Mental health care for children with disruptive behavior problems: a view inside therapists' offices

In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care.

Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months.

Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing).

Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.