Toward tailored care for families with multiple problems: A quasi-experimental study on effective elements of care.

Several effective interventions have been developed for families with multiple problems (FMP), but knowledge is lacking as to which specific practice and program elements of these interventions deliver positive outcomes. The aim of this study is to assess the degree to which practice and program elements (contents of and structure in which care is provided) contribute to the effectiveness of interventions for FMP in general and for subgroups with child and/or parental psychiatric problems, intellectual disabilities, or substance use. We performed a quasi-experimental study on the effectiveness of practice and program elements provided in attested FMP interventions. Using self-report questionnaires, we measured primary (child's internalizing and externalizing problems) and secondary (parental stress and social contacts) outcomes at the beginning, end, and three months thereafter. By means of Latent Profile Analysis, we identified groups of families receiving similar combinations of practice elements ("profiles"), and we calculated propensity scores. Next, we assessed how practice element profiles and program elements affected improvement in outcomes, and whether these effects were moderated by subgroup characteristics. We found three practice element profiles (explorative/supportive, action-oriented, and their combination), which were equally effective. Regarding program elements, effects were enhanced by more frequent telephone contact between visits and more frequent intervision. Effectiveness of practice and program elements varied for specific FMP subgroups. Variations in the content of care for FMP do not affect its effectiveness, but variations in the structure of the care do. This finding can help to further improve effective interventions.

Se han desarrollado varias intervenciones eficaces para familias multiproblemáticas, pero se sabe poco acerca de qué elementos específicos de la práctica y de los programas de estas intervenciones producen resultados positivos. El objetivo de este estudio es evaluar el grado en el cual los elementos de la práctica y de los programas (los contenidos de la asistencia y la estructura en la cual se presta) contribuyen a la eficacia de las intervenciones para familias multiproblemáticas en general, y para subgrupos de padres o hijos con problemas psiquiátricos, discapacidades intelectuales o consumo de sustancias. Realizamos un estudio cuasiexperimental sobre la eficacia de los elementos de la práctica y de los programas proporcionados en intervenciones certificadas para familias multiproblemáticas. Utilizando cuestionarios de autoinforme, medimos los resultados primarios (los problemas de interiorización y de exteriorización de los niños) y secundarios (estrés de los padres y contactos sociales) al comienzo, al final y tres meses a partir de entonces. Por medio del análisis de perfiles latentes, identificamos grupos de familias que recibían combinaciones similares de elementos de la práctica ("perfiles") y calculamos los puntajes de propensión. Después, evaluamos cómo los perfiles de los elementos de la práctica y los elementos del programa afectaron las mejoras en los resultados, y si estos efectos estuvieron moderados por las características de los subgrupos. Encontramos tres perfiles de elementos de la práctica (exploratorio/comprensivo, orientado a la acción y su combinación) que fueron igualmente eficaces. Con respecto a los elementos de los programas, los efectos mejoraron con el contacto telefónico más frecuente entre visitas y una intervisión más frecuente. La eficacia de los elementos de la práctica y de los programas varió según los subgrupos específicos de familias multiproblemáticas. Las variaciones en el contenido de la asistencia para las familias multiproblemáticas no afectan su eficacia, pero las variaciones en la estructura de la asistencia, sí. Estos resultados pueden ayudar a mejorar aún más las intervenciones eficaces.

Exploring Change in Children's and Art Therapists' Behavior during 'Images of Self', an Art Therapy Program for Children Diagnosed with Autism Spectrum Disorders: A Repeated Case Study Design.

(1) Background: 'Images of Self' (IOS) is a recently developed and evaluated art therapy program of 15 sessions to reduce difficulties in 'sense of self', 'emotion regulation', 'flexibility', and 'social behavior' of children diagnosed with Autism Spectrum Disorders (ASD). In this paper, it is explored whether change in the child's behaviors corresponds to the therapist's actions during IOS and 15 weeks later. (2) Method: In a repeated case study design, twelve children and seven therapists participated. Art therapists monitored their own and the children's behavior by applying two observation instruments: the OAT (Observation of a child with autism in Art Therapy) and EAT (Evaluation of Art Therapist's behavior when working with a child with autism). Child behaviors during art making were-individually and as a group-compared with therapist's actions at three moments during the program. (3) Results: Ten of twelve children showed a substantial or moderate positive behavior change considering all OAT subscales at the end of the program and 15 weeks after treatment. Improvement of 'social behavior' stood out. Halfway treatment art therapists most prominently showed support of 'emotion regulation', 'flexibility', and 'social behavior'. Clear one-on-one relationships between changes in children's behavior and actions of therapists could not be identified. (4) Conclusion: The study provides new insights in the AT treatment process by monitoring children's and therapists' behavior. The art making itself and the art therapy triangle (child, art making, therapist) offer opportunities to improve verbal and nonverbal communication skills of the child.

Reasons for placement decisions in a case of suspected child abuse: The role of reasoning, work experience and attitudes in decision-making.

Child welfare and child protection workers regularly make placement decisions in child abuse cases, but how they reach these decisions is not well understood. This study focuses on workers' rationales. The aim was to investigate the kinds of arguments provided in placement decisions and whether these arguments were predictors for the decision, in addition to the decision-makers' risk assessment, work experience and attitudes towards placement. The sample consisted of 214 professionals and 381 students from the Netherlands. The participants were presented with a vignette describing a case of alleged child abuse and were asked to determine whether the abuse was substantiated, to assess risks and to recommend an intervention. The participants' placement attitudes were assessed using a structured questionnaire. We found that the participants provided a wide range of arguments, but that core arguments - such as the suspected abuse, parenting and parent-child interaction - were often missing. Regression analyses showed that the higher the perceived danger to the child and the more positive the participants' attitudes towards placement, the more likely the participants would be to propose placing the child in care. Arguments related to the severity of the problems (i.e., suspected abuse, parenting and the child's development) as well as the parents' perceived cooperation also influenced placement decisions. The findings indicate trends in the decision-making process, in the sense that participants who decided to place the child out-of-home emphasized different arguments and had different attitudes towards out-of-home placement than those who did not. We discuss the implications of our findings.

Deciding on child maltreatment: A literature review on methods that improve decision-making.

Assessment and decision-making in child maltreatment cases is difficult. Practitioners face many uncertainties and obstacles during their assessment and decision-making process. Research exhibits shortcomings in this decision-making process. The purpose of this literature review is to identify and discuss methods to overcome these shortcomings. We conducted a systematic review of the published literature on decision-making using PsychINFO and MEDLINE from 2000 through May 2014. We included reviews and quantitative research studies that investigated methods aimed at improving professional decision-making on child abuse and neglect in child welfare and child protection. Although many researchers have published articles on decision-making including ideas and theories to improve professional decision-making, empirical research on these improvements is scarce. Available studies have shown promising results. Structured decision-making has created a greater child-centred and holistic approach that takes the child's family and environment into account, which has made practitioners work more systematically and improved the analysis of complex situations. However, this approach has not improved inter-rater agreement on decisions made. Shared decision-making may improve the participation of parents and children and the quality of decisions by taking client treatment preferences into account in addition to scientific evidence and clinical experience. A number of interesting developments appear in recent research literature; however, child welfare and child protection must find additional inspiration from other areas, e.g., mental health services, because research on decision-making processes in child welfare and child protection is still rare.

Degrees of freedom and degrees of certainty: a developmental model for the establishment of evidence-based youth care.

There are many psychosocial interventions for children and adolescents. The effects of these interventions in day-to-day practice are nevertheless often unclear. Researchers typically take the randomized controlled trial (RCT) as the "gold standard" for the supply of evidence regarding the effectiveness of an intervention. However, such trials are rarely performed in youth care practice because they are difficult to conduct and sometimes meet with ethical objections. RCTs may also be prematurely and thus unnecessarily conducted on interventions that are not yet fully developed or interventions that have yet to be accepted into actual practice. In this article, a four-stage model for the classification and development of effective interventions carried out in actual youth care practice is presented. Stage 1 (potential interventions) requires specification of the core elements of an intervention (e.g., objectives, target groups, activities) and may involve both descriptive and implementation studies. Stage 2 (plausible interventions) requires the explication of an underlying intervention theory (e.g., what works with whom and why) and may involve both literature reviews and techniques to elicit the knowledge of experts. Stage 3 (functional interventions) requires preliminary evidence that the intervention works in actual practice and may involve client satisfaction studies, goal attainment studies, pre-post test studies, quality control studies, benchmark studies, correlational studies, and quasi-experimental studies. Stage 4 (efficacious interventions) requires clear evidence that the intervention is responsible for the observed effects and may involve RCTs and well-designed repeated case studies.

Reliability of the ICD-10 classification of adverse familial and environmental factors.

BACKGROUND: The tenth revision of the International Classification of Diseases (ICD-10) contains a number of categories and guidelines for coding different types of adverse familial and environmental situations. These categories have been selected on the basis of empirical evidence that the adverse situations might represent important psychiatric risk factors. Prior studies, using written case vignettes or video- or audiotaped semi-structured interviews, showed that the interrater reliability of these classifications is satisfactory. METHOD: We have tested the interrater reliability of the categories in a multicentre study by using an 'in vivo' design. Classifications were performed in day-to-day practice, using information that is normally available. Three hundred children from 0 to 13 years were involved in the study. These cases had been admitted to various institutes for children with psychiatric disorders, developmental delays and/or adverse psychosocial circumstances. Two clinicians and a student classified the psychosocial situation of each child. In total, 51 clinicians and 6 undergraduate students were involved in the study. RESULTS: It was found that, with the exception of more or less objective categories, the reliability is not satisfactory. Post hoc analyses showed that the insufficient reliability is only partly due to confounding factors: no clear indications were found for information variance, but observation variance may have played a part. Having additional information from two family questionnaires hardly contributes to a better reliability. CONCLUSIONS: The reliability of the psychosocial axis of the ICD-10 is not satisfactory if tested in day-to-day practice. In comparing this result with other reliability studies, it seems that the absence of adequate information to code the psychosocial axis may be a fundamental problem in obtaining sufficient interrater agreement. Apparently, the classification of this axis requires information that is often not available in common practice.