Temporal Relationships of
Child and Family Outcomes Across In-home Family Therapy[1]
Jennifer R. Lannigan, Lindsey R. Shorts, and Jeanne M.
Slattery[2]
(Clarion University)
In-home family therapy is an
intensive treatment option, requiring multiple contacts with the child, family,
and various sub-systems per week.
Therapists maintain frequent, on-going communication with Child
Protective Services (CPS), the school, doctors, and other involved agencies, so
that all agencies are working in concert.
Because this treatment is offered in a less restrictive environment (the
home and community) than hospital or residential treatments, it is also more
humane (Slattery & Knapp, 2003).
Mental health professionals can take several steps to determine whether the services they provide are beneficial. Ideally, children and families will be assessed at intake to and termination from therapy to measure improvement. We will discuss four of the six measures that we use: the Child and Adolescent Functional Assessment Scales (CAFAS), the Family Assessment Device (FAD), the Global Assessment of Functioning (GAF), and the Global Assessment of Relational Functioning (GARF). The CAFAS is administered to parents in an interview format and is used to assess children’s behavior in eight realms of home, school, and the community (Hodges, 1999; Hodges, Doucette-Gates, & Liao, 1999; Hodges & Kim, 2000). The FAD is a self-report completed by the family and used to assess family functioning and interactions (Kabacoff, Miller, Bishop, Epstein, & Keitner, 1990). The GAF and GARF, respectively, assess individual and relational functioning and are based on therapists’ interactions with the family.
Child functioning is believed
to both result from and contribute to family functioning (Minuchin, 1974). One way that we can assess our work is
to look at the relationships among family and individual outcomes across
time. While we expect that
correlations across realms (family and child) would be more modest than
relationships within a single realm (either child or family), we did expect to
see statistically significant relationships, and that these would decrease
across our measurement period.
That is, we expect to see stronger correlations among family and child
outcomes at intake than between intake and exit.
Methods
We examined 240 cases of
children and their families who were seen at Family Links, since its opening in
May of 1994. Clients considered
for the study were those who had terminated treatment by the last data collection
point in August 2003 and had given consent to have their information used in
the study. In thirty-two of the
cases, the identified patient (IP) had gone through the program multiple times. Throughout the course of treatment
clients were evaluated with four assessment scales, the CAFAS, FAD, GAF, and
GARF.
Client and family assessments
were to be administered upon entry into the program and just prior to
termination from the treatment.
Because this population is less “organized” than other
groups, many do not complete outcome assessments at each point (Slattery et
al., 2000). With the exception of
the CAFAS, which was first administered in 1997, more than 50 % of the clients
examined were administered each assessment within one month of entry and also
upon exit. Only 99 of the 240
clients (41%) seen had completed both the entry and exit CAFAS. The GAF and GARF measures were also
distributed during the third month of treatment, however, only 5% of the
clients had completed a mid-GAF assessment, whereas 59% of clients had a
mid-GARF.
All identified patients were
between the ages of two and eighteen, 90 females and 150 males. The mean age for females entering the
program was 12.8 years (SD = 3.38)
with the youngest client at 3.7 years and the oldest 17.4. The mean age for males entering the
program was 11.6 (SD = 3.47) with
the youngest client being 2.7 and the oldest 18.4. The average length in treatment for clients was 156.4 days (SD = 4.29) with a minimum stay of 11 days and the
longest stay 383 days.
All data were entered into StatView. We conducted a correlation analysis with StatView, investigating relationships among the four assessment scales over three periods: within one month of intake, within one month of exit, and at the third month of treatment (GAF and GARF only).
Results
CAFAS entry scores and the
difference between CAFAS scores at entry and exit (change score) were
positively correlated (r(101)=
.629, p<.0001), while exit
CAFAS data were negatively correlated (r(99)=
-.284, p=.0042).
A similar pattern was found with FAD scores (entry-change: r(126)=.434, p<.0001; exit-change: r(125)=
-.418, p<.0001).
We also compared the FAD and
CAFAS measures to each other.
Looking at the entry scores of both measures, a small but significant
positive correlation was found (r(172)=
.275, p=.0002). Similar relationships were observed in
the exit data of these assessments (r(102)=.223,
p=.0243), and their change scores
(r(98)=.293, p=.0033).
GAF and GARF scales were
compared to themselves and to each other. In both cases we found that intake data are positively
correlated with exit data, but the strength of these correlations decreased
over time (intake to mid-GARF: r(138)=.438,
p<.0001; intake to exit GARF: r(154)=.347, p<.0001). GAF scores
were compared in the same fashion, although the mid-GAF assessments were only
administered to 14 clients. This
number was too small to make generalizations. However, the entry GAF was positively correlated with the
exit-GAF (r(153)=.222, p=.0056).
Conclusions
Measures were correlated with
themselves across all points and in general, tend to be less correlated at
later than more recent points in time.
Furthermore, clients displaying more problems at entry changed more by exit
on all assessment measures (CAFAS, FAD, GAF, GARF). We suspect that this is because people with more problems initially
were able to make more change across treatment. We also found positive
relationships between the functioning of the child and the functioning of the
family. Such correlations suggest
that child and family functioning are related to each other.
These outcome data are, by
necessity, limited (Slattery et al., 2000). Although we have not compared outcomes with other
treatments, most of the clients were reported “failures” of traditional
outpatient therapy. In effect, the
families serve as their own comparison group. We are also aware that families who complete all assessments
may be different than those who do not and that this may limit generalizations made
about the overall effectiveness of the program.
Finally, we have not yet
begun to pull apart the various treatment elements that might lead to the
effectiveness of this program and cannot identify with confidence the cause of
the changes we have observed. We
can only note that most of the clients had been seemingly unsuccessful in other
programs, whereas many succeeded with in-home family therapy.
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