Scott C. Leon

Therapist effects in outpatient psychotherapy: A three-level growth curve approach

Evidence suggests that a moderate amount of variance in patient outcomes is attributable to therapist differences. However, explained variance estimates vary widely, perhaps because some therapists achieve greater success with certain kinds of patients. This study assessed the amount of variance in across-session change in symptom intensity scores explained by therapist differences in a large naturalistic data set (1,198 patients and 60 therapists, who each treated 10–77 of the patients). Results indicated that approximately 8% of the total variance and approximately 17% of the variance in rates of patient improvement could be attributed to the therapists. Cross-validation and extreme group analyses validated the existence of these therapist effects.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patients response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Methodological background of decision rules and feedback tools for outcomes management in psychotherapy

Abstract Systems to provide feedback regarding treatment progress have been recognized as a promising method for the early identification of patients at risk for treatment failure in outpatient psychotherapy. The feedback systems presented in this article rely on decision rules to contrast the actual treatment progress of an individual patient and his or her expected treatment response (ETR). Approaches to predict the ETR on the basis of patient intake characteristics and previous treatment progress can be classified into two broad classes: Rationally derived decision rules rely on the judgments of experts, who determine the amount of progress that a patient has to achieve for a given treatment session to be considered “on track.” Empirically derived decision rules are based on expected recovery curves derived from statistical models applied to aggregated psychotherapy outcomes data. Examples of each type of decision rule and of feedback systems based on such rules are presented and reviewed.

Evaluating Psychiatric Hospital Admission Decisions for Children in Foster Care: An Optimal Classification Tree Analysis.

This study explored clinical and nonclinical predictors of inpatient hospital admission decisions across a sample of children in foster care over 4 years (N = 13,245). Forty-eight percent of participants were female and the mean age was 13.4 (SD = 3.5 years). Optimal data analysis (Yarnold & Soltysik, 2005) was used to construct a nonlinear classification tree model for predicting admission decisions. As expected, clinical variables such as suicidality, psychoticism, and dangerousness predicted psychiatric admissions; however, several variables that are not direct indications of acute psychiatric distress, such as the presence of family problems and the location of the hospital screening, impacted decision making in a subsample of cases. Further analyses indicated that the model developed in Year 1 reliably and consistently predicted admission decisions (with 64%–68% overall accuracy) across the next 3 years. Policy, research, and clinical implications are discussed.

Effect of Organizational Climate on Youth Outcomes in Residential Treatment

This study examined the association between organizational climate and changes in internalizing and externalizing behavior for youth in residential treatment centers (RTCs). The sample included 407 youth and 349 front-line residential treatment staff from 17 RTCs in Illinois. Youth behavior was measured using the Child Functional Assessment Rating Scale. Organizational climate was measured via the Areas of Worklife Survey. Using hierarchical linear modeling, results demonstrated that a higher perception of person-job match on community among front-line staff was associated with more improvement on youth externalizing behaviors. Counter-intuitively, higher person-job match on fairness and workload were each associated with less improvement on internalizing and externalizing behavior. These results offer several potential implications for residential treatment leadership, front line workers, policymakers, youth, and researchers.

Person‐Job Match Among Frontline Staff Working in Residential Treatment Centers: The Impact of Personality and Child Psychopathology on Burnout Experiences

Prior research has shown that the personality variables extraversion and neuroticism predict burnout among frontline staff working in residential treatment centers. This study tested the hypothesis that the effect of personality on burnout would be moderated by the psychiatric characteristics of the youth served on the milieu. Two hundred and three frontline staff working in 21 residential treatment centers in Illinois serving troubled youth completed surveys regarding opinions about their jobs, the Big Five Inventory (BFI), a youth presenting problems scale for the entire milieu, and the Maslach Burnout Inventory (MBI). Results indicated that the effect of neuroticism on burnout is moderated by psychosis and posttraumatic stress disorder (PTSD); high and moderate milieu ratings of psychosis and PTSD showed a positive relationship between neurosis and burnout, while low ratings of these conditions showed no relationship. These findings suggest that the optimal work setting is a function of the interaction between specific personality characteristics and specific work environments, with implications for personnel selection and future research on person-environment fit.

Father involvement in child welfare: Associations with changes in externalizing behavior

Nonresident fathers can have a significant impact on childrens behavioral outcomes. Unfortunately, the impact of nonresident father involvement on the behavioral outcomes of children with child welfare involvement has received scant attention in the literature, a limitation the current study sought to address. A sample of 333 children in state custody in Illinois between the ages of six and 13 participated and were assessed using the externalizing behavior scale of the Child and Adolescent Needs and Strengths (CANS) at regular intervals throughout their time in care. Father involvement was measured through a review of case files and interviews with child welfare workers. Growth trajectories were fit to childrens externalizing behavior across time and were predicted using Time 1 characteristics. Father involvement, total non-father relative involvement, and gender (girls) was associated with lower baseline externalizing behavior and the African American children in the sample experienced higher baseline externalizing behavior. However, only Time 1 father involvement predicted slope trajectories after controlling for Time 1 externalizing behavior; more father involvement was associated with lower externalizing behavior trajectories. These results suggest that even in the unique and stressful context of child welfare, father involvement can be protective regarding childrens externalizing behaviors.

Predictors of Clinically Significant Sexual Concerns in a Child Welfare Population

This study employed a risk and resilience paradigm to examine the correlates of youth with and without clinically significant sexual concerns (Trauma Symptom Checklist for Children) in a child welfare sample. Participants were 158 youth in substitute care with sexual behavior problems, as well as their caregivers. A multivariate classification tree analysis yielded an overall classification rate of 88%. Youth with clinically significant sexual concerns were more likely to have been sexually abused, have a substantial number of prior placements, and be residing in residential placements. For youth without a sexual abuse history, being female and witnessing community violence was associated with sexual concerns. This study demonstrated that a range of variables interact in complex ways to predict sexual concerns symptoms.

Confirmatory factor analysis of the Behavior Rating Inventory of Executive Functioning (BRIEF) in children and adolescents with ADHD

The Behavior Rating Inventory of Executive Functioning (BRIEF) is a parent report measure designed to assess executive skills in everyday life. The present study employed a confirmatory factor analysis (CFA) to evaluate three alternative models of the factor structure of the BRIEF. Given the executive functioning difficulties that commonly co-occur with attention-deficit/hyperactivity disorder (ADHD), the participants included 181 children and adolescents with a diagnosis of ADHD. The results indicated that an oblique two-factor model, in which the Monitor subscale loaded on both factors (i.e., Behavioral Regulation, Metacognition) and measurement errors for the Monitor and Inhibit subscales were allowed to correlate, provided an acceptable goodness-of-fit to the data. This two-factor model is consistent with previous research indicating that the Monitor subscale reflects two dimensions (i.e., monitoring of task-related activities and monitoring of personal behavioral activities) and thus loads on multiple factors. These findings support the clinical relevance of the BRIEF in children with ADHD, as well as the multidimensional nature of executive functioning.

Emergency shelter care utilization in child welfare: Who goes to shelter care? How long do they stay?

Emergency shelter care for children entering foster care is widely used as a temporary first placement, despite its contraindications. However, little research has examined predictors of utilization (e.g., entry into care, length of stay in care). A sample of 123 children (ages 6-13) entering foster care was studied to explore the variables associated with an initial placement in shelter care versus kinship care and variables associated with children staying less than 30 days in the shelter versus 30 days or longer. After applying a classification tree analysis (CTA via Optimal Data Analysis), results indicated that variables across the childs ecology--specifically the microsystem, mesosystem, and exosystem--were associated with increased emergency shelter utilization, including older age, entering as a dependency case, more relatives and fictive kin with barriers to involvement in the childs life, and the child welfare agency serving the child. These results suggest that although emergency shelter care utilization may be determined by a complex interaction of variables across the childs ecology, policy and programmatic attention to some of these risk factors might be effective in limiting utilization so that children can enter care with a more long-term, family-based placement.