might participate in behavior therapy and take medication to alleviate his hyperactivity and inattention. However, these behavior problems have likely alienated him from classmates. Consequently, the therapist might have an additional goal of helping the child gain acceptance in the classroom and overcome a history of peer rejection.
Fourth, children and adolescents often have less control over their ability to change than do adults. Adults usually have greater autonomy over their behavior and environmental circumstances than do children. For example, a woman who is depressed might decide to exercise more, join a social support group, practice meditation, change jobs, or leave her partner. However, a child who is depressed because of his parents’ marital conflict is less able to alter his environment. Although he might decide to exercise or participate in extracurricular activities, he is unable to leave home or get new parents. Instead, the boy’s social–emotional functioning is closely connected to the behavior of his parents. Consequently, the boy’s capacity to change is directly associated with his parents’ involvement in therapy.
Finally, children and adolescents are more likely to have multiple psychiatric conditions compared to adults. Among youths in the community, approximately 40% who have one disorder also have a second disorder. Among youths referred to clinics, rates of comorbidity range from 50% to 90%, depending on the age of the child and the specific problem. Clinicians who treat children and adolescents must address multiple disorders simultaneously, often without the zealous participation of their young clients (Weisz, 2014).
Review
Children are often less motivated than adults to participate in therapy and may lack the cognitive or self-regulation skills necessary to participate in many therapies originally designed for adults.
Whereas adult psychotherapy focuses largely on symptom reduction, child psychotherapy also involves promoting children’s growth and development.
Children are more likely than adults to experience comorbid problems and less able than adults to alter their life circumstances to improve their functioning.
Does Child Psychotherapy Work?
Overall Efficacy of Therapy
John Weisz and colleagues (2017) used meta-analysis to examine the effects of psychotherapy on children and adolescents. Recall that meta-analysis is a statistical technique in which researchers combine the results of many studies into a single metric called an effect size (ES). The effect size reflects the difference between children who receive treatment and children in the control group (Del Re & Fluckiger, 2018).
Their meta-analysis combined the results of 447 studies involving 30,431 youths conducted over the past 50 years. The overall effect of psychotherapy on youths’ outcomes immediately after treatment was medium in magnitude (ES = .46). Youths who participated in therapy showed approximately one-half standard deviation better functioning than youths in the control group (Figure 4.7).
The effect of psychotherapy on youths’ outcomes approximately 1 year after treatment was a bit lower (ES = .36) but still significant. Even 1 year after treatment, the functioning of youths who participated in therapy was one-third standard deviation better than youths who did not receive treatment.
The effect of therapy on children’s functioning also depended on the nature of children’s presenting problem. Therapy worked best for children with anxiety disorders but was somewhat less efficacious for children with depression. Moreover, therapies that targeted multiple problems simultaneously had a small effect on children’s outcomes. This is concerning given that children who are referred to therapy often have multiple problems that merit treatment.
Figure 4.7 ■ Does Child Psychotherapy Work?
Note: Overall, therapy has a medium effect on children’s functioning after treatment (ES = .46) and approximately 1 year later (ES = .36). The effect of therapy also depends on the nature of children’s problems. Based on Weisz and colleagues (2017).
Which Therapy Works Best?
Although it is encouraging to know that child therapy works, we also want to know which system of therapy works best. Researchers who study adult psychotherapy have concluded that all forms of therapy are equally efficacious. No single system of psychotherapy works best under all circumstances (Norcross & Lambert, 2020). Some researchers refer to this phenomenon as the dodo verdict (Parloff, 1984; Rosenzweig, 1936). In Alice in Wonderland, Alice watches a race in which each contestant starts in a different position, each races in a different direction, and all contestants win. One of the characters in the story, the dodo bird, concludes, “Everybody has won, and all must have prizes.” So, too, in adult psychotherapy, there is little evidence that any form of therapy is superior to any other form of therapy, overall (Image 4.1).
Is the dodo verdict also true for child psychotherapy? The results are mixed (Weisz et al., 2017). On one hand, children responded equally well to all of the approaches to therapy that the researchers examined. For example, behavioral and cognitive therapies were as efficacious as other approaches to therapy (e.g., interpersonal therapy, family therapy). Furthermore, therapies that focused chiefly on caregivers and other family members were as efficacious as therapies that focused mostly on children and adolescents themselves. These findings largely support the dodo verdict.
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On the other hand, the efficacy of each approach to therapy depended on who reported children’s outcomes. Overall, behavioral and cognitive therapies were associated with the best outcomes as reported by parents, teachers, and children themselves. Other forms of therapy (e.g., interpersonal, family systems) were not as efficacious when outcomes were reported by teachers or other adults outside the family. These findings do not support the dodo verdict; instead, they suggest that behavioral and cognitive therapies involving children yield the most robust effects across home and school settings.
The effects of therapy did not vary as a function of children’s age, gender, or ethnicity. Children and adolescents responded equally well to therapy. Similarly, the effects of therapy were similar for boys and girls. Therapy also seems to be equally efficacious for White and non-White youths, although more research examining psychotherapy with ethnic minority children and families is needed.
Efficacy vs. Effectiveness
Overall, Weisz and colleagues’ (2017) meta-analysis demonstrates the efficacy of psychotherapy for most childhood disorders. Researchers use the term efficacy to refer to the effects of therapy on children’s functioning when examined in research studies under ideal conditions. For example, the studies included in the meta-analysis were conducted by university-based research teams with well-trained, supervised clinicians. Clinicians tend to use only one form of treatment, which was carefully planned and followed, using a therapy manual—that is, step-by-step guidelines describing how treatment should proceed. Participants in efficacy studies are typically voluntary; they agree to participate in the research project. Participants are also carefully selected. They are screened to make sure they have the disorder or problem that the researcher is interested in studying, and they typically do not have comorbid conditions.
In contrast, most child and adolescent psychotherapy is not administered under optimal conditions. Researchers use the term effectiveness to refer to the effects of therapy on children’s functioning in real-world conditions. For example, most children receive therapy in mental health clinics, hospitals, and schools rather than university research centers. Clinicians are usually not trained in any one specific form of therapy;