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Randomised, unblinded, controlled trial with up to 3 years of follow up.
6 elementary and middle public schools with socioeconomically disadvantaged children in Nashville, Tennessee, USA.
160 children (mean age 10 y, 63% boys, 55% African-American) with psychopathology and their families (54% single mother, 23% two biological parents, mean number of children in home 2.7). On the basis of the Teacher Report Form (TRF), children had scores in the borderline clinical range for the following domains: anxiety, depression, or both (41%); aggression (65%); attention problems or hyperactivity (60%); delinquency (57%); somatic problems (25%); and being withdrawn (47%). These children were not, however, clinically referred. 86% of children were included in ≥1 of the previously listed domains and 60% were included in ≥2 domains. Follow up was 83%.
Children were allocated to child oriented psychotherapy (n=76) or academic tutoring (n=84). Psychotherapy was given for up to 2 years by 1 of 7 therapists who selected which treatments and modalities to use; the mean number of sessions was 60 for individual therapy, 4 for group therapy, 13 for school personnel consultations, 1 for psychiatric consultation, and 18 for parent sessions. Children in the control group received a mean of 53 tutoring sessions that were 45 minutes in duration. Children were treated in their schools.
Main outcome measures
The main outcome measure was a variant of the Target Problems Scale (TPS), which used parent, teacher, peer, and self reports. Child psychopathology was also assessed by other parent report measures (Child Behavior Checklist and Brief Symptom Inventory); teacher report measures (TRF and Teacher Behavior Questionnaire); peer report measures (Peer-Report Measure of Internalizing and Externalizing Behavior); self report measures (State-Trait Anxiety Inventory for Children, Vanderbilt Depression Inventory, and Child School Behavior Questionnaire); and academic grades and school attendance. Children and their families were assessed at 6, 12, and 18 months and at 1 year after the end of treatment. Peer report measures were not included in the 1 year assessment. Parents were given a consumer satisfaction survey at the 1 year assessment.
No differences between groups existed for TPS scores or other psychopathology outcomes. Parents of children in the psychotherapy group reported greater overall satisfaction and perception of change in mental health problems than did parents of children in the academic tutoring group.
Traditional psychotherapy did not reduce psychopathology in children. Parents of children who received psychotherapy reported higher levels of satisfaction with services than did parents of children who received academic tutoring.
The most frequently used treatments in clinical practice are those based on general tenets of psychodynamic, relationship, and family therapy, which are often combined as an eclectic intervention. Weiss et al make a major contribution by conducting a large scale evaluation of treatments as practised with multiple outcome measures and meticulous evaluation of the results. The findings support previous work suggesting that for the treatments most commonly practised in clinical settings, evidence attesting to their effectiveness does not exist.
Researchers and practitioners will no doubt quibble about the fact that this is not a study of clinical patients in a clinical setting. Also, the evaluation is hampered by the combination of many different treatments, sometimes given to the same child. Strictly speaking, there is no treatment called “traditional therapy”; specific treatments that are not merely clumped together need to be evaluated.
For the practitioner, the findings raise a key question. Under what conditions ought one to use the treatments evaluated in this study? For many child and adolescent problems (eg, anxiety, depression, and conduct disorder) there are now evidence-based treatments.1 Clearly, one of these ought to be used long before resorting to the treatments included in this study. Over 550 forms of psychotherapy are now in use for children and adolescents.2 Most of these have no evidence on their behalf. The practice of unevaluated treatments or treatments with accumulating evidence that they may not be effective raises ethical as well as clinical practice issues. Of course, use of an evidence-based treatment may not be effective in any given case. Consequently, treatments used in clinical practice need to be systematically evaluated on a case by case basis to ensure progress is occurring or to inform treatment decisions about how to proceed.
Sources of funding: in part, National Institute of Mental Health and Substance Abuse and Mental Health Services Administration.
For correspondence: Dr B Weiss, Box 512 Peabody, Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee 37203, USA. Fax +1 615 343 9494.
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