Evidence-Based Psychotherapies



Evidence-Based Psychotherapies


Keith Cheng MD

Cindy Smith MD, MPH



Introduction

“Evidence-based practice” is a term used to describe the integration of scientific research and best clinical practice. Various health experts, institutions, or professional guilds like the American Academy of Pediatrics (AAP), the American Medical Association (AMA), the National Registry of Evidence-Based Programs and Practices (NREPP), the Cochrane Collaboration, the American Psychological Association (APA), the Institute of Medicine (IOM), and the American Academy of Child and Adolescent Psychiatry (AACAP) have independently developed definitions and/or position statements regarding evidence-based practice. According to these expert guidelines, evidence-based treatments should be based on data from several independent, randomized, double-blinded, placebo-controlled studies demonstrating statistically significant superiority over an alternative intervention. The traditional example of evidence-based practice in medicine is the pharmacologic treatment of illness based on rigorous medication trials. Similarly, evidencebased psychotherapy refers to psychosocial treatments for which systematic controlled studies have established efficacy. During the past two decades, rigorous research methods have been used to investigate the efficacy of psychotherapy and related interventions for mental disorders of childhood and adolescence. There are now hundreds of studies establishing the efficacy of psychotherapies for multiple juvenile disorders. However, these efficacious therapies have not yet been fully implemented in community settings. The purpose of this chapter is to provide clinicians an overview of the evidence-based psychotherapies that have been developed for children and adolescents and the status of their dissemination in the community.


Background

Research on the efficacy of psychotherapy for children began in the 1950s and 1960s. In a review of contemporary treatments, Leavitt concluded that they did not seem more effective than “tincture of time.” These early approaches that were based on anecdotal reports and case studies have given way to evidence-based practice as in other areas of health care. Multiple professional organizations have developed guidelines to define “evidence-based psychotherapies.” However, there is no consensus yet among these guidelines in establishing the levels of evidence.

The Cochrane Collaboration and the APA have developed definitions of evidence-based practice, requirements for which include (1) randomized controlled research, (2) research designs with adequate sample size and defined study populations, and (3) independent replication. In 1995, the APA Task Force expanded these requirements in defining evidence-based effectiveness to consider feasibility, generalizability, cost, and benefit. Hoagwood and colleagues note that efficacious treatments are based on carefully controlled research protocols generally conducted in an academic setting with homogenous study populations and multiple exclusionary criteria, while effective treatments are based on research in naturalistic settings with heterogeneous
populations and fewer exclusionary criteria using real-world practitioners rather than research therapists. Therefore, what is efficacious in controlled studies may not be effective in clinical practice, and ideally evidence-based treatments examined in research settings would later be examined in community settings.

In 2001, the IOM released a report titled “Crossing the Quality Chasm.” In this report the IOM noted that “between the health care we have and the care we could have lies not just a gap, but a chasm.” The report called for a major revision of the health care system. Notably, one of the key elements cited for change included the need for health professionals to use evidencebased practices that integrate the best research with clinical expertise and patient values.

In October 2006, the AACAP published a policy stating that the “ultimate goal” of evidence-based practice is to base clinical decision-making in the areas of causation, diagnosis, prognosis, treatment, and practice parameters on empirical evidence. Child and adolescent psychiatry as one of the youngest medical specialties acknowledges through this policy that many treatments in the mental health care of pediatric populations need more rigorous assessment of efficacy. As many children and adolescents present with multiple diagnoses, complex psychosocial factors, and unique developmental paths that are rarely addressed in efficacy research, further investigation of effectiveness is also needed. This policy statement encourages clinicians to use all available empirical data in developing individual treatment plans.

Currently, the institutional implementation of evidence-based practice is occurring on a national basis. California, Colorado, Hawaii, Michigan, New York, and Ohio belong to the Child and Family Evidence-Based Practices Consortium. As a group, they are involved in a wide range of evidence-based program and policy development. The consortium provides a forum for sharing experiences and ideas on the implementation of evidence-based practice. Other states, such as Connecticut, Oregon, and Washington, require the implementation of evidence-based treatments for youth whose care is supported by state funding. Ironically, private insurance companies often do not support evidence-based psychotherapies.


Classifications of Evidence-Based Treatments

Currently, there is no consensus regarding the criteria for classifying evidence-based psychotherapies. Rating systems have been developed by various guilds and organizations to evaluate evidence-based practice, including the AAP, the APA, the US Preventive Services Task Force, and the Cochrane Collaboration. These systems vary in defining the research methodologies that constitute levels of evidence. The NREPP provides an online searchable database of interventions available for the prevention and treatment of mental health and substance-use disorders. This resource aids consumers, agencies, and organizations in implementing datasupported programs. Two examples of these rating systems are described as follows in the organizations’ own words.

The APA defines four levels of criteria:

Criteria 1 level or “well-established” treatments are based on positive data from at least two good group-design experiments conducted at two independent research settings. Resulting data should show results that are statistically superior to control groups such as placebo, medication treatments, other psychological treatments, or well-established treatments.

Criteria 2 level or “probably-efficacious” treatments are based on data from at least two good experiments showing the treatment is superior to a wait-list control group. If one or two experiments by the same research team meet the well-established treatment criteria, this also qualifies as probably efficacious.

Criteria 3 level or “possibly-efficacious” treatments need to be supported by only one good study showing a treatment to be efficacious in the absence of conflicting studies.


Criteria 4 level or “experimental” treatments are defined by lack of any studies using a wellestablished methodology.

The US Preventive Services Task Force uses the following system for ranking evidence regarding treatment efficacy:

Level I treatments require evidence obtained from at least one randomized controlled study.

Level II-1 treatments require evidence obtained from well-designed, controlled trials without randomization.

Level II-2 treatments are based on evidence obtained from well-designed, cohort, or case-control analytic studies, preferably from more than one center or research group.

Level II-3 treatments are based on evidence obtained from multiple time series with or without intervention. Also, dramatic results from uncontrolled studies might be regarded as Level II-3 evidence.

Level III treatments are based on opinions of respected authorities, drawn from clinical experience and descriptive studies, or reports of expert committees.


Categories of Psychotherapies

The development of evidence-based psychotherapy has built on the existing knowledge of psychotherapeutic process. Traditionally, psychotherapies have been classified according to (1) participants or (2) theoretic construct.


Participant-Based Approaches

Therapies based on participants include individual, group, and family therapies. Modeled after adult psychotherapies, individual therapy with children denotes a child meeting with a therapist on an individual basis without the presence of a parent, although additional psychotherapeutic sessions with the parent may be needed. This form of therapy assumes that a child or an adolescent will be able to work with a therapist without the assistance of a parent. Lewis emphasizes that there is no indication for individual psychotherapy with younger children without concomitant parental interventions, such as parental guidance and counseling, parent skills training, or family therapy. Sometimes parental interventions may be limited to simple support to ensure that parents continue to involve their child in treatment. In adolescence, the role for parental intervention and involvement is more variable. The available research has supported the involvement of parents in some specific therapies such as Interpersonal Therapy for Adolescents, but not for others such as Group Cognitive-Behavioral Therapy.

During the past 10 years, several hundred publications have presented an evidence base for various forms of group psychotherapy. Participants in group psychotherapy may be similar or diverse diagnostically, but usually are of the same developmental stage. Group psychotherapy has become an integral part of inpatient and outpatient treatment planning. A meta-analysis by Hoag and Burlingame in 1997 examined 56 outcome studies on the effects of group treatment for children and adolescents. The results showed that group psychotherapy was more efficacious than placebo controls or wait-list control groups. Group psychotherapies for children and adolescents are frequently constructed around specific problems. For example, group therapy is a mainstay of treatment for substance-use disorders and is often incorporated into treatment for depression, anxiety, bereavement, poor social skills, and impulse-dyscontrol problems. In most problem-oriented groups, group membership consists of youth in the same developmental phase so that they share similar challenges and so that core techniques are applicable to the entire group. In some group treatments, however, groups of families are formed, and in this case, ages of youth may vary. Group therapy is increasingly difficult to find for privately insured individuals due to poor financial reimbursement. Ironically, in some public agencies, group treatments are used to reduce individual treatments that are considered more costly.


Family psychotherapy refers to interventions aimed at changing maladaptive or harmful interactions among family members so as to improve the functioning of individuals as well as the family as a whole. Parental skills training and psychoeducation should not be considered a form of family therapy because they do not focus on family relationships. Family therapy for children and adolescents is especially indicated for families whose parents have already received skills training but are unsuccessful because of their individual resistance or family dysfunction. Family interventions have an evidence base for treating pediatric depression, anxiety, substance abuse, attention-deficit hyperactivity disorder (ADHD), bipolar disorder, and psychosis. Current approaches to child treatment stress the integration of family therapy into the comprehensive treatment plan. For example, family therapy is an integral intervention in multimodal treatment plans for ADHD and anxiety disorders. Family psychotherapies may include many different constellations of family members. In its most traditional format, family therapy includes members of the nuclear family. The constellation of family members included in treatment sessions may change as therapy progresses. Family therapy may start with parental sessions with one or both parents and progress to include all family members.


Theory-Based Approaches

Psychotherapies are frequently categorized according to a theoretic perspective. The US Department of Health and Human Services’ Surgeon General’s report of 1999 states that the major specific psychotherapeutic interventions for children are Psychodynamic Psychotherapy, Supportive Psychotherapy, Cognitive-Behavioral Psychotherapy, Interpersonal Psychotherapy, and Family Systemic Interventions. With the exception of the last approach, these therapies originally were developed for adults and then adapted for children based on developmental considerations.

Psychodynamic psychotherapies, also termed insight-oriented psychotherapies, rely on theories of intrapsychic development and functioning. There are several such theories with different foci. The most traditional and older therapies posit that children show maladaptive behaviors because of overwhelming or unresolved intrapsychic conflicts. These conflicts can be caused by multiple sources ranging from mother-child relationship problems to environmental trauma and, according to the psychoanalytic theories, the child’s psychosexual development. For example, a 6-year-old child who witnessed his mother being robbed at gunpoint on a bus may develop transient hysterical blindness anytime he sees a bus. A young child may become anxious about his anger at his mother for not gratifying his wishes because his anger conflicts with his need for her love. Psychodynamic Therapy for older children or adolescents requires a level of psychological development that allows conscious awareness of conflict and the ability to tolerate anxiety-provoking interpretations that connect feelings and behaviors during therapy. This higher level of psychological development and verbal skills is also needed in order for the youth to maintain a working relationship with his or her therapist during difficult times throughout the treatment process and to not act out in a self-destructive or socially harmful manner. For example, a teenager whose parents have had a contentious divorce may enter treatment because she feels uncomfortable in dating and has started cutting herself. After connecting her psychological discomfort with her guilty distortions that she caused her parents’ divorce, such a youth may be able to better tolerate a romantic relationship. In psychodynamic approaches with younger children, often referred to as Play Therapy, conscious insight into troubled feelings may not be gained. However, unconscious conflicts may be resolved in the metaphor of the play themes acted out in treatment sessions. Mastery over a psychic insult (a perception of danger to the ego) may be gained through the expression of internal experiences during play coupled with appropriate interpretations. This mastery over a threatened ego and confusing emotions may then generalize to a youth’s outer world, evidenced by movement from a regressed position of self-protection to an adaptive position of meeting developmental challenges.

Psychoanalytic and psychodynamic therapies do not have a strong evidence base supporting their use in children, as there are no randomized controlled studies of their efficacy. Lewis
notes that play therapy with preschool or school-aged children in the absence of any other interventions is not an effective treatment for preschool and school-aged children.

Supportive Psychotherapy originated in psychoanalytic theory. However, in contrast to psychoanalytic therapies, Supportive Psychotherapy focuses on supporting the individual’s psychological strengths and defenses, not uncovering unconscious conflicts or exploring the meaning of maladaptive behaviors that is anxiety provoking for the patient. The focus is on containing the individual’s anxiety. Supportive interventions are typically used when a patient is in crisis or not psychologically minded and so is not able to make use of insight-oriented interventions. When the crisis has been stabilized, psychodynamic techniques may be useful for many patients who seek change in their lives or to understand themselves. In Supportive Therapy, a therapist may help a child to better understand his or her parents’ divorce and maintain positive relationships using statements such as “Your parents say you did not cause their divorce; it is nobody’s fault,” and then helping the child to develop strategies to maintain relationships with each parent. A depressed teen might be gently confronted about her overreaction to breaking up with her boyfriend with supportive statements such as “It is difficult now, but you have shown the ability to cope with a previous breakup; this does not have to affect your other relationships and schoolwork. How did you get through the past breakup?” A therapist will encourage a child to use verbal skills in dealing with a school bully and help him to develop copies strategies based on the child’s abilities in other areas, for example, “You are good at using words, so let’s think about some statements you can use in these situations.” The therapist may also provide limited advice, such as when to involve adults when being bullied. In addition, Supportive Psychotherapy utilizes direct environmental interventions. The therapist may suggest to children and parents specific ways of changing their physical environment to meet the challenges of perceived problems. In the bullying example, a therapist might suggest that the child avoid walking home alone after school, speaking to the principal, talking to the parents of the bully, or even enrolling the child in martial art training.

While supportive psychotherapeutic techniques are commonly used in the treatment of both adults and children, there is little evidence of their efficacy in pediatric populations. For example, a 2007 study of treatments for bulimia led by le Grange showed that teenagers with bulimia are more likely to recover if they are in family-based therapy than if they are in individual supportive therapy.

Cognitive therapies are based on social learning theory and also integrate several psychotherapeutic techniques based on operant and classical conditioning. According to Aaron Beck, Cognitive Therapy (CBT) describes five major interrelated elements that contribute to psychological difficulties: interpersonal-environmental context, an individual’s unique physiology, emotional functioning, behavior, and cognition. These elements form the complex system that is addressed by Cognitive Therapy. Depressed children and adolescents, similar to depressed adults, display Beck’s “depression triad,” that is, negative attitudes (or distortions) regarding themselves, their environment, and the future. “Catastrophizing” and perceiving situations only in “black and white” are other maladaptive attributional styles used by depressed youth. Cognitive therapists consider a youth’s particular circumstances and intervene at both cognitive and behavioral levels to influence thinking, acting, feeling, and somatic reaction patterns. According to McClure and Friedberg, the framework for Cognitive Therapy sessions includes the following six components: (1) mood or symptom check-in, (2) homework review, (3) agenda setting, (4) addressing session content, (5) homework assignments, and (6) eliciting feedback. Successfully integrating each of these elements in a Cognitive Therapy session facilitates effective and efficient interventions. Through cognitive treatments, a child learns the relationships between his or her cognitions (thoughts or thinking style), feelings (emotions), and behaviors (actions). Ultimately, changing underlying cognitions can reduce depressed or anxious emotions and maladaptive or inappropriate behaviors. Thus, the cognitive therapies do not rely on exploration of
underlying conflicts, intrapsychic origins of the depressed or anxious feelings, or the youth’s selfexpression through verbal or play interaction.

Multiple systematic studies support the use of CBT in the treatment of various juvenile psychiatric disorders, including depression, anxiety, and obsessive-compulsive disorder (OCD). Using the APA criteria, CBT for these disorders are considered “well-established” and effective.

Behavioral therapies are a mainstay of evidence-based treatments for a variety of childhood disorders. These therapies are now widely accepted in mainstream practice, as they have an evidence base in treating various psychiatric disorders from self-harming behaviors that occur in autism to avoidant behaviors characteristic of anxiety. Behavioral therapies, most notably implemented as Behavior Modification, are based on the behavioral concepts of classical and operant conditioning. Classical Conditioning is the type of learning made famous by Pavlov’s experiments with dogs. An example of behavior modification using classical conditioning is the use of the bell and pad for an enuretic child. The major theorists in the development of Operant Conditioning are Edward Thorndike, John Watson, and Burrhus F. Skinner. Positive reinforcement or the use of “rewards” is an example of Operant Conditioning used to shape behaviors. A Token Economy is a system in which a child is positively reinforced, or “receives tokens,” for demonstrating specific adaptive behaviors. Teaching parents about such behavioral interventions is major part of Parent Skills Training. Because behavioral therapies, in general, have a strong evidence base for treating children, they should be part of a clinician’s approach to caring for children with disturbed behavior.


Review of Evidence-Based Psychotherapies

As research has progressed in the treatment of child psychiatric disorders, the number of evidence-based psychotherapies has increased, particularly for the most common disorders such as ADHD, depression, and anxiety. Therapies for these disorders have been examined in both single site and large multisite studies. Other disorders, such as eating disorders, still lack an evidence base to guide clinicians, as studies have not met the criteria of any rating system to support efficacy. The following review uses the APA’s system for classifying evidence-based psychosocial treatments for children and adolescents.


Attention-Deficit Hyperactivity Disorder

ADHD is the most extensively studied psychiatric illness of childhood. Since the 1937 classic study, “The Behavior of Children Receiving Benzedrine,” thousands of treatment studies have been published. Pharmacotherapy is the most commonly used efficacious and effective treatment. Stimulant medications, and more recently atomoxetine, have met the APA standard of a “well-established” evidence-based psychotherapy. There is a growing body of work, however, supporting behavioral interventions, such as Behavioral Management Training (BMT) and Behavior Contingency Management (BCM) in the classroom, as “well-established” treatments. Nonetheless, in recent research, the combination of pharmacotherapy and psychosocial interventions has not been shown to be more effective than medication alone in cases of ADHD without comorbidity. The idea of using a combination of treatments for ADHD has existed for the past three decades. Satterfield first reported on the use of Multimodal Therapy for ADHD, which showed evidence that multiple treatment interventions are more effective than any treatment used in isolation. These findings, however, were not replicated in the 1999 Multimodal Treatment Study of Children with ADHD (MTA Study), which has served as the “gold standard” for clinical practice in the treatment of ADHD. However, for ADHD comorbid with oppositional defiant disorder (ODD), the addition of psychosocial interventions to algorithm-based pharmacologic treatment did improve outcomes. While the AMA, AAP, and AACAP support pharmacotherapy as the sole treatment of uncomplicated ADHD, with
behavioral interventions a secondary or augmenting treatment, the APA Task Force contends that behavioral treatments should be employed as the initial or primary treatment for ADHD and that medications should be added as adjunctive treatment when behavioral interventions are not efficacious.

The AAP guidelines have included BCM in the classroom setting as a “well-established” treatment based on the review by Pelham and Fabiano of 23 studies supporting BCM. This review also found that Behavioral Parent Training (BPT) met the criteria for a “probablyefficacious” treatment, and with liberal interpretation of the APA Task Force criteria, barely met the standard for “well-established” treatments. This review also concluded that there was no evidence supporting cognitive interventions for ADHD or peer-group interventions such as social skills training or summer treatment programs. Also important is that Pelham and Fabiano note that most ADHD treatment studies have investigated boys under 13 years of age. Therefore, by strict criteria, there is no “well-established” or “probably-efficacious” ADHD psychosocial treatment for teens or girls.


Disruptive Behavior Disorders

Disruptive behavior disorders (DBDs) apply to a broad range of psychiatric behaviors. The DSM-IV-R category of DBDs includes three major diagnoses: ADHD, ODD, and conduct disorder (CD). Research studies tend to separate treatments for ADHD from that for CD and ODD, and so in this section, we focus on CD and ODD. In 1998, Brestan and Eyberg identified 12 treatments that met the criteria for being either “probably efficacious” or “well established.” In a 2008 review in the Journal of Child and Adolescent Psychology on evidence-based psychotherapies for disruptive behaviors, 15 psychotherapies were identified as “efficacious” and only one treatment met the standard for a “well-established” treatment, the Parent-Management Training Oregon Model (PMTO). The majority of these treatments are psychoeducational interventions for parents. Of the six parent-management training interventions cited by Eyberg, Nelson, and Boggs, only one is targeted for elementary or high school youth. Four of the interventions are designed for a skills training group therapy format. Treatments created for preschool and early-school-aged children include Helping the Noncompliant Child, The Incredible Years, Parent-Child Interaction Therapy, Triple P, and PMTO. For adolescents, Multisystemic Therapy (MST) and Multidimensional Treatment Foster Care (MTFC) have been extensively studied.

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Jun 29, 2016 | Posted by in PSYCHIATRY | Comments Off on Evidence-Based Psychotherapies
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