Evidence-based psychotherapies for children and adolescents by Weisz and Kazdin (third edition) – Book summary
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Some structured, manual-guided treatments may show reduced effects when they are implemented in more clinically representative contexts and compared to usual practice in those contexts. This may be because treatments tend to be developed away from the clinical practice. There are several potential mismatches between evidence-based practice and real-world clinical care:Clinicians in practice settings typically carry diagnostically diverse caseloads but most evidence-based practices on one problem or a homogeneous cluster.Clinically referred youth typically present with comorbidity.Treatment may need to shift during treatment while evidence-based practice often does not take this into account.Everyday clinical care often has an unpredictable course contrary to the design of evidence-based practices which are standardized.The deployment-focused model of treatment development and testing includes a series of steps aimed at building and testing interventions with the clients and clinicians and within real-world contexts. It is also tested whether interventions improve on current practice in those contexts. Making evidence-based practice work well in practice mainly involves making the treatments fit variations in individual and family characteristics. Personalized mental health interventions include strategies for selecting treatments, deciding whether and how to combine them, determining what problem to target first and with what techniques and using information about individual client characteristics and ongoing treatment response to inform clinical decision making. In other words, treatment should be personalized. There are several methods of identifying an individual’s optimal treatment:Meta-analyses comparing treatments for specific client characteristicsThis includes a meta-analysis which compares different treatments based on specific characteristics of the patient. This can help guide selection. Individualized metrics (e.g....
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Psychotherapy refers to any interventions that is designed to reduce distress or maladaptive behaviour or enhance adaptive functioning and uses means such as counselling and structured and other planned psychosocial interventions. The goals include improving adjustment and functioning in both intrapersonal and interpersonal spheres. Next, the goal is to reduce maladaptive behaviours and psychological and/or physical complaints.
Nowadays, guidelines for making studies to evaluate psychotherapy exist. There is no consensus for when something can be considered evidence-based psychotherapy (EBP). Most guidelines includes something as evidence-based when there are at least two studies with the following:
Evidence-based is a continuum.
Anxiety disorders are common in youth with a prevalence rate of 10% to 20%. It is associated with difficulties in academic achievement, social and peer relations and future emotional health. It is a risk factor for comorbidity and comorbidity is also very common.
Anxiety consists of a behavioural (1), physiological (2) and cognitive component (3). Anxiety is part of normal development (i.e. it cautions one against danger) and can bolster performance (e.g. tests). However, too much anxiety can quickly become distressing. Youth with anxiety view the world as dangerous (1), experience physical complaints (2) and avoid certain situations (3). Avoidance reinforces feelings of anxiety and avoidance behaviours.
Coping Cat is a treatment for anxiety disorders for children from the age of 7 to 13. This treatment targets all aspects of anxiety (i.e. tripartite model). It includes psychoeducation (1), somatic management skills (2), cognitive restructuring (3), gradual exposure to feared situations (4) and relapse prevention plans (5). Affective awareness is increased during the early stages of treatment and corrective information about anxiety is provided (e.g. normalization of feelings of anxiety). Somatic management techniques are introduced as adaptive responses. Cognitive restructuring focuses on challenging maladaptive thoughts and shifting to coping-focused thinking. The C.A.T. project is a treatment for anxiety disorders for adolescents. CBT may also be useful.
The goal of the Coping Cat treatment is to teach youth to recognize signs of anxiety and implement strategies to better cope with the distress rather than completely eliminate anxiety. There is typically an individual meeting with the child for several weeks and two meetings with the parents. Coping Cat mainly focuses on practicing the application of anxiety management strategies in real, anxiety-provoking situations.
In the first half of the treatment, children are being taught a four-step FEAR plan to organize the psychoeducational content into problem-solving steps:
Major depressive disorder (MDD) is one of the most prevalent mental disorders among adolescents. The prevalence in adolescence is 15% to 20%. Early onset is marked by a recurrent course, psychiatric comorbidity and a range of negative outcomes (e.g. poor academic achievement). Adolescent MDD has a mean duration of six months but longer episodes are associated with earlier onset or suicide ideation.
The experience of MDD impacts almost all domains of functioning. People who have had a depression continued to experience differences on domains of functioning compared to never-depressed peers. There likely is not a single maintaining or causal factor for depression. Comorbidity is very common at almost 50% with anxiety disorders (1), substance use disorder (2) and conduct disorder (3) being most common. Comorbidity is higher in adolescence than in adulthood.
The cognitive vulnerability model states that individuals at risk for depression selectively focus and have better memory recall for negative rather than positive stimuli. One important goal of cognitive-behavioural treatment (CBT) is to help people become aware of pessimistic thoughts (1), depressotypic beliefs (2) and causal attributions of self-blame (3). After recognition, these cognitions can be changed for more realistic ones.
Behavioural theories of depression emphasize the role of maladaptive actions in the onset and maintenance of depression. It holds that depressive symptoms develop and persist as the result of decreased environmental reward (1), reductions in positively reinforced behaviours (2) and reinforcement of depressive behaviours (3). The goal of behaviour based treatment is to increase engagement in activities that are personally reinforcing.
CBT combines cognitive and behavioural strategies. It includes focus on specific and current actions and cognitions (1), structured sessions (2), repeated skills practice (3), the use of rewards and contracts (4), homework assignments (5) and a relatively small number of sessions (6). CBT tries to teach adolescents a variety of coping strategies that will allow them to counteract the diverse factors that contribute to their depression and deal more effectively with new problems.
The adolescent coping with depression course (CWD-A) is a group-based CBT intervention for depression. It consists of 16 two-hour sessions over 8 weeks. It includes eight components:
Multisystemic therapy refers to a treatment for adolescents with severe antisocial behaviour and includes their families. It is appropriate and cost-effective for youth referred to by the juvenile justice system with serious and chronic patterns of offending and at high-risk of out-of-home placement due to the relative intensity of the treatment. Teenagers with conduct disturbances and substance abuse problems can also be included.
MST aims to address multiple risk factors associated with juvenile offending and bases itself on Bronfenbrenner’s model. Therefore, MST tries to target risk actors at multiple levels (e.g. individual; family; peer; school). MST also needs to address difficulties between the systems (e.g. caregiver interaction with teachers and peers). The factors that create barriers to the effective functioning of proximal systems must be addressed. MST thus tries to understand behaviour within its naturally occurring context. The intervention is delivered in ecologically valid environments (e.g. home; school) and whenever possible, delivered by key ecology members (e.g. teachers; caregivers).
The caregivers are seen as the main conduits of change. Interventions focus on empowering them with the resources and skills they need to be more effective. The therapist guides the caregiver efforts to successful outcomes. The main goals are improving parenting and decreasing youth association with deviant peers. The therapist works with the family and uses family strengths to overcome barriers to caregiver effectiveness. The therapist helps the caregiver design and implement interventions aimed at decreasing youth antisocial behaviour when the caregiver effectiveness increases. It is important to try and surround the adolescent with a context that supports prosocial behaviour, effectively replacing the context that contributes to antisocial behaviour.
The MST clinicians should be available 24/7 to make sure the sessions can occur at times convenient for the families. This allows the therapist to react quickly to crises (e.g. caregiver needs evening support for drug relapse). The duration of the intervention is 3 to 5 months but is intensive.
MST does not follow a rigid manual and is based on nine principles. The interventions are designed to promote generalization and long-term maintenance. All aspects of MST must be strengths-based and the ecological strengths need to be used as mechanisms of change. The therapist thus needs to identify strengths and use these.
At the beginning of treatment, referral behaviour and other problem behaviours to be targeted are specified from the perspectives of stakeholders (e.g. caregivers). At this point, ecological strengths are also identified and perspectives on why problem behaviour keeps occurring is assessed. The desired goals are synthesized into overarching goals of the treatment. The ecological factors that appear to be driving the problem are organized into a coherent conceptual framework (i.e. fit). The therapist then outlines intermediary goals that need to be achieved to achieve the overarching goals. Based on this, specific intervention strategies are designed. The advances and barriers of treatment effectiveness are then measured and this is used to re-evaluate whether the ecological factors that drive the problem behaviour
.....read moreInterventions for ADHD need to be constructed in a way which allows them to be conducted for years and it needs to be implemented across settings since ADHD is a chronic disorder. The most common treatment is medication with central nervous system stimulants. This leads to short-term improvements. However, there are several limitations to medication:
Behaviour modification is another common treatment for ADHD. This teaches skills to parents, teachers and children to overcome some of the key functional impairments associated with ADHD. However, outpatient behavioural interventions alone may not be sufficient to improve acute functioning.
Effective treatments need to focus on peer relationships (1), parenting (2) and academic functioning (3) as impairments in these domains lead to negative long-term outcomes in children with psychopathology.
Social skills training is not efficacious for improving peer relationships although this can be targeted in the recreational settings (e.g. sports). ADHD is often comorbid with learning disabilities. Combining recreational activities with educational activities increases children’s attendance. This may lead to greater benefit from summer schools. The summer can also be used to teach parent skills while working intensively with children with ADHD during the day to help these skills generalize. It is important to maintain treatment over the summer as treatment gains may otherwise be lost.
The Summer Treatment Programme (STP) is a summer treatment for children with ADHD which aims to improve children’s peer relationships (1), interactions with adults (2) and self-efficacy (3) while training their parents in behavioural management. It focuses on functional impairments rather than symptoms.
It is a weekday programme for children and adolescents from 3-16 years. The programme typically runs for 7-8 weeks for 8-9 hours per day. The children are placed in a group and these groups stay together over the summer to make sure that they receive intensive experience in group functioning (1), making friends (2) an interacting appropriately with adults (3). For 2-3 hours per day, there are classroom activities and the remainder of the day is used for recreationally-based group activities. Parent training is weekly. The treatment consists of several components:
Trauma-focused cognitive behavioural therapy (TF-CBT) addressed problems specifically associated with traumatic events that children experience or witness (e.g. PTSD). TF-CBT targets PTSD symptoms and outcomes associated with trauma. A PTSD diagnosis is not required.
PTSD includes negative cognitions about oneself, others or the world and negative affective states. There may be dysregulation in affective, behavioural, cognitive and physiological areas of functioning. TF-CBT targets reregulation in each of these areas with the goal of optimizing children’s adaptive functioning after trauma.
The main goal of TF-CBT is to help children overcome traumatic avoidance (1), shame (2), sadness (3), fear (4) and other trauma-specific emotional and behavioural difficulties (5). TF-CBT is not a first line treatment but can help children after they have stabilized.
TF-CBT includes cognitive-behavioural, attachment, family, humanistic, and psychodynamic therapy principles. The overall level s of adjustment in all areas (e.g. physiological; emotional) impact each other and influence overall well-being. TF-CBT thus attempts to reduce the impact of trauma across these areas and this is believed to lead to overall improvements.
There are several pathways to PTSD after trauma:
These theories state that exposure is essential. The social-cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. It states that trauma-related feelings and thoughts should be reviewed to process the experience fully and correct dysfunctional beliefs and emotional reactions.
The family environment and the therapeutic relationship is also essential. TF-CBT may reduce parental distress and enhances parents’ support for their children.
Goals of TF-CBT include:
TF-CBT focuses on children between the ages of 3 and 18. The treatment is adapted depending on the developmental stage of a child and parents receive TF-CBT in parallel individual or joint child-parent sessions.
TF-CBT consists of several components named PRACTICE:
Autism spectrum disorder (ASD) is characterized by persistent deficits in social communication and social interaction. In addition to that, there is a presence of restricted, repetitive patterns of behaviour, interests or activities. The symptoms cause clinically significant impairment in social, occupational or other important areas of functioning.
The Early Start Denver Model (ESDM) is a treatment that addresses the needs of children with ASD under three years of age. It is designed for children ages 12 to 60 months who are diagnosed with ASD or are at risk for ASD. The goal is to accelerate children’s developmental rates in cognitive, social-emotional, language, and adaptive domains and to reduce the disabling effect of ASD symptoms.
The Denver Model states that it is important to build close relationships between children with ASD and other children and adults to facilitate development. Following this model, EDSM includes sensory social routines. This includes seeking out social partners, initiate routines and continue them through non-verbal and verbal communication. Other principles of ESDM include a focus on assessing and teaching to all developmental areas (1), the use of an interdisciplinary team (2), a focus on teaching play and imitation skills (3), utilizing imitation to teach skills in other domains (4), an emphasis on both verbal and non-verbal communication (5) and partnership with parents (6).
Children with ASD may have impairments in imitation skills, which are necessary to learn a lot of social skills. ESDM focuses on strengthening imitation skills in young children to improve this. The social motivation hypothesis states that children with ASD demonstrate impaired sensitivity to the reward value of social stimuli. This leads to reduced attention to and interaction with such stimuli and fewer opportunities for social learning. The lack of social interaction leads to increased impairments in communication an social-emotional skills. A primary goal of ESDM is to enhance the reward value of social interaction.
ABA holds that antecedent (A), behaviour (B) and consequence should be used to teach people at risk for ASD or diagnosed with ASD. This means that the antecedent should be clear. There should be appropriate consequences for children showing certain behaviour and there should be shaping and chaining behaviours to help children learn new skills.
When a child begins treatment, skills are assessed using the ESDM curriculum checklist. This is used to determine developmentally appropriate treatment objectives. These objectives guide the intervention. The skills that are chosen for the treatment objectives represent the skills that are the next in line, developmentally. It is then turned into measurable treatment objectives containing clear descriptions of the antecedents that should cue the demonstration of the skill (1), the skill (2) and requirements for mastery and generalization of the skill (3). The treatment objectives originate in a manualized curriculum but are individualized to a particular child. Each treatment objective is broken down into several teaching steps based on a task analysis of the skill (i.e. child’s current baseline level and ending with
.....read moreDifficulties in social communication in ASD may result in disruptive behaviours (e.g. aggression). This is a significant source of stress to families.
Researchers have attempted to identify pivotal responses. The idea is that when certain core areas are targeted, widespread changes in numerous other untargeted behaviours would occur, leading to fluid and integrated behavioural gains.
Motivation to respond to social and environmental stimuli is essential for typical development. However, children with ASD may fail to understand the interconnection between their behaviour and the consequences from their environment as a result of repeated failures and non-contingent assistance and reinforcement from adults as a result of their social communication problems. This will, eventually, lead to an overreliance on adult support (i.e. learned helplessness).
Pivotal response training (PRT) focuses on decreasing the presence of learned helplessness by enhancing the relationship between children’s responses and reinforcement. This can help children to become motivated to respond, which leads to a positive feedback loop where more learning opportunities are provided. This, in turn, generates the social-environmental conditions for the development of more complex behaviours which are necessary for social, communicative and cognitive competence. PRT makes use of operant conditioning format of ABA but focuses more on increasing and maintaining the intrinsic motivational qualities within the ABA interaction. It uses the motivational strategies child choice (1), task variation (2), interspersal of maintenance tasks (3), reinforcement of response attempts (4) and the use of natural and direct reinforcement (5).
Children respond better to PRT when they begin before the age of 3. Fewer children respond with increasing age.
Self-initiation is common in typically developing children and serves multiple functions (e.g. information seeking). The form of self-initiation differs (e.g. joint attention; elaborate questions) but is inherently social in nature. Self-initiation occurs infrequently or is absent in children with ASD. Children who are taught to use self-initiations have more favourable outcomes. This means that motivating children to self-initiate can result in learning that increases autonomy as children become less reliant on adult-delivered learning opportunities. Motivating children to self-initiate provides them with tools that result in self-learning.
Children with ASD are often unmotivated to socialize but are motivated to engage with the non-social aspects of their immediate environment. The salient characteristics of non-social interests may be identified and embedded within a reciprocal social activity. This can enhance motivation to socialize, which, in turn, can lead to improvements in other areas of functioning. Incorporating restricted interests in mutually-reinforcing social activities (i.e. for the child with ASD and the typically developing peer) can lead to intrinsic motivation for social play.
The goal of PRT is to provide comprehensive intervention in key areas that increase independence and self-education throughout the day with rapid, widespread improvement of ASD. The teaching of pivotal areas is coordinated throughout the children’s day with parents, teachers and other service providers. Treatment is provided in a natural and inclusive setting to maximize the likelihood of typical
.....read moreSubstance use disorders typically emerge after age 14 though the precursors can be seen before adolescence. The most prominent influences are the family (e.g. conflict; parent substance use), larger social-ecological context (e.g. drug availability) and the adolescents’ genetic vulnerability (e.g. poor impulse control). Substance use is common and substance abuse is prevalent at 8% for youth between the ages of 12 and 17 and 20% for youth aged 18 to 25.
Youth with substance use disorders often first use to pursuit specific pharmacological effects (e.g. managing negative emotions) but it is associated with high risk for long-term functional impairments (e.g. cognitive deficits).
Adolescents are vulnerable to the consequences of substance use because they have a fully functional reward-seeking and pain-avoidance system in place and less impulse control and judgement. Substance use disorders typically first appear during adolescence and is associated with susceptibility to comorbidity. Adolescents with SUD and a comorbid disorder often have behavioural skills deficits (1), limited coping strategies (2) and emotion dysregulation (3). A treatment should consider these properties and the unique pharmacological and addictive properties of different substances. Family-based interventions are associated with improvement.
Functional family therapy (FFT) is a family systems therapy which conceptualizes alcohol and drug abuse as behaviours that develop and are maintained in the context of maladaptive family relationships. Changing the family interactions and improved relationship functioning is thus key to reduce adolescent substance use. The locus of problem behaviour is relational. This treatment is able to target comorbid disorders as well. It links treatment strategies into a unity family-centred approach.
The treatment goals include reducing substance use and co-occurring problems (1), improving family relationships (2) and increase adolescents’ productive use of time. The treatment tries to make sure that the functions of substance use are met through other, more adaptive behaviours. The treatment consists of 14 weekly 1-hour sessions with more frequently or longer sessions initially to potentiate the initial change process. The sessions may be spaced farther apart near completion. Treatment follows five methods which are completed in order:
Some structured, manual-guided treatments may show reduced effects when they are implemented in more clinically representative contexts and compared to usual practice in those contexts. This may be because treatments tend to be developed away from the clinical practice. There are several potential mismatches between evidence-based practice and real-world clinical care:
The deployment-focused model of treatment development and testing includes a series of steps aimed at building and testing interventions with the clients and clinicians and within real-world contexts. It is also tested whether interventions improve on current practice in those contexts. Making evidence-based practice work well in practice mainly involves making the treatments fit variations in individual and family characteristics.
Personalized mental health interventions include strategies for selecting treatments, deciding whether and how to combine them, determining what problem to target first and with what techniques and using information about individual client characteristics and ongoing treatment response to inform clinical decision making. In other words, treatment should be personalized.
There are several methods of identifying an individual’s optimal treatment:
Further personalization after selecting a treatment may occur through monitoring client progress and using the resulting data to adjust interventions. This can be done in several ways:
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