ABSTRACT
OBJECTIVES: In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care. METHODS: Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months. RESULTS: Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing). CONCLUSIONS: Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.
Subject(s)
Attention Deficit and Disruptive Behavior Disorders/therapy , Psychotherapy/statistics & numerical data , Adolescent , Adult , Attention Deficit and Disruptive Behavior Disorders/psychology , Child , Child, Preschool , Family Therapy/statistics & numerical data , Female , Health Care Surveys , Humans , Male , Parents/psychology , Psychiatric Status Rating Scales , Treatment Outcome , United StatesABSTRACT
OBJECTIVE: Limited alternatives exist to residential treatment or hospitalization for children with the most serious emotional disturbances. Community-based interventions are intended to offer less restrictive and expensive options than traditional treatment. One such program is New York State's Home and Community-Based Services (HCBS) Waiver Program. METHODS: From 1996 to 2002, 169 children were enrolled in the Manhattan HCBS. All spent at least one month on the wait list prior to admission to the waiver program. We used our wait list as a control group (WLC), allowing for comparison of the HCBS intervention. RESULTS: Sample consisted of 169 children between the ages of five and eighteen. The ethnic composition was 46.8% Hispanic (N = 79), 47.9% African-American (N = 81), and 5.3% Caucasian (N = 9). Average stay was 12 months in the HCBS program and 3.5 months for the WLC. Only 30% of children in the WLC were maintained in the community, while 81% of children in the HCBS were similarly maintained (P < 0.001). Also, the rate of hospitalization for the HCBS group was significantly lower (3 versus 41%; P < 0.001). There was also a trend for the WLC group to have had substantially higher rates of removal by the Administration for Children's Services (New York City's protective service agency) (8.3 versus 1.8%) and to more frequently require residential treatment (13.0 versus 8.9%). CONCLUSIONS: It would seem that the HCBS program appears to be a clinically and cost-effective method of maintaining children in their community.
