Psychotherapies for Young People - Trends Over Time

This post will discuss an article titled “Are Psychotherapies for Young People Growing Stronger? Tracking Trends Over Time for Youth Anxiety, Depression, Attention-Deficit/Hyperactivity Disorder, and Conduct Problems.” The article was published by Weisz, Kuppens, Yi-Ng, Vaughn-Coaxum, Ugueto, Eckshtain, and Corteselli in December of 2018 in the APS journal, Perspectives on Psychological Science. The authors of this article sought to investigate changes over time in treatment effects for four of the most frequently treated mental health problems in youth; anxiety, depression, attention-deficit hyperactivity disorder (ADHD), and conduct disorder.

What did they do?

The authors accumulated a collection of randomized controlled trials (RCTs) that were published between January of 1960 and May of 2017. Included articles involved youth between the ages of 4 and 18 years. A total of 453 RCTs were identified, encompassing 31,933 participants. In order to track the trends associated with psychotherapy, the authors tracked temporal trends for each problem domain and then examined multiple study characteristics that might impact those trends.

Why did they do it?

As noted by the authors, nearly half of all lifetime disorders emerge by the age of 14 years, with 1 in 3 youths experiencing some form of mental health disorder by the age of 16. Given the impact and rising extent to which youth are experiencing mental health problems, the investigation and development of youth psychotherapy is of great interest to clinicians.

Although many beneficial therapies have emerged over time, there is always room for improvement. The authors pose an important question: Are our methods of developing and testing youth psychological therapies producing improvement?

How did they do it?

The authors conducted a systematic review of existing literature regarding the development of empirically supported treatments for youths, specifically. The final group of studies included in this review was made up of 453 studies that were published between 1963 and 2016. Of the 31,933 participants subsequently included, the mean age was 10.50 years (SD = 3.80), the mean percentage of males was 61.02% (SD = 25.35), and 64.57% of the study samples were White.

The authors defined “psychopathology” as meeting criteria for a DSM or International Classification of Diseases (ICD) disorder, or showing elevated symptoms in one of the areas of interest. Multiple study characteristics were examined, including target problem of the study, problem assessed in outcome, study quality, attrition, objective, power, control conditions, whether a diagnosis was required for study inclusion, sample source, treatment setting, treatment duration, demographic information, and treatment type. Effect sizes for problem-relevant outcomes were analyzed using multilevel meta analysis.

What did they find?

Overall, there was no significant change in treatment effect sizes over the years for anxiety or ADHD. However, there were significant decreases in treatment effects over time for depression and conduct problems. Moderation analyses were completed to further evaluate these associations.

For anxiety, there were no significant changes in treatment effect sizes over time. Moderation analyses revealed an interaction with measure attrition, such that effect sizes increased significantly over time for measures associated with low attrition.

Regarding depression, the significant decline in effect sizes over time was qualified by interactions relative to the clinical representativeness of the studies: Effect sizes increased significantly over time in studies with clinically referred youths and near significantly (p = .058) for studies in clinical settings. However, treatment effect sizes decreased over time in studies with non-referred youths and in nonclinical settings. These findings suggest broadly that the effects of treatment for clinically depressed youth may have grown stronger across time.

Analyses of ADHD treatment studies showed no significant change in treatment effect sizes over time, but a significant interaction was revealed between study year and measure objectivity. While there was no evidence to support temporal change in effect when subjective measures (e.g., self-report or other-report) were used, there was a significant decrease in effect sizes when objective measures (e.g., behavioral counts such as on-task vs. off-task behavior in class for ADHD studies or event data such as arrest counts for conduct problem studies) were used.

Conduct problem treatment effects showed a fairly uniform decrease overtime. Two interactions were revealed: (1) an interaction between measurement attrition and study year, and (2) an interaction between measure objectivity and study year. Specifically, there was a significant decrease in treatment effect for measures with low attrition, and a significant decrease in treatment effect for objective measures (e.g., behavioral counts such as on-task vs. off-task behavior in class, event data such as arrest counts).

What does it all mean (our take)?

This review is a fantastic resource for clinicians interested in learning more about how we’ve been progressing over time with regard to treating our youth. Reader beware - when you are reviewing meta-analytic articles and the authors discuss moderation effects, these interactions tell an important story about driving factors that are impacting the effects reported. We encourage you to not only focus on overall effects, but spend a considerable amount of time evaluating the moderation effects.

Overall, it seems that results from this article suggest that, as a field, we can continue getting stronger with regard to our ability to treat youth mental health problems. We should continue to do our best to approach intervention not just from a clinical perspective, but from a population health perspective. The continued leveraging of technology to accomplish this goal will be critical - but as a field we need to step up to the plate and accept the challenge. Let’s continue forging forward and developing new ways to help our young population as best as we can!