Using the DLA 20 to measure functional outcomes in a child and adolescent population Ron Van Treuren, Ph.D. Division Director Seven Counties Services, Inc., Louisville, KY 26th Annual Children’s Mental Health Research and Policy Conference Tampa, FL March 2013

Shifting focus from symptom reduction to functional level … • We are good at measuring symptoms such as anxiety,

depression, behavior check lists, etc. • When presenting symptom reduction data to community

partners they would say, “… that’s interesting, but are they functioning better, are they better able to complete school work, are they more likely to stay in the home or are they at risk of removal …”

• In other words, “ … as a result of our mental health interventions are the children we serve more likely to lead productive and satisfying lives …”

Daily Living Activities: 20 Item Functional Assessment

Youth Version • The DLA 20 provides a means of obtaining a reliable and valid

approximation of the Children’s Global Assessment Scale (Axis V, DSMIV - TR)

• Measures functioning not pathology • Easy to train and administer • Takes 5-7 minutes to complete if you know your client well • There are 4 versions: ▫ Substance Abuse ▫ MR/DD ▫ Adult MH ▫ Youth MH

Daily Living Activities include: Health Practices Housing Stability Communication Safety Managing Time Managing Money Nutrition Problem Solving Family Relationships Alcohol/Drug

• Leisure • Community Resources • Social Network • Sexuality • Productivity • Coping Skills • Behavior Norms • Personal Care/Hygiene • Grooming • Dress

5 Steps to ensure Reliability: 1. Rate only level of functioning that occurred within the last

month. 2. If level of functioning varied, rate the “lowest” level of

functioning within the last month. 3. For each item ask yourself, “is this a strength or a

weakness”. Strengths are within normal limits (5,6,7), weaknesses are not within normal limits (1,2,3,4)

4. If functioning is narrowed down to two points, pick the lowest and move on.

5. If you do not have enough information, do not rate the functioning. If you skip more than 5 items do not complete the DLA 20, it is not valid.

Children’s Global Assessment Scale (Axis V, DSMIV - TR)

• The DLA20 is scored by taking the average and multiplying by 10

• The CGAS ranges from 1 – 100 • The DLA 20 ranges from 1 – 70 • The DLA20 provides an approximation of the

CGAS that standardizes the assessment yielding higher validity and reliability

Children’s Global Assessment Scale Continued …

• Below 50 functioning describes major to serious impairment in several areas (i.e., not within normal limits)

• Above 50 functioning varies from sporadic difficulties or symptoms to functioning optimally (i.e., within normal limits)

• The break point of “50” encourages the clinician to consider short-term outpatient counseling or begin discharge planning

Challenges • The DLA 20 was not integrated electronically

into our EMR ▫ Done on paper and entered into ACCESS Database ▫ Costly in terms of administrative time ▫ Limited data set: Total score on everyone Item analysis limited to specific programs based on

data entry resources • Training and “Booster Training”

Three years focus on School Services FY07; FY09; FY10

School Data from FY07

50.47 52.01

40.00

42.00

44.00

46.00

48.00

50.00

52.00

54.00

56.00

58.00

60.00

T1 T2

DLA

20

SCO

RES

TIME

SCHOOL BASED SERVICES N = 88

t = -2.43, df = 87, p = .017

Preliminary School Based Data from FY09

46.92

49.51

30.00

35.00

40.00

45.00

50.00

55.00

Sep 08 May 09

School Based Services FY09: Greater Than 60 Days

N=198

DLA 20 Scores t = -7.932, df = 197,

p < .0001

3.96

4.57 4.35

4.81

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Sep 08 May 09

School Based Services: FY09 Greater Than 60 Days

N = 193 - 198

Behavioral Norms t = -5.683, df = 192, p < .0001

Problem Solving

t = -6.613, df = 197, p < .0001

School Data from FY10

47.66 48.85 50.35

40

45

50

55

60

Time 1 Time 2 Time 3

SCHOOL BASED SERVICES FY10 DLA 20

Average 228 - 234 days between administration Time 1 - Time 2 - Time 3

DLA 20

Significant increase in functioning over Time N = 68, F = 6.899, df = 2, p = .002

Present series of studies examined services across the full continuum of

care: School Based, Home Based, Community Based, and Office Based

Basic Design: • Pre-Post DLA20 analysis • Focus on new clients only (done at intake) • Minimum of 90 days continuous (3 months) service • Child and Family Population • Sample includes ages 6 – 17 • Continuum of care includes: ▫ Office Based ▫ School Based ▫ Home Based ▫ Community Based

Percentage of Sample by Program

FY11 FY12

School Based,

303, 35%

Brief Tx Unit, 37,

4% WEST, 69, 8%

BHS SOUTH, 86, 10%

TRANS SOUTH, 42, 5%

Western Waller, 111, 13%

Family Recovery Program, 189, 22%

First In Care, 24,

3%

N = 861 School Based,

200, 35%

Brief Tx Unit, 9,

2% WEST,

105, 18%

BHS SOUTH, 96, 17%

TRANS SOUTH,

31, 5%

Family Recovery Program,

47, 8%

First In Care, 87,

15%

N = 576

47.98 49.11 47.54

45.85

50.31

48.35

50.49 50.91 50.76 50.38

55.67

51.39

40.00

42.00

44.00

46.00

48.00

50.00

52.00

54.00

56.00

58.00

60.00

SBS West South FRP FIC Tot C & F

DLA 20 Summary FY 11 Child and Family Jefferson County Data by Site

N = 576

TIME 1 TIME 2

DL

A 20

S

CO

RE

All sites displayed showed a significant increase in DLA 20 scores during FY11, (p < .012)

49.25 48.57 48.19

49.95 49.32

46.70

51.08

49.28

52.51

50.59

53.23 52.93

50.46

52.37

57.92

52.29

40.00

42.00

44.00

46.00

48.00

50.00

52.00

54.00

56.00

58.00

60.00

SBS Brief Tx West South Western FRP FIC Tot C & F

DLA 20 Summary FY12 Child and Family Jefferson County Data by Site

N = 861

TIME 1 TIME 2

DL

A 20

S

CO

RE

All sites displayed showed a significant increase in DLA 20 scores during FY12, (p < .039)

Domestic Violence Program Data

• FY11: t = -0.851, df 30, p = .401 • FY12: t = -1.732, df 41, p = .091 • Not Significant ▫ Sample size was small ▫ Mean scores were in the predicated direction ▫ Three months may not be sufficient with this

population to show meaningful increases in functioning as measured by DLA 20

ACUTE: Child Crisis Services • Analyzed separately due to the brief intensive nature

of the intervention (i.e., crisis stabilization.) • Acute averaged 67.33 days of service which fell

below our minimum threshold of 90 days continuous service

• This team chose several additional items to analyze before we began collecting data ▫ Safety ▫ Coping ▫ Behavior Norms

46.44

51.38

30.00

35.00

40.00

45.00

50.00

55.00

60.00

65.00

70.00

Mean Time 1 Mean Time 2

DL

A 2

0 S

core

Acute DLA 20 Means FY12

N = 39

t = -7.222, df = 38, p <.001

5.16

5.87

3.84

4.39 3.76

4.82

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Mean Time 1 Mean Time 2

DL

A 2

0 I

tem

Ave

rage

Item Analysis DLA 20 Acute FY12 N = 38

Safety Coping Behavior Norms

Safety: t = -4.33, df = 37, p <.001 Coping: t = -4.48, df = 37, p < .001 Behavior Norms: t = -6.10, df = 37, p < .001

Summary and Conclusions • In all programs mean scores were in the predicted range both at

intake (mid 40’s) and at follow-up (mid to low 50’s) ▫ This held true across two independent samples from FY11 and FY12 ▫ This held true across a wide spectrum of services along our continuum of

care (Home, Office, School, Community) • School Based Services comprised nearly 1/3 of our sample and

included elementary, middle and high school students • The DLA has utility for assessing functional outcomes in youth

regardless of developmental stage or age ▫ In completing the DLA20 the assessor must evaluate based on “ … how

often or how well the child independently, as age-appropriate, performed each of the 20 Activities of Daily Living”

▫ This is a training and supervision issue

Next Steps … • Longitudinal follow up • Correlate DLA20 with known

variables ▫ Grades ▫ Attendance ▫ In home placement ▫ Hospital diversion

• Pursue more formal data sharing agreements ▫ School System ▫ DCBS

Contact information: Ron Van Treuren, Ph.D. Division Director Seven Counties Services, Inc. rvantreu@sevencounties.org For more information regarding the DLA 20: http://www.mtmservices.org/DLA20-FAQ.html