Transforming Teen Behavior: Parent Teen Protocols for Psychosocial Skills Training
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About this ebook
Transforming Teen Behavior: Parent-Teen Protocols for Psychosocial Skills Training is a clinician's guide for treating teens exhibiting emotional and behavioral disturbances. Unlike other protocols, the program involves both parents and teens together, is intended for use by varied provider types of differing training and experience, and is modular in nature to allow flexibility of service. This protocol is well-established, standardized, evidence-based, and interdisciplinary. There are 6 modules outlining parent training techniques and 6 parallel and complementary modules outlining psychosocial skills training techniques for teens. The program is unique in its level of parent involvement and the degree to which it is explicit, structured, and standardized. Developed at Children’s Hospital Colorado (CHCO), and in use for 8+years, the book summarizes outcome data indicating significant, positive treatment effects.
- Useful for teens with varied clinical presentations
- Evidence-based program with efficacy data included
- Explicit, user-friendly protocols, for easy implementation
- Appropriate for use by varied provider types in varied settings
- Includes activities, patient handouts, and identifies structured format and delivery
Mary Nord Cook
Mary Nord Cook, MD is an Associate Professor of Psychiatry at the Colorado School of Medicine, who served as the Medical Director of Outpatient Services for the Department of Psychiatry at the Children’s Hospital Colorado (CHCO) from 2005-2014. She has been extensively involved in the training of medical students, psychology and social work graduate students, along with psychiatry residents. She recently won a resident nominated award for teaching excellence and has also been recognized by the American Academy of Child & Adolescent Psychiatry (AACAP), as an Outstanding Mentor. She specializes in working with families presenting with youngsters who’ve been diagnosed with Disruptive Behavior and Mood Disorders. She spearheaded the development of a series of multidisciplinary, outpatient specialty clinics, along with intensive outpatient programs at the Children’s Hospital Colorado. She recently wrote a book detailing the evidence-based, standardized, skills building treatment protocols used for the school-aged patient population, in both the routine and intensive outpatient programs, titled Transforming Behavior: Training Parents & Kids Together. She also co-authored a peer reviewed journal article that described the positive clinical outcomes obtained in the intensive outpatient program for children with disruptive behavior. She has authored books, chapters, review articles and contributed to the AACAP Practice Parameters on family interventions. She frequently performs presentations in the community for school, primary care and youth outreach programs. In addition, she routinely presents at regional and national, professional conferences, often on an invited basis. Her passions are developing and applying family and strengths-based approaches, pursuant of a goal to minimize medication, while optimizing parenting and psychosocial skills. Her mantra is “More Skills =’s Less Pills! Dr. Cook received her bachelor’s degree (psychology) with honors, from the University of Michigan and her doctoral degree (medicine) from Wayne State University. She completed her general psychiatry residency at the Naval Medical Center, San Diego and her child fellowship training at the University of California, San Diego.
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Transforming Teen Behavior - Mary Nord Cook
Transforming Teen Behavior
Parent—Teen Protocols for Psychosocial Skills Training
Mary Nord Cook
Department of Psychiatry, Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
Table of Contents
Cover image
Title page
Copyright
Dedication
List of Contributors
Foreword
References
Author Biography
Acknowledgment
To the Reader
Chapter 1. Introduction and Background: Unmet Child Mental Health Needs
Child Mental Health Provider Shortage
Child Mental Health Provider Misdistribution
Managed Care and Fiscal Challenges
Challenges Translating Research to Real World
Role of Parents in Child Mental Health Treatment
Family-Based Approaches
Family-Focused Therapy
Multifamily Psychoeducational Groups
Cognitive Behavioral Therapy
Parent Management Training Programs
Collaborative Problem Solving
Psychodynamic Approaches
Limitations of Available Treatments
IOP as a Solution
2′×4′
Methodology of IOP Program
Chapter 2. Parenting Approaches for Challenging Kids—Teen and Mastery of Psychosocial Skills—Teen: Overview of Format and Operations
Target Population
Guiding Principles and Goals
Settings and Service Delivery Options
Organization of Materials
Rolling Admission
Group Format and Size
Scheduling
Caregiver Participation
Provider Teams
Provider Preparation
Charting
Provider Training
Strategies for Limit Setting
PACK and MaPS Teen Intensive Outpatient Psychiatry Program
Insurance Contracting and Fiscal Sustainability of PACK and MaPS Teen
PACK and MaPS Teen IOP Program Components
Children’s Colorado Hospital Format for PACK and MaPS Teen IOP
Creative Arts Therapy Component of PACK and MaPS Teen IOP
Individual or Family and Care Coordination Session for PACK and MaPS Teen IOP
Intake Process for PACK and MaPS Teen IOP
Outcome Assessments for Pack and MaPS Teen IOP
Chapter 3. Outcome Data for PACK and MaPS Teen Intensive Outpatient Program
Objective
Method
Results
Cost-Effectiveness, Retention, and Attendance Data
Chapter 4. PACK-Teen Treatment Protocol
Established Parent Introductions and Check-Ins
Workshop Guidelines
New Parent Introductions and Check-Ins
New Parent Orientation
Managing Parental Resistance
Workshop Format, Past Topic Review, Family Homework
What About My Teen?
Examples
Handouts and Business Cards
Introductions, Check-Ins, and Orientation Summary Outline
PACK-Teen Module 1
Introductions and Guidelines
Review
Treatment Goals: Individual and Family
Feelings: Good, Bad, and Ugly Ones
Lowering Arousal
PACK-Teen Module 1 Summary Outline
Treatment Goals: Individual and Family
Feelings: Good, Bad, and Ugly
PACK-Teen Module 2
Introductions, Check-Ins, Guidelines, and New Parent Orientation
Effective Coping Skills
Healthy Habits
Parental Empathy Part I
PACK-Teen Module 2 Summary Outline
PACK-Teen Module 3
Introductions, Check-Ins, Guidelines, and New Parent Orientation
Empathy Test
Empathy Busters
Review of Multiple Choice Test on Empathy
Identifying Feelings in Others
Feelings Vocabulary
Mirroring
Overcoming Barriers to Empathy
The 3-Minute Rule
Empathy Role-Plays
Parental Resistance
Family Homework
Joint Session for Module 3
PACK-Teen Module 3 Summary Outline
PACK-Teen Module 4
Win–Win
Conflict Resolution
Parental Resistance
Setting the Stage for PST
Lowering Arousal
Picking Your Battles
Zoning
Behaviors
Problem Solving Together
PACK Module 4 Summary Outline
Pack-Teen Module 5
Introductions and Guidelines
Communication Test
Cooperation Busters
Review Test on Communication
What About My Teen Examples?
Four Styles of Communication
Practice with Assertive Communication
Expressing Positive Feelings Using the Assertiveness Formula
Cooperation Builders
Cooperation Building Role-Plays
Love Languages
Responding to Parental Resistance
Family Homework
Joint Session for Module 5
PACK-Teen Module 5 Summary Outline
PACK-Teen Module 6
Thought Correction
Self-Talk
PACK-Teen Module 6 Summary Outline
Chapter 5. MaPS-Teen Treatment Protocol
New Patient Orientation
Managing Teen Resistance
Icebreaker or Fun
Question
New Patient Introductions
Established Patient Introductions and Check-Ins
Workshop Guidelines
Workshop Format, Past Topic Review, and Family Homework
What About Me?
Examples
Handouts and Business Cards
MaPS-Teen Workshop Summary Outline
MaPS-Teen Module 1
Treatment Goals: Individual and Family
Feelings: Good, Bad, and Ugly Ones
Interpersonal Boundaries
MaPS-Teen Module 1 Summary Outline
MaPS-Teen Module 2
Effective Coping Skills
Healthy Habits
Relaxation Training
MaPS-Teen Module 2 Summary Outline
MaPS-Teen Module 3
MaPS-Teen Module 3 Summary Outline
MaPS-Teen Module 4
MaPS-Teen Module 4 Summary Outline
MaPS-Teen Module 5
Love Languages
MaPS-Teen Module 5 Summary Outline
MaPS-Teen Module 6
Thought Correction
Self-Talk
MaPS-Teen Module 6 Summary Outline
Chapter 6. Conclusion
References
Index
Copyright
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Dedication
To Mary, Sam, and Nate—forever holding me accountable, tethering me to a course of lifelong growth and learning.
To Sean—our steadfast anchor, protector, and fixer of all things.
List of Contributors
Mary Nord Cook, Department of Psychiatry, Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
Patrice S. Crisostomo, Intensive Outpatient Programs, Bay Area Children’s Association, Oakland, CA, USA
Douglas A. Kramer, University of Wisconsin School of Medicine and Public Health, Middleton, WI, USA
Jocelyn N. Petrella, Parker Pediatrics & Adolescents, Parker, CO, USA
Tess S. Simpson, Department of Rehabilitation Medicine, Children's Hospital Colorado, Aurora, CO, USA
Foreword
Douglas A. Kramer, MD, MS, Middleton, Wisconsin
I wish I had thought of that!
That was my first thought as I read Transforming Teen Behavior, by Mary Nord Cook, MD. My second thought was, I am learning things here.
That’s a nice experience for someone who will begin his eighth decade before Transforming is published. Dr. Cook is a physician specializing in child and adolescent psychiatry with special expertise in treating families. To my mind, her work is not in family therapy, but in family psychiatry. She brings to her work and to this book the medical background of a physician, beginning with dissecting a human cadaver as a first year medical student, later seeing patients in the emergency room, the operating room, and the delivery room. In the latter, she goes into the procedure with one patient and emerges with two, the mother and infant, and ideally the father and perhaps older siblings. This represents the essence of child psychiatry, the true patient being the relationship between the parent(s) and child, the life-giving, nurturing, and loving relationship that results ultimately in a healthy independent adult.
As a child and adolescent psychiatrist, Dr. Cook brings to this project her knowledge of child and adolescent development, including physiological, psychological, and relational development; her knowledge and experience with child and adolescent psychiatric disorders, including the developmental processes that underlie these disorders; and her knowledge of child and adolescent counseling, individual psychotherapy, group psychotherapy, family psychotherapy, and pharmacotherapy. Bringing all of these areas of expertise and experience together creates a family psychiatrist. Notice that the last area of expertise listed is pharmacotherapy, because with most disorders affecting adolescents this is the least important and ideally the last utilized modality.
Child and adolescent psychiatry began in Chicago in 1909 in what is known today as the Institute for Juvenile Research (Levy, 1968; Richmond, 1960; Truitt, 1926). It was the first of hundreds of child guidance clinics. From the first day in this first clinic, the child guidance model involved both the child or adolescent and his or her parents. Typically, the child or adolescent would be interviewed and counseled by a child psychiatrist or child psychologist, and the parents would be interviewed and counseled by a psychiatric social worker. This model persisted into the 1940s, increasingly informed by the prevalent theory of the time—psychoanalytic theory—with an associated decrease in parent involvement. The child’s intrapsychic conflicts became the target of treatment efforts.
In the early 1950s, a group of child psychiatrists, along with clinicians and theorists from other disciplines, began exploring the idea of treating whole families. The initial advocates were Nathan Ackerman, MD (Ackerman, 1972; Ackerman & Sobel, 1950), Gregory Bateson, MA (Bateson, 1972, 1978, 1979; Lipset, 1980; Ruesch & Bateson, 1951), and Carl Whitaker, MD (Whitaker, 1946, 1966, 1975, 1976, 1989; Whitaker & Malone 1953), the two physicians having trained in child psychiatry, and Mr. Bateson in anthropology (Bateson, 1958). In the meantime, child and adolescent psychiatry continued with a psychoanalytic and psychodynamic approach until the mid-1970s (McDermott & Char, 1974), when an initially gradual, but rapidly accelerating, emphasis on medication treatment emerged. The child’s synapses and neurotransmitters were the new target of treatment efforts.
Thus, child psychiatry began in the child guidance clinics with parent and child treatment, moved into university centers and private practice settings with a primary focus on the individual child, and finally to an even more reductionistic worldview when the medication era became paramount. The treatment of families, with a number of theoretical orientations, remained multidisciplinary as the field matured over the second half of the twentieth century. In addition to Drs. Ackerman and Whitaker, two other child psychiatrists were instrumental in the foundation of family psychiatry, John Bowlby, MD (Bowlby, 1969, 1988; Bowlby & Robertson, 1953), and Salvador Minuchin, MD (Minuchin, 1965; Minuchin, Auerswald, King, & Rabinowitz, 1964).
Of all of the early advocates of treating whole families from all of the various disciplines, including general psychiatry, the contributions of the four founding child psychiatrists have been the most lasting (Kramer, in press). Three subsequent generations of child psychiatrists have contributed to both keeping family psychiatry a healthy presence within general and child psychiatry, but have made and continue to make additional contributions and refinements in theory and technique. Dr. Cook is an important member of this fourth generation of child psychiatrists who practice family psychiatry. She and her colleagues at Children’s Hospital Colorado have brought children, parents, and families back into treatment, drawing on the lessons of the founders of both child psychiatry and family psychiatry, in a context that emphasizes developmental, psychodynamic, and family systems principles, and based on the emerging sciences of interaction (Josephson & Kramer, 2014; Kramer, 2012, 2014). Hence, my initial thought, I wish I had thought of that!
But that’s how it should work in healthy systems. It’s exciting to observe.
Based on the scientific advances of the past 30 years, I have often wondered—in terms of what is known as a thought experiment—what psychiatry would look like if we were tasked to invent it today—if somehow all of the rest of medicine had evolved as it has but without the invention of psychiatry? The last 15 years of the twentieth century and the first 15 of the twenty-first have seen the conception, intrauterine development, and birth of the sciences of interaction. At a minimum, these include gene×environment interaction (G×E) (Caspi et al., 2002; Caspi et al., 2003; Suomi, 2004), epigenetics (Champagne & Meaney, 2001; Kramer, 2005a; Weaver, Cervoni, Champagne, D’Alessio, Meaney 2004), and nonlinear brain dynamics (Asano & Freeman, 2012; Freeman, 1991, 1995, 2003; Pincus, Freeman, & Modell, 2007), the latter possibly being thought of as brain×environment interaction (B×E) (Kramer, 2005b).
The most important result of sequencing the human genome has been the discovery that variation among humans is more a function of G×E at the organismic level, and epigenetics at the chromosomal level, than strictly a gene driven result. Psychiatry’s love affair with pharmacological treatments, although certainly helpful (and harmful) to many patients, rested on the belief that allelic differences contribute to synaptic and receptor variations and lead to psychiatric disorders.
Interestingly, my answer to our proposed thought experiment is that psychiatry, and more importantly child psychiatry, would look more like it did at the origin than it has during the psychoanalytic and psychopharmacologic eras. The one difference from those early years is that it would be understood, based on the sciences of interaction, that the patient would not be the child or adolescent (or the adult), nor would the patient be the parents. The patient would be the whole family—however constituted. For both trait and state differences, this is the unit where G×E and B×E interactions occur. These processes influence normal developmental, as well as facilitate possible corrections with respect to developing traits that may lead to or already constitute a psychiatric disorder (Kramer, in press).
In the introductory section of the adolescent portion of Transforming Teen Behavior, Dr. Cook describes her overall perspective: An interactive, experiential, and psycho-educational style workshop is facilitated, each session covering specific topics of skill sets, as outlined by the syllabus. The clinicians use a method of psycho-educational and Socratic teaching in conjunction with empathic and reflective listening, to inspire adolescents to ponder and brainstorm, about themselves, their families, and peers.
A similar parent-oriented statement occurs in their section.
In what context is this interactive, experiential, and psycho-educational style
implemented? Although a number of reasonable modifications to the standard treatment format are suggested, especially as a function of staffing differences, the default condition is three Intensive Outpatient Program (IOP) sessions per week for 6 weeks. The first of the three IOPs involves two, concurrently run, parent and teen workshops of 90 minutes duration each. The second IOP might occur the following afternoon, and includes concurrent parent and teen workshops for 60 min, and either a 60-min multi-family group therapy session including all families in the current track, or individual family psychotherapy sessions for the (no more than) six current families. The last of the IOP sessions would logically occur on Thursday afternoon. This IOP uses a creative arts therapy approach—either art or music—to utilize a nonverbal modality to practice psychosocial skills learned in the first two sessions of the week. This IOP is multi-family, but also includes siblings 6 years and older, and might include grandparents as well (Kramer, 1988). There is continuity of therapists over the course of each 6-week treatment group. Intakes, orientation, urgent, and medication appointments are provided outside the IOP format.
Although an adolescent typically catalyzes a family to enter this treatment experience, the patients are the families (in multi-family groups), the parents (in parent groups), and adolescents (in teen groups). Neuroscientist Walter J. Freeman states, "… the most important function of brains is to interact with each other to form families and societies (Freeman, 1995)." How better to facilitate the learning (not the teaching) of psychosocial skills than through experience in a natural interactional setting, i.e., peer groups (either adolescent or adult/parent), multi-family groups (society), or single families, the primary source of G×E and B×E for developing children and adolescents?
This particular IOP approach is probably not for every struggling adolescent, but it offers wider applicability than one might anticipate at first glance. It is designed to be either a step-down option from a more acute setting, e.g., inpatient hospital or partial hospitalization; or a step-up option from traditional outpatient treatment. Because a rolling admission process is recommended, it might be used as an option for adolescents seen in crisis in the emergency room, or other crisis entry points, e.g., school guidance counselor, or community crisis intervention programs. In an integrated healthcare delivery system, it would be ideal for most adolescents admitted in crisis to inpatient units, to transfer to IOP after 1–2 days of initial evaluation and ascertainment of safety.
In situations where a family is able to self-pay, it might be used for prevention or early intervention, perhaps with a health plan supplement following completion of the program; and similarly as an option for families considering outdoor therapeutic programs, therapeutic boarding schools, or military schools. Why not use it in residential treatment programs where the families are from the local area? Although not mentioned directly by the author, I believe it would also be ideal for families struggling with substance abuse, which for adolescents is often a coping mechanism absent the kinds of psychosocial skills learned in this program, but with the added benefit of concurrent parent and family complementary change.
Transforming Teen Behavior: Parent–Teen Protocols for Psychosocial Skills Training, by Mary Nord Cook, MD, is so ingenious it feels magical. We have all heard the statement, It isn’t rocket science.
Well, this is rocket science. Why is it rocket science? Rocket science is simply the ability to both understand 100,000 moving parts and simultaneously the entity or context in which these parts are operating. That is what Dr. Cook has accomplished. It isn’t simply teaching empathy. It’s learning empathy in a family context, empathy for the adolescent by the parent, empathy for the parents by the adolescent, empathy for each other in peer groups, all in a family and multi-family context. This goes directly to the purpose of the human (and primate) brain (Kramer, in press) which is to form families and societies
(Freeman, 1995) through G×E and B×E interaction over the individual and family developmental stages.
Transforming Teen Behavior is perfectly integrated, yet easily modifiable. The rolling admissions concept eliminates the waiting list problem, and keeps the treatment group alive through having new members learning from members with longer tenure. The 15–18 sessions in 6 weeks is intense, but a reasonably short duration for most families as documented by an 85% completion rate. It is certainly cost-effective as typically measured, but parents, siblings, and even grandparents, as well as non-custodial parents potentially, are receiving free
treatment (prevention)—thus possibly eliminating or reducing future insurance plan costs. In short, I wish I had thought of that!
March 2015
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Author Biography
Mary Nord Cook, MD is an Associate Professor of Psychiatry at the Colorado School of Medicine, who served as the Medical Director of Outpatient Services for the Department of Psychiatry at the Children’s Hospital Colorado (CHCO) from 2005 to 2014. She has been extensively involved in the training of medical students, psychology and social work graduate students, along with psychiatry residents. She recently won a resident nominated award for teaching excellence and has also been recognized by the American Academy of Child & Adolescent Psychiatry (AACAP), as an Outstanding Mentor. She specializes in working with families presenting with youngsters who’ve been diagnosed with Disruptive Behavior and Mood Disorders. She spearheaded the development of a series of multidisciplinary, outpatient specialty clinics, along with intensive outpatient programs at the CHCO. She recently wrote a book detailing the evidence-based, standardized, skills-building treatment protocols used for the school-aged patient population, in both the routine and intensive outpatient programs, titled Transforming Behavior: Training Parents & Kids Together. She also co-authored a peer-reviewed journal article that described the positive clinical outcomes obtained in the intensive outpatient program for children with disruptive behavior. She has authored books, chapters, review articles, and contributed to the AACAP Practice Parameters on family interventions. She frequently performs presentations in the community for school, primary care, and youth outreach programs. In addition, she routinely presents at regional and national, professional conferences, often on an invited basis. Her passions are developing and applying family- and strengths-based approaches, pursuant of a goal to minimize medication, while optimizing parenting and psychosocial skills. Her mantra is More Skills=Less Pills!
Dr. Cook received her bachelor’s degree (psychology) with honors from the University of Michigan and her doctoral degree (medicine) from Wayne State University. She completed her general psychiatry residency at the Naval Medical Center, San Diego and her child fellowship training at the University of California, San Diego.
Acknowledgment
No pediatric behavioral health program with any merit functions without the ongoing input and service of a synergistic multidisciplinary team. The Children’s Hospital Colorado (CHCO) Teen General Intensive Outpatient Program (G-IOP) team was comprised of several talented professionals, including child psychiatrists, child psychologists, clinical social workers, psychiatric nurses, and mental health counselors. Dr. Jeffrey Dolgan was considered the Father
of the Teen G-IOP program and served as the most credible person in the room for several years, demonstrating the highest capacity for empathic understanding and unconditional acceptance. Dr. Kelly Caywood and Eric Hansen persistently displayed a keen knack for knowing just how to read and reach adolescents. Mindy Stephens and Mandie Roark were the organizational and management glue
that kept the parts and pieces of G-IOP working together, like a well-oiled machine.
They additionally were gifted in their aptitude for engaging even the most defensive and disruptive youngsters. Dr. Jocelyn Petrella, Dr. Tess Simpson, and Dr. Patricia Crisostomo contributed countless hours toward building, maintaining, analyzing, and summarizing the program’s outcome data. Dustin Lamb deployed his creative ingenuity to help shape patient materials into a more teen-friendly and aesthetically pleasing style. Katherine Reed and Anthony Edelblute were among the original pioneers for the CHCO Teen G-IOP, beginning in January 2006—they were steadfast constants who contributed compassion, creative energy, and an artistic and musical balance that completed the program, in a way that only they could.
To the Reader
There are three fundamental principles which have long steered the course to which I have steadfastly adhered in my professional life:
1. One should always strive to do the greatest good for the greater number.
2. One should always strive to serve to the best of one’s ability.
3. One should always make the best use of whatever resources are at one’s disposal.
At every juncture, in every setting, serving any population, in any capacity, those guiding principles have compelled me to write and write and write. As I have faced opportunities to participate in clinical program development, careful documentation of treatment protocols has served as the essential fulcrum, around which meaningful interventions have pivoted. Writing has been, in my experience, the most effective tool that can be harnessed in the pursuit of the following:
1. Distilling information and crystalizing thoughts.
2. Packaging information and thoughts in a way others can understand.
3. Generating a tool that can be used to disseminate information broadly.
Any time I have garnered useful information, encountered effective methods, formulated relevant insights, or experienced meaningful transactions, I feel inspired and compelled to share them with others, to the degree possible, in an effort to spread and magnify the impact. As we have fastidiously evolved a program for families with children and adolescents presenting with varied concerns, which has demonstrated robust and enduring positive outcomes, the knowledge, experience, and wisdom collectively amassed by our talented and diverse clinical teams, over 9 years, has been carefully recorded for the sake of optimizing the chances to do the greatest good for the greatest number. The explicit and comprehensive documentation of the aforementioned programs has culminated in the production of the two books, including the one that follows, which describes a program developed for teens and their families. The parallel program that was evolved for families with school-aged children was described previously in a book titled: Transforming Behavior: Training Parents & Kids Together (2012, Brookes Publishing).
If I had to choose one value, that I most passionately embrace, with respect to my work, it would be empowerment. My underlying goal in participating in clinical program development is to empower the providers and trainees serving on the interdisciplinary teams that deliver care to families. Likewise, my underlying goal in approaching any patient, together with their family and other key change agents around them in schools, communities, and other healthcare settings, is to empower. The end goal in everything I do professionally is to amass knowledge and skills and then disseminate them to others (providers, students, families, school staff), such that others can become increasingly empowered with tools to independently and effectively manage challenges they face. In my mind, the best way to serve patients and their families is to cultivate skills that enhance their capacity to maintain their own overall health and wellness. If there is a mechanism to realize this goal that is more effective and powerful than writing, I don’t know it. I hope this material is experienced as useful and interesting to readers and those who they serve. The process of writing it down has certainly enlightened and rejuvenated me.
Chapter 1
Introduction and Background
Unmet Child Mental Health Needsa
Mary Nord Cook
In an era of ever-decreasing inpatient and partial hospitalization stays, coupled with shrinking community resources, increasing numbers of patients need intensive outpatient services that are readily accessible, convenient, and efficacious, as well as covered by insurance. There is a significant need for clinic-ready, best practice programs for diagnostically complex, treatment-refractory youngsters, who present with a range of emotional and behavioral disturbances. Programs which intervene with youth, and their parents, to an equivalent degree, while ensuring clinical efficacy, as well as fiscal sustainability, would fill a significant, real-world need. A best practice, manualized Intensive Outpatient Program (IOP) was developed at Children’s Hospital Colorado (CHCO) in January 2006 to serve a broad and diffuse patient population, aged 7–18 years old, and their families, referred on the basis of clinical acuity rather than primary diagnosis. To ensure standardization of service delivery and enable program dissemination, the written materials were deliberately evolved to be explicit and readily followed, by numerous provider types, with variable levels of training, experience, and psychological mindedness. The book that follows was composed to enable broad dissemination of this best practice IOP, while preserving the program’s integrity and quality, to the degree possible.
Keywords
Intensive Outpatient Program; IOP; psychiatry; psychology; counseling; best practice; evidence-based; family; parent training; psychosocial skills training; group therapy; manualized; protocols; multidisciplinary; cost effective; standardized; child; adolescent
Although most American youth experience normal, healthy development, research has demonstrated that as many as 1 in 10 youngsters, aged 9–17 years old, will suffer symptoms of mental illness significant enough to cause some level of impairment, in any given year (Department of Health and Human Services [DHHS], 1999). However, fewer than 20 percent of those youth who need mental health services will receive them (Kataoka, Zhang, & Wells, 2002). US annual expenditure estimates for behavioral health services for youth range from $11.7 to $14.07 billion (Ringel & Sturm, 1998). Left untreated, mental health disorders in youth are associated with higher rates of suicide, violence, school dropout, family dysfunction, juvenile incarcerations, substance abuse, and accidents.
Child Mental Health Provider Shortage
The Council on Graduate Medical Education (COGME, 1990) reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000. In 2009, only 7418 child and adolescent psychiatrists were practicing in the United States—more than 22,000 short of the stated need (American Medical Association, 2009). The demand for child and adolescent psychiatrists is expected to increase by 100 percent between 1995 and 2020 (DHHS, 2008). Ideally, the nation would have 14.38 child and adolescent psychiatrists per 100,000 youth, or approximately one provider per 1700 youth.
Child Mental Health Provider Misdistribution
As of 2006, ratios of child and adolescent psychiatrists per 100,000 youth ranged from 3.1 in Alaska to 21.3 in Massachusetts, with a national average of 8.7 (Thomas & Holzer, 2006). The problem, however, is not just a simple numbers issue. There is a severe misdistribution of child and adolescent psychiatrists in the United States, with children and adolescents in rural and low-socioeconomic areas facing significantly reduced access to psychiatric care. Child and adolescent psychiatrists tend to cluster around training institutions and in urban areas large enough to support a Children’s Hospital, and child psychiatrists in private practice often do not take Medicaid or low-reimbursing insurances. The result of these patterns is that the majority of counties in the United States have no local child psychiatry services. Pediatric mental health care is provided primarily by primary care providers, including family practitioners, pediatricians, general internists, physician assistants, and nurse practitioners. Care is also often delivered by general psychiatrists, who may have limited training in treating the pediatric population. The US Surgeon General declared the following in his report:
There is a dearth of child psychiatrists. … Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals…. This places a burden on pediatricians, family physicians, and other gatekeepers to identify children and adolescents for referral and treatment decisions.
(DHHS, 1999, p. 7)
Managed Care and Fiscal Challenges
State-of-the-art specialized psychiatric treatments for children and adolescents are difficult to sustain in a managed care environment; and grant funding sources, especially government-derived, are increasingly scarce. Academic programs, in particular, are generally embedded within tertiary care centers or large hospitals, and reimbursements for behavioral health services generally fall short of covering the costs of providing treatment in those settings. Most insurance carriers carve out
behavioral health benefits to behavioral health insurance vendors that either cannot afford or are unwilling to negotiate payment rates that can support the maintenance of high-level, specialized mental health services for families. Many employers are unwilling or unable to afford to provide behavioral health benefits to their employees, instead offering insurance plans that contain provisions only for medical care physical ailments minus coverage for psychiatric treatments for mental illness.
Children and adolescents with serious emotional and behavior disturbances and their families warrant and deserve intensive mental health and educational services; unfortunately, few have access to appropriate and sufficient services. As the gap between the demand and availability of pediatric behavioral health specialty services widens, the burden for service delivery is shifting more and more toward educational and primary care settings (O’Donohue, Byrd, Cummings, & Henderson, 2005). Child psychiatrists and psychologists are functioning more and more in consultant roles—serving to educate, train, or consult around behavioral health program development—whereas direct treatment is being shifted to nonmental health professionals serving in nonbehavioral health settings such as primary care settings and schools. The field of pediatric mental health is faced with the challenge of evolving creative, cost-effective, and replicable systems of service delivery that hold the most promise for the greatest impact across the broadest and most treatable patient populations.
Challenges Translating Research to Real World
It is widely appreciated that translation of research-based protocols, to real-world, clinical environments, can be challenging, and limited, for a host of reasons. The Director of the National Institute of