From Research to Practice: The C-DISC in Clinical Services
William F. Bacon, Ph.D.
The
C-DISC in Clinical Services is a
multi-year, NIMH-funded study examining the impact of introducing a
standardized, computerized assessment procedure into the intake process of
community-based mental health clinics.
The study has been described in considerable detail in previous issues
of the Center’s journal Practice & Research (Fisher & Jackson, 1994; Bacon, 1997). This article summarizes the
study and describes some analyses that are underway.
The
Computerized Diagnostic Interview Schedule for Children (C-DISC) was developed
in recent years by the National Institute of Mental Health and has already
proven its usefulness for research purposes.
It is a reliable, valid, and inexpensive means of identifying
psychiatric disorders and psychological symptoms in children and adolescents
(Shaffer et al., 1993; Piacentini et al., 1993). The present study was designed to determine
whether the C-DISC can be of value in clinical services. It involves introducing the instrument into
the child-client intake process at a number of Madeleine Borg Community
Services (MBCS) outpatient mental health clinics of the Jewish Board of Family
and Children’s Services (JBFCS). Seven
MBCS clinics, located in four of the five boroughs of
To
test the value of the C-DISC in clinical services, the instrument was
administered to a sample of children and their caretakers prior to their being
seen for initial intake interviews by a JBFCS clinician. For each participating client, a
computer-generated C-DISC report, including probable and possible diagnoses and
endorsed symptoms, was presented to the intake clinician before the first scheduled
meeting with the child and caretaker.
The chief question of the study is whether clinicians’ diagnostic
practices or treatment recommendations are influenced by the availability of
the C-DISC reports. The study also
examines clinicians’ subjective impressions of whether the reports are helpful and useful, and whether the clients’
satisfaction with the intake process is affected by the addition of a C-DISC
interview.
Data
collection began with a prospective baseline phase in order to gather information
on diagnostic and treatment practices of the participating clinicians prior to
the introduction of the C-DISC. This
phase of the study ran from September 1995 to August 1997 and included various
changes in the experimental design and procedures in response to challenges
faced in implementing the study. In all,
data were collected during the prospective baseline phase on 142 child intake
cases seen by 52 clinicians.
The
experimental phase of the study began in December 1997 and was completed in
June 1999. Twenty-two clinicians in four
MBCS clinics participated in the experimental phase. Study staff conducted 194
interviews (97 children and 97 caretakers) prior to intakes with participating
clinicians. For each case, information
was also collected from the children, caretakers, and clinicians at the
conclusion of the intake visit. Children
and caretakers reported on the client’s symptoms and their satisfaction with
the intake process; clinicians provided information about symptoms, diagnoses,
and treatment recommendations for the client.
Similar information was also collected on 96 control cases—children and
caretakers who underwent the standard intake procedure without the addition of
a C-DISC interview.
The
study is currently in the final stages of data collection. C-DISC staff are in
the process of collecting retrospective baseline data—examining case records of
child intakes seen by participating clinicians before their first participation
in the C-DISC study. These data will
show whether clinician diagnostic practices (during the prospective baseline
phase) changed as a mere result of being observed, which will help clarify
inferences about which effects are attributable to the introduction of the
C-DISC. Data analysis will begin when
data collection is completed, which is expected to be in the spring of 2000.
The majority of the study hypotheses are to be tested using a mixed model
nested-factorial design (method nested within clinicians and then within
clinic) in which the assessment method (C-DISC or checklist) is treated as a
fixed effect and the clinics and clinicians are treated as random effects.
Along with the core hypotheses
concerning the effects of the C-DISC on diagnostic practices and on
satisfaction with the intake appointment, data from the study may be used to
examine a number of other research questions.
For example, after indicating their level of satisfaction with their
intake appointment on the post-intake checklist, clients, caretakers and
clinicians also provided open-ended descriptions of the basic problem requiring
clinical attention. Once these
statements are appropriately coded and categorized, it will be possible to
examine the concordance between problems as described by parents, caretakers
and clinicians, and also to examine whether the C-DISC interview changed how
clinical problems were conceptualized by any of the parties.
The
data set on diagnoses as assigned by the C-DISC and by the clinician is also
very rich and may yield a number of interesting findings. For example, how frequently do clinicians
disregard or reject the diagnoses suggested by the C-DISC? How does client satisfaction vary with
diagnosis or with concordance between clinician and C-DISC diagnosis? C-DISC staff at the Center and at the New
York State Psychiatric Institute will be pursuing answers to these and many
other questions in the coming months.
The study is being conducted under a
subcontract to the Center for the Study of Social Work Practice (
References
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From research to practice: The C-DISC (Diagnostic Interview Schedule for
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