About 16% of the children exposed to a trauma develop posttraumatic stress disorder (PTSD). This is associated with psychiatric comorbidity (1), functional impairment (2) and persistence into adulthood (3). Early and effective treatment is needed to reduce the negative effects of PTSD. Trauma-focused psychological therapies are recommended as first-line approach. Trauma-focused cognitive behavioural strategies (CBT) involve a combination of coping skills training (1), cognitive restructuring (2), therapist- and client-led exposure (3) and parent interventions (4). Eye movement desensitization and reprocessing (EMDR) therapy is a brief, trauma-focused treatment for PTSD. During this treatment, the patient holds a disturbing image from the trauma memory in mind while engaging in sets of saccadic eye movements. There is evidence that it works for adults. Both CBT and EMDR appear effective in reducing PTSD symptoms in adults. The sessions consist of history taking (1), treatment planning (2), preparation (3), reprocessing (4), installation of a positive cognition (5), check for and processing any residual disturbing body sensations (6), positive closure (7) and evaluation (8).Cognitive behavioural writing therapy (CBWT) involves exposure to the trauma memory and restructuring of trauma-related beliefs through writing and updating of the trauma memory on a computer with the support of a therapist. It can be relatively brief as it focuses on exposure and reprocessing of the trauma memory. It does not include coping skills training or parent-focused sessions. The sessions include psychoeducation (1), imaginal exposure (2), cognitive restructuring (3), promoting healthy coping strategies (4) and enlisting support from loved ones or friends (5). Both EMDR and CBWT include six sessions of 45 minutes. They do not include parent sessions and there are no instructions for parents to encourage their child to discuss the trauma or to confront reminders....
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Prins, Ollendick, Maric, & MacKinnon (2015). Moderators and mediators of youth treatment outcomes.” – Article summary 
Almost one-third of children being treated do not improve. There are two ways in which the efficacy of a treatment can be tested:
Moderators refer to variables for which treatment has differential effect at different values of the moderating variables. Mediators refer to variables that describe the process through which treatment achieves its effects. There is no causal relationship between the treatment and the outcome for moderators but there is a causal relationship for mediators.
Predictors refer to pre-treatment variables which have a main effect on treatment outcomes but no interactive effect. It can predict the response in different treatment groups but the effect size of the treatment is the same regardless of the value of the target measure.
A potential moderator variable needs to be measured before random assignment (i.e. prescriptive indicator). The interaction between the moderator variable an different treatment conditions establishes a moderation effect. Moderators may allow for personalized approaches as it tells us for which population a treatment may be effective. Predictors are also called prognostic indicators. They predict change across treatment conditions.
Common moderators or predictors are socio-demographic information (1), parent characteristics (2), family characteristics (3), child characteristics (4), school-related factors (5) and aspects of the disorder itself (6). There are a lot of variables that could be included as moderators and predictors. As there are too many, the choice of variables should be guided by theory, clinical experience and empirical studies.
Comorbidity does not predict or moderate immediate treatment outcomes. However, they may predict long-term outcomes. The effects of moderators and predictors need to be evaluated over time.
A test of moderation provides information about whether two treatments differ from one another due to characteristics of the sample or contextual differences but it also demonstrates whether treatments have similar effects across these dimensions (e.g. find evidence that something is not a moderator, then treatments can be applied across both groups of patients). The consistency of the treatments across subgroups and contexts provides important information about the generalizability of the effectiveness of a treatment.
Common mediating factors include parental characteristics (e.g. parenting practices) (1), child characteristics (e.g. emotion regulation) (2), familial characteristics (e.g. cohesion) (3) and school functioning (e.g. relationship with teacher) (4). Treatment theory typically guides the way in determining mediators that need to be investigated. Previous findings of therapeutic interventions may also inform the choice of mediators. Lastly, mediators may be conceptualized as risk factors and this can help guide the choice of mediators.
Both specific and non-specific factors should be tested as mediators. Specific factors refer to the processes aimed to be changed
.....read more Weersing, Schwartz, & Bolano (2015). Moderators and mediators of youth treatment outcomes.” – Article summaryThe prevalence of depression is 5% with the prevalence being between 10% to 20% in adolescence. It is associated with a host of negative outcomes and is comorbid with other mental health problems (e.g. anxiety). It is also a risk factor for the development of substance use and abuse. Depression in youth is a risk factor for the recurrence of depressive disorder across the lifespan.
Mild severity refers to meeting the minimal diagnostic criteria for a depressive disorder. Moderate or severe severity refers to people with clinical symptom levels (1), longer term histories of depressive illness (2), more impairment across several areas of their life (3) or a high level of suicidality (4).
CBT or IPT are efficacious for depressed adolescents with mild to moderate depression. A combination of CBT with medication may be most effective for those with moderate to severe depression. CBT programmes for youth depression typically start with psychoeducation and the theory of intervention and an early application of behavioural techniques. After this, cognitive restructuring is used. CBT manuals differ in supplemental cognitive and behavioural techniques employed (1), relative focus on cognitive change versus behavioural skill building (2), dosing of each technique (3), number of sessions (4), format (5) and level of parental involvement (6). Involvement in negative cognitive style and behavioural mood regulation skills are the mechanisms of CBT effects. Cognitive change appears to mediate the effectiveness of CBT.
Depression is believed to arise from the experience of stressful life events in combination with genetic vulnerability toward mood dysregulation in response to stress, maladaptive behavioural responses to stress and inaccurate, overly negative cognitive interpretations of stressful events.
In the Beckian cognitive theory and the learned helplessness theory, biased, overly negative cognitive processing is thought to arise from stressful early life experience. Individuals learn that the world is an unsafe and unpredictable place and that they are not good At handling stress. These beliefs are activated when faced with stressful circumstances and this interferes with coping and positive mood. Depressogenic thinking is resistant to disconfirmation, partially due to the enduring styles of information processing that promote belief maintenance (e.g. focus on negative information).
A behavioural approach to depression holds that depression results from low levels of positive reinforcement and high levels of punishment and aversive control. This leads to people withdrawing from negative interactions and avoid situations that may produce low mood. This exacerbates the problem of low positive reinforcement. This depressive cycle eventually leads to depression and may be brought about through environmental change or a mismatch between environmental demands and behavioural skills.
Interpersonal psychotherapy (IPT) is a treatment for depression. It conceptualizes depression as occurring within an interpersonal matrix and targets the resolution of psychosocial stresses that coincide with the depressive episode. It does not see environmental factors as the cause of depressive episodes but see them as co-occurring. Nonetheless, alleviating environmental stressors can help in reducing the symptoms of depression. The
.....read more Hudson et al. (2015). Comparing outcomes for children with different anxiety disorders following cognitive behavioural therapy.” – Article summary The recovery rate of CBT for anxiety disorders is approximately 60%. Treatment tries to treat underlying constructs of anxiety even though different anxiety disorders exist and are often highly heterogeneous. However, there may be a differential response to different treatments per disorder as this is the case with adults.
The presence of social anxiety disorder at pre-treatment leads to slower rate of change and poorer diagnostic outcomes at post-treatment and follow-up compared to children with other anxiety disorders. This is not affected by age or comorbid depression.
Children with SAD may have poorer diagnostic outcomes because the group setting is more aversive for them. Next, children with SAD have often shown behavioural inhibition since infancy and this may make it more resistant to change. It may thus be necessary to have a longer treatment programme for children with SAD. The presence of SAD may also make the therapeutic relationship more problematic. Children with SAD may have impairments in interpersonal interactions and this may impact the successful execution of exposure tasks. This may lead to exposure having the opposite effect of the one desired. Social situations are also more ambiguous making it more difficult to see whether one’s initial interpretation was false or not.
Children with SAD may need a more tailored programme that helps them disconfirm their negative social expectations (e.g. equip children with social skills prior to exposure).
For a family-based group CBT, children with GAD were more likely to experience remission immediately following treatment and showed a greater reduction in diagnostic severity. While this holds for mother-reported symptoms, this does not necessarily hold for child-reported symptoms. Children with OCD had a better outcome on clinician-rated diagnostic severity compared to other anxiety disorders but did not differ across diagnostic remission or child or mother-reported symptom change.
Telman et al. (2020). Modular CBT for youth social anxiety disorder: A case series examining initial effectiveness.” – Article summary Social anxiety disorder (SAD) refers to a persistent, intense fear of social situations in which the individual may be negatively evaluated by others. This fear must occur in peer settings and not just in adult settings for children. The prevalence rate is 10% in adolescence and first incidence after the age of 21 is very low.
Not treating SAD is associated with impairments in interpersonal functioning (1), loneliness (2), school refusal (3), drop-out (4), lower educational level (5), subsequent anxiety (6), subsequent depressive disorders (7) and subsequent substance use disorders (8). It typically persists into adulthood when it is left untreated.
Cognitive behavioural therapy (CBT) is the most efficacious treatment for anxiety disorders in children and adolescents. About 50-70% of the children with an anxiety disorder are free of it after treatment. CBT for childhood anxiety disorders typically consists of skill-building (1), psychoeducation (2), cognitive restructuring (3), coping (4) and exposure (5). However, general CBT is less effective for SAD than for other anxiety disorders.
Modular treatment may allow for the therapist to spend more time on more problematic areas in the child with SAD. This may lead to better outcomes. Including mindfulness in CBT treatment for SAD may also be useful as there are six change mechanisms of attentional processes training in SAD:
A relatively short modular CBT is effective for 50% of the youth with SAD (i.e. they were free of diagnosis) and for 80% at a 10-week follow-up. Children receiving modular treatment showed faster improvements than youth in usual care. It is not clear whether the personalization by the therapists to the individual client or the inclusion of mindfulness led to the results.
Koegel, Koegel, Ashbaugh, & Bradshaw (2014). The importance of early identification and intervention for children with or at risk for autism spectrum disorders” – Article summaryThe new criteria for ASD in the DSM-5 may influence the incidence of ASD as the diagnosis between people may now differ based on timing rather than symptoms (e.g. a person diagnosed in 2004 compared to a person diagnosed in 2015). The DSM-5 makes use of severity to tackle the difficulty disentangling whether symptoms are due to ASD or due to another comorbid disorder. The DSM has changed the ASD criteria to improve the precision of diagnosis (1), characterize the ASD symptoms within a single name (2) and use a description of severity level (3).
ASD does not need to be a life-long disabling condition. With intervention, children may either lose diagnosis or be included in regular education classrooms. However, a lot of children diagnosed with ASD remain non-verbal throughout their lives, although this number has been declining as the quality of intervention has been improving.
Early intervention leads to better outcomes than later intervention when it comes to ASD. The “wait and see” method may lead to significant negative outcomes. Early interventions also save money as later interventions need to be more intensive for a longer period of time and are thus more expensive.
Individuals with ASD often show aggression (1), tantrums (2) and self-injury (3). The disruptive, secondary symptoms of ASD often have a communicative function. Early intervention, which may improve verbalisation, may reduce these secondary symptoms. Comorbid symptoms are often related to difficulties with socialization and this may thus be reduced as well as a result of early intervention.
Parents experience stress when a child has a disability. This could reduce their ability to parent, leading to worse outcomes and more stress. Early intervention could provide parents with tools to address symptoms and this could lead to more self-confidence and a feeling of empowerment, allowing parents to parent more effectively which leads to even better outcomes.
Early intervention treatments are often seen as experimental since there are no RCTs yet. However, this may help demonstrate the efficacy of these treatments but is not necessary. RCTs may not necessarily work in demonstrating efficacy in behavioural interventions for ASD because of several reasons:
While there may not be a lot of RCTs, there are a lot of valid and sound single-case studies. It may be more beneficial to treat behavioural dysfunction even when there is no disorder as the cause than waiting to see if it is indeed because of a disorder.
Schreibman et al. (2015). Naturalistic developmental behavioural interventions: Validated treatments for autism spectrum disorder”. – Article summary Toddler interventions for ASD are often delivered in a naturalistic and interactive social context (e.g. play). It typically involves child-directed teaching strategies (e.g. child-preferred materials). Naturalistic developmental behavioural interventions (NDBI) refer to interventions that employ a naturalistic and interactive social context and involve child-directed teaching strategies.
Learning is facilitated by an affective exchange between the child and the therapist. However, children with autism have deficits in affective sharing and social motivation. This thus needs to be promoted for children with autism for interventions to be effective.
NDBIs make use of a constructivist approach where children’s learning experiences are designed to actively engage attention (1), help them connect new experiences with existing knowledge (2), teach within developmental sequences (3) and systematically increase the complexity of learning experiences (4). Child initiative and spontaneity are fostered and rewarded. Everyday routines are a rich learning context for children and interventions within these contexts allows for adaptive functioning in natural contexts and environments.
Varying teaching stimuli (1), alternative prompting strategies (2), use of child-preferred activities (3), use of incidental teaching strategies (4) and consideration of developmental prerequisites (5) increase children’s motivation and performance. It makes use of more natural rewards (1), reinforcement of attempts (2) and treatment delivery in a more naturalistic and developmentally sensitive context (3).
Generalization of newly learned skills is better when these skills are taught in naturalistic contexts for children with autism. Using naturalistic contexts for interventions when children are still very young has the following benefits:
There are several core components of NDBI interventions:
There are several common
.....read more Daley et al. (2014). Practitioner review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with ADHD” – Article summary Behavioural interventions refer to interventions which are directed at improving an individual’s conduct using reinforcement and social learning principles. This includes increasing desired behaviours and decreasing undesired behaviours. Among these treatments are classical contingency management (1), behaviour therapy (2) and cognitive behavioural therapy (3).
Not all studies investigating these interventions had blinded measures (e.g. symptom rating by an independent researcher) as most used non-blinded measures (e.g. parent symptom rating). This makes evidence more difficult to interpret. When blinded vs. non-blinded measures are taken into account, behavioural intervention can not be supported for the treatment of core ADHD symptoms. However, behavioural interventions did influence parenting effectively making behavioural interventions a form of parent training.
Improving parental knowledge about ADHD may be necessary for subsequent therapeutic interventions. Enhanced knowledge increases the likelihood of engagement in treatment. However, it is not clear whether behavioural interventions improve parental knowledge about ADHD.
Improving parents’ behaviour towards their children with ADHD may improve child behaviour and may improve the quality of the parent-child relationship. Behavioural interventions appear to improve parenting behaviour and reduce child oppositional behaviour. This may lead to increased engagement and cooperation from the child towards the parent and this may improve the parent-child relationships, although this is not entirely clear.
Parent training may not reduce core ADHD symptoms but the interventions change parental perceptions of their child’s behaviour and this can be important as well. Conduct problems are very common in ADHD and behavioural interventions may reduce behavioural problems. However, there is less evidence that behavioural interventions lead to improved emotional functioning in children with ADHD.
Children with ADHD often have impairments in social and academic functioning due to their ADHD symptoms. Behavioural interventions may benefit social skills or academic functioning, especially when an academic or organisational skills component delivered at school is included in the treatment.
It is not entirely clear what the active components of behavioural interventions are. The components should thus not be used in isolation. ADHD-specific programmes are not necessarily superior to generic programmes. The effects of behavioural interventions do not vary across treatment setting and delivery structure although it is important to consider patient preferences and cost of delivery to minimize patient drop-out. A good therapist is important for the delivery of behavioural interventions although evidence for this is limited. The therapist needs to be motivated and deliver the treatment as intended.
It may be useful to involve both parents as this may increase the consistency of the implementation of strategies and shared understanding of ADHD. This, in turn, may lead to better outcomes. However, there is limited evidence to the added value of using both parents.
Behavioural interventions may only need to be used when parents have clear parenting deficits or difficulties as the intervention provides parents with enhanced strategies to deal with a child with ADHD. However, there is no evidence that improvements only occur in families with low pre-existing parenting
.....read more Evans et al. (2021). The efficacy of cognitive video game training for ADHD and what FDA clearance means for clinicians.” – Article summary EndeavorRX refers to a videogame-delivered cognitive training treatment intended to improve neurocognitive deficits associated with ADHD. Children play the game for 30 minutes or more every day for several weeks. The idea is that when core cognitive deficits are reduced, the problems that are associated with these deficits will also reduce. This treatment has some evidence for near-transfer but there is very limited evidence for far transfer of skills.
The hyperactive subtype of ADHD is often attributed to frontrostriatal dysfunction. It projects from the striatum to the prefrontal cortex and is involved in reward-based learning. The striatum may be under-responsive to anticipated rewards in people with the hyperactive subtype. They require larger and more immediate rewards and they habituate to rewards more quickly. In this subtype, inattention may be a secondary symptom due to low motivation as a result of frontoparietal and temporal lobe dysfunction. Next to the neural mechanisms, there are several underdeveloped neurocognitive abilities which leads to heterogeneity in ADHD (e.g. working memory deficits).
Treatment needs to improve both the neurocognitive deficiency and impairment exhibited by children with ADHD (e.g. failure to complete tasks). The outcomes thus need to generalize. Cognitive therapy may not always lead to reduced impairments in children with ADHD as it improves neurocognitive functioning but this may not generalize. Improving neurocognitive functioning may be necessary but insufficient for improvement in daily tasks (i.e. reduce impairment). Computer games may achieve far transfer which CT often fails at.
To evaluate interventions, several things are essential:
Proximal outcomes refer to measures of direct treatment targets (e.g. hypothesized maintaining factors of presenting problems). This provides valuable information about the treatment but may not directly address presenting problems. Proximal measures help in establishing underlying mechanisms of treatment and their relations to the presenting problems. However, treatment should also impact specific impairments. This is measured using impairment measures. Treatments with long-term gains as opposed to short-term improvements are preferred.
Treatments are most effective when they result in meaningful individual change on an ecologically valid outcome that is prioritized by the client and persists over time.
CT is classified as an experimental treatment due to non-significant findings in RCTs. However, this may be due to methodological issues as most CT treatments target different neurocognitive functions while some are still intact in children with ADHD. Occasionally, there is near transfer but
.....read more Staff et al. (2021). Effectiveness of specific techniques in behavioral teacher training for childhood ADHD: A randomized controlled microtrial.” – Article summary Behavioural teacher training is the most effective psychosocial classroom intervention to treat ADHD. Additionally, it reduces teacher burden and increases levels of teacher self-efficacy. In this training, teachers are taught to change a child’s behaviour by using stimulus control techniques. This aims to change behaviours by manipulating their antecedents or stimulus conditions to increase the chance that a child elicits desired behaviour.
Antecedent-based techniques include providing structure and clear instructions. It is aimed at clarifying what behaviour is expected of a child in a specific situation. Consequent-based techniques include manipulating the consequences of actions to influence the frequency of behaviour (e.g. reinforcement). This can include praise, mild punishment or ignoring.
A time-out is effective in reducing disruptive behaviour problems in children with ADHD symptoms. Consequent-based techniques are more effective in reducing off-task and disruptive classroom behaviour of children with ADHD.
The antecedent and consequent-based techniques are both highly effective in reducing problem behaviours related to ADHD on the short and longer-term. The effect is large for problem behaviours related to inattention and oppositional defiant behaviour. The effect is medium-sized for hyperactive-impulsive behaviour. There is no difference between the two techniques in effectiveness.
Providing teachers with a detailed intervention plan that can be implemented directly into the classroom may be more effective compared to general recommendations on parenting strategies for ADHD that are not tailored to individual needs.
Antecedent-based techniques are more effective for older children. Consequent-based techniques are more effective for younger children. This may be because older children have more intrinsic motivation whereas extrinsic motivation is most important for younger children. Next, higher grade teachers already have less structure and higher expectation, making it understandable that improving this could benefit children with ADHD.
Class size is a moderator of technique effectiveness. The beneficial effects of antecedent-based techniques increased when the number of students per class decreased (i.e. smaller classes). The effectiveness of consequent-based techniques does not depend on class size.
Van der Pol et al. (2019). Common elements of evidence-based systemic treatments for adolescents with disruptive behaviour problems.” – Article summary Identifying common elements between treatments could render them more effective. Many treatments have common elements yet a unique focus. This could help personalize the treatments. Knowing common elements of treatments allows therapists to implement these techniques in treatment more easily. Knowledge of treatment mechanisms and identification of potent treatment techniques can support enhanced precision in matching systemic treatments to the needs of adolescents and their families.
There are several common elements across individual systemic treatment protocols:
The treatments typically had one to three sessions a week and lasted between three and 12 months. Conflict management and communication skills were techniques that are used in all systemic treatments. There are several common techniques in most systemic treatments:
Price & Ansari (2013). Dyscalculia: Characteristics, causes and treatments.” – Article summary Developmental dyscalculia (DD) refers to a learning disorder which specifically affects the ability to acquire school-level arithmetic skills. It occurs when a child has a substantially lower mathematical ability compared to what can be expected for the person’s chronological age (1), measured intelligence (2) and age-appropriate education (3). The prevalence is 3% to 6%. It is often comorbid with other learning difficulties (e.g. dyslexia; ADHD).
There is a lot of heterogeneity within DD. This maybe due to variation across studies in criteria used to identify mathematical difficulties (e.g. discrepancy criteria vs. percentile cut-off points). This may include individuals whose math deficits stem from exogeneous sources (e.g. poor teaching quality) rather than those whose math deficits result from a learning disorder. Another reason is that math skills are heterogeneous and vulnerable to disruption from a wide range of endogenous and exogenous sources, leading to heterogeneity in DD.
Primary dyscalculia refers to math deficits that stem from an impaired ability to acquire those skills. Secondary dyscalculia (i.e. pseudo-dyscalculia) refers to math deficits caused by external factors (e.g. poor teaching quality). Children with the most severe math deficits have cognitive deficits in very basic number processing (i.e. number sense) while children with moderate impairments do not. Primary versus secondary dyscalculia may thus be a distinction in DD severity.
DD is characterized by a poor retrieval of arithmetic facts from memory and the perseverant use of immature calculation strategies (e.g. counting on a hand). However, there may also be impairments in a neurobiological system for processing numerical magnitudes. This neurobiological impairment may give rise to the difficulties associated with DD.
Children with DD fail to develop fluent fact-retrieval mechanisms and they know fewer arithmetic facts. Due to the impaired fact retrieval in DD, they use immature or inefficient problem-solving strategies. However, despite these characteristics, DD is difficult to identify as math difficulties may emerge at varying stages of the educational process (e.g. different grades).
The skills required for successful mathematical performance change over the course of development. Some children may have a specific deficit at an early learning stage and this may disrupt the acquisition of later skills. This disruption may occur because foundational skills are not present or because inefficient or immature procedural skills (e.g. manner of calculation) result in extra effort to carry out simple calculations. This extra effort may make it more difficult for the children to follow and learn more complex procedural knowledge.
The number sense refers to a cognitive mechanism that supports the representation and processing of numerical magnitudes. There may be a deficit in the number sense in DD. Numerical magnitude information is not activated automatically in DD children. There may thus be a reduced automatic activation of semantic numerical representations in DD. There appear to be very elementary deficits in basic number processing in DD.
The distance effect refers to the increase in reaction times and errors as the distance between numbers
.....read more Vellutino, Scanlon, Zhang, & Schatschneider (2008). Using response to kindergarten and first grade intervention to identify children at-risk for long-term reading difficulties.” – Article summary The IQ-discrepancy definition for problematic readers (e.g. dyslexia) is subpar as they often show average scores on measures of word level skills. Intelligence tests do not differentiate the atypically achieving children from a group of typically achieving children when it comes to reading performance. Early reading difficulties in most beginning readers are caused primarily by experiential and instructional deficits rather than basic deficits in reading-related cognitive abilities.
Most struggling readers can become average-level readers if they are provided with effective intervention. Those who continue to experience difficulties mat require more intensive or more individualized instruction to achieve this level.
The three-tier model of remedial intervention consists of three sequentially ordered intervention strategies:
All strategies rely on continuous monitoring of student progress. This determines the eligibility for a given tier. The idea is that when a child does not respond to any given intervention, the child moves up a tier.
Using response to intervention (RTI) may be useful to identify at-risk children for literacy difficulties. This includes early screening and subsequent response to an intervention determines whether these children should be classified as continued at-risk or no risk.
The kindergarten intervention (i.e. small group supplementary intervention or other instructional activities) is effective in improving literacy skills of children judged to be at-risk for early reading difficulties at the beginning of kindergarten. Poor readers who had difficulty consolidating intervention-based gains at the end of first grade were more likely to be at-risk for continued reading difficulties.
Children at risk for early and long-term reading difficulties can and should be identified at the beginning of kindergarten. Their difficulties can be prevented if they are provided with supplementary remedial services. Children with persistent reading difficulties (i.e. after intervention) appear to have a weak cognitive profile. Identification of at-risk children or poor readers was more accurate with time and especially when losses over the summer period were taken into account.
Response to kindergarten intervention predicted performance on measures of response to first grade intervention. The response to first grade intervention predicts follow-up measures and this thus justifies using RTI. RTI is a good way of identifying children who may be at risk for early and long-term reading difficulties. RTI is a better way of identification between continued-risk and no-longer-at-risk children (i.e. after initial screening for at-risk children) than other psychometric measures.
Early identification has some risk for false positives but not
.....read more Dunning et al. (2019). Research review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents – A meta-analysis of randomized controlled trials.” – Article summary Mindfulness refers to intentionally directing attention to present moment experiences with an attitude of curiosity and acceptance. Higher levels of mindfulness is associated with better functioning for several psychological and physical health outcomes. Mindfulness skills can be augmented through training. The enhancement of proximal skills (e.g. non-judgemental attention control) may influence distal outcomes (e.g. reduced symptoms; improved behaviour).
Mindfulness may be introduced to youth to enhance core cognitive skills to support academic and social functioning. Mindfulness may be especially useful as self-regulation and executive functioning strongly develop during this period. Next, it is also a period in which many mental disorders first appear.
An active control group in MBI studies refers to something that is expected to benefit its participants and matches the MBI in non-specific factors (e.g. engagement with therapist).
Mindfulness-based interventions (MBI) lead to greater improvements of mindfulness (1), executive functions (2) and attention (3) compared to controls. There were improvements in depression (1), anxiety and stress (2) and negative behaviours (3).
Age moderates the effects of MBIs on executive functions. There are greater benefits when a child is older. Older adolescents may benefit more from MBIs than younger children due to the window of opportunity. This refers to the period between 14-18 years and is a key time for mindfulness to be effective due to heightened brain plasticity. During this period, there is also an increase in self-reflection (1), social-perspective taking (2) and a greater interest in understanding the self and others (3). The dose of MBI moderates negative behaviour. More training is associated with fewer negative behaviours. MBI effects on negative behaviour are also moderated by age. Younger children have greater improvements than older children or adolescents.
When MBI is compared to an active control group, there were improvements on mindfulness (1), depression (2) and anxiety and stress (3). The other positive outcomes are still there but are not significantly higher compared to an active control group.
Publication bias may play a role in the positive effects of MBIs.
Lynch et al. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations.” – Article summary Dialectical behaviour therapy (DBT) is a well-established treatment for borderline personality disorder (BPD). It seems to be efficacious and this also holds for chronically depressed older adults and individuals with eating disorders. DBT decreases problem behaviours in BPD (e.g. self-injurious behaviour; suicide attempts; suicidal ideation; hopelessness; bulimic behaviour; depression).
DBT focuses on the balance between acceptance (i.e. no complete acceptance of behaviour due to the seriousness but no blame) and change (i.e. no complete focus on change as this can be seen as critique but no apathy). The dialectic refers to the process by which a behaviour, phenomenon or argument is transformed. It consists of three stages:
Tension develops between the thesis and the antithesis and the synthesis between the two is the new thesis. The process is then repeated. DBT thus treats the whole patients and does not focus on a discrete disorder (e.g. it targets the whole emotion system). It recognizes that all elements of the system are interrelated.
The biosocial theory of BPD states that the transaction between a biological tendency toward emotional vulnerability and an invalidation rearing environment produces a dysregulation of the patient’s emotional system. A synthesis of these two processes need to be found (i.e. dialectic). Emotional vulnerability refers to a biologically mediated predisposition for heightened sensitivity and reactivity to emotionally evocative stimuli and a delayed return to baseline emotional arousal. The invalidating environment is characterized by punishing (1), ignoring (2) or trivializing (3) the individual’s communication of thoughts and emotions as well as self-initiated behaviours. The intense emotional reactions elicit invalidating behaviour and this elicits further emotional dysregulation.
Individuals with BPD often experience disruption of their cognitive, emotional and behavioural systems when emotionally aroused. Many of the behaviours associated with BPD are seen as inevitable consequences of dysregulated emotions or as maladaptive methods of altering emotional experiences.
DBT views reductions in emotion dysregulation and increases in behavioural skills as the primary controlling variables underlying treatment change. An excessive focus on change in treatment may mirror the invalidating environment. However, acceptance may not express the severity of the symptoms. Therefore, a synthesis needs to be found.
Mindfulness in DBT is related to the quality of awareness that an individual contributes to the present experiences. It refers to a state or quality of awareness which involves keeping one’s consciousness alive to the present reality. It includes letting go of attachments and becoming one with the current experience. Mindfulness in DBT includes the skills observing (1), describing (2) and participating fully in one’s actions and experiences in a non-judgemental and one-mindful manner (3). It also includes radically accepting a current situation, thought, emotion or experience and maintaining
.....read more De Roos et al. (2017). Comparison of eye movement desensitization and reprocessing theory, cognitive behavioural writing therapy, and wait-list in pediatric posttraumtic stress disorder.” – Article summaryAbout 16% of the children exposed to a trauma develop posttraumatic stress disorder (PTSD). This is associated with psychiatric comorbidity (1), functional impairment (2) and persistence into adulthood (3). Early and effective treatment is needed to reduce the negative effects of PTSD.
Trauma-focused psychological therapies are recommended as first-line approach. Trauma-focused cognitive behavioural strategies (CBT) involve a combination of coping skills training (1), cognitive restructuring (2), therapist- and client-led exposure (3) and parent interventions (4).
Eye movement desensitization and reprocessing (EMDR) therapy is a brief, trauma-focused treatment for PTSD. During this treatment, the patient holds a disturbing image from the trauma memory in mind while engaging in sets of saccadic eye movements. There is evidence that it works for adults. Both CBT and EMDR appear effective in reducing PTSD symptoms in adults. The sessions consist of history taking (1), treatment planning (2), preparation (3), reprocessing (4), installation of a positive cognition (5), check for and processing any residual disturbing body sensations (6), positive closure (7) and evaluation (8).
Cognitive behavioural writing therapy (CBWT) involves exposure to the trauma memory and restructuring of trauma-related beliefs through writing and updating of the trauma memory on a computer with the support of a therapist. It can be relatively brief as it focuses on exposure and reprocessing of the trauma memory. It does not include coping skills training or parent-focused sessions. The sessions include psychoeducation (1), imaginal exposure (2), cognitive restructuring (3), promoting healthy coping strategies (4) and enlisting support from loved ones or friends (5).
Both EMDR and CBWT include six sessions of 45 minutes. They do not include parent sessions and there are no instructions for parents to encourage their child to discuss the trauma or to confront reminders. Information about PTSD and a brief explanation of the treatment was offered to the youth and parents in the first sessions. Parents had five minutes at the start and end of each session to share their observations regarding the child’s functioning.
Both EMDR and CBWT have high rates of diagnostic remission from PTSD. Treatment drop-out tends to be very low. Both treatments lead to reductions in child- and parent-reported symptoms of PTSD (1), anxiety (2), depression (3) and behavioural problems (4). It also led to reductions in child-reported negative trauma-related appraisals (5). The treatments were equal to each other in outcomes. The outcomes were maintained at 12 month follow-up.
People who received EMDR treatment made further gains compared to CBWT on child- and parent-reported PTSD symptoms between the 3- and 12-month follow-up. Overall, the difference between the treatments during the follow-up period were minor. This means that both treatments can be seen as efficacious for treating PTSD in youth who were exposed to a single traumatic event. EMDR appears to lead to positive outcomes faster than CBWT, though this is not entirely clear.
Maric, Willard, Wrzesien, & Bögels (2019). Innovations in the treatment of childhood anxiety disorders: Mindfulness and self-compassion approaches." - Article summaryThe most cost-effective treatment for childhood anxiety disorders (CAD) is cognitive behavioural therapy (CBT). It typically includes elements of cognitive restructuring and exposure activities aimed at targeting common anxiety symptoms. Involving the parents or family in CBT for CAD is only beneficial under certain conditions. However, about a third of the children do not respond to treatment and children with social anxiety disorder benefit less well than children with other disorders.
Attention problems play an important role in anxiety disorders (e.g. attentional bias). Mindfulness may affect attention as it is related to focusing one’s attention. Mindfulness implies welcoming daily hassles with acceptance, calmness, self-compassion and gratefulness. Mindfulness refers to awareness that arises by paying attention on purpose (1), focusing on the present moment (2) and non-judgementally (3). It is a mental state achieved by focusing on one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, bodily sensations, and action tendencies. Beginner’s mind refers to opening oneself to an experience as if it were the first experience.
The primary goal of mindfulness-based treatment include helping the child and system recognize triggers for anxiety and identify skills to use in those situations while simultaneously working to reduce heightened physiological arousal. Mindfulness-based therapy should begin with interviewing the child and the caregivers. Identifying symptoms and triggers of anxiety offers clinicians insight in the best ways and times to help the child integrate mindfulness skills into daily life and anxiety-provoking situations. Engaging caregivers an educators will reinforce practice and progress in the child.
One goal of mindfulness is to have the child practicing mindfulness on his own to regulate anxiety and avoidance independently. However, anxious children need systemic support and reinforcement for this. Relevant adults need to help children recognize and understand the triggers of anxiety and reinforce using mindfulness skills. Parents suffer from high stress when their child has severe anxiety disorders. Developing mindfulness in the parents can reduce this stress and facilitate progress in the child. This allows the parents to become a model for their child in how to apply mindfulness skills in stressful situations.
Mindfulness based cognitive therapy for anxious children (MBCT-C) refers to a manualized treatment that consists of 6 weekly 45-minute sessions and aims to train the children’s attention by focusing on bodily sensations and perceptions. Mindfulness is integrated in breathing exercises, walking and sensory experiences. The emphasis is on learning through experience, describing experiences and not judging them or labelling them. There are group activities and parents are engaged by using psychotherapy (1), having therapist-conducted mindfulness sessions for the parents (2), teaching parents about different mindfulness exercises (3), having parents participate in homework activities of children (4) and having parents participate in post-training qualitative interviews (5).
UvA minds refers to a treatment with 8 weekly two-hour group sessions. The aim is to teach adolescents to cope with difficult and worrisome thoughts, learning how to relax, sleep and concentrate better. It consists of
.....read more Van der Oord, Lucassen, van Emmerik, & Emmelkamp (2010). Treatment of post-traumatic stress disorder in children using cognitive behavioural writing therapyPTSD symptoms may persist into adulthood if children are not treated adequately. Cognitive behavioural treatment is more effective than a waitlist condition (1), community treatment (2), supportive therapy (3) or child-centred therapy (4) on short- and long-term outcomes. However, there is no consensus regarding essential aspects of the treatment (e.g. should anxiety management procedures be added?). Furthermore, most studies focus on a single traumatic event rather than complex trauma (i.e. multiple traumatic events).
Imaginal exposure and cognitive restructuring of trauma-related dysfunctional cognitions are seen as essential to CBT. Written exposure may be effective through the same mechanisms as exposure in CBT. Cognitive behavioural writing assignments produce materials which can be shared with partners or parents (i.e. social sharing). Social sharing may promote social support which reduces PTSD symptoms.
The narrative exposure treatment (NET) only uses the trauma narrative. It aims to reduce PTSD symptoms by confronting the patient with the memories of the traumatic event. The goal is to integrate the fragmented, gap-filled reports of traumatic experiences into a coherent narrative and bring about the habituation of emotional responses to reminders of the trauma. Cognitive restructuring and social sharing are not explicitly included in NET. NET seems to be effective in reducing PTSD symptoms.
The most important elements of cognitive behavioural writing therapy (CBWT) are psychoeducation (1), exposure (2), cognitive restructuring (3), promoting adequate coping (4) and social sharing (5). It does not include relaxation training. In the case of multiple traumas, a timeline is constructed and the most distressing trauma is then described into more detail. The written account of the traumatic event is further integrated into a complete storyline during the course of treatment.
Sessions are individual but joint parent-child sessions can be provided when necessary. The first session is devoted to the rationale of the treatment and psychoeducation. The therapist helps the child write by asking explicit questions and giving examples of what other children may feel. During the writing, the therapist helps the child to restructure the maladaptive thoughts (i.e. cognitive restructuring) and learns the child how to identify and restructure maladaptive thoughts.
In each therapy session, the child rereads the story of the trauma as this serves as exposure and then continues describing the remainder of the story. At the end of the story, the therapist and the child generate potential coping strategies for the future. Afterwards, the story is shared with important people.
CBWT leads to a decrease of PTSD symptoms (1), depressive symptoms (2) and internalizing and externalizing behavioural problems (3). This was maintained at 6-months follow-up. The results are comparable to other evidence-based interventions. However, there was no control condition so it is difficult to compare to other treatments.
CBWT uses a computer and this may be especially motivating for children. The use of a storyline facilitates the child to make a coherent story of the traumatic event with a beginning and an end. This may facilitate
.....read more McCauley et al. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial.” – Article summary Prior suicide attempts are indicators of suicide death. Prior suicide attempts and non-suicidal self-injury (NSSI) are indicators of future suicide attempts. Therapeutic interventions for reducing self-harm have better outcomes than treatment as usual.
Dialectical behavioural therapy (DBT) refers to a multicomponent cognitive-behavioural treatment that targets treatment engagement and the reduction of self-harm and suicide attempts. It focuses on teaching skills for enhancing emotion regulation (1), distress tolerance (2) and building a life worth living (3). It is efficacious in reducing suicide attempts and NSSIs.
DBT is efficacious among adolescents for reducing suicide attempts (1), NSSI (2) and self-harm (3) for people at risk for suicide. At six months after the treatment, participants who followed DBT had a lower suicide risk than those who followed IGST. At twelve months, there were no differences. After twelve months, half of the participants stopped with self-harm in the DBT group. This was one third in the IGST group.
Participation was higher in the DBT group. The results may thus occur due to increased exposure. Greater participation may have occurred as DBT included greater family involvement. This may have learned parents and youth new coping skills.
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