Transforming Teen Behavior: Parent Teen Protocols for Psychosocial Skills Training

Transforming Teen Behavior

Parent—Teen Protocols for Psychosocial Skills Training

Mary Nord Cook

Department of Psychiatry, Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA

Table of Contents

Cover image

Title page

Copyright

Dedication

List of Contributors

Foreword

References

Author Biography

Acknowledgment

To the Reader

Chapter 1. Introduction and Background: Unmet Child Mental Health Needs

Child Mental Health Provider Shortage

Child Mental Health Provider Misdistribution

Managed Care and Fiscal Challenges

Challenges Translating Research to Real World

Role of Parents in Child Mental Health Treatment

Family-Based Approaches

Family-Focused Therapy

Multifamily Psychoeducational Groups

Cognitive Behavioral Therapy

Parent Management Training Programs

Collaborative Problem Solving

Psychodynamic Approaches

Limitations of Available Treatments

IOP as a Solution

2′×4′ Methodology of IOP Program

Chapter 2. Parenting Approaches for Challenging Kids—Teen and Mastery of Psychosocial Skills—Teen: Overview of Format and Operations

Target Population

Guiding Principles and Goals

Settings and Service Delivery Options

Organization of Materials

Rolling Admission

Group Format and Size

Scheduling

Caregiver Participation

Provider Teams

Provider Preparation

Charting

Provider Training

Strategies for Limit Setting

PACK and MaPS Teen Intensive Outpatient Psychiatry Program

Insurance Contracting and Fiscal Sustainability of PACK and MaPS Teen

PACK and MaPS Teen IOP Program Components

Children’s Colorado Hospital Format for PACK and MaPS Teen IOP

Creative Arts Therapy Component of PACK and MaPS Teen IOP

Individual or Family and Care Coordination Session for PACK and MaPS Teen IOP

Intake Process for PACK and MaPS Teen IOP

Outcome Assessments for Pack and MaPS Teen IOP

Chapter 3. Outcome Data for PACK and MaPS Teen Intensive Outpatient Program

Objective

Method

Results

Cost-Effectiveness, Retention, and Attendance Data

Chapter 4. PACK-Teen Treatment Protocol

Established Parent Introductions and Check-Ins

Workshop Guidelines

New Parent Introductions and Check-Ins

New Parent Orientation

Managing Parental Resistance

Workshop Format, Past Topic Review, Family Homework

What About My Teen? Examples

Handouts and Business Cards

Introductions, Check-Ins, and Orientation Summary Outline

PACK-Teen Module 1

Introductions and Guidelines

Review

Treatment Goals: Individual and Family

Feelings: Good, Bad, and Ugly Ones

Lowering Arousal

PACK-Teen Module 1 Summary Outline

Treatment Goals: Individual and Family

Feelings: Good, Bad, and Ugly

PACK-Teen Module 2

Introductions, Check-Ins, Guidelines, and New Parent Orientation

Effective Coping Skills

Healthy Habits

Parental Empathy Part I

PACK-Teen Module 2 Summary Outline

PACK-Teen Module 3

Introductions, Check-Ins, Guidelines, and New Parent Orientation

Empathy Test

Empathy Busters

Review of Multiple Choice Test on Empathy

Identifying Feelings in Others

Feelings Vocabulary

Mirroring

Overcoming Barriers to Empathy

The 3-Minute Rule

Empathy Role-Plays

Parental Resistance

Family Homework

Joint Session for Module 3

PACK-Teen Module 3 Summary Outline

PACK-Teen Module 4

Win–Win Conflict Resolution

Parental Resistance

Setting the Stage for PST

Lowering Arousal

Picking Your Battles

Zoning Behaviors

Problem Solving Together

PACK Module 4 Summary Outline

Pack-Teen Module 5

Introductions and Guidelines

Communication Test

Cooperation Busters

Review Test on Communication

What About My Teen Examples?

Four Styles of Communication

Practice with Assertive Communication

Expressing Positive Feelings Using the Assertiveness Formula

Cooperation Builders

Cooperation Building Role-Plays

Love Languages

Responding to Parental Resistance

Family Homework

Joint Session for Module 5

PACK-Teen Module 5 Summary Outline

PACK-Teen Module 6

Thought Correction

Self-Talk

PACK-Teen Module 6 Summary Outline

Chapter 5. MaPS-Teen Treatment Protocol

New Patient Orientation

Managing Teen Resistance

Icebreaker or Fun Question

New Patient Introductions

Established Patient Introductions and Check-Ins

Workshop Guidelines

Workshop Format, Past Topic Review, and Family Homework

What About Me? Examples

Handouts and Business Cards

MaPS-Teen Workshop Summary Outline

MaPS-Teen Module 1

Treatment Goals: Individual and Family

Feelings: Good, Bad, and Ugly Ones

Interpersonal Boundaries

MaPS-Teen Module 1 Summary Outline

MaPS-Teen Module 2

Effective Coping Skills

Healthy Habits

Relaxation Training

MaPS-Teen Module 2 Summary Outline

MaPS-Teen Module 3

MaPS-Teen Module 3 Summary Outline

MaPS-Teen Module 4

MaPS-Teen Module 4 Summary Outline

MaPS-Teen Module 5

Love Languages

MaPS-Teen Module 5 Summary Outline

MaPS-Teen Module 6

Thought Correction

Self-Talk

MaPS-Teen Module 6 Summary Outline

Chapter 6. Conclusion

References

Index

Copyright

Academic Press is an imprint of Elsevier

125 London Wall, London EC2Y 5AS

525 B Street, Suite 1800, San Diego, CA 92101-4495, USA

225 Wyman Street, Waltham, MA 02451, USA

The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK

Copyright © 2015 Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

ISBN: 978-0-12-803357-9

For information on all Academic Press publications visit our website at http://store.elsevier.com/

Publisher: Nikki Levy

Acquisition Editor: Nikki Levy

Editorial Project Manager: Barbara Makinster

Production Project Manager: Julia Haynes

Designer: Matt Limbert

Typeset by MPS Limited, Chennai, India www.adi-mps.com

Printed and bound in the USA

Dedication

To Mary, Sam, and Nate—forever holding me accountable, tethering me to a course of lifelong growth and learning.

To Sean—our steadfast anchor, protector, and fixer of all things.

List of Contributors

Mary Nord Cook,     Department of Psychiatry, Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA

Patrice S. Crisostomo,     Intensive Outpatient Programs, Bay Area Children’s Association, Oakland, CA, USA

Douglas A. Kramer,     University of Wisconsin School of Medicine and Public Health, Middleton, WI, USA

Jocelyn N. Petrella,     Parker Pediatrics & Adolescents, Parker, CO, USA

Tess S. Simpson,     Department of Rehabilitation Medicine, Children's Hospital Colorado, Aurora, CO, USA

Foreword

Douglas A. Kramer, MD, MS, Middleton, Wisconsin

I wish I had thought of that! That was my first thought as I read Transforming Teen Behavior, by Mary Nord Cook, MD. My second thought was, I am learning things here. That’s a nice experience for someone who will begin his eighth decade before Transforming is published. Dr. Cook is a physician specializing in child and adolescent psychiatry with special expertise in treating families. To my mind, her work is not in family therapy, but in family psychiatry. She brings to her work and to this book the medical background of a physician, beginning with dissecting a human cadaver as a first year medical student, later seeing patients in the emergency room, the operating room, and the delivery room. In the latter, she goes into the procedure with one patient and emerges with two, the mother and infant, and ideally the father and perhaps older siblings. This represents the essence of child psychiatry, the true patient being the relationship between the parent(s) and child, the life-giving, nurturing, and loving relationship that results ultimately in a healthy independent adult.

As a child and adolescent psychiatrist, Dr. Cook brings to this project her knowledge of child and adolescent development, including physiological, psychological, and relational development; her knowledge and experience with child and adolescent psychiatric disorders, including the developmental processes that underlie these disorders; and her knowledge of child and adolescent counseling, individual psychotherapy, group psychotherapy, family psychotherapy, and pharmacotherapy. Bringing all of these areas of expertise and experience together creates a family psychiatrist. Notice that the last area of expertise listed is pharmacotherapy, because with most disorders affecting adolescents this is the least important and ideally the last utilized modality.

Child and adolescent psychiatry began in Chicago in 1909 in what is known today as the Institute for Juvenile Research (Levy, 1968; Richmond, 1960; Truitt, 1926). It was the first of hundreds of child guidance clinics. From the first day in this first clinic, the child guidance model involved both the child or adolescent and his or her parents. Typically, the child or adolescent would be interviewed and counseled by a child psychiatrist or child psychologist, and the parents would be interviewed and counseled by a psychiatric social worker. This model persisted into the 1940s, increasingly informed by the prevalent theory of the time—psychoanalytic theory—with an associated decrease in parent involvement. The child’s intrapsychic conflicts became the target of treatment efforts.

In the early 1950s, a group of child psychiatrists, along with clinicians and theorists from other disciplines, began exploring the idea of treating whole families. The initial advocates were Nathan Ackerman, MD (Ackerman, 1972; Ackerman & Sobel, 1950), Gregory Bateson, MA (Bateson, 1972, 1978, 1979; Lipset, 1980; Ruesch & Bateson, 1951), and Carl Whitaker, MD (Whitaker, 1946, 1966, 1975, 1976, 1989; Whitaker & Malone 1953), the two physicians having trained in child psychiatry, and Mr. Bateson in anthropology (Bateson, 1958). In the meantime, child and adolescent psychiatry continued with a psychoanalytic and psychodynamic approach until the mid-1970s (McDermott & Char, 1974), when an initially gradual, but rapidly accelerating, emphasis on medication treatment emerged. The child’s synapses and neurotransmitters were the new target of treatment efforts.

Thus, child psychiatry began in the child guidance clinics with parent and child treatment, moved into university centers and private practice settings with a primary focus on the individual child, and finally to an even more reductionistic worldview when the medication era became paramount. The treatment of families, with a number of theoretical orientations, remained multidisciplinary as the field matured over the second half of the twentieth century. In addition to Drs. Ackerman and Whitaker, two other child psychiatrists were instrumental in the foundation of family psychiatry, John Bowlby, MD (Bowlby, 1969, 1988; Bowlby & Robertson, 1953), and Salvador Minuchin, MD (Minuchin, 1965; Minuchin, Auerswald, King, & Rabinowitz, 1964).

Of all of the early advocates of treating whole families from all of the various disciplines, including general psychiatry, the contributions of the four founding child psychiatrists have been the most lasting (Kramer, in press). Three subsequent generations of child psychiatrists have contributed to both keeping family psychiatry a healthy presence within general and child psychiatry, but have made and continue to make additional contributions and refinements in theory and technique. Dr. Cook is an important member of this fourth generation of child psychiatrists who practice family psychiatry. She and her colleagues at Children’s Hospital Colorado have brought children, parents, and families back into treatment, drawing on the lessons of the founders of both child psychiatry and family psychiatry, in a context that emphasizes developmental, psychodynamic, and family systems principles, and based on the emerging sciences of interaction (Josephson & Kramer, 2014; Kramer, 2012, 2014). Hence, my initial thought, I wish I had thought of that! But that’s how it should work in healthy systems. It’s exciting to observe.

Based on the scientific advances of the past 30 years, I have often wondered—in terms of what is known as a thought experiment—what psychiatry would look like if we were tasked to invent it today—if somehow all of the rest of medicine had evolved as it has but without the invention of psychiatry? The last 15 years of the twentieth century and the first 15 of the twenty-first have seen the conception, intrauterine development, and birth of the sciences of interaction. At a minimum, these include gene×environment interaction (G×E) (Caspi et al., 2002; Caspi et al., 2003; Suomi, 2004), epigenetics (Champagne & Meaney, 2001; Kramer, 2005a; Weaver, Cervoni, Champagne, D’Alessio, Meaney 2004), and nonlinear brain dynamics (Asano & Freeman, 2012; Freeman, 1991, 1995, 2003; Pincus, Freeman, & Modell, 2007), the latter possibly being thought of as brain×environment interaction (B×E) (Kramer, 2005b).

The most important result of sequencing the human genome has been the discovery that variation among humans is more a function of G×E at the organismic level, and epigenetics at the chromosomal level, than strictly a gene driven result. Psychiatry’s love affair with pharmacological treatments, although certainly helpful (and harmful) to many patients, rested on the belief that allelic differences contribute to synaptic and receptor variations and lead to psychiatric disorders.

Interestingly, my answer to our proposed thought experiment is that psychiatry, and more importantly child psychiatry, would look more like it did at the origin than it has during the psychoanalytic and psychopharmacologic eras. The one difference from those early years is that it would be understood, based on the sciences of interaction, that the patient would not be the child or adolescent (or the adult), nor would the patient be the parents. The patient would be the whole family—however constituted. For both trait and state differences, this is the unit where G×E and B×E interactions occur. These processes influence normal developmental, as well as facilitate possible corrections with respect to developing traits that may lead to or already constitute a psychiatric disorder (Kramer, in press).

In the introductory section of the adolescent portion of Transforming Teen Behavior, Dr. Cook describes her overall perspective: An interactive, experiential, and psycho-educational style workshop is facilitated, each session covering specific topics of skill sets, as outlined by the syllabus. The clinicians use a method of psycho-educational and Socratic teaching in conjunction with empathic and reflective listening, to inspire adolescents to ponder and brainstorm, about themselves, their families, and peers. A similar parent-oriented statement occurs in their section.

In what context is this interactive, experiential, and psycho-educational style implemented? Although a number of reasonable modifications to the standard treatment format are suggested, especially as a function of staffing differences, the default condition is three Intensive Outpatient Program (IOP) sessions per week for 6 weeks. The first of the three IOPs involves two, concurrently run, parent and teen workshops of 90 minutes duration each. The second IOP might occur the following afternoon, and includes concurrent parent and teen workshops for 60 min, and either a 60-min multi-family group therapy session including all families in the current track, or individual family psychotherapy sessions for the (no more than) six current families. The last of the IOP sessions would logically occur on Thursday afternoon. This IOP uses a creative arts therapy approach—either art or music—to utilize a nonverbal modality to practice psychosocial skills learned in the first two sessions of the week. This IOP is multi-family, but also includes siblings 6 years and older, and might include grandparents as well (Kramer, 1988). There is continuity of therapists over the course of each 6-week treatment group. Intakes, orientation, urgent, and medication appointments are provided outside the IOP format.

Although an adolescent typically catalyzes a family to enter this treatment experience, the patients are the families (in multi-family groups), the parents (in parent groups), and adolescents (in teen groups). Neuroscientist Walter J. Freeman states, "… the most important function of brains is to interact with each other to form families and societies (Freeman, 1995)." How better to facilitate the learning (not the teaching) of psychosocial skills than through experience in a natural interactional setting, i.e., peer groups (either adolescent or adult/parent), multi-family groups (society), or single families, the primary source of G×E and B×E for developing children and adolescents?

This particular IOP approach is probably not for every struggling adolescent, but it offers wider applicability than one might anticipate at first glance. It is designed to be either a step-down option from a more acute setting, e.g., inpatient hospital or partial hospitalization; or a step-up option from traditional outpatient treatment. Because a rolling admission process is recommended, it might be used as an option for adolescents seen in crisis in the emergency room, or other crisis entry points, e.g., school guidance counselor, or community crisis intervention programs. In an integrated healthcare delivery system, it would be ideal for most adolescents admitted in crisis to inpatient units, to transfer to IOP after 1–2 days of initial evaluation and ascertainment of safety.

In situations where a family is able to self-pay, it might be used for prevention or early intervention, perhaps with a health plan supplement following completion of the program; and similarly as an option for families considering outdoor therapeutic programs, therapeutic boarding schools, or military schools. Why not use it in residential treatment programs where the families are from the local area? Although not mentioned directly by the author, I believe it would also be ideal for families struggling with substance abuse, which for adolescents is often a coping mechanism absent the kinds of psychosocial skills learned in this program, but with the added benefit of concurrent parent and family complementary change.

Transforming Teen Behavior: Parent–Teen Protocols for Psychosocial Skills Training, by Mary Nord Cook, MD, is so ingenious it feels magical. We have all heard the statement, It isn’t rocket science. Well, this is rocket science. Why is it rocket science? Rocket science is simply the ability to both understand 100,000 moving parts and simultaneously the entity or context in which these parts are operating. That is what Dr. Cook has accomplished. It isn’t simply teaching empathy. It’s learning empathy in a family context, empathy for the adolescent by the parent, empathy for the parents by the adolescent, empathy for each other in peer groups, all in a family and multi-family context. This goes directly to the purpose of the human (and primate) brain (Kramer, in press) which is to form families and societies (Freeman, 1995) through G×E and B×E interaction over the individual and family developmental stages.

Transforming Teen Behavior is perfectly integrated, yet easily modifiable. The rolling admissions concept eliminates the waiting list problem, and keeps the treatment group alive through having new members learning from members with longer tenure. The 15–18 sessions in 6 weeks is intense, but a reasonably short duration for most families as documented by an 85% completion rate. It is certainly cost-effective as typically measured, but parents, siblings, and even grandparents, as well as non-custodial parents potentially, are receiving free treatment (prevention)—thus possibly eliminating or reducing future insurance plan costs. In short, I wish I had thought of that!

March 2015

References

1. Ackerman NW. The growing edge of family therapy. In: Sager CJ, Kaplan HS, eds. Progress in group and family therapy. New York, NY: Brunner/Mazel; 1972:440–456.

2. Ackerman NW, Sobel R. Family diagnosis: an approach to the preschool child. The American Journal of Orthopsychiatry. 1950;20(4):744–753.

3. Asano T, Freeman WJ. How brains make up their minds: a precis in historical perspective. Mind & Matter. 2012;9(2):171–184.

4. Bateson G. Naven: a survey of the problems suggested by a composite picture of the culture of a New Guinea tribe drawn from three points of view 2nd ed. Stanford, CA: Stanford University Press; 1958.

5. Bateson G. Steps to an ecology of mind New York, NY: Ballantine Books; 1972.

6. Bateson G. The pattern which connects. The CoEvolution Quarterly. 1978;18:4–15.

7. Bateson G. Mind and nature: A necessary unity New York, NY: E. P. Dutton; 1979.

8. Bowlby J. Attachment and loss: Volume I Attachment New York, NY: Basic Books; 1969.

9. Bowlby J. Developmental psychiatry comes of age. American Journal of Psychiatry. 1988;145(1):1–10.

10. Bowlby J, Robertson J. A two-year old goes to hospital. Proceedings of the Royal Society of Medicine. 1953;46(6):425–427.

11. Caspi A, McClay J, Moffitt TE, et al. Role of genotype in the cycle of violence in maltreated children. Science. 2002;297(5582):851–854.

12. Caspi A, Sugden K, Moffitt TE, et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science. 2003;301(5631):386–389.

13. Champagne F, Meaney MJ. Like mother, like daughter: evidence for non-genomic transmission of parental behavior and stress responsivity. Progress in Brain Research. 2001;133:287–302.

14. Freeman WJ. The physiology of perception. Scientific American. 1991;264(2):78–85.

15. Freeman WJ. Societies of brains: A study in the neuroscience of love and hate Hillsdale, NJ: Lawrence Erlbaum Associates; 1995.

16. Freeman WJ. Neurodynamic models of brain in psychiatry. Neuropsychopharmacology. 2003;28(Suppl. 1):S54–S63.

17. Josephson AM, Kramer DA. Why the family is relevant for the contemporary child psychiatrist. AACAP News. 2014;45(1):10–11.

18. Kramer DA. Like (grand-) father, like (grand-) son: the implications of the transference relationship and developmentally sensitive periods for learning on the three-generational system. Denison Journal of Biological Science. 1988;25(1):18–35.

19. Kramer DA. Commentary: gene-environment interplay in the context of genetics, epigenetics, and gene expression. Journal of the American Academy of Child and Adolescent Psychiatry. 2005a;44(1):19–27.

20. Kramer DA. Ethology, psychiatry, and an infertile mule. AACAP News. 2005b;36(2):68–69 77.

21. Kramer DA. The decline of the biopsychosocial model and the demise of psychiatry. AACAP News. 2012;43(3):120–121.

22. Kramer DA. DSM-5, NIMH, and the dark cave of reductionism in twenty-first century psychiatry. AACAP News. 2014;45(1):18–19.

23. Kramer, D. A. History of family psychiatry: from social reform to the primate social organ system. Child and Adolescent Psychiatric Clinics of North America, Philadelphia, PA: Elsevier. 24, in press.

24. Levy DM. Beginnings of the child guidance movement. The American Journal of Orthopsychiatry. 1968;38(5):799–804.

25. Lipset D. Gregory Bateson: The legacy of a scientist Englewood Cliffs, NJ: Prentice-Hall; 1980.

26. McDermott Jr JF, Char WF. The undeclared war between child and family therapy. Journal of the American Academy of Child Psychiatry. 1974;13(3):422–436.

27. Minuchin S. Conflict-resolution family therapy. Psychiatry. 1965;28:278–286.

28. Minuchin S, Auerswald E, King CH, Rabinowitz C. The study and treatment of families that produce multiple acting-out boys. The American Journal of Orthopsychiatry. 1964;34:125–133.

29. Pincus D, Freeman W, Modell A. A neurobiological model of perception: considerations for transference. Psychoanalytic Psychology. 2007;24(4):623–640.

30. Richmond JB. The pediatrician and the individual delinquent. Pediatrics. 1960;26(1):126–131.

31. Ruesch J, Bateson G. Communication: The social matrix of psychiatry New York, NY: W. W. Norton & Company; 1951.

32. Suomi SJ. How gene-environment interactions can influence emotional development in rhesus monkeys. In: Garcia-Coll C, Bearer EL, Lerner RM, eds. Nature and nurture: The complex interplay of genetic and environmental influences on human behavior and development in rhesus monkeys. Mahwah, NJ: Lawrence Erlbaum Associates; 2004:35–51.

33. Truitt RP. The role of the child guidance clinic in the mental hygiene movement. American Journal of Public Health. 1926;16(1):22–24.

34. Weaver IC, Cervoni N, Champagne FA, D’Alessio AC, Meaney MJ. Epigenetic programming by maternal behavior. Nature Neuroscience. 2004;7(8):847–854.

35. Whitaker C. A family is a four-dimensional relationship. In: Philip J, Guerin J, eds. Family therapy: Theory and practice. New York, NY: Gardner Press; 1976:182–192.

36. Whitaker C. Midnight musings of a family therapist New York, NY: W. W. Norton & Company; 1989.

37. Whitaker CA. Ormsby village; an experiment with forced psychotherapy in the rehabilitation of the delinquent adolescent. Psychiatry. 1946;9:239–250.

38. Whitaker CA. Family treatment of a psychopathic personality. Comprehensive Psychiatry. 1966;7(5):397–402.

39. Whitaker CA. A family therapist looks at marital therapy. In: Gurman AS, Rice DG, eds. Couples in conflict: New directions in marital therapy. Boulder, CO: Jason Aronson; 1975:165–174.

40. Whitaker CA, Malone TP. The roots of psychotherapy New York, NY: Blakiston; 1953.

Author Biography

Mary Nord Cook, MD is an Associate Professor of Psychiatry at the Colorado School of Medicine, who served as the Medical Director of Outpatient Services for the Department of Psychiatry at the Children’s Hospital Colorado (CHCO) from 2005 to 2014. She has been extensively involved in the training of medical students, psychology and social work graduate students, along with psychiatry residents. She recently won a resident nominated award for teaching excellence and has also been recognized by the American Academy of Child & Adolescent Psychiatry (AACAP), as an Outstanding Mentor. She specializes in working with families presenting with youngsters who’ve been diagnosed with Disruptive Behavior and Mood Disorders. She spearheaded the development of a series of multidisciplinary, outpatient specialty clinics, along with intensive outpatient programs at the CHCO. She recently wrote a book detailing the evidence-based, standardized, skills-building treatment protocols used for the school-aged patient population, in both the routine and intensive outpatient programs, titled Transforming Behavior: Training Parents & Kids Together. She also co-authored a peer-reviewed journal article that described the positive clinical outcomes obtained in the intensive outpatient program for children with disruptive behavior. She has authored books, chapters, review articles, and contributed to the AACAP Practice Parameters on family interventions. She frequently performs presentations in the community for school, primary care, and youth outreach programs. In addition, she routinely presents at regional and national, professional conferences, often on an invited basis. Her passions are developing and applying family- and strengths-based approaches, pursuant of a goal to minimize medication, while optimizing parenting and psychosocial skills. Her mantra is More Skills=Less Pills!

Dr. Cook received her bachelor’s degree (psychology) with honors from the University of Michigan and her doctoral degree (medicine) from Wayne State University. She completed her general psychiatry residency at the Naval Medical Center, San Diego and her child fellowship training at the University of California, San Diego.

Acknowledgment

No pediatric behavioral health program with any merit functions without the ongoing input and service of a synergistic multidisciplinary team. The Children’s Hospital Colorado (CHCO) Teen General Intensive Outpatient Program (G-IOP) team was comprised of several talented professionals, including child psychiatrists, child psychologists, clinical social workers, psychiatric nurses, and mental health counselors. Dr. Jeffrey Dolgan was considered the Father of the Teen G-IOP program and served as the most credible person in the room for several years, demonstrating the highest capacity for empathic understanding and unconditional acceptance. Dr. Kelly Caywood and Eric Hansen persistently displayed a keen knack for knowing just how to read and reach adolescents. Mindy Stephens and Mandie Roark were the organizational and management glue that kept the parts and pieces of G-IOP working together, like a well-oiled machine. They additionally were gifted in their aptitude for engaging even the most defensive and disruptive youngsters. Dr. Jocelyn Petrella, Dr. Tess Simpson, and Dr. Patricia Crisostomo contributed countless hours toward building, maintaining, analyzing, and summarizing the program’s outcome data. Dustin Lamb deployed his creative ingenuity to help shape patient materials into a more teen-friendly and aesthetically pleasing style. Katherine Reed and Anthony Edelblute were among the original pioneers for the CHCO Teen G-IOP, beginning in January 2006—they were steadfast constants who contributed compassion, creative energy, and an artistic and musical balance that completed the program, in a way that only they could.

To the Reader

There are three fundamental principles which have long steered the course to which I have steadfastly adhered in my professional life:

1. One should always strive to do the greatest good for the greater number.

2. One should always strive to serve to the best of one’s ability.

3. One should always make the best use of whatever resources are at one’s disposal.

At every juncture, in every setting, serving any population, in any capacity, those guiding principles have compelled me to write and write and write. As I have faced opportunities to participate in clinical program development, careful documentation of treatment protocols has served as the essential fulcrum, around which meaningful interventions have pivoted. Writing has been, in my experience, the most effective tool that can be harnessed in the pursuit of the following:

1. Distilling information and crystalizing thoughts.

2. Packaging information and thoughts in a way others can understand.

3. Generating a tool that can be used to disseminate information broadly.

Any time I have garnered useful information, encountered effective methods, formulated relevant insights, or experienced meaningful transactions, I feel inspired and compelled to share them with others, to the degree possible, in an effort to spread and magnify the impact. As we have fastidiously evolved a program for families with children and adolescents presenting with varied concerns, which has demonstrated robust and enduring positive outcomes, the knowledge, experience, and wisdom collectively amassed by our talented and diverse clinical teams, over 9 years, has been carefully recorded for the sake of optimizing the chances to do the greatest good for the greatest number. The explicit and comprehensive documentation of the aforementioned programs has culminated in the production of the two books, including the one that follows, which describes a program developed for teens and their families. The parallel program that was evolved for families with school-aged children was described previously in a book titled: Transforming Behavior: Training Parents & Kids Together (2012, Brookes Publishing).

If I had to choose one value, that I most passionately embrace, with respect to my work, it would be empowerment. My underlying goal in participating in clinical program development is to empower the providers and trainees serving on the interdisciplinary teams that deliver care to families. Likewise, my underlying goal in approaching any patient, together with their family and other key change agents around them in schools, communities, and other healthcare settings, is to empower. The end goal in everything I do professionally is to amass knowledge and skills and then disseminate them to others (providers, students, families, school staff), such that others can become increasingly empowered with tools to independently and effectively manage challenges they face. In my mind, the best way to serve patients and their families is to cultivate skills that enhance their capacity to maintain their own overall health and wellness. If there is a mechanism to realize this goal that is more effective and powerful than writing, I don’t know it. I hope this material is experienced as useful and interesting to readers and those who they serve. The process of writing it down has certainly enlightened and rejuvenated me.

Chapter 1

Introduction and Background

Unmet Child Mental Health Needsa

Mary Nord Cook

In an era of ever-decreasing inpatient and partial hospitalization stays, coupled with shrinking community resources, increasing numbers of patients need intensive outpatient services that are readily accessible, convenient, and efficacious, as well as covered by insurance. There is a significant need for clinic-ready, best practice programs for diagnostically complex, treatment-refractory youngsters, who present with a range of emotional and behavioral disturbances. Programs which intervene with youth, and their parents, to an equivalent degree, while ensuring clinical efficacy, as well as fiscal sustainability, would fill a significant, real-world need. A best practice, manualized Intensive Outpatient Program (IOP) was developed at Children’s Hospital Colorado (CHCO) in January 2006 to serve a broad and diffuse patient population, aged 7–18 years old, and their families, referred on the basis of clinical acuity rather than primary diagnosis. To ensure standardization of service delivery and enable program dissemination, the written materials were deliberately evolved to be explicit and readily followed, by numerous provider types, with variable levels of training, experience, and psychological mindedness. The book that follows was composed to enable broad dissemination of this best practice IOP, while preserving the program’s integrity and quality, to the degree possible.

Keywords

Intensive Outpatient Program; IOP; psychiatry; psychology; counseling; best practice; evidence-based; family; parent training; psychosocial skills training; group therapy; manualized; protocols; multidisciplinary; cost effective; standardized; child; adolescent

Although most American youth experience normal, healthy development, research has demonstrated that as many as 1 in 10 youngsters, aged 9–17 years old, will suffer symptoms of mental illness significant enough to cause some level of impairment, in any given year (Department of Health and Human Services [DHHS], 1999). However, fewer than 20 percent of those youth who need mental health services will receive them (Kataoka, Zhang, & Wells, 2002). US annual expenditure estimates for behavioral health services for youth range from $11.7 to $14.07 billion (Ringel & Sturm, 1998). Left untreated, mental health disorders in youth are associated with higher rates of suicide, violence, school dropout, family dysfunction, juvenile incarcerations, substance abuse, and accidents.

Child Mental Health Provider Shortage

The Council on Graduate Medical Education (COGME, 1990) reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000. In 2009, only 7418 child and adolescent psychiatrists were practicing in the United States—more than 22,000 short of the stated need (American Medical Association, 2009). The demand for child and adolescent psychiatrists is expected to increase by 100 percent between 1995 and 2020 (DHHS, 2008). Ideally, the nation would have 14.38 child and adolescent psychiatrists per 100,000 youth, or approximately one provider per 1700 youth.

Child Mental Health Provider Misdistribution

As of 2006, ratios of child and adolescent psychiatrists per 100,000 youth ranged from 3.1 in Alaska to 21.3 in Massachusetts, with a national average of 8.7 (Thomas & Holzer, 2006). The problem, however, is not just a simple numbers issue. There is a severe misdistribution of child and adolescent psychiatrists in the United States, with children and adolescents in rural and low-socioeconomic areas facing significantly reduced access to psychiatric care. Child and adolescent psychiatrists tend to cluster around training institutions and in urban areas large enough to support a Children’s Hospital, and child psychiatrists in private practice often do not take Medicaid or low-reimbursing insurances. The result of these patterns is that the majority of counties in the United States have no local child psychiatry services. Pediatric mental health care is provided primarily by primary care providers, including family practitioners, pediatricians, general internists, physician assistants, and nurse practitioners. Care is also often delivered by general psychiatrists, who may have limited training in treating the pediatric population. The US Surgeon General declared the following in his report:

There is a dearth of child psychiatrists. … Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals…. This places a burden on pediatricians, family physicians, and other gatekeepers to identify children and adolescents for referral and treatment decisions.

(DHHS, 1999, p. 7)

Managed Care and Fiscal Challenges

State-of-the-art specialized psychiatric treatments for children and adolescents are difficult to sustain in a managed care environment; and grant funding sources, especially government-derived, are increasingly scarce. Academic programs, in particular, are generally embedded within tertiary care centers or large hospitals, and reimbursements for behavioral health services generally fall short of covering the costs of providing treatment in those settings. Most insurance carriers carve out behavioral health benefits to behavioral health insurance vendors that either cannot afford or are unwilling to negotiate payment rates that can support the maintenance of high-level, specialized mental health services for families. Many employers are unwilling or unable to afford to provide behavioral health benefits to their employees, instead offering insurance plans that contain provisions only for medical care physical ailments minus coverage for psychiatric treatments for mental illness.

Children and adolescents with serious emotional and behavior disturbances and their families warrant and deserve intensive mental health and educational services; unfortunately, few have access to appropriate and sufficient services. As the gap between the demand and availability of pediatric behavioral health specialty services widens, the burden for service delivery is shifting more and more toward educational and primary care settings (O’Donohue, Byrd, Cummings, & Henderson, 2005). Child psychiatrists and psychologists are functioning more and more in consultant roles—serving to educate, train, or consult around behavioral health program development—whereas direct treatment is being shifted to nonmental health professionals serving in nonbehavioral health settings such as primary care settings and schools. The field of pediatric mental health is faced with the challenge of evolving creative, cost-effective, and replicable systems of service delivery that hold the most promise for the greatest impact across the broadest and most treatable patient populations.

Challenges Translating Research to Real World

It is widely appreciated that translation of research-based protocols, to real-world, clinical environments, can be challenging, and limited, for a host of reasons. The Director of the National Institute of