Mary Nord Cook
The target population for Parenting Approaches for Challenging Kids (PACK) and Mastery of Psychosocial Skills (MaPS) Teen presented with a broad array of primary psychiatric diagnoses, but nearly all were 12–18 years old and manifested primarily with a constellation of externalizing or disruptive behaviors, along with significant mood and anxiety symptoms, in most cases. The youth served presented with varying levels of social, academic, and behavioral impairments, and nearly all were experiencing significant family discord, often particularly high levels of parent–adolescent conflict and were generally described by adults as oppositional, disrespectful, and defiant. The PACK and MaPS Teen program focused on training families on broad and universally applicable parent and psychosocial skills that had clinical relevance for a diverse patient population. Likewise, the psychosocial skills covered with youth, including anger management, relaxation, problem-solving, cognitive restructuring, assertive communication, and social skills, were experienced as broadly applicable and universally relevant. Because the program is modular, specific components can be isolated and used in a stand-alone way, in the event that targeted treatment is desired or time constraints preclude whole program delivery.
Modular; psychosocial skills; parent training; adolescents; teens; family conflict; universal applicability; diverse patient population; comorbidity; format; operations
The target population for Parenting Approaches for Challenging Kids (PACK) and Mastery of Psychosocial Skills (MaPS) Teen presented with a broad array of primary psychiatric diagnoses, but nearly all were 12–18 years old, and manifested primarily with a constellation of externalizing or disruptive behaviors, along with significant mood and anxiety symptoms, in most cases. The youth served presented with varying levels of social, academic, and behavioral impairments and the majority were struggling with emotion regulation and impulse control. Nearly all patients enrolled were experiencing significant family discord, often particularly high levels of parent–adolescent conflict and were generally described by adults as oppositional, disrespectful, and defiant.
The majority of parents whose youngsters were enrolled in the PACK and MaPS Teen program were initially focused primarily on goals of reducing their adolescent’s acting out risky and defiant behaviors, improving his or her social and academic functioning and enhancing family cohesion. The most common diagnoses among the adolescents enrolled were mood, anxiety, and disruptive behavior disorders and virtually all patients met criteria for two or more DSM-IV-TR diagnoses (American Psychiatric Association, 2000). No individuals with primary diagnoses of psychosis, autism, or severe developmental delays were enrolled in our PACK and MaPS Teen programs. An IQ score of at least 70 and a Global Assessment of Function (Startup, Jackson, & Bendix, 2002) score of 40 were minimum prerequisites. Additional details regarding the patient population served are provided in Chapter 3. PACK and MaPS curricula for children aged 7–12 years old and their families have also been developed and were published separately. Occasionally, 12 year olds who appeared and behaved older, respectively, than their chronological age also were accommodated in the teen program.
Guiding principles utilized to develop the psychosocial skills and parent training components were gleaned from extant, empirically validated, psychosocial treatment programs for adolescents including Family-Focused Therapy, developed by David Miklowitz and colleagues (2004), Adolescent Coping with Depression Course, developed by Clarke, Lewinsohn, and Hops (1990), and the Services for Teens at Risk manual series, developed by Brent and Poling (1997). The constructs from these programs were considered to possess face validity and therefore served as fundamental tenets during program development. Common threads running through all extant, evidence-based, skills training programs include elements of psycho-education, therapist demonstration of skills, patient rehearsal of skills in session and assignment of homework to patients for real-world application and practice of skills, with recurring forums to assess progress and provide iterative feedback. Varied strategies with known efficacy infused the resulting curricula to include group and family therapy, paper and pencil worksheets, topical handouts, along with music and art therapy. The resulting curricula were titled “Parenting Approaches for Challenging Kids (PACK) Teen,” and “Mastery of Psychosocial Skills (MaPS) Teen.”
The PACK and MaPS Teen program focused on training families on broad and universally applicable parent and psychosocial skills that had clinical relevance for a diverse patient population. Clinical experience with the program demonstrated that parenting strategies, which worked, tended to cut across broad diagnostic domains and socioeconomic levels. The underlying principles of approaches which worked well, typically distilled down to the same basic elements, across a broad patient population. The parenting approaches taught were reported by parents as effective for typical or “normal” developing siblings, as well as for youth presenting with psychiatric problems. Likewise, the psychosocial skills covered with youth, including anger management, relaxation, problem-solving, cognitive restructuring, assertive communication, and social skills, were experienced as broadly applicable and universally relevant.
In some settings—because of logistical, time, and/or resource constraints—the PACK and MaPS programs may be offered separately or delivered in abbreviated formats. Because the program is modular, specific components can be isolated and used in a stand-alone way, in the event that targeted treatment is desired or time constraints preclude whole program delivery. It is possible to use only the MaPS Teen curricula, if only adolescents are available for treatment or only the PACK Teen curricula if only parents are available for intervention. The dose of treatment delivered can also be limited by provider, space, payer, or patient availability.
Another model of service delivery might involve first offering several weeks of treatment only for the parents followed by several consecutive sessions directly with the teens, or vice versa. In this model, the facilitators could arrange for “joint” sessions intermittently during which parents and teens would practice new skills with active coaching by peers and therapists. Alternatively, it is possible to alternate curricula and format from week to week, such as convening with teens using MaPS Teen, then convening with parents using PACK Teen and then convening with parents and teens together, to practice skills, with live coaching from therapists. The sessions offered in the prior weeks would cover parallel topics or skills but the style of presentation would have been customized for either parent or teen consumption. These variations in service delivery models offer options for addressing the practical limitations of program implementation in the “real world.” However it is intuitively obvious and borne out in the author’s experience that the concurrent training of parents covering the complete set of PACK modules associated with complementary psychosocial skills training for affected youth covering all MaPS modules, offers the most promise for a robust impact with the greatest potential for generalization and durability of effect.
The parenting and psychosocial skills featured in PACK and MaPS Teen were designed to be universally relevant; in addition, the materials were evolved to be user-friendly and to lend themselves to immediate, practical application. The PACK and MaPS Teen curricula were organized into six discrete “modules,” with parent and teen topics paralleling and complementing one another. Each module can be covered over the course of two group therapy sessions, enduring 90–120 minutes each. The modular format was critical for enabling “rolling” admission, which facilitated timely access to treatment, typically within a few days of referral.
Parent and teen workbooks, containing worksheets, acronyms, cartoons, and psycho-educational materials, were developed, following the modular curricula. The modules are related to one another, but the program was set up in such a way that each module could more or less stand alone, if necessary. The goal was to organize the materials so that a family might join at any time and still be able to comprehend and make use of the materials being presented. The modules were developed to be highly structured and explicit to increase the level of standardization and consistency of the program across time and across facilitators.
The treatment protocols were organized such that the materials for each module were presented first in a detailed, narrative format followed by a brief, bulleted outline for ease of use. Nearly all of the modules contain associated therapist tools, which are available in digital format on the book’s companion website. Most of the modules are likewise associated with parent or teen handouts, copies of which appear at end of the treatment protocols as well as in digital format on the book’s companion website.
In the PACK and MaPS Teen Intensive Outpatient Program (IOP) program, the complete collections of parent and teen handouts were compiled together in separate parent and teen workbooks. Copies of the parent and teen workbooks were provided to families on their first day and were used during sessions. The teen workbooks were then collected and maintained by the therapists between sessions. For cases in which two parents attended sessions, it was recommended that one parent keep his or her workbook at home and the other parent bring in his or her workbook to be collected and maintained by the therapists for use during the workshops. At the point of graduation, all parents and teens were given their workbooks to keep and take home.
An additional unique aspect of the PACK and MaPS programs is the potential for rolling admissions. The materials are organized into discrete modules, which enabled patients to enroll or graduate, at any time. This strategy ensured the maintenance of a steady census, which optimized cost-effectiveness and utilization of staff and space resources. In addition, it improved access to care compared to closed-ended groups, which typically require extensive waiting for some families. The rolling admission process was comprised of families continually rotating in and out of the program; however, at no point, did the program admit more than two new families on the same day. The turnover pace that worked best was comprised of admitting and graduating no more than two families each week.
The rolling admission process additionally conferred significant clinical advantages in that the more seasoned youth and parents tended to mentor, teach, support, and inspire the newer members. The established families were explicitly recruited by the therapists during the workshops to help welcome and orient the newer families.
A model of concurrently run, parent and teen groups was deployed, with additional opportunities for clinician-guided, skills rehearsal sessions, for individual families. The group format served to optimize access to care and cost-effectiveness, as well as conserve space and staff resources.
In consulting the literature regarding group treatments for youth, it was noted that group sizes varied widely across extant, empirically validated programs (Brent & Poling, 1997, Clarke et al., 1990; Lochman, Barry, & Pardini, 2003; Sukholdosky, Kassinove, & Gorman, 2004); some groups were composed of as few as four members, whereas other groups had 15 or more members. Because of the widely varied recommendations in the literature, we let clinical experience serve as a guide in establishing a size parameter for the PACK and MaPS Teen IOP workshops. Because of the level of clinical acuity and intensity of treatment associated with the IOP level of care, the number of families served concurrently in the teen arm of the IOP program did not exceed six. The program typically maintained a full census, with a short wait-list of one to three patients. The wait time for admission was generally kept down to less than 1 week and rarely did it exceed 2 weeks. The child arm of the IOP program, likewise, could accommodate up to six families at once.
Late-afternoon or after-school scheduling is necessary for group therapy programs because parents are usually reluctant to pull their adolescents from school on a weekly basis for several weeks running. In addition, working parents typically are better able to attend a program in the late afternoon as opposed to one hosted in the morning or midday. We intentionally conducted our sessions after school between the hours of 3 p.m. and 6 p.m. The PACK and MaPS Teen IOP program was composed of three sessions, per week. Starting all three sessions at the same time of the day, and spreading them over the course of the week, excluding Fridays, was an important ingredient in helping families stay organized and adherent.
Attendance by all parents or primary caregivers (e.g., mother, father, grandparents) who were significantly involved in raising an affected youngster was strongly encouraged. In our PACK and MaPS programs, parents occasionally expressed concern about child care for siblings, which unfortunately was not available at our site. In instances in which only one parent could attend because the other needed to remain home to supervise siblings, we strongly recommended that the parent with whom the affected adolescent had the most conflict attended regularly. Several families affected by divorce also participated in our program; in many cases, two sets of parents and/or two sets of grandparents participated at the same time. On several occasions, co-parents from a contentious divorce were able to attend PACK and MaPS Teen IOP concurrently and benefitted tremendously, while refraining from hostile or disruptive interactions with ex-spouses. The high level of structure inherent in the workshop format likely contributed to minimizing inappropriate expressions of hostility between couples with histories of difficult or unresolved divorces.
The PACK and MaPS Teen program was staffed by a multidisciplinary team, comprised of psychiatry, psychology, clinical social work, nursing, and creative art therapy providers. At least one clinician in each provider pair that facilitated each workshop had to be a licensed, independent provider; however, the second provider could be a nurse, mental health counselor, or technician; a psychology or social work intern; or a psychiatry resident. The PACK and MaPS treatment protocols, both the teen and child versions, were designed such that they might be readily used by school and clinical counselors, therapists, school and clinical psychologists, special educators, psychiatrists, and pediatric providers with expertise in working with youth and families.
Each of the PACK and MaPS Teen workshops (we commonly used the word workshop, as it implied that all attendees would be working and play an active role) we ran was facilitated by two clinicians. The PACK Teen workshops, served to deliver parent training, while the concurrently run MaPS Teen workshop, served to deliver psychosocial skills training to the adolescents. The continuity and pairing of providers was preserved to the degree possible, to protect “culture continuity” and program integrity. Consistency among providers was paramount for developing rapport and establishing a safe and trusting environment. The continuity also enabled the two or three group facilitators for each workshop to evolve into a cohesive team with a particular rhythm and style, which worked well. Because the facilitators were familiar with each other, they became adept at reading each other’s signals and complementing one another’s styles, backgrounds, and personalities.
It is recommended that the facilitators for PACK and MaPS Teen meet regularly—at least weekly—to discuss observations and share information related to the families being served. In addition, the therapists can use that forum to discuss and problem-solve regarding operational and clinical issues, with an eye toward optimizing the success of the interventions while considering the individual strengths and challenges of the current families enrolled. A PACK and MaPS Teen team meeting also can serve as a forum to review and discuss new families pending admission and exchange clinical information on established patients, especially between the facilitators of different workshops.
The provider teams reviewed therapeutic materials and met, prior to each PACK and MaPS Teen session, to prepare for the ensuing workshops, and ensure consistent, well-orchestrated care for all families. Weekly treatment team meetings were hosted, to provide opportunities for supervision with senior psychiatry and psychology faculty, customization of care, processing, collaborating, and training.
In clinical settings, all PACK and MaPS Teen sessions were appropriately documented, in the identified patient’s medical record. The progress notes followed the documentation requirements for intensive outpatient, family, group or multifamily group psychotherapy billing codes, depending on the service delivery format used. Because these workshops were highly structured and very content-driven, it enabled the development of standardized and digitalized, progress note templates that were shared by all providers. The templates were digitally loaded into the library of clinical progress note templates within the electronic medical record, which enabled straightforward, consistent, and efficient charting.
For each service or session delivered, the provider could use the template for the module covered to comprise the bulk of his or her note but in addition was required to customize each note to reflect a specific issue, observation, symptom, or behavior related to each individual family that was noted during that particular session. Parent and adolescent sessions were each documented in separate progress notes, in the same record, under the same episode of care, if they occurred concurrently, as part of a multifamily group or intensive outpatient session.
The materials in this manual were developed to be user-friendly, explicit, and easily applied; nonetheless, training in their use is recommended. Information about formal training can be obtained by contacting the authors.
The high level of structure and standardization inherent within the PACK and MaPS programs helps ensure that the focus during the workshops remains on the content and skill sets being trained. The structured format of the workshops diminishes the odds of parents and adolescents spending inordinate amounts of time venting or relating personal stories in a manner that is not productive or conducive to learning new skills. In other words, the workshop structure inherently provides for firm therapeutic limits and serves to rein in wayward participants who otherwise might consume more than their share of group time and energy. In the workshops we conducted, the therapists were able to readily redirect parents or youth who did attempt to monopolize the workshop time by referencing the materials or skill sets intended for the current module.
Although the materials in this manual have been used successfully in a variety of settings, by a multitude of provider types, with a broad array of patient populations, the most systematic and standardized use occurred in a hospital-based, psychiatry clinic in the form of an IOP program. To the best of our knowledge, at the time of publication of this manual, no other published, manualized programs are available, that target a broad and diverse patient population referred to an IOP program based on acuity, symptoms, and skill impairments rather than diagnosis. Likewise, to our knowledge, no other manualized program exists that simultaneously targets both youth and their caregivers to an equivalent degree. Our program has been operating at The Children’s Hospital Colorado in affiliation with the University of Colorado, School of Medicine, since January 2006. The program is tailored to adolescents, ages 13–18 years, and their families. A school-age IOP program for youth ages 7–12 years was also developed and operates concurrently to the teen program.
The IOP program at The Children’s Hospital Colorado initially was developed in response to a need for a program for youth stepping down from higher levels of care, including psychiatric inpatient or day treatment programs, who remained too acute to be managed effectively with routine outpatient treatment. In addition, patients who had failed to respond adequately to routine outpatient care also “stepped up” into the IOP program. A need existed for a program that could simultaneously increase parental effectiveness and bolster psychosocial skills in youth, thereby reducing symptoms and improving functioning. The manualized PACK and MaPS Teen therefore included two major treatment components, including parent training and psychosocial skills training for patients aged 12–18 years old.
Before the launch of PACK and MaPS IOP programs, the hospital negotiated the addition of IOP to the majority of active contracts with commercial insurance companies, which already included the higher levels of psychiatric care, including inpatient and day treatment. Most commercial managed care companies were eager to contract for IOP, at rates which generally covered the costs of service delivery, because they were interested in a program that could potentially serve as a “hospital diversion” and maintain patients in a lower, less expensive, level of care. It was estimated that the cost of 18 sessions, or a typical, 6-week course of IOP, equated to the cost of five psychiatric inpatient, or eight partial-hospitalization, days. Government insurances, including Medicaid and Tricare, did not offer IOP as a covered benefit and so families with such insurance plans generally could not be served, at that level of care.
An additional marketing point was that, it can be argued that treating an entire family while the child or adolescent is being cared for at home is a much more rational and effective strategy than admitting a youngster to the hospital, which necessitates separation from caregivers and limits the opportunity to intervene with families and effect change in the home environment. The PACK and MaPS IOP program was also marketable on the basis that it offered intensive parent training and psychosocial skills training for the child or adolescent, with the goal of inoculating families against relapse into aversive, conflict-ridden patterns of relating.
The combination of the acquisition of managed care contracts at reasonable rates for IOP; the use of highly standardized, explicit treatment protocols that enabled a pool of multidisciplinary providers to deliver the service with integrity; a group format; and the use of a rolling admissions process led to the creation of an outpatient psychiatric program that was sustainable in an academic and hospital-based setting on the basis of insurance reimbursements.
Typical insurance or managed care criteria for an IOP program require that a sponsoring facility offer at least three IOP sessions or episodes of care per week and that each IOP session must equate to at least 3 hours’ worth of treatment or service delivery. Usually, IOP programs are comprised of coordinated and multidisciplinary services, typically delivered by teams of psychologists, social workers, nurses, mental health counselors, and creative art therapists. IOP programs should be able to offer psychosocial assessments, as needed; multiple treatment modalities; care coordination; and access to psychiatric or medication consultations, if indicated. The access to psychiatry or medication consultation services must be timely, with an expectation that it be offered, when indicated and desired, within 1 week of admission to the IOP program. It is standard practice for these physician services to be billed separately and not included within the bundled contracted facility rates for the IOP sessions.
Several options are possible for achieving the typical minimum insurance or managed care requirement of 3 hours of treatment per IOP session using the PACK and MaPS curricula. For instance, in a setting where at least four multidisciplinary providers could be made available at once after school for a few hours, one option would be for one pair of clinicians to provide parent training separately for 90 minutes while the second team of therapists provides psychosocial skills training to the adolescents for 90 minutes, for a total of 3 hours of treatment. In a setting where only one team or pair of clinicians is available, however, the team might alternatively provide 90 minutes of parent training followed sequentially by 90 minutes of psychosocial skills training with the teens, for a total of 3 hours of therapy. Another option available to sites limited to one team of providers might include working with entire families concurrently for at least 3 hours. Alternatively, a single team of clinicians could work with parents for 75 minutes, followed by adolescents for 75 minutes, followed by parents and teens together for 30 minutes. A final option, consider optimal by the author, is detailed below.
The Colorado site where the materials were developed was fortunate to have the luxury of a fairly large pool of talented multidisciplinary providers to enable simultaneous but separate treatments for the majority of the IOP sessions. In this program, clinical experience informed the IOP-Teen teams that an ideal format of service delivery for IOP sessions involved assembling two multidisciplinary clinician pairs—one to provide parent training using the PACK materials and the second to concurrently provide psychosocial skills training to the teens. PACK Teen modules 1–6 complemented and ran parallel with MaPS Teen modules 1–6. The standard length of treatment for the IOP-Teen was 6 weeks, with one module covered weekly, on average, in both the PACK and MaPS Teen workshops.
The three IOP sessions each week, varied from one another, to optimize the depth, scope, and mastery of the skills training. The first IOP-Teen session of the week occurred on Mondays and was comprised of separate, but concurrently run, parent and teen workshops, each of which was hosted for 90 minutes, for a total of 3 hours of treatment. During these sessions, since the families had not met since the previous week, a more prolonged check-in period was allowed, as each adolescent or set of parents relayed the events of the previous weekend, to the group and facilitators. However, it was important that the check-in and introductions follow a structure and are kept circumscribed. The therapists must carefully manage time and ensure that no more than 5 minutes is allocated per teen or parent, for individual check-ins. Without tight time management and clear limits for check-ins, the group tends to spontaneously spend most or all of the session checking in. Parents and teens often enjoy reporting to a group of peers, and relish having an audience and garnering support and validation. That common natural tendency can lend itself to long-winded storytelling and ventilating of feelings that can become counterproductive and diminish or eliminate opportunities for psycho-education, skill building, and skills practice.
Following introductions and check-ins, the facilitators would introduce new material and skill sets each week, using a method of Socratic, didactic teaching. The teen and teen parent groups separately discussed and rehearsed new skills, within their respective workshops. The participants of each workshop were encouraged to share relevant past experiences and generate ideas for rehearsal of new skills, based on their own lives. If offered alone, without adolescents present, the 90 minutes of parent training would be considered a multifamily group, comprised of multiple sets of parents, from different families. The 90 minutes of psychosocial skills training for the teens would be considered comparable to a typical, psychotherapy group, comprised of patients only.
The second IOP-Teen session of the week, held on Tuesday afternoons, was comprised of hosting a parent and teen workshop separately, but concurrently, for 60 minutes (totaling 2 hours of treatment), followed by a 60-minute “joint” session, during which families were brought together for the sake of practicing skills, for a total of 3 hours of intervention. During this second session, previously introduced topics were reviewed and additional discussion and rehearsal of new skills was facilitated. One option for the “joint” portion of this session was to facilitate the practice of skills together, as a large group, by having families take turns or alternatively, the group was divided into individual family units, with each assigned a facilitator. The intention of either format was to enable each family to practice their newfound parenting and psychosocial skills, while the therapists provided hands-on consultation and coaching, in real time. If offered alone, with a therapist assigned to coach each family, these 60-minute sessions would be considered comparable to family therapy. Ensuring provider continuity across the skill-building sessions was an essential ingredient to the success of the program. The third weekly session, organized around creative arts therapy, included additional providers, as described below, but at least one staff member from the first two sessions attended the third to preserve continuity of care and bolster topical links to earlier, language-based skills training groups.
The third weekly IOP session, held on Thursday afternoons, used a creative arts therapy approach and was offered to entire families, including all siblings, aged 6 years and older. Children younger than 6 years could not be accommodated because they required continuous parental attention and supervision, which tended to derail the therapeutic process. The weekly, multifamily, creative arts therapy session provided a venue for entire families to practice skills, as well as process feelings and explore family dynamics, using the media of art and music. In our program, this third weekly session, which ran for 2 hours and 15 minutes, alternated between art and music therapy and was designed to provide a forum for the open processing and discussion of feelings in a less structured and prescriptive manner than the first 2 weekly sessions. The art and music therapists developed a series of exercises that incorporated topics and skills covered in the earlier parent and psychosocial skills training sessions. Families were invited to work collaboratively, using art or music as a medium, to apply and practice new skills in a creative and fun way.
The Creative Arts Therapy IOP session lasted for 2 hours and 15 minutes; the remaining 45 minutes that were necessary to meet the criteria of 3 hours of intervention for the third weekly IOP session were fulfilled through weekly individual or family therapy and care coordination sessions. Each of the IOP group therapy providers was assigned two or three families at a time with whom they were responsible for meeting each week. The providers met with individual teens or their families immediately prior to or immediately after IOP group sessions. Half of patients were seen for their individual or family session on Monday and the other half on Tuesday. This session was used flexibly and adapted to the needs of the individual teen and their family. If the teen had a history of safety issues, such as physical aggression, self-injury or suicidality, then the individual session therapist would use the session to monitor safety, along with provide psycho-education and guidance to the patient and family, around safety monitoring and planning, at home. The individual sessions could be customized in several ways, including flexible inclusion of various family members, options for which included the following:
In addition, the session could be used for psycho-education, parent guidance, parent, teen or sibling support, or reinforcement and/or rehearsal of psychosocial skills covered in group workshops. Despite advanced verbal and written orientations, new families have sometimes opted to use at least their first individual and/or family session for the purpose of receiving a program overview and asking questions regarding program content, logistics, operations, and disposition planning.
A further purpose of these weekly individual or family interventions was to provide a forum for parents and youth to relay concerns or ask questions that might not have been covered in the other IOP components, which were largely delivered in a group format. The clinician often used these interchanges to problem-solve with individual patients or families and offer more customized recommendations, as well as address the unique issues faced by each teen and his or her family.
A psychiatric nurse coordinated the intake process for the program and managed its overall operations, as well as co-facilitated IOP psychosocial skill-building workshops. Youth referred to the IOP program initially were scheduled to receive a psychosocial assessment by a licensed clinical social worker prior to admission. The social worker who performed these evaluations obtained authorization from insurance for IOP and served as a co-facilitator for the IOP parent training workshops. This continuity of providers from point of intake to facilitation of the actual workshops strengthened the program and enabled one of the team members to obtain a detailed history from each family and disseminate relevant information to the remaining team members as clinically indicated.
The clinical information gleaned from the intake was used as a basis for determining the appropriateness of the IOP program for the adolescent and caregivers; if indicated, the clinician would then seek authorization from the patient’s insurance. Because IOP is a higher level of care and more expensive than routine outpatient care, managed care companies routinely do require special authorization. The clinical material presented as the basis for justifying IOP must be current and obtained within 1–2 days of the phone call seeking authorization from the insurance company. However, compared with obtaining authorization for even higher levels of care, such as day treatment or inpatient treatment, our clinicians found insurances generally amenable to authorizing a full course—averaging 15 sessions—of IOP.
As part of program development, since the IOP program’s inception, patients ages 7 and above and their parents or caregivers were asked to fill out weekly questionnaires using the Ohio Youth Scales (Ogles, Dowell, Hatfield, Melendez, & Carlston, 2004). The Ohio Youth Scales were chosen for their practicality of use; they use self-report, take 5–10 minutes to complete and are affordable. In addition, the scales tap into all major outcome domains including problems, functioning, effectiveness, prognosis, and patient satisfaction. The scales have been validated empirically and are shown to have good internal consistency and test–retest reliability, with validity comparable to the Achenbach CBCL (Achenbach & Rescorla, 2001) and Youth Self Report (Achenbach & Rescorla, 2001). The Ohio Youth Scales were designed to assess outcomes of programs that serve broad and diverse populations.
At the start of the first IOP session of the week, clinicians asked adolescents and parents to complete the Ohio Youth Scales. Outcome rating scales were a component of the program and initially were included for the purposes of program development. Once completed in the initial session, staff checked over the scales for the sake of ensuring they were completely and accurately filled out. The therapists and clinicians reviewed and discussed these scales each week at the IOP team meeting, paying particular attention to specific, written comments made by parents and youth; when indicated, these comments were addressed directly with families. At the start of the second IOP session each week, the therapists spent a few minutes inviting the children, adolescents, and their parents to offer their suggestions related to further enhancing and strengthening the program.