+Evidence Based Psychosocial Treatments for Children and Adolescents: A Ten Year Update

Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders

Emily Haygeman11.15.2009

US Office of Education 84.325KH325K080308

Journal of Clinical Child & Adolescent Psychology, 37(1), 1–7, 2008

+ Evidence Based Practice in Psychology

The Second Special Issue on Evidence-Based Psychosocial Treatments for Children and Adolescents:

A 10-Year Update Wendy K. Silverman and Stephen P. Hinshaw

+ Background

1998 First special issue focused on “empirically supported treatments.”

Primary task: to examine the evidence for the efficacy of psychosocial interventions to be used with children and adolescents

5 articles reviewed the evidence for interventions for : Autism, Depression, Phobic and Anxiety Disorders, Disruptive Behavior Disorders (ODD and CD), and ADHD

The issue became widely used and cited, suggesting a growing interest in interventions that are supported by research

+Current Considerations

Urgent issues remain in the field Especially relevant to this article is the gap between

research and practice This means the gap between what we know works and

what clinicians actually do in practice One goal of the current article is to narrow this gap

+

This issue has the following functions: To contribute to scholarship in the area of clinical child

and adolescent treatment To educate It should be “descriptive and evaluative rather than

prescriptive.” In short, to “present a scholarly treatise of the current

status of the psychosocial treatment research literature with respect to empirical evidence for efficacy.”

The Second Issue: Functions

+ Functions cont’d

Should inform the audience (clinicians, parents, teachers) of

1. The treatments that have been reviewed and scrutinized, and

2. Which treatments have been found to possess a “greater level of evidence relative to other treatments.”

All articles were peer reviewed, and additionally reviewed by an anonymous evaluator, changes were made when necessary and then submitted for reevaluation

+ Limits The treatment studies reviewed varied greatly by

domain of coverage (for example, a SSD would be appropriate for an autism or ADHD case but would not make sense to use with anxiety or disruptive disorders which have a larger base rate)

Contributors were given room to decide individually which interventions to evaluate in their respective areas (this can be both positive and negative)

Evidence was contextualized in one area Can contributors be “unbiased” in the evidence they

present? Conclusions confined to what is currently being most

used and researched in the field (ie cognitive-behavioral therapy)

+ Reader Considerations

Always critically evaluate, even when something is labeled “evidence-based”

This Issue can serve as a starting point, but always include other criteria (such as APA Presidential Task Force on EBP) when making a final decision re: treatment methods

+ “Evidence based” vs “Empirically supported” or “Empirically validated”

“Evidence based” is now preferred over “empirically supported” (1998) and “empirically validated” (1995)

“Evidence” is a word that is easily understood by nonpsychologists (health care administrators, policymakers, teachers, parents), and therefore can reach and benefit a wider range of people involved in the treatment of children and adolescents

+ Specific Disorders Reviewed in the Second Issue Autism Depression Phobic and Anxiety Disorders Disruptive Disorders (ODD and CD) ADHD Also includes: OCD (now recognized as distinct from

other anxiety disorders), eating disorders and substance abuse disorders, and trauma and related reactions and symptoms

Also an article on the efficacy of psychosocial treatments specifically with minority youth

+ Contributors Included:

Narrative evaluative summaries (sample size, age ethnicity, sex, recruitment procedures, inclusion/exclusion criteria, outcome measures, therapist characteristics and specific treatment procedures)

Efficacy vs effectiveness Generalizability Mediators and Moderators

+ Efficacy vs Effectiveness

Efficacy: Whether a treatment has been found to work by means of

experimental procedures such as random assignment, control groups, and manualized protocols

Effectiveness: Whether a treatment has been found to provide benefit in

settings/conditions in which treatment will actually be administered (mental health, private practice, etc.)

+Mediation and Moderation

Mediation: How therapeutic change is produced

Moderation: For whom or under what conditions this change occurs

An understanding of what needs to be changed and for whom allows the clinician to be able to adapt to variations

By studying the mechanisms of treatment we can improve clinical practice and patient care

+ Criteria for Classifying Evidence-Based Psychosocial Treatments Criteria 1: Well-Established Treatments 1.1 Must be at least 2 good group-design

experiments, conducted in at least 2 independent research settings and by independent investigatory teams, demonstrating efficacy 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

+ Criteria cont’d

AND 1.2 Treatment manuals or logical equivalent were used

for treatment 1.3 conducted with a population, treated for specific

problems, for which inclusion criteria have been delineated in a reliable, valid manner

1.4 reliable and valid outcome assessment measures, at minimum tapping the problems targeted for change were used, and

1.5 appropriate data analyses

+ Criteria cont’d: Criteria 2

Criteria 2: Probably Efficacious Treatments 2.1 There must be at least two good experiments

showing the treatment is superior (statistically significantly so) to a wait-list control group OR

2.2 One or more good experiments meeting the Well-Established Treatment Criteria with the one exception of having been conducted in at least two independent research settings and by independent teams

+ Criteria cont’d: Criteria 3 and 4

Criteria 3: Possibly Efficacious Treatments At least one “good” study showing the treatment to be

efficacious in the absence of conflicting evidence

Criteria 4: Experimental Treatments Treatment not yet tested in trials meeting task force

criteria for methodology

+ Strength of Treatment Effects

Authors could combine the effect sizes across studies using meta-analyses or could calculate the effect size for each study individually

Effect size is a uniform metric However, such metrics have a limited qualitative value

+ Six Types of Treatment Studies Type 1: most rigorous, involve randomized, prospective

clinical trial methodology; have comparison groups with random assignment, blind assessments, clear presentation of inclusion and exclusion criteria, state-of-the-art diagnostic methods, adequate sample size and clearly described statistical methods.

Type 2: Clinical trials testing an intervention, but one aspect of Type 1 is missing, or there is a clear but “not necessarily fatal” flaw (such as no follow-up)

Type 3: Methodologically limited. Open trials aimed at obtaining pilot data. Subject to bias but do indicate whether the study would be worth pursuing more in depth

Type 4: Reviews with secondary data analyses (such as meta-analyses)

Type 5: Review without secondary data analyses Type 6: Case studies, essays, and opinion papers

+ These Treatment Studies…

The majority were Type 1, 2, and 3 Type 6 lacks rigor and Type 4 and 5 were excluded

because the contributors themselves were writing those types of reports

+ Concluding Comments

Much progress has been made in this area in the past decade

Considerable work remains Hopefully this issue will begin to bridge the gap

between research and practice These articles call for more research that is more

sophisticated, rigorous and statistically powerful