Issues in Clinical Child Psychology

Jarrod M. Leffler
Elisabeth A. Frazier Editors

Handbook of
Evidence-Based Day
Treatment Programs for
Children and
Adolescents
Issues in Clinical Child Psychology

Series Editor
Michael C. Roberts , Clinical Child Psychology Program,
University of Kansas, Lawrence, KS, USA
The Issues in Clinical Child Psychology book series represents a broad spectrum
of professional psychology books, integrating clinical psychology with the
development of children, adolescents, and their families and developmental
psychopathology. The age coverage ranges from infancy to childhood to
adolescence. Populations of interest include normally developing children
and those exhibiting problems in developmental, behavioral, psychological,
health, and academic realms. Settings include schools, mental health clinics,
independent practice, pediatric offices and centers, and juvenile facilities.
Topics of interest include developmental psychopathology, externalizing and
internalizing disorders, assessment and diagnosis, interventions and
treatments, consultation, prevention, school mental health, normal and
abnormal development, family psychology, service delivery, diversity and
cultural differences, and ethical and legal issues in clinical practice and
research.
Jarrod M. Leffler • Elisabeth A. Frazier
Editors

Handbook
of Evidence-Based Day
Treatment Programs for
Children and
Adolescents
Editors
Jarrod M. Leffler Elisabeth A. Frazier
Department of Psychiatry, Division of Department of Psychiatry and Human
Child and Adolescent Psychology Behavior, Bradley Hospital/Brown
Virginia Commonwealth University University
Children’s Hospital of Richmond and Providence, RI, USA
Virginia Treatment Center for Children
Richmond, VA, USA

ISSN 1574-0471
Issues in Clinical Child Psychology
ISBN 978-3-031-14566-7    ISBN 978-3-031-14567-4 (eBook)
https://doi.org/10.1007/978-3-031-14567-4

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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whether the whole or part of the material is concerned, specifically the rights of translation,
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To my wife and daughters for their love and support, and all
the children and families who have allowed me the opportunity
to be a part of their lives and entrust me with their
care. – J.M.L.

To all the families, colleagues, and mentors that have helped

shape my career and inspired me. – E.F.
Preface

The concept for this book was initiated prior to the COVID-19 pandemic to
provide a resource for clinicians, trainees, administrators, educators, research-
ers, and patients looking to better understand current models of intermediate
mental health care, which includes partial hospitalization programs (PHPs)
and intensive outpatient programs (IOPs). The impact of the COVID-19 pan-
demic as this book was written further emphasizes the importance of these
treatment programs for youth with mental health concerns. Day treatment pro-
grams for youth including PHPs and IOPs provide an intermediate level of
treatment between outpatient and acute inpatient psychiatric hospitalization
(IPH). These programs have traditionally utilized a multidisciplinary approach
using process and skill-based groups and individual therapy. However, over
the past decade, some IOPs and PHPs have begun to integrate evidence-based
treatment (EBT) and caregivers into their treatment model. Additionally, the
admission criteria have become more focused on a particular illness or disor-
der (e.g., anxiety, depression, and suicide). Further, caregivers and referral
sources may not be aware of the range of programs available. Additionally,
mental health organizations may benefit from information to develop their
own intermediate treatment models. A review of literature found a dearth of
resources focused on PHPs and IOPs for youth. The current book (1) provides
an up-to-date overview of IOPs and PHPs for youth, (2) identifies the variety
and breadth of these programs, (3) includes strategies for developing and
implementing new programs as well as measuring outcomes, (4) reviews top-
ics relevant to accessing PHPs and IOPs, and (5) overviews programs likely to
be accessed as pre- or post-care for youth utilizing PHPs and IOPs.
This book is the first of its kind to review evidence-based treatment mod-
els in PHP and IOP settings. It also provides the reader with insight into
program development, implementation, and considerations for sustainability
in practice. We also offer information to educate consumers about the process
of accessing and utilizing these intensive services as well as additional treat-
ment resources that may be necessary in the continuum of care for youth
who require PHP or IOP interventions. We hope this handbook becomes a
resource for professionals, families, and learners. We thoughtfully developed
this resource by recruiting a range of outstanding authors with expertise in

vii
viii Preface

developing, implementing, researching, and overseeing these programs as

well as providing direct care to youth and their families.

Richmond, VA, USA Jarrod M. Leffler

Riverside, RI, USA Elisabeth A. Frazier
Acknowledgments

We would like to acknowledge the work and dedication of the numerous

treatment programs included in this text as well as those we were not able to
include. Thank you for the tremendous work you do to care for and improve
the lives of so many children, adolescents, and families! This is even more
important given the changing landscape of mental health care for youth fol-
lowing the COVID-19 pandemic and the impact on providers, programs, and
families. We are greatly appreciative of the mentorship, encouragement, and
guidance of Dr. Michael Roberts, and the publishing team at Springer.

ix
Contents

Part I Building Blocks of Day Treatment Programs

1 
Introduction and Overview of Day Treatment Programs����������    3
Jarrod M. Leffler and Elisabeth A. Frazier
2 
The History and Purpose of Day Treatment Programs��������������   15
Megan E. Rech, Jaime Lovelace, Megan Kale,
Jarrod M. Leffler, and Michelle A. Patriquin
3 Program Development and Administration in
Day Treatment Settings ����������������������������������������������������������������   31
Jarrod M. Leffler, Eric Schwartz, and Brittany Hayden
4 Implementation and Training ������������������������������������������������������   55
Tommy Chou, Heather A. MacPherson,
Maya Massing-­Schaffer, Anthony Spirito, and Jennifer Wolff
5 Assessment and Evaluation of Outcomes in Youth
Day Treatment Programs��������������������������������������������������������������   69
Megan E. Rech, Jaime Lovelace, Megan Kale,
and Michelle A. Patriquin

Part II Partial Hospitalization Programs (PHPs)

6 Perspectives on General Partial Hospital Programs

for Children������������������������������������������������������������������������������������   81
Sarah E. Barnes, John R. Boekamp, Thamara Davis,
Abby De Steiguer, Heather L. Hunter, Lydia Lin,
Sarah E. Martin, Ryann Morrison, Stephanie Parade,
Katherine Partridge, Kathryn Simon, Kristyn Storey,
and Anne Walters
7 
Child and Adolescent Integrated Mood Program (CAIMP)������ 103
Jarrod M. Leffler, Kate J. Zelic, and Amelia Kruser
8 The UCLA Achievement, Behavior, Cognition
(ABC) Program�������������������������������������������������������������������������������� 127
Ruben G. Martinez, Benjamin N. Schneider,
James T. McCracken, and Tara S. Peris

xi
xii Contents

9 Center
 for Autism and Developmental Disabilities Partial
Hospitalization Program �������������������������������������������������������������� 143
Maria Regan and Giulia Righi
10 Dialectical Behavior Therapy�������������������������������������������������������� 157
Kristen L. Batejan, Julie Van der Feen, and Peg Worden
11 Obsessive
 Compulsive and Related Disorders���������������������������� 175
Abbe Garcia and Michael Walther
12 Family-Based
 Interdisciplinary Care for Children
and Families with Comorbid Medical and Psychiatric
Conditions: The Hasbro Children’s Partial
Hospital Program�������������������������������������������������������������������������� 195
Katharine Reynolds, Heather Chapman, Jamie Gainor,
Cheryl Peck, Ana Crook, Donna Silva, and Jack Nassau

Part III Intensive Outpatient Programs (IOPs)

13 Development
 and Implementation of an Intensive Outpatient
Program for Suicidal Youth���������������������������������������������������������� 217
Jessica K. Heerschap, Molly Michaels, Jennifer L. Hughes,
and Betsy D. Kennard
14 Seattle
 Children’s Hospital’s Obsessive Compulsive
Disorder-­­Intensive Outpatient Program�������������������������������������� 235
Geoffrey A. Wiegand, Lisa Barrois, Anna Villavicencio,
Jiayi K. Lin, Alyssa Nevell, and Tilda Cvrkel
15 Evidenced-Based
 Programming for LGBTQ Young
Adults: An Intensive Outpatient Model �������������������������������������� 261
Laura M. I. Saunders and Derek A. Fenwick
16 A
 dolescent Dialectical Behavior Therapy
Intensive Outpatient Programs���������������������������������������������������� 281
Stephanie Clarke, Anaid Atasuntseva, Micaela Thordarson,
and Michele Berk
17 Co-occurring Disorders ���������������������������������������������������������������� 301
Robert Miranda Jr

Part IV Programs of Special Interest

18 Pediatric
 Pain Programs: A Day Treatment
Model at Boston Children’s Hospital ������������������������������������������ 323
Caitlin Conroy and Yasmin C. Cole-Lewis
19 T
 ransitioning to Adult Services: Young Adult Partial
Hospitalization and Intensive Outpatient Programs������������������ 341
Erin Ursillo and Gerrit van Schalkwyk
Contents xiii

20 
Integrating Day Treatment in the School Setting������������������������ 353
Carla Correia and Greta Francis
21 Wilderness Therapy ���������������������������������������������������������������������� 375
Anita R. Tucker, Christine Lynn Norton, Steven DeMille,
Brett Talbot, and Mackenzie Keefe

Part V Special Topics on Service Utilization and Follow-Up Care

22 
Family Engagement and Coaching in a Five-Day Intensive
Treatment Program for Youth with Anxiety Disorders
and OCD ���������������������������������������������������������������������������������������� 397
Elle Brennan and Stephen P. H. Whiteside
23 
Telehealth Adaptations in Day Treatment Programs ���������������� 415
Miri Bar-Halpern, Christopher Rutt, and Ryan J. Madigan
24 Inpatient Psychiatric Hospitalization������������������������������������������ 435
Alysha D. Thompson, Kyrill Gurtovenko, Connor Gallik,
McKenna Parnes, Kashi Arora, and Ravi Ramasamy
25 The Youth Crisis Stabilization Unit: An Alternative
Psychiatric Treatment Model�������������������������������������������������������� 447
Joyce T. Chen, Ericka Bruns, Zachary Schellhause,
Chanta Garcia, and Mary A. Fristad
26 Strategies to Navigate Day-­Treatment Services
and Follow-up Plans: A Guide for Families and Providers�������� 461
Jarrod M. Leffler, Stephanie Clarke, and Tara Peris
Index�������������������������������������������������������������������������������������������������������� 475
About the Editors

Jarrod M. Leffler is Associate Professor at Virginia Commonwealth

University (VCU) and Chair of the Division of Child and Adolescent
Psychology in the Department of Psychiatry. Dr. Leffler is involved in pro-
gram development and implementation and clinical activities in outpatient,
day-treatment, and inpatient settings at Virginia Treatment Center for
Children and Children’s Hospital of Richmond. Prior to joining VCU Dr.
Leffler spent 10 years developing and implementing treatment programs at
Mayo Clinic. Dr. Leffler developed and directed the Child and Adolescent
Integrated Mood Program (CAIMP), a two-week family-based partial hospi-
talization program (PHP) for youth with mood disorders and their caregivers,
and the Pediatric Transition Program (PTP) a traditional intensive outpatient
program (IOP) for youth with comorbid psychopathology as well as a dialec-
tical behavior therapy (DBT)-focused IOP. Dr. Leffler also co-developed a
consultation psychology position for the child and adolescent inpatient psy-
chiatric unit and the COVID-19+ care model for youth in need of psychiatric
care. Dr. Leffler also has experience developing a pre-school PHP. Dr. Leffler
provides clinical supervision to psychology and psychiatry fellows and
interns as well as staff members in these clinical settings. Dr. Leffler has pub-
lished clinical research on treatment models for youth and caregivers includ-
ing Multifamily Psychoeducation Psychotherapy (MF-PEP), CAIMP, and
individual-based treatment for youth with mood disorders. He has also pub-
lished research on training staff on implementing EBTs and diversity and
inclusion training. Dr. Leffler co-developed and founded the Acute,
Residential and Intensive Services Special Interest Group (AIRS SIG) of
Division 53 of the American Psychological Association and is the current co-­
chair. Dr. Leffler has also served two terms as the president of the American
Board of Child and Adolescent Psychology (ABCCAP).

Elisabeth A. Frazier is Clinical Associate Professor of Psychiatry and

Human Behavior at the Alpert Medical School of Brown University and an
attending psychologist at the Emma Pendleton Bradley Hospital. She cur-
rently provides direct clinical care to high-risk teens and families and con-
ducts supervision of psychology and psychiatry trainees across various levels
of care including inpatient, partial hospitalization, intensive outpatient, out-
patient, and juvenile detention settings. Dr. Frazier serves as the team leader
for the Bradley Hospital REACH program, a virtual telehealth adolescent
partial hospitalization program serving youth and families in the Northeastern

xv
xvi About the Editors

United States. Prior to this role, she provided clinical care in the in-person
Adolescent Partial Hospitalization Program at Bradley Hospital, a family-
based, short-­term, intensive program treating adolescents with a wide range
of psychiatric presenting problems. She was also a supervising psychologist
in the Bradley Hospital Co-Occurring Disorders Intensive Outpatient
Program, which provides evidence-­based treatment for youth with co-occur-
ring psychiatric and substance use disorders. This program was recently rec-
ognized by SAMHSA as a model program for integrated treatment. Dr.
Frazier has published clinical research including adaptation and implementa-
tion of empirically based treatment in psychiatric acute care settings, factors
contributing to pediatric mood disorders and co-morbid high-risk behaviors,
and intervention research in teens with mood, disruptive behavior, and sub-
stance use disorders in intensive outpatient and community outpatient set-
tings. Dr. Frazier also serves as co-chair of the Practice Committee of the
Acute, Residential and Intensive Services Special Interest Group (AIRS SIG)
of Division 53 of the American Psychological Association.
Contributors

Kashi Arora, BA Department of Psychiatry and Behavioral Medicine,

Seattle Children’s Hospital, Seattle, WA, USA
Anaid Atasuntseva, PhD Stanford University School of Medicine, Stanford,
CA, USA
Miri Bar-Halpern, PsyD Boston Child Study Center and Harvard Medical
School, Boston, MA, USA
Sarah E. Barnes, PhD Yale New Haven Psychiatric Hospital, Yale University
School of Medicine, New Haven, CT, USA
Lisa Barrois, PhD Department of Psychiatry and Behavioral Sciences,
Seattle Children’s Hospital, Seattle, WA, USA
Kristen L. Batejan, PhD McLean Hospital/Harvard Medical School,
Belmont, MA, USA
Michele Berk, PhD Stanford University School of Medicine, Stanford, CA,
USA
John R. Boekamp, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Elle Brennan, PhD Akron Children’s Hospital, Akron, OH, USA
Ericka Bruns, MS, Ed, LPCC-S Nationwide Children’s Hospital Big Lots
Behavioral Health Services, Columbus, OH, USA
Heather Chapman, MD Rhode Island Hospital/Hasbro Children’s Hospital,
and Department of Pediatrics, Alpert Medical School of Brown University,
Providence, RI, USA
Joyce T. Chen, MD Nationwide Children’s Hospital Big Lots Behavioral
Health Services and The Ohio State University Department of Psychiatry and
Behavioral Health, Columbus, OH, USA
Tommy Chou, MS Department of Psychiatry and Human Behavior, Alpert
Medical School of Brown University, Providence, RI and The Department of
Psychology, Florida International University, Miami, FL, USA

xvii
xviii Contributors

Stephanie Clarke, PhD Cadence Child & Adolescent Therapy, Seattle, WA,
USA
Yasmin C. Cole-Lewis, PhD, MPH Psychiatry Consultation Service,
Boston Children’s Hospital, and Department of Psychiatry and Behavioral
Sciences, Harvard Medical School, Boston, MA, USA
Caitlin Conroy, PsyD Mayo Family Pediatric Pain Rehabilitation Center,
Boston Children’s Hospital, and Department of Anesthesia, Critical Care, and
Pain Medicine, Department of Psychiatry and Behavioral Sciences, Harvard
Medical School, Boston, MA, USA
Carla Correia, PsyD Department of Psychiatry & Human Behavior, Alpert
Medical School of Brown University, Providence, RI, USA
Lifespan School Solutions, Cumberland, RI, USA
Ana Crook Rhode Island Hospital/Hasbro Children’s Hospital, Providence,
RI, USA
Tilda Cvrkel, PhD, MS Department of Clinical Psychology, Seattle Pacific
University, Seattle, WA, USA
Thamara Davis, MD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Steven DeMille, PhD Redcliff Ascent, Enterprise, UT, USA
Julie Van der Feen, MD McLean Hospital/Harvard Medical School,
Belmont, MA, USA
Newton-Wellesley Hospital, Newton, MA, USA
Derek A. Fenwick, PsyD Institute of Living - Hartford HealthCare, Hartford,
CT, USA
Greta Francis, PhD, ABPP Department of Psychiatry & Human Behavior,
Alpert Medical School of Brown University, Providence, RI, USA
Lifespan School Solutions, Cumberland, RI, USA
Elisabeth A. Frazier, PhD The Alpert Medical School of Brown University,
Providence, RI, USA
E.P. Bradley Hospital, Riverside, RI, USA
Mary A. Fristad, PhD, ABPP Nationwide Children’s Hospital Big Lots
Behavioral Health Services and The Ohio State University Department of
Psychiatry and Behavioral Health, Columbus, OH, USA
Jamie Gainor, MD Rhode Island Hospital/Hasbro Children’s Hospital, and
Department of Psychiatry and Human Behavior, Alpert Medical School of
Brown University, Providence, RI, USA
Connor Gallik, PhD Department of Psychiatry and Behavioral Medicine,
Seattle Children’s Hospital, Seattle, WA, USA
Contributors xix

Abbe Garcia, PhD E.P. Bradley Hospital, Riverside, RI, USA

Alpert Medical School of Brown University, Providence, RI, USA
Chanta Garcia, LISW-S Nationwide Children’s Hospital Big Lots
Behavioral Health Services, Columbus, OH, USA
Kyrill Gurtovenko, PhD Department of Psychiatry and Behavioral
Medicine, Seattle Children’s Hospital, Seattle, WA
Department of Psychiatry and Behavioral Sciences, University of Washington,
Seattle, WA, USA
Brittany Hayden, PhD Sarah A. Reed Children’s Center, Erie, PA, USA
Jessica K. Heerschap, PhD Department of Psychiatry, Children’s Health
Children’s Medical Center, and Department of Psychiatry, University of
Texas Southwestern Medical Center, Dallas, TX, USA
Jennifer L. Hughes, PhD, MPH Department of Psychiatry and Behavioral
Health, The Ohio State University and Big Lots Behavioral Health Services,
Nationwide Children’s Hospital, Columbus, OH, USA
Heather L. Hunter, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Megan Kale, MSW, , LCSW-S The Menninger Clinic, Houston, TX, USA
Mackenzie Keefe, BS University of New Hampshire, Durham, NH, USA
Betsy D. Kennard, PsyD, ABPP Department of Psychiatry, Children’s
Health Children’s Medical Center, and Department of Psychiatry, University
of Texas Southwestern Medical Center, Dallas, TX, USA
Amelia Kruser, MA Department of Psychiatry and Psychology, Mayo
Clinic, Rochester, MN, USA
Jarrod M. Leffler, PhD, ABPP Department of Psychiatry, Virginia
Commonwealth University, Children’s Hospital of Richmond, and Virginia
Treatment Center for Children, Richmond, VA, USA
Jiayi K. Lin, PsyD Columbia University Clinic for Anxiety and Related
Disorders (CUCARD), Columbia University Medical Center New York, NY,
USA
Lydia Lin, BA E.P. Bradley Hospital, Riverside, RI, USA
Jaime Lovelace, MSN, BS, RN, PMH-BC Children’s Hospital of
Richmond, and Virginia Treatment Center for Children, Richmond, VA, USA
Heather A. MacPherson, PhD Clinical Psychology Department, William
James College, Newton, MA, USA
Ryan J. Madigan, PsyD Boston Child Study Center, Boston, MA, USA
Sarah E. Martin, PhD Psychology Department, Simmons University,
Boston, MA, USA
xx Contributors

Ruben G. Martinez, PhD University of California, Los Angeles, Los

Angeles, CA, USA
Maya Massing-Schaffer, MA Department of Psychiatry and Human
Behavior, Alpert Medical School of Brown University, Providence, RI, USA
James T. McCracken, MD University of California, Los Angeles, Los
Angeles, CA, USA
Molly Michaels, MA Department of Psychiatry, University of Texas
Southwestern Medical Center, Dallas, TX, USA
Robert Miranda Jr, PhD Brown University Center for Alcohol and
Addiction Studies, Providence, RI, USA
E.P. Bradley Hospital, Riverside, RI, USA
Ryann Morrison, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Jack Nassau, PhD Rhode Island Hospital/Hasbro Children’s Hospital, and
Department of Psychiatry and Human Behavior, Alpert Medical School of
Brown University, Providence, RI, USA
Alyssa Nevell, PhD Department of Psychiatry and Behavioral Sciences,
Seattle Children’s Hospital, Seattle, WA, USA
Christine Lynn Norton, PhD, MSW Texas State University, San Marcos,
San Marcos, TX, USA
Stephanie Parade, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
McKenna Parnes, MS Department of Psychiatry and Behavioral Medicine,
Seattle Children’s Hospital, Seattle, WA, USA
Department of Psychiatry and Behavioral Sciences, University of Washington,
Seattle, WA, USA
Katherine Partridge, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Michelle A. Patriquin, PhD, ABPP The Menninger Clinic, and Baylor
College of Medicine, Houston, TX, USA
Cheryl Peck, RN Rhode Island Hospital/Hasbro Children’s Hospital,
Providence, RI, USA
Tara S. Peris, PhD University of California, Los Angeles, Los Angeles, CA,
USA
Contributors xxi

Ravi Ramasamy, MD Department of Psychiatry and Behavioral Medicine,

Seattle Children’s Hospital, and Department of Psychiatry and Behavioral
Sciences, University of Washington, Seattle, WA, USA
Megan E. Rech, BA The Menninger Clinic, Houston, TX, USA
Maria Regan, LICSW E.P. Bradley Hospital, Riverside, RI, USA
Katharine Reynolds, PhD University of Colorado, Anschutz Medical
Campus, and Children’s Hospital Colorado, Aurora, CO, USA
Giulia Righi, PhD E.P. Bradley Hospital, Riverside, RI, USA
Christopher Rutt, PhD Boston Child Study Center, Boston, MA, USA
Laura M. I. Saunders, PsyD, ABPP Institute of Living - Hartford
HealthCare, Hartford, CT, USA
Gerrit van Schalkwyk, MD Department of Pediatrics, Division of
Behavioral Health, University of Utah School of Medicine, Salt Lake City,
UT, USA
Zachary Schellhause, LPCC-S Nationwide Children’s Hospital Big Lots
Behavioral Health Services, Columbus, OH, USA
Benjamin N. Schneider, MD University of California, Los Angeles, Los
Angeles, CA, USA
Eric Schwartz, PsyD, ABPP Private Practice, Hopewell Health Solutions,
Glastonbury and West Hartford, CT, USA
Donna Silva Rhode Island Hospital/Hasbro Children’s Hospital, Providence,
RI, USA
Kathryn Simon, PhD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Anthony Spirito, PhD Department of Psychiatry and Human Behavior,
Alpert Medical School of Brown University, Providence, RI, USA
Abby De Steiguer, MSc Department of Psychology, The University of
Texas at Austin, Austin, TX, USA
Kristyn Storey, MD E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Brett Talbot, PhD Redcliff Ascent, Enterprise, UT, USA
Alysha D. Thompson, PhD Department of Psychiatry and Behavioral
Medicine, Seattle Children’s Hospital, Seattle, WA
Department of Psychiatry and Behavioral Sciences, University of Washington,
Seattle, WA, USA
xxii Contributors

Micaela Thordarson, PhD Children’s Hospital of Orange County, Orange,

CA, USA
Anita R. Tucker, PhD, MSW Department of Social Work, University of
New Hampshire, Durham, NH, USA
Erin Ursillo, LMHC Care New England, Butler Hospital, Partial Hospital
and Intensive Outpatient Programs, Providence, RI, USA
Anna Villavicencio, PhD Washington Anxiety Center of Capitol Hill,
Washington, DC, USA
Anne Walters, PhD, ABPP E.P. Bradley Hospital, Riverside, RI, USA
Department of Psychiatry and Human Behavior, Alpert Medical School,
Brown University, Providence, RI, USA
Michael Walther, PhD E.P. Bradley Hospital, Riverside, RI, USA
Alpert Medical School of Brown University, Providence, RI, USA
Stephen P. H. Whiteside, PhD, ABPP Department of Psychiatry and
Psychology, Mayo Clinic, Rochester, MN, USA
Geoffrey A. Wiegand, PhD Department of Psychiatry and Behavioral
Sciences, Seattle Children’s Hospital, Seattle, WA, USA
Jennifer Wolff, PhD Department of Psychiatry and Human Behavior, Alpert
Medical School of Brown University, Providence, RI, USA
Peg Worden, PsyD McLean Hospital/Harvard Medical School, Belmont,
MA, USA
Kate J. Zelic, PhD Children’s Hospitals and Clinics of Minnesota,
Minneapolis, MN, USA
 Part I
Building Blocks of Day Treatment
Programs
 Introduction and Overview of Day
Treatment Programs 1
Jarrod M. Leffler and Elisabeth A. Frazier

Navigating the mental healthcare system in the is a more restricted, acute, and short-term treat-
United States that consists of a range of services ment) that are sometimes referred to as interme-
across a care continuum can be overwhelming diate levels of care or more commonly day
and confusing. Within this mental healthcare treatment programs. These programs can fill a
continuum, there are many different types of pro- treatment void between outpatient and inpatient
viders, treatment settings, and interventions, treatment and may provide more intensive and
which can complicate and potentially delay appropriate treatment for specific mental health
access to the most appropriate and effective treat- concerns. This book aims to cut through the con-
ment. Further, this care continuum and access to fusion of the mental healthcare continuum and
mental health services within the continuum can provide a comprehensive resource for under-
vary by geographic location, age, presenting con- standing mental health day treatment programs
cern, and insurance coverage. As a result of this for youth, which include partial hospitalization
daunting and confusing system, patients and fam- programs (PHPs) and intensive outpatient pro-
ilies may experience a delay in accessing care grams (IOPs). This handbook is intended for cli-
leading to an increase in mental health struggles nicians, trainees, administrators, educators,
and potential crises (Merikangas et al., 2011). researchers, and consumers of mental health ser-
This delay can further result in a mental health vices looking to better understand current PHP
crisis requiring a higher level of care (e.g., emer- and IOP treatment models. Our aim is for this
gency department visits and inpatient psychiatric text to lay out the purpose, content, and impact of
hospitalization). these day treatment programs as well as provide
Within the mental healthcare continuum, there practical information on how to implement and
are services between traditional outpatient ther- access programs at this level of care (LOC). IOPs
apy (e.g., weekly one-hour therapy sessions) and and PHPs have evolved for decades and have
inpatient psychiatric hospitalization (IPH; which included the addition of evidence-based treat-
ment interventions along with measurement of
treatment outcomes (Block et al., 1991; Block &
J. M. Leffler (*)
Department of Psychiatry, Division of Child and Lefkovitz, 1991; Casarino et al., 1982; Haag
Adolescent Psychology, Virginia Commonwealth Granello et al., 2000; Kiser et al., 1995;
University, Children’s Hospital of Richmond, and Kotsopoulos et al., 1996; Leffler et al., 2021;
Virginia Treatment Center for Children, Leffler & D’Angelo, 2020; Martino et al., 2020;
Richmond, VA, USA
e-mail: [email protected] Shaffer et al., 2019; Weir & Bidwell, 2000), and
these modifications will be highlighted along
E. A. Frazier
Department of Psychiatry and Human Behavior, with unique elements of this level of care. Further,
Bradley Hospital/Brown University, this handbook will provide an overview of strate-
Providence, RI, USA gies to develop and assess treatment programs
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 3

J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_1
4 J. M. Leffler and E. A. Frazier

that implement science into their treatment and managing the stressors associated with a
approach with many programs implementing more typical level of daily functioning.
evidence-based and evidence-informed treatment PHPs and IOPs share several commonalities.
protocols targeting specific treatment concerns Both of these intermediate LOC provide more
and goals. intensive services than what can be accessed in an
outpatient setting and are a step-down LOC from
IPH or residential programs. Unlike IPH and resi-
What Are Day Treatment Programs? dential programs, day treatment programs occur
several hours during the day, and the patient
Mental health day treatment programs for youth returns home each day after program. These pro-
provide an intensive, milieu-based treatment set- grams can be held at hospitals, academic medical
ting that provides a higher level of care and more centers, community mental health centers, and
intense and frequent therapeutic support than larger group practices. They are typically run by
typical outpatient psychotherapy. This LOC is multidisciplinary and integrated care teams con-
often utilized as a step-up (increased LOC from sisting of psychiatrists, nurses, psychologists,
outpatient) as well as a step-down (decreased social workers, and therapists/behavioral health
LOC from IPH). More specifically, youth, their specialist. There may be other medical providers
families, and their treatment providers may find on staff and complementary interventions pro-
that meeting with a therapist once a week in an vided by art therapists, music therapist, occupa-
outpatient setting no longer meets that patient’s tional therapists, recreation therapists, academic
needs, or perhaps an increase in psychosocial tutors/teachers, and dieticians and nutritionists
stressors has exacerbated psychiatric symptoms depending on the treatment population of the pro-
and reduced functioning, and the patient requires gram. Programming typically consists of various
more intensive care for a period of time, on a group therapies; medication management; indi-
locked IPH unit. On the other hand, perhaps a vidual and family therapy; coordination of care
youth who has been medically and psychiatri- with community providers, schools, and other
cally stabilized on an IPH unit is determined to agencies involved in the youth’s care; and the
be safe enough to leave the inpatient hospital set- complementary services provided by the afore-
ting, but they need a gradual decrease in support mentioned specialists.
in order to maintain safety and practice therapeu- While there are some similarities among PHPs
tic skills in the context of their daily life so that and IOPs, there are also many differences that
they do not quickly reexperience a mental health make them distinct LOC. PHPs are more inten-
crisis and subsequently require rehospitalization. sive and tend to require at least 4 hours a day and
Day treatment programs provide this supportive occur at least 5 days a week (Rosser & Michael,
environment and gradual decrease in service 2021). These programs are designed to address
intensity to encourage a smooth transition the needs of patients with acute psychiatric needs
through the continuum of mental health LOC and yet do not require the 24/7 observation and moni-
prevent IPH rehospitalization during the high-­ toring that is offered in an IPH. IOPs still provide
risk period of the month following discharge a more intensive LOC compared to outpatient
from an IPH (Chung et al., 2019; Fontanella treatment, but these programs are typically less
et al., 2020). Rather than transitioning from intense than PHPs. They tend to last at least
around the clock care to seeing an outpatient 3 hours a day for at least 3 days a week (Rosser &
therapist for an hour or two a week, PHPs and Michael, 2021). IOPs are designed for youth who
IOPs provide an opportunity for ongoing and require more support than outpatient therapy but
consistent treatment multiple days a week for are able to manage the demands of attending
several hours of the day while supporting youth school and other daily responsibilities and are
in transitioning back to living at home, engaging functioning at a more independent level than
in daily social, work, and education expectations, those who may be experiencing a more acute cri-
1 Introduction and Overview of Day Treatment Programs 5

sis and require the higher LOC consistent with  art I: Building Blocks of Day
P
PHP. Treatment Programs

In the first section of the handbook (Chaps. 2, 3,

Handbook Overview 4, and 5), we provide general information about
day treatment programs, starting with their his-
The goal of this book is to provide a valuable tory and purpose. These programs have been
addition to any student, practitioner, available for several decades and have undergone
researcher, education, administrator, or con- modification and changes impacted by treatment
sumer of psychiatric services for youth. In the needs of patients as well as financial drivers and
following chapters, we review the history of the COVID-19 pandemic. Chapter 2 provides an
PHPs and IOPs and highlight current PHP and overview of almost a century of mental health
IOP care models, demonstrating the increase care and the role of day treatment programs for
in the development and implementation of evi- youth. The authors discuss the role of day treat-
dence-based day treatment programs for ment programs within the larger continuum of
youth. This book is the first of its kind to psychiatric care for youth as well as types of day
review these treatment models in PHP and IOP treatment programs, the functions and goals of
settings and provides insight into program these programs, and the populations they aim to
development, implementation and training, serve. Information provided in this chapter will
and considerations for dissemination and sus- lay the foundation for the content covered
tainability. The following chapters provide throughout this handbook, using the diverse
descriptions of interventions designed to youth programs developed at The Menninger
enhance the well-being of youth experiencing Clinic since its foundation in 1925, as an illustra-
a range of mental health concerns and their tive example of this intermediate level of mental
families. Additionally, we share feasible strat- health care.
egies for implementing assessment and mea- Due to the need for day treatment programs
surement to gather and integrate meaningful within the continuum of treatment for youth,
clinical outcomes in PHP and IOP programs. mental health facilities may need to consider
The current handbook can also be utilized as developing or adapting and implementing a PHP
a treatment referral resource for professionals or IOP. Chapter 3 provides content for such
and laypersons. This text provides information needs. Content in Chap. 3 addresses consider-
about the process of accessing and utilizing ations for assessing the need for a day treatment
these intensive services as well as additional program within a larger mental healthcare sys-
treatment resources that may be necessary in the tem. This includes identifying and accessing
continuum of mental health care for youth. resources, working with administration and
This book is a must-have resource for other key stakeholders, staffing models, financial
clinicians/therapists and related professionals, considerations, treatment selections, determin-
researchers, educators, and consumers of men- ing the patient population, engaging community
tal health services, as well as graduate and referral networks, and various other consider-
undergraduate students in pediatric, clinical ations when developing and implementing day
child and adolescent, school, and developmental treatment programs for youth. The authors pro-
psychology, psychiatry, social work, counsel- vide concrete steps and considerations for build-
ing, family studies, and public health and policy, ing a day treatment program from determining
as well as other areas of medicine, mental health the type of program and treatment duration that
service, and administration. would be needed, identifying federal and hospi-
6 J. M. Leffler and E. A. Frazier

tal accreditation regulations, setting up the phys- As day treatment programs have evolved so
ical program space, and essential treatment has assessment and measurement of treatment
elements, to determining the program’s target interventions and factors impacting treatment
population, level of family involvement, medical and functional outcomes, staff and stakeholder
needs, facilitating access to care, billing and experiences, use of data to inform treatment
insurance issues, and integrating evidence based interventions, and program evaluation. To address
assessment and treatment. This chapter illus- these updates and strategies, Chap. 5 reviews
trates models for program development, strate- assessment and clinical outcomes in day treat-
gies for working with stakeholders, staffing ment programs. In this chapter, the authors pres-
models, and building an integrated treatment ent the history and importance of
team. There are also suggestions for working measurement-based care (MBC) in child and
with community providers and schools as well as adolescent day treatment programs, providing
cultural considerations for providing inclusive clinical examples from ongoing outcomes moni-
programming. toring in a child and adolescent day treatment
Given the multidisciplinary and integrated program at The Menninger Clinic. This chapter
treatment team structure of PHPs and IOPs, they includes discussion of the unique vulnerabilities
are ripe for training staff and other learners. To that youth in day treatment programs face that
address this element of day treatment programs, necessitate outcomes monitoring as well as its
we provide general considerations regarding advantages and limitations in these intensive care
training and the implementation of empirically settings. Rationale for integrating MBC in acute
based treatment in day treatment settings in care settings and tips for successful implementa-
Chap. 4. This includes adaptations to consider tion are discussed, along with a review of the evi-
when translating research into practice, common dence based for MBC in adults and youth,
hurdles and suggestions for overcoming these proposed mechanisms of action, and benefits of
issues, maintaining treatment fidelity and reduc- use. The authors also provide examples of barri-
ing drift while tailoring treatment to the individ- ers and recommendations for overcoming the
ual patient, and practical strategies for training challenges of integrating MBC in day treatment
treatment providers and students in day treatment programs for youth.
settings. The authors share models such as the
Mental Health Systems Ecological Model
(MHSE; Southam-Gerow et al., 2006, 2012) to  art II: Partial Hospitalization
P
guide implementation of empirically based treat- Programs (PHPs)
ment beyond the research setting. They then pro-
vide suggestions for adapting interventions for The second section of this handbook details sev-
day treatment programs by considering patient eral different PHPs in the United States, special-
factors common in acute care settings, such as izing in certain age groups, psychopathologies,
comorbid presenting problems and high acuity, and interventions. Chapter 6 begins with general-
developmental limitations, challenging family ist, family-based programs for infancy through
system dynamics, patient diversity, and time con- latency age children, treating a wide variety of
straints that may impact treatment planning due presenting problems and psychosocial chal-
to insurance coverage and the often short-term lenges. This chapter will focus on the strengths
nature of day treatment programs. Therapist and and challenges of programs for young children
organizational factors are also discussed that may that welcome a wide range of psychiatric and
impact engagement in adopting evidence based functional impairments. Issues of program devel-
techniques. Lastly, this chapter covers training opment and tailoring treatment while managing
models, methods to address burnout, and lessons diverse caseloads will be discussed in addition to
learned to maintain fidelity and longevity of the crucial role of parents and families in the
intervention implementation. intensive treatment of young children. The
1 Introduction and Overview of Day Treatment Programs 7

authors provide details regarding the evolution of group programming, and management of mental
their PHPs for young children, highlighting health crises and high-risk behaviors. This chap-
issues of inclusion and exclusion criteria, safety ter also provides a model for program design and
management related to aggression and self-harm, implementation; staffing recommendations; how
financial considerations and getting support from to structure and organize group, individual, and
stakeholders, and details of their daily program- family therapy treatment modalities within a two-­
ming. They provide details regarding adaptations week program; and the process of integrating
of well-established treatments such as Incredible evidence-based assessment to inform treatment
Years (Webster-Stratton et al., 2004) and Parent-­ approaches and determine efficacy and effective-
Child Interaction Therapy (Berkovits et al., 2010) ness. The authors also share an overview of
as well as other CBT, DBT, and mindfulness evidence-­based treatments for youth with mood
interventions used in their programs. This chap- disorders and the importance of disseminating
ter also provides details about the standardized such interventions through collaborations in the
assessment battery of psychopathology, child community. Lastly, this chapter ends with lesson
functional outcomes, parent-child relationship, learned regarding how to integrate research and
parental functioning, and family dynamics used practice to inform the field of evidence-based
to inform case conceptualization and treatment care in day treatment programs in addition to pro-
planning. The authors highlight the importance viding high quality care for patients, as well as
of family therapy and consistent communication considerations for building a similar program in
and collaboration between families and the treat- other healthcare systems.
ment team as well as collaboration with schools Next, Chap. 8 details the implementation of an
and community providers in order to maximize evidence-based PHP for children with comorbid
and generalize treatment gains. They also discuss psychopathology and explores the management
the role of psychiatry and psychotropic medica- of challenging behavioral concerns within a cog-
tion in treating young children with acute mental nitive behavioral therapy (CBT) and parent
health challenges and the various disciplines that training-­focused program known as the
come together in their interdisciplinary team to University of California – Los Angeles
provide high quality care. Lastly, the authors Achievement, Behavior & Cognition (ABC) pro-
share information about their active clinical gram. This chapter outlines the ABC program’s
research projects examining descriptive and history and goals, describes the demographics of
effectiveness studies within their day treatment their patient population consisting of multiple
programs. psychiatric and medical comorbidities, the struc-
Chapter 7 focuses on an integrated PHP for ture and collaborations of the interdisciplinary
children and adolescents with mood disorders. team required to treat these children, and the
Here we review the Child and Adolescent holistic approach that incorporates empirically
Integrated Mood Program (CAIMP), a two-week based treatment to help children and families
family-based PHP for youth with mood disorders improve their well-being. The authors describe a
who require more intensive treatment beyond tra- typical treatment course in this PHP including
ditional outpatient therapy or who are stepping admission screening, clinical assessment, case
down from IPH. This multidisciplinary program conceptualization, measurement-based care,
for youth ages 8 to 18, and their caregivers inte- individual, group, and family interventions, dis-
grates evidence-based treatment elements into a charge planning, and communication with exter-
unified treatment program. The authors discuss nal providers. Program development issues
the unique needs of this population and provide related to costs, staffing, navigating institutional
details about demographics of the youth they limitations, and capturing indices of success are
serve as well as concrete information about the also detailed in this chapter. Lastly, the authors
program structure such as a detailed program provide insights into lessons they have learned in
schedule, physical space needs, specifics of skills treating acute psychopathology in children with
8 J. M. Leffler and E. A. Frazier

multiple presenting problems and diagnoses at of group therapy/skills training, individual ther-
the PHP level of care. apy, family involvement, psychiatric consultation,
Chapter 9 reviews the unique treatment homework, parent and youth skills coaching, con-
approaches required for developmental sultation team, program extensions, and discharge
­disabilities and autism spectrum disorders. This planning. This chapter also provides guidance
chapter highlights these specific needs and how regarding diversity considerations, training, work-
intensive services were designed and imple- ing with stakeholders and within the expectations
mented to provide an appropriate and successful of a larger institution, and the challenges of insur-
treatment approach using evidence-based inter- ance reimbursement for this intensive treatment
ventions specific to this population. The authors model with highly acute youth. Lastly, the authors
detail their patient population and the various share their ongoing clinical research and future
strategies utilized throughout the program day initiatives.
that differ from programs for neurotypical youth, Chapter 11 explores an intensive exposure
such as specific environmental consideration in with response prevention (ERP)-based day treat-
the physical program space, need for visual ment program for youth with obsessive-­
instructions and prompts, specialized training, compulsive disorder (OCD) and other anxiety
integration of speech and language and occupa- disorders. This chapter details program develop-
tion therapies, and specialized assessments and ment and design of the unique structure of pro-
therapeutic interventions. Addressing safety viding hospital-based as well as community-based
issues related to aggression and self-injurious interventions in this population. Issues related to
behaviors are addressed. This chapter discusses staff training, billing, building individualized
the various groups required to meet the variety of treatment plans, and utilizing the strengths of an
needs in this population, including social skills, interdisciplinary team are discussed. This chapter
music therapy, art therapy, nursing education, also highlights integration of a robust clinical
emotion regulation skills, occupational therapy, research program that seamlessly bridges science
and speech and language therapy. The authors and practice. The authors present their full-day
discuss integration of reward systems, social sto- and half-day PHPs, including the use of home
ries, picture schedules, and other adaptations to visits to generalize treatment gains to each
support treatment gains. They also discuss the patient’s daily life. Collaboration with families
challenges of diagnosis and evidence-based tools and teaching them to become exposure coaches
used to assess autism spectrum disorders. A case for their children helps empower families in this
example is included to help illustrate the program program and increases treatment dose through
structure and benefits. Clinical outcomes research homework between sessions. This chapter
is discussed, providing an example of how to includes details regarding finances and working
integrate research and practice to continue to with stakeholders, including parent stakeholders
grow along with the evidence base and provide as a crucial piece of program longevity. Concrete
cutting-edge treatment. information about the program day, including the
Chapter 10 focuses on the world-renowned structure of assessments and interventions, a
dialectical behavior therapy (DBT) PHP for youth daily schedule, rationale behind the program
at McLean Hospital. In addition to exploring how design, and strategies of integrating families,
programming addresses the high-risk population schools, and outpatient providers are also
it serves in this acute care setting, this chapter also included. Lastly, the authors discuss the chal-
highlights issues related to managing trauma, sui- lenges of integrating clinical research in the PHP
cidality, and self-injurious behaviors in the day setting and share tips for managing and expand-
treatment setting. The authors provide a brief his- ing programming to meet patient needs.
tory of their program, the structure and goals of Lastly, in the second section of this handbook,
treatment in this PHP, a description of the patient Chap. 12 focuses on managing the treatment
population, and details regarding the components needs of youth with comorbid medical and psy-
1 Introduction and Overview of Day Treatment Programs 9

chiatric issues in the PHP setting. This chapter the need for IOP LOC with this population and
illustrates the thoughtful conceptualization, indi- review the development and implementation of
vidualized treatment planning, and the SPARC program. They provide details
­multidisciplinary teamwork that integrates vari- regarding program structure, intake procedures,
ous specialties to address the needs of this popu- and the treatment components (teen groups,
lation. The critical role of family involvement, multifamily groups, parent education, individual
coordination of care, and the importance of therapy, family therapy, and medication manage-
simultaneously addressing the transactional rela- ment) that make this program effective and
tionship between physical and mental health is unique. The authors highlight their safety proce-
discussed. The authors provide information on dures, which are described in detail, including
the history and evolution of their program and the the use of chain analysis to inform treatment
unique benefits and challenges of working within planning. Lastly, this chapter provides helpful
a medical hospital setting to treat comorbid men- information on how to integrate outcome mea-
tal health and physical illness. They offer guid- sures and quality improvement efforts in a busy
ance regarding “Community Rules” and IOP environment.
expectations for being a member of their PHP Chapter 14 details the treatment of OCD in the
community and milieu and the structure of the IOP setting in the family-based Seattle Children’s
milieu environment, including the use of the Hospital Obsessive Compulsive Disorder-­
“Point Store” reward system. This chapter high- Intensive Outpatient Program (Scheme OCD-­
lights the important contributions of various dis- IOP). This program utilizes exposure and
ciplines to create an interdisciplinary team that response prevention (ERP) therapy to treat severe
provides unified messaging to patients and fami- OCD in youth from multiple states (Washington,
lies about program philosophy. The authors share Alaska, Montana, and Idaho). Treatment format
their approach to individual and family therapies, and outcomes are presented along with modifica-
collaborations with pediatrics, psychiatry, and tions during the COVID-19 pandemic. The
nutrition and discuss the use of after-hours sup- authors share how they target three main goals:
port. Case examples are included to illustrate the (1) reduce OCD symptomatology and related
presenting problems, impressive teamwork, and impairment, (2) help the patient and family build
assessment and interventions strategies utilized CBT skills to manage OCD in their daily lives,
in this medical/psychiatric PHP for youth. and (3) provide training to students and profes-
sionals to improve access to evidence-based care
for OCD in surrounding communities. Details
 art III: Intensive Outpatient
P regarding the evolution of this program are
Programs (IOPs) described from building stakeholders to main-
taining integration of research and practice to dis-
Part III of the handbook discusses the structure seminate empirically based interventions and
and treatment elements of several innovative provide high-quality care at an acute level.
IOP care models. Chapter 13 focuses on address- Program details including a weekly schedule,
ing suicide in the IOP setting, highlighting the how empirically based assessments are incorpo-
Suicide Prevention and Resilience at Children’s rated, clinical approaches to utilizing ERP in the
(SPARC) program for adolescents, which imple- IOP format, family involvement, and coordina-
ments evidence based elements to address sui- tion with schools are included. The authors pro-
cide with positive outcomes. Components of vide all of this information within the framework
CBT, DBT, mindfulness CBT, and relapse pre- of following the program’s Four Golden Rules
vention CBT are discussed. Updated statistics on (Ride the Wave, Do the Opposite, Thoughts Not
adolescent suicide and a review of current effec- Actions, and Be an OCD Detective) and share
tive treatments, including technology-based several past and future clinical research
treatments, are included. The authors describe endeavors.
10 J. M. Leffler and E. A. Frazier

Chapter 15 explores potential reasons for Lastly in this section, Chap. 17 covers the his-
why LGBTQ+ individuals represent a dispro- torical arbitrary separation of mental health and
portionate percentage of youth in intensive psy- substance use treatment despite research support-
chiatric services. This chapter discusses the ing integrated treatment and the remaining hesi-
factors ­contributing to stressors in this popula- tancy many clinicians have treating substance
tion and how a treatment program was devel- misuse, particularly in youth. This chapter pro-
oped to meet the specific needs of these youth. vides an overview of how empirically based
The authors review the steps they took to build treatments for co-occurring disorders are adapted
this IOP from the ground up, developing their to youth in an intensive outpatient setting. It also
team structure, navigating billing and insur- discusses the challenges of treating substance use
ance, and figuring out how this program fits in a facility designed for psychiatric care and the
within their greater healthcare system. unique confidentiality issues that arise in this
Theoretical foundations and clinical consider- population. This chapter focuses on Bradley Vista
ations in building the program are reviewed in an IOP for adolescents with co-occurring disor-
detail and illustrated with a case example. ders at Bradley Hospital. Bradley Vista is a model
Specifics regarding referrals, intake procedures, treatment program designated by the Substance
the therapeutic impact of the program milieu, Abuse and Mental Health Services Administration
considerations related to self-­disclosure, crises (SAMHSA). Concrete details regarding assess-
management, daily programming, managing ment and treatment protocols; managing the
stigma and shame, and support services related milieu; coordinating individual, group, and fam-
to vocational and care coordination are also ily therapies; converting to a telehealth platform;
included. and integrating research and practice are pro-
Next, Chap. 16 discusses the ways in which vided to inform clinicians, administrators, and
standard DBT has been embedded within an other stakeholders about how to build and main-
IOP treatment setting, with specific focus on the tain an empirically based program for adolescent
Stanford-Children’s Health Council Reaching co-occurring mental health and substance use
Interpersonal and Self Effectiveness (RISE) disorders to provide high-quality care for this
program and the Children’s Hospital of Orange underserved population.
County (CHOC) IOP. This chapter includes
considerations for when to refer to an IOP, and
extant and future directions for research in this Part IV: Programs of Special Interest
area. The authors provide a brief review of sui-
cide and non-­suicidal self-injury in adolescence, In the fourth section of this handbook, we explore
how these two separate actions are related, and specialized programs that treat chronic pain, sup-
current empirically supported treatments for port youth transitioning into young adulthood,
these high-­ risk behaviors. The author’s over- and focus on the importance of family engage-
view of the RISE and CHOC IOP DBT pro- ment in the successful treatment of youth in day
grams includes highlights of the similarities and treatment settings. Chapter 18 details the Mayo
differences in how standard DBT has been Family Pediatric Pain Rehabilitation Center
adapted to fit the needs of the patients in the IOP (PPRC) a unified intensive interdisciplinary pain
level of care. Issues of generalizing treatment treatment (IIPT) day treatment program for chil-
gains and collaborating with families and out- dren and adolescents between 8 and 18 years of
side providers are discussed as well as issues age who experience ongoing chronic pain and
related to insurance and cost-effectiveness, functional impairments. This chapter focuses on
safety and potential contagion on the milieu, the use of the day treatment model of care as an
careful considerations about admission criteria effective and unique approach to treating pediat-
and preadmission commitments, and virtual ric chronic pain, emphasizing interdisciplinary
care models. collaboration and the unique value of day treat-
1 Introduction and Overview of Day Treatment Programs 11

ment in comparison to inpatient or outpatient Next, Chap. 20, details the integration of day
treatment approaches. The authors provide a treatment in the school setting, highlighting the
detailed overview of their program, from admis- programming at Lifespan School Solutions. This
sion through discharge and collaborating with chapter explores how this agency implements
providers in various fields. This program sup- individualized educational services in support of
ports the ultimate goal of helping patients return the academic, emotional, social, and behavioral
to functioning and potentially reduce pain long health of youth. Strategies for blending program-
term. Program elements unique to this special- ming and therapeutic structure to seamlessly
ized IOP such as treatment team members and integrate clinical support services into a school
cross-discipline collaborations, admission crite- day for youth with varying mental health needs
ria, physical program space, navigating insurance are discussed. The authors provide information
reimbursement, family involvement, and the spe- on the evolution of their program and the students
cialized daily programming are all discussed in they serve as well as the critical collaborations
detail within the theoretical framework of the with local schools and educational agencies that
program. Assessment methods, treatment make this program so special. Detailed informa-
approaches, behavioral management, and crisis tion on the process of creating and maintaining
intervention are also discussed with a case exam- this program, including administration and staff-
ple included to highlight the patient experience. ing structure, classroom schedules and integrated
The authors include insights on collaborations educational and academic interventions, staff
and keys to success for generalizing treatment development and ongoing trainings, integration
gains and maintaining a high-quality, evidence-­ of trainees, building and maintaining stakehold-
based IOP in this population. ers, and keeping up with educational guidelines
Next, Chap. 19 is devoted to the unique chal- and laws are discussed. In addition, the authors
lenge youth face when transitioning from pediat- highlight clinical approaches for crisis manage-
ric mental health services into the adult mental ment, using evidence-based assessment and
health system. There are practical challenges intervention, working collaboratively with fami-
related to insurance, housing, and confidentiality, lies and school districts, and considerations for
all which occur in the context of the developmen- cultural adaptations including case examples to
tal challenges of late adolescence and young illustrate their approach.
adulthood. This chapter explores the develop- Lastly in Part IV, Chap. 21 overviews the
ment and implementation of a day treatment pro- structure and use of wilderness programs,
gram specifically designed to meet the needs of referred to as Outdoor Behavioral Healthcare
the young adult population and how program- (OBH). OBH provides an intermediate level of
ming is tailored to address the aforementioned care which engages youth for prolonged periods
stressors. It also outlines coordination of care to of time, living outdoors in a group setting, often
bridge youth and adult services and how clini- on expedition, with ongoing individual, family,
cians balance fostering independence with broad- and group therapy. This chapter provides a brief
ening social supports. The authors explore some history of OBH programs, the evolution of regu-
of the lessons they have learned throughout the latory agencies in this field, and presents stan-
development, implementation, and maintenance dards of care in OBH programs. The authors
of this unique program. They share features describe types of OBH treatment, common com-
related to access to care, patient and program ponents of treatment, the role of nature, risk man-
goodness of fit, designing a developmentally agement and safety, family involvement, and
appropriate curriculum, and facilitating psycho- insights into populations served by these pro-
social success within their program’s philosophy grams. Outcome research and the importance of
focused on strength and resilience. Special con- training and supervision within the OBH model
siderations related to family involvement and to develop and maintain best practices are dis-
aftercare planning are also discussed. cussed. The authors also highlight current
12 J. M. Leffler and E. A. Frazier

endeavors and future directions for OBH includ- pros and cons of telehealth versus in-person treat-
ing client progress monitoring, insurance and ment for youth. Issues related to training and ori-
accessibility, and diversity of staff and clients. entation, confidentiality, liability, technological
considerations, risk assessment, work-life bal-
ance with remote work, and potential future utili-
Part V: Special Topics on Service zation of telehealth day treatment are also
Utilization and Follow-Up Care addressed.
Chapter 24 highlights inpatient psychiatric
The fifth and final section of this handbook cov- hospitalization, which may be necessary if it is
ers topics related to service utilization and fol- determined that a child or adolescent in a day
low-­up care options after discharging from a day treatment program needs a higher level of care,
treatment program. This section begins with most likely due to the inability to maintain safety
Chap. 22, which illustrates the importance of outside of a locked hospital setting. Youth may
family engagement and coaching in effective also step down to day treatment services from
treatment of youth in day treatment settings. This IPH programs as an intermediate treatment option
chapter describes a 5-day IOP for anxiety disor- for additional support prior to returning to or
ders in youth which incorporates hands-on beginning outpatient services. This chapter pro-
therapist-­lead coaching for anxious youth and vides an overview of IPH care and how it fits into
their parent(s) to engage parents in becoming the mental healthcare continuum for youth. Youth
ERP experts alongside their child(ren). This stepping down from IPH after stabilizing from an
treatment model not only produces efficient acute mental health crisis can benefit from PHP
symptom reduction through streamlined focus on and IOP services due to the duration and fre-
ERP but also enables families to maintain and quency of the day treatment programs. Topics
expand upon progress achieved during clinician-­ addressed include accessing and utilizing IPH
guided treatment even after leaving the clinic. including reasons for admission to this level of
The authors provide a brief overview of child- care and the interventions offered as part of IPH.
hood anxiety disorders and the currently avail- The authors also review coordinating follow-­up
able evidence-based interventions designed to care and considerations following discharge.
treat these disorders, including barriers to their Next, Chap. 25 presents an alternative model
success. They then provide a detailed look at to the standard IPH unit, detailing the Youth
Parent-Coached Exposure Therapy (PCET; Crisis Stabilization Unit (YCSU) at Nationwide
Whiteside et al., 2020a, b) and how they utilize Children’s Hospital. This innovative level of care
this approach in their 5-day IOP. The structure moves away from the typical milieu-based set-
and goals of the program are discussed as well as ting for psychiatric inpatient care for youth and
details of treatment activities and strategies for instead focuses on intensive, short-term individ-
success. A case example is included to further ual and family-based CBT interventions, result-
illustrate the patient and family experience in this ing in an average 3–4-day length of stay, which is
IOP. shorter than typical IPH admissions. The authors
Chapter 23 discusses the development and provide details about the unique design and
implementation of telehealth adaptations of day development of this innovative program and the
treatment programs, a type of service delivery integrated, cross-disciplinary teamwork that
that has expanded drastically due to the makes the YCSU possible. Readers will learn
COVID-­ 19 pandemic. A brief review of the about how county-based funding was trans-
sparse literature available on telehealth day treat- formed into a billable service that manages high-­
ment programs is provided. This chapter then risk youth with intensive individualized and
focuses on how to manage the challenges of tele- caregiver involvement treatment to facilitate
health adaption in a private practice setting and faster return to the community. Issues related to
details this process along with a discussion of physical infrastructure, coordination with referral
1 Introduction and Overview of Day Treatment Programs 13

sources, facilitating funding, implementing engaging youth and their caregivers, and the
evidence-­based assessment and brief adaptions importance of measuring outcomes. Readers may
of evidence-based treatment, and novel staffing find the treatment, evaluation, administration,
models are discussed. and learning models provided within this hand-
Finally, Chap. 26 presents strategies for navi- book beneficial when considering strategies to
gating day treatment services as well as follow- develop their own models of PHP and IOP
­up plans for providers and families. Parents often intervention.
have limited to no experience with intensive
mental health care when their child is first admit-
ted to a PHP or IOP. This chapter, written with References
parents as the audience in mind, outlines the
common expectations for family participation Berkovits, M. D., O’Brien, K. A., Carter, C. G., & Eyberg,
S. M. (2010). Early identification and intervention for
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parents express during admission, such as when therapy. Behavior Therapy, 41, 375–387.
would their child’s symptom warrant IOP or PHP Block, B. M., & Lefkovitz, P. M. (1991). American
Association for Partial Hospitalization standards and
services, what to expect regarding treatment guidelines for partial hospitalization. International
offered in these programs, strategies to work with Journal of Partial Hospitalization, 7, 3–11.
the treatment team, what will happen with school Block, B. M., Arney, K., Campbell, D. J., Kiser, L. J.,
expectations and ways to work with their child’s Lefkovitz, P. M., & Speer, S. K. (1991). American
Association for Partial Hospitalization Child and
school during admission, and next steps follow- Adolescent Special Interest Group: Standards for
ing discharge. child and adolescent partial hospitalization programs.
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Casarino, J. P., Wilner, M., & Maxey, J. T. (1982).
Conclusion American Association for Partial Hospitalization
(AAPH) standards and guidelines for partial hos-
Day treatment programs which represent an pitalization. International Journal of Partial
intermediate level of mental health care have Hospitalization, 1, 5–21.
Chung, D., Hadzi-Pavlovic, D., Wang, M., Swaraj, S.,
been available for decades and have provided ser- Olfson, M., & Large, M. (2019). Meta-analysis of sui-
vices to youth and their caregivers in a variety of cide rates in the first week and the first month after psy-
formats and approaches. These IOPs and PHPs chiatric hospitalization. BMJ Open, 2019(9), e023883.
have evolved over time in response to financial https://doi.org/10.1136/bmjopen-­2018-­023883
Fontanella, C. A., Warner, L. A., Steelesmith, D. L., Brock,
and insurance factors, intervention approaches G., Bridge, J. A., & Campo, J. V. (2020). Association
influenced by evidence-based assessment and of timely outpatient mental health services for youths
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and most recently the COVID-19 pandemic. The suicide. JAMA Network Open, 3(8), e2012887. https://
doi.org/10.1001/jamanetworkopen.2020.12887
current text offers a comprehensive overview of Haag Granello, D., Granello, P. F., & Lee, F. (2000).
day treatment programs and elements associated Measuring treatment outcome in a child and adoles-
with developing, implementing, modifying, cent partial hospitalization program. Administration
adapting, and measuring interventions within this and Policy in Mental Health, 27, 409–422.
Kiser, L. J., Culhane, D. P., & Hadley, T. R. (1995). The
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with treatment outcomes and next steps for pro- of the American Academy of Child and Adolescent
grammatic changes and evaluations. Content Psychiatry, 34, 1336–1342.
Kotsopoulos, S., Walker, S., Beggs, K., & Jones, B.
throughout this text highlights the importance of (1996). A clinical and academic outcome study of
an integrated treatment team, engaging learners children attending a day treatment program. Canadian
in these team-based programs, implementing and Journal of Psychiatry, 41, 371–378.
utilizing evidence-based treatment models,
14 J. M. Leffler and E. A. Frazier

Leffler, J. M., & D’Angelo, E. J. (2020). Implementing (2019). Emotion regulation intensive outpatient pro-
evidence-based treatments for youth in acute and gramming: Development, feasibility, and acceptabil-
intensive treatment settings. Journal of Cognitive ity. Journal of Autism and Developmental Disorders,
Psychotherapy, 34, 185–199. 49, 495–508.
Leffler, J. M., Esposito, C. L., Frazier, E. A., Patriquin, Southam-Gerow, M. A., Ringeisen, H. L., & Sherrill, J. T.
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Martino, M., Schneider, B. N., Park, M., Podell, J. L., & mentation of evidence based treatments for youth:
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Practice in Child and Adolescent Mental Health, 5, Webster-Stratton, C., Reid, M., & Hammond, M. (2004).
28–41. Treating children with early onset conduct problems:
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Rosser, J., & Michael, S. (Eds.). (2021). Standards and (2020a). Exposure therapy for child and adolescent
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 The History and Purpose of Day
Treatment Programs 2
Megan E. Rech , Jaime Lovelace, Megan Kale,
Jarrod M. Leffler, and Michelle A. Patriquin

Introduction vices offered in outpatient, in-home, and school-­

based settings; day treatment programs (DTPs);
Mental health services for youth include a range emergency and acute psychiatric inpatient set-
of interventions offered in a variety of settings. tings; and residential treatment facilities. More
However, while there is a continuum of mental recently, many of the interventions offered in
health care that offers a range of services (Stroul these settings have been offered virtually to meet
& Friedman, 1986; Zimet & Farley, 1985), access patient’s and family’s needs during the COIVD-­19
to these programs can be impacted by costs and pandemic. The services provided as part of this
insurance coverage, geographic location, age of continuum of care can fall into different levels of
the patient, and the patient’s abilities and func- care. Often the initial level of care accessed is
tioning. Additionally, the utilization of mental ambulatory or outpatient and includes office- and
health services for youth with any psychiatric school-based services. The next level is consid-
issue is low with only 20–36.2% of youth receiv- ered intermediate or intensive and includes in-­
ing mental health treatment (Collins et al., 2004; home services, and DTPs that include partial
Merikangas et al., 2010) and fewer receiving hospitalization programs (PHPs) and intensive
evidence-based treatment (EBT; Rivard et al., outpatient programs (IOPs). Following interme-
2012). diate or intensive services is the acute level of
Mental health services for youth across this care, which includes inpatient psychiatric hospi-
care continuum have evolved and modified the talization (IPH), crisis centers, and crisis beds.
way these services are offered and accessed. Acute assessment services are often provided in
Traditionally, this care continuum consists of ser- emergency department settings. The highest level
of treatment is traditionally provided through
M. E. Rech · J. Lovelace · M. Kale long-term levels of care which include residential
The Menninger Clinic, Houston, TX, USA treatment facilities, wilderness programs, or ther-
J. M. Leffler apeutic boarding schools.
Virginia Commonwealth University, Children’s The role of DTPs within the context of a
Hospital of Richmond and Virginia Treatment Center broader mental healthcare continuum is critical
for Children, Richmond, VA, USA and has been considered a necessary component
M. A. Patriquin (*) of care since its inception in the mid-1900s
The Menninger Clinic, Houston, TX, USA (McGongile et al., 1992). In 2013, PHP and IOP
Baylor College of Medicine, Houston, TX, USA services were identified as essential “intermedi-
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 15

J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_2
16 M. E. Rech et al.

ate behavioral healthcare” treatment options motivation to learn and improve academic
(Hyde, 2013). The general purpose of DTPs is to skills, increase self-knowledge, develop self-
provide a clinically appropriate “step down” control and enhance self-esteem” (Zimet &
from IPH or “step up” from outpatient care. Farley, 1985). The outcomes of day treatment
“Stepping down” to a PHP or IOP from IPH care include clinically significant reduction in psy-
provides opportunities to build upon the stability chiatric symptoms and the ability to maintain
achieved in the IPH setting through additional safety and stability in the home environment.
intensive therapy work and medication Instability of symptoms and safety outside of
management with continued monitoring for
­ the day treatment setting, including the resur-
safety on an almost daily basis. This “step down” gence of symptoms/worsening of symptoms,
to a PHP or IOP provides a gradual immersion elevated acute risk of suicide, severe self-injury,
into everyday life following an IPH to increase psychosis, worsening depression, or mania,
success and prevent relapse and readmission to may indicate the need to continue treatment or
IPH through increased psychological, emotional, increase the level of care (e.g., IPH
and behavioral support while reintegrating the admission).
child back into their home and social environ-
ment. Conversely, “stepping up” to a DTP from
an outpatient level of care can help stabilize indi- History and Evolution
viduals and families prior to a severe mental
health crisis occurring. More specifically, attend- DTPs have been providing services for almost
ing a PHP or IOP may prevent unnecessary IPH 80 years (Goldman, 1989; McGongile et al.,
by providing additional therapeutic support and 1992; Zimet & Farley, 1985). However, the initial
monitoring when an outpatient level of care is implementation of these programs was spars. In
insufficient. 1963, day treatment for youth was mandated
Regarding the scope and function of DTPs, through the Community Mental Health Center
they typically fit in four broad areas: (1) day units Act. The Community Health Center Act was
for disruptive behavior (Grizenko, 1997; Rey implemented as part of the deinstitutionalization
et al., 1998); (2) day treatment that has expertise movement with the recognition that treatment for
in the treatment of younger children with devel- mental illness could be more efficacious and
opmental disorders (e.g., autism spectrum disor- cost-effective if provided in community settings
der, speech language delays, attention-deficit/ rather than in traditional state psychiatric hospi-
hyperactivity disorder), which often involves the tals. During the 1960s, there was a significant
integration of treatment between the child, fam- increase in DTPs, and day treatment was noted to
ily, and school; (3) day treatment that focuses be a significant contribution to the mental health-
mainly on the relationships between family mem- care model (Joint Commission on Mental Illness
bers (e.g., parent-child relational issues, child and Health, 1961). However, at the end of the
maltreatment; Asen et al., 1982); and (4) mood 1960s, millions of youth were not receiving
disorders (Leffler et al., 2017). Further, youth needed mental health services, and many who
DTPs can focus on specialty areas including received mental health care were treated in
addiction/dual diagnosis, obsessive-compulsive restrictive treatment settings of state mental hos-
disorder, as well as specific therapeutic pitals (Joint Commission on Mental Health of
approaches (e.g., dialectical behavior therapy, Children, 1969). During that time, DTPs
cognitive behavioral therapy) (Leffler & increased from 10 in 1961 to 90 in 1972
D’Angelo, 2020). (Westman, 1979). In the 1960s, a group of clini-
DTPs focus on efforts to “relieve anxiety, cians working within this new form of treatment
promote the development of adaptive skills, organized and developed the American
improve interpersonal relationships, increase Association for Partial Hospitalization (AAPH;
2 The History and Purpose of Day Treatment Programs 17

Association of Ambulatory Behavioral Health, Treatment interventions for youth provided in

2022). In 1970, DTP were offered by one-fourth DTP have been found to be effective at address-
of the mental health organizations in the United ing symptoms, functioning, and sustained change
States (Sunshine et al., 1992). By the early 1980s, (Clark & Jerrott, 2012; Kennair et al., 2011;
there were over 350 DTPs in the United States Leffler et al., 2017; Thatte et al., 2013). DTPs, by
(Prevost, 1981), and by1988, nearly half of all their design of offering intensive services in the
mental health organizations provided DTPs, with least restrictive environment and allowing
youth accounting for 17% of the patient popula- patients to return home at the end of each treat-
tion (Sunshine et al., 1992). In the 1980s and ment day, are different from IPH, wilderness pro-
1990s, authors were addressing DTP models of grams, residential treatment facilities, therapeutic
care, their importance in the treatment continuum boarding schools, crisis beds, or respite services.
of youth, and program development and imple- Because of their format, there are several options
mentation strategies (Farley & Zimet, 1991; for structuring DTP interventions. This can
Zimet & Farley, 1991). In 1982, the International include full and half-day programs, inclusion of
Journal of Partial Hospitalization was first pub- caregivers, different group formats (e.g., youth
lished and focused on elements of development, only, youth and caregivers, caregivers only) as
management, structure, operation, implementa- well as group content (e.g., psychoeducation,
tion, and evaluation of DTPs. Unfortunately, the process, and skills), individual and family ses-
journal was last published in 1992. Also, by the sions, range of diagnoses treated, direct work
early 1990s, AAPH membership significantly with schools, medication evaluation, prescribing,
increased to over 1200 members. In the mid-­ and monitoring, and the integration of evidence-­
1990s, after redefining the organizations’ mission based treatment protocols.
and goals, the AAPH changed its name to the
Association for Ambulatory Behavioral
Healthcare (AABH; Association of Ambulatory Program Models
Behavioral Health, 2022). AABH publishes
Standards and Guidelines for Partial Since their inception, DTPs have been provided
Hospitalization and supports development and in a range of professional settings (e.g., hospitals,
integration of PHP and IOP interventions. Since community mental health settings, schools), with
the 1990s, publications addressing DTPs have multiple models (e.g., length of time, number of
continued to focus on development, implementa- days, etc.), organizational and team structure,
tion, measurement, and outcomes. In an effort to and variety of treatment approaches (Leffler &
provide a resource for collaboration and support D’Angelo, 2020; Sunshine et al., 1992). For
to professionals providing evidence-based treat- example, some programs provide treatment
ment and leadership in day treatment settings, the focused on a broad range of problems where
Acute, Intensive, and Residential Service Special other programs focus on a specific treatment pop-
Interest Group (AIRS SIG) was developed in ulation such as eating disorders (Hayes et al.,
2020 (Leffler et al., 2021a, b, c) and within a year 2019; Homan et al., 2021), behavioral concerns
had 158 members. Additionally, this group pub- (Clark & Jerrott, 2012), and anxiety disorders
lished two special journal issues focused on clini- (Davis et al., 2009; Storch et al., 2007; Whiteside
cal work, research, training, and diversity efforts & Brown Jacobsen, 2010) or a specific treatment
in acute, intensive, and residential settings modality such as dialectical behavior therapy
(Leffler et al., 2021a, b, c). Since their inception, (DBT; Clarke et al., 2022) or exposure (Brennan
DTPs have provided a vital link between outpa- & Whiteside, 2022). Additionally, DTPs provide
tient and inpatient levels of care and the opportu- services for youth of all ages (Furniss et al., 2013;
nity for a more comprehensive continuum of Martino et al., 2020; Sommerhalder et al., 2021;
mental health care. Sunshine et al., 1992).
18 M. E. Rech et al.

 he History and Role of Academics

T psychoeducation and other therapeutic resources.
in Day Treatment Programs Medication evaluation and management is also
included in many DTPs. These services are usu-
Some DTPs evolved from day school programs, ally provided by psychiatrists or advance practice
and many include an education or school-based providers (e.g., advance practice nurse, nurse
component. This element varies by program and practitioners, or physician assistants). Many pro-
is often influenced and directed by state require- grams also have a nurse and may have an educa-
ments for education activities, while a child is tional specialist. Similarly, some programs utilize
admitted to a DTP. Some programs do not offer milieu or direct care staff to assist with clinical
or provide academic time or learning activities activities, support the goals of the program, and
during the course of the treatment day, while work with youth and caregivers. In addition to
­others may offer 3–4 hours a day. Programs that these team members, auxiliary services may be
offer academic activities can provide them in-­ provided by occupational therapists, physical
person with a teacher through the local school therapists, recreation therapists, dieticians, nutri-
district or have an educational specialist. tionists, music therapists, and art therapists. The
Additionally, some programs provide academic DTP medical director is often a physician or psy-
activities virtually based on the students’ aca- chiatrist, and the clinical director is often a psy-
demic arrangements and resources available chologist, social worker, or other professionals.
within the DTP. Additionally, some DTPs that are The program will likely utilize an interdisciplin-
offered less than 5 hours a day may allow the ary approach to treatment, which integrates the
patient to attend their home school, in person or information and treatment provided by each pro-
virtually, for part of the day and then attend the vider and professional discipline to maximize the
DTP. This model is more likely offered in IOPs interventions offered. An interdisciplinary pro-
due to the difference in the structure and time gram builds on the various interventions and
commitment of the programs. More specifically, skills offered by different team members.
DTPs vary in length and frequency, and as a Effective communication and professional
result, PHPs are considered a higher level of care engagement within the treatment team between
compared to IOPs. Typically, PHPs consist of 4 team members are essential. The success of the
or more hours a day and offered 4–5 days a week, treatment is dependent on how effective team
and IOPs typically are offered 3–5 hours a day members communicate within the team as well
and can run 3–5 days a week (Rosser & Stephen as with caregivers and external providers and ser-
Michael, 2021). vices (e.g., other mental health providers and
schools) (Javorsky, 1992).

Treatment Team
Treatment Setting
The treatment team is a crucial element of the
care model. Treatment teams are multidisci- DTPs are offered in general and psychiatry hos-
plinary and consist of medical providers (e.g., pitals, community mental health centers, and for-­
psychiatrists) and potentially other physicians profit mental health agencies. The treatment
(e.g., physical medicine and rehabilitation) setting is different than other treatment settings
depending on the medical model associated with as noted above. However, like acute and residen-
the program. Historically, DTP staffing models tial settings, the treatment setting includes a treat-
have included social workers, psychologists, and ment milieu which is a therapeutic environment
psychiatrist (Sunshine et al., 1992). The team that can enhance how youth benefit from the
psychologists, social workers, and counselors treatment (Gunderson, 1978). The utilization of
may provide therapy (e.g., individual, family, or milieu treatment for youth has been discussed for
group) as well as conduct assessments or offer decades (Abroms, 1969; Aichhorn, 1935;
2 The History and Purpose of Day Treatment Programs 19

Bettelheim & Sylvester, 1949; Silvan et al., 1999;  reatment Components and Program
T
Zeldow, 1979) and includes considerations for Outcomes
the necessary elements, various models and
approaches, and strategies for implementation. A DTPs have utilized elements of psychoanalytic,
milieu presents a stable, consistent, safe, and sup- behavioral, cognitive, cognitive-behavioral,
portive environment (Javorsky, 1992) to facilitate acceptance and commitment, and dialectical
engagement in treatment, access to supportive behavioral treatments (Cole & Kelly, 1991;
and engaged staff, and space to practice skills and Farley & Zimet, 1991; Robinson et al., 1999;
apply new knowledge in a nonjudgmental and Zimet & Farley, 1985). Treatment interventions
supportive atmosphere. Additionally, the treat- have been designed to address specific treatment
ment setting consists of other youth experiencing needs based on patient age and presenting con-
mental health difficulties. While some programs cern as well as functioning and intellectual abili-
combine patients with a range of presenting men- ties. Additionally, the approach to treatment
tal and physical health concerns, other programs within the DTP milieu has included individual,
focus on a specific type of mental health concern family, and group therapy. DTPs for youth have
(e.g., eating disorder, anxiety, depression, mood focused on ways to integrate and engage caregiv-
disorders, etc.) (Leffler & D’Angelo, 2020). ers and families in treatment (Cole & Kelly,
Families and youth have voiced satisfaction and 1991; Furniss et al., 2013; Girz et al., 2013;
feeling more supported in programs designed to Homan et al., 2021; Leffler & D’Angelo, 2020;
address a specific diagnosis or mental health con- Martino et al., 2020; Silvan et al., 1999). In addi-
cern compared to more general focused DTPs tion to these mental health interventions, auxil-
(Mayo Clinic, 2016). This also allows the DTP to iary interventions may also be offered and include
apply evidence-based treatments that have been physical therapy to assist with small and large
found therapeutically successful at addressing a motor movements, eye hand coordination, and
specific diagnosis or clinical presentation. reconditioning the physiological functioning of
The safety of patients and staff is a priority in the youth. Occupational therapy can be utilized
DTPs. To address safety concerns, the program to assist with various coping skills to be imple-
may use a variety of techniques. For example, the mented in daily settings, sensory issues, assis-
program may use daily check-ins with the patient tance with returning to school activities, and
and caregiver, ask the patient to complete a daily planning. Recreational therapy may be
screening questionnaire, or give updates on how included to assist the patient and family in ways
they are feeling and functioning. If at any time to engage in pleasurable and meaningful activi-
the patient demonstrates unsafe behaviors or ties that help build mastery, problem-solving,
expresses unsafe thoughts and feelings, the treat- cooperation and teamwork, and relaxation skills.
ment team will work with the patient to address Nutrition and dietary interventions may provide
these thoughts, feelings, and behaviors and education about healthy nutrition, understanding
develop a plan to address the patient’s safety as ways to select meals and snacks to address appe-
well as the other patients and staff in the DTP. The tite concerns, health management of medication
DTP treatment team also works with the patient’s side effects, or weight restoration. Music and art
caregiver(s) to address safety concerns when out- therapies may also be offered to assist with alter-
side of program and develop a plan for acute psy- native ways to express oneself as well as provide
chiatric emergencies. This may include an active a range of coping and relaxation skills.
safety plan that the patient and caregiver commit The appropriateness for day treatment to
to implementing. The safety plan should include address a child or adolescent mental health need
skills to manage emotions and may also include relies on a combination of identification of pre-
information on ways to contact supportive adults senting problems and core issues, clinical
in the patient’s life and access emergency depart- decision-­making, payor request (e.g., insurance
ment services if needed. company), youth developmental level, outcomes
20 M. E. Rech et al.

measurement, and risk of safety. While DTPs Children’s services at The Menninger Clinic
vary in how they assess and measure these fac- began in 1929 with the opening of the Southard
tors, most programs utilize some method of School, which in 1946 was integrated and com-
intake and discharge evaluation. Despite these bined with other programs at The Menninger
efforts and decades of clinical work in DTPs, Clinic. The Southard School was a unique setting
there is limited research on the exact combination that had youth within various levels of care
of predictors for the correct levels of care, and including inpatient, outpatient, and those that
therefore, researchers have advocated for ran- attended the school only. In 1961, The Menninger
domized control studies in order to test which Clinic opened a Children’s Division. In 1971, the
level of care leads to the best outcomes, for which Children’s Division opened a preschool day treat-
group of youth (Lamb, 2009). However, method- ment center, as well as services for school-aged
ological difficulties are present when conducting children through 17 years old. The Menninger
research in DTPs, given the shorter duration of Clinic relocated from Topeka, Kansas, to
care and limited follow-up compared to lab-­ Houston, Texas, in 2003. Outpatient services
based research protocols and opportunities for were closed for a time and then reopened in 2012
follow-up in outpatient settings. As a result, pro- to provide care to children on an outpatient as
grams continue to work toward identifying the well as inpatient basis. The DTP for children and
most appropriate level of care and types of inter- adolescents was reopened in 2019, providing
ventions for youth, which has influenced the evo- care to youth aged 12–17 with a primary mental
lution of DTPs over the years. health diagnosis or comorbid substance use
diagnosis.

The Menninger Clinic

PHP Programming
One of the oldest treatment programs for youth in
the United States is The Menninger Clinic. The Menninger Clinic’s inpatient and PHP pro-
Similar to programs across the country, the diver- gramming are similar as the inpatient unit is con-
sity of clinical programming for youth at The sidered subacute (i.e., requires voluntary
Menninger Clinic has evolved over the last admission). Admission guidelines for PHP
100 years. Herein, we review the history and evo- include evaluation (e.g., includes chart review,
lution of day treatment at The Menninger Clinic clinical interview, suicide risk assessment with
for youth and utilize this program to highlight the Suicide Behaviors Questionnaire – Revised
elements of DTPs. (SBQ-R; Osman et al., 2001) by the PHP medical
director and/or another qualified clinician in the
following areas: (1) the presence of behavioral
History health condition, substance use disorder, or pro-
cess addiction; (2) marked impairments in level
Notably, The Menninger Clinic (Houston, Texas) of functioning (e.g., self-care, age-specific role
was one of the early pioneers of psychiatric treat- expectations); (3) risk/dangerousness is judged
ment for youth. Youth interventions began with not to be at imminent risk to self – or others (i.e.,
the establishment of the Southard School in 1926, not requiring inpatient psychiatric treatment), but
which provided residential care and schooling. the youth may exhibit some identifiable risk for
Since this time, The Menninger Clinic’s youth harm to self or others yet is willing to engage in
interventions have evolved into the current ser- clinical programming; (4) readiness for change
vice line approach: inpatient psychiatric care, will be examined and the capacity for minimum
PHP, IOP, assertive community treatment team, engagement in identification of goals for treat-
and general outpatient therapy and medication ment and willingness to participate actively in
management services. relevant components of the program are impor-
2 The History and Purpose of Day Treatment Programs 21

tant; and (5) level of care assessment indicates ing, smart recovery, alternative peer group) and
that the individual exhibits acute symptoms or “Rainbow Space” to support LGBTQ+ patients.
loss of function that necessitates an intermediate For example, Rainbow Space is a hybrid process
level of care, or the individual has relapsed and and psychoeducational group for patients who
failed to make significant clinical gains in a less identify as LGBTQ+. Process-oriented meetings
intensive level of care but does not require are a space for patients to speak on any issues or
24-hour support such as with inpatient experiences related to their identities. The groups
hospitalization. include processing identity exploration, self-­
Importantly, there are key exclusionary crite- disclosure, family and peer support, and activities
ria in order to ensure the compliance and ability (e.g., LGBTQ+ history quiz and creative arts
to learn new information in the program that indi- activities). Additional offerings include groups
cates that the individual (1) is imminently at risk supporting self-esteem/resiliency, nutrition and
of suicide or homicide and lacks sufficient body image, and psychoeducation about medica-
impulse/behavioral control to maintain safety tions, which all have an established evidence-­
and requires hospitalization (e.g., on the SBQ-R); based for youth (Ferrin et al., 2014; Ngo et al.,
(2) has cognitive dysfunction that precludes inte- 2020; Rahimi-Ardabili et al., 2018).
gration of newly learned material, skill enhance- Patients also develop and practice implement-
ment, or behavioral change (e.g., indicated during ing new coping skills through creative (e.g., art)
clinical interview or in prior psychological and music therapies to help reflect and process
assessment testing); (3) is uninterested or unable core issues, family systems, and psychosocial
to engage in identifying goals for treatment and/ stressors in a nonthreatening alternative medium.
or declines participation, as mutually agreed Additionally, offerings include daily gym time
upon, in the treatment plan; (4) participation may and recreation therapy (60 mins/day) in order to
pose a risk to other members of the milieu, based improve the bidirectional relationship between
on clinical judgment; (5) the milieu consists of a physical wellness and mental health, as well as
peer (or peers) with whom the individual has a behavioral activation.
dual relationship, based on clinical interview; (6)
or family displays an unwillingness or incapacity Milieu Therapy
to adhere to reasonable program expectations or Importantly, a distinguishing feature of adoles-
personal responsibilities which are detrimental to cent day treatment (and inpatient treatment) at
the PHP and is unwilling or unable to contract for The Menninger Clinic is the therapeutic milieu.
change. Traditionally, milieu therapy was characterized
primarily by containment (physical safety) and
Schedule support (reduction of distress and anxiety;
Typical mornings are devoted to schoolwork sup- encouragement; Gunderson, 1978). Subsequently,
ported by a tutor, and the patients meet twice structure (predictably scheduled activities,
weekly with their treatment team (physician, accountability) emerged as another critical com-
nurse, social worker). Afternoons are spent in ponent of milieu treatment, particularly follow-
psychoeducational and evidence-based psycho- ing its emphasis by Menninger in the 1930s
therapy groups. The treatment model includes (Gunderson, 1978; Menninger, 1936). Since
more than 20 hours per week of groups grounded then, involvement (social interaction and partici-
in evidence-based modalities including pation) and validation (acceptance, affirmation of
Dialectical Behavioral Therapy, Cognitive individuality) have also been established as ther-
Behavioral Therapy, Acceptance and apeutic functions of milieus. Menninger’s PHP
Commitment Therapy, and Narrative Therapy. therapeutic milieu is an active ingredient in both
Several referral-based groups are also offered, the assessment and treatment of patients (e.g.,
such as “Reaching Recovery,” serving patients practice of skills or exposures from individual
with substance use (e.g., motivational interview- therapy; increased belongingness, decreased iso-
22 M. E. Rech et al.

lation and burdensomeness to lower suicide risk; empirical evaluation in order to determine the
increased behavioral activation). appropriate level of care for a child or adolescent
given their symptom presentation. DTPs will
likely continue a model of open or closed admis-
Outcomes sions, treatment-specific models, or general pro-
gram structures. These models offer pros and
Since the development of the PHP, the program cons and are reviewed throughout the current
has proactively collected and used outcomes data text. However, no matter which elements of a
to improve patient care. The Menninger Clinic DTP model are utilized, DTPs are strongly
has a longstanding history of outcomes measure- encouraged to consider how science informs their
ment across the hospital for more than a decade. assessment and intervention and consider strate-
The outcomes protocol has intentionally mir- gies to implement and measure the use of
rored the outcomes measurement in the inpatient evidence-­ based treatments and evidence-based
setting in order to ensure continuity of measure- assessment. Evidenced-based treatment models
ment throughout the child and adolescent con- are strongly encouraged to be implemented based
tinuum of care. These measures include an on fit with the treatment setting and patient popu-
evidence-based, structured clinical interview lation. Additionally, assessment and measure-
(K-SADS; Kaufman et al., 1997) as well as self-­ ment of patient symptoms and functioning are
reported (e.g., PHQ-9, GAD-7, DERS-SF; Gratz key to pairing youth into the most appropriate
& Roemer, 2004; Kroenke & Spitzer, 2002; level of care needed to address their clinical dif-
Spitzer et al., 2006; anxiety, depression, emotion ficulties and functioning. Assessment as part of
regulation problems, team therapeutic alliance, admission, monitoring, discharge planning, and
suicide risk), parent-reported (e.g., CBCL; follow-up can assist the program in identifying
Achenbach & Edelbrock, 1992), and executive patients appropriate for the specific treatment
functioning measures (via the iPad app – NIH program, assist with developing meaningful
Toolbox, cognition battery). See Tables 2.1 and goals and discharge criteria, and assist with
2.2 for self- and parent-reported measures, informing the DTP to what extent patient’s func-
respectively. All self- and parent-reported mea- tioning changes associated with the intervention.
sures are collected via a cloud-based survey soft-
ware (Qualtrics). As such, the program is able to
track individuals who step down from inpatient Telehealth Adaptions
care to PHP care and continue to conduct
evidence-­based measurement of their changes in With regard to treatment settings, the COVID-
symptoms and have this as part of their clinical 19 pandemic and virus mitigation measures
pictures. Additionally, this data helps to deter- have altered care delivery models and systems.
mine if a “step down” continues to be As part of these modifications, programs were
appropriate. offered through virtual platforms, in-person
census was reduced, and staffing models were
changed. It is likely these modifications will
Future of Day Treatment Programs continue to be implemented to some degree
moving forward. Virtual programming may aid
DTPs have evolved over the past several decades in the sustainment and access of this necessary
and continue to demonstrate new and meaningful and at times critical level of mental health care.
adaptations taking into consideration treatment DTPs will likely continue to engage in partial
and assessment science, treatment demands, and or full implementation of virtual options.
technology. Notably, DTPs, as well as the full While virtual programs may not replace in-
inpatient, outpatient, and residential treatment person programs given the benefit of a thera-
care continuum for youth, require ongoing peutic milieu that is not fully replicated in a
 2

Table 2.1 Self-reported child and adolescent PHP outcomes measures

2W 3M 6M 1Y
Construct Measure Abbreviation Admission Weekly Discharge follow-up follow-up follow-up follow-up
Demographics Patient information – ATP PI X
DSM-5 disorders Kiddie – schedule for affective disorders and KSADS-PL X
schizophrenia – Present and lifetime version
Anxiety Generalized anxiety disorder 7-item GAD-7 X X X X X X X
Depression Patient health questionnaire for adolescents PHQ-A X X X X X X X
Emotion regulation Difficulties in emotion regulation scale, short form DERS-SF X X X
problems
Nighttime sleep Pittsburgh sleep quality index PSQI X X X X X X X
quality
Daytime sleepiness Epworth sleepiness scale for children and ESS-­ X X X X X X X
adolescents CHAD
The History and Purpose of Day Treatment Programs

Insomnia Insomnia severity index ISI X X X X X X X

Nightmares Disturbing dreams and nightmares scale DDNSI X X X X X X X
Suicide risk Suicide behaviors questionnaire – revised SBQ-R X X X X X X X
Suicidal thought & Self-injurious thoughts and behaviors interview, SITBI X
behaviors self-report
Trauma symptom The child PTSD symptom scale for DSM-5 CPSS-5 X X X X X X X
severity
Attachment Relationship structures questionnaire ECR-RS X
Emotion and Youth self report YSR X X X X
behaviors
Patient satisfaction Menninger quality of care MQOC X
Therapeutic alliance Working alliance inventory – short revised: WAI-SR X X
treatment team
Executive function NIH toolbox cognition battery (ages 7–17) NIH X X
toolbox
23
 24

Table 2.2 Parent-reported child and adolescent PHP outcomes measures

Construct Measure Abbrev Adm D/C 2 W follow-up 3 M follow-up 6 M follow-up 12 M follow-up
Demographics Family information PI-family X X X
Emotions and behaviors Child behavioral CBCL X X X X
checklist
Treatment Treatment utilization TUS X X X X X
Patient satisfaction Menninger quality of MQOC-parent X
care
Health Child’s health history CHH X
Abbrev abbreviation, D/C discharge, M month, W week
M. E. Rech et al.
2 The History and Purpose of Day Treatment Programs 25

virtual atmosphere, these programs will likely health concerns or crises. Additionally, given the
see a level of sustainment and insurance cover- ongoing access and use of digital apps and
age. Various chapters in this book will high- mobile devices, DTPs may enhance their ser-
light these modifications and review pros and vices and delivery of treatment by implementing
cons of virtual programs. However, virtual pro- technology-­based interventions via digital plat-
gramming is likely an essential component of forms (Brennan & Whiteside, 2022; Hussey &
ongoing mental health care given the uncer- Flynn, 2019; Lenhart, 2015; Madden et al.,
tainty of the COVID-19 pandemic, the increase 2013) or mhealth apps. Research suggests par-
in mental health access it provides, and the fact ents support the use of these resources for their
that ­utilization of technology across the age child to communicate with their providers
range is not slowing down. It is likely that vir- (Thompson et al., 2016) and are open to using
tual programming may offer another level of these resources to assist their child’s mental
care within DTP. For example, some youth health treatment (Leffler et al., 2021a, b, c).
might complete an in-person DTP and step These approaches can provide a variety of
down to a virtual format of the DTP prior to resources to the patient, caregiver, and family.
returning to outpatient care. Additionally, some Apps can include breathing exercises, coping
youth might be evaluated or screened into a skills, mood ratings, reminders to practice thera-
virtual DTP versus an in-­person DTP due to peutic activities, and other resources (Archangeli
presenting with less acute mental health needs et al., 2017). These “real-­time” interventions can
or a higher level of mental health stability post minimize recall bias when youth are asked about
IPH discharge. Additionally, some virtual pro- utilization and their mental health experiences
grams may work with mental health partners in by their providers (Heron & Smyth, 2010; Kolar
their state as well as outside their state to offer et al., 2014). Given the high level of access to
a virtual DTP that can reach more youth and digital devices, these mhealth apps can go with
families. the patient wherever they go. Further, data is
individualized to the unique patient, and infor-
mation entered and utilized on these apps can be
Integrating Technology shared with future providers, increasing the
sharing of therapeutic information across set-
Regarding technology, many youth are utilizing tings and between providers to improve continu-
digital and wearable devices which are being ity of care.
integrated into resources for health care (Byun
et al., 2018; Hollis et al., 2017; Smuck et al.,
2021; Wong et al., 2020). As a result, it is likely Family Involvement
that DTPs will embrace the use of wearable
devices or actigraphy to gather real-time data on Another element of DTPs to consider is that
patient’s health and wellness and integrate this patients and families can benefit from integrat-
information into the individual’s treatment. ing caregivers into the treatment. While some
Information gathered through the use of wear- DTPs offer weekly family therapy and/or
able devices can be utilized to inform treatment weekly caregiver groups, it is important to
and can assist the individual and their caregiver(s) understand how supporting, educating, and
on how to continue to use this data outside of and preparing the child’s caregiver(s) for the child’s
following completion of the DTP. Further, the return home can enhance the treatment offered
patient can utilize this resource in outpatient to the patient. DTP are encouraged to review
therapy to assist with managing elements of their models and approach to care and deter-
health and wellness that can signal mental health mine the cost/benefit and potential outcomes of
distress or events that might exacerbate mental including caregivers in treatment.
26 M. E. Rech et al.

Future Research be fully maximized to offer benefits for patients

and caregivers. Since their inception, DTPs have
Finally, DTPs are ripe for research given the provided care for a variety of youth and have
various treatment models consisting of inter- experienced various modifications and improve-
disciplinary care. Similar to previous consider- ments. DTPs will likely continue to be an integral
ations related to further understanding the part of youth mental health care and will experi-
benefits and models of care in DTPs (Zimet & ence modifications and enhancements that will
Farley, 1985), further research on DTPs to continue to improve how they address youth
inform providers, consumers, stakeholders, mental health needs.
and reimbursement entities is warranted. DTPs
are encouraged to consider how to uniformly
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Assessment, 8, 443–454. University Child Development Center.
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Sunshine, J. H., Witkin, M. J., Atay, J. E., & Manderscheid, Whiteside, S. P., & Brown Jacobsen, A. (2010). An uncon-
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child psychiatry (Vol. 3, pp. 288–299). Basic Books. ment for children with emotional disorders volume 1:
A model in action. Plenum Press.
 Program Development
and Administration in Day 3
Treatment Settings

Jarrod M. Leffler, Eric Schwartz,

and Brittany Hayden

Overview of Day Treatment goals of DTPs, the development, implementa-

Programs tion, management, and administration of these
programs are different than that of inpatient psy-
Day treatment programs (DTPs), which include chiatric units and outpatient or school-based
partial hospitalization program (PHP) and inten- interventions. The difference in the structure and
sive outpatient program (IOP) interventions, goals as well as the clinical need for this level of
were developed with the goal of providing a less care is due to the mental health needs of the treat-
restrictive treatment setting compared to inpa- ment population (e.g., not in acute mental health
tient psychiatric hospitalization (IPH) and more crisis but requiring a higher level of treatment
intensive treatment options compared to outpa- than outpatient care can address). To address
tient therapy. As a result, DTPs are often these concerns, the format of the intervention
described as “step-up” or “step-down” programs (e.g., intense but youth are not monitored
because youth can “step up” to day treatment if 24-hour day), the structure of the intervention
they are in outpatient services (e.g., traditional (e.g., group, individual, and family therapy
office-based therapy, school-based therapy, etc.) within a milieu), and the staffing model are
due to needing a higher level of care to address unique to DTPs.
their mental health needs and daily functioning Program development and ongoing evaluation
(see Fig. 3.1). Similarly, youth can “step down” and revision of programming are common ele-
to day treatment services after being discharged ments of interventions within DTPs as many pro-
from IPH. Given the function, structure, and grams are developed to meet a specific institution,
community, or population need and may need to
be created from the ground up or modified from
existing interventions. This requires an under-
J. M. Leffler (*) standing of the impact of the specific treatment
Virginia Commonwealth University, Children’s
Hospital of Richmond, and Virginia Treatment Center elements; population’s mental, medical, and
for Children, Richmond, VA, USA physical health needs; patient and caregiver avail-
e-mail: [email protected] ability; access to intervention; billing practices
E. Schwartz and covered services; stakeholder expectations
Hopewell Health Solutions, Glastonbury, CT, USA and goals; staffing models and needs; facility and
B. Hayden space considerations; and accreditation and regu-
Sarah A. Reed Children’s Center, Erie, PA, USA latory requirements.
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 31

J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_3
32 J. M. Leffler et al.

Fig. 3.1 Continuum of

mental health care Inpaent
Psychiatric
Day Treatment Hospitalizaon
Se ngs
Outpaent
and School
Treatment
Se ngs

a differential payment structure between IOPs

Titles of Day Programs and other more traditional outpatient services
(Leung et al., 2009). Rosser and Stephen Michael
Nomenclature is important when identifying lev- (2021) define PHP as a program that is four or
els of care in behavioral health. A program’s label more hours a day and includes group therapy,
reflects the definition, structure, framework, psychoeducational training, and other types of
expectations, and intent of the program, as well therapy as the primary treatment modalities. IOP
as the culture of the host organization, population suggests more than traditional single service out-
served, standards, and regulations that provide patient service, but not as intensive and extensive
the foundation for delivering the specific service as the services provided in a PHP. IOP typically
type. Of the terms identified, only partial hospi- provides service daily and is utilized at least
talization has a distinct definition in the Code of one day a week. IOPs provide up to 11 treatment
Federal Regulations (CFR). As defined within appointments/sessions per week (Rosser &
e-CFR, Title 42, Part 410, “Partial hospitalization Stephen Michael, 2021). Similar to the IOP level
services means a distinct and organized intensive of care, therapeutic after-school and extended
ambulatory treatment program that offers less DTPs are not defined in the Code of Federal regu-
than 24-hour daily care other than in an individu- lations but exist within behavioral health systems
al’s home or in an inpatient or residential setting of care created and guided by state regulations
and furnishes the services as described in 410.43” and standards established by different payors.
(CFR). As noted earlier, day treatment is a label
that is most often used to describe the same level
of care as partial hospitalization; however, the Treatment Elements
term is not defined in federal regulation.
Additionally, in some areas (e.g., New York) day Most PHPs and IOPs utilize group-based therapy
treatment may suggest the program has more models in a therapeutic milieu. The elements of
education interventions built into the program. treatment for youth typically include some form
Intensive outpatient is a term often used under of skill-based work (e.g., problem-solving, cop-
the general rubric of outpatient services. It does ing, communication, safety planning, etc.) and
not have a specific CFR definition. Instead, the psychoeducation. Additionally, some programs
CFR defines outpatient as follows, “Outpatient utilize process versus skills groups. Some pro-
means a person who has not been admitted as an grams also provide life skills, health and wellness
inpatient but who is registered on the hospital or content, and recreational groups that might
Critical Access Hospital (CAH) records as an include art therapy, occupational therapy, physi-
outpatient and receives services directly from the cal therapy, recreational therapy, dietician and/or
hospital or CAH” (42 CFR, 410.2). According to nutritionist consults, and music therapy. In addi-
a report distributed by the Centers for Medicare tion to group therapy, there are individual and
and Medicaid in 2009, there is no standard or family therapy sessions. Medication manage-
official definition of intensive outpatient (i.e., it is ment is also provided in most programs. There
not a statutorily defined level of care) nor is there may also be treatment groups for caregivers with
3 Program Development and Administration in Day Treatment Settings 33

a similar focus on skills, psychoeducation, and sonal and family obligations, while their child is
health and wellness. admitted to a DTP.

 opulation Mental, Medical,

P Program Access
and Physical Health Needs
Patients and their parents may be referred to
Youth requiring day treatment interventions are DTPs from the same agency as where the pro-
those who present with mental health needs that gram is offered or from providers from other
are more intense than those seen in outpatient agencies and services, which include IPH units,
programs. Additionally, these individuals are not outpatient therapy services, in-home treatment
in the midst of an acute mental health crisis that services, school-based services, and emergency
presents a concern to their or other’s safety. departments. As a result, the information youth
Further, these individuals are not experiencing and caregivers may receive about the DTP may
impaired reality testing or functioning that not accurately represent and explain the program
impacts their ability to safely and effectively and its expectations. Because parents often report
meet daily expectations. Their mental health that they do not know what to expect from mental
needs can include behavioral and emotional dis- health services, it is important to contact the care-
tress, failure to meet daily expectations, eating givers of youth who are referred to the program
and substance use concerns, pain and functional to review the programs treatment goals and
impairments, as well as social and academic dif- expectations prior to admission. This contact pro-
ficulties. While DTPs provide services across the vides an opportunity to discuss the DTPs expec-
developmental life span, the current chapter will tations with the patient and family to allow them
focus on the treatment of individuals below age a better chance to be informed consumers of care.
18. More specifically, this provides an opportunity to
discuss how to access the program, what is
expected of them, and the duration of care. This
Patient and Caregiver Availability in turn can have an impact on engagement, atten-
dance, adherence, and completion of the pro-
DTPs are usually offered for 2–8 hours a day. The gram. Additionally, if the patient is placed on a
program duration requires youth to be available waitlist, this should be communicated, and the
to attend the program regularly. Often patients caregiver should be provided information about
are dismissed or discharged from a program for what this process entails and how a start date for
missing too many treatment days. Attendance their child will be determined and communicated
may impact other personal, education, work, and to them.
family demands. As a result, the patient and care- Program hours also influence access to DTP
giver should be provided clarity about attendance services. This includes the time of day the pro-
expectations and how to contact the program if gram is offered, the number of hours a day, and
the patient is not able to attend the program. the length of stay. Programs may follow a full-­
Additionally, caregivers are required to attend day model, often identified as a PHP, or less than
some DTPs for part of or all of the day through- full-day program, often referred to as an IOP.
out the program. Team members may also need These programs will be discussed in more detail
to speak with caregivers when their child is expe- throughout the current handbook. While regula-
riencing a crisis, which may require the caregiver tory definition of program hours is defined above,
to speak on the phone, via telehealth, or in per- in practice, a PHP is often 6–8 hours per day
son. These expectations may require parents to 5 days a week, and an IOP is often 3–4 hours per
adjust their work schedule as well as their per- day 3–5 days a week. Daily start and end times
34 J. M. Leffler et al.

and the days the program is offered may impact be mindful of how program leaders develop, mar-
which patient populations (e.g., by age or grade ket, and engage the payer in treatment as well as
in school) might be able to attend the program. what payor sources will provide coverage for the
Additionally, youth are often transported to and program. Having a range of payor sources often
from the program by their caregiver, which also has the benefit of an array of payers who can par-
impacts who might attend due to the caregiver’s ticipate in the program. Limited payor sources
schedule and financial resources to provide trans- limit reimbursement and revenue options.
portation or secure alternative methods for trans- Managed care companies and Medicaid are
portation (e.g., school transportation, Uber, the two biggest payor sources for child and ado-
transportation vouchers, etc.). lescent mental health services. These funding
sources along with Social Security Disability
Insurance (SSDI)/Supplemental Security Income
 illing Practices and Covered
B (SSI) and other programs have influenced how
Services mental health services are funded and reimbursed
(Mechanic, 1999). Additionally, the Children’s
Billing practices and collections or revenue may Health Insurance Program (CHIP) is funded
impact the daily practice or offering of some jointly by federal and state governments through
DTPs. Similar to IPH programs, DTPs may be a formula based on the Medicaid Federal Medical
viewed by agency leaders and stakeholders as a Assistance Percentage (FMAP). It is important to
health necessity and be offered despite their understand this federal government program as it
financial performance in order to meet the mental can have an impact on seeking and accessing ser-
health needs of youth, caregivers, and the com- vices for youth and families (CHIP https://www.
munity. Despite this consideration, costs, medicaid.gov/chip/financing/index.html). Value-­
expenses, and revenue will be reviewed for every based purchasing (VBP) is another payment
service provided by nearly every institution. model impacting behavioral health care, includ-
Knowing that finances can have an impact on a ing DTPs. VBP ties payment to performance,
program’s growth, modification, and sustainabil- shifting away from simple fee-for-service and
ity (e.g., adding or updating space and the physi- setting quality standards for which providers can
cal environment, adding additional staff, offering earn financial incentives for providing effective
an additional service or program, etc.), it is care. The extent to which DTPs across the coun-
important to be familiar with financial language, try are engaged in VBP varies; however, identify-
practices, evaluation process, and agency and ing and implementing best practices are key to
stakeholder expectations. Further, due to pro- meeting possible VBP expectations and certainly
gram format and billing structure, some DTPs improve behavioral health outcomes (National
may have limited flexibility for the administrator Council for Mental Wellbeing, 2021).
to pivot or modify their practice to increase rev- Additionally, billing practices can vary by the
enue or decrease costs. Despite these nuances, it design of the program and services offered. There
is sound business practice for the program’s is a difference between individually billed or
administrator and director, and in most cases the bundled service billing. Most DTPs are billed as
DTP staff, to be aware of how the program is per- a service or bundled payment, while some DTPs
forming. As a result, we provide a brief overview bill individual sessions throughout the day. For
of financial program oversight. example, some groups might meet separately
As an administrator or director discussing throughout the day and individual providers bill a
financial aspects of the program, individuals may group code for each of those sessions. Some pro-
hear terms such as “payor source,” which can grams include multiple group sessions each day
refer to the company or entity who covers the that are offered by several providers from differ-
payer. The payer is often the individual paying a ent disciplines (e.g., psychologist, social worker,
bill (e.g., customer or patient). It is important to counselor, nurse practitioner, occupational
3 Program Development and Administration in Day Treatment Settings 35

t­ herapist, etc.) who individually bill for the groupphase includes piloting, fully implementing, and
they facilitate resulting in various billing charges then modifying the program based on data from
each day. Regarding providers, the discipline of the review and evaluate phase. The last two
the provider will impact, in some models, the phases continue to be revisited and integrated
billing and cost of service. Further, some pro- over the life of the program.
grams provide groups and other services within Various tools are available to assist with pro-
dedicated hospital space and may be able to gram development and modification. One tool
charge a facility fee for that group. This fee that can be utilized to assist with program devel-
results in increased billing for services. Therefore,opment and planning is the logic model (Calley,
it is necessary to understand how billing practices 2011; Kettner et al., 2017). The logic model (see
impact the overall cost of the program to indi- Fig. 3.2) provides a framework for leaders to con-
viduals who pay out of pocket as well as those nect necessary resources, interventions, and out-
covered by insurance. comes based on their initial aims/goals for the
program. When considering the potential need
for or actual modifications to existing programs,
Developing and Maintaining a Day process improvement models such as Lean and
Treatment Program Six Sigma can offer strategies to improve effi-
ciency and outcomes (George et al., 2005; Lucas
DTP leaders are often tasked with program devel- et al., 2015). Six Sigma identifies ways to improve
opment, modification of an existing program, or the program’s process or processes within the
overhaul of an existing program. Each form of program to eliminate waste and improve quality
program development, implementation, and and efficiency. Process improvement utilizing
maintenance presents its own challenges that lean principles focuses on decreasing unneces-
include staffing, building therapeutic content, sary and wasteful steps, so only steps that directly
treatment intervention training, and managing add value to the product are utilized. A review of
physical space, technology needs, billing, refer- strengths, weakness, opportunities, and threats
ral sources, and accreditation. Several resources (SWOT) can be conducted via a SWOT analysis
are available to assist leaders in addressing these looking at internal and external elements of the
concerns (e.g., Calley, 2011; Issel & Wells, 2018; program (Namugenyia et al., 2019). A SWOT
Kettner et al., 2017; Royse et al., 2016). Calley analysis can be completed with a variety of stake-
(2011) presents a 14-step comprehensive pro- holders and staff members, and the data can be
gram development model. Additionally, a 10-step organized and utilized to identify ways to enhance
strategy for program design and implementation and sustain elements of the program. Another
has been described by Leffler and D’Angelo project management tool that could assist leaders
(2020). This model consists of four phases: (1) in their implementation, enhancement, and main-
brainstorming and planning, (2) resource gather- tenance of their program includes the Plan-Do-­
ing and front-end work, (3) review and evaluate, Check-Act (PDCA) cycle, which is a series of
and (4) work. The brainstorming and planning steps to assist with the continual improvement of
phase consists of identifying broad goals and a process, service, or product (Patel & Deshpande,
specific targets. The research gathering and front-­ 2017).
end work phase consists of identifying the need
for the service and resources required to initiate
the program and achieve goals and targets; com- Working with Stakeholders
municating the program goals; integrating sci- and Leaders
ence and practice; and identifying remaining gaps.
The review and evaluate phase includes review- All the program types discussed in this chapter
ing the initial outcomes of piloting the program typically exist within a continuum of services
and consideration for modifications. The work within a larger framework of a general system of
36 J. M. Leffler et al.

Short-Term Impact
Input Outcomes
Acvies (Long-Term)
(Client Variables Outputs (What immediate
(Process, Methods, (What changes do
Staff Varialbles (Products produced) changes do we
Services, etc.) we expect eventually
Resources needed) expect as a result of
our program) of our program)

Fig. 3.2 Logic model: How the program should work

care that exists within a cultural context at a deeply interconnected with a bidirectional com-
moment in time. There will be multiple stake- munication between the two entities. The pro-
holders at all levels, and those stakeholders may gram’s contribution at this level is in its products
change over time in terms of the direction, fre- (successes in terms of program outcomes,
quency, intensity, and duration of communication employee performance, financial stability-profit
between each of them. In considering working and loss, margin to the agency budget). The orga-
with different stakeholders, it may be useful to nization’s contribution as a stakeholder lies in its
adapt, as a heuristic device, Bronfenbrenner’s support of the program through its allocation of
Ecological Systems Theory (Bronfenbrenner, resources. If the program’s products are on target
1979) to think about the role of stakeholders and (i.e., outcomes are good, profit and loss are at or
how the program exists and communicates with above budget), this is communicated through
different stakeholders cross-sectionally. Applying various strategies to the organization, and the
this as a model, one could think of the program at organization will in turn communicate its
the center of an existing series of concentric cir- increased support of the program. The next level
cles that have a complex set of systemically inter- in Bronfenbrenner’s model is the exosystem.
connected relationships. At the microsystem According to Bronfenbrenner, the exosystem
level, the DTP is at the center of this model, and includes those structures and entities (both for-
the relationship between the program and all the mal and informal) which do not contain the cen-
stakeholders within the microsystem (employees, tral core microsystem but, as a stakeholder, exert
leadership, children, and families) is bidirec- an influence on the organization and program
tional. That is, the program influences the actors, itself. The stakeholders in this example might
and the actors influence the program. This is the include such entities as insurance and managed
most personal and direct set of relationships that care companies (reimbursement), state regulators
exist, and the communication is at the most direct (e.g., Department of Children and Families
level. We can look at how these relationships are (DCF), the Department of Public Health, the
negotiated and navigated to get a better under- Office of Mental Health and Substance Abuse
standing of the role of the next level of Services etc.), accreditation organizations (e.g.,
stakeholders. The Joint Commission), and federal agencies like
The next level is the mesosystem. The organi- the Centers for Medicare and Medicaid Services
zation in which the program functions can be (CMS), Office of Safety and Health
considered analogously to Bronfenbrenner’s Administration (OSHA), and the Department of
mesosystem. In this context, the systems are Labor (DOL).
3 Program Development and Administration in Day Treatment Settings 37

The macrosystem is the next level. The local 5 days a week for 3 or more hours. However, dur-
community including the state, city, township, ing the COVID-19 pandemic, the requirement for
and county function, in part, as a cultural context daily treatment hours was reduced.
and thus would be best located within the macro- An example of a child and adolescent PHP is
system. Local norms, customs, values, beliefs, housed at The Sarah A. Reed Children’s Center in
and ideals are communicated through various Erie, Pennsylvania. Sarah A. Reed Children’s
channels and inform the program and organiza- Center has two levels of PHP serving children
tion’s development over time. Each DTP will 3–18. The Center has a full-day PHP that typi-
look and feel different as a reflection of the mac- cally begins at 8:30 a.m. and ends at 2:30 p.m.
rosystemic community context and the roles that and runs five days per week. This program pro-
these stakeholders play in relationship to the pro- vides youth with a comprehensive behavioral
gram. The last level is the chronosystem. In this health and academic experience with a length of
level, the general zeitgeist of the time exerts an stay based on attainment of agreed upon treat-
influence on the programs, organizations, and ment goals. The Center also has an acute PHP,
larger systems. For example, the popularity of which is a full-day program (8:30 a.m. to
one or other model can be influenced by current 2:30 p.m.) running five days per week for youth
events including research that emerges that either 3–18, with a length of stay of 15 days. This pro-
provides additional support or refutes a particular gram is intended to serve youth who are experi-
model or governmental and regulatory policies encing an immediate mental health crisis in the
on payment methodologies. Using community, including children diverted from the
Bronfenbrenner’s Ecological Systems theory emergency room of local hospitals who do not
allows for a broad and comprehensive perspec- meet criteria for admission for IPH.
tive on the complex roles of various stakeholders A step below PHP is IOP. IOPs typically run
regardless of the specific environmental context 3–5 days a week and include up to 3–4 hours of
in which each program exists. treatment each day for shorter periods of time.
The limited treatment hours and treatment time
are based on a person’s level of stability and acu-
Program Length and Duration ity. Similar to PHPs, IOPs allow the individual to
continue to remain at home and more fully
The amount of time (hours per day, hours per engage in community-based activities (e.g.,
week) associated with DTPs is structured to meet school, job) while attending the program. In the
the specific needs of the population being served ASAM criteria, IOPs are defined as having
as well as conform to standards and regulations greater than nine hours per week for adults and
established by various oversight and regulatory greater than six hours each week for
bodies including the federal government (Code adolescents.
of Federal Regulations), payors (Medicaid, A residual category of treatment programs
Medicare, Commercial Insurers, and Managed that often fall into this intermediate level of care
Care Companies), and clinical organizations is termed therapeutic after-school or extended
(The American Society of Addiction Medicine; day treatment programs (EDTPs). These models
ASAM), which define partial hospitalization as a most often serve youth who attend up to five days
level of care with at least 20 hours or more of each week for up to three hours each day and are
service each week, and various accreditation intended to provide additional behavioral health
bodies (The Joint Commission, Commission on support for students stable enough to remain in
Accreditation). In general, PHPs are considered their regular school setting during the day. For
the highest level of day treatment programming example, in Connecticut, EDT is defined as “a
within the behavioral health system that still center-based, multi-component intervention for
enables an individual to remain at home in their children and adolescents, 5–17 years of age, with
community. This level of care is typically offered emotional and behavioral problems and their
38 J. M. Leffler et al.

families, that is delivered during the after-school stay (LOS) can be between 5 and 30 days in
hours” (Vanderploeg et al., 2010). As Vanderploeg PHPs and IOPs. LOS in longer-term programs
and colleagues indicate, the intent of this level of may be over 30 days.
care is to support and maintain children and ado-
lescents in their homes, schools, and communi-
ties. The primary difference between therapeutic Patient Considerations
after-school programs or EDTs and IOPs that and Characteristics
occur after school is probably driven more by the
specific system of care in place in a particular Patient needs will impact the development of
community or region than anything else. In programs and specific elements and treatment
Connecticut, the level of care guidelines differen- content. Patient’s presenting diagnosis, function-
tiates PHPs and IOPs from EDTs based on inten- ing, and health concerns will be a major factor in
sity and duration of the service type. According how a DTP is structured, staffed, and billed as
to the guidelines, PHP and IOP are identified as well as impact space needs and treatment
more intense over a shorter period with the goal approach. The specific treatment intervention and
of stabilizing a patient’s functioning, while EDT how it is delivered by trained staff will be influ-
provides clinical and rehabilitative interventions enced by the patient’s treatment needs. This will
and services over a longer period of time and also aid in developing marketing and referral
includes community-based activities as a primary information given the program’s admission and
component in the treatment plan. exclusion criteria. Additionally, youth with
The length of program for patients can vary. comorbid medical needs will require specialized
Because admission is based on clinical need due staff and program content (e.g., diabetes manage-
to acute mental health distress or functional ment, functional neurologic disorders/conversion
impairment, discharge from treatment is often disorder, postural orthostatic tachycardia syn-
determined by meeting treatment goals. For drome, chronic pain, etc.). Specific diagnoses
example, a patient who presents with low mood (e.g., eating disorders, substance use disorders,
and chronic passive suicidal ideation will work chronic suicidality, psychosis) may require spe-
with their treatment team at admission to deter- cific and specialized treatment elements.
mine goals for care, and then these goals will be Intellectual and adaptive abilities and daily func-
evaluated and monitored by the treatment team tion may impact the age level of materials and
for the duration of admission. As the patient pace at which content is provided. Diversity and
approaches their goals, the treatment team will ethnicity characteristics of patients should also
discuss discharge planning with the patient and be considered and are discussed later in this
their caregivers. In some time-limited programs, chapter.
discharge is based on the duration of program Additionally, the characteristics of patients
(e.g., Leffler et al., 2017; Whiteside et al., 2014). admitted to the program will influence safety
In a time-limited program where the length of monitoring throughout the program (upon admis-
stay is fixed (e.g., 1–3 weeks), all patients are sion, daily, discharge, etc.). Within some DTP,
informed of the goals of treatment and the dura- patient’s safety is assessed at the beginning of
tion of the program. The treatment team works each day and monitored and addressed as needed
with each patient as the program moves toward daily. This level of safety and severity monitoring
completion to coordinate discharge planning is important given the acuity of patients who are
with the patient and their caregiver. The treat- going home at the end of each treatment day and
ment team documents in the patient’s record the often scheduled to return the following day or
patient’s progress and achievement of discharge later that week. Additionally, the patient’s level
goals or needs for continued engagement in the of emotional and behavioral dysregulation may
program. Typical length of service or length of impact their level of acting out toward self,
3 Program Development and Administration in Day Treatment Settings 39

o­thers, and/or property. These actions can be culture of the organization, availability of pro-
addressed with various crisis interventions that fessional staff, salaries, etc. Zulman et al. (2018)
do not require physical contact (e.g., conflict de-­ interviewed representatives from multiple IOPs
escalation techniques; https://www.jointcommis- and found that staff representing the various pro-
sion.org/-­/ media/tjc/documents/resources/ grams identified team composition as a key com-
workplace-­violence/cpi-­s-­top-­10-­de-­escalation-­ ponent to facilitating patient involvement.
tips_revised-­01-­18-­17.pdf). Depending on the Drilling down on this concept, the authors also
patient’s behavior in the milieu, staff may encour- found that the multidisciplinary structure of the
age the patient to engage in self-soothing skills or teams was cited as critical to making sure that
coping strategies. If the patient requires a higher patients’ needs were addressed (Zulman et al.,
level of intervention, this may require escorting 2018). According to the Centers for Medicare
the patient to a quiet room. As a result, policies and Medicaid, PHP, which is the only federally
and procedures, staff training in these strategies, defined program within this level of care, has
as well as the designation of such treatment established program criteria focused on support-
spaces in DTPs are important considerations to ing and maintaining a person’s community ties
plan for in advance. Policies, procedures, and in the context of a structured program comprised
staff training should also be developed around of a multidisciplinary team under the direction
responding to a patient when he/she leaves the of a physician. As per CMS regulations, multi-
program without staff consent, which is usually modal, individualized core services include indi-
referred to as “elopement.” vidual or group therapy with physicians,
psychologists, or other mental health practitio-
ners, occupational therapy, family counseling,
Staffing Models and Needs medication management, and recreational or
activity therapy (Medicare Benefit Policy
Most DTPs are staffed by multidisciplinary or Manual, 2020). Beyond these requirements, the
interdisciplinary teams, which include staff from remainder of program staffing will be impacted
multiple disciplines that work together to address by population served, size of the program, diag-
the patient’s care needs. However, there is a nota- nostic considerations, location of the program,
ble difference between these two team models. cost considerations, payment considerations,
Primarily, an interdisciplinary team model program needs such as transportation, billing,
focuses on a collaborative care plan in which and case management.
each team member builds on each other’s exper- Most DTPs have a medical director and clini-
tise to achieve common or shared goals. Readers cal director who work to provide program leader-
interested in leadership elements and consider- ship. Medical directors are typically professionals
ation within interdisciplinary team models are with advanced training in psychiatry. Clinical
directed to Ong et al. (2020). Multidisciplinary directors typically provide clinical administrative
teams utilize the strengths and expertise of each oversight. Professionals in this role may include
team member to address the patient’s needs but a psychologist or social worker. Directors often
not through an integrated approach (Stanos & share some responsibilities such as staff hiring
Houle, 2006). Additionally, the patient and the and training, developing expectations for patient
patient’s parents should be included as part of the care, programmatic and procedural development,
team to allow for patient-centered care and and communicating with internal and external
involvement in treatment planning. stakeholders. They may also have separate activi-
Staffing models for DTPs and other similar ties and responsibilities such as providing clini-
levels of care often vary. Many different factors cal services in their specialty area. In most
can influence the staffing composition of these programs, a medical director will complete an
types of programs. Such factors can include pop- initial medical evaluation; however, in some pro-
ulation served, location, payment models, costs, grams, this may be completed by a nurse
40 J. M. Leffler et al.

p­ractitioner (NP), physician assistant (PA), or space, and need for specialized program (e.g.,
other advance practice medical provider. exposures, family meals, etc.).
When determining the scope and role of pro- Team members provide a range of services
viders in a DTP, it is important to start with the that include medication evaluation and manage-
treatment components of the program and ment, biopsychosocial evaluations, symptom and
accreditations and reimbursement demands on functional assessment and monitoring, therapy,
the program. Most DTPs are staffed with provid- and psychoeducation. When considering the staff
ers licensed in their area of professional practice. needed for the program, consider the profession-
Historically, this has included psychiatrists, psy- al’s scope of practice and what is clinically nec-
chologists, social workers, counselors, registered essary or required by accreditation and practice
nurses, advance practice nurses, occupational standards and build the day treatment team
therapists, recreational therapists, music thera- around these expectations. For example, a psy-
pists, art therapist, dieticians, and teachers. As chologist, social worker, and counselor can facil-
mentioned previously, programs often include a itate evidence-based psychosocial interventions
core group of providers consisting of psychia- in group, individual, and family formats.
trists, psychologists, nursing, and licensed master However, the financial cost each of these provid-
lever providers (social workers and counselors). ers presents to the program is very different.
Beyond this core group of providers, the unique Additionally, each provider type has been identi-
services and focus of each program will dictate fied by practice patterns and insurance compa-
what other providers and how many of those pro- nies to have different reimbursement rates.
viders are included in the program. When deter- Traditionally, a psychologist would be a more
mining the necessary number of providers, we expensive FTE to the program than a social
encourage directors to decide what interventions worker or counselor; however, it is possible that a
will be offered throughout the day (e.g., four to psychologist would be able to bill at a higher rate
five treatment groups a day and the content of for reimbursement of the services. Given these
those groups, individual and family therapy, cre- decisions, it is important to know state licensure
ative therapy groups per day or week, school or practice guidelines and insurance reimbursement
education time, etc.). This information will assist rates and provider coverage. For example, some
in identifying what professionals are needed to providers may not be covered to bill group ser-
offer the interventions and how much full time vices. Additionally, social workers and counsel-
equivalent (FTE) of each provider type is needed. ors can conduct initial intakes, develop treatment
Additionally, some accreditation requirements plans, and complete discharge summaries.
will determine if a specific provider is required. However, in some programs, these may need to
For example, as mentioned earlier, a psychiatrist be signed off on by the medical or clinical direc-
may be required to fulfill the role of the medical tors. Further, a psychologist might be the pro-
director. Some reimbursement limitations may vider on the team who is most trained to review
designate a social worker, instead of a license psychological testing results or admission ques-
mental health counselor, provide specific clinical tionnaires and integrate these results into the
activities. In addition to the treatment model, the treatment team’s conceptualization of the patient;
number of patients admitted to the program will however, other team members are also trained to
impact the number of staff. For example, some integrate information into the conceptualization
reimbursement entities and regulatory bodies set of the patient.
a limit of eight patients per provider per group. In
this model, if the program were to admit more
than eight patients, program leaders would need Team Communication
to plan for two providers per group. Additionally,
the patient to staff ratio will be driven by factors Team members benefit from regular communica-
such as the patient’s clinical concerns and acuity, tion opportunities to facilitate discussion about
length of stay, involvement with parents, physical patient and program needs. Ideally, the DTP has
3 Program Development and Administration in Day Treatment Settings 41

structured meeting times between two to five components of the interventions (e.g., group ther-
times a week, in the form of team or staff meet- apy content, family and individual therapy, etc.).
ings that allow the treatment team to review and While this is extremely important, it is not the
discuss patient treatment progress and needs, only priority. Staff in DTPs should be trained in
review upcoming discharges and admissions, communication and problem-solving strategies,
address milieu concerns, make modifications and crisis de-escalation, documentation, policies and
updates to programming, address staffing models procedures, and other areas germane to the day-­
and coverage, and other topics relevant to the to-­day operations of the program. Additionally,
functioning of the program. Additional meetings staff training is fluid and may include small or
may include monthly or quarterly meetings that slight updates or changes (e.g., updated or new
include the treatment team as well as other staff, policies, changes in crisis protocols, changes to
such as billing and revenue specialists, research the type of electronic health record, etc.) and may
assistants, administrators, and information tech- also include complete retraining (e.g., learning a
nology. Additionally, staff will often require fre- new treatment model or developing a new pro-
quent in the moment contact between groups or gram with a different patient population). While
treatment sessions to update each other on patient programs often cannot shut down while staff are
progress or needs as well as address acute patient learning, the program’s environment will have to
concerns, treatment interfering concerns, as well be conducive to introducing, teaching, and refin-
as any patient or staff behaviors that are impact- ing the learning of staff with potential ongoing
ing the milieu. supervision, while the program continues to run
and staff continue to provide their daily clinical,
administrative, research, and education activities.
Staff Training Further, when implementing a new element to the
program, program leaders may need to plan for
Staff training is an important element of the pro- regular follow-up meetings, problem-solving
gram and one that can make or break a program’s activities, and updates based on updated
success. This is because if staff are not trained to information.
provide the treatment as planned or promised, The interdisciplinary treatment team model
there is most likely going to be dissatisfaction by and day treatment atmosphere provides a colle-
the directors, team members, patients, patient’s gial setting to support training opportunities for
caregivers, referral sources, and agency leaders. learners who are in training for their professional
This dissatisfaction can lead to complaints, burn- career. Learners may include individuals in disci-
out, staff turnover, and decreased referrals result- plines that are represented by team members
ing in not meeting financial targets. As such, it is (e.g., psychiatry, psychology, social work, nurs-
critical to engage in meaningful, effective, and ing). Additionally, other learners from disciplines
efficient staff training and development. While not represented in the program (e.g., pediatrics,
there are costs associated with this in terms of family medicine) may rotate through or shadow
staff time and less clinical practice, cost of a the program to gain an understating of the model
trainer or training materials, and ongoing super- of care and help inform their clinical practice and
vision, these costs are an investment in the suc- understand referral options. Learners can take on
cess and further financial return from the many roles given their level of training, interest
program. Additionally, it is more likely that satis- in the program, and skill set. For example, some
fied and successful staff are more likely to stay learners such as graduate students may shadow or
with the program or institution and therefore observe clinical interventions, whereas more
reduce staff turnover and costs incurred by the advanced learns such as interns and fellows may
agency to onboard new staff. observe, co-facilitate or facilitate groups, provide
At first pass, one might think of staff training care management, individual and family therapy,
around learning and delivering the treatment develop treatment plans, and complete discharge
42 J. M. Leffler et al.

planning or summaries under the supervision of a gram. Mental health programs are often evalu-
licensed provider in their area of training. Cross-­ ated based on earnings; however, some programs
discipline training is also available in the DTP may not demonstrate fiscal success or even sus-
setting. For example, a psychologist might be the tainment. In fact, some programs may actually
supervisor of a psychiatry fellow conducting demonstrate a financial loss for an institution.
group, individual, or family therapy. That may not necessarily suggest the program
When working with a learner, it is important will not be sustained if it is developed to meet a
to discuss with them the training opportunities, specific treatment niche or serve a specific patient
goals, and expectations. Also, review with the population. DTP administrators and directors can
learner the program model, goals, and expecta- benefit from meeting with a billing and revenue
tions, as well as familiarize them with program specialist to discuss the planned billing practices
policies and access to additional programmatic and revenue models associated with cost expecta-
needs, such as who to contact if there is a patient tions. This practice allows the program adminis-
crisis, and who to reach out to for answers to pro- trator or director to clearly articulate with the
gram questions with which they are not familiar. financial specialists the type of services being
Further, it is important for staff to introduce planned as part of the program to provide the
learners to the patients and caregivers and treat most accurate and meaningful billing and cost
the learner as an equal within the team. Most pro- modeling. As suggested earlier in this chapter, it
grams inherently develop and refine their own is important to know the number and type of ser-
microculture as discussed earlier. Within that cul- vices being offered as part of the program (e.g.,
ture, it is important that all staff and learners be medication evaluation, medication appointments,
represented equitably and consistently so not to individual, group, and family therapy; occupa-
confuse patients and caregivers of the importance tional therapy; etc.) and who will be offering the
of the learner and avoid questioning them based services (e.g., psychiatrist, nurse practitioner,
on their abilities. Supervisors should use supervi- psychologist, social worker, counselor, occupa-
sion and contact with the learner outside of clini- tional therapist, etc.), as well as where the service
cal activities to discuss training and professional will be offered (e.g., outpatient setting, dedicated
growth needs and progress. Further, staff meet- hospital space, etc.).
ings can be used to review and discuss staff and Monitoring the program’s financial perfor-
program activities to provide a learning and mance will be necessary. This information pro-
growth experiences for all staff and learners. vides a method to communicate with agency
While some learners may not be receiving formal leaders and other stakeholders how the program
clinical supervision, providing information about is functioning and provides insight into ways to
the program and model of care is helpful. Staff modify or more accurately capture billing prac-
members providing clinical supervision are tices and adjust expenses and costs. This infor-
encouraged to consider a specific supervision mation is provided through financial reports
model or approach (e.g., Bernard & Goodyear, which detail billing, revenue, and expenses
2009; Falender & Shafranske, 2004) and utilize through different line items associated with a cost
that consistently within the learner’s level of pro- center or program. DTP leaders are encouraged
fessional development and training needs. to review each line item routinely for accuracy
and consistency. For example, sometimes staff
FTE may shift over time or a staff member may
Financial Aspects of the Program split their time between programs, and this cost is
not accurately captured or reflected in the pro-
We present the financial aspects of the program gram costs. Additionally, annual adjustments are
after the section on building the team and prior to made due to acquisition of new fees and charges
program physical space, as these are two major that cover resources that may be shared across an
factors that will impact the finances of the pro- institution, like a staff member’s FTE who may
3 Program Development and Administration in Day Treatment Settings 43

be involved peripherally with multiple programs. gramming, and some continued in-person pro-
Leaders may also be asked to monitor and adjust gramming with alterations to number of patients,
costs, and if the costs are not accurate to begin social distancing, wearing masks and eye protec-
with, leaders may need to assess these costs tion, screening patients and staff for health-­
before they can make a meaningful change. related concerns as well as increased their
Similarly, leaders may be able to adjust revenue approach to cleaning the physical space (Leffler
by reassessing billing practices due to staff et al., 2021). During this time, some programs
changes (e.g., change in the discipline providing provided a telehealth version of their DTP, which
a service over time) or the patient population continue to be implemented. To offer this new
being served. treatment option, programs required establishing
a virtual or telehealth infrastructure that allowed
for connectivity between the physical DTP loca-
Facility and Space Considerations tion and patients via telehealth, using stable and
reliable connections and secure platforms. The
DTPs require space that offers group rooms to daily programming was modified with changes to
accommodate the total number of patients and timing and format of groups, how content was
staff who facilitate the groups. In many institu- presented and covered, managing crises during
tions, the cost of square footage of clinical space virtual sessions, engaging caregivers, and pro-
may contribute to the total cost of the program. vided a secure environment for all participants
Assessing space needs and square footage related to being able to see others virtually in
became more critical during the COVID-19 pan- their living settings and trusting the group and
demic given a need in most indoor settings for a therapy exchanges remained confidential and
six-foot spacing between members. As a result, safe. Communication between staff was modified
group spaces that may have accommodated and, in some instances, increased with frequency
10–12 people sitting at a large table together and availability of staff due to virtual platforms.
prior to the COVID-19 pandemic may only However, this also presented challenges as some
accommodate four to six people spread out on the staff were working from home and not physically
parameter of the room in single chairs. present in the DTP space. Telephonic options
Some group rooms are set up with a table in were initially utilized to connect patients with the
middle and staff and patients sitting around it. DTP and were also necessary in case there was a
Other group rooms may use chairs with writing disruption to connectivity or if a safety issue
surfaces spread around the room in a circle with arose with the patient during a virtual session.
the facilitator present within the circle of chairs. Given these changes, programs are encouraged to
Different group room setups may be necessary consider both physical and technology resources
for different reasons. For example, in a group that necessary to offer their program successfully.
requires the use of worksheets, binders, books, or
significant writing, it is strongly encouraged to
have a writing surface available to the patient Referrals and Working
either in the form of a desk-type chair placed in a with the Community
circle or all group members sitting at a large con-
ference style table. In the former setup, the group The development of referral sources is critical for
facilitator will usually sit in a chair as part of the launching and sustaining a DTP. Additionally,
circle and in the latter example will sit at the table providing support to referral sources is necessary
in a position that allows for all group members to to ease the process of connecting providers and
see the facilitator. patients with the DTP. This may require program
In 2020 with the response to COVID-19, most leaders and staff to engage local, regional, and
DTPs made modifications to how they delivered potentially national referral sources in discussing
their interventions. Some stopped or paused pro- gaps and needs in treatment services on the front
44 J. M. Leffler et al.

end of the developing the program. DTP leaders overview of strategies for considering diversity
are encouraged to provide referral sources with and equity elements in program development.
marketing information about the patients who are The patient demographics within a DTP may
appropriate for the program, the treatment model, vary depending on several factors including, but
and how to access the program. Gaining feed- not limited to, location, target population served,
back from referral sources regarding accessing resources, and needs of the community. The
and utilizing the program can be very useful. National Mental Health Services Survey
Following up with referral sources regarding (N-MHSS), conducted by the Substance Abuse
referrals they have provided, the appropriateness and Mental Health Services Administration
of the program for their patients and other related (SAMHSA), plays an important role in rigor-
topics can also provide useful information for ously collecting data and information regarding
program maintenance, modification, and sustain- DTPs throughout the country, among other
ability. Further, when considering meeting the behavioral health organizations. The N-MHSS is
community and patient’s needs, it can be useful an annual survey of all known public and private
to develop a clinical partnership with treatment facilities in the United States that provide mental
resources to bolster the continuity of care in the health treatment to individuals with mental ill-
community for youth and families. ness, and the response rate for 2018 was 90%
(SAMHSA, 2019). The 2018 N-MHSS offers
information regarding the different facilities as
Cultural Considerations well as the patients they served. The facility types
include outpatient mental health facilities, com-
The US population is changing, and the demo- munity mental health centers, residential treat-
graphics of youth and families seeking services is ment centers (for adults and children), Veterans
diverse. In response to these changes, providers Administration medical centers, psychiatric hos-
and team members should be familiar with the pitals (public and private), and DTPs. It is impor-
role and utilization of interpreters in family, indi- tant to note that there are often DTPs within these
vidual, and group sessions. Additionally, know- various facilities. For example, multi-setting
ing patient demographics within the DTPs mental health facilities, community mental health
treatment catchment area can help in educating centers (CMHCs), outpatient mental health facil-
staff about cultural and ethnicity considerations ities, and IPH may also provide some “less than
which may include providing materials in the 24-hour” DTPs (e.g., 11% of CMHCs offer some
patient’s native language, enhancing staff train- version of a DTP; SAMHSA, 2019). According
ing and skills to provide culturally informed care, to this survey, of the 11,682 mental health facili-
and the use of culture awareness and curiosity. ties that responded, approximately 15% were
Some programs provide training to staff in these classified as standalone DTPs. The median num-
models (Benjamin et al., 2019). Additionally, ber of patients in DTPs was 39 (SAMHSA,
several resources are available for staff working 2019).
with diverse patients and their families (Breland-­ In the United States, day treatment facilities
Noble et al., 2016; Canino & Spurlock, 2000; serve individuals of different ages and back-
McGoldrick et al., 2005; Parekh et al., 2021). grounds presenting with an array of mental health
Awareness and appreciation of healthcare ineq- challenges. About 17% of DTPs serve all ages of
uity and trauma-informed care are also strongly patients. Thirty-two percent serve children under
encouraged. Staff can also benefit from ongoing 12 years of age, and nearly 45% work with chil-
learning and supervision in diversity, equity, and dren ages 13–17. Seventy-three percent of DTP
inclusion efforts as well as how services are made patients served in the country fall between 18 and
available to the community and how community 25 years old. Similarly, approximately 66% of
partnerships can be developed, fostered, and sus- partial/day treatment programs serve individuals
tained. Calley (2011) also provides a helpful 26–64 years of age. Seniors (over age 65) are
3 Program Development and Administration in Day Treatment Settings 45

admitted to around 63% of DTPs. Several DTPs dance and engagement make concerted efforts to
offer treatment programs tailored specifically for address any potential transportation barriers for
certain patient populations or presentations: patients. As a result, some DTPs may have their
children/adolescents with emotional disturbance, own transportation where they will pick patients
transitional age, 18 and older with serious mental up from their homes and return them at the end of
illness, 65 years and older, co-occurring sub- the program day. While this increases liability
stance use and mental health disorders, eating and staffing costs to the program, it greatly
disorders, trauma/PTSD, traumatic brain injury, improves access to and engagement in medically
veterans/active duty military and families, LGBT necessary services (Chen et al., 2021; Whetten
individuals, forensic patients, and patients with et al., 2006; Wolfe & McDonald, 2020). With the
AIDS/HIV (SAMHSA, 2019). addition of telehealth options due to the response
According to DTPs surveyed by N-MHSS, to shelter in place orders and social distancing
both males and females were equally represented requirements related to the COVID-19 pandemic
among the patients who received care. Patients (Leffler et al., 2021), transportation barriers may
aged 0–17 represented about 23% of patients in become less of a concern for treatment access
DTPs, while 69% of patients were ages 18–64. and attendance.
Only about 8% of patients were older than
65 years of age (SAMHSA, 2019). The majority
of DTP patients’ racial identifications were either Working with Schools
unknown or not collected (53.4%); however,
available data suggest the racial composition of While primarily designed to treat the behavioral
day treatment patients was 28.2% White, 14.2% health needs of children and youth, DTPs inevita-
Black or African American, 3% had two or more bly must confront the reality that children strug-
races, 0.3% American Indian or Alaska Native, gling with behavioral health issues must also
and 0.1% Native Hawaiian and Pacific Islander. have their academic needs met. The blending of
Regarding ethnicity of clients served, 13% were behavioral health and education is a complex
Hispanic/Latino and approximately 42% were brew of ingredients with often divergent and/or
non-Hispanic/Latino (SAMHSA, 2019). Notably, conflicting agendas focused on whipping up a
a significant percentage of demographic data was recipe of disjointed and sometimes fragmented
unknown or not collected. ingredients in hopes of implementing a coordi-
nated, collaborative, and constructive holistic
program. Often the best-case scenario is an awk-
Transportation ward and clumsily integrated approach that tries
valiantly to meet each child’s needs but risks not
Transportation to and from day treatment ser- doing enough to meet either set of needs in the
vices can vary widely depending on the nature of child.
the program, as well as the population served. Programs exist in a variety of configurations
DTPs that treat children and youth typically and settings. There are PHPs in schools, in hospi-
coordinate with the patients’ individual school tals, in community mental health centers, and in
districts to organize transportation. There are also private provider settings, and some are free stand-
instances of contracted services with local trans- ing. IOPs tend to be more consistently operated
portation providers who may also be transporting in strictly behavioral health settings and less so in
individuals from throughout the community. schools. Additionally, there have even been col-
Patients utilizing behavioral health services such laborative efforts between universities and public
as these may also transport themselves if they schools to design programs to address the needs
have the means to do so, with their own vehicles, of children with serious emotional disturbance
ridesharing, or the use of public transportation. (Vernberg et al., 2004). In this example, the pro-
Programs which hope to have consistent atten- gram provided intensive mental health
46 J. M. Leffler et al.

i­nterventions for 3 hours each day in a special- are several organizations that offer guidelines
ized therapeutic classroom in a public school regarding best practices in DTP (Rosser &
setting. Stephen Michael, 2021); however, there are typi-
At the Sarah A. Reed Children’s Center in cally three regulatory entities that manage the
Erie, PA, the PHP is housed within a private pro- licensure of PHPs and IOPs. First, most states
vider agency and is a long-standing blended men- have departments responsible for licensing
tal health and educational model. The children behavioral health programs. Typically, these
attend each day for up to six hours and participate departments (usually housed under health and
in an academic curriculum provided by special human services or social services) outline the
education teachers. In addition, children are specific requirements that must be met for a spe-
engaged in a variety of intensive mental health cific program and facility to be licensed. For
interventions including group therapy, individual example, in Pennsylvania, a facility seeking to
therapy, family therapy, case management, and open a PHP must first apply for a certificate of
medication management. All staff in the program compliance with the Department of Human
are employees of the program and thus function Services (PA Code Title 55 Chapter 20 & 5210).
as an integrated multidisciplinary team. Payment In Pennsylvania, the licensure for PHP is issued
for the services is comprised of insurance by the Department of Human Services, Office of
(Medicaid, commercial) and school funding by Mental Health and Substance Abuse Services
districts. (OMHSAS). This license is issued following an
Children are referred from multiple school inspection by OMHSAS, and a full license is
districts, and thus each school district plays a key good for one year. In Connecticut, licensure for
role at all points that the program engages the child IOP, PHP, and EDTP is handled under the
child. There are regular meetings at the adminis- auspices of the Department of Children and
trative and supervisory level with personnel from Families (DCF). For example, the EDTPs that
the different districts to minimize the loss of aca- provide after-school treatment are licensed by
demic progress impacting the child from being DCF under section 17a-147-1 on a biennial basis
out of a regular school setting and to provide (https://portal.ct.gov/DCF/Policy/Regulations/
updated information and recommendations to the L i c e n s i n g -­o f -­E x t e n d e d -­D a y -­Tr e a t m e n t -­
district as the child moves through treatment and Programs). The state offers general provisions
ultimately back to their home district school. The which specify expectations of the PHP or IOP
importance of a balanced approach to treatment including goals and objectives, program stan-
and education within DTP in Pennsylvania was dards, organization and structure, linkages with
outlined in a white paper distributed by the other aspects of service systems, staffing, psychi-
Department of Human Services/Department of atric supervision, treatment planning/records,
Public Welfare and the Pennsylvania Department treatment team, policies and procedures, and the
of Education to outline the broad strokes of a size of the program. Licensure for certain pro-
consensus on the application and implementation grams may require additional accreditation (such
of PHPs for children and youth (Pennsylvania as with an organization like Joint Commission on
Departments of Education and Public Welfare, Accreditation of Healthcare Organizations;
2007). JCAHO); however, many DTPs seek out non-
mandatory accreditation to ensure safe and qual-
ity programming above minimum standards,
 rogram Licensure, Accreditation,
P which will be explored in the next section. Once
and Regulatory Requirements a facility obtains licensure for its program(s),
continued inspection and/or audits are carried out
Program licensure is a necessary process for the at least annually to ensure ongoing compliance
development of DTPs, and the process varies with stated regulations. Most local standards
widely on local standards and guidelines. There indicate facilities are subject to inspections at any
3 Program Development and Administration in Day Treatment Settings 47

time the governing departments deem warranted. best practice and high standards of care; delivery
In addition to licensure of the facility, there may of quality services to clients; attracting highly
also be requirements for licensure of program qualified personnel who hope to be employed
staff. All states have agencies that regulate the with an accredited site; support for staff by pri-
licensing of different professionals (Rosser & oritizing health and safety; ongoing collaboration
Stephen Michael, 2021), and each state has spe- and communication with the accrediting body;
cific regulations on who can provide a specific tools and resources for improvement efforts; and
service. inspiring confidence in a program’s board and/or
In addition to regulatory standards, payors donors, legislators, and the community. When
have requirements for DTPs. As noted previ- considering which accrediting organization to
ously, the CMS typically set the protocols for choose, facilities should first consult their state’s
reimbursement requirements; however, there are regulations, as there may be an identified organi-
times that certain payors are not in alignment zation that is expected to be utilized. For exam-
with CMS, which creates potential challenges for ple, in Pennsylvania, for-profit programs must
programming and billing. Additionally, private receive JCAHO accreditation to obtain state
insurances have their own set of standards for licensure under the Department of Human
DTPs, which may be more rigorous than other Services (PA Code Title 55 Chapter 5210). Some
payors and result in program requirements that payors may also require accreditation. Other con-
are difficult to meet with the resources sufficient siderations for an accrediting body may include
for other regulating bodies. Other payors may the population being served by the DTP. That is,
require accreditation as well (Rosser & Stephen a program that hopes to serve a specific popula-
Michael, 2021). Prior to program approval, some tion (e.g., age, diagnostic presentation, medically
managed care organizations require evidence of complex, etc.) can pursue a population designa-
support from local municipalities, such as a letter tion in the accreditation process. In many ways,
of support indicating need in the community for accreditation is a seal of approval that communi-
specific programming. Additionally, managed cates dedication to continuous quality
care organizations often provide performance improvement.
standards to ensure quality services. If these stan-
dards are met, programs may be eligible for
financial incentives associated with value-based Evidence-Based Assessment
purchasing; if these standards are not met, an and Outcome Measurement
audit may be triggered to ensure that service pro-
vision is meeting all standards. Assessment is a critical component of treatment
As mentioned previously, many DTPs seek as it identifies the concerns and level of function-
out accreditation to communicate to the commu- ing of the patient at admission and can be utilized
nity and other stakeholders that service provision to evaluate the patient’s progress and functioning
is both safe and of good quality. Most accrediting throughout treatment (Ogles et al., 2002; Lambert
organizations review the quality of the clinical et al., 2011). Data gathered through assessment
care provided by behavioral health programs and can inform discharge decisions and planning.
offer feedback regarding program strengths and Evidence-based assessment (EBA) includes the
areas for growth. There are three organizations use of research to inform the specific purpose of
that offer accreditation for behavioral health assessment and how it is approached, utilization
organizations JCAHO, Council on Accreditation of reliable and valid measures that are standard-
(COA), and the Commission on Accreditation of ized using a cohort or population of individuals
Rehabilitation Facilities (CARF). Each organiza- that represents the identified patient being evalu-
tion emphasizes the potential benefits that ated, and the awareness of the inherent decision-­
accreditation offers facilities, such as in-depth making associated with this process along with
and intense analyses of facilities to encourage the impact assessment has on the patient and the
48 J. M. Leffler et al.

overall outcomes (Hunsley & Mash, 2007). scoring along with collection and utilization of
Despite clinicians being interested in receiving data in real time present challenges to programs.
data on their patients’ outcomes and progress and Given these concerns, DTP directors and staff are
using outcome measures to provide this informa- encouraged to plan and problem-solve ways to
tion (Bickman et al., 2000; Hatfield & Ogles, address implementing MBC in their programs as
2004), they report barriers such as time, concerns the benefits can outweigh the costs. Chapter 5 in
of EBA benefits over clinical judgment, and ease the current text provides an overview of EBA and
of use and integration (Cho et al., 2021; Jensen-­ MBC in DPTs. Additionally, several chapters
Doss & Hawley, 2010) that impact the use of overview assessment practices unique to the pre-
EBA in DTPs. Strategies that may facilitate rou- sented treatment program.
tine data collection are offered by Hall et al.
(2013).
Although barriers to assessment exist, there is Implementation of Evidence-Based
a need for utilizing EBA within DTPs given the Treatments
benefit of information that it provides. Further,
EBA can be integrated into a measurement-based DTP leaders should develop programming that
care (MBC) model as part of ongoing symptom meets the needs of the communities they plan to
and functioning monitoring. MBC focuses on the serve, which may require in-depth analyses of the
systematic collection of clinical data to evaluate unique challenges and presentations of a particu-
patient’s progress and inform clinical care and lar region or population. DTPs historically have
decision-making (Scott & Lewis, 2015). MBC provided services for a range of mental health
has been found to offer benefits to providers and concerns, often in the same treatment cohort.
patients in various treatment settings (Lewis There is limited research on the clinical effective-
et al., 2019). Elements of MBC include routine ness and outcomes of these programs, and the
collection of patient-reported outcomes, sharing extent to which EBTs are implemented
outcomes about progress in a timely manner with (Robinson, 2000; Thatte et al., 2013). Limited
the patient, and utilizing the data to inform the research of traditional DTPs suggests functional
course of patient care (Oslin et al., 2019; Resnick improvement (Thatte et al., 2013). More recently,
& Hoff, 2020). MBC with youth has been found over the past decade, DTPs have been developed
to demonstrate positive outcomes (Bickman with a focus on addressing specific diagnostic or
et al., 2011; Cooper et al., 2013; Douglas et al., presenting concerns. This focus on treatment ele-
2015; Kodet et al., 2019) and continues to evolve ments results in a different approach to program
(Parikh et al., 2020). development, implementation, and delivery, as
DTPs are encouraged to consider the best way well as patient admission criteria and treatment
to integrated MBC with EBA strategies. This may cohorts. Historically, DTPs offered process
be necessary to demonstrate success of the pro- groups, educational opportunities, and a social
gram at alleviating clinical symptoms, improving experience within a treatment milieu. The inter-
functioning, reducing readmission rates, or other ventions, which were patient centered or diagno-
program-specific goals. Data from assessment sis specific, were often provided in individual and
can aid in communicating to stakeholders such as family therapy sessions that varied from daily 30-
internal executives or department and division to 60-minute sessions to weekly 60-minute ses-
leaders and insurance companies about the pro- sions. However, newer models of DTP have taken
gram’s success, viability, and clinical benefit. EBT models for outpatient and from laboratory
Additionally, referral sources and patients’ care- research settings and modified or integrated ele-
givers may want to know the success and benefits ments of the treatment into the DTP framework.
of the program. Costs associated with assessment This model can be conceptualized as taking the
measures and questionnaires, staff training, and structure or “bones” of the traditional DTP and
potentially technology for administration and/or hanging elements of EBT on that structure.
3 Program Development and Administration in Day Treatment Settings 49

Evaluation of these programs often includes therapy, family engagement, supervised meals,
implementation science (Proctor et al., 2009, and medication management (Hayes et al., 2019;
2011) or a deployment approach to clinical Wilson et al., 2000). Specific treatment interven-
research (Weisz et al., 2005). tions include family-based treatment, Fairburn’s
Many DTPs that have implemented EBT into CBT-E model, and integrated therapeutic ele-
their treatment are presented in this text. As a ments of DBT and ACT (Dalle Grave et al., 2013;
result, the current chapter only provides a brief Hayes et al., 2019).
overview of these programs and their content. Most of the programs reviewed offer their
For example, there are three chapters focused on intervention with a PHP or IOP model of care
implementing EBTs for suicide and mood con- that can range from a week to over a month and
cerns via utilizing cognitive behavioral therapy utilize a treatment milieu. Within that format,
(CBT), dialectical behavioral therapy (DBT), most programs are providing group-based inter-
mindfulness, and interpersonal psychotherapy ventions along with individual therapy and some
(IPT). The examples of interventions for youth element of family involvement that can range
with mood disorders include a 2-week family-­ from caregivers attending the program all day
focused approach for youth with depression and with the patient to weekly family therapy ses-
bipolar disorders that implement CBT, mindful- sions or a weekly caregiver group.
ness, and IPT elements (Leffler et al., 2017, DTP leaders may find it useful to consider
2020) as well as CBT, DBT, mindfulness CBT, strategies for implementing EBTs in their pro-
and Relapse Prevention CBT focused program- grams. In this case, resources are available to pro-
ming for youth with suicidal ideation (Kennard vide guidance and suggestions (Becker & Wiltsey
et al., 2019). These interventions are consistent Stirman, 2011; Breitenstein et al., 2010). For
with various EBTs for mood disorders and asso- example, Fixsen et al. (2010) identify a four-step
ciated mood symptoms (David-Ferdon & Kaslow, model that includes identifying a need for the
2008; Fristad & MacPherson, 2014). intervention and assessing the goodness-of-fit
Some DTP have focused on anxiety disorders, between the intervention and population needs;
and most of these programs have utilized expo- preparing staff, stakeholders, and organization
sure and CBT-based interventions, which have for change, training staff to enhance competence
demonstrated positive outcomes in outpatient and fidelity, providing time and compensation for
settings (Higa-McMillan et al., 2016; McKay training, and adapting policies and procedures;
et al., 2015). These DTPs include a five-day putting the program or intervention into practice,
exposure-based model (Whiteside et al., 2014) as assessing adherence and fidelity, and problem-­
well as one with various treatment models (Davis solving implementation barriers; and finally
et al., 2009; Storch et al., 2007). Additional pro- monitoring and managing fidelity and outcomes
grams of varying length and duration have of the changes. Another model of implementing
focused on separation anxiety (Santucci et al., EBTs in systems of care includes the ACCESS
2009) and panic disorder (Elkins et al., 2016). model (Wiltsey Stirman et al., 2010), which is a
Pediatric pain interventions have been evalu- six-step process. Additionally, elements of Leffler
ated and show promise for symptom reduction and D’Angelo’s ten-step strategy to program
(Fisher et al., 2014). DTPs focused on treating design and implementation could also be utilized
youth with chronic pain symptoms have utilized (2020).
elements of CBT and acceptance and commit- The programs highlighted above have taken
ment therapy (ACT) with caregiver participation EBT elements and integrated them into their
(Benjamin et al., 2020; Gauntlett-Gilbert et al., DTP. This is a great first step to begin to imple-
2013; Logan et al., 2012, 2015; Weiss et al., ment more of a patient-centered approach within
2019). DTPs for eating disorders in youth typi- DTPs rather than a “one-size-fits-all” model. It is
cally consist of 3–5 days a week of treatment. strongly recommended the DTPs continue to
These programs include individual and group approach their care models by implementing ele-
50 J. M. Leffler et al.

ments of EBT within their programs and engage toring, especially if the supervisor is not part of
in research to evaluate the feasibility, acceptabil- the DTP institution. Leaders should also plan for
ity, sustainability, and additional elements of staff retraining and recertification.
implementation as well as treatment and func-
tional outcomes.
Evaluating program implementation as well Conclusion
as treatment and functional outcomes in a clinical
setting can be useful for making program deci- Developing, implementing, maintaining, and
sion, identifying program staffing and patient leading a DTP can be a very rewarding and posi-
needs, and offering feedback to staff, patients, tive professional experience. In doing so, leaders
patient’s caregivers, and stakeholders about the and administrators are encouraged to consider
care being provided. As a result, it is strongly rec- the format, structure, and goals of the DTP to
ommended that DTP leaders plan for, develop, help guide their efforts. Several resources are
and prepare to implement evaluation strategies at available and reviewed in this chapter to assist
the onset of the program and intervention as early with this process. Content in this chapter can pro-
as possible. Part of this process will include iden- vide a starting point for leaders and administra-
tifying aims and goals of the evaluation, identify- tors interested in navigating this process.
ing targets to measure and strategies to measure Elements of program development, implementa-
these elements. Information throughout this tion, and project management, along with suc-
chapter and the current text provide suggestions cessfully engaging and working with various
and insights into strategies for implementation stakeholders, are critical to starting and maintain-
science (e.g., acceptability, feasibility, sustain- ing a clinical program. Additionally, identifying
ability, etc.) (Proctor et al., 2009, 2011; and meeting the needs of the patient population
Rubenstein & Pugh, 2006), as well as evidence-­ will impact how the program is structured and
based assessment. In line with program develop- formatted as well as the overarching goal of the
ment and evaluation, data collected can be shared DTP. Staff training, supervision, and expertise
with stakeholders to demonstrate meeting set along with working with referral sources will be
goals or objectives, as well as identifying areas an important element of the success of the
that were not fully realized as planned and how to DTP. The integration of evidence-based assess-
continue to address these goals. It is good prac- ment and intervention along with meaningful
tice to evaluate program goals (e.g., finances, data from measurement-based care will offer a
LOS, outcomes, etc.) on a regular basis as well as solid foundation for assessment and practice, and
to have the opportunity to report these outcomes can aid in structuring the program as well as
on a regular basis to stakeholders, leaders, and tracking and reporting treatment and functional
administrators. outcomes and financial sustainability of the
Another area for DTP leaders to focus on is DTP. There is demand for developing and
staff training related to the EBT content that will enhancing DTPs to meet the mental health needs
be provided. This would include time and costs of youth as well as offer services to bridge the
that are incurred with onboarding and training gap between outpatient and IPH through in-­
staff to implement EBTs. DTP leaders are encour- person and virtual formats.
aged to consider and plan for costs associated
with trainings, associated training and treatment
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 Implementation and Training
4
Tommy Chou, Heather A. MacPherson,
Maya Massing-Schaffer, Anthony Spirito,
and Jennifer Wolff

Introduction & Blase, 2011). Prior work has focused on trans-

lating EBTs to outpatient and community mental
Current research indicates a 17-year gap between health services (Friedberg et al., 2009; Weersing
the scientific evaluation and practical implemen- et al., 2017); however, research on best practices
tation of evidence-based mental health practices, for EBT implementation in intensive treatment
with only 14% of evidence-based treatments settings remains sparse (Leffler & D’Angelo,
(EBTs) reaching patient care settings (Chambers, 2020). The lack of attention to EBT delivery in
2018). Accordingly, efforts to operationalize and these settings warrants concern given the high
improve EBT access and implementation have acuity of the patients they serve (Leffler &
grown substantially in recent decades (Atkins & D’Angelo, 2020). Past studies also show an unde-
Frazier, 2011; Damschroder et al., 2009; Kazdin rutilization of EBTs in intensive treatments
(Blanz & Schmidt, 2000; James et al., 2017), indi-
cating a need for more examination of the unique
T. Chou (*) challenges and opportunities for EBT adoption at
Department of Psychiatry and Human Behavior,
Alpert Medical School of Brown University,
higher levels of care. Fortunately, prior work on
Providence, RI, USA barriers and facilitators to EBT implementation in
Department of Psychology, Florida International
other outpatient settings (e.g., Beidas et al., 2016;
University, Miami, FL, USA Beidas & Kendall, 2010; Herschell et al., 2010)
e-mail: [email protected] provides insights and relevant considerations for
H. A. MacPherson intensive outpatient programs (IOPs) and partial
Clinical Psychology Department, William James hospitalization programs (PHPs).
College, Newton, MA, USA Existing theoretical models of implementation
M. Massing-Schaffer have outlined several key considerations for suc-
Department of Psychiatry and Human Behavior, cessfully implementing EBTs outside of research
Alpert Medical School of Brown University,
Providence, RI, USA
settings (Aarons et al., 2011; Fixsen et al., 2005;
Meyers et al., 2012; Proctor et al., 2009; Rogers,
Department of Psychology and Neuroscience,
University of North Carolina at Chapel Hill,
2003; Sanders & Turner, 2005; Southam-Gerow
Chapel Hill, NC, USA et al., 2006). Among them, the Mental Health
A. Spirito · J. Wolff
Systems Ecological Model (MHSE; Southam-­
Department of Psychiatry and Human Behavior, Gerow et al., 2006, 2012) stresses the importance
Alpert Medical School of Brown University, of children’s broader ecology beyond their spe-
Providence, RI, USA cific disorder (e.g., major depressive disorder) or

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 55

J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_4
56 T. Chou et al.

problem type (e.g., disruptive behavior) when and complicated treatment histories while creat-
adapting EBTs for various settings. For example, ing a clinical milieu that remains therapeutic for
therapist attitudes toward EBTs (Aarons, 2004), all youth.
the culture and climate of a service organization
(Glisson et al., 2008), and system-wide policies
(Schoenwald & Hoagwood, 2001) all greatly Comorbidity and Acuity
affect intervention outcomes. As such, the MHSE
model emphasizes (1) child and family factors, With patient complexity in mind, assessment and
(2) therapist factors, (3) agency/organization fac- case conceptualization in IOPs and PHPs require
tors, and (4) systems-wide factors when translat- staff to have a working knowledge of a range of
ing EBTs in a particular setting. The diagnostic categories and differential diagnoses.
systems-contextual (SC) approach (Sanders & Furthermore, the high rates of comorbidity in
Turner, 2005; Turner & Sanders, 2006) extends many of these settings (Forman & Nagy, 2006;
the MHSE by emphasizing the role of training as Ritschel et al., 2012) necessitate strong, flexible
an avenue for disseminating EBTs. The SC per- case conceptualization skills among PHP/IOP
spective holds that adequate therapist training providers. The need to address multiple symp-
represents a cornerstone driving successful EBT toms in adolescent patients may introduce chal-
adoption. Moreover, this model states that effec- lenges to staff training with providers of varying
tive training depends on contextual factors within levels and underscores the need to balance scien-
the specific treatment setting, such as therapist tific precision with the unpredictable realities of
variables, organizational support, and client vari- daily patient care if we are to advance the adop-
ables. In keeping with these models, this chapter tion of EBTs in these multidisciplinary settings.
discusses the dissemination and implementation At the same time, research demonstrates that
of EBTs in IOPs and PHPs through the lens of comorbidity does not predict treatment response
provider training. We specifically focus on four in rigorous empirical trials of EBTs specifically
areas of consideration: (1) patient factors, (2) designed for intensive settings (e.g., Rudy et al.,
therapist factors, (3) organizational factors, and 2014), highlighting the potential for well-selected
(4) training factors. EBTs to produce positive outcomes even when
patients present with multiple diagnoses.
While evaluations of transdiagnostic EBTs
Patient Factors demonstrate their ability to greater improvements
in less time (Weisz et al., 2012), traditional inter-
Patients in IOPs and PHPs typically present with vention research has historically examined
more severe and complex mental illness than single-­target protocols provided over 8–12 weeks
those seeking care in outpatient settings (Leffler (Leffler & D’Angelo, 2020). In contrast, IOPs
& D’Angelo, 2020). The American Psychological and PHPs deliver condensed, high-intensity treat-
Association (2019) relates this discrepancy to ment over a shorter period of time. Further, as
complicated psychiatric and medical comorbidi- previously discussed, IOPs and PHPs must meet
ties and, in some cases, contextual factors such as the needs of youth with a variety of mental health
increased family conflict and limited financial concerns. Thus, providers must distill active
resources or school support. Moreover, previous ingredients of complementary treatments and
work indicates that users of intensive day treat- apply them to patients and families in a way that
ment services often have multiple admissions, is not consistent with the existing research litera-
resulting in a population of children and families ture. While science examining the “kernels,” i.e.,
who may have participated in more psychothera- essential mechanisms, of EBTs has grown in
pies than most youth (Leffler & D’Angelo, 2020). recent years (Embry & Biglan, 2008), the needs
As a result, individual interventions must address of real-world intensive day treatment services
high patient needs, diverse presenting problems, have continued to outpace ongoing applied
4 Implementation and Training 57

research efforts. This discrepancy has resulted in Diversity

a lack of clarity as to which “best practices”
might provide optimal coverage of patient needs. Similarly, the current literature offers no guid-
At the same time, resource constraints (e.g., time, ance on appropriate cultural adaptations and con-
costs) limit training in a wide range of siderations for EBTs in intensive treatment
interventions, and current literature lacks evi-
­ settings (Siegel et al., 2011). While existing
dence regarding the most resource-efficient treat- research suggests an underutilization of certain
ment protocols for intensive treatment settings. IOPs by racial and ethnic minority youth (van der
Ven et al., 2020; Williams et al., 2015), investiga-
tors have discussed the importance of IOPs for
 amily System and Developmental
F youth of color, particularly those living in low
Considerations resource urban areas, as they experience dispro-
portionately high rates of psychiatric hospitaliza-
Beyond considerations relevant to patients’ indi- tion (Lapointe et al., 2010). Recent work also
vidual needs, families that enter into intensive describes challenges faced by transgender and
day treatment often have multiple sources of nonbinary youth at higher levels of care, such as
stress and adverse conditions that increase the a risk of compounding existing stressors through
opportunity cost – or the loss of potential gain misgendering by peers or treatment providers
from alternative uses of time and energy, were it (Coyne et al., 2020). Given evidence supporting
not spent in an IOP or PHP – conferred by the the importance of culturally relevant program-
burden of treatment (Kazdin, 1996). ming for IOP treatment completion among
Understanding patients’ treatment seeking deci- minority youth (e.g., for substance use treatment;
sions as a goal within a network of multiple pri- Saloner et al., 2014), the paucity of evidence-­
orities reinforces the importance of therapeutic based guidance towards implementing EBTs
alliance and rapport with the family system, with cultural humility in IOPs and PHPs warrants
which in turn reduces the likelihood of treatment further examination.
non-completion. Prior work indicates that family
members’ at-home behaviors (e.g., accommoda-
tion of child’s psychiatric problems) and engage-  reatment Planning and Potential
T
ment in treatment significantly predict youth Barriers to Care
treatment outcomes (Rudy et al., 2014; Weir &
Bidwell, 2000). In addition, because most youth Lastly, insurance restrictions on the length of stay
are not self-referred but rather are brought to in IOPs and PHPs pose additional challenges to
treatment after their behavior has alarmed others treatment planning. Although providers may be
(Smith & Anderson, 2001), it can be difficult for well trained in providing an EBT (e.g., dialectical
youth to form a working alliance with one thera- behavior therapy for self-injury), length of stay
pist – let alone multiple treatment providers – in may force adapting an EBT to fit within the time
the context of the relatively brief period of stay constraints or to not finish an EBT due to an
(e.g., several weeks) typical in IOPs, and espe- unplanned early discharge. Consequently, plan-
cially PHPs. Poor rapport in intensive outpatient ning for complex cases can prove challenging. In
settings proves particularly relevant to outcomes addition, discharge planning can prove difficult if
as reviews of the literature on IOPs highlight a patient has not received an adequate course of
absenteeism as a substantial barrier to the success an EBT. Furthermore, lack of available providers,
of intervention (Weir & Bidwell, 2000). which disproportionately impacts families with
low resources relying on public insurers such as
Medicaid, may lead to fewer options for outpa-
tient care after IOP or PHP discharge. These fam-
ilies, in turn, face limited options for continuity
58 T. Chou et al.

of care particularly concerning receipt of an EBT Engagement and Support

(Semansky & Koyanagi, 2004). As a result, youth of Implementation
who would otherwise benefit from continued
treatment with a particular EBT may require a Current literature provides little guidance for the
different degree of preparation for discharge implementation of EBTs specifically in intensive
should this option not be available or accessible. settings (Leffler & D’Angelo, 2020); however,
In sum, providers and staff of IOPs and PHPs research on clinician factors that affect the adop-
must retain a diverse and flexible skill set to tion and sustainability of EBTs in other mental
appropriately meet the needs of a wide variety of health settings may also be relevant for IOPs and
mental health and contextual concerns presented PHPs. First, prior evidence speaks to the impor-
by their patient population. The complexities of tance of both goodness of fit and relative advan-
cases presenting to IOPs and PHPs and the barri- tage, as perceived by program providers, to
ers to care delivery suggest that trainings must support their continued use of an EBT (Bearman
provide sufficient breadth and depth to allow for et al., 2019). In other words, the degree to which
flexible application to address a wide range of clinicians believe a new treatment addresses the
needs. These characteristics point to the need for needs of their patients more than other types of
a multitiered training model that utilizes a variety treatments affects the extent to which they will
of training modalities (e.g., workshops, supervi- continue to use this practice. Even within indi-
sion, ongoing external consultation) and differen- vidual members of the same professional disci-
tiate content based on level of professional pline (e.g., psychologists), providers may
experience and theoretical orientations. disagree on the utility of a new treatment com-
pared to interventions they have used for extended
periods of time. Furthermore, the introduction of
Therapist Factors a new treatment or EBT within a multidisci-
plinary team may require a higher degree of col-
IOPs and PHPs vary in structure by setting (e.g., laboration. Thus, adoption may hinge on
traditional hospital or clinic versus in-home), tar- successful discussion regarding the value of add-
get problems, and intended population. In gen- ing the novel practice and its place in the bundle
eral, intensive day treatment programs rely on of services provided by the program.
multidisciplinary teams from a broad range of In addition, the degree to which the new prac-
professional backgrounds (Leffler & D’Angelo, tice relates and fits into existing workflows and
2020). In addition to traditional mental health therapies can affect its maintenance over time
providers, such as psychologists, psychiatrists, (Bearman et al., 2019). Here too, introduction to
social workers, mental health counselors, and a multidisciplinary team adds complexity as pro-
trainees from each of these fields, staff may also viders with different theoretical backgrounds and
include nurses, dieticians, occupational thera- roles (e.g., milieu therapists, individual, group,
pists, physical therapists, art therapists, music and/or family therapists, case managers) carry
therapists, or bachelors-level behavioral health different responsibilities and priorities which
specialists/milieu staff. Team members represent may interact or interfere with the characteristics
a range of clinical experiences, have completed and procedures of a novel EBT. Lastly, logistic
varying levels of education from bachelors to considerations for individual therapists, such as
doctoral degrees, and may work with the pro- their ability to bill for new services (Bearman
gram on a full-time, part-time, or as needed (i.e., et al., 2019) or their distribution of hours to IOP
per diem) basis. Given this range of workforce and PHP programming (e.g., full-time, part-time,
characteristics, conceptualizing training and consultation basis), can impact the speed of adop-
implementation efforts across IOPs and PHPs tion and depth of comprehension for new EBTs.
can prove challenging.
4 Implementation and Training 59

Working with a Treatment Team team dynamics and collaboration toward ensur-
ing that interventions complement each other in
While multidisciplinary teams allow for the pro- the service of an overarching plan for deploy-
vision of a wide spectrum of services within indi- ment of EBTs in intensive day treatment
vidual programs, they also complicate the process programs.
by which teams select and implement mental
health interventions. Treatment teams can benefit
from identifying and employing a unifying theo- Organizational Factors
retical framework for delivering treatment within
the program (Wolff et al., 2020). Teams may also The literature regarding organizational factors
benefit from consideration of specific skill sets and their application to EBT adoption and sus-
and content areas brought by providers of each tainability indicates that culture, psychological
discipline. For example, in a PHP for obsessive-­ climate, and organizational climate affect the
compulsive disorder (OCD), trainings for all dis- implementation of new interventions (Glisson
ciplines would involve an orientation to cognitive et al., 2008). Culture, broadly defined, refers to
behavioral therapy (CBT) and exposure and “how we do things” (e.g., we are a flexible team
response prevention techniques. Psychiatrists versus we are a rigid team; we work together ver-
would deliver specialized psychopharmacology; sus we work independently). Psychological cli-
psychologists may deliver intensive group, indi- mate refers to an individual team member’s
vidual, and family therapy; and milieu staff may perception of how their work environment and
focus on behavior management and facilitating culture impact their mental health (e.g., an indi-
practicing exposure and response prevention vidual therapist within the team finds the work-
exercises. This allows for a coordinated approach place stressful). Organizational climate refers to
to treatment that allows each discipline to con- a work group’s overall impressions of their work
tribute specific components that are consistent environment and culture (e.g., the team agrees in
with their skill level and expertise. their perception that the workplace is stressful).
Staff in IOPs and PHPs consist of a multi- The culture of an organization – particularly as it
tiered professional and preprofessional work- relates to readiness to change, openness to trying
force with a broad range of training and new things, and supportiveness, both within
experience. There is no guidance on best prac- teams of providers and between providers and
tices on training preprofessional staff in thera- program administrators, can significantly impact
peutic approaches with youth in intensive day how novel EBTs are received by staff. Similarly,
treatment programs. However, literature on task psychological climate and organizational climate
shifting in other areas of mental health (e.g., influence the stress, satisfaction, and burnout of
Johns et al., 2018) indicates that talented, experi- staff members, which, in turn, can influence the
enced preprofessional staff could move beyond ability of individuals and clinical teams to adapt
providing supportive therapy and deliver specific and gain competence in a new intervention and
skills or reinforce therapists with appropriate integrate it with existing procedures and
training. To this end, investigators have described workflows.
the flexibility of a multidisciplinary team as a
strength of IOPs and PHPs, particularly where
providers utilize complementary interventions Clinical Burden and Burnout
(Graham, 2009). At the same time, others have
stressed the importance of program cohesion Researchers have found high rates of burnout
around a central theory or set of components among mental health workers overall (Morse
guiding interventions to advance replicability et al., 2012). The features of burnout, including
and improve program quality (Vanderploeg et al., feeling less satisfaction in one’s job, not having
2010). These factors highlight the importance of the energy to complete work-related tasks (emo-
60 T. Chou et al.

tional exhaustion), and having less compassion of cases, may necessitate unique training consid-
for others (depersonalization), have strong impli- erations and personalization. Below we review
cations for patient care (Green et al., 2014) and the literature on effective training methods and
may inhibit the learning of new tasks by defini- active training strategies generally, followed by
tion. In their research, Green et al. (2014) found recommendations specific to IOPs and PHPs
that components of burnout, such as emotional based on work in this area.
exhaustion and depersonalization, were higher Training methods have advanced beyond the
among mental health workers who felt they were simple provision of manuals and brief work-
assigned more tasks than they had time to com- shops. According to a recent review (Frank et al.,
plete, and among those who felt overwhelmed by 2020), the most commonly researched training
competing demands (e.g., there were too many modalities include (1) workshops; (2) workshops
tasks for them to manage at any given time). plus consultation; (3) online training; (4) “train
These findings suggest that attempts to imple- the trainer” (i.e., training an existing clinician on
ment new EBTs in intensive day treatment set- how to train incoming providers in the EBT of
tings may benefit from careful consideration interest); and (5) intensive training (i.e., at least
regarding (1) which staff members take on what 20 h of training plus two or more aforementioned
roles; (2) what added demands new services training components). Findings indicated that
might have for each member of the team; and (3) while workshops alone may change therapists’
whether or not these new requirements are man- attitudes toward and knowledge of EBTs, they do
ageable given the current responsibilities in not sufficiently change therapists’ behavior and
place. Additionally, they highlight the impor- use of EBTs. Thus, more intensive and multi-
tance of clearly defining the goals and procedures component training models, including workshops
for providers and creating ways in which they can (online or offline) plus ongoing consultation or
give feedback and resolve issues that may arise as intensive training, were recommended.
implementation moves forward. Moreover, trans- Prior research presents the relationship
formational leadership qualities and actions can between continued post-workshop consultation
both support implementation and reduce burnout with increased therapist use of and competence
(Aarons et al., 2015). Current evidence supports in delivering EBTs, in addition to improved cli-
practices such as providing individualized sup- ent outcomes (Beidas et al., 2012). Also, in stud-
port for team members’ needs, demonstrating ies comparing traditional didactic workshops to
knowledge and competence in the services pro- those with active follow-up training, the latter
vided by the program, and having a clear mission resulted in increased knowledge and skills
for the team. (Beidas et al., 2012) and more frequent use of
EBTs (Bryson et al., 2017). While “train the
trainer” models showed promise particularly for
Training Factors and Methods the sustainability of EBTs, additional research on
this strategy is needed. Finally, intensive training
Training factors and methods are also important appears to have the most promise for increasing
to consider in the implementation of EBTs in competence and the use of EBTs, particularly for
IOPs and PHPs; however, the majority of research more complex interventions (Frank et al., 2020).
on effective training methods has been with The combination of ongoing expert consulta-
licensed providers (e.g., psychologists, social tion with active training strategies with experien-
workers) in outpatient settings (Beidas & tial activities is considered gold standard training
Kendall, 2010; Frank et al., 2020; Herschell approaches (Beidas & Kendall, 2010; Frank
et al., 2010). While some of this literature may et al., 2020; Herschell et al., 2010), and they are
apply to IOPs and PHPs, the variability in profes- associated with improved client outcomes
sional backgrounds of EBT providers in these (Matthieu et al., 2008). Prior work highlights the
intensive settings, coupled with the complexity promise of three specific active training strategies
4 Implementation and Training 61

in improving use and delivery of EBTs (Gordon, quent, long-term) are associated with continued
1991; Hogue et al., 2015; Kostons et al., 2012; improvement in adherence and skill (Cuijpers
Waltman et al., 2016): (1) self-assessment rat- et al., 2011). Indeed, active coaching and super-
ings; (2) role plays; and (3) supervision. Although vision have demonstrated stronger effects in
there is mixed evidence to support the accuracy improving staff skills than didactic training alone
of clinician self-assessment, the process of (Collins et al., 2016). These findings are robust,
engaging in self-assessment is known to improve appearing across in-person and remote/online
learning outcomes (Creed et al., 2020). Ongoing formats (Bearman et al., 2013; Gordon, 1991).
self-monitoring with feedback is an effective Although most of the research on effective
training strategy for improving the quality of training methods has focused on mental health
clinical care provided (Wyman et al., 2008). providers in outpatient settings, the limited work
Moreover, evidence with health professionals that has been conducted in more intensive treat-
suggests that self-assessment accuracy improves ment settings has yielded similar results. For
with training (Frazier et al., 2019; Gilbody et al., instance, in one of the few studies of training
2006). In addition, training that incorporates role approaches with direct service staff (Parsons
plays has been found to improve clinician use of et al., 1993), results showed: (1) single-session,
EBTs (Cuijpers et al., 2011). in-service trainings result in minimal change; (2)
feedback on staff performance results in signifi-
cant increases in target staff behaviors, though
 raining Models in Day Treatment
T staff do not maintain improvements over time;
Programs and (3) role-playing yields the strongest positive
outcomes.
Research has identified the essential role of train-
ing and ongoing supervision or expert consulta-
tion on the sustainability of a new practice Recommendations for Training
(Bearman et al., 2019). These components allow Strategies in Day Treatment Settings
providers to obtain an understanding of the
underlying principles and feel competent in The findings describe above, alongside the
delivering the treatment to their patients. Training broader training literature and our own work in
and support become more complex in the context intensive settings, highlight several recommen-
of teams where staff have varying levels of expe- dations for training adaptations for PHPs and
rience, prior learning, and backgrounds. In par- IOPs. First, and as previously noted, PHP and
ticular, IOPs and PHPs that rely on a therapeutic IOP staff have varying levels of foundational
milieu – often run by bachelors or masters level education and experience, ranging from creden-
behavioral health specialists, milieu therapists, tialed and licensed psychologists, psychiatrists,
and nursing staff – may have existing structures and social workers to bachelors-level milieu staff.
of supervision and therapeutic perspectives that In particular, milieu staff present with consider-
differ from those of psychologists, psychiatrists, able variability in their education and formal
social workers, and their trainees (Wolff et al., training, familiarity with mental health concepts
2020). Aligning the process by which the team and EBTs, and experience working with youth
adopts a new intervention within existing prac- with psychiatric disorders (Wolff et al., 2018,
tices across program staff may serve a critical 2020). At the same time, milieu staff often repre-
role in sustaining its use. sent the largest segment of the workforce and
Finally, to sustain the use of EBTs, supervi- accrue the largest number of direct contact hours
sion may help providers continue learning, using, with patients, especially in PHPs (Wolff et al.,
and honing specific techniques. There is clear 2018). Moreover, prior reviews and recent work
evidence for the benefit of case-based supervi- conclude that therapist experience has only a
sion, and higher supervision doses (i.e., more fre- small to modest impact on client outcomes (Crits-­
62 T. Chou et al.

Christoph & Mintz, 1991; Goldberg et al., 2016). regularly in supervision is important to ensure
Thus, identifying effective, resource-efficient adequate adherence to and competency in treat-
ways to train milieu staff may significantly ment techniques that are very susceptible to drift.
advance feasibility and overall impact. In addi- For each skill, we present typical treatment sce-
tion, training should optimize dosage, complex- narios and ask the clinician to role-play the ses-
ity, and format to maximize feasibility and sion. Feedback is given on fidelity to the approach
engagement. Similarly, intensive settings see as well as therapeutic style. For example, when
high levels of turnover within their workforce. role playing a problem-solving session, thera-
Research in settings faced with similar chal- pists are given feedback on the session elements
lenges (i.e., high burnout and turnover) has dem- as well as their ability to collaboratively select a
onstrated a need for resource-efficient, brief problem and potential solution. Fourth, getting
trainings that can be readily applied to allow for therapists to record sessions for supervision often
swift onboarding of new staff (Frazier et al., presents both overt and covert challenges. The
2019). Although this is counter to the recommen- extent to which therapists feel uncomfortable
dation of more intensive training (Frank et al., taping sessions should not be underestimated.
2020), the use of ongoing consultation and “train Spending time discussing the usefulness of taped
the trainer” models may be particularly relevant sessions in supervision must be emphasized from
for PHP and IOP settings. the start. Showing a session of your own to super-
visees, especially a session which can be used to
point out areas of improvement, can prove more
 pplication of Training Lessons
A valuable than presenting a flawless session.
Learned Graded feedback, focusing on positive feedback,
especially for the first few tapes, and then gradu-
Through our experience training masters-level ally increasing constructive feedback are typi-
therapists in CBT for use in an IOP, we have cally most effective for novice staff. Maintaining
learned valuable lessons about promoting learn- a one-to-one minimum of positive to constructive
ing of and adherence to treatment protocols. In feedback is also important. It may also be helpful
terms of content, we begin by focusing on train- to have therapists complete ratings of their own
ing therapists in the core sessions and only move competency and fidelity in sessions to increase
on to other modules in a protocol after the basic awareness and self-reflection on fidelity and
sessions have been mastered. This approach competency. Fidelity rating scales are individu-
reduces the training burden on therapists and ally tailored to the content of the intervention.
increases confidence in their ability to master a For example, a safety plan fidelity checklist
structured protocol. Emphasizing key CBT skills would include items such as did the provider: dis-
also helps to convey the key ingredients in a cuss warning signs, assist teen in identifying cop-
course of treatment. Second, as we teach core ing skills and supportive adults, discuss ways to
modules, we integrate key CBT principles into make the home environment safe, and review rea-
the discussion. We have found that even though sons for living? With respect to competency,
many therapists in the community have had a there are both generic- and skill-specific mea-
wide range of therapy experiences, theoretical sures. An example of a generic competency scale
underpinnings of CBT typically take a secondary is the “General Therapeutic Subscale” of the
role in training to practical concerns about treat- Cognitive Therapy Rating Scale (Dobson et al.,
ment delivery. A review of CBT principles, there- 1985; Young & Beck, 1980), a six-item scale that
fore, helps provide the necessary underpinning to measures general therapy skills. Items include
the clinical work to which they may have had ratings such as the ability to listen and empathize
little exposure. Third, although observing videos and the degree of warmth, concern, confidence,
of accomplished therapists conducting a specific genuineness, and professionalism. An example of
CBT module is very useful, conducting role plays a specific competency scale is the Motivational
4 Implementation and Training 63

Interviewing Treatment Integrity (MITI) Code day treatment settings which argue strongly for
Version 3.0 (Moyers et al., 2010). The MITI the need for further implementation research in
includes ratings on key motivational interviewing these settings. First, the dosage of treatment is
concepts such as expressing empathy, rolling significantly greater in IOPs and PHPs. Children
with resistance, the use of open-ended questions and adolescents receive several hours of treat-
and reflective statements, and collaboration. ment each day in these settings. Youth also par-
We have found similar training approaches ticipate in multiple treatment modalities during
and strategies applicable not only to mental an intensive day treatment program. Research
health therapists but also to other providers questions include: What is the best way to pro-
including bachelor’s level milieu staff, though vide EBTs in intensive day treatment programs to
with some modifications (Wolff et al., 2018, avoid resistance from youth who may feel bur-
2020). First, a stronger emphasis on the theoreti- dened by the intensity of treatment? What is the
cal foundation of the EBT of interest may be nec- best way to sequence the different treatments
essary, as non-licensed staff have likely had less common to intensive day treatment programs?
exposure to and training in EBTs. Second, focus Currently, PHPs and hospital-based IOPs typi-
on core components of a treatment protocol and cally vary the types of treatment delivered during
less complex skills can be useful. For instance, the day. Do the variations in treatment modalities
teaching an inexperienced staff member the intri- increase skill uptake for youth? How do youth
cacies of cognitive restructuring may prove chal- integrate potentially conflicting information
lenging and better saved for mental health received from different providers? And what
providers with some background. However, more treatments should be prioritized when insurance
concrete skills with proscribed steps, such as restrictions on the length of stay vary across
behavioral activation and problem-solving, may patients in a program? Tailoring EBTs to meet
be more feasible for staff to implement. Third, an the unique challenges of PHPs and IOPs is impor-
even stronger emphasis on close supervision, tant but also runs the risk of modifying EBTs in
experiential activities/role plays, review of ways that may affect their efficacy.
recorded sessions, and positive feedback is criti- The list of potential clinical research ques-
cal for novice staff with less experience, who tions for intensive day treatment programs
may feel less well prepared to facilitate EBTs extends significantly beyond the questions out-
with youth in PHPs and IOPs. Thus, while many lined above. A basic question is methodological:
of the training methods and strategies from the What is the best way to study these programs?
broader training literature apply to PHPs and Are best practice interviews with multiple direc-
IOPs, consideration of varying staff levels and tors of intensive treatment programs the best
prioritizing key components of interventions is approach for arriving at key strategies that both
even more critical in these intensive settings. increase implementation of EBTs and increase
the efficacy of these programs? Or should an
empirical approach be used where different pro-
Conclusions gram components are manipulated to derive con-
clusions about program content? Some
This chapter presented an overview of theoretical combination of these two approaches is likely
models and implementation findings relevant to best, but conducting research in IOPs and PHPs
intensive day treatment programs as well as chal- is challenging at both the provider and organiza-
lenges in implementing EBTs in these settings. tional level.
Given the high acuity patient population in IOPs Implementation of EBTs, as well as their
and PHPs, the lack of attention to the implemen- maintenance, will be affected by the degree to
tation of efficacious treatments and evidence-­ which any new recommended practices fit into
based principles in these settings is noteworthy. existing workflows on PHPs and IOPs. Preparing
There are a few challenges unique to intensive staff for change can be challenging, and directly
64 T. Chou et al.

addressing reluctance to try something new Bearman, S. K., Weisz, J. R., Chorpita, B. F., Hoagwood,
K., Ward, A., Ugueto, A. M., & Bernstein, A. (2013).
should be a first step in implementing any More practice, less preach? The role of supervi-
changes in a closed system like intensive day sion processes and therapist characteristics in EBP
treatment programs. While many of the training implementation. Administration and Policy in Mental
methods and strategies from the broader training Health, 40(6), 518–529. https://doi.org/10.1007/
s10488-­013-­0485-­5
literature apply to PHPs and IOPs, for Bearman, S. K., Bailin, A., Terry, R., & Weisz, J. R. (2019).
­implementation to be successful, training clini- After the study ends: A qualitative study of factors
cians with varying levels of experience is best influencing intervention sustainability. Professional
facilitated by flexible application of these EBTs, Psychology: Research and Practice, 51(2), 134–144.
https://doi.org/10.1037/pro0000258
i.e., “flexibility within fidelity” (Kendall et al., Beidas, R. S., & Kendall, P. C. (2010). Training therapists
2008). A multitiered training model is likely best in evidence-based practice: A critical review of stud-
suited to account for variable levels of training ies from a systems-contextual perspective. Clinical
and professional experience among the staff of Psychology: Science and Practice, 17(1), 1–30.
https://doi.org/10.1111/j.1468-­2850.2009.01187.x
intensive day treatment programs. Beidas, R. S., Edmunds, J. M., Marcus, S. C., & Kendall,
Effective training in and implementation of P. C. (2012). Training and consultation to promote
EBTs in intensive day treatment programs must implementation of an empirically supported treat-
balance the benefits of therapist and staff behav- ment: A randomized trial. Psychiatric Services, 63(7),
660–665. https://doi.org/10.1176/appi.ps.201100401
ior change with costs/demands on therapists, Beidas, R. S., Stewart, R. E., Adams, D. R., Fernandez, T.,
staff, trainers, and the system as a whole. Applied Lustbader, S., Powell, B. J., Aarons, G. A., Hoagwood,
research on implementation and training in inten- K. E., Evans, A. C., Hurford, M. O., Rubin, R., Hadley,
sive day treatment programs is needed to provide T., Mandell, D., & Barg, F. (2016). A multi-level exam-
ination of stakeholder perspectives of implementation
an evidence base and improve the treatment effi- of evidence-based practices in a large urban publicly-­
cacy of intensive day treatment programs. funded mental health system. Administration and
Policy in Mental Health and Mental Health Services
Research, 43(6), 893–908. https://doi.org/10.1007/
s10488-­015-­0705-­2
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 Assessment and Evaluation
of Outcomes in Youth Day 5
Treatment Programs

Megan E. Rech, Jaime Lovelace, Megan Kale,

and Michelle A. Patriquin

Imagine an individual visited their doctor after additional considerations unique to the youth
starting a new medication for high cholesterol. day treatment setting.
The doctor asks how the patient thinks their
cholesterol is doing, and the patient responds
that perhaps it has improved, the doctor judges Overview
the medication to be working, and the patient is
sent on their way. It is likely that the patient Definition
would not be satisfied with this approach; they
would expect their cholesterol to be measured A critical component of quality treatment in
and tracked to determine how they are respond- youth day programs is measurement-based care
ing to the medication, if the treatment approach (MBC), also called progress monitoring and
needs to be changed, and when their cholesterol feedback, routine outcome monitoring, or
has been sufficiently lowered. Yet, these same feedback-­informed treatment. Herein, we define
expectations seem not to translate to mental MBC as the practice of systematically using
health care, with just 11% of therapists and 18% psychometrically sound outcome measures to
of psychiatrists routinely administering rating inform clinical care at the patient level (e.g.,
scales to measure client progress and assess Fortney et al., 2017). This measurement allows
deterioration (Fortney et al., 2017; Hatfield clinicians to monitor whether the patient is pro-
et al., 2010; Zimmerman & McGlinchey, 2008). gressing in treatment as expected, identify those
Here, we discuss the importance of implement- who are stagnating or worsening, and adjust
ing measurement-based care in mental health treatment accordingly, ultimately improving
treatment, its advantages and limitations, and outcomes and reducing deterioration (Lambert
et al., 2003). Moreover, MBC has been shown to
increase mental health diagnostic accuracy
M. E. Rech · M. Kale (Jeffrey et al., 2020), promote the therapeutic
The Menninger Clinic, Houston, TX, USA alliance (Cheyne & Kinn, 2001; Katzelnick
J. Lovelace et al., 2011), and enhance treatment efficiency
Children’s Hospital of Richmond and Virginia (Bickman et al., 2011). It has also been shown to
Treatment Center for Children, Richmond, VA, USA increase the cost-effectiveness of care by
M. A. Patriquin (*) informing dosage, with the number of sessions
The Menninger Clinic, Houston, TX, USA varying according to whether clients demon-
Baylor College of Medicine, Houston, TX, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 69

J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_5
70 M. E. Rech et al.

strate progress as expected versus risk of dete- back to be clinically actionable, measures must
rioration (Lambert et al., 2003). be reliable and sensitive to change; a number of
empirically validated, brief, diagnosis-specific
measures are available in the public domain for
Components mental health (e.g., Beidas et al., 2015). Second,
data must be current and available; ideally, symp-
In light of the lack of consistent terminology to tom severity should be assessed frequently and
describe MBC in mental health, it is important to just before or during each encounter (Fortney
identify and emphasize distinguishing factors. et al., 2017). Certainly, adhering to this guideline
First, MBC encompasses routine administration is not always feasible in a day treatment setting,
of validated measures coinciding with each clini- but the amount of time between data collection
cal encounter (Lewis et al., 2015, 2018). It is dis- and review should be minimized as logistics
tinct from a one-time screening, which has been permit.
shown not to improve outcomes even when Finally, feedback must be interpretable; it
accompanied by treatment recommendations should both reflect the patient’s current symp-
(Gilbody et al., 2008; Rollman et al., 2002). toms and track their progress over time (Knaup
Infrequent assessment and assessments out of et al., 2009), and scores should be classified into
sync with the timing of mental health clinical meaningful categories (remission, response, non-
encounters have likewise failed to demonstrate response, relapse, recurrence) to facilitate
better outcomes than usual care (Schmidt et al., decision-­making (Fortney et al., 2017).
2006; Slade et al., 2006). Second, MBC involves Moreover, the effects of feedback can be
clinician review of data (Lewis et al., 2015). strengthened when feedback compares
Though an important benefit of MBC data is the patients’ expected and current symptom trajec-
ability to use aggregate data for evaluation and tories and communicates the patient’s status to
decision-making across levels of the organization providers. For example, in a model described
(e.g., for quality improvement) (Connors et al., by Lambert et al. (2003), mental health clini-
2021), the primary intended context is at the level cians received color-coded feedback ranging
of the individual patient and clinician (Fortney from white (indicating normal client function-
et al., 2017). Third, MBC includes patient review ing suggesting termination may be considered)
of data (Lewis et al., 2015). Though not all con- to red (indicating client functioning is not
ceptualizations of MBC have specifically pro- improving as expected and is at risk for treat-
moted the sharing of feedback with patients, ment failure, so a referral or intensification of
citing mixed findings (e.g., Wise & Streiner, treatment should be considered). Compared to
2018), a growing evidence base supports this the control condition, the feedback condition
practice, particularly through structured discus- was associated with a decrease in deterioration
sion (Knaup et al., 2009; Krägeloh et al., 2015; rate and increase in reliable and clinically sig-
Lewis et al., 2018). Fourth, MBC requires col- nificant change rate.
laborative reexamination of the treatment plan Additionally, the benefits of feedback are aug-
guided by the results (Lewis et al., 2015, 2018). mented by alerts drawing providers’ attention to
Distinct from progress monitoring, feedback critical information (e.g., high suicidality), ide-
must inform decisions about treatment. Ideally, ally through a specific channel distinct from the
MBC data guides providers to make their next standard feedback communication pathway
immediate clinical decision such as continuing (Lyon et al., 2016). A study of 299 youth receiv-
with the current treatment plan and intervention, ing home-based community mental health treat-
beginning a new intervention, or reviewing a pre- ment found that feedback effects were enhanced
vious intervention (Connors et al., 2021). by “problem alerts” identifying patients’ item
Successful implementation of MBC is contin- responses in the top 25th percentile of severity
gent upon “clinically actionable” data. For feed- (Douglas et al., 2015).
5 Assessment and Evaluation of Outcomes in Youth Day Treatment Programs 71

In addition, some MBC proponents have apists to have worsened (Hannan et al., 2005).
emphasized the utility of pairing feedback with Likewise, a study by Hatfield et al. (2010) found
clinical decision support tools. One study by that only 21% of clinicians who relied solely on
Harmon et al. (2007) found that the provision of clinical judgment detected that their client’s
clinical support tools (feedback on the clients’ symptoms had worsened.
perception of the therapeutic relationship, moti- Clinician detection and prediction of stagnant
vation for change, and social support) in conjunc- progress appears even more challenging (Hannan
tion with a decision tree enhanced the effect of et al., 2005), concerning given the common phe-
feedback. Yet, more recent work has indicated nomenon of “clinical inertia,” or the absence of
that the potential benefits of such formal tools change to a patient’s treatment plan despite lack
remain unclear (Lewis et al., 2018; Shimokawa of improvement (Fortney et al., 2017; Henke
et al., 2010). et al., 2009). Thus, there is a clear need to aug-
ment providers’ clinical judgment with additional
data to improve detection and prediction of treat-
Rationale ment nonresponse and to adjust treatment accord-
ingly. In fact, MBC is well suited to this function
Importantly, MBC is intended to supplement, not and has demonstrated the greatest efficacy in
supplant, clinical judgment. Yet, recent findings improving outcomes and minimizing deteriora-
suggest that clinical judgment alone is subject to tion specifically among “not on track” patients at
limitations and biases in key areas that MBC is risk of treatment failure (Shimokawa et al., 2010).
well-positioned to address. In particular, mental Given the above challenges and opportunities,
health providers are vulnerable to positive self-­ youth day treatment settings seem particularly
perception bias; their perceived ability is greater well-suited for MBC. Considering that many
than both their true ability and their statistically patients may step up to day programs after failed
probable ability (Walfish et al., 2012). In fact, on outpatient treatment, avoiding clinical inertia
average, mental health clinicians rate their skills (e.g., perpetuating clinical refractory symptoms)
to be at the 80th percentile and believe that 77% is imperative (Fortney et al., 2017; Henke et al.,
of their patients improve due to their care (Walfish 2009). Moreover, given that a cohort of day treat-
et al., 2012); these estimates contrast with find- ment patients step down from acute inpatient sta-
ings that only a third of clients typically improve, bilization, and that the first days and weeks
and 8% show deterioration at termination following inpatient discharge confer particularly
(Hansen et al., 2002). Moreover, a 6-year study high suicide risk (Hunt et al., 2009), patients in
of 71 therapists found that even when receiving day programs face unique vulnerabilities that
care from the top 10% of most effective clini- necessitate progress monitoring and identifica-
cians, 5.20% of clients deteriorated and only tion of potential deterioration. These consider-
21.54% improved (Okiishi et al., 2006). ations support the implementation of MBC in
In addition, clinicians have demonstrated poor youth day programs.
ability to consistently detect deterioration and
predict treatment failure. A study by Hannan
et al. (2005) found that while 40 of 550 (7.3%) Evidence Base
clients were found to be worse off by the end of
therapy, only 3 of 550 (0.01%) were predicted by Adult Populations
clinicians to fail treatment, and only one of those
three did in fact show deterioration at the end of Though a full review of the adult literature is
therapy. Moreover, while 26 of 332 (7.8%) cli- beyond the scope of this chapter, MBC has a
ents showed worsening symptoms at the time of strong evidence base among adult patients, sig-
a particular session (independent of outcome at nificantly improving outcomes in randomized
termination), only 16 clients were judged by ther- controlled trials across care settings, treatment
72 M. E. Rech et al.

orientations, and patient populations (Fortney ated with category five studies, in which results
et al., 2017; Lewis et al., 2018; Peterson et al., of patient-reported outcomes measures were
2018). An early landmark meta-analysis by reported to both clinician and client, formally
Lambert et al. (2003) of three studies found discussed, and considered in treatment planning
that providing therapists with feedback on and decision-making.
patient outcomes and alerts of potential treat- Importantly, a review by Lewis et al. (2018)
ment failures had a small effect on deteriora- summarizing 9 review articles and 21 random-
tion rate and achievement of reliable or ized clinical trials reiterates that MBC improves
clinically significant change compared to usual clinical outcomes and reduces the likelihood of
care; this effect was even larger among patients deterioration, particularly among nonresponders,
with a poor initial response (“signal alarm” or with medium to large effect sizes. The authors
“not on track” patients). A similar meta-­ note that although a 2016 Cochrane review of 17
analysis of six studies (Shimokawa et al., randomized clinical trials of adults found no dif-
2010), three of which were included in the ference between MBC and usual care, the review
2003 meta-analysis (Lambert et al.), echoed excluded studies in which patient-reported out-
these subgroup findings; the authors concluded come measures were used to inform treatment
that patient progress feedback provided to both decisions (Kendrick et al., 2016), reflecting a
patients and therapists, with or without addi- conceptualization of MBC differing from that
tional clinical support tools, improved treat- adopted here.
ment outcomes and helped prevent treatment
failure particularly among patients not on
track. Youth Populations
In addition to analysis by patient subgroup,
more recent work has also investigated effects of Though the evidence supporting MBC among
modality and intensity of feedback. Specifically, adult patients is well-established, there remains a
a meta-analysis of 12 studies by Knaup et al. dearth of studies examining child and adolescent
(2009) showed that patient-reported feedback populations. Indeed, a systematic review and
had a small effect on short-term outcomes. meta-analysis conducted by Tam and Ronan in
Moreover, an examination of moderators revealed 2017 identified only 12 studies involving contin-
that in addition to providing feedback frequently ual feedback from youth (ages 10–19) used by
(rather than only once) to both patient and clini- the clinician to inform mental health treatment
cian (rather than one or the other) and providing (note: eligibility criteria did not include provision
feedback on patient progress over time (rather of feedback to youth/families or use of formal
than only current status) improved the effect on decision support tools). Findings indicate that
short-term patient outcomes. Similarly, a scoping feedback-informed treatment improves outcomes
review (Krägeloh et al., 2015) built upon these across a variety of settings (school, home, com-
findings, grouping 27 studies into 5 categories by munity, outpatient, inpatient, military) with small
degree of feedback: (1) PROMs used with no to large effect sizes (Tam & Ronan, 2017).
feedback provided to the clinician or patient, (2) A recent review summarized 14 studies exam-
PROM results reported back to the clinician, (3) ining the effectiveness of MBC among youth
PROM results reported back to the clinician and 4–18 (Parikh et al., 2020) by treatment setting and
client, (4) PROM results reported back to the cli- concluded that the evidence demonstrates effec-
nician and client, with opportunities created for tiveness of MBC in school- and outpatient-­based
discussion, and (5) PROM results reported back individual therapy settings, but not in group set-
to the clinician and client, with a formal proce- tings, though only two group setting studies were
dure in which discussion of the PROMs can included. Of particular relevance to day treatment
affect subsequent treatment. Results revealed that settings, MBC implementation with youth in indi-
improved outcomes were most strongly associ- vidual therapy settings was associated with faster
5 Assessment and Evaluation of Outcomes in Youth Day Treatment Programs 73

symptom improvement (Bickman et al., 2011) Though more research is needed, particularly
and greater therapeutic efficiency (Timimi et al., examining effects (and best practices for imple-
2013) compared to usual care, as well as reduced mentation) of MBC in group therapy, preliminary
patient distress (Kodet et al., 2019). Moreover, conclusions have important implications for the
outcome ­improvement was dose-dependent, with use of MBC in day treatment settings. To our
greater improvement exhibited by patients whose knowledge, no study has examined the use of
clinicians viewed results more often (Bickman MBC in programs with treatment teams provid-
et al., 2016) and by patients who completed more ing patients both group and individual therapy.
measures per month (Nelson et al., 2013). A 2012 Because a substantial portion of many day treat-
study by Lester and colleagues of 120 hospital- ment programs consists of group therapy, with
ized patients found that MBC was associated with individual therapy only occurring a few times per
greater therapeutic alliance but not youth-reported week, it will likely be important to consider how
symptoms or length of stay; however, participants a patient’s feedback can best be disseminated to
only received an average of two therapy sessions, and interpreted by the multiple clinicians who
likely insufficient to manifest a potential effect interact with the patient across various treatment
(Lester, 2013). Additionally, a 2015 study by settings which may be targeting disparate treat-
Hansen and colleagues of 73 Australian outpa- ment goals. Moreover, consideration should
tients found that MBC positively affected thera- likely be given to how decision support tools may
pist- but not patient-rated measures, though these be tailored to clinicians based on treatment set-
results may be attributable to limited therapist ting, with the understanding that the individual
uptake of MBC (Hansen et al., 2015). therapy environment may offer more opportunity
Regarding efficacy of MBC in youth group and flexibility for individually tailored interven-
therapy settings, there is a dearth of literature, tion informed by feedback.
though Parikh et al. (2020) present two such stud-
ies. In both cases, there was no effect of system-
atic feedback provision to a group therapist on Mechanisms, Benefits,
outcomes of youth with behavior challenges; and Stakeholders
however, limitations include the use of a single
self-report questionnaire to measure outcomes, Proposed Mechanisms
limited guidance regarding recommendations for
adapting treatment in response to feedback, lim- At the patient level, numerous mechanisms have
ited opportunities to implement individually tai- been proposed. Completing outcome measures
lored treatment plans in a group setting can validate patients’ feelings and buffer against
(particularly with “highly disruptive” youth), and self-blame (Fortney et al., 2017). In addition,
therapist inexperience with group therapy engaging in MBC can increase patients’ knowl-
(Shechtman & Sarig, 2016; Shechtman & Tutian, edge about their disorders, enabling greater par-
2017). ticipation in conversations and shared
Ultimately, findings from the studies reviewed decision-making about treatment planning
by Parikh and colleagues support the use of MBC (Valenstein et al., 2009). Receiving feedback on
in individual therapy settings and confirm that for measures also promotes greater awareness of
MBC to be effective, measures must be adminis- symptom fluctuations and warning signs for
tered before and during encounters, results must potential deterioration (Valenstein et al., 2009).
be immediately reviewed by clinicians and shared In addition, feedback can draw attention to early,
with patients, and this feedback must guide treat- small-scale improvements that may otherwise go
ment. Moreover, results underscore that effects of undetected, promoting patient hopefulness and
MBC are contingent upon sufficient time in treat- treatment adherence (Fortney et al., 2017;
ment and clinician adoption. Zimmerman & McGlinchey, 2008). Finally,
74 M. E. Rech et al.

MBC can improve patient-provider communica- organization. Among individual providers, MBC
tion and enhance the therapeutic alliance (Fortney aggregate data can be used for professional
et al., 2017; Katzelnick et al., 2011). development, as a means of both honing their
Of note, a common criticism of MBC in youth skills and monitoring the effectiveness of various
treatment settings is that children and adolescents types and components of treatment in the patient
may not be motivated to provide valid responses population they serve (Scott & Lewis, 2015). At
on self-report measures. Certainly, patients may the practice level, if the same measures are used
underreport in an attempt to discharge sooner, consistently, data can be used for program evalu-
overreport to demonstrate the intensity of their ation and quality improvement (Fortney et al.,
distress, lack insight into their symptoms, or 2017). Moreover, practices may use data to dem-
respond at random without reading items to mini- onstrate their effectiveness to referral sources,
mize distress and/or complete measures more potential clients, and accreditation agencies and
quickly (e.g., Cannon et al., 2010). These chal- quantify their value to payers (Harding et al.,
lenges may be especially common among youth, 2011; Scott & Lewis, 2015). In particular, insur-
who often do not present to treatment on their ance companies may rely on aggregate data to
own volition (DiGiuseppe et al., 1996). Yet, determine benefits and reimbursement policies
because implementation of MBC with fidelity (Fortney et al., 2017). In addition, widespread
involves discussion of feedback with patients and use of MBC throughout the facility can also pro-
the use of feedback to guide treatment decisions, mote a culture of transparency and accountabil-
patients are incentivized to provide honest and ity, ultimately encouraging all providers to
thoughtful responses (Fortney et al., 2017). In implement evidence-based and efficacious prac-
fact, particularly among youth, MBC may pro- tices (Jensen-Doss et al., 2020; Scott & Lewis,
mote a sense of autonomy, control, and choice, 2015), as well as utilizing data-based decision-­
improving motivation for and engagement in making when advocating for care decisions in the
treatment (Tam & Ronan, 2017). Furthermore, it best interest of the patient (e.g., use in discus-
has been proposed that for youth, MBC may not sions with insurance companies when a patient
only serve as a means of tracking progress and may need a longer length of stay).
informing treatment but as a therapeutic tool in An additional proposed application of MBC
and of itself (Tam & Ronan, 2017). data is the development of “pay for performance”
initiatives; however, such programs should be
approached with caution. Certainly, many patient
Benefits to Stakeholders variables influence outcomes (e.g., social deter-
minants of health), and measures cannot possibly
Beyond the advantages to individual patients, capture every aspect of patients’ improvement
MBC also affords secondary benefits to other (Fortney et al., 2017; Hermann et al., 2007).
stakeholders. For caregivers, MBC may increase Recently, The Menninger Clinic imple-
clinicians’ attunement and responsiveness to top- mented MBC in our newly implemented PHP
ics and problems salient to them (Douglas et al., program for children and adolescents. One of
2015). In addition, sharing feedback with care- the key motivating factors for patients in engag-
givers could enhance families’ investment in the ing in MBC is that an “Outcomes Group” is part
treatment process, particularly when youth have of the PHP schedule. In this setting, all patients
demonstrated improvement. Similarly, providing who are able and willing complete their weekly
feedback that a patient has not yet achieved outcome measures. Further motivating their
response or remission may help convince care- engagement is that the results of their outcomes
givers of the need for more time in treatment. are provided to the multidisciplinary team to
More broadly, outcomes data aggregated integrate into their clinical care. These data are
across patients can benefit multiple levels of the provided in a visualization that is easy to inter-
5 Assessment and Evaluation of Outcomes in Youth Day Treatment Programs 75

pret and plots the patient’s trajectory across treatment decisions (Edbrooke-Childs et al.,
many relevant psychological constructs (e.g., 2016), and believe that their expert clinical judg-
anxiety, depression, therapeutic alliance, emo- ment makes MBC unnecessary (Jensen-Doss &
tion regulation problems, etc.) in an easy-to- Hawley, 2010). To take the burden of administer-
understand format. ing assessments off of providers, patients in day
treatment settings can be administered outcome
measures during a scheduled recurring group
Barriers and Recommendations rather than individually, though this format likely
increases the delay from data collection to use in
At the level of the individual patient, barriers to clinical decision-making. Barriers may also be
implementation of MBC in youth day treatment minimized by integrating feedback into the elec-
settings include the additional time needed to tronic medical record (Lewis et al., 2018;
complete measures and concerns about privacy Steinfeld et al., 2016), providing training
and confidentiality (Gleacher et al., 2016; Lewis (Edbrooke-Childs et al., 2016; Gleacher et al.,
et al., 2018). Potential strategies to address these 2016), designating local champions (Boswell
barriers include administering measures elec- et al., 2015; Gleacher et al., 2016), providing
tronically (e.g., on an iPad) rather than via paper incentives for implementation of MBC indepen-
and pencil, incorporating adaptive testing, and dent of performance (Boswell et al., 2015), and
using HIPAA-compliant technologies and prac- educating multiple levels of stakeholders includ-
tices (Lewis et al., 2018). Some patients’ symp- ing organization leadership (Borntrager & Lyon,
toms (e.g., psychosis) and/or disabilities (e.g., 2015; de Jong, 2016; Lewis et al., 2018).
cognitive impairment) may impede completion
of measures (Lewis et al., 2018). Though high
fidelity is ideal, some flexibility in the timing of Conclusion
measure administration may be required for
patients who require an initial period of stabiliza- MBC is a necessary component of mental health
tion before they are able to tolerate surveys and/ care delivered in youth day treatment settings.
or provide valid responses. Likewise, alternative More research is needed to identify the precise
measure administration formats (e.g., questions mechanisms related to the best treatment out-
read aloud) may be necessary for patients who comes; however, prior research demonstrates that
have difficulty independently responding to writ- the continuous utilization of MBC is critical for
ten items (Lewis et al., 2018). Patients may also counterbalancing the clinician biases that often
worry that their responses (e.g., to satisfaction positively skew their patient’s outcomes (Hannan
surveys) will impact their relationship with their et al., 2005; Hatfield et al., 2010; Walfish et al.,
provider (Lewis et al., 2018; Snyder et al., 2013). 2012). MBC can reduce the impact of these
This barrier underscores the importance of a cul- biases, validate a patient’s experience, and ulti-
ture of feedback and positive attitudes toward mately provide data-supported clinical decision-­
outcomes across the organization. To further mit- making in the approach to maximize outcomes in
igate patients’ concerns, organizations may youth mental health day treatment.
choose to separate quality of care data and pro-
vide this feedback only after a patient has dis- Conflict of Interest We have no known conflict of inter-
charged and/or only in aggregate (Lewis et al., est to disclose.
2018; Snyder et al., 2013).
Among providers, barriers include adminis-
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 Part II
Partial Hospitalization Programs (PHPs)
 Perspectives on General Partial
Hospital Programs for Children 6
Sarah E. Barnes, John R. Boekamp, Thamara Davis,
Abby De Steiguer, Heather L. Hunter, Lydia Lin,
Sarah E. Martin, Ryann Morrison,
Stephanie Parade, Katherine Partridge,
Kathryn Simon, Kristyn Storey, and Anne Walters

Child partial hospitalization programs (PHPs) tion of individual therapy, family therapy, group
provide specialized, intensive, and interdisciplin- therapy, medication management, and educa-
ary day treatment for children with significant tional services to meet the individual needs of
social, emotional, and behavioral needs that war- each child and his/her family and to improve
rant a higher level of care than outpatient therapy, social, emotional, and behavioral functioning in a
but a less intensive care setting than admission to comprehensive manner (Kiser et al., 1996;
an inpatient unit. Most PHPs provide a combina- Grizenko, 1997). For the current chapter, we
define PHPs as hospital-based programs that uti-
lize evidence-based approaches to provide spe-
S. E. Barnes cialized, intensive, and interdisciplinary day
Yale New Haven Psychiatric Hospital, Yale
University School of Medicine, treatment for children with social, emotional, and
New Haven, CT, USA behavioral needs. We will focus on two PHPs
e-mail: [email protected] located at a children’s psychiatric hospital, part
J. R. Boekamp · T. Davis · H. L. Hunter · R. Morrison of a large multisite healthcare system in the US
· S. Parade · K. Partridge · K. Simon · K. Storey · northeast. These programs serve children ages
A. Walters (*) 0–12 and their families. One program (called
E.P. Bradley Hospital, East Providence, RI, USA
Pediatric Partial Hospital Program, or PPHP),
Department of Psychiatry and Human Behavior, with a typical daily census of 11–15 patients,
Alpert Medical School, Brown University,
Providence, RI, USA serves patients ages 0–6, and the other (called
e-mail: [email protected]; thamara.davis2@ Children’s Partial Hospital Program, or CPHP),
lifespan.org; [email protected]; rmorrison@ with a typical daily census of 12–15, serves
lifespan.org; [email protected]; patients 7–12.
[email protected]; [email protected];
[email protected]; [email protected] Length of partial hospitalization treatment
varies by program, but the intensive, multifaceted
A. De Steiguer
Department of Psychology, The University of Texas nature of the services provided typically warrants
at Austin, Austin, TX, USA several weeks to months of treatment (Granello
L. Lin et al., 2000; Bennett et al., 2001). For example,
E.P. Bradley Hospital, East Providence, RI, USA the average length of stay for patients in Bradley
e-mail: [email protected] Hospital’s partial programs for younger children
S. E. Martin ranges from 37 to 40 days and is influenced by
Psychology Department, Simmons University, utilization management processes. Care teams in
Boston, MA, USA
e-mail: [email protected]
81
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_6
82 S. E. Barnes et al.

PHPs often include specialists trained in psychia- risk. For our school age PHP (ages 7–12), we
try, psychology, social work, education, nursing, often assess for the number of settings in which
occupational therapy, recreation therapy, art/ the aggressive behavior is displayed as a means
music therapy, nutrition, and speech language of judging safety for admission. For example, if a
pathology to provide a variety of therapeutic child is aggressive toward parents and siblings at
interventions that address different factors con- home, but not toward peers at school, we move
tributing to a child’s social, emotional, and forward with admission. If they are aggressive in
behavioral functioning. Milieu therapy is also multiple settings, we may wish for the family to
incorporated throughout each treatment day to engage in home-based treatment to reduce the
support children individually as they build practi- level of aggression so that we can then admit
cal coping skills, practice social interaction skills them without endangering staff or other patients.
with adults and peers, and develop positive self-­ However, for our younger child PHP (ages 0–6),
esteem and confidence. aggressive behavior is the most frequent reason
To date, limited literature on PHPs demon- for referral, and we will admit a child who is
strates that these programs are effective in aggressive in multiple settings in order to divert
improving social, emotional, and behavioral from a higher level of care whenever clinically
problems from admission to discharge. Granello feasible. With the youngest children, aggression
et al. (2000) found that a PHP designed to treat is almost always part of the clinical picture, and
Axis I diagnoses reduced attention problems, so exclusion from the program is not practical
anxiety-withdrawal, conduct disorder, muscle and would result in most children being turned
tension excess, and socialized aggression. away. Physical management is possible in a
Moreover, PHPs reduce externalizing and inter- smaller space, and often techniques such as dis-
nalizing behavior problems to the normative or traction and redirection can be successful with
nonclinical range in children from 2 to 19 years the youngest. With the older group, aggression is
of age (Martin et al., 2013; Milin et al., 2000). often a more established pattern, cannot be man-
Additionally, PHPs are more cost-effective com- aged in a small space, and can easily result in
pared to residential and inpatient treatments staff injury. Practically speaking the level of dis-
(Grizenko & Papineau, 1992), and behavioral ruption to the overall programming is more of an
improvements may be maintained posttreatment issue with older children. For this reason, we
(Grizenko, 1997). might refer older children to home-based inten-
Inclusion and exclusion criteria can be impor- sive treatment to reduce aggression so that
tant considerations when designing these pro- remaining symptoms can then be managed within
grams. When identifying inclusion and exclusion the PHP.
criteria, most programs would consider suicidal An additional consideration is whether the
ideation/behavior an important risk factor to con- child can be safely transported to the facility by
sider. In our programs, we use the Columbia-­ the family. A shift in any of these factors during
Suicide Severity Rating Scale (C-SSRS; Posner admission to escalating symptoms can also be a
et al., 2008) to assess suicidality with the goal of prompt to transfer the child to a higher level of
monitoring patient function and safety as well as care, such as psychiatric inpatient hospitalization
developing appropriate safety plans, and/or refer- (IPH). When IPH treatment results in stabiliza-
ring to a higher level of care when clinically war- tion, readmission to the PHP level of care is
ranted. A more detailed discussion of this topic optimal.
and process occurs in the section “Assessing Other considerations for exclusion may come
Suicidality” later in this chapter. Programs may up when thinking about addressing medical
also wish to assess the level of aggressive behav- issues such as diabetic noncompliance or eating
ior with which a child presents prior to admission disorders. PHPs must ensure they have the medi-
so that the milieu is not overly disrupted by this cal and nursing time to address these disorders
behavior and/or patient and staff safety are at within their setting; this also comes up when
6 Perspectives on General Partial Hospital Programs for Children 83

c­onsidering managing encopresis which can care system, we developed a two-tier system of
involve substantial bathroom time as well as care that consists of full-day and half-day (after-
nursing intervention. In our system, we are fortu- noon) PHPs that treat children ages 9–18, which
nate to have a separate partial hospital program are funded at different rates. For children ages
within a medical hospital that has the medical 9–12, we generally consider the afternoon PHP
resources to address these issues, and so signifi- as a best match for children who are not display-
cant comorbid medical concerns become exclu- ing symptoms in school.
sion criteria for our PHPs. This is not practical
for all but important to consider when designing
new programs. Training Opportunities

PHPs are highly desirable training opportunities

Program Development because of the intensity of treatment, compli-
and Implementation cated diagnostic profiles in patients, and longer
lengths of stay than is true for PIH programs. In
The first step in designing a PHP is to determine both of our child programs, we are fortunate to
need. In the 1990s, in our large healthcare sys- train child psychiatry fellows, clinical child and
tem, a PHP for infant and preschool-aged chil- school psychology interns, postdoctoral fellows,
dren took the place of a day treatment program and graduate students; student nurses; medical
that was previously funded by schools. The day students; occupational therapy (OT) and speech/
treatment program became outdated when more language pathology (SLP) graduate and under-
public schools developed inclusion preschool graduate students; and social work interns. This
models, whereas there was a dearth of shorter-­ in turn is helpful in providing more access to care
term intensive programs that were insurance for each patient as well as helping all members of
rather than local education authority funded. the team stay up to date on evidence-based treat-
Starting with a planned lower census as programs ments (EBTs) and providing a vibrant learning
are developed allows need to be ascertained, and community.
our programs gradually expanded as local knowl- When there are options to develop a treatment
edge of the program grew. Additionally, tele- model and provide training in this model prior to
health is an option to explore in rural areas of the the opening of the program, this can greatly con-
country where transportation to the program, that tribute to a cohesive treatment process. For exam-
occurs daily, would be problematic. Although ple, in our PHP, we were able to contract with a
this can be a challenge with younger children, local trainer/research psychologist to provide
half-day PHPs may be an appropriate treatment Incredible Years (IY; Webster-Stratton, 1992)
venue in these situations. parent training to our entire staff prior to opening
the program. We were most interested in ensuring
that the milieu had an underlying treatment phi-
 inancial Planning
F losophy that relied heavily on positive behavioral
support, as well as a common language that we
It is helpful to have a contracting department that could share with parents and caregivers and gen-
is accustomed to working closely with insurance eralize to the child’s home environments.
companies to begin to set pricing and ensure
funding. It is also true that hospital-based pro-
grams, with their access to multidisciplinary Stakeholder Involvement
teams, can command rates that provide for thera-
peutic levels of staffing, and this in turn allows In terms of stakeholder involvement, a parent sat-
for optimal treatment. Over time in our health- isfaction survey process is immensely helpful in
84 S. E. Barnes et al.

learning what aspects of the programming “feel” tions as well as child-directed interactions, staff
most helpful to parents, as well as aspects that observe the child’s interactions and skills during
could be improved. Navigating institutional and less structured time, provide social
referring provider expectations can be more chal- coaching/parent coaching, and prepare for transi-
lenging. For example, as the team identifies the tions. Children and staff then engage in morning
factors that influence treatment success, the group, which looks different for PPHP and
screening process for admission may shift. For CPHP. At PPHP, with a census of 13–14 children,
example, in our programs, family involvement is there is a 1:2 staffing ratio, and children are
critical to progress, and this means that children assigned to different rooms where they are pro-
with families who cannot commit to everyday vided slightly different programming based to
attendance and twice weekly family therapy will developmental level. PPHP groups are structured
not be admitted. This can be challenging when a around practicing various therapeutic skills. For
referring provider wants to access a certain dis- example, there may be a “feelings day” where the
position plan even when it is not the best fit. goal is to label different feelings in different
Taking the time to explain reasoning behind these situations.
decisions, especially when the program is first At CPHP, group time consists of collaborative
opening, will contribute to long-term success. goal setting between patients and staff and
For children who are not able to move forward reviewing the day’s schedule. With a census of
with admission, our intake department works 13–15, the children are divided into two smaller
with the families to ensure that they have an alter- groups based on developmental considerations
native disposition plan (community provider or for most of the day. Following morning group, at
agency). CPHP, children have a snack before they begin
reading and school blocks which fill most of the
morning. At PPHP, children engage in therapeu-
Day-to-Day Programming tic activity groups, with periods of less structured
free play to permit children to practice skills
Daily Schedule highlighted in activity groups, until lunch.
Mealtimes at both programs allow for the real-­
At both PHPs, the day begins with a direct care world practice of therapeutic intervention activi-
provider (in our programs, these individuals are ties and skills as indicated (e.g., taking turns,
bachelor’s level employees termed Behavioral appropriate conversation skills, making requests,
Health Specialists [BHS]) checking in with the food exposure, sustaining a meal, sitting for a
child’s caregiver to collect information from the meal, pacing a meal, transitioning to and from a
prior night on biological functions like eating, meal, etc.). Before and after lunch, children par-
sleeping, toileting, or medical concerns; chal- ticipate in different group activities dependent on
lenging behaviors; improvements; strategies that the day. These include art therapy led by a certi-
worked well or not so well; and safety concerns. fied art therapist, OT groups in the hospital sen-
During this time, children transition to the milieu sory room, relaxation group led by a BHS, music
to engage in unstructured free play by engaging therapy, yoga, and cognitive behavioral therapy
in games, puzzles, drawing, coloring, or playing (CBT) groups. At CPHP, children also participate
with various toys/figures. Children also have the in dialectical behavior therapy (DBT) groups led
option to eat breakfast when they arrive. Rounds by a postdoctoral psychology fellow. At the end
occur 4 days a week in each program, where the of each day, BHSs check in with caregivers about
primary clinicians, the psychiatrist, nursing, and each child’s day, allowing for open lines of com-
assigned BHS meet as a team to discuss treat- munication between families/caregivers and the
ment progress for each child. During morning program.
centers, where children engage in activity sta-
6 Perspectives on General Partial Hospital Programs for Children 85

In-Person Treatment Day Schedule routines like rules, songs, reviewing the plan for
the day, group work activities to practice the skill
7:30–8:00 Morning telephone check-in of the day, video groups, social coaching, biblio-
8:15–8:30 Program arrival/health screening
therapy, and movement. Both PPHP and CPHP
8:30–9:30 Breakfast and free play (morning
centers) provide treatment from a multisystemic perspec-
9:30–11:00 Milieu programming tive with coordination and consultation with rel-
11:00– Lunch/relaxation evant parties (e.g., school teams, early
12:00 intervention, child protection, etc.).
12:00–2:15 Milieu programming
2:00–2:15 Program departure/afternoon checkout
Clinical Approaches

Theoretical Framework Clinical approaches include CBT for family ther-

apy and individual therapy. At CPHP, CBT, DBT,
PPHP and CPHP are both approached from a and mindfulness approaches are used for group
family systems theoretical framework. Both pro- therapy. In the PHP setting, the importance of
grams require high levels of family commitment, creating a therapeutic environment, or milieu, is
including family therapy sessions twice per also notable. This combination of clinical
week, and families are heavily involved in treat- approaches and therapeutic interventions is
ment. More specifically, for PPHP, there is a approached from a transtheoretical perspective
heavy emphasis on dyadic parent-child therapy. (Hashemzadeh et al., 2019) involving the child
Each week, parents are scheduled to spend “floor- and the family system, as well as clinical discre-
time” at the program, where the PPHP team pro- tion throughout the child’s time in the program.
vides in vivo coaching to the dyad. This important In this integrative and flexible approach, EBTs
in vivo coaching and exposure is also provided in are implemented to meet the unique needs of
other settings through home visits, school transi- each child and their family system.
tion visits, grocery store visits, etc. At CPHP,
skills that the children are working on in individ-
ual therapy and group therapy are shared with the Treatment Modalities
family during sessions. In addition, each clini-
cian identifies family goals that prioritize safety In addition to group, individual, and family
and stabilization within the family system. Both therapy, psychopharmacology is offered by the
models are best thought of as transdiagnostic program psychiatrist. Consults including OT,
(Chu et al., 2016), and because of the high levels art therapy, nutrition, and speech and language
of comorbidity, we often draw upon multiple are also available as additional treatment com-
modular treatment systems and adapt these ponents. One important distinction to note
according to child need. between PPHP and CPHP is that at PPHP, it is
The IY parent training modules serve as a much less frequent and only for older children
guide and toolkit for caregivers of children at (6- to 7-year-­olds) that individual intervention
PPHP and CPHP. Additionally, at PPHP, a modi- is used. While individual therapy is not empha-
fied portion of the IY group work, titled sized at PPHP, individual goals are still worked
“Incredible Friend’s Club,” is used to structure on, but in the context of the group and family
the group work of programming. Each day’s work. For example, a child may have individual
group work supports the practice of various ther- goals related to feeding or toileting that the
apeutic skills, from a “feelings day” to a PPHP team will address with the child and their
“problem-­solving day,” and includes therapeutic family.
tools such as social scripts with puppets, group
86 S. E. Barnes et al.

 risis and Safety Response

C treatment. Parent-child interaction and dyadic/
and Management triadic problem-solving and communication, as
well as family expectations and problem identifi-
Crisis management is done in the moment cation, are assessed to develop and refine treat-
through use of de-escalation strategies, redirec- ment targets.
tion, safe space areas, and limits to what a PHP Due to the short-term and intensive nature of
can manage. For example, if a child were to show our work, we apply assessments in a practical
severe aggression over extended periods of time, manner to assess functioning at a triage/screen-
require the frequent use of PRN medication, or ing level, while intervention is occurring.
express suicidal intent, a higher level of care is Assessments aid in formulating diagnostic
considered in the interests of keeping the child, impressions, establishing treatment goals, assess-
peers, and staff safe. ing symptom severity, tracking progress in treat-
ment, and making appropriate referrals for
specialized assessments as needed (e.g., full psy-
Use of Evidence-Based chological evaluations, autism spectrum disorder
and Empirically Informed diagnostic evaluation, or neuropsychological
Assessment evaluations). We select measures that are useful
for both clinical assessment and clinical research
Few programs exist at the PHP level of care for purposes (see the section “Integrating Research
infants, toddlers, preschoolers, and school-age and Practice” later in this chapter for additional
children. Best practice assessments for very details).
young children must address multiple challenges,
including limited availability of instruments
designed for clinical use at the PHP level of care Assessing Suicidality
and lack of representation of hospitalized young
children in norms. To address this gap, we use One of the most important areas of assessment
evidence-based assessments developed in outpa- represented in a PHP setting is the assessment of
tient settings and track core symptoms repeatedly suicidality. The C-SSRS (Posner et al., 2008) is
throughout the course of treatment to assess often considered the “gold standard” assessment
response to intervention. for suicidality (Posner et al., 2011) and was
Young children are generally not able to pro- endorsed by the US Food and Drug Administration
vide reliable and valid reports of psychiatric in 2012 (United States Food and Drug
symptoms. As such, the “gold standard” for most Administration, United States Department of
assessments is caregiver report (Godoy et al., Health and Human Services, 2014) in addition to
2019). However, all assessments include some many other healthcare leaders. However, the
direct child assessment, including cognitive C-SSRS, written at the 4.3 grade level (Horowitz,
screenings, risk assessments, and behavior obser- 2021), also requires reading and language skills
vations of the child interacting with her/his pri- typically first displayed by 9-year-olds. Although
mary caregiver, peers, and program staff. By the C-SSRS is completed with all children ages 6
contrast, a wider variety of self-report measures and older as part of the intake evaluation prior to
exists for school-age children, and these are used admission, we complete the C-SSRS with the
in combination with caregiver report when pos- parent on all children ages 4–7 years on the day
sible in the PHP populations. With the family-­ of admission.
focus of our work with younger children, we also Despite the importance of assessments based
screen parent strengths and areas of challenge on parent report, we also regularly assess risk for
and, based on findings, provide additional refer- self-harm in children as young as age 4 or 5 when
rals for family members above and beyond what they make statements on the program such as, “I
can be addressed indirectly through the child’s want to die,” while attempting to climb out of a
6 Perspectives on General Partial Hospital Programs for Children 87

window in the program. To accomplish this, we Table 6.1 Assessment measures

interview the child (e.g., what the child said and Broadband semi-structured interviews
did before, during, and after the incident), obtain Diagnostic Infant and Preschool Assessment (DIPA)
behavior observations (the ability of the child to (Scheeringa & Haslett, 2010)
Kiddie Schedule for Affective Disorders and
work with adults to regulate or settle his behav- Schizophrenia Present and Lifetime version, DSM5
ior, the persistence of the ideation/self-harm (Early Childhood) (Gaffrey & Luby, 2012)
behavior, the ability of the child to maintain Kiddie Schedule for Affective Disorders and
future oriented thinking in a developmentally Schizophrenia Present and Lifetime version, DSM5
(Kaufman et al., 2016)
appropriate manner, etc.), and integrate this Broadband diagnostic and functional impairment
information with cognitive assessments, includ- Child Behavior Checklist (Achenbach, 1991)
ing a brief cognitive interview assessing the Disorder-specific screeners
child’s biological understanding of death ADHD Conners (Conners,
(Slaughter & Griffiths, 2007), and assessment of 2008)
caregiver’s confidence and ability to keep the OCD Children’s Yale-­
Brown Obsessive-­
child safe at home. Assessment of self-harm in
Compulsive Scale
young and very young children is quite challeng- (Scahill et al., 1997)
ing due to their cognitive and verbal abilities as Trauma Child and Adolescent
well as very limited research to guide clinical Trauma Screen
assessment (Cwik et al., 2020). (CATS) (Sachser
et al., 2017)
Relatedly, associated safety planning inter-
Anxiety Screen for Anxiety
ventions utilized in the field are often highly lan- and Related Disorders
guage based which serves as a significant barrier (SCARED)
in situations when the patients making these (Birmaher et al.
1997)
statements cannot read. We safety plan with chil-
Depression Revised Children’s
dren and their parents together and use visual Anxiety and
supports to promote child understanding and Depression Scale
engagement. (RCADS) (Chorpita
et al., 2000)
Children’s
Depression Inventory
 he PHP Standard Assessment
T (CDI-II) (Kovacs &
Battery Beck, 1977; Kovacs,
1992)
Autism spectrum Autism Spectrum
Upon admission, every child receives a standard
Rating Scales (ASRS)
battery consisting of a semi-structured parent (Goldstein &
interview of the child’s symptoms, broadband Nagliera, 2009)
parent-report measures of symptoms (child self-­ Autism Spectrum
Quotient (AQ)
report is obtained in older children as is develop-
(Baron-Cohen et al.,
mentally appropriate, items read to the child), 2001)
screening of parent functioning, cognitive screen- Developmental/adaptive Vineland Adaptive
ing, suicide screening, and autism spectrum dis- functioning Behavior Scales
order (ASD) screening. Additionally, specific (Sparrow et al., 2016)
Personality (older children) Millon Pre-­
screeners are utilized for diagnostic clarification
Adolescent Clinical
as needed such as the Children’s Yale-Brown Inventory (M-PACI)
Obsessive-Compulsive Scale (Scahill et al., (Millon, 2005)
1997). Table 6.1 provides examples of estab- Parent functioning
lished assessments that we often utilized in each (continued)
of these assessment categories; the standard bat-
tery varies with age group.
88 S. E. Barnes et al.

Table 6.1 (continued) sion, self-injurious behaviors (SIBs), elopement

Center for Epidemiological Studies-Depression attempts, and safety interventions provided to
(CES-D) (Radloff, 1977) dangerous behavior to the child or others. We
Parenting Stress Index, fourth edition, short form
(Haskett et al., 2006)
also collect behavioral data in a variety of for-
Patient Health Questionnaire (PHQ-4) (Kroenke et al., mats including staff observation over the treat-
2009; Löwe et al., 2010) ment day, parent daily reports of home
Multidimensional Assessment of Parenting Scale functioning, and structured observations. We
(MAPS) (Parent & Forehand, 2017) administer a select number of our intake mea-
PedsQL Family Impact Module (Varni et al., 2004) sures (e.g., Child Behavior Checklist, Parenting
Coparenting Relationship Scale (CRS) (Feinberg
Stress Index) at the time of discharge to provide
et al., 2012)
Parent Motivation Inventory (PMI) (Nock & Photos, standardized assessment of change over the
2006) course of admission. We may also repeat other
Parent-child functioning assessments based on clinical considerations
Crowell Procedure (Crowell, 2003) such as changes in family recognition of the
DPICS Dyadic Parent-Child Interaction Coding impact of exposure to traumatic life events on the
System (DPICS) Clinical Manual (4th Edition)
(Eyberg et al., 2014) child’s self-regulation skills.
Cognitive screening In summary, the task of assessment in this set-
NIH Toolbox (Zelazo & Bauer, 2013) ting must be balanced with implementation of
intervention to meet clinical goals in the hospital
setting. Assessments serve multiple purposes
Importantly, we individualize assessments as across clinical and research interests and are uti-
appropriate and provide support to facilitate lized in a practical manner to inform treatment
engagement and completion as needed. For and determine next steps during care.
young children, visual supports have been used to
help children understand the Likert scales.
Children with language and/or reading chal- Use of Evidence-Based
lenges, or for caregivers with literacy challenges, and Empirically Informed
a staff member may read items to the child or par- Interventions
ent in a quiet area or separate treatment room to
ensure privacy. Whenever possible, we utilize The generalized and complex nature of present-
measures developed and normed in the child or ing concerns in our PHPs necessitates selecting
caregiver’s primary language. We develop con- interventions from a variety of EBTs to best meet
tingency management plans for children to facili- the most pressing needs of children and families
tate cooperation and compliance with assessment at the time when they present for treatment. The
procedures. For example, some children benefit existing literature on effective treatments for
from taking breaks and may earn time for a pre- children with a variety of diagnostic presenta-
ferred activity if they complete a set number of tions offers promising direction for providers,
minutes on the measure. Flexibility ensures that though there are also notable gaps in our under-
we collect relevant data to inform treatment and standing. This is true particularly for the treat-
aftercare planning. ment of symptoms necessitating hospital-level
Behavioral symptom tracking is also an essen- interventions as the severity of symptoms is
tial part of assessing appropriateness for level of much greater and the goals of treatment are stabi-
care, treatment progress, and readiness for dis- lization to allow further treatment at lower levels
charge (i.e., maintaining safety at home and in of care. To our knowledge, there are no interven-
program, a stable medication regimen if indi- tions that are considered evidence-based for the
cated, appropriate aftercare supports in place, treatment of symptoms for our age group at the
etc.). For example, we collect daily frequency partial hospital level of care, in a milieu setting.
data on several risk behaviors, including aggres- Therefore, we draw creatively from the pool of
6 Perspectives on General Partial Hospital Programs for Children 89

EBTs that are often delivered in outpatient Developmental Disorders of Infancy and Early
­individual, family, and/or group formats for use Childhood (DC: 0-5) in accordance with infant
in our setting. mental health principles, we do conceptualize
psychiatric conditions in the context of the child,
including the parent-child relationship (Zero to
Evidence-Based Interventions Three, 2016). Some of our young patients can
engage in EBTs for depression and anxiety that
In this section, we will briefly summarize EBTs would typically be utilized for older children but
relevant to presenting concerns in our respective require some amount of reading skills (e.g.,
populations, and in the next section, we will dis- Coping Cat Workbook for ages 7–13; Beidas
cuss how we approach adapting these interven- et al., 2010). Of note, Luby et al. (2018) have
tions. In our PHPs, we believe that the family developed additional emotion focused modules
system is central to the intervention that we uti- in the PCIT approach (PCIT-ED) that is showing
lize. Therefore, we will not attempt intervention promise for younger children.
at this level of care if there are no caregivers will- In addition to disruptive behaviors, behavioral
ing/able to participate in our family-focused interventions specifically related to developmen-
treatment, which is consistent with most treat- tal/biological functions manifest at a range of
ment models for infancy and childhood as severity in the early childhood population pre-
detailed below. senting for intensive services. For example, picky
We use a biopsychosocial model to inform eating may be one of many treatment targets
treatment planning. Many children present with related to anxiety but may not be the primary
concerns about severe aggression and disruptive focus of treatment. Alternatively, in the case of a
behavior. Well-established treatments for disrup- severe feeding disorder where the child is at risk
tive behavior in young children (Kaminski & of needing a feeding tube to meet nutritional
Claussen, 2017) include either parent group requirements for weight sustainability, the feed-
behavioral therapy (e.g., Incredible Years ing concerns (and any co-occurring psychiatric
[Webster-Stratton et al., 2004]) or individual par- concerns) will be the primary treatment targets.
ent behavioral therapy with child participation Interventions for biologically based concerns
(e.g., Parent-Child Interaction Therapy [Berkovits (e.g., feeding disorders, elimination disorders,
et al., 2010]). Additionally, we incorporate ele- and sleep problems) are often built on behavioral
ments of interventions that are probably effica- principles and parent education (Linscheid, 2006;
cious that include different configurations of Moturi & Avis, 2010; Shepard et al., 2017).
group parent behavioral therapy (with or without Relatedly, there are times when other medical/
child participation), child group behavioral ther- genetic comorbidities are a related or a primary
apy, individual parent behavioral therapy (with or factor of presentation in treatment including
without child participation), individual child adherence/compliance with medical treatment
behavior therapy (with or without parent partici- components (e.g., medication administration, the
pation), group parent-focused therapy, group use of a feeding tube, injections, etc.), particu-
child-centered play therapy, and individual child larly when other psychiatric symptoms (e.g.,
centered play therapy (Kaminski, & Claussen, anxiety) interfere with compliance. Behavioral
2017). We use elements of well-established difficulties related to developmental concerns
dyadic therapies to address psychiatric symptoms may also be addressed, though children with mild
and parent-child relationship challenges, includ- to severe ASD would only be admitted to address
ing Child-Parent Psychotherapy (Lieberman comorbid challenges, including severe aggres-
et al., 2015) and Parent-Child Interaction Therapy sion, self-injury, elopement, or mood/anxiety
(PCIT) (McNeil, & Hembree-Kigin, 2011). impairments.
While we do not formally diagnose using the For the older children presenting with mood
Diagnostic Classification of Mental Health and concerns (i.e., depression, bipolar spectrum dis-
90 S. E. Barnes et al.

orders), behavior therapy and CBT (whether and rule violation that may not be effective as
comprehensive, group, or technology-assisted) written for many of the youth in our PHPs.
have been found to be possibly efficacious for Factors that likely impact the usefulness of time-­
children, though the literature is lacking on well-­ out for our PHP patients include long-duration
established and probably efficacious treatments temper loss with aggressive and self-injurious
(Weersing et al., 2017). Family skill building plus behavior, occasionally requiring safety interven-
psychoeducation and DBT are well-established tions, and negative impact of physical interven-
and probably efficacious treatments, respectively, tions by parent on the quality of the parent-child
for bipolar spectrum disorders (McClellan et al., relationship.
2007). Regarding anxiety disorders, several well-­ In response to disruptive behavior, we use
established treatments are available (i.e., CBT, parent-coaching principles to help manage and
exposure, modeling, CBT with parents, educa- teach/coach parents on how to manage behav-
tion, CBT with medication) for children over age ioral escalations. These interventions include
8 (Higa-McMillan et al., 2016), while additional scripted language prompts, neutral response to
treatments have been shown to be well estab- undesired behaviors, differential reinforcement,
lished (i.e., family-based CBT) and probably effi- and redirection, among others, to interrupt nega-
cacious (i.e., group parent CBT and group parent tive behavior and promote emergence of positive
CBT + group child CBT) for younger children behavior. In parent-coaching/family sessions, we
(Comer et al., 2019). For children presenting can provide feedback on tools that the child uses
with self-injurious behaviors and/or suicidal ide- successfully and strategies to promote general-
ation, dialectical behavior therapy for adoles- ization of progress to home and community set-
cents (DBT-A) is well-established in reducing tings. Notably, our program does not teach
self-harm and suicidal ideation (Rathus & Miller, caregivers to physically restrain their children;
2002), while a variety of other treatments have rather, our team members are trained to utilize
shown to be probably efficacious (CBT, physical interventions (e.g., escorts, restraints,
Integrated Family Therapy, Psychodynamic and seclusions) to maintain the safety of the child
Therapy, Parent Training, Interpersonal Therapy and others as a last resort when other de-­
for Adolescents; Glenn et al., 2019). Children escalation strategies (e.g., naming and validating
presenting with ADHD benefit from several emotions, distraction, redirection, incentives,
behavioral interventions (e.g., Behavioral Parent offering choices, and coping skills practice) are
Training, Behavioral Classroom Management, unable to effectively prevent imminent risk for
and Behavioral Peer Interventions) that have harm (e.g., high-intensity aggression, high-­
been well established as effective treatments intensity self-injury, climbing on furniture,
(Evans et al., 2014). Finally, individual parent attempted elopement, etc.) to self or others.
behavior therapy with child participation and Overall, our intervention adaptations in PPHP
group parent behavior therapy has been well-­ are drawn from the primary components of effec-
established for disruptive behavior disorders tive treatment for young children (e.g., group
(Kaminski & Claussen, 2017). child behavioral therapy, individual parent behav-
While many of the adaptations we make to ioral therapy, parent behavioral therapy with
established interventions have not been formally child involvement, parent-child/dyadic therapy,
evaluated, our experiences suggest that certain and individual child therapy with parent involve-
elements can be easily adapted for the PHP level ment) with modifications for symptom severity,
of care, while others seem much less feasible milieu setting, daily meeting frequency, and
given the level of dysregulation. For example, lengths of stay that average 4–6 weeks. We con-
most parent behavioral therapy and parent behav- duct groups and in vivo skills practice that focus
ioral therapy with child participation (e.g., IY on a daily topic (e.g., emotion identification, cop-
and PCIT) utilize a highly scripted/structured ing skills, positive thinking/attributions, social
time-out approach to managing noncompliance skills, and problem-solving) in the context of
6 Perspectives on General Partial Hospital Programs for Children 91

being a Monday–Friday program. An example of Components of interventions in CPHP often

this would be a morning group with puppets that need to be further adapted and delivered through
focus on common problem-solving situations. means that are less reliant on verbal and written
Throughout the day, staff focus on providing language such as visual aids. While each child’s
coaching and pointing out instances of positive individual therapy in CPHP is tailored to their
problem-solving. We follow up at the end of the presentation, many children receive individual
treatment day with reading a children’s book therapy that is rooted in CBT or DBT, in addition
with a theme of problem-solving to provide to twice weekly DBT and CBT group therapy.
rehearsal opportunities during departure transi- However, children are not receiving manualized
tions and at home. treatments; rather, components are often selected
Parent/caregiver coaching is a core facet of based on what they can potentially contribute to a
our treatment programs. Our parent-child coach- child’s treatment. For example, for older tween-­
ing sessions (“Floor times”) permit milieu staff aged patients who present with suicidality,
and clinician support for in vivo coaching skills depression, and self-harm, a modified form of a
presented in family therapy and therapeutic group diary card may be used as a self-monitoring tool
activities. In addition, we also focus on coaching to uncover patterns of ineffective behaviors,
skills in settings where the challenging behaviors intense emotions, and skills use. When teaching
occur (e.g., home, community, daycare/school), children how to recognize and challenge auto-
though during the COVID-19 pandemic, these matic negative thoughts, a core tenet of CBT, we
coaching sessions in other settings have been read a book (Amen, 2017) which describes auto-
conducted virtually. On the milieu, we curate sce- matic negative thoughts as “ANTs” and has
narios to provide coaching in areas where the child-friendly names and visuals for the different
dyad has struggled (e.g., completing schoolwork, types of cognitive distortions (e.g., an ant seated
completing specific activities of daily living in front of a crystal ball to represent the “fortune
(ADLs) (e.g., eating a meal together, sibling teller ANT”). After children are introduced to the
interactions, etc.). Clear stepwise and mastery-­ types of “ANTs,” we discuss how to “squash”
based approaches to parent coaching are gener- them using “superhero questions” that help chil-
ally not feasible due to frequency of safety events dren engage in cognitive restructuring. In these
and the goal of short-term treatment/stabiliza- examples, the language and the corresponding
tion. As such, caregiver coaching focuses on visuals help children understand and internalize
small steps and integrates interventions across content and skills to apply to their presenting
modalities to provide multiple sources of support concerns.
for behavior targets. Adaptations also exist in our therapy groups.
Group parent behavior therapy is considered a For example, to tailor language to children’s
well-supported intervention for disruptive/oppo- developmental level, we refer to rational/reason-
sitional/noncompliant behavior. However, due to able mind as “Robot Mind” when we teach states
multiple barriers, including children with multi- of mind from DBT, and we generally do not
ple risks in the context of multiple stresses, time, include skills content on dialectics, as this has
space, and staffing constraints, we focus on proven too complex for our age range
addressing behaviors that pose challenges to (7–12 years). With all these adaptations, our
accessing these services after discharge. In addi- milieu staff can reinforce therapeutic skills and
tion, we also address coordination of care and principles in real time, a marked difference from
discharge planning which often includes referral an outpatient setting where some of these treat-
to home-based treatment and psychiatric medica- ments have historically been studied.
tion management with the hope that maintaining This frequent, real-time coaching and praise is
behavioral changes might enhance aftercare par- a central ingredient in reinforcing treatment gains
ticipation in group parent behavior therapy. in our patients. Additionally, we utilize numerous
visuals that are often individualized for children
92 S. E. Barnes et al.

and their goals, which facilitate identification of a family with one or more children in treatment
various feeling states and coping skills that may with PPHP and one or more children in treatment
be helpful. Further, our therapy groups often con- with CPHP simultaneously.
tain role-playing activities where children can Notably, many of our families have at least
practice the skills they have just learned. Our some experiences with mental health treatment;
BHSs are critical in relaying information to fami- however, some of our families have limited expe-
lies about how children have performed on the rience, particularly for their child, and it can be
milieu and giving clear, concise instructions an anxiety-provoking and painful experience for
about what to practice/target at home, using a some families to step onto the milieu, see other
child’s individualized visual plans and other struggling children/families, and recognize that
strategies addressed in treatment sessions. Family their child’s functioning warrants this level of
therapy sessions also allow for more structured intervention. Understanding the cultural and reli-
practice/instruction of family goals. gious backgrounds of our families is also impor-
tant in understanding factors such as beliefs that
may influence a child’s understanding of death in
Cultural Considerations the interpretation of statements such as “I want to
go to heaven” and/or helping guide a family in
We strive to make interventions consistent with supporting their child in processing the death of a
each family’s cultural backgrounds and provide grandparent, while they are grieving as well.
culturally competent treatment. This includes We attempt to tailor interventions in a manner
assessing relevant cultural/social facets of fami- that is consistent with the resources that families
lies upon admission and incorporating those into have available to them. We recognize that our
the evidence-based approaches we use. For treatment model is a significant commitment for
example, we work with many different types of our families that involves many sacrifices includ-
families that may include single parents, grand- ing transportation or work interruptions to par-
parents as primary caregivers, foster parents, ticipate in treatment. We work to identify financial
adoptive parents, married parents, separated par- supports, including the hospital family support
ents, etc. which can drastically change the goals/ fund, to address imminent needs as appropriate to
approach to treatment. For example, in working create greater access to treatment. We have also
with a child in foster care, we may be working worked with caregivers to address the challenges
primarily with the foster parent, primarily with in procuring materials used in virtual telehealth
the biological parent, or with both caregivers sessions, such as toys to facilitate “teamwork”
depending on the status of the case plan goals practice. Alternatively, if a goal of treatment is to
with the child protection system. Treatment may increase positive parent-child interactions but the
include involving extended family members dyad spends little time together due to
beyond primary caregivers in treatment and work/school schedules, we may implement an
exploring families’ perceptions about mental intervention like “special play time” to practice
health treatment, family history of mental health child-directed play during an activity that is
concerns, multigenerational trauma, and family already a part of the routine (e.g., having the par-
beliefs about parenting (e.g., beliefs about the ent practice these skills during dinner time or
role corporal punishment as a behavior manage- bath time).
ment strategy or beliefs about the role of a child As can be seen, there are many resources that
in a family). Given the family-focused nature of can be utilized to create a functional treatment
both programs, we also strive to work with sib- plan in the PHP setting for children. However,
lings as indicated as part of treatment. Further, there remains much to be learned and studied
there are times when siblings may be admitted regarding mental health interventions for chil-
together in the same program and/or the PPHP dren, particularly in the context of mental health
and CPHP teams work collaboratively to support crises that warrant intensive interventions.
6 Perspectives on General Partial Hospital Programs for Children 93

 he Role of Psychiatry in the Partial

T therapy provided and implementation of recom-
Hospital Program Treatment Team mended parenting practices. A comprehensive
review of the rationale for the use of medication
The PHP treatment team as conceptualized at our and the consideration of risks and benefits of said
programs integrates the role of psychiatry with medication trial becomes extremely important as
the behavioral and psychotherapeutic compo- we guide parents in making these often-difficult
nents of treatment. The psychiatrist benefits from decisions. The importance of validation, clarifi-
the direct observation of the young patient across cation, and psychoeducation cannot be overstated
times of the day, therapeutic activities (e.g., free and is most effective when conducted jointly with
play, parent-child interactions, social emotional other members of the team present.
coaching opportunities), and intervention modal- The recommended approach to psychophar-
ities (e.g., group therapy, CBT, behavior thera- macologic treatment of young children with
pies) among others. emotional and behavioral dysregulation requires
In addition to the extensive direct observation, comprehensive assessment, best estimates for
the psychiatric evaluation encompasses the infor- diagnoses, and consideration of response to non-­
mation gathered from family report, school pharmacological interventions before medication
reports, and outpatient providers, as well as per- is considered (Gleason et al., 2007). In the case of
spectives provided by members of our interdisci- CPHP, 64.2% of children admitted in 2020 were
plinary team. Within the team, the psychiatrist taking medication at the time of admission, while
plays a key role in interpreting and integrating the 35.8% were not actively taking medication upon
impact of the biological aspects associated with admission. Of these same children, 59.7% were
the current psychiatric condition, as well as iden- reported to have taken medication in the past, and
tifying target symptoms to be addressed. The 40.3% were reported to never had taken psycho-
psychiatrist offers feedback to families that inte- tropic medication.
grate the biological and psychosocial aspects of A strength of the PHP setting is including par-
behavioral health disorders to inform biologi- ents in initial medication administration and sup-
cally focused elements of the child’s treatment porting gradual medication administration at
plan. Such feedback is best offered jointly with home. Additionally, administering medication
the clinician who provides both individual and doses on the program provides opportunities to
family psychotherapy, with the goal of enhancing closely monitor patients during medication initia-
family understanding of the biological impact of tion or dose changes, evaluating for efficacy and
behavioral recommendations and how medica- possible side effects. Reporting of medication
tions could support these goals. effects in program as well as at home provides
In our experience, families often present to valuable information compared to only observing
this level of care having experienced not only in one setting, such as on the inpatient unit. This
high levels of stress but also a certain sense of also allows for the ability to make medication
helplessness, hopelessness, and ineffectiveness, changes at a faster rate than might be possible in
based on our clinical experience. For example, an outpatient setting.
they may carry preconceived ideas regarding the Daily medication administration can be a
role of medications. Some families may see med- challenging task for children in the PPHP and
ication as the only hope for change, while others CPHP. In general, typically developing pediatric
may fear that access to this level of care means patients will often refuse to take medications,
they must use medication to treat their very whether due to anxiety, illness, or other factors,
young son or daughter. The role of the child psy- and those with severe intellectual or behavioral
chiatrist is to bring balance to that view where the disabilities have even more difficulty. This may
role of medication is seen as one of the strategies be due to altered sensory perception, where sen-
leading to behavioral and emotional stability and sory stimuli that are benign to typically develop-
valuable only in conjunction with the behavioral ing children may be intolerable, uncomfortable,
94 S. E. Barnes et al.

or even painful (Epitropakis & DiPietro, 2015). Collaborations and Generalizing

In this setting, the aid of a skilled psychiatric Treatment Gains
nurse is invaluable to help identify tangible rein-
forcements for taking medication and to cre- Inclusion of Family and Caregivers
atively offer medication in different foods and
drinks. In addition to facilitating medication Parenting sessions are ideal vehicles for support-
administration, psychoeducation about medica- ing parents in the process of collaborating in the
tion safety in the home, including keeping medi- creation of treatment goals, discussing both par-
cations in an area that is not accessible to children, ent and staff/clinician perceptions of progress in
is a critical role for both the psychiatric nurse and treatment, and identifying and prioritizing con-
child psychiatrist. tinued areas of concern. Dyadic or family ses-
Monitoring and ensuring medication adher- sions provide clinicians and staff with the
ence can be challenging. There is evidence across opportunity to observe and interact with identi-
pediatric populations that children and adoles- fied patients in the context of their relationships
cents with behavioral and emotional challenges with caregivers and siblings. These sessions also
have poorer adherence medications, with rates provide opportunities to identify the strengths in
ranging from 30% to 80% for psychiatric medi- the dyad or family’s communication patterns as
cations, and may be lower than rates reported by well as targets for intervention to support
children or family members. Poor medication improved communication and functioning.
adherence correlates with worse health outcomes Additionally, such sessions provide opportunities
across the life span and is attributable to a variety for in-the-moment reflection and intervention to
of factors. First, individual and family character- implement aspects of the treatment goals by dis-
istics influence medication adherence via paren- rupting and replacing less helpful or effective
tal stressors or psychopathology (Hamrin et al., communication or behavioral patterns with
2010; McQuaid & Landier, 2017). Parental replacement techniques. When family members
depression, for example, may interfere with a spend time with their child in the PHP, they
child consistently receiving a daily medication. observe programmatic routines and responses in
Second, many cultural factors can affect medica- real time, can ask questions and offer recommen-
tion adherence (McQuaid & Landier, 2017). dations to the clinical team based on their own
These include beliefs about medication in gen- expert knowledge of their child, and can receive
eral, feelings about the child’s diagnosis, and coaching and support to manage emotional and
about the necessity of medication to treat symp- behavioral problems that arise. The structure of
toms. Evidence has shown (Hamrin et al., 2010; the PHP is ideal for working with families to
McQuaid & Landier, 2017) that adherence to identify goals that they can work on overnight,
medication is typically higher in diseases with a guided by the treatment team from their work
greater perceived threat to health, such as cancer, with the child during the day.
as opposed to chronic conditions, such as anxiety,
and a parent’s attitude about a child’s diagnosis
can affect how important medication compliance Working with Schools
seems. Families with limited English proficiency
and/or literacy may also experience greater com- It is also critical to contact outside treatment pro-
munication barriers about medications, including viders, who share invaluable insights from their
confusion about dosing and timing of medication work with the child and family, often over lengthy
administration. Providing medication summary periods of time. They can assist with diagnostic
handouts in different languages, diagrams of how conceptualization, with observations of family
to cut and administer tablets, and modeling dose structure and communication patterns, and with
administrations have been helpful in addressing background history that would otherwise take
these challenges. more time to understand. Perhaps most
6 Perspectives on General Partial Hospital Programs for Children 95

i­mportantly, they can help the current team to suggests that a lack of coordination with the
build on previous success, avoid interventions youth’s home school may increase the risk of the
that have already been unsuccessful, or at least to youth being rehospitalized (Weiss et al., 2015).
point to the need for a new “frame” for these PHP staff can provide pertinent observations dur-
interventions. ing the school block. For example, as noted pre-
Once parental consent is provided, it is benefi- viously, many children undergo medication
cial to communicate with the child’s home school changes during which staff can closely observe
during their stay in a PHP as many staff in youth and monitor a child’s functioning. Further, during
treatment facilities express concerns about the the COVID-19 pandemic, collaboration with
youth’s academic work after discharge (Nickerson schools included staying informed of any changes
et al., 2007). Additionally, research suggests that in locations or types of learning and also allowed
individuals with mental illness are less likely PHP staff to help prepare the child to return to
than their peers to complete primary school, high school in person, virtually, or through a hybrid
school, attend college, and graduate from college model.
(Breslau et al., 2008). Many children in the PHP Although many children enter PHPs with an
level of care have academic struggles in addition IEP or 504 plan, some children who have aca-
to their emotional or behavioral symptoms. demic struggles enter PHPs with no formal edu-
Furthermore, many of these school-aged youth cational supports. These students may benefit
have Individualized Education Programs (IEP) or from the supports available in a PHP, and the
504 plans prior to their partial hospitalization diagnostic clarity received during their time in
(Zigmond, 2006). At the time of intake, PHP staff the program may provide valuable data for the
can communicate with a child’s home school to school to begin an evaluation for accommoda-
gain data on their school functioning. During this tions or special programming. For younger chil-
collaborative time, school personnel can provide dren (i.e., toddlers and preschool-aged), who
invaluable information on the student’s behav- may have had limited exposure to educational
ioral functioning, academic strengths and areas settings and resources, informing parents about
of growth, any pertinent testing results, peer rela- and supporting them through the process of
tionships and social skills, and more. accessing early intervention or early childhood
This early collaboration also allows PHP staff special education supports can be a critical com-
to provide information on the nature of the pro- ponent of treatment.
gram and to clarify that the focus is mental health.
By having this conversation early, school and
PHP staff can gain a mutual understanding that Coordinating with Outside
the child may make fewer academic gains during Treatment Providers
their time in program as the goal is to achieve or
improve emotional and behavioral stability. This Discharge Planning
also allows the child and family to focus on men-
tal health rather than the stress of attempting to Prior to discharge, PHP staff will readminister
maintain schoolwork during this time. Still, many many of the assessments conducted at intake to
PHPs have a school component during the day. obtain posttreatment data. These scores are com-
While collaborating with school personnel, PHP pared to the family’s scores on their first day in
staff can explain the resources available during program to assess if symptomology decreased
the school block, and the teacher can provide during treatment. The child’s clinician also com-
appropriate work for the student to complete. pletes a discharge summary of the child’s assess-
While the child is in the PHP, staff can com- ment results, reason for admission, progress in
municate progress, strengths, and areas of growth program, skills gained, and recommendations for
to school personnel. In similar settings, research aftercare. The goal of this document is to provide
96 S. E. Barnes et al.

the family and future providers with a detailed Integrating Research and Practice
account of the treatment course with rich
­recommendations to support coordination across Intensive clinical settings such as PHPs offer
providers. unique opportunities for clinical and translational
It is beneficial for PHP staff to communicate research. Children admitted to intensive psychi-
with schools and other providers (e.g., pediatri- atric settings present with complex clinical prob-
cian, outpatient therapist, care coordinators) lems that are important to study empirically, and
prior to a child’s discharge. Such communica- conversely, research on the nature, etiology, and
tion allows for coordination of care and pre- treatment of such problems informs clinical care.
vents gaps in treatment. Once a discharge date Particularly for younger children, our knowledge
is set, the child’s PHP clinician, caregivers, of the causes and correlates of serious emotional
school personnel, community providers, and, if and behavioral impairments is quite limited. In
developmentally appropriate, the child can hold addition to caring for patients with pronounced
a series of transition meetings. School staff or extensive impairments in functioning, PHP
present in these meetings can include the child’s care is often delivered daily for several weeks,
teacher, special education teacher, school psy- requiring adaptation of evidence-informed
chologist, school counselor, school social assessments and interventions which typically
worker, principal, and more. During the transi- have been developed for use in outpatient settings
tion meetings, the PHP clinician can provide with older preteens and teenage populations.
treatment updates, progress, and areas of con- Research in intensive settings permit investiga-
tinued growth with the follow-­up team. This tions of the feasibility and effectiveness of empir-
can also include any relevant diagnostic impres- ically informed treatment adaptations for younger
sions, particularly if referral for higher-tier children receiving daily care. As such, research in
interventions (such as response to intervention, intensive settings with children hold the promise
IEP or 504 plan) is recommended. of improving not only patient outcomes earlier in
During transition meeting(s) or at discharge, life but also our recognition of promising treat-
the clinician can also share the discharge sum- ment targets and effects.
mary and any pertinent safety concerns with the In our PHPs, we have focused on two key
school. School staff and the PHP teams can work areas of research. First, we have aimed to empiri-
together to plan for individualized transition cally describe the youth and families served by
activities, which may include brief reexposures our programs, with particular focus on diagnostic
to the school setting to help the child reestablish and clinical issues, as well as underlying pro-
relationships with school staff and peers and to cesses and correlates. Our descriptive research
slowly readjust to school expectations and rou- questions are often informed by what we observe
tines. One major goal of the discharge process is clinically, for example, impaired sleep (Boekamp
to orient the child to the school setting by allow- et al., 2015), severe temper loss and irritability
ing them to reconnect with school personnel and (Martin et al., 2016), and suicidal thoughts and
share their perspective on their functioning and behaviors (Martin et al., 2016). These descriptive
needs. Research suggests that a child’s percep- questions are also driven by our recognition of
tion of their mental illness, their hospitalization, the challenges of adapting evidence-based prac-
and responses from school personnel and peers tices to very young children presenting with mul-
can impact the success of the transition back to tiple risks, including traumatic life event
school (Savina et al., 2014). Thus, the discharge exposure, very high levels of family stress, finan-
meeting can also be a space to assess the youth’s cial insecurity, and early challenges with learning
perception of their stay and transition back to and school functioning, among other challenges.
school and address any potential concerns or We also addressed gaps in the practice literature,
stigmas they may possess. including examining rates of adverse events asso-
ciated with psychopharmacologic interventions
6 Perspectives on General Partial Hospital Programs for Children 97

in highly impaired young children receiving par- impact clinical service delivery and the kinds of
tial hospital care (Lee et al., 2015). research questions that can feasibly be investi-
Second, we have conducted effectiveness gated with available measures.
studies to empirically evaluate patient treatment Despite challenges, given the limited under-
outcomes associated with partial hospitalization standing of specific risk factors for the emergence
in young children. This work has focused primar- of self-harm thoughts and behaviors, irritability,
ily on predictors of treatment outcome, including and aggression, among other serious problems,
mediators and moderators of treatment response there are important research opportunities on
(Martin et al., 2013), conducted without the inter- PHPs to help inform development of effective
pretative benefit of examining change in com- prevention and treatment efforts. These opportu-
parison to a no-treatment control group. Although nities include projects that emphasize detailed
we explored control group options, we have not observations of young patients interacting with
been able to identify a comparably impaired peers, staff, and primary caregivers. In addition,
group of young children not receiving care. given the central importance of caregiver prac-
Moreover, given that highly distressed families tices in facilitating social and emotion regulation
were seeking treatment to address behavioral skills, and managing significant risk behaviors,
impairments in their young children, given scien- observational research of parent-child interaction
tific support for the effectiveness of early inter- with more impaired patients in the context of
vention, we have been concerned about the intensive treatment is another important opportu-
ethical implications of delaying treatment to nity to advance early intervention efforts. Use of
develop a control group. The lack of a compara- multimethod and multi-informant designs is
ble counterfactual group has been frequently more feasible in the context of intensive day
identified as a significant methodological limita- treatment programs because the children are
tion in peer reviews of our submitted work. In present for several hours daily, permitting ratings
addition to treatment outcome, we have also been of each child by two or more observers. Other
interested in examining the longer-term impact of benefits of research on PHPs are the ability to use
serious emotional and behavioral difficulties in short-term intensive longitudinal designs to test
the population we serve. treatment moderators including person-level
Conducting scientifically sound research on a variables predicting poor response to treatment.
busy clinical service for children comes with
many challenges. Developmentally, some young
children may be unable to self-report on psychi-  essons Learned, Resources,
L
atric symptoms, necessitating reliance on parent-­ and Next Steps
report or staff observations as primary sources of
clinical research data. However, cross-informant For youth with complex psychiatric needs which
discrepancies in reports of child psychopathol- have not responded to a lower level of care, PHPs
ogy are common (e.g., De Los Reyes & Kazdin, offer an opportunity for children and their fami-
2005), and parents and other caregivers may be lies to access specialized, intensive, day treat-
less aware of internalizing symptoms such as ment from an interdisciplinary team of providers
sadness, anxiety, or suicidal thoughts (e.g., in a single setting. Frequently, PHPs specialize in
Deville et al., 2020; Hourigan et al., 2011; Pereira stabilization of psychiatric symptoms which
et al., 2015). In addition, some parents may dis- place the safety of patients and/or others at risk
miss more severe behaviors as attention seeking and interfere with day-to-day functioning outside
rather than potential signs of distress. In addition, the treatment setting.
the paucity of reliable and valid measures for Although the specific needs of each child pre-
important problems in early childhood, such as senting for care within a child PHP varies, for
irritability, compliance, loss of many patients and their families, PHPs offer a
pleasure/depression, and suicidal ideation, range of advantages with respect to diagnostic
98 S. E. Barnes et al.

clarification of complex presenting concerns, families seeking treatment as well as members of

access to specialty services, close medical and the medical community, these specialty settings
medication monitoring, and an integrated care provide a rich atmosphere for innovative treat-
plan. In addition, given the ability for PHP teams ment, training, and scientific practice.
to work closely with family members and to
incorporate in vivo learning opportunities, PHPs
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 Child and Adolescent Integrated
Mood Program (CAIMP) 7
Jarrod M. Leffler, Kate J. Zelic, and Amelia Kruser

Mood disorders (depressive disorders and bipolar socially). Additionally, family system dynamics
disorders) in children and adolescents are among can be negatively impacted by youth illness (e.g.,
the more severe childhood disorders and can Tompson et al., 2012). A multitude of parental
result in significant impairment in multiple areas factors can also impact youth mood, including
including academic, social, family, and physical parental depression, ineffective communication
functioning (Curry, 2014; Fristad & Macpherson, strategies, and limited coping and problem-­
2014; Waslick et al., 2002). Ghandour and col- solving skills (Garber & Flynn, 2001; Inoff-­
leagues found that nearly 1.9 million or 3.2% of Germain et al., 1992; Lovejoy et al., 2000;
US children and adolescents had current depres- Nomura et al., 2002; Restifo & Bögels, 2009).
sion, with 9.7% rated as severely affected and Taken together, the family system can influence
45% rated as mildly or moderately affected by and be influenced by youth mood disorders.
their parents (Ghandour et al., 2019). Prevalence Ultimately, incorporating family involvement
rates of bipolar spectrum disorders in youth are into interventions for youth with mood disorders
approximately 2.06% (Goldstein et al., 2017). may help address family system issues that can
Mood disorders are often chronic and recurrent help with symptom reduction and improved fam-
illnesses resulting in children and adolescents ily dynamics.
with mood difficulties experiencing difficulties To treat the range of mood disorders youth
into adulthood. There is evidence that even sub- might experience (e.g., depressed or elevated
clinical levels of depressive symptoms in adoles- mood states, symptoms and clinical presentation
cence are predictive of major depressive episodes that can range from mild to severe and present
in adulthood (Pine et al., 1999). with or without psychosis, etc.), there are various
Mood disorder symptoms can result in impair- levels and models of intervention. These include
ment in functioning across multiple contexts individual- and family-based psychotherapy
(e.g., family, home, work, and models offered in one-on-one or group sessions,
health and wellness strategies, and psychoeduca-
J. M. Leffler (*) tion activities that can range from 8 weeks to sev-
Virginia Commonwealth University, Children’s eral months. Within these treatments, the
Hospital of Richmond, and Virginia Treatment Center
therapeutic intervention can vary (Clarke et al.,
for Children, Richmond, VA, USA
e-mail: [email protected] 1990; David-Ferdon, & Kaslow, 2008; Fristad
et al., 2002, 2011; Fristad & MacPherson, 2014;
K. J. Zelic
Children’s Hospitals and Clinics of Minnesota, Greco & Hayes, 2008; Lewinsohn et al., 1991;
Minneapolis, MN, USA Mufson et al., 2004; Miklowitz et al., 2006;
e-mail: [email protected] Tompson et al., 2007; West et al., 2007; Young &
A. Kruser Fristad, 2007).
Mayo Clinic, Rochester, MN, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 103
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_7
104 J. M. Leffler et al.

These evidence-based treatments (EBTs) have at least one caregiver commit to attending
include outpatient group or individual treatment the program.
for youth with unipolar and bipolar mood disor- CAIMP was offered to youth and their care-
ders and their families. Elements of these EBTs givers in age-matched cohorts with younger
usually include psychoeducation; affect educa- youth (ages 8–11), middle school youth (ages
tion/awareness; goal setting; coping, problem-­ 11–13), and high school youth (14–18). The aim
solving, conflict resolution, communication, and of CAIMP is to address functional difficulties
relaxation skills; mood monitoring; behavioral related to mood disorders. Based on the focus
activation; sleep hygiene; nutrition; physical and format of the program, youth without a mood
activity; social engagement; interpersonal skills disorder, low intellectual functioning, moderate
(e.g., peers, siblings parents, and authority fig- to severe autism spectrum disorder, active sub-
ures); parent training; and addressing an imbal- stance abuse, active and untreated eating disorder
ance in the family system (e.g., Fristad, et al., or psychosis, or youth whose caregivers were not
2011; Tompson et al., 2007, 2012). able to attend the program with them (e.g., youth
in temporary placements) were not enrolled in
the program. Additionally, youth who struggle to
 hild and Adolescent Integrated
C engage in a group setting or complete written and
Mood Program (CAIMP) oral activities may need additional considerations
or modification to successfully participate in pro-
The Child and Adolescent Integrated Mood gram. Individuals with suicidal ideation are
Program (CAIMP) is a family-based two-week assessed by their referral source (e.g., inpatient
partial hospitalization program (PHP) at Mayo psychiatric hospital team, outpatient provider, or
Clinic designed for youth diagnosed with a pri- emergency department staff) to determine their
mary mood disorder. Treatment admission crite- clinical need for acute psychiatric hospitaliza-
ria include youth between the ages of 8 and tion. Safety considerations involving suicidal
18 years old with a primary mood disorder (uni- ideation and self-injury are reassessed by CAIMP
polar or bipolar). CAIMP was initiated in 2012 providers upon admission and throughout the
and ran until 2019. At that time, CAIMP was program.
paused due to reassess elements of the program
and the COVID-19 pandemic.
Demographics

Attendance Requirements CAIMP was offered twice a month with a rotat-

ing offering of a high school and younger group
Youth must be accompanied by a parent or pri- (e.g., either a middle school or younger child
mary caregiver (throughout the text caregiver group). Most groups offered from 2012 to 2019
will be used to refer to both parents and primary prior to the program being paused included high
caregivers) able to fully participate in the pro- school groups with the average age of partici-
gram as well. Youth and caregivers need to be pants being 15 years old. Patients admitted to
motivated to work on improving daily function- CAIMP over the 7 years prior to 2019 include
ing and interpersonal interactions within a group predominantly females (63.10%). The majority
treatment modality. Patients most appropriate for of participants were Caucasian (84.80%). Youth
treatment in CAIMP include those who have had also identified as Hispanic/Latino (4.43%),
little or no progress while engaging in outpatient Black/African American (0.80%), Asian (0.80%),
therapy, those whose symptom severity warrants American Indian/Alaskan Native (0.20%), and
an intensive treatment approach, those whose Biracial (0.60%). Given the focus of the program,
family system has difficulty assisting in success- all youth admitted were identified to have a pri-
ful management of illness, and those who can mary mood disorder. Diagnostically, youth
7 Child and Adolescent Integrated Mood Program (CAIMP) 105

p­resented with major depressive disorder not meet clinical criteria for inpatient psychiatric
(79.96%), persistent depressive disorder (8.23%), hospitalization (IPH) but are significantly strug-
disruptive mood dysregulation disorder (4.85%), gling in daily functioning or (2) are being dis-
depressive disorder not otherwise specified or charged from IPH and require more intensive
unspecified (2.53%), bipolar disorder (1.90%), treatment than weekly outpatient therapy. CAIMP
mood disorder not otherwise specified (0.84%), is provided for 10 days, Monday through Friday
and cyclothymia (0.63%). Most common comor- 8:00 am to 4:30 pm. The majority of program-
bid diagnoses included generalized anxiety disor- ming (75 total hours) is provided in a group for-
der (30.60%), attention-deficit/hyperactivity mat, with youth spending 30 hours in youth
disorder (21.94%), oppositional defiant disorder groups and caregivers spending 26 hours in care-
(14.98%), social anxiety disorder (14.35%), and giver groups over the two weeks. There are also
multiple other mental health diagnoses account- 41 hours of multifamily groups during the
ing for less than 10% comorbidity (Leffler et al., two weeks which include all youth and caregiv-
2021b). ers. In addition, approximately four hours over
the course of the two weeks are spent in individ-
ual and family therapy sessions. Additionally,
Theoretical Overview two hours of the program are spent in clinical
team rounds, and one to two hours include medi-
CAIMP was developed with an understanding of cation evaluations. Over time, with feedback
factors that facilitate, exacerbate, and maintain from families and providers, the length of the day
mood disorders and their resulting impairments was shortened to 8:00 am to 4:00 pm by cutting
in functioning in various domains. The program out some of the break time between sessions
draws from multiple treatment components and throughout the day to increase efficiency of time
integrates EBTs for mood disorders. The CAIMP in program and allow families and patients more
treatment model is similar to the multifamily psy- time to engage in after-program activities.
choeducation psychotherapy (MF-PEP) model Patients and caregivers are expected to attend
(Fristad et al., 2011) for addressing both depres- group, individual, and family sessions and com-
sive and bipolar illness patterns. Similar to other plete therapeutic work during program and out-
EBTs for youth mood disorders (David-Ferdon side of program. There is an optional one-week
& Kaslow, 2008; West & Pavuluri, 2009), “booster session” available to families that com-
MF-PEP includes psychoeducation about mood plete CAIMP, and after returning home to work
disorders along with, family involvement, skill with their local providers, find themselves expe-
building, and cognitive behavioral therapy (CBT) riencing difficulty with managing their child’s
strategies. CAIMP integrates cognitive behav- mood symptoms and functioning.
ioral, interpersonal psychotherapy, mindfulness,
and acceptance and commitment therapy content.
Additional aspects of the treatment consist of Programming
psychoeducation, medication management, and
health and wellness strategies. Treatment inter- CAIMP programming revolves around the treat-
ventions address areas of impairment including ment phrase “I am responsible for managing my
social and emotional functioning, as well as mood and actions.” The focus of treatment is to
physical well-being. (1) enhance the patient’s ability to put forth their
best effort to manage their symptoms and (2)
encourage the family system to work together in
Structure supporting their child to take responsibility in
managing their symptoms. Part of the interven-
CAIMP was created to provide an intensive level tion is also focused on psychoeducation to edu-
of care to youth with mood disorders who (1) do cate youth and their caregivers on potential
106 J. M. Leffler et al.

internal and external factors that can impact their ted to the IPH unit. Additionally, once the IPH
mood in a healthy and unhealthy way. This is unit staff evaluate and determine the patient is not
critical and allows an individualized approach to in acute distress for harm to self or others, the
care, given each patient’s awareness of healthy patient can attend CAIMP with their caregivers.
and unhealthy personal factors. Patients, caregiv- Given CAIMP is located across the hallway from
ers, and staff work with each patient to identify the IPH unit, IPH staff escort the patient to
how they will utilize skills to address their overall CAIMP each morning, and then the patient’s
health and wellness. Steps toward achieving that CAIMP therapist escorts the patient back to the
goal include the acronym PRACTICE which IPH unit at the end of the program day. During
highlights the skills and techniques for mood the day, the patient’s therapist and the program
management and health and wellness. Elements director touch base with the patient and assess
of PRACTICE are presented in Table 7.1. his/her level of safety at least twice, and more
often if warranted by patient, caregiver, or staff
concern. The patient’s caregivers can attend
 anaging Mental Health Crises
M morning IPH unit rounds each day prior to join-
During Program ing CAIMP. Additionally, the patient’s caregivers
can attend evening visitation hours and work on
Youth are admitted to CAIMP due to needing a CAIMP content from that day.
more intense level of care but not meeting criteria
for inpatient psychiatric hospitalization.
However, there are times during the program Discharge and Follow-Up Care
when youth present with emotional distress and
struggle to apply effective coping and problem-­ Since CAIMP is a two-week closed-group pro-
solving skills resulting in unsafe thoughts or gram, all participants are scheduled to start and
behaviors. During these events, staff meet with discharge at the same time (e.g., at the end of the
the patient and discuss applying safe coping 10 days). Following discharge, patients either
skills, utilizing their safety plan, and formulating return home to follow-up with their previous pro-
a plan with their caregivers to remain safe. After vider with new information and skills to work on,
this intervention and an assessment for maintain- connect with a new therapist, or step down to an
ing safety, patients are asked to commit to this intensive outpatient program (IOP). In the latter
plan. If they are unable to commit to implement- option, youth can attend either the IOP within our
ing the safety plan, there is access to either an medical center which is a 5-day 3.5-hour program
emergency department evaluation or direct or an IOP closer to their home. All patients and
admission to the IPH unit contingent on bed caregivers begin discussing discharge goals and
availability. Caregivers have the option to con- follow-up plans during their first team rounds,
tinue to attend CAIMP, while their child is admit- which occur on the second day of program. This

Table 7.1 Overview of PRACTICE

Topic Example of activities
P Problem-solving and planning Stop, plan, do activities
R Relaxation/coping Mindfulness practice
A Affect awareness Daily mood recognition and charting
C Crisis/safety planning Safety planning as a family
T Thoughts/cognitions Identifying and challenging cognitive distortions
I Interpersonal interactions Identifying health and unhealthy relationships
C Communication Identifying verbal and nonverbal communication
styles and using “I Feel Statements”
E Exercise and eating Behavioral activation and setting daily goals
7 Child and Adolescent Integrated Mood Program (CAIMP) 107

allows for the patient’s primary therapist to begin tings, these interventions are not readily available
navigating goals to focus on throughout the pro- to all youth. Further, while some youth can ben-
gram as well as identify potential follow-up efit from outpatient therapy, some youth with
resources. As the program progresses, the patient mood disorders require higher levels of care. In
and their caregiver(s) are provided more clarity this case, they may benefit from more intensive
about specific mental health and education fol- interventions (e.g., IOP or PHP). However, most
low-­up plans. This includes the patient and care- IOPs and PHPs may not focus specifically on
givers speaking with mental health providers and issues experienced by youth with mood disorders
school personnel with support from their thera- and their caregivers. Typically, in traditional
pist or engaging in conference calls with these IOPs and PHPs, caregiver involvement is limited
professionals with their therapist to discuss inter- (e.g., 1–3 hours a week). Therefore, CAIMP was
ventions and resources to support the patient and designed to provide a high dose of treatment for
caregivers following discharge. Additionally, all youth and their caregivers by providing a range
patients and their caregivers receive a copy of the of treatment components to address mood disor-
patient’s discharge summary to help guide their ders while allowing for individualization of care
follow-up plan and share with providers and through the intensity of a 10-day, family-based
school professionals as needed to achieve their treatment model.
goals. Specific multifamily groups focus on CAIMP was implemented in 2012 as part of a
developing and implementing an education plan unified multiservice model for child and adoles-
and follow-up mental health plan to allow care- cent mood disorders within a Midwestern medi-
givers and patients to discuss ways to commit to cal center. Stakeholders including institution,
and maximize these plans. Additionally, there is a department, and division leaders requested a
caregiver group focused specifically on navigat- treatment model to address mood disorders for
ing and engaging mental health services for their youth served locally, nationally, and internation-
child. ally. CAIMP was developed and implemented to
fill a treatment gap as part of the larger assess-
ment and treatment model within the medical
Program Development center that included medication follow-up and
therapy within an integrated behavioral health
The chapter’s first author developed CAIMP in model, an outpatient diagnostic and referral
2011 based on previous work with youth with clinic, outpatient individual therapy and groups
mood disorders and their families. These experi- for middle school and high school youth, and
ences included working with patients and their inpatient psychiatric care.
families in inpatient, residential, in-home, day-­ CAIMP was developed within the context of a
treatment, outpatient, and research study settings. ten-step strategy to program design and imple-
The focus of developing the program was to inte- mentation (Leffler & D’Angelo, 2020) that is
grate treatment elements evaluated to provide presented in Table 7.2.
benefit to youth with mood disorders as well as
engage their family system to support their suc-
cess. Caregivers often request more knowledge Staffing
and skills to support their child in their symptom
management and mental health function; how- CAIMP’s original staffing plan in 2012 started
ever, few programs offer this opportunity for par- with 1.0 full-time equivalent (FTE) registered
ticipation in their child’s care due to access nurse (RN), 0.5 FTE licensed psychologist, 1.0
issues, the provider’s training, treatment focus, FTE licensed clinical social worker (LICSW),
and reimbursement issues. Additionally, while 1.0 certified nurse practitioner (CNP), 0.2 FTE
there are several EBTs for youth with mood dis- occupational therapist (OT), 0.2 FTE recreation
orders tested and implemented in outpatient set- therapist (RT), 0.1 FTE of psychiatry, and one
108 J. M. Leffler et al.

Table 7.2 Program design and implementation model

Phase Step Action
Brainstorming and Planning Phase Aspirations Identify broad goals
Ask “What would we ideally like to achieve?”
Aim Identify specific targets
Ask “What are our specific aims, goals, and targets?”
Resource Gathering and Front-End Acknowledge Identify the need for the service and resources required to
Work Phase initiate and sustain it
Ask “What do we need to achieve our goals and targets?”
Articulate Develop and refine your message (Consider a 5-minute
elevator speech)
Ask “To whom and how do we communicate our goals
and aims?”
Aggregate Integrate information from research and program
stakeholders (e.g., patients, caregivers, consumers,
leaders, staff, etc.)
Ask “How do we enhance the meaning of our message?”
Address Identify remaining gaps and needs
Ask “What are we missing, how do we address this?”
Work Phase Apply Implement the service
Ask “How long do we pilot the program to obtain usable
and meaningful results?”
Review and Evaluate Phase Assess Review the implementation of the service with a focus on
continuous quality improvement
Ask “What worked and did not work and how do we
improve the program?”
Review input from stakeholders and results from data
collected
Revisit current research as needed
Using implementation science benchmarks (e.g.,
acceptability, costs, feasibility, penetration, etc.)
Ask “Did we meet our goals and aims?” “Do we
continue, modify, or discontinue the service?”
Adapt Identify modifications and strategies for improvement
with a focus on modifying, enhancing, and improving the
services
Ask “How do modifications address efficacy,
effectiveness, satisfaction, and implementation outcomes
as well as add value to the process”
Work Phase Again Re-implement the updated service, and reassess the
intervention utilizing procedures from the evaluate phase
Ask “How is the current version of the program meeting
stakeholder’s identified needs and areas of process
improvement and implementation science?”
7 Child and Adolescent Integrated Mood Program (CAIMP) 109

hour a week of dietician services. The LICSW and conducting individual and family therapy
and psychologist provided group therapy as well sessions with regular supervision and review of
as individual and family therapy. The program skills. Weekly supervision was provided for
CNP provided medication education and health LPCC and LICSW staff to address specific cases
and wellness groups along with medication man- concerns and treatment needs. Twice weekly
agement appointments. The program psychiatrist team meetings were also used to present, concep-
provided supervision and consultation to the tualize, and plan for treatment interventions for
CNP as needed and provided clinical support for all patients. The team also used frequent
patients requiring inpatient psychiatric admis- impromptu touch points or “curb side meetings”
sion. Staff clinical activities and daily schedule and “huddles” throughout the day to present and
are detailed in Table 7.3. The staffing model was discuss patient progress, treatment interfering
modified in 2014 due to increased patient vol- behaviors, group dynamic topics, and safety con-
ume. At that time, staffing changed to include 1.5 cerns for both patients and their caregivers as
FTE licensed professional clinical counselor they presented.
(LPCC), and the LICSW FTE was transferred to
our IOP. With the addition of 0.5 LPCC FTE, the
0.2 of the psychologist’s time was shifted to other Day-to-Day Programming
clinical and administrative activities and pro-
vided less individual and family therapy time in CAIMP, like many PHPs, consists of group-­
CAIMP. Additionally, psychiatry time was based programming, which is provided in a set-
increased to 0.2 to attend family rounds and team ting of up to eight patients and their caregivers,
meetings along with as needed consultation for prior to the COVID-19 pandemic. Programming
medication concerns and assistance with inpa- is provided to developmentally similar cohorts
tient psychiatric admissions. (e.g., middle school, junior high, and high
school). Patients and caregivers are expected to
attend all groups unless needing to attend simul-
CAIMP Daily Schedule taneous program events (e.g., medication
appointment, individual therapy, etc.) or other
Trainees medical appointments. Active participation is
Psychology and psychiatry fellows rotate through encouraged in a respectful manner to share per-
CAIMP as part of their training. Psychology fel- sonal struggles and successes. All groups are skill
lows observe and lead groups in a co-facilitator and psychoeducation focused. There are no open
and lead facilitator model. They also conduct process groups. This approach was taken to focus
individual and family therapy. Psychiatry fellows as much time as possible for skill introduction,
observe groups and provide individual and fam- practice, implementation, and development.
ily therapy. Weekly and sometimes daily supervi- Additionally, given events such as self-harm,
sion for both psychiatry and psychology fellows risk-taking behaviors, and suicidal ideation that
is provided by the program psychologist along can present for youth with depression and bipolar
with input and feedback from the programs’ disorder, the treatment team decided to limit the
LPCCs and CNP. free-flowing content of a process group which
might allow members to share topics that cause
Supervision distress for other group members. Groups were
The LICSW, LPCC, and CNP staff were trained formatted to offer youth- and caregiver-only
in group content and evidence-based treatment groups as well as participation with other fami-
and assessment of mood disorders by the pro- lies in multifamily groups. This was determined
gram psychologist. This included reviewing pro- based on previous group work of the first author
gram content, role-playing, modeling, and in various clinical settings and evidence-based
co-facilitating groups prior to running program practices (see Fristad et al., 2011). Youth- and
 110

Table 7.3 Child and adolescent integrated mood program 8:00 am–4:00 pm daily schedule
Team member Time Monday Tuesday Wednesday Thursday Friday
RN 8:00am RN – intake paperwork 1st RN – goals setting RN – goals setting RN – goals setting RN – goals setting
OT Monday (individual and (individual and (individual and (individual and
OT assessment 1st family) family) family) family)
Monday
Psychologist and 8:00am Family or individual Family or individual
LPCC therapy therapy
Psychologist, 8:00am–10:00am Family rounds Family rounds
Psychiatry, CNS,
LPCC
RN 8:40am Light body movement Light body movement Light body movement Light body movement Light body movement
LPCC or CNS 9:00am 9:30am Program Stress Management/ Stress management/ Stress management/ Stress Management/
orientation (1st Monday) mindfulness mindfulness mindfulness mindfulness
9:50am Break Break Break Break Break
RN, CNS, LPCC, 10:00am RN: healthy habits – sleep CNS – med LPCC – IPT (Y) Diet – healthy LPCC –IPT (Y)
Diet or communication skills evaluations RN – parenting skills Habits – nutrition CNS – med educ. (P)
RN – family skills (P)
OT & RN 11:00am OT – group (family) OT – group (Y) OT – group (Y) OT – group (Y) OT – group (family)
RN parent skills group RN – parent skills RN – parent skills
group Group
11:50am Lunch Lunch Lunch Lunch Lunch
RN, Psychologist, 1:00pm Psychology and LPCC – Psychology and Psychology and Psychology and Psychology and
LPCC family or individual LPCC – family or LPCC – family or LPCC – family or LPCC – family or
therapy individual therapy individual therapy individual therapy individual therapy
RN – skill practice/review RN – skill practice/ RN – skill practice/ RN – skill practice/ RN – skill practice/
review review review review
RT 1:45pm RT – group (Y) RT – group (Y) RT – group (family) RT – group (Y) RT – group (Y)
1:45pm Parent self-care Parent self-care Parent self-care Parent self-care
Psychologist 2:30pm Multifamily group Multifamily group Multifamily group Multifamily group Multifamily group
Psychologist 3:15pm Parent group Parent group Parent group Parent group Parent group
LPCC 3:15pm Youth group Parent group Parent group Parent group Parent group
Notes: CNS certified nurse specialist, Diet dietician, IPT interpersonal psychotherapy, LPCC licensed professional clinical counselor, OT occupational therapy/therapist, RN
registered nurse, RT recreation therapy/therapist, P parent, Y youth
J. M. Leffler et al.
7 Child and Adolescent Integrated Mood Program (CAIMP) 111

caregiver-only groups provide a group dynamic Additionally, this schedule models for patients
to support youth and caregivers around topics and caregivers ways to engage in “starting and
germane to the unique experiences of the partici- planning for their day” when they return home.
pants. Participants in these groups set individual At the start of each treatment day, patients and
goals for therapy work but also integrate this primary caregivers separately set goals for the
work into the content of their family goals. The day. Education is provided on goal setting in the
benefit of multifamily groups is that multiple program and ongoing use of goal setting after the
youth and caregiver perspectives can be provided program. Daily goals are identified and planned
on the same topic and facilitated by a trained to help facilitate clinical gains of patients’ over-
mental health provider. Additionally, youth and all treatment goals. Goals are reviewed midday
caregivers learn content together, discuss how to assess treatment gains. Additionally, at that
they can implement them individually as well as time, patients and caregivers are asked to review
from a family perspective, and set shared goals and address potential barriers that might prevent
for practice. engaging in their daily goal outside of program.

 tress Management Mindfulness

S
Groups Group
Mindfulness-based strategies are offered every
Groups in CAIMP include psychoeducation and day in a 50-minute multifamily group format
skill-focused content. All groups were facilitated facilitated by either a LPCC or CNP. This group
by a primary provider, and occasionally, for introduces mindfulness techniques and strate-
training purposes, co-facilitators may attend. gies to integrate them into daily practice. The
Additionally, if staff had safety concerns for a mindfulness group content focuses on topics
patient or the group given a recent event (e.g., a related to understanding the brain and how the
child hitting a caregiver, or threatening to leave mind works, mindful observation, mindful eat-
program), the team RN would also attend group ing, mindful communication, mindful journal-
to assist with milieu and group management. ing, and managing negative thoughts and
The program utilized two group rooms. One emotions to improve confidence. Regular prac-
smaller group room that was used for the youth- tice of mindfulness-­based exercises is introduced
only groups (due to the maximum program cen- as a way to practice staying engaged in the pres-
sus of eight patients), as well as family-rounds, ent moment.
and one larger room that was utilized for the
multifamily and caregiver-only groups (as there  ealth and Wellness Group
H
were often more than eight caregivers per Fifty-minute health and wellness groups are
session). offered daily and conducted by providers based
on topics. Topics included sleep hygiene led by
 ight Stretch, Goal Setting, and Daily
L either the RN or CNP, communication styles led
Goal Review Groups by the CNP, behavioral activation led by the
CAIMP starts at 8:00 am with a light movement LPCC, healthy eating led by the dietician, and
and goal setting group led by the program medication compliance and management led by
RN. This was purposefully formatted to ease the CNP.
patients and caregivers into the treatment day
and build in a potential buffer for youth and care- Multifamily Group
givers who may run into difficulties arriving at The Multifamily Group is attended by patients
8:00 am. Additionally, twice a week the patient and caregivers. In this 50-minute group, the team
and caregivers meet with the treatment team in psychologist presents psychoeducation and skills
the morning so this limited missing an hour of focused on mood disorders and the impact of
therapy. Further, late arrivals would not disrupt symptoms on the patient and family system.
therapeutic or psychoeducation group. Content introduced includes affect recognition,
112 J. M. Leffler et al.

expressed emotion patterns, verbal and nonverbal Recreational Therapy Group

communication, review of safety and safety plan- Recreation therapists facilitate this 50-minute
ning, impact of educational stressors on mood group which engages youth in learning and prac-
and vice versa, problem-solving as a family, ticing leisure skills. This includes team building,
behavioral activation planning, creating plans for creativity, socialization, and family activities.
follow-up services and identifying and address- Once a week caregivers attend the group and
ing potential barriers, and implementing these engage in family activities focused on leisure and
plans following discharge. bonding activities.

 outh CBT Group

Y Caregiver Group
The LPCC facilitates the Youth CBT Group The program psychologist conducts this
and provides psychoeducation along with skill 50-­minute group for caregivers to expand and
introduction and practice using a cognitive elaborate with more specific conversations with-
behavioral approach (e.g., identifying and out youth involved on topics introduced in the
addressing the connection between thoughts, Multifamily Group and mirrors content in the
feelings, and behaviors). In this 50-minute group, Youth CBT Group. Additional psychoeducation
youth are introduced to ways to improve problem-­ is provided on the cognitive behavioral approach,
solving and communication strategies, coping such as the connection between thoughts, feel-
skills, responding in healthy ways to internal and ings, and behaviors. Caregivers also learn strate-
external events, behavioral activation, and the gies to enhance problem-solving techniques and
impact of substance use on mood. Additionally, communication skills. Additional content
youth focus on next steps following discharge includes identifying and working with mental
and accessing ongoing treatment. health and education teams, family care and
safety planning, and caregiver and family self-­
Interpersonal Therapy Group care. In this group, caregivers are also provided
Interpersonal therapy group is a 50-minute youth-­ with additional support in planning for discharge
only group facilitated by the program and follow-up care, as well as maintaining treat-
LPCC. Elements of interpersonal psychotherapy ment gains upon return home.
(IPT) are introduced, including the interpersonal
inventory, connection of mood symptoms and Caregiver Skills Group
interpersonal relationships, utilization of The caregiver skills group facilitated by the pro-
strengths and communication to improve inter- gram RN allowes caregivers to discuss topics
personal relationships, and work on implement- related to parenting a child with a primary mood
ing interpersonal strategies. disorder including parenting styles, conflict
styles, self-care, caregiver coping, self-esteem,
Occupational Therapy Group and cognitive distortions.
This 50-minute group is facilitated by an occupa-
tional therapist and helps youth build skills to Crisis and Safety Response
utilize in day-to-day functioning. Skills are intro- Management
duced to assist youth with time management, life Given that patients with mood disorders often
balance, healthy socialization, values-driven struggle with suicidal ideation and self-injury,
behaviors, social media access and utilization, safety considerations are an ongoing area of
addressing academic needs and strategies, and assessment. During the program, if concerns
engaging in positive self-talk. Once a week, care- arise for suicidal ideation or intent, a clinical pro-
givers also attend the group and engage in week- vider conducts an assessment to determine the
end planning with their child. patient’s level of safety. As part of the assess-
7 Child and Adolescent Integrated Mood Program (CAIMP) 113

ment, information about level and intent of self-­ and connect skills and education topics to the
injury/suicidal ideation is gathered along with patient’s program goals. Therapy also addresses
access to means. Additionally, clinicians evaluate treatment barriers and plans for follow-up care.
and assist with planning for protective factors Additional therapy sessions or crisis manage-
(e.g., enjoyable activities, social and family con- ment sessions are utilized as needed. Weekly
nections, etc.), access and willingness to utilize 50-minute family therapy is provided by the staff
coping skills, and reaching out to trusted adults. member providing individual therapy for conti-
The patient’s level of commitment to the plan and nuity of content with a focus on addressing how
safety are also evaluated. The therapist and the family is applying skills and education of the
patient discuss a plan for how best to share this program and problem-solving around treatment
information with the patient’s caregiver to plan barriers related to the family system or follow-up
for safety outside of program. Consideration is plans. The family also meets with the larger team
given to whether the patient should remain in the twice a week for 15 min to address similar topics
program or requires the need for further assess- in a more condensed fashion and receives input
ment for potential need for higher level of care. from all program providers in a unified way using
Initial and ongoing evaluation processes are the validation, empathy, and support.
same for other potential concerns that may arise,
such as self-injurious behaviors, psychosis, active
substance use, or difficulties associated with eat-  se of Daily Projects and SMART
U
ing disorders. The clinical team communicates Goals
with the patient’s caregiver in attendance, as ethi-
cally and clinically warranted, about safety status In the first Multifamily Group, youth and caregiv-
updates and/or recommendations for higher or ers identify three youth, three caregivers, and
more specialized (e.g., substance abuse program) three family goals to work on during the two
levels of care. If self-injury is noticed in program weeks of program. Each day youth and caregivers
or brought to the treatment team’s attention, the set individual goals during the Goals Group using
patient meets one on one with a nurse to assess a SMART goal approach and report to the group
the appropriate medical response needed. The how they worked toward or reached their daily
patient also meets with a therapist for further goal. SMART goals are utilized throughout the
assessment of patient’s safety and review of program in terms of setting and attaining self-­
safety plan and other skills (e.g., coping skills, goals. Using a SMART goals approach, youth and
behavioral activation, communication, affect rec- caregivers develop goals that are specific, measur-
ognition and expression, etc.). All CAIMP able/meaningful/motivating, agreed upon/attain-
attendees are informed of program guidelines able, relevant/realistic, and timely. To address
that ban discussing self-injurious behaviors in these goals, each group provides skills or educa-
group and exposure of self-inflicted injury to oth- tion content to be addressed between treatment
ers. Appropriate active ignoring skills are taught days by youth and caregivers.
to staff and caregivers after the patient is taught
ways to better manage emotional or cognitive
processes contributing to self-injury. Miscellaneous Activities

During the day, youth and caregivers have a built-

Individual and Family Therapy ­in lunch hour and often eat lunch either as a family
or as groups of families. This time allows for
Each patient receives weekly individual therapy, ongoing social interaction and skill practice away
typically a 50-minute session, provided by the from the treatment team. Similarly, outside of pro-
program LICSW, LPCC, or psychologist. The gram hours, families engage in activities together
focus is to individualize the treatment content in the evenings (e.g., dinner, bowling, rock climb-
114 J. M. Leffler et al.

ing, shopping, ceramics/crafts, working out/box- Augenstein, 2012; Waslick et al., 2002). There
ing, etc.). During the day, caregivers also have are a multitude of interviews and rating scales
time outside of groups to practice self-­care, and for assessment of children’s mental health symp-
this might include following up with family mem- toms and will not be entirely reviewed here (for
bers not participating in program, going for a walk,
additional details on reviews of various inter-
reviewing skills, or practicing mindfulness. view schedules and rating scales most common
Additionally, caregivers can use this time to follow
for identification and diagnosis of depression in
up with their work/employer, external treatment childhood reference Klein et al., 2005; D’Angelo
providers, other necessary services at the treat- & Augenstein, 2012). There are many ratings
ment facility (e.g., medical appointments, labs, scales allowing for child, parent, teacher, or cli-
etc.), their child’s education team, insurance com-nician format. Some common scales include the
pany, and any other needed activities. Children’s Depression Rating Scale—Revised
(CDRS:R; Poznanski & Mokros, 1996), the
Children’s Depression Inventory (CDI; Kovacs,
Implementation of Evidence-Based 1979), the Depression and Anxiety in Youth
Assessment Scale (Newcomer et al., 1994), the Reynold’s
Adolescent Depression Scale and Reynold’s
Evidence-based assessment consists of three spe- Adolescent Depression Scale 2nd edition (RADS
cific components: (1) research and theory-­ & RADS-2; Reynolds, 1986, 2004), the Center
informed target symptoms for assessment, (2) for Epidemiological Studies Depression Scale
assessment measures that are created and selected for Children (CES-DC; Faulstich et al., 1986;
by empirically supported methods and measures, Weissman et al., 1980), and the Patient Health
and (3) continuous review of the assessment pro- Questionnaire-9 (PHQ-9) and Patient Health
cess (D’Angelo & Augenstein, 2012; Hunsley & Questionnaire-9 modified (PHQ-9 M) (Jeffrey
Mash, 2007). et al., 2002; Kroenke et al., 2001; Spitzer et al.,
1999), to name a few.

Depression
Bipolar Disorder
Given the prevalence and significant sequelae of
depression, the US Preventative Services Task Measures of pediatric bipolar disorder have
Force recommends screening for major depres- increased over the years although are not as
sive disorder in adolescents between the ages of numerous as those for pediatric depression.
12 and 18 years, provided that there is a system Checklists have been helpful in detecting cases
in place that can follow through with diagnosis, needing more in-depth evaluation of symptoms
treatment, and follow-up (Siu, 2016). Guidelines related to pediatric bipolar disorder, with the fol-
for best practice assessment include child clini- lowing manic symptom scales that have been
cal interview, caregiver clinical interview, broad- identified as faring well at identifying pediatric
band ratings, and review of previous reports. The bipolar disorder: The Parent General Behavior
aforementioned information is integrated to Inventory (PGBI; Youngstrom et al., 2004,
form a symptom profile and preliminary diag- 2011), the Child Mania Rating Scale (CMRS;
nostic impressions. If diagnosis of depression is Pavuluri et al., 2006), the Mood Disorders
suspected, the clinician can use depression-spe- Questionnaire-­Adolescent Version (MDQ-A;
cific measures and depression-specific inter- Wagner et al., 2006), and the parent version of
views for additional information. Diagnosis of the Mood Disorder Questionnaire (MDQ;
depressive disorders can be enhanced through a Goldstein et al., 2017). Checklists can improve
combined use of formal interviews and rating diagnostic decision-­making in the clinical set-
scales (Klein et al., 2005; D’Angelo & ting, although likely not accurate enough to jus-
7 Child and Adolescent Integrated Mood Program (CAIMP) 115

tify use alone or universal screening for children. utility in clinical and research settings (Leffler
The best method of establishing a pediatric bipo- et al., 2015) also noting the limitation of the
lar disorder diagnosis is via semi-structured or assessment tool given it has not been updated for
structured diagnostic interviews that systemati- the Diagnostic and Statistical Manual of Mental
cally evaluate mood symptoms as well as deter- Disorders (DSM- 5; American Psychiatric
mine symptom severity (Goldstein et al., 2017). Association, 2013). To address the limitations
with diagnosis such as posttraumatic stress disor-
der (PTSD), and disruptive mood dysregulation
Assessment Strategies for Youth disorder (DMDD) (McTate & Leffler, 2017),
additional items were queried with patients and
Assessment of youth psychopathology empha- caregivers to better assess these disorders in line
sizes multiple informants. However, disagree- with the DSM-5 criteria. Patients and caregiver(s)
ment between child and parent report of also complete various self- and parent-report
depressive symptoms often exists. Parents are measures, both broad- and narrowband measures.
more likely to report externalizing symptoms Mood-specific self-report measures include the
such as irritability, while children are more likely CES-DC (Faulstich et al., 1986), a 20-item ques-
to report internalizing symptoms such as tionnaire that assesses the presence of depressive
depressed mood (Richardson & symptoms in youth; the PHQ-9M (Jeffrey et al.,
Katzenellenbogen, 2005). Assessment can also 2002; Kroenke et al., 2001; Spitzer et al., 1999),
be complicated by parent psychopathology. For a 9-item questionnaire used to assess symptoms
example, depressed mothers have been found to of depression and suicide risk in adolescents; and
overreport their child’s depressive symptoms the MDQ-A (Wagner et al., 2006), a 13-item
(Renouf & Kovacs, 1994). As a result, we con- screener for bipolar disorder symptoms in ado-
sider the data gathered by parent report in the lescents, and, as a result, were not used with all
context of the functioning of the patient in pro- patients in the program given the age range. A
gram, along with the patient’s self-report, and broadband measure is used to gather a wider
staff assessment of symptoms and functioning. range of information regarding symptom presen-
tation and severity and overall functioning. The
broadband measure implemented in CAIMP, due
Assessment in CAIMP to having both depression and mania scales, is the
Conners Comprehensive Behavior Rating Scales
Admission (CBRS; Conners, 2008). The CBRS is a broad-
Before involving youth in mental health services, based measure that assesses (ages 6–18) emo-
a thorough assessment of symptoms and func- tional, behavioral, and academic functioning in
tioning is warranted to formulate the problem(s), youth (ages 6–18) through self-, parent-, and
establish a diagnosis, and inform the treatment teacher-report forms. The Child Sheehan
plan. At the beginning of CAIMP, each patient Disability Scale adapted for mood disorders
receives a comprehensive biopsychosocial evalu- (CSDS) is an adaptation of the Sheehan Disability
ation by the program psychologist or colleagues Scale (SDS; Sheehan, 1986), a measure of
(psychiatrists and psychologists) in the institu- impairment in functioning. The CSDS and
tion specializing in the presentation of mood dis- CSDS-P for parents were designed to measure
orders in youth. The program psychologist, interference of child anxiety symptoms with
LPCC, or LICSW complete a structured clinical daily functioning and has similar properties to
interview utilizing the Children’s Interview for the adult SDS (Whiteside, 2009). Youth complete
Psychiatric Syndromes (ChIPS; Weller et al., the PHQ-9M, CDSR, MDQ-A, CBRS, and CSDS
1999) with each patient and their caregiver(s). at the beginning and end of program as well as at
The ChIPS covers 20 DSM-IV Axis I disorders 1-, 3-, 6-, and 12-month follow-up time points.
and is appropriate for children between 6 and Caregivers complete the CBRS, MDQ-A, and
18 years of age. The ChIPS was chosen for its CSDS at the same time points as the youth.
116 J. M. Leffler et al.

Staff also utilize the Clinical Global Implementation of Evidence-Based

Impression – Severity of Illness (CGI-S). The Interventions
CGI-S (Guy, 1976) which is a clinician-­
completed eight-point Likert scale is used pre- Recent meta-analytic reviews and updates to the
and posttreatment to evaluate the clinical severity literature base for psychosocial treatments for
of the patient’s and family’s functioning. youth depression and bipolar disorder outline
Additionally, staff used the Clinical Global treatments based on guidelines for well-­
Impression – Global Improvement (CGI-IG). established, probably efficacious, and possibly
The CGI-IG (Guy, 1976) is a clinician-completed efficacious treatments (Fristad & MacPherson,
eight-point Likert scale and was used to measure 2014; Weersing et al., 2017). For adolescent
the patient’s and family’s improvement at the end depression, CBT delivered in an individual for-
of treatment. At admission, caregivers also com- mat meets criteria for well-established treatment,
pleted a family history questionnaire and patient while group IPT meets criteria for probably effi-
treatment history questionnaire that gathered data cacious. Bibliotherapy CBT and family-based
on medications and various treatments the patient intervention are considered possibly efficacious,
utilized prior to CAIMP (e.g., IPH, PHP, IOP, and technology-assisted CBT meets criteria as
school-based, outpatient, in-home services, etc.). experimental. For child depression, group CBT,
Information collected at admission is used by the technology-assisted CBT, and behavior therapy
treatment team to aid in diagnostic and case con- all meet criteria for possibly efficacious treat-
ceptualization, develop treatment goals, and ment of depression. Individual CBT, family-­
assist in individual and family therapy along with based intervention, and psychodynamic therapy
identifying necessary follow-up services. all meet criteria for experimental treatment. The
literature base for child depression treatments
Discharge and Follow-Up appears to be much smaller and methodologi-
To evaluate patient and caregiver acceptance of cally weaker than the adolescent literature base
CAIMP, the CAIMP Satisfaction Survey is com- for depression treatment. As such, there are no
pleted at discharge, which is a questionnaire cre- current child depression treatments that meet cri-
ated by program staff for the purpose of assessing teria for well-established or probably efficacious.
acceptability of program components. Youth and Furthermore, limited research exists for treat-
parent versions assess participants’ perception of ment of youth bipolar disorder. Family psycho-
CAIMP related to content, activities, and benefit. education plus skill building meets criteria for
Additionally, 1, 3, 6, and 12 months following probably efficacious (i.e., Multifamily
discharge, patients and caregivers receive a Psychoeducational Psychotherapy, Family-­
CAIMP Follow-Up Survey which was created Focused Treatment; Fristad et al., 2011). CBT
for the purpose of assessing multiple domains meets criteria for possibly efficacious. Both dia-
following completion of the program. Youth and lectical behavior therapy (DBT) and ­interpersonal
parent versions contain the same questions, and and social rhythm therapy (IPSRT) were identi-
both surveys consist of 13 items. Additionally, to fied as experimental. Thus, there are no well-
assess clinical benefit after completing CAIMP, established treatments for youth bipolar disorder.
we reviewed the number of IPH admissions par- Given the evidence base, an empirically informed
ticipants experienced prior to and following intervention combining youth with mood disor-
CAIMP provided on admission and follow-up ders in general should consider incorporating
questionnaires. In addition to the collection of aspects of CBT, IPT, family-based intervention,
self- and parent-report questionnaires on follow- psychoeducation, and skill building.
­up service utilization, internal electronic chart Multiple interventions exist to address mood
reviews are conducted to evaluate service symptoms in youth in the outpatient treatment
utilization. setting. Specifically, some interventions to
7 Child and Adolescent Integrated Mood Program (CAIMP) 117

address depression include Adolescents Coping mood disorders (e.g., Clarke et al., 1990; Fristad
with Depression (Clarke et al., 1990; Lewinsohn et al., 2011; Miklowitz et al., 2006; Mufson et al.,
et al., 1991), Family-Focused Intervention 2004; West et al., 2007).
(Tompson et al., 2007), and Interpersonal More specifically, CBT treatment components
Therapy for Depressed Adolescents (Mufson include behavioral activation; scheduling and
et al., 2004). Some interventions that address engaging in enjoyable activities; problem-­
bipolar disorder include child- and family-­ solving; affect recognition and expression; com-
focused CBT (West et al., 2007) and Family bating negative thinking patterns; interaction
Focused Therapy (Miklowitz et al., 2006). Other among events, thoughts, feelings, and behaviors;
interventions were designed to address both and coping skills. Youth and caregivers partici-
depression and bipolar illnesses such as multi- pate in separate CBT-focused groups. In contrast,
family psychoeducation psychotherapy (Fristad IPT treatment components emphasize targeting
et al., 2011), acceptance and mindfulness inter- improvement in interpersonal functioning and
ventions (Greco & Hayes, 2008), as well as a communication skills within specific contexts of
transdiagnostic approach with various evidence-­ grief, role/family disputes, role/family transi-
based strategies (Ehrenreich-May et al., 2014). tions, and interpersonal deficits. Youth participate
IOP and PHP models of care focused on mood in IPT groups addressing interpersonal relation-
disruption and suicide risk in youth have imple- ships, adapting to changes in relationships, and
mented multiple EBT components. Specifically, forming interpersonal relationships. Additionally,
an IOP addressing youth suicidality implemented ACT, mindfulness, and stress reduction treatment
multiple EBT elements and demonstrated posi- components include emphasis on the present
tive outcomes, as well as acceptability and feasi- moment, application of mindfulness to various
bility (Kennard et al., 2019). This intervention activities (e.g., relaxation-based exercises, eat-
utilizes CBT, DBT, mindfulness CBT, and ing, journaling, communication, etc.), and rou-
Relapse Prevention CBT, as well as individual tine practice of mindful meditation. Patients and
and family therapy, medication management as caregivers participate in this group conjointly and
needed, and parent psychoeducation group practice activities together. Furthermore, psycho-
focused on skill building. EBTs are often devel- education, medication management, and health
oped and tested in research or outpatient settings. and wellness strategies are integral treatment
Unique aspects of acute and intensive treatment components. Effectiveness trials have shown that
settings may impact delivery, and therefore treat- family psychoeducation plus skill-building
ments may need to be adapted or modified to fit a approaches have excellent acceptability and sus-
group-based milieu model (Leffler & D’Angelo, tainability in community contexts (MacPherson
2020). et al., 2014, 2016).
CAIMP integrates components from family-­ The inclusion of elements from multiple
based, CBT, IPT, mindfulness, and acceptance treatment modalities aims to provide youth and
and commitment therapy (ACT) techniques. caregivers with a thorough understanding of the
Techniques are utilized in group, individual, and patient’s unique mood disorder as well as
family therapy session formats. Additional treat- enhance knowledge and application of skills to
ment components include psychoeducation, address the child’s and family’s functioning.
medication management, and health and well- Daily skills practice occurs with patients and
ness strategies. CAIMP follows a similar caregivers in groups, individual, and family ses-
approach to the multifamily psychoeducation sions, and the family engages in similar activi-
psychotherapy (MF-PEP) model (Fristad et al., ties outside of the program. Therapeutic
2011) involving intervention for depressive dis- scaffolding techniques (Brems, 2008) are used to
orders and bipolar disorders. Program content meet patients and families where they are and
and treatment elements were selected from foster development of skills. Exposure to a vari-
family-­ based outpatient treatment models for ety of treatment components from different
118 J. M. Leffler et al.

modalities and time for practice during program- stakeholders. One stakeholder includes referral
ming allows the patient and their caregivers to sources and follow-up team members. The
experience and identify interventions most help- CAIMP team has worked for years to develop
ful to them. By involving both patients and their these relationships with local and national men-
caregivers, there is an opportunity to work on the tal health providers. This has happened as pro-
dynamics within the family system, which offers viders hear about the program and reach out to
an integral path toward achieving treatment discuss its effectiveness and appropriateness for
gains when returning home. their patients. Additionally, families will self-
An important component of any treatment refer, and the CAIMP team works with the pro-
program includes goal setting. While overall vider to plan for the patient’s participation and
treatment goals are created akin to any outpa- return to them for ongoing care following dis-
tient or day treatment setting, additional daily charge. These contacts can include phone calls
goals are identified in order to encourage patients to share clinical information; engage providers,
and caregivers to take small steps toward learn- patient, and caregivers in conference calls; and
ing and practicing skills each day. Content is share treatment progress and follow-up needs.
routinely reviewed and integrated in all groups. Similarly, the CAIMP team works with schools
Although all program participants are involved by discussing the patient’s progress, and aca-
in the same groups, the treatment team works demic and mental health services to consider
with each family in clinical rounds, family ses- when the patient returns to school, etc. This is
sions, and individual sessions to assist with goals communicated through the patient’s discharge
specific to each patient, caregiver, and family summary, phones calls, and conference calls that
system. have included a range of participants (e.g.,
Another important component of treatment patient, caregivers, special education team, spe-
includes the effective communication among the cific teachers, principals, psychologist, coun-
multidisciplinary treatment team in order to best selor, etc.).
help patients and caregivers. Given the size of the Developing and implementing CAIMP as the
treatment team and other key staff members, as first of its kind program at a specific institution
well as stakeholders that comprise the program, required developing working relationships with a
communication strategies are essential to support variety of colleagues and engaging stakeholders
effective patient monitoring and consistency of on a regular basis to identify and adjust expecta-
communication. Communication of the EBT ele- tions that ranged from the start time of the pro-
ments also impacts intervention delivery. gram, staffing, and access to physical space to
Therefore, daily treatment team meetings, brief safety planning in the physical space, training
and frequent impromptu team huddles and curb- staff, and developing policies and procedures
side consults, at least twice a week clinical rounds specific to the program. Additionally, given the
with the patient and family, and handoffs in nuances of billing a day treatment program, there
between groups are important aspects to ensure was a need for frequent front-end and regular
communication amongst the treatment team is standing touchpoint meetings with billing and
ongoing throughout programming. revenue specialists that included reviewing bud-
get sheets, FTE allocations and benefits, as well
as reimbursement practices for bundled or indi-
Collaborations and Generalizing vidual payment models. Within this context,
Treatment Gains there were also considerations for the cost of the
program for families without insurance coverage
There are several factors that impact the imple- to make it accessible. As with most day treatment
mentation and sustainment of a program. One of programs, CAIMP is less expensive than IPH and
these factors is working with and developing more expensive than outpatient therapy (Leffler
meaningful and collaborative relationships with et al., 2020a).
7 Child and Adolescent Integrated Mood Program (CAIMP) 119

Integrating Research and Practice while even more caregivers (83.70%) sug-
gested that the sleep component of treatment
CAIMP is a family-based program for youth with was important or very important. Given the
mood disorders that incorporate evidenced-based need to increase access to care and the COVID-
intervention within a PHP (Leffler et al., 2017). 19 pandemic, it is important to consider alter-
Preliminary study of clinically related outcomes native care delivery models. Regarding interest
of CAIMP is essential to inform future program- in technology-based treatment components,
matic development and implementation. Initial caregivers reported greater likelihood than
investigations support reductions in mood symp- youth to utilize technology for continued treat-
toms and improvements in youth functioning in ment. This was an interesting finding given the
the family, social, and school domains after par- prevalence of smartphone and technology use
ticipating in CAIMP. In addition, staff ratings among youth.
revealed a reduction in illness severity from pre- Given that youth and caregivers valued the
to post-treatment. Notably, most youth participat- sleep-based interventions, current research proj-
ing in the pilot study of CAIMP significantly ects are exploring both subjective and objective
reduced their IPH readmissions. Moreover, addi- indices of sleep in participants of CAIMP.
tional analyses have reviewed access, utilization, Specifically, subjective measures of sleep
insurance coverage, and participant satisfaction hygiene and sleep quality were added to the
in the program (Leffler et al., 2020b). Results assessment battery at pretreatment and post-
suggested high attendance rates and low attrition treatment. In terms of objective sleep indices,
rates for those enrolled in CAIMP. Additionally, ongoing efforts are geared toward evaluating the
participants expressed satisfaction with program- feasibility of utilizing wearable devices to track
ming content. Access, utilization, and patient health information (i.e., sleep, physical activ-
insurance coverage were found to be favorable ity). Taken together, the goals of ongoing
and suggest the potential for program sustainabil- research aim to evaluate effectiveness of evi-
ity. Taken as a whole, findings suggest prelimi- dence-based interventions on sleep outcomes,
nary support for the feasibility and acceptability as well as continued assessment of outcomes
of this innovative intervention for youth with related to functioning in home, social, and aca-
mood-related difficulties and provide initial sup- demic domains.
port for considering the sustainability of CAIMP
(Leffler et al., 2020b).
More recent research endeavors in CAIMP  essons Learned and Program
L
have targeted gaining a better understanding of Longevity
participant’s interest in sleep hygiene given its
impact with mood and technology-based treat- Over the 10 years that CAIMP has been devel-
ment models to address impairments in home, oped, implemented, evaluated, and modified,
social, and academic functioning (Leffler et al., many lessons have been learned. One lesson is
2021b). Data analyses were based on 474 youth graduate school curriculum does not prepare psy-
and their caregivers who participated in chologists well for some of the business and lead-
CAIMP. Youth and caregiver report revealed ership aspects of program development,
reduction in impairment across school, social, implementation, administration, and manage-
and home domains, consistent with the afore- ment. Much of these skills are learned in the
mentioned preliminary findings of improved work environment. Chapter 3 in this book high-
functioning. The majority of youth ratings lights these topics. As a result, in this section, we
(64.30%) suggested that the sleep component will focus on topics specific to CAIMP and our
of treatment was important or very important, experience with developing a PHP.
120 J. M. Leffler et al.

Program Development and Goals between electronic health records to work with
colleagues to assist with developing documenta-
When working with a variety of stakeholders, it tion and billing needs. This included concerns
is important to have a clear understanding of the about how multiple providers document and bill
institution’s “ask” of the program and “needs.” on the same day for similar services for the same
This information allows for clarity in developing, patient.
staffing, and implementing a program.
Additionally, this allows the team to identify pro-
grams goals, and treatment goals for patients and Physical Space and Milieu
caregivers, as well as meaningful and evidence-­
based strategies for measuring these goals. Planning and designing the therapy and milieu
Further, it is important to determine what the physical space and footprint are important. Our
treatment population will need in terms of EBT program is provided in a suite with three group
and assessment. Once these elements are deter- rooms (one for another program but can be flexed
mined, leadership can identify ways to train staff if we need it) and individual offices for therapy or
effectively and efficiently and maintain necessary meeting with caregivers and patients as needed.
supervision over time to facilitate fidelity. Fidelity Office space is designated for a quiet or de-­
with treatment and assessment is important espe- stimulation area, which proves useful at times.
cially if there is regular staff turnover, because When a patient requires the use of this space, we
the loss of staff over time negatively impact pro- meet with the patient in an office and decide on
gram continuity and consistency. Strategies to the most clinically necessary area needed for the
identify, track, and measure fidelity are important patient at that time. This might require using the
so the program does not drift and unintentionally office space or relocating to a group room that is
alter the focus and delivery of content. not being used. All provider offices are in the
same suite, so it is very easy to meet and consult
as needed, and all patients and caregivers can be
Finances easily engaged with team members. Since all
staff are in close proximity to individual therapy
Individual’s developing a treatment program may and group rooms, it is easy to request and receive
find it helpful to work with billing and revenue support in response to mental health crises.
specialists to identify financial models.
Additionally, when building a treatment program,
it is useful to develop an understanding of cost Internal and External Resources
analysis, billing and revenue codes, staffing mod-
els, program costs and other costs, reimburse- For implementation and sustainability purposes,
ment rates for various group and individual it has been important to develop relationships
therapy activities, and the availability of facility with colleagues within our facility as well as
fees. It will also be helpful to know if insurance within the community. Over time, we have devel-
company reimbursement rates can be negotiated oped working relationships with providers in
or if they are fixed. The longevity of a program various states who refer complex patients on a
unfortunately is often determined by the financial regular basis. Additionally, one state’s National
sustainability and not clinical utility, outcome, or Alliance on Mental Health (NAMI) organization
population need. This is not a negative view, it is also provides our contact and program informa-
a realistic view and one that should be under- tion to families. This has allowed for increased
stood and managed successfully to sustain the awareness and access to the program.
clinically necessary, effective, and efficient treat- Additionally, we have been fortunate to have
ments that are provided for youth and families. access to our Ronald McDonald House for fami-
We found it extremely important when migrating lies to stay if needed during the two weeks. Other
7 Child and Adolescent Integrated Mood Program (CAIMP) 121

families from out of town have used hotels and otherwise encountered if placed with peers with
various home and apartment rental options to mental health concerns the patient is not experi-
increase accessibility for national and interna- encing, rolling versus closed enrollment, as well
tional patients. as time-limited versus treatment-dependent
length of stay, which can be impacted by waitlist
management and pressure to see more patients.
Considerations for Development
and Implementation of Similar
Programs  esources for Program Development
R
and Maintenance
When considering the development of a new PHP
or IOP or revamping an existing program, it is Resources for developing, implementing, evalu-
important to discuss these plans with stakehold- ating, and maintaining PHPs and IOPs often con-
ers within your department or agency that include sist of financial sustainability, which will be
direct supervisors, administrators, and clinical important to address at the onset with billing and
leaders. These considerations are reviewed in revenue staff and monitoring these factors on a
Chap. 3 of this text so will only be highlighted regular basis (e.g., quarterly). Further, PHPs and
here. With these discussions, it will be important IOPs can be impacted by agency space needs and
to connect with local mental health providers and staff availability. Because of these factors, it is
schools to gain a sense of how to maximize a important that the program director has access to
continuity of care model, meet community needs, considerations for these resources within the
support patient’s discharge planning, maintain department, division, or agency. In addition to
referral sources, and facilitate return to function- costs, the clinical need for these programs is
ing following treatment. This will help identify measured by number of patients referred to the
the length of and approach to treatment as well as program, which can impact program longevity.
administrative elements of the program, treat- Building and sustaining appropriate referral
ment goals, structure and format of the program, sources and developing professional connections
staffing needs, treatment modalities implemented with colleagues to expand discharge options that
in the program, and billing and revenue needs. In assist with stepping patients out of the program
addition to these elements, it is important to for- are critical. This model of appropriate referral
malize assessment practices to measure the and discharge resources can enhance program
implementation of the program as well as quality sustainability and scalability. More specifically, it
improvement needs and treatment outcomes. provides options that can help minimize a bottle-
These program development strategies are neck of admissions resulting in long waitlists.
addressed by Leffler and D’Angelo (2020). Over time, long waitlists may result in disruption
Consideration for program development should of referral options that impact referral sources.
also focus on the implementation of EBT strate- As a result, professionals and patients and care-
gies and, in doing so, can strengthen the approach givers seek alternative and more accessible treat-
for a specific treatment population identified by ment options, minimizing the overall number of
diagnosis, functional impairment, etc. possible referrals that materialize into admis-
Alternatively, the program may consist of a more sions. It is imperative to “do the math” and know
traditional eclectic focus. There are pros and cons the impact of long waitlists and referrals based on
to both models that usually consist of referral the natural ebb and flow of youth mental health
availability, structure of the program and staffing services needed (e.g., natural dips and upticks in
needs (e.g., providers trained to provide EBTs services around the start and end of school, sum-
with fidelity versus use of process groups along mertime and the winter holidays, etc.). Anyone
with support), the possibility of exposing patients considering developing a PHP or IOP is encour-
to behaviors or information they may not have aged to utilize information in this book as well as
122 J. M. Leffler et al.

the Acute, Intensive, and Residential Services are not fluent in other languages. While having
Special Interest Group (AIRS SIG) (Leffler et al., an interpreter in individual and family sessions
2021a) as a resource. Additionally, contacting and even some smaller groups may be success-
directors of current PHPs and IOPs will be help- ful, the overall success of such interventions is
ful in determining your model of care, structur- not well known in larger groups. Additionally,
ing, and implementing a program that meets your the access to interpretive services for a full-day
agency needs. program has some limits to consider and
address.
CAIMP was testing using a modified version
Ongoing Initiatives and Next Steps of the program at the end of 2018, which was
paused in 2019 to reevaluate its structure and
CAIMP is a two-week family-based day treat- consider alternative staffing and potential space
ment program for youth with mood disorders. models. However, these plans were placed on
CAIMP staff have provided service to over 500 hold in 2020 due to the COVID-19 pandemic.
youth and their families with favorable to strong At that time, the focus shifted to consider start-
financial outcomes, treatment outcomes, and ing up the institution’s Pediatric Transitions
staff and consumer feedback. Despite these out- Program (PTP) which was originally a three-
comes, there is always room for improvement, week IOP which has also been paused and was
alteration, and modification to continue to meet reworked to provide a DBT-informed approach
agency, referral source, and patient/caregiver to care. PTP requires less space since there are
needs. CAIMP collects data on program develop- six to seven patients in the program and only
ment and maintenance as well as treatment out- one caregiver group per week. Due to the spac-
comes to help drive clinical and program ing requirements in indoor settings associated
decision-making. Discussions about modifica- with COVID-19, infectious disease within the
tions have consisted of modifying or eliminating institution limited group room capacity for six
a one-week booster session due to limited refer- individuals. These requirements limit only one
rals for this intervention. Additionally, some caregiver per patient attending program and less
referral sources have asked about altering the than five patients per group. We continue to con-
everyday or all-day expectation for caregiver sider treatment options for in-person or tele-
involvement. This has been discussed as part of health multifamily groups and are using our IOP
the current pause, but at this point, no final deci- to evaluate treatment and staffing needs related
sion has been made due to the important role to the current space limitations due to
caregiver involvement plays in youth mental COVID-19.
health functioning. Further, with the impact of
the COVID-19 pandemic on in-person day treat-
ment programs, especially those that offer multi- Conclusion
family groups and large group participation, there
is consideration for the ability to pivot to smaller CAIMP was developed to provide a day treat-
group census as well as consideration for maxi- ment program for youth with mood disorders uti-
mizing and scaling telehealth options. lizing EBT to assist patients to step up from
Given the low attendance rate of patients outpatient services and step down from IPH.
from minority backgrounds, there is consider- CAIMP has demonstrated initial positive out-
ation for how accessible CAIMP is to all patients comes as a day treatment program for youth with
and providers who are referring patients. mood disorders and their caregivers. CAIMP
Discussions focused on brainstorming strategies continues to evaluate stakeholder input and pro-
to improve access to the program, which is cov- gram outcomes and consider necessary and
ered by insurance and Medicaid. Additionally, meaningful modifications to meet system and
CAIMP is provided in English, and current staff consumer needs. The program has been used as a
7 Child and Adolescent Integrated Mood Program (CAIMP) 123

model for development, implementation, evalua- Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali,
M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J.
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M. P., Findling, R. L., Fristad, M., Kowatch, R. A.,
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 The UCLA Achievement, Behavior,
Cognition (ABC) Program 8
Ruben G. Martinez, Benjamin N. Schneider,
James T. McCracken, and Tara S. Peris

Day treatment, also referred to as partial hospital- are admitted as a stepdown from inpatient or resi-
ization, is intensive, multidisciplinary treatment dential treatment settings.
that provides a therapeutic milieu and a compre-
hensive set of services for children and families
experiencing acute psychiatric concerns. These Program History
programs may take a number of forms, and their
structure, timeframe, and intensity may vary The ABC program began as a child inpatient unit
(Forgeard et al., 2018). The University of as part of the UCLA Neuropsychiatric Institute
California – Los Angeles Achievement, Behavior (NPI). The original unit opened in 1961 along-
& Cognition (ABC) program is a partial hospital- side the larger institute, with James Q. Simmons,
ization program (PHP) located in a large metro- MD as Unit Director. The unit had a strong
politan academic medical center in Los Angeles, behavioral orientation from the outset with the
California. involvement of Ivar Lovaas, PhD, including stud-
ies of original conceptualizations of Applied
Behavior Analysis as well as psychopharmaco-
 hich Children/Families Are
W logical reports on the effects of L-DOPA and
Admitted to ABC? lysergic acid diethylamide (LSD) involving
patients with autism spectrum disorder (ASD).
The ABC program serves children ages 6–12 As the hospital expanded with the help of fund-
experiencing the full spectrum of psychopathol- ing from the National Institute of Child Health
ogy, including medical comorbidities. Most chil- and Human Development, the unit relocated to a
dren present with high levels of symptom severity new space in 1969.
and impairment. The typical child in the ABC From its inception, the program embodied
program has had multiple previous psychiatric multidisciplinary treatment, maintaining a child
and psychological treatment courses that have psychiatrist as director with a unit psychologist as
not improved the individual’s trajectory or co-director. Hans Miller, PhD and Richard
impairment or the family’s functioning. A subset Mattison, MD led the program for most of the
1970s, followed by Mary O’Connor, PhD and
R. G. Martinez · B. N. Schneider · J. T. McCracken · Leenora Petty, MD beginning in the early 1980s.
T. S. Peris (*) Dr. O’Connor completed her postdoctoral train-
University of California, Los Angeles, CA, USA ing on the unit at the same time as Geraldine
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 127
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_8
128 R. G. Martinez et al.

Dawson’s fellowship, and strengthened the devel- ily therapy and separate behavioral parent train-
opmental psychopathology teaching as well as ing. In addition, there is a weekly parent
expanded her interest in the effects of fetal alco- mindfulness group aimed at helping parents
hol exposure. Lengths of stay averaged attune to and manage their own emotional
3–4 months at that time, with some children stay- responses to challenging behaviors. An optional
ing longer. Dr. Petty infused structural family parent support group is also available each week.
therapy training that she received under Salvador When necessary, the program offers live observa-
Minuchin at the University of Pennsylvania, mak- tion and coaching of parent–child interactions.
ing the rotation even richer for child psychiatry
fellows and child psychology interns. Bryan King,
MD took over as Unit Director for the early 1990s Patient Population
and brought a cutting edge perspective on child
psychopharmacology, emphasizing a stronger, On average, children present with 2.77 diagno-
evidence-based approach to monitoring treatment ses, with 37% of children with two, 31% with
on the unit. His protégé, Bhavik Shah, MD, three, and 26% with four or more diagnoses at
replaced him and built on these strengths. baseline. They are usually taking multiple medi-
Converging economic effects of a recession and cations (M = 2.69; range = 0–7) and have com-
insurance restrictions on length of stay prompted plex medication histories. They may present with
the unit to transform into its current day treatment a range of medical comorbidities including dia-
model in 2005, again allowing longer intensive, betes, asthma, and epilepsy (n = 34; 27%). ABC
multidisciplinary treatment experiences in a more patients may additionally present with other
ecologically valid model. Since 2013 and 2014, developmental difficulties or disabilities, includ-
respectively, Benjamin Schneider, MD and Tara ing learning disabilities, sensory processing dis-
Peris, PhD have served as Medical Director and orders, speech and language problems, dyslexia,
Program Director. The program is now situated dysgraphia, learning disability, and social prag-
across the street from the main hospital, and the matic communication disorder (n = 29; 22%).
current adolescent inpatient unit retains beds that A review of data collected between March
can accommodate younger patients when needed. 2016 and January 2020 (N = 132) provides an
illustrative snapshot of the patient population.
Children are on average 10.39 years old
Program Format (SD = 1.61) and primarily male (n = 79; 60%).
The majority of admitted children are white and
The ABC PHP provides a holistic set of services not Hispanic or Latino (n = 100; 76%). A small
and a whole child approach that broadly concep- number of children are Latino (n = 9; 7%), Black/
tualizes child health and well-being. The pro- African American (n = 8; 6%), Asian (n = 5; 4%),
gram typically runs from 7:30 am–2:30 pm Native American/Indigenous (n = 2; 2%), or mul-
Monday through Friday. During that time, chil- tiracial (n = 5; 4%). Some children at ABC are
dren participate in a variety of evidence-based adopted (n = 18, 14%) and a significant propor-
groups aimed at bolstering emotion regulation, tion come from homes with separated or divorced
problem-solving, and coping skills. All children parents (n = 28; 21%). On average, 29% (n = 38)
participate in school on-site through a contract of children present to ABC with a previous inpa-
with the Los Angeles Unified School District tient hospitalization or psychiatric emergency
(LAUSD). Children also receive daily individual department (ED) visit (n = 19; 14%). The most
psychotherapy and medication management at common primary diagnoses are attention deficit
least three times a week. Building on the pro- hyperactivity disorder (ADHD; n = 38; 29%),
gram’s longstanding emphasis on the larger fam- anxiety (n = 27; 20%), ASD (n = 20; 15%), mood
ily system, there is a robust family intervention disorder (n = 26; 20%), and obsessive-­compulsive
component. Families participate in weekly fam- disorder (OCD; n = 12; 9%).
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 129

In addition to psychiatric diagnoses, the treat- targets of intervention as diagnostic clarifica-

ment team also identifies target treatment prob- tion—often spanning several weeks—unfolds.
lems to help guide intervention. The most Although inclusion criteria for ABC are broad,
common primary problems for ABC children are some children are not well served in this setting.
aggression (n = 63; 48%), suicidality (n = 17; In order to be admitted to ABC, children must
13%), nonsuicidal self-injury (n = 11; 8%), have enough verbal ability to interact in therapy,
school refusal (n = 14; 11%), and impulsivity sufficient independence to not require a 1:1 aide,
(n = 10; 8%). A small number of children have and they must be able to attend to their own daily
other primary problems (e.g., emotion dysregula- living skills with relative independence. Exclusion
tion), and the vast majority (n = 115; 87%) are criteria are shaped largely by the physical space of
experiencing multiple co-occurring primary the PHP, which is not locked, and include children
problems. with a history of elopement. In addition, children
Children and families are drawn from a broad must have no recent history of aggression with
catchment area in Southern California encom- peers outside the home. Finally, parents must
passing a population of over 10 million people in agree to actively participate in treatment. For
urban, suburban, and rural areas. Occasionally working families, this is not trivial as it involves
they come from farther away, including elsewhere daily transport to and from the program.
in the state, out of state, or internationally. The
region is highly diverse and includes families
from myriad countries and cultural, racial, and The Multidisciplinary
ethnic backgrounds. Immigrant families and those Treatment Team
with salient religious/cultural considerations are
not uncommon. As noted above, despite diversity The program is co-led by a clinical psychologist
in these domains, most families are insured and and child psychiatrist who share responsibility
present with a relatively stable set of resources. for the management of the program. The psy-
All youth are English speaking, although many chologist (Dr. Peris), who serves as Program
parents speak other languages in the home; Director, oversees all clinical programming
Spanish-speaking staff are available, as are inter- including group-based interventions and track-
preter services. Despite these accommodations, ing of clinical outcomes; she also directs the
however, rates of racial and ethnic minority research protocol. The child psychiatrist (Dr.
enrollment do not mirror those of the surrounding Schneider) serves as Medical Director and over-
community. This gap is influenced by a number of sees all medical needs of the patients, including
factors, including existing health system contracts standing and emergency medications, separate
that limit use of Medi-Cal. In addition, access health issues, and psychiatric holds. The direc-
issues arise by virtue of the program’s geographic tors share responsibility for program develop-
location on the far end of a sprawling city with ment, clinical supervision, teaching, and
limited public transportation. administration.
Given the diagnostic complexity of the aver- The treatment team comprises a full-time reg-
age child in ABC, the hallmark feature of clinical istered nurse who tracks vitals, oversees medica-
presentation is not necessarily related to symp- tion administration, and participates in clinical
toms and diagnoses. Rather, it is significant programming. The staff psychologist leads
impairments in functioning that signal potential groups, provides parent management training to
escalation to a higher level of care (like inpatient families, and conducts assessments as needed.
or residential). Often, children admitted to the The social work team leads evidence-based
program are best understood in terms of transdi- groups, collaborates with case coordinators in
agnostic domains of impairment, including diffi- family therapy, assists families with disposition
culties with impulsivity, irritability, and peer planning, and liaises with schools or, when indi-
relationships. These features become the direct cated, the Department of Child and Family
130 R. G. Martinez et al.

Services. The occupational therapist engages often focus on specific functional challenges that
children in constructive group tasks related to led to the admission (e.g., school refusal, explo-
emotion regulation and problem-solving, and sive tantrums at home). Working together, the
provides formal assessment of visual/motor family and team identify a target problem—often
development/executive function/task-based skills a broad category such as aggression or suicidal
that affect their daily functioning (e.g., following ideation—around which treatment goals are
multistep instructions, problem-solving). focused. Goals are then broken down into short
Throughout the day, two mental health practitio- and long-term objectives and anchored in mea-
ners (MHPs) manage the milieu. MHPs are surable outcomes. One common example might
trained in behavioral intervention and provide be a child presenting with a target problem of
support to group leaders and provide additional anxiety and school refusal. The long-term goals
assistance to patients who may need more may be “in the next month, patient will (a) be
focused care. ABC also has an educational con- able to verbalize a “coping plan,” (b) demonstrate
sultant to help liaise with schools to bolster sup- three to four self-soothing or coping strategies,
ports for patients upon discharge. and (c) attend >75% of all school sessions held at
Trainees from a variety of disciplines also ABC.” The short-term goals might be “in the next
rotate through the ABC PHP, including child psy- week, patient will (a) identify one physical/
chiatry, psychology, social work, and nursing. somatic symptom of anxiety, (b) practice one
Child psychiatry fellows and predoctoral psy- coping skill with their therapist or demonstrate
chology interns serve as case coordinators who one coping skill to a staff member, (c) discuss at
oversee all aspects of care for up to three primary least one situation that increases their anxiety
patients, coordinating across the multidisci- with their therapist.” As treatment becomes more
plinary team. Child psychiatry fellows are paired targeted and case conceptualizations more
with each predoctoral intern as a “medical back- refined, goals may change. For instance, if it
­up” for up to three cases. Fellows thus may carry became clear in the above example that the
up to three medication management cases in patient had primary separation anxiety, treatment
addition to their primary cases; in this role, fel- goals would become more focused on separation
lows only provide medication management and anxiety (e.g., patient will be able to tolerate being
do not deliver any psychotherapy. at home with babysitter at least one night per
Medical students and psychology externs, week).
who are still in graduate training, routinely rotate During the admissions process, members of
through the program as well. Medical students the multidisciplinary team evaluate the child
may participate in many facets of treatment, and along multiple dimensions to obtain a multifac-
may collect collateral, join and participate in eted view of the presenting problem. This
family meetings, and join the milieu; they do not includes features such as visual/motor develop-
provide individual therapy. Predoctoral psychol- ment, school, and medical history as well as rel-
ogy externs and social work trainees help with evant family, cultural, and community
milieu management, group therapy, and research, considerations. Based on these assessments, the
depending on their training goals. team creates the master treatment plan (MTP),
which integrates data and perspectives from each
discipline. This document consists of the target
Goals and Treatment Planning problem, long- and short-term goals, and
­progress toward goals. Over the course of treat-
The goals of the program are tailored to the indi- ment, the MTP is updated weekly by the team to
vidual needs of each child and family. They are reflect any progress toward goals; these changes
developed in collaboration with the child and are tracked daily in progress notes so that inter-
family at the beginning of treatment, and they ventions have direct relevance.
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 131

Typical Treatment Course dictability and structure and they begin to meet
with their case coordinator. Individual psycho-
Overview therapy in these early stages is focused on rapport
building and further assessment. As children set-
The average length of stay is 6–8 weeks. The first tle in, the focus shifts to skill building with an
week of the admission is typically devoted to emphasis on their particular treatment target.
assessment and helping children acclimate to the Psychotherapy takes a principle-based approach
milieu. Occasionally, a child with school refusal to matching techniques to the problem at hand
may spend significant time in the first week tran- (e.g., behavioral activation for depression), and
sitioning into the milieu setting. Beyond the ini- medication changes are made based on daily
tial intake, team members get to know the child observation and child, parent, and staff reports.
and family and conduct behavioral observations Parent training moves from psychoeducation to
in program alongside further formal assessment. applied skills practice with praise, differential
This happens through daily phone calls with par- attention, and limit setting. Family therapy
ents, weekly family therapy, and the many activi- explores systemic issues which may present bar-
ties staff engage in with children every day. riers to change, and it begins to identify needs
In order to help children acclimate to the following ABC treatment. As children make con-
milieu, time is devoted to helping them learn the tinued gains, the focus switches to generalization
structure and format of the day—first, that the to community settings, applied practice of new
day begins with a community meeting and check- skills outside of program, and refinement of the
­in, which provide an opportunity to set goals and disposition plan.
plan for the day ahead. They then learn about
program expectations for “ABC appropriate
behavior” and about a reward system that incen- Admission Screening
tivizes their effort in engaging in the program.
They also get a sense of a daily schedule (see Admission screening is conducted by program
Fig. 8.1 for an example) designed to promote pre- social workers. They perform an initial phone

Fig. 8.1 Sample ABC program schedule. (Note: CBT cognitive behavioral therapy, OT occupational therapy, RT rec-
reational therapy)
132 R. G. Martinez et al.

screen to collect preliminary clinical informa- designed for lay use, and easily disseminated to
tion, gauge eligibility, and determine insurance trainees who rotate through the service with con-
status. Those who meet inclusion criteria com- siderable frequency. At the same time, there are
plete further assessment with the social work many competing demands in the first week of
team, and when ready for admission, schedule a treatment, and children’s tolerance for clinical
preliminary tour. During this tour, families are interviewing vary; thus, in some cases, it is most
oriented to the physical space, the structure of the reasonable or necessary to administer the inter-
day, and program expectations. The team also view over the course of several sessions.
attempts to preview how common clinical chal- Psychiatry fellows also gather a detailed medical
lenges will be handled. For example, a child with history and conduct a physical examination; this
severe separation anxiety and school refusal may is standard practice when a child is admitted into
have difficulty transitioning away from parents a hospital setting to ensure that no medical issues
on the first day; the team may discuss the pro- are causing or amplifying the child’s clinical pre-
gram’s approach for shaping this behavior incre- sentation (Chun et al., 2016).
mentally over the first few days of the program.
Parents are coached in what to expect and how to
respond, and support is offered. Similarly, the Case Conceptualization
tour provides an opportunity for the team to dis-
cuss how unsafe behaviors will be managed in All data collected at baseline are used to develop
the program and to describe when and how the a multidisciplinary case conceptualization as part
determination for medications and/or psychiatric of treatment planning meetings. The case concep-
holds will be made. tualization is fluid, hypothesis-driven, and
changes throughout the course of treatment in
conjunction with ongoing evidence-based assess-
I nitial Assessment and Clinical ment methodology (Christon et al., 2015; Hunsley,
Interview 2015; McLeod et al., 2018) and data gathered as
part of measurement-based care (Jensen-Doss
Evidence-based assessment in the ABC PHP is et al., 2020; Youngstrom et al., 2017).
multimethod and multi-informant, meaning that
multiple reporters’ perspectives are gathered and
used in decision-making (De Los Reyes, 2011, Measurement-Based Care
2013; De Los Reyes et al., 2015). Assessment
may include gathering questionnaires, subjective Prior to 2014, the process used to track outcomes
ratings, or collateral from parents, other family in ABC was variable and inconsistently adminis-
members that live in the home, teachers, or other tered. Beginning in 2014, efforts were made to
providers. Upon first visit, children and parents begin systematically characterizing children who
complete a baseline assessment of self-report require PHP level care. This was done via the
measures and a semi-structured diagnostic inter- aforementioned admission battery, which was
view under the guidance of the case coordinator. supplemented by systematic collection of the
Baseline measures are global (e.g., sleep, distress Clinician Global Impression-Severity/
tolerance) and domain-specific (e.g., anxiety, Improvement scales administered during each
depression, irritability). These data are used to week of admission (CGI-I and CGI-S; Guy &
identify domains for more targeted assessment. Bonato, 1970). CGI scores are commonly used in
Case coordinators most commonly use the Mini-­ clinical trials research because they are pragmatic
International Neuropsychiatric Interview for to gather and interpret. They were chosen as an
Children and Adolescents (MINI-Kid; Sheehan initial step in tracking outcomes because they
et al., 1998), a semi-structured diagnostic inter- offered a uniform metric that could be applied
view. The MINI-Kid is ideal because it is brief, across a clinically diverse patient population.
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 133

Despite these advantages, the team also recog- use routine MBC to guide clinical
nized limitations of this approach. In particular, decision-making.
although it offers a global score, the CGIs do not
contain patient-specific information on progress Nomothetic assessment As noted above, a
and on their own, do little to inform treatment component of the assessment approach involves
modifications. In other words, given the simplic- patient-centered, domain-specific measurement.
ity of the rating, it is hard to know what has Once the initial assessment and case conceptual-
improved and what lags behind. In addition, this ization have been completed, the clinical team
approach does not allow for meaningfully sum- identifies one to two nomothetic, or standardized,
marized and aggregated data, further weakening measures to assess progress toward goals (See
its utility to inform decision-making. To address Table 8.1). Nomothetic measures are particularly
this concern, the team began to collect weekly helpful when comparing children’s development
data on specific target domains (e.g., depression, to same-age peers. Symptom- and impairment-­
irritability, impulsivity) and use these data to focused measures may be included.
track progress. This approach is consistent with
best practices in measurement-based care (MBC;
Connors et al., 2021; Lewis et al., 2019). In 2020, Idiographic assessment As the team has refined
the team engaged in quality improvement proj- its approach to MBC, a particular challenge has
ects to improve rates of data capture, the ABC been to find measures that adequately reflect and
program implemented a fully digital, automated capture change in the patient population.
MBC system through Qualtrics (Qualtrics, Provo, Although nomothetic measurement gives valu-
UT; Martinez et al., in prep). able information about symptom clusters, it does
In line with recommendations from the MBC not always capture change in high acuity cases.
literature, these data are used to guide individual On occasion, children have appeared to look
children’s treatment and broader changes in the worse on the SCARED or MFQ despite clear
program. At the individual case level, data are clinical gains and functional improvements.
used for regular outcome monitoring, case con- Often, this is because the scores reflect more
ceptualization, treatment planning meetings, and willingness to acknowledge and sit with difficult
weekly supervision. This may take the form of feelings and/or parents making changes to how
discussing trajectories, changes (or lack thereof),
and brainstorming for future sessions. At the pro-
Table 8.1 Nomothetic measures used in ABC PHP
grammatic level, data inform systemic changes at
ABC. For instance, the integration of the Youth Measurement #
Measure domain Item
Top Problems measure (YTP; Weisz et al., 2011)
Affective Reactivity Index Irritability 7
uncovered a significant gap in programming (ARI; Stringaris et al., 2012)
focused on decreasing aggression. Given that no Child Obsessive–Compulsive Obsessions/ 33
specific programming focused on aggression, the Impact Scale-Revised Compulsions
staff psychologist adapted the transdiagnostic (COIS-R; Piacentini et al.,
2007)
group CBT treatment to include components
Mood and Feelings Mood 34
from an evidence-based protocol for child aggres- Questionnaire (MFQ; Messer
sion (Lochman & Wells, 2003, 2004). Along et al., 1995)
these lines, data will continue being collected and Screener for Child Anxiety Anxiety 41
used to inform quality improvement projects at and Related Disorders
(SCARED; Birmaher et al.,
ABC (e.g., increasing outcome measure response
1999)
rates, number of parenting sessions). As a whole, Swanson, Nolan, and Pelham Inattention/ 26
these data—and the processes by which they are Questionnaire (SNAP; Hyperactivity
tracked—offer a valuable teaching tool for stu- Swanson, 1992; Swanson
dents from different disciplines to learn how to et al., 2001)
134 R. G. Martinez et al.

they respond to difficult behaviors. Idiographic useful marker moving forward. It is not uncom-
measures, which are individualized measure- mon for children with severe ADHD and disrup-
ments that compare a child to themselves as a tive behavior to present to ABC unmedicated
baseline, have the potential to address this short- and unable to complete even brief (<15 min)
coming in measurement (Christon et al., 2015). assessments. As such, and even with the number
While clinicians may create any number of idio- of providers working with these children,
graphic measures (e.g., number of times went to assessment in this setting can be difficult to
a social event over past week), all parents com- obtain regularly and requires significant flexibil-
plete the YTP, which is a way for parents to iden- ity and modification. For instance, staff fre-
tify their top three problems in treatment and quently engage in behavioral observations in the
rank them hierarchically. The YTP is collected as school and milieu settings through two-
a monthly outcome measurement and used as way glass. Milieu staff may also be asked to fill
additional data in the MTP. The YTP provides a out a measure of a child’s disruptive behavior, in
patient-centered way to measure progress toward addition to the parent’s report.
idiosyncratic goals and engage parents in the pro-
cess of clinical measurement.
Evidence-Based and Empirically
Informed Interventions
Other testing and referrals Other testing
includes occupational therapy assessments, such Given the complexity of ABC cases, interven-
as the Beery Visual Motor Inventory (Beery, tions tend to be delivered in a flexible and modu-
2004), and measures of adaptive functioning lar way, with a focus on “flexibility within
including the Vineland (Sparrow et al., 1984). fidelity” (Kendall et al., 2008; Kendall & Frank,
Other assessments are considered on an as-­ 2018). Martino et al. (2020) describe the flexible
needed basis, including cognitive and achieve- use of evidence-based practices in ABC, so this
ment testing, neuropsychological assessment chapter instead reviews the guiding theoretical
and/or ASD evaluation. Other referrals or consul- principles that underlay treatment at ABC.
tations include genetics and neurology.

Individual Interventions
Difficulties with assessment in this set-
ting The unfortunate reality of fast-paced PHP Cognitive and behavioral therapies Staff and
settings is that 100% data collection may be trainees come to ABC with a wide variety of
impossible to achieve. As such, the goal is to training experiences and clinical practices. In
collect as much high-quality data as possible individual treatment, providers are encouraged to
without further distressing or burdening fami- use components of traditional cognitive and
lies. The most significant challenge in this pro- behavioral therapies (e.g., anxiety exposures,
cess is protecting the integrity of the assessment cognitive restructuring), as well as third-wave
process. Some assessments need to be broken cognitive and behavioral therapies (e.g., dialecti-
up across several sittings, and there is consider- cal behavioral therapy, acceptance and commit-
able variability in what patients can tolerate. ment therapy; Coyne et al., 2011; Linehan &
Thus, deciding what and how much is feasible to Wilks, 2015). In general, the majority of ABC
assess, given the complexity of these cases, is cases engage in some combination of (a) emotion
one significant decision point. Further, deciding education, (b) coping and self-soothing skills
when to test so that results are most accurate and (e.g., relaxation, distraction), (c) exposure, (d)
valid is an issue. Children must be reasonably social skills training, and (e) safety or coping
stable in presentation so that testing provides a planning.
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 135

Relational focus The therapeutic alliance, or match because it was designed and tested in a
the (a) relational bond and (b) extent to which a small group format with a focus on skills train-
patient and therapist are on the same page about ing, social rules, and applied practice. Over the
what they are doing together and why they are years, this program has been supplemented with
doing it, has significant implications for treat- elements from other social skills protocols
ment outcomes (McLeod, 2011; Karver et al., (Laugeson & Frankel, 2011) as well as specific
2018). Therapists in the ABC program are adaptations developed by the ABC team. These
encouraged to conduct therapy in the context of include modules on hygiene and social media
the therapeutic alliance, with a strong focus on use.
relationship building, collaboration, and
engagement.
Mindfulness group Children at ABC partici-
pate in a weekly mindfulness group. The group,
Group Interventions adapted from existing DBT protocols for adoles-
cents, focuses on a skill-based approach to dis-
CBT The transdiagnostic CBT group draws on tress tolerance. Children learn about and practice
components of several evidence-based interven- behavioral coping skills as well as mindfulness.
tions to teach modules on (a) emotion education, Mindfulness groups always include an experien-
(b) helpful/unhelpful thoughts, (c) links between tial mindfulness or relaxation activity, including
thoughts, feelings, and behaviors, and (d) coping activities like yoga, guided mindfulness medita-
skills. Over the years, staff members have added tions, and breathing strategies.
to the protocol with heavy adaptation from grad-
uates of Dr. Phil Kendall’s lab at Temple (Coping
Cat; Kendall & Hedtke, 2006); Dr. Jill Ehrenreich-­ Family/Parent Interventions
May’s lab at University of Miami (Unified
Protocol; Barlow et al., 2010; Ehrenreich-May Parents are expected to participate in multiple
et al., 2009); and current treatments for aggres- interventions throughout treatment. The data sug-
sion in children (Coping Power; Lochman & gest that on average, parents attended 4.33 parent
Wells, 2003, 2004). Intervention is delivered training sessions (range = 0–10) and 5.29
through interactive games, books, media, and (range = 0–11) family sessions over their treat-
activities (e.g., feelings detective; Beidas et al., ment course.
2010, Kendall & Hedtke, 2006; Webster-Stratton,
2011), which are described in more detail in Family therapy Family therapy may include
Martino et al. 2020. multiple parents and the child, or just parents,
depending on the goal of the session. The goal of
family therapy often depends on parent insight
Social skills Virtually all children in the ABC and engagement, as well as the stage in treat-
PHP exhibit social skills deficits. Whether due to ment. Early in treatment, family therapy may
internalizing or externalizing symptoms—or a focus on continued assessment, rapport building,
combination of both—ABC patients struggle to psychoeducation, and diagnostic clarification.
make and keep friends and to use peer relation- Parents presenting to ABC are often in significant
ships as a positive source of support. The UCLA distress, so this time may also be used to provide
Friendship Program developed by Fred Frankel, a space for parents to discuss their own ­reactions/
PhD, played a central role in shaping ABC’s core interactions with their children. As treatment pro-
curriculum. Unlike the CBT program, which was gresses and the team and parents begin to accli-
borrowed from several protocols originally mate, the role of family therapy typically shifts to
developed and tested for individual psychother- discuss management of specific problems, which
apy, the Friendship Program provided a natural range in content. One example of these may be,
136 R. G. Martinez et al.

“we don’t know what to say to her when she tells Parent–child observations The ABC program
us about her obsessions.” Parents are always has a number of two-sided mirrors for observa-
given a chance to discuss any concerns or ques- tion. In some cases, parents may ask or be asked
tions from the week. Other topics include case to participate in a behavioral observation of their
conceptualization, problem-solving, safety plan- child. These observations aid in assessment and
ning, or crisis management. case conceptualization, and they can also be used
for real-time coaching and practice of new
behaviors.
Behavioral parent training (BPT) Multiple
members of the team have formal training in
BPT, including the nurse, several members of Communication About Cases
the social work team, and staff psychologist.
The goal of the ABC BPT is to reduce coercive Internal Communication
and negative patterns of parenting, while
increasing positive parenting strategies (Martino Team meetings are intentionally staggered
et al., 2020; Forgatch & Patterson, 2010. Such throughout the week to provide multiple points of
strategies are in line with established behavioral contact for the whole team. The week begins with
principles that focus on identifying and chang- treatment planning on Monday, followed by
ing patterns of reinforcement and punishment rounds on Wednesday, and group supervision on
by changing antecedents and consequences Friday. In between there are standing “huddles”
related to maladaptive behavior (Forehand et al., where the MHPs and group leaders come together
2013; Garland et al., 2008). These strategies, to discuss day-to-day clinical management
described in further detail in Martino et al. issues. When needed, there are also “mini-team
(2020), include differential attention, establish- meetings” where the providers responsible for a
ing structure and routine, limit-setting, relation- given patient (i.e., case coordinator, social
ship-building, problem-solving, and parent worker, parent trainer) gather to discuss issues of
emotion regulation. clinical concern and possible modifications to the
child’s plan. In addition, team members often ini-
Children at ABC may be aggressive with par- tiate informal consultations as they run into each
ents or siblings, which can lead to a number of other in the unit and discuss how the day is going.
deleterious outcomes, including hospitalization
and contact with law enforcement. Thus, the Moving to higher/lower levels of
other primary focus of ABC BPT is safety plan- care Occasionally, patients on ABC may exhibit
ning. Given the level of acuity, parenting sessions behaviors that are unsafe. Examples of this include,
are typically focused on specific problem behav- but are not limited to suicidal gestures, elopement,
iors (e.g., a child who tries to get out of the car on and physical aggression toward peers or staff.
the way to program), and usually results in a ABC is an unlocked unit and staff are “hands-off”
highly detailed and collaborative plan that is (i.e., staff cannot physically prevent a child from
shared with the treatment team. eloping), so in some cases it may be appropriate to
transfer a child to a setting that can offer appropri-
Mindfulness/support group Parent mindful- ate safety and containment. ABC’s protocol in
ness groups are run weekly by a social worker or these situations is that the child and situation are
trainee. The focus of these groups is to provide a immediately evaluated by an MD on the unit. If it
space for parents to learn and incorporate new is determined that the child’s ­behavior is markedly
mindfulness skills and gain support from other unsafe and there is concern for the physical well-
parents in the program. being of that child or others on the unit, the patient
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 137

is placed on an involuntary hold and transferred ming. For children with a confirmed ASD diag-
safely to the emergency department for consider- nosis, the team may refer to genetic testing
ation of inpatient hospitalization. (Barton et al., 2018; Freitag, 2007; Reddy, 2005).
For children with suspected ASD, the team will
Sometimes, outside of emergency circum- typically refer for developmental testing to con-
stances described above, it is determined that an firm or rule out an ASD diagnosis. It is not
ABC patient is best served by referral to a higher uncommon for children in acute levels of care to
level of care such as inpatient or residential. In have speech and language difficulties, so the
those circumstances, appropriate referrals are team will often refer to an outside speech and
given. Alternatively, as patients and their families language assessor (Pearce et al., 2014). Other
make progress in ABC toward treatment goals, referrals focus on areas of growth that are not
the treatment team assists in planning for step- primary domains of impairment, including aca-
ping down to lower levels of care—most com- demic coaching and social skills curricula. Other
monly standard outpatient practice including referrals focus on services that may support ABC
medication management, individual therapy, and families, including respite care, food and nutri-
continued family interventions. tion services, and other county social services.

External Communication Program Development

and Implementation
A routine part of care involves communicating
and collaborating with outside providers, includ- As discussed earlier, the program has a long
ing psychiatrists, psychologists, and school sys- and distinguished history of providing multi-
tems. This process begins upon admission as the disciplinary care. Although the program is
team reaches out to previous providers to (a) small relative to others, the larger health system
obtain information on the case and (b) coordinate has demonstrated commitment to it, both as a
with the school to understand the child’s aca- vital training ground for students and a much-
demic needs and history. It continues throughout needed service for children who would other-
the course of the admission as community pro- wise need to be hospitalized.
viders are kept apprised of progress and updates
related to the child’s discharge. Team members
may provide results from occupational therapy or Cost and Coverage
psychological testing, with tailored recommen-
dations for managing challenging behaviors, Program administration and staff have priori-
understanding neurodiversity, or individualizing tized establishing productive relationships with
the education plan. Team members often join insurance providers who recognize that PHP
individualized education plan (IEP) meetings to care offers a cost-effective strategy for helping
assist in this process. There may be additional acutely ill children, and the administrative sup-
medical consultation as needed for the manage- port team continues to help secure lengths of
ment of pre-existing conditions and/or medica- stay that stretch well beyond those of many
tion side effects. As discharge from the program other programs.
approaches, this process intensifies and the team
coordinates across settings to ensure a smooth
hand-off, either to the previous referring provid- Staffing
ers or, when necessary, to new providers.
A key inflection point in ABC program history
Referrals The ABC program refers to a wide came with the transition from its original inpa-
range of assessments and therapeutic program- tient format to its current PHP structure. Beyond
138 R. G. Martinez et al.

the structural change of sending children home at Including Stakeholders

night and working with parents to develop the and Navigating Institutional
skills to keep them safe, this shift brought signifi- Expectations and Limitations
cant changes to staffing. In particular, as an inpa-
tient service, ABC had four to five nurses and a ABC, and PHP programs in general, are situated
single social worker who focused primarily on in a unique space on the continuum of psychiatric
family therapy and disposition planning. This care within the larger health system, existing
structure remained the same in its early days as a between the inpatient and outpatient levels of
PHP. However, the new format did not have the care. The overarching goal is thus to best meet
same intensive nursing demands as a 24-h inpa- the needs of patients who fall between these lev-
tient service, and over time, it transitioned to the els, whose acuity may not meet criteria for inpa-
current structure of four social workers and one tient hospitalization but be too complex for
nurse. This shift allows for significant support for traditional outpatient settings. As such, stake-
clinical programming throughout the day as holders are both internal (hospital administration,
social workers engage in disposition planning providers in higher levels of the institution’s care
and administer core interventions. Indeed, their model such as inpatient, providers in outpatient
role is so robust that the program often uses dis- clinical settings) and external (community mem-
cretionary funds to send social workers to confer- bers, schools, outpatient community providers).
ences such as the Association for Behavioral and ABC team members are routinely invited to give
Cognitive Therapies, and to specialized trainings talks in the community to parent groups, schools,
in Parent-Child Interaction Training (Eyberg & and advocacy groups to build stronger communi-
Boggs, 1998; McNeil & Hembree-Kigin, 2010). cation and relationships with these key
In Fall of 2020, all social workers participated in stakeholders.
a CBT skills training led by master clinician and
trainer Dr. Jill Ehrenreich-May.
 hat Does Clinical Change Look
W
Like at ABC?
Family Strategies
Given the complexity of these cases, the clinical
Other program developments have centered on change reflected by children in ABC can be dif-
strengthening the family intervention compo- ficult to quantify with symptom- and domain-­
nent. Recognizing that families may need help specific measures. Children entering the ABC
applying parent training skills in their daily lives, program may not see significant symptom reduc-
the team engages in daily check-ins at the start tion, even in cases where the team and family
and close of the program day. These check-ins, note significant improvements in impairment.
typically done with the case coordinator, allow This is demonstrated here with two commonly
for an update on the prior evening, a chance to used outcome metrics. In terms of clinical sever-
review home notes (completed as part of daily ity, the average CGI-S upon admission was 6.03
homework), and an opportunity to prompt and (SD = 0.39), while the average CGI-S upon dis-
refine skill use. Similarly, as families head home charge was 5.57 (SD = 0.61). A paired-samples
for the day, the team can instill support and t-test comparing the admission-discharge
encouragement and remind them of specific ­standard deviations of the CGI-S demonstrates
times to practice specific skills. These daily inter- that this difference (0.45, 95% CI [0.34, 0.56]) is
actions have highlighted the emotional toll of statistically significant t(127) = 8.19, p < 0.001.
psychiatric illness on families, in turn prompting The effect size for this difference was d = 0.52, a
further program development related to the par- medium effect (Lakens, 2013). The average
ent support group and a separate mindfulness CGI-I was 2.68 (SD = 0.76), which corresponds
group. to a mild or minimal improvement in symptom
8 The UCLA Achievement, Behavior, Cognition (ABC) Program 139

severity. A total of n = 43 children stepped up to focus on fostering this environment of support

a higher level of care (either residential or inpa- and respect.
tient), while n = 90 children stepped down to a Equally important is a commitment to self-­
lower level of care (intensive outpatient, tradi- assessment (at both the individual and program
tional outpatient). levels) and growth mindset. Reviewing data gath-
ered at ABC—be it on patient satisfaction or
patient outcomes—and considering program
Lessons Learned and Next Steps improvements is an iterative and ongoing pro-
cess. A similar process is used for reviewing the
Several factors contribute to the success of the clinical approach and its alignment with current
ABC PHP, including its robust family compo- science and practice guidelines. Accordingly, the
nent, evidence-based focus, and multidisciplinary program anticipates revisiting its curriculum in
team. These components would have limited key content areas (e.g., mindfulness, social skills)
value, however, were it not for a supportive and in the interval to come, with an eye toward maxi-
collaborative team culture that is foundational to mizing the benefits of the services. As data from
this work. Considerable effort goes into preserv- ongoing MBC efforts are analyzed, further inno-
ing healthy team dynamics, monitoring for burn- vations will follow.
out, and fostering open and candid
communication. Beyond creating several oppor-
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 Center for Autism
and Developmental Disabilities 9
Partial Hospitalization Program

Maria Regan and Giulia Righi

Program Overview Exclusion criteria for the program include

family members’ inability to provide transporta-
The Center for Autism and Developmental tion and/or actively participate in treatment, fre-
Disabilities Partial Hospitalization Program quency, or intensity of unsafe behaviors
(CADD PHP) is a family-based day treatment warranting a higher level of care, and
program for children and adolescents (ages 5–18) children/adolescents refusing to participate.
diagnosed with autism spectrum disorder (ASD)
or other developmental disabilities, with co-­
existing emotional or behavioral disorders.  rogram Structure
P
For admission to CADD PHP, children and
adolescents must meet general partial hospital Participants attend an average of 4–6 weeks,
criteria, which include the following: Monday through Friday, for six hours per day.
Participants receive individualized treatment,
• The child or adolescent manifests significant including behavioral assessment and treatment,
or profound impairment in daily functioning medication evaluation and monitoring, individual
due to psychiatric and/or behavioral concerns therapy, family therapy, and group therapy. The
in addition to their developmental disabilities. structured daily schedule includes a morning
• The severity of presenting symptoms indicates check-in/consultation with caregivers at drop-off,
that the child or adolescent (and his or her a one-hour academic period where patients
family) is unable to be treated safely or ade- receive support from a special education teacher
quately in a less intensive outpatient setting. who coordinates with their home schools, skills
• The child or adolescent is judged to be in need groups run by direct care staff (behavioral health
of daily monitoring (Monday through Friday), specialists), groups run by masters’ level clini-
support, and ongoing therapeutic intervention cian or clinical psychologist, lunch, and supple-
to promote stabilization. mental activities such as yoga, dance, and nursing
education groups. The day ends with a check-out/
consultation with caregivers prior to dismissal.

M. Regan (*) · G. Righi

Emma Pendleton Bradley Hospital,
East Providence, RI, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 143
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_9
144 M. Regan and G. Righi

Patient Presentation or speech–language pathologist) as recom-

mended by the treatment team.
Participants’ primary presenting concerns at Patients are discharged to a lower level of care
admission include emotional and behavioral dys- when the treatment team, including parents/care-
regulation, depression, anxiety, aggression, and givers, assesses that the patient’s condition (e.g.,
self-injurious behaviors. Participants are referred functioning and clinical presentation) has stabi-
by schools, outpatient providers, parents/caregiv- lized to a degree that the patient can return to regu-
ers, and pediatricians. Referrals are typically ini- lar daily expectations, such as school, and continue
tiated following attempts to address presenting to participate in treatment with outpatient and/or
concerns at lower levels of care (outpatient, home-based treatment providers. At times, patients
home-based treatment). Patients are often present with escalating safety issues related to
referred due to safety concerns related to behav- aggressive, self-harming, and impulsive behaviors
ioral dysregulation. Patients also present with or are determined to need medication adjustments
functional impairment related to their psychiatric requiring 24-hour monitoring. When this occurs,
symptoms, for example, regression in self-care/ the team works with families to initiate transfer to
hygiene or difficulty getting to or engaging in a higher level of care.
school or other activities outside of the home due
to depression or anxiety. Parents and family
members have often been significantly impacted Program Development
both by safety concerns and stress related to and Implementation
behaviors presenting at home, as well as by
impacts on family functioning. Caregivers’ abil- The creation of the CADD PHP was spurred by
ity to work outside of the home, maintain social the growing need for specialty mental health ser-
connections with friends and family, and provide vices for individuals with developmental disabili-
for the needs of their other children are all ties. There were considerable gaps in service
affected by dealing with the demands of having a provision, which included:
child with ASD who is struggling with additional
behavioral and emotional difficulties. • General child and adolescent programs are not
well suited for this population for the follow-
ing reasons:
Program Goals and Expectations –– Heavy reliance on verbal instruction
–– Staff are not usually adequately trained to
The primary goal of the CADD PHP is to help work with this population
children and adolescents maintain safety at home –– Limited attention to environmental prac-
while they and their families work on clinical and tices that are important to consider for this
functional issues that could otherwise lead to population
hospitalization or residential treatment. –– Limited access to speech and language ser-
Expectations for participation in treatment are vices and occupational therapy for support
established at admission and include daily atten- –– Clinical staff may not be as familiar with
dance for patients, commitment for parents/care- healthcare needs of families for after care
givers to provide transportation, participate in
daily consultations with staff at check-in and The CADD PHP provides the necessary sup-
check-out, complete written documentation ports and specialized programming to treat chil-
daily, participate in weekly family meetings with dren and adolescents with autism spectrum
the primary clinician, participate in program disorder and other developmental disabilities.
observations as well as parent training in behav- Programming is modified as needed based on
ioral interventions, and participate in consulta- patients’ cognitive and communication needs. For
tion with other staff (e.g., occupational therapist example, visual supports are provided to support
9 Center for Autism and Developmental Disabilities Partial Hospitalization Program 145

verbal instruction and are modified additionally as addition to overseeing the collection of behav-
needed through consultation with the speech–lan- ioral data. OT and SLP run therapeutic groups
guage pathologist. The environment is also modi- with patients in addition to completing individual
fied to minimize patient exposure to items that consults and then sharing recommendations with
may be unsafe or overly stimulating. Alternative the team, parents/caregivers, and schools or other
spaces are available to patients who may require a outside providers. The program nurse completes
quiet area and, in consultation with the occupa- an initial nursing assessment, addresses any gen-
tional therapist, a variety of sensory tools are eral health concerns, administers medication,
available such as weighted lap pad, weighted provides liaison between families and the psy-
blanket, fidgets, noise-canceling headphones, and chiatrist regarding day-to-day issues that may
a sensory room. Direct care staff receive training come up related to medication, and runs nursing
and education through in-­services provided by education groups. The behavioral health special-
clinical staff and ongoing support/consultation ists (BHS) are bachelors’ level direct care provid-
through twice weekly team meetings with the full ers that provide care and supervision for each
team to review each patient’s treatment plan and patient throughout the day. Additionally, they
progress and make modifications as needed. track behavioral data, provide consultation to
In addition to the concerns regarding meeting families daily to help to coordinate approaches
this population’s needs in less specialized pro- across home and program settings, provide train-
grams, the hospital’s Center for Autism and ing and feedback to parents, school personnel,
Developmental Disabilities inpatient unit had home-based staff and extended family members
been consistently maintaining a lengthy waiting as needed, and ensure the consistent implementa-
list and there was a clear need for additional ser- tion of programming as determined by the team.
vices to divert children and adolescents, when Team meetings are held a minimum of twice
possible, from inpatient care as well as for an weekly. These include a review of each patient’s
interim level of care for those who may require treatment plan, data, progress, and necessary
more intensive treatment as they transition home modifications to treatment for all disciplines. The
following an inpatient admission. team meeting allows the team to discuss progress
The CADD program was a result of a team towards treatment goals and to coordinate or
effort with clinicians from various disciplines modify programming based on how the patient is
and with experiences across varying levels of responding. It includes opportunities for all team
care. A multidisciplinary treatment team was members to share their observations and to rec-
formed, including psychology, psychiatry, clini- ommend modifications to the plan. In addition to
cal social workers/counselors, board-certified observations, specific data is collected on fre-
behavior analyst (BCBA), nursing, occupational quency and duration of behaviors (for example
therapist (OT), speech–language pathologist aggression, self-injurious behavior, dysregulated
(SLP), and bachelors level direct care staff. A outbursts). This data collection provides objec-
psychologist or masters’ level clinician (LICSW, tive measures of progress toward many treatment
LMHC) serves as the primary clinician for each goals and helps to guide recommendations
patient and provides family therapy, individual regarding medication and behavioral
therapy, and case management. The attending interventions.
child psychiatrist provides medication manage-
ment and coordinates care with outpatient medi-
cation providers, in addition to participating as Referral Sources
necessary in family meetings. The BCBA com-
pletes an assessment to determine the functions One of the challenges has been balancing the
of the patient’s behaviors, develops a behavior needs from multiple referral sources, including
intervention plan, and provides parent and staff the hospital’s emergency services department
training in the implementation of the plan, in seeking to divert patients from inpatient care, the
146 M. Regan and G. Righi

inpatient units referring patients requiring ongo- Day-to-Day Programming

ing intensive treatment as they transition from
inpatient care, and an extensive waiting list of CADD PHP follows a structured daily schedule,
community referrals from families, schools, and including an hour of academics, provided by the
outpatient providers. patient’s home school and supported by a special
education tutor who is present in the program,
each morning. Additionally, patients participate
Billing, Reimbursement, in several daily groups which include occupa-
and Insurance tional therapy groups, co-taught occupational
therapy and speech–language groups, social
The program accepts funding through commercial skills groups, art therapy, music therapy, nursing
insurance and through Medicaid. Contracts are set education, and groups facilitated by masters’ and
up with payors and the hospital’s utilization review doctoral level clinicians which are focused on
department coordinates obtaining authorizations emotion regulation skills. Clinical groups focus
and completing concurrent reviews. on topics such as identifying emotions and rating
their intensity and identifying and practicing
strategies for coping with emotions (e.g., taking a
Training break, distraction, checking in with a trusted
adult, physical activity, progressive muscle relax-
The program also serves as a training rotation ation). Additionally, patients receive family ther-
for a variety of disciplines. Psychiatry fellows apy, provided by the primary clinician, a
complete rotations under the supervision of the minimum of once weekly. Primary issues
attending child psychiatrist. Psychiatry trainees addressed within family therapy include working
have the opportunity to follow patients for med- on implementing behavioral treatment recom-
ication management, meet with families to mendations, such as developing a predictable
review their impressions and medication recom- routine, providing clear and consistent expecta-
mendations, obtain consent for medication tions, and providing consistent responses when
changes, and present to the team regarding their behaviors occur. Often, families need support and
formulation and treatment. Training rotations education to improve consistency among care-
are also available for psychology post-doctoral givers as well. Families participate in establish-
fellows, under the supervision of a clinical psy- ing goals for family treatment, which may include
chologist. In addition to the educational and addressing the impacts of stress on family rela-
research opportunities offered by the training tionships, dealing with feelings of grief and guilt
program through the hospital’s affiliation with that are often experienced by parents of children
the Warren Alpert Medical School of Brown with ASD, and working on improving communi-
University, post-­doctoral fellows are assigned cation among family members. Patients who
cases within the program, providing individual have the cognitive and verbal ability to partici-
and family therapy as well as running therapeu- pate, with visual supports as needed, receive indi-
tic groups and participating in the multidisci- vidual therapy one to two times weekly in
plinary team. Additionally, the program provides addition to behavioral assessment and treatment.
training to MSW interns, nursing students, and Goals for individual therapy include working on
practicum students working toward a master’s identifying emotions, triggers, and coping skills.
degree in Applied Behavioral Analysis. Finally, patients are assessed by a child psychia-
trist who may provide medication evaluation and
9 Center for Autism and Developmental Disabilities Partial Hospitalization Program 147

monitoring when appropriate and with parental the skills to meet their needs using more adap-
consent. tive ways.
The daily schedule provides opportunities for • Effective interventions are based on a deep
patients to be observed across a wide variety of understanding of the individual and the con-
activities, including academics/highly structured text and function of the problem behavior.
seated activities, structured groups requiring peer
interactions, less structured leisure and move- The CADD PHP provides a family-based
ment activities, and transitions between various treatment model, with a strong emphasis on par-
types of activities as well as physical transitions. ents/caregivers active involvement in treatment.
The schedule also includes opportunities for Patients are assigned a primary clinician
patients to earn reinforcers or “cash-ins” for par- (Licensed Independent Clinical Social Worker/
ticipation in scheduled activities while maintain- LICSW, Licensed Mental Health Counselor/
ing positive behaviors. The first cash-in is earned LMHC, Clinical Psychologist/PhD) who pro-
for a successful morning routine and transition vides individual and family therapy, consultation/
into program, as reported by parents/caregivers. coordination with schools, and case manage-
Additionally, patients’ interactions with parents ment. Patients are also assigned a primary direct
and family members are observed through the care staff (Behavioral Health Specialist; BHS)
check-in/check-out process each day as well as who, while trained and familiar with all of the
through parent observations that take place within patients, assumes primary responsibility for the
the program milieu. daily consultations with parents/caregivers, data
collection, and ensuring treatment plan recom-
Sample Daily Schedule mendations are communicated and consistently
8:00 am: Arrival, check-ins, cash-in implemented within the therapeutic milieu.
8:30 am: Academics
9:30 am: Snack, morning meeting
10:00 am: Sensory group Use of Evidence-Based
10:45 am: Emotion Regulation Group and Empirically Informed
11:30 am: Cash-in Assessment
12:00 pm: Lunch
12:45 pm: Music Therapy Due to the structure of the program and billing
1:30 pm: cash-in, check-outs challenges, the program does not include a for-
mal assessment service. Nevertheless, various
types of assessments are integrated in the service
Theoretical Framework on a case-by-case basis, depending on the pre-
senting problems and diagnostic questions that
The CADD PHP program is broadly based on arise during the early stages of treatment. These
positive behavior support (PBS; Reid & Parsons, assessments are focused on two primary issues:
2007). PBS posits the following: (1) assessing for the presence of ASD, and (2)
assessing for psychiatric co-morbidities.
• Problem behaviors are related to the context in The assessment of ASD was integrated within
which they take place and are triggered and the service in order to serve patients for whom
maintained by something in an individual’s establishing the presence of this diagnosis was an
environment and not their disability. important piece of the referral question. This pro-
• Problem behaviors serve a function and allow cess involves several steps as to match suggested
individuals to meet their needs when they lack guidelines for best practices (Huerta & Lord,
148 M. Regan and G. Righi

2012). These steps include an interview with lack of measures developed specifically for chil-
caregivers, with a particular emphasis on gather- dren and adolescents with developmental dis-
ing medical and developmental histories, as well abilities, we rely on well-validated pediatric
as current behaviors. Parents may also be given measures including the Vanderbilt ADHD
standardized symptom measures, such as the Diagnostic Rating Scale (VADRS; Wolraich
Social Communication Questionnaire (SCQ; et al., 2003), the Screen for Child Anxiety Related
Rutter et al., 2003) and/or the Social Emotional Disorders (SCARED; Birmaher et al.,
Responsiveness Scale, 2nd Edition (SRS-2; 1999) for anxiety spectrum disorders, the Beck
Constantino & Gruber, 2012). Direct observation Depression Inventory for Youth for depressive
by expert clinicians plays a significant role as symptoms (Beck et al., 2005), and the Children’s
part of this assessment and is conducted in the Yale-Brown Obsessive Compulsive Scale
program milieu under different circumstances (CY-BOCS; Scahill et al., 1997) or the ASD-­
and sets of expectations (e.g., both during periods adapted version of the CY-BOCS (Scahill et al.,
of downtime and structured activities), in order to 2014) for obsessive-compulsive symptoms. After
evaluate various types of behaviors. In addition, all interviews and assessment measures are com-
patients are evaluated using the Autism pleted and reviewed, the diagnostic impression is
Diagnostic Observation Schedule, 2nd Edition formulated as a team.
(ADOS-2; Lord et al., 2012). The ADOS-2 is
administered by a clinician (usually a psycholo-
gist) who had been trained in the administration Use of Evidence-Based
and scoring of the instrument. In addition, the and Empirically Informed
program speech and language pathologist and Interventions
occupational therapist conduct brief evaluations
as well, to better evaluate strengths and needs in The National Clearinghouse on Autism Evidence
their domains of expertise. At the end of the and Practice (NCAEP) released a recent report
assessment process, the treatment team reviews identifying 28 Evidence-Based Practices (EBP;
all available data and provides feedback to the Steinbrenner et al., 2020) in the treatment of chil-
family. In some cases, if specific documentation dren, youth, and young adults with autism. Many
is needed by the family (e.g., for service eligibil- of these EBPs are used within the CADD PHP
ity), a brief report would be compiled by the pro- treatment model including social skills training,
gram psychologist. functional behavioral assessment, differential
The assessment of each patient’s psychiatric reinforcement, prompting, antecedent-based
presentation is an essential component of the ser- interventions, extinction, visual supports, and
vices provided in the program and apply to the parent-implemented intervention.
vast majority of patients. The assessment of psy- Patients in the CADD PHP receive social
chiatric co-morbidities in the context of develop- skills training through daily groups. Skills groups
mental disabilities poses significant challenges as topics are shared with parents at the end of each
the patients’ cognitive and communication chal- day so they are aware of what their child is work-
lenges can affect their clinical presentation. In ing on in program and can reinforce skills at
addition, few standardized measures of psychiat- home. Resources used to provide social skills
ric symptoms have been adapted to this patient training include Skillstreaming (McGinnis &
population (Ameis & Szatmari, 2015). Our pro- Simpson, 2017) and The Social Compass
cess includes several steps: (1) information from Curriculum (Boyd et al., 2013). Skills that are
caregivers, including both in the form of a clini- covered include relationship/communication
cal interview and standardized measures, (2) skills, social comprehension, problem-solving,
information from the patient when possible, and expressing feelings. Skills are taught through
including a clinical interview and self-report a combination of modeling, role-playing, and
measures, and (3) direct observations. Given the providing feedback.
9 Center for Autism and Developmental Disabilities Partial Hospitalization Program 149

Upon admission, a Functional Behavioral attempts to engage with staff and, when staff
Assessment (FBA) is completed by a Board-­ withheld attention, behaviors would become
Certified Behavior Analyst. This assessment more prevalent. Based on this assessment, atten-
includes the QABF (Questions About Behavioral tion, escape, and access to tangibles were
Function: a behavioral checklist for functional hypothesized to be the functions of Simon’s
assessment of aberrant behavior), direct observa- behaviors.
tions and ABC (antecedents, behaviors, conse- A behavior intervention plan was developed
quences) recording, and indirect observations that included the following basic components:
that include interviews with family and with
direct care staff. Based on the outcome of the 1. Staff and caregivers were advised to give
FBA, a behavior intervention plan is developed directions and set limits/expectations in a
using differential reinforcement (reinforcing calm and neutral tone and to be certain to
other behaviors incompatible with the target have Simon’s attention prior to giving
behavior), prompting (verbal, gestural, visual, directions.
physical prompts), antecedent-based interven- 2. A prompting plan was put in place that
tions (modifying the environment or activity to included giving the initial direction or setting
reduce target behaviors) and extinction (with- a limit, waiting 5 seconds for him to respond,
drawing the positive reinforcer that maintains a then prompting him and waiting 5 seconds
target behavior). Baseline data for target again before providing a second prompt.
­behaviors is obtained and data collection contin- 3. Simon was noted to respond to a predictable
ues throughout the implementation of a behavior and structured routine and a visual schedule
intervention plan. Visual supports are incorpo- was developed to help prepare him for.
rated within antecedent-based strategies (e.g., (a) Transitions to and from non-preferred and
schedules, visual prompts) and reinforcement preferred activities.
plans. The following is a case example that briefly (b) Changes in routine, whether planned or
illustrates this process. unplanned.
(c) Accessing preferred activities (items or
situations).
Case Example (d) Non-preferred activities that he needs to
complete or participate in before access-
Simon is an 8-year-old male referred for con- ing preferred items.
cerns regarding escalating dysregulated behav- 4. Simon’s schedule was tied into a reinforce-
iors including screaming/yelling, aggression/ ment plan with a self-monitoring contract. In
threats, elopement from the area, suicidal state- addition to completing the routine expecta-
ments, and homicidal statements. Assessment tions of the contract based on the schedule,
was completed through staff observations, inter- Simon participated in identifying behavioral
view with parent and completion of the goals which included:
QABF. Across home and program settings it (a) Being respectful/using kind words.
was noted that transitions from preferred to non-­ (b) Listening/following directions.
preferred activities frequently resulted in behav- (c) Being safe.
iors, as well as adults setting non-preferred 5. Simon identified 15-minutes of time on a tab-
demands or setting limits in terms of what he let as his reinforcer for completing routine
could access. In program, staff reported that expectations while meeting behavioral expec-
Simon, when becoming dysregulated, would tations. Through the program he was able to
threaten to harm others or himself, tease/pro- earn the reinforcer each time he successfully
voke peers and refuse to follow directions. completed four blocks of his schedule, while
During these episodes he was noted to make also meeting behavioral expectations.
150 M. Regan and G. Righi

Additional guidelines for staff included: 7. Simon should be provided with sensory sup-
ports, as recommended by OT. These strate-
1. When Simon engages in target behaviors, gies should be used before he escalates, as we
remain neutral and calm and provide remind- do not want to inadvertently reinforce his
ers regarding expectations and what he is problematic behaviors by providing him with
working on earning (time on the tablet). OT sensory strategies in response to negative
2. When prompting him, focus on the desired behaviors.
behaviors vs. the behaviors targeted for reduc- 8. Simon should be given an opportunity to pre-
tion. For example, say “remember you’re view scheduled expectations and transitions.
working on being safe” rather than “stop As you are reviewing the schedule with him,
hitting.” engage him in the process: “Simon, can you
3. This program was developed to focus on tell me what is next on your schedule?”
Simon’s positive, prosocial behavior. He
should never lose or not earn access to a rein- Simon’s parents completed observations
forcer; rather he can earn access to his rein- within the CADD PHP milieu and participated in
forcer whenever he completes four developing a self-monitoring reinforcement plan
expectations on his schedule. If Simon does modeled on the one used in the program and
not meet behavioral expectations while work- modified for use at home. Through the consistent
ing on one of his scheduled activities, when he approach across settings, in combination with
is calm his schedule should be adjusted to add medication adjustments which were made during
a fourth activity so he can resume working Simon’s partial hospitalization, he made consis-
towards earning a reinforcer. tent progress and was discharged with signifi-
4. Be particularly aware of times when Simon is cantly reduced rates of target behaviors.
not engaging in the target behaviors and rein-
force whatever “other” behavior is occurring
with praise and attention. Appropriate “other” Refining and Generalizing
behavior should be reinforced as frequently as Interventions
possible with praise and attention.
5. If Simon starts to engage in target behaviors, Following the implementation of a behavior
DO NOT provide him with a lot of attention to intervention plan, the effectiveness of the plan is
the problematic behavior. Simply remind him reviewed through ongoing data collection and
what he needs to do (schedule) and remind program staff observations. When the plan is
him of strategies he can use to help self-­ found to be effective, based on data collection
manage (i.e., take a break, breathing, and staff observations, parents/caregivers receive
walking.). training, which most often includes in vivo train-
6. Simon should be provided with opportunities ing within the program milieu, and plans are
to use his coping strategies, and this includes modified as necessary to be implemented at
accessing breaks or a physical space to self-­ home. In order to lay the groundwork for parent
manage. Any appropriate request to take space training in behavioral interventions, within the
or take a break should be granted. Breaks are first 2 weeks of treatment, each family partici-
time limited to 5 min. The goal is to reinforce pates in a multifamily group run by the behav-
appropriate requests to escape without inad- ioral analyst and supported by a clinician. The
vertently reinforcing his need to entirely group provides an overview of the ABC (anteced-
escape from non-preferred expectations. Keep ents, behaviors, consequences) model, anteced-
in mind that Simon may not consistently initi- ent strategies, and consequence strategies, using
ate a request to take a break. Staff should pro- materials from the RUBI Parent Training for
vide him with a reminder to take a break to Disruptive Behaviors Manual (Bearss et al.,
maintain safe behavior. 2015). The ABC model provides a framework for
9 Center for Autism and Developmental Disabilities Partial Hospitalization Program 151

understanding how antecedents and conse- includes an assessment of cultural or religious

quences that occur around a behavior may result beliefs and how they may impact treatment.
in increasing or decreasing that behavior. There are situations in which parents’ cultural
In addition to initial training with the behavior beliefs and experiences related to discipline or
analyst, ongoing training and supportive family expectations regarding children’s behavior are
therapy with their primary clinician, and in vivo not consistent with the program’s model of posi-
training within the program milieu, families tive reinforcement-based strategies. For example,
receive consultation on day-to-day questions and parents may have a cultural background that
issues that may arise during their daily check-ins includes the use of physical forms of discipline
and check-outs with their primary BHS. Parents and may already have been involved with child
find these consultations very helpful in address- protective services as a result. In these situations,
ing questions regarding the implementation of parents often need greater education regarding
recommended behavioral interventions at home. their child’s behavioral presentation and how it
For example, parents may want to review an inci- may be impacted by their cognitive and language
dent that occurred the evening before and ask for delays. Parents also are provided support in
feedback regarding how they responded and any understanding how to teach their child to learn
recommendations for the future. Staff also pro- more adaptive behaviors through reinforcement
vide details about what the child worked on and modeling.
­during the program day and may set a goal for
that evening with the child and parent. The
attending psychiatrist is also active in family Collaborations and Generalizing
therapy sessions, supporting psychoeducation for Treatment Gains
parents regarding psychiatric symptoms and
treatment as well as reviewing medication rec- As previously stated, intensive family involve-
ommendations and assessing response across set- ment in treatment serves a primary role in gener-
tings as medication adjustments are in progress. alizing treatment gains. In addition to parents/
This model of intensive family involvement in primary caregivers, extended family members are
treatment has been crucial to maximizing treat- often included in treatment, particularly when
ment gains. they provide some direct care for the child. For
separated or divorced parents, a focus of family
treatment is often working with both parents on
Culturally Competent Treatment co-parenting and increasing consistency in terms
of behavioral approaches, expectations, and lim-
The program, the hospital, and the larger health- its across both parents’ homes.
care organization has measures in place to The CADD PHP primary clinician also col-
address concerns regarding patient needs related laborates extensively with the child’s school.
to diversity in terms of race, ethnicity, sexual This collaboration includes obtaining informa-
orientation/gender identity and socioeconomic tion, with parental consent, about the child’s pre-
status. These include staff training regarding sentation at school prior to admission, concerns
issues related to diversity and a diversity commit- noted by the school team, and the behavioral and
tee that works on identifying and addressing con- social-emotional supports that the child was
cerns. For example, they have initiated changes receiving at school. Frequent concerns expressed
to the dietary program to include more diverse by schools include non-compliance with aca-
food choices and obtaining skincare and haircare demic expectations, school refusal, disruptive or
products to meet the diverse needs of patients. unsafe behaviors, and challenging peer interac-
Additionally, there is a committee addressing the tions. Following the child’s assessment and treat-
promotion of a more diverse workforce. ment there is a meeting with the school team to
Upon admission, a psychosocial assessment is provide an overview of the patient’s treatment,
completed by the primary clinician, which progress, and recommendations, if applicable,
152 M. Regan and G. Righi

for the school setting. Recommendations often step by step and they are written within the per-
include providing the child with increased sup- son’s comprehension level, including pictures
ports, such as staff support for transitions within when needed to support comprehension (see
the school or other times of day that may be par- Fig. 9.1).
ticularly challenging, visual supports, behavioral CADD PHP clinicians also collaborate with
reinforcement plans, sensory breaks, social skills other providers involved in the patient’s care. The
groups, or connecting the child with a peer men- attending psychiatrist establishes contact with the
tor. Finally, a transition plan is developed that outpatient attending medication provider shortly
varies widely depending upon the individual after admission to obtain information regarding
child/adolescent’s needs and the level of support medication history and symptoms that have been
requested by the school and family. In addition to targeted previously. Additional communication
meetings to discuss findings and needs, transi- takes place as needed and a written summary is
tions may include school staff observing the provided at discharge. Outpatient clinicians who
patient in the CADD PHP or CADD PHP staff were treating a child prior to CADD PHP admis-
accompanying the patient to one or two transition sion are able to provide a summary of their clini-
visits to the school. Often, transition plans also cal formulation as well as the patient and family’s
include the development of social stories to pre- response to past treatment.
pare a patient for return to school, transition to a Many patients in the CADD PHP require
new school setting, return to riding the bus, or ongoing intensive behavioral and family inter-
more general social stories, such as dealing with vention upon discharge, which is often best pro-
changes/transitions, or strategies to use when vided through home-based therapeutic services,
feeling anxious, angry, or frustrated. Social sto- which generally include a clinician and a direct
ries present social information to people with care provider. Often, patients and families require
ASD in a format that is clear and easily under- support in the home to help generalize skills
stood (Gray & Garand, 1993). They may describe learned within program. Additionally, as patients
a setting, an activity, or a behavioral expectation transition back to school or other situations that

Fig. 9.1 Sample social

story
9 Center for Autism and Developmental Disabilities Partial Hospitalization Program 153

may be stressful, ongoing support is needed. or skill is recorded from the perspective of the
Collaboration with home-based treatment pro- learner (Franzone & Collet-Klingenberg, 2008).
viders, whether they were existing providers This clinical research project will include data
prior to CADD PHP admission, or established as collection, staff training, fidelity checks, and
a follow-up treatment provider, is essential to evaluation of outcomes in a single-subject design.
maximizing potential for generalization of gains
for both the child/adolescent and the parent/care-
giver. Sharing specifics of the treatment plan,  essons Learned, Resources,
L
including behavioral interventions, visual and and Next Steps
other communication supports, sensory strategies
recommended by the occupational therapist, and Five years after opening CADD PHP, we are able
schedules/reinforcement plans developed in the to identify the primary areas of strength within
CADD PHP, increases the likelihood that patients the program and the primary challenges of the
and parents will receive the ongoing support they program. When the program opened, staff needed
need to maintain skills learned in program. Often, a great deal of support, mentoring, and supervi-
in addition to participating in meetings with the sion. Despite being fortunate enough to have
family and CADD PHP clinician, home-based opened the program with direct care staff who
clinicians and staff complete observations within had experience from working on an inpatient
the program milieu in order to see how program- psychiatiric unit, working closely with families
ming is implemented and to observe patients’ was new for the direct care staff, and they needed
responses. support in learning to provide parental support
and training. Staff also required mentoring and
supervision to serve families from different back-
Integrating Research and Practice grounds. Staff continue to require ongoing edu-
cation and training around understanding how
The CADD PHP, as indicated previously, seeks families’ cultural experiences and beliefs impact
to use EBPs when developing interventions. their understanding of their childrens’ develop-
Presently, the program is embarking on a clinical mental delay and mental health needs, as well as
research project which will involve using video how they parent their children.
modeling to provide individualized treatment to One of the primary strengths of the program is
children with ASD that require additional support the level of family involvement in treatment.
in tolerating procedures such as having their Unfortunately, this can also become a barrier for
blood pressure checked, having labs drawn for some families if they are unable to have their
bloodwork, or obtaining EKGs. Presently, many child admitted to the program due to not having
patients require physical holds for these proce- transportation resources or the ability to modify
dures. Video modeling is an EBP that uses video their work schedule to be available to participate
recording and display equipment to provide a in treatment and transport their child to and from
visual model of the skill or behavior that is being program. Although we attempt to seek other
taught (EBP; Steinbrenner et al., 2020). Types of resources, including transportation provided
video modeling include basic video modeling, through some Medicaid insurance plans and
video self-modeling, and point-of-view video financial resources through the hospital’s family
modeling. Basic video modeling involves record- support fund, there continue to be families who
ing someone besides the learner engaging in the are unable to access the program for these
target behavior or skill. The video is then viewed reasons.
by the learner at a later time. Video self-modeling One of the primary challenges has been serv-
is used to record the learner displaying the target ing a very broad range of ages and presenting
skill or behavior and is reviewed later. Point-of-­ problems. This has required the program to be
view video modeling is when the target behavior flexible and make ongoing adjustments to treat-
154 M. Regan and G. Righi

ment models and group structure. Given the rela- to be more successful in home and social situa-
tively short-term nature of the program, there is tions. In addition to meeting these patients’ needs
always turnover in terms of the patients and their without disrupting their participation in school, for
needs. Depending upon the patient population, it some childen and adolescents who may need more
may be necessary to adjust staffing numbers, intensive treatment as they transition back to
groupings of patients, materials used in groups school, the program provides additional support as
and other activities, and the program schedule. they discharge from CADD PHP.
This further complicates planning admissions
into the program, as we seek to provide a cohort
of appropriate peers for patients. We have also Conclusion
had to consider re-admissions carefully and on a
case-by-case basis. Factors considered when a The CADD PHP has added to the continuum of
patient presents for re-admission include level of care available for children and adolescents with
engagement of patient and family during previ- ASD and other developmental disabilities at
ous admission, level of engagement in follow-up Bradley Hospital, which now includes outpatient,
care that was set up at discharge, and whether home-based, therapeutic day school, intensive
another level of care is better suited to meet treat- outpatient, partial hospitalization and inpatient
ment goals. Identifying and being able to access levels of care. The program has become a valu-
the most appropriate follow-up treatment appears able resource for providers, schools, and the
to decrease the likelihood of patients returning or community in addition to referrals from within
requiring other intensive services. This is compli- Bradley Hospital. We continue to evaluate and
cated by a lack of available resources and long revise programming to meet the varying needs of
waiting lists. the individuals we serve by implementing EBPs
As a new program, it was also challenging to and collaboratively work with patients and their
build up to adequate staffing to be able to address families in our interdisciplinary team approach.
all of the patient needs. For example, integration
of clinical data collection within a busy clinical
service is challenging without dedicated person- References
nel. While the program has been able to increase
both census and staffing over time, there contin- Ameis, S., & Szatmari, P. (2015). Common psychiatric
comorbidities and their assessment. In E. Anagnostou
ues to be a need for increased direct care staff FTE & J. Brian (Eds.), Clinician’s manual on autism spec-
(full-time equivalents). This is presently supple- trum disorder. Springer International Publishing.
mented by per diem, as well as clinical staff FTE, Bearss, K., Johnson, C., Handen, B., Butter, E., &
and once these staffing holes are filled, it will Lecavalier, L. (2015). The RUBI autism network par-
ent training for disruptive behavior. Oxford University
allow the program to more effectively develop Press.
procedures for evaluating clinical outcomes. Beck, J. S., Beck, A. T., Jolly, J. B., & Steer, R. A. (2005).
In terms of next steps, despite the addition of Beck youth inventories second edition for children and
the CADD PHP several years ago, and its ever-­ adolescents. PsychCorp.
Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J.,
expanding census, there continues to be an exten- Monga, S., & Baugher, M. (1999). Psychometric
sive waiting list for the program. As a result, a new properties of the Screen for Child Anxiety Related
Intensive Outpatient Program, which meets after Emotional Disorders (SCARED): A replication
school hours, was launched within the past few study. Journal of the American Academy of Child and
Adolescent Psychiatry, 38(10), 1230–1236.
months, serving 10- to 17-year-olds. This program Boyd, L., Reynolds, C., & Chanin, K. (2013). The social
takes place after school hours and therefore is suit- compass curriculum: A story-based intervention pack-
able for patients who are able to function within age for students with Autism Spectrum Disorders.
the structured environment of school but need Brookes Publishing.
additional support building emotion regulation,
distress tolerance, and social skills to allow them
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Constantino, J. N., & Gruber, C. P. (2012). Social Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort,
Responsiveness Scale, Second Edition (SRS-2). S. I., King, R. A., Goodman, W. K., Cicchetti, D., &
Western Psychological Services. Leckman, J. F. (1997). Children’s Yale-Brown obses-
Franzone, E., & Collet-Klingenberg, L. (2008). Overview sive compulsive scale: Reliability and validity. Journal
of video modeling. The National Professional of the American Academy of Child and Adolescent
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Waisman Center, University of Wisconsin. Scahill, L., Dimitropoulos, A., McDougle, C. J., Aman,
Gray, C., & Garand, J. (1993). Social stories: Improving M. G., Feurer, I. D., McCracken, J. T., … & Vitiello,
responses of students with autism with accurate social B. (2014). Children’s Yale-Brown obsessive compul-
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Huerta, M., & Lord, C. (2012). Diagnostic evaluation of structure and correlates of symptom checklist.
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Intellectual and Developmental Disabilities. Simmons, T., & Worley, K. (2003). Psychometric
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 Dialectical Behavior Therapy
10
Kristen L. Batejan, Julie Van der Feen,
and Peg Worden

 verview of 3East Partial

O based, which allows for interactions with same-­
Hospitalization Program DBT aged peers, opportunities to provide feedback to
and Adolescents each other, and role-play for “in the moment”
skills practice. Individual therapy and family
The McLean 3East Dialectic Behavior Therapy involvement are individualized to each adoles-
Partial Hospital Program (DBT PHP) is a four-­ cent and family’s needs.
week program for adolescents ranging in age
from 13 to early 20s. The adolescents in the pro-
gram experience significant emotion dysregula- History of the DBT PHP
tion and a myriad of impulsive behaviors. The
DBT PHP has adapted Marsha Linehan’s DBT McLean Hospital has treated adolescents and
outpatient format to meet adolescents’ develop- young adults for decades. The campus includes
mental needs. DBT is an evidence-based behav- two therapeutic schools and a variety of units
ioral therapy targeting problematic thoughts, designed to treat adolescents and their families.
urges, behaviors, and emotions by teaching In the 2000s, McLean began attracting more
acceptance- and change-based skills and strate- national and international high-risk adolescent
gies. The DBT PHP is modeled after a traditional referrals. Families were seeking evidence-based
school day. In 4 weeks, the adolescents learn treatments and well-trained clinicians for their
DBT skills, and, with practice outside of therapy, children with high-risk behaviors like suicidality
begin generalizing the skills in various settings. and self-injury. As the different programs
The teaching portion of the DBT PHP is group-­ accepted more of these referrals, the clinical staff
within the Nancy and Richard Simches Center of
Excellence in Child and Adolescent Psychiatry at
K. L. Batejan (*) · P. Worden McLean needed specialized training and support
McLean Hospital/Harvard Medical School,
Belmont, MA, USA to optimize these adolescents’ treatment. As a
e-mail: [email protected]; result, clinicians from each program began
[email protected] attending Behavioral Tech’s DBT Foundational
J. Van der Feen and Intensive trainings.
McLean Hospital/Harvard Medical School, The McLean Hospital Intensive DBT
Belmont, MA, USA Residential Program, created in 2007, was in
Newton-Wellesley Hospital, Newton, MA, USA response to the high demand for more compre-
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 157
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_10
158 K. L. Batejan et al.

hensive and specialized care for adolescent girls lation (e.g., dissociation, black and white/
suffering from symptoms of mood dysregulation distorted thinking, obsessive/ruminative thought),
and high-risk behaviors. As the adolescents on and self-dysregulation (e.g., sense of emptiness,
the residential unit improved, it became clear unstable sense of self).
they required a “step down” into a less restrictive While the DBT PHP has been open for over a
setting to generalize their skills in preparation for decade, the program prioritized data collection
returning home. Therefore, the DBT PHP opened within the past few years. From July of 2018 to
in January of 2008. At the same time, DBT was August of 2021, the DBT PHP has had 250
becoming sought after for adolescents and young admissions, with 239 unique adolescents (i.e.,
adults in the local community and out of state. some adolescents discharged to an inpatient
The DBT PHP leadership wanted to make DBT level of care and later readmitted, some returned
widely available and combined the “step down” for a “booster”). About 10% of the adolescents
residential referrals with the community refer- were stepped up to a higher level of care during
rals. The DBT PHP became gender-inclusive, their admission (e.g., inpatient or residential),
accepting in-state, out of state, and international with the majority not returning to the DBT PHP.
referrals. Seventy-­nine percent of admissions completed
the PHP, with almost 20% of adolescents extend-
ing in the PHP. The age range is 13–24, with the
The DBT PHP average age being 17.7, with 16- and 17-year-old
adolescents being the mode. Seventy-five per-
Structure cent reside in Massachusetts, with 21% coming
from out of state and 4% from international loca-
The DBT PHP collapses Marsha Linehan’s 6- tions. Most adolescents are white (84%), 5%
to 12-month outpatient model into a four-week biracial, 4% South Asian, 3% Asian, and 2%
curriculum. The program runs every Monday Hispanic. A little over 70% identify as female,
to Thursday from 8:30 AM to 3:00 PM and 20% as male, 7% as non-binary/genderfluid, and
Friday from 8:30 AM to 2:00 PM. Before 3% as transgender. Fifty-two percent identify as
admission to the DBT PHP, prospective ado- straight, 22% as bisexual, 8% as gay/lesbian, and
lescents and their parent/guardian(s) meet with 10% as unsure or questioning. Five percent of
a clinician for a commitment interview to the admissions have received a scholarship.
assess their willingness and motivation to par-
ticipate in the DBT PHP (described in more
detail in the “Use of Empirically Treatment Goals
Informed Assessmenttt” section).
The overarching treatment goal in the DBT PHP
is to teach the core DBT skills to help adolescents
Patient Overview rapidly acquire the skills they need to reduce and
eliminate maladaptive and destructive behaviors
The adolescents receiving treatment in the DBT that interfere with self-growth and healthy func-
PHP have difficulties in many domains: mood tioning. At the heart of DBT is the concept of dia-
dysregulation (e.g., chronic depressive symp- lectics, the understanding that two seemingly
toms, chronic anxiety, rapid mood shifts, “roller- opposing things can exist simultaneously. One of
coaster emotions”), behavior dysregulation (e.g., the core principles of DBT is the balance between
self-injury, suicidal ideation, substance use, dis- acceptance (“everyone is doing the best they can”)
ordered eating, impulsivity), interpersonal dys- and change (“everyone can be motivated to try
regulation (e.g., communication deficits, trouble harder”). DBT’s biosocial model encompasses
making or maintaining friends, unstable relation- the theory of how symptoms arise and are main-
ships, parent–child conflict), cognitive dysregu- tained. It helps conceptualize an individual’s suf-
10 Dialectical Behavior Therapy 159

fering as transactional, where the combination of the middle path (e.g., dialectical thinking, parent-­
emotional sensitivity and an invalidating environ- child dialectical dilemmas).
ment leads to emotion dysregulation. Validation is The DBT PHP also includes two Cognitive
used with cognitive behavioral strategies to help Behavioral Therapy groups addressing cogni-
adolescents stay committed to treatment and tive distortions, cognitive reappraisal, core
attempt to change well-established, ineffective beliefs, and principles of exposure work. The
behaviors, including suicidal thoughts, self-harm, DBT PHP has clinicians with expertise around
impulsivity, negative self-judgments, lashing out transition planning (e.g., returning to school,
at others, isolation/avoidance, substance use, and finding jobs/volunteering) that lead a weekly
eating-disordered behaviors. For a comprehensive group and are available for one-on-one assis-
review of DBT, please refer to the adult treatment tance. Additionally, the schedule includes two
manuals (Linehan, 1993a, b, 2014a, b). community meetings (described in more detail
in the “Generalizing treatment gains and col-
laborations” section). Groups are didactic,
Program Components where clinicians are teaching skills and assign-
ing homework, or agenda-­based, where adoles-
Standard DBT includes four treatment compo- cents may request more specific help from other
nents: skills training in group therapy, individual group members in accessing/troubleshooting a
therapy, skills coaching, and the consultation skill (Table 10.1).
team. Adolescents receive group therapy, indi-
vidual therapy, psychiatric consultation, and Individual Therapy
skills coaching weekly in this program. Individual therapy is agenda-based around the
Additionally, because this is an adolescent pro- priorities of the adolescent’s diary card. The
gram, parents/guardians are included in the treat- diary card is a tool used to track a patient’s
ment and receive family sessions, parent skills problematic behaviors, urges, thoughts, emo-
coaching, and a parent skills group. tions, and skills use. The diary card prioritizes
different targets, including life-threatening
Group Therapy behaviors, therapy-­interfering behaviors, qual-
There are 34 groups during the four-week stay ity of life interfering behaviors, and skills
(seven groups per day; five in the morning and acquisition. Typical target behaviors included
two after lunch). The four DBT modules (i.e., on a diary card are suicidal urges/actions, self-
emotion regulation, distress tolerance, interper- harm urges/actions, eating-­disordered behav-
sonal effectiveness, and mindfulness) follow a iors, substance use, avoidance/isolation, and
“teach, show, do” learning model. As this is an “lashing out” urges/action. There are many
adolescent program, the fifth module from the ways to track these behaviors, which may
adolescent DBT skills manual (Rathus & Miller, include a Likert scale of the intensity of the
2015), walking the middle path, is included in the urge, yes/no if the behavior happened, or time
curriculum. Adolescents learn about mindfulness spent engaging in the behavior. For example,
(e.g., how to be fully aware, in the present suppose an adolescent engages in a problem-
moment, using a non-judgmental stance), emo- atic target behavior, the clinician and adoles-
tion regulation (e.g., how to identify emotions, cent will a complete behavioral chain analysis
how to change emotions, how to decrease vulner- to understand the function of the target behav-
abilities), distress tolerance (e.g., how to tolerate ior, ­including precipitating events, vulnerabil-
emotions, how to accept life’s circumstances), ities, emotions, thoughts, and behaviors that
interpersonal effectiveness (e.g., how to maintain led to the target behavior, and the conse-
relationships, set limits, validate), and walking quences of having engaged in the behavior.
160 K. L. Batejan et al.

Table 10.1 Weekly program schedule

Monday Tuesday Wednesday Thursday Friday
8:30– Check-in/Goals Check-in/Goals Check-in/Goals Check-in/Goals Check-in/Goals
9:00 group group group group group
9:00– Weekend review Mindfulness 1 Mindfulness 2 Addressing identities Emotion
9:50 regulation 3
10:00– Distress tolerance Emotion Distress tolerance Psychiatric consult Interpersonal
10:50 1 regulation 1 2 effectiveness 3
11:00– PLEASE group Components of Emotion Cognitive behavioral Cope ahead
11:50 DBT regulation 2 therapy 2 – exposure
11:50– Lunch Lunch Lunch Lunch Lunch
12:30
12:30– Homework Homework Homework Homework Homework
1:00
1:00– Interpersonal Interpersonal Mindfulness Distress tolerance 3 Community
1:50 effectiveness 1 effectiveness 2 practices meeting
2:00– Behavioral chains Community Cognitive Adulting 101
2:50 meeting behavioral
therapy 1
10 Dialectical Behavior Therapy 161

This chart is an example of a DBT diary card. charges from the program. Additionally, the
Adolescents identify behaviors to track with their 3East continuum runs regular two-day weekend
treatment team, and for each behavior, track intensive DBT parent education and skill work-
urges to engage in the behavior and actions. This shops, which parents are encouraged to attend.
adolescent is tracking suicidal ideation, non-­
suicidal self-injury, cannabis usage, isolation/ Psychiatric Consultation
avoidance, and minimizing emotions/urges/ Psychiatric consultation focuses on reviewing the
actions. Minimizing is considered a therapy-­ adolescent’s history and symptoms, ensuring that
interfering behavior in DBT and tracking it on medications are appropriate, and clarifying diag-
the diary card helps both the therapist and the noses for adolescents, their families, and their
adolescent remain aware of how this behavior outpatient providers. Most of the adolescents in
impacts treatment. Adolescents also rate several the program have had multiple trials of medica-
emotions and their skill usage for target behav- tions that have not helped regulate their emo-
iors. They fill out their suicidal and self-injury tions. Given the program’s focus on teaching
urges before and after their twice-weekly indi- DBT skills, the psychiatric consultants work to
vidual therapy sessions. On the lower half of the decrease reliance on medications and medication
diary card, they are encouraged to circle the DBT changes to ameliorate psychiatric symptoms. The
skills they have used. The diary card is reviewed psychiatric clinicians are all intensively trained in
at least twice weekly during the individual DBT DBT and function as full treatment team mem-
therapy session at the PHP. bers: leading groups, teaching skills, assessing
target behaviors, and completing behavioral
Family Involvement chain analyses as necessary.
Family sessions are solution-focused and address
the more immediate challenges between parents/ Homework
guardians and their child, including helping par- DBT homework is a vital component of the pro-
ents increase their validation of their child and gram by rehearsing new skills, practicing coping
decrease their attempts solving their child’s prob- strategies, and restructuring ineffective behaviors
lems. These sessions also teach them the practi- and thoughts. Most of the groups have assigned
cal use of DBT skills. Parts of the session may homework exercises, which require practicing a
include psychoeducation around dialectical skill or concept taught in the group and then
dilemmas (e.g., fostering dependence vs. forcing recording the details step by step on a worksheet.
independence), contingency management, and The program has built-in time for homework
the biosocial model. Additionally, family ses- review and numerous opportunities for adoles-
sions allow adolescents to practice asking for cents to learn skills/concepts they may have
help, sharing more information about their strug- missed or not understood clearly. All students are
gles, and setting limits with their parents around responsible for all the homework assigned during
problem-solving. Family sessions often use the the week, even if they miss all or parts of a group
functional chain analysis to understand the trans- for numerous reasons (e.g., being late, having a
actional processes within families to understand program individual or family session, receiving
each member’s role in a problematic interaction skills coaching). Homework from the previous
and then troubleshoot a more effective plan mov- week is reviewed at the start of the corresponding
ing forward. Parents/guardians are also strongly group where the adolescents share their assign-
encouraged to attend the parent skills group that ments aloud for feedback from the group leaders
provides an overview of each DBT skills module and the other group members. This process helps
and is open to all parents who have an adolescent validate and support them in their skills practice
on the 3East continuum. The parent skills group and helps them share what did and did not work.
is offered weekly for 2 hours. Parents can con- The homework review often involves some trou-
tinue attending this group after their child dis- bleshooting to help them maximize the effective-
162 K. L. Batejan et al.

ness of their skills practice. Additionally, staff Adolescent Skills Coaching (example blurb
emailed by skills coach to the entire clinical team)
may assign additional assignments outside of J. called at 8 PM last night for coaching. She
group therapy that includes behavioral chains reported feeling upset (with help identified fear
(e.g., regarding being late to a group, engaging in and sadness) and anger about tomorrow’s family
a target behavior, engaging in a recurrent ineffec- meeting. She had self-injury urges and confirmed
she was committed to not acting on them. She had
tive behavior), exposure hierarchies, or specific not tried skills yet. We came up with a plan for her
skills practice for homework. to take a TIPP shower after moving the razor out of
Academic homework is strongly discouraged the bathroom. We discussed self-soothe (listening
during the duration of the program. Adolescents to music) and ACCEPTS (playing a game on her
phone). I validated the emotions given the family
and parents are told that because the PHP is an session agenda and the long-standing history of
intensive treatment program, the adolescent’s discord between J. and her parents. I encouraged J.
sole focus should be exclusively on the program’s to call back if these skills were not working and
homework during the first half (2 weeks). At the she needed more support.
discretion of the adolescent’s treatment team,
small amounts of academic work may be added Of equal importance is making sure the parents
during the final half of the program, especially if have access to a skills coach. The DBT PHP pro-
it relates to treatment goals (e.g., helping an ado- gram director is on call for the parents/guardians,
lescent use skills to tolerate distress, not avoid, during the day and after program hours, so par-
advocate for needs). Massachusetts’s public edu- ents can receive support handling a conflict with
cation system provides tutors to students who are their adolescent, effectively managing their own
absent from school for more than 14 days; these emotions, or responding to their adolescent’s
tutors can support students as they transition back behaviors. Parents may receive validation, coach-
to school. Most Massachusetts public schools ing using specific DBT skills, applying behav-
have transition programs to support students’ ioral strategies to reinforce/extinguish behaviors,
return to school after medical or mental health or generalizing their skills in these situations.
absences. Many private schools have similar pro- Parent Skills Coaching (example blurb sent via
grams or alternative expectations around missing email by skills coach to the entire clinical team)
school. M.’s mom called for parent skills coaching at 5
PM. Mom stated that M. was “melting down,” sob-
bing and saying she has been sad for days. Mom
Skills Coaching suspects today’s family session may have height-
Skills coaching is a unique feature of DBT for ened M’s emotions. Mom called because she had
adolescents and their parents/guardians. Skills suggested skills for M. and did not know what to
coaching provides in the moment access to a cli- do next. I told mom this is the opposite of what we
want her to do and she needed to notice the urge to
nician for help in using and generalizing skills help before M. asks for help. I suggested mom use
and is available during the program day and after her distress tolerance and mindfulness skills (she
program hours. Adolescents are encouraged to had to prepare dinner and answer some emails). I
practice and ask for skills coaching during the encouraged her to try paced breathing and doing
one thing in the moment.
daytime groups and reach out to the on-call cli-
nician after program hours. These skills coach-
ing sessions are not therapy, per se, but relatively Consultation Team
brief interactions of direct guidance in identify- Clinicians are required to sit on a consultation
ing the help the adolescent needs (e.g., identify- team when implementing DBT. The consultation
ing a problem/solution, implementing a solution, team is a weekly hour-long meeting where clini-
validation, facilitating a repair). Adolescents cians help each other manage the stress and
may access skills coaching in moments of potential burnout of working with high-risk ado-
intense emotional or behavioral dysregulation, lescents. The consultation team supports clini-
where they need help to stay effective and avoid cians by addressing emotional exhaustion, feeling
crises. ineffective in delivering the treatment, holding
10 Dialectical Behavior Therapy 163

each other accountable to the principles of DBT, tioning issues or assistance with academic/voca-
and monitoring treatment fidelity. The DBT PHP tional plans. Lastly, some adolescents choose to
staff consists of various clinical disciplines, return to the PHP for a one- to two-week
including psychology, social work, psychiatry, “booster” to refresh their skills. These adoles-
nursing, and mental health support staff, all of cents are required to interview and submit goals
whom participate in the consultation team. for this second course of treatment at the PHP.

Program Extensions
While the DBT PHP is considered a four-week  risis and Safety Response/
C
bootcamp, some goals are more challenging to Management
achieve in that time frame, given the complexity
of symptoms, obstacles/barriers implementing When working with adolescents with emotion
skills, and different learning styles. Therefore, dysregulation, there will be moments when their
the DBT PHP offers extended programming symptoms become more acute and when the ado-
skills generalization and application, up to two lescent is in crisis. Throughout the DBT PHP,
additional weeks. To extend in the DBT PHP, the adolescents are constantly assessed for risk dur-
adolescent must first fill out an application iden- ing individual therapy sessions, family sessions,
tifying goals and rationale for a potential exten- psychiatric sessions, and diary card reviews.
sion. The application requests a detailed Skills coaching, available during the program
explanation of what skills have helped and which day and after program hours, can be particularly
still require more practice and generalization. helpful when adolescents are having urges to act
The team reviews the application and determines on target behaviors or experiencing a crisis.
the clinical wisdom in an extension. The exten- Adolescents are encouraged to request skills
sion is considered a reward for hard work and coaching before acting on urges. If/when there is
effort and is not granted to adolescents using it as increased acuity beyond what can be managed
avoidance. It is also a reward for effective behav- with skills coaching calls, the team consults to
ior and improvements in target behaviors. determine the most effective plan. Parents/guard-
ians assist in creating a crisis plan for their child
Discharge Planning/Recommendations to remain in an outpatient level of care.
After a four-week, or up to a six-week course of A goal at the DBT PHP is to maintain adoles-
DBT PHP, the adolescent transitions back into cents at the partial hospital level of care and avoid
outpatient therapy and other adjunctive support emergency room or hospital stays; yet this is not
as needed (e.g., group therapy, family sessions, always possible. Suppose the adolescent’s
psychopharmacology). The PHP team does not increase in acuity includes an acute safety crisis
provide case management, although they will (e.g., inability to contract to remain safe, signifi-
provide recommendations for continued services cant mood alterations, change in household that
and may provide a DBT referral list for local creates instability/lack of safety), and the
families. The clinical team most often recom- adolescent/family are unwilling or unable to do
mends continuing with DBT therapy, although the work to remain safe in an outpatient setting.
some families prefer to return to their outpatient In that case, the adolescent and family are
provider, even if they are not trained in DBT. directed to go to the emergency room for an eval-
Additional recommendations might include a uation to determine the appropriate level of care
skills generalization/advanced DBT group, espe- and next treatment steps. Should an adolescent
cially if the adolescent found the peer support in present with high acuity and an inability to com-
the PHP helpful, a neuropsychological evaluation mit to a skills plan to maintain safety, there are
if there are concerns around the adolescent’s cog- many options for a higher level of care (inpatient
nitive profile, and transitional support, which programs, acute residential units, as well as eat-
may help the adolescent around executive func- ing disorders, OCD, anxiety, substance use, and
164 K. L. Batejan et al.

DBT residential units) connected to McLean Behavioral Tech, started by Dr. Marsha
Hospital. If/when an adolescent needs a higher or Linehan, offers training for clinicians to learn
different level of care, it is often easy to facilitate and apply DBT in adherent ways. All the clini-
this within the McLean Hospital system. cians and medical staff have attended Behavioral
Tech’s DBT foundational and advanced trainings
(see https://behavioraltech.org/ for more infor-
 iversity Considerations Related
D mation). Additionally, staff have pursued special-
to Staff, Adolescents, and Access ized training, including dual diagnosis, obsessive
to Care compulsive disorder (OCD), eating disorders,
and prolonged exposure treatment for trauma.
The DBT PHP values diversity to provide the The weekly consultation team also provides
most comprehensive and effective care in treating training and teaching. McLean Hospital has four
hundreds of diagnostically complex adolescents Behavioral Tech trainers on staff for ongoing
from varied families, schools, and social systems mentorship and supervision. The mental health
from all over the world. Clinicians have become staff attend DBT training for milieu manage-
acquainted with numerous ethnic, religious, gen- ment, seminars, and weekly individual and group
der, and cultural groups while treating adoles- supervision. McLean Hospital is a member of the
cents from 28 states and six continents. Staff is extensive Mass General Brigham Healthcare
committed to understanding how culture/diver- System, which offers countless seminars and
sity issues contribute to adolescents’ and/or their training.
families’ mental health and treatment perspec- The DBT PHP staff are fortunate to have con-
tives. For example, the team has learned the siderable resources for support and consultation:
importance of remaining open-minded and curi- an enormous community of mental health profes-
ous about how mental health issues are discussed sionals with a variety of specialties at McLean
(or not) and the role emotions play in family sys- Hospital, a widespread DBT community of like-­
tems. The adolescents must be fluent in English; minded clinicians who understand the trials and
however, parents/guardians do not have to be flu- tribulations of doing DBT therapy, and an ever-­
ent. Clinicians have access to hospital interpret- increasing number of past clinicians, trainees,
ers to assist in communication during family and staff who have remained in touch.
sessions when language is a barrier. The DBT Additionally, the clinicians subscribe to DBT
PHP makes efforts to provide materials in the Listservs and attend the International Society for
spoken language if such material exists. For the Improvement and Teaching of Dialectical
example, the program was able to have the mate- Behavior Therapy (ISITDBT) and Association
rials translated into Spanish. Additionally, for Behavioral and Cognitive Therapies (ABCT)
McLean Hospital offers numerous specialty pro- conferences annually. McLean Hospital and the
grams and initiatives to provide consultation, more extensive healthcare system are a rich
training, and support regarding diversity, equity, source of training.
and inclusion.

Building Stakeholders
Training and Navigating Institutional
Expectations/Limitations
McLean Hospital is a training hospital affiliated
with Harvard Medical School, dedicated to pub- Discussions were ongoing with the McLean
lic and professional education and clinical train- administration on how to create the DBT PHP
ing. The DBT PHP includes clinical psychology that could support adolescents who were step-
doctoral students, predoctoral interns, as well as ping down from an intensive residential level of
postdoctoral fellows. care and open a new level of care accessible to
10 Dialectical Behavior Therapy 165

families in the immediate Boston area. As plan- gram or those older than 18 and still in high
ning for the DBT PHP began, the administration school. Within a year or so of being open, it
engaged in a thoughtful process to determine the became clear that there was a gap in treatment for
suitable staffing and the critical demographics for people aged 18–21 who were vulnerable and
who would receive services, including identify- undertreated. In 2010, the age range expanded to
ing age ranges and addressing safety concerns include individuals into their mid-20s, typically
around acuity. in college and supported by their parents/guard-
ians. They “fit” better in the adolescent mental
health system versus the adult mental health sys-
Staffing tem. A unique feature of the DBT PHP places a
strong emphasis on family involvement, where
As an academic psychiatric hospital, McLean weekly family sessions are a requirement, regard-
places a strong emphasis on programming to less of the patient’s age which is typically uncom-
include the presence of advanced practice clinical mon in other treatment programs that treat
staff (i.e., doctoral level clinicians), to provide patients over the age of 18.
exceptional, compassionate clinical care and sup- Working with Division leadership and hospital
port robust training programs and state of the art administration, the DBT PHP developed robust
treatment. Core clinical staff work individually criteria that would allow the program to address
with the adolescents and are woven into the the needs of young adults. For example, to qualify
milieu of the day-to-day programming (e.g., for the program, individuals over 18 needed to be
leading DBT groups, skills coaching, supervision dependent on their parents/guardians and present
of milieu staff). Given the high level of involve- (both the adolescent and the parents) with motiva-
ment of the PHP’s psychiatrist/psychiatric nurse tion and commitment to learn DBT. Having these
practitioner, the adolescents in the DBT PHP criteria in place allowed the DBT PHP to fill a gap
reap the benefits of having a two-person team in need, serving as a highly specialized, unique
dedicated to teaching DBT skills to them and program that would not overlap or recreate other
their families. McLean, as an institution, values programs at McLean Hospital (such as the adult
and prioritizes training. Over the past 13 years, substance abuse PHP and the adult behavioral
the DBT PHP has been able to hire well-trained health PHP, which offer shorter lengths of stay
staff and support the clinical program with vari- and cater to adults that would be considered more
ous levels of trainees including clinical psychol- independent/autonomous from their parents).
ogy doctoral students, predoctoral interns, and Additionally, by setting the expectation before
postdoctoral fellows. Creating this training pro- admission of actively involving parents in their
gram with the support and guidance of the older adolescent’s treatment and emphasizing
McLean administration allows for a clinically direct communication and sharing in family ses-
rich program. sions, the program has been able to help foster
their continued wishes for independence while
also navigating their family system.
Patient Age Range

Many mental health facilities have made clear Level of Acuity

distinctions between adolescent and adult treat-
ment programs. For many programs, 18 is the As mentioned in other sections of this chapter,
designated age that differentiates adolescent pro- the DBT PHP admits adolescents who struggle
grams from adult programs. When the DBT PHP with high risk, dangerous behaviors and the pro-
first opened, adolescents aged 13–18 were only gram requires a level of stability that allows the
accepted, with some exceptions made for young adolescent to commit to asking for help (during
adults stepping down from the residential pro- the day in person, or after the program day via
166 K. L. Batejan et al.

skills coaching). The DBT PHP is comfortable pies, if an adolescent were to call their therapist
accepting adolescents who engage in target and say they were suicidal or at risk of hurting
behaviors that include suicidal ideation and plan- themselves, they would be instructed to call 911
ning, non-suicidal self-injury, substance misuse, or immediately go to the nearest hospital. While
and eating disordered behaviors. Adolescents are there are risks associated with skills coaching
expected and trusted to be honest on their diary adolescents who are suicidal or self-injuring,
cards and open to completing chain and behav- skills coaching is an effective intervention to
ioral analyses after engaging in a target increase skills use and decrease impulsivity.
behavior. Therefore, McLean and the DBT PHP developed
Given the treatment of high-risk adolescents, a protocol, to allow licensed clinicians to be on
it has been necessary to find a middle path call after hours, and the program director and
between McLean Hospital policy and procedures medical director are accessible if the situation
and DBT guiding principles. One example of becomes emergent. The following is an example
reaching the middle path was how to increase of how the DBT PHP seeks the middle path in
adolescents’ independence/autonomy in the pro- addressing risk while balancing the adolescent’s
gram while also recognizing their minor and at-­ treatment goals:
risk status. Adolescents can have unsupervised D. has a history of self-injury, suicidal ideation,
breaks between groups as well as an unsuper- running away, and substance misuse. D. was in an
vised lunch break. Some argued that these breaks outpatient therapy session when he became dys-
offer plenty of time to “get into trouble” or regulated and ran out. The outpatient therapist
called the parents and the police. In the meantime,
engage in target behaviors. The DBT PHP’s phi- D. called for skills coaching with the on-call PHP
losophy is that these breaks also allow plenty of clinician. The clinician assessed D.’s risk and
time to try new skills, ask for help if needed, and coached D. to use distress tolerance skills to reduce
form relationships with their peers. The hospital the emotion, return to the office, and not worsen
the problem. As D. approached the office, while
administration and the PHP leadership had many still on the phone with the on-call PHP clinician,
discussions about the number and length of the parents and police were in the premise search-
breaks and lunch. The consensus was to mimic a ing for D. The on-call PHP clinician spoke with the
school day and offer unsupervised breaks police to provide details on what had occurred. The
on-call PHP clinician also provided coaching with
between groups (about 10 minutes) and an unsu- the parents on how to access their skills, while get-
pervised break for lunch (30 minutes). Along the ting curious and non-judgmental about what had
same lines, adolescents can drive themselves to occurred with D.
the PHP. If they demonstrate or report dysregula-
tion, they are encouraged to use skills coaching Typically, in this situation, D. would have been
before leaving the campus for the day. If they are escorted to the local hospital for an evaluation. In
in danger to drive home, their parent/guardian is this instance, the DBT skills coach prevented a
contacted for transportation home or a hospital hospital visit and helped the adolescent and fam-
for an evaluation. ily access skills to remain in the DBT PHP. The
Another middle path example arose with the subsequent family session reviewed the chain
introduction of skills coaching after program analyses from both adolescent and their parents
hours. Adolescents are strongly encouraged to and helped them identify ways to communicate
call for skills coaching in the evenings and week- more effectively moving forward.
ends, especially when suicidal or having self-­
injury urges. Rather than hospitalizing them
immediately, the clinician works with the adoles-  avigating Insurance Coverage
N
cent on committing to remain regulated (not act and Billing
impulsively) for several hours or until the next
day. This idea was novel, not only to the McLean The McLean DBT PHP does not accept insur-
administration but also to the adolescents and ance, mainly because the adolescents may not
their families. Traditionally, in non-DBT thera- meet the “level of care” established by insurance
10 Dialectical Behavior Therapy 167

standards. While some of the adolescents would Adolescents typically share this homework
initially meet the level of care for a PHP, there openly in the group for feedback. In addition, cli-
tends to be a rapid improvement in symptoms nicians may assign written homework. For exam-
and behaviors, which insurance providers would ple, if an adolescent struggles with finding the
deem this level as “not medically necessary” and motivation to give up self-injury, a clinician may
require discharge. assign a DBT Pros and Cons to be completed
The DBT PHP has a set length of stay that is before the next session. Clinicians may also
20 days, which is the amount of time necessary to assign behavioral homework such as having an
teach all the DBT skills. In Massachusetts, insur- adolescent struggling with anxiety participate in
ance providers often cover 7–10 days for a PHP, a group or reach out to a friend. If an adolescent
which is not enough time for adolescents to learn is repeatedly late to the first group of the day, they
and start to generalize the DBT skills. At the end will be assigned a chain analysis to help them
of the four-week program, families can submit a analyze their problematic behavior of being late.
letter documenting treatment to their insurance Diary cards and behavioral chain analyses may
provider for potential reimbursement. be completed or reviewed with mental health
Additionally, the DBT PHP offers scholarships support staff and practicum students, who often
based on financial hardship, and families are wel- provide 1:1 instruction, practice, or feedback
comed to apply for this assistance. regarding specific DBT skills. Having the adoles-
cents in the program for 4 weeks allows the treat-
ment team to see firsthand how their skills deficits
Generalizing Treatment Gains can impact mood, relationships, work comple-
and Collaborations tion, and ability to ask for help. The benefit of the
milieu is that immediate feedback and skills
In addition to the specific services offered at the teaching is available to enhance skill develop-
DBT PHP (i.e., group, individual, and family ment. Twice weekly community meetings pro-
therapies), other components that actively work vide opportunities for all staff and adolescents to
to maximize treatment gains for adolescents. For come together as a group to introduce new mem-
example, treatment reviews are scheduled for bers to the milieu, practice mindfulness exer-
adolescents with wavering motivation and cises, raise concerns, discuss skills use, give
­commitment or if the adolescent is repeatedly constructive feedback, ask for help with treat-
engaging in target behaviors, not reaching out for ment goals, and say goodbye to people discharg-
help or skills coaching, arriving late to groups or ing. When adolescents meet homework
not completing homework, diary cards, assigned expectations for the week, a “homework party”
behavioral chains, or if there is an ongoing intra- takes the place of a group the following week.
family conflict or poor communication. They are These homework parties encompass activities
typically scheduled at the halfway point in the such as sharing specific foods for breakfast or
program. Treatment reviews include all treatment lunch, talent showcases, holiday-themed parties,
team members, the adolescent, and their parents/ arts and crafts, playing games, outdoor field
guardians. Typical treatment review agenda items games, and watching movies.
include progress toward initially identified goals, Collaborations are varied and regularly
need for additional program goals, treatment include other McLean Hospital programs and
interfering behaviors, obstacles to treatment, rec- providers. Outside treatment providers are rou-
ommendations for a program extension, and tinely contacted to gather adolescent and family
aftercare planning. history. Adolescents are encouraged to main-
Milieu treatment offers numerous ways for the tain contact and visits with their outpatient pro-
program adolescents to practice and generalize viders while in the program to keep them
their skills. Most groups have homework assign- informed about their goals and progress in the
ments, which entail practicing a DBT skill. DBT PHP. Other essential collaborations
168 K. L. Batejan et al.

include contact with schools to understand an adolescent helps the clinician assess and clarify
adolescent’s difficulties and help school staff the adolescent’s motivation for and commitment
understand what DBT coping strategies an ado- to engaging in the DBT treatment program. The
lescent may be using when they return to adolescent will submit their treatment goals in
school. Additionally, other community mem- writing following the interview. These goals
bers, including mental health state agencies, must include addressing life-threatening behav-
child protective services, educational consul- iors if the adolescent has that history. Once the
tants, executive function coaches, clergy mem- adolescent’s goals are received, the treatment
bers, transition specialists, and providers team will review the potential admission. If
conducting neuropsychological testing, have approved, an admission date is scheduled. A typ-
been consulted with throughout an adolescent’s ical applicant has chronic depression, mood dys-
treatment in the PHP. regulation, anxiety symptoms, interpersonal
issues, and often a history of suicidality and
self-injury.
Use of Empirically Informed While most of the interviewed adolescents are
Assessment admitted to the program, there are several exclu-
sion criteria. These include active suicidal ide-
The DBT PHP serves a unique gender-inclusive ation with a plan and inability to commit to a
population of adolescents from ages 13 to early safety plan, active self-injury with no willingness
20s, with various psychiatric diagnoses ranging to target and decrease these behaviors, use of
from depression and anxiety to substance use dis- substances that require detox or medical monitor-
orders and borderline personality disorder. ing (e.g., cocaine, alcohol, heroin, prescription
McLean Hospital has assessments required for medications), medically compromised eating dis-
the hospital population and specific assessments orders, and active psychosis. Additionally, ado-
required for patients in the Child and Adolescent lescents will not be accepted if they are not
Center of Excellence. The DBT PHP pre-­ motivated or willing to work on suicidality and
admission assessment process is extensive. It self-injury. During the commitment interview,
includes sending out referral forms, scheduling a clinicians work to elicit willingness to address
commitment interview, receiving goals from the the above issues. If the adolescent is unwilling,
applicant, reviewing the applicant with the they are referred to their outpatient team for fur-
­treatment team, scheduling an admission date if ther motivational work or to a more general PHP
approved. The referral forms gather the pertinent and higher levels of care, if necessary. In many
clinical history of psychiatric symptoms and past cases, they can schedule another interview when
treatment and the rationale for this level of care in they are more stable or willing to learn DBT.
the adolescent’s own words. Upon admission, clinical interviews with the
The clinical team reviews these forms, and a individual therapist and psychiatrist/psychiatric
commitment interview is scheduled with one of nurse practitioner are scheduled within the first
the program clinicians. This interview serves 48 hours to review goals, assess DSM-V diagno-
two critical functions: (1) to provide information ses, and identify DBT treatment targets for the
and education about DBT and the services pro- DBT diary card. The team screens the adolescent
vided by the PHP and (2) to determine if the ado- for depression, anxiety, and the presence of life-­
lescent’s symptom profile fits DBT, including threatening behaviors. A suicide risk assessment
assessing their motivation and commitment. The includes the Ask Suicide-Screening Questions
clinician interviews the adolescent 1:1, with spe- (Horowitz et al., 2012) for adolescents up to age
cific attention paid to life-threatening behaviors 17, the Columbia Suicide Severity Rating Scale
(e.g., suicidal ideation and self-injury), treat- (Posner et al., 2011) for over 17, and a McLean
ment interfering behaviors, and quality of life Hospital modified internal risk assessment. The
interfering behaviors. This 1:1 time with the adolescent also completes several clinical mea-
10 Dialectical Behavior Therapy 169

sures required by the hospital focused on PTSD, trial found that adolescents receiving DBT,
depression, borderline personality disorder, and compared to enhanced usual care, had a reduc-
substance use. The DBT PHP also collects addi- tion in depressive symptoms, suicidal ideation,
tional data on more specific measures related to and self-harm (Mehlum et al., 2014). On an ado-
DBT, including suicidality, positive/negative lescent inpatient unit, those receiving DBT
affect, validation/invalidation/self-validation, compared to treatment as usual had fewer inci-
DBT coping skills, emotion regulation, mindful- dents of suicide attempts and self-­ injury,
ness, and family functioning. These assessments restraints, and days hospitalized (Tebbett-­Mock
occur at admission and discharge, and for adoles- et al., 2020). Studies examining DBT treatment
cents who have opted to extend, their assessments among adolescents show promising results in
will be admission, day 20, and discharge. Please reducing suicidality, self-injury, BPD symp-
see the “Integrating Research and “Practice” sec- toms, depressive symptoms, hopelessness, dis-
tion for more details about the measures. While sociative symptoms, and anger (see MacPherson
in the program, adolescents receive ongoing et al., 2013 for a review).
assessments focused on motivation and commit- Fewer studies have examined DBT in PHPs. A
ment to treatment and target behaviors (e.g., sui- few studies examining adults in a DBT PHP
cidality, self-harm, aggression, eating-disordered found reductions in depression, anxiety, hope-
behaviors, substance use). These ongoing assess- lessness, and degree of suffering (Lothes et al.,
ments occur during individual sessions, psychiat- 2014; Mochrie et al., 2019). Another study of
ric consultation, family sessions, diary card women participants in a DBT PHP found a
review, and daily homework assignments. decrease in depression, hopelessness, anger
expression, dissociation, and general psychopa-
thology (Yen et al., 2009). Examinations of DBT
 se of Empirically Informed
U in a PHP among adolescents have found a reduc-
Interventions tion in symptoms of depression and interpersonal
sensitivity, but not anxiety or hostility (Lenz
DBT is considered the gold standard treatment et al., 2016; Lenz & Del Conte, 2018).
for borderline personality disorder (BPD; The DBT PHP has blended traditional adult
Miller, 2015). The Suicide Prevention Resource DBT with DBT-A, using both treatment manu-
Center (2006) has designated DBT as a “pro- als and worksheets. As this is an adolescent pro-
gram with evidence of effectiveness” based on gram, there is a strong emphasis on family
the rating scale of The Substance Abuse and treatment. Every family gets weekly family ses-
Mental Health Services Administration’s sions to address the more immediate concerns
(SAMHSA) National Registry of Evidence- around communication, validation, and family
Based Programs and Practices. Several random- roles. While the program does not include mul-
ized controlled trials have demonstrated the tifamily groups, parents are strongly encour-
benefits of DBT over treatment as usual (e.g., aged to attend the weekly two-hour parent/
Linehan et al., 1991, 1999; Koons et al., 2001; guardian only skills group where they learn the
Pistorello et al., 2012) in adult populations. same DBT skills their adolescent learns. Given
DBT treatment manuals have been adapted for the diverse psychopathology experienced by the
adolescents (DBT-A; Miller et al., 2007; Rathus adolescents in the DBT PHP, including sub-
& Miller, 2014) and children (DBT-C; stance misuse, there are additional lessons from
Perepletchikova et al., 2011). One randomized DBT for Substance Abusers (Dimeff & Linehan,
trial, comparing DBT to treatment as usual, 2008) focused on dialectical abstinence. There
found adolescents with bipolar disorder in the have also been modifications to programming
DBT group to have fewer depressive symptoms around diary cards, skills tutoring, and skills
and less suicidal ideation in a 12-month follow- training for younger adolescents and adoles-
up (Goldstein et al., 2015). Another randomized cents with executive functioning deficits, cogni-
170 K. L. Batejan et al.

tive impairment, or with an autism spectrum be more candid about their usage in the online
disorder. At one point, the DBT PHP had a sepa- assessment compared to in-person clinical inter-
rate trauma track using DBT Prolonged views. These screenings often help uncover addi-
Exposure (Harned et al., 2012). However, the tional substances or increased severity of
eventual consensus was that all admitted adoles- substance use not disclosed during an admission
cents could benefit from exposures and emo- interview assessment, which can then inform fur-
tional processing. The curriculum was then ther clinical discussions with the adolescent and
modified to include more anxiety-­ focused possibly be included as a targeted diary card goal.
groups incorporating CBT and exposure strate- The DBT PHP also collects data on more spe-
gies rather than a separate trauma track. cific measures related to DBT, including suicidal-
ity, positive/negative affect, validation/invalidation/
self-validation, DBT coping skills, emotion regu-
Integrating Research and Practice lation, mindfulness, and family functioning. The
Suicidal Behaviors Questionnaire (Linehan, 1996)
McLean Hospital has developed a required measures past and current suicidal ideation, past
assessment battery for most of the hospital’s suicide threats, future suicide attempts, and the
treatment, including specific assessments for likelihood of dying from attempting suicide. The
patients in the Child and Adolescent Center of Ways of Coping Checklist – DBT Version (Neacsiu
Excellence. The purpose of the data collection is et al., 2010) assesses the adolescent’s use of DBT
for program evaluation. McLean Hospital uses skills and ineffective coping responses. When
REDCap, which is a secure online data collection examined at discharge, the adolescents can see
tool. Data is collected using self-report surveys to how many skills they have learned and are starting
assess diagnoses and symptoms at admission and to master and how their target behaviors have
discharge, including PTSD, depression, border- reduced in frequency.
line personality disorder, and substance use. Parents are assessed at their adolescent’s
Follow-up data are collected at three, six, and admission and discharge using the same mea-
12 months post-discharge from the DBT PHP. sures around PTSD, borderline personality disor-
Not all the measures administered have been der, depression, anxiety, validation/invalidation/
normed in adolescent populations; however, they self-validation, DBT coping skills, emotion regu-
are used for clinical purposes rather than research. lation, mindfulness, and family functioning.
While this section will not delve into each mea- Parents are sent follow-up measures at three, six,
sure, a few measures are worth noting as they and 12 months post-discharge from the DBT
provide a better conceptualization of the adoles- PHP. While the DBT PHP currently has no active
cent’s struggles. While the DBT PHP no longer research studies, there are plans to analyze the
has a specific trauma track, the PTSD Checklist data for dissemination.
for DSM-5 (Weathers et al., 2013) has given the
clinical team a deeper understanding of the
impact trauma has on an adolescent’s suffering  essons Learned, Resources,
L
and skills use. The team has also found that and Initiatives
trauma treatment can incentivize adolescents to
take the program more seriously in reducing tar- Over the years, the DBT PHP has continually
get behaviors and using more skills. Substance updated programming in response to feedback
use screenings (i.e., Alcohol Use Disorders from program staff, adolescents, and their fami-
Identification Test (Bush et al., 1998), Drug lies. In the spirit of direct communication, staff
Abuse Screening Test (Skinner, 1982), Heaviness inquire about aspects of the program that have
of Smoking Index (Heatherton et al., 1989)) help proved beneficial or have not been helpful to ado-
elucidate the extent of substance use, as anecdot- lescents and their parents/guardians while in the
ally, the DBT PHP has found the adolescents to PHP. In addition, adolescents are gifted at “not
10 Dialectical Behavior Therapy 171

mincing words” and have used plenty of irrever- to be approved by the larger team. Often
ence and wit when communicating their likes and behavioral contingencies are set for this addi-
dislikes. The following are lessons learned over tional period of program attendance. An
the last 13 years of programming: extension in the program is a “reward” for
ongoing commitment and skills use.
• Curriculum: The curriculum is annually • Lunch Breaks: While initially permitted an
reviewed to reflect the most updated DBT hour for lunch, adolescents are more effective
material. Groups are appraised to ensure they with less unstructured time and are currently
are teaching the most relevant skills in an only allowed a 30-minute break for lunch on
engaging, thoughtful manner. the hospital grounds.
• Admissions: The clinicians have developed a • Parental Involvement: Adolescents improve
higher comfort level in taking adolescents faster if both parents are actively involved in
with more varied and complex symptoms in their treatment by attending the parent skills
addition to higher risk as they have developed group and family session. When there is con-
more expertise from specific trainings. The tention between parents due to divorce or
DBT PHP also limits the admission of middle other reasons, this may require splitting fam-
school adolescents due to their immaturity, ily sessions, much to the adolescent’s conster-
difficulties managing in an older-aged milieu, nation who must attend two family meetings
and their motivation level. per week.
• Program Absences: There is a restricted num- • Environmental Interventions: The DBT PHP
ber of “excused” days off (i.e., can miss one has few environmental interventions, includ-
day that will be excused), which has resulted ing not checking bags when entering the
in nearly all adolescents adhering to this pol- building, not using drug screens, and not
icy. An adolescent can miss for any reason administering medications during the day.
(sick, refusal) and will get an added day with- Skills coaching is encouraged over PRN (“as
out charge. However, if adolescents make a needed”) medications.
pattern of this, they will not be granted addi- • Suicides: Given the treatment of a high-risk
tional days and may be discharged if the team population, the DBT PHP has sadly lost ado-
deems they are not committed to treatment. If lescents to suicide while enrolled in the pro-
there is an extended illness, they will be gram and following discharge from the
required to provide medical documentation to program. Staff have consulted with McLean’s
resume treatment or they will be discharged Spirituality and Mental Health Program, held
from the PHP and placed back on the waitlist. team meetings for families coping with the
• DBT Homework: There is a built-in home- suicide of their child, encouraged adolescents
work group during the program day, which in the program to grieve, spoken at memorial
has helped prevent homework non-­completion. services, and maintained contact with families
The homework group helps adolescents strug- who lost their child.
gling with completing assignments, so they • Social media/friendship: It has not been fea-
can receive extra help sooner. Additionally, sible to restrict social media, although the
there is a “homework party” as a reward for importance of not posting photos of other ado-
the group completing 94% of assignments, lescents in the program for confidentiality is
and this has been remarkably successful in stressed. Adolescents are permitted to connect
motivating adolescents to complete the work. and form friendships within the program. Staff
• Program Length: The program was initially highlight not engaging in target behaviors
four weeks in length. The DBT PHP now with each other and not using each other for
allows an extension in the program for up to skills coaching.
two weeks (or ten additional days), provided • Out of state/International families: Clinicians
they fill out a program extension application have had to set expectations for out-of-state
172 K. L. Batejan et al.

and international families when the adolescent screening test for problem drinking. Ambulatory Care
Quality Improvement Project (ACQUIP). Archives
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home. Families are encouraged to return home Dimeff, L. A., & Linehan, M. M. (2008). Dialectical
over the weekend to practice using skills in behavior therapy for substance abusers. Addiction
Science & Clinical Practice, 4, 39–47. https://doi.
their more natural environment. org/10.1151/ascp084239
• Virtual Care Delivery: In March of 2020, the Goldstein, T. R., Fersch-Podrat, R. K., Rivera, M.,
DBT PHP closed for in-person treatment at Axelson, D. A., Merranko, J., Yu, H., Brent, D. A., &
the start of the COVID-19 pandemic, and Birmaher, B. (2015). Dialectical behavior therapy for
adolescents with bipolar disorder: Results from a pilot
within 2 weeks, launched a telehealth program randomized trial. Journal of Child and Adolescent
to offer DBT treatment. The schedule was Psychopharmacology, 25, 140–149. https://doi.
modified and condensed, offering DBT groups org/10.1089/cap.2013.0145
in the morning (9:00 AM to 12:00 PM) and Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan,
M. M. (2012). Treating PTSD in suicidal and self-­
individual, family, and psychiatry consulta- injuring women with borderline personality disor-
tion in the afternoon (12:00 PM to 3:00 PM). der: Development and preliminary evaluation of a
This structure allowed for screen breaks and Dialectical Behavior Therapy Prolonged Exposure
some flexibility in the afternoon hours for the protocol. Behaviour Research and Therapy, 50, 381–
386. https://doi.org/10.1016/j.brat.2012.02.011
adolescents. At least one parent/guardian was Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., Rickert,
required to be home during program hours to W., & Robinson, J. (1989). Measuring the heaviness of
be available for contact if their child did not smoking: Using self-reported time to the first cigarette
show up or unexpectedly signed off during of the day and number of cigarettes smoked per day.
British Journal of Addiction, 84, 791–799. https://doi.
treatment. Adolescents were required to show org/10.1111/j.1360-­0443.1989.tb03059.x
their faces, get out of bed, and not mute Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E.,
­themselves. The DBT PHP resumed in-person Klima, J., Rosenstein, D. L., Wharff, E. A., Ginnis,
treatment in May of 2021. K., Cannon, E., Joshi, P., & Pao, M. (2012). Ask
suicide-­screening questions (ASQ): A brief instrument
for the pediatric emergency department. Archives of
Pediatrics and Adolescent Medicine, 166, 1170–1176.
Conclusion https://doi.org/10.1001/archpediatrics.2012.1276
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R.,
Gonzalez, A. M., Morse, J. Q., Bishop, G. K.,
The DBT PHP has evolved, treating more diag- Butterfield, M. I., & Bastian, L. A. (2001). Efficacy
nostically complex adolescents from around the of dialectical behavior therapy in women veter-
world, complicated family and school systems, ans with borderline personality disorder. Behavior
with an increase in unprecedented stressors. The Therapy, 32, 371–390. https://doi.org/10.1016/
S0005-­7894(01)80009-­5
inherent flexibility of DBT has allowed the PHP Lenz, A. S., & Del Conte, G. (2018). Efficacy of dia-
to continue to do program assessment and self-­ lectical behavior therapy for adolescents in a partial
reflection on how the PHP is doing the best it can hospitalization program. Journal of Counseling and
do and needs to do better. Throughout all this, the Development, 96, 15–26. https://doi.org/10.1002/
jcad.12174
DBT PHP’s treatment approach has remained Lenz, A. S., Del Conte, G., Hollenbaugh, M., & Callendar,
steadfast in teaching adolescents to use the skills K. (2016). Emotional regulation and interpersonal
to tolerate difficult emotions, challenge problem- effectiveness as predictors of treatment outcomes
atic thoughts, and reduce target behaviors, and within a DBT treatment program for adolescents.
Counseling Outcome Research and Evaluation, 7,
ultimately build a life worth living. 73–85. https://doi.org/10.1177/2150137816642439
Linehan, M. M. (1993a). Cognitive-behavioral treatment
of borderline personality disorder. Guilford Press.
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 Obsessive Compulsive and Related
Disorders 11
Abbe Garcia and Michael Walther

Program Overview and anxiety disorders (Miranda et al., 2005).

However, such demographics do not reflect char-
The Intensive Program for Obsessive-Compulsive acteristics of the general population in our hospi-
and Related Disorders at The Pediatric Anxiety tal’s catchment area. Such areas are much more
Research Center (PARC) at Bradley Hospital ethnically diverse compared to our patient popu-
treats children and adolescents with primary lation. Patients range in age from 5 to 18 and are
diagnoses of obsessive-compulsive disorder evenly distributed between males and females.
(OCD) and anxiety disorders (e.g., generalized Although the primary diagnosis is OCD or an
anxiety disorder, social anxiety disorder, panic anxiety disorder, comorbidities are very common
disorder, etc.). The program was developed to and do not, in and of themselves, exclude chil-
offer a high dose of staff-supported exposure dren from participating. However, if a comorbid-
therapy delivered in multiple contexts to promote ity is of primary concern or would likely interfere
generalization of gains for patient who had not with engagement with treatment, alternate refer-
benefited from exposure therapy at the outpatient rals are then provided. There are no differences in
level of care or for patients who were so function- the treatment model when the primary diagnosis
ally impaired by their symptoms that they could is an anxiety disorder and not OCD. Although
not engage in treatment without extensive there are no rituals in such cases, the function that
support. rituals serve – escape and avoidance – are still
present in these anxiety disorders cases and
become the center of the behavioral treatment
Patient Population planning.

Patients in this program have been predominantly

Caucasian (97%), which is comparable to sample Program Focus
characteristics in randomized controlled trials
examining exposure with response prevention The Intensive Programs for Obsessive-­
(ERP) in youth with OCD (Williams et al., 2010) Compulsive and Related Disorders are full- and
half-day partial hospitalization services and
A. Garcia · M. Walther (*) involve patients participating in 4 or 6 hours of
Bradley Hospital and Warren Alpert Medical School treatment per day (half- and full-day partials,
of Brown University, Providence, RI, USA respectively), 5 days per week. There is a high
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 175
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_11
176 A. Garcia and M. Walther

level of family involvement in treatment. Families bility is the norm to help patients achieve this
receive either two (half-day partial) or five (full-­ goal. For example, a patient might be over-
day partial) “home” visits per week. The home whelmed about being in a room and speaking
visits, which may or may not actually occur at the with strangers; therefore, on their first day, they
patient’s home, are conducted by bachelor’s might be paired 1:1 with a BHS and they can be
degree-level behavioral health specialists (BHSs). eased into group participation gradually over
The purpose of the visits is to support skill gener- time as clinically appropriate.
alization to real-life contexts (e.g., home, school,
public places) in which the patient’s symptoms
are most interfering. During visits, family mem-  ength of Stay and Follow-Up Care
L
bers learn how to become exposure coaches, first Models
by watching how the BHSs run the exposure
exercises and later in treatment by taking the lead Our program’s average length of stay is 32 days,
in running exposures while receiving BHS sup- but there is a lot of variability in length of stay
port. Visits are also a prime opportunity for BHS because our approach is competency-, as opposed
staff to collect observational data about accom- to curriculum-based. Occasionally, patients must
modation of OCD that may occur within the fam- be moved to higher levels of care. The two most
ily, but which has become so engrained in the accessed higher levels of care include transfers to
system that it may not have been reported during inpatient psychiatric units and referrals to spe-
the intake process. Parents are also expected to be cialized residential programs. Transfers to inpa-
available for weekly family therapy sessions held tient psychiatric units occur when a patient
by their team’s psychologist and psychiatrist. requires a higher level of care to maintain safety
Exposure with Response Prevention (ERP) is to self or others (e.g., active suicidality that has
at the heart of the interventions delivered in our not improved despite being addressed in pro-
partial programs. The goal of ERP is to promote gram, sustained aggression) or emergence of
habituation, or the lessening of distress, by more severe illness (e.g., hallucinations or mania
encouraging the patient to gradually approach (as requiring hospitalization). Referrals to special-
opposed to avoid) triggers of distress, while ized residential care occurs when a child other-
simultaneously supporting the modification, wise meets inclusions criteria for our program,
reduction, and/or elimination of accompanying but severity of symptoms or other factors lead to
rituals. A central idea underlying ERP is that in suboptimal improvements or difficulties consis-
those with OCD and the anxiety disorders, behav- tently engaging in treatment. For such patients
iors such as ritualizing, avoiding, and escaping and families, specialized, exposure-based resi-
serve to prevent habituation, and that such behav- dential care can provide greater structure and
iors increase over time because they are nega- control over the environment compared to partial
tively reinforced. For patients who have already hospitalization.
received ERP in other contexts, our goals are to Transitions to lower levels of care are explicit
optimize the dose of exposure received and to goals in treatment. The most common transition
troubleshoot any obstacles encountered in prior to a lower level of care involves discharging from
treatment. For patients who have not previously our program and continuing treatment at the out-
received ERP, which is the more common situa- patient level of care. A primary indicator of readi-
tion, our main goal is to initiate a course of expo- ness to transition to outpatient care is a child’s or
sure therapy and move the patient and family far family’s autonomy in use of exposure skills.
enough into the process that they can be success- Given how exposure therapy delivered at the out-
ful completing it at the outpatient level of care. patient level of care involves repeated practice of
Understandably, given the nature of our popula- exposures between sessions, it is critical that
tion, many children are anxious about attending families be in a position of having independent
program. Daily attendance is expected, but flexi- success away from program in carrying out expo-
11 Obsessive Compulsive and Related Disorders 177

sures. Thus, specific attention is paid to teaching therapy sessions in their daily lives, where the
families exposure-based skills, and then building symptoms were more intense and impairing than
in room for independent practice. An additional during office-based outpatient sessions. We knew
criterion for demonstrating readiness to transition that the core feature of any more intensive pro-
to outpatient care involves consideration of over- gram had to be flexible, in real-life support for
all level of impairment. Remission of symptoms exposure tasks.
is not expected during partial hospitalization;
rather, proficient use of skills, relative stability in
functioning, and projected ability to make a Resources, Finances
­successful transition to next steps in care (e.g., and Stakeholders
returning to school) are collectively weighed.
Although our program is defined as partial We were lucky to be part of a hospital system that
hospitalization, we at times work with families has a dedicated child and adolescent psychiatry
and insurance companies to create a more grad- hospital within it. We were also fortunate that this
ual reduction in the intensity of treatment. We are hospital had already been successful launching
especially likely to consider such an approach for several other partial hospitalization programs
children and families where an abrupt transition (PHPs). There were already negotiated insurance
from partial hospitalization to outpatient care is contracts that were flexible enough that we could
clinically contraindicated. For example, we may fit our model of care within their parameters.
propose that “stepping down” from 5 days per Hospital leaders already had financial models
week to fewer days per week for a designated based on those contracts and there were manag-
period is a more clinically sound approach and ers who helped us figure out how to adapt these
eases a child and family into the transition away generalist services to our specialty population
from our program and into outpatient care. (e.g., staffing ratios, interdisciplinary models).
Hospital leadership was willing to fast-track our
launch in the middle of a fiscal year giving us
Program Development space that was vacated by 2:30 pm each day. We
and Implementation launched with nine patients, one psychiatrist,
three psychologists, part of a shared nurse, one
Our program grew out of PARC’s treatment out- social worker, and four full-time bachelor’s level
come research laboratory and associated training BHSs. We benefitted from the fact that Bradley
clinic for advanced child and adolescent psychia- Hospital already had general training for bache-
try and psychology trainees (residents and fel- lor’s level staff, and we were able to hire three of
lows). The need for a model of care that could our four initial BHSs from other units at Bradley.
support flexible delivery of a higher dose of staff-­ Because of PARC’s long history of training both
supported ERP was evident as the number of psychiatry and psychology trainees, we were also
patients who had not been able to benefit from able to integrate both types of trainees into our
ERP at the outpatient level of care began to over- service delivery model. Our model does not
whelm our outpatient training and research cen- depend on trainees to run, but when a trainee is
ter’s ability to provide quality care. We had a assigned to our rotation it enriches the care we
plethora of patients who did not need inpatient can provide.
care and had not benefitted from partial hospital- Stakeholder engagement has been a very
ization in general service programs. Their func- important part of the success of our program.
tioning (e.g., school performance, ability to do Despite having pre-existing insurance contracts
activities of daily living at developmentally typi- and expert utilization reviewers at the hospital,
cal levels) was highly impacted by their symp- the first group of stakeholders that we needed to
toms. They, and their families, were unable to cultivate were the insurance companies. One part
successfully practice ERP homework outside of of this effort included negotiating for higher rates
178 A. Garcia and M. Walther

for our initial program with some of the insur- reunions for all program graduates and their par-
ance companies who had grouped our services ents. These events have been a huge success.
under the Intensive Outpatient Services heading Patients come from far and wide to reconnect
in their billing contracts although we were pro- with each other and the treatment team. We also
viding much more care than those services typi- come together annually as a team for the Ten
cally deliver. We were able to use our expertise as Thousand Steps for OCD Awareness walk hosted
treatment outcome researchers to collect careful by the International Obsessive Compulsive
data on our early patients to demonstrate to Disorder Foundation. We are proud to have won
­insurers the effectiveness of the services we were the award for largest team every year that we
delivering. In another vein, our utilization review- have attended. Several of our graduates have
ers were educating their counterparts on the gone on to become advocates for mental health
insurance side during initial and concurrent awareness on the internet and/or in their local
reviews. These insurance representatives were communities.
most accustomed to higher levels of care being Navigating institutional expectations has been
driven by safety concerns and, in the absence of part of our experience throughout our existence.
those, they were at first hesitant to approve our We have applied for a lot of waivers from the
patients’ admissions beyond just a few days. usual hospital policies. For example, before the
Over time, we and our utilization reviewers pandemic, we had to convince hospital leader-
became more adept at highlighting the way that ship why it made sense to disable the hand sani-
our patients’ severe impairments in activities of tizer dispensers in our section of the hospital and
daily living (ADLs) were just as valid for satisfy- why we did not want each of our patients given
ing the medical necessity criterion as the safety their own personal bottle of hand sanitizer at
issues so common on other units. admission. We lost the battle to allow us to keep
a large meat cleaver in our program closet, but we
were grateful to be able to be more liberated
Patient Caregivers as Stakeholders about exposure content during home visits. We
learned how to document contamination expo-
The second group of stakeholders that we have sures in the medical record so as not to inflame
been so fortunate to have on our team are our the risk managers at the hospital. Specifically, we
former patients and their families. Very soon document in the chart what cleaning procedures
after we launched, one of the parents of a recent we use before the patient engages with the “con-
graduate of the program was able to start a par- taminated” trigger at the hospital. We obviously
ent support group that met once a month at the do not do these cleaning protocols in front of
hospital. At first, none of the program staff were patients. Lastly, as we have developed the role of
involved; it was a purely parent-led initiative that our BHSs over the years, we have realized that
was supported by the Family Liaison coordina- their training and job expectations are quite dif-
tor at the hospital. As an outgrowth of that group, ferent from those on other units in the hospital,
a smaller group of parents formed, who were and we were recently granted permission to offi-
focused on helping the program grow and pros- cially change their titles and job descriptions. We
per, calling themselves the PARC Parent did this because the hospital had been treating
Advisory Group. The parents in this group were BHSs as interchangeable across units, and
especially focused on how long it had taken their because of the specialized training our staff have
children to be properly diagnosed and how long received in the principles and practical skills for
it had taken them to find effective treatment. delivering exposure therapy with high fidelity to
These parents helped us see how important it the behavioral model, we were not able to accept
was to cultivate a sense of belonging to a larger staff from other units. We also felt that the more
community of advocates among our patients and generic title of BHS did not acknowledge the
staff. With the help of the director of develop- expertise our staff have in a specific treatment
ment at the hospital, we started hosting annual modality.
11 Obsessive Compulsive and Related Disorders 179

Day-to-Day Programming child with OCD, compulsions/rituals are main-

tained by the distress reducing function they
Because we offer several different intensive pro- serve. Escape and avoidance behaviors function
grams within our service line, what follows is an similarly in those with anxiety disorders.
example of one such program. In our “six-hour” Although such behaviors serve to negate, reduce,
PHP, families arrive at the hospital at 8:30 am, or prevent distress, such behaviors also prevent
and children are picked up at 1:00 pm. Each day the patient from developing mastery over distress-­
involves a slightly different schedule in terms of inducing situations.
specific activities, but a representative day would Stemming from our theoretical framework,
involve: we aim to provide patients with the opportunity
to develop mastery over distress-inducing situa-
• 8:30–8:45 – Drop off, parent check-in with tions through the use of ERP. This involves the
staff, while patients transition into the milieu. gradual approach to (as opposed to avoidance of
• 8:45–9:00: group check-in in the milieu or escape from) triggers of distress. ERP addi-
(group discussion of each patient’s homework tionally involves teaching the child to modify,
and troubleshooting; goal setting for in-­ reduce, and/or eliminate compulsions/rituals that
program ERP groups) occur in response to obsessions. ERP is thought
• 9:00–9:45 – Exposure Group I: Individual to facilitate a learning process that leads to the
ERP in the milieu, supported by BHSs gradual reduction of distress over repeated learn-
• 9:45–10:00 – Snack ing trials (Foa & Kozak, 1986).
• 10–10:45 – Group therapy/mindfulness
practice
• 10:45–11:30: Art therapy/physical activity Structure of Intervention
• 11:30–12:00: Lunch
• 12:00–12:45: Exposure Group II: Individual Children and families in our programs participate
ERP in the milieu, supported by BHSs in individual therapy, weekly family therapy,
• 12:45–1:00: Check out and planning for home group therapy, and medication management.
visits that will occur that afternoon. ERP skills are typically taught through a combi-
• 1:00: Parent pick up and check out with BHSs nation of individual therapy (provided by pro-
gram psychologists and psychiatrists) and group
Daily, each patient has a 90-minute home therapy (provided by BHSs). During group ther-
visit. Usually these occur between 2:00 pm and apy, exposure work is supported by peers, and
5:00 pm, but occasionally patients may have their completed in a milieu-based setting. Weekly fam-
visit before program hours in the morning ily therapy typically involves teaching families
(6:30 am–8:00 am) if their symptoms are espe- about our treatment model and gathering input
cially entangled in their morning routine. about the impact of a child’s symptoms on family
functioning. Also, because parental accommoda-
tion of symptoms is typically very high in those
Theoretical Framework with OCD and anxiety disorders (Lebowitz et al.,
2013), family members are taught how to gradu-
The theoretical framework used in our programs ally reduce such accommodation (e.g., providing
broadly encompasses cognitive behavioral ther- reassurance, completing tasks for their child that
apy (CBT). Within this framework, we aim to would otherwise elicit distress, etc.). ERP work
understand a patient’s symptoms through case is also supported through “home” visits in which
conceptualization in which the variables that BHSs travel to a family’s home (or meet with
maintain symptoms are identified. Understanding them out in the community); a primary function
negative reinforcement is almost always part of of such visits is to generalize exposure skills to
such a conceptualization. For example, for a environments outside of the hospital setting.
180 A. Garcia and M. Walther

Such work also provides additional opportunity could appear to score high on the CYBOCS and
for our team to coach family members how to use similarly someone with OCD could appear to
ERP or other types of skills covered in weekly score high on a measure of social responsiveness.
family therapy sessions in real life settings. By the time of discharge, 11% of patients leave
our program with an ASD diagnosis.

 se of Empirically Informed
U
Assessment  se of Empirically Informed
U
Interventions
The gold standard, empirically supported assess-
ment tool for OCD in children and adolescents is  vidence Base for Outpatient Level
E
the Children’s Yale Brown Obsessive Compulsive of Care
Scale (CYBOCS) (Scahill et al., 1997). In our
program, all patients with an OCD diagnosis To date, there have been three comprehensive
have a CYBOCS completed at the time of admis- reviews of the psychosocial treatments for pedi-
sion, and ideally it is repeated at discharge. The atric OCD (Barrett et al., 2008), 16 studies pub-
CYBOCS is the tool used in all clinical research lished between 1994 and 2007; (Freeman et al.,
with OCD and therefore the CYOBCS score can 2014), 18 studies published between 2007 and
be used to compare symptom severity from our 2012; (Freeman et al., 2018), and 26 studies pub-
context to those in other programs. The median lished between 2013 and 2017. These reviews
baseline CYBOCS score for our patients is 28 out evaluated the evidence base according to, first,
of 40 (severe range is 24–31). In total, 29% of the Chambless and Hollon (1998) criteria, and
patients rank in the extreme range at admission then using an update to those criteria offered by
(scores ≥ 32). It is our intention to use the Southam-Gerow and Prinstein (2014). These
Pediatric Anxiety Rating Scale (PARS; Research reviews have all deemed CBT a probably effica-
on Pediatric Psychopharmacology Anxiety Study cious treatment for youth with OCD at the outpa-
Group (2002)) as an alternative to the CYBOCS tient level of care. In addition to these literature
when the patient’s primary diagnosis is an anxi- reviews, multiple meta-analyses have been con-
ety disorder and not OCD. However, compliance ducted looking at psychosocial treatment of OCD
with using this measure is much lower than with in children (Rosa-Alcázar et al., 2015) and of
the CYBOCS. Our clinicians are less familiar CBT for pediatric OCD specifically (Ivarsson
with the PARS because they use it less often than et al., 2015; McGuire et al., 2015; Öst et al.,
the CYBOCS and, as a result, in our busy clinical 2016). The clear conclusion from these analyses
context, the PARS is often pushed aside. We are is that there is robust support for CBT as an effec-
working to integrate both measures more fully tive treatment for pediatric OCD at the outpatient
into the clinical workflow by embedding them in level of care.
the medical record. Regarding the evidence base for the use of
One of the assessment challenges in our medication in the treatment of youth with OCD,
patient population is differential diagnosis with the most recent Practice Parameters from the
co-occurring autism spectrum disorders (ASD). American Academy of Child and Adolescent
Often it is not clear at the time of admission Psychiatry (Geller & March, 2012), based on
whether a patient’s repetitive behaviors are more “careful examination of 65 publications” that
consistent with OCD or ASD or whether they were deemed high quality and clinically relevant,
have features of both. We are further constrained indicate that for mild to moderate OCD, CBT
by the lack of adequate assessment tools that can should be the first line treatment, and for moder-
distinguish between these two categories. For ate to severe OCD there is a role for medications
example, without clinical judgment guiding the as augmentation agents. Among medication
choice of assessment tool, someone with ASD agents, selective serotonin reuptake inhibitors
11 Obsessive Compulsive and Related Disorders 181

(SSRIs) are considered the first-line class of  vidence Base for Higher Levels of Care
E
medications for pediatric OCD. In addition, the Despite the established benefits of CBT and medi-
Practice Parameters recommend use of medica- cation treatment reviewed above, some people do
tion to address “any situation that could impede not respond to these treatments at the outpatient
successful delivery of CBT,” which may include level of care. This reality has led to the develop-
using medication to treat comorbid conditions ment of more intensive treatment delivery sys-
(e.g., mood disorders, ADHD). tems like residential, intensive day treatment, and
Given the importance of gaining access to even inpatient hospitalization. In addition to
CBT for OCD, novel adaptations to the delivery patients with inadequate response to lower levels
method of CBT have been increasingly com- of care, patients with complex presentations
mon over the last 15 years, including intensive including multiple comorbid diagnoses and
delivery approaches. Intensive approaches were extreme functional impairment are also candi-
also reviewed in the psychosocial evidence dates for these higher levels of care. In children
base updates mentioned previously. The stan- and adolescents, there is little data about the out-
dard approach in these delivery formats is to comes from these higher intensity formats. One
provide longer sessions (range: 90 min- exception to this is the report on the naturalistic
utes–3 hours) on consecutive (or nearly con- outcomes of 172 youth who had residential treat-
secutive) days for a shorter period (e.g., Storch ment for OCD at Rogers Memorial Hospital
et al., 2007 where total ERP dose was 21 hours (Leonard et al., 2016). Youth in that study received
over 3 weeks). This contrasts with the typical an average of 26.5 hours per week of CBT for
delivery format of 1 hour, once a week for about OCD; they had around-the-clock staff monitoring
3–4 months. The rationale for these approaches and support to assist with ritual prevention, home-
is that people who do not have access to CBT work compliance, and other treatment compo-
for OCD in their local area may be able to travel nents for comorbid conditions. Patients
to a site where specialized intensive treatment experienced significant decreases in OCD and
is available. In an attempt to make this model of depression severity from intake to discharge.
delivery even more feasible, newer models have We could not find any published reports of
tested delivery of intensive CBT in even shorter outcomes for youth with OCD who were treated
durations such as 8 hours and 20 minutes over in inpatient or partial hospitalization levels of
5 days (Whiteside et al., 2014) or 7 hours over care. One study examining cost-effectiveness of
three sessions in 3 weeks, with three 45-minute treatment alternatives for treatment of refractory
Skype sessions for the three immediate weeks OCD in youth (Gregory et al., 2020) references
afterward (Farrell et al., 2016). There have been an outcomes database held at Rogers Memorial
several controlled trials of these outpatient- Hospital and refers to data from the partial hospi-
based intensive approaches, all of which show tal level of care in the cost-effectiveness analysis,
strong initial efficacy (Farrell et al., 2016; but no details are given about the sample size, the
Storch et al., 2007; Whiteside et al., 2014). In outcomes themselves, nor any details about the
addition, some propose that concentrated, pro- components of the partial hospital treatment. We
longed exposure practice may allow for more believe that partial hospitalization is an important
fear extinction opportunities than traditional alternative to other high level of care treatment
formats (Farrell & Milliner, 2014). Other adap- options because many patients’ OCD symptoms
tations of the intensive treatment delivery are rooted in their homes or in other places in
approach have included group-based CBT for their real lives, and neither residential nor inpa-
OCD, which have demonstrated positive out- tient treatment addresses symptoms that occur
comes (Olino et al., 2011; Sperling et al., 2020). outside the hospital setting.
182 A. Garcia and M. Walther

 pplication of Empirically Informed

A ing to engage in rituals), in which they use tally
Treatment marks to track the number of successful expo-
In our program, each patient is assigned one pro- sures (resists), the number of exposures that
gram psychologist and one program psychiatrist. involve ritualizing (submits), and of those that
The psychologist leads the behavioral part of the included a ritual, they record the number of expo-
treatment plan and the psychiatrist leads the med- sures that included a re-initiation of the exposure
ical/medication part of the treatment plan. The (re-exposure). Boss Books are used during all
treatment team meets daily to create and update parts of the program day as well as before and
the treatment plan with an emphasis on titration after program hours. Patients provide the data
of the planned exposure exercises. Each week the from their Boss Books each morning during
psychologists provide two individual therapy ses- check-in, and this provides an opportunity to
sions, the psychiatrist provides at least one medi- publicly commit to the goals of exposure, cele-
cation management session, and the two providers brate successes, and support and brainstorm
collaborate for at least one family therapy ses- when troubleshooting is necessary. These data
sion. Unlike in outpatient therapy, the focus in are shared at the daily treatment team meetings to
the sessions with the psychologist is less on assist with exposure titration for upcoming expo-
delivery of ERP and more on planning for ERP sure exercises. One of the BHSs at PARC dedi-
and troubleshooting any obstacles that could cates 20 hours per week to a research assistant
occur when BHSs are delivering ERP in the role – managing the collection and cleaning of all
milieu or in community settings. Individual ses- of these clinical data.
sions also offer an opportunity to deliver other
CBT interventions for comorbid conditions and Milieu Activities The other milieu activities
to plan with patients for their involvement in delivered during the program day are all designed
family therapy sessions. to support effective use of ERP. Team building
The core adaptation in the treatment delivery and a culture of collaboration among the whole
approach at PARC is the use of bachelor’s level treatment team and the patients is a very potent,
staff as the primary exposure delivery labor force. non-specific treatment element at PARC. Patients
There are four bachelor’s degree-level BHSs on engage in collaborative projects, psychoeduca-
each treatment team at PARC. Patients work with tional games, and art therapy. These activities
all BHSs on their team during their admission. support a culture that helps motivate patients to
The BHSs run the program milieu, which is the take on harder exposures than they might be will-
group in which the patients are engaged when ing to try if they were doing ERP in a more tradi-
they are not in a therapy session with one of their tional, individual treatment approach.
doctors. Each program day includes two one-­
hour exposure groups. During exposure group,
each patient is working on an individually Home Visits The other core innovation at PARC
designed ERP task and the two to three BHSs in is that the BHSs provide daily, one-on-one
the room flow from patient to patient providing “home” visits. The main objective during these
assistance and direction as needed to keep visits is to practice ERP in the real-life contexts
patients on task and to help titrate exposure dif- in which patient’s symptoms interfere. Staff
ficulty as needed. When patient exposures cannot schedules are set up strategically across the day
be done in the milieu room, staffing patterns are to allow for visits in the early morning (i.e.,
flexible enough to allow patients to go elsewhere before coming to program), visits in the evening,
on the hospital campus with a BHS to complete as well as visits during the school day to assist
their assigned task. Patient progress on daily with school transitions. These daily visits also
exposures is recorded on daily exposure tracking provide important opportunities for transfer of
grids. In addition, all patients are given a small control of the exposure process from the treat-
notebook called a “Boss book” (derived from the ment team to the patient and family. Indeed, par-
idea that a child is “bossing back” OCD by refus- ent involvement in these visits is one of the key
11 Obsessive Compulsive and Related Disorders 183

ways that we train parents how to respond more in their symptoms. In addition, family members
effectively to their child’s symptoms. The fre- are often key players involved in the generaliza-
quency of these visits as well as the sometimes tion process during “home” visits. For example,
intimate setting in which they occur (e.g., around home visits often include repetition of the same
the family dinner table) provide a level of trust exposure exercises – first with the BHS leading
and connection between patients, their parents, and then with a parent leading. Specific training
and our staff that is rarely achieved in more tradi- for how to create a collaborative tone during
tional delivery formats. When patients are exposure planning is a key part of these visits.
­graduating from our program, they or their par- Many parents are so accustomed to being in
ents frequently list the relationship with the BHSs charge that they need extra support and direct
as one of the key ingredients of the program that modeling for how to work together with their
led to success and one of the pieces they are most child to assess the level of difficulty of a potential
sad to leave when they discharge. exposure exercise and how to brainstorm alterna-
tives that are harder and easier. Managing patient
Regarding diversity, equity, and inclusion, refusals to participate in exposures and recovery
PARC is in the early stages of reviewing our from highly charged emotional outbursts are
treatment approach to make it more accessible to other key lessons parents learn by watching our
a wider range of patients and their families. The staff interact with their child. Parents accumulat-
current model is very resource-intensive for fam- ing some verbal and nonverbal tools to try on
ilies – someone must drive the patient to and their own. They are also learning that distress
from the hospital five-days/week, at least one during exposures is temporary. This experience
parent must be available to participate in weekly gives them confidence to stay the course rather
family therapy sessions during prime daytime than reverting to soothing or accommodating,
hours (8:30 am–1:00 pm), and patients who have which would bring the exposure to a premature
parents who can participate in daily visits clearly and less effective ending.
have an advantage over those who do not. The
COVID-19 pandemic forced all PARC program-
ming to go virtual, which has afforded more flex- Schools
ibility for families – no transportation is needed,
and parents can participate in family therapy and We also frequently collaborate with schools. It is
community visits with less time lost from work common for patients in our program to have trou-
or other duties. We are hopeful that the insurance ble attending school due to OCD and anxiety-­
contracts and state laws will continue to support related triggers occurring in the school
the integration of some virtual work into our core environment. Such difficulties can lead to tardi-
model even after the pandemic is over. We have ness, refusal to attend, and/or a decline in func-
been collecting data during the pandemic so that tioning in the academic setting. As is the case in
we will be able to make decisions about which our family work, collaboration with schools often
elements are effective when delivered virtually. involves finding key stakeholders at the school
(e.g., guidance counselors, adjustment counsel-
ors, case managers, school social workers, and
Collaborations and Generalizing psychologists), and where clinically appropriate,
Treatment Gains with family’s consent, we often work to educate
the school personnel about OCD and its treat-
Families ment. Those at a given school often benefit from
guidance about the appropriateness of school-­
Our treatment model relies heavily on direct based accommodations. Such guidance often
training of important adults in our patients’ lives. involves striking a balance between accommoda-
Children and adolescents with OCD and anxiety tions that are needed (at least temporarily) versus
disorders often directly involve family members those that could lead to more escape and avoid-
184 A. Garcia and M. Walther

ance behaviors. At times, school-based accom- since opening in 2013. REDCap is a secure
modations are too numerous and extreme, which web application for building and managing
can inadvertently prevent patients from gaining online surveys and databases. Table 11.1 lists
mastery over anxiety-provoking situations at the current data being collected in our pro-
school. At other times, however, a child may not gram. There are multiple reporters all contrib-
yet have been identified as needing uting data to the pool – patient, parents,
­accommodations even if they are clinically war- psychologist, psychiatrist, and BHSs. There
ranted. If accommodations are clinically indi- are three modes of data collection. For the
cated, members of our treatment team collaborate attendings and the BHSs, some of the data are
with a child’s school so that clinically informed extracted from the standard documentation in
accommodations can be introduced. the medical record that they complete as part
Patients in our programs also often benefit of their daily duties. Compliance is highest for
from a clinically informed return to school. Some these measures. For patients and families, we
patients may have been out of school for months have tried a few different methods of collect-
before being able to return. We often collaborate ing self- and parent-report questionnaires. We
with schools to create a transition plan that had poor compliance when patients and fami-
involves having a child tackle some elements of lies were given packets of measures to be com-
the school transition before discharge. For exam- pleted outside of program hours by paper and
ple, some patients start tutoring to catch up aca- pencil, and this also meant long delays in data
demically. Other patients need to be doing availability for the team due to data entry bur-
school-based exposures before their return, espe- den. We also had compliance issues when
cially if their symptoms present unique chal- patients and families were emailed a link to
lenges at the school (e.g., the school bathrooms complete surveys of those same question-
being uniquely contaminated). naires, again, on their own time. All of this led
to the current strategy which is to integrate
data collection using the REDCap platform
Treatment Providers and Others into some of the initial clinical contacts during
the admission. The task of electronically com-
Collateral contact with outside treatment provid- pleting the patient intake packet offers a grad-
ers occurs at admission to help with treatment ual way to integrate them into the milieu.
planning and case conceptualization. Similarly, When parents are completing their packet dur-
coordination of care as patients approach dis- ing the orientation at the first home visit, the
charge is carefully considered including inviting patient can engage with the BHS staff more
the community providers to be part of the transi- independently while being in the presence of
tion plan for important contexts in the patient’s their parent (i.e., parents are busy so less likely
life (e.g., school, activities). Occasionally, we to dominate the conversation during the first
will also connect with other adults in our patients’ visit). Lastly, psychologists are asked to com-
lives (e.g., clergy, coaches) so that they can plete measures about their patients at intake,
understand how they can support the child as they discharge, and through brief weekly ratings.
return to more typical daily activities. These are the gold standard OCD and anxiety
ratings (CYBOCS, PARS, CGI-S/CGI-I),
which unfortunately our hospital has not been
Integrating Research and Practice able to build in the electronic medical record
in a way that facilitates data analysis.
From program inception, we have been obtain- Predictably, compliance with these procedures
ing patient and parent consent to collect data has been the most variable over time and
about the process and outcomes of treatment. appears largely dependent on the tenacity of
We have been using the REDCap platform the research assistant charged with overseeing
with varying levels of success across time the data collection.
11 Obsessive Compulsive and Related Disorders 185

Table 11.1 Intensive program for OCD and related disorders measures
Measure Timing Reporter Description
Children’s Yale-Brown Admission, Clinician (CY-BOCS; (Scahill et al., 1997). A well-known
obsessive compulsive discharge ten-item semi-structured clinician rated interview. It
scale – If the child has assesses current OCD symptom severity. Obsessions
primary OCD and compulsions are rated on 0–4 point-scales for
five dimensions (time, interference, distress,
resistance, control). The CY-BOCS yields a total
obsession score (0–20), a total compulsion score
(0–20), and a combined total score (0–40). Adequate
reliability and validity have been demonstrated. This
measure is part of standard care
Pediatric Anxiety rating Admission, Clinician (PARS; The Research Units on Pediatric P, 2002):
scale (PARS) – If the child discharge Clinician rating of severity of anxiety symptoms
has an anxiety diagnosis
other than OCD as primary
Clinical global impressions Admission, Clinician (CGI; (Guy, 1976)). The CGI is used to assess overall
(CGI-I and CGI-S) weekly, clinical impressions of severity and improvement
discharge based on symptoms observed and impairment
reported (7-point scale). The 7-point clinician-rated
scale has been used successfully in patients with
OCD (Garvey et al., 1999; Perlmutter et al., 1999).
This measure is part of standard care
Children’s global Admission, Clinician (CGAS; (Green et al., 1994); (Shaffer et al., 1983)).
assessment scale (CGAS) discharge The CGAS ranges from 1 to 100, with scores over 70
indicating normal adjustment. This measure is part of
standard care
Clinician note Admission, Clinician This is the standard summary note that clinicians
discharge complete after meeting with the child and his/her
family. The note will be used to obtain intake and
discharge diagnoses. This measure is part of standard
care
Core obsession themes Admission, Clinician Other researchers have looked at the classification of
discharge OCD symptoms into two core obsession themes of
harm avoidance and incompleteness. This form
determines the primary and secondary symptoms that
fall into each of those two themes. This measure is
part of standard care
OCD treatment history Admission Parent (Abramowitz, 2005). This form assesses whether the
form for assessing the participant has had an adequate trial of Cognitive-­
adequacy of previous Behavioral Therapy for treating OCD. This measure
cognitive-Behavioral is part of standard care
therapy trials
Behavioral health Daily in BHS This is the routine clinical note completed by the
specialist (BHS) note program program’s BHSs about each participant’s day in the
program. Of specific interest is the “exposure
success?” question which will be used to determine
the participant’s quality of exposure therapy received
that day. This measure is part of standard care
Medication history form Admission, Psychiatrist This form summarizes participants’ past medication
discharge treatment history and if the participant has been
responsive to that intervention. This measure is part
of standard care
(continued)
186 A. Garcia and M. Walther

Table 11.1 (continued)

Measure Timing Reporter Description
Clinical global impressions Admission, Parent This form has been modified from the original
(CGI-I and CGI-S) – weekly, Clinical Global Impressions scale (CGI; (Guy, 1976))
Parent version discharge to be administered to parents of participants. The
CGI is used to assess overall judgment of
improvement based on symptoms observed and
impairment reported (7-point scale)
Demographics Admission Parent This questionnaire assesses psychiatric history,
questionnaire for parents medical history, developmental history, academic
history, living environment, and family history
Behavior rating inventory Admission, Parent, child (BRIEF; (Gioia et al., 2000)). The BRIEF includes
of executive function discharge both a parent- and child-report version measuring the
child’s executive functioning. It includes eight
clinical scales (Inhibit, Shift, Emotional Control,
Initiate, Working Memory, Plan/Organize,
Organization of Materials, Monitor) and two validity
scales (Inconsistency and Negativity). The BRIEF is
a widely used measure in psychiatric conditions and
has established reliability and validity
Children’s anxiety impact Admission, Parent (CAIS; (Langley et al., 2004)). The CAIS provides a
scale discharge standardized format for assessing the impact of
anxiety on psychosocial functioning. The CAIS
consists of three subscales: Social Impact (11 items),
School Impact (10 items), and Home/Family Impact
(6 items). This measure has been revised to instruct
parents to rate their child’s impairment due to both
anxiety and OCD.
Pediatric accommodation Admission, Parent (PAS; (Benito et al., 2015)) The PAS is a 5-item
scale discharge questionnaire assessing the frequency and
interference associated with accommodating the
child’s anxiety
Sensory questions Admission, Parent This 2-item questionnaire briefly assesses if
discharge participants are experiencing sensory issues
Parent tic questionnaire Admission, Parent (PTQ; (Chang et al., 2009)). The PTQ is a parent-­
discharge report of child motor and vocal tic severity and
frequency
Depression anxiety stress Admission, Parent (DASS-21; (Lovibond & Lovibond, 1995)). This
scales discharge self-report scale measures negative affective
experiences and includes three factors, each
comprising seven items, including Depression
(DASS-D), Anxiety (DASS-A), and Stress (DASS-S)
Pediatric quality of life Admission, Parent, child (PedsQL; (Varni et al., 1999)) The PedsQL is both a
inventory discharge child and parent report measure of quality of life.
This measure has demonstrated good psychometric
properties
Disgust propensity and Admission, Child (DPSS-R; (Olatunji et al., 2007)). This measure has
sensitivity scale-revised discharge good reliability and validity. The literature calls for
further research in the role of disgust in anxiety
disorders. No studies to date have investigated its
role in pediatric OCD
Obsessive compulsive Admission, Child (OCI-CV; Foa, Coles, Huppert, Pasupeli, & Franklin,
inventory discharge in preparation). The OCI-CV is a 21-item self-report
measure that is designed to assess the severity of
children’s OCD
(continued)
11 Obsessive Compulsive and Related Disorders 187

Table 11.1 (continued)

Measure Timing Reporter Description
Child anxiety impact Admission, Child (CAIS-C; (Langley et al., 2014)): examines
scale-child version discharge child-rated functional impairment due to anxiety
(revised) symptoms. This measure has been revised to instruct
children to rate their impairment due to both anxiety
and OCD
Revised children’s anxiety Admission, Child (RCADS; (Chorpita et al., 2000)). The RCADS is a
and depression scale discharge (grades 47-item, youth self-report questionnaire measuring
3rd-12th) total anxiety, total low mood (internalizing), and
subscales, including separation anxiety disorder,
social phobia, generalized anxiety disorder, panic
disorder, obsessive compulsive disorder, and major
depressive disorder
Revised children’s anxiety Admission, Parent (RCADS-P; (Chorpita et al., 2000)). The RCADS-P
and depression scale – discharge is a 47-item parent report that measures the child’s
Parent version frequency of various symptoms of anxiety and low
mood for children in grades 3rd–12th. This measure
produces a total anxiety and low mood (internalizing)
score; and subscales, including separation anxiety
disorder, social phobia, generalized anxiety disorder,
panic disorder, obsessive compulsive disorder, and
major depressive disorder
Parent accommodation Admission, Parent (PAS; (Meyer et al., 2018)). The PAS is a 12-item
scale discharge questionnaire assessing the frequency of and beliefs
about parental accommodation
Affective reactivity Admission, Child (ARI-S; (Stringaris et al., 2012)) The ARI-S is a
index – Self report discharge (ages 6–17) 7-item self-report questionnaire assessing irritability
Affective reactivity Admission, Parent (ARI-P; (Stringaris et al., 2012)) The ARI_P is a
index – Parent version discharge 7-item parent report questionnaire assessing child’s
irritability
Distress intolerance index Admission, Parent This is a 10-item self-report questionnaire assessing
discharge the inability to tolerate negative somatic and
emotional states

Data collection is only one of the challenges et al., 2017; Drljaca et al., 2018; Garcia et al.,
with doing research in a fast-paced clinical envi- 2016; Georgiadis et al., 2017a, b, c, 2018;
ronment. Cleaning the data and creating useable Ramanathan et al., 2017; Stewart et al., 2016;
datasets has also been a monumental task that has Sung et al., 2018a, b). Being able to use data col-
been complicated by changes in the battery of lected in real time to inform clinical care during a
assessments used over time and inconsistencies patient’s admission remains an aspiration for our
in data entry methods. After almost 8 years of team but will require more technological support
data collection, we are just now on the cusp of to make this a reality.
having a dataset of useable data from almost 300
patients with OCD with nearly complete data,
and more than 800 patients with data drawn pri- Research Team
marily from the medical record. Although we do
not have any outcome or predictor data to share at PARC has a very active research team that
this time, program data have yielded a number of works alongside the clinical team. The research
smaller, exploratory conference posters and sym- team has several federally funded projects that
posia over the years (Arora et al., 2018; Conelea are tightly connected to the treatment approach
188 A. Garcia and M. Walther

used in the Intensive Program. The IMPACT  essons Learned, Resources

L
Study, funded by the Patient Centered and Next Steps
Outcomes Research Institute (PCORI; PI
Jennifer Freeman, PhD) is a direct outgrowth Training and Communication
of the treatment delivered in the intensive pro-
gram. As referenced previously, patients and In the years that PARC’s intensive programs have
their parents have been very vocal about the been operating, we have tried to be as attentive as
wish to continue with a BHS doing community possible to training BHSs in delivering high qual-
exposure work after discharge from program, ity ERP. As our census has grown, we have
and yet, our existing insurance contracts do not learned important lessons about training and
allow for this kind of work by a non-licensed growth. In our experience, our BHSs have not
professional at the outpatient level of care. The benefitted as much from workshops and purely
IMPACT Study has been comparing an outpa- didactic teaching compared to experiential learn-
tient level of care adaptation of BHS-­assisted ing and training. When a new BHS joins our
weekly home/community visits to a more tra- team, they shadow a team across its modalities of
ditional office-based outpatient approach. Part treatment, mostly by shadowing other BHSs.
of the project includes negotiations with insur- Because of the milieu-based nature of our pro-
ance companies to cover such services in the gram, such junior staff are often paired in the
future. In another line of PARC research, the room with multiple, more senior staff, and in
Intensive Program has been the beneficiary of a doing so, collaborative exposure work between
series of NIMH-funded studies (PI Kristen staff occurs. Newer staff also shadow BHSs on
Benito, PhD) looking at provider behavior dur- daily home visits. After demonstrating profi-
ing exposure activities. The Exposure Guide is ciency with our treatment model, newly hired
a self-­rated tool to assist with fidelity to the staff begin to engage with children and families
treatment model. We have just begun having with greater autonomy, and eventually graduate
BHSs complete the Exposure Guide for each of from the shadowing role.
their community visits. These data will not We have also found it extremely important to
only allow the research team to make further constantly circle back to improving team com-
revisions of the tool for this type of provider, munication. Treatment is fast paced, compli-
but it will also allow us to report on dose and cated, and with many team members involved,
quality of exposure delivered to program communication could become fragmented. Daily
patients. Lastly, another line of NIH-funded Rounds, in which team members from all roles
research at PARC is examining therapist train- are represented, are critical in disseminating
ing (PI Joshua Kemp, PhD). In addition to the information, reviewing a child’s current exposure
daily treatment team meetings, part of what is work, and collaborating around next steps in
essential for having a highly competent bache- care. Rounds is also a time when team members’
lor-level BHS delivering exposure treatment is needs are expressed, such as having a team mem-
the training and supervision process. This line ber obtain support after a challenging clinical
of research has both drawn on the real-­ life interaction.
experiences training the BHSs at PARC and
has contributed to future trainings by creating
more structured training modules with video Managing Growth: Differentiation
simulations and role play exercises. Just like
exposure therapy itself, training highly compe- As our census has grown since 2013, we have
tent BHSs requires a hands-on, experiential been able to hire attendings with important addi-
approach to training. tional skill sets. For example, because of the
11 Obsessive Compulsive and Related Disorders 189

number of patients treated in our program with This move required several important changes to
comorbid ASD, we have an ASD specialist on treatment delivery. For some children, switching
our team. Similarly, we saw the need to develop a to a virtual format was helpful with exposure
sub-track within our program for youth with work. As children participated virtually from
severe emotion dysregulation accompanied by their homes, some exposure targets were more
urges to self-harm. These youth were not able to accessible. Rather than “home” visits being the
complete exposures without additional tools primary time in which generalization of ERP
being offered concurrently. Therefore, we added occurs, virtual programming provided many
a dialectical behavior therapy (DBT) specialist to additional opportunities for generalization. For
the team and are in the process of launching the example, there may be areas of the home that a
DBT-X Track (Dialectical Behavior Therapy + child has not been able to set foot in due to con-
Exposure). tamination (or other) concerns. As the child ini-
Over time, we have also made structural tially engages from another area of the home, live
changes to our partial programs. Recently, as our exposure work targeting avoided areas of the
six-hour PHP grew, it became untenable to home became more feasible for longer periods of
remain a single team. Because our BHSs work time each day. Exposure titration has also been
with every child in each program, we began to easier, at times. For example, for socially anxious
feel like a maximum size limit was being children, it is often very difficult to come to the
breached. For example, there is a limit to our hospital and acclimate to the group. Although we
abilities to recall important parts of a child’s attempt to ease a child’s participation in person in
treatment plan. In addition, as the census grew, a gradual and clinically mindful manner, our vir-
each staff member was having, on average, fewer tual experiences demonstrate that some children
interactions with each child, making it harder to can do so more effectively in the comfort of their
build rapport and keep up with advances in a own home. Virtual programming from a techno-
child’s treatment. Accordingly, our six-hour par- logical standpoint also offers unique exposure
tial program was split into two “teams,” both titration options, such as having children partici-
involving six-hour partial hospitalization, but pate verbally with their video cameras off (as an
autonomous in their staffing and patients. Such intermediate step toward being on camera and
revamping of the structure of our programs also speaking). For some children, such options have
allowed for a more feasible way to introduce our been very helpful in increasing engagement.
DBT-X track, as that track involved very inten- Virtual programming has also provided addi-
sive training of staff and is currently only offered tional flexibility for involving family members.
on one of the six-hour partial teams. For example, parents can join virtual program-
ming when they are at work. Furthermore, for
families who live in areas that would have other-
 dapting to New Realities:
A wise prevented them from participating (or would
Opportunities and Challenges have required them to temporarily relocate to
Rhode Island), treatment has also been made
Because of the COVID-19 pandemic, PARC more accessible. In states that have provided a
made many programming changes. When it mechanism for temporary medical licensing, we
became increasingly clear that the pandemic have provided care to families residing in states
would fundamentally alter the ability to treat where options for specialized, exposure-based
children and families “as usual,” plans were care is lacking.
quickly developed to transition into a fully virtual The virtual experience led to some changes to
program, in which children and families accessed our day-to-day programming. For some children,
our care through a videoconferencing/telemedic it was harder to build a sense of community
ine format. By April 2020, PARC moved all par- within program and making interpersonal con-
tial programming to a completely virtual format. nections through videoconferencing was diffi-
190 A. Garcia and M. Walther

cult. We found value in making more purposeful gramming have been instrumental in creating the
efforts to create community and stronger inter- vision for an outpatient model that is better suited
personal connections between the treatment team for families and exposure work.
and families. We added more time to our sched-
uled daily “community meetings” at the start of
each program day, where relationship building References
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 Family-Based Interdisciplinary
Care for Children and Families 12
with Comorbid Medical
and Psychiatric Conditions:
The Hasbro Children’s Partial
Hospital Program

Katharine Reynolds, Heather Chapman,

Jamie Gainor, Cheryl Peck, Ana Crook,
Donna Silva, and Jack Nassau

Program Overview and History tion, the program comprised two rooms on the
medical floors of Hasbro Children’s which is the
The Hasbro Children’s Partial Hospital Program pediatric division of Rhode Island Hospital. Our
(HCPHP) opened in June 1998 as a collaboration original patient census included only one patient
between the Department of Pediatrics and the and, consistent with the goal of providing inte-
Division of Child and Adolescent Psychiatry of grated care, our staff included pediatrics, child
Alpert Brown Medical School/Rhode Island psychiatry, child psychology, nursing, milieu
Hospital in Providence, Rhode Island. At incep- professionals, and special education teachers.
One room was for staff, the other for patients.
The program census expanded up to six patients
K. Reynolds (*) within this two-room setting, before moving to a
University of Colorado School of Medicine,
newly renovated space in 2000 in another part of
Aurora, CO, USA
the hospital that included an outdoor courtyard.
Children’s Hospital Colorado, Aurora, CO, USA
Within that location, the program expanded to a
e-mail: [email protected]
capacity of 16 patients separated into two milieus.
H. Chapman
During our most recent expansion of the same
Rhode Island Hospital/Hasbro Children’s Hospital,
Providence, RI, USA space in 2015, the program expanded to a capac-
ity of 24 patients across three milieu rooms to
Department of Pediatrics, Alpert Medical School of
Brown University, Providence, RI, USA better accommodate patients across the develop-
mental spectrum. Patient average length of stay
J. Gainor · J. Nassau
Rhode Island Hospital/Hasbro Children’s Hospital, ranges from 4 to 6 weeks. Most patients step
Providence, RI, USA down to an outpatient level of care following dis-
Department of Psychiatry and Human Behavior, charge; however, a minority of patients require
Alpert Medical School of Brown University, brief inpatient admissions for stabilization prior
Providence, RI, USA to completing HCPHP (e.g., stepping up to inpa-
C. Peck · A. Crook · D. Silva tient to step back down to HCPHP). Once ­families
Rhode Island Hospital/Hasbro Children’s Hospital, have discharged to an outpatient level of care, the
Providence, RI, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 195
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_12
196 K. Reynolds et al.

need for a re-admission to HCPHP is framed as a Our staff includes an interdisciplinary team of
“booster” admission to supplement prior treat- over 40 team members, reviewed in further detail
ment. Notably, “booster” admissions are often below. Across expansions, the primary goal of
shorter than our typical length of stay. HCPHP has been to provide day-hospital treat-
Currently, the program treats patients ranging ment for children presenting with comorbid med-
in age from 6 to 18 years (Average of 13 years), ical and psychiatric conditions within a
separated roughly into elementary, middle-­ family-systems treatment model. The founding
school, and high school age/developmental members of our program (psychiatrist Thomas
groups with a wide range of primary presenting Roesler, MD and pediatrician Pamela High, MD)
diagnoses (see Fig. 12.1). For patients who have sought to develop a program that would collab-
also participated in clinical research, the major- oratively support children struggling with comor-
ity identify as Caucasian (88%), with small bid psychiatric and medical difficulties, as many
minorities of patients identifying as African of these children were not making positive gains
American (5%), Asian (5%), and mixed race/ within the typical standard care models of siloed
other (2%). Regarding gender, the majority of medical and siloed psychiatric care within the
our patients identify as cisgender female (58%), community (Roesler et al., 2018).
with 29% identifying as cisgender male, 10% The acuity of our patients and families has
identifying as gender fluid, and 3% identifying increased over the years, paralleled by HCPHP’s
as gender queer/non-binary. Although all chil- growing national and international reputation.
dren admitted to HCPHP must speak English, These changes are linked with the physical
non-English speaking families have access to expansion and larger census of our program as
Rhode Island Hospital interpreter services noted above, the opening of the Hasbro Children’s
throughout their interactions with all clinical and Medical/Psychiatric Unit, Selya 6 (located on the
administrative staff. sixth floor of the hospital) in 2005, and the suc-

Primary Psychiatric Diagnosis (N=130)

Child Protecve
Concerns
Adherance/Coping 1%
Concerns
18% Somac Symptom
Disorder
22%

Psychiatric
28%
Eang Disorders
31%

Fig. 12.1 Presenting conditions at HCPHP

12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 197

cess we have had with treating many families approach is especially important within our com-
struggling with complex medical/psychiatric plex medical/psychiatric population, as there is
conditions over the last 20 years (Roesler et al., evidence that parents of children with chronic ill-
2018). Families have traveled from within the ness are slightly more demanding and less emo-
region (e.g., New York, Vermont, New tionally warm than parents of healthy children
Hampshire), nationally (e.g., California, without chronic medical conditions (Pinquart &
Arkansas, Florida) and internationally (e.g., Shen, 2011). Notably, authoritative parenting
Germany, Peru) to receive treatment in our styles have been linked with positive outcomes
program. among children with diabetes (Monaghan et al.,
When considering that HCPHP provides treat- 2012), and are less common in families of chil-
ment that (1) occurs at a partial hospital level of dren with chronic pain when compared to healthy
care, (2) integrates families into all components peers (Shaygan & Karami, 2020).
of treatment, (3) treats psychiatric conditions, In line with HCPHP “Community Rules,”
and (4) treats medical conditions, it is no surprise children admitted to the program are often expe-
such a complicated task requires a large team. riencing fatigue (medically related, linked with
Each team member plays a role in supporting the depressive or other psychiatric symptoms, or
overall structure and context of our program, both), and are expected to participate in all parts
which is grounded in the use of the therapeutic of the daily milieu schedule. This expectation is
milieu, balancing empathy and expectations, and in line with the broader literature focusing on
strong behavioral and family systems principles. functioning within somatic symptom disorders as
a primary target for treatment (Lynch et al., 2015;
Randall et al., 2018; Robinson et al., 2019) and
 mpathy and Expectations: HCPHP
E use of exposure with response prevention for tar-
Community Rules geting habituation to distress (Chu et al., 2016;
Silverman et al., 2008). When HCPHP patients
Upon admission to HCPHP, each child and fam- refuse to participate in the program day or attempt
ily are asked to sign both consent to treatment to sleep, they are asked to step out of the milieu
forms as well as our “Community Rules.” The into a side room (framed as “taking a time out”).
HCPHP Community Rules (See Fig. 12.2) is a If a pattern of difficulty participating continues,
list of expectations that provide patients and fam- additional behavioral reinforcements either
ilies with specific program guidelines and rules within HCPHP (e.g., utilizing our “Point Store”
that they agree to abide by for the duration of reward system; discussed below) or reinforce-
their admission. These guidelines help patients ments/contingencies implemented at home (e.g.,
and families know what to expect while attending losing access to preferred activity briefly or until
the program. Community Rules are written in the desired behavior is produced) are often inte-
clear, simplistic terms and in multiple languages. grated into the structure of a child’s behavior
This early introduction to clear and consistent plan. Of note, when patients violate a community
limits sets the tone for the expectations within the rule, such as swearing in the milieu or being dis-
milieu, and the broader theme of consistency in respectful to a peer or staff, they must repair the
limit setting. relationship (e.g., apologize publicly within the
To meet criteria for HCPHP admission, chil- milieu or directly to staff; explain what they were
dren must have a functional impairment that experiencing that led to inappropriate behavior)
impacts their daily life. The empathy of milieu before they are permitted to continue with their
providers, in conjunction with our clear and con- day, echoing one of the core tenets of Radically
sistent limits serves as a proxy for authoritative Open Dialectical Behavioral Therapy (RO-DBT;
parenting, thereby modeling a parenting approach Lynch et al., 2015). In some cases, this means
for families that they can generalize to home over that patients are removed from the milieu and
the course of a child’s HCPHP admission. This remain in a side room for an extended period of
198 K. Reynolds et al.

HCPHP Community Rules

1. This is a smoke free environment.
2. Alcoholic beverages and non-prescribed drugs are not allowed on Rhode Island Hospital grounds.
3. Community members’ arrival times are based on the milieu they are in. Milieu #1 check in time is 7:45a.m.,
Milieu #2 check-in time is 8:00am, and Milieu #3 check in time is 8:15 am. Upon arrival at the program,
parents and patients need to submit a completed attestation form as part of program screening upon
entering the program. Once they have been cleared by the screener(s), parents remain in the waiting room
while patients are escorted into their respective milieus.
4. Community members are expected to participate in all program activities, therapy sessions, and medical
appointments.
5. Community members must remain in their assigned program area unless accompanied by a staff member.
6. Consideration and care should be shown for all hospital property as well as the property of other community
members.
7. Community members using inappropriate language such as swearing, name-calling, racial slurs, rude
comments, threats etc., will be removed from the area immediately.
8. Breakfast, lunch, and snacks are provided daily during the program hours. Food (including gum and candy)
and drinks are not to be brought from home.
9. Physical or sexual contact between community members is not permitted.
10. The program strongly discourages outside communication such as telephone calls, e-mail, any social media
forum (Instagram, Snapchat, Twitter, Facebook, etc.), or in-person visits between patients.
11. Picture taking or videotaping by any community member of other community members is prohibited.
12. No gift exchanges are allowed between patients.
13. Community members are not allowed to bring in any electronic devices from home unless approved by staff,
(for example a laptop computer to use during school time). If a community member brings in any
unapproved electronic device, it will be stored in the office until check-out.
14. With staff approval and supervision, community members may be allowed to use specific electronic devices
during the program day. Using any electronic device for social networking is not permitted. Staff must
approve access to websites.
15. Items that are not allowed in the program include: Smartwatches, Fitbits, Heelys, Fidget Spinners. Other
items brought in by patients that staff deem to be contraband, or a safety risk, will not be allowed in program.
16. During school time:
a. Community members are expected to work quietly without disturbing their peers. The teacher will
ask any disruptive community member to leave the room.
b. If a community member refuses to do schoolwork during school time, he or she will be asked to
leave the room.
c. If agreed upon by one’s parent/guardian, primary therapist and teacher, community members may
benefit from a homework plan. Community members on ‘homework plan’ will have homework
assigned by the program teacher each evening; if homework is not done at home, the expectation
is typically to make-up the work the following day during a predetermined portion of the program
day, instead of participating in other program activities during that time frame.
d. Headphones are for academic use only.
17. The parent, guardian, or caregiver who is required to bring in medication from home needs to leave the
medication with the nursing staff at check-in time. All medications must be in the original container.
18. Permission from a staff member is required before telephone calls can be made.
19. No blankets are allowed while in the program. The temperature in the dayrooms often fluctuates; it is
advised that patients bring a sweater or sweatshirt.
20. Clothing that is deemed to be derogatory or offensive to others will not be permitted in the program.
21. Clothing that is provocative or revealing is not permitted. Specifically, no spaghetti straps, exposed bra
straps, low cut necklines (cleavage must not show), or exposed midriffs. Shorts, dresses, and skirts must
fall at least to the mid-thigh. Undergarments should NOT be visible. Baggy pants that sit below the hips
exposing underwear are not permitted.
22. Former PHP patients may visit staff. However, they are not permitted to enter the dayroom or visit with any
patients that are currently in the program.

Fig. 12.2 HCPHP Community Rules

time until they can process their experience and “ruled” by their child’s illness rather than by
shift to a place of willingness to apologize. The clear and consistent parental decision-making.
clear and consistent limits around respect is one Themes of empathy and expectation are mir-
of many ways the structure and expectations of rored within family therapy, in the milieu, and
our programming support and model clear and across medical providers at HCPHP. When chil-
consistent limit setting for families that are often dren are struggling to meet expectations across
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 199

settings, parents are encouraged to validate their the program day. Their participation is monitored
child’s struggle while also continuing to message and reinforced by a “point system,” through
clear expectations (e.g., “I can see this is really which each child can earn points on a standard
challenging for you, and we need to get to pro- scale for their participation in each part of the
gram this morning”; or “I can tell from your tone program day (see Fig. 12.3). This system is based
of voice how upset you are, and we need to move on the well-established principles from behavior-
forward with your diabetic care. If you’re not ism and learning theory (Skinner, 1991;
able to check your blood sugar, I will help you Thorndike, 1911; Watson, 2007), including posi-
and I’ll keep your phone until your next meal.”). tive reinforcement, shaping, and punishment that
These messages are grounded in the framework are well documented as effective interventions
of dialectics from DBT, highlighting that two for children (Parrish, 1993).
seemingly opposing truths (“I’m working as hard At HCPHP, patients earn points throughout
as I can, and I need to work harder”) can both be the day for each activity, with higher points
true simultaneously (Miller et al., 2007). HCPHP awarded for higher levels of effort or adherence
providers are highly trained in messaging empa- to expectations. Patients can earn points (on
thy and validation while also holding clear and likert-­
type scale ranging from 0 to 4; 0 = “I
firm limits regarding each child’s expectations. In refused,” 1 = “I participated,” 2 = “I did a good
line with these principles, patients are often job,”3 = “I was very good,” 4 = “I was fantastic”)
encouraged to “take space” with milieu therapy for each portion of the treatment day, and for
team members to individually check-in outside treatment activities each evening at home. Based
of the milieu if they are struggling. Because every on the total number of points a child earns each
patient admitted to HCPHP is working on some- day, they can “cash in” their points for an item
thing different and may have different expecta- from the point store on the corresponding shelf,
tions, our team has developed both a standard with higher point earnings receiving a larger
model for managing behavioral expectations, as range and higher quality of accessible prizes.
well as methods for close communication to Some examples of prizes on the “fourth shelf”
ensure that all members of the team understand (e.g., highest value) include board games, large
each child’s expectations/behavior plan and are tins of silly putty, puzzles, sketch pads, paints,
aware of when and how each child’s plan should and action figures/dolls. Although many parents
be enforced. arrive to HCPHP reporting that their child is not
motivated by rewards, we often discover that
children are motivated by the daily recognition
Behavioral Principles: The HCPHP they get from their points (rather than from the
“Point Store” prizes/rewards). For other children, the linking of
HCPHP points to other motivators (e.g., technol-
Behaviorist principles are embedded into the ogy/phone access at home; access to preferred
HCPHP program structure. Patients are expected activities) is particularly effective.
to participate in a variety of activities throughout

Fig. 12.3 HCPHP daily Time Activity

schedule
8:30am - 9:00am Breakfast
9:15am -9:45am Daily Goal Setting (Community Meeting)
9:45am - 10:20am Skills Building
10:20am - 12:00pm School
12:00pm - 1:00pm Lunch
1:00pm - 2:00pm Group Therapy (1x/wk ArtReach)
2:00pm-2:30pm Afternoon activity
2:30pm - 2:45pm Afternoon snack
200 K. Reynolds et al.

Though each child begins with a standardized After-Hours Support

point sheet, additional personalized expectations
are often added to each child’s plan and point In line with assisting parents with consistent limit
sheet over the course of their admission. For setting, another component of HCPHP is the sup-
example, children who struggle with getting to port we provide after program hours. To promote
HCPHP in the morning may have a contingency consistency with limits and expectations, parents
associated with their ability to earn “4th shelf (and sometimes older/teenage patients) are pro-
prizes” such that if they do not get to HCPHP on vided with after-hours emergency access to their
time, they lose all opportunity to earn a “4th assigned clinical team members (psychologist,
shelf” prize, regardless of how many points they psychiatrist, and pediatrician who have been
earn through the rest of the day. working with the family since the admission
In addition to the larger behaviorally based day). Parents are encouraged to call the clinical
reward structure of the program, within family team for emergent or timely behavioral concerns
therapy sessions, parents are encouraged to (e.g., child is refusing to come to program in the
generate other positive rewards (e.g., earning morning by refusing to get out of bed or into the
opportunity for fun outing with family; labeled car; child is engaging in unsafe behaviors at
praise) and negative punishments (e.g., losing home), or for emergent or timely medical con-
access to technology) for compliance/non-com- cerns (e.g., acute food refusal over the weekend,
pliance with specific and prioritized aspects of new physical or medical symptoms for which
a child’s behavior plan. The assigned psycholo- parents are considering taking the child to the
gist for each patient works collaboratively with emergency room).
the family to develop behavior plan goals. The After hours support from each family’s direct
psychologist then bridges the goals identified clinical team is particularly impactful for fami-
with the family to the milieu therapy team. In lies as the treatment team has the most up-to-
collaboration with the milieu therapy team, a date information on the patient’s day and on any
more concrete behavior plan is agreed upon and recent changes to the behavior plan as discussed
circulated among all staff to ensure consistency. in family therapy. As consistency of parenting
Ongoing monitoring of a child’s behavior plan has been identified as a key element of parenting
within HCPHP is a collective effort across the interventions (Kaminski et al., 2008), after
milieu, nursing, and clinical teams. If any mem- hours support provides a unique layer of access
ber of the HCPHP team is struggling with sup- to support consistency for parents who may be
porting a particular child in the milieu, a struggling with making these shifts in their par-
program wide “break out” can be called as a enting styles. A family that is struggling can
method for brainstorming and problem-solving receive an “in the moment response” and can
with the entire HCPHP staff regarding potential reach a quicker/more effective resolution.
supports, expectations, contingencies, and Families can reach a member of their clinical
rewards for a particular child. Reviewing team through the hospital crisis line, and typi-
behavior plan changes with children in the con- cally receive a call back from their clinical pro-
text of family therapy supports parents with vider within 10–20 minutes following the
increasing their own use of limit setting at family’s initial outreach. Similar to crisis con-
home, with the HCPHP team serving to “back tacts in a DBT model, phone conversations with
up” parents should they struggle with maintain- families emphasize implementing skills in the
ing these limits and showing the child that team moment, are short in duration, and are solution
members, including parents, are all on “the focused. The ability to help families tolerate
same page.” their own distress in managing behaviors and
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 201

symptoms at home is both empowering to par- member’s range of responsibilities. The relation-
ents and supports the larger healthcare system ships among treatment team members also serves
by reducing the frequency of potentially as a parallel process to the family dynamics that
unneeded trips to the emergency room for psy- providers at HCPHP support and encourage
chiatric or medical concerns that can be man- across each family’s admission to HCPHP.
aged at the partial hospital level of care. “It’s like soccer. I can practice myself and learn all
the skills I can, and we can practice together as a
team, but our chances of winning will be better if
 nified Messaging Across Teams
U each of us are doing both individual and team
practice to improve our individual skills and our
at HCPHP ability to work together. I’m working on myself
here in program, and I think it will help if you also
“You know, I’ve heard that same phrase from 3 get your own individual therapist in addition to the
other people today—everyone said the same family work we’re doing.”
thing…” - HCPHP Parent —15yo HCPHP patient advocating for parents to
seek individual treatment
Despite the wide variety of typical presenting
complaints (see Fig. 12.1), unified messaging The theme of teamwork permeates individual
across team members and across cases is a key therapy, family therapy, the therapeutic milieu,
ingredient of the HCPHP treatment model. As a and professional coordination that occurs while
program based in family systems theory, commu- families are admitted to HCPHP. Patients and
nication in our interdisciplinary rounds, occur- families are oriented to our family-based, inter-
ring four times per week, is one of many ways we disciplinary treatment model starting on admis-
support all members of the team with staying “on sion day when each clinical discipline is present
message.” Similar to family therapy, unified mes- and participating in the admission meeting
saging in HCPHP has a number of primary (teacher, nursing, psychology, psychiatry, and
themes: pediatrics, and milieu therapist who transitions
the patient from the admission meeting to the
1. Functioning despite distress, for both kids and milieu setting). Within this context, families are
families. introduced to the team, and their own role on the
2. Creating an environment that provides both treatment team is highlighted. In addition to
empathy and expectations. engaging parents and children as active team
3. Approaching distressing topics and process- members, our large interdisciplinary team of over
ing disagreements rather than facilitating or 40 people is made up of the following smaller
encouraging avoidance (i.e., transparency). “micro-teams”:
4. For children and families working on nutri-
tion/eating specific plans, nutrition framed as 1. Nursing Team.
medication and treated as a prescription. 2. Milieu Therapy Team.
5. Focusing on the process of treatment rather 3. Nutrition Team.
than the outcome, in effort to discourage emo- 4. Clinical Team:
tional avoidance and encourage adaptive man- (a) Psychology.
agement of and acceptance of emotions. (b) Psychiatry.
(c) Pediatrics.
(d) Outpatient providers.
 ssential Ingredients: Components
E 5. Support Team(s).
for Treatment (a) Intake Coordinator/Social Work.
(b) Consultative Teams.
Within any interdisciplinary team, there is a (i) Physical Therapy.
dynamic balance between working collabora- (ii) Occupational Therapy.
tively and understanding each individual team (iii) Speech Therapy.
202 K. Reynolds et al.

(c) Healing Arts (Yoga, Improv, ArtReach patient acuity and/or staffing matrices. There are
Providers). also two certified nursing assistants (CNAs) and
(d) Program Evaluation. two medical assistants (MA) within the staffing
matrix. The CNAs and Mas are responsible for
safe patient care including bathroom and meal
Nursing observation as needed, obtaining orthostatic vital
signs and weight checks based on patient-specific
After the patient’s first day, each morning when a protocols, documentation, ordering supplies and
patient arrives at HCPHP, they will be “checked- linens, quality control of point of care testing
­in” by a nurse prior to entering the therapeutic (POCT) supplies, and various or limited clerical
milieu. The nursing team at HCPHP is made up duties.
of pediatric nurses who specialize and are trained During an HCPHP admission for a patient
in both medical and behavioral health care. The with diabetes, nurses routinely provide diabetic
team follows the C.A.R.E. values created by the care in collaboration with the patient’s HCPHP
Lifespan organization which are shared among pediatrician and outpatient endocrinology team.
all employees. Nurses provide family-centered Nurses collect the daily logs for meals, blood
compassionate, accountable, respectful, and glucose readings, and insulin dosing, and fax
excellent high quality, safe patient care. The nurs- records to the outpatient endocrine team and then
ing team works intimately with the interdisciplin- implement the necessary order changes through
ary team to ensure treatment plans, medication education with the patient and family.
regimens, and care plans are being met. Nurses Additionally, nurses provide broad or targeted
holistically and comprehensively care for HCPHP diabetic education for patients and families as
patients whose diagnoses include but are not lim- needed, that reinforces messaging and teaching
ited to: diabetes, eating disorders, encopresis, from the endocrinology team.
functional neurological disorder, depression with HCPHP nurses also provide additional nutri-
suicidal ideation and/or self-injurious behavior, tional support for patients with various eating
and anxiety disorders (see Fig. 12.1). disorders through placement/use of nasogastric
During the interdisciplinary admission pro- feeding tubes, either indwelling or intermittent
cess on a patient’s first day at HCPHP, the nurse tube placement, depending on individualized
is responsible for noting current medications, treatment plans. For patients in treatment for
nutrition status, sleep hygiene, allergies, and best nutritional restoration, functional activity restric-
contact information. Each treatment day, nurses tion is monitored daily in combination with
have a check-in and check-out meeting (or call blinded weights, heights, calorie counts, routine
during COVID-19 protocols) with a parent or EKGs, and lab surveillance. Additionally, for
guardian. Behavior patterns, toileting plans, patients with somatic symptom disorders, nurses
sleep, nutrition intake, medication adherence, utilize our Functional Pain Assessment Tool,
safety, or other treatment goals are briefly designed by our program as traditional pain mon-
reviewed in the context of the daily check-in/ itoring was deemed countertherapeutic in our set-
check-outs. Nursing check-in/check-out also pro- ting. Use of this faces-pain-scale tool reinforces
vides opportunity for modeling and supporting our focus on functioning and a multipronged
parents limit setting. For example, “I see you approach to pain management.
documented that Johnny refused to take his medi- The nursing team must also be present to
cation last night, but he received full points for assist and document during patient restraints. All
this. Do you want to take the opportunity to mod- team members are Crisis Prevention Intervention
ify his point sheet to more accurately reflect his (CPI) certified for behavioral de-escalation and
behavior?” safety techniques. Interdisciplinary team debrief-
Each nurse at HCPHP typically carries a five ings are held after every difficult restraint in
to seven patient assignment, dependent upon HCPHP, which can include adjusting treatment
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 203

plans, identifying common themes or triggers, respect everyone regardless of race, gender, etc.
and disclosing/monitoring staff or patient injuries When a community member patient/staff is dis-
and emotional distress. The charge nurse per- respected, the individual(s) that exhibited the
forms a daily huddle at 7:15 am with the milieu inappropriate behavior will be asked to leave the
therapy team to highlight any high-level patient milieu and cannot return to the milieu unless
safety risks and communicates any imperative there is an apology by the offending community
leadership announcements (mandatory educa- member.
tion, upcoming staff meetings, etc). This community expectation also creates a
need for flexible use of space, which often
requires fluidity of physical space on a program-
Milieu matic level. For example, if a patient refuses to
apologize for being disrespectful, and does not
The therapeutic milieu in the HCPHP plays a comply with milieu therapy team directions to
vital role when treating patients with a combina- leave the milieu or stop engaging in the offending
tion of medical and psychological diagnoses. As behavior, this refusal does not halt the milieu day.
noted above, core elements to a successful milieu Instead, the milieu space is cleared to maintain
include daily structure, consistency, clear expec- consistent expectations for the patient.
tations, safety, communication, and validation. A Meanwhile, the milieu day continues to move
key component to maintaining a therapeutic forward in an alternate space within the HCPHP
milieu with the elements described above is program space (e.g., milieu moves to a multipur-
developing and maintaining a strong milieu ther- pose meeting room).
apy team. Our milieu therapists play a critical role in
The basis of our strong milieu therapy team is collaborating and partnering with the interdisci-
extensive orientation. This orientation includes plinary team. Their observations, real-time clini-
daily team communication during the morning cal interventions, and the relationships they
huddle with nursing, facilitating a group meeting develop with patients collectively help the clini-
each day for patients (community meeting), cal team have a clear picture of patient needs,
developing and maintaining a skills-building cur- interventions, and reinforcements that are appro-
riculum, communicating succinctly when report- priate for facilitating patient treatment progress.
ing in interdisciplinary rounds, developing an The milieu environment creates an ideal (con-
understanding of patient group dynamics, and tained, but naturalistic) setting for patients to
extensive training in limit setting, behavioral practice working on different aspects of their
interventions and other skills that are necessary treatment. Patients struggling with social anxiety
for the milieu therapy role. The goal of the milieu have a consistent supportive environment to prac-
environment is to foster trust, acceptance, and tice being with other peers and learning how to
positive peer interactions. Patients can “be them- engage; they often complete exposure with
selves” in a setting that creates a non-judgmental response prevention (ERP) assignments from
environment, building on positive peer feedback their individual therapy sessions within the
and active participation among the milieu mem- milieu. For patients with somatic symptoms, the
bers. Often, some of the most valuable feedback primary expectation is to function during the day
and advice that patients retain comes from their by following the program schedule, to the best of
“milieu mates” who offer adaptive suggestions their ability, regardless of symptom flares (Lynch-­
within the context of the therapeutic milieu. Jordan et al., 2014; Williams & Zahja, 2017), and
Along with the nursing team, the milieu thera- to utilize interdisciplinary layers of support
pist makes sure that Community Rules (discussed (Gasparini et al., 2019). For children with diabe-
above) are maintained and followed within the tes, providing appropriate education to peers and
confines of the milieu. One powerful and impact- practicing completing diabetic care in the context
ful guideline is that community members must of the day builds a pattern of behavior that is
204 K. Reynolds et al.

more easily translatable to the school environ- approach for children with chronic medical con-
ment with peers and teachers (Wysocki et al., dition (Fiese, 2005; Kazak et al., 2017; Weihs
2017). These examples demonstrate how, in the et al., 2002). The most central theme of family
milieu, patients cannot avoid their challenges and therapy in our setting is joining with the family in
must learn how to use coping skills. their journey, which has been discussed in detail
Coping skills are introduced within the skills-­ in prior work (Roesler et al., 2018). In caring for
building curriculum. Patients are oriented to vari- children who have been coping with severe medi-
ous tools they may find helpful on a weekly basis. cal/psychiatric illnesses, HCPHP is rarely the
Each day of the week features a different coping first treatment attempt families have made. Many
framework: mindfulness skills based in DBT families arrive to HCPHP reporting they have
(Miller et al., 2007; Rathus & Miller, 2015), chal- “tried everything,” when “nothing has worked,”
lenging negative thoughts and behavioral activa- and when “no one can give us an answer.” Joining
tion strategies based in Cognitive Behavioral with the family around their distress associated
Therapy (CBT; Beck, 2011), emotional expres- with the long-term aspects of their treatment
sion (Southam-Gerow, 2013), relaxation training endeavors is essential for building rapport as well
(Thabrew et al., 2018), and weekend review to as understanding the family’s beliefs about their
anticipate and plan for potential challenges. The child’s illness and the family dynamics around
milieu therapy team creates activities to help fur- treatment. Common themes that arise in early
ther explore the skills-building curriculum with treatment conversations and become key targets
patients. for treatment include:
One of the most dynamic activities is our
“mask activity.” During emotional expression, 1. Quality of life for the child and/or the family
patients are encouraged to draw a mask and then has become severely impacted.
visualize wearing that mask and express or write 2. Child has inadvertently become insulated
what they hide behind “their mask.” This activity from day-to-day expectations due to illness.
gives patients permission to show what they have 3. Child has become closer with one or both par-
been hiding in a non-threatening forum. Another ents due to intensive treatment (e.g., spending
activity central to our skills-building curriculum a lot of time with mom while in the hospital).
is the “letter to my illness” exercise. Although 4. Parents have shifted/changed careers or jobs
children admitted to HCPHP may have a number as a result of the illness.
of different diagnoses, they are encouraged to 5. A number of additional family stressors have
compose a letter to the illness that they identify. been occurring, but not processed or attended
Patients have written to their anxiety, their cystic to due to the child’s illness.
fibrosis, their eating disorders, or their parents (in 6. Child’s relationship with siblings or friends
situations with high levels of family conflict). has shifted as a result of illness/intensive
This activity encourages children to externalize treatment.
their illness or stressor, allowing for cognitive 7. Underlying anxiety/depressive symptoms
challenging of their thoughts about their illness have become more apparent in the context of
related experiences. a medical illness or presentation of somatic
symptoms.
8. Conflict between parents or between child and
Family Therapy one or both parents is impacting treatment or
has shifted during treatment.
Within HCPHP, family therapy sessions are
dynamic, often involving the entrance and exit of Beginning with processing these themes, family
multiple team members, while integrating all therapy sessions within HCPHP are typically
members of the team into a family systems 45–90 minutes (often depending on the level of
approach, supported by a large body of work conflict occurring or number of providers present
showing the benefits of utilizing a family-based within any meeting). Family therapy sessions
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 205

occur twice weekly, with some parents struggling p = 0.021), a significant decrease in illness impact
to meet this expectation. Family therapy sessions (t = 2.673, p = 0.009), a significant increase in
are run by the primary clinician (psychologist or understanding (t = −7.468, p < 0.001), and a sig-
psychiatrist) on the case, and sessions often nificant decrease in helplessness (t = 4.71,
involve meeting with one or both parents for the p < 0.001) from admission to discharge.
majority of the meeting, with the potential to Collectively, findings suggest that a key factor in
include psychiatry, pediatrics, and/or nutrition HCPHP treatment is the family-based shift in ill-
team members for a portion or duration of the ness beliefs, which we look forward to exploring
meeting. Children typically join the last further in future research.
15–30 minutes of the family therapy session,
depending on the content of the conversation,
with child participation typically increasing over Individual Therapy
the course of the admission. As treatment pro-
gresses, family therapy sessions are often focused Individual therapy with each patient in HCPHP
on developing and implementing a home-based occurs between two and four times per week.
behavior plan consistent with parental behavioral Patients are typically pulled out of the milieu dur-
goals and with behavior plans in place at ing portions of the day to complete their individ-
HCPHP. Further, family therapy focuses on pro- ual therapy sessions, though clinicians avoid
cessing family conflict and shifting family meeting with patients during Community
dynamics to empower parents to take control of Meeting (goal-setting time), and group therapy
their lives and their child’s life, while simultane- (formatted as a process group). Individual ther-
ously minimizing the impact of the illness on the apy session durations are highly variable and tai-
family system. Family therapy within HCPHP is lored to the individual child’s needs; as such,
broadly based within a structural family therapy sessions range from a 10-minute check-in to a
framework, although elements of CBT and DBT 45-minute session. Sessions typically incorporate
are also integrated into family work. mindfulness-based skills, challenging cognitive
We have conceptualized family change in ill- distortions, exposure with response prevention
ness beliefs as a central component to successful interventions, or encouraging emotional expres-
HCPHP intervention. An HCPHP-developed sion. A 10-minute check-in might include rein-
measure of parent-reported illness beliefs (Illness forcing a patient’s completion of exposures
Belief Questionnaire; Nassau, et al., in prep) has conducted in the milieu, reviewing behavioral
been used to assess domains of: psychological activation plans for the upcoming weekend, and/
factors of the illness (perceived role of stress in or setting a goal for a home exposure in the eve-
illness), 1 year impact of illness (how much con- ning. Alternatively, longer sessions may involve
trol and impact the illness has had over family progressive muscle relaxation, in vivo exposures,
life in the last year), overall impact of illness safety assessments and safety planning, or sup-
(how much control and impact the illness has had porting patients with utilizing grounding strate-
over family life), illness understanding (family gies in moments of acute distress. There is also a
understanding of the illness), helplessness (how significant overlap in content discussed within
hopeful the family is about illness control), and individual and family therapy in HCPHP, as each
frustration (family frustration regarding the ill- child’s individual therapist also serves as their
ness) related to the child’s illness within our family therapist. Children are not typically seen
population. for individual therapy on days a family therapy
In a recent sub-sample of patients admitted to session occurs unless urgent/safety issues arise.
the HCPHP (admissions occurring between April Across clinicians in HCPHP, a variety of
2016 and December 2019; N = 106), preliminary evidence-­based interventions are used within
analyses indicated significant decrease in illness individual and family therapy, including CBT,
belief domains of 1 year illness impact (t = 2.326, DBT, and acceptance and commitment therapy.
206 K. Reynolds et al.

When appropriate, other team providers may also ies, and to contact outpatient providers to further
join individual sessions. For example, when pro- enhance understanding of goals for the admis-
cessing emotions around meal-plan changes for sion, evaluations completed, and past treatments
children with eating disorders on a prescribed and perspectives of long-standing relationships
nutrition plan, the nutritionist or pediatrician on with providers. The pediatric role in family-based
the child’s team may also join in a portion of an treatment continues throughout the admission
individual therapy session. with pediatricians joining family therapy ses-
sions, as needed, with several goals in mind.
Aside from demonstrating that all team members
Pediatrics are “on the same page,” pediatricians review
progress, are part of treatment planning, review
Pediatricians are a collaborative and integral part medical data, and provide diagnostic clarity.
of the HCPHP medical/psychiatric treatment Components of diagnostic clarity can include
team, reinforcing consistent messaging in the removing medical diagnoses that no longer
context of individualized medical treatment. reflect the clinical picture, providing appropriate
Pediatrics at HCPHP is not practicing primary framework for reported symptoms’ origin and
care in a psychiatric setting, but rather working response, validating symptom reports and obsta-
collectively with other disciplines. This involves cles in functioning, and transparent discussion
understanding the frame and messaging around around a common worry that “something medi-
symptoms/behaviors, contributing to individual- cal is being missed.” Typically, patients admitted
ized treatment plans within the context of each to HCPHP have had comprehensive medical
child’s HCPHP participation, goals and medical workups and infrequently require additional test-
diagnoses, and collaborating with outpatient pro- ing which aids open discussion around pros/cons
viders as children and families transition back to of testing for reassurance. Additional pediatric
an outpatient level of care. contributions are providing feedback after
The pediatrician is integrally involved begin- focused examinations, offering recommenda-
ning with the initial referral and interdisciplinary tions to support functioning, and modeling
admission meeting. Though the pediatrician may validation-­focused language for parents from the
have been involved in record review/referral medical perspective.
assessment, it is beneficial to hear “the story,” Individualized treatment is a foundation for
review the patient and family’s understanding for any patient and family participating in HCPHP. As
referral and treatment goals, further facilitating such, the pediatric role does not include examin-
the theme of “joining with the family” (Rickerby ing every patient every day, but selectively and
et al., 2017) as discussed above. Each admission individually making decisions on when to exam-
has a primary “leader” with each discipline ask- ine a patient, and when NOT to examine a patient.
ing questions to fill in information gaps pertinent For patients with multiple somatic symptoms in
to their role including review of allergies, medi- the context of anxiety, the pediatrician may plan
cations, and specific nutrition needs. Prior to for scheduled, more frequent check-ins with the
transitioning the child to the milieu, treatment patient rather than responding to the patient’s
plan details may be discussed as appropriate and requests that he/she needs to be examined by the
specific to the child’s referral diagnoses (i.e., toi- pediatrician for a new symptom. In the context of
leting, nutrition, medications to be given at pro- standing check-ins, the pediatrician will continue
gram, behavior management). Additionally, on to gather information and encourage the use of
admission day, the patient will have a physical other coping skills through the day. As treatment
exam by the pediatrician assigned to their team to progresses, this plan may shift to selectively
establish a baseline. An early goal for the pedia- examining a patient to minimize risk of overmed-
trician is to review medical history and labs/stud- icalizing and maximize opportunities to practice
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 207

utilizing other coping skills. Consistent program acceptance of interdisciplinary treatment and
attendance provides opportunities to observe importance of addressing the emotional impact
physical symptoms, understand patterns and con- of symptoms and illness. Although the patient or
tributing factors, including variability between family may continue to believe that “something
home and program, and assess response to is being missed,” extensive testing is not a central
interventions. part of treatment unless objective data warrants
The pediatrics team also plays a role in consis- further evaluation. The one caveat to this state-
tent messaging around functioning despite dis- ment is if a family is “stuck” on a specific ele-
tress. For children with chronic pain, the focus on ment of their child’s presentation. The treatment
functioning is paramount. With emphasis on team may decide to move forward with a test,
functioning despite pain, a potential response of referral, or evaluation allowing for a therapeutic
“we’re going to support you to function even as “what-if” discussion with the family (what if the
you have pain” is the message we encourage par- test is positive, what if the test is negative/nor-
ents to send to their children. Simultaneously, the mal) and allow shifts in illness beliefs.
family is encouraged to continue with routines Additionally, the pediatrician shares information,
and plans by helping the child cope rather than observations, and shifts in family perceptions
letting the pain dictate family activities (e.g., with the receiving and referring providers, in
avoiding meals or family time). For example, if a addition to reasoning for referral and/or testing
child chooses not to join fun family time, we rec- despite low suspicion of illness.
ommend that the family system allow for this With collaboration and transparency existing
natural consequence to play out (i.e., continue as a core concept to treatment at HCPHP, pedia-
with the fun activity with other family members tricians have a critical role putting this into prac-
and not accommodating the pain by changing the tice. Not only are pediatricians collaborating with
activity so the child can engage), rather than the interdisciplinary HCPHP treatment team,
accommodating the child’s pain response. patient, and families, collaboration with outpa-
Depending on where a patient and family is with tient medical providers and valuing their relation-
their HCPHP treatment, a decision may be made ship with the patient and family is critical for
to examine the child to gather further information ongoing treatment. Understanding the long-lens-­
(level of distractibility, presence/lack of focal view of how a patient got to a point of compro-
findings, vital sign review, expression of pain) mised functioning, understanding outpatient
during a pain episode. Additionally, HCPHP uti- interventions that have been used and why they
lizes the program designed Functional Pain were or were not effective, and involving provid-
Assessment Tool to support patient functioning, ers in the partial program treatment process help
while also gathering subjective data from the patients and families build rapport with the
patient and nursing observation. Being able to HCPHP team, understand the broad definition of
share interpretations and perceptions of the team support that exists for their child, and enrich
child’s pain experience from an experienced the medical home to which they will return.
pediatrician in the context of family therapy with HCPHP pediatricians contact outpatient provid-
psychology and psychiatric involvement allows ers as appropriate on admission, at discharge, and
for holistic treatment of the child considering as needed during the admission; often outpatient
medical and nonmedical treatment options. providers also participate in a family therapy ses-
Prior to admission to HCPHP, patients often sion prior to discharge from HCPHP to bridge
have completed comprehensive medical work- treatment from the HCPHP team back to the out-
ups, had many medical referrals, numerous tests, patient providers. Contact may also include prior
and multiple medication trials to support func- treatment providers, accessing parent providers
tioning as a treatment goal. The completion of (both with proper consent), and coordinating
referrals and tests prior to admission increases with new treatment providers as part of discharge
208 K. Reynolds et al.

planning. Information exchange centers on iden- chologist with real time coaching. This also gives
tifying goals, obstacles for success, problem-­ the nutrition team a snapshot into family meal
solving around available resources, and discharge preparation and plating.
planning. Additionally, involvement of outpatient
support services, including Child Protection and/
or Department of Youth, Children, and Family, Psychiatric Medication Management
may be utilized for patients and families.
Every child admitted to HCPHP is assigned a
psychiatrist, one of the three members of the
Nutrition patient’s core clinician team, alongside a psy-
chologist and a pediatrician. Each psychiatrist is
Patients may be referred to HCPHP with known typically assigned 8–10 cases. Psychiatrists at
nutritional issues, but often nutritional concerns HCPHP contribute to patient care in many ways
become apparent early in a child’s HCPHP treat- that are typical of this role at more intensive lev-
ment course. With an on-site dietary team and els of care. For example, psychiatrists participate
structured meals and snacks during the program in interdisciplinary admission assessments, col-
day, a nutritional baseline assessment can be lect developmental and psychiatric history, col-
completed with objective data versus solely rely- laborate with outpatient psychiatrists and/or
ing on parent report to fully understand an indi- psychiatric nurse practitioners, make psychiatric
vidual’s needs and how best to meet them. diagnoses, and prescribe psychiatric medication.
Additional data are often requested by soliciting At HCPHP, psychiatrists are also highly involved
historical growth records from primary care and in the therapeutic work on each case, particularly
outpatient providers, home meal records and/or in the context of family therapy, where they col-
meal photos with real-time clarification by the laborate with the psychologist on each case in a
nutrition team. Baseline assessment can lead to co-therapy model. Psychiatrists also meet with
an individualized meal plan prescription that may patients throughout the week as needed to assess
include nutritional supplementation and, when response to medication changes and to meet
malnutrition and food refusal are more severe, individually or in conjunction with a patient’s
the use of a nasogastric tube as a tool to deliver a psychologist to continue individual therapeutic
full dose of prescribed nutrition. Having nutrition work. Additionally, psychiatrists are available to
embedded into HCPHP allows for individualized families after-hours to provide therapeutic sup-
treatment planning relative to diagnosis and port and recommendations around any as-needed
goals, immediate feedback on nutrition for par- medications to support the child in completing
ents and families, and meal correction to provide their treatment plan at home. Examples include
balance and structure. Additionally, access to helping a child move forward with a nutrition
nutritional support allows us to maximize oppor- plan despite emotional and behavioral dysregu-
tunities for education and feedback to patients lation or have success in leaving the home to
and families as appropriate and for nutrition team attend program despite significant anxiety.
members to join family therapy sessions for con- Psychiatrists also participate in managing epi-
sistent messaging. If appropriate, family meals sodes of severe emotional and behavioral dys-
may also be recommended as an additional edu- regulation that may require behavioral restraints
cational opportunity for parents or guardians and alongside the milieu team during the program
provide useful insight to mealtime experience of day, which sometimes necessitate psychophar-
the patient and family. For a family meal, a parent macologic intervention.
or guardian is asked to provide an appropriate Most discussions about medications with
meal or snack for their child and themselves and patients and their families occur in the context of
are supported through the meal by the team psy- family therapy sessions which allow the HCPHP
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 209

team to deliver a unified message related to the for example, serving more preferred foods to a
medication recommendations. This approach is child with an eating disorder in order to avoid
helpful for many families who are ambivalent episodes of dysregulation or allowing a child
about initiating psychiatric medications, espe- with chronic abdominal pain to pause engage-
cially for cases in which a child’s symptoms may ment in schoolwork in order to minimize symp-
have been viewed more exclusively through a toms. As expectations that support improved
medical lens during previous workup and treat- functioning are increased, we often support fami-
ment instead of in a more global manner, incor- lies with disrupting this understandable, yet ulti-
porating both physical and emotional factors into mately undesirable, pattern of accommodation
case conceptualization. Examples of common that has fostered maladaptive family homeosta-
psychopharmacology discussions facilitated by sis. In this context, the child typically requires
psychiatrists include starting a Selective more support via a variety of sources, for exam-
Serotonin Reuptake Inhibitor (SSRI) in a child ple, increased parental emotional support,
with Functional Neurological Disorder (FND) in increased academic support, and/or increased
order to address anxiety theorized to play a role biological support. Thus, children who do not ini-
in precipitating symptoms, starting a dopamine tially have a medication as part of their plan may
blocker to augment treatment for a patient with a ultimately demonstrate they would benefit from
severe eating disorder to support consumption of one as expectations increase.
adequate nutrition, and the management of The HCPHP psychiatry and pediatrics teams
entrenched eating disorder cognitions, and using also work together to de-prescribe or decrease
short-term treatment with a benzodiazepine for utilization of medications where appropriate.
an anxious child with abdominal pain during epi- One common scenario is the team working
sodes of increased symptoms in the place of other together to decrease reliance on a medication
as-needed medications for pain or nausea to help prescribed to target a specific physical symptom;
build insight into the mind-gut connection and for example, ondansetron to target nausea or ibu-
emotional factors contributing to aversive physi- profen to target headaches, when that medication
cal experiences. has ultimately been ineffective in adequately
Medication is often framed as “biological sup- addressing symptoms or supporting function for
port” meant to work in conjunction with emo- that child. In these circumstances, the team works
tional support from the family and the support together to identify whether a different form of
provided by ongoing, appropriate limits and biological support, for example an SSRI to
expectations. It is also described as one “tool” address underlying anxiety, may be helpful and
among many. Children and families are encour- support the family in making the shift. The col-
aged to utilize all available tools including medi- laboration between pediatrics and psychiatry
cation, while also understanding that medication supports families in such situations exploring the
will typically not be effective for children requir- emotions associated with moving away from
ing partial hospital level of care if used in isola- medications or treatments they view as strictly
tion of other supports. As children often have “medical” and accepting emotional contributions
significantly impaired functioning once they to their child’s illness.
require a partial hospital level of care, families
are encouraged to consider both the risks and
benefits associated with a particular medication Case Examples
as well as the risks and benefits associated with
avoiding or delaying medication use. Given the dynamic nature of providing interdisci-
Prior to admission, families often achieve plinary care to children with complex comorbid
some degree of homeostasis, reducing their medical and psychiatric diagnoses, we could not
child’s distress by reducing their expectations, fully describe our program without reviewing
210 K. Reynolds et al.

how treatment layers and team members inter- to her FND symptoms/episodes would reinforce
twine in the context of case examples. Identifying these behaviors. On the occasions when Claire
information has been altered to protect confiden- was not able to remain safe in her chair, she was
tiality of the case examples below. slowly moved by MT and nursing staff to the
ground, and a privacy screen was placed between
Claire and the rest of the patients within the
Claire: 16-Year-Old with Functional milieu. Staff provided periodic verbal reminders
Neurological Disorder (FND) to Claire that staff are present and ready to sup-
port her and talk “when she is ready.” This inter-
Claire arrived at HCPHP with a recent diagnosis vention provided a form of covert monitoring,
of FND, a history of depression, and Post-­ allowing staff to observe Claire and ensure her
Traumatic Stress Disorder (PTSD). In Claire’s safety, while not over-attending to her functional
interdisciplinary admission meeting, this history symptoms.
was reviewed, as well as her experience of a trau- The theme of persistence in the context of
matic event 3 years prior when she witnessed a ongoing symptoms and/or distress were high-
peer have a cardiac event. During the course of lighted in Claire’s individual therapy sessions.
her HCPHP admission, Claire also disclosed that Within individual therapy, Claire and her primary
she had felt traumatized by a relationship with a clinician worked collaboratively on a concrete
female peer who had shown her unwanted roman- document focused on supporting Claire and her
tic attention. parents with better understanding her FND diag-
Treatment in HCPHP primarily focused on nosis. Broadly, this document was developed to
optimizing Claire’s functioning in the context of outline the following:
emotional and physical distress. Upon admission,
Claire’s FND episodes ranged from 20 minutes 1. Claire’s understanding of her specific symp-
to 2 hours (based on parent report) and presented toms as FND.
similarly to epileptic seizures. Over her two and a 2. The multifactorial nature of what increases
half month HCPHP admission, she developed a risk for FND (reviewing her many stressors).
large number of FND presentations (including 3. Highlighting the importance of emotional
drop spells, partial paralysis, abdominal disten- expression and continued functioning in day-­
tion, difficulty speaking), many of which our to-­day life.
team was able to observe in the milieu during the 4. That having fewer episodes or putting pres-
program day. When parents became distressed sure on Claire to have fewer episodes is not
about episodes/strange symptoms after HCPHP helpful.
hours, parents made appropriate use of our after-­ 5. That gradually, over time, and with increased
hours support, which enabled the family to awareness, Claire will be able to gradually
decrease their trips to the emergency room related “grab” more and more control of her
to both Claire’s suicidal thoughts and novel FND episodes.
presentations.
Within the milieu, Claire often experienced Given Claire’s traumatic experiences, she also
episodes more frequently during certain parts of reported frequently experiencing flashbacks in
the day. Due to her pattern, staffing during these the context of FND episodes, as well as more
portions of the day were adjusted so that Claire typical flashback and re-experiencing symptoms
had 1:1 proactive, rather than reactive, support consistent with her diagnosis of PTSD. Given the
from the milieu therapy (MT) team. As Claire overlap of PTSD symptoms and FND symptoms,
often remained in her chair during her FND epi- Claire also worked within individual therapy on
sodes, milieu therapists supported the other processing some of her traumatic memories
patients with continuing conversation and activi- within a Trauma Focused-CBT (TF-CBT),
ties during her episodes in order to minimize Exposure with Response Prevention (ERP)
attention to her symptoms, as increased attention framework.
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 211

Claire’s parents participated in family therapy of poorly controlled diabetes. During Tommy’s
sessions twice per week. Her parents also fre- interdisciplinary admission meeting, his family
quently joined the parent support groups offered shared they began having more difficulty with
twice weekly, which is a service offered for all managing his diabetes when Tommy entered a
HCPHP parents. Family therapy sessions primar- private school after being homeschooled by his
ily focused on facilitating emotional communica- mother for many years. Notably, while Tommy
tion, with an emphasis on supporting Claire with was homeschooled, his mother closely managed
expressing emotions to her parents, encouraging his diabetes. Though the private school was a
parents to continue validating Claire and her good fit for Tommy academically, the school
experiences, while also gradually increasing her nurse was only on site at the school one day per
expectations. Claire’s parents also expressed a week. This was a concern as Tommy struggled
significant amount of their own distress within with programing his continuous glucose monitor
family sessions, and parenting strategies to sup- and injecting insulin using his pump without
port them with gradually reducing their tendency close adult intervention and supervision.
and desire to “walk on eggshells” around Claire Tommy’s parents also reported that although
were discussed. Finally, Claire’s parents were Tommy was typically very empathic, he often
encouraged to engage in their own marital ther- became aggressive and combative when his blood
apy, which fortunately began during the course of sugar was high. For example, he would often
Claire’s admission. break into cabinets to get food that the family had
Regarding Claire’s psychiatric medications locked up due to the carbohydrate content and
during her admission, several medication changes Tommy’s tendency to binge eat. Early in his
were made, including increasing her SSRI and admission, the milieu therapy team also noted
adding an atypical antipsychotic due to the that Tommy expressed some rigid moral beliefs
severely entrenched nature of her suicidal and generally struggled with theory of mind
thoughts. She was also weaned off several medi- skills.
cations targeting sleep disruption that were not Tommy responded well to the structure and
having a positive effect. consistency of the therapeutic milieu, which was
Another key intervention during Claire’s in direct contrast to the chaotic environment of
HCPHP admission was utilizing the multiple his home. Both parents reported feeling that since
milieus as a naturalistic environment to support Tommy’s mother had returned to working,
Claire’s positive identity development by tutor- Tommy often appeared to be “sabotaging family
ing younger children in the program. With per- functioning.” Shaping behavioral expectations at
mission from families, Claire began providing home and supporting parents with following
academic tutoring to children in the younger through with limits and consequences was a pri-
milieus. This created a natural setting in which mary focal point of family therapy. Over the
conversations about professionalism and bound- course of Tommy’s admission, a clear and
aries could be discussed, while also exposing detailed behavioral plan was developed with the
Claire to a higher level of functioning and higher family. Behavioral targets of this plan included
expectations, while ensuring she was safe from allowing parents to supervise insulin administra-
indirect consequences of any FND episodes she tion, eating while supervised, encouraging
had while tutoring other students. Tommy to disclose any “uncovered eating,” and
encouraging Tommy to utilize adaptive coping
strategies for managing anger. Consequences for
 ommy: 13-Year-Old Boy with Poorly
T unsafe behavior as well as consequences for
Controlled Diabetes refusing to allow insulin and eating to be super-
vised involved Tommy’s technology access (e.g.,
Tommy presented to HCPHP with both his par- turning off Wi-Fi) being withheld for a predeter-
ents due to his aggressive behavior in the context mined period of time.
212 K. Reynolds et al.

Pediatrics was highly involved in Tommy’s environment. Tommy’s transition to a mixed

family therapy sessions. In collaboration with the insulin pen allowed him to return to his school as
pediatric endocrine clinic, the recommendation he only required insulin administration twice a
to shift from a pump for insulin administration to day and these could occur with parents at home
a mixed insulin pen was processed and discussed rather than with his teachers at school.
at length with the family and with Tommy. This Tommy participated in 4 days of a graduated
recommendation was made due to Tommy’s school transition during his last week in
inconsistency in checking his blood sugars when HCPHP. This gradual school transition included
insulin administration was needed during the a transition meeting, in which Tommy’s behav-
school day when 1:1 supervision was not always ioral and medical accommodations were reviewed
possible. Tommy’s poor diabetic control was with school personnel, his parents, and the
often discussed in the context of parental emo- HCPHP team. Tommy then completed three
tions and anger about Tommy “sneaking food.” mornings of gradually building time at school
Minimizing judgement of this behavior and (i.e., attending one class his first day, two classes
reframing it as “eating uncovered” was processed his second day and three classes his final day),
with the family regularly, both by psychiatric and returning to HCPHP each afternoon for the
medical providers. This approach is recom- opportunity to process his school experiences.
mended for supporting individuals who are strug- This transition also provided his family with the
gling to manage their diabetes, as identifying the opportunity to practice eating breakfast and com-
problematic behavior (eating without insulin) is pleting morning insulin administration for sev-
made more difficult when there is negative emo- eral days prior to HCPHP discharge.
tionality associated with this disclosure—to
address the problem, transparency is needed.
High levels of emotionality between Tommy Summary
and his parents continued across the admission.
In addition to the family’s high levels of emo- Since its inception in 1998, the HCPHP has
tional distress and anger about Tommy’s resis- focused on empowering families to help children
tance to diabetic care, Tommy’s family also and adolescents thrive in the context of combined
struggled with their emotions regarding Tommy’s medical and psychiatric conditions that have
sexuality. As treatment progressed, Tommy’s interfered with normative development, physical
bisexuality was processed within family therapy and mental health management, and family life.
sessions, as his sexual orientation clashed with By providing family-based integrated care within
his family’s religious values. Individual therapy a milieu-based day treatment setting, the interdis-
focused on supporting Tommy with developing ciplinary team of professionals joins with fami-
improved emotion regulation, distress tolerance, lies to develop and communicate a unified
and cognitive restructuring skills, as well as on treatment message that facilitates child and fam-
processing the potential pros and cons of engag- ily functioning. The intensity of the treatment
ing in further conversations with parents regard- environment (e.g., daily participation and obser-
ing his sexuality. Family therapy focused on vation within the milieu, twice daily nursing con-
supporting Tommy’s parents with developing tact with parents, individual and family therapy
greater emotional awareness and empathy toward multiple times per week, specific additional inter-
their son, as well as on psychoeducation focused ventions and goals) facilitates the family’s ability
on the positive impact of supporting adolescent to engage in treatment that combines empathy for
exploration of identity and development of self. their child’s struggles with expectations that their
The HCPHP team also worked closely with child move forward. At the same time, parents
Tommy’s school to develop a sustainable dis- and caregivers are expected to address their own
charge plan that would allow for more monitor- challenges (e.g., unresolved differences in par-
ing of his diabetic care within the school enting styles) that may be inhibiting their ability
12 Family-Based Interdisciplinary Care for Children and Families with Comorbid Medical and Psychiatric… 213

to provide the support and structure that their Monaghan, M., Horn, I. B., Alvarez, V., Cogen, F. R., &
Streisand, R. (2012). Authoritative parenting, parent-
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erates stress as beliefs are challenged and all fam- 1 diabetes. Journal of Clinical Psychology in Medical
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 Part III
Intensive Outpatient Programs (IOPs)
 Development and Implementation
of an Intensive Outpatient 13
Program for Suicidal Youth

Jessica K. Heerschap, Molly Michaels,

Jennifer L. Hughes, and Betsy D. Kennard

Introduction keeper trainings (Burnette et al., 2015; Substance

Abuse and Mental Health Services Administration
Recent research shows there is an increasing rate of [SAMHSA], 2020). Despite efforts to prevent sui-
death by suicide in adolescents (CDC, 2020; Ivey- cide, US suicide rates are climbing, and suicide is
Stephenson et al., 2020; Ruch et al., 2019). In 2017, the second leading cause of death amongst adoles-
7.4% of adolescents made a suicide attempt, and cents (Arango et al., 2021). Rising rates of suicide
13.6% had ideation deemed clinically significant as in youth, which grew even worse during the
well as a suicide plan (Kann et al., 2018). A 2017 COVID-19 pandemic (Hill et al., 2021), have cre-
study by Hughes and colleagues shows the preva- ated a public health need for improved treatments
lence of suicidal ideation in adolescents ranged for suicidal thoughts and behaviors.
from 19.8% to 24.0%. Additionally, approximately
33% of adolescents who report suicidal ideation
will make a suicide attempt (Nock et al., 2013). Overview of Effective Treatments
Prevention and early intervention services for youth for Suicidal Youth
include the following: assessing suicide risk,
increasing access to care, routinely screening for Given the increasing rates of suicide among
mental disorders, safety assessments, and gate- youth, there is a need for the development of
interventions targeting both suicide prevention
and the decrease of suicidal ideation and behav-
J. K. Heerschap · B. D. Kennard (*) iors. In addition, strategies that improve safety
Department of Psychiatry, Children’s Health and reduce rates of reattempt are needed.
Children’s Medical Center, Dallas, TX, USA Hospitalization is the most common recom-
Department of Psychiatry, University of Texas mended treatment for youth with suicidality
Southwestern Medical Center, Dallas, TX, USA (Gliatto & Rai, 1999). Although inpatient pro-
e-mail: [email protected]
grams have been shown to provide a safe and
M. Michaels stable space for youth, with medication manage-
Department of Psychiatry, University of Texas
Southwestern Medical Center, Dallas, TX, USA ment oversight and daily therapeutic interven-
tions, no direct studies have measured the
J. L. Hughes
Department of Psychiatry and Behavioral Health, The efficacy of inpatient programs in reducing sui-
Ohio State University and Big Lots Behavioral cidal behavior in youth. Research has shown that
Health Services, Nationwide Children’s Hospital, inpatient programs are effective in linking
Columbus, OH, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 217
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_13
218 J. K. Heerschap et al.

patients to outpatient treatment (Hughes et al., for deliberate self-harm. One intervention met
2017), and that lethal means restriction counsel- Level 3 criteria as possibly efficacious: Family
ing and cognitive behavioral therapy (CBT) Based Therapy-Ecological for reducing suicide
modules, such as those that address safety plan- attempts in adolescents (Glenn et al., 2019). A
ning, may be effective in reducing readmission recent SAMHSA review in 2020 called DBT and
to the hospital for suicidal youth (Connell et al., ABFT “evidence-based,” with DBT having
2021; Wolff et al., 2018). Given the increasing “strong evidence” and ABFT having “moderate
rates of children’s hospital encounters for youth evidence”; and Multisystemic Therapy-­
suicidal thoughts and behaviors (Plemmons Psychiatry (MST-Psych), Safe Alternatives for
et al., 2018), coupled with the increasing chal- Teens and Youth (SAFETY), Integrated Cognitive
lenges in providing quality care with reduced Behavioral Therapy (I-CBT), and Youth
length of hospitalization stays (Glick et al., Nominated Support Team-Version II (YST-II)
2011), there is an increased need for effective were considered “promising.”
brief interventions, particularly in acute care set-
tings subsequent to suicidal behavior or worsen- Integration of Technology
ing of suicidal ideation. Technology-based interventions, used to aug-
Despite recent efforts to develop and test treat- ment treatment outcomes, are an emerging field
ments preventing recurrent suicidal behavior in of study. Recent research indicates that approxi-
adolescents, there are relatively few that are mately 95% of youth either own or have access
effective and durable (Bridge et al., 2014; Spirito to a smartphone (Anderson & Jiang, 2018), and
et al., 2021). While CBT (Stanley et al., 2009; with adolescents’ increasing utilization of tech-
Asarnow et al., 2017), attachment-based family nology, it is timely to consider incorporating
therapy (ABFT; Diamond et al., 2016), dialecti- technology into suicide prevention efforts. The
cal behavior therapy (DBT; Mehlum et al., 2014; integration of technology into suicide preven-
McCauley et al., 2018; Saito et al., 2020), and tion efforts can expand accessibility, increase
mentalization-based therapy (MBT; Rossouw & awareness, provide psychoeducation and sup-
Fonagy, 2012) have shown efficacy, there is a port, and connect individuals with services.
need for more replication studies to robustly sup- While many suicide prevention phone appli-
port this evidence (Ougrin et al., 2015). DBT-A cations are becoming available to the public,
currently meets Level 1 criteria (two independent recent research shows a disconnect between com-
trials supporting efficacy) and is a well-­ monly used suicide prevention phone applica-
established treatment for adolescents with suicid- tions and evidence-based prevention methods
ality (Asarnow & Mehlum, 2019; McCauley (Martinengo et al., 2019). The use of mobile
et al., 2018). While DBT has shown good out- phone apps for suicide prevention is a novel con-
comes after 6 months of treatment, these out- cept that is quickly gaining popularity, yet there
comes were not sustained at 12-month follow-up. have not been extensive longitudinal studies on
As summarized by Glenn et al. (2019), there are the efficacy of these apps. A study by Kennard
additional level 2 and 3 treatments that are prom- et al. (2018) tested the efficacy of evidence-based
ising but require further study (see Table 13.1). suicide prevention interventions such as safety
Six treatments meet Level 2 criteria as being planning, chain analysis, and coping skills pre-
probably efficacious: CBT-Individual + CBT-­ sented through a phone application. In a sample
Family + Parent Training for suicide attempters of 66 adolescents hospitalized for suicidality, the
(Esposito-Smythers et al., 2011), Family Based app intervention showed promise in reducing sui-
Therapy-Parent training (Pineda & Dadds, 2013), cide attempts post-discharge. Further studies
Family Based Therapy-Attachment for suicidal incorporating app technology into suicide pre-
ideation (Diamond et al., 2010), Interpersonal vention intensive outpatient programs (IOPs) are
Therapy (IPT)-Individual for suicidal ideation needed to assess the feasibility, acceptability, and
(Tang et al., 2009), and psychodynamic therapy-­ efficacy of increased technological methods of
individual + family (Rossouw & Fonagy, 2012) suicide prevention.
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 219

Table 13.1 Evidence-based interventions for youth with suicidality

Level 5:
Level 1: Well Level 3: Possibly Questionable
established Level 2: Probably efficacious efficacious Level 4: Experimental efficacy
DBT-A (DSH, DBT-A (NSSI, SA) Multiple systems CBT-individual (SA, Eclectic group
SI) therapy (SA) SI) therapy
CBT-individual + CBT-­ CBT-individual + Support-based
family + Parent training CBT-family (SI) therapy (SA)
Integrated family therapy Psychodynamic therapy Resource
(SA) family-based intervention (SA)
IPT-A-individual (SI) Integrated family
therapy (NSSI)
Psychodynamic therapy-­ Family therapy
individual + family (DSH)
Parent training (SITB) Multiple systems
therapy (SI)
Brief family-based
therapy
Support-based therapy
(SI)
Brief skills training
Motivational
interviewing (SI)
Resource interventions
(DSH, SI)

 eed for Intensive Outpatient

N  eveloping an IOP for Suicidal
D
Program (IOP) Level of Care Youth

Suicidal youth are most often treated in inpatient In this section, we report on our experience in
settings; however, with rising rates of suicide, developing an IOP that is transdiagnostic and
more options for lower levels of care are needed targets suicidal thoughts and behaviors. Our
(Thompson et al., 2021). IOPs have become a program, Suicide Prevention and Resilience at
more common treatment route after inpatient Children’s (SPARC), focuses on reducing risk
care, as well as with patients who do not need factors related to suicidal behavior and increas-
hospitalization and who are a better fit for an out- ing protective factors (Cha et al., 2018). SPARC
patient setting based on severity and acuity of is grounded in CBT (Asarnow et al., 2017;
symptoms (Ritschel et al., 2012). Few treatment Stanley et al., 2009) and includes components
programs have been shown to reduce risk of of DBT (McCauley et al., 2018; Rathus &
recurrent attempts after inpatient treatment Miller, 2014), mindfulness CBT (Segal et al.,
(Hughes & Asarnow, 2013; Spirito et al., 2002), 2002), and Relapse Prevention CBT (RP_CBT;
and very few IOPs exclusively target suicidal Kennard et al., 2016). SPARC has been operat-
thoughts and behaviors in adolescents. Yet, ing since 2014 and has served an increasing vol-
research has identified common elements that ume of adolescents and their families annually.
should be considered in treatment programs, such An established IOP program, Services for Teens
as comprehensive assessment to inform treat- at Risk at the Western Psychiatric Institute in
ment, safety planning, family involvement in Pittsburgh (Brent et al., 2011) provided consul-
separate and joint sessions, coping skills training tation and guidance on program development.
to match needs identified in the assessment, and The development of the program treatment
promotion of continuity of care (SAMHSA, manual included an iterative process. We began
2020). by interviewing a wide range of stakeholders for
220 J. K. Heerschap et al.

input, including treatment providers, research- Intake Procedures

ers, parents, and youth currently in treatment. In
piloting the treatment, we conducted multiple Adolescents (ages 12–18) are referred to SPARC
group sessions using clinical staff as providers after a recent suicide attempt or increased sui-
and simulated patients (Kennard et al., 2019). cidal ideation that warrants a higher level of care,
We piloted the manual with actual patients for a as determined by the referring provider in col-
two-month period with one group cohort. At the laboration with the family. SPARC receives refer-
end of 2 months, the clinical staff made deci- rals from outpatient providers (i.e., psychiatrists,
sions regarding what treatment components psychologists, therapists), local inpatient units,
would be included in the manual, and what and emergency rooms. Our care coordinator
changes to these components would be benefi- screens referrals and schedules intakes with a
cial. Primarily, we learned to include more SPARC provider (psychologist or masters-level
breaks, high energy activities and games, therapist) and a registered nurse (RN). In SPARC,
snacks, and techniques to make learning the there is a variety of caregiver involvement,
skills as interactive as possible. including both parents, single parent,
The program structure consists of teen groups stepparent(s), or other caregivers (e.g., aunt,
twice weekly, individual therapy, multifamily uncle, or grandmother). The parent(s)/caregiver/
groups, weekly skills-based parent psychoedu- guardian will be referred to as “parent” through-
cation groups, family therapy (as indicated), and out the remainder of the chapter.
medication management as needed. All teen During the intake, the therapist discusses the
group sessions and parent psychoeducation rationale and structure of the program with the
groups are packaged together and occur with the patient and their parent, completes a brief diag-
same revolving cohort. All therapy components nostic assessment, administers the Columbia-­
are billed as a “bundled” charge; however, indi- Suicide Severity Rating Scale (C-SSRS; Posner
vidual and medication management are billed et al., 2011) to assess the patient’s suicidal
separately. See Table 13.2 for frequency of treat- thoughts and behaviors, safety plans with the
ment components. Patients spend 7–9 hours in patient and parent, and discusses the SPARC
treatment each week and participate in program- treatment schedule and commitment to engaging
ming for 4–6 weeks, based on individual need in SPARC treatment. The therapist who conducts
(see below for more information on discharge the intake then takes the role of individual thera-
planning). pist during the patient’s treatment (and will be
referred to as “therapist” throughout the remain-
der of this chapter). The RN completes a medical
Table 13.2 Treatment components assessment of current and previous medications,
SPARC components Frequency current medical conditions, and reinforces home
Teen group Two times per week (3 hours safety procedures with the parent (see more
each) information under safety planning). At intake,
Individual therapy One per week (1 hour) patients also complete self-report assessments,
Multifamily group One per week for the first including measures of depressive symptoms,
2 weeks (3 hours each)
active suicidal ideation, and family functioning
Parent One per week (1 hour)
psychoeducation (measures are described in greater detail in the
group Program Outcomes Section). Parents complete
Family therapy As indicated measures of their child’s depressive symptoms
Medication As indicated and their assessment of family functioning. Both
management patients and their parents complete measures
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 221

Table 13.3 Intake procedures The therapist collaboratively discusses with

Intake assessment – brief diagnostic assessment, the patient that limiting access to means can help
assessment of the patient’s suicidal thoughts and the patient tolerate the crisis without acting on
behaviors, and a brief medical assessment (conducted
by the RN) to determine if SPARC is clinically
suicidal thoughts/urges. The therapist also
indicated (i.e., patient does not require a higher level encourages the patient to identify any objects in
of care or could manage easily in a lower level of care) their immediate environment (i.e., room, back-
Safety planning pack, locker) that may be used for self-injurious
1. Review event leading to SPARC, including risk and behaviors (e.g., razors, needles). Home safety is
protective factors
also discussed individually with the parent where
2. Complete initial safety plan with patient; identify
parent role in safety plan, including making the a more detailed list of safety precautions is
environment safe shared, including discussing the safe storage of
Orientation to treatment schedule and initial chemicals, lock boxes for medications, and ide-
commitment – discussion of treatment schedule and ally removing firearms from the home (and at a
willingness to participate in the program; patient
minimum locking unloaded guns and storing
agrees to safety plan
ammunition in a separate locked location).
Note: The safety plan is an iterative process and is con-
tinually revisited during individual therapy sessions Details of home safety and a companion handout
are discussed individually with parents to limit
patients’ exposure to additional suicide methods.
again at discharge, along with a treatment satis- See Appendix A (Hughes & Fancher, 2015) for
faction measure. See Table 13.3 for intake parent home safety handout.
procedures. After home safety, the therapist and patient
engage in a collaborative discussion of warning
signs that have imminently occurred before a sui-
Safety Planning cidal crisis. These signs could include situations,
emotions, thoughts, behaviors, and urges. Next,
Safety planning is an established intervention in the patient and therapist discuss internal coping
the treatment of suicidal adolescents (Stanley strategies that the patient can utilize as a first
et al., 2009; Brent et al., 2009). A safety plan is a step. These strategies are pulled from distress tol-
list of prioritized strategies that the patient uti- erance in DBT and can include distracting or
lizes in the event of a suicidal crisis. The goal of soothing activities such as listening to music,
the safety plan is for the patient to tolerate a sui- watching a favorite show, or taking a shower
cidal crisis without engaging in self-harm or sui- (Rathus & Miller, 2014; Linehan, 2014). If the
cidal behaviors. At the intake, the therapist internal strategies are ineffective at alleviating
completes a safety plan with the patient to address the suicidal crisis, then the patient is encouraged
immediate safety, and the plan is revisited regu- to move to external strategies. External strategies
larly to reinforce learning and use of the safety are what they can do with other people to distract
plan and to add new skills/strategies learned themselves. At this stage, patients do not neces-
throughout treatment. sarily need to disclose their suicidal state.
The safety plan is a prioritized set of strategies Examples of external strategies include calling or
for the patient to follow that is designed collab- texting with friends, watching a favorite show
oratively with the therapist. The first step of the with mom, playing a videogame with brother, or
safety plan is to discuss home safety with the taking a walk with dad. Lastly, if these internal
patient, and later their parent. The rationale of and external strategies have not reduced suicidal
home safety is to limit access to lethal means thoughts and/or urges, then the final step is to ask
available to the patient, including firearms, pills, an adult for help. The adult list often includes a
and sharps, as access to lethal means is a risk fac- parent, an extended family member, family
tor for death by suicide (National Action Alliance, friend, and/or a suicide hotline. We also encour-
2014). age patients to identify adults in their school
222 J. K. Heerschap et al.

environment, such as a trusted coach or coun- can be difficult to retell details about the day of
selor, they could reach out to if they are in crisis the event, it can increase the patient and thera-
at school. In addition, SPARC offers an on-call pist’s understanding of the contributing factors
number that patients can utilize to communicate and aid in developing an effective treatment plan.
with a SPARC therapist after hours if they are The therapist first asks the patient to walk him
struggling with a suicidal crisis. After individual or her through the external events of the day by
discussions, the patient, parent, and therapist prompting, “When did things begin to go down-
meet to review the safety plan, including com- hill?” The therapist elicits additional information
municating about warning signs parent may by asking questions about specific details related
notice and ways the parent can support the to the events, including who was there and what
patient. the patient was thinking, feeling, doing, or hav-
ing urges to do throughout the day. The therapist
and patient should also collaboratively discuss
Chain Analysis potential vulnerability factors that made that day
different such as not eating, difficulty sleeping
Chain analysis is a functional analysis of any the night before, and substance use. After the sui-
behavior used to better understand what causes or cidal event occurs in the chain, the therapist
maintains a behavior. Chain analysis is common enquires about short-term and long-term conse-
in CBT, DBT, and behavioral therapy. In SPARC, quences and environmental responses (e.g.,
we utilize a chain analysis of the suicidal event “What happened immediately after the attempt?
leading to IOP level of care based on strategies How did your family react?”) Assessing the
developed on the Treatment of Adolescent short-term consequence is key, because the
Suicide Attempters study (Brent et al., 2009; immediate consequence can be a robust rein-
Stanley et al., 2009; Asarnow et al., 2015). forcer of behavior (e.g., relief of emotion pain
When discussing the event leading to treat- immediately after cutting.) In addition to identi-
ment, we prioritize suicidal behaviors (i.e., fying vulnerabilities and consequences, it is help-
attempt; preparatory behavior of gathering medi- ful to highlight skillful behavior and identify
cine if attempt did not occur) over suicidal ide- existing protective factors such as future goals,
ation. However, if increased suicidal ideation was involvement in meaningful activities, a support-
the index event leading to treatment, then we will ive peer group, or an adult role model.
utilize this event for the chain analysis.
Adolescents often struggle to identify the events, Treatment Planning
thoughts, feelings, and behaviors/urges that pre- After the chain analysis, the therapist and patient
ceded the suicidal event. The chain analysis can collaboratively review the events to look for
help the patient identify reasons for the specific “weak links” or any skills deficits that occurred
problem behavior and identify vulnerabilities and proximally to the attempt such as interpersonal
skills deficits for treatment planning (Brent et al., difficulties, difficulty utilizing distress tolerance
2011). skills, or cognitive distortions. It is helpful to
identify those targets that, if changed, would have
 omponents of a Chain Analysis
C prevented the suicidal crisis; the goal is to iden-
During the first individual session, we introduce tify the therapeutic target that would “break the
the rationale of the chain analysis to increase chain” to prevent suicide. Collaborative input
awareness of the events, internal factors, and from the patient is essential. After the patient and
external factors that surrounded the suicidal therapist have discussed the treatment plan, then
event. We often liken the approach to viewing the it is presented to parents for their input. Upon
day in freeze frames (Wexler, 1999) or watching agreeing on the treatment plan and therapeutic
a movie in slow motion. We validate that while it targets for individual and family therapy, the
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 223

therapist orients the patient and parent to all treat- Table 13.4 Group modules
ment modalities (patient group, parent group, Group modules Description
multifamily group, and therapy) and describes Reasons for Patients learn to identify and/or recall
how each will contribute to the treatment plan living reasons for living to help them
tolerate crisis situations and increase
goals. The therapist obtains a commitment from hopefulness for the future. Patients
the patient and parent to participate in SPARC make hope kits as a tangible way to
and to use the safety plan in response to suicidal recall reasons for living
ideation or urges. Mindfulness Patients practice focusing on the
present moment in a non-judgmental
manner. Patients practice recognizing
their current emotions, thoughts, and
Treatment Components physiological sensations. Mindfulness
is foundational to all the skills
because patients need to be aware of
Teen Group Therapy what they are feeling and recognize
Teen group is the most time-intensive component when skills are needed to help them
of SPARC, occurring 6 hours a week over two reach their goals
group sessions (groups are spaced 3 days apart). Behavioral Patients are taught to recognize their
Group has historically been composed of 8–10 activation mood states. The relationship
between activities and mood is taught
patients and two therapists. During COVID-19, through experiential practices.
group was modified to include a hybrid compo- Patients plan pleasant, social, and
nent to maintain the standard census while reduc- mastery activities to enhance mood
ing in person numbers by allowing patients to Problem-­ Patients learn a strategy to problem-­
solving solve, including how to look at all
join virtually as clinically appropriate. The aim
sides of the problem and develop a
of teen group is to teach and practice skills asso- plan to tackle difficulties
ciated with decreasing risk factors for suicidal Emotional Patients learn to identify
behaviors. Skills are grounded primarily in CBT, regulation vulnerabilities, events (either internal
along with elements of other evidence-based or external), and the role emotions,
interpretations, and behaviors or
treatments, such as DBT (Rathus & Miller, 2014; urges can have on the situation.
Linehan, 2014) and RP-CBT (Kennard et al., Patients learn skills to help them
2016) (see Table 13.4 for outline of specific mod- manage strong emotions in a way that
ules covered). Teen group is revolving with an is congruent with their goals.
Distress Patients learn that acute distress is
open format for patients to enter at any point and
tolerance temporary and learn skills to “ride
leave when they are displaying discharge readi- out” strong emotions in crisis
ness (see individual therapy section for discharge situations without acting impulsively
planning). SPARC groups are led by SPARC pro- Walking the Patients learn to examine situations in
viders (e.g., psychologists, masters-level clini- middle path a dialectical manner – considering all
points of view. Patients practice
cians, psychology trainees); in some instances, challenging “all-or-nothing” thinking
the SPARC group leader may be the SPARC and extreme beliefs
therapist for patients in the group. Socialization Patients focus on enhancing their
Each patient completes a diary card at the and support social support – particularly during
crises. This module includes
beginning of each group that assesses the inten-
increasing family communication and
sity of suicidal thoughts, intent, and plan since identifying positive peer supports
last session (rated 0–5 with 5 being the most Interpersonal Patients learn to improve
intense). See Appendix B for an example diary effectiveness communication and enhance
card. Patients also record if other behaviors relationships through validation,
negotiation strategies, and assertive
occurred, including suicide attempts (yes/no), communication strategies
non-suicidal self-injury (yes/no), and other rele- (continued)
vant clinical factors. The diary card is a key com-
224 J. K. Heerschap et al.

Table 13.4 (continued) group leaders aim to provide consistent skills

Group modules Description teaching to both the patient and parent in the
Positive Patients learn strategies for activating same session, allowing the parent to also benefit
affect positive emotional states by engaging from the application of mood monitoring and
in pleasant activities and/or recalling
wellness skills for themselves. Additionally, the
positive events
Wellness/ Patients learn to identify and enhance
multifamily group format allows for patients
relapse their strengths. As part of relapse and parents to recognize that other families are
prevention prevention, lapses in mood are also going through challenges and can provide a
normalized and patients develop sense of belonging and validation.
individualized plans for how they will
cope with lapses to prevent relapses
(i.e., crisis behaviors that lead to IOP) Parent Education
Parent support has been shown to be an important
element of successful treatment for suicidal ado-
ponent of safety planning as it alerts the SPARC lescents (Brent et al., 2013). Parents participate
group therapists when a brief check-in, safety in a weekly 1-hour psychoeducation group led by
plan review/modification, and/or a crisis session a SPARC therapist that runs concurrently with
are needed. Check-ins occur individually with a their teen’s group treatment. Parents have the
therapist to limit potential contagion. opportunity to review the skills that their teens
Additionally, group expectations include no “war have learned that week during teen group. There
stories” (i.e., limiting detailed discussions regard- is a particular emphasis on how parents can rein-
ing suicidal thoughts and behaviors to individual force skill use in the home environment. There is
therapy and/or check-ins.) In about addition to also about 15–20 minutes allocated for parents to
diary card completion, group format also includes ask parenting- and treatment-related questions to
a mindfulness exercise, review of group expecta- the therapist and to get support from other par-
tions, skills review, teaching a new skill, recre- ents. Parents receive a companion treatment
ation therapy (once a week), practice assignment, booklet that covers the skills taught in teen group,
and check out. as well as contains psychoeducational resources
specific for suicidal adolescents.
Multifamily Group Therapy Multifamily
group therapy is included in SPARC. The cur- Individual Therapy
riculum is rotating (Week A and Week B), and Each patient participates in weekly individual
the SPARC therapist works with the family to therapy while enrolled in the IOP. See Table 13.5
identify the weeks to attend (typically recom- for individual therapy components. The initial
mended in the first 2 weeks of a patient’s SPARC task of the therapist is to conduct a chain analysis
participation). Week A focuses on teaching vali- of the index suicidal event leading to treatment.
dation to enhance communication and deesca- As discussed above, this aids the therapist in
late conflict in the family, which is based on identifying the most proximal skills deficits and/
DBT (Rathus & Miller, 2014; Linehan, 2014). or risk factors related to the event. It also informs
Week A also focuses on skills to aid in mood the individual therapist of protective factors to
monitoring and communication about distress, enhance. From this initial session and chain anal-
via use of an emotions thermometer, and is ysis, the therapist and patient collaboratively
based on the Family Intervention for Suicide identify individual treatment goals during IOP
Prevention/SAFETY-­ Acute model (Asarnow treatment (e.g., increasing a patient’s distress tol-
et al., 2009, 2011; Hughes & Asarnow, 2013). erance skills, enhance reasons for living, and
Week B focuses on strategies to enhance family increasing family support). The individual thera-
wellness and protective factors, based on pist also facilitates the development of the safety
RP-CBT (Kennard et al., 2016). By teaching plan in collaboration with the patient and their
these skills in a multifamily format, SPARC parent(s).
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 225

The therapist’s next task is to integrate skills Table 13.5 (continued)

learned in group to the patient’s individual treat- Individual therapy
ment goals. The therapist helps the patient to tai- modalities Goal of modality
lor the skills to their unique situation and supports Discharge planning/ Discharge planning is
relapse prevention/care assessed via reduced suicide
the patient in identifying a practice plan each linkage risk, utilization of the safety
week. The safety plan is also reviewed regularly plan, and progress toward
treatment goals. An
individualized relapse
Table 13.5 Individual therapy modalities prevention plan is created
where “lapses” (e.g., minor
Individual therapy
setbacks, worsening of
modalities Goal of modality
mood or ideation) are
Rapport For an effective therapeutic normalized and the patient
building/therapeutic experience, the patient must established a plan for
alliance feel safe and validated preventing a relapse (i.e.,
(Brent et al., 2011). Taking often an index event that
time to establish rapport and preceded SPARC.) Care
trust is foundational to the linkage for patients without
rest of the treatment outpatient providers begins
Chain analysis In the first individual weeks before discharge so
session after the intake, the care is established prior to
chain analysis of the index SPARC completion
event is conducted to
identify the proximal skills
deficits and/or risk factors
related to the event. It also in individual therapy and is modified as patients
informs the individual learn and apply new skills.
therapist of protective
factors to enhance Regarding discharge readiness, the individual
Treatment planning The therapist utilizes the therapist assesses for: reduction of suicide risk
chain analysis to (as evidenced by decreased suicidal ideation and
collaboratively identify with behaviors on diary cards and per patient report);
the patient what skills to
enhance and identify
the utilization of the safety plan and progress
individual treatment goals toward treatment goals; education of the family
Teaching/reinforcing The therapist emphasizes on enhancing support and safety; development of
individual skills and the teaching and practice of a relapse prevention plan; linkage to outpatient
reinforcing application skills identified during mental health treatment.
of teen group skills treatment planning that are
hypothesized to have the
highest likelihood of Family Therapy
reducing future suicidal Parents are routinely involved in individual ther-
behavior. The therapist is apy and are required to attend multifamily ther-
also aware of the skills
being covered in teen group apy alongside the patient. As needed, when
and reinforces the patient’s family communication difficulties appear to be
individual application and associated with the patient’s suicidal thoughts
practice outside of session and/or behaviors, short-term family therapy is
Review and refinement The safety plan is reviewed
of safety plan during crises and/or after an
offered. Family therapy in the IOP is short-term
elevated diary card. and is related to increasing healthy communica-
Additionally, the safety plan tion and reducing conflict (e.g., truces on hot top-
is revisited throughout ics). Family-based approaches to youth suicide
individual therapy when the
patient learns new skills to
prevention, such as multifamily group and family
add or removes a strategy therapy, have shown promise across multiple
that was ineffective for them interventions, such as CBT and DBT (Diamond
(continued) et al., 2014).
226 J. K. Heerschap et al.

Medication Management consistency (a = 0.84). Both patients and parents

SPARC is based in an outpatient psychiatric completed the QIDS at intake and discharge.
clinic with access to psychiatry fellows and The Concise Health Risk Tracking – self
attending psychiatrists. As needed, patients have report (CHRT-SR; Trivedi et al., 2011). Patients
the opportunity to be followed by psychiatry for rate their thoughts over the past week using a
medication management through SPARC. Other five-item Likert scale: strongly disagree, dis-
patients come into SPARC with an external psy- agree, neither agree nor disagree, agree, or
chiatrist or advanced practice provider; these strongly agree. Three items represent the Active
patients can also be seen in the clinic for a second Suicidal Thoughts score to estimate active risk
opinion as needed. (e.g., current suicidal thoughts and plans). The
score ranges from 0 to 12 with a score of 4 or
greater indicative of higher risk. The CHRT-SR
Program Outcomes has good internal consistency reliability coeffi-
cients a = 0.774–0.915, as well as good construct
 rogram Evaluation Outcomes
P and content validity. Patients completed the
Clinical data has been collected since the IOP CHRT-SR at intake and discharge.
began for the purpose of monitoring patient The Client Satisfaction Questionnaire (CSQ-­8;
improvements and for program evaluation. Nguyen et al., 1983) is completed at discharge by
Outcomes presented below were prospectively both the patient and parent. The CSQ-8 is an eight-
collected on patients enrolled in the IOP between item scale on which patients and parents rate their
January 1, 2014 and December 31, 2019. satisfaction with treatment on a scale of 1 to 4, with
higher ratings being indicative of higher satisfac-
 uality Improvement Outcomes
Q tion. This measure has been shown to have satisfac-
Measures tory internal consistency with an alpha of 0.93.
Patients and parents completed a measure of fam- Following discharge from the program,
ily functioning (Family Assessment Device patients and their families are contacted at
General Functioning Scale (FAD GF; Ryan et al., 1 month and 6 months by phone to assess subse-
2005)) at intake and discharge, which guided quent suicidal behaviors and treatment utilization.
clinical care and treatment recommendations. If a patient is struggling with suicidal thoughts or
The therapist assessed history of attempt and behaviors, the therapist will offer treatment rec-
non-suicidal self-injury (NSSI) at intake via the ommendations and/or booster sessions to review
Columbia-Suicide Severity Rating Scale clinical key skills with the individual therapist.
interview (C-SSRS; Posner et al., 2011). The key
outcome measures are described below. Program Outcomes
The Quick Inventory of Depressive A total of 955 patients were eligible and attended
Symptomatology (QIDS) for Adolescents Self-­ at least one group session. The mean number of
Report (QIDS-A, SR-17) and Self-Report Parent groups attended was 9.6 ± 3.5 (range 1–21). The
(QIDS-A-SR[P]). The QIDS-A is a 17-item self-­ majority of patients were Caucasian and non-­
report measure that assesses the presence and Hispanic girls (see Table 13.6 for demographic
severity of depressive symptoms within the last information.) Referrals were predominately
7 days (Haley, 2009). The QIDS-A-SR[P] is a internal referrals from the hospital (see Table 13.7
self-report parent measure designed for the par- for referral sources.)
ent to report the depressive symptomatology of Nearly half of the sample (46.9%; n = 448)
their child. Score interpretation ranges include: was referred to IOP following a suicide attempt,
6–10 (mild depression), 11–15 (moderate depres- while the other 53.1% (n = 507) had severe ide-
sion), 16–20 (severe depression), and 21–27 ation warranting an urgent evaluation. Sixty-two
(very severe depression). This measure has percent of patients had a lifetime history of at
acceptable reliability (a = 0.78) and good internal least one attempt. Almost 72% had also engaged
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 227

Table 13.6 Demographic and clinical characteristics of Table 13.7 Referral source of those enrolled in IOP
those enrolled in IOP
Total
Total Referral source N = 955
N = 955 Internal referral 73.2% (699)
Age 14.9 ± 1.5  Psychiatric inpatient unit 58.8% (411)
Sex  Emergency department 26.8% (187)
 Female 78.0%  Psychiatric outpatient clinic 9.9% (69)
(745)  Psychiatry consult team 3.7% (26)
 Male 22.0%  Psychiatric day treatment 0.8% (6)
(210) External referral 26.8% (256)
Ethnicity  Psychiatrist 32.0% (82)
 Hispanic 19.9%  Therapist 25.8% (66)
(190)
 Psychiatric inpatient unit 12.5% (32)
 Non-Hispanic 79.5%
 Self-referred 12.1% (31)
(759)
 Other 11.3% (29)
 Unknown 0.6% (6)
 School 2.3% (6)
Race
 Psychiatric day treatment 2.0% (5)
 Caucasian 85.8%
(819)  PCP 1.2% (3)
 African American 8.3% (79)  Emergency department 0.8% (2)
 Asian 2.9% (28)
 More than one race 0.9% (9)
 American Indian 0.1% (1) the QIDS-A. At baseline, patients reported active
 Pacific islander 0.2% (2) suicidal ideation, indicating most patients were
 Unknown 1.8% (17) experiencing intent and/or plan within the past
Depression diagnosis 92.8% week. Additional baseline clinical characteristics
(886) are provided in Table 13.6.
# attempts (lifetime) 1.2 ± 2.2 The majority of patients completed the IOP
None 38.4%
program (82.8%; n = 791), which was defined as
(367)
1 37.5%
completing at least five teen groups and being
(358) determined by the SPARC treatment team as
2 11.6% ready for a lower level of outpatient care. While
(111) there is no set minimum for parent involvement,
3+ 12.5% we find parents are necessary for ensuring their
(119)
teens attend group treatment, that safety planning
Non-suicidal self-injury (lifetime) 71.0%
Yes (678) extends to the home, and that the outpatient care
Non-suicidal self-injury (ongoing) 53.9% plan is feasible. When a parent cannot sufficiently
Yes (515) participate (i.e., struggle to take their teen to
Baseline QIDS-A parenta 13.5 ± 4.8 treatment and/or engage with the clinical team)
Baseline QIDS-A teena 14.0 ± 5.8 therapists engage the parent in a collaborative
Baseline CHRT active suicidal 5.0 ± 3.6 discussion on a resolution which could include
ideationb
discharge.
a
Calculated using the Quick Inventory of Depressive
Symptomology-Adolescent-Self Report Version, scores
Changes in the clinical outcome measures
range from 0 to 27 (QIDS-A, QIDS-A-SR[P], and CHRT-SR) over
b
Calculated using the Concise Health Risk Tracking Self-­ the acute intervention period (baseline to dis-
Report – Suicide Risk subscale, scores can range from 0 charge) were examined using paired sample t
to 12
tests, and Cohen’s d was calculated to estimate
effect sizes for the within-subjects mean change
in NSSI with over half engaging in NSSI over the score (see Table 13.8). Both parents and patients
past 2 weeks. At baseline, parents and patients reported significant reductions in depression
reported moderate levels of depression based on severity (large effect size; d = 0.8), and patients
228 J. K. Heerschap et al.

Table 13.8 Paired samples t-tests for outcome measures for patients who completed the program (N = 791)
Baseline Discharge
M SD1 M2 SD2 Mean diff. T df p
QIDS-A self-report 13.9 5.8 9.3 5.4 4.6 21.9 713 <0.001
QIDS-A parent report 13.5 4.8 8.2 4.6 5.3 26.2 640 <0.001
CHRT active suicidal ideation 5.0 3.6 2.3 2.7 2.7 21.1 713 <0.001

reported a marked improvement in active suicidal including patient, multifamily, and parent groups,
ideation (large effect size; d = 1.0). as well as access to medication management and
Upon completion of the program, patients and family therapy sessions as needed, and focuses
parents completed the CSQ-8 to assess satisfac- on reducing the risk for future attempt. Qualitative
tion. Both patient and parent satisfaction were improvement data is an important component of
very high. In response to the question, “In an the program. Since its inception, feasibility and
overall, general sense, how satisfied are you with acceptability outcomes have been positive and
the service you have received?” – 99% of parents retention rates are satisfactory, with nearly 83%
and 96% of patients responded that they were completing the program. Both patients and par-
mostly satisfied or very satisfied. The average ents indicated that the treatment was acceptable,
score across items on the CSQ-8 for those who with over 95% of parents and patients reporting
were enrolled in the program was 3.8 for parent being satisfied or very satisfied with the SPARC
(n = 680), and 3.6 for patient (n = 745) on a program. These numbers indicate that the pro-
4-point scale (with 4 indicating the highest level gram was both well tolerated and found accept-
of satisfaction). able by both patients and their families. Outcomes
To assess sustained improvement following related to future attempts were also positive. The
the program, all patients who attended at least attempt rate at six months was less than 12%.
one visit were contacted to assess subsequent sui- Within six months, those who did not complete
cidal behaviors and continued engagement with the program had a higher rate of suicide attempts.
treatment. Follow-up information on suicidal This suggests that the program may be effective
behaviors was obtained from 79.7% (n = 761) of in preventing attempts post discharge if the
those who entered the program at one-month patient completes the program (i.e., attends five
follow-up, and from 70.9% (n = 677) at six-­ or more teen group sessions). A recent meta-­
month follow-up regarding attempt. In total, analysis (Ougrin et al., 2015) found a 28% over-
11.7% (n = 79) of respondents reported a suicide all rate of attempt post-treatment for youth treated
attempt within 6 months of discharge from the for suicidal thoughts and behaviors through a
IOP, 34.2% (n = 27) of which were reported as wide variety of treatment interventions covering
being during the first month following discharge. both individual and group treatments (i.e., DBT,
Of the patients that completed SPARC, 10.8% CBT) compared to a 33% rate of attempt for
reported an attempt within 6 months of program- those who received treatment as usual. Other
ming compared to 17.9% of patients who dropped studies that have reported six-month outcomes
out of treatment before completion (trend towards post treatment, suggest reattempt rates of 10–43%
significance, p = 0.059). with variability occurring due to differing treat-
ments and follow up periods (Ougrin et al., 2015).
Thus, our six-month outcome data compares
Discussion favorably to previous literature.
There are several limitations to our under-
In this chapter, we report on our experiences in standing of SPARC’s effectiveness at this time,
developing a suicide-specific, evidence-based which provide opportunities for future inquiry.
treatment program for adolescent patients and We have not conducted a randomized controlled
their families. The program is skills-based, trial of SPARC and do not have a comparison with
13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 229

a control group. Given this is a clinical program in Conclusions

a large hospital system, this has not been the goal
of implementation to date. A future study to com- While there has been an increase in RCT’s
pare SPARC to other IOP approaches, or to designed to facilitate reduction in self-injurious
develop and test a treatment matching or referral thoughts and behaviors over the past 50 years,
algorithm to better understand how SPARC fits these study interventions have yielded small
within the existing continuum of care (ED and/or effect sizes and little improvement in outcomes
inpatient hospitalization) would be beneficial. (Fox et al., 2020). More work is needed to iden-
In addition, our population served to date is tify and target common causes of self-injurious
largely female and Caucasian, limiting the gener- thoughts and behaviors (Fox et al., 2020), to
alizability of our outcomes to more heterogenic improve treatment outcomes, as well as access to
populations. Given that we know suicide rates are suicide-specific care. Glenn and colleagues did
on the rise in Black and Latinx youth, it will be note shared components of efficacious treatments
particularly important to engage these popula- for youth, which included being family-centered
tions in SPARC and to assess acceptability and and inclusion of skills training, yet there contin-
efficacy of the program in these populations. ues to be a lack of clarity about the necessary
Furthermore, our program includes multiple treatment dose to make a meaningful impact
treatment components and modalities, and we do (Glenn et al., 2019). There has been a call for the
not have information as to what components of development of briefer, scalable interventions,
treatment are most effective. A component analysis and the SPARC IOP model offers an approach
study compared standard DBT (DBT skills training that is scalable within many existing healthcare
and DBT individual therapy), DBT-S (DBT skills systems, where inpatient and outpatient services
training plus case management), and DBT-I (DBT are offered to suicidal or self-harming youth but
individual therapy plus activities group) in 99 adult there are not defined intensive brief intervention
women, and found that all conditions led to opportunities between these two common levels
improvement in frequency and severity of suicide of care. SPARC is intensive, but with much of the
attempts, suicidal ideation, and reasons for living skills content delivered in a group format (similar
and decreased use of crisis services due to suicidal- to DBT-A) and brief (4–6 weeks). Additionally,
ity (Linehan et al., 2015). However, compared to SPARC includes components shown to make
DBT-I, only DBT and DBT-S demonstrated great meaningful impact, including family-centered
improvements in frequency of NSSI, depression, interventions (i.e., parent group, multifamily
and anxiety. DBT had lower dropout rates from group, and family sessions) and teaching and
treatment and participants were less likely to use reinforcing skills. Future research is needed to
crisis services and psychiatric hospitalization. As investigate the active components of treatment,
such, it is possible that only certain components of the most effective treatment dose, and best prac-
SPARC are contributing to the overall effect of the tices for triaging youth to this level of care (e.g.,
program. Finally, while we have up to six months is SPARC most helpful as step-down from inpa-
of outcome data, we do not have data beyond that tient, or after an ED visit?). This innovative pro-
point. Other studies have indicated less promising gram has been key in reducing suicide risk in our
outcomes past the six month time period (McCauley clinical program, and further dissemination and
et al., 2018). implementation efforts are underway.
230 J. K. Heerschap et al.

Appendix A: Home Safety Checklist

13 Development and Implementation of an Intensive Outpatient Program for Suicidal Youth 231

Appendix B: Diary Card

Name:
Alcohol/ Mood
Self-Harm Suicidal Thoughts and Behaviors School Self-Care
Drugs Rating
0=
Meds
Are You In Slept Worst
Date Urge Action Thoughts Urge Intent Plan Action Urge Action Attended Taken/ Exercised
Pain? Well? 10 =
Helping?
Best

0-5 Yes/No 0-5 0-5 0-5 0-5 Yes/No 0-5 Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No 0-10

treatment for adolescent suicide attempters. Journal

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 Seattle Children’s Hospital’s
Obsessive Compulsive 14
Disorder-­Intensive Outpatient
Program

Geoffrey A. Wiegand, Lisa Barrois,

Anna Villavicencio, Jiayi K. Lin, Alyssa Nevell,
and Tilda Cvrkel

Overview and Program Goals Patients must be able to safely tolerate

Exposure and Response Prevention Therapy
The Seattle Children’s Hospital Obsessive (ERP) on an outpatient basis. Those patients who
Compulsive Disorder-Intensive Outpatient are unable to comply with parent or clinician
Program (SCH OCD-IOP) serves children and directives without engaging in seriously aggres-
adolescents ages 10–18 from Washington, sive behaviors are excluded. Patients who are
Alaska, Montana, and Idaho with a primary diag- actively engaging in non-suicidal self-injury, cur-
nosis of obsessive compulsive disorder (OCD). rently endorsing suicidal ideation, and/or engag-
Admitted patients have OCD in the Severe to ing in suicidal behaviors may be excluded based
Extreme Range as measured by the Children’s on clinician judgement regarding their ability to
Yale-Brown Obsessive Compulsive Scale withstand ERP safely. Similarly, patients with
(CY-BOCS; Scahill et al., 1997) by clinician-­ co-occurring eating disorders are assessed to
rated interview. Prior to admission, patients must determine if symptoms are stable enough to
have attempted at least 10 weeks of once weekly engage in ERP without decompensating. They
outpatient therapy without adequate reduction in must be able to functionally engage in group and
symptoms to qualify. individual therapy (and during COVID-19, be
able to stay on camera for telehealth sessions).
The SCH OCD-IOP program goals are three-
fold: (1) significantly decrease OCD symptom-
G. A. Wiegand (*) · L. Barrois · A. Nevell
Department of Psychiatry and Behavioral Sciences,
atology and impact, (2) develop Cognitive
Seattle Children’s Hospital, Seattle, WA, USA Behavioral Therapy (CBT) for OCD skills such
e-mail: [email protected] that the patient (and their parents/caretakers) can
A. Villavicencio continue to keep OCD under excellent control,
Washington Anxiety Center of Capitol Hill, and (3) substantially improve access to evidence-­
Washington, DC, USA based care in our state by graduating trainees
J. K. Lin who are thoroughly trained in CBT for OCD,
Columbia University Clinic for Anxiety and Related confident in their abilities to treat OCD, and
Disorders (CUCARD), Columbia University Medical
Center, New York, NY, USA
intend to make OCD a focus of their practice.
Individual patients engaged in the program
T. Cvrkel
Department of Clinical Psychology, Seattle Pacific
receive high-quality, evidence-based, intensive
University, Seattle, WA, USA outpatient treatment with the expectation of

235
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_14
236 G. A. Wiegand et al.

reducing both symptom severity and functional scores of patients from beginning the program
impairment. Parents are also provided with (baseline) to week 12 for the years of 2016 to
extensive training in CBT for OCD skills. This 2019. Our data shows that the average patient
allows them to maximize the number of ­exposures will start the program with a CY-BOCS score of
that their teen engages in during treatment and approximately 30 (Severe Range). Their scores
encourages the promotion of a “family exposure are then predicted to decrease week by week,
lifestyle” to prevent relapse in the future. with a predicted CY-BOCS score of approxi-
Given the paucity of evidence-based care for mately 23 (moderate range) after 4 weeks in the
OCD in our community, training a large cadre of program, 14 (mild range) after 8 weeks in the
masters and doctoral level students who will go program, and 5 (sub-clinical range) after
on to deliver CBT for OCD is a high priority. 12 weeks in the program (Nevell, 2020).
Toward that end, we have trained approximately The following figure (Fig. 14.2) illustrates
45 students over the last 4 years and are now at predicted OCD severity scores for patients over 8
a point where our first trainees have finished weeks in the program when broken down into
their graduate training and are practicing in the low, average, and high age. Overall, these results
community. Exit interviews and observations indicate that age is not a factor in determining
suggest that most, if not all, of our graduates are whether the program is successful in reducing
going on to treat OCD in their clinical OCD severity scores, and that children and ado-
practices. lescents between the ages of 11 and 18 are pre-
As seen in the figure below (Fig. 14.1), out- dicted to benefit similarly from participation in
comes for patients who participate in our OCD-­ the OCD-IOP.
IOP are encouraging. Our data shows that This final figure (Fig. 14.3) again shows OCD
treatment in the IOP is linked to weekly reduc- severity scores change over time and illustrates
tions in OCD symptom severity, indicating con- that children and adolescents who spend overall
tinual benefit throughout the duration of more time in the OCD-IOP (high days in pro-
treatment. This chart illustrates the predicted gram) have a slower rate of improvement com-

Fig. 14.1 Participation in OCD-IOP associated with steady decline in OCD symptom severity total scores on the
CYBOCS
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 237

Fig. 14.2 OCD-IOP effective regardless of age for participants between the ages of 11 and 18

Fig. 14.3 Patients who improve more slowly benefit from more days in program

pared to children and adolescents who spend tain number of weeks in program, and instead
overall less time in the OCD-IOP (low days in continuing intervention and waiting to discharge
program). These results are consistent with our patients whose OCD severity scores are not
OCD-IOP model of not limiting patients to a cer- decreasing as quickly.
238 G. A. Wiegand et al.

Origins and Program Development (ARNP) to manage the psychotropic medication

needs of the teens in our program. Our ARNP
The Scheme OCD-IOP grew out of an attempt to attends our weekly rounds to coordinate care.
develop a Tourette’s Center of Excellence at Having part of their time dedicated to our pro-
Seattle Children’s Hospital. Upon failing to be gram significantly reduces wait time for our
awarded a Tourette’s Association Center of patients and allows the ARNP to begin to opti-
Excellence grant, the first author decided to pro- mize the teen’s medication prior to starting the
ceed in developing the clinic regardless of grant OCD-IOP.
funding. The clinic began with training a group Trainees were, and continue to be, an essential
of 11 clinicians at Seattle Children’s Hospital part of the OCD-IOP. We typically have 10–12
(seven psychologists, one psychiatrist, two clini- trainees at a time for the year with some variation
cal psychology postdoctoral fellows, and one regarding how many might be in the OCD-IOP
social worker) in the evidence-based assessment each day (typically between two and six trainees
and treatment of Tourette’s and co-occurring dis- attend each session per day). Trainees have been
orders. Since the clinicians largely already had recruited from one master-level and three
expertise in treating attention deficit hyperactiv- doctoral-­level training programs in Seattle (two
ity disorder (ADHD), depression, and learning doctoral-level clinical psychology programs and
disabilities, this meant that the primary focus was one doctoral-level school psychology program).
teaching CBT for OCD and Comprehensive Trainees gain experience in directing the group
Behavioral Intervention for Tics (CBIT). portion of sessions, the individual (teen and par-
Supervision and training in CBT for OCD and ent) exposure sessions, act as case managers for
CBIT was provided to the group for 90 minutes 1–2 cases, and for advanced doctoral students,
per week for 12 months. Group members carried provide live coaching for less experienced
two to three tic and OCD cases from assessment trainees.
through the completion of CBT for OCD and
CBIT.
Shortly thereafter, we discovered that insur- Stakeholders
ance companies were beginning to cover inten-
sive mental health services. At the same time, our The training institutions from which we draw our
hospital and psychiatry department were looking trainees have in effect become stakeholders in
to promote new innovative evidenced-based our program in the sense that they have benefited
models for care. There was particular interest in from our providing training for many of their stu-
developing programs that would help to divert dents in multiple types of evidence-based care.
teens from out of state residential care. Prior to Our Psychiatry and Behavioral Sciences
the inception of the SCH’s OCD-IOP, teens with Department is also a major stakeholder given the
severe OCD were often referred to Rogers extensive departmental resources we consume
Memorial Hospital’s residential program or (i.e., three attending psychologists [2.6 Full Time
UCLA’s OCD-IOP in Los Angeles. Equivalent [FTE]], an ARNP [0.2 FTE], and an
Having a cadre of trained CBT for OCD pro- administrative assistant [1.0 FTE]). Historically,
viders simplified the start-up of the OCD-IOP, we have been able to more than cover these costs
and four of the psychologists and a postdoctoral while providing evidence-based care with docu-
fellow became the first staff of the OCD-­ mented positive clinical outcomes (see section
IOP. Initially, the program depended upon access- “Lessons Learned, Resources, and Next Steps”
ing medication through the typical department for impact of telehealth on cost-effectiveness fol-
referral/triage process, which was very slow. lowing the COVID-19 pandemic). This led to
Once it was clear that the program was support- institutional support. We facilitated organiza-
ing itself financially, we were able to add a dedi- tional goodwill with our early decisions to engage
cated Advanced Registered Nurse Practitioner in routine outcomes monitoring and to provide
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 239

outcome data to administrators. In effect, by col- ficiently to be classified as “well-established,”

lecting and publicizing information regarding our CBT for OCD and ERP meet evidence-based
outcomes within our institution, we became “a standards for “probably efficacious” (Freeman
shining example of evidence-based care” when et al., 2014). Research has demonstrated that
they wanted to highlight activities for the hospital CBT for OCD and ERP are also effective in pedi-
board and the community at large. Providing out- atric and adolescent populations (Rapoport &
come information and patient feedback to people Inoff-Germain, 2000; Bolton & Perrin, 2008;
all the way up the chain of command in our insti- Geller & March, 2012; Torp et al., 2015).
tution has helped us to be known by hospital However, after years of clinical experience
executives. We have given tours which included working with OCD clients, the first author
presenting outcome data to hospital vice-­ observed that many CBT for OCD clients return
presidents, lobbyists, and departmental adminis- to treatment years after their initial period of
trators. As a result, and to our benefit, the intervention with little to no retention of CBT for
OCD-IOP is now well known within our OCD principles. Both research and practice sug-
organization. gest that OCD has a chronic course despite inter-
Perhaps our most important stakeholders are vention (American Psychiatric Association,
the network of former patients and their families. 2013), suggesting that intervention needs to
Unsolicited, they organized themselves into a address patients’ abilities to deal with OCD urges
Facebook group, which allows them to keep in years later. Examination of books on CBT for
contact and support each other. Seattle Children’s OCD for even primary school-age children and
Hospital has over 200 guilds which raise millions their parents reveal they are often too complex
of dollars each year to support uncompensated for them to remember and utilize years later when
care and program enhancement hospital wide. OCD urges return. The complexity of CBT for
Two years ago, former OCD-IOP families cre- OCD manuals also interferes with trainees’ con-
ated an OCD-IOP Guild. This guild is only the fidence that they could subsequently treat OCD
second guild to support mental health services in well after what are often short clinical rotations.
the hospital’s 100 + −year history. While the
guild (and our program) are in their infancy, they
have already contributed enough money to par- SCH OCD-IOP Program Model
tially support an OCD-IOP post-doctoral position
for the last 2 of our 4 years. To address the challenges noted above, the first
author has distilled CBT for OCD into four key
principles. We emphasize these four basic con-
Use of Evidence-based cepts throughout the program with the goal of
and Empirically Informed maximizing the ability of patients, parents, and
Interventions trainees to remember these concepts and to have
confidence in their ability to apply them for the
The primary intervention model of the SCH rest of their lives. During their first week in the
OCD-IOP is CBT for OCD with particular program, teens and parents are oriented to our
emphasis on ERP. Several controlled, random- Four Golden Rules.
ized studies have demonstrated that CBT for The Four Golden Rules:
OCD and ERP, either alone or combined with
pharmacotherapy, show significant increases in 1. Ride the Wave
symptom improvement over pharmacotherapy or We teach teens that their anxiety will ini-
placebo interventions alone (Pediatric OCD tially go up as they approach their feared
Treatment Study (POTS) Team, 2004; Simpson object or situation, but if they do not flee/
et al., 2008). While no comprehensive interven- attempt to escape or engage in a compulsion/
tion for pediatric OCD has yet been studied suf- ritual, then their anxiety (including their heart
240 G. A. Wiegand et al.

rate) will eventually come down. Each time Rules 1 and 2 (Ride the Wave and Do the
they do this, it will get easier and easier and Opposite) are meant to prepare patients to begin
easier. Eventually, they are likely to find that exposure work. Rules 3 and 4 (Thoughts Not
they are no longer afraid of the situation or Actions and Be an OCD Detective) are the
object.* groundwork for the cognitive part of CBT for
*We do highlight that other outcomes are OCD that we emphasize later in treatment.
possible (e.g., they do the exposure and their Clinicians reinforce these concepts during ses-
anxiety does not fully subside, but they are sions, praising patients for “riding the wave”
able to tolerate it without avoidance and after difficult exposures and encouraging “OCD
extreme distress over time). detective work.” Group session icebreakers often
2. Do the Opposite (of what your OCD tells you involve each group member describing their cur-
to do) rent favorite rule/concept, and each relapse pre-
We explain that “Doing the Opposite” is vention plan focuses on how patients see
the main active ingredient in CBT for OCD. themselves integrating these rules into their lives.
3. Thoughts Not Actions While cognitive interventions are included in
We remind teens that people can have odd the program, we try to maximize the amount of
or distressing thoughts, but as long as they do time spent on exposure. Following the research
not act on them, they do not need to worry or that ERP is more effective than CBT or pharma-
feel guilty about having had the thought. We cotherapy alone (Franklin & Foa, 2002) and that
explain, for example, “if you see a knife and focusing primarily on exposure improves OCD
think for a moment that you might stab your- intervention success (McLean et al., 2001), the
self or someone else, you don’t need to feel SCH OCD-IOP is designed to maximize expo-
guilty or worried about this thought as long as sures. We follow Franklin and Foa’s (2002) spe-
you don’t act on it. Having OCD without a cific clinical suggestions to maximize ERP
history of acting on these thoughts, and the effectiveness. This includes prolonged exposure
scrupulosity/rule following that frequently sessions of 90 minutes or greater and strict
accompanies OCD, suggests that you are at response prevention.
VERY low risk for acting on these thoughts.” Our patients spend the majority of each ses-
4. Be an OCD Detective sion, anywhere from 120 to 180 minutes each,
We remind teens to engage with their OCD performing exposures. When possible, we per-
by “checking the facts.” When they have a form in vivo exposures to directly target obses-
thought that worries them or causes distress, sions, such as applying honey to hands of patients
before they get worked up, it helps to decide if who cannot yet tolerate sticky substances or let-
it is a realistic worry that they need to pay ting a spider crawl on a patient’s hand to chal-
attention to or whether it is likely to be an lenge contamination obsessions and fear of
OCD worry/unrealistic worry. We say, for spiders. Our sessions are active. When we provide
example, “If I worry that I’m going to fail a services in person, we utilize our department
math test when in fact I have studied for the kitchen, bathroom, and outdoor grounds to create
math test, I’m good at math, and I do well on opportunities for exposures. During telehealth,
tests, then worrying about failing the math test we have taken advantage of the patient’s location
is an unrealistic worry likely to be associated in their home, using the opportunity to reduce
with OCD. If, on the other hand, I have not hoarded stuffed animals, for example, or encour-
studied, I find math difficult, and I do not do aging parents to “contaminate” the teen’s bed-
well on math tests, then worrying about fail- room. For obsessions and compulsions where
ing the math test is a realistic worry. With real- in vivo exposures are inappropriate, such as sex-
istic worries, it is best to change our behavior ual or some aggressive obsessions, we utilize ima-
(e.g., study for the test next time).” ginal exposures through scripts and/or videos.
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 241

Trainee case managers create weekly treat- may collaborate with the adolescent in patterns
ment plans for each patient, under the supervi- of avoidance and reassurance. They may also feel
sion of the attending psychologists. Weekly burned out and overwhelmed. Our program tar-
exposure targets are initially drawn from the gets family accommodation by including parents
patient’s intake CY-BOCS and intensified as the as “coaches” during exposures and by providing
patient progresses. In the first 2 weeks of the pro- psychoeducation in effective behavior
gram, while patients are going through orienta- management.
tion and learning the Four Golden Rules, While OCD is our primary therapeutic focus,
clinicians lead them through potentially less many of our patients come to us with co-­occurring
challenging exposures to introduce them to the conditions that need treatment for CBT for OCD
mechanics of ERP and subjective unit of distress to be effective. Frequently, patients present with
scale (SUDs) monitoring. These “easier” intro- sleep disorders. We address sleep problems using
ductory exposures are an attempt to provide Cognitive Behavior Therapy for Insomnia (CBT-­
patients with a sense of mastery and increase I) (Smith et al., 2005). Similarly, when patients
treatment compliance and motivation going for- present with tic disorders that impair their ability
ward. After the first week or two, however, we to participate in group therapy or complete expo-
follow the suggestions of Craske et al. (2008) and sures, we provide concurrent CBIT (Woods et al.,
intentionally mix up subsequent exposures in 2008). Patients also frequently present with co-­
terms of difficulty level. To promote inhibitory occurring depression for which we use utilize
learning, we plan exposures that vary in SUDs-­ Behavioral Activation for Depression homework
generation, including gentle, moderate, and dif- (Martell et al., 2013).
ficult exposures in most sessions. When patients’ OCD has remitted to the mod-
The OCD-IOP encourages patients to take erate range or lower and it appears that they have
advantage of combined treatment (psychotropic defeated the bulk of their symptoms, they are
medication and CBT for OCD) consistent with ready to be discharged to a lower level of care. In
research suggesting that moderate to severe OCD our program, this is a powerful moment.
is most effectively treated with combined treat- Following the work of Yalom (2005), the end of
ment (March et al., 1998; Geller & March, 2012). our program involves a ceremony that publicly
Given that our population begins our program marks a “before” and “after.” Patients spend the
with OCD in the Severe or Extreme Range, we week before their graduation ceremony working
connect our patients with medication providers at on a relapse prevention presentation that they
the beginning of treatment and coordinate care will deliver to their peers, parents, and clinicians
with those providers as the patient continues in in their final group therapy session. They list the
treatment. The majority, but not all, of our OCD symptoms they have “crushed,” what symp-
patients elect to pursue medication management toms they have left to work on (if any), explain
concurrent to CBT for OCD. the Four Golden Rules and other lessons they
The SCH OCD-IOP also targets environments have learned, and describe how they plan to live
that may maintain OCD symptoms or hinder an exposure-filled life moving forward. Their
treatment. Family accommodation is common final group session is spent celebrating their
with pediatric and adolescent OCD and must accomplishments, and there are frequently tears
itself be a target of assessment and intervention of pride (sometimes from the teens and often
(Geller & March, 2012). While family accommo- from their parents). We treat this moment as a
dation of OCD symptoms may not be our pri- sacred transition or rite of passage and use it as a
mary treatment target, decreasing levels of relapse prevention tool. By “graduating” from
accommodation have shown significant correla- the OCD-IOP, we are firmly signaling that we do
tions with improved OCD outcomes (Merlo not expect them to need us again. Furthermore,
et al., 2009; Garcia et al., 2010). Families, out of we make it clear that graduates are not able to re-­
love and a desire to support their teen with OCD, enroll in the program once they graduate, even if
242 G. A. Wiegand et al.

their OCD relapses. Given the design of our pro- (Goodman et al., 1989), and it shows sensitivity
gram, the nature of avoidance and OCD, and the to change, with a 25–35% reduction in score (i.e.,
high unmet demand for intensive services, approximately 8 points) considered a good
patients are only given one trial of OCD-IOP. We response to treatment (Koen & Stein, 2015). The
encourage patients to feel the weight of their CY-BOCS takes approximately 45–60 minutes to
transition to a new stage of life once they gradu- complete, though this may vary depending on
ate. We want them to know that they have the age and developmental level of the child, and
tools they need to move forward with keeping whether the clinician deems it appropriate to also
their OCD under good control. interview the child and primary caregiver
separately.
The CY-BOCS measures a wide variety of
Use of Evidence-based obsessive symptoms, including contamination,
and Empirically Informed aggressive and sexual obsessions, hoarding/sav-
Assessment ing, magical/superstitious thoughts, somatic, and
religious obsessions, including scrupulosity.
The OCD-IOP utilizes a variety of evidence-­ Measured compulsions include washing/clean-
based and empirically supported assessment to ing, checking, repeating, counting, ordering/
monitor treatment progress, inform intervention, arranging, hoarding/saving, games/superstitious
and to identify when treatment goals have been behaviors, rituals involving others (e.g., reassur-
achieved. The primary method of assessing the ance seeking), and other miscellaneous symp-
effectiveness of the OCD-IOP is the Children’s toms (Scahill et al., 1997). Once the symptoms
Yale-Brown Obsessive Compulsive Scale are defined by the child and primary caregiver,
(CY-BOCS; Scahill et al., 1997). The CY-BOCS the informants are asked ten severity questions,
is considered the gold standard in the assessment including five relating to obsessions and five
of OCD symptom presence and severity (Storch, relating to compulsions such as, “How much
Khanna, et al., 2009; Storch, Lehmkuhl, et al., time is spent on the obsessions/ compulsions?,”
2009) and it is the most widely used clinician-­ “How long can you go without doing a compul-
rated interview to assess OCD and response to sion?,” and “How much do these thoughts upset
treatment (Koen & Stein, 2015). The CY-BOCS you?” Responses to each of these questions are
is administered on the first day of the program, rated by the clinical interviewer on a scale from 0
every four weeks, and upon discharge. The (None) to 4 (Extreme). Scores on the CY-BOCS
CY-BOCS is an empirically validated scale with range from 0 to 40, with scores in the 0–7 range
good interrater reliability for total r = 0.84, obses- considered Sub-Clinical, 8–14 Mild, 15–23
sions r = 0.91 and compulsions r = 0.66, and Moderate, 24–31 Severe, and 32–40 Extremely
internal consistency r = 0.87 (Scahill et al., 1997). Severe (Scahill et al., 1997).
This scale is intended for use in children and ado- In addition to using the CY-BOCS as the pri-
lescents and can be administered by either a clini- mary assessment for program effectiveness, a
cian or a trained interviewer in a semi-structured variety of other evidence-based measures are
fashion (Scahill et al., 1997). In general, the used to gather additional information on patient
interview is conducted with the primary care- progress and program effectiveness. For a self-­
giver and child together, and ratings should be report measure of OCD, we use The Children’s
made based on symptoms experienced over the Florida Obsessive Compulsive Inventory
prior 2 weeks. Ratings depend on the child’s and (C-FOCI; Storch, Khanna, et al., 2009; Storch,
the primary caregiver’s report of symptoms; Lehmkuhl, et al., 2009). The C-FOCI was
however, the final rating is based on clinician designed as a brief measure for assessing
judgement (Scahill et al., 1997). The CY-BOCS obsessive-­compulsive symptoms in children and
was developed to be used primarily in research adolescents in both clinical and community set-
settings and to document treatment outcomes tings. This measure was originally derived from
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 243

the Leyton Obsessional Inventory (Berg et al., Emotional Problems subscale is divided further
1986), and consists of two parts, a symptom into Negative Mood/Physical Symptoms and
checklist and severity scale (Storch, Khanna, Negative Self-Esteem, which are meant to cap-
et al., 2009; Storch, Lehmkuhl, et al., 2009). The ture symptoms such as sadness, guilt, loss of
C-FOCI demonstrated acceptable internal con- interest in activities, and disturbed sleep (Kovacs,
sistency and construct validity in a study con- 2012). The Functional Problems subscale is also
ducted with 82 children and adolescents (Storch, divided into two sub-categories: Ineffectiveness
Khanna, et al., 2009; Storch, Lehmkuhl, et al., and Interpersonal Problems. These scales are
2009). While not always perfectly aligned with meant to capture challenges in social relation-
scores on the clinician rated CY-BOCS, gather- ships, issues in school such as declining grades,
ing information about children and adolescents’ and troubles with peers or family due to irritabil-
perspective when reporting on their own OCD ity resulting from depression (Kovacs, 2012).
symptoms and severity can be helpful in gather- Patient depression is also assessed using parent-­
ing insight regarding subjective thoughts and report of the severity and presence of depressive
feelings regarding their progress in treatment. symptomatology utilizing the CDI-2 parent
In addition to assessing OCD symptoms, report (CDI-2; Kovacs, 2012). This is important
evidence-­based measures are also used to gather because parents often provide another perspec-
information on more general anxiety symptoms, tive on their child’s depression symptoms that are
life interference due to anxiety, depressive symp- important to incorporate when understanding
toms, and family accommodation. Anxiety is current depressive symptomology in children and
assessed using the Multidimensional Anxiety adolescents (Kovacs, 2012). Similar to the CD-2
Scale for Children 2 edition-Self Report (MASC-­ self-report, the CDI-2 parent-report includes two
2-­SR; March, 2013). The MASC-2-SR provides scales—Negative Mood and Physical
an overall anxiety score and includes six scales Symptoms—but they are not divided into more
(Separation Anxiety/Phobias, Generalized specific subscales as on the self-report. Both the
Anxiety Disorder Index, Social Anxiety, self and parent-report versions of the CDI-2 dem-
Obsessions and Compulsions, Physical onstrate acceptable to high internal consistency,
Symptoms, and Harm Avoidance) and four sub- construct validity and discriminant validity
scales (Humiliation/Rejection, Performance (Kovacs, 2012).
Fears, Panic, and Tense/Restless) of anxiety. A final important assessment instrument
Another aspect of anxiety is assessed using the employed in the SCH OCD-IOP is the Pediatric
Child Anxiety Life Interference Scale (CALIS; Accommodation Scale-parent report (PAS-PR;
Lyneham et al., 2013), which is an empirically Benito et al., 2015), which assesses the frequency
supported self- and parent-report measure and impact of family accommodation on youth
designed to assess both how anxiety interferes and families with OCD. Accommodation is typi-
with the child/adolescent’s life as well as the par- cally defined as the participation of a family
ent’s life (Lyneham et al., 2013) Domains of member in OCD rituals (Flessner et al., 2009).
functioning assessed include social, academic, The PAS-PR was developed as an alternative to
and occupation, both for the child as well as the the clinician-administered pediatric accommoda-
parent. The CALIS is a helpful tool for gathering tion scale (Grabill, 2011). The PAS-PR takes less
some limited information on how much anxiety time to administer and an investigation of the
symptoms in general are impacting functioning. psychometric properties by Benito et al. (2015)
Depressive symptomatology is assessed using indicates good overall reliability and validity of
the Children’s Depression Inventory, second edi- the scale. The PAS-PR is a 5-item parent-report
tion (CDI-2), self-report, and parent-report with two questions per item: one regarding fre-
(Kovacs, 2012). The CDI-2 self-report has two quency of the accommodation, and the other
specific scales related to depression: Emotional regarding the degree to which it interferes with
Problems and Functional Problems. The daily functioning. Each item has several exam-
244 G. A. Wiegand et al.

ples to illustrate the principle of accommodation. more accurately assess current challenges and
The items on the PAS-PR were selected from the symptoms in order to provide appropriate
most frequently endorsed items on the original intervention.
PAS. Each item regarding frequency is rated by The assessments used in this program have
the caregiver on a scale from 0 (never) to 4 not been specifically adapted for use with diverse
(always), and each item for interference is rated client populations, which is a weakness we do
from 0 (none) to 4 (extreme). Examples of items not take lightly. We are committed to carefully
include “In the past week, how often did you or taking into account individual and cultural back-
other family members reassure your child about ground when assessing OCD symptoms, given
his/her fears?,” “In the past week how much has that certain patterns of behavior might be mal-
needing reassurance from family members gotten adaptive or OCD-related in a Euro-centric cul-
in the way of things for your child, like school, ture, but not in another culture (e.g., sleeping in
spending time with friends, or family life?,” “In the same bed or room as parents or other family
the past week, how often have you changed your members). These behaviors may be typical and
family’s routine in any way to reduce your child’s expected in other cultures. Approaching cultural
anxiety?,” and “In the past week, how much has practices regarding hygiene or dietary rules, for
changing the family routine gotten in the way of example, with care and nuance allows us to both
things for you or your family like your family conduct more accurate assessments and craft
life, at work, with your friends, or your spouse?” more respectful, culturally appropriate
The assessments we use in the OCD-IOP are exposures.
appropriate for use in community, clinical, and
research settings and have not required any spe-
cific adaptations for use in an intensive outpatient Programming
hospital setting. Our assessments were developed
specifically for use with children and adoles- Prior to COVID-19 and the switch from in-­person
cents, though some were ‘downward’ revisions group and individual sessions to telehealth,
of adult assessments that existed previously. For patients’ length of stays in our program averaged
example, the CDI-2 was based on the already 8–12 weeks. Length of stays appear to have
existing Beck Depression Inventory (BDI; Beck increased significantly with the move to tele-
et al., 1996). Similarly, the CY-BOCS is a child health due to COVID-19 (we are in the process of
and adolescent version of the Yale-Brown examining this data currently). Criteria for dis-
Obsessive Compulsive Scale (Y-BOCS; charge to a lower level of care are a CY-BOCS
Goodman et al., 1989). While similar overall, the score in the Moderate Range or lower, with
CY-BOCS has some different queries on the related improvement in functional impairment as
symptom checklist, and it also specifically well as evidence that the patient will be able to
advises that the interview be conducted with both make adequate progress in further treatment with
parent and child. a lower level of care. From a more pragmatic per-
Another important aspect of evidence-based spective, we tell teens that discharge is connected
assessment for our patient population is the to their “getting through their list of exposures,”
incorporation of parent-report in addition to self-­ rather than based on time in the program. This
report assessment measures. Given the stigma seems critical to orienting teens and parents,
around OCD, children and adolescents may be since there is a fair chance that teens might con-
reluctant to report some symptoms they are tinue to avoid exposures right up to the discharge
embarrassed or anxious about confronting. week if it was based on time in the program
Adolescents may also lack insight into the mal- alone.
adaptive nature of some of the symptoms or Criteria for transitioning to a higher level of
behaviors. Parent report can provide a wealth of care is the failure to make adequate progress with
additional information, allowing clinicians to intensive outpatient care. Transition to a higher
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 245

level of care is also suggested when a patient A parent-only group therapy session is con-
proves unable to safely engage in ERP as an out- ducted once weekly and occurs while the teen is
patient. Engaging in non-suicidal self-injurious, in their individual exposure session. Parent group
suicidal, eating disordered, and/or seriously therapy sessions focus on reducing parental
aggressive behaviors can lead to discharge from accommodation, training parents in using the 4
the OCD-IOP and referral for residential care. Golden Rules, and on offering parents an oppor-
tunity to raise other issues without their teen
present. Although it is not the primary purpose of
Clinical Approaches the group, parents report that this group therapy
session builds community and support for
Each daily session starts with a group therapy parents.
session attended by clinicians, patients, and par- After patients are discharged from the OCD-­
ents. This group therapy session consists of three IOP, a once-monthly, “drop-in” group session is
main components. First, patients report whether offered to support relapse prevention. During this
all exposure homework has been completed. group, OCD-IOP graduates and their parents
Reviewing homework in the group setting pro- receive continued psychoeducation on maintain-
vides positive reinforcement for completing ing treatment gains and review/practice previ-
assigned exposures as well as taking advantage ously learned skills. Patients report that they
of peer pressure for homework compliance. Next, enjoy meeting and socializing with fellow gradu-
group members are asked to identify one expo- ates. Interestingly, they often note that they are
sure homework item that went well and one that “inspired” by other graduates’ stories of struggle
was more challenging. Finally, group members and success. Patients are eligible to participate in
complete in-group exposures. We schedule expo- this aftercare group for 24 months.
sures that will be most effective in a social setting Due to COVID-19 restrictions, our program
for this time. Clinicians take advantage of oppor- abruptly became a virtual IOP in the spring of
tunities to highlight the Four Golden Rules and to 2020. After transitioning to telehealth, modifi-
encourage compliance with completing all expo- cation of the program schedule was required for
sures assigned. both logistic and financial reasons. We contin-
Following the initial group therapy session, ued to start sessions with group therapy, fol-
patients and their parents are paired with a clini- lowed by individual treatment sessions.
cian and/or trainee for individual sessions. Attending psychologists now maintain a set
Individual session time is utilized to engage in schedule of time with each patient rather than
exposures, review the response to the previous moving between sessions and adjusting time
night’s exposure homework, plan the next night’s spent based upon need. While this set schedul-
exposure homework and in-group exposures, as ing affords less flexibility, it enables the pro-
well as address other treatment needs relevant to gram to continue to be financially viable in the
the treatment of OCD. Parents are present and context of telehealth.
engaged in treatment unless contraindicated, Early after switching to the telehealth version
which is a rare event (e.g., child abuse). of OCD-IOP, we doubled the program to include
Consistently involving parents supports their a second OCD-IOP program in the afternoon
ability to plan and execute exposures in the home with a second group of patients. Figure 14.4
setting. During individual session time, an attend- shows the weekly schedule for the two OCD-­
ing psychologist typically rotates into sessions IOPs. After half a year, we changed back to a
with trainees to provide additional intervention single program due to decreased revenue as a
and live coaching. result of not being able to charge facility charges.
246 G. A. Wiegand et al.

Fig. 14.4 Weekly schedule for running 2 OCD-IOPs concurrently

Since we were not meeting in person we could no in treatment, including supervising their child’s
longer charge a facility fee which had allowed us between-session exposure homework. We work
to bill for trainee time). We expect that this would with parents to address any issues at home that
not be a problem if we are ultimately able to interfere with exposure homework completion
return to an in-person program again. and provide specific feedback on strategies to
resist providing reassurance or other accommo-
dations. By including parents throughout the
Parent and Family Involvement treatment, we hope to increase the likelihood of
generalization outside of the OCD-IOP and
The OCD-IOP was designed as a family-based decrease relapse.
intervention and requires a patient’s parent/care-
giver to attend all sessions throughout their treat-
ment. Research on parent-based treatment for School Involvement
childhood anxiety has demonstrated strong effi-
cacy by addressing family over-accommodation Schools are important partners in the provision of
and parenting stress for children with anxiety dis- intensive services for OCD. Due to severe OCD,
orders (Lebowitz et al., 2020). Given that research many of our patients have struggled with school
has shown improved treatment outcomes when avoidance, often to the extent that absences mea-
parental accommodation is addressed, we view sure in years and months, rather than days and
the inclusion of parents in the OCD-IOP as essen- weeks. In an effort to support a student’s progress
tial for treating severely impairing OCD in chil- in school, we, and others, have found that school
dren and adolescents. Parents are included at staff often develop educational support plans
every stage of their child’s treatment: initial eval- with avoidance-oriented supports that further
uation, orientation to the program, group expo- reinforce OCD (Conroy et al., 2020). For exam-
sure and individual exposure sessions, and ple, a 504 plan might include extended time on
relapse prevention planning. During their teen’s tests, which inadvertently reinforces OCD per-
treatment, parents are expected to actively engage fectionism. Instead of alleviating the symptoms
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 247

that significantly interfere with academic func- community-­based provider can see what has been
tioning, educational accommodations may successfully addressed and what symptoms
worsen OCD. Due to the intensity of our treat- remain. Similarly, each teens’ Relapse Prevention/
ment, we ask that patients temporarily reduce graduation presentation contains CBT for OCD
their course load so that they have the time and concepts and lessons learned, symptoms
energy to fully attend to the exposure work of the “crushed,” and how the teen plans to live their life
OCD-IOP. We provide consultation with schools in a way that keeps OCD in check. In other words,
to implement strategies that effectively support a “blueprint” for treatment that they can provide
the student during treatment as well as post-­ their community based outpatient therapist after
discharge with their relapse prevention plan. To discharge from OCD-IOP.
date, schools have consistently recognized the
importance of defeating the student’s OCD and
supported the treatment necessary. The academic Integrating Research and Practice
prowess of each patient is put to the test in OCD-­
IOP by engaging in exposures involving the com- Despite a lack of research funding, data collec-
pletion of increasingly complex and longer tion with the intent to engage in outcome research
school assignments with a goal of their being was built into the OCD-IOP from its inception.
able to complete grade level assignments effi- Data is collected on the patient’s first day in the
ciently, without procrastination/perfectionism, IOP, every 4 weeks, and the day before they dis-
and to make them ready to return to school full charge. When the OCD-IOP was in person, these
time. Exposures on school campuses are often measures were filled out and collected during
assigned pre-discharge so that school avoidance their session for that day. With the switch to tele-
has been addressed and the transition back to health, the OCD-IOP’s program coordinator
school facilitated (i.e., pre-Covid-19 restric- securely emails the packet of measures to the
tions). Schools have been very supportive of our family’s preferred email address for them to fill
program requirements and school transition out.
plans. The Start of Program Questionnaire asks fam-
ilies to rate their initial knowledge of OCD and
OCD interventions, as well as how much they
Coordinating Care expect it to be effective on a scale of 1 (least) to 6
(most). Specific goals for treatment and any bar-
Another important source of support are the riers that they may foresee are also solicited. The
patient’s community-based treatment providers. Mid-point Questionnaire assesses the helpfulness
During the evaluation screening session, all fami- of the sessions, group leaders, group discussions,
lies are asked to maintain a connection with their use of exposures, and use of homework on a scale
community outpatient provider since they return of 1 (not helpful) to 6 (very helpful). It also asks
to care with this provider after completing OCD-­ for the average amount of time spent completing
IOP. As mentioned earlier, the IOP case manager exposure homework outside of the IOP as well as
coordinates care with the community outpatient any significant barriers to participating in the IOP
provider (e.g., communicating about any safety and any comments or feedback. The End of the
issues, providing updates on progress in treat- Program Questionnaire asks families to rate on a
ment, coordinating discharge, providing consul- scale of 1 (least) to 6 (most) their ending knowl-
tation on how to address any remaining symptoms edge of OCD and OCD interventions, how effec-
after discharge). Upon discharge, we provide a tive they felt the OCD-IOP was, how much they
progress note that is cumulative (i.e., including feel that their specific goals were met, and how
every CY-BOCS administered, which includes satisfied they were with the IOP. Information
symptoms and severity scores) so that the regarding amount of time spent on exposure
248 G. A. Wiegand et al.

homework outside of IOP, what was most helpful have found disparate effects of each of these can-
about IOP, what was least helpful, and any barri- didate predictors, and a consensus has not yet
ers to treatment compliance are also included on been reached on whether or how these factors
this questionnaire. The Start of Program, Mid-­ influence OCD treatment outcomes in a variety
point, and End of Program Questionnaires were of settings (i.e., outpatient, intensive outpatient,
created specifically for this program. residential). While the predictive utility of many
of these factors is challenging to replicate, a few
potential predictors remain on the forefront and
Predictors (Moderators/Mediators) have shown more consistent relationships to
pediatric OCD treatment outcomes. The follow-
A number of studies have examined potential ing section details some promising and poten-
predictors of pediatric OCD treatment outcomes tially important predictors in several of the
in a variety of settings with different samples of categories mentioned above that we consider for
children and adolescents. There remains little both clinical and research purposes.
consistency in how OCD treatment outcome and
predictor variables are measured, making identi- Depression and Comorbidity
fication of reliable predictors an even greater Because comorbidity with other psychiatric con-
challenge. Ginsburg et al. (2008) summarized 21 ditions for children and adolescents with OCD is
randomized control trials (RCTs) conducted extremely common, it should be considered the
between 1985 and 2007. Of those 21 studies, six rule, not the exception (Walitza et al., 2011). One
examined predictors of OCD treatment out- of the most observed and investigated comorbid
comes. In these six studies, nine “candidate” pre- conditions in the treatment of OCD is depression
dictors were established: age, gender, duration of (Keeley et al., 2008). Despite this, the relation-
illness, baseline OCD severity, symptom presen- ship between depression and OCD outcomes
tation (e.g., presence of hoarding, sexual obses- remains unclear, and findings are highly incon-
sions), neuropsychological factors, and family sistent regarding the predictive utility of depres-
factors. sion on treatment outcomes (Brown et al., 2015).
In addition to the RCTs reviewed by Ginsburg Numerous studies have demonstrated a relation-
et al. (2008), naturalistic studies have examined ship between baseline depressive symptomology
and identified other potential predictors of treat- and poor OCD treatment outcomes (e.g.,
ment outcomes. They include age at symptom Overbeek et al., 2002; Rufer et al., 2005; Storch
onset, socioeconomic status, comorbidities such et al., 2008; Torp et al., 2015). Other studies,
as internalizing symptomatology and disorders however, have found no connection between
(e.g., depression, anxiety disorders) and external- depression and treatment outcomes (e.g., Anholt
izing symptomatology and disorders (e.g., et al., 2011; Garcia et al., 2010; Mataix-Cols
ADHD, conduct disorders), levels of functional et al., 2002).
impairment, comorbid tic disorders, substance Overbeek et al. (2002) found that despite
use, parental psychiatric history, family history matched OCD symptom severity at baseline,
of OCD, parenting styles, and family accommo- patients with comorbid depression showed less
dation of anxiety (e.g., Barrett et al., 2005; Bloch improvement than non-depressed patients on a
et al., 2009; Brennan et al., 2014; Ferrão et al., variety of scales including measures of OCD,
2006; Merlo et al., 2009; Rudy et al., 2014; Torp depression, and overall anxiety. Storch et al.
et al., 2015). Further, these candidate predictors (2008) found that compared to a 92% remission
have been organized by several researchers into rate (e.g., CY-BOCS <10) for youth in their study
four categories: demographic predictors, aspects/ with no comorbid conditions, only 42% (p < 0.05)
presentation of OCD symptomatology, comor- of children and adolescents with depression
bidity, and family factors (Keeley et al., 2008; achieved remission status. Interestingly, the treat-
Torp et al., 2015). Unsurprisingly, many studies ment response rates, defined as at least a 30%
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 249

decrease in CY-BOCS score from baseline to of therapy or causing it to be less effective. It is

post-treatment, for non-depressed youth com- also possible that children and adolescents with
pared to depressed youth was not statistically sig- depressive symptomatology may have less moti-
nificant at 92% versus 71% (Storch et al., 2008). vation to engage in exposures, have less hope
Torp et al. (2015) examined a large number of that treatment will work, and may struggle more
predictors and found that children and adoles- than non-depressed individuals to imagine the
cents with higher levels of parent-reported benefits of their OCD symptoms improving.
depressive symptoms had higher post-treatment They may also become more discouraged by the
CY-BOCS scores after controlling for pre-­ typical challenges related to engaging in ERP
treatment CY-BOCS scores. Overall, these stud- (Storch et al., 2008). Finally, Abramowitz et al.
ies suggest that youth with elevated depressive (2007) demonstrated children and adolescents
symptoms and OCD may have an attenuated with comorbid OCD and depression are more
response to CBT with ERP compared to youth likely than patients without depression to mis- or
without depressive symptoms. over-interpret the importance of their intrusive
These results may be representative of find- thoughts, indicating that perhaps the poorer
ings from outpatient samples, but they may not treatment response may be due to susceptibility
reflect intensive settings. Leonard et al. (2014) to obsessional thoughts. Rumination (i.e., the
examined depressive symptoms as a predictor of tendency to repeatedly go over thoughts or prob-
OCD treatment outcome in a residential sample lems in the mind) is often a core feature of
of adolescents with severe OCD. Their results depression and may compound individuals’ vul-
differed from many of the studies on youth outpa- nerability to obsessions and intrusive OCD
tient samples and found that depression severity thoughts.
was not associated with duration of treatment, Several studies have found that depression
and depression severity upon admission was not symptoms tend to ameliorate after OCD treat-
associated with a worse OCD treatment outcome ment even when depression symptoms are not
(Leonard et al., 2014). In addition, the team specifically targeted (Anholt et al., 2011; Olino
found that after controlling for OCD severity on et al., 2011). While this is good news for the effi-
admission, greater change in depression severity cacy of CBT for OCD and ERP in treating sev-
significantly predicted lower OCD severity at eral forms of psychopathology, it also does not
discharge, indicating that beginning treatment diminish the possible impact of depression on
with high levels depression did not detract from OCD treatment response and the clinical impli-
OCD treatment outcomes. cations for treatment planning (Storch et al.,
Several researchers have put forth theories as 2008). If the presence of depressive symptom-
to why depressive symptomatology has pre- atology is associated with a weaker or slower
dicted less favorable outcomes in outpatient response to therapy, it may be beneficial to con-
OCD treatment. One hypothesis is that when sider specific treatment protocols for depression
depressive symptomatology is present, the clini- alongside typical CBT with ERP for OCD. In
cian must focus not only on the OCD symptoms, our OCD-IOP, we have elected to treat depres-
but also the comorbid condition. This may sion with Behavioral Activation for Depression
reduce the available time in each session to interventions and made them a part of a patient’s
engage in OCD-­ related treatment tasks, thus “exposure” homework. Furthermore, we have
decreasing effectiveness of treatment if the num- elected to err on the side of including behavioral
ber of sessions is predetermined or leading to activation assignments beginning early in treat-
longer treatment duration if the number of ses- ment even when patients don’t meet full criteria
sions is variable (Storch et al., 2008). Abramowitz for a major depressive episode. We would rather
(2004) also posited that the presence of depres- not wait to see if they ultimately meet full crite-
sive symptoms and associated emotional reactiv- ria and find it relatively seamless to bundle
ity may hinder the typical habituation process behavioral activation assignments into their list
that occurs during ERP, drawing out the length of nightly exposure homework.
250 G. A. Wiegand et al.

 amily Accommodation and Family

F youth re-engage in age-appropriate tasks and
Factors activities, whereas family accommodation allows
One particularly challenging aspect of treating the child or adolescent to avoid feared situations
OCD is that symptoms do not only affect the and stimuli or get reassurance about unrealistic
diagnosed child or adolescent. Parents, caregiv- worries and obsessions (Merlo et al., 2009).
ers, and siblings are often impacted heavily by When studies have assessed levels of accom-
the disorder, and response to the OCD symptoms modation, generally high levels are found in fam-
of the affected family member may play a role in ilies of youth with OCD. Perris and colleagues
the course of the disorder (Derisley et al., 2005; (2008) found that on a daily basis, 56% of care-
Lebowitz & Bloch, 2012; Storch, Khanna, et al., givers in their sample provided reassurance, 46%
2009; Storch, Lehmkuhl, et al., 2009). The participated in rituals, and nearly 100% of care-
importance of family in the development and givers reported engaging in some form of accom-
maintenance of OCD symptoms has gained atten- modation. Other studies reported the prevalence
tion over the last several decades (Calvocoressi of family accommodation based on the total of
et al. 1995; Garcia et al., 2010; Peris et al., 2008; the scale used (FAS-PR; Pinto et al., 2015) and
Storch et al., 2007). In particular, the role and reported average scores of between 20 and 30 out
prevalence of family accommodation in pediatric of 50, indicating generally moderate to severe
OCD began its rise to prominence after levels of accommodation (Merlo et al., 2009;
Calvocoressi et al. (1995) suggested that accom- Storch et al., 2008; Storch et al., 2010). Storch
modation by caregivers of patients with OCD et al. (2007) found that higher levels of accom-
may be related to family distress and dysfunc- modation are also associated with more severe
tion. After finding support for this hypothesis, baseline OCD symptoms, functional impairment,
other researchers began exploring whether fam- and internalizing and externalizing behavioral
ily accommodation may be related to OCD treat- challenges. Overall, research suggests that family
ment outcomes as well. Because family variables accommodation is prevalent, highly counterpro-
and the environment in which OCD exists can be ductive to the goals of OCD treatment, and can
manipulated, unlike the genetic component of and should be targeted as part of a family inclu-
OCD, for example, there is an undeniable practi- sive treatment plan (Peris et al., 2008). For these
cal component to understanding the role family reasons, family accommodation of anxiety has
accommodation plays in OCD treatment. emerged as both a predictor of interest, and as a
One of the ways in which families may affect specific intervention target to consider when
OCD outcomes is through the accommodation of designing a comprehensive treatment protocol
symptoms. Other accommodation behaviors for pediatric OCD like OCD-IOP.
might include being lenient on rules that apply to Despite interest in the relationship between
others in the house, helping a child complete age-­ family accommodation and OCD, few studies
appropriate tasks they should be able to complete have examined it as a predictor for OCD treat-
on their own, or providing specific objects a child ment outcomes in youth. One of the first studies
might need to engage in a ritual (Storch et al., to examine its predictive utility was conducted by
2007). Parents often feel that their accommoda- Amir et al. (2000), who found that after control-
tion behaviors are making life easier at home ling for baseline OCD severity, family accommo-
(Merlo et al., 2009). While this may be true in the dation was significantly related to symptom
short-run, accommodating OCD typically main- severity at post-treatment. In addition, their study
tains or worsens symptoms in the long-run by replicated Calvocoressi’s et al., (1995) findings,
providing immediate relief, thereby negatively demonstrating that higher levels of accommoda-
reinforcing the behavior and preventing any sort tion were related to more family distress and
of habituation from occurring (Merlo et al., depression in relatives of patients with OCD, fac-
2009). CBT for OCD and ERP aim to teach adap- tors that have been shown to increase the chances
tive ways of coping with anxiety and helping of relapse (Foa & Wilson, 1991). Merlo et al.
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 251

(2009) extended this research and found that par- Overall, family accommodation shows signifi-
ticipation in a family-based treatment for OCD cant promise as an important factor in pediatric
resulted in a decrease in family accommodation OCD treatment outcomes. However, like most
behaviors in caregivers. Additionally, larger other predictors of OCD outcomes, the small
decreases in family accommodation over the body of evidence requires that far more research
course of treatment predicted lower symptom be conducted on the topic. Family accommoda-
severity at post-treatment after controlling for tion as a predictor is particularly interesting con-
baseline severity. Their results suggest that sidering the potential ease with which it can be
directly targeting family accommodation as part targeted as part of treatment. Treating high levels
of an OCD treatment protocol may be critical in of family accommodation may be comparatively
improving treatment outcomes (Merlo et al., easy. Children and adolescents typically already
2009). have a caregiver involved in treatment in some
The most recent study examining family capacity, and simply being more intentional
accommodation in pediatric OCD patients was about discussing and intervening on family
conducted by Rudy et al. (2014) in the context of accommodation of symptoms can be a natural
an intensive outpatient treatment format consist- addition to treatment in a variety of settings.
ing of 14 daily sessions lasting 90 minutes each. As a result of this overall body of research, we
Their findings were consistent with previous have elected to specifically target family accom-
research, demonstrating that children and adoles- modation in our OCD-IOP. Accommodation is
cents who achieved remission (e.g., post-­ often so severe and entrenched at the start of a
treatment CY-BOCS <10) had significantly less family’s time in OCD-IOP that we spend signifi-
family accommodation at baseline compared to cant time working with parents to quit speaking
those who did not achieve remission (Rudy et al., for and prompting their teen each and every time
2014). These results contribute to a growing body the teen is asked a question. Ultimately, we have
of evidence that higher levels of family accom- to desensitize parents to seeing their teen struggle
modation contribute to poorer OCD treatment for their teen to have the opportunity to stop,
outcomes, such as higher symptom severity at think, and hazard a guess or answer. The latency
post-treatment and lower remission and treat- of response due to scrupulosity and perfection-
ment response rates. ism that teens with OCD exhibit makes it hard for
Finally, it should be noted that not all studies parents to resist “helping them.” We know that
have found family accommodation to be a sig- children or teens are getting close to being ready
nificant predictor of treatment outcomes. One to graduate when parents show that they are able
large, long-term study (NordLOTS), which uti- to sit back, relax, observe, and watch their child
lized a family-based weekly outpatient treatment or teen struggle without rescuing them.
approach, found results contrary to their original
hypothesis that family accommodation would be Symptom Presentation
associated with an attenuated response to treat- OCD symptom presentation (i.e., obsessions and
ment (Torp et al., 2015). Their results did not compulsions present based on CY-BOCS inter-
show that family accommodation levels at base- view) may be an important predictive factor in
line predicted whether children and adolescents treatment outcomes that is lacking investigation
would be treatment responders with a CY-BOCS in the pediatric OCD literature. One under-­
score of 15 or lower at post-treatment (Torp et al., researched symptom dimension that may have
2015). Torp and team postulated that this may be specific applicability in pediatric populations is
due to the family approach to treatment, which the presence of sexual obsessions. Several studies
explicitly encouraged parental involvement and and one large scale review paper reported that
may have worked to address family accommoda- sexual obsessions are associated with a variety of
tion from the very beginning of treatment (Torp poorer outcomes in both behavioral and pharma-
et al., 2015). cological treatments in adult OCD populations
252 G. A. Wiegand et al.

(Boschen et al., 2010; Keeley et al., 2008; lifetime and identified that sexual obsessions
Steketee et al., 2011). Alonso et al. (2001) found (e.g., obsessions often comprising taboo thoughts,
a significantly greater frequency of sexual obses- impulses, or ideas) typically onset during puberty,
sions in patients who were considered non-­ an average of 4 years earlier than non-taboo
responders to outpatient treatment. Mataix-Cols related obsessions such as contamination (Grant
et al.’ (2002) research demonstrated that higher et al., 2006). It is hypothesized that the onset of
scores on a sexual obsessions factor predicted these symptoms during puberty and adolescence
worse treatment outcomes for adults who under- may be related to the specific developmental,
went ERP behavior therapy. Only 21% of patients psychological, and hormonal changes occurring
with sexual obsessions were treatment respond- during this age range (Grant et al., 2006). Grant
ers compared to 50% of patients without these et al. (2006) also found that patients with these
symptoms, a statistically significant difference sexual obsessions tended to spend a longer
(Mataix-Cols et al., 2002). Ferrão et al. (2006) amount of time in treatment than those without.
found the presence of sexual obsessions was sig- If sexual obsessions are frequently present in
nificantly associated with treatment refractory pediatric populations, it is critical to understand
OCD (i.e., less than 25% symptom reduction how they may be related to treatment outcomes.
from initial Y-BOCS score after at least three Sexual obsessions are often difficult to treat, as
medication trials and 20 hours of ERP therapy). the social implications of discussing these types
Rufer et al. (2006) research indicated that adult of obsessions may make individuals less likely to
inpatients with sexual obsessions tended to disclose their thoughts. Patients, especially chil-
respond less frequently to CBT with ERP inter- dren and adolescents who are often engaging in
vention; however, these results did not reach sta- treatment with their caregiver, may feel embar-
tistical significance (p = 0.07). rassed about the thoughts and be reluctant to dis-
In contrast with the aforementioned studies, close them, potentially leading to a delay in
Steketee et al. (2011) found that the presence of treating those symptoms (Grant et al., 2006). The
sexual obsessions actually predicted better OCD moralistic component of sexual obsessions may
treatment outcomes (Steketee et al., 2011). increase general distress as the child or adolescent
However, these conflicting findings may be due struggles to understand the meaning of or reason
to differences in treatment protocol compared to behind their obsession. Each time the brain expe-
the majority of other OCD treatment studies. As riences distress around a thought, it signals that
opposed to the more commonly employed and the thought must be important and attended to,
heavily researched behavioral model of therapy making the unwanted thought even “stickier” in
emphasized in ERP, Steketee et al., (2011) deliv- the mind (March & Benton, 2007). This increased
ered a comprehensive cognitive therapy treat- focus may lead to greater concern that obsessions
ment. These findings present interesting potential are actual manifestations of what they believe,
evidence that ERP may be less effective for cer- how they will act, or what might happen to them
tain obsessional beliefs, namely, sexual (Keeley et al., 2008).
obsessions. It is also more difficult to design exposures
Despite sexual obsessions demonstrating for sexual obsessions, as in vivo exposures are
potential as a reliable predictor for treatment out- generally not an option. Instead, imaginal expo-
comes in adults, relatively few studies examining sures, which are often slower to produce
predictors of OCD treatment outcomes have change, and cognitive restructuring techniques
explored symptom presentation as a factor. In are often employed (Steketee et al., 2011). It is
addition, no studies to date have looked at sexual also more challenging to monitor rituals around
obsessions as a predictor of OCD treatment out- sexual obsessions, as they are often more
come in pediatric populations. Sexual obsessions covert. Determining what the mental rituals are
may be of particular interest as a potential predic- and subsequently preventing them is much
tor based on a study that examined OCD over the more challenging than, for example, preventing
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 253

a child or adolescent from washing their hands  essons Learned, Resources,

L
due to contamination fears (Keeley et al., 2008). and Next Steps
The relationship between sexual obsessions and
treatment outcomes for children and adoles- Over the years, our program has changed and
cents with OCD is currently unknown; how- evolved. We have identified areas of success and
ever, the presence and potential salience of this grown in response to challenges. Below is a col-
symptom dimension during early adolescence lection of lessons we have learned and areas we
makes it an important potential predictor to hope to further develop. Our success depends
consider. upon parent involvement in treatment. By enlist-
Our treatment approach regarding sexual ing parents as coaches and participants in our
obsessions has evolved over time. When we IOP, we increase the amount of time our patients
began OCD-IOP a little over 4 years ago, we spend with supportive, attentive, non-OCD
tended to focus on utilizing exposure scripts, accommodating adults. It also lets us create an
which we did not begin until midway to late in environment conducive to exposures. Franklin
treatment, thinking that they would be easier to and Foa (2002) stress the importance of strict
address and less overwhelming for the child or response preventions for effective ERP. Given
teen once the bulk of their OCD symptoms had that we only have 3 hours a day during which we
been treated. Over time, we noticed that scripts can directly target response prevention, enlisting
could take as long as 2–3 months to work, and the full participation of parents means we can tar-
consistent with much of the research, that sexual get much broader stretches of the day. This makes
obsessions seemed to be associated with longer our “daily effective dose” of ERP much larger.
time in treatment and poorer outcome. As a Including parents in treatment is not a trivial
result, we have been emphasizing a cognitive task. It is an OCD-IOP requirement that at least
intervention in the form of “Thoughts Not one parent is in each session with their teen each
Actions” and start exposure with scripts early in day, and that means at least one parent carving
treatment. out 3 hours a day, 4 days a week, away from their
work and other childcare. Our IOP takes as much
time and commitment from parents as it does
 ngoing Research Projects,
O from patients. Effective parent involvement also
Publications, and Presentations means targeting behaviors that may be long-­
standing and deep-seated on the part of the par-
There are current ongoing research projects con- ent. OCD is frequently genetic, and we often
ducted by practicum students, postdoctoral fel- have parents who are prone to anxiety, avoidance,
lows, and psychologists from the OCD-IOP (see and/or OCD themselves. Helping their adoles-
Appendix). Every year, the new practicum stu- cent means parents must be willing to challenge
dents are offered the opportunity to participate in these behaviors in themselves. We use the motto
research and encouraged to design and conduct “Your teen is too smart to allow you to get away
their own projects. Students have produced with ‘Do as I say, not as I do’.” Our weekly par-
poster presentations, submissions to the ent group is an opportunity for parents to work on
International Obsessive Compulsive Disorders their own challenges, and to be maximally effec-
Foundation (IOCDF), and the Association for tive, parents must stop accommodating their
Behavioral and Cognitive Therapies (ABCT) teens’ OCD, thwart compulsions, and face their
conferences. Research on outcome is ongoing. own anxiety/avoidance.
An examination of our outcomes over the course We are proud of the data we collect, but we
of our first 3 years was recently completed and is also know there is important information not yet
in the process of being submitted for being tracked. While there are a variety of
publication. evidence-­ based and empirically supported
254 G. A. Wiegand et al.

assessments for gathering information on the insurance carriers, with the exception of
OCD-IOP’s effectiveness in treating both OCD Medicaid, starting to allow “Intensive Outpatient
symptoms as well as common comorbid symp- Charges” (note: these charges are surprisingly
tomatology, one potential area for growth is gath- similar to charges for day treatment, which has
ering information regarding functional gone in and out of vogue regardless of efficacy).
impairment. Most tools used in assessment focus In our program, we were also able to bill a facil-
on the presence of specific symptoms and/or the ity charge for the care provided by graduate-level
severity of those symptoms, such as how much trainees under the supervision of licensed psy-
distress they cause, how much time they take up, chologists prior to the COVID-19 pandemic and
and how frequently the symptom is experienced. the required switch to telehealth.* This pre-­
Little information is gathered regarding how telehealth model strengthened the financial via-
those symptoms and severity lead to impairment bility of the model and allowed for more flexible
in specific domains of functioning (social, aca- and live observation of trainees.
demic, occupational). It does not seem prudent to Sustainability does not stop at financial stabil-
assume that high symptom severity is always ity. A successful program must also be sustain-
associated with higher functional impairment. It able for staff and trainees. Many communities
is possible that some individuals experience rela- have shortages of therapists who are well-trained
tively low OCD symptom severity, but are more in evidence-based treatment for OCD. By build-
functionally impaired by that level of severity ing training into our program model, we grow the
than other individuals with higher symptom pool of evidence-based providers. After only 4
severity scores. While clinicians are able to years, we are already beginning to make a real
gather qualitative information from patients impact on the availability of CBT for OCD in our
regarding functional impairment related to OCD community. We did this by designing the pro-
symptoms, an empirically validated measure gram around the trainees. Adolescents work with
focusing on functional impacts would be benefi- both attending psychologists and clinical trainees
cial in aiding clinicians to make decisions about every day in the program. Not only does this help
treatment and care. with generalization of exposures, it offers the
We have also learned that a successful pro- opportunity for frequent live observation of train-
gram is a financially sustainable program. While ees. Reaching out to masters- and doctoral-level
we are not in this business to maximize profit, training programs in your area to establish your
generating even small amounts of positive reve- program as a routine practicum training site to
nue means that the program is less vulnerable ensure you have a steady stream of dedicated and
during a recession, and is not starved for money enthusiastic trainees has many advantages. The
to improve via materials, technology, and/or best advertising for our program as a practicum
staff. Positive revenue means that program expan- site has been our current and former trainees
sion will be welcomed by administrators rather soliciting their peers.
than judged a financial liability. Over decades of To help ensure that our trainees develop genu-
training and working in multiple mental health ine competence in evidence-based protocols for
settings, we have seen many an innovative and OCD, we require that trainees participate long
effective treatment program wither away due to enough to become proficient in CBT for OCD. In
the variability and scarcity of mental health practice, this means that trainees commit to a
resources. Years later, demand requires re-­ minimum of either 2 days a week for 6 months or
inventing similar programs, before they too 1 day a week for 12 months. This helps us gradu-
wither due to lack of resources. Reinventing the ate trainees that are well versed in CBT for OCD,
therapeutic wheel over and over is an expensive confident in their abilities, and determined to
and inefficient folly. A financially strong program make this one of their clinical specialties. Most
can last long enough to grow, endure, and of our trainees choose to work at least 2 days per
improve. Our OCD-IOP became possible due to week for a full year, and a few stay on for a sec-
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 255

ond year in more supervisory roles. Exit inter- ward, we look forward to expanding our range of
views and informal tracking suggests that the outcome measures, particularly the ability to
majority of our trainees are following up with function despite OCD symptoms.
careers treating OCD. We also look forward to becoming more of a
In addition to being a training center, we aim resource to the community of outpatient provid-
to hire people who bring high levels of skill and ers in our area. To address the difficulty that fami-
expertise. At start-up, we hired Dr. Michael lies often experience in identifying
Vitulano, who had been an intern at the UCLA community-based providers well versed in CBT
OCD-IOP, as a postdoctoral fellow. Dr. Vitulano’s for OCD, we are exploring the utility and sustain-
knowledge of how their OCD-IOP worked was ability of providing peer consultation groups or
very helpful in getting started, and his enthusi- expert consultation on difficult OCD cases. We
asm was infectious. One of the current authors, hope that more patients might be effectively
Dr. Villavicencio, had prior experience working treated in the community if their providers have
at the Anxiety Disorder Center’s OCD-IOP at more ready access to expert consultation and sup-
Hartford Hospital. There is no substitute for hir- port. Similarly, we are investigating ways that we
ing people who have previous experience getting might train community providers by having them
a program off the ground. spend time in OCD-IOP. Finding a way to make
Creating new programs is no small undertak- this work for community providers will require
ing, and it is worth investigating if there are any creativity on our part, but telehealth may make it
available community resources or agency-based more feasible.
startup grants. The development of the SCH During the COVID-19 pandemic, we are run-
OCD-IOP was aided by a $10 k grant from ning our IOP through telehealth. At some point,
Seattle Children’s Hospital. This grant allowed we expect that we’ll be presented with a choice
the director of the program to have time to gener- of returning our IOP to in-person or continuing
ate materials, outlines, and start-up documents. it via telehealth. During our time doing tele-
Financial resources can ease some of the start-up health, we have been able to provide services to
burden, but for insight into the mechanisms of patients in distant, rural parts of the state that
program creation, nothing is more effective than would not otherwise have had easy access to a
observing a similar program in person. Before program like ours. Thinking about justice,
starting the SCH OCD-IOP, we observed the equity, inclusion, access, and treatment efficacy
OCD-IOP at UCLA. We owe a debt of gratitude will be important considerations in designing
to colleagues at OCD-IOP and The Anxiety what comes next.
Disorders Program at UCLA’s Semel Institute for The OCD-IOP has been fortunate to be
allowing us to observe their program. We are staffed by at least one bilingual attending psy-
much better for it. chologist (English and Spanish). This allows us
Moving forward, we have a number of ongo- to conduct some individual sessions in Spanish.
ing initiatives and goals. First and foremost, as We are also fortunate to have a diverse group of
clinicians dedicated to evidence-based care, we trainees in terms of race, gender, and sexual ori-
generate a large amount of data that we would entation. This diversity in our trainees and staff
like to evaluate. We hope to form a collaborative contributes to the success of the program.
research partnership with a graduate training pro- However, as can be seen in the charts below
gram, and envision a symbiotic relationship (Figs. 14.5 and 14.6), which compare the racial
where we provide a rich database of outcome and makeup of our patient population with the
process data and students and faculty produce demographics of the county in which we are
research that allow us to document our efficacy located, we have a lot of room for improvement
and improve our program. At the end of our first in terms of who we serve.
4 years, it is apparent to us that broadening our Our patients are disproportionately white and
assessment of outcome is warranted. Moving for- middle-to-high SES. We initially attributed the
256 G. A. Wiegand et al.

Fig. 14.5 IOP racial demographics

SES imbalance to our state’s Medicaid system, health provider is required, this may inadvertently
which differs county by county. Despite promises impact underserved communities who are likely to
by several referring community mental health be less well served by these referrers. Some mem-
agencies that Medicaid would cover intensive out- bers of these populations may also have greater
patient charges, we found out after the fact that difficulty participating in a program that requires
both partial hospitalization and intensive services more than 12 hours per week of parental involve-
are not part of the state’s Medicaid benefit. Despite ment. In the meantime, our team is dedicated to
this, our hospital supported continuing to serve our own anti-oppressive and anti-­racist education
Medicaid families, while we lobbied the state to through monthly anti-racism book/journal clubs
cover these services. In the past year, the and by adopting cultural humility and sensitivity
Washington State Legislature was convinced to in our treatment plans and weekly rounds. We rec-
allocate pilot funding to demonstrate clinical value ognize that this is just a beginning.
and cost-effectiveness of covering intensive One area in which we are attempting to
charges. However, we know that fixing this part of improve is our ability to offer treatment to those
the problem will not fix all of the disparities in with a primary language other than English.
access to care. Toward that end, we have begun translating writ-
Providing racially and culturally appropriate ten materials into other languages and are work-
intervention to underserved populations is the ulti- ing to improve our ability to use simultaneous
mate challenge. We are examining potential barri- interpretation during both our group and individ-
ers to care and ways to recruit a more racially ual sessions. We have started this process by hav-
diverse client base. Given that a referral from ing our hospital’s interpreter services educate us
either a primary medical care provider or mental on how best to use interpreter services in a cultur-
14 Seattle Children’s Hospital’s Obsessive Compulsive Disorder-Intensive Outpatient Program 257

Fig. 14.6 Racial demographics for King County Washington per U.S. Census Bureau Quick Facts: King County
Washington (2022)

Alonso, P., Menchon, J., Pifarre, J., Mataix-Cols, D.,

ally sensitive way and are beginning a dialog Torres, L., Salgado, P., & Vallejo, J. (2001). Long
regarding issues particular to mental health term follow-up and predictors of clinical outcomes
assessment and treatment. in obsessive-compulsive patients treatment with
serotonin reuptake inhibitors and behavioral ther-
The best advice we have been given, and the apy. Journal of Clinical Psychiatry, 62(7), 535–540.
advice we strive to follow, is “Don’t let perfec- https://doi.org/10.4088/JCP.v62n07a06
tionism be the enemy of starting.” We are expo- American Psychiatric Association. (2013). Diagnostic
sure therapists, and we spend much of our days and statistical manual of mental disorders (5th ed.).
Author.
challenging scrupulosity and perfectionism. We Amir, N., Freshman, M., & Foa, E. (2000). Family distress
encourage you to do the same. and involvement in relatives of obsessive–compulsive
disorder patients. Journal of Anxiety Disorders, 14,
209–217.
Anholt, G., Aderka, I., Balkom, J., Smit, J., Hermesh,
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 Evidenced-Based Programming
for LGBTQ Young Adults: 15
An Intensive Outpatient Model

Laura M. I. Saunders and Derek A. Fenwick

Program Development support group, we would ask: “How did you find
and Implementation out about the group?” If the answer was, “it was
weird… I found this flyer in a book at my
The Initial Groundwork library!” – we knew our covert marketing strat-
egy was working!
“Do you want to start an LGBTQ Specialty Track This true anecdote and decade-long weekly
intensive outpatient program (IOP) in Young volunteer experience of running the support
Adult Services?” That was the question which group was the basis of a clinical interest and
started the process to develop an evidenced-based expertise in working with LGBTQ teens and
program tailored to meet the unique emotional young adults. It helped formulate an understand-
and developmental needs of this population, the ing of unique stressors and damaging toll of con-
first of its kind in Connecticut. For me (LMIS), cealment, stigma, and minority stress on these
this journey started in the 1990s, running Your young people.
Turf, a weekly lesbian, gay, bisexual, transgen-
der, questioning (LGBTQ) support group in the
greater Hartford, Connecticut, area. There was Process of Building an IOP
nothing available for queer youth at that time
and, since it was before the internet, no way to Young Adult Services (YAS), as a developmental
advertise except to tell current teens/young adults carve out between Child and Adolescent Services
in the support group to spread the word or take a and Adult Ambulatory, was started in 2011 at the
flyer, go to their local school or community Institute of Living. The Institute of Living,
library and insert the flyer in the likely only book founded in 1822, was one of the first psychiatric
on homosexuality in the library and hope that the hospitals in the United States, and the first hospi-
next questioning youth who sought out informa- tal of any kind in Connecticut. The initial IOPs in
tion would run across that lifesaving flyer. When YAS were a general mental health track and an
a new person came to the discrete location of the early psychosis program for individuals who
were experiencing first break psychotic episodes.
Within a couple of years, it was observed that
L. M. I. Saunders (*) · D. A. Fenwick
Hartford HealthCare/Institute of Living, Young Adult there was an overabundance of LGBTQ young
Services, adults within the general mental health track.
Hartford, CT, USA There was a movement within the hospital sys-
e-mail: [email protected]; Derek.
[email protected]
261
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_15
262 L. M. I. Saunders and D. A. Fenwick

tem to create more specialized programming and long conference was planned with submitted pre-
develop specialty tracks in the various divisions. sentations on topics relevant to treatment and
In order to create a specific LGBTQ track within clinical issues within the LGBTQ population.
YAS, clinical staff with expertise in this area Both the yearly networking events for local clini-
were sought. It was a daunting task to create a cal providers and the daylong conference were
mental health program within YAS to meet the meant to serve dual purposes: (1) to increase the
unique needs of the LGBTQ population. There expertise of clinicians on LGBTQ issues and (2)
were no current models of specialized program- to serve as referral sources for the IOP.
ming to pull from that were not solely based in
addiction. As such, research on minority stress
factors, mental health disparities, and unique risk  eam Setup and Involvement
T
factors were reviewed to form the foundation of a of Trainees
program tailored to manage the mental health
needs of the LGBTQ young adult community. The initial “team” was a psychologist with exper-
The program model would be strength based with tise in LGBTQ issues who also developed the
a focus on healthy coping directed at integrated basic model. Since the program was housed
identity development. Some of the overarching within YAS, there were other general mental
treatment goals were to validate transgender or health track clinicians to consult with and receive
lesbian, gay, and bisexual (LGB) identities, clinical feedback. Over time, as the program
reduce concealment and invalidation by family grew in census, other clinicians became a part of
and community, reduce isolation and social anxi- the team to facilitate structured groups and open-­
ety, and understand complex trauma associated ended process sessions. Given that it was a new
with negative life experiences and/or stigma and program on the Institute of Living campus, vari-
discrimination. This program evolved into The ous clinical staff reached out and were interested
Right Track/LGBTQ Specialty Track in YAS. in running a group in order to gain experience
The “Right Track” name comes from Lady working with the LGBTQ population.
Gaga’s Born This Way song, which espouses Given that the Institute of Living is a training
pride in positive identity development: “You are hospital with predoctoral psychology interns,
on the right track baby, you were born this way!” social work interns, postdoctoral psychology fel-
(Lady Gaga, 2011, Track 2). lows, and psychiatry fellows, clinical training is
Once a basic model and group format were integrated in most inpatient and ambulatory pro-
formulated, referral sources were developed. Any grams. Our self-imposed criteria for including
outpatient clinician who had expertise in LGBTQ trainees in our programming is that they have to
issues was contacted. In addition, before the show a vested interest in LGBTQ issues, mean-
actual start of the program, a free networking ing their engagement in this program is not just
event was held at the Institute of Living, and invi- an assignment but a clinical experience they are
tations were sent out to a mailing list. The mail- seeking out due to genuine interest. As the pro-
ing list of clinicians was compiled by searches gram grew in visibility, students in psychology,
through insurance provider lists of anyone who social work, and nurse practitioner programs
included LGBTQ issues on their list of expertise. sought out clinical experiences, eliminating the
A local speaker was brought in, and refreshments need to actively recruit trainees.
were offered to entice local providers to come
and hear about this new IOP. This networking
event was offered on a yearly basis to keep local  avigating Insurance Coverage
N
providers informed of the program mission and and Billing
to serve as a point of connection for potential
peer supervision. In year five of The Right Insurance coverage was not a significant issue
Track/LGBTQ Specialty Track in YAS, a day- simply because the hospital had an established
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 263

system of ambulatory billing. Therefore, insur- for others, serves to reinforce the belief in one’s
ance reviews with justification based on medical difference and inferiority” (p. 35–36).
necessity for continued care were part of the Meyer (2015) breaks down the minority stress
ongoing responsibilities of the program’s clinical model into both distal minority stressors, which
staff. include interpersonal discrimination, victimiza-
tion, familial rejection, microaggressions, and
social stigma secondary to one’s identity
 ationale for LGBTQ Specific
R (Burgess, 2000; Meyer, 2003, 2015), and proxi-
Program mal minority stressors, which include internal-
ization of social stigma and experiences of
Risk Factors for LGBTQ Youth victimization, expectations of stigma resulting in
anxiety and worry, and identity concealment.
In designing a program that address the unique These factors can lead to negative internalized
clinical needs of the LGBTQ population, some of attitudes toward aspects of LGBTQ identity (i.e.,
the core symptoms that would need to be targeted internalized heterosexism, internalized bi-­
include social isolation, trauma, depression, sui- negativity, and internalized trans-negativity,
cidal ideation, and social anxiety. Furthermore, Meyer & Frost, 2013; Meyer, 2015).
the minority stress theory (Meyer, 2003; Meyer Understanding the particular risk factors for
et al., 2008) provides the empirical framework this population is a starting point. The specific
for creating an LGBTQ-affirmative mental health risk factors around health disparities, mental
program. Minority stress is that hidden or under- health problems, and suicide are well docu-
lying stressor that negatively impacts individuals mented in various research articles for this popu-
based on an aspect of identity. Social and minor- lation (Aranmolate et al., 2017; Health
ity status exposes stigmatized individuals and considerations for lgbtq youth, 2019; Johns et al.,
groups to excess stress. According to Meyer 2019; Taylor, 2019; Vance & Rosenthal, 2018).
(2003), minority stress correlates to excess symp- The risk factors can be summarized under four
tomatology and vulnerabilities toward mental ill- categories: identity, mental health vulnerabilities,
ness. It contributes to mood disorders, anxiety isolation/stigma, and family acceptance. Further,
symptoms, and substance use as a means of LGBTQ youth experience sexuality-based verbal
coping. and physical harassment disproportionate to het-
Minority stress is additive, chronic, and erosexual, cis-gendered peers (Kosciw et al.,
socially based: additive in that it requires adapta- 2012). Another aspect of minority stress, hetero-
tion above other stressors, chronic whereby it sexism, was found to be the strongest predictor of
impacts underlying social and cultural structures, psychological distress among a population of
and socially based because it stems from social LGBTQ youth (Kelleher, 2009). Compared to
processes, institutions, and structures beyond the heterosexual counterparts, LBGTQ individuals
individual. Living in a shame-based culture may experience both increased rates and intensity of
create a variety of behavioral and psychological violent victimization (Almeida et al., 2009;
disorders. Concealment is a stressor particular to Birkett et al., 2009). Such experiences of victim-
the LGBTQ population (Hetrick & Martin, ization and bullying have been found to be a sig-
1987). “Individuals in such a position must con- nificant predictor of suicide attempts (Hershberger
stantly monitor their behavior in all circum- et al., 1997). Similarly, for trans and gender non-
stances: how one dresses, speaks, walks, and binary youth, gender-based victimization has
talks become a constant source of possible dis- been identified as a significant predictor of sui-
covery. One must limit one’s friends, one’s inter- cide attempts (Goldblum et al., 2012).
ests and one’s expression, for fear. Each In one survey, almost 18% of lesbian and gay
successive act of deception, each moment of youth met the criteria for major depressive disor-
monitoring which is unconscious and automatic der in the previous 12 months (Kessler et al.,
264 L. M. I. Saunders and D. A. Fenwick

2012). For posttraumatic stress disorder, 11.3% (e.g., substance use, self-injurious behaviors, sui-
met the criteria in the previous 12 months; 31% cidal thoughts/behaviors). Therefore, an IOP
of the LGBT sample reported suicidal behavior where all individuals mirror an aspect of LGBTQ
in their life. National rates for these diagnoses identity can be, in itself, healing. Sharing one’s
and behaviors among youth are 8.2%, 3.9%, and symptoms and struggles, allowing others to bear
4.1%, respectively (Nock et al., 2013). witness based on similar experiences and facili-
Social isolation is often related to stigma. tate emotional growth – this is where the clinical
Individuals in the LGBTQ community who have magic happens!
faced shame, harassment, and invalidation have Let us take a moment to examine a young
learned that hiding fosters emotional safety. This adult whose gender identity is nonbinary. For this
can fuel underlying anxiety and manifest as example, the young adult identifies as neither
social anxiety, which is increased as a function of male nor female. If this individual is witnessed
shame around identity and fear of being seen and/ by others as, say a female, this would be incon-
or rejected (Wilson & Cariola, 2019). At times, gruent with their self-view and may lead to dis-
this fear can lead to avoidance and isolation, and tress or destruction of that self. But, if they are
therapeutic work must focus on creating small, able to see other nonbinary individuals and con-
achievable goals to aid individuals in facing their nect to similar folks with an understanding of
anxiety and gain a sense of accomplishment and what it means to be in that social group, it can
mastery from achieving their goal. Increasing create a buffer to that psychological distress. This
connection is one of the key emphasis areas is a vital element to our work within the IOP. A
within the program, thus hopefully reducing iso- beautiful quote to sum up this concept is, “Each
lation. We always say, “isolation is like gasoline of us needs to know that people who we think are
on the fire of depression.” But most patients tend like us also see us as like them. We need to know
to either feel isolated or are physically isolated that we are recognized and accepted by our peers.
from others secondary to severe anxiety (social We need to know that we are not alone” (Devor,
and/or generalized anxiety), depression, and/or 2004, p. 47).
gender dysphoria.
Humans are social beings that crave other
human interaction and engagement; however, it Theoretical and Clinical
may be hard for LGBTQ individuals to feel con- Considerations
nected to similar folks and may not be around
others who are alike, thus leading to a sense of There is a need for clinical guidelines regarding a
loneliness. With that in mind, it is important to specialty track which focuses on sexual orienta-
understand and incorporate the concept of wit- tion or gender identity (American Psychological
nessing and mirroring (Devor, 2004). As Devor Association, APA Task Force on Psychological
(2004) states, “each of us has a deep need to be Practice with Sexual Minority Persons, 2021;
witnessed by others for whom we are. Each of us Cochran et al., 2007). The specialty track is about
wants to see ourselves mirrored in others’ eyes as creating a culture in which sexual orientation or
we see ourselves” (p. 46). This is an essential ele- gender identity are recognized as factors that are
ment for navigating through identity and self-­ as important as ethnicity, spirituality, socioeco-
discovery, especially for those with a minority nomic status, or other demographic variables.
status. When both of these processes work, it can Dialectical Behavior Therapy (DBT), Trauma
lead to validation and confirmation surrounding Informed, or Cognitive Behavior Therapy (CBT)
identity status; however, when there is a discon- programs have a set of behavioral tenets that
nect between messages one receives comparative guide them and provide consistency across insti-
to their internal experience, it may lead to psy- tutions. Without any foundational guidelines for
chological distress (e.g., depression, anxiety, LGBTQ services within these empirically based
social isolation) and/or maladaptive behaviors interventions, an intervention format was con-
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 265

structed for our program incorporating research developed a lifespan approach to sexual identity
in minority stress, identity development, and formation that emphasizes biological, environ-
health disparities with a focus on a strength-­ mental, and personal constructs. D’Augelli’s
based approach. This format was constructed model encompasses not only gay and lesbian
with the hope that such specialty programs for individuals, but also bisexual and transgender
LGBTQ youth can be replicated at other individuals (Bilodeau & Renn, 2005; Broderick
institutions. & Blewitt, 2006; Fassinger & Miller, 1996).
The world in which we live today, although D’Augelli (1994) proposed that everyone will
advancing, is still largely viewed as binary (rela- have different developmental situations and their
tive to gender and sexual orientation). Invalidation pathway to uncovering their sexual identity will
comes about when one does not fit within that be different. In addition, the pathway of sexual
binary relative to their self-identified identity identity will be fluid and continuous (D’Augelli,
(gender identity or sexual orientation). Research 1994; Stevens, 2004). This highlights a key com-
by Martin (1991) showed that growing up as gay ponent that is always in the back of our mind as
in a world where it is not fully socially accepted clinicians as patients enter our program, and that
can cause individuals to take years to acknowl- is every single person’s journey (both gender and
edge their feelings and to begin to confront their sexual orientation) is unique. It is imperative to
own view in relation to homophobia. With that, allow each person to create their own journey on
many individuals may choose to delay acknowl- their own timeline.
edgement or acceptance of their gay identity, D’Augelli’s (1994) identity formation model
which as we know can lead to detrimental physi- includes six developmental tasks that are inde-
cal and mental health effects for these individuals pendent of each other, meaning that development
(Hetrick & Martin, 1987; Meyer & Frost, 2013; of that individual can be strong in one task, yet
Meyer, 2015). weaker in another task. The six developmental
There continues to be the societal assumption tasks are (1) exiting heterosexual identity, (2)
that one’s gender is always the same as their sex developing personal gay identity status, (3)
assigned at birth (i.e., gender is binary, either developing a gay sexual identity, (4) becoming a
male or female), which is inaccurate. We know gay offspring, (5) developing a gay intimacy sta-
that individuals may identify as male, female, tus, and (6) entering a gay community.
neither male or female (gender nonbinary), both Throughout the lifespan, the development in the
male and female (gender fluid), transgender, or tasks can be influenced by interpersonal relation-
agender. In addition, heterosexism, which can be ships, development of one’s self-concept, lifes-
defined as a system of beliefs and attitudes that pan experiences, social influence, and connections
heterosexual is the dominant sexual orientation to peer groups (Bilodeau & Renn, 2005).
(Sue & Sue, 2003), can lead to shame and isola- While sexual and gender identity is an integral
tion (Lukes & Land, 1990; Moses & Hawkins, factor in understanding how minority stress cou-
1982). ples with social stigma and family environment,
At the heart of sexual identity research is the it is not the only factor to consider. In different
identity formation for gay, lesbian, and bisexual therapeutic dynamics, revealing LGBTQ status
individuals (Broderick & Blewitt, 2006; Fassinger or “coming out” is a theme or issue in treatment.
& Miller, 1996). Due to the nature of society, In an LGBTQ Specialty Track, this barrier is
sexual minority individuals must navigate around eliminated. All group members hold an aspect of
the sexuality paradigm where it is assumed that LGBTQ identity, and there is reduced need for
everyone is heterosexual. D’Augelli (1994) coming out or hiding.
266 L. M. I. Saunders and D. A. Fenwick

Family Involvement and Support children have developmentally normative levels

of depression and only minimal elevations in
 oving Families Along the Continuum:
M anxiety, suggesting psychopathology is not inevi-
Negative Versus Tolerant Versus table (Olson, 2016; Olson et al., 2016). So, in
Accepting looking at the research, family tolerance, and in
Negative family reactions to an adolescent or the best circumstances, acceptance, significantly
young adult are associated with negative health reduces negative health risks and mental health
outcomes (Ryan, 2009; Ryan et al., 2009). risk factors for trans youth.
Adverse, punitive, and traumatic reactions from
parents and caregivers towards a young person’s Case Example
sexual orientation or gender identity increases An example of moving families along the con-
high-risk behavior and negative health outcomes. tinuum is evidenced by the story of Gabriel, a
Ryan and colleagues research on health outcomes 16-year-old transgender male in The Right Track.
demonstrates that negative parental reactions can Gabriel had been saying that his mother was
have serious effects on their LGBTQ child’s refusing to use his preferred name and would not
physical and emotional health (Ryan, 2009; Ryan consider a referral for an endocrinology consult,
et al., 2009). believing his trans identity was “just a phase.”
For there to be integration in identity, family Over the course of several family sessions, there
acceptance and validation is critical. While fam- were opportunities to answer any of Gabriel’s
ily support is crucial for youth to develop self-­ mom questions, understand her reluctance, nor-
confidence and a sense of self-worth, moving malize her concerns, and provide information
parents and caregivers from negative or intoler- that, in fact, Gabriel’s trans male identity had
ant to fully accepting can be daunting (Fisher been quite persistent since age 12, which was
et al., 2012). Parents may blame themselves for almost one-third of Gabriel’s life. Realistically,
their child’s identity issues or lack an under- Gabriel’s mom didn’t move from negative to
standing of atypical identities. At times, cultural fully accepting, but tolerant enough to allow a
or religious paradigms lead to unyielding views referral to an endocrinologist for a hormone
of identity and sexual orientation. Regarding replacement therapy consult.
treatment, it may be more realistic to strengthen Allowing families to move from rejecting to at
family connections through psychoeducation, as least tolerant can mean life-saving support for
well as model, encourage, and promote non- LGBTQ youth. Many parents need to grieve the
judgmental attitudes from parents to their loss or change in their child’s identity (Collins &
children. Collins, 2017). Allowing parents this grieving
Compared to youth from highly rejecting fam- period validates their needs as well. It should not
ilies, lesbian, gay, or bisexual young adults from necessarily be up to the youth to educate their
families with no or low levels of rejection show parents, so identifying LGBTQ support programs
significantly lower risk of depression, suicidality, and online resources is critical. PFLAG (2021)
illicit substance use, and risky sexual behavior [Note: In 2014, the organization officially
(Ryan, 2009; Ryan et al., 2009, 2010). Olson changed its name from ‘Parents, Families, and
et al. (2016) examined mental health of socially Friends of Lesbians and Gays to, simply, PFLAG]
transitioned transgender children (ages 3–12; is one such national organization with 400 chap-
n = 73) compared to a control group of non-­ ters in the United States. They provide confiden-
transgender children in the same age range tial peer support, education, and advocacy to
(n = 49 siblings of transgender participants). The LGBTQ+ people, their parents, and families in
results showed that socially transitioned trans all 50 states (PFLAG, 2021).
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 267

 lements Specific to an LGBTQ+

E Admission (Criteria and Procedures)
Program
Admission criteria are fairly simple, although it
Referrals is important to consider each of the background
and psychiatric factors. Initial intake addresses
In an LGBTQ-specific IOP such as ours, referrals directly that there is an aspect of shared LGBTQ
come from a variety of sources: community ther- identity for everyone in the program while the
apist, self-referral, and inpatient units. Having a focus of treatment is symptom reduction. Gender
variety of referral sources is optimal to keep a identity or sexual orientation is often not the sole
steady census. The goal is to foster relationships focus of treatment but impacts symptom presen-
with community-based clinicians via yearly net- tation. Program admission is also based on deter-
working events and presentations on LGBTQ mination that the patient has treatment goals to
clinical issues to local mental health agencies. work on, verbal expressive ability to participate
One of the most important aspects in the referral in process groups, has the temperament to give
process is having referral sources understand the and receive feedback, and, most importantly, has
nature of the program and its treatment goals. In a personality style that will fit in the current
the first few years of The Right Track/LGBTQ milieu (determined by clinical judgment). The
Specialty Track, there were frequent misunder- therapeutic milieu morphs and changes with the
standings that this was a clinical program to help ebb and flow of admissions and discharges, so the
individuals simply figure out if they identify as a evaluation process to include a new group mem-
sex or gender minority. Rather, the program is ber is done after each intake.
about treating people with mental illness (trauma, Given that The Right Track/LGBTQ
severe anxiety, depression, mood disorders, etc.) Specialty Track has members from ages 16
who also have the shared LGBTQ identity, and through 24, developmental age, maturity, and
this is what helps facilitate emotional healing. family support are also important to consider.
Our overall goals are to provide a safe, affirming While it may seem that a patient at age 16 may
space where sexual and gender minority individ- be very different from another patient who is 24,
uals can identify and modulate stress and stigma it has been our experience that emotional matu-
from the environment (i.e., society, familial rela- rity can vary greatly despite age and may be
tionships, political stressors, etc.) while also more influenced by exposure to trauma, age of
expanding on the individual’s positive coping coming out, family dynamics, and life experi-
skills and personal strengths. ences. Due to issues related to identity develop-
ment and identity integration, age may not be as
significant an admission criterion as it may seem
Intake on the surface.
For our program, there is a capacity of 12
The intake process with patient and/or parent patients/group members in the group at any one
focuses on psychiatric history, psychiatric risk time; all group members attend all three groups
factors, vocational or educational functioning, together as a cohesive milieu. Twelve members
current medications, any past diagnoses, sub- per group is a regulatory requirement mandated
stance history, and family psychiatric history. A by the Department of Public Health of
unique component of the intake is understanding Connecticut based on Medicaid guidelines.
the patient’s sex and gender history. It is often Given this, the members can become more con-
worded as a sex and gender “journey” and it takes nected and gain support/feedback from their fel-
the form of a narrative. It is an opportunity for low group members each day. As the connections
patients to reflect on their gender identity or sex- strengthen over time and group members start to
ual orientation and share how it has unfolded in feel more comfortable in the group setting, you
their life. Relevant stressors that negatively can see the cohesive effects of the milieu
impact their gender journey are also discussed. working.
268 L. M. I. Saunders and D. A. Fenwick

Therapeutic Effect of a Milieu problem. Exploring life experiences (both good

and traumatic) can foster cognitive flexibility
The emotional safety of a shared milieu allows when done in the context of emotional safety
deeper exploration of identity and how it inter- within the group milieu. It is not that everyone’s
sects with trauma, anxiety, depression, and sui- experience is the same, but a specialty track
cidal ideation. The milieu is an important where all members and likely clinical staff iden-
component of group therapy and takes on its own tify somewhere on the LGBTQ spectrum allows
form based on the combination of group mem- for a level of comfort, safety, and mutual
bers. The central tenet of a milieu is that all understanding.
aspects of care contribute to a patient’s treatment Other clinicians have asked about clinician
goals and recovery. Group therapy has proven to self-disclosure of personal characteristics, in this
be a helpful intervention for teens and young case sexual orientation or gender identity status
adults. Whether patients derive greater benefit in an LGBTQ Specialty Track. Depending on
from structured groups or the interpersonal com- training and theoretical orientation, psychody-
ponents of the group therapy milieu, what is most namic vs humanistic vs cognitive behavioral, to
critical is the shared identity that is lacking in name a few, therapist self-disclosure is limited
other aspect of their lives (Snyder et al., 1999; (Hill & Knox, 2001). Therapists are generally
Thomas et al., 2002). Intensive outpatient pro- aware of how self-disclosure can have negative
gramming offers clinical support, skill develop- consequences for clients. Therapist motivation
ment, and interpersonal connectedness to manage for disclosure of sexual orientation or gender
symptoms, decrease re-hospitalizations, and identity status is meant to increase perceived sim-
facilitate achievement of treatment goals. ilarity, connectedness, and facilitate greater ther-
apeutic alliance. Our experience on self-disclosure
of sexual orientation/gender identity has been
Self-Selection and Self-Disclosure extremely positive. Clients feel connected, and it
has only served to increase our credibility.
There are a variety of ways that issues of gender
identity or sexual orientation can emerge in clini-
cal treatment (Nealy, 2017). One way is when  onceptualization of the Right Track
C
youth come into treatment to deal specifically IOP
with their core gender identity or sexual orienta-
tion. The gender dysphoria or coming out process Erik Erikson’s psychosocial stages have been a
has caused the young adult much emotional way to conceptualize our patients within the pro-
anguish and likely family distress. Parents or gram (Batra, 2013). With the IOP being based
youth have questions about how identity impacts within a young adult setting, typically patients
their development or family dynamics. Families are working through the stages of “identity vs.
frequently ask questions: “Is this a phase?’ “How role confusion” or “intimacy vs. isolation.”
do we know this will stick?” “Did I do something Patients are trying to figure out who they are and
wrong in raising them?” understand their internal experiences of the self,
An LGBTQ Specialty Track is a self-selected while also navigating social and intimate rela-
option. It is not as if one checks a box, identifies tionships within their life. In this sense, the young
as a sex/gender minority and then they are sent to adults we work with follow a typical trajectory of
a specific program. It was important in the devel- other adolescent and young adults. However,
opment of this program that clients felt they had with the added context of their minority status, it
a choice. This program was not designed to help creates another layer of complexity that must be
people “figure out” if they were LGBTQ, but examined and addressed. This intersectionality
rather designed for those who already identified can lead to the health/mental health disparities
as such and had a co-occurring mental health that we know LGBTQ individuals face each day.
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 269

Fig. 15.1 The Right Track/LGBTQ Specialty Track day program group schedule

Based on our review of risk factors and needs, Program Intervention

the following goals were established to guide treat- and Treatment
ment. While these seem general, they are tailored
for each individual’s treatment needs. The overarch-  ay-to-Day Programming and Daily
D
ing treatment goals for The Right Track/LGBTQ Schedule
Specialty Track include the following:
The IOP runs three days per week (Monday/
• Build on protective factors and positive, Wednesday/Thursday), three hours per day with
healthy coping skills: capitalize on personal three separate groups each day. Figure 15.1
strengths and resilient traits shows a visual depiction of our current group
• Foster positive adult role models and support- schedule. Although these are our current groups,
ive school personnel we have changed out groups at various times to
• Validate and affirm identity address specific needs within a given milieu. At
• Facilitate community engagement and times, there has been more of a focus within rela-
support tionships (friendships, romantic relationships,
• Strengthen family connections and create familial relationships) where we have added a
family of choice support systems healthy relationships process group. In the past,
• Support a functional outcome in addition to we have also incorporated a “Family Meal” group
symptom reduction into the schedule; however, more recently, this
270 L. M. I. Saunders and D. A. Fenwick

has been removed (see section “Creating Family Mondays), we ask each group member to set
of Choice Experiences (“The Family Meal”)”). treatment goal(s) that they can focus on related
Every program day starts out with the same to practical goals (i.e., school, work) and psy-
group titled, “What’s on Top?” The term origi- chological goals (i.e., emotional, coping,
nated from the co-counseling international move- relational).
ment in the 1970s (Co-Counseling
International – USA. (n.d.)). The What’s on Top
group is meant to be an assessment/check-in Team Members and Roles
group for all members, with the premise being
that one needs to examine the initial feelings on With a cap of 12 patients allowed in our pro-
top in order to understand the underlying uncon- gram at one time, we are a small team of clini-
scious emotions and defenses that lead to dis- cians. Typically, there are two clinicians
tress, which helps validate and affirm one’s (psychologists and/or social workers) that pro-
unique emotional experience. vide the primary therapeutic interventions to all
We have found that for many individuals who patients and a primary medication provider
enter the program, there is a heightened level of (psychiatrist and/or advanced practice regis-
anxiety in joining a new setting and having to tered nurse). In addition, within our larger YAS
share/disclose within the group therapy format. team, there is a vocational counselor who helps
As such, we created a “What’s on Top” clip- run a group related to vocational/life skills that
board with prompting questions to help guide are useful for our young adult population. We
the check-in process (see Fig. 15.2). Over time also have trainees with specialized interest in
as individuals become more connected within working with the LGBTQ population who rotate
the group, they typically can check-in and through the IOP for various lengths of time.
examine their feelings/coping mechanisms These trainees have varied from psychology
without much help from the visual aid of the interns or postdoctoral fellows, social work
clipboard. Additionally, to start off the week (on interns, and psychiatric residents.

Fig. 15.2 What’s on

Top? Check-in guide
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 271

Evidence-Based Treatment utilize necessary skills under times of intense

for LGBTQ Youth psychological distress. That is why a primary
focus of the group-based programming is on skill
Effective treatments for LGBTQ individuals are building and implementation. Several treatment
distinct in their treatment goals in order to have approaches utilized within the program are dia-
more positive and functional outcomes (Moradi lectical behavior therapy (DBT) skills (Linehan,
& Budge, 2018). Identity integration (Bilodeau 1993), self-compassion (Germer & Neff, 2019;
et al., 2005) and symptom reduction are impor- Neff, 2011; Neff & Germer, 2018), and a specific
tant treatment goals for an LGBTQ behavioral focus on building individualized positive, healthy
health program. Identity integration, in theory, coping skills.
becomes an easier process when co-occurring
mental health symptoms are also ameliorated. In
his book, Good Psychiatric Management of Expressive and Vocational Therapy
Borderline Personality Disorder (Gunderson &
Links, 2014), Gunderson focuses on functional An important aspect for group members is imple-
outcome as a key element in treatment. While it is menting both expressive (creative writing/art
vital for functioning to have a better integrated therapy) and vocational based groups. Since there
identity and a reduction in symptoms, functional is an emphasis on functional outcomes and treat-
outcomes marked by stepping into a vocational ment goals, having an established group that
goal or educational setting signals that mental addresses barriers to vocational skills is impera-
health has improved to the point of being able to tive. Vocational topics may include interviewing
integrate back into a community. Thus, in addi- skills, resume writing, money management,
tion to skill building and enhancement, support- building your credit score, and communication
ing functional outcomes is a major treatment skills to name a few. Vocational groups are often
target in our program (i.e., helping the young presented in a playful, engaging format such as
adult get a job or enroll in school). Within our interview jeopardy (e.g., How long it takes for an
program, we are lucky enough to have a voca- interviewer to develop a perception of the appli-
tional counselor who assists our patients in find- cant? Answer: 12 seconds).
ing jobs, creating/reviewing applications, Expressive therapy group is often a favorite of
preparing for interviews, searching for educa- our patients. Pelton-Sweet and Sherry (2008) dis-
tional programs, etc. The one-on-one attention cuss the integration of art therapy with LGBT
has been a vital element for the young adults that clients. There is evidence to support a relation-
have come into our program. ship between individual creative expression and
emotional health, as it relates to sex and gender
minorities. Creative expression allows young
 kill Implementation and Process
S adults to “try-on” various identities. Encouraging
Therapy self-expression skills foster positive coping abili-
ties that can generalize outside of a treatment set-
An essential element of the Right Track is imple- ting. Creative writing prompts (e.g., “Write a
menting various skills to address the individuals’ letter to your past and/or future self”) can also
mental health symptoms. Although the Right encourage self-reflection around identity.
Track is an LGBTQ specialized program, the
focus is also on comorbid mental health con-
cerns. Patients present with severe depression,  ialectical Behavior Therapy (DBT)
D
anxiety, bipolar disorder, trauma histories, sub- Skills
stance use disorders, gender dysphoria, and more.
As such, many of the youth that we see within Based upon Linehan’s model, throughout our
our program lack the ability to focus in on and program, we use skills from all of the DBT
272 L. M. I. Saunders and D. A. Fenwick

skills modules, including mindfulness, interper-  tigma Management: Understanding

S
sonal effectiveness, emotion regulation, and dis- Shame
tress tolerance skills (Linehan, 1993, 2015a).
For the sake of this chapter, we are not going to Living in a shame-based culture contributes to a
specifically discuss these skills in depth as there variety of behavioral and psychological disor-
are other chapters in this handbook focused ders. Specifically, the LGBTQ young adults that
exclusively on DBT. However, we will discuss we work with often describe a heavy shame built
how these skills are applied to the LGBTQ com- up based upon living in a binary world, one where
munity and why they are needed (Sloan et al., judgement is surrounding them, and negative
2017) connotations and stigmas are tied not only to
Linehan’s Biosocial Theory proposes that minority identity status but also to poor mental
there is a transaction between a biological ten- health.
dency toward emotional vulnerability and an Kort (2018) discusses covert cultural sexual
invalidating environment, thus producing dys- abuse that can have devastating physiological and
regulation within one’s emotional system. Now psychological consequences, leading to shame
think about this from a societal viewpoint where and guilt. He defines covert cultural sexual abuse
everything is viewed as binary. If one does not fit as “chronic verbal, emotional, psychological, and
within that binary, this can lead to invalidation of sometimes sexual assaults against an individual’s
that individual’s identity. The social environment gender expression, sexual feelings, and behav-
in which one lives actively creates invalidation iors” (p. 54). He further adds that “covert cultural
for LGBTQ people (Sloan et al., 2017). sexual abuse involves bullying through humilia-
An example of institutional level invalida- tion, offensive language, sexual jokes, and
tion is evident in the absence of discrimination obscenities… what I define as covert cultural
protections for transgender individuals in sexual abuse is the expression of heterosexism, a
housing, work settings, and other public sec- belief in mainstream society that demands that all
tors (Movement Advancement Project, 2016; people be – or pretend to be heterosexual” (p. 55).
Sloan et al., 2017) and in the emergence of Shame can build upon itself until it is solidi-
“bathroom bills” inciting fear about the poten- fied, creating a crippling effect of distress, avoid-
tial for sexual predation by transgender indi- ance, and fear, limiting an individual’s motivation
viduals (GLAAD, 2016; Sloan et al., 2017). to step into a sense of acceptance and eventually
Further, invalidation from the social environ- pride in their identity. For individuals in the
ment may also take place. Childhood abuse, LGBTQ community that veer from the binary
intimate partner violence, and violent victim- world, shame has to be broken down over time.
ization are examples of invalidation to which Through identification of the situations and envi-
transgender individuals are disproportionately ronments that have caused shame, one can start to
exposed (Sloan et al., 2017). These forms of move into a more authentic self. A key element in
marginalization and discrimination create an helping one move into acceptance can be as sim-
invalidating environment, in which the domi- ple as helping these young adults enter into an
nant cultural environment dismisses, disre- LGBTQ inclusive space outside of the therapeu-
gards, trivializes, and actively punishes tic context. Being around other LGBTQ
transgender identity as socially unacceptable ­individuals who have a sense of pride can show
(Lombardi et al., 2002; Norton & Herek, 2013; those living with shame that there is nothing to be
Reisner et al., 2014; Shipherd et al., 2011; ashamed about. For example, we have given indi-
Sloan et al., 2017). As such, one can expect viduals a treatment goal of going to a Gay Brunch
that the invalidation faced by the LGBTQ com- as an exposure to decrease avoidance secondary
munity would impact their psychological well- to anxiety surrounding their LGBTQ identity.
being (Blosnich et al., 2016; Sloan et al., Further, one of the additional ways we can help
2017). attenuate shame for these individuals within the
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 273

program is through the introduction of self-­ that there is nothing inherently wrong with being
compassion skills, which is discussed in the next LGBTQ. GAT is not a system of therapy but a
section. framework that informs therapeutic work with
LGBTQ clients (Friedman & Downey, 2002).
Based on this, we as providers help patients
Self-Compassion understand their sexual and/or gender identity,
validate that identity, and help them explore
Within our work, the majority of these young within a safe and connected LGBTQ affirming
adults enter into treatment with a lack of self-­ space. Most of this work is explored in groups
acceptance. In particular, as discussed before, from a process-oriented approach within various
shame is prevalent (at least early on in the com- contexts that will be further discussed below.
ing out experience) for LGBTQ individuals,
which can lead to negative internalizations (inter-
nalized homophobia/transphobia). Neff (2011) Building and Understanding Healthy
describes three elements of self-compassion that Relationships
we view as essential, including self-kindness vs.
self-judgment, common humanity vs. isolation, LGBTQ individuals can be faced with difficult
and mindfulness vs. overidentification. First, relationship dynamics, whether it be from famil-
self-kindness vs. self-judgment focuses on being ial discord and/or lack of acceptance, intimate
warm and understanding toward ourselves when partner violence, or even discrimination from
we suffer, fail, or feel inadequate, rather than society. In this regard, there can be difficult
ignoring our pain or flagellating ourselves with attachment relationships stemming from history
self-criticism. Second, common humanity vs. (i.e., trauma) or even feelings associated with
isolation, in which all humans suffer, highlights abandonment/distress from an invalidating envi-
the idea that the very definition of being “human” ronment. Keeping this in mind, one critical ele-
means that one is mortal, vulnerable, and imper- ment that we focus on throughout our groups is
fect. Therefore, self-compassion involves recog- that of navigating relationships (e.g., family, sig-
nizing that suffering and personal inadequacy is nificant other(s), friend(s)). This further relates to
part of the shared human experience – something the next section “Creating Family of Choice
that we all go through rather than being some- Experiences (“The Family Meal”).” However,
thing that happens to “me” alone (Germer & what we specifically focus on in the group setting
Neff, 2019; Neff, 2011, 2018; Neff & Germer, is using a process-oriented framework to explore
2018). Third, mindfulness vs. overidentification the individual’s relationship patterns, help illumi-
is described by Neff (2018) as mindfulness being nate negative patterns regarding one’s ability to
a nonjudgmental, receptive mind state in which relate, and gain insight around communicating
one observes thoughts and feelings as they are, within the therapeutic setting that can then be
without trying to suppress or deny them. We can- transferred into a real-life context.
not ignore our pain and feel compassion for it at
the same time. However, mindfulness requires
that we not be “overidentified” with thoughts and Creating Family of Choice
feelings, so that we are caught up and swept away Experiences (“The Family Meal”)
by negative reactivity.
Our program also utilizes elements based As a treatment goal, building family relationships
upon gay affirmative therapy (GAT). Malyon or recreating family-of-choice connections is
(1982) coined the GAT term on how to use psy- critical. Family-of-choice, also known as chosen
chotherapy techniques without stigmatizing family, is the concept whereby friends are inte-
LGBTQ clients. The primary premise for GAT is grated into a family system and satisfy the role of
274 L. M. I. Saunders and D. A. Fenwick

family as a support system. It serves as a contrast tional sharing. Reviewing the high-low for the
to biological family or family of origin who can week sets up reflection on the week’s emotional
be intolerant or outright rejecting of LGBTQ experiences.
identity. The term started in the LGBTQ commu-
nity (Carlson & Dermer, 2017) and was used to
describe early gatherings like the Drag Balls in  risis and Safety Response/
C
the late nineteenth century. Family of choice is Management
meant to offset family rejection and isolation
faced by those rejected by their families due to Being that the setting is an IOP, many patients are
aspects of identity. referred to us as either a step-down following
Creating a group called The Family Meal their inpatient hospitalization or a step-up from
was also reflective of earlier clinical experi- individual therapy due to their provider feeling as
ences with children. It was observed during a though the patient needs further wrap-around
weekly social skills group on an inpatient child care and support. With this in mind, consistent
psychiatric unit where sitting around a table, assessment of risk regarding suicidality is imper-
sharing a snack together, and asking each child ative. We are always assessing safety in the con-
about their day made the lack of family routine text of the therapeutic relationship with the goals
quite evident. Many of these children had not of avoiding hospitalization and/or rehospitaliza-
shared a meal, sitting at a table with their fam- tion due to self-harm and suicide risk.
ily. This was a revelation. Those children did Suicide is the third-leading cause of death
not have anyone asking how their day was or among adolescents (Liu & Mustanski, 2012), and
giving them a forum to share their daily experi- research has shown that LGBTQ (lesbian, gay,
ences. It was the seemingly simple act of par- bisexual, transgender, questioning) youth and
taking in a snack and sharing conversation that young adults are at a higher risk for depression
enlightened this clinician about their need for (Cochran et al., 2006; Lewis et al., 2006) and sui-
family connection, and it soon became every- cide compared to their heterosexual counterparts
one’s favorite group. (Haas et al., 2011; Liu & Mustanski, 2012; Yildiz,
The Family Meal Group at The Right Track 2018). A recent study reported that there is an
was designed to be a wrap-up format, the last increased risk of suicide attempts and thoughts of
group of the week, where we share a meal or suicide in the sexual minority population that
snack between everyone. Asking each client encompasses lesbian, gay, bisexual, transgender,
about their high point or low point of their week queer, questioning, intersex, asexual, ally, pan-
allowed self-reflection. Weekend planning with sexual/polysexual, and two-spirited (Yildiz,
an eye towards reducing isolation and making 2018). Further research shows that “the reported
social connections is also part of this group for- likelihood of suicide attempts among trans-men
mat. We mimicked what families do to increase and women were five times greater than that of
communication and create cohesion in the format heterosexuals, and 19 times greater than the prob-
of meal sharing. Just like the children on the ability of completed suicides” (Dhejne et al.,
inpatient unit, this became everyone’s favorite 2011; Yildiz, 2018, p. 650). Another longitudinal
group in our IOP. study showed that when examined at age 21,
Due to COVID and the ensuing regulations lesbian, gay, and bisexual (LGB) individuals
­
around physical distancing and food, the Family were six times more likely to report one or more
Meal has been altered in the group format. We are lifetime suicide attempts compared to their het-
not able to share food, and eating is discouraged erosexual counterparts (Fergusson et al., 1999).
in a group setting. However, we are able to dis- A follow-up with these same individuals at age
cuss the importance of partaking in a meal as a 25 revealed that LGB individuals reported a sig-
family and reinforce the concept of open emo- nificantly higher rate of suicide attempts since
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 275

age 21 than did their heterosexual counterparts  ummary, Lessons Learned,

S
(Fergusson et al., 2005). In addition, among the and Next Steps
transgender population, rates of suicidal ideation,
suicide attempts, and deaths are significantly When developing and launching this program,
higher than the general population (for a review, we created a fairly set group format (see
see Wolford-Clevenger et al., 2018). A recent Fig. 15.1), which provided structure and consis-
study has found that 29% of trans and gender tency for the patients. However, it became evi-
nonbinary young adults attempted suicide in the dent that there were times when group topics
last year (Hatchel et al., 2019) compared to 6% of needed to change, or we needed to infuse new
their cis-gendered counterparts (Olson et al., ideas into our groups so that groups did not
2016). become stale. In those times, the group leaders
This research demonstrates the need to fully would solicit suggestions for feedback from
be aware of and address suicidal ideation, behav- group members about what their needs were or
iors, desires, and attempts within this population. topics they would like to include in Open Topic.
A key part of our discussion with these young Using ideas and suggestions from group mem-
adults regarding risk assessment is that of reduc- bers was often viewed as very favorable and
ing the shame and stigma surrounding talking seemed to boost investment. If the group idea
about suicidal thoughts. The aim of this focus can worked, it was kept in the rotation of group ideas
lead to clarity and transparency in knowing the under that topic/heading.
mindset of the patient and allow us as clinicians The most helpful and grounding aspects of
to fully provide them with the best care at that developing this IOP were to have a clear frame-
time. We validate that people may have suicidal work, solid treatment goals, and a common
thoughts and ideation, but that if we can have an thread – mirroring and witnessing in support of
open dialogue about their risk, then we can put a LGBTQ identities at our therapeutic core (see
plan in place as a team, which includes the Fig. 15.3 for treatment model). The overarching
patient, to keep them safe. Part of this assessment treatment goals of The Right Track/LGBTQ
and safety planning relates to what we view as Specialty track in Young Adult Services and
trauma-informed care. The elements that we nav- developmental framework of the minority stress
igate within this context are as follows: (1) safety model (Meyer, 2003), along with integrating ele-
(such as reducing access to lethal means in the ments from other evidenced based treatments
environmental context), (2) trustworthiness and (CBT and DBT), combined to meet the unique
transparency (building a strong therapeutic alli- needs of the LGBTQ population.
ance and allowing the patient to see that we are When it comes to lessons learned, the most
there to help and keep them safe, creating trust), important foundational step was keeping a clear
(3) peer support (utilizing the lived experiences focus on functional goals. A functional goal is
of peers to help promote healing), (4) collabora- when a treatment goal is based on an achievable
tion (between patient, family, and multidisci- and easily measurable outcome, usually either an
plinary team members), (5) empowerment (of educational or vocational criteria. Gunderson
allowing these young adults to feel a sense of (2014) emphasizes a similar model, noting
autonomy and decision making within their treat- change is expected, and there is a focus on life
ment), and (6) cultural, historical, and gender outside of treatment. While reduction in symp-
issues (offers access to gender responsive ser- toms is important, functional change – taking a
vices, leverages the healing value of traditional class, starting a job, and taking on a volunteer
cultural connections, incorporates policies, pro- activity – is easily measurable. We have learned
tocols, and processes that are responsive to the that functional goals help the LGBTQ patient
racial, ethnic, and cultural needs of individuals feel more self-sufficient.
served) (SAMHSA’s Trauma and Justice Strategic In addition to focusing on functional out-
Initiative, 2014). comes, we have also learned the benefits of
276 L. M. I. Saunders and D. A. Fenwick

Foster Strengthen
Support
posive family
Facilitate funconal
Idenfying Establishing Validate and adult role connecons,
Building on community outcome in
protecve resilient Affirm models and Create family
strengths engagement addion to
factors traits identy supporve of choice
and support symptom
school support
reducon
personnel systems

Fig. 15.3 The Right Track/LGBTQ Specialty Track treatment model

providing ongoing education to community coaching, and other trans-related care to support
providers, mental health agencies, and other the physical and mental health of our patients.
referral sources about LGBTQ issues. Investing
in these endeavors allowed those organizations
to keep our program in mind as more and more  ase Example: A Reflection
C
gay and trans folks openly identified and on Treatment
wanted a program that would be more specific
to their identity. Our yearly networking event To conclude this chapter, we share some reflec-
with an invited speaker became a day-long tions from Harry, a 27-year-old trans male who
conference in 2018, titled “Treating the Whole attended The Right Track/LGBTQ Specialty
Person: LGBTQ Identity Development from a Track IOP when he was 22 years old. The follow-
Clinical Perspective.” Presenters offered a ing was his response to the question, “How was
variety of topics including Supporting Families IOP helpful with your mental health and your
When Their Children Come Out, Gender gender journey?”
Dysphoria and Borderline Personality “Prior to The Right Track/LGBTQ Specialty
Functioning, and Trans Persons with Substance Track I didn’t know anyone else in the ‘commu-
Addiction: Treatment Tools, to name a few. nity.’ I had been in a lot of treatment – psychiatric
This conference continues to address the over- hospitals, other IOP and PHP programs. I didn’t
arching goal of improving clinical competence know any trans people. Being around LGBTQ
in community providers in LGBTQ clinical young adults allowed me to understand how I
care. was feeling. I learned I wasn’t alone. My social
Regarding next steps and future directions, the anxiety decreased in the IOP. A lot of what I was
ultimate hope is that our large healthcare system feeling was relatable to others and vice versa. It
(>30,000 employees and seven hospitals) can allowed me to identify the emotions I was feeling
create an integrated Center for Gender Health. because other group members had similar feel-
This would ideally serve the myriad needs of the ings. It helped me realize who I was as a trans-
trans and LGB population, who, as previously man and feel good about it. I learned about the
documented, struggle with marginalization and concept of family of choice. I had never heard of
impaired access to adequate healthcare. Such a that term or concept before. My parents died
service could help facilitate referrals for endocri- when I was a teen, and being able to create a fam-
nology, primary care, surgery, gynecology, voice ily of choice and call them my family was mean-
15 Evidenced-Based Programming for LGBTQ Young Adults: An Intensive Outpatient Model 277

ingful. The word ‘family’ has a stronger disorders among lesbians and gay men from exist-
ing national health data. In A. Omoto & H. Kurtzman
connection than just friends. It helped that there (Eds.), Sexual orientation and mental health, examin-
was a focus on vocational goals. My anxiety ing identity and development in lesbian, gay and bisex-
made it hard to think about work, but I was able ual people (pp. 143–165). American Psychological
to get a job before I left the program. I hadn’t Association.
Cochran, B. N., Peavy, K. M., & Robohm, J. S. (2007).
worked in a long time before that.” Do specialized services exist for LGBT individu-
als seeking treatment for substance misuse? A
study of available treatment programs. Substance
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 Adolescent Dialectical Behavior
Therapy Intensive Outpatient 16
Programs

Stephanie Clarke, Anaid Atasuntseva,

Micaela Thordarson, and Michele Berk

Introduction cent DBT IOPs: (1) Children’s Health Council/

Stanford Children’s Heath’s, Reaching
Dialectical behavior therapy (DBT) is the only Interpersonal and Self Effectiveness [RISE]
well-established treatment for self-harming ado- Program, and (2) the DBT IOP at Children’s
lescents at high risk for suicide. Standard DBT Hospital of Orange County. We begin by review-
was designed to treat complex, high-risk patients; ing the statistics on, and relationship between,
however, currently there are no empirically sup- suicidal and self-harming behavior in teens. We
ported higher levels of care (e.g., intensive outpa- then review the evidence base for DBT, which is
tient programs [IOPs], partial hospitalization currently the only well-established, evidence-­
programs [PHPs], and residential treatment cen- based treatment for reducing suicidal thoughts
ters [RTCs]) for adolescents whose risk level or and behaviors in adolescents (Mehlum et al.,
presentation requires more intensive interven- 2016; McCauley et al., 2018). We go on to dis-
tion. Clinicians and researchers may find a poten- cuss the utility of DBT IOPs. We then focus on
tial solution to this problem in higher levels of describing DBT-based IOPs, first reviewing the
care that have standard DBT as their core treat- empirical efforts in this area before describing in
ment component. detail the programs mentioned above and the
This chapter will discuss the application of unique challenges of implementing DBT in this
standard DBT in an IOP treatment setting, with a level of care (e.g., managing a milieu through the
specific focus on describing two existing adoles- lens of DBT). We conclude this chapter with
commentary on the lessons learned and critical
considerations in developing and delivering a
S. Clarke (*) DBT-based IOP for suicidal and/or self-harming
Cadence Child & Adolescent Therapy, adolescents.
Seattle, WA, USA
e-mail: [email protected]
A. Atasuntseva · M. Berk Terminology
Stanford University School of Medicine,
Stanford, CA, USA
e-mail: [email protected] In this chapter, suicide refers to the act of inten-
M. Thordarson tionally ending one’s own life. Suicide ideation
Children’s Hospital of Orange County, (SI) refers to thoughts about engaging in behav-
Orange, CA, USA ior intended to end one’s own life. Suicide attempt

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 281
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_16
282 S. Clarke et al.

(SA) refers to self-injurious behavior associated ties and differences. As previously mentioned,
with at least some, nonzero intent to die although individuals do not engage in NSSI to
(Silverman et al., 2007). Non-suicidal self-­ end their lives, NSSI is a significant risk factor
injurious behavior (NSSI) refers to damage to for future SAs (Asarnow et al., 2011; Monto
one’s bodily tissue through such means as cutting et al., 2018; Wilkinson et al., 2011). Adolescents
or burning oneself without the intent to die (Nock often engage in both NSSI and suicidal behavior
& Prinstein, 2005; Nock et al., 2006). (e.g., SAs) at the same time, and most teens who
engage in NSSI also have a history of SAs (Glenn
Suicide in Adolescents et al., 2017; Whitlock et al., 2013; Nock et al.,
Suicide is a major public health problem among 2006). A temporal relationship among SI, NSSI,
adolescents. Suicide is the second leading cause and SA has been identified, such that SI typically
of death among adolescents in the United States precedes NSSI, and NSSI typically precedes SAs
(CDC, 2021; American Foundation for Suicide (Glenn et al., 2017). Researchers have hypothe-
Prevention, 2021), with rates of suicide among sized that NSSI may act as a “gateway” to SA
US youth having increased exponentially in because, through repetitive NSSI, adolescents
recent decades (Kann et al., 2016). According to increase their willingness and ability to engage in
the most recent data from the Youth Risk Behavior progressively riskier self-injurious behaviors
Survey, a biennial national survey of high school (Whitlock et al., 2013).
students, 18.8% reported seriously considering
attempting suicide and 8.9% reported having
attempted suicide in the past year (Ivey-­ Evidence-Based Treatment
Stephenson et al., 2020). Strikingly, more than for Suicidal Youth
one-third of teens who report experiencing sui-
cide ideation go on to make a suicide attempt DBT is currently the only well-established,
(Nock et al., 2013). evidence-­based treatment for self-harming ado-
lescents at high risk for suicide (Mehlum et al.,
Non-suicidal Self-Injury in Adolescents 2016; McCauley et al., 2018) based on DBT’s
The occurrence of NSSI is high among adoles- performance in two independent randomized
cents. In a national survey of high school stu- controlled trials (RCTs) by two separate research
dents, 18% of all students and 24% of groups (Chambless & Hollon, 1998). There are
female-identifying students reported engaging in other treatments that have been shown to be
NSSI at least once over the preceding year promising, although they have a less robust evi-
(Monto et al., 2018). It is important to assess for dence base (i.e., Mentalization-Based Therapy,
and target NSSI in treatment and not minimize Integrated Cognitive Behavioral Therapy (CBT),
the seriousness of NSSI by conceptualizing it as the Safe Alternatives for Teens and Youth
a “suicide gesture” or “attention-seeking” behav- (SAFETY) Program, and Developmental Group
ior; this is because research has shown that self-­ Psychotherapy; Ougrin et al., 2015). In 2020, a
harming adolescents are at significant risk for meta-analysis of 25 RCTs of therapeutic inter-
making a future suicide attempt (Monto et al., ventions for self-harming youth with suicidal
2018). Therefore, such attitudes can lead to inad- ideation and depressive symptoms found that
equate safety planning due to poor understanding when comparing therapeutic intervention to an
and underestimation of risk. active control intervention, only DBT showed
significant improvement in treatment outcomes
Relationship Between NSSI and SAs (Kothgassner et al., 2020).
in Adolescents
NSSI and SAs may appear similar as they both
typically involve engaging in self-harm; how-
ever, it is vital to understand both their similari-
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 283

 omprehensive Dialectical Behavior

C DBT therapy, typically once per week; (2) DBT
Therapy in Practice skills class, typically once per week (delivered in
DBT is a combination of second-wave cognitive-­ a multifamily format for adolescents); (3) tele-
behavioral therapy and third-wave concepts, such phone coaching, typically 24 h per day, 7 days
as mindfulness and acceptance. At the heart of per week; and (4) a weekly consultation team for
DBT lies the biosocial theory, which posits that therapists, which helps clinicians remain adher-
emotion dysregulation and impulsivity result ent to DBT principles and practices and also
from a transaction between hard-wired, or bio- seeks to help reduce clinician burnout as working
logical, emotion sensitivity (i.e., high sensitivity, with high-risk clients can be particularly stressful
high reactivity, and a slow return to baseline (see Table 16.1). Only a treatment package that
emotional state) and an invalidating environment. includes all four components is considered com-
An invalidating environment is one in which prehensive. For example, if a clinician is provid-
one’s emotions are misunderstood, belittled, ing a client individual psychotherapy using DBT
ignored, or deemed to be “bad” or “too much.” techniques and protocols, telephone coaching,
The transaction between biological sensitivity and DBT skills group but is not on a DBT thera-
and an invalidating environment gives rise to pist consultation team, then the clinician is not
problematic behaviors, such as NSSI, by creating providing comprehensive DBT.
an environment in which only extreme emotional Given the high level of risk for death by sui-
displays are paid attention to and therefore rein- cide for teens engaging in NSSI and/or suicidal
forced (Linehan, 1993). behavior, as reviewed above, it is imperative to
DBT ultimately works to help individuals provide evidence-based treatment protocols
reduce and ideally eliminate self-harming and (Koerner et al., 2021). Therefore, adolescents
suicidal behaviors by teaching more effective who are struggling with self-harming behaviors
skills for responding to high emotion and other and/or have engaged in suicidal behavior should
life problems. The skills class, a core component ideally receive comprehensive DBT when possi-
of DBT, teaches teens and their parents skills in ble. The primary difference between DBT with
four areas – Mindfulness, Distress Tolerance, adults and adolescents is the inclusion of families
Emotion Regulation, and Interpersonal (Linehan, 1993; Miller et al., 2007). Parents
Effectiveness. The Middle Path module, aimed to attend skills classes with teens in a multifamily
decrease family conflict and increase validation format, participate in family and collateral ses-
in the home, was added for adolescents (Rathus sions as needed with the individual therapist, and
et al., 2015) and has now become a part of stan- are offered telephone coaching (Miller et al.,
dard DBT for all ages. A primary goal of DBT is 1997, 2007).
to help the client remain in the natural environ-
ment, to use higher levels of care as infrequently  BT in Intensive Outpatient Levels
D
as possible, and to build a “life worth living” of Care
(Linehan, 1993). While DBT was developed to be delivered in a
It is important to understand the difference typical outpatient clinic setting, there may be sev-
between “DBT-informed treatment” and “com- eral benefits to a more intensive DBT-based treat-
prehensive” or “standard” DBT (the terms “com- ment setting. First, some adolescents may need
prehensive” and “standard” can be used more frequent safety assessment and supervision
interchangeably; Koerner et al., 2021). The data by mental health professionals to maintain safety
supporting DBT as an effective treatment for than is provided within the standard DBT model.
self-harming youth at high risk for suicide tested That is, while standard DBT includes one indi-
only comprehensive DBT and not individual vidual therapy session and one multifamily group
DBT components (e.g., skills group only). session per week, IOPs offer several hours per
Comprehensive DBT includes (1) individual week of individual and group therapy sessions.
284 S. Clarke et al.

Table 16.1 Components of stage I standard DBT

Component Frequency Rationale In-session structure
Individual 1x/week Enhances skills capacity Diary card used to determine
Psychotherapy Generalizes skills application treatment hierarchy: (1) life-­
to patient’s unique interfering behavior, (2) therapy-­
circumstances interfering behavior, (3)
Increases motivation and quality-of-life-interfering behavior
reduce ineffective behavior
Creates structure to reinforce
effective behavior and skills
use
Group Skills Training At least 1x/ Teach skills: Mindfulness, Each group includes: (1) Mindfulness
(Teen Skills Groups and week more Distress Tolerance, Emotion exercise, (2) homework review, (3)
Multifamily Group) frequent in Regulation, Interpersonal teaching of new skill
IOP Effectiveness
Telephone coaching As needed, Help with skills application in Brief, focused calls for (1) supporting
available 24/7 a crisis skills use in a crisis, (2) repairing
Unavailable for 24 h after therapist-patient rupture, (3) sharing
patient engages in self-­ good news
injurious behavior to reduce
incidental reinforcement
Therapist Consultation 1x/week Support therapist’s motivation, Structure includes (1) mindfulness
Team adherence, and effectiveness, exercise, (2) presentation of clinical
decrease burn out concerns, including any therapist’s
TIB

Next, as mentioned previously, a primary goal of residential treatments. Overall, there are several
DBT is to help the adolescent remain in her or his potential benefits of embedding standard DBT
natural environment. The benefit of keeping the into a higher level of care for self-harming and
teen at home is that problems in the client’s envi- suicidal adolescents.
ronment that may be contributing to psychiatric
problems can be worked on and improved rather
than left to be dealt with when the client returns Research on DBT IOPs
home (Linehan, 1993). Third, for patients whose
mental health symptoms significantly interfere At the time of writing of this manuscript, the
with daily functioning (e.g., unable to attend authors identified only one published study of an
school, difficulty getting out of bed or leaving the adult IOP that had all four components required
home), the IOP provides a structured yet thera- for a comprehensive DBT program (Ritschel
peutic setting to improve basic functioning, teach et al., 2012). While this study demonstrated
adaptive coping, and apply new skills learned to improvements in anxiety and depressive symp-
current problems. Fourth, a higher “dose” of toms, it did not assess self-harming or suicidal
treatment may lead to quicker treatment gains behavior, which is the primary target of compre-
(although this remains an empirical question), hensive DBT. The adaptation of DBT to higher
which may be particularly beneficial for patients levels of care is an understudied area, and addi-
with high suicidality and significantly impaired tional research is needed. While it stands to rea-
functioning. Fifth, the increased contact with son that embedding an evidence-based practice
mental health professionals in an IOP program into a higher level of care would continue to yield
may provide an opportunity to increase medica- positive results, it cannot be assumed to do so.
tion doses at faster rates. Finally, an IOP program The most pressing empirical question currently is
may serve to prevent the need for even more whether comprehensive DBT remains effective at
restrictive settings, such as hospitalizations and
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 285

reducing suicidal and self-harming behavior and/or medical instability, schizophrenia, pri-
when provided in a more intensive setting. mary substance abuse disorder) requiring very
While several IOPs for adolescents have specialized treatment that cannot wait for inter-
incorporated DBT skills and concepts, we were vention until the completion of the IOP. Both
able to identify only a small handful of compre- IOPs adhere to the DBT requirement that par-
hensive DBT IOP programs in the United States ticipants are not engaged in other individual
via outreach on relevant national listservs, includ- therapies while in DBT.
ing the DBT and APA Division 53 Acute, Consistent with the DBT model, the treatment
Intensive, and Residential Services (AIRS) length is fixed for the RISE (12 weeks) and
Special Interest Group (SIG) listserv. In the next CHOC (8 weeks) programs, in order to ensure
section, we describe two real-world examples of that teens receive all of the DBT skills. At pres-
DBT-based IOP programs for youth at high risk ent, there are no empirical guidelines as to which
for suicide: (1) the RISE DBT IOP and (2) the skills account for change; hence, all standard
CHOC DBT IOP. DBT skills are taught. Enrollment and graduation
are staggered so that patients can enter the pro-
gram at the beginning of each group skills mod-
Description of DBT Intensive ule in order to receive all skills contained within
Outpatient Programs that module. We have observed that allowing
teens to enter the program at different times
Overview of Programs enhances social learning as “veteran” teens take
on leadership roles in teaching and modeling
RISE and the CHOC program are both after-­ skills use for newer participants. Veteran parents
school, four-day-per-week teen IOPs that have similarly welcome new parents and help instill a
DBT at the core of their programming. Both sense of hope in those just getting started, often
programs were developed with the purpose of enthusiastically sharing that DBT will make an
providing effective treatment for suicidal and/or observable difference in their teens.
self-harming youth. While admissions criteria Below, we will describe the specific aspects of
based on suicidality and self-harm are different the RISE and CHOC programs separately. Please
for each program (see below), admissions see Table 16.2 for a side-by-side comparison of
requirements for both programs include a need program components.
for a higher level of care than what is offered in
standard outpatient treatment (i.e., generally Reaching Interpersonal and Self
once-per-week psychotherapy). Because IOPs Effectiveness (RISE) Overview
have a teen milieu, teens must be able to attend The RISE (Reaching Interpersonal and Self
groups without engaging in aggressive or out- Effectiveness) Program, named by one of its first
of-­
control behavior. Additionally, both pro- patient cohorts, is a 12-week IOP for 13- to18-­
grams require a substantial amount of time from year-­olds that has a comprehensive DBT program
caregivers both within program hours (e.g., embedded within it. The 12-week program length
attending family skills groups and talking with is based on the standard six-month DBT curricu-
the teen’s individual therapist and psychiatrist) lum used in a prior RCT of DBT called the
and outside of program hours to manage the Collaborative Adolescent Research on Emotions
teen’s safety. Caregivers are relied on to restrict and Suicide (CARES) study (McCauley et al.,
the teen’s access to lethal and self-harming 2018). Given that the program is exactly half the
means (e.g., pills, sharps, poisons) and provide length of standard DBT, youth receive individual
high levels of supervision. Both programs therapy and multifamily skills group twice per
accept teens with a wide variety of symptoms week. Therefore, adolescents and families get the
and problems, and both do not accept teens with same dose of standard DBT components in half
certain diagnoses (e.g., AN with low weight the time.
286 S. Clarke et al.

Table 16.2 RISE and CHOC side-by-side comparison

Program
information Rise CHOC
Ages 13–18 (8th–12th) 13–18 (9th–12th)
(grades)
Length of 12 weeks 8 weeks
program
Length of 4 weeks each of distress tolerance, 2 weeks each of distress tolerance, emotion regulation,
modules emotion regulation, interpersonal interpersonal effectiveness, and walking the middle path
effectiveness Mindfulness integrated daily
Mindfulness and middle path repeat at
start of each module
Inclusion of 2x/weekly multifamily group 1x/weekly multifamily group
families 1x/weekly parent skills groups
Hours per 13–14 h 13–14 h
week
Languages English only English only
Inclusion Prior suicide attempt, repetitive NSSI, or Current suicidal thoughts and/or behavior, non-suicidal
criteria SI with preparatory actions in the past self-injury urges and/or behaviors, and/or severe
3 months impairments to daily functioning
Exclusion No severe eating disorder, primary No cognitive/intellectual functioning below an 8th grade
criteria psychotic disorder, bipolar disorder I, or level, no primary diagnosis of a substance use disorder,
substance use disorder requiring a psychotic spectrum disorder, or eating disorder. No
immediate treatment. history of severe aggression
No history of severe aggression
Open or Staggered entry (open for first 2 weeks Staggered entry (open every 2weeks)
closed of each module)
groups
Team 90-minute DBT consult team 90-minute consult team
meetings 60-minute staff meeting 90-minute treatment team
Insurance Private insurance, single case All commercial insurances, no public insurance option
accepted agreements, scholarships (i.e., medical)
No public insurance option (i.e.,
medical)

Because standard DBT is the evidence-based cannot wait for treatment. Therefore, intake
treatment for self-harming adolescents at high consultation meetings are offered only when
­
risk for suicide, RISE requires clients to have there will be availability to start the program
made a recent suicide attempt, engaged in repeti- within 2 weeks.
tive NSSI, and/or had SI that included prepara- When adolescents present with other primary
tory actions (e.g., researching suicide methods, presenting problems [e.g., depression, obsessive
purchasing materials for a suicide attempt, hoard- compulsive disorder (OCD)], we refer to the
ing medications; Posner et al., 2011) in order to evidence-­based treatment for that diagnosis. For
enroll in the program. New teens can enter the example, if a teen presents with severe depres-
program every 4 weeks as each of the three mod- sion, some suicidal ideation (without preparatory
ules is 4 weeks in length and first complete a pre- actions or intent), and significantly impaired
liminary telephone screening to determine initial functioning, we might recommend a program
eligibility and then a longer intake consultation that uses CBT and behavioral activation as their
meeting to solidify fit and teen/parent commit- core components.
ment to the program requirements. The RISE
program does not carry a waitlist as suicidal teens
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 287

 hildren’s Hospital of Orange County

C supervision of licensed staff. All licensed clinical
IOP (CHOC) Overview staff have been trained by Behavioral Tech
The IOP at CHOC has a comprehensive DBT (https://behavioraltech.org/, the official DBT
program embedded within an eight-week pro- training program run by Dr. Marsha Linehan, the
gram for teens in high school (grades 9 through treatment developer). A care manager is available
12). Each module (Distress Tolerance, to assist families with insurance coverage, which
Interpersonal Effectiveness, Emotion Regulation, is typically provided through single case
and Walking the Middle Path) is covered by two agreements.
consecutive weeks of program time, with Core
Mindfulness skills woven through every day of  HOC Program Development
C
program. While most teens are experiencing sui- CHOC developed a DBT IOP with a primary
cidal thoughts or behaviors and/or NSSI, this is goal of serving teens at high risk for suicide.
not required for admission. To be considered for The IOP at CHOC represents a blossoming
admission to the CHOC IOP, teens must meet growth into the “purely” mental health area of
medical necessity criteria for an IOP level of services for the hospital system. Until 2017, all
care – a definition that broadly states that a teen’s the mental health services available within
psychopathology is severe enough that it cannot CHOC were either pediatric psychology (medi-
be managed at a standard outpatient level of care. cal plus mental health) or neuropsychology spe-
Similar to RISE, admissions are staggered. New cialties. This context is vital to consider in the
teens start the program every 2 weeks when a development of the IOP as there was tremen-
new module is opened. dous concern from the hospital regarding the
safety of IOP patients, other patients, and
employees. To address these concerns, we
Program Development opened our program and team to the department
and Implementation and hospital at large to demystify acute mental
health services. People from different areas
 ISE Program Development
R were welcomed into our team meetings. Our
The RISE Program was developed in response to team provided training to other services about
a high demand in the community for services for the skills we teach in program. Once we found
youth at risk for suicide and a lack of existing support to start the program, the CHOC reputa-
services, particularly at the IOP level. In 2008– tion in Orange County led to referral sources
2009 and again in 2014–2015, Palo Alto experi- promptly adding the IOP to their list of trusted
enced a cluster of suicides among local high resources. Additionally, insurance providers
school students (Garcia-Williams et al., 2016). were also relatively quick to negotiate contracts
These events highlighted the need for additional so that the IOP at CHOC would be in-network
services for suicidal youth in the local commu- for their members. As covered DBT providers,
nity. The program was developed as a partnership there are now a large number of people seeking
between a local community clinic (Children’s admission to the IOP as the only way to access
Health Council) and a university-based Child and comparatively low-cost DBT treatment. New
Adolescent Psychiatry clinic (Stanford Children’s patients are admitted every 2 weeks with the
Health), leveraging the complementary expertise goal that no family will wait longer than that for
of both groups. Providers include psychologists, services. Families in need of immediate support
social workers, Licensed Marriage and Family are offered a bridge session during which spe-
Therapists (LMFTs), psychiatrists, and occupa- cific crisis skills are taught (e.g., TIPP, self
tional therapists. Trainees in psychology and psy- soothe) and other DBT orientation and commit-
chiatry also serve as program clinicians under the ment strategies are employed. If there are more
288 S. Clarke et al.

teens waiting for admission than we have spots urges to engage in self-harming or suicidal
for, the clinical team assigns the admission slots behavior are high, who and at what point the teen
based on level of risk and the teen’s current will inform a parent or caregiver about the urges,
access to services. how a parent will respond, and what parents and
The team includes one psychologist, one psy- teens should do in case of emergency.
chiatrist, two LMFTs, one art therapist, one While standard DBT includes the use of
financial coordinator, and psychology trainees. behaviorism in group and individual sessions to
Psychologists, LMFTs, and psychology trainees understand and respond to behavior, both pro-
act as skills coaches and individual therapists, grams have expanded the use of behaviorism, in
while the art therapist supports DBT-based mind- formal and informal ways, given the need to
fulness and expressive arts groups. Psychiatrists manage a teen milieu in an IOP setting. Both pro-
meet with patients as needed for medication grams heavily rely on these principles to decrease
management. Trainees include three predoctoral ineffective or undesirable behavior (e.g., being
externs and two postdoctoral fellows. disruptive in the milieu) and increase effective
behavior (e.g., paying attention and participating
in group).
Day-to-Day Programming

Both CHOC and RISE make use of comprehen- RISE Programing

sive DBT in form and function. Both programs
provide the four components endemic to compre- RISE runs Monday through Thursday from
hensive DBT: individual psychotherapy, 3:00 pm to 6:15 pm and includes all standard
­multifamily skills class, telephone consultation, DBT components. Within this time frame, teens
and a consultation team for therapists. All three participate in two individual psychotherapy ses-
DBT skills modules (Distress Tolerance, Emotion sions per week, one medication management per
Regulation, and Interpersonal Effectiveness; week, two multifamily skills classes (with par-
Linehan et al., 2015) are taught to teens and their ents/caregivers also in attendance), and teen-only
parents with mindfulness and Middle Path skills groups, which include further work in DBT skills
incorporated throughout treatment. In addition to or concepts, or are provided with DBT content
the standard DBT components, both programs and principles (e.g., visual depiction of dialectics
also have additional patient and/or parent groups project in art group). In adherence with the goals
and staff meetings to discuss patients and address of standard DBT, the primary goals for patients in
the wide variety of issues that arise in an IOP set- our program include reduction and elimination of
ting (e.g., activities that need revision, supplies suicidal and self-harming behaviors and acquisi-
that need to be ordered, rules that need tion of DBT skills. While other symptoms and
attention). problems will be addressed, reduction and elimi-
Given that a primary focus of both programs is nation of suicidal and self-harming behaviors and
reducing suicidal and self-harming behavior, acquisition of DBT skills will always take prior-
both programs conduct in-depth safety planning ity in every interaction (e.g., individual psycho-
with both teens and parents, such as restricting therapy, telephone coaching) and in the treatment
access to means of self-harm (e.g., scissors, paper overall. While all team members are kept up to
clips, and other objects with sharp edges) and date on each patient’s progress and functioning, it
close parental monitoring of the teen. Crisis man- is the individual therapist who provides telephone
agement outside of program revolves around a coaching and drives the treatment and any inter-
written safety plan (Stanley & Brown, 2012) that ventions designed for the milieu (e.g., planning
is created with the adolescent and family during for staff to ignore distracting comments during
the first individual psychotherapy session. It group in order to decrease the behavior). With the
includes coping skills to use when emotions or exception of telephone coaching, all psychother-
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 289

apy and other treatment sessions occur during team members kept apprised of every patient’s
program hours with only occasional exceptions progress and challenges for optimal group and
(e.g., an extra parent-only session to discuss an milieu intervention, any skills coach may con-
urgent issue that cannot be resolved during a duct individual, family, and crisis intervention
brief coaching call). sessions if necessary. Additionally, while ser-
When patients become emotionally dysregu- vices are generally provided within program
lated during group, standard DBT approaches are hours, teens and families can come in for psycho-
used. These include practical interventions that therapy or coaching sessions during non-program
help the adolescent regulate and return as quickly days and hours.
as possible to the task at hand (e.g., group) and
are done in a way so as not to reinforce emotional
escalation. For example, if an adolescent is taken Collaborations and Generalizing
from group and given extended periods of time Treatment Gains
with their favorite individual therapist, emotional
escalation will be reinforced and is likely to occur Both RISE and the CHOC programs connect
again. Therefore, the adolescent is given skills-­ with previous providers when teens are admitted
based coaching in the least reinforcing way pos- to the program. Additionally, both programs
sible with the aim of assisting the adolescent in work with teens’ schools, as needed, to acquire
returning to the task at hand (i.e., group accommodations or put safety plans in place so
activity). the teen can attend school safely. Many families,
after learning DBT, wish to continue care with a
DBT therapist and therefore are in the position of
CHOC Programing needing to find a new therapist after completing
the IOP. We have a very difficult time locating
The IOP at CHOC runs Monday, Tuesday, outpatient providers who take insurance, treat
Thursday, and Friday from 3:30 pm to 6:45 pm. teens, practice some form of a behaviorally based
Scheduled programming is predominantly group therapy, and are not intimidated by a history of
based with one weekly individual session, a one-­ SI/NSSI. For more information about care link-
time psychiatry consultation and as-needed age, see section “Aftercare and Staying
ongoing psychiatry services, and family sessions. Connected.”
There are both teen- and parent-only groups. The While all therapies want clients to generalize
weekly multifamily group is designed for active, skills to their natural environment, DBT – and
experiential practice of skills between teens and the RISE and CHOC IOP programs – have for-
parents, within and between family units. Family mal ways of generalizing the skills to the envi-
sessions are scheduled as clinically indicated but ronment. Both programs have skills coaching to
unlike RISE are not a fixed part of the program help teens and parents apply skills in real time
(i.e., some families receive weekly sessions, oth- to problems that arise, and both programs
ers receive baseline, midpoint, and discharge ses- require outside skills practice through multi-
sions). Individual sessions are increased in family skills group homework for all skills
frequency for teens needing more stabilization or taught. Additionally, clients receive more prac-
as reinforcers for desired behavior. All clinicians tice discussing and practicing skills in addi-
including psychologist, psychiatrists, LFMTS, tional groups.
psychology trainee, and art therapists are called
skills coaches to emphasize the focus on skills
and the active clinical approach used. While each Working with Parents
family is assigned a primary skills coach, who
will principally manage their treatment, treat- Parents are significant participants and collabora-
ment is ultimately team based. Not only are all tors in treatment. Both RISE and the CHOC pro-
290 S. Clarke et al.

grams require a significant level of involvement discharge from IOP. Unique to the CHOC IOP
from parents or caregivers. In addition to needing are the 75-minute parent only skills groups.
to be immediately available in case of emergency Parents are taught the week’s worth of skills with
during program hours, attend several groups, and primarily lecture and discussion-based teaching
work closely with IOP staff to obtain risk, safety, strategies. A great deal of troubleshooting and
and other updates, caregivers must also provide problem solving is applied to the skills so that
high levels of supervision of their teens outside of parents understand how to most effectively apply
program given that intervening successfully on the concepts at home. The final 15 min of the par-
suicidality and self-harm require close monitor- ent skills group is a skills practice activity where
ing. Because of this, we routinely discuss the parents are practicing newly taught skills with
Family Medical Leave Act (FMLA) with parents each other.
and caregivers and assist with needed documen-
tation. While inclusion of the family is present in
most evidence-based interventions for suicidal  ritical Considerations and Lessons
C
youth (Ougrin et al., 2015), this may prevent Learned
single-­parent families, families with unique cir-
cumstances such as no transportation, or families In this final section, we review the complexities
that live in rural areas from participating in our of applying DBT in an IOP setting for self-­
programs. Both programs also offer additional, harming adolescents at high risk for suicide while
as-needed support for parents when they are trying to remain adherent to core DBT principles
struggling to effectively manage their teen’s and components. We review the lessons we have
behaviors at home. learned, offer helpful resources for organizations
seeking to create a DBT-based higher level of
care, and discuss unresolved issues we have
RISE Skills Generalization faced. Ultimately, research is needed on the
effectiveness of DBT-based higher levels of care
Currently, parents also have the opportunity to for these high-risk adolescents.
participate in a research study, which offers
DBT parenting skills in its treatment arm. While
occasional work with a family dyad (e.g., Adopt or Adapt
mother and adolescent) may occur, typically to
address safety concerns or issues that are closely DBT is a time- and labor-intensive treatment,
linked to suicidal or self-harming behavior, and there has been some debate about what
family therapy is not provided. Should there be components are essential. Linehan et al. (2015)
a need for this, families are encouraged to gain published a dismantling study of DBT, finding
DBT skills during the IOP, and referrals to fam- that while variations of DBT (e.g., individual
ily therapy are made at the next phase of their DBT psychotherapy only) were effective in
treatment after IOP completion. It is often use- reducing suicidal behavior, it was only the full
ful for the family to get skills in place to manage model that resulted in improvements in other
emotions and conflicts before embarking on imperative treatment targets (i.e., retention,
family therapy. reduction in self-harming behavior, and
improvements in other mental health symp-
toms). Therefore, evidence continues to suggest
CHOC Skills Generalization that provision of standard DBT is optimal. In
outpatient clinic settings, this is often more of a
For those teens with identified outpatient thera- challenge when there are fewer resources to pro-
pists, we make every effort to collaborate so that vide all components. The training and staffing
therapists are prepared to accept teens back upon requirements for a standard DBT outpatient pro-
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 291

gram are significant as DBT providers require and formats. For example, after teaching “accu-
intensive training and experience; there are mulate positive experiences,” teens pair up and
three modules worth of skills to learn in addi- compete to generate a list of positive experi-
tion to myriad treatment protocols and thera- ences from A to Z and then identify in what way
pist’s manner in interaction with clients the activity itself was pleasurable. Additionally,
depending on the situation at hand. Additionally, after teaching the pros and cons of skills, teens
providers must be willing to provide coaching are given a target behavior and then deliver the
outside of regular office hours, and DBT pros and cons in a debate-­style format. Both
requires both group skills class and individual programs work to ensure that even these cre-
sessions. A strength of a higher level of care is ative adjunctive groups continue to follow basic
that these components, except for telephone principles of DBT and strive to enhance practice
coaching, are part and parcel for these services of skills rather than introduce new therapeutic
(e.g., weekly team meetings, groups, individual concepts from other modalities.
therapy). This does, however, require programs
to ensure they are providing the evidence-based
treatment by offering, and not straying from or Insurance
changing too much, the four core components
even when treatment is supplemented with addi- Insurance coverage for these types of programs
tional groups and activities. can vary. CHOC’s program is covered in-network
Given that DBT upholds the tenet of function by many commercial insurance companies while
over form, programs can be creative with imple- RISE is not. Instead, RISE staffs a care manager
mentation; however, again they should take care who works to obtain single case agreements with
not to change these modes so much that they client’s insurance providers and is successful
lose their essence and, therefore, effectiveness. most of the time. Even when an insurance com-
Programs will also need to think through the pany provides initial coverage, ongoing coverage
services offered in addition to the core after some evidence of remission of symptoms
­comprehensive DBT components, and whether and behaviors has presented problems; however,
those additions are adding or detracting from the evidence for DBT stands only for those who
the core DBT treatment. One reason patients are have completed the entire course of treatment,
not allowed to be in other treatments while in and, in combination with the cost-effectiveness
DBT is not to confuse the patient with other of DBT overall (see next section), this can be pre-
treatment approaches, styles, and skills given sented to insurance companies in peer-to-peer
the multitude of skills the patient has to learn in reviews or case appeals to support continued cov-
DBT. At both the RISE and CHOC programs, erage. When the program is not covered by insur-
we have made other groups DBT consistent. For ance, families can pay for the program out of
example, both programs have DBT-based mind- pocket or apply for financial assistance through
fulness and art components. However, to remain Children’s Health Council (CHC). CHC’s policy
DBT consistent, neither program has added a is that families in need of this service will not be
group based on other treatment approaches turned away based on inability to pay.
(e.g., psychodynamic approaches). At RISE, for
example, we have a Life Worth Living group
where teens develop what constitutes their Life DBT Cost Effectiveness
Worth Living and make weekly Build Mastery
goals to make steps toward the life they want to Accumulating evidence over the past two decades
live. At CHOC, teen-­ only skills groups are shows that DBT reduces treatment costs both
highly experiential and creative, offering many while clients are in DBT and afterward. The
opportunities to learn skills in different ways American Psychiatric Association (1998) esti-
292 S. Clarke et al.

mated that participation in comprehensive DBT Adolescent Milieu and Contagion

reduced treatments costs by 56% for adults in a
community sample when comparing the cost of A primary concern in DBT IOPs is the issue of
1 year of DBT treatment and the treatment costs contagion. According to the US Department of
of the year prior to entering DBT. This study Health and Human Services, suicide contagion is
revealed that DBT participants’ use of notori- defined as “exposure to suicide or suicidal behav-
ously expensive emergency department visits and iors within one’s family, peer group, or through
psychiatric hospitalizations were significantly media reports of suicide and can result in an
lower following completion of DBT services. increase in suicide and suicidal behaviors” (US
Another study of US veterans in DBT treatment Department of Health and Human Services,
revealed that those who received DBT decreased 2019). Social contagion originates from social
their use of mental health services the following learning theory and the notion that behavior is
year by 49% (Meyers et al., 2014). These argu- learned by observing others’ modeled behavior
ments are often used when insurance companies (Bandura, 1971). Individuals are more likely to
are pushing back on paying for individual and replicate an action when they see themselves as
group in the standard outpatient model; however, having something in common with the person
this same evidence can be used to argue for cov- modeling the behavior, such as being of the same
erage within an IOP setting that houses a compre- age or gender, when the other possesses desirable
hensive DBT program within it. In fact, such qualities, and when the behavior is seen to be
programs are often the final opportunity for out- effective (Insel & Gould, 2008). Adolescents
patient treatment before a client is referred for often look to peers’ behaviors to guide their
residential placement which, again, may not be choices and are therefore at increased risk of con-
evidence based, are expensive, and are disruptive tagion (Insel & Gould, 2008; Berk & Clarke,
to the teen and family. 2019).
In order to address the issue of contagion in
both programs, there are several in-program and
Admissions Criteria post-program guidelines. At RISE, group mem-
bers are encouraged at orientation to think of
Given the programs’ focus on repetitive self-­ each other as teammates who are learning skills
harm and suicidality, providers and community together for the time they are in the IOP together.
members can feel frustrated or confused about At both RISE and CHOC, we emphasize the
why teens who clearly need more help (e.g., importance of first learning to rely on adults for
aren’t getting out of bed, have conflictual rela- safety (i.e., clinicians, parents) and explicitly dis-
tionships, and have significant difficulty regulat- cuss how relying on other teens could increase
ing emotion) are not admitted. The reasoning risk for both teens. In line with standard DBT
here is twofold: while a comprehensive DBT pro- rules, patients are not allowed to form private
gram teaches skills that are helpful to everyone, relationships or have contact with one another
including a wide range of presentations and dis- outside of the group while in DBT. Teens are
orders, the overall focus of the program is on monitored during breaks to decrease risk for
reduction of self-harming and suicidal behaviors. forming private relationships outside of group,
Therefore, there will be a disconnect with regard and if it is discovered that teens are in touch out-
to the primary focus of a standard DBT program; side of group – a rare occurrence – the conse-
additionally, in order to reduce the risk of conta- quences range from a warning to dismissal from
gion (see below), we do not want to introduce a the program. Additionally, at RISE we make
teen into a setting where peers are engaging in explicit recommendations to teens and families
these behaviors, but the teen is not. that they do not exchange contact information to
keep in touch or build friendships after both are
finished with the program, in which parents are
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 293

encouraged to monitor and enforce. Given the Working with Minoritized Groups
reality that many teens and families do form
friendships and are in touch with one another Given the suicide rates for youth who identify
after program, at CHOC, we focus on the impor- with minority groups, it is essential that staff are
tance of safety and connecting skillfully post trained to work with marginalized youth and that
program. your organization be a safe space for all. For
In both programs, we have found that teens example, at both RISE and CHOC, there are gen-
who meet in program and go on to form outside erally a robust subset of teens who are either
relationships have the program as the basis of questioning their gender or sexual orientation or
their friendship. We have received several calls already identify with marginalized gender iden-
over the years from former members who are tity or sexual orientation groups. In both pro-
calling because they are concerned about another grams, it is common practice to state our gender
former member, with whom they are in touch, pronouns during introductions. Providers have
who is engaging in self-harming or suicidal information and resources to help teens with all
behaviors, or who is heavily depending on the aspects of their gender and sexual orientation
calling teen to help them manage urges. While identity process (e.g., working with clients and
this is anecdotal and would benefit from empiri- families with psychoeducation and support of the
cal exploration, based on our experience across teen, offering outside referrals and resources for
both programs, we simply recommend that teens families, and offering referrals to local gender
do not form outside relationships even after clinics, to name a few). Additionally, publica-
program. tions are emerging with ideas and recommenda-
Also, we do not have any process groups tions for delivering DBT with gender- and
owing to the risk of contagion. Instead our groups sexual-orientation-inclusive (Weiler et al., 2021)
are instruction based or activity based. Guidelines and black, Indigenous, and people of color
across groups include use of the term “problem (BIPOC)-inclusive (Bolden et al., 2020; Mercado
behavior” to refer to any self-harming, suicidal, & Hinojosa, 2017) adaptations.
or other behaviors or symptoms that may be trig-
gering for others if discussed in group. These top-
ics are dealt with in depth in individual therapy Creating a Safe Environment
rather than the group setting. Both programs pro-
vide group-specific scaffolding for how to par- While many IOPs provide high levels of supervi-
ticipate effectively and keep everyone safe, with sion, it is imperative that there be plans for con-
the hopes that these skills will generalize beyond stant supervision of self-harming and suicidal
treatment and into adolescents’ friendships. For adolescents during these programs. This is criti-
example, in group, teens give enough background cal both for attending to individual risk factors
for the group members to understand the most and group risk (e.g., comparing self-harm scars,
important components of their problems, and “competing” for most severe suicide attempt, ref-
then the group focuses on skills the teen can use erencing substance use). At RISE, when we were
and provides validation. To elaborate, it is there- in person, parents needed to accompany teens to
fore less important that a teen describe self-harm RISE, walk them into the classroom, and check
urges in detail that result from conflict with par- them in with a staff member. Only in rare circum-
ents; rather, for the group to provide validation or stances, when the teen has shown to be safe to
support, they need only know that the teen strug- transport themselves, are teens allowed to come
gles to regulate emotions and may have difficul- to or leave program on their own. At CHOC,
ties with problem behavior urges during family there is a permission slip signed for this privilege
conflict. that may be revoked by the treatment team or par-
ents at any time either due to teen behavior/risk
294 S. Clarke et al.

or parents’ failure to answer a call while the teen neutral, and with a focus on helping the teen
is at the clinic. During program, teens are super- return to group rather than reinforcing emotion
vised at all times, which requires enough staffing dysregulation or other issues that disrupt the
to, for example, walk teens to and from individ- teen’s learning and participation in group with
ual appointments and for bathroom breaks. individual therapist time and attention.
Supervision of teens is shared jointly among indi-
vidual therapists and milieu staff.
Additionally, just as we walk parents through Helpful Resources
restricting access to means at home, we also
restrict access to means during program. At Since there is a dearth of research on the effec-
RISE, we have an IOP classroom, and each day, tiveness of embedding a comprehensive DBT
staff sweep the room to ensure any potentially program within a higher level of care, Behavioral
hazardous items (e.g., sharps, such as scissors, Tech and the Linehan Institute are the best
tacks, staples) or areas (e.g., open windows) are sources for implementing adherent DBT.
secured. At CHOC, we do not use staples, paper
clips, scissors, or lead pencils that would require
sharpening, and IOP spaces used by teens are  ngoing Initiatives and Areas
O
exclusively for IOP. Any of these office supplies to Improve
are maintained in our secured reception area.
There are several program areas that remain
works in progress. We describe these issues and
Use of DBT Principles our current solutions below.

In accordance with DBT, we use principles of  rogram Intake Process

P
behaviorism, favoring positive reinforcement, Given the high acuity level and need to start ser-
and extinction over punishment to manage our vices as soon as possible, while also balancing
milieu. To shape and reinforce the behaviors we the need to screen potential patients in enough
want to see, we give teens behavioral definitions depth to determine if they are likely to benefit
of, for example, paying attention (e.g., making from DBT, the optimal process for screening and
frequent eye contact with the leader or looking intake remains a work in progress. At RISE, fam-
up, are on the correct page in binder). At RISE, ilies expressing interest are first scheduled for a
we use a token reinforcement system where we one-hour phone screen where admissions staff
give stamps for these behaviors which they can obtain an overall sense of the teen’s fit for our
cash out for prizes. At CHOC, we use privileges program, provide information about the program,
such as first to pick snack and first to check out and ensure families are aware of expectations and
personal belongings as incentives. In accordance commitments. If families are still interested and
with DBT practice, when teens engage in therapy-­ are eligible, they are invited for an evaluation and
interfering behavior (e.g., not completing diary commitment session (approximately 2 h). While
card or being late to program) or community-­ admission staff do their best to determine whether
destroying behaviors (e.g., severe and significant clients meet admission criteria in the phone
interruption of groups), they are required to do a screen, it is not uncommon for a teen to attend the
chain analysis to bolster understanding of the full evaluation and commitment session and be
problem, generate a plan for handling future determined ineligible for the program given that
problems differently, and make a repair or cor- it is only in the context of a more extensive evalu-
rect/overcorrect to the group. Additionally, we ation that more is learned about symptoms and
are thinking of principles of behaviorism in every presentations that preclude inclusion in our pro-
interaction. For example, if a teen needs skills gram. This is understandably frustrating for fami-
coaching during group, we keep coaching brief, lies and referring providers. At the same time,
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 295

starting RISE is a time-intensive endeavor for IOP) several weeks into program. Given the chal-
families, staff, and the case manager who works lenges with finding outpatient providers, we
to obtain single case agreements, and therefore decided to lean towards a lower threshold for
we do not want to waste the family’s or staff’s evaluation so that families seeking support would
time by admitting teens who we ultimately can- at least receive brief psychoeducation about their
not serve, which also means further delay of the teen’s difficulties, a safety plan (when needed),
teen obtaining much-needed treatment. We used and would be more likely to follow through on
to do longer evaluations (3 h) in an effort to be recommendations. Similar to RISE, CHOC’s
able to determine immediately whether a teen evaluation process can likely be improved to pro-
met criteria for the program; however, we decided vide a more thorough picture of diagnosis and
that it was too much of a hardship on teens and family functioning prior to entry.
families and time intensive for our staff for teens
who still may not ultimately be offered admission  retreatment Commitment in the IOP
P
to the program. Instead, we realize we may not Setting
get a complete clinical picture in the time we Another challenge at the IOP level of care is
have, and we therefore made the first 2 weeks of youth commitment to participating in treatment.
a teen’s program participation probationary as we Paradoxically, youth are often referred to a
further assess and understand the client’s full “higher level of care” (IOP) when they have been
clinical picture. During this probationary period, unable to comply with the requirements of a
teens and families are required to complete all “lower level of care” (standard outpatient care).
program requirements. This aspect of RISE could This presents a dilemma for how to engage youth
use further revision, and we continue to work on to participate effectively in an IOP. A critical
finding a model for intakes that reduces burden component to initiating DBT treatment is the pre-
on families and teens. treatment commitment phase (Linehan, 1993),
At CHOC, families complete a brief 15-­minute where clients agree to work on reducing self-­
phone screen to determine whether the teen pos- harming and suicidal behavior, attend all treat-
sibly meets medical necessity criteria and our ment components, and engage fully in treatment.
program inclusion criteria and to ensure that fam- While with adolescents we will often take what
ilies understand what an IOP level of care entails we can get, we still require some degree of will-
and then are scheduled for a two-hour evaluation ingness (i.e., they are not refusing to attend or
with a program clinician if they seem like a good refusing to engage in the treatment being offered)
fit for IOP. Many families call the IOP at CHOC to attend group and work on reducing and elimi-
seeking individual therapy only, psychiatry only, nating self-harming and suicidal behavior
or would like IOP for other presenting problems (Rathus & Miller, 2015). We have had little suc-
(e.g., OCD, severe social anxiety). DBT is trans- cess with clients who are steadfast in their desire
diagnostic and emphasizes problem behaviors, not to be in our program. In a standard outpatient
and therefore the evaluation is not a comprehen- setting, the therapist and patient have up to four
sive diagnostic assessment. Instead, the time is sessions to address commitment and make a deci-
focused on broad symptoms of pathology (e.g., sion together about whether the client will move
sleep and appetite disturbance, energy levels, forward in DBT. In the IOP context, complexities
mood) with screening questions for primary related to the need for quick decisions for highly
exclusion criteria, current functioning, and a acute patients, billing, and agency structure
detailed assessment of risk-related behaviors. require us to shorten that process. We work to
This approach reduces the barriers to families as obtain basic commitment during the phone screen
well as limits program resources required for and intake and do not move forward with clients
evaluation; it also means that we occasionally who are either unwilling to work on reducing
discover teens have other significant mental self-harming and suicidal behavior and/or unwill-
health concerns (not effectively treated by our ing to attend treatment. To address this, at RISE,
296 S. Clarke et al.

we have a two-week trial period in the event that attend treatment without their adolescent. We felt
adequate commitment is not present and thera- this honored the DBT rule that individuals cannot
peutic interventions are unhelpful. At CHOC, be in outside treatments concurrently while in
families complete an Orientation session in the DBT while providing intervention for refeeding.
week prior to admission. Additionally, we require all of our clients with
At CHOC, teens who are more disinterested in AN to be monitored regularly (e.g., weekly) by
treatment are on a day-by-day evaluation of their PCP and are required to have a gowned
whether the IOP is the right fit for their needs. weight, orthostatic vitals, and any other neces-
While we expect teens’ commitment to wax and sary labs or tests, which must be communicated
wane during the program, similar to RISE, we to our program psychiatry team by the PCP’s
have found that significant displeasure of being office. At CHOC, we continue to struggle with
in program and showing no willingness impairs this dilemma. Our general guideline is that teens
the ability of the therapist to be helpful to the teen must have their eating disorder managed (i.e.,
and family, and therefore another course of action medically stable, following meal plan) and must
is needed (i.e., typically a residential level of also be monitored by their PCP or our internal
care). Additionally, it is important to consider eating disorders clinic in order to be eligible for
whether the behavior of members who are not the DBT IOP. This means that any teen in the pre-
committed interfere with the group morale or contemplation stage of change for their eating
other individuals’ treatment, which is a unique disorder typically does poorly in our program.
concern to the IOP format given the addition of
the milieu component.  alancing School and IOP
B
It is not uncommon for families to have concerns
 reating Comorbid Disorders
T about the impact of IOP participation on school
and Special Considerations for Care and academics. First, teens often need to leave
At RISE, our team has explored how we might be school early to attend RISE. However, even if a
able to serve adolescents with both significant teen can attend a full day of classes before attend-
suicidality and self-harm behaviors as well as ing IOP, this is discouraged as it is often too bur-
other symptoms and diagnoses (e.g., AN, sub- densome for the teen. We work with families and
stance use disorders). We have received a ­growing schools to help reduce course load and homework
number of calls from families of teens who have and obtain extended time for tests, and other
significant self-harm and suicidality and signifi- accommodations as appropriate. In both pro-
cant symptoms of, or full-blown, AN. These cli- grams, we often help families prioritize by con-
ents’ symptoms presented as too severe not to be sidering the most pressing problems at hand (i.e.,
addressed directly over the 12 weeks of RISE, the teen’s suicidality) and then work with the teen
and they were more or less left with the option of and parents to find a plan for balancing academ-
a residential placement as eating-disorder- ics and treatment that will support success in both
focused IOPs and PHPs would not accept our endeavors.
teens due to their self-harming and suicidal
behaviors. We were then faced with the dilemma  ftercare and Staying Connected
A
of whether to refer an adolescent to residential With regard to obtaining services in our geo-
care where they would likely not receive evi- graphic area (the northern California/bay area),
dence-based treatment for suicidality and self-­ parents and caregivers have generally reported
harm (i.e., comprehensive DBT) or AN (i.e., troubling stories about the guidance they have
Family-Based Treatment, FBT) or to try to keep received from hospitals or other providers when
these teens in our program. Within the eating dis- teens are transitioning out of their care but need
orders literature, there is growing empirical sup- further treatment. We hear stories of families
port for parent-separated FBT (LeGrange et al., being discharged from psychiatric hospitaliza-
2016; Hughes et al., 2015), where parents can tions without referrals or a care plan, and teens
16 Adolescent Dialectical Behavior Therapy Intensive Outpatient Programs 297

returning home from residential treatment in sim- group. This group has intermittently created chal-
ilar conditions. In Orange County, the standard of lenging milieu situations with teens befriending
practice is often “ask your insurance.” While nei- and dating each other, requiring regular interven-
ther of our IOPs have case managers who can tion and discussion around the relationship rule.
help families secure treatment, we begin discuss- We are still in the process of devising some form
ing next steps almost immediately given the of aftercare that reinforces skillful behavior,
lengthy wait times and paucity of providers who allows teens to maintain a connection to our com-
can provide evidence-based care for the problems munity, and attends to the various safety consid-
with which our teens present. We provide fami- erations. Teens are able to reenter program; we
lies with recommendations for next steps in terms do not readmit within 6 months unless the patient
of the level (e.g., standard outpatient, partial hos- left program without completion in their first
pital) and type of care (e.g., stage 2 DBT, expo- round. In an evaluation for a second admission,
sure and response prevention for OCD), and we more emphasis is placed on how things are differ-
give families any referrals we have. We also help ent for the teen at that time, how parents will
families with strategies for working with insur- engage differently, and what therapy interfering
ance providers to help them find both psycho- behaviors will need to be addressed.
therapy and medication management for their
teens. In addition to collaborating with future  irtual and Hybrid Program Models
V
providers to ensure they have clinical informa- In March of 2020, we launched an entirely virtual
tion they need as well as an understanding of the version of RISE in response to the COVID-19
DBT treatment the client has received, at RISE, pandemic (Clarke et al., 2020), and 1 year later,
we also provide in-depth discharge summaries as of the writing of this manuscript, we continue
for families to give to future providers. At CHOC, to remain completely virtual. CHOC’s program
we use a printable treatment plan, discharge plan, also transitioned into a virtual service model. In
and skills list that are collaboratively generated determining how to provide DBT with safety and
throughout the IOP so that families are familiar fidelity within a telehealth format, we had many
with all information that will be sent home upon safety and treatment concerns, particularly given
discharge. While it is general practice for parents the lack of empirical evidence for virtual delivery
to bear the brunt of the burden of finding ­available of adolescent DBT programs. Anecdotally speak-
providers, this is an area we would like to further ing, the telehealth format did not critically impact
develop in order to reduce the strain on families DBT effectiveness, compromise adolescent
during the already stressful time of leaving our safety, or significantly hinder therapeutic alli-
program. ance. Conversely, offering a telehealth arm of the
CHOC has extremely limited outpatient ser- IOP program made treatment more accessible to
vices. The local DBT clinics are typically not families that may not have otherwise been able to
covered by insurance, and many private practice participate due to challenging home situations
clinicians in the area are unwilling to treat youth (e.g., ill parent, other child in need of care, no
with chronic suicidal ideation, even if the ide- transportation) or living too far away. It is our
ation is well managed. Prior to the COVID-19 hope that our programs will continue to be able to
pandemic, we also offered a once weekly drop-in offer a telehealth arm beyond COVID-19 precau-
“aftercare” group for patients that are in ongoing tions and restrictions, which may provide a
outpatient therapy and have eliminated stage I much-needed option for suicidal adolescents to
behaviors (e.g., NSSI, suicide attempts). This access desperately needed care.
group encourages peer leadership where the teens
are leading skill review and facilitating discus-
sion while clinicians supervise and guide the
298 S. Clarke et al.

Conclusion Berk, M., & Clarke, S. (2019). Safety planning and risk
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As adolescent suicide rates continue to increase, ence into practice (pp. 63–86). American Psychiatric
IOPs are uniquely poised to provide much-­needed Association Publishing.
evidence-based treatment to self-harming adoles- Bolden, L. S., Gaona, L., McFarr, L., & Comtois, K.
(2020). DBT–ACES in a multicultural community
cents at high risk for suicide while also keeping mental health setting: Implications for clinical prac-
them in their home environment. As the gold stan- tice. In The handbook of dialectical behavior therapy
dard in the treatment of adolescent suicidality and (pp. 307–324). Academic Press.
self-harm, DBT is the natural choice when consid- Center for Disease Control and Prevention. (2021). 10
leading causes of death by age group, United States,
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this population. Numerous factors must be consid- Chambless, D. L., & Hollon, S. D. (1998). Defining
ered when developing an IOP: creating a consis- empirically supported therapies. Journal of Consulting
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both the acquisition and generalization of adaptive Clarke, S., Atasuntseva, A., & Berk, M. (2020). Delivering
skills, various logistics from space to staffing to an adolescent comprehensive DBT intensive outpa-
training, and, above all, attention to safety. A tient program via telehealth during the Covid-19 pan-
group-based program capitalizes on social learn- demic. DBT Bulletin, 3(2), 5–6.
Garcia-Williams, A., O’Donnell, J., Spies, E., Zhang,
ing and decreases the sense of isolation many X., Young, R., Azofeifa, A., & Vagi, K. (2016). Epi-­
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This chapter provides an introductory guide to our self-injurious thoughts and behaviors in outpatient
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Journal of Abnormal Psychology, 114(1), 140–146. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., &
Nock, M. K., Joiner, T. E., Jr., Gordon, K. H., Lloyd-­ Goodyer, I. (2011). Clinical and psychosocial predic-
Richardson, E., & Prinstein, M. J. (2006). Non-­ tors of suicide attempts and nonsuicidal self-injury
suicidal self-injury among adolescents: Diagnostic in the adolescent depression antidepressants and
correlates and relation to suicide attempts. Psychiatry psychotherapy trial (ADAPT). American Journal of
Research, 144(1), 65–72. Psychiatry, 168(5), 495–501.
Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A.,
Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C.
 Co-occurring Disorders
17
Robert Miranda Jr

For more than two decades, the United States has outpatient program (IOP) for adolescents strug-
battled its worst-ever drug crisis, and the latest gling with co-occurring mental health and
statistics show this epidemic is escalating. In substance-­ related problems (i.e., co-occurring
2020, overdose deaths reached the highest annual disorders). The vast majority of adolescents who
number ever recorded and marked the largest present for SUD treatment struggle with a co-­
single-year percentage increase in the past occurring non-substance psychiatric disorder
20 years (Ahmad et al., 2021). More than one out (Robinson & Riggs, 2016). Integrated care that
of every ten Americans, or more than 27.5 mil- targets not only substance use but also comorbid
lion people, will suffer from a substance use mental health conditions is essential for maxi-
problem at some point in their lives (Jones et al., mizing treatment gains. Bradley Vista, which
2020), and the vast majority first start using alco- launched in late 2017, is considered a model
hol or other drugs during their teenage years. treatment program by the Substance Abuse and
Historically, substance-related problems were Mental Health Services Administration
deemed societal or criminal problems that were (SAMHSA, 2021). The goal for this chapter is to
beyond the scope of traditional health-care sys- provide clinicians, health-care administrators,
tems, especially pediatric settings. Treatment and other key stakeholders interested in imple-
options for a substance use disorder (SUD) were menting similar services with a proven road map
limited to self-help groups and select specialty for delivering developmentally tailored evidence-­
services that were generally not available to ado- based care to youth with co-occurring disorders.
lescents and not covered by insurance. There is Particular emphasis is placed on the integration
increasing recognition, however, among research- of science and practice. Merging the latest scien-
ers, clinicians, and policy makers alike, that inte- tific findings with the art of delivering empathetic
grating recovery services across health-care client-centered services that consider the unique
systems is essential for expanding access to qual- developmental, sociocultural, and clinical char-
ity treatment and curbing the drug epidemic. acteristics of each adolescent is key to our
Consequently, health-care systems—including approach. This chapter also describes some chal-
pediatric organizations—increasingly look to lenges to effective implementation along with
integrate substance use treatment into their ways to help ensure success.
broader scope of services.
This chapter describes the development and
implementation of Bradley Vista, an intensive Scope of the Problem

R. MirandaJr (*) The high prevalence of substance use and the

Center for Alcohol and Addiction Studies, Brown development of substance-related problems dur-
University, Providence, RI, USA ing adolescence is well documented.
Bradley Hospital, East Providence, RI, USA Recreational drinking and other drug use as well
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 301
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_17
302 R. Miranda

as the ­emergence of SUDs typically begin dur- et al., 2011; Goldstein et al., 2013; Groenman
ing adolescence (Degenhardt et al., 2016). More et al., 2017; Wilens et al., 2008). Additionally,
than three out of every four youths in the United adolescent substance use is associated with
States have consumed alcohol by late adoles- increased risk for a range of neurocognitive and
cence, and nearly half have used an illicit drug mental health problems, such as executive func-
(Swendsen et al., 2012). Yet, despite widespread tion deficits, suicidal thoughts and behavior, anti-
substance use among teenagers, it is not benign social behavior, binge-purge eating behaviors,
and potentially more harmful than adult use. and post-traumatic stress disorder (Giaconia
The adverse effects of adolescent substance use et al., 2000).
are irrefutable and include premature death, low Although researchers have proposed several
academic achievement, infectious disease, and possible explanations for the link between sub-
possible irreversible damage to the developing stance use and mental health issues, such as over-
brain (Hingson & White, 2014). Moreover, sub- lapping neurobiological pathways and shared
stance use is a major cause of disease burden in genetic and environmental factors (e.g., history
adolescents, especially for males, and it is of trauma), our understanding of these complex
directly linked with the three leading causes of associations is at a nascent stage. Even so, the
death among youth (i.e., accidents, homicide, clinical importance of these associations is well
suicide). documented. Younger adolescents are more likely
Adolescent substance use also confers height- to struggle with a co-occurring psychiatric disor-
ened liability for addiction. About 3% of adoles- der, and those with co-occurring disorders expe-
cents ages 13 or 14 years old struggle with an rience worse substance withdrawal symptoms,
SUD, and approximately 16% of 17- to 18-year-­ earlier relapse, and greater utilization of outpa-
old youth experience clinically significant tient and inpatient treatment (Grella et al., 2001;
substance-­related problems (Swendsen et al., Rowe et al., 2004; Vida et al., 2009). We know
2012). Moreover, mounting preclinical data sug- that integrated treatments that target both sub-
gests that repeated substance use, regardless of stance use and psychiatric symptoms yield better
type, during key neurodevelopmental time points outcomes (Brewer et al., 2017).
in adolescence yields long-term hypersensitivity
to the reinforcing effects of alcohol and other
drugs due, in large part, to alterations in dopami- Bradley Vista
nergic transmission (Volkow et al., 2016; Volkow
et al., 2012). This hypersensitivity is thought to Founded in 1931, Bradley Hospital was the
confer liability for rapid progression from recre- nation’s first psychiatric hospital devoted exclu-
ational to problematic substance use. Thus, ado- sively to children. Today, the hospital is an inter-
lescence appears to be a “critical window” for nationally recognized center for children’s mental
setting the stage for addiction, and earlier health care, as well as for training and research.
repeated use produces the greatest negative long-­ Each year, Bradley serves more than 4000 chil-
term effects. dren with complex psychiatric, behavioral, and
Adolescence is also a key period for the onset developmental disorders primarily from south-
of myriad non-substance-related psychiatric dis- eastern New England.
orders, and estimated rates of co-occurring psy- Bradley Vista is an IOP for adolescents who
chiatric disorders among adolescents with struggle with a wide variety of mental health and
substance use problems range from 60% to 75% substance use issues. The program maintains a
(Hoffmann et al., 2004; Turner et al., 2004). census of ten adolescents and has served over 150
Childhood-onset psychiatric disorders, such as adolescents ranging in age from 13 to 19 years
depression, anxiety, and attention-deficit/hyper- old, with an average age of 15 to 16 years old.
activity disorder (ADHD), potentiate risk for Youth present with a host of mental health issues,
adolescent- and adult-onset SUDs (Charach most commonly depression or anxiety, and many
17 Co-occurring Disorders 303

have a history of trauma. Most adolescents chiatric symptoms, and preparing the adolescent
struggle with alcohol or marijuana misuse,
­ for a lower level of care. The projected length of
though some primarily use other drugs (e.g., ben- stay is 6–8 weeks; however, treatment duration is
zodiazepines, inhalants, or opiates). governed by the specific goals for each adolescent
Treatment begins with a comprehensive eval- and their level of progress. Although Bradley
uation of the adolescent’s mental health, sub- Vista is an integrated hospital-based program
stance use, and safety. Eligibility is determined within the larger span of behavioral services
based on the adolescent’s clinical presentation offered through Bradley Hospital, the services
and safety risk profile. Our IOP level of care is described in this chapter can be implemented in a
indicated for adolescents who do not require “freestanding” facility. It is important to note,
inpatient medical detoxification or 24-hour however, that our integration within a broader
supervision due to safety concerns but need hospital setting affords opportunities to seam-
more than traditional weekly outpatient services. lessly incorporate a comprehensive range of
The program is considered an intermediate level enhanced services beyond those provided through
of ambulatory care that can serve as a treatment our core programming. Some of these enhanced
entry point when clinically indicated, a step- services include medical detoxification, nutrition
down level of care for youth discharged from an services, and occupational and physical therapies.
inpatient or residential facility, or a step-up when It is imperative that nonhospital-based programs
an adolescent is unsuccessful in a standard out- foster and maintain strong professional relation-
patient setting and requires more intensive treat- ships with other local providers to ensure their
ment. Importantly, ongoing monitoring of each clients can access related services when needed.
adolescent’s risk profile is essential, and transi-
tions to higher or lower levels of care are made
when indicated. Program Development
As an IOP-level service, Bradley Vista is simi- and Implementation
lar to partial hospitalization or “day” programs
except youth attend the program only 3 hours per Our vision for Bradley Vista was to fill an unmet
day, 3 days per week; program hours are yet critical clinical need by providing adolescents
Tuesdays, Thursdays, and Fridays, 3:00 PM to and their families with the highest quality care
6:00 PM. This schedule provides youth with during an optimal developmental period for inter-
intensive treatment while affording them the abil- vention. Program development was driven by the
ity to attend school and practice newly acquired goal of creating a clinical service that leverages
skills in their daily lives. In addition, this level of the latest research to provide evidence-based care
care provides youth and families with frequent in a manner that is viable across health-care set-
access to a multidisciplinary team of specialists. tings. Getting started required considerable time
Overall, the major objectives of the program are and effort, which meant financial resources were
fourfold: needed. Start-up funds for program development
came from contributions of Bradley Hospital’s
• Establish initial abstinence. generous donor community. Foundational activi-
• Improve family functioning and support. ties involved defining the scope and objectives of
• Assist adolescents (and their families) with the program, including careful consideration of
building motivation and a robust set of key target outcomes (e.g., substance use, psychi-
evidence-­based cognitive-behavioral skills to atric symptoms; for details, see section
address substance use and co-occurring psy- “Evidence-Based and Empirically Informed
chiatric disorder symptoms. Assessments”), determining staffing and budget
• Stabilize pharmacotherapy when indicated. needs, and securing support from key
stakeholders.
These treatment objectives serve as catalysts Considerable time was spent creating a spec-
for sustaining behavior change, improving psy- trum of manualized treatment curricula based on
304 R. Miranda

the latest research that spanned individual, fam- Close collaboration among team members
ily, and group therapies. Given that most youth ensures that all elements of care are coordinated
who seek treatment for an SUD also struggle to maximize treatment benefit.
with a co-occurring mental health condition We are also committed to training the next
(Robinson & Riggs, 2016), program develop- generation of clinicians and behavioral scientists
ment centered on integrated care that targets both to advance clinical care for adolescents with co-­
substance use and co-occurring psychiatric disor- occurring disorders. Developing and expanding a
ders. There is clear evidence that targeting both highly trained clinical workforce equipped to
substance use and psychiatric symptoms yields meet the treatment needs of this vulnerable popu-
the best outcomes (Brewer et al., 2017). This lation is a priority, and thus, a major objective of
requires delivering comprehensive evidence-­ the program is to provide much-needed special-
based substance use and mental health interven- ized training to individuals who wish to pursue
tions in one setting by one treatment team. this area of health care. Our close relationship
Setting up our team involved recruiting an with the Warren Alpert Medical School at Brown
interdisciplinary group of professionals trained in University and other local health-care training
best practices for treating substance use as well programs affords the opportunity to integrate
as a range of non-substance psychiatric disorders. trainees from a range of disciplines, including
Our fully integrated multidisciplinary team clinical psychology, medicine, and nursing.
includes clinical psychologists, a child psychia- Treatment fidelity is monitored through live
trist, a nurse practitioner, and a master’s-level supervision of group, individual, and family ther-
behavioral support staff. Doctoral-level clinical apy sessions by clinical psychologists who spe-
psychologists provide all individual, family, and cialize in this population and these treatment
group therapy, and our child psychiatrist and modalities and by supervising clinical psycholo-
nurse practitioner provide medication manage- gists reviewing recordings of individual and fam-
ment and arrange for laboratory or other diagnos- ily therapy sessions. A minimum of 3 hours of
tic services. Master’s-level staff support the care group supervision and 30 minutes of individual
and safety of adolescents and help ensure effec- supervision is provided each week.
tive implementation of our day-to-day program-
ming. For example, master’s-level staff conduct
an initial check-in with adolescents each day, Day-to-Day Programming
make sure adolescents transition from group
therapy sessions to individual and family therapy Our core treatment service is comprised of indi-
sessions as scheduled, and assist with managing vidual, group, and family therapy as well as med-
any behavioral issues that arise during group ication management when indicated (see
sessions. Table 17.1). Each adolescent receives a minimum
In addition to our core treatment services, of two 45-minute individual therapy sessions and
team members also consult with schools and one 60- to 90-minute family therapy session per
engage in professional collaborations with week. Caregiver (i.e., parent or legal guardian)
health-care providers to coordinate services engagement in treatment is required except in
across systems. Navigating insurance coverage rare circumstances (e.g., teen living in a group
and billing is also key to the success of any home/residential facility without parental
health-care service. Administrative and clerical involvement). Each youth is assigned a clinical
staff coordinate treatment referrals, insurance psychologist who provides both individual and
coverage, and related activities. Our team-based family therapy as well as a child psychiatrist or
approach leverages the unique contributions of nurse practitioner who provides medication man-
different disciplines and appreciates that different agement. All modes of treatment, including both
practitioners will assume principal responsibili- psychosocial and pharmacological interventions,
ties for specific elements of an adolescent’s care. strictly adhere to the latest evidence-based prac-
Table 17.1 Daily schedule
17 Co-occurring Disorders

Tuesday Thursday Friday

2:30–3:00 Team meeting/group supervision Team meeting/group supervision Team meeting/group supervision
(30 min)
3:00–3:15 Check-in and community meeting Check-in and community meeting Check-in and community meeting
(15 min)
3:15–4:00 Skill development Individual and family Skill development group 1:1/family Skill development group Individual and family
(45 min) group sessions Interpersonal skills Substance focused sessions
Emotion regulation
4:00–4:05 Break Break Break
(5 min)
4:05–4:50 Skill development Individual and family Skill development group 1:1/family Skill development group Individual and family
(45 min) group sessions Problem-solving skills Substance focused sessions
Emotion regulation
4:50–5:00 Break Break Break
(10 min)
5:00–5:45 Skill development Individual and family Health behavior group 1:1/family Relapse prevention/weekend Individual and family
(45 min) group sessions planning group sessions
Substance focused
5:45–6:00 Review/wrap-up Review/wrap-up Review/wrap-up
(15 min)
6:00–6:30 Supervision and notes Supervision and notes Supervision and notes
(30 min)
305
306 R. Miranda

tices. This approach translates into a largely and maintain confidentiality for the teenager as
cognitive-­
behavioral and neuroscience-driven well as other group participants. We strongly rec-
framework for case conceptualization and treat- ommend that teenagers use headphones during
ment. For details regarding our treatment group and individual sessions. During the intake
approach, see section “Evidence-Basedand process, we carefully assess whether adolescents
Empirically Informed Interventions”. and families can access the technology needed to
participate in treatment via a virtual platform
Adapting to a Telehealth Platform along with other potential barriers to care (e.g.,
Due to mounting public health concerns regard- medical, legal, housing, social, or other
ing COVID-19 and federal and state recommen- personal/family needs). We are committed to pro-
dations and mandates to limit social contact, we viding high-quality care to a diverse range of cli-
suspended in-person services in March 2020. To ents, including families who are economically
ensure teenagers and families continued to access disadvantaged. When needed, we assist families
high-quality intensive care during this unprece- with acquiring the required technology (e.g.,
dented and challenging time, we transitioned to technology devices, headphones, etc.).
an online videoconferencing platform. Think of Our program admits new clients regularly.
this virtual experience as an extension of our in-­ Consequently, group membership is heteroge-
person program. As with our in-person services, neous in their motivation to change their alcohol
our online program offers three hours of care or other drug use; some members are highly
three days per week. The schedule for our virtual motivated for change, while others are still pre-­
program mirrors the in-person service (see contemplative and uncertain about whether
Table 17.1). changing their use is right for them. Thus, as with
Transitioning to online programming pre- our in-person program, teenagers are discour-
sented some unique challenges. We expect teen- aged from communicating with each other out-
agers to maintain the same behavioral side program hours and instructed not to share
expectations (being on time, engaged, respectful, their digital personal information (i.e., e-mail
and appropriate, etc.) as if they were physically addresses, social media names, etc.) with fellow
present in the program. Just like our in-person group members. At the start of each program day,
program, timely and regular attendance is teenagers are admitted to a “private room” in the
expected; unexcused absences and late arrivals virtual program one at a time to verify their iden-
can impact insurance coverage, and missed days tity and ensure their username includes only their
could lead to premature discharge. We ask that a first name.
caregiver be present in the home during program Although infrequent, we remove anyone from
hours, especially if there are any identified safety a group therapy session who disrupts the milieu.
concerns. If this is not possible, we ask that a Likewise, to mitigate distractions, we expect
caregiver is available by mobile phone. In addi- teenagers to place their cell phone and other elec-
tion, adolescents are required to provide their tronic devices in a separate space unless they are
current physical location (i.e., street address) at being used for the session. In terms of substances,
the start of each program day in case of emer- teenagers must be sober while participating in
gency, including but not limited to concerns group therapy sessions. Additionally, no drug
about self-harm. paraphernalia, alcohol, or illicit substances may
We prioritize confidentiality, and privacy is be present during sessions. Consistent with our
essential during all virtual sessions. Recording in-person programming, if we suspect that a teen-
any group, individual, or family session is strictly ager is under the influence during the program,
prohibited. Except for family meetings, adoles- we remove them from the virtual group and
cents must be alone while participating in a vir- address it directly with them and their parents. If
tual session. Friends, caregivers, relatives, and a youth appears to be medically compromised in
others must be out of the room to provide privacy any way, we contact their caregiver immediately
17 Co-occurring Disorders 307

and develop a plan (e.g., call 911) for immediate Urine toxicology screens are also key and pro-
transfer to the nearest emergency department. If vide an objective measure of the adolescent’s
an adolescent expresses any significant safety substance use. Pairing an objective biomarker
concerns, we contact their caregiver immediately, with self-reported substance use is best practice.
and, if emergency services are deemed necessary, Urine toxicology screens can not only capture the
we call 911 and provide the location of the patient presence or absence of recent substance use
as necessary. across the full spectrum of drug classes but also
provide levels of use. Quantifying levels of use is
particularly helpful for cannabis, where an ado-
Evidence-Based and Empirically lescent can continue to test positive for THC
Informed Assessments weeks after they last used. By quantifying the
level of THC in the adolescent’s system, we can
From the outset, we carefully considered how to monitor and reinforce weekly reductions in THC
assess whether adolescents are appropriate for levels even before the teenager produces a nega-
the program and whether our services yield the tive test result. Conversely, increases in THC
intended benefit on substance use and mental quantification levels typically indicate new or
health functioning. Both objectives require care- increased use, which is also important for tailor-
ful assessment of substance use and psychiatric ing interventions.
symptoms, as well as family and social function- Psychiatric diagnoses, including SUDs, are
ing, school/academic performance, and other key derived using the Kiddie Schedule for Affective
domains. Here, we focus on best practices for Disorders and Schizophrenia for School-Age
capturing substance-related constructs; psychiat- Children, a semi-structured interview (Kaufman
ric symptoms and other constructs are reviewed et al., 1997). All diagnoses are determined
in detail elsewhere in this book. using the Diagnostic and Statistical Manual of
Alcohol and other substance use monitoring Mental Disorders (American Psychiatric
includes the quantity and frequency of use as Association, 2013); SUD severity is based on a
well as substance-related problems. Sources of continuum with mild (2–3 symptoms), moder-
information include adolescent and caregiver ate (4–5 symptoms), and severe (6+ symptoms)
self-report via semi-structured interviews with specifiers. Other key domains of assessment
clinicians and weekly urine toxicology tests. include but are not limited to readiness for
Adolescent and caregiver-reported substance use change, family functioning, school perfor-
is assessed using timeline follow-back (TLFB) mance, and suicidality and self-harm, which are
interview (Sobell & Sobell, 1992), which is the captured via self-report assessments or semi-
gold standard for capturing alcohol and other structured clinical interviews.
drug use among adolescents and adults. For
example, this method of estimating daily quanti-
ties of cannabis use has shown evidence of reli- Evidence-Based and Empirically
ability and validity (Mariani et al., 2011; Norberg Informed Interventions
et al., 2012), and the TLFB is shown to correlate
strongly with plasma tetrahydrocannabinol Our core therapeutic services at Bradley Vista
(THC) levels—the principal psychoactive con- adhere to the latest evidence-based practices
stituent of cannabis (Hjorthoj et al., 2012). across all modalities (SAMHSA, 2021). These
Clinicians administer the TLFB at admission, services are comprised of best practices for
typically capturing the past 28 days, and it is group, individual, and family therapies as well as
repeated at each program day to capture the time medication management, which are integrated
since the last assessment (i.e., the adolescent’s and tailored to meet the individual needs of each
last program day). youth. All youth receive these core services as
308 R. Miranda

part of our standard treatment package. Additional short-term treatment goals, their influence is
services such as school consultation, nutrition, often transient. Therefore, our chief objective
and occupational therapy are added when clini- from the outset of care, including the initial
cally indicated and delivered by our team or intake assessment appointment, is to build a
through other service providers within the larger strong therapeutic alliance and foster intrinsic
Bradley system. Integrated care, as described ear- motivation. At Bradley Vista, this responsibility
lier in this chapter, that targets not only substance falls on the entire interdisciplinary team; how-
use but also comorbid mental health conditions is ever, there is no question this task is more
essential for maximizing treatment gains. Other squarely planted on the shoulders of the adoles-
chapters in this volume provide detailed informa- cent’s assigned clinical psychologist and medical
tion about best practices for treating non-­ service provider.
substance-­ related psychiatric disorders. This
chapter will focus on the treatment of substance Group Therapy
use disorders. Group therapy is common in adolescent (and
adult) SUD treatment settings in part because it is
Setting Treatment Goals more economical and time efficient than individ-
Our interdisciplinary treatment model empha- ual or family therapy formats (French et al.,
sizes building and sustaining motivation and 2008; Kaminer, 2005). Each group at Bradley
treatment engagement, establishing early absti- Vista is scheduled for 45 minutes, with short
nence and developing the skills to maintain breaks between each session (see Table 17.1).
sobriety, and attenuating co-occurring psychi- Group sizes typically range from 5 to 10 adoles-
atric symptoms. The ultimate goal is to prepare cents, depending on the number of youth meeting
adolescents and their families for success at a with other providers (e.g., individual or family
lower level of care, typically standard outpa- therapy, medication management). Group rules
tient therapy, either weekly or twice weekly or, and expectations are reviewed at the start of each
in some cases, home-based services. Treatment session. At least two team members attend all
is driven by each adolescent’s individualized groups, regardless of if the session is virtual or in
treatment plan. This plan sets clearly defined person, including the clinical psychologist facili-
goals through close collaboration with adoles- tating the group and our master’s-level behavior
cents and their families. Each goal is paired support specialist who helps maintain a support-
with specific interventions designed to achieve ive milieu environment and ensures adolescents
the identified goals as well as the measurable attend their individual and family therapy
metrics that will be used to gauge progress. appointments and meet with other treatment team
Progress is measured at least weekly, and treat- providers as necessary.
ment plans are updated and revised Our group therapy sessions focus on psycho-
accordingly. education, skill development, and motivational
interviewing (MI) and motivational enhance-
 nhancing and Sustaining Motivation
E ment therapy (MET). Research suggests that
and Treatment Engagement psychoeducation helps reduce adolescent sub-
The importance of motivation and treatment stance use (Kaminer et al., 2002), and this effect
engagement cannot be overstated. Few adoles- may be stronger when psychoeducation is paired
cents present to SUD treatment with an intrinsic with other evidence-based treatments. By pro-
desire for change. Most present in response to an viding corrective factual information in a sup-
extrinsic motivator, such as caregiver insistence portive and nonjudgmental setting,
or perhaps court involvement. Although extrinsic psychoeducation ­combats dysfunctional beliefs
pressures can initially motivate teenagers to about substance use and its consequences that
engage in clinical services and even achieve are commonly held by adolescents and their
17 Co-occurring Disorders 309

families. Indeed, teenagers commonly hold inac- and stress management, and communication/
curate and sometimes dangerous beliefs about assertiveness skills.
substance use and addiction. Like many adults, Group therapy also focuses on building moti-
they acquire these beliefs from their family vation for engaging in treatment and changing
members and their broader social circle, which substance use. Not surprisingly, research shows
includes considerable misinformation perpetu- that combining MI and MET with CBT produces
ated on social media and other online platforms. positive outcomes (Dennis et al., 2004; Ramchand
By correcting misinformation and imparting an et al., 2011). Although developing strategies to
awareness of the facts related to substance use, adaptively navigate challenging situations is cen-
psychoeducation allows youth to explore their tral to treatment, it is highly unlikely that an ado-
own behavior from a more informed perspective. lescent will leverage those skills without
Psychoeducation also serves to address stigma sufficient motivation to change. MI involves a
often associated with addiction and its treatment. collaborative interpersonal communication style
Adolescents who struggle with substance use that is devoid of judgment, emphasizes compas-
and their families often experience shame or sion, and thoughtfully explores each adolescent’s
embarrassment. Psychoeducation on the nature own thoughts about their use and their personal
of addiction, including its neurobiological reasons for considering change (Miller &
underpinnings, helps allay these concerns. Rollnick, 2013). Research by our team and others
Didactic components of our psychoeducation finds that MI is well suited for teenagers who are
programming are paired with multimedia (e.g., often ambivalent about changing their alcohol or
videos) and interactive activities (e.g., drug fact other drug use and resistant to adult directives
games) to help maximize engagement and (Dennis et al., 2004; Miranda Jr. et al., 2017;
accommodate different learning styles. Tevyaw & Monti, 2004). Using MI, our clini-
Research also shows that cognitive-behavioral cians engage with adolescents as equal partners,
therapy (CBT) can facilitate the development of avoiding confrontation and unsolicited advice.
key skills to improve self-regulation and problem-­ The goal is to listen and help youth carefully
solving abilities among youth in SUD treatment examine their unique circumstances, thoughts
(Waldron & Turner, 2008). When it comes to about treatment engagement and behavior
alcohol and other drug use, a core tenet of CBT is change, and evaluate their range of possible
that substance use is initiated and maintained by options (Miller & Rollnick, 2009). MET is a vari-
a host of interoceptive (e.g., thoughts, emotions) ation of MI that provides adolescents with nor-
and exteroceptive (e.g., certain people or places) mative feedback about their substance use using
influences (Collins et al., 1985; Spirito et al., a supportive and nonjudgmental style. The goal is
2020). Skill development groups teach adoles- to correct any misperceptions about the preva-
cents to identify these triggers and learn how to lence of similar substance use among similarly
effectively and adaptively navigate these high-­ aged peers. For additional information regarding
risk contexts. The group setting affords the group therapy for adolescent substance use, read-
opportunity for youth to practice newly learned ers are directed to several sources (Bukstein,
skills through role-plays with clinicians and fel- 2019; D’Amico & Feldstein Ewing, 2018). For a
low group members. Allowing constructive feed- detailed review of MI and MET, readers are
back and sharing thoughtful suggestions fosters a directed to other resources (Miller & Rollnick,
supportive milieu while providing the opportu- 2013; Spirito et al., 2020).
nity for youth to receive developmentally tailored
feedback from their peers. Common types of Individual Therapy
skills training include but are not limited to Individual therapy sessions follow the same
problem-­solving training, setting SMART goals, evidence-­based approach used in group therapy.
alcohol and drug refusal skills, relapse preven- In addition, during individual therapy, particular
tion strategies, increasing social supports, anger attention is focused on the adolescent’s non-­
310 R. Miranda

substance psychiatric disorder. While group ther- ing, appropriate autonomy granting), and foster-
apy addresses substance use and broader ing adaptive family problem-solving skills
transdiagnostic treatment targets that span com- (Liddle, 2016; Liddle et al., 2001; Liddle et al.,
mon psychological vulnerabilities for a variety of 2018). However, we adopt a flexible approach
psychiatric disorders (Dalgleish et al., 2020), that leverages key elements shared across
such as emotional awareness and cognitive evidence-­ based family therapy approaches
appraisal/reappraisal (Barlow et al., 2010; Black (Chorpita et al., 2011; Hogue et al., 2017).
et al., 2018), individual therapy affords the oppor- Consistent with a dissemination framework for
tunity for tailored interventions that address each adolescent SUD treatment (Hogue et al., 2017),
adolescent’s unique presenting needs. For exam- we find this strategy permits us to prioritize key
ple, group therapy may generally focus on man- core elements of research-supported treatments
aging and tolerating emotions, and individual in a way that is readily implementable in real-­
therapy provides the forum to engage in specific world practice. Indeed, mounting research shows
cognitive-behavioral strategies for treating a co-­ that a core-elements approach to child and ado-
occurring anxiety disorder, such as exposure lescent behavioral health services produces
therapy. Additionally, during individual therapy strong effects, perhaps even superior outcomes
sessions, considerable emphasis is placed on over some manualized modalities (Hogue et al.,
building and maintaining a strong therapeutic 2015; Weisz et al., 2012).
alliance. Research shows the therapeutic alliance A conceptual distillation of family therapies
plays a significant role in treatment outcomes for adolescent substance use identified four core
across a range of psychiatric and substance prob- elements that cut across different “brand-name”
lems among adolescents (Diamond et al., 2006; manualized interventions (Hogue et al., 2017).
Hogue et al., 2006; Ibrahim et al., 2021; Marcus The first common element is family engagement,
et al., 2011). which focuses on enhancing and maintaining
caregiver involvement and investment in treat-
Family Therapy ment by strengthening the therapeutic alliance
Grounded in the idea that the family unit holds between the family members and the therapist.
the greatest potential to confer lasting influences The second common element is relational
on adolescent substance use, family therapy gives reframing, which shifts thinking toward concep-
considerable attention to family communication tualizing all clinical issues within a systemic
and conflict, cohesiveness, and problem solving. (family) context. By shifting the identified source
Research shows that involving parents or legal of the presenting problem away from the adoles-
guardians in adolescent AUD treatment is partic- cent to encompass a more systemic issue, the
ularly important, and there is growing evidence goal is to motivate family members to think about
that family-based interventions yield better out- and implement family-based changes. The third
comes than individual or group therapies alone element is family behavior change. This element
(Hogue et al., 2014; Hogue & Liddle, 2009; focuses on the family’s acquisition of new skills
Tanner-Smith et al., 2013). Several manualized, to enhance communication and improve intrafa-
empirically supported family-based therapies milial relationships. And the fourth element is
exist for adolescent SUD, including brief strate- family restructuring, which aims to facilitate
gic family therapy, functional family therapy, shifts in attachment and emotional processes
multidimensional family therapy, and multisys- between family members. Family therapy at
temic family therapy (Baldwin et al., 2012). Bradley Vista supplements the fundamental
At Bradley Vista, we favor multidimensional aspects of multidimensional family therapy with
family therapy—an approach that focuses on these four common elements to complement
reducing adolescent-parent conflict and improv- individual and group therapy.
ing communication and cohesion, facilitating key
parenting practices (e.g., limit setting, monitor-
17 Co-occurring Disorders 311

Pharmacotherapy been done by our team (Emery et al., 2021; Gray

Adolescents who present to treatment for a SUD et al., 2018; Miranda Jr., Ray, et al., 2014;
typically receive a psychological intervention, Miranda Jr. et al., 2017; Treloar Padovano &
and pharmacotherapy is limited to targeting the Miranda Jr., 2018). Emerging research suggests
co-occurring psychiatric disorder. Although med- that medications may help treat adolescent sub-
ications are commonly used to treat a broad array stance use. A complete review of research on
of psychiatric diagnoses in adolescents, includ- pharmacotherapy for adolescents with an SUD is
ing youth with co-occurring disorders, pharma- beyond the scope of this chapter. Readers are
cotherapy specific to adolescent substance use is directed to other comprehensive reviews for a
at a nascent stage (Belendiuk & Riggs, 2014; more detailed discussion about this issue
Clark, 2012; Courtney & Milin, 2015; Lord & (Miranda Jr. & Carpenter, 2020; Miranda Jr. &
Marsch, 2011; Waxmonsky & Wilens, 2005). No Treloar, 2016; Miranda Jr. & Treloar Padovano,
medication is approved by the Food and Drug 2018).
Administration (FDA) to treat an SUD during
adolescence except Suboxone, which is approved
to treat opioid use disorder among individuals Collaborations and Generalized
ages 16 years and older. All other medications Treatment Gains
used to treat an SUD in adolescents are pre-
scribed off-label, meaning they are used to treat a Integrating families and fostering professional
condition or patient population for which they are collaborations with schools, other health-care
not officially FDA approved. providers, and other individuals and organiza-
Most clinical trials of medications for treating tions is central to the services we provide at
an SUD were conducted with adults, typically Bradley Vista. Caregiver involvement, namely,
defined as 18 years or older. These studies were parents or legal guardians, is typically required
not designed to inform pharmacotherapy for ado- and plays a key role in our treatment approach.
lescents, and there is compelling evidence that There is strong empirical evidence, as reviewed
the safety and efficacy of prescribing medica- above, that family-based treatments yield the
tions to adolescents cannot be inferred from clin- strongest clinical outcomes for youth who strug-
ical trials with adults (Bridge et al., 2007; Mayes gle to reduce their substance use. Therefore, inte-
et al., 2007; Safer, 2004). This concern may be grating families in all aspects of the program,
especially important when it comes to treating an from initial screening and assessment to family-­
SUD (Simkin & Grenoble, 2010). Adolescents based psychotherapy and medication manage-
differ considerably from adults in terms of their ment of the adolescent, is a major component of
symptom presentation, course, and associated our treatment scope services.
features, and these differences appear to be driven We provide myriad consultative activities,
in part by substantial neuronal remodeling that including collaborations with schools and pri-
occurs during adolescence (Brown et al., 2008; mary care providers, as well as cross-system
Spear, 2014; Winters et al., 2014). These changes coordination of care, including but not limited to
impact adolescents’ sensitivity to alcohol and collaborative discharge planning. Building these
possibly other drugs; heighten their vulnerability collaborative professional relationships across
to heavy drinking, other drug use, and the devel- systems is often warranted based on the severity
opment of substance use problems; and possibly or complexity of the adolescent’s clinical presen-
impact how they respond to medications (Miranda tation. By the time of admission, many youth
Jr., Monti, et al., 2014; Spear, 2014). struggle with significant academic or social dif-
The past decade has witnessed a marked ficulties in school, and improving school func-
increase in medication research for treating tioning is often a major focus of treatment.
SUDs, namely, alcohol and cannabis use disor- Helping to resolve academic challenges and fos-
ders, among adolescents. Much of this work has ter stronger connections with school can afford
312 R. Miranda

useful supports that help maintain treatment Our research has shown that when adolescents
gains following discharge from an IOP level of encounter alcohol or cannabis cues, they experi-
care. ence spikes in craving, and these spikes are stron-
ger among youth with more severe
substance-related problems (Mereish et al., 2018;
Integrating Research and Practice Miranda Jr., Ray, et al., 2014; Ramirez & Miranda
Jr., 2014). Perhaps most importantly, higher lev-
We are committed to providing adolescents and els of craving prospectively predict greater sub-
their families with the best available evidence-­ sequent drinking levels in the natural environment
based therapies as well as access to clinical trials (Ramirez & Miranda Jr., 2014). These findings
of innovative behavioral and pharmacological support craving as an important treatment target
interventions. Although our clinical service for youth, and coping with cravings is a specific
began in 2017, for nearly two decades our team topic in individual, group, and family therapy at
has successfully executed clinical research, Bradley Vista.
funded by the National Institutes of Health (NIH) We also characterized adolescents’ subjective
and private foundations, to advance treatment responses to alcohol and cannabis use (Miranda
options for adolescents and adults who struggle Jr., Monti, et al., 2014; Treloar Padovano &
with SUDs. With some of the leading scientists Miranda, 2018). Prior to this advance, because of
on treatment development for addiction and legal and ethical restrictions on administering
state-of-the-art facilities located at Brown alcohol or cannabis to youth in the human labora-
University Center for Alcohol and Addiction tory, our understanding of how alcohol affects
Studies, we are highly qualified, technically and teenagers relied entirely on retrospective reports,
practically, to help improve treatment options for animal models, and one small alcohol adminis-
youth who struggle to reduce their substance use. tration study with boys, ages 8–15, nearly
A major focus of our work is to elucidate not 35 years ago (Behar et al., 1983). This was a clin-
only whether treatments work but also how they ically important gap in understanding of adoles-
work. Over the past decade, we developed an cent substance use, given that many medications
innovative research program that pairs human for treating addiction in adults work by curbing
laboratory paradigms with ecological momentary craving or the intoxicating effects of substance
assessment (EMA) methods to provide an effi- use. Expanding this work to adolescents allowed
cient test of the effects of novel treatments on us to test, for the first time, whether medications
substance-related behaviors among adolescents. work similarly in adolescents. By developing
Using EMA methods (also referred to as experi- new methods that capture, in real time and in the
ence sampling), data on momentary events are natural environment, alcohol and cannabis’
collected in real time in participants’ natural effects in adolescents, we are now able to better
environments, affording a truly prospective anal- test hypotheses about mechanisms of treatment
ysis of the relationship between specific events effects, particularly pharmacotherapy, in youth
and substance use. Momentary assessments are that involve subjective response to effects of sub-
particularly important when the phenomena of stance use and real-time experience of craving.
interest are subject to rapid change, as are sub- For example, in a study of naltrexone with ado-
stance use, craving, and the acute subjective lescents, we found the medication reduced the
effects of alcohol and other drugs. likelihood of drinking and heavy drinking,
This work embodies our philosophy of con- blunted craving in response to alcohol cues, and
ducting interdisciplinary, translational work that altered subjective responses to alcohol consump-
is specifically focused on understanding the most tion. These findings are consistent with a trial of
promising ways (i.e., treatment targets) to young adults, which also found that naltrexone
advance clinical care. reduced the quantity of alcohol use on drinking
17 Co-occurring Disorders 313

days (O'Malley et al., 2015). This suggests that ensuring our service delivery model was ulti-
naltrexone might be particularly well suited for mately self-sustainable, developing new channels
adolescents because their drinking patterns are for patient referrals, and marketing the program
characterized by episodic heavy drinking rather to boost our financial stability. Although the true
than more frequent drinking and because youth marker of success is always improving the lives
may be less likely to embrace abstinence as a of adolescents and their families, the business
treatment goal (Winters et al., 2014). side of health care cannot be overlooked. Without
financial stability, services are not sustainable.
Another key lesson is the critical importance
Lessons Learned, Next Steps, of evidence-based step-down care following dis-
and Resources charge. Substance misuse is considered a chronic
condition that requires ongoing high-quality
In this chapter, we reviewed how we created and care. Much like hypertension or diabetes,
implemented an IOP for adolescents with co-­ substance-­ related problems require ongoing
occurring disorders. The goal is to support other monitoring and clinical care, especially during
groups interested in building a similar program the early phase of recovery. Unfortunately, stan-
by providing a proven instructional guide. It is dard outpatient services for teenagers with co-­
important to appreciate, however, there is consid- occurring disorders are not available in many
erable heterogeneity across health-care systems. locations. This dearth includes counseling ser-
This chapter presents one way in a specific con- vices as well as medication management. We
text. Other pathways toward implementation may encountered this reality firsthand shortly after
be necessary based on differences in the size and launching Bradley Vista. Finding appropriate
scope of the health-care setting, level of engage- providers took weeks, and we often had to pro-
ment and support from key stakeholders, avail- vide standard outpatient care after discharge from
ability of providers, and geographic location. the IOP as a bridge until a community-based cli-
Even so, providing high-quality evidence-based nician was located. To address this problem, in
care is critical and should not be compromised. collaboration with Bradley Hospital leadership,
Developing and implementing Bradley Vista we received a generous grant from CVS Health
posed many opportunities as well as some chal- Foundation to develop a specialty clinic that pro-
lenges. Others seeking to create similar services vides standard outpatient care to adolescents with
might benefit from our lessons learned. From the co-occurring disorders. This service, now called
outset, we received unwavering support from the Wave Clinic, dovetails with Bradley Vista to
hospital leadership. The benefits of this support, offer a continuum of care within one system that
practical and financial, cannot be overempha- adopts the same treatment philosophy and
sized. The ever-evolving landscape of health care approach. For systems without this continuum of
is influenced by many forces, both internal and care, it is essential that program clinicians
external to a given organization or system. These develop and maintain collaborative professional
influences can directly affect the success or fail- relationships with local treatment options to
ure of new initiatives, including the sustainability facilitate transfers to other levels of care.
of new programs. In health care, like most sys- Related to continuing services, facilitating a
tems, leadership plays a central role in establish- seamless transition to a lower level of care is
ing priorities and allocating resources to achieve important for maintaining treatment engagement.
identified objectives. For Bradley Vista, support Transitioning between levels of care is a point of
from leadership played an instrumental role in heightened risk for treatment dropout, perhaps
building trusted relationships with other key especially for adolescents who are often weary of
stakeholders, both within the system and the treatment providers. Facilitating a “warm” transi-
broader community, securing the needed start-up tion to another provider is critical for maintaining
funds to support this new initiative while also treatment gains achieved during IOP services.
314 R. Miranda

One way to achieve this objective in a strates that telehealth is an effective way to
­comprehensive setting like Bradley Hospital is to deliver services for a range of psychiatric disor-
integrate clinicians across both IOP and standard ders, client populations, age groups, and treat-
outpatient levels of care. Not surprisingly, we ment modalities (Acierno et al., 2016; Myers
find that adolescents are much more likely to et al., 2015).
attend and engage in continuing care when a ther-
apeutic alliance with the outpatient clinician is
already established. Although this type of trans- Next Steps
fer is not always possible, even at Bradley
Hospital, we find that inviting the new outpatient As Bradley Vista seeks to continue to serve as an
provider to join individual and family sessions in exemplar treatment program for adolescents with
the week or so before IOP discharge can help co-occurring disorders, we aim to continue to
smooth the transition and increase the chances of integrate current research and new technologies
continued engagement. into our clinical practice to better serve the ado-
At Bradley Vista, we learned firsthand how lescents it treats. A growing body of work high-
telehealth can overcome common barriers to co-­ lights factors that need to be better addressed in
occurring services faced by many adolescents treatment for youth with co-occurring disorders.
and caregivers. People who struggle with alcohol Specifically, time spent with substance-using
and other substances experience one of the larg- peers (Meisel et al., 2021; William Best & Ian
est gaps between treatment need and treatment Lubman, 2016; Yurasek et al., 2019), momentary
utilization; less than one in ten people, adoles- craving, negative affect, stress (Hawkins, 2009;
cents and adults alike, who need SUD treatment Van Zundert et al., 2012), and family conflict
receive it. The COVID-19 pandemic revolution- (Hogue et al., 2017; Skeer et al., 2009) are all
ized how people access health-care services. strong predictors of relapse for youth in treat-
Telehealth became a primary medium for deliver- ment. Although treatment at Bradley Vista targets
ing a host of health-care services in a safe and these risk factors, they emerge outside of pro-
cost-effective way. By leveraging video and tele- gram hours in real-world situations that can be
conferencing platforms, telehealth—also referred difficult for parents and adolescents to manage.
to as telepsychology, telepsychiatry, or behav- Both parents and adolescents in the program have
ioral telehealth—allows people to access care expressed a desire for increased access for tools
from their homes. Beyond safety and conve- to manage these risk factors in the moment out-
nience, telehealth enhances accessibility and side of program hours.
acceptability of mental health and SUD services. Extraordinary growth in computer science and
Our in-person programming required caregivers mobile connectivity over the past decade gave
to transport their adolescent to and from a child rise to mobile health (mHealth) technologies that
psychiatric hospital 3 days per week for 2 or hold potential to transform addiction treatment.
more months. Virtual programming eliminates There is no question that the coming years will
travel time and related expenses and extends witness unprecedented integration of mHealth
access to geographically remote and underserved technologies across a spectrum of health-care
populations. By accessing services in the privacy fields, including psychiatry and behavioral health
of one’s home rather than a psychiatric and SUD (Marcolino et al., 2018). Unobstructed by barri-
treatment facility, telehealth can decrease stigma ers to traditional treatment options, smartphone-­
and increase treatment engagement. These based interventions (i.e., apps) can supplement
important benefits may be particularly salient for the best available treatments, including telehealth
adolescents (and adults) seeking SUD treatment, services, by providing point-of-need interven-
given long-standing and pervasive stigmatizing tions in far-reaching and unmatched ways.
attitudes and false beliefs about the nature of Indeed, mHealth platforms are gaining traction as
problematic substance use. Research demon- important tools that enable patients struggling
17 Co-occurring Disorders 315

with substance misuse to self-monitor a host of for adolescents with co-occurring disorders.
target variables (e.g., mood, drug craving, and These resources provide detailed information
high-risk contexts) and receive personalized in-­ about best practices as well as practical steps for
the-­moment feedback, as well as facilitate better implementing high-quality care. In particular, the
patient engagement in standard care (Carreiro Substance Abuse and Mental Health Services
et al., 2020). Administration has disseminated several impor-
Although systematic reviews support the tant published works that describe this process
potential for mHealth to reduce substance use, (Center for Substance Abuse Treatment, 2006;
there is inconsistency in efficacy across inter- SAMHSA, 2021).
ventions, potentially due to the low quality of
many trials and considerable variation in terms Note This work was supported in part by a grant from
of intervention content, design, and duration National Institute on Alcohol Abuse and Alcoholism
(AA026326).
(Hutton et al., 2019; Kazemi et al., 2017; The author has no conflicts of interest to disclose.
Milne-Ives et al., 2020; Palmer et al., 2018;
Quanbeck et al., 2014; Song et al., 2019).
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annurev-­pharmtox-­010611-­134625 73–83.
 Part IV
Programs of Special Interest
 Pediatric Pain Programs: A Day
Treatment Model at Boston 18
Children’s Hospital

Caitlin Conroy and Yasmin C. Cole-Lewis

Program Overview impairment by prioritizing a rehabilitative model

with a focus on returning to functioning rather
Pediatric chronic pain is a significant health con- than eliminating pain (Hirschfeld et al., 2013;
cern that impacts youth’s daily functioning and Hechler et al., 2015; Simons et al., 2018). In
quality of life (Hechler et al., 2015; Odell & addition to these functional improvements, some
Logan, 2013). Prevalence rates for pediatric com- IIPT program patients also report improvements
mon pain conditions, including headache, in pain intensity over time (Hechler et al., 2015;
abdominal pain, back pain, and musculoskeletal Stahlschmidt et al., 2016; Simons et al., 2018;
pain, range from 11% to 38% (King et al., 2011). Randall et al., 2018).
Youth with chronic pain often become disen-
gaged from academic and physical activities,
experience disruptions in social and familial rela- Patients
tionships, and experience emotional distress
associated with ongoing functional impairment The Mayo Family Pediatric Pain Rehabilitation
(Hechler et al., 2015). Intensive interdisciplinary Center (PPRC) at Boston Children’s Hospital is
pain treatment (IIPT) programs demonstrate pos- an IIPT program that serves youth ages 8–18.
itive, robust, and long-term outcomes among Families have traveled from 36 states across the
youth with profound pain-related functional USA and 14 countries around the world to seek
treatment for their child’s chronic pain condi-
C. Conroy (*) tions. Of the PPRC patients, 89.6% identified as
Mayo Family Pediatric Pain Rehabilitation Center, White, and approximately 81% of participants
Boston Children’s Hospital, Department of identified as female. The mean age of patients is
Anesthesiology, Critical Care, and Pain Medicine, 14. These demographics are consistent with
Boston, MA, USA
chronic pain population demographics across
Department of Psychiatry and Behavioral Sciences, studies and US-based pain programs (Simons &
Harvard Medical School, Boston, MA, USA
e-mail: [email protected] Kaczynski, 2012; Simons et al., 2018; Randall
et al., 2018). This homogeneity represents a con-
Y. C. Cole-Lewis
Psychiatry Consultation Service, Boston Children’s sistent trend in the literature and is a larger issue
Hospital, Department of Psychiatry and Behavioral of concern regarding populations who may not be
Sciences, Harvard Medical School, receiving needed treatment.
Boston, MA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 323
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_18
324 C. Conroy and Y. C. Cole-Lewis

Youth admitted to the PPRC have been diag- Further exclusion criteria include patients pre-
nosed with chronic pain, considered pain lasting senting with episodes of unconsciousness that
more than 3 months (IASP, 2019). Common pain have resulted in injury, not receiving medical
diagnoses among PPRC patients include com- clearance for weight-bearing or intense activities,
plex regional pain syndrome (CRPS) (46.5%), active arthritis flare, being within 8 weeks of
conditions with features of musculoskeletal pain major illness/injury/surgery including concus-
(21.9%), chronic headaches (12.8%), non-CRPS sion, or active contagious infection. While not an
neuropathic pain (7.6%), and chronic abdominal absolute contraindication, lack of patient or fam-
pain (7.2%). IIPT is often the recommended ily willingness to engage in a self-management,
treatment model for these pain conditions when rehabilitation approach to chronic pain requires
traditional outpatient treatment has been ineffec- further review and, at times, an additional screen-
tive and youth continue to experience significant ing with the PPRC admission team. The referring
pain-related functional impairment. Functional providers also assess for any substance use and
impairment may include disruption in a young make recommendations for any appropriate treat-
person’s daily activities, such as school refusal ment or weaning plans prior to admission. The
(e.g., minimal or no attendance, significant time PPRC also requires patients to be willing to avoid
spent in the nurse’s office during school days), marijuana use while in the program. Patients can
discontinuation of activities or sports, disengage- engage in treatment while undergoing medica-
ment in family life (e.g., not completing chores tion weaning, as long as they are medically
or attending family outings), and requiring sup- cleared to do so.
port or accommodation for activities of daily liv-
ing (e.g., using crutches or wheelchair rather than
ambulating). Program Goals and Expectations

Overarching program goals and expectations are

Admission centered around supporting patients’ return to
functioning with the ultimate, long-term goal of
Patients undergo an outpatient multidisci- pain reduction (Simons et al., 2018; Randall
plinary pain treatment evaluation to be consid- et al., 2018). Interdisciplinary treatment goals
ered for the PPRC. This initial evaluation include the understanding and implementation of
includes a pain physician, a psychologist, and a self-management strategies for chronic pain;
physical therapist, who assess and provide improving strength, endurance, and tolerance for
diagnostic clarification within each of their spe- daily activities, including exercise; and replacing
cific disciplines and offer recommendations for an image of disability with one of wellness.
treatment. Recommendations might include Chronic pain treatment necessitates patients’
initiation or continuation of outpatient treat- acknowledgment of the value in returning to typi-
ment or a referral to the PPRC. The multidisci- cal daily tasks and acceptance of improved func-
plinary evaluation also serves as an initial tioning as progress. Patients who believe and
assessment to determine eligibility for the adopt this mindset are often more inclined to
PPRC. Appropriate candidates will have made achieve success (Gauntlett-Gilbert et al., 2013).
efforts to treat chronic pain via outpatient ther- As youth gradually resume more typical engage-
apies, including physical therapy and psycho- ment in their lives and activities, chronic pain
logical therapy. Individuals experiencing severe becomes less of a focus, which allows patients’
and acute psychopathology (e.g., active suicid- continued engagement in preferred activities.
ality, psychosis, eating disorder) that warrants For this reason, the PPRC is an immersive
specialized intensive treatment or a higher level treatment program, to which patients and fami-
of psychiatric care are not eligible for admis- lies are expected to wholly commit. Patients
sion to the PPRC. achieve the best results by minimizing ­distractions
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 325

that may influence their engagement in treatment. ommend a more appropriate program or treat-
During the day, staff engage patients in several ment option. For example, new onset of
therapeutic sessions. In the evening, patients psychiatric symptoms that would require a higher
complete evening assignments. Families are level of care would necessitate a transition from
asked to support patients’ full engagement in the the PPRC to pursue a higher level of care.
treatment process. Specifically, families are
requested to arrive on time daily and complete
evening assignments, such as their home exercise Referral Process
program (HEP) and psychology home practice
activities. Additionally, caregivers are expected All PPRC referrals are internal and require an ini-
to be engaged in treatment by attending family tial referral to the outpatient multidisciplinary
therapy sessions and supporting patients to com- pain clinic. Often, referrals originate from pro-
plete their HEP and evening assignments. The viders within the hospital system who are aware
PPRC encourages a self-management approach of the outpatient multidisciplinary pain clinic or
to chronic pain, which assures caregivers of their the PPRC. Importantly, providers outside of the
child’s capacity to independently cope with pain. clinic must be aware of one or both programs to
Related to this, caregivers do their own work to provide the appropriate referral. Alternatively,
learn and refine their understanding of how to families must be aware of one or both programs
support their child with chronic pain by attending and advocate for these referrals or be directed to
caregiver sessions and learning strategies and navigate the appropriate systems to gain access to
best practices to coach their child. treatment at the PPRC. The referral process cer-
Average length of stay varies for each patient, tainly limits access to the PPRC to those who
though typically ranges between 4 and 6 weeks. know about the program and understand the pop-
This time frame typically varies based on patient ulation treated at IIPT programs. However, it is
readiness and progress in meeting shared treat- possible that with the expansion of telehealth,
ment team goals. For patients, these goals are there may be additional opportunities to broaden
related to functional rehabilitation and self-­ access and potentially expand the PPRC referral
management of pain; for caregivers, these goals base.
are related to increased understanding of chronic
pain and appropriate expectations for their child’s
level of functioning and self-management. Program Development
Program staff, patients, and families work collab- and Implementation
oratively during the admission to develop more
specific, targeted, and individualized treatment The PPRC program was developed as part of the
goals that are in line with these more general Pain Treatment Service (PTS) at Boston
shared treatment goals. As patients progress Children’s Hospital, a multidisciplinary program
through the program, providers engage in regular established in 1986 consisting of an inpatient
check-ins to assess readiness for discharge. If acute pain service and an outpatient chronic pain
patients maintain consistent progress toward clinic. Prior to the development of the rehabilita-
individualized treatment goals, their treatment tion program, patients with chronic neuropathic
team will help them prepare for their next steps, pain were either treated with inpatient admis-
which may include a lower level of care such as sions to a medical unit or outpatient therapy. On
outpatient treatment for ongoing support and the inpatient unit, they received physical therapy,
maintenance. If regular check-ins and assess- consultation from psychiatry and procedural
ments consistently indicate that patients are intervention, such as regional anesthetic nerve
experiencing interference that inhibits their full blocks. Outpatient services would typically
participation and engagement at the PPRC and/or include physical therapy and psychology. Pain
are struggling to meet their goals, staff may rec- leadership recognized that these models were not
326 C. Conroy and Y. C. Cole-Lewis

adequately meeting the needs of the most com- Physical Space

plex patients.
The inpatient model provided more intensive The day treatment facility was chosen to be located
medical supervision and access to round-the-­ at a suburban satellite location of Boston Children’s
clock care; however, this was not consistent Hospital, which allowed for an individualized
with the recommendation that chronic pain design tailored to the clinic’s needs. Special atten-
patients engage in functional activities and min- tion was placed on the environment of the clinic
imize medical intervention when possible. It and the intention for the space to avoid a more tra-
was challenging to try and establish a more typi- ditional hospital look and feel. The space was
cal daily schedule of activities on a hospital unit designed to include a large gym where all patients
and even more challenging to generalize new could work together, along with individual treat-
skills and routines to the home environment. ment spaces for each discipline. The layout also
The outpatient model, however, did not provide included additional group space for education time
the level of intensity of services that more com- and family and team meetings.
plex patients required to make sustained prog-
ress despite the reduction in more medically
focused management. The directors of the Pain Treatment Team
Treatment Service made plans to develop a
model that would address the needs of these The treatment team provider disciplines included
patients. in the PPRC were initially based on a more tradi-
The day treatment model was chosen due to a tional rehabilitation model and included medi-
number of identified benefits. Patients could cine, nursing, psychology, and physical therapy
receive an increased intensity of treatment, (PT). After a brief period of operation, occupa-
8 hours a day, 5 days per week, while also remain- tional therapy (OT) was included as well. The
ing in their home environments or with their fam- multidisciplinary approach to the treatment of
ilies in the evenings and weekends. Avoiding an pediatric chronic pain is well documented in the
inpatient admission was also considered helpful literature (Odell & Logan, 2013), and the disci-
in emphasizing normal function and de-­ plines at the PPRC were chosen to reflect the bio-
emphasizing the sick role for these youth and psychosocial model of understanding pediatric
their families. Increasing intensity from an outpa- chronic pain (Liossi & Howard, 2016).
tient model allowed complex patients to receive a Development of the program included key stake-
beneficial increased “dose” of treatment (Simons holders of the leadership groups of each disci-
et al., 2013). The day hospital model also allows pline at the hospital. With the expansion of the
for shared physical proximity of care providers, program, census and innovation in treatment
which results in frequent communication and delivery, recreational therapy, music therapy, and
care collaboration. This level of coordination and social work have been added. Each discipline is
communication is critical in caring for youth involved in the training of clinicians from short
with chronic pain who have not responded to out- clinical rotations to more long-term fellowships.
patient treatment. Further, the day treatment
model is less costly than an admission to an inpa-
tient medical-surgical unit. Philanthropic funding Insurance Coverage
was secured from a donor with a particular inter-
est in the treatment of chronic neuropathic pain. Acquiring the support of insurance payers for a
In 2006, these funds were used to establish an new model of care was a challenge faced in the
intensive rehabilitative day hospital program for opening of the program. Billing codes did not
pediatric CRPS and other chronic pain condi- exist for the types of services that would be
tions, and in 2008, the program officially opened offered at the PPRC. PPRC leadership met with
its doors. insurance executives from regional companies to
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 327

discuss the benefits of the program on health-care ple of a daily schedule. In the early days of the
utilization and overall cost. The hospital and pro- COVID-19 pandemic, the PPRC paused opera-
gram leaders negotiated a per diem rate with each tions for the safety of patients, families, and staff.
insurer, which included a bundled charge for PT, After several months, and with new safety proto-
OT, psychology, and nursing services. Physicians’ cols in place, treatment resumed in a hybrid
time is billed separately. Payment agreements model of care. Within the hybrid model, patients
have been met for a majority of local insurers, attend the PPRC in person for a half day, and the
and single-case agreements have been provided remainder of the day is conducted virtually. This
for other out-of-state patients. Since opening, the hybrid model prioritizes holding physical and
program has been consistently financially viable. occupational therapy sessions in person to gain
the maximum effect of these treatments. Other
therapies alternate between in person and virtual,
Day-to-Day Programming such that only half of the patients are on-site at a
time. Following federal, state, and hospital guide-
PPRC days are structured with multiple therapy lines, the PPRC plans to return to full in-person
sessions throughout the day and week. Each day treatment days as safety protocols allow.
begins at 8:00 a.m., and patients engage in treat-
ment until 4:00 p.m. During this time, each Theoretical Framework
patient attends hour-long treatment sessions. Interdisciplinary pain treatment at the PPRC is
Session formats alternate between individual, based on a biopsychosocial framework. This the-
family, or group treatment modalities, with daily oretical framing highlights the multidimensional
physical therapy, occupational therapy, and psy- nature of pain and indicates the need for a treat-
chological therapy sessions. Patients also engage ment plan that addresses each dimension. The
in rotating recreational therapy and music ther- biopsychosocial model of pain identifies that
apy sessions throughout the week. In addition to pain is associated with biological, psychological,
therapy sessions, patients engage in daily check- and social factors of a person’s experience and
­in meetings with PPRC medical staff (physician, can likewise impact those same areas of function-
nurse practitioner, and clinical assistant [typi- ing (Gatchel, 2004; Gatchel et al., 2007; Liossi &
cally a CNA]) and are allotted 1 hour each for Howard, 2016). Biological factors such as age,
study hall and lunch. See Table 18.1 for an exam- sex, family history, illness, or injuries influence
an individual’s predisposition for chronic pain
Table 18.1 Example daily schedule of PPRC patient (Liossi & Howard, 2016). Psychological factors
Time Activity including an individual’s mood, proclivity for
8:00– Family therapy (e.g., family OT) worrying, temperament, expectations of them-
9:00 a.m. selves or others, and ways of thinking, feeling,
9:00– Individual therapy (e.g., PT) and engaging with the world are also factors that
10:00 a.m.
can affect chronic pain (Gatchel, 2004; Gatchel
10:00– Individual therapy (e.g., psychology)
11:00 a.m. et al., 2007; Liossi & Howard, 2016). These fac-
11:00– Group therapy (e.g., group PT) tors often act in concert with social factors such
12:00 p.m. as how important others in an individual’s life
12:00– Medical team visits/study hall respond to their pain experience as well as an
1:00 p.m. individual’s level of engagement in social or pre-
1:00– Lunch/study hall
ferred activities with peers or family members
2:00 p.m.
2:00– Group therapy (e.g., group (Gatchel, 2004; Gatchel et al., 2007; Liossi &
3:00 p.m. recreational therapy) Howard, 2016).
3:00– Individual therapy (e.g., OT) Equally important to consider is the effect that
4:00 p.m. these factors have on pain. When youth ­disengage
4:00 p.m. Dismissal from their lives as a result of chronic pain, their
328 C. Conroy and Y. C. Cole-Lewis

physical functioning often declines as they are disciplines; for example, psychology providers
more likely to become deconditioned (Liossi & might join an occupational therapy session to
Howard, 2016). Youth often experience increased coach patients to practice implementing dia-
anger, sadness, and anxiety as a result of the phragmatic breathing during a desensitization
intense focus on pain and worries about pain, activity in occupational therapy. Patients are also
leading to less engagement at home or with peers required to complete PT/OT HEPs, home prac-
(Gatchel, 2004; Gatchel et al., 2007). Lack of tice of psychology skills, and evening or week-
engagement further impacts social experiences, end recreational activities that align with
as youth are less likely to engage with peers and therapeutic goals. This offers patients and care-
families often struggle to determine the most givers an opportunity to practice what they learn
helpful response to their child’s pain (Liossi & in sessions and allows providers to engage in
Howard, 2016). problem-solving with families.

Treatment Modalities  ehavioral and Crisis Management

B
PPRC treatment modalities include psychology, Challenges with behavior management often
physical therapy, occupational therapy, recre- arise, as participant may experience significant
ational therapy, music therapy, and medicine. In behavioral responses to treatment. When patients
addition to the shared treatment goals, each disci- engage in pain behaviors (e.g., avoidance, behav-
pline has its own treatment focus. Psychological ioral dysregulation) that interfere with treatment,
therapy supports the development of coping skills PPRC providers will often collaborate to identify
and assessment of emotional and behavioral con- a behavior management plan to implement both
tributions to pain and provides family education on-site with staff and off-site with families. As a
and support. Physical therapy focuses on aerobic result, patients may have limited access to pre-
exercise, strengthening and balancing, and ferred items (e.g., electronics), when having dif-
stretching, all in the context of specific and func- ficulty engaging in treatment, and can earn these
tional movement skills that are useful for day-to-­ and other rewards for appropriate engagement in
day activities. Occupational therapy supports treatment. Consistency with such plans allows
patients in identifying and meeting functional patients and families to practice generalizing
goals related to school, extracurricular activities, skills learned at the PPRC across settings.
self-care, or other daily tasks; treatment activities PPRC staff make efforts to maintain open
may range from sensory retraining (desensitiza- communication with patients and families to pre-
tion) to engaging in schoolwork. Recreational empt any adverse reactions or crisis situations.
therapy utilizes leisure activities to support Despite best efforts, if patients experience physi-
patients’ return to their preferred activities and cal or emotional challenges that require addi-
become reengaged in their communities. Music tional support, providers are trained in behavior
therapy provides opportunities for patients to management principles to respond appropriately
experience the therapeutic effects of music as a to ongoing dysregulation. Additionally, a psy-
coping strategy and support their ability to man- chologist is always on-site to support and offer
age pain and engage in self-expression through assistance when patients are receiving in-person
music. treatments. Should patients require additional
Patients meet daily with the PPRC physician, support, the hospital behavioral response team is
nurse practitioners, and clinical assistant to assess available for assistance. During the initial psy-
clinical changes and manage or discontinue med- chology assessment, or at any point during a
ications as necessary. The medical team’s pri- patients’ PPRC tenure, if providers become
mary focus is collaboration with the PPRC aware of acute psychiatric risk, including active
therapists to ensure a holistic approach to treat- suicidality, self-injurious behaviors, acute behav-
ment. Providers may also implement combined ioral dysregulation, or other high-risk behaviors,
treatment sessions to encourage continuity across they enact the psychiatric emergency plan. This
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 329

plan includes an assessment by an on-site psy- tered an assessment battery of psychosocial

chologist, safety planning as needed, and disposi- measures, including assessment of pain intensity
tion planning with the on-site crisis assessment and frequency, physical functioning, school
team. The team works with on-site administrators attendance and attitudes toward school, pain-­
on duty for potential transfer to the local emer- specific anxiety, general anxiety and depression,
gency department if required. On-site psychol- and perfectionism (see Table 18.2). Caregivers
ogy providers will engage in safety planning for are also administered a battery assessing for care-
passive suicidal ideation and continue to assess giver response to their child’s pain, pain-related
risk and potential need for higher level of care. If fears, and perfectionism. Given the significant
patients require acute support related to safety participation of caregivers in the treatment pro-
concerns while participating in virtual PPRC ses- gram and the influence of caregiver behavior and
sions, providers instruct caregivers to present response on child outcomes, assessment of care-
with the patient to the local emergency depart- giver outcomes is equally as important as those of
ment. If concerns persist and the family declines their children (Palermo et al., 2014).
to report to the emergency department, providers In addition to the psychosocial battery prior to
contact the local authorities to perform a well- admission, each discipline conducts an initial
ness check. assessment upon admission. Physical therapists

Table 18.2 List of core psychosocial assessment

Assessment measures
Child measures
Assessment of patients attending the PPRC is Functional Disability Inventory (FDI; Walker &
valuable for both clinical and research purposes. Greene, 1991)
All patients admitted to the PPRC are given a Fear of Pain Questionnaire (FOPQ-C; Simons et al.,
2011)
multidisciplinary battery of assessments at
Pain Catastrophizing Scale (PCS-C; Goubert et al.,
admission, discharge, and three follow-up time 2003)
points (6–8 weeks post-discharge, 6 months post-­ Adolescent Sleep-Wake Scale (ASWS; LeBourgeois
discharge, and 1 year post-discharge). The assess- et al., 2005).
ment of patients at these time points provides the Child-Adolescent Perfectionism Scale (CAPS; Flett
et al., 2016)
treatment team with the ability to create individu-
PROMIS Depression – short form (Cella et al., 2010)
alized treatment plans, set realistic and measur-
PROMIS Anxiety – short form (Cella et al., 2010)
able clinical goals, and evaluate treatment Frost Multidimensional Perfectionism Scale (FMPS;
outcomes following discharge. Further, with con- Frost et al., 1990)
sent of patients and caregivers, participation in Caregiver measures
clinical research provides valuable data to the Pediatric Quality of Life Inventory (PEDSQL; Varni
growing field of intensive interdisciplinary treat- et al., 1999)
ment of pediatric chronic pain. Fear of Pain Questionnaire (FOPQ-P; Simons et al.,
2011)
The PPRC assessment methods are influenced Pain Catastrophizing Scale (PCS-P; Goubert et al.,
by the core outcome domains recommended for 2003)
pediatric chronic pain trials as recommended by Adult Response to Child Symptoms (ARCS; Van Slyke
the PedIMMPACT consensus meeting (McGrath & Walker, 2006)
et al., 2008). These domains include pain inten- Bath Adolescent Pain – Parental Impact Questionnaire
(BAP-PIQ; Jordan et al., 2008)
sity, physical functioning, emotional functioning,
Depression-Anxiety-Stress Survey – short form (DASS
satisfaction with treatment, economic factors, 21; Lovibond & Lovibond, 1995)
role functioning, and sleep. These outcome Helping for Health Inventory (HHI; Harris et al.,
domains map onto the biopsychosocial model of 2008)
chronic pain and the treatment areas of the pro- Frost Multidimensional Perfectionism Scale (FMPS;
gram. Prior to admission, patients are adminis- Frost et al., 1990)
330 C. Conroy and Y. C. Cole-Lewis

spend the initial days of the patient’s admission, outcomes following pain treatment, including but
administering developmentally appropriate and not limited to patient emotional, cognitive, and
empirically validated measures of strength, behavioral factors, pain-specific factors like
endurance, functioning, coordination, balance, intensity and duration, and environmental influ-
and agility. They also assess for pain interference ences like family system functioning (Palermo
with tasks of physical functioning. Occupational et al., 2014; Simons et al., 2018; Williams et al.,
therapists assess the patient’s participation in 2020). Further knowledge of these contributing
activities of daily living, school functioning, factors will assist IIPTs in development of empir-
coordination and agility, pain sensitivity, sensory ically validated treatments and targeted
profile, and the patient’s self-identified occupa- interventions.
tional goals. Medical and nursing staff also con-
duct a thorough evaluation at the time of
admission, assessing for any biomedical contrib- Interventions
uting factors to the patient’s pain presentation. At
the end of a patient’s admission, the treatment Evidence Base
team will repeat the assessment battery and meet The treatment provided at the PPRC is based
with the patient and caregivers to review treat- upon evidence-based interventions from existing
ment outcomes. The progress demonstrated in literature on chronic pain treatment as a whole
these assessments helps the team to set goals for and from research within each discipline.
the next touchpoint in the treatment, the follow- Existing literature on pediatric chronic pain sup-
­up visit. Follow-up evaluations occur at the 6- to ports the use of multidisciplinary treatment as an
8-week, 6-month, and 1-year post-discharge time effective model for the treatment of youth with
points. this condition (Odell & Logan, 2013; Hechler
Over time, the PPRC has made important et al., 2015). Disciplines included in treatment
adjustments to the battery of assessment mea- may depend on the type of chronic pain (e.g., pri-
sures, influenced by the broadening research on mary headache, gastrointestinal or neuropathic
pediatric chronic pain as well as the developing pain) and range from outpatient coordination
research inquiries of the treatment staff. The between two disciplines to inpatient treatment
assessment process has become more interdisci- with a variety of disciplines included. It is unclear
plinary over time, including the development of if there is a specific treatment level of care that is
measures that cut across disciplines and reflect more effective as there are few published studies
the nature of the program to set patient treatment focused on day treatment models exclusively
goals that span specific disciplines. For example, treating youth with chronic pain. In one study by
the PPRC staff is developing an interdisciplinary Simons et al. (2013), more intensive treatment
adherence measure to assess patient commitment was associated with larger gains in functional
to the treatment recommendations post-­discharge. disability and pain-related fear than matched
The measure includes goals that are created by controls in traditional outpatient multidisci-
the team, rather than by one specific discipline. plinary care.
Empirically validated and evidence-based
assessment in intensive interdisciplinary pain is  ey Components of Intervention
K
important in the evaluation of the patient as well The goal of multidisciplinary treatment gener-
as the evaluation of the program itself. Growing ally, and in the PPRC specifically, is to help
the body of research on assessment measures in patients improve their physical functioning and
pediatric IIPT will help ensure that the treatment engage in developmentally appropriate daily
provided is successful in accomplishing its activities, including engagement in school,
intended goals and meeting patients’ needs. sports, recreation, and family life. Interventions
Research suggests that there may be a number of used within the PPRC are centered in the
influential patient and caregiver factors on patient biopsychosocial model described earlier and
­
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 331

draw from a framework of the fear-avoidance lation strategies, and use of physical movement
model of chronic pain as well as the vicious cycle are also included and implemented throughout all
of pain. These models have been described in disciplines’ treatment. The key to the success of
existing literature (Simons et al., 2012; Dobe & these interventions is the consistency and fre-
Zernikow, 2014). These models acknowledge the quency in which they are carried out.
contributions of cognitive appraisals of pain as
dangerous or catastrophic, emotional and physi-
cal responses to pain and fear, and the role of Keys for Success
avoidance of activity and pain as a significant
contributor to pain-related disability. The PPRC treatment team utilizes the day treat-
Interventions in the PPRC focus on breaking the ment model to its full extent. The colocation of
cycle of avoidance through graded activity pro- disciplines within one physical area, the fre-
gression and exposure to feared activities within quency of team communication, and the develop-
a supportive and structured environment. The ment of shared goals allow for the consistency
intervention allows the patient to challenge cata- that is required for success. Psychologists, physi-
strophic thinking about pain, receive coaching in cal therapists, and occupational therapists col-
active coping strategies, and break cycles of laborate on the setting of short-term goals and
avoidance that have contributed to isolation, utilize the same language, techniques, and strate-
deconditioning, and mood disruption. gies to encourage patient participation and prog-
This progression is supported with active cop- ress. The combination of the consistency among
ing education, founded in cognitive behavioral providers and frequency of daily sessions allows
therapy, acceptance and commitment therapy, for many opportunities for rehearsal of new
family support and education, and psychological skills. This shared approach is taught to caregiv-
support for any identified mood or behavioral ers so that they can learn to provide the same con-
barriers. The interventions utilized are individu- sistency in their home setting. The day treatment
alized to each patient but are founded in evidence-­ model allows them to practice these approaches
based treatments for pediatric mental health as each evening and on weekends when their chil-
well as pediatric chronic pain (Fisher et al., dren are not in the care of the PPRC. Staff pro-
2014). Examples of interventions used to achieve vide patients and caregivers homework to
physical functioning goals are varied. They complete in the evenings and on weekends to
include biobehavioral strategies, such as relax- assess the acquisition of this approach.
ation, guided imagery, progressive muscle relax- In addition to the benefits of consistency and
ation, and mindfulness. Cognitive strategies frequency afforded by the day treatment model,
include the education for the patient and caregiv- the benefit of flexibility is also available. While
ers about the science of pain and the biopsycho- the PPRC has a structured daily schedule for
social model of understanding pain. Psychologists patients and families, there is unique flexibility
engage patients in identification of unhelpful within that schedule to provide tailored treat-
thinking patterns, fears, and depressive thoughts ment. For example, patients who struggle with
and develop strategies to manage these thinking school attendance can participate in a school
patterns through cognitive behavioral and simulation session with one of our occupational
acceptance-­ based models. Other acceptance-­ therapists where they are coached in how to
based techniques include identification of patient implement school-based coping strategies. A
and family values, enhancing patient and parent patient with a goal to return to sports may work
distress tolerance, and engaging in problem-­ with our physical therapist and psychologist
solving techniques with the aim of helping the together to work on both the mechanics of their
patient to adopt a confident, self-management physical participation and the emotions, like fear,
approach to their pain. Behavioral reinforcement that may contribute to avoidance of this activity.
plans, graded exposure ladders, emotional regu- While the PPRC utilizes evidence-based inter-
332 C. Conroy and Y. C. Cole-Lewis

ventions in the treatment of pediatric pain, it is their role in supporting their child’s recovery and
the creative application of these interventions self-management of pain.
within a unique care model that is often identified PPRC providers support caregivers through-
by patients and families as the key to their out the program and provide anticipatory guid-
success. ance about transitioning home, as patients are
likely returning to environmental and situational
stressors. Self-management and pacing are
Collaborations and Generalizing important goals of IIPT, and determining ways to
Treatment incorporate both as patients reintegrate into their
home lives can be difficult. While patients should
PPRC treatment prioritizes the inclusion of fam- be expected to engage in their required tasks
ily and caregivers through formal caregiver ses- (school, chores) and preferred activities (sports,
sions and additional programming. Families are socializing with friends) and independently man-
included in the treatment through daily family age their pain, it is important to do so in a sustain-
sessions with each of the therapies. Caregivers able way. Caregivers are expected to be available
will have opportunities to observe their child’s for support while encouraging a developmentally
progress in physical therapy, occupational ther- appropriate level of independent functioning to
apy, or psychology on a daily basis. Though less promote and maintain increased self-efficacy to
frequent, family sessions for recreational therapy manage pain. Providers engage in relapse preven-
and music therapy also engage caregivers in sup- tion by helping to prepare families for this transi-
porting their child’s coping and self-management tion prior to discharge. This coordination of care
of pain. Meeting regularly with caregivers allows can often reduce conflict between patients and
providers to discuss and problem-solve around families while also improving mood and building
caregiver engagement with their child in the con- confidence to manage challenging situations.
text of pain and model helpful strategies for
responding when patients experience challenges.
In addition to caregiver engagement with Working with Schools
patients, caregivers have programming designed
specifically for their edification. PPRC providers Another significant part of the treatment includes
lead caregiver education sessions in a variety of working with schools throughout patients’ PPRC
interdisciplinary topics, which also allow for admission. With caregiver consent, psychology
group conversation and discussion of common providers and occupational therapists collaborate
themes in pediatric chronic pain. Both in this with patients’ schools to inform them of the treat-
context and in family sessions, providers take ment and identify realistic goals for accessing
care to openly communicate caregiver expecta- and completing schoolwork. Providers work col-
tions in the program and encourage caregivers to laboratively with schools and caregivers to con-
consider current patterns of engagement that con- duct school meetings during treatment and
tribute to their child’s impairment. Caregivers develop school reentry plans prior to discharge as
also have access to a weekly support group, a pertinent part of treatment. Prior to discharge, a
which provides opportunities to connect with formal school conference call is held with the
other PPRC caregivers, as well as an informal patients’ primary treatment team, parents, and
coffee hour for ongoing community connection. key stakeholders from their school. Patients are
PPRC providers also encourage caregivers to typically not in attendance, though older adoles-
take advantage of opportunities to schedule regu- cents may request to join the meeting.
lar individual meetings with the PPRC social Psychoeducation about chronic pain manage-
worker. These individual meetings are useful ment within the academic environment is dis-
when caregivers require additional support or cussed and supported by written documentation.
would like to gain an improved understanding of School staff receive copies of the written docu-
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 333

mentation and copies of the coping plans devel- treatment plans initiated by the outpatient
oped during the participant’s admission. provider.

Outpatient Follow-Up Care Case Example

In addition to support with school reintegration, Alexa is a 12-year-old white female who pre-
PPRC providers regularly coordinate care with sented for treatment at the PPRC due to persistent
outside treatment providers to ensure patients can pain in her right leg following an injury she sus-
return to an environment with ongoing support. If tained during a dance competition 9 months prior.
caregivers approve, PPRC providers contact out- Alexa was initially evaluated for her injury,
patient therapists, coaches, and physicians to which was diagnosed as an ankle sprain, treated
offer insight regarding patients’ treatment and with conservative measures such as ice, rest, and
progress toward functional restoration. Providers staying off of her right ankle until her swelling
offer education and resources to facilitate addi- and pain subsided. Despite these interventions,
tional knowledge of chronic pain treatment for Alexa’s pain continued, and she followed up with
outpatient providers. When appropriate and help- her PCP, who recommended a walking boot for a
ful, PPRC providers also communicate with period of 1 month. During that time, Alexa’s pain
other community members with whom patients worsened and after a period of 3 months post-­
typically interact, such as athletic coaches, dance injury, her pain was severe. She had started to
instructors, gym teachers, and other extracurricu- develop new symptoms including sensitivity to
lar activity leaders, to provide recommendations touch and discoloration of the skin on her leg.
about paced reentry into sports and activities. Her pain had increased beyond her ankle and
Collaboration with these helpers is often essen- included her entire lower leg beneath her knee.
tial to support the patients’ safe and appropriate Alexa was referred to the Pain Treatment
return to functioning at home, in school, and in Service at Boston Children’s Hospital and was
athletic and leisure activities. Following dis- seen for a multidisciplinary evaluation with a
charge, PPRC providers maintain communica- pain physician, a pain psychologist, and a physi-
tion with families and outpatient providers for cal therapist. Alexa received a diagnosis of com-
ongoing support and collaboration as necessary. plex regional pain syndrome, or CRPS. CRPS is
Following discharge, patients and their fami- a chronic pain condition characterized by persis-
lies receive a check-in phone call during their tent pain, typically in the extremities, as well as
first week back at home. PPRC nurse practitio- other specific features including increased sensi-
ners place these calls and ask patients about their tivity of the skin, color and temperature changes
adjustment to school or other activities, compli- of the affected area, swelling, and/or motor
ance with their post-discharge recommendations, impairments. Her initial physical therapy assess-
and field any questions on the transition process. ment indicated that Alexa had experienced some
Caregivers receive guidance prior to discharge on muscle loss in her right leg and a decrease in her
the appropriate times to call the PPRC for guid- range of motion and strength. Her psychology
ance, including difficulties with compliance, evaluation indicated that Alexa was endorsing
poor school attendance, significant declines in symptoms of generalized anxiety and pain-­
functioning, or questions regarding any medica- specific fear and avoidance and she endorsed pas-
tion plans initiated while at the PPRC. Families sive suicidal thoughts. She was prescribed a
are advised to reach out to their local providers course of outpatient physical therapy and recom-
(primary care physician [PCP], mental health mended to pursue treatment with a psychologist
provider, or any treating PT or OT) for more gen- with a focus on cognitive behavioral therapy. She
eral health concerns, assessment of new injury, or was also provided with a prescription for
334 C. Conroy and Y. C. Cole-Lewis

g­ abapentin in an effort to try and control her sig- struggled with the recommendation to reduce
nificant nerve pain. pain assessment and passive strategies, such as
Alexa returned for a follow-up visit with her rest or avoidance of painful activities, and they
pain physician 3 months later. She had been benefited from the supplemental support pro-
engaging in outpatient physical therapy and had vided by the social worker at the PPRC.
started to see a counselor. However, she contin- Alexa was able to successfully wean out of her
ued to endorse significant levels of pain, and her walking boot and off of her crutches after the
functioning had declined. Alexa was no longer third week of treatment. She started to walk with
able to attend school regularly and was advised to a more normalized gait pattern and engaged in
engage in homebound instruction as a result. She desensitization of her sensitivity on her lower leg,
had not been able to participate in her dance allowing her to wear preferred clothing (e.g., leg-
classes, and her social activities had decreased in gings, jeans) and place her leg in a running water
frequency. Alexa’s parents reported frustration stream, both of which had been avoided due to
and anxiety about the lack of progress and felt pain. In her fifth week, however, Alexa appeared
that they did not have the tools they needed to to plateau in her progress, and her affect was
help Alexa succeed. increasingly irritable and anxious. A team meet-
Alexa and her family were referred for admis- ing was arranged to discuss the potential contrib-
sion at the PPRC. Alexa’s case was reviewed by uting factors to this shift. Alexa’s parents and her
the PPRC admission team, and she was deter- primary team members met to discuss the poten-
mined to be an appropriate candidate. Given her tial barriers. Alexa’s parents discussed their
history of passive suicidal ideation, a psycholo- impression that Alexa was anxious about the
gist at the PPRC consulted with her treating pro- expectations that might be place upon her now
vider to discuss potential safety risks. The treating that she was able to return to school and sports.
therapist felt that Alexa had developed a good Alexa was previously a very accomplished
safety plan and shared this plan with the treat- dancer and a high-achieving student. Her move-
ment team at the PPRC, with parental consent ment toward functioning may also represent a
and release of information. movement toward the pressure associated with
Alexa was admitted for a 6-week admission at these activities.
the PPRC. During her initial assessment at the In the remaining treatment days, the team
PPRC, Alexa continued to endorse high levels of assisted Alexa and her family to discuss reason-
pain-related fear, general anxiety, sleep disrup- able expectations for Alexa’s return to dance. A
tion, and a high level of perceived disability. She conference call was held with administration
continued to use a walking boot and crutches for from Alexa’s school to provide them with educa-
ambulation and vocalized anxiety about the tion about her condition and recommendations
potential for these devices to be discontinued. for her return to school. The education empha-
During Alexa’s admission, her therapists worked sized the importance of the focus on functioning
together on creating graded exposures and activ- and the recognition of the role of stress on func-
ity hierarchies to treat Alexa’s fear and avoidance tion. Alexa developed a plan with her psycholo-
behaviors. In psychology sessions, she worked to gist of how to talk with her classmates about her
develop skills to enhance her engagement in condition, and her dance teacher set up sessions
treatment and address symptoms of anxiety, such where she would gradually return to her previous
as relaxation strategies, cognitive restructuring of class. Alexa’s progress became more consistent,
anxious and depressive thinking, motivational and at discharge, she was expressing more confi-
enhancement, and use of behavioral contingency dence in her abilities. Discharge results indicated
plans to reinforce engagement in treatment. Her significant gains in strength, endurance, range of
parents engaged in family therapy sessions to motion, sensitivity, and speed. She also endorsed
learn about how they could support Alexa’s inde- clinically significant improvements in anxiety
pendent management of her pain. They initially and depressive symptoms, as well as reductions
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 335

in pain-related fear and avoidance. She denied statement for chronic pain, such as physical func-
ongoing passive suicidal ideation. Her parents tioning, emotional and behavioral functioning,
endorsed a reduction in protective responses and school attendance and functioning, and sleep.
overall anxiety. Data collected also includes areas of interest in
After discharge, Alexa reintegrated back into the potential influence of pediatric pain treatment
school, attending full time with an added aca- outcomes, such as pain-specific outcomes like
demic support class in her schedule to provide fear, avoidance, and catastrophizing. These spe-
some time during her day to complete homework, cific psychological constructs have been detailed
go for a short walk or stretch, or engage in some in the literature as influential in the outcomes of
relaxation exercises. She continued to endorse pediatric pain rehabilitation (Simons et al., 2012;
pain in her lower extremity but at a lower level Weiss et al., 2013). Further, psychological
than preadmission. She contacted the PPRC on research at the PPRC evolved over time to include
two occasions due to experiencing a rapid new areas of interest and incorporate observa-
increase in her pain, also called a “pain flare,” tions of the treatment population. For example,
that was increasing her distress and anxiety perfectionistic tendencies have been noted in the
symptoms. Alexa’s primary treatment providers pediatric chronic pain population, but the empiri-
at the PPRC met with her and her parents via cal data supporting such observations is minimal.
phone to review her coping plans and ensure that The PPRC is currently exploring the clinical data
she was attending her outpatient counseling ses- to support this observation (Randall et al., 2021).
sions. At her first post-discharge follow-up, Alexa Patients at the PPRC participate in clinical
had met her short-term goals of continued research upon consent at five time points; admis-
improvement in strength and agility, full return to sion, discharge, 6–8-week post-discharge,
school, and reintegration to her dance class. 6-month post-discharge, and 1-year post-­
discharge. The post-discharge time points coin-
cide with clinical follow-up evaluations with the
Integrating Research and Practice treatment team and as such are useful for clinical
data as well. Data collection occurs via online
The interdisciplinary team at the PPRC is invested survey and occurs during the in-person evalua-
in conducting research with the aims of investi- tion. Post-discharge data collection is crucial in
gating the clinical outcomes of the treatment pro- helping to draw conclusions about the short- and
gram as well as contributing to the field of long-term impact of treatment. Longer-term data
research on intensive interdisciplinary pain treat- collection is also included in the PPRC research
ment. Data collection starts prior to admission efforts, although long-term clinical follow-up is
and continues well beyond discharge from the not.
program. Each discipline collects data within Published research from the PPRC focuses
their field, and different disciplines frequently primarily on clinical outcomes of the program
collaborate with each other. Research efforts are and the various factors that influence these out-
supported by a dedicated research assistant and comes. Initial outcomes from the first year of
data coordinator along with a dedicated research patient data found improvements across nearly
committee comprised of an interdisciplinary every domain from admission to discharge,
group of staff clinicians. This research effort is including physical functioning, pain intensity,
part of the larger efforts of the Pain Treatment and emotional functioning (Logan et al., 2012a).
Service at Boston Children’s Hospital and the This study was followed later by a 5-year out-
commitment to investigation, understanding, and come study that described maintained improve-
treatment of pediatric pain. ments over time in the areas of functioning in
The data collected within the discipline of 80% of respondents. Thirty percent of respon-
psychology includes important outcome mea- dents reporting being pain free, and 89% had
sures, as detailed in the PedIMMPACT (2008) graduated from school on-time (Simons et al.,
336 C. Conroy and Y. C. Cole-Lewis

2018). In addition to these broad-reaching publi- more reliably measured. Staff are also engaging
cations on the outcomes of the patients over time, in local, national, and international conferences
research has also been published on specific fac- to disseminate research findings, collaborate with
tors of interest, including the changes in sleep the global pediatric pain community, and con-
and changes in willingness to self-manage pain tinue to educate our staff on the latest research in
after participation in the treatment (Logan et al., the field.
2012b, 2015).
Research efforts at the PPRC have also focused
on predictors of treatment success. Specifically, Lessons Learned and Next Steps
readiness to change, fear of pain, caregiver pro-
tective responses, and level of disability have been The development of the PPRC was the result of
identified as important variables that can shape key stakeholder’s efforts recognizing the need for
success. These patient and caregiver factors have a method of care delivery that would best suit the
been associated with both short-term success dur- needs of the patients as well as the interests of
ing the admission and longer-­term success after payers to reduce health-care costs. Fortunately,
discharge (Logan et al., 2012b; Simons et al., philanthropic donors were also interested in sup-
2012; Sieberg et al., 2017). In one such study, porting the access to health care for youth and
Simons et al. (2018) utilized a trajectory model of families with complex needs. It is likely that
data analysis to determine variables associated other clinics may not have access to this type of
with treatment response or nonresponse. Older funding or individualized space to develop a free-­
age, higher levels of pain, and lower readiness to standing pediatric pain rehabilitation program.
take a self-management approach to pain were More likely is the possibility of offering a more
variables associated with a lack of response to intensive outpatient or day treatment model
treatment (did not report significant changes in through existing pain treatment clinics and staff.
pain or functioning). When planning the development of an outpa-
Ongoing research continues to evaluate the tient pediatric pain treatment program, there are a
short- and long-term outcomes of treatment in number of important considerations in this pro-
the PPRC. Interdisciplinary collaboration is a cess. The PPRC has some unique features that are
growing initiative in our research efforts with the keys for promoting the success of the patients and
intention to replicate our treatment philosophy in the model in general. First, is the high staff-­to-­
our research efforts. Education, mentorship, and patient ratio. The initial census of the PPRC was
dedicated research time are starting to be offered four patients, all with a primary diagnosis of com-
to all disciplines at the PPRC, and publications plex regional pain syndrome (CRPS), with seven
including a diverse spectrum of authors are treating clinicians. Each patient has a core team of
increasing. Clinician researchers on staff are cur- providers who provide both individual and fam-
rently exploring unique contributing factors to ily-based treatments at a high dose of interven-
pediatric pain treatment, including the role of tion. Previous literature has highlighted the value
perfectionism in youth and caregivers and the of increased dose of treatment for patients with
impact of caregiver mental health on child out- CRPS, and this is only possible if there are avail-
comes. Projects are also exploring novel treat- able staff (Simons et al., 2012). Additionally, the
ment approaches such as virtual reality and staff at the PPRC primarily work in the pain reha-
piloting clinical protocols to increase patients’ bilitation center and are not dispersed among
preparedness to participate in treatment. Physical other clinics during their workday. This staffing
therapy and occupational therapy staff are focus- model allows for frequent communication, colo-
ing on the development of more accurate assess- cation, and consistency that helps patients suc-
ment tools so that treatment response may be ceed and contributes to staff cohesion. Staff also
18 Pediatric Pain Programs: A Day Treatment Model at Boston Children’s Hospital 337

have opportunities to participate in clinic leader- (Griffin et al., 2020). The use of this technology
ship, committee membership, and research initia- may also provide an opportunity to simulate
tives, all of which have the potential for creating a environments not found in a clinic setting. Other
healthy work environment and commitment to ongoing initiatives in the PPRC include the
improvement of the program. Acquiring approval development and validation of accurate assess-
for a high staff-to-patient ratio may present a chal- ment measures for symptoms of chronic pain
lenge for many institutions. Demonstrating finan- such as phono- and photophobia, allodynia, and
cial solvency, putting forth a detailed yearly pain efficacy. Many projects are in collaboration
budget, and highlighting the outcomes research with national and international pediatric pain col-
for chronic pain rehabilitation may all be useful in leagues. The PPRC continues to collect caregiver
advocating for these resources. and patient information about satisfaction, expe-
The PPRC has expanded to treat eight patients rience in treatment, and ways to improve the
at one time with a variety of chronic pain diagno- patients’ engagement in treatment. This is some
ses with 14 full-time clinicians. The next steps of the most valuable data collected and greatly
for the PPRC are to continue to expand our ser- assists the program in our continued mission to
vices not only to our current patient population provide quality care to youth with chronic pain.
but also to new populations. Since its opening in
2008, the diagnoses treated have expanded to
include chronic headaches, chronic abdominal Conclusion
pain, and widespread musculoskeletal pain.
Future growth of the clinic is expected with the The Mayo Family Pediatric Pain Rehabilitation
hope of continuing to provide unique and indi- Center at Boston Children’s Hospital effectively
vidualized treatment to a broader spectrum of utilizes the day treatment model of care to pro-
patients with debilitating chronic pain. For exam- vide integrated health services to a population of
ple, one potential population in need of more youth with high health-care needs. Using the bio-
intensive services is the young adult population. psychosocial framework, the treatment of youth
Young adults present with unique challenges, with chronic pain requires the provision of mul-
developmental tasks, and neurobiological and tiple services in a coordinated effort, which can
functional deficits and likely require a more spe- be most successfully achieved when those pro-
cialized approach (Rosenbloom et al., 2017). viders have the flexibility and shared physical
Unfortunately, there is a lack of rehabilitation location afforded by the free-standing day treat-
programs for this unique population. ment model. Further, the day treatment model
In addition to clinical growth, the PPRC plans itself serves as an intervention, allowing patients
to continue its research and clinical innovation and families to learn and practice new skills in
growth as well. Interdisciplinary projects are cur- the structured environment of the clinic as well as
rently moving forward with hopes to utilize outside of the clinic with their caregivers and
advancing technology in addition to the estab- family members. Key components of the success
lished evidenced-based treatments to aid in the of this model include assessment and interven-
treatment of chronic pain. Current research and tion based in evidence from the field of pediatric
clinical efforts are ongoing to incorporate virtual chronic pain, education of staff members in the
reality technology to assist in the exposure-based theoretical framework that results in consistency
treatment of youth with chronic pain. Virtual of the intervention, connection and collaboration
reality technology use in the pediatric pain popu- with community providers, and follow-up post-­
lation is in its beginning phases and is showing discharge with patients and families to promote
good promise for enhancing engagement in activ- generalization of the skills acquired in
ity, reducing fear, and promoting relaxation treatment.
338 C. Conroy and Y. C. Cole-Lewis

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 Transitioning to Adult Services:
Young Adult Partial 19
Hospitalization and Intensive
Outpatient Programs

Erin Ursillo and Gerrit van Schalkwyk

Introduction diverse as to the outcomes of their personality

styles, coping structures, and psychosocial
Young adults (ages 18–26) may benefit from pathways. It is thus well justified to invest con-
intensive levels of treatment, such as partial siderable resources in supporting the success of
hospital programs (PHPs) and intensive outpa- this group of individuals.
tient programs (IOPs). The rationale for a focus In this chapter, we will describe the principles
on young adult mental health in general is made of intensive (PHP and IOP) treatment of young
throughout this volume – but what about the adults, drawing on the literature where possible
specific reasons to consider young adult PHPs but also from our experience of developing and
and IOPs? Perhaps the most important reason is managing six such programs at a large psychiatric
that young adults do not only have mental hospital in New England. It is this experience that
health problems but also often quite serious showed the limitations of providing treatment for
ones. This includes the fact that the first episode young adults in the same treatment settings as
of psychosis is most likely to occur in young those provided for adults in general, who are more
adulthood (Amminger et al., 2006) and data heterogeneous in terms of their symptoms, con-
that suggests a relatively high and increasing text, goals, and potential. We will describe the rea-
rate of suicide in this population (Stone et al., sons we took this approach to young adult-specific
2018). A second major reason is that young programming and will describe the features of our
adults have likely left high school and are thus program including overall structure, program cur-
required to rely on less robust sources of struc- riculum, staffing, and other special considerations.
ture and support. A third reason is that the pos- We hope that readers will be left with the why and
sible rewards are great; young adults remain how of designing and implementing intensive ser-
vices for young adults.

E. Ursillo (*)
Care New England, Butler Hospital, Partial Hospital  hy PHP and IOP, and Why Young
W
and Intensive Outpatient Programs, Providence, RI,
USA Adult Specific?
e-mail: [email protected]
G. van Schalkwyk With increasing suicide rates for young adults
Department of Pediatrics, Division of Behavioral (Stone et al., 2018), it is as important as ever to
Health, University of Utah School of Medicine, Salt address crises for young adults in the moment
Lake City, UT, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 341
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_19
342 E. Ursillo and G. van Schalkwyk

and in the most expedited manner possible. Keys to Success

Group-based PHP and IOP programs allow for
such accelerated treatment. PHPs and IOPs A group-based approach has proven central to the
(young adult specific or not) have significant clinical success and sustainability of our young
benefit for the delivery of clinical material to adult IOPs and PHPs. Generally speaking, group
patients in a short and intensive episode of therapy allows for dialogue between patients by
care. Material that could take 8–12 weeks to way of offering support, challenging one another,
cover in individual therapy may feasibly be and relating to one another. One benefit we have
taught in 1–4 weeks in a traditional PHP and found is that young adult-specific intensive pro-
IOP format due to the intensity of the programs grams have helped generate a deeper connection
in terms of frequency and length of contact – between patients and significantly greater group
typically several hours a day, most days of the cohesion than that of groups of patients with
week. greater age differences. Patients in this age range
In our experience, prior to opening young are relatively similar both in neurodevelopmental
adult-specific programming, treatment of young stage and in life stage where many are defining
adults occurred in our already existing “adult” and developing their adult selves (Roisman et al.,
PHP and IOP programs. While treatment was 2004). This project cuts across domains of per-
certainly beneficial for those who participated sonal values, academic aspirations, career goals,
and completed the programming, it was evident relationship goals, and romantic ideals.
that the young adult experience in particular Delivering clinical material to patients who have
was different in these programs. Internal atten- such similarities has led to more profound group
dance tracking at the time highlighted that the discussions and interconnection.
dropout rate for young adults in these greater Another benefit we found is that the feedback
adult age range programs was higher than that from young adult peers in group appears to have
of other age groups. For those young adults who more of an impact on patient insight than if such
did engage and complete the program, we feedback were to come from an older patient or
observed that smaller subset groups of young staff member. This relates both to the greater eco-
adult patients were forming within the larger logical validity of advice given by peers who live,
milieu. We also experienced patient feedback work, and learn in similar environments to one-
through anonymous surveys that it was difficult self and the impacts of being in a developmental
to share in group and relate to others due to the stage where developing independence requires
differences in peers’ ages and life stages. creating renewed distance from figures that are
Additionally, for those who completed treat- seen as controlling or parental. Further, patients
ment, pre- and post-­treatment symptom rating have described less anxiety about sharing prob-
scales indicated comparatively less improve- lems with young adults than with older adults,
ment for young adult compared to general adult fearing that their problems will be perceived as
patients. “small” or “trivial” as compared to some of the
These findings brought to light the need for problems older adults bring to groups.
young adult-specific programming, which was Socialization with peers is another benefit to
introduced in 2015. This change has seen sub- age-specific group programming and reflects the
stantial benefits across the domains of access, stated importance of universality and acceptance
treatment experience, dropout rates, and clinical as key therapeutic factors in group psychotherapy
outcomes – both anecdotally and based on symp- (Yalom, 1985). For those patients who value
tom rating scales after completion of treatment. social connectedness or who are otherwise iso-
Further, the experience of creating, expanding, lated, social connections made in group can be a
and refining our young adult programming over huge motivator for continued treatment and
the last several years has fostered notable insights engagement. We find this population experiences
as to the key ingredients for success. a greater atmosphere of connection as compared
19 Transitioning to Adult Services: Young Adult Partial Hospitalization and Intensive Outpatient Programs 343

to our general adult population. Patients tend to and of the utmost concern for both patients and
spend time together more on breaks and speak staff, diversity can at times be more accepted in
more to one another off program hours than our youth, which could provide a small sense of com-
general adult programs. While there are clear and fort to patients seeking care. Since the aforemen-
definite concerns regarding group dynamics and tioned topics can at times contribute to the reason
enmeshment among patients when they commu- someone is seeking treatment, it is highly benefi-
nicate outside of group (which will be discussed cial to pair patients up within this age range, cre-
later), this sense of community and support can ate a culture of acceptance, and provide clear
also be categorized as beneficial. signaling that diversity is accepted and cele-
Considering the maturity levels of young brated, in hopes to welcome all young adult
adults and the fact that at 18 years of age they are patients.
deemed adults who need to make their own deci-
sions about accessing care, one might predict that
absences would be a common issue in young  eatures of Young Adult
F
adult-specific programming. Interestingly, our Programming
young adult-specific programs have better atten-
dance rates than our general adult programs tend While IOP and PHP levels of care traditionally
to have, with around 91% of patients presenting operate with standard components of group ther-
for intake compared to rates of 70–80% in our apy, individual therapy, and medication manage-
other PHPs. We believe that the social connected- ment, successful program development requires
ness mentioned earlier highly contributes to this special attention to the nuances of the population
finding. As patients become more socially con- of focus. In order to understand our programming
nected to peers in the milieu, they often hold one rationale, we will discuss the issues of access,
another accountable for attendance and treatment curriculum, philosophy, staffing, and other spe-
engagement. cial considerations that have proven fruitful over
Stigma surrounding mental illness appears to time.
be less of a barrier to accessing care in young
adult patients. Young adult patients appear to be
fairly in tune to the importance of mental well- Access
ness and appear less influenced by stigma as
compared to older patient populations. In fact, While there are already many potential barriers to
when new patients present for treatment and have seeking, enrolling in, and engaging successfully
stigma-related concerns or beliefs, we typically in treatment, every effort should be made to
find they are more likely to have these views ensure that barriers are as minimal as possible for
challenged by peers. In a group setting, this often this population due to the high suicide rate and
promotes a positive and healthy approach to other age-specific factors described above. One
treatment and acceptance that can enhance must first take into consideration the typical
engagement and foster collaboration throughout schedule of a young adult when determining the
the program. format of the program. For the program schedule,
Finally, young adult patients belong to a more days of week and times of day must make sense
diverse generation than prior generations in the for the young adult lifestyle. Late evening/night
United States. For patients who present with con- (when many young adults socialize, work, or
cerns surrounding topics such as religion, poli- study) might not be the best time to host pro-
tics, gender identity, sexuality, gender expression, gramming. Extremely early in the morning when
culture, etc., it can be somewhat less intimidating some youth struggle to get up and engage with
to engage when paired with other young adults motivation is also a challenge. We have found
for treatment. While the risk of discrimination that daytime and early evening hours work best
and judgment are real and possible in treatment for the young adults in our community.
344 E. Ursillo and G. van Schalkwyk

Enrollment into programs must be as stream- patients what will be expected of them in treat-
lined as possible. Many young adults lack both ment as well as what they can expect from group
interest and experience in navigating complex therapy, the program therapist, and the psychia-
healthcare systems, understanding insurance, and trist, as a way to ensure there are no misconcep-
advocating for themselves. Referral should be tions about the treatment itself and to expose
possible through emergency rooms, community barriers they may have personally to engaging in
providers, and self-referral. Regarding the latter, treatment at this level of care. Once all parties are
a 24-hour call intake line is critical and should in agreement, the patient begins the program that
facilitate a rapid assessment of the most suitable same day.
program and provide a start date within a few If the evaluation results in a different level of
days in most cases. care being indicated, education is provided to the
patient about our recommendations and the ratio-
nale. A discharge planner assists the patient in
Assessing Fit setting up the next appropriate treatment, and the
patient would not admit to the program. We have
In an effort to avoid any barriers to a young adult found that this approach in the beginning of treat-
accessing treatment, patients can be scheduled ment helps align the patient and providers in
for the program by sharing only minimal infor- engagement and allows for a dialogue to reflect
mation about their current struggles as long as back upon should engagement waiver throughout
they meet the minimum criteria of age. Referral the program.
sources are made aware of the overall structure
and philosophy of the program, but beyond this,
patients could be referred to the program without  rogram Curriculum: Incorporating
P
any formal screening or assessment prior to their Empirically Informed Interventions
start date.
On a patient’s first day, we begin treatment In selecting program curriculum for the young
with a formal psychiatric evaluation with the adult-specific population, we took into account
goals of diagnosing, assessing risk, understand- the fact that young adults are transitioning into
ing a patient’s goals, and determining if the pro- adulthood, learning independence, and finding
gram the right fit. Additionally, we use three their own voice. Theoretically, we found it impor-
self-report assessment tools to aid in determining tant to incorporate skills from cognitive behav-
the appropriate level of care for a new patient: the ioral therapy (CBT) (Butler et al., 2006) and
24-item Behavior and Symptom Identification dialectical behavioral therapy (DBT) (Butler
Scale (BASIS 24; Cameron et al., 2007), which et al., 2006). These two theories combined offer
evaluates depression and functioning, relation- the ability to understand feelings, recognize
ships, self-harm, emotional lability, psychosis, thinking patterns, change behavior, learn about
and substance use over a one-week period; the interpersonal effectiveness, learn how to regulate
Clinically Useful Depression Outcome Scale intense emotions, and better manage distress.
(CUDOS; Zimmerman et al., 2008), which eval- Additionally, we decided upon incorporating
uates depression symptoms over the last 24 hours; acceptance and commitment therapy (ACT) in
and the Clinically Useful Anxiety Outcome Scale our curriculum (Hayes et al., 2015). Under this
(CUXOS; Zimmerman et al., 2010), which eval- theory, we emphasize values identification,
uates anxiety symptoms over the last 24 hours. If acceptance, and cognitive diffusion. For values
it is determined that a patient would benefit from clarification, many youth are branching off of
the program once the assessment and tools are their childhood influences and determining what
complete, time is then spent orienting the patient they value as newfound adults. ACT endorses the
to our program philosophy. Prior to joining the idea that living life in line with our values tends
first group session, we review with all new to generate more moments of happiness (Hayes
19 Transitioning to Adult Services: Young Adult Partial Hospitalization and Intensive Outpatient Programs 345

et al., 2015). The concept of acceptance stresses philosophy at the forefront of all patient interac-
that, at times, we need to accept intense emo- tions helps us empower the patient to take an
tions, thoughts, and circumstances if they cannot active role in treatment. It also helps avoid adding
be changed right away. ACT emphasizes the to inadvertent “treatment failures” whereby the
energy cost of trying to manage every difficult patient does not fully understand what is wrong
feeling when it arises and acculturates to the and the expectations in terms of what will be
alternative of allowing it to persist while moving required of them, what will be required of the
on productively anyway. This theory can be par- team and the role of medicine, and what recovery
ticularly helpful for patients with intrusive will look like. Failing to make these factors
thoughts or first break psychotic symptoms (Bach explicit could lead to perceived treatment failure
et al., 2012). due to a failure to understand the task at hand.
Patient and treatment team collaboration is
imperative. Treatment progress and readiness for
Program Philosophy discharge is determined through collaborative
discussions and a combination of patient self-­
Managing group-based programs with multiple report and therapist perspective regarding group
disciplines involved is very different than manag- participation, motivation, and individual therapy
ing a single provider outpatient setting. In a check-ins.
group-based program where there are several
providers interacting with a patient, especially
who is a young adult, it is important that all pro- Prioritizing Psychosocial Recovery
viders participating have investment and adher-
ence to a well-articulated treatment philosophy. Young adulthood is an incredibly important time
In our program, we developed a philosophy to make progress on a range of developmental
that focuses on a patient’s strengths and resil- tasks. Our hope is that most individuals will exit
iency. We ensure that all patients (and patient this period of their lives with substantial achieve-
supports) understand our formulation of the ments around their overall sense of self, career
patient, which includes our interpretation of what goals, relationships, financial wealth, and inde-
they are experiencing biologically (brain-based pendence. When symptoms of poor mood and
factors, including overall cognitive level), how anxiety present during this period, it is important
their personality has developed (how does their that they be addressed – to this end, skills-based
personality serve their wellness vs. are there vul- groups incorporating principles like distress tol-
nerabilities that might be getting in the way), and erance, thinking errors, cognitive distortions, and
what their environment is like (are there environ- interpersonal effectiveness are commonly
mental aspects that could interfere with recov- employed. However, it is also important that
ery). Once a patient understands this formulation, patients continue to work toward achieving the
our team will work with them to identify how tasks of young adulthood. The theoretical
they can use treatment to the fullest and achieve approach of ACT provides an empathic way of
wellness. There is a strong emphasis on the delivering this message and organizing psycho-
patient’s desire/motivation to change, providing therapy accordingly. But it is also important to
necessary skills and support to create change, and consider how biological and social aspects of
recognizing when a patient might not be ready to treatment, as well as the structure of the program
commit to all the requirements needed for as a whole, reinforce this message.
improvement. Although some effort is made to In the course of biological formulation and
try and build motivation at times, ultimately, treatment, there is an opportunity to understand
patients who were not interested in recovery are the extent of the patient’s symptoms, their goals
unlikely to be suitable for the program at that in terms of symptom relief, and how this is inter-
point in time. Ensuring that our team keeps this secting with their overall functioning. Patients
346 E. Ursillo and G. van Schalkwyk

frequently describe how high anxiety and poor other treatment-interfering behaviors. To ensure
mood have led to them not attending classes or that team members consistently embrace the
getting out of bed and that their highest priority is shared commitment to the philosophy, we hold a
to “feel better.” In such a case, we will consider daily treatment team meeting whereby we review
medication-based options that may reduce symp- each patient assessing for group participation,
toms and treat underlying biological vulnerabili- motivation, milieu engagement, medication com-
ties, but it is important to emphasize to patients pliance/needs, risk assessment, and progress
that they cannot wait for this to “kick in” before toward goals. During these meetings, staff work
working on other strategies to regain some of together to ensure our philosophy remains intact
their functioning. It is further the case that symp- for each patient and the unit as a whole.
tom relief is less likely to occur in the absence of
significant changes in behavior and choices, as  hysician/Medical Provider Role
P
exemplified by the comparatively greater effect Given the multidisciplinary nature of a high-­
sizes of behavioral activation when compared to quality intensive treatment program, it is critical
medication monotherapy (Anderson, 1998; that the primary role of the physician or medical
Cuijpers et al., 2007). provider (hereafter referred to as “medical pro-
We also make liberal use of occupational ther- vider”) be well understood and operationalized.
apy resources in helping patients who are not in This is not the exclusion of the medical provider
college work on finding and maintaining employ- participating in other aspects of treatment but to
ment. A group-based program that emphasizes ensure that treatment is being applied with con-
doing better over feeling better may embody a sistency and transparency and to reduce risk of
more optimistic tone and drive collaborative splitting and poor engagement. The medical pro-
efforts at problem-solving between patients and vider will meet with the patient individually upon
providers, as well as patients themselves. Of intake, discharge, and around once or twice in
course, this is not easily achieved, and it is criti- addition, depending on overall need.
cal to invest time in addressing the concerns In a nutshell, the medical provider is respon-
(legitimate and otherwise) that may interfere sible for crafting the biological formulation and
with patients reaching their potential. recommending associated treatment. This
requires a more sophisticated approach than a
simple DSM diagnosis and extends to a deeper
Program Treatment Providers hypothesis as to what components of the patient’s
difficulties relate to brain-based factors. In real-
Staffing ity, the vast majority of patients with significant
mental health problems have biological, psycho-
Like many traditional PHPs and IOPs, we staff logical, and social determinants of their prob-
our programs with independently licensed thera- lems. Working to understand the relative
pists (LCSWs and LMHCs) and psychiatrists. contribution of each is critical. For example, if a
For the young adult population, we also staff our patient presents with symptoms of poor mood but
program with occupational therapists. For each is in a chronically stressful and untenable envi-
discipline, we incorporate students who learn the ronment, the medical provider and therapist
discipline-specific role as well as the treatment should first seek to collaborate on problem-­
philosophy we uphold. When selecting our staff solving rather than immediately applying a bio-
(and students), our top priority is ensuring a logical treatment to a social problem. Similarly, if
shared commitment to the treatment philosophy a provider notices a patient has prominent diffi-
and to working in synchrony. When providers culties with balanced attention, energy, motiva-
prioritize their own individual clinical approach tion, and ability to experience joy, they may
at the expense of the shared approach, it can recommend medication and help the therapist
cause confusion for the patient, splitting, and understand the patient’s biological barriers to
19 Transitioning to Adult Services: Young Adult Partial Hospitalization and Intensive Outpatient Programs 347

engagement. Communication among providers message that it is the patient who must commit to
can ensure integrated care that takes all dimen- treatment and do the hard work of recovery.
sions of the biopsychosocial model into account Young adults may not have a good understanding
when conceptualizing and treating our young of what treatment entails, perhaps anticipating
adult patients. that the primary goal is to be able to “vent” and
It is particularly important that medical pro- be “heard” and with unrealistic expectations that
viders provide realistic expectations as to what the therapist can and should seek to remove their
can be hoped for from medication-based treat- negative emotions. These unhelpful beliefs can at
ments. Fortunately, the context of a PHP and IOP times be easy for the patient to identify and sort
means that patients will be presented with a very through with the therapist. At other times, we
broad range of tools for solving problems and have seen patients present as more resistant to a
should not have reason to feel hopeless in the solution-oriented approach, which can lead to
face of a balanced presentation of what medica- more significant treatment-interfering behaviors
tion can and cannot do. In fact, it is possible that (such as help rejection, splitting, or
engagement will be greater in other aspects of self-sabotage).
treatment if patients are helped to understand When such beliefs are identified, it is the ther-
that, even in the best-case scenario, they are apist’s job to deliver the message and formulate
likely to need many more tools and strategies more realistic goals, so the patient can make
than medication in order to truly recover. The choices about how to proceed – or indeed, if
medical provider thus works to foster self-­ unready to proceed, to discuss any difficult emo-
efficacy and decrease reliance on medication, set- tions that come up as a result. It is possible that a
ting the patient up for a more positive treatment therapist might get caught up in the intense emo-
experience both within the program and in the tions patients display in crisis. Similarly, provid-
future. ers might inadvertently miss therapy-interfering
Young adults may be particularly prone to behavior or shy away from confronting such
pushing boundaries within treatment and may behavior. In a PHP or IOP level of care, this has
idealize their medical provider to the exclusion of at times appeared to put the patient and therapist
the therapist – or vice versa. This presents a major at risk of getting “stuck” in treatment or creating
barrier to effective treatment. It is thus important a treatment failure, thus halting progress.
that medical providers maintain good boundaries In these instances where difficult conversa-
in session and provide empathic, kind, but asser- tions need to occur that challenge a patient’s
tive explanations for why the content and extent approach/views of treatment, it is important that
of their sessions cannot resemble those of the the therapist take a partnership approach that
therapist. Further, the medical provider should incorporates empathy, validation, challenge, and
minimize instances of being in the position of support – a willingness to challenge by an expe-
“advocating” for the patient with the therapist rienced therapist may be a catalyst for improved
and rather direct the patient to bring up their con- self-exploration by the patient (Anderson, 1968).
cerns with the therapist directly. Learning to tol- Being a partner to the patient means that the ther-
erate this more assertive approach to apist provides the patient with the empathy, vali-
communication is an essential developmental dation, and confrontation/challenging they need
task, and the motivation to achieve it will be in order to empower the patient to make deci-
greater if we are not taking this upon ourselves as sions about their engagement in care. Once the
a treatment team. therapist and patient have a clear and realistic
idea of what to expect for engagement and
Therapist Role improvement, the therapist acts as a partner with
Therapists should act as the primary source of the patient to decide if they are at a place where
support and psychological treatment within the they desire to make necessary changes and do the
patient’s treatment team while maintaining the hard work of recovery. If not ready, therapy
348 E. Ursillo and G. van Schalkwyk

changes course in that the goals become examin- may be more feasible on a case-by-case basis.
ing the barriers to engagement and providing Unfortunately, such agencies are the minority, so
space for a patient to vocalize feelings about the we recommend researching resources at the local
same (it is ok to have negative feelings about how and state level so that staff can assist patients in
hard therapy is and how unfair it feels to have to accessing what they fundamentally need in order
do it) (Ursillo et al., 2021). to start recovery.

 ccupational Therapist (OT) Role

O
In a psychiatric setting, the lens of an OT focuses Parent Involvement
on learning by doing and change through action.
Many young adults are still in, or have recently Young adults frequently maintain a range of ties
left, the school environment. Some may still to their families – including financial, insurance
struggle with attention deficits and challenges in related, emotional, and others. Although it may
motivation, organization, and maintaining their seem tempting to invest heavily in resources to
own structure. OT allows for the content and engage families, there are both pros and cons to
principles of the program curriculum to be deliv- this approach. There is a need to not only include
ered in a hands-on way, which can facilitate more the family where it makes sense but also think
effective engagement for patients with such vul- about the progress the young adult is making
nerabilities. Including OT also adds to the diver- toward a greater degree of independence. Further,
sity of disciplines participating in the care of our it is important that when family is included, it be
young adult patients and increases the odds that for the purpose of goal-directed, strategic ther-
at least one approach will resonate and motivate apy, or to discuss the formulation and treatment
sustained participation in the program. recommendations. In our experience, families
will frequently request a meeting to try and form
an alignment against the patient, use the treat-
Special Considerations ment team to force the patient to do something
they do not want to do, or with the goal of manag-
There are many special considerations when ing their own anxieties around the patient’s
establishing young adult-specific programming. behavior and trajectory. It is important to realize
These include access to basic human needs, that even a quiet and passive 18-year-old patient
parent/family involvement, the role of expanded has absolute decision-making over their care, is
assessment, and aftercare planning, the primary patient, and has the greatest role in
directing their care. Family therapy is not pro-
vided in this program; although if family dynam-
Basic Human Needs ics are seen to be an important factor in sustaining
or driving the patients’ symptoms, this will be
When working with young adults, treatment discussed, and we may recommend ongoing
teams should expect that many patients will lack treatment to address this specifically.
the basic human resources they need to thrive in A particular challenge emerges when there is
the world even before one begins to assess mental clearly a need to involve family (perhaps to com-
health concerns. Reliable social supports, shelter, municate a safety concern or the onset of a severe
financial means, food, medical care, and trans- psychiatric illness which will require significant
portation can be huge barriers for young adults support), but patients are unwilling to provide
accessing mental healthcare. Ensuring that pro- consent for such contact. In the overwhelming
grams offer a variety of dependable resources for majority of cases, this can be effectively navi-
each barrier will be imperative. For agencies that gated by ongoing discussion and engagement
have expendable funds, assistance in these areas with the patient around the importance of involv-
19 Transitioning to Adult Services: Young Adult Partial Hospitalization and Intensive Outpatient Programs 349

ing their family, including an explanation of what dimension. As a result, we found utility in creat-
will be disclosed and why. Parents may call a ing a population-specific track within our IOP
program requesting information, and at times this called “pathfinders.” Pathfinders patients are
can create an untenable situation, such as when referred because they are having a particularly
the patient’s family is clearly aware of their pres- difficult time fostering successful independence
ence in the program, but no consent has been pro- in young adulthood, they can recognize this fact,
vided for contact. In such cases, we explain to the and they are showing signs that they are ready to
patient that we have no compelling way of deny- address it. In this track, patients work together to
ing their presence in the program and cannot be uncover any maladaptive patterns that might have
held responsible if parents make such inferences. developed during childhood that can negatively
Again, it is very seldom the case that patients impact adult perceptions, functioning, and mood
cannot come to understand why at least some (using the principles of schema therapy). Patients
degree of parental involvement is required. set small, realistic personal goals that they will
Intensive young adult services are an opportu- focus on over the course of the 4-week program.
nity to provide containment and structure in the These goals will be vocalized in group so that the
absence of them living in the home of their par- patient, peers, and staff can work together to
ents. Young adults who are attending residential monitor progress and hold a patient accountable.
colleges may find that, although they receive Barriers to goal achievement are of course antici-
some degree of support from peers and staff, they pated, and as they arise, the group processes each
do not feel as supported as when they were at through the use of schema therapy. The goal of
home and have outstanding needs for contain- schema therapy is to uncover any maladaptive
ment and guidance. This is an appropriate role for patterns that people develop in childhood that can
an intensive young adult program but needs to be negatively impact adult perceptions, functioning,
provided in the context of an overall treatment and mood (Young et al., 2003). We place a strong
plan. Specifically, it needs to be made clear to emphasis on success and celebration when such
patients that the kind of support they will receive insights are gained and there is any movement
will have boundaries and be time limited in toward goal achievement.
nature. The goal should be to reduce the need for
support over the course of the program, build
capacity for self-care, and then consider appro- Expanded Assessments
priate parameters for a return to the program. It
has occasionally been the case that young adults As mentioned previously, one of the benefits of
have tried to use our programs as their long-term having occupational therapy as part of our pro-
strategy for support and connection, potentially gramming is that they are able to conduct func-
to the exclusion of ongoing engagement with a tional assessments that could benefit the young
difficult family situation. When identified, this adult patient. Vocational assessments can assist
needs to be addressed assertively by the treat- young adults in determining areas of interest for
ment team, and a strategy should be developed to future employment as well as highlight attributes
alter the dynamic over time. of strength that will serve them well in the work-
ing world. Where possible, community partner-
ships and local awareness of employers who may
 rogram and Patient-Specific Focus:
P provide a supportive work environment may be
The Pathfinders Track of tremendous value. Patients who experience
minority stress may benefit from having this
Prioritizing psychosocial recovery can allow for characterized so that the team can help the patient
meaningful early victories in care, as there are develop strategies for managing this problem. In
frequently small steps patients can take to get our program therapists are given additional time
their lives to a better place across at least one for conducting more specialized diagnostic
350 E. Ursillo and G. van Schalkwyk

assessments where indicated, although in our References

experience, comprehensive neuropsychological
testing is seldom prioritized in this level of care. Amminger, G. P., Harris, M. G., Conus, P., Lambert, M.,
Elkins, K. S., Yuen, H. P., & McGorry, P. D. (2006).
Treated incidence of first-episode psychosis in the
catchment area of EPPIC between 1997 and 2000.
Aftercare Planning Acta Psychiatrica Scandinavica, 114(5), 337–345.
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Anderson, I. M. (1998). SSRIS versus tricyclic antide-
It is imperative that some staff hours are dedi- pressants in depressed inpatients: A meta-analysis
cated to the case management aspect of young of efficacy and tolerability. Depression and Anxiety,
adult care, whether there is an identified case 7(Suppl 1), 11–17. Retrieved from http://www.ncbi.
manager on staff or a portion of the clinicians’ nlm.nih.gov/pubmed/9597346
Anderson, S. C. (1968). Effects of confrontation by
hours are dedicated to this task. As mentioned high- and low-functioning therapists. Journal of
previously, many young adults are new to navi- Counseling Psychology, 15(5, Pt.1), 411–416. https://
gating the healthcare system. Many need assis- doi.org/10.1037/h0026201
tance in establishing outpatient treatment, Bach, P., Hayes, S. C., & Gallop, R. (2012). Long-term
effects of brief acceptance and commitment therapy
including medical providers (psychiatric and pri- for psychosis. Behavior Modification, 36(2), 165–181.
mary care) and providers for individual therapy. https://doi.org/10.1177/0145445511427193
It is often helpful to connect patients to other out- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck,
side resources, such as support groups, to try and A. T. (2006). The empirical status of cognitive-­
behavioral therapy: A review of meta-analyses.
sustain the positive experiences of group affilia- Clinical Psychology Review, 26(1), 17–31. https://doi.
tion experienced during an intensive treatment org/10.1016/j.cpr.2005.07.003
program. It is a goal that patients have a follow- Cameron, I. M., Cunningham, L., Crawford, J. R.,
­up appointment within a week of discharge from Eagles, J. M., Eisen, S. V., Lawton, K., et al. (2007).
Psychometric properties of the BASIS-24© (behav-
our programs. This standard helps with post-­ iour and symptom identification scale–revised) men-
discharge success and aims to lower the likeli- tal health outcome measure. International Journal of
hood that someone will need to readmit to the Psychiatry in Clinical Practice, 11(1), 36–43.
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meta-analysis. Clinical Psychology Review, 27(3),
318–326. https://doi.org/10.1016/j.cpr.2006.11.001
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J. (2015). 13 Acceptance and commitment therapy:
Model, processes, and outcomes. In The act in context:
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intensive partial hospital and intensive outpatient 279). https://doi.org/10.4324/9781315745138-­25
services for young adults, and such programs Roisman, G. I., Masten, A. S., Coatsworth, J. D., &
have the capacity to achieve significant clinical Tellegen, A. (2004). Salient and emerging develop-
mental tasks in the transition to adulthood. Author
success in a sustainable manner. However, suc- (s): Glenn I. Roisman, Ann S. Masten, J. Douglas
cess is not achieved through business as usual, Coatsworth and Auke Tellegen Published by: Wiley
and there are a number of critical considerations on behalf of the Society for Research in Child
specific to the young adult population that must Development Stable URL. Child Development, 75(1),
123–133.
be addressed to facilitate positive outcomes. In Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R.,
this chapter, we have described a treatment phi- Yuan, K., Holland, K. M., et al. (2018). Vital signs:
losophy that impacts decisions ranging from cur- Trends in state suicide rates — United States, 1999–
riculum to intake procedures. We trust that 2016 and circumstances contributing to suicide — 27
states, 2015. MMWR: Morbidity and Mortality Weekly
readers will take from this chapter some key Report, 67(22), 617–624. https://doi.org/10.15585/
insights to inform their own program develop- mmwr.mm6722a1
ment and quality improvement.
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Ursillo, E., Sundin, K., & van Schalkwyk, G. I. (2021). Zimmerman, M., Chelminski, I., McGlinchey, J. B., &
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therapy: A practitioners guide. Guilford Publications.
 Integrating Day Treatment
in the School Setting 20
Carla Correia and Greta Francis

Overview of Program opened in the southwestern part of Rhode Island

in 2003, and, from there, a fourth school was
History opened in the southernmost part of Rhode Island
in 2009. In 2015, we ventured out of Rhode
What is now known as Lifespan School Solutions Island and into the northeastern part of
(LSS) started in the 1970s as a small school-­ Connecticut to open a fifth school. In 2014, our
funded day hospital program located in a wing of original Bradley School moved off the campus of
Bradley Hospital, a children’s psychiatric hospi- the hospital and into a school building centrally
tal located in East Providence, Rhode Island. The located in Providence, Rhode Island. At around
Charles Bradley Day Hospital, as it was called, the same time, the Bradley Schools incorporated
served about 40 patients from Rhode Island with and became an individual affiliate within our
a primary focus on providing mental health treat- health-care system parent company. We are now
ment that included individual, group, and family Lifespan School Solutions, Inc. doing business as
therapy for all attending the school milieu. Bradley Schools. By 2016, we opened a sixth
Treatment was delivered in the context of six school in the northern part of Rhode Island to
self-contained classrooms. By 1992, the day serve just elementary-aged students, and our
treatment program evolved into the Bradley Providence location pivoted to serve just middle
School and those “patients admitted” became and high school students. During this time, our
“students enrolled.” The school moved out of a smallest program located in the southernmost
wing of the hospital and into a separate building part of Rhode Island closed, and students were
on the hospital campus in 1994. A second school relocated to our other sites. Our most recent
was opened in the southeastern part of Rhode expansion was our second school in Connecticut,
Island in 1995 in order to better serve students which opened in 2019, this time embedded within
closer to where they lived. A third school was a public school near the Connecticut/
Massachusetts border. Currently, we operate a
total of six schools, four in Rhode Island and two
C. Correia · G. Francis (*)
Department of Psychiatry & Human Behavior, Alpert in Connecticut. Five of these schools are stand-­
Medical School of Brown University, alone sites, and one is fully embedded within a
Providence, RI, USA public school.
Lifespan School Solutions, Cumberland, RI, USA At the same time that our stand-alone school
e-mail: [email protected]; sites were growing in number, we began to enter
[email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 353
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_20
354 C. Correia and G. Francis

into partnerships with public schools in Rhode paid by the local public school district. Parents
Island in which a classroom staffed by Bradley are not responsible for any costs. The typical rea-
School employees was housed within an existing son for referral is that the student has, or is sus-
public school. This started in 1997 with a partner- pected to have, mental health challenges that are
ship classroom in a local middle school near our interfering significantly with their ability to be
stand-alone site in Portsmouth, Rhode Island. successful in a less restrictive educational setting.
Each partnership classroom is attached adminis- Students may or may not have comorbid develop-
tratively to a stand-alone site. Over the years, the mental challenges. As we are considered a highly
number of partnership classrooms has varied and restrictive setting on the school continuum, stu-
currently stands at six (one in an elementary dents often have received multiple supports in a
school, one in a middle school, and four in high variety of settings prior to referral. This also
schools). means that we are most likely to see referrals of
students whose psychiatric symptoms are reflec-
tive of severe illness. A sampling of typical refer-
Population Served ral concerns that interfered with the student’s
functioning in school are as follows: (1) a
We currently serve approximately 425 students 14-year-old girl with an acute onset of psychotic
across our various sites. This translates into symptoms that have not resolved following an
approximately 50 self-contained classrooms. Our inpatient admission; (2) a 10-year-old boy with
largest site enrolls about 150 students, while the long-standing behavioral dysregulation that has
smallest site enrolls about 20 students. Our other worsened to the point of aggressive outbursts
four sites enroll from 60 to 90 students each. Our toward peers; (3) a 7-year-old boy with extreme
students are enrolled in grades K through 12+. noncompliance with diabetes management in
Those in grades 12+ are students whose needs school, resulting in aggression toward the school
require transitional educational services up nurse; and (4) a 17-year-old boy on the autism
through age 22. All students either have an indi- spectrum who made public threats of violence on
vidualized educational plan (IEP) or are in the social media.
process of being evaluated to determine eligibil- As a more detailed example, a 13-year-old
ity for special education. Students reside in boy (Jimmy) was referred to us following 2 years
Rhode Island, Massachusetts, or Connecticut. of complete school avoidance. He lived with his
Each school has students attending from multiple biological parents and younger sister. His mother
school districts within their state. All of our worked part time outside of the home and his
Rhode Island schools have students from out of father was on disability. Both parents were highly
state as well as those from Rhode Island. Most anxious. Jimmy was housebound other than a
students live at home, while a small number monthly session with an adult psychiatrist. He
reside in local congregant care settings like group was prescribed Prozac and Xanax, which were
homes. Transportation is provided and funded by taken on a daily basis. The special education
the local public school district in which the stu- director of Jimmy’s public school arranged for an
dent resides. outpatient psychologist with expertise in school
avoidance to work with Jimmy in the home. At
the onset of treatment, Jimmy would not leave his
Admission and Exclusion Criteria bedroom when the psychologist and her postdoc-
toral fellow were in the home. The psychologist’s
All students are referred by the special education assessment was that Jimmy was suffering from
director of their local public school district. extreme social anxiety and that his parents simi-
Referral to and placement in our schools is done larly were very anxious about anything that made
using the IEP process for a change in placement Jimmy uncomfortable. After multiple home-­
for a student. The entire cost of the placement is based sessions over the course of 3 months using
20 Integrating Day Treatment in the School Setting 355

gradual exposure for Jimmy and support/educa- their needs or the caregiver is not in agreement
tion for parents, Jimmy was able to leave his bed- with the placement. The typical caregiver con-
room and walk to the end of his short driveway cerns include fear of stigma, wish to try other
once. Given the slow pace of progress, the special options within a public school setting, or prefer-
education director decided to refer Jimmy to us. ence for another placement.
After consulting with the home-based psycholo-
gist, we went to their home to meet with Jimmy
and his parents. One of our social workers took Program Goals and Expectations
on the role of family therapist, and one of our
psychologists served as Jimmy’s individual ther- Our overall goal is that students remain in the
apist. A gradual exposure entry plan was devel- program only as long as necessary to gain the
oped that initially involved Jimmy’s father skills needed to transition back to a less restric-
driving Jimmy to school and Jimmy coming to tive educational setting. As such, transition is a
the classroom for increasing amounts of time point of discussion from the very beginning of
over the course of his first week. By the end of our relationship with students. In support of this
the week, Jimmy was in the classroom all day but goal, we also work with students and families to
did not speak to anyone, eat, or take off his coat. maintain (and eventually grow) as many connec-
Over the course of 4 years, we developed and tions with their home community as possible. For
implemented a series of gradual exposure exer- example, a student attending our school may
cises targeting Jimmy’s extensive avoidance. have a longer bus ride than if they were still
Several predoctoral and postdoctoral clinical attending public school, and this may interfere
psychology trainees assisted with this treatment. with their ability to make it to Little League base-
Jimmy’s parents needed extensive psychoeduca- ball practice. In this case, we would work with
tion and support from the family therapist those involved to find a solution so that the stu-
throughout his stay with us. While exposure was dent could make it to baseball practice to main-
the primary treatment modality, contingency tain that important community connection.
management and modeling were also used. All students arrive after having struggled sig-
Collaboration between our individual therapist, nificantly in a less restrictive setting. Their care-
family therapist, school nurse, child/adolescent takers typically are highly stressed, and the
psychiatrist, and classroom staff was critical. relationships among the student, caretakers, and
Over time, Jimmy became able to participate public school staff often have frayed. As such,
actively in class discussions and change classes, rapport building is an important first step. The
ride in the car with nonfamily drivers, take the focus of the initial placement is to complete a
school bus, leave his home to go to a variety of thorough evaluation of the student within the
locations like fast-food restaurants and stores, context of the school environment while consid-
and be weaned off psychotropic medications. His ering all other factors relevant to the student’s
parents were very proud of his success and sup- ability to function in school (e.g., family, cultural,
portive of his drive for independence. He com- peer). In this way, school serves as a window into
pleted 12th grade, learned how to drive, and the student’s functioning across multiple
obtained a job in a bank. At the time of discharge, domains.
Jimmy received a high school diploma from his As students typically are referred for an initial
local public school district. 6- to 9-week placement, we can assess students
Because our schools serve students with a across time and in a wide variety of situations.
wide range of mental health needs (plus or minus More information about this assessment period is
developmental challenges), very few students are provided in the section “Use of Evidence-Based
excluded once referred. The most common rea- Assessment”. This time frame also allows for
sons for exclusion are that we do not have space many opportunities for relationship building with
in a classroom appropriate for the student given and among students, caregivers, and public
356 C. Correia and G. Francis

school personnel. The primary goal of this assess- the section “Setting Up Your Team and Working
ment is to identify, and then begin to provide, the with an Interdisciplinary Team”. IEP meetings
educational and therapeutic supports/services are held after the initial placement (i.e., about
needed to allow the student to access their 7–10 weeks after admission) and then again at
education. least yearly during a student’s stay in the pro-
Once appropriate supports/services are in gram. IEPs must be reviewed at least yearly as
place within the therapeutic school setting and per special education law. Our students often
the student is making progress, then the task at have IEP meetings scheduled more frequently
hand becomes to titrate those supports/services than yearly in order to bring the team together to
as much as possible to build the student’s capac- review progress and consider transition. The
ity for independence and prepare them for transi- location of IEP meetings varies according to the
tion back to a less restrictive educational setting.purpose of the meeting. For example, while the
Ongoing progress monitoring is used to assess student is attending school with us, we hold IEP
readiness for that move, and extensive collabora- meetings in person (or virtually) at our site; but
tion is needed with the local educational author- when we are working to transition the student to
ity (LEA) to plan for a successful transition. a less restrictive setting, we typically hold the
Throughout this transition, a strong working alli- IEP meetings at the new site as part of the process
ance with students and caretakers is vital to facil-of helping the student and family get accustomed
itate a successful transition. to the new setting.
An IEP meeting is held to review relevant data
Length of Stay and determine if a student is ready for transition
Length of stay varies widely. Some students to a less restrictive setting. If, for example, a stu-
spend less than 6 months in our program, and dent is coping successfully with daily challenges,
they are most likely to be those with academic, consistently completing academic work in a
behavioral, and emotional struggles of a rela- manner expected given their individual strengths
tively short duration prior to enrollment, those and weaknesses, and interacting appropriately
from families with fewer psychosocial stressors with peers, then it would be reasonable to discuss
and mental health challenges, and/or those from transition, assuming the LEA and guardian are in
school districts that have existing public school agreement. In contrast, if what was shared at the
programs with high-quality academic and social-­ IEP meeting was that the student was coping suc-
emotional learning (SEL) supports. Other stu- cessfully with daily challenges only 25% of the
dents spend more than one school year in our time, struggling to consistently complete aca-
program, and they are most likely to be those demic work provided at appropriate grade levels
with long-standing and significant mental health given their individual strengths and weaknesses,
challenges, those from highly stressed families, and engaging in age-appropriate or prosocial
and/or those from school districts with limited peer interactions only 50% of the time, then it
options for providing ongoing significant mental would appear that the student is not yet ready to
health/SEL supports. As an example, a look at the transition to a less restrictive setting. In this case,
length of stay at our elementary school site most benchmarks would be discussed that would indi-
recently showed that 50% of students stayed for cate readiness so that the IEP team has shared
more than 1 year and 50% stayed for less than goals with which to work to move forward toward
1 year. Of those who stayed less than 1 year, 50% transition.
stayed 6 months or less. As noted above, transition to a less restrictive
All movement into, out of, and through our educational setting is a goal for all students
program is driven by the IEP process. That is, the referred to us. In addition to the readiness of the
student’s IEP team (which includes the student, student and willingness of parents to transition,
guardian, LEA, and our team) is where decisions there is also a need for an appropriate placement
are made. Details about our team are provided in to be available. Like everywhere, the resources
20 Integrating Day Treatment in the School Setting 357

available within public schools vary tremen- The diversity of our student population mir-
dously from community to community. In the rors the communities in which our students live.
best of circumstances, a community has public Our sites that serve students from more urban
school classrooms managed by staff who are locations tend toward more diversity with respect
accustomed to helping students transition back to race, culture, and language as compared to
from more restrictive settings, and these class- sites that serve students from more rural loca-
rooms are ideal transition locations for our stu- tions. For example, our middle/high school pro-
dents. It is always easier for students to return to gram located in Providence, Rhode Island, is our
their public schools when the public school is most diverse site, and we make concerted and
confident and welcoming of students returning to ongoing efforts to recruit classroom and clinical
them from more restrictive placements. staff who also are diverse with respect to race,
For those communities that do not have access culture, and language. Attention is given to issues
to such public school classrooms, we have our of diversity, equity, and inclusion (DEI) across all
partnership classrooms. These classrooms are sites by both regular staff in-service training on
located within public schools, but staffing is pro- the topic and a monthly DEI staff newsletter. In
vided by our team, which includes a special edu- addition, we have contracted with local agencies
cation teacher, classroom behavior specialist to provide interactive workshops on topics related
(typically an experienced employee with a bach- to DEI. We also ascribe to a clinical practice in
elor’s degree), and clinician (clinical social which diversity, equity, and inclusion are empha-
worker or psychologist). Students in these class- sized in case conceptualization, treatment plan-
rooms can become involved in the larger public ning, and intervention.
school community while receiving specialized
social-emotional and academic supports.
Partnership classrooms provide an opportunity Program Development
for a gradual step out of a highly restrictive set- and Implementation
ting into a more normative setting. From there,
the transition back to a full public school setting Process of Building Our Program
is a much smaller and more manageable step. On
the other hand, partnership classrooms also serve Between the 1970s and the late 1980s, the then
as an entry point for students who do not require Charles Bradley Day Hospital served as a clini-
our intensive stand-alone school setting but do cally focused program funded by local school
require significantly more support than can be districts. All day patients received individual,
provided in a typical public school setting. family, and group therapies along with medica-
tion management (as needed) and ongoing psy-
chiatric consultation. Though the day hospital
 iversity Considerations Related
D had the general structure of a school (i.e., class-
to Staff, Patients, and Access to Care rooms, teachers), education was a secondary
focus, and the primary focus was on providing
According to the 2020 Rhode Island Kids Count mental health treatment. By the early 1990s, it
Factbook, 15% of public school students in was becoming clear that our customers (i.e.,
Rhode Island received special education services. school departments that referred students and
Of these students, 67% identified as male and funded the placements) were starting to become
33% as female. Fifty-five percent identified as dissatisfied with our primary focus on utilizing
White, 28% as Hispanic, 10% as Black, 5% as the school milieu to provide mental health
multiracial, 2% as Asian/Pacific Islander, and 1% services.
as Native American. Ten percent were multilin- In response, our program reached out to our
gual learners. Forty-eight percent of students in customers to set up a meeting to discuss their
Rhode Island qualified for free or reduced lunch. feedback directly. They were unhappy about our
358 C. Correia and G. Francis

limited focus on education, the characterization a child may recommend in their report that the
of their students as patients, the “more is better” child receive an IEP in school. In fact, the process
view of therapeutic support, inadequate attention for determining eligibility for an IEP is a legal
paid to working collaboratively with them to and prescriptive task that cannot be directed by a
transition students back to more normative set- provider outside of the school system. It is the
tings, and the extended removal of students from responsibility of the IEP team to review all rele-
their own community supports/resources. All that vant data and make decisions about eligibility.
said, they were happy that the program served We have learned how to “talk so that schools can
their students with the most challenging mental listen,” and this has involved making recommen-
health needs and that the quality of clinical ser- dations within the context of the required eligibil-
vices provided was top-notch. ity process. In this example, the report might
In response to this feedback, we began a con- recommend that the parent make a request to the
certed effort to transform from a day hospital to a school principal that the student be evaluated to
school that provided academic instruction and determine their eligibility for special education
individualized mental health supports. This services, given the areas of concern demonstrated
required us to become more collaborative with in the school setting.
our customers, more proficient in the language of Our attempts to help students remain con-
schools, and more focused on keeping commu- nected to their communities took several forms.
nity connections for students. The first practical First, as noted earlier, we grew from one school
task was to rename the program as the Bradley on the grounds of a hospital to having all our
School. This renaming made our mission clear to school programs located in the communities
those LEAs referring students to us and those stu- where our students live. Second, rather than hav-
dents being referred. Of note, students and their ing a family discontinue services with commu-
families also communicated that they did not nity providers so that we could provide all
wish to be labeled as patients as that essentially therapeutic services, we worked to maintain
erased their normative identity as students. community-based services and add school-based
We view the task of becoming proficient in the services if and when necessary. We also worked
language of schools as a lifelong learning task. It with individual school departments to allow stu-
behooves us to remain aware of national, state, dents to continue their participation in activities,
and local changes in public education so as to such as sports teams, field trips, and school
“talk the talk” when communicating with our dances, if those activities were important to the
customers. Schools now use the term “social-­ student and family.
emotional learning” (SEL) to describe most of We are fortunate to be an affiliate of a health-­
what we as clinicians label as mental health care organization with strong ties to the medical
strengths and challenges. It is important that we school at Brown University. Many of our clinical
embed our clinical formulations and recommen- staff hold faculty appointments at Brown, which
dations into the social-emotional learning lan- allows us ready access to state-of-the-art research
guage that schools understand. For example, we and training in evidence-based practice.
might include learning objectives in the SEL area Maintaining this academic connection has been
of self-management in the IEP of a fourth grader an important asset to our program. For example,
diagnosed with attention deficit hyperactivity most of our psychologists are graduates of the
disorder (ADHD) or learning objectives in the Brown University Clinical Psychology Training
SEL area of social awareness in the IEP of an Consortium and frequently train with us during
11th grader diagnosed with autism. their residency and fellowship years.
It also is important for us to remain attentive Ongoing staff development and training has
to procedural issues that differ between mental been another critical part of building our pro-
health and school systems. For example, an out- gram. We build in-service training into our yearly
patient psychologist completing an evaluation of school schedule. This includes 6 to 8 full days
20 Integrating Day Treatment in the School Setting 359

each year as well as monthly ½ days set aside for as the forum to discuss continuity/consistency of
professional development in areas such as yearly service delivery across sites, problem-solve com-
crisis intervention recertification, tools for con- mon administrative issues (e.g., corrective action
ducting a functional behavior analysis, uncon- for an employee with performance concerns,
scious bias trainings, and clinical topics relevant challenging interactions with a particular LEA,
to the population at each site (e.g., working with plan to bring employees back to work during the
students who have early onset psychosis). In pandemic), generate ideas/plans for program
addition, we fund other relevant trainings that are development, debrief on sentinel events (e.g., a
discipline specific (e.g., specialized reading student who brought a weapon to school), and
instruction training for teachers, Autism sharing of resources.
Diagnostic Observation Schedule (ADOS-2; Our school site clinical directors report to our
Lord et al., 2012) training for psychologists, medical director and receive mentorship from our
rapid COVID-19 antigen test training for nurses). administrative clinical director. We made the
decision back in the 1990s that having schools
run by psychologists rather than educators was
Setting Up Your Team and Working the best way to ensure that the complex clinical
with an Interdisciplinary Team needs of the student population would be met.
While we have revisited that decision many times
The central administrative structure of LSS con- over the years, we have continued to stick with it.
sists of a full-time medical director Our strategy has been to provide support to our
(child/adolescent psychiatrist), full-time clinical clinical directors by fostering a collaborative
director (doctoral level psychologist), and full-­ relationship between them and our education
time education director (master’s level special director so that each clinical director is well
education director). In addition to clerical sup- versed in the language and process of special
port in the form of two administrative assistants, education. Students are referred to us because of
we have a dedicated human resources recruiter their clinical needs not because of their educa-
who also serves as project manager for a variety tional needs, so it has been important to keep that
of ongoing large projects (e.g., sourcing and clinical focus in the forefront while at the same
obtaining personal protective equipment (PPE) time developing and maintaining a strong educa-
during the pandemic), a business manager, and a tional product.
school technology specialist. This group consults The creation of our school site interdisciplin-
regularly with our large parent company around a ary teams was guided by the requirements of
variety of issues but functions relatively indepen- multidisciplinary school teams. As such, our
dently with respect to managing the nuts and teams consist of the required core elements of the
bolts of the business. IEP team: special education teacher and those
The administrative structure of each school providing specialized services in the IEP (e.g.,
site consists of a full-time doctoral level psychol- OT, SLP, nurse, group therapist). Our teams also
ogist in a clinical director role functioning as include classroom behavior specialists who work
head of the school. All staff report up to the site’s hand in hand with our teachers in the
clinical director. Some staff also have ancillary classrooms.
departmental reporting relationships (e.g., spe- Our classroom teams are led by a clinical team
cial education teachers receive support from the leader. Our clinical team leaders are doctoral
education director, occupational therapists (OT) level psychologists, doctoral level social work-
and speech-language pathologists (SLP) receive ers, master’s level clinical social workers, or mas-
support from a senior rehab specialist, nurses ter’s level board certified behavior analysts
receive support from the medical director). (BCBA). The role of the team leader is to guide
Our clinical director group holds a weekly the rest of the team to deliver services in their
leadership group meeting. These meetings serve areas of expertise while providing the clinical
360 C. Correia and G. Francis

Fig. 20.1 Lifespan School Solutions organizational chart

context within which to do that work effectively supervision to those earlier in their training.
(Fig. 20.1). Trainees participate in team meetings and IEP
We also have supervisory structures in place meetings as well as supervision. Pre- and post-
for staff. Teachers are supervised by a senior doctoral psychology trainees may also participate
teacher, and classroom behavior specialists are in the development and presentation of staff in-­
supervised by a behavioral coordinator. Team service trainings in their areas of clinical research
leaders are supervised by the clinical director. expertise.
These supervisors form a local management team Trainees from other disciplines also rotate
for each school site. It is the job of the school through our schools. These include social work
management team to guide and oversee the local interns, speech-language students, OT students,
implementation of educational and therapeutic student nurses, student teachers, and child psy-
services for the students enrolled at their site. chiatry fellows. Their placements are individual-
ized to meet the specific training requirements of
their discipline.
Involvement of Trainees

As a training site for the Alpert Medical School Building Stakeholders

of Brown University, our child/adolescent psy- and Navigating Institutional
chiatrist and most of our psychologists are on the Expectations/Limitations
faculty at Brown. We routinely have psychology
trainees working in our schools. Most common Because our current administration inherited this
are clinical psychology practicum students, pred- program back in the 1990s, we have had multiple
octoral residents, and postdoctoral fellows. A opportunities to engage stakeholders and navi-
developmental model of supervision typically is gate changing waters. This process has involved
used when working with trainees, and this helps establishing and maintaining relationships with
us to determine which activities are best suited to the school districts that refer students to our pro-
each trainee. These activities may include indi- gram. We have also developed relationships with
vidual therapy, family consultation, group ther- training institutions to maintain a flow of trainees
apy, and psychological assessment (clinical/ from multiple disciplines. This has helped us
diagnostic and cognitive). Learning how to do keep up to date with evidence-based knowledge
consultation in the context of our specialized and has been an effective tool to grow our
school environments is another common activity. workforce.
When possible, and under the supervision of All major decisions regarding model and loca-
licensed faculty, advanced trainees can provide tion switches were driven by stakeholder
20 Integrating Day Treatment in the School Setting 361

f­ eedback. As noted earlier, stakeholder feedback communication about both the clinical and aca-
was the primary motivator for moving from a day demic needs of the students in our schools.
hospital model to a school model and moving
away from the hospital and into the community.
Around 2010/2011, we began to get feedback  avigating Insurance Coverage
N
from our stakeholders that, while they viewed our and Billing
clinical product as very strong, our educational
process was viewed as adequate. Our education Funding for students referred to our programs
director was getting ready to retire, so we used comes entirely from the public school making the
that opportunity to recruit and hire our next edu- referral. We do not accept any referrals other than
cation director from the public school sector. those made through the school department. Our
This allowed us to become more familiar with, rates are set yearly and approved by the states of
and attentive to, issues relevant to our participa- Rhode Island, Connecticut, and Massachusetts.
tion in the IEP process at both the program orga- The basic rate structure for our stand-alone
nization and individual student levels. We schools includes a standard rate, intensive rate,
reorganized our teacher supports, purchased a and clinically intensive rate to reflect the staffing/
variety of new educational curriculum materials, support needs of the students referred. Our stan-
and provided extensive in-service training to dard rate is for students whose needs can be met
bring our teachers up to date on innovations in in a self-contained classroom staffed by one
assessment, progress monitoring, supports, and teacher and one classroom behavior specialist
interventions for students in special education. with case management and clinical support pro-
We also reorganized our IEP meeting structure to vided by a team leader. Our intensive rate is for
put a focus on academic and social-emotional students who need more daily support in the form
learning within the context of the student’s clini- of two classroom behavior specialists in the
cal formulation rather than vice versa. classroom. Our clinically intensive rate is for stu-
After a few years, we realized that we had dents whose clinical needs require additional
become so effective at improving and emphasiz- support from the team leader including things
ing our educational process that we had begun to like pull-out individual or family therapy. The
shortchange the clinical side of the house when frequency of pull-out therapies is individualized
describing/discussing our work to our customers. and can vary from once weekly to multiple times
Clinicians were working very hard to provide a day. For example, a family involved in parent
evidence-based supports for students but were management training may need once weekly ses-
seeing those supports as routine and thus not sions, while a student struggling with acute psy-
emphasized when communicating with LEAs. chotic symptoms may need multiple short
We had gotten to the point of assuming that our treatment sessions each day. Some students, par-
LEAs knew that we provided strong clinical sup- ticularly those with developmental challenges,
ports and felt there was little need to flesh out the also may need 1:1 support in the form of an
specifics in meetings. Again, based on feedback assigned classroom behavior specialist who
from those LEAs, we learned that they wanted works with them individually to address areas of
more information about clinical supports to help need, such as activities of daily life (ADL).
them better understand the needs of their stu- The rate structure for our partnership pro-
dents. We realized that it was important to regu- grams has rates that are lower than what is
larly and concisely provide information about charged at our stand-alone sites. Students in our
those clinical supports, so we made another partnership classrooms require less intensive
adjustment to rebalance the amount of educa- staffing and less clinical support in order to be
tional and clinical reporting in meetings. This successful in the public school setting, and this is
rebalancing has resulted in richer and clearer reflected in the lower rates.
362 C. Correia and G. Francis

Day-to-Day Programming are student supervision needs that cannot be met

by classroom staff, such as a student requesting a
Each of our sites has a slightly different schedule break outside the classroom.
for day-to-day programming that reflects primar- Daily programming integrates academic,
ily the age/grade range of the site. For example, social, emotional, and behavioral supports. Each
our middle/high school site includes an extensive classroom is staffed by a certified special educa-
course schedule in which students change classes, tion teacher who provides curriculum-based aca-
while that is not the case for our elementary site. demic instruction. In vivo and digital curricula
The content of programming also varies by site. are used, and all students have a Chromebook.
For example, dialectical behavior therapy for Instruction is provided in all academic areas (e.g.,
adolescents (DBT-A; Rathus & Miller, 2015) is a reading, math, writing, science, social studies).
common group intervention for our middle and Consistent with the needs and accommodations
high school students, while Second Step® outline in each student’s IEP, academics are
(Committee for Children, 2016) is often used for adapted and individualized and include the use of
our elementary school students. In order to direct individual, small group, and whole group
describe day-to-day programming in an efficient instruction. Multimodal approaches to learning
manner, we are using our elementary school site are emphasized, and students use a combination
as the example in this section. of technology and paper-based tools. All students
participate in weekly physical education/health
and art/music classes. Adaptive physical educa-
Daily Schedule tion, occupational therapy, and speech and lan-
guage therapy are also provided by school-based
Students attend school for 6 hours per day for a staff based on individual student needs outlined
total of 185 school days. Many students also in the IEP. As much as possible, these therapies
qualify to attend the extended school year (ESY) are provided via a “push-in” model, where the
program, which follows the same 6-hour sched- SLPs and OTs provide treatment in the classroom
ule and runs for 6 weeks during the summer rather than pulling students out of class into indi-
(July–August). Referring districts provide trans- vidual sessions.
portation to and from school by van or bus. Some To provide routine and structure, each class-
districts contract with statewide agencies to pro- room follows their own daily schedule, which is
vide transportation services, and in some cases, posted visually in the room. Some students uti-
families choose to provide transportation for their lize micro schedules at their desk to help them
students. Upon arrival at school, students are follow along and attend to the daily expectations,
greeted by school staff and undergo daily safety and others have more individualized schedules
checks that include the use of metal detectors and that include additional breaks and other supports
inspection of backpacks and other materials as needed. Breaks for all students are incorpo-
brought into school. Students are then directed to rated throughout the day. For younger students,
their classrooms to begin their daily program- these include recess and/or “cash in” times,
ming. At the end of the day, staff help prepare where students are encouraged to engage in
students for dismissal, and they are called out to movement, play, and other activities of their
their buses as they arrive. Staff supervise students choosing. For older students, these breaks might
at all times throughout the day, including during include listening to music or taking a walk. Other
hallway transitions. For example, when going to breaks throughout the day include bathroom
gym, recess, or bathroom, students transition in breaks, snacks, and lunch. The last period of each
groups as often as possible and are always accom- day is a “cash in” period, where students access
panied by either a teacher or classroom behavior earned privileges. With our youngest students, a
specialist. Staff are able to call for additional sup- midday “cash in” period often is added
port on walkie-talkies worn by all staff if there (Fig. 20.2).
20 Integrating Day Treatment in the School Setting 363

8:00-8:25 Morning Work/Breakfast dents as part of larger systems, including their

8:25-8:45 Break classroom, school, family, and community. These
8:45-9:00 Morning Meeting systems create a continuum of supports that can
9:00-9:45 Math
address the unique needs of each student and
9:45-10:00 Snack
10:00-10:45 Art allow for continuity of care and generalization of
10:45-11:15 Recess treatment gains. This model of school-based
11:15-11:45 Lunch mental health differs from a one-on-one approach
11:45-12:30 Reading to counseling in its ability to utilize the entire
12:30-1:00 Writing system and work with students at all levels of risk
1:00-1:35 Social Studies/Science
(Christner et al., 2012).
1:35-2:00 Cash-in
2:00-2:15 Pack Up Our system of supports includes special edu-
2:15-2:30 Dismissal cation teachers, behavior specialists, clinicians,
nurses, and administrators, all of whom are on
Fig. 20.2 Sample weekday schedule site. Each classroom is considered its own team
and is staffed by a certified special education
Each classroom utilizes a classroom behavior teacher, one to two classroom behavior special-
program to provide structure, clear and consistent ists, and a clinician. Other team members include
expectations, incentives/positive reinforcement occupational therapists and speech and language
for appropriate behaviors, and consequences for pathologists, who work directly with students
challenging behavior. Classroom behavior pro- who receive services through their IEP but are
grams vary depending on the age and needs of the also available to consult on general classroom
students in each classroom and are adapted issues. School nurses are on-site and are available
depending on the individual needs of each stu- to provide support, consult on medical concerns,
dent. The classroom behavior program provides and communicate with outside medical profes-
the reinforcement-based framework for each stu- sionals when needed.
dent’s individualized target behaviors. To provide Outside of the school, families are encouraged
an example, a typical elementary classroom to maintain connections with community provid-
behavior program consists of the day being bro- ers to help bridge the gaps between systems and
ken up into half-hour blocks. Students can earn to aid with transitions, such as when students are
checks or points in each block for maintaining ready to step down to less restrictive settings.
safe and expected classroom behaviors and for Team leaders serve as the primary contact for
remaining on task with academic expectations. families and as the liaison between LSS schools
At designated break times, students can “cash in” and referring districts.
their points for preferred activities. Classrooms Clinical services are overseen by the team
generally have three cash in levels, with the most leader and include daily direct and consultative
preferred activities requiring the highest level of support to students and staff. Student supports
points earned. When students are beginning to include individual clinical coaching sessions,
show off-task behavior in the classroom, staff are social-emotional learning (SEL) groups in the
often able to easily redirect them back to task by classrooms, and crisis management. Groups are
reminding them of the positive incentives they scheduled and occur on a regular basis. Clinical
can earn through the behavior program. coaching sessions can be initiated by students or
staff and occur as needed but can also be sched-
uled. For example, if a student is new to the pro-
 heoretical Framework and Clinical
T gram and is struggling with peer interactions,
Approaches clinical coaching sessions can be scheduled to
help them problem-solve and work toward the
Our school programs generally follow a systems goal of improving social relationships. Team
framework that conceptualizes individual stu- leaders also communicate regularly with families
364 C. Correia and G. Francis

regarding student challenges and progress and out services and integrate supports into the
maintain contact with LEAs. School-based mul- classroom. Support and consultation are provided
tidisciplinary team meetings occur weekly, are to families, but family therapy is not typically
led by team leaders, and provide an opportunity included in programming unless specified in the
for the school team to give updates on student student’s IEP. Instead, families are encouraged to
progress, engage in problem-solving, and plan maintain connections with outside providers with
for IEP meetings using data-based the goal of these supports remaining in place
decision-making. when students are ready to transition to a less
Clinical approaches are primarily rooted in restrictive educational environment.
cognitive behavioral theory and are adapted to
meet the needs of students and classrooms.
Supports are multidisciplinary and integrated  risis and Safety Response/
C
throughout all aspects of programming. The gen- Management
eral therapeutic structure of the program focuses
on providing routine and structure, coaching in All school staff are trained in de-escalation and
self-regulation, and teaching and modeling of physical intervention techniques to manage cri-
social, emotional, and behavioral coping skills. ses and safety concerns. Most behavioral epi-
An emphasis is placed on establishing positive sodes can be managed using de-escalation
and collaborative relationships with students and techniques most commonly implemented by
families. Toward this goal, clinical team leaders classroom behavior specialists. Alternative
interact directly and frequently with classroom spaces for de-escalation are available outside of
staff and students and are directly available to the classroom, including a “quiet room” that is
families and outside providers. free of furniture and/or materials and used solely
for de-escalation. More commonly used options
for de-escalation outside the classroom include
Treatment Modalities sitting or taking a walk in the hallway with staff,
meeting with a clinician in an office, or utilizing
Treatment modalities primarily include individ- a sensory strategy in the occupational therapy
ual and group interventions. Clinicians lead room. If all de-escalation strategies have failed to
weekly social-emotional learning groups in the resolve a significant safety issue, then physical
classrooms and conduct individual clinical management is used to manage that unsafe
coaching sessions with students as needed. behavior in the least restrictive way possible. Our
Groups typically last 30–45 minutes. The length goal is always to end such physical management
of individual coaching sessions varies but are as quickly as possible and to focus on helping the
meant to be kept brief so as not to keep students student regain control of their emotions and
out of the classroom for extended periods of time. behavior. When students exhibit unsafe behavior
Social-emotional coaching is provided through- or make statements about wanting to harm them-
out the day as needed by classroom staff, with selves or others, clinicians conduct safety assess-
support from the clinical team leader when ments using modified safety planning tools
needed. An example of these supports is included appropriate to the age and developmental level of
in the following section. Depending on student the student. The on-site school nurse is consulted
needs outlined in the IEP, students may receive when necessary to assess any medical risks or
direct therapy services from their designated concerns, such as when a student is engaging in
team leader, as all team leaders are either clinical self-injurious behavior. Clinicians consult with
social workers or psychologists. In general, how- outside providers as necessary and use emer-
ever, the goal of the program is to minimize pull-­ gency services if further psychiatric evaluation
20 Integrating Day Treatment in the School Setting 365

for hospitalization is needed. Parents/guardians Use of Evidence-Based Assessment

are always notified of any such assessment and
are involved in the decision-making process in Evidence-based assessment is emphasized when
the case of the need for further evaluation. In considering best practices in child and adolescent
­general, however, most students can remain in mental health care (Mash & Barkley, 2007; Mash
school following a safety assessment in which & Hunsley, 2005) but is inconsistently imple-
they are not deemed to be at risk. This helps alle- mented in community-based settings due to a
viate the burden often placed on families in previ- variety of practical barriers, including time con-
ous settings where they may have been required straints, limited financial resources, and ques-
to pick up their student from school in the event tions of social validity (Garland et al., 2003;
of any behavioral escalation. Hatfield & Ogles, 2007; Jensen-Doss & Hawley,
The following example illustrates how the 2011). These barriers are especially relevant in
range of clinical supports described above would school mental health settings where clinicians are
be integrated and delivered in our elementary more likely to be treating youth with comorbid
school site: conditions from complex, high-risk, and low-­
A fifth-grade student is demonstrating an increase resource families and social systems (Connors
in social withdrawal and oppositional behavior in et al., 2015). Although similar barriers exist in
the classroom that have not been observed since LSS programs, where students often have com-
the start of his fourth-grade year when he first tran- plicated presentations and come from diverse
sitioned to the program. He no longer greets staff
each morning and does not engage with his peers backgrounds, evidence-based assessments and
during break times. Each time academics are pre- data collection are utilized to guide academic and
sented to him, he puts his head down on his desk. therapeutic planning and decision-making.
When staff prompt him or ask him if he needs help, Assessments are typically driven by the IEP
he either ignores them or begins yelling, cursing,
ripping school materials, and trying to walk out of process. Formal evaluation needs are discussed
the classroom. On one occasion, the student shoved by a student’s IEP team. The special education
a staff member who was attempting to de-escalate process includes an initial evaluation to deter-
the situation by offering to take him for a walk. mine whether a student is eligible for special edu-
Following this incident, the classroom behavior
specialist and clinician meet with the student to try cation services and then discussion of the need
and identify triggers and remind him of coping for subsequent reevaluations every 3 years to
strategies he learned in SEL group. The clinician determine continued eligibility. Evaluations may
learns in a phone call with the student’s parent that include cognitive, clinical, social-emotional,
he has been showing increased irritability at home
and was overheard talking to his neighborhood behavioral, academic, speech-language, and
friends about middle school. The clinician meets occupational testing, depending on the needs of
with the classroom teacher and behavior specialist, the student. Results of the evaluations are shared
and they discuss the possibility that the student is and discussed with a student’s educational team
showing an increase in behaviors due to anxiety
about an upcoming transition to middle school. and are used to guide further planning.
The clinician plans an SEL group lesson to address Evaluations may also be requested upon referral
the social and emotional implications of transition- to LSS programs as well as outside of the 3-year
ing to middle school, including identifying and period to address questions related to a student’s
labeling common emotions associated with
change, how to say goodbye, and how to make new functioning.
friends. The teacher and classroom behavior spe- Our psychologists utilize a range of evidence-­
cialist make a plan to check in with the student at based, standardized assessment tools when com-
the start of the next school day to remind him of pleting formal cognitive, clinical, and educational
what strategies are available should he become
frustrated, validate any feelings he may be having, assessments. Commonly used cognitive assess-
and offer the opportunity to speak further with ment instruments include the Wechsler
them or his clinician. The clinician maintains con- Intelligence Scale for Children (WISC-V;
tact with the student’s parent to encourage com- Wechsler, 2014) and the Stanford-Binet
munication, emotion validation, and modeling of
appropriate reactions in the home environment. Intelligence Scales (SB-5; Roid, 2003).
366 C. Correia and G. Francis

Assessment of adaptive functioning, utilizing Student Strengths Assessment (DESSA; LeBuffe

scales such as the Adaptive Behavior Assessment et al., 2009), a standardized, strength-based SEL
System (ABAS-3; Harrison & Oakland, 2015) or assessment. Classroom staff also collect daily
the Vineland Adaptive Behavior Scales data related to academic, behavioral, and social-­
(Vineland-3; Sparrow et al., 2016), is often part emotional functioning of students. These data are
of the testing battery for students with cognitive used to determine the strengths and needs of stu-
or developmental challenges. Clinical assess- dents when formulating annual IEP goals, to
ment tools include structured and semi-structured design and implement interventions to target
interviews, such as the Kiddie Schedule for areas of weakness, to provide regular progress
Affective Disorders and Schizophrenia updates on those goals, and to drive decision-­
(K-SADS-PL DSM-5; Kaufman et al., 2016), the making related to daily student programming.
parent version of the Children’s Interview for
Psychiatric Syndromes (P-ChIPS; Weller et al.,
1999), and the Mini International Cultural Considerations
Neuropsychiatric Interview for Children and and Adaptations
Adolescents (MINI-KID; Sheehan et al., 2010).
A number of our psychologists are also trained in Clinicians consider a range of factors when select-
the Autism Diagnostic Observation Schedule ing and administering assessments. Age, develop-
(ADOS-2; Lord et al., 2012). In addition to clini- mental level, assessment history, language,
cal interviews, comprehensive and targeted culture, and functional level are taken into account
social, emotional, and behavior rating scales are when selecting instruments, setting up the testing
used to gather information from parents, teach- environment and schedule, and interpreting
ers, and students to assist in providing diagnostic assessment findings. When working with fami-
clarification or for progress monitoring. lies, bilingual rating scales and interpreter ser-
Commonly used tools include broad-based rating vices are utilized with non-English-speaking
scales like the Behavior Assessment System for families. Clinicians also coordinate with referring
Children (BASC-3; Reynolds & Kamphaus, school districts who may have bilingual evalua-
2015) and targeted rating scales like the tion teams that are most suitable when assessing
Children’s Depression Inventory (2nd ed.; CDI-­ multilingual learners. When interpreting assess-
2; Kovacs, 2010) or the Screen for Child Anxiety ment findings, clinicians integrate observations
Related Emotional Disorders (SCARED; and discussion of factors that may have influenced
Birmaher et al., 1997). LSS clinicians may also standardized scores or findings. It is also impor-
complete social histories and conduct functional tant to be mindful of keeping information included
behavioral assessments. Academic evaluations, in evaluation reports relevant to the referral ques-
such as the Woodcock-Johnson Tests of tion at hand, as these become part of a student’s
Achievement (WJ IV ACH; Schrank et al., 2014) educational record. Clinicians are therefore sensi-
and the Wechsler Individual Achievement Test tive to issues of privacy and confidentiality regard-
(WIAT-III; Wechsler, 2009), are typically com- ing family history.
pleted by the special education teachers, but LSS Assessing students in the school setting allows
psychologists are also trained and able to conduct for flexibility and adaptations that may not be
these evaluations. possible in other settings. Students can complete
In addition to formal evaluations requested by assessments over multiple sessions and at times
a student’s IEP team, assessment tools are uti- that work best with their schedule to optimize
lized to provide ongoing progress monitoring of their performance. Incorporating positive rein-
student functioning and to inform IEP goal devel- forcement and incentives from the classroom
opment. For example, we use the Devereux often helps with student engagement and persis-
20 Integrating Day Treatment in the School Setting 367

tence. Opportunities to observe students in a nat- tive self-talk using discussion, activities, and
uralistic setting also provide extremely valuable visuals to reinforce the concept. Classroom staff
information about how students interact with oth- will then incorporate and utilize the language and
ers, confront daily challenges, and apply skills. supports from the lesson to continue teaching and
reinforcing the skills as challenges arise in the
classrooms. Clinicians may also introduce con-
Use of Evidence-Based cepts and strategies in individual coaching ses-
Interventions sions with students and share these concepts and
strategies with classroom staff so that all team
School settings provide consistent access to members are able to help students utilize and
youth and offer an opportunity to address unmet generalize skills when needed. Successful strate-
mental health needs. The research base for the gies are also shared with parents and outside pro-
use of evidence-based practice in school mental viders to promote generalization of skills into the
health programs, however, is limited (Hoagwood home environment.
et al., 2007; Fazel et al., 2014). Barriers to the Classroom behavior management with an
delivery of high-quality and evidence-based emphasis on positive reinforcement and reteach-
practices in schools include limitations around ing of skills is another key treatment component
funding, specialized training, and implementa- in LSS programs. Each classroom has a clear set
tion support (Eiraldi et al., 2015; Forman et al., of rules and routines that help students under-
2009; Langley et al., 2010; Reinke et al., 2011). stand what behaviors are expected, how behav-
To address these barriers, researchers recom- iors will be reinforced, and what consequences
mend designing and adapting interventions that will be used for inappropriate behaviors. Staff
fit within the school context and can be reason- provide positive praise and reinforcement
ably supported and implemented, such as ongo- throughout the day for expected behaviors, and
ing coaching and incentives (Weist et al., 2019). students can earn incentives and preferred activi-
ties through their structured behavior programs.
When inappropriate behaviors occur, staff main-
Key Treatment Components tain a positive framework by using language that
encourages students to remember the rules and
Like a modular approach (see Chorpita, 2006; expectations of the classroom or by encouraging
Chorpita & Weisz, 2009), which allows for flexi- them to use a strategy. For example, a student
bility and individual tailoring of treatments, may be given a “reminder” to use appropriate
interventions delivered in LSS programs incorpo- language in the classroom or may be encouraged
rate and adapt principles and components of to “stop and think” if they are becoming frus-
evidence-­based practices and programs. trated. Staff will also process difficult situations
Commonly used components of CBT include with students after they occur to validate their
psychoeducation, goal setting, cognitive restruc- emotions and problem-solve positive solutions
turing, emotion recognition and management, for how to handle future challenges.
relaxation, self-monitoring, social skills training,
role-playing, problem-solving, and positive self-­
talk. These interventions are most often delivered  etailed Adaptations of Evidence-­
D
through in vivo social-emotional coaching, indi- Based Interventions for Setting
vidual clinical coaching sessions with students, and Patient Population
and social-emotional learning groups in the
classroom. For example, a clinician may deliver a LSS clinicians utilize a combination of structured
classroom SEL group lesson on the topic of posi- and manualized programs as well as components
368 C. Correia and G. Francis

of evidence-based interventions. Depending on multiple opportunities to practice skills within

each student and classroom’s needs, interven- group settings, and then classroom staff prompt
tions are adapted and individualized. A variety of and reinforce those skills in the real-life class-
tools are utilized to deliver the core principles room environment. Because students usually are
and elements of evidence-based interventions, with us for months, this allows us to make these
including interactive and multisensory activities, accommodations with relative ease.
visual supports, and technology. Depending on
the developmental and functional level of stu-
dents, problem-solving scenarios and role-plays  ips for Maximizing Treatment Gains
T
are adapted to match the language and level of in Population/Level of Care
understanding of students. Structured and manu-
alized programs are most often utilized when Therapeutic supports are integrated throughout
delivering group interventions in the classroom. all aspects of programming in an effort to gener-
Programs include the Second Step® curriculum alize and promote maintenance of skills. Pull-out
(Committee for Children, 2016), a lesson-based services are minimized so that students can
program to teach SEL skills in the classroom; the remain in the classroom environment, where
Incredible 5-Point Scale (Buron & Curtis, 2003), there are more opportunities for skill practice and
a support that provides a concrete and visual way reinforcement. In the classroom, staff are coached
for individuals to label and control their emotions to provide frequent reinforcement for positive
and behaviors; and the Circles Curriculum behaviors, be aware of and minimize contingen-
(Walker-Hirsch et al., 2018), a program that edu- cies that may reinforce problem behaviors, and
cates individuals about appropriate social bound- encourage students to practice skills across mul-
aries and interpersonal skills. For older students, tiple contexts. These practices have been shown
structured group interventions such as DBT-A to help with generalization and maintenance of
(Rathus & Miller, 2015) are used. Many of these therapeutic gains (Swan et al., 2016). Outside of
programs are also utilized in public schools, the classroom, LSS clinicians collaborate with
making them more familiar to students transi- families and outside providers to promote gener-
tioning in and out of LSS programs. alization of skills by sharing information about
Multidisciplinary clinical interventions are also progress, challenges, and helpful strategies.
used, integrating programs originally developed Careful attention is also given to transition sup-
from speech-language and occupational therapy. ports when students are ready to move to less
Examples of programs include the Zones of restrictive settings. These include supported vis-
Regulation (Kuypers, 2011), a curriculum that its and meetings between school teams, provid-
teaches individuals how to identify and label ers, and families. Families are also encouraged to
their emotions and choose appropriate coping maintain relationships with outside providers for
strategies, and the Social Thinking curriculum the duration of a student’s enrollment to help
(Winner & Crooke, 2008), which teaches indi- bridge potential gaps and maintain a consistent
viduals how to observe, interpret, and respond to support when a transition occurs.
social situations.
The modifications most common in our set-
ting are to the timing and pacing of interventions.  roviding Culturally Competent
P
Our students often require information to be Intervention in an Empirically
chunked into smaller parts and simplified in Supported Context
terms of language. We typically then use shorter
duration sessions over longer periods of time to Cognitive-behavioral and other interventions and
deliver interventions. Our students benefit from techniques can be effective when used with
20 Integrating Day Treatment in the School Setting 369

diverse children and families in educational set- Inclusion of Family and Caregivers
tings, but practitioners must work to recognize
how cultural factors can influence these interven- One of the primary roles for the clinical team
tions (Ortiz, 2012). In our programs, treatment leader is to be the conduit of information between
team leaders work to establish strong and posi- home and school. Most of our students have com-
tive working relationships with students and their plex needs inside and outside of school, so con-
families in order to best understand family sys- nection with caregivers is vitally important to our
tems, how cultural factors may be affecting the tasks of assessing, treating, and educating stu-
student, and how to appropriately adapt clinical dents. The school-home connection also helps
interventions. Translation/interpretation services generalize skills learned in school to the home
for non-English-speaking families are available setting. Because we typically work with students
for phone calls as well as IEP meetings. Our most over lengthy periods of time, we can help fami-
common need is interpretation in English/ lies manage the ebb and flow of daily life stress-
Spanish. In our large and diverse high school site, ors. This frequently involves crisis intervention
we are fortunate to employ two bilingual Spanish-­ to deal with periods of high stress, unsafe behav-
speaking clinicians who are also available to iors, or deterioration in functioning. For example,
assist all our clinical staff across sites. Some of in the case of a student who is experiencing an
our students require ongoing interpreter services exacerbation of depressive symptoms and self-­
in the form of a 1:1 aid to accompany them injury, the clinical team leader would collaborate
throughout the day. For example, we have had with outside providers, work with the student and
students who required an aide fluent in Spanish, family to assess for safety, determine the appro-
Portuguese, or American Sign Language. priate level of therapeutic intervention, develop a
In the classroom, clinicians facilitate discus- safety plan, monitor and modify that safety plan,
sions among school team members about how and prompt the use of the plan at school and at
cultural factors should be considered when adapt- home.
ing classroom groups and activities. For example,
it is common in school settings to discuss and do
activities for various holidays throughout the Working with Schools
school year. Clinicians guide classroom staff to
consider cultural factors, including family struc- Given the nature of our work, collaboration with
ture, religious preferences, and socioeconomic schools is inherent in what we do every day. This
differences, when discussing and planning these involves working at both local and administrative
activities. levels. For example, we need to work with the
special education director as part of the IEP pro-
cess, and it is very important to keep this person
Collaborations and Generalizing apprised of their student’s functioning in school.
Treatment Gains As students become ready to transition back to
public school, then we need to work with the
Collaboration between the school team, a stu- principal and staff of the identified school to
dent’s family, and outside providers is an impor- learn about the culture of that school and identify
tant aspect of LSS programs. Clinical team the point people for developing a transition plan.
leaders are on-site daily and maintain regular These point people may include regular and spe-
contact with families, referring school districts, cial education teachers, guidance counselors,
and outside treatment providers. This allows for school psychologists, school social workers, and
the development of healthy working relationships school nurses. Visiting the identified school is a
with all involved and for successful transitions to great way to learn about that school’s own cli-
less restrictive settings. mate and culture in order to best prepare the stu-
dent to enter that new environment.
370 C. Correia and G. Francis

Transition plans vary depending on the needs and families stay connected to their communities,
of a student. For example, some students benefit so this coordination is particularly important as
from multiple visits to a new program, whereas we plan for students to transition to public school.
some do better with few or no visits. Often, tran- In the above example, the student’s family may
sitions are planned to take place during natural choose to invite outside treatment providers to
breaks during the school year, such as following meetings so that they can also support the student
a holiday break, at the beginning of a semester, or and family during the transition.
at the beginning of the school year. The following
example illustrates the collaboration and p­ lanning
involved when transitioning a student back to a  orking with Other Community
W
public school program: Members
At a fourth-grade student’s annual IEP meeting,
her parents, LSS staff, and LEA discuss the signifi- We work with a variety of community members
cant behavioral and academic progress she has for different purposes. For example, to enhance
made and agree to begin exploring a transition our academic curriculum, we provide instruction
back to a public school setting. The LEA arranges
for the LSS clinician and the student’s parents to in art, music, and theater. This is done through
visit an in-district special education program with partnerships with local agencies, including an art
behavioral and social emotional supports. The LSS museum, music school, and repertory theater
clinician and parents meet with the special educa- company. In order to build in opportunities for
tion coordinator, teacher, school social worker, and
principal of the school where the program is students to practice interacting with less familiar
located. They learn more about the program, have people, we also schedule field trips to places like
the opportunity to ask questions, and get a tour of zoos, aquariums, ball fields, and recreation cen-
the building. The LSS clinician, family, and LEA ters. For our older students, exposure to the world
later discuss any questions or concerns of the fam-
ily in a series of phone calls and agree that the pro- of work is an important part of their curriculum,
gram is a good fit for the student. The parents then so we invite community members to give job
schedule a time to bring the student to visit the talks, have students visit job sites, and have stu-
program, and the LSS clinician meets them at the dents participate in vocational assessments and
school to provide support. The IEP team recon-
venes and agrees to have the student attend the job placements.
summer extended school year (ESY) program at Like all mandated reporters, we work with
the new school and fully transition to the new pro- state departments of children’s services. Students
gram at the start of her fifth-grade school year. The with developmental disabilities are involved with
LSS clinician schedules individual coaching ses-
sions with the student to help address any ques- the state agencies that provide services and sup-
tions they have and to help them prepare for their ports to that population. Our older students get
upcoming transition. They also maintain commu- involved with the state offices of vocational reha-
nication with the special education coordinator, bilitation as part of the routine process of transi-
teacher, and school social worker to provide them
with helpful information about the student’s aca- tion planning for students approaching
demic, social, emotional, and behavioral graduation.
functioning.

Integrating Research and Practice

Coordinating with Outside Treatment
Providers We view one of our missions as providing
evidence-­based assessments and interventions in
We coordinate with whatever outside providers the context of a school milieu. Since ongoing
are working with our students. This often includes assessment (called progress monitoring in the
outpatient providers like therapists, child psychi- world of education) is required for all students on
atrists, in-home workers, BCBAs, and pediatri- an IEP, this expectation helps us stay consistent
cians. As noted above, our goal is to help students with the ongoing process of evaluating our aca-
20 Integrating Day Treatment in the School Setting 371

demic and therapeutic interventions. As noted viding this ongoing training has helped with staff
above, our selection of assessment and treatment recruitment, longevity, and morale.
strategies is guided by the scientific evidence Be nimble. Accept the need for continuous
base. monitoring of the worlds of education and child-
We do not currently have research projects hood mental health. Accept that things will need
underway. However, we do keep our students and to change over time even though you are sure that
families apprised of ongoing research in our you’ve finally developed the perfect product. As
medical school that may be relevant to their par- John Maxell said, “The pessimist complains
ticular circumstances, and we have worked about the wind. The optimist expects it to change.
­collaboratively with researchers to allow projects The leader adjusts the sails.”
to be run at our sites. Examples include our high
school students participating in risk prevention
groups during the school day as part of an HIV Helpful Resources
prevention project and students on the autism
spectrum being recruited to join a statewide The US Department of Education website (www.
autism registry. ed.gov) provides excellent information about
special education law. It is also essential to
become familiar with your state department of
 essons Learned, Resources,
L education website as that is another treasure trove
and Next Steps of information. For example, we are frequent
visitors to the RI Department of Education web-
Tips for Developing site (www.ride.ri.gov). Finally, extensive infor-
and Implementing Similar Programs mation about social-emotional learning can be
found on the CASEL website (www.casel.org).
While there are many things unique to our busi-
ness, there are four tips that we can share. First, it
is important to know your customer and be able Ongoing Initiatives
to speak fluently in their language. This includes
learning to balance the customer needs with the We have a number of current initiatives under-
clinical/academic product being provided to stu- way that are designed to improve our program.
dents. Using a systems lens helps with the ongo- Some are ongoing and others are newly planned.
ing process of balancing those needs. It also These initiatives include the following: (1) fur-
includes asking for feedback from your custom- ther refinement of assessment, intervention, and
ers on a regular basis so that you can provide ser- educational services for students with comorbid
vices that they actually need rather than services developmental challenges; (2) ongoing monitor-
that you think they need. This can be time-­ ing of the status of public education on a national,
consuming and sometimes uncomfortable, but it state, and local level; (3) ongoing training on the
is necessary. use of educational technology (e.g., digital cur-
Be as local as possible. Though it may be eas- riculum, integration of digital content with in-­
ier to have one big school in a central location, person delivery); and (4) further enhancement of
running several schools in the communities distance learning strategies for academic and
where students live offers numerous advantages therapeutic use, given our experience during the
if your goal is to help students remain connected pandemic.
and return to their community schools. Refinement of services for students with
Commit to ongoing training and professional comorbid developmental challenges is underway.
development for your staff. They are your most Our clinical directors have been meeting on a
important commodity. We have found that pro- biweekly basis for several months and have
developed a staff training plan. One of our clini-
372 C. Correia and G. Francis

cal directors is an expert in the area of autism and We have continued to develop strategies to
developmental disabilities (autism/DD), so she is enhance distance learning knowing that students
the lead for this project. Initial training was vir- are likely to continue to dip in and out of distance
tual and focused on data collection and graphing. learning while on quarantine or in isolation dur-
All staff were required to attend. We have identi- ing the pandemic. We have ensured that all stu-
fied a behavior specialist or coordinator at each dents have access to a Chromebook to use at
site to be the point person “on the ground” for the home. Since our staff need to be able to service
implementation of the training. These individuals students in person and remotely concurrently, we
will be meeting together once monthly through- have purchased sit-to-stand workstations for their
out the school year. Their tasks are to support laptops, portable cameras for desktops, and high-­
classroom staff to use the training provided, quality microphones and headphones. Sharing of
gather information about what is or is not “what works” happens routinely in small and
­working, and engage in problem-solving with our large groups as staff share ideas for including
autism/DD expert during monthly meetings. remote students in classroom academic activities,
Clinical directors from each site will also partici- therapeutic groups, and therapy sessions.
pate in monthly meetings. We view this as a mul-
tiyear project that will result in system-wide
improvements in the assessment, intervention, Conclusions
and educational services for students with comor-
bid developmental challenges. In this chapter we have detailed the development
Monitoring of the status of public education and day-to-day programming of Lifespan School
on a national, state, and local level is necessarily Solutions (LSS), a system of schools that provide
an ongoing process. Management of the academic, social, emotional, and behavioral sup-
COVID-­19 pandemic serves as a good example. ports for a diverse range of youth with significant
On a national level, we followed COVID-19 psychiatric needs. In general, schools have
guidelines coming out of the US Department of become increasingly involved in teaching social,
Education to get a sense of any national mandates emotional, and coping skills in addition to pro-
or guidelines. Statewide guidance was crucial in viding academic instruction. Consistent and daily
determining the details about COVID-19 isola- access to students provides great opportunities
tion rules, quarantine rules, and identification of for observation, assessment, relationship build-
close contacts. Both Rhode Island and ing, and meaningful intervention in a natural set-
Connecticut allowed parents to choose distance ting. In LSS programs, students learn, practice,
learning for their children up through August and directly apply social and emotional skills and
2021, but this choice went away in both states as strategies in the variety of situations and chal-
of September 2021. At the most local level, we lenges they face. Staff provide in vivo coaching
needed to be aware of how/when remote learning and support to assist with skill building and
was to be implemented in the public schools in problem-­solving. Clinical leaders and adminis-
which our partnership classrooms were located. trators across LSS programs are well positioned
We review our use of educational technology to integrate mental health supports in an aca-
on a monthly basis. Our school technology spe- demic setting with their clinical knowledge,
cialist works with our senior teachers and educa- background, and training. All of this is done
tion director to identify what curricula and within a system framework that acknowledges
supports are working well, what additional train- the importance of systems beyond the school,
ing is needed to support staff, and what new cur- including families, school districts, and commu-
ricula/supports the educators would like to trial. nity providers.
Virtual and in-person training is provided as We have learned that effectively integrating
needed throughout the school year. therapeutic and academic supports requires a sig-
nificant deal of flexibility. The ability to manage
20 Integrating Day Treatment in the School Setting 373

transitions, adapt to change, and think flexibly Promotion, 8, 124–140. https://doi.org/10.1080/17547

30X.2015.1037848
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grams that must also be exercised daily by LSS Mental health interventions in schools 1: Mental
staff and administration. Classroom teams must health interventions in schools in high-income coun-
adapt curriculum, behavior programs, and inter- tries. The Lancet Psychiatry, 1(5), 377–387. https://
doi.org/10.1016/S2215-­0366(14)70312-­8
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Clinicians and administrators must support the M., & Saka, N. (2009). Evidence-based intervention
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 Wilderness Therapy
21
Anita R. Tucker, Christine Lynn Norton,
Steven DeMille, Brett Talbot, and Mackenzie Keefe

I ntroduction to Outdoor Behavioral youth may need a more residential setting to

Healthcare address their treatment needs through a meaning-
ful separation from their families and communi-
The field of child and adolescent mental health ties (Harper & Russell, 2008). If an adolescent
requires an integrated service delivery system in has high-risk behaviors associated with a mental
order to meet the complex treatment needs of cli- health or substance use disorder that cannot be
ents across a continuum of care. In order to effectively treated in a community-based setting
develop best practices and treatment guidelines, or is unsafe to continue treatment in a community-­
this book examines the intricacies and protocols based setting, families may look to wilderness
of day treatment for children and adolescents. therapy as a next step on the continuum of care
Day treatment serves youth with acute mental (Scott & Duerson, 2010). In fact, 25% of youth
health needs, though not severe enough to require who attend programs affiliated with the Outdoor
hospitalization, and can be a step-up on the way Behavioral Healthcare Council have participated
to hospitalization and a step-down from hospital- in day treatment or intensive outpatient programs
ization (Substance Abuse and Mental Health before attending wilderness treatment programs
Services Administration (SAMHSA), 2006). (Outdoor Behavioral Healthcare Center, 2021).
Though day treatment provides an outpatient This chapter is an overview of wilderness
community-based option to serve highly acute therapy programs that provide outdoor behav-
youth with serious emotional, behavioral, and ioral healthcare (OBH). OBH is part of the larger
substance abuse issues, there are times when field of adventure therapy. “Adventure therapy is
the prescriptive use of adventure experiences pro-
A. R. Tucker (*) vided by mental health professionals, often con-
University of New Hampshire, Durham, NH, USA ducted in natural settings, that kinesthetically
e-mail: [email protected] engage clients on cognitive, affective and behav-
C. L. Norton ioral levels” (Gass et al., 2020, p. 1). Adventure
Texas State University, San Marcos, TX, USA experiences include any activity that provides
S. DeMille challenge to the client, requires problem-solving,
Redcliff Ascent, Enterprise, UT, USA and involves elements of communication and
B. Talbot cooperation to complete (Alvarez et al., 2021).
The Ascent Programs, Enterprise, UT, USA Active engagement in these experiences not only
M. Keefe allows the client to be immersed physically and
University of New Hampshire, Durham, NH, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 375
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_21
376 A. R. Tucker et al.

behaviorally but also allows clients to consider clinical information related to best practices in
their thoughts and emotions that arise in real assessment, treatment implementation, and pro-
time. Adventure therapy is a holistic intervention gram evaluation.
where practitioners use intentionally crafted
activities to engage clients in a multisensory
experience where clients have the opportunity to  rigins of Outdoor Behavioral
O
learn and rehearse real life skills (Alvarez et al., Healthcare
2021).
While OBH is also facilitated in community The origins of OBH can be traced back to the
settings, the focus of this chapter is on OBH prac- emergence of summer camps in the United States
tice that closely aligns with wilderness therapy. in the 1800s (Gass et al., 2020). Some of the ear-
This intervention includes a 24-hour intermediate liest organized summer camps such as Camp
level of care and an outdoor group living environ- Chocorua (1881) were created to focus on the
ment that provides post-acute care through group, physical and mental growth for young people
individual, and family therapy (Tucker et al., during the unstructured months of summer due to
2016a). According to Gass et al. (2019), “these a perceived moral decline of youth due to indus-
therapies are designed to address behavioral and trialization. Camp Ramapo and Dallas
emotional issues by utilizing treatment modali- Salesmanship Club Camp (1946) were the first
ties centered on nature, challenging experiences camps to specialize in emotionally challenged
combined with reflection/mindfulness, interper- young people and employ professional mental
sonal development, and intrapersonal growth” health workers such as psychiatrists, social work-
(p. 3). OBH programs may provide a next level of ers, and counselors. The emergence of Outward
care for youth and young adults in need of a more Bound USA, Brigham Young University 480, and
comprehensive treatment approach (Scott & Youth Leadership Through Outdoor Survival
Duerson, 2010). However, the decision to move marked the start of mountaineering, and survival-­
from outpatient to inpatient or residential treat- based character development and personal
ment is one that requires significant clinical growth programs in the United States aimed to
assessment and should not be made lightly. If serve challenging populations such as juvenile
clinically indicated, moving through the contin- offenders and college dropouts (Gass et al.,
uum of care into a more comprehensive and resi- 2020).
dential level of care should be a collaborative As these programs saw growth and success,
process with the youth client as much as possible. the programs continued to adapt to serve more
The intervention should not be aimed at “fixing” diverse populations for mental health and sub-
the youth client, but rather creating change in the stance abuse treatment. Project Adventure (1971)
entire family system (Tucker et al., 2016b). marked the beginnings of moving adventure-­
Though beyond the scope of this chapter, based therapy into school and hospital settings
OBH programs should work with youth and fam- using a variety of experiential activities such as
ilies to develop care plans that enhance the volun- ropes courses and challenge initiatives (Gass
tary commitment of clients to pursue treatment, et al., 2020). Between 1970 and 1990, there was
this includes minimizing the use of involuntary a rapid growth of wilderness therapy programs
youth transport and avoiding any coercive prac- beginning to emerge with different population
tices that may re-traumatize clients. Currently, focuses and general program models. Along with
these practices are under scrutiny, and the field of rapid growth in the field, came the need for stan-
OBH has responded by adhering to ethical guide- dard practices throughout the field to ensure pro-
lines and accreditation standards to enhance risk fessionalism, safety, and efficacy. In 1996,
management and promote ethical and effective leaders from wilderness therapy programs joined
treatment (Norton et al., 2014). This chapter together to form the nonprofit organization called
seeks to elevate treatment standards by including the Outdoor Behavioral Healthcare Council
21 Wilderness Therapy 377

(Russell, 2003a). This council introduced the The difference, however, is that in an outdoor
term OBH in an effort to align better with tradi- experiential setting versus a talk therapy setting,
tional behavioral health (Gass et al., 2020). Since the awareness and integration of thoughts, feel-
then, professional groups such as the Therapeutic ings, and behaviors occurs in the context of active
Adventure Professional Group (TAPG) of the problem-solving and feedback in the here and
Association of Experiential Education (AEE), now. This provides clients concrete new evidence
the Outdoor Behavioral Healthcare Council of themselves and their capacity to grow and
(OBHC), the Outdoor Behavioral Healthcare change, which can be hard to experience in a
Center at the University of New Hampshire, and talk-therapy setting. OBH treatment has been
several state licensure boards have worked described as taking traditional therapy “off of the
together to create best practices, ethical guide- couch and into nature” (Lavin, 2018).
lines, and risk management procedures based on This section will discuss common program
research for programs to adhere to and demon- characteristics such as standards of care, day-to-­
strate for accreditation (Gass et al., 2020). day programming structure, individual therapy,
Accreditation encourages high standards of prac- group therapy, family therapy, and the role of
tice in the field of Outdoor Behavioral Healthcare. nature in wilderness therapy treatment. Although
differences will exist between programs based on
legislative, geographic variances, and program
Program Characteristics models, which are defined by organizational pol-
icy, there are some minimum standards of care
Multimodal, Multisystemic, consistent with most OBH programs, which are
Multidisciplinary Treatment Team presented in Table 21.1 (Austin et al., 2020).
OBH programs use a multimodal, multisystemic, Parents, mental health practitioners, and other
multidisciplinary treatment team model of inte- referring professionals should carefully examine
grated care (Tucker et al., 2016a). All experiences if OBH programs have these standards of care in
throughout the day are considered treatment, and place.
everyone involved is considered a part of the The OBH treatment team is multidisciplinary
treatment team. The OBH process is based on the and includes masters and/or PhD level clinicians
experiential learning cycle of action, reflection, who engage in individual, group, and family ther-
and integration (Gass et al., 2020). It was par- apy with the adolescent clients and their family;
tially developed out of Walsh and Gollins (1976) medical staff including doctors, psychiatrists,
in which a participant’s motivation to change is and nurse practitioners; the clinical supervisor or
enhanced by a prescribed physical and social clinical director; adventure or recreational direc-
environment impacted by adventure- and tors; and field guides. In OBH, field guides play a
wilderness-­ based experiences, the role of the unique role similar to direct care staff in residen-
instructor, success/mastery, and transfer of learn- tial treatment centers; however, OBH field guides
ing. In the wilderness therapy process, the use of or field instructors often work on a 7 or 14 day
metaphor is a critical aspect in the transfer of rotation, living full time with adolescent clients,
learning, which can help maximize treatment running daily groups, and supervising the physi-
gains and link them to the client’s life context cal and emotional safety of the group as they
outside of the treatment milieu (Hartford, 2011). teach them the skills needed to live and navigate
Each OBH program often identifies program in the wilderness (Karoff et al., 2018). Field
goals and expectations related to the clinical and instructors are provided with intensive training
social-emotional use of the outdoor environment. upon hire as well as ongoing weekly in-service
OBH is designed to kinesthetically engage cli- trainings (Austin et al., 2020). Clinicians and
ents on cognitive, affective, and behavioral levels field staff work collaboratively to help clients
in the context of physically and emotionally safe meet their clinical goals. Clinicians usually meet
relationships and environment (Gass et al., 2020). out in the field with students once or sometimes
378 A. R. Tucker et al.

Table 21.1 Standards of care in outdoor behavioral days, small groups of students (usually 4–8 stu-
healthcare programs
dents led by 2–4 guides) will engage in a series of
1. Services are provided and overseen by mental activities and groups that center around an adven-
health professionals licensed in the state the program
operates
ture or other experiential activity. For example,
2. Care coordination occurs with other care providers when a group is on a backpacking expedition, the
and social services daily activities consist of a camp cleanup,
3. Clinical assessment at time of admission and hygiene, and breakfast. After this, the group will
ongoing to ensure appropriate treatment fit break down the campsite and pack up for that
4. Individual and group therapy day’s backpacking activity. Once they arrive at
5. Family therapy or other family programming to
their destination, the group will debrief the activ-
engage parents and/or guardians in the treatment
process ity, set up a new camp, engage in other experien-
6. Appropriate supervision ratios as defined by the tial or academic activities as time permits, and
state licensing and/or accrediting organization end the day with a dinner routine. Throughout
7. Medical history review and examination prior to each day, there are various group processes that
participation in the outdoor program
occur to teach, process experiences, problem
8. Supervised medication administration or
self-administration solve, and promote change and growth.
9. Nursing staff on-site or on call and available The second type of daily program is for sta-
24 hours a day tionary days. Stationary days can occur in differ-
10. On-site supervision in compliance with licensing ent ways, but a core feature is the group is not on
and accreditation standards (generally, 24 hours per expedition and is usually in a predetermined
day, 7 days a week, although some activities, such as
Solosa, may have exceptions) location or camp. The types of stationary camps
11. Parent training or development curriculum vary by program, some include a primitive cabin
12. Preliminary treatment plan at admission and more or other camp structure, some include permanent
refined treatment plan to guide treatment course tents such as a large wall tent, and others use
13. Discharge planning prior to leaving treatment and mobile camp structures such as tents or other
a discharge summary completed by a licensed mental shelters the group sets up. Activities on these
health professional
14. Initial and ongoing psychiatric evaluation as
days include formal individual, group, and family
defined by the treatment plan therapy. Participants often engage in academics,
15. Psychosocial assessment by a licensed mental and planning and preparing for the next expedi-
health professional tion often occurs on the stationary camp days.
16. Therapeutic outdoor activities as defined by the This is also when medical or other mental health
treatment plan to support the achievement of clinical
goals
professional visits occur. Each program will vary
in their day-to-day programming; however, this
a
Solos are when clients spend usually 24–48 hours by
themselves out in nature as a time of reflection and soli- provides a broad overview on the common activi-
tude while given all the appropriate food and shelter. ties that occur in an OBH program.
Clients are usually given a certain area where they do their
solos, and staff are close and able to check on clients visu-
Individual Therapy
ally and verbally, if needed
OBH includes the application of evidence-based
interventions based most notably on the princi-
multiple times per week; however, field instruc- ples of cognitive behavioral therapy. Along with
tors are responsible for adolescents for 24 hours traditional cognitive behavioral approaches, the
per day and an essential part of the multidisci- most used treatment approaches in OBH, accord-
plinary treatment team (Myrick et al., 2021). ing to a recent program survey, include motiva-
tional interviewing and trauma-informed
 ay to Day Programming
D approaches, including trauma-focused cognitive
The day-to-day programming tends to be broken behavioral therapy (CBT), dialectical behavioral
up into two types of daily programming: expedi- therapy (DBT), and family-centered treatment
tion days and stationary days. On expedition (OBH Center, 2020).
21 Wilderness Therapy 379

Individual therapy often occurs with a client (Alvarez et al., 2021; Gass et al., 2020; Gillen,
weekly or biweekly, and the therapist usually 2003; Newes & Bandoroff, 2004). Common
travels to the location of the participant while in group topics may include cognitive restructuring
the backcountry. Therapy occurs with nature and skills, self-awareness practices, and coping skills
the outdoors as the backdrop for the session. practice, along with personal assignments to
Licensed mental health clinicians provide track progress on skills learned (Craske, 2017;
evidenced-­based treatment for clients based on Pederson, 2015; Westrup, 2014).
the presenting problem and clinical diagnoses.
The individual treatment is guided by the indi-
vidualized treatment plan. Individual therapy in Mindfulness Groups Mindfulness activities are
an OBH program often also involves a high often used in OBH programs to increase aware-
degree of experiential activities and interventions ness of emotions and help clients with emotional
in addition to traditional psychotherapy regulation, distress tolerance, somatic awareness,
methods. and cognitive problem-solving skills (Norton &
Peyton, 2017). Norton and Peyton (2017) found
Group Work that OBH programs identified relaxation breath-
While individual and family therapy are used in ing, guided imagery meditation, walking or sen-
OBH, the use of group work is also common and sory meditation, progressive muscle relaxation,
integrated throughout OBH treatment on a daily single-pointed meditation, yoga, body scanning,
basis. Groups can be facilitated by recreational and loving-kindness meditation as the primary
directors and field guides often guided by clini- practices used with clients. Likewise, Russell
cians or in conjunction with clinical staff. While et al. (2016) found a strong relationship between
the type of groups varies across programs, below mindfulness-based experiences and a reduction
are some common groups that run across OBH in wilderness therapy clients’ subjective distress,
programs. which promotes improved well-being.

Support and Feedback Groups A feedback

group is a structured group that includes self-­ Reflection Groups Often at the end of each day,
reflection, expression of emotions, and providing field instructors facilitate a reflection on the
and receiving feedback. These groups are process events of the day. This group includes the indi-
focused and occur in a “circle up” or around the vidual functioning of each member and the over-
campfire in the morning or evening and can be all functioning of the group. Specific struggles
used when needed during an activity. They can are discussed, and feedback can be requested.
happen at any time and are often used when a This group is intended to create awareness around
group or individual is struggling and needs spe- the functioning of the day and to consolidate and
cific support. Support groups involve the inclu- internalize any lessons learned from the day. This
sion of Alcoholics Anonymous or other structured group also includes the use of journaling to docu-
support groups for clients struggling with spe- ment learning and to assist in the reflection
cific issues. process.

Psychoeducation Groups These groups are Adventure and Experiential Groups In addi-
topic focused and are intended to teach clients tion to the activities involved with living and trav-
about models or concepts that can improve their eling in the wilderness, many OBH programs
personal life and relationships. The models, con- also intentionally include additional adventure
cepts, or skills that are taught in the psychoedu- and experiential activities with groups. These can
cation groups often come from CBT, DBT, or vary from rock climbing, canyoneering, moun-
acceptance and commitment therapy (ACT) tain biking, challenge courses, and games and
380 A. R. Tucker et al.

initiatives. The integration of group adventure fire, and motivation to drive forward in life
experiences can add to the impact of OBH requires similar skills, and this powerful meta-
(Magle-Haberek et al., 2012) by providing an phor is unique to the novel primitive skills
additional setting for participants to see how both required in the OBH program environment.
maladaptive and adaptive ways of being impact
themselves and the group. Adventure therapy Family Therapy
activity interventions are intentionally planned Adolescent problems with mental health also
and facilitated for clients to experience emotions, negatively affect the lives of family and friends
thoughts, and behaviors that parallel those expe- (O’Connell et al., 2009), not just the adolescent.
rienced in their daily lives in the safe and healthy While early OBH programs focused solely on
environment provided by the group. These activi- adolescent and young adult mental health treat-
ties are shaped toward individual and group treat- ment, current best practices include providing
ment goals and provide clients an opportunity to treatment to the family system as a whole (Tucker
rehearse new ways of coping, thinking, and com- et al., 2016b). Changes in OBH treatment include
municating in relation with themselves and oth- setting family treatment goals and helping fami-
ers (Alvarez et al., 2021). Adventure activities lies enhance family functioning. The focus is on
inherently require a healthy level of risk taking, improving communication, conflict resolution,
trust in oneself and others, communication, emo- and problem-solving skills within the family sys-
tional regulation, problem-solving, and adapta- tem. This is accomplished using traditional fam-
tion, which are in line with therapeutic goals for ily therapy modalities, psychoeducation, and
clients in OBH programs. For example, rock experiential activities with the family unit.
climbing requires trust between the climber and While an adolescent is attending OBH, weekly
belayer, communication about how the belayer family therapy sessions with the guardians are
can support the climber, an ability to manage any facilitated, usually by phone or online, by the cli-
nerves or anxiety that arise with climbing off the nicians. At the beginning of treatment, this is often
ground, and a level of choosing how much risk to done without the adolescent present, as a common
take by choosing how high to climb. This activity goal of OBH programming is to assess and disrupt
elicits a wide range of client engagement that can unhealthy family dynamics. Although specific
be processed with the group and clinician for family therapy models for OBH are limited, there
therapeutic gains. is some research on effective family therapy mod-
els being applied in OBH (Merritts, 2016).
Narrative family therapy is one model that has
Primitive Skills Groups Many OBH programs been adapted to an OBH treatment setting.
have a primitive skills emphasis. In order to pro- Narrative family therapy involves asynchronous
mote skill mastery, clients in an OBH program interventions that can be adapted to overcome the
learn primitive skills relevant to their physical financial and distance limitations that are inher-
environment that they use to meet their emo- ent in having a child away from home for treat-
tional, social, and physical needs. These activi- ment. Narrative therapists often work alone with
ties include primitive fires, primitive bags and a client, or flexibly, with individuals and parts of
chairs, lantern making, knots, lashings, cordage, families, by interacting with one person in the
and others. While these primitive skills have family while the others listen. This process or the
direct relation to survival in the wilderness envi- telling and retelling of the family story makes the
ronment, they also support rich metaphors that family an audience to each other and their per-
can enrich the therapeutic process for clients. For sonal narratives. This approach is useful in an
example, making a primitive bow-drill fire OBH setting, as adaptation can be made to tell
requires preparation, patience, resilience, and and retell the narratives through writing, an
determination to get the spark required to make a important feature of OBH programs (DeMille &
coal and build a fire. Finding one’s spark, inner Montgomery, 2016).
21 Wilderness Therapy 381

Psychoeducation is a common component of distress tolerance, which can be helpful in other

accomplishing family treatment goals. Parents challenging situations; in fact, the wilderness
participate in parenting seminars and learn essen- can be seen as a co-facilitator of change (Taylor
tial skills and concepts to improve family et al., 2010).
functioning. Psychoeducation is done through
­
webinars, bibliotherapy, and prerecorded video  isk Management and Safety
R
training. In addition, many programs have in per- In 2007, the US Government Accounting Office
son family therapy components in which the fam- (GAO) report and testimony before Congress
ilies come together with their adolescents for a entitled Concerns Regarding Abuse and Death in
multiday retreat to work specifically on family Certain Programs for Troubled Youth (Kutz &
functioning, usually toward the end of treatment. O’Connell, 2007) drew negative attention to the
All OBH programs assess their impact on family field of wilderness therapy. The GAO described
functioning by administering the Family the programs under investigation as “wilderness
Assessment Device (Epstein et al., 1983). therapy programs, boot camps, and academies”
Research in this area has shown that family par- that “provide a range of services, including drug
ticipation is associated with superior outcomes and alcohol treatment, confidence building,
when a family member is receiving treatment out military-­
style discipline, and psychological
of the home (Hair, 2005) and general improve- counseling for troubled boys and girls with a
ments in family functioning (Harper et al., 2007; variety of addiction, behavioral, and emotional
Harper & Russell, 2008). problems.” This report encouraged the profes-
sional field of OBH to continue to differentiate
Role of Nature good programs from bad programs by not only
While OBH wilderness therapy programs pro- continually developing standards of practice but
vide clients with many of the same integrated also forming an accreditation body to regulate
treatment modalities of a traditional residential these standards.
treatment program, the natural environment is an In 1999, researchers began to develop a
important distinction. The element of nature in research base informing evidence-based practice
OBH is commonly overlooked and undervalued. and standardized risk management practices. In
Several studies and established theories high- 2013, the OBH Council joined with the
light the physiological and psychological bene- Association of Experiential Education to create
fits of human interaction in nature (Martin & an accreditation body that developed a detailed
Beringer, 2003; Gillis & Ringer, 1999; Mitten, set of ethical risk management and treatment
2009). The theory of biophilia supports that con- standards (Austin et al., 2020). There are cur-
nection to nature is inherent, instinctual, and rently 20 AEE-OBH accredited programs whose
essential to human cognitive, emotional, and operations are monitored and therefore differen-
physical health (Seymour, 2016). Research has tiated from other therapeutic wilderness pro-
found that direct time in nature improves sleep grams. These OBH programs must also be
patterns, mood, creativity, resiliency, and mem- licensed and accredited within their own states,
ory. Time in natures also reduces blood pressure based on various criteria for either residential
and attention deficit hyperactivity disorder treatment or wilderness programs. Currently,
(ADHD) symptoms and facilitates increased there is no federal oversight of these programs,
executive functioning (Hart, 2016; Harper et al., which is a criticism of those concerned about the
2017; Seymour, 2016). Nature is a novel envi- lack of client autonomy and safety in totalistic
ronment that provides a restorative, experiential treatment programs (Chatfield, 2019). However,
context in which clients can heal and grow the OBH Council consistently monitors risk
(Kaplan & Berman, 2010). Learning how to management data as each member program is
cope effectively amidst the changing conditions required to submit yearly reports on risk
of nature helps promote skills of self-care and management.
382 A. R. Tucker et al.

Who Attends OBH? American Indian/Alaskan Native (OBH Center,

2021; Tucker et al., 2016b). Most participants
Outdoor behavioral healthcare programs have who attend OBH are male (68%), 30% female,
provided treatment to adolescents between the and a little over 1% identify as nonbinary.
ages of 12 and 18, who predominantly identify as Historically, most OBH participants are around
White. Historically, OBH has provided program- 16 years old and attend OBH programs for around
ming for mostly White and mostly middle to 65–75 days (OBH Center, 2021; Tucker et al.,
upper class youth due to the cost of this type of 2016a, b).
treatment. This is a limiting factor in which it is In addition, most youth have a history of men-
not accessible to all youth who may benefit from tal health treatment prior to attending an OBH
it and has been an area of focus in the field. OBH program (Bettmann et al., 2011; OBH Center,
is not necessarily covered by private insurance; 2021). Around 85–90% of OBH participants
however, with the passage of the Affordable Care have been previously involved in outpatient treat-
Act and the Mental Health Parity Law, OBH has ment, 25–30% have been previously hospitalized
been increasingly covered by insurance as an for psychiatric care at least one time (Bettmann
intermediate level of care for youth who have et al., 2011; Lewis, 2013; OBH Center, 2021),
failed in other community-based systems, and and 25% have previously attended day treatment
programs recommend families work with a or intensive outpatient programs (OBH Center,
healthcare advocate (OBH Council, 2019). While 2021). Most youth (over 90%) who attend OBH
coverage is usually first denied and families programs have more than one presenting issue
appeal before getting reimbursement, over and are complex clients with a history of trauma
six million dollars has been paid to families in the (Bettmann et al., 2011; Tucker et al., 2014,
past few years to cover OBH treatment (OBH 2016a). Common presenting issues include anxi-
Center, 2019). ety disorders, depressive disorders, attachment
Additional efforts in OBH include a focus on disorders, oppositional defiant disorders, trauma
increasing diversity training for OBH programs disorders, and substance use disorders (Bettmann
and practitioners, including specific keynote con- & Tucker, 2011; Demille et al., 2018; Lewis,
ferences on diversity, equity, and inclusion at 2013; Norton, 2008; Tucker et al., 2014).
professional meetings like the Wilderness
Therapy Symposium, and conducting a large
scale research study on OBH with diverse youth Treatment and Program
to understand its benefits in various populations Considerations
(Ray, 2021).
Until this study is completed, the most up to  dmission and Exclusion Criteria
A
date data collected on OBH participants can be In many cases, treatment is best provided in the
found in the National Association of Schools and community that a client resides or plans to reside.
Program’s Practice Research Network (PRN). However, due to the severity of symptoms, this
The PRN is a large aggregate database of infor- may not be appropriate, and past attempts of
mation collected from participants across a vari- community-based treatments may have failed,
ety of private pay mental health programs necessitating a higher level of care. Although
(NATSAP, 2021). Sixteen different OBH pro- program differences exist, some general guide-
grams contribute to the PRN, which collects data lines for the eligibility and exclusion criteria for
at intake, discharge, and 6- and 12-months post-­ OBH are presented in Table 21.2. It is essential to
discharge from youth, guardians, and staff. A assess a youth’s current health and physical capa-
recent report on adolescent clients in OBH from bilities prior to placement. In many cases, medi-
the PRN found that 82% identified as White, cal care is more than an hour away; therefore,
6.0% Hispanic, 2.5% African American, 3.0% some clients may not be appropriate for OBH
Asian, 7.0% mixed race, and less than 1% treatment. Clients with active psychotic
21 Wilderness Therapy 383

Table 21.2 Admission and exclusion criteria for OBH ment, and some disorders may not be able to
participation
benefit from these interventions, like youth with
Common admission criteria significant development delays, autism spectrum
Academic and employment difficulties. This includes disorders, or low intellectual ability. There may
expulsion from school, fired from work due to
behavioral concerns in the workplace, chronic failure be intellectual or communication limitations that
in school, employee misconduct, and refusal to attend may exclude clients from benefiting from an
school OBH program. There may be OBH programs that
Significant family conflict that disrupts the well-being provide services to clients with some of these
of the client and/or other family members
exclusion criteria. In those cases, programs pro-
Unable to maintain behavioral controls such as
outbursts, disruptive impulsivity, and other self-­ vide specific descriptions of services offered to
destructive behaviors justify an appropriate placement of that client in
Anxiety and other somatic concerns that significantly the program.
impair the functioning of the client
Depressive symptoms that significantly impair the Assessment
functioning of the client
As with any healthcare intervention, screening
Trauma disorders, include physical and sexual trauma,
combated veterans, and developmental trauma and assessment is a vital part of the treatment
Nonsuicidal self-harm process. OBH programs often utilize a variety of
Past or low to moderate suicidal ideation well-established screening, assessment, and eval-
Illegal activity (destruction of property, theft, uation practices. Prior to a participant’s admis-
disorderly conduct, probation violation, etc.) sion, the program generally undertakes a
Significant social withdrawal or isolation
prescriptive screening to determine eligibility,
Clients with underdeveloped coping skills that
significantly impair clients functioning at home,
indications for treatment, and the identification of
school, or work, such as anger management or other contraindicated conditions. Preadmission screen-
emotional regulation or social skills ings often include a review of treatment history,
Exclusion criteria physical health history, and specific screenings
Active and serious suicidal ideation including for pain, nutrition, disabilities, trauma, and other
expressing a wish to die and having a plan to carry out
the death may not be appropriate for an OBH program
related symptomatology and conditions that may
Significant risk of harm including physical or sexual limit one’s ability to participate in an OBH
violence to others. Significant destruction of property, program.
repetitive fire setting behaviors, or harm toward OBH programs often develop policies regard-
animals ing the admissions approval process. This pro-
Significant impulsivity leading to harm of self and
others
cess includes gathering sufficient information
There is limited research to support OBH treatment about the potential participant to confidently
with clients under 12 years of age and programs who determine the client’s needs and that those needs
provide services to clients under 12 should have clear can be met. Some attention is given to specific
clinical justification for doing so client-therapist fit prior to admission. Approval
OBH may not be appropriate for clients with an active
from clinical and administrative leadership is
and persistent eating disorder
There are medications that may cause a client to be often required in order to determine if the partici-
particularly vulnerable to dehydration, heat pants will be better served at a different level-of-­
exhaustion, sunburn, or increase cold sensitivity. Some care or by another program.
medication may exclude clients from participation in Upon admission, the program commonly
an OBH program
administers (through staff or contracted services)
assessments and evaluations such as medical/
physical exam, medical history and review of
s­ ymptoms may not be appropriate for treatment. systems, psychiatric evaluation and review of
These symptoms may include schizophrenia, medications, risk assessment for safety to self
mania, or other psychotic disorders. OBH pro- and others, and a biopsychosocial assessment or
grams also use metaphor as a regular part of treat- mental health assessment. Most of these assess-
384 A. R. Tucker et al.

ments are developed by programs; however, cal interview, review of records, informant (e.g.,
some do use more standardized tools to gather parent) interviews, mental status exam (i.e., alert-
more specific psychological functioning infor- ness, speech rate, affect, and attitude and insight),
mation such as the Youth Outcomes Questionnaire and assessments of intellectual abilities (e.g., IQ
(Wells et al., 2003) to get a sense of initial func- and memory), achievement (e.g., reading, writ-
tioning at intake. These assessments and evalua- ing, spelling, and learning disorders), personality
tions are used for the initial development of (e.g., patterns and preferences), and assessments
traditional treatment plans and individual goal or screenings of specific symptoms and condi-
setting. Throughout treatment, the treatment plan tions (e.g., substance abuse, depression, anxiety,
is reviewed and updated to reflect new informa- abuse/trauma, mood, ADHD, and social-­
tion and adjustments in treatment goals, problem emotional). The results of these components are
areas, objectives, and interventions used to then interpreted by a psychologist and conclu-
accomplish desired outcomes. sions are determined. Conclusions often include
Another common type of evaluation received International Classifications of Diseases-11
in OBH programs is a complete psychological (World Health Organization, 2019) and/or
evaluation. A psychological evaluation, some- Diagnostic and Statistical Manual of Mental
times referred to as “testing and assessment” or a Disorders-5 (American Psychiatric Association,
“psych eval” (different from a psychiatric evalua- 2013) (DSM-5) diagnoses, identified treatment
tion administered by a psychiatrist to determine issues, recommendations for treatment, and treat-
medication needs), is administered by licensed ment prognosis.
psychologists (Bettmann et al., 2014). The evalu-
ation includes tests and other assessment tools to  rogram and Clinical Goals
P
measure and observe a client’s symptoms and While each OBH treatment program will have
behaviors to arrive at a diagnosis and to guide unique differences and treatment approaches,
treatment (American Psychological Association, there are commonly accepted program goals and
2013). Examples of standardized measures used expectations. Treatment is customarily targeting
for these formal evaluations can include the specific emotional, behavioral, social, and physi-
Minnesota Multiphasic Personality Inventory-­ cal needs of the participant. Safety, both emo-
Adolescent (MMPIA; Butcher et al., 1992), tional and physical, is often the paramount
Millon Adolescent Clinical Inventory (MACI; program goal. This allows each participant to
Millon et al., 2006), the Woodcock Johnson III more effectively address individual treatment
(Wendling et al., 2009), and the Substance Abuse goals in immediate and long-term efforts.
Subtle Screening Inventory for Adolescents Clinical involvement is also of central impor-
(SASSI-A; Miller & Lazowski, 2001) to name a tance to the OBH treatment approach. In the early
few. Programs may recommend a complete psy- evolution of OBH treatment, clinically trained
chological evaluation in order to gain a more therapists and counselors were included in pro-
comprehensive understanding of a client’s his- gramming to provide psychotherapy and coun-
tory, strengths, limitations, etc., as compared seling in the field. Full-time doctoral-level
with others of similar age and demographic licensed psychologist involvement can be traced
background. back to 1988 (Gass et al., 2020). Since then, the
Psychological evaluations help the client, sophisticated clinical treatment that had been
family, and program understand the current more common in traditional inpatient and outpa-
issues at hand in the context of the whole person, tient treatment settings has been standard in OBH
including symptoms and conditions that may be treatment. Programs most often employ masters-­
affecting current behaviors but are not being spe- level mental health counselors, licensed clinical
cifically addressed as a treatment issue. social workers, clinical mental health counselors,
Conventional components of a psychological and psychologists. The most frequently reported
evaluation include, but are not limited to, a clini- clinical presenting issues include school prob-
21 Wilderness Therapy 385

lems, substance abuse, emotional illiteracy, or Collaborations and Stakeholders

behavioral problems (Russell & Phillips-Miller, Outdoor behavioral healthcare is situated with
2002; Tucker et al., 2011). Clinical treatment the larger field of mental health treatment and pri-
goals often also include improving interpersonal vate pay programs as well as outdoor education.
and familial relationships, identification of symp- Within this context, wilderness programs includ-
tom patterns and diagnostic criteria, development ing OBH Council program members work col-
of emotional management skills, and other laboratively with other nonprofit member
evidence-­ based interventions specific to clini- organizations such as the Gap Year Association
cally indicated diagnoses, such as depression, (GYA, 2021), the National Association of
anxiety, substance use, and ADHD. Therapeutic Schools and Programs (NATSAP,
Other common program goals and expecta- 2021), the Independent Education Consultants
tions include family/system involvement, Association (IECA, 2021), Therapeutic
removal from disruptive environments, commit- Consulting Association (TCA, 2021), and the
ment to completion of treatment, stabilization, Association for Experiential Education (AEE,
social skills development, resiliency building, 2021). The collaboration with other professional
observation, and assessment. Despite common organizations promotes best practices with OBH
misconceptions, often driven by a history of programs and the various clients, professionals,
unregulated programs in decades past, today’s and families they work with.
program goals and expectations DO NOT At the program level, in addition to the treat-
include, “breaking someone down” to “build ment team at the OBH program that oversees and
them back up,” “Boot camp” style approaches, coordinates the OBH treatment service, various
challenging participants beyond their ability to other stakeholders are involved. These stakehold-
cope with, or to put a participant into a “survival” ers include schools, past or concurrent medical
situation (Norton, 2011). and mental health treatment providers, social ser-
vice systems, and other community members
Ongoing Focus on Risk Management (such as religious leaders). One of the major con-
and Safety siderations when providing treatment in an OBH
As discussed earlier, OBH programs, specifically program is the delivery and continuation of aca-
member programs of the OBH Council, are demic activities, for which there are several mod-
required to collect ongoing risk management data els. Some OBH programs will work with previous
on a yearly basis. Javorski and Gass (2013) education providers to a continuation of their
reviewed 10-years of incident monitoring trends academics. In other programs, school is inte-
in outdoor behavioral healthcare and found that grated in the program, and the program provides
OBH clients are at less risk than youth who did academic credits; hence, school collaborations
not participate in these programs and documented are ongoing during treatment.
a lower injury rate than youth in community set-
tings (Javorski & Gass, 2013). OBH clients were
six times less likely to be restrained in treatment Research on OBH
than youth in inpatient mental health care in the
United States, based on a comparison of data Treatment Outcomes
from the National Association of State Mental The evidence base for OBH has grown signifi-
Health Program Directors Research Institute. cantly over the past 10 years. OBH programs
This research also monitored and documented affiliated with the Outdoor Behavioral Healthcare
decreases in client illnesses, therapeutic holds, Council not only collect and report risk manage-
and restraints, continuing to highlight the impor- ment data but also collect outcome data through
tance of the client’s emotional and physical safety the NATSAP PRN. The primary outcome rating
(Javorski & Gass, 2013). tool is the Youth Outcomes Questionnaire
386 A. R. Tucker et al.

(Y-OQ), which measures parent assessment and youth (wilderness programs g = 0.72; nonwilder-
adolescent self-reports and is designed for ness programs g = 0.89). Despite these differ-
repeated measurement of clients’ emotional and ences, these effect sizes were found to be larger
behavioral symptoms (e.g., at admission, during than Bettmann and colleagues’ findings (2016),
therapy, at termination, and also at follow-up yet still limited in the lack of longitudinal post-­
intervals; Burlingame et al., 2005; Wells et al., treatment data.
1996, 2003). The Y-OQ has strong psychometric Several studies have aimed to address this
properties and provides clinical benchmarks limitation in the OBH research by looking longi-
including clinical cutoffs and reliable change tudinally to see if youth who attend OBH main-
indices. tain clinical improvements at 6- or 12-months
The development of the Outdoor Behavioral post-treatment. Tucker and colleagues (2016b)
Healthcare Center in 2015 brought together found that both youth and parents reported clini-
research scientists from universities around the cally significant improvements at discharge as
United States and Canada to contribute indepen- measured by the Y-OQ (Wells et al., 2003). Youth
dent research in the field. These researchers have report these findings to last 6 months post-­
evaluated OBH programs and interventions both treatment. In this study, mothers reported their
in residential and community-based settings with youth at 6 months to be functioning a few points
data from the NATSAP PRN, as well as data col- (M = 49.7) above the clinical cutoff (47) in a
lected from community-based samples. Though clinically acute range, while fathers reported
some of this research is funded by the Outdoor their youth to be functioning within a normative
Behavioral Healthcare Council and the National range. Combs and colleagues looked at parent
Association of Therapeutic Schools and Y-OQ reports on youth functioning (Combs
Programs, all of the studies conducted by research et al., 2016b) and adolescent self-assessments
scientists affiliated with the OBH Center have (Combs et al., 2016a) and found both were on
been reviewed and approved by university inter- average below the clinical cutoff at 6- and
nal review boards to maintain research ethics and 18-months post-treatment, supporting the main-
have also undergone rigorous double-blind peer tenance of improvement over time. Though this
review to ensure the rigor and objectivity of the research highlighted important findings, it did
research. not require that studies include comparison
Overall outcomes of wilderness therapy have groups.
been explored through meta-analyses, longitudi- Additional research has since implemented
nal research, and cost-benefit analysis. Bettmann more rigorous quasi-experimental designs with
et al.’ (2016) meta-analysis of 36 studies focus- comparison group studies aimed at providing evi-
ing on wilderness therapy outcomes with 2399 dence of OBH as a well-established, efficacious
private pay clients showed medium effect sizes in treatment for children and adolescents. DeMille
the areas of improving self-esteem (g = 0.49), et al. (2018) compared a group of youth who
locus of control (g = 0.55), behavioral observa- attended an OBH program and returned home
tions (g = 0.75), personal effectiveness (g = 0.46), after OBH with those who chose to seek treatment
clinical measures (g = 0.50), and interpersonal in their communities. OBH participants, as
measures (g = 0.54), findings comparable to tra- reported by their parents, were functioning three
ditional mental healthcare services. Gillis et al. times better than the community-based treatment
(2016) explored the outcomes of youth in wilder- as usual group one year following the program as
ness and nonwilderness programs from 21 differ- measured by the Y-OQ. Youth who remained in
ent studies that used the Y-OQ to measure changes their communities were still at acute levels of psy-
between pre- and post-treatment. Effect sizes for chosocial dysfunction during the same time span.
youth in wilderness settings were higher than Building on this research, the OBH Center is cur-
nonwilderness settings (g = 1.38 vs g = 0.74) as rently conducting a randomized control trial
reported by parents, but lower as reported by (RCT) study to compare the impact OBH with
21 Wilderness Therapy 387

CBT on youth, with an aim to address criticism of active in their treatment (Dobud et al., 2020;
the lack of RCT research in the field (Ray, 2021). Russell et al., 2018).

Cost Effectiveness Research Limitations

Cost-effectiveness data has also been evaluated to Despite a large growth in research on OBH in the
supplement outcome and risk management past 10 years, gaps in the research remain, includ-
research. Gass et al. (2019) compared a 90-day ing population specific research to determine
treatment program for both OBH and substance what type of client and what clinical issues are
abuse treatment as usual (TAU; the recommended best served by OBH, as well as who or what
minimum by SAMHSA for substance use disorder issues may be contraindicated. Like any interven-
(SUD) treatment) to calculate cost-­effectiveness. tion, there cannot be a one-size-fits-all approach,
The study showed that OBH is less expensive than and there needs to be a research on the psycho-
TAU. Given higher rates of completion, this study logical risks or pitfalls of this type of therapy as
reported OBH as a more cost-­effective post-acute well. Furthermore, research needs to be con-
care treatment regimen for SUD than TAU with ducted on where OBH should exist on the con-
regard to short-term utilization, health improve- tinuum of care. Far too many clients leave OBH
ment, longevity, and general societal benefits programs, only to go on to some other form of
including improved worker productivity and crim- residential treatment, and more research is
inal justice issues. However, given the fact that needed to see if this ongoing involvement in resi-
OBH treatment is often mandated for clients under dential care is necessary or if it can have dimin-
the age of 18, more research is needed to explore ishing returns. This tendency also creates barriers
the complexity and validity of treatment comple- to conducting longitudinal research on OBH
tion in youth. Though only a small subset of the when clients are moving on to other forms of
overall body of research on OBH, this research care, creating numerous variables that need to be
provides important data supporting OBH as a accounted for. Future research also needs to high-
promising practice within the adolescent behav- light the youth perspective regarding the often
ioral health continuum of care. mandated aspects of the treatment process,
including issues of involuntary youth transport.
 rogress Monitoring and Research
P Although several studies have shown that invol-
Informed Practice untary youth transport does not negatively impact
Research on OBH extends beyond clinical out- overall treatment outcomes (Tucker et al., 2015,
comes, as there has been a rise in the use of prog- 2018), little to no research exists looking at the
ress monitoring across OBH programs (Gillis lasting traumatic effects on youth clients, as well
et al., 2016; Russell et al., 2018). Best practices as possible ruptures in the family system when
suggest that clinicians engage in ongoing moni- treatment is forced upon the youth. In addition,
toring of progress of their clients weekly or one of the main limitations of existing OBH
biweekly during treatment, not just at the begin- research, particularly about wilderness therapy,
ning and end of treatment (Lambert, 2017; have been critiqued as lacking rigor due to the
Russell et al., 2018). In addition, inclusion of the lack of randomized control group studies. While
client in the process can increase the success of efforts are currently underway to address this
treatment, as clients can see their report of their limitation (Ray, 2021), the field remains open to
functioning and reflect on what is driving their scrutiny as it is unclear if OBH interventions are
improvements as well as setbacks in order to indeed responsible for client improvements or if
redirect treatment if needed (Dobud et al., 2020; clinical gains are due to other factors (Dobud &
Russell et al., 2018). It is argued that progress Harper, 2018).
monitoring in OBH treatment should be the norm Research has broadly examined outcomes
not the exception as it helps to see when change related to youth and family functioning but has
occurs and empowers clients to be engaged and not provided enough insight about the process
388 A. R. Tucker et al.

variables that may or may not be related to the ning to offer coverage for residential treatment
change process. Researchers have sought to facilities (Lavin & Gass, 2019).
“unlock the black box” of OBH and adventure The American Hospital Association’s recogni-
therapy by creating the Adventure-Therapy tion of OBH care as a viable form of treatment
Experience Scale (ATES; Russell & Gillis, 2017). and the National Uniform Billing Committee’s
This psychometric scale can be used alongside establishment of an insurance billing code for
measures of treatment efficacy to better under- OBH care in July 2016 (“Outdoor/Wilderness
stand the therapeutic components of the interven- Behavioral Healthcare, Revenue Code: 1006”)
tion, focus on being in nature, challenge and were important steps forward for OBH treatment.
adventure activities, interpersonal and intraper- This billing update and the corresponding change
sonal opportunities for growth, as well as reflec- to the UB-04 billing manual support OBH’s
tion and mindfulness (Russell & Gillis, 2017). increasing recognition by both the general medi-
Using the ATES, preliminary research has shown cal community and federal organizations as a
weeks in treatment when clients reported higher valid treatment modality (Lavin & Gass, 2019).
levels of challenge/adventure and mindfulness Further, outdoor behavioral health programs are
are associated with lower OQ scores, reflective of now eligible for national accreditation under
healthier mental health functioning (Russell well-established and trusted organizations, such
et al., 2017). Although the past 20 years have as The Joint Commission’s Comprehensive
shown a large increase in the amount of research Accreditation Manual for Behavioral Healthcare
on OBH treatment, which supports clinical (The Joint Commission, 2021). Historically,
improvements for youth clients, future research insurance providers have denied OBH treatment
needs to focus on the factors that influence claims classifying them as “experimental” or
change in OBH (Russell et al., 2017) and explore “unproven.” However, through the rise in atten-
when during treatment that change occurs tion to risk management outcomes research in the
(Russell et al., 2018; Dobud et al., 2020), utiliz- field and accreditation, OBH programs have been
ing comparison groups to improve the scientific able to work with insurance companies and pro-
rigor of these studies (Dobud & Harper, 2018). vide the necessary evidence showing how OBH
Council programs are safe and effective.

Additional Considerations  iverse Populations in OBH Programs

D
While increased insurance reimbursement will
 edical Insurance and OBH
M create more opportunities for diverse populations
Insurance coverage is continually changing, cov- to have access to treatment, this is an area in
ering greater services, particularly regarding which OBH programs need to grow and improve.
mental health and substance abuse coverage. For many years due to the nature of OBH being
Insurance companies recognize established men- private pay, programs have predominantly served
tal health practices, which historically fell gener- clients who identify as white and report incomes
ally into inpatient hospitalization and outpatient within the middle and upper class (Combs et al.,
therapy. Intensive outpatient care and partial hos- 2016a). Hence, it is unclear the true impact of
pitalization care were some of the first major OBH on participants of color, as their representa-
mental health services to be recognized and reim- tion in the research is small in size and often not
bursed by insurance companies and later analyzed (Combs et al., 2016a, b; Tucker et al.,
expanded to include residential treatment centers. 2016b, 2018). Scholars in the field have addressed
These facilities offer longer-term intermediate the importance of cultural issues in adventure
care for patients suffering from chronic mental programming and adventure therapy and the need
health issues. The passage of the 2008 Mental to apply culturally sensitive frameworks so that
Health Parity and Addictions Equity Act also the treatment modality is culturally relevant
played a role in health insurance carriers begin- (Chang et al., 2016). For families of some cul-
21 Wilderness Therapy 389

tural backgrounds, the idea of sending their child youth who attend OBH (Bolt, 2016). Hence, ado-
away from home and out into the wilderness may lescent clients may go to another residential
increase anxiety and feelings of traumatic treatment center or therapeutic boarding school
response, and again, more research is needed to after OBH treatment (Russell, 2005). While this
adapt OBH to various cultural contexts. level of intensive treatment is not mandatory
OBH has recognized its lack of attention post-OBH, it is important for families to under-
around issues of diversity, and particular focus stand that aftercare is an important consideration
has been given to providing educational sessions before entering treatment. This should be dis-
at the annual Wilderness Therapy Symposium on cussed with families as part of the decision-­
topics of diversity. While there is a desire to making process when inquiring about sending
increase representation of diverse clients, there is their child to an OBH Program (Becker, 2010).
also a lack of persons of color working within Aftercare planning should be part of ethical OBH
OBH programs across all roles (field guides, cli- treatment, as it is essential for long-term improve-
nicians, and leadership) (Bryant et al., 2019). ments. Parents and youth clients need to be a part
Having diverse clinicians is especially important of that discussion, and programs need to take
as research has found that minority clients with responsibility for preparing families for leaving
clinicians of a similar race (matching) drop out of and getting the appropriate level of treatment fol-
therapy less, attend therapy longer, have a stron- lowing OBH participation (Becker, 2010).
ger therapeutic alliance, and have better out-
comes (Meyer & Zane, 2013). In addition, clients
of color find matching clinicians to better under- Moving Forward
stand their lived experiences of discrimination,
racism, and oppression (Meyer & Zane, 2013). In the development of future wilderness therapy
Not only is an increase in representation impor- programs, collaboration and consultation are
tant, but also ongoing training around diversity essential. For too long, programs were developed
and equity is critical. OBH programs need to in isolation without consideration of best prac-
understand how to recognize inequity when it tices and client voice. The Outdoor Behavioral
occurs and “institutionalize and promote account- Healthcare Council and the Association for
ability” throughout all levels of their programs Experiential Education Accreditation Council
(Bryant, 2019). While matching can impact treat- may provide guidance and support for practitio-
ment success for minority clients, it is also impor- ners who want to develop and implement ethical
tant for White clinicians to address elements of and effective programming. However, client
race and ethnicity when working with diverse voice should also be considered in program
clients. In fact, client satisfaction and outcomes development and evaluation, as post-program
for minorities are limited when clinicians fail to survey data shows both positive and negative
provide culturally sensitive care (Meyer & Zane, experiences reported by adolescents who attended
2013). Hence, ongoing efforts are needed to cre- a Canadian residential treatment program that
ate inclusive programs, which can attract and included wilderness therapy for co-occurring
retain diverse staff and clinicians and responsibly addition and mental health (Harper et al., 2019).
provide culturally responsive treatment to diverse Given the importance of client preference in
adolescents. mental health treatment, all of these perspectives
should be taken into account (Swift et al., 2018).
 ftercare
A Client preference and client voice should also
Aftercare refers to what happens to youth after factor into the method of transporting clients to
they leave OBH programs (Bolt, 2016). Some treatment. Involuntary youth transport is a
would argue that the moving from the intensity of ­practice that should be minimized and used only
wilderness treatment to home is a too big transi- in clinically indicated situations if wilderness
tion for maintaining improvements for some therapy is to be truly trauma-informed. Though
390 A. R. Tucker et al.

OBH programs do not transport youth them- Bettmann, J., & Tucker, A. (2011). Shifts in attachment
relationships: A study of adolescents in wilderness
selves, estimates suggest the use of youth trans- treatment. Child & Youth Care Forum, 40(6), 499–
port services ranges from 30% to as high as 83% 519. https://doi.org/10.1007/s10566-­011-­9146-­6
across out-of-­ home behavioral healthcare pro- Bettmann, J. E., Lundahl, B. W., Wright, R. A., Jasperson,
grams (Gass, 2018; SAMHSA, 2014). Involving R. A., & McRoberts, C. (2011). Who are they? A
descriptive study of adolescents in wilderness and res-
youth in decisions about this practice, along with idential programs. Residential Treatment for Children
ongoing inclusion of client voice and progress and Youth, 28(3), 198–210. https://doi.org/10.1080/08
monitoring, is essential for advancing the field 86571X.2011.596735
(Dobud et al., 2020). Bettmann, J., Tucker, A. R., Tracy, J., & Parry, K. (2014).
An exploration of gender, client history and function-
OBH programs should continue to collect and ing in wilderness therapy participants. Residential
share risk management and outcome data, always Treatment for Children & Youth, 31(3), 155–170.
remaining vigilant regarding clients’ physical Bettmann, J. E., Gillis, H. L., Speelman, E. A., Parry,
and emotional safety, and provide both step-up K. J., & Case, J. M. (2016). A meta-analysis of wilder-
ness therapy outcomes for private pay clients. Journal
and step-down options for aftercare. OBH has the of Child and Family Studies, 25(9), 2659–2673.
potential to offer meaningful alternatives for Bolt, K. (2016). Descending from the summit: Aftercare
highly acute youth and their families. When planning for adolescents in wilderness therapy.
youth have access to an alternative treatment Contemporary Family Therapy, 38(1), 62–74. https://
doi.org/10.1007/s10591-­016-­9375-­9
option that immerses them in nature, community, Bryant, D. (2019, August 22–24). Train the trainer
and integrated clinical care, they may experience [Conference session]. Wilderness Therapy
a level of treatment success unavailable to them Symposium, Park City. https://obhcouncil.com/wp-­
in a community-based setting; however, it is only content/uploads/2019/05/2019-­WTS_UT-­Program-­
text-­updated-­on-­5.28.19.docx
through the transfer of this learning back to the Bryant, D., Lepinske, B., Fishburn, D., Fernandes, E.,
client’s life and family context that the power of Roberts, L., Christensen, N., & Heizer, R. (2019,
OBH can fully be realized. August 22–24). Are we really prepared to treat
the marginalized clientele we so enthusiastically
seek? [Conference Session]. Wilderness Therapy
Symposium, Park City. https://obhcouncil.com/wp-­
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 Part V
Special Topics on Service Utilization and
Follow-Up Care
 Family Engagement and Coaching
in a Five-Day Intensive Treatment 22
Program for Youth with Anxiety
Disorders and OCD

Elle Brennan and Stephen P. H. Whiteside

Chapter Overview  rief Background on Childhood

B
Anxiety Disorders
Anxiety disorders and obsessive-compulsive dis-
order (OCD), collectively referred to as child- Anxiety and associated disorders (e.g., general-
hood anxiety disorders (CADs) herein, represent ized anxiety disorder (GAD), social anxiety dis-
some of the most common mental health prob- order (SA), separation anxiety disorder (SAD),
lems during childhood and adolescence. This specific phobias, panic disorder (PD), and OCD)
chapter will describe the application of parent are characterized by intrusive worries, inappro-
coached exposure therapy (PCET) within a five-­ priate fear, and impairing behavioral avoidance/
day intensive outpatient treatment program for rituals. Collectively, CADs represent some of the
anxious youth and their parent(s). PCET com- most common mental health problems facing
bines therapist-lead instruction and modeling to children and adolescents. These diagnoses often
engage families in hands-on practice with expo- appear early in life and affect up to approximately
sure therapy, enabling parents to become experts 32% of youth (Beesdo et al., 2009; Cartwright-­
in the treatment of CADs alongside their Hatton et al., 2006; Merikangas et al., 2010;
child(ren). The five-day intensive amplifies this Ruscio et al., 2010). At clinical levels, CADs are
treatment model, which not only produces effi- associated with significant functional impairment
cient symptom reduction through streamlined across several domains (e.g., social, academic,
focus on exposure but also enables families to work, family, and health) and may persist into
maintain and expand upon progress achieved adulthood if left un- or undertreated (Copeland
during clinician-guided treatment after leaving et al., 2014; Ezpeleta et al., 2001; Piacentini
the clinic. et al., 2003; Sukhodolsky et al., 2005; Valderhaug
& Ivarsson, 2005). Fortunately, substantial
research has illuminated effective treatments for
CADs, including approaches aligned with
cognitive-­behavioral theory (CBT) (Chorpita
et al., 2011; Kendall, 1994; Kendall et al., 1997;
E. Brennan (*) March & Mulle, 1998; Pliszka & AACAP, 2007;
Mayo Clinic, Rochester, MN, USA
Reynolds et al., 2012; Wang et al., 2017).
Akron Children’s Hospital, Akron, OH, USA
S. P. H. Whiteside
Mayo Clinic, Rochester, MN, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 397
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_22
398 E. Brennan and S. P. H. Whiteside

Evidence-Based Treatment for CADs training and anxiety management), pharmaco-

logical interventions (dependent upon dosing),
Exposure has long been recognized as the active treatment as usual (TAU; e.g., parent training,
ingredient in psychotherapeutic interventions for talk therapy, and social skills training), and wait-
anxiety and OCD (Abramowitz et al., 2019; Ale list controls (Abramowitz et al., 2005; Lewin
et al., 2015; Barlow, 2004; Kendall et al., 2005; et al., 2014; Reid et al., 2021; Romanelli et al.,
Peris et al., 2017; Peris et al., 2015; Stewart et al., 2014; Storch et al., 2013; Watson & Rees, 2008).
2016; Whiteside et al., 2020c), with nearly 90% However, typical CBT for OCD has not been
of well-established treatments for youth anxiety found to consistently outperform alternative
incorporating the practice (Higa-McMillan et al., active treatments (e.g., cognitive therapy, satia-
2016). Prominent manualized approaches to CBT tion therapy, and eye movement desensitization
for CADs commonly combine exposure with reprogramming) (Reid et al., 2021), and upwards
other skills practice. For example, one collection of 30% of youth are again often left with clini-
of multicomponent CBT for CADs protocols cally significant symptoms following many
dedicates several sessions to psychoeducation on weeks of treatment (Pediatric OCD Treatment
and implementation of various anxiety manage- Study (POTS) Team, 2004; Torp et al., 2015).
ment strategies (AMS; e.g., emotion identifica-
tion, relaxation training, problem-solving, and
cognitive strategies), which are later integrated Barriers to Efficacious Treatment
into exposure-based exercises (Kendall, 1994; for CADs
Kendall et al., 1997). Some treatment studies uti-
lizing multicomponent CBT for CADs have Compounding the incomplete treatment out-
reported favorable outcomes, including large comes noted above, access to evidence-based
effect sizes in comparison to waitlist/no treat- treatment for CADs – including multicomponent
ment controls and small effect sizes in compari- CBT – remains problematically inadequate for
son to active alternative treatments (e.g., countless youth and their families (Costello et al.,
psychoeducation, supportive therapy, relaxation 2005; Whiteside et al., 2016a). One significant
training, and parent training) (Chorpita et al., contributing factor is a lack of adequate train-
2011; Higa-McMillan et al., 2016; Lenz, 2015; ing – in evidence-based practice broadly and
Reynolds et al., 2012; Walkup et al., 2008). exposure more specifically – for community cli-
However, CBT for CADs has not been demon- nicians (Becker-Haimes et al., 2017; Becker
strated to reliably outperform treatment as usual et al., 2004; van Minnen et al., 2010). This lack of
(TAU) (Whiteside et al., 2020c). Moreover, training may fuel the untested assumptions that
approximately 20–50% of youth do not respond children require AMS in order to tolerate and
to treatment (Lenz, 2015; Podell et al., 2010). benefit from exposure (Crawley et al., 2013;
CBT-based treatment protocols specifically Kendall et al., 1997; Manassis et al., 2010), or
for pediatric OCD typically place greater empha- even cause clinicians to avoid exposure entirely
sis on exposure with response prevention (ERP), due to misconceptions that it is ineffective and
which involves facing one’s fears/focusing on intolerable, will worsen a child’s anxiety, will
one’s worries without engaging in compensatory result in damaged rapport, and/or will result in
rituals, with family-focused CBT identified as the negative parent reactions (Crawley et al., 2013;
only well-established treatment (Freeman et al., Deacon et al., 2013; Kendall et al., 1997;
2018). Even so, these approaches often incorpo- Manassis et al., 2010; Meyer et al., 2014; Reid
rate cognitive strategies (Franklin et al., 2003; et al., 2017; Schneider et al., 2020).
March & Mulle, 1998; Pediatric OCD Treatment Contrastingly, but in alignment with the con-
Study (POTS) Team, 2004). Though mixed, find- sensus that exposure is the active ingredient in
ings generally suggest that CBT for OCD is supe- CBT for CADs, evidence suggests that greater
rior to psychological placebos (e.g., relaxation use of exposure is linked to improved outcomes
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 399

in treatment (Ale et al., 2015; Tiwari et al., 2013; cialty clinic to address this need (Whiteside et al.,
Vande Voort et al., 2010; Whiteside et al., 2015; 2020c, e). Preliminary support for PCET has
Whiteside et al., 2020c) and that youth actually been demonstrated within a small feasibility-­
tolerate stand-alone exposure quite well focused randomized controlled trial (Whiteside
(Whiteside et al., 2015, 2020c, d). Thus, it is not et al., 2015). The design of PCET permits the
surprising that multicomponent CBT for CADs majority of session time, following one or two
notably underperforms more exposure-heavy psychoeducation and planning sessions, to be
interventions (Ale et al., 2015). What is more solely dedicated to the practice of planned expo-
concerning is that AMS continue to be regularly sures. Accordingly, clinicians and families are
prioritized in treatment despite a lack of evidence enabled to focus their efforts on applying a single
to support their benefit. Moreover, longstanding concept (facing fears) across a variety of situa-
studies on prominent CBT for CADs protocols tions and contexts, without being distracted by
suggest that symptom reduction does not actually the potentially detrimental interference of AMS,
begin until exposure has been introduced and while capitalizing on recommendations out-
(Kendall et al., 1997; Ollendick, 1995; Ollendick lined by Craske and colleagues (e.g., expectancy
et al., 1991), and AMS do not appear to be addi- violation, toleration of fear, reduction in safety
tive at that point (Ollendick & King, 1998). From behaviors, and variability in exposures; (Craske
the perspective of inhibitory learning theory et al., 2008, 2014). Introducing active exposure
(Craske et al., 2008; Craske et al., 2014), includ- practice earlier in therapy may also support
ing AMS in treatment for CADs may even reduce shorter treatment duration while still achieving
the effectiveness of exposure and may suggest to similar effectiveness to longer and more compli-
youth and families that anxiety is intolerable and cated protocols (Whiteside et al., 2015, 2016b).
to be feared in itself. Instead, mounting evidence Because the core skillset within PCET is very
suggests that individuals with anxiety disorders focused, this approach to treatment for CADs can
should be encouraged to progressively immerse be flexibly applied to youth of varying ages (e.g.,
themselves in their fears/worries and physiologi- elementary school-aged to graduating high
cal anxiety responses as fully as possible, in as school) who present with a wide variety of anxi-
many contexts as possible, to create new learning ety disorders (e.g., in vivo exposures for youth
pathways to compete with previous ineffective with social fears, imaginal exposures for youth
associations toward the ultimate goal of reducing with general worries, and interoceptive expo-
distress and improving functioning (Craske et al., sures for those with panic symptoms). Moreover,
2014). youth with a considerable range of symptom
severity and related impairment can also all typi-
cally be accommodated within the same setting.
 arent Coached Exposure Therapy
P As little to no time is devoted to concepts unre-
(PCET) lated to exposure, participating families are able
to learn to apply the same core principles and
Efforts to better align psychotherapeutic inter- skills to the symptoms that are disrupting their
ventions for CADs with the leading theoretical lives in ways that best fit their unique needs.
framework (i.e., inhibitory learning theory), These factors make PCET particularly well
while also improving the accessibility of expo- adapted to use in both individual and group treat-
sure for CADs, are necessary to improve treat- ment settings, as well as both intermittent (i.e.,
ment outcomes for anxious youth and their bi-weekly and PRN/booster session) and more
families. Parent Coached Exposure Therapy intensive formats. The remainder of this chapter
(PCET), a treatment approach where the primary will outline the general principals of PCET and
therapeutic mechanism is delivery of exposure will describe and discuss an implementation of
alone, without any AMS, was created within a PCET through a five-day intensive outpatient
multidisciplinary pediatric anxiety disorders spe- treatment program designed to provide families
400 E. Brennan and S. P. H. Whiteside

of youth with CADs hands-on experience coach- increase treatment efficiency and shorten treat-
ing their child(ren) through implementation of ment duration (Gryczkowski et al., 2013;
exposure for various anxiety symptoms Whiteside et al., 2020c). Toward this goal, par-
(Whiteside & Jacobsen, 2010; Whiteside et al., ents quickly take ownership of facilitating the
2008, 2014, 2018). This treatment model not therapeutic progress, with structured guidance
only produces efficient symptom reduction and support from the therapist(s), which encour-
through streamlined focus on exposure but also ages greater family accountability and reduces
enables families to maintain and expand upon dependence upon therapy (Khanna & Kendall,
progress achieved during clinician-guided treat- 2009; Silverman & Kurtines, 1996; Whiteside
ment after formal treatment has ended. et al., 2020e). In this way, parents actively learn
what their child is learning while working along-
side them to plan exposures, coaching them
Parental Involvement in PCET through facing challenging fears, facilitating the
completion of between-session practice, and fol-
As time and financial costs represent significant lowing through with rewards for effort and
burdens and often barriers for families seeking accomplishments, as well as consequences for
treatment for CADs, additional efforts to stream- avoidance, as appropriate.
line the provision of exposure for CADs have
also been integrated into the design of PCET. For
example, as indicated by its name, PCET was Parent-Focused Skills in PCET
designed with the intention of parents being
actively involved not only in nearly all therapeu- In preparation for parents to take on the coaching
tic planning but also as direct coaches throughout role described above, one of the first things fami-
exposure execution (with modifications based on lies learn in PCET is what factors contribute to
child age/developmental level and when parental the maintenance of anxiety, as well as how the
presence would hamper the benefit of an expo- cycle of avoidance can be redirected through
sure). Clinicians facilitating treatment thus pri- exposure and elimination of avoidance behaviors
marily function to provide psychoeducation, (e.g., safety signals and compulsions). An impor-
instruct families in how to conduct exposure tant benefit of direct parental involvement from
exercises, and model to parents how to coach the start is the opportunity for parents to quickly
youth through the process, ultimately empower- develop a better understanding of their own con-
ing families to take ownership of the therapeutic tributions to their child’s anxiety through behav-
process early on. iors such as parental accommodation (Flessner
This parent-driven approach is in alignment et al., 2017; Kagan et al., 2017; Lebowitz et al.,
with evidence suggesting the benefit of parental 2020). Increased awareness can then enable par-
involvement in psychotherapy for youth (Haine-­ ents to alter their own behaviors and reactions
Schlagel & Walsh, 2015), including anxious and to more broadly translate skills learned in
youth (Barrett et al., 2004; Kreuze et al., 2018; session to the home environment and life outside
O’Leary et al., 2009), and exposure for CADs in of therapy (e.g., through homework completion)
particular (Knox et al., 1996; Rudy et al., 2017), (Whiteside et al., 2014), allowing greater oppor-
but diverges from typical CBT for CADs where tunities for learning in “real-world” contexts.
only a few parent check-ins are incorporated Parent supervision of their child’s engagement
across treatment (Kendall, 2006; Walkup et al., and progress in therapy (i.e., ability to encourage
2008; Whiteside et al., 2016a, 2020c). While their child to complete exposures) is further bol-
these more traditional models are associated with stered by the incorporation of basic behavioral
longer courses of treatment, the combination of management strategies into PCET. Such strate-
earlier introduction of exposure with immediate gies have shown benefit in other approaches to
integration of parents in PCET is intended to the treatment of CADs (Knox et al., 1996; Lewin
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 401

et al., 2014; Manassis et al., 2014), even in cases strated the initial success of the individual five-­
where symptoms are complicated by comorbid day intensive with three adolescents diagnosed
disruptive behavior (Piacentini et al., 1994; with highly impairing OCD, two of whom had
Sukhodolsky et al., 2005). Namely, parents are previously participated in traditional (non-ERP)
encouraged to communicate clear expectations psychotherapy and experienced little to no bene-
for treatment progress (e.g., how frequently to fit. This paper presented favorable clinical out-
practice exposures and what difficulty level a comes, while also highlighting the efficiency,
youth is expected to complete), provide warmth feasibility, acceptability, and generalizability of
and support through increasingly difficult expo- gains associated with the intensive protocol.
sures, and employ simple rewards (e.g., praise, Furthermore, post-treatment symptom trajecto-
tokens, and small prizes) when goals are met, as ries for two of the three participating youth pro-
well as short-term consequences (e.g., removal of vided support that families can successfully
attention and loss of privilege) when youth are continue to apply skills learned in treatment to
noncompliant. This serves both to help youth ongoing or new symptoms with little ongoing
remain motivated in treatment and to help parents therapist involvement.
overcome lingering urges to accommodate their In the years since, evidence has accumulated
child’s distress when new challenges present. supporting that high doses of exposure imple-
Through progressively taking ownership of mented over short periods of time (i.e., intensive
the therapeutic process within the highly focused treatment protocols) can produce substantial and
framework of PCET, families become increas- lasting symptom reduction and quality of life
ingly able to independently apply the concepts improvements, while remaining both time and
and skills acquired in session to their lives both cost effective (Öst & Ollendick, 2017). The evi-
during and after “active” treatment, even if new dence in support of the application of PCET
symptoms later arise. This movement toward within the five-day intensive model has similarly
independence is an important aspect of PCET for, maintained a positive trajectory. For example,
as was noted previously, clinicians trained in Whiteside and Jacobsen (2010) reported contin-
evidence-­based practices such as exposure, who ued success with a larger sample of individual
implement it with fidelity, are astonishingly youth with OCD. This uncontrolled trial demon-
scarce, which severely limits the amount and strated that, though post-treatment symptom
quality of treatment available to anxious youth. severity was incomplete following such a brief
intervention, symptom reduction continued
through a follow-up period consistent with the
 ive-Day Intensive Outpatient
F timeframe of traditional weekly therapy.
Group Treatment Program Whiteside et al. (2014) again found favorable
results in the treatment of OCD in individual
In response to this dearth of access to effective youth using the five-day intensive protocol
treatment options, a brief intensive application of through a baseline-controlled comparison at two
PCET was developed to promote efficient separate sites, demarcating symptom improve-
evidence-­based care for youth with CADs. ment at the start of treatment, which continued
Specifically, an individual five-day intensive into follow-up. Additionally, this examination
treatment protocol was established in order to identified notable reductions in parental accom-
improve the accessibility of efficient treatment modation behaviors, which also extended into
(Whiteside et al., 2008), particularly for families follow-up.
traveling from out of town due to inadequate To further improve access to effective and effi-
alternatives (e.g., no access to local mental health cient treatment, the five-day intensive model
providers and limited time and resources to con- evolved into a group-based protocol following
tinuously commute to sessions). A case series the same structure but incorporating multiple
presented by Whiteside et al. (2008) demon- families per session. Importantly, a retrospective
402 E. Brennan and S. P. H. Whiteside

comparison of archival data from over two dozen faculty and one masters level allied health pro-
five-day intensive groups found that treatment vider). Occasionally, groups are also facilitated
benefits held similarly for youth with OCD and by a doctoral level postdoctoral psychology fel-
other CADs (Whiteside et al., 2018). Moreover, low and may be observed by other learners (e.g.,
this format not only allowed families to benefit psychiatry resident or fellow, medical student,
from positive vicarious learning while taking and nurse). As such, there is typically a ratio of
ownership of the therapeutic process early on but one therapist to three or four patients. Facilitators
also indirectly increased access to treatment by collaborate in communicating didactic aspects of
reducing therapist time required per patient. the group and share responsibility for more indi-
Accordingly, the five-day intensive has become a vidualized work with each family (e.g., helping
standard offering for families struggling with to identify and plan appropriate exposures).
CADs who present to the multidisciplinary pedi- Though unique treatment plans are established
atric anxiety disorders specialty clinic at a large for each family in order to address the above
Midwestern academic medical center. goals (e.g., exposure content tailored to each
youth’s fears and developmental level), the
broader educational and experiential aspects of
 verview of Goals for the Five-Day
O treatment are uniform across families regardless
Intensive of what specific symptoms youth present with.
This allows for a highly consistent approach to
Though the structure of the five-day intensive has the general structure of the week, which can be
encountered some minor adjustments over time broken down into stages characterized by learn-
(e.g., parent participation has increased, and tim- ing and planning, putting knowledge into action
ing of specific session content has shifted (exposure), and reviewing/practicing outside of
slightly), its stated goals have remained the same. session (homework).
These include the following: (1) providing edu-
cation to youth and their families about the devel-
opment, maintenance, and treatment of CADs,  verview of Structure for the Five-­
O
(2) engaging in frequent exposure practice to pro- Day Intensive
duce initial symptom reduction, and (3) building
youth and parents’ confidence in their ability to  he Initial Assessment
T
continue to conduct exposures independently Each family presenting to the multidisciplinary
after treatment. At present, these goals are met pediatric anxiety disorders specialty clinic begins
through completion of an initial individual with a comprehensive evaluation of anxiety-­
assessment and nine 90- to 120-minute group-­ related symptoms conducted by members of the
based treatment sessions divided among the 5 clinical team (e.g., doctoral level psychologist,
days, with two appointments occurring each day postdoctoral pediatric psychology fellow under
(one in the morning and one in the afternoon) and supervision, masters level therapist,
assignments to be completed between each ses- child/adolescent psychiatrist, advance-practice
sion. See Fig. 22.1 for visualization of intensive nurse, and psychiatry resident/fellow under
schedule. supervision). This evaluation is foremost intended
As with all PCET applications, group sessions to help direct families to the best treatment option
are attended jointly by youth and their parent(s), based on their particular clinical needs. During
with the exception of a brief separation during this appointment, youth and parent(s) are jointly
the third session where parenting strategies are (as well as individually when appropriate based
addressed without youth present. Groups are typ- on child age) interviewed by a member of the
ically attended by six to nine families and are anxiety specialty clinic team using a semi-­
facilitated by two clinicians with expertise in structured diagnostic interview that utilizes por-
exposure therapy for CADs (one doctoral level tions of the Mini International Neuropsychiatric
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 403

Fig. 22.1 Details of five-day intensive group treatment program schedule. Session 0 (initial assessment) may or may
not take place during Monday morning for some intensive participants

Interview for Children and Adolescents (MINI-­ in Whiteside et al. (2018), which provides a char-
KID; (Sheehan et al., 2010). Youth and one par- acterization of 143 youth who participated in the
ent also complete self-report measures to assess intensive over a 2-year period (2013–2015).
pretreatment symptom severity (Spence Based on this sample, youth typically present
Children’s Anxiety Scale, SCAS-C/P; (Spence, with a variety of primary CADs (e.g., 52.4%
1998)) and related impairment (Child Sheehan OCD, 16.8% social anxiety, 9.8% GAD, 5.6%
Disability Scale, CSDS-C/P; (Whiteside, 2009)). separation anxiety, 2.8% specific phobia, 2.1%
Based on the outcome of this evaluation, fami- panic/agoraphobia, and 1.4% selective mutism),
lies are directed to the care that best suits their though some present with other primary diagno-
needs (e.g., community-based nonanxiety treat- ses (e.g., 3.5% attention deficit hyperactivity dis-
ment, standard specialty clinic care, and intensive order (ADHD), 1.4% depressive disorder, 1.4%
treatment). Families directed to the five-day oppositional defiant disorder (ODD), and 2.8%
intensive group typically meet the following cri- other) comorbid to their anxiety, as well as sec-
teria: (1) youth age 7–18, (2a) anxiety severity ondary concomitant diagnoses (e.g., autism spec-
suggestive of need for intensive structured treat- trum disorder.). Though the overall treatment
ment and/or (2b) limited access to appropriate model within the intensive is relatively uniform,
treatment options near home, (3) family is will- individual treatment plan considerations are
ing and able to attend five consecutive days of made for each family to best accommodate their
therapy, and (4) no symptoms are present that particular presentations and goals (e.g., greater or
would contraindicate anxiety treatment (e.g., lesser strictness within behavior and greater or
severe depression, suicidal ideation, active eating lesser independence encouraged for the youth).
disorder, psychotic features, and severe intellec- Concurrent pharmacological interventions
tual impairment) or group-based care (e.g., intended to address emotional and/or behavioral
aggression and significant disruptive behaviors). concerns (e.g., selective serotonin reuptake
Additional information regarding typical patient inhibitors (SSRIs) and simulants) are permitted,
demographics (e.g., Mage = 13.93 ± 2.9 years, though the use of anxiolytics (e.g., benzodiaze-
57.3% female, and 90.2% White) can be reviewed pines and sedatives) is discouraged due to
404 E. Brennan and S. P. H. Whiteside

p­otential interference with exposure effective- to provide the short-term intervention to local
ness (Otto et al., 2010; Rosen et al., 2013). Of populations.
note, any safety concerns that arise during the
course of the 5 days are handled on an individual  utline of Treatment Activities
O
basis (e.g., terminate treatment due to suicidal The Learning Phase Days 1 and 2 of the five-­
ideation or unsafe behaviors, increase parental day intensive group are considered to fall within
monitoring, and implement adjustments in the “learning-focused” portion of the treatment
behavior plan to address safety). protocol. Clinicians utilize the initial assessment
We acknowledge the lack of racial and ethnic detailed above (Session 01) to better understand
diversity within our typical patient population. the needs of the families presenting to the five-­
This represents a weakness in the evaluation of day intensive in order to best inform treatment
the five-day intensive and the treatment literature planning. Session 1 takes place in the afternoon
on anxiety treatment as a whole (Pina et al., on the first day and represents the first time par-
2019). Fortunately, existing literature suggests ticipating families are together in a group setting.
that CBT (including exposure) is effective in Session content consists of orienting families to
treating anxious racial minority (primarily treatment materials, reviewing general “house-
African American) youth within inner city school keeping” guidelines (e.g., confidentiality, the use
settings (Ginsburg et al., 2012; Ginsburg & of phones/technology in clinical spaces, and
Drake, 2002). Approximately, one-fifth of inten- methods of contacting treatment team between
sive participants live locally to the specialty sessions/after treatment), providing psychoedu-
clinic, which is located within a relatively cation on the cycle of anxiety and avoidance and
homogenous demographic region. Additionally, the structure and function of exposure (see
the requirement of families to be able to partici- Fig. 22.2), and introducing the concept of the
pate in five consecutive days of therapy, and, for motivation plan. With support and guidance from
the other four fifths of families, travel an average the treatment team, youth and parents also spend
of 400 miles to the specialty clinic and pay for time diagraming the cycle(s) of anxiety and
upward of 5 days of lodging, may be somewhat avoidance most pertinent to their particular treat-
self-selecting as to who is able to participate. ment goals and begin to construct one or multiple
Families from diverse backgrounds are wel- fear ladders (i.e., lists of exposures to be com-
comed into the intensive, and individual family pleted during treatment) to help guide subsequent
beliefs and/or culture are taken into account when sessions. See Fig. 22.3 for an example fear lad-
identifying appropriate exposures within individ- der. Homework for the first day consists of
ualized treatment plans. Though treatment mate- reviewing treatment materials, adding to fear lad-
rials are currently only available in English and ders, and discussing potential rewards and conse-
sessions are conducted in English, families who quences to be incorporated into the motivation
do not speak English (e.g., Spanish speaking and plan.
Arabic speaking) have successfully participated
in the intensive with assistance from interpreters The next morning, families attend brief
trained specifically to work within medical and (20–25-minute) individual check-ins (Individual
psychological care settings. Potential efforts to Family Session) with a group facilitator (i.e., cli-
increase access to additional families represent- nician scheduled to colead the five-day intensive
ing diverse backgrounds, as well as to better that week) to address any lingering questions
study the intensive protocol within a broader
demographic range, could include actively mar- 1
For many families participating in the 5-day intensive,
keting the intensive to families from more urban this evaluation takes place during the morning of the first
day of the treatment. Some families complete the initial
or non-English speaking communities or creating evaluation at a date prior to the 5-day intensive they are
a “mobile” intensive where trained clinicians scheduled to attend, however. In such cases, these families
could travel to underserved areas of the country essentially start the first day with the afternoon session.
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 405

Fig. 22.2 Visual depictions of the cycle of anxiety and avoidance and how to break the cycle using exposure

from the day prior, for assistance finalizing any on their motivation plan (homework review).
incomplete fear ladders, to check in regarding the Group facilitators describe and demonstrate the
structure of the family’s intended motivation plan three different types of exposure techniques (e.g.,
(e.g., identified rewards and consequences for the in vivo, imaginal, and interoceptive) and demon-
week), and plan the initial exposure for Session strate how to use group handouts to record the
2. Session 2 follows shortly hereafter and contin- completion of an exposure (learning). Families
ues the process of elaborating upon previous then select an initial low-level exposure, which
learning while presenting opportunities to begin they are expected to complete in session with cli-
practice of exposure. Specifically, youth are nician guidance (exposure). Afterwards, youth
asked to report in on the general focus(es) of their are asked to report on their experience with this
fear ladder(s), and parents are asked to report in first exposure (e.g., did their fear come true? what
406 E. Brennan and S. P. H. Whiteside

contemplate the “mastery exposure” they would

like their child to complete.

The Practice Phase Days 3 and 4 are best char-

acterized by their focus on “facing fears” through
regular practice of exposures. Session 4 begins
with a brief check-in where youth report on how
their evening exposure homework went (home-
work review). Additionally, parents report in on
whether their child earned their planned reward
for completing all four exposures the day prior,
or whether a consequence had to be enacted due
to refusal/avoidance. This provides the group
facilitators with a chance to provide feedback and
recommendations regarding the selected expo-
sure, as well as to help support parents around the
implementation of their family’s motivation plan,
if necessary. Content discussed in the separate
Fig. 22.3 Example of fear ladder for dog phobia example child and parent meetings during session 3 is also
illustrated in Fig. 22.2
reviewed to reemphasize the importance of main-
taining motivation, cooperation, and collabora-
happened to their anxiety?), highlighting what tion. Families then once again select a mid-level
they have learned. Prior to the end of this appoint- exposure to conduct during session time and,
ment, families select a low-level exposure to be after reporting their plan to the group, complete
completed independently during the lunch break the exposure. At this point in the week, though
(homework). group facilitators periodically check in and are
Families return that afternoon to cap off the available whenever necessary, families are
initial learning phase with Session 3. The session encouraged to explore increasing levels of inde-
again starts with a brief check-in about how the pendence in attempting exposures (i.e., parents
lunchtime exposure went (homework review), acting as primary exposure coaches). To com-
followed by picking out another low- to mid-­ plete the session, families once again describe
level exposure to be completed in session. their experience with their chosen exposure and
Families are then expected to complete the expo- select another mid-level exposure to complete
sure they selected with support from group facili- over the lunch break (homework).
tators (exposure). Afterwards, youth are again
asked to report in how their exposures went, and Sessions 5 through 7 are constructed much the
families begin to plan an exposure to be com- same including initial check-in (homework
pleted independently that evening (homework). review), planning and completion of in-session
During the second half of this appointment, youth exposure with increasing independence (expo-
and parents split into separate groups each lead sure), and planning and check-in about selected
by one of the group facilitators. Youth spend time lunch/evening exposure (homework). Session 5,
building group cohesion, discussing helpful and which represents the midpoint in the week and
unhelpful parenting behaviors, and contemplat- just past the halfway point in the group intensive,
ing their “mastery exposure” to be completed on incorporates the addition of a brief discussion to
the last day (described later). Parents review the encourage families to prioritize exposures that
principals of the motivation plan, engage in dis- will help prepare the youth to successfully com-
cussion about any concerns that have arisen, and plete their mastery exposures on the final day of
the five-day intensive. Group facilitators also
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 407

take the time to normalize families’ hard work by home, in school, and/or in their communities.
comparing the amount of work they have done in Psychoeducation is also provided about how
3 days to that normally accomplished across 2 symptoms may return or evolve in the future, and
months in typical outpatient practice. Sessions 6 recommendation is provided for families to rein-
and 7 are uniquely characterized by focus on state daily planned exposures in such cases. Upon
increasingly challenging exposures, particularly determining whether the three initial goals of the
those related to the intended mastery exposure. treatment program were met, families are then
dismissed.
The Mastery Phase Day 5 represents the cul-
mination of everything families have accom-
plished throughout the week and is an opportunity Case Example
for them to “demonstrate success” to the group
and to themselves. Session 8, in particular, repre- Alice was a 12-year-old female who presented
sents the peak of the intensity within the inten- with her mother to the five-day intensive with pri-
sive. Following the obligatory check-in mary diagnoses of social anxiety disorder and
(homework review), youth are expected to com- OCD, as well as comorbid ADHD. Alice had pre-
plete the mastery exposure that they and their viously participated in outpatient therapy where
parent(s) agreed upon (exposure). The intention she learned calming strategies (e.g., deep breath-
of the mastery exposure is for youth to prove ing and relaxation) intended to help manage her
their ability to successfully face something that symptoms, but had not experienced symptom
they would not have considered attempting prior improvement. Upon arrival to the intensive, Alice
to participating in the five-day intensive due to was reportedly spending over three hours each
fear/avoidance. Though group facilitators are day engaging in compulsive behaviors associated
again always available when their assistance is with fears of contamination (e.g., hand washing
needed, families are encouraged to complete this and spending excessive time in the bathroom)
exposure as independently as possible to demon- and “just rightness” (e.g., arranging her belong-
strate to themselves that they will be able to con- ings just so and rewriting her homework to look
tinue completing challenging exposures upon just right). She had also reportedly quit several
returning home. After completing the morning’s preferred activities (e.g., soccer and band) due to
exposure, youth are directed to check in and take feeling highly anxious while around her peers
time to celebrate their successes with the group. and was struggling to remain focused in classes
As usual, families then plan another exposure to despite taking medication for ADHD. Some
complete over the lunch break (homework), symptoms (e.g., redoing her hair and/or changing
though they are expected to aim for a lower-level her outfit several times each morning) appeared
challenge in order to rest a bit after the morning’s to be associated with both “just rightness” and
hard work. fears of social judgment. Additionally, Alice fre-
quently sought reassurance from her parents
The final session of the five-day intensive, throughout the day (e.g., “is this OK?” “are you
Session 9, begins as most of the others with a mad at me?” and “is ___ OK to touch?”) and
brief check-in about the lunch exposure (home- would apologize excessively. Collectively,
work review) and ongoing praise and celebration Alice’s symptoms caused significant impairment
for all of the families’ dedication and hard work both for her and her family as a whole.
over the past several days. The remainder of the During the intensive week, group facilitators
session is spent discussing expectations for after- and Alice’s mother coached Alice through com-
care (e.g., continued daily planned exposure pletion of explicit exposures involving touching
practice, shifting to “on the fly” exposures, and “contaminated” surfaces, wearing “dirty” cloth-
transition to typical daily activities) and planning ing, contaminating her mother, turning in messy
out the next week of exposures to be conducted at assignments, initiating conversations with
408 E. Brennan and S. P. H. Whiteside

s­ trangers, ordering food for herself, giving brief mother learned how to help design and complete
presentations in group, walking around the clinic various exposures based on Alice’s worries and
with messy hair, and doing silly dances and som- compulsions. Both also learned how to identify
ersaults in public settings. Additionally, Alice and reduce additional safety behaviors while also
practiced repeating worry thoughts (e.g., being improving their communication skills to address
contaminated, getting sick/getting others sick, such issues in a calm and collaborative manner.
being judged by others, and upsetting others) Alice’s mother gained skills and confidence
until they became boring. Alice and her mother around implementing a behavior plan specifically
also worked to decrease and ultimately eliminate tailored to addressing anxiety and OCD and suc-
several rituals and safety behaviors. For example, cessfully implemented it both during the inten-
she reduced excessive hand washing and her sive week and in their home setting. For example,
mother stopped answering Alice’s repetitive she reached out to the specialty clinic team fol-
questions to encourage her to tolerate the associ- lowing the intensive week to problem solve some
ated discomfort, which helped Alice to stop seek- continued avoidance around particularly difficult
ing such reassurance in the first place. Her mother worries (e.g., wearing messy hair or mismatched
worked to catch her own accommodating behav- clothing in social settings) and was able to pro-
iors, such as by encouraging Alice to speak for vide effective incentives (e.g., rewards to work
herself both in group and out in the community toward and undesired consequences to avoid) to
between sessions. Alice and her mother practiced help motivate Alice to continue to challenge her-
using language to encourage effort (e.g., “you are self. Ultimately, Alice continued to make signifi-
doing great”) in place of attempting to provide cant progress while back at home such that she,
comfort (e.g., “everything will be ok”). Alice’s on most occasions, was able to engage with pre-
mother also utilized a structured behavior plan to viously feared (i.e., contaminated) objects and
help keep Alice motivated throughout the week. surfaces without needing to clean her hands
For example, Alice was able to pick their dinner within a week after completing active treatment.
(sushi) one night after completing all four of her Additionally, Alice was reportedly reengaging
exposures. Though Alice was relatively compli- with friends and rebuilding her social network
ant throughout the week, her mother did employ both through active exposure practice (e.g., call-
a short-term consequence (Alice had to hand over ing a friend to make plans) and on-the-fly activi-
her phone) one afternoon when Alice refused to ties (e.g., getting ice cream after school with
complete an exposure that she and her mother friends on impulse).
had agreed upon previously (i.e., touching a toilet
in a public bathroom, contaminating her clothing
and hair, and not washing hands or changing Conclusion
before eating lunch). Fortunately, Alice was able
to complete the exposure later in the day (i.e., In this chapter, we have briefly summarized the
before dinner) to earn her phone back and com- current knowledge about CADs and their treat-
plete her day’s treatment expectations. ments, namely, traditional CBT and exposure
Ultimately, Alice and her mother successfully therapy. We have also surveyed several barriers to
learned several exposure-based strategies to help the receipt of care for youth with CADs and their
manage Alice’s anxiety and OCD during the five-­ families, including baseline lack of providers
day intensive and left with a plan on how to con- available in certain settings (e.g., rural communi-
tinue their progress at home. Specifically, they ties), limited training for those providers who
learned how rituals and avoidance perpetuated practice in community settings, and misconcep-
Alice’s particular symptoms and what specific tions about and hesitation to employ exposure
exposures could reduce her distress and impair- (often due to said limited training). The 5-Day
ment. Alice learned how to actively face her fears Intensive Group Treatment Program was devel-
to learn from her own experiences, and her oped in response to the first barrier, in particular.
22 Family Engagement and Coaching in a Five-Day Intensive Treatment Program for Youth with Anxiety… 409

As has been discussed, empirical evidence exists time (e.g., less than seven therapist-hours per
in support of its effectiveness and feasibility patient across the 5 days) (Whiteside et al., 2018).
(Whiteside & Jacobsen, 2010; Whiteside et al., Emphasizing the expectation that parents will
2008, 2014, 2018). Overall, the delivery of PCET coach their child(ren) through exposures as early
for youth with CADs through an intensive time- as the second day of treatment ultimately serves
line produces favorable clinical outcomes at post-­ this goal. With parents taking on greater respon-
treatment with continued gains into follow-up. sibility within the intensive sessions to help direct
Accordingly, the procedures described herein and motivate their child(ren), therapists are able
represent a highly efficient and effective approach to flexibly provide support on an as needed basis
to providing evidence-based treatment (i.e., during the majority of sessions. This in turn
exposure) for CADs. allows more families to benefit from therapist
Not only does this treatment model represent a guidance and unique perspectives within a small
method to maximize access to effective treatment window of time, further maximizing therapist
for families with limited access to local provid- time and effort.
ers, it also capitalizes on gains made over a short Despite these promising findings, much is yet
period of time while empowering families to con- to be done to continue to improve upon access to
tinue to utilize skills learned in therapy. Unlike effective care for youth with CADs. Several
traditional approaches to CBT for CADs, which approaches may be undertaken to reduce the
typically demonstrate improvement in symptoms breadth of barriers to receipt of evidence-based
from baseline to post-treatment but rarely contin- exposure-focused treatment for CADs that youth
ued improvement into follow-up (Barrett et al., and their families face. One such approach to
2004), families who participated in intensive improving access to care involves the dissemina-
applications of PCET have reported additional tion of information about the acceptability of
reductions in symptoms and accommodation exposure for CADs to clinicians more broadly
well after active treatment has ended (Whiteside and increased opportunities for training and sub-
& Jacobsen, 2010; Whiteside et al., 2008, 2014). sequent consultation for exposure cases. Given
As anxiety naturally ebbs and flows across time the considerable financial and time costs typi-
and context, it is likely that most youth who cally associated with specialized training,
receive treatment for a particular grouping of Whiteside and colleagues (2020a) trialed a brief
symptoms will experience either a return of the (90 minute) training in technology-assisted expo-
same symptoms or a new presentation at some sure for CADs with community therapists.
point. While youth with reasonable access to Participating providers had access to the Anxiety
resources can, of course, always return to therapy Coach app with built-in psychoeducation materi-
should this happen, the PCET treatment approach als, templates to construct fear ladders, and ways
delivered through the five-day intensive quickly for patients to track their completed exposures
enables families to handle such situations inde- which the therapists could then view. Though
pendently, or at least with minimal therapist sustained use of the technology by providers was
intervention (Whiteside & Jacobsen, 2010). minimal, the training and technology were both
Based on the literature discussed previously, found to be acceptable. More importantly, thera-
most families who participated in the five-day pist’s positive beliefs about exposure increased,
intensive did occasionally reach out to the thera- reported intention to implement exposure
pists following program completion but were increased, and actual reported use of exposure
generally able to continue implementing expo- following the training increased. Findings from
sure concepts and practices on their own this study support the feasibility of disseminating
(Whiteside et al., 2018). stand-alone exposure for CADs to community
In addition to the patient-focused benefits therapists. As therapist’s confidence in treatment
mentioned above, the five-day intensive group is likely to influence treatment outcomes (Gillihan
also promotes highly efficient use of therapist et al., 2012; Williams & Chambless, 1990),
410 E. Brennan and S. P. H. Whiteside

c­ ontinued improvements to access to training on efforts to disseminate knowledge about this treat-
exposure therapy is likely to impact its availabil- ment to more effectively increase its use in com-
ity and even effectiveness for youth with CADs. munity settings.
Improving therapist understanding of, beliefs
about, and execution of exposure for CADs is an
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 Telehealth Adaptations in Day
Treatment Programs 23
Miri Bar-Halpern, Christopher Rutt,
and Ryan J. Madigan

Day treatment programs serve as an important evidence-based care, reducing costs for both
component in the greater continuum of psychiat- patients and providers, and reducing stigma-­
ric care for youths and often bridge the gap related barriers associated with mental health ser-
between inpatient hospitalization/residential vices (Fletcher et al., 2018; Wangelin et al.,
treatment programs and other forms of outpatient 2016).
therapy. While most day treatment programs Despite the various benefits associated with
have been historically provided as in-person sys- the use of telehealth modalities, little known
tems of care, there has been a recent transition to research to date has focused on the use of tele-
offering more therapeutic programs virtually health or virtual programs as part of day treat-
(Baweja et al., 2020: Childs et al., 2020; Datta ment programs or partial hospitalization
et al., 2020; Hom et al., 2020). This recent pivot programs (PHPs). This dearth of research created
to virtual care has been accelerated in response to a significant dilemma at the onset of the
the challenges associated with the COVID-19 COVID-­19 pandemic in that day treatment, and
pandemic. PHP providers were left without a necessary
The use of technology to assist or aid in the blueprint on how to best transition to a virtual
process of therapy is not new to the fields of psy- telehealth model despite a pressing need to do so
chiatry and behavioral health (Barnett & in a very short period of time. In an effort to cir-
Huskamp, 2019; Wangelin et al., 2016). Although cumvent the metaphor of “building the plane
a comprehensive review of research investigating while flying it” for current and/or future day
the use of telehealth and telemedicine is beyond treatment and PHP practitioners, this chapter is
the scope of this chapter, prior studies have intended to address recent transitions and adapta-
shown that the use of psychotherapy adminis- tions in telehealth within the context of day treat-
tered electronically can be beneficial for a multi- ment programs for youth.
tude of mental health and physical health The specific components of this chapter
difficulties (Barnett & Huskamp, 2019; Wangelin include (a) a review of existing research and lit-
et al., 2016). In addition, telehealth practices may erature on telehealth adaptations for day treat-
be increasingly beneficial to improving access to ment programs, (b) a discussion of the
development and application of our own virtual
PHP program in private practice, (c) a review of
M. Bar-Halpern · R. J. Madigan (*) adaptations for specific evidence-based treat-
Boston Child Study Center, Boston, MA, USA ments used in conjunction with day treatment
Harvard Medical School, Boston, MA, USA programs, and (d) an examination of the pros and
e-mail: [email protected] cons of telehealth adaptations for day treatment
C. Rutt
Boston Child Study Center, Boston, MA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 415
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_23
416 M. Bar-Halpern et al.

programs as well as recommendations for future PHP at the time of their report, preliminary
adaptations. acceptability and feasibility data looked
promising.
In an analysis focusing specifically on youth
Existing Research/Literature populations (i.e., children and adolescents),
on Telehealth Day Treatment Baweja et al. (2020) reported on their develop-
Programs ment of telehealth PHPs across two different
sites in the United States over a period of 3–4
As indicated above, the use of telehealth and tele- weeks. Similar themes emerged as compared to
medicine has been the focus of an increasing the Hom et al. (2020) study described above,
number of research studies over the past including the need to adapt clinical services
10–15 years (Wangelin et al., 2016). Limited offered, managing risk assessments, and chal-
research, however, has focused specifically on lenges associated with maintaining confidential-
adapting day treatment programs for virtual use. ity. Baweja et al. (2020) indicated that by the
At least two known studies (Baweja et al., 2020; second week of virtual programming, the total
Hom et al., 2020) to date (one with adults and one number of daily program hours was reduced
with youths) have specifically focused on the from six hours to one for elementary-­ aged
development and implementation of telehealth patients and from six hours to four for adoles-
PHPs and may serve as benchmarks for current cents. The authors reported that this change was
and future treatment practitioners. made in response to feedback from patients and
In a report detailing the transition from an their families that maintaining focus online for 6
established in-person PHP to a virtual-only hours was too challenging. Despite these adapta-
modality, Hom et al. (2020) provided a detailed tions, the authors highlighted that patient
analysis of the necessary steps associated with engagement remained a challenge throughout
quickly pivoting to telehealth services for adult their virtual PHP, which necessitated a need to
patients. Critical themes that stand out include (a) include components of motivational enhance-
modifications to intake and admission proce- ment therapy into clinical programming.
dures, (b) adaptations to clinical services offered, Taken together, these two studies suggest
(c) administrative considerations such as training important considerations for developing and
staff and coordinating care, and (d) managing implementing day treatment programs and PHPs
clinical needs such as privacy/confidentiality, virtually. Cross-cutting challenges ranging from
risk assessments, medication management, fam- administrative to programmatic to clinical
ily meetings, and aftercare planning. Specific to decision-­making appear to exist on various lev-
treatment and programming, these authors indi- els. In order to expand on the existing literature
cated that the number of daily group therapy ses- related to virtual day treatment programs, we
sions was reduced from five 50-minute sessions next transition to an analysis of our virtual PHP
(from their original in-person PHP) down to three (vPHP), delivered by the Boston Child Study
50-minute sessions (in the virtual PHP). This Center (BCSC) clinical staff, in March 2020 fol-
decision was made in an effort to reduce screen lowing stay-at-home orders during the COVID-­19
and sedentary time. In addition, the total number pandemic.
of group therapy sessions offered per week was
streamlined down to only 15 groups that all
enrolled patients were asked to attend. The Development and Implementation
authors noted that their plan was to increase the of a vPHP in a Private Practice
weekly offering of group sessions from 15 to Setting
30 in order to better tailor the sequence of ther-
apy groups to patients’ presenting problems and The COVID-19 pandemic had a profound impact
goals. While these authors were unable to report on mental health service providers beginning in
specific outcomes associated with their virtual early 2020. As the pandemic progressed, provid-
23 Telehealth Adaptations in Day Treatment Programs 417

ers of psychiatric care were tasked with quickly associated with establishing a telehealth program
pivoting from in-person models to telehealth-­ (i.e., technology, privacy, legal considerations,
only modalities. Such a transition did not occur training/orientation, and working remotely), spe-
overnight and resulted in a gap of psychothera- cific features associated with our vPHP, and
peutic services, especially in the context of inpa- adaptations to various evidence-based treatments
tient, residential, and intensive outpatient used in conjunction with our virtual program.
programs (Leffler et al., 2021). Our clinical team
at the BCSC was faced with the reality that
numerous patients were prematurely discharged Technological Considerations
from residential and PHP settings. This reality
forced our team to pivot quickly and develop a There are multiple technological considerations
vPHP program to support our clients and those in that should be addressed in order to effectively
the community left without the necessary treat- transition from an in-person to virtual modality.
ment they required. These considerations include, but are not limited
At the BCSC, prior to COVID-19, we pre- to, (a) selecting a telecommunication platform
dominantly utilized telehealth to augment largely that is HIPAA compliant, (b) reliable access to
in-person services and as a tool to decrease barri- the Internet, (c) hardware and lighting, and (d)
ers to accessing mental health care (e.g., clients access to multiple devices for high conflict fam-
who lived in rural or underserved areas). We typi- ily therapy (e.g., computers, tablets, and
cally used telehealth to provide individual ther- smartphones).
apy, parent/caregiver coaching, family therapy,
and in some rare cases skills training groups for
caregivers unable to attend in-person groups due Telecommunication Platform
to work schedules. However, once it was decided
to provide only telehealth services due to Various forms of electronic communication are
COVID-­19 safety recommendations, we adapted available for use between medical providers and
all of our services (except neuropsychological patients, including written (e.g., electronic mes-
testing, which was paused) to an online platform, sages such as e-mail or text messages), auditory
including individual/family therapy, groups, only (e.g., telephone contact), and auditory +
assessments, intensive outpatient programs visual (e.g., videoconferencing). Results of prior
(IOP), and partial hospitalization programs research have suggested that the use of videocon-
(PHPs). Working predominantly in our private ferencing technologies may be more strongly
practice outpatient settings located in Boston, associated with patient outcomes as compared to
Massachusetts, and Los Angeles, California, we auditory-only technologies, but that both tech-
experienced significant challenges and delays in nologies are highly acceptable by patients in vari-
referring our patients to higher levels of psychiat- ous settings (Fletcher et al., 2018; Kennedy et al.,
ric care. Many in-person programs in our referral 2020; Kim et al., 2018; Lynch et al., 2020; Owen,
network that provide treatment for high risk 2019).
youth were abruptly closed due to COVID-19; In an effort to maximize patient acceptability,
therefore, there was a clear increase in the need we opted for a videoconferencing platform for
for providing daily structure and intensive sup- telehealth psychotherapy sessions. Prior to the
port both to our regular clients and high demands pandemic, we employed a licensed Google Meet
from new referrals. In response to this dearth of account, which was included in the Google
referral resources, we initiated a process of tran- Business Suite of applications covered by busi-
sitioning our existing Summer IOP Program to a ness associate agreement (BAA) with Google,
more comprehensive day treatment program/ ensuring compliance with the US Health
vPHP. An analysis of this transition to a vPHP is Insurance Portability and Accountability Act
provided below, including necessary components (HIPAA). A BAA is a legal contract whereby the
418 M. Bar-Halpern et al.

licensing organization (in this case Google) takes tem that can work from any location would allow
responsibility for ensuring security/encryption teams to communicate and work seamlessly with
standards are HIPAA compliant. The receiving each other regardless of physical locations. Many
organization (in this case BCSC) agrees to utilize videoconferencing platforms are now included in
the software in certain ways to avoid undermin- other cloud-based applications that provide this
ing the integrity of the security and encryption diverse range of virtual products. Examples
standards. At the start of the pandemic (March include the Google Business Suite package (as
2020), the Google Meet platform worked well for described above), Microsoft Teams, and Zoom
small meetings with two to four individuals. (which recently expanded its applications beyond
However, it presented challenges for larger meet- videoconferencing). We expect even more
ings (e.g., staff meetings, rounds, workshops, and options and platforms to emerge to meet the
trainings). After researching alternative plat- growing need for virtual workspaces.
forms, we added a licensed Zoom account
(https://zoom.us), which also provided a BAA
ensuring HIPAA compliance and worked more Internet Access
seamlessly for larger groups and offered other
features such as breakout rooms, waiting rooms, The lack of consistent, reliable, and secure access
virtual white boards, and single link access to to the Internet can serve as a significant barrier to
provide to all of our clients (rather than schedule engaging in telehealth services (Grundstein et al.,
individual meetings on a meeting-by-meeting 2020). Reliable and quality Internet access is
basis). In addition to the technological advan- necessary for both patients and service providers.
tages of Zoom in 2020, most of our clients knew Our experience with utilizing videoconferencing
this platform due to its growing use and familiar- platforms has led to the recommendation of hav-
ity among children and adolescents in virtual ing Internet download speeds of at least 100
academic settings. Google Meet has since mbps to avoid disruptions in videoconference
updated their software to provide a comparable quality. In our phone screen and intake process
set of functions to Zoom. This may be important with patients and families, we routinely assessed
to note for budgeting, as Google Meet is included technological needs and encouraged families to
in the Google Business Suite of HIPAA compli- run Internet speed tests to assess Internet quality
ant applications, which practitioners may also (a free website www.SpeedTest.net provides an
benefit from or already be using (i.e., HIPAA easy speed check with a single click of a button
secure email, phone, text, website hosting, and a for staff and clients). For families that lacked the
cloud-based drive allowing providers to share necessary technological tools, we offered to loan
documents and files in the cloud). families hardware (e.g., smart tablets) and subsi-
When considering virtual programming, it is dize the cost of upgrading to faster Internet
insufficient to only consider videoconferencing speeds where upgrades were available. Treatment
options, as staff members within various organi- interfering issues related to telehealth could often
zations may also be working remotely only or in be prevented through a few quick telehealth
a hybrid of work from home and work from related check-in questions such as, “Hi good to
office. In our consultations to other treatment see you, where are you calling in from? Do you
providers, we found that many programs not only have privacy? Is your device fully charged? Have
struggled to shift to a videoconferencing plat- you done a speed check” (speed checks take
form but also struggled in collaboration and com- approximately 5–10 seconds to complete). We
munication between staff, as they previously found in providing consultation to many other
relied on paper charts, hardline phones, and face-­ centers during this time of transition that clini-
to-­face collaboration. In an effort to maximize cians often do not check the Internet speed of
efficiency, ideally, a medical record, shared stor- their network and their clients’. The importance
age drive, email, phone, and text messaging sys- of preventing the frustration and disappointment
23 Telehealth Adaptations in Day Treatment Programs 419

of a meeting “freezing” or audio cutting out in sion). For clients who expressed fears around
the middle of a critical discussion cannot be confidentiality in their home, we recommended
overlooked. white noise machines or apps (commonly used in
mental healthcare settings). Many of our clients
reduced privacy-related anxiety after download-
Hardware and Lighting ing white noise apps on their phones and playing
via Bluetooth speakers or by placing their phones
Similar to quality Internet access, various forms outside of or near their bedroom door for added
of hardware are necessary in order to engage in sound dampening.
telehealth sessions. We recommended that In terms of lighting, we recommended (a) suf-
patients and families use a desktop or laptop ide- ficient lighting facing the client (either directly
ally, or alternatively a tablet or smartphone for behind the camera or two lights diagonally facing
virtual therapy sessions. Computers were recom- the client from either side to avoid glare) and (b)
mended over smartphones and tablets due to the to minimize lighting behind patients and clini-
size of the screen and ease of integration in using cians in order to reduce glare and shadows that
all the built in features of a videoconferencing may obscure faces. When using plugin web cam-
platform (e.g., screen sharing and virtual white- eras that automatically correct for high or low
boards were originally designed to be most easily lighting, the need to purchase additional lighting
used by a computer rather than a smart device). may be eliminated (e.g., Logitech brand cameras
Alternatively, one benefit of tablets or smart- proved to be relatively affordable and provided
phones with children or teens who struggle to automatic light adjusting software).
effectively manage distractions is that smart
devices often have the capability to easily lock on
one application at a time. The size and brightness Multiple Devices and Software Tools
of screens was also a consideration in recom-
mending the use of computers over tablets or In some instances, we recommended that patients
smartphones; the larger the screen, the more and families utilize more than one device to
immersive the subjective experience when con- access therapy sessions. At the BCSC, we fre-
necting with others. If a client prefers to use a quently engage in family therapy sessions and
tablet or smartphone with a smaller screen, it recurring team meetings. When necessary (i.e.,
may be important for the clinician to adjust their families experiencing high conflict), clinicians
proximity to the camera so as to fill the entire utilize a “revolving door” method (Fruzzetti &
screen. Payne, 2020), which includes temporarily plac-
As described above, we offered to loan these ing certain meeting participants into the virtual
devices to families who were in need of addi- waiting room so that clinicians can meet with one
tional hardware. If not built into existing hard- participant to address specific issues that arise
ware, we requested families to utilize a high (e.g., skills coaching a dysregulated client so as
definition (HD) camera to accurately capture to successfully return to the family session more
video and headphones to transmit audio. effectively). Consequently, we encouraged
Headphones, especially wireless headphones, patients and family members to log into high
have additional benefits including the following: conflict family therapy sessions and team
(a) providing the clearest audio in both direc- ­meetings from both separate devices and separate
tions, (b) improved mobility (i.e., helpful in con- rooms to help facilitate this therapeutic
ducting exposure activities or coaching a parent technique.
through a child’s tantrum as in the case of deliv- In terms of utilizing specific software tools as
ering parent–child interaction therapy), and (c) part of teletherapy, there may be times where
adding more privacy or perceived privacy by the using the chat feature, white board, and/or screen
client (e.g., teen worried others can hear their ses- sharing may enhance the virtual meeting.
420 M. Bar-Halpern et al.

Regarding the chat function, we have typically ing difficult emotions. As mentioned above, we
used it on a case-by-case basis. For example, dur- frequently recommended the use of headphones
ing group therapy, we often have limited chat fea- to protect some privacy. In addition, we recom-
tures such that clients can send a message to the mended the use of a sound or white noise machine
clinician but not to everyone else to address client to dampen voices that may otherwise carry. A
questions and reduce distractions. Family/team common mistake that both clinicians and clients
meetings are also times when the chat feature may make is placing the white noise machine
may be of benefit, especially to propose agenda inside the room; when placed in the same room,
items or pose questions to be addressed. However, it may actually undermine privacy as it prompts
we made every effort to orient all participants to individuals to speak louder to compensate for the
when the chat feature is being used to make sure additional white noise. When placed outside of
the other family members do not assume we are the therapy rooms (in shared hallways just out-
distracted and to facilitate direct communication side the door), it provides the intended privacy.
within the family. Technology-related privacy concerns (caused
Screen sharing and white board use can be an by faulty settings in programs like Zoom) have
effective way to engage clients with handouts or been shown to increase the risk for additional pri-
other therapeutic materials. We have experienced vacy breaches (sometimes referred to as “Zoom-­
anecdotal success with utilizing videos or audio bombing” a meeting). Some solutions to these
that compliment therapeutic techniques that are privacy concerns are available. In Zoom, for
often used in the course of psychotherapy. example, the use of personal meeting links paired
Examples include engaging in guided mindful- with virtual waiting rooms and the appropriate
ness, progressive muscle relaxation, PDFs of settings (e.g., participants must be admitted by
therapy handouts and worksheets, and using the host) are likely to reduce or eliminate these
white boards to visually display content from problems. Settings within Zoom can be adjusted
therapy. It was also helpful to save all the hand- in a few ways: (1) an administrator can adjust the
outs on the client’s confidential folder on the settings that apply to all licensed staff accounts,
drive for future reference. or (2) staff accounts can be further adjusted by a
Zoom user or an IT administrator in person or via
“shared desktop.” Using the shared desktop fea-
Privacy Considerations ture allows one individual to temporarily allow
another user (i.e., administrator working
Similar to in-person psychotherapy, maintaining remotely) to view and control their desktop and
privacy and confidentiality in virtual modalities mouse to ensure the settings have been adjusted
is paramount to the therapy process. However, correctly.
unlike in-person psychotherapy, virtual modali-
ties often present unique benefits and challenges
to privacy. When attending a session virtually Legal Considerations
from an individual’s home, there is no longer a
concern about being seen in waiting rooms or Legal considerations are a necessary component
entering specific office spaces. In terms of chal- of any type of psychiatric care and include vari-
lenges, with an increase in parents and caregivers ous components such as consent for treatment
working from home due to the COVID-19 pan- and releases of information to name a few. These
demic as well as many youths attending school components maintain their necessity for virtual
virtually, privacy concerns were routinely modalities, especially in terms of meeting pri-
assessed during our intake procedures and early vacy and HIPAA standards. One possible exten-
therapy sessions. Whenever possible, we encour- sion of legal considerations when engaging in
aged patients to virtually participate in therapy in telehealth services is the ability to digitally record
a private setting where they can speak openly and components of therapy sessions. In our vPHP
feel comfortable being vulnerable and experienc- programming, we limited screen recording privi-
23 Telehealth Adaptations in Day Treatment Programs 421

leges in Zoom to only the meeting hosts and software plug-in (Virtru.com) and (b) a HIPAA
explicitly prohibited any other forms of digital compliant cloud-based drive (Google Business
recording (i.e., screenshots, digital videos, or Suite). To ensure patient/client videos are pro-
photographs). In situations when the client is tected, we used two measures. First, all videos
shutting off their camera, or the camera is not containing PHI were saved in designated pro-
pointed at them, we asked them directly to turn tected folders on our HIPAA compliant cloud-­
their camera on or point it toward themselves. If based drive. Second, shareable links to these
they were unwilling to do so, we explored rea- folders were created within the Google Business
sons within the therapeutic relationship and grad- Suite. These files/folders within Google Business
ually increased comfort with telehealth and Suite were set preemptively as “View Only”
commitment in general. Examples of strategies when creating these shareable links (this pre-
for shaping effective camera usage include utiliz- vented clients from mistakenly saving videos to
ing shorter therapy sessions initially, having cam- devices that are not secure). Finally, these share-
eras on for only part of the time, and/or using able links to therapy videos were sent via
coping skills to regulate difficult emotions or encrypted email (i.e., Virtru) to ensure front and
other internal experiences associated with cam- back end encryption.
era use. In other words, we conceptualized diffi- To ensure patient privacy is fully protected, it
culties with using cameras as avoidance, and is important for clinicians and practitioners to
these avoidant behaviors became a treatment understand the limits of standard email vs.
goal. HIPAA secure email. Standard email accounts
In some instances, however, we have found that are not licensed under a HIPAA secure BAA
that digital recordings of specific content may be are not secure on the sender (clinician) or receiv-
clinically relevant and useful. For example, er’s (client) end. Email accounts that are licensed
recordings of virtual group and or individual under a HIPAA secure BAA (e.g., Google
therapy sessions may be useful for training and Business Suite) are secure on the clinician’s end
consultation purposes. In addition, the ability to but not the client’s end. Clinical staff can send
digitally record may be an effective therapeutic emails to one another with both ends secure and
tool for certain treatment modalities. One such protected by Google’s software. However, emails
example includes the use of prolonged exposure sent from a secure email address to an account
for patients experiencing difficulties with post-­ outside of one’s agency are no longer secure once
traumatic stress disorder (PTSD). This type of received by the client. To ensure security/encryp-
therapy involves having patients recount their tion on both ends (both clinicians and clients), an
past experiences with trauma in narrative form additional software plug-in may be required. As
and replaying these narratives over the course of indicated above, we utilized a plug-in service
therapy as between session exposure homework offering HIPAA encryption with a BAA (Virtru is
activities. Engaging in this type of therapy virtu- a Google compatible plug-in that allows clini-
ally allows for clinicians to digitally record cians to send emails that are secure on the send-
patients recounting these narratives and for ing and receiving end).
patients to watch these recordings as homework Since telehealth has become a popular method
assignments in between scheduled telehealth of communication in various fields, especially
sessions. academic settings, we found it important to
As with other identifiable materials used dur- address inappropriate behaviors, (such as dress
ing treatment, any components of therapy that are code), appropriate physical locations (e.g., sitting
digitally recorded should be considered protected at a desk vs. lying in bed), and multitasking on
health information (PHI), and necessary privacy more than one screen or trying to record sessions
and legal standards should apply to the storage without consent (one helpful feature is that Zoom
and dissemination of these recordings. We used a will make an announcement if someone attempts
combination of two methods to maximize pri- to record the screen and allow others to leave the
vacy: (a) a HIPAA compliant encrypted email meeting if they are not comfortable). These types
422 M. Bar-Halpern et al.

of problems were typically addressed through a Working Remotely

combination of appropriate software settings and
direct communication as indicated. Specific to The BCSC made sure that staff had a comfort-
our vPHP, we found that leading groups with co-­ able working environment and delivered office
leaders allowed the group leader to progress supplies, computer screens, office chairs, etc. to
through the curriculum while a co-leader all employees who were in need. Staff also
addressed relevant problem behavior with an completed training about maximizing the use of
individual (typically in a breakout room). telehealth and ways to ensure confidentiality.
When delivering mental health care from home,
we found it highly effective to have a sound
Training and Orientation machine outside your door and to orient family
members or other residents of the home that
Similar to the training procedures described by they cannot walk into the room while you are
Hom et al. (2020), we employed an iterative pro- working. While this is true for many fields, it is
cess in orienting and training our staff to the use even more important for mental health provid-
of videoconferencing technology. Similarly, ers in order to maintain our client’s confidenti-
patients and families were oriented to videocon- ality. On the other hand, working from home
ferencing technology during intake assessments can create more flexibility in terms of working
and were offered ongoing maintenance and sup- hours and may create a shared camaraderie
port by clinical staff members on an as-needed between clients and clinicians as both are
basis. In most cases, staff were able to help cli- adjusting to the processes of telehealth and the
ents troubleshoot technological issues verbally. shared experience of coping with a worldwide
However, in situations where the issue was more pandemic.
challenging, Zoom and Google offered in app In summary, there are multiple components
functions allowing the clinician to temporarily and considerations that are necessary when plan-
view and control the client’s desktop screen and ning a transition to virtual-only psychotherapy,
mouse, so as to make the necessary changes for many of which we have described here. While
the client. During the vPHP, all virtual program- some of the considerations may not be feasible in
ming was facilitated by a minimum of two staff all contexts, we encourage thoughtful planning of
members; one designated as the clinical lead and the various administrative and technical consid-
the other in a supportive role to manage patient erations described above. We are also mindful
difficulties and technological challenges on a that this is not an exhaustive list, and conse-
case-by-case basis. The staff at BCSC is com- quently encourage practitioners to actively seek
posed of licensed clinicians including psycholo- out consultation on transitioning to telehealth
gists, social workers, mental health counselors, whenever possible.
and psychiatrists, as well as practicum students, In the following parts of this chapter, we tran-
interns, and postdoctoral fellows. Our faculty sition to describing specific adaptations of our
hold positions at BCSC as well as top hospitals PHP at the BCSC from an in-person to telehealth-­
and universities in the region, and our clinicians only model. More specifically, we address the
specialize in a variety of evidence-based treat- methodologies used for completing assessments
ments. In most instances, we attempted to pair and intakes as part of the vPHP, adaptations to the
licensed clinicians with unlicensed trainees to clinical programming offered, and tools utilized
facilitate learning according to each trainee’s to monitor and track client progress throughout
interest and level of training. the vPHP.
23 Telehealth Adaptations in Day Treatment Programs 423

 linical Adaptations of a Partial

C the Clinical Director scheduled a 15-minute
Hospital Program to Telehealth informational call to discuss practice informa-
Treatment Rational tion, logistics, and the intake process, as well as
to review Registration Packets and to hand off the
As described above, the BCSC vPHP was devel- client to an appropriate Intake Coordinator for
oped and implemented to address the service gap next steps. The Intake Coordinator then sched-
that arose as part of the COVID-19 epidemic. This uled an initial consultation with the appropriate
vPHP was created to provide intensive therapeutic Program Director and was present during the
behavioral and mental health services for youth intake for documentation and to act as a point
and young adults ranging in age from 12 to person/coordinate care between families and the
21 years. The treatment program was designed to BCSC. During this initial consultation, the
increase structure, social interaction, and emo- Program Director assessed client difficulties via a
tional regulation skills. The program’s primary flexible, semi-structured interview that was
curriculum, values-based exposure therapy developed by the BCSC team, with the client and
(Madigan, 2016), was adapted and expanded by relevant family members. At the conclusion of
integrating components of comprehensive dialec- this initial consultation, families were provided
tical behavioral therapy (DBT; Linehan, 2014) with diagnostic clarification, clinical formula-
with acceptance and commitment therapy (ACT; tions with an emphasis on functional impairment,
Hayes et al., 2012), cognitive behavioral therapy and treatment recommendations. Upon receiving
(CBT; Beck, 2020), exposure and response pre- treatment recommendations, families were pro-
vention (Rowa et al., 2007), and behavioral activa- vided opportunities to ask questions and collab-
tion (Martell et al., 2001) to address adolescent oratively participate in the treatment planning
and young adult symptoms of anxiety and depres- process. Families were then given the opportu-
sion and difficulties with emotion regulation. The nity to officially enroll in the vPHP. Four to six
vPHP also provided an additional individualized weeks after the initial consultation, the clinical
therapy plan for each participant based on their team, Program Director, and Intake Coordinator
specific needs, including specific DBT groups attended an update meeting with families to
(separate from the vPHP), individual therapy, fam- ensure adherence to treatment, follow-up on
ily therapy, and parent coaching. Outside of sched- goals, and overall effectiveness of treatment.
uled therapy sessions, we provided phone-­based Initial consultation questions included the
skills coaching, crisis and risk assessments (via individual’s presenting problem, assessment of
telehealth or in-person as indicated), and medica- suicidal ideation, history of suicide attempts and
tion management. Notably, while we developed a nonsuicidal self-harming behaviors (e.g., cutting,
plan for implementing in-person risk assessments, scratching, and burning), and assessment of the
the need for these services never materialized dur- need for psychiatric medication treatment. Other
ing the course of this program. Prior to enrolling in questions aimed to collect specific information
the program, every client was scheduled for an ini- related to presenting problems and clinical his-
tial assessment and consultation. tory. The information collected helped to deter-
mine the type of individual therapy intervention
(CBT, DBT, and ACT) and the need for other ser-
Initial Consultation vices such as parent/caregiver coaching, family
therapy, and medication management.
A series of steps were utilized to complete initial Importantly, part of the initial consultation was
consultations with clients and enroll them into assessing clients’ access to the resources needed
the vPHP. As a first step, the Clinical Director to utilize this program (i.e., sufficient access to
responded to initial calls/emails from clients and high speed Internet, technology such as laptops
sent clients and their families the necessary and tablets, and a safe/confidential place to par-
administrative information and paperwork. Next, ticipate in virtual sessions).
424 M. Bar-Halpern et al.

The initial consultation yielded categorical included three therapeutic skills training groups
diagnoses and functional and emotional formula- every morning, followed by three activity groups
tions identifying which step in the emotion regu- in the afternoon. The three morning skills train-
lation sequence an individual was struggling to ing groups followed the values-based exposure
navigate effectively (i.e., identify, understand, or therapy paradigm with the first group teaching
manage). If recent neuropsychological reporting skills to better identify thoughts, feelings, and
was available, this data was utilized to further actions urges; the second group facilitating a bet-
identify why an individual may be experiencing ter understanding of thoughts, feelings, and
difficulties with their ability to identify, under- action urges; and the third group teaching and
stand, and manage thoughts, feelings, and action practicing strategies to effectively manage
urges. thoughts, feelings, and action urges. The after-
noon activity groups were designed to provide
behavioral activation, social interaction, expo-
vPHP Intervention sure opportunities, and structured recreation
(e.g., Yoga, cooking, academics, trivia, creative
Theory art, and music).

As mentioned above, the vPHP curriculum was

based on the foundation of values-based expo- Group Structure
sure therapy. The main goal of the program was
to teach the fundamentals of effective emotion All groups lasted approximately 45–50 minutes
regulation through improving an individual’s with 10–15-minute breaks between each group
ability to identify, understand, and manage (see Fig. 23.1). Identifying groups were predomi-
thoughts, feelings, and action urges/actions in nantly mindfulness based and included both edu-
sequence (Pincus et al., 2014). These principles cation and experiential components.
of identifying, understanding, and managing Understanding groups were focused on helping
served not only as the theoretical underpinning of individuals to identify and clarify their core
the treatment but also as a guiding structure for ­values, determine values-based goals, and teach
the program curriculum. The vPHP program necessary components of emotion regulation

Monday 1 Theme Activity/Skill

Introduction to Emotions Overview Identify and
Manage Emotions 101 (Myths and Facts about
9-9:50 Identify thoughts/feelings Emotions)
Understand The Values Based Exposure Anxiety & Depression
10-10:50 thoughts/feelings - Biosocial Theory
Managing thoughts and Intro to Values Based Exposure (ExRP +
11-11:50 feelings Behavioral Activation)
12-1 LUNCH BREAK
1-1:50 ACTIVITY Coping with COVID-19 - Creating Structure
2-2:50 ACTIVITY Expressive Arts
3-3:50 ACTIVITY Mindful Music Group

Fig. 23.1 Daily schedule at the vPHP

23 Telehealth Adaptations in Day Treatment Programs 425

skills (e.g., understanding the function of emo- outpatient therapy). The criteria for increasing
tions). Finally, managing groups focused on services or graduating from the vPHP were done
teaching distress tolerance strategies, interper- on an individual basis that took into account each
sonal effectiveness skills, and principles of expo- client’s safety concerns, daily structure, and over-
sure and response prevention (as well as planning all therapeutic and familial support. In an effort
and coping ahead for afternoon exposure to help guide these clinical decisions through
opportunities). measurement-based care, the BCSC partnered
Afternoon activity groups were developed with a behavioral health outcomes software com-
based on clinicians’ expertise, hobbies, and per- pany (Mirah, Inc.) to routinely assess client out-
sonal values-based activities and aimed to pro- comes. These outcomes were assessed via
vide structure and opportunities for self-care and standardized outcome questionnaires (specific
to improve daily living skills. These groups were questionnaires varied depending on clinical tar-
varied to explore a wide range of interests and gets, but examples included the Depression
exposure to new experiences. Examples of these Anxiety Stress Scale (Szabó, 2010), Revised
groups included activities such as yoga, scaven- Children’s Anxiety and Depression Scale
ger hunts, trivia, role plays (e.g., giving a TED [Ebesutani et al., 2012], Caregiver Strain
talk), fundamentals of behaviorism (e.g., live Questionnaire [Brannan et al., 1997], and
training of a clinician’s puppy), cooking, strate- Borderline Symptom List 23 [Bohus et al., 2009],
gies for increasing gratitude, creating a vision etc.) that are accessible through a HIPAA compli-
board, specific ways of coping with COVID-19, ant online platform that automatically processed,
executive functioning coaching, virtual traveling, scored, and graphed each client’s data. Clinical
creative arts, music, and more. Our goal was to data was shared with clients in individual and
provide accessible treatment that strongly family therapy sessions to provide feedback
adhered to evidence-based practice while simul- about symptom changes and to highlight areas
taneously cultivating a therapeutic milieu that that need to be targeted in current treatment
promoted appropriate social interactions within a planning.
virtual space. As described in the sections above, we relied
As mentioned above, many clients received heavily on existing in-person assessment, treat-
additional services such as individual therapy, ment, and consultation models that were then
parent/caregiver coaching, parent/caregiver skills adapted for a virtual-only context as part of our
group, family therapy, and group therapy vPHP. This adaptation was conducted in an itera-
(evidence-­based therapy groups that have differ- tive manner, such that the various stages and
ent curricula and were open to individuals out- components of the vPHP were continually
side of the PHP as well). These services were assessed by our team in a collaborative manner,
added in the afternoon to allow individuals access and adjustments were made as needed to meet the
to all components of treatment. needs of our participating clients and their
families.
In the final section of this chapter, we will now
 ata Collection to Support
D transition to providing greater specificity in terms
Treatment of the clinical adaptations that were used as part
of the development, implementation, and refine-
In order to promote effective communication and ment of our vPHP. These include specific adapta-
to collaborate about cases, we held clinical tions to the format and structure of therapy
rounds twice a week to discuss clients’ formula- (individual, family, and group therapeutic ser-
tions and specific treatment goals and to assess vices) and the specific evidence-based
each client’s need for a higher level of care and/ interventions that were delivered during the
­
or graduating from the vPHP (typically to weekly vPHP (i.e., ERP, DBT, and DBT PTSD).
426 M. Bar-Halpern et al.

 linical Adaptation of Selected

C unique information that added to our assessment
Interventions to Telehealth and formulations (e.g., what physical items were
present in their room and were physical spaces
The following intervention formats were used to clean/messy/organized). On the other hand, criti-
augment the vPHP and were prescribed based on cal information germane to the intricacies of psy-
the initial assessment and the formulation of the chotherapy were lost or blurred, especially things
client. Specifically, they were added to the cli- such as body language, physical limitations/
ent’s day based on their specific needs before or impairments (e.g., if someone is using a wheel-
after their vPHP groups. These various formats chair or has a disability that we could not observe
included individual therapy, family sessions, and and was not reported), and methods for providing
adjunctive group therapy. functional validation (e.g., handing a tearful cli-
ent a box of tissues during in-person sessions).
Consequently, the need for thoughtful and pre-
Individual Therapy scribed assessment in virtual therapy can be that
much more important, and slowing down the
Similar to traditional in-person therapy, virtual pace of therapy (via more frequent questions
individual therapy sessions focused initially on assessing a client’s experience of therapy, inquir-
functional assessment of needs and building rap- ing about and validating perceived emotions,
port with clients. With telehealth meetings, there etc.) may be necessary. Virtual therapy may pres-
is often a need for more clarification about the ent the need for clinicians’ body language to
process, expectations, and structure of treatment change. For example, clinicians who take notes
(e.g., how to use the online platform and different during sessions may need to orient their clients to
features within it as needed). We frequently used this note-taking so that a lack of eye contact is not
screen sharing options for psychoeducation perceived as the clinician being distracted.
materials and the whiteboard feature for specific Finally, since many clients are also attending
interventions (e.g., chain analysis, mindfulness school/work virtually, they might feel fatigue
games, exposure hierarchies, and psychoeduca- from being in front of the screen all day.
tion). In contrast to in-person therapy, we ori- Brainstorming about the right time/day for ses-
ented our clients to issues of privacy and sions can help increase overall motivation and
confidentiality and made efforts to return to ques- participation.
tions of privacy at the start of every individual
therapy session. Our goal was to ensure that cli-
ents were in a safe environment where they could Family Therapy
feel as comfortable as possible during sessions.
For many individuals, the in-person therapy Transitioning from in-person to virtual therapy
office can be seen as a “safe haven” where vul- presented what many of our clinicians reported as
nerabilities and difficult emotions can be a surprising benefit within the context of family
expressed openly. When engaging with therapeu- therapy. A common strategy that is utilized in
tic services virtually, this “safe haven” was often family therapy, especially with our DBT clients,
put at risk, especially for our youth, teen, and has been coined as the “revolving door” method
young adult clients who were commonly still liv- (Fruzzetti & Payne, 2020). The “revolving door”
ing with family members. Consequently, we method seeks to identify, block, and replace mal-
made every effort to collaboratively problem adaptive behaviors within family interactions
solve ways to mimic a “safe haven” environment with adaptive coping skills taught and reinforced
within the context of clients’ homes. during family sessions. To accomplish this task,
We found that there are various pros and cons this approach typically incorporates having all
to engaging in therapeutic services virtually. On but one participant of a family therapy session
one hand, seeing our clients at home gave us leave the clinician’s office so that the clinician
23 Telehealth Adaptations in Day Treatment Programs 427

can address, validate, and provide coaching ing and direct communication when family
around emotion regulation strategies to a specific members have a tendency to fragilize them-
family member. Once this coaching is complete, selves or others and may rely heavily on the
the clinician then invites all other parties to rejoin therapist. This type of intervention can reduce
the therapy session to resume where things left treatment interfering behaviors such as avoid-
off. This strategy may be implemented multiple ance of direct communication as family mem-
times in the course of one family therapy session bers are oriented to practice their skills with
with one or more of the participating family scaffolding from the therapist. With any inter-
members. When engaging with this strategy dur- vention, it is important to orient clients in
ing in-person family, it can create logistical chal- advance and follow-up with discussion and pro-
lenges such as where do other family members cessing as needed. Following the use of this
go when they are asked to leave the room (the technique, we would spend time processing the
waiting room, the hallway, or a separate office?) reasons for its use during the session including
and can privacy considerations be maintained for pros/cons and possible alternative solutions for
the family member remaining with the clinician the next family therapy session.
if others are standing right outside the door.
One of the benefits of using telehealth for
family therapy is the ability to use “breakout Group Therapy
rooms” or the virtual waiting room as described
above, breakout rooms are a feature within many Starting a group with clients who do not know
videoconferencing platforms that allow for the one another is often a challenging task, and likely
creation of separate “rooms” with a virtual meet- even more so when engaging via telehealth.
ing space. Similarly, a virtual waiting room is a Similar to strategies described above, adaptations
virtual space where meeting participants can wait for virtual group therapy were largely grounded
before being approved to join a virtual meeting. in methods from in-person therapy. In the orien-
These breakout and waiting rooms were found to tation to and application of virtual group therapy,
be highly effective tools for applying the “revolv- we consistently worked to create a safe
ing door” method within a virtual meeting space. environment/milieu for all participants. Group
Prior to engaging in virtual family therapy, we participants were oriented to a standard set of
would orient families to this strategy and practice basic group rules that included confidentiality
as needed. During the course of a family therapy (making sure there is no one else in the room off
session, clinicians would create and assign par- camera), keeping their cameras on whenever pos-
ticipants to separate breakout rooms as needed or sible, and no recording/pictures of the group ther-
return certain family members to the meeting’s apy members. In addition, we ensured that virtual
virtual waiting room. In the case of joint therapy chat options were set so clients could not mes-
sessions with another therapist, breakout rooms sage each other privately. Virtual group therapy
would be utilized to provide individualized sup- sessions typically started with a mindfulness
port to multiple family members simultaneously. activity and/or taking an agenda, during which
Once individual coaching was completed, or we time screen sharing and/or white board features
were able to deliver a target intervention, all fam- were often employed by the group leader. Screen
ily members would be returned to the same room sharing and/or white board features were also
to reengage with family therapy. commonly utilized during the course of the ther-
Similar to breakout/waiting rooms, another apy groups to share/show psychoeducational
strategy that may be of benefit when using tele- materials, worksheets, and videos from the
health for family therapy is having the clinicians Internet.
turn off their own cameras. This is a specific One additional consideration in the transition
intervention that aims to increase problem solv- from in-person to virtual group therapy is how
428 M. Bar-Halpern et al.

to effectively create a group milieu and establish  linical Adaptations of Specific

C
the therapeutic alliance in a virtual setting. Evidence-Based Treatment
During in-person group therapy, group leaders Interventions Used in Virtual PHP
would often have the opportunity to check in
briefly with participants and to facilitate casual Exposure Response Prevention (ERP)
group conversations. However, these informal
moments can be much harder to cultivate as vir- Numerous studies have supported the efficacy of
tual group participants often log on/off quickly CBT delivered through telehealth (TCBT) for a
or at variable times from the group. variety of mental health issues (e.g., depression
Consequently, we found there were far fewer and anxiety) for youths and adults (Davies et al.,
organic opportunities for “small talk.” In an 2014; Spence et al., 2011; Wright et al., 2017).
effort to solve this problem, group leaders would As part of our vPHP, we sought to consistently
meet with group participants for a brief intro- deliver a treatment curriculum, adapted from
duction and orientation meeting prior to enroll- well-established evidence-based treatments, that
ing in the group therapy. In addition, group would work well with groups, apply to a diverse
leaders would routinely check in with partici- range of anxiety and depressive symptoms and
pants through break out rooms or using the chat emotion disorders, and work well through tele-
feature according to each participant’s level of health. As introduced above, the curriculum we
engagement during the group therapy session. implemented, values-based exposure therapy
In an effort to create and maintain a positive (VBE; Madigan, 2016), adapted key elements of
group culture/milieu, group leaders were DBT, ACT, behavioral activation, and exposure
encouraged to leave a few minutes at the end of and response prevention (ERP). This model com-
the group for participants to talk and directly bined emotional processing (i.e., teaching and
ask for participants to provide feedback to one practicing identification and understanding of
another during the group sessions. In particular, emotional experience to maximize gains made in
we found that having at least two group leaders exposure therapy), with an inhibitory learning
was necessary so that one leader could teach the model that highlighted expectancy violations.
relevant material/run the group while the other Specific adaptations to traditional exposure
leader worked toward checking in on group and ERP methodologies as part of our vPHP
members or working to establish/maintain the were made in various ways. First, based on their
group milieu. individual needs, clients were assigned to either
Although similar to the process of in-person “classic” exposure activities (with the goal of this
group therapy, we found it important (and possi- intervention focused on generating expectancy
bly more important) to routinely assess group violations) or values-based exposure (VBE)
leaders’ burn out and ability to stay engaged with activities (with the goal of this intervention to
participants in a virtual group setting. Leading combine principles of behavioral activation to
virtual groups can be difficult and at times drain- address symptoms of depression with an ACT-­
ing, depending on the level of engagement and informed delivery of ERP to address symptoms
willingness of group members. Maintaining of anxiety). Anecdotally, we found the VBE
focus, attention, and engagement from clients model to be especially useful when delivering
can be a significant challenge in a virtual context, exposure therapy virtually, as motivation and
and as such, group leaders may need to be more engagement for exposure activities can be more
active, enthusiastic, and animated. We encour- challenging via telehealth. While expectancy
aged our group leaders to share strategies and ­violations are still important in VBE, they are not
tools for maintaining client engagement, and the primary focus or goal. Instead of seeking to
developed a shared electronic spreadsheet with break an expectation or rule, the client is oriented
resources for group leaders to utilize throughout to the main goal being to connect with a personal
the vPHP. value through a meaningful activity or an inter-
23 Telehealth Adaptations in Day Treatment Programs 429

personal connection. In doing so, the client inevi- interventions that was adapted for use in our
tably runs into anxiety-based rules, which present vPHP (Linehan et al., 2015; Mehlum et al.,
the urge to avoid the activity and further discon- 2016). Assessing and managing safety concerns
nect from their life. The client is oriented to may be even more challenging when engaging
notice (though mindfulness training) when their with clients via telehealth. Notably, it is vital to
mind becomes preoccupied with the anxious rule develop thorough safety plans with clients that
and redirect their attention to the personal value include their address, phone number, and contact
(combining principles of inhibitory learning and information of other individuals who may need to
diffusion simultaneously). While many rules are be contacted in the time of crisis. We recommend
violated in the process of these activities, the pri- keeping this plan handy in the client’s file (e.g., a
mary focus is in helping the client create new confidential Google drive) as it might be more
learning experiences such as, “even though peo- difficult to contact a client if they end a telehealth
ple probably judged me, it was worth it to make a session abruptly versus if they leave a session
new friend.” This approach appeared to help that is conducted in person. For our younger cli-
combat “Zoom fatigue” and motivational strug- ents and clients with more acute safety concerns,
gles as clients were immediately reinforced with we asked that a parent/caregiver would be at
reconnecting to meaningful parts of their life they home during virtual sessions to provide supervi-
previously avoided due to anxiety. sion and monitoring as needed.
A key component of successful exposure ses- An important factor that mediates suicide is
sions via telehealth was reducing distractions the client relationship with the clinician (Ring &
such as text messages, receiving emails on screen, Gysin-Maillart, 2020). Telehealth might affect
and other notifications that may pop up on the one’s ability to connect with others due to the
screen. In an effort to shape and maintain focus physical distance and the loss of nonverbal cues.
during virtual exposures, we often started with a Therefore, it might take longer to build rapport
mindfulness activity to ground both the client and and gain client’s commitment. This is an impor-
the clinician. We would also frequently remind tant step and should not be skipped.
the client to eliminate or reduce potential distrac- One benefit of utilizing DBT in a virtual con-
tions in advance. Another important aspect, simi- text is the structure DBT inherently provides for
lar to in-person exposures, was to engage with addressing behaviors that interfere with treat-
the client during the exposure. Whenever possi- ment directly (Zalewski et al., 2021). Treatment
ble, we completed the exposure with the client at interfering behaviors may be more prevalent dur-
the same time (e.g., looking at pictures together, ing telehealth. For example, clients might read
singing, and dancing), checked for and practiced texts that pop up on their screen, sit or lay in posi-
strategies to remain present, and provided cheer- tions that may make it more difficult to remain
leading statements as needed. It was also impor- focused, turn off the camera, prematurely log off
tant to complete a thorough assessment of safety virtual sessions (especially since this can be done
behaviors, as one might not be able to see some simply by clicking a button on a screen), or
behaviors that the client was engaging with dur- engage in substance use, (e.g., vape). Orienting
ing exposure (e.g., holding an object that pro- clients to expectations during sessions and
vides reassurance). addressing these behaviors as they arise can help
with the effectiveness of treatment.

Dialectical Behavioral Therapy (DBT)

DBT- Prolonged Exposure/DBT-Post-­
DBT is typically considered the gold standard traumatic Stress Disorder
treatment for individuals who engage in high risk
behaviors, suicide, and/or nonsuicidal self-­ Numerous studies have shown the effectiveness
injurious behaviors, and it is one of the primary of providing prolonged exposure (PE) via tele-
430 M. Bar-Halpern et al.

health (Gros et al., 2018; Hernandez-Tejada may be highly beneficial for engaging in these
et al., 2014; Wells et al., 2020). When conducting types of exposures.
PE treatment through the models of DBT-PE Finally, one helpful adaptation when engag-
(Harned, 2013) or DBT-PTSD (Bohus et al., ing in trauma-based exposures via telehealth is
2020), there are various considerations that may the ease of recording sessions that is typically
be necessary in order to make treatment success- built into most videoconferencing platforms. As
ful within a virtual context. First, clinicians described above, recorded sessions can be
should ensure that their clients are in a safe, con- shared with clients in HIPAA compliant ways,
fidential space and should make necessary which may impact the willingness of clients to
accommodations to address this topic (as practice imaginal exposure in between sched-
described above). It is also important to discuss uled therapy sessions. One possible area for
with clients, similar to sessions in general, how to future research in telehealth practice could be
orient family and/or household members not to investigating the fidelity to exposure-based
interrupt during imaginal exposures that are inte- homework for in-­person vs. telehealth PE. Our
gral to PE work for trauma. Imaginal exposures anecdotal experience in recording in-person
in PE may require more concentration and may trauma exposures (for homework assignments)
lead to more emotional vulnerability as com- has often resulted in clients expressing an
pared to nontrauma exposures. Therefore, it is increase in anxiety and/or resistance to be
highly recommended to proactively minimize recorded, especially when there is a visible
any distractions and reduce any worry about camera in the therapy office. One of the possible
interruptions during trauma exposures. benefits of using telehealth is that clients may be
A second important consideration for engag- less concerned about cameras and being
ing in trauma exposures via telehealth is to proac- recorded. Though speculative in nature, this
tively assess each client’s ability to perform may be due to general familiarity with video-
grounding and anti-dissociative strategies as conferencing, feeling more at ease due to being
needed. Strategies that may be beneficial for in their own home, or by being able to focus
grounding via telehealth include providing cli- more effectively by looking at their clinician on
ents with a balance board in their home (standing the screen or hearing their clinician’s voice
on balance boards during exposures may limit directly through earphones.
dissociative experiences), identifying fidgets or
other salient objects to keep on hand, and using
computer applications that allow clinicians to Conclusion
control their clients’ computers to play loud
music as needed (provided clients agree to this in The COVID-19 pandemic has changed the deliv-
advance). ery of services in numerous fields of medicine,
A further consideration in adapting PE to tele- including psychotherapy. In a short period of
health and vPHP settings is consideration of tone time, programs such as intensive day treatments
and volume of voice. In our in-person experience had to adapt and implement high-quality care
with trauma exposures, we have observed that with increased demands for these services and
clinicians often use softer and/or quieter tones of limited prior research to guide this process. A
voice when encouraging and guiding clients dur- common metaphor that was frequently used by
ing exposure exercises. In a virtual setting, voice practitioners during the early stages of the
tone and volume may be highly dependent on the COVID-19 pandemic was “building the plane
client’s specific audio settings. It may be benefi- while flying it.” This metaphor has largely served
cial to practice how a clinician’s voice will be as the impetus for this chapter. It is our hope that
experienced during trauma-based exposures. by providing information and reflections on the
Notably, the use of headsets or earphones (espe- development and implementation of our vPHP at
cially those that offer noise cancelling features) the BCSC, others will have the building blocks,
23 Telehealth Adaptations in Day Treatment Programs 431

or at least a starting point, for an instruction man- mation can be lost or glazed over when meeting
ual on how to both “build and fly a plane.” with clients in person at the therapy office. Seeing
Our experience with developing and imple- clients in their home settings often provided
menting a vPHP was far from perfect, and we invaluable information into the functional deficits
learned valuable lessons along the way. We rec- associated with mental health difficulties and
ognize that operating within a private practice barriers to effective care. Also, from a clinical
provided some advantages that may not be feasi- perspective, by using telehealth with exposure-­
ble in other settings. In particular, the ability to based therapy, clinicians can practice in vivo
adjust our therapeutic programming so quickly exposures in real-life situations with their clients,
was helpful in many ways. First, we were able to hopefully increasing the ecological validity of
maintain our current client population and pro- these exposures and leading to more learning and
vide them support as they continued to face generalization.
emerging and often novel challenges in life. By Transitioning to telehealth also presented new
adapting our clinical services to telehealth, and unexpected challenges. For some clients,
increasing sessions (as needed), and offering a telehealth may make it more difficult to build
highly structured vPHP that was grounded in rapport and establish a strong therapeutic alliance
evidence-based care, we were able to provide with their clinicians (especially younger chil-
comprehensive support for clients who otherwise dren, individuals on the autism spectrum, and/or
may not have had access to those levels of care. clients who experience difficulties with sitting
Since many other treatment providers and pro- for long periods of time). Some clinicians from
grams were closed or had a long waiting list, we our practice provided anecdotal reports that not
were able to accommodate our clients via inten- seeing a client’s body language and not actively
sive care while simultaneously supporting clients engaging with clients in the room felt like a sig-
in their homes and modeling the idea of continu- nificant hindrance in therapy. This may be espe-
ing with their lives according to their values out- cially true for clients who experience difficulties
side of hospitals or residential treatment centers. with dissociation and are used to a more “hands
Some unexpected benefits of working on” form of in-person treatment (e.g., holding
remotely included spending less time on travel hands with a clinician during trauma exposures
and commuting. This offered some clinicians as a grounding technique). In these situations,
more flexibility in schedules, which may have led identifying the differences between telehealth
to being able to accommodate more clients. In and in-person sessions, speaking about expecta-
addition, clients were often able to schedule ses- tions of virtual therapy, and proactively engaging
sions in the middle of the day (sometimes during in problem solving as needed is often crucial.
lunch breaks) and saved time and money on Being flexible about the structure of therapy ses-
transportation to our offices. By offering a vPHP, sions can also be helpful (i.e., shorter sessions,
we were able to expand our outreach, reduce our taking breaks, turning cameras off briefly, watch-
waitlists for services, and provide treatment and ing a video together, and playing a game).
structure for a sensitive population of children While we were able to reach more clients
and teenagers who, in many cases, were no lon- through our transition to telehealth and our vPHP,
ger permitted to attend school in person or social- we were also aware that some individuals and
ize with their peers. During this transition to families did not have the luxury of access to high
virtual services, we noticed anecdotal evidence speed Internet connections, computers or smart
of reductions in client no shows to therapy and devices, or the privacy necessary to engage in
clients more consistently being on time for treatment. It is necessary to be aware of relevant
sessions. cultural, technological, financial, and educational
Another unexpected benefit of utilizing tele- factors that may inhibit youth and families from
health was gaining greater access to clients’ lives accessing evidence-based care. One highly valu-
and their home environments. Much of this infor- able lesson learned for our practice in the transi-
432 M. Bar-Halpern et al.

tion to virtual services that we continue to explore In sum, COVID-19 has frequently been a
was how to improve our ability to reach any fam- humbling experience on multiple levels and has
ily in need, regardless of the limiting factors at taught all of us the importance of adaptation and
play. We recently created an internal task force flexibility. The mental health field has been fortu-
dedicated to this mission, which has been helpful nate to continue providing care via telemedicine,
in problem solving specific situations and and it seems that telemedicine is rapidly growing
reminding staff of the importance of ensuring as a primary resource for delivering care.
telehealth equity. Telehealth has been essential in eliminating geo-
An important area that should be the focus of graphic and logistical barriers to treatment, pro-
future programs and governing bodies is how to vides opportunities for live coaching in the very
become more efficient, effective, and practical environment that problems are commonly occur-
in the context of telehealth laws and telehealth ring, and offers flexibility in many other unex-
etiquette. It will be helpful to have clear recom- pected areas. While there are many benefits
mendations and flexible regulations regarding associated with telehealth and telemedicine, it is
telehealth services for mental and behavioral also necessary to take into consideration the
health, especially across state lines. In our work importance of adhering to evidence-based treat-
with teens and young adults, many of whom ment, factors such as therapists’ “burn-out,” and
travel out of their home states to attend schools research supported strategies for continued adap-
and colleges or live with various family mem- tations that can occur quickly and flexibly.
bers, it has been cumbersome, confusing, and at Ongoing research to assess the efficacy, effec-
times damaging to the therapeutic relationship tiveness, and best practices for the dissemination
with clients and their treatment goals due to of various virtual programming (such as virtual
unclear, incomplete, or inflexible licensing laws PHPs) in comparison to delivering interventions
and guidelines. We encourage all providers who in-person will be crucial for the future.
engage in telehealth services to make every
effort to stay up-to-date with the rapid changes
in the regulation of telehealth and to maintain References
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clinic-based CBT for adolescent anxiety. Journal of
 Inpatient Psychiatric
Hospitalization 24
Alysha D. Thompson, Kyrill Gurtovenko,
Connor Gallik, McKenna Parnes, Kashi Arora,
and Ravi Ramasamy

Inpatient psychiatric hospitalization (IPH) is an chiatrists, clinical psychologists, social workers

essential part of the mental health continuum of and/or case managers, and milieu support staff.
care. In this chapter, we briefly review the role, Additionally, some inpatient units may also
scope, and characteristics of IPH. We then dis- include music therapists, art therapists, occupa-
cuss where it falls in the continuum of care and tional therapists, dieticians, educators, yoga
how it interfaces with other levels of care such as instructors, therapy animals, and additional sup-
outpatient, intensive outpatient programs (IOP), port services in their unit programming.
partial hospitalization programs, (PHP), and resi- Youth IPUs may vary based on age and scope
dential treatment programs. We provide guide- of patients served. However, across psychiatric
lines, principles, and recommendations for future inpatient programs, inpatient care is most typi-
work to improve the continuum of care through- cally utilized by youth in crisis. Common youth
out our discussion of these topics. crises leading to IPH include: high levels of sui-
cidality and suicidal intent, suicide attempts, self-­
injury, severe instances of aggressive behavior,
Inpatient Psychiatric and grave disability due to mental illness (Hayes
Hospitalization: What Does Care et al., 2018). Additionally, inpatient psychiatric
Look Like? programs see high levels of trauma in their patient
populations (Darnell et al., 2019). Recent data
Care on inpatient psychiatric units (IPUs) varies demonstrates high levels of youth presenting for
across programs but typically includes an inter- emergency psychiatric care for suicidality and
disciplinary approach consisting of nurses, psy- self-harm. Approximately 25% of patients evalu-
ated in pediatric psychiatric emergency depart-
ments and 50% of patients who are psychiatrically
A. D. Thompson (*) · K. Gurtovenko · M. Parnes · admitted present with suicidality (Dobson et al.,
R. Ramasamy
Seattle Children’s Hospital, Department of Psychiatry 2017; Adrian et al., 2019). In terms of self-harm,
and Behavioral Medicine, Seattle, WA, USA over 60% of adolescents who are psychiatrically
University of Washington, Department of Psychiatry admitted have engaged in nonsuicidal self-injury
and Behavioral Sciences, Seattle, WA, USA (Dobson et al., 2017; Adrian et al., 2019).
e-mail: [email protected] Aggression is a common reason for inpatient psy-
C. Gallik · K. Arora chiatric hospitalization among younger children,
Seattle Children’s Hospital, Department of Psychiatry with almost two-thirds of referrals for ­children
and Behavioral Medicine, Seattle, WA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 435
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_24
436 A. D. Thompson et al.

under age 12 being related to aggression (Pikard sis, teaching skills to manage safety issues, and
et al., 2018). In addition, an estimated 33% of safety planning prior to discharge. In addition,
youth demonstrate aggressive behavior while hos- this model identifies ways to provide support
pitalized (Dutch & Patil, 2019), and there is a sub- across those three domains: providing support to
set of adolescents experiencing suicidal ideation the youth as they stabilize the acute crisis, sup-
coupled with high levels of aggressive behaviors porting skill development regarding safety and
(Buitron et al., 2018). Lastly, youth presenting for regarding the underlying mental health concerns,
inpatient psychiatric treatment are more likely and identifying necessary supports for a safe dis-
than youth presenting for outpatient psychiatry or charge plan. Use of this model on IPUs can help
medical treatment to experience trauma and have guide clinical teams in decision making regard-
a higher number of trauma exposures (Darnell ing treatment planning while on the unit and at
et al., 2019). Some studies have found up to 96% discharge planning.
of youth on IPUs have experienced a traumatic IPUs typically utilize a milieu-based treat-
event, with one in three meeting criteria for post- ment approach. More specifically, while there
traumatic stress disorder (Havens et al., 2012; may be some individualized services (e.g., indi-
Allwood et al., 2008). Thus, it is reasonable to vidual and family therapy and medication man-
conclude that for most youth admitted to IPUs, an agement), treatment generally focuses on
acute mental health crisis involves some combina- providing a safe environment where there is
tion of suicidality, self-injury, aggressive behav- reduced access to means of harm and high levels
ior, mania, or psychosis driven by a host of of supervision. IPUs typically have a daily struc-
vulnerability factors that may be a result of expo- ture and schedule with a focus on group-based
sure to trauma and significant stress. Youth served programming.
on IPUs are among those with the most serious
mental illness, seen at their most acute periods of
illness. The need for IPH is indicated when such Inpatient Psychiatric
acute crisis events cannot be safely or adequately Hospitalization and Evidence-Based
managed by lower and less restrictive levels of Psychotherapies
mental health care.
IPUs average length of stay (LOS) is approxi- According to youth who experienced IPH, the
mately 1–2 weeks, with LOS becoming increas- most helpful aspects of hospitalization were
ingly shorter over the past two decades due to the interpersonal support from peers and staff, learn-
movement away from institutionalization and ing cognitive and behavioral coping strategies,
toward more community-based care, like PHP and group therapy (Moses, 2011). Given the
and IOP programs (Glick et al., 2011). The result diverse, acute, and complex diagnostic presenta-
of this movement is an increasing focus on stabi- tion of patients needing higher levels of pediatric
lization of the acute crisis and connection to out- mental health care, it is not surprising that there is
patient or day-treatment services. Factors such as no one single psychotherapy or psychosocial
LOS and readmission rates are likely signifi- intervention that is considered best practice for
cantly influenced by accessibility of adequate inpatient psychiatric hospitalization. Historically,
levels of psychiatric and mental health supports IPH, residential, PHP, and IOP interventions
in the community (Zhang et al., 2011). have utilized a variety of theoretical approaches
To address the need for quick stabilization and and therapeutic strategies to address concerns
treatment of youth on IPUs, Calhoun et al. (2022) during IPH. The typically short LOS calls for
outline the 5S model of inpatient psychiatric brief, flexible, and targeted psychotherapy inter-
care: safety, support, stabilization, skills, and ventions. In many cases, such interventions are
send-Off. In this model, IPUs are encouraged to adaptations of evidence-based psychotherapies
identify ways to improve safety both on the IPU that have been primarily studied in an outpatient
and at home through stabilization of the acute cri- context.
24 Inpatient Psychiatric Hospitalization 437

Several evidence-based psychotherapy A wide variety of other psychosocial interven-

approaches are common and useful within these tions are common and useful during IPH, includ-
higher levels of care. Cognitive behavioral ther- ing but not limited to behavioral modification
apy (CBT), one of the most well-supported treat- approaches, positive behavior supports (PBS),
ments for a variety of mental health problems in collaborative problem solving, family and sys-
youth like depressive and anxiety disorders (Curry temic therapies, and psychodynamic approaches
& Meyer, 2019; Palitz et al., 2019), is one (Calhoun et al., 2022). With such a rich and
approach utilized within IPH. CBT can be deliv- diverse landscape of interventions to choose from
ered as a modular transdiagnostic treatment and and limited research on which interventions are
used to address a range of comorbid symptoms most appropriate and effective for which youth in
and underlying transdiagnostic issues at once higher levels of care, deciding how to select and
(García-Escalera et al., 2016). Treatment modules maximize the effects of treatments during IPH is
common across a range of CBT-based interven- a challenge. There are several guiding principles
tions for youth include psychoeducation, safety we recommend considering when choosing
planning, mood monitoring, behavioral activa- evidence-­based interventions for youth across the
tion, problem solving, cognitive restructuring, continuum of higher levels of care.
and relapse prevention (Curry & Meyer, 2019). First, we recommend that intervention selec-
The empirical evidence based on CBT for IPH tion should always be preceded and guided by
pediatric mental health care is growing, and stud- evidence-based assessment and case conceptual-
ies show that CBT interventions can help decrease ization (see Thomassin & Hunsley, 2019). The
mental health symptoms and school absenteeism best efforts to intervene are bound to fail if the
(Walter et al., 2010), self-harm and suicidality clinical team has not adequately assessed and
(Sinyor et al., 2020), and readmission rates to understood the patient’s care needs. Following
inpatient psychiatric units (Wolff et al., 2018). assessment and case conceptualization, it’s
Dialectical behavior therapy (DBT) is a important to consider which treatment targets are
cognitive-­behavioral principle-driven treatment most proximal or relevant to what prompted and/
that flexibly integrates a variety of change and or is maintaining the need for a more restrictive
acceptance-based strategies to effectively man- treatment setting. For example, if a suicide
age and treat patients with complex clinical con- attempt prompted hospitalization, suicide-­
cerns (Ritschel et al., 2015). DBT contains focused interventions, which identify and address
specific skills training modules that can be flexi- drivers of suicidality, should be prioritized. These
bly taught in individual or group formats; many interventions should aim to increase the patient’s
DBT skills represent essential tasks and treat- safety and ability to utilize lower levels of mental
ment goals for inpatient youth (e.g., learning health supports (e.g., outpatient care), thus miti-
strategies to tolerate intense distress without gating the risk of further crises that could require
making the situation worse and practicing skills rehospitalization. If a patient reaches IPH because
for decreasing vulnerability to painful emotions). the caregivers themselves go into crisis during
Although DBT was originally developed as an periods of intense family conflict, thereby losing
outpatient treatment, there is growing evidence the ability to maintain safety and stability at
for its effectiveness in IPH settings for adoles- home, family-based interventions and case man-
cents (Katz et al., 2004; McDonell et al., 2010). agement efforts to provide additional supports for
Studies to date have found that DBT supports the caregivers may be a high priority. The clinical
better treatment retention and fewer behavioral team should also work to identify which treat-
incidents during IPH (Katz et al., 2004), reduces ment targets or clinical problems need to be
nonsuicidal self-injury (NSSI) and improves addressed for the patient to be able to s­ uccessfully
functioning (McDonell et al., 2010), and leads to step down in the continuum of care. For example,
fewer restraints and less days hospitalized if the youth is reporting hopelessness and a lack
(Tebbett-Mock et al., 2020). of motivation to engage in outpatient treatment,
438 A. D. Thompson et al.

such “treatment interfering” behaviors can be or unable to create a safety plan. Additionally,
actively targeted using techniques such as moti- IPH services may be utilized in cases where a
vational interviewing (Harder, 2018) or DBT patient’s outpatient treatment team does not feel
commitment strategies (Ben-Porath, 2004). confident in the patient’s or family’s ability to use
Another principle for selecting interventions for a safety plan.
youth in IPH is to consider the most appropriate
scope given the setting and how specific interven-
tions factor into continuity of care. Treatment  HP and IOP’s Role in the Mental
P
providers should generally aim to utilize inter- Health Continuum of Care
ventions that can be delivered as brief standalone
packages capable of being completed before dis- PHPs and IOPs are an important part of the con-
charge from the IPU or choose interventions that tinuum of mental health care, especially as a
have a high likelihood of being successfully step-up from outpatient care and step-down from
handed off to the next treatment team and contin- inpatient care. Youth are at notable risk for sui-
ued at the next stage of care. For example, teach- cidal behaviors and IPH readmission immedi-
ing discrete distress tolerance skills and ately after discharge from IPUs (Ilgen et al.,
completing a safety plan for managing future cri- 2008; Olfson et al., 2016), highlighting a critical
ses can be readily handed off, summarized, and need for continuity of care (Cheng et al., 2017;
generalized to the next stage of care. On the other Ilgen et al., 2008). Step-down services, including
hand, beginning exposure-based treatment for PHP and IOP, offer an intermediate level of care,
PTSD for a patient with an extensive trauma his- which provide more intensive support than rou-
tory, when the patient may or may not have access tine outpatient services in a less restrictive envi-
to a provider who can continue and complete this ronment than inpatient care. PHPs are often
work postdischarge, may not be particularly structured to offer scheduled activities through-
helpful or effective (even though treatment for out the day (e.g., individual therapy, group ther-
PTSD in this case is indicated in the long run). apy, family therapy, milieu therapy, and academic
Although these principles may seem obvious, we programming) and utilize an interdisciplinary
believe they can offer a helpful starting place for approach. Care teams typically involve nurses,
ways to consider how to maximize the effective- psychologists, mental health therapists, psychia-
ness of therapeutic interventions during IPH. trists, case managers, educators, and rehabilita-
tion specialists to support stabilization and
facilitate recovery following IPH discharge
Inpatient Psychiatric (Durbin et al., 2016; Khawaja & Westermeyer,
Hospitalization’s Role in the Mental 2010). The comprehensive intensive treatment
Health Continuum of Care approach can support youth in developing and
practicing coping skills, as well as reintegrating
IPH occupies a unique position in the mental back into their community and family system. In
health continuum of care. It is a high intensity addition to supporting transitions from IPH, IOPs
service provided during the height of severity or and PHPs can also decrease LOS and/or help
acuity of an individual’s mental illness (see youth avoid hospitalization, providing a more
Fig. 24.1). There are several less-intensive ser- cost-effective and efficient alternative (Khawaja
vices that are ideally accessed prior to IPH, such & Westermeyer, 2010); they have been shown to
as integrated mental/behavioral health in primary elicit stronger behavioral outcomes when com-
care settings, routine outpatient services, and pared to outpatient treatment (e.g., Kennair et al.,
intermediate levels of care such as IOP and PHP. 2011). While the supervised and structured
However, IPH remains a necessary level of care ­setting of the IPH is specially designed to mini-
in cases where youth are at imminent risk of mize acute safety risk, it may not ensure that a
harming themselves or others and are unwilling patient/family will be able to maintain safety
24 Inpatient Psychiatric Hospitalization 439

Fig. 24.1 Mental health continuum of care. (Figure design adapted from ideas of consultation group SG2)

upon discharge home. PHPs can provide a similar of pediatric psychiatric care is critical for sup-
level of supervision and structure as an IPU for a porting youth mental health in the long term.
significant portion of each day, reducing the time There is no “one-size-fits-all” when it comes to
a patient/family must maintain safety at home; youth mental health needs, and IPH, residential
they can also provide daily support for problem treatment facilities, IOP, PHP, and outpatient
solving when adapting safety and crisis plans or treatment each have their own strengths, draw-
utilizing positive coping strategies. backs, and scopes of practice. Matching patients
to the proper level of care based on their clinical
needs is essential to maximizing the efficiency
 HP and IOP as Step-Down Services
P and effectiveness of pediatric mental health care
from Inpatient Psychiatric Care systems.
There are several important considerations
One of the best predictors of positive outcomes when deciding if PHP/IOP is the appropriate next
following IPH admission for youth is timely con- step for a patient following discharge from an
nection to services following discharge (Chen inpatient unit, which potentially include the
et al., 2020; Cheng et al., 2017; Fontanella et al., following:
2010; Fontanella et al., 2020). In addition, we
assert the importance not only of timely connec- • What is the current risk of suicide or
tion to services but connection to the appropriate self-harm?
level of care. For example, a patient may no lon- • What level of supervision and support is nec-
ger need the level of care of an IPU but may still essary to minimize that risk for the patient?
be underserved by routine outpatient services. In • What levels of supervision and support are
the absence of adequate levels of intermediate available at home? Will the patient have long
support (e.g., IOP or PHP), the patient, family, stretches of alone or unsupervised time?
and treatment team may be left to choose between • If aggression is a problem behavior, is there a
two less-than-ideal levels of care. A patient’s PHP/IOP that can manage and contain those
LOS may be unhelpfully prolonged at a more types of behaviors?
restrictive level of care merely because it was the • Is the patient/family able to commit to
safest of two less than ideal options. Thus, access PHP/IOP? Commitment includes but is not
to and coordination between the full continuum limited to: time, ability to provide transporta-
440 A. D. Thompson et al.

tion to and from, and engagement in treatment need, level of aggression, intellectual ability, and
as examples. development level). In addition, given a finite
• Does the patient/family need services to begin number of inpatient beds, some youth may have
immediately following discharge? to board in emergency departments while await-
• Is the patient likely to decompensate by ing an opening on an inpatient unit (Hazen &
returning to routine outpatient services and Prager, 2017).
present an elevated risk of rapid readmission Another dilemma associated with stepping up
to an IPU? in level of care is the limited research to guide
• Is there availability for admission in a specifically what types of patients benefit in step-
PHP/IOP or is there availability for admission ping up in care and under what conditions. While
soon? increasing immediate safety and levels of support
• Can a PHP/IOP admission reduce a patient’s may be an obvious short-term benefit, there is
LOS on an IPU? debate about the long-term therapeutic impact of
• Is there another resource or type of care that chronic reliance on higher levels of care. For
may be a more appropriate clinical fit for this example, some therapeutic approaches such as
patient and family? DBT generally hold a bias against the use of cri-
sis services and hospitalization to manage acute
periods of risk (Coyle et al., 2018). Hospitalization
 tepping Up to Inpatient Psychiatric
S and more restrictive treatment settings can tem-
Hospitalization from PHP or IOP porarily relieve stressful environmental demands
for youth (e.g., a break from schoolwork, family
While PHP and IOP programs often serve as a conflict, and peer stress), thereby inadvertently
step down in care following IPH, there also may negatively reinforcing suicidality or other crisis
be cases where PHPs or IOPs are not the appro- behaviors and symptoms. More restrictive levels
priate level of care and a patient needs to step up of care may also prevent the learning and gener-
the intensity of their services to inpatient psychi- alization of coping skills to the patient’s natural
atric care. In many areas, patients are evaluated in environments, arguably the place where they
emergency departments to determine if they need most need to be learned and practiced to mitigate
an inpatient level of care. Typically, patients are future crises (Coyle et al., 2018; Paris, 2004). In
not able to be directly admitted from their PHP or addition, prolonged periods of full or partial hos-
IOP to an IPU. When considering if a patient in a pitalization can exacerbate stigma, social isola-
PHP or IOP should step up to IPH, PHP and IOP tion, academic delays, and family financial stress,
teams should first create a safety plan with the which can have significant negative impacts on a
patient. Additionally, some patients may not be youth’s longer-term quality of life (Edwards
appropriate for IPH, such as cases where IPH is et al., 2015; Jones et al., 2021). This dilemma of
reinforcing to suicidality. Notably, even for cases balancing short-term acute care needs with con-
of severe crisis when safety planning within the siderations of potentially negative long-term con-
PHP or IOP team has been unsuccessful and a sequences following hospitalization presents a
decision to pursue IPH has been made, inpatient particular challenge when deciding who needs
admission is not a guarantee. Admission to an step up care and when. On the other hand, when
IPU is determined by patients’ level of risk, outpatient services are not enough given the acu-
assessed by a mental health evaluation team in ity and severity of a patient’s mental illness, step-
the emergency department and the mental health ping up from outpatient to an IOP can provide
evaluation team may not find cause to admit a increased support and dose of intervention while
patient at the time of evaluation. The IPU team avoiding the potential pitfalls of full inpatient
may also have criteria regarding which patients hospitalization. Such effective intermediate
are clinically appropriate for the specific IPU options are only possible when treatment is read-
treatment milieu (e.g., level of mental health ily available at all levels of care along the care
24 Inpatient Psychiatric Hospitalization 441

continuum. More research is needed to better inpatient care. Consideration of the patient’s
identify which youth benefit most from step ups home environment is critical; a PHP or IOP may
in care, and under what conditions, to improve feel confident about their own ability to manage a
and maximize the effectiveness of mental health highly distressed patient in program but feel less
care systems. confident about the type of supervision and sup-
port the patient is receiving at home.

PHP and IOP as Prevention of IPH

Access to PHPs and IOPs from IPH
In addition to being an option to step-down from
IPUs, PHP and IOP can also be utilized to pre-  ow Inpatient Teams Decide About
H
vent IPH. A recent position statement from the PHP and IOP
American Psychiatric Association has noted that
most states have less than half the inpatient beds When inpatient treatment teams engage in dis-
needed to address serious mental illness in youth position planning and consider the most suitable
(Krishna et al., 2016). Since patients must first be option for aftercare following hospitalization,
assessed for medical need in the emergency they must consider diagnosis, acuity, safety risk,
department (ED) prior to IPH admission, there is and availability of appropriate services. In some
an increase demand on these ED services that instances, there are outpatient programs
impact staff and room availability for medical designed for psychiatric illnesses that require
emergencies (Hazen & Prager, 2017). specialized treatment, (i.e., eating disorders and
Additionally, a lack of IPH bed availability can obsessive-­compulsive disorder). For most hos-
prolong a patient’s stay in the ED as they await pitalized patients who present with some combi-
disposition planning and transfer to an IPU. As a nation of imminent risk of harm to self and/or
result, a lack of available IPH beds has led to others, the chronicity and acuity of safety risk
increased wait times in EDs for psychiatric and often drives this decision. Involved in this risk
medical emergencies. Additionally, lack of IPU assessment are the patient’s presentation on the
beds leads to patients boarding in emergency IPU and hospital course, willingness and ability
departments and medical beds while awaiting of the patient and family to engage in treatment,
admission (Claudius et al., 2014). Claudius et al. availability of adequate supervision outside the
(2014) also noted that during the time patients hospital, past treatment course and outcomes,
were boarding in pediatric EDs and medical beds, and the current safety risk of the patient at time
they were receiving suboptimal psychiatric care. of discharge. Patients who are especially suit-
PHPs and IOPs may be able to divert youth from able for admission to a PHP or IOP following
inpatient care, easing pressure on IPUs and IPH discharge include youth who continue to
reducing boarding time in EDs and on medical have passive suicidal a­ nd/or homicidal ideation,
floors. Some research has supported intensive need more intensive monitoring and treatment
community services, such as PHPs and IOPs, as than an outpatient level of care, and who can
potentially effective alternatives to IPH for chil- participate in milieu groups that are part of most
dren and adolescents (Kwok et al., 2016). PHPs and IOPs. Though some specific programs
PHP and IOP teams may be able to provide may not rely on milieu group-based program-
appropriate support to highly distressed youth in ming, many PHPs and IOPs do, and therefore a
their programs without needing to escalate to youth who is unable to participate in milieu
inpatient care. When working with patients who groups may not be appropriate for these treat-
have intense behaviors, PHP and IOP teams ment programs.
should consider what support and safety planning In addition to considering if a patient needs a
is needed for them to feel confident they can higher level of care than outpatient (thus leading
manage a patient safely without needing to access to a decision regarding PHP or IOP level of
442 A. D. Thompson et al.

care), inpatient teams must also consider if a Coordination of care may also help reduce
patient’s presentation is too severe and chronic length of stay on the IPU. If the IPU can coordi-
to be managed in PHP or IOP settings and if nate with the PHP or IOP for a patient’s treatment
residential treatment is necessary. Unfortunately, placement to be held, the IPH stay can be brief
there is limited research or guidelines to help and focus on stabilizing the patient’s crisis before
teams make these treatment decisions and rec- discharging them back to the PHP or IOP. This is
ommendations. Typically, youth who are important as treatment may be more effective
referred to residential treatment programs have when the patient is residing at home and able to
“failed out” of lower levels of care, such as out- practice and apply the skills learned in treatment
patient, PHPs, or IOPs and continue to need to their everyday environment. Finally, for some
24-hour supervision provided by the inpatient patients, IPUs may be reinforcing of problematic
unit. behaviors, and some youth may experience a
contagion effect by being around others exhibit-
ing problematic behaviors (Jarvi et al., 2013).
 oordination of Care Between PHP
C Coordination with the PHP or IOP to hold the
and IOP and IPUs youth’s treatment placement for return as soon as
possible limits the amount of reinforcement for a
Youth may access PHPs or IOPs as a diversion problematic behavior and potential contagion
from needing inpatient care or following dis- effects of an IPU.
charge from an IPH. As such, coordination For youth stepping down from inpatient
between PHPs and IOPs and IPUs can play a care, care coordination between IPUs and
critical role in maximizing mental health treat- PHPs and IOPs can improve timely access to
ment for youth. services. Many youth discharging from IPUs
For youth who need to step up to inpatient still need a higher level of care than routine
care, coordination between PHPs and IOPs and outpatient services. PHPs and IOPs are the
the IPU may facilitate the exchange of useful ideal level of care for many youth discharging
information for inpatient care. For example, pro- from IPUs; however, there is a need for imme-
viders in the PHP or IOP are likely aware of a diate access to these services. Coordination
patient’s unique emotional and behavioral trig- between IPUs and PHPs and IOPs can help
gers for behaviors that might present as problem- facilitate this care transition and improve the
atic in the IPU milieu, such as self-harm or time it takes for families to connect with inten-
aggression, which may be useful for providers sive services outside of the inpatient environ-
and staff on the IPU to know. Additionally, a ment. Research has demonstrated that timely
patient may have been practicing specific skills in connection to outpatient services post-IPH dis-
the PHP or IOP that were useful, and making charge is associated with better outcomes
inpatient staff aware of this information may help (Fontanella et al., 2020). Ideally, a patient
in de-escalating crisis situations related to the would discharge from the IPU and start treat-
patient while on the IPU. Through a family sys- ment in a PHP or IOP the same day or the fol-
tems lens, understanding family engagement in lowing day, to minimize length of time between
treatment, including caregiver attendance in ser- transitions and ensure that patients connect to
vices and groups offered by PHPs and IOPs, par- care as timely follow-­up of care is associated
ticipation in family therapy, and caregiver with reduced readmission rates (Fontanella
follow-through in implementing therapeutic rec- et al., 2020). However, barriers such as lack of
ommendations at home, may be valuable infor- insurance coverage for two levels of care on
mation to contextualize youth behavior and the same day, access to a PHP or IOP in the
inform approaches to including caregivers in area, resources required to attend such a pro-
treatment while on an IPU (e.g., Foster et al., gram (transportation, time off work, etc.), and
2021). availability of an open spot in such a program
24 Inpatient Psychiatric Hospitalization 443

to facilitate timely services can impact the Limitations to Access

immediacy of transition from IPU to a PHP or
IOP. Following discharge, inpatient teams One significant challenge for child and adoles-
should coordinate with PHP/IOP teams by pro- cent IPU teams is the lack of appropriate options
viding clinical hand-off including by not lim- for discharge. This can vary dramatically by
ited to: patient’s level of acuity, region. States in which Medicaid does not cover
conceptualization regarding their presentation, PHPs or IOPs have fewer programs, therefore
helpful coping strategies patient has been further limiting access to these services. In these
using, medications started or changed, and instances, IPU teams need to be creative to find
safety plan created with the patient and family appropriate step-down options and are often
on the inpatient unit. forced to discharge patients to inadequate levels
of care. In fact, treatment factors such as type of
aftercare following inpatient admission is one of
 hallenges with Discharging to PHP
C the strongest predictors of readmission rates for
or IOP from the IPU youth who have been psychiatrically hospital-
ized, suggesting the need for careful discharge
PHPs and IOPs present several logistical chal- planning (Fontanella, 2008). A comparison by
lenges for some families. These programs typi- these authors of the states who have better access
cally involve a substantial time commitment. to mental health treatment (Reinert et al., 2021)
Caregivers may have to take time away from with the suicide rate for teens per 100,000 youth
work and other children in the home for drop (America’s Health Rankings, 2021) indicates that
offs, pickups, family meetings, and meetings there is significant overlap between those states
with providers. This may be prohibitive for some with poor access to mental health treatment and
families. Additionally, in the United States, an increase in suicide rate.
access to PHPs and IOPs is often dependent on In states where access is easier, given better
the state a family lives in. Not all states currently coverage by insurance providers in combination
reimburse for PHPs or IOPs through Medicaid, with the presence of more PHPs and IOPs, it is
which limits access to care in ways that dispro- possible to discharge from the IPU directly to
portionately impact Black, Indigenous, and peo- PHP or IOP the same day. However, in many
ple of color (BIPOC) youth and families with low cases, such as when there are far fewer PHP or
socioeconomic status (SES). However, lack of IOP treatment slots compared to inpatient beds
Medicaid funding may also inhibit the develop- (thus unable to meet the need), PHP and IOP
ment of PHPs and IOPs in these states, contribut- waitlists are often weeks to months long, requir-
ing to inadequate access. Many states do not ing patients to wait for one of these treatment
currently have enough PHPs or IOPs to meet the slots while receiving no or subclinical levels of
need for this level of care. Given that PHPs and care. We argue that this likely impacts the effi-
IOPs may function as a step before and/or a step cacy of these programs as we believe that they
after IPH and they tend to be longer programs would be more effective at preventing suicide and
(2–3 week LOS compared to about 1 week on treating mental illness if these programs were
IPH), more PHP and IOP treatment options than immediately accessible when a youth is in crisis
IPU beds are needed. However, many states do or stepping down from the IPU. Having to wait to
not have the mental health infrastructure to be receive a lower level of care than what is needed
able to accommodate this. As a result, there may based on the individual’s mental health symptom
be a wait time for PHP and IOP following inpa- acuity likely leads to worsening mental health
tient care, which can lead to increased risk during symptoms and potential safety issues, such as
the critical time period postdischarge (Fontanella increases in self-injurious behaviors, suicide
et al., 2020). attempts, and ultimately deaths by suicide.
444 A. D. Thompson et al.

When appropriate levels of step-down ser- ing death due to the complexity and acuity of the
vices are not available within the metal health patient’s mental health symptoms.
care continuum in a given community, youth may
be at risk of decompensating during their IPH
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 The Youth Crisis Stabilization Unit:
An Alternative Psychiatric 25
Treatment Model

Joyce T. Chen, Ericka Bruns, Zachary Schellhause,

Chanta Garcia, and Mary A. Fristad

Program Overview occurs. This has created a need for additional

options to provide short-term crisis intervention
The number of adolescents aged 12–17 in the and stabilization in a secure setting.
United States who died from suicide doubled The Youth Crisis Stabilization Unit (YCSU) is
from 2003 to 2018 (https://www.cdc.gov/injury/ a unique setting that offers an interprofessional
wisqars/LeadingCauses.html). For youth at high program model to treat youth in crisis, especially
risk of suicide, inpatient psychiatric hospitaliza- those with high suicide lethality or psychiatric
tion has been recommended when safety in the decompensation, who might otherwise be hospi-
community is unable to be maintained (Shain talized on a traditional inpatient psychiatric unit
et al., 2016). However, access to these services (IPU). The YCSU treatment model focuses on
has decreased over the last several decades as the intensive individual and family work, using cog-
availability of inpatient psychiatric beds for ado- nitive behavioral therapy (CBT) as the founda-
lescents has steadily declined (Geller & Biebel, tional concept. A key feature of the YCSU is the
2006). Against this backdrop, inpatient admis- absence of a milieu and group treatment, which is
sions for suicidal behavior and intentional self-­ a novel approach to psychiatric treatment of hos-
injury among youth have more than doubled pitalized youth. The YCSU is geared toward
between 2006 and 2015 (Torio et al., 2015; treating patients whose parents are willing to par-
Plemmons et al., 2018). With increased wait ticipate in daily family sessions. (Note that “par-
times caused by the bottleneck of supply and ents” in this chapter will be used interchangeably
demand, the crisis has often long since passed, with “family” or “caregiver” to denote the pri-
and the individual may be less motivated to mary caregiver/legal guardian.) Most patients
engage in treatment by the time an admission admitted to this unit are discharged home within
3–4 days.
The YCSU began as a hospital-based, grant-­
J. T. Chen · M. A. Fristad (*)
Nationwide Children’s Hospital Big Lots Behavioral funded program in response to the limited
Health Services, Columbus, OH, USA resources available for youth and families need-
The Ohio State University, Department of Psychiatry ing mental health treatment. The original intent
and Behavioral Health, Columbus, OH, USA was for therapists to provide brief crisis counsel-
e-mail: [email protected] ing to youth presenting to the emergency depart-
E. Bruns · Z. Schellhause · C. Garcia ment (ED) following a psychiatric crisis. The
Nationwide Children’s Hospital Big Lots Behavioral goal was to avert psychiatric hospitalization for
Health Services, Columbus, OH, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 447
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_25
448 J. T. Chen et al.

those who were able to successfully safety plan who agree to participate in treatment, are admit-
and be discharged home. Over the past ten-plus ted voluntarily, and are physically and psycho-
years, a short-term stay unit was established and logically able to tolerate being in single rooms
has evolved to treat youth with a wide array of for the duration of their hospitalization. This
psychiatric situations and psychopathology. leads to a natural exclusion of patients with
Presently, the YCSU is a 16-bed unit. Its treat- extreme dysregulation or hyperactivity that
ment team includes child and adolescent psychia- would otherwise impair their ability to partici-
trists, nurses, master’s level clinical therapists, pate in individualized therapy. As such, patients
bachelor’s level mental health specialists, and under 8 years old are not usually admitted.
therapeutic recreational therapists, with access to Likewise, patients who are cognitively impaired
medical services provided by hospital pediatrics or psychotic to the extent that they would be
and subspecialty consultation services. Parent unlikely to benefit from therapy over a few days
advocates, who are familiar with the mental would not be an appropriate referral. The pro-
health system through lived experiences with gram accepts patients through age 18, though
their own child(ren), are available to provide exceptions have been made for older youth on an
nonclinical support to parents. individual case basis.

Population Served Average Length of Stay

The YCSU specifically treats youth with active The average length of stay is 3–4 days. This
safety concerns, recent suicide attempts, and/or shorter hospital length enables a higher frequency
acute psychiatric decompensation. Most patients of discharges over time and thus improved access
present with some form of self-harm or suicide to care.
attempt in the context of a recent crisis or deterio-
ration in their mental health and typically meet
the criteria for hospitalization on a traditional  riteria to Move to Higher/Lower
C
IPU. A key decision when referring a patient to Levels of Care
the YCSU versus an IPU is the family’s motiva-
tion to participate in daily family therapy. While Most YCSU patients (over 90%) are discharged
in-person sessions are strongly preferred, the home to their parents (Otterson et al., 2021).
COVID-19 pandemic has made telehealth more Occasionally, patients are taken into custody of
readily available and familiar to therapists and Children Protective Services or transferred to an
families. The patient’s willingness to engage and IPU. In the latter situation, these are patients not
waitlist times are secondary factors. A recent engaging sufficiently to show progress and may
comparison of patients who presented to our psy- actually benefit from having peer interactions in
chiatric crisis department for a primary psychiat- the context of a milieu. Direct residential place-
ric concern and were eligible for admission to ment is atypical.
both our YCSU and IPU indicated no clinical or
demographic differences between those ulti-
mately admitted to the two different settings Diversity Considerations
(Otterson et al., 2021).
Patient diversity reflects community demograph-
ics and diagnostic gender distributions. Based on
Admission/Exclusion Criteria a review by the first author of all admissions from
March 2020, when the unit moved into our new
Patients eligible for admission are children or psychiatric facility, until November 2021, we
adolescents who are school-aged, have parents treat a predominantly female population (79%);
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 449

85% are aged 13–17. European Americans con- pital beds awaiting psychiatric consultation,
stitute a majority of patients (71%), with African while one-third were transferred to outside psy-
Americans being the second largest group (13%) chiatric facilities, as our hospital did not have an
and multiracial the third largest (7%). Hispanic/ IPU at that time.
Latinx youth comprise 5% of our patients, 3% Patients who were awaiting consultation were
identify as Asian, Hispanic, Native Hawaiian or scattered throughout the hospital, wherever there
Other Pacific Islander, American Indian/Alaska was an available bed. Disruptive patients (e.g.,
Native, or other, and 1% did not provide this exhibiting aggressive behavior or trying to leave
information. the room) led to a highly tense atmosphere on
Upon admission, patients are asked about medical units for staff not accustomed to working
their preferred name and pronoun choice. Many with this population. It also created an uncom-
patients identify differently than their genotypic fortable and sometimes precarious experience for
gender, and it is important to YCSU culture that other patients, due to the noise and presence of
all patients feel welcomed and safe on the unit. At protective services staff for additional safety. It
times, parents do not know about their child’s led to frustration for families who were seeking
gender or sexual preference(s), which adds a treatment for their medically ill child and want-
layer of complexity to the clinical case formula- ing a calm environment. In response to these con-
tion and treatment. cerns, the hospital designated a specific medical
Most YCSU patients speak English fluently. unit where boarders who were awaiting further
When English is not the preferred language, psychiatric consultation could co-locate and be
whether for the patient or parents, interpreter ser- more centralized while boarding. This allowed
vices are available in person, by telehealth and by for nurses working on this unit to receive addi-
phone. The COVID-19 pandemic decreased tional training on verbal de-escalation strategies
availability of in-person interpreters resulting in and to become more adept at working with youth
greater use of telehealth interpreter services. in psychiatric crisis. This was a helpful strategy
YCSU staff are educated to approach patients for providing better care to our patients and in
and families in a culturally sensitive manner. All mitigating potential behavioral escalations. This
staff, upon being hired into the service line, com- shared medical unit continues to be used, both for
plete a “Behavioral Health (BH) 101” course that medically ill youth and for overflow patients sent
includes fundamental concepts of cultural com- from our ED when an IPU or YCSU bed is
petence, as well as training on unconscious bias, needed, but unavailable. When the number of
racial trauma, and cultural humility. A new course boarders exceeds the number of beds on this
focused on the assessment and treatment of shared medical unit, however, other units con-
gender-­ related concerns is currently under tinue to absorb the overflow.
development.

Building Stakeholders
Program Development and Navigating Institutional
and Implementation Expectations/Limitations

The YCSU was developed to meet the sharply In 2010, given the limited IPU beds in our region,
increased mental health needs of children and our behavioral health service line, with the sup-
adolescents within our community. Based on port of hospital senior leadership, submitted a
hospital records, from 2005 to 2010, there was an project proposal to our county Alcohol, Drug,
84% increase in primary psychiatric concerns and Mental Health (ADAMH) Board to fund a
presenting to our hospital’s ED. During that time, crisis stabilization unit. At that time, ADAMH
40–50% of these youth were admitted. Of these funding had been used to provide respite beds
youth, two-thirds were boarded on medical hos- throughout the county. However, use of these
450 J. T. Chen et al.

beds was limited due to strict admission criteria, the medical attendings placed admission orders
often leading to open, unused beds. Actively for patients being admitted to the YCSU during
suicidal youth were not allowed to use these
­ the early years of program development. Over
respite beds, and the beds could only be used for time, we developed a workflow whereby the psy-
24 hours. Further, providing referrals at discharge chiatrist would collaborate with the medical
or follow-up care was not part of the expectations attending to facilitate the admission process.
for the use of respite beds. Patients would be medically evaluated by the ED
We proposed a treatment model, different attending while the YCSU admission order set
from an IPU, to provide short-term crisis stabili- would be completed by a psychiatrist. This made
zation to youth 18 and younger who had psychi- sense for both disciplines, as the ED physician
atric presentations of suicidal ideation, homicidal could attend to other patients with medical emer-
ideation, depression, anxiety, or other mood dis- gencies, while the psychiatrist, who had staffed
orders and for whom returning home was unsafe the case with the BH clinician by phone and/or
due to lethality or decompensation. An advantage had assessed the patient in person in the ED,
of not being a traditional IPU was the proposed could decide if additional psychotropic medica-
program did not require licensing as a psychiatric tions needed to be ordered upon YCSU
unit. This allowed for more flexibility, including admission.
the ability to individualize treatment without the As the demand for YCSU beds increased over
distraction of a milieu or group therapy. In this time, cases became more complex and the need
setting, patients were not able to be “invisible”, for psychiatric presence increased. Psychiatrists
e.g., as silent members within a group session. became increasingly involved in care and many
At that time, our hospital’s general ED con- administrative discussions focused on the staff-
sisted of 35 rooms and 42 beds, including a five-­ ing model and optimization of patient care.
bed observation suite. We dedicated two Psychiatrists became specifically dedicated to the
observation beds as “youth crisis stabilization program in 2014. During these early years of the
beds.” We collaborated with ED leadership to YCSU, much energy was spent on collaborating
create staffing strategies and safety policies and with nursing and ED staff, defining roles, and
procedures. The YCSU thus began in 2011 as a forming relationships between the BH team and
two-bed “BH Unit” within a medical suite in the psychiatrists, who were concurrently working on
ED. The medical team supported medical inter- other services.
ventions, while the BH team – comprised exclu- Initially, we only provided services for patients
sively of licensed, master’s prepared professional residing within our immediate county, given our
clinical counselors and social workers – provided funding source. Our initial stakeholders were the
crisis intervention with 24/7 staffing. county’s various EDs and behavioral health agen-
Patients admitted to these two beds were pri- cies. Given our program’s initial success, other
marily staffed by the BH team and medically counties’ ADAMH boards began to fund our ser-
evaluated by the hospital attending. These service vices, resulting in growth for the YCSU (census
components were originally separated out to in 2012, four beds; 2013, six beds; and 2014,
ensure clarity of workflow and “patient owner- seven beds). By 2015, the YCSU moved out of
ship.” While psychiatrists were not part of the BH the ED onto a medical inpatient floor and the
team, they were informally consulted at times number of crisis beds increased to eight.
when patients presented with greater complexi- Overnight shifts for therapists were eliminated,
ties, such as with autism or if they were on mul- as patients were generally asleep during that
tiple psychotropic medications and parents had time. With little clinical intervention to attend to
concerns related to this aspect of treatment. in the early morning hours, nursing staff who
Since patients were being seen in medical were primarily medically (not psychiatrically)
beds, all patient discharges ultimately remained trained took over responsibility of managing
the responsibility of the ED attending. Similarly, overnight shifts.
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 451

“Code Violets” (signifying violent or aggres- “observation status” to a medical floor. There, the
sive patients) were addressed by YCSU staff in psychiatry consult-liaison (C-L) team evaluates
the early years. During the day, any patient in the the patient and continually reassesses disposition
main hospital who coded could pull YSCU staff to ensure the initial recommendation remains
away from being able to treat their own patients. clinically appropriate; if not, an alternative dispo-
Psychiatry was also expected to assist. Overall, sition is created. Patients who may initially
this plan was disruptive and not well synchro- require medical attention for a suicide attempt,
nized. These concerns, along with having non- for example, are also assessed by the C-L team to
psychiatric nurses manage psychiatric concerns determine the most appropriate disposition for
overnight, led the BH service line to create an further psychiatric treatment. It is not uncommon
Acute Crisis Response (ACR) team. Now, the that, if there is a lengthy waitlist, patients origi-
ACR team provides efficient, coordinated care; nally designated for YCSU may ultimately dis-
one of their responsibilities is to respond to charge home, or patients awaiting IPU placement
“Code Violets” throughout main campus. may be switched to YCSU due to its higher turn-
A challenge that required thoughtful planning over rate. The process of determining disposition
was how to utilize the physical space in a safe if a patient has been awaiting placement for sev-
manner, as many patients were actively or eral days entails consideration of the current clin-
recently suicidal. As medical rooms being used ical presentation, level of family and patient
by the YCSU were not outfitted as safe rooms, engagement at this point, availability of an after-
patients had to be assigned a constant attendant to care plan, and the patient’s current suicide risk
be present throughout hospitalization. This was level. If the YCSU is still recommended by the
often uncomfortable for patients and families, clinical team and parents agree, parents can pro-
costly, and created staffing issues. Camera moni- vide verbal consent for admission. The psychia-
toring was eventually installed to ameliorate try C-L team then provides a “What to Expect”
these concerns as census continued to increase handout describing the YCSU to help families
(2016, 10 beds; 2018, 12 beds). receive clear and consistent messaging about the
During these initial years, much energy was YCSU program and expectations.
placed on developing a culture of collaboration
and shared vision. Therapist training was essen-
tial to ensure staff understood the treatment  avigating Insurance Coverage
N
model. Over time, responsibilities for all mem- and Billing
bers of the interprofessional team evolved and
clarified. In 2020, our hospital opened the Big Initially, our local county ADAMH board pro-
Lots Behavioral Health Pavilion (BHP), and the vided a per diem stipend for this service. It was
YCSU moved to this new facility, expanding its intended as a “proof of concept” to see if we
size to 16 beds. The new unit was designed with could demonstrate that, with intensive therapeu-
safety concerns in mind, as described later in this tic intervention, we could discharge patients
chapter. home within 3–4 days and avoid a typical IPU
As of 2020, since our move into the BHP, admission. As of 2016, we began billing room
youth with mental health emergencies are evalu- and board charges to families’ insurances. Our
ated and triaged in our psychiatric crisis depart- setup impacts the billing structure. The youth’s
ment (PCD). Patients can be admitted directly to medical insurance is billed for the physical stay
the YCSU from the main PCD, which includes as rooms are licensed as medical, not psychiatric
nine consult rooms and a “comfort” room for beds. Patients are admitted on “observation sta-
patients, or its 10-bed extended observation suite tus.” Individual and family therapy sessions are
(EOS) following evaluation. If no bed is avail- billed as outpatient services to the child’s behav-
able, patients are transported via a safe car to the ioral health insurance. Crisis and group therapy
nearby main hospital building and admitted on codes are not utilized. Careful documentation of
452 J. T. Chen et al.

the need for these services has met with fiscal psychiatrist assesses patients’ safety concerns
success without the need for intensive advocacy. and suicide risk each day and collaborates with
Insurance companies increasingly are paying for the therapist to identify interventions that will
these costs, including multiple services per day, help patients meet their program goals. The psy-
as the average cost of a YCSU admission is lower chiatrist is ultimately responsible for the patient’s
than that of an admission to an IPU (Otterson hospital discharge and ensures that patients are
et al., 2021). Our local ADAMH board continues clinically appropriate for discharge. When indi-
to provide an annual financial contribution in rec- cated, the psychiatrist provides adjunctive indi-
ognition of the benefit the YCSU provides to our vidual and family therapy in addition to daily
community. patient sessions. This active involvement enables
the psychiatrist to provide guidance and direction
on treatment course and identify potential barri-
Setting Up the Team ers that may be limiting treatment progress.
There are 21 master’s level clinicians; these
Team collaboration is integral to achieving include social workers, professional clinical coun-
patient progress in this program. One formal part selors, and marriage and family therapists. Two are
of the treatment team’s schedule is a daily inter- clinical lead supervisors and 19 serve as therapists.
professional meeting or “rounds,” which is used There is also one dedicated discharge planner (1.0
to share perspectives, provide an update on FTE) who assists with aftercare referrals. Clinical
patient progress, and determine clinical disposi- lead supervisors hold 1.0 FTE positions and pro-
tion. Additional communication occurs infor- vide supervision to the therapists. Independently
mally among team members to further discuss licensed therapists receive biweekly supervision
cases throughout the day, ensuring alignment of and nonindependently licensed therapists receive
treatment plans. With unified clinical goals in weekly supervision. Therapists hold a 0.9 FTE
mind, team members can align their efforts, thus appointment and work three consecutive 12-hour
allowing for more efficient delivery of care and shifts. Therapists are assigned two patients at a
better patient outcomes. The type and number of time and dedicate approximately three hours of
team members described below represent the direct care per day per patient. Therapists work
staff for our current 16-bed unit. closely with the psychiatrist to ensure that hospi-
Child and adolescent psychiatrists staff the talization objectives are addressed. Their role is
YCSU Monday through Friday, with weekend described in greater detail below.
on-call coverage provided by other child and There are 33 nurses on the YCSU. These
adolescent attendings. For many years, two full-­ include 22 floor staff nurses (holding 0.6 or 0.8
time psychiatrists staffed YCSU, along with FTE positions), three contingent staff RNs, three
working in the outpatient setting. With the permanent charge nurses (one 1.0 FTE, two 0.8
increase to 16-beds, the YCSU is currently staffed FTE), two weekend charge nurses (both 0.75
by three psychiatrists, one of whom sees a few FTE), two clinical lead nurses (one each for days
cases each day and is available to provide cross-­ and evenings, both 1.0 FTE), and one program
coverage during the weekdays when one of the director (1.0 FTE). Floor nurses work eight-hour
other two attendings is on vacation or ill. shifts; they can add additional shifts on other
Psychiatrists are actively involved in each units within our system of care. As it is challeng-
patient’s care from the initial diagnostic assess- ing to maintain vigilance and therapeutic
ment through discharge. They play a key role in approaches for direct care nursing staff when
conceptualizing the case and understanding working long shifts (e.g., 12 hours), eight-hour
underpinnings of the patient’s pathology that has shifts allow staff necessary recovery time, while
contributed to the current crisis. As such, the psy- keeping them acclimated to unit routines and
chiatrist provides leadership to the team and familiar with the patients. These shorter (versus
guides development of therapeutic goals. The 12-hour) shifts have been demonstrated in a qual-
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 453

ity improvement project to link with fewer errors Day-to-Day Programming

that affect patient care (personal communication,
S. Benton, BH Director of Nursing, 1/25/2022). Daily Schedule
Weekend charge nurses work 12-hour shifts.
Nurses play an important role in building rapport A patient’s day on the YCSU begins with break-
with the patient and parents, as well as managing fast in their room at 8:00 am, followed by a pro-
psychiatric medications and medical needs that gression of therapeutic interventions with their
may arise in collaboration with the psychiatrist psychiatrist, therapist, and recreational thera-
and hospital pediatric consultant. The nursing pist. Patients usually have three individual/fam-
staff is dedicated to ensuring a smooth flow of ily therapy sessions daily between 9:00 am and
patients during admission and discharge. 9:00 pm. Schedules are typically altered for
There are 26 regular and three contingent younger patients or those with other develop-
mental health specialist (MHS) staff. MHSs are mental factors; frequent but briefer sessions are
bachelor-level team members who report to nurs- often more beneficial for that population. All
ing, maintain close supervision of patients, and meals are served individually to the patient in
help patients implement their daily schedules. their room; lunch is at noon and dinner at
They also hold 0.6–0.8 FTE positions (the unit is 6:00 pm. In between interventions, patients are
budgeted for 19.6 FTEs) and may float to other encouraged to relax, engage in self-care activi-
areas within our service line. Although all rooms ties, or work on assigned therapeutic homework
are monitored by cameras, the MHSs provide to build new skills and work toward their
additional 15-minute in-person checks to ensure discharge.
that patients are otherwise safe and doing well. Therapists work three consecutive 12-hour
MHSs address patients’ immediate needs, take shifts, from 9:00 am to 9:00 pm, and are typically
patients on supervised walks in the unit corridors assigned two patients at a time. This allows for
and may provide one-to-one recreational time continuity of care, given the average 3–4 day
when clinically indicated (e.g., play a card game). length of stay. Therapists complete approxi-
There are four 0.9 FTE therapeutic recreational mately 200 minutes of face-to-face therapy time
therapists who work three sequential 12-hour per patient per shift (a combination of individual
shifts throughout the week. Therapeutic recre- and family sessions). This represents 55% of a
ational therapists spend 45–60 minutes daily with 12-hour shift. The other 45% is for documenta-
each patient they are assigned; they also provide tion, self-care, and collaboration (both internal
backup to the rest of the BHP. They work with and external). A therapist’s typical day may flow
patients to enhance clinical therapy, particularly as follows:
behavioral activation and coping skills. Chosen
activities are complementary to goals of the over- 9:00–9:30a Chart review, contact caregivers,
arching treatment plan. For example, they may develop plan for the day
help a patient struggling with organizational skills 9:30a–12:00p Complete one session each with both
patients and document
to develop a daily schedule, utilize arts and crafts 12:00–12:30p Rounds
to facilitate a patient’s self-­expression, or engage 12:45–1:30p Lunch, self-care, phone calls
in physical activity with a sedentary patient. 1:30–4:00p Complete one session each with both
Therapeutic recreational therapists have exclusive patients and document
use of an activity room that has mats, a table, and 4:00–5:00p Self-care, phone calls, professional
games. Only one patient and therapist at a time development, dinner
5:00–8:00p Complete one session each with both
are in the room to maintain the individual focus of
patients and document
therapy and avoid peer distractions. 8:00–9:00p Brief sessions, update handoff tools
454 J. T. Chen et al.

Theoretical Framework deploy. Through this process, the clinical team

learns more about the patient’s stressors and mal-
The team begins by examining the contributing adaptive responses, as well as their level of hope-
factors leading up to the crisis, utilizing a sys- fulness and willingness to change.
temic framework. Identifying crucial factors
leading to the patient’s decompensation and
maintenance within the immediate family system Treatment Modalities
allows for thoughtful sessions. A far more com-
plex psychosocial history and psychiatric pathol- Introducing CBT concepts requires creativity,
ogy often belies the initial presenting symptoms. flexibility, and skillfulness on the therapist’s part.
As such, the team obtains a thorough presenting While it is the mainstay of the treatment program,
history from the patient and parent. Barriers to other therapeutic techniques may be incorpo-
maintaining stability are assessed, and patient rated, as needed, into therapy sessions.
goals are established. Motivational interviewing (MI; Kaufman et al.,
2021) and concepts from dialectical behavioral
therapy (DBT; e.g., mindfulness and distress tol-
Clinical Approaches erance; MacPherson et al., 2013) are routinely
utilized. As families are integral to treatment, in
A key element to effectiveness of the YCSU addition to utilizing CBT principles at a family
model is maintaining a low patient to therapist level, concepts from insight-oriented psychody-
ratio. Therapists work with two families at a time namic approaches, Bowenian or structural family
to allow for better focus and ability to maximize therapy, and brief-solution focused therapy may
intensity of treatment. From their first few be incorporated into sessions (Gouze & Wendel,
encounters with a patient, the therapist’s objec- 2022).
tives are to (1) identify treatment goals, (2) build
rapport, and (3) understand the sequence of
events that led to the crisis or reason for hospital-  risis and Safety Response/
C
ization. Throughout each encounter, the therapist Management
also assesses the patient’s risk level. Therapists
typically begin by sequencing recent events to Several aspects of the YCSU decrease the need
understand how the current crisis has occurred. for crisis intervention. These include patient and
They record events that led to the crisis along program factors and its physical structure. Patient
with accompanying thoughts, feeling, and behav- factors include voluntary admission status and a
ioral responses. Youth and parents learn to iden- rule-out of extremely dysregulated patients.
tify maladaptive thought processes and patterns Programmatically, the relatively short length of
of behaviors that factor into the crisis. stay and elimination of a milieu reduces potential
The next phase of therapy is teaching adaptive for peer-initiated conflict/aggression or attention-­
skills according to CBT principles. seeking behaviors. Importantly, design features
Psychoeducation, behavioral activation, emotion of our new YCSU physical space also enhance
awareness, positive coping strategies, challeng- overall safety. The nursing station, for example,
ing negative thinking, exposures, problem solv- is strategically located at the center of an
ing, and communication exercises are utilized. L-shaped unit and has a clear line of sight down
Patients and parents are coached on utilizing cop- each corridor. Nurses and MHSs can clearly see
ing skills or adaptive behaviors in response to if patients attempt to leave their rooms.
stressors. Therapists take into consideration the Additionally, patients who may require more
patient’s age, cognitive level, and target goals as attention due to being at risk for self-injurious
well as family dynamics and barriers to past behavior or have medical concerns are intention-
treatment progress when choosing strategies to ally placed in rooms closer to the nurse’s station.
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 455

“Cool” color choices (i.e., a focus on greens ent and treatment team, nursing staff is notified
and blues rather than red, yellow, and orange immediately. Not only do we make sure that
hues), furniture selection (i.e., rounded edges and parental consent has been given for specific visi-
weighted to avoid the ability to throw items), tors, but that visitors are behaviorally/verbally
remote control capability for water and power appropriate with patients and staff. As patients
(i.e., staff have a tablet that connects to the power, are only hospitalized for a few days, we limit
lighting, and water sources in each room so that visitors who may otherwise be a distraction or
should a safety concern arise, these can be turned impede the patient’s progress. Instead, we
off), lighting (i.e., this can be adjusted based on encourage patients to practice coping skills and
sensory needs or patient preference), antibarri- to complete tasks or homework assigned by the
cade doors, sound reduction materials, ligature therapist when not in a therapy session. We find
resistant design, and individual rooms that bal- that minimizing nonessential visits, such as from
ance safety with a “deinstitutionalized” appear- siblings and peers, helps treatment progress more
ance are meant to reduce risk of escalation and efficiently in the short course of intensive
access to means of compromising safety. All per- treatment.
sonal small-item belongings such as toothbrush
and hairbrushes are locked up.
The YCSU does not include a seclusion Use of Evidence-Based Assessments
room, as we have fewer patient escalations than
a typical IPU. It does, however, offer a comfort  hronological Assessment of Suicide
C
room with sensory materials to help practice Events (CASE)
coping or to experience soothing sensory stimu-
lation. The YCSU utilizes a philosophy of Most YCSU patients have a history of or are
engagement around safety and encourages staff admitted for suicidal ideation, self-injury, or a
to assess and meet patient needs in advance of suicide attempt. Thus, therapists are taught to dis-
any escalation, rather than take a reactive stance cuss the topic of suicide using the Chronological
to aggression or safety concerns. “Code Violets” Assessment of Suicide Events (CASE) approach
are occasionally called, during which staff assis- (Shea, 1998). During the initial encounter with a
tance is utilized using a trauma-informed lens to patient, CASE provides a helpful framework by
deescalate tension. Pro re nata (PRN) medica- which to obtain suicide and other safety-related
tions may be utilized under these circumstances. information in a more consistent manner and to
YCSU staff are trained to deescalate patients in reduce possible omissions (Shea, 1998). It also
response to dysregulation, rather than using uses validity techniques to increase honest
physical intervention as the main mode during a responses to sensitive questions.
crisis. While staff are prepared to utilize physi-
cal intervention if necessary, physical restraints
are very rarely utilized. All rooms are camera-  olumbia-Suicide Severity Rating
C
monitored 24/7 by staff in a separate control Scale (C-SSRS)
room. These live-stream cameras do not record
or have audio capability to maintain patient Each day, therapists complete and document
confidentiality. safety assessments using the Columbia-Suicide
Visitors need to sign in prior to being allowed Severity Rating Scale (C-SSRS; Posner et al.,
onto the YCSU, which is a locked unit. They are 2011). The C-SSRS is a structured tool that helps
provided lockers outside the unit to store outer- identify suicide risk and need for intervention.
wear and belongings, including phones, rather YCSU therapists use the C-SSRS Frequent
than bringing them onto the unit. Visitors pass Screener version, which contains six questions
through a metal detector before entering. . If that assess current suicidal thoughts and suicidal
someone has not been given approval by the par- behaviors since the last contact. This streamlined
456 J. T. Chen et al.

tool allows for a consistent review of current risk Collaborations and Generalizing
severity, as it explores whether there is a specific Treatment Gains
plan or intent with suicidal thoughts.
Inclusion of Family and Caregivers

Use of Evidence-Based Throughout hospitalization, building blocks are

Interventions being laid toward successful discharge. From the
first day of treatment, safety measures are
Review of Existing Evidence-Based reviewed with parents. Discussions about sharps,
Interventions weapons, locking up medication, and other
safety measures to implement at home are
CBT provides the underlying theoretical frame- reviewed. Parents are encouraged to do room
work for treatment, as it has demonstrated effi- checks and obtain passwords to electronic
cacy in treating multiple psychiatric disorders, as devices if this is a concern. Education and rec-
well as in preventing suicide (Goldston & ommendations provided to families around
Asarnow, 2021; Higa-McMillan et al., 2016; safety measures focus on limiting access to
Weersing et al., 2017). CBT is considered a well-­ lethal means, increasing supervision, and build-
established intervention for adolescent depres- ing healthy social connections in the patient’s
sion (Weersing et al., 2017) and anxiety natural environment. Aftercare planning is initi-
(Higa-McMillan et al., 2016), the most common ated as soon as treatment goals are established to
YCSU diagnoses, and is a component of best ensure that linkage is arranged prior to discharge
practices for suicide prevention (Goldston & home.
Asarnow, 2021). CBT is also an effective compo- Parents are involved in treatment daily,
nent of treatment for comorbid conditions fre- whether in person, telehealth, or by phone. A pri-
quently present in YCSU patients. DBT, which is mary goal for family sessions is to improve com-
related to CBT, further enhances treatment by munication and identify unhealthy interaction
providing specific skills to decrease self-­ patterns in the family system that may impede the
destructive behaviors, increase mindfulness, and patient’s recovery. Family sessions are often held
improve interpersonal relationships (MacPherson in the evenings to accommodate parents’ sched-
et al., 2013). ules. When patients live with someone other than
MI is utilized as well, given its proven efficacy their parent, the focus of treatment is adjusted to
in helping youth and families with the process of match the context. For example, a child in foster
change, including youth in crisis (Kemp et al., care may have sessions with the foster parent,
2021). As it is not meant as a stand-alone inter- and a case worker may also attend. At times, a
vention, it does not have an efficacy rating in patient may live with a caregiver who is not the
relation to treating adolescent internalizing disor- guardian – though the latter is involved to some
ders and suicidal behavior. Finally, family ther- capacity. In these situations, we carefully articu-
apy is utilized. Family-based treatment as a late the goal of family sessions and decide
stand-alone treatment is considered as possibly accordingly who is most relevant to attend ther-
efficacious in treating adolescent depression apy. Barriers to improving the child-parent rela-
(Weersing et al., 2017), family-based CBT is tionship are explored in family sessions, and
well-established in treating anxiety in youth patients are encouraged to teach caregivers the
(Higa-McMillan et al., 2016), and family involve- skills they have learned as a means of reinforcing
ment is an essential element of best practices in concepts. Patients also practice emotional expres-
suicide intervention (Goldston & Asarnow, sion and different communication styles with
2021). their parents.
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 457

Prior to discharge, a safety plan is created with School safety plans are created with each
the patient and parents, which summarizes many patient. They include identifying warning signs,
elements already discussed in earlier treatment coping skills, and adult supports. It is important
sessions. Each patient must engage in a meaning- that the adults identified as a support in school
ful dialogue about their safety plan, which con- are aware of their role and can communicate
sists of realistic coping skills for emotion safety concerns to caregivers. Families are
regulation, relaxation, mindfulness, and distress encouraged to meet with school administration
tolerance. Therapists will highlight previously upon the child’s return to school to review the
identified negative automatic thoughts, physical safety plan and modify as needed. At times,
symptoms, and behaviors that may have contrib- patients identify academic concerns as a primary
uted to prior safety concerns. Common goals are stressor. In these instances, collaboration occurs
identified, and exploration of reasons for living is in advance of hospital discharge to assist with
discussed. Psychoeducation on safety precau- problem solving around this issue.
tions is reviewed again, and resources on suicide
prevention are given should a crisis arise in the
future. Therapists engage in open, honest dia- Coordinating with Outside Treatment
logue with families about their home situation Providers
and other scenarios that may require adaptations
to the general safety planning. This may include Follow-up care must be established and con-
how to increase safety precautions in blended or firmed prior to discharge. Patients are typically
extended families, school, extra-circular activi- scheduled to see a therapist within 7–10 days and
ties, faith communities, peer groups, and job set- a psychiatrist within 30 days following return
tings. Often, this conversation is part of a family home. It is explained to families that while YCSU
session that discusses changes and/or new expec- provides crisis intervention and introduces foun-
tations upon discharge home. dational building blocks of treatment, patients
will need to continue treatment after discharge to
continue in their progress. Individual needs are
Working with Schools factored into referral plans, and suggestions are
discussed with parents. If patients are linked
Electronic devices (including laptops, cell directly with an outpatient provider while they
phones, iPads, and video game devices) are not are hospitalized, therapists will communicate
allowed in YCSU patient rooms. Parents are information directly to the new treatment pro-
asked to make phone calls outside of patient vider, with parental consent, at the time of
rooms to avoid patients taking and utilizing the discharge.
phone without permission. As a result, patients The YCSU’s dedicated discharge planner
are also unable to complete schoolwork electron- focuses on linkage options within the community
ically. Instead, patients are encouraged to focus and helps to place both internal and external
on treatment goals. Families are informed of this referrals. The YCSU fosters a close relationship
rule at the start of the program. with many community agencies and will inter-
By the time a patient is admitted to the YCSU, mittently seek updated information to ensure
parents have typically informed the school of hos- knowledge of available resources. The YCSU
pitalization and the reason for the child’s school invites representatives from community agencies
absence. If a parent requires assistance and pro- to visit and present information about their vari-
vides a release of information, the treatment team ous programs. We have found this helps to build
will contact school to inform them of the hospital community relationships and interagency
admission and discuss postdischarge and reinte- collaboration.
gration plans. This is not a standard process, how- Historically, when patients did not have outpa-
ever, given the relatively short hospital stay. tient providers prior to their hospitalization on
458 J. T. Chen et al.

the YCSU, the child and adolescent psychiatrists ing patients with an aftercare plan in place. As
would continue to see these patients in their out- our discharge planner works a Monday through
patient clinics until patients were linked with Friday schedule, patients discharged home on
ongoing care providers for medication manage- weekends are likely to begin with our bridging
ment and/or therapy. This proved to be very chal- clinic until transfers to other providers are
lenging, given the high acuity level of some complete.
patients, and was not a sustainable model. Given
that hospitalization is typically under a week,
patients coming in without preexisting providers Integrating Research and Practice
would not usually have an intake appointment by
the time they went home. The YCSU psychiatrist Two studies have examined the YCSU model.
would continue to bridge this patient to ensure First, we completed an open pilot study (5/7/15
that there was continuity of care. As the YCSU to 2/8/17) with 50 adolescents (Mean [M]
expanded, this form of psychiatry bridging age = 15.1 years; 86% female, 78% European
became more difficult to sustain, as many patients American, and 92% non-Hispanic) admitted to
still required frequent monitoring. Though these the YCSU for suicidal ideation and/or attempts
patients had been psychiatrically stabilized on (McBee-Strayer, et al., 2019). All participants
the YCSU, they remained at higher risk than scored >31 and/or endorsed ≥3 of 6 critical items
youth, for example, who had not had suicidal on the Suicidal Ideation Questionnaire (SIQ-JR;
thoughts or behaviors in over a year, were stable Reynolds & Mazza, 1999) for study inclusion.
on their medication, and were in weekly therapy. Average baseline anxiety (Screen for Child
These newly discharged patients were often more Anxiety-Related Emotional Disorders-5 item
time-consuming, as they required more support screener [SCARED-5], Birmaher et al., 1999,
than monthly psychiatry visits. At times, patients M ± SD = 4.8 ± 2.5), depression (Patient Health
and families would be reluctant to transition to a Questionnaire-9 [PHQ-9]; Kroenke et al., 2001,
new provider and thus decline a psychiatry intake M ± SD = 19.1 ± 4.4), suicidal ideation (SIQ-JR
after waiting several months to get connected, M ± SD = 54.3 ± 12.9), and functioning
and then the referral process would need to start (Columbia Impairment Scale [CIS], Bird et al.,
over. Other barriers, such as referrals getting lost, 1993, M ± SD = 19.7 ± 9.0) scores all were in the
unfortunately also occurred on occasion. With clinical range. Baseline SIQ-JR scores were
increase clinical cases coming from the YCSU, higher than those reported in prior studies of ado-
more emphasis was placed on families to reach lescents psychiatrically hospitalized with pre-
out on their own to locate aftercare. Currently, senting concerns of suicidal ideation and/or
this has improved aftercare connections. behavior (Czyz & King, 2015; Katz et al., 2004).
Additionally, our outpatient psychiatry service A majority of participants (56%) reported a prior
has expanded and streamlined how patients are suicide attempt. All were discharged home after
scheduled for initial intake appointments. an average length of stay (ALOS) of 3.0 days.
Given that many programs have a waitlist, our Follow-up data were provided by 88% of the
behavioral health service line created a bridging sample with no significant differences found in
clinic to provide uninterrupted care, if needed, demographic or baseline characteristics between
until patients successfully link with outpatient those with and without follow-up data. Families
providers. This clinic is able to accept patients reported a high level of preparedness for transi-
who are being discharged from the YCSU but tion to outpatient services (Care Transitions
who do not already have linkage. It can often see Measure-15 item [CTM15]; Coleman et al.,
patients within 7–10 days following discharge. 2005; M ± SD = 90.5 ± 12.3). Parents also
The bridging clinic has expanded due to high reported high consumer satisfaction (Client
demand within out behavioral health service line Satisfaction Questionnaire [CSQ], Attkisson &
and has allowed the YCSU to continue discharg- Zwick, 1982, M ± SD = 30.2 ± 2.4). Significantly
25 The Youth Crisis Stabilization Unit: An Alternative Psychiatric Treatment Model 459

lower suicidal ideation was reported by adoles- IPU (M ± SD = 9.4 ± 5.1, median = 8,
cents on the SIQ-JR at 30 day range = 4–22, p < 0.001) with no significant dif-
(M ± SD = 20.9 ± 13.5) and 3-month follow-up ference in readmission rates or time to readmis-
(M ± SD = 20.1 ± 12.8) compared to baseline sion found across units. As a result, the YCSU is
(M ± SD = 54.3 ± 12.9; both p < 0.0001), a large able to admit twice as many patients per bed than
effect size (Cohen’s d = 2.2 for both). Parents the IPU, which helps to alleviate strain of place-
reported significantly better functioning on the ment for our PCD and C-L service.
CIS for adolescents at 30 day
(M ± SD = 16.2 ± 7.6) and 3-month follow-up
(M ± SD = 15.1 ± 9.5) compared to baseline  essons Learned and Future
L
(M ± SD = 19.7 ± 9.0; p = 0.003, p = 0.002, Directions
respectively) and a medium effect size when
compared to baseline (d = −0.4 at 30 days; The YCSU has evolved over the last 12 years
d = −0.5 at 3 months). The clinical significance from a two-bed unit housed within a general ED
of these findings is particularly noteworthy given to a 16-bed unit designed specifically with the
sample acuity. needs of youth and families in crisis in mind.
Second, we compared ALOS, readmission Staffing has expanded from several therapists and
rates, and time to readmission for youth who a psychiatrist available on call to a full interpro-
were eligible for but assigned based on first avail- fessional team. The YCSU is a valued resource
able bed to either the YCSU or our IPU (Otterson within our larger community.
et al., 2021). Charts of 118 adolescents (M As the YCSU continues to evolve, future
age = 14.4 years; 78.0% female, 60.2% European directions include moving toward an increasingly
American, and 96.6% non-Hispanic) eligible for holistic approach to treatment. We recognize the
both and admitted to either the YCSU (N = 73) or difficulty of patients being confined to a single
IPU (N = 45) from January to June 2017 were room, particularly if they have already been wait-
reviewed. Primary reasons for admission were ing several days for an open YCSU bed. Finding
suicidal ideation (61.0%) and/or suicide attempt balance among various forms of therapeutic
(26.3%). Most patients received a mood-related modalities, in addition to psychotherapy, can fur-
diagnosis (87.3%). Prior admissions were ther reinforce creativity and exercise as healthy
reported by 5.9% of the sample; 94.1% were dis- ways to cope with distress. Ancillary services
charged home. No significant demographic or such as music or physical therapy or adding exer-
clinical differences were found between those cise time are being explored. Having expanded to
diverted to the YCSU and those admitted to the 16 beds in 2020, we are already planning a unit
IPU. After applying winsorization to address out- expansion. An ongoing initiative is providing
liers (two YCSU patients had LOS > 7 days and more family therapy training for therapists, as
two IPU patients had LOS > 22 days), YCSU addressing family systems issues can be highly
ALOS was significantly shorter (M ± SD = 4.5 complex and varied. We hope that the lessons
± 1.2, median = 4, range = 3–7)1 compared to the gained from developing the YCSU can be a
resource for other institutions who are interested
in providing care for similar populations.
1
Of note, LOS was calculated in two different ways in the
two studies. In the first study, if admission occurred, for
example, on a Monday and discharge on a Thursday, the
difference in days was determined to be three. In the sec- References
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& Chorpita, B. F. (2016). Evidence base update: 50 Shain, B., Committee on Adolescence (P.K. Braverman,
years of research on treatment for child and adoles- W.P. Adelman, E.M. Alderman, C.C. Breuner,
cent anxiety. Journal of Clinical Child & Adolescent D.A. Levine, A.V. Marcell, R.F. O’Brien). (2016).
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Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller, A. L. peds.2016-­1420.
(2004). Feasibility of dialectical behavioral therapy Shea, S. (1998). The chronological assessment of sui-
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Kaufman, E. A., Douaihy, A., & Goldstein, T. R. (2021). Torio, C. M., Encinosa, W., Berdahl, T., McCormick,
Dialectical behavior therapy and motivational inter- M. C., & Simpson, L. A. (2015). Annual report on
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Practice, 28, 53–65. for children with mental health conditions. Academic
Kemp, K., Webb, M., Wolff, J., Affleck, K., Casamassima, Pediatrics, 15(1), 19–35.
J., Weinstock, L., & Spirito, A. (2021). Screening and Weersing, V. R., Jeffreys, M., Do, M.-C. T., Schwartz,
brief intervention for psychiatric and suicide risk in the K. T. G., & Bolano, C. (2017). Evidence-base update
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The PHQ-9: Validity of a brief depression severity
 Strategies to Navigate
Day-­Treatment Services 26
and Follow-up Plans: A Guide
for Families and Providers

Jarrod M. Leffler, Stephanie Clarke, and Tara Peris

Introduction one’s child, often because of the frequency of use

and social acceptance of these services. As a
Identifying and accessing mental health services result, caregivers are more likely to ask for refer-
for a child in acute psychiatric distress can be rals for pediatricians, dentists, and medical spe-
extremely difficult. These challenges often pres- cialists. However, there is often a level of caution,
ent during a time of emotional distress for care- concern, and distress for caregivers when talking
givers (caregiver will be used throughout the about their child’s emotional or behavioral diffi-
chapter to refer to caregivers, parents, and others culties and then asking for suggestions, ideas, or
responsible for the child’s care) related to helping referrals for services. Consequently, there is less
their child and family manage mental health cri- networking and information readily available
ses, which can result in feelings of fear, disap- about navigating the mental health system and
pointment, confusion, and myriad additional accessing services.
emotions. Limited access to evidence-based While there are resources available, many
treatment, therapists, and medication prescribers caregivers may not know where to start to locate
can exacerbate stress for families during this the right resource and may settle for what is first
challenging time. Further, the stigma of talking available. This is often driven by necessity of
with other families and friends about mental being in a distressing or acute mental health situ-
health issues can make this complex situation ation and needing quick access. Mental health
even more cumbersome. There is typically less services and access to these services can vary by
stigma requesting physical medical resources for city, county, and state. Similarly, services offered
through schools can vary by school district.
Finding and accessing youth mental health
J. M. Leffler (*) services is a stressful task for all caregivers. It is
Virginia Commonwealth University, Children’s especially challenging to find treatment services
Hospital of Richmond, and Virginia Treatment Center
for Children, Richmond, VA, USA that offer interventions beyond outpatient therapy
e-mail: [email protected] (e.g., day-treatment programs). Beyond navigat-
S. Clarke ing the challenging youth behaviors and symp-
Cadence Child and Adolescent Therapy, toms which prompt the very need for help,
Seattle, WA, USA caregivers must find their way through an unfa-
T. Peris miliar and cumbersome labyrinth of providers,
University of California – Los Angeles, programs, insurance requirements, and protocols.
Los Angeles, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 461
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4_26
462 J. M. Leffler et al.

Few caregivers have had to think about how to county agencies. Services in schools can include
find and coordinate multiple elements of care, therapy (e.g., individual and group), while those
including individual psychotherapy, medication in county agencies may include case manage-
management, and psychoeducation. Additionally, ment, therapy (e.g., individual, group, and fam-
caregivers may not have experience evaluating ily), and in-home services. Therapists in private
whether a given program constitutes a good fit or outpatient practice often offer individual, group,
is rooted in scientific approaches that are likely to and family therapy. Mental health services
work. The result is a knowledge gap that can offered through hospitals, mental health centers,
make a complicated situation for a family all the and larger practices can include individual,
more difficult. The current chapter offers a brief group, and family therapy as well as day-­
review of the levels of mental health care and treatment programs and inpatient psychiatric
provides strategies specific to intermediate level care. Medication management is often provided
of care programs or day-treatment services, by psychiatrists, physicians, and advance nurse
including resources to assist caregivers in access- practitioners. Additionally, integrated behavioral
ing, engaging, and utilizing day-treatment health services offered in some pediatric, family
services. medicine, physician, or integrated behavioral
health settings can provide brief assessment and
intervention options for youth and families.
Levels of Mental Health Care
Day-Treatment Programs
Mental health difficulties affect 20% of youth in When mental health symptoms and resulting
the United States (Merikangas et al., 2009). An impairment persist over time and/or worsen,
unfortunate reality is that most youth never con- however, families and providers both begin to
nect with the type of care they need to effectively think about what other interventions and services
treat their mental health conditions (Merikangas may be clinically helpful. Beyond making a med-
et al., 2011; Reinert et al., 2021). This is concern- ication change or seeing a therapist more often,
ing given mental health services for youth are more intensive services may be necessary. These
provided across a continuum of care (see Chap. 3 services can take many forms and include day-­
of this text). This care continuum includes less treatment programs that consist of intensive out-
restrictive programs such as outpatient therapy to patient programs (IOPs) and partial hospitalization
restrictive programs such as residential treatment programs (PHPs). They often bring together a
facilities. suite of services that would be hard for an indi-
vidual family to coordinate on their own (e.g.,
 utpatient Mental Health
O individual and group therapy, skills training,
Typically, outpatient services may involve indi- medication management, and family work). IOPs
vidual psychotherapy, pharmacotherapy, or both. may operate a few days a week for a few hours a
Caregivers may also be included as needed based day. PHPs may run the bulk of the school day (or
on the child’s age and presenting problem. For more) five days a week. In both settings, youth go
example, caregivers may receive psychoeduca- home at night, and families must feel comfort-
tion and therapy skills in programs addressing able transporting their child safely to and from
attention deficit hyperactivity disorder, anxiety, program and managing clinical concerns at night
or disruptive behaviors for younger children. For and on the weekend. PHPs and IOPs provide
these outpatient services, youth may meet with more intensive support beyond outpatient therapy
their therapist weekly or monthly/bimonthly but less support compared to inpatient psychiat-
for pharmacotherapy. Providers may ratchet up ric hospitalization (IPH), in which youth stay
the frequency of appointments when the patient overnight in highly contained and regulated set-
is experienicng more difficulty. Mental health tings designed to keep them safe and to stabilize
services can also be offered through schools and very severe mental health concerns.
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 463

I npatient Psychiatric Hospitalization Day-treatment programs often have more focus

and Residential Treatment Facilities on therapy and therapeutic interventions within a
IPH programs consist of the child being admitted less restrictive environment compared to IPH.
to a 24-hour locked unit. IPH is often used for Similarly, while IPH may involve parents through
acute mental health crisis stabilization and can treatment team rounds, family therapy, and con-
include group, individual, and family therapy, but sent for medications, PHP and IOP models more
access and use of these interventions vary signifi- often engage parents on a regular basis through
cantly by program. Most IPH programs assess some form of family therapy, groups, and touch-
and utilize medication options along with therapy points with the treatment team. Additionally, par-
worksheets and workbooks. More specifically, ents are often involved with transporting their
some youth experience acute mental health cri- child to and from the program. PHP and IOP ser-
ses, and as a result, require emergency evalua- vices are often utilized as an intermediate level of
tions and admissions to a higher level of care, care between weekly or regular outpatient ther-
which may include IPH. The duration of these apy and IPH. Children discharging from IPH
admissions typically ranges from 2 to 10 days. In may “step down” to PHP or IOP services, or
some instances, admission may be 30 days, youth in outpatient care may “step up” to PHP or
although this is less common at this level of care. IOP services.
Additionally, some IPH programs have moved to
a family-focused model allowing caregivers to
spend more time on the IPH unit with their child Access
and even stay overnight. Beyond IPH, a higher
level of care includes residential treatment facili- Caregivers may find themselves accessing PHP
ties. These treatment programs may include or IOP services when their child’s mental health
lengths of stay from 30 days to several months. In treatment needs exceed those of school and
these programs, youth live away from their care- outpatient-­based services. If day-treatment ser-
givers and participate in a daily routine that often vices are needed and their child is working with a
includes school, social or community, and ther- therapist, that provider will make a referral for
apy activities. PHP or IOP services. Similarly, if their child is
admitted for IPH, their child’s IPH treatment
team should discuss the potential need to follow
Day-Treatment Programs up with PHP or IOP services. If this is the case,
often the IPH team will coordinate an intake
Youth with mental health distress often have appointment or start date.
access to a range of mental health services as When referred to a PHP or IOP, it is important
described above; however, some youth with mod- to know where the treatment facility is located
erate to severe mental health needs may require a and ask for information about the details of the
level of care higher than outpatient that would program. This can be provided by the treatment
include day-treatment services such as a PHP or team and located on the Internet. As much lead
IOP, which offer more intensive, comprehensive time as possible between referral and start date
services. PHP and IOP models of care offer ser- with the day-treatment program can allow care-
vices in full- or half-day settings usually consist- givers to coordinate plans for school arrange-
ing of 2–8 hours of programing each day. ments, transportation to the program, and time
Children attending these programs return home off work or from other responsibilities as required
each day after program, and caregivers are often to participate in the program. These requirements
involved in their child’s treatment in day-­ will vary by program and have been highlighted
treatment levels of care. Day-treatment programs throughout this book. We will provide some gen-
utilize groups and benefit from the dynamic of eral information related to program expectations
the treatment group and the treatment milieu. for youth and caregivers in the current chapter.
464 J. M. Leffler et al.

Accessing a PHP or IOP from a referral may tion, employment, or other challenges. As there is
be less stressful for children’s caregivers com- more transition back to in-person services, some
pared to locating a day-treatment program on programs are remaining virtual or offering hybrid
their own. Some programs may offer an intake as options, where a subset of youth are completely
part of their agency or hospital to determine the virtual or the entire group attends virtually some
child’s clinical fit and potential benefit from the days, and in-person others. When considering
program. Some programs require a comprehen- whether a virtual program may be right for a
sive evaluation prior to being referred to their child and family, it is important to consider such
program. Once connected with the program, factors as whether insurance will pay for virtual
caregivers will need to determine if the services care, the child’s bandwidth and ability to pay
and interventions offered meet their child’s attention and engage online (particularly if they
needs. Most programs have descriptions of their are fulfilling any other obligations, such as
programs online, which can include the daily school, through full or partial online course-
hours of the program, potential length of stay in work), and what is required of the family. For
the program, the therapeutic approach imple- example, while the second author’s previous pro-
mented (e.g., cognitive behavioral therapy, mind- gram at Stanford offers virtual care, it requires a
fulness, and dialectical behavior therapy), and caregiver to be home and immediately available
structure of the program. Caregivers can search should the child log off or experience a crisis.
for “mental health day-treatment,” “partial hospi- Here, for a family who must work outside the
talization program,” or “intensive outpatient pro- home, it may be more beneficial to work out a
gram” to locate programs near them. Caregivers plan for transporting the child to and from the
can also contact their insurance provider and ask program rather than needing to have a caregiver
about mental health services and providers in at home during program hours. While the virtual
their network. program may seem more convenient and less
Geographic location will also come into play time-consuming, it may pose further unforeseen
for some families to access PHP or IOP services. challenges and obligations for families that must
For example, in 2011 when first author began be considered when determining the best care for
working at Mayo Clinic, there were no PHP or their child.
IOP services operating within a 60-minute radius. Some caregivers have reported not having
The first author then developed and imple- access to PHP or IOP services in their areas,
mented a PHP in 2012 (Leffler et al., 2017) and an while as noted earlier, a city with a population of
IOP in 2015. In 2014, another agency began IOP 100,000 can have multiple day-treatment pro-
services and has recently added PHP services. grams, which speaks to a fragmented and incon-
However, for some time prior to 2012, families in sistent state and national mental health system. In
need of these services had to drive a considerable addition to availability of programs in reasonable
amount of time to access them. Similarly, in light proximity to a child and family, another potential
of the COVID-19 pandemic, some programs barrier is financial coverage of the program (e.g.,
reviewed in the current text have offered PHP and insurance and Medicaid). This varies by insur-
IOP services virtually. More recently, institutions ance panel, but a guiding rule is that youth need
have begun to develop stand-alone virtually based to have attempted services at a lower level of care
day-treatment programs. before making a case that more intensive services
The COVID-19 pandemic led to rapid growth (e.g., IOP or PHP) are needed. Additionally,
in the provision of virtual mental health services, mental health providers can assist with referrals
including higher levels of care such as IOPs and to a program but may not know which programs
PHPs. This has increased the accessibility of are covered by the family’s insurance. As a result,
treatment for families living in rural areas or it is very useful for caregivers to contact their
areas without access to these levels of care and mental health benefits plan to confirm what pro-
for families who are constrained by transporta- grams are covered.
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 465

Costs mation for caregivers related to accessing pro-

grams, addressing barriers, and planning for
The cost of IOP and PHP is less expensive than discharge and follow-up services once a day-­
inpatient psychiatric care but more expensive treatment program is completed.
than traditional outpatient therapy (Leffler et al., Once a family connects with a day-treatment
2021). Some insurance plans cover this level of program, they will go through a process in which
care, and others may not. It is important to check their child is evaluated for admission and mem-
with your specific insurance company about bers of the treatment team determine the child’s
mental health benefits. Some programs are billed fit with the specific program. If the child meets
as a bundled payment on a daily basis for the time admission criteria, they will either be admitted
the child is admitted to the program. Other pro- and provided a start date or be placed on a wait-
grams bill services separately (e.g., family ther- list based on available openings in the program.
apy, group therapy, individual therapy, medication Program waitlists can be days to months.
management, and other axillary health services Programs will move children up on the waitlist if
such as occupational therapy or art therapy). other individuals opt out or drop off the list so the
When gathering information about the day-­ actual start date may not be as long as initially
treatment program, it will be helpful to know anticipated. Some programs use a severity rating
how services are billed. for children and those with higher acuity may
move up the list faster than those with moderate
or mild levels of distress. It is important to dis-
Identifying and Addressing Barriers cuss the program’s admission process and know
who to contact with questions.
Caregivers may find some challenges with utiliz- Additional considerations for access include
ing day-treatment programs. Some of these chal- transportation to and from the program. Most
lenges are connected to the larger fragmented and programs require the caregiver to transport the
difficult to navigate mental health systems that child to and from the program. Some programs
vary from state to state and county to county. have transportation provided by local school dis-
These challenges have only been amplified with tricts, through county mental health or other
the COVID-19 pandemic (Protecting youth men- funds, or offer cab or transportation vouchers and
tal health: The U.S. Surgeon General’s Advisory, parking vouchers. Not only is the cost of trans-
2021) with states (Olivo, 2021) and organizations portation and parking a potential barrier, but the
(Bohannon, 2021; Colorado Children’s Hospital, time commitment for the caregiver, if necessary,
2021) identifying mental health crises. Access to to have time away from work, other obligations,
mental health services can be difficult to navigate and other family members can be challenging.
as multiple parents have shared with the authors Program staff often work with families to mini-
“The {mental health} system is broken,” “We mize demands on the caregivers related to these
were on multiple waitlists for over 6 months,” factors, because parent and caregiver investment
and “Parent’s don’t know how to access and and involvement in their child’s treatment is
schedule appointments with a mental health pro- essential.
vider like they do a dentist or physician.” Caregivers may also be asked to attend group
Specific barriers to PHPs and IOPs can include or family therapy sessions during the time their
several topics such as access to an evaluation, child is in a day-treatment program, which can
admission and start time, transportation, access run from one week to eight or more weeks. These
to the program based on when it is provided (e.g., sessions can vary from one family and caregiver
days of the week, frequency during the week, and group session a week to all day attendance
hours of operation), insurance coverage, and (Leffler et al., 2020; Weiss et al., 2019; Whiteside
requirements for caregiver involvement. et al., 2014), with the latter being less common.
Figures 26.1 and 26.2 provide additional infor- In addition to attending these, usually 45- to
466 J. M. Leffler et al.

Is the program fixed in length (e.g., 8 weeks?) or determined by youth’s symptoms (e.g.,
youth will be discharged once symptoms improve to a certain degree)?

Does the program accept insurance?

If so, does the program work with insurance directly to determine the family’s out-
of-pocket cost?

If so, does the program work with insurance ongoing to determine coverage? (FYI -
some insurances will cover a certain number of days of care, not an entire program,
and require updates from the program)

If so, will parents be notified in a timely manner (i.e., prior to services being
rendered) if insurance coverage is denied or insurance will not renew coverage after
a period of time?

If not, what is the cost of the program (overall and daily/service rates)?

If not, does the program communicate directly with insurance to determine any out-
of-network coverage or determine whether a single case agreement with the
insurance company may be an option?

If not, are there any financial assistance programs available?

Does the youth/family need to discontinue other therapeutic services related to the youth
while in the program?

Does the program include medication management?

What level of involvement is required from parents during program hours (e.g., group
attendance, check-ins with individual therapist, immediately availability in case of
emergency, transportation to/from program)?

What is required from parents outside of program hours (e.g., constant or close supervision
of youth, need to be available immediately by phone to youth)?

If parental requirements exceed what is possible given parents’ vocation, can the program
assist parents in obtaining FMLA or other resources?

What is included or recommended with regard to school and academics (students have time
to work on school during the program day, program recommends reduced school schedule)?

Does the program offer step-down services, provide ongoing therapeutic services, or help
with connecting the youth to therapeutic support after the youth is discharged from the
program, or is this wholly the responsibility of the parent?

Fig. 26.1 Helpful questions for parents looking at day treatment programs
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 467

Name of Program: (PHP or IOP)

Admission Date and Time:

Dates and Time of Program:

Program contact number:

Therapist’s name:

Therapist’s contact number:

Medication prescriber information:

Discharge Date and Time:

Follow up Plan:

Contact for Follow up Plan:

Safety plan and resources:

Skills to manage emotions:

Personal and professional contacts:

Fig. 26.2 Caregiver notes

90-minute sessions, caregivers may be asked to very beneficial for caregivers and their child. This
complete weekly or daily therapeutic activities might mean taking extra time during lunch to
on their own, with their child or with other family complete the activities or catch up on work activ-
members. While finding the time to attend these ities that you were not able to complete due to
sessions and complete the activities provided by attending a session. This is not easy and can be
the treatment team may be challenging, it will be distressing, overwhelming, and frustrating.
468 J. M. Leffler et al.

However, the skills learned from program can be ally may also be provided as part of the program
useful to address these emotions. Despite these and/or coordination with your child’s school
emotions, caregivers, children, and their family guidance counselor, school social worker, or
members can benefit from committing to the administrator.
activities of the program. Additionally, these
activities are critical to maximize the benefits of
the program and can aid in the child’s chances for Working with the Treatment Team
successful completion of the program and
improved future functioning (Leffler et al., 2017).  eam Composition and Communication
T
Chapter 3 of the current handbook reviews IOP
and PHP staffing models and team composition.
Intervention Additionally, several treatment chapters explain
this in great detail. Most programs consist of a
The current text provides a range of information medical director who is typically a psychiatrist.
regarding assessment and specific treatment However, some pain programs may have a physi-
interventions. Many PHPs and IOPs provide an cal medicine and rehabilitation provider or other
evaluation of each child as part of the admission medical provider in this role. There is typically a
process. Additionally, some programs continue to program director or clinical director as well. The
provide daily evaluations of safety and function- director or clinical director role may consist of a
ing. Beyond these evaluations, some programs psychologist, social worker, or advance practice
may also include more broad evaluations of cog- nurse depending on how the program is struc-
nitive, emotional, and behavioral functioning tured and staffed. Therapists in the program usu-
while the child is admitted to the program, at dis- ally include social workers, counselors, or
charge, and following the program. This data is psychologists. Programs may also have a regis-
often utilized to help inform the program and tered nurse and other advance practice nurses or
assist with modifying and improving the program physician assistants. Caregivers will be provided
to best serve children and families. Additionally, information about the structure and staffing of
some programs will inform children and caregiv- the program either verbally or in written materi-
ers about the potential use of this information in als. It is important to know this structure and staff
research activities to communicate how these model to assist with gaining more information
programs can aid other children experiencing about their child’s engagement and progress.
mental health difficulties and their families. It is also helpful for caregivers to know the
Regarding intervention, the programs treatment team and program structure to under-
reviewed in this text share a range of specific stand how the program might provide communi-
interventions, which highlight the utilization of cation with caregivers on topics of their child’s
evidence- or science-based treatments that have safety, progress, medication changes and approv-
been developed through research activities and als, treatment needs and recommendations, and
have been modified and enhanced to best serve discharge plans including follow-up providers.
children and families. Most PHP and IOP inter- Programs vary in how this information is com-
ventions include group and individual therapy for municated. However, some examples include
youth. Some also include family therapy, family daily verbal check-ins before and after the pro-
groups, and caregiver therapy and psychoeduca- gram, the use of a daily update sheet, phone calls,
tion groups. There is also a range of medication and in family therapy or treatment team rounds
education, monitoring, and changes. In addition, with the child and caregiver. Caregivers of chil-
auxiliary services focused on health, wellness, dren with mental health needs have many roles
and daily functioning may be provided including and responsibilities. Two of those roles are being
art therapy, recreation therapy, music therapy, an advocate for their child’s mental health needs
occupational therapy, physical therapy, and and a consumer of services. Caregivers should
dietary services. School services on site or virtu- feel supported, validated, and empowered by
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 469

their child’s treatment team. As such, caregivers will only share with caregivers if there is an ele-
are encouraged to use the communication options vated safety concern requiring the child to be fur-
available to them to share and discuss their expe- ther evaluated or admitted for an acute psychiatric
riences, observations, concerns, and consider- emergency. It is important that caregivers discuss
ations for their child’s mental health needs. This with the treatment program how their child’s
increases the information the team gathers safety will be assessed and monitored and when
regarding the child and can assist with addressing and how they will be informed about this.
treatment needs in a more effective and efficient Regarding mental health crises, it can also be
way. Additionally, caregivers may not see or be helpful for caregivers to ask the treatment team
aware of the activities the treatment team is about what to do in case of crisis or emergency
engaging in to assist the child and assist with situations when the child is at home, school, or in
follow-up services for mental health care and the community while admitted to the program.
school needs. To assist with better knowing this For example, does the program offer after-hours
information, caregivers are encouraged to enquire or crisis services or guidance to youth and care-
about information they do not have in a neutral givers or is the family to rely on calling 911 or
and nonjudgmental style. going to their local emergency room. If the latter,
how does the family include the day-treatment
Safety and Crises program in this process (e.g., signing releases of
Managing patient safety in PHPs and IOPs is a information so the day-treatment program can
critical component of care due to the presenting communicate with the hospital or other emer-
concerns of the patients. Programs must consider gency service, procedure for when and how to
protecting the safety of children and staff as well contact the program should a child seek or be
as the potential safety issues that may arise when admitted to emergency service such as an inpa-
the child returns home each afternoon. To address tient psychiatric hospital unit).
these concerns, programs may ask caregivers to
give a daily update to the team or a specific staff
member verbally upon drop-off, electronically Working with Schools
(using email or a patient portal), or through a
daily sheet that caregivers complete and return Academics are a primary weekly responsibility for
with their child each day. Staff will also assess most youth nine months a year and for some year-
the child’s thoughts, feelings, and behaviors as round. As a result, attending a PHP or IOP may
part of the program. This can occur in the first impact the child’s ability to attend school even if
group of the day, separately with each child, or as there are virtual options for school and the PHP or
part of a completed daily check-in or assessment IOP. The authors have found that when a child is
form. If safety concerns arise as a part of this pro- admitted to a day-treatment program, many care-
cess or throughout the course of the treatment givers are not sure what to do about school.
day, team members will discuss with your child Some day-treatment programs offer school as
their level of unsafe or risky thoughts, feelings, part of the daily curriculum while others do not. It
and/or behaviors and develop a plan with them will be important to know if there is time offered
regarding how to keep them and the other chil- as part of the treatment day for the child to focus
dren and staff safe. They will also discuss a plan on academics and how that will be addressed. As
for remaining safe outside of program. Programs mentioned, some PHPs and IOPs include time to
can vary on how they share this information with engage in schoolwork through the local school
caregivers. Some programs will only inform district. This can include in person contact with an
caregivers of these concerns if the child contin- educator on site at the treatment facility and
ues to struggle with remaining safe and manag- through virtual options. Often this will include
ing their unsafe behaviors. Some programs will core classwork but no electives. If a child is
report each day to caregivers how the child did enrolled in a school that is not part of the public
with managing their safety, and other programs school district where the PHP or IOP is offered,
470 J. M. Leffler et al.

the curriculum and learning content may be dif- ment of the youth at home. There are two aspects
ferent than what the child had been working on. to caregiver involvement in programs: (1) the
At admission, it is important that caregivers extent to which the primary therapist/treatment
inform their child’s school that the child will be team update the caregiver and the access the care-
away from school. How caregivers communicate giver has to the primary therapist and treatment
this will depend on several factors. These factors team and (2) the level of guidance and support
include the caregiver’s relationship with the offered to caregivers to manage their child at
school, the information the day-treatment pro- home, particularly during difficult times.
gram shares with the caregivers that they typi- Programs vary greatly in expectations of and
cally tell schools regarding the child’s time in the opportunities for caregiver involvement.
program, and the type of schooling the child is Logistically, it is important for caregivers to
attending (e.g., homeschool curriculum and vir- consider the level of involvement required of
tual or brick and mortar school). Details shared them. For example, some programs may require a
with the school might include the child’s absence caregiver or guardian to drop off, check in, and
is due to a medical necessity, how long the child pick up their child from a program; mandatory
will be away, and what schoolwork is required caregiver groups, multifamily groups (youth and
while the child is out of school. Most schools will caregivers attend together, typically to teach fam-
require the child to complete critical and essen- ilies various skills), and/or family therapy ses-
tial work only, and some schools may waive sions; expected caregiver availability during
some missed work. Critical and essential work program (e.g., in the second author’s program,
decreases the overall amount of makeup work caregivers must be available immediately by
required by the child upon return and is focused phone during all program hours); and expected
on the core elements of the content being taught, caregiver responsibility (e.g., increased monitor-
reducing the amount of work students who are in ing of their child) outside of program hours.
school may complete for a lesson or topic. These expectations can also vary based on
Additionally, caregivers may be asked to sign a whether the program is offered in person or
release of information (ROI) form allowing com- virtually.
munication between the school and day-­treatment In addition to logistical considerations, it is
program. As part of the return to school plan, dis- important for caregivers to consider their own
cussed later in the chapter, caregivers should dis- needs with regard to parenting their child. Again,
cuss with the school how the school demands and programs vary widely in services and support
day will be structured when their child returns to offered to caregivers and families. At a minimum,
school. This can provide time for the child and caregivers will want to know who the point of
caregiver to prepare for this schedule. This is contact is within the program for the exchange of
important as some children return to full days of information about their child, what the frequency
attendance at a school building while other chil- of contact will be, and the procedure for getting
dren return to partial or half days for a while to in touch. Parenting youth who are in a position to
readjust to school after being away due to a men- need a higher level of mental health care often
tal health crisis. leaves families feeling ill-equipped to effectively
manage symptoms and behaviors, not to mention
the typical parenting challenges of raising
Caregiver Involvement ­children and adolescents, including setting limits
and expectations in the context of mental health
It is important to consider a program’s level of challenges. Additionally, youth mental health dif-
expected caregiver involvement and limitations ficulties can amplify challenging family dynam-
on caregiver involvement both for logistical pur- ics, and family dynamics can exacerbate mental
poses and to determine if a program will meet the health difficulties for youth. Therefore, it is
needs of the caregiver and behavioral manage- important for caregivers to take stock of what
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 471

they need and ask the program what it offers for to transition to a provider who can continue this
caregiver and family support. There are a range work. It is therefore helpful for caregivers and
of services programs offer caregivers and can youth to have conversations with their estab-
include caregiver guidance, after-hours caregiver lished providers and the treatment team working
phone coaching, family therapy, multifamily with their child and family in the treatment pro-
skills training and resources for their own or gram to discuss various treatment options upon
other family member’s mental health needs. discharge from the program.
Specific questions to ask about discharge
planning and follow-up care are included in
Discharge and Follow-Up Planning Fig. 26.1 and include whether the program offers
ongoing care, bridge care (seeing the youth until
There are several issues to consider with regard other services are established), or step-down
to discharging from a PHP or IOP, many of which care, and whether these are covered by insurance,
will be beneficial to consider at the start of the whether the program offers assistance with estab-
program. This can save a lot of time and stress at lishing care with providers to whom the child
the tail end of a program, which already is often will transition upon discharge, and how long
stressful for caregivers and youth alike. Issues to waitlists in the community tend to be for what the
consider include ongoing care and referrals for child may need. It can be impossible, given the
therapy and medication management, school and nature of the child’s struggles, to know upon
academic plans, and caregivers’ and youth’s rein- admission what type or level of care they will
tegration into the community after reducing or need at the end of the program. If a caregiver
withdrawing from school or work for a period of lives in a community where there is a dearth of
time. available providers, it may be most beneficial to
get on waitlists of various levels of care in order
Discharge Planning to ensure their child has available care at the end
First, it is important to ask about and start plan- of their participation in the program. In other
ning for discharge when starting, or even prior to areas, provider availability is less of an issue and
entering, a program. In the California Bay Area, caregivers can wait until the child’s treatment
where the second author’s program is located, needs are clearer. In most cases, the most practi-
there are months-long waitlists for pediatric psy- cal place to start is talking with the child’s current
chiatrists and therapists; in her program, there- providers and treatment team about what the
fore, families are encouraged to get on providers’ child may need at the end of the program, deter-
waitlists so there is not a gap in care when the mining the availability of providers in the com-
youth finishes the day-treatment program. munity and therefore when to start calling and
Waitlists and delays for treatment across the con- placing the child on waitlists if needed, and if so,
tinuum of care are becoming more common to what level the program assists in the process of
across the country with the COVID-19 pandemic. the child transitioning out of the program. If the
Even if you are in the position of having provid- program does not offer transition care (step-­
ers who have agreed to see the child upon their down, bridge care) or assistance with establish-
completion of the program, it can be useful to ing care postprogram, it can still be worth asking
think through such issues as whether the child the program if they have any referrals or referral
may need different supports upon program grad- lists they give to families, or any ideas they have
uation. In the programs of the first and second about where to obtain recommendations for com-
authors, it is not entirely uncommon for youth to munity providers. Even if programs do not offer
have plans to return to their previous therapist case management services for connecting youth
upon graduating our program, but then the youth to providers postprogram, they often are aware
and family feel the type of therapy offered in the and knowledgeable about community resources.
program has been beneficial, and they would like Insurance companies can also help with this. If a
472 J. M. Leffler et al.

family is experiencing difficulties finding a cov- specific to the child (e.g., the child’s depressive
ered provider, some insurance companies have episodes tend to be preceded by turning in
case managers who can assist; in our experience, assignments late, withdrawing from friends, and
this can require a significant amount of time and being more irritable with family), and what to do
effort on the part of the family to obtain greater (e.g., caregivers will communicate what they are
assistance from insurance companies. observing to the child’s treatment providers,
When transitioning out of a program, it is also psychiatrist, and therapist, and the symptoms
important to have a good understanding of what and behaviors will be addressed immediately).
has been successfully addressed and what needs This often helps empower the child to feel more
continued work. This not only helps guide what confident that they will have the necessary sup-
expertise and types of providers to pursue post- ports should they start to struggle again, as well
discharge, as discussed above, but also is impor- as a plan that could help them course-correct
tant information to share with new providers. before symptoms or behaviors worsen. With
Some programs offer a treatment summary, either regard to the child’s psychotherapy, too often the
automatically or upon request, that can be very authors hear of cases where a child is in treat-
useful to give to new providers. It is also reason- ment; however, the provider rarely speaks with
able to ask your program to communicate with the caregivers. We therefore recommend that
new providers to assist with the transition of care. there is regular contact (e.g., weekly or monthly
It can be helpful to discuss this within your last depending on the child’s mental health needs
weeks of a program and sign any needed docu- and functioning) between the therapist and care-
mentation (e.g., releases of information) in givers. Since providers have different ways of
preparation. managing this, we recommend discussing the
following with potential therapists: what infor-
 ental Health Follow-Up
M mation caregivers want from providers (e.g., any
Next, stepping down from the level of care dangerous behavior or urges to engage in dan-
offered by a program often includes reintegration gerous behavior, resurgence of certain symp-
into school and the community. Even if these toms, and what is generally being worked on in
have been minimally interrupted, the child is typ- therapy), what the therapist is willing to share
ically in the position of engaging in the commu- with caregivers, and the amount of contact the
nity with fewer support structures in place than caregiver would like to have with the therapist.
what were offered by the program. Therefore, it For a child who has been in a higher level of
can also be helpful to consider and have in place care, it is recommended that there be regular,
a relapse prevention plan (i.e., warning signs the frequent contact between the therapist and care-
child is struggling and what to do should it occur), givers. It is generally the case that if a child or
enhanced community supports (e.g., looping in adolescent feel everything they tell a therapist is
the school counselor and having scheduled repeated to caregivers, they will not fully engage;
check-ins), and an understanding of how school this is mitigated when therapist, youth, and care-
and academics will be managed during and after givers are clear on what will and will not be
program, including earning and making up shared with caregivers at the outset, and it is the
credits. second author’s experience that this does not
Programs vary in their provision of a relapse prohibit youth from sharing that which the thera-
prevention plan upon discharge. A relapse pre- pist has previously stated she will share with
vention plan details what supports are in place to caregivers (e.g., self-harming behavior). If a
detect any recurrence of symptoms or difficulties therapist is unwilling to have regular contact
functioning (e.g., weekly check-ins with the with caregivers and share pertinent information
school counselor and frequent check-ins between about the child’s safety, the treatment, or resur-
the caregiver and child in addition to seeing a gence of concerning symptoms, it may be impor-
therapist each week), signs of relapse that are tant to find a provider who is willing to do this.
26 Strategies to Navigate Day-Treatment Services and Follow-up Plans: A Guide for Families and Providers 473

Returning to School at treatment admission and discharge can help aid

and the Community in how the caregiver, child, and school work to
When youth are involved in an IOP or PHP, this develop a return to school plan.
often includes increased time away from school A return to school plan is a critical component
and other activities. As the child is more fully of a successful reentry to the learning environ-
reintegrating back into the community, it can be ment. In our experience, balancing academic
helpful to have a plan about what explanations needs and mental health treatment in a way that
and details to give when peers ask questions or maximizes full engagement in treatment and
the child or family want to share the details of the recovery, while minimizing delaying academic
child’s treatment and mental health concerns. obligations, is most beneficial for the child. It is
While there has been progress in decreasing the challenging for youth to graduate a day-treatment
stigma around mental health challenges, stigma program but then face an overwhelming amount
continues to exist, and it varies greatly in extent of coursework to make up, needing to take a full
from community to community. Therefore, fami- load of challenging courses, and/or attending
lies will benefit from talking together about what summer school. It can be helpful to explore with
they feel comfortable sharing. Families can also the school and day-treatment program what
ask the child’s treatment team for suggestions on opportunities exist to assist the child in obtaining
the type details or information to share. The child credits, and as much as possible, not fall too far
and family could also role-play with the child’s behind their peers. A return to school plan can
providers how to engage in these social allow the child to identify strengths and weak-
exchanges. It is also important to prioritize what ness related to their learning environment and
the child is comfortable having shared. Many expectations. This can include classes, teachers,
times, caregivers, with the best of intentions, will timing of events, social engagement, and aca-
give detailed explanations to school personnel, demic resources. In the first authors program, this
relatives and family friends, and other important activity was completed in a multifamily group to
community members that leave the child feeling allow youth and caregivers to work on this
exposed, vulnerable, betrayed, and uncomfort- together. It was initiated by the child identifying
able. It can be helpful to keep in mind this is the these areas of strengths and weakness and then
child’s personal health information, and the child discussing it with their caregiver to allow the par-
may provide guidance to family members (e.g., ent to appreciate their child’s situation, use skills
caregivers and siblings) on the story or narrative for validation, and brainstorm any additional
to share. Keep it simple. More details are harder resources or needs. A focus of this plan is allow-
to recall and can spin out of control quickly. ing the child to determine what skills they have
Additionally, even close friends and family mem- learned that would aid them in a successful return
bers may ask for more details. It is ok to share to their learning environment and what resources
what you are comfortable sharing and ask them would help support their success.
to appreciate your boundaries, knowing this may
change over time. Additionally, friends and fam-
ily members may choose to share this informa- Conclusion
tion with others, which is no longer under your
control. It can also be helpful to consider how The continuum of mental health services for
caregivers can receive the support they need from youth includes a variety of interventions.
family members and friends while keeping in However, not all services are available to all fam-
mind what details might not need sharing. With ilies, and the wide range of services and interven-
schools, we generally recommend starting with tions can be difficult to identify and decipher. As
sharing the minimum necessary for the school to a result, it is well known that caregivers often
help the child and keep them safe in the school experience challenges with navigating, access-
environment. Talking with the school personnel ing, and engaging in this labyrinth of mental
474 J. M. Leffler et al.

health services. Simply navigating and accessing Colorado Children’s Hospital. (5/25/2021). Children’s
Hospital Colorado Declares a ‘State of Emergency’
these services has been described as exhausting, for Youth Mental Health. https://www.childrenscolo-
frustrating, and overwhelming. This is unfortu- rado.org/about/news/2021/may-­2021/youth-­mental-­
nate as this process can cause some families to health-­state-­of-­emergency/. Accessed 7/30/2021.
avoid pursing services for their child. However, Leffler, J. M., Junghans-Rutelonis, A. N., McTate, E. A.,
Geske, J., & Hughes, H. M. (2017). An uncontrolled
youth and families can benefit from engaging in pilot study of an integrated family-based partial hos-
mental health treatment. In addition, sometimes pitalization program for youth with mood disorders.
more intense treatment services beyond tradi- Evidence-Based Practice in Child and Adolescent
tional outpatient therapy are clinically necessary Mental Health, 3-4, 150–164.
Leffler, J. M., Junghans-Rutelonis, A. N., & McTate,
for a child. Utilizing more intensive services, E. A. (2020). Feasibility, acceptability, and consider-
such as day-treatment programs, is often required ations for sustainability of implementing an integrated
when there is a need for more frequent or com- family-­based partial hospitalization program for chil-
prehensive treatment to address the child’s men- dren and adolescents with mood disorders. Evidence-­
Based Practice in Child and Adolescent Mental
tal health needs beyond outpatient therapy. Health, 5, 383–397.
Similarly, day-treatment programs can be very Leffler, J. M., Borah, B., & Eton, D. (2021). Health and
successful to aid a child’s return home and to wellness for youth and families: Evaluating the clini-
their community after being discharged from cal and fiscal outcomes of an innovative family-based
treatment for mood disorders. Mayo Clinic Values
IPH. As developers, directors, and providers of Council Research Committee.
day-treatment programs, the authors are well Merikangas, K. R., Nakamura, E. F., & Kessler, R. C.
aware of how to assist families and maximize the (2009). Epidemiology of mental disorders in children
benefits of these programs. While caregivers may and adolescents. Dialogues in Clinical Neuroscience,
11, 7–20.
be familiar with outpatient and IPH services, they Merikangas, K. R., He, J. P., Burstein, M., Swendsen,
often are less aware and familiar with PHPs and J., Avenevoli, S., Case, B., et al. (2011). Service
IOPs. However, knowing what to expect and how utilization for lifetime mental disorders in U.S.
to navigate these programs can increase the ben- adolescents: Results of the National Comorbidity
Survey-Adolescent Supplement (NCS-A). Journal
efit of the services for the child and caregiver and of the American Academy of Child & Adolescent
aid in successful treatment follow-up. Caregivers Psychiatry, 50, 32–45.
can enhance their and their child’s experience in Olivo, A. (7/20/2021). Prince William pushes Virginia
day-treatment programs with the information in to fund community crisis centers amid gaps in men-
tal health staffing. Washington Post. https://www.
the current chapter focused on identifying pro- washingtonpost.com/local/virginia-­politics/virginia-­
grams, being familiar with the treatment team, mental-­health-­prince-­william/2021/07/20/48f675f4-­
communication, safety process, and expectations e8d0-­11eb-­97a0-­a09d10181e36_story.html. Accessed
for caregivers and working with the treatment on 7/30/21.
Protecting youth mental health: The U.S. Surgeon
team, the school, and follow-up treatment provid- General’s Advisory. (2021). https://www.hhs.gov/
ers. We hope the information in the current chap- sites/default/files/surgeon-­g eneral-­y outh-­m ental-­
ter and throughout this handbook provides health-­advisory.pdf.
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 Index

A 270–272, 276, 277, 284, 295, 302, 310, 328, 329,

ABC model, 150 333–335, 342, 344–346, 348, 354, 365, 380,
Acceptance and commitment therapy (ACT), 21, 49, 382–385, 389, 397–400, 402–409, 419, 423, 425,
105, 117, 134, 205, 331, 344, 345, 379, 423, 428 428–430, 437, 450, 456, 458, 462
Access, 3, 6, 9, 11, 13, 15, 19, 22, 25, 26, 31–34, 42, 44, 45, Autism spectrum disorder (ASD), 16, 86, 87, 89, 104,
49, 55, 83, 84, 92, 93, 97, 98, 106, 107, 112, 113, 127, 128, 134, 137, 143, 144, 146, 147, 152–154,
118–122, 129, 144, 149, 150, 153, 154, 162, 164, 170, 180, 189, 190, 235, 403
166, 181, 190, 196, 197, 199, 200, 208, 211, 217, Avoidance learning, 179
218, 221, 226, 228, 229, 235, 255, 256, 275, 276,
285, 287, 288, 294, 297, 301, 303, 306, 312, 314,
325, 326, 328, 332, 336, 342–344, 348, 356–358, B
362, 367, 372, 388, 390, 398, 401–404, 409, 410, Behavior intervention plan, 145, 149, 150
415, 417–419, 423, 425, 431, 436, 438, 439, Billing, 6, 8, 10, 31, 34–35, 39, 41–43, 47, 118, 120,
441–444, 447, 448, 455, 456, 461, 463–465, 470 121, 123, 147, 178, 262–263, 295, 304, 326, 361,
Acute care, 6, 8, 218, 440 388, 451–452
Acute mental health, 7, 12, 25, 31, 33, 38, 287, 375, 436, Binary, 265, 272
461, 463 Bipolar, 49, 89, 90, 103–105, 109, 114–117, 169, 271
Adaptation of evidence-based assessment and
interventions, 367–369
Administration, 5, 10, 11, 13, 31–50, 70, 75, 86, 89, 93, C
94, 119, 129, 137, 138, 148, 164–166, 169, 211, Cannabis, 161, 307, 311, 312
212, 301, 311, 312, 315, 334, 360, 373, 378, 457 Care coordination, 10, 378, 442
Adolescents, 5–7, 9, 10, 12, 19–24, 34, 37, 38, 45, 56, Caregiver involvement in treatment, 13, 122, 310, 311,
63, 72, 74, 87, 90, 94, 103, 107, 114–116, 128, 470–471
132, 135, 143–145, 148, 152–154, 157–159, Center for Epidemiological Studies Depression Scale for
161–172, 175, 177, 180, 181, 183, 195, 212, Children (CES-DC), 114, 115
217–222, 224, 228, 235–237, 239, 241–244, 246, Child and Adolescent Integrated Mood Program
248–254, 261, 266, 268, 274, 281–298, 301–304, (CAIMP), 7, 104–107, 109, 111, 113, 115–119,
306–315, 329, 332, 355, 359, 360, 365, 366, 375, 122, 123
377, 378, 380–382, 384, 386, 387, 389, 397, Child anxiety, 115, 133, 148, 243, 366
401–403, 416, 418, 423, 435–437, 441, 443, Child and family-focused CBT, 117
447–449, 452, 456, 458, 459, 470, 472 Child Mania Rating Scale (CMRS), 114
Adolescents Coping with Depression, 117 Child partial hospitalization programs, 81
Aftercare planning, 11, 88, 167, 348, 350, 389, 416, 456 Childhood OCD, 133
Alcohol, 128, 168, 170, 301–303, 306, 307, 309, 311, Children’s Depression Inventory (CDI), 87, 114, 243, 366
312, 314, 381 Children’s Depression Rating Scale—Revised
Antecedent-based interventions, 148, 149 (CDRS:R), 114
Anxiety, 8, 12, 16, 17, 19, 21–23, 49, 75, 87, 89, 90, 93, Children’s Interview for Psychiatric Syndromes
94, 97, 105, 128, 130, 132–134, 144, 148, 158, (ChIPS), 115
163, 167–170, 175, 176, 179, 180, 183–187, Chronological Assessment of Suicide Events (CASE), 455
202–204, 206, 208, 209, 229, 239, 240, 243, 244, Clinical Global Impression – Global Improvement
246, 248, 250, 253, 255, 262–264, 266–268, (CGI-IG), 116

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 475
Springer Nature Switzerland AG 2022
J. M. Leffler, E. A. Frazier (eds.), Handbook of Evidence-Based Day Treatment Programs for
Children and Adolescents, Issues in Clinical Child Psychology,
https://doi.org/10.1007/978-3-031-14567-4
476 Index

Clinical Global Impression-Severity of Illness (CGI-S), 244, 248–250, 263, 264, 266–268, 271, 274, 286,
116, 132, 138, 184–186 302, 329, 344, 384, 385, 403, 423, 425, 428, 450,
Coach, 8, 90, 162, 166, 168, 176, 180, 184, 222, 241, 456, 458
253, 288, 289, 325, 328, 333, 400, 406, 409 Depression and Anxiety in Youth Scale, 114
Cognitive-behavioral therapy (CBT), 7, 9, 12, 16, 21, 49, Developmental disabilities, 8, 143–145, 148, 154,
59, 62, 84, 85, 90, 91, 93, 105, 112, 116, 117, 370, 372
131, 133, 135, 138, 159, 160, 170, 179–182, 204, Devor, 264
205, 218, 219, 222, 223, 225, 228, 235, 236, Dialectical behavior therapy (DBT), 7–10, 16, 17, 49, 57,
238–241, 247, 249, 250, 252, 254, 255, 264, 275, 84, 85, 90, 91, 116, 117, 135, 157–172, 189, 199,
282, 286, 309, 331, 333, 344, 367, 378, 379, 387, 200, 204, 205, 218, 219, 221–225, 228, 229, 264,
397–400, 404, 408–410, 423, 428, 437, 447, 454, 271–272, 275, 281–298, 344, 378, 379, 423, 425,
456, 464 426, 428, 429, 437, 438, 440, 454, 456, 464
Columbia-Suicide Severity Rating Scale (C-SSRS), 82, Dietician, 4, 18, 32, 40, 58, 109, 111, 435
86, 220, 226, 455–456 Discharge planning, 7, 8, 22, 38, 41–42, 57, 91, 95, 96,
Community collaboration, 358 121, 163, 207–208, 220, 223, 225, 311, 378, 436,
Connection, 43, 112, 113, 121, 144, 183, 189, 190, 209, 443, 471–472
247, 248, 262, 264–267, 269, 273–275, 277, 297, Disruptive mood dysregulation disorder (DMDD),
311, 332, 337, 342, 349, 355, 358, 363, 364, 369, 105, 115
381, 429, 431, 436, 439, 442, 456, 458 Dissemination, 5, 56, 170, 229, 310, 409, 421, 432
Conners Comprehensive Behavior Rating Scales Distress tolerance, 132, 135, 154, 159, 160, 162, 166,
(CBRS), 115 212, 221–224, 283, 284, 287, 288, 331, 345, 379,
Continuum of care, 15, 22, 26, 154, 229, 313, 375, 376, 381, 425, 438, 454, 457
387, 435, 437–439, 444, 462, 471
Co-occurring disorders, 10, 238, 301–315
COVID-19, 9, 12, 13, 26, 37, 43, 45, 91, 95, 104, 109, E
119, 122, 172, 183, 189, 202, 217, 223, 235, 238, Educational resources, 462
244, 245, 254, 255, 297, 306, 314, 327, 359, 372, Emergency department (ED), 3, 15, 19, 104, 106, 128,
415–417, 420, 423, 425, 430, 432, 448, 449, 464, 137, 227, 229, 292, 307, 329, 440, 441, 444, 447,
465, 471 449, 450, 459
Crisis, 3–5, 7, 10–12, 15–17, 25, 31, 33, 37, 39, 41–43, Emergency services, 145, 307, 364, 469
86, 92, 106, 112, 113, 120, 136, 162, 163, 200, Emotion dysregulation, 129, 157, 159, 163, 189, 283, 294
202, 221–225, 229, 274–275, 284, 287–289, 301, Emotion regulation, 8, 22, 23, 75, 97, 128, 130, 136, 146,
328–329, 341, 347, 359, 363–365, 369, 423, 429, 147, 154, 159, 160, 169, 170, 212, 283, 284, 287,
435–440, 442, 443, 447–452, 454–457, 459, 461, 288, 423, 424, 427, 457
463–465, 469, 470 Erik Erikson, 268
Curriculum, 11, 46, 135, 137, 139, 148, 158, 159, 170, Escape learning, 179
171, 203, 204, 224, 285, 298, 303, 341, 343–345, Evidence-based, 4–8, 11, 12, 19, 21, 22, 40, 48–50, 55,
348, 350, 361, 362, 368, 370–373, 378, 422–425, 57, 63, 74, 83, 86, 88, 96, 104, 105, 109, 117,
428, 469, 470 119, 120, 128, 129, 133–135, 139, 148, 157, 169,
205, 218, 223, 239, 242–244, 253, 254, 284, 290,
298, 303, 304, 307–313, 330, 331, 358, 360, 361,
D 365, 367–370, 378, 381, 385, 398, 401, 409, 415,
Data, 6, 13, 22, 25, 26, 35, 44, 45, 47, 48, 50, 70, 71, 74, 417, 422, 425, 428, 436, 437, 455–456
75, 88, 95, 97, 108, 115, 116, 119, 122, 123, 128, Evidence-based approaches, 81, 92, 128, 309
130, 132–135, 139, 145, 147–150, 153, 154, 158, Evidence-based assessment (EBA), 7, 11, 13, 22, 47–48,
169, 170, 176, 178, 181–184, 187, 188, 206–208, 50, 114, 132, 238, 244, 330, 365–367, 437
226, 228, 229, 236, 239, 244, 247, 253, 255, 282, Evidence-based care, 236, 238, 239, 255, 297, 301, 303,
283, 302, 312, 329, 335–337, 341, 356, 358, 365, 313, 401, 410, 415, 431
366, 372, 381, 382, 385–387, 389, 390, 402, 410, Evidence-based therapy, 312, 425
416, 424, 425, 435, 458, 468 Evidence-based treatment (EBT), 3, 7, 13, 15, 17, 48–50,
Day treatment, 6, 8, 10–12, 16, 17, 19–21, 31–50, 56, 57, 55–60, 63, 109, 117, 118, 120–122, 228, 254,
60–63, 69–73, 75, 97, 107, 127, 128, 181, 212, 281–284, 286, 291, 296, 298, 315, 398, 409,
227, 254, 323–337, 353–373, 375, 382, 415, 430, 428–430, 461
436, 461–474 Evidence-informed care, 4, 96
Day treatment program, 5–7, 10–12, 15–26, 31, 35–47, Exposure therapy, 175, 176, 178, 185, 188, 310, 397,
58, 59, 61, 63, 64, 73, 83, 97, 122, 143, 353, 399, 400, 402, 408, 410, 428
415–417, 461–474 Exposure with response prevention (ERP), 8, 9, 12,
Depression, 16, 19, 22, 23, 49, 75, 87, 89, 91, 94, 97, 175–177, 179–182, 188, 189, 197, 203, 205, 210,
103, 109, 114–117, 131–133, 144, 148, 168–170, 235, 239–241, 245, 249, 250, 252, 253, 398, 425,
181, 186, 202, 210, 226, 227, 229, 238, 241, 243, 428–429
Index 477

Expressive therapy, 271 229, 235, 236, 239, 242, 247, 250, 255, 262, 264,
Extinction, 148, 149, 181, 294 267–277, 283, 284, 287, 288, 291, 301, 303,
308–310, 313, 324–325, 328–332, 335, 341, 342,
344–350, 355–357, 363, 364, 366, 367, 370, 371,
F 377, 378, 380, 381, 384, 385, 399–404, 407, 409,
Family, 3–13, 15–19, 21, 24, 25, 31–34, 36, 38–41, 416, 421, 423–426, 428, 432, 437, 447, 452–454,
44–46, 48, 49, 56–58, 72, 74, 81, 82, 84–86, 456, 457
88–90, 92–98, 103–107, 109–114, 116–122, Group therapy, 4, 8, 11, 19, 32, 39, 41, 46, 49, 73, 81, 85,
127–132, 134, 135, 137–139, 143–154, 157, 159, 91, 93, 109, 130, 143, 159, 162, 163, 179, 205,
161–167, 169–172, 176–180, 182–186, 188–190, 223–224, 241, 245, 268, 270, 283, 304, 306,
195–213, 218–226, 228, 229, 236, 239, 241, 243, 308–310, 342–344, 357, 360, 377, 378, 416, 420,
244, 246–248, 250–251, 255, 256, 262, 263, 425–428, 436, 438, 450, 451, 462, 465
265–269, 273–277, 283, 285, 287–297, 303, 304, Gunderson, 271, 275
306–315, 323–334, 336, 337, 348, 349, 355–358,
360–366, 368–372, 375–378, 380–385, 387–390,
397–410, 416, 418–420, 422, 423, 425–427, H
430–432, 437–444, 447–449, 451–454, 456–459, Habituation, 176, 197, 249, 250
461–474 Health and wellness, 25, 32, 33, 103, 105, 106, 109,
Family accommodation, 241, 243, 248, 250–251 111, 117
Family Focused Therapy, 117 Heterosexism, 263, 265, 272
Family involvement, 6, 8, 9, 11, 25, 49, 84, 103, 105, Home visit, 8, 85, 176, 178, 179, 183, 184, 188
151, 153, 157, 161, 165, 176, 219, 246, 266,
348, 456
Family meals, 40, 269, 273–274 I
Family of choice, 269, 273–274, 276 Identity, 21, 160, 211, 212, 262–269, 271–276, 293,
Family psychoeducation psychotherapy, 105, 117 306, 358
Family-systems treatment, 196 Identity formation, 265
Family therapy, 4, 7, 9, 10, 25, 31, 32, 40–42, 46, 48, 49, Implementation, 5–7, 9, 11, 12, 16, 17, 19, 22, 26, 31,
59, 81, 84, 85, 90–92, 105, 109, 113, 116, 117, 35, 46, 48–50, 55–64, 70–75, 83, 88, 93, 98,
128, 129, 131, 135, 138, 143, 145–147, 151, 167, 107–109, 114, 116, 118–121, 123, 145, 149–151,
176, 179, 180, 182, 183, 198, 200, 201, 204–208, 177, 217–229, 261–263, 271, 287–288, 291, 301,
211, 212, 220, 222, 225, 228, 290, 304, 307, 308, 303, 304, 313, 324–332, 357–361, 367, 372, 376,
310, 312, 325, 334, 348, 353, 361, 364, 376–381, 398–400, 406, 416, 417, 425, 430, 449–453
417, 419, 423, 425–427, 436, 438, 442, 448, Improving care, 71
451–454, 456, 459, 462, 463, 465, 468, 470, 471 In vivo exposure, 205, 399, 431
Feedback, 44, 47, 50, 60–63, 69–75, 90, 93, 105, 109, Individual therapy, 8, 9, 21, 41, 46, 49, 72, 73, 81, 85, 91,
122, 145, 148, 151, 157, 161, 167, 170, 203, 107, 109, 113, 120, 130, 137, 143, 145, 146, 157,
206, 208, 239, 246, 247, 262, 267, 275, 309, 159, 161, 163, 179, 182, 201, 203, 205–206, 210,
315, 342, 357, 358, 361, 371, 377, 379, 406, 212, 220, 221, 223–225, 229, 235, 274, 283, 285,
416, 425, 428, 432 291, 293, 295, 304, 309, 310, 342, 343, 345, 350,
Financial oversight, 34 360, 377–379, 417, 421, 423, 425, 426, 438, 465,
Formulation, 146, 152, 345, 346, 348, 358, 361, 468
423–426, 449 Inpatient, 3, 4, 11, 12, 15, 17, 20–22, 31, 32, 71, 72, 81,
Functional behavioral assessment (FBA), 148, 149 82, 93, 104, 107, 109, 127–129, 137–139, 145,
Functional outcomes, 6, 7, 50, 269, 271, 275 146, 153, 154, 158, 163, 169, 176, 177, 181, 195,
217, 219, 220, 227, 229, 252, 262, 267, 274, 302,
303, 325, 326, 330, 354, 376, 384, 385, 388, 415,
G 417, 435–443, 447, 450, 462, 465, 469
Gay, 158, 261–263, 265, 266, 272, 274, 276 Inpatient psychiatric hospitalization (IPH), 3, 4, 12, 15–17,
Gay-affirmative therapy (GAT), 273 25, 26, 31, 33, 34, 37, 44, 82, 105, 106, 116, 118,
Gay, bisexual, transgender, queer/questioning, 261, 274 119, 122, 435–444, 447, 449, 462, 463, 474
Gender, 164, 196, 203, 248, 255, 263–265, 267, 268, Inpatient psychiatry, 3, 12, 15, 20, 31, 104–107, 109,
271, 272, 275, 276, 292, 293, 343, 448, 449 176, 435–444, 447
Gender identity, 151, 264–268, 273, 293, 343 Institute of Living, 261, 262
Goals, 4, 5, 7–9, 11, 12, 17, 18, 20–22, 31, 33, 35, Insurance, 3, 6, 8, 10–13, 15, 19, 25, 34–36, 40, 46–48,
37–39, 42, 46, 48, 50, 57, 60, 73, 82, 84–86, 88, 57, 63, 74, 83, 114, 118–120, 122, 128, 132, 137,
91–96, 104, 106–108, 111, 113, 116, 118–121, 146, 153, 166, 167, 177, 178, 183, 188, 190, 238,
130, 131, 133–138, 144–146, 149–151, 154, 158, 254, 262–263, 286, 287, 289, 291, 292, 297, 301,
160, 162, 163, 166–168, 170, 176, 179, 182, 190, 304, 306, 326, 344, 348, 361, 382, 388, 417, 442,
195, 196, 200, 202, 203, 205–208, 212, 221–225, 443, 451–452, 461, 464, 465, 471, 472
478 Index

Integrated programming, 353–373 314, 315, 331, 333, 336, 341, 346, 348, 353–358,
Integrated research, 86, 96–97 363, 365, 367, 371–373, 375–380, 382–385, 388,
Integrated treatment, 6, 10, 13, 302, 381 389, 397, 401, 415–417, 422, 423, 428, 431, 432,
Intensive interdisciplinary pain treatment (IIPT), 10, 435–444, 447–449, 451, 453, 461–465, 468–470,
323–325, 330, 332, 335 472–474
Intensive intervention, 26, 92, 107, 281 Meyer, 263, 265, 275, 292, 389, 398
Intensive outpatient, 10, 32, 57, 139, 143, 154, 178, 235, Milieu, 9, 10, 18, 19, 21, 22, 31, 32, 39, 41, 48, 49, 56,
244, 248, 251, 254, 256, 261–277, 283–284, 336, 58, 59, 61–63, 82–85, 88, 90–92, 111, 117, 120,
350, 388, 397, 399, 401–402 127, 130, 131, 134, 147, 148, 150, 151, 153, 164,
Intensive outpatient programs (IOPs), 3–6, 9–13, 15–18, 165, 167, 171, 179, 182, 184, 195, 197–206, 208,
20, 31–33, 37–39, 45, 46, 49, 55–64, 106, 107, 210–212, 267–269, 281, 285, 288, 289, 292–294,
109, 116, 117, 121–123, 154, 218–229, 236, 245, 296, 297, 306, 308, 309, 342, 343, 346, 353, 357,
247, 248, 253, 255, 256, 261–262, 264, 267–270, 370, 377, 425, 427, 428, 435, 438, 440–442, 447,
274–276, 281–298, 301–303, 312–314, 341–350, 448, 450, 454, 463
375, 382, 417, 435, 436, 438–444, 462–465, 468, Mindfulness, 7, 9, 49, 85, 105, 106, 111, 114, 117, 128,
469, 471, 473, 474 135, 136, 138, 139, 159, 160, 162, 167, 169, 170,
Intensive psychotherapy, 399, 401 179, 204, 219, 223, 224, 273, 283, 284, 286–288,
Intensive treatment, 6–8, 31, 55, 57, 61, 63, 82, 97, 104, 291, 331, 376, 379, 388, 420, 424, 426, 427, 429,
105, 117, 145, 146, 154, 162, 181, 204, 303, 324, 454, 456, 457, 464
330, 346, 350, 389, 401, 403, 438, 455 Minority stress, 261–263, 265, 275, 349
Interdisciplinary, 10, 18, 26, 41, 177, 195–213, 304, 308, Monitoring, 4, 6, 12, 16, 17, 22, 38, 40, 42, 48–50,
312, 324, 327, 329, 330, 332, 335–337, 435, 438 69–71, 74, 82, 94, 98, 104, 118, 121, 128, 133,
Interdisciplinary day treatment, 81 139, 143, 144, 147, 163, 168, 181, 200, 202, 203,
Interdisciplinary team, 7–9, 39, 93, 97, 154, 196, 210, 212, 224, 226, 238, 241, 263, 288, 290, 303,
201–203, 212, 308, 335, 359–360 307, 310, 313, 356, 361, 366, 370–372, 385, 387,
Intermediate level of care, 11, 21, 37, 376, 382, 438, 390, 404, 429, 437, 441, 451, 458, 468, 470
462, 463 Mood disorder, 7, 16, 19, 49, 103–105, 107, 109, 111,
Interpersonal effectiveness, 159, 160, 223, 283, 284, 287, 112, 115–117, 119, 122, 128, 181, 263, 267, 450
288, 344, 345, 425 Mood Disorder Questionnaire (MDQ), 114
Interpersonal therapy (IPT), 49, 90, 110, 112, 116, Mood Disorders Questionnaire-Adolescent Version
117, 218 (MDQ-A), 114, 115
Interpersonal Therapy for Depressed Adolescents, 117 Multidisciplinary treatment team, 118, 129, 145,
377–378
Multifamily, 105, 107, 109–111, 117, 122, 228, 283–285,
L 288, 289
Leadership, 17, 36, 39, 60, 75, 119, 120, 158, 165, 166,
177, 178, 203, 285, 297, 313, 325, 326, 337, 359,
376, 383, 389, 432, 449, 450, 452 N
Lesbian, 158, 261–263, 265, 266, 274 Neff, 271, 273
LGBTQ, 261–277 Negative reinforcement, 179
LGBTQ+, 10, 21, 266–269 Non-binary, 57, 158, 196, 263–265, 275, 382
Linehan, 134, 157–159, 164, 169, 170, 221, 223, 224, Non-suicidal self-injury (NSSI), 10, 161, 166, 219,
229, 271, 272, 283, 284, 287, 288, 290, 294, 295 226, 227, 229, 235, 282, 283, 286, 287, 289, 297,
435, 437

M
Measurement-based care (MBC), 6, 7, 48, 50, 69–75, O
132, 133, 139, 425 Obsessive-compulsive disorder (OCD), 8, 9, 59, 87, 128,
Medical-psychological, 203 163, 164, 175, 176, 178–187, 235–255, 286, 295,
Medication management, 4, 9, 16, 20, 32, 39, 46, 49, 81, 297, 397, 398, 401–403, 407, 408, 441
91, 105, 109, 117, 128, 130, 137, 145, 146, 179, Occupational therapy (OT), 8, 19, 32, 39, 42, 82–85, 98,
182, 208–209, 217, 220, 226, 228, 241, 288, 297, 107, 110, 112, 131, 134, 137, 144–146, 150, 201,
304, 307, 308, 311, 313, 343, 357, 416, 423, 436, 308, 326–328, 332, 333, 336, 346, 348, 349, 359,
458, 462, 465, 471 360, 362, 364, 368, 465, 468
Mental health, 3–7, 9–13, 15–22, 25, 26, 31–34, 36, 37, OCD intensive outpatient program development evidence
39, 40, 42, 44–46, 48, 50, 55, 56, 58–61, 63, based, 235–257
69–72, 75, 89, 92, 95, 98, 105, 107, 111, 112, Organizational change, 59, 60
114, 115, 118, 120–122, 130, 144, 147, 153, Outcomes, 3, 5, 6, 8, 9, 11, 13, 16, 17, 19, 20, 22–26,
162–165, 167–169, 171, 178, 212, 225, 238, 239, 34–36, 47–50, 56, 57, 60, 61, 69–75, 94, 96, 97,
254, 256, 257, 261–263, 265–268, 271, 272, 276, 108, 117, 119–122, 129, 130, 132–136, 138, 139,
283, 284, 287, 290, 292, 295, 301–304, 307, 308, 149, 153, 154, 177, 178, 181, 184, 187, 188, 197,
Index 479

201, 218, 220, 226–229, 236, 238–242, 246–253, Positive behavior support (PBS), 147, 437
255, 266, 275, 282, 302–304, 309–311, 315, 323, PRACTICE, 4, 11, 31, 34–35, 42, 43, 46, 48, 55, 57,
329, 330, 335–337, 341, 342, 344, 350, 381, 59–61, 63, 73–75, 93, 96, 97, 106, 109, 118, 121,
384–390, 398, 399, 401, 403, 409, 416, 417, 425, 133, 134, 144, 147, 148, 160, 169, 223, 304–307,
438, 439, 441, 442, 452 310, 315, 375–377, 379–381, 383, 385, 387–389,
Outdoor Behavioral Healthcare (OBH), 11, 12, 375–390 401, 409, 410, 415, 432
Outdoor therapy, 375–379, 382–389 Pre/post assessment, 86–88
Outpatient, 3, 4, 8, 9, 11, 12, 15–17, 20, 22, 25, 31–33, Process therapy, 271
42, 44, 48, 49, 55–57, 60, 61, 71–73, 86, 89, 91, Program, 3–13, 15–22, 25, 26, 31–50, 58–61, 63, 69, 71,
93, 96, 98, 104, 107, 116–118, 122, 137–139, 73, 74, 81–88, 90–93, 95, 96, 98, 104–123,
144–146, 152, 154, 157, 158, 161, 163, 166–168, 127–133, 135–139, 143–154, 157–159, 161–172,
175–177, 180–183, 188, 190, 195, 201, 202, 175–180, 182–185, 187–190, 195–211, 217,
206–208, 218–220, 225–227, 229, 235, 245, 219–229, 235–242, 244–248, 253–256, 261–271,
247–249, 251, 252, 255, 262, 283, 285, 287, 289, 273, 275–277, 281, 282, 284–298, 301–304, 306,
290, 292, 295, 297, 302, 303, 313, 314, 324–326, 307, 311–315, 323–337, 341–350, 353–358,
330, 333–336, 345, 350, 354, 358, 370, 375, 376, 360–365, 367–373, 375–390, 397, 399, 401–403,
382, 384, 407, 410, 417, 432, 435–442, 451, 452, 407–410, 415–418, 420, 423, 424, 430–432, 435,
457, 458, 462, 463, 474 436, 440–444, 447–452, 454, 457, 458, 461–465,
Outpatient therapy, 3, 4, 7, 20, 25, 26, 31, 33, 81, 104, 468–474
105, 107, 118, 163, 166, 182, 235, 297, 308, 324, Program development, 5–8, 17, 31–50, 83, 119–122, 129,
325, 388, 407, 415, 425, 461–463, 465, 474 138, 177, 219, 238–239, 261–263, 287–288, 303,
304, 325–332, 343, 350, 357–361, 389, 449–453
Program evaluation, 6, 74, 170, 202, 226, 376
P Protective factor, 113, 219, 221, 222, 224, 225, 269
Pain rehabilitation, 10, 335–337 Psychiatrist, 4, 18, 40, 42, 58, 59, 61, 69, 84, 85, 93, 94,
Parent, 6–9, 12, 13, 25, 33, 39, 40, 82–95, 97, 103, 104, 109, 115, 127, 129, 137, 145, 146, 151, 152, 165,
110, 114–117, 128, 129, 131–136, 138, 144–151, 168, 176, 177, 179, 182, 184, 185, 196, 200, 205,
153, 158, 159, 161–167, 169–172, 176, 178, 179, 208, 209, 220, 226, 227, 238, 270, 285, 287–289,
182–189, 197, 199–202, 204–208, 210–212, 304, 344, 346, 354, 355, 359, 360, 370, 376, 377,
219–229, 235, 236, 238–241, 243–246, 250, 251, 384, 402, 422, 435, 438, 448, 450, 452, 453,
253, 266–268, 276, 283, 285, 286, 288–290, 457–459, 462, 468, 471, 472
292–294, 296, 297, 304, 306, 310, 311, 314, 315, Psychiatry, 5, 7, 9, 18, 39, 41, 42, 82, 83, 93–94, 98, 107,
331, 332, 334, 335, 348–349, 353–356, 358, 359, 109, 110, 128, 130, 132, 145, 146, 157, 163, 172,
361, 365–367, 370, 372, 377, 378, 381, 384, 386, 177, 180, 195, 201, 205, 209, 226, 227, 238, 262,
389, 397–407, 409, 417, 419, 420, 423, 425, 429, 287, 289, 295, 296, 314, 325, 360, 402, 415, 436,
447–451, 453–459, 461, 463, 465, 473 451, 458
Parent-coached, 12, 399–401 Psychoeducation, 17, 18, 21, 32, 33, 40, 90, 93, 94,
Parent Coached Exposure Therapy (PCET), 12, 397, 103–105, 109, 111, 112, 116, 117, 131, 135,
399–402, 409, 410 151, 161, 212, 218, 220, 224, 241, 245, 266,
Parent training, 83, 85, 90, 104, 128, 131, 135, 138, 144, 293, 295, 308, 309, 332, 355, 367, 379–381,
150, 218, 378, 398 398–400, 404, 407, 409, 426, 437, 454, 457,
The Parent General Behavior Inventory (PGBI), 114 462, 468
Parents, Families, and Friends of Lesbians and Gays Psychosocial, 4, 6, 11, 21, 40, 93, 116, 151, 180, 181,
(PFLAG), 266 186, 268, 304, 329, 341, 345, 346, 349, 356, 378,
Partial Hospital, 88, 97, 143, 163, 181, 197, 201, 209, 386, 436, 437, 454
297, 350
Partial Hospital Program, 81, 83, 157, 195–213, 341, 423
Partial hospitalization, 16, 17, 31, 32, 37, 81, 95, 97, 127, Q
150, 154, 175–177, 181, 189, 256, 303, 341–350, Quality, 7, 9, 11, 23, 24, 26, 34, 35, 46, 47, 59–61, 69,
388, 440 70, 74, 75, 90, 108, 119, 121, 133, 159, 168, 177,
Partial hospitalization programs (PHPs), 3–9, 12, 13, 180, 185, 186, 188, 199, 202, 204, 218, 226, 292,
15–18, 20–24, 31–33, 37–39, 45, 46, 49, 55–64, 301, 303, 315, 323, 329, 337, 350, 356, 358, 367,
74, 81–90, 92–98, 104, 107, 109, 116, 117, 119, 401, 418, 419, 430, 440, 452–453
121–123, 127–130, 132–135, 137–139, 143, 144,
146–148, 150–154, 157–159, 161–172, 177, 179,
189, 190, 276, 281, 296, 341–343, 346, 347, R
415–417, 422, 425, 428–430, 432, 435, 436, Recreation therapy, 21, 82, 224, 468
438–444, 462–465, 468, 469, 471, 473, 474 Reimbursement, 8, 11, 26, 34, 36, 40, 47, 74, 107, 118,
Patient Health Questionnaire-9 modified (PHQ-9M), 120, 167, 382, 388
114, 115 Reinforcement, 90, 94, 136, 148–153, 197, 199, 203,
Pediatric chronic pain, 10, 323, 326, 329–332, 335, 337 245, 284, 294, 331, 363, 366–368, 442
480 Index

Research, 6–11, 17, 20, 25, 26, 35, 37, 41, 47–50, Stakeholder, 5–11, 26, 31, 34–37, 39, 42, 47–50, 73–75,
55–58, 60–64, 73, 75, 83, 86–88, 95–97, 107, 83, 84, 107, 108, 118, 120–122, 138, 177–178,
108, 114–117, 119, 123, 129, 130, 132, 146, 183, 219, 238–239, 301, 303, 313, 326, 332, 336,
153, 169, 170, 177, 180, 182, 184–188, 190, 360–361, 385, 449–451
196, 205, 217–219, 229, 239–242, 244, Stigma Management, 272–273
246–253, 255, 262, 263, 265, 266, 274, 275, Substance use, 10, 20, 21, 33, 38, 45, 57, 112, 113, 158,
282, 284–285, 290, 294, 298, 302–304, 159, 163, 168–170, 222, 248, 263, 264, 266, 271,
308–314, 329, 330, 335–337, 358, 360, 367, 286, 293, 296, 301–304, 307–312, 314, 315, 324,
370, 371, 377, 380–383, 385–389, 397, 410, 344, 375, 382, 385, 387, 429
415–417, 430, 432, 437, 440–442, 458–459, 468 Suicidal ideation, 38, 49, 82, 90, 97, 104, 109, 112, 113,
Return to school plan, 470, 473 130, 158, 161, 166, 168–170, 202, 217, 218, 220,
Reynold’s Adolescent Depression Scale and Reynold’s 222, 223, 225, 227–229, 235, 263, 268, 275, 282,
Adolescent Depression Scale 2nd edition (RADS 286, 297, 329, 334, 335, 383, 403, 404, 423, 436,
& RADS-2), 114 450, 455, 458, 459
The Right Track, 262, 266–269, 271, 274–276 Suicide, 9, 10, 16, 20–23, 49, 71, 87, 115, 117, 168–171,
Risk assessment, 12, 20, 86, 168, 275, 346, 383, 416, 217–223, 225–229, 263, 274, 275, 281–283,
423, 441 285–287, 290, 292, 293, 297, 298, 302, 341, 343,
Risk management, 11, 376, 377, 381, 385, 387, 388, 390 423, 429, 435, 437, 439, 443, 447, 448, 451, 452,
455, 456, 458, 459
Suicide prevention, 9, 169, 217–219, 224, 225, 282,
S 456, 457
Safety planning, 32, 87, 106, 112, 118, 136, 205, Supervision, 11, 41, 42, 44, 46, 50, 58, 61–63, 109,
218–222, 224, 227, 275, 282, 288, 329, 364, 436, 120, 129, 133, 136, 145, 146, 153, 164, 165,
437, 440, 441, 457 188, 211, 212, 238, 241, 254, 262, 283, 285,
School, 4–9, 11, 13, 15–20, 31–34, 37, 38, 40, 45–46, 287, 290, 293, 294, 303–305, 326, 360, 362,
56, 72, 82–85, 91–93, 95, 96, 98, 104, 107, 109, 378, 400, 402, 429, 436, 439, 441, 442, 452,
118, 119, 121, 128–132, 134, 137, 138, 143–147, 453, 456
151, 152, 154, 157, 159, 162, 164–166, 168, 171, SWOT analysis, 35
172, 176, 177, 182–184, 186, 196, 204, 211, 212,
221, 222, 227, 238, 243, 244, 246–247, 261,
269–271, 282, 284, 287, 289, 296, 303, 304, 307, T
308, 311, 324, 328–335, 341, 348, 353–372, 376, Technology, 22, 25, 35, 41, 43, 48, 75, 119, 199, 200,
382–386, 389, 399, 404, 407, 408, 420, 426, 431, 211, 218, 254, 306, 314, 337, 362, 368, 371, 372,
432, 437, 457, 461–465, 468–474 404, 409, 415, 417, 422, 423
School interventions, 367 Telehealth, 10, 12, 22, 25, 33, 43, 45, 83, 92, 122, 172,
School plan, 470, 473 235, 238, 240, 244, 245, 247, 254, 255, 297,
Self-compassion, 273 306–307, 314, 325, 415–423, 426–432, 448,
Self-harm, 7, 86, 87, 90, 91, 97, 109, 159, 169, 189, 218, 449, 456
221, 274, 282, 285, 288, 290, 292, 293, 296, 298, Telemedicine, 189, 415, 416, 432
306, 307, 344, 383, 435, 437, 439, 442, 448 Therapeutic alliance, 22, 23, 57, 69, 73–75, 135,
Sensory, 19, 84, 93, 128, 145, 147, 150, 152, 153, 186, 225, 268, 275, 297, 308, 310, 314, 389,
328, 330, 364, 379, 455 428, 431
Sex assigned at birth, 265 Therapist, 4–6, 18, 35, 40, 42, 56–64, 69, 71–73, 84, 96,
Sexual orientation, 151, 212, 255, 264–268, 293 106, 107, 112, 113, 130, 135, 144, 145, 148, 153,
Shame, 10, 264, 265, 272–273, 275, 309 161, 166, 168, 188, 190, 201, 203, 205, 210,
Skill implementation, 271 220–227, 247, 254, 257, 267, 268, 283–285,
SMART goals, 113, 309 287–291, 294–296, 310, 324, 328–334, 344–349,
Social-emotional learning (SEL), 356, 358, 361, 355, 359, 363, 370, 379, 380, 384, 400–402, 409,
363–368, 371 410, 427, 432, 435, 438, 447, 448, 450–455, 457,
Social isolation, 263, 264, 440 459, 461–463, 468, 470–472
Social skills training, 134, 148, 367, 398 Trainees, 3, 11, 58, 61, 109, 130, 132, 134, 136, 146,
Social stories, 8, 152 164, 165, 177, 223, 235, 236, 238, 239, 241,
Special education day treatment, 354–359, 361–366, 245, 246, 254, 255, 262, 270, 287–289, 304,
369–371, 373 355, 360, 422
Staffing, 5–7, 11, 13, 18, 22, 31, 35, 39–41, 45, 46, 50, Training, 5, 6, 8, 9, 11, 12, 17, 32, 35, 39, 41–42, 44,
83, 84, 91, 107, 109, 118, 120–123, 137, 138, 154, 48–50, 55–64, 75, 83, 98, 107, 109, 111, 118,
165, 177, 182, 189, 202, 210, 290, 294, 298, 303, 127–130, 134–138, 145, 146, 150, 151, 153, 157,
336, 341, 343, 346, 357, 361, 450, 451, 459, 468 159, 164, 165, 169, 171, 177, 178, 183, 188, 189,
Index 481

203, 204, 217–219, 229, 236, 238, 245, 254, 255, W

262, 268, 284, 287, 290, 291, 298, 302, 304, 309, Wilderness therapy, 375–377, 379, 381, 382, 386, 387, 389
326, 357–361, 367, 371, 372, 377, 381, 382, 389, Workforce support, 62
398, 408–410, 416–418, 421, 422, 424, 425, 429,
437, 449, 451, 459, 462, 471
Trans, 263, 266, 275, 276 Y
Transgender, 57, 158, 261, 262, 265, 266, 272, 274, 275 Young adult, 11, 148, 157, 158, 165, 261–277, 312, 337,
Trauma informed, 264, 378, 389, 455 341–350, 376, 380, 423, 426, 432
Treatment team, 6, 7, 11, 13, 18–21, 23, 38, 40, 41, 46, Young Adult Services (YAS), 261, 262, 270, 275, 349
59, 73, 93–94, 98, 109, 111, 113, 116, 118, 129, Youth, 3–13, 15–23, 25, 26, 31–34, 37, 38, 44–46,
136, 137, 144, 148, 161, 162, 167, 168, 178, 182, 48–50, 56–59, 61, 63, 69–75, 90, 95–97,
184, 188, 190, 200, 201, 206, 207, 227, 286, 293, 103–107, 109–113, 115–117, 119–122, 129, 133,
304, 308, 325, 326, 329–332, 334, 335, 345–349, 148, 175, 180, 181, 187, 189, 208, 217–229, 243,
369, 377, 385, 404, 438, 439, 441, 444, 448, 452, 248–250, 261, 263–266, 268, 271–275, 282–285,
455, 457, 463, 465, 467–471, 473, 474 287, 290, 293, 295, 297, 298, 301–304, 306–309,
311–314, 323, 324, 326–328, 330, 336, 337, 343,
344, 365, 367, 372, 375, 376, 381–390, 397–410,
V 415–417, 420, 423, 426, 428, 431, 435–444,
Virtual partial hospitalization program, 422, 423 447–451, 454, 456, 458, 459, 461–464, 468–474
Vocational therapy, 271 Youth Crisis Stabilization Unit (YCSU), 12, 447–459