Child and adolescent psychotherapy in research and practice contexts: review of the evidence and suggestions for improving the field

The body of evidence on child and adolescent psychotherapy outcomes has now grown to more than 500 studies. Here we summarize key findings, focusing on effectiveness and efficacy research. Research is sparse on the effectiveness of treatment in everyday practice, but available evidence suggests little benefit. By contrast, extensive research on efficacy of structured treatments administered under controlled conditions shows very substantial evidence of benefit. We note several specific treatments for which evidence is encouraging, and we offer suggestions for future research. Particularly important will be research on treatment models most often used in practice settings, tests of outcome mediators and moderators, tests employing a broadened range of treatment delivery models, and research bridging the gap between lab-tested treatments and the conditions of real-world practice.

Why are we here at the clinic? Parent-child (dis)agreement on referral problems at outpatient treatment entry

Do clinic-referred children and their parents agree on the problems for which treatment is undertaken? The authors asked 381 outpatient-clinic-referred children and their parents to list, independently, the child's target problems. Of the parent-child pairs, 63% failed to agree on even a single problem. When problems were grouped into broad categories (e.g., delinquent, withdrawn), more than a third of the pairs still failed to agree on a single broad problem area. Parent-child agreement was higher for externalizing than for internalizing problem categories (though poor for both). Low parent-child agreement may help explain the poor outcomes often reported for clinic-based child therapy.

Why are we here at the clinic? Parent-child (dis)agreement on referral problems at outpatient treatment entry

Do clinic-referred children and their parents agree on the problems for which treatment is undertaken? The authors asked 381 outpatient-clinic-referred children and their parents to list, independently, the child's target problems. Of the parent-child pairs, 63% failed to agree on even a single problem. When problems were grouped into broad categories (e.g., delinquent, withdrawn), more than a third of the pairs still failed to agree on a single broad problem area. Parent-child agreement was higher for externalizing than for internalizing problem categories (though poor for both). Low parent-child agreement may help explain the poor outcomes often reported for clinic-based child therapy.

Reliability of the services assessment for children and adolescents

OBJECTIVE

This study examined the test-retest reliability of a new instrument, the Services Assessment for Children and Adolescents (SACA), for children's use of mental health services.

METHODS

A cross-sectional survey was undertaken at two sites. The St. Louis site used a volunteer sample recruited from mental health clinics and local schools. The Ventura County, California, site used a double-blind, community-based sample seeded with cases of service-using children. Participating families completed the SACA and were retested within four to 14 days. The reliability of service use items was calculated with use of the kappa statistic.

RESULTS

The SACA- Parent Version had excellent test-retest reliability for both lifetime service use and previous 12-month use. The SACA also had good to excellent reliability when administered to children aged 11 and older for lifetime and 12-month use. Reliability figures for children aged nine and ten years were considerably lower for lifetime and 12-month use. The younger children's responses suggested that they were confused about some questions.

CONCLUSIONS

This study demonstrates that parents and older children can reliably report use of mental health services by using the SACA. The SACA can be used to collect currently unavailable information about use of mental health services.

Specificity of relations between children's control-related beliefs and internalizing and externalizing psychopathology

The authors examined the specificity of the relation between 3 types of control-related beliefs and internalizing and externalizing psychopathology in a sample of 290 clinic-referred children aged 7 to 17 years. Self-reported beliefs about control (the capacity to cause an intended outcome), contingency (the degree to which a desired outcome can be controlled by a relevant behavior), and competence (an individual's ability to produce the relevant behavior) across 3 domains (academic, behavioral, and social) showed more specific relations with psychopathology than have been previously reported. Among children with externalizing psychopathology, internalizing psychopathology may be specifically associated with increased self-critical awareness about their conduct; externalizing psychopathology may attenuate the specific negative relation between internalizing psychopathology and control-related beliefs in the social domain.

Control-related beliefs and depressive symptoms in clinic-referred children and adolescents: developmental differences and model specificity

The contingency-competence-control (CCC) model links contingency and competence beliefs to perceived control and, in turn, to depression. However, a developmental perspective suggests that noncontingency may be too abstract a concept to be directly tied to depression before adolescence. We tested the CCC model and this developmental notion, using structural equation modeling, with 360 clinic-referred 8- to 17-year-olds. The CCC model fit the data well for the full sample accounting for 46% of the variance in depression. Separate analyses by age group placed perceived contingency in the best-fit model for adolescents (ages 12-17 years) but not for children (8-11 years). This suggests that abstract cause-effect concepts may have more direct affective impact after the cognitive changes of adolescence (e.g., formal operations) than before. Finally, the CCC model accounted for much more variance in depression than conduct problems, suggesting diagnostic specificity.

Specificity of relations between children's control-related beliefs and internalizing and externalizing psychopathology

The authors examined the specificity of the relation between 3 types of control-related beliefs and internalizing and externalizing psychopathology in a sample of 290 clinic-referred children aged 7 to 17 years. Self-reported beliefs about control (the capacity to cause an intended outcome), contingency (the degree to which a desired outcome can be controlled by a relevant behavior), and competence (an individual's ability to produce the relevant behavior) across 3 domains (academic, behavioral, and social) showed more specific relations with psychopathology than have been previously reported. Among children with externalizing psychopathology, internalizing psychopathology may be specifically associated with increased self-critical awareness about their conduct; externalizing psychopathology may attenuate the specific negative relation between internalizing psychopathology and control-related beliefs in the social domain.

Control-related beliefs and depressive symptoms in clinic-referred children and adolescents: developmental differences and model specificity

The contingency-competence-control (CCC) model links contingency and competence beliefs to perceived control and, in turn, to depression. However, a developmental perspective suggests that noncontingency may be too abstract a concept to be directly tied to depression before adolescence. We tested the CCC model and this developmental notion, using structural equation modeling, with 360 clinic-referred 8- to 17-year-olds. The CCC model fit the data well for the full sample accounting for 46% of the variance in depression. Separate analyses by age group placed perceived contingency in the best-fit model for adolescents (ages 12-17 years) but not for children (8-11 years). This suggests that abstract cause-effect concepts may have more direct affective impact after the cognitive changes of adolescence (e.g., formal operations) than before. Finally, the CCC model accounted for much more variance in depression than conduct problems, suggesting diagnostic specificity.

The Service Assessment for Children and Adolescents (SACA): adult and child reports

OBJECTIVE

To describe differences in parent-child responses to the Service Assessment for Children and Adolescents (SACA).

METHOD

Studies were done at UCLA and Washington University based on service-using and community subjects drawn from community households or public school student lists, respectively. Results are presented for 145 adult-youth pairs in which the youth was 11 or older.

RESULTS

The SACA adult-youth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (kappa = 0.43-0.86, with most at 0.61 or greater). Similarly, the SACA showed a good to excellent correspondence for services that had been used in the preceding year (kappa = 0.45-0.77, with most greater than 0.50). The parent-youth correspondence for use of specific service settings in the above generic categories ranged from poor to excellent (kappa = 0.25-0.83, with half at 0.50 or greater).

CONCLUSIONS

The SACA has better adult-youth correspondence than any service use questionnaire with published data, indicating that both adult and youth reports are not needed for all research on mental health services. This is especially encouraging news for researchers working with high-risk youth populations, in which a parent figure is often not available.

Can we trust parent reports in research on cultural and ethnic differences in child psychopathology? Using the bicultural family design to test parental culture effects

Research comparing cultural and ethnic groups on child psychopathology has relied heavily on parent reports. But don't parents' own cultural backgrounds bias their reports, undermining valid assessment of actual child behavior? The question is hard to address because parent and child culture tend to be confounded. To solve this problem, we assembled an unusual but heuristically valuable sample: 50 bicultural families, each with an ethnic Thai parent reared in Thailand and a Caucasian parent reared in the U.S. Parents in each pair independently completed standardized problem checklists on the same child in their family. Across all 10 empirically derived problem syndromes, no parental culture effect was either significant or larger than "small," by Cohen's (1988) standards; across all 140 specific problems, the mean percent of variance accounted for by parent culture was less than 1%. Results do not point to a biasing effect of parental culture.

Can we trust parent reports in research on cultural and ethnic differences in child psychopathology? Using the bicultural family design to test parental culture effects

Research comparing cultural and ethnic groups on child psychopathology has relied heavily on parent reports. But don't parents' own cultural backgrounds bias their reports, undermining valid assessment of actual child behavior? The question is hard to address because parent and child culture tend to be confounded. To solve this problem, we assembled an unusual but heuristically valuable sample: 50 bicultural families, each with an ethnic Thai parent reared in Thailand and a Caucasian parent reared in the U.S. Parents in each pair independently completed standardized problem checklists on the same child in their family. Across all 10 empirically derived problem syndromes, no parental culture effect was either significant or larger than "small," by Cohen's (1988) standards; across all 140 specific problems, the mean percent of variance accounted for by parent culture was less than 1%. Results do not point to a biasing effect of parental culture.

Efficacy and effectiveness of child and adolescent psychotherapy and pharmacotherapy

Decades of intervention research have produced a rich body of evidence on the effects of psychotherapies and pharmacotherapies with children and adolescents. Here we summarize and critique that evidence. We review findings bearing on the efficacy of psychosocial treatments and medications under controlled experimental conditions. We also report evidence, where available, on the effectiveness of both classes of treatment with clinically referred youth treated in real-world clinical contexts. In general, the large body of evidence on efficacy contrasts sharply with the small base of evidence on effectiveness. Addressing this gap through an enriched research agenda could contribute importantly to linking scientific inquiry and clinical practice-to the benefit of both ventures. This is one element of a multifaceted agenda for future research and for synthesis of research, which will require the interplay of multiple disciplines related to child and adolescent mental health.

Culture, coping, and context: primary and secondary control among Thai and American youth

Do cultural values and traditions influence the development of coping styles ? To address this question, we compared self-reports of coping by 6-14-year-olds in Thailand and the U.S. One hundred and forty-one children were interviewed about six common stressors: separation from a friend, injection in a doctor's office, adult anger, peer animosity, school failure, and physical injury. Children's self-reported coping methods were coded as overt or covert. Coping goals were coded as reflecting primary control (attempts to influence objective conditions), secondary control (attempts to adjust oneself to objective conditions), or relinquished control. Although findings revealed numerous cross-national similarities, there were also multiple main and interaction effects involving culture, suggesting that sociocultural context may be critical to our understanding of child coping. Consistent with literature on Thai culture, Thai children reported more than twice as much covert coping as American children for stressors involving adult authority figures (i.e. adult anger, injection in doctor's office). Thai children also reported more secondary control goals than Americans when coping with separation, but American children were five times as likely as Thais to adopt secondary control goals for coping with injury. The findings support a model of coping development in which culture and stressor characteristics interact, with societal differences most likely to be found in situations where culture-specific norms become salient.

Homesickness in preadolescent and adolescent girls: risk factors, behavioral correlates, and sequelae

Examined homesickness in 117 girls ages 8 to 16 during a 2-week stay at summer camp. (Homesickness is the distress or impairment caused by an actual or anticipated separation from home. It is characterized by acute longing and preoccupying thoughts of home and attachment objects.) Elevated preseparation levels of homesickness, high expectations of homesickness, negative separation attitudes, low decision control, and little previous separation experience predicted in-camp levels of homesickness. During the separation, homesickness was associated with insecure interpersonal attitudes, negative initial impressions of the novel environment, high perceived distance from home, and low perceived control. Female surrogate caregivers rated homesick girls as having lower social status and more somatic complaints, social problems, and externalizing behavior than less homesick girls. Although the prevalence, intensity, and longitudinal course of homesickness in girls did not differ from analogous samples of boys, girls' profile of risk factors, correlates, and sequelae is unique in its mixed behavioral presentation and small correlations with age and experience.

Finding, evaluating, refining, and applying empirically supported treatments for children and adolescents

Structured child and adolescent treatments, tested through controlled clinical trials, have produced beneficial effects in hundreds of studies. By contrast, the limited pool or research on traditional clinical treatments raises doubts about their effectiveness. Thus, identification of empirically supported treatments may contribute something of real value to clinical practice and training. The Child Task Force report represents an important initial step in this direction. Here we offer both praise and critique, suggesting a number of ways the task force process and product may be improved. In addition, we suggest several ways to strengthen and enrich the clinical trials research available to the Task Force, emphasizing the need to test empirically supported treatments with referred youth in practice settings.

Identifying and developing empirically supported child and adolescent treatments

Child and adolescent therapy outcome research findings attest to the efficacy of a variety of treatments. This article illustrates promising treatments for selected internalizing (anxiety and depression), externalizing (oppositional, and antisocial behavior), and other (obesity and autism) conditions, and for other aims (preparation for medical and dental procedures). Studies in these areas illustrate worthwhile characteristics that can help inform the search for empirically supported treatments. These characteristics include randomized controlled trials, well-described and replicable treatments, tests with clinical samples, tests of clinical significance, broad-based outcome assessment including measures of real-world functioning, and others. Continued research progress will depend on greater attention to magnitude and maintenance of therapeutic change, long-term follow-up, moderators and mediators of change, and development and testing of treatment in conditions relevant to clinical practice.

Identifying and developing empirically supported child and adolescent treatments

Child and adolescent therapy outcome research findings attest to the efficacy of a variety of treatments. This article illustrates promising treatments for selected internalizing (anxiety and depression), externalizing (oppositional, and antisocial behavior), and other (obesity and autism) conditions, and for other aims (preparation for medical and dental procedures). Studies in these areas illustrate worthwhile characteristics that can help inform the search for empirically supported treatments. These characteristics include randomized controlled trials, well-described and replicable treatments, tests with clinical samples, tests of clinical significance, broad-based outcome assessment including measures of real-world functioning, and others. Continued research progress will depend on greater attention to magnitude and maintenance of therapeutic change, long-term follow-up, moderators and mediators of change, and development and testing of treatment in conditions relevant to clinical practice.

Experimental task and speaker effects on parent-child interactions of aggressive and depressed/anxious children

Parent-child interactions of aggressive and depressed/anxious clinic-referred children were observed during two different tasks: planning a vacation and discussing a conflict. Marked group differences were found as a function of the type of task, who was speaking (parent vs. child), and type of child psychopathology. Negative behaviors (e.g., Belittling and Blaming) were especially pronounced in the conflict task, whereas positive behaviors (e.g., Nurturing and Protecting) were more common in the planning task. Parents displayed other-directed behavior (e.g., Watching and Controlling), whereas children showed more self-directed behavior (e.g., Walling Off and Distancing), and patterns of child psychopathology interacted with task and speaker in theoretically important ways; for example, parents of aggressive children showed more Belittling and Blaming than their children in the conflict task, but not in the planning task. The findings highlight key factors that may need to be incorporated into models of parent-child interaction and child psychopathology.

Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training

Elementary school children with mild-to-moderate depressive symptoms were randomly assigned to a control group or an 8-session Primary and Secondary Control Enhancement Training program. The program focused on (a) primary control (changing objective conditions to fit one's wishes; e.g., through activity selection and goal attainment) and (b) secondary control (changing oneself to buffer the impact of objective conditions; e.g., altering depressogenic thinking, practicing mood-enhancing cognitions). At immediate posttreatment and 9-month follow-up, the treatment group showed greater reductions than the control group in depressive symptomatology on the Children's Depression Inventory and the Revised Children's Depression Rating Scale, and treated children, more than controls, shifted from above to within the normal range on both measures. Future research is needed to test treatment effects with severely depressed youths.

Ego control, Ego resiliency, and the Five-Factor Model as predictors of behavioral and emotional problems in clinic-referred children and adolescents

The relations of Ego control (EC), Ego resiliency (ER), and the Five-Factor Model of Personality (FFM) with behavioral and emotional problems were explored among 116 clinic-referred children. Within the EC-ER model, Ego undercontrol was most important in predicting externalizing problems, and both Ego brittleness (the relative absence of ER) and Ego undercontrol made equal contributions to predicting internalizing problems. Within the FFM, Extraversion and Agreeableness were independent predictors of externalizing problems, whereas only Neuroticism predicted internalizing problems. When the EC-ER model was tested against the FFM, the latter model appeared to outperform the former in predicting externalizing but not internalizing problems; when clinical syndrome groups were examined, dimensions from both personality models were differentially salient for children with primary internalizing, externalizing, or comorbid problems.

Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training

Elementary school children with mild-to-moderate depressive symptoms were randomly assigned to a control group or an 8-session Primary and Secondary Control Enhancement Training program. The program focused on (a) primary control (changing objective conditions to fit one's wishes; e.g., through activity selection and goal attainment) and (b) secondary control (changing oneself to buffer the impact of objective conditions; e.g., altering depressogenic thinking, practicing mood-enhancing cognitions). At immediate posttreatment and 9-month follow-up, the treatment group showed greater reductions than the control group in depressive symptomatology on the Children's Depression Inventory and the Revised Children's Depression Rating Scale, and treated children, more than controls, shifted from above to within the normal range on both measures. Future research is needed to test treatment effects with severely depressed youths.

Ego control, Ego resiliency, and the Five-Factor Model as predictors of behavioral and emotional problems in clinic-referred children and adolescents

The relations of Ego control (EC), Ego resiliency (ER), and the Five-Factor Model of Personality (FFM) with behavioral and emotional problems were explored among 116 clinic-referred children. Within the EC-ER model, Ego undercontrol was most important in predicting externalizing problems, and both Ego brittleness (the relative absence of ER) and Ego undercontrol made equal contributions to predicting internalizing problems. Within the FFM, Extraversion and Agreeableness were independent predictors of externalizing problems, whereas only Neuroticism predicted internalizing problems. When the EC-ER model was tested against the FFM, the latter model appeared to outperform the former in predicting externalizing but not internalizing problems; when clinical syndrome groups were examined, dimensions from both personality models were differentially salient for children with primary internalizing, externalizing, or comorbid problems.

"You can try or you can just give up": the impact of perceived control and coping style on childhood homesickness

Research on children's coping with homesickness during relatively uncontrollable separations has suggested that secondary control coping (i.e., adjusting oneself to fit objective conditions) is often preferred over primary control coping (i.e., modifying objective conditions to fit oneself). Related research suggests that negative affect is associated with (a) relinquishing control or using primary control to cope with uncontrollable stressors and (b) perceiving low control over stressors. The convergence of these factors was examined for the stressor of homesickness. Among 1,032 boys and girls spending 2 weeks at residential summer camps, the most frequent and effective way of coping with homesickness was to exert secondary control by engaging in a distracting physical activity. Contrary to speculation, the use of secondary control coping rose in adolescence. Congruent with empirical predictions, the most homesick children perceived low control over homesickness and separation, and coped by relinquishing control.

More of what? Issues raised by the Fort Bragg study

The sobering findings of the Fort Bragg study illustrate why ambitious demonstration projects must be combined with objective outcome evaluations. The study does suggest that "more is not always better" (L Bickman, 1996), but more of what? Little is known about the specific interventions that were combined to form the Fort Bragg system of care, so the study does not really reveal what failed or what needs to be changed. Moreover, there is no evidence that the specific treatments used had any empirical support. Combining and systematizing various treatments may not produce improved outcomes if the treatments are not effective in the first place. Costly demonstration programs that combine untested treatments may be a poor investment. A better strategy may be to develop and test an array of well-documented treatments for an array of child and family problems, creating the building blocks needed for effective systems of care in the future.

"You can try or you can just give up": the impact of perceived control and coping style on childhood homesickness

Research on children's coping with homesickness during relatively uncontrollable separations has suggested that secondary control coping (i.e., adjusting oneself to fit objective conditions) is often preferred over primary control coping (i.e., modifying objective conditions to fit oneself). Related research suggests that negative affect is associated with (a) relinquishing control or using primary control to cope with uncontrollable stressors and (b) perceiving low control over stressors. The convergence of these factors was examined for the stressor of homesickness. Among 1,032 boys and girls spending 2 weeks at residential summer camps, the most frequent and effective way of coping with homesickness was to exert secondary control by engaging in a distracting physical activity. Contrary to speculation, the use of secondary control coping rose in adolescence. Congruent with empirical predictions, the most homesick children perceived low control over homesickness and separation, and coped by relinquishing control.

More of what? Issues raised by the Fort Bragg study

The sobering findings of the Fort Bragg study illustrate why ambitious demonstration projects must be combined with objective outcome evaluations. The study does suggest that "more is not always better" (L Bickman, 1996), but more of what? Little is known about the specific interventions that were combined to form the Fort Bragg system of care, so the study does not really reveal what failed or what needs to be changed. Moreover, there is no evidence that the specific treatments used had any empirical support. Combining and systematizing various treatments may not produce improved outcomes if the treatments are not effective in the first place. Costly demonstration programs that combine untested treatments may be a poor investment. A better strategy may be to develop and test an array of well-documented treatments for an array of child and family problems, creating the building blocks needed for effective systems of care in the future.

Reciprocal influences among adrenocortical activation, psychosocial processes, and the behavioral adjustment of clinic-referred children

The reciprocal effects among cognitive-behavioral, environmental, and biological influences on clinic-referred children's (N = 64; 34 boys; M age 12.71 years) short-term psychological and psychiatric adjustment were studied. At clinic intake and 6 months later, standardized measures of adjustment and control-related beliefs were assessed. Before and after conflict-oriented parent-child interaction tasks the children's saliva was sampled. Adrenocortical responses (i.e., increases in salivary cortisol) to the social conflict task predicted children's internalizing problem behaviors and anxiety disorders at follow-up. Consistently high adrenocortical reactivity at intake and follow-up was associated with deflated social competence over the 6-month period. Also, specific patterns of discontinuity in children's internalizing behavior problems predicted individual differences in their subsequent adrenocortical responsiveness. Specifically, rising behavior problem levels across time predicted higher and declining behavior problem levels predicted lower adrenocortical reactivity at follow-up. Findings are among the first to suggest links among internalizing behavior problems, adrenocortical responsiveness to social challenge, and clinic-referred children's short-term cognitive-behavioral and emotional adjustment.

Help-seeking preceding mental health clinic intake among African-American, Latino, and Caucasian youths

OBJECTIVE

Pathways into child mental health clinics were studied to test this hypothesis: Prior to contacting clinics for their child's problems, African-American and Latino families are less likely than Caucasian families to seek help from agencies and professionals (and more likely to contact family and community sources).

METHOD

Regression analyses, applied to a sample of 192 clinic-admitted families, assessed the impact of ethnicity and income, child gender and age, and parent perceptions of child problem severity and likely treatment benefit, on preclinic help-seeking.

RESULTS

As predicted, African-American and Latino families, compared with Caucasian families, sought help from professionals and agencies much less often, as a first step and as a percentage of all their preclinic help-seeking. With income, age, gender, and parent perceptions in the model, both African-American and Latino families were 0.37 as likely as Caucasian families to seek initial help from a professional or agency.

CONCLUSION

Although many minority youths are admitted to mental health clinics, seeking help from professionals may not have been their parents' preference. The apparent reluctance of minority parents carries implications for clinical intervention and alliance formation with minority group families and for the design and evaluation of ethnic community outreach programs.

Bridging the gap between laboratory and clinic in child and adolescent psychotherapy

Meta-analyses of laboratory outcome studies reveal beneficial effects of psychotherapy with children and adolescents. However, the research therapy in most of those lab studies differs from everyday clinic therapy in several ways, and the 9 studies of clinic therapy the authors have found show markedly poorer outcomes than research therapy studies. These findings suggest a need to bridge the long-standing gap between outcome researchers and clinicians. Three kinds of bridging research are proposed and illustrated: (a) enriching the research data base on treatment effects by practitioners in clinical settings--including private practice and health maintenance organizations, (b) identifying features of research therapy that account for positive outcomes and applying those features to clinical practice, and (c) exporting lab-tested treatments to clinics and assessing their effects with referred youths. If these bridging strategies were widely adopted, despite the numerous obstacles described herein, real progress might be made toward more effective treatment in clinical practice.

Determinants and consequences of children's coping in the medical setting: conceptualization, review, and critique

The recent burgeoning of theory and research on how children cope with painful medical stressors warrants close scrutiny. The authors examine the prominent typologies of coping and the research on child adjustment and outcomes stimulated by those typologies. They focus on what researchers know and need to know about moderators (characteristics of the child and the environment that influence coping and outcome) and mediators (mechanisms linking stress, coping, and adjustment). It is argued that important advances can be achieved through efforts to (a) conceptualize and study pain and coping within a multidisciplinary framework; (b) clearly distinguish among coping responses, goals, and outcomes; and (c) replace simplistic conceptualizations with transactional and goodness-of-fit models.

Bridging the gap between laboratory and clinic in child and adolescent psychotherapy

Meta-analyses of laboratory outcome studies reveal beneficial effects of psychotherapy with children and adolescents. However, the research therapy in most of those lab studies differs from everyday clinic therapy in several ways, and the 9 studies of clinic therapy the authors have found show markedly poorer outcomes than research therapy studies. These findings suggest a need to bridge the long-standing gap between outcome researchers and clinicians. Three kinds of bridging research are proposed and illustrated: (a) enriching the research data base on treatment effects by practitioners in clinical settings--including private practice and health maintenance organizations, (b) identifying features of research therapy that account for positive outcomes and applying those features to clinical practice, and (c) exporting lab-tested treatments to clinics and assessing their effects with referred youths. If these bridging strategies were widely adopted, despite the numerous obstacles described herein, real progress might be made toward more effective treatment in clinical practice.

Relative effectiveness of behavioral versus nonbehavioral child psychotherapy

Some researchers have concluded that, for children and adolescents, behavioral interventions may be more effective than nonbehavioral interventions. Other researchers, however, have proposed artifactual hypotheses for the apparent superiority of behavioral treatments. In this study, one such hypothesis was evaluated: that the apparent superiority of behavioral interventions among children is due to differences in the methodological quality of studies of behavioral and nonbehavioral treatments. Meta-analytic results reported in this article found little support for this hypothesis.

Effects of psychotherapy with children and adolescents revisited: a meta-analysis of treatment outcome studies

A meta-analysis of child and adolescent psychotherapy outcome research tested previous findings using a new sample of 150 outcome studies and weighted least squares methods. The overall mean effect of therapy was positive and highly significant. Effects were more positive for behavioral than for nonbehavioral treatments, and samples of adolescent girls showed better outcomes than other Age x Gender groups. Paraprofessionals produced larger overall treatment effects than professional therapists or students, but professionals produced larger effects than paraprofessionals in treating overcontrolled problems (e.g., anxiety and depression). Results supported the specificity of treatment effects: Outcomes were stronger for the particular problems targeted in treatment than for problems not targeted. The findings shed new light on previous results and raise significant issues for future study.

Relative effectiveness of behavioral versus nonbehavioral child psychotherapy

Some researchers have concluded that, for children and adolescents, behavioral interventions may be more effective than nonbehavioral interventions. Other researchers, however, have proposed artifactual hypotheses for the apparent superiority of behavioral treatments. In this study, one such hypothesis was evaluated: that the apparent superiority of behavioral interventions among children is due to differences in the methodological quality of studies of behavioral and nonbehavioral treatments. Meta-analytic results reported in this article found little support for this hypothesis.

A multimethod study of problem behavior among Thai and American children in school: teacher reports versus direct observations

Previous literature describes Thai children as unusually polite, deferent, and behaviorally restrained. Yet, in a recent study employing teacher reports, Thai children were reported to show many more behavior problems than American children. Such a finding may reflect culture-linked differences in the perspective of Thai versus American teachers. To explore this possibility, we used trained observers to conduct direct observations of Thai and American children's school behavior, and we obtained teacher reports on the same children. Observational results were precisely the opposite of previous and present teacher-report findings: Observers reported twice as much problem behavior and off-task behavior in American children as in their Thai age-mates. This pattern may reflect Thai-U.S. differences in teachers' style, societal values and practices, even child temperament. The finding support the value of direct behavior observation in cross-national research on child problems.

Child and adolescent psychotherapy outcomes in experiments versus clinics: why the disparity?

In a recent article, Weisz, Weiss, and Donenberg (1992) compared the effects of child and adolescent psychotherapy in experimental studies and in studies of clinic practice. Here we update that report with new information and we explore 10 possible reasons why, to date, therapy in experiments appears to have shown larger effect sizes than therapy in clinics. We find that beneficial therapy effects are associated with three factors which are more common in research therapy than in clinic therapy: (a) the use of behavioral (including cognitive-behavioral) methods, (b) reliance on specific, focused therapy methods rather than mixed and eclectic approaches, and (c) provision of structure (e.g., through treatment manuals) and monitoring (e.g., through review of therapy tapes) to foster adherence to treatment plans. These three factors all involve dimensions along which clinic procedures could be altered.

Neuroendocrine reactivity, internalizing behavior problems, and control-related cognitions in clinic-referred children and adolescents

Literature on neuroendocrine-behavior relations suggests that cortisol reactivity to social challenge may be associated with children's internalizing problem behavior. To explore this possibility, and the role of control-related beliefs, we studied 102 7-17-year-old clinic-referred children. Measures of problem behavior, depression and anxiety, and control-related beliefs were collected, and Ss' saliva was sampled before and after a parent-child conflict task. Neuroendocrine activation (i.e., cortisol increase) in response to the interaction task was associated with Ss' (a) social withdrawal, social anxiety, and social problems; (b) socially inhibited behavior during the task; and (c) low levels of perceived social contingency and high levels of external attributions for personal successes and failures. Our findings are among the first to link children's behavioral response to social challenge, neuroendocrine activation, cognitions, and psychopathology.

Primary and secondary control among children undergoing medical procedures: adjustment as a function of coping style

The literature suggests that optimal adjustment to relatively uncontrollable stressors may require adjusting oneself to the stressors rather than trying to alter them. This possibility was explored, for low-controllability stressors (e.g., painful medical procedures) associated with leukemia. Children's reports of coping strategies and goals were classified as primary control coping (attempts to alter objective conditions), secondary control coping (attempts to adjust oneself to objective conditions), or relinquished control (no attempt to cope). Secondary control coping was positively associated with (a) general behavioral adjustment assessed by the Child Behavior Checklist and (b) illness-specific adjustment assessed by children's own distress ratings and by behavioral observations during painful procedures. All significant group differences showed better adjustment among secondary control children than among the primary or relinquished groups.

Parental caregiving and child externalizing behavior in nonclinical samples: a meta-analysis

A meta-analysis of 47 studies was used to shed light on inconsistencies in the concurrent association between parental caregiving and child externalizing behavior. Parent-child associations were strongest when the measure of caregiving relied on observations or interviews, as opposed to questionnaires, and when the measure tapped combinations of parent behaviors (patterns), as opposed to single behaviors. Stronger parent-child associations were also found for older than for younger children, and for mothers than for fathers. Finally, externalizing was more strongly linked to parental caregiving for boys than for girls, especially among preadolescents and their mothers. The meta-analysis helps account for inconsistencies in findings across previous studies and supports theories emphasizing reciprocity of parent and child behavior.

Neuroendocrine reactivity, internalizing behavior problems, and control-related cognitions in clinic-referred children and adolescents

Literature on neuroendocrine-behavior relations suggests that cortisol reactivity to social challenge may be associated with children's internalizing problem behavior. To explore this possibility, and the role of control-related beliefs, we studied 102 7-17-year-old clinic-referred children. Measures of problem behavior, depression and anxiety, and control-related beliefs were collected, and Ss' saliva was sampled before and after a parent-child conflict task. Neuroendocrine activation (i.e., cortisol increase) in response to the interaction task was associated with Ss' (a) social withdrawal, social anxiety, and social problems; (b) socially inhibited behavior during the task; and (c) low levels of perceived social contingency and high levels of external attributions for personal successes and failures. Our findings are among the first to link children's behavioral response to social challenge, neuroendocrine activation, cognitions, and psychopathology.

Primary and secondary control among children undergoing medical procedures: adjustment as a function of coping style

The literature suggests that optimal adjustment to relatively uncontrollable stressors may require adjusting oneself to the stressors rather than trying to alter them. This possibility was explored, for low-controllability stressors (e.g., painful medical procedures) associated with leukemia. Children's reports of coping strategies and goals were classified as primary control coping (attempts to alter objective conditions), secondary control coping (attempts to adjust oneself to objective conditions), or relinquished control (no attempt to cope). Secondary control coping was positively associated with (a) general behavioral adjustment assessed by the Child Behavior Checklist and (b) illness-specific adjustment assessed by children's own distress ratings and by behavioral observations during painful procedures. All significant group differences showed better adjustment among secondary control children than among the primary or relinquished groups.

Control-related beliefs and self-reported depressive symptoms in late childhood

Research thus far links depressive symptoms in children to one type of control-related belief: low levels of perceived personal competence. However, child research, unlike adult research, has not supported a linkage between depressive symptoms and another theoretically important control-related belief: perceived noncontingency of outcomes. Here we reexamined the issue, adjusting for limitations in previous methodology by using (a) psychometrically stronger measures of control beliefs, and (b) a general population sample rather than children being treated in mental health clinics. In contrast to previous results, we found that both perceived incompetence and perceived noncontingency were strongly related to children's depression, together accounting for 40% of the variance in Child Depression Inventory scores. We also found, as in previous research, that depressive symptoms were correlated with uncertainty as to the causes of outcomes, especially successes. The findings suggest that children may be susceptible to both "personal helplessness" and "universal helplessness" forms of depression.

Control-related beliefs and self-reported depressive symptoms in late childhood

Research thus far links depressive symptoms in children to one type of control-related belief: low levels of perceived personal competence. However, child research, unlike adult research, has not supported a linkage between depressive symptoms and another theoretically important control-related belief: perceived noncontingency of outcomes. Here we reexamined the issue, adjusting for limitations in previous methodology by using (a) psychometrically stronger measures of control beliefs, and (b) a general population sample rather than children being treated in mental health clinics. In contrast to previous results, we found that both perceived incompetence and perceived noncontingency were strongly related to children's depression, together accounting for 40% of the variance in Child Depression Inventory scores. We also found, as in previous research, that depressive symptoms were correlated with uncertainty as to the causes of outcomes, especially successes. The findings suggest that children may be susceptible to both "personal helplessness" and "universal helplessness" forms of depression.

Behavioral and emotional problems among Thai and American adolescents: parent reports for ages 12-16

We studied adolescents' behavioral and emotional problems in the United States and in Thailand, a Buddhist country in which, reportedly, aggression is discouraged and self-control, emotional restraint, and social inhibition are encouraged. Standardized parent reports on 118 problems revealed 45 Thai-U.S. differences. Thai adolescents were reported to show more overcontrolled problems (e.g., shyness, compulsivity, inhibition of talking, fearfulness, and constipation) than American adolescents (p < .0001). The two groups did not differ reliably in total undercontrolled problems, but Americans showed higher levels of direct, overt, and interpersonally aggressive undercontrol (e.g., fighting and bullying), whereas Thais showed more indirect and subtle undercontrol that was not interpersonally aggressive (e.g., sulking and sullenness). The findings suggest that different cultures may be linked to different styles of adolescent problem behavior.

Parent reports of behavioral and emotional problems among children in Kenya, Thailand, and the United States

The behavioral and emotional problems children develop may differ from one cultural context to another. We explored this possibility, comparing 11-15-year-old Embu children in Kenya, Thai children, African-American children, and Caucasian-American children. Standardized parent reports on 118 problems revealed 62 significant (p < .01) culture effects. Caucasian-Americans were rated particularly high on undercontrolled problems (e.g., arguing, disobedient at home, cruel to others). Embu children were rated particularly high on overcontrolled problems (e.g., fears, feels guilty, somatic concerns), largely because of the numerous somatic problems reported. The findings may relate to the strict emphasis on compliance and obedience among the Embu, as opposed to the greater independence permitted in the United States. But alternative interpretations are discussed as well, including the effects of parent sensitivities and Third World living conditions.

Relations among self-reported depressive symptoms in clinic-referred children versus adolescents

Although there is consensus regarding the existence of childhood depression, disagreement remains as to whether symptoms are developmentally isomorphic. Previous studies focused on developmental differences in symptom levels; analyses of relations among symptoms may be more appropriate, however. Here both approaches were used to compare the Children's Depression Inventory responses from 1,030 clinic-referred children and adolescents. Four of nine symptom categories showed significant developmental differences in their correlations with total score. Externalizing behavior and guilt were more strongly related to depression in children than adolescents; affective symptoms and concerns about the future showed the reverse pattern. Results illustrate the importance of considering relations among symptoms as well as differences in symptom levels when evaluating theoretical claims about developmental differences in the nature of clinical syndromes.