Schimmelmann, Benno

Schmidt, Stefanie

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EDITORIALEvidence-based psychotherapy in children and adolescents:advances, methodological and conceptual limitations,and perspectivesStefanie J. Schmidt • Benno G. SchimmelmannPublished online: 4 April 2013 Springer-Verlag Berlin Heidelberg 2013IntroductionMental disorders have a high prevalence of up to 20 % inchildren and adolescents worldwide and are often associ-ated with substantial psychosocial impairments [1]. Manymental disorders with an early onset in childhood or ado-lescence have a high likelihood of persistence or recurrenceof symptoms and are risk factors for other psychiatricdisorders in adulthood [2]. Against this background, sig-nificant attention has been paid to the development ofpsychological therapies for children and adolescents thataim to reduce current symptom levels and their detrimentaleffects on functioning and developmental trajectories.The earliest reviews of these psychological therapiesincluded studies with mostly low methodological quality.They found that the rate of improvement did not differsignificantly whether or not any type of psychotherapy wasprovided. The authors [3, 4] emphasized the need for morestringent standards in intervention research and morespecified, well-documented treatments. This led to anincrease in randomized controlled trials (RCTs) whichdemonstrated that psychotherapy can indeed produce sig-nificant benefit compared to control conditions (e.g. [5–7]).These results have coalesced into evidence-based treat-ments for children and adolescents applicable to severaldiagnostic categories including anxiety disorders, depres-sive disorders, eating disorders, autism spectrum disorders,substance abuse, and attention deficit hyperactivity disor-ders [8, 9]. The majority of these treatments under study inthis age group can be described by the umbrella term‘cognitive-behavioural therapy’ (CBT); they include bothprogrammes designed specifically for children and ado-lescents and generic approaches for all age groups such asCBT for anxiety disorders [8, 10]. With the number ofevidence-based treatments expanding, research has startedto draw on the relative efficacy of treatments for specificsubtypes of disorders [10] and different intervention tech-niques for the same disorder [11]. For example, the reviewby Leenarts et al. [11] in this issue reported that trauma-focused CBT techniques revealed better empirical supportfor the treatment of children exposed to maltreatment thanboth non-trauma focused methods and trauma-specifictreatments for children and adolescents with comorbiddisorders. Recent studies also investigated combinedeffects of psychopharmacologic and psychotherapeuticinterventions but found no consistent evidence favouringintegrated interventions (e.g. [12]). In summary, child andadolescent psychotherapy research has shown remarkableprogress towards evidence-informed treatments in recentyears. However, it seems important to move on to sur-mount methodological and conceptual limitations.Methodological aspectsDespite the increase in the quantity of evaluation studies,child and adolescent psychiatry is still far from having aknowledgebase sufficient for creating evidence-informeddecisions about psychotherapy for all mental disorders.This is at least partially due to the low methodologicalquality of the majority of these studies. Therefore, theconclusions of recent meta-analyses and reviews of treat-ment efficacy for given disorders were often preliminary orinconclusive, because the number of included RCTs wasS. J. Schmidt (&)  B. G. SchimmelmannUniversity Hospital of Child and Adolescent Psychiatry,University of Bern, Bolligenstrasse 111,3000 Bern 60, Switzerlande-mail: stefanie.schmidt@kjp.unibe.ch123Eur Child Adolesc Psychiatry (2013) 22:265–268DOI 10.1007/s00787-013-0415-9generally small, often with low statistical power and a highor even unknown risk for biased sample selection andrandomization procedures [10, 13, 14]. In addition, most ofthese studies suffered from selective outcome reporting,and about one-third of the published studies included afollow-up assessment with a mean time-lag of 5 monthsafter therapy only [8, 14]. Therefore, the durability oftreatment effects remains largely unclear. As a conse-quence, we do not know yet whether treatment gains couldbe maintained by additional treatments or booster-sessions.This underlines the need for larger, methodologicallysound RCTs assessing long-term effects. In addition, cost-benefit analyses may highlight psychotherapy’s potential toreduce the direct and indirect costs associated with childand youth mental health problems by alleviating psycho-social impairments.Current assessments of therapeutic change are oftenlimited to symptom domains and are mostly administeredin a highly standardized setting in the laboratory. Treat-ment effects, however, should also generalize to differentfacets of the problem (e.g. cognitive, emotional, social,behavioural aspects) and to different contexts in everyday-life [15]. Therefore, one measure or informant is not able tocapture all of these aspects of treatment efficacy. Anotherlimitation of current outcome assessment in child andadolescent psychotherapy research is the reliance on fewand often non-blinded informants with low inter-informantagreement across settings, for example, teachers and par-ents [14, 16, 17]. This may lead to biased or inconsistentinformation about treatment effects. A key issue in theassessment of treatment effects is whether improvementsfound in standardized, nomothetic measures that place theindividual’s functioning in a normative context are alsoclinically relevant for the individual patient. Idiographicassessments that take the individual patterns of change andthe individual developmental state into account are largelyignored in the current literature [18].Therefore, multiple measures and multiple informants areneeded to evaluate different aspects of the problem. More-over, symptom and diagnostic measures should be supple-mented by measures of real world-functioning acrossvarious contexts like direct observation of the patient’sbehaviour (e.g. behaviour in school, at home, with friends).The event sampling method (ESM) [19] may be a promisingmeasure of real world-functioning, because it allowsresearchers to study individual experiences that vary acrosstime in their natural environment. As ESM minimizes recallbiases by the event-contingent assessment, it may also beadequate for children with low levels of cognitive func-tioning, who are otherwise often excluded from studies.Newly developed person-focused assessments [20] addressthe shortcomings of standardized, nomothetic measures.They seem to be an efficient strategy for identifying intra-individual changes in personally relevant treatment goals byrepeatedly assessing the problems that patients and theircare-givers consider to be most important.The application of several measures and informants,however, raises the question of how to deal with incon-sistent findings. For example, what if some measuressupport treatment efficacy but others do not? This questionhas not been adequately addressed, because manyresearchers tried to circumvent discussing inconsistentfindings by focussing only on significant outcomes or byusing terms such as ‘probably effective’ or ‘almost evi-dence-based’ [21]. It seems important to develop clearstandards on how to integrate conflicting results based onmultiple outcome domains and outcome measures and howto interpret them in terms of treatment efficacy.The range of possible changes (RPC) model [22] may bea helpful framework to this end, as it has been designed toidentify and integrate within- and between-study consis-tencies in a systematic way. Future studies are needed toassess the reliability and validity of RPC’s proposed clas-sification scheme and the relevance of its clinicalimplications.Meta-analyses and reviews indicate that many kinds ofpsychotherapy produce therapeutic effects in children andadolescents (9, 34). However, more in depth-analyses oftreatment effects are necessary to identify under whatconditions these treatments work best (i.e. moderators; e.g.gender, therapy setting and age) and to investigate howthey lead to change (i.e. mediators; e.g. therapeutic allianceand self-efficacy expectations) [24, 25]. For example, fewtreatments have been adapted to the special needs of pre-school children [10]. Assessing the moderating effect ofage may have important implications towards a differentialindication of these interventions and may emphasize theneed to tailor therapies to the developmental stage ofparticipants. Mediation analysis may shed light on changemechanisms on a cognitive [26], behavioural [25], and aneuronal level [27] as well as their interactions. Mediationanalysis may also be an appropriate statistical method totest critical components of multimodal treatments. Identi-fying possible mechanisms of change would have impor-tant clinical implications. Therapists could optimize effectsof current treatments by focusing on change mechanismsthat need to be targeted [28].Conceptual aspectsOnly a few manuals have been specifically developed forchildren or adolescents. Many CBT treatments for childrenand adolescents can be viewed as downward extensions ofintervention programmes originally designed for adultpatients [29]. This was done based on the assumption that266 Eur Child Adolesc Psychiatry (2013) 22:265–268123the underlying theoretical models are directly generalizableto younger age groups, but this has rarely been formallytested. This assumption implies that patients with the samediagnosis would all benefit from the same interventionacross the lifespan. However, this is not congruent withempirical evidence reporting, e.g. smaller effect sizes forchildren than for adolescents [30].This highlights the need for studies to test the validity ofthe underlying models and mechanisms of change acrossdifferent age groups. For example, it is important to gain aprecise understanding of the cognitive, emotional andinterpersonal prerequisites of the numerous interventiontechniques used in child and adolescent psychotherapy.This may help in choosing the techniques most appropriateto the current developmental state of an individual ratherthan age per se.A range of evidence-based treatments have beendeveloped in the past, however, they were only rarelyincorporated into clinical practice [31], and their efficacywas substantially reduced when they were tested underclinically representative general care conditions [23].Possible implementation barriers accounting for these dif-ferences may be that patients in service settings havehigher rates of comorbidities and more psychosocialimpairments as well as motivational problems. It is alsopossible that different mechanisms leading to a respectivemental disorder are present in routine clinical care than inresearch settings, thus rendering deviations from treatmentprotocols mandatory [23]. These differences raise concernsthat treatments tested in RCTs may not be applicable topatients treated in routine clinical care [32], because theadherence to a predefined sequence of sessions with pre-determined therapy contents in RCTs may constrain thetherapist’s ability to adapt each therapy session to theindividual treatment needs of a patient.To address these concerns, modular [33] or stepped-caremodels may be promising approaches. As more individu-alized approaches they may facilitate the coverage ofcomorbid problems and sequential changes in treatmentresponse without a substantial loss of internal validity.Evaluation of such treatment concepts in child and ado-lescent psychiatry is recommended to bridge the gapbetween efficacy and effectiveness.ConclusionsIn summary, psychotherapy research in children and ado-lescents has generated several evidence-based interventionsin recent years. At this point, we know much about whatoutcomes are produced by treatments but have littleunderstanding what drives these changes. The need forindividualization in assessment and therapy is not new butstill in its infancy. Furthermore, treatments should beadapted to a patient’s developmental level to optimizetreatment efficacy. 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Evidence-based psychotherapy in children and adolescents: advances, methodological and conceptual limitations, and perspectives

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Evidence-based psychotherapy in children and adolescents: advances, methodological and conceptual limitations, and perspectives

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