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Measuring and Predicting Outcomes of Psychiatric Hospitalizations in England

There is increasing pressure to perform rigorous evaluations of the outcomes of services. The pressure to perform outcome evaluations is especially acute for psychiatric hospitalizations of children because of the severity and life-threatening nature of the disorders, the high cost of hospital care, and controversies over whether hospitalizations help or hurt disturbed children. There are many obstacles to comparing hospitalization with other interventions via rigorous randomized controlled trials. As an alternative, a British team has used a waiting-list control condition, plus multi-informant assessments to evaluate severely disturbed 6- to 17-year-olds at referral, admission to two hospitals, discharge, and 6-month follow-ups (Green et al., 2001). Assessments between referral and admission showed no significant changes in symptoms. However, the CBCL/4-18, TRF, and ratings by clinicians and researchers showed significant improvements from admission to discharge and follow-up. The significant improvements in TRF scores from admission to follow-up were regarded as especially important, because they were based on ratings by teachers at schools external to the hospitals.

To test predictors of improvement, the researchers regressed changes from admission to follow-up TRF scores on measures of parental engagement and the degree of therapeutic alliance by the child. Parental engagement showed an especially strong contribution to improvements in TRF Internalizing scores, while child alliance contributed significantly to improvements in TRF Externalizing and Total Problems scores. Green et al. concluded that " The teacher ratings thus give useful information on treatment process and independent support to the therapeutic impact of hospitalization on social adjustment in the child's community of origin" (p. 330). Among the clinical implications of the study, Green et al. stated pointed out that "There was particular value in the external teacher ratings of symptoms, both because it was external to the treatment process and because the teacher rating forms an important measure of the child's general social adaptation outside the unit" (pp. 331-332).

Reference: Green, J., Kroll, L., Imrie, D., Frances, F.M., Begum, K., Harrison, L., & Anson, R. (2001). Health gain and outcome predictors during inpatient and related day treatment in child and adolescent psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 325-332.