Research on Child and Adolescent Mental Health

Szapocznik, et al., 1988). A similar engagement
intervention has been used among inner-city,
primarily minority families to increase attendance
at initial mental health service appointments
(McKay, McCadam, & Gonzales, 1996; McKay,
Stoewe, McCadam, & Gonzales, 1998). These
preliminary efforts at increasing engagement are
particularly noteworthy given the research that
supports the importance of involving children’s
caretakers in mental health treatment. For
instance, family participation during and following
day-treatment hospitalizations (Kutash & Rivera,
1995) and inpatient hospitalizations (Pfeifer &
Strzelecki, 1990) has been shown to be essential to
obtaining and maintaining positive outcomes.
Consequently, continued efforts to increase mental
health service engagement and entry are necessary.
Finally, an important body of work is uncovering
potentially ineffective treatments. As pointed out
by Weisz and Hawley (1998), null or even
negative effects can be instructional but,
unfortunately, are often not reported. The recent
report “Youth Violence: A Report of the Surgeon
General” (U.S. Public Health Service, 2001)
estimates that many of the services provided to
delinquent juveniles have little or no evidence
base. Worse yet, a recent study indicated that peer
group-based interventions might actually increase
behavior problems among high-risk adolescents
(Dishion, McCord, & Poulin, 1999). In addition,
despite their prevalent use in mental health
settings, there is little empirical justification for
the use of nonbehavioral psychotherapies to treat
disruptive behavior disorders (Weisz, Donenberg,
Han, & Weiss, 1995). Finally, common treatments
for children with complex emotional and behavior
problems are group homes and inpatient
hospitalization (Burns, Hoagwood, & Mrazek,
1999). Yet existing research indicates that
improvements are not maintained once the child
is returned to the community (Kirigin,
Braukmann, Atwater, & Wolf, 1982). The lesson
to be learned from these examples is that in some
cases, it is wrong to assume that some treatment
or service is better than nothing at all.
OBSTACLES AND GAPS
While progress in creating an evidence base on
combined treatments and services has been rapid
in the past 10 years, the need to link clinical
treatments more forcefully to service provision is
underscored by the fact that most of the services
available in most communities have no empirical
support behind them (English, in press). Further,
the number of children with untreated mental
illnesses is as high now as it was 20 years ago
(U.S. Public Health Service, 2000).
To address the significant unmet mental health
needs of children and their families, the
traditional paradigm for creating an evidence base
on the clinical safety, efficacy, and utility of
treatments must be revisited. The traditional
paradigm involves conducting a series of
controlled laboratory trials, with dissemination,
implementation, and deployment appended at the
end of the process. This model, called the Clinic-
Based Treatment Development Model, may not be
well-suited to ultimate use in clinics or
community settings, because many of the realworld
factors that researchers consider “nuisance
variables”— and therefore rule out or control
experimentally— are precisely those variables that
need to be understood and addressed if treatments
are to work well in real-world practice (Weisz,
2000). These variables, or real-world exigencies
(e.g., providers too overwhelmed to learn a new
treatment protocol, comorbidity, parent substance
abuse or pathology, and life stressors that lead to
early terminations or no-shows), may need to be
directly addressed within the development,
refinement, and testing of treatments and services
if these interventions are to be maximally
effective.
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