Factor Analysis of Therapist-Identified Treatment Targets in Community-Based Children's Mental Health

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.

Greater Focus on Strengths is Associated with Successful Discharge in Youth Public Mental Health Treatment

The positive psychology literature suggests focusing on strengths in mental health treatment improves well-being, reduces symptomology, and is linked to positive outcomes. However, there is little research on the use of strengths in treatment and their association with outcomes in youth clinical populations. The present study used multi-level modeling to examine the association between the proportional targeting of strengths and treatment outcomes for 1,841 youth ages 3-19 receiving intensive in-home services through a public mental health system. A greater percentage of targets endorsed during treatment that were strength-focused was associated with increased likelihood of successful treatment discharge, even after accounting for other predictors, including episode length, youth age, and level of impairment at treatment start. Specifically, as the percentage of strengths targeted increased from 46 to 64% of total targets endorsed, the odds of successful discharge increased by 21%. Such practice-based findings derived from aggregated data regarding services to multiethnic low-income families extend the strength-based intervention literature to include youth with significant life challenges. Study findings point to the need to develop structured interventions suitable for examination via clinical efficacy and effectiveness trials. Clinical practice, dissemination, implementation, and future research implications are discussed.

Practices Derived from the Evidence Base for Depression Predict Disruptive Behavior Progress in Adolescent Community Mental Health Care

Disruptive behavior problems develop along multiple causal pathways and are associated with a wide variety of co-occurring problems, including mood disorders. In usual care, effective treatment practices for youth disruptive behavior might differ from what the efficacy research suggests, given treatment setting and population demographic differences. The current study examined whether practices derived from the evidence base for disruptive behavior and/or depressed mood predicted progress on disruptive behavior problems in an adolescent usual care sample. Monthly clinical data, including therapeutic practices, treatment targets, and progress on selected treatment targets, for 1210 youth ages 13-17 who received intensive in-home services and were treated for disruptive behavior problems were examined utilizing multilevel modeling techniques. Practices derived from the evidence base for only depressed mood and practices derived from both disruptive behavior and depressed mood literatures predicted disruptive behavior progress, while practices derived from only the disruptive behavior evidence-based literature did not. All five practice elements exclusive to depressed mood treatment predicted positive disruptive behavior progress, while two of eleven disruptive behavior practices and four of seven practices derived from both problem areas predicted positive progress. Findings held when other predictors were included as covariates, including youth age and functional impairment. Although directionality remains unclear and further research is vital, usual care settings might present barriers to disruptive behavior treatment as prescribed by the evidence base, and youth-focused treatments based on depressed mood treatments merit further examination as a potentially promising route to effective treatment in such settings.

Where Does It Begin? Community-Based Therapists' Intentions for Treating Non-comorbid Youth

This study examined patterns and predictors of 79 public sector therapists' practice element (PE) intentions for treating hypothetical single problem area youth with either anxiety or disruptive behavior problems. Analyses of intention profiles suggested that PE intentions varied by diagnosis and included both a majority of practices derived from the evidence base (PDEBs) and a large number of practices with minimal evidence support (PMESs) for each problem area. Hierarchical multiple regression results indicated the only significant predictor of higher PDEB intentions for both problem areas was reporting more PMES intentions. Implications for community-based research and implementation efforts are discussed.

Disruptive Behavior Treatment Progress as a Function of Therapy Focus and Youth Diagnosis in a Community Mental Health Setting

Monthly disruptive behavior treatment progress for 613 youth ages 7-18 receiving intensive in-home services was examined. Multilevel modeling indicated carrying a depressive mood diagnosis predicted less disruptive behavior progress compared to youth with only externalizing diagnoses. Paradoxically, more monthly focus on disruptive behavior treatment targets predicted lower concurrent progress ratings, while greater focus on depressive mood targets predicted greater disruptive behavior progress for youth with a depressive mood diagnosis. Findings held when other predictors of disruptive behavior progress were included as covariates, including episode length, youth age, and functional impairment. Treatment and research implications are discussed.