Research Networks

Network on Youth Mental Health Care

Objectives

One-fifth of the children in the United States have a diagnosable mental disorder. About 10 percent of American children receive some form of mental health care each year. Unfortunately, many of those who do receive treatment may not be getting effective treatment: most of the mental health interventions children receive today have not been shown scientifically to work.

It’s not that effective treatments don’t exist. In fact, there are evidence-based interventions for most of the problems that bring children and adolescents into treatment. The problem is that most of these interventions are used primarily in universities and other research settings. Out in the field, in most clinical settings, care is generally not guided by empirical evidence, and the outcomes are not nearly as good.

Why is there such a gap between state-of-the-art, evidence-based treatment and what is typically delivered in practice? And how can scientific advances be brought into real-world settings, where they have the potential to benefit millions of children with mental disorders? These are the questions that drive the Network on Youth Mental Health Care. Its objectives are to identify scientifically validated treatments, make them practical for use in clinical settings, and develop strategies to encourage and facilitate their implementation — bringing appropriate, effective, and efficient care to young people with mental illness.

Approach

The Network’s core group members represent the fields of psychology, pediatrics, psychiatry, sociology, social work, anthropology, statistics, family advocacy, and state mental health program administration. They began their work by identifying the treatments that have the strongest scientific support. Next, they examined reasons for the gap between science and practice — including inadequate financing, inappropriately designed benefits, and fragmentation of services — and they identified steps that could bring research findings into real-world settings. From that exploration grew two complementary, multi-site research projects:

Clinic Treatment Project. This study will help practitioners in busy, community-based clinics incorporate evidence-based procedures into their work, and then assess whether they adhere to these procedures and how this affects outcomes for the children and families they serve. The researchers are testing two different approaches to organizing and delivering evidence-based practices: standard manuals, used exactly as they were originally tested in clinical trials, and modular manuals that can be individualized for each child using a guiding clinical algorithm. The special significance of the study lies in its use of real-world clinics, the practitioners they employ, and the children they ordinarily see.

Clinic Systems Project. The second project is a descriptive study — the first ever to examine the factors that are likely to influence the use of evidence-based practices in mental health clinics and systems. The factors being studied include governance structures across several service sectors, including mental health, child welfare, juvenile justice, education, and health; service financing structures and reimbursement mechanisms; and service provider organizations. The information for this project will be provided by the CEOs and clinical staff of 200 clinics nationwide.

Progress and Findings

The timeline for the Clinic Treatment Project calls for enrollment of children and families through the summer of 2008, continued treatment and monitoring of child and family outcomes until late spring of 2009, and data analysis and preparation of findings extending well into 2010. While this project continues, network members have published a description of the strategy they have developed for using information resources to guide clinical decision-making in the project (Chorpita et al., 2008), as well as the findings of some early ethnographic work embedded within the project (Palinkas et al., 2008). In addition, the Network has completed the Clinic Systems Project, and a number of findings have now been reported (see Schoenwald, Kelleher, & Weisz, 2008). This section summarizes some key points of these Network publications.

The care provided to children in the Clinic Treatment Project is guided by a set of information resources and a clinical decision-making logic that have been developed to support the use of evidence-based procedures in clinical care settings. These resources, the logic, and the visual display that guides their use are described in an article by member Bruce Chorpita and Network and project colleagues (Chorpita et al., 2008). As one example, the Network has developed a brief standardized problem checklist that can be administered in a few minutes over the phone, to children in treatment and to their parents. In the Clinic Treatment Project, this checklist is administered weekly, to monitor each child’s progress, with improvement indexed by reductions in problem scores over time. The figure below shows the “dashboard” used by the Network to display these scores, in this case for a child in treatment for depression. The top panel shows changes in the child’s problem scores from day 01 to day 130, as reported by the child (in red) and the parent (in green); the “internalizing” score (which includes depression-related problems) for child and parent drops sharply from about day 30 to about day 70; by day 105, the score is at zero for both child and parent, and it remains at zero for the remainder of treatment, suggesting a treatment success. The middle panel displays treatment activity each week; the names of the various depression treatment procedures (or “modules”) are shown at the left, the modules planned for a particular week are shown by circles in the body of the panel, and the modules actually carried out in the treatment sessions are shown by red diamonds. With this arrangement, “adherence” to the treatment plan is signified by red diamonds within circles. More information is packed into the dashboard, and other information resources and display strategies are presented, as discussed by Chorpita et al. (2008). The broad idea conveyed in this article is that the Network has developed an array of information and decision supports that can be used to facilitate the systematic and thoughtful use of evidence-based practices with children.

An important part of the Network’s focus on evidence-based practices has been an effort to understand why some clinicians who are trained to use these practices soon abandon them, while others readily adopt the new practices and continue to use them over time. An ethnographic approach to this question has been taken by member Larry Palinkas and his Network colleagues (Palinkas et al., 2008). Using participant observation and extended semi-structured interviews with Network trainers and supervisors, plus 52 clinicians who were trained for the Clinic Treatment Project, Palinkas and colleagues identified a number of factors associated with the clinicians’ perceived likelihood of continuing to use the evidence-based treatments in which they had received training. Some of these factors predated clinicians’ actual use of the treatments; for example, when the new treatments fit well with the clinicians’ previous views and practices, the clinicians expected to continue to use them in the future; not so when the treatments clashed with clinicians’ own views and previous practices. In addition, clinicians who had positive interactions with their supervisors, and those who found their supervisors to be flexible about ways of implementing the treatments, also anticipated continued long-term use of the evidence-based treatments. Overall, the findings suggested that sustainability of evidence-based practices is fostered by a blend of pre- and post-implementation factors, some of which are under the control of trainers and supervisors.

Within the Network’s Clinic Systems Project, the national survey of mental health clinics serving children made it clear that some important trends are now prevalent around the country. These include delivery of child mental health care through private organizations that rely on public reimbursement (especially Medicaid), continued provision of training programs and clinical supervision to improve care, the use of productivity requirements to ensure that clinicians earn the income needed for organizational stability, and—importantly—monitoring of the outcomes of treatment. An interesting and unexpected finding was that for-profit organizations are actually more likely than non-profit organizations to offer new treatments and services.

Member Charles Glisson and his Network colleagues (Glisson et al., 2008a,b) used Glisson’s standardized Organizational Social Context (OSC) profiling system to assess the culture and climate of the 200 clinics in our national sample, relative to national norms. They found that organizational characteristics predicted important outcomes for the clinics. For example, clinics showing the most favorable climates (e.g., engaged and cooperative) had annual staff turnover rates less than half the rates of clinics with the worst climates (e.g., stressful, emotionally draining; 10% vs. 22%); and clinics with the best organizational culture profiles (e.g., client-focused, emphasis on building staff competence) were able to sustain new treatment and service programs more than twice as long as clinics with the worst organizational cultures (e.g., rigid, bureaucratic).

Members Kimberly Hoagwood and Evelyn Green and their Network colleagues (Hoagwood et al., 2008) complemented the national survey of clinics with a national survey of family advocacy organization directors in the same geographic areas as the 200 clinics. These family-focused organizations often play important roles as voices for treated children and their families within the system of mental health care in a community. The survey revealed a network of local grassroots organizations, typically comprised of small groups with fragile fiscal support but a strong idealistic commitment to family involvement in children’s mental health care. High on the agenda for these organizations are efforts to promote effective screening to identify children who have mental health care needs, sound assessment of diagnoses and problems, effective treatments, including evidence-based interventions, and strong relationships between therapists and family members. This important work highlights the expanding role—and the potential and challenges—of families as consumers in the planning and delivery of mental health services by professionals.

Next Steps

As a final phase of its work, dubbed ChildSTEPs III, the Network will integrate previously separate elements of its approach to improving clinical care for children and implement the integrated approach within test sites in California and Maine. As an example, in the Clinic Treatment Project, treating clinicians used treatment manuals, and clinical supervisors had access to weekly assessments of child progress, displayed on an electronic dashboard; in ChildSTEPs III, the treating clinicians will use the manuals guided by their own direct access to the dashboard. The expectation is that clinicians’ ability to adjust and improve treatment will be improved by ongoing feedback about how each child is responding to treatment. In addition, in ChildSTEPs III, the family component, a subject of the Network’s previous survey research, will be brought directly into the treatment process, with strategies employed for engaging families’ support of their child’s treatment. In addition, the Network is seeking ways to link an organizational perspective to the learning potential of ChildSTEPs III. The hope is that such previously separate strands of the Network’s treatment studies can be woven together to form a seamless fabric, magnifying the benefit to children and their families.