A Structural Equation Model of Risk Behaviors and the Length of Behavioral Health Services Among Youth with Mental Health Disorders

Background and Purpose: Understanding the association of a strengths- and needs-based approach with the length of stay is critical to guide outcome-oriented interventions. A few studies primarily conducted in congregate care settings predicted a shorter length of stay by the severity of disorders and awareness of treatment need (Megna et al. 2015; Pavkov, Goerge, & Czapkowicz, 1997; Stewart, Kam, & Baiden, 2014). A few studies considered that there is a substantial effect of strengths on behavioral health treatment outcomes (Quiroga & Walton, 2013; Radigan & Wang, 2013). This study aimed to (1) identify the direct and indirect impacts of risks and behavioral/emotional needs, and (2) determine to what extent life functioning and strength domains were mediated.

Methods: The sample included children and youth (ages five through 20) who participated in behavioral health services in Midwestern state. Of children and youth who received services during state fiscal year 2019 (N=8,877), only those who completed services were selected (n=2,363). We used the Child and Adolescent Needs and Strengths (CANS; Lyons, 2009) assessment, which includes six domains: (1) strengths, (2) functioning, (3) cultural factors, (4) caregiver needs and resources, (5) behavioral or emotional needs, and (6) risks. This study focused on the behavioral/emotional, functioning, and strengths domains. Each item has a four-point scale, ranging from 0 to 3. Strength ratings of 0 and 1 were “usable strength”; needs ratings of 2 or 3 were considered “actionable,” indicating needs for services. Confirmatory factor analysis and structural equation modeling (SEM) were conducted to identify direct and indirect effects of risks and behavioral/emotional needs (e.g., suicide, impulsivity, depression, and anger control) on the length of stay. Using the AMOS 26, the model estimation terminated normally within the default convergent criterion. The model fit values were close to the criteria recommended by Hu and Bentler (1999), which confirmed that the hypothesized model globally fits our data.

Results: The results indicated the fully mediated effects of life functioning and strengths between risk behaviors and the length of stay. In this regard, selected risks and social/emotional needs influenced days in the system indirectly but had no direct effect on the length of stays. Life functioning exerted a positive mediation effect (Effect size=.209, p<.001) between behavioral/emotional and risks and days in the system. Similarly, the strength domain presented a positive mediation effect (Effect size=.091, p<.001) between social/emotional and risks and days.

Conclusion and Implications: The findings suggest that positive changes in both life functioning and strength domains were associated with a shortened length of stays in the system. Improvements in life functioning and strength development efforts could lead individuals to achieve shorter stays in the system, potentially leading to earlier mental health recovery. Further research is needed to explore the relationship between strengths, behavioral/emotional needs, risks, cultural factors, caregiver needs, length of services, and outcomes.