Skip to main content
SpringerLink
Log in

Treatment Focus Diffusion is Associated with Long-term Outcomes in Youth Public Mental Health Care

  • Original Paper
  • Published:
Journal of Child and Family Studies Aims and scope Submit manuscript

Abstract

Youth and families who receive services in public mental health care (PMHC) often present with complex co-occurring concerns. These challenges might appear to necessitate spreading the foci of treatment across multiple targets during therapy, herein referred to as treatment focus diffusion (TFD). Higher TFD has recently been found to be related to poorer short-term clinical outcomes, but longer term clinical and system outcomes have not been examined. Utilizing routine clinical data from two PMHC-based intensive in-home service formats (implemented Multisystemic Therapy [MST] and standards-based services), this study examined whether TFD was associated with returning to the system for additional services at the same or more intensive/restrictive level and with treatment expenditures related to any service utilization following the treatment episode under study. When examined together and in separate models for MST and standards-based intensive in-home services, more TFD was significantly related to higher odds of returning to the system for additional services. Additionally, more TFD was significantly associated with higher treatment expenditure in the combined and MST-only models. These findings suggest that TFD could serve as a useful and measurable early treatment factor for predicting poorer outcomes. As such, monitoring TFD and using supervision and/or case reviews to adjust services where treatment focus diffuses would likely be beneficial in PMHC systems.

Highlights

  • More treatment focus diffusion (TFD; spreading treatment focus across multiple concerns) was related to worse long-term outcomes.

  • This relationship between TFD and poorer outcomes was particularly strong in the implemented Multisystemic Therapy service format.

  • TFD could be a useful tool for treatment monitoring and clinical decision-making in public mental health care systems.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Alegría, M., Green, J. G., McLaughlin, K. A., & Loder, S. (2015). Disparities in child and adolescent mental health and mental health services in the US. New York, NY: William T. Grant Foundation.

  • Alexander, J. F., & Sexton, T. L. (2002). Functional family therapy: A model for treating high-risk, acting-out youth. In F. W. Kaslow (Ed.), Comprehensive Handbook of Psychotherapy: Integrative/eclectic, Vol. 4 (p. 111–132). John Wiley & Sons, Inc.

  • Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitive-behavior therapy (CBT) for panic disorder: Relationship of anxiety and depression comorbidity with treatment outcome. Journal of Psychopathology and Behavioral Assessment, 32(2), 185–192.

    Article  PubMed  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.

  • Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Latin, H. M., Ellard, K. K., Bullis, J. R., & Cassiello-Robbins, C. (2017). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. Oxford University Press.

  • Becker, E. M., Becker, K. D., & Ginsburg, G. S. (2012). Modular cognitive behavioral therapy for youth with anxiety disorders: A closer look at the use of specific modules and their relation to treatment process and response. School Mental Health, 4(4), 243–253.

    Article  Google Scholar 

  • Boswell, J. F., Constantino, M. J., Kraus, D. R., Bugatti, M., & Oswald, J. M. (2016). The expanding relevance of routinely collected outcome data for mental health care decision making. Administration and Policy in Mental Health and Mental Health Services Research, 43(4), 482–491.

    Article  PubMed  Google Scholar 

  • Boustani, M., Regan, J., & Stanick, C. (2020). Modular CBT for youth: Principles and guides. In Cognitive Behavioral Therapy in Youth: Tradition and Innovation (pp. 231–249). Humana, New York, NY.

  • Bruns, E. J., Suter, J. C., Force, M. M., & Burchard, J. D. (2005). Adherence to wraparound principles and association with outcomes. Journal of Child and Family Studies, 14, 521–534.

    Article  Google Scholar 

  • Bruns, E. J., Walker, J. S., Bernstein, A., Daleiden, E., Pullmann, M. D., & Chorpita, B. F. (2014). Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents. Journal of Clinical Child & Adolescent Psychology, 43(2), 256–269.

    Article  Google Scholar 

  • Child and Adolescent Mental Health Division, Hawai’i Department of Health. (2008). Instructions and codebook for provider monthly treatment and progress summary. Honolulu, HI: Hawai’i Department of Health Child and Adolescent Mental Health Division.

  • Child and Adolescent Mental Health Division, Hawai’i Department of Health. (2018). Child and Adolescent Mental Health Performance Standards. Retrieved from: https://health.hawaii.gov/camhd/files/2018/06/Teal-Book-2018.pdf.

  • Child and Adolescent Mental Health Division, Hawai’i Department of Health. (2012 - 2020). Child and Adolescent Mental Health Annual Evaluation Summary: Fiscal Year 2018. Retrieved from: https://health.hawaii.gov/camhd/files/2019/05/CAMHD-Annual-Eval-FY2018-Prez-POST-2019_05_16.pdf.

  • Chorpita, B. F., Daleiden, E. L., Park, A. L., Ward, A. M., Levy, M. C., Cromley, T., & Krull, J. L. (2017). Child STEPs in California: A cluster randomized effectiveness trial comparing modular treatment with community implemented treatment for youth with anxiety, depression, conduct problems, or traumatic stress. Journal of Consulting and Clinical Psychology, 85(1), 13.

    Article  PubMed  Google Scholar 

  • Chorpita, B. F., Taylor, A. A., Francis, S. E., Moffitt, C., & Austin, A. A. (2004). Efficacy of modular cognitive behavior therapy for childhood anxiety disorders. Behavior Therapy, 35(2), 263–287.

    Article  Google Scholar 

  • Chorpita, B. F., Weisz, J. R., Daleiden, E. L., Schoenwald, S. K., Palinkas, L. A., Miranda, J., & Gibbons, R. D. (2013). Long-term outcomes for the Child STEPs randomized effectiveness trial: a comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology, 81(6), 999.

    Article  PubMed  Google Scholar 

  • Daleiden, E. L., Chorpita, B. F., Donkervoet, C., Arensdorf, A. M., Brogan, M. & Hamilton, J. D. (2006). Getting better at getting them better: health outcomes and evidence-based practice within a system of care. Journal of the American Academy of Child & Adolescent Psychiatry, 45(6), 749–756. https://doi.org/10.1097/01.chi.0000215154.07142.63.

    Article  Google Scholar 

  • Daleiden, E. L., Pang, D., Roberts, D., Slavin, L. A., & Pestle, S. L. (2010). Intensive home based services within a comprehensive system of care for youth. Journal of Child and Family Studies, 19(3), 318–325.

    Article  Google Scholar 

  • De Haan, A. M., Boon, A. E., Vermeiren, R. R., Hoeve, M., & de Jong, J. T. (2015). Ethnic background, socioeconomic status, and problem severity as dropout risk factors in psychotherapy with youth. Child and Youth Care Forum, 44(1), 1–16.

    Article  Google Scholar 

  • Den Dunnen, W., St. Pierrre, J., Stewart, S.L., Johnson, A., Cook, S., & Leschied, A.W. (2012). Predicting residential treatment outcomes for emotionally and behaviorally disordered youth: The role of pretreatment factors. Residential Treatment for Children & Youth, 29(1), 13–31.

    Article  Google Scholar 

  • Dickson, K.S., Stadnick, N.A. & Lind, T. (2020). Defining and Predicting High Cost Utilization in Children’s Outpatient Mental Health Services. Administration and Policy in Mental Health and Mental Health Research, 47, 655–664. https://doi.org/10.1007/s10488-019-00988-1.

    Article  Google Scholar 

  • Evans, S. C., Weisz, J. R., Carvalho, A. C., Garibaldi, P. M., Bearman, S. K., & Chorpita, B. F. (2020). Effects of standard and modular psychotherapies in the treatment of youth with severe irritability. Journal of Consulting and Clinical Psychology, 88(3), 255.

    Article  PubMed  Google Scholar 

  • Fife, D. (2020). The eight steps of data analysis: A graphical framework to promote sound statistical analysis. Perspectives on Psychological Science, 15(4), 1054–1075.

    Article  PubMed  Google Scholar 

  • Franco, M., Durkee, M., & McElroy-Heltzel, S. (2021). Discrimination comes in layers: Dimensions of discrimination and mental health for multiracial people. Cultural Diversity and Ethnic Minority Psychology, 27(3), 343.

    Article  PubMed  Google Scholar 

  • Fusar‐Poli, P., Correll, C. U., Arango, C., Berk, M., Patel, V., & Ioannidis, J. P. (2021). Preventive psychiatry: a blueprint for improving the mental health of young people. World Psychiatry, 20(2), 200–221.

    Article  PubMed  PubMed Central  Google Scholar 

  • Garland, A. F., Bickman, L., & Chorpita, B. F. (2010). Change what? Identifying quality improvement targets by investigating usual mental health care. Administration and Policy in Mental Health and Mental Health Services Research, 37(1-2), 15–26.

    Article  PubMed  Google Scholar 

  • Groth-Marnat, G., & Wright, A. J. (2016). Handbook of Psychological Assessment (6th ed.). Hoboken, New Jersey US: Wiley.

  • Guan, K., Boustani, M. M., & Chorpita, B. F. (2019). “Teaching moments” in psychotherapy: Addressing emergent life events using strategies from a modular evidence-based treatment. Behavior Therapy, 50, 101–114.

    Article  PubMed  Google Scholar 

  • Heck, R. H., Thomas, S. L., & Tabata, L. N. (2013). Multilevel and Longitudinal Modeling with IBM SPSS. Routledge.

  • Henggeler, S. W. (1999). Multisystemic therapy: An overview of clinical procedures, outcomes, and policy implications. Child Psychology and Psychiatry Review, 4(1), 2–10.

    Article  Google Scholar 

  • Henggeler, S. W. (2011). Efficacy studies to large-scale transport: The development and validation of multisystemic therapy programs. Annual Review of Clinical Psychology, 7, 351–381.

    Article  PubMed  Google Scholar 

  • Hodges, K. (1998). Child and Adolescent Functional Assessment Scale (CAFAS). Ann Arbor, MI: Functional Assessment Systems.

  • Hodges, K., & Gust, J. (1995). Measures of impairment for children and adolescents. The Journal of Mental Health Administration, 22(4), 403–413.

    Article  PubMed  Google Scholar 

  • Hodges, K., & Wong, M. M. (1996). Psychometric characteristics of a multidimensional measure to assess impairment: The Child and Adolescent Functional Assessment Scale (CAFAS). Journal of Child and Family Studies, 5, 445–467.

    Article  Google Scholar 

  • Holmes, K. L., & Mueller, C. W. (2021). Treatment focus diffusion predicts poorer clinical progress in children’s public mental health care. Journal of Behavioral and Cognitive Therapy, 32(2), 99–110. https://doi.org/10.1016/j.jbct.2021.09.002.

    Article  Google Scholar 

  • Holmes, k. L., & Mueller, C. W. (in press). Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment. Administration & Policy in Mental Health & Mental Health Services Research.

  • Izmirian, S. C., Milette-Winfree, M., Jackson, D. S., & Mueller, C. W. (2019). Predicting repeated child and adolescent residential treatment placements. Residential Treatment for Children & Youth, 36(4), 282–297.

    Article  Google Scholar 

  • Jackson, D.S. (2017). Average Total Service Cost Per Youth During Their CAMHD Enrollment. Honolulu, HI: Child and Adolescent Mental Health Division.

  • Jackson, D.S., Hill, K.A., Sender, M., & Mueller, C., (2016). Youth Outcome Patterns Across Levels of Care in CAMHD Services. Hawaii Child and Adolescent Mental Health Division: Honolulu, HI.

  • Jackson, D., Keir, S., Sender, M., & Mueller, C. (2017). Reliable change and outcome trajectories across levels of care in a mental health system for youth. Administration & Policy in Mental Health & Mental Health Services Research, 44, 141–154. https://doi.org/10.1007/s10488-015-0690-5.

    Article  Google Scholar 

  • Knapp, M., Funk, M., Curran, C., Prince, M., Grigg, M., & McDaid, D. (2006). Economic barriers to better mental health practice and policy. Health Policy and Planning, 21(3), 157–170.

    Article  PubMed  Google Scholar 

  • Larson, M. J., Miller, K., Sharma, S., & Manderscheid, R. (2004). Children’s mental health services in fee-for-service Medicaid. Health Care Financing Review, 26(1), 5.

    PubMed  PubMed Central  Google Scholar 

  • Linehan, M. (2014). DBT? Skills Training Manual. Guilford Publications.

  • Littell, J. H., Campbell, M., Green, S. & Toews, B. (2005). Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10‐17. Cochrane Database of Systematic Reviews, 1(1), 1–63. https://doi.org/10.4073/csr.2005.1.

    Article  Google Scholar 

  • Love, A. R., Mueller, C. W., Tolman, R. T., & Powell, A. K. (2014). Frequency, level, and rate of improvement for treatment targets in a children’s mental health community-based intensive in-home therapeutic setting. Administration and Policy in Mental Health and Mental Health Services Research, 41(4), 421–433.

    Article  PubMed  Google Scholar 

  • Love, A. R., Okado, I., Orimoto, T. E., & Mueller, C. W. (2018). Factor analysis of therapist-identified treatment targets in community-based children’s mental health. Administration and Policy in Mental Health and Mental Health Services Research, 45(1), 103–120.

    Article  PubMed  Google Scholar 

  • Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989.

    Article  Google Scholar 

  • Mueller, C. W., Tolman, R., Higa-McMillan, C. K., & Daleiden, E. L. (2010). Longitudinal predictors of youth functional improvement in a public mental health system. The Journal of Behavioral Health Services and Research, 37(3), 350–362.

    Article  PubMed  Google Scholar 

  • Nakamura, B. J., Daleiden, E. L., & Mueller, C. W. (2007). Validity of treatment target progress ratings as indicators of youth improvement. Journal of Child and Family Studies, 16(5), 729–741.

    Article  Google Scholar 

  • Nock, M. K., & Ferriter, C. (2005). Parent management of attendance and adherence in child and adolescent therapy: A conceptual and empirical review. Clinical Child and Family Psychology Review, 8(2), 149–166.

    Article  PubMed  Google Scholar 

  • Okamura, K. H. (2016). Therapists’ knowledge of evidence-based practice: Differential definitions, measurement, and influence on self-reported practice. (Doctoral dissertation, University of Hawai’i at Manoa).

  • Okamura, K. H., Jackson, D. S., & Nakamura, B. J. (2019). Therapist and youth predictors of specific practices derived from the evidence-base in community mental health. Administration and Policy in Mental Health and Mental Health Services Research, 46(5), 609–619.

    Article  PubMed  Google Scholar 

  • Olson, J. R., Benjamin, P. H., Azman, A. A., Kellogg, M. A., Pullmann, M. D., Suter, J. C., & Bruns, E. J. (2021). Systematic review and meta-analysis: Effectiveness of wraparound care coordination for children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 60(11), 1353–1366.

    Article  Google Scholar 

  • Orimoto, T. E., Mueller, C. W., Hayashi, K., & Nakamura, B. J. (2014). Community-based treatment for youth with co-and multimorbid disruptive behavior disorders. Administration and Policy in Mental Health and Mental Health Services Research, 41(2), 262–275.

    Article  PubMed  Google Scholar 

  • Painter, K. (2009). Multisystemic therapy as community-based treatment for youth with severe emotional disturbance. Research on Social Work Practice, 19(3), 314–324.

    Article  Google Scholar 

  • Rosselló, J., Bernal, G., Muñoz, R. F., Aguilar-Gaxiola, S., & Guzmán, J. (2007). Treatment Manual for Cognitive Behavioral Therapy for Depression. Center for Psychological Services and Research University of Puerto Rico, Rio Piedras.

  • Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clinical Psychology Review, 72, 101751.

    Article  PubMed  Google Scholar 

  • Schlabach, S. (2013). The importance of family, race, and gender for multiracial adolescent well-being. Family Relations: An Interdisciplinary Journal of Applied Family Studies, 62, 154–174. https://doi.org/10.1111/j.1741-3729.2012.00758.x.

    Article  Google Scholar 

  • Southam-Gerow, M. A., Chorpita, B. F., Miller, L. M., & Gleacher, A. A. (2008). Are children with anxiety disorders self-referred to a university clinic like those from the public mental health system? Administration and Policy in Mental Health and Mental Health Services Research, 35, 168–180.

    Article  PubMed  Google Scholar 

  • Southam-Gerow, M. A., Weisz, J. R., & Kendall, P. C. (2003). Youth with anxiety disorders in research and service clinics: Examining client differences and similarities. Journal of Clinical Child and Adolescent Psychology, 32(3), 375–385.

    Article  PubMed  Google Scholar 

  • Stambaugh, L. F., Mustillo, S. A., Burns, B. J., Stephens, R. L., Baxter, B., Edwards, D., & Dekraai, M. (2007). Outcomes from wraparound and multisystemic therapy in a center for mental health services system-of-care demonstration site. Journal of Emotional and Behavioral Disorders, 15(3), 143–155.

    Article  Google Scholar 

  • Stroul, B. A., Blau, G. M., & Sondheimer, D. L. (2008). Systems of care: A strategy to transform children’s mental health care. In Stroul, B. A., & Blau, G. M. (Eds.), The System of Care Handbook: Transforming Mental Health Services for Children, Youth, and Families (3–23). Paul H. Brookes Publishing Co.

  • Stroul, B. A., & Friedman, R. M. (1986). A System of Care for Severely Emotionally Disturbed Children & Youth. CASSP Technical Assistance Center.

  • Substance Abuse and Mental Health Services Administration. (2015). Racial/ Ethnic differences in mental health service use among adults. (Report No. SMA-15-4906). Retrieved from Substance Abuse and Mental Health Services Administration: https://www.integration.samhsa.gov/MHServicesUseAmongAdults.pdf.

  • Sung, J.Y., Kacmarek, C.N. & Schleider, J.L. (2021). Economic Evaluations of Mental Health Programs for Children and Adolescents in the United States: A Systematic Review. Clinical Child and Family Psychology Review, 24, 1–19. https://doi.org/10.1007/s10567-020-00333-1.

    Article  PubMed  Google Scholar 

  • Sunseri, P. A. (2004). Family functioning and residential treatment outcomes. Residential Treatment for Children & Youth, 22(1), 33–53.

    Article  Google Scholar 

  • Tolman, R. T., Mueller, C. W., Daleiden, E. L., Stumpf, R. E., & Pestle, S. L. (2008). Outcomes from Multisystemic Therapy in a Statewide System of Care. Journal of Child and Family Studies, 17, 894–908.

    Article  Google Scholar 

  • Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-Coaxum, R., & Weersing, V. R. (2017). What five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2), 79.

    Article  PubMed  Google Scholar 

  • Wright, D. R., Katon, W. J., Ludman, E., McCauley, E., Oliver, M., Lindenbaum, J., & Richardson, L. P. (2016). Association of adolescent depressive symptoms with health care utilization and payer-incurred expenditures. Academic Pediatrics, 16(1), 82–89.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was supported in part from a research and evaluation contract awarded to the second author by the State of Hawai’i Department of Health, Child and Adolescent Mental Health Division.

Author information

Authors and Affiliations

  1. University of Hawaiʻi at Mānoa, 2530 Dole Street, Sakamaki C400, 96822-2294, Honolulu, HI, USA

    Kalyn L. Holmes & Charles W. Mueller

Authors
  1. Kalyn L. Holmes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Charles W. Mueller
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kalyn L. Holmes.

Ethics declarations

Conflict of Interest

The authors declare no competing interests.

Consent to participate

Upon entry to the system of care under study, youth and caregivers provided written informed consent for their data to contribute to ongoing research as part of enrollment in the system of care under study.

Ethics Approval

This study was submitted to and approved by the University of Hawai’i’s Committee on Human Studies Institutional Review Board as well as the State Department of Health’s Child and Adolescent Mental Health Division.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Holmes, K.L., Mueller, C.W. Treatment Focus Diffusion is Associated with Long-term Outcomes in Youth Public Mental Health Care. J Child Fam Stud 32, 3742–3754 (2023). https://doi.org/10.1007/s10826-023-02680-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10826-023-02680-3

Keywords

Search

Navigation