Eilis Kennedy

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.

Reactive attachment disorder in looked‐after children

The great majority of children living in foster or residential care have been abused and neglected. Mental health problems are common and the nature of these problems may be rooted in early attachment relationships. The carers of 82 children in care in Scotland and 125 children from local schools completed questionnaires on mental health problems including Reactive Attachment Disorder. More than half (53%) of the children in care fulfilled criteria for mental health problems compared with 13% of the control group, and children living in care scored significantly higher for conduct problems, emotional problems (anxiety and depression), hyperactivity, problems with peer relations and Reactive Attachment Disorder. This has important implications for service development for this vulnerable group of children.

Relationships and learning: a review and investigation of narrative coherence in looked‐after children in primary school

This review and investigation draws on principles from attachment theory regarding the importance of early relationships and their impact on the coherence and organisation of psychological functions. Comparisons are made between the narrative coherence scores of an experimental group of 17 looked‐after children with problematic relationship histories in mainstream school and a matched control group of 17 of their peers. There were significant differences between the groups in the coherence of childrens narratives, denial and avoidance in story play themes and in their use of intentionality. The paper considers the theory and discusses the results in terms of the implications for teaching, learning and intervention.

Editorial: evaluating interventions in child mental health: the importance of care provider and contextual influences.

B R U C E WA M P O L D I N H I S B O O K The great psychotherapy debate, highlights the tension between a narrow, ‘medical’ model of evaluating psychological treatments and a broader evaluative framework which takes contextual factors into account, including the influence of the therapists themselves on treatment outcome (Wampold, 2001). Such ideas have fuelled an interesting debate in the field of psychological treatment research and a special section of the journal Psychotherapy Research was recently devoted to the topic of the extent to which therapist effects had a bearing on treatment outcome (Hill, 2006). Wampold’s main contention is that therapists account for a greater proportion of the variance in treatment outcome than any particular model of psychological intervention and hence greater attention should be paid to the attributes of effective therapists. One of the studies to be examined most in relation to this issue is the NIMH Treatment of Depression Collaborative Research Program (TDCRP) Multicentre Randomized Controlled Trial (RCT). This RCT compared the outcome of Cognitive Behaviour Therapy (CBT) vs. Interpersonal Psychotherapy (IPT) vs. Antidepressant medication vs. Placebo in adults with Major Depression. Minimal differences between different models of intervention were identified, and subsequent re-analyses of the data looking for therapist effects in the CBT and IPT arms came to conflicting conclusions. One analysis found significant therapist effects (Kim, Wampold, & Bolt, 2006) while another, using different statistical methods, found no effects (Elkin, Falconnier, Martinovich, & Mahony, 2006)! What is the relevance of all this to child mental health? Intuitively as practitioners many of us will hold the view that the qualities and skills of the person delivering a particular treatment and the setting in which the treatment is undertaken may be as important as the actual model of intervention itself. However, this issue has received little attention in the field of child mental health research. This is likely to change in future following the publication of the CONSORT guidance extension for RCTs of nonpharmacologic treatments (Boutron, Moher, Altman, Schulz, & Ravaud, 2008). CONSORT, or the Consolidated Standards of Reporting Trials, is the gold standard guidance by which RCTs are reported. Researchers generally undertake to conduct and report on trials according to CONSORT. The new guidance, published this year, emphasizes that in fields such as surgery or psychotherapy, where the intervention is generally complex and multi-dimensional and influenced by the skills and expertise of the ‘care provider’ as well as the setting in which the treatment is undertaken, care must

Developing interventions in child and adolescent mental health services: Do we really know what works for whom?

A recent Cochrane Review of psychological therapies and antidepressants for depression in children and adolescents concludes ‘on the basis of the available evidence, we do not know whether psychological therapy, antidepressant medication or a combination of the two is most effective to treat depressive disorders in children and adolescents’ (Cox et al., 2014). This candid conclusion is made despite evidence from 11 randomised controlled trials (RCTs) involving 1307 participants being included in the review. The differing and at times contradictory results of these trials made it impossible to state with certainty which treatment option was most effective.... Language: en

Orchids and dandelions: How some children are more susceptible to environmental influences for better or worse and the implications for child development:

Boyce and colleagues (1995) first put forward their theory of “Biological Sensitivity to Context” based on the findings of two prospective studies focusing on children’s propensity to develop respiratory illness. It was noted that young children who appeared more biologically “reactive” (e.g. high cardiovascular or immune reactivity to stressors) were most likely to develop asthma when reared in conditions of adversity but unexpectedly, these same biologically reactive children were the ones least likely to develop the illness when reared in low risk supportive environments, even compared to children with low biological reactivity reared in similarly supportive environments. This finding was replicated in a second study showing that children characterized by a heightened susceptibility to develop respiratory illness when in a high stress environment were those least likely to develop illness when in a low stress environment. Two years later Jay Belsky independently developed “Differential Susceptibility Theory,” arguing that a proportion of children with underlying genetic and temperamental vulnerability were prone to the best or worst developmental outcomes depending on the quality of the early child rearing environment (Belsky, 1997). This idea that a group of children can be identified with underlying neurobiological sensitivity that can lead to bidirectional outcomes for “better or worse” challenges the more prevalent “dual risk” or “stress diathesis” paradigm (i.e. that vulnerability and stress interact to produce adverse outcomes). Whereas the majority of children might be conceptualized as “Dandelion” children, relatively hardy and able to withstand the vicissitudes of a range of environments, such neurobiologically sensitive and reactive children are designated “Orchid” children in their capacity to develop beautifully given sensitive nurturance alongside their tendency to develop adverse developmental outcomes in less than optimal environmental conditions (Boyce & Ellis, 2005; Ellis, Boyce, Belsky, Bakermans-Kranenberg, & Van IJzendoorn, 2011). Increasingly, these theories of biological sensitivity to context and differential susceptibility have been tested in empirical research and there is mounting evidence of the implications for understanding child development as well as targeting interventions at those children most likely to benefit. Examples of recent research include that of Knafo, Israel, and Ebstein (2011) whereby children with the 7 repeat allele of the DRD4 dopamine gene were the least social children in the absence of positive parenting but the most prosocial in the presence of such parenting, and a study by Pleuss and Belsky (2009) showing that children with difficult temperaments as infants exhibited more behavior problems when provided with low quality childcare care and fewer when experiencing high quality childcare than children with easy temperaments. The 7 repeat allele of the DRD4 gene has attracted particular attention, with children with this gene variant showing more positive and negative outcomes with regard to externalizing problems and attachment security depending on the quality of maternal caregiving (Backermans-Kranenberg & Van IJzendoorn, 2007; Backermans-Kranenburg, van IJzendoorn, Pijlman, Mesman, & Juffer, 490338 CCP18310.1177/1359104513490338Clinical Child Psychology and PsychiatryEditorial 2013

Psychodynamic psychotherapy for children and adolescents: an updated narrative review of the evidence base

While the evidence base for psychodynamic therapy with adults is now quite substantial, there is still a lack of research evaluating the effectiveness of psychodynamic therapies with children and young people. Those studies that have been carried out are also not widely known in the field. To help address the second point, in 2011, we carried out a review of the evidence base for psychodynamic psychotherapy for children and adolescents, which identified 35 studies which together provided some preliminary evidence for this treatment for a range of childhood disorders. The present study is an updated review, focusing on research published between March 2011 and November 2016. During this period, 23 additional studies were published, of which 5 were reports on randomised controlled trials, 3 were quasi-experimental controlled studies and 15 were observational studies. Although most studies covered children with mixed diagnoses, there were a number of studies examining specific diagnostic groups, including children with depression, anxiety and disruptive disorders. whilst the quality of studies was mixed, some were well-designed and reported, and overall indicated promising findings. Nevertheless, further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy across a range of different disorders, and to ensure that services can provide a range of evidence-based treatments for children and young people.

Stratified medicine and child psychology and psychiatry: An old or new paradigm?

In its recently published strategy for mental health research, the Medical Research Council (MRC, 2017) in the United Kingdom declared the need to ‘embrace a stratified medicine approach’ (p. 5). Stratified medicine ‘describes the identification of groups of people with specific, identifiable features, and looks beyond conventional diagnostic categories to find new treatments and better ways of using existing treatments’ (MRC, 2017, p. 12). This impetus to focus on tailored treatments that address particular patient characteristics is not especially new, and for some time now, the National Institute of Mental Health in the United States has called for mental health researchers to ‘expand and deepen the focus to personalise intervention research’ (Fisher & Bosley, 2015 p.67). What are the implications of all this for clinical practice? Is this a radical new paradigm or one in fact familiar to child mental health practitioners? Notable recent shifts in thinking allied to a perspective of stratification or personalisation in child mental health include an increased recognition of heterogeneity within standard diagnostic categories. From conduct problems to depression, there is greater awareness of heterogeneous subgroups within broader diagnostic categories that are likely to benefit from tailored treatment approaches. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), for example, has added a new specifier of LPE or ‘Limited Prosocial Emotions’, noting that this describes a subgroup of children with conduct disorder that may differentially respond to treatment (American Psychiatric Association (APA), 2013; Hawes, Price & Dadds, 2014). Stringaris in a recent editorial on the pros and cons of depression as a diagnostic category highlights how advances in neuroimaging, treatment approaches and developmental research show promise for the subtyping of depression so that

Personalised interventions for subgroups of children with conduct problems

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of personalised, psychosocial interventions for subgroups of children with conduct problems.

Poor investment in child mental health research should not be tolerated

Wolpert and colleagues highlight the limitations of the current evidence base for treatment in child mental health.1 That child mental health is “everybody’s business”2 has long been the mantra of clinicians working in the field, so recognising the pivotal role of the wider community in children’s wellbeing is uncontroversial, but we must also focus on increasing …