Doctor of Philosophy (Phd) / Despite general agreement that severely emotionally disturbed children and adolescents are an "at risk" group, and that ongoing evaluation and research into the effectiveness of services provided for them is important, very little outcome evaluation actually takes place. The absence of well-conducted and appropriately interpreted studies is particularly notable for day or residential treatment programs, which cater for the most severely emotionally disturbed youths. This thesis outlines the main areas of conceptual, pragmatic and methodological confusion and neglect which impede progress in research in this area. It argues for plurality of data analytic strategies and research designs. It then critically reviews the reported findings about the effectiveness of day and residential treatment in specialist facilities, and the predictors of good outcomes for this treatment type. This review confirms that there is very little to guide practice. Having argued for the legitimacy of its methods and the necessity to address basic questions, the thesis reports the results of a naturalistic study based on data accumulated during a decade-long evaluative research program taking place at Arndell Child and Adolescent Unit, Sydney. The study addresses the question of what child, family and treatment variables predict outcome for 159 children and adolescents treated at this facility from 1990 to 1999. Statistically significant results with large effect size were obtained. Among the most disturbed subgroup of forty three children, (a) psychodynamic milieu-based treatment was shown to be more effective than the “empirically-validated” cognitive-behavioural treatment which superseded it in 1996, and (b) children from step-families showed better outcome than those from other family structures. Furthermore, it was found for the study sample as a whole that severe school-based problem behaviours were associated with a limited trajectory of improvement in home-based problem behaviour. These results are discussed with regard to implications for treatment, research methodology, policy and further studies.

Syftet med denna studie är att utvärdera ett HVB-hem vilket bedriver miljö- och individualte-rapeutisk behandling av ungdomar i åldrarna 16-19 år. Vidare syftar studien till att utvärdera verksamhetens arbetssätt vid kritiska händelser enligt critical incident-metoden. Således fin-ner författarna följande frågeställningar relevanta för utvärderingen: Vilka slags kritiska hän-delser uppstår i verksamheten enligt personalens upplevelser? Hur löses/slutar de kritiska händelserna i verksamheten? Är lösningarna av de kritiska händelserna förankrade i miljöte-rapeutisk teori? Utvärderingen grundas i uppgifter från nio respondenter, varav en av respondenterna är utvärderingens författare. Datainsamlingen utgörs i sin tur av observationer, frågeformulär och kompletterande intervjuer. Materialet består av 50 stycken kritiska händel-ser varav 47 händelser redovisas i tabeller under resultat och analys samt kopplas till miljöte-rapeutisk teori och tidigare forskning. I materialet framkommer sex stycken kärnproblem: hot och våld, yrkesroll och arbetsgrupp, alkohol och narkotika, bryter mot verksamhetens struk-tur, ungdomar mot arbetsgruppen samt förändring hos enskild ungdom. Analysen av resultatet visar på att samtliga lösningar i utvärderingen är förankrade i miljöterapeutisk teori. / The purpose of this study is to evaluate an institution which carries out milieu and individual therapy regarding youth. Furthermore, the purpose of this study is to evaluate the way of working in critical situations according to critical incident-method. Therefore, the author found the following questions relevant to this evaluation: Which sort of critical situations arise according to employee’s experiences? How can we solve these critical situations within the operation? Are the solutions of these critical situations anchored to the milieu therapeutic theory? The evaluation is based upon information from 9 respondents, of which one of the respondents is the evaluator’s writer. The collected information represents observation, question formulas and supplementary interviews. The material consists of 50 critical situations in which 47 situations account for tables under the result of analysis plus connection to the milieu therapeutic theory and earlier research. In the material 6 core problems emerge: threats and violence, occupational roll, and work groups, alcohol and nar-cotics break towards the operational structure, youth towards work groups and shifts in indi-vidual youths. The result shows that all solutions are supportive of the milieu therapeutic theory.

Doctor of Philosophy (Phd) / Despite general agreement that severely emotionally disturbed children and adolescents are an "at risk" group, and that ongoing evaluation and research into the effectiveness of services provided for them is important, very little outcome evaluation actually takes place. The absence of well-conducted and appropriately interpreted studies is particularly notable for day or residential treatment programs, which cater for the most severely emotionally disturbed youths. This thesis outlines the main areas of conceptual, pragmatic and methodological confusion and neglect which impede progress in research in this area. It argues for plurality of data analytic strategies and research designs. It then critically reviews the reported findings about the effectiveness of day and residential treatment in specialist facilities, and the predictors of good outcomes for this treatment type. This review confirms that there is very little to guide practice. Having argued for the legitimacy of its methods and the necessity to address basic questions, the thesis reports the results of a naturalistic study based on data accumulated during a decade-long evaluative research program taking place at Arndell Child and Adolescent Unit, Sydney. The study addresses the question of what child, family and treatment variables predict outcome for 159 children and adolescents treated at this facility from 1990 to 1999. Statistically significant results with large effect size were obtained. Among the most disturbed subgroup of forty three children, (a) psychodynamic milieu-based treatment was shown to be more effective than the “empirically-validated” cognitive-behavioural treatment which superseded it in 1996, and (b) children from step-families showed better outcome than those from other family structures. Furthermore, it was found for the study sample as a whole that severe school-based problem behaviours were associated with a limited trajectory of improvement in home-based problem behaviour. These results are discussed with regard to implications for treatment, research methodology, policy and further studies.