Author Topic: ASTART Report: Treatment Research Lacks Good Science  (Read 1883 times)

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Offline Ursus

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ASTART Report: Treatment Research Lacks Good Science
« on: December 09, 2011, 08:22:41 PM »
An oft-cited "research study" in Aspen Ed marketing literature and web presence is the "Report of Findings from a Multi-Center Study of Youth Outcomes in Private Residential Treatment" by Ellen Behrens and Kristin Satterfield.

This "report of findings" never made it to publication in a peer-reviewed journal. Rather, after its debut at the 114th Annual Convention of the American Psychological Association (New Orleans, Louisiana; August 12, 2006), Aspen opted to "publish" it via copious use in their marketing and promotional materials.

ASTART has recently come out with a Report of their own which seriously questions the scientific soundness, perhaps also the scientific validity, of many of the "findings" of the Behrens & Satterfield Report.

Here's ASTART's email announcement thereof:

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ASTART Report: Treatment Research Lacks Good Science

We at ASTART have long been concerned about deceptive tactics used to market teen residential programs, and the dearth of research on the effectiveness of residential programs. One study of wilderness programs is frequently cited in youth residential treatment marketing and promotional materials: a study by Ellen Behrens and Kristin Satterfield.

ASTART has released a new report detailing the problems with this research, including:

• Conflicts of interest
• Flaws in methodology
• Questionable findings

Further, industry websites make several claims about the findings and their meaning that go far beyond what the data show, and that our experts believe are misleading to parents, providers and youth.

ASTART invites advocates, colleagues and supporters to read and share our new report, and access more resources at our website.

Read: Treatment Research Lacks Good Science
Visit: http://www.astartforteens.org
Support: Help ASTART Protect Teens and Families
Contact: Email ASTART

Thank you!
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Offline Ursus

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Re: ASTART Report: Treatment Research Lacks Good Science
« Reply #1 on: December 09, 2011, 08:50:45 PM »
To help jog folk's memories, the Behrens & Satterfield "Report of Findings" has also been the subject of many a thread here on fornits, e.g., to name but a few:

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Offline cmack

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Re: ASTART Report: Treatment Research Lacks Good Science
« Reply #2 on: December 10, 2011, 12:10:42 AM »
Thanks for posting Ursus. This report needs to be gotten into the hands of parents. It could be a powerful tool to dissuade parents from placing their teens in programs as well convincing others to pull their children out of existing placements.
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Offline AuntieEm2

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Re: ASTART Report: Treatment Research Lacks Good Science
« Reply #3 on: December 10, 2011, 12:26:00 PM »
Aspen is very fond of claiming they have evidence their programs work, and here is their favorite research report completely discredited.

Too many parents who placed their children with Aspen programs were bamboozled by this phony research. It's marketing, not research.

Auntie Em
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Offline Ursus

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ASTART Report: Treatment Research Lacks Good Science
« Reply #4 on: December 11, 2011, 10:28:09 AM »
So... here's that report in full (pdf download):


[Alternate source (webpage link, contains some formatting differences)]

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S E P T · 2 0 1 1
ASTART Report: Treatment Research Lacks Good Science

A DETAILED SCIENTIFIC CRITIQUE OF BEHRENS STUDY FINDINGS

By Nicole Bush, PhD, Robert Friedman, PhD, Charley Huffine, MD, Barbara Huff, and Phil Elberg, JD

We at ASTART have been concerned about the marketing of teen residential programs that highlights the findings from a study by Ellen Behrens and Kristin Satterfield. Two reports are widely cited in youth residential treatment marketing and promotional materials: Report of Findings from a Multi-Center Study of Youth Outcomes in Private Residential Treatment (Aug 2006; available on the web) and A Multi-Center, Longitudinal Study of Youth Outcomes in Private Residential Treatment Programs (April 2007; not publicly available, summary of select findings available via marketing materials).

There is a dearth of research on the effectiveness of residential programs, and this study does provide some information for consideration. However, there are striking conflicts of interest in the research and several flaws in the methodology of the study that make its findings questionable. Further, industry websites make several claims about the findings and their meaning that go far beyond what the data show, and that our experts believe are misleading to parents, providers and youth.

Study funders have conflict of interest

This study was funded by a company that owns and operates for-profit residential programs, which is a conflict of interest. When for-profit companies pay for research to confirm the effectiveness of their product or treatment, their goal is generally to find anything that might act as evidence for the effectiveness of their facilities. In such situations, studies are designed and data is very often analyzed and presented in a way that is most beneficial to the company, rather than what is most scientific or accurate, and it is quite difficult for the consumer to detect and understand this bias.

Researcher not "independent," and Aspen not just a "participant"

The Aspen Education Group ("Aspen") website is misleading when it begins to describe the research by stating "Aspen Education Group participated in the nation's first large-scale study of its kind"—Aspen funded the research on their own programs, making them far more than just "participants." Aspen's website also claims that the study was conducted by an independent research company, yet Behrens's company, Canyon Consulting, was hired and paid by Aspen to perform this research, which can influence objectivity.

Importantly, the 2006 paper does not indicate that all 9 participating programs were owned by Aspen, and any conflict of interest disclosures made are relatively hidden from the consumer (e.g. the study authors briefly list Aspen as a funder only at the very end of their manuscript reference list, embedded in a paragraph with unrelated content, and Aspen discloses that they funded the research subtly at the end of the webpage after presenting their eye-catching, selective interpretation of the findings).

Financial motives and incentives call research into question

The findings presented in the reports go beyond the actual data and suggest the programs studied (or similar "struggling teen residential treatment programs") are effective—which is likely to influence their earnings potential, and thus, the financial interests of the company should be strongly considered when viewing these results.

The programs involved in the research were Academy at Swift River, Aspen Ranch, Copper Canyon Academy, Mount Bachelor Academy, Stone Mountain School, Pine Ridge Academy, SunHawk Academy, Turnabout Ranch, and Youth Care, Inc. The widely publicized 2006 report does not acknowledge that the nine widely varying programs have the same parent company (Aspen Education Group). The 2007 report does state this, but this report is not publicly available and this information is not included in marketing materials that cite this research.

Results as presented cannot be attributed to the "treatment"

The study uses a pre-post design with no comparison group, so results cannot be attributed to the "treatment." This study and the reports associated with it do not have control groups (a group of similar youth who needed treatment but did not receive it). As teens mature, many symptoms decrease naturally without any treatment.

Without any comparison group, it is not possible to determine what would have happened without any treatment. Many youth would decrease in symptoms many months to many years later as they mature or as depression remits naturally, regardless of treatment, and so declines in symptoms cannot be attributed to the Aspen programs given the study design (although Aspen routinely makes this claim when marketing their programs).

It is typical with study designs that use scores on behavior problem checklists (such as the Achenbach CBCL that they used to measure problems) will be higher at admission than at any other time—this is in fact the time of greatest crisis. So showing a decline in symptoms over time could really be unrelated to attendance in such programs.

The timing and quality of the outcomes examined make the findings questionable

The 2006 findings are based on reports from the children and parents at two critical times--first when the child enters the program which is a time when the parents and child see things at their worst, and second when the child is being discharged, which may be a time of optimism. Parents were asked to report on their child's status when they had not lived around them for months or years.

The 2006 report fails to describe the timing of the "discharge" assessment and Aspen program's criteria for program completion. The problem with this is that youth in these programs are NOT generally discharged unless they report decreases in depression and anger and show improved communication with parents, thus parents are usually quite pleased with the adolescent's behavior upon discharge (the authors do acknowledge this possibility on p. 13) and youth often report that they are not experiencing problems in order to leave the program. Also, parents have not been living with or regularly interacting with their child while he/she was away, so their perceptions of their child's improvement are likely not reflective of true functioning.

It is more optimal to report the assessment of youth and family functioning several months after discharge, as those seem to be times when (after a brief "honeymoon") many youth return to drug use, acting out behavior, and depression, etc. and significant increases in family discord occur. The 2007 longitudinal report (which is not publicly available) does report those findings, but as we note below, only in a biased sample, and the follow-up findings are not nearly as positive as the discharge findings presented—even with that biased sample.

No valid, independent measures of improvements in functioning

The authors describe effects as "change in functioning" which is misleading. Measures are only for changes in perceptions of functioning. There are no valid, independent measures of actual functioning. There is also no discussion of how the parents came to have perceptions of their children's functioning. The vast majority of these youth lived apart from their parents the entire treatment period and often had few if any home visits in between. How much time did parents actually spend with them during treatment or after discharge? Were parent reports based on what staff told them? Was this consistent across all programs? There may be other interpretations of these perceptions, other than that the child has made progress. The reports from the child and family may be influenced by the context and may have little to do with actual changes in the child/family.

The sample used in analyses is quite biased—making the findings biased

Children who do poorly in Aspen programs are dropped from the analyses in both reports. Throwing out subjects from your analyses because your treatment did not work with them significantly biases your findings to be positive, and is a questionable practice.

It is noteworthy that in the 2006 the clinical teams at these nine programs classified 50 of the 551 youngsters who were in the discharged sample as "treatment beyond scope." This refers to a group of youngsters for whom the program was not a suitable match, and who were transferred to "a more appropriate setting." The authors report that this group did less well than the others, but their data were excluded from the analyses because "it was deemed that a program making an early referral for students who required alternative clinical care would constitute appropriate, ethical care rather than a 'failure' on the part of the program."

Youth who left the program are not included in the analysis

Aspen programs enrolled those youth and "treated them" and it didn't work so they were sent elsewhere, thus they should have been included in the analyses. "Intention to treat analysis" (in which you count dropouts and non-responders to surveys as "failures of treatment" or at least as "more likely to be failures") is the standard for treatment studies. For example, if you have a drug that produces 100% success at lifting depression in the 13 people who didn't stop taking it due to side effects when 87% dropped out of the study, it's not exactly going to be approved by the FDA or become a widely-prescribed drug.

Missing data creates a significant bias in the data

The authors misrepresent the sample size throughout the papers and they do not handle analysis of their missing data in an appropriate scientific manner. The results for the majority of youth—six out of ten—are dropped from the reporting.

In both the 2006 and 2007 reports, there is tremendous inconsistency in the sample used in analyses. In fact, most families did not complete the majority of assessments during the study, so their data is missing from outcome analyses. In fact, 60% of parents and 37% of youth did not complete discharge assessments, and, on average, 81% of the youth and 73% of parents assessed at intake didn't participate in the follow-up study assessments!

This "missing data" described above significantly biases the findings—generally, families most satisfied with treatment are the ones that complete all forms in a timely fashion and those who are dissatisfied with the services or continue to be in crisis do not fill out questionnaires. Subsequently, the write ups of the findings are, at times, misleading in that they compare findings from the admission sample to those in the pre-post-test sample, suggesting they are the same group of youth across findings, which is not true because of the huge drop in sample size.

In the abstract for the 2006 paper, the authors talk about a "sample of nearly 1000 adolescents, from nine private residential programs," which is misleading, given the numbers who actually participated in the key data collection were considerably fewer. Later, their method section acknowledges that, for their analyses of changes from admission to discharge, their sample was actually only 403 adolescents and 211 parents, but they do not conduct analyses to discern whether it was the "best functioning youth" to begin with who completed both admission and discharge data--although that is easy to test and should be reported. This report does not address this when interpreting the findings or discuss it as a limitation of the study.

Similarly, the 2007 report starts off talking about a study of 1027 kids, but at the end there are reports from 138 kids and 250 parents (response rates at 12 months post-discharge of 13.5% for young people and 24.5% for parents). In Table 2, the authors report percent of surveys returned for each time period, and they later describe analyses to assess for response bias. The 2007 report does acknowledge that for those who actually completed discharge surveys (already a biased sample from those who were assessed at intake), those who didn't return follow-up status surveys reported less treatment satisfaction, less change in their children's problems from treatment, and higher problems at discharge (in fact, nearly 50% higher total problems for those youth)—which means that the results reported for the longitudinal follow up are based on a sample of youth with the lowest problems at discharge whose parents were most satisfied with the programs.

Importantly, non-responders were also four times more likely to have pulled their children out of treatment against program advice, which suggests they did not find the treatment optimal—and their children's outcomes are not included in the analyses.

Inadequate statistical methods were used to analyze the data

A more appropriate model would have been to use a "nested" design for analyses (e.g. multilevel modeling), because the data was drawn from nine discrete sites, and proper analyses should account for that in the statistical model. Otherwise, the effects of one program can drive effects for the entire analyses and lead to biased results, or some programs with clear harm can be "washed out" by programs that are helpful.

Indeed, in the 2007 report, the authors state that "curriculum and programming across sites was very diverse" (p.3), which implies that effects across sites may be very different and should be considered. So nested analyses should be conducted to assess for that before you make statements about the entire sample and "all Aspen" or "private residential treatment programs."

Even within the biased sample, substance use barely decreases

It is important to note that, even in this biased sample, youth report a substantial increase in alcohol and drug use over the 12 month post-discharge period, and while this increase still doesn't bring them to the level it was reported to be at admission, it is pretty high and close to rates at admission (for alcohol, 3.02 at admission, 1.24 at discharge, and 2.66 one year post-discharge—for drugs it is 3.84 at admission, 1.29 at discharge, and 2.68 one year post-discharge).

This suggests that youth still had significant substance use problems, at almost their original rate, after their lengthy and expensive treatment. These results can only be seen by carefully reviewing the tables as the authors do not write about these results or discuss them in their paper, instead focusing their comments on outcomes with better change results.

There is precious little discussion of the treatment that is purported to be effective

Reading the reports, one can find no discussion of what "treatment" took place. What were the treatment modalities used? "Residential" is a place, not a "treatment modality." There is no description making it clear what was being done to lead to the gains they claim. And it is doubtful that all nine programs did the same thing, equally well or equally well for all youth, especially given the acknowledgment that the nine programs were highly varied in enrollees and treatment modality.

Additionally, one of the nine programs evaluated, Mount Bachelor Academy, was recently shut down by the authorities for documented abuse of youth, citing, in particular, that the "treatment modality" itself was found to be psychologically damaging to the participants and conducted by unqualified staff who lacked mental health training.

"Clinical team" and their credentials and methods not identified

Finally, no mention is made in the report of who made up the "clinical team," or how they were trained to discern "discharge status"—typically there would be a report of how consistency across raters was established (or "reliability across ratings"). It is unusual for quality research to not describe this central measure of their study.

Weaknesses and limitations of the study are not explained

The study authors do not adequately acknowledge the study weaknesses or alternative explanations for results. To their credit, Behrens and Satterfield acknowledge a few of their study's limitations in their reports. They note the need for a control group and the need for further research to determine the merit of these findings, especially in light of the many surprising findings. They also acknowledge that parents may "underreport" their child's symptoms at discharge if they are motivated to release their child from treatment prior to the time advised by program staff, which may bias outcome data in a positive fashion, misrepresenting the efficacy of the treatment. However, as described above, they often misrepresent their study sample size and largely fail to acknowledge the many methodological flaws in their study and alternative interpretations of surprising findings that might reflect weaknesses on the part of their funders' programs.

The study authors and study funders overstate the findings

There is insufficient caution about the findings in both the 2006 and 2007 reports by Behrens and Satterfield, and certainly by the for-profit industry websites. Despite the many concerns and flaws outlined above, the 2007 report states, "Clearly, the present study provides evidence of lasting benefit for youth in private residential treatment."(p 16), and the Aspen website states "Aspen Education Group's Residential Therapeutic Schools and Programs: Proven Effective." These studies simply do not support these claims.

Scientific method and research standards articulate that one study, especially a study with poor methodology and biased analyses, cannot "provide evidence of lasting benefit" or "prove" treatments effective. The Aspen website also states that "Aspen's programs helped teens to develop stronger emotional well-being" and that "teens behave better as a result of Aspen's programs," attributing any improvements (real or imagined) in youth health to Aspen programming, but as described above, research that lacks experimental design (such as having a control group) cannot determine the cause of changes in outcomes.

There are concerning findings that Aspen does not highlight on its website

The omissions suggest that there is a one-size-fits-all treatment, and that outside factors—such as age, parental income or use of medication—have no influence on a child's functioning during treatment.

First, it is striking that the only variables in analyses that predicted improvement over time in the regression analyses were things such as youth having "no mood disorder" and "low level of problems at entry" etc. This quote on their website should raise intense red flags: "In other words, change in functioning during treatment does not depend on age, gender, ethnicity, parental income, number and type of problems, presence/absence of psychiatric medication, prior treatment, length of stay, or discharge status" (2006, p. 12). It is quite unusual for all of those factors to NOT relate to treatment effectiveness—making it likely that this study has invalid data. The authors comment on this being a surprising finding, and in an Aspen website video about the 2007 report Behrens describes the findings as "remarkable," but it is more than surprising—it is alarming.

It is generally accepted in the field of psychological research that there are not treatments that have universally positive effects for such a range of complex youth problems. For example even highly-focused interventions by the nation's leaders in ADHD research with large-scale, multisite, expert-run interventions struggle to demonstrate sizable positive effects of treatment for ADHD. Moreover, the world's leading researchers on Depression generally only find successful remission of symptoms in one-third to one-half of their subjects, and not a 100 percent decline in symptoms.

Further, at admission, parents rated their youngsters as having more severe problems than the youngsters rated themselves as having, but this was reversed at discharge—then the youth rated themselves as having more serious problems than did their parents. The finding that parents rated their teens as having more serious problems at admission than the teens themselves did is very typical, but the finding at discharge that the teens rated themselves as having more serious problems is unusual. One interpretation is that the parents were clearly more satisfied consumers of service than were the adolescents themselves. Modern standards of practice articulate the importance of meeting the rights, needs, and perspectives of the youth undergoing the treatment, so this youth perspective is important.

Other Concerns About Scientific Merit

The Behrens and Satterfield reports have not been confirmed by any outside scientists or refereed competitive science publications as scientific evidence. "Peer-review" means experts on the topics that are investigated in the study evaluate the research and critique the findings to determine whether it is of high enough quality to be published. Research findings that have not been published in peer-reviewed journals are of questionable merit.

Although one report was apparently presented as a "poster" at the American Psychological Association (APA) meeting in 2006, conferences are only a forum for sharing findings, and presentation at one does not suggest that the APA approved of the study or that any objective scientists reviewed the study to discern whether the study was conducted properly and interpreted with appropriate caution.

The 2006 report also is published in an outdoor behavioral health trade journal, which appears to provide some enhanced credibility, but it must be noted that the criteria and motives for publication in trade journals can be very different than that of competitive science journals. The second longitudinal study is presented in a video presentation or slide presentation on the Aspen website, and the accompanying paper can only be obtained by request to Ellen Behrens as it is not publicly available. Given this, the findings from both reports should be interpreted with great caution.

These findings have not been replicated

A major principal of scientific method is that research findings must be replicated by another independent researcher in order to consider study findings scientifically valid—otherwise one cannot determine whether a particular finding was due to chance (a fluke) or whether the first researcher's bias was influencing results. Particularly in treatment research, it is very important to replicate findings, as the effects of therapies are quite complex and varied, and multiple studies are needed to understand when and how they work, and for whom. Without replication, the Behrens and Satterfield findings are questionable.

Summary

In summary, this study has major scientific flaws. There is excessive bias in the methodology and analyses that favor positive treatment outcomes, which is particularly concerning given that Aspen paid for the research. Further, Aspen appears to "cherry pick" the results that support their industry and programs and makes claims about the causes of change in children's health that are not justified by this data. As it stands, this research, as is currently presented to the public, appears to be more marketing and promotion than scientific research on treatment efficacy, so it should be viewed with great caution.

Although many studies require replication or have methodological flaws, this particular body of research has considerable weaknesses and obvious biases. Moreover, research published in rigorous, well-respected scientific journals suggests that the techniques used by some private residential wilderness programs (including techniques used by the programs evaluated in this research) use approaches that can be harmful to youth. Specifically, research has shown that approaches such as "scared straight," expressive-experiential psychotherapies (e.g., releasing anger or fear by yelling, criticism, etc), boot camp interventions, and peer-group interventions for conduct disorder are likely to harm some youth (Lilienfeld, 2007).

We provide our perspectives on this study and the use of its findings to offer alternative views on the data collected and presented. We are not and have not been privy to the research design process or writing of the results but base our comments on the information presented by the researchers and the funders in their written documents and web-based media presentations.

We recognize the methodological challenges of research like this and acknowledge that it is difficult to conduct—it is hard to obtain comparison groups, to prevent attrition in the subject population, and to get good baseline and follow-up data. The fact that it is hard, however, does not diminish the responsibility of researchers to highlight these problems, and only increases the responsibility of researchers to express conclusions in a conservative way.

We strongly believe that there is great need for research assessing the effectiveness of residential treatment programs for "struggling teens" and their families, and we would like to see such research funded and published. However, this need must be met by scientifically rigorous, unbiased research conducted by financially objective parties.

We also acknowledge that we approach this research from our own perspective, which is one of concern about inappropriate and even harmful or abusive treatment. This is why at every stage in a project like this it is important to have unbiased people, who lack conflict of interest, involved—if not in designing the study, then in reviewing the design; if not in drawing conclusions, then in reviewing the conclusions that have been drawn and the analyses that have been done. While we offer our own view of the data here, we welcome views of others who are less involved in this industry, and hope these comments promote advancements in the science and improvements in the treatment of youth and their families.

Last updated: 11/29/11
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Offline wdtony

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Re: ASTART Report: Treatment Research Lacks Good Science
« Reply #5 on: December 13, 2011, 04:51:40 AM »
Great post Ursus.

Reminded me about KHK's success rate being close to 90%. My mother helped gather the research when she was on executive staff as public relations director at the program. She later told me some details.

*For instance only program graduates were included in the "study".
*The data was gathered by phone calls only.
*If no one answered or didn't want to be a part of the study, they were not included.
*The study was conducted entirely by KHK executive staff and sent to a research organization to print the findings. These "fondings" were written as KHK had sent them and transposed as KHK wished. KHK (and KHK only) directly paid the research organization.
*There were only 50 or 60 people who were included in the study (my mother made most of the calls).
*The questions asked were about current drug use, had they stayed sober etc. These were questions which if someone were to admit to having relapsed, this could have resulted in dire consequences for the ex-program kid. My mother knew that to tell the truth about these questions was unlikely.

i.e. a totally bogus study.

Strangely enough (prior to the bogus study my mother took part in) KHK used a licensed psychologist/program parent to conduct a "real study of KHK's methods and outcomes. After this study was concluded, it was quickly hidden away due to the fact that it proved that the methods used in KHK were not helpful and, in fact, harmful and less effective than other treatment methods in general.

I know this "legitimate" study occurred because it is written in old KHK newsletters that I possess, but there is no trace of this study existing otherwise. It has merely been disappeared.
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Offline Ursus

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KHK study that was "disappeared"
« Reply #6 on: December 13, 2011, 11:04:24 AM »
Quote from: "wdtony"
Strangely enough (prior to the bogus study my mother took part in) KHK used a licensed psychologist/program parent to conduct a "real study of KHK's methods and outcomes. After this study was concluded, it was quickly hidden away due to the fact that it proved that the methods used in KHK were not helpful and, in fact, harmful and less effective than other treatment methods in general.

I know this "legitimate" study occurred because it is written in old KHK newsletters that I possess, but there is no trace of this study existing otherwise. It has merely been disappeared.
I bet a lot of folks would be grateful (I know *I* would be) if you transcribed or scanned those sections mentioning that old study and posted them somewhere on this forum. I imagine that the results probably didn't get published in the newsletters (save perhaps in diluted form), but the mere fact that this study was undertaken, and then dropped, is quite telling.

It might also inspire someone else to add to those posts, who may have more info or who may know what happened to that study. Ya never know...
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Offline wdtony

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Re: ASTART Report: Treatment Research Lacks Good Science
« Reply #7 on: December 13, 2011, 05:04:54 PM »
Yes, they are in diluted form. I will attempt to scan and post them online somehow. Then I will post the link here.
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Offline Ursus

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Researcher not "independent," and Aspen not just a "particip
« Reply #8 on: December 14, 2011, 07:32:51 PM »
From the above article:

    Researcher not "independent," and Aspen not just a "participant"

    The Aspen Education Group ("Aspen") website is misleading when it begins to describe the research by stating "Aspen Education Group participated in the nation's first large-scale study of its kind"—Aspen funded the research on their own programs, making them far more than just "participants." Aspen's website also claims that the study was conducted by an independent research company, yet Behrens's company, Canyon Consulting, was hired and paid by Aspen to perform this research, which can influence objectivity.[/list][/size]
    Canyon Research & Consulting, if I'm not mistaken, primarily does research on Aspen programs (although there was a preliminary "study" done for Redcliff Ascent prior to the study that came out in 2006). I wonder if many folk being bombarded with this marketing hooplah presented as "research" ... really know the full extent of Behren's associations with programs?
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    Offline wdtony

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    Re: ASTART Report: Treatment Research Lacks Good Science
    « Reply #9 on: December 15, 2011, 04:49:46 AM »
    In the newsletters it states that a grant was being sought for this study about KHK's methods. But, in other newsletters it is stated that the government grant for the study was not granted. I think this was the smokescreen to cover the bad study.

    I do not have every newsletter posted online yet, but somewhere I had read that the executive staff member had conducted this study with negative results.

    I am sorry that I can't find that newsletter, but I will look through my files and try to find it.

    At any rate, if Penny Walker (Program Director) wanted a true, research study about KHK that would have increased profits, it would have been conducted.

    In her 25 years as program director, she never produced such a study. I will keep looking.
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    Offline wdtony

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    Re: ASTART Report: Treatment Research Lacks Good Science
    « Reply #10 on: December 15, 2011, 04:59:39 AM »
    I posted some here: http://www.pfctruth.com/apps/photos/

    Far from complete.
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    Offline cmack

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    KHK Documents
    « Reply #11 on: December 15, 2011, 07:28:20 AM »
    Quote from: "wdtony"
    I posted some here: http://www.pfctruth.com/apps/photos/

    Far from complete.

    Thanks, very interesting. Below are a few of the 66 images wdtony uploaded.












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    Offline cmack

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    Surgeon General's Mental Health Report
    « Reply #12 on: January 03, 2012, 04:08:13 PM »
    In keeping with the general theme of the ASTART Report I thought some might appreciate having the Surgeon General's Report available for quick reference.

    http://www.surgeongeneral.gov/library/m ... /sec7.html

    Services Interventions

    Treatment Interventions

    This section examines the effectiveness of such treatment interventions as outpatient, partial hospitalization/day, residential, inpatient treatments, and medication. Much of the research on their effectiveness deals with children’s outcomes largely independent of diagnosis. As noted earlier in this chapter (see Treatment Strategies), practitioners and researchers previously shied away from diagnosis because of the inherent difficulty of making a diagnosis, concerns about labeling children, and the limited usefulness of DSM classifications for children. Each intervention was developed to treat a host of mental health conditions in children and adolescents. Each also was delivered in a wide range of settings. Over time, the combination of interventions and settings, with the exception of medication, became conceptualized as “treatments,” which stimulated research on their effectiveness (Goldman, 1998). They are not, however, treatments in the conventional sense of the term because they are less specific than other treatments with respect to indications, intensity (i.e., “dose”), and elements of the intervention. There is little research describing treatment in actual clinical settings.

    Outpatient Treatment
    The term “outpatient treatment” covers a large variety of therapeutic approaches, with most falling into the broad theoretical categories of the psychodynamic, interpersonal, and behavioral psychotherapy. Outpatient psychotherapy is the most common form of treatment for children and adolescents, utilized annually by an estimated 5 to 10 percent of children and their families in the United States (Burns et al., 1998). It is also the most extensively studied intervention and, with over 300 studies, has the strongest research base (Weisz et al., 1998). Outpatient therapy is offered to individuals, groups, or families, usually in a clinic or private office. The duration of treatment varies from 6 to 12 weekly sessions to a year or longer. Newer outpatient interventions (e.g., case management, home-based therapy) that were developed more recently for youth with severe disorders are provided with greater frequency (i.e., daily) in the home, school, or community. Those interventions are reviewed later in this chapter.

    The strongest support for the effectiveness of outpatient treatment comes from a series of meta-analyses. Meta-analyses are an important type of research methodology, described in Chapter 1, that enable one to combine research findings from separate studies. Nine meta-analyses, published between 1985 and 1995, probed the effectiveness of research on individual, group, and family therapy for children and adolescents (Casey & Berman, 1985; Hazelrigg et al., 1987; Weisz et al., 1987; Kazdin et al., 1990; Baer & Nietzel, 1991; Grossman & Hughes 1992; Shadish et al., 1993; Weisz & Weiss, 1993; Weisz et al., 1995). Although these meta-analyses vary in time period, age groups, and meta-analytic approach, they were largely restricted to studies of treatment given in a research clinical setting, and their findings are relatively consistent. The major findings indicated that the improvements with outpatient therapy are greater than those achieved without treatment; the treatment is highly effective, as was found in meta-analyses of adults (Brown, 1987); and the effects of treatment are similar, whether applied to problems such as anxiety, depression, or withdrawal (internalizing problems) or to hyperactivity and aggression (externalizing problems) (Kazdin, 1996).

    Given strong evidence of efficacy for outpatient treatment, the question of applicability to real-world settings has been examined. A meta-analysis was performed on studies of the effectiveness of various types of outpatient treatment, regardless of whether their efficacy had been established through research (Weisz et al., 1995). The researchers were able to identify only nine studies of treated children in nonresearch clinical settings where therapy was a regular service of the clinic and was carried out by practicing clinicians. Those nine studies demonstrated little or no effect. Clearly, real-world therapy was found to be less effective than that provided through a research protocol. A variety of factors may account for the gap, including less attention in real-world settings to careful matching of patients with treatments, less adherence to a treatment protocol, and less followup care.

    Partial Hospitalization/Day Treatment
    Partial hospitalization, also called day treatment and partial care, has been a growing treatment modality for youth with mental disorders. Research on partial hospitalization as an alternative to inpatient treatment generally finds benefit from a structured daily environment that allows youth to return home at night to be with their family and peers.

    Partial hospitalization is a specialized and intensive form of treatment that is less restrictive than inpatient care but is more intensive than the usual types of outpatient care (i.e., individual, family, or group treatment). The most frequently used type of partial hospitalization is an integrated curriculum combining education, counseling, and family interventions. The setting, be it a hospital, school, or clinic, may be tied to the theoretical orientation of the treatment, which ranges from psychoanalytic to behavioral. Partial hospitalization has also been used as a transitional service after either psychiatric hospitalization or residential treatment, at the point when the child no longer needs 24-hour care but is not ready to be integrated into the school system. It also is used to prevent institutional placement.

    Overall, the research literature points to positive gains from adolescent use of day treatment, but most of the studies are uncontrolled. Gains relate to academic and behavioral improvement; reduction in, or delay of, hospital and residential placement; and a return to regular school for about 75 percent of patients (Baenen et al., 1986; Gabel & Finn, 1986). Day treatment programs are not being used as frequently as they might be because third-party payers are reluctant to support this form of treatment. They claim that the modality is ambiguous, that it induces demand among those who would not otherwise seek treatment, and that its length, treatment outcomes, and costs are unpredictable (Kiser et al., 1986). Research is needed to address these issues.

    To date, the only controlled study of partial hospitalization compared outcomes for young children (ages 5 to 12) with disruptive behavior disorders who received intensive day treatment with children who received traditional outpatient treatment services (in fact, a waiting list control) (Grizenko et al., 1993). The results at 6 months favored day treatment in reducing behavior problems, decreasing symptoms, and improving family functioning.

    Findings from uncontrolled studies of partial hospitalization are informative, although not conclusive. Based on approximately 20 studies, multiple benefits have been reported even over the long term (see reviews by Kutash & Rivera, 1996; Grizenko, 1997). In general, child behavior and family functioning improve following partial hospitalization. Findings for improved academic achievement are mixed and possibly suggest that implementation of school-based models should be considered. About three-fourths of youth are reintegrated into regular school, often with the help of special education or other school- or community-based services. Several uncontrolled studies found that day treatment could prevent youth from entering other costly placements (particularly inpatient and residential treatment centers), which suggests that partial hospitalization may reduce overall costs of treatment (Kutash & Rivera, 1996). Finally, family participation during and following day treatment is essential to obtaining and maintaining results (Kutash & Rivera, 1996).

    Residential Treatment Centers
    Residential treatment centers are the second most restrictive form of care (next to inpatient hospitalization) for children with severe mental disorders. Although used by a relatively small percentage (8 percent) of treated children, nearly one-fourth of the national outlay on child mental health is spent on care in these settings (Burns et al., 1998). However, there is only weak evidence for their effectiveness.

    A residential treatment center (RTC) is a licensed 24-hour facility (although not licensed as a hospital), which offers mental health treatment. The types of treatment vary widely; the major categories are psychoanalytic, psychoeducational, behavioral management, group therapies, medication management, and peer-cultural. Settings range from structured ones, resembling psychiatric hospitals, to those that are more like group homes or halfway houses. While formerly for long-term treatment (e.g., a year or more), RTCs under managed care are now serving more seriously disturbed youth for as briefly as 1 month for intensive evaluation and stabilization.

    Concerns about residential care primarily relate to criteria for admission; inconsistency of community-based treatment established in the 1980s; the costliness of such services (Friedman & Street, 1985); the risks of treatment, including failure to learn behavior needed in the community; the possibility of trauma associated with the separation from the family; difficulty reentering the family or even abandonment by the family; victimization by RTC staff; and learning of antisocial or bizarre behavior from intensive exposure to other disturbed children (Barker, 1998). These concerns are discussed below.

    In the past, admission to an RTC has been justified on the basis of community protection, child protection, and benefits of residential treatment per se (Barker, 1982). However, none of these justifications have stood up to research scrutiny. In particular, youth who display seriously violent and aggressive behavior do not appear to improve in such settings, according to limited evidence (Joshi & Rosenberg, 1997). One possible reason is that association with delinquent or deviant peers is a major risk factor for later behavior problems (Loeber & Farrington, 1998). Moreover, community interventions that target change in peer associations have been found to be highly effective at breaking contact with violent peers and reducing aggressive behaviors (Henggeler et al., 1998). Although removal from the community for a time may be necessary for some, there is evidence that highly targeted behavioral interventions provided on an outpatient basis can ameliorate such behaviors (Brestan & Eyberg, 1998). For children in the second category (i.e., those needing protection from themselves because of suicide attempts, severe substance use, abuse, or persistent running away), it is possible that a brief hospitalization for an acute crisis or intensive community-based services may be more appropriate than an RTC. An intensive long-term program such as an RTC with a high staff to child ratio may be of benefit to some children, especially when sufficient supportive services are not available in their communities. In short, there is a compelling need to clarify criteria for admission to RTCs (Wells, 1991). Previous criteria have been replaced and strengthened (i.e., with an emphasis on resources needed after discharge) by the National Association of Psychiatric Treatment Centers for Children (1990).

    The evidence for outcomes of residential treatment comes from research published largely in the 1970s and 1980s and, with three exceptions, consists of uncontrolled studies (see Curry, 1991).

    Of the three controlled studies of RTCs, the first evaluated a program called Project Re-Education (Re-Ed). Project Re-Ed, a model of residential treatment developed in the 1960s, focuses on training teacher-counselors, who are backed up by consultant mental health specialists. Project Re-Ed schools are located within communities, facilitating therapeutic work with the family and allowing the child to go home on weekends. Camping also is an important component of the program, inspired by the Outward Bound Schools in England. The first published study of Project Re-Ed compared outcomes for adolescent males in Project Re-Ed with untreated disturbed adolescents and with nondisturbed adolescents. Treated adolescents improved in self-esteem, control of impulsiveness, and internal control compared with untreated adolescents, according to ratings by Project Re-Ed staff and by families (Weinstein, 1974). A 1988 followup study of Project Re-Ed found that when adjustment outcomes were maintained at 6 months after discharge from Project Re-Ed, those outcomes were predicted more by community factors at admission (e.g., condition of the family and school, supportiveness of the local community) than by client factors (e.g., diagnosis, school achievement, age, IQ). This suggested that interventions in the child’s community might be as effective as placement in the treatment setting (Lewis, 1988).

    The only other controlled study compared an RTC with therapeutic foster care through the Parent Therapist Program. Both client groups shared comparable backgrounds and made similar progress in their respective treatment program. However, the residential treatment cost twice as much as therapeutic foster care (Rubenstein et al., 1978).

    Despite strong caveats about the quality, sophistication, and import of uncontrolled studies, several consistent findings have emerged. For most children (60 to 80 percent), gains are reported in areas such as clinical status, academic skills, and peer relationships. Whether gains are sustained following treatment appears to depend on the supportiveness of the child’s post-discharge environment (Wells, 1991). Several studies of single institutions report maintenance of benefits from 1 to 5 years later (Blackman et al., 1991; Joshi & Rosenberg, 1997). In contrast, a large longitudinal six-state study of children in publicly funded RTCs found at the 7-year followup that 75 percent of youth treated at an RTC had been either readmitted to a mental health facility (about 45 percent) or incarcerated in a correctional setting (about 30 percent) (Greenbaum et al., 1998).

    In summary, youth who are placed in RTCs clearly constitute a difficult population to treat effectively. The outcomes of not providing residential care are unknown. Transferring gains from a residential setting back into the community may be difficult without clear coordination between RTC staff and community services, particularly schools, medical care, or community clinics. Typically, this type of coordination or aftercare service is not available upon discharge. The research on RTCs is not very enlightening about the potential to substitute RTC care for other levels of care, as this requires comparisons with other interventions. Given the limitations of current research, it is premature to endorse the effectiveness of residential treatment for adolescents. Moreover, research is needed to identify those groups of children and adolescents for whom the benefits of residential care outweigh the potential risks.

    Inpatient Treatment
    Inpatient hospitalization is the most restrictive type of care in the continuum of mental health services for children and adolescents. Questions about excessive and inappropriate use of hospitals were raised in the early 1980s (Knitzer, 1982) and clearly documented thereafter in rising admission rates from the 1980s into the mid-1990s, without evidence of increased social or clinical need for such treatment (Weller et al., 1995). Inpatient care consumes about half of child mental health resources, based on the latest estimate available (Burns, 1991), but it is the clinical intervention with the weakest research support. Nevertheless, because some children with severe disorders do require a highly restrictive treatment environment, hospitals are expected to remain an integral component of mental health care (Singh et al., 1994). More concerted attention to the risks and benefits of hospital use is critical, however, along with development of community-based alternative services.

    Research on inpatient treatment mostly consists of uncontrolled studies (Curry, 1991). Factors that are likely to predict benefit have been identified from such studies. Beneficial factors were found to include higher child intelligence; the quality of family functioning and family involvement in treatment; specific characteristics of treatment (e.g., completion of treatment program and planned discharge); and the use of aftercare services. Neither age nor gender affected prognosis after hospitalization. The prognosis was poor for several clinical characteristics, including children with a psychotic diagnosis and antisocial features with conduct disorder (Kutash & Rivera, 1996).

    Only three controlled studies evaluated the effectiveness of inpatient treatment: one that randomized antisocial children to specific interventions on an inpatient unit (Kazdin et al., 1987a, 1987b) and two older clinical trials (Flomenhaft, 1974; Winsberg et al., 1980). All three studies demonstrated that community care was at least as effective as inpatient treatment.

    More recently there have been preliminary favorable findings from a randomized trial of inpatient treatment versus multisystemic therapy (MST), an intensive home-based intervention. For example, MST was more effective than psychiatric hospitalization in reducing antisocial behavior, improving family structure and cohesion, improving social relationships, and keeping children in school and out of institutions (after the initial period when the control group was in the hospital). Hospitalized youth reported improved self-esteem, and youth in both treatment conditions showed comparable decreases in emotional distress (Henggeler et al., 1998). A great deal more research is needed on inpatient hospitalization, as it is by far the costliest and most restrictive form of care. Recent changes in health care management have resulted in short lengths of stay for children and adolescents. Preliminary results from the study of MST indicate that intensive home-based services may be a viable alternative to hospitalization. However, even when such services are available, there may be a need for brief 24-hour stabilization units for handling crises (see Crisis Services).
    Newer Community-Based Interventions

    Since the 1980s, the field of children’s mental health has witnessed a shift from institutional to community-based interventions. The forces behind this transformation are presented in a subsequent section, Service Delivery. This section attempts to answer the question of whether community-based interventions are effective. It covers a range of comprehensive community-based interventions, including case management, home-based services, therapeutic foster care, therapeutic group homes, and crisis services. Although the evidence for the benefits of some of these services is uneven at best, even uncontrolled studies offer a starting point for studying the effectiveness and feasibility of their implementation. Many of the evaluations to date offer a first glimpse into the benefits of these services and the extent to which they may be valuable for further examination. Of these inter- ventions, the most convincing evidence of effectiveness is for home-based services and therapeutic foster care, as discussed below.

    There is a special emphasis throughout this section on “children with serious emotional disturbances,” as many of these community-based services are targeted to this population of the most serious severely affected children. The term serious emotional disturbance refers to a diagnosed mental health problem that substantially disrupts a child’s ability to function socially, academically, and emotionally. It is not a formal DSM-IV diagnosis but rather a term that has been used both within states and at the Federal level to identify a population of children with significant functional impairment due to mental, emotional, and behavioral problems who have a high need for services. The official definition of children with serious emotional disturbance adopted by the Substance Abuse and Mental Health Services Administration is “persons from birth up to age 18 who currently or at any time during the past year had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the DSM-III-R, and that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities” (SAMHSA, 1993, p. 29425). The term is used in a variety of Federal statutes in reference to children fitting that description and does not signify any particular diagnosis per se; rather, it is a legal term that triggers a host of mandated services to meet the needs of these children (see Service Delivery section).

    Case Management
    Case management is an important and widespread component of mental health services, especially for children with serious emotional disturbances. The main purpose of case management is to coordinate the provision of services for individual children and their families who require services from multiple service providers. Case managers take on roles ranging from brokers of services to providers of clinical services. There is a considerable amount of variation in models of case management. In one important model, called “wraparound,” case managers involve families in a participatory process of developing an individualized plan focusing on individual and family strengths in multiple life domains. Research on wraparound is still in its early stages (Burns & Goldman, 1999).

    There have been controlled studies of three programs that used case managers who work individually rather than as part of an interdisciplinary team (discussed later). In one study of the Partner’s Project in Oregon, case management was compared with “usual services,” which did not include case management (Gratton et al., 1995). The authors found at 1-year followup that children in the Partner’s Project scored significantly higher on measures of social competence and had received more individualized, comprehensive services, and a greater degree of service coordination.

    The second study compared the outcomes of intensive case management and regular case management for mentally ill homeless children in Seattle (Cauce et al., 1994). The case managers in the intensive condition had lower caseloads, were required to spend more hours supervising the youth, had flexible funds (for clothing, transportation, etc.) at their disposal, spent more hours in consultation with psychologists, and were of higher educational status. After 1 year, the study found that both groups showed substantial yet similar improvement in mental health and social adjustment.

    A model known as Children and Youth Intensive Case Management (CYICM) was evaluated in two controlled studies. The program has been described as an Expanded Broker Model, which means that the case manager, in addition to brokering services, is responsible for assessment, planning, linking, and advocating on behalf of the youth and family. Case managers, with caseloads of 10 children, are given $2,000 of flexible funds per child each year to purchase treatment and ancillary services (e.g., transportation and educational aids). In the first study, the authors found that children in the program spent significantly more days in the community between episodes of psychiatric hospitalization and were hospitalized for fewer days than before enrollment (Evans et al., 1994). A subsequent study evaluated a random sample of 199 children enrolled in CYICM (Evans et al., 1996b). Findings at 3-year followup indicated significant behavioral improvements and decreases in unmet medical, recreational, and educational needs compared with findings at enrollment. As in the previous study, children who had been in CYICM for 2 years had spent fewer days in psychiatric hospitals and more days in community settings during the intervals between hospitalizations. This study went further to compare their hospital utilization with that by children not enrolled in the program. Although CYICM clients spent more days in psychiatric hospitals before enrollment, they used inpatient services after enrollment significantly less than did non-enrollees. CYICM clients’ hospital admissions declined fivefold after enrollment whereas among non-enrollees the decline in admission rates was less than half that value. This difference translated into a savings of almost $8,000,000 for New York State, where the project took place.

    Some research has investigated the effects of extending case management on children with a dual diagnosis of a mental disorder and a substance abuse problem. Within the CYICM program, researchers looked at whether adolescents with mental disorders and substance abuse problems derived comparable benefits from the program as did those without substance abuse problems (Evans et al., 1992). No significant differences were found in the average number of inpatient admissions both before and after enrollment. There was also no significant difference between groups in the average decrease from pre- to postenrollment in the number of days spent in hospitals. These results indicate that case management can be as effective for youth presenting with substance abuse problems as for youth presenting with other psychiatric disorders.

    Team Approaches to Case Management
    Several studies assessed the value of case management as part of a treatment team. In a randomized trial in North Carolina (Burns et al., 1996), youth served by an interdisciplinary treatment team led by a case manager were compared with a control group of youth served by a treatment team led by their primary clinician in the role of case manager (also called clinician case manager). At 1-year followup, case managers in the experimental group reported spending significantly more time with their clients, as well as significantly more time on the core functions of case management (e.g., outreach; assessment of strengths, needs, and resources; service planning and monitoring; linking, referral, and advocacy; and crisis intervention). The experimental group also remained in the case-managed program longer, spent fewer days in psychiatric hospitals, and received more community-based services and a more comprehensive array of services. Although both groups showed similar clinical and functional improvements, parents of youth in the experimental group reported more satisfaction with the service system. The study concluded that traditional case managers, rather than clinician case managers, provide a more cost-effective method for attaining positive behavioral outcomes and access to mental health services.

    Another example of a team approach to case management is the Family Centered Intensive Case Management (FCICM) program. This was originally created as a variation of Child and Youth Intensive Case Management in New York, with the later addition of a wraparound approach. The wraparound approach is based on a belief that the child and family should be placed at the center of an array of coordinated health and mental health, educational, and other social welfare services and resources, which a case manager wraps around the patient and family. In a randomized trial, children were assigned to either FCICM or Family-Based Treatment (Evans et al., 1996a). Family-Based Treatment included training, support, and respite care for foster families but did not include case managers.

    The findings at 18 months (or at discharge) indicated that children in FCICM had significantly fewer behavioral symptoms and significantly greater improvements in overall functioning than those in Family-Based Treatment. In addition, the average annual cost of FCICM was less than half that of Family-Based Treatment.

    The Fostering Individualized Assistance Program (FIAP) is an example of case management provided through a wraparound approach. The effectiveness of this model, which used clinical case managers, was compared with standard foster care in a randomized trial involving 131 children and their families (Clark et al., 1998). The most important duty of the FIAP case managers was to arrange monthly team meetings for the monitoring of individualized service plans. Although both groups showed significant improvement in their behavioral adjustment over a 3_-year period, children in the FIAP group were less likely to change placements, and boys in the group reported better social adjustment and fewer delinquencies. Older youth in the group were more likely to maintain placements in homes of relatives and less likely to run away. Youth in FIAP were also absent from school less often and spent fewer days suspended from school. Overall, youth in the FIAP group showed more improvement than did youth in standard foster care. Multiple uncontrolled studies of case management using a wraparound approach were summarized in a recent monograph focusing on the wraparound process (Burns & Goldman, 1999). Overall, the reviewed studies, although using uncontrolled methods, offer emerging evidence of the potential effectiveness of case management using a wraparound process.

    While evidence is limited and many of the positive outcomes focus on service use rather than clinical status, there is some indication that case management is an effective intervention for youth with serious emotional disturbances. Studies in this area are difficult to conduct because of resource limitations and of varying approaches to case management. Agreement on standards for specific case management models is

    needed in order to proceed with efficient and reliable controlled research in this area. In addition, future research needs to address the issue of cost-effectiveness, as some evidence presented above has shown savings from less utilization of institutional care.

    Home-Based Services
    This section describes the strong record of effectiveness for home-based services, which provide very intensive services within the homes of children and youth with serious emotional disturbances. A major goal is to prevent an out-of-home placement (i.e., in foster care, residential, or inpatient treatment). Home-based services are usually provided through the child welfare, juvenile justice, and/or mental health systems. They are also referred to as in-home services, family preservation services, family-centered services, family-based services, or intensive family services.

    Stroul (1988) identified three major goals of home-based services: to preserve the family’s integrity and prevent unnecessary out-of-home placements; to put adolescents and their families in touch with community agencies and individuals, thus creating an outside support system; and to strengthen the family’s coping skills and capacity to function effectively in the community after crisis treatment is completed. The specific services provided most often include evaluation, assessment, counseling, skills training, and coordination of services. The historical evolution of home-based services is discussed further under Support and Assistance for Families in Service Delivery.

    The evidence for the benefits of home-based services was recently evaluated in a meta-analysis of controlled studies only (Fraser et al., 1997). The analysis referred to home-based services as “family preservation services”; these were sponsored either by the child welfare or juvenile justice systems. For 22 studies the authors analyzed specific measures such as out-of-home placement, family reunification, arrest, incarceration, and hospitalization, with the control group defined as youth receiving “usual” or “routine” services. While a majority of the studies demonstrated marginal gains in effectiveness, other services appeared to be significantly more effective than usual services. The findings are presented below according to their organizational sponsorship by either child welfare or juvenile justice system.

    Family Preservation Programs Under the Child Welfare System
    Within the child welfare system, particularly effective family reunification programs were the Homebuilders Program in Tacoma, Washington, which was designed to reunify abused and neglected children with their families by providing family-based services (Fraser et al., 1996), and the family reunification programs in Washington State and in Utah (Pecora et al., 1991). Studies suggested that 75 to 90 percent of the children and adolescents who participated in such programs subsequently did not require placement outside the home. The youths’ verbal and physical aggression decreased, and cost of services was reduced (Hinckley & Ellis, 1985). The success of these family preservation programs is based on the following: services are delivered in a home and community setting; family members are viewed as colleagues in defining a service plan; back-up services are available 24 hours a day; skills are built according to the individual needs of family members; marital and family interventions are offered; community services are efficiently coordinated; and assistance with basic needs such as food, housing, and clothing is given (Fraser et al., 1997).

    Multisystemic Therapy
    Multisystemic therapy programs within the juvenile justice system have demonstrated effectiveness. MST is an intensive, short-term, home- and family-focused treatment approach for youth with severe emotional disturbances. MST was originally based on risk factors that were identified in the published literature and was designed for delinquents. MST intervenes directly in the youth’s family, peer group, school, and neighborhood by identifying and targeting factors that contribute to the youth’s problem behaviors. The main goal of MST is to develop skills in both parents and community organizations affecting the youth that will endure after brief (3 to 4 months) and intensive treatment. MST was constructed around a set of principles that were put into practice and then expanded upon in a manual (Henggeler et al., 1998). Elaborate training, supervision, and monitoring for treatment adherence make this an exemplary approach. Furthermore, publication of an MST manual and the high level of clinical training in MST distinguish this model from other types of family preservation services.

    The efficacy of MST has been established in three randomized clinical trials for delinquents within the juvenile justice system. The first of these studies took place in Memphis, Tennessee, and revealed that MST was more effective than usual community services in decreasing adolescent behavioral problems and in improving family relations (Henggeler et al., 1986). The second was conducted in Simpsonville, South Carolina, and compared outcomes for 84 juvenile offenders randomly assigned to either MST or usual services. At 59 weeks after referral, youth who had received MST had fewer arrests and self-reported offenses and had spent an average of 10 fewer weeks incarcerated than did the youth in usual services. In addition, families served by MST reported increased family cohesion and decreased youth aggression in peer relations (Henggeler et al., 1992). In the third study, MST was compared with individual therapy in Columbia, Missouri, and was found to be more effective in ameliorating adjustment problems in individual family members. A 4-year followup of rearrest data indicated that MST was more effective than individual therapy in preventing future criminal behavior, including violent offenses (Borduin et al., 1995). Studies found improved behavior, fewer arrests, and lower costs. These findings encouraged the investigators to test the effectiveness of MST in other organizational settings (e.g., child welfare and mental health), allowing them to target other clinical populations, including youthful sex offenders (Borduin et al., 1990), abused and neglected youth (Brunk et al., 1987), and child psychiatric inpatients (see Inpatient Treatment section). Initial results are promising for youth receiving MST instead of psychiatric hospitalizations (Henggeler et al., 1998). As expected, some adjustments to MST are required to handle children who are dangerous to themselves and who do not respond as quickly to treatment as the delinquent youth in previous studies. The efficacy of MST was demonstrated in real-world settings but only by one group of investigators; thus, the results need to be reproduced by others and future effectiveness research needs to determine whether the same benefits can be demonstrated with less support from experts.
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