Jared S. Warren

Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings.

OBJECTIVE The authors compared symptom change trajectories and treatment outcome categories in children and adolescents receiving routine outpatient mental health services in a public community mental health system and a private managed care organization. METHOD Archival longitudinal outcome data from parents completing the Youth Outcome Questionnaire (Y-OQ) were retrieved for children and adolescents (4-17 years old) served in a community mental health system (n = 936, mean age = 12 years, 40% girls or young women, 28% from families of color) and a managed care organization (n = 3,075, mean age = 13 years, 45% girls or young women, race and ethnicity not reported). The authors analyzed Y-OQ data using multilevel modeling and partial proportional odds modeling to test for differences in change trajectories and final outcomes across the 2 service settings. RESULTS Although initial symptom level was comparable across the 2 settings, the rate of change was significantly steeper for cases in the managed care setting. In addition, 24% of cases in the community mental health setting demonstrated a significant increase in symptoms over the course of treatment, compared with 14% of cases in the managed care setting. CONCLUSIONS These results emphasize the need for increased attention to negative outcomes in routine mental health services and provide a stronger foundation for identifying youth cases at risk for treatment failure. In addition, given the overall differences observed across treatment settings for average rate of change and deterioration rates, results suggest that setting-specific model heuristics should be used for identifying cases at risk for negative outcomes.

Reliability and validity of the youth outcome questionnaire self-report

The psychometric properties of an adolescent mental health outcome instrument (Youth Outcome Questionnaire Self-Report version [Y-OQ-SR]) were examined. Participants were 206 adolescents (ages 12-18; mean age=15). The Y-OQ-SR was evaluated in terms of its internal consistency, test-retest reliability, and concurrent validity. Criterion measures included the Behavior Assessment System for Children, Self-Report of Personality-Adolescent Version (SRP), and the Child Behavior Checklist Youth Self Report (YSR). Analyses revealed very good internal consistency and test-retest reliability of the Y-OQ-SR total score and subscales, and moderate to good concurrent validity with the SRP and YSR. The Y-OQ-SR appears to be a valid and reliable self-report measure of psychosocial distress that warrants further study in youth psychotherapy research.

Sensitivity to change of youth treatment outcome measures: a comparison of the CBCL, BASC-2, and Y-OQ†‡

This study evaluated the relative sensitivity to change of the Child Behavior Checklist/6-18 (CBCL), the Behavior Assessment System for Children-2 (BASC-2), and the Youth Outcome Questionnaire 2.01 (Y-OQ). Participants were 134 parents and 44 adolescents receiving routine outpatient services in a community mental health system. Hierarchical linear modeling analyses were used to examine change trajectories for the 3 measures across 3 groups: parent informants, parent and adolescent dyads, and adolescent informants. Results indicated that for parent-report measures, the Y-OQ was most change sensitive; the BASC-2 and CBCL were not statistically different from each other. Significant differences in change sensitivity were not observed for youth self-report of symptoms. Results suggest that the Y-OQ may be particularly useful for evaluating change in overall psychosocial functioning in children and adolescents.

Change Trajectories for the Youth Outcome Questionnaire Self-Report: Identifying Youth at Risk for Treatment Failure

This study used longitudinal youth outcome data in routine mental health services to test a system for identifying cases at risk for treatment failure. Participants were 2,715 youth (M age = 14) served in outpatient managed care and community mental health settings. Change trajectories were developed using multilevel modeling of archival data. Expected change trajectories served as the basis for a warning system designed to identify cases at risk for treatment failure. Tests of the predictive accuracy of the warning system yielded moderately high sensitivity rates for both youth self-report and parent-report measures. Incorporating data from multiple sources (youth, parents, and others) yielded the highest sensitivity in identifying at-risk cases. Results emphasize the importance of using empirically derived methods for identifying youth at risk for negative outcomes in usual care.

Youth Psychotherapy Change Trajectories and Early Warning System Accuracy in a Managed Care Setting

OBJECTIVES To examine change trajectories in routine outpatient mental health services for children and adolescents in a managed care setting, and to use these trajectories to test the accuracy of two variations of an early warning system designed to identify cases at risk for deterioration. METHOD Multilevel modeling procedures were used to examine longitudinal Youth Outcome Questionnaire (YOQ) data for 16,091 youth aged 4-17 years (39% female, mean age 10.5) referred for treatment in a managed care system. RESULTS Clients with more frequent YOQ administrations had slightly lower baselines and faster rates of change. Both the traditional and simplified versions of the early warning system demonstrated good accuracy in identifying clients who deteriorated, with a sensitivity of .63, specificity of .83, and hit rate of .81. CONCLUSIONS Results provide further evidence that patient-focused early warning systems can accurately identify most youth who are at risk for negative outcomes in routine mental health services.

Predicting patient deterioration in youth mental health services: community mental health vs. managed care settings

OBJECTIVE To examine differences across a community mental health system and a private managed care system in the accuracy of a warning system designed to identify youth at risk for deterioration in mental health services. DESIGN Longitudinal outcome data from the Youth Outcome Questionnaire (Y-OQ) were examined using multilevel modeling for 2,310 youth ages 4-17 who received outpatient treatment. RESULTS The warning system correctly identified 69% of cases that ultimately ended in deterioration in the community mental health setting, compared to 61% in the managed care setting. The overall hit rate (overall accuracy in classifying cases as deteriorators/non-deteriorators) was the same in the two settings (75%). CONCLUSIONS Results are consistent with previous research demonstrating that patient-focused warning systems can be reasonably accurate in identifying youth cases at risk for treatment failure.

Implementing Strong Kids School-Wide to Reduce Internalizing Behaviors and Increase Prosocial Behaviors

Instruction and training in social and emotional learning (SEL) is an important component in addressing the emotional and behavioral needs of students. This study is the first to examine whether Strong Kids, an SEL program, delivered school-wide in all classrooms, could result in decreased internalizing behaviors and increased prosocial behaviors for both at-risk and general education students. This study also evaluated whether teachers could implement Strong Kids as designed and whether they viewed it as socially valid. A non-equivalent control group design was used. The treatment school consisted of 348 student participants and 17 teacher participants in grades K–6. The control school consisted of 266 student participants and 11 teacher participants in grades K–6. Pretest and posttest teacher ratings revealed significant decreases in students’ internalizing behaviors at the treatment school, while these behaviors increased at the control school. Students at risk for emotional and behavioral disorders improved significantly more than those not at risk on ratings of internalizing symptoms and prosocial behaviors, even when the intervention was delivered school-wide in all classrooms. Teachers were able to implement Strong Kids with a high level of fidelity and they held moderately favorable views of the program.

Parenting self-efficacy as a predictor of child psychotherapy outcomes in usual care: a multi-dimensional approach.

Abstract Three theorized dimensions of perceived parenting self-efficacy (Parental Connection, Psychological Autonomy, and Behavioral Influence) were used to predict psychotherapy outcomes in 271 youth (age = 4–17 years, mean age = 10.4, 42% girls) receiving routine outpatient services in a community mental health setting. We used individual growth curve modeling to examine patterns of change in self-efficacy domains and corresponding changes in parent-reported child symptoms. Parenting self-efficacy scores at pre-treatment did not predict treatment outcomes. Parenting self-efficacy scores for Parental Connection and Psychological Autonomy increased over the course of therapy, and increases in parenting self-efficacy dimensions (particularly Psychological Autonomy) were significantly associated with improvements in child symptoms over the course of treatment. Parenting self-efficacy appears to merit further study as a candidate mechanism of therapeutic change in child mental health treatment.

Youth self-efficacy domains as predictors of change in routine community mental health services

Abstract Objective: This study examined how youth self-efficacy in four domains—Social, Academic Diligence, Academic Proficiency, and Behavioral Regulation—was associated with youth symptoms and psychotherapy outcomes. Method: Participants were 104 youth (aged 12–17, mean age 14.6) and their parents/guardians. Youth completed a measure of perceived self-efficacy and the Youth Outcome Questionnaire–Self-Report (YOQ-SR) regularly over the course of treatment; parents/guardians also completed the Youth Outcome Questionnaire. Results: Although none of the self-efficacy domains significantly predicted changes in parent reports of symptoms, individual growth curve models indicated that increases in three of the four self-efficacy domains (Social, Academic Diligence, and Behavioral Regulation) over the course of treatment were associated with concurrent improvements in youth-reported symptoms. Conclusions: Results suggest that youth self-efficacy warrants further study in relation to change processes in youth mental health services.

Youth motivation as a predictor of treatment outcomes in a community mental health system

Abstract Objective: The purpose of this study was to examine the relationship between youth motivation and psychotherapy outcomes in routine community mental health settings. Method: One hundred fifty youth, ages 12–17, from three community mental health clinics completed the Youth Outcome Questionnaire and Treatment Support Measure at frequent intervals over the course of treatment. Results: Increases in motivation followed a curvilinear trajectory. On average, youth motivation significantly increased over the course of therapy according to both self- and parent reports (p < .001). The slope for youth motivation over the course of therapy was negatively associated with the slope for mental health symptoms (p < .001). Initial youth motivation did not predict overall change or the rate of change in symptoms. However, there was significant individual variability in patterns of youth motivation. Conclusions: Our findings demonstrate that youth show increases in motivation over the course of therapy with most gains occurring in the first few sessions. Because increases in motivation over the course of therapy were related to decreases in mental health symptoms, further research is needed to examine how treatment interventions or other factors such as parent motivation may moderate this relationship. Additional research examining the likely complex relationship between initial youth motivation and treatment outcomes in community mental health settings is needed.