Case Study Day Treatment Outcome with Severely Disturbed Children

Case Study Day Treatment Outcome with Severely Disturbed Children STEWART GABEL, M.D., MARK FINN, PH.D.,

AND

ANJUM AHMAD, M.S.W.

Abstract. Day treatment for psychiatrically disturbed children is a relatively new but increasingly used treatment modality. Outcome has only been studied empirically on relatively few occasions. This report assesses outcome of a group of severely disturbed, mostly black children from an urban area and disorganized home and family environments who had been treated in a psychodynamically oriented, hospital-based treatment program over several years. Slightly more than half the group was referred to out-of-home residential or inpatient hospitalization on discharge. Placement in hospital or residential setting on discharge was associated with preadmission variables of child abuse/maltreatment, parental substance abuse, suicidality, and severe assaultive/ destructive behavior. If these findings can be generalized to other day treatment settings, important implications for admission criteria and program design of children's day treatment programs would have been established. J. Am. Acad. Child Adolesc. Psychiatry, 1988, 27, 4:479-482. Key Words: day treatment, discharge placement, admission criteria.

Day treatment for children with severe psychiatric disorders has been a therapeutic option for over 40 years. It has only been more recently, however, that the concept of children's day treatment has been recognized as a significant innovation in mental health care, and only in the last decade has the number of programs increased dramatically. There are now reportedly over 350 day treatment programs for psychiatrically disturbed children in the United States (Zimet and Farley, 1985). The list may grow. Current trends in medical care and psychiatric care have made long-term inpatient hospitalization costly. Third party payers increasingly question the need for lengthy inpatient hospitalization. There continues to be a trend toward deinstitutionalization of the chronic mental patient (Voineskos, 1976). Innovative recent approaches, which sometimes combine day treatment programs with inns or hospice settings for overnight stays, have demonstrated not only improved cost effectivenessbut also the ability to provide good clinical care, at least with adult populations (Gudeman et aI., 1985). Recent legislative action has also worked to increase the appeal of outpatient day treatment programs for psychiatrically disturbed children. Public Law 94-142 mandates free appropriate education for all handicapped children

AcceptedJanuary tt. 1988. Dr. Gabel is Assistant Professor of Psychiatry. and Dr. Finn was a Postdoctoral Fellow in Psychology. The New York Hospital-Cornell Medical Center. Westchester Division. He is now Senior Psychologist. Dept. ofPsychiatry. North Central Bronx Hospital. Bronx. New York. Dr. Ahmad is StaffSocial Worker. New York Foundling Hospital. Reprint requests to Dr. Gabel. Assistant Professor ofPsychiatry. Unit Chief, Children's Day Hospital. The New York Hospital-Cornell Medical Center. Westchester Division. 21 Bloomingdale Road. White Plains. NY 10605. The authors wish to acknowledge the contribution of Cynthia R. Pfeffer. M.D. to the conceptualization ofpart ofthis study. 0890-8567/88/2704-Q479$02.00/0© 1988 by the American Academy of Child and Adolescent Psychiatry. 479

and placement of these children in the "least restrictive environment" available for them. Unfortunately, few studies have been done to evaluate the outcome of day treatment for psychiatrically disturbed children generally, or for specific psychiatric populations. The literature that is available is generally more descriptive and clinical than empirical in nature (see Zimet and Farley, 1985 for a review). The Children's Day Hospital (CD.H.) of The New York Hospital-Cornell Medical Center, Westchester Division, is a hospital-based day treatment program serving severely disturbed, mainly minority children, from chaotic home environments. Mental health services are provided by the hospital faculty and staff, whereas educational services are provided by the local school division. The treatment approach has been mainly psychodynamic with an emphasis on individual and group psychotherapy. This paper reports on the outcome of children treated in CD.H. over several years. No study of day treatment of which we are aware focuses specifically on outcome in the severely disturbed, multi-problem, mostly black child population discussed in this report. Method

Procedure Data were collected retrospectively from the charts of consecutive discharges from CD.H. over a 5-year period, 1981 to 1985. There were 56 discharges during this time; four charts could not be located, leaving 52 discharges in the study. Each chart was reviewed independently by two of the authors (S. G. and M. F.). In addition to various demographic and diagnostic information compiled from the charts related to age, sex, and living situation, we also reviewed the charts of all the discharges to assess whether there had been a preadmission history of any of the following: (I) child abuse/ maltreatment (as indexed by outside agency involvement and occurring at any point in the child's life); (2) parental sub-

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stance abuse occurring at any point in the child's life (alcohol and other drugs were not distinguished); (3) suicidal ideation or attempts occurring within 6 months of admission; or (4) severe assaultive or destructive behavior (as indexed by use of objects as weapons in fights,aggression toward adults, destruction of non-play objects or property such as walls or furniture) also occurring within 6 months of admission. Each child was rated as exhibiting or not exhibiting each of these four factors independently by both S. G. and M. F. After the ratings were completed, agreement was reached by consensus, based on joint chart review and discussion, to yield one yes or no response to each of these factors for each child. Finally, discharge placement recommendations were recorded. Because a generally accepted criterion for success in day treatment is continued residence in a home environment on discharge rather than out-of-home placement in a residential setting or inpatient hospitalization, this dichotomy of inversus out-of-home residence was used as the outcome measure. Sample Children between the ages of 4 and 12 were referred to C.D.H. mainly by local school divisions in southern Westchester County, New York, when their behavior became unmanageable in the local school setting despite the variety of special services offered in the local school divisions. A minority of the patients in the C.D.H. were referred on discharge from inpatient psychiatric units. The children generally were referred because of overt behavior disorders such as impulsivity, conduct disturbance, hyperactivity, etc. Child abuse and maltreatment, family disruption, family violence, and social service involvement with these children were the rule rather than the exception. Of the 52 children in the group, 39 were nonwhite (mostly black) and 13 were white. Forty of the cases were male and 12 were female. The large majority of the children were from the lowest Hollingshead-Redlich (1958) socioeconomic status categories of 5 and 6, but the indeterminacy of the head of household in many families and the shifting nature of these children's living situations made precise socioeconomic status determinations difficult. Twenty-six of the 52 children (50%) had been subject to physical abuse and/or maltreatment severe enough to warrant outside agency involvement. Their family histories were also strikingly positive for drug and alcohol abuse (also 26 out of 52) and for antisocial personality disorders, although the latter often could not be assessed completely according to DSM-III criteria because of lack of information in the charts. Suicidal ideation and/or behavior was found in 14 of the 52 children within 6 months of admission. Severe assaultive/destructive behavior was found in 19 of the 52 children within 6 months of admission. Child abuse/maltreatment and parental substance abuse were significantly related, such that 18 of the children had histories of both child abuse/maltreatment and parental substance abuse (x 2 = 7.69, df= I, P < 0.01). Many children had more than one of the four preadmission factors; however, except for the child abuse/neglect and parental substance abuse relationship, there were no other statistically significant relationships among the four factors.

This group of multi-problem, severely disordered children presented a challenge to diagnostic assessment. Twenty-two of the children carried a diagnosis of conduct disorder on admission on DSM-III axis I, and many carried multiple diagnoses that included dysthymic disorder, adjustment disorder, major depression, atypical psychoses,atypical pervasive developmental disorder, schizophrenia, and elective mutism. Twelve children were diagnosed as having attention deficit disorder on admission. Results Interrater reliability in the initial assessment of the four preadmission factors was high. Kappa values were as follows: 0.84 for child abuse/maltreatment, 0.81 for parental substance abuse, 0.86 for suicidal ideation/behavior, 1.00 for severe assaultive/destructive behavior. Overall, 29 discharges (56%) were recommended for outof-home placement and 23 discharges (44%) were recommended for in-home placement. Taken independently, each preadmission factor tended to or was significantly associated with out-of-home placement recommendations on discharge (child abuse/maltreatment, x 2 = 3.82, df = I, p = 0.05; parental substance abuse, x 2 = 6.32, df = I, p < 0.02; suicidality, x 2 = 4.04, df = I, p < 0.05; assaultive/destructive behavior, x 2 = 18.4, df = I, p < 0.00 1). These relationships are shown in Table I. The variance accounted for by these four factors in terms of in- or out-of-home placement recommendations was nearly 70% (Somer DYX = 0.835), with the factors of assaultive behavior and parental substance abuse being most influential in predicting outcome. Table 2 indicates the relationship between the number of preadmission factors with recommended placement. Although the numbers of children with zero to four of the factors present in each category is small, there appears to be a clear trend in the table. There were, for example, II children with none of the preadmission factors present; IO of these children were recommended for in-home placement and only TABLE

I. Characteristics of CD.H. Patients

Recommended Disposition

Demographic Characteristics

In Home

Out of Home

15

25 4

Significance"

Sex

NS

Male

Female Race White Nonwhite Preadmission history of: Child abuse/ neglect

8

NS 6 17

7 22

= 0.05

8

18

p

Parental substance abuse

7

19

p< 0.02

Suicidality

3

11

p< 0.05

18

p

Severe assaultive/destructive behavior a

All tests are x 2, df= I.

< 0.001

OUTCOME IN A DAY TREATMENT PROGRAM

one was recommended for out-of-home placement. On the other hand, children with three and four of the factors present were all recommended for out-of-home placement. Children with one and two factors present were in between. Another way of approaching the data is to evaluate which of the four preadmission factors is most important in predicting outcome. This was done through Logistic Regression Analysis. Table 3 provides data indicating that of the four preadmission factors, histories of assaultiveness and parental substance abuse provide the most crucial information required to predict outcome. Admission diagnoses of conduct disorder and attention deficit disorder were common. Yet, whereas conduct disorder diagnoseson admission were significantlyassociated with outof-home placement recommendations (x 2 = 4.44, df = I, P < 0.05), assaultive behavior was more strongly associated with subsequent out-of-home placement recommendations than a diagnosis of conduct disorder. The majority of the children were nonwhite and male, but perhaps because of the small number of white children and girls, definite correlations between these factors and out-ofhome placement recommendations could not be made. The mean length of stay in day treatment for children receiving out-of-home placement recommendations was 17.4 months; whereas the mean length of stay for children receiving inhome placement recommended dispositions was 26.4 months. Discussion

The results indicate that a majority (56%) of children discharged from CO.H. between 1981 and 1985 were recommended for out-of-home placements in residential or inpatient settings. On the other hand, 44% of the children discharged during this time could be recommended for continued home residence and were referred to what were often less structured or restrictive academic or therapeutic settings than CO.H. TABLE

2. No. ofPreadmission Factors and Outcome"

No. of Factors 0 I 2 3 4

Children with Recommended Placement In Home

Out of Home

10 7 6 0 0 29

I 5 13 5 5 23

Total II

12 19 5 5

"x 2 = 19.85, df= 4, P < 0.002 for the association of number of factors with outcome. Because cell expectancies are low, x 2 analysis may not be valid. TABLE

3. Prediction ofOutcome by Logistic Regression Analysis

Preadmission Factor Child abuse Parental substance abuse Suicidality Assaultiveness

x2

p

R

1.52 4.18

0.2181 0.0410

0.00 -0.175

2.36 10.96

0.1244 0.0009

-0.071 -0.354

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Given that nearly all referrals to CO.H. come from local public schools after a child has been in one or more programs for the emotionally or behaviorally disturbed and has been too disorganized or disruptive to function in that setting, the number of children who were discharged from CO.H. to less restrictive environments may be notable, given that a more restrictive placement than CO.H. would have to be an outof-home placement. In contrast, the results of this study may indicate a poorer outcome than those of LaVietes et al, (1965), Gold and Reisman (1970, 1971), and Halpern et al, (1978), who reported that approximately 75% to 80% of the children in their groups returned to community schools. Data about the populations in those studies is limited, however, and no definite conclusions about comparative efficacy of the programs can be drawn. A rather striking finding in this study (which must be viewed as tentative given the small size of the group studied, the retrospective nature of the study, and the limited scope of the data), is the strong association between histories of child abuse/maltreatment, parental substance abuse, suicidal ideation/behavior, and severeassaultive/destructive behavior with discharge recommendations to inpatient hospitalization or residential treatment. This is noteworthy because one of the main goals of day treatment is to keep the child in the home environment. The results ofthis study clearly show that multiproblem, largely minority group children who have nonsubstance abusing parents, who have not been severelyabused or maltreated, and who have not had suicidal ideation/behavior or severe assaultive/destructive behavior, by the criterion of out-of-hospital or residential placements, do extremely well in day treatment. Day treatment programs serving urban minority populations such as those described in this study should be alert to these factors as likely major contributors to failure in day treatment and as indicators for major intervention early in the course of day treatment. In addition, although studies are available that point to parental factors of substance abuse and antisocial personality as being associated with child abuse (Kaplan et al., 1983; Smith, 1984), the authors know of no studies that have previously linked these factors to poor outcome in day treatment. Comparisons of children with suicidal ideation/behavior and assaultive behavior have also been made in inpatients, outpatients, and nonpatients (Pfefferet al. 1980, 1984, 1987). The authors know of no study in which these characteristics have been studied in day treatment patients, however, although their potential importance in predicting outcome may be considerable. This study also raises a number of additional questions. In addition to its reported value as a therapeutic modality that maintains some children in home environments who otherwise might have to be hospitalized or placed in residential treatment programs, day treatment is generally held to be cost effective when compared with inpatient or residential treatment. The current daily reimbursement for day treatment at CO.H. is approximately one third that of inpatient hospitalization. Children in this study were treated for lengthy periods of time. For those with few risk factors who were not severely aggressive and who were recommended for less intensive settings on discharge, the cost of treatment may have been

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reasonable. Residential treatment or hospitalization may have been prevented. One cannot say, however, whether alternative use of these other modalities for these same children would have resulted in earlier improvement and return to the community. For children with a number of risk factors who were likely to be hospitalized or referred to residential treatment on discharge despite lengthy treatment in C.D.H., the program may not have been cost effective. This cannot be stated with certainty, because it is not known whether these children would have done better clinically with earlier treatment in hospital or residential settings. A longer-term prospective study comparing children treated in day treatment settings and children treated in residential or hospital settings would help answer these questions. Additional methodological limitations of this study should be mentioned. The sample size in this study was small and was limited to the population ofjust one center, which had a psychodynamic orientation for the most part. Although the findings were significant for the population of this center, one cannot say that the findings can be generalized to other centers with a different type of patient population or a different treatment approach. If the study had had a larger number of children, the findings mayor may not have remained the same. Race and sex, which were not significant in predicting outcome in this study, may have become significant in a larger sample. The study also considered outcome only in terms of recommended placement for the children on discharge. It could be argued that discharge decisions might have been made by clinicians based on their knowledge of the child's past history rather than on the child's clinical status at discharge or on behavioral changes over time when in treatment. To address these methodological issues further, to provide additional information about the generalizability of these findings to other day treatment programs, and to further address the issue of cost effectiveness of day treatment, a larger, multicenter, prospective study employing standardized behavioral rating instruments, periodic ratings, and an appropriate comparison group (e.g., children in residential treatment) is needed. This type of project is now being planned. In conclusion, this study seems to indicate that day treatment may be effective for certain urban, minority children who are from disorganized, chaotic homes and who present with behavior problems, attention deficit disorder, and im-

pulsivity as assessed by the children's being able to return to a home environment on discharge. On the other hand, day treatment seems to be far less effective for children of similar demographically defined backgrounds if certain preadmission historical factors are present, despite treatment that often is rather lengthy in nature. The factors associated with poor outcome, as assessed by out-of-home recommended placement on discharge, include child abuse/maltreatment, parental substance abuse, suicidality, and severe assaultive/destructive behavior. These findings, if replicated, may have important implications for helping to define admission criteria and helping to devise program strategies for day treatment of disturbed children. References Gold, J. & Reisman, J. M. (1970), An outcome study of a day treatment unit school in a community mental health center. Am. J. Orthopsychiatry, 40:286-287. - - - - (1971), An outcomestudy of a day treatment unit school in a community mental health center. Bulletin of the Rochester Mental Health Center, 3:15-22.

Gudeman,J. E., Dickey, B., Evans, A. & Shore, M. E. (1985), Fouryearassessment of a day hospital-inn program as an alternative to inpatienthospitalization. Am. J. Psychiatry, 142:1330-1333. Halpern, W. I., Kissel, S., & Gold,J. (1978), Day treatmentas an aid to mainstreaming troubledchildren. Community Ment. Health J., 14:319-326.

Hollingshead, A. B. & Redlich, F. C. (1958), Social Class and Mental Illness: A Community Study. NewYork: Wiley. Kaplan, S. J., Pelcovitz, D., Salzinger, S. & Ganeles, D. (1983), Psychopathology of parents of abusedand neglected children and adolescents. J. Am. Acad. Child Psychiatry, 22:238-244. LaVietes, R., Cohen, R., Reens, R. & Ronall, R. (1965), Day treatment center and school: seven years experience. Am. J. Orthopsychiatry, 35:160-169.

Pfeffer, C. R., Conte, H. R., Plutchik, R. & Jerrett, I. (1980), Suicidal behavior in latency-age children: an outpatientpopulation. J. Am. -

Acad. Child Psychiatry, 23:416-423. Zuckerman, S., Plutchik, R. & Mizruchi, M. S. (1984), Suicidal

behavior in normal school children: a comparison with child psychiatricinpatients. J. Am. Acad. Child Psychiatry, 23:416-423. - - Plutchik, R., Mizruchi, M. & Lipkins, R. (1987), Assaultive behavior in child psychiatric inpatients, outpatients, and nonpatients. J. Am. Acad. Child Adolesc. Psychiatry, 26:256-261. Smith, S. L. (1984), Significant research findings in the etiology of childabuse. Social Casework: The Journal ofContemporary Social Work, 65:337-346.

Voineskos, G. (1976), Part-time hospitalization programs: the neglected field of community psychiatry. Can. Med. Assoc. J., 114:320-234.

Zimet, S. G. & Farley, G. K. (1985), Day treatment for children in the United States. J. Am. Acad. Child Psychiatry, 24:732-738.