Assessing the effects of clinic-based psychotherapy with children and adolescents

Recent meta-analyses suggest that psychotherapy is quite effective with children and adolescents. However, most research in those analyses involved controlled laboratory interventions that may not represent typical therapy in clinics. We studied more representative treatment as it routinely occurs, in 9 clinics. We compared 93 youngsters who completed a course of therapy with 60 who dropped out after intake. At intake, the groups did not differ on demographic, family, or clinical measures, including Child Behavior Checklist (CBCL) scores. Six months later (when therapy had ended for 98% of the treated children) and again 1 year later, the 2 groups were compared on CBCL scores, parent ratings of each child's major referral problem, and (for a subsample) teacher reports. No comparison showed significant main effects of therapy. The findings (a) raise questions about the generalizability of findings from research-oriented therapy and (b) suggest that the control and precision of research therapy may be needed in clinical practice.     

A meta-analysis of the effects of psychotherapy with sexually abused children and adolescents

This paper presents a meta-analysis of the psychotherapy treatment outcome studies for sexually abused children and adolescents. There were 39 studies included, most of which aimed to treat the psychological effects of childhood sexual abuse. Separate meta-analyses were conducted according to study design and outcome domain, in keeping with meta-analytic conventions. However, given heterogeneity across studies and the need for sufficient n in each category for meaningful moderator analyses, the study designs were pooled into a repeated measures meta-analysis. There were large effect sizes for global outcomes (g = 1.37) and PTSD/trauma outcomes (g = 1.12). More moderate effect sizes were evident for internalizing symptoms (g = 0.74), self-appraisal (g = 0.63), externalizing symptoms (g = 0.52), and sexualized behavior (g = 0.49), while small effects were found for measures of coping/functioning (g = 0.44), caregiver outcomes (g = 0.43), and social skills/competence (g = 0.38). Effects were maintained at follow-up more than six months after treatment for some outcome domains but not others. Studies represented diverse treatment approaches, and most treatments were effective in symptom reduction. Presence of probable moderators of treatment outcome varied across symptom domains, reflecting importance of targeting therapy to individual needs.     

Ethical issues in psychotherapy with adolescents

Treating adolescents in psychotherapy presents a number of unique ethical challenges. Because many adolescents who enter treatment have not yet attained the age of majority, reside in families that include other people with emotional difficulties, attend school, become involved with community agencies (e.g., the courts), and must generally take direction from adult authority figures, the role of the therapist becomes particularly complex. The unique dilemmas include developing specialized clinical competence, treatment contracting, choice of treatment modality, direction of the therapeutic process, and confidentiality. This article discusses the range of ethical concerns involved in treating adolescents and suggests strategies for optimal ethical care.     

Storytelling through pictures: Culturally sensitive psychotherapy for Hispanic children and adolescents

Examined treatment effects with Hispanic children and adolescents using a culturally sensitive storytelling intervention. Inner-city 9- 13-year-olds (N = 90) were screened for symptomatc7bgy by structured interview, randomly assigned to an 8-week intervention or attention-control group, and pre- and posttested with standardized instruments measuring anxiety, depression, and phobic symptomatology and school conduct. No treatment differences in depression were found. Differences in favor of storytelling were found on the remaining outcomes, most consistently among 11- to 13-year-olds. Results are discussed in t e r n of programmatic research on culturally sensitive modalities for specific age groups and in support of the broader role of narrative processes in psychotherapy.     

Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people.     

Questions of guidance and supervision at the beginning of psychotherapy in children and adolescents

Firstly, the significance of the establishment of a positive working alliance in children and adolescents at the beginning of a potential psychotherapy is described. Secondly, questions of supervision by means of psychodramatic treatment of transitional situations are discussed. (1) Children and adolescents are mostly presented by the parents and initially have no or hardly any motivation for psychotherapy. The author therefore recommends inter alia a ten-wish phantasy game at the first encounter with the child or adolescent irrespective of the reason for presentation by the parents. The possibility of being able to express ten wishes or changes which a fairy or a magician would fulfill for the child encourages the patient to name the most diverse levels and dimensions of his/her psychological reality and to reflect it in the form of wishes. The therapist thus provides space for yearnings and compensatory 'counterworlds', frequently leading to a positive contact in a subsequent dialog about the wishes. (2) In training, the young psychotherapist is often not aware of his transference and countertransference relationship. Psychodramatic role play in a supervised colleague group or in the development of a psychodramatic 'family sculpture' may frequently clarify the situation quickly by own experience and by 'psychodramatic reflection technique'.     

Qualitative clinical research with children and adolescents.

This article provides an overview of how qualitative research methods (QRMs) can augment the literature in child and adolescent clinical psychology by contributing to theory and hypothesis building. We discuss the utility of qualitative methods in examining the nature of clinical processes and obtaining deeper understandings about quantitative findings. We also present strategies for designing and conducting qualitative investigations, address ethical issues involved in conducting qualitative research with minors, and discuss limitations on inferences that can be made from qualitative findings.     

Efficacy of brief dynamic psychotherapy for children with emotional disorders.

BACKGROUND: Child psychiatry has enjoyed a long tradition of using brief psychotherapy with children, but research on its efficacy and effectiveness in the setting of routine clinical care is remarkably sparse; the aim of this study was to evaluate the efficacy of an original model of brief psychodynamic psychotherapy (BPP) for children with emotional disorders in a clinical outpatient setting. METHODS: A sample of 30 subjects (6.3-10.9 years old) was divided into an experimental BPP group and a control group. Each subject was evaluated at the beginning, after 6 months and at an 18-months follow-up. Outcome measures were Children's Global Assessment Scale and Child Behavior Check-List. Statistical and clinical significance of change were evaluated. RESULTS: At the first evaluation, the experimental group showed a better improvement in global functioning; at follow-up, the two groups improved to a comparable degree, but only the mean of the experimental group moved to a functional range. The experimental group showed a significant reduction in total behavioral problems and externalizing problems at the follow-up. CONCLUSIONS: The better improvement of the experimental group in two outcome measures suggests that BPP is efficient in emotional disorders. The hypothesis that BPP introduces changes at long term (sleeper effects) is suggested. The improvement in global functioning of the two groups is discussed in relation to specific characteristics of emotional disorders. Finally, limitations of the study are discussed and in particular the bias introduced by lack of randomization.     

Culturally sensitive psychotherapy for Puerto Rican children and adolescents: a program of treatment outcome research

Recognition of cultural distance between Hispanic clients and non-Hispanic therapists has prompted efforts to introduce culture into therapy, but there is little evidence that such efforts influence treatment outcomes. This article evaluates treatment outcomes from a program of research on modeling therapy with Puerto Ricans, targeting anxiety symptoms, acting-out behavior, and self-concept problems. Evaluation of outcomes confirmed the impact of culturally sensitive modeling therapy on anxiety symptoms and other selected target behaviors, but negative treatment effects also were evident. Results suggest that new approaches to psychotherapy for special populations, such as Hispanic children and adolescents, should be buttressed by programmatic research oriented toward the comparative evaluation of treatment outcomes and should be attuned to therapeutic processes mediating between culture and outcome.     

The outcomes of psychotherapy with adolescents: a practitioner-friendly research review

This article summarizes the outcome findings of psychotherapy with adolescents through an examination of the research literature. In this problem-focused review of the research literature, we consider adolescent treatment of anxiety disorders, depression, eating disorders, disruptive behavior disorders, multiple problems of adolescence, and health risk behaviors. The evidence base for the effectiveness of various psychotherapies for adolescents is mixed. Psychotherapy in general has been a ripe field in which unsupported approaches have grown, and this is certainly true for psychotherapeutic interventions with adolescents. Nonetheless, there is a growing body of evidence to support various types of interventions as effective for different presenting problems. Researchers and clinicians need to recognize the complexity of the diverse characteristics of adolescents, including variations of culture, race, ethnicity, gender, class, physical disability, family definitions and constellation, and sexual orientation. These require sensitivity, responsiveness, and competence by the therapist, but clinical research has not fully examined these considerations.     

Effectiveness of psychotherapy and combination treatment for chronic depression

Although considerable research has been conducted on the efficacy of psychotherapy for depression, with and without medication, relatively few studies have focused on chronic forms of depression. Approximately 20% of individuals with depression experience episodes that last for two years or longer. We review the controlled research on the effectiveness of treatments separately for dysthymia and chronic major depression, focusing on the practical implications of the research for clinicians. In trials conducted with dysthymics, medication has been superior to psychotherapy, with limited evidence that combined treatment has advantages over medication or psychotherapy alone. In chronic major depression, combined treatment has demonstrated significant superiority over medication or psychotherapy alone. Possible explanations for the discrepant findings among dysthymics and those with chronic major depression are discussed.     

Tiotropium in children and adolescents with asthma

BackgroundAsthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium—a long-acting muscarinic antagonist—as add-on therapy to an inhaled corticosteroid with or without a long-acting β₂-agonist provides clinical benefit with a safety profile similar to placebo.ObjectiveTo review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s).MethodsWe searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events.ResultsOverall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection.ConclusionOnce-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.