Effectiveness of a Multimodal Day Treatment Program for Children with Disruptive Behavior Problems

Effectiveness of a Multimodal Day Treatment Program for Children with Disruptive Behavior Problems NATALIE GRIZENKO, M.D., F.R.C.P.(C), DANIELLE PAPINEAU, M.Sc., AND LILIANE SAYEGH, M.ED. Abstract. Objective: Children with disruptive behavior disorders are often also dysfunctional in academics, social skills, and self-esteem. The efficacy of multi modal day treatment in addressing these deficits was evaluated. Method: Thirty children, assigned to day treatment or a waiting list, were compared on measures of behavior, selfperception, academics, peer relations, and family functioning. Results: Multivariate analyses of covariance showed that the treatment group improved significantly more on measures of behavior and self-perception. Six-month follow-up findings indicate that treated children had improved over time on all measures except academics. Conclusions: This study demonstrates that compared with a waiting list control group, day treatment produces greater gains, and that these gains are maintained at 6 months' follow-up. It also shows the need for a treatment that combines multiple modalities in dealing with children with disruptive behavior disorders. J. Am. Acad. Child Adolesc. Psychiatry, 1993,32, 1:127-134. Key Words: day treatment, children, behavior problems. Among children, the most common reasons for referral to psychiatric treatment are disruptive behavior disorders such as attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) (Anderson et aI., 1987). Although classified as separate entities with different types of acting-out behaviors as core diagnostic criteria, these diagnoses have a high degree of comorbidity (Spitzer et aI., 1990). They are widely described as having similar associated secondary problems: affected children often also suffer from impaire<:i social functioning, depression, and low self-esteem, as well as academic underachievement or failure (Donnelly, 1989; Lawrence, 1985; Satterfield et aI., 1979; Westman, 1989). This occurs because these children's behavior is highly disruptive to others, for example, through loudness, impulsivity, open defiance, or destruction of property. As a result, they are at odds with their social environment in school, in the family, and at play, leading others to react punitively or to break contact. This largely negative social response often leads, over extended periods, to the development of a poor self-image as well as to depressive affect (Gard and Berry, 1986; Grizenko and Sayegh, 1990; Kelly et aI., 1989; Patterson, 1976). Because of their short attention span or lack of motivation in school, they often fail to acquire certain skills or to integrate information necessary for later learning. In the long run, these children tend to lag behind their age mates academically (Douglas, 1983). There are many approaches to the treatment of these disor-

Accepted July 22, 1992. From the Lyall Preadolescent Day Treatment Program, Douglas Hospital, and Department of Child Psychiatry, McGill University, Montreal, Canada. This research was supported by grant RS-1649 from the Conseil Quebecois de La Recherche Sociale. We are grateful to Elizabeth Sourial and Deborah Weissberg, M.Ed., for their assistance with the subject assessments and data entry. Reprint requests to Dr. Grizenko, Lyall Pavilion, Douglas Hospital, 6875 LaSalle Blvd., Verdun, Quebec, Canada H4H lR3. 0890-8567/93/3201-0127$03.00/0©1993 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 32:1, January 1993

ders. The most commonly employed target the reduction of deviant behaviors, either through the use of medication (Pelham et aI., 1985), behavior modification (Hersher, 1985), often with the parent being trained in management techniques (Roberts et aI., 1978; Wahler et aI., 1977), or both (Pelham et aI., 1988). The rational is that once the disruptive behaviors come to an end, the associated social and personal consequences will gradually improve without intervention. Unfortunately, this is not always the case. Riddle and Rapoport (1976) found that hyperactive boys treated with methylphenidate over a 2-year period continued, according to their teachers, to experience serious disruption in peer relationships. Pelham and Bender (1982) reported that the combination of behavior therapy and methylphenidate was effective in changing the behavior of children with ADHD but not in normalizing peer relationships. They suggest using of social skills training followed by a contingency management program to ensure that socially acceptable behaviors elicit a positive response. Furthermore, studies with oppositional children have shown that in many cases, training parents to manage the child is not enough. Some parents drop out of treatment, others assimiliate the teaching while in treatment but are unwilling or unable to apply the techniques on their own (Gard and Berry, 1986). These parents have been found to benefit from "parent enhancement therapy" in which their need for help with marital and extrafamilial relationships are also addressed (Griest et aI., 1982). Another cause for concern has been the lack of generalization of acquired skills from one setting to another; typically these children are disruptive both at home and in school. According to Wahler et ai. (1977), successful home intervention usually does not generalize to the school setting and can even increase the level of classroom misbehavior (Johnson et aI., 1976). Therefore, there is a growing consensus that interventions for behavior disorders should target the child's social system as a whole. Garrett and Marler (1989) describe the problems of delinquent children and youth as extensive and interrelated. These authors recommend that agencies target both the delinquency itself and the many associated areas of mal127

GRIZENKO ET AL.

adaptive behaviors exhibited by the child and by members of his or her social system. They conclude that' 'long-term change of delinquent behavior patterns depends on the establishment of ties to structures in the community that will support the youth in a non-delinquent lifestyle." They note that families, peers, schools, and eventually employers should be targeted in a systemic integration effort. To date, alternative treatment approaches addressing both the deviant behaviors and their associated consequences have been used in outpatient settings (Satterfield et aI., 1979, 1981,1987; Winsberg et aI., 1980), in day treatment (Sayegh and Grizenko, 1991; Zimet and Farley, 1991), and in residential treatment (Lyman et aI., 1989). Generally, a multidimensional assessment is followed by the drawing-up and implementation of an individualized multimodal treatment plan for the child and his or her family. Available therapies typically include many of the following: medication; individual, group, couple, and family therapy; as well as parent training to stabilize chaotic home situations. Furthermore, direct intervention in the school or liaison with school personnel is usually initiated. Although it is possible to implement a multimodal treatment program in each of the three mentioned settings, such settings have different advantages and drawbacks. Winsberg et al. (1980) have shown that even severe behavior disorder cases can be managed in the community if enough support is given. In fact, children who were treated in the community rather than in an inpatient setting tended to do better. For example, at 18 months to 3-year posttreatment follow-up, Winsberg et al. (1980) found that 78% of children who had been randomly assigned to outpatient community treatment were still living at home compared with 52% of those assigned to inpatient treatment. Coates et aI., (1978) found that delinquent youth are less likely to recidivate when treated in a more normalized as opposed to an institutional setting. Nevertheless, successful outpatient treatment as provided by Satterfield et al. (1987) requires optimally 2 to 3 years of weekly intervention. The need for such lengthy attendance increases the risk that families will drop out, either because they are poorly motivated to begin with or out of a genuine feeling that enough improvement has been achieved after a full year of treatment. Satterfield et al. (1979) report that of their initial sample of 117 patients, 28% dropped out of treatment in the first year and only 47% completed the 2 or 3 years of treatment. As compared with a residential treatment environment, day treatment offers the advantages of community location and preservation of links to the family and peer group. Unlike outpatient treatment, day treatment is an intensive intervention that, for severely affected children, cuts down on treatment time, reducing the risk of dropouts. Day treatment for children with behavior disorders is a promising modality, its effectiveness however, especially at followup, only recently is being investigated in a rigorous and comprehensive manner. The growing awareness that the problems of behavior disordered children are multidimensional has led to a parallel increase in the sophistication of outcome measures with unidimensional criteria. For example, school reintegration 128

rates have given way to assessments of treatment efficacy that consider the child's psychosocial functioning as well as the responsiveness and adequacy of his or her environment. A one-group, pre-post pilot study (Grizenko and Sayegh, 1990) based on 23 cases (21 boys and 2 girls), was carried out at the same day-treatment center. It demonstrated that children improved mainly in behavior and self-perception. Building on these preliminary findings, the present study sought to determine, in a nonoverlapping sample, the effectiveness of a multimodal day-treatment program in reducing the expression of acting-out behaviors and in improving the self-concept, family, social and academic functioning of children with disruptive behavior disorders, as compared with a waiting list control group. Continued treatment efficacy was ascertained at 6-month follow-up on the same variables. Methods Experimental Design

A quasi-experimental design was used with sequential assignment to groups, the treatment group being filled first. Children in the waiting-list group were offered treatment as soon as space became available. While on the waiting list, one child received methylphenidate, one parent was being observed for depression by her general practitioner, and another child's parents were in couple therapy. These treatments were ongoing at the intake assessment. No new psychiatric or psychological treatments were initiated during the waiting period by control group participants. Two research assistants, blind as to treatment modality and assessment period, conducted the testing. A mixed model design was used to compare the two groups with repeated measures at intake and discharge (in the week preceding treatment entry for those on the waiting list). A repeated measures design was used to compare the treatment group's evolution over time with measures being collected at intake, discharge, and 6-month follow-up. Population

Participants in this study included 30 children seeking admission to a day-treatment program. Children met the following admission criteria: age between 5 and 12 years; normal intelligence; a DSM-III-R (American Psychiatric Association, 1987) diagnosis of attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, or adjustment disorder with disturbance of conduct; willingness of the parent(s) to participate in family therapy; no neurological or physical disorder that would limit participation; not being too physically aggressive or suicidal to participate in day treatment. Children with a diagnosis of psychosis, severe developmental delay, or autism were referred to a different unit in the hospital. The sample included 23 boys and seven girls, with a mean age of 9 (SD = 1.7) at admission and a mean WISC-R full scale score of 100 (SD = 16). The DSM-III-R diagnosis was obtained using the following information: (1) the intake assessment report based on an interview with the family and the child conducted by the psychiatrist (N. G.), (2) school J. Am. Acad. Child Adolesc. Psychiatry, 32: 1,January 1993

EFFECfrVENESS OF DAY TREATMENT FOR CHILDREN

records, (3) information from the referring agency. Each chart was reviewed independently by two of the authors (N. G. and D. P.). Mter the ratings were completed, cases in which there was disagreement were reviewed by the same two clinicians, agreement was then reached by consensus, based on joint chart reviews and discussion. Interrater reliabilitywas calculated'over all diagnostic categories by dividing the number of agreements by the sum of agreements and disagreements. It was found to be 0.93. Primary diagnoses were: (1) treatment group: five ADHD, nine ODD, and one conduct disorder, (2) control group: three ADHD, nine ODD, two conduct disorder, and one adjustment disorder with disturbance of conduct. Children were referred to the program because they were no longer able to function in their home and school settings. Sixty percent of the children were referred by their school; 37% were referred by a social worker or by outpatient services, and the remaining 3% by another day-treatment facility. At admission, 13% (N = 4) of the children were in foster care, and 87% (N = 26) lived at home. Twenty-seven percent had been permanently expelled from school, 33% were in a special class or a special school, and 40% still attended a regular classroom program in their community school, although many of these children were on the verge of expulsion. Forty-seven percent of the children came from families with a combined yearly income of $20,000 or less, and 53% from single parent families. The children attended the program for a period of 4.4 months on average (SD = 1.3) or remained on the waiting list for a mean 3.9 months (SD = 1.2). This difference was not significant. Preliminary analyses were run to examine whether the groups were comparable at intake. They were found to be similar in terms of diagnosis, severity of distress as measured by the Child Global Assessment Score (Shaffer et aI., 1983), WISC-R full scale score, referral source, prevalence of single parents, and family income. The age at admission into the study was significantly different: children in the control group were younger on average (F = 4.5, dj1, 28, P < 0.05). To take this discrepancy into account, age was used as a covariate in all subsequent analyses. The two groups' tests scores at intake were similar with the exception of scores on the Index of Peer Relations (F = 7.74, df 1, 28,p < 0.01) with treatment group children experiencing more distress in this area, although each group's average score was situated in the problem zone. Setting

The preadolescent day-treatment program provides multimodality therapy with a psychodynamic orientation. The aim is to reintegrate the children to the community as soon as possible. The program specializes in the treatment of children who exhibit disruptive behavior. It can concurrently accommodate 15 children. Activities consist of a daily 2.5-hour block of special education and a 3-hour block of psychotherapy including individual play therapy, social skills and task groups, psychodrama, pet, art, occupational, and group therapies. Family therapy using an integrative approach (Nichols and Everett, 1986) is conducted weekly. Children are grouped J. Am. Acad. Child Adolesc. Psychiatry, 32: 1, January 1993

according to age, with a maximum of five children per class or therapy group. Education is under the direction of the local school board. All teachers have been trained in special education and the curriculum follows that of public school classes. The overall staff-patient ratio is 1 to 2.5. Medication (methylphenidate) is used when indicated. Treatment is administered and monitored weekly by a multidisciplinary team including a psychiatrist, psychologists, nurses, social worker, occupational therapist, teacher, and child care workers. To facilitate reentry at the end of treatment, child care workers visit the school once or twice to discuss each former patient's situation with the teacher. Family therapy also is offered at lengthening intervals for up to two months postdischarge. Treatment goals vary depending on individual needs but usually include: getting the child to express feelings verbally instead of through acting-out behaviors, setting limits on disruptive behavior, trying to understand how the family system maintains the child's deviant behaviors, developing the child's socialization and communication skills, increasing self-esteem, and improving scholastic performance. Measures

The children were assessed using standardized questionnaires to evaluate behavioral, self-perception, peer relationships, and family and academic variables. A questionnaire concerning the child's history and family demographic variables also was completed at intake. Behavior was assessed using the Revised Child Behavior Profiie (RCBP), as completed by the parent. The RCBP (Achenbach and Edelbrock, 1983), a 113-item questionnaire measures internalizing and externalizing behaviors. Norms were developed using a group of 1,300 children. Test-retest reliability of mother's report, over one week was r = 0.89. Both construct and content validity are high. Scores over 69 indicate dysfunction. Self-perception and peer relationships were assessed using self-report scales administered to the children. The following scales, described in Corcoran and Fisher (1987), were used to measure self-perception. (1) The Hare SelfEsteem Scale (HSES), consisting of three lO-item subscales evaluating peer, school, and home self-esteem, test-retest reliability over 3 months was r = 0.74. The test has good concurrent validity with a correlation of 0.83 with both the Coopersmith Self-Esteem Inventory and the Rosenberg SelfEsteem Scale. Scores of 90 and below fall in the problem range. (2) The I8-item Depression Self-Rating Scale (DSR), with internal reliability of 0.73 and 0.86 in two studies. Testretest reliability was 0.80. There is good concurrent validity, r = .81 with the Children's Depression Inventory. Scores greater than 13 indicate problems. (3) The Hopelessness Scale for Children (HSC), a 17-item instrument. High scores on the HSC have been shown to be related to depression and low self-esteem. Internal reliability using the a coefficient was reported to be 0.71. Scores of 5 or more are considered abnormally elevated. Peer relationships were measured using (1) the Index of Peer Relations (IPRYa 25-item scale with an internal reliability coefficient of 0.94 (Corcoran and Fisher, 1987), (2) the

129

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Matson Evaluation of Social Skills with Youngsters (MESSY), a 62-item scale measuring five factors: appropriate social skills, inappropriate assertiveness, impulsive behavior, overconfidence, and jealousy/withdrawal (Matson et aI., 1983). Scores more than 34 on the IPR and more than 140 on the MESSY fall in the problem range. Family functioning was evaluated using the General scale of the Family Assessment Measure (FAM), administered to one parent and to the child. This 50-item scale (Skinner et aI., 1983) ascertains strengths and weaknesses within the family system in seven areas. Normative data was based on the scores of 312 persons. Internal reliability estimates for the items contributing to the total score were in the low 0.90s for both parents and children from 475 normal and troubled families. On the General scale, standardized scores between 40 and 59 fall in the normal range and scores of 60 and more indicate problems. Academic performance was measured with the Wide Range Achievement Test-Revised (WRAT-R) (Jastak and Wilkinson, 1984; Woodward et aI., 1975). Internal reliability is high, ranging from 0.90 to 0.95 for the three subtests. Validity is also high with WRAT-R levels and mid-term grades showing a correlation of r = 0.88. Standardized scores between 80 and 89 indicate low average performance, 70 to 79 borderline functioning, and scores of 69 and below are deficient. The success of scholastic reintegration was measured on a 4-point ordinal scale: 1 = regular class in a regular school, 2 = special class in a regular school, 3 = specialized facility providing either day or inpatient treatment, 4 = expelled from school. Results GROUP COMPARISONS

Test Scores

Multivariate analyses of covariance were run to study treatment effects in five spheres of interest, as discussed below. Because the groups were assigned to treatment sequentially rather than at random, initial scores on the relevant dependent variables were used as covariates in the analyses. Age at admission also was added as a covariate inasmuch as the groups differed on this variable, and it has been shown that age can be a factor in predicting success in day treatment (Grizenko and Sayegh, 1990). Means and standard deviations for the groups' test scores are regrouped in Table 1. Behavioral functioning. Reports on the child's behavior, as measured by the RCBP, were obtained from a parent at intake and discharge. At intake, both groups of children had scores in the problem range. At discharge, only the average score of treated children had moved to the normal zone. To test for treatment effects on behaviors, a MANCOVA was run with the externalizing and internalizing subtotal standardized scores as dependent variables. The treatment group was found to have improved significantly more than the waiting-list group on the combination of these variables, using Hotelling's T 2 criterion, F = 30.97, df = 2,24, p < 0.0001. Univariate F statistics showed that both scores had 130

improved (F externalizing = 59.0, F internalizing = 46.2, = 1,25, p < 0.0001). An ANCOVA with the RCBP total score as the dependent variable was also significant (F = 90.24, df = 1,26, P < 0.0001). Self-perception. The children's self-reports were obtained on measures of self-esteem, depression, and hopelessness. At intake, the scores of both -groups were in the problem zone for self-esteem and hopelessness. At discharge, treated children had normal scores for these tests, although control group scores remained abnormally elevated. A MANCOVA was run with scores on the HSES, DSR, and HSC as dependent variables. Significant differences emerged using Hotelling's T2 criterion, F = 8.16, df = 3,22, P < 0.001. Univariate F tests revealed significant treatment effects for all three variables taken separately, F (HSES) = 25.0, p < 0.0001; F (DSR) = 7.42, p < 0.02; F (HSC) = 11.03, df = 1,24, p < 0.002. Peer relations. The children's self-reports were obtained on two measures of the quality of peer relationships, the IPR and the MESSY. At intake, control group children's scores were slightly elevated on both indices; treatment group children had scores in the problem area for the IPR only. By the end of treatment, all scores had moved out of the problem zone. A MANCOVA was run with scores on these two tests as dependent variables. No group differences were found. Family functioning. The children's and parents' reports were obtained using the FAM-III general scale. Mean scores remained normal for both groups at all times. A MANCOVA was run using the parents' and the children's FAM-III scores as dependent variables. No treatment effects were found. Academic performance. The children's knowledge of reading, spelling, and arithmetic was ascertained using the WRAT-R. Initial mean standardized scores showed that the children were underperforming in terms of their age cohort: average percentiles varied from a low of 5% in spelling (treatment group) to a high of 30% in reading scores (control group). A MANCOVA was run using standardized scores in each of the three areas as dependent variables. No group differences were found.

df

School Reintegration

This variable was coded on an ordinal scale, therefore, two Mann-Whitney U tests were performed to compare the groups at intake and discharge. There were no initial differences. At the discharge assessment, however, the treatment group had a significantly better school reintegration ranking (z = 3.21, p < 0.001). TREATMENT GROUP OVER TIME

Test Scores

Doubly multivariate analyses of variance (Tabachnick and Fidell, 1989) were run to study treatment effects in the five spheres of interest, as discussed below. Six-month follow-up results were based on the scores of 14 children because one child could not be located. All test scores fell in the normal range at follow-up, except scores on the WRAT-R which fell in the low average range. Behavioral functioning. A MANOVA was run comparJ. Am. Acad. Child Adolesc. Psychiatry, 32: 1, January 1993

EFFECTIVENESS OF DAY TREATMENT FOR CHILDREN TABLE I. Means and Standard Deviations (SD) a/Test Scores/or Treatment (N

=

15) and Control (N

Treatment Group Intake Test Behavior RCBP Total Externalizing Internalizing Self-perception HSES DSR Hopelessness Peer relations Peer Index MESSY Family functioning FAM General scale Parent total Child total Academics WRAT-R Reading Spelling Arithmetic

(SD)

82 81 77

(4.6) (4.3) (4.3)

73 10 7

15) Groups

Control Group Discharge

X

=

X

Intake

Discharge

(SD)

X

(SD)

X

(SD)

60 61 60

(8.4) (8.6) (8.3)

82 79 75

(4.1) (5.4) (4.0)

78 77 73

(5.3) (5.4) (5.7)

(13.7) (5.4) (2.1)

93 5 4

(13.2) (3.5) (2.1)

79 12 5

(10.9) (5.3) (3.4)

82 II 6

(9.3) (5.9) (4.3)

60 121

(31.4) (28)

21 106

57 54

(8.4) (5.3)

50 50

81 75 85

(16.4) (15) (10.3)

79 75 83

(25) (31)

34 142

(18) (27)

30 135

(5.7) (6.9)

52 56

(10) (6)

53 56

(9.4) (6.2)

(15) (12.2) (14.1)

92 85 90

(23.4) (16.8) (17.7)

93 86 88

(19) (13.8) (16)

(18) (23 )

Note: RCBP = Revised Child Behavior Profile, HSES = Hare Self-Esteem Scale, DSR = Depression Self-Rating Scale; MESSY = Matson Evaluation of Social Skills with Youngsters; FAM = Family Assessment Measure; WRAT-R = Wide-Range Achievement Test-Revised.

ing the RCBP total scores at the three assessment periods. The multivariate F, using Hotelling's T 2 criterion, was highly significant (F = 127.6, df = 2,12, p < 0.0001) with . children's scores improving over time. A further analysis showed that scores remained significantly lower at 6-month follow-up (X = 58, SO = 10.4) than at intake (F = 98.5, df = 1,13, p < 0.0001). A second MANOVA was used to analyze the change in externalizing and internalizing subtotals over the three time periods, showing a significant reduction in deviant behaviors (F = 43.9, df= 4, lO,p < 0.0001). Self-perception. A MANOVA, using Hotelling's T2 criterion, was used to analyze the combined change in the three test scores over the three time periods (F = 9.1, df = 6,8, p < 0.003), showing improvement over time. A further analysis showed that scores remained significantly lower at follOW-Up (HSES: X = 94, SO = 12; HSC: X = 4, Sp = 2.5; OSR: X = 6, SO = 3.9) than at intake (F = 10.2, df = 3,11, p < .002). Peer relationships. A MANOVA used to analyze the change in scores on the two peer relation measures (lPR, MESSY) over the three time periods revealed significant improvement using Hotelling's T 2 criterion (F = 13.03, df = 4,9, p < 0.001). Comparisons between initial and followup scores (IPR: X = 20, SO = 16; MESSY: X = 110, SO = 41.3) showed that improvement was maintained at followup (F = 16.5, df = 2,12, p < 0.001). Family functioning. A MANOVA used to analyze the combined evolution of the child and parent's scores over time showed significant overall improvement using Hotelling's T2 criterion (F = 7.1, df= 4,9,p < 0.01). Comparisons between initial and follow-up scores (parent: X = 50, l. Am. Acad. Child Adolesc. Psychiatry, 32: 1, January 1993

SO = 6.3; child: X = 51, SO = 7.4) showed that improvement was maintained at follow-up (F = 11.2, df = 2,11, p < 0.002). Academic performance. A MANOVA was used to analyze the change in the three WRAT-R subscores over time. No difference was found. Average standardized scores on all three test scores were highest at 6-month follow-up, although they remained below the 20th percentile. School Reintegration

This variable was coded on an ordinal scale, two Wilcoxon Matched-pairs Signed-ranks tests were performed comparing the type of school attended at intake with the type of school attended at discharge and at follow-up. After treatment, the children were reintegrated into community schools to a significant extent (z = 2.54, p < 0.01) and remained so at 6-month follow-up (z = 2.5, p < 0.01), as illustrated in Figure 1. Discussion Group Comparisons

As expected, both groups of children presented with problems in the areas of behavior, self-perception, peer relations, and academics. Family functioning was rated in the normal range by both parents and children. Clinical experience with the families in therapy, however, revealed the presence of problem areas in the parent-child relationship. Families often tend to minimize systemic problems and to focus instead on the difficulties in the relationship with the identified patient (Nichols and Everett, 1986). Accordingly, the FAM

131

GRIZENKO ET AL. 80% , - - - - - - - - - - - - - - - - - - - - - - - , 70%

·---------------·----------64%---- - . 60%

60% 50% 40% 30% 20% 10% 0%

Intake _

Regular class

~ Special school

Discharge

Follow-up

~ Remedial class •

Expelled

FIG. I. Type of school attended by day treatment group.

General scale may underestimate certain problems, inasmuch as family members are asked to give a rating based on family interactions as a whole, including relationships between parents and unaffected siblings. Recent reports from studies using the FAM suggest that in clinical studies, the dyadic scale of the FAM, which focuses on the parentchild dyad per se, is more sensitive than is the General scale in highlighting problems in the affected child's relationship with his or her parents (Bernstein et ai, 1990; Schachar and Wachsmuth, 1991). These studies have used both FAM scales to uncover areas of dysfunction. Attendance in the day program led to a significant reduction in the children's expression of maladaptive externalizing and internalizing behaviors, as compared with children in the control group. Standardized behavior scores for the treated children progressed from the problem to the normal range although those of untreated children remained abnormally elevated. Treatment also had a significant effect in ·terms of self-perception: the children reported higher selfesteem, lower depressive affect, and an improved outlook on their future. These changes reflect the strengths of our multimodal program, with its dual emphasis on behavioral management within the context of academic and task groups, and on psychodynamics within the context of individual and group psychotherapies. On the other hand, no group differences were found in the areas of peer relations, family functioning, and academics. There was some improvement in peer relations for the treated children but not enough to reach significance when compared with the control group. This suggests that our program's social skills training activities should be revised and strengthened. Furthermore, the 2.5 daily hours of schooling provided in day treatment were enough to maintain the children at their initial level of performance relative to their age group but not to improve it. There is much evidence that improving academic functioning should be considered a long term goal. Reviews of day-program outcome report that behavioral functioning improves more than do academics while the children are in treatment (Baenen et aI., 1986; Sayegh and Grizenko, 1991; Zimet et aI., 1985). For example, Cramer Azima et al. (1989) stated that a group of children attending their day program for an average of 2 years progressed 1.5 years in their grade level, suggesting that they were barely 132

keeping up with their grade level. Winsberg et al. (1980) noted that academic gains in their program "were considered trivial from the standpoint of remediation." Although behavioral improvements are immediately noticeable in a child's environment, age-appropriate academic performance implies catching up on cognitive skills and prerequisites that have been poorly assimilated earlier (Douglas, 1983). This process requires time and much effort on the child's part. Nevertheless, there was a significant difference in the groups' school integration rate at the end of the study period. The treated children's behavior had improved enough for readmittance into a community school, in a regular or remedial class. In the long run, these children may catch up academically if their behavioral performance remains stable. Academic success and acceptance by the peer group in school are also crucial if the child is to retain an improved self-perception. Evolution of the Treatment Group Over Time

Significant improvements, maintained at 6-month followup, were noted in terms of deviant behaviors, self-perception, peer relations and family functioning, as well as in school reintegration. As for academic performance, the children retained a stable and below average position (at the 20th percentile or less) for their age group. These findings confirm those of a pilot study with a similar group of children (Grizenko and Sayegh, 1990). Although significant improvement was then reported in all spheres at discharge, academic improvement was less extensive than was behavioral improvement. The present study reports continued treatment efficacy at 6-month follow-up, indicating lasting change at home, in the school (as evidenced by the child's maintenance in a community school), and in the child's selfperception. Part of this success can be attributed to the treatment program itself and its lasting effects on both the child and the family. In addition, successful school integration necessitated both an enlightened choice based on the child's observed capacities and the establishment of close links with school personnel and administrators. Parents and children were offered a few follow-up sessions to facilitate the posttraumatic transition. Although they did not progress significantly over time, the children's academic scores relative to their age cohort were highest at the 6-month followup. Inasmuch as these scores tend to improve more slowly, this is an encouraging finding. Data to be collected at future follow-up assessments will provide a more comprehensive assessment of the program's effectiveness at this level. Efforts at coordination between the different components of a child's environment are in direct contrast to the situation that prevailed in the days when residential treatment of severe behavior disorders was the norm. Children were then repeatedly removed from their home and displaced to residential treatment some distance away to be sent back when insurance funds ran out (Hamm, 1989). Recent experience in community psychiatry has demonstrated the benefits to be accrued from strategies that maximize continuity of care and communication between the therapeutic and community milieu (Meyerson and Herman, 1983), and from the proviJ. Am. Acad. Child Ado/esc. Psychiatry, 32: 1,January 1993

EFFECTIVENESS OF DAY TREATMENT FOR CHILDREN

sion of transitional aftercare services following intensive treatment (Pfeiffer and Strzelecki, 1990). The present study's outcome compares favorably to the results obtained by Satterfield et aI. (1979, 1981) in outpatient treatment. Both programs used a multimodal treatment with similar individual, group, and family psychotherapeutic interventions. Because the day treatment was intensive, however, children were ready for discharge well within the same academic year whereas the treatment of Satterfield et aI. stretched over 3 years. This resulted in a much lower dropout rate in the present program with only one child leaving treatment earlier than planned because her father believed she had made enough progress. Although this study's 6-month follow-up is not comparable to the 8year follow-up data gathered by Satterfield et aI. (1987), these early findings are in the anticipated direction and are encouraging.

Conclusion The present study demonstrates that, compared with a waiting list control group, multimodal treatment for a psychiatric population of children with disruptive behavior disorders produces greater gains. Treatment gains were maintained at a 6-month follow-up. This is an improvement over many studies in the day-treatment literature that do not include a control group or follow-up results (Grizenko and Sayegh, 1990; Sayegh and Grizenko, 1991), and that report the outcome of mixed populations of developmentally delayed, emotionally, or behaviorally disturbed children (Cohen et aI., 1987). On the other hand, the fact that the groups were sequentially rather than randomly assigned is a limitation that may have affected the comparability of the two groups. Children who were referred to the program later in the academic year and were placed on the waiting list may have been perceived differently by their parents or by school personnel than were those referred earlier who formed the treatment cohort. Although the groups were similar at intake, and a statistical correction was introduced by using the initial test score as a covariate, random assignment to groups would have been preferable. Future studies should find a way to address this issue, perhaps through intensive recruitment. This study also presents a rationale for the necessity of a treatment approach combining multiple modalities when dealing with disruptive behavior disorders. The contention that affected children present deficits in the behavioral, affective, and social spheres was largely supported by the intake assessment of the 30 cases seeking admission to the program. The present analysis leads to the following recommendations for additional investigation. It would be interesting to compare directly the outcome over several years of outpatient and day treatment for children with behavior disorders. Such comparisons could be undertaken by randomly assigning children who meet criteria for day treatment to either of these two treatment modalities. Furthermore, the use of behavioral observations and of process measures would give a much fuller picture of day treatment, when coupled with measures of outcome (Pinsof, 1989). J. Am. A cad. Child Adolesc. Psychiatry, 32: 1, January 1993

It is also important to study the long-term effectiveness of day treatment in view of the fact that children with disruptive behavior disorders are at high risk for developing juvenile delinquency in adolescence (Huessy et aI., 1974) and major dysfunctions in adulthood (Kazdin et aI., 1989). Because day-treatment programs are usually small, data from multiple cohorts of children treated in different years must be aggregated. To do this, stability of treatment effects over several cohorts will need to be achieved and demonstrated. Day treatment is an expanding treatment modality that shows great promise. Clinical advances in this area are being evaluated through the use of more rigorous research methodologies. Time will tell whether such intensive intervention affects recidivism rates as treated children grow into adolescence and adulthood.

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