Service Utilization for Parent Management of Early Childhood Behavior Problems in a Private Outpatient Behavioral Clinic: The Impact of Out-of-Pocket Cost, Travel Distance, and Initial Treatment Progress.

Poorly-managed early childhood disruptive behavior disorders (DBDs) have costly psychological and societal burdens. While parent management training (PMT) is recommended to effectively manage DBDs, appointment adherence is poor. Past studies on influential factors of PMT appointment adherence focused on parental factors. Less well studied are social drivers relative to early treatment gains. This study investigated how financial and time cost relative to early gains influence PMT appointment adherence for early childhood DBDs in a clinic of a large behavioral health pediatric hospital from 2016 to 2018. Using information obtained from the clinic's data repository, claims records, public census and geospatial data, we assessed how owed unpaid charges, travel distance from home to clinic, and initial behavioral progress influences total and consistent attendance of appointments for commercially- and publicly-insured (Medicaid and Tricare) patients, controlling for demographic, service, and clinical differences. We further assessed how social deprivation interacted with unpaid charges to influence appointment adherence for commercially-insured patients. Commercially-insured patients had poorer appointment adherence with longer travel distances, or having unpaid charges and greater social deprivation; they also attended fewer total appointments with faster behavioral progress. Comparatively, publicly-insured patients were not affected by travel distance and had higher consistent attendance with faster behavioral progress. Longer travel distance and difficulty paying service costs while living in greater social deprivation are barriers to care for commercially-insured patients. Targeted intervention may be needed for this specific subgroup to attend and stay engaged in treatment.

Outcomes Accountability Systems for Early Childhood Disruptive Behaviors: A Scoping Review of Availability.

Early childhood disruptive behaviors are common mental health problems among American youth, and if poorly-managed, pose costly psychological and societal burdens. Outcomes accountability systems in clinical practice are vital opportunities to optimize early intervention for common mental health problems; however, such systems seem rare. A scoping review was conducted to summarize the current availability of outcomes accountability systems in clinical programs addressing early childhood disruptive behaviors, particularly in the US. We used PsycINFO to identify peer-reviewed literature published in English from 2005 to 2021, from which we selected 23 publications from the US, UK, and Netherlands on outcomes accountability systems within clinical programs treating common childhood mental health problems. Only 3 out of 23 publications described outcomes accountability efforts specifically for early childhood problems. Within the 3 studies, only one UK-based study specifically targeted early childhood disruptive behaviors. We did not find publications specifically describing outcomes accountability efforts in US-based clinical programs to treat early childhood disruptive behaviors. There are multi-level challenges preventing changes to the prevalent US model of paying a fee for each unit of child mental healthcare, with little regard for patient outcomes. However, opportunities exist to improve US-based accountability efforts; from top-down expansion of financial incentives, accountability initiatives, and PDT evidence-based practices to an iterative, bottom-up development of meaningful outcomes measurement by providers. Greater adoption of outcomes monitoring in US clinical practice for common mental health problems can optimize management of early childhood disruptive behaviors and mitigate long-term societal and economic burdens.

Clinician-Identified Factors in Success of Parent-Directed Behavioral Therapy for Children's Tantrums.

Disruptive behavior disorders (DBD) are the most common behavioral health problems in young American children. When not well-managed in early childhood, DBD can progress to lifetime mental health problems with personal, economic, as well as societal impacts. The evidence-based intervention of choice for DBD is outpatient parent-directed behavioral therapy (PDT). However, little is known about clinicians' perspectives on the factors influencing PDT's effectiveness in routine care. The current study directly assesses clinicians' perspectives on factors they believe impact PDT's success for disruptive behavior problems, in particular tantrums, at two outpatient behavioral therapy clinics specializing in PDT. In-depth interviews with 19 clinicians across three experience levels (doctoral intern, post-doctoral, licensed staff psychologist) were conducted and analyzed using qualitative methods. Two major themes were identified as enabling and limiting treatment success: (1) appointment attendance, (2) primary caregiver buy-in to treatment approach. Additional identified factors include caregiver's familial and social support, caregiver's physical and emotional capacities, complexity of the child's behavior problems, the extent to which the home environment can support positive changes, competing family/home demands, and care coordination among hospital programs. The primary factors identified by clinicians highlight the importance of fostering appointment attendance and parental psychoeducation that can be addressed by implementing multi-level administrative, training, and clinical initiatives to improve PDT's real-world effectiveness for DBD.