▪ Treatment Programs: A Continuum of Approaches



▪ Treatment Programs: A Continuum of Approaches





Current approaches to delivery of mental health services to children and adolescents encompass a range of services from community-based clinics and private care providers to home-based services and, for those who need it, hospitalization and residential services. The range of services available today evolved over the past century in parallel with the many changes in demographics in the United States and the shift from a primarily agrarian society to an urbanized one. Indeed, some of the first attempts to provide community-based care arose in the context of providing treatment and rehabilitation to children involved in the juvenile justice system. This in turn was the stimulus for development of child guidance clinics through various care providers; these clinics were intended to provide a range of treatments, often at low cost, to children and their families. The organization of child psychiatry as a discipline and the increased interest of the federal government, beginning in the Kennedy administration, were also important in shaping the ways mental health services were delivered (Pumariega & Winters, 2007).

Provision of inpatient and residential treatment has its origin in development of institutions devoted to the care of children with chronic problems related to brain damage or mental retardation. The impact of psychoanalysis in the 1930s to 1960s also had an important impact given the tendency to view environmental factors as major in the pathogenesis of mental illness (i.e., it made theoretical sense to remove a child from a pathogenic environment with the residential setting presumed to help the child return to a path of normal development). Not surprisingly, this process was thought to be a long-term one, and lengths of stays were correspondingly prolonged.

Starting in the 1960s, the growth of experimental psychology began to have a major impact. The awareness that new behavioral methods could be used in patients with disorders such as autism or in other conditions (e.g., phobic disorders) had an important impact on treatment, and behavioral psychologists began to work actively in long-stay institutions. This approach had a number of advantages. It was explicit in terms of behaviors to be encouraged or discouraged through use of reinforcement or punishment. Both operant and classical conditioning procedures were used. The methods of applied behavior analysis were able to produce major behavior changes and were used to teach new skills such as anger management, assertiveness, anxiety reduction, and so forth (see Chapter 22).


The book Unclaimed Children (Knitzer, 1982) became a stimulus for establishing community-based services and was one of the factors that led to development of the Child and Adolescent Service System Program (CASSP) to provide community-based care (Stroul & Friedman, 1986). The CASSP helped in developing the system-of-care approach with the goal of providing a range of services and supports to children and their families. The CASSP program has now become one part of the Substance Abuse and Mental Health Services Administration (SAMSA), which funds a range of activities throughout the country.

Over the past 2 decades, an awareness of the importance of attempting, whenever possible, to treat children and adolescents in family and community settings and of the potential negative effects of long-stay institutions led to major shifts in provision of service with development of more comprehensive community and family- and home-based treatment approaches. Today, hospitalization is most frequently used only when problems are serious and pose a significant danger to the child or family or when problems are sufficiently complex that it becomes more efficient to conduct an inpatient assessment (Blader & Foley, 2007).


COMMUNITY-BASED SERVICES

Typically, the first-line providers of mental health care to children and adolescents are primary care providers. This is particularly true in areas with limited access to specialty services. The primary care setting has considerable potential for serving as the first line for screening, although usually, primary care providers have had little training in child mental health.

The availability of specialists is limited given issues of reimbursement and some aspects of the current system (e.g., provision of Medicaid carve-outs led to a separation of mental health and medical reimbursements, further complicating delivery of care). Fortunately, a few states, notably Vermont and Massachusetts, have facilitated access to child mental health consultation. In other states, there has been an emphasis on training primary care practitioners in use of specific screening methods and better use of mental health services. Other approaches (e.g., involving telemedicine) are also being explored.

Current approaches to integrated care emphasize the range of services children and families need. They emphasize child and family engagement in treatment and the need for flexibility in approach. For example, children and adolescents with circumscribed problems can often have their needs met effectively by time-limited or very specific service delivered by a single mental health provider in an office or clinic setting. Children with multiple and complex problems more typically are engaged for a longer period of time and often have service needs involving multiple systems and agencies. For these children, use of a multidisciplinary treatment can be particularly helpful.

The wraparound model of service provides a high individualized set of treatment and community supports designed for the particular child or adolescent. It aims to build on strengths and use community-based services as well as other supports (VanDenBerg & Grealish, 1996). Several studies have supported the usefulness of this approach in terms of improving functioning and decreasing problem behaviors as well as reducing placements outside the family.

There are many challenges in work with children and adolescents with more complex needs or life situations. The juvenile justice system exemplifies many of these challenges. Philosophically, there is a major divergence between a focus on rehabilitation and those who favor punishment. The desire to maintain public safety combined with the punitive approach has led to significant increases in the population served by the juvenile justice system. Although mandated to receive services, overcrowding, lack of access to service, and high rates of psychiatric needs have prompted a host of lawsuits. More than half of the youth in this system have serious emotional difficulties, and incarcerated juveniles include a disproportionate share of minority youth. Typically, these children and adolescents have not as frequently used mental health services before their entry into juvenile justice systems. High proportions of minority youth reflect the impact of psychosocial adversity and poverty and limitations of service access. Fortunately, there has been a recent tend to attempt an integration of mental health
services within the juvenile justice system. As noted subsequently, alternative models of care, including multisystemic therapy (MST), have been shown to significantly reduce out-of-home placement.

Children being served by state child protective agencies and the child welfare system face other challenges. Children who have been removed from the care of their parents because of abuse or abandonment are at very high risk of mental health problems but have been significantly underserved in terms of mental health services. Given the significant risk posed by trauma and loss of parent contact, the high level of need is understandable (see Chapter 20). Although foster placements are frequently made, many children go through several such placements and may need residential treatment programs. Unfortunately, a lack of appropriate services in these programs leads to custodial care, a lack of emphasis on education and vocational training, and overreliance on medication.

Foster care presents its own problems. Even when, as often happens, children are returned to the care of their biological parents, there may be a lack of support for the child and family in the process of reunification. The various differences among the states in their approach to this problem are noteworthy. Both state and federal courts frequently become involved in attempts to reduce the use of residential treatments and foster care. For some families, involvement with child welfare is the only alternative when children are in need of costly mental health services (inpatient or residential treatment).

With the mandate for educating all children under Public Law 94-142, schools were forced to deal with children with serious learning, developmental, and emotional disorders in a more serious way. This in turn has led to controversies about funding.

Children with psychiatric and developmental disabilities often present with a range of needs, but in most cases, coordination with other providers and agencies is challenging. For example, children may be in the child welfare system, attending school, and have some involvement with the juvenile justice system simultaneously but with little or no coordination among service providers. Recent attempts to foster interagency systems of care through school-based services are of great potential interest in this regard. These clinics can potentially provide health and mental health services within schools, and several different models have now been implemented across the country (Pumariega & Winters, 2007).

The advent of more rigorously defined, manualized psychotherapy treatment models (see Chapter 22) has presented other challenges for community-based care. Although these models have a strong evidence base, they can be difficult to implement effectively in “real-world” (i.e., not university-based clinic) settings. Similar issues arise with drug treatments. As discussed in Chapter 21, a range of effective pharmacological treatments are now available and have an important role in the management of mental health problems in children and adolescents. Their effective use requires careful assessment and management, including monitoring of potential benefits and risks. Particularly in settings where various professionals are involved, medication should be one aspect of comprehensive treatment planning.

In some situations (e.g., management of attention-deficit/hyperactivity disorder in an outpatient setting), primary care providers may be comfortable doing most of the medication management, but for other problems, consultation with a specialist in the area is frequently needed. Depending on the situation, this may involve a more consultative model with the primary care provider working collaboratively with the specialist.


HOME-BASED SERVICES

Home-based programs, particularly if they are more intensive, provide an important alternative to hospitalizations. These services trace their beginning to the efforts of social workers in the early 1900s, who frequently made family visits to help needy families avoid child placement. The effort to development alternatives to detention for youth in the juvenile justice system was also an important stimulus for development of community- and home-based services. The importance psychoanalysis attributed to early experience and the increasing awareness of the adverse effects of institutional rearing on children’s development added further impetus to
the movement for treatments delivered in children’s homes and communities. This movement received additional support in the Adoption Assistance and Child Welfare Act of 1980 (Public Law 96-272), which mandated states to provide supports for avoiding out-of-home placement. Various treatment models have been developed (see Rowland et al., 2007). Their focus, format, and use of various treatment models and procedures vary. Various terms may be used to refer to rather similar treatment programs (e.g., family preservation, intensive-in-home services, and home-based family therapy). They all share a major goal of avoiding removal of children from families. They also typically differ in several ways from more traditional, office-based treatment settings. Services are intensive, provided in home and community settings, and are provided at times convenient for the family. Although treatment is usually time limited, intensive support (including availability for crises and emergencies) is available. In contrast to more traditional models, the clinician typically works with a small case load at any point in time. Treatment approaches typically draw on multiple theoretical models. For example, the crisis intervention model provides brief (4 to 6 weeks) and concrete support. The home-based model has a somewhat expanded clinical orientation with more highly trained clinicians, typically has a duration of several months, and makes use of a broader range of clinical intervention strategies. In contrast, the family treatment model typically uses case manager (as opposed to therapists) for home-based service delivery with therapists available in an outpatient setting.

Research on outcomes of these programs has increased in sophistication over the years. Early research consisted mostly of program description and limited outcome data. Early enthusiasm was tempered as more sophisticated research approaches were used and important questions of the effectiveness of these program were raised, suggesting that the crisis intervention approach had relatively modest effects on averting out-of-home placements. Lindsey et al. (2002) summarized some of the reasons that early models were less effective, including lack of attention to important therapeutic issues, lack of flexibility in approach, degree of psychosocial stresses encountered, brevity of the intervention, and difficulties in targeting children most at risk. As a result of these concerns, new approaches to home-based intervention have been developed. These include Project 12 Ways and MST, both of which provide intensive home-based interventions in family and community settings. Project 12 Ways focuses on families in which issues of abuse or neglect place a child at risk for placement. Evaluation results have been promising. The MST approach has similarly been shown in a randomized clinical trial (RCT) to reduce the risk of placement for adolescents relative to physical abuse. The MST model has also been shown to be effective in work with youth at risk for placement because of juvenile justice or substance abuse issues, and its emphasis on ongoing staff training and quality assurance (to ensure treatment fidelity) is an important aspects of this approach. A series of research reports have demonstrated the efficacy of MST in reducing rates of re-arrest and out-of home placements with an average effect size (see Chapter 22) of 0.55. In this model, the therapist usually works with between four and six families for a period of 4 or 5 sessions with contacts with family and other important individuals (e.g., teachers, neighbors, peers) to the youth at risk. Problem behaviors are addressed through a range of treatment modalities (e.g., parent management training, behavioral or cognitive behavioral treatments, drug treatments).

Other treatment models include multidimensional treatment foster care (MTFC) and functional family therapy (FFT). Although not home based, both share a strong family focus. For example, in the MTFC approach for children in foster care, a set of highly trained foster parents are provided along with a full-time case manager and other therapists and supporters. The FFT approach provides a behavioral family therapy approach with emphasis on parent training and a focus on behaviors associated with delinquency.

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Aug 1, 2016 | Posted by in PSYCHIATRY | Comments Off on ▪ Treatment Programs: A Continuum of Approaches

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