Hospital-based behavior modification program for adolescents: evaluation and predictors of outcome

Adolescence, Summer, 1996 by Ahmed Al Ansari, Stephen Gouthro, Khalil Ahmad, Corinne Steele

INTRODUCTION

Conduct problems, aggressiveness, and antisocial behavior constitute between one third to one half of all child and adolescent referrals to psychiatric clinics (Kazdin, 1987). Conduct-disordered youth are likely to drop out of school, be unemployed, and have poor interpersonal relationships. These factors translate into increased financial and social costs to the community (Shamsi, 1990).

In addressing these concerns, various treatments and combinations of treatment have been applied over the last several decades. Studies published over the past thirty-five years can be broken into two periods - those done before and after 1980. Studies done prior to 1980 reported primarily negative results, while some promising and successful approaches have been reported since 1980 (Shamsi & Hluchy, 1991).

It is unfortunate that the long-term effects of these programs as assessed by the rate of recidivism, remain disappointing (Garrett, 1985; Basta & Davidson, 1988; Whitehead & Lab, 1989).

Blotcky, Demperio, and Gossett (1984) and Pfeiffer and Strzelecki (1990) evaluated criticisms regarding the effectiveness of inpatient psychiatric treatment of children and adolescents. They reviewed all published child inpatient follow-up studies from 1932 to 1987 which included children and adolescents with mixed diagnoses. Both studies reached the conclusion that inpatient treatment is often beneficial. Moreover, they identified a number of factors which indicate favorable prognosis. These include: adequate intelligence, nonpsychotic and non-organic diagnoses, absence of antisocial features, healthy family functioning, later onset of symptoms, adequate length of stay, specialized treatment programs, and involvement in aftercare (Blotcky et al., 1984; Pfeiffer & Strzelecki, 1990). In 1988 a program designed to deal primarily with conduct-disordered adolescents was implemented at the Nova Scotia Hospital, Princess Alexandra Unit. The program utilizes behavior modification principles whereby positive and punitive consequences are applied to adolescent behavior within the context of a token economy (BMP). Targeted behaviors are assigned point values, and accumulated point totals determine privilege levels for the following day.

The present paper reports the results of an evaluation of the efficacy of this program in reducing the frequency of undesirable behaviors. An attempt has also been made to identify the factors associated with better outcome.

The treatment unit under consideration provides 20 beds for male and female adolescents, ages 12 to 18. Referrals were from children's aid societies, correctional services, hospitals, families, private practitioners, and the educational system. The adolescents exhibited a wide range of conduct problems such as truancy, running away, promiscuity, aggressive acting out behavior, poor peer relationships, drug abuse, and depression. In addition, some of the adolescents presented with repeated suicide attempts as well as poor academic achievement. The unit included a school program geared to special education, occupational therapy, vocational training, recreation, and leisure activities. The core program was provided by living and learning environments in which staff presented opportunity for counselling and modelling of pro-social behaviors. The adolescents were rewarded points for appropriate behavior. The accumulated points at the end of the day determined privileges for the next day. With increased accumulations of points, teens were granted additional privileges and responsibilities. Average length of stay was approximately three months.

METHOD

Subjects were adolescents aged 12 to 18 (N = 60) who had been admitted to the Princess Alexandra Unit, Nova Scotia Hospital between April 1989 and November 1990, and had completed eight weeks or more on the behavioral program. The eight-week period was chosen arbitrarily by the treatment team as the minimum time necessary to produce a measurable impact of the behavior program. The ratio of males to females was 1.5:1; mean age was 14.48 years. The diagnoses at admission included conduct disorder, oppositional defiant disorder, attention deficit disorder with hyperactivity, adjustment disorder, and dual diagnosis according to DSM-R III (American Psychiatric Association, 1987).

The study utilized a retrospective analysis of events. The files of all subjects were examined for information regarding their overall performance in the program as measured by the points earned daily. Points lost for exhibiting a specific behavior (e.g., noncompliance, verbal and physical aggression) were analyzed separately. In addition, data regarding age, gender, diagnosis, length of stay, age at onset, other treatments received, and level of education were obtained and coded. The weekly balance total for each subject (points earned for appropriate behaviors minus points lost for undesirable behaviors) was split in half. A student t-test for pairs was then used to compare the mean score over the first four weeks (pre-test) and last four weeks (post-test) of treatment. The same was applied with respect to the significance of each outcome predictor under study. These included age, gender, presence of conduct disorder diagnosis, age at onset before and after six years, and presence of an academic deficit as measured by a lag of at least two years on educational assessment. The length of stay was divided into four periods: less than 12 weeks, 13 to 18 weeks, 19 to 24 weeks, and more than 24 weeks. The Pearson product-moment correlation and analysis of variance (ANOVA) were also used in the analysis wherever applicable.