Mental health care in an adolescent medical setting

JOURNAL OF ADOLESCENT HEALTH CARE 1:108-115, 1980

Mental Health Care in an Adolescent Medical Setting

ROSLYN SELIGMAN, M.D.1 GOLDINE GLESER I Ph .D .1 JOSEPH L. RAUHI M.D.1 AND

CAROLYN WINGET~ M . A .

Two hundred sixty-four troubled adolescents referred to a medical adolescent clinic were randomly assigned to one of three therapists and to one of four condit ions def ined by whether treatment was delayed for 6 w e e k s or not, and whether or not the case was presented to a psychiatrist. Patients were assessed by parents and self-reports at intake and at 6, 12, and 24 w e e k s , using the Adolescent Life Assessment Check List (ALAC). This 40-item instrument y ie lded a total and six sub- scores. Patients in all treatment condit ions showed improvement across t ime as measured by the ALAC (patient or parent). Improvement was noted for each race- sex group, for each of the four conditions, and for patients ass igned to each therapist. Differences in outcome were noted for immediate vs. delay groups and for groups g iven psychiatric consultation. By 6 months , scores on the adolescent ALAC approximated those of a matched normative sample tested. Although successful , the program should be replicated before its f indings are generalized.

KEY WORDS:

Adolescents Assessment of treatment Delivery of mental health Outcome

Psychologically troubled adolescents are a major public health problem. The increasing rates of teenage pregnancies, sexually transmitted diseases, accidents, alcohol and drug abuse, and suicide

From the Departments of Psychiatry and Pediatrics (Division of Adolescent Medicine), University of Cincinnati and Children's Hospi- tal Medical Centers, Cincinnati, Ohio.

This study was partially supported by The Bureau of Community Health Services, HEW, MCHS Grant No. MC-R-390201.

Direct reprint requests to: Roslyn Seligman, M.D., 7212 College of Medicine, 231 Bethesda Ave., Cincinnati, OH 45267.

Manuscript accepted April 25, 1980.

suggest the magnitude of the health care needs of persons between the ages of 12 and 20. Of the approximately 40 million adolescents in the United States (1-3), 10-16% are estimated to be emotion- ally disturbed (4). Many of these adolescents ex- press their difficulties in the ways noted above with an estimated three-fifths appearing in the general medical sector (5). This may be fortunate, because the 2800 child-adolescent psychiatrists in the United States could not provide the direct services needed for this large number of adolescents. The dearth of child psychiatrists will likely continue (6). In light of this information, there is a need to assess whether quality mental health care can be provided in general medical centers.

In an effort to provide adequate care with lim- ited psychiatric resources, a clinical research project was designed. Its four main objectives were: (1) to develop a mental health delivery service in an established adolescent clinic in a medical center; (2) to utilize health care professionals as primary psychiatric care providers (PCPs, i.e., therapists); (3) to utilize a single psychiatric presentation after intake with the PCPs; and (4) to utilize a delay group to observe the therapeutic effect of antici- pated help. The purpose of this paper is to report the methods and major findings of this project.

M e t h o d s

A l l patients applying to the adolescent clinic with psychological and/or behavioral complaints were randomly assigned within sex and race strata to one of four experimental conditions. The four conditions involved immediate or delayed treatment (6 weeks after intake) and presenting or not presenting the patient information to a psychiatrist on one prescheduled occasion. The delay and present condition (Condition 3) was defined specifically as one

108 O Society for Adolescent Medicine, 1980 ISSN 0197-0070/80/020108-08/$02.25 Published by Elsevier North Holland, Inc., 52 Vanderbilt Ave., New York, NY 10017

December 1980 MENTAL HEALTH CARE FOR ADOLESCENTS 109

in which the patient presentation to the psychiatrist took place more than 6 weeks after intake and just after the therapist had seen the patient once or twice for evaluation before therapy.

Presentation to a Psychiatrist

Yes No

Immediate treatment Condition I Condition 2 Delayed treatment Condition 3 Condition 4

Patients in each condition were scheduled for assessment at intake and at 6, 12, and 24 weeks (T1, T2, T3, and T4, respectively). They were also assigned within each condition to one of the three PCPs: a psychologist, nurse, or social worker. The three therapists were white females 25-30 years of age. They were recent graduates with almost no experience with adolescents. Within the masters progran~ of the social worker and the doctoral program of the psychologist, there had been didactic lectures about the psychology of families and their adolescents and some minimal clinical experience. The nurse had had fewer lectures and clinical experience in her training.

The therapists saw patients as they deemed necessary, and no standard was set for the frequency of appointments or who in the family would be seen. Therapists did not collaborate; only one therapist worked with a patient and his or her family. Termination decisions were the responsi- bility of the therapists. However, patients were regularly assessed, whether terminated or still in therapy. These assessments were performed by an independent staff member who had no other contact with patients or their parents.

The program consisted of two phases: an initial phase from 1972 to 1974 and a replication phase from 1974 to 1976. The pilot phase experience suggested that such a program was effective and without detriment to the patients. The replication phase used the same basic design. The therapists in the replication study were matched on demographic and personality variables with the three original PCPs. This report deals with the replication phase.

Before intake, demographic information was obtained during the referral phone call. This information identified the person making the call as well as the name, address, phone number, birth date, age, race, and sex of the referred adolescent; whether

the adolescent was in school and the highest grade completed; and where medical care was usually obtained. Information about the family included composition, number of sibs, birth order of the adolescent, socioeconomic status, and religion of the mother and father. The caller was also asked to identify the presenting problem, how long the problem had existed, and to whom in the family or community it had been most upsetting.

A s s e s s m e n t I n s t r u m e n t s

A new measuring instrument, the Adolescent Life Assessment Checklist (ALAC), was developed for the replication phase (7). It allowed the patient and parent to assess the adolescent independently so that the assessments could be compared. The ALAC consists of 40 items regarding the frequency of certain feelings and behaviors followed by five alternative responses ranging from never to almost always. The parent's form parallels items of the adolescent's form, with statements rephrased in terms of observable behaviors. For example, the adolescent's form contains the statement "felt sad and depressed," while the corresponding item for the parent is "appeared sad and depressed." Seven items are not exactly parallel, although they were intended to assess the same underlying factors. For example, the item "has stolen from others" in the parent's form replaces the item "borrowed others' things without asking" in the adolescent's checklist.

Based on factor analysis, items were clustered into subscales (7). Briefly, the six adolescent report subscales are as follows: Affective Distress consists of items such as feeling depressed, irritable, and worthless. Peer Alienation encompasses items such as difficulty making friends and keeping friends and having frequent fights. Unproductivity refers to a constellation of items such as starting a task and not finishing, difficulty concentrating, and difficulty with school subjects. Somatic Complaints consists of items such as difficulty sleeping, stomach pains, and headaches. Sociopathy contains items about drinking, use of street drugs, and trouble with the law. Tolerance of Intimacy (the higher the score the greater the tolerance for intimacy) contains items such as participated in sports or hob- bies, and had someone you felt close to. The internal consistency reliabilities for these subscales ranged from 0.61 for Tolerance of Intimacy to 0.82 for Affective Distress. As a set, they significantly (P < 0.01) differentiated the clinic patients at intake

110 SELIGMAN ET AL. JOURNAL OF ADOLESCENT HEALTH CARE Vol. 1, No. 2

from a group of 112 normative adolescents stratified for age, sex, and race. They also were sensitive to differences in race, sex, and age.

The subscales of the parent report include Affec- tive Distress, Unproductivity, Sociopathy, and Somatic Complaints. Also included are an Interpersonal Alien- ation subscale, which contains items expressing alienation such as prefers to be alone, and those implying good interpersonal relations such as warm relations with parents, and a Belligerence subscale containing items about irritability, arguments at home, and temper tantrums. These subscales had internal consistency reliabilities ranging from 0.56 to 0.81. They significantly differentiated parents of a sample of medically ill patients from the parents of adolescents in this sample. There also were significant race differences in both samples. The correlation between the set of scores for parents and their offspring was significant (P ~ 0.01) (8).

A 5-minute verbal sample obtained from the patient with standardized instruction on each test- ing occasion was also a part of the assessment procedure. Results obtained using the Gottschalk-Gleser Methodology (9,10) are reported elsewhere (11-14).

Referrals During the summer of 1974, notification of the opening of intake and information about the project was sent to 200 physicians and social service agencies in the Cincinnati area, encouraging referral of adolescents 12-19 years of age. The letter stated that the adolescent clinic was expanding its services to include outpatient treatment for teenag- ers with emotional and behavioral complaints and would welcome such referrals.

No person calling to make a referral was re- fused. A total of 264 phone referrals was required to fill the treatment cells. From these referrals, 42 subjects were assigned to each of four treatment conditions (total 168). Randomization was carried out for black and white males and females separately. The stratification allowed each therapist to see four white males, four white females, three black males, and three black females in each treatment condition. All white subjects and black females were recruited within 10 months; it took an additional 5 months to complete the intake for black males.

From the phone referral information we were able to obtain demographic data on three large

groups of subjects: (1) those who provided information by telephone but did not keep their intake assessment appointment (N = 43), (2) those who had an initial assessment (T1) but did not enter therapy (N = 45), and (3) those who started therapy (N = 168). Excluded from this number were eight subjects: four were white males in ex- cess of the research design; three subjects required a change of experimental condition for medical reasons, and one subject was oriental.

In this paper, the three groups making the referral call are compared, using the demographic data from the telephone intake sheet. ALAC data are provided for the two groups who appeared for an initial assessment. The 168 assigned to the four treatments are compared, using demographic data. Finally, treatment outcome as assessed by patient and parent ALAC are discussed. These data were separately analyzed by multivariate analysis of covariance, using initial scores as covariates. Uni- variate tests of significance were also applied to the separate subscales.

The total referred sample contained approximately an equal number of males and females: 57% were white and 43% were black; 56% were younger than 15 years and 44% were 15 years and older; 41% were lower socioeconomic status (SES), 52% middle, and 7% upper middle (15). Approxi- mately 40% of our sample were living with both parents, 38% with either mother or father, 13% with mother or father and another, and 9% with one or more adults other than parents.

The presenting telephone interview complaints of the 264 adolescents referred to the adolescent clinic were similar to those of patients referred to a general psychiatric clinic. If an illness such as epilepsy, diabetes, or asthma was identified as the primary problem, the patients were referred to the medical component of the clinic. If, however, behavior-emotional complaints were identified as primary and the illness as secondary, the adolescent was entered into the project.

Complaints were classified as affective, interpersonal, antisocial, school and somatic. Examples of presenting problems classified as interpersonal were fighting, suicide, incest, irresponsible, un- motivated, keeping bad company; as antisocial were stealing, sniffing glue, drug abuse, trouble with the law; as school were problems such as refusal to attend classes, suspension, truancy, and subject failure; as affective were depressed, crying, withdrawn, and feeling inadequate; and as somatic were dizzy spells, bodily complaints, vomiting, and


headaches . R u n a w a y and family com m un ica t i on p rob l ems were classified as ei ther in te rpersona l or affective, d e p e n d i n g u p o n the c i rcumstances and invo lved behavior . Within this categor izat ion , 45% of our sample p rov ided combina t ion ( two or more) compla in ts , 25% were in terpersonal , 15% affective, and school, somatic, and antisocial 5% each.

Because none of the therapis ts was exper ienced in the use of psychiatric classification, and knowing the low reliability in the use of such sys t ems (16), we dec ided to classify subjects only by p resen t ing p rob lem.

Results

At the t ime of referral, 95 % of the adolescents were in school. According to the referral source, the p resen t ing p rob l em had been obse rved 1 year or less in 46% of the sample and over a year in 44%.

Comparison of Groups Making Referral Call

The three g rou ps of pa t ients m ak i ng referral calls were quite h o m o g e n e o u s with respec t to race, sex, age, referral source, and residence. Howev e r , they differed wi th respect to socioeconomic status, as indicated by educa t ion and occupat ion of the head of the household . Those not enter ing the rapy were m e m b e r s of families whose SES was significantly lower (P < 0.05) than the 168 subjects enter ing therapy . The 45 subjects w h o were assessed but did not enter the rapy were character ized by hav ing an u n e m p l o y e d head of the household . Also, a h igher pe rcen t were not in school as c o m p a r e d wi th those enter ing therapy . Those enter ing

the rapy and those w h o were assessed but d r o p p e d out pr ior to t he rapy were quite comparab le wi th respec t to ALAC scores at intake (T1).

The pa t ien ts w h o were ass igned to t r ea tmen t g r o u p s and began the rapy were closely comparab le in age, family constellat ion, and n u m b e r of sib- lings. In each t r ea tmen t g roup approx ima te ly 42% of the subjects had bo th natura l pa ren t s p resen t in the home .

Treatment Outcome

The ou tcome of t r ea tmen t at 6 m o n t h s (T4), as assessed by adolescent r e sponses to the ALAC, is s h o w n in Table 1. Significant i m p r o v e m e n t (P < 0.001) was repor ted on all subscales of the ALAC except for Soc iopa thy and Tolerance of In- t imacy. I m p r o v e m e n t was ob ta ined for all r ace - sex s u b g r o u p s combined regardless of t r ea tment condi- t ion or therapist . There were no differences in ou t come at t r ibutable to sex or race except for Toler- ance of In t imacy in which the whi te adolescents statistically i m p r o v e d more than the blacks (P < 0.05). The males indicated s o m e w h a t less Af- fective Distress and Unproduc t iv i ty and both males and females indicated fewer Somatic Compla in t s than the controls.

Treated adolescents w h o were assessed at 6 m o n t h s indicated res idual p rob lems comparab le wi th or less ex t reme than a nonpa t i en t sample ma tched for age, race, and sex w h o were tes ted on only one occasion (7).

A greater decrease in total score at 6 weeks (T2) was ob ta ined for those adolescents w h o had no t r ea tmen t as c o m p a r e d wi th those w h o did

Table 1. Initial (T1) and Six-Month (T4) Mean ALAC Subscale Scores from Adolescents' Reports According to Sex and Race

Male Female

Black White Black White (N = 30) (N = 38) (N = 29) (N = 35)

Subscales T1 T4 T1 T4 T1 T4 T1 T4

Total sample (N = 132)

T1 T4

Affective Distress a 16.1 11.2 i6.1 11.3 8:9 7.4 12.9 7.5 13.8 9.5 Peer Alienation ~ 9.8 6.7 8.0 6.2 7.2 5.8 8.6 6.1 8.5 6.2 Unproductivity a 13.9 10.6 13.1 9.7 10.7 7.7 12.4 7.3 12.6 8.8 Somatic a 11.7 7.9 10.0 6.8 8.4 5.4 8.0 5.1 9.5 6.3 Sociopathy 2.4 2.0 2.7 1.7 1.8 1.5 2.2 2.2 2.3 1.9 Intimacy a 8.5 8.3 8.9 9.7 10.4 8.7 7.3 7.6 8.8 8.7 Total b 56.1 41.8 52.2 38.1 39.0 31.7 48.0 37.7 49.2 37.5 Age 13.6 14.5 13.9 14.2

~Significant improvement (P < 0.001). bWhites improved (T4 > T1) more than blacks (P ~ 0.05).


(P < 0.03). H o w e v e r , s u b s e q u e n t t h e r a p y in the nex t 6 w e e k s s e r v e d o n l y to m a i n t a i n the s ta tus of

those p r e v i o u s l y d e l a y e d f o r t r e a t m e n t , w h e r e a s

the i m m e d i a t e t r e a t m e n t g r o u p s c o n t i n u e d to im- p r o v e d u r i n g this t ime p e r i o d (T3). By T4 the re w a s n o overal l d i f fe rence b e t w e e n those t r ea ted im-

m e d i a t e l y a n d those de layed . W h e n sex a n d race were c o n s i d e r e d , h o w e v e r , it a p p e a r e d tha t de l ay m a k e s little d i f fe rence for females r ega rd le s s of

race; it m a y e n h a n c e o u t c o m e s o m e w h a t for w h i t e ma l e s b u t m a y be d e t r i m e n t a l for b lack ma les as j u d g e d b y total score (P [race x sex x cond i t i on ]

< 0.05). This f i n d i n g was also s ign i f i can t for Pee r A l i e n a t i o n a n d Somat i c C o m p l a i n t s (Table 2).

Psychia t r ic p r e s e n t a t i o n w h e n a v e r a g e d over all

r a c e - s e x g r o u p s r e s u l t e d in s ign i f i can t ly g rea te r im- p r o v e m e n t t h a n n o n p r e s e n t a t i o n for the subsca le

To le rance of I n t i m a c y a t T4 (P < 0.05). The differ-

ence , h o w e v e r , was m a i n l y d u e to the inc rease for i m m e d i a t e l y t r ea ted ma les of b o t h races a n d de- l ayed t r e a t m e n t females (P [sex x cond i t i on ]

< 0.02) (Table 2). The o u t c o m e s Of t r e a t m e n t as a s se s sed by the

p a r e n t s o n the A L A C are g i v e n in T a b l e 3. In

s u m m a r y , p a r e n t s g iv ing & m o n t h f o l l o w - u p as- s e s s m e n t s r e p o r t e d tha t the i r o f f sp r ing s h o w e d

s ign i f i can t ly fewer a n d less severe p r o b l e m s t h a n

in i t ia l ly o n all scales except I n t e r p e r s o n a l A l i ena -

Table 2. Initial (T1) and Six-Month (T4) Mean ALAC Subscale Scores from Adolescents' Reports According to Race, Sex, and Treatment Condition

Immediate Delay

Present Not present PreSent Not present

T1 T4 T1 T4 T1 T4 T1 T4

BLACK FEMALES (/'4 = 8) (N = 8) (N = 7) (N = 7) Affective Distress 12.1 7.9 16.6 13.8 15.3 9.3 21.0 14.0 Peer Alienation 8.0 4.9 8.2 6.8 10.4 7.3 13.0 8.3 Unproductivity i l .9 7.4 15.4 10.9 13.9 9.6 14.6 15.1 Somatic a 10.5 8.0 12.1 9.8 13.1 5.1 11.1 8.4 Sociopathy 1.5 1.0 1.5 2.9 3.1 0.9 3.6 3.3 Intimacy b 7.0 7.5 8.5 7.8 8.0 8.7 10.6 9.4 Total a 48.8 34.8 56.0 47.0 57.3 34.4 63.4 51.3

BLACK MALES (N = 7) (N = 8) (N = 6) (N = 8) Affective Distress 9.1 6.6 9.0 5.0 8.3 8.7 9.1 9.5 Peer Alienation a 5.6 3.1 7.1 4.5 4.5 5.0 10.6 10.0 Unproductivity 7.4 5.4 12.9 6.2 7.7 7.8 13.5 11.0 Somatic a 9.6 5.0 11.1 3.8 5.3 6.7 7.1 6.5 Sociopathy 1.0 1.0 2.8 0.9 1.0 1.0 2.2 3.0 Intimacy b 11.1 11.9 11.5 8.5 10.2 9.0 8.9 5.9 Total ~ 34.1 23.7 42.6 24.9 31,3 32.8 45.4 44.8

WHITE FEMALES (N = 9) (N = 10) (N = 9) (N = 10) Affective Distress 15.8 12.1 17.0 11.9 18.8 13.2 13.0 8.4 Peer Alienation a 5.2 6.1 10.0 6.1 7.9 6.0 8,7 6.6 Unproductivity 10.1 10.8 16.8 9.2 12.7 9.9 12.3 9.0 Somatic a 9.7 6.9 12.0 6.4 11.6 8.9 6.8 5.2 Sociopathy 3.6 3.0 3.9 1.4 2.0 0.9 1.5 1.6 Intimacy ~ 10.1 8.8 9.2 10.2 9.0 11.4 7.5 8.3 Total ~ 46.7 42.1 60.0 37.7 54.9 39.3 46.9 33.9

WHITE MALES (N = 9) (N = 7) (N = 11) (N = 8) Affective Distress 11.9 9.0 13.1 6.4 15.2 9.3 10.6 4.2 Peer Alienation ~ 8.2 6.9 7.0 6.4 9.8 5.7 8.9 5.2 Unproductivity 12.3 8.1 11.3 6.3 13.3 7.9 12.2 6.4 Somatic" 9.4 7.0 5.0 3.4 9.7 6.4 6.8 2.8 Sociopathy 2.4 2.8 1.1 1.6 2.3 1.3 2.8 3.4 Intimacy b 8.3 9.4 7.0 6.3 7.2 7.8 6.4 6.4 Total ~ 47.0 36.3 42.0 29.6 53.7 34.9 46.5 27.5

aRace x sex x immediate bImprovement greater for

treatment (P < 0.02).

vs. delay treatment significant (P < 0.05). "present" than "not present" conditions for males treated immediately and females who had delayed


Table 3. Initial (T1) and Six-Month (T4) Mean ALAC Subscale Scores from Parents' Reports According to the Treatment Condition of Offspring

Presen t Not p re sen t Total

T1 T4 T1 T4 T1 T4

IMMEDIATE TREATMENT (N = 27) (N = 26) (N = 53) Affective Dis t ress 13.0 6.7 a 12.0 8.7 12.5 7.7 b Unproduc t iv i t y 13.2 7.9 a 14.1 10.i 13.7 9.0 b Soc iopa thy 7.3 3.5 6.5 3.9 6.9 3.7 b BeUigerence 13.8 9.0 14.5 10.2 14.2 9.6 b In te rpersona l 11.7 10.5 12.1 10.6 11.9 10.6 Somat ic C ompl a i n t s 5.3 3.0 a 6.9 5.6 6.1 4.3 b Total 62.4 39.6 a 64.2 47.8 63.3 43:7 b

DELAYED TREATMENT (N = 30 ) (N = 24) (N = 54) Affective Dis t ress 12.0 8.4 ~ 10.0 9.1 11.1 8.7 Unproduc t iv i ty 10.8 8.6 ~ 12.8 11.1 11.7 9.7 Soc iopa thy 5.2 4.2 7.3 6.9 6.1 5.4 Belligerence i2 .6 9.9 12.6 11.6 12.6 10.7 In te rpersona l 10.9 9.3 13.8 13.5 12.2 11.2 Somatic C ompl a i n t s 5.6 4.7 a 5.6 6.0 5.6 5.3 Total 61.1 43.9 ¢ 60.0 56.3 60.6 49.4

q m p r o v e m e n t significantly greater t han " n o t p r e s e n t " (P ~ 0.05). b I m p r o v e m e n t s ignif icantly greater t h a n de layed t r e a tmen t (P < 0.05).

tion (P ~ 0.01). These results held, regardless of race, sex, treatment condition, Or therapist. Signifi- Cant differences were observed on Affective Dis- tress, Unproductivity, and Belligerence (P < 0.05) at the end of 12 weeks for those treated immediately as compared with those whose treatment was delayed. These differences become even more marked and generalized by 6 months: those treated immediately showed the most improvement on total scores and all scales except Interpersonal Alienation (P ~ 0.05). Adolescents presented to the psychiatrist improved significantly more than those not presented on total score and in particular for Affective Distress, Unproductivity, and Somatic Complaints.

Discussion The study of patient behavior in regard to physical and mental health service delivery is not new. Factors that determine if and where a patient of a given age seeks help for a variety of complaints, whether the patient continues with the Service agency (including private practitioners) once contact has been made, and whether the contact, if sustained, leads to better health and adjustment have been studied.

Most studies, however, have dealt with those younger or older in age than the adolescent popu- lation. The lack of research on health delivery to

adolescents may be due to the relatively small proportion of adolescents prior to 1960, arid there- fore the tendency to lump them with either children or adult services--even though their needs are clearly distinct.

Although the recognition of adolescents as a separate group with its own characteristics and health needs occurred in the 1960s, the impact of this age group on the health care system was not clearly appreciated until a decade later (1). Even as recently as 1978, a task panel of the President's Commission on Mental Health (17) stated that American adolescents are the most medically underserved group.

Our data suggest the feasibility of delivering mental health services to this underserved group within a medical adolescent clinic by a variety of health care professionals. Patients in all 'treatment conditions showed improvement across time as measured by the ALAC (patient or parent). Im- provement was noted in each race-sex group, under each of the four treatment conditions, and for patients assigned to each therapist. By 6 months, the adolescent ALAC scores approximated those of a normative sample matched with the clinic patients for age, race, and sex and tested on a single occasion. After the project ended, the adolescent clinic continued this service with new funding. Both the need and success of the program are reflected by the fact that in 1978, mental health


service constituted 42% of the clinic's health delivery.

The literature about the type of mental health service described herein is sparse. A somewhat parallel service treating all ages, the neighborhood health centers, has reported findings similar to ours (18-20). These findings include a high utilization rate, early case finding, successful referrals for treatment, and coordination of health-mental health care.

Regarding engagement and continuance in therapy, little was learned about predicting who would drop out of therapy. In general, patients were less likely to become engaged in therapy if the family's socioeconomic Status was low, if the head of the household was not working or was menially employed, or if the adolescent was n0t in school. Cole (21)and Goin (22) found class-linked differences to be influential only in the first 10 visits, and thereafter the possibility of continuance in treatment or being discharged as improved was the same for all classes. In our study, drop-out rates, initially and during therapy, were not related to age, sex, race, or treatment condition. These findings support Garfield's contention that drop-out rates are unrelated to age and sex (23). There were no differences in drop-out rates by therapist through the 6 months.

One major question our research addressed was whether a n adolescent, knowing help was forth- coming, would improve without therapy via some self-curative means in contrast to those who received immediate therapy. At intake, every patient was given the name of his therapist and the date of his first appointment. Delay did not affect the rate of drop out. Patients who had no therapy for 6 weeks showed as much or more improvement at the 6-week assessment than those who had had 6 weeks of therapy. This finding was more striking on the adolescent's ALAC data than on the parent's ALAC. Perhaps the initial evaluation and anticipation of help as communicated to the patients and parents were therapeutic. Yet, those patients who received immediate treatment showed more improvement in some areas with 12 weeks of therapy than the delay group, who had had only 6 weeks of therapy. This trend became more pronounced at the 6-month assessment, at which time it was most marked on the parent's ALAC.

Regarding race and sex, at 6 months the delayed condition made no difference for females regardless of race, but it appeared to enhance outcome some-

what for white males and to be detrimental for black males. In the delayed treatment group, after their first 6 weeks of therapy (T3), black females also showed a similar negative response, as did the black males. However, by 6 months, the females were able to reverse the regressive trend and showed improvement. Because the regressive trend

for these blacks occurred after 6 weeks of therapy rather than immediately after delay, the question arises as to whether a belated response occurred to delay per se or whe the r delay permitted fantasied expectation s regarding the therapists and therapy which were then unfulfilled. Because this occurred only for black patients seeing white therapists, one wonders if having black therapists would reverse this seemingly race-related finding.

Another major question was whether presentation to a child-adolescent psychiatrist would enhance the therapeutic results by the therapists who had had little previous experience working with adolescents. This single presentation, held shortly after therapy began, did not involve the psYchia- trist meeting with the patient. The primary goal of the psychiatrist was to help the therapist find something to like about the patient and/or the patient's family--something that would enhance the bonding process within the adolescent- therapist relationship. The psychiatrist paid careful attention to any nuances in the therapist presentation that could indicate areas of frustration, bias, concern, fear, or hopelessness for the therapist. Perceived areas of difficulty were sometimes addressed directly and at other times subtly, but always with the goal of strengthening the therapist's feeling of competency.

Secondary goals were educational in nature. They included teaching ways to assess the emotional and/or organic meaning of a somatic com- plaint, to identify the unspoken communication of a patient, to distinguish between abnormal and normal adolescent behavior presenting difficulty for the family, and to assess whether a psychological intervention, e.g., therapy, or placement was indicated.

By 6 months, with the use of the parent's and adolescent's ALAC, a composite of those adolescents presented to the psychiatrist in contrast to those not presented could be composed: "A more calm and happy person, less critical of self and others, able to be productive while less preoccu- pied with her or his body, and more able to enjoy the company of peers." Perhaps, then, presentation accomplished the primary goal set by the psy-


chiatrist to assist i n the process whereby the therapist and adolescent work together to reverse a pathologic process and allow normal development to proceed. The improvement of their offspring noted by parents on the ALAC at 6 months was a striking finding, as neither parent nor patient knew who had been presented.

Even though this program was successful, one should refrain from generalizing about these findings until they have been replicated. The delay treatment group as compared with the treatment group was studied for a relatively short period without therapy. This was done for ethical reasons, because a number of studies (24,25) suggest that adolescent disturbance does not disappear with time. It is unfortunate, however, that we did not retest our normative sample at 6 months. Not only does this study need replication, but similar studies using males and blacks as therapists would likely enhance and extend the meaning of these findings.

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Mental health care in an adolescent medical setting