Profiles and Service Utilization for Children Accessing a Mental Health ...

Journal of Evidence-Based Social Work, 10:338–352, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2012.663676

Profiles and Service Utilization for Children Accessing a Mental Health Walk-In Clinic versus Usual Care Melanie Barwick Research Institute and Learning Institute, The Hospital for Sick Children; Department of Psychiatry and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Diana Urajnik Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada

Linda Sumner and Sharna Cohen Yorktown Child and Family Services, Toronto, Ontario, Canada

Graham Reid Psychology and Family Medicine, University of Western Ontario, London, Ontario, Canada

Karen Engel Yorktown Child and Family Services, Toronto, Ontario, Canada

Julie E. Moore Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada

Many children and adolescents with mental health problems do not receive the treatment they need. Unmet need raises questions about specific barriers that may prevent service use, and/or the characteristics of children and families who are less likely to receive care. Brief interventions or single– session psychotherapy delivered in a highly accessible manner are methods of addressing the problems associated with waitlists and limited access to care. In the current study the authors offer an exploratory evaluation of the West End Walk-In Counseling Centre for children and youth with psychosocial problems. Children 4 to 18 years of age who accessed the Walk-In Counseling Centre and a comparison group of clients who accessed usual care were assessed at intake, post-treatment, and 3-month follow-up on demographic characteristics, behavioral/emotional adjustment and functioning, client satisfaction, and service use. Children in the walk-in group had more severe behavioral/emotional adjustment and functioning than usual care clients at baseline. At post-treatment, walk-in clients had lower scores on Total Mental Health Problems and Internalizing Behaviors, and exhibited fewer

Address correspondence to Melanie Barwick, Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada. E-mail: [email protected]

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problems across all scales at follow-up. Walk-in clients found the wait time for service more reasonable and at follow-up, felt the service addressed concerns and had higher regard for counselor availability and cultural sensitivity of the service than usual care clients. Service utilization, assessed at post– treatment and 3-month follow-up, showed that both groups were more likely to access mental health and education services rather than health or child welfare services, and were more likely to have used services in the 12 months prior to service than the 3 months following service completion. Walk– in clients had steeper rates of improvement compared to usual care clients despite equivalence in psychosocial functioning at baseline. The walk-in model may be an effective alternative to usual care, particularly for those clients only willing to wait up to 2 weeks for service. Keywords: Service utilization, mental health, walk-in, child mental health

Many children and adolescents who suffer from mental health problems do not receive the treatment they need (e.g., Burns et al., 1995; Farmer, Stangl, Burns, Costello, & Angold, 1999; Offord et al., 1987; Verhulst, & Van Der Ende, 1997). Multiple aspects of treating children with mental health problems require improvement, including overcoming barriers to care and increasing service use (Blais, Breton, Fournier, St.-Georges, & Berthiaume, 2003; McKay, McCadam, & Gonzales, 1996). Recent estimates, based on a combination of epidemiological studies indicate that of the 14% of children with mental health disorders, only 18% of children receive specialized services for their difficulties (Waddell, Offord, Shepherd, Hua, & McEwan, 2002). Certain groups of children, such as those with special needs, immigrant children, those living in certain geographic areas or in disadvantaged economic conditions, and those with different cultural backgrounds may be further at risk of reduced service accessibility (Boydell & Pong, 2003). The implications of untreated mental health problems have become increasingly serious for children, their families, and society. Children who do not receive treatment are at risk for a host of negative outcomes, such as school failure, inadequate family and social functioning, and poor physical health (Costello & Angold, 2000; Waddell et al., 2002). Approximately 50% of untreated childhood disorders persist into adulthood (Hofstra, Van der, & Verhulst, 2000; Tremblay, 1992). This underscores the importance of prevention and early intervention for children who are, or may be, at risk of mental health problems. The issues associated with the unmet need for children’s mental health services raises questions about specific barriers that may prevent service use, and/or the characteristics of children and families who are less likely to receive care. Barriers that inhibit access to services include distance to care, competing time or scheduling demands, and waiting for treatment (e.g., McKay et al., 1996). However, it is important to highlight that accessing children’s services is largely dependent upon parental recognition of, and help-seeking for their child’s problem. Factors that impact parental help-seeking have been identified in the literature, and include lack of parental knowledge of available resources (Zwaanswijk, Van der Ende, Verhaak, Bensing, & Verhulst, 2005), demographic factors (e.g., parent age, education, income; Pavuluri, Luk, & McGee, 1996), and parent psychosocial functioning (e.g., depression; Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, & Leaf, 2000). Furthermore, families who experience social adversity (e.g., family stress, lack of social support) may have difficulty in accessing care. Research shows that children in single-parent or impoverished homes, who experience trauma (e.g., child abuse), and whose families are mobile, are significantly less likely to seek help for their mental health difficulties (Flisher et al., 1997; Kazdin et al., 1997). Perceptions of services—such as unrealistic treatment expectations and dissatisfaction with prior services—can also prevent parents from choosing to use services (McKay et al., 1996; Polgar et al., 2001). Waiting for treatment is a particular focus of concern in the current behavioral health care environment. The use of waiting lists is conventionally viewed as necessary when service capacity is outstripped by demands for treatment (Brown, Parker, Godding, 2002). Health services managers

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are expected to set priorities based on patient need and evidence-based criteria (Ministry of Community and Social Services, South West Region [MCSS-SW], 2001; Noseworthy et al., 2003; Smith, & Hadorn, 2002; Walker, 1998). However, lengthy waiting times for service remain a significant barrier to receiving mental health treatment when and where children and families need it most. Children endure a variety of costs when access to treatment is delayed or prevented through placement on a waiting list. At a minimum, waiting for treatment introduces an additional obstacle to receiving care; it is likely that the use of waitlists compounds existing access difficulties. Waiting may exacerbate mental health conditions, prolong distress, and occasionally lead to death in times of crisis. Many waitlists lack both organization and fairness, having been implemented quickly due to pressing situations and time constraints (Smith & Hadorn, 2002). Given the issues associated with waitlists and the small percentage of children with mental health disorders receiving appropriate care, it is clear that children’s mental health is an aspect of health care that could be improved. Difficulties with service accessibility and the utilization of care for children with mental health difficulties has been emphasized in policy documents aimed at addressing these issues (e.g., BC-Ministry of Children and Family Development [BCMCFD], 2004; Children’s Mental Health Ontario [CMHO], 2004; United States Public Health Service [USPHS], 2000). Decision makers have indicated the need for evidence-based research to advocate for improved services or different forms of services and support (e.g., Canadian Health Services Research Foundation [CHSRF], 1999). Efforts to improve access to mental health services have been undertaken (see Pumariega & Winters, 2003), such as systems-of-care, wraparound intervention (Kamradt, Gilbertson, & Lynn, 2005), and large-scale projects (e.g., Fort Bragg demonstration; Bickman, 2001). However, the dilemma faced by research and practice communities is how best to respond in a cost efficient and timely manner to rising demand and lack of access without compromising the quality of services (Brown et al., 2002; Kroll, 2003). This issue requires a change in thinking about current services in terms of intervention type and mode of delivery. There is a critical need for alternative and effective intervention models that are highly accessible—particularly to capture those children who do not access mental health care. Walk-In Treatment Model Brief interventions or single session psychotherapy delivered in a highly accessible manner are one method of addressing the problems associated with waitlists and limited access to care (e.g., Heather, 1995; Hoyt, 1995; Stallard, 1998); however few empirical studies have been conducted on the effectiveness of single-session psychotherapy interventions and those that have been conducted are inconclusive (Bloom, 2001; Cameron, 2007). One such intervention is walk-in treatment, which is an innovative, new model of mental health service delivery that addresses the growing problem of barriers to service delivery (Clouthier, Fennema, Johnston, Veenendaal, & Viksne, 1997; Miller, & Slive, 2004). Created in Calgary, Alberta under the umbrella of Woods Homes (Slive, MacLaurin, Oakarden, & Amundson, 1995), this unique form of intervention has evolved as service providers have responded to rapid societal change. Over time clients have had increased expectations of convenience and immediacy, which has been accompanied by an expanding need for service (Slive et al., 1995; Talmon, 1990). It is within this framework that an easily accessible form of therapy has been developed. Although no one therapeutic framework is employed, the walk-in model of service delivery is based on a systemic and brief therapy orientation that emphasizes already existing client resources (e.g., social support, client strengths). Interventions are pragmatic, and aim to provide a clear outcome for clients when they leave their single session. The nature of the service eliminates many of the barriers (e.g., waiting) that traditionally prevent access to mental health care. Evidence from clinical practice and prior evaluation work has suggested that mental health walk-in service delivery is successful in achieving better client outcomes (e.g., Cohen & Engel,


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2000; Harper-Jaques, McElheran, Slive, & Leahey, 2008; Slive et al., 1995; Young, 2008; Young, Dick, Herring, & Lee, 2008) and has the potential to be an effective strategy at targeting minority populations (Bobele, Lopez, Scamardo, & Solorzano, 2008). However, despite the relatively lengthy history of brief therapies and single-session counseling (e.g., Boyhan, 1996; Budman & Gurman, 1988; Clouthier, Fennema, Johnston, Veenendaal, & Viksne, 1996; Hoyt, Rosenbaum, & Talmon, 1992; Miller, 1998; Miller & Slive, 2004; Slive, McElheran, & Lawson, 2008), few outcome studies using standardized measures have focused on the effectiveness of walk-in service for children and youth presenting with psychosocial problems (Cameron, 2007; Perkins, 2006). Yorktown Child and Family Centre: West End Walk-In Counseling Centre The West End Walk-In Counseling Centre located at Yorktown Child and Family Centre (YCFC) was established in 1999 in response to the growing need for immediate and accessible treatment— particularly in the former City of York, which has traditionally been a high-risk and under-serviced area. The walk-in service is operated as a partnership of children’s mental health agencies (YCFC, Oolagen Community Services, COSTI immigrant social service agency) and is partially funded by the United Way. Adapted from the Slive et al. (1995) walk-in model (Calgary, Alberta, Woods Homes), the goal of the service is to provide high-quality, accessible treatment. Service delivery entails immediate access to culturally relevant counseling, provided at no cost to clients. The walkin consultation format allows clients to receive help at their chosen time of need. An appointment or referral is not necessary, there is no lengthy intake process, and the service operates during evening hours. The model also emphasizes community capacity through a Community Volunteer Therapist Program. This program trains clinicians in the use of the walk-in model in exchange for service. The nature of the service eliminates barriers (such as waiting for treatment) that traditionally prevent access to mental health care. Prior evaluations based on client satisfaction, self-report of symptoms, usefulness of services, and anecdotal evidence have suggested that this type of service delivery is successful (e.g., Cohen & Engel, 2000; Harper-Jaques et al., 2008; Miller, 2008; Slive et al., 1995; Young, 2008; Young et al., 2008). Preliminary evaluations found that the center provided an accessible, immediate therapeutic response to a high level of need. A diverse range of ethno-specific and special needs clientele received help for a variety of mental health problems—at their chosen time of need. The center was an important first point of access for those children and families who had not had previous counseling. Clients expressed a high level of satisfaction with treatment and an improvement in the problem that had brought them to the service (e.g., child behavior issues; YCFC, 2003; Miller, 2008; Miller & Slive, 2004). Clients were also largely satisfied with the structure (e.g., no-cost, no appointment or waiting list) and culturally relevant/respectful nature of the service provided, and its usefulness in addressing their needs. However, there is no clear and composite profile of the mental health characteristics of children/ youth who access this model of care. Standardized assessment of the psychosocial adjustment/ outcomes of children receiving walk-in service has not been undertaken (Miller & Slive, 2004). Few outcome studies have used standardized measures to assess walk-in service for children with psychosocial difficulties (e.g., Perkins, 2006), despite the documented success of brief and singlesession therapies (e.g., Boyhan, 1996; Budman, & Gurman, 1988; Clouthier et al., 1996; Hoyt et al., 1992; Miller, 1998; Miller & Slive, 2004; Slive et al., 2008).

Current Study The current study is an exploratory evaluation of the West End Walk-In Counseling Centre for children and youth with psychosocial problems. Through this study the authors contributes to the

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evidence base on alternative sources of mental health service delivery and help-seeking among children and families. Delineating the service pathways of walk-in clients—in addition to those who have accessed usual care—can provide important information with which to inform efforts aimed at service accessibility and coordination. Moreover, the model may prove to be an effective strategy to reduce waitlist bottlenecks throughout the provincial system. The authors objectives included: (1) describe the mental health characteristics of walk-in and the usual care child and youth clients; (2) compare the psychosocial adjustment over a 3-month period of time of walk-in clients with those accessing standard care at Yorktown Child and Family Centre; and (3) describe the service utilization of walk-in clients prior to and following walk-in service delivery.

METHOD Sample Participants in the walk-in group were children and youth (4 to 18 years) who accessed the WestEnd Walk-In Counseling Centre, from October 11, 2006 to December 31, 2008. Of the 151 eligible walk-in clients, 112 agreed to participate, representing a 74.2% recruitment rate at baseline (parent and youth informants combined). Of the112 who participated at baseline, 68 completed the post service measures at follow-up (60.7%). Forty-six of these clients continued with the 3-month interview (n D 40 parent informants, n D 6 youth informants with full assessment data). Fourteen of the 44 clients that did not complete the post interview completed the 3-month interview, for a total of 60 interviews at the 3-month follow-up. Therefore, 53.6% of recruited clients completed the study. The comparison group or the YCFC usual care group was comprised of clients (4 to 18 years) who accessed service via the standard intake process at YCFC for the CORE Counseling Program. Among usual care clients, 60 of 157 of eligible clients agreed to participate (38.2%). Of these clients, 32 completed the post interview, and 26 were interviewed at the 3-month assessment point (22 parents and 4 youth). Twelve additional clients who had not completed the post-test interview completed the 3-month assessment for a total of 38 completed 3-month interviews (63.3% of participants). Procedure Participants in the walk-in group were recruited on an iterative basis as they entered the WestEnd Walk-In Counseling Centre during two weekday evenings (Monday, Wednesday). Study recruitment for the usual care group occurred at intake; at Yorktown this is the client’s Initial Client Consultation (ICC) meeting with a therapist which typically occurs within two weeks of the initial call for service. Measures Demographic information. The Client Intake Information (CII) form is a standard intake sheet that gathers demographic data for walk-in center clients. Demographics characteristics consisted of child age, gender, parent/guardian age, gender, education, income, marital status, and cultural background. The form also captures information about the number of adults and children present, and whether the current visit is the first time the family has visited the walkin clinic. Walk-in clients completed this form at intake. For the usual care group, demographic information was also collected at intake as part of the standard intake process (computerized intake).


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Brief Child and Family Phone Interview (BCFPI). The BCFPI version 3 (Cunningham, Pettingill, & Boyle, 2003) is a standardized measure of behavioral/emotional adjustment, and functioning for children 3 to 18 years of age. The measure has a total of 51 items which are collapsed into four scales: Externalizing Behaviour (18 items), Internalizing Behavior (18 items), Impact on Child Functioning (8 items), and Impact on Family Functioning (7 items). The Externlizing and Internalizing Behavior scales combine to create a Total Mental Health Problems scale (36 items). The Externalizing Behaviour scale is a composite measure that is made up of three subscales: Regulating Attention, Impulsiveness and Activity Level; Cooperativeness; and Conduct. The Internalizing Behaviour composite scale includes three subscales: Separation from Adults, Managing Anxiety, and Managing Moods. Impact on Child Functioning assesses the extent to which problems have adversely affected the child’s social participation, quality of social relationships, and school achievement. The Impact on Family Functioning Scale includes items describing family activities and family comfort and assesses how the child’s behavior affects family interactions. An interviewer administers the measure to a parent or adolescent by telephone or in-person, which takes approximately 30 minutes. The BCFPI was completed by parents or youth at baseline, via phone at post-test (two weeks after the baseline assessment) and at the 3-month follow-up assessment. The BCFPI’s items were derived from the survey measurement tools of the Ontario Child Health Survey (OCHS; Boyle et al., 1993; Boyle, Offord, Racine, Szatmari, & Fleming, 1993). The psychometric properties of the measure have been well-established with samples of community and clinic referred children derived from the OCHS, with Cronbach’s alphas ranging from .75 to .86 (Cunningham & Boyle, 2006; Cunningham et al., 2002). Reliability for the current study was in a similar range: Externalizing Behaviour (alpha D 0.82); Internalizing Behaviour (alpha D 0.86); Child Functioning (alpha D 0.74); and Family Functioning (alpha D 0.77). The instrument is a mandated tool in Ontario for approximately 110 funded providers of children’s mental health services (Barwick, Boydell, Cunningham, & Ferguson, 2004), and thus provides comparison against provincial, regional, and Yorktown norms. The responses were normed to have a standardized distribution with a mean of 50, and a SD of 10; scores of 70—higher than 98% of the norming population—are considered to be significantly elevated, or within the “clinical” range. Client satisfaction. A Client Satisfaction Questionnaire (CSQ) was used to assess participant satisfaction with the services received from the walk-in center. Clients were asked to indicate: the extent of service usefulness, overall satisfaction, whether they would recommend the counseling center, whether the service was respectful of cultural values, the importance of being able to see a counselor without an appointment, and what they consider is a reasonable amount of time to wait to get help. All responses were on a four-point scale, with high scores indicating greater satisfaction, with the exception of an item that assessed perceptions of wait time for service (seven-point scale). Higher scores for this item represented a longer length of time. The CSQ measured standard client care satisfaction. Participants completed the CSQ after the first session with the clinician and at the 3-month follow-up. Service use. Service use was captured through the use of a semi-structured interview (Reid et al., 2005). This interview assessed help-seeking behavior/trajectory of service use in the community. Assessments of formal service utilization included: type of agency/provider (e.g., Children’s Mental Health Centre, private practitioner), sector (e.g., education, health, mental health), services received, and number of contacts with a service provider within the last 12 months. Respondents also reported informal sources of help (e.g., help received from family). The interview items were guided by the Ontario Child Health Study-Revised (OCHS-R; Boyle et al., 1987), the Child and Adolescent Services Assessment (CASA; Ascher, Farmer, Burns, &

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TABLE 1 Demographic Characteristics by Group

Youth age Youth gender: Male Youth immigrant Parent age Parent gender: Male Parent immigrant Family type: Single parent Family income below $40,000

Walk-In Group N D 94

YCFC Group N D 56

Group Differences t-test

10.5 (SD D 3.87) 52.1% 84.1% 39.0 (SD D 8.4) 12.8% 56.2% 58.5% 57%

10.4 (SD D 3.64) 64.3% 85.5% 38.9 (SD D 9.1) 5.4% 48.2% 64.8% 70%

0.20 1.34 0.22 0.05 1.61 0.93 0.75 1.24

Note. No significant differences by group.

Angold, 1996), Services Assessment for Children and Adolescents (SACA; Stiffman et al., 2000). These widely used measures of service utilization (or service use items in the case of the OCHSR), have well-established psychometric properties (e.g., Burns et al., 1995; Farmer et al., 1999; Waddell et al., 2002). Participants in the walk-in and usual care groups completed the measure of service use at post-test and the 3-month follow-up.

RESULTS Demographic Characteristics Demographic information by group is presented in Table 1. The average age of the children was similar across groups: 10.5 years of age for the walk-in group and 10.4 years for the YCFC usual care group. Overall there were more males (n D 85) than females (n D 65). This was particularly true in the YCFC group (males D 36; females D 20) compared to the walk-in group (males D 49; females D 45). Parents’ average age was 39 years (walk-in: mean D 39.0; SD D 8.4; YCFC: mean D 38.9; SD D 9.1). Informants were predominately female (e.g., mothers), but there were more males in the walk-in than the YCFC group (walk-in female D 87.2%, male D 12.8%; YCFC female D 94.6%, male D 5.4%). Around half of parent informants (walk-in D 56.2%; YCFC D 48.2%) were from countries other than Canada (e.g., immigrants), whereas the majority of the children were born in Canada (walk-in: n D 84.1%; YCFC: n D 85.5%). Most parents reported English as the primary language spoken in the home (walk-in D 80% vs. YCFC D 84%). The majority of the children were from single-parent families (60.8%)—with a larger percentage of YCFC single-parent families (64.8%) than walk-in (58.5%). Seventy percent of YCFC families had annual incomes of less than $40,000 compared to 57% of walk-in families. No significant demographic differences were found between clients in the walk-in group and the usual care group. Baseline Psychosocial Adjustment Baseline measures of psychosocial adjustment were assessed using four composite scales from the BCFPI and the Total Mental Health Problems scale, baseline scores are presented in the top panel of Table 2. The BCFPI is normed to have a mean of 50 and a standard deviation of 10; scores above 70 are considered to be significantly elevated or in the “clinical” range. At baseline,


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TABLE 2 Means and Standard Deviations of Psychosocial Outcomes over Time by Group

Scale Baseline Total mental health problems Externalizing behaviors Internalizing behaviors Child functioning Family functioning Post-Test Total mental health problems Externalizing behaviors Internalizing behaviors Child functioning Family functioning Follow-Up (3 months) Total mental health problems Externalizing behaviors Internalizing behaviors Child functioning Family functioning

Overall with Complete Data Mean (SD)

Walk-In Group Mean (SD)

YCFC Group Mean (SD)

N D 62

N D 94

N D 56

66.0 67.9 60.1 67.0 73.4

(10.0) (11.2) (11.5) (15.4) (23.5)

N D 62 62.3 62.2 59.6 63.7 68.5

(10.7) (11.4) (12.4) (15.2) (19.7)

N D 62 58.9 59.0 58.2 61.0 63.7

(14.4) (13.6) (11.1) (15.4) (17.3)

67.7 67.7 63.5 67.6 73.3

(11.8) (11.8) (13.5) (13.3) (24.0)

N D 57 59.1 58.8 57.3 60.8 65.4

(10.4) (10.2) (11.7) (14.1) (19.6)

N D 51 56.4 56.0 55.2 57.0 59.0

(11.2) (12.0) (10.4) (14.3) (16.4)

65.9 65.4 62.7 66.1 70.2

(11.0) (11.6) (13.8) (15.8) (15.7)


0.96 1.32 0.36 0.60 0.94

N D 28 65.4 63.5 63.9 66.5 70.4

(11.3) (13.2) (13.5) (15.6) (17.8)

2.55* 1.81 2.30* 1.69 1.08

N D 33 64.5 64.6 63.5 64.5 68.8

(16.3) (13.1) (11.4) (13.7) (18.0)

2.70** 3.09** 3.44** 2.40* 2.61*

*p < .05. **p < .01.

children in the walk-in group had a mean score of 67.7 (SD D 11.8) for the Total Mental Health Problem scale, 67.7 (SD D 11.8) for the Externalizing Behaviours, 63.5 (SD D 13.5) for the Internalizing Behaviours, 67.6 (SD D 13.3) for the Child Functioning, and 73.3 (SD D 24.0) for the Family Functioning scale. The baseline scores for the YCFC group were 65.9 (SD D 11.0) for the Total Mental Health problems, 65.1 (SD D 11.6) for Externalizing, 62.7 (SD D 13.8) for Internalizing, 66.1 (SD D 15.8) for Child Functioning, and 70.2 (SD D 15.7) for Family Functioning. No significant group differences were found at baseline on any of the composite scales; however, children in the walk-in groups were higher on all BCFPI subscales.

Attrition Analyses All further analyses were run using only respondents with complete data (walk-in: n D 40; YCFC: n D 22). Therefore, attrition analyses were run to compare participants with complete data to those without complete data on demographic characteristics and baseline psychosocial adjustment. No significant differences by group on any of the demographic characteristics (youth age, youth gender, youth immigrant status, parent age, parent gender, parent immigrant status, family type, or family income). There were no significant differences on four of the five BCFPI scales (Total Mental Health Problems, Externalizing Behavior, Child Functioning, and Family Functioning); a significant difference was found for Internalizing Problems (p D .02), such that youth with complete data had significantly fewer Internalizing Problems (60.1) than youth without complete data (65.4) at baseline.

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TABLE 3 Repeated-Measures ANOVA: Main Effects by Group and Time and Interaction of Time by Group Scale

Main Effect of Group

Total mental health problems Externalizing behaviors Internalizing behaviors Child functioning Family functioning

F F F F F

D D D D D

5.17* 4.47* 4.33* 2.36 0.77

Main Effect of Time F F F F F

D D D D D

8.40*** 20.72*** 1.04 3.47* 6.22**

Time by Group Interaction F F F F F

D D D D D

5.05** 7.20** 8.63*** 7.58** 7.69**

*p < .05. **p < .01. ***p < .001.

Psychosocial Adjustment over Time Means and standard deviations for the BCFPI scales at post-test and follow-up are presented in the bottom two panels of Table 2. Group comparisons were conducted with the walk-in group and the YCFC group for each of the measures. At post-test, group differences were found for Total Mental Health Problems (p D .013) and Internalizing Behaviors (p D .024), such that children and youth in the Walk-In group had lower scores on both scales. At follow-up there were significant group differences on all five scales (p < .05) with the walk-in group exhibiting fewer problems than the YCFC group for all scales. A repeated measures ANOVA was used to assess changes in mental health outcomes over time using baseline, post-test, and 3-month follow-up assessments for the composite BCFPI scales for clients with complete data. The model included group as a between-subject factor, time as a within-subject factor, and the interaction between group and time. Table 3 presents the results of the repeated measures ANOVA. The interaction between time and group was significant for all domains: Total Mental Health (F2;120 D 5.05, p D .008, partial eta2 D .08); Externalizing Behaviours (F2;120 D 7.20, p D .001, partial eta2 D .11); Internalizing Behaviours (F2;120 D 8.63, p D .000, partial eta2 D .13); Child Functioning (F2;120 D 7.58, p D .001, partial eta2 D .11); and Family Functioning (F2;120 D 7.69, p D .001, partial eta2 D .12). When an interaction is significant in a repeated-measures ANOVA, the main effects for the variables included in the interaction should not be examined. As the interactions between time and group were significant for all outcomes, the main effects for group and time will not be interpreted. To interpret the results of the interactions, the means over time by group are presented in Figure 1 for each of the four composite scales. In all cases, the walk-in group had steeper rates of decline on the BCFPI than the YCFC group. This reflects the greater extent of improvement for the walk-in children over time as compared to the YCFC clients. Furthermore, there was slippage (an increase in problems) for the Internalizing, Child Functioning, and Family Functioning scales for YCFC clients at the time of the second assessment. Client Satisfaction Participants completed the Client Satisfaction Questionnaire at baseline and at the three-month follow-up (Table 4). At baseline, only one of the items was significant, the length of time the client feels is a reasonable amount of time to wait for help (p < .001). At follow-up five of the six questions were significantly different by group: compared to the YCFC group, walk-in clients were more likely to report that the center addressed their concerns (p D .007), that they would recommend the center to a friend (p D .026), that the center was culturally respectful (p D .001), and that they thought being able to walk in and see a counselor was important (p < .001). When asked how long they thought was reasonable to wait to get help, those in the walk-in group


FIGURE 1

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Psychosocial outcomes over time by group.

TABLE 4 Client Satisfaction over Time by Group

Scale Baseline Addressed concerns Overall satisfaction Recommend center Respect cultural values Reasonable wait time Importance of counselor availability Follow-Up (3 months) Addressed concerns Overall satisfaction Recommend center Respect cultural values Reasonable wait time Importance of counselor availability

Walk-In Group Mean (SD)

YCFC Group Mean (SD)

N D 98

N D 44

3.25 3.55 3.73 3.95 3.21 3.84

(0.68) (0.56) (0.51) (0.22) (1.66) (0.42)

N D 45 3.40 3.62 3.75 3.93 2.91 3.96

(0.65) (0.49) (0.44) (0.26) (1.41) (0.21)

3.27 3.61 3.68 3.93 4.80 3.80

(0.76) (0.49) (0.47) (0.26) (1.19) (0.55)


0.20 0.64 0.59 0.46 5.63*** 0.57

N D 31 2.94 3.43 3.47 3.55 4.19 3.58

(0.81) (0.63) (0.57) (0.51) (1.30) (0.50)

2.75** 1.38 2.30* 3.74** 4.02*** 3.93***

Note. Responses are on a 4-point scale from 1 to 4. Responses for “Reasonable wait time” are on a 7-point scale from 1 to 7. *p < .05. **p < .01. ***p < .001.

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FIGURE 2 Percentage of service use by walk-in and YCFC clients.

reported a shorter time (p < .001). There were no differences between the groups on the overall satisfaction question. Service Utilization Service utilization was tracked at post-test and 3-month follow-up. Figure 2 presents the data on service utilization (i.e., contact with mental health service providers) for walk-in and YCFC clients in the 12 months prior to their baseline visit (captured at the post-test), and in the 3 months after the initial contact (assessed at the 3-month follow-up) based on parent informants with complete follow-up data (n D 46 for walk-in; n D 26 for YCFC). Walk-in and YCFC comparison clients were most likely to access mental health and education services as compared to other sectors (e.g., general medical, child welfare). Participants were more likely to have used services in the 12 months prior to the baseline visit than the 3 months following the visit.

DISCUSSION Given the low rate of treatment among children and youth who suffer from mental health difficulties (Waddell et al., 2002), time- and cost-efficient methods of treatment need to be identified and implemented. The walk-in model of service delivery is a highly accessible, brief intervention designed to help clients utilize existing resources after a single session (Slive et al., 1995). In the current study we used a quasi-experimental design to compare children and youth who received care from a walk-in clinic to those who received service as usual. This data has allowed us to track changes in the psychosocial functioning of clients to determine the impact of the service, such as to determine if gains were sustained. At baseline there were no significant group differences on measures of psychosocial functioning. There was a significant interaction between group and time for all psychosocial adjustment scales, such that those in the walk-in group had steeper rates of decline on psychosocial problems over three months than the YCFC group. The extent of change(s) seen for walk-in children versus the YCFC clients may speak to the nature


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of the walk-in model. For example, walk-in clients are choosing to attend the walk-in, to receive help immediately, and this may be indicative of higher readiness for change—a characteristic known to be important relative to behavior change (Prochaska et al., 1994). Moreover, close to 70% (23 of 34 responses) of walk-in clients were only willing to wait upwards of 2 weeks for service, which could be indicative of their perceived sense of urgency. By comparison, usual care clients did not receive treatment immediately, and their baseline measures were taken at intake. Usual care clients have, therefore, not received treatment at the time of baseline, and some clients may still be waiting for treatment at the time of follow-up assessments. Within this context, more than half (60%) of the usual care clients were willing to wait a month or more for treatment (9 of 15 responses). In short, our data provide some empirical support for the immediate behavioral problems and family crises commonly observed for families and children seen at the walk-in upon entry to service, and suggest that the walk-in model may be accessed more frequently by families with problems in these areas, although differences were not significant. Service utilization data for both groups measured at post- and 3-month follow-up showed, not surprisingly, that both walk-in and YCFC usual care group clients reported seeking more treatment from mental health and education services, than from the general medical sector and child welfare prior to seeking service at YCFC. At follow-up, approximately one-third of both groups sought mental health support, suggesting that even walk-in clients still feel the need for, or require mental health services even after a single consultation. Caution must be exercised when interpreting the service use data, as the type or nature of “treatment” was not captured (e.g., could be brief treatment contacts, individual, family counseling). Client satisfaction data suggests that the length of time clients are willing to wait for service is a defining feature, as stated above. Additionally, however, we find that walk-in clients perceive the service addressed their concerns, respected cultural values, and was strengthened by counselor availability compared to usual care clients who waited for service. Walk-in parents appear similar to those identified as Action oriented in a study of the information preferences of parents seeking child mental health services that used a quantitative consumer preference modeling method. Cunningham and colleagues (2008) demonstrated that two out of three types of parents preferred to wait for child mental health information until their child was assessed or treated. A third group of parents—the Action group—were more likely than the Overwhelmed or Information parent segments to prefer information while waiting for treatment. Among the limitations of this study, the biggest challenge was the rate of recruitment of YCFC usual care clients. The number of YCFC clients recruited for baseline assessment was below the planned recruitment rate. There were several reasons for this occurrence, including a clinician shortage that reduced case assignment expectations (e.g., staff turnover), a higher than expected cancellation/no show rate for clients with existing appointments, clients who were not eligible to participate (e.g., due to study inclusion criteria), and clients that clinicians were unable to recruit due to high-risk situations. To help solve this problem, the recruitment strategy was adapted for this group to include clients recruited at the time of agency intake (clients’ first phone call for service). Additionally, there were issues with client retention to the study and collecting post-test and follow-up data. The YCFC group was comprised of clients who attended intake/an initial client meeting, and does not necessarily reflect all clients initially coming to YCFC, or going into service. In other words, the composition of this group of clients who are subsequently placed on a waitlist for service, may represent those who “self-select” (e.g., affected by motivational factors) to come to an initial intake or consultation (“business”) meeting. It may also be that more impaired YCFC clients either go straight to service, or have difficulty in attending intake procedures (meeting included), and that these clients are not fully represented in our sample. A third issue relative to recruitment is that while parents, youth, and families have been increasingly using the Walk-In Counseling Centre, many of the clients accessing the center were adults and couples. Over 60%

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of clients accessing the walk-in during the study period presented with adult issues, and were not eligible for study participation. Lastly, the outcome results presented are based on study clients with complete follow-up data. It is entirely possible that the pattern of results may be different for the whole sample, including those clients with missing follow-up data. All of these real-world context sampling issues must be considered in the interpretation of our findings. This study provides an encouraging view of walk-in service as an alternative to usual care for child and youth mental health. In particular, it appears to provide a service option that may be more desirable to a segment of the client population. Outcomes including psychosocial, service utilization, and client satisfaction are promising.

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