Does psychotherapy help some students? An overview of psychotherapy outcome research

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1 1 ARTICLE: Does psychotherapy help some students? An overview of psychotherapy outcome research Professional School Counseling, June, 2006 by Kelly C. Eder, Susan C. Whiston This article provides a brief overview of the outcome research on psychotherapy with children and adolescents. Outcome research indicates that psychotherapy can be effective with both children and adolescents, with meta-analyses indicating that youth who participated in this type of intervention tended to score on the outcome measures half of a standard deviation or more above those who did not receive any intervention. Little is known about the process of psychotherapy with children, but there are some indications that the therapeutic relationship is important. Moreover, there is some research that supports the assumption that certain types of treatment are most helpful with specific clinical issues. In the ASCA National Model[R] proposed by the American School Counselor Association (2005a), school counselors have the responsibility for promoting the academic, career, and personal/social development of all students. This includes students who are experiencing difficulties and those who may meet diagnostic criteria for a psychiatric disorder. Furthermore, policy initiatives at national and state levels, such as the No Child Left Behind Act of 2001 (2002), are requiring that all children succeed academically; however, this may be difficult for children who are experiencing emotional problems. The number of students experiencing difficulties does not appear to be trivial. For example, the National Institute of Child Health and Human Development (2005) recently reported that an estimated 2.7 million children are noted by their parents to suffer from noticeable or severe emotional or behavioral problems that may interfere with their family life, their ability to learn, and their abilities to make friends.

2 2 Kazdin and Johnson (1994) noted that prevalence studies indicate that between 17% and 22% of youth under 18 years of age suffer developmental, emotional, or behavioral problems. Costello et al. (1996) had similar findings that 20.3% of children between the ages of 9 and 13 met the criteria for mental disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). This is also consistent with Doll's (1996) findings that a typical school can expect to find between 18% and 22% of students with diagnosable psychiatric disorders, most frequently anxiety disorders, conduct disorder, oppositional defiant disorder, and attention deficit disorder. In secondary school populations, Doll also found that depression and suicidal behaviors were prevalent. Schools and, subsequently, school counselors may be in a strategic position to provide services to children and adolescents in need. The child or adolescent's relations to peers, problem behaviors, prosocial functioning, and academic performance can be observed and assessed within the school. This allows professionals in the school to identify when an intervention is needed and to evaluate whether an intervention is having an impact (Kazdin & Johnson, 1994). Additionally, the school setting has a broader reach as nearly all children are required to attend school. Thus, schools have direct access to nearly all children and adolescents and have the potential to reach more children than clinic settings where parents must seek out and take the child or adolescent for treatment. Thus, by default, schools become the only avenue for some students to receive the mental health services they need (Hoagwood & Erwin, 1997). The intent of this article is to review the research related to psychotherapy with children and adolescents to determine if these types of services or interventions are helpful to students who are experiencing moderate to severe emotional or behavioral difficulties. In addition, this article is designed to review psychotherapy research with the goal of informing school counselors about aspects of psychotherapy that may assist them in either

3 3 referring students for appropriate treatment or providing services within a school setting. OVERALL EFFECTIVENESS OF CHILD AND ADOLESCENT PSYCHOTHERAPY In considering the needs of students with emotional, behavioral, and developmental disorders, the first issue is what can be done to assist these students. For many of these students, it does appear that psychotherapy can be quite effective and helpful. In metaanalytic studies, researchers seek to statistically combine results from different studies in order to analyze across studies the effectiveness of certain interventions. For each study, an effect size is typically calculated by subtracting the mean of the control group from the mean of the treatment group and dividing by the pooled standard deviation, which results in a numerical index of whether the individuals receiving the intervention did better or worse on the outcome measure than those who did not receive the intervention during the time of the study. These effect sizes then are combined and often weighted related to sample size and error variance, which produces an overall effect size for the intervention. There are different ways to interpret effect sizes, such as noting whether they are significantly different from 0 and using Cohen's (1988) classification system. Although many factors need to be considered when examining the magnitude of an average effect size, Cohen hesitantly defined effect sizes as small when d =.20, medium when d =.50, and large when d =.80. Casey and Berman (1985) conducted one of the first meta-analyses to examine the effectiveness of psychotherapy with children and adolescents. Although there are different definitions of psychotherapy, this study included various forms of psychotherapy with the most prevalent being behavioral therapy. The age range of children was between 3 and 15 years old and the studies included a wide range of clinical problems. The average effect size for the 75 studies was.71, which indicates that, on average, the treatment or intervention groups scored almost three-quarters of a standard deviation above the

4 4 control groups on various outcome measures. Some of the more common measures used in these early studies were social adjustment, global adjustment, achievement, and cognitive skills. Weisz, Weiss, Alicke, and Klotz (1987) conducted a second major meta-analysis in which they defined psychotherapy as "any intervention designed to alleviate psychological distress, reduce maladaptive behavior, or enhance adaptive behavior through counseling, structured or unstructured interaction, a training program, or a predetermined treatment plan" (p. 543). This metaanalysis identified 108 well-designed studies that were conducted with 4- to 18-year-olds. In addition, they included treatments conducted by nontrained professionals (e.g., parents and teachers) and included clients with a broad range of psychological and social problems. Their average effect size was quite similar to that of Casey and Berman (1985) and was.79. Weisz, Weiss, Han, Granger, and Morton (1995) revisited the effects of psychotherapy with children and adolescents and used more sophisticated statistical techniques to analyze studies published between 1967 and The unweighted mean effect size (.71) was similar to that of the two previous meta-analyses; however, with the use of a procedure recommended by Hedges and Olkin (1985) that considers sample size and variance, the mean effect size was.54. Therefore, even with this more conservative procedure, children and adolescents who received some form of psychotherapy scored on average a little more than a half of a standard deviation above the control group. A meta-analysis of school-based studies of psychotherapy was conducted by Prout and DeMartino (1986). They limited their metaanalysis to psychotherapy studies conducted in a school or addressing school-related problems, with the broad definition of psychotherapy that included the informed and planful application of techniques derived from established psychological principles by persons qualified through training

5 5 and experience to understand these principles and to apply these techniques with the intention of assisting individuals to modify such personal characteristics as feelings, values, attitudes and behaviors which are judged by the therapist to be maladaptive or maladjustive. (Prout & DeMartino, pp ) Unlike the previous meta-analyses, Prout and DeMartino's (1986) school-based analysis examined the effect sizes of psychotherapy on achievement as well as on other outcomes such as behavior ratings, cognitive skills/ability, problem-solving, and self-concept. They also focused only on interventions conducted by trained professionals. They found that interventions in schools had an overall average effect size of.58, with effect sizes of.68 for grade point average,.58 on behavior ratings, 1.25 on observed behaviors,.66 on cognitive abilities, and.94 on problem-solving outcomes. These effect sizes are very encouraging. They suggest that school counseling interventions are moderately effective overall with students who participate in the interventions, and they have a substantial impact on observed behaviors and problem-solving. This Prout and DeMartino study included 33 studies published from 1962 to 1982, and Prout and Prout (1998) later expanded on this study and analyzed 17 additional school-based psychotherapy studies published between 1985 and They found an overall effect size of.97; however, this result should be taken with some caution because it is based on a relatively small number of studies. Stage and Quiroz (1997) also conducted a meta-analysis of schoolbased interventions and analyzed the effectiveness of interventions designed to decrease disruptive classroom behaviors. Based on 99 studies, they found that these interventions had an effect size of In this case, a negative effect size indicates the interventions were quite effective as disruptive behaviors declined when students received treatment.

6 6 In qualitative reviews Of research related to psychotherapy with children and adolescents, Kazdin (2003, 2004) supported the overall effectiveness of therapeutic interventions with children and adolescents. Kazdin (2003) argued that there is strong evidence for the efficacy of certain treatments for certain issues. This conclusion raises important issues related to which individuals benefit from which types of psychotherapy and, furthermore, which types of treatments may be applicable in school environments. CLIENT FACTORS Demographic Factors and Outcome A significant amount of the psychotherapy outcome research with children and adolescents has focused on client factors such as age, grade, and gender. Casey and Berman (1985) did not find differences in effect sizes for treatments based on age, intellectual functioning, or school grade. Other research findings related to age and grade level, however, are more equivocal. Although there is some speculation that psychotherapy is more effective with older children, Weisz et al. (1987) found the opposite, with studies on treatments involving children (ages 4 to 12 years) having an effect size of.92, which was significantly larger than the mean effect size of.58 for the studies of treatments involving adolescents (13 to 18 years). Conversely, Weisz et al. (1995) found the reverse related to outcome and age. Using a statistical weighting procedure, they found a larger mean effect size for adolescents (.65) than for studies treating children 11 years and younger (.48). The same conflicting findings regarding at what age psychotherapy with children is most effective also are found when the psychotherapy is conducted in school settings. Prout and DeMartino (1986) concluded that psychotherapy interventions in schools were slightly more helpful to adolescents or those at the secondary level compared to elementary. However, using a smaller number of studies, Prout and Prout (1998) found a larger effect size (1.31) for elementary students and a somewhat smaller one (.73) for

7 7 secondary school-age students. On the other hand, in the metaanalysis on interventions to decrease disruptive classroom behavior in public education settings, Stage and Quiroz (1997) did not find a significant difference in effect sizes between grade levels. Another focus of psychotherapy outcome research is whether there are gender differences, with some researchers speculating that girls are more likely to have positive outcomes. Weisz et al. (1987) did not find significant differences in effect sizes based on gender composition of the treatment groups, even though the groups that were predominately female tended to have slightly larger effect sizes than those groups that were predominately male. Casey and Berman (1985) also found that effect sizes tended to be smaller when the sample was predominately males. In Weisz et al.'s (1995) meta-analysis, the researchers did find a significant gender main effect, with the mean effect size for females being.71 as compared to.41 for the predominately male sampies. This gender difference remained significant even after controlling for type of problem. Client Problems Kazdin (1991) described two broad categorical areas: overcontrolled and undercontrolled problems. Overcontrolled problems refer to "inward-directed child disturbances, such as anxiety, depression, and social withdrawal. Internalizing behaviors is another term used for this category" (Kazdin, p. 788). Undercontrolled problems refer to "outward-directed child behaviors, such as hyperactivity, tantrums, aggression, and antisocial behavior" (p. 788). Acting out and externalizing behaviors are other terms often used for this category of undercontrolled problems. Weisz et al. (1987) found that psychotherapy was equally effective with children and adolescents with no difference in outcome between those with overcontrolled or undercontrolled problems. Casey and Berman (1985) examined the effects of psychotherapy with children according to the reported target problems and found psychotherapy to be highly effective related to issues of impulsivity/hyperactivity, phobias, and somatic problems and somewhat less effective with

8 8 social adjustment issues. In terms of client problems, Kazdin (2004) argued that psychotherapy with children and adolescents should not be considered as a uniform set of procedures as there are more than 550 types of psychotherapy, and given that children have a range of psychological issues and dysfunctions, specific psychotherapeutic approaches may be more effective with certain problem types. COUNSELOR FACTORS In psychotherapy research with adults, there is a history of examining whether training and experience have an effect on outcome (Lambert, Bergin, & Garfield, 2004), and, although the results vary, the general trend is that training and experience tend not to have a significant impact on positive outcome (Beutler et al., 2004). However, with younger clients as compared to adults, researchers have identified some interesting trends. For example, Weisz et al. (1987) found that trained professionals were for the most part equally effective with all different age groups, but graduate students and paraprofessionals were more effective with younger clients and less effective with adolescents. In terms of overcontrolled and undercontrolled problems, with overcontrolled problems the level of therapist training appeared to make a difference, with a finding that as the amount of formal training increased, so did the effectiveness of the psychotherapy. This relationship between training and outcome, however, was not evident with children with undercontrolled problems (Weisz et al.). In their later study, Weisz et al. (1995) found somewhat more complex findings regarding the interactions among problem type, child age, and therapist training. For overcontrolled youth, professionals and students achieved higher effect sizes than did paraprofessionals. Paraprofessionals, however, were more effective than professionals and students were with undercontrolled youth. Thus, with children and adolescents, training does appear at times to play a complex role in terms of the effectiveness of psychotherapy. What may be pertinent here are ethical standards

9 9 and the need for counselor practitioners to practice within their competencies (American Counseling Association, 2005; ASCA, 2004). Hence, only counselors and others who have adequate training to provide psychotherapy to children and adolescents with specific problems should do so. TREATMENT FACTORS Modality For school counselors, there often are issues of time management that may include decisions on whether to see a student individually or in a group. Although it was not a statistically significant difference, Weisz et al. (1987) found a somewhat larger effect size for individual therapy than for group therapy, with effect sizes of 1.04 and.62, respectively. This difference further dissipated in the later meta-analysis, in which Weisz et al. (1995) found only a slightly higher mean effect size for individually conducted treatments (.63) than for group treatments (.50). Unlike the metaanalyses on child and adolescent therapy in various settings, Prout and DeMartino (1986) found that in schools, group treatments were more effective than individual interventions, with effect sizes of.63 and.39, respectively. In addition, Prout and Prout's (1998) findings suggested that in school research, group modalities have been the primary focus of research, with 20 of the 25 studies involving group interventions. Interestingly, Prout and Prout found an effect size for group interventions of.95; however, they also found a small number of studies that involved a combination of group and individual interventions that produced a quite large effect size of Theoretical Orientation In terms of general psychotherapeutic approach, Casey and Berman (1985) found in their meta-analyses that behavioral therapies led to greater effect sizes (.91) than nonbehavioral therapies (.40). One of the aspects to consider with this finding, however, is that

10 10 differences appeared to be restricted to certain types of outcome measures. Behavioral therapies were more likely to be evaluated by outcome measures that were very similar to activities that occurred during treatment. When differences in types of outcome were controlled in Casey and Berman, many of the advantages of behavioral therapies dissipated. Others have argued that the relative effectiveness of behavioral versus nonbehavioral child psychotherapy is due to the methodological quality of studies that examine the different treatment types; however, Weiss and Weisz (1995) conducted a meta-analysis to address this claim and their results found little support for this hypothesis. Furthermore, Weisz et al. (1987) found that behavioral techniques resulted in better outcomes for clients than nonbehavioral techniques even when secondary or unnecessary outcomes were removed. Weisz et al. (1987) also examined treatment subtypes and found no significant difference between behavioral subtypes (e.g., operant, modeling) and nonbehavioral subtypes (e.g., psychodynamic, clientcentered). In addition, these researchers found that the efficacy of behavioral approaches applied across problem types and with different age groups. Weisz et al. (1995) found, by using more sophisticated meta-analytic weighting techniques, that behavioral therapies were more effective with children and adolescents than were nonbehavioral therapies. Similar to the findings in the meta-analyses on child and adolescent psychotherapy in general, the school-based meta-analysis by Prout and DeMartino (1986) found that behavioral interventions produced stronger effects than did other approaches. Specifically within the behavioral interventions category, they found that the cognitive/rational interventions were particularly effective. Prout and Prout (1998), however, delineated treatment type slightly differently and grouped the treatment types into cognitivebehavioral, relaxation, and skills training. Using these categories, they found cognitive-behavioral interventions to have the largest effect size across all outcome variables. Hoagwood and Erwin

11 11 (1997) also found support for cognitive-behavioral approaches with students in their examination of the effectiveness of mental health services provided in schools. Process Factors The term process in the psychotherapy research often denotes specific happenings or events that occur in therapy and can include specific actions, experiences, or the degree of relatedness (Orlinsky, Roonestad, & Willutzki, 2004). In adult psychotherapy research, the relationship between the client and the counselor has been found to be particularly important and one of the best predictors of positive outcome (Horvath, 2001; Norcross, 2001; Sexton & Whiston, 1994). Oetzel and Scherer (2003) contended that considerably less is known about the process of psychotherapy with children and adolescents; however, they found that the therapeutic relationship between the therapist and child or adolescent is critical to positive change. They further argued that establishing a therapeutic alliance is often more difficult with younger clients than adults because of the stigma attached with psychotherapy and that children are often forced, as compared to volunteering, to attend psychotherapy. Kazdin (2004) stressed that psychotherapy has clear benefits for many children and adolescents, but there needs to be additional research that will clearly explain precisely the processes and mechanisms of that positive change. EVIDENCE-BASED PRACTICE Although there are some other general conclusions that psychotherapy has applicability to many problems that youth experience, numerous researchers and practitioners have argued the most critical issue is what treatment works with which clients (Evans & Seligman, 2005; Kazdin, 2003). As Kazdin indicated, there are hundreds of available psychotherapeutic approaches for children and adolescents, and not all of these are equally effective with different types of problems. It is important to keep in mind that meta-analytic reviews usually devise superordinate classes to group

12 12 techniques (e.g., behavior therapy, family therapy), and these reflect broad orientations to treatment and not specific techniques (Kazdin & Johnson, 1994). Findings of meta-analyses indicate there are effective interventions for children with mental health problems, but they do not always indicate the specific type of interventions that were analyzed. Lonigan, Elbert, and Johnson (1998) tenaciously argued that the identification of specific interventions for specific problems and diagnoses is required to best serve children in need of mental health services. Although there are differing definitions and some debate about what constitutes empirically based or empirically supported interventions (American Psychological Association, 2005; Wampold, Lichtenberg, & Waehler, 2002), we are not going to enter that debate, but we will provide some suggestions related to empirically based interventions that school counselors can explore further. Concerning children and adolescent anxiety, fear, and phobias, Kazdin (2003, 2004) contended there is sufficient evidence to support systematic desensitization, modeling, reinforced practice, and cognitive behavior therapy. King, Muris, and Ollendick (2005) and Ollendick and King (1998) contended that in vivo/imaginal desensitization, modeling, and contingency management have substantial empirical support in the treatment of childhood phobias. They also asserted that, although there is less research related to cognitive-behavioral treatments as compared to behavioral interventions, there is support for the efficacy of cognitivebehavioral strategies with problems related to anxiety, fear, and phobias. Readers interested in a manual for cognitive-behavioral treatment for children with anxiety disorders that has been empirically investigated should see Kendall (2000). There is also support for cognitive-behavioral therapy for the treatment of youth with depressive symptoms or subsyndromal depression (Asarnow, Jaycox, & Tompson, 2001). A cognitivebehavioral-based intervention for depression is the Adolescent Coping with Depression Course (CWD-A), which has been examined

13 13 in four randomized trials studies with positive results. The applicability of this treatment may vary depending on the school setting as this treatment includes 16 2-hour sessions over a period of 8 weeks. It should be noted, however, that Evans and Seligman (2005) found very little empirical evidence related to the treatment of serious depression in preadolescents. Sexton, Alexander, and Mease (2004) found substantial support for some specific types of family therapies (i.e., functional family therapy and multi-systemic therapy) for youth with oppositional defiant disorder and conduct disorder. Kazdin (2004) also cited the effectiveness of parent management training related to treatment for oppositional and conduct disorders. Parent management training also has been found to be helpful with attention deficit hyperactivity disorder (Pelham, Wheeler, & Chronis, 1998). There are hundreds of studies related to the effectiveness of family therapies, but the literature is extensive and will not be addressed in this review as our focus is primarily on psychotherapy. In their review of mental health services provided in schools, Hoagwood and Erwin (1997) found very few studies that examined which treatments assisted children with specific psychiatric problems. They further argued for the need for closer attention to school-based mental health services, packaging those techniques that are most effective in schools for replication, and making better connections between school-based services and promising community treatments. CONCLUSIONS Related to the mental health of children, the U.S. Department of Health and Human Services (1999) determined to promote costeffective, proactive systems of behavioral support at the school level, which should include systems of behavioral support that emphasize prevention while including selective individual student supports for those who have more intense and long-term needs. This effort seems laudatory as the National Institute of Mental

14 14 Health (NIMH, 1999) found that 1 in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment, yet fewer than 1 in 5 of these children receive treatment. NIMH concluded that without treatment, schoolwork may suffer, normal family and peer relationships may be disrupted, and violent acts may occur. Some may suggest that schools are the best place to reach the 80% of students who need mental health assistance but are not receiving it. The issue then becomes who in schools has the responsibility for mental health services. In a recent survey of school personnel, Romer and McIntosh (2005) asked 1,402 schools for the individual most knowledgeable of the mental health services of the school, and 49.1% of the time they spoke with a school counselor. Other times these researchers were directed to the school psychologist (25.7%), school social worker (11.2%), school nurse or nurse practitioner (3.0%), special educator (2.9%), principal or assistant principal (2.8%), special services or student services director (2.3%), teacher (0.3%), or other (2.8%). Hence, it is clear that many schools see school counselors as having the most knowledge of and responsibilities for mental health services in a school; yet, providing these services seems practically impossible with caseloads averaging in this country around 481 students to 1 school counselor (ASCA, 2005b). From this review, it appears that there are many children and adolescents who might benefit from psychotherapeutic interventions, yet many of them are currently not receiving those services that are supported empirically. In conclusion, this review reflects that psychotherapy can be very effective for many children and adolescents, but these youth need the opportunities to receive these types of treatment in order be assisted.

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