Mental Health Care for Children With Disruptive Behavior Problems: A View Inside Therapists' Offices

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 (UC) treatment for children. Objectives of this study were to a) characterize UC out-patient psychotherapy for children with disruptive behavior problems, and b) identify consistencies and inconsistencies between UC and common elements of evidence-based practices to inform efforts to implement evidence-based practices in UC. Methods Participants included 96 psychotherapists and 191 children ages 4–13 presenting for treatment for disruptive behavior to one of six UC 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 1215 randomly selected (out of 3241 collected) videotaped treatment sessions for up to 16 months. Results Most children received a lot of treatment (mean number of sessions=22, plus other auxiliary services), and there was great variability in amount and type of care received. Therapists employed a wide array of treatment strategies directed to children and parents within and across sessions, but all strategies were delivered at low average intensity. Several strategies conceptually consistent with evidence-based practices were observed frequently (e.g., affect education, positive reinforcement); however, others were observed rarely (e.g., assigning/reviewing homework, role-playing). Conclusion UC treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and UC, thus identifying potentially potent targets for improving the effectiveness of UC.

Observational Assessment of Engagement Strategies to Promote Parent Homework Planning in Community-Based Child Mental Health Treatment: A Pilot Study

“…Although preliminary, the overall low extensiveness of delivery of therapist engagement strategies is somewhat expected given that community-based therapists frequently spend much time using eclectic strategies to engage clients, which may come at expense of delivering evidence-based strategies with high extensiveness (Garland et al 2010; McLeod and Weisz 2005). For example, the strategy of assigning or reviewing homework is not commonly implemented by therapists in community-based child MH settings, and when it is observed, it occurs with low extensiveness of therapist delivery (Garland et al 2010).…”

“…The engagement strategies in the coding system were based on (a) a training manual developed by the second author on treatment engagement strategies, (b) a review of the literature, (c) review of treatment session recordings, and (d) clinical experience. The coding system was developed to align with the structure of an existing observational coding system for capturing therapists’ delivery of therapeutic strategies from a large-scale study of psychotherapy for children presenting with disruptive behavior problems ( Scoring Manual for the PRAC Study Therapy Process Observational Coding System for Child Psychotherapy: Strategies Scale; Garland et al 2008; Garland et al 2010). The coding system captures extensiveness, which reflects both frequency and thoroughness of use of each strategy.…”

“…However, most families only attend three to four treatment sessions before dropping out prematurely (Armbruster and Fallon 1994; Harpaz-Rotem et al 2004; Kazdin 1996; Pellerin et al 2010), and parents are often not actively involved in community-based MH service settings (Baker-Ericzén et al 2013; Garland et al 2010; Martinez et al 2015). Community-based MH settings are locations in which MH services, which may or may not be evidence-based, are delivered to children, families, and adults within a “usual care” context, versus settings such as university training clinics or for efficacy research that do not provide care as it is typically provided (Garland et al 2013).…”

“…Treatment focus on the parent is particularly needed for child disruptive behavior problems (e.g., parent management training; Garland et al 2008), which are the most common presenting problems in community-based mental health settings (Garland et al 2001). There is great variability in the amount and type of care received in community-based MH care for child disruptive behavior problems (Garland et al 2010). While community-based therapists employ a wide-array of practices with both children and parents, some of which are evidence-based, they often do not execute these strategies with the sufficient intensity that would be expected from evidence-based treatments (Garland et al 2010).…”

“…There is great variability in the amount and type of care received in community-based MH care for child disruptive behavior problems (Garland et al 2010). While community-based therapists employ a wide-array of practices with both children and parents, some of which are evidence-based, they often do not execute these strategies with the sufficient intensity that would be expected from evidence-based treatments (Garland et al 2010). Thus, efforts are needed to understand factors impacting therapist implementation of evidence-based practices in community-based MH settings, particularly when it impacts parent engagement in child MH treatment.…”