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  • 1. 1 EmpiricallySupportedTreatmentsfor Children and Adolescents What is Evidence Based Practice and Empirically Supported Treatments? Evidence based practice (EBP) is an approach to patient care that encourages clinicians to consider and synthesize empirical evidence, clinical expertise, and patient values in implementing treatments. Empirically-supported treatments (ESTs) are treatments whose demonstrated efficacy meets a standard of empirical investigation as determined by various methodological criteria. Why is Evidence Based Practice Important? There are a number of reasons for why it is important to use Evidence Based Practice. First APA has adopted a policy statement on EBP as a preferred approach to psychological treatment for young people. Second, it is our ethical responsibility to discuss EBPs with a family because provision of therapy that is not based on empirical evidence is associated with greater treatment failure. Finally, insurance companies increasingly demand evidence for the empirical basis for an assessment or treatment approach before reimbursing for services. There are many interventions that have shown efficacy for youth and their families. The list and descriptions provided below are just a sample of some empirically supported treatments for child and adolescent populations. How Are Empirically Supported Treatments Rated by Division 53? Division 53 has given each EST a rating based on the empirical support for that EST in the literature. There are three ratings: Well-Established, Probably Efficacious, and Possibly Efficacious.  Well-Established- There must be at least two good group-design experiments that are conducted in at least two independent research settings and by independent investigatory teams. Efficacy must be demonstrated by showing the treatment to be: a) statistically significantly superior to pill or psychological placebo or to another treatment OR b) equivalent (or not significantly different) to an already established treatment in experiments with statistical power being sufficient to detect moderate differences AND a) treatment manuals or logical equivalent were used for the treatment b) conducted with a specified population, for whom inclusion criteria have been delineated in a reliable, valid manner c) reliable and valid outcome assessment measures, at minimum taping the problems targeted for change d) appropriate data analyses.  Probably Efficacious- There must be at least two good experiments showing that the treatment is superior (statistically significantly) to a wait-list control group OR one or more good experiments meeting the Well-Established Criteria with the one exception of having been conducted in at least two independent research settings and by independent investigatory teams.
  • 2. 2  Possibly Efficacious- There must be at least one good study showing the treatment to be efficacious in the absence of conflicting evidence. General Empirically Supported Treatments Cognitive Behavioral Therapy (CBT) for Anxiety is a short-term integrative approach based on the assumption that both cognitive and behavioral processes can cause and maintain anxiety. Most CBT protocols aim to teach children and adolescents new approach behaviors, concrete problem-solving skills, and strategies for challenging maladaptive or unrealistic thoughts and beliefs. CBT can also provide behavioral parent training. CBT for anxiety is rated as Probably Efficacious by Division 53. Cognitive Behavioral Therapy (CBT) for Depression is based on the assumption that emotions and depressed feelings are influenced by thoughts and behaviors and that it is possible to change negative emotions by changing the way children and adolescents think and act in response to stressful situations. Group CBT for adolescents, children and parents is rated as Well-Established by Divisions 53. Cognitive Behavioral Therapy (CBT) for Pediatric Bipolar Disorder (PBD) may differ in emphasis and prioritization of specific methods, but commonly incorporates psychoeducation, affect regulatory strategies, cognitive restructuring techniques, behavioral management strategies, problem-solving skills training, and social skills training. CBT for PBD has shown promising results when used as an adjunct to pharmacotherapy. CBT for PBD is rated as Possibly Efficacious by Division 53. Cognitive Behavioral Therapy (CBT) for Substance Abuse aims to help adolescents replace their drinking or drug use with less risky behavior by recognizing and avoiding antecedents of their use, as well as by learning how to cope more effectively with problems that lead to increased use. Group CBT for adolescent substance abuse is rated as Well-Established by Division 53. Interpersonal Psychotherapy (IPT) is a brief treatment focusing on the quality of interpersonal relationships for adolescents with depression. Problem areas area identified and addressed in therapy through education and enhancement of various skills including problem- solving and communication. IPT has also been adapted for use with other disorders, such as bipolar disorder and eating disorders. IPT is rated as Well-Established for adolescent depression by Division 53. Please see http://www.interpersonalpsychotherapy.org/ for more information. Behavior Therapy for ADHD is a comprehensive psychosocial intervention for youth with ADHD, which may be used in combination with medication.Behavior Therapy includes components of parenting training, teacher consultation/school interventions, and child-focused treatments such as peer interaction. Behavior Therapy is rated as Well-Established for child and adolescent ADHD by Division 53. In fact, the literature suggests that Behavioral Therapy is the only psychosocial treatment that is effective for ADHD. Multisystemic Therapy (MST) is an intensive family-based treatment for youth with disruptive behavior problems, delinquency, and substance abuse. MST is based on a social-
  • 3. 3 ecological model and offers treatment in collaboration with the youth and their family in natural settings (e.g., home, school, community). MST focuses on enhancing natural strengths and resources, as well as on removing barriers to service access. MST is rated as Probably Efficacious for ODD and CD by Division 53. Please see http://www.mstservices.com/ for more information. Family Therapy for Eating Disorders is a family-based treatment for adolescents with an eating disorder. The family is viewed not as the cause of the problem, but as a resource to assist recovery. The treatment consists of first putting parents charge of what, when, and how much the adolescent eats. When the adolescent is becoming healthier, he/she is put back in charge of developmentally appropriate tasks. Family Therapy is rated as Well-Established for Anorexia Nervosa and as Possibly Efficacious for Bulimia Nervosa by Division 53. Specific, Manualized ESTs Anxiety The Coping Cat is a program for children aged 6-13. There is also an adolescent program (i.e., the C.A.T. Project). Both programs are cognitive-behavioral treatments that focus on unwanted and distressing anxiety. Youth learntheir own cues for when they are becoming anxious, as well as how to use these cues to initiate the implementation of coping skills. The Coping Cat is rated as Probably Efficacious for general anxiety symptoms and social phobia by Division 53. Social Effectiveness Training for Children (SET-C) is a multi-component treatment program that helps children and adolescents aged 7-17 decrease their social anxiety, increase their interpersonal skills, and expand their range of enjoyable social activities. SET-C combines group social skills training, structured peer generalization sessions, and individualized behavioral exposure treatment to help children eliminate their social anxiety. SET-C is rated as Probably Efficacious for Social Phobia by Division 53. Depression Penn Prevention Program (PPP) is a small-group curriculum designed to promote resilience and prevent symptoms of depression in youth aged 10-14. PPP is based on CBT and problem-solving interventions. The cognitive component teaches participants to identify their self-talk and to think more flexibly about the problems they encounter. The problem-solving component teaches skills to help youth cope with day-to-day stressors. PPP is rated as Probably Efficacious by Division 53. Please see http://www.ppc.sas.upenn.edu/prpsum.htm for more information. Adolescents Coping with Depression (CWD-A) is a group CBT program for depressed adolescents aged 12-18. The therapy typically occurs twice a week for 8weeks. CWD-A emphasizes monitoring mood, increasing pleasant activities, decreasing anxiety, and challenging unrealistic thinking that contributes to depression. It also addresses interpersonal skills, such
  • 4. 4 as conflict resolution and communication. CWD-A is rated as Probably Efficacious by Division 53. IPT for Depressed Adolescents (IPT-A) is a brief psychosocial intervention with the objective to decrease depressive symptoms and improve social functioning within the context of the adolescent’s significant relationships. IPT-A has been developed to address developmental issues most common to adolescents, such as separation from parents, development of dyadic interpersonal relationships with members of the opposite sex, and peer pressure. IPT-A is rated as Probably Efficacious by Division 53. Disruptive Behavior Problems Rational-Emotive Mental Health Program (REMH) is a school-based intervention based on cognitive-behavioral principles for high-risk 11th and 12th graders with disruptive behavior problems. Students participate in daily small group sessions that include activities such as cognitive restructuring through adaptive rational appraisal, in vivo role playing, group-directed discussion, and therapy "homework" assignments. REMH is rated as Probably Efficacious by Division 53. Helping the Noncompliant Child is a parent skills-training program aimed at teaching parents how to obtain compliance in their children to reduce conduct problems and prevent subsequent juvenile delinquency and other problem behaviors. The parent(s) and child attend sessions in a playroom setting, and parenting skills are taught using active teaching methods (e.g., role play). The program is rated as Probably Efficacious by Division 53. Triple P (Positive Parenting Program) is a multi-level system of parenting and family support interventions delivered through varying formats (e.g., individual, group). Although the core programming focuses on parents of children aged 1 to 12 years, Triple P also extends to parents of teenagers. Triple P draws on empirical literatures related to child development, applied behavior analysis, social learning, cognitive functioning, and family dynamics. Triple P is rated as Probably Efficacious by Division 53. Incredible Years Training Series (IY) is a set of three comprehensive, multifaceted, and developmentally-based curricula for parents, teachers, and children aimed at treating disruptive behavior problems in youth. Overall, IY is designed to promote emotional, social, and problem- solving competence, as well as to prevent, reduce, and treat aggression and emotional problems in children. The IY is rated as Probably Efficacious by Division 53. Reaching Educators, Children, and Parents (RECAP) is a school-based, cognitive- behavioral and social skills training program for elementary school children with co-occurring externalizing and internalizing problems. RECAP focuses on the development of socio- emotional and problem-solving skills and positive behavior management. It heavily emphasizes teacher training and ongoing consultative support for the classroom teacher. RECAP is rated as Possibly Efficacious by Division 53. First Step to Success Program is a joint home and school-based intervention for kindergartners who either display, or are at risk for, antisocial behavior patterns. The program
  • 5. 5 teaches children social skills and appropriate classroom and schoolwork habits. Often, parents are enlisted as partners with teachers and school staff. First Step is rated as Possibly Efficacious by Division 53. Self-Administered Treatment, plus Signal Seat is designed to improve misbehavior in children aged 2-7 by using behavioral management techniques. This is accomplished by supplementing traditional "time-out" punishment with the Signal Seat, a time-out chair which sounds an alarm whenever the child leaves the chair without permission. The Self-Administered Treatment, plus Signal Seat is rated as Possibly Efficacious by Division 53. Substance Abuse Multidimensional Family Therapy (MDFT) is a comprehensive family-based intervention for youth ages 11-18with antisocial behavior and substance abuse. MDFT is a theoretically- derived multicomponent treatment incorporating comprehensive assessment, an integrated treatment approach, and specialized engagement and retention protocols. MDFT is rated as Well-Established for adolescent substance abuse by Division 53. See http://www.med.miami.edu/ctrada for more information. Functional Family Therapy (FFT) is a short-term family-based intervention that integrates both systemic and cognitive-behavioral components to treat youth with conduct problems and/or substance abuse. FFT was developed specifically for difficult to treat youth ages 10-18, who may have few resources, multiple diagnoses, and a history of resistance (i.e., lack of engagement). FFT is rated as Well-Established for adolescent substance abuse by Division 53. Please see http://www.fftinc.com/ for more information. Brief Strategic Family Therapy (BSFT) is a short-term family-based intervention for youth (ages 8-17) presenting with a variety of behavioral problems, risky behaviors or mild substance abuse. The goal is to increase the youth's psychosocial functioning by improving family interactions. BDFT has been used primarily with inner-city Hispanic and African American families. BSFT is rated as Probably Efficacious for adolescent substance abuse by Division 53. Please see http://www.abct.org/sccap/docs/pro_BSFT_Manual.pdf for more information. Strength Oriented Family Therapy (SOFT) is a family-based therapy program for adolescents with substance abuse disorders. Key features include motivational interviewing during the pre-treatment phase, a strengths and resources assessment, solution-focused language and techniques, family relapse prevention planning, and family communication skills training. SOFT is rated as Possibly Efficacious for adolescent substance abuse by Division 53. Minnesota Model 12 Step is a program for adolescents with substance abuse including components of individual and group therapy, family education, and aftercare planning. The program integrates behavioral strategies with the 12 spiritual steps used in Alcoholics Anonymous. This program can also be adapted to treat other addictions, including gambling and
  • 6. 6 sexual compulsion. The program is rated as Possibly Efficacious for adolescent substance abuse by Division 53. See http://archives.drugabuse.gov/adac/ADAC11.html for more information.
  • 7. 7 Anorexia Nervosa Psychoanalytic Therapy for Anorexia Nervosa is a treatment program for adolescents based on “self psychology”, a modern version of psychoanalysis. In this model, it is believed that adolescents develop eating disorders because they are unable to rely to people for emotional support. Adolescents are taught to turn to people instead of food. Psychoanalytic Therapy is rated as Possibly Efficacious for adolescent AN by Division 53. Cash's Body Image Therapy, plus Virtual Reality is a treatment for adolescents with body image problems that combine cognitive-behavioral therapy with Virtual Reality (VR) components. In addition to traditional cognitive-behavioral components, VR is used for repeated exposure to the adolescent’s body in a variety of stressful situations. The program is rated as Possibly Efficacious for adolescent anorexia nervosa by Division 53. Please see http://www.abct.org/sccap/docs/pro_POP_VirtualBody_english.pdf for more information. Bipolar Disorder Family-Focused Treatment for Adolescents (FFT-A) is conducted with bipolar children or adolescents, one or more of their parents, and siblings. The treatment focuses on assessment, psychoeducation, communication enhancement skills training, and problem-solving skills training. The treatment is commonly used in conjunction with medication, and canimprove medication adherence. The program is rated as Probably Efficacious for child and adolescent bipolar disorder by Division 53. Multi-Family Psychoeducation is an intervention for children and adolescents with a mood disorder, including bipolar disorder. The biopsychosocial intervention integrates psychoeducation, support, and skill-building based on cognitive-behavioral and family systems principles. The psychoeducational psychotherapy can be delivered in a multi-family or individual family format. The program is rated as Probably Efficacious for child and adolescent bipolar disorder by Division 53. Dialectical Behavior Therapy (DBT) was initially developed for adults with borderline personality disorder, but has been adapted to suicidal adolescents and adolescents with bipolar disorder. DBT for adolescents with bipolar disorder consists of Family Skills Training in combination with Individual DBT Therapy. DBT is a cognitive-behavioral treatment that uses a skills-based approach targeting emotion dysregulation, suicidal behavior, interpersonal deficits, and treatment resistance. DBT is rated as Possibly Efficacious by Division 53. Please see http://depts.washington.edu/brtc/about/dbt for more information. Autism Lovaas' Model of Applied Behavior Analysis is an intervention for children with autism, based on principles from Applied Behavior Analysis. Lovaas is adapted to fit each individual child’s need and developmental level. Skills taught through various behavioral strategies are related to communication, relationships, academic readiness, self help, and independent leisure
  • 8. 8 time. Lovaas is rated as Well-Established by Division 53. See http://www.lovaas.com/resources.php for more information. PTSD, Abuse, and Complex Trauma Attachment, Self-Regulation, and Competence (ARC) is a guideline for individuals working with traumatized children in the community. Interventions focus on building secure attachments, enhancing self regulatory capabilities, and increasing competencies across multiple domains. ARC targets children who have experienced chronic trauma such as sexual abuse, physical abuse, neglect, domestic violence, and community violence. ARC is rated as a Promising Practice by the NCTSN. Child-Parent Psychotherapy (CPP) integrates a focus on the way the trauma has affected the parent-child relationship and the family’s connection to their culture and cultural beliefs, spirituality, intergenerational transmission of trauma, historical trauma, immigration experiences, parenting practices, and traditional cultural values. It is a dyadic attachment-based treatment for young children exposed to interpersonal violence. CPP is rated as a Promising Practice by the NCTSN. Parent-Child Interaction Therapy (PCIT) is an evidenced-based treatment model with highly specified, step-by-step, live coached sessions with both the parent/caregiver and the child. Parents learn skills through PCIT didactic sessions. Using a transmitter and receiver system, the parent/caregiver is coached in specific skills as he or she interacts in specific play with the child. Generally, the therapist provides the coaching from behind a one-way mirror. The emphasis is on changing negative parent/caregiver child patterns. PCIT is rated as a Promising Practice by the NCTSN. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) aims to address the biopsychosocial needs of children with Posttraumatic Stress Disorder (PTSD) or other problems related to traumatic life experiences, and their parents or primary caregivers. TF-CBT is a model of psychotherapy that combines trauma-sensitive interventions with cognitive behavioral therapy. Children and parents are provided knowledge and skills related to processing the trauma; managing distressing thoughts, feelings, and behaviors; and enhancing safety, parenting skills, and family communication. TF-CBT is rated as a Promising Practice by the NCTSN. *There are several other empirically supported treatments and promising practices evaluated by the National Child Traumatic Stress Network. Please visit http://www.nctsnet.org for more information.
  • 9. 9
  • 10. 10 Concerns and Alternatives There are some concerns about the definition, identification, and cataloguing of ESTs, most of which are based on misunderstandings. However, it is should be noted that some concerns are warranted and that alternatives to ESTs have been proposed by various researchers. For example, researchers have noted that many ESTs appear to work for similar reasons, and that "empirically supported principles of change” (e.g., exposure for anxiety) may be a more parsimonious solution (Rosen & Davison, 2003). Others argue that it would be helpful to map specific clinical procedures with client or contextual features (Chorpita & Daleiden, 2009). Finally, the list of ESTs can guide choices about effective treatments, but does not warn against potentially harmful treatments (Chorpita et al., 2002; Lilienfeld, 2007). Recommended Reading and Resources EBP and Identifying ESTs 1. Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716. 2. Norcross, J. C., Beutler, L. E., & Levant, R. F. (Eds.). (2005). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association. 3. Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-663. Utilizing ESTs and CBT 1. Kazdin, A. E., & Weisz, J. R. (Eds.). (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford. 2. Barlow, D. H. (Ed.). (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). New York: Guilford. 3. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. 4. Nathan, P. E., & Gorman, J. M. (Eds.) (2007). A guide to treatments that work (3rd Ed.). New York: Oxford University Websites Division 53: http://www.effectivechildtherapy.com Evidence Based Mental Health Treatment for Children/Adolescents: http://www.abct.org/sccap/ Evidence Based Behavioral Practice: http://www.ebbp.org/
  • 11. 11 Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry for Evidence-Based Practice (NREPP): http://www.nrepp.samhsa.gov/ National Child Traumatic Stress Network: http://nctsn.org Table of ESTs Empirical Status Pediatric Disorder Well-established Probably Efficacious Possibly Efficacious Anxiety Interpersonal Psychotherapy (IPT) CBT Coping Cat* Social Phobia Social Effectiveness Training* Depression Group CBT Penn Prevention Program* Adolescents Coping with Depression* IPT for Depressed Adolescents* Bipolar Disorder CBT Family-Focused Treatment for Adolescents* Multi-Family Psychoeducation* Dialectical Behavior Therapy* Substance Abuse Group CBT Multidimensional Family Therapy* Functional Family Therapy* Brief Strategic Family Therapy* Transitional Family Therapy* Strength Oriented Family Therapy* Minnesota Model 12 Step* ADHD Behavior Therapy Conduct Disorder & Oppositional Defiant Disorder Multisystemic Therapy Disruptive Behavior Problems Rational-Emotive Mental Health Program* Helping the Noncompliant Child* Triple P (Positive Parenting Program)* Incredible Y ears Training Series* Reaching Educators, Children & Parents* First Step to Success* Self-Administered Treatment + Signal Seat*
  • 12. 12 Autism Lovaas’ Model of Applied Behavioral Analysis* Anorexia Nervosa Family Therapy Psychoanalytic Therapy* Cash’s Body Image Therapy + Virtual Reality* Bulimia Nervosa Family Therapy