The effectiveness of Cognitive Behaviour Therapy for childhood externalising disorders in routine settings
Riise and colleagues (2020) report on a meta-analysis of studies of cognitive behaviour therapy for children and adolescent externalising problems (ADHD, Conduct Disorder [CD], and Oppositional Defiant Disorder [ODD]) conducted in non-university settings. The review included 51 studies involving 5295 children clients, current at May 2020. 77% clients were boys, with a mean age of 8.2 years. Comorbidity was not well reported, but the best estimates were that 53% had at least one comorbid disorder. 42% ADHD clients were also on medication as were 20% CD/ODD clients. Treatment type for each study was classified as child-focused (10% studies), parent-focused (49% studies), or child and parent focused (41%). Parental involvement was rated as low if parents were not involved in sessions but informed about progress (8%), moderate if parents were only present for some of the sessions or only part of all sessions (42%), and high if parents were present throughout all sessions (50%). 49% treatment was provided in groups, 43% individually, and 8% combined group and individual. The average number of sessions was 17 and treatment was typically carried out over 12 weeks for ADHD and 18 weeks for CD/ODD. ADHD treatment involved on average 4 hours/week and CD/ODD 2 hours/week. Treatment programs for ADHD included New Forrest Parenting Package, Plan My Life, Family Stars, Outsmart, and Family School Success among others. Treatment programs for CD/ODD included Parent-Child Interaction Therapy, Stop Now and Plan, The Incredible Years, and the Positive Parenting Program among others. 12.7% declined the treatments offered. 12% dropped out of ADHD treatment and 16% dropped out of CD/ODD treatment.
The authors found “large” effect sizes for ADHD (g = 0.80) and CD/ODD (g = 0.98). It’s important to note that these were within-group effect sizes; most meta-analyses report between-group effect sizes. Nevertheless, within-group effect sizes should be meaningful for clinicians – it represents the amount of change from baseline to end of treatment, in numbers of standard deviations (of the baseline score). So, to put these results in context – based on Mellor’s (2005) Australian norms - if you gave the parents of your child clients with ADHD the Strengths and Difficulties Questionnaire (SDQ), on average, you could expect a 5-point change in the total score, or perhaps a 2-point change in the Hyperactivity subscale. You could expect a 6-point change in the total SDQ scores of your CD or ODD clients, or perhaps a 1-2 point change in their Conduct Problems subscale scores. Importantly, the authors found that routine service providers achieved equivalent effect sizes to those achieved by studies conducted in universities. Interestingly, these values are lower than the best available estimate of the reliable change index for the SDQ Total (i.e., a change in scores that can be reliably discriminated from retest error) (Wolpert et al., 2015), although this reliable change index was not strictly correctly calculated (- it was based on internal consistency rather than test-retest reliability). Furthermore, the authors noted there was probably publication bias; a more robust estimate of effect size (for ADHD and CD/ODD combined) was probably closer to g = 0.72 (or a 4-point difference in total SDQ scores). Child psychotherapists reading this are probably feeling a lot better about their outcomes right now!
Mean remission rates were respectable but not spectacular, at 38% for ADHD and 48% for CD/ODD. More encouragingly, the remission rate was 51% at follow-up, which on average occurred 11 months after therapy.
Neither whether the intervention was focused on parent or child or both, whether it was provided in groups or individually, the degree of parental involvement, presence of teacher involvement or the therapist’s profession made a difference to the amount of improvement achieved. Interestingly, studies conducted in Australia had significantly higher effect sizes (g = 1.37) compared to America and Europe. The authors cautioned the sample size was too small to place too much weight on this finding, but of course, we in Australia recognise this for the blatant European bias that it is 😉. Ozzie ozzie ozzie, oi oi oi! Other factors that influenced degree of improvement were: baseline severity – those with higher severity achieved greater improvement; age – older children made less improvement and fewer achieved remission; taking medication was associated with less improvement and fewer achieving remission; and studies with more sessions achieved higher remission rates.
The authors concluded that CBT is effective for child externalising problems and similarly effective in routine services as when delivered in university settings. A less generous assessment might be that improvement and recovery rates have considerable room for improvement. Despite the high demand for child psychological services, there seems to be a dearth of funding and research evaluating psychological interventions for children, compared to adults. This research is arguably more difficult and costly to do, but equally, has far greater potential to save morbidity through improving educational attainment and preventing future psychological disability.
Clinician implications
On average, CBT produces reductions in ADHD symptoms of ~g = .8 and Conduct Disorder/Oppositional Defiant Disorder symptoms of ~g = 1.0 but when adjusting for publication bias the effect is closer to ~g = 0.7.
On average, treatments last 17 sessions, and longer treatments are associated with greater symptom reduction
Whether treatment was delivered via group or individually, or directed at parents or at both parents and children did not influence the degree of improvement
For the original article go to: https://www.sciencedirect.com/science/article/pii/S0272735820301422#s0230
REFERENCES
Mellor, D. (2005). Normative data for the Strengths and Difficulties Questionnaire in Australia. Australian Psychologist, 40, 215-222.
Riise, E.N., Wergeland, G.J.H., Njardvik, U., & Ost, L-G. (2020). Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis. Clinical Psychology and Psychotherapy.
https://doi.org/10.1016/j.cpr.2020.101954
Wolpert, M., Gorzig, A., Deighton, J., Fugard, A.J.B., Newman, R., & Ford, T. (2015). Comparison of indices of clinically meaningful change in child and adolescent mental health services: difference scores, reliable change, crossing clinical thresholds and 'added value' - an exploration using parent rated scores on the SDQ. Child and Adolescent Mental Health, 20, 94-101.