Issue Brief 86: Making the Most of the Moment: Brief Interventions Can Improve Children’s Behavioral Health Services

September 6, 2022

Making the Most of the Moment:

Brief Interventions Can Improve Children's Behavioral Health Services

Increased need for children’s behavioral health services coupled with significant workforce shortages have resulted in many children going without the care they need, when they need it. More children are experiencing anxiety and depression in recent years.^1,2 The COVID-19 pandemic accelerated this trend with a significant increase in children with behavior and conduct problems. It also negatively affected parents’ own mental health, impairing their ability to cope with parenting demands. Further, the children’s behavioral health workforce is in crisis as staff vacancies and turnover continue to increase. 

Long-standing treatment gaps have meant only one in three children with a mental health concern get treatment.³ Closing this gap requires a more efficient “stepped-care” approach, which recognizes that not all children need intensive, long-term, or specialty treatment to improve. Innovative service delivery models can match families with the most effective yet least resource-intensive treatment they need. Brief interventions, some as short as a single session, are a promising strategy to better match many families’ needs and help address the increasing number of children with behavioral health concerns amidst the behavioral health workforce crisis.

The Challenges of Traditional Outpatient Behavioral Health Treatment 

In Connecticut, nearly half (49%) of children who begin outpatient treatment leave before their clinician feels they are ready.⁴ Thirteen percent drop out of treatment within the first three sessions, with children of color more likely to leave treatment during this time. This mismatch between the traditional approach to therapy and family perceptions of treatment needs is also reflected in the national data. Outpatient service protocols on average call for 16 sessions,⁵ yet nationally, children only attend an average of four.⁶ Lengthy treatment protocols are not only at odds with the reality of shorter treatment duration for many children; it is not clear that more treatment sessions are beneficial. A meta-analysis of 447 studies across 50 years found the number of treatment sessions was not associated with outcomes; further, the longer children were in treatment, the less improvement they made.”⁷ A stepped-care approach that offers flexibility and matches families to the appropriate service intensity helps families and providers. Some children will need and benefit from longer-term treatment; others will be better served by having shorter or less intensive options, which could reduce wait lists and help mitigate workforce shortages.

One factor that is consistently associated with improved outcomes is the use of evidence-based treatments (EBTs). In Connecticut, clinicians report that 54% of children served in outpatient clinics receive at least part of an EBT protocol. The EBTs in Connecticut’s outpatient system, such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT); Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC); and Cognitive Behavioral Therapy (CBT), offer clear goals, a structured approach, and measures of progress. Compared to treatment as usual (TAU), EBTs provide clear parameters to ensure treatment time is used effectively. Many EBTs, however, are resource intensive for agencies to deliver. Families also need to make a significant time commitment, as most EBTs are typically structured to last at least several months. Outpatient services can build on the strong foundation of existing EBTs, to develop a continuum of effective treatments that include briefer and less-intensive options to better match the intensity of services to child needs and family preferences.  

Brief Treatments are a Promising Option to Expand Capacity and Improve Services 

There is a growing body of evidence demonstrating the effectiveness of brief treatments for children. The briefest of these are single-session interventions (SSIs). SSIs are “specific, structured programs that intentionally involve just one visit or encounter with a clinic, provider, or program.”⁸ Rather than assuming it will take months to make progress, these interventions are designed to make improvements in as little as an hour. A meta-analysis of 50 SSIs, including both clinician-administered and online self-administered interventions, found modest improvements in child outcomes in a single session, with some effects lasting for months.⁹ Most of the studies included relatively small groups of children, and few delivered SSIs widely across service settings. More research is needed about which SSIs can be “scaled up” (and how) across a behavioral health system and to develop SSIs that are considered EBT’s. However, they are a promising approach to improving care by offering a brief alternative option for youth who might otherwise not receive any services at all or to augment or facilitate engagement in traditional treatments.

For example, one model that appears appropriate for outpatient settings is single-session consultation (SSC),¹⁰ which is based on solution-focused brief therapy. Schleider and colleagues at Stony Brook University developed and are testing SSC as a flexible model to address a range of problem types and acuity levels. Clinicians delivering SSC work with children and families to select a specific, modifiable problem; identify the “smallest-possible step” they can take; and develop an action plan to enact the identified next step, all within a single session. The intervention can be repeated for several sessions as needed. A family might attend several sessions, but each is approached as if it were a single session and the same steps are followed, ensuring a solution is identified by the end of the session in case it does end up being the last session. SSC can also be used as part of the initial assessment process, ensuring families have a meaningful first encounter that helps increase engagement as they transition into longer-term therapy. Recent research shows that SSC can be delivered via telehealth with comparable outcomes and higher rates of session completion than in-person SSC.¹ 

Another feature of SSC is that it can be delivered by clinicians with any level of training; it is even being tested with staff who are not mental health clinicians, such as school counselors and nursing students. This allows the possibility of combing two strategies: SSIs and task shifting. Task shifting takes some components of care traditionally delivered by a clinician and transfers them to someone with different training or less experience.¹² Originally developed as a strategy for delivering health care in countries with resource constraints; it has been successfully extended to mental health services to increase capacity for service delivery by expanding the number and type of staff who provide services. Taking this approach in children’s outpatient behavioral health clinics would mean other staff, such as peer support specialists, community health workers, paraprofessionals, trainees, nurses, or lay providers, could potentially deliver or support the delivery of SSIs depending on regulations and billing requirements. Such a brief encounter may be sufficient for some children and families; for others, it may help them transition to treatment with a clinician.

Adding Brief Treatments to Connecticut’s Service Array

As the need for behavioral health services for children is on the rise nationally and in Connecticut, a flexible array of treatment options that can be matched to family needs and preferences is ideal for both families and providers. We make the following recommendations to incorporate brief interventions into Connecticut’s service array:

• Expand the service array by training clinicians in brief and single-session interventions that meet the needs of the outpatient population. SSC is one promising model to consider.
• Identify and address regulations and billing requirements for use of brief interventions in outpatient settings, as well as task shifting to support non-clinical staff who may be able to deliver SSIs and support other aspects of care.
• Establish a stepped-care approach to outpatient services with protocols to match families to the most appropriate level of services, including brief/single-session interventions. This process should use standardized assessments, measurement-based care, and family preferences to make initial recommendations as well as ongoing treatment planning and changes to services.  
• Once models are available, increase public awareness and advertising about brief and single-session interventions as a treatment option.
• Evaluate the use of brief interventions and their effectiveness and potential cost savings. Use data to understand for which populations (e.g., ages, diagnoses) brief interventions are most effective. Use data to inform improvements to stepped care approaches and algorithms.
• Expand the behavioral health workforce to include professionals who are not mental health clinicians, and explore stepped-care approaches that involve these individuals in the delivery of appropriate brief interventions. Consider piloting such an approach with non-clinical staff delivering the SSC model.

This Issue Brief was written by Kellie Randall, Jason Lang, Heather Solak, and Jessica Schleider (Stony Brook University).  For more information, visit www.chdi.org or contact Dr. Randall at randall@uchc.edu.

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References

1. Lebrun-Harris L. A, Ghandour RM, Kogan MD, Warren MD. Five-Year Trends in US Children’s Health and Well-being, 2016-2020. JAMA Pediatr. 2022;176(7):e2200. doi:10.1001/jamapediatrics.2022.0056
2. Racine, N., McArthur, B. A., Cooke, J. E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA pediatrics, 175(11), 1142-1150.
3. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in US adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011; 50: 32-45.
4. Child Health and Development Institute of Connecticut, Inc. (2021). Connecticut’s Outpatient Psychiatric Clinics for Children FY21 Annual Report, 1-41.
5. Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-Coaxum, R., ... & Fordwood, S. R. (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2), 79.
6. Harpaz-Rotem, I., Leslie, D., & Rosenheck, R. A. (2004). Treatment retention among children entering a new episode of mental health care. Psychiatric Services, 55(9), 1022-1028.
7. Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-Coaxum, R., ... & Fordwood, S. R. (2017). What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2), 79.
8. Schleider, J. L., Dobias, M. L., Sung, J. Y., & Mullarkey, M. C. (2020). Future directions in single-session youth mental health interventions. Journal of Clinical & Adolescent Psychology, 49 (2), 264-278.
9. Schleider, J. L., & Weisz, J. R. (2017). Little treatments, promising effects? Meta-analysis of single-session interventions for youth psychiatric problems. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 107-115.
10. Schleider, J., L. (2020). Single-Session Consultation for Emotional and Behavioral Health. https://doi.org/10.17605/OSF.IO/XNZ2T
11. Sung, J., Bugatti, M., Vivian, D., & Schleider, J.L (preprint). Evaluating a Telehealth Single-Session Consultation Service for Clients on Psychotherapy Wait-Lists.  https://psyarxiv.com/k7u4r/
12. Kazdin AE. Annual research review: expanding mental health services through novel models of intervention delivery. J Child Psychol Psychiatry. 2019;60:455-472. doi.org/10.1111/jcpp.12937)

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