Integrating Parenting Practices Into Partial Hospital Treatment of Children: Initial Outcomes

by Anne Walters, PhD; Marta Majczak, MD; and Steven J. Barreto, PhD

Mental and behavioral health problems in children are a growing and significant health issue in the United States, with estimates that one in five children have a diagnosable psychiatric disorder. These issues affect children across all backgrounds and contexts, and are linked to poor outcomes in educational achievement and in long-term family income, and most agree that effects of mental health problems over time in children are cumulative. Mental health impairment affects children’s health and behavior across all contexts: school, community, and home.

CABL logoThis article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.

At the same time, there are often significant barriers to receiving mental health services, in the form of lengthy wait lists and inadequate numbers of child trained clinicians. For example, in Rhode Island, “an estimated 34% of children who needed mental health treatment or counseling in the past 12 months did not receive it” (RI Kids Count, 2012). These barriers to treatment in turn result in visits to local emergency departments, which can be costly, as well as admissions to inpatient programs for children who might not have needed that level of care had other options been available. For this reason, treatment providers have sought additional methods to provide services. We view partial hospital treatment as a viable alternative to more costly inpatient treatment. We see the treatment as providing uniquely powerful opportunities to instruct and model evidence-based parenting practices to reduce the intensity and frequency of aggression, promote compliance with expectations for school attendance, and diminish corresponding symptoms of anxiety and depression.

Unique to the partial hospital model is the ability to utilize the hospital day treatment milieu combined with family and individual therapy to interrupt the frequently coercive cycle of parent-child interaction and implement more effective limit-setting practices as alternatives to negative discipline. These changes in parenting practices can be associated with reduction in self-reported emotional distress (e.g., depression, anxiety) and also perceptions of school success. Additionally, a classroom tutoring module as part of the day provides opportunities to generalize these limit-setting approaches across hospital, classroom, and home environments (e.g., contingency management, persistence coaching, self-control instruction).

About the program

Integrating parenting practices into partial hospital treatment of children: Initial outcomesThe Children’s Partial Hospital Program (CPHP) is a clinical program based at Bradley Hospital, part of Bradley Hospital’s Intensive Child and Adolescent Services. CPHP provides intensive, partial hospital-level diagnostic and treatment services for children ages 7 to 12 with serious emotional and behavioral difficulties. Partial hospitalization is offered as a step down from a more intensive level of care (inpatient) or as a means of step-up from intensive outpatient treatment to prevent a more restrictive level of care that involves separation of child and family overnight. Referrals come from local emergency departments (EDs), schools, parents, and providers for problems of aggression, suicidal behavior, and school avoidance, or any other psychiatric problem leading to significant impairment in functioning. Generally these referrals reflect the failure of community-based services to reduce/control these behaviors. In developing our program, we aimed to integrate an evidence-based parenting assessment instrument targeting the parenting practices, perceptions, and parenting stressors that are commonly associated with referral problems of aggression, highly disruptive behavior, suicidal ideation, and school avoidance. While assessment of symptoms has long been an initial practice in child psychiatric treatment, we aimed to link the initial parenting self-report assessment directly to the initial family interventions, which were implemented through a combination of family- and milieu-based therapies. We expected these parenting changes to be associated with changes in self-reported symptoms, such as depression, anxiety, and attitudes toward school.

Family checkup

To this end, we modified the Family Checkup (FCU) (Stormshak & Dishion, 2009) to fit our short-term treatment service. The FCU was designed to apply risk factor research findings on early conduct problems into an ecological, family-based intervention that is tailored to the needs of different ages, populations, and specific issues. With such a robust literature behind it, this instrument seemed ideally suited for use with our population as a means to target and drive areas of intervention. This is completed by the family the day prior to admission, and scored for use by the family clinician in the first meeting with the family post-admission. This instrument assesses family functioning in three areas: child-focused strengths and needs, parenting-focused strengths and needs, and family-focused strengths and needs. After scoring, results are utilized to identify the areas that families are most concerned about and are likely to be most motivated to change. Initial assessment of children is completed via self-report from the identified patient using the BASC-2 (Behavior Assessment Scale for Children-2), which provides an overall view of the child’s perception of their functioning across a wide range of areas that can be grouped into both externalizing (e.g., hyperactivity) and internalizing (e.g., anxiety, depression) disorders as well as on attitude toward school and personal adjustment. In addition, the child completes the Scale for Anxiety and Related Disorders (SCARED) and the Child Depression Inventory (CDI- 2) to assess symptoms in these two areas. All of these child- and family-based measures are then repeated at the time of discharge from the program.

Parenting model

Extending the model of employing evidence-based practices, we also train all program staff in group treatment using the Incredible Years parenting group model. Our intent is to employ direct care staff to provide support at morning and afternoon contact with parents for the behavioral parent training that is so essential to stabilize externalizing behavior over the course of treatment. This allows clinicians to focus on aspects of family functioning identified as problematic in the modified Family Checkup assessment process.

A pilot study completed at the end of the first 18 months of the program (43 consecutive admissions) yielded promising results. Consistent with our hypothesis, several child self-reported areas of functioning demonstrated statistically significant improvement. Child depressive symptoms, problematic attitudes toward school and teachers, internalizing problems, and overall emotional symptoms improved significantly following a course of treatment. Child-reported relationship with parents and personal adjustment did not change significantly. Also consistent with our hypothesis, parent-reported outcomes changed significantly. Parents reported increases in limit setting along with decreases in negative discipline. Also, parents reported significant improvement in child conduct problems.

At present, we have moved to web-based administration and data capture for all measures utilized in the program from the time of admission to discharge, which will allow analysis across a variety of measures and factors aimed at documenting clinical outcomes. Our hope is to continue to refine our assessment and intervention process so as to obtain optimal clinical outcomes within a short-term treatment package.

Case study

Bobby is an 11-year-old male referred to CPHP from the inpatient unit where he was hospitalized for several aggressive and violent outbursts in the context of parents setting limits on his video game use. On intake, parents rated “needs attention” on Bobby’s emotional adjustment, conduct, hyperactivity, and coping and self-management control. They rated significant concern with their parenting in the domains of positive parenting, proactive parenting, limit setting, and discipline. Over the course of partial hospitalization, parents were provided psychoeducation about joint problem-solving, consistency when setting limits, and using a warm and firm approach when setting limits. They were coached to withdraw attention from Bobby and not engage with him when he was agitated and/or using unkind words, and to help him label his negative emotions in an empathic manner (i.e., you’re angry right now, you seem really stuck, I can tell this is hard for you, etc.). Each day on arrival and departure, Bobby’s primary direct care staff provided him and his parents with goals for the evening to practice skills learned in the program, and Bobby earned points based on his success at home.

In individual therapy sessions, Bobby was able to acknowledge that not getting what he wanted was difficult for him and agreed to participate in exposures to this. He also provided his input on developing clear limits for his video game use as well as reasonable consequences for poor behavior at home. Psychoeducation was provided to describe the thoughts, feelings, behaviors, and bodily sensations associated with Bobby’s anger. He was provided with a list of disputing questions to challenge his negative thoughts and could identify thinking errors he was using (particularly all-or-nothing thinking and emotional reasoning). He also learned about assertiveness training and using “I" statements to communicate with family members. He identified himself as using passive-aggressive or aggressive communication styles at home a lot of the time. By discharge Bobby demonstrated improved insight into the thinking errors he was prone to having while angry. Family reported it was particularly helpful to Bobby to be reminded that he was capable of changing his mind, particularly when feeling “stuck." They identified themselves as using less negative discipline strategies.

During daily group therapy, Bobby further learned about using relaxation strategies, including deep breathing and progressive muscle relaxation. He reported this was helpful to him when he was starting to feel angry. At discharge, parents rated Bobby with lower scores on his issues with emotional adjustment, conduct, coping, and self-management.

Their parenting scores indicated decreased concern with positive parenting, proactive parenting, limit setting, and discipline. Parents also participated in a school meeting with the clinician where they talked about their improved success in managing Bobby’s outbursts and educated the staff about being “warm and firm.” The school team agreed to start accommodations in their setting that were helpful to Bobby in the program. At the end of treatment, Bobby was transitioned back to outpatient services for family therapy.

Conclusions

In the CPHP, our goal continues to be embedding an assessment of clinical outcomes in a treatment service, as well as for efficacy of treatment from both child and family perspectives. Assessment at admission offered important information about the focus of treatment for both child and family, and measures pre- and post-treatment yielded positive change. Outcome-based assessment needs to become a routine part of all clinical treatment to establish broad-based benchmarks and enhance quality.

Anne Walters, PhD, is clinical director of the Children's Partial Hospital Program and chief psychologist at Bradley Hospital. She is also a clinical associate professor at the Warren Alpert Medical School of Brown University.

Steven J. Barreto, PhD, is a pediatric psychologist at Bradley Hospital.

References

RI Kids Count. RI Kids Count Factbook. Providence, RI: 2012.

Stormshak EA, Dishion TJ. A school-based family-centered intervention to prevent substance abuse: The family check-up. Am J Drug Alcohol Abuse 2009; 35(4):227-232.