Jun 23, 2008, 07:23

Toward Better Outcome and Risk Management In Therapeutic Residential Settings
By: Dorothy D. Johnson, MD

In residential treatment, listening to and eliciting specific information from parents and student are the first key steps in obtaining adequate information to clarify problems, make diagnoses and be alerted to risks. In addition to providing necessary data, the interviews acknowledge the value of the experiences and insights of the parents and student, and engage them in the therapeutic process.

While intake testing and interviews with the student are standard, a residential setting’s initial contact with parents is typically limited. But parents have essential information that the therapeutic program needs. The parents have observed the student’s behaviors and ills over years at all hours of day and night, at home, in playgroups and carpool, in clubs or sports. They have taken the student for evaluations, therapies and tutoring, attended parent-teacher conferences, struggled with the student over homework assignments or pulled hair at the failure of the student to turn in completed assignments. They are aware of bed-wetting relevant to program placement, and family history of cardiovascular disease that may be important to medication selection and wilderness safety. And the parents can give perspective on traumas, family dynamics and stresses important to the student’s and family’s treatment and the student’s successful re-entry into the family.

Relying on outside evaluations is unsatisfactory for gathering parent information. Good professionals often get incomplete information because of time limitations, because parents and students are not interviewed separately, or because only a single parent is interviewed, omitting the views of each/all parents. And clinical interviews are guided by the professional’s specialty and clinical experience, as well as the family’s presenting crises. Psychological and educational assessments tend to focus on testing and interviewing the student, omitting the parent.

Rating scales alone are too narrow in scope. Paper questionnaires cannot probe in depth and require staff time to compute data results or transfer the information into an electronic record. These tools are too limited to optimize a residential treatment setting’s comprehensive intervention plan and outcomes. An alternative is the branching computeradministered interview.

A well-designed computer interview:

  • Can elicit and document much more information than occurs with face-to-face interviews. 1

  • Is systematic and thorough. It asks its component first-level questions to one and all and delves deeper when indicated by first responses. In a face-to-face interview, neither parents nor interviewer can think of everything or even most things that turn out to be important, particularly in the midst of a crisis situation.

  • Saves professional time in eliciting and recording parent history.

A computer interview can aid communication:

  • Responses to computer interviews are generally more honest than in face to face interviews, particularly in regard to sensitive topics. 2 Compared to using a computer-administered interview, in a face to face interview parents may be more reluctant to mention things that embarrass themselves or that they think may preclude a student from being accepted for placement.

  • Educational information for the parent can be integrated into the report, and side comments to the provider can be provided separately from the formal report.

  • Graphs of gathered data can facilitate recognition of strengths and concerns.

A computer-administered interview program may provide options including:

  • Interviews representing different disciplines, such as medical, educational, and psychological.

  • Interviews for different reporters, as parent, student and teacher.

  • Rating scales.

  • More or less detailed interviews.

The professional benefits from automatically generated electronic results:

  • The electronic report provides for entirely legible and easily transmitted communication between providers.

  • The computer program can provide statistical interpretation of results or provide response rates, as positive responses out of total possible responses, in a given diagnostic or symptom category.

  • A population study of symptom profiles may be feasible if the same sequence of questions is asked for each student.

  • The computer data may be program or passwordprotected.

There are some considerations in adding computeradministered interviews.

  • If done in the office, there must be space and time as well as the computer for the family to complete the interview.

  • If the interview is being done from home, consider technical support for the family and confidentiality if information is going over the Internet.

  • Professionals must have the capacity and willingness to read and utilize the information provided by the interview.

  • - If the interview program includes multiple sections, in some settings it works best to give only one interview section per clinical visit.

    - For a residential team, it is logical to obtain all the data initially, designate one team member to review the entire report and have that individual delegate intervention responsibility to the appropriate team members.

    - When the family is using an Educational Consultant, it may be preferable for the parent(s) to complete the computer interview in that office. This allows the Consultant to utilize that information in recommending programs, and, with the client’s permission, confidentially deliver the information to the accepting Residential setting. (If the Residential setting also has the computer program, the electronic results can be e-mailed confidentially.)

There are several diagnostic mental health inventories focusing on DSM-IV diagnoses that have a computeradministered version. These include the BASC or Behavior Assessment System for Children and the lengthy DICA-R or Diagnostic Interview for Children and Adolescents Revised typically used for research.

The mental health inventories do not include the medical, family and neurocognitive information that is also needed to optimize risk management and intervention. With struggling pre-teens and teens, presenting manifestations may be any combination of school failure, socialization impairments, withdrawal or unacceptable behavior, such as anorexia, aggression or substance abuse. But other factors are involved:

  • Behavioral and psychiatric problems are oftenintegrally associated with learning disabilities, family issues and traumatic experiences.

  • Medical factors, particularly chronic illness, sleep disturbance, poor diet and pre- or post-natal brain insult as well as genetics may contribute to symptoms.

  • Medical issues such as bedwetting, headaches, sleep patterns, seizures, diabetes or asthma and cardiovascular history are important with regard to student function, feelings, safety and management.

All of these have placement and treatment implications.

COMPASS-Eval™, a recently released suite of computer-administered parent interviews providing the option to obtain medical, psychosocial, family and neurocognitive data, was demonstrated at the November 2007 IECA conference. It also includes a multidisciplinary placement inventory for RTC’s and a standard ADHD rating scale. Apart from the ADHD scale, it does not provide DSM-IV diagnoses but is descriptive, focusing on symptom and history clusters directly related to intervention.

Parents, though seldom on site, are critical to student safety and outcome in residential treatment centers. A good computer-administered parent interview can tap the parents’ critical information and insights helping the program to “get it right from the start” and initiate parental involvement in the therapeutic process.

1) John Bachman, MD (2007) Improving Care with an Automated Patient History. Fam Pract Manag. 2007;14(7):39-43. ©2007 American Academy of Family Physicians

2) Steven J. Stein (1987) Computer-assisted Diagnosis in Children’s Mental Health. Applied Psychology 36 (3-4) , 343–355 doi:10.1111/j.1464-0597.1987.tb01196.x

About the Author: Dorothy D. Johnson, MD FAAP, is a Diplomate in Developmental-Behavioral Pediatrics. She works with Nancy P. Masland & Associates in Tucson, Arizona and can be reached at 520-760-3012.

(This system of obtaining adequate information from parents has been initiated in the office of Nancy P. Masland & Associates and they report it has been very helpful –Lon)

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