Developing a research agenda for child and adolescent psychotherapy.

Child and adolescent therapy has progressed considerably, as reflected in the sheer number of controlled studies, their methodological quality, and identification of empirically supported treatments. Even so, research is not likely to make significant advances, in light of the way in which treatment is studied and the emphasis on technique-focused questions. This article raises 3 questions: What are the goals of child and adolescent psychotherapy research? What type of research is needed to obtain these goals? How can we determine whether we are making progress toward the goals? This article provides a plan to advance research that (1) emphasizes understanding the mechanisms or processes through which therapeutic change occurs, (2) draws on developmental psychopathology research to inform treatment, (3) expands the range of questions that guide treatment research, and (4) elaborates multiple treatment outcomes on which to base conclusions. Recommendations are made to both develop the research agenda and to evaluate progress.

Coming to terms with the terms of risk.

Terms such as risk, risk factors, and especially the term cause are inconsistently and imprecisely used, fostering scientific miscommunication and misleading research and policy. Clarifying such terms is the essential first step. We define risk and a risk factor (protective factor) and their potency, set out the conceptual basis of the methods by which risk factors are identified and potency demonstrated, and propose criteria for establishing the status of a risk factor as a fixed or variable marker or a causal risk factor. All definitions are based on the state of scientific knowledge (empirical documentation), rather than on hypotheses, speculations, or beliefs. We discuss common approaches and pitfalls and give a psychiatric research example. Imprecise reports can impede the search for understanding the cause and course of any disease and also may be a basis of inadequate clinical or policy decision-making. The issues in risk research are much too important to tolerate less than precise terminology or the less than rigorous research reporting that results from imprecise and inconsistent terminology.

Assessment of depression in mentally retarded adults.

Depression and psychopathology were assessed in 110 adult patients (ages 18-71 years) classified as borderline, mildly, moderately, or severely mentally retarded. Patients completed modified versions of the Beck Depression Inventory, the Zung Self-Rating Depression Scale, the MMPI depression scale, the Thematic Apperception Test, and the Psychopathology Instrument for Mentally Retarded Adults. Clinicians and ward personnel rated the patients on the Hamilton Rating Scale for Depression and an informant version of the Psychopathology Instrument for Mentally Retarded Adults. The measures correlated significantly with each other and were consistently related to the diagnosis of depression.

Withdrawal symptoms after graduated cessation of imipramine in children.

In a systematic retrospective study the authors reviewed charts of 22 depressed children on a clinical research unit who were withdrawn from high-dose imipramine. Significant withdrawal symptoms were found over seven symptom categories despite an average tapering period of 6.4 days. These results suggest that withdrawal symptoms in children may be much more prevalent and intense than previously recognized.

Psychiatric illness in the mothers of anxious children.

The authors compared maternal lifetime psychiatric illness for children with separation anxiety disorder and/or overanxious disorder (N = 58) and for children who were psychiatrically disturbed but did not manifest an anxiety or affective disorder (N = 15). The vast majority (83%) of mothers of children with separation anxiety disorder and/or overanxious disorder had a lifetime history of an anxiety disorder. Moreover, over one-half (57%) of the mothers presented with an anxiety disorder at the same time at which their children were seen for similar problems. Both of these rates significantly differed from those obtained for control subjects.

Separation anxiety and school phobia: a comparison using DSM-III criteria.

Children who met DSM-III criteria for separation anxiety disorder (N = 48) or a phobic disorder of school (N = 19) were compared with respect to demographic characteristics, symptoms, associated psychiatric disorders, and maternal psychiatric illness. More children with separation anxiety disorder were female, prepubertal, and from families with lower socioeconomic backgrounds. Children with separation anxiety disorder were less likely to exhibit school refusal than children with school phobia. However, they were more likely to meet criteria for an additional DSM-III diagnosis. Finally, their mothers had a rate of affective disorders four times greater than that of mothers of children with school phobia.

Evaluation of the Pleasure Scale in the assessment of anhedonia in children.

The Pleasure Scale for Children, a measure developed to assess anhedonia in school-age children, was evaluated. Psychometric properties and concurrent validity of the scale were evaluated with 232 child psychiatric inpatient children (ages 6-13) and their parents. Based on prior research with adults, predictions were made that children with a diagnosis of major depression would evince greater anhedonia on the scale and that anhedonic children (low Pleasure Scale scores) would show a negative attributional style in relation to rewarding experiences. The results indicated that the Pleasure Scale was internally consistent, yielded moderate to high item-total score correlations, appeared to reflect a single dimension, and correlated positively and significantly with other measures of pleasurable affect. Depressed children showed greater anhedonia, as reflected in lower total Pleasure Scale scores and in their pattern of responding to individual items on the scale. Children high in anhedonia, independently of their diagnosis, showed less active involvement in seeking rewards, were higher in their expectations of negative outcomes, and were more likely to attribute unrewarding outcomes to their own behavior than to external causes. Overall, the results provide initial support for the construct validity of the scale. Further research to evaluate nonclinic samples, to develop alternative assessment strategies, to examine developmental differences in reporting pleasurable experiences, and to study the relation of anhedonia to subtypes and clinical course of depression is briefly discussed.

Parent management training: evidence, outcomes, and issues.

OBJECTIVE: To describe and evaluate parent management training (PMT) as a treatment technique for oppositional, aggressive, and antisocial behavior. METHOD: Recent research is reviewed on the efficacy of PMT; factors that contribute to treatment outcome; the range of outcomes related to child, parents, and family; and variations of treatment currently in use. Limitations are also discussed related to the impact of treatment, clinical application, and dissemination of treatment. RESULTS AND CONCLUSIONS: PMT is one of the more well-investigated treatment techniques for children and adolescents. Notwithstanding the large number of controlled studies attesting to its efficacy, fundamental questions remain about the magnitude, scope, and durability of impact.

Therapeutic changes in children, parents, and families resulting from treatment of children with conduct problems.

OBJECTIVE: To examine changes in child, parent, and family functioning over the course of child therapy among children who completed outpatient treatment. METHOD: Children (N = 250, ages 2-14 years) referred for oppositional, aggressive, and antisocial behavior received variations of cognitive-behavioral treatments. Outcome was evaluated by changes in the children (multiple symptom domains), parents (symptoms, stress), and family (relationships, family functioning, support, marital satisfaction). RESULTS: Child, parent, and family functioning improved significantly over the course of therapy. The magnitude of these changes indicated large improvements for child outcome measures and smaller improvements for parent and family outcome measures. Improvements in children, parents, and family measures were significantly and moderately correlated. Finally, the pattern of predictors varied among child, parent, and family outcomes. CONCLUSIONS: The benefits of child therapy extended to parent and family functioning, even though these were not focused on directly. The broad changes have significant implications for evaluating the effectiveness of treatment and the benefits and costs of delivering services to children.

Children's descriptions of their firesetting incidents: characteristics and relationship to recidivism.

OBJECTIVE: The primary purpose of the study was to identify characteristics of children's firesetting incidents and examine the relationship of reported characteristics to psychopathology and firesetting history. METHOD: A sample of 95 firesetters were interviewed using the Fire Incident Analysis for Children (FIAC). Other child or parent measures were obtained reflecting behavioral correlates and risk factors for firesetting at initial assessment, and firesetting history measures at 2-year follow-up. RESULTS: Access to incendiaries, lack of child remorse and parental consequences, and motives of curiosity and fun were commonly reported characteristics. Certain firesetting characteristics were associated with follow-up recidivism. Repeat versus single-incident firesetters at initial assessment were similar in firesetting characteristics but differed in measures of psychopathology and follow-up recidivism. CONCLUSIONS: Children can report on personal and environmental details of their firesetting incidents, which may help to identify those children most at-risk for setting an additional fire. The findings bear implications for understanding firesetting risk-assessment measures, the role of specialized child interviews, and potential predictors of firesetting recidivism among children.

DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics.

This study investigated the characteristics of each of the specific DSM-III-R (American Psychiatric Association, 1987) anxiety disorders in a clinic sample of 188 anxiety disordered children. Characteristics examined included sociodemographic variables (age-at-intake, gender, and race of the child, and family marital and socioeconomic status) and clinical variables (disorder age-at-onset and severity, and history of additional disorders). Findings are discussed in light of the contemporary literature on childhood anxiety disorders.

Treatment outcome among children with externalizing disorder who terminate prematurely versus those who complete psychotherapy.

OBJECTIVE: To compare the clinical dysfunction at the end of treatment of children who dropped out of therapy prematurely (dropouts) versus those who completed treatment (completers). We predicted that (1) children who terminated prematurely would show greater impairment at the end of treatment than would children who completed treatment, and (2) the differences at posttreatment would result from subject selection variables and severity of child dysfunction at pretreatment rather than from termination of treatment, per se. METHOD: Children (N = 75, aged 4 to 13 years) referred for oppositional, aggressive, and antisocial behavior formed three groups: dropouts, completers, and completers matched to dropouts on subject and demographic variables and severity of child dysfunction. RESULTS: At the end of treatment children who terminated prematurely showed greater impairment at home, at school, and in the community, compared with children who completed treatment. Outcome differences were less evident between dropouts and completers when pretreatment child severity of dysfunction was controlled. CONCLUSIONS: The findings suggest that selection factors and severity of impairment may relate both to attrition and limited responsiveness among patients who continue.

A prospective study of childhood anxiety disorders.

OBJECTIVE: To evaluate course and outcome of DSM-III-R anxiety disorders prospectively in clinically referred children. METHOD: Children were blindly and repeatedly assessed with a structured diagnostic interview over a 3- to 4-year period to determine recovery from anxiety disorder and development of new psychiatric disorders. Both psychopathological (attention-deficit hyperactivity disorder, n = 50) and never psychiatrically ill (NPI, n = 83) controls served as comparison groups for children with anxiety disorders (n = 84). RESULTS: The majority of children (82%) were free from their intake anxiety disorders by the end of the follow-up. Relapse of these anxiety disorders after remission was rare (8%). During follow-up, anxious children were more likely to develop new psychiatric disorders (30%), primarily new anxiety disorders (16%), than were NPI children (11% and 2%, respectively), but not psychopathological controls (42% and 10%, respectively). CONCLUSIONS: Overall, results suggest a favorable outcome with respect to diagnostic status for clinically referred children with anxiety disorders. However, these children may be at risk for new psychiatric disorders over time.

Lowering the burden of suffering from child psychiatric disorder: trade-offs among clinical, targeted, and universal interventions.

OBJECTIVE: To examine the trade-offs among clinical, targeted, and universal interventions aimed at lowering the burden of suffering from child psychiatric disorders. METHOD: Data from clinical and research studies were organized to show the advantages and disadvantages of the three strategies. RESULTS: Important trade-offs exist among these three approaches. The strategy to reduce the burden of suffering from child psychiatric disorder should consist of a number of concurrent steps. First, effective universal programs should be in place. Targeted programs should follow for those not helped sufficiently by the universal programs. Finally, for those unaffected by the targeted programs, clinical services should be available. CONCLUSION: An optimal mix of universal, targeted, and clinical programs is needed. The nature of the combination will change as knowledge accumulates, and there will always be trade-offs among these three. Acad.

Contributions of risk-factor research to developmental psychopathology.

Risk-factor research refers to the study of antecedent conditions and subsequent outcomes and the ways in which these are interrelated. The research encompasses a broad range of questions and research strategies. The paper discusses the characteristics and contributions of risk-factor research in the context of developmental psychopathology. The ways in which causal paths are conceptualized, the capacity to integrate multiple influences, and applications that can be derived from the findings are discussed. The progression of research is illustrated in relation to key concepts (correlate, risk factor, marker, causal risk factor) that reflect varied levels of understanding antecedent-outcome relations. The identification of causal relations, progressions, and paths over the course of development and the interplay of theory, research, and application are illustrated and discussed.

The meanings and measurement of clinical significance.

The previous articles in this special section make the case for the importance of evaluating the clinical significance of therapeutic change, present key measures and innovative ways in which they are applied, and more generally provide important guidelines for evaluating therapeutic change. Fundamental issues raised by the concept of clinical significance and the methods discussed in the previous articles serve as the basis of the present comments. Salient among these issues are ambiguities regarding the meaning of current measures of clinical significance, the importance of relating assessment of clinical significance to the goals of therapy, and evaluation of the construct(s) that clinical significance reflects. Research directions that are discussed include developing a typology of therapy goals, evaluating cutoff scores and thresholds for clinical significance, and attending to social as well as clinical impact of treatment.

Effectiveness of psychotherapy with children and adolescents.

This article reviews the outcome evidence of psychotherapy for children and adolescents. The questions that guide treatment research, conclusions about alternative treatments, and the impact on different types of problems are reviewed. Alternative treatments for children and adolescents have produced change across a diverse range of emotional and behavioral problems. Progress and advances in treatment research are illustrated by highlighting alternative treatments and factors that contribute to outcome in the treatment of conduct problem children. Although important advances can be readily identified in outcome research, the pace of progress has been thwarted by challenges of the subject matter (e.g., developmental issues, comorbidity, and the diverse parent, family, and other contextual factors in which child dysfunction is embedded) and deficiencies in current research (e.g., ambiguity in the characteristics of the samples, weak statistical power, departure of treatment conditions in research from those that characterize clinical work). Notwithstanding the recency of empirical attention to the topic, progress is evident in developing effective treatments for a wide range of problems.

Identifying and developing empirically supported child and adolescent treatments.

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

Dropping out of child psychotherapy: distinguishing early and late dropouts over the course of treatment.

The present study examined child, parent, and family factors that predict dropping out from therapy among children (ages 4-13) referred for the treatment of oppositional, aggressive, and antisocial behavior. It was proposed that factors predicting attrition would vary as a function of whether families dropped out early or late in treatment. Several factors related to family (e.g., socioeconomic disadvantage, adverse child-rearing practices), parent (e.g., stress, life events, history of antisocial behavior), and child functioning (e.g., severity and chronicity of antisocial behavior, lower IQ, peer relations) predicted premature termination from treatment. A different pattern was evident in the factors predicting early and late termination from therapy. The findings have implications for conceptualizing the process of engaging and retaining families in treatment and for preventing premature termination.