Hospital-based behavior modification program for adolescents: evaluation and predictors of outcome.

Ansari, Ahmed Al ; Gouthro, Stephen ; Ahmad, Khalil 等

INTRODUCTION

Conduct problems, aggressiveness, and antisocial behavior constitute between one third to one half of all child and adolescent referrals to psychiatric clinics (Kazdin, 1987). Conduct-disordered youth are likely to drop out of school, be unemployed, and have poor interpersonal relationships. These factors translate into increased financial and social costs to the community (Shamsi, 1990).

In addressing these concerns, various treatments and combinations of treatment have been applied over the last several decades. Studies published over the past thirty-five years can be broken into two periods - those done before and after 1980. Studies done prior to 1980 reported primarily negative results, while some promising and successful approaches have been reported since 1980 (Shamsi & Hluchy, 1991).

It is unfortunate that the long-term effects of these programs as assessed by the rate of recidivism, remain disappointing (Garrett, 1985; Basta & Davidson, 1988; Whitehead & Lab, 1989).

Blotcky, Demperio, and Gossett (1984) and Pfeiffer and Strzelecki (1990) evaluated criticisms regarding the effectiveness of inpatient psychiatric treatment of children and adolescents. They reviewed all published child inpatient follow-up studies from 1932 to 1987 which included children and adolescents with mixed diagnoses. Both studies reached the conclusion that inpatient treatment is often beneficial. Moreover, they identified a number of factors which indicate favorable prognosis. These include: adequate intelligence, nonpsychotic and non-organic diagnoses, absence of antisocial features, healthy family functioning, later onset of symptoms, adequate length of stay, specialized treatment programs, and involvement in aftercare (Blotcky et al., 1984; Pfeiffer & Strzelecki, 1990). In 1988 a program designed to deal primarily with conduct-disordered adolescents was implemented at the Nova Scotia Hospital, Princess Alexandra Unit. The program utilizes behavior modification principles whereby positive and punitive consequences are applied to adolescent behavior within the context of a token economy (BMP). Targeted behaviors are assigned point values, and accumulated point totals determine privilege levels for the following day.

The present paper reports the results of an evaluation of the efficacy of this program in reducing the frequency of undesirable behaviors. An attempt has also been made to identify the factors associated with better outcome.

The treatment unit under consideration provides 20 beds for male and female adolescents, ages 12 to 18. Referrals were from children's aid societies, correctional services, hospitals, families, private practitioners, and the educational system. The adolescents exhibited a wide range of conduct problems such as truancy, running away, promiscuity, aggressive acting out behavior, poor peer relationships, drug abuse, and depression. In addition, some of the adolescents presented with repeated suicide attempts as well as poor academic achievement. The unit included a school program geared to special education, occupational therapy, vocational training, recreation, and leisure activities. The core program was provided by living and learning environments in which staff presented opportunity for counselling and modelling of pro-social behaviors. The adolescents were rewarded points for appropriate behavior. The accumulated points at the end of the day determined privileges for the next day. With increased accumulations of points, teens were granted additional privileges and responsibilities. Average length of stay was approximately three months.

METHOD

Subjects were adolescents aged 12 to 18 (N = 60) who had been admitted to the Princess Alexandra Unit, Nova Scotia Hospital between April 1989 and November 1990, and had completed eight weeks or more on the behavioral program. The eight-week period was chosen arbitrarily by the treatment team as the minimum time necessary to produce a measurable impact of the behavior program. The ratio of males to females was 1.5:1; mean age was 14.48 years. The diagnoses at admission included conduct disorder, oppositional defiant disorder, attention deficit disorder with hyperactivity, adjustment disorder, and dual diagnosis according to DSM-R III (American Psychiatric Association, 1987).

The study utilized a retrospective analysis of events. The files of all subjects were examined for information regarding their overall performance in the program as measured by the points earned daily. Points lost for exhibiting a specific behavior (e.g., noncompliance, verbal and physical aggression) were analyzed separately. In addition, data regarding age, gender, diagnosis, length of stay, age at onset, other treatments received, and level of education were obtained and coded. The weekly balance total for each subject (points earned for appropriate behaviors minus points lost for undesirable behaviors) was split in half. A student t-test for pairs was then used to compare the mean score over the first four weeks (pre-test) and last four weeks (post-test) of treatment. The same was applied with respect to the significance of each outcome predictor under study. These included age, gender, presence of conduct disorder diagnosis, age at onset before and after six years, and presence of an academic deficit as measured by a lag of at least two years on educational assessment. The length of stay was divided into four periods: less than 12 weeks, 13 to 18 weeks, 19 to 24 weeks, and more than 24 weeks. The Pearson product-moment correlation and analysis of variance (ANOVA) were also used in the analysis wherever applicable.

RESULTS

Table 1 shows the characteristics of the study sample. The majority were males, members of broken families, diagnosed with conduct disorder, and had identified learning problems. At least two thirds of the cases stayed less than 18 weeks in hospital and received other types of interventions in addition to the BMP.

Table 1

THE DISTRIBUTION OF CASES BY AGE, GENDER, DIAGNOSIS, AGE AT ONSET,
TREATMENT, FAMILY STRUCTURE, EDUCATIONAL LEVEL, AND LENGTH OF STAY

Variable No. %

AGE:

13-16 49 81.7
16-18 11 18.3

GENDER:

Males 36 60.0
Females 24 40.0

DIAGNOSES:

Conduct disorder 21 35.0
Attention deficit disorder
with hyperactivity 4 6.7
Adjustment disorder 8 13.3
Oppositional defiant disorder 8 13.3
Dual diagnosis 16 26.7
Other 3 5.0

FAMILY STRUCTURE:

Single mother 21 35.0
Step father 19 31.7
Adopted 8 13.3
Biological parent 12 20.0

TREATMENT:

BMP only 16 26.7
BMP + individual therapy 10 16.7
BMP + group therapy 3 5.0
BMP + chemotherapy 6 10.0
BMP + family therapy 1 1.6
BMP + combination therapies 24 40.0

LENGTH OF STAY:

[less than] 12 weeks 20 33.3
13-18 weeks 20 33.3
19.24 weeks 15 25.0
[greater than] 24 weeks 5 8.4

AGE AT ONSET:

[less than] 6 years 26 43.3
[greater than] 6 years 34 56.7

EDUCATIONAL LEVEL:

Age appropriate 22 36.7
2 levels less than
expected for age 38 63.3

The subject's performance on the program as measured by the mean difference of pre- and post-scores, was significant, F = 2.42, p = .019. The scores were higher for those who received only the BMP as compared with those who participated in other treatments in addition to the BMP (t = 3.00, p = .009). Performance on the BMP was not significantly correlated with age (r = .042). Table 2 shows the influence of subject and treatment factors on the outcome variable. Factors such as female gender, nonconduct disorder diagnosis, age at onset over six years, living with the parent family, and absence of learning problems were positively correlated with better outcome.

There was no significant difference between pre- and post-scores when factors involving male gender, conduct disorder diagnosis, single-mother family, and presence of learning problems were considered. The length of stay in hospital was not found to be significantly related to positive outcome on the BMP, F = 1.54, p = .335.

DISCUSSION

Behavioral techniques such as positive reinforcement, behavioral contracts, modeling, and role playing resulted in improvement in pro-social behaviors as demonstrated by point increases within the token economy. Results support the existing facts (Basta & Davidson, 1988). Transfer of the behavior gains to the community await proof by a follow-up study assessing community-based adjustment. The design employed in the present study is similar to a pre/post test without a control group. This is normally considered a weak design since occurrence of events, regression to the mean, maturation, testing effects, and change in instrumentation, affect the validity (Cote, Paul, Harris, & Vipond, 1986). Cook & Campbell (1979). However, using average scores of points assigned to a behavior, counted continuously by different staff members over a period extending to four weeks, should eliminate some of the criticisms. Inclusion of an equivalent control group would no doubt add strength to the design, but in practice, such a group is virtually impossible to obtain. The present study supports the view that healthier patients (i.e., those with less severe psychopathology) respond favorably to inpatient psychiatric treatment. The presence of florid antisocial features, learning problems, absence of father or father substitute, were associated with no improvement. Gender is considered a weak predictor in the majority of studies (Pfeiffer & Strzelecki, 1990; Gosset, Barnhart, Lewis, & Phelps, 1977). In this study, the female gender was associated with favorable adjustment. One may raise a question as to whether males showed less progress due to a higher incidence of conduct disorder diagnosis, but detailed examination of representation of gender by type of disorder showed equal distribution in the conduct disorder category.

Table 2

MEAN DIFFERENCE OF PRE AND POST SCORES OF OUTCOME PREDICTORS

 CASE MEAN t p
VARIABLE NOS. DIFF. SEM VALUE VALUE

GENDER:

Male 36 - 23.958 53.536 -0.45 NS
Female 24 -207.395 54.502 -3.81 0.001
TOTAL: 60 -389.333 161.008 -2.42 0.019

DIAGNOSIS:

Non-Conduct 29 -168.508 37.098 -4.54 0.000
Conduct 31 - 30.750 68.263 -0.45 NS

AGE ONSET:

[less than] 6 Years 26 -115.836 60.069 -1.93 0.06
[greater than] 6 Years 34 - 83.183 54.841 -1.52 NS

BEHAVIOR
MODIFICATION
Program (BMP)

Only Treat. 16 -214.328 71.359 -3.00 0.009
BMP + Other
Treatments 44 - 54.789 47.199 -1.16 NS

PRESENCE OF
FATHER:

Sgl. Mother 21 -139.952 332.739 -0.42 NS
Others(*) 39 -523.615 170.851 -3.08 0.004

EDUCATIONAL
LEVEL:

Age
Appropriate 22 -213.647 50.114 -4.26 0.000
Non-Age(**)
Appropriate 38 - 29.993 54.036 -0.56 NS

* Others include biological, step & adopted fathers

** At least two levels below expected for age.

Surprisingly, age at onset before age six was associated with better results in comparison with those who developed symptoms at a later age. In the literature, age at onset was linked with poor prognosis for patients with conduct disorder (Shamsi, 1990; Shamsi & Hluchy, 1991). One way of explaining this result is that conduct disorder was more prevalent among the group who developed symptoms after age six.

Adolescents who participated in the BMP obtained higher scores than did those who participated in the BMP plus other treatment modalities. This may reflect the difference in severity of psychopathology in the two groups. It is a common practice to add other approaches for those who presented with multiple problems or did not have a fast response to the BMP.

It is important to note that the BMP is of short duration (average eight to ten weeks), dictated by high bed demand and the need for rapid turnover. The finding that length of stay was a weak predictor of positive outcome lends support to the length of the existing program. In the authors' opinion, such a relatively brief program is beneficial for the majority of youth with behavior disorders with the exception of those with the diagnosis of conduct disorder. This opinion is supported by the detailed analysis of mean difference scores and length of stay. A small number of patients stayed longer than 24 weeks (n = 5). Although this group were diagnosed as conduct disordered upon admission, they were eventually able to demonstrate significant point gains on the token economy. It is therefore possible that even patients with more severe conduct disorders may benefit from such a program with an extended length of stay. More longitudinal studies using well-defined criteria that measure post-discharge success are needed. Such research is now in progress.

REFERENCES

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Health Disorders (3rd. ed. rev.).

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Cook, T.D., & Campbell, D.T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Chicago: Rand McNally.

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Pfeiffer, S.I., & Strzelecki, S.C. (1990). Inpatient psychiatric treatment of children and adolescents: A review of outcome studies. Journal of American Academy of Child Adolescent Psychiatry, 29(6), 847-853.

Shamsi, J. (1990). Youth with conduct disorder. What is to be done? A publication of the Institute for the study of Antisocial and Violent Behavior in youth.

Shamsi, J., & Hluchy, C. (1991). Youth with conduct disorder: A challenge to be met. Canadian Journal of Psychiatry, 36, 405-414.

Whitehead, J.T., & Lab, S.P. (1989). A meta-analysis of juvenile correctional treatment. Journal of Research in Crime and Delinquency, 26(3), 276-295.

Stephen Gouthro, MSC, Clinical Psychologist; Khalil Ahmad, MBBS, DPM, Director, Adolescent Services; Corinne Steele, MSW, Social Worker, Nova Scotia Hospital, Dartmouth, N.S. Canada.

Reprint requests to Ahmed Al Ansari, MBCHB, FRCPC, Consultant Child Psychiatrist, Psychiatric Hospital, Ministry of Health, P.O. Box 12, State of Bahrain, Arabian Gulf.