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Collection of Evidence-based Practices for Children and
Adolescents with Mental Health Treatment Needs
TO THE GOVERNOR AND THE GENERAL ASSEMBLY OF VIRGINIA
SENATE DOCUMENT NO. 6COMMONWEALTH OF VIRGINIARICHMOND2017
6TH EDITION
REPORT OF THE VIRGINIA COMMISSION ON YOUTH
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COMMONWEALTH of VIRGINIA Commission on Youth
Senator Barbara A. Favola, Chair Delegate Richard P. Bell, Vice
Chair _________________
Execu t ive Director Amy M. Atk inson
Pocahontas Bu ilding 900 E. Main Street, 11th Floor
Richmond, Virgin ia 23219-3513
ht tp:/ / vcoy.virginia.gov
December 28, 2017
Dear Fellow Citizen of the Commonwealth:
It is my pleasure as Chair of the General Assembly’s Commission
on Youth to present the 6th Edition of the Collection of
Evidence-based Practices for Children and Adolescents with Mental
Health Treatment Needs. The Collection summarizes current research
on those mental health treatments that have been proven to be
effective in treating children and adolescents. The Collection is
intended to serve a broad readership, including educators, service
providers, parents, caregivers, and others seeking information on
evidence-based mental health practices for youth.
Section 30-174 of the Code of Virginia establishes the Virginia
Commission on Youth and directs the Commission to “study and
provide recommendations addressing the needs of and services to the
Commonwealth’s youth and their families.” This section also directs
the Commission to “encourage the development of uniform policies
and services to youth across the Commonwealth and provide a forum
for continuing review and study of such services.”
The 2002 General Assembly, through Senate Joint Resolution 99,
directed the Virginia Commission on Youth to coordinate the
collection of empirically-based information to identify the
treatments that are recognized as effective for children, including
juvenile offenders, who have mental health treatment needs,
symptoms, and disorders. The resulting publication entitled
Collection of Evidence-based Practices for Children and Adolescents
with Mental Health Treatment Needs was compiled by the Commission
with the assistance of an advisory group of experts pursuant to
Senate Joint Resolution 99. The Collection was published in House
Document 9 and presented to the Governor and the 2003 General
Assembly.
To ensure that this information remained current and reached the
intended audience, the 2003 General Assembly passed Senate Joint
Resolution 358, which requires the Commission on Youth to update
the Collection biennially. The resolution also requires the
Commission to disseminate the Collection via web technologies. The
Secretaries of Health and Human Resources, Public Safety and
Education, along with the Advisory Group, were requested to assist
the Commission in updating the Collection, as were various state
and local agencies. Since 2003, the Commission has updated this
resource and made it available through the Commission on Youth
website and in print editions.
The Commission on Youth gratefully acknowledges the
contributions of its Advisory Group members. For more information
about the Virginia Commission on Youth or the Collection, I
encourage you to visit our website at http://vcoy.virginia.gov.
Sincerely,
Barbara A. Favola
http://vcoy.virginia.gov/http://vcoy.virginia.gov/
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MEMBERS OF THE VIRGINIA COMMISSION ON YOUTH
Senate of Virginia Barbara A. Favola, Chair Charles W. “Bill”
Carrico
Dave W. Marsden
House of Delegates Richard P. “Dickie” Bell, Vice Chair
Richard L. “Rich” Anderson Peter F. Farrell Daun S. Hester
Mark Keam Christopher K. Peace
Gubernatorial Appointments from the Commonwealth at Large
Karrie Delaney Deidre S. Goldsmith
Chris Rehak
Commission Staff Amy M. Atkinson, Executive Director
Will Egen, Senior Policy Analyst
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DISCLOSURE STATEMENT
The information contained herein is strictly for informational
and educational purposes only and is not designed to replace the
advice and counsel of a physician, mental health provider, or other
medical professional. If you require such advice or counsel, you
should seek the services of a licensed mental health provider,
physician, or other medical professional. The Commission on Youth
is not rendering professional advice and makes no representations
regarding the suitability of the information contained herein for
any purpose.
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CONTENTSIntroduction
..................................................................................................................................................
1 Role of the Family in Treatment Programs
.................................................................................................
10 Key Components of Successful Treatment Programs
.................................................................................
16
Reference Chart of Disorders and Evidence-based Practices
.....................................................................
23
Introduction to Neurodevelopmental Disorders
..........................................................................................
38 Intellectual Disability
...........................................................................................................................
43 Autism Spectrum Disorder
...................................................................................................................
60 Attention-Deficit/Hyperactivity
Disorder.............................................................................................
97 Motor Disorders
.................................................................................................................................
114
Developmental Coordination Disorder Stereotypic Movement
Disorder Tic Disorders
Tourette Disorder Persistent (Chronic) Vocal or Motor Tic
Disorder Provisional Tic Disorder
Schizophrenia
........................................................................................................................................
129 Bipolar and Related Disorders
..................................................................................................................
146
Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder
Depressive Disorders
................................................................................................................................
164 Disruptive Mood Dysregulation Disorder Major Depressive
Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual
Dysphoric Disorder
Anxiety Disorders
.....................................................................................................................................
181 Separation Anxiety Disorder (SAD) Social Anxiety
Disorder/Social Phobia Specific Phobia Generalized Anxiety Disorder
Agoraphobia Panic Disorder Panic Attack Selective Mutism
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Obsessive-Compulsive and Related Disorders
.........................................................................................
197 Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding
Disorder Trichotillomania Excoriation Disorder
Trauma- and Stressor-Related Disorders
..................................................................................................
222 Post-traumatic Stress Disorder Acute Stress Disorder
Disinhibited Social Engagement Disorder Reactive Attachment
Disorder
Adjustment Disorder
.................................................................................................................................
242 Feeding and Eating Disorders
...................................................................................................................
251
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder
Disruptive, Impulse-Control, and Conduct
Disorders...............................................................................
275 Oppositional Defiant Disorder Conduct Disorder Intermittent
Explosive Disorder Pyromania Kleptomania
Substance Use Disorders
...........................................................................................................................
293 Youth Suicide
........................................................................................................................................
322 Antidepressants and the Risk of Suicidal Behavior
.................................................................................
338 Nonsuicidal Self-Injury
............................................................................................................................
345
Juvenile Offending
...................................................................................................................................
356 Juvenile Firesetting
..................................................................................................................................
372 Sexual Offending
.....................................................................................................................................
383
General Description of Providers
..............................................................................................................
398 Providers Licensed in Virginia
.................................................................................................................
400 Terms Used in Virginia’s Mental Health Delivery System
......................................................................
404 Commonly Used Acronyms and Abbreviations
.......................................................................................
427 Index of Disorders, Issues, and Areas of Concern
....................................................................................
433
Appendix A: Advisory Group Members
...................................................................................................
436 Appendix B: Senate Joint Resolution 99
..................................................................................................
437 Appendix C: Senate Joint Resolution 358
................................................................................................
438
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INTRODUCTION Return to Table of Contents
Background of Child and Adolescent Mental Health Epidemiology
and Burden of Child and Adolescent Mental Health Problems Serious
Emotional Disturbance Providing Optimal Treatment Identifying and
Encouraging the Use of Evidence-based Treatments
Benefits of Evidence-based Treatments Limitations of
Evidence-based Treatments Background of the Collection
Using the Collection 6th Edition Conclusion
Background of Child and Adolescent Mental Health
The recognition that children and adolescents suffer from mental
health disorders is a relatively recent development. Throughout
history, childhood was considered a happy period. It was believed
that because children were spared the stressors that afflict
adults, they did not suffer from true mental disorders (American
Psychiatric Association [APA], 2002). It is now well-recognized
that mental or emotional distress in youth may not just be a stage
of childhood or adolescence, but can be evidence of a mental
disorder caused by genetic, developmental, and physiological
factors.
Although research conducted in the 1960s revealed that children
do suffer from mental disorders (APA, 2002), it was not until 1980,
when the third edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-III) was published by the APA, that child and
adolescent mental disorders were assigned a separate and distinct
section within the classification system (National Institute of
Mental Health [NIMH], 2001). The development of treatments,
services, and methods for preventing mental health disorders in
children and adolescents has continued to evolve over the past
several decades.
The National Alliance for the Mentally Ill (NAMI) defines mental
illness as a disorder of the brain that may disrupt a person’s
thinking, feeling, moods, and ability to relate to others (2005).
In 2013, the APA released the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). Significant changes
were made to the criteria and categories of mental disorders and
these changes are discussed in detail throughout this Collection.
The definition of a mental disorder was also modified in the DSM-5
as follows:
A mental disorder is a syndrome characterized by clinically
significant disturbance in an individual's cognition, emotion
regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying
mental functioning. Mental disorders are usually associated with
significant distress in social, occupational, or other important
activities. An expectable or culturally approved response to a
common stressor or loss, such as the death of a loved one, is not a
mental disorder. Socially deviant behavior (e.g., political,
religious, or sexual) and conflicts that are primarily between the
individual and society are not mental disorders unless the deviance
or conflict results from a dysfunction in the individual, as
described above (APA, 2013).
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Introduction
In early December 1999, U.S. Surgeon General David Satcher
released the first ever Surgeon General’s report on Mental Health.
This report called attention to the seriousness of mental illness
as an “urgent health concern” (U.S. Department of Health and Human
Services, 1999). The report also discussed the needs of specific
populations such as children and provided the first comprehensive,
nationwide, longitudinal data on the development of children’s
mental health. This report noted that mental health disorders
appear in families of all social classes and backgrounds. However,
some children are at greater risk due to other factors. These
factors include physical problems, intellectual disability, low
birth weight, family history of mental and addictive disorders,
multigenerational poverty, and caregiver separation or abuse and
neglect (U.S. Department of Health and Human Services). Risk
factors and causal influences for mental health disorders in youth
vary, depending on the specific disorder.
Child and adolescent mental health has emerged as a distinct
arena for service delivery. With the increased attention given to
children’s mental health and the development of systems of care for
children with serious emotional disorders and their families,
mental health has emerged as a new focus in the field of early
childhood (Woodruff et al.). Family members, practitioners, and
researchers have become increasingly aware that mental health
services are an important and necessary support for youth who
experience mental, emotional, or behavioral challenges and their
families.
Epidemiology and Burden of Child and Adolescent Mental Health
Problems
According to the New Freedom Commission on Mental Health
established by President George W. Bush, childhood is a critical
period for the onset of behavioral and emotional disorders (2003).
Between 13 to 20 percent of children living in the United States
experience a mental disorder in a given year (Centers for Disease
Control and Prevention [CDC], 2013). Researchers supported by the
National Institute of Mental Health (NIMH) found that half of all
lifelong cases of mental health disorders begin by age 14 (Archives
of General Psychiatry, as cited by the NIMH, 2005). Moreover, there
are frequently long delays between the first onset of symptoms and
the point at which people seek and receive treatment. This study
also noted that a mental health disorder left untreated could lead
to a more severe, more difficult-to-treat illness and to the
development of co-occurring mental health disorders. In addition,
nearly half of all individuals with one mental disorder met the
criteria for two or more disorders (NIMH).
The National Comorbidity Survey Replication Adolescent
Supplement (NCS-A) is a nationally representative face-to-face
survey of 10,123 adolescents aged 13 to 18 years in the United
States. Conducted between 2001 and 2004, the survey was designed to
estimate the lifetime prevalence, age-of-onset distributions,
course, and comorbidity of mental health disorders among children
and adolescents. NCS-A found the overall prevalence of youth with
mental health disorders with severe impairment and/or distress to
be 22 percent (Merikangas et al., 2010). Study results revealed
that anxiety disorders were the most common condition, followed by
behavior disorders, mood disorders, and substance use disorders,
with approximately 40 percent of those with one class of disorder
also meeting criteria for another class of lifetime disorder
(Merikangas et al.).
There has been little research to measure the financial burden
of mental health disorders in children and adolescents. However, a
team of researchers analyzed various data sources to locate
information on the utilization and costs associated with mental
health disorders in youth. They estimated that the cost of mental
disorders among persons younger than 24 years of age in the United
States was $247 billion annually (CDC, 2013). This includes costs
associated with health care, special education, juvenile justice,
and decreased productivity. Mental disorders were among the most
costly conditions to treat in children (CDC). This analysis, along
with other studies, pointed to two reasons why national health
expenditures for child and adolescent mental disorders are
difficult to estimate, including:
• Mental health services are delivered and paid for in the
health, mental health, education, childwelfare, and juvenile
justice systems; and
2
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Introduction
• No comprehensive national datasets exist in this area (CDC;
Sturm et al. 2001; Ringel & Sturm,2001).
Child and adolescent preventive interventions have the potential
to significantly reduce the economic burden of mental health
disorders by reducing the need for mental health and related
services. Furthermore, such interventions can improve school
readiness, health status, and academic achievement and reduce the
need for special education services (National Institute for Health
Care Management, 2005). These interventions also translate into
societal savings by lessening parents’ dependence on welfare and
increasing educational attainment and economic productivity
(National Institute for Health Care Management).
Serious Emotional Disturbance
Serious emotional disturbance (SED) refers to a diagnosable
mental health problem that severely disrupts a youth’s ability to
function socially, academically, and emotionally. While SED is
defined by federal regulation, states may provide additional
guidance to professionals (Substance Abuse and Mental Health
Services Administration [SAMHSA], 2016). Virginia’s Department of
Behavioral Health and Developmental Services (VDBHDS) outlines the
following as criteria for SED:
1. Problems in personality development and social functioning
that have been exhibited over at leastone year’s time;
2. Problems that are significantly disabling, based on the
social functioning of most children of thechild’s age;
3. Problems that have become more disabling over time; and4.
Service needs require significant intervention by more than one
agency (VDBHDS, 2013).
Estimates of the number of children suffering from SED vary
significantly depending on the study cited. One study attempting to
collect SED prevalence rates found that variations in estimates for
SED might be explained due to the varying objectives for collecting
the data as well as the types of methodology used for selecting the
study populations. A follow up literature review of this study
effort found that national SED estimates range from five to 26
percent (Brauner & Stephens, 2006). According to prior
research, about one out of every ten youths with a current mental
disorder fulfill criteria for SED based on the Substance Abuse and
Mental Health Services Administration (SAMHSA) definition (i.e., a
mental health problem that has a drastic impact on a child’s
ability to function socially, academically, and emotionally)
(Merikangas et al., 2010).
A recent study conducted by the Federal Interagency Forum on
Child and Family Statistics (2015) found that the percentage of
children with SED was about five percent in most years between 2001
and 2013 (2015). Among children with SED, 23 percent received
special education services for an emotional or behavioral problem,
43 percent had a parent who had contacted a general doctor about
the child's emotional or behavioral problem, and 55 percent had a
parent who had contacted a mental health professional about the
child (Federal Interagency Forum on Child and Family Statistics).
In Virginia, it is estimated that between 117,592 and 143,724
children and adolescents have a SED, with between 65,329 and 91,461
exhibiting extreme impairment (VDBHDS, 2013).
Providing Optimal Treatment
The acknowledgment of mental health needs in youth has prompted
further study on a variety of disorders and their causes,
prevention, and treatments. Child and adolescent mental health
represents a major federal public health priority, as reflected in
the U.S. Surgeon General’s Report of the Surgeon General's
Conference on Children's Mental Health: A National Action Agenda
(2000). The report outlines the following three steps that must be
taken to improve services for children with mental health
needs:
3
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Introduction
• Improving early recognition and appropriate identification of
disorders within all systems serving children;
• Improving access to services by removing barriers faced by
families; and • Closing the gap between research and practice to
ensure evidence-based treatments for children.
Without appropriate treatment, childhood mental health disorders
can escalate. Untreated childhood mental health disorders may also
be precursors of school failure, involvement in the juvenile
justice system, and/or placement outside of the home. Other serious
outcomes include destructive, ambiguous, or dangerous behaviors, in
addition to mounting parental frustration. The resulting cost to
society is high in both human and financial terms. Identifying a
child’s mental health disorder early and ensuring that the child
receives appropriate care can break the cycle (New Freedom
Commission on Mental Health, 2003).
Identifying and Encouraging the Use of Evidence-based
Treatments
There have been more than two decades of research in treating
child and adolescent mental health disorders. However, there are
challenges to helping families and clinicians select the best
treatments. The field of child and adolescent mental health is
multi-disciplinary, with a diverse service system. Today, there are
a multitude of theories about which treatments work best, making it
is very difficult for service providers to make informed
choices.
Scientific evidence can serve as a guide for families,
clinicians, and other mental health decision-makers. Interventions
that have strong empirical support are referred to as empirically
validated treatments, empirically supported treatments,
evidence-based treatments, or evidence-based practices. All of
these terms attempt to capture the notion that the treatment or
practice has been tested and that its effects have been
demonstrated scientifically.
Benefits of Evidence-Based Treatments
Evidence-based medicine evolved out of the understanding that
decisions about the care of individual patients should involve the
conscientious and judicious use of current best evidence (Fonagy,
2000). Evidence-based treatments allow patients, clinicians, and
families to see the differences between alternative treatment
decisions and to ascertain what treatment approach best facilitates
successful outcomes (Donald, 2002). Treatments that are
evidence-based and research-driven complement a clinician’s
experience in practice. Evidence-based medicine has significantly
aided clinicians in the decision-making process by providing a
fair, scientifically rigorous method of evaluating treatment
options.
Evidence-based medicine also helps professional bodies develop
clearer and more concise working practices and establish treatment
guidelines. The accumulated data for evidence-based treatments
support their consideration as first-line treatment options (Nock,
Goldman, Wang, & Albano, 2004). With literally hundreds of
treatment approaches available for some disorders, it is difficult
for clinicians to select the most appropriate and effective
intervention (Nock et al.). The strongest argument in support of
using evidence-based practices is that they enable clinicians to
identify the best-evaluated methods of health care. Evidence-based
treatments are recognized as an important component in behavioral
health care by professional organizations, and increasingly,
insurance companies and other payers are reluctant to pay for
services without an evidence base (Society of Clinical Child &
Adolescent Psychology, 2012).
Another driving force in the utilization of evidence-based
medicine is the potential for cost savings (Fonagy, 2000). With
rising awareness of mental health issues and a demand by consumers
to obtain the best treatment for the best price, the emphasis on
evidence-based practices is both practical and justified. Few
people have time to conduct research in order to evaluate best
practices. Evidence-based medicine provides a structured process
for clinicians and patients to access information on what is
effective.
4
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Introduction
Moreover, studies have shown that evidence-based practices work
in a relatively short time span and lead to long-standing
improvements.
Limitations of Evidence-Based Treatments
There are stakeholders in the field of children’s mental health
who have regarded the evidence-based treatment movement with
skepticism. According to Michael Southam-Gerow, Assistant Professor
of Clinical Psychology and Director, Graduate Studies at the
Department of Psychology at Virginia Commonwealth University, there
are several criticisms surrounding the utilization of
evidence-based treatments (Personal Communication, December 15,
2009). These include the following:
• There is too much information, making it difficult for a
service provider to choose a treatmentamong many that may be
supported for a particular problem.
• There is too little information and there are distinct problem
areas for which there is still verylittle known.
• The evidence is inadequate and it has been argued that there
is insufficient supportive data tofavor one treatment versus
another. Furthermore, the long-term effects of many treatments
areunknown. More studies are needed before treatments are
categorized as being evidence-based.
• Because a treatment has not been tested does not mean it is
not effective. Some commonly usedtreatments are not deemed to be
evidence-based treatments because they have not been tested.
Additionally, evidence-based practices as currently developed
and implemented may have inherent limitations that prevent their
widespread delivery (Kazdin, 2011). Many of the evidence-based
practices cannot reach individuals at the scale needed,
particularly if they are provided on a one-to-one, in-person basis.
There are challenges in extending evidence-based practices to
patient care on a scale sufficient to have impact on the personal
and social burdens of mental illness. As noted previously, many
mental health disorders do not yet have an accompanying
evidence-based practice. While there are limitations in the
development and implementation of evidence-based practices, a
number of these practices are effective across a range of
disorders, suggesting some common mechanisms or core processes
(U.S. Department of Health & Human Services, 2015).
Background of the Collection
The 2002 General Assembly, through Senate Joint Resolution 99,
directed the Virginia Commission on Youth to coordinate the
collection of treatments recognized as effective for children and
adolescents, including juvenile offenders, with mental health
disorders. The resulting publication, the Collection of
Evidence-based Practices for Children and Adolescents with Mental
Health Treatment Needs (Collection) was compiled by the Commission
on Youth with the assistance of an advisory group of experts.
In 2003, the General Assembly passed Senate Joint Resolution
358, requiring the Commission to update the Collection biennially.
The resolution also required the Commission to disseminate the
Collection via web technologies. As specified in this resolution,
the Commission received assistance disseminating the Collection
from the Advisory Group and other impacted agencies. The Collection
has been updated five times since 2002.
In 2013, the American Psychiatric Association made several
significant changes to the categorization of disorders included in
the Diagnostic and Statistical Manual Fifth Edition (DSM-5). The
Commission has made significant revisions to the Collection 6th
Edition to incorporate these changes.
Using the Collection 6th Edition
With the limitations of evidence-based treatments in mind, the
Collection 6th Edition has been updated to reflect the current
state of the science. It has been developed and updated to provide
information to
5
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Introduction
families, clinicians, administrators, policymakers and others
seeking information about evidence-based practices for child and
adolescent mental health disorders. The Collection 6th Edition has
four categories that represent different levels of scientific
support for a particular treatment. These levels are summarized in
Table 1. Because research is ongoing, treatments are expected to
move around among the categories with time.
The Collection 6th Edition also includes information on
assessment instruments. This is to emphasize that all clinical
decisions should be made in consultation with the data. Patient
data should be collected to justify treatment plans, changes in
treatment plans, and terminations. Clinicians and mental health
treatment organizations are becoming both data-driven and data
collectors, allowing for greater opportunities for outcome measures
to be collected and reviewed during the course of treatment.
Table 1 Treatment Categories Used in Collection 6th Edition
Levels of Scientific Support Description
What Works (Evidence-based
Treatment)
Meets all of the following criteria: 1. Tested across two or
more randomized controlled trials (RCTs); 2. At least two different
investigators (i.e., researcher); 3. Use of a treatment manual in
the case of psychological treatments; and 4. At least one study
demonstrates that the treatment is superior to an
active treatment or placebo (i.e., not just studies comparing
the treatment to a waitlist).
What Seems to Work Meets all but one of the criteria for “What
Works” or Is commonly accepted as a valid practice supported by
substantial evidence
What Does Not Work Meets none of the criteria above but meets
either of the following criteria: 1. Found to be inferior to
another treatment in an RCT; and/or 2. Demonstrated to cause harm
in a clinical study.
Not Adequately Tested
Meets none of the criteria for any of the above categories. It
is possible that such treatments have demonstrated some
effectiveness in non-RCT studies, but their potency compared to
other treatments is unknown. It is also possible that these
treatments were tested and tried with another treatment. These
treatments may be helpful, but would not be currently recommended
as a first-line treatment.
Conclusion
Effective mental health treatments that have undergone testing
in both controlled research trials and real-world settings are
available for a wide range of diagnosed mental health disorders.
The Collection 6th Edition is designed to encourage use of these
treatments by professionals providing mental health treatments. The
Collection 6th Edition is also designed to provide parents,
caregivers, and other stakeholders with general information about
the various disorders and problems affecting youth.
Evidence-based treatments have been developed with the express
purpose of improving the treatment of child and adolescent mental
health disorders (Nock et al., 2004). Clinicians can incorporate
these well-documented treatments while still adequately addressing
the patient’s individual differences (Nock et al.).
6
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Introduction
Resources and Organizations
American Academy of Family Physicians https://www.aafp.org
American Association of Child & Adolescent Psychiatry
(AACAP) http://www.aacap.org/ American Psychiatric Association
(APA)
http://www.psych.org http://www.parentsmedguide.org
American Psychological Association (APA) http://www.apa.org/
Familydoctor.org https://familydoctor.org/
Medscape Today Resource Centers (from WebMD)
https://www.medscape.com/internalmedicine
National Alliance for the Mentally Ill (NAMI)
https://www.nami.org/ National Institute of Mental Health
(NIMH)
http://www.nimh.nih.gov/index.shtml National Registry of
Evidence-based Programs and Practices
http://www.nrepp.samhsa.gov National Technical Assistance Center
for Children’s Mental Health
https://gucchdtacenter.georgetown.edu/ Substance Abuse and
Mental Health Services Administration (SAMHSA) Caring for Every
Child’s Mental Health Campaign
https://www.samhsa.gov/children
U.S. Department of Education Office of Special Education and
Rehabilitative Services
https://www2.ed.gov/about/offices/list/osers/index.html?src=mr
U.S. Department of Health and Human Services Centers for Disease
Control and Prevention
https://www.cdc.gov/ U.S. National Library of Medicine and the
National Institutes of Health Medline Plus
https://medlineplus.gov/
Virginia Resources and Organizations
1 in 5 Kids Campaign
https://vakids.org/our-work/mental-health
Mental Health America of Virginia https://mhav.org/
National Alliance for the Mentally Ill Virginia (NAMI
Virginia)
https://namivirginia.org/ Virginia Department of Behavioral
Health and Developmental Services (DBHDS)
http://www.dbhds.virginia.gov/ Virginia Office of Children’s
Services http://www.csa.virginia.gov/ Voices for Virginia’s
Children
https://vakids.org/
7
https://www.aafp.org/http://www.aacap.org/http://www.psych.org/http://www.parentsmedguide.org/http://www.apa.org/https://familydoctor.org/https://www.medscape.com/internalmedicinehttps://www.medscape.com/internalmedicinehttps://www.nami.org/http://www.nimh.nih.gov/index.shtmlhttp://www.nrepp.samhsa.gov/https://gucchdtacenter.georgetown.edu/https://www.samhsa.gov/childrenhttps://www2.ed.gov/about/offices/list/osers/index.html?src=mrhttps://www2.ed.gov/about/offices/list/osers/index.html?src=mrhttps://www.cdc.gov/https://medlineplus.gov/https://vakids.org/our-work/mental-healthhttps://mhav.org/https://namivirginia.org/http://www.dbhds.virginia.gov/http://www.csa.virginia.gov/https://vakids.org/
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Introduction
References
American Psychiatric Association (APA). (2002). Childhood
disorders. Retrieved from www.psych.org/public_info/childr~1.cfm.
Not available December 2017.
American Psychiatric Association (APA). (2013). Diagnostic and
statistical manual of mental disorders (5th ed.) (DSM-5).
Washington, DC: Author.
Bayer, J. K., Ukoumunne, O. C., Lucas, N., Wake, M., Scalzo, K.,
& Nicholson, J. (2011). Risk factors for childhood mental
health symptoms: National longitudinal study of Australian
children. Pediatrics, 128(4), 865-879.
Brauner, C. B., & Stephens, C. B. (2006). Estimating the
prevalence of early childhood serious emotional/behavioral
disorders: Challenges and recommendations. Public Health Reports,
121(3), 303-310.
Centers for Disease Control and Prevention (CDC). (2013). Mental
health surveillance among children—United States, 2005–2011.
Morbidity and Mortality Weekly Report, 62(02), 1-35.
Centers for Disease Control (CDC). (2012). Prevalence of autism
spectrum disorders—Autism and developmental disabilities monitoring
network, 14 sites, United States, 2008. Surveillance summaries.
Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6103a1.htm?s_cid=ss6103a1_w
Donald, A. (2002). A practical guide to evidence-based medicine.
Medscape Psychiatry & Mental Health eJournal, 9(2).
Federal Interagency Forum on Child and Family Statistics.
(2015). America’s children: Key national indicators of well-being.
Washington, DC: U.S. Government Printing Office.
Fonagy, P. (2000). Evidence based child mental health: The
findings of a comprehensive review. Paper presented to “Child
mental health interventions: What works for whom?” Center for Child
and Adolescent Psychiatry.
Kazdin, A. E. (2011). Evidence-based treatment research:
advances, limitations, and next steps. American Psychologist,
66(8), 685-698.
Merikangas, K. R., He, J., Burstein, M., Swanson, S. A.,
Avenevoli, S., Cui, L., … Swendsen, J. (2010). Lifetime prevalence
of mental disorders in U.S. adolescents: Results from the national
comorbidity study-adolescent supplement (NCS-A). Journal of the
American Academy of Child and Adolescent Psychiatry, 49(10),
980-989.
National Alliance for the Mentally Ill (NAMI). (2005). About
mental illness. Retrieved from
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/About_Mental_Illness.htm.
Not available December 2017.
National Institute for Health Care Management. (2005).
Children’s mental health: An overview and key considerations for
health system stakeholders. Retrieved from
https://www.nihcm.org/pdf/CMHReport-FINAL.pdf
National Institute of Mental Health (NIMH). (2005). Mental
illness exacts heavy toll, beginning in youth. Retrieved from
http://www.nih.gov/news/pr/jun2005/nimh-06.htm. Not available
December 2017.
National Institute of Mental Health (NIMH). (2001). Blueprint
for change: Research on child and adolescent mental health. Report
of the National Advisory Mental Health Council’s Workgroup on Child
and Adolescent Mental Health Intervention.
New Freedom Commission on Mental Health. (2003). Achieving the
promise: Transforming mental health care in America. DHHS Pub. No.
SMA-03-3832. Rockville, MD.
Nock, M., Goldman, J., Wang, Y., & Albano, A. (2004). From
science to practice: The flexible use of evidence-based treatments
in clinical settings. Journal of the American Academy of Child and
Adolescent Psychiatry, 43(6), 777-780.
Ringel, J., & Sturm, R. (2001). National estimates of mental
health utilization and expenditures for children in 1998. Journal
of Behavioral Health Services and Research, 28, 319-333.
Society of Clinical Child & Adolescent Psychology. (2012).
What is evidence-based practice (EBP)? Effective Child Therapy.
Retrieved from
http://effectivechildtherapy.org/content/evidence-based-practice-0.
Not available December 2017.
Sturm, R., Ringel, J., Bao, C., Stein, B., Kapur, K, Zhang, W.,
& Zeng, F. (2001). National estimates of mental health
utilization and expenditures for children in 1998. In Blueprint for
change: Research on child and adolescent mental health, Vol. VI,
Appendices. Washington, DC: National Advisory Mental Health Council
Workgroup on Child and Adolescent Mental Health Intervention,
Development, and Deployment.
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2016). Mental and substance use disorders. Retrieved
from https://www.samhsa.gov/disorders
8
https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6103a1.htm?s_cid=ss6103a1_whttps://www.nihcm.org/pdf/CMHReport-FINAL.pdfhttps://www.nihcm.org/pdf/CMHReport-FINAL.pdfhttps://www.samhsa.gov/disorders
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Introduction
U.S. Department of Health and Human Services. (2015).
Evidence-based psychotherapies: Novel models of delivering
treatment. Agency for Healthcare Research and Quality. Retrieved
from
https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/kazdin.html
U.S. Department of Health and Human Services. (1999). Mental
health: A report of the Surgeon General. Rockville, MD.
U.S. Department of Health and Human Services. (2001). Mental
health: Culture, race, ethnicity–supplement to mental health:
Report of the Surgeon General. Rockville, MD: Author.
U.S. Public Health Service. (2000). Report of the Surgeon
General's Conference on Children's Mental Health: A national action
agenda. Washington, DC: Department of Health and Human
Services.
Virginia Department of Behavioral Health and Developmental
Services (VDBHDS). (2013). Comprehensive state plan 2014 to 2020.
Retrieved from
http://www.dbhds.virginia.gov/library/quality%20risk%20management/opd-stateplan2014thru2020.pdf
Woodruff, D., Osher, D., Hoffman, C., Gruner, A., King, M.,
& Snow, S. (1999). The role of education in a system of care:
Effectively serving children with emotional or behavioral
disorders. Systems of care: Promising practices in children’s
mental health, 1998 series, volume III. Washington, DC: Center for
Effective Collaboration and Practice, American Institutes for
Research.
9
https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/kazdin.htmlhttp://www.dbhds.virginia.gov/library/quality%20risk%20management/opd-stateplan2014thru2020.pdfhttp://www.dbhds.virginia.gov/library/quality%20risk%20management/opd-stateplan2014thru2020.pdf
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ROLE OF THE FAMILY IN TREATMENT PROGRAMS Return to Table of
Contents
Over the past several years, the focus of mental health
treatment and support for youth and families has increasingly been
on evidence-based practices (National Alliance on Mental Illness
[NAMI], 2007). Evidence-based practices are those that research has
shown to be effective. However, although there is growing emphasis
on evidence-based practices, it is equally important to emphasize
the role of families as partners in the treatment process
(NAMI).
To ensure successful treatment outcomes, it is crucial that
family members are involved in child and adolescent services
(Kutash & Rivera, 1995; Pfeifer & Strzelecki, 1990).
Research has shown that the effectiveness of services hinges less
on the particular type of treatment than on the family’s
participation in planning, implementing, and evaluating those
services (Koren et al., 1997), as well as on their control over the
child’s treatment (Curtis & Singh, 1996; Thompson et al.,
1997). Family participation promotes an increased focus on
families, a provision of services in natural settings, a greater
awareness of cultural sensitivity, and a community-based system of
care. Research also confirms that family participation improves not
only service delivery, but also treatment outcomes (Knitzer,
Steinberg, & Fleisch, 1993).
There is a growing body of evidence indicating that children
from vulnerable populations, children of single mothers, and
children who live in poverty are more likely to exhibit the most
serious problems. They are also the most likely to prematurely
terminate treatment (Kadzin & Mazurick, 1994). Additional
research is necessary to determine the factors that contribute to
this early termination.
In recognition of this problem, it is important for mental
health providers to ensure that families that have these
characteristics are actively engaged in the services that their
children receive in order to maximize the potential for successful
outcomes. This goal is complicated by the fact that both families
and providers may be confused and hesitant about the role that
family members should play in treatment efforts. In addition, other
barriers may preclude families from procuring high-quality mental
health services for their children.
In an attempt to combat this problem, researchers have
identified six broad roles that families should play in the
treatment process (Friesen & Stephens, 1998). These roles are
listed below:
Contributors to the Environment – Family members are a constant
in the environment in which a child resides. Consequently,
treatment providers often try to identify ways in which the
behavior and interactions among family members influence the
child’s emotional and behavioral problems. With the assistance of
the treatment provider, family members should consider ways to
improve the home environment and the relationships within the
family in order to provide the child with the most stable,
supportive environment possible. In addition, family members should
seek external support from their extended family and community to
reduce the stress of raising a child with emotional or behavioral
difficulties.
Recipients of Service – Family members are an important part of
the therapeutic process. Service providers often focus on the
family unit as a whole, creating interventions and strategies that
target the health of the entire family. These interventions are
intended to assess the strengths and weaknesses that exist within
the family structure, to enhance the well-being of parents and
other family members, and to help families locate support
mechanisms in the community. The provider also assists family
members in developing the skills necessary to support the special
needs of the child. Services may include supportive counseling,
parental training and education, development of coping
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Role of the Family in Treatment Programs
skills and stress management techniques, respite care, parental
support groups, transportation, and financial assistance.
Partners in the Treatment Process – Family members serve as
equal contributors in the problem-solving process. They should work
with treatment providers to identify the goals of treatment and to
plan realistic strategies to achieve these goals. Additionally,
family members should play a key role in implementing these
strategies to help ensure that treatment goals are met. When
performing these functions, family members should not be afraid to
ask questions and to voice their opinions and preferences. It is
crucial that they are fully informed and that their preferences are
considered in all treatment decisions.
Service Providers – The treatment process is incomplete unless
family members also provide services to the child. Family members
are responsible for providing information and emotional support to
the child and to other family members, and for filling in the gaps
in the services being received by the child. Furthermore, they
often coordinate services by requesting and convening meetings and
transporting the child to appointments. It is a crucial role, the
importance of which cannot be overstated. Parents and caregivers
need to remain vigilant and involved in all aspects of the child’s
treatment. This includes keeping all follow-up appointments,
becoming knowledgeable about any prescribed medications, and
keeping track of all treatments that have been unsuccessful.
Advocates – Family members often serve as their child’s only
voice in the mental health system. They should therefore actively
advocate for the child to ensure that he or she receives
appropriate services. They also must voice any concerns regarding
undesirable practices and policies. There are several local, state,
and national organizations that can assist parents and caregivers
in these efforts, allowing them to serve as part of a larger voice
in their communities.
Evaluators and Researchers – It is important that families
participate in research and evaluation activities so that their
opinions can be heard regarding which treatments and services are
most beneficial and convenient. The input of family members is
crucial to ensure that all children receive services that are
efficient and effective.
Because family members play important supporting roles in
combating mental health disorders, it is important that they assume
each of these roles in order to provide the effective support
network that is necessary for the child’s continued improvement.
Family members who support and encourage their child and create a
favorable environment for services will maximize the potential for
successful outcomes.
The following information is attributed to the U.S. Substance
Abuse and Mental Health Services Administration (SAMHSA, 2000).
Families must recognize that, although they are obtaining services
for their child, they are the experts in understanding the
following:
• How their child responds to different situations; • Their
child’s strengths and needs; • What their child likes and dislikes;
and • What has worked and has not worked in helping their
child.
Families are ultimately responsible for determining what
services and supports their children receive. Thus, family members
must communicate to service providers their children’s strengths
and weaknesses, as well as their own priorities and expectations.
They must also not hesitate to inform service providers if they
believe treatment is not working so that appropriate modifications
can be made (SAMHSA, 2000).
These recommendations also hold true for children who come into
contact with the juvenile justice system. Family involvement is
particularly critical for these youth to ensure positive outcomes
(Osher & Hunt, 2002). It is imperative that family members
provide information on the child’s diagnosis and
11
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Role of the Family in Treatment Programs
treatment history, use of medications, education history and
status (including whether the child is enrolled in special
education), and any other special circumstances that affect the
child (Osher & Hunt). It is also important that they
communicate their ability to participate in treatment. Ideally,
families should be involved in decision-making and treatment at
each stage of service provision (Osher & Hunt). Families and
juvenile justice officials must cooperate to ensure that all have
mutual responsibility for the child’s outcomes (Osher &
Hunt).
Without family involvement, it is extremely difficult for
service providers to ensure that the gains achieved by the child in
treatment are maintained and solidified. Moreover, the combined
efforts of service providers, family members, and advocates are
necessary to ensure that the services provided in the community
effectively meet the needs of all children and families. It is
important that parents and caregivers understand the results of any
evaluation, the child's diagnosis, and the full range of treatment
options. If parents are not comfortable with a particular clinician
or treatment option or are confused about a specific
recommendation, they should consider seeking a second opinion.
If medication is suggested as a treatment option, families must
be informed of all associated risks and benefits. In addition,
children and adolescents who are taking psychotropic medications
must be closely monitored and frequently evaluated by qualified
mental health providers (NAMI). The decision about whether to
medicate a child as part of a comprehensive treatment plan should
be made only after parents carefully weigh these factors (NAMI,
2007). Figure 1 outlines questions parents should ask about
treatment services.
Supplementary Issues for Families
Continuous news coverage of events such as natural disasters,
catastrophic events, and violent crime may cause children to
experience stress, anxiety, and fear (AACAP, 2002). In addition,
some children may be unable to distinguish the difference between
reality and the fantasy presented in the media (AACAP, 2001). As a
result, children may be exposed to behaviors and attitudes that can
be overwhelming or difficult to understand (AACAP, 2001).
Caregivers should be made aware that violent media images can have
a greater impact upon children with emotional and behavioral issues
than might otherwise be the case (AACAP, 2015).
Systems of Care and Family Involvement
Unless otherwise cited, information in this section is
attributed to Systems of Care: A Framework for System Reform in
Children’s Mental Health (Stroul, 2002). A system of care is
defined as “a comprehensive spectrum of mental health and other
necessary services which are organized into a coordinated network
to meet the multiple and changing needs of children and their
families.” It is not a program, but a philosophy. According to the
primary values of the systems-of-care philosophy, services for
children are:
• Community-based; • Child-centered and family-focused; and •
Culturally competent.
Families are designated partners in the design of effective
mental health services and supports. Families have a primary
decision-making role in the care of their own children, as well as
in the policies and procedures governing care for all children in
their communities. This includes:
• Choosing supports, services, and providers • Setting goals •
Designing and implementing programs • Monitoring outcomes
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Role of the Family in Treatment Programs
• Partnering in funding decisions• Determining the effectiveness
of all efforts to promote the mental health and well-being of
children and youth (AACAP, 2009)
Figure 1 Questions Parents or Caregivers Should Ask About
Treatment Services
Before a child begins treatment, parents should ask the
following:
• Does my child need additional assessment and/or testing
(medical, psychological, etc.)?• What are the recommended treatment
options for my child?• Why do you believe treatment in this program
is indicated for my child? How does it
compare to other programs or services that are available?• What
are the advantages and disadvantages of the recommended service or
program?• How long will treatment take?• What will treatment cost,
and how much of the cost is covered by insurance or public
funding? Will we reach our insurance limit before treatment is
completed?• How will my child continue education while in
treatment?• Does my child need medication? If so, what is the name
of the medication that will be
prescribed? How will it help my child? How long before I see
improvement? What are theside effects that occur with this
medication?
• What are the credentials and experience of the members of the
treatment team?• How frequently will the treatment sessions occur?•
Will the treatment sessions occur with just my child or the entire
family?• How will I be involved with my child's treatment?• How
will we know if the treatment is working? What are some of the
results I can expect
to see?• How long should it take before I see improvement?• What
should I do if the problems get worse?• What are the arrangements
if I need to reach you after-hours or in an emergency?• As my
child's problem improves, does this program provide less
intensive/step-down
treatment services?• How will the decision be made to discharge
my child from treatment?• Once my child is discharged, how will it
be decided what types of ongoing treatment will
be necessary, how often, and for how long?
Source: American Academy of Child & Adolescent Psychiatry
(AACAP), 2000.
Systems of care establish partnerships that work because the
system is guided by the family. They use the family’s expertise to
steer decision-making in service and system design, operation, and
evaluation. In recent years, studies have found that children whose
families were involved in their treatment experienced improved
educational outcomes and well-being. They also spent less time in
out-of-home placements and residential settings (Jivanjee et al.,
2002).
While families must take care to ensure that their child is
properly treated, they must also understand that the family may
also require support. Family members often experience considerable
stress physically, emotionally, socially, and spiritually due to
both the child’s health problems and the stress of interacting with
medical professionals. Ensuring that the family is also well
supported can empower the family to support the child’s treatment
(SAMHSA, n.d.).
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Role of the Family in Treatment Programs
Resources and Organizations
American Academy of Family Physicians https://www.aafp.org
American Association of Child & Adolescent Psychiatry (AACAP)
http://www.aacap.org/ American Psychiatric Association (APA)
http://www.psych.org American Psychological Association (APA)
http://www.apa.org/ Familydoctor.org https://familydoctor.org/
Medscape Today Resource Centers (from WebMD)
https://www.medscape.com/internalmedicine
Mental Health America (MHA) http://www.mentalhealthamerica.net/
National Alliance for the Mentally Ill (NAMI) https://www.nami.org/
National Mental Health Information Center Child, Adolescent and
Family Branch, Center for Mental Health Services
https://www.samhsa.gov/children National Technical Assistance
Center for Children’s Mental Health
https://gucchdtacenter.georgetown.edu/ U.S. Department of Education
Office of Special Education and Rehabilitative Services
https://www2.ed.gov/about/offices/list/osers/index.html?src=mr
U.S. Department of Health and Human Services
https://www.hhs.gov/ U.S. National Library of Medicine and the
National Institutes of Health (NIH) Medline Plus
https://medlineplus.gov/ Substance Abuse and Mental Health
Services Administration (SAMHSA) National Registry of
Evidence-based Programs and Practices
https://www.nrepp.samhsa.gov/landing.aspx Virginia Resources and
Organizations
Mental Health America of Virginia https://mhav.org/ National
Alliance for the Mentally Ill Virginia (NAMI Virginia)
https://namivirginia.org/ Virginia Department of Behavioral Health
and Developmental Services (DBHDS) http://www.dbhds.virginia.gov/
Virginia Office of Children’s Services http://www.csa.virginia.gov/
Voices for Virginia’s Children https://vakids.org/
References American Academy of Child & Adolescent Psychiatry
(AACAP). (2000). Facts for families: Questions parents or
caregivers should ask about treatment services. Retrieved from
http://www.aacap.org/web/aacap/publications/factsfam. Not available
December 2017.
American Academy of Child & Adolescent Psychiatry (AACAP).
(2001). Facts for families: Children and watching TV. Retrieved
from
http://www.aacap.org/cs/root/facts_for_families/children_and_watching_tv.
galleries/FactsForFamilies/67_children_and_the_news.pdf. Not
available December 2017.
American Academy of Child & Adolescent Psychiatry (AACAP).
(2002). Facts for families: Children and the news. Retrieved from
http://www.dallaspsychiatry.com/files/Download/67_children_and_the_news.pdf
14
https://www.aafp.org/http://www.aacap.org/http://www.psych.org/http://www.apa.org/https://familydoctor.org/https://www.medscape.com/internalmedicinehttps://www.medscape.com/internalmedicinehttp://www.mentalhealthamerica.net/https://www.nami.org/https://www.samhsa.gov/childrenhttps://gucchdtacenter.georgetown.edu/https://www2.ed.gov/about/offices/list/osers/index.html?src=mrhttps://www2.ed.gov/about/offices/list/osers/index.html?src=mrhttps://www.hhs.gov/https://medlineplus.gov/https://www.nrepp.samhsa.gov/landing.aspxhttps://mhav.org/https://namivirginia.org/http://www.dbhds.virginia.gov/http://www.csa.virginia.gov/https://vakids.org/http://www.dallaspsychiatry.com/files/Download/67_children_and_the_news.pdf
-
Role of the Family in Treatment Programs
American Academy of Child & Adolescent Psychiatry (AACAP).
(2009). Family and youth participation in clinical decision-making.
AACAP Policy Statement. Retrieved from
http://www.aacap.org/aacap/policy_statements/2009/Family_and_Youth_Participation_in_Clinical_Decision_Making.aspx
American Academy of Child & Adolescent Psychiatry (AACAP).
(2015). Facts for families: Children and video games: Playing with
violence. Retrieved from
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-and-Video-Games-Playing-with-Violence-091.aspx
Curtis, I., & Singh, N. (1996). Family involvement and
empowerment in mental health service provision for children with
emotional and behavioral disorders. Journal of Child and Family
Studies, 5, 503-517.
Friesen, B., & Stephens, B. (1998). Expanding family roles
in the system of care: Research and practice. In M. Epstein, K.
Kutash, & A. Duchnowski (Eds.), Outcomes for children &
youth with behavioral and emotional disorders and their families.
Austin, TX: Pro-Ed.
Jivanjee, P., Friesen, B., Robinson, A., & Pullman, M.
(2002). Family participation in systems of care: frequently asked
questions (and some answers). Research and Training Center on
Family Support and Children's Mental Health. Retrieved from
https://www.pathwaysrtc.pdx.edu/pdf/pbFamParCWTAC.pdf
Kadzin, A., & Mazurick, J. (1994). Dropping out of child
psychotherapy: Distinguishing early and late dropouts over the
course of treatment. Journal of Consulting and Clinical Psychology,
62, 1069-1074.
Knitzer, J., Steinberg, Z., & Fleisch, B. (1993). At the
schoolhouse door: An examination of programs and policies for
children with behavioral and emotional problems. New York: Bank
Street College of Education.
Koren, P., Paulson, R., Kinney, R., Yatchmonoff, D., Gordon, L.,
& DeChillo, N. (1997). Service coordination in children’s
mental health: An empirical study from the caregivers’ perspective.
Journal of Emotional and Behavioral Disorders, 5, 62-172.
Kutash, K., & Rivera, V. (1995). Effectiveness of children’s
mental health services: A review of the literature. Education and
Treatment of Children, 18, 443-477.
National Alliance on Mental Illness (NAMI). (2007). Choosing the
right treatment: What families need to know about evidence-based
practices. Retrieved from
http://www2.nami.org/namiland09/CAACebpguide.pdf. Not available
December 2017.
Osher, T., & Hunt, P. (2002). Involving families of youth
who are in contact with the juvenile justice system. Research and
program brief. National Center for Mental Health and Juvenile
Justice. Retrieved from
https://www.nttac.org/views/docs/jabg/mhcurriculum/mh_involving_families.pdf.
Not available December 2017.
Pfeiffer, S., & Strzelecki, S. (1990). Inpatient psychiatric
treatment of children and adolescents: A review of outcome studies.
Journal of the American Academy of Child and Adolescent Psychiatry,
29, 847-853.
Stroul, B. (2002). Systems of care: A framework for system
reform in children’s mental health. Georgetown University Child
Development Center, National Technical Assistance Center for
Children’s Mental Health.
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2000). Family guide to systems of care for children with
mental health needs. National Mental Health Information Center.
Retrieved from
http://dhhs.ne.gov/behavioral_health/Documents/FamiliesSystemsofCareGuide.pdf
Substance Abuse and Mental Health Services Administration
(SAMHSA). (n.d.). Involving and supporting families. Retrieved from
http://www.samhsa.gov/co-occurring/about/involving_and_supporting_families.aspx.
Not available December 2017.
Thompson, L., Lobb, C., Elling, R., Herman, S., Jurkidwewicz,
T., & Helluza, C. (1997). Pathways to family empowerment:
Effects of family-centered delivery of early intervention services.
Exceptional Children, 64, 99-113.
15
http://www.aacap.org/aacap/policy_statements/2009/Family_and_Youth_Participation_in_Clinical_Decision_Making.aspxhttp://www.aacap.org/aacap/policy_statements/2009/Family_and_Youth_Participation_in_Clinical_Decision_Making.aspxhttp://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-and-Video-Games-Playing-with-Violence-091.aspxhttp://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-and-Video-Games-Playing-with-Violence-091.aspxhttps://www.pathwaysrtc.pdx.edu/pdf/pbFamParCWTAC.pdfhttp://dhhs.ne.gov/behavioral_health/Documents/FamiliesSystemsofCareGuide.pdf
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KEY COMPONENTS OF SUCCESSFUL TREATMENT PROGRAMS Return to Table
of Contents
Integrated Programming – The “Systems” Approach Screening and
Assessment Individualized Care Planning Discharge Planning Engaging
Families in Treatment Culturally-Competent Service Delivery
Psychosocial and Pharmacological Treatments
While studies have identified numerous strategies and techniques
that are effective in the treatment of mental health issues, a
growing body of research shows that there are several guiding
principles that provide a foundation for any treatment program.
These principles will be discussed in detail in the following
paragraphs.
Integrated Programming – The “Systems” Approach
Research continues to support the idea that the mental health
needs of children and adolescents are best served within the
context of a “system of care” in which multiple service providers
work together in an organized, collaborative way. The
system-of-care approach encourages agencies to provide services
that are child-centered and family-focused, community-based, and
culturally competent. The guiding principles also call for services
to be integrated. Linking child-serving agencies and programs
allows for collaborative planning, development, and implementation
of services. Additional information on systems of care is provided
in the “Role of the Family” section.
Systems of care produce important system improvements. For
example, studies have shown that systems of care improve the
functional behavior of children and reduce the use of residential
and out-of-state placements. Parents also appear to be more
satisfied with services provided within systems of care than with
more traditional service delivery systems.
The Virginia Department of Behavioral Health and Developmental
Services (VDBHDS) emphasizes the need for agency collaboration at
both the state and local levels (2004). This can be achieved by
promoting integration of services and establishing policies that
require service providers to conduct a single, comprehensive intake
addressing the areas of mental health, intellectual disability, and
substance abuse. Moreover, community partnerships can be
strengthened or enhanced to improve the delivery of child and
adolescent mental health services.
Screening and Assessment
Comprehensive assessment, screening, and evaluation are
necessary for children and adolescents experiencing a mental health
crisis. Children should also be screened to identify potential
delayed or atypical development, thus determining the appropriate
level of assessment (Pires, 2002). In addition to screening,
assessment and evaluation collectively address the needs and
services of the child and family (Pires).
Parents of youth who are identified with a possible problem
should be offered a full assessment by a professional clinician. A
qualified mental health professional can determine whether a
comprehensive
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Key Components of Successful Treatment Programs
psychiatric evaluation for serious emotional behavior problems
is necessary (American Academy of Child & Adolescent Psychiatry
[AACAP], 2005). Such a step will lead to accurate assessment and,
if needed, appropriate, individualized treatment. In addition,
every step of the assessment process must include parental consent
and youth assent (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2011).
Individualized Care Planning
In order to make certain that there is a continuity of
treatment, a framework should be established that ensures that a
child can transition with ease from one service to another. The
efficiency of these transitions is enhanced through the creation of
effective individualized service plans. These plans, which are
targeted to the child’s specific needs, identify problems,
establish goals, and specify appropriate interventions and
services. Developed in partnership with the child and family, an
individualized service plan allows for services to be matched with
the unique potential and needs of each child and family (Stroul
& Friedman, 2011).
Once screening and assessment have taken place, an individual
care plan ensures that the distinct needs of the child are met. The
goal is to plan and provide appropriate services and supports to
the child. Elements that must be acknowledged include building
trust, engaging the family, and tailoring family supports (Pires,
2002). Some components to be included in such a plan are:
• Background information and family assessment • Identifying
information • Child development and behavior • Needs • Family
functioning style • Social support network • Safety issues and
risks • Goals • Sources of support and/or resources • Action plan •
Progress evaluation
Discharge Planning
Service providers have found that a breakdown in the system of
care is frequently encountered in the area of discharge planning. A
discharge plan should be created whenever a child is transitioning
from inpatient or residential treatment back into the community.
These plans should be updated in consultation with the child’s
family before the child is released from treatment. They should
describe the therapy and services that were provided in the
facility and recommend any necessary follow-up services, which
should then be coordinated by a case manager. Although they are
frequently overlooked, discharge plans are a key component of a
comprehensive system of care, as they help to ensure that the gains
made in an inpatient or residential setting are continued once the
child returns to the community.
Engaging Families in Treatment
Service providers and researchers have increasingly realized the
important role that families play in the treatment of children with
mental health disorders. The mental health system has taken steps
to make families partners in the delivery of mental health services
for children and adolescents (U.S. Department of Health and Human
Services, 1999). For further discussion of the roles that families
should play in treatment services, see the “Role of the Family in
Treatment Programs” section of the Collection.
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Key Components of Successful Treatment Programs
Engagement involves the participation of people who both deliver
and seek services. With effective engagement, the likelihood of
ongoing participation in services and supports increases (National
Alliance on Mental Illness [NAMI], 2016). When care is respectful,
compassionate, and centered on an individual’s life goals, the
likelihood of recovery is sharply increased.
According to the New Freedom Commission on Mental Health
established by President George W. Bush, local, state, and federal
officials must engage families in planning and evaluating treatment
and support services (2003). The direct participation of families
in developing a range of community-based, recovery-oriented
treatment and support services is important. Families of children
with serious emotional disturbances have a key role in mental
health care delivery in that they can advocate for a system that
focuses on recovery through the use of appropriate evidence-based
treatments.
The New Freedom Commission also specifies that mental health
care should be consumer and family driven. Consumers their families
should be encouraged to be fully involved in care, which will help
promote a recovery-based mental health system. Families can take
part in this process by becoming educated about the appropriate
treatments for their child, as well as the provider qualifications
necessary to delivery these treatments. For more information about
mental health providers’ qualifications, please see the “General
Description of Providers” section of the Collection.
Culturally-Competent Service Delivery
Virginia, like the nation as a whole, is becoming more racially
diverse. The minority share of the population has increased from
29.8 percent in 2000 to 35.2 percent in 2010 (Sturtevant, 2011).
During this period, the biggest gain was among Virginia’s Hispanic
population, which grew by more than 300,000, or 92 percent (Cai,
2011). The Asian population grew by 68.3 percent, and the
population of all other minority races (including persons of two or
more races) grew by 50.8 percent (Sturtevant). This increase in
diversity has significant implications for service providers in the
Commonwealth, as cultural factors are becoming increasingly
important in the evaluation and treatment of mental health
disorders.
Culture has been found to influence many aspects of mental
health disorders. Individuals from specific cultures may express
and manifest their symptoms in different ways. They may also differ
in their styles of coping, their use of family and community
supports, and their willingness to seek and continue treatment.
Moreover, clinicians may be influenced by their own cultural
values, which may affect diagnosis, treatment, and service delivery
decisions (U.S. Department of Health and Human Services, 2001).
The variability within a culture and among different cultural
groups is described in Table 1.
The following is attributed to Kumpfer and Alvarado (1998).
Cultural competency involves addressing the various folkways,
mores, traditions, customs, rituals, and dialects that are specific
to each culture and ethnicity (Saldana, 2001). Research has shown
that tailoring interventions to the cultural traditions of the
family improve outcomes. Culturally-relevant values can be
integrated into existing model programs for a variety of ethnic
groups. Such an approach can address the various nuances that
cultures may exhibit, such as specific values and beliefs. These
cultural beliefs should be incorporated into an organized,
culturally sensitive treatment framework.
Cultural differences may also affect the success of mental
health services. The mental health treatment setting relies
significantly on language, communication, and trust between
patients and providers. In addition, children may be reticent to
share elements of their cultural orientation with persons who do
not share their culture. Therefore, therapeutic success may hinge
on the clinician’s ability to understand a patient’s identity,
social supports, self-esteem, and perception of stigma.
Consequently, mental health service providers must recognize
underlying cultural influences so they can effectively address the
mental health needs of each segment of the community (U.S.
Department of Health and Human Services, 1999).
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Key Components of Successful Treatment Programs
Table 1 Addressing Cultural Variability
Variability Factor Description
Acculturation This reflects the extent to which a person is
familiar with and proficient within U.S. mainstream culture.
Poverty There may be difference in resources, as well as a lack
of awareness of traditional mental health interventions and the
importance of compliance.
Language Clients may not be as fluent in English as they are in
their native language. Different dialects within the same language
may also create communication barriers.
Transportation, housing and childcare
A lack of available resources and supports may interfere with
access to treatment and adherence with provider expectations.
Reading ability/ educational background
Individuals may vary substantially in academic experience. This
is true within ethnic subgroups, as well as between subgroups.
Beliefs
People from diverse cultures vary in their beliefs about what is
considered “illness,” what causes an illness, what should be done
to address an illness, and what the treatment outcome should be.
Providers cannot assume their clients’ views match theirs.
Physical characteristics People of different ethnic backgrounds
sometimes differ in their appearance, even within the same ethnic
group. Source: Saldana, 2001.
Culturally competent treatment programs are founded upon an
awareness of and respect for the values, beliefs, traditions,
customs, and parenting styles of all individuals who reside in the
community. Providers should be aware of the impact of their own
culture on the therapeutic relationship with their clients and
consider these factors when planning and delivering the services
for youth and their families. Ideally, culturally competent
programs include multilingual, multicultural staff and provide
extensive community outreach (Cross et al., 1989).
The services offered within a community should also reflect a
respect for cultural diversity. For example, the inclusion of
extended family members in treatment efforts should be incorporated
within certain treatment approaches, when appropriate. It would
also be beneficial for mental health agencies to display culturally
relevant pictures and literature in order to show respect and
increase consumer comfort with services. Finally, agencies should
consider the holidays or work schedules of consumers when
scheduling office hours and meetings (Cross et al., 1989).
Cultural differences other than ethnicity must also be
considered. For example, Americans living in isolated and
impoverished rural areas may display unique characteristics that
present barriers to mental health services. Some may not seek care
because of a perceived stigma attached to mental health disorders,
a lack of understanding about mental illnesses and treatments, a
lack of information about where to go for treatment, or an
inability to pay for care. Furthermore, factors such as poverty and
geographic isolation may affect the quality of mental health care
available to these individuals. These issues are further
complicated by the limited availability of mental health
specialists, such as psychiatrists, psychologists, psychiatric
nurses, and social workers, in rural areas (National Institute of
Mental Health [NIMH], 2000).
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Key Components of Successful Treatment Programs
It is important to consider the impact of culture on mental
health service delivery. Culturally competent programming has been
found to promote service utilization for all ages, including
children (Snowden & Hu, 1997). Furthermore, children and
families enrolled in mental health programs that are aligned with a
community’s culture are less likely to drop out of treatment than
those in mainstream programs (SAMHSA, 2014; Takeuchi, Sue, &
Yeh, 1995). Culturally competent training and service planning
serve as important components of the mental health delivery
system.
Psychosocial and Pharmacological Treatments
Because of the increasing recognition of the impact mental
health disorders have upon children and adolescents, there has been
greater scrutiny regarding the effectiveness and safety of mental
health interventions used to treat children. Accordingly, the
number of scientific studies of treatment effectiveness has risen
dramatically. Several federally sponsored clinical trials have been
conducted to address the effectiveness of interventions for
childhood disorders (American Psychological Association [APA],
2006).
Child and adolescent mental health treatments may be
psychosocial, pharmacological, and/or combined. Psychosocial
treatments are treatments that include different types of
psychotherapy and social and vocational training. These
interventions aim to provide support, education, and guidance to
children with mental health conditions (NAMI, 2015).
Pharmacological treatments use medication to treat the mental
health disorder.
The APA’s working group on psychotropic medications recommends
that, for most children and adolescents, psychosocial interventions
should be considered first (APA, 2006). The working group noted a
variety of reasons why psychosocial interventions were preferred,
with the primary reason being that these interventions are safer
than psychotropic medications (APA). There are vast developmental
differences in child and adolescent populations that influence
physiological, cognitive, behavioral, and affective functioning.
Development also has implications with respect to medication
management. For instance, physiological differences can result in
markedly different rates of medication absorption, distribution in
the body, and metabolism among youth of different ages and stages
of development (Brown & Sammons, 2002, as cited by APA).
Children are also less able than adults to accurately describe
changes in their physiological and psychological functioning, the
course of these changes over time, and any adverse effects of
psychotropic medications. In addition, parents are responsible for
both the decision to use pharmacotherapy and the administration of
medication. In the school setting, it may be the school nurse or
the teacher who administers medication. As a result, parents’ and
school personnel’s attitudes toward medication may influence
whether a child adheres to medical regimens. For these reasons, the
unique issues in child and adolescent psychopharmacology must be
considered when prescribing and monitoring medication in pediatric
populations (APA).
If medication is recommended as a treatment, the physician
recommending its use should be experienced in treating psychiatric
illnesses in children and adolescents (AACAP, 2012). He or she
should fully explain the reasons for medication use, the benefits
the medication should provide, the possible risks and adverse
effects, and any other treatment alternatives. When pharmacological
treatments are necessary, their use should be carefully monitored,
and dosage should be tapered off as soon as possible (Tweed et al.,
2012). In addition, psychiatric medication should not be used
alone. The use of medication should be based on a comprehensive
psychiatric evaluation and be one part of a comprehensive treatment
plan.
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Key Components of Successful Treatment Programs
References
American Academy of Child & Adolescent Psychiatry (AACAP).
(2005). Facts for families: Comprehensive psychiatric evaluation.
Retrieved from
http://www.aacap.org/App_Themes/AACAP/docs/facts_for_families/
52_comprehensive_psychiatric_evaluation.pdf
American Academy of Child & Adolescent Psychiatry (AACAP).
(2012). Psychiatric medication for children and adolescents: Part I
– How medications are used. No. 21. Retrieved from
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspx
American Psychological Association (APA). (2006). Report of the
working group on psychotropic medications for children and
adolescents: Psychopharmacological, psychosocial, and combined
interventions for childhood disorders: Evidence base, contextual
factors, and future directions. Washington, DC: Author.
Cai, Q. (2011). A decade of change in Virginia’s population, The
Virginia News Letter, 87(4), Retrieved from
http://www.coopercenter.org/sites/default/files/publications/Virginia%20News%20Letter%202011%20Vol.
%2087%20No%204.pdf. Not available December 2017.
Cross, T., Dennis, K., Isaacs, M., & Bazron, B. (1989).
Towards a culturally competent system of care, National Technical
Assistance Center for Children's Mental Health at Georgetown
University, Washington, DC.
Kumpfer, K., & Alvarado, R. (1998). Effective family
strengthening interventions. Juvenile Justice Bulletin. Office of
Juvenile Justice and Delinquency Prevention.
National Alliance on Mental Illness (NAMI). (2016). Engagement:
A new standard for mental health care. Retrieved from
https://www.nami.org/engagement
National Alliance on Mental Illness (NAMI). (2015). Psychosocial
treatments fact sheet. Retrieved from
http://www.namidupage.org/wp-content/uploads/2015/05/Psychosocial-Treatments-Fact-Sheet.pdf
National Institute of Mental Health (NIMH). (2000). Fact sheet:
Rural mental health research at the National Institute of Mental
Health. Retrieved from
http://www.nimh.nih.gov/publicat/ruralresfact.cfm. Not available
December 2017.
Pires, S. (2002). Building systems of care: A primer.
Washington, DC: Georgetown University Child Development Center,
National Technical Assistance Center for Children’s Mental Health.
Collaborative.
President’s New Freedom Commission on Mental Health. (2003).
Achieving the promise: Transforming mental health care in America.
DHHS Pub. No. SMA-03-3832. Rockville, MD: Author.
Saldana, D. (2001). Cultural competency, a practical guide for
mental health service providers. Hogg Foundation for Mental Health.
The University of Texas at Austin.
Snowden, L., & Hu, T. (1997). Ethnic differences in mental
health services among the severely mentally ill. Journal of
Community Psychology, 25, 235-247.
Stroul, B. A., & Friedman, R. M. (2011). Effective
strategies for expanding the system of care approach. A report on
the study of strategies for expanding systems of care. Atlanta, GA:
ICF Macro.
Sturtevant, L. (2011). Virginia’s changing demographic
landscape. Virginia Issues & Answers. Retrieved from
https://www.jmu.edu/lacs/_files/Virginias-Changing-Demographic-Landscape.pdf
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2011). Identifying mental health and substance use
problems of children and adolescents: A guide for child-serving
organizations. HHS Publication No. SMA 12-4670. Rockville, MD.
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2014). Improving cultural competence. Treatment
Improvement Protocol (TIP) Series No. 59. HHS Publication No. SMA
14-4849. Rockville, MD.
Takeuchi, D., Sue, S., & Yeh, M. (1995). Return rates and
outcomes from ethnicity-specific mental health programs in Los
Angeles. American Journal of Public Health, 85, 638-643.
Tweed, L., Barkin, J.S., Cook, A., & Freeman, E. (2012). A
weighty matter: Anti-psychotic medications for children and youth
should be chosen carefully and used only as long as needed. Maine
Independent Clinical Information Service
U.S. Department of Health and Human Services. (1999). Mental
health: A report of the Surgeon General. Rockville, MD.
U.S. Department of Health and Human Services. (2001). Mental
health: Culture, race, ethnicitySupplement to mental health: Report
of the Surgeon General. Rockville, MD: Author.
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http://www.aacap.org/App_Themes/AACAP/docs/facts_for_families/%2052_comprehensive_psychiatric_evaluation.pdfhttp://www.aacap.org/App_Themes/AACAP/docs/facts_for_families/%2052_comprehensive_psychiatric_evaluation.pdfhttp://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspxhttp://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspxhttp://www.coopercenter.org/sites/default/files/publications/Virginia%20News%20Letter%202011%20Volhttp://www.coopercenter.org/sites/default/files/publications/Virginia%20News%20Letter%202011%20Volhttps://www.nami.org/engagementhttp://www.namidupage.org/wp-content/uploads/2015/05/Psychosocial-Treatments-Fact-Sheet.pdfhttps://www.jmu.edu/lacs/_files/Virginias-Changing-Demographic-Landscape.pdf
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Key Components of Successful Treatment Programs
Virginia Department of Mental Health, Mental Retardation and
Substance Abuse Services (VDBHDS). (2004). F