Academic journal article Education & Treatment of Children

Level 1 Research: Where the Rubber Meets the Road in the Treatment of Serious Mental and Physical Health Problems

Academic journal article Education & Treatment of Children

Level 1 Research: Where the Rubber Meets the Road in the Treatment of Serious Mental and Physical Health Problems

Article excerpt


Level 1 research (Hawkins & Matthews, 1999, is an underutilized strategy for monitoring clinical cases, demonstrating accountability in applied settings, and maximizing applied clinicians' effectiveness in the delivery of psychological service. Two single-case examples are presented using Level 1 research to guide the clinician(s) to socially acceptable resolution of problems. The first case is a 14-year-old girl in an out-of-home care setting who presented seriously escalated disruptive behavior, including assault. She had an extensive history of sexual and physical abuse and a diagnosis of borderline personality disorder. Moreover, she was a candidate for an extensive series of cranial facial surgeries for a badly repaired cleft palate. However, without emotional and behavioral stability the cranial facial team would not operate. Level 1 research strategies were used to modify a token economy, monitor and teach treatment fidelity, identify setting events, monitor effects of medication and intensive psychot herapy, and ultimately as evidence for behavioral and emotional stability. The second case is a 12-year-old boy with escalating nocturnal enuresis who lived in a residential care setting. Ongoing Level 1 data (including an enuresis item) were already being easily and efficiently collected through the use of a 28-item behavioral problems checklist (Parent Daily Report; Chamberlain & Reid, 1987). Interventionists used the charted bedwetting item for descriptive analyses and to monitor interventions.

It is commonly known, but rarely reflected on, that there is no a priori way to know if a given clinical intervention will work on an individual case. Two impediments to judging whether an intervention will work are limits to generalization and measurement of effects using global reports. For example, even if a given intervention is known to be involved in clinical improvement by group studies or single case studies, there are limits to the generalization of the conclusions of both types of studies; and when global reports are used as measures of improvement approximately two thirds of clients or parents will indicate that there are significant improvements m problem behaviors when in fact there are not (Patterson, 1982). Unfortunately, even though these facts are fairly well known to researchers and clinicians, very little progress has been made in reducing reliance on global reports in the assessment of treatment outcome. Level 1 research (Hawkins & Matthews, 1999) is an underutilized strategy for monitori ng clinical cases, demonstrating accountability in applied settings, and efficiently improving the assessment of treatment outcome over that provided by global reports.

Although clinical researchers, therapists, and other interventionists face some daunting obstacles in trying to ascertain clinical change on an individual basis when working in applied settings, measurement systems can be developed that employ frequent measurement and provide the interventionist and client with information that is less responsive to biases than the typical "how did things go this week?" This paper presents two case examples of the use of Level 1 research techniques to monitor and improve the delivery of clinical services.

Case# 1

Susan was a 14-year-old girl living in a Specialized Treatment Program (Moore, Osgood, Larzelere, & Chamberlain, 1994) group home that was using a Teaching-Family (Daly, Coughlin, & Baron, 1984; Father Flanagan's Boys' Home, 1986; Phillips, 1968; Phillips, Phillips, Fixen, & Wolf, 1974) model of care. She had developed very escalated and severe disruptive behavior, including assault. In addition, Susan had a severe cleft palate that had been badly repaired and caused her continuous grief. Her speech and appearance were affected, and she did not like how she looked or sounded. She had an official psychiatric diagnosis of borderline personality disorder and borderline intellectual ability. …

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