Adolescents' Well-being in Community-based Treatment Versus Residential Treatment

A Quasi-experimental Longitudinal Study of Adolescents' Well-being in Community-based Treatment Versus in a Psychiatric Residential Treatment Facility (PRTF)

This is a quasi-experimental longitudinal study to compare the outcomes of youth in a Psychiatric Residential Treatment Facility (PRTF) compared to youth in the community-based Child-Focused Assertive Community Treatment Team [Child ACTT] program. The hypothesis is that Child ACTT will be associated with better outcomes and lower cost than PRTF among adolescents admitted to Child ACTT or PRTF.

Study Overview

• Status: Completed
• Conditions: Mental Disorders, Severe; Adolescent Well-Being

Detailed Description

Psychiatric Residential Treatment Facility (PRTF) care is expensive, removes adolescents from their communities, and is not necessarily effective. Managed care organizations (MCO) are exploring other methods of providing intensive care at home. Several states (e.g., Maine, Minnesota, Florida) have initiated and maintained Youth -Assertiveness Community Treatment (ACT) programs that are adapted from the evidence-based adult ACT model. Children's Hope Alliance (CHA) has been offering the Child-Focused Assertive Community Treatment Team [Child ACTT] Program as a service for potential clients since December 2019.

RECRUITMENT PROCEDURES

1. The MCO will send a letter to PRTF treatment providers to inform them about this study.
2. CHA and the PRTFs will inform the legal guardians of children who meet the inclusion criteria about a potential study opportunity.
3. If the legal guardian verbally consents to being contacted by Outcome Referrals, Inc. (ORI) about the study, CHA or PRTF will forward the contact information for the legal guardian of the eligible participant to ORI via an encrypted email.
4. ORI will contact the legal guardian to describe the study and review the eligibility criteria with potential participants (within 5 days of treatment authorization).

Individuals who meet the eligibility criteria and are interested in participating in the study will be sent electronic copies of the assent and consent forms to review and sign. ORI will inform the original referral source (CHA or specific PRTF) if the family is not able to be contacted or does not consent for study.

METHODS AND PROCEDURES

A randomized controlled trial was originally selected as the study design for this project because it is the gold standard for testing for causality; however, given recruitment issues, it was decided to transition to a quasi-experimental study instead. Although the investigators cannot conclude that one treatment is more efficacious than another, this quasi-experimental longitudinal study will provide important comparative information about these two treatment options for high need youth and families.

After study assent and consent forms are received by ORI, ORI will inform the referral source (CHA or PRTF) that the family consented to participate in the study: CHA or the PRTF will provide ORI with the contact information for the case manager at the facility for each participant. ORI will send an email to the case manager to inform them of that client's participation and request a time to train them on study assessment procedures.

ORI will administer a) the electronic assents and consents through an e-signature platform, and b) study assessments to both participants and their legal guardians during and post-treatment through ORI's secure platform, WellnessCheck.net.

• Study Type: Observational
• Enrollment (Actual): 124

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Framingham, Massachusetts, United States, 01701
      • Outcome Referrals, Inc.

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Participants will be recruited from PRTF and Child ACTT. For example, the MCO reported these data from 2020: 131 unique members were served in PRTFs. Their summary demographic characteristics for gender, race, and age were as follows: 43.5 percent female and 55.7 percent male; 18 percent Black, 78 percent White, 3 percent Other and an average age of 14.5 years. Potential primary diagnoses expected are major depressive disorders, psychotic disorders, anxiety disorders, disruptive behavior disorders and bipolar disorder.

Description

Inclusion Criteria:

• Between the ages 12 and 18
• Has primary mental health diagnosis
• Admitted for treatment in a participating program (i.e., Psychiatric Residential Treatment Facility (PRTF) or Child ACTT)
• A trained ORI staff member determines that the youth is able to understand and sign an assent for participation
• Documentation of the youth's assent to participate in the study
• A legal guardian provides consent for the youth to participate in the study

Exclusion Criteria:

• The client is not admitted to treatment in a participating program
• The client has dropped out of this study during a previous treatment episode
• Client does not initiate treatment

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Child ACTT - Experimental; Excerpt from the Partners Child ACTT service definition in North Carolina (Revised 5-23-19): Program Requirements: Child ACTT (Assertive Community Treatment Team) is a team-based multi-disciplinary approach to serve children in their homes, kinships placements, foster homes ... The team will have daily meetings to prioritize activities, share information, and discuss individual members. The team will be available to respond 24/7 for crisis de-escalation and assessment, inclusive of availability by phone within 15 minutes and face to face within no more than 2 hours. This will include face-to-face assessment by a clinician, or nurse if this is determined to be needed for the individual. The psychiatric provider will be available minimally by phone 24/7 for consultation and treatment recommendations. The team will assess the overall needs of the family to ensure that all necessary treatment and supports are in place for entire family system.
PRTF - Treatment as Usual; Psychiatric Residential Treatment Facilities (PRTFs) are non-hospital facilities intended to provide inpatient services to Medicaid-eligible individuals who are under the age of 21. A PRTF's mission is to either improve residents' condition or prevent further regression to ultimately remove the need for such services. PRTFs provide a range of comprehensive services intended to treat residents' psychiatric conditions under the supervision and direction of a psychiatrist. The core components in a PRTF program include at least weekly medication management, 24 hours nursing services, high staff-to-client ratio with awake staff during night hours, individual, group, and family therapy, intensive psychoeducation, behavioral model of care designed to teach new functional skills, and comprehensive assessments as needed.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Average Z-score From Participant Self Report on Domains in the Clinical Scale of the Treatment Outcome Package (TOP-CS) at Study Intervention Endpoint	TOP is a comprehensive well-being assessment that is used in behavioral health and child welfare settings. The Adolescent TOP Clinical Scale (TOP-CS) is a 58-item scale for adolescents who are between the ages of 11 - 21. The TOP-CS assesses the client's past 2-week experience on 12 domains including Depression, Attention Problems, Conduct Problems, and Suicidality. Participants indicate "All" to "None of the Time" for each item on a 6-point Likert scale. The z-scores for each domain were averaged together to create one summary z-score. Summary z-scores range from -0.62 to 11.30 (0 = the general population mean). A higher average domain score suggests higher severity/lower behavioral health well-being.	Study intervention endpoint (discharge or 6 months)
Average Z-score From Participant Self Report on Domains in the Clinical Scale of the Treatment Outcome Package (TOP-CS) at Post-discharge Follow-up	TOP is a comprehensive well-being assessment that is used in behavioral health and child welfare settings. The Adolescent TOP Clinical Scale (TOP-CS) is a 58-item scale for adolescents who are between the ages of 11 - 21. The TOP-CS assesses the client's past 2-week experience on 12 domains including Depression, Attention Problems, Conduct Problems, and Suicidality. Participants indicate "All" to "None of the Time" for each item on a 6-point Likert scale. The z-scores for each domain were averaged together to create one summary z-score. Summary z-scores range from -0.62 to 11.30 (0 = the general population mean). A higher average domain score suggests higher severity/lower behavioral health well-being.	Completed follow-up within 28 days to 6 months from discharge date during 6- month study intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Satisfaction Score From Participant Self-report on the Overall Provider Quality Subscale of the TOP Satisfaction Scale	The Overall Provider Quality subscale of the TOP Satisfaction Scale assesses patient satisfaction with behavioral health care. It includes 4 Likert scale items about satisfaction with treatment. Scores range between 1 and 6 (higher scores indicate higher satisfaction).	At intervention discharge (up to Month 6) or at Month 6 (study intervention endpoint)
Qualitative Satisfaction Data From Participant Self-report on the Overall Provider Quality Subscale of the TOP Satisfaction Scale	A single qualitative item (i.e., What are two reasons for your rating of the overall quality of the treatment received?) was included at the end of the Overall Provider Quality subscale of the TOP Satisfaction Scale.	At intervention discharge (up to Month 6) or at Month 6 (study intervention endpoint)
Average Z-score From Legal Guardian Ratings on Domains in the Clinical Scale of the Treatment Outcome Package (TOP-CS) at Study Intervention Endpoint	TOP is a comprehensive well-being assessment that is used in behavioral health and child welfare settings. The Adolescent TOP Clinical Scale (TOP-CS) is a 58-item scale for adolescents who are between the ages of 11 - 21. The TOP-CS assesses the client's past 2-week experience on 12 domains including Depression, Attention Problems, Conduct Problems, and Suicidality. Legal guardians of participants indicated "All" to "None of the Time" for each item for their child on a 6-point Likert scale. The z-scores for each domain were averaged together to create one summary z-score. Summary z-scores range from -0.62 to 11.30 (0 = the general population mean). A higher average domain score suggests higher severity/lower behavioral health well-being.	Study intervention endpoint (discharge or 6 months)
Average Z-score From Legal Guardian Ratings on Domains in the Clinical Scale of the Treatment Outcome Package at Post-discharge Follow-up	TOP is a comprehensive well-being assessment that is used in behavioral health and child welfare settings. The Adolescent TOP Clinical Scale (TOP-CS) is a 58-item scale for adolescents who are between the ages of 11 - 21. The TOP-CS assesses the client's past 2-week experience on 12 domains including Depression, Attention Problems, Conduct Problems, and Suicidality. Legal guardians of participants indicated "All" to "None of the Time" for each item for their child on a 6-point Likert scale. The z-scores for each domain were averaged together to create one summary z-score. Summary z-scores range from -0.62 to 11.30 (0 = the general population mean). A higher average domain score suggests higher severity/lower behavioral health well-being.	Completed follow-up within 28 days to 6 months from discharge date during 6- month study intervention
Satisfaction Score From Legal Guardian Report on the Overall Provider Quality Subscale of the TOP Satisfaction Scale	The Overall Provider Quality subscale of the TOP Satisfaction Scale assesses patient satisfaction with behavioral health care. It includes 4 Likert scale items about satisfaction with treatment. Scores range between 1 and 6 (higher scores indicate higher satisfaction).	At intervention discharge (up to Month 6) or at Month 6 (study intervention endpoint)
Qualitative Satisfaction Data From Legal Guardian Ratings on the Overall Provider Quality Subscale of the TOP Satisfaction Scale	A single qualitative item (i.e., What are two reasons for your rating of the overall quality of the treatment received?) was included at the end of the Overall Provider Quality subscale of the TOP Satisfaction Scale.	At intervention discharge (up to Month 6) or at Month 6 (study intervention endpoint)
Z Scores for Individual Domains From Participant Self Report on the Clinical Scale of the Treatment Outcome Package (TOP-CS) at Study Intervention Endpoint	The Adolescent TOP Clinical Scale (TOP-CS) is a 58-item scale that assesses the client's past 2-week experience on 12 domains. Participants indicate "All" to "None of the Time" for each item on a 6-point Likert scale. Only results for the CONDUCT PROBLEMS domain are presented in the Baseline Characteristics section and below because PRTF scores were significantly improved compared to Child ACTT for this one domain. All other domains (Attention Problems, Depression, Mania, Social Conflict, Worrisome Sexual Behavior, Poor School Functioning, Violence, Substance Abuse, Suicidality, Sleep Problems, Psychosis) showed no significant treatment differences at endpoint after controlling for baseline scores and individual trajectories. Z-scores for the Conduct Problems domain range from -0.20 to 27.01. A z-score of 2 or more standard deviations from 0 (the general population mean) is considered a moderately severe score.	Study intervention endpoint (discharge or 6 months)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cost of Treatment at Study Intervention Endpoint	Estimated treatment cost per condition will be assessed by calculating the number of days in treatment times cost per day	Through study treatment completion, a maximum of 6 months

Collaborators and Investigators

• Sponsor: Outcome Referrals, Inc.
• Collaborators: The Duke Endowment; Children's Hope Alliance

Publications and helpful links

General Publications

• Kraus DR, Seligman DA, Jordan JR. Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The Treatment Outcome Package. J Clin Psychol. 2005 Mar;61(3):285-314. doi: 10.1002/jclp.20084.
• Baxter EE, Alexander PC, Kraus DR, Bentley JH, Boswell JF, Castonguay LG. Concurrent validation of the child and adolescent versions of the Treatment Outcome Package (TOP). Journal of Child and Family Studies. 2016; 25(8): 2415-2422.

Study record dates

Study Major Dates

• Study Start (Actual): January 4, 2022
• Primary Completion (Actual): June 20, 2025
• Study Completion (Actual): June 20, 2025

Study Registration Dates

• First Submitted: June 25, 2024
• First Submitted That Met QC Criteria: July 5, 2024
• First Posted (Actual): July 12, 2024

Study Record Updates

• Last Update Posted (Actual): June 2, 2026
• Last Update Submitted That Met QC Criteria: May 6, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders
• Other Study ID Numbers: WCG IRB Protocol #20211997

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No