Predicting service utilization with the Child and Adolescent Functional Assessment Scale in a sample of youths with serious emotional disturbance served by center for mental health services-funded demonstrations

Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment

PURPOSE

Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy.

METHOD

This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses.

RESULTS

A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant.

CONCLUSION

Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Assessing the impact of mental health difficulties on young people's daily lives: protocol for a scoping umbrella review of measurement instruments

INTRODUCTION

An important consideration for determining the severity of mental health symptoms is their impact on youth's daily lives. Those wishing to assess 'life impact' face several challenges: First, various measurement instruments are available, including of global functioning, health-related quality of life and well-being. Existing reviews have tended to focus on one of these domains; consequently, a comprehensive overview is lacking. Second, the extent to which such instruments truly capture distinct concepts is unclear. Third, many available scales conflate symptoms and their impact, thus undermining much needed analyses of associations between the two.

METHODS AND ANALYSIS

A scoping umbrella review will examine existing reviews of life impact measures for use with children and youth aged 6-24 years in the context of mental health and well-being research. We will systematically search six bibliographic databases (MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, and the COSMIN database of systematic reviews of outcome measurement instruments), and conduct systematic record screening, data extraction and charting based on methodological guidance by the Joanna Briggs Institute. Data synthesis will involve the tabulation of scale characteristics, feasibility and measurement properties, and the use of summary statistics to synthesise how these instruments operationalise life impact. The protocol was registered prospectively with the Open Science Framework (osf.io/ers48).

ETHICS AND DISSEMINATION

This study will provide a comprehensive road map for researchers and clinicians seeking to assess life impact in youth mental health, providing guidance in navigating available measurement options. We will seek to publish the findings in a leading peer-reviewed journal in the field. Formal research ethics approval will not be required.

Predictors of functional improvement in children and adolescents at a publicly funded specialist outpatient treatment clinic in a Canadian Prairie City

Children's mental health problems substantially impact their functioning. For clinically treated children and adolescents, we explored the impact of mental health treatment on functioning and identified predictors of functional improvement. Outpatient clinical data from a regional publicly funded specialist outpatient treatment clinic were analyzed. The Child and Adolescent Functional Assessment Scale (CAFAS) was used to assess outcomes. Non-parametric tests were used to compare baseline and exit scores. Logistic regression analysis was used separately for children and adolescents to examine predictors of improvement. Total CAFAS scores at exit showed a significant decrease from initial scores for both age groups, indicating improvements in clients' functioning. Children and adolescents had shared predictors for initial level of dysfunction, length of treatment and the presence of pervasive behavioral impairment (PBI). Primary presenting problem, caregiver support and area of residence were only associated with outcome among children. Clients with higher initial levels of dysfunction and PBI require longer treatment cycles to reach an acceptable outcome. Shortening the length of treatment cycles may improve the efficiency of resource use but can be detrimental to some clients. Personalized treatment should be tailored to the clients with specific characteristics and needs.

Measures of Child Emotional and Behavioral Strengths and Family Functioning: A Preliminary Report on the Reliability and Validity of their Spanish Translations

There is a documented need for reliable and valid Spanish-translated child mental health assessment tools. Although the psychometric properties of some of the more commonly used Spanish translations have been demonstrated, many instruments that were developed, tested, and normed in English are being Spanish-translated and used without further psychometric investigation. The current study found preliminary support for the internal consistency and convergent validity of the Spanish-translated Family Assessment Device and Behavioral and Emotional Rating Scale using data from the national evaluation of the Comprehensive Community Mental Health Service for Children and Their Families Program. A discussion of these findings as they relate to the psychometric properties of the English versions is included. Finally, next steps for more in-depth psychometric analyses are outlined.

The Effectiveness of Cultural Adjustment and Trauma Services (CATS): generating practice-based evidence on a comprehensive, school-based mental health intervention for immigrant youth

A collaborative study of Cultural Adjustment and Trauma Services (CATS), a comprehensive, school-based mental health program for traumatized immigrant children and adolescents, was conducted to generate practice-based evidence on the service delivery model across two school districts. Program effectiveness was assessed by testing whether client functioning and PTSD symptoms improved as a result of 7 separate service elements. An array of clinical services including CBT, supportive therapy, and coordinating services were provided to all students, and an evidence-based intervention for trauma, TF-CBT, was implemented with a subset of students. Greater quantities of CBT and supportive therapy increased functioning, while greater quantities of coordinating services decreased symptoms of PTSD. TF-CBT services were associated with both improved functioning and PTSD symptoms, although TF-CBT was implemented with fidelity to the overall comprehensive service model rather than the structured intervention model. Results suggest the comprehensive school-based model was effective, though different service components affected different student outcomes. Implications of these findings for immigrant mental health interventions and implementing structured evidence-based practices into community mental health programs are discussed. Suggestions are made for future research on existing mental health practices with immigrants.

Maternal drug abuse history, maltreatment, and functioning in a clinical sample of urban children

OBJECTIVE

This study examined the association between maternal drug abuse history, maltreatment exposure, and functioning, in a clinical sample of young children seeking therapy for maltreatment.

METHODS

Data were collected on 91 children, mean age 5.3years (SD 1.0). The Preschool and Early Childhood Functional Assessment Scales (PECFAS) was used to measure functional impairment. A child maltreatment exposure (CME) score was developed based on maltreatment history. Data on maternal risk factors including maternal drug abuse (MDA) were obtained. Data were analyzed using descriptive statistics and regression modeling.

RESULTS

Approximately half (47.3%) of the children had a history of MDA. MDA history was associated with increased odds of neglect (OR=5.6, 95% CI=2.2-14.6) and abandonment (OR=3.3, 95% CI=1.3-8.3), and decreased odds of sexual abuse (OR=0.35, 95% CI=0.2-0.8). There were no statistically significant differences in CME scores for children with MDA history when compared to children without MDA history. Children with MDA history had an increased mean functional impairment score (mean 15 points; 95% CI=1.3-29.2) compared to children without MDA history. Following adjustment for maltreatment, no difference in impairment score was found.

CONCLUSION

Although MDA history was associated with higher odds of neglect and abandonment, it was not associated with total CME or functional impairment. Adverse socio-environmental experiences associated with urban environments may confer a high risk of CME and functional impairment, irrespective of MDA history.

PRACTICE IMPLICATIONS

In addition to maternal drug abuse, clinicians working with children need to identify other factors which could place the child at added risk for maltreatment. Further research is needed to better understand the role of adverse socio-environmental experiences on maltreatment and functional impairment in children. This study highlights the need for a multi-disciplinary approach to prevention and intervention programs needed to diminish adverse socio-environmental conditions prevalent in urban environments.

Improvement in symptoms versus functioning: how do our best treatments measure up?

We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts.

Behavioral and Emotional Strengths among Youth in Systems-of-Care and the Effect of Race/Ethnicity

Behavioral and emotional strengths are important to consider when understanding youth mental health and treatment. This study examined the association between youth strengths and functional impairment, and whether this association is modified by race/ethnicity. Multinomial logistic regression models were used to estimate the effects of strengths on impairment, and examine whether race and ethnicity modified this relationship in 8,129 Caucasian, African American, Hispanic, and American Indian/Alaska Native youth, between 5 and 18 years of age. Results suggest that youth with average and above average strengths were less likely to have impairment compared to youth with below average strengths. Race and ethnicity modified this relationship in both expected and unexpected ways. Among youth with average and above average strengths, racial and ethnic minority youth appear to have more impairment than Caucasian youth. However, among youth with below average strengths, racial and ethnic minority youth have less impairment than Caucasian youth. Findings highlight the importance of incorporating strengths-based approaches in youth mental health treatment and the need for further research to understand the specific nature of strengths as it effects impairment across racial/ethnic groups. Implications and recommendations are discussed.

An Independent Effectiveness Trial of Multisystemic Therapy With Juvenile Justice Youth

This study examines the effectiveness of an evidence-based practice, multisystemic therapy (MST), conducted in a real-world mental health setting with juvenile justice involved youth and their families. Importantly, this is the first randomized clinical trial of MST with juvenile offenders in the United States conducted without direct oversight by the model developers. This study reports outcomes achieved for 93 youth randomly assigned to MST or treatment as usual (TAU) services through 18-month follow-up posttreatment for offense data and 6-month follow-up posttreatment for ratings of the Child and Adolescent Functional Assessment Scale (CAFAS). Outcomes include significant reduction in rearrest and improvement in 4 areas of functioning measured by the CAFAS for youth who received MST. Implications for delivery of empirically supported treatments in real-world settings are discussed.

Longitudinal predictors of youth functional improvement in a public mental health system

The present study examined youth characteristics that predict level of impairment at entry into a system of care and rate of improvement over the course of service provision. Youth characteristics studied included gender, age, specific diagnostic categories, and comorbidity. A total of 2,171 youth served in a state-wide public mental health system were included in the study. Hierarchical linear modeling was used to analyze longitudinal data derived from quarterly ratings of functional status. Gender had no relationship to initial level of impairment or rate of improvement. Older youth, those with disruptive behavior disorders, and those with more than one DSM diagnosis were more impaired at system entry. Those with attentional disorders began services less impaired. Older youth improved at faster rates. Youth with a disruptive behavior disorder diagnosis improved at slower rates. Neither comorbidity nor the presence of a mood or attentional disorder affected the rate of improvement. Both researchers and systems of care developers should consider these patterns in their future work.

Differences in mental health service sector utilization among African American and Caucasian youth entering systems of care programs

Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

Are CAFAS subscales and item weights valid? A preliminary investigation of the Child and Adolescent Functional Assessment Scale

Presents a psychometric analysis of the Child and Adolescent Functional Assessment Scale (CAFAS), one of the most commonly used measures of functional impairment in youths with emotional and behavioral disorders. Specific aims of the current investigation were to (a) examine the conceptual organization of the CAFAS items, (b) explore its scaling properties, and (c) investigate its construct validity. In Phase 1, a group of advanced graduate students and clinicians rated CAFAS items with respect to the degree that they reflect the originally assigned subscales. In Phase 2, additional raters assigned severity values to the subset of CAFAS items selected from Phase 1. Items were then scaled using simplified successive intervals scaling techniques. Results show differences between new empirically derived item weights and the original scoring method. This investigation highlights the benefits of continued examination and critique of level-of-functioning scaling for diagnosis, treatment, and prognosis in children and adolescents.

Variation in functioning, psychosocial characteristics, and six-month outcomes among suicidal youth in comprehensive community mental health services

In this study we compared the psychosocial (n = 7,896) and clinical (n = 4,664) characteristics and 6-month functional outcomes (n = 2,594) of suicidal and nonsuicidal youth. Repeat and previous attempters were more likely than first-time and never attempters to experience psychosocial problems and to be functionally impaired in a variety of domains. Differences in functional impairment persisted at 6 months. Among those who were not severely functionally impaired at baseline, repeat attempters were more likely to be severely impaired at 6 months. Subgroups of suicide attempters may present to treatment differently, have a different expression of problems over time, and have different treatment needs.

The use of propensity scores to evaluate outcomes for community clinics: identification of an exceptional home-based program

This article presents a model for mental health programs to estimate causal effects of treatment in community settings, where experimental studies, in which subjects are randomly assigned to treatment and control groups, are not feasible. This article describes an observational study that used a propensity score analysis with stratification and a repeated-measures analysis of covariance model to estimate treatment effects. This article includes results from one example site that was identified as having an exceptional home-based community program. The results include treatment effects for 3 outcomes identified as useful goals for home-based community programs. The study also serves as a model of how local programs can establish credibility where no evidence-based treatments exist for severely impaired youths.

Ten-year review of rating scales, VII: scales assessing functional impairment

OBJECTIVE

This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement.

METHOD

The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche.

RESULTS

These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need.

CONCLUSIONS

Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

Predictors of outcome for children with behavior problems served in public mental health

This study investigated whether pervasiveness of problems across settings predicted successful reduction of impairment in school, home, and interactions with others after controlling for other variables that may be stronger predictors. The data of 4,434 youths between the ages of 7 and 17 years in public mental health services in Michigan were examined employing logistic regressions, with 4 sets of predictors, as follows: demographic characteristics, risk factors, therapist's perception of impairment in the youth's caregiving environment, and pervasiveness of the youth's problems. The results indicated that pervasiveness of problems was the strongest predictor of poor outcomes for each domain. In addition, impaired caregiving environment, previous hospitalization for psychiatric or substance use problems, and placement out-of-home were also negatively associated with successful outcome. The implications of the findings for practice and research are discussed.

Gender differences in patterns of risk factors among children receiving mental health services: latent class analyses

Latent class analyses were used to analyze data from a sample of children participating in the national evaluation of the Comprehensive Communities Mental Health Services for Children and Their Families Program (N = 6786). Lifetime risk experiences of the child were analyzed to identify 4 classes of boys and girls with similar risk patterns. While low-risk, status-offense, abuse, and high-risk classes were identified for both boys and girls, there were nearly half the number of girls in the low-risk class, almost as many in the status-offense class, twice as many in the abuse class, and more than 3 three times as many in the high-risk class as there were boys. These findings suggest that there are specific groups of children entering services who differ as a function of their lifetime risk exposure. In addition, the relationship between class membership and child functioning, and class membership and family lifetime risk experiences. Understanding these differences provides critical information to the service planning process. In addition, it may result in immediate improvement in the triage of children into services and a better understanding of their behaviors during and after treatment.

Child functioning in rural and nonrural areas: how does it compare when using the service program site as the level of analysis?

The current study uses data from the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program to examine child functioning in rural (n = 8) as compared to nonrural (n = 18) system-of-care communities across the United States. In this study, the topic of rural versus nonrural differences is approached from a community-level perspective with aggregated functional impairment scores as the dependent variable of interest in weighted least squares regression. The demographic characteristics of children, particularly age, were more important predictors of functional impairment than geographic locale (i.e., rural vs nonrural). Specifically, while children served in nonrural communities were older than those served in rural communities, after controlling for this difference functional impairment levels were similar. It appears from these analyses that youth served in rural and nonrural communities with systems of care were more similar than they were different with regard to their level of functional impairment. This lack of aggregate functional difference between the rural and nonrural sites reminds policymakers and funding agents that youth in rural areas need equity in both access and resource for mental health services. As indicated by the findings in the current investigation youth in rural areas are not immune to the types of mental health challenges often publicized by researchers examining youth in nonrural areas.

Children with reported histories of sexual abuse: utilizing multiple perspectives to understand clinical and psychosocial profiles

OBJECTIVE

The current study examines multiple empirically based perspectives (i.e., child, caregiver, and clinician) of behavior and functioning as they contribute to the clinical and psychosocial profile of children (aged 5 to 17.5 years) with reported histories of sexual abuse.

METHOD

A large, multi-site data set of children referred into Comprehensive Community Mental Health Services both with and without reported histories of sexual abuse, was examined. Seven hundred and fifty-nine children with a reported history of sexual abuse were compared to 2722 without such a history on caregiver and child reported behavior, clinician rated functioning, diagnosis, demographic variables, and life challenges.

RESULTS

The multiple perspectives contributed unique and specific information to regression models: caregiver-reported behavior contributed information about externalizing behavior while child-reported behavior added information about internalizing behavior and clinician ratings about self-harmful behavior. Children with reported histories of sexual abuse were also more likely to be female, Caucasian, and have reported histories of life challenges (e.g., physical abuse, substance use, running away). Child sexual abuse was associated with higher rates of depression and anxiety diagnoses, and lower rates of substance abuse, conduct, and attention deficit disorder diagnoses.

CONCLUSIONS

The findings indicate that the profile of children entering into Comprehensive Community Mental Health Services with reported histories of sexual abuse, as compared to those without such histories, is complex and best understood via multiple perspectives. Caregiver, child and clinician rated information, when taken together, provide a comprehensive clinical and psychosocial profile around which to plan and implement individualized service plans.

Suicide attempts in the "comprehensive community mental health services for children and their families" program

OBJECTIVE

To compare clinical characteristics of youths who had attempted suicide recently, previously but not recently, repeatedly, or never.

METHOD

The sample comprised 4,677 youths receiving services between 1993 to 1998 in 22 communities and participating in the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. Data on suicide attempts, demographics, and clinical characteristics were obtained from intake interviews and referring agencies. Chi-square and univariate analyses of variance were used for between-group comparisons.

RESULTS

Twenty-one percent of the sample had a history of attempted suicide. Previous and repeat attempters were more likely to have a history of family violence and substance abuse. Repeat attempters were most likely to have depression, while never and previous (but not recent) attempters were more likely to have conduct disorder. Other clinical differences were also found.

CONCLUSIONS

Among children receiving mental health services, those who attempt suicide experience more and different types of distress, depending on the recency and frequency of attempts. Clinicians should be aware that depression is not a necessary factor in predicting suicide attempts and that suicide risk is also associated with violent and aggressive behaviors.

Client typology based on functioning across domains using the CAFAS: implications for service planning

Cluster analysis was used to develop a five-group typology based on the eight subscales of the Child and Adolescent Functional Assessment Scale (CAFAS) using data on 4,758 youths referred to Community Mental Health Service Providers in Michigan. The groups are described in terms of clinical diagnoses, overall impairment in functioning, past and current use of services from other agencies (i.e., juvenile justice, social services), and caregiver resourcefulness. From most to least impaired, the clusters were the following: Substance Users/Externalizers, Comorbid/Self-Harmful, Delinquents, Marked/School Problems, and Adjustment Problems with Impairment/Secondary Prevention. The results are being used to help identify the most impaired youths with serious emotional disturbance (SED) youths, develop specific programs and services for the different types of youths being served, determine staff training needs, and foster clinical practice in which the youth's progress is continually monitored.

Psychometric study of the Child and Adolescent Functional Assessment Scale: prediction of contact with the law and poor school attendance

The predictive validity of the Child and Adolescent Functional Assessment Scale (CAFAS) is investigated using the data set generated by the national evaluation of the demonstration service grants funded by the Center for Mental Health Services. Logistic regressions were performed separately for contact with the law and poor school attendance, which were both assessed at 6 months postintake. Other variables included in the model besides the CAFAS total score at intake were age, gender, and family risk factors. The results show that the CAFAS total score at intake was a positive predictor of the likelihood of contact with the law and poor school attendance, even after controlling for age, gender, and risk factors. Furthermore, the CAFAS total score was predictive even after excluding scores on CAFAS subscales, which may have been influenced by absenteeism or delinquency. These findings are consistent with recent research indicating that the CAFAS predicts recidivism in juvenile delinquents.