trial is not a flawless methodology. Upon these often-noted and widely accepted points, D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004a; see record 2004-15935-005) built a critique of ESTs and EST research. However, important work developing effective, clinically relevant treatments for serious problems was omitted from the Westen et al. (2004a) review. Little documentation was offered for the purported "assumptions" of EST methodology that Westen et al. (2004a) criticized; and different review standards were applied to studies supporting versus those disagreeing with Westen et al.'s (2004a) views. Finally, the correlational research designs proposed as a remedy by Westen et al. (2004a) have far more serious weaknesses than randomized trials, thoughtfully applied to real-world clinical care.

Predictors of outpatient mental health service use--the role of foster care placement change

This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health.

The impact of managed care on children's outpatient treatment: a comparison study of treatment outcome before and after managed care

This study examined treatment outcome pre- and post-managed care in 3 samples of patients (N = 885; ages 5 to 18 years) at an urban-based children's psychiatric outpatient clinic. Although the post-managed care groups were seen for fewer sessions than the pre-managed care group, there was no difference between the pre- and post-managed care groups in clinical outcome.

Reported maltreatment among clinic-referred children: implications for presenting problems, treatment attrition, and long-term outcomes

OBJECTIVE

To examine the treatment implications of a reported history of maltreatment in a sample of 343 children referred to Los Angeles area mental health clinics for emotional and behavioral problems.

METHOD

Child Protective Service records identified 161 of the 343 families as having a documented history of maltreatment. Parent reports of child behavior problems were obtained following clinic intake and at 2-year follow-up, and attrition was assessed via medical records. The authors examined the associations between a history of maltreatment and severity of child presenting problems, treatment attrition, and long-term mental health outcomes.

RESULTS

Compared to other clinic-referred children, youngsters with a history of maltreatment entered treatment with more externalizing behavior problems, were more likely to exit treatment early and without therapist consent, and continued to show greater externalizing problems 2 years later.

CONCLUSIONS

Maltreated children have significant mental health needs that may not be well addressed currently in community mental health clinics.

Propensity score matching: an illustrative analysis of dose response

BACKGROUND

Health services researchers are often interested in the effect of a treatment or a service in situations in which randomization is difficult or impossible. One useful alternative involves propensity score methods, a means for matching members of different groups based on a range of characteristics. Under certain assumptions, comparisons of the matched groups reveal the impact of the treatment of interest.

OBJECTIVES

This article reviews propensity score methods and illustrates their use in an analysis of dose response, the relationship between the volume of services received, and treatment outcomes. In mental health policy, this question is central to key issues such as parity.

RESEARCH DESIGN

Data for the illustrative analysis are taken from a well-known study of children's mental health services. This analysis estimates the impact of outpatient therapy based on comparisons of individuals receiving different treatment doses. Those comparisons are adjusted for preexisting observed differences among the groups using propensity score methods.

SUBJECTS

The study includes 301 participants aged 5 to 18 years treated at the study sites.

MEASURES

The analyses are based on family characteristics and the mental health status of children and adolescents reported in interviews with parents as well as administrative data on service use.

RESULTS

Analyses using propensity score matching suggest that added services improve treatment outcomes, especially child functioning. However, at least for the services and outcomes considered, the marginal benefits to high levels of treatment are limited.

CONCLUSIONS

These analyses illustrate the potential value of propensity score methods to health services researchers.

A two-year follow-up of psychodynamic psychotherapy for internalizing disorders in children

OBJECTIVE

To evaluate short- and long-term effects of time-limited psychodynamic psychotherapy (PP) for children with internalizing disorders.

METHOD

Fifty-eight outpatient children (6.3-10.9 years old), seen in a process of routine care and meeting criteria for depressive or anxiety disorder, were assigned to either active treatment or community services. Subjects were measured at baseline, after 6 months, and at a 2-year follow-up, by Children's Global Assessment Scale (C-GAS) and Child Behavior Checklist (CBCL).

RESULTS

Major improvements in the experimental group were found in C-GAS and CBCL. These differences are noted at different times, with the C-GAS findings seen at 6 months and the CBCL findings at 2-year follow-up. Significant differences were found also for externalizing syndrome scales.

CONCLUSIONS

PP is effective in treating internalizing disorders in routine outpatient care. The benefits of treatment are manifest both immediately and with delayed onset (sleeper effect). The finding that PP patients sought mental health services at a significantly lower rate than comparison conditions represents an important economic impact of PP.

Rates and predictors of aftercare services among formerly hospitalized adolescents: a prospective naturalistic study

OBJECTIVE

To examine rates and predictors of aftercare use, lengths of service use, and predictors of the duration of aftercare service use among 180 adolescents monitored for up to 8.1 years after discharge from an inpatient psychiatry unit.

METHOD

Drawing upon the Anderson-Newman model of service use, severity of illness, enabling, and predisposing factors assessed during the hospitalization were examined as potential predictors of service use. Information about outpatient mental health specialty services after hospitalization was assessed repeatedly and verified with treatment records.

RESULTS

Seventy-three percent of adolescents received aftercare within the first month after discharge, and 92% eventually received outpatient services. Fifty-seven percent of adolescents remained in treatment 6 months after initiation of services. Psychiatric comorbidity, prior service use, and presence of a biological parent or grandparent in the home were related to initial service use. Psychiatric comorbidity and history of repeated suicide attempts were related to longer duration, and older age and minority group status were related to shorter duration of aftercare service use.

CONCLUSIONS

Most adolescents receive aftercare services, but there are certain groups that are relatively less likely to access or remain in services. Interventions to decrease the barriers to care in such groups may be beneficial.

The component model of treatment in child and adolescent psychiatry: theoretical concept and empirical results

The paper describes the theoretical concept and practical realization of the component model of treatment in child and adolescent psychiatry. Treatment procedures in a university department of child and adolescent psychiatry are analyzed based on a sample of 4545 patients in different settings (inpatient, day patient, and outpatient settings) and applying five different treatment components (individual psychotherapy with the patient, functional therapies, parent- and family-oriented interventions, other environmental interventions and psychotropic medication). These five treatment components were applied in variable combination to different disorders and in various settings. Treatment success based on therapists' ratings is described regarding a variety of ICD-9 diagnoses. Effect sizes were calculated for outpatient treatments (total sample 1682) and for inpatient treatments (total sample 1490). The effect size in the outpatient setting was 1.01 for normal completers vs. drop-outs, 1.27 for normal completers vs. non-beginners, and 0.34 for non-beginners vs. drop-outs. The corresponding effect sizes for inpatients were 0.74 for normal completers vs. drop-outs 1.27 for normal completers vs. non-beginners, and 0.84 for non-beginners vs. drop-outs. In spite of some methodological restrictions, the results of this naturalistic study can be used to improve empirically based treatment procedures under realistic clinical conditions.

Community clinic treatment of depressed youth: benchmarking usual care against CBT clinical trials

This study used a benchmarking strategy to evaluate the effectiveness of community psychotherapy for depressed youth relative to evidence-based treatment in clinical trials. Symptom trajectories of depressed youth treated in community mental health centers (CMHCs) were compared with trajectories of youth treated with cognitive-behavioral therapy (CBT) in clinical trials. Overall, outcomes of CMHC youth more closely resembled those of control condition youth than youth treated with CBT. Within the CMHC sample, ethnic minority status and low therapy dose were related to worse outcomes. However, when outcomes for Caucasian youth and youth receiving longer term services were examined, the CMHC sample still performed more poorly than youth treated with CBT. The findings support the value of developing, testing, and exporting effective therapies for depressed youth to community clinic settings.

Multicentre controlled trial of parenting groups for childhood antisocial behaviour in clinical practice

OBJECTIVE

To see whether a behaviourally based group parenting programme, delivered in regular clinical practice, is an effective treatment for antisocial behaviour in children.

DESIGN

Controlled trial with permuted block design with allocation by date of referral.

SETTING

Four local child and adolescent mental health services.

PARTICIPANTS

141 children aged 3-8 years referred with antisocial behaviour and allocated to parenting groups (90) or waiting list control (51).

INTERVENTION

Webster-Stratton basic videotape programme administered to parents of six to eight children over 13-16 weeks. This programme emphasises engagement with parental emotions, rehearsal of behavioural strategies, and parental understanding of its scientific rationale.

MAIN OUTCOME MEASURES

Semistructured parent interview and questionnaires about antisocial behaviour in children administered 5-7 months after entering trial; direct observation of parent-child interaction.

RESULTS

Referred children were highly antisocial (above the 97th centile on interview measure). Children in the intervention group showed a large reduction in antisocial behaviour; those in the waiting list group did not change (effect size between groups 1.06 SD (95% confidence interval 0.71 to 1.41), P<0.001). Parents in the intervention group increased the proportion of praise to ineffective commands they gave their children threefold, while control parents reduced it by a third (effect size between groups 0.76 (0.16 to 1.36), P=0.018). If the 31 children lost to follow up were included in an intention to treat analysis the effect size on antisocial behaviour was reduced by 16%.

CONCLUSIONS

Parenting groups effectively reduce serious antisocial behaviour in children in real life conditions. Follow up is needed to see if the children's poor prognosis is improved and criminality prevented.

Looking for the disorder in conduct disorder

Besides their well-known externalizing behavior, children with conduct disorder (CD) often have additional impairments outside the criteria for the CD diagnosis. In a 5-year study of 984 treated children (ages 5-17 years), those with CD had an average of 2.2 primary diagnoses. Children with CD showed the worst problem and impairment scores in comparison with 11 common diagnoses. Compared with other treated children, children with CD achieved worse scores on 14 of 15 syndromes, including internalizing problems such as withdrawal and major depression. The average child with CD had larger relapse scores in the 1.5- to 3-year period after admission to treatment. This pattern, pervasive at intake and chronic in course, resembles a global disability more than a circumscribed problem managed with a narrow range of treatments specific to it.