level systems: inpatient programming whose time · pdf filelevel systems: inpatient...

Level Systems: Inpatient Programming Whose TimeHas Passed

Wanda K. Mohr, PhD, APRN, CS, FAAN, and Andres J. Pumariega, MD

TOPIC. Structuring of inpatient behavioral

programming in child-adolescent psychiatric,

residential treatment, and juvenile justice

settings.

PURPOSE. To review the underlying theory

underpinning current practices and recommend

remedies to the uncovered problems.

SOURCES. A review of the literature from 1965 to

2001 from selected nursing and medical

psychiatric and mental health publications.

CONCLUSIONS. Intensive professional and staff

education and greater precision in corjimunication

about patients' behaviors are needed in many

settings. There is also a need to move away from

generic treatment approaches and return to

individual treatment planning based on individual

assessments and the unique needs of an increasingly

volatile and complex in-patient population.

Search terms: Child and adolescent psychiatric

inpatient care, behavioral intervention programs,

juvenile justice interventions, residential care,

psychiatric staff education

Wanda K. Mohr, PhD, APRN, CS, FAAN, is AssociateProfessor, Psychiatric-Mental Health Nursing, University ofMedicine and Dentistry, Newark, NJ. Andres J. Pumariega,MD, is Professor, Child Adolescent Psychiatry, East TennesseeState University Medical School, Johnson City, TN.

Journal of Child and Adolescent Psychiatric Nursing, Volume 17,Number 3, pp. 113-125.

behavioral intervention programs are designed to pro-duce changes in a person's behavior in the context ofdaily life. With advances in behavioral technology, thistreatment approach, and its close relative cognitive be-havior therapy, have much to offer the field of psychi-atric nursing. Moreover, both forms of treatment, whichhave their foundation in learning theories, are well estab-lished and have been demonstrated to be empirically ef-ficacious in the treatment of a wide variety of psychiatricconditions (Crits-Christoph, 1998; DeRubeis & Crits-Christoph, 1998).

Behavioral intervention programs emerged in psychi-atric settings as a result of discontentment with milieutherapy approaches (Hersen, 1985). Therapeutic ap-proaches diat are behaviorally oriented were shown tobe both cost-effective and effective in residential and out-patient psychiatric settings (Donat & McKeegan, 1990;Liberman, Cardin, McGill, Falloon, & Evans, 1987; Paul& Lentz, 1977). Applied behavior analysis became thesine qua non of these programs, which emphasizedstructural and functional analyses of behaviors.

Despite repeated demonstrations of the utility of be-havioral interventions, research has demonstrated thatbehavioral interventions are seldom employed effec-tively, and that direct care staff often have low levels ofcompetence in behavioral programming and indeedmay inadvertently reinforce unwanted behaviors (Donat,1998; Donat & McKeegan, 1990; Gelfand, Gelfand, &Dobson, 1967). Such a lack of competence may under-mine any therapeutic benefit of a hospitaUzation or stayin a residential treatment facOity. It also may result in theincreased use of physical and chemical restraints (psy-choactive medications) and the seclusion of patients withboth little therapeutic benefit and much risk to the safetyof the patient.

JCAPN Voliune 17, Number 3, July-September, 2004 113

Level Systems: Inpatient Programming Whose Time Has Passed

As a discipline with scientific underpinnings, nursingpractice ideally should be influenced by sound theoryand research. Practitioners have an ethical obligation touse, where possible, treatments that are researdi based,and interventions with demonstrated efficacy, safety, andefficiency should be supported programmatically andeducationally within the discipline.

In this article we review the theory underpinning acommon way of structuring inpatient behavioral pro-gramming in child-adolescent treatment settings. Wealso discuss and challenge the utility of that structure inpractice. We make a number of recommendations forstaff education and training and call for a return of indi-vidual treatment planning based on individual assess-ments and unique needs of an increasingly volatile andcomplex inpatient population.

Background

Behavior therapy, behavior management, behaviormodification, or any number of similar approaches to be-havior are based on the same foundation. They arefounded on the premise that environmental conse-quences, when linked to particular behaviors^ either in-crease (reinforce) or decrease (extinguish) the likelihoodof a person responding in the same manner when con-fronted with similar consequences in the future. The ideabehind these approaches is that behavior is developedthrough associative learning. The notion of emphasizingconditioning was pioneered in the 1910s by the Russianphysiologist Pavlov and is referred to as classical condi-tioning or stimulus-response (S-R) theory (Shorter, 1997).Pavlov's work was further elaborated and refined byseveral psychologists, such as John B. Watson, Edward L.Thomdike, John Dollard, Neal E. Miller, Joseph Wolpe,and B.F Skinner (Hall, Campbell, & Lindzey, 1997).

All behavior theories posit that two basic learningprocesses underpin two kinds of behavior: classical con-ditioning and operant conditioning. Classical condition-ing is the mechanism of learning that results when suchnatural stimuli are paired or associated with other (condi-tioned) stimuli so that the latter leads to the same (re-

sponse) respondent behavior (Goldfried & Davison, 1994;Hall et al., 1997). Thus, Wolpe (Kazdin, 2001) conceptual-ized that certain cues or stimuli in the environment canelicit fear or anxiety and result in avoidance of that stimu-lus (phobia). By the same token, he reasoned that the fearcan be altered by conditioning an alternative responsethat is incompatible with fear. Employing this line of rea-soning, he developed the technique to treat human anxi-ety and phobias we know as systematic desensitization.Operant conditioning includes the majority of human ac-tivity. Although he was not a dinidan. Skinner's operantconditioning theory has had enormous influence on inter-ventions developed for clinical and educational settings(Kazdin, 2001). Practicing a strict brand of positivism, hisresearch brought scientific empiricism to the study ofhuman beings' behavior. His own work, as well as thesubsequent research of many other behavior theorists,demonstrated the powerful effects of environmental con-sequences (whether positive or negative) on behavior,particularly when they are arranged or delivered in an or-ganized and systematic fashion (Hall et al.).

All behavior theories posit that two basic

learning processes underpin two kinds of

behavior: classical conditioning and

operant conditioning.

Key concepts within Skinner's system are the prind-ples of reinforcement and punishment. Reinforcing aparticular behavior involves carrying out an operationthat changes the probability of occurrence of that behav-ior in the future. A positive reinforcer is one that is intro-duced and strengthens the likelihood of a particular be-havior. It is usually, but not always, a pleasant event. Anegative reinforcer is a stimulus whose withdrawal in-

114 JCAPN Volume 17, Number 3, July-September, 2004

creases the strength of the behavior that follows it. It isusually but not always, a negative event. The descriptors"positive" and "negative" in this theory have nothing todo with the value of the reinforcer. Positive reinforce-ment (being rewarded) and negative reinforcement (get-ting rid of something unpleasant) influence the immedi-ately preceding behavior in the same way; they bothstrengthen it. Another concept in operant conditioningtheory—punishment—is also frequently confused withnegative reinforcement, partly because of the negativelabel but primarily because the threat of some punish-ment is often the cause of the stress that is avoided or es-caped (producing the relief). An easy way of telling thedifference between punishment and negative reinforce-ment is to consider the effects. If the target behavior de-clines rapidly, it was probably punished; if the target be-havior increases, it was surely reinforced.

Clinicians sometimes have difficulty grasping theseideas, thus a clinically meaningful example might be rel-evant. Suppose you try to quiet a child who is acting outby offering a cookie, and the child responds by smilingand reaching out to hug you. The smQe and hug are pos-itive reinforcers, and the chances are that you will re-spond with a cookie the next time the child acts out. Sup-pose that the child responds in a screeching rage andknocks the cookie out of your hand. Your approach tothe problem has been punished by the duld; you won'ttry that again. Then, suppose you become angry andlash out at the child in anger, and the child immediatelybecomes quiet and compliant. Your angry outburst hasjust been negatively reinforced (you would say "re-warded": i.e., the unpleasant crying stopped) and youhave become a little more likely to become angry andyell when faced with a screeching child in the future.This child becoming quiet has had the same effect onyour behavior as if the child had given you a cookie forgetting angry and yelling.

Operant behavior involves individuals operating ontheir world directly or indirectly and emphasizes the roleof consequences on behavior. One major difference fromthe classical paradigm is that in the classical S-R model,behavior is elicited (by a certain stimulus), whereas in

operant conditioning, behavior is emitted. AlthoughSkinner recognized the importance of stimuli (an-tecedent events), he said that some responses do not ap-pear to be tied to a readily identifiable eUdting stimulus.He observed that these responses appeared to be sponta-neous and voluntary. Moreover the frequency of theresponse seemed to change according to the event thatfollowed it—the event being either a reinforcer or pun-ishment (Skinner, 1953).

Research on these two basic and distinct learningprocesses (operant and respondent) have resulted inmuch of our knowledge of learning and human behavior.They also underpin our behavioral interventions in psy-chotherapy and in many organizational settings. Most be-havioral programming is based on operant pdndples.

A critical aspect to both these processes, however, istheir requirement for specificity of the behavior beingmodified and the assodated consequential stimuli (Car-son & Mineka, 1999). Although behavior researchershave demonstrated the capacity for humans to general-ize behavior and learning to a broader repertoire of be-haviors and environmental settings, the power of theselearning processes is directly correlated to how individu-alized and focused the learning process is designed to be(Singh, 1997).

Level Systems: One Size Does Not Fit All

Therapeutic programming in residential treatment fa-cilities and inpatient child-adolescent psychiatric hospi-tals is based on principles of behavior theory, stressingpositive reinforcement for appropriate behavior 0ohnson,1995). Youngsters are rewarded for following rules androutines and attaining daily goals. In programs using abehavioral system, the number of points earned deter-mines the children's level and privileges for the next dayor days. More points result in a higher level and moreprivileges. Higher levels presumably reflect the appropri-ateness of a child's behavior, as well as his or herprogress. Patients or residents are expected to partidpatein the daily activities with dear appropriate consequencesif they choose not to partidpate. The level system method

JCAPN Volume 17, Number 3, July-September, 2004 115


of programming is considered to be a contingency ap-proach. More privileges and a higher level are contingenton patients demonstrating certain desired behaviors andwithheld for demonstrating imdesired behaviors (Foxx,1998; Johnson).

On the face of it, a level system appears to be astraightforward positive reinforcement arrangement,based on operant reinforcement principles. In ovtr clinicalexperience with such programs, however, rather thanwithholding points, privileges are often removed andlevels are often "dropped" in response to undesirable be-havior. Research by scholars and study by other practi-tioners underscore our own findings (Braxton, 1995;Kazdin, 1981, 2001; Singh, 1997). While the word "conse-quence" is applied to what is meted out for undesirablebehavior, the child is actually punished, punishmentbeing defined in classical behavioral terms as a conse-quence introduced in order to lessen certain behaviorsby aversive means (Mateson & DiLorenzo, 1984). Whilepunishment sometimes reduces inappropriate behaviorquickly, if also is known to reduce it only temporarily,usually only until such time as the aversive situationceases for the youngster (Kazdin, 2001; Krumboltz &Krumboltz, 1972). After a time, inappropriate behaviorgradually resumes.

Another difficulty with a level system as practiced inpsychiatric and residential treatment settings is that be-havior generalization is highly unlikely from inpatient tocontexts from which patients come and to which they re-turn (Kazdin, 1996a). Indeed, the Surgeon General's re-port (U.S. Department of Health and Human Services[USDHHS], 1999) on residential treatment programmingfor children is pessimistic about its outcomes, citing alack of adequate research demonstrating its long-termefficacy.

In theory, when appropriate behaviors have been rein-forced, as in the case of youngsters' responses to a levelsystem of privileges in residential treatment programs,those behaviors are expected to be maintained accordingto the principle of generalization. In other words, thechildren should continue to exhibit the appropriate be-havior at home and community when they are dis-

charged from inpafient settings. However, behavior the-ory posits that generalization responses vary consider-ably in strength depending on the similarities of general-ized stimuli to conditioned stimuli (Blackwood, 1971;Goldfried & Davison, 1994). As those stimuli become lesssimilar, the strength of responses becomes weaker.Locked inpatient units and residential treatment facilitiesare relatively controlled, and as such they are very dis-similar to patients' homes and communities. The contin-gencies present in residential programs and hospitalsrepresent significant departures from the contingenciespresent in everyday life for children. Kazdin (1996a,2001) posits that although it is not inevitable that behav-iors return to baseline levels when contingencies arewithdrawn, they usually do. Understanding this, schol-ars suggest that such programs should not be expectedto achieve long-term, real-world behavior change with-out a careful consideration of larger systems issues(Kazdin, 1996a, 2001; Leventhal, 1984; Singh, 1997).

Children's behavior, no matter how

aberrant, is always meaningful.

In addition to the issue of generalization, there is theproblem of staff members assuming that aberrant behav-ior that appears similar on its face is deviant (Fagan &Fantuzzo, 1999; Fantuzzo et al., 1995; Feldman & Grif-fiths, 1997). Those of us who have worked with childrenknow that often their behaviors, while appearing similaracross different populations, may have very different un-derlying motivations. Children's behavior, no matterhow aberrant, is always meaningful. Meaningful in thissense refers to the facf fhaf particular behaviors are de-pendent on many factors, which include a myriad of his-torical and contemporary variables (Cicchetti, 1984,1993;Fagan & Fantuzzo; Fantuzzo et al.). Depending on thiscomplex stew of variables, one child's aberrant behavior

116 JCAPN Volume 17, Number 3, July-Seplember, 2004

may have very different functions than another's. Thosefunctions may span a range from sensory stimulation,avoidance or escape from pain or frustration, attentionfrom peers or staff, response to overstimulation, exhaus-tion, escape from boredom, and opposition or defiance(Coucouvanis, 1997; Singh, 1997).

The fallacy of the level system is that it fails to takeinto account that the same stimuli operate in differentways across highly diverse groups of children. Thesechildren differ in gender, race, socioeconomic status, cul-ture, cognitive skills, family structure, family back-groimd, and so forth. All these differences lead to differ-ent sets of environmental contingencies operating on thechild, with different factors reinforcing or extinguishingbehaviors. These factors go beyond the diversity in indi-vidual psychopathology, but in tandem they determinethe child's previous cogrutive and behavioral "program-ming" (Sroufe, 1997).

A fourth problem with the use of generic level sys-tems for children in treatment settings is that they failto take into consideration children who have develop-mental or constitutional inability to profit from conse-quences. Some scholars suggest there is a subset of chil-dren who are diagnosed with conditions who simplymay not be amenable to contingency approaches, nomatter how attractive the reward or how harsh thepurushment. These explosive, impulse-driven, and in-flexible children can have a number of diagnoses (e.g.,BPD, OCD, ADHD, Tourette's syndrome) and may beprone to intense and overwhelming seizurelike ragesduring which they carmot appreciate the meaning ofwhat parents or caregivers are attempting to teach them(Greene, 1998; Papalos & Papalos, 1999). Moreover,during these rages they also may be incapable of draw-ing on prior information learned from previous experi-ences (Papalos & Papalos). Thus, in the case of these ex-tremely volatile youngsters, the threat of an aversiveconsequence in the face of unwanted behaviors may ac-tually provoke a violent reaction. The promised re-wards of a potential rise in privilege level, coupled withwarnings of aversive consequences, presents these chil-dren with a cruel give-and-take cycle in which they are

unable to understand the rules of the game or to benefitby them.

Likewise, there is a subset of child patients who, be-cause of their difficulties with receptive speech, may mis-interpret a staff member's directives. The neuropsycho-logical deficits in children who exhibit disorders ofconduct and behavior have been demonstrated to be inverbal and executive functions (Moftitt, 1993). Their lowlevels of encoding skills may limit both their understand-ing of what behavior is desired and how to convey theirthoughts and feelings about those expectations (Weisz,1998). Staff members often are taught to issue a directiveonly once or twice before applying a consequence fornoncompliance. These children may be unable to processthe directives and, therefore, may ignore the directive, orthey may interpret it as a menace to their well-being. Ineither case, they are penalized for not having sufticientlinguistic fadiity or processing skills.

Although generic level systems are not

effective in practice, behavioral

management techniques based on solid

learning theory have been shown

repeatedly to be effective therapeutic tools.

Moreover, many children who have histories oftrauma or maltieatment are at a significant disadvantagein situations of high stress where demands are put onthem to make "appropriate" decisions and remain ratio-nal. Statements by staff members may appear to bethreatening to these children. For example, a frequentstaff member communication goes something like this:"If you don't [blank], then [blank]." Presumably the staffmember is stating a consequence that will be invoked, or



may be stating to the child that he/she will not earnpoints and, thereby, not earn more privileges and ahigher level. Such a statement to a child with a history ofmaltreatment of trauma may evoke a catastrophic reac-tion based on the interpretation of this statement and themeaning that such statements have had in their previouscontexts (Perry, 1997; Perry & Pollard, 1998; Perry, Pol-lard, Blakley, Baker, & Vigilante, 1995).

Another issue, and one that has been acknowledged inthe psychiatric literature, is the issue of staff training andknowledge (Braxton, 1995; Donat, 1998; Donat & McKee-gan, 1990; Petti, Mohr, Somers, & Sims, 2001). Althoughour argument in this article is that generic level systemsare not effective in practice, behavioral management tech-niques based on solid learning theory have been shownrepeatedly to be effective therapeutic tools. Appropriaterewards applied to children that are tailored to them asindividuals can be extremely powerful tools to helpshape appropriate behaviors. However, in too many in-stances, line and professional staff are unaware of whenand how to reward, and when to withhold rewards.

For many years, scholars have commented on the factthat the people with the least amount of training andknowledge have the greatest contact and responsibilityon a daily basis with patients in psychiatric settings(Braxton, 1995; Goffman, 1961; Perrow, 1965). Their ob-servations are also borne out in empirical studies under-scoring staff members' lack of a solid theoretical founda-tion for practice. Research suggests that behavioralmanagement techniques have not been widely adoptedby practitioners, and that staff members working withpsychiatric patients have little knowledge of behavioralprinciples on which behavior management and behaviormodification are based. More than two decades ago, thisissue was being discussed in the nursing literature.Niemeier (1983) observed that patients' desirable behav-iors were inadequately reinforced when she conducted anaturalistic study that included nurses and nursing assis-tants. These observations were confirmed in a later studyby Burdett and Milne (1985).

A 1986 study commissioned by the state of Virginia(Virginia Department of Planning and Budget, 1986) con-

cluded that institutional settings fostered and reinforcedpassive institutional behaviors and at times actually pro-moted behavioral management problems. Similar find-ings were reported by Gelfand et al. (1967), who found apositive correlation between the severity of patients' psy-chotic behavior and the inappropriateness with whichthey were reinforced. In fact, they observed that patientsthemselves were the best behavioral engineers with re-spect to providing appropriate behavioral principles totheir fellow patients.

Finally, with the great cultural diversity of the U.S.population, therapies and treatments should be at leastadaptable to ethnic and radal minorities on the assump-tion that they will generalize to individuals who are notfrom the dominant culture. However, given that there islittle empirical research that generic level systems are ef-ficacious at all, there are important considerations withrespect to cultural appropriateness to be considered. Al-though the available studies on treatment effectivenessof psychotherapies are limited in number and design,some researchers have foimd that some treatments andtheir adaptations may actually be harmful to minoritygroup members (Chambless & WilUams, 1995; Gibbs &Huang, 1997; Telles et al., 1995). Thus, assuming thattherapeutic approaches have been conceptualized byand for the dominant culture, they may not be applicableto all patients (Sherev, 1997).

Treatment Implications

Although systematic data collection has not been con-ducted to substantiate that the children seen in psychi-atric settings are more acutely ill than in the past, cer-tainly with the large-scale changes in health care thathave influenced reimbursement practices, practifioners'anecdotes and our own clinical experiences would sug-gest that this is the case. Our colleagues report that psy-chiatric settings are analogous to intensive care units,with higher levels of acuity and a higher proportion ofviolent and impulse deficient patients (USDHHS, 2001).Bearing out such experienfial reports, research by Achen-bach and Howell (1993) suggested that children's psy-


chological distress in hospitals and residential settingshas increased as measured by the Child Behavior QieckList (CBCL) (Achenbach & HoweU). Yet the structure oftreatment settings remains fixed, and little research hasbeen conducted to determine whether level systems, orfor that matter any modality employed in residentialtreatment settings, produce the outcomes for which theywere intended (Lundy & Pumariega, 1993; USDHHS,1999).

The changes in reimbursement and the changes in ourpatient populations underscore the need to move for-ward to develop new approaches, or to validate the oldones by way of research study.

Recommendations

Some of the practices we recommend are not new, butbear repeating; there are many settings where they havenot been employed (Donat & McKeegan, 1990; Kazdin,1984,1996a, 1996b; Gelfand et al., 1967; Niemeier, 1983).

Interventions and treatments are bound to

fail when they are not developed on the

basis of individuals' development and are

not sensitive to their various cognitive,

social, and emotional domains and needs.

Contextualized assessment, behavior analysis, andindividualized interventions. The psychology literatureis replete with the vicissitudes of unidimensional ap-proaches to practice and research. One prominent exam-ple is the exclusive dependence on global IQ in diagnos-ing mental deficiency in children (Grossman, 1983). Thus,a recommendation that children's assessments should be

individual and multidimensional may be neither originalnor new. The most significant feature of multidimension-ality is its ability to provide more comprehensive andgeneralizable assessments. Another feature is that it al-lows for more precise treatment programming.

Interventions and treatments are bound to fail whenthey are not developed on the basis of individuals' de-velopment and are not sensitive to their various cogni-tive, sodal, and emotional domains and needs Qohnson,1995; Kazdin, 2001; March, 2000; Singh, 1997). As obvi-ous as the above might be, in our years of clinical experi-ence we have found the reality that individual assess-ment, and often individual treatment, may be anunrealized ideal. The use of checklists, structured inter-views, and standardized instruments, though efficient,runs the risk of practitioners building assessments andasking questions that are devoid of context, therebyomitting many important portions of clinical reality(Kazdin, 2001; King, Schwab-Stone, Peterson, & Thies,2000; Singh, 1997). Without knowing the context of thechild's home, many questions may be virtually meaning-less. One such example is asking a child if he/she hasever attacked a member of the family. While such activ-ity is undesirable, it is understood very differently whenviewed from the context of repeated abuse of the child'smother and the youngster's trying to intervene in the do-mestic violence situation.

This kind of decontextualization is a serious draw-back of current assessment in many mental health set-tings (Offord et al., 1996). We have observed in our clini-cal practices that assessments in progress notes in manyinpatient and residential settings are too often vague andimprecise, in spite of the vast empirical literature avail-able that speaks to the value of deciphering an individ-ual's cognitive and behavioral "programming." Howthat programming "operates" for each child is key toknowing how, where, and why to intervene (King et al.,2000; March, 2000). Thoroughly assessing orbits of influ-ence such as family, peers, schools, and community pro-vides dues as to antecedent conditions that elidt, as wellas conditions that reir\force or maintain, certain behav-iors. For example, families of origin may range in their



childrearing practices from very punitive to very lax,making it crudal that assessment include an appraisal oflearned "disciplinary" approaches and the natural envi-ronmental contingencies for the individual child. Failtireto do so may waste much time and resources, while at-tempted interventions fail (King et al., 2000; Singh, 1997).

Two kinds of analyses have been found useful in pre-cisely establishing the factors (contexts) under whichcertain behavior takes place: structural analysis andfunctional analysis of behaviors. The former involves as-sessing factors antecedent to or concurrent with the be-havior, and the latter attempts to isolate the consequenteffect that a behavior has on the environment (Axelrod,1987).

An assessment and analysis of structural variables iscritical to any effort at imderstanding the behavior of anyindividual. While behavioral acts are not elicited by envi-ronmental events, many environmental events can func-tion as a source of control over behavioral events. Exam-ples might be the size of a child's classroom or thepresence of loud backgrotmd noise. Environmental fac-tors involve the internal environment as well; thus, othervariables might include boredom, hunger, cognitivedeficits, or fatigue.

In applied behavior analysis, a functional analysis isdone to examine contingencies and use causal informa-tion to identify effective interventions (Kazdin, 2001).The idea here is that there is no single function that aparticular behavior serves for all or even most individu-als. Based on the available research, aberrant behaviorcan be clustered into three major propositions: (a) Aber-rant behavior is an operant behavior maintained by posi-tive sodal reinforcement (positive reinforcement hypoth-esis), (b) aberrant behavior is an operant behaviormaintained by the termination of an aversive stimulus(negative reinforcement hypothesis), and (c) aberrant be-havior is maintained by the production of sensory stimu-lation (sensory reinforcement hypothesis). Thus, the vastrange of possible functions underl)nng behavior, as wellas the wide range of structural variables to which a childis exposed, argues for individual programming. Thevery complexity of contextual factors argues that simple

explanations of individual behavior should be avoided,and it predicts that assessment and intervention programexpressed as boilerplate treatment approaches to chil-dren and their families are doomed to failure (Axelrod,1987; King et al., 2000; Kazdin, 2001; MARSH, 2000;Singh, 1997).

Moreover, assessment must be informative and use-ful. The value of an assessment can be thought of interms of its "consequential validity" (Messick, 1980). Thepsychometridan Samuel Messick posits that consequen-tial validity is at the core of successful measurement andassessment. What he means is that the ultimate purposeof conducting an assessment is to identify a problem pre-dsely, which in turn shotild invoke the most promisingtreatment or intervention. Thus, any assessment that failsto do so is an assessment of dubiotis value.

Finally, there is a moral obligation to assessment. Qini-dans must identify areas of maladaptation as well as areasthat can be thought of as strengths or competence. With-out the indtision of competence and strengdis, our assess-ments are not just incomplete, but they also may lead tonegative labeling that has the potential to stigmatize.

Clarity of behavioral description is critical

in communicating about patients with

others.

Descriptive analysis, data language, and opera-tionalization. Complementing assessment that is con-textually based and employs functional and structuralanalyses is the use of a data language in doctimentation.Serious problems can arise when language that lacksclarity is employed in clinical settings. Qarity of behav-ioral description is critical in commtmicadng about pa-tients with others. While patients remain the same peo-ple in their medical records, the people recording in that


record are very different and may frequently change.Thus, it is important that case histories and other reportsbe written in dear, unambiguous language so that dini-dans over time will have accurate pictures of behavioralchanges that may have occurred and will be able tomake meaningful behavioral comparisons. Rigorous be-havioral descriptions play an important role in assessingthe effectiveness of any treatment programs (Kazdin,2001; March, 2000; Singh, 1997).

Three decades ago Greenspoon (1976) suggested thata rigorous data language should meet at least two crite-ria: (a) individuals using a given word or set of wordsshould employ those words in the same manner, and (b)the data language should consist of a relatively small vo-cabulary. These are crudal considerations in clinical set-tings where professional jargon is used, sometimes indis-criminately (Mohr, 1999). While professional jargonserves as a kind of shorthand between caregivers andcan be effident and useful, it often obscures rather thanillumines when used inappropriately (Lutz, 1989).

The word "affed" and its various modifiers come tomind as frequent examples of imprecise language thatsignifies very Uttle and that often is used in very differentways by different staff members. In a review of morethan 4,000 entries in children's medical records, Mohrand Noone (1997) found impredse labels applied to theterm affed such as superfidal, belligerent, dysfunctional,and argumentative, although these qualifiers can hardlybe thought of as describing one's mood state and are notlisted as such in the DSM. Illustrating staff members'confusion over the term, Mohr found an entry thatstated: "[Patient] lying in bed with eyes dosed. Appearsto be asleep. Affed Hat" (p. 1056).

Rather than employing jargon, simple description ofbehaviors, their frequency, and the circumstances underwhich they occur are more empirical and predse ways ofassessing patients at baseline and throughout their hos-pital stay. Directing staff members to describe discretebehaviors and when they occur without the use of jargonwords and vague modifiers (such as the word "manipu-lative," for example) would reduce ambiguity. Moreover,such documentation would enhance dinidans' effective-

ness because they can make objective evaluations of thebehavioral changes that occur in patients. Such objectiveevaluations are helpful in determining the success or fail-ure of interventions by communicating patient behaviorin more unambiguous and quantifiable terms (Olson &Mohr, 2002).

Professional and staff training and education. Aswe have mentioned, studies have highlighted the needfor adequate training of direct care staff (Burdett &Milne, 1985; Knowles & Landesman, 1986). One of themost disturbing studies that flies in the face of conven-tional belief that supervising nurses might be better pre-pared than the mental health workers was conduded byDonat and McKeegan (1990). They found that mentalhealth workers scored higher than registered nurses ontests of behavioral knowledge, despite their lower educa-tional attainment. The same study found no differencebetween behavioral knowledge of RNs and LPNs. Whilewe can only speculate as to reasons for these findings,our own review of the following psychiatric nursingtexts yielded scant information about children's pro-gramming or behavioral management techniques forchild or adolescent populations (Burgess, 1997; Fontaine& Fletcher, 1999; Frisch & Frisch, 1998; Johnson, 1995;Townsend, 1999). In our review of several undergradu-ate psychiatric mental health nursing texts, we foundone textbook omitted learning and behavior theoriescompletely (Towr send), and two contained less than onepage on the subject (Burgess; Fontaine & Fletcher). Yetanother was completely in error in its explanations ofpositive and negative reinforcement (Frisch & Frisch).Only one textbook that we reviewed (Varcarollis, 1998)spoke to the issue of child inpatient and residential treat-ment in any depth.

Stuart (2001) noted that nursing texts are woefully de-void of discussions on empirically validated theory andevidence-based interventions. Both Stuart and McCabe(2000) have called for incorporating evidence-based psy-chiatric nursing care in educational programs. We con-cur, and urge that textbooks and curricula focus on evi-dence-based interventions and practice, on promisingbut tentative interventions, practice guidelines, and



away from "traditional and intuition driven practice"(Stuart, p. 110).

In addition, the low level of behavioral knowledgeamong direct care staff noted by several scholars (Corri-gan, Holems, Luchins, Parks, & Basit, 1994; Donat, 1998;Donat & Keegan, 1990; Harchick, Sherman, Hopkins,Strouse, & Sheldon, 1989) make staff training and educa-tion as crudal a component of service delivery as the ac-tual patient care that is rendered. Given that these samestudies indicate that professional leaders themselvesmay have inadequate knowledge of how behavioralmethods can be applied in inpatient settings, it meansthat the entire staff culture (line staff as well as profes-sional staff) must be imbued with, committed to, andguided by a strong theoretical grounding.

Ideally, before they work with vulnerable and chal-lenging children, staff and professionals should be as-sessed on their knowledge of behavioral interventionsand the underlying theory and rationale. Those presentlyworking with these children should be assessed in orderto remediate those areas that evidence weakness, lowlevels of competence, and represent myth-based, ritualis-tic practices learned "on the job." Moreover, given thepropensity of new learning in behavioral procedures tobe abandoned shortly after training or consultation(Harchick et al., 1989), ongoing professional oversight isnecessary to preserve the investment that has been madeto educate staff.

Not only should staff education and training includesolid learning theory and technique, but such trainingalso should include content on the differences betweenthe average child and the child with a serious emotionaldisorder (SED). Moreover, staff members' expectations ofchildren with cognitive and emotional challenges shouldbe clearly in line with the capacities of their charges. Ed-ucational programs should stress that children with anSED are not average children who have learned to toler-ate a great deal of caregiver inconsistency and ambiguityof contingencies, as well as parental reactivity, and thattheir needs for structure and consistency may vary.

Finally, education and training should not be limitedto staff members alone. Rather, parents should be active

participants in such education. Not only would there begreat value in offering such workshops to parents as partof the menu of residential treatment or hospital services,but parents also should be integral participants in de-signing interventions based on what they learn. Theycould then test their individual child's behavioral plan athome in a more informed manner.

Conclusion

We have argued that the level system as standard be-havioral programming in child and adolescent psychiatricsettings is a flawed intervention from a theoretical stand-point. There is little empirical evidence that settings usinggeneric level systems produce better patient outcomes, andyet they are virtually ubiquitous in children's psychiatrichospitals and residential treatment facilities. Scholars(Dawes, 1994, 2001; Meehl, 1973; Stanovich, 2001; Stuart,2001) have called for grounding the practice of psychother-apeutics in empirical study. Our practices in psychiatricsettings must be based in empirical study and demonstrateefficacy in terms of outcomes (Lundy & Pumariega, 1993).

The entire staff culture (line staff as well as

professional staff) must be imbued with,

committed to, and guided by a strong

theoretical grounding.

Admittedly, not every intervention that we employ inpsychiatric settings meets this standard, but those thatdo not deserve to be evaluated critically. Level systemsare such interventions. They constitute a practice whosetime has passed in psychiatric care of patients. Perhapsin the days before managed care, when patients wereplaced for many months into milieus to be resocialized


away from the contingencies of their natural environ-ments to those of the program, a level system may havebeen a defensible approach to care. Yet, even in thosedays programming was criticized when the child re-gressed upon returning to his home (Peniston, 1988).

With markedly truncated programs and dramaticallyreduced lengths of stay, it makes far more sense to con-duct assessments that center on where the youngsterlives—in homes and communities. It also makes sense toinclude parents and other natural helpers from thechild's community in the assessment and treatment. Thisway, the child's program of care can be continuous anduninterrupted by the turbulence that might arise fromchanges between different systems of care.

Finally, although systematic empiricism (Stanovich,2001) has been the goal of tbe behavioral sciences, toooften practice interventions such as level system pro-gramming bave been based in what Dawes (1994) char-acterizes as the "mytb of expertise" and practice by con-sensus. Historically, sucb foundations for clinical practicebave resulted in several categories of unvalidated thera-pies and practices. Professionals are called on to takestrong positions against outdated and unvalidated thera-pies. Level systems are but one example of these. In thecurrent fiscally conservative payer environment, man-aged-care organizations have shown keen interest intreatment tbat is safe, effective, and efficient. Simple eco-nomics and business acumen would predict tbat profes-sionals and practitioners wbo fail to demonstrate thattheir tberapeutic interventions are efficacious would bevictims of an eventual sbakeout from that environment.

Author contact: [email protected], with a copy to the Editor:[email protected]

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