What Works for Whom?, First Edition: A Critical Review of Treatments for Children and Adolescents / Edition 1 available in Paperback
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- Guilford Publications, Inc.
This comprehensive book evaluates the evidence for the full range of widely used child and adolescent mental health treatments, providing vital knowledge to inform clinical decision making. Organized around major presenting problems, the book synthesizes findings from hundreds of carefully selected studies on both psychosocial and pharmacological approaches. Each chapter introduces the clinical problem at hand, systematically reviews the available outcome research, and spells out recommendations for evidence-based practice. Written by experienced researchers and practitioners, the volume emphasizes the importance of tailoring all interventions to the needs of the individual child.
|Publisher:||Guilford Publications, Inc.|
|Edition description:||First Edition|
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About the Author
Peter Fonagy, PhD, FBA, is Freud Memorial Professor of Psychoanalysis and Director of the Sub-department of Clinical Health Psychology at University College London, UK. He is also Director of the Child and Family Center at the Menninger Foundation, Kansas, and Director of Research at the Anna Freud Centre, London.
Mary Target, PhD, is a Senior Lecturer in the Sub-department of Clinical Health Psychology at University College London, and Deputy Director of Research at the Anna Freud Centre.
David Cottrell, MA, FRCPsych, holds the Foundation Chair in Child and Adolescent Psychiatry at the University of Leeds, UK, where he is also Director of Learning and Teaching at the School of Medicine and Associate Professor of Psychology.
Jeannette Phillips, MB, BS, MRCP(UK) MRCPsych, MRCPCH, is a consultant psychiatrist in Dartford and Gravesham, UK, where she and her team are working to rebuild a community service.
Zarrina Kurtz, MB, BS, MSc FRCP, FRCPCH, FFPHM, is an independent consultant in public health and health policy. In recent years, she has focused on the development and implementation of policy and service evaluation in child and adolescent mental health.
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What Works for Whom?A Critical Review of Treatments for Children and Adolescents
By Peter Fonagy Mary Target David Cottrell Jeannette Phillips Zarrina Kurtz
The Guilford PressCopyright © 2002 The Guilford Press
All right reserved.
Chapter OneIntroduction and Review of Outcome Methodology
The Importance of Outcome Measurement
EVIDENCE-BASED MEDICINE AND ITS JUSTIFICATIONS
Evidence-based medicine is founded on an ideal-that decisions about care of individual patients should involve the conscientious, explicit, and judicious use of current best evidence. The arguments in favor of this approach are that (1) it makes more effective use of resources, (2) it enhances the clinician's knowledge, (3) it improves communication with patients, and (4) it allows the best-evaluated methods of health care to be identified and enables patients and doctors to make better-informed decisions. All these are good reasons, but all were as relevant to medicine in the past as at present. So why the current emphasis?
The real driving force behind evidence-based medicine is unlikely to be solely concern for the quality of care but rather economic considerations and the hope that health care organizations may be able to reduce escalating costs by focusing on the most cost-effective option, given a range of treatments.
The health economist Martin Knapp(1997) provided a helpful overview of both latent and manifest factors that have impacted on young people's mental health services over recent years, leading to an increased emphasis on the demonstration of the cost-effectiveness of the mental health care provided. The latent demands all entail scarcity of resources of some kind and may be summarized as follows:
1. The growing prevalence of most types of childhood disorder, including depression, suicide, alcohol abuse, drug dependency, and juvenile crime.
2. The gap between need and the capacity of the delivery systems (Kurtz, Thornes, & Wolkind, 1994).
3. Cultural, social, and economic changes, adding up to heightened strain experienced by families (Diekstra, 1995).
4. Changed social and family expectations, placing more importance on the mental health of youth (Parry-Jones, 1995).
5. Market forces and pressures, with payers demanding better value for their money (Fuller, 1995).
These latent demands have become manifest as explicit requests in a number of contexts. These were usefully summarized by Knapp: (1) The demand by purchasers to know that they are obtaining the best treatment for the price (Yates, 1994); (2) the sharp increase in the cost of mental heath care falling to employers and other payers arising out of perverse incentives (supplier-induced demand or indulgence of users' wishes) (Bickman et al., 1996); (3) the establishment of quasi-markets in the United Kingdom and the emergence of managed care (health maintenance organizations) in the United States (Subotsky, 1992); (4) the wish to develop policies that limit the damaging consequences of the fragmentation of children's mental health services (Hoagwood & Rupp, 1995; Jaffa, 1995); (5) the wish to evaluate new treatments, care settings, or new ways of organizing delivery (Kazdin, in press-a); and (6) the wish to justify and promote the purchase of new pharmaceutical treatment products (Freemantle & Maynard, 1994).
The upshot of these demands has been general acceptance of greater accountability of professionals to the funders and purchasers of health care. The emphasis on outcomes is a direct consequence of this shift in power. Pressures associated with reimbursement, managed care, and fiscal stringency in general, exercise a powerful influence on clinical practice and practice guidelines. Governments and health funders are attracted to the notion of allocating health resources on the basis of evidence.
SOME PHILOSOPHICAL CONCERNS ABOUT EVIDENCE-BASED MEDICINE
Evidence-based medicine is a practical example of "consequentionalism," that is, the proposition that the worth of an action may be assessed by the measurement of its consequences. There are several problems with the consequentionalist argument, most significant of which is the difficulty of measuring outcomes.
Many important outcomes of any medical treatment are not quantifiable. Evidence-based medicine claims to provide a simple, logical process for reasoning and decision making: (1) systematic scrutiny of the available evidence, (2) drawing appropriate conclusions leading to (3) a clinical decision as to the appropriateness of a treatment. Within this framework, for any decision to be balanced, all relevant consequences of a treatment must be considered. Unfortunately, given the current methods for child psychiatric measurement, many important outcomes can only be indirectly or inadequately measured. Child psychiatry concerns complex internal states in developing individuals, such as the degree of distress or pain experienced by a child. Often these complex states are reduced to simpler, easily quantifiable, subjective reports, such as experiences related to depression (Kovacs, 1985), anxiety (Papay & Spielberger, 1986), or total symptomatology (Achenbach, 1991a). If such measures are used without sophistication, they may become reified, causing researchers or users of research to conflate the measure with the phenomenon it aimed to quantify. Thus, the Children's Depression Inventory (CDI) score is not childhood depression and the total internalizing score of the Child Behavior Checklist (CBCL) is not equivalent to psychological distress. Similarly, the Parenting Stress Index (Abidin, 1997) does not capture in its entirety the guilt-ridden family's struggle to cope with an oppositional child. Exclusive reliance on these measurements may fail to do justice to the complex cognitive, affective, and physiological processes implicated by these terms.
Better measures will be developed for many of the domains of outcomes entailed in the treatment of child mental health problems, but other aspects, such as a "dignified childhood," a "sense of purpose," or "ethical childcare," are probably inherently unmeasurable. Even more troublesome are key domains that are not even well defined, let alone measurable. One such is the often cited "quality of life." Many attempts have been made to provide a metric for this in the adult physical and mental health literature (e.g., Dijkers, 1999), yet in the absence of a general consensus as to what a reasonable quality of life might entail for an adult, let alone a child, it is hard to imagine how meaningful measurement is possible.
There is a clear danger that a therapy "without substantial evidence" will be thought by all to be "without substantial value" (Evidence Based Care Resource Group, 1994). Once this idea is allowed to flourish, a cultural change becomes inevitable, which at least temporarily has the power to stop funded research and the development of potentially valuable approaches. It would be regrettable if uncritical reading of the evidence base were to lead to a series of self-fulfilling prophecies.
As we have said, the driving force of the recent upsurge of interest in outcomes assessment is more likely to be the motivation to impose social and political controls on the professional practitioner rather than simply to bring about improvements in patient care. Yet this is not to say that insistence on treatment programs "of known effectiveness" is an adverse outcome of social and structural changes in the field of mental health. There have been major shortcomings in systems of care delivery that can be clearly linked to the absence of adequate interest in research findings. The hospitalization of children may have been driven more by the perverse incentives for providers than by the known benefits of inpatient care. Most pediatric psychopharmacological treatments have not been thoroughly evaluated, and many are still not FDA-approved for use with children (Spencer, Wilens, & Biederman, 1995[vi]). Many treatments in common use are, in all probability, not efficacious. It is an illusion that clinical experience can tell us what is effective. Historians of medicine could give dramatic counter examples of ineffective and even iatrogenic treatments that were warmly embraced by the profession (such as insulin coma therapy or the use of the centrifuge in the treatment of schizophrenia); this, unfortunately, is not just an issue of yesteryear. Ethically and professionally, it is essential to eradicate treatments that are likely to waste scarce resources.
Most would agree that, notwithstanding genuine scientific and clinical considerations, the interactions between social anxieties and professional concerns, public demand, and clinical opinion will determine whether certain interventions continue to be offered. For example, interventions for substance misuse and self-harm are not particularly effective (Committee on Child Health Financing and Committee on Substance Abuse, 1995), yet their elimination would create an intolerable clinical gap and potentially undermine the possibility of discovering new interventions and effective management strategies. We shall return to the key issue of the dialectic between petrification consequent upon rigid implementation of evidence-based practice, and a free-for-all where outcome information is generally ignored.
WHAT IS "OUTCOME"?, OR WHOSE OUTCOME IS IT ANYWAY?
The Complexity of Outcome Measurement
Child mental health outcomes cannot be considered in absolute terms, yet a range of fundamental questions that have practical implications are rarely asked. For example, when is the preservation of a family unit a positive outcome, or, rather, for whom is that outcome positive-the child, the parents, the clinician, or the purchaser who would be required to fund alternative care? What if the outcomes diverge-if what is optimal for the child is less favorable to other members of the family or to the service provider? We should be aware of the adage: "In many instances the most cost-effective intervention is to do nothing."
A possible practical problem arising out of this conceptual issue is the frequent low level of agreement between informants about the child's symptomatology or adaptation. Even at the level of symptoms, teachers, mothers, and fathers appear to share little more than 10% of variance concerning the child's internalizing symptoms (Achenbach, 1995). It cannot be assumed that parents' perceptions will accurately reflect the child's feelings and needs. A mother's mental health is a good predictor of the accuracy of her perception of the degree of her child's disability, even when this is of a physical nature (Jessop, Reissman, & Stein, 1988). Strikingly, children's views concerning their own treatment are rarely taken into serious consideration (House of Commons Health Committee, 1997), and indeed very little is known about children's understanding of mental health (Chesson, Harding, Hart, & O'Loughlin, 1997). Our understanding of this issue is increasing (Harris, 1989), but very little of this new knowledge has found its way into the treatment evaluation literature.
Psychotherapy researchers are particularly conscious of the danger of imposing ethnically rooted cultural biases on the definitions of "needing treatment" or a "good outcome" (Bernal, Bonilla, & Bellido, 1995). For instance, the achievement of selfhood through the separation-individuation process (Mahler, 1971) is one of the cornerstones of psychodynamic psychotherapeutic interventions, and yet is Lasch (1978) not correct that the emphasis on individual achievement in Western culture is excessive, and that an appropriate submission to the goals of the family and community may be a better indicator of healthy adaptation? Such considerations are particularly pertinent to the area of parenting practices, where legitimacy for harsh, even cruel disciplinary methods is sometimes eloquently claimed on the basis of cultural specificity. Rogler (1989) outlined some of the practical steps that culturally sensitive outcome research requires. In particular, interventions ought to be consonant with the subjective culture of the ethnic group to which they are applied, and the instruments used should be able to integrate cultural meanings with the pertinent scientific categories.
A further consideration complicating the issue of outcomes for childhood interventions is the developmental framework that now dominates child psychiatry and psychology (Cicchetti & Toth, 1995). Developmental psychopathology implies that symptoms cannot be considered the sole, or even the most important, criterion of treatment effectiveness. If psychiatric disorder is not just the end result of a series of interactions of biological, social, and psychological characteristics across time, but is itself part of a complex transactional causal chain, good outcome might sometimes be an increase rather than a decrease in symptomatology. We raise these issues to draw the reader's attention to a major limitation of this volume and other similar attempts at integrating information concerning treatment efficacy. Evidence is not absolute. Inevitably, its significance is determined by the cultural context that demanded it and gives it meaning. The results reported in this review should be considered within this relativist framework.
Levels of Outcome Measurement
A further complexity of outcome measurement concerns the range of domains that may be considered pertinent to the evaluation of specific programs. Distinguishing these domains is obviously a heuristic exercise. In this book, we broadly follow a classification proposed by Hoagwood and Jensen (Hoagwood, Jensen, Petti, & Burns, 1996) and Kazdin and Kendall (Kazdin & Kendall, 1998), differentiating five levels of outcome:
The Symptomatic or Diagnostic Level
A child is referred to treatment because of dysfunction in a specific domain. Both researchers and clinicians are most likely to focus on the child's presenting problem and target complaints. In most studies symptom reduction is the primary criterion for a good outcome (Kazdin, 2000c). Current measurement of child mental health outcomes is most sophisticated at this level. Both categorical (Angold & Costello, 1995) and dimensional checklist-based (Achenbach, 1991a) assessments may be achieved reliably with relative ease. The computerization of such assessments will overcome many remaining practical problems. Outcome studies frequently use a range of symptom measures; they vary in length, ease of administration, and quality of standardization. The best-validated checklist measure, by some margin, is the CBCL (Achenbach, Howell, McConaughy, & Stanger, 1995a; Achenbach, Howell, McConaughy, & Stanger, 1995b; Achenbach, Howell, McConaughy, & Stanger, 1995c), which has parent, teacher, and self rating forms.
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Table of Contents
I. Introduction and Review of Outcome Methodology: The Importance of Outcome Measurement
3. Anxiety Disorders
4. Depressive Disorders
5. Disturbance of Conduct
6. Attention-Deficit/Hyperactivity Disorder
7. Tourette's Disorder
8. Psychotic Disorders
9. Pervasive Developmental Disorders
10. Self-Harming Disorders
11. Children with Physical Symptoms
12. Specific Developmental Disorders
13. Conclusions and Implications
Appendices: 1. Glossary of Psychopharmacological Treatments. 2. Search Terms
Researchers, practitioners, and students in child clinical psychology, child and adolescent psychiatry, and clinical social work. Also of interest to health care administrators and planners. Serves as a text in graduate-level courses in child and adolescent psychotherapy research and practice.