The key to successful outpatient juvenile treatment: Have the first appointment!

By Norbert Ralph, PhD

The adverse effects of delays in starting mental health treatment for juveniles have been discussed in the literature. Kataoka, Zhang, and Wells (2002) examined the consequences of delays in accessing psychiatric treatment for different ethnic groups and insurance status. Conn et al. (2019) noted the impact of delays for children and teens in accessing appropriate psychiatric treatment through a qualitative study. In California, a large health organization, Kaiser Permanente, was repeatedly fined for delays in treatment for adolescents, resulting in adverse outcomes (Pfeifer & Terhune, 2015). However, there is a lack of studies specifically focusing on delays in treatment for juveniles who sexually offend, including the prevalence, causes, or effects of such delays.

With no directly relevant research, this blog is based on my experiences as a county administrator and consultant for California counties. It aims to highlight the importance of making the first treatment appointment with the fewest steps, while providing positive support to the youth and their families. Delays negatively impact treatment outcomes, as treatment cannot be effective if it does not start, and delays may have toxic effects. For instance, I recently consulted on a case where, due to family moves and changes in probation officers, court-ordered treatment had not started even after a year.

Possible factors contributing to treatment delays include:

•           Absence of policies guiding the implementation of court-ordered outpatient treatment or everyday issues like probation officers being on leave or cases being transferred to new officers or units.

•           Lack of a list of qualified clinicians for probation officers, particularly in rural and urban counties.

•           Availability of prompt, efficient, and respectful acceptance of new patients by qualified clinicians on the list.

•           Collaboration between probation officers and clinicians to address potential complications related to transportation, afterschool activities, working hours of parents, or language.

•           Availability of telehealth options.

•           Payment for treatment by the county.

•           Realistic and supportive addressing of the client's concerns and motivation for treatment.

•           Lengthy litigation delaying the resolution of the issue.

This list is not exhaustive but serves as examples of potential problems.

Consequences of delayed treatment initiation include:

•           Longer time on probation due to delays.

•           Increased stress for clients, including prolonged worry, adverse effects, limitations of probation, and uncertainty.

•           Impaired development of trust and working alliance with probation and clinicians due to issues with timeliness, support, and treatment initiation efficiency.

•           Decreased client motivation for treatment with prolonged delays.

•           Delayed treatment for the underlying problem, increasing the likelihood of recidivism or further problematic sexual behaviors in youth and problematic of "enabling" family or individual belief systems.

Solutions to avoid delays involve a systems perspective, which is often overlooked. The goal is to minimize steps, reduce barriers, and increase the likelihood of successful progression. These initial contacts also shape the client's first experience with the therapeutic process. Starting off with support, collaboration, and efficiency is crucial for establishing a productive treatment alliance. Sustaining the administrative and collaborative framework behind the scenes requires focused effort.

One approach employed in several California counties is establishing an "in-house" mental health team with a coordinator to oversee and facilitate the process. Having the team located alongside probation is advantageous. Alternatively, maintaining a list of external providers who can collaborate may serve as an effective alternative or complement. Establishing policies and protocols streamlines the process, benefitting probation officers and their supervisors. Providing informative and supportive guidance to clients, akin to medical procedures, is essential for reducing anxiety. Close collaboration and problem-solving between probation officers and clinicians regarding obstacles contribute to successful outcomes. These initial administrative contacts are integral to the therapeutic process and set the tone for facilitating a working alliance with clients.

An analogy from basketball illustrates some of these issues. If someone makes free throws approximately 80% of the time, the chance of them making five in a row is 33%. However, if their success rate increases to 95%, the likelihood of making three in a row jumps to 86%. Similarly, in treatment planning, having the first appointment with the fewest steps and a high probability of success, delivered in a warm and friendly manner, enhances the chances of successful treatment.

To summarize, for outpatient juvenile treatment to be more successful, the first appointment should be scheduled promptly, supportively, and with minimal obstacles. Delays and barriers to treatment initiation are likely to decrease treatment effectiveness, increase client distress, and erode trust in the probation system.

References:

Conn, A. M., Szilagyi, P. G., Nadeem, E., Wang, H., Sterling, E. W., & Franke, T. M. (2019). The mental health system failed our child: Qualitative insights from families of children with serious emotional disturbance. Psychiatric Services, 70(10), 885-890.

 

Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 1548-1555.

 

Pfeifer, S., & Terhune, C. (2015). California again slams Kaiser for delays in mental health treatment. Los Angeles Times. Retrieved from https://www.latimes.com/business/la-fi-kaiser-mental-health-20150225-story.html