[Show abstract][Hide abstract] ABSTRACT: Past research suggests that girls, more than boys, tend to act and think in ways consistent with entity theories of personal traits: beliefs that such traits are unchangeable. This study explored how this gender difference might develop and relate to mental health problems in early adolescents across an academic year (N=59, ages 11-14). Overall, girls endorsed stronger entity theories of thoughts, feelings, and behavior than boys. Further, girls’ entity theories grew stronger across the school year, while boys’ did not. Additional analyses suggested that entity theories were more strongly associated with mental health problems in girls than in boys. Finally, girls with greater baseline mental health problems were more likely to develop entity theories of feelings six months later.
Full-text · Article · Feb 2016 · Journal of Social and Clinical Psychology
[Show abstract][Hide abstract] ABSTRACT: Background:
Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs).
Aims and scope:
The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.
The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.
The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.
Full-text · Article · Oct 2015 · Journal of Child Psychology and Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Introduction
Anxiety disorders are associated with significant public health burden in young individuals. Cognitive-behavioural therapy (CBT) is the most commonly used psychotherapy for anxiety disorders in children and adolescents, but previous reviews were hindered by a limited number of trials with direct comparisons between different psychotherapies and their deliveries. Consequently, the main aim of this research was to investigate the comparative efficacy and acceptability of various types and deliveries of psychotherapies for anxiety disorders in children and adolescents.
Methods and analysis
We will systematically search PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, ProQuest Dissertations and LiLACS for randomised controlled trials, regardless of whether participants received blinding or not, published from 1 January 1966 to 30 January 2015 (updated to 1 July 2015), that compared any psychotherapy with either a control condition or an active comparator with different types and/or different delivery formats for the acute treatment of anxiety disorders in children and adolescents. Data extraction, risk of bias and quality assessments will be independently extracted by two reviewers. The primary outcome for efficacy will be mean overall change scores in anxiety symptoms (self-rated or assessor-rated) from baseline to post-treatment between two groups. The acceptability of treatment will be measured as the proportion of patients who discontinued treatment during the acute phase of treatment. We will assess efficacy, based on the standardised mean difference (SMD), and acceptability, based on the OR, using a random-effects network meta-analysis within a Bayesian framework. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings.
Ethics and dissemination
No ethical issues are foreseen. The results will be published in a peer-reviewed journal and will be disseminated electronically and in print. The meta-analysis may be updated to inform and guide management of anxiety in children and adolescents.
Trial registration number
[Show abstract][Hide abstract] ABSTRACT: Mental health disorders are common and disabling for young people because of the potential to disrupt key developmental tasks. Implementation of evidence-based psychosocial therapies in New Zealand is limited, owing to the inaccessibility, length, and cost of training in these therapies. Furthermore, most therapies address one problem area at a time, although comorbidity and changing clinical needs commonly occur in practice. A more flexible approach is needed. The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) is designed to overcome these challenges; it provides a range of treatment modules addressing different problems, within a single training program. A clinical trial of MATCH-ADTC in the USA showed that MATCH-ADTC outperformed usual care and standard evidence-based treatment on several clinical measures. We aim to replicate these findings and evaluate the impact of providing training and supervision in MATCH-ADTC to: (1) improve clinical outcomes for youth attending mental health services; (2) increase the amount of evidence-based therapy content; (3) increase the efficiency of service delivery.
This is an assessor-blinded multi-site effectiveness randomized controlled trial. Randomization occurs at two levels: (1) clinicians (≥60) are randomized to intervention or usual care; (2) youth participants (7–14 years old) accepted for treatment in child and adolescent mental health services (with a primary disorder that includes anxiety, depression, trauma-related symptoms, or disruptive behavior) are randomly allocated to receive MATCH-ADTC or usual care. Youth participants are recruited from ‘mainstream’, Māori-specific, and Pacific-specific child and adolescent mental health services. We originally planned to recruit 400 youth participants, but this has been revised to 200 participants. Centralized computer randomization ensures allocation concealment. The primary outcome measures are: (i) the difference in trajectory of change of clinical severity between groups (using the parent-rated Brief Problem Monitor); (ii) clinicians’ use of evidence-based treatment procedures during therapy sessions; (iii) total time spent by clinicians delivering therapy.
If MATCH-ADTC demonstrates effectiveness it could offer a practical efficient method to increase access to evidence-based therapies, and improve outcomes for youth attending secondary care services.
Australian and New Zealand Clinical Trials Registry ACTRN12614000297628.
[Show abstract][Hide abstract] ABSTRACT: Research shows relations between entity theories—i.e., beliefs that traits and abilities are unchangeable—and youth psychopathology. A common interpretation has been that entity theories lead to psychopathology, but another possibility is that psychopathology predicts entity theories. The two models carry different implications for developmental psychopathology and intervention design. We tested each model’s plausibility, examining longitudinal associations between entity theories of thoughts, feelings, and behavior and psychopathology in early adolescents across one school year (N=59, 52% female, ages 11-14, 0% attrition). Baseline entity theories did not predict increases in psychopathology; instead, baseline psychopathology predicted increased entity theories over time. When symptom clusters were assessed individually, greater youth internalizing (but not externalizing) problems predicted subsequent increases in entity theories. Findings suggest that the commonly proposed predictive model may not be the only one warranting attention. They suggest that youth psychopathology may contribute to the development of certain kinds of entity theories.
Full-text · Article · Sep 2015 · Child Psychiatry and Human Development
[Show abstract][Hide abstract] ABSTRACT: Efforts to help young people have ancient historical roots, but “youth psychotherapy” has only been practiced for about a century and studied empirically for 50 years. Nonetheless, hundreds of randomized trials have now accumulated, and many specific treatments have sufficient empirical support that they are classified as evidence-based psychotherapies (EBPs). We examine the strength of that support, highlight specific EBPs for specific forms of youth dysfunction, and consider strategies for understanding how, with which groups, and under what conditions, the treatments produce beneficial effects. We also examine how specific these effects are (e.g., whether benefit is greatest for targeted symptoms), how robust (e.g., whether “blind” informants perceive benefit, whether effects vary with type of control group), and how effective when extended to youths in ethnic minority groups, low- and middle-income countries, war-torn regions, and the criminal justice and child protection systems. We discuss the challenge of disseminating EBPs and implementing them within the everyday practice of youth mental health care. Strategies for improving youth psychotherapies and intervention science are proposed, including making intervention research look more like clinical practice, leveraging the heuristic potential of usual clinical care, conducting more high-risk/high-gain research and finding ways to learn from treatment “failure,” restructuring EBPs to fit clinical practice, boosting treatment effectiveness through monitoring and feedback, enriching our understanding of what makes treatments work, and building efficient and accessible delivery methods and models.
[Show abstract][Hide abstract] ABSTRACT: Child depression is an impairing condition for which tested treatments have shown relatively modest mean effects. One possible explanation is that the treatments have generally adopted an individual child focus, without addressing the dysfunctional parent-child interactions that often accompany child depression. The present study provides preliminary evidence bearing on this hypothesis, using data from a treatment outcome study in which clinically referred children with a depression diagnosis could receive individual cognitive behavioral therapy (CBT) focusing on the depression or behavioral parent training (BPT) focusing on comorbid conduct problems. Among children in the study who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed.) depressive disorders, we identified two groups, matched on gender and age: 15 who received only CBT focused on child depression and 15 who received only BPT focused on child conduct problems. Children were 7 to 13, 20 of whom were male, and race included Caucasian (17), Latino (5), African American (2), and multirace (6). Measures assessed depressive diagnoses and symptoms, as well as parenting stress. Analyses focused on whether BPT alone might lead to reduced depression, and if so how that reduction would compare to the depression reduction achieved through CBT that focused on depression. Both groups showed significant reductions from pre- to post-treatment in depressive diagnoses and depression symptoms, and there were no BPT versus CBT group differences at post-treatment. BPT that focuses on child conduct problems, with no emphasis on depression treatment, may produce significant depression reduction in comorbid children who meet criteria for depressive disorders.
No preview · Article · Jul 2015 · Journal of Clinical Child & Adolescent Psychology
[Show abstract][Hide abstract] ABSTRACT: Research shows significant relations between entity theories—i.e., beliefs that traits and abilities are fixed and unchangeable—and youth mental health problems. A common interpretation has been that entity theories lead to mental health problems, but an alternative possibility is that mental health problems predict entity theories. The two predictive models carry different implications for developmental psychopathology and for intervention design. We used a longitudinal design to test the plausibility of the two models with respect to entity theories of thoughts, feelings, and behavior, examining associations between entity theories in these domains and mental health outcomes in early adolescents across three assessment points during one school year (N=59, 52% female, ages 11-14, no attrition at any time point). Findings showed concurrent, associations between entity theories and mental health problems across all assessment points. Importantly, baseline entity theories did not predict increases in mental health problems; instead, baseline mental health problems predicted increased entity theories over time. In addition, when symptom clusters were assessed individually, greater youth internalizing problems (but not externalizing problems) predicted increases in entity theories of thoughts, feelings, and behaviors across the study period. The findings support an alternative to the predictive model most commonly proposed. They suggest that youth mental health problems, and especially internalizing problems, may contribute to the development of certain kinds of entity theories.
[Show abstract][Hide abstract] ABSTRACT: Parent engagement in treatment for child disruptive behavior has been associated with improved child outcomes in care. However, many families who enter care do not receive an adequate dose of treatment, and parents are often not involved. We examined therapists' use of psychoeducation, a therapeutic practice used to present factual information about target problems and treatments, and its association with parent engagement in child psychotherapy. Participants were drawn from the Child System and Treatment Enhancement Projects' multisite trial contrasting standard evidence-based treatments, modular treatment, or usual care. We included an ethnically diverse sample of 46 youth (ages 7-13) who received treatment for disruptive behavior in modular treatment or usual care. A reliable observational coding system was developed to assess therapists' in-session use of psychoeducation strategies (e.g., discussing causes of misbehavior, describing and providing rationale for treatment, etc.), as well as other engagement strategies (e.g., collaborative goal setting, managing expectations, etc.), in the early phase of treatment. Findings revealed that modular treatment therapists provided more psychoeducation and other engagement strategies compared with usual care therapists. Furthermore, psychoeducation strategies employed by therapists early on uniquely predicted subsequent parent involvement in treatment, over and above the use of other engagement strategies. Finally, therapists' use of the psychoeducation strategy of discussing causes of child's misbehavior mediated the effect of treatment condition on parent involvement in their child's therapy. These findings suggest that the implementation of psychoeducation strategies upon entry into care promotes parent involvement in child psychotherapy for disruptive behavior.
Full-text · Article · Jun 2015 · Journal of Clinical Child & Adolescent Psychology
[Show abstract][Hide abstract] ABSTRACT: The modest efficacy of psychological interventions for youth depression, including evidence-based psychotherapies (EBPs), suggests a question: Do the therapy components match the coping strategies youths find helpful when dealing with depressed mood? Answering this question may help strengthen treatments. We asked 105 middle schoolers across a range of depression symptom levels to identify the coping strategies they used when they felt sad (habitual responses) and those that made them feel better (perceived-effective responses). Habitual and perceived-effective responses were coded for resemblance to EBPs, and each youth's habitual responses were coded for their match to the youth's perceived-effective responses. Most perceived-effective responses (92.6%) matched EBP components (most frequent: Behavioral Activation); however, 65.0% of the EBP components did not match any youth's habitual or perceived-effective responses. Youths at higher depression symptom levels were significantly more likely than low-symptom youths to report (a) habitual responses that did not match EBP components, (b) habitual responses that did not match their own perceived-effective responses, and (c) perceiving no effective response. The higher their depression symptom level, the less likely youths were to use strategies identified by researchers and perceived by themselves as effective, and the less likely they were to identify any perceived-effective coping strategy. The findings suggest a need to (a) determine which EBP components do in fact enhance youth coping, (b) design the most effective ways to help youths master those effective components, and
(c) facilitate more frequent use of those strategies the youths already find effective.
Full-text · Article · Jun 2015 · Journal of Clinical Child & Adolescent Psychology
[Show abstract][Hide abstract] ABSTRACT: Five decades of research have produced scores of empirically tested psychotherapies for youths who have mental health problems and disorders. These empirically supported treatments (ESTs), most of them focused on single disorders or single problem domains (e.g., depressive disorders), have shown substantial effects in randomized controlled efficacy trials. However, the ESTs do not fare as well when tested against usual clinical care with clinically referred youths treated in clinically representative conditions. One reason may be that referred youths and their clinical care contexts are sometimes more complex than the ESTs. For example, most youths referred for treatment have multiple problems and disorders, and their treatment needs shift over time. To address the differences between efficacy research conditions and clinical practice, we have proposed a deployment-focused model of treatment development and testing, recommending research that focuses on the kinds of individuals and intervention contexts for which the treatments are ultimately intended. Our work with colleagues consistent with the deployment-focused model has led to a transdiagnostic intervention approach, Child STEPs. STEPs uses an integrative modular treatment protocol derived from the psychotherapy evidence base, with treatment guided by frequent feedback to clinicians on youth treatment response. In a multisite randomized trial of this approach, applied to youths with anxiety, depression, and conduct problems, STEPs markedly outperformed usual clinical care on measures of clinical symptoms and diagnosis. The findings illustrate the potential of the deployment-focused approach to narrow the gap between clinical science and everyday clinical care.
No preview · Article · Jun 2015 · Verhaltenstherapie
[Show abstract][Hide abstract] ABSTRACT: Previous meta-analyses of psychotherapies for child and adolescent depression were limited because of the small number of trials with direct comparisons between two treatments. A network meta-analysis, a novel approach that integrates direct and indirect evidence from randomized controlled studies, was undertaken to investigate the comparative efficacy and acceptability of psychotherapies for depression in children and adolescents. Systematic searches resulted in 52 studies (total N=3805) of nine psychotherapies and four control conditions. We assessed the efficacy at post-treatment and at follow-up, as well as the acceptability (all-cause discontinuation) of psychotherapies and control conditions. At post-treatment, only interpersonal therapy (IPT) and cognitive-behavioral therapy (CBT) were significantly more effective than most control conditions (standardized mean differences, SMDs ranged from −0.47 to −0.96). Also, IPT and CBT were more beneficial than play therapy. Only psychodynamic therapy and play therapy were not significantly superior to waitlist. At follow-up, IPT and CBT were significantly more effective than most control conditions (SMDs ranged from −0.26 to −1.05), although only IPT retained this superiority at both short-term and long-term follow-up. In addition, IPT and CBT were more beneficial than problem-solving therapy. Waitlist was significantly inferior to other control conditions. With regard to acceptability, IPT and problem-solving therapy had significantly fewer all-cause discontinuations than cognitive therapy and CBT (ORs ranged from 0.06 to 0.33). These data suggest that IPT and CBT should be considered as the best available psychotherapies for depression in children and adolescents. However, several alternative psychotherapies are understudied in this age group. Waitlist may inflate the effect of psychotherapies, so that psychological placebo or treatment-as-usual may be preferable as a control condition in psychotherapy trials.
[Show abstract][Hide abstract] ABSTRACT: The measurement of treatment adherence (a component of treatment integrity defined as the extent to which a treatment is delivered as intended) is a critical element in treatment evaluation research. This article presents initial psychometric data for scores on the Cognitive-Behavioral Therapy Adherence Scale for Youth Anxiety (CBAY-A), an observational measure designed to be sensitive to common practice elements found in individual cognitive-behavioral therapy (ICBT) for youth anxiety. Therapy sessions (N = 954) from 1 efficacy and 1 effectiveness study of ICBT for youth anxiety were independently rated by 2 coders. Interrater reliability (as gauged by intraclass correlation coefficients) for the item scores averaged 0.77 (SD = 0.15; range .48 to .80). The CBAY-A item and scale (skills, model, total) scores demonstrated evidence of convergent and discriminant validity with an observational measure of therapeutic interventions and an observational measure of the alliance. The CBAY-A item and scale scores also discriminated between therapists delivering ICBT in research and practice settings and therapists delivering nonmanualized usual clinical care. We discuss the importance of replicating these psychometric findings in different samples and highlight possible application of an adherence measure in testing integrity-outcome relations. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Full-text · Article · May 2015 · Psychological Assessment
[Show abstract][Hide abstract] ABSTRACT: To investigate the association between protocol design and therapist satisfaction in the Child STEPs Randomized Effectiveness Trial (Weisz et al., 2012).
Therapist report was obtained at the close of 145 cases seen by 77 therapists, each of whom was randomized to a Standard evidence-based treatment (EBT), modular EBT, or usual care (UC) condition.
Analysis of satisfaction items revealed 2 correlated factors representing perceived effectiveness and perceived responsiveness of the treatments. Therapist total satisfaction scores were significantly higher for cases in the modular condition than for those in the standard EBT or UC conditions. With regard to specific dimensions, the modular and UC cases were rated significantly higher than standard EBT cases on the Responsiveness scale, whereas modular and standard EBT cases were rated significantly higher than UC on the Effectiveness scale. Finally, increases in Effectiveness scores from first to second case were significantly larger for Modular cases than for cases in both other study conditions, and increases from first to second case in Total Satisfaction scores were significantly larger for modular cases than for UC cases.
Therapist satisfaction with a treatment approach has independent dimensions, which can vary as a function of the protocol design. By virtue of being perceived as more effective than UC and more responsive than standard EBTs, the modular protocol design was also viewed as more overall satisfying than both, and secondary analysis suggested that these results were not due to mere first impressions of the protocols. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Full-text · Article · May 2015 · Journal of Consulting and Clinical Psychology
[Show abstract][Hide abstract] ABSTRACT: Efforts to identify empirically supported treatments (ESTs) for youth's mental health problems are valuable, but the descriptor empirically supported does not guarantee that a treatment will work well in everyday clinical use. The voltage drop often seen when ESTs move from efficacy studies to clinical practice contexts may reflect limited exposure to real-world conditions during development and testing. One result may be interventions that are focused more narrowly and are more linear than the clinical practice they are designed to enhance. In this article, we suggest three strategies for building and refining ESTs that are robust for real-world application: (a) designing interventions to fit the contexts of youth treatment, (b) structuring interventions that can be tailored to fit individual youth characteristics, and (c) building programs for nontraditional intervention contexts. In addition, we describe how to develop interventions that are ready for practical implementation: the deployment-focused model.
No preview · Article · Apr 2015 · Child Development Perspectives
[Show abstract][Hide abstract] ABSTRACT: Most youth psychotherapy research involves conditions quite unlike the clinical practice it is designed to strengthen. Most studies have not tested interventions with clinically referred youths and practicing clinicians in clinical care settings, nor have they tested whether new treatments produce better outcomes than usual practice. Limited exposure to real-world conditions and questions may partially explain why empirically supported treatments show such modest effects when tested under more representative conditions, against usual care. Our deployment-focused model calls for intervention development and testing with the kinds of participants (e.g., clients and clinicians) and in the contexts (e.g., clinics) for which the interventions are ultimately intended, and for randomized comparisons to usual clinical care. Research with the Child STEPs (system and treatment enhancement projects) treatment approach illustrates the methods and potential benefits of the deployment-focused model. Findings supporting Child STEPs are but one part of a rich research matrix needed to shrink the gap between intervention research and clinical practice.
Full-text · Article · Mar 2015 · Annual Review of Clinical Psychology
[Show abstract][Hide abstract] ABSTRACT: Crohn's disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease.
Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Children's Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohn's disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34).
Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohn's disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohn's disease Activity Index (P = 0.03) after CBT.
Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.
Full-text · Article · Mar 2015 · Inflammatory Bowel Diseases
[Show abstract][Hide abstract] ABSTRACT: Objective:
Research has examined the effects of parental psychopathology, family functioning, and caregiver strain on treatment response in anxious youths. Although these variables have shown individual links to youth treatment response, theoretical models for their combined effects remain unexplored. This study tested the hypothesis that improvements in family functioning and reductions in caregiver strain explained the effects of parental psychopathology on youth treatment outcome in an anxiety treatment trial.
A multiple mediation technique was used to test the proposed model across independent evaluator (IE), parent, and youth informants in 488 youths, aged 7-17 years (50% female; mean age = 10.7) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for social phobia, separation anxiety, and/or generalized anxiety disorder. Youths were randomized to receive 12 weeks of cognitive-behavioral treatment (Coping Cat), medication (sertraline), their combination, or a pill placebo. At pre- and posttreatment, parents completed self-report measures of global psychopathology symptoms, family functioning, and caregiver strain; parents, youths, and IEs rated youths' anxiety symptom severity.
Changes in family functioning and caregiver strain jointly explained relations between parental psychopathology and reductions in youth anxiety. Specifically, across IE and parent informants, families with higher pretreatment parental psychopathology showed more improvement in family functioning and caregiver strain, which in turn predicted greater youth anxiety reductions. Further, higher pretreatment parental psychopathology predicted greater caregiver strain reductions and, in turn, greater youth anxiety reductions, based on youths' reports of their own anxiety.
Findings suggest that improvements in family functioning and reductions in caregiver strain can influence treatment outcomes for anxious youths, especially among youths with more distressed parents.
Full-text · Article · Feb 2015 · Journal of Consulting and Clinical Psychology