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Two major reform movements have shaped child and adolescent mental health services over the past quarter-century: the Systems of Care movement, and more recently, the movement toward evidence-based practice. Results from several studies indicate that youth served in traditional residential or inpatient care may experience difficulty re-entering their natural environments, or were released into physically and emotionally unsafe homes (Bruns & Burchard, 2000; President's Commission on Mental Health, 1978; Stortz, 2000; Stroul & Friedman, 1986; U.S. Department of Health and Human Services, 1999). The cost of hospitalizing youth also became a policy concern (Henggeler et al., 1999b; Kielser, 1993; U.S. Department of Health and Human Services, 1999). For example, it is estimated that from the late 1980s through 1990 inpatient treatment consumed nearly half of all expenditures for child and adolescent mental health care although the services were found not to be very effective (Burns, 1991; Burns & Friedman, 1990). More recent analyses indicate that at least 1/3 of all mental health expenditures for youth are associated with inpatient hospitalization (Ringel & Sturm, 2001).

As we have discussed, recognition of the specialized needs of children and adolescents has taken place late in many domains. The same could be said with regard to the mental health services research enterprise. Kimberly Hoagwood, a prominent child mental health services researcher and for many years the program officer overseeing the National Institute of Mental Health's services research portfolio in the area of child mental health services research, recently observed that research in this area has lagged behind that for adults by roughly 10 years (Hoagwood, 2005). Indeed, as late as 1999, Burns was calling for the development of a services research agenda for youth with serious emotional disturbances (Burns, 1999).