This study examined treatment processes and outcome for a subgroup of children with ASD and disruptive behavior problems receiving care in community mental health clinics. It represents the first research reporting detailed observational data on community mental health services for children with ASD. Further, it provides important descriptive information about the characteristics of children with ASD and rich contextual data about a matched comparison group without ASD receiving care in this setting.
The children with ASD were an average of 8 years old and primarily male, with almost all having a high functioning (i.e., Asperger’s Disorder) or non-specific (i.e., PDD-NOS) diagnosis on record (i.e., DSM-IV 299.80). This high rate of Asperger’s/PDD-NOS diagnoses may be related the eligibility requirements of publicly-funded community mental health services in our county. That is, a primary
diagnosis of autistic disorder is excluded for reimbursement in the publicly-funded mental health service system, as the MR/DD system (not the mental health system) is responsible for funding services for children with this diagnosis. Asperger’s Disorder and PDD-NOS, however, are not excluded diagnoses. Children in the ASD sample were also diagnostically complex, with over 70% labeled as having at least one co-morbid additional psychiatric diagnosis (most frequently ADHD). This rate is consistent with studies examining the prevalence of psychiatric problems in children with ASD (Leyfer et al. 2006b
; Simonoff et al. 2008
). Lastly, funding for a majority of the children with ASD was provided through the school district. This finding is consistent with national trends indicating that the education system plays a significant role in providing mental health services for children with a broad range of mental health problems (Roanes and Hoagwood 2000
The observational data on treatment strategies delivered to children with ASD indicate that therapists do frequently deliver a number of strategies conceptually consistent with research-based behavioral methods (delivering positive reinforcement and punishment/limit setting) and certain cognitive behavioral strategies (problem-solving/social skills, affect education, affect management) (e.g., Rogers and Vismara 2008
; Wood et al. 2009
). However, these strategies were delivered, on average, with low to moderate intensity (i.e. thoroughness). These findings indicate that while therapists in community mental health clinics are targeting many of the same general areas as research-based child skill-building interventions, the interventions are not being delivered in the same manner. The observed occurrence of behavioral parent training strategies (e.g., covering operant conditioning principles) and active teaching strategies typically employed in research-based parent training programs (e.g., role-play/practice, homework) was low. Likewise, when these strategies were observed to be delivered with parents, average intensity was low. While the observational measure used in this study is not a measure of fidelity to a particular treatment model, the low intensity suggests that the strategies are not being delivered as thoroughly as would likely be present in a research-based treatment model. Taken together, these findings replicate results from the larger PRAC study which indicate that certain strategies conceptually consistent with evidence-based practices for children with disruptive behavior problems are delivered with some frequency in community mental health clinics, but they are not delivered very intensively (Garland et al. in press). Further, the findings are consistent with research on community early intervention services that indicate that there are gaps between research-based practices and those that are provided in the community (Stahmer 2007
; Stahmer et al. 2005
It is important to highlight that observed treatment process was very similar for children with and without ASD who are receiving care from the same (or very similar) providers. This finding suggests that therapists may not tailor treatment to the unique characteristics of children with ASD, which may be explained by the limited specialized ASD training reported by therapists in these settings (Brookman-Frazee 2009
). It also supports the general lack of specificity of treatment strategies based on child primary diagnosis reported in analyses of the full PRAC study which indicate that variability in practice patterns is not associated with child diagnosis (Brookman-Frazee et al. 2009b
Outcomes across a number of different domains were measured. Statistically significant improvements in child behavior problems, caregiver strain, and family-related empowerment were observed at 8 month follow-up and medium effect sizes were observed. Significant improvements in parent discipline practices were not seen. These findings provide preliminary evidence of the positive impacts of community services, particularly related to child behavior problems and parent functioning, however, the effect sizes are smaller than those reported in intervention trials (e.g., Wood et al. 2009
). It is also important to interpret these findings with caution given that there was no control group. Thus, no conclusions can be drawn about the impact of treatment on these outcomes. More research is needed on the potential impact of treatment provided in this context on social and adaptive functioning. Further, examination of change in internalizing psychiatric symptoms (particularly anxiety) is warranted given that over one quarter of the ASD sample was diagnosed with an anxiety disorder.
This study adds to the literature in a number of different ways. First, it expands the literature on ASD services research. While much of the existing work in this area relies on large administrative datasets to describe the broad types of services that child with ASD receive (e.g., Mandell et al. 2005
; Mandell and Palmer 2005
; Ruble et al. 2005
) this study provides detailed observational data on the nature of outpatient treatment actually delivered in treatment sessions in community practice. These data have important implications for bridging the research-practice gap. For example, they can be used as baseline data for future studies that attempt to implement research-based ASD interventions in community settings. Further, the findings provide a “roadmap” for specific treatment strategies that should potentially be the focus of therapist training. For example, the low intensity/thoroughness of all strategies delivered suggest that increasing the intensity with which strategies are delivered may be a primary focus. Further, the low frequencies of behavioral parent training and active teaching strategies (role-play/practice and homework) need to be explicitly targeted. This is particularly important given that many of the children also had ADHD and DBD diagnoses for which there is also strong empirical support for behavioral parent training. It is important to note that certain research-based strategies were observed relatively frequently, suggesting that there is some overlap between community services and research-based care and that therapists may be open to learning more about research-based strategies. Overall, the findings highlight the heterogeneity of usual care psychotherapy. While some aspects of usual care treatment resemble research-based models, it is not entirely consistent. The findings also suggest that using treatment as usual is an important control group for future interventions studies.
This study also adds to the research on mental health services more generally. To date, there has been limited attention to ASD in mental health services research (see Brookman-Frazee et al. 2009a
). This study confirms that children with ASD are being served in community-based mental settings. That is, they represent almost 10% of children presenting with disruptive behavior problems sequentially recruited into the PRAC study. Since therapists in our community indicate that they have limited training on treatment for ASD, it suggests that efforts to improve mental health services overall should include some targeted training efforts for this population. This study also provides information about the characteristics of children with ASD served in general community mental health settings. This information is important because it facilitates our understanding of who
is receiving these services. Lastly, this study provides information on the delivery of psychotherapeutic strategies for all
children receiving care in these settings. Consistent with other analyses of the full PRAC study sample (e.g., Brookman-Frazee et al. 2009b
), the data for this subgroup indicate that overall intensity of observed strategy delivery was relatively low for strategies directed towards both children and parents. Since evidence-based practices for most childhood disorders (including ASD) typically include thoroughly pursuing specific goals (i.e., intensity), this finding suggests the need for training interventions to strengthen therapists’ use of active and directive techniques to increase the thoroughness of strategies delivered.