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Child and Adolescent Psychotherapy
Child and Adolescent Psychotherapy AE Kazdin, Yale University, New Haven, CT, USA r 2016 Elsevier Inc. All rights reserved.
Glossary Consolidated Standards of Reporting Trials (CONSORT) A set of guidelines developed to improve the reporting of randomized controlled trials. The guidelines provide recommendations to report on multiple facets of the trial design and execution (e.g., how the sample was identified, how many started in the trial and completed treatment, statistical power, whether participants received the intended treatment). The CONSORT standards have been adopted by hundreds of professional journals from many disciplines and countries. Researchers conducting clinical trials are routinely required to present study details when submitting a manuscript for publication. Effect size A measure of the magnitude of a relation between an intervention or experimental intervention and change. There are many different measures of effect size and magnitude of relations. The effect size measure most frequently reported is Cohen’s d and is the mean difference between two conditions or groups on some outcome measure and is expressed in standard deviation units. By convention, small, medium, and large effect sizes are 0.2, 0.5, and 0.8, respectively. Evidence-based treatment (EBT) Interventions with controlled trials attesting to their efficacy. There are many definitions and criteria for EBTs in use among different agencies, organizations, and professions within a country (e.g., United States) and among many different countries. The common feature requires a minimum of two randomized controlled trials of an intervention with a control (e.g., no treatment and treatment as usual) with one of the studies being completed by an independent investigator or team of investigators. Mechanism The steps or processes through which the intervention (or some independent variable) actually unfolds and exerts its influence. Mechanism explains more about underlying processes and how they lead change and goes beyond merely a statistical association (mediation). Mediator A construct that shows a statistical relation between an experimental manipulation or intervention and the dependent variable or outcome. This is an intervening construct that suggests processes about why change occurs or on which change depends.
Introduction Psychotherapy for children and adolescents has advanced enormously. The advances are reflected in the quantity and quality of the research, development of evidence-based treatments (EBTs), and efforts to extend the treatments to clinical practice. Also, the questions and challenges that guide child therapy research have
Encyclopedia of Mental Health, Volume 1
Moderator A variable or characteristic that influences the direction or magnitude of the relation between two or more other variables (A and B). If the effect of an experimental manipulation varies as a function of some other characteristic (e.g., sex, ethnicity, temperament, genetics, and neural activity), that other characteristic is referred to as a moderator. Randomized controlled trial (RCT) An experimental arrangement in which participants are randomly assigned to intervention and controlled conditions. Typically pretreatment and posttreatment assessments are conducted and as relevant those involved in administering key facets of the study (e.g., medication and assessments) are naïve (blind) with regard to the interventions the participants have received. RCTs are commonly regarded as the ‘gold standard’ for evaluating interventions. Task shifting A method of strengthening and expanding the healthcare workforce by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional health care workers (e.g., doctors and nurses). This redistribution allows an increase in the total number of health workers (e.g., nonprofessionals and lay individuals) to scale up the scope of providing services. Transdiagnosis An approach toward psychiatric and psychological disorders and refers to the study of processes and underlying influences that span many different manifestations of clinical dysfunction. Transdiagnosis is in contrast the current approaches to psychiatric diagnosis that focuses on individual disorders. Transdiagnosis emerged as an approach in light of shared underpinnings (e.g., genetic and psychological processes) of many disorders, shared symptoms of many disorders, and high rates of comorbidity among disorders otherwise considered as distinct. Treatment as usual The routine treatment that is provided in a given setting for a given clinical problem. This is a control condition often used to evaluate the impact of another intervention. The benefits of the control condition are that nothing is withheld from clients and many common factors of treatment (attending sessions and expecting improvement) are controlled.
evolved and new priorities have emerged well beyond demonstrating that treatments can be effective. This article highlights advances and challenges in child therapy research and several key areas and questions that guide contemporary research. (I use the term children to represent both children and adolescents (youth 18 years of age and under), unless the distinction is pertinent to a particular point or discussion.)
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Advances in Child Therapy Research Quantity and Quality of Controlled Treatment Studies Advances in child psychotherapy are reflected in the sheer quantity of treatment outcome studies. No official count is available, but by the end of 1999, approximately 1500 controlled trials of treatment were identified (Kazdin, 2000a). One can surmise that at least a few thousand studies are now available given the number of journals devoted to psychosocial treatment and clinical dysfunction among children. Relatedly, treatment has been studied in relation to a broad range of recognized psychiatric disorders and developmental disabilities that youth experience (see Christopherson and Vanscoyoc, 2013; Evans et al., 2005; Steele et al., 2008; Weisz and Kazdin, 2010). The quality of treatment outcome studies has improved over the past 25 years. Randomized controlled trials (RCTs) continue to be viewed as the gold standard for evaluating interventions. In treatment research generally, more stringent requirements when reporting research have increased attention to critical issues at the design stage. Prominent among these are the Consolidated Standards of Reporting Trials (CONSORT; Moher et al., 2001). The standards provide recommendations to report on multiple facets of the trial design and execution (e.g., how the sample was identified, how many started in the trial and completed treatment, statistical power, and whether participants received the intended treatment). The CONSORT standards have been adopted by hundreds of professional journals from many disciplines and countries. Researchers conducting clinical trials of treatments are routinely asked to present study details in keeping with the CONSORT guidelines. Several specific practices illustrate the improved quality of research. First, treatment manuals are more commonly used than ever before to codify procedures and facilitate replication. These vary from general principles to guide treatment to quite prescriptive illustrations of therapist tasks, materials, and intervention administration (e.g., LeCroy, 2008). Second, studies more routinely evaluate the clinical significance of treatment-induced change. Criteria that are most frequently used include showing that performance of the sample at the end of treatment falls within normative levels of functioning (e.g., range of functioning of a nonclinical sample), changes that are marked (e.g., improvement of two standard deviations on critical outcome measures), and no longer meeting criteria for the diagnosis that may have been required for entry into the study. Third, ‘stronger’ control procedures are used to evaluate therapy as reflected in the more common use of ‘treatment as usual’ to see whether a new treatment improves upon procedures used in routine care. Finally, much more attention has been accorded ethnic and cultural issues in treatment research to see whether and to what extent treatments need to be adapted (e.g., Miranda et al., 2005). In addition, multiple programs of research have developed ethnically and culturally sensitive treatments with underrepresented samples (e.g., Malgady, 2011; Weisz and Kazdin, 2010).
of child therapy studies, as referred to previously in reference to the scope of dysfunction that is amenable to treatment. Evidence clearly demonstrates that treatment is better than no treatment for a variety of disorders (e.g., depression, anxiety, attention-deficit/hyperactivity disorder, eating disorders, and substance abuse) and across many outcome domains and measures (e.g., symptoms, social functioning, and school performance). Enumerating EBTs is well beyond the scope of this article. Two examples illustrate the rich offerings of EBTs for children and adolescents. First, for ‘Autism spectrum disorder (ASD),’ interventions based on applied behavior analysis have had marked and enduring effects on the disorders. For example, a recent well-controlled randomized trial showed that an intensive version of treatment (2 h sessions, 2 times per day, 5 days a week for 2 years) had impact 2 years after treatment began, as reflected in measures of cognitive and adaptive functioning in multiple domains (Dawson et al., 2010). Moreover, significantly more children in the intervention group no longer met diagnostic criteria for ASD, compared to children in the routine care control group. Many studies attest to the effects of intensive behavior analytic treatment (Reichow, 2012; Vismara and Rogers, 2010). Although the condition of ‘autism’ is not ‘cured,’ the interventions markedly improve adaptive behaviors (e.g., self-care, social interaction, and academic performance). Second, Conduct disorder (CD) consists of antisocial behavior (e.g., aggression, stealing, and firesetting) that emerges in childhood and has a poor long-term prognosis (e.g., approximately 80% have a psychiatric diagnosis in adulthood). Child therapy research has identified at least seven EBTs for the range of problems that comprise CD and these vary with respect to the ages of the youth to which they can be applied (e.g., young children and adolescents) and the severity of dysfunction and impairment that can be addressed (e.g., outpatient cases with aggressive behavior, violent children referred for inpatient treatment, and adolescents adjudicated for multiple crimes). Well-supported treatments include: anger control training, brief strategic family therapy, cognitive problemsolving skills training, functional family therapy, multidimensional treatment foster care, multisystemic therapy, and parent management training (Kazdin, 2007). The case of CD and related antisocial behaviors demonstrates that there is often more than one EBT available for a given clinical child problem. The two examples I have noted are the tip of the iceberg in terms of the interventions that are now evidence-based and the range of clinical problems to which they are applied. Indeed, the wealth of EBTs raises a host of challenges from the standpoint of research (e.g., How do all these treatments work? By what processes?) and even more so perhaps for clinical practice (e.g., How do we train people to select and implement some or many of these treatments?).
Caveats and Challenges Identification of Effective Treatments
Interpretation of Findings of Evidence-Based Treatments
Certainly the highlight of child therapy research is the development of EBTs. There are now many reviews and compendia
There are qualifiers about what we know and what can be said about EBTs. No single definition or set of criteria has been
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used to designate treatments as evidence-based. Several countries, professions, organizations within professions, and other parties (e.g., third-party payers, state, provincial, and federal governments) have delineated EBTs with varying criteria. Even so, commonly used criteria are that the treatment has been studied in RCTs, shown to be more effective than another condition (e.g., no treatment and treatment as usual), and these effects have replicated, preferably across independent research teams. ‘More effective’ means that the treatment condition was statistically better than a control group. Often effect sizes complement tests of statistical significance to convey the magnitude of the relation between treatment and therapeutic change (Cohen, 1988). It is important to bear in mind that neither statistical significance nor effect size (even if large) has any necessary connection to the clinical or practical importance of the therapeutic change. It is easy to show that statistically significant differences between groups and large effect sizes can be readily obtained with little or no clinical benefit (Kazdin, 2013). Thus, the clinical utility of EBTs and their superiority over other conditions (e.g., treatment as usual) are not so clear. The significance of this latter point is hardly trivial. In addition to knowing which EBTs lead to greater therapeutic change than many control conditions, we must also understand if and how this translates to client functioning in everyday life. Another issue that qualifies interpretation of EBTs pertains to how the studies are reported. Typically, studies of EBTs use multiple measures to evaluate therapeutic change. Frequently, some measures show the predicted differences in support of the EBT, whereas other measures do not. Researchers often consider the former to support the effectiveness of treatment. Yet, the measures that do not show the treatment effect are often excluded or minimized when drawing conclusions (see De Los Reyes and Kazdin, 2006). The implication for rendering conclusions across many studies is not knowing which indicators have changed and which have not, and, most importantly, what conclusions could be drawn if all available measurement data were considered. These concerns illustrate some of the ambiguity regarding the interpretation of EBTs. However, this is not grounds for abandoning or dismissing EBTs in clinical practice. In many instances, EBTs have been shown to make a difference and to surpass the gains achieved through usual or more traditional interventions. Yet, the qualifiers about what we can say about EBTs are not minor and require further research to redress them.
Dissemination of Evidence-Based Treatments Developing effective interventions does not mean they will be adopted or used in clinical practice. Even when techniques are used in clinical practice, their effectiveness drops sharply from what the results show in controlled treatment studies (e.g., Wampold et al., 2011; Weisz et al., 2006). Beyond concerns regarding the fidelity of treatment application, the vast number of EBTs now available means that the task of extending even a small set of these to a clinic or set of therapists is enormous. Moreover, most training programs (e.g., graduate work in clinical psychology or social work and residency training in psychiatry and child psychiatry) are not likely to include EBTs
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as part of course work, let alone supervised training and mastery of EBTs. Finally, dissemination is not merely a matter of discussing treatment, completing a continuing education experience, or seeing the treatment in action. Many EBTs involve specialized knowledge and skill sets. How to provide the requisite training and experience in EBTs constitutes a formidable challenge for the field. Possible solutions have been advanced (see Chorpita and Daleiden, 2009; Shafran and Craske, 2009; Weisz et al., 2014), including identifying components of treatments or modules that can be more readily used than all the individual EBTs, developing unified treatment protocols for treatments that have impact across a diverse range of disorders, training many nonprofessionals on a national scale (e.g., UK) to address a few but highly prevalent clinical problems (e.g., depression and anxiety), developing research that begins with clinical practice settings rather than research settings, providing training and certification in highly specialized interventions (e.g., behavior analysis, dialectical behavior therapy, and parent management training). Dissemination of treatment and implementation of those treatments are effective in clinical practice and have enormous challenges worthy of chapters in their own right. I highlight these issues here to underscore that this is an area of active work. Professional and governmental organizations, thirdparty payers, state and federal legislation, and training programs in the mental health profession all have a role to play in disseminating EBTs (see Weisz et al., 2014).
Clinical Practice Related to dissemination of course is clinical practice, which provides a useful context for evaluating EBTs. First, there are hundreds of psychotherapy techniques in use for children and adolescents. A now-dated count identified over 550 treatments in use (Kazdin, 2000b), and treatments have continued to proliferate. The vast majority of treatments in use clinically have not been evaluated empirically. Thus, when reviews of therapy research conclude that psychotherapy is effective for children, this refers to a very thin slice of available treatments. Second and related, often components or features of EBTs are adapted or combined with other practices in the repertoire of therapists. I have already noted that EBTs in clinical practice evidence diminished effects, relative to those obtained in controlled research. Add to that, the frequent eclecticism of clinical practice through the combination of different treatment components and attempts to individually tailor treatment to ‘meet the individual’s needs.’ Unlike ‘real’ tailoring (e.g., of clothing), no measurements are taken to permit one to decide what treatments (technique, dose, and duration) best suit the needs of an individual child. We do not yet know how to individualize therapy in a way that has been shown to be reliable (i.e., consistent within a therapist over time for similar patients, and consistent across therapists who would see very similar or virtually identical patients). Also, whether individualizing therapy by mixing and matching various techniques leads to better treatment outcomes than implementation of the best single EBT remains to be investigated. Third, in clinical practice, patient progress rarely is evaluated in a systematic way. It is important to monitor treatment
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effects in an ongoing way to make decisions about continuing, altering, or terminating treatment on the basis of how well the patient is doing. It is now well documented that some patients make rapid and enduring changes quite early in treatment (i.e., sudden therapeutic gains) (e.g., Hofmann et al., 2006; Tang and DeRubeis, 1999), whereas others may not make expected changes and are unresponsive even to extended treatment (Lambert et al., 2003). The use of any particular treatment (e.g., EBT or eclectic combination) does not guarantee client improvement. User friendly (brief and straightforward) measures are readily available for clinical use. One example is the Outcome Questionnaire (OQs-Measures, 2013), which includes multiple versions for therapy with adults as well as children. Versions of the measure have been thoroughly evaluated with thousands of patients and with individuals of different cultures and nationalities and shown to predict response to treatment (e.g., Lambert and Shimokawa, 2011; Shimokawa et al., 2010; Simon et al., 2012). Moreover, when the measure is used to provide feedback to therapists, patient outcomes are improved by decreasing the number of patients who deteriorate with therapy. The absence of systematic and routine evaluation in clinical practice is a critical issue regardless of whether or not an EBT is the core treatment. Overall, the hiatus between research and clinical practice continues to be an issue in both child and adult clinical work. Amidst the aforementioned challenges of dissemination, most EBTs are not used in clinical practice on a routine basis. Moreover, when these treatments are used, evidence suggests they are diluted and their effectiveness is reduced. Thus, in terms of the status of child therapy, more is needed in the way of both research and clinical work to improve treatment impact and patient care.
Research Priorities and Future Directions Several topics are high priorities for research. In some cases the research foci are not new, but the approaches used to address them are.
Moderators ‘Moderator’ refers to some characteristic that influences the direction or magnitude of the relation between the intervention and outcome. If treatment outcome varies as a function of characteristics of the child or therapist (e.g., sex, ethnicity, temperament, genetics, and neural activity) or treatment delivery (e.g., individual vs. group treatment), these characteristics are moderators. Historically, the dominant question that has guided psychotherapy has been about moderators, as illustrated by, “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?" (Paul, 1967, p. 111). The question continues to receive prominence as the treatment agenda to guide research (e.g., Roth and Fonagy, 2005). After decades of study, the literature is saturated with moderators, but we rarely understand why they moderate and it is nearly impossible to translate the findings to assign people to treatments for which they are well suited. For example,
culture or perceptions of the therapist may serve as moderators for a given treatment. However, by itself, this information does not tell us if that moderator impeded or enhanced therapeutic change, nor if that moderator would influence any or all treatments or just the given treatment under study. In the absence of further explanation, moderator research to date has not advanced our understanding of the underpinnings of treatment effects, nor has it been especially useful for decision making when selecting among treatments. Two lines of moderator research may point the way to future advances. First, efforts to understand moderators and how they relate to fundamental features of information processing may hold special promise. For example, biological features of how patients process information (e.g., neuromarkers) and psychological characteristics with which they are associated (e.g., processing social cues, working memory, and emotion regulation) serve as moderators of treatment response (psychotherapy and medication) (e.g., Doehrmann et al., 2013; Furey et al., 2013). These moderators can relate to fundamental biological features of disorders and elucidate targets for psychosocial and biological treatments. Such work has the potential of elaborating unifying processes across diverse treatments. Second, the ways in which moderators are studied are likely to change in the coming years. Moderators (e.g., severity of dysfunction, comorbidity, and culture) usually are studied one at a time in any individual study. Individual moderators tend to be weak in how they predict outcome (e.g., effect size) and may not emerge as statistically significant, even when they exert practically significant influences on treatment–outcome relations. Recently, methods for integrating and combining multiple moderators have been elaborated (Kraemer, 2013). When multiple moderators are combined moderator treatment interactions emerge that otherwise would not be evident (e.g., Frank et al., 2011; Wallace et al., 2013). Improvements in moderator research are greatly needed to advance clinical practice and decision making. Few studies are theoretically driven to predict how and why moderators operate. In addition, it has been difficult to direct patients to treatments from which they are very likely to profit and away from those from which they are not. Therapy research would profit from selecting and evaluating moderators in ways that translate to better care.
Mediators and Mechanisms of Change A critical research priority is to understand why and how therapy works. Presumably, the hundreds of therapies in use do not achieve their changes through different processes. Understanding basic processes of change might unify seemingly disparate interventions. In addition, without understanding how therapeutic change is achieved, we are at a disadvantage in knowing how we might optimize change through activation of specific components or processes. Research on mediators and mechanisms underlying therapeutic change aims to elaborate how treatment works. ‘Mediator’ is a construct that shows a statistical relation between an intervention and outcome. This is an intervening construct that suggests processes about why change occurs or
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on which change depends. Mediation is evident when several conditions are met: (1) the intervention leads to change in outcome measures, (2) the intervention alters the proposed mediator, (3) the mediator is related to outcome, and (4) outcome effects are not evident or significantly (statistically) less evident if the mediator did not change. These relations convey that change was mediated (e.g., correlated with or depended on) by some construct. However, even when these conditions are met, ambiguity can remain about the precise role of the mediator. The mediator may not, and usually is not intended to, explain precisely how the change comes about. For example, cognitions may be shown to mediate change in therapy. However, this does not explain precisely how the change came about (i.e., what are the intervening steps between cognitive change and reduced stress or anxiety?). ‘Mechanism’ refers to a greater level of explanatory specificity than mediator and reflects the steps or processes through which therapy (or some independent variable) actually unfolds and produces the change. Mechanism explains how the intervention translates into events that lead to the outcome or precisely what was altered that led to symptom change. Psychotherapy research with adults has benefitted from advances in cognitive, affective, and social neuroscience, as well as the development of noninvasive neuroimaging and other biological assays to examine the structure, function, and activity of the brain that are associated with clinical dysfunction (especially anxiety and depression) and/or changes over the course of psychotherapy among adults (e.g., Frewen et al., 2008; Porto et al., 2009; Quidé et al., 2012; Roffman et al., 2005). To date, neuroimaging has emphasized functional magnetic resonance imaging (fMRI), positive emission tomography (PET), and single-photon emission computed tomography (SPECT) (see Section Glossary). Much of this work, but certainly not all, is correlational when characterizing disorders or change processes. Yet, the strength of the research stems from multiple lines of converging evidence that move closer to identifying mechanisms of action. For example, from the reviews mentioned previously, research has:
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identified neurological characteristics associated with specific disorders and subtypes; evaluated change in neural processes in ‘regions of interest’ in light of characteristics associated with specific disorders; induced or provoked symptoms (e.g., sadness manipulations in healthy samples and trauma stimuli in PTSD patients) to demonstrate experimentally brain areas implicated in dysfunction; demonstrated ‘normalization’ of neurological structures, function, and activity after therapy is completed; elucidated similarities and differences in specific brain processes altered by different interventions (e.g., medication and psychotherapy) for a given disorder (e.g., major depression); and documented some similarities in what brain processes are altered by the same intervention (e.g., cognitive behavior therapy) as applied to different disorders (e.g., obsessive compulsive disorders and depression).
Neuroimaging studies capitalize on a set of tools to elaborate processes involved in therapeutic change. Additional
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methods have been used to study brain receptors, intracellular signaling, and target genes that reflect dysfunction and change over the course of treatment. As one example, antidepressant effects of medication relate to the expression of a protein in the brain synapses (brain-derived neurotrophic factor (BDNF)) that stimulates growth and differentiation of new neurons and synapses. We know from several studies with humans that major depression is characterized by low BDNF levels and that these levels increase after successful antidepressant treatment (Sen et al., 2008). In nonhuman animal studies, antidepressant effects can be manipulated experimentally to isolate the mechanism underlying these changes (e.g., infusing BDNF into the hippocampus directly, gene-knockout studies, blocking studies negating the operation of the BDNF gene, and manipulating exercise that attains a therapeutic-like antidepressant effect and alters BDNF) (e.g., Duman et al., 2008; Shirayama et al., 2002). These studies move us toward identifying precisely what is involved in successful intervention and symptom change. A clear research direction and priority will be elaborating biological changes that underlie and are associated with changes in symptoms, behaviors, and subjective experience. There is a concern that drawing on advances in neural assessment methods unwittingly will contribute to the biologizing of psychotherapy, i.e., reverting to biological and ‘reductionist’ explanations. However, core psychological and biological processes increasingly are studied together (e.g., cognitive and social neuroscience) to elaborate the connections, reciprocal relations, and conversions of experience and brain processes.
Transdiagnosis and Transtreatment Research on clinical dysfunction has relied heavily on psychiatric diagnosis. Psychiatric diagnosis have been based on the view that there are discrete entities (syndromes and disorders) such as major depression, bipolar disorder, and a few hundreds more (e.g., American Psychiatric Association, 2013; World Health Organization (WHO), 2010). Treatments were (and continue to be) developed with a disorder focus. Yet, an alternative view, referred to as transdiagnosis, has taken hold as a novel model for understanding clinical dysfunction, underlying processes, and treatment. Transdiagnosis refers to the study of processes that span many different manifestations of clinical dysfunction (e.g., Harvey et al., 2004; Kring and Sloan, 2009). Several factors have served as impetus for a transdiagnostic conceptualization of clinical dysfunction. Among the key interrelated influences are findings that:
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there are high rates of comorbidity so that individuals (children or adults) who meet criteria for one disorder are likely to meet criteria for at least one other disorder as well (e.g., Kessler et al., 1994; Wichstrøm et al., 2012); underlying processes that maintain ‘different disorders’ often are quite similar (e.g., Fairburn et al., 2003; Green et al., 2010; Jagannath et al., 2013); several disorders share common biological underpinnings as reflected in brain structures, neurotransmitters, and genes (e.g., Meyer-Lindenberg and Tost, 2012; Smoller et al., 2013);
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a number of EBTs (e.g., cognitive behavior therapy and mindfulness) are effective across a range of disorders suggesting some common mechanisms or core processes (e.g., working memory and emotion regulation) (e.g., Johnston et al., 2013); and broad characteristics such as a general psychopathology factor (a ‘p factor’), neuroticism, perfectionism, and tolerance of uncertainty might serve as underlying or mediating characteristics of many different disorders (Barlow et al., 2014; Caspi et al., 2014; Egan et al., 2011; McEvoy and Mahoney, 2012).
These findings have inspired efforts to search for core psychological (e.g., working memory and cognition), environmental (e.g., exposure to trauma, violence, and parent with depressed affect), and biological processes (e.g., neuromarkers and genetic), and their interrelations (e.g., epigenetic) that unite several types of clinical dysfunction that have been viewed as discrete diagnostic entities in conventional practice. Budding efforts to focus diagnosis on core psychological and biological processes also are emerging in new diagnostic work that may inform disorders from a transdiagnostic perspective (e.g., Cuthbert and Insel, 2013). Transdiagnostic conceptualizations have altered treatment and treatment research. Rather than adding to burgeoning lists of EBTs for specific disorders, attention is now being directed to the search for transdiagnostic treatments. Terms such as transdiagnostic treatment, unified treatment protocol, and unified cognitive behavior therapy are increasingly evident in treatment literature (e.g., Allen et al., 2008). It is likely that research will continue to explore treatments that are broad in applicability across diverse disorders.
Reaching Children and Families in Need The scope and impact of psychological dysfunction, whether conceived from a disorder specific or transdiagnostic perspective, is extraordinary. Among children, adolescents, and adults, 20–25% of community samples meet criteria for at least one psychiatric disorder. Prevalence does not convey the burden to individuals or society. Mental disorders are more impairing than common chronic medical disorders, with particularly greater impairment in the domains of home, social, and close-relationship functioning (Druss et al., 2009). As a dramatic illustration, in 2004, the burden of depressive disorders (e.g., years of good health lost because of disability) was ranked third among the list of mental and physical diseases (World Federation for Mental Health, 2011). By 2030, depression is projected to be the number one cause of disability, ahead of cardiovascular disease, traffic accidents, chronic pulmonary disease, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (WHO, 2008). A critical aspect to reducing the burden of mental illness is the ability of effective interventions to reach those in need of services. Recent years have seen an increase in the proportion of people in need who receive treatment in the United States, from 20.3% of individuals suffering from a disorder receiving treatment (e.g., psychiatry services, complementary and alternative medicine) between 1990 and 1992 and 32.9% of
individuals with a psychiatric disorder receiving some form of treatment between 2001 and 2003 (Kessler et al., 2005). Despite these gains, 70% of individual in need of services are not receiving them. Ethnic disparities with respect to access to mental healthcare add important challenges of providing services. Ethnic minority groups (e.g., African, Hispanic, and Native Americans) have much less access to care than do European Americans (e.g., McGuire and Miranda, 2008; Wells et al., 2001). The lack of available services for most people and systematic disparities among those services that are available underscore the importance of delivering services in ways that can reach many more people while targeting (and likely responding to the unique needs of) special groups. The dominant model of delivery across varied therapy techniques is administration by a highly trained (e.g., master’s or doctoral level) mental health professional in one-to-one, in-person sessions with a client who visits a particular setting (e.g., clinic, private office, and healthcare facility). This is referred to as the dominant model because clinical practice, graduate training, clinical program accreditation, pre- and postdoctoral internships, and research on psychosocial interventions draw heavily on this model. The one-to-one, inperson model is enduring, in demand, and suitable to deliver many EBTs to individuals who access them. Within the mental health professions, models of delivering psychosocial interventions are expanding. Many of these involve the use of technology and online versions of treatment that draw on the Internet and other media including video, phone, and application software (apps) for smartphones and tablets. Some uses of technology are variants of the dominant model in the sense that they are one-to-one and face-to-face (e.g., individual sessions by webcam), but extend to places where there may be no service or suitable facilities available (e.g., Wooton, 2003). Other extensions include self-help interventions and a vast array of techniques (e.g., online interventions and expressive writing techniques) that are available 24/7 and require little or no assistance from a trained professional (L’Abate, 2007). Several Internet, computerbased, self-help, and low-cost psychological interventions are evidence-based and achieve effects (i.e., effect sizes) at least on par with the similar technique administered in person by a trained mental health professional, and are high in client adherence to and satisfaction with treatment (e.g., Andrews et al., 2010; Cartreine et al., 2010; Harwood and L’Abate, 2010). Novel models of delivery are needed that include but go well beyond the use of technology. Models are needed that have such characteristics as:
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Reach: Capacity to reach individuals not usually served or well served by traditional service delivery models. Scalability: Capacity to be applied on a large scale or larger scale than traditional service delivery. Affordability: Relatively low cost compared to the usual model that relies on individual treatment by highly trained (Master’s, doctoral degree) professionals. Expansion of nonprofessional workforce: Increase the number of providers who can deliver interventions. Expansion of settings where interventions are provided: Bring interventions to locales and everyday settings where people in need are likely to participate or attend already.
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Feasibility and flexibility of intervention delivery: Ensure the interventions can be implemented and adapted to varied local conditions to reach diverse groups in need.
There are several such models available that have emerged from global health care, from business models of delivering innovations, and from nontraditional forms of interventions for mental health treatment (see Kazdin and Rabbitt, 2013). As one illustration, task shifting is a method of strengthening and expanding the healthcare workforce by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional healthcare workers (e.g., doctors and nurses) (see WHO, 2008). Task shifting is an evidence-based model of delivery that has been used extensively in treating and preventing physical disease but also has been extended to treatment of psychiatric disorders (e.g., anxiety, depression, and schizophrenia) (e.g., Balaji et al., 2012; Patel et al., 2010; Rahman et al., 2008). Research has focused almost exclusively on EBT. In the coming years, much greater priority is likely to be given to evidence-based ‘models of delivery.’ It is obvious we have many interventions that simply cannot get to the people in need. Even broad treatments (e.g., transdiagnostic treatments) and dissemination of current EBTs to clinicians in practice will not have a palpable effect on reducing the burdens of mental illness until we can take these efforts to scale. We still need to attend to evidence of course, but we must direct our attention to evidence that supports interventions that can be effective, administered on a large scale, and reach many unserved segments of the populations in need (see Kazdin and Blase, 2011; Kazdin and Rabbitt, 2013).
Conclusion The development of EBTs for children and adolescents is a major advance. Still, it is surprising how little we know about how treatments actually achieve the changes that are now well demonstrated. In the coming years, key issues that are likely to receive major attention include:
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disseminating and evaluating treatment in clinical practice settings; identifying common ingredients or transdiagnostic treatments that may not only facilitate dissemination, but also establish a new way to conceptualize interventions and clinical dysfunction; elaborating moderators of treatment that can be clinically useful and guide decision making; elucidating the mechanisms through which therapeutic change occurs; and scaling up our interventions to reach people in need of services.
The notion of translational research from medicine captures broadly key issues and priorities for therapy research in the coming years. Translational research focuses on ‘bench to bedside’ (i.e., laboratory to clinical application), and also ‘bedside to community’ (i.e., scaling up interventions to have impact). Extending treatments to practice and communities on a larger scale increasingly will serve as points of departure for developing interventions.
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Acknowledgments The author’s research on treatments for children is supported in part by grants from the National Institute of Mental Health (MH093326-01A1), the Humane Society of America, and the Laura J. Niles Foundation.
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Glossary Consolidated Standards of Reporting Trials (CONSORT) A set of guidelines developed to improve the reporting of randomized controlled trials. The guidelines provide recommendations to report on multiple facets of the trial design and execution (e.g., how the sample was identified, how many started in the trial and completed treatment, statistical power, whether participants received the intended treatment). The CONSORT standards have been adopted by hundreds of professional journals from many disciplines and countries. Researchers conducting clinical trials are routinely required to present study details when submitting a manuscript for publication. Effect size A measure of the magnitude of a relation between an intervention or experimental intervention and change. There are many different measures of effect size and magnitude of relations. The effect size measure most frequently reported is Cohen’s d and is the mean difference between two conditions or groups on some outcome measure and is expressed in standard deviation units. By convention, small, medium, and large effect sizes are 0.2, 0.5, and 0.8, respectively. Evidence-based treatment (EBT) Interventions with controlled trials attesting to their efficacy. There are many definitions and criteria for EBTs in use among different agencies, organizations, and professions within a country (e.g., United States) and among many different countries. The common feature requires a minimum of two randomized controlled trials of an intervention with a control (e.g., no treatment and treatment as usual) with one of the studies being completed by an independent investigator or team of investigators. Mechanism The steps or processes through which the intervention (or some independent variable) actually unfolds and exerts its influence. Mechanism explains more about underlying processes and how they lead change and goes beyond merely a statistical association (mediation). Mediator A construct that shows a statistical relation between an experimental manipulation or intervention and the dependent variable or outcome. This is an intervening construct that suggests processes about why change occurs or on which change depends.
Introduction Psychotherapy for children and adolescents has advanced enormously. The advances are reflected in the quantity and quality of the research, development of evidence-based treatments (EBTs), and efforts to extend the treatments to clinical practice. Also, the questions and challenges that guide child therapy research have
Encyclopedia of Mental Health, Volume 1
Moderator A variable or characteristic that influences the direction or magnitude of the relation between two or more other variables (A and B). If the effect of an experimental manipulation varies as a function of some other characteristic (e.g., sex, ethnicity, temperament, genetics, and neural activity), that other characteristic is referred to as a moderator. Randomized controlled trial (RCT) An experimental arrangement in which participants are randomly assigned to intervention and controlled conditions. Typically pretreatment and posttreatment assessments are conducted and as relevant those involved in administering key facets of the study (e.g., medication and assessments) are naïve (blind) with regard to the interventions the participants have received. RCTs are commonly regarded as the ‘gold standard’ for evaluating interventions. Task shifting A method of strengthening and expanding the healthcare workforce by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional health care workers (e.g., doctors and nurses). This redistribution allows an increase in the total number of health workers (e.g., nonprofessionals and lay individuals) to scale up the scope of providing services. Transdiagnosis An approach toward psychiatric and psychological disorders and refers to the study of processes and underlying influences that span many different manifestations of clinical dysfunction. Transdiagnosis is in contrast the current approaches to psychiatric diagnosis that focuses on individual disorders. Transdiagnosis emerged as an approach in light of shared underpinnings (e.g., genetic and psychological processes) of many disorders, shared symptoms of many disorders, and high rates of comorbidity among disorders otherwise considered as distinct. Treatment as usual The routine treatment that is provided in a given setting for a given clinical problem. This is a control condition often used to evaluate the impact of another intervention. The benefits of the control condition are that nothing is withheld from clients and many common factors of treatment (attending sessions and expecting improvement) are controlled.
evolved and new priorities have emerged well beyond demonstrating that treatments can be effective. This article highlights advances and challenges in child therapy research and several key areas and questions that guide contemporary research. (I use the term children to represent both children and adolescents (youth 18 years of age and under), unless the distinction is pertinent to a particular point or discussion.)
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Advances in Child Therapy Research Quantity and Quality of Controlled Treatment Studies Advances in child psychotherapy are reflected in the sheer quantity of treatment outcome studies. No official count is available, but by the end of 1999, approximately 1500 controlled trials of treatment were identified (Kazdin, 2000a). One can surmise that at least a few thousand studies are now available given the number of journals devoted to psychosocial treatment and clinical dysfunction among children. Relatedly, treatment has been studied in relation to a broad range of recognized psychiatric disorders and developmental disabilities that youth experience (see Christopherson and Vanscoyoc, 2013; Evans et al., 2005; Steele et al., 2008; Weisz and Kazdin, 2010). The quality of treatment outcome studies has improved over the past 25 years. Randomized controlled trials (RCTs) continue to be viewed as the gold standard for evaluating interventions. In treatment research generally, more stringent requirements when reporting research have increased attention to critical issues at the design stage. Prominent among these are the Consolidated Standards of Reporting Trials (CONSORT; Moher et al., 2001). The standards provide recommendations to report on multiple facets of the trial design and execution (e.g., how the sample was identified, how many started in the trial and completed treatment, statistical power, and whether participants received the intended treatment). The CONSORT standards have been adopted by hundreds of professional journals from many disciplines and countries. Researchers conducting clinical trials of treatments are routinely asked to present study details in keeping with the CONSORT guidelines. Several specific practices illustrate the improved quality of research. First, treatment manuals are more commonly used than ever before to codify procedures and facilitate replication. These vary from general principles to guide treatment to quite prescriptive illustrations of therapist tasks, materials, and intervention administration (e.g., LeCroy, 2008). Second, studies more routinely evaluate the clinical significance of treatment-induced change. Criteria that are most frequently used include showing that performance of the sample at the end of treatment falls within normative levels of functioning (e.g., range of functioning of a nonclinical sample), changes that are marked (e.g., improvement of two standard deviations on critical outcome measures), and no longer meeting criteria for the diagnosis that may have been required for entry into the study. Third, ‘stronger’ control procedures are used to evaluate therapy as reflected in the more common use of ‘treatment as usual’ to see whether a new treatment improves upon procedures used in routine care. Finally, much more attention has been accorded ethnic and cultural issues in treatment research to see whether and to what extent treatments need to be adapted (e.g., Miranda et al., 2005). In addition, multiple programs of research have developed ethnically and culturally sensitive treatments with underrepresented samples (e.g., Malgady, 2011; Weisz and Kazdin, 2010).
of child therapy studies, as referred to previously in reference to the scope of dysfunction that is amenable to treatment. Evidence clearly demonstrates that treatment is better than no treatment for a variety of disorders (e.g., depression, anxiety, attention-deficit/hyperactivity disorder, eating disorders, and substance abuse) and across many outcome domains and measures (e.g., symptoms, social functioning, and school performance). Enumerating EBTs is well beyond the scope of this article. Two examples illustrate the rich offerings of EBTs for children and adolescents. First, for ‘Autism spectrum disorder (ASD),’ interventions based on applied behavior analysis have had marked and enduring effects on the disorders. For example, a recent well-controlled randomized trial showed that an intensive version of treatment (2 h sessions, 2 times per day, 5 days a week for 2 years) had impact 2 years after treatment began, as reflected in measures of cognitive and adaptive functioning in multiple domains (Dawson et al., 2010). Moreover, significantly more children in the intervention group no longer met diagnostic criteria for ASD, compared to children in the routine care control group. Many studies attest to the effects of intensive behavior analytic treatment (Reichow, 2012; Vismara and Rogers, 2010). Although the condition of ‘autism’ is not ‘cured,’ the interventions markedly improve adaptive behaviors (e.g., self-care, social interaction, and academic performance). Second, Conduct disorder (CD) consists of antisocial behavior (e.g., aggression, stealing, and firesetting) that emerges in childhood and has a poor long-term prognosis (e.g., approximately 80% have a psychiatric diagnosis in adulthood). Child therapy research has identified at least seven EBTs for the range of problems that comprise CD and these vary with respect to the ages of the youth to which they can be applied (e.g., young children and adolescents) and the severity of dysfunction and impairment that can be addressed (e.g., outpatient cases with aggressive behavior, violent children referred for inpatient treatment, and adolescents adjudicated for multiple crimes). Well-supported treatments include: anger control training, brief strategic family therapy, cognitive problemsolving skills training, functional family therapy, multidimensional treatment foster care, multisystemic therapy, and parent management training (Kazdin, 2007). The case of CD and related antisocial behaviors demonstrates that there is often more than one EBT available for a given clinical child problem. The two examples I have noted are the tip of the iceberg in terms of the interventions that are now evidence-based and the range of clinical problems to which they are applied. Indeed, the wealth of EBTs raises a host of challenges from the standpoint of research (e.g., How do all these treatments work? By what processes?) and even more so perhaps for clinical practice (e.g., How do we train people to select and implement some or many of these treatments?).
Caveats and Challenges Identification of Effective Treatments
Interpretation of Findings of Evidence-Based Treatments
Certainly the highlight of child therapy research is the development of EBTs. There are now many reviews and compendia
There are qualifiers about what we know and what can be said about EBTs. No single definition or set of criteria has been
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used to designate treatments as evidence-based. Several countries, professions, organizations within professions, and other parties (e.g., third-party payers, state, provincial, and federal governments) have delineated EBTs with varying criteria. Even so, commonly used criteria are that the treatment has been studied in RCTs, shown to be more effective than another condition (e.g., no treatment and treatment as usual), and these effects have replicated, preferably across independent research teams. ‘More effective’ means that the treatment condition was statistically better than a control group. Often effect sizes complement tests of statistical significance to convey the magnitude of the relation between treatment and therapeutic change (Cohen, 1988). It is important to bear in mind that neither statistical significance nor effect size (even if large) has any necessary connection to the clinical or practical importance of the therapeutic change. It is easy to show that statistically significant differences between groups and large effect sizes can be readily obtained with little or no clinical benefit (Kazdin, 2013). Thus, the clinical utility of EBTs and their superiority over other conditions (e.g., treatment as usual) are not so clear. The significance of this latter point is hardly trivial. In addition to knowing which EBTs lead to greater therapeutic change than many control conditions, we must also understand if and how this translates to client functioning in everyday life. Another issue that qualifies interpretation of EBTs pertains to how the studies are reported. Typically, studies of EBTs use multiple measures to evaluate therapeutic change. Frequently, some measures show the predicted differences in support of the EBT, whereas other measures do not. Researchers often consider the former to support the effectiveness of treatment. Yet, the measures that do not show the treatment effect are often excluded or minimized when drawing conclusions (see De Los Reyes and Kazdin, 2006). The implication for rendering conclusions across many studies is not knowing which indicators have changed and which have not, and, most importantly, what conclusions could be drawn if all available measurement data were considered. These concerns illustrate some of the ambiguity regarding the interpretation of EBTs. However, this is not grounds for abandoning or dismissing EBTs in clinical practice. In many instances, EBTs have been shown to make a difference and to surpass the gains achieved through usual or more traditional interventions. Yet, the qualifiers about what we can say about EBTs are not minor and require further research to redress them.
Dissemination of Evidence-Based Treatments Developing effective interventions does not mean they will be adopted or used in clinical practice. Even when techniques are used in clinical practice, their effectiveness drops sharply from what the results show in controlled treatment studies (e.g., Wampold et al., 2011; Weisz et al., 2006). Beyond concerns regarding the fidelity of treatment application, the vast number of EBTs now available means that the task of extending even a small set of these to a clinic or set of therapists is enormous. Moreover, most training programs (e.g., graduate work in clinical psychology or social work and residency training in psychiatry and child psychiatry) are not likely to include EBTs
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as part of course work, let alone supervised training and mastery of EBTs. Finally, dissemination is not merely a matter of discussing treatment, completing a continuing education experience, or seeing the treatment in action. Many EBTs involve specialized knowledge and skill sets. How to provide the requisite training and experience in EBTs constitutes a formidable challenge for the field. Possible solutions have been advanced (see Chorpita and Daleiden, 2009; Shafran and Craske, 2009; Weisz et al., 2014), including identifying components of treatments or modules that can be more readily used than all the individual EBTs, developing unified treatment protocols for treatments that have impact across a diverse range of disorders, training many nonprofessionals on a national scale (e.g., UK) to address a few but highly prevalent clinical problems (e.g., depression and anxiety), developing research that begins with clinical practice settings rather than research settings, providing training and certification in highly specialized interventions (e.g., behavior analysis, dialectical behavior therapy, and parent management training). Dissemination of treatment and implementation of those treatments are effective in clinical practice and have enormous challenges worthy of chapters in their own right. I highlight these issues here to underscore that this is an area of active work. Professional and governmental organizations, thirdparty payers, state and federal legislation, and training programs in the mental health profession all have a role to play in disseminating EBTs (see Weisz et al., 2014).
Clinical Practice Related to dissemination of course is clinical practice, which provides a useful context for evaluating EBTs. First, there are hundreds of psychotherapy techniques in use for children and adolescents. A now-dated count identified over 550 treatments in use (Kazdin, 2000b), and treatments have continued to proliferate. The vast majority of treatments in use clinically have not been evaluated empirically. Thus, when reviews of therapy research conclude that psychotherapy is effective for children, this refers to a very thin slice of available treatments. Second and related, often components or features of EBTs are adapted or combined with other practices in the repertoire of therapists. I have already noted that EBTs in clinical practice evidence diminished effects, relative to those obtained in controlled research. Add to that, the frequent eclecticism of clinical practice through the combination of different treatment components and attempts to individually tailor treatment to ‘meet the individual’s needs.’ Unlike ‘real’ tailoring (e.g., of clothing), no measurements are taken to permit one to decide what treatments (technique, dose, and duration) best suit the needs of an individual child. We do not yet know how to individualize therapy in a way that has been shown to be reliable (i.e., consistent within a therapist over time for similar patients, and consistent across therapists who would see very similar or virtually identical patients). Also, whether individualizing therapy by mixing and matching various techniques leads to better treatment outcomes than implementation of the best single EBT remains to be investigated. Third, in clinical practice, patient progress rarely is evaluated in a systematic way. It is important to monitor treatment
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effects in an ongoing way to make decisions about continuing, altering, or terminating treatment on the basis of how well the patient is doing. It is now well documented that some patients make rapid and enduring changes quite early in treatment (i.e., sudden therapeutic gains) (e.g., Hofmann et al., 2006; Tang and DeRubeis, 1999), whereas others may not make expected changes and are unresponsive even to extended treatment (Lambert et al., 2003). The use of any particular treatment (e.g., EBT or eclectic combination) does not guarantee client improvement. User friendly (brief and straightforward) measures are readily available for clinical use. One example is the Outcome Questionnaire (OQs-Measures, 2013), which includes multiple versions for therapy with adults as well as children. Versions of the measure have been thoroughly evaluated with thousands of patients and with individuals of different cultures and nationalities and shown to predict response to treatment (e.g., Lambert and Shimokawa, 2011; Shimokawa et al., 2010; Simon et al., 2012). Moreover, when the measure is used to provide feedback to therapists, patient outcomes are improved by decreasing the number of patients who deteriorate with therapy. The absence of systematic and routine evaluation in clinical practice is a critical issue regardless of whether or not an EBT is the core treatment. Overall, the hiatus between research and clinical practice continues to be an issue in both child and adult clinical work. Amidst the aforementioned challenges of dissemination, most EBTs are not used in clinical practice on a routine basis. Moreover, when these treatments are used, evidence suggests they are diluted and their effectiveness is reduced. Thus, in terms of the status of child therapy, more is needed in the way of both research and clinical work to improve treatment impact and patient care.
Research Priorities and Future Directions Several topics are high priorities for research. In some cases the research foci are not new, but the approaches used to address them are.
Moderators ‘Moderator’ refers to some characteristic that influences the direction or magnitude of the relation between the intervention and outcome. If treatment outcome varies as a function of characteristics of the child or therapist (e.g., sex, ethnicity, temperament, genetics, and neural activity) or treatment delivery (e.g., individual vs. group treatment), these characteristics are moderators. Historically, the dominant question that has guided psychotherapy has been about moderators, as illustrated by, “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?" (Paul, 1967, p. 111). The question continues to receive prominence as the treatment agenda to guide research (e.g., Roth and Fonagy, 2005). After decades of study, the literature is saturated with moderators, but we rarely understand why they moderate and it is nearly impossible to translate the findings to assign people to treatments for which they are well suited. For example,
culture or perceptions of the therapist may serve as moderators for a given treatment. However, by itself, this information does not tell us if that moderator impeded or enhanced therapeutic change, nor if that moderator would influence any or all treatments or just the given treatment under study. In the absence of further explanation, moderator research to date has not advanced our understanding of the underpinnings of treatment effects, nor has it been especially useful for decision making when selecting among treatments. Two lines of moderator research may point the way to future advances. First, efforts to understand moderators and how they relate to fundamental features of information processing may hold special promise. For example, biological features of how patients process information (e.g., neuromarkers) and psychological characteristics with which they are associated (e.g., processing social cues, working memory, and emotion regulation) serve as moderators of treatment response (psychotherapy and medication) (e.g., Doehrmann et al., 2013; Furey et al., 2013). These moderators can relate to fundamental biological features of disorders and elucidate targets for psychosocial and biological treatments. Such work has the potential of elaborating unifying processes across diverse treatments. Second, the ways in which moderators are studied are likely to change in the coming years. Moderators (e.g., severity of dysfunction, comorbidity, and culture) usually are studied one at a time in any individual study. Individual moderators tend to be weak in how they predict outcome (e.g., effect size) and may not emerge as statistically significant, even when they exert practically significant influences on treatment–outcome relations. Recently, methods for integrating and combining multiple moderators have been elaborated (Kraemer, 2013). When multiple moderators are combined moderator treatment interactions emerge that otherwise would not be evident (e.g., Frank et al., 2011; Wallace et al., 2013). Improvements in moderator research are greatly needed to advance clinical practice and decision making. Few studies are theoretically driven to predict how and why moderators operate. In addition, it has been difficult to direct patients to treatments from which they are very likely to profit and away from those from which they are not. Therapy research would profit from selecting and evaluating moderators in ways that translate to better care.
Mediators and Mechanisms of Change A critical research priority is to understand why and how therapy works. Presumably, the hundreds of therapies in use do not achieve their changes through different processes. Understanding basic processes of change might unify seemingly disparate interventions. In addition, without understanding how therapeutic change is achieved, we are at a disadvantage in knowing how we might optimize change through activation of specific components or processes. Research on mediators and mechanisms underlying therapeutic change aims to elaborate how treatment works. ‘Mediator’ is a construct that shows a statistical relation between an intervention and outcome. This is an intervening construct that suggests processes about why change occurs or
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on which change depends. Mediation is evident when several conditions are met: (1) the intervention leads to change in outcome measures, (2) the intervention alters the proposed mediator, (3) the mediator is related to outcome, and (4) outcome effects are not evident or significantly (statistically) less evident if the mediator did not change. These relations convey that change was mediated (e.g., correlated with or depended on) by some construct. However, even when these conditions are met, ambiguity can remain about the precise role of the mediator. The mediator may not, and usually is not intended to, explain precisely how the change comes about. For example, cognitions may be shown to mediate change in therapy. However, this does not explain precisely how the change came about (i.e., what are the intervening steps between cognitive change and reduced stress or anxiety?). ‘Mechanism’ refers to a greater level of explanatory specificity than mediator and reflects the steps or processes through which therapy (or some independent variable) actually unfolds and produces the change. Mechanism explains how the intervention translates into events that lead to the outcome or precisely what was altered that led to symptom change. Psychotherapy research with adults has benefitted from advances in cognitive, affective, and social neuroscience, as well as the development of noninvasive neuroimaging and other biological assays to examine the structure, function, and activity of the brain that are associated with clinical dysfunction (especially anxiety and depression) and/or changes over the course of psychotherapy among adults (e.g., Frewen et al., 2008; Porto et al., 2009; Quidé et al., 2012; Roffman et al., 2005). To date, neuroimaging has emphasized functional magnetic resonance imaging (fMRI), positive emission tomography (PET), and single-photon emission computed tomography (SPECT) (see Section Glossary). Much of this work, but certainly not all, is correlational when characterizing disorders or change processes. Yet, the strength of the research stems from multiple lines of converging evidence that move closer to identifying mechanisms of action. For example, from the reviews mentioned previously, research has:
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identified neurological characteristics associated with specific disorders and subtypes; evaluated change in neural processes in ‘regions of interest’ in light of characteristics associated with specific disorders; induced or provoked symptoms (e.g., sadness manipulations in healthy samples and trauma stimuli in PTSD patients) to demonstrate experimentally brain areas implicated in dysfunction; demonstrated ‘normalization’ of neurological structures, function, and activity after therapy is completed; elucidated similarities and differences in specific brain processes altered by different interventions (e.g., medication and psychotherapy) for a given disorder (e.g., major depression); and documented some similarities in what brain processes are altered by the same intervention (e.g., cognitive behavior therapy) as applied to different disorders (e.g., obsessive compulsive disorders and depression).
Neuroimaging studies capitalize on a set of tools to elaborate processes involved in therapeutic change. Additional
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methods have been used to study brain receptors, intracellular signaling, and target genes that reflect dysfunction and change over the course of treatment. As one example, antidepressant effects of medication relate to the expression of a protein in the brain synapses (brain-derived neurotrophic factor (BDNF)) that stimulates growth and differentiation of new neurons and synapses. We know from several studies with humans that major depression is characterized by low BDNF levels and that these levels increase after successful antidepressant treatment (Sen et al., 2008). In nonhuman animal studies, antidepressant effects can be manipulated experimentally to isolate the mechanism underlying these changes (e.g., infusing BDNF into the hippocampus directly, gene-knockout studies, blocking studies negating the operation of the BDNF gene, and manipulating exercise that attains a therapeutic-like antidepressant effect and alters BDNF) (e.g., Duman et al., 2008; Shirayama et al., 2002). These studies move us toward identifying precisely what is involved in successful intervention and symptom change. A clear research direction and priority will be elaborating biological changes that underlie and are associated with changes in symptoms, behaviors, and subjective experience. There is a concern that drawing on advances in neural assessment methods unwittingly will contribute to the biologizing of psychotherapy, i.e., reverting to biological and ‘reductionist’ explanations. However, core psychological and biological processes increasingly are studied together (e.g., cognitive and social neuroscience) to elaborate the connections, reciprocal relations, and conversions of experience and brain processes.
Transdiagnosis and Transtreatment Research on clinical dysfunction has relied heavily on psychiatric diagnosis. Psychiatric diagnosis have been based on the view that there are discrete entities (syndromes and disorders) such as major depression, bipolar disorder, and a few hundreds more (e.g., American Psychiatric Association, 2013; World Health Organization (WHO), 2010). Treatments were (and continue to be) developed with a disorder focus. Yet, an alternative view, referred to as transdiagnosis, has taken hold as a novel model for understanding clinical dysfunction, underlying processes, and treatment. Transdiagnosis refers to the study of processes that span many different manifestations of clinical dysfunction (e.g., Harvey et al., 2004; Kring and Sloan, 2009). Several factors have served as impetus for a transdiagnostic conceptualization of clinical dysfunction. Among the key interrelated influences are findings that:
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there are high rates of comorbidity so that individuals (children or adults) who meet criteria for one disorder are likely to meet criteria for at least one other disorder as well (e.g., Kessler et al., 1994; Wichstrøm et al., 2012); underlying processes that maintain ‘different disorders’ often are quite similar (e.g., Fairburn et al., 2003; Green et al., 2010; Jagannath et al., 2013); several disorders share common biological underpinnings as reflected in brain structures, neurotransmitters, and genes (e.g., Meyer-Lindenberg and Tost, 2012; Smoller et al., 2013);
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a number of EBTs (e.g., cognitive behavior therapy and mindfulness) are effective across a range of disorders suggesting some common mechanisms or core processes (e.g., working memory and emotion regulation) (e.g., Johnston et al., 2013); and broad characteristics such as a general psychopathology factor (a ‘p factor’), neuroticism, perfectionism, and tolerance of uncertainty might serve as underlying or mediating characteristics of many different disorders (Barlow et al., 2014; Caspi et al., 2014; Egan et al., 2011; McEvoy and Mahoney, 2012).
These findings have inspired efforts to search for core psychological (e.g., working memory and cognition), environmental (e.g., exposure to trauma, violence, and parent with depressed affect), and biological processes (e.g., neuromarkers and genetic), and their interrelations (e.g., epigenetic) that unite several types of clinical dysfunction that have been viewed as discrete diagnostic entities in conventional practice. Budding efforts to focus diagnosis on core psychological and biological processes also are emerging in new diagnostic work that may inform disorders from a transdiagnostic perspective (e.g., Cuthbert and Insel, 2013). Transdiagnostic conceptualizations have altered treatment and treatment research. Rather than adding to burgeoning lists of EBTs for specific disorders, attention is now being directed to the search for transdiagnostic treatments. Terms such as transdiagnostic treatment, unified treatment protocol, and unified cognitive behavior therapy are increasingly evident in treatment literature (e.g., Allen et al., 2008). It is likely that research will continue to explore treatments that are broad in applicability across diverse disorders.
Reaching Children and Families in Need The scope and impact of psychological dysfunction, whether conceived from a disorder specific or transdiagnostic perspective, is extraordinary. Among children, adolescents, and adults, 20–25% of community samples meet criteria for at least one psychiatric disorder. Prevalence does not convey the burden to individuals or society. Mental disorders are more impairing than common chronic medical disorders, with particularly greater impairment in the domains of home, social, and close-relationship functioning (Druss et al., 2009). As a dramatic illustration, in 2004, the burden of depressive disorders (e.g., years of good health lost because of disability) was ranked third among the list of mental and physical diseases (World Federation for Mental Health, 2011). By 2030, depression is projected to be the number one cause of disability, ahead of cardiovascular disease, traffic accidents, chronic pulmonary disease, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (WHO, 2008). A critical aspect to reducing the burden of mental illness is the ability of effective interventions to reach those in need of services. Recent years have seen an increase in the proportion of people in need who receive treatment in the United States, from 20.3% of individuals suffering from a disorder receiving treatment (e.g., psychiatry services, complementary and alternative medicine) between 1990 and 1992 and 32.9% of
individuals with a psychiatric disorder receiving some form of treatment between 2001 and 2003 (Kessler et al., 2005). Despite these gains, 70% of individual in need of services are not receiving them. Ethnic disparities with respect to access to mental healthcare add important challenges of providing services. Ethnic minority groups (e.g., African, Hispanic, and Native Americans) have much less access to care than do European Americans (e.g., McGuire and Miranda, 2008; Wells et al., 2001). The lack of available services for most people and systematic disparities among those services that are available underscore the importance of delivering services in ways that can reach many more people while targeting (and likely responding to the unique needs of) special groups. The dominant model of delivery across varied therapy techniques is administration by a highly trained (e.g., master’s or doctoral level) mental health professional in one-to-one, in-person sessions with a client who visits a particular setting (e.g., clinic, private office, and healthcare facility). This is referred to as the dominant model because clinical practice, graduate training, clinical program accreditation, pre- and postdoctoral internships, and research on psychosocial interventions draw heavily on this model. The one-to-one, inperson model is enduring, in demand, and suitable to deliver many EBTs to individuals who access them. Within the mental health professions, models of delivering psychosocial interventions are expanding. Many of these involve the use of technology and online versions of treatment that draw on the Internet and other media including video, phone, and application software (apps) for smartphones and tablets. Some uses of technology are variants of the dominant model in the sense that they are one-to-one and face-to-face (e.g., individual sessions by webcam), but extend to places where there may be no service or suitable facilities available (e.g., Wooton, 2003). Other extensions include self-help interventions and a vast array of techniques (e.g., online interventions and expressive writing techniques) that are available 24/7 and require little or no assistance from a trained professional (L’Abate, 2007). Several Internet, computerbased, self-help, and low-cost psychological interventions are evidence-based and achieve effects (i.e., effect sizes) at least on par with the similar technique administered in person by a trained mental health professional, and are high in client adherence to and satisfaction with treatment (e.g., Andrews et al., 2010; Cartreine et al., 2010; Harwood and L’Abate, 2010). Novel models of delivery are needed that include but go well beyond the use of technology. Models are needed that have such characteristics as:
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Reach: Capacity to reach individuals not usually served or well served by traditional service delivery models. Scalability: Capacity to be applied on a large scale or larger scale than traditional service delivery. Affordability: Relatively low cost compared to the usual model that relies on individual treatment by highly trained (Master’s, doctoral degree) professionals. Expansion of nonprofessional workforce: Increase the number of providers who can deliver interventions. Expansion of settings where interventions are provided: Bring interventions to locales and everyday settings where people in need are likely to participate or attend already.
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•
Feasibility and flexibility of intervention delivery: Ensure the interventions can be implemented and adapted to varied local conditions to reach diverse groups in need.
There are several such models available that have emerged from global health care, from business models of delivering innovations, and from nontraditional forms of interventions for mental health treatment (see Kazdin and Rabbitt, 2013). As one illustration, task shifting is a method of strengthening and expanding the healthcare workforce by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional healthcare workers (e.g., doctors and nurses) (see WHO, 2008). Task shifting is an evidence-based model of delivery that has been used extensively in treating and preventing physical disease but also has been extended to treatment of psychiatric disorders (e.g., anxiety, depression, and schizophrenia) (e.g., Balaji et al., 2012; Patel et al., 2010; Rahman et al., 2008). Research has focused almost exclusively on EBT. In the coming years, much greater priority is likely to be given to evidence-based ‘models of delivery.’ It is obvious we have many interventions that simply cannot get to the people in need. Even broad treatments (e.g., transdiagnostic treatments) and dissemination of current EBTs to clinicians in practice will not have a palpable effect on reducing the burdens of mental illness until we can take these efforts to scale. We still need to attend to evidence of course, but we must direct our attention to evidence that supports interventions that can be effective, administered on a large scale, and reach many unserved segments of the populations in need (see Kazdin and Blase, 2011; Kazdin and Rabbitt, 2013).
Conclusion The development of EBTs for children and adolescents is a major advance. Still, it is surprising how little we know about how treatments actually achieve the changes that are now well demonstrated. In the coming years, key issues that are likely to receive major attention include:
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disseminating and evaluating treatment in clinical practice settings; identifying common ingredients or transdiagnostic treatments that may not only facilitate dissemination, but also establish a new way to conceptualize interventions and clinical dysfunction; elaborating moderators of treatment that can be clinically useful and guide decision making; elucidating the mechanisms through which therapeutic change occurs; and scaling up our interventions to reach people in need of services.
The notion of translational research from medicine captures broadly key issues and priorities for therapy research in the coming years. Translational research focuses on ‘bench to bedside’ (i.e., laboratory to clinical application), and also ‘bedside to community’ (i.e., scaling up interventions to have impact). Extending treatments to practice and communities on a larger scale increasingly will serve as points of departure for developing interventions.
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Acknowledgments The author’s research on treatments for children is supported in part by grants from the National Institute of Mental Health (MH093326-01A1), the Humane Society of America, and the Laura J. Niles Foundation.
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