Elizabeth M. Z. Farmer

Review of the evidence base for treatment of childhood psychopathology: Externalizing disorders.

This article reviews controlled research on treatments for childhood externalizing behavior disorders. The review is organized around 2 subsets of such disorders: disruptive behavior disorders (i.e., conduct disorder, oppositional defiant disorder) and attention-deficit/hyperactivity disorder (ADHD). The review was based on a literature review of nonresidential treatments for youths ages 6-12. The pool of studies for this age group was limited, but results suggest positive outcomes for a variety of interventions (particularly parent training and community-based interventions for disruptive behavior disorders and medication for ADHD). The review also highlights the need for additional research examining effectiveness of treatments for this age range and strategies to enhance the implementation of effective practices.

The Child and Adolescent Services Assessment (CASA) Description and Psychometrics

The Child and Adolescent Services Assessment (CASA) is a self- and parent-report instrument designed to assess the use of mental health services by children ages 8 years to 18 years. The CASA includes 31 settings covering inpatient, outpatient, and informal services provided by a variety of child-serving providers and sectors. This instrument collects information on whether a service was ever used and more detailed information (length of stay/number of visits, focus of treatment) on services used in the recent past. A description of the instrument, information on interviewer training and coding of data, psychometric data on clinical samples, and a case study are presented.

Effectiveness of nonresidential specialty mental health services for children and adolescents in the "real world".

OBJECTIVE Although many studies demonstrate the efficacy of a variety of treatments for child and adolescent psychiatric disorders, studies showing the effectiveness of such treatments in ordinary clinical settings have not been forthcoming. This report presents a study of the effectiveness of outpatient treatment in a community sample of 9- to 16-year-olds. METHOD Four annual waves of data were collected from a representative sample of 1,422 children and their parents in the southeastern United States. Interviews were conducted with the Child and Adolescent Psychiatric Assessment to determine clinical status and the Child and Adolescent impact Assessment to measure the impact of psychiatric disorder on the lives of the childrens families. RESULTS Treated individuals were more severely disturbed and showed deterioration in their clinical status, even before they received treatment, indicating that comparisons with untreated individuals required controls not only for pretreatment clinical status, but for pretreatment clinical trajectory. A significant dose-response relationship was found between the number of specialty mental health treatment sessions received and improvement in symptoms at follow-up. However, no effect of treatment on secondary psychosocial impairment or parental impact was identified. CONCLUSIONS Child and adolescent outpatient psychiatric treatment has positive effects on psychiatric symptoms, even when conducted outside the academic units where efficacy research usually takes place. The dose of treatment required to produce such effects (more than 8 sessions) suggests that attempts to limit child psychiatric treatment to very short-term interventions may be counterproductive.

Development of substance use and psychiatric comorbidity in an epidemiologic study of white and American Indian young adolescents the Great Smoky Mountains Study

The progression of substance use and the patterns of comorbidity of substance use and psychiatric disorders are explored prospectively in young adolescents enrolled in the Great Smoky Mountains Study. This study is an epidemiologic study of white and American Indian youths living in rural Southern Appalachia. Results from this study indicate that alcohol use without permission predicts subsequent use of illicit drugs and regular tobacco use. Use of tobacco was not associated with either later alcohol or drug use. Patterns of comorbidity showed strong cross-sectional relationships between substance use and behavioral disorders, but not emotional disorders. Use of alcohol was also associated with psychiatric diagnosis at a later interview. There were some differences between white and American Indian youths in the pattern of comorbidity of tobacco use and psychiatric disorder and the relationship between prior psychiatric disorder and later alcohol use. These findings suggest that alcohol use without permission may be an important marker for youths who are at risk for illicit drug use and/or psychiatric diagnoses.

Reliability of self-reported service use: Test-retest consistency of children's responses to the Child and Adolescent Services Assessment (CASA)

This paper reports on the reliability of childrens responses on the Child and Adolescent Services Assessment (CASA) — a self-report instrument for use with 8− to 18-year-olds that gathers information about services used to address mental health problems. Findings were based on interviews completed by 77 children at a one week test-retest interval. Results showed that reports of lifetime service use were as reliable as were reports of service use in the preceding three months. Children reported restrictive and intrusive services more reliably than services that were provided in their natural environment. Reliability appeared to be associated more strongly with characteristics of the type of service than with characteristics of the child. Children also could report reliably on some details about their encounters with service providers (e.g., length of stay, number of visits, and onset of service use).

Treatment Foster Care in a System of Care: Sequences and Correlates of Residential Placements.

We examined Treatment Foster Care (TFC) in residential trajectories for youth with psychiatric disorders and aggressive behavior. We analyzed residential placements of a statewide sample of youth during the 12 months preceding and following admission to TFC. Prior to TFC, the majority of youth were residing in more restrictive settings (group homes or residential treatment). Two-thirds of youth remained in TFC throughout the follow-up year. Of those who left, nearly half returned home, and slightly fewer were discharged to group homes. By the end of the 12-month follow-up period, rates of group home use were similar to those seen in the pre-TFC period. Movement out of TFC during the year was associated with being older at placement and with increased problem behavior (particularly externalizing behaviors). TFC serves as a step-down placement for a substantial number of youth. However, this is not the only way it is used, and models based on short-term transitioning or reunification with families may not be widely implemented or relevant in practice. Additional research is needed to understand current functions of TFC in residential trajectories and to maximize its utility in systems of care.

The Role of Schools in Outcomes for Youth: Implications for Children's Mental Health Services Research

We explore the role of schools in childrens mental health services research. Recent literature has suggested that schools play an important role in delivering services to children and adolescents with emotional and behavioral problems. Research in services research, though, has taken a fairly narrow view of which dimensions of school environments are relevant for inclusion in studies. We suggest that a broader view of school environments is appropriate and potentially beneficial to the field. Using Bronfenbrenners ecological model as a guide, we conceptualize schools as microsystems. Such an approach suggests that all aspects of school environments (treatment as well as non-treatment) are likely to influence many of the outcomes that childrens mental health services research frequently targets (e.g., behavioral problems, problematic peer relationships, academic achievement, school attendance). We review literature from a variety of disciplines to suggest relevant features of schools, with particular attention to the role of peer dynamics within schools. We conclude with implications of this expanded conceptualization of schools for childrens mental health services research.

Issues confronting effective services in systems of care

Abstract Service provision for children and adolescents with mental health problems has changed dramatically in the past decade. The current paradigm revolves around values and principles of a “system of care.” There is now consistent evidence in the literature that systems can be changed to reflect this new paradigm—agencies can work together, a full continuum of services can be developed, services can be individualized to meet family and child needs. At this point, however, the field is confronted with a lack of convincing evidence about the individual-level effectiveness of these system changes. This paper describes the current state of the field and discusses conceptual and methodological challenges for moving forward. It concludes with suggestions for productive directions for assessing and improving effectiveness of childrens mental health services.

Implications of Social Development Research for School-Based Interventions for Aggressive Youth with EBD.

Current views of the role of social relations in the development of aggressive and disruptive behavior are presented, and advances in social development research are summarized. The primary points of the articles in this special issue are considered against this backdrop and synthesized with regard to implications for the development of preventative interventions and positive behavioral supports for aggressive youth with or at risk of emotional and behavioral disorders. Together these articles suggest that the social growth of such youth is highly complex and involves multiple factors, including the social goals and characteristics of the student, the affiliative patterns and social roles of the student, and the interactional dynamics among students and between students and teachers. School-based interventions should focus not only on the behavior of the student, but also on social-cognitive processes and social contextual factors that support aggressive and disruptive behavior.

Assessing Conformity to Standards for Treatment Foster Care

In this article we examine conformity to the Program Standards for Treatment Foster Care (Foster Family-Based TreatmentAssociation, 1995).Treatment foster care (TFC) is an increasingly common community-based residential placement option for youth with emotional and behavioral disorders.At present, findings from model programs suggest that TFC can be effective for producing desired outcomes. However, little is known about variations of TFC in real-world practice.The standards of care developed by the Foster Family-Based Treatment Association are used to examine variations in conformity to the standards in a statewide sample of TFC programs. Findings suggest fair to good overall conformity, with considerable variation among programs.The article includes a discussion of methodological and substantive considerations for future research and evaluation using this approach.