Variably Effective Provider

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Research On The Reach of Child and Adolescent
Clinical Services
Kimberly Hoagwood, Ph.D. National Institute of
Mental Health June 2001
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A Brief History

• 1970s Deinstitutionalization for adults
• 1982 Jane Knitzers Unclaimed Children
• 1986 Stroul and Friedmans System of Care
  Monograph
• 1989 Child and Adolescent Services Research
• Program created at NIMH
• 1989 IOM Report
• 1990 National Plan for Research on
  Child/Adolescent
• Mental Disorders, NIMH
• 1992 NIMH and CMHS administratively split

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A Brief History (contd)

• 1994 Set-aside research funds for services
  research, NIMH
• 1994 Childrens Community Services Program,
  CMHS
• 1999 Surgeon Generals Report on Mental
  Health
• 2000 Surgeon Generals National Action Agenda
  on
• Child Adolescent Mental Health
• 2000 Joint NIMH/CMHS research announcement
• 2001 NIMH National Advisory Council Report
  A Blueprint for Change Research on Child
  Adolescent Mental Health

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Total Child Mental Health Expenditures by Age
Group
Total Expenditures 11.75 billion
(Sturm et al., 2000)
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Total Child Mental Health Expenditures by
Service Type
Total Expenditures 11.75 billion
(Sturm et al., 2000)
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Evidence-based Practice Reviews

•  Psychosocial Treatments
• APAs Division 12 Review of evidence-based
  therapies,
• 1998 Kazdin, Psychotherapy for children and
  adolescents
• Directions for research and practice. Oxford,
  2000
• School-Based Approaches
• Rones Hoagwood, School-based mental health
  services,
• Clinical Child and Family Psychology Review, 2000
• Psychopharmacology
• JAACAP special issue on psychopharmacology, 1999
• Community-based Treatments and Services
• Burns, Hoagwood, Mrazek Child Clinical and
  Family
• Psychology Review, 2000

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Outpatient Evidence-Based Treatments
(Externalizing)
Well-Established
Probably Efficacious
ADHD

• Behavioral Management
• Training

• Behavioral Parent Training
• Behavioral Interventions in
• the Classroom

DISRUPTIVE BEHAVIOR Preschool

• Delinquency Prevention
• Program
• Parent-Child Interaction
• Therapy
• Parent Training Program
• Time-Out Plus Signal Seat
• Treatment

• Living with Children
• Videotape Modeling

Source Journal of Clinical Child Psychology,
Volume 27, Number 2, 1998
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Outpatient Evidence-Based Treatments
(Externalizing)
Well-Established
Probably Efficacious
DISRUPTIVE BEHAVIOR
School Age

• Anger Coping Therapy
• Problem Solving Skills
• Training

Adolescent

• Anger Control Training
• with Stress Inoculation
• Assertiveness Training
• Multisystemic Therapy
• Rational-Emotive Therapy

Source Journal of Clinical Child Psychology,
Volume 27, Number 2, 1998
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Outpatient Evidence-Based Treatments
(Internalizing)
Well-Established
Probably Efficacious
DEPRESSION

• Self-Control (children)
• Coping with Depression
• (adolescents)
•  

• None

ANXIETY  

• Cognitive-Behavioral
• Imaginal and In Vivo
• Desensitization
• Live or Filmed Modeling

• None
•  
• Participant Modeling
• Reinforced Practice

PHOBIAS
Source Journal of Clinical Child Psychology,
Volume 27, Number 2, 1998
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Psychopharmacology Evidence Base
STRONG   ADHD
Stimulants  
MODERATE   DEPRESSION Selective Serotonin
Reuptake Inhibitors (SSRIs) AUTISM
Antipsychotics OBSESSIVE COMPULSIVE SSRIs,
TCAs DISORDER    
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Psychopharmacology Evidence Base
MODERATE OPPOSITIONAL DEFIANT Antipsychotics,
mood DISORDER stabilizers, stimulants
WEAK BIPOLAR DISORDER Lithium ANXIETY SS
RIs TOURETTES SYNDROME Antipsychotics DEPRESSION
TCAs From JAACAP Special Issue on
psychopharmacology, 1999
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MTA 14-Month Outcomes
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MTA Study - 14 Month OutcomesConsumer
Satisfaction (Parent)
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Would You Recommend This Treatment?
Medmgt Beh Comb Declined/dropped out 16
0 3 Not recommend 8 5 3 Neutral
8 2 1 Slightly Recommend 4 2
2 Recommend 33 24
15 Strongly recommend 36 67
76
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Challenge Psychotherapies in Routine Clinic
Settings Have Little to no Effect
Children Adolescents
Adults
University
Mean Effect Sizes
Clinic settings
Weisz et al., 1995
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Comprehensive Community- Based Interventions
Intensive Case Management (including Wraparound)

• 5 RCTs and 1 quasi-experimental
• less restrictive placements
• some increased functioning

• 22 studies (effect size .38-1.5
• above .80 for 5)
• 70-90 remain with family
• reduced aggression, fiscal savings

Multi-systemic therapies (home-based) Family
preservation
Family Education and Support

• 1 RCT
• Increased knowledge and
• self-efficacy

Source Burns, Hoagwood, Mrazek Review of
evidence-based services, Child Clinical and
Family Psychology Review, 2000
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Comprehensive Community- Based Interventions
Mentoring

• 1 RCT
• less substance use and aggression
• better school, peer, and family
• functioning

• 4 RCTs
• more rapid improvement
• decreased aggression better
• post-discharge outcomes

Therapeutic Foster Care
Respite Services Crisis Services
0 controlled 0 controlled
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Institutionally-Based Care
3 RCTs Findings in favor of community
comparison   Residential 2
quasi-exp Treatment Project Re-Ed gains vs
untreated Centers RTC TFC x   Group
homes 2 quasi-exp Mixed findings gains and
deterioration   Partial hosp 1 RCT, PH vs. wait
list controls 6 month benefits for
symptoms and family functioning
Hospital
Source Burns, Hoagwood, Mrazek. Review of
evidence-based services, Child Clinical and
Family Psychology Review, 2000
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Youth Violence Model Programsfrom Youth
Violence Report of the Surgeon General, 2001

• Targets violence or serious delinquency
• Seattle Social Development Project
• Prenatal and Infancy Home Visitation by Nurses
• Functional Family Therapy
• Multisystemic Therapy
• Multidimensional Treatment Foster Care

• Targets risk factors for violence
• Life Skills Training
• The Midwestern Prevention Project

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Youth Violence Promising ProgramsFrom Youth
Violence Report of the Surgeon General, 2001

• Targets violence or serious delinquency
• School Transitional Environmental Program
• Montreal Longitudinal Study/Preventive Treatment
  Program
• Syracuse Family Development Research Program

• Perry Preschool Program
• CASASTART Striving Together to Achieve
  Rewarding Tomorrows
• Intensive Protective Supervision Project

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Youth Violence Promising ProgramsFrom Youth
Violence Report of the Surgeon General, 2001

• Targets risk factors for violence
• PATHS Promoting Alternative Thinking Strategies
• I Can Problem Solve
• Iowa Strengthening Families Program
• Preparing for the Drug-Free Years
• LIFT Linking the Interests of Families and
  Teachers
• The Incredible Years Series

• Bullying Prevention Program
• Good Behavior Game
• Parent Child Development Center Programs
• Parent-Child Interaction Training
• Yale Child Welfare Project
• FAST Families and Schools Together
• Preventive Intervention
• The Quantum Opportunities Program

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Challenge Family Engagement

• 40-60 families may drop out of services before
  their formal completion
• (Kazdin et al., 1997)
• Children from vulnerable populations are less
  likely to stay in treatment past the 1st session
  (Kazdin, 1993)
• Factors related to drop-out Stressors
  associated with treatment, treatment irrelevance,
  poor relationship with therapist (Kazdin et al.,
  1997)

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Challenge Limited Outcomes and High Costs of
Residential Tx

• Groups homes, inpatient and residential treatment
  centers seem to result in behavioral improvements
  during stay, but sustained gains are questionable
• Outcomes of controlled trials demonstrate
  improved or equivalent outcomes for alternative
  interventions, which may also be less costly
  (Schoenwald et al., 2000 Winsberg et al., 1980)

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Challenge Unmet Need for Mental Health
Services
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Challenge Some Treatments And Services are
Ineffective but are Still Used

• Non-behavioral interventions for disruptive
  behavior disorders and/or ADHD (Weisz et al.,
  1995 Pelham et al., 1998)
• Group, peer-based interventions may facilitate
  deviancy training. Noted increases in rates of
  substance abuse, delinquent behaviors, and
  violence post-intervention (Dishion et al.,
  1999).

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Challenge Evidence-based Care is Poorly
Defined, Rarely Used

• Research to practice gap widening (Surgeon
  Generals National Action Agenda, 2001)
• How EBT is defined and constructed varies
  enormously (Hoagwood, Burns, Kiser, et al., 2001)
• Service contexts as nuisance variables
• (Weisz, 2000)
• Intervention development has followed
  medical/pharmaceutical models, which may not be
  appropriate for psychosocial treatments or
  services

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Challenge Implementing EBP in Child/Adolescent
Mental Health

• EBP no consistent definition
• Local adaptation usu. needed but may obviate
  scientific validity
• Need to define core components of EBP
• Need to examine cost-effectiveness of EBP
• Science base lags behind policy Policies develop
  independently of EBP
• Reimbursement not tied to EBP

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Challenge Basic Sciences not Informing
Intervention Development

• HPA axis, stress regulation child abuse/neglect
  interventions
• Mood dysregulation treatments for depression
• Fear extinction anxiety treatments
• Attention regulation, executive functioning,
  memory prevention/treatment/services for ADHD
• Behavioral change theories provider practices

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Reaching back Basic sciences and their
application to clinical services

• Basic science and its relation to services
• HPA axis stress regulation, abuse/neglect
• Mapping the brain, imaging studies
• The genome project
• Behavioral theories and their application
  engagement, changing provider behavior
• Cognition and affect how separate?
• Prospects for understanding etiology

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Reaching Out Role of Community Collaborations
in Clinical Services Research

• New Directions within NIH and for the Field
• Efficacy to Effectiveness Research From
  clinical
• treatments to clinical services
• Effectiveness The contexts of practice and
  diffusion
• Community Collaboration Casebook (Trickett,
• Hoagwood, Jensen, McKay)
• Research Ethics Engaging families and the
  ethics of
• informed dissent (NIMH, APA, Fordham U)

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Blueprint for Change Research on Child and
Adolescent Mental Health NIMH Advisory Council
Report

• Intervention development Linking basic science
  and services
• Impact of development on gene expression and
  cellular processes and circuits drug targets
• Impact of development on mood regulation,
  cognition, emotional learning
• Intervention deployment Focus on dissemination,
  stakeholder involvement
• Research networking to avoid disciplinary
  insularity

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Blueprint for Change

• Interdisciplinary research networks
• Developmental and clinical processes
• Treatment development and practice networks
• Implementing evidence-based practice
• Research training
• Dissemination Centers

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(No Transcript)
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Social Ecological Model of Treatment
Transportability

• Extra-Organizational Context
• (Referral, Reimbursement, Disposition)
• Organization Clinician Child
• Adherence Outcomes
• Clinician Variables
• Professional Training Experience

Source Schoenwald, 11/98
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Clinic/community Intervention Development and
Deployment Model (CID)
Step 1 Theoretically and clinically-informed
construction, refinement, and
manualizing of the protocol within the
context of the practicesetting where it is
ultimately to be delivered Step
2 Initial efficacy trial under controlled
conditions to establish potential for
benefit Step 3 Single-case applications in
practice setting with progressive adaptations to
the protocol Step 4 Initial effectiveness test,
modest in scope and cost
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Clinic/community Intervention
Development and Deployment
Model (CID)

• Step 5 Full test of the effectiveness under
  everyday practice
• conditions, including cost
  effectiveness
• Step 6 Effectiveness of treatment variations,
  effective ingredients,
• core potencies,moderators,
  mediators, and costs
• Step 7 Assessment of goodness-of-fit within the
  host organization,
• practice setting, or community
• Step 8 Dissemination, quality, and long-term
  sustainability
• within new organizations, practice
  settings, or communities