(PS1-D77) Treatment Practices for Aggression in Community-based Residential Care for Youth: A Comparison with Recommendations from the Evidence-base

In community-based residential (CBR) care youth receive intensive, integrated treatment while residing in a structured residential setting (CAMHD, 2018). Residential treatment settings like CBR are common in public mental health care (PMHC) systems, but the exact treatment approaches therein are not well known. Aggression is a particularly problematic concern commonly treated in CBR (Cornaggia et al., 2011). There are multiple recommendations from the treatment research literature regarding youth aggression: behavior therapy, family involvement, and psychoeducation (Pappadopulos et al., 2011). However, PMHC studies, both generally and examining CBR specifically, suggest that such settings might operate differently than those commonly seen in the evidence-base (Izmirian et al., 2017; Wilkie et al., 2021). Previous CBR research found that higher use of practices-derived from the evidence-base (PDEB) as well as minimally supported practices predicted better outcomes, but this work examined disruptive behaviors broadly (Izmirian et al., 2017). The current study aims to analyze treatment practices and outcomes specifically for youth with aggression in CBR care.

This study included clinical data from youth who received at least 90 days of treatment in a publicly funded CBR setting from July 1, 2008, to June 30, 2018, and had aggression targeted at least once during the treatment episode (N = 263). Data was collected from the Monthly Treatment and Progress Summary (MTPS; CAMHD, 2008), a monthly report of treatment targets, associated progress ratings (7-point scale; ranging from 0 = deterioration to 6 = complete improvement), and practices utilized. A two-level multilevel model was used to examine the association between each individual practice and aggression treatment progress at six months. 

The most frequently endorsed practices, those reported for at least 95% of youth where aggression was a treatment focus, related to family involvement (family therapy), skill development (communication skills, problem-solving), and therapeutic processes (goal setting, rapport building). Consistent with findings from the evidence-base, specific PDEBs such as praise, commands, and youth and caregiver psychoeducation (β = 0.34 to 0.63, p< 0.05) significantly predicted more progress. Some practices not supported by the evidence-base also predicted more clinical progress including peer pairing, interpretation, and catharsis (β = 0.33 to 0.54, p< 0.05). Despite being highly supported by the evidence-base, family involvement practices (family therapy [β = -0.05, p=0.64]; family engagement [β = -0.17, p=0.98]) were associated with worse progress, albeit not significantly.
      Our findings suggest that treatment in publicly funded CBR does not align precisely with what we know from aggression treatment research. Given this potential difference, future studies should include publicly funded CBR care when examining PDEB effectiveness and implementation. Continuing this kind of research can help develop a deeper understanding of what works and what does not work for treating aggression in these unique settings.