A Comparison of Day Treatment and Outpatient Treatment for Children with Disruptive Behaviour Problems* NATALIE GRIZENKO, M.D. 1 , DANIELLE PAPINEAU, M.Sc. 2 AND Ln..IANE SAYEGH, M.Ed. 3 The authors explored the relative merits of outpatient and day treatment for 30 children with severe behaviour prob- lems. The effectiveness of treatment on behaviour, self-- perception, and social and family functioning was assessed. Day treatment was found to be more effective in reducing behaviour problems, alleviating depressive symptoms, increasing social skills and improving family functioning. D ay treatment is presently an established treatment modality for children with behaviour problems (1-4). It has been shown to significantly reduce disruptive behaviour and promote successful reintegration into community schools. Day treatment is also effective in improving the secondary symptoms, such as depression, low self-esteem and poor peer relations, frequently seen in these children (5). Furthermore, it has been shown that children with severe behaviour problems do not simply improve with time (6). Researchers now need to compare the effectiveness of day treatment and other treatment settings, such as outpatient services, taking into account diagnosis, length of stay, the therapeutic modalities involved and their cost. . Outpatient treatment is also effective for children with behaviour problems, for example, weekly family therapy sessions were found to benefit delinquents (7), oppositional (8) and hyperactive children (9). Unfortunately long term outpatient treatment is frequently required. Satterfield (9,10) in his work with multimodal outpatient therapy for hyperac- tive children demonstrated that two to three years of weekly intervention was necessary to produce maximal effect. There has been much research done comparing the differ- ential effectiveness of outpatient and day treatment that would justify the greater expense and staff time required in the latter more intensive modality. Winsberg et al (11) showed that children treated in the community tend to do better than *This research was supported by grant RS-I649 from the Conseil Quebecois de la Recherche Sociale. Manuscript received April 1993. lDirector, Lyall Preadolescent Day Treatment Program, Douglas Hospital, Verdun, Quebec; Assistant Professor, Department of Child Psychiatry, McGill University, Montreal, Quebec. 2Researcher, Lyall Preadolescent Day Treatment Program, Douglas Hospital Centre, Verdun, Quebec. 3psychologist, Lyall Preadolescent Day Treatment Program, Douglas Hos- pital Centre, Verdun Quebec. Can. J. Psycbiatry, Vol. 38, August 1993 432 those treated as inpatients. For example, at 18 months to three years follow-up, they found that 78% of children randomly assigned to outpatient treatment were still living at home, compared with 52% of those assigned to inpatient treatment. Unfortunately, similar studies on day treatment have not been carried out. This prospective pilot study looked at the feasibility of comparing groups of children attending either a day program or an outpatient clinic. The sample consisted of a cohort of patients that did not overlap with those of previously reported studies (5,6). Preliminary results of the relative effectiveness of these two modalities are presented. Method Subjects The sample included 30 children between the ages of six and 12 seeking admission to day treatment or outpatient services of a psychiatric hospital. The day treatment group consisted of 13 boys and two girls, while the outpatient group consisted of 11 boys and four girls. Both groups had a mean age of nine. The children were referred to both programs mainly by school psychologists, social workers and parents. Initially the more disruptive children were referred to the day treatment program, but once the day treatment program was full, the very disruptive children were also admitted to the outpatient program. It is important to note that every year there are many more referrals to the day treatment program than spaces available. The inclusion criteria for participation in the study were being of normal intelligence, having been referred for disruptive behaviour in school or at home, and having a total score on the Revised Child Behavior Profile (RCBP) (12) in the problem zone (70 and over), indicating clinically severe behaviour problems. The subjects were diagnosed by experienced clinicians using the DSM-III-R criteria. Interrater reliability using Kappa was 0.87. The children in the day treatment and outpatient groups had the same distribution of diagnosis: four had attention-deficit hyperactive disorder (ADHD) and 11 had oppositional defiant disorder (ODD). All children with ADHD also had a diagnosis of ODD. All the children with ADHD received methylphenidate throughout treatment in doses ranging from 1.0 to 1.5 mg/kg per day. In both the day treatment and the outpatient groups, eight of the 15 children had failed one academic year. Only one child from the day treatment group was in foster care; all the rest of the children were living at