• By Dartington SRU
  • Posted on Tuesday 19th August, 2014

Failed RCT highlights challenges of preventing dropout

A failed randomised controlled trial provides valuable insights into how to prevent treatment dropout among traumatised children and their families. The research suggests that investing in formal engagement strategies pays dividends in the quest to engage and retain vulnerable populations treated in community-based settings.

The trial was initially set up to evaluate the efficacy of a treatment model called Trauma Systems Therapy (TST) for children experiencing symptoms of post-traumatic stress. Twenty children and their families were randomly allocated to either receive TST or receive care as usual. Just three months into the research project, only one patient in the care as usual group was still enrolled in the study – compared to nine of ten in the TST group.

The disastrous dropout rate among the patients receiving care as usual meant that the researchers did not have enough data to compare outcomes across the two groups. The RCT had to be terminated.

But although almost all the control group participants dropped out, almost all the treatment group participants stuck with the study. Why were there such dramatic differences between TST and “services as usual” from the hospital’s child psychiatry clinic?

Based on the failed RCT, the researchers, led by Glenn Saxe of the New York University School of Medicine, offer three insights on how to retain children and families in psychological treatment programmes.

1.   Build skills in the child’s social context

The first insight is that connecting the child’s social context to the treatment plan may help to retain children and families. According to the developers of TST, traumatic stress is the result of both the child’s inability to regulate emotions and behaviour, as well as a limited capacity among family members and others in the child’s social environment to help him or her regulate their emotions and behaviour.

“The ability to successfully engage members of a child’s social environment is critically important for the effectiveness of any treatment,” the authors say. Although the youth in the treatment as usual group received individual psychotherapy provided by their social worker or psychologist, the absence of the rest of the family from the treatment plan may have contributed to the children not fully accessing the treatment.

2.   One collaborative treatment plan

The second tip is to bring a variety of services together in a single treatment plan. The TST model has capacity to provide four different services, including skill-based psychotherapy, psychopharmacology, home- and community-based care, and systems advocacy. Youth receiving the standard treatment might have received the same four services, but they would likely be the subject of multiple treatment plans developed by different professionals and agencies.

The difference with TST is that all of the services are coordinated and integrated into one multi-agency, collaborative treatment plan, rather than a variety of plans that were developed by disparate providers. “Organizationally, agencies implementing TST bring together different services to provide collaborative treatment under a common model,” according to Saxe and colleagues.

Why did this encourage retention? Because it streamlines the referral process and assembles a variety of services that simultaneously meet the family’s multiple needs.

3.   Begin by engaging families in the treatment

The third insight is that a formal strategy for working on solutions with the whole family may help. TST is structured around a sequence of modules, the first of which is called “Ready-Set-Go!” This module has three goals: first, to form a treatment alliance with the family; second, to troubleshoot practical barriers to treatment engagement; and third, to provide psychoeducation about the nature of traumatic stress and the family’s involvement in TST.

The authors argue that by proactively assessing potential barriers to treatment access at the outset and by developing, in partnership with the family, a set of practical solutions, the family and child are more likely to stay engaged.

These are three factors that Saxe and colleagues believe contributed to the stark difference in retention rates amongst the patients in their study. They do, however, acknowledge that further research is needed in order to rule out other plausible explanations of the dropout rates. For example, there were more girls in the intervention group, and more boys in the control group. Are girls more likely to stay engaged than boys?

Future research into retention strategies is certainly warranted. As the authors say, “Engaging and retaining children and their families in treatment continues to be a critical issue for evidence-based programmes, especially in traditional outpatient settings and with marginalised populations… in community-based settings, more than two-thirds of youth drop out of treatment by seven sessions, which is a significant obstacle given the length of most evidence-based treatments.”

Saxe, G., Heidi Ellis, B., Fogler, J.,& Navalta, C.P. (2012). Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout. Child and Adolescent Mental Health, 17, 1, 58-61.

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