Individual Course of Improvement 1 Running head : MEASURING EXPECTED COURSE OF IMPROVEMENT Measuring Mental Health Improvement Among Children Receiving Community-Based Services in a System of Care

The system of care (SOC) approach for treating children and adolescents with emotional and behavioral disorders has been implemented in counties, cities, and states throughout the United States. The goal of this study was to assess the predicted course of improvement for individuals enrolled in a statewide program that purports to adhere to SOC principals. 595 children and adolescents (mean = 11.3 years at time of initial contact) receiving community-based SOC services from 26 different agencies throughout Illinois were evaluated using the Child and Adolescent Needs and Strengths (CANS). Hierarchical linear modeling was utilized to measure course of improvement; the problem behaviors factor score of the CANS as the outcome measurement. The results indicate that initial clinical severity, and demographics such as age and gender after controlling for initial clinical severity, predict improvement, and agencies differ in client symptom reduction and in client initial problem behaviors. Future research will explore the factors associated with variability in outcomes at the agency level. Individual Course of Improvement 3 Measuring Mental Health Improvement Among Children Receiving Community-Based Services in a System of Care; An Idiographic Approach The system of care (SOC) approach is the most widely employed method of mental health service delivery to children and adolescents with severe behavioral and emotional disturbances in the United States (Stroul & Friedman, 1986; Stroul & Friedman, 1994). The SOC philosophy stresses the involvement of families as part of the treatment process in providing culturally competent services, permanency for children within their own community, and placement in the least restrictive clinically appropriate setting (see Table 1). Therefore, in keeping with these guidelines, communities rich in resources and effective services are seen as the centerpiece of a healthy SOC. The SOC program is designed to optimally serve children and adolescents' needs; and certainly the vast majority of policy makers that adapt SOC principals have the best interests of children in mind. However, outcome research on SOC programs is necessary to determine if the SOC framework is effective in terms of individual improvement, implementation, and dissemination in real world settings. The research on SOC outcomes is limited overall; previous literature has compared SOC treatment with treatment as usual (e.g., Bickman, Noser, & Summerfelt al., 1999), and these findings provided only modest support for the SOC model. However, this body of research did not provide an idiographic model of outcome that would offer individualized expected courses of improvement for children utilizing SOC. An idiographic approach would allow for the study of how child and ecological variables (i.e., agency providing services) moderate the impact of behavioral health outcomes in an SOC model. Individual Course of Improvement 4 Prior research indicates that the recipient of care and his or her presenting clinical characteristics and demographics play a role in the study of behavioral healthcare outcomes (Clarkin & Levy, 2004). Differences in the average course of improvement may exist depending on demographic (gender, age, ethnicity) and clinical (initial severity, diagnosis) variables (Leon, Kopta, Howard, & Lutz, 1999). Therefore, an approach to outcomes management in a SOC should model outcomes at the individual level. In addition to differences that may exist at the individual level, variability in outcome may also be attributable to the provider or organization that the individual receives services from. Despite its groundbreaking role in current approaches to service organization and delivery, the SOC model was designed to be a broad philosophy. SOCs are not intended to fit one specific population, and the SOC concept does not utilize strict therapeutic guidelines and does not advocate a particular model of prevention or intervention (e.g. empirically supported treatments; Lemanek, Kamps, & Chung, 2001) or organizational practices. Therefore, it is reasonable to assume that within the context of the multilayered SOC system (Rosenblatt, 1998) service providers operating under the SOC banner approach the implementation of SOC principals and the utilization of empirically supported treatments with significant variability, and that this variability may influence individual outcomes. The aim of the present study is to assess the real world effectiveness for individuals enrolled in a statewide program that purports to adhere to SOC principals. The two units of analysis are youth receiving a variety of therapeutic interventions and their service providers operating within the context of SOC. A model containing these two units of analysis has two primary applications: (1) to model variability in youth Individual Course of Improvement 5 outcomes (slopes) as a means of providing individualized expectations for improvement for every unique youth in the system and; (2) to model variability in outcomes across providers of care as a point of departure for quality improvement efforts. In addition, variability in outcome measures at the point of initial contact (intercepts) is obtained in order to assess any baseline differences that may exist between individuals. A model for the prediction of individualized outcome data for adolescents involved in SOC would benefit policy makers, clinicians, and families by providing expectations for change tailored to the individual. Furthermore, if variability exists at the level of the provider, these results could be used to develop and export best practice models among agencies or support existing best practices and treatments. The subsequent literature review first explores the history of mental health service delivery for youth and the emergence of the SOC philosophy in the mid-1980s. It then addresses variability across service providers as a starting point for future efforts to study differences relating to SOC model adherence, provider organization and climate, and decisions relating to type of intervention utilized within the core framework of SOC. Established empirically effective treatment options that fit well within the SOC framework exist and are summarized briefly. In addition to the influence of service provider, the previous research that has demonstrated the influence of demographic and clinical variables on outcomes is discussed. An idiographic, multi-level approach to outcomes monitoring is presented based on prior research that includes both the provider and the individual as levels of analysis. The aim of this approach is to shed light on the differences that may exist between service providers, and create a method for predicting Individual Course of Improvement 6 expected individual course of improvement for children receiving SOC community-based care. System of Care Background and Overview Community mental health approaches for the treatment of at risk adolescents grew out of early services for homeless and immigrant children that were first in place at the turn of the twentieth century (Terpstra & McFadden, 1993). In the 1950s, advancements in drug treatment led to decreases in hospitalization. Therefore, the U.S. Congress established the Community Mental Health Center Construction Act of 1963 in order to meet the needs of deinstitutionalized individuals living in the communities. This Act created a nationwide network of community mental health centers (CMHCs). Because the Act did not specifically include children, and many of the CMHCs did not offer services for children or served them in inappropriately restrictive settings, an amendment to the Act, Part F, was passed in 1972 to include programs for children with serious mental health needs (Lourie, 2003). Although legislation was now in place pertaining specifically to children with behavioral and emotional disorders, a turning point in the history of community services for children occurred when the Children’s Defense Fund published a report indicating that children and their families were not provided adequate services (Knitzer, 1982). The report, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services, indicated that nearly two thirds of children in need of services were either not provided with services or placed in inappropriately restrictive settings. Furthermore, the report noted that most state mental health offices did not have policies specifically for children and adolescents. In response Individual Course of Improvement 7 to these findings, in 1984, the federal government started another program, the Child and Adolescent Service System Program, better known as CASSP. A goal of the CASSP was to ensure that multiple agencies work with each other and the families of the children in order to facilitate the most appropriate treatment (Day & Roberts, 1991). It was designed to be community focused and to discourage fragmented service delivery. In addition, the program placed emphasis on family involvement at the system level and the recognition of the importance of cultural diversity. It is from this framework that the system of care model for children with severe emotional disturbances was developed (Stroul & Friedman, 1986). The SOC model encompasses a range of services and treatments guided by an underlying philosophy (Stroul & Friedman, 1986). In keeping with the provisions set forth by the CASSP, the philosophy involves the coordination of multiple agencies and multiple services in order to facilitate a comprehensive, cohesive treatment effort. The multiple agencies that may be employed in the context of community-based SOC treatment include educational agencies, juvenile justice services, mental health, vocational, child welfare, and primary health care (Holden, 2001; Hansen, Litzelman, Marsh, & Milspaw, 2004). These agencies work collaboratively to deve