Bridging the enormous gaps of theory with therapy research and practice.

Convey remarkable advances in therapy outcome research and exemplify how leading investigators connect interventions to conceptual views about therapy. These comments focus on the distinction between broad conceptual views and theory about therapeutic change processes. Although there are explanations of why a treatment focus seems reasonable, there is very little testable theory or tests of theory in therapy research. The role, importance, and paucity of theory in child and adolescent psychotherapy research is described, underscored, and lamented, respectively, in these comments. Recommendations are made to move toward the goal of this series, namely, to bridge the gap of theory and clinical practice but also the gap of theory and therapy research.

Two-year prediction of children's firesetting in clinically referred and nonreferred samples.

This study provides the first prospective evaluation of the course and predictors of children's involvement with fire over a 2-year period in 268 nonpatient and patient children (ages 6-13 yrs). Selected predictor variables obtained at initial (intake) assessment, which included fire-specific and general psychosocial measures, were examined in each sample using hierarchical logistic regression. Both samples reported heightened involvement in matchplay and firesetting at follow-up, though the frequency of each behavior was nearly four times higher in patients than in nonpatients. Fifty per cent and 59% of the initial firesetters in the nonpatient and patient samples, respectively, became recidivists. In the nonpatient sample, the child's initial involvement in firesetting and level of covert antisocial behavior were the only psychosocial predictors of follow-up firesetting that added incremental variance beyond demographics. In the patient sample, the child's initial involvement in fire-related acts and level of covert antisocial behavior were the only predictors of follow-up firesetting beyond any initial involvement in matchplay. The findings highlight somewhat different risk factors for subsequent firesetting in nonpatient and patient children, especially prior firesetting and matchplay, respectively, and bear implications for the prevention of firesetting recidivism.

Developing a research agenda for child and adolescent psychotherapy.

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

Treatments for aggressive and antisocial children.

Many different types of treatment have been applied to conduct-disordered youths. Unfortunately, little outcome evidence exists for most of the techniques. Three treatments with the strongest evidence to date were highlighted in this article: PMT, PSST, and MST. Parent management training is directed at altering parent-child interactions in the home, particularly those interactions related to child-rearing practices and coercive interchanges. Cognitive problem-solving skills training focuses on cognitive processes that underlie social behavior. Multisystemic therapy focuses on the individual, family, and extrafamilial systems and their interrelations as a way to reduce symptoms and to promote prosocial behavior. Each of these treatments has multiple controlled studies on its behalf, and some of the techniques (e.g., PMT) have been extraordinarily well evaluated. Significant issues remain to be addressed to accelerate treatment advances. We cannot yet say that one intervention can ameliorate conduct disorder and overcome the poor long-term prognosis. On the other hand, much can be said. Much of what is practiced in clinical settings is based on psychodynamically oriented treatment, general relationship counseling, generic family therapy, and group therapy (with antisocial youths as members). These and other procedures, alone and in various combinations in which they are often used, have not been evaluated carefully in controlled trials. Of course, absence of evidence is not tantamount to ineffectiveness. At the same time, promising treatments have advanced considerably, and a very special argument might be needed to administer treatments that have neither basic research on their conceptual underpinnings in relation to conduct disorder nor outcome evidence from controlled clinical trials on their behalf. Promising treatments, at best, leave important questions unanswered. Further development of treatments clearly is needed. Apart from treatment studies, further progress in understanding the nature of conduct disorder is likely to have very important implications for improving treatment outcome. Improved triage of patients to treatments that are likely to work will require understanding of characteristics of children, parents, and families that will make them more or less amenable to current treatments.

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

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

Predictors of barriers to treatment and therapeutic change in outpatient therapy for antisocial children and their families.

This study examined the role of parent psychopathology and quality of life in predicting barriers to participation in outpatient treatment and therapeutic change among clinically referred children. Children (N = 169) referred for oppositional, aggressive, and antisocial behavior and their families participated. The major findings were that (1) higher levels of parent psychopathology and lower levels of quality of life predicted the subsequent emergence of perceived barriers to treatment in the parents and therapeutic changes among the children, (2) these effects were not explained by socioeconomic disadvantage or severity of child dysfunction, (3) perceived barriers and therapeutic changes were related and this relation was not explained by other family and child predictors, (4) as the level of perceived barriers increased among families, the amount of therapeutic change and the proportion of children who made a marked change decreased, and (5) parent perception of the relevance and demandingness of treatment were salient dimensions contributing to the relation between perceived barriers and therapeutic change. The conceptual and applied implications of relating barriers to treatment and therapeutic change are discussed.

Current (lack of) status of theory in child and adolescent psychotherapy research.

Considers fundamental issues raised by current child and adolescent psychotherapy research, including the neglect of theory in psychotherapy research, the distinction between theories of onset of dysfunction and therapeutic change, and the progression of knowledge from description to explanation and from risk factors to causal agents. The complex relations of proposed influences and clinical outcomes and constraints of current statistical models illustrate key challenges for understanding the nature of clinical disorders and therapeutic change. Much more attention to understanding how treatment achieves therapeutic change is needed, not only to address conspicuous lacunae in the knowledge base but also to optimize the effects of treatment in clinical work.

Barriers to treatment participation and therapeutic change among children referred for conduct disorder.

Examined predictors of therapeutic change among children seen in outpatient therapy. Children (N = 200) referred for oppositional, aggressive, and antisocial behavior and their families participated. The major findings were that (a) socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction predicted therapeutic change from pretreatment to posttreatment; (b) barriers to participation in treatment also were significantly associated with therapeutic change and this effect was not explained by the other family, parent, and child predictors; (c) as the level of perceived barriers to participation in treatment increased among families, the amount of therapeutic change decreased; and (d) among children at risk for relatively little therapeutic change, the perception of few barriers to treatment increased the degree of child improvement. The implications for further work on predictors of therapeutic change and the role of barriers in the treatment process are discussed.

The meanings and measurement of clinical significance.

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

Current progress and future plans for developing effective treatments: comments and perspectives.

Examined the conclusions and implications of articles in this special issue. Treatments can be differentiated on their empirical basis and, for the problems reviewed, one can identify treatments of choice. To build on the documented advances, we provide a blueprint for progress in treatment research. The blueprint focuses on a series of steps that involve conceptualization of clinical dysfunction and treatment, supportive research on these conceptual views, careful specification of treatment, evaluation of treatment outcome, and tests of mediators and moderators of treatment. To improve research, we recommend expanding assessment, addressing a broad range of questions about treatment, attending to measures of clinical significance, replicating key findings, and investigating the transportability of the findings to service-oriented clinical settings.

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

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

Identifying and developing empirically supported child and adolescent treatments.

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

Barriers to Treatment Participation Scale: evaluation and validation in the context of child outpatient treatment.

This study examined barriers that families experience during treatment and the role these barriers play in participation and completion of therapy. We developed the Barriers to Treatment Participation Scale and evaluated performance among children (N = 260, ages 3-13) and families referred for outpatient treatment. The results indicated that: (a) the scale yielded high levels of internal consistency; (b) the experience of barriers to participation, whether rated by parents or therapists, predicted higher rates of dropping out of treatment, fewer weeks in treatment, and higher rates of cancelled appointments and not showing up for sessions; (c) the perception of barriers was distinguishable from several family, parent, and child characteristics assessed at intake and the experience of critical life events during treatment; and (d) perceived barriers added significant information in predicting participation in treatment, over and above other characteristics that are already known to predict poor participation in treatment. Barriers associated with treatment participation can help identify cases at risk for dropping out and suggest targets for intervention to improve retention of families in treatment.

Parent management training: evidence, outcomes, and issues.

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

A model for developing effective treatments: progression and interplay of theory, research, and practice.

The central thesis of this article is that advances in psychotherapy research for children and adolescents are limited, despite the large number of controlled studies and consistent conclusions about demonstrated effectiveness. The ways in which individual studies are conducted and the lack of an overall plan for the progression of research to identify effective treatments have contributed to the limited conclusions. In this article, I identify steps toward developing effective treatment that entail conceptualization and investigation of clinical problems, processes of change, and conditions that influence treatment outcome. Progress will not only require more systematic accretion of research, but also expansion in the range of questions, outcomes, and models of treatment delivery that are examined. Efforts to improve the knowledge base and to integrate knowledge into clinical practice can also be greatly enhanced by modifying the ways in which clinical work is conducted and specifically by systematically monitoring treatment implementation and patient progress.

Family experience of barriers to treatment and premature termination from child therapy.

Barriers to participation in treatment were proposed as a basis for dropping out of treatment among children seen in outpatient therapy. Families (N = 242) of children referred for treatment for oppositional, aggressive, and antisocial behavior participated. The main findings were that (a) barriers to participation in treatment contributed significantly to dropping out of therapy; (b) perceived barriers to treatment were not explained by family, parent, and child characteristics that also predicted dropping out; and (c) among families at high risk for dropping out of treatment, the perception of few barriers attenuated risk. Parent perceptions of the difficulties of participating in treatment (including stressors and obstacles associated with treatment, perceptions that treatment is not very relevant, and a poor relationship with the therapist) influenced who dropped out.

Coming to terms with the terms of risk.

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

Practitioner review: psychosocial treatments for conduct disorder in children.

The present paper reviews promising treatments for conduct disorder among children and adolescents. The treatments include problem-solving skills training, parent management training, functional family therapy and multisystemic therapy. For each treatment, conceptual underpinnings, characteristics and outcome evidence are highlighted. Limitations associated with these treatments (e.g. paucity of long-term follow-up evidence and of evidence for the clinical significance of the change) are also presented. Broader issues that affect treatment and clinical work with conduct-disordered youths are also addressed, including retaining cases in treatment, what treatments do not work, who responds well to treatment, comorbidity, the use of combined treatments and the need for new models of treatment delivery.