Initial hospitalization and community tenure outcomes of intensive case management for children and youth with serious emotional disturbance

Since 1988 New York State's Children and Youth Intensive Camse Management (CYICM) program has enrolled more than 1,700 children. The program goal is to maintain children in the least restrictive environment approriate to their needs. This linkagke and advocacy focussed program uses a small caseload and flexible service money to meet its goal. We review the program model, describe the enrolled children, highlight some of the problems associated with determining program outcomes, and present the outcomes related to hospitalization and community tenure. Using two analytic techniques, CYICM was shown to be associated with fewer hospital admissions and fewer days in the hospital over a two-year period following the intervention of CYICM than prior to enrollment.     

Families-at-risk and home-based intervention: A therapist training model

Home-based family therapy programs are designed to provide intensive family intervention for at-risk children and adolescents. However, examination of the literature reveals limited publications about training therapists for this difficult task. The purpose of this paper is to describe a therapist training model based upon a family-as-context approach to crisis intervention. Specific units covered during the course include: family-as-a-system, structural family therapy, family crisis intervention, family assessment and simulation. It is concluded that the effective prevention of placement for at-risk children and adolescents requires both a home-based family treatment program and a specific therapist training model for family intervention.John J. Zarski, PhD, is a professor in the marriage and family therapy training program at the University of Akron. Carol A. Pastore is program coordinator for the T.I.E.S. program in Canton, OH. A. Lynette Way and Richard N. Shepler are home-based therapists with T.I.E.S. The authors would like to express their appreciation to Professor John West for his helpful comments on drafts of this article.     

The child parent drop-in center: Community based primary prevention

A community supported child-parent drop-in program that provides services to families with few financial resources or to those who may not seek help from other service agencies is described. Services are provided free or at a minimal cost. The family oriented program provides short-term, respite care for children from birth to kindergarten age, educational programs and social opportunities for parents, short-term crisis counseling, referral to other community resources, and volunteer opportunities and training. Three centers are housed in facilities that donate the space. The centers recruit, train and actively involve parents, students, senior citizens and other volunteers to work in the program. Service groups and businesses aid in fund-raising and human service agencies provide consultation, act as referral resources and help with program operation. Each center is individualized to meet the needs of the community it serves.     

Family crisis intervention in war contexts: a case study of a traumatised Palestinian family

The aim of this study was to analyse the phases of an innovative in vivo exposure intervention in which all family members were present at the scene of a traumatic incident. Clinical practice has borne out the efficacy of family intervention and its benefits for traumatised individuals and family groups. The intervention discussed here was conducted with a Palestinian family that had suffered trauma in a missile attack during the Israeli–Lebanese war of summer 2006. Narrative and meaning-reconstruction methods were combined with cognitive-behavioural techniques. The study highlights the limitations of the intervention as well as suggesting future directions for integrated models of crisis intervention; development of an evidence-based model is recommended.     

Is early identification of children of alcoholics necessary for preventive intervention? Reaction to Havey and Dodd

Havey and Dodd (1995, this issue) address the question of how to best identify early adolescents who are at risk for later substance abuse, with a particular focus on children of alcoholics (COAs). They conclude that stressful family events are preferable to COA status as an at-risk indicator. In addition, they question the well-substantiated at-risk status of COAs, claiming support for the null hypothesis regarding individual and family differences between COAs and non-COAs. This article addresses both conceptual and methodological concerns about identification and intervention for COAs in general, and about the Havey and Dodd study in particular. I first discuss a theoretically-empirically based approach to identification and risk prevention that supports a more complex, less parsimonious, model than that suggested by Havey and Dodd. Second, I present research to support the at-risk status of COAs. Third, I discuss issues related to identification of COAs and question the validity of Havey and Dodd's identification techniques. On the basis of conceptual and methodological arguments, I contend that Havey and Dodd's conclusions are not well-founded in their own or others' research and that the at-risk status of COAs cannot be dismissed on the basis of their research. I also contend that early identification may not be necessary for intervention with COAs or other at-risk groups. Alternatively, primary prevention programs provide the context for both service delivery and identification of individuals who might not otherwise be easily identified, particularly those at risk for developing mental health problems because of family environment factors (e.g., family alcoholism or conflict), or those currently experiencing mild or internalized (e.g., depression) adjustment difficulties.     

Training program in psychosocial intervention for high-risk infants and their families

A multidisciplinary training program for psychosocial intervention in the Neonatal Intensive Care Unit (NICU) was developed. The purpose of the program was to train mental health and health care professionals in a psychosocial preventive intervention model for high-risk infants and their families throughout the infants' hospital course in the NICU. The program was divided into modules that include assessment and intervention with the infant, parents, family, and larger caregiving environment. Over a 3-year period 40 trainees from 9 disciplines were trained. A randomized clinical trial was conducted which showed the positive effects of the intervention. A clinical service including inpatient and outpatient follow-up has been established in the NICU based on the psychosocial model developed from the training program.     

Organizational Cultural Competency: Shifting Programs for Latino Immigrants from a Client-Centered to a Community-Based Orientation

This paper discusses how the organizational cultural competency of social service agencies may be improved by shifting the philosophy of service delivery from a client-centered to a community-based orientation. This analysis is based on two years of fieldwork and interviews that were conducted as part of an action research project initially developed to increase the number of certified Spanish speaking Latino family childcare providers and knowledge about Latino immigrant families in the Midwest. In developing a culturally-specific certification program in Spanish, both the Latino participants and the bilingual program director challenged the agency to consider how the social context and social location of its participants required a more holistic community approach.     

NGO-government relations and immigrant services: Contradictions and challenges

This article critically examines the “Canadian model” of immigrant settlement service delivery. This is a system where most settlement services are provided through community-based, including ethno-specific, agencies funded primarily by the various levels of government. Although this model has been widely celebrated as an efficient, immigrant-friendly, and inclusive model to be emulated elsewhere, we argue that it is a system in crisis. Rather than continuing to promote this model uncritically, we examine the roots of this crisis and in this light offer a reconsideration of a series of current policy issues in immigrant service provision in Canada.     

The Milan method—a preliminary critique*

The elegance of the techniques developed by the Milan group has tended to blind family therapists to the many problems inherent in their approach. A close reading of their work uncovers many ethical and political issues which need to be addressed. This paper is a preliminary attempt to develop a critique of the group's method which recapitulates some of the most alienating aspects of the traditional medical model. It will concentrate solely on a critical reading of Paradox and Counterparadox and will not seek to come to terms with the more recent evolution of the Milan school.     

Teen Line: a descriptive analysis of a peer telephone listening service

Teen Line is a peer telephone listening service for adolescents. During its first year of operation, 2,270 phone calls were received. After an initial novelty effect, counts document a consistent level of use of the service. Two-thirds of the callers were female. Although 4% of topics discussed dealt with crisis situations (suicide, physical abuse), 96% were concerned with common, less urgent adolescent issues, such as peer relationships, family dynamics, and the need to have someone "just to talk to." This paper presents a model for an adolescent listening service and provides data garnered over a year's utilization. Consistent use documents its acceptance as a source of information for teenagers.     

Challenges of Evaluating Multilevel Interventions

This article uses the Comprehensive Mixed-Methods Participatory Evaluation (CMMPE; Nastasi and Hitchcock Transforming school mental health services: Population-based approaches to promoting the competency and wellness of children, Thousand Oaks, CA: Corwin Press with National Association of School Psychologists 2008; Nastasi et al. School-based mental health services: creating comprehensive and culturally specific programs. Washington, DC: American Psychological Association 2004) model as a framework for addressing the multiplicity of evaluation decisions and complex nature of questions related to program success in multilevel interventions. CMMPE defines program success in terms of acceptability, integrity, social or cultural validity, outcomes (impact), sustainability and institutionalization, thus broadening the traditional notions of program outcomes. The authors use CMMPE and an example of a community-based multilevel sexual risk prevention program with multiple outcomes to discuss challenges of evaluating multilevel interventions. The sexual risk program exemplifies what Schensul and Tricket (this issue) characterize as multilevel intervention–multilevel evaluation (M–M), with both intervention and evaluation at community, health practitioner, and patient levels. The illustration provides the context for considering several challenges related to M–M designs: feasibility of randomized controlled trials within community-based multilevel intervention; acceptability and social or cultural validity of evaluation procedures; implementer, recipient, and contextual variations in program success; interactions among levels of the intervention; unanticipated changes or conditions; multiple indicators of program success; engaging multiple stakeholders in a participatory process; and evaluating sustainability and institutionalization. The complexity of multilevel intervention and evaluation designs challenges traditional notions of evaluation research and experimental designs. Overcoming these challenges is critical to effective translation of research to practice in psychology and related disciplines.     

A behavioural and systems approach to family therapy: a position paper

An integrated model of a behavioural and systems approach to family therapy is presented, the main premise being that family interactions are affected by reciprocal determination of cognitions, feelings and behaviours in relation to the environment. Assessment involves a systematic exploration of the interaction and transactional patterns within the family, and the identification of the dysfunctional aspects of such patterns. The main aim of the intervention is to produce change in family behaviour by addressing the important cognitive and affective issues. This entails techniques such as cognitive restructuring, social modelling and operant conditioning which can be used separately, in parallel, or in combination. Whether one or more of these techniques is used depends on the nature of the family's problems and the aims of treatment.     

Crisis intervention and the prevention of institutionalization: An interrupted time series analysis

In the context of the community mental health movement in Illinois, the evolution and development of a crisis intervention program aimed at avoiding state hospitalization and bringing more appropriate and efficacious resources to bear on the difficulties of the individual and/or family is described. This intervention program is characterized by a more active-seeking style of delivering mental health services. With the novel application of interrupted time series analysis to both the targeted and matched nonequivalent control communities the efficacy of this more active intervention in reducing the number of state hospital administrations diagnosed as "mentally ill" is highlighted. The cost/benefit to the taxpayer is also discussed.     

The effectiveness of positive psychology interventions in enhancing positive behaviors and family relationships in Hong Kong: A community-based participatory research project

This paper describes a program of brief, universal, positive psychology-based interventions to increase targeted behaviors that enhance family relationships, developed and delivered to over 1500 participants using a community-based participatory approach. The cluster-randomized design combined interventions based on one of three themes (gratitude, hope, or open-mindedness) in one of two structures (intervention, or intervention with planning). The latter structure supplemented with materials and exercises derived from the Health Action Process Approach model of behavior change. Planning was more effective in increasing attitude and intention to perform behaviors, frequency of the targeted behaviors, and family health and happiness (Cohen’s ds: 0.10–0.16, p < 0.05), particularly in the theme targeting open-mindedness. Qualitative data supported effectiveness. This project was a first effort to develop a large-scale preventive psychological intervention in an understudied culture with the goal of maximizing acceptability and utilization by involving community stakeholders in every stage of the design.     

Training Community Members to Serve as Paraprofessionals in an Evidence-Based,Prevention Program for Parents of Preschoolers

Widespread dissemination of evidence-based programs for underserved populations may require non-traditional means of service provision. Collaboration with paraprofessionals from communities that are targeted for intervention holds promise as a delivery strategy that may make programs more accessible and acceptable, especially to parents living in low-income, urban neighborhoods. We describe a paraprofessional training program for individuals living in a community targeted for preventive intervention based on high levels of poverty and community violence. The design and implementation of the training program are described in the context of issues related to the use of paraprofessionals in community-based, preventive interventions with parents of young children. We also provide insight into lessons learned from a feasibility study as well as general guidelines for the development of paraprofessional training programs for delivery of evidence-based programs.     

Family Sculpting in Preventive Work with "Well Families"

This paper will describe an experimental community project aimed at "well families". The program was designed to be preventive by providing service to families before their problems escalated into crisis proportions. It emphasized an educational rather than treatment bias; this orientation forced us to expand concepts, experiment with new techniques, and re-evaluate our ideas on how families change. Of particular importance to us was the emphasis on behavioral change rather than intellectual insight. In the course of this work, family sculpting came to be an increasingly valuable tool.     

Innovative Community Services for Rape Victims: An Application of Multiple Case Study Methodology

A qualitative multiple case study design was used to examine communities across the United States that have developed coordinated community-based programs to assist rape victims. Previous studies have suggested that coordinated community programs help victims obtain needed resources and services. This study provided a follow-up examination of how and why these programs are helpful to rape victims. In-depth interviews were conducted with rape victim advocates, rape crisis center directors, police officers, prosecutors, doctors, nurses, and rape survivors from 22 communities with coordinated programs. A comparison sample of 22 communities with fewer coordinated programs was also obtained. Results indicated that the high coordination communities had three types of programs to address sexual assault: coordinated service programs, interagency training programs, and community-level reform groups. Although not all of these programs directly address service delivery for rape victims, they help create a community culture that is more responsive to victims' needs. The research team and participants developed an explanatory model of why these program are effective in addressing rape victims' needs. This model hypothesizes that coordinated programs reflect an understanding of the multiple contexts of service delivery and embody that knowledge in services that are consistent with victims' needs. Narrative data from the interviews with service providers and rape survivors are used to develop and support this model.     

The Relationship Between Caregiver Capacity and Intensive Community Treatment for Children with a Mental Health Crisis

We studied 9,220 children referred to a comprehensive mental health crisis stabilization program to examine the impact of caregiver capacity on crisis worker decisions to refer children for intensive community-based treatment as opposed to inpatient psychiatric hospitalization. Due to the different role of caregivers in the child welfare system, analyses were stratified by state custody status. Among both groups, there was a significant inverse association between child mental health need and referral to intensive community-based treatment. For children not in state custody with low mental health need, there was no difference in the likelihood of referral to intensive community-based treatment across levels of caregiver capacity. However, for children not in state custody with medium and high mental health needs, those whose caregivers were deficient or severely deficient were significantly more likely to be referred for intensive community-based treatment than were those who had capable caregivers. Multivariate analyses demonstrated similar results after controlling for potential confounding variables and confirmed that caregiver capacity contributes significantly to the logistic model’s classification accuracy. Results suggest further investigation of the impact of caregiver capacity on mental health crisis worker referral decisions is needed.     

Infant mental health programs: Experimenting with innovative models—One center's experience with new program funding

This article describes one child and family treatment center's process of creating a long‐awaited, new infant/child early intervention program. An experimental service model is discussed in the context of the need for empirically validated assessment and intervention for very young clients in high‐risk families. Case examples and illustrations of service flow are provided. Some features of this program, such as the fact that it was set up for a seamless transition to a treatment research project, are highlighted.     

Combating Foster Care Drift: An Ecosystemic Treatment Model For Neglect Cases

The neglect of children may take many forms, but always represents the diminished capacity of the entire system of which the children are a living part. Child, parent, family, neighborhood, and community variables mutually influence one another. Once children are removed from a home, these same individual, relational, and contextual factors may result in foster placements of indefinite term and goals. Families are not reunited nor are the children legally freed to be placed in permanent homes. Because of the multiplicity of transacting influences there needs to be a stage-wise, systemic approach to remediation. This begins with crisis intervention and life stabilization. Later it includes more traditional family therapy work. However, the marital and family therapist contributes substantially at each stage.