E. Warren Lambert

Evaluating managed mental health services: The Fort Bragg experiment.

Introduction. Methods. Description of the Evaluation Sample. Access and the Intake and Assessment Process. The Treatment Process and Service Utilization. Mental Health Outcomes. Cost Outcomes. Implications and Conclusions. Index.

Assessing the impact of parent and teacher agreement on diagnosing attention-deficit hyperactivity disorder

This study examines the impact of interrater reliability on the diagnosis of attention-deficit hyperactivity disorder (ADHD). A screening of 6171 elementary school children identified 1573 children with a high risk for ADHD according to teacher rating. Follow-up parent interviews and information from teachers were collected on 243 children. Before screening, health care professionals had diagnosed ADHD in 40% of the identified children. There was low agreement between the parent and teacher reports of ADHD symptoms according to DSM-IV–based questionnaires: Inattentive (r = .34, κ = 0.27), Hyperactive/Impulsive (r = .27, κ = 0.22), and Performance Impairment (r = .31, κ = 0.07). When the two-setting requirement was strictly enforced, poor interrater agreement decreased diagnostic rates for all three types of ADHD in this clinical sample: Inattentive (15%–5%), Hyperactive/Impulsive (11%–3%), and Combined (23%–7%). Parent and teacher agreement was low concerning ADHD symptoms and performance. The recommendation of multiple informants significantly decreased the prevalence. Allowing for observer disagreement by using more lenient core symptom scores could reduce the effect.

Teachers' screening for attention deficit/hyperactivity disorder: comparing multinational samples on teacher ratings of ADHD.

This study evaluates a measurement model for Attention Deficit/Hyperactivity Disorder (ADHD). The DSM-IV divides 18 symptoms into two groups, inattentive and hyperactive/impulsive. Elementary school teachers rated 21,161 children in 4 locations: Spain, Germany, urban US, and suburban US. Confirmatory factor analysis suggested that the 2-factor model (inattention, hyperactivity/impulsivity) shows the best fit. A third factor, impulsivity, was too slight to stand-alone. Children with academic performance problems were distinguished by inattention, but children with behavior problems typically had elevations in inattention, hyperactivity, and impulsivity. Between-site differences were statistically significant, but so small that we conclude that same measurement model fits all 4 samples in 2 continents.

Youth therapeutic alliance in intensive treatment settings.

Therapeutic alliance (TA), the helping relationship that develops between a client and clinician, has received little attention in child treatment studies until recently, though it is the factor found to be most predictive of clinical outcomes. Furthermore, TA is cited as one of the most important components to effective therapy according to practicing clinicians. This study examines the TA that develops between teacher/counselors and children in 2 settings, a partial hospital/day school and a wilderness camp. An important finding in this study is the lack of relationship between the teacher/counselors view of TA and the youths view. Moreover, this correlation does not improve according to how long the counselors have known or have treated the youth. The implications of this and other findings are discussed.

Dose Effect in Child Psychotherapy: Outcomes Associated With Negligible Treatment

OBJECTIVE To compare the outcomes of children who received negligible amounts of outpatient treatment to children receiving more treatment. METHOD A random regression longitudinal model was used to analyze outcomes of children (aged 5-17 years) from the Fort Bragg Evaluation Project. RESULTS In examining several outcomes, the results show no statistically significant dose effect. CONCLUSIONS Children receiving substantial amounts of treatment showed no better mental health outcomes than those receiving negligible amounts of treatment. The results do not support the existence of a dose effect consistent enough to guide clinicians, administrators, or policymakers.

Evaluation of a Congressionally Mandated Wraparound Demonstration.

In order to determine whether expenditures for mental health could be reduced and quality improved, Congress mandated that the Department of Defense conduct a demonstration project utilizing a wraparound mental health service system for child and adolescent military dependents. A longitudinal quasiexperimental design was used to evaluate the cost-effectiveness of the demonstration. The results showed that children in the Wraparound Group received more wraparound services than those in the treatment as usual (TAU) Comparison Group. These services included case management, in-home treatment, and other nontraditional services. The Demonstration also provided better continuity of care. Multiple methods were used to investigate the impact of wraparound. Both groups showed some improvement on some measures but there were no differences between the groups in functioning, symptoms, life satisfaction, positive functioning, or sentinel events. Regardless of which statistical model was used to estimate costs, the Demonstration was also more expensive. The higher level of expenditures for the Wraparound group was a result of some expensive traditional care and the addition of nontraditional services. Several possible explanations of these results are provided.

Who Gets Hospitalized in a Continuum of Care

OBJECTIVE To compare children and adolescents hospitalized under a continuum of care with those hospitalized under traditional insurance coverage. METHOD With comprehensive data, logistic regressions were used to predict hospitalization and to identify its determinants. RESULTS As expected, the probability of being hospitalized was much higher under traditional care. In addition, the predictors of hospitalization differed by site. Accuracy of predictions was high. CONCLUSIONS Different kinds of children were hospitalized under a continuum of care than under a traditional insurance system. Hospitalizations under both systems were highly predictable.

A Comparison of Systematic Screening Tools for Emotional and Behavioral Disorders: A Replication

In this article, the authors examine the psychometric properties of the Student Risk Screening Scale (SRSS), including evaluating the concurrent validity of the SRSS to predict results from the Systematic Screening for Behavior Disorders (SSBD) when used to detect school children with externalizing or internalizing behavior concerns at three assessment points during one academic year. Results suggest strong internal consistency and test—retest stability. Analyses of receiver operating characteristics curves also suggest that the SRSS is more accurate for detecting externalizing than internalizing behaviors. The authors conclude by offering recommendations to school site teams and researchers interested in conducing systematic screenings at the elementary level. Limitations and future directions are offered.

Clinical outcomes of a children's mental health managed care demonstration.

The Fort Bragg Evaluation Project hypothesized that the mental health of children treated in the Demonstration’s continuum of care would improve more than that of children receiving traditional mental health services at a comparison site. Program theory further predicted site differences in outcome for certain subgroups of children, such as those with severe mental health problems. These hypotheses were tested at 6-month and 1-year follow-ups in several ways, but results showed only slightly more site differences than expected by chance. For the evaluation sample ofN=984 treated children aged 5–17, site differences favored the Comparison about as often as the Demonstration. Children at both sites improved, but there was no overall superiority in mental health outcomes at the Demonstration.The Fort Bragg Evaluation Project hypothesized that the mental health of children treated in the Demonstration’s continuum of care would improve more than that of children receiving traditional mental health services at a comparison site. Program theory further predicted site differences in outcome for certain subgroups of children, such as those with severe mental health problems. These hypotheses were tested at 6-month and 1-year follow-ups in several ways, but results showed only slightly more site differences than expected by chance. For the evaluation sample ofN=984 treated children aged 5–17, site differences favored the Comparison about as often as the Demonstration. Children at both sites improved, but there was no overall superiority in mental health outcomes at the Demonstration.

The Fort Bragg managed care experiment: Short term impact on psychopathology

Many concerns have been raised about mental health services for children and adolescents. These concerns have included not treating those in need and providing inappropriate services to those who are treated. The continuum of care philosophy purports to remedy these problems by offering a comprehensive and coordinated range of services emphasizing community-based treatment. Services in the continuum include alternatives to trditional restrictive forms of care such as hospitalization. The provision of more appropriate care is hypothesized to improve the clinical outcomes of children treated in a continuum of care. The Fort Bragg Evaluation compared quality, use, outcome, and cost of the continuum of care model to a more traditional, fragmented system of care. This paper presents the effects of a service delivery system on short term psychopathology outcomes.