A review of child psychotherapy research since 1963.

SPECIAL ARTICLE A Review of Child Psychotherapy Research Since 1963 R. JOFFREE BARRNETT, M.D. , JOHN P. DOCHERTY, M.D. ,

AND

GAYLE M. FROMMELT, PH.D.

Abstract. Reports on individual nonbehavioral child and adolescent psychotherapy since 1963 are reviewed . Inclusion criteria required some minimal contrasting group. Forty-three studies were assessed for basic methodological adequacy and main findings. The authors conclude that summary impressions from this body of literature cannot be made due to the magnitude of the flaws in basic psychotherapy research methodology . Suggestions are made regarding the future of child and adolescent psychotherapy research. J. Am. Acad . Child Adolesc . Psychiatry. 1991,30, 1:1-14. Key Words: child, adolescent , psychotherapy, research review .

The history of the literature of child psychotherapy has evolved along two separate axes. The first axis is a descriptive one that involves the description of various types of intervention and an articulation of their theoretical underpinnings. Much of this literature is anecdotal in nature and does not lend itself to objective evaluation. The second important axis has emerged from the long-standing concern in this field for measuring the outcome and effectiveness of psychotherapy and has attempted to evaluate objectively various types of interventions with children and adolescents. This review focuses on the second axis and examines controlled trials of individual child psychotherapy over the last 27 years. Individual child psychotherapy, as used here, refers to one-on-one psychotherapy with children and adolescents using a verbal or play mode of treatment. Not included in this evaluation are behavioral or cognitive behavioral forms of treatment. The rationale for excluding behavioral or cognitive behavioral treatments is that these have been extensivelyreviewed elsewhere (e.g., Ollendickand Clerny, 1981 ; Harris, 1983; O'Leary and Carr, 1982; and Ollendick, 1986). These reviews demonstrate and document the effectiveness of this treatment methodology, as a whole, for the amelioration of specific behavioral disorders in children. Specifically, the following findings emerge from this literature. There are four classes of intervention: operant-, modeling-, and cognitive-based procedures and desensitization procedures. Each of these has become standardized enough to allow assessment in clinical trials. All of these treatments have demonstrated efficacy in the short run with anxiouswithdrawn behaviors. Cognitive-, modeling-, and operantbased procedures have demonstrated efficacy with oppositional and aggressive behaviors. Operant procedures have been used successfully with pervasive developmental disorders to reduce behaviors such as self-injury and self-stimulation (Ollendick, 1986). Major questions, however, reAccepted May 29,1990. All authors are with Brookside Hospital, Nashua, NH. Reprint requests to: Dr. Barrnett, c/o Brookside Hospital, 11 Northwest Blvd., Nashua, NH 03063 . 0890-8567/9113001-0001$02. OO/O© 1991 by the American Academy of Child and Adolescent Psychiatry. l .Am.Acad. Chi/dAdolesc. Psychiatry, 30:1 ,January 1991

main concerning behavioral treatment. Comparative studies between pure types of behavioral treatments or between behavioral and other treatments are scant. Issues regarding the long-term outcome remain unanswered. Much of the behavioral literature relies on the N = 1 (Hersen and Barlow, 1976) methodology that raises questions regarding the generalizability of the results. However, despite the methodological refinement of these therapies and their demonstrated efficacy, important limitations exist with these forms of therapy. The foremost investigators in these areas have noted these limitations; in particular, the inability to deal with patients with complicated personality disorders or whose behavioral problems stem from traumatic events or other deep structures. The need for treatments to address such patients is manifest. The focus of this review is on the data that currently exist regarding the clinical trials of traditional verbal psychotherapies with children. This form of psychotherapeutic intervention, although it is supported by an enormous base of clinical experience, has because of its complexity and its history been less amenable to the application of the contemporary scientific method of clinical trials. Fortunately, however, in the area of the adult psychotherapy, great progress has been made in recent years in the development of a methodology to effectively study such traditional psychotherapies (Waskow, 1984). Given this background, it is opportune to review the base of knowledge in child psychotherapy with a view toward the application of the methods developed in the adult field to the study of children. In the last 27 years, there are a total of nine general reviews of child and adolescent psychotherapy. Each made suggestions of scientific refinements and reached differing conclusions regarding the efficacy of psychotherapy. The first major effort to assess child psychotherapy was Levitt's (1957, 1963) examination of child psychotherapy outcome research. Levitt contrasted the total percentage of treated children who improved with the total percentage of untreated children who improved. In 1957, he estimated that 78% of the treated children had improved at followup, while 72.5% of the untreated children had improved. His evaluation in 1963 yielded similar results. Levitt concluded that his results did not support the hypothesis that 1

BARRNETI ET AL.

psychotherapy facilitated recovery from emotional illness in children. Levitt's studies have been criticized for the following reasons: 1. The studies that he reviewed were from the 1930s to 1950s, and the therapeutic techniques and clinical populations differed in many ways from later techniques and patient populations (Barrett et aI., 1978). 2. Levitt's estimate of improvement of untreated children may not have been valid because of his inclusion of an estimate of improvement from two studies with nonrepresentative samples and thus were of questionable methodology (Barrett et aI., 1978). 3. Many of the "untreated" children received diagnostic assessments, although they did not continue in psychotherapy. It can be argued that there may have been systematic differences apart from treatment status between those who did not participate beyond the assessment and those who continued in treatment. For example, those children who did not continue may have had a greater ability to cope, found some other help for their problems, or found the initial assessment sufficient treatment (Heinicke and Strassman 1975' Barrett et aI., 1978; Chess and Thomas, 1979)~ Thus : these " untreated" subjects may have been the most healthy. 4. All of the studies that Levitt used have significant methodological flaws (Saxe et al., 1986). For example, the outcome measures are not appropriate to reflect critical clinical differences . Eight years later, Levitt again reviewed the status of the of psychotherapy with children (Levitt , 1971). In addition to summarizing his previous arguments and conclusions regarding outcome and child psychotherapy, he surveyed a variety of studies touching on alternative therapeutic approaches and issues regarding methodology in a s~mew~lat anecdotal manner. He concluded that, based upon his review, the child psychotherapists should involve the parents in treatment, outcome is related to treatment inten~ity, pe~issiveness of the expression of negative feelings i~ ~ desi~able treatment procedure while punishment is not, hvmg With a family is more therapeutic than institutionaliza.ti~n, and ~ucces~ful therapies were those with adequate trammg. In his closmg remarks, Levitt continued to express ~oncern that it appeared child psychotherapists were spendm~ mUCh. of th~ir time with patients who might improve With or Without mterventions and urged additional long-term follow-up studies for examining therapy outcome and process. " Heinicke and Strassman (1975) reevaluated the question, Does psychotherapy do any good?" They reviewed the research regarding conditions or variables that might affect the ?utcome of children in psychotherapy . They pointed to the madequacy of the global question of the effectiveness of ~sychotherapy and stressed the need to assess the specific vanable.s that affect process and outcome in therapy. They also delineated key methodological issues in psychotherapy research evaluation. These issues included: inclusion and exclusion criteria; careful baseline assessment; the need to lite~a~ure

2

control for a variety of variables , such as age , sex, and IQ; the need for homogeneity among the treatment groups; the requirement for control and contrast groups that are appropriate to the initial questions asked; the nature of the therapist and how therapists are assigned to children ; and the need to have follow-up assessments made longitudinally, even after treatment, to evaluate "sleeper" effects. Lastly, they recommended that study populations and design be constructed in a way that would allow replication. Wright et al. (1976) reviewed the outcome literature of individual child psychotherapy and paid particular attention to studies where the assessments distinguished between the close of therapy and the follow-up period of time. They argued that there was demonstrated improvement in outco.m~ status from the end of therapy to follow-up and that this improvement was positively correlated with the number of psychotherapy sessions . They also advocated the requirement of including follow-up periods of assessment to examine outcome issues in child psychotherapy. Several years later, Barrett et al. (1978) also examined the field. These authors reviewed the controversy initiated by Levitt regarding the efficacy of psychotherapy and highlighted the limitations of his results. They argued that little was to be gained by reworking the data that Levitt examined because the critical question was not " does psychotherapy work?" Instead, they felt it was critical to address the now well-known refrain of contemporary psychotherapy research, " Which set of procedures is effective when applied to w~at kind of patients, with what kinds of problems as practiced by what sort of therapist ." They reviewed a variety of methodological issues , such as: (1) the differential response to treatment by different diagnostic categories; (2) the lack of control in much of the literature for developmental stages of the patient; (3) the high degree of responsiveness of children to their environment; and (4) the need to specify and define the intervention employed. Tramontana (1980) reviewed 10 years worth of psychotherapy outcome literature focusing on adolescents from 1967 to 1977. Included in his evaluation were 33 studies of individual, group, and family therapy. Only five were judged as having adequate methodological scope and rigor. The focus of the major part of his discussion was reevaluation versus no therapy conditions . In spite of the methodological deficiencies, he felt the available evidence pointed toward a superiority of psychotherapy. Tramontana additionally pointed out the paucity of information regarding specific patient , therapist , and process variables relevant to adolescent therapy outcome. In 1980, Smith et al. examined 500 control studies using the statistical technique of metanalysis. Metanalysis is a method of statistically summarizing and integrating information from a variety of different studies. It entails calculating a measure called the effect size. The effect size is obtained by dividing the mean difference in outcome scores between the treatment and control groups by the standard deviation (usually) of the control group . The resultant statistic is essentially a difference in standard (z) score means . The effect size is thus comparable for outcome measures l .Am.Acad. Child Ado/e sc. Psychiatry ,30 :1,January 1991

CHILD PSYCHOTHERAPY RESEARCH

originally expressed in different raw units. The effect size yields an estimate of the percentile of distribution of the control patients in which the average (that is, the patient at the 50th percentile of the experimental group) would fall following treatment. This method has been used in a variety of different areas such as the assessment of the effect of social class on achievement, the effect of class size on attainment, and the effect of sex differences on conformity. Of the 500 studies, approximately 50 assessed the treatment of children and adolescents. The overall analysis revealed significantly better outcome for patients who were being treated with psychotherapy versus controls. Unfortunately, however, the approximately 50 children and adolescent studies were not analyzed separately from the original 500 studies, and thus no effect size can be reported. In addition, some of the studies on child and adolescents contained treatments other than individual psychotherapy. They did report, however, in a correlational analysis, that the patient's age had little effect on treatment outcome. Critics of this study have indicated that these authors included studies that were composed of poor as well as good design (Eysenck, 1978). Casey and Burman (1983) published a review of 75 studies on child psychotherapy outcome, dating from 1952 to 1983. Their review focused on studies with children with a mean age of younger than 13 years at the time of treatment. It included behavioral and cognitive-behavioral treatments along with the nonbehavioral psychotherapies and was restricted to those studies that utilized control groups of untreated children from the same general population. The same metanalytic techniques used by Smith et al. (1980) were used in this review. An effect size of 0.40 (0.49 for client centered and 0.21 for dynamic psychotherapy) was obtained for nonbehavioral psychotherapy. Overall, it was found that those children receiving psychotherapy were better off than two-thirds of the control children. There was little evidence that one modality differed from any other in overall effectiveness, and outcomes for those children whose parents were treated concomitantly did not differ from those children whose parents were not. One important criticism of this study is the fact that only 24% of the total 75 studies reviewed utilized children who were seeking treatment as subjects. Most of the remaining studies utilized school children not seeking treatment or community volunteers for special projects in mental distress, but who had not sought treatment. Thus, it is not clear how representative these results actually are of clinical practice (Saxe et al., 1986). In summarizing the reviews of child psychotherapy occurring in the last 25 years, it appears that the field has been preoccupied by the initial question raised by Levitt; "Is child psychotherapy effective?" All of the authors have noted the paucity of well-controlled, methodologically sound studies. The reviews do not clearly delineate the efficacy of psychotherapy for children and adolescents. Hence, there have been repeated calls for more methodologically rigorous research on what type of treatment is appropriate for what type of child with what kind of problem. In the last decade, there have been important advances in psychotherapy research that have been very healthy for l.Am.Acad. Child Adolesc.Psychiatry, 30:1 ,January 1991

TABLE

1. Methodological Features of Clinical Trials

Inclusion and exclusion criteria I. Specific diagnostic criteria or standardized objective measures that identified the signs, symptoms, or the problem areas of the sample subjects. 2. Exclusionary criteria that eliminated inappropriate candidates for psychotherapy, such as psychosis, brain damage, etc., or eliminated subjects that might bias the results. 3. A homogeneous sample that would lead to conclusions regarding that specific group. 4. Adequate sample size. Specification of therapy I. Type, duration, and frequency of treatment. 2. A detailed description of the treatment types other than a heading (such as analytic or client-centered). 3. Delineation of the characteristics, background, and training oftherapists. 4. Control of other forms of treatment that might influence the results. 5. Control of the degree of parent involvement. 6. Monitoring the adequacy or appropriateness of the delivery of therapy. Matching procedures and control groups I. Use of control groups and specification of the type (i.e., new, other treatment, or no treatment). 2. Assignments to experimental and contrasting groups made randomly. 3. Matching of groups for age, sex, IQ, and other variables that would indicate similarity or reduce the effect of these pretreatment variables on the study's outcome. Measurements and outcome evaluations I. Use of standardized and objective ratings of dependent or outcome measures rather than just relying on clinical judgment. 2. Use of clinical judgments made with appropriate interrater reliability or other measures to ensure their uniformity and replicability. 3. Outcome ratings obtained blind to the treatment, group assignment, or pretreatment assessments. 4. Outcome measures that were relevant to the subject of study.

the field (Williams and Spitzer, 1984; Docherty et al., in press). In addition to methodological techniques outlined in these child psychotherapy reviews such as metanalysis, the major advance in psychotherapy research has occurred in the delineation of treatment that allows the application of the "clinical trial" model of methodology. Before this advance, much of the research in psychotherapy was limited by the following problem areas: (1) the systematic bias in expertise in which therapy is practiced and administered; (2) the bias in favor of simpler procedures; and (3) not all procedures are uniform enough to allow clinicians to perform them evenly. To reduce these areas of bias, psychotherapy research now requires: (1) an acceptable level of competence in the skill of the therapist performing the procedure; (2) equivalent skill across all therapists; (3) consistency in applying the skills throughout the treatment trial; and (4) fully described procedures similarly applied by all therapists. 3

BARRNETT ET AL.

10 9

8

7

NUMBER OF

6

STUDIES PUBLISHED

5

4 3

2

63

64 65

66

67

68

69 70

71 72

73

74

75 . 76

77 78

79

80

81

82

83

84 85

86

87 88

YEAR OF PUBLICATION FIG .

1. Studies of child psychotherapy per year.

In light of these advances, the authors wanted to reexamine the field of child and adolescent psychotherapy to see if any of them have been incorporated and to assess the knowledge base of the field. Simply put, what is known regarding child psychotherapy in light of the current advances in research of adult psychotherapy? To examine this question, a review of all the research done in the last 27 years was undertaken to obtain studies that examined groups of children and adolescents receiving psychotherapy . In order to be included in this review , the following criteria had to be met: (I) the study needed to include a group of children and/or adolescents that were receiving individual psychotherapy; (2) the study had to include at least one comparison group; (3) the study could not focus entirely on behavioral , cognitive-behavioral, family, group interventions, or psychopharmacology. Studies that had a mixture of adolescents and adults in their sample were also eliminated. A total of 43 studies were located that met the criteria and are listed in alphabetical order in the Appendix. (The Appendix contains all of the studies reviewed . They are numbered as reference points to allow easy identification between the text and the Appendix. For example: Study 5 states....) In addition to establishing these methodological criteria for inclusion, each article was assessed for the presence or absence of important methodological features considered important for establishing the internal and external validity of the investigation . These methodological features are delineated in Table I. The methodological issues were obtained by collapsing many of the recommendations made over the last 27 years by a number of reviewers (Levitt, 1963; Heinicke and Strassman , 1975; Wright et al., 1976; Barrett et al., 1978; Casey and Burman, 1983; Shaffer, 1984; Williams and Spitzer, 1984). For descriptive purposes , these methodological issues were grouped into four categories of general issues or headings. Often, each of these items contains within it multiple other aspects related to appropriate research design that are not necessarily reflected in the current text. 4

This methodological list outlined in Table I can only be considered to be a review of the "bare minimum" that might be required by current psychotherapy research standards and not an all inclusive list. The authors are thus taking what is felt to be a modestly "hardnosed" approach to the evaluation of the current data base. To begin the overview of the literature, Figure I is a bar graph of the number of psychotherapy studies and the year of their publication since 1963. An overview since 1963 of the number of studies published shows a dramatically decreasing number per year that drops off very significantly after 1973. Since 1973, there have been no more than two studies published in I year, and only a total of five studies published . Table 2 lists the length of treatment across all the publications reviewed. Of the total studies, the vast majority deal with treatment of less than 6 months duration. One study (2%) focuses on six sessions or less. Seventeen out of 43 (39%) studies focus on treatment of seven to 24 sessions or up to 6 months duration. Only four studies (9%) examine treatment of greater than 24 sessions, and one study (2%) examines a mixed treatment length. However, 20 (46%) studies do not specify treatment length clearly . Table 3 lists the ages of the subjects in the current sample of 43 studies. Thirteen studies (30%) focus on a study group with ages of 12 years or less, and 10 (23%) studies focus on adolescents of age 13 or more. Ten reports (23%) look at both age groups. Ten studies (23%) do not report the ages of their subjects. . The substantive results of all of these studies can be grouped into five categories: (1) psychotherapy versus no treatment or dropouts, (2) psychotherapy versus other treatment, (3) therapy variables, (4) patient variables, and (5) therapist variables. One of the largest categories examines the issue of the outcome of treated versus untreated children. A total of 21 reports detailing the results of 17 studies dealt with this issue, 12 reports cited improvement (5, 7, 9, 14, 27, 28, J .Am.Acad.Child Adolesc. Psychiatry ,30 :] .January ]99]

CHILD PSYCHOTHERAPY RESEARCH TABLE

2. Length of Psychotherapy

Treatment Length

Appendix Study Number

Brief; 6 sessions or less

5

Intermediate ; 7-24 sessions or 6 months Long-term; greater than 24 sessions Mixed Unspecified length

2, 3, 6, 9, 14, 19, 20, 23, 24-28, 30-32,43 10-12, 39 42 1,4,7,8,13, 15-18, 21, 22, 29, 33-38, 40, 41

TABLE

Ages Total 1

17

4

Grade school 13/43

< 12 years

Study Number

2,4,5,9,10,11,12, 18,26, 31, 33, 42, 43

Junior high school > 12 years or high school 10/43

3, 13, 22, 27, 28, 35, 36, 37, 38, 39

Both grade school and above 10/43

7, 19,21,23,24,25, 30, 32, 34, 40

Unknown ages 10/43

1,6,8,14,15 ,16,17 , 20,29,41

1

20

33, 35-38) as a result of individual psychotherapy, whereas nine reports showed no difference between the treated and untreated conditions 0, 4,8, 19,20,21,30,34,42). Two lengthy studies (27, 28) and (35-38) detailing a total of six reports have focused on adolescents with antisocial characteristics. In the first, incarcerated male juvenile delinquents were randomly assigned to individual and group therapy versus no treatment. The treated group showed improvement in anxiety ratings and Minnesota Multiphasic Personality Inventory (MMPI) scales following treatment and at follow-up showed improved community adjustments (27, 28). Although this study picked subjects matched on a variety of demographic and psychopathological traits and then randomly assigned them to treatment and new treatment conditions, there was no delineation of diagnostic psychopathology and little description of the treatments and the therapists . The second study (35-38) focused on adolescents with antisocial behavior and school disciplinary problems and randomly assigned them to treatment and nontreatment groups. The treatment group improved at the conclusion of treatment and at the follow-up assessments of 2, 5, and 10 years. This study's results must be questioned because the initial sample was only of20, and the follow-up comparisons were done on small subsample sizes of five each. While this is potentially a homogeneous sample, it is not clear why the initial 20 were chosen over the entire potential pool of possible subjects. Only a general description of a flexible supportive contact without time boundaries was given to delineate the nature of the therapeutic intervention and there was no description of the therapists. Follow-up outcome measures consisted of anecdotal reporting of vocational outcome and number of arrests and achievement scores . Three of the studies citing improvement with psychotherapy focused on school populations. In the first (9), teachers subjectively nominated low-assertive children who were then divided into treated and untreated groups and given therapy by trained teachers. The treated group showed a statistically significant rise in assertiveness. In the second study (4), fourth grade students with poor peer relations were assigned to group and individual counseling, teacher l.Am.Acad. Child Adolesc.Psychiatry, 30:1 , January 1991

3. Ages of Subjects

guidance, or control and showed a significant improvement in peer relations after treatment. The last sample (33) was a collection of highly aggressive or withdrawn children randomly assigned to therapy or no treatment who also showed improvement in the treatment group. The major problem of these studies consists of the lack of clear, consistent diagnostic inclusion criteria. It is not clear that these samples are clinically relevant samples, and they are selected with enough ambiguity that it would be impossible to duplicate these samples to repeat the study. All three of the studies gave vague descriptions of the treatment and therapist characteristics, with the exception of one (9) that delineated in a brief way the discussion of the training for the teachers who are the therapists and the fact that they were supervised in a group. This study (9) is complicated by the fact that the teachers had sustained other contact with their subjects in nontherapeutic classroom situations. Lastly, while one study (4) used random assignment , and another reported equal divisions between the groups (33) of the subjects' sex and degree of aggression, there is little other comparison between the treatment and nontreatment groups. These problems make the results difficult to evaluate. Another study examined former child outpatient children and a control group of children who received no psychiatric treatment, who are followed up in military service, to assess the relationship of earlier contact and psychopathology to diagnosis received in the military service (29). The results suggest that the nature of the former contact with the clinic was the strongest predictor of subsequent diagnosis , with those receiving a "systematic course" of treatment having the lowest risk of later problems. While this was a wellmatched, very large sample, there was little control for initial diagnostic problems, no characteristics were given of the therapy and therapist, and there was little delineation of the objectiveness of the outcome measures. In another study , "disturbed" foster children (7) were randomly assigned to treatment and nontreatment groups and then compared with an additional well-adjusted foster group . The treated subjects showed a higher degree of improvement. While this study exhibited good matching between the treated and untreated groups for age, IQ, sex, race, and broad diagnostic class; there was no evidence of standardized diagnostic assessment; the sample was an extremely heterogeneous one; there was no characterization 5

BARRNETT ET AL.

of therapy and therapist; and the outcome measures were global and unblind. The last study reporting improvement with psychotherapy examined children about to undergo cardiac catheterization, randomly divided into treated and untreated groups that were seen by the same therapist and given two sessions of mixed psychotherapy before their cardiac catheterization (5). The results indicated that the treated children showed less emotional disturbance during the catheterization by blind assessment and more willingness to return to the hospital afterwards . While this study was of a more sophisticated methodology than the majority of the other studies, the results have little relevance to the application of psychotherapy to clinical samples because of the use of a nonclinical subject group. Studies that found no differences between treated and untreated groups occurred in a sample of disturbed mentally retarded individuals (1) compared with a sample of undisturbed mentally retarded individuals. While this sample was collected by an assessment of trained mental health professionals, the behavioral criteria were vague. There was no description of the therapy characteristics or treaters and no comparison between the treatment and control groups . In another study (34) that found no difference between treated and untreated subjects, a sample of voluntary children attending an outpatient clinic was compared with matched population controls. This study included an extremely heterogeneous sample that excluded severe and involuntary cases and may have selected a good prognosis group. In addition , the treatment was unspecified and the outcome assessments were not blind to initial assessment data, although they were to group assignment. Several studies focused on school children whose results indicated that maladjusted (19), moderately emotionally disturbed (42), and misbehaving (30) school children of poor sociometric status (20) compared with similarly identified untreated individuals did not show any differences between treated and untreated groups. In the first study (30), there was little description of what' 'misbehaving" meant. Treatment was described only as 16 sessions given by school counselors. There was no comparison between treated and untreated groups, and outcome measures were not clearly blind to group assignment. In the second study (40), the group included both withdrawn and disruptive individuals . Again, that is the extent to which the inclusion criteria were described. There is very little description of therapy except the length. The assignment to the different groups was nonrandom, and there was no comparison between the treated and untreated groups. While the outcome measures used blind behavior ratings by teachers' and students' self-ratings, these instruments were not standardized. Another school sample of maladjusted school children given psychotherapy and parent counseling showed no behavioral or academic improvement in comparison with a group receiving information feedback (19). Problems in this study relate to vague inclusion criteria that yielded a very heterogeneous population with no control for learning disabilities that might effect academic outcome. There is a brief description of the frequency and length of the therapy but little description of 6

the nature of the intervention. Parent conduct was not well controlled for as the parents were seen at the therapists discretion. There was no comparison of the equivalence between treated and untreated groups. In the last study (20), low sociometric status, grade-school children were randomly assigned to individual and group therapy versus teacher guidance or no contact groups . The results showed no difference on the effect of sociometric status. Although they were homogeneous in having low sociometric status, the nature of these subjects is uncharacterized. There are no exclusionary criteria, the treatment and therapists were poorly delineated, and there was no comparison between groups for their equivalence. An outpatient sample consisting of consecutive outpatient clinic children with "learning problems due to emotional handicaps" showed no difference in outcome academic achievement scores compared with a sample of treatment dropouts (4). While this study utilized agreement by two psychologists of the diagnosis of "emotional handicap," there was no additional specification for inclusion criteria. There was no specification of the type of frequency or duration of treatment. The control group dropped out after the assessment and thus may have had some treatment. While the subjects were matched for age, race, and socioeconomic status, there was no comparison between the two groups of other variables and no follow-up of whether the dropouts received other or subsequent treatment. The use of the achievement tests as an outcome measure, although standardized, assumes that improvements in the score reflect improved psychological adjustment. An additional outpatient study included secondary school children who were receiving psychotherapy in a mental health clinic compared to those not receiving therapy (8). In this sample, the treated group had no overall decrease in anxiety while the controls did. This study does not delineate the study size, the subjects' ages, the reasons for referral for treatment, or the characteristics of therapy and therapists. The treatment and nontreatment groups were only compared for age and sex. The outcome assessments were not blind. The last study finding treatment and nontreatment conditions similar examined a 30-year follow-up of difficult and average youths who were matched by age, degree of delinquency, family background, and home environment and then randomly assigned them to treated and untreated groups. They showed no demonstrated benefits from the therapy program that lasted for approximately 5 years (21). While the treated subjects felt that they had derived benefit, there were a host of life problems associated with the treatment group, such as illnesses and deaths. This study does not specify the therapy characteristics or therapists. The diagnostic inclusion criteria are vague. Follow-up measures consisted of self-report questionnaires and state records. There was a high rate of nonavailability for follow-up in both the treated and untreated groups. These issues raise questions about the validity of the results. In examining those studies that compared improvement in groups receiving psychotherapy versus those that did not, any summary conclusion is difficult to come to because of the degree of methodological flaws across all of the studies. J. Am. Acad. Child Adolesc. Psychiatry, 30: 1, January 1991


All of the above studies lack clear specification of the nature of the problems of the group included for study. In some cases, these are samples of questionable clinical relevance (5, 9, 14, 19, 30, 33, 42). In others, while it is clear that clinicians were involved in the assessment (1, 4, 34, 42), the lack of clear specification of the characteristics that were assessed would make it impossible to replicate the study. Another limiting factor is that across all of the studies there is little description of the nature and characteristics of the treatment and therapists. While several of the studies used outcome measures that involved a mixture of objective and other assessments that were blind to the assignment to treatment and nontreatment conditions or an appropriate wellmatched control group, these methodological procedures in and of themselves cannot make up for the deficits in other areas. In this area of psychotherapy research with children and adolescents, the authors results indicate that any conclusion must wait until the completion of an appropriately done clinical trial. A total of thirteen studies focused on comparing individual psychotherapy with other types of treatment. Five studies (3,6,25,32,39) found the other form of treatments superior to individual psychotherapy. Eight studies found individual psychotherapy equivalent to the other treatment (2, 18, 20, 23, 24, 26, 40, 43). No studies found individual psychotherapy superior to another treatment. Five studies compared individual psychotherapy with behavioral treatment. Two reports (3, 25) found behavioral treatment superior to individual psychotherapy. One study (3) found that behavioral treatment reduced anxiety in underachievers better than client centered treatment, but there was no difference in academic functioning, and the other (25) concluded that operant conditioning had a significantly better effect than play therapy in improving schizophrenic male children. Although, the first study (3) used random assignment to the two treatment conditions, the study was composed of a nonclinical subject population. There was poor articulation of the treatments involved, no comparison between the two groups of variables that might affect the outcome, and outcome measures were not clearly blind (3). The second study (25) is remarkable for the fact that this is one of the few studies that used clear diagnostic criteria. The 20 subjects were randomly assigned to either analytic play therapy or operant conditions for 50 sessions followed by 50 sessions of the other treatment. Individuals were chosen and matched on a variety of variables, and then each pair was assigned to one therapist and randomly assigned to begin either treatment. The major flaws in this study are that it appears that the outcome measurements were biased in favor of examining the effect of the behavioral treatment, and there is virtually no description of the psychoanalytical play therapy. Lastly, the therapists were described as "aides" with no description of their training. The use of these therapists biases the results in favor of the behavioral treatment. The studies that found behavioral and individual psychotherapy treatments equivalent examined a population of disruptive school children (2) and phobic anxious children (23, 24). The first study (2) is a sample of children referred by teachers for high "out of seat" behaviors. Although ranJ.Am.Acad. Child Adolesc. Psychiatry, 30:1, January 1991

domly assigned to different groups, the diagnostic and inclusion criteria were vague and would not allow replication. There is little description of the individual psychotherapy, no description of the therapists, no comparison between the treatment and control groups, and the teacher rated outcome measures do not appear to be blind to other follow-up assessments. The second two reports are of a follow-up study (23, 24). This study is also remarkable for using more explicit clinically relevant inclusion criteria with respect to the assessment of mono- and polyphobic children. The subjects were randomly assigned to a two by three factorial repeated measures covariate design with two male therapists and three groups consisting of behavioral treatment, psychoanalytical therapy, and waiting list control. Methodologically, the problem areas include a lack of exclusionary criteria, poor description of the nature of therapy, and, although the therapists are described in terms of their level of experience, there is no description of whether or not they had formal and equivalent training in both treatments. Lastly, the control groups are not well matched. While two of the studies comparing behavioral and psychotherapeutic treatments, one indicating the superiority of behavioral treatment (3) and one indicating the equivalence of treatments (23, 24), are of a more sophisticated methodological level than the majority of the studies reviewed, given the overall level of methodological problems, it is not felt that a conclusion can be drawn regarding the comparison of behavioral and individual psychotherapy with these five studies. Three studies have examined comparisons between family and individual psychotherapy. Two of them (6, 32) found family treatments superior to individual therapy. One study (18) found them equivalent. Family treatment was found superior in a sample of school-referred children that were randomly assigned to individual treatment, parent group psychotherapy or combined treatments (6), and in a sample of hospitalized adolescents that were randomly given either individual or family therapy (32). The first study suffers from the fact that it is not clear why the children were being referred and is likely to be a heterogeneous sample (6). There is no characterization of the therapy or therapist and no comparison of the treatment groups for equivalence and the reliance on interpretive data for outcome measurements. The second study (32) did not control for diagnosis leading to a higher number of schizophrenics in the family treated group and a higher number of drug abusers in the individual treated group, which may have biased the outcome. The inclusion criteria, while a homogeneous hospitalized sample, did not indicate that there was any control for chronicity. In addition, there was no description of the treatment approaches. The one study finding family and individual treatments equivalent (18) was again a school-referred sample assigned to individual, family teacher intervention, or no treatment. Again, this study appears to be a nonclinical sample that is vaguely defined with little delineation of the actual treatments involved. There is no comparison of the treatment and control groups, and outcome measures were not clearly made blind to group assignment. As with the case of the

7

BARRNETT ET AL.

comparison between behavioral and individual treatment, the level of methodological errors in the three studies comparing individual and family treatments lead to the conclusion that no adequate comparison between these treatments has as yet been undertaken. The third treatment comparison is one between individual psychotherapy and group therapy . One study (39) found that group treatment was superior to individual psychotherapy . This paper presented a sample of incarcerated female juvenile offenders who were randomly divided into group, individual, and no treatment conditions. This study's results must be questioned because there is no clear diagnostic inclusion criteria and little description of the study sample. There was only a brief description for the group treatment reported with no characterization of the therapists or comparison between the treatment and control groups for equivalence. The outcome measures were not blind to group assignment or the initial assessment. Three studies (26, 40, 43) showed that group therapy and individual therapies were equivalent. A group of mildly disturbed children (26) were first divided into low and high ego functioning groups and then matched for IQ, socioeconomic status, age, sex, color , and degree of behavioral disturbance and then assigned to either group or individual therapy. This study lacked any clear inclusion criteria and did not delineate the therapy . It was not clear from the study that the assignment to the different treatment conditions was done on a random basis, and the measures of ego strength were not standardized . The outcome behavioral rating scale was not completed in a blind fashion. Another school-referred sample of children with withdrawn and disruptive behaviors (40) were nonrandomly assigned to group or individual and combined treatments, and no difference was found between the treatment conditions. This was again a heterogeneous group with little characterization. There was no discussion of treatment or the therapists and no comparison between the control groups. The third study (43) consisted of fourth grade underachievers randomly assigned to individual or group therapy, reading instruction, "Hawthorn effect, " and no contact groups, and no difference was found in grade point average or in the California test of personality at outcome . Again, this is a heterogeneous nonclinical population with poor delineation of the therapy. No comparison was made between the different groups with the exception of matching for age. In examining the studies comparing group and individual psychotherapy, because of the level of methodological flaw, no conclusion can be reached regarding their comparison because of the lack of methodologically adequate studies. Three studies have examined therapist variables. One study, previously described (9) , suggested that the degree of withdrawn children's improvement was related to the therapist's role of performance. The conclusions of this study have been criticized above. A second study (17) found that the degree of counselor/patient similarity influenced the outcome of therapy. This report consisted of a sample of delinquent inmates. Again , this study did not exhibit any clear inclusion criteria, and there was no description of the treaters or therapy. The subjects were assigned to compar-

8

ison groups in four different ways, and assessments were not clearly blind to the treatment conditions. A study of "mildly" disturbed outpatients (41), who were divided into groups based upon the therapists ' characteristics on measures of accurate empathy, nonpossessive warmth, and how genuine they were, found that improvement in psychotherapy as rated by the parents and the therapist was associated with a high degree of accurate empathy , nonpossessive warmth, and the degree of genuineness of the therapist but not of the blind outcome raters . This study again was comprised of an uncharacterized heterogeneous group, with little delineation of the therapy characteristics. There was no comparison of the contrasting groups, and the sample sizes were very small. A total of four reports have examined therapy variables other than differences in responses to various types of treatment described above. Two reports (11, 12) focus on the same study, a small sample of children, with learning problems linked to psychological disturbances, who received different frequencies of therapy, and improvement was found in the group receiving more frequent therapy. This study population was poorly characterized. The characteristics of the therapy were only described as analytically oriented and only delineated in terms of the frequency of contact. Outcome assessments appeared to use nonstandardized interviews and intelligence, achievement, and projective psychological testing. There was no measure of reliability for the interpretative tests. Another study (31) examined a 1year follow-up of individuals randomly assigned to either brief versus long-term therapy in an outpatient clinic and were reevaluated at 3, 6, and 12 months by a variety of objective measures and global clinical judgment by the therapists, parents, and teachers. The results indicated that there was a higher percentage of success in treatment with the long-term treatment group . This study however had a very heterogeneous population with no control for the child 's underlying problem. The type of treatment was poorly characterized and the degree of parental involvement was not controlled for. The therapists consisted of a variety of different clinicians with varying degrees of training, all of whom were described as eclectic. The last study in this group was of elementary school children (42) and is also described above. It indicated that an increased amount of time spent with the therapist was related to a higher change in self-esteem. This study is also criticized above. A variety of studies have focused on patient variables related to therapy . A group of child outpatients were divided into therapy continuers versus therapy completers and compared on a variety of MMPI scores suggesting that poor prospects for therapy are adolescents with marked rebellion toward authority (13). This study is a retrospective study . The subjects were included based upon whether or not there were pretreatment MMPI scores. There was no characterization of the study group, the therapy or therapist characteristics, and no comparison of the continuers versus completers, which leads to questions regarding the validity of the results of the study. A second retrospective study (15) of consecutive outpatient adolescents was divided into improved and unimproved treatment completers and treatment J.Am.Acad. Child Adolesc. Psychiatry, 30:1, January 1991

CHILD PSYCHOTHERAPY RESEARCH TABLE

4. Methodological Areas of Flaws in Psychotherapy Studies

Area of Methodology Poor inclusion or exclusion criteria Unspecified details of therapy, therapists Poor matching or control groups Poor measurements or outcome assessments

dropouts and suggested that treatment completers were less disorganized and impulsive than treatment dropouts, and improvements in therapy were related to "alloplastic" adaptation. Problems with this study again center on the fact that it is an extremely heterogeneous sample with no description of the therapy and therapists. There is no comparison of the equivalence among the three groups. The assessments relied upon a measurement of global outcome determined by a parent-assessed behavioral checklist. This checklist was then factor analyzed, and then discriminate function analysis was applied to the factor analysis. It is not clear from the study that the sample size was large enough to warrant this kind of multivariate statistical approach. A third retrospective study (16) of a heterogeneous sample of outpatients, who were divided into six different groups, suggested that improvement in the child was related to improvement in the mother. This study again used an unspecified inclusion criteria with unspecified therapy and therapist characteristics. There was no comparison of similarity between the different groups, and the outcome assessments were made unblind by the therapist. A fourth (22) study examined students who were in counseling and their need for approval. It divided the subjects into a group of high versus low need for approval and found that individuals with a high need for approval rated counselors and therapy more positively. The results of this study can be criticized because of the lack of diagnostic inclusion criteria, unspecified therapy and therapist characteristics, a lack of comparison between the groups, and reliance entirely on self-report measures. A last report (10) of mildly mentally retarded (MR) children were matched on "as many variables as possible" and divided into two groups, one receiving therapy and the other not. The authors concluded that MR children respond to psychotherapy in a similar way as standard outpatient clinic samples. This subject group included many different other diagnoses besides MR that were subjected to wide differences in treatment length. The treatment and therapists were not clearly described. The treatment group received additional remedial help, and outcome measures were unblind and global. A last study discussed above (17) suggested that a patient's level of adjustment influences the outcome of therapy. This study was previously criticized above. An overview of those studies examining therapist, therapy, and patient variables yields the same ambiguity because of the lack of adequate adherence to basic methodological standards. No firm conclusions can be drawn about any of the variables in any of these three areas. To summarize the evaluation of this literature, the cateJ.Am.Acad. Child Adolesc. Psychiatry, 30:1 ,January 1991


Total

1-22,26-43

40/43 40/43

1-4, 6-8, 10-18, 20-43 1-4, 6-20, 22-24, 26, 30-33, 35-43 1-4,6-8,10-13,15-19,21,25,26, 29, 30, 32, 39, 42, 43

36/43 25/43

gories of methodological problems have been separated into four areas: (1) poor inclusion or exclusion criteria; (2) lack of specification of the characteristics of the therapy and/or therapists; (3) poor control groups, or a lack of matching in assigning patients to control groups for variables that might affect outcome, or lack of comparison between control and treatment groups; and (4) errors in the measurement process using unreliable or invalid measures, where the raters were not blind to treatment assignments, or outcome measures were done in a nonstandardized way. Table 4 presents a boxscore review of the methodological problem areas of each study reviewed, organized into the four areas outlined in the above paragraph. One area where the majority of the studies failed to meet methodological criteria was in the specification of treatment. Forty out of the 43 (93%) studies failed to clearly specify the nature or type of intervention, who was making the intervention, how they were trained, and failed to monitor the progress of the intervention. In defense of the majority of the papers reviewed, they were undertaken at a time before the implementation of this research technique. Delineating the characteristics of the therapy by including a therapeutic manual and using therapists of a high level of motivation who are trained to a competent level of treatment delivery and then monitored throughout the period that treatment is delivered represent one of the major advances to the psychotherapeutic research field (Docherty et al., 1989). Often the description of therapy and therapists was limited to just a phrase or word indicating an orientation of the therapist such as "Rogerian," "client centered," or "psychoanalytic." In studies comparing individual psychotherapy with other forms of treatment, there was often a more detailed description of the other treatment than of the individual therapy (3). In defense of several of the studies, they were not truly designed to examine issues related to psychotherapy and were retrospective or follow-up studies of child outpatient treatment (8, 13, 16, 29). These studies were included in the current sample because they met the authors' original criteria, and they presumably did reflect something about child individual therapy. In other studies, it is not even clear that the intervention is equivalent to psychotherapy and may actually represent case management activity (7). Three studies in the current sample give more detailed descriptions of the therapist and therapies (5, 9, 19). However, only one incorporates some kind of supervision or check on the way therapy is delivered (9). In Study 19, there is no check on the treatment delivery. In Study 9, in spite of the training, it is not clear that the confound between the efficacy of the therapist and the efficacy of

9

BARRNETI ET AL.

therapy is eliminated . For example , if both competent and incompetent therapists are included together , it is entirely possible to make the wrong conclusion about the efficacy of the treatment. Overall, therapists in many of the 43 reports were of mixed background and training. Lastly, Study 5 was a study of one therapist. An overview of the area of delineating the therapy and therapists indicates that there are essential problems throughout all of these studies in the operationalization and standardization of treatments . The research does not reflect what in fact happens in clinical practice, namely, that the therapies are picked with a hypothesis of the underlying problem, the process of recovery, and the nature of psychotherapy. Unfortunately, much research has reflected the naive assumption that something generically called psychotherapy, applied in a nonspecific manner, will in a diffuse and unspecified fashion exert a beneficial effect onjust about any child with any particular problem. An equally large area of methodological lapse was in delineating inclusion and exclusion criteria. Again, 40 out of the 43 (93%) studies included poorly defined problem areas or subjects, leading to questions about which type of children were actually being treated for what problems. Only three studies clearly delineated objective criteria for inclusion in the study (23, 24, 25), and of these only one (25) specified the objective nature of these criteria . The lack of standardized diagnostic criteria was not the only issue that was neglected. Often there were no exclusionary criteria, so that the sample would be free from individuals who might have underlying conditions that would contaminate their response to individual psychotherapy . Another one of the major problems with this literature was the inclusion of nonclinical samples that were the focus of psychotherapeutic study. A total of 12 studies (2,3 ,5 ,9,14,17 ,20,30,33 , 40, 42, 43) are made up of nonclinical samples, and thus, even if these studies were well controlled in other ways, it is not clear how relevant the results might be toward the clinical practice of psychotherapy. Even when a homogeneous group was picked, as in the case of examining behavioral problems usually referred to as juvenile delinquency or antisocial behaviors (18, 19,27 ,28 ,35-39) , the characteristics of these children are not well delineated . While some of the individuals in these studies clearly have met a social criterion of requiring incarceration, it is not clear that: (I) they met any psychopathological diagnostic criteria , or (2) that they are not indeed a very heterogeneous diagnostic group in addition to having the specified behavioral problems that led to their incarceration . By the lack of delineation of clear inclusion and exclusion criteria, even if the remainder of the study was methodologically well done, the study would not be able to be replicated because the same clinical population could not be found. Thirty-six of the 43 (83%) studies had problems in the procedures used for developing control groups or matching the control and treatment groups . Twenty-two of the reports (5 1%) examined did use the procedure of randomly assigning subjects to different groups (2,3,5,6, 14,20,21,23-25,27,28,30-33,35-38,42, 43). While there was more reasonable adherence to this 10

TABLE

5. Number of Areas of Methodological Flaws per Study

Number of Areas of Methodological Raw per Study


4

1-4 , 6--8, 10-13, 15-19, 26, 30, 32, 42, 43

3

14,20-22,29,31,33,40,41

9/43

2

9,23-25 ,27 ,28 , 34-38

11143

I

5

1/43

Total

22/43

basic methodological standard, there was rarely any comparison between the groups that were randomized to assess whether or not they appeared to be equivalent in terms of some of the basic features that can influence the outcome of treatment such as age, sex, IQ, socioeconomic status, etc. Researchers cannot assume that random assignment alone overcomes any problem or bias with the subject population selection process. In addition, basic reporting of the details of the subject population was a major problem throughout this whole sample. For example, two studies did not report the size of the subject groups (8, 18) and as outlined in Table 3, 10 studies did not even report the subjects' ages. Twenty-five out of the 43 (58%) studies demonstrated problems in the areas of the measurement process or the measures used for outcomes. Using adequate measurements was an area that showed a higher level of sophistication in comparison with the other areas. More of the studies used a combination of what appeared to be objective rating measures in combination with clinical judgments . However, few of the studies used any standardized instruments that had been subjected to some kind of reliability and validity. In some studies that compared psychotherapy with other treatments, there was a failure to demonstrate or control for experimenter bias in the measurement process . Study 25 can be criticized on this basis; it appears to be biased against play therapy in favor of behavioral treatment. The second problem in this methodological area is the fact that the outcomes or what was measured for outcome appear to be ambiguously related to the initial disorder. Several studies in the current sample examined school achievement in response to psychotherapy. For example, Studies 4 and 43 used school achievement as a measurement of outcome . Relying entirely on this as an outcome measure assumes that school achievement is equivalent to either psychological health or response to treatment , and that there are no other underlying problems that might mitigate against academic improvement. Additionally, children can improve academically but not necessarily show an improvement in grade particularly in the acquisition of basic skills. A third problem was that a variety of studies (2, 7, 8, 9, 26, 39) clearly have unblind outcome assessments , and many others do not clearly state if outcome measures were blind. Lastly, other studies (7 , 10, 16) relied only on global clinical judgments for outcome . To view the summary results in another way, Table 5 presents the summary box score of the studies clustered by J . Am . Acad. Child Adolesc. Psychiatry , 30 :1, January 1991


the frequency of errors in each one of these four methodological areas: 22 of the 43 (51%) studies had a flaw in each one of the four areas; nine of the 43 (20%) studies had a flaw in three of the four areas; 11 of the forty-three (25%) studies had a flaw in two of the four areas; and only one (2%) study had a flaw in one of the four areas. There were no studies that were not flawed in these basic and critical methodological areas. This review has attempted to examine the literature of child and adolescent psychotherapy in the light of recent advances in the area of adult psychotherapy research (Williams and Spitzer, 1984; Docherty, 1989) to enhance the scientific creditability for this treatment beyond what existed in the 60s and 70s. An overview of psychotherapy could have used one or more of the general review techniques; the anecdotal method, the box-score method, or metanalysis. The anecdotal method was eliminated because of the field's preoccupation with and difficulty in delineating scientific rigor. Metanalysis for this sample is inappropriate because it would yield misleading conclusions. It is clear that the methodology of the entire sample does not support the accumulation of summary statistics or conclusions because there is an insufficient body of well-done studies. This is true even of attempting to answer the question, "Does child psychotherapy work?" There is also currently not a large enough body of studies to use metanalysis to examine a more focused question. Thus, the authors are left with the box-score technique to review them. The box-score summary of the areas of methodological flaws in the controlled studies of child psychotherapy since 1963 show that there are a high number of methodological errors in the studies sampled leading to questions regarding the validity of the results. This is true for conclusions drawn in support of child and adolescent psychotherapy or against it. The major conclusion drawn from this review is that many questions regarding child and adolescent psychotherapy including efficacy remain largely untested according to contemporary methodological standards. In defense of these researchers, it is quite clear that many of the studies were done in the 1960s and 1970s. During this time, what is now considered methodologically sound was not in regular practice. Thus, many of these studies met the standards of their day. However, these results clearly point to a major deficit in the knowledge base of child and adolescent psychotherapy, which is not demonstrable in other areas of child and adolescent psychosocial treatment, such as behavioral treatment or cognitive-behavioral therapies (Ollendick and Clerny, 1981; O'Leary and Carr, 1982; Harris, 1983; Ollendick, 1986). In each of these, more attention has been paid to appropriately conducted treatment trials that have led to a rather large knowledge base, such that issues relevant to patient, therapy, or outcome variables have all been addressed, although there are still significant limitations in this area (Ollendick, 1986). Traditional psychotherapy has the potential to improve upon these limitations. There have been a number of alarms regarding the dramatic increase in various child and adolescent problems, such as drug abuse, suicide, eating disorders, and concerns J.Am.Acad. Child Ado/esc. Psychiatry, 30:1, January 1991

regarding the increasing use of adolescent hospitalization. If we, as a discipline, are to fulfill our responsibility to address these concerns, then the entire field needs to be mobilized. Current third party reimbursement for psychotherapy lags far behind interventions of other types of illness. In part, this appears to have been initiated by earlier inappropriate conclusions (that psychotherapy is ineffective) based upon poorly done studies. Clearly, third party reimbursement is motivated to contain costs, and the entire field of psychiatry is coming under examination by independent reviewers. Thus, the field must demonstrate support for its intervention in order to justify the expansion of available treatment. Advocates of child psychotherapy must overcome the neglect of the repeated calls for adherence to basic methodological standards. The hope is that psychotherapists will not place themselves in a position where patients and third party reimbursers will "just say no" to psychotherapy. Yet, this study agrees with previous authors who have suggested that the assessment of whether or not psychotherapy works is an inappropriate question. It is akin to asking, "Does surgery work?" Attention must be paid to what treatment is appropriate for what patients with what problems. At this juncture, there is a critical need in the area of child psychotherapy for the development of well-delineated, measurable, and differentiable models of treatment that will lend themselves to basic and comparative study. In adult psychotherapy, examples of such models of individual psychotherapy for depression include Klerman et al. (1984) and Beck et al. (1979). It is recommended that for children above the age of puberty, the mode of treatment would involve interpersonal, talking, reflective types of individual psychotherapies. For children below the age of puberty, interactive play or activity types of individual psychotherapies need to be developed. The second critical area to be addressed within the development of appropriate models of child psychotherapeutic treatment is the operationalizing and standardization of specific treatments. This has been an issue that has plagued psychotherapy research generally. Recent developments in the study of adult psychotherapy have reduced these concerns (Docherty, 1989a). The development of specific manuals that outline interventions in detail have allowed standardization of treatments across clinicians and settings. Videotaping of treatment has allowed objective measurement by independent raters of the success in operationalizing and implementing these treatments. The use of experienced, motivated, and adequately trained therapists has allowed for the reduction of therapist bias in comparative treatments. Lastly, these strategies also allow a much higher order conceptual model to be implemented and examined. Instead of mindless application, the interventions can be conducted by a therapist who understands his treatment and can be implemented on a moment-to-moment basis following welldescribed guidelines. Over the last 15 years, there has been a major advance in the research study of psychotherapy with adults. This advance has been present in many areas and has generated a revolutionary restructuring of the methodology of clinical 11

BARRNETI ET AL.

trials of psychotherapy . This development has caused a high level of enthusiasm and morale, which is unprecedented in psychotherapy research, and permitted the field to conduct the first cross-national collaborative study comparing the effectiveness of various therapies for the treatment of depression (Elkin et al., 1989). These developments in the methodology for the conduct of clinical trials have allowed the establishment of the efficacy of a number of distinct psychotherapies for major disorders. For the treatment of depression , at least five therapies now have a documented base efficacy: interpersonal psychotherapy, cognitive behavior therapy, psychoeducational therapy, social skills treatment, and self-control therapy (Docherty, 1989b). Similarly, efficacy has been established for several approaches to the psychotherapeutic amelioration of conditions predisposing to relapse of schizophrenia (McGlashan , 1986). Some of the most impressive work, however, has been in the recent advances in anxiety disorders. Through the use of purely psychosocial treatments addressing three distinct aspects of anxiety disorderbehavior, cognition, and physiological arousal-in excess of 90% of patients can be made free of panic attacks without the need for concomitant medications (Michelson, 1984; Barlow, 1988). In addition to these specific advances in the efficacy of psychotherapy, there has been the development of an extensive body of literature documenting the general effectiveness of combined treatment with medication for depression and schizophrenia (Conte et al., 1986; Hogarty et al., 1988), the specific efficacy of psychosocial treatment for preventing social functioning morbidity in depression , and medication for preventing the relapse of neurovegetative symptoms. Interesting findings are also emerging regarding the indications and contraindications for psychosocial or pharmacological treatments . Such work includes the finding that learned resourcefulness predicts differential response to cognitive behavior therapy or antidepressant medication in depressed patients. Patients high in learned resourcefulness do better with psychotherapy. Those low in learned resourcefulness do better with the pharmacotherapy. (Simmons et al., 1985) In the area of the psychodynamic therapies, much has been learned regarding the central importance of the therapeutic alliance for the outcome of this form of treatment. A range of measures has been developed to assess this construct from various perspectives (Marziali, 1984), and the study of this phenomenon has been extended to sicker patients. Frank's work has demonstrated, for example, that the therapeutic alliance remains a potent predictor of outcome, even with schizophrenic patients. Importantly, her work demonstrated that it may take 3 to 6 months for a good alliance to develop with such disturbed patients (Frank and Gunderson, 1990). In addition to the continued demonstration of the relationship of the therapeutic alliance to good outcome in psychodynamic therapy , the significance of this phenomenon has been extended to an understanding of good outcome in pharmacotherapy. Both compliance and outcome of pharmacotherapeutic treatments appear partially dependent upon the development of a positive therapeutic

12

alliance (Docherty and Fiester, 1985). Psychodynamic process research has also begun to yield some understanding regarding the core structures that are addressed by psychodynamic therapy. Useful methods have been developed for reliably ascertaining and assessing these structures. Such work has included Hartvig Dahl's development of the " frame" concept (Dahl, 1988), Luborsky's development of the "core conflictual relationship theme" method (Luborsky , 1984), and Horowitz's development of the "consensual response" method (Horowitz et al. , 1989). These and many other developments speak to the great strength and health of this field of research . Unfortunately, similar work or concepts have yet to be applied to the study of children. In closing this review article of child and adolescent psychotherapy, the authors wish to stress that from their perspective , developing a knowledge base and refining models of treatment is a continual process. What might seem appropriate in one era may become inadequate or even irrelevant in the next. The authors do not feel they are "flogging a dead horse," but attempting to bring the field up to current developments in adult psychotherapy. Like any other event , whether the release of acetylcholine at neuromuscular junctions, the response of killer T cells to viral infections, or the development of infant monkeys deprived of their mothers, psychotherapy is studiable, and a methodology exists to examine it. Child psychotherapy research is a ripe area for investigation, and the methodology of adult psychotherapy research can be readily applied. Any such study will represent a major contribution. What then is the status of the literature in child psychotherapy? These data do not allow a hardnosed scientific conclusion . It would be inappropriate to conclude as Levitt did that child psychotherapy is ineffective . The authors' impression is that there are multiple decades of the clinical evidence of the usefulness of child psychotherapy and several decades of developing attempts to establish scientific legitimacy. It is now up to the field to establish itself with the standards of current methodology. Appendix I. Albini, J. L. & Dinitz, S. (1965), Psychotherapy with disturbed and defective children: an evaluation of changes in behavior and attitudes. Am . J . of Ment. Defic . 69:560-567 . 2. Alper, T. G. & Kranzler, G. D. (1970), A comparison of the effectiveness of behavioral and client-centered approaches for the behavior problems of elementary school children . Elementary School Guidance and Counseling, 5:35-43 . 3. Andrews, W. R. (1971), Behavioral and client centered counseling of high school underachievers . Journal of Counseling Psychology, 18:93-96. 4. Ashcraft, C. W. (1971), The later school achievement of treated and untreated emotionally handicapped children. Journal of School Psychology , 9:338-342 . 5. Cassell, S. (1965), Effect of brier-puppet therapy upon the emotional responses of children undergoing cardiac surgery . Journal of Consulting Psychology, 29:1-8 . 6. D'Angelo R. & Walsh, J. (1967), An evaluation of various therapy approaches with lower socioeconomic group children . J . Psychol . 67:59-Q4. 7. De Fries, Z., Jenkins, S. & Williams, E.C . (1964) , Treatment of disturbed children in foster care. Am . J . Orthopsychiatry , 34:615624.

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8. Endler, N. & North, C. (1973), Changes in adolescents' selfreport anxiety during psychotherapy. Psychotherapy: Theory, Research and Practice. 10:251- 252. 9. Guerney, B. G. & Fluemen, A. B. (1970), Teachers as psychotherapeutic agents for withdrawn children. Journal ofSchool Psychology, 8:107- 112. 10. Hayes, M. (1977), The responsiveness of mentally retarded children to psychotherapy. Smith College Studies in Social Work, 47:112-153. II. Heinicke, C. H. (1965), Frequency of psychotherapeutic session as a factor affecting the child's developmental status. Psychoanal. Study Child , 20:42-98. 12. - - - - (1969), Frequency of psychotherapeutic session as a factor affecting outcome. J. Abnorm. Psychol. , 74:553-560. 13. Horton, M. & Rornvaldas, K. (1970), Minnesota Multiphasic Personality Inventory differences between terminators and continuers in youth counseling. Journal of Counseling Psychology, 17:98-101. 14. Kranzler, G. D., Mayer, G. R. , Dyer, C. O. & Munger, P. F. (1966), Counseling with elementary school children: an experimental study. Personnel and Guidance Journal, 44:944-949 . 15. Lessing, E. E. , Black, M., Barbarera, L. & Seibert, F. (1976), Dimensions of adolescent psychopathology and their prognostic significance to treatment outcome. Genet. Psychiatry Monog. , 93:155-168. 16. Lessing, P. & Schilling, F. H. (1966), Relationship between treatment selection variables and treatment outcome in a child guidance clinic: an application of data processing methods. J . Am . Acad . Child Adolesc. Psychiatry , 5:313-348 . 17. Levinston, R. B. & Kitchen, H. L. (1966), Treatment of delinquents: comparison offour methods for assigning inmates to counselors. Journal of Consulting Psychology , 30:364. 18. Lewis, M. (1970), The effects of counseling and consultation upon the sociometric status and personal and social adjustment of third grade pupils. Elementary School Guidance and Counseling. 5:44-52. 19. Love, L. R. , Kaswan, J. & Bugental, D. T. (1972), Differential effectiveness of three clinical interventions for different socioeconomic groupings. J . Consult. Clin. Psychol., 39:347-360 . 20. Mayer, G. R., Kranzler, G. D. & Mathhes, W. A. (1967), Elementary school counseling and peer relations. Personnel and Guidance Journal , 46:360-365. 21. McCord, J . (1978), A thirty-year follow-up of treatment effects. American Psychology, 33:284-289. 22. McNally, H. & Drummond, R. (1973), Clients need for social approval and perceptions of counseling relationship and outcomes. Psychol. Rep.; 32:363-366 . 23. Miller, L. C., Barrett, C. L. , Hampe, E. & Noble, H. (1972), Comparison of reciprocal inhibition, psychotherapy and waiting list control for phobic children. J . Abnorm. Psychol., 79:269279. 24. Hampe, E. , Noble, H., Miller, L. C. & Barrett, C. L. (1973), Phobic children one and two years post treatment. J. Abnorm. Psychol. , 82:446-453. 25. Ney, P. G., Palversky, A. E. & Markely, J. (1971), The relative effectiveness of operant conditioning and play therapy in childhood schizophrenia. J . Autism Child Schizophr. , 1:337- 349. 26. Novick, J. L (1965), Comparison between short-term and group and individual psychotherapy in effecting changes in non-desirable beha vior in children. Journal of Group Psychology, 15:366-373 . 27. Persons, R. (1966), Psychological and behavioral change in delinquents following psychotherapy. J. Clin. Psychol., 22:337340. 28. Persons, R. (1966), Relationship between psychotherapy with institutionalized delinquent boys and subsequent community adjustment. Journal of Consulting Psychology, 31:137-141. 29. Piha, J. (1988), Psychosocial coping in young adulthood of male child psychiatric outpatients: implications of early treatment. Am . J . Orthopsychiatry, 58:524-31. 30. Quarter, J. J . & Laxer, R. M. (1970), A structured program of teaching and counseling for conduct problem students in a junior high school. Journal of Educational Research, 63:229-231. J.Am .Acad. Child Adolesc .Psychiatry , 30 :1.January 1991

31. Rosenthal, A. J. & Levine, S. V. (1970), Brief psychotherapy with children: a preliminary report . Am . J. Psychiatry , 127:646651. 32. Ro-Trock, G. K. , Wellisch, D. & Schoolar, J. (1977), A family therapy outcome study in an inpatient setting. Am. J . Orthopsychiatry , 47:514-5 22. 33. Seeman, J. , Barry, E. & Ellinwood, C. (1964), Interpersonal assessment of play therapy outcome. Psychother. Theory Res. Pract., 1:64-66. 34. Shepherd, M. , Oppenheim, A. N. & Mitchell, S. (1966), Childhood behavior disorders and the child guidance clinic: an epidemiological study. J. Child Psychol, Psychiatry, 7:39-5 2. 35. Shore, M. F. & Massimo, J. L. (1966), Comprehensive vocationally oriented psychotherapy for adolescent delinquent boys. Am . J . Orthopsychiatry, 36:609-6 15. 36. Shore, M. & Massimo, J. (1969), Five years later: a follow-up study of comprehensive vocationally oriented psychotherapy . Am . J. Orthopsychiatry, 39:769-773. 37. Shore, M. & Massimo, J. (1973), After teen years: a follow-up study of psychotherapy. Am . J . Orthopsychiatry, 43:128-132. 38. Massimo, J. & Shore, M. (1963), The effectiveness of a comprehensive vocationally oriented psychotherapeutic program for adolescent delinquent boys. Am. J . Orthopsychiatry , 33:634-642. 39. Taylor, A. (1967), An evaluation of group psychotherapy in a girls' borstal. Int. J . Group Psychother. 17:168-177 . 40. Tolor, A. (1971), Effectiveness of various therapeutic approaches: a study of subprofessional therapists . International Journal of Group Psychiatry Therapy, 20:48-62 . 41. Traux, C. B., Altman, H., Wright, L. & Mitchel, K. M. (1973), The effects of therapeutic conditions in child therapy . Journal of Community Psychology, 1:313-31 8. 42. Vander Kolk, C. J. (1973), Paraprofessionals as psychotherapeutic agents with moderately disturbed children. Psychology in the Schools, 10:238-242. 43. Winkler, R. C., Teigland , J. J., Munger, P. F. & Kranzler, G. D. (1965), The effects of selected counseling and remedial techniques on underachievers elementary school students . Journal of Counseling Psychology , 12:384-387 .

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Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch . Gen. Psychiatry , 46:971-984 . Eysenck, H. J. (1978), An exercise in megasilliness . Am . Psychol ., 33:517. Frank, A. F. & Gunderson, J. G. (1990), The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and outcome. Arch. Gen. Psychiatry, 47:228-236. Harris, S. L. (1983), Behavior therapy with children. In: The Clinical Psychology Handbook . eds . M. Hansen, A. E. Kajdin, & A. S. Bellark. Elmsford, NY: Pergamon . Heinicke , C. M. & Strassman, L. H. (1975), Toward more effective research on child psychotherapy, J. Am . Acad. ChildAdolesc. Psychiatry, 14:561-588 . Hersen, M. & Barlow, D. H. (1976) , Single Case Experimental Designs: Strategies for Studying Behavior Change . New York: Pergamon. Hogarty, G. E., McEvoy , J. P., Munetz, M. D. et aJ. (1988) , Dose of fluphenazine , familial expressed emotion , and outcome in schizophrenia . Arch. Gen. Psychiatry , 45:797-805 . Horowitz, L. M ., Rosenberg, S. E. , Ureno, G. , Kalehzan, B. M . & O'Halloran, P. (1989) , Psychodynamic formulation, consensual response method , and interpersonal problems. J . Consult . Clin . Psychol., 57:599-606. Klerman, G. F., Weissman, M. M., Ronsaville-Chevron, B. & Chevrones, J. (1984), Interpersonal Psychotherapy of Depression. New York: Basic Books. Levitt, E. E. (1957), The results of psychotherapy with children : an evaluation . Journal of Consulting Psychology , 21:186-189. - - (1963) , Psychotherapy with children : a further evaluation . Behav. Res. Ther. 60:326-329 . - - (1971) , Research on Psychotherapy with children . In: Handbook of Psychotherapy and Behavior Change , eds . A. E. Bergin & S. Garfield. New York: Wiley, pp. 474-493. Luborsky, L. (1984), An example of the core conflictual relationship theme method-its scoring and research supports. In: Principles of Psychoanalytic Psychotherapy: A Manualfor Supportive-Expressive Treatment , New York: Basic Books . pp. 199-228. Marziali, E. (1984), Three viewpoints on the therapeutic alliance: similarities, differences, and associations with psychotherapy out-

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From Early Issues of the Journal This lack of fruitful communicationbetween "clinician" and "researcher" has handicapped many serious efforts to examine the clinical process by means of rigorous research designs and obscured the potential contribution of the clinical process as part of an experimental research model. JAACP, Vol. 2, No. I January, 1963

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l .Am.Acad. Child Adolesc. Psychiatry, 30:1 .January 1991

Urinary tuberculosis: a review of 44 cases treated since 1963.

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Empirical and clinical focus of child and adolescent psychotherapy research.

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Conversion from child psychotherapy to child analysis.

The Epidemiology of Traumatic Brain Injury in Children and Youths: A Review of Research Since 1990.

Language behaviour and child psychotherapy.

Psychotherapy of a child in a custody dispute.

Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research.

Medical research in the Sudan since 1903.

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[Interpersonal psychotherapy from research to practice].

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