Discussion: Issues with Young Children
Journal of Child and Family Studies, Vol. 15, No. 3, June 2006 ( C© 2006), pp. 287–301 DOI: 10.1007/s10826-006-9021-5
Investigating the Impact of Strength-Based Assessment on Youth with Emotional or Behavioral Disorders
Kathleen F. Cox, Ph.D., L.C.S.W1,2
Published online: 4 May 2006
The trend toward adopting a strengths approach to mental health practice with children and adolescents amounts to a paradigm shift from an emphasis on diag- nosing disorders to tapping child capacities and assets toward the achievement of treatment goals. While the potential value and challenges associated with this shift has received ample attention in the literature, minimal research has been conducted to assess the benefits and barriers related to the use of strength-based strategies with youth. Utilizing an experimental design, this author examined the impact of strength-based assessment using the Behavioral and Emotional Rat- ing Scale (BERS) with seriously emotionally or behaviorally disturbed children and adolescents. Results revealed that child functioning outcomes were signifi- cantly better for youth who received BERS-guided assessment versus the usual deficit-based assessment protocol only when the treating therapist reported an ori- entation toward service that reflects highly strength-based attitudes and practices. Furthermore, high adherence to the strength-based assessment protocol was asso- ciated with significantly higher parent satisfaction with services and lower rates of missed appointments. These findings highlight the importance of accounting for practitioner effects and treatment fidelity in future studies of strength-based practice effectiveness.
KEY WORDS: strength-based assessment; children’s mental health; practitioner orientation.
Recent mental health policies, including the Children’s System of Care ini- tiative (Stroul & Friedman, 1994) and California’s Mental Health Services Act (2005), have promoted the use of a strength-based approach to treatment for children and adolescents. This promulgation of strength-based service delivery is
1Clinical Director, EMQ Children and Family Services, Sacramento, CA. 2Correspondence should be directed to Kathleen F. Cox, EMQ Children and Family Services, 8801 Folsom Blvd., Sacramento, CA 95825; e-mail: kcox@emq.org.
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founded on the premise that even the most troubled youth have unique talents, skills, and other resources that can be marshaled in the service of recovery and development. The recognition of such capacities by mental health practitioners is thought to convey a sense of genuine respect for the client, resulting in heightened motivation toward the attainment of enduring change (Weick, 1992; Weick & Chamberlain, 2002). Thus, a strengths orientation is viewed as a less stigmatizing approach to children’s mental health treatment than models focused on deficits and pathology.
Strength-based assessment, the cornerstone of strengths-focused practice, broadens the scope of traditional mental health assessment protocols that empha- size the identification of youth problems, symptoms, and impairments. As defined by Epstein & Sharma (1998, p. 3), strengths-based assessment is:
The measurement of those emotional and behavioral skills, competencies and characteristics that create a sense of personal accomplishment; contribute to satisfying relationships with family members, peers and adults; enhance one’s ability to deal with adversity and stress; and promote one’s personal, social, and academic development.
Consistent with this definition, the Behavioral and Emotional Rating Scale (BERS; Epstein & Sharma, 1998) assesses child strengths within the dimensions of: interpersonal capacity, family involvement, intrapersonal competence, school functioning, and affective ability. Scoring of this instrument produces an overall strengths quotient and standard subscale scores within each of these domains. The BERS is recommended by its developers as a tool for use in mental health clinics, schools, and social service agencies due to its potential for: engaging chil- dren in service planning, facilitating parent-professional collaboration, increasing youth motivation, identifying strengths and weaknesses for intervention, and doc- umenting progress toward skill mastery. Evidence in support of these purported advantages of strength-based assessment is scarce, however. There is considerable research documenting the sound psychometric properties of the BERS (Epstein, Harniss, Pearson, & Ryser, 1999; Epstein, Nordness, Nelson, & Hertzog, 2002; Epstein & Sharma, 1998; Friedman, Friedman, & Weaver, 2003; Friedman, Leone, & Friedman, 1999; Reid, Epstein, Pastor, & Ryser, 2000; Trout, Ryan, LaVigne, & Epstein, 2003; Walrath, Mandell, Holden, & Santiago, 2004) but none demon- strating its contribution to treatment outcomes with emotionally and behaviorally disturbed children and adolescents.
The literature does recognize the challenge inherent in the adoption of such strength-focused protocols in mental health settings. In fact, much has been written on the “tenacious attachment” of human service providers to deficit oriented beliefs and attitudes—a bond that inhibits their embrace of strength-based strategies and methods (Blundo, 2001; Saleebey, 2002). Theorists have also discussed the misconceptions that pervade social service settings regarding the purpose and principles of the strengths approach (Graybeal, 2001; Saleebey, 1996). However, the author is aware of no research to date that systematically studies the impact of
Strength-Based Assessment with Children and Adolescents 289
such contextual factors in promoting or impeding successful implementation of strength-based practices.
In recognition of these gaps, this study sought to advance knowledge of the benefits and barriers associated with the incorporation of BERS-guided assessment into mental health service delivery. A primary aim was to assess the proximal and distal outcomes attributable to strength-based assessment with seriously emotion- ally or behaviorally disturbed youth. Secondly, practitioners’ beliefs and attitudes regarding strength-based practice were explored. Finally, the relationship between strength-focused views/practices on the part of participating therapists and mental health treatment outcomes was examined.
METHOD
Study Participants
The sample consisted of eighty-four youth who were requesting or receiving psychotherapy services from a public mental health agency in Northern California. These children ranged in age from 5 to 18 years, with 77% above the age of 11 years. A majority were male (66%), while approximately 86% were Caucasion, 8% were of mixed race, 2% were African-American, 2% were Asian-American, and 1% were Latino. All of these youth held at least one mental health diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994).
Participating therapists included 3 licensed clinical psychologists, 4 psy- chology interns (master’s level psychologists), 3 licensed clinical social workers, 1 licensed marriage and family therapist, 2 master’s level social workers, and 1 M.S.W. student. The level of experience of these practitioners in the mental health field varied greatly, ranging from 1 to 30 years (M = 12.72, SD = 9.1). All were familiar with the principles of strength-based practice as a result of their attendance at a 2-hour training overview on this topic provided by the investigator just prior to the onset of the study.
Study Design
A pretest-posttest randomized block design was used for this investigation in which assignment of subjects to assessment conditions was performed separately for new intake clients and on-going outpatient therapy clients. An experimental design was selected due to its capacity to control for threats to internal validity (Bickman, 1992). Blocking was performed in order to allow for an efficient ex- amination of the degree to which intake and on-going cases differed as to impact of the experimental protocol on treatment outcomes.
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Subjects assigned to the experimental condition received strength-based as- sessment, as produced by the Behavioral and Emotional Rating Scale (BERS), in addition to the usual diagnostic assessment. The youth’s caregiver (parent or guardian) was asked by the investigator to complete this measure along with the other pretest instruments. The primary therapist was subsequently given a copy of the BERS results including: ratings for individual BERS items, standardized subscale scores, strengths quotient, answers to open-ended questions regarding specific strengths and resources of the child, written interpretations and recom- mendations. This clinician was encouraged to share these results with the youth and parent during the process of service planning and/or intervention formulation.
Participants assigned to the control group received the usual format for mental health assessment. Based on client interview, an admission assessment form was also completed by the intake clinician, yielding information in the following areas: presenting problems, symptoms, health conditions, desired changes, risk factors, psychiatric history, and mental status. This initial evaluation culminated with the provision of a mental health diagnosis included in the DSM-IV. On-going assessment information was documented in clinical progress notes and service plans, the latter completed on an annual basis.
Measures
Child Functioning
Outcomes with respect to child symptomatology and functioning were as- sessed from the perspective of the youth, caregiver, and primary therapist using the following instruments. First, the Child Behavior Checklist (CBCL; Achenbach, 1991a) was completed by the parent or guardian at study enrollment and again at 6-months post enrollment. This measure consists of 118 items that require the respondent to rate the child’s behavioral, emotional, and social problems using a Likert-type scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). Scoring produces a Total Problems score as well as raw scores within two broad-band groupings of syndromes (Internalizing and Externalizing Problems) that are displayed in relation to percentiles and T scores based on a nationally representative sample of children of the subject’s gender and age. The CBCL has been found to have very good psychometric properties, including in- ternal consistency, test-retest reliability and discriminant validity (Achenbach & Rescorla, 2001). Second, the Youth Self-Report (YSR; Achenbach, 1991b) was completed by the youth at enrollment and the 6-month follow-up. This measure utilizes a format that is parallel to the CBCL, with scoring also producing Inter- nalizing and Externalizing Problem scores, as well as a Total Problem score. Like the CBCL, the YSR has demonstrated sound psychometric properties (Achenbach & Rescorla, 2001). Lastly, the Child and Adolescent Functional Assessment Scale
Strength-Based Assessment with Children and Adolescents 291
(Hodges, 1990) was completed by the primary therapist at pre-test and post-test. This instrument measures the negative effects of problem behaviors and symp- toms on child functioning across a variety of real-life domains (i.e. School, Home, Community, Behavior Toward Others, Moods/Emotions, Self-Harmful Behaviors, Substance Use, Thinking). Subscale scores in these dimensions are summed to produce a total CAFAS score, with a higher value indicating more severe impair- ment. The CAFAS has demonstrated high inter-rater reliability (Hodges & Wong, 1996; Pernice, Gust, & Hodges, 1997), as well as adequate internal consistency (Hodges, Doucette-Gates, & Liao, 1999; Hodges & Wong, 1996) and discriminant validity (Hodges et al., 1999; Hodges & Wong, 1996).
Parent Satisfaction
Consistent with the strengths model emphasis on parent-professional collabo- ration (Epstein & Sharma, 1998), the parent or guardians’ satisfaction with services was also deemed an important dependent variable in this study. Thus, the eighth version of the Client Satisfaction Scale (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) was administered to the parent or guardian at 6-months post- enrollment. This 8-item instrument provides a unidimensional self-report measure of an individual’s satisfaction with a specific health or human service received. The CSQ-8 has enjoyed widespread use by investigators and administrators for program planning and evaluation and has been found to have desirable psycho- metric properties, including internal reliability and construct validity (Attkisson & Greenfield, 1999).
Service Measures
Based on the hypothesis that clients motivated through a focus on strengths would be less inclined to miss therapy appointments and/or discontinue services prematurely, treatment retention was selected as a proximal outcome for this investigation. This dependent variable was operationalized as: (1) the percentage of therapy appointments either missed or cancelled over the 6-month study period and (2) the presence or lack of presence of an unplanned termination of services (treatment drop-out). Additionally, adherence to the strength-based assessment protocol was assessed through a review of experimental case records. Written service plans and clinical progress notes were examined at the 6-month follow-up for evidence of therapist-guided discussion of BERS results with client and/or parent.
Measure of Therapist Orientation
To assess the influence of therapist orientation on treatment outcomes at the client and service level, a questionnaire (referred to as the Clinician
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Survey) was devised by the investigator and administered to participating thera- pists at the close of the study. The first section of this measure includes open-ended questions that inquire as to the therapist’s view of the strengths and limitations of the BERS. Multiple-choice questions in the next two sections of the survey were informed through a review of the literature pertaining to the philosophy and principles characterizing strength-based practice. The first of these sections taps the clinician’s attitudes and beliefs regarding mental health practice. Three of 12 items ask the therapist to indicate the extent to which they agree (strongly agree, agree, not sure, disagree, or strongly disagree) with statements that are consistent with the strengths-perspective. The remaining 9 items request that the therapist indicate the level of their agreement with statements that are in- consistent with a strengths-orientation. In tabulating this data, the investigator assigned the following values to responses to the statements reflecting a strengths- focus: strongly agree = 2, agree = 1, not sure = 0, disagree = −1, strongly dis- agree = −2. The values were reversed for statements inconsistent with a strengths perspective. By summing the response values in this section, a score was ob- tained for each clinician within the domain labeled as Therapist Perspective. In the second section of multiple choice questions, clinicians are asked to indicate the extent to which they had utilized certain interventions during the study pe- riod (very often, often, occasionally, rarely, or never). Half of 12 items reflect interventions typical of strengths-based practice. The other 6 items in this section refer to interventions that are more consistent with a deficit-based approach. For the responses to items reflecting strengths-focused practice, the response values were assigned as follows: very often = 2, often = 1, occasionally = 0, rarely = −1, never = −2. Summation of these response values produced a score labeled as In- terventions Used. The scores for Therapist Perspective and Interventions Used were then summed to produce a Strength-Based Orientation (SBO) score for each therapist. These SBO scores were collapsed to form an ordinal level variable, with values assigned as low, medium, and high in relation to strength-focused orientation.
RESULTS
Preliminary Analyses
I initially examined whether groups (intake versus on-going therapy clients; experimental versus control subjects) differed in demographic characteristics and impairment level at study enrollment. Independent t-tests and chi square tests showed no between-groups differences in age, gender, or Total Problem scores on the CBCL, YSR and CAFAS at pre-test.
Strength-Based Assessment with Children and Adolescents 293
Child Functioning Outcomes
Repeated measures ANOVA’s conducted on the CBCL, YSR and CAFAS data collected at baseline and the 6-month follow-up revealed main effects for time on all measures except the YSR Externalizing Problems scale and the CAFAS scores measuring impairment in Community Role Performance, Substance Use, and Thinking. Pre-post reductions in problem behaviors and symptomatology for the total study sample emerged on the CBCL Total Problems scale (F = 23.75, df = 1, p = .000), CBCL Externalizing Problems scale (F = 9.76, df = 1, p = .003), CBCL Internalizing Problems scale (F = 26.83, df = 1, p = .000), YSR Total Prob- lems scale (F = 5.48, df = 1, p = .022), YSR Internalizing Problems scale (F = 5.00, df = 1, p = .029), and CAFAS domains of Total Functioning (F = 20.55, df = 1, p = .000), School Role Performance (F = 13.35, df = 1, p = .000), Home Role Performance (F = 6.28, df = 1, p = .014), Behavior (F = 15.14, df = 1, p = .000), Moods (F = 4.37, df = 1, p = .040), Self-Harm (F = 8.45, df = 1, p = .005).
Analysis of data for differences in child functioning attributable to condition or case type revealed no significant group effects. Additionally, no significant interactions between the impact of time and treatment condition were observed on any measure, thus disconfirming the hypothesis that youth provided strength- based assessment would make greater gains in functioning over the 6-month study period. With respect to interactions between the impact of time and case type, only one proved significant. On the CAFAS dimension of Self-Harm, a significant time × case type interaction was detected (F = 5.36, df = 1, p = .023). Intake clients showed a greater reduction in self-harmful tendencies over the study period than on-going clients. This result was likely due to the greater difficulty evidenced by intake youth in this domain of functioning at baseline, with a mean CAFAS score of 7.22 (SD = 10.31), as contrasted with 3.10 (SD = 7.15) for on- going clients. No significant interactions were found between time, condition, and case type. Overall, these findings indicated that intake and on-going therapy clients did not differ substantially with respect to the impact of strength-based assessment on child functioning outcomes.
A second series of repeated measures analyses of variance was performed to assess the main and interaction effects attributable to the therapists’ orientation toward strength-based practice, as assessed using the SBO measure within the Clinician Survey. While no main effects emerged for therapist orientation, a sig- nificant interaction was found between therapist SBO score, condition, and time on the CBCL Total Problems score (F = 3.99, df = 2, p = .023) and the CBCL In- ternalizing Scale (F = 4.54, df = 2, p = .014). On both measures, the experimental clients of highly strength-based therapists made greater improvements in function- ing over time than the control clients of these clinicians. A series of Wilcoxon sign rank tests confirmed that for experimental clients, only those with therapists
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scoring high in strengths orientation made significant pre-post gains on the ba- sis of the CBCL Total Problems scale (Z = −2.20, p = .028), CBCL Internal- izing Problems scale (Z = −2.09, p = .037), and CBCL Externalizing Problems scale (Z = −2.32, p = .020). Conversely, the control subjects of therapists scoring medium or low with respect to strengths orientation improved to a greater extent on both scales than their experimental counterparts. For these clients, only those with a therapist scoring medium or low in strengths-orientation made significant pre- post gains, as measured by the CBCL Total Problems scale (Z = −2.46, p = .014; Z = −2.02, p = .044, respectively) and the CBCL Internalizing Problems scale (Z = −2.94, p = .003; Z = −2.26, p = .024, respectively).
The CAFAS data reflected a slightly different view of the impact of therapist orientation. For both experimental and control clients, only those with a therapist scoring medium with respect to a strengths orientation made significant pre-post gains, as assessed by the CAFAS Total Problems score (Z = −2.86, p = .004; Z = −2.73, p = .006, respectively). This finding may, however, be due to the higher level of impairment demonstrated by these clients at baseline on this measure (F = 4.19, df = 78, p = .019). Clients with a therapist scoring medium in strength- based orientation had a mean CAFAS Total Problems score of 105.79 (SD = 39.1) at study enrollment, while those with a clinician scoring high or low in SBO had mean scores of 78.75 (SD = 44.1) and 77.89 (SD = 47.2), respectively. Tables I and II present an overview of the nonparametric test results confirming the differing child functioning outcomes on the basis of the therapist’s orientation toward strength-based practice.
Parent Satisfaction
The mean CSQ-8 score for study participants at follow-up was 27.06 (SD = 13.29), just slightly below the norm-group mean for this instrument of 27.09 (SD = 4.01) (Nguyen, Attkisson, & Stegner, 1983). Parent satisfaction for experimental subjects (M = 27.68; SD = 5.05) was higher than that for control subjects (M = 26.48; SD = 4.9), although the difference between treatment groups on this measure was not significant. Further analysis of the parent satisfaction data focused on the difference in CSQ-8 scores between cases in which discussion of BERS results with clients and/or parents was documented in case records versus those in which such documentation was not present, including control cases. (As will be discussed below, a distinction between experimental cases on the basis of adherence to this element of the BERS assessment protocol is important.) The Kruscal-Wallis test revealed a significant difference between these groups on the CSQ-8 (χ2 = 4.63, df = 1, p = .031), with cases in which BERS discussion was documented evidencing higher parent satisfaction scores (M = 29.05, SD = 3.05) than those in which such discussion of youth strengths was not noted (M = 26.29, SD = 5.41).
Strength-Based Assessment with Children and Adolescents 295
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296 Cox
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Strength-Based Assessment with Children and Adolescents 297
Treatment Retention
Unplanned or premature termination of services occurred in 20% of the total cases in the study sample. A lower percentage of experimental cases ended prematurely (16%) than control cases (37%), but the between group difference here was not significant. Similarly, a lower premature termination percentage was found for cases in which discussion of BERS results with the client and/or parent was documented (9%) than those in which this notation was not present in case records, including control cases (25%).
The percentage of scheduled appointments missed by participants over the 6-month study period ranged from 0 % to 67% (M = 13%). While experimental subjects evidenced, on average, a lower percentage of missed appointments than their control counterparts (10.4%; 14.5%, respectively), these groups did not differ significantly on this service variable. A significant difference in the percentage of missed appointments was found, however, between cases in which BERS dis- cussion with clients was documented and those in which this notation was absent from case records (χ2 = 4.72, df = 1, p = .03). The former group had a lower mean percentage of appointments cancelled or not attended (8%) than the latter (14%).
DISCUSSION
The purpose of this study was two-fold: (1) test the effectiveness of strength- based assessment, as performed using the Behavioral and Emotional Rating Scale (BERS) and (2) explore the impact of therapist orientation toward strength-based practice on proximal and distal outcomes. Results of the experiment revealed that youth receiving strength-based assessment did not make significantly greater gains in functioning than those receiving the usual deficit-focused assessment pro- tocol. This “no difference” finding is not surprising, given that major studies of children’s mental health system reform (Bickman, 1996; Bickman, Sommerfelt, Firth, & Douglas, 1997) and of promising clinic-based treatment interventions (Weisz, Weiss, & Donenberg, 1992) have failed to demonstrate substantial effects on child and adolescent functioning. Of particular interest in the present investiga- tion, is that therapist orientation toward strength-focused service (encompassing attitudes and reported use of strength-based intervention) modified the impact of assessment type on parent reported changes in child symptomotology and functional impairment over time. Youth provided BERS assessment demonstrated statistically significant treatment gains (as measured by the CBCL) when, and only when, they received services from a highly strengths-oriented therapist. In con- trast, children provided the traditional assessment protocol evidenced such gains when, and only when, they received services from a provider scoring medium or low in strengths-orientation. This finding suggests that the therapeutic process is benefited by the use of a standardized strength-based assessment measure only
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when providers value the data it generates. It falls short of confirming that youth with serious emotional or behavioral disturbance make greater improvements in treatment when provided strengths-based assessment.
Along with this practitioner effect, fidelity or adherence to the experimen- tal protocol emerged as an important intervening variable in this investigation. Treatment fidelity has been defined as “confirmation that the manipulation of the independent variable occurred as planned” (Moncher & Prinz, 1991, p. 247). The assessment of fidelity in the present project, conducted primarily through record review, revealed that the BERS was administered to the parent or guardian of all experimental subjects, scored and returned to the clinician with a complete pro- file of standard scores and written recommendations for treatment. Additionally, monthly meetings were held over a 4-month period with participating therapists for the purpose of discussing BERS results and exploring interventions that could be used to build on child strengths identified. However, only 56% of the experimental case records contained notation indicating that the BERS results were discussed with the client and/or parent in session for purposes of treatment planning or intervention. Not surprisingly, the therapist’s orientation toward strength-based practice appeared to have some bearing on the likelihood of this disclosure oc- curring, with highly strength-based clinicians sharing BERS results with 67% of their experimental clients and therapists scoring moderate or low in strengths orientation doing so with a lower proportion (58% and 40%, respectively). These findings beg the question as to whether experimental subjects would have demon- strated significantly greater child functioning outcomes than their control group counterparts, had their therapists more consistently incorporated BERS results into service planning and delivery. Further research utilizing enhanced implementation controls is needed to further explore this question.
The significance of adherence levels was apparent in data pertaining to parent satisfaction and treatment retention. Analysis revealed that subjects assigned to the experimental condition (for whom it’s clear only that administration of the BERS took place) did not differ significantly from control subjects on either de- pendent variable. However, youth for whom BERS results were not only obtained by the investigator but also shared in treatment sessions by the clinician (hereto- fore referred to as the High BERS Adherence Group) did differ significantly on these variables from youth for whom BERS data was either not gathered or not discussed. This latter group of subjects (heretofore referred to as the No/Low BERS Adherence Group) included those in the control group, as well as those in the experimental group for whom documented disclosure of BERS results with client/parent, a prescribed element of the strength-based assessment protocol, did not occur. The formation of the No/Low BERS Adherence Group on an a priori basis was founded on the premise that subjects for whom BERS results were not disclosed in session had an experience with the therapeutic process that was more similar to that of control clients than to experimental clients for whom BERS
Strength-Based Assessment with Children and Adolescents 299
results were incorporated into the treatment process. Results revealed that the High BERS Adherence Group did evidence significantly greater parent satisfaction and significantly lower rates of missed appointments than the No/Low BERS Adher- ence Group. These findings indicate that the BERS must not only be administered to parents, but scored and utilized in the process of treatment in order for improve- ments in parent satisfaction and treatment retention to occur. They also imply that the adoption of such strength-based assessment tools by mental health programs does little to enhance child and family engagement if practitioners fail to recognize their worth or integrate the information they produce over the course of treatment.
It should be recognized, however, that the faithful incorporation of strength- focused protocols in settings dominated by the medical model presents with nu- merous challenges. The professional language used in such service settings centers on disease and disorder, diverting attention away from client capacities (Goldstein, 1992). Reimbursement structures often require practitioners to define problems as personal pathology, thus reinforcing an emphasis on client deficits (Graybeal, 2001). Misunderstanding abounds on the part of administrators and clinicians alike regarding the nature and scope of strengths-based practice. The assertion prevails, as was reflected in therapist comments obtained by the Clinician Survey, that the strengths perspective is naı̈ve or simplistic and downplays real mental health disorders (Saleebey, 1996).
Staff development efforts are sorely needed that assist children’s mental health therapists in viewing clients through a different lens, one that recognizes their resilience and potential. Blundo (2001) notes that such a “re-vision” can be quite difficult for some providers to attain in that it requires them to adopt new frames of reference. Such frames are said to contain constructed meanings that they share with others in their profession. When asked to alter these, some may find it easier to “attach a small aside to an existing frame” rather than make a substantial shift in their perceptions and practices (p. 299). This tendency was apparent in the present study when providers accommodated the administration of the BERS for their clients but failed to utilize the results in a meaningful way. In order to avoid this dilution of strengths-based protocols, providers must be recruited for future effectiveness research that are prepared to make a more fundamental shift in their approach to treatment with children and families.
The findings of this study must be considered in light of its limitations. First, the SBO measure developed for this project demonstrated promise as a tool for assessing the degree to which providers embrace the attitudes and practices con- sistent with the strengths approach. However, its psychometric properties have not been the focus of examination. Further research is needed to determine the validity and reliability of this measure. Second, the external validity of this investigation is limited by the lack of ethnic diversity of the sample. Because the study was performed in a rural region with a sample heavily dominated by Caucasion youth, it is unclear if the results can be extended to ethnically diverse populations and/or
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urban settings. Another methodological limitation pertains to the process of ran- dom assignment utilized. Because it was not feasible at the study site to randomly assign subjects to therapists, they were assigned instead to treatment conditions in which all participating therapists carried cases. In other words, clinicians were crossed with conditions and therefore provided services to both experimental and control clients. This aspect of the research design elevated the risk for diffusion, or the spread of treatment effects from experimental to control groups. To guard against this threat to internal validity in future experimental studies, therapists should be nested within treatment conditions. While this method will not control for all practitioner effects, it could potentially increase treatment integrity. For in- stance, therapists might be assessed regarding their attitudes toward the strengths perspective (possibly using this study’s SBO measure), and those who appear most strength-oriented could be recruited as providers for the experimental con- dition. With on-going therapist training and fidelity controls, this methodological change should result in enhanced capability for the detection of treatment effects attributable to strength-based assessment.
ACKNOWLEDGMENTS
The author gratefully acknowledges the advisement of Ferol Mennen, Ph.D., Devon Brooks, Ph.D., and Niraj Verma, Ph.D., of the University of Southern California, in the development of this research project. This study was also supported by the administration of Shasta County Mental Health in Redding, California.
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