- Email: [email protected]
Outcome Assessment in Residential Treatment
BOOK REVIEWS
is the fine tuning of this concept. This presentation calls for more studious knowledge of phases of development, especially in the cognitive realm. For example, the effectiveness of interpretation as a change process may be moderated by the child's cognitive developmental level. The therapist's use of interpretation that connects current beh avior or emotion to internal processesor past events that may also be outside the child's awareness is incongruent with the child's tendency to focus on situational and temporal proximal explanations for behavior or emotions. The discrepancy between the therapist's level of casual understanding and the child's level of casual reasoning may render many interpretations incomprehensive to children. The developmental level can moderate the effectiveness of specific interventions. Therefore, in designing interventions for children, the therapist must consider the developmental parameters of their interventions. This presentation gives us much food for thought, calling us back to lessons that we had learned previously and are in jeopardy of forgetting. The authors implore us to incorporate concepts of process, case formulation, and child development, including language and cognition, to enhance the effectiveness of our work. I thank Drs. Shirk and Russell for their dialog with us. David W Cline, M.D. Clinical Professor Department of Psychiatry University of Minnesota Medical School, Minneapolis
Outcome Assessment in Residential Treatment. Edittd by Steven 1. Pftiffir, Ph.D., A.B.RR Ntw York: Tht Hayworth Press, Inc. , 1996, 99 pp., $29.95 (hardcover). In his preface, Dr. Pfeiffer emphasizes the monumental importance of clinical outcome research in residential treatment of children and adolescents. The necessity of documenting the efficacies of outcome are described not only in the context of improved quality of treatment but in the wider realm of politics, health care industry, and society at large. The purposes of the book include education of clinicians and researchers regarding the history of clinical research in residential settings, demonstration of the importance of clinical outcome studies, and practical suggestions for designing scientificallysound and clinically useful studies. In their introductory chapter, Pratt and Moreland provide an extensiveliterature reviewbeginning with a brief history of child and adolescent inpatient treatment. The value of treatment and measurement of treatment success or failure are described as particularly relevant in today's society and
1480
current climate of health care policies and managed care. Pratt and Moreland provide a thorough discussion of the literature, focusing on the range of variablesstudied previously, common research design flaws, and the difficulty in interpreting meta-analysis studies of outcomes. Differences between treatment provided in research settings versus clinical practice are noted as relevant to improved outcomes, but the reader is reminded that effective treatments and techniques may be subsequently introduced co general clinical practice. The authors provide a thoughtful discourse on the difficulties inherent in operationalizing clinical improvement as well as the source and timing of assessment. A number of assessment tools are described, including the Devereaux Scale of Mental Disorders (DSMD) , which is analyzed in more detail in the last chapter of the book. The authors discuss the difficulties inherent in the study of outcome in children reinforcing the complexities of family dysfunction, the difficulty in defining normal from abnormal in light of child development, the frequency of comorbid psychiatric disorders, and issues of informed consent. The chapter concludes with suggestions for future research, which nicely sets the stage for the remainder of the book. The second chapter, by Green and Newman, introduces a novel and pragmatic approach co identifying optimal outcome assessment tools for residential studies . Green and Newman propose a five-step processfor evaluating assessment tools, suggesting that each step optimally be performed in order. The steps include (1) deciding what to measure; (2) identifying unwanted effects to measure; (3) developing an assessment plan that covers all areas of assessment; (4) identifying the assessment instruments that fit the plan; and (5) evaluating rival instruments within an area by applying the ideal outcome measure criteria. Each step is discussed in detail with the intended goal being a best fit between the variables measured, the setting, the source, and the instrument or instruments chosen. Step 5, evaluating rival instruments, consists of 11 individual criteria ranging from psychometric strengths to low cost and the ability to be understood by a nonprofessional audience. Green and Newman have developed an ingenious schema to guide the researcher in selecting the most appropriate and scientificallysound instrument for the task at hand . The five-step process is nicely illustrated with a hypothetical example, including a schematic diagram of step 1 and a table illustrating a clinical example of step 3. Commonly used assessment instruments are discussed by Zimmerman in chapter 3. The chapter begins with a brief discussion of the importance of outcome research and proceeds directly to a concise description of selected structured interviews, rating scales, and objective and projective personality inventories. The chapter includes useful references for more in-depth investigation of assessment tools.
}. AM. ACAD . C H I LD ADOLESC. PSYCHIATRY, ,36: 10, OCTOBER 199 7
BOOK REVIEWS
Pfeiffer and Shott tie the preceding information neatly together with a broad-based chapter on conducting outcome research in the modern institutional setting. The authors encourage researchers to "start small" with straightforward projects before progressing to more sophisticated outcome projects. Suggestions on practical issuessuch as promotion of involvement and shared "ownership" by staff members, clients, and family are often overlooked but vital components to the success of most projects. The authors provide practical and novel approaches to these issues. Hints and suggestions are provided for handling the logistics of project development, including data collection and data analysis. The ethical issues inherent in outcome research are discussed in a concise but thorough format. Throughout the fourth chapter, Pfeiffer and Shott provide useful discussion of issues such as setting realistic goals, securing technical assistance, and linking outcome projects with continuous quality improvement efforts. The authors reveal a wealth of practical knowledge that should prove invaluable to the beginning researcher. The final chapter describes the DSMD, which is a useful outcome assessmenttool. The scale is comprised of 10 clinical indices, including a total scale score composed of three components and six first-order scales. The advantages of the scales include their statistical reliability and measures indicating whether change is clinically meaningful. Clinical outcomes have been operationalized to assess a given score to
J.
indicate "optimal," "very favorable," "favorable," "equivocal," or "negative" outcomes. LeBuffe and Pfeiffer, who contributed to the development of the DSMD, point out that by the scales' reliability, change can be interpreted as occurring by means other than chance. By its measures of clinical meaningfulness, one can gain some insight regarding the impact of treatment on client functioning. That the author/editor has chosen to conclude the book with this chapter is somewhat curious, as it would seem to fit more logically after Zimmerman's discussion of common assessment instruments. This is a minor point. In summary, the text is concise, well organized, and clearly written. The editor succeeds in packaging a substantial amount of useful information into a relativelysmall volume. This volume should serve beginning researchers well in designing scientifically sound and clinically useful outcome studies of residential treatment in children and adolescents. Dwight V. Wolf, M.D. Assistant Professor of Psychiatry and Behavioral Sciences Department of Psychiatry University of Texas Medical Branch, Galveston
Note to Publishers: Books for reuieu: should b~ sent to Dean X Parmelee, M.D.• Division of Child & Adolescent' Psychiatry. PD. Box980489, Richmond. VA 23298-0489.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:10. OCTOBER 1997
1481
is the fine tuning of this concept. This presentation calls for more studious knowledge of phases of development, especially in the cognitive realm. For example, the effectiveness of interpretation as a change process may be moderated by the child's cognitive developmental level. The therapist's use of interpretation that connects current beh avior or emotion to internal processesor past events that may also be outside the child's awareness is incongruent with the child's tendency to focus on situational and temporal proximal explanations for behavior or emotions. The discrepancy between the therapist's level of casual understanding and the child's level of casual reasoning may render many interpretations incomprehensive to children. The developmental level can moderate the effectiveness of specific interventions. Therefore, in designing interventions for children, the therapist must consider the developmental parameters of their interventions. This presentation gives us much food for thought, calling us back to lessons that we had learned previously and are in jeopardy of forgetting. The authors implore us to incorporate concepts of process, case formulation, and child development, including language and cognition, to enhance the effectiveness of our work. I thank Drs. Shirk and Russell for their dialog with us. David W Cline, M.D. Clinical Professor Department of Psychiatry University of Minnesota Medical School, Minneapolis
Outcome Assessment in Residential Treatment. Edittd by Steven 1. Pftiffir, Ph.D., A.B.RR Ntw York: Tht Hayworth Press, Inc. , 1996, 99 pp., $29.95 (hardcover). In his preface, Dr. Pfeiffer emphasizes the monumental importance of clinical outcome research in residential treatment of children and adolescents. The necessity of documenting the efficacies of outcome are described not only in the context of improved quality of treatment but in the wider realm of politics, health care industry, and society at large. The purposes of the book include education of clinicians and researchers regarding the history of clinical research in residential settings, demonstration of the importance of clinical outcome studies, and practical suggestions for designing scientificallysound and clinically useful studies. In their introductory chapter, Pratt and Moreland provide an extensiveliterature reviewbeginning with a brief history of child and adolescent inpatient treatment. The value of treatment and measurement of treatment success or failure are described as particularly relevant in today's society and
1480
current climate of health care policies and managed care. Pratt and Moreland provide a thorough discussion of the literature, focusing on the range of variablesstudied previously, common research design flaws, and the difficulty in interpreting meta-analysis studies of outcomes. Differences between treatment provided in research settings versus clinical practice are noted as relevant to improved outcomes, but the reader is reminded that effective treatments and techniques may be subsequently introduced co general clinical practice. The authors provide a thoughtful discourse on the difficulties inherent in operationalizing clinical improvement as well as the source and timing of assessment. A number of assessment tools are described, including the Devereaux Scale of Mental Disorders (DSMD) , which is analyzed in more detail in the last chapter of the book. The authors discuss the difficulties inherent in the study of outcome in children reinforcing the complexities of family dysfunction, the difficulty in defining normal from abnormal in light of child development, the frequency of comorbid psychiatric disorders, and issues of informed consent. The chapter concludes with suggestions for future research, which nicely sets the stage for the remainder of the book. The second chapter, by Green and Newman, introduces a novel and pragmatic approach co identifying optimal outcome assessment tools for residential studies . Green and Newman propose a five-step processfor evaluating assessment tools, suggesting that each step optimally be performed in order. The steps include (1) deciding what to measure; (2) identifying unwanted effects to measure; (3) developing an assessment plan that covers all areas of assessment; (4) identifying the assessment instruments that fit the plan; and (5) evaluating rival instruments within an area by applying the ideal outcome measure criteria. Each step is discussed in detail with the intended goal being a best fit between the variables measured, the setting, the source, and the instrument or instruments chosen. Step 5, evaluating rival instruments, consists of 11 individual criteria ranging from psychometric strengths to low cost and the ability to be understood by a nonprofessional audience. Green and Newman have developed an ingenious schema to guide the researcher in selecting the most appropriate and scientificallysound instrument for the task at hand . The five-step process is nicely illustrated with a hypothetical example, including a schematic diagram of step 1 and a table illustrating a clinical example of step 3. Commonly used assessment instruments are discussed by Zimmerman in chapter 3. The chapter begins with a brief discussion of the importance of outcome research and proceeds directly to a concise description of selected structured interviews, rating scales, and objective and projective personality inventories. The chapter includes useful references for more in-depth investigation of assessment tools.
}. AM. ACAD . C H I LD ADOLESC. PSYCHIATRY, ,36: 10, OCTOBER 199 7
BOOK REVIEWS
Pfeiffer and Shott tie the preceding information neatly together with a broad-based chapter on conducting outcome research in the modern institutional setting. The authors encourage researchers to "start small" with straightforward projects before progressing to more sophisticated outcome projects. Suggestions on practical issuessuch as promotion of involvement and shared "ownership" by staff members, clients, and family are often overlooked but vital components to the success of most projects. The authors provide practical and novel approaches to these issues. Hints and suggestions are provided for handling the logistics of project development, including data collection and data analysis. The ethical issues inherent in outcome research are discussed in a concise but thorough format. Throughout the fourth chapter, Pfeiffer and Shott provide useful discussion of issues such as setting realistic goals, securing technical assistance, and linking outcome projects with continuous quality improvement efforts. The authors reveal a wealth of practical knowledge that should prove invaluable to the beginning researcher. The final chapter describes the DSMD, which is a useful outcome assessmenttool. The scale is comprised of 10 clinical indices, including a total scale score composed of three components and six first-order scales. The advantages of the scales include their statistical reliability and measures indicating whether change is clinically meaningful. Clinical outcomes have been operationalized to assess a given score to
J.
indicate "optimal," "very favorable," "favorable," "equivocal," or "negative" outcomes. LeBuffe and Pfeiffer, who contributed to the development of the DSMD, point out that by the scales' reliability, change can be interpreted as occurring by means other than chance. By its measures of clinical meaningfulness, one can gain some insight regarding the impact of treatment on client functioning. That the author/editor has chosen to conclude the book with this chapter is somewhat curious, as it would seem to fit more logically after Zimmerman's discussion of common assessment instruments. This is a minor point. In summary, the text is concise, well organized, and clearly written. The editor succeeds in packaging a substantial amount of useful information into a relativelysmall volume. This volume should serve beginning researchers well in designing scientifically sound and clinically useful outcome studies of residential treatment in children and adolescents. Dwight V. Wolf, M.D. Assistant Professor of Psychiatry and Behavioral Sciences Department of Psychiatry University of Texas Medical Branch, Galveston
Note to Publishers: Books for reuieu: should b~ sent to Dean X Parmelee, M.D.• Division of Child & Adolescent' Psychiatry. PD. Box980489, Richmond. VA 23298-0489.
AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 36:10. OCTOBER 1997
1481