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Open Access 19-09-2024 | Original Paper

An Archival Study of the Relationship Between Treatment Duration, Functioning, and Out-of-Home Placement for Youth with Serious Emotional Disturbance in a State-Wide Intensive In-Home Family Treatment Program

Auteurs: C. Wayne Jones, Steve Simms, Jesse Troy, Scott Suhring, Dan Warner, Tara Byers

Gepubliceerd in: Journal of Child and Family Studies | Uitgave 10/2024

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Abstract

The main aim of this study was to evaluate the effectiveness of Pennsylvania’s state-wide intensive in-home treatment for youth with serious emotional disturbance (SED), EcoSystemic Structural Family Therapy-Family Based Mental Health Services (ESFT-FBMHS). Despite its long history of implementation, the program remains empirically under-evaluated. In this archival study, out-of-home placement and youth functioning outcomes were compared across four tiers of length of stay. Given the high-risk population treated in ESFT-FBMHS, it was hypothesized that the families and youth who completed the full duration of treatment (169–224 days) would have better outcomes than those who stopped treatment after 168 days or less. We utilized an ex post facto quantitative research design analyzing archived medical claims data of 2251 youth treated between 2018 and 2022 to assess out-of-home placement rates and analyzed archived data from six domains of the Child and Adolescent Needs and Strengths (CANS; Problem Presentation, Risk Behaviors, Functioning, Child Safety, Caregiver Needs, and Child Strengths) to assess changes in youth functioning post-discharge (90 and 180 days). An analysis using generalized estimating equations (GEE), controlling for potential confounding variables such as demographics and clinical features, suggest that length of stay in ESFT-FBMHS was significantly associated with out-of-home placement and youth improvement on the CANS at both 90- and 180-days post-discharge. As a group, youth with SED who did not complete the full duration of the program had 2–3 times the odds of out-of-home placement at 90 days post-discharge and 1–3 times the odds at 180 days post-discharge as compared to program completers. CANS scores showed improvement in 40.1% of youth who completed the program as compared to only 11.7%–18.2% for those who did not. The results of this study suggest that ESFT-FBMHS is effective for youth with SED as a group and can improve youth functioning and reduce out-of-home placement.
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Supplementary information

The online version contains supplementary material available at https://​doi.​org/​10.​1007/​s10826-024-02906-y.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
It is estimated that six million children and adolescents—or about one in 10—have emotional, social, and behavioral problems so severe they have trouble functioning in their day-to-day activities at home, at school and in their communities (Williams et al., 2018). The term “serious emotional disturbance” (SED) is used by state and federal agencies to describe this diagnostically diverse group of children and adolescents (youth) with multiple and severe emotional and behavioral problems. The safety risks these youth can pose to themselves, their families, and their communities results in frequent mental health crises that demand more intensive levels of care. Youth with SED drive the public mental health system’s most costly out-of-home services such as psychiatric inpatient hospitals and residential treatment facilities (Feng et al., 2017; Pires et al., 2013; Soni, 2014). To address this important and vulnerable population, there has been a proliferation of intensive home-based treatment programs emerge across all 50 US states designed as a first line of intervention to support, stabilize, and treat these youth in the community (Bruns et al., 2021). The argument for treating youth with SED in their home and communities as opposed to out-of-home placement is that it helps to maintain the youth’s attachments to the family unit and to natural supports and resources, creates opportunities for addressing the systemic issues that perpetuate or exacerbate children’s psychiatric disorders, and fosters generalization of treatment effects (Adnopoz, 2002).
In Pennsylvania, an intensive in-home approach, EcoSystemic Structural Family Therapy-Family Based Mental Health Services (ESFT-FBMHS), has been a part of the public behavioral health offerings for over three decades. Like most time-limited in-home intensive programs serving youth with SED the goal of ESFT-FBMHS is to improve youth functioning and to reduce repeated out-of-home placements in both residential treatment facilities and psychiatric hospitals (Lindblad-Goldberg et al., 1998; Pennsylvania Department of Public Welfare, 1993). Unlike the strong evidence base established in the literature by home-based family treatment models designed to reduce out-of-home placements of youth involved in either the child welfare system or juvenile justice system, such as Family Centered Treatment (FCT; Bright et al., 2017; Pierce et al., 2022), Multi-Systemic Therapy (MST; Vidal et al. (2017)), Functional Family Therapy (FFT; Sexton & Turner, 2010), and Brief Strategic Family Therapy (BSFT; Szapocnik et al., 2012), the empirical evidence for the effectiveness of family treatment models integrated with intensive in-home programs serving youth with severe psychiatric problems remains limited (Moffett et al., 2018). One possible reason for the disparity in the volume of research generated by intensive in-home approaches with an embedded family therapy component is that FCT, MST, FFT, and BSFT represent clinical treatment approaches developed for narrowly defined clinical populations while home-based approaches for youth with SED developed primarily as an out-of-home placement diversion program, de-linked from specific diagnoses or specific clinical models.
Pennsylvania’s ESFT-FBMHS program, first launched in 1988, is a 32-week, trauma-informed intensive, in-home team-delivered service for children and youth ages birth to 21 deemed at-risk for out-of-home placement (Pennsylvania Department of Public Welfare, 1993). There are one and often two or more of these programs in Pennsylvania’s 67 counties, serving over 4000 youth annually (A. Herschell, personal communication, January 10, 2024). Families enrolled in ESFT-FBMHS typically receive between three to 10 hours of service/week, which usually includes an individual session with the identified youth, a conjoint session with the caregivers, and a family therapy session (Jones, 2019). In addition to youth, parent, and family therapy, service components include parent education, family support services, school-based consultation, case management, service coordination, crisis intervention, and 24 hour on-call emergency service. Family focused interventions are designed to strengthen caregivers’ executive skills, caregivers’ emotional support of the identified youth, and the family’s ability to de-escalate conflict and problem solve when tensions are high. Therapists work through caregivers to address youth-focused goals which include reducing symptoms and distress, helping them to participate more fully and adaptively in the home, school, and community, and building skills for managing emotions and coping with stress (Lindblad-Goldberg et al., 1998).
What makes Pennsylvania’s Family Based Mental Health Services unique among intensive in-home programs is that it is fully integrated with a highly specified trauma-informed family therapy clinical model, EcoSystemic Structural Family Therapy (ESFT; Jones, 2019; Lindblad-Goldberg et al., 1998). Adapted from Structural Family Therapy (Minuchin, 1974), ESFT is designed specifically to meet the needs of youth with serious emotional disturbance. Intensive in-home services blended with a clinical model, such as ESFT-FBMHS, theoretically have the potential not only to stabilize youth and families in crisis, but also to address underlying systemic issues creating and maintaining the youth’s vulnerability, thereby reducing the need for out-of-home placement for the long term. However, despite its 35-year history of implementation, and considerable accumulated practice-based evidence of its effectiveness (Lindblad-Goldberg & Northey, 2013), there is only one major quasi-experimental study of ESFT-FBMHS effectiveness (Dore, 1996; Lindblad-Goldberg et al., 2004), a study completed during the first seven years of implementation, before the model had well-established fidelity measures and a manual operationalizing concepts and treatment tasks.
There is promising evidence from studies of other models, however, that a clinically focused intensive home-based approach, such as ESFT-FBMHS, can be effective for youth with SED and their families. For example, Connecticut’s Intensive In-Home Child and Adolescent Psychiatric Services (IICAPS) was studied in a large-scale pre–post quasi-experimental study with a sample of 7169 youth (Barbot et al., 2016). It was found that the IICAPS approach to intensive in-home treatment reduced problem severity and improved youth functioning at discharge. Although this study is encouraging and contributes to the evidence that intensive in-home services informed by a clear, specified family focused clinical model can be beneficial to youth with SED, the research did not include a comparison group nor data on out-of-home placements, and was thus limited in explaining the program’s impact, or being able to generalize findings. There was also an experimental study of intensive in-home services in Ontario’s system of care (Wilmshurst, 2002), where youth were randomly assigned to either a 5-day/week residential treatment program utilizing a solution focused brief therapy approach or an intensive in-home program utilizing an amalgam of cognitive behavioral treatment and Multi-Systemic Therapy (MST). Both treatments lasted three months and included family involvement. The results suggested that youth receiving intensive in-home treatment reaped greater benefits, such as reductions in anxiety, depression, and externalizing symptoms as compared to those receiving residential treatment, but the absence of clear differentiation between the treatment conditions leave open the possibility that the changes were more a function of treatment modality (such as cognitive behavioral treatment) rather than a function of home-based treatment (Preyde et al., 2011).
MST-Psychiatric (Henggeler et al., 1999; Pane et al., 2013; Rowland et al., 2005) and adaptations of MST, such as Youth Villages Intercept (Barth et al., 2007), provide an example of an effective and established clinical model of family therapy specifically targeting youth with serious emotional problems that is integrated with intensive in-home services. Both MST-Psychiatric (Henggeler et al., 1999) and ESFT-FBMHS (Jones, 2019) identify underlying vulnerabilities and negative interactional patterns in the family and community ecosystem that are linked to the youth’s emotional or behavioral functioning and then focus interventions on reducing these vulnerabilities. MST-Psychiatric prioritizes family structure and the caregivers’ executive functioning (Henggeler et al., 2003) and ESFT-FBMHS prioritizes the attachment relationship between youth and their caregivers, the co-caregiver alliance, and family emotion regulation (Jones, 2019). Further, ESFT-FBMHS has a longer standard course of treatment (32 weeks) compared to MST-Psychiatric (4 months). In 1999, Henggeler demonstrated that compared to hospitalized youth, youth receiving MST-Psychiatric reported improved school attendance, lower levels of externalizing behaviors, higher caregiver satisfaction, and improved family functioning at the end of four months of treatment (Henggeler et al., 1999). However, follow-up studies (Henggeler et al., 2003; Huey et al., 2004) found short-lived impacts on out-of-home placement. One possible explanation for reduced impact over time is treatment duration. The youth and families receiving MST-Psychiatric treatment was limited to four months (Henggeler et al., 1999) which may be sufficient for briefly stabilizing high-risk severely symptomatic youth, but inadequate for addressing underlying chronic and severe problems in family functioning. Thus, while MST-Psychiatric research shows strong promise for in-home clinical models, testing other models which can show longer term impact are warranted.
One factor that may be responsible for the dearth of experimental studies on intensive in-home approaches is the difficulty in identifying clinically relevant comparison groups. In some studies, youth outcomes in intensive in-home treatment are compared to youth in treatments that were far less intensive, such as enhanced case management (Evans et al., 2003) and office-based therapy (Crane et al., 2005). Other studies compare intensive in-home services to highly restrictive out-of-home treatments, such as inpatient psychiatric hospitalization (e.g., Henggeler et al., 1999) or residential treatment (Barth et al., 2007; Wilmshurst, 2002), treatment approaches which have little in common with intensive in-home treatment. There is a question of whether the population of youth served by more restrictive programs are the same as those in intensive, in-home programs. For example, Preyde et al. (2011) found major demographic differences between the two groups in their 3-year follow-up study of youth outcomes in Ontario’s system of care. Although the randomized clinical trial can control for selection bias and is the gold standard for establishing treatment efficacy, it is not always ethically possible to randomly assign children and adolescents with severe, and potentially life-threatening mental health issues to nontreatment conditions or treatment conditions with unknown benefits (De Meulemeester et al., 2018). This methodological dilemma is particularly true in the Pennsylvania system of care where there is a widely available treatment, such as ESFT-FBMHS, which has a long-standing history of practice-based evidence of effectiveness (Lindblad-Goldberg & Northey, 2013). In Pennsylvania, the option of “no treatment” is not an option.
A solution recommended by Moffet et al. (2018) is that studies consider comparing one intensive in-home treatment approach to itself but at different dosage levels. This study of ESFT-FBMHS uses this methodological approach to demonstrate its effectiveness. While dose-effect has been widely examined in studies of individual therapy in outpatient settings and have found little relationship between treatment duration and outcomes (e.g., Salzer et al., 1999; Stulz et al., 2013), a search of the literature reveals no published studies of dose-effect or treatment duration focused on intensive in-home treatment for youth with SED. The closest dose-effect study on this population is a retrospective study of SED youth enrolled in a Children’s Psychosocial Rehabilitation (CPSR) program, a less intensive service than intensive in-home treatment. Williams (2009) found that youth who received more hours of CPSR showed a greater reduction in suicidal thoughts and self-harm behaviors and greater clinical improvement in their day-to-day lives. This is the relationship between treatment duration and outcomes that would be expected for youth with SED in intensive in-home treatment given the severity of youth and family problems in the treatment population. Youth with SED served by intensive in-home treatment programs often live in highly stressed, multi-problem families destabilized by significant adversity and trauma (Byers et al., 2021; Jones, 2019; Landy & Menna, 2007). These are conditions which affect caregivers’ well-being and can compromise their ability to participate in treatment and provide sustained emotional support to the child, critical to the child’s recovery.
Moffett et al. (2018) noted that among the intensive in-home treatment empirical studies they reviewed, interventions of longer durations (4–6 months) reported consistently greater youth improvement than those enrolled in programs of shorter duration. Four to six months is the typical length for Medicaid-funded intensive in-home programs in most states (Stroul et al., 2021). In ESFT-FBMHS, youth with SED and their families typically receive services up to 32 weeks. The longer range of treatment duration and the real-world likelihood that not all youth and families who enroll in ESFT-FBMHS will complete the program, leaving at different times during treatment, creates naturally occurring comparison groups for a test of the link between treatment duration and outcomes, and a test of the model’s effectiveness. If youth who complete the full duration of ESFT-FBMHS treatment show significantly reduced risk of out-of-home placement and improved youth functioning when compared to youth who received less of the treatment, this suggests that the treatment is effective, and it provides valuable information about which duration of treatment is optimal.
An early large-scale program evaluation study of ESFT-FBMHS suggests that this intensive in-home approach has the potential to reduce out-of-home placements for both youth and other family members (e.g., Dore, 1991, 1996). An analysis of pre- and post-treatment measures of 1968 families at 39 different program sites showed that prior to enrollment in the program, 80% of youth experienced psychiatric hospitalization. After 32 weeks of ESFT-FBMHS, the rate fell to 28% for any family member, 20% for the identified youth with SED, and only 13% of families utilized emergency room care for psychiatric crises (Lindblad-Goldberg et al., 2004). The generalizability of the findings is limited, however, by the absence of a control or comparison group, the absence of information about the youth who did not complete the program, and the absence of treatment fidelity measures to ensure all youth were receiving the intervention as intended. At the time of this first study, ESFT-FBMHS suffered from many of the same inadequate quality assurance mechanisms as other state homegrown intensive in-home treatment programs described by Hammond and Czyszczon (2014).
Today, ESFT-FBMHS has considerable and robust oversight consistent with other evidence-based treatments (e.g., a treatment manual, therapist and supervisory measures of adherence, and 3 hours of required weekly team supervision). All therapists and supervisors in ESFT-FBMHS participate in a 3-year (85 hours annually) training program focused on cultivating systemic thinking, assuring adherence, and developing competence (Lindblad-Goldberg et al., 1998; Simms et al., 2021). There are multi-layered structures built into ESFT-FBMHS implementation that ensure clear practice parameters, organizational requirements, training and coaching expectations, and fidelity and outcomes monitoring. Likewise, since ESFT-FBMHS is regulated by and monitored by the state, all intensive in-home treatment service characteristics are controlled and consistent across all agencies including length of stay, level of service intensity, team sizes, and staff training (Pennsylvania Department of Public Welfare, 1993). Regardless of which agency houses the ESFT-FBMHS program, or in which county or region, the approach can be expected to be similar. This level of model and program uniformity presents a unique research opportunity for evaluating the effectiveness of a clinical family treatment approach to intensive in-home services. Using this study’s methodological design, which compares groups who receive different dosages of a more operationalized ESFT-FBMHS, revisits the findings of this initial program evaluation study.

Purpose of Study

The main purpose of this study is to empirically examine the effectiveness of ESFT-FBMHS. This study also seeks to (1) add to the current evidence base establishing intensive in-home services blended with clinical family treatment as an effective approach for youth with SED, (2) determine the extent to which treatment duration for youth with SED and their families is linked to outcomes, and (3) explore the role family therapy may play in outcomes maintained post-discharge. These findings may provide data that could guide decision-making in Medicaid-funded intensive in-home programs with respect to standards related to length of stay and required service components, such as family therapy.

Research Hypotheses and Questions

This study asks the question, “Does this intensive in-home treatment, ESFT-FBMHS, do what all intensive in-home treatments are intended to do, reduce out-of-home placement of youth with SED and improve their psychosocial functioning? This question is addressed by analyzing youth and family service utilization via archived claims data, comparing treatment outcomes across four different groups defined by the youth’s length of stay in the program: up to 84 days (i.e., 12 weeks), 85–168 days (i.e., 13–23 weeks), and 169–224 days (i.e., 24–32 weeks). The latter group are considered program completers because the length of stay is within the range called for by the clinical model. A fourth group who remained in the program beyond 224 days, the youth given extensions, were also examined. These four length-of-stay tiers were created by the managed care organization (MCO) as part of a transition to a value-based purchasing (VBP) model of reimbursing agencies for providing services. An examination of service utilization data by the managed care agency showed these four distinct time periods for length of stay in ESFT-FBMHS and suggested that length of stay may be linked to out-of-home placements. The MCO developed a financial incentive system that increased case rates, when compared to the traditional fee for service payment, for retention of families in ESFT-FBMHS. The current study sought to answer the following research questions.
Research Question 1. Do youth whose families complete ESFT-FBMHS, remaining for 169–224 days, (tier 3) show significantly lower rates of out-of-home placement at 90 days post-discharge, and 180 days post-discharge compared to those who stayed 225+ days (tier 4) or those who left in 168 days or less (tiers 1 and 2)? It is hypothesized that youth who complete ESFT-FBMHS (tier 3) will have fewer out-of-home placements because they received the intended dose of the treatment model. Youth who are granted extensions in the program (tier 4) would have met the MCO’s medical necessity criteria suggesting a continued high level of need and therefore are expected to have similar risks for out-of-home placement as the youth who drop out (tiers 1 and 2).
Research Question 2. Do youth who complete ESFT-FBMHS, remaining for 169–224 days (tier 3), show improvement as measured on the six domains of the Child and Adolescent Needs and Strengths (CANS; Problem Presentation, Risk Behaviors, Functioning, Child Safety, Caregiver Needs, and Child Strengths) assessment? It is hypothesized that youth who complete the program (tier 3) will have fewer needs and more strengths because they received the intended dose of the treatment model.
Research Question 3. Do youth who show improvement on the CANS at discharge show a reduced out-of-home placement risk at 90 days and 180 days? It is hypothesized that youth who have fewer identified needs and more identified strengths at discharge from ESFT-FBMHS will have reduced risk for out-of-home placement.

Method

Procedures

We utilized an ex post facto quantitative research design with two archived data sets to address each of our research questions. For the first research question on out-of-home placement, we analyzed archived medical claims data from five central Pennsylvania counties comprising the Capital Area Behavioral Health Collaborative (CABHC). CABHC is a not-for-profit, quasi-governmental agency that manages the risk-based contract for the Medicaid managed behavioral health contract with the state of Pennsylvania’s Department of Human Services, Office of Mental Health, and Substance Abuse on behalf of the counties of Cumberland, Dauphin, Lancaster, Lebanon, and Perry. To address the second and third research questions, we focused on changes in child strengths and needs by analyzing archived CANS data collected by the Community Data Roundtable (CDR), a nonprofit organization in Pennsylvania contracted with the MCO serving the central region to implement a Transformational Collaborative Outcomes Management system based on the CANS (Lyons, 2022).
One of the advantages of using aggregated claims data is that it provides complete anonymity to patients and their families, leaving all personal health care information fully protected. As such, masked claims data do not require patient authorization for use, and therefore did not warrant Institutional Review Board (IRB) approval. Access to these two sets of masked archival data was authorized by CABHC upon signing Business Associate Agreements with researchers outside the organization. No financial incentives were offered to children or caregivers for participating in ESFT-FBMHS treatment, research, or CANS outcomes assessment.

Participant Characteristics

Both data sets were limited to youth who began and ended ESFT-FBMHS services during the period between December 2017 and September 2022 and who received services at one of the 16 ESFT-FBMHS providers located within the five county CABHC catchment area where value-based purchasing (VBP) was being implemented within the ESFT-FBMHS level of care. The youth and families represented in this archival dataset were authorized by CABHC’s subcontracted managed care organization (MCO), PerformCare, for this voluntary level of care. To be eligible, the youth had to be between the ages of 3 and 21 and meet State regulations outlining Medical Necessity for FBMHS (Commonwealth of Pennsylvania, 2021). The criteria for FBMHS included (1) an active DSM-5 (ICD 10) diagnosis; (2) current clinically significant symptoms that create risk for removal from the home through an acute care psychiatric hospitalization or residential treatment placement; and/or (3) risk for the youth’s removal from the home due to neglect, abuse, and/or family instability (e.g., Child Protective Services involvement). All youth who applied for ESFT-FBMHS within this time-period who met program eligibility criteria, and who were then subsequently enrolled and discharged in the defined time-period were included in this study.
Prior to analysis we excluded 305 ESFT-FBMHS episodes for which the CANS ratings were outside of a 60-day window around either the start or end of treatment. The details of the study sample are shown in Supplementary Fig. 1. Briefly, we identified a total of 2469 ESFT-FBMHS treatment episodes among 2251 clients meeting the criteria for inclusion in our study. From this set, we excluded 305 episodes where the only available CANS evaluations were more than 60 days from either the ESFT-FBMHS start or end dates. This left 2164 episodes from 1998 clients for descriptive analysis. This dataset covered ESFT-FBMHS treatment episodes occurring between 5/29/2018 and 9/14/2022. A small number (N = 89) of these episodes were excluded from our statistical models due to missing data for one or more of the variables we identified as potential confounders (age, sex, race, ethnicity, and ICD diagnosis code). Demographic and clinical features for each of the included ESFT-FBMHS treatment episodes are shown in Table 1. The mean age of clients was 12 years at the start of treatment, with approximately equal representation of males and females. Most treatment episodes were for Caucasian or African American and non-Hispanic clients. The most common primary diagnoses were mood disorders and behavior and emotional disorders. Nearly 20% of episodes were for clients who had multiple primary diagnoses. As expected, nearly 2/3 of the sample (N = 1352 episodes, 62.5%) had a tier 3 length of stay. The remaining 812 episodes were at tier 1 (N = 205), tier 2 (N = 335), or tier 4 (N = 272).
Table 1
Demographic and clinical characteristics for ESFT-FBMHS treatment episodes
 
FBMHS episodes
(N = 2164)
Age at ESFT-FBMHS episode (years)
 
 Mean (SD)
12.0 (3.49)
 Median [min, max]
13.0 [0, 23.0]
 Missing, n (%)
70 (3.2)
Sex, n (%)
 
 Female
999 (46.2)
 Male
1165 (53.8)
Race, n (%)
 
 Caucasian
1503 (69.5)
 African American
269 (12.4)
 Asian
23 (1.1)
 North American Indian
10 (0.5)
 Other
339 (15.7)
 Missing, n (%)
20 (0.9)
Ethnicity, n (%)
 
 Non-Hispanic
1837 (84.9)
 Hispanic
307 (14.2)
 Missing
20 (0.9)
Primary Diagnosis, n (%)
 
 Multiple primary diagnoses
431 (19.9)
 F01–09: mental disorders due to known physiological conditions
1 (0.0)
 F10–19: mental and psychological disorders due to psychoactive substance abuse
2 (0.1)
 F20–29: schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders
9 (0.4)
 F30–39: mood (affective) disorders
550 (25.4)
 F40–48: anxiety, dissociative, stress related, somatoform, and other non-psychotic mental disorders
358 (16.5)
 F50–59: behavioral syndromes associated with physiological disturbances and physical factors
5 (0.2)
 F60–69: disorders of adult personality and behavior
28 (1.3)
 F70–79: intellectual disabilities
5 (0.2)
 F80–89: pervasive and specific developmental disabilities
266 (12.3)
 F90–98: behavioral and emotional disorders with onset usually occurring in childhood or adolescence
506 (23.4)
 F99: unspecified mental disorder
3 (0.1)
Tier, n (%)
 
 (1) 1–84 days
205 (9.5)
 (2) 85–168 days
335 (15.5)
 (3) 169–224 days
1352 (62.5)
 (4) 225+ days
272 (12.6)
Length of stay (days)
 
 Mean (SD)
199 (76.8)
 Median [min, max]
219 [8.00, 720]
Youth received services from 1 of 16 different ESFT-FBMHS programs in five central Pennsylvania counties. These programs represented nine behavioral health agencies, all of whom were following state-wide ESFT-FBMHS service implementation standards. All ESFT-FBMHS treatment was delivered in the home by two-person teams comprised at minimum of one master’s level therapist. The second therapist was usually a bachelor’s level therapist. The treatment was intensive, with therapists in the home multiple times per week meeting with various family subsystems (individual child, caregivers, and the whole family). All therapists who delivered treatment received three hours of ESFT supervision each week and were either currently in the mandatory 3-year ESFT-FBMHS training (273 h) or were graduates of it.
The ESFT-FBMHS programs who participated in this study were enrolled in the CABHC PerformCare provider network. The 2019 Census data suggest that, together, these five Pennsylvania counties represent a diverse geography and population. They range from sparsely populated rural Perry County with 83.4 people per square mile to the more densely populated Dauphin and Lancaster Counties with 510.6 and 550.4 persons per square mile. The US Census data shows the counties also vary with respect to racial diversity. Perry County, with a population of 46,272, is 95% white, while Dauphin County, with a population of 268,299, shows it is 9.9% Hispanic or Latino and 19.2% Black or African American. Lancaster County, the most populous of the five counties with a population of 545,724, shows 11% Hispanic or Latino and 5.2% Black or African American. Poverty rates range from a low of 7.2% in Cumberland County to 11.3% in Dauphin County.

Sample Size, Power, & Precision

The sample size for this study was constrained by the period of performance of the value-based purchasing program and the number of clients served by ESFT-FBMHS at participating clinics during the study period. However, an initial investigation suggested that we could expect a sample of ~2000 treatment episodes. Under the assumption that each treatment episode reflects the experience of a unique client, we expected the study to have 80–90% power to detect a 50% increase in the odds of out-of-home placement (odds ratio = 1.5) comparing the reduced-incentive lengths of stay (tiers 1, 2, and 4) to the preferred tier 3 length of stay across a range of possible rates for out-of-home placement in tier 3 from 10% to 50%. These power calculations assumed the sample would be split 2/3 among the preferred tier 3 (N = 1320 episodes) and 1/3 among the reduced-incentive tiers 1, 2, and 4 (N = 680) and a two-sided Type I error rate of 5%. We also treated these calculations as an indication of the utility of the study for identifying factors associated with moderate-to-large sized differences in CANS improvement. It was decided prior to conducting the study that we would not apply statistical adjustments to constrain the false positive rate given our intent to maximize the potential for insight into the functioning of a complex system.

Measures

To measure clinical improvement, we used the Community Data Roundtable Child and Adolescent Needs and Strengths assessment (CDR CANS), a tool with demonstrated efficacy as an outcomes measure in community-based behavioral health (Troy et al., 2021). The CDR CANS includes 53 top-level items organized into five domains representing needs (Problem Presentation, Risk Behaviors, Functioning, Child Safety, and Caregiver Needs) and a single domain for Child Strengths (Lyons et al., 2022). The rater uses available information including observation, caregiver interview, and documentation to generate the best estimate of the child’s and family’s needs and strengths.
Lyons et al. (2014) and Anderson et al. (2003) show CANS’ interrater reliability is acceptable with individual item coefficients ranging from 0.6 to 0.9. Lyons compared the CANS to the Child and Adolescent Functional Assessment Survey (CAFS; Hodges et al., 1982) and yielded statistically significant correlations between the CANS and CAFS dimension scales supporting the conclusion that the CANS possesses concurrent and predictive validity. Finally, Lyons et al. (2014), with a large sample of clinical cases, used a discriminant analysis to demonstrate that the CANS correctly classified 63% of all cases into their actual level of care supporting the conclusion of good predictive validity.
All raters in this study were ESFT-FBMHS clinicians who were trained and then certified as reliable on the CDR CANS at a 0.7 level using the Praed Foundation Transformational Collaborative Outcomes Management Training CANS certification web page. The CANS was completed by ESFT-FBMHS clinicians treating the family at the 45-day mark of care, which is when the initial treatment plan is due to the managed care company. The CANS was administered again at the discharge meeting. As is true in all CANS rating events, the initial CANS was used to inform treatment planning, and the discharge CANS was used to inform disposition care planning.
CANS outcomes were used to evaluate program performance for the purposes of receiving a financial incentive through a value behavior purchasing model. A specific set of CANS items were identified by the MCO as requiring improvement to qualify for the incentive. The items were identified through an analytic process conducted by Community Data Roundtable as a part of its implementation of the CDR CANS into the ESFT-FBMHS Value Based Purchasing plan. To qualify for the incentive, a case had to have sufficient needs initially and then undergo meaningful change by the end of treatment so that the patient could transition to a lower level of care. The final analytic used by the managed care company to determine if a program qualified for an incentive was client improvement on at least six items from the Problem Presentation, Risk and/or Functioning Domain, and improvement on at least two items on the Caregiver and Strengths Domains. These scores on the CANS counted as a clear and unambiguous successful outcome for both the Value Based Purchasing model and the analysis of ESFT-FBMHS.
The Episodes Measure Group was used to measure treatment episodes. This is a standardized method developed and used by the Capital Area Behavioral Health Collaborative (CABHC) to determine a treatment episode. It is based on information derived by combining paid claims rendered to the same consumer, within the same Person Level Encounter (PLE) claims service category, within a specific period. Only the last claim in a chain of claims that also contained voided or adjusted claims was included; voids and adjustments earlier in the chain were excluded. An episode for a consumer was counted as ended when there were no subsequent claims for that consumer within the same PLE service category that defines the episode. The number of days that can elapse between services for it to be considered as part of the same episode was configured in the database by PLE service category. For example, the allowable gap for inpatient psychiatric services was one day, while for outpatient psychiatric services ESFT-FBMHS, it was 30 days.

Analytic Strategy

The unit of analysis was the ESFT-FBMHS treatment episode. For each episode, we identified three sets of variables: dependent, independent, and confounding. Set one is comprised of three dependent or outcome variables. Outcome variable 1 is out-of-home placement (OHP) at 90 days post-discharge (or not). Outcome variable 2 is defined as out-of-home placement at 180 days post-discharge (or not). Finally, outcome variable 3 is improvement in CANS scores from intake to discharge (or not). The primary independent variable of interest is broadly labeled as the family’s length of stay in ESFT-FBMHS and was defined as (1) up to 84 days (tier 1), (2) 85–168 days (tier 2), (3) 169–224 days (tier 3), and (4) >224 days (tier 4). The set of confounding variables included age, sex, race, ethnicity, and primary diagnosis.
We collected and summarized relevant demographic and treatment-related data. Next, we fit generalized estimating equations (GEE; Ghisletta & Spini, 2004) with a logit link and exchangeable working correlation structure to estimate odds ratios (OR) and 95% confidence intervals (CI) comparing the odds of each outcome in tiers 1, 2, and 4 to tier 3 with adjustment for the confounding variables. In all our models, an odds ratio above 1 suggests the outcome is more common in tiers 1, 2, and 4 as compared to tier 3 whereas a value of 1 indicates no difference, and a value below 1 indicates the outcome is less common in tiers 1, 2, and 4 relative to tier 3. All potentially confounding variables were included in our models regardless of whether they were statistically significant. GEE was chosen because of our interest in estimating population-level impacts on the Pennsylvania ESFT-FBMHS system, e.g., by asking how much of a difference the program might expect in out-of-home placement if all treatment episodes were at the tier 3 length of stay as compared to the tier 2 length of stay. It is important to note that our analyses do not address how an individual youth’s length of stay in ESFT-FBMHS treatment impacts the probability of their out-of-home placement. Stated simply, the results describe the relationship between group membership and outcome, not the individual and their unique clinical outcome (Ghisletta & Spini, 2004).

Results

Research Question 1. Do Youth Who Completed ESFT-FBMHS, Occupying Tier 3, Show Significantly Lower Rates of Out-of-Home Placement at 90 Days and 180 Days Post-Discharge Compared to Those Occupying Tiers 1, 2, and 4?

The results of our descriptive analysis are shown in Table 2. A total of 12.2% of tier 1 episodes, 14.3% of tier 2 episodes, and 15.1% of tier 4 episodes resulted in out-of-home placement at 90-days post-discharge compared to 4.7% of tier 3 episodes. Similarly, 14.1% of tier 1, 17.9% of tier 2, and 19.1% of tier 4 episodes resulted in out-of-home placement at 180-days post-discharge compared to 7.2% of tier 3 episodes. This pattern persisted after adjustment for potentially confounding variables. As shown in Table 3, the tiered length-of-stay in ESFT-FBMHS was significantly associated with out-of-home placement at both 90- and 180-days post-discharge after adjustments for youth age, sex, race, ethnicity, and psychiatric diagnosis (P < 0.001 in both models). Length-of-stay at tiers 1, 2, and 4 experienced 2–3 times the odds of out-of-home placement at 90 days post-discharge compared to tier 3. For example, tier 2 was associated with 3.18-times the odds of out-of-home placement (OR) at 90 days compared with tier 1 (OR = 3.18, 95%, confidence interval: 2.07, 4.89) after adjustment for demographic and clinical features. Results were similar for the model of out-of-home placement at 180 days with tiers 1, 2, and 4 experiencing 1–3 times the odds of out-of-home placement compared to tier 3 after adjusting for demographic and clinical features.
Table 2
Out-of-home placement (OOH) and improvement on the Child and Adolescent Needs and Strengths (CANS) by tiered length of stay
 
Tier
 
(1) 1–84 days
(2) 85–168 days
(3) 169–224 days
(4) 225+ days
Overall
(N = 205)
(N = 335)
(N = 1352)
(N = 272)
(N = 2164)
OOH @ 90 days post-discharge, n (%)
     
 Yes
25 (12.2)
48 (14.3)
63 (4.7)
41 (15.1)
177 (8.2)
 No
180 (87.8)
287 (85.7)
1289 (95.3)
231 (84.9)
1987 (91.8)
OOH @ 180 days post-discharge, n (%)
     
 Yes
29 (14.1)
60 (17.9)
98 (7.2)
52 (19.1)
239 (11.0)
 No
176 (85.9)
275 (82.1)
1254 (92.8)
220 (80.9)
1925 (89.0)
CANS improvement at discharge, n (%)
     
 Yes
24 (11.7)
61 (18.2)
542 (40.1)
86 (31.6)
713 (32.9)
 No
181 (88.3)
274 (81.8)
810 (59.9)
186 (68.4)
1451 (67.1)
Table 3
Adjusted model for improvement on the Child and Adolescent Needs and Strengths (CANS) improvement at discharge
 
Adjusted OR (95% CI)
P value
Tier
 
<0.001
 Tier 3
Ref
 
 Tier 1
0.18 (0.11, 0.29)
 
 Tier 2
0.33 (0.24, 0.45)
 
 Tier 4
0.76 (0.57, 1.02)
 
Age (1-year increment)
0.99 (0.97, 1.02)
0.707
Sex
 
0.031
 Female
Ref
 
 Male
1.25 (1.02, 1.53)
 
Race
 
0.728
 White
Ref
 
 African American
1.11 (0.83, 1.5)
 
 Other race
0.96 (0.71, 1.29)
 
Ethnicity
 
0.922
 Non-Hispanic
Ref
 
 Hispanic
1.02 (0.74, 1.4)
 
Diagnosis
 
0.006
 F30–39: mood (affective) disorders
Ref
 
 F40–F48: anxiety, dissociative, stress related, somatoform and other non-psychotic mental disorders
0.96 (0.7, 1.32)
 
 F80–F89: pervasive and specific developmental disabilities
1.54 (1.1, 2.15)
 
 Multiple diagnoses
0.94 (0.69, 1.29)
 
 Other diagnoses
1.35 (1.02, 1.79)
 
This table shows the results of a single regression model for the binary outcome of improvement on the Child and Adolescent Needs and Strengths (CANS) at discharge from Family Based Mental Health (FBMH) treatment. The model was fit using generalized estimating equations (GEE) as described under “Methods” section. The model includes 2075 ESFT-FBMHS episodes from 1915 clients with non-missing data for the model covariates (see Table 1). This represents 95.9% of all episodes included in the study (N = 2164 episodes; N = 1998 clients)
OR odds ratio, CI confidence interval

Research Question 2. Do Youth Who Completed ESFT-FBMHS, Occupying Tier 3, Show Improvement as Measured on the Child and Adolescent Needs and Strengths (CANS) Assessment?

As shown in Table 3, CANS scores improved in 40.1% of tier 3 episodes as compared to only 11.7%, 18.2%, and 32.9% of tier 1, 2, and 4 episodes, respectively. This pattern persisted after adjustment for demographic and clinical features (P < 0.001) as shown in Table 3. For example, tier 1 (OR = 0.18, 95% CI: 0.11, 0.29) and tier 2 (OR = 0.33, 95% CI: 0.24, 0.45) had lower odds of CANS improvement compared to tier 3. However, there was no evidence of a difference comparing the odds of CANS improvement in tier 4 vs. tier 3 (OR = 0.99, 95% CI: 0.97, 1.02).

Research Question 3. Do Youth Who Show Improvement on the Child and Adolescent Needs and Strengths (CANS) Assessment at Discharge Demonstrate a Reduced Out-of-Home Placement Risk at 90 Days and 180 Days?

This research question was addressed by inclusion of CANS improvement as a covariate in our GEE models for out-of-home placement at days 90 and 180 post-discharge (Table 4). These models show that, after adjustment for the length of stay as well as demographic and clinical features, that CANS improvement was associated with a 56% reduction in the odds of out-of-home placement at Day 90 (OR = 0.44, 95% CI: 0.28, 0.68) and a 45% reduction in odds of out-of-home placement at Day 180 (OR = 0.55, 95% CI: 0.38, 0.80). Importantly, this illustrates that CANS improvement is independently associated with reduced odds of out-of-home placement regardless of tier.
Table 4
Adjusted models for out-of-home placement (OOH) at days 90 and 180 post-discharge
 
Model for OOH at day 90 post-discharge
Model for OOH at day 180 post-discharge
 
Adjusted OR (95% CI)
P value
Adjusted OR (95% CI)
P value
Tier
 
<0.001
 
<0.001
Tier 3
Ref
 
Ref
 
Tier 1
2.12 (1.2, 3.72)
 
1.64 (0.98, 2.77)
 
Tier 2
3.18 (2.07, 4.89)
 
2.72 (1.83, 4.03)
 
Tier 4
2.05 (1.28, 3.29)
 
1.65 (1.07, 2.54)
 
Age (1-year increment)
1.09 (1.03, 1.14)
0.001
1.13 (1.07, 1.18)
<0.001
Sex
 
0.138
 
0.032
Female
Ref
 
Ref
 
Male
0.76 (0.53, 1.09)
 
0.71 (0.51, 0.97)
 
Race
 
0.003
 
0.078
White
Ref
 
Ref
 
African American
1.98 (1.29, 3.04)
 
1.58 (1.05, 2.39)
 
Other race
0.79 (0.44, 1.4)
 
0.96 (0.62, 1.49)
 
Ethnicity
 
0.963
 
0.809
Non-Hispanic
Ref
 
Ref
 
Hispanic
1.01 (0.57, 1.81)
 
0.94 (0.58, 1.53)
 
Diagnosis
 
<0.001
 
<0.001
F30–39: mood (affective) disorders
Ref
 
Ref
 
F40–F48: anxiety, dissociative, stress related, somatoform and other non-psychotic mental disorders
0.7 (0.36, 1.35)
 
0.7 (0.4, 1.22)
 
F80–F89: pervasive and specific developmental disabilities
1.08 (0.53, 2.16)
 
0.96 (0.52, 1.78)
 
Multiple diagnoses
4.51 (2.94, 6.94)
 
5.12 (3.48, 7.54)
 
Other diagnoses
0.38 (0.19, 0.76)
 
0.45 (0.25, 0.8)
 
CANS improvement
 
<0.001
 
0.002
No
Ref
 
Ref
 
Yes
0.44 (0.28, 0.68)
 
0.55 (0.38, 0.8)
 
This table shows the results of two regression models, one for the binary outcome of out-of-home placement at 90 days after discharge from ESFT-FBMHS treatment, and another model for out-of-home placement at 180 days after discharge from ESFT-FBMHS treatment. Models were fit using generalized estimating equations (GEE) as described under “Methods” section. Both models include 2075 ESFT-FBMHS episodes from 1915 clients with non-missing data for the model covariates (see Table 1). This represents 95.9% of all episodes included in the study (N = 2164 episodes; N = 1998 clients)
OR odds ratio, CI confidence interval

Discussion

This study evaluated the effectiveness of ESFT-FBMHS by comparing youth outcomes across four different tiers of treatment duration on two indicators of change: reduced out-of-home placement and youth clinical improvement as defined by the Child and Adolescent Needs and Strengths (CANS) scores. The demographic data and the generalized estimating equation (GEE) models generated in this study show that treatment duration in ESFT-FBMHS (up to 84 days, 85–168 days, 169–224 days, and more than 224 days) is associated with both out-of-home placement at 90- and 180-days post-discharge and CANS scores at discharge. Specifically, youth remaining in ESFT-FBMHS for 169–224 days (i.e., 24–32 weeks) are more likely to reside in the home at 90- and 180-days post-discharge. This group is referred to as program completers since it is within the range of the intended duration of time youth receive ESFT-FBMHS services. In contrast, the GEE models predict that youth receiving 84 days or less (i.e., 12 weeks) or between 85 and 167 days (i.e., 13–23 weeks) of ESFT-FBMHS are two to three times more likely to be placed out-of-the-home at 90- and 180-days post-discharge. This was also true for youth remaining in the program longer than 224 days (i.e., 33 weeks or more), who have received service extensions. As for the second indicator of change, youth receiving 84 days or less (i.e., 12 weeks) or between 85 and 168 days (i.e., 13–23 weeks) of ESFT-FBMHS are several times less likely to show meaningful change in CANS scores at discharge. A third of the youth remaining in ESFT-FBMHS more than 224 days showed gains on the CANS (32.9%), which suggests similar odds of benefiting from the program as youth who remained in the program for 169–224 days (40.1%).

Similarity of Results

This study offers a major step forward in establishing the effectiveness of ESFT-FBMHS with youth who have severe emotional disturbance (SED) with a diverse range of psychiatric diagnoses and who are at risk for out-of-home placement. The finding of improved youth outcomes validates and builds on smaller scale studies of ESFT applied to a rapid response home-based program (Clossey et al., 2018) and confirms years of practice-based data collected by Pennsylvania MCOs and FBMHS agencies providing ESFT. The significant reduction in out-of-home placement found in this study, the main goal of most intensive in-home treatment programs, replicates the first large-scale assessment of the effectiveness of ESFT-FBMHS (Dore, 1996; Lindblad-Goldberg et al., 2004), completed almost 30 years ago. Beyond ESFT-FBMHS, the findings are consistent with other studies broadly supporting intensive in-home treatment as an effective mode of service delivery to improve youth functioning and keep high risk youth in their homes and communities (e.g., Bruns et al., 2021; Moffet et al., 2018).
Most importantly, this study advances the existing empirical evidence supporting the effectiveness of intensive in-home approaches integrated with a highly specified family treatment clinical model, such as MST-Psychiatric (Henggeler et al., 1999; Pane et al., 2013; Rowland et al., 2005) and adaptations of MST, such as Youth Villages Intercept (Barth et al., 2007). However, in contrast to findings from MST-Psychiatric (Henggeler et al., 2003), which found short-lived impacts on out-of-home placement, this study of ESFT-FBMHS shows sustained reductions in out-of-home placement for youth who remained in the program for 169–224 days (i.e., 24–32 weeks). One explanation for these different findings on the stability of post-treatment changes is treatment duration. The youth and families receiving MST-Psychiatric treatment was limited to 4 months (Henggeler et al., 1999, 2003), which may be sufficient for briefly stabilizing high-risk severely symptomatic youth, but inadequate for addressing underlying chronic and severe problems in family functioning. This study of ESFT-FBMHS lends support to Williams’ (2009) finding that intensive in-home treatment programs of longer duration result in more sustained improvement for youth with SED, an observation also made by Moffet et al. (2018) in their comprehensive review of empirical studies on intensive in-home programs.

Interpretation

Although it is beyond the scope of this study to identify the exact reasons 24–32 weeks (169–224 days) of ESFT-FBMHS treatment was more successful for youth, it is possible to speculate based on what is known about the treatment population and the treatment model. The youth and caregivers served by intensive in-home programs, and ESFT-FBMHS specifically (Byers et al., 2021), show a high prevalence of complex trauma and chronic adversity, which often undermines their capacity for self-regulation. Collins et al. (2010) describe caregivers with a history of complex trauma as often struggling to collaborate with the treatment team on behalf of their child because of poor self-regulation, negative attributions toward the child, lack of confidence in their ability to effect change, and difficulty sustaining a recovery-oriented narrative. These caregivers may require additional emotional support before they can engage fully with treatment programs, something that is available to caregivers in the initial stages of ESFT-FBMHS (Jones et al., 2021). Perhaps those caregivers who received additional support during the initial stages of ESFT-FBMHS and who were better able to self-regulate were more likely to remain in the program for 24–32 weeks (169–224 days), thereby receiving a full dose of the treatment and more opportunities for growth. This hypothesis is, in part, grounded in the large body of research on parent self-regulation and its link to successful outcomes in parenting intervention programs (e.g., Sanders, 2008; Sanders & Mazzucchelli, 2013). The family therapy component in ESFT-FBMHS, like that of MST-Psychiatric (Henggeler et al., 1999) is designed to strengthen the caregivers’ ability to independently support the youth’s emotional stability and lower the risk of needing more restrictive out-of-home placement. The difference is that families receive the family therapy component for a longer duration in ESFT-FBMHS.
Drop-out rates as high as 30% have been reported by some intensive in-home programs, such as Connecticut’s Intensive In-Home Child and Adolescent Psychiatric Services (Galloway, 2017). In this study, 25% of youth and families left ESFT-FBMHS before completing the program (see tiers 1 and 2, Table 1). Although the reasons that caregivers and youth left ESFT-FBMHS prematurely were not measured in this study, there is literature on factors associated with treatment retention among youth and adults with severe mental illness (e.g., Lemieux et al., 2018) which may help explain early discharges. One major factor found in studies of treatment retention is the strength of the therapeutic alliance (Smith et al., 2013). Although the therapists delivering ESFT-FBMHS are well-trained, gaining buy-in to a family systems approach from both the youth and their caregivers is complex. Caregivers may be overwhelmed and angry with their child and the child may have lost trust in their caregivers. The therapeutic relationship can be derailed when therapists have an uneven alliance with the youth and caregivers, a factor associated with premature withdrawal from family treatment (Robbins et al., 2008). Although no differences in treatment duration based on race or ethnicity were evident in this study, some studies have found the ethnic match between the family and the treatment team to be a factor in the therapeutic alliance and in clinical outcomes (Gamst et al., 2000, 2004) a factor that deserves further study.
There are also caregiver, family, and larger ecosystem factors that can affect the length of stay in intensive in-home treatment. For example, caregivers may not feel they have the emotional resources to participate as actively as the treatment program requires due to undertreated mental health problems or overwhelming environmental stressors and demands in their lives. Byers et al. (2021) found that caregivers with a high level of current adversity in their life had a reduced length of stay in ESFT-FBMHS. Similar findings have been reported in programs serving families with youth in the juvenile justice system. For example, Sheerin et al. (2024) found that caregivers with significant levels of psychiatric distress predicted lower levels of engagement in youth treatment. Another potential factor influencing early withdrawal from ESFT-FBMHS is limitations in the current implementation of the treatment model. Perhaps therapists applying the model do not adequately prioritize and address the needs of those caregivers who, at the time of the youth’s admission to the program, are experiencing a high level of stress and adversity in their family and larger ecosystem. It is critical that future studies of intensive in-home treatment in general, and ESFT-FBMHS specifically, include measures that assess the reasons caregivers remain or leave treatment programs.
Likewise, it is important to explore possible reasons that youth who extended their stay in ESFT-FBMHS beyond 224 days (i.e., 33 weeks or more) remain at high risk for out-of-home placement. After all, this group received a higher dose of the clinical model. Demographic data from this study shows these youth had the highest number of multiple, co-morbid psychiatric diagnoses (48.5%). As a group, perhaps they remained unstable and continued to be at risk at the end of the authorization period for ESFT-FBMHS, despite showing gains in functioning (according to CANS scores) commensurate with those who complete the program. This suggests another factor, such as family functioning, may be at play. Except for ratings on the Caregiver Needs domain on the CANS, comprehensive family functioning was not measured in this study. It is reasonable, however, to speculate that the families in this group of extenders could not make enough changes to support the continued recovery of the youth post-discharge without the treatment team. Preyde et al.’s (2011) study of Ontario’s intensive in-home programs suggests the severity of compromised family functioning can play a big role in who may best benefit from less restrictive in-home treatment.

Limitations and Generalizability

The methodological approach used in this study for establishing efficacy was to compare treatment outcomes of groups with varying levels of exposure to the clinical model, ESFT-FBMHS. This is an approach for testing the efficacy of intensive in-home treatment described by Moffet et al. (2018) as one alternative to randomized controlled trails. The results of this study suggest comparing groups with different levels of exposure to the intervention may be an effective method for evaluating a treatment model’s efficacy when randomized trials are not feasible. Given the severe, potentially life-threatening mental health issues of the children and adolescents served by intensive in-home treatment programs, random assignment to nontreatment conditions or treatment conditions with unknown benefits cannot be justified, particularly when there is a treatment like ESFT-FBMHS available with a thirty-five-year history of practice-based evidence of effectiveness. To fully evaluate the efficacy of ESFT-FBMHS and the operative clinical model, it would be important to have a meaningful comparison group and randomly assign youth to the different groups. The strength of this quasi-experimental design comparing different dosage levels of the model is that it demonstrates a clear relationship between ESFT-FBMHS intervention and outcomes without the ethical problems of randomization. The main limitation of this approach, however, is that it is impossible to rule out the impact of other variables on the outcomes. An effort was made in this study to reduce this limitation by using adjusted GEE models for both out-of-home placement and CANS scores, factoring in probable confounding variables such as gender, age, race/ethnicity, and diagnosis. Finally, there are the limitations of using archival data based on the referred youth’s individual medical and service utilization record, which limits the detailed information available about caregivers and the family, critical variables in determining the level of family functioning and caregiver distress.

Conclusions and Implications

This study answers the question as to whether ESFT-FBMHS, a family therapy approach, effectively does what intensive in-home services are designed to do for youth with serious emotional disturbance, reduce the risk of out-of-home placement and improve youth functioning. The youth who remained in the program for 168–224 days (i.e., 24–32 weeks), the treatment duration built into the clinical model, and who showed improved CANS scores, showed statistically significant reduced odds of out-of-home placement at 180 days discharge when compared to youth who remained in the program less than 168 days. This study offers another example of a rigorous approach of an in-home intensive family therapy model for youth with serious emotional disturbance (SED), and one that shows promise in accomplishing long-term outcomes. Longer follow-up studies of these youth at one- or two-years post-discharge are needed to evaluate the degree to which the positive outcomes of ESFT-FBMHS are sustained. Prospective studies are recommended to explore the specific factors that predict which youth and families complete ESFT-FBMHS treatment and have positive outcomes vs. those who leave the program early and make few changes. Toward this end, not only should future studies include comprehensive measures of family functioning, but they should also include a measure of parent self-regulation (PSR) and the extent to which treatment teams focus on it. It is predicted that youth in ESFT-FBMHS would have more positive outcomes when treatment teams specifically focus on building parent self-regulation capacity. There is strong evidence that parent self-regulation or dysregulation directly affects children’s mental health functioning and treatment outcomes in parenting programs (Lunkenheimer et al., 2023; Deater-Deckard et al., 2012). It is important that future studies exam whether more targeted and intense support of caregivers in the early stages of treatment increases caregivers’ self-regulatory processes, and results in the youth and family receiving higher doses of intervention.
Future studies should also clarify the unique needs of the 12.6% youth and families who remained in ESFT-FBMHS beyond 224 days (i.e., 33 weeks or more) and remained at high risk for out-of-home placement. Since family functioning may play a big role in this group of extenders, it is important that intensive in-home treatment programs include measures of clinically meaningful domains of family functioning, such as level of support for caregivers, the strength of caregiver-child attachment, the caregiver alliance, and the caregivers’ executive functioning, are necessary to both plan treatment and to evaluate the role of different domains of family functioning on treatment completion and treatment outcome. One such measure used in some Pennsylvania intensive in-home programs is the Modified Family Assessment Form (Simms et al., 2024). A more extensive study of the families of youth who do not show marked improvement from their time in ESFT-FBMHS is critical to tailoring the approach to better meet the needs of this group.
This study’s findings also have important implications for practice. Given the prevalence of complex trauma among the caregivers in the multi-stressed families served by these programs, intensive in-home programs may be more effective at engaging caregivers and sustaining their involvement if given more support and help with self-regulation early in treatment. While the ESFT-FBMHS treatment model promotes this focus theoretically, it is unclear the extent to which treatment teams directly meet these caregivers’ additional needs. The findings of this study indirectly support Byers et al. (2021) recommendation that caregivers who need extra support should be identified early, during admission, and then an early treatment phase added that focuses only on building natural supports for these caregivers and strengthening self-regulation capacity. The idea would be to reduce the caregiver burden of taking on the usual expectations for partnering with the team in treating the child until they are emotionally ready, and instead more directly and intentionally addressing the caregivers’ basic needs.
There are also policy implications of this study’s findings that broadly apply to all Medicaid-funded intensive in-home programs. One, in states where homegrown intensive in-home programs limit the length of stay to 5 months or less for youth with severe emotional disturbance at risk for inpatient hospitalization or residential treatment (see Stroul et al., 2021), consideration should be given to extending standard authorizations for a longer duration, giving treatment programs the opportunity to address systemic issues maintaining problems, going beyond youth and family stabilization. Two, the caregivers and families of youth treated in intensive in-home programs have complex needs and their functioning can either undermine or promote caregiver responsiveness to treatment and youth responsiveness to treatment. It is critical that comprehensive family assessment be as routine in the practice of intensive in-home programs as is the clinical assessment of youth, and that the results inform clinical decision-making. Three, it is critical that intensive in-home treatment, a comprehensive program comprised of multiple services, not only includes family therapy as one of its many components but prioritize it for optimizing long-term youth outcomes.

Supplementary information

The online version contains supplementary material available at https://​doi.​org/​10.​1007/​s10826-024-02906-y.

Acknowledgements

The authors thank Mark Belding at Alan Collautt Associates for his assistance with the data.

Compliance with Ethical Standards

Conflict of Interest

Two of the authors, C.W.J. and S.S., are executive directors of family therapy training organizations that receive fees from behavioral health agencies across the commonwealth of Pennsylvania for family therapy training, which includes ESFT-FBMHS. None of the other authors have direct or indirect financial or proprietary interest in any material discussed in this article.

Ethical Approval

This study used aggregated claims data that provides complete anonymity to patients and their families, leaving all personal health care information fully protected. Given the de-identified nature of data, Institutional Review Board (IRB) approval was not sought. Access to these two sets of masked archival data was authorized by The Capital Area Behavioral Health Collaborative (CABHC) upon signing Business Associate Agreements with researchers.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Literatuur
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Metagegevens
Titel
An Archival Study of the Relationship Between Treatment Duration, Functioning, and Out-of-Home Placement for Youth with Serious Emotional Disturbance in a State-Wide Intensive In-Home Family Treatment Program
Auteurs
C. Wayne Jones
Steve Simms
Jesse Troy
Scott Suhring
Dan Warner
Tara Byers
Publicatiedatum
19-09-2024
Uitgeverij
Springer US
Gepubliceerd in
Journal of Child and Family Studies / Uitgave 10/2024
Print ISSN: 1062-1024
Elektronisch ISSN: 1573-2843
DOI
https://doi.org/10.1007/s10826-024-02906-y