Unidisciplinary

This term in the past has not been included as a model of teamwork, because it was traditionally used to refer to one professional working independently in his or her specialty. Historically, in terms of the interdisciplinary approach, it also implied a professional who perceived himself or herself as have the knowledge and skills needed to identify and address all areas related to his or her field of focus. The well-known fable of “The Blind Men and the Elephant” has often been used as a metaphor in describing unidisciplinary functioning. Just as each man who was blind determined what the elephant was like on the basis of the individual part the man touched, each discipline perceives the individual in a unique, valid way and yet risks remaining “blind” to the total individual. With the emergence of single-discipline group practices, the term is also used at times to refer to two of more professionals in a discipline who share the same professional skills and training, have a common language, and function in a group.⁴² As a result of increased specialization within medicine, unidisciplinary, or what sometimes is referred to as intradisciplinary, has been used to describe a team of professionals in a discipline who have additional professional skills and training in varying specialty areas and, although they share some common language, have developed a language specific to their specialty. An example of a unidisciplinary team would be a pediatric urologist, a pediatric neurologist, and a pediatric orthopedist who communicate with each other and share information in the provision of care to an individual child.

Multidisciplinary

This team is sometimes used to refer to an intradisciplinary team but in most instances is used to refer to a team that is composed of two or more disciplines. The features most often identified in relationship to the multidisciplinary team are as follows:

Some authorities also equate the multidisciplinary team model with “The Blind Men and the Elephant” in that each discipline “feels” or focuses on its own area. The difference with the multidisciplinary team is that there is some form of communication about the information that was obtained that potentially contributes to decision making with regard to the “whole.” There is, as a result, less chance for one person’s mistakes or biases to determine the course of events.⁴³ However, the model can result in simply piecing information together on the basis of the individual discipline results, especially if the model is implemented without the opportunity for interaction between team members at a team meeting.³⁸

Interdisciplinary

This term is increasingly being used interchangeably with interprofessional, which is widely used in health care team publications from the United Kingdom and Canada. The features most frequently identified in relationship to interdisciplinary teams are as follows:

One of the strengths of the interdisciplinary model is the integration of the individual contributions of team members to address a common set of issues or problems.^37,45–47 Another strength is the collaborative decision making that occurs to establish a holistic plan of care or recommendations.^37,45,47 Over time, the team members also develop a “common language” that facilitates communication and collaborative decision making.^36,37 The interdisciplinary team model, however, also presents several challenges, which are discussed separately.

Transdisciplinary

The features most frequently identified in relationship to transdisciplinary teams are as follows:

Strengths of the transdisciplinary model include a high degree of interaction and coordination; increased agreement among team members about the acceptability of recommendations; enhanced opportunities for team members to learn from one another; decreased fragmentation of services; and increased continuity and consistency of services.⁴³ Also, in the area of early intervention, limiting the number of people who come in contact with a very young child prevents duplication of services and unnecessary intrusion into family activities and routines.⁴⁴ Although the high degree of interaction and coordination is a strength, it is also a potential challenge in that the required degree of role sharing and transfer may lead to role ambiguity, role conflict, and role release to the extent of loss of professional identity.⁴³

Transdisciplinary has also been used to refer to teams of multiskilled health practitioners who are trained to provide a wide range of services in a specific field, such as geriatrics, apart from training in a traditional discipline.³⁸ This approach to the provision of health care has also been referred to as a pandisciplinary model, in which a single new discipline’s role spans all areas of competence relevant to a specific field.⁴² Unfortunately, in many ways, the pandisciplinary model brings teamwork full circle back to an unidisciplinary approach in which practitioners from one discipline assume that they have all the knowledge and skills needed to provide services in a particular field.

Each model of teamwork described has its strengths and challenges. Some professionals advocate one model over, implying that the particular model is better than others. It is more constructive to think of the models as points along a continuum of approaches, all of which have the common goal of providing high-quality services to children with developmental disabilities and to their families. Different programs serving children with developmental disabilities and their families use different models along this continuum to reach the common goal. For a program that provides ongoing services to a large number of children with medically complex health needs that necessitate the involvement of multiple medical specialties, the multidisciplinary team model may be the only feasible model. However, in a program that provides diagnostic and treatment services for children of varying ages with a broad range of developmental disabilities, the interdisciplinary team approach may be the model by which services are provided for older children, and the transdiciplinary model, by which services are provided for very young children and their families.

In the interdisciplinary and transdisciplinary model, and frequently in the multidisciplinary model, decision making involves face-to-face interaction. A new type of team, the virtual team, is emerging in the health care field. Virtual teams have been used in business for some time and consist of geographically or organizationally dispersed members who use technologies to perform team tasks.⁴⁸ Rather than communication during face-to-face meetings, communication and decision making are accomplished through such technologies as email or video teleconferencing. Within health care, with the increasing demands for productivity and changing reimbursement, traditional models of teamwork may no longer be as functional as they once were and may be replaced by virtual teams.^49,50 According to a developing body of knowledge about virtual teams, virtual teams apparently go through the same stages of team development and confront the same interpersonal process issues that exist in teams that meet face to face.^51,52

Changes in Hospital Policies Affecting Families Rights and Responsibilities

Even until the late 1950s, most medical professionals believed that visits from parents to their hospitalized children would inhibit effective care. Observations that children cried more in the presence of a parent or became distressed when their parent left led physicians and nurses to interpret parental visits as harmful for children.¹¹ As a result, parents were regularly excluded from partnership in medical decision making about their children. By the 1970s, because of accumulating evidence that episodes of separation from their parents had the potential to harm children’s psychological well-being,^12–14 U.S. hospital policies began allowing parents to stay with their children during admissions.¹⁵ Newborns began rooming in with their mothers instead of group nurseries, and fathers were permitted in the delivery room to support mothers during labor.¹⁶ The restrictive hospital policies before the 1970s that curtailed the family’s ability to comfort a hospitalized child (or other family member) provide an example of strategies that maintained institutional and staff control and exemplify system-centered models of health care delivery.

Epidemiological Changes in Children’s Health and Broadening Views of Health Determinants

In the 1970s, health services researchers brought attention to the growing prevalence of children’s psychosocial difficulties. Haggerty and colleagues called this growing challenge “the new morbidity” in their 1975 publication, Child Health and the Community,¹⁷ and conceptualized the interdependence of the family, the community, and children’s health. The authors asserted that for pediatricians to remain relevant to the well-being of children, pediatric training and practice would have to shift from focusing solely on the individual child to examining broader contextual aspects, including the family. The shift in thinking that Haggerty and colleagues’ work prompted, together with the rising tide of consumerism, undoubtedly fostered child health professionals to begin exploring the value of encouraging parents to be partners in medical decision making.

Further support for the importance of the family to children’s health came in 1977 in Engel’s classic article presenting the biopsychosocial medical model.¹⁸ His argument for a new paradigm of medical thinking that moved beyond a solely biomedical view to one that incorporated the inseparability of social and psychological influences on human health lent further support to Haggerty and colleagues’ argument that pediatricians needed to shift their focus beyond the child to the family context in order to foster children’s health.

Children with Special Health Care Needs and Their Families

Increasing recognition of the growing proportion of CSHCN and the ability of the U.S. health care system to successfully meet their needs spurred public organizers and government policy makers to improve the lives of these children and their families. In the U.S., key agencies that pioneered the CSHCN and family-centered care movement included the Maternal and Child Health Bureau (MCHB), the Association for the Care of Children’s Health (ACCH), Association of University Centers of Excellence in Disabilities, and the American Academy of Pediatrics (AAP). As a division of the Health Resources and Services Administration of the U.S. federal government’s Department of Health and Human Services, MCHB has long been charged with improving all children’s, women’s, and families’ health and is the designated organization that allocates funds from the federal Social Security Title V Act. ACCH, a now-defunct public organization originally formed in the 1960s, advocated along with MCHB for children’s health care system improvements. In the 1980s and 1990s, both organizations, along with the AAP and Association of University Centers of Excellence in Disabilities, were instrumental in broadening the conceptualization of children’s chronic disabling health conditions beyond one divided into specific disease categories to a more general category labeled children with special health care needs, defined as:

Former Surgeon General C. Everett Koop’s 1987 Conference on Children with Special Health Care Needs disseminated the first widely acknowledged definition of family-centered care in the United States.²⁰ This definition, formulated before the conference by parents, professionals, and policy makers active in the ACCH and MCHB, was published as a monograph, “Family-centered Care for Children with Special Health Care Needs,” that came to be commonly known as “Big Red” because of the red color of the cover.²¹ The ACCH made further refinements of the “Big Red” definition in 1994,⁹ which resulted in the key principles of family-centered care listed in Table 8B-1.²² Although the ACCH eventually disbanded, the Institute for Family-Centered Care, established in 1992, assumed the role that ACCH played and continues to disseminate information to promote the practice of family-centered care through annual conferences, information publications, guidelines for hospitals, and consultations to individual health organizations.²³ MCHB also continues to include family-centered care into its improvement mandates for CSHCN:

TABLE 8B-1 Key Elements of Family-Centered Care

From Shelton TL, Stepanek JS: The key elements of family-centered care. In Family-Centered Care for Children Needing Specialized Health and Developmental Services, 3rd ed. Bethesda, MD: Association for the Care of Children’s Health, 1994, p vii.

The concept of family-centered care has undergone further refinements by researchers interested in early intervention services for CSHCN. Dunst and colleagues found that early intervention professionals and programs employing an empowering or enabling helpgiving relationship model more effectively achieve desirable child and family outcomes. The work of Dunst and colleagues has focused on outcomes, including family self-determination, decision-making capability, control, and self-efficacy and has precipitated a deeper understanding of the family-centered concept.²⁵ They have extended the notion of family-centered care from one of simply incorporating parents in the delivery of health care to their children to the broader ideals of family-empowerment and marshalling community supports that are individualized by child and family need instead of imposing help from menu-driven service systems. Family empowerment has been explained as follows: “Family empowerment refers to families acquiring the capacity to exercise power. It makes them not just into actors, but into agents capable of shaping the conditions in which they live as they would want to shape them.”²⁶ Dunst and colleagues proposed employing a conceptual framework of helpgiving relationships that empowers families by promoting family competency to identify and manage their child’s needs. Their model of empowerment requires specific conditions for both families and professionals. They require that families have (1) an increased understanding of their child’s needs, (2) the ability to deploy competencies to meet those needs, and (3) self-efficacy (a belief that they are capable) to do so.²⁷ Among the conditions for help givers in their model are that professionals (1) have a proactive stance (help givers believe help seekers are already competent or have the capacity to become competent), (2) create opportunities for competence to be displayed (help givers provide enabling experiences to help seekers), and (3) allow help seekers to use their competencies to access resources and attribute success to their own actions, not the professional’s. In essence, Dunst and colleagues suggested that viewing the relationship from a strengths-based perspective rather than a deficit one is a more effective way to achieve desired outcomes for CSHCN and their families.

The multidisciplinary research group at McMaster University in Ontario, Canada also has done extensive work on refining the concept of family-centered care as it relates to CSHCN (note that they use the word service in place of the word care). In a summary of the theoretic and research literature,²⁸ Rosenbaum attempted to organize the sometimes disparate meanings of family-centered service by dividing the concept into a three-level framework consisting of (1) basic premises or assumptions, (2) guiding principles, and (3) elements or key service provider behaviors. The basic premises are beliefs, values, and ideals about families and together form the backbone of the concept of family-centered service. Each premise has several guiding principles directed to professionals to help them ground their interactions with families. The elements are specific provider behaviors that follow from the assumptions and guiding principles. The addition of the key elements was an attempt to approach a definition that included measurable behaviors. Their conceptualization is summarized in Table 8B-2.

TABLE 8B-2 Premises, Principles, and Elements of Family-Centered Service

Adapted from Rosenbaum P: Family-Centered Service. Phys Occup Ther Pediatr 18(1):1-20, 1998.

Summary of Evidence

Our discussion to this point has focused on the development of the concept of family-centered care. Now we turn to an examination of the empirical evidence regarding this process of care. At first glance, in view of the convincing arguments of the many stakeholders interested in disseminating family-centered care improvements throughout the health care system, the reader might conclude that shifting existing care processes to those that are more family-centered is the most desirable method to successfully support families as they adapt to raising a child with special health care needs. However, before widespread dissemination of any improvement strategy, it is desirable to explore the intervention for the possibility of lack of desired benefit or even potential to harm.²⁹ In addition, understanding how organizational structure affects patient outcomes is important but suffers from a lack of available methods of studying this aspect of care.³⁰ Furthermore, despite the existing literature on family-centered and patient-centered care, commentaries and qualitative studies continue to point out that parents and professionals have limited or conflicting ideas about the meaning and scope of these concepts.^31–34

Before discussing the research regarding family-centered care interventions and outcomes, an example involving the “Mr. Yuk” sticker in the childhood poisoning prevention campaign illustrates the importance of empirical evaluation of interventions. “Mr. Yuk,” created by the Pittsburgh Poison Center at the Children’s Hospital of Pittsburgh in 1971, was based on a logical assumption that applying these bright green stickers with a scowling face to bottles of medicines and other potentially toxic substances would help discourage children from ingesting the contents. Distributing these stickers to parents of young children became routine practice in most ambulatory child health care settings after clinicians incorporated the expert recommendation to do so. However, at least two studies^35,36 done in the 1980s long after the intervention was entrenched suggested that “Mr. Yuk” stickers do not effectively keep toddlers away from potential poisons and may even attract children to them. One of the studies did note, however, that the stickers might work for older children or as part of a larger poisoning prevention campaign, highlighting the importance of tailoring interventions.³⁶

Research linking family-centered care to desired outcomes is available but challenging to summarize as a whole because of the heterogeneity of the definitions of the concept, study populations, focus of investigation, and methodological quality across studies. Furthermore, a complete review of the existing literature on family-centered care is beyond the scope of this chapter. With these limitations in mind, we have chosen to explore several articles linking family-centered care and outcomes and summarized several other articles according to quality of study methodology in Table 8B-3. Evidence is listed alphabetically by author’s names in columns based on the commonly used categorization scheme that organizes studies according to strength of the methodological quality.³⁷ Class I evidence is considered the strongest for drawing valid conclusions between interventions and outcomes and results from randomized controlled trials. Class II evidence is second most powerful and includes nonrandomized trials, before-and-after evaluations, and studies in which participants serve as their own controls. Class III evidence refers to cross-sectional and case-control designs. Class IV evidence, derived from the weakest study designs, pertains to descriptive studies, case reports, and expert opinion. Note that classes III and IV evidence hold value in that they provide starting points for further study and suggested practices in the absence of higher classes of data.

Selected Class I Evidence Regarding Family-Centered Care and Outcomes

Randomized controlled trials of components of family-centered care summarized in the two left columns of Table 8B-3 are described in further detail. Ireys and colleagues evaluated the effect of referral to parent-to-parent support for mothers caring for children with chronic illness and found that mothers in the intervention group had lower anxiety levels, as measured by the Beck Depression Inventory and the Psychiatric Symptom Index.³⁸ Stein and Jessop showed that in a longitudinal family-centered support program for families of CSHCN (the Pediatric Ambulatory Care Treatment Study), the group receiving intervention showed greater satisfaction with care, improvements in children’s psychological adjustment, and fewer psychiatric symptoms for mothers.³⁹ In Australia, Sanders demonstrated in multiple studies the effectiveness of a family-centered parenting intervention, the Positive Parenting Program (Triple-P) for problematic child behaviors.^39a Another study done in Sweden with children with newly diagnosed insulin-dependent diabetes mellitus showed associations between outpatient family-centered care processes and parent-reported improvement in family climate but failed to show a relationship to children’s glycemic control or rate of readmission.⁴⁰ The last report mentioned in the randomized controlled trials in Table 8B-3 is a summary of class I studies that failed to show a simple link between care processes and child outcomes.⁴¹ Instead, the authors argued that only if interventions addressed maternal responsiveness were they successful in improving children’s developmental outcomes.

Using the three-level framework conceptualization of family-centered care noted in Table 8B-2, researchers in the Ontario group documented an association between family-centered care for CSHCN and their families in Canadian children’s rehabilitation centers and outcomes such as parent satisfaction with services,^42,43 as well as improved parent and child psychosocial well-being.⁴⁴ In these and other studies listed in Table 8B-3 in the two right columns, the investigators used methods that make it difficult to draw firm conclusions between family-centered care and outcomes. Furthermore, criticisms of using satisfaction and psychosocial well-being as outcomes are derived from the bias presumed inherent in subjective data and the observation that the measurement of traits is more psychometrically reliable than the measurement of states (i.e., satisfaction). In a summary of selected evidence, Rosenbaum found five randomized controlled trials evaluating family-centered care and provided a summary of other pertinent publications, most of who authors had used methods in the class II to class IV categories.²⁸ Shields and associates published a Cochrane Colloquium review protocol for meta-analysis of family-centered care for hospitalized children in 2003 (updated in 2004) but have not begun collecting studies based on the protocol.⁴⁵ We were not able to find any other publications of controlled trials or meta-analyses pertaining to family-centered care, despite an extensive search.

Other Selected Evidence Regarding Receipt of Family-Centered Care and CSHCN

MCHB, in collaboration with the National Center for Health Statistics of the Centers for Disease Control and Prevention, surveyed a nationally representative sample of more than 100,000 households across the country to measure the health and well-being of U.S. children.^46,47 The National Survey of Children’s Health (NSCH), administered to families by telephone, included more than 38,000 families across the United States that had at least one child with special health care need and included questions to measure the six core outcomes listed in Table 8B-4. To assess the progress in achieving their national agenda for CSHCN, the survey included questions regarding families’ perceptions that their care was family-centered. Prevalence estimates from this study showed that 12.8% of children (9.3 million) younger than 18 years need a special health care issue to be addressed. Approximately one third of the families surveyed indicated that they were dissatisfied by the lack of critical elements of family centeredness. Questions regarding family centeredness emphasized the extent to which care provided by the child’s physicians and nurses focused on the family’s needs and not simply the child’s medical condition. Areas addressed included whether the professional (1) met information needs, (2) made the parent feel like a partner, (3) was sensitive to family values and culture, (4) spent enough time, and (5) listened to family concerns. One third of the families reported being usually or always dissatisfied with at least one family-centered aspect of their child’s care. Furthermore, families of such children living in poverty and from minority groups were more likely to be dissatisfied with these aspects of care. Although the data were based on self-report and collected cross-sectionally, which precluded causal conclusions, this study provides an important starting point from which to design more in-depth evaluations of family-centered aspects of the health care system and family health care provider interactions.

TABLE 8B-4 Maternal and Child Health Bureau Core Outcomes for CSHCN

CSHCN, children with special health care needs.

From McPherson M, Weissman G, Strickland BB, et al: Implementing community-based systems of services for children and youths with special health care needs: How well are we doing? Pediatrics 113:1538–1544, 2004.

History and Definition of the Medical Home Concept

The AAP has called for children to have a “medical home” since the 1960s.⁴⁸ The original 1967 AAP definition referred to a single location of all medical information about a patient, especially children with chronic disease or disabling conditions.⁴⁹ The idea evolved over the next 35 years to the current one, which emphasizes a concept broader than the notion of a single location. Now the medical home is conceptualized as a quality approach to providing cost-effective primary health care services in which families, health care providers, and related professionals work as partners to identify and access medical and nonmedical services to help children and their families achieve their maximum potential. In 2002, the AAP published a more definitive operational definition clarifying specific activities within each of seven medical home domains: accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective (see Appendix, Chapter 8B for a more complete description of the domains).^50–52 Despite progress in clarifying the concept, significant challenges to establishing medical homes for all children remain; an important one is the lack of an adequate reimbursement structure for physicians’ services provided in a medical home. The next section describes a model that has been used to study the implementation of the medical home concept.

Efforts to Promote the Medical Home Concept

The MCHB funded the National Initiative for Children’s Healthcare Quality (NICHQ) to conduct multistate learning collaboratives to help disseminate the medical home concept throughout the United States.⁵² NICHQ staff and faculty, state Title V leaders, and private practices constituted two consecutive 15-month Medical Home Learning Collaboratives, the first occurring in 2003 to 2004 and the second in 2004 to 2005. The first collaborative included 30 practices in 12 states: Colorado, Connecticut, Florida, Louisiana, Michigan, New York, North Carolina, Ohio, Oklahoma, Utah, Virginia, and Wisconsin. The second consisted of nine states and multiple practices in the District of Columbia, Illinois, Maine, Maryland, Minnesota, Pennsylvania, Texas, Vermont, and West Virginia. The Learning Collaboratives studied the recommended best practices for making changes to enhance care for CSHCN. They employed NICHQ’s framework for improvement, which is based on a synthesis of models from the Institute for Healthcare Improvement’s Breakthrough Series Model,⁵³ the Model for Improvement,^54–56 and the Chronic Care Model.⁵⁷ NICHQ’s model for improvement highlights the need for four key components of practice Microsystems: a clinical information system, effective decision support, a well-designed delivery system emphasizing planned care, and expert support for both family and developmentally appropriate child self-management. The model, schematically represented in Figure 8B-1, also highlights the key role of organizational leadership and the importance of linking health services and community resources.⁵⁸ The second collaborative used process information regarding what did or did not work from the first learning experience and assessed resulting outcomes occurring as a result of incorporating medical home principles in primary care practices.

FIGURE 8B-1 The care model for child health in a medical home.⁵⁸

(Adapted from Wagner’s Chronic Care Model in Wagner EH: Chronic disease management: What will it take to improve care for chronic illness? Effect Clin Prac 1:2-4, 1998. Reprinted with permission from National Initiative for Children’s Healthcare Quality.)

Select Evidence Regarding Elements of the Medical Home and Outcomes

Documented outcomes from the second NICHQ Medical Home Learning Collaborative included an increase in implementation of medical home concepts in the practices, an improvement in participation of parents in their children’s care, a decrease in unplanned hospitalization rates for CSHCN, a reduction in emergency department visits, decreases in numbers of missed school and work days, and an increase in capability of Title V organizations to implement, spread, and sustain medical home concepts within practices. A report on the implementation process and outcomes can be accessed at NICHQ’s Web site.⁵⁸

A descriptive study with a screening tool to identify CSHCN⁵⁹ in primary care settings revealed that the screener has the potential to identify a vulnerable group of children who need comprehensive and coordinated care. An example study of care coordination’s effect on outcomes demonstrated that care coordination was accepted by families and resulted in increased services, but the authors were not able to link the process of coordinating care with the outcomes.⁶⁰

Practical Suggestions for Practitioners Wishing to Implement a Medical Home

NICHQ, the AAP National Center for Medical Home Initiatives for Children with Special Health Care Needs (http://www.medicalhomeinfo.org/), and the Center for Medical Home Improvement (http://www.medicalhomeimprovement.org/) have a wealth of information available for practitioners interested in implementing components of a medical home in their practice or who desire to advocate at a systems level for children with special health care needs. NICHQ has organized specific suggestions by area of focus, including community, health care organization, care partnership support, delivery system design, decision support, and clinical information systems, and these suggestions are listed in Table 8B-5. The AAP National Center for Medical Home Initiatives and Georgetown University collaborated on a report outlining specific methods for creating improvements in communication between primary care practitioners and subspecialists.⁶¹ The report contains practical suggestions and non-copyrighted form templates (a medical home-based care plan; an emergency information form for a child with special health care needs; a family-centered health care plan; a referral fax-back form; and examples of disease-specific forms, such as an action asthma plan) that practitioners can use to implement components of the medical home in their practices. In additiony, example templates for cataloguing resources and for tracking referral responses are included in Appendix, Chapter 8B.

TABLE 8B-5 Ideas for Improvement in Care for CSHCN Found on the NICHQ Web Site

Stimulants

Stimulants remain the most commonly prescribed medication for behavioral disorders.⁵ Psychostimulants are thought to exert their influence on the catecholamine system by reuptake inhibition, enhanced release, or both.⁶ Amphetamines affect reuptake inhibition, enhanced release, and storage. Methylphenidate appears to work primarily through presynaptic reuptake inhibition of dopamine and norepinephrine.

The effectiveness of stimulants for the short-term treatment of ADHD is well documented.⁶ By 1996, 161 randomized controlled trials had been published, including 5 in preschool-aged patients, 150 in school-aged patients, 7 in adolescents, and 9 in adults (American Academy of Child and Adolescent Psychiatry practice parameters, 2002⁶). The finding of improvement in the patients randomly assigned to receive stimulants was robust in comparison with the finding in patients assigned to receive placebo. Studies consistently noted a positive response for core ADHD symptoms, reduced aggression, and improved behavioral compliance. Methylphenidate is the best studied, but dextroamphetamine and amphetamines salts are also reported to be efficacious.⁶ Stimulant medications are FDA approved for use with ADHD (minimum age of 3 for dextroamphetamine, minimum age of 6 for methylphenidate). Although the majority of the studies were short term, lasting less than 12 weeks, longer term trials of up to 24 months also revealed stable long-term improvements, as long as medication was taken.⁷ Of interest is that during a naturalistic followup over 24 to 60 months, there appeared to be a gradual increase in noncompliance with treatment and fewer physician visits per year.⁸

Relaxation Training

Relaxation training is a class of techniques that include slow, controlled breathing; deep muscle relaxation (wherein the major muscle groups are tensed and relaxed); and guided imagery (e.g., the child is encouraged to imagine a calm, soothing scene). It has been examined in two studies^36,37 for children with elevated levels of depressive symptoms; both studies showed significant decreases in depressive symptoms in comparison to no treatment. Relaxation training has not yet been examined in children with diagnosed depressive disorders. Furthermore, these two studies included only white children. Thus, although such techniques may well be worthwhile for children experiencing mild to moderate levels of distress, it remains to be seen whether these techniques alone would suffice for those experiencing diagnosable levels of depression.

Cognitive-Behavioral Therapy

As shown in Table 8D-1, CBT has received the most research attention. CBT has been supported across numerous clinical trials, some targeting just the children for intervention and others targeting both the children and their parents. CBT has demonstrated positive effects across a wide range of ages, across diverse racial and ethnic groups, and both with children who demonstrate elevated levels of depression symptoms and with those who meet diagnostic criteria for major depressive disorder, dysthymic disorder, or depression not otherwise specified. It been administered successfully in both individual and group formats. In addition to showing beneficial effects when tested in research settings, CBT has also been used effectively in school settings.^36,38,39 It has also been examined as bibliotherapy (i.e., having children learn about the therapy components through reading, rather than interaction with a therapist) but with little success.⁴⁰ To date, the successful CBT trials have all involved mental health professionals as therapists, and most of the investigators provided them with additional training, supervision, and a manual to guide the intervention.

CBT treats depression by addressing emotional, behavioral, and cognitive skill deficits linked with the onset and maintenance of depression. Several different CBT manuals have been examined. The Adolescent Coping with Depression Course developed by Clarke and colleagues^41,42 has been used successfully across the greatest number of trials. For children, manuals include Taking Action⁴³ and Primary and Secondary Control Enhancement Training.⁴⁴ The manuals for children and adolescents vary in developmental level, but they share many core components:

Psychoeducation about the nature of depression and the treatment rationale.

Affective education and mood monitoring (the child learns to recognize and label his or her own feelings and the feelings of others, and to monitor and chart his or her mood).

Relaxation training (described previously).

Pleasant activity scheduling (the child learns to increase pleasant activities and decrease unpleasant and solitary activities).

Cognitive restructuring (the child learns to identify and challenge irrational, negative thoughts and replace them with realistic, positive thoughts).

Thought stopping or interruption (the child learns to distract himself or herself to stop ruminating, or obsessively thinking, about depressing topics).

Social skills and assertive communication (the child learns strategies to make friends, improve his or her social support system and resolve interpersonal conflicts).

Problem solving skills (the child learns to generate and evaluate potential solutions to problems and to make plans to implement the chosen solution).

Reinforcement and self-reinforcement (the child is rewarded, and learns to reward himself or herself, for a variety of behaviors, including increasing activity level, problem solving, and social interaction).

In CBT, parents are often involved in their child’s treatment. Typically, parents are (1) informed of the skills their child is learning, (2) taught to reinforce their child’s efforts and behavior changes, and (3) encouraged to communicate better with their child via negotiation and problem solving. In most programs, this parent involvement occurs when one or both parents join the child’s session for a few minutes at the end of each appointment or, occasionally, attend an entire session together with the child or alone with the therapist. In other programs, parent involvement is more intense, including a series of parent or family sessions in addition to the sessions with the child. Two of the CBT studies actually tested the benefit of combined child CBT plus parent CBT versus child-focused CBT.^45,46 Neither study found the combined treatment significantly better than child-focused CBT.

Interpersonal Therapy for Adolescents

Interpersonal therapy has been examined in two studies, each focused on adolescents with a diagnosis of a depressive disorder.^47,48 Interpersonal therapy has been tested primarily with Hispanic adolescents, but non-Hispanic adolescents made up one third of the sample in the trial by Mufson and colleagues.⁴⁸ Mufson and colleagues also included adolescents with comorbid anxiety and were able to treat them successfully. Interpersonal therapy for adolescents has been administered only in an individual format. In both trials, mental health professionals were employed as therapists and were provided with additional training, supervision, and a manual to guide intervention.

Interpersonal therapy for adolescents is designed to reduce depressive symptoms by focusing on important interpersonal relationships, including the parent-child relationship, peer friendships, and romantic relationships. It stems from research indicating that significant interpersonal difficulties often both precipitate and maintain depression.^49–51 Some features of interpersonal therapy for adolescents are reminiscent of CBT, but the overarching focus is the interpersonal problem associated with the onset of depression. Interpersonal therapy includes the following:

Although interpersonal therapy is an adolescent-focused intervention, parents and other significant individuals in the adolescent’s life are sometimes brought into treatment sessions to assist the adolescent in dealing with interpersonal problems that the adolescent may be experiencing with those individuals.

Summary and Recommendations

The evidence for the treatment of depression in children supports three psychological interventions: relaxation training, CBT, and interpersonal therapy. Of these, CBT currently has the most consistent evidence across a wide range of ages, ethnicities, and symptom severity levels. CBT has thus far been administered only by mental health professionals, the majority of whom received additional specialty training in those techniques. Therefore, we recommend referral to a child mental health provider specializing in CBT for depression. If trained providers are available, the clinician might consider referring Hispanic adolescents for interpersonal therapy, as this appears to be an effective treatment for that group, perhaps because of the fit between the principles of interpersonal therapy and the collectivist nature of Hispanic culture.⁴⁸

Relaxation Training

Relaxation training, including muscle relaxation and imagery, was examined in six studies, published between 1969 and 1996, for children with anxiety-related problems. Thus far, it has been examined only in children aged 7 to 18 with anxiety symptoms or fearful behavior but without a diagnosis of anxiety. Despite these early promising findings and the simplicity of the intervention, relaxation training has not been examined as a stand-alone intervention with children who have a diagnosed anxiety disorder. Instead, relaxation training has been integrated into both exposure-based therapies and CBT (see later discussion). In view of these findings, relaxation training may be a helpful intervention for children who show fearfulness and anxiety-related symptoms, but it is unclear whether relaxation alone would provide clinically significant benefit for children with a diagnosed anxiety disorder.

Exposure with Reinforcement, Relaxation, and/or Modeling

The majority of supported interventions involve controlled exposure to the feared object or situation (e.g., a specific object such as a spider or dog; public speaking; social interaction; separation from parents). Exposure has been tested as a stand-alone intervention in 29 studies; exposure is also a key component of CBT for anxiety (see later discussion). It has demonstrated positive effects across a wide range of ages, across diverse racial and ethnic groups, and both with children who show elevated levels of anxiety symptoms and those who meet diagnostic criteria for specific phobia^55–57 and posttraumatic stress disorder (see Table 8D-2).⁵⁸ One trial of exposure involved participants who had comorbid depression and enuresis and found that the presence or absense of comorbidity was unrelated to treatment outcomes.⁵⁵

Exposure therapy has been administered successfully in both individual and group formats. In addition to producing beneficial effects when tested in research settings, it has also been used effectively in school settings^58–63 and, once, in a dental practice.⁶⁴ In one study, the investigators conducted exposure through videotaped modeling without the involvement of a therapist, but they achieved little success.⁶⁵ The majority of successful trials of exposure therapy have employed mental health professionals; however, researchers in one study of children with dental fears successfully trained dental students to implement the procedures.⁶⁴ In addition, most investigators have not reported extensive additional training, supervision, or manuals to guide intervention, but it is not clear from the published reports whether these efforts were unnecessary or simply not described.

Exposure is typically graduated, beginning with real or imagined situations that are minimally threatening and progressing to those that are maximally anxiety provoking. The therapist generally works with the child to develop a fear hierarchy, with the feared stimuli ordered from least to most anxiety provoking. Then, the child moves through the hierarchy in a graduated manner, with the therapist’s assistance, so that each new exposure is challenging but not overwhelming. For a child with separation anxiety, for example, the initial exposure may entail being in a different room from the caregiver for a few minutes, working up to longer periods of time and greater distances, until the child is able to stay with a babysitter for a parent’s evening out.

Exposure is often accompanied by relaxation training (19 studies), reinforcement or rewards (2 studies) and/or modeling (12 studies). (In total, there were more than 29 studies because some included more than one exposure condition.) Systematic desensitization combines graduated exposure with relaxation training so that the child uses relaxation skills in order to cope more easily with the real or imagined anxiety-provoking situation. Reinforced exposure entails rewarding the child with praise, a privilege or a desired prize on completion of each step in the exposure hierarchy. Modeling has also been combined with exposure with good effect. In this situation, the therapist, another child, or an actor in a video undergoes exposure to the feared situation or object so that the fearful child can observe the model and see that the model is unharmed. After the child observes the model, he or she is encouraged to imitate the model and thus undergo exposure himself or herself. Often, combinations of these techniques are employed (e.g., exposure with relaxation and reinforcement).

Cognitive-Behavioral Therapy

CBT has received the greatest empirical attention in treating anxiety-related problems and disorders. CBT has been supported in versions targeting just the child for intervention (40 studies) and in versions targeting both the child and his or her parent or parents together (4 studies) and separately (9 studies). Two studies also included a teacher consultation component.^66,67 This component has demonstrated positive effects across a wide range of ages, across diverse racial and ethnic groups, and both with children who show elevated levels of anxiety symptoms and with those who meet diagnostic criteria for social phobia,^55,68–70 generalized anxiety disorder,^70–77 separation anxiety,^71–77 posttraumatic stress disorder,⁷⁸ and obsessive-compulsive disorder.^79–81 Several trials have revealed positive treatment effects even when participants have comorbid conditions in addition to their anxiety.^{55,67,68,72–74,76–82}

CBT for anxiety has been successfully administered in both individual and group contexts. In addition to showing beneficial effects in research settings, it has also been used effectively in jail⁸³ and school settings.^{61,75,84–86} In the majority of successful trials of CBT, the investigators have employed mental health professionals; however, two groups successfully trained college students to implement the procedures.^87,88 The amount of additional specialty training and supervision has varied across studies, but in most, therapists were provided with a manual to guide intervention.

CBT for anxiety and CBT for depression share a focus on emotions, behaviors, and cognitions. However, exposure, which is not present in CBT for depression, is a core component of CBT for anxiety. Several different CBT manuals have been examined and shown success, including Coping Cat,^89,90 FRIENDS,^91–93 social effectiveness training,⁹⁴ and family anxiety management.⁹⁵

CBT for child anxiety typically involves the following:

Psychoeducation about the nature of anxiety and fear, and the treatment rationale.

Affective education and monitoring (discussed previously).

Relaxation training (discussed previously).

Cognitive restructuring (discussed previously; in this situation, anxiety-provoking thoughts are targeted).

Thought stopping or interruption (described previously; in this situation, anxious rumination is targeted).

Fear hierarchy and planning for success (the child learns to generate a fear hierarchy to break down a big problem into smaller steps and to plan ahead for how he or she will successfully navigate anxiety-provoking situations).

Exposure (described previously).

Skill building (the child learns to improve skills that may contribute to his or her anxiety, such as social skills and problem-solving).

Reinforcement and self-reinforcement (described previously; in this situation, the rewards are for using coping skills and engaging in feared activities).

As in CBT for child depression, parents of anxious children are often involved in their child’s treatment. During occasional check-in or complete sessions, parents are educated about the treatment their child is receiving and are provided with the necessary skills to implement intervention components with their child at home. In 15 studies, parents were provided with a more extensive intervention. For example, in family anxiety management training,⁹⁵ parents are provided with a CBT program to help them deal with their own anxiety and to help them more effectively assist their child with the treatment program. The parents attend a group that covers essentially the same therapeutic content as in the child’s sessions (described previously). In addition, parents are taught to act as role models to show their children how to manage anxiety successfully. They also learn to provide reinforcement to their child for completing exposures and engaging in feared activities outside of sessions. Finally, parents learn to discourage repeated displays of anxiety through planned selective ignoring (e.g., the parent intentionally fails to notice their child’s whining or clinging, rather than responding by allowing the child to avoid a feared situation). Some of these studies directly tested the benefit of this additional parent involvement by comparing the effects of traditional child-focused CBT with child-focused CBT plus parent CBT. The results of these studies have been mixed, some indicating superior effects of combined treatments (e.g., Deblinger et al⁷⁸) and others finding no differences (e.g., King et al⁶⁷ and Nauta et al⁹⁶).

Client-Centered Therapy

Client-centered therapy has yielded positive effects across five studies. In client-centered therapy, children are encouraged to express themselves openly while the therapist listens supportively and encourages the children to accept their feelings and gain greater self-awareness. This therapy has been examined in both individual and group formats and has demonstrated efficacy across a wide range of ages. In one study of client-centered therapy for anxiety, involving African American and Hispanic children, investigators reported treatment effects that were smaller than in the studies including only white children. In addition, none of the studies involved participants with an anxiety disorder diagnosis, instead focusing on children with subclinical levels of anxiety, and none included children with comorbidity. Thus, it is not clear whether this intervention would be effective with children from minority groups or with those experiencing more severe anxiety.

Summary and Recommendations

The evidence for the treatment of anxiety and fears in children supports four psychological interventions: relaxation training, graduated exposure, CBT, and client-centered therapy. Of these, CBT and exposure-based interventions with reinforcement, relaxation, and modeling currently show the most consistent success across a wide range of ages, ethnicities, and symptom severity levels. Some investigators have successfully trained paraprofessionals to administer these treatments to children who have mild anxiety, but most have employed trained mental health professionals. Therefore, we recommend additional training for providers interested in implementing these procedures in their own practices. For children with moderate to severe levels of anxiety, we recommend referral to a child mental health provider who specializes in administering exposure-based interventions.

Relaxation Training

Relaxation training, including controlled breathing and muscle relaxation, was tested in six studies for children with inattention, impulsivity, and/or hyperactivity. It has been successfully implemented in both individual and group formats and has been used with success in school settings.^98–101 Interestingly, despite the relative simplicity of these techniques, relaxation training for ADHD has been tested only with trained mental health professionals as therapists. Thus far, it has been examined only in children aged 6 to 12 who exhibited symptoms of inattention, impulsivity, and/or hyperactivity but who had no diagnosis of ADHD and no comorbid conditions. Furthermore, the studies are quite old in comparison with the rest of the evidence base (the newest one is dated 1984), and the samples are poorly described (e.g., no information is provided about the ethnicity of the clients). Thus, although relaxation training may be a worthwhile recommendation for children who show somewhat greater activity levels than others, it is unclear whether it would provide benefit for children with a diagnosis of ADHD.

Multimodal Cognitive and Behavioral Intervention

The most promising psychological intervention for children with ADHD is a combination of child-focused CBT, BPT, and/or teacher consultation or classroom management training (CMT). Some combination of these treatments has been tested in three trials: one trial involved CBT and CMT,¹⁰² and two trials involved CBT and BPT.^103,104 These multitargeted interventions showed positive effects with both white and African American children between the ages of 7 and 13. They have been used successfully with children who had a diagnosis of ADHD, as well as undiagnosed hyperactivity problems. Furthermore, one trial successfully used this intervention with participants whose comorbid conditions included conduct disorder, oppositional defiant disorder, anxiety disorders, and dysthymic disorder.¹⁰⁴ In each trial, mental health professionals were employed as therapists and were provided with either ongoing supervision or a manual to guide intervention.

In these multitargeted interventions, the children are taught self-control skills while parents and teachers are taught behavioral child management skills. Child CBT generally focuses on teaching children how to use self-instruction to reduce impulsivity, increase reflection and control, and improve performance on tasks requiring concentration. BPT is aimed at helping parents create contingencies in the home that will make appropriate, on-task behavior more rewarding than less desirable behavior. Iindividual or group sessions with the parents focus on learning and applying behavioral principles and methods. Coverage usually includes maximizing parental attention and praise in response to appropriate child behavior, withholding attention (and praise) when behavior is inappropriate, developing reward and incentive systems (e.g., charts, points, tokens) to encourage desired behavior, and using time-out and mild punishment (e.g., losing a point or privilege) for noncompliance. Parents are also taught how to issue commands aligned with the child’s ability to respond (e.g., issuing one directive at a time). Like BPT, teacher-focused CMT is aimed at helping teachers to establish and maintain contingencies at school that will reinforce self-control, attention to schoolwork, and appropriate social behavior with teachers and peers. Similar to BPT, coverage usually includes such behavioral interventions as developing reward and incentive systems (e.g., charts, points, tokens) to encourage desired behavior, issuing more appropriate instructions or commands, and organizing the classroom to help the child attend (e.g., seating the child near the front, removing distractions).

Summary and Recommendations

The evidence for the treatment of ADHD and associated symptoms supports two psychological interventions: relaxation training and multitargeted cognitive and behavioral treatment. Relaxation training has not been examined with children meeting diagnostic criteria for ADHD, and neither intervention has been examined in a controlled trial with children older than 13 years. In contrast, pharmacological interventions, and psychostimulants in particular, have shown consistently positive effects for children with ADHD (see Chapter 8C). Indeed, stimulant medication has repeatedly demonstrated superiority to psychological treatment (e.g., “Multimodal Treatment Study of Children with ADHD”¹⁰⁵ and Abikoff et al¹⁰⁶), although controversy still exists regarding whether a combination of medication and multimodal psychological treatment may be superior to medication alone (e.g., Pelham et al¹⁰⁷), especially in children with comorbid anxiety and behavior problems¹⁰⁸ or in children from more highly educated families.¹⁰⁹ In view of the available evidence, medications are currently the treatment of choice for ADHD. Cognitive and behavioral interventions for the child, parent, and teacher may provide a helpful complement but are not recommended as the sole treatment for children with ADHD.