Page 74 - Age of onset of disruptive behavior of residentially treated adolescents -Sjoukje de Boer

psychiatric problems, the sample should be considered heterogeneous. We therefore do not know to what extent the treatment adherence and treatment results were influenced by the comorbid psychiatric disorders. We recommend extending future research to larger groups and examining the effect of specific disorders and comorbidity. Further, a standardized instrument (e.g., Structured Clinical Interview for DSM-IV Axis I Disorders; Spitzer, Gibbon, & Williams, 1998) to reliably assess the psychiatric disorders should be used. Such an instrument was not used in the present study and although the psychiatrists involved have diagnosed conscientiously, this should be seen as a limitation.
Second, because of the naturalistic design with absence of a control group, it is not possible to determine which part of the outcome was attributable to the treatment. Besides, changes in treatment program did occur over time because of experience and new insights. Also, during the 14-year period there were changes in therapists, which obviously must have affected the treatment and hence the treatment outcome. Also, it is not clear what outcomes were in the long term, because no follow- up data were examined.
Third, it would have been informative if specific disruptive behaviors had been assessed over the course of the treatment. Unfortunately, there is a lack of instruments that can be used to measure changes in specific disruptive behaviors in a reliable way. Obviating this by assessing change in externalizing problems between admission and discharge, for example through the Child Behavior Checklist or Youth Self Report (Achenbach & Rescorla, 2001), would also encounter problems. It has been found that the majority of adolescents with disruptive behavior do not report high levels of externalizing problems on such instruments (e.g., Vreugdenhil, Van den Brink, Ferdinand, Wouters, & Doreleijers, 2006).
Querying the parents in this sample would also have created difficulties, because only a portion of them had sufficient insight into how their child was functioning. Prior to the admission, many youngsters have not lived with their parents for a long time. Besides, parents may have been reluctant to cooperate or would be difficult to reach, as was found in research among conduct disordered samples (Colins et al., 2012).
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