CHAPTER Empirically Supported Treatments for Children - PDF document

CHAPTER 1 Empirically SupportedTreatments for Children Advances Toward Evidence-Based Practice Thomas H. OllendickVirginia Polytechnic Institute and State University,USANeville J. KingMonash University,AustraliaAbout 50 years ago,Eysenck (1952) published his now (in)famous review of theeffects of adult psychotherapy.Boldly,he concluded that psychotherapy practicesin vogue at that time were no more effective than the simple passage of time.Subsequently,Levitt (1957,1963) reviewed the child psychotherapy literature andarrived at a similar conclusion.These reviews were both contentious and provoca-tive,leading many to question the continued viability of the psychotherapy enter-Fortunately,as noted by Kazdin (2000),these reviews also served as a wake-upcall and led to a host of developments including advances in child psychopathology,psychiatric diagnostic nomenclature,assessment and treatment practices,and experimental designs for the study of treatment process and outcome.These Handbook of Interventions that Work with Children and Adolescents:Prevention and Treatment.Edited by P.M.Barrett and T.H.Ollendick.© 2004 John Wiley & Sons,Ltd.ISBN 0-470-84453-1. Correspondence to Thomas H.Ollendick,Virginia Polytechnic Institute and State University,Blacksburg,Virginia24061-0436;email:tho@vt.eduThe term childrenis used throughout to refer to both children and adolescents,unless otherwise speciÞed. developments,in turn,resulted in well over 1500 studies (Durlak et al.,1995;Kazdin,(Casey & Berman,1985;Kazdin et al.,1990;Weisz et al.,1987,1995).As notedrecently by Weersing and Weisz (2002),there is now little doubt that at present childlies.Consistently,these reviews demonstrate that therapy for children outperformswaiting list and attention-placebo conditions;moreover,in several studies,it isbecoming clear that some forms of therapy work better than others.As a result,psychology has moved beyond the simple question,ÒDoes psychotherapy work forchildren?Óto identify the efÞcacy of behavioural,emotional,and social problems.Basically,then,the Þeldhas moved from the generic question of whether psychotherapy ÒworksÓat all forvarious treatments and the conditions under which they are effective.This is anexciting time in the Þeld of child psychotherapy research,and the various chapterschildhood problems and disorders.This chapterdant to this movement.First,it should be acknowledged that this movement is partof a larger zeitgeist labelled Òevidence-based medicineÓ(Sackett et al.,1997,2000),which we refer to here as Òevidence-based practiceÓ.Evidence-based practice is atcomes (Alvarez & Ollendick,2003).It is not wedded to any one theoretical pos-ition or orientation.It holds that treatments of whatever theoretical persuasionobtained from randomized clinical trials (RCTs),whenever possible.In a RCT,chil-another or to some control condition,such as a waiting list or attention-placebo con-dition.Although such a design is not failsafe,it appears to be the best strategy forthat can result in misleading research Þndings.By its nature,evidence-based prac-tice values information or opinions obtained from observational studies,logical intu-ition,personal experiences,and the testimony of experts less highly.Such evidenceis not necessarily ÒbadÓor ÒundesiredÓ,it is just less credible and acceptable froma scientiÞc,evidentiary-based standpoint.And,it simply occupies a lower rung onthe evidentiary ladder of evidence.The movement to develop,identify,disseminate,and use empirically supportedpsychosocial treatments (initially referred to as empirically ÒvalidatedÓtreatments;see Chambless,1996,and Chambless & Hollon,1998) has been controversial.Onthe surface,it hardly seemed possible that anyone could or would object to the initialreport issued by the Society of Clinical Psychology (Division 12) of the American 4INTERVENTIONS FOR CHILDREN AND ADOLESCENTS Portions of this chapter are based on Ollendick,T.H.,& King,N.J.(2000).Empirically supported treatments for chil-dren and adolescents.In P.C.Kendall (Ed.),Child and adolescent therapy:Cognitive-behavioural procedurespp.386Ð425).New York:Guilford Publications. Psychological Association in 1995 or that the movement associated with it wouldbecome so controversial.Surely,identifying,developing,and disseminating treat-ments that have empirical support should be encouraged,not discouraged,espe-cially for a profession that is committed to the welfare of those whom it serves.Sensible as this may seem,the task force report was not only controversial,butit also,unfortunately,served to divide the profession of clinical psychology andrelated mental health disciplines (Ollendick & King,2000).In this chapter,we Þrstof such treatments.In doing so,we illustrate the potential value of these treatments.Other chapters in this volume provide in-depth detail on the efÞcacy of these treat-ments for speciÞc problems and disorders.Next,we illustrate and discuss some ofpromulgation.We conclude our discourse by offering recommendations for futureresearch and practice.ON THE NATURE OF EMPIRICALLY SUPPORTED TREATMENTSIn 1995,as noted earlier,the Society of Clinical Psychology Task Force on Promo-ically validated psychological treatments.The task force was constituted of memberswho represented a number of theoretical perspectives,including psychodynamic,interpersonal,and cognitive-behavioural points of view.This diversity in member-psychotherapies of proven worth,not just thoseemanating from one particular school of thought.DeÞning empirically validatedtreatments proved to be a difÞcult task,however.Of course,from a scientiÞc stand-point no treatment is ever fully validated and,as noted in the task force report,thereare always more questions to ask about any treatment,including questions aboutthe essential components of treatments,client characteristics that predict treatmentoutcome,and the mechanisms or processes associated with behaviour change.Inrecognition of this state of affairs,the term Three categories of treatment efÞcacy were proposed in the 1995 report:(1) ,(2),and (3)(see Table 1.1).The primary distinction between been shown to be superior to a psychological placebo,pill,or another treatmentwaiting list or no treatment control only.In addition,effects supporting a well-tory teams,whereas the effects of a probably efÞcacious treatment need not be (theeffects might be demonstrated in two studies from the same investigator,forexample).For both types of empirically supported treatments,characteristics of the clients should be clearly speciÞed (e.g.,age,sex,ethnicity,diagnosis) and the EMPIRICALLY SUPPORTED TREATMENTS5 clinical trials should be conducted with treatment manuals.Furthermore,it wasrequired that these outcomes be demonstrated in ÒgoodÓgroup design studies or aseries of controlled single case design studies.ÒGoodÓdesigns were those in whichtreatment and not due to chance or confounding factors such as passage of time,the effects of psychological assessment,or the presence of different types of clientsin the various treatment conditions (Chambless & Hollon,1998;also see Kazdin,1998,and Kendall,Flannery-Schroeder,& Ford,1999,for a fuller discussion ofresearch design issues).Ideally,and as noted earlier,treatment efÞcacy should belogues.Finally,at least probably efÞcacious.This category was intended to capture long-standingones not yet put to the test of scientiÞc scrutiny.The development of new treat-ments was particularly encouraged.It was also noted that treatments could ÒmoveÓover time.That is,an experimental procedure might move into probablyefÞcacious or well-established status as new Þndings became available.The cate-gorical system was intended to be ßuid,not static. 6INTERVENTIONS FOR CHILDREN AND ADOLESCENTS Table 1.1Criteria for empirically validated treatmentsWell-established treatmentsA.At least two good between-group design experiments demonstrating efÞcacy in oneor more of the following ways:1.Superior to pill or psychological placebo or to another treatment2.Equivalent to an already established treatment in experiments with adequatestatistical power (about 30 per group)B.A large series of single case design experiments (9) demonstrating efÞcacy. Theseexperiments must have:1.Used good experimental designs, and2.Compared the intervention to another treatment as in A.1.Further criteria for both A. and B.:C.Experiments must be conducted with treatment manuals.D.Characteristics of the client samples must be clearly speciÞed.E.Effects must have been demonstrated by at least two different investigators orinvestigatory teams.Probably efÞcacious treatmentsA.Two experiments showing the treatment is more effective than a waiting-list controlB.One or more experiments meeting the well-established treatment criteria A, C, D,C.A small series of single case design experiments ( established treatment criteria B, C, and D. EMPIRICALLY SUPPORTED PSYCHOSOCIAL TREATMENTSFOR CHILD BEHAVIOUR PROBLEMS AND DISORDERSThe 1995 Task Force Report on Promotion and Dissemination of Psychological Pro-ments,using the criteria described above and presented in Table 1.1.Of these 25efÞcacious treatments,only iour modiÞcation for developmentally disabled individuals,behaviour modiÞcationfor enuresis and encopresis,and parent training programs for children with opposi-identiÞed.As noted in that report,the list of empirically supported treatments wasintended to be representative of efÞcacious treatments,not exhaustive.In recog-with children,concurrent task forces were set up by the Society of Clinical Psy-chology and its offspring,the Society of Clinical Child and Adolescent Psychology(Division 53 of the American Psychological Association).The two independent taskJournal ofClinical Child Psychology.with autism,anxiety disorders,attention deÞcit hyperactivity disorder (ADHD),depression,and oppositional and conduct problem disorders were included in thespecial issue.As noted by Lonigan,Elbert,and Johnson (1998),the goal was not totreatments;rather,the goal was to focus on a number of high-frequency problemslems.As such,a number of problem areas were not reviewed (e.g.,eating disorders,childhood schizophrenia),and the identiÞcation of empirically supported treat-ments for these other problem areas remains to be accomplished,even to this day.Overall,the goal was to identify effective psychosocial treatments for a limitedAnnual Review of Psychology,Chambless and fying empirically supported treatments for children and adults.Namely,editedbooks by Roth et al.(1996,What works for WhomA Guide to Treatments that WorkSociety of Clinical Child and Adolescent Psychology.In general,the criteria usedby the various groups have been similar,although some relatively minor differencesare evident (see Chambless & Ollendick,2001,for details).In Table 1.2,we presentto be empirically supported by at least one of these four review groups.In many,ifnot most,instances the same treatments were identiÞed as effective by two or moreof these groups.As shown in Table 1.2,it is evident that many well-established and probably efÞ-cacious treatments have been identiÞed.Yet,we must be somewhat modest,inas- EMPIRICALLY SUPPORTED TREATMENTS7 such common problems as autism,childhood depression,or childhood anxiety.ably efÞcacious,it is evident that support for them is relatively meagre.Rarely didfor oppositional and conduct problem children and for children with ADHD).Ittreatments are based on behavioural and cognitive-behavioural principles.As aresult,using these criteria,we do not really know whether frequently practiced treat-ments from other orientations work or not (e.g.,play therapy,interpersonal psy- 8INTERVENTIONS FOR CHILDREN AND ADOLESCENTSTable 1.2Well-established and probably efÞcacious psychosocial treatments for children (adapted from Chambless & Ollendick, 2001, and Ollendick & King, 2000) Problem/Treatments Well-establishedProbably efÞcaciousADHDBehavioural parent trainingCognitive-behaviour therapyBehaviour modiÞcation in classroomAnxietyNoneCognitive-behaviour therapyCognitive-behaviour therapy AutismNoneContingency managementDepressionNoneBehavioural self-control therapyCognitive-behavioural coping skillsEnuresisBehaviour modiÞcationEncopresisBehaviour modiÞcationOCDNoneExposure/response preventionODD/CDBehavioural parent trainingAnger control training with stressFunctional family therapyinoculationMultisystemic therapyAnger coping therapyVideotape modellingAssertiveness trainingCognitive-behaviour therapyDelinquency prevention programParentÐchild interaction therapyProblem-solving skills trainingRational-emotive therapyTime out plus signal seat treatmentPhobiasGraduated exposureImaginal desensitizationParticipant modellingIn vivoReinforced practiceLive modellingFilmed modellingCognitive-behaviour therapy :Anxiety Generalized Anxiety Disorder, Separation Anxiety Disorder, Social Phobia; OCD Obsessive-Compulsive Disorder; ODD chotherapy);in many instances,they simply have not been evaluated sufÞciently.Still,the value of identifying and promulgating treatments that do have support fortheir use is apparent.Demonstration of the efÞcacy of treatments in well-controlledments in real-life clinical settings (see Chorpita et al.,2002).ON EMPIRICALLY SUPPORTED TREATMENTS: As noted in our opening comments,the movement to identify,develop,disseminate,and use empirically supported psychosocial treatments has been contentious.Asnoted by Ollendick (1999),three major concerns about this movement have beenraised:(a) some treatments have been shown to be more effective than others and,as a result,the ÒDodo BirdÓeffect (i.e.,no one treatment is superior to another)longer be asserted;(b) use of treatment manuals might lead to mechanical,inßex-ible interventions and that such Òmanually drivenÓtreatments might stiße creativ-ity and innovation in the therapy process;and (c) treatments shown to be effectivebe generalizable or applicable to Òreal-lifeÓclinical practice setting.What is themight they be addressed? In the sections that follow,we address these concerns inDifferential Effectiveness of Psychosocial TreatmentsRegarding the Þrst issue,our previous reviews of the literature (Ollendick & King,1998,2000) as well as the present one reveals a rather startling Þnding.It is obviousfore cannot be said to be well established or probably efÞcacious.For example,across such frequently occurring problem areas of autism,depression,phobias,anxiety,ADHD,oppositional behaviours,and conduct problems,controlled trials using ÒgoodÓexperimental designs were found for psychodynamicefÞcacious than behavioural parenting programs;seeBrestan & Eyberg,1998).In addition,only two studies were found to examine theefÞcacy of interpersonal psychotherapy (Mufson et al.,1994,1999),and they werelimited to the treatment of depression in adolescents.Inasmuch as these treatmentshave not been evaluated systematically,we simply do not know whether or not theyare effective.They could be;but,we must determine whether that is or is not basedon evidentiary support,and not on the absence of well-controlled studies. EMPIRICALLY SUPPORTED TREATMENTS9 analytic studies of treatment outcomes with children;see Weisz et al.,1987 and 1995,for reviews that indicate the superiority of behavioural over Ònon-behaviouralÓtreatments),we were able to identify only two well-established psychosocial treat-ments for speciÞc phobias in children (participant modelling,reinforced practice),two well-established treatments for ADHD (behavioural parent training,operantclassroom management),and two well-established treatments for oppositional andconduct problems (Webster-StrattonÕs videotape modelling parent training,and PattersonÕs social learning parent training program).Thus,even support for be-havioural and cognitive-behavioural interventions is modest,at best.What should we do in our clinical practices in the absence of Þrmer support forour interventions? Unfortunately for the children and families we serve,we prob-ably need to continue Òtreatment as usualÓuntil such support is available;however,it seems to us that these alternative treatments,as well as many behavioural andcognitive-behavioural ones,urgently need to be submitted to systematic enquiry inRCTs before their routine use can be endorsed.We simply do not have sufÞcientevidence at this time for the efÞcacy of psychosocial treatments for many childbehaviour problems (excepting perhaps speciÞc phobias,ADHD and oppositional/conduct problems,where we also have a number of probably efÞcacious treat-ments).Although the desirability and utility of RCTs for obtaining Òreasonable evidenceÓhas been the focus of much debate (see Persons & Silberschatz,1998),efÞcacy of various treatments.Of course,the transportability of such treat-ments to practice settings and their efÞcacy in such settings (i.e.,their effectiveness)nered,we pose the obvious question:ÒWhat is the current status of Ôtreatment asusualÕ in clinical practice settings? And,how effective is it?ÓWeisz,Huey,and Weersing (1998) examined this question in a re-analysis of their 1995 meta-analyticstudy.They searched for studies that involved treatment of clinic-referred childrentreated by practicing clinicians.Nine candidate studies,spanning a period of 50years,were identiÞed that compared Òtreatment as usualÓin a clinical setting to acontrol group who received no treatment or a placebo condition.Effect sizes asso-ciated with these nine studies were computed:they ranged from 0.29,witha mean effect size of 0.01,falling well below the average effect size (in their overall meta-analyses of ÒresearchÓand ÒclinicÓbased treatments.The effectsize of 0.01 indicates that,after treatment,the treated children were no better offthan the untreated children.Clearly,based on these analyses,outcomes associatedwith Òtreatment as usualÓare most disquieting.a comprehensive mental health services program for children (Bickman,1996;Bickman et al.,1995).Popularly known as the Fort Bragg Project,the United States 10INTERVENTIONS FOR CHILDREN AND ADOLESCENTS hensive intervention (treatment as usual) in a matched comparison site.Althoughhigher levels of client satisfaction,the program cost signiÞcantly more and,mostimportantly for our purposes,failed to demonstrate clinical and functional outcomessuperior to those in the comparison site.In brief,the Fort Bragg children and theirfamilies received more interventions at a higher cost,but their outcomes were notFinally,in a recent study conducted by Weiss et al.(1999),a RCT was used toas usualÓ) in a school setting.A total of 160 children who presented with problemsof anxiety,depression,aggression,and attention were randomly assigned to treat-ment and control conditions.Children were enrolled in normal elementary andmiddle schools and their mean age was 10.3.Treatment was provided by mentalclinicians and one was a doctoral level clinical psychologist);therapists reportedones.Treatment itself was open-ended (i.e.,not guided by manuals) and deliveredover an extended two-year period on an individual basis.Overall,results of the trialprovided little support for the effectiveness of Òtreatment as usualÓin this setting.In fact,treatment produced an overall effect size of 0.08,indicating that the treat-academic tutoring.Even so,parents of children who received treatment reporteddemic tutoring condition.These results,along with those of Bickman and colleagues,in addition to those reported by Weisz,Huey,and Weersing (1998) in their meta-analytic review,argue for the importance of developing,validating,and transport-ing effective treatments to clinical settings.Apparently,Òtreatment as usualÓis noteffective treatmentÑsuch ÒtreatmentsÓhave little support for their ongoing use andremind us of the conclusions derived by Levitt (1957,1963);namely,Òtreatment asusualÓis no more effective than the mere passage of time.In fact,these Þndingssuggest that,for some children,it may be detrimental to their ongoing functioning.and,in fact,in some instances have been shown to be harmful (recall that the effectsizes for the nine clinic-based studies reviewed by Weisz et al.ranged from 0.29 and that the effect size reported by Weiss et al.was 0.08).As psychologists,the identiÞcation,promulgation,and use of empirically supported treatments is cer-tainly in accord with ethical standards asserting that psychologists Òshould rely onsional judgmentsÓ(Canter et al.,1994,p.36).Yet,as noted in a lively debate on thisissue (Eiffert et al.,1998;Persons,1998;Zvolensky & Eiffert,1998,1999),the iden-On the one hand,it might seem unethical to use a treatment that has not beenempirically supported;on the other hand,inasmuch as few empirically supportedtreatments have been developed,it might be unethical to delimit or restrict prac-tice to those problem areas and disorders for which treatment efÞcacy has been EMPIRICALLY SUPPORTED TREATMENTS11 established (Ollendick & King,2000).What,after all,should we do in instances inported treatments have not yet been developed? Quite obviously,there are no easysolutions;nor,can we address them in sufÞcient depth in this chapter.However,weÒEmpirically supported treatments:What to do until the data arrive (or now thatthey have)?Ó.He suggests:Generally,clinicians should develop a formulation of the case and select the clinician is competent.Clinicians should remain informed about advances intreatment,including empirically supported treatments,and maintain their ownin which they are already accomplished.Because there are limitations to howmany treatments any one clinician can master,a key professional competence isthe client.This,in turn,requires at least a basic ongoing familiarity with the evo-populations.(p.4)We concur.Manualization of Psychosocial TreatmentsThe recommendation that well-established and probably efÞcacious treatmentsÞed by Ollendick (1999).As noted by Chambless et al.(1996),there were tworeasons for this requirement.First,inclusion of a treatment manual leads to the stan-dardization of treatment.In experimental design terms,the manual provides anoperational deÞnition of the treatment.That is,a treatment manual provides ament,as intended,was actually delivered (i.e.,the treatment possesses ÒintegrityÓ).Second,use of a manual allows other mental health professionals and researcherscedures were supported in the efÞcacy trial.Manualization (as it has come to becalled) is especially important to clarify the many types or variants of therapy.Forexample,there are many types of cognitive-behavioural therapy or psychodynamictherapy.To say that cognitive-behaviour therapy or psychodynamic therapy is efÞ-cacious is largely meaningless.What type of psychodynamic therapy was used in thisstudy? What form of cognitive-behavioural therapy was used in that study? Therefall under any one type of psychotherapy.As Chambless et al.(1996,p.6) noted,Òthe brand names are not the critical identiÞers.The manuals are.ÓA ßood of commentariesÑsome commendatory,others derogatoryÑÞlled thepages of several major journals,including the American PsychologistAustralianPsychologistJournal of Clinical PsychologyJournal of Consulting and Clinical Psy-chologyClinical Psychology:Science and PracticeClinical Psychology Review,andPsychotherapy.Some authors viewed manuals as Òpromoting a cookbook mental-ityÓ(Smith,1995),Òpaint by numbersÓ(Silverman,1996),Òmore of a straitjacket 12INTERVENTIONS FOR CHILDREN AND ADOLESCENTS than a set of guidelinesÓ(Goldfried & Wolfe,1996),Òsomewhat analogous to cookiecuttersÓ(Strupp & Anderson,1997),and a Òhangman of lifeÓ(Lambert,1998).Others viewed them in more positive terms (e.g.,Chambless & Hollon,1998;Craighead & Craighead,1998;Heimberg,1998;Kendall,1998;King & Ollendick,1998;Ollendick,1995,1999;Strosahl,1998;Wilson,1996a,1996b,1998).Wilson(1998,p.363),for example,suggested Òthe use of standardized,manual-based treatments in clinical practice represents a new and evolving development with far-In its simplest form,a treatment manual can be deÞned as a set of guidelines thatinstruct or inform the user as to Òhow to doÓa certain treatment (Ollendick,1999).They specify and,at the same time,standardize treatment.Although many oppo-respect to the effects of psychotherapy,they are concerned that treatments evalu-ated in research settings will not be generalizable to Òreal-lifeÓclinical settings andtreatment procedures.Seligman (1995,p.967),for example,indicated that unlikethe manual-based treatment of controlled,laboratory researchÑin which Òa smallnumber of techniques,all within one modalityÓare delivered in Þxed order for aÞxed duration,clinical practice Òis self-correcting.If one technique is not working,another techniqueÑor even modalityÑis usually tried.ÓAs noted by Wilson (1998),this characterization or depiction of a manual-based treatment is simply wrong.Avariety of treatments have been ÒmanualizedÓ,including those embedded in psy-chodynamic (e.g.,Strupp & Binder,1984),interpersonal (e.g.,Klerman et al.,1984),and behavioural (Patterson & Gullion,1968) or cognitive-behavioural theory (e.g.,Beck et al.,1979);moreover,these manuals allow for ßexible use and,for themost part,are responsive to progress or regress in treatment.One Þnal comment about manuals should be offered.The movement to manual-ization of treatment practices existed long before the Task Force issued its reportin 1995.Almost 30 years earlier,Patterson and Gullion (1968) published their now-Living with Children:New Methods for Parents and Teachers,a ÒhowtoÓparent and teacher manualthat has served as the foundation for many behav-ioural treatments of oppositional,deÞant,and conduct problem children.Not surprisingly,treatment based on this ÒmanualÓwas one of the Þrst treatments designated as Òevidence basedÓ.Over a decade prior to the issue of the Task ForceReport,Luborsky and DuRubeis (1984) commented upon the potential use of treat-ment manuals in a paper entitled ÒThe use of psychotherapy treatment manuals:Asmall revolution in psychotherapy research styleÓ.Similarly,Lambert and Ogles(1988) indicated that manuals were not new;rather,they noted,manuals have beenused to train therapists and deÞne treatments since the 1960s.It seems to us thatthe 1995 Task Force Report simply reafÞrmed a movement that had been presentfor some years and had become the unofÞcial,if not ofÞcial,policy of the NationalInstitute of Mental Health for funding research studies exploring the efÞcacy ofvarious psychotherapies.On the other hand,and this is where its actions becamecontentious,the Task Force Report asserted that psychotherapies described andseminated to clinical training programs,practicing mental health professionals,the EMPIRICALLY SUPPORTED TREATMENTS13 public,and to third party payers (i.e.,insurance companies,health maintenanceorganizations).Many authors were concerned that such actions were premature and that they would prohibit or,in the least,constrain the practice of those psy-chotherapies that had not yet been manualized or not yet shown to be efÞcacious.They also were concerned that the development of new psychotherapies would becurtailed,if not stißed totally.Although these are possible outcomes of the move-ment to manualize and evaluate psychotherapies,they need not be the inevitableoutcome.In fact,some have argued that these developments can serve to stimulatetreatments as well as the therapeutic mechanisms of change (see Kendall,1998,andWilson,1998,for examples),a position in which we are in full accord.What is the current status of this movement toward manualization in the treat-ment of children? First,it should be clear that the studies summarized in our reviewgested by the Task Force Report [1995] and by Chambless et al.[1996]).As we notedearlier,manuals are simply guidelines that describe treatment procedures and therapeutic strategies and,in some instances,provide an underlying theory ofchange on which the procedures or techniques are based.Kendall and his colleagues(Kendall,1998;Kendall & Chu,in press;Kendall et al.,1998) have addressed somewe undertake systematic research of the issues identiÞed.They identiÞed six(mis)perceptions that plague manual-based treatments:How ßexible are they? Doand thereby stiße improvement and change? Are manual-based treatments effec-tive with patients who present with multiple diagnoses or clinical problems? Aremanuals primarily designed for use in research programs,with little or no use orapplication in service-providing clinics? Although answers to each of these pene-trating questions are not yet available,Kendall and his colleagues submit thatcareful research is needed to explore each of these perceptions.In addition,theythat at least some of these issues or questions may be pseudo ones,or at least notparticularly esoteric.For example,ßexibility of treatment implementation is an issuethat many critics have raised;accordingly,it should be investigated empirically tooutcome.Does it really make a difference? In a recent study by Kendall and ChuFlexibility can be deÞned in a variety of ways;in their research,it was deÞned asa construct that measures the therapistÕs adaptive stance to the behavioural,manual-based treatment for anxious children (Kendall et al.,1992).Flexibility ratings were obtained retrospectively on a 13-item questionnaire,withmenting treatment (e.g.,ÒThe manual suggests that clinicians spend 40Ð45 minutes 14INTERVENTIONS FOR CHILDREN AND ADOLESCENTS session playing games.How ßexible with this were you?ÓAnd,ÒDuring therapy ses-sions,how ßexible were you in discussing issues not related to anxiety or directlyrelated to the childÕs primary diagnoses?Ó).Firstly,results revealed that therapistsgeneral and with speciÞc strategies).Secondly,and perhaps unexpectedly,thetreatment outcome.The important point here is that ßexibility,however deÞned,is amenable to careful and systematic inquiry.Kendall (1998)to empirical investigation and need not remain in the area of ÒheatedÓspeculation.be addressed empirically.In these studies,primarily conducted with adults,manual-based treatments have been ÒindividualizedÓin a ßexible manner by matchingor components of previously established effective treatments.These efforts havebeen labelled Òprescriptive matchingÓby Acierno et al.(1994).At the core of thistive in producing positive treatment outcomes than a nomothetic approach (e.g.,notKiesler,1966).For example,in one of these studies,Jacobson et al.(1989) designedindividually tailored marital therapy treatment plans,where the number of sessionsand the speciÞc modules selected in each case were determined by the coupleÕs spe-ciÞc needs and presenting problems.Individualized treatments were compared to a standard cognitive-behavioural treatment program.Each was manualized.Atpost-treatment,couples treated with individually tailored protocols could not be distinguished from those receiving standardized protocols.However,at six-monthfollow-up,a greater proportion of couples receiving standardized treatment showedtailored program maintained their treatment gains,suggesting that individually tailored programs may help to reduce relapses.depression (Nelson-Gray et al.,1990).In this study,Nelson-Gray et al.assignedadult depressed patients to treatment protocols (e.g.,cognitive treatment,social(e.g.,irrational cognitions,social skills problems).Those in the matched conditionsSimilarly,Ost,Jerremalm,and Johansson (1981) examined the efÞcacy of social skillswere categorized as either ÒbehaviouralÓor ÒphysiologicalÓresponders.Physiolog-behavioural responders showed the most beneÞt from the social skills program.Notall studies with individualized treatments have produced such positive results,however.For example,Schulte and colleagues (1992) found that standardized treat-ment,contrary to expectations,proved more successful than either matched or EMPIRICALLY SUPPORTED TREATMENTS15 phobias.Mersch and coworkers (1989) also failed to demonstrate the value of ioural deÞciencies and assigning them to matched or mismatched treatments.Matched treatments were not found to be superior to mismatched treatments.In the child arena,Eisen and Silverman (1993,1998) have provided preliminaryanxious children.In the Þrst study,the efÞcacy of cognitive therapy,relaxation train-ing,and their combination was examined with four overanxious children,6 to 15years of age,using a multiple baseline design across subjects.The children receivedboth relaxation training and cognitive therapy (counterbalanced),followed by acombined treatment that incorporated elements of both treatments.Results sug-lems of the children.That is,children with primary symptoms of worry respondedsomatic complaints responded best to relaxation treatment.Similar Þndings wereobtained in the second study (Eisen & Silverman,1998) with four children between8 and 12 years of age who were diagnosed with overanxious disorder.The inter-the response class (cognitive therapy for cognitive symptoms,relaxation therapy forment effectiveness.These Þndings must be considered preliminary because of lim-itations associated with the single case designs used to evaluate their efÞcacy;to ourknowledge,no controlled group design studies have been conducted examiningthese issues.Nonetheless,these studies and those conducted with adults show yetuse of empirically supported treatment manuals.In sum,issues with the manualization of treatment are many.However,as notedby Kendall (1998),most of these issues are open to experimental scrutiny.It seemsvery long time,and such debate would likely be stimulating and fruitful;however,for the beneÞt of children and the families we serve,it seems to us that it would besupported treatments,and carefully reÞning those manuals that we do have to makethem more clinician-friendly,determining how they can be used in a clinically sensitive and ßexible manner (Ollendick & King,2000).Issues with EfÞcacy and Effectiveness: The Transportability of TreatmentsStill,a third major concern about the empirically supported or evidence-based treat-studies (Hibbs,1998;Hoagwood et al.,1995;Ollendick,1999).Basically,efÞcacy studies demonstrate that the beneÞts obtained 16INTERVENTIONS FOR CHILDREN AND ADOLESCENTS factors that threaten the internal validity of the demonstration of efÞcacy.Typically,as noted by Seligman (1995),these studies are conducted in laboratory or univer-sity settings under tightly controlled conditions.Most consist of RCTs and provideclear speciÞcation of sample characteristics,features reßective of ÒgoodÓexperi-mental designs.Appropriate concern has been raised about the exportability ofthese Òlaboratory-basedÓtreatments to the real worldÑthe world of clinical prac-tice.Arguments have been mustered that the ÒsubjectsÓin randomized clinical trialsdo not represent real-life ÒclientsÓor that the ÒexperimenterÓtherapists in thesetrials do not represent ÒclinicalÓtherapists in applied practice settings.Moreover,or so it is argued,the settings themselves are signiÞcantly differentÑranging fromin practice settings.Weisz et al.(1995) refer to practice settings as the Òreal testÓorthe Òproving groundÓof interventions.To many of us,this distinction raises the ever-of clinical training.Building this bridge is admittedly not easy,and a gap betweenefÞcacy and effectiveness studies remains.Nonetheless,it is evident that effectiveness studies that demonstrate the externalvalidity of psychotherapies are very important;moreover,they need to be conductedchanges observed in our clientsÑnot chance or other extraneous factors.Demon-stration of both internal and external validity is important,and one should not beviewed as more important than the other (Ollendick & King,2000).Of course,notshown to be effective in clinical settings.Such failures may be associated with a hostof difÞculties,including problems in implementing the treatment procedures in less-controlled clinical settings and the ÒacceptabilityÓof the efÞcacious treatments to clients and therapists alike.In the Þnal analysis,whether the effects found in Òreal-worldÓclinical settings is an empirical question that awaits additional research(see Kendall & Southam-Gerow,1995,and Persons & Silberschatz,1998,for furtherThe issues surrounding transportability and efÞcacy versus effectiveness studiesare numerous and well beyond the scope of this chapter (e.g.,training of therapists,supervision of therapists,homogeneous/heterogeneous samples,development ofmanuals,adherence to manuals,competence in executing manual-based treatment,and the acceptability of manual-based treatments to clinicians and clients,amongothers).Weisz,Huey and Weersing (1998) have examined these issues in some detailpsychotherapy outcome research that distinguishes efÞcacy from effectivenessresearch.They are reproduced in Table 1.3 under the headings of Òresearch therapyÓand Òclinic therapyÓ.As evident in Table 1.3,Weisz et al.characterize ÒresearchÓsevere forms of child psychopathology and who present with single-focus problems. EMPIRICALLY SUPPORTED TREATMENTS17 Although the gap is being closed,as will be illustrated later in this chapter. Moreover,they suggest that such studies are conducted in research laboratories orschool settings with clinicians who are ÒreallyÓresearchers,are carefully trained andsupervised,and have ÒlightÓclient loads.Finally,such studies typically use manual-ized treatments of a behavioural or cognitive-behavioural nature.In contrast,ÒclinicÓtherapy is characterized by heterogeneous groups of children who are fre-lems.Treatment in such settings is,of course,delivered in a clinic,school,or hospitalsetting by ÒrealÓtherapists who have ÒheavyÓcaseloads,little pre-therapy training,and are not carefully supervised or monitored.Finally,treatment manuals are rarelyClearly,a number of differences are evident.Although such distinctions areimportant to make,in our opinion they tend to be broad generalizations that mayclinical settings.Moreover,they may serve to accentuate differences in types of studies rather thanto deÞne areas of rapprochement and,inadvertently,create a chasm,rather than abridge,between laboratory and clinic research.We shall illustrate how these dis-tinctions become blurred by describing three studies:(a) a ÒresearchÓtherapy studyconducted by Kendall et al.(1997);(b) a ÒclinicÓtherapy study conducted by Weisset al.(1999);and (c) a study examining the transportability of effective treatmentinto a practice setting (Tynan,Schuman,& Lampert,1999).In the Kendall et al.(1997) study,the efÞcacy of cognitive-behavioural treatmentfor anxious children was compared to a wait-list condition.EfÞcacy of treatmentwas determined at post-treatment and at one-year follow-up.A RCT was under-taken,detailed but ßexible manuals were used,and the therapists were well-trained 18INTERVENTIONS FOR CHILDREN AND ADOLESCENTSTable 1.3Some characteristics frequently associated with child psychotherapy in outcome research (research therapy) and in clinics (clinic therapy)Research therapyRecruited cases (less severe, study volunteers)Narrow or single-problem focusTreatment in lab, school settingsResearcher as therapistVery small caseloadsHeavy pre-therapy preparationMonitoring of therapist behaviourBehavioural methodsClinic therapyClinic-referred cases (more severe, some coerced into treatment)Broad, multi-problem focusTreatment in clinic, hospital settingsProfessional career therapistsVery large caseloadsLittle/light pre-therapy preparationLittle monitoring of therapist behaviour Non-behavioural methods and supervised graduate clinicians who carried ÒlightÓclinical loads.Treatment wasconducted in a university-based clinic.Ninety-four children (aged 9Ð13 years) andtheir parents,referred from multiple community sources (not volunteers or normalchildren in school settings),participated.All received primary anxiety disorder diag-noses (attesting to the relative severity of their problems),and the majority wasincluding other anxiety disorders,affective disorders,and disruptive behaviour dis-orders).In short,a relatively heterogeneous group of children with an anxiety dis-order was treated.Treatment was found to be highly effective both at post-treatmentand one-year follow-up.In reference to Table 1.3,it is evident that some of the char-acteristics associated with ÒresearchÓtherapy obtained and that in at least somerespects ÒclinicÓtherapy was enacted.In the Weiss et al.(1999) study previously described,treatment as routinely prac-attention control placebo (academic tutoring).The seven therapists were hiredhumanistic or cognitive strategies).No manuals were used.They received no ad-amount of supervision.One hundred and sixty children participated and were ran-domly assigned to one of the two ÒexperimentalÓconditions.Children were identi-Þed in the school setting and presented with problems of anxiety,depression,aggression,and inattention.Diagnostic data were not obtained;however,the iden-multiple and serious problems.As noted earlier,traditional therapy,as implementedin this study,was determined to be largely ineffective.In reference to Table 1.3,itis evident that only some of the characteristics of ÒclinicÓtherapy obtained and thatat least in some respects ÒresearchÓtherapy was examined.Finally,in the study undertaken by Tynan,Schuman,and Lampert (1999),theand ADHD in children between 5 and 11 years of age (behavioural parent man-agement training and child social skills training) was examined in a Òreal-lifeÓclin-ical setting (a child psychiatry outpatient clinic).Therapy was conducted in a groupformat.All children who were referred for ADHD or oppositional deÞant disorderwere assigned to the groups as the Þrst line of treatment.Parents and children weretreated in separate groups.Diagnostic interviews were conducted and the childrencomorbid with other disorders.Problems were judged by the clinicians to be serious.Treatment was manualized and therapists in this clinical setting were carefullytrained and supervised by the primary author.No control group was used and nofollow-up data were reported.Nonetheless,the treatment was shown to be highlytreatment).Although several methodological problems exist with this Òuncon-trolledÓclinical trial,it nicely illustrates the potential to extend Þndings from laboratory settings to clinical settings.This study also illustrates characteristics ofÒresearchÓtherapy and ÒclinicÓtherapy.To which is it more similar? EMPIRICALLY SUPPORTED TREATMENTS19 These three studies illustrate that demarcations between efÞcacy and effective-ness studies are not always easy or true to form.Perhaps more importantly,theybetween research and clinic settings.Recently,Chorpita and his colleagues (2002)illustrates this rapprochement.In 1994,the State of Hawaii settled a class actionlawsuit brought before federal court on behalf of children with special needs.TheFeliz Consent Decree (named for the index plaintiff) ensured that the state wouldthe school settings.Basically,the state agreed to develop a coordinated and com-prehensive system of care for students aged 0 to 20 with mental health needs.Asnoted by Chorpita et al.,the number of children identiÞed and receiving mentalhealth services as part of this decree increased from 1400 to over 11000 over a six-year period.In 1999,the Child and Adolescent Mental Health Division of the Stateof Hawaii established the Empirical Basis to Services Task Force whose charge wasand adolescence and to train and disseminate such practices.Although this initia-tive is still in its early stages,it represents the exact kind of work that is needed and awaits us in the years ahead.Through such efforts a ÒbridgeÓmight actually beSummary of Issues Attendant to Empirically Supported Treatmentsexist,these three major concerns (some treatments are more effective than others,use of treatment manuals and the independence of the therapist,and the trans-central to most arguments in support or against this movement.For many of us,considerable promise;for others,however,it signiÞes a major pitfall,full of lurkingand unspeciÞed dangers (Ollendick,1999).Continued dialogue between cliniciansand researchers on these issues is of utmost importance.with children and adolescents.We have concluded that some treatments are moreeffective than others,that manualization need not be a stumbling block to provid-ing effective psychotherapies in both research and clinic settings,and that the trans-feasible (although still being tested).We have also noted that tensions remain about 20INTERVENTIONS FOR CHILDREN AND ADOLESCENTS each of these issues,and we have illustrated various avenues of possible Somewhat unexpectedly,however,our present overview of empirically supportedÒlightÓand that more work remains to be done.We really do not have very manylet alone clinical settings.Still,we assert that this is an exciting time and that weand that rapprochement is on its way (see Chorpita et al.,2002).Children and theirand clinically sensitive practices (Ollendick & King,2000).Acierno,R.,Hersen,M.,Van Hasselt,V.B.,& Ammerman,R.T.(1994).Remedying theAchilles heel of behaviour research and therapy:Prescriptive matching of interventionand psychopathology.Journal of Behaviour Therapy and Experimental PsychiatryAlvarez,H.K.,& Ollendick,T.H.(2003).Evidence based treatment.In T.H.Ollendick andC.Schroeder (Eds.),Encyclopedia of clinical child and pediatric psychology.New York:Kluwer 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