Popping the hood : disruptive behavior disorders, comorbidity, and therapeutic practices in community mental health

Abstract

Comorbidity in usual care practice is often viewed as a barrier to the use of evidence-based treatments. Yet studies of outcome research indicate that comorbid (i.e., the presence of two diagnoses) and multimorbid (i.e., the presence of three or more diagnoses) youth often have comparable outcomes to youth with one diagnosis. In order to examine this issue further, the current study evaluated whether community therapists adjusted their treatment, specifically providing more and a more diverse set of therapeutic practice elements, as a function of (a) type of comorbidity or (b) number of diagnoses. Clinical data from 444 youth with either a pure disruptive behavior disorder (DBD; n=165), a DBD and an attentional disorder (n=164), or a DBD and an internalizing disorder (n=115) receiving intensive in-home (IIH) services from the State of Hawaiʻi, Child and Adolescent Mental Health Division (CAMHD) were examined. Eight measures of practice element (PE) diversity and dosage were compared across diagnostic groups. An additional sample of 569 youth with a pure DBD (n=165), a DBD and only one additional disorder (n=279), or a DBD and two or more additional disorders (n=125) were compared on the same measures. Overall, diversity and dosage of practices did not vary as a function of type of comorbidity but did differ as a function of number of diagnoses. Youth with a DBD and two or more diagnoses (multimorbid) received treatment characterized by more diverse and greater use of therapist practices than the other two groups. Results suggest that multimorbidity, rather than comorbidity, may influence the types and frequencies of practices applied. Limitations and clinical and research implications are discussed.