Long-term outcomes for the Child STEPs randomized effectiveness trial: a comparison of modular and standard treatment designs with usual care

Trajectories of Functioning Into Emerging Adulthood Following Treatment for Adolescent Depression

PURPOSE

It is well established that empirically supported treatments reduce depressive symptoms for most adolescents; however, it is not yet known whether these interventions lead to sustained improvements in global functioning. The goal of this study is to assess the clinical characteristics and trajectories of long-term psychosocial functioning among emerging adults who have experienced adolescent-onset major depressive disorder.

METHODS

Global functioning was assessed using the Clinical Global Assessment Scale for children (participants ≤18 years), the Global Assessment of Functioning (participants ≥ 19 years) and the Health of the Nation Outcome Scales for Adolescents among 196 adolescents who elected to complete 3.5 years of naturalistic follow-up subsequent to their participation in the Treatment for Adolescents with Depression Study. The Treatment for Adolescents with Depression Study examined the efficacy of cognitive behavior therapy, fluoxetine, and the combination of cognitive behavior therapy and fluoxetine (combination treatment) over the course of 36 weeks. Mixed-effects regression models were used to identify trajectories and clinical predictors of functioning over the naturalistic follow-up.

RESULTS

Global functioning and achievement of developmental milestones (college, employment) improved over the course of follow-up for most adolescents. Depressive relapse, initial randomization to the placebo group, and the presence of multiple psychiatric comorbidities conferred risk for relatively poorer functioning.

CONCLUSIONS

Functioning generally improves among most adolescents who have received empirically supported treatments. However, the presence of recurrent major depressive disorder and multiple psychiatric comorbidities is associated with poorer functioning trajectories, offering targets for maintenance treatment or secondary prevention.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

Modeling the Impact of School-Based Universal Depression Screening on Additional Service Capacity Needs: A System Dynamics Approach

Although it is widely known that the occurrence of depression increases over the course of adolescence, symptoms of mood disorders frequently go undetected. While schools are viable settings for conducting universal screening to systematically identify students in need of services for common health conditions, particularly those that adversely affect school performance, few school districts routinely screen their students for depression. Among the most commonly referenced barriers are concerns that the number of students identified may exceed schools' service delivery capacities, but few studies have evaluated this concern systematically. System dynamics (SD) modeling may prove a useful approach for answering questions of this sort. The goal of the current paper is therefore to demonstrate how SD modeling can be applied to inform implementation decisions in communities. In our demonstration, we used SD modeling to estimate the additional service demand generated by universal depression screening in a typical high school. We then simulated the effects of implementing "compensatory approaches" designed to address anticipated increases in service need through (1) the allocation of additional staff time and (2) improvements in the effectiveness of mental health interventions. Results support the ability of screening to facilitate more rapid entry into services and suggest that improving the effectiveness of mental health services for students with depression via the implementation of an evidence-based treatment protocol may have a limited impact on overall recovery rates and service availability. In our example, the SD approach proved useful in informing systems' decision-making about the adoption of a new school mental health service.

Intentional, explicit, systematic: Implementation and scale-up of effective practices for supporting student mental well-being in Ontario schools

Increasingly, the potential for school mental health programming to enhance the well-being of children and youth is being recognized and realized. When evidence-based practices in mental health promotion and prevention are adopted in a whole school manner, students show positive social emotional and academic benefits. These findings have stimulated a proliferation of mental well-being programming for Canadian schools, with variability across offerings in terms of supporting evidence, costs and ease of implementation. In the absence of coordination and guidance, there has been uneven uptake of high-quality programming, resulting in a patchwork of sometimes competing efforts across our country. In order to build cohesive and sustainable evidence-based programming, intentional, explicit and systematic effort must be afforded to matters of implementation and scale-up. In Canada, School Mental Health ASSIST has been developed to provide leadership, implementation support and embeddable resources to the province of Ontario’s 72 school districts, and 5000 schools, with a view to ensuring long-term sustainability of best-in-class school mental health practices. Key elements for uptake and scale-up are described, with an implementation science lens and an emphasis on aspects that are generalizable across jurisdictions.

Animal-Assisted Therapies for Youth with or at risk for Mental Health Problems: A Systematic Review

To systematically review experimental evidence about animal-assisted therapies (AAT) for children or adolescents with or at risk for mental health conditions, we reviewed all experimental AAT studies published between 2000-2015, and compared studies by animal type, intervention, and outcomes.

METHODS

Studies were included if used therapeutically for children and adolescents (≤21 years) with or at risk for a mental health problem; used random assignment or a waitlist comparison/control group; and included child-specific outcome data. Of 1,535 studies, 24 met inclusion criteria.

RESULTS

Of 24 studies identified, almost half were randomized controlled trials, with 9 of 11 published in the past two years. The largest group addresses equine therapies for autism.

CONCLUSION

Findings are generally promising for positive effects associated with equine therapies for autism and canine therapies for childhood trauma. The AAT research base is slim; a more focused research agenda is outlined.

Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes

A modular, transdiagnostic approach to treatment design and implementation may increase the public health impact of evidence-based psychosocial interventions. Such an approach relies on algorithms for selecting and implementing treatment components intended to have a specific therapeutic effect, yet there is little evidence for how components function independent of their treatment packages when employed in clinical service settings. This study aimed to demonstrate the specificity of treatment effects for two components of Acceptance and Commitment Therapy (ACT), a promising candidate for modularization. A randomized, nonconcurrent, multiple-baseline across participants design was used to examine component effects on treatment processes and outcomes in 15 adults seeking mental health treatment. The ACT OPEN module targeted acceptance and cognitive defusion; the ACT ENGAGED module targeted values-based activation and persistence. According to Tau-U analyses, both modules produced significant improvements in psychiatric symptoms, quality of life, and targeted therapeutic processes. ACT ENGAGED demonstrated greater improvements in quality of life and values-based activation. ACT OPEN showed greater improvements in symptom severity, acceptance, and defusion. Both modules improved awareness and non-reactivity, which were mutually targeted, though using distinct intervention procedures. Both interventions demonstrated high treatment acceptability, completion, and patient satisfaction. Treatment effects were maintained at 3-month follow up. ACT components should be considered for inclusion in a modular approach to implementing evidence-based psychosocial interventions for adults.

Extending parent-child interaction therapy for early childhood internalizing problems: new advances for an overlooked population

Although efficacious psychological treatments for internalizing disorders are now well established for school-aged children, until recently there have regrettably been limited empirical efforts to clarify indicated psychological intervention methods for the treatment of mood and anxiety disorders presenting in early childhood. Young children lack many of the developmental capacities required to effectively participate in established treatments for mood and anxiety problems presenting in older children, making simple downward extensions of these treatments for the management of preschool internalizing problems misguided. In recent years, a number of research groups have successfully adapted and modified parent-child interaction therapy (PCIT), originally developed to treat externalizing problems in young children, to treat various early internalizing problems with a set of neighboring protocols. As in traditional PCIT, these extensions target child symptoms by directly reshaping parent-child interaction patterns associated with the maintenance of symptoms. The present review outlines this emerging set of novel PCIT adaptations and modifications for mood and anxiety problems in young children and reviews preliminary evidence supporting their use. Specifically, we cover (a) PCIT for early separation anxiety disorder; (b) the PCIT-CALM (Coaching Approach behavior and Leading by Modeling) Program for the full range of early anxiety disorders; (c) the group Turtle Program for behavioral inhibition; and (d) the PCIT-ED (Emotional Development) Program for preschool depression. In addition, emerging PCIT-related protocols in need of empirical attention--such as the PCIT-SM (selective mutism) Program for young children with SM--are also considered. Implications of these protocols are discussed with regard to their unique potential to address the clinical needs of young children with internalizing problems. Obstacles to broad dissemination are addressed, and we consider potential solutions, including modular treatment formats and innovative applications of technology.

Modular Approach to Therapy for Anxiety, Depression, Trauma, or Conduct Problems in outpatient child and adolescent mental health services in New Zealand: study protocol for a randomized controlled trial

BACKGROUND

Mental health disorders are common and disabling for young people because of the potential to disrupt key developmental tasks. Implementation of evidence-based psychosocial therapies in New Zealand is limited, owing to the inaccessibility, length, and cost of training in these therapies. Furthermore, most therapies address one problem area at a time, although comorbidity and changing clinical needs commonly occur in practice. A more flexible approach is needed. The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) is designed to overcome these challenges; it provides a range of treatment modules addressing different problems, within a single training program. A clinical trial of MATCH-ADTC in the USA showed that MATCH-ADTC outperformed usual care and standard evidence-based treatment on several clinical measures. We aim to replicate these findings and evaluate the impact of providing training and supervision in MATCH-ADTC to: (1) improve clinical outcomes for youth attending mental health services; (2) increase the amount of evidence-based therapy content; (3) increase the efficiency of service delivery.

METHODS

This is an assessor-blinded multi-site effectiveness randomized controlled trial. Randomization occurs at two levels: (1) clinicians (≥60) are randomized to intervention or usual care; (2) youth participants (7-14 years old) accepted for treatment in child and adolescent mental health services (with a primary disorder that includes anxiety, depression, trauma-related symptoms, or disruptive behavior) are randomly allocated to receive MATCH-ADTC or usual care. Youth participants are recruited from 'mainstream', Māori-specific, and Pacific-specific child and adolescent mental health services. We originally planned to recruit 400 youth participants, but this has been revised to 200 participants. Centralized computer randomization ensures allocation concealment. The primary outcome measures are: (i) the difference in trajectory of change of clinical severity between groups (using the parent-rated Brief Problem Monitor); (ii) clinicians' use of evidence-based treatment procedures during therapy sessions; (iii) total time spent by clinicians delivering therapy.

DISCUSSION

If MATCH-ADTC demonstrates effectiveness it could offer a practical efficient method to increase access to evidence-based therapies, and improve outcomes for youth attending secondary care services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12614000297628 .

Review: Comprehensive treatments for youth comorbidity - evidence-guided approaches to a complicated problem

BACKGROUND

Evidence-based treatments (EBTs) with a single-disorder focus have improved the potential for youth mental health care, yet may be an imperfect fit to clinical care settings where diagnostic comorbidity and co-occurring problems are commonplace. Most EBTs were developed to treat one diagnosis or problem (or a small homogenous cluster), but most clinically referred youths present with multiple disorders and problems.

FINDINGS

Three emerging approaches may help address the comorbidity that is so common in treated youths. Conceptually unified treatments target presumed causal and maintaining factors that are shared among more than one disorder or problem area; preliminary open trials and case studies show promising results. Modular protocols combine the 'practice elements' that commonly appear in separate single-disorder EBTs and repackage them into coordinated delivery systems; one modular protocol, MATCH, has produced positive findings in a randomized effectiveness trial. Monitoring and Feedback Systems (MFSs) provide real-time data on client progress to inform clinical decision-making, encompassing comorbid and co-occurring problems; one study shows beneficial effects in everyday practice with diverse youth problems.

CONCLUSIONS

All three approaches - conceptually unified, modular, and MFS - can be strengthened by increased research attention to treatment integrity, clinician user-appeal, design simplicity, and the infrastructure necessary for successful implementation.

Classification models for subthreshold generalized anxiety disorder in a college population: Implications for prevention

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders on college campuses and often goes unidentified and untreated. We propose a combined prevention and treatment model composed of evidence-based self-help (SH) and guided self-help (GSH) interventions to address this issue. To inform the development of this stepped-care model of intervention delivery, we evaluated results from a population-based anxiety screening of college students. A primary model was developed to illustrate how increasing levels of symptomatology could be linked to prevention/treatment interventions. We used screening data to propose four models of classification for populations at risk for GAD. We then explored the cost considerations of implementing this prevention/treatment stepped-care model. Among 2489 college students (mean age 19.1 years; 67% female), 8.0% (198/2489) met DSM-5 clinical criteria for GAD, in line with expected clinical rates for this population. At-risk Model 1 (subthreshold, but considerable symptoms of anxiety) identified 13.7% of students as potentially at risk for developing GAD. Model 2 (subthreshold, but high GAD symptom severity) identified 13.7%. Model 3 (subthreshold, but symptoms were distressing) identified 12.3%. Model 4 (subthreshold, but considerable worry) identified 17.4%. There was little overlap among these models, with a combined at-risk population of 39.4%. The efficiency of these models in identifying those truly at risk and the cost and efficacy of preventive interventions will determine if prevention is viable. Using Model 1 data and conservative cost estimates, we found that a preventive intervention effect size of even 0.2 could make a prevention/treatment model more cost-effective than existing models of "wait-and-treat."

Alltagswirksamkeit ambulanter Verhaltenstherapie von Kindern und Jugendlichen im Urteil der Eltern in einer universitären Ausbildungsambulanz

Zusammenfassung. Hintergrund: Die Wirksamkeit von kognitiver Verhaltenstherapie bei Kindern und Jugendlichen unter Routinebedingungen ist bislang noch wenig untersucht. Fragestellung: Es wurden Veränderungen psychischer Auffälligkeiten von Kindern und Jugendlichen im Elternurteil während ambulanter Verhaltenstherapie in einer universitären Ausbildungsambulanz untersucht. Die Therapien wurden durchgeführt von Diplom-Psychologen, Pädagogen, Sozialpädagogen und Sozialarbeitern in fortgeschrittener Ausbildung zum Kinder- und Jugendlichenpsychotherapeuten mit Schwerpunkt Verhaltenstherapie. Alle Therapien wurden im Verhältnis 1:4 supervidiert. Methode: Für 976 Therapien wurden Completeranalysen als Prä-Post-Vergleiche mit Effektstärken auf der Child Behavior Checklist (CBCL) berechnet und die klinische Bedeutsamkeit der Veränderungen analysiert–jeweils für die Gesamtgruppe und für die auf der CBCL zu Therapiebeginn klinisch Auffälligen. Zusätzlich wurde die Repräsentativität dieser Analyse für die gesamte Stichprobe überprüft. Ergebnisse: In der Gesamtgruppe fanden sich kleine bis mittlere, in der Gruppe der im Elternurteil auf der CBCL klinisch Auffälligen hauptsächlich große, statistisch signifikante Verminderungen psychischer Auffälligkeiten, die nicht durch Spontanveränderungen oder Regressionseffekte erklärt werden können. Allerdings wurden 1/4 bis 1/3 der Patienten auch nach Therapieende von ihren Eltern weiterhin als klinisch auffällig eingeschätzt. Schlussfolgerungen: Die Ergebnisse weisen auf die Wirksamkeit kognitiv-behavioraler Therapie bei psychisch kranken Kindern und Jugendlichen unter Anwendungsbedingungen hin. Aufgrund der mangelnden experimentellen Kontrolle ist die Aussagekraft der Ergebnisse begrenzt.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

Validity of therapist self-report ratings of fidelity to evidence-based practices for adolescent behavior problems: correspondence between therapists and observers

Developing therapist-report fidelity tools to support quality delivery of evidence-based practices in usual care is a top priority for implementation science. This study tested the reliability and accuracy of two groups of community therapists who reported on their use of family therapy (FT) and motivational interviewing/cognitive-behavioral therapy (MI/CBT) interventions during routine treatment of inner-city adolescents with conduct and substance use problems. Study cases (n = 45) were randomized into two conditions: (a) Routine Family Therapy (RFT), consisting of a single site that featured family therapy as its standard of care for behavioral treatment; or (b) Treatment As Usual (TAU), consisting of five sites that featured non-family approaches. Therapists and trained observational raters provided FT and MI/CBT adherence ratings on 157 sessions (104 RFT, 53 TAU). Overall therapist reliability was adequate for averaged FT ratings (ICC = .66) but almost non-existent for MI/CBT (ICC = .06); moreover, both RFT and TAU therapists were more reliable in reporting on FT than on MI/CBT. Both groups of therapists overestimated the extent to which they implemented FT and MI/CBT interventions. Results offer support for the feasibility of using existing therapist-report methods to anchor quality assurance procedures for FT interventions in real-world settings, though not for MI/CBT.

Service Use Findings from the Child STEPs Effectiveness Trial: Additional Support for Modular Designs

This study expands upon the Chorpita et al. (J Consult Clin Psychol 81:999-1009, 2013) findings by examining the impact of treatment protocol on youths' service utilization up to 2 years after starting an episode of: standard manualized treatment (Standard); modular treatment (Modular); or usual care (UC). Results showed that youths who received Modular accessed fewer service settings at their one-year follow-up relative to youths who received Standard or UC. Findings suggest that modular treatment may offer an advantage over standardized treatment manuals and UC in terms of sustained clinical benefits, and highlight the importance of treatment design considerations for service systems.

25 years of systemic therapies research: progress and promise

OBJECTIVE

In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of therapeutic change in couple and family systems.

METHOD

We begin by explaining how we view "systemic therapies" as different from individual approaches and then summarize what we have learned in the past 25 years about this set of treatments, how we have learned it, and what we have yet to learn.

RESULTS AND CONCLUSIONS

We consider current trends in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the interrelated domains of systemic research and practice.

Causality and Causal Inference in Social Work: Quantitative and Qualitative Perspectives

Achieving the goals of social work requires matching a specific solution to a specific problem. Understanding why the problem exists and why the solution should work requires a consideration of cause and effect. However, it is unclear whether it is desirable for social workers to identify cause and effect, whether it is possible for social workers to identify cause and effect, and, if so, what is the best means for doing so. These questions are central to determining the possibility of developing a science of social work and how we go about doing it. This article has four aims: (1) provide an overview of the nature of causality; (2) examine how causality is treated in social work research and practice; (3) highlight the role of quantitative and qualitative methods in the search for causality; and (4) demonstrate how both methods can be employed to support a "science" of social work.

A case for modular design: Implications for implementing evidence-based interventions with culturally-diverse youth

Community-based therapists are frequently faced with the complex task of applying existing research knowledge to clients who may differ markedly from those enrolled in controlled outcome studies. The current paper examines the utility of modular psychotherapy design as one method of facilitating the flexible delivery of evidence-based mental health services to ethnically and culturally diverse children and families. Modularity complements existing approaches to the provision of culturally-sensitive, empirically-informed treatment through its ability to balance the prioritization of research evidence and local practitioner cultural knowledge. Specific applications of modular principles to clinical work with diverse youth are highlighted. Special considerations and limitations relevant to modular psychotherapy and the overall mental health services research literature are discussed, as well as the continued importance of individual clinicians' cultural competence and use of treatment progress monitoring, both of which should be combined with identified treatment modules to support the delivery of high-quality care.

Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform children's mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of "common elements" of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.