The effectiveness of traditional child psychotherapy

Effects of a modular teacher coaching program on child attention problems and disruptive behavior and on teachers’ self-efficacy and stress

Symptoms of attention-deficit/hyperactivity and oppositional defiant disorder are associated with a multitude of psychosocial developmental risks, e.g. academic underachievement. Various cognitive behavioral interventions have proven to be effective in reducing problem behavior in school settings. Drawing on this previous work and on our parent-focused preventive and therapeutic programs, we developed the school-based coaching for elementary school teachers of children with attention deficits or disruptive behavior problems (SCEP). Based on functional behavior assessment, SCEP addresses teachers of children with severe externalizing behavior problems in an individualized modular manner. It consists of a one-day training course and fortnightly one-to-one or team-coaching sessions. We analyzed the effects of SCEP in a within-subject control group design ( N = 60), with student attention problems and rule-breaking behavior during class as the primary outcome measure. SCEP was found to reduce problem behavior during lessons, with small to medium effect sizes ( d = 0.42–0.6). After the intervention, teachers reported changes in their use of praise and felt more confident managing the class ( d = 0.58). The results of SCEP are discussed in light of multi-tiered preventive approaches that suggest extensive individualized interventions based on functional behavior analysis for children with severe problem behavior.

Parent- and Teacher-Rated Effectiveness of Cognitive-Behavioral Therapy for Children and Adolescents Under Usual Care Conditions in a University Outpatient Clinic

Compared to randomized controlled trials, studies examining the effectiveness of cognitive behavioral therapy (CBT) in children and adolescents with mental disorders are rare, and a teacher perspective is scarce. The present study investigated the effectiveness of routine CBT in 519 patients aged 6-18 years with mental disorders. Changes in mental health problems were assessed in teacher (Teacher Report Form, TRF) and parent rating (Child Behavior Checklist, CBCL) and were analyzed within the total sample, yielding statistically significant, small to medium effect sizes (teacher rating: d = .74-2.39; parent rating: d = .65-1.18). Changes in a subgroup of patients with elevated symptom scores at treatment start were compared to a historical control group receiving weekly academic tutoring. Net total score effect sizes lay between d = 0.98 and d = 1.29 for teacher rating (parent rating: d = 0.84 to d = 1.01). Nevertheless, a substantial number of patients remained in the clinical range. Symptom changes during family- and patient-based CBT interventions did not differ from treatments including additional school-based interventions, as was also the case for the comparison of treatments with and without additional pharmacotherapy.

Efficacy of an Individualized Computer-Assisted Social Competence Training Program for Children With Oppositional Defiant Disorders/Conduct Disorders

Group-based child-centered cognitive behavioral therapy (CBT) for children with aggressive behavior has been found to significantly reduce child behavior problems. Nevertheless, most children suffer from residual symptoms at the end of treatment. Therefore, individualized interventions that treat the specific problem-maintaining factors and that use digital support may enhance treatment effects. However, enhanced computer-facilitated interventions have not been examined in clinical samples. Therefore, we tested the efficacy of an individualized computer-facilitated social skills training for children with clinically referred aggressive behavior problems. Fifty children aged 6-12 years with peer-related aggressive behavior problems were included in a within-subject design with two phases (waiting, treatment). The course of the outcome measures during an 8-week waiting phase was compared with that in the subsequent treatment phase (16 weekly child sessions and 2 parent psychoeducation contacts at the beginning of the treatment) using multilevel modeling. The primary outcome was peer-related aggressive behavior rated by parents. Further outcome measures included parent ratings and patient self-reports of aggressive and prosocial behavior. No significant changes occurred for any of the outcome variables during the waiting phase. During treatment, most parent-rated outcome measures (including the primary outcome measure) showed a significant decrease, which was stronger than changes in the waiting phase. Most self-rated outcome measures also showed significant decreases during treatment, but a stronger decrease than in the waiting phase was only found for peer-related aggressive behavior. The computer-facilitated social skills training appears to be an effective CBT intervention for children with peer-related aggressive behavior.

Evidence-based psychosocial treatments of conduct problems in children and adolescents: an overview

The aims of the present study were to identify empirically supported psychosocial intervention programs for young people with conduct problems and to evaluate the underpinnings, techniques and outcomes of these treatments. We analyzed reviews and meta-analyses published between 1982 and 2016 concerning psychosocial intervention programs for children aged 3 to 12 years with conduct problems. Parent training should be considered the first-line approach to dealing with young children, whereas cognitive-behavioral approaches have a greater effect on older youths. Family interventions have shown greater efficacy in older youths, whereas multi-component and multimodal treatment approaches have yielded moderate effects in both childhood and adolescence. Some limitations were found, especially regarding the evaluation of effects. To date, no single program has emerged as the best. However, it emerges that the choice of intervention should be age-specific and should take into account developmental differences in cognitive, behavioral, affective and communicative abilities.

Effectiveness of outpatient cognitive-behavioral therapy for adolescents under routine care conditions on behavioral and emotional problems rated by parents and patients: an observational study

Few studies have examined the effectiveness of outpatient cognitive-behavioral therapy (CBT) delivered in routine care settings for children and adolescents with mental disorders. This observational study examined changes in behavioral and emotional problems of adolescents with mental disorders during routine outpatient CBT delivered at a university outpatient clinic and compared them with a historical control group of youths who received academic tutoring of comparable length and intensity. Assessments were made at the start and end of treatment (pre- and post-assessment) using parent ratings of the German versions of the Child Behavior Checklist (CBCL) and self-ratings of the Youth Self-Report (YSR) scale. For the main analysis, 677 adolescents aged 11‒21 years had complete data. Changes from pre- to post-assessment showed significant reductions in mental health problems on both parent- and self-ratings. Pre- to post-effect sizes (Cohen's d) were small-to-medium for the total sample (d = 0.23 to d = 0.62) and medium-to-large for those adolescents rated in the clinical range on each (sub)scale at the start of treatment (d = 0.65 to d = 1.48). We obtained medium net effect sizes (d = 0.69) for the CBCL and YSR total scores when patients in the clinical range were compared to historical controls. However, a substantial part of the sample remained in the clinical range at treatment end. The results suggest that CBT is effective for adolescents with mental disorders when administered under routine care conditions but must be interpreted conservatively due to the lack of a direct control condition.

Non-diagnostic based approaches to helping children who could be labelled ADHD and their families

Mental health services are not always good for you. There are some troubling facts to confront such as the increase in the use of diagnostic based approaches and psychotropic medications for children and young people being associated with poorer rather than better outcomes. In this article I will outline some of the evidence around outcome as a result of treatment for young people diagnosed with attention deficit hyperactivity disorder (ADHD) and for those who are prescribed long-term stimulants. I will then discuss clinical approaches that move beyond a focus on symptom management that diagnostic paradigms encourage. This includes clinical models that take account of the diversity of contextual and relational issues that young patients present with and the possibility afforded of engaging in more positive and hopeful therapeutic approaches such as the Relational Awareness Programme (RAP).

Exploring Acceptability and Feasibility of Evidence-Based Practice in Child Welfare Settings: A Pilot Study with Attachment-Based Family Therapy

The Flemish Child Welfare System (CWS) is in great need of a shared empirically informed clinical strategy for working with depressed adolescents and their families. Many evidence-based practices (EBP) exist, but little is known as to whether they can be successfully imported in the CWS. Therefore, the current study explores the implementation of a particular EBP, Attachment-Based Family Therapy (ABFT), in home-based services of the Flemish CWS in Belgium. Specifically, the study focused on (1) the acceptability of ABFT by counselors and whether negative attitudes about EBP can be changed (n = 73 counselors), and (2) the feasibility of implementing ABFT (n = 43 adolescents, 11-17 years old, 72% female) by exploring initial effectiveness. The results suggest that (1) initial negative attitudes of counselors towards ABFT were significantly more positive after attending training and discussions about ABFT, and that (2) ABFT could be used by counselors to successfully reduce adolescent depressive symptoms. Future research should include a control group to draw stronger causal conclusions. Strengths and limitations of the study's design and implications for further dissemination are discussed.

Maximizing Psychotherapy Outcome beyond Evidence-Based Medicine

Despite evidence that psychotherapy has a positive impact on psychological disorders, 30% of patients fail to respond during clinical trials, and as many as 65% of patients in routine care leave treatment without a measured benefit. In addition, therapists appear to overestimate positive outcomes in their patients relative to measured outcomes and are particularly poor at identifying patients at risk for a negative outcome. These problems suggest the need for measuring and monitoring patient treatment response over the course of treatment while applying standardized methods of identifying at-risk cases. Computer-assisted methods for measuring, monitoring, identifying potential deteriorators, and providing feedback to clinicians are described along with a model that explains why feedback is likely to be beneficial to patients. The results of 12 clinical trials are summarized and suggest that deterioration rates can be substantially reduced in at-risk cases (from baseline rates of 21% down to 13%) and that recovery rates are substantially increased in this subgroup of cases (from a baseline of 20% up to 35%) when therapists are provided this information. When problem-solving methods are added to feedback, deterioration in at-risk cases is further reduced to 6% while recovery/improvement rates rise to about 50%. It is suggested that the feedback methods become a standard of practice. Such a change in patterns of care can be achieved through minimal modification to routine practice but may require discussions with patients about their clinical progress.

The Oregon Model of Behavior Family Therapy: From Intervention Design to Promoting Large-Scale System Change

This paper reviews the evolution of the Oregon model of family behavior therapy over the past four decades. Inspired by basic research on family interaction and innovation in behavior change theory, a set of intervention strategies were developed that were effective for reducing multiple forms of problem behavior in children (e.g., Patterson, Chamberlain, & Reid, 1982). Over the ensuing decades, the behavior family therapy principles were applied and adapted to promote children's adjustment to address family formation and adaptation (Family Check-Up model), family disruption and maladaptation (Parent Management Training-Oregon model), and family attenuation and dissolution (Treatment Foster Care-Oregon model). We provide a brief overview of each intervention model and summarize randomized trials of intervention effectiveness. We review evidence on the viability of effective implementation, as well as barriers and solutions to adopting these evidence-based practices. We conclude by proposing an integrated family support system for the three models applied to the goal of reducing the prevalence of severe problem behavior, addiction, and mental problems for children and families, as well as reducing the need for costly and largely ineffective residential placements.

A Program Evaluation Strategy in a Community-Based Behavioral Health and Education Services Agency for Children and Families

Evaluation research and outcomes measurement in the arena of behavioral health services for children must be adapted for the community agency setting. Through evaluation research, it is possible to address service goals as well as more traditional academic research goals. This article examines a variety of activities that have been implemented to evaluate children’s behavioral and educational services in a Northern California non-profit community agency. It is noted that there are multiple formats for collecting information from and providing comments to children’s parents, their clinicians, and program administration staff, all of which can be used to effectively address service-focused evaluation research goals. Challenges to doing scientifically rigorous research in a community setting require additional considerations regarding organizational culture and structure. Based on the experiences of the authors and the experiences of others, the article describes general principles that can guide evaluation research and outcomes measurement with children and their families in the community health agency setting.

Efficacy of an individualized social competence training for children with Oppositional Defiant Disorders/Conduct Disorders

OBJECTIVES

Group-based Cognitive-Behavioral Therapy of children with aggressive behavior has resulted in significant reductions of behavior problems with small to medium effect sizes. We report the efficacy of an individualized Treatment Program for Children with Aggressive Behavior.

METHOD

A within-subject design with two phases (waiting, treatment) was chosen. Sixty boys aged 6-12 years with peer-related aggressive behavior were included. The course of the outcome measures (growth rates) during a 6-week waiting phase was compared with those in the subsequent treatment phase (24 weekly child sessions together with an average of 8 parent contacts) by multilevel modeling. Primary outcome was peer-related aggressive behavior rated by parents. Further outcome measures included parent ratings and patient self-reports of aggressive and prosocial behavior.

RESULTS

During the treatment, growth rates for all parent-rated outcome measures were significant (p < .001) and comparison with the waiting phase indicated a stronger decrease in aggressive behavior and a stronger increase in prosocial behavior. For all self-rated outcome measures, growth rates during the treatment were significant (p < .01), but comparison with the waiting phase indicated a stronger decrease only for disturbance of social interaction.

CONCLUSIONS

The treatment program is an effective intervention for children with peer-related aggressive behavior.

Treatment Effectiveness of PMTO for Children's Behavior Problems in Iceland: Child Outcomes in a Nationwide Randomized Controlled Trial

Well-documented treatment methods must be tested following their implementation in community service agencies and across different cultures to ensure continuing effectiveness. This study was a randomized controlled trial (RCT) of Parent Management Training-the Oregon model (PMTO), conducted within a nationwide implementation in Iceland. Families of 102 clinically referred children with behavior problems were recruited from five municipalities throughout Iceland. Child age ranged from 5 to 12; 73% were boys. Families were randomly assigned to either PMTO or services usually offered in the communities (SAU). Child adjustment was measured with a latent construct based on parent, child, and teacher reports of externalizing and internalizing problems and social skills. Prepost intent-to-treat analyses showed that PMTO treatment led to greater reductions in child adjustment problems relative to the comparison group, obtaining a modest to medium effect size based on the construct score. Only one indicator (parent-rated Social Skills) showed significant change independently and information on amount and kind of treatment in the SAU was limited. Overall, findings indicate that PMTO is an effective method to treat children's behavior problems in a Northern European culture and supply evidence for the method's successful implementation in community settings in Iceland. This is one of few nationwide implementation studies of PMTO outside the United States and the first RCT in Iceland to test a treatment model for children's behavior problems.

Promoting Educational Resiliency in Youth with Incarcerated Parents: The Impact of Parental Incarceration, School Characteristics, and Connectedness on School Outcomes

The United States has the highest incarceration rate in the world, and as a result, one of the largest populations of incarcerated parents. Growing evidence suggests that the incarceration of a parent may be associated with a number of risk factors in adolescence, including school drop out. Taking a developmental ecological approach, this study used multilevel modeling to examine the association of parental incarceration on truancy, academic achievement, and lifetime educational attainment using the National Longitudinal Survey of Adolescent Health (48.3 % female; 46 % minority status). Individual characteristics, such as school and family connectedness, and school characteristics, such as school size and mental health services, were examined to determine whether they significantly reduced the risk associated with parental incarceration. Our results revealed small but significant risks associated with parental incarceration for all outcomes, above and beyond individual and school level characteristics. Family and school connectedness were identified as potential compensatory factors, regardless of parental incarceration history, for academic achievement and truancy. School connectedness did not reduce the risk associated with parental incarceration when examining highest level of education. This study describes the school related risks associated with parental incarceration, while revealing potential areas for school-based prevention and intervention for adolescents.

Alltagswirksamkeit ambulanter Verhaltenstherapie von Kindern und Jugendlichen im Urteil der Eltern in einer universitären Ausbildungsambulanz

Zusammenfassung. Hintergrund: Die Wirksamkeit von kognitiver Verhaltenstherapie bei Kindern und Jugendlichen unter Routinebedingungen ist bislang noch wenig untersucht. Fragestellung: Es wurden Veränderungen psychischer Auffälligkeiten von Kindern und Jugendlichen im Elternurteil während ambulanter Verhaltenstherapie in einer universitären Ausbildungsambulanz untersucht. Die Therapien wurden durchgeführt von Diplom-Psychologen, Pädagogen, Sozialpädagogen und Sozialarbeitern in fortgeschrittener Ausbildung zum Kinder- und Jugendlichenpsychotherapeuten mit Schwerpunkt Verhaltenstherapie. Alle Therapien wurden im Verhältnis 1:4 supervidiert. Methode: Für 976 Therapien wurden Completeranalysen als Prä-Post-Vergleiche mit Effektstärken auf der Child Behavior Checklist (CBCL) berechnet und die klinische Bedeutsamkeit der Veränderungen analysiert–jeweils für die Gesamtgruppe und für die auf der CBCL zu Therapiebeginn klinisch Auffälligen. Zusätzlich wurde die Repräsentativität dieser Analyse für die gesamte Stichprobe überprüft. Ergebnisse: In der Gesamtgruppe fanden sich kleine bis mittlere, in der Gruppe der im Elternurteil auf der CBCL klinisch Auffälligen hauptsächlich große, statistisch signifikante Verminderungen psychischer Auffälligkeiten, die nicht durch Spontanveränderungen oder Regressionseffekte erklärt werden können. Allerdings wurden 1/4 bis 1/3 der Patienten auch nach Therapieende von ihren Eltern weiterhin als klinisch auffällig eingeschätzt. Schlussfolgerungen: Die Ergebnisse weisen auf die Wirksamkeit kognitiv-behavioraler Therapie bei psychisch kranken Kindern und Jugendlichen unter Anwendungsbedingungen hin. Aufgrund der mangelnden experimentellen Kontrolle ist die Aussagekraft der Ergebnisse begrenzt.

Community-based treatment for youth with co- and multimorbid disruptive behavior disorders

Little is known about the types of psychotherapeutic practices delivered to youth with comorbid and multimorbid diagnoses in community settings. The present study, based on therapists' self-reported practices with 569 youth diagnosed with a disruptive behavior disorder (ODD or CD), examined whether specific therapeutic practice applications varied as a function of the number and type of comorbid disorders. While type of comorbid disorder (AD/HD or internalizing) did not predict therapists' practices, youth with more than two diagnoses (multimorbid) received treatment characterized by a more diverse set and a higher dosage of practices.

The family check-up and service use in high-risk families of young children: a prevention strategy with a bridge to community-based treatment

Integration of empirically supported prevention programs into existing community services is a critical step toward effecting sustainable change for the highest-risk members in a community. We examined if the Family Check-Up--known to reduce disruptive behavior problems in young children--can provide a bridge to the use of community treatment services among high-risk indigent families. The study's 731 income-eligible families with a 2-year-old child were screened and randomized to the Family Check-Up (FCU) intervention or a control condition. Families were provided yearly FCUs from age 2 through age 5. Regression analyses on families' service use at child age 7.5 revealed increased service use, compared with that of the control group. Child disruptive behavior and socioeconomic status moderated the effect of the intervention on service use. Families who reported higher levels of disruptive child behavior and lower socioeconomic status showed more service use, suggesting the intervention increased service use among the highest-risk families. Greater use of community services did not mediate the effect of the FCU on reduced oppositional-defiant child behavior. Implications of these findings for the design and ecology of community treatment services in the context of evidence-based practices are discussed.

Children and Young People's Improving Access to Psychological Therapies: inspiring innovation or more of the same?

In 2007 the UK Government announced a substantial expansion of funding for psychological therapies for those presenting with common mental health problems. This 'Improving Access to Psychological Therapies' (IAPT) project was widely welcomed, however, evidence backed, economic, and conceptual critiques were voiced from the start and the project remains controversial. In 2011, the UK government announced it was extending the IAPT project to encompass services for children and young people with the aim of 'transforming' the way mental health services are delivered to them. Here I critically reflect on the problems associated first with IAPT and then with CYP-IAPT and ponder whether CYP-IAPT is significantly different to the problematic adult IAPT project or more of the same.

Searching for elements of evidence-based practices in children's usual care and examining their impact

Most of the knowledge generated to bridge the research-practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.

The occasional case against broad dissemination and implementation: retaining a role for specialty care in the delivery of psychological treatments

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Childhood sexual abuse: community-based treatment practices and predictors of use of evidence-based practices

BACKGROUND

Cognitive behavior therapy with abuse-focused components is empirically supported for children/adolescents who have experienced childhood sexual abuse (CSA). We examined the extent to which community-based psychologists use evidence-based practices (EBP) for CSA and identified predictors of EBP use.

METHOD

Psychologists (N = 231) providing CSA treatment services to children/adolescents in Ontario (Canada) were identified through the first census of child and adolescent psychology clinicians registered with the College of Psychologists of Ontario. Participants completed a questionnaire on treatment strategies, sociodemographics, work setting, treatment provision, and attitudes toward EBP. Data were collected between December 2009 and June 2010.

RESULTS

The majority (78%) of psychologists providing CSA services reported never having received training in specific treatment approaches for this population. Only 5% of psychologists received training in the EBP of trauma-focused cognitive behavior therapy. Multiple regressions indicated that age, theoretical orientation, continuing education, and attitudes predicted the use of an empirically based intervention for CSA.

CONCLUSION

Study findings show that few community-based psychologists have received training in specific treatment approaches for CSA victims and very few are trained to deliver EBP for this population. There are ethical concerns about the practice of psychologists who are untrained and unsupervised doing this work. Research findings, which underline the need for training, supervision, and continuing education, need to be translated into clinical practice.

Cultural diversity: do we need a new wake-up call for parent training?

In 1996, Forehand and Kotchick concluded that parent-training (PT) interventions largely ignored cultural influences on parenting behavior. They reasoned that the failure to integrate the influence of ethnicity into theories of parenting behavior could result in culturally biased and less effective interventions. The present article addresses whether their "wake-up call" went unheard. We review research on PT treatment studies and examine (a) the rate of inclusion of ethnic minority parents in PT research, (b) the effectiveness of PT across ethnic groups, and (c) the effectiveness of culturally adapted PT interventions. Results show that there has been an increase in the ethnic diversity of PT treatment studies over the past three decades, yet only one methodologically sound study directly examined ethnicity as a moderator of PT treatment outcome. Despite the paucity of evidence that ethnicity is a moderator of parent-training outcomes, a number of culturally adapted PT treatments have been developed. These adapted interventions have rarely been tested against the unadapted interventions on which they are based. The results fail to support the current emphasis on ethnicity in efforts to improve the effectiveness of PT. We present methodological and conceptual limitations in the existing literature and provide recommendations for researchers studying the effects of ethnicity on PT outcomes.

Outcome Orientated Child and Adolescent Mental Health Services (OO-CAMHS): a whole service model

The international evidence base on factors that most influence outcomes in mental health care finds that matching therapeutic intervention to diagnosis has a clinically insignificant impact on outcomes. Decades of outcome research into treatment of psychiatric disorders shows that, despite the development of many new techniques, the outcomes being achieved in studies 30 years ago are similar to those being achieved now. In the last few years, new service models that incorporate systems of feedback on progress and alliance have emerged and show promise with regards improving overall outcomes for mental health service users. Growing familiarity with this outcome literature, together with a desire to be part of a service that can continue to improve patient outcomes, led a small community Child and Adolescent Mental Health Services team to develop a new whole service model - Outcome Orientated Child and Adolescent Mental Health Services (OO-CAMHS). OO-CAMHS incorporates key aspects of the evidence base on what could make a differential positive impact on outcomes and relinquishes those aspects that do not. In this paper, we outline the evidence base on which OO-CAMHS is built, describe the key features of the approach and present some of the early findings on its impact.

Improving community-based mental health care for children: translating knowledge into action

There is urgent need for improvement in community-based mental health care for children and families. Multiple studies have documented serious limitations in the effectiveness of "usual care." Fortunately, many empirically-supported strategies to improve care have been developed, and thus there is now a great deal of knowledge available to address this significant public health problem. The goal of this selective review is to highlight and synthesize that empirically-supported knowledge to stimulate and facilitate the needed translation of knowledge into action. The review provides a sound foundation for constructing improved services by consolidating descriptive data on the status quo in children's mental health care, as well as evidence for an array of promising strategies to improve (a) Service access and engagement; (b) Delivery of evidence-based practices; and (c) Outcome accountability. A multi-level framework is used to highlight recommended care improvement targets.

Outcome domains in child mental health research since 1996: have they changed and why does it matter?

OBJECTIVE

Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995).

METHOD

Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review.

RESULTS

There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95%) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder.

CONCLUSIONS

Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world.

[Nothing new since «Little Hans» and «Little Peter»? Psychotherapy for anxiety disorders in childhood and adolescence]

Anxiety disorders are among the most frequent psychological disorders in childhood and adolescence. They are characterized by early onset, tend to remain stable over time, and act as a significant risk factor for developing a psychological disorder in adulthood. Over the last few years, research has shown that anxiety disorders in children and adolescents can be treated effectively. However, to date only cognitive behavioral therapy (CBT) has received convincing empirical support as an effective psychotherapeutic treatment. Evidence for the effectiveness of other psychotherapeutic treatments such as nonbehavioral family therapy or psychodynamic interventions is rather scant. Recent randomized controlled trials (RCT) proved CBT to be effective from preschool age onwards. Contrary to long-held beliefs, however, the involvement of parents in a treatment program does not appear to be crucial to therapeutic outcome. Issues regarding the effectiveness of disorder-specific treatments and the combination of psychotherapeutic treatments with the application of selective serotonin reuptake inhibitors (SSRIs) are increasingly being taken up in recent studies. In addition to «classic» cognitive behavioural treatment programs there are some promising suggestions for the effectiveness of novel treatment methods such as attention bias modification or computer-assisted behavioral therapy.

Differential immune system DNA methylation and cytokine regulation in post-traumatic stress disorder

DNA methylation may mediate persistent changes in gene function following chronic stress. To examine this hypothesis, we evaluated African American subjects matched by age and sex, and stratified into four groups by post-traumatic stress disorder (PTSD) diagnosis and history of child abuse. Total Life Stress (TLS) was also assessed in all subjects. We evaluated DNA extracted from peripheral blood using the HumanMethylation27 BeadChip and analyzed both global and site-specific methylation. Methylation levels were examined for association with PTSD, child abuse history, and TLS using a linear mixed model adjusted for age, sex, and chip effects. Global methylation was increased in subjects with PTSD. CpG sites in five genes (TPR, CLEC9A, APC5, ANXA2, and TLR8) were differentially methylated in subjects with PTSD. Additionally, a CpG site in NPFFR2 was associated with TLS after adjustment for multiple testing. Notably, many of these genes have been previously associated with inflammation. Given these results and reports of immune dysregulation associated with trauma history, we compared plasma cytokine levels in these subjects and found IL4, IL2, and TNFα levels associated with PTSD, child abuse, and TLS. Together, these results suggest that psychosocial stress may alter global and gene-specific DNA methylation patterns potentially associated with peripheral immune dysregulation. Our results suggest the need for further research on the role of DNA methylation in stress-related illnesses.

On the meaning of change in a clinician's routine measure of outcome: HoNOSCA

OBJECTIVE

With the advent of routine outcomes across Australia and New Zealand, clinicians, managers, parents and children will be interested in change on these measures. This paper presents a number of approaches and the implications.

METHOD

Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) collected during clinical practice for 911 patients were examined for changes over time, clinical significance, treatment status, effect size, and reliable and clinically significant change.

RESULTS

Statistically significant changes in symptom severity were found related to treatment status and to changes in the number of clinically significant scales. An effect size of almost one standard deviation was noted and the proportion of patients who improved was examined. While the reliable change index was calculated, there are clinical complications with this approach. The impact of the capacity to change on specific scales illustrates a critical issue in describing outcomes.

CONCLUSION

From a number of perspectives, change in HoNOSCA total and scale scores is valid. However, several clinical dilemmas must be faced in deciding which approach should be used. The implications of these choices may affect clinicians, patients, carers and managers in understanding change.

Change what? Identifying quality improvement targets by investigating usual mental health care

Efforts to improve community-based children’s mental health care should be based on valid information about effective practices and current routine practices. Emerging research on routine care practices and outcomes has identified discrepancies between evidence-based practices and “usual care.” These discrepancies highlight potentially potent quality improvement interventions. This article reviews existing research on routine or “usual care” practice, identifies strengths and weaknesses in routine psychotherapeutic care, as well as gaps in knowledge, and proposes quality improvement recommendations based on existing data to improve the effectiveness of children’s mental health care. The two broad recommendations for bridging the research-practice gap are to implement valid, feasible measurement feedback systems and clinician training in common elements of evidence-based practice.

Exploring the black box: measuring youth treatment process and progress in usual care

The session report form (SRF) is a 25-item self-report measure scheduled to be completed by clinicians at the end of each session. This study addresses the utility of the SRF for describing session content by exploring patterns of self-reported behavior of 235 clinicians in 7,058 sessions with 600 clients. Results indicate that the SRF has a distinct subscale of treatment process and provides an adequate range of topics related to session content while also discriminating between client and clinician influences on patterns of topics addressed. The SRF is a promising measure meeting a significant need in describing session content in usual care.

Mental health care for children with disruptive behavior problems: a view inside therapists' offices

OBJECTIVES

In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care.

METHODS

Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months.

RESULTS

Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing).

CONCLUSIONS

Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics

This study evaluated the effectiveness of cognitive-behavioral treatment for childhood anxiety in a community clinic setting in Hong Kong, China. Forty-five clinically-referred children (age 6-11 years) were randomly assigned to either a cognitive-behavioral treatment program or a waitlist-control condition. Children in the treatment condition showed significant reduction in anxiety symptoms-both statistically and clinically-whereas children in the waitlist condition did not. After the waitlist period was over, the control group also received the treatment program and showed a similar reduction in symptoms. For the full sample of 45 children, the effectiveness of the intervention was significant immediately after treatment and in 3- and 6-month follow-ups. In addition, children's anxiety cognition and their ability to cope with anxiety-provoking situations fully mediated the treatment gains. These results offer empirical support for cognitive-behavioral treatment programs in a non-Western cultural context and plausible mediators for how cognitive-behavioral therapy works.

Factors associated with use of evidence-based practice strategies in usual care youth psychotherapy

The purpose of this study was to gain an understanding of how therapists providing usual care (UC) psychotherapy are using elements of treatment common to evidence-based practices (EBPs) for children with disruptive behavior disorders (DBPs) and to identify client and therapist characteristics that may be associated with EBP strategies directed toward children and those directed to their caregivers. Results indicate that certain child, family, and therapist characteristics are associated with use of EBP strategies; however, much of the variability in practice was not explained by the variables examined. These findings highlight the complexity of UC psychotherapy and provide directions for future research on implementation of EBPs in UC.

Context Specific Mental Health Services for Children in Foster Care

Although a high proportion of foster children receive mental health services, existing research suggests limited accessibility and effectiveness of these services. This paper discusses strategies to develop a model to deliver evidence-based services using the unique opportunities apparent within publicly funded child welfare systems. An ecologically-focused model providing enhanced services in children's homes and schools could capitalize on these opportunities and radically improve access and effectiveness of mental health services for foster children. We present data from four focus groups conducted with foster parents, caseworkers, and therapists to understand the feasibility of implementing this type of service model. Results support the need for services focused on enhancing interactions in children's foster homes and schools, but also suggest that issues related to priorities and primary roles could limit the extent that caseworkers and agency-based mental health providers would follow through with the proposed service model.

Child psychoanalytic psychotherapy in the UK National Health Service: an historical analysis

This review developed from a discussion with the late Professor Richard Harrington about interventions in Child and Adolescent Mental Health services (CAMHS) that lacked an evidence base. Our aim is to investigate the literature for signs that child psychoanalysis is a declining paradigm within the Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom (UK). We present the literature chronologically since the inception of the UK National Health Service. This study shows that there have been a number of threats to child psychoanalytic psychotherapy, but no significant consistent decline. The profession is beginning to develop the social profile of a scientific discipline. We conclude that child psychoanalytic psychotherapy does not consistently demonstrate features of a declining scientific paradigm.

Does parent management training for children with externalizing problem behavior in routine care result in clinically significant changes?

The clinical significance of a parent management training that is part of the Prevention Program for Externalizing Problem Behavior (PEP) was assessed in an effectiveness trial. Parent management training was offered under routine care conditions in a setting where a high proportion of children were expected to show clinically relevant symptoms of externalizing problem behavior. At the beginning of the study, 32.6% to 60.7% of children were classified as clinical cases (dysfunctional) on three outcome measures of child behavior problems. Three months after treatment, 24.8% to 60.4% of children were judged to be recovered. Parent management training can result in clinically significant changes in children with externalizing behavior problems.

One-Year Follow-up of a Parent Management Training for Children with Externalizing Behaviour Problems in the Real World

Background: The long-term effectiveness of parent training for children with externalizing behaviour problems under routine care within the German health care system is unclear. We report the 1-year follow-up results of the parent training component of the Prevention Program for Externalizing Problem Behaviour (PEP) for 270 children aged 3–10 years with externalizing behaviour problems. Method: Outcome measures included child behaviour problems (externalizing behaviour problems, Attention-Deficit/Hyperactivity Disorder symptoms and Oppositional Defiant Disorder symptoms) and parenting (self efficacy of parenting and perceived ability to solve difficult parenting situations). Data were analysed using multilevel modelling. Results: Comparison of the changes during the 3-month waiting and treatment periods revealed significantly stronger treatment effects on all outcome measures, indicating a substantial decrease in child behaviour problems and a significant increase in parenting due to treatment. At 1-year follow-up, initial treatment effects on child behaviour problems were maintained, while parenting continued to improve. Conclusions: Families whose children exhibited externalizing problem behaviour profit from PEP and improvements are maintained for at least one year.

The Child and Adolescent Symptom Inventory-Progress Monitor: a brief Diagnostic and Statistical Manual of Mental Disorders, 4th edition-referenced parent-report scale for children and adolescents

The Child and Adolescent Symptom Inventory-Progress Monitor-Parent Form (CASI-PM-P) is a 29-item rating scale designed to evaluate symptom change for commonly referred child and adolescent disorders. Its intended applications include monitoring longer-term changes in clinical status and assessing intervention responsiveness. To enhance practicality, there is one version of the CASI-PM-P for all age groups with a common set of norms for both genders. Scoring procedures allow clinicians to assess whether observed symptom changes exceeded chance fluctuations. Using a clinical sample of 2,693 children ages 3-17 years, the 29 symptom-related items were identified that had the best item-to-total minus item correlations on the three age-appropriate scales of the Symptom Inventories. Item-to-total minus item correlations of similar magnitude were also obtained for those items with the standardization sample. In clinical samples, the CASI-PM-P scores had both high levels of internal consistency and test-retest reliability and were sensitive to change in a treated sample. Collectively, the findings support the reliability and validity of the CASI-PM-P as a measure of behavioral change in clinical settings, while continued research will be necessary to improve clinical utility and provide better documentation of the scale's strengths and weaknesses.

Trends in Child Welfare's Focus on Children's Mental Health and Services from 1980-2004

This study examined how one of the oldest and most widely distributed child welfare practice journals addressed children's mental health issues over a 25-year period. The content of 478 articles was coded. Logistic regression findings indicate that mental health issues were discussed less frequently over the first half of the period examined, and then more frequently over the last decade. Residential treatment was discussed less frequently over time, but other community-based alternatives to residential treatment were rarely discussed at any point, so that overall the content related to treatment of mental health issues decreased as discussion of residential treatment decreased. These findings suggest that although the child welfare literature has recently focused more on children's mental health, dissemination of specific concepts from the mental health to the child welfare literature does not naturally occur over time. Efforts targeted at dissemination of effective community-based mental health interventions for foster children may be needed to support this process.

Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children

The objective of this study was to investigate the cost-effectiveness of family cognitive-behavioral therapy (CBT) compared with individual CBT in children with anxiety disorders. Clinically anxious children (aged 8-18 years) referred for treatment were randomly assigned to family or individual CBT and were assessed pre-treatment, post treatment, and at 3 months and 1 year after treatment. Cost-effectiveness ratios were calculated expressing the incremental costs per anxiety-free child and the incremental costs per Quality Adjusted Life Year (QALY) for the referred child. Neither societal costs nor effectiveness were significantly different between individual and family CBT. However, the point estimates of the cost-effectiveness ratios resulted in dominance for individual CBT, indicating that individual CBT is more effective and less costly than family CBT. These results were confirmed by bootstrap analyses and cost-effectiveness acceptability curves. Several secondary and sensitivity analyses showed that the results were robust. It can be concluded that family CBT is not a cost-effective treatment for clinically anxious children, compared with individual CBT.

Integrative module-based family therapy: application and training

The field of marriage and family therapy is currently at a crossroads. The challenge for contemporary therapists is how to incorporate the wisdom of previous models with the accountability that comes from evidence-based practice. The Integrative Module-Based Family Therapy treatment model provides a formalized series of steps that clinicians can use in their case planning and implementation. It is based on nine clinically relevant modules for assessment and intervention that are consistent with current best practices and empirically supported treatments. It thus meets the need for a structured family therapy practice and training approach that is respectful of the "art" of family therapy while still adhering to the principles of the "science" of evidence-based treatment.

Evidence-based psychosocial treatments for ethnic minority youth

This article reviews research on evidence-based treatments (EBTs) for ethnic minority youth using criteria from Chambless et al. (1998), Chambless et al. (1996), and Chambless and Hollon (1998). Although no well-established treatments were identified, probably efficacious or possibly efficacious treatments were found for ethnic minority youth with anxiety-related problems, attention-deficit/hyperactivity disorder, depression, conduct problems, substance use problems, trauma-related syndromes, and other clinical problems. In addition, all studies met either Nathan and Gorman's (2002) Type 1 or Type 2 methodological criteria. A brief meta-analysis showed overall treatment effects of medium magnitude (d = .44). Effects were larger when EBTs were compared to no treatment (d = .58) or psychological placebos (d = .51) versus treatment as usual (d = .22). Youth ethnicity (African American, Latino, mixed/other minority), problem type, clinical severity, diagnostic status, and culture-responsive treatment status did not moderate treatment outcome. Most studies had low statistical power and poor representation of less acculturated youth. Few tests of cultural adaptation effects have been conducted in the literature and culturally validated outcome measures are mostly lacking. Recommendations for clinical practice and future research directions are provided.