A Pragmatic Approach for Troubled Kids

By Leila Abboud,  The Wall Street Journal

With persistent concerns about using powerful psychiatric drugs on children, there is growing interest in counseling techniques for troubled kids that aim to change destructive behavior.

These therapies are getting a push because they have been shown in numerous clinical trials over the past decade to be effective on kids with severe behavioral problems, where other approaches have often failed. The techniques take a pragmatic approach, often using a set curriculum to teach new behaviors, rather than ferreting out the underlying emotional problem as with traditional psychotherapy. In another departure from traditional talk therapies, much of the counseling is often directed at parents.

Developed mostly in the past decade at academic centers, the therapies target kids with diagnoses like conduct disorder, oppositional defiant disorder or bipolar disorder, who are at risk of getting kicked out of school or breaking laws. By some estimates, there are 1.4 million to 4.2 million children who meet the criteria for conduct disorders alone.

Today, many of these kids are placed on powerful psychiatric medications such as Eli Lilly & Co.’s Zyprexa and Johnson & Johnson’s Risperdal that aren’t well-studied in children. The drugs are often ineffective, and parents worry about side effects, especially in the wake of news about the potential link between antidepressants and suicidal tendencies in teens. These newer behavioral therapies, including Parent Management Training at Yale University and the Incredible Years program at the University of Washington, Seattle, can reduce the need for drugs, or be effective where drugs alone have not, say the programs’ developers.

The techniques are often called “evidence-based” therapies because their efficacy has been demonstrated in rigorous studies. The more traditional forms of talk therapy haven’t been studied as extensively because they vary so widely by individual practitioner.

Among efforts to expand access to these therapies, experts at Columbia University’s Center for the Advancement of Children’s Mental Health have distilled a selection of techniques into a course and workbooks to make it easier to train mental-health practitioners. Six hundred therapists from Florida’s state-funded mental-health clinics have taken the course, and others from New York are also enrolling. Another course teaches parents about the therapies.

Several academics who designed the therapies have founded companies to market training materials and work with state and local agencies to offer the treatments. And professional organizations such as the American Psychological Association, and government agencies including the Substance Abuse and Mental Health Services Administration (www.samhsa.gov), have compiled lists of therapies with the strongest scientific evidence behind them.

These approaches are still little-known outside of the universities where they were developed. Unlike drugs, which are backed by pharmaceutical companies’ marketing machines, no system exists for disseminating effective psychotherapies. And there are significant obstacles to wider use. Some therapists dislike what they view as a cookie-cutter approach that affects their rapport with patients. Often the therapies are shortened or modified when used outside of the university setting, so that they no longer correspond to what was originally proved to have worked.

The therapies can also be expensive; one approach costs $4,500 for a three-to-five-month program. Mental-health services aren’t always covered by insurance, and insurers that do pay for it typically don’t require that practitioners use evidence-based approaches.

Here is a closer look at three of the most well-known evidence-based therapies for children.

Parent Management Training
Developed by Alan Kazdin, a child psychologist at the Parenting Center and Child Conduct Clinic at Yale University, the program treats children ages two to 13 who display aggressive and antisocial behavior. During the typical program of five to 15 weeks, therapists train parents how to manage their children’s behavior through role-playing exercises and a disciplined system of rewards and punishments that is implemented in specific steps.

Since age 4, Robin Ruxer’s son Alexander had thrown frequent, violent fits when asked to do simple things like come to the dinner table. He was aggressive with his younger sister and was repeatedly sent to the principal’s office at school for being disruptive. “I was at the end of my rope,” says Ms. Ruxer, of Westhaven, Conn. Alex’s pediatrician diagnosed attention deficit hyperactivity disorder and suggested medication, but Ms. Ruxer and her husband, Duane, refused.

So they turned to the Child Conduct Clinic. Each week the therapist taught Ms. Ruxer a new technique, which she would explain to her husband at home. The first was called “positive opposite” in which instead of just telling the child to stop doing something or getting angry, the parent tells him what behavior would be better. If Alex was screaming in the house, Ms. Ruxer would say: “If you need to be loud, go outside in the yard and then come back in when you’re done.” She learned a very specific way to praise Alex when he did something right.

About six months later, Alex’s teachers said he was like a different kid, Ms. Ruxer says, and life at home was far less stressful. Now age 7, Alex plans to start his own individual therapy in a supplemental program. Parent Management Training has been widely studied in the past 20 years. Dr. Kazdin cites over 50 controlled studies that support use of the technique, and has done 10 major studies himself that ranged in size from 50 to 250 kids.

At the Yale clinic, each session costs $20-$100 on a sliding scale based on need, and may be paid for by insurance that covers mental-health visits. PMT is currently done at a handful of university medical centers outside of Yale, including the University of Washington at Seattle and the Oregon Social Learning Center, in Eugene, Ore.

The Incredible Years
The Incredible Years program is intended for parents who have children, ages two to 8, with conduct problems. Usually the parent attends about three months of group sessions led by a therapist, which are structured around videos depicting difficult situations with children. The section that targets children uses a character called Dina Dinosaur to teach kids to manage anger, practice conversational skills and behave appropriately in class. School districts have used another module of the program to train teachers to handle disruptive kids in the classroom.

Seven studies over the past 20 years support the Incredible Years approach, according to Carolyn Webster-Stratton, the clinical psychologist who developed the program at the University of Washington. The therapy was associated with better parent-child interactions, reduced child-conduct problems at home and school, and reduced reliance on critical or violent forms of discipline.

The therapy is free at Dr. Stratton’s clinic, which is funded largely by the National Institutes of Health. The center also markets training materials to government health-care agencies, mental-health clinics, hospitals and schools, and fees vary at those facilities. Training modules have been sold in 49 states. Dr. Stratton maintains a database of 8,826 professionals who have been trained in the Incredible Years programs for parents, children, and schools in the past eight years.

Multi-systemic Therapy
Developed at Medical University of South Carolina, MST is used primarily for juvenile offenders ages 12 to 17. Adolescents are usually referred to the treatment by a court because they are at high risk of being incarcerated or sent to a residential facility or foster care. The intense intervention, lasting three to five months, focuses on changing the factors that make the adolescent prone to risky behavior. The therapist looks at all areas of the teen’s life: family, school, peer group and probation officer. The therapist comes to the home or school, often multiple times a week, and is available by phone 24 hours a day.

MST trains the caregiver in much the same way Parent Management Training does, setting defined rules for the adolescent’s behavior, monitoring compliance with the rules, and doling out punishments or rewards. But MST also addresses problems the parent may have, such as substance abuse, a psychiatric condition or a stressful full-time job. The therapist seeks practical solutions like finding child care or keeping parents on their psychiatric medications. At school, the therapist might try to decrease the teenager’s association with deviant friends, while encouraging him to make other friends.

Fourteen clinical trials of MST have been published in scientific journals. In three trials with violent and chronic juvenile offenders, MST produced 25 percent to 70 percent decreases in the long-term rates of re-arrest, and 47 percent to 64 percent decreases in long-term rates of out-of-home placements. While MST typically costs about $4,500 a person, proponents say it can produce significant savings by keeping the teens out of jail or psychiatric facilities, and from committing crime.