Evidence-Based Treatments for Children and Adolescents: An Updated Review of Indicators of Efficacy and Effectiveness

Transcription

1 Evidence-Based Treatments for Children and Adolescents: An Updated Review of Indicators of Efficacy and iveness Bruce F. Chorpita, University of California, Los Angeles Eric L. Daleiden, PracticeWise, LLC Chad Ebesutani, University of California, Los Angeles John Young, University of Mississippi Kimberly D. Becker, Johns Hopkins Bloomberg of Public Health Brad J. Nakamura, University of Hawaii Lisa Phillips, PracticeWise, LLC Alyssa Ward, University of California, Los Angeles Roxanna Lynch, University of Hawaii Lindsay Trent, University of Mississippi Rita L. Smith, University of California, San Francisco Kelsie Okamura, University of Hawaii Nicole Starace, University of California, Los Angeles This updated review of evidence-based treatments follows the original review performed by the Hawaii Task Force. Over 750 treatment protocols from 435 studies were coded and rated on a 5-level strength of evidence system. Results showed large numbers of evidencebased treatments applicable to anxiety, attention, autism, depression, disruptive behavior, eating problems, substance use, and traumatic stress. Treatments were reviewed in terms of diversity of client characteristics, treatment settings and formats, therapist characteristics, and other variables potentially related to feasibility and generalizability. Overall, the literature has Address correspondence to Bruce F. Chorpita, Department of Psychology, University of California, Los Angeles, Box , Los Angeles, CA chorpita@ ucla.edu. expanded considerably since the previous review, yielding a growing list of options and information available to guide decisions about treatment selection. Key words: children, dissemination, evidence-based, services. [Clin Psychol Sci Prac 18: , 2011] Numerous reviews of the child and adolescent treatment literatures have been conducted over the past 30 years (Lonigan, Elbert, & Bennett-Johnson, 1998; Silverman & Hinshaw, 2008; Weisz, Hawley, & Jensen-Doss, 2004; Weisz, Weiss, Han, Granger, & Morton, 1995). Our last comprehensive report (Chorpita et al., 2002) preceded several advances, both in the scope and methods of review and in the children s mental health literature. The mental health field in general continues its focus on evidence-based practice, although there has been continued controversy over definitions (e.g., APA Presidential Task Force on Evidence-Based Practice, Ó 2011 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association. All rights reserved. For permissions, please permissionsuk@wiley.com 154

2 2006; Barkham & Mellor-Clark, 2003; Lilienfeld, 2007; Weisz, Sandler, Durlak, & Anton, 2006; Westen, Novotny, & Thompson-Brenner, 2004). We have identified over 140 new randomized clinical trials (RCTs) since 2000, more than the total number in our initial review (Chorpita et al., 2002). As new perspectives and new findings emerge, we maintain the position articulated by Stuart and Lilienfeld (2007) as well as others that the debate is about how evidence should inform clinical practice, not whether it should. That said, the manner in which evidence-guided practice has evolved, from one that emphasized lists of treatments to a model of evidence-guided decision support, in which the treatment outcome literature plays a critical role for some decisions, but not for others (e.g., Daleiden & Chorpita, 2005). This distinction is consistent with the distinction between evidence-based practice in psychology and evidence-based treatments offered by the APA Presidential Task Force on Evidence-Based Practice in Psychology (2006): EBPP articulates a decision-making process for integrating multiple streams of research evidence including but not limited to summaries of evidence-based treatments (p. 273). For example, the issue of treatment selection is perhaps best informed by the treatment outcome literature, but the decision regarding when to end an episode of clinical care might be guided by the outcomes gathered on that child. Thus, reviews of the outcome literature represent a critical information source seated in the larger context of an evidenceinformed decision model that prioritizes different sources of evidence as a function of the different decisions being made. Another shift in the field is an increasing emphasis on external validity associated with treatment approaches (e.g., Weisz et al., 2004). Although the pioneering work in the area of classification of evidencebased treatments initially emphasized indicators of effectiveness (Acceptability, Feasibility, Cost Benefit; APA Task Force on Psychological Intervention Guidelines, 1995), for years the field has focused on definitions of evidence-based practice that rely almost exclusively on uniform summaries of indicators of efficacy ( leveling systems using number of replications, nature of control groups, etc.) with limited or less uniform reviews of indicators of effectiveness. Given the continued growth of the outcome literature, we feel that these indicators of effectiveness are becoming increasingly important. For example, 10 successful replications supporting a particular treatment (assuming the absence of predictors of differential outcome) would tell us little about whether that treatment is better suited for a given child than a treatment supported by only two replications. In the decision-making framework, those 10 replications are primarily useful to the extent that they extend the findings to new populations, settings, or contexts. Perhaps one treatment has been tested with children whose characteristics are highly similar to the child in question and another equally efficacious treatment has not, thus guiding our decision toward the more externally valid match. Overall, perhaps the evidence-based label is no longer sufficiently informative. One other change in emphasis involves the movement toward comprehensiveness as opposed to sufficiency in organizing reviews of the evidence base. Early work by the APA Division 12 (Task Force on Promotion and Dissemination of Psychological Procedures, 1995) was implicitly characterized by a sufficiency heuristic, in which a treatment was declared evidence based when a minimum criterion had been exceeded (e.g., two or more RCTs). However, to produce a representative classification of some of the indicators of effectiveness of treatments, it is important to consider the full literature. Even our initial report, which strove for comprehensiveness relative to contemporary lists of evidence-based practices for children, indexed only 115 treatment outcome studies in children s mental health. Ironically, the great increase in the number of published RCTs has led us to focus our recent review efforts on those designs exclusively, which is a departure from some of our early methodologies. Thus, single-subject experimental designs are not represented in this review, despite their value, particularly with respect to low base rate or atypical child problems or characteristics. In an attempt to balance our ideals for a comprehensive review with the feasibility issues inherent in that process, we prepared this updated summary with the primary aim of supporting clinical decision making in applied contexts. This review builds on existing reviews by (a) organizing treatments into broad categories based on procedural and theoretical similarities, (b) offering a systematic EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 155

3 classification of indicators of effectiveness that is uniform across the literature, and (c) adding two new strength of evidence levels to expose a number of potentially promising treatments that failed to meet more rigorous criteria. METHOD Studies of psychosocial and combined treatments from 1965 to 2009 were identified through (a) computerized searches using electronic databases (e.g., PsycINFO, Medline, SCOPUS) conducted by a team of over 15 professionals who over a period of four years received small, monetary rewards for any new study identified (thus, electronic search terms were not standardized); (b) evaluation of studies contained in other major literature reviews (e.g., Silverman & Hinshaw, 2008; Weisz et al., 2004); (c) personal communication with national scholars in treatment outcome research; (d) nominations from members of Hawaii s Evidence Based Services Committee and the Minnesota Department of Human Services; and (e) nominations from the professional community to an online, interactive version of earlier reviews. To be included, the study had to (a) test at least one active psychosocial or combined treatment relative to a control group, (b) use random assignment, and (c) report outcome measures at posttreatment. We excluded articles that described followup evaluations only, universal prevention studies, uncontrolled efficacy trials, or studies in which the majority of participants were over the age of 21. Of over 1,500 articles screened, 413 articles describing 435 studies had sufficient treatment descriptions, comparative outcome data at posttreatment assessments, evidence of random assignment, and were coded. Of those coded 435 studies, 374 ultimately met the above eligibility criteria, and 314 of those fell into problem areas that were a focus of this review (references are available upon request). With respect to indicators of clinical severity, 64 studies (14.7%) used both a diagnostic measure and a criterion cutoff score on a separate measure, 113 studies (26.0%) used diagnosis only, 128 studies (29.4%) used a cutoff score only, and 130 (29.9%) used neither a cutoff nor a diagnostic measure. Problem areas for review were based on a recent factoring of the treatment literature (Chorpita & Daleiden, 2009) and feedback from the Hawaii committee and other stakeholders. The final problem areas were the following: anxiety and avoidance, attention and hyperactivity, autism spectrum, depression or withdrawal, disruptive behavior, eating problems, substance use, and traumatic stress. Strength of Evidence We employed a set of standards based in part on the original standards of APA Division 12. Nevertheless, in the broader paradigm of knowledge management in health care (e.g., Graham et al., 2006), the application of science to practice is characterized by a diversity of strategies and standards that evolve over time as part of a broader cycle of knowledge (Frenk, 2009) and that there are limitations to any single strategy, including those in the tradition of tallying replications of significant contrasts (see Rodgers, 2010). Thus, this 5-level system is not proposed as a definitive view of the literature; rather, it is provided as an illustration of a collectively determined set of standards representing priorities from a balanced membership of stakeholders in children s mental health (including input from researchers, policymakers, families, and providers. As in our previous review, the grading uses a 5- level system, with the first two levels corresponding to definitions established by the APA Division 12 Task Force for Promotion and Dissemination of Psychological Procedures (1995), with the exception that we did not consider single-subject designs in this review (see Table 1). Additional levels to these first two were added as part of the multiyear stakeholder participation process outlined previously. Of note is that Level 4 in the current review refers to interventions that performed better than waitlist in at least one study, which were not considered distinct from the no support group in our previous review. Our new Level 5 refers to treatments that have been tested but did not perform significantly better than any controls. Because Level 5 treatments are only a small and unrepresentative sample of the larger population of protocols without support (many of which have never been tested), their characteristics are not summarized in the results tables. Leveling decisions were based on outcomes involving measures coded as relevant to target symptoms CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

4 Table 1. Strength of evidence definitions only. Specifically, a treatment had to meet the strength of evidence requirements on a measure that was deemed the primary outcome measure for the expected target of the intervention (e.g., depressed mood in a study targeting depression). Moreover, coders identified a single measure from each study determined to be the best measure of the target symptoms. In the face of ambiguity, coders were instructed to select those measures that had greater frequency of occurrence across the literature (a rough indicator of higher standardization and benchmarking ability). All treatments in a study were assigned leveling contrasts, which reflected significant outcome differences on this measure observed between groups. These contrasts were then aggregated across all studies within a given problem domain to yield strength of evidence ratings for each treatment. Level 1: Best Support I. At least two randomized trials demonstrating efficacy in one or more of the following ways: a. Superior to pill placebo, psychological placebo, or another treatment. b. Equivalent to all other groups representing at least one Level 1 or Level 2 treatment in a study with adequate statistical power (30 participants per group on average; cf. Kazdin & Bass, 1989) and that showed significant pre post change in the index group as well as the group(s) being tied. Ties of treatments that have previously qualified only through ties are ineligible. II. Experiments must be conducted with treatment manuals. III. s must have been demonstrated by at least two different investigator teams. Level 2: Good Support I. Two experiments showing the treatment is (statistically significantly) superior to a waiting list or no-treatment control group. Manuals, specification of sample, and independent investigators are not required. OR II. One between-group design experiment with clear specification of group, use of manuals, and demonstrating efficacy by either: a. Superior to pill placebo, psychological placebo, or another treatment. b. Equivalent to an established treatment (see qualifying tie definition above). Level 3: Moderate Support One between-group design experiment with clear specification of group and treatment approach and demonstrating efficacy by either: a. Superior to pill placebo, psychological placebo, or another treatment. b. Equivalent to an already established treatment in experiments with adequate statistical power (30 participants per group on average). Level 4: Minimal Support One experiment showing the treatment is (statistically significantly) superior to a waiting list or no-treatment control group. Manuals, specification of sample, and independent investigators are not required. Level 5: No Support The treatment has been tested in at least one study, but has failed to meet criteria for levels 1 through 4. Treatments Families We chose a broad level of analysis for defining treatments such that interventions sharing a majority of components with similar clinical strategies and theoretical underpinnings were considered to belong to a single treatment family. For example, rather than score each Cognitive Behavior protocol for anxiety on its own (we coded over 40 such protocols for this report), these were collectively considered a single group that could achieve a particular level of scientific support, with many replications. Guided by stakeholder input, this approach sought a balance of a reliable separation between constructs of interest in the applied setting and a focus on generic as opposed to brand-name treatment modalities when clear empirical justification for such distinctions did not exist (Chorpita & Daleiden, 2009; Chorpita & Regan, 2009). Although we realize that proposing definitions of treatment families can introduce subjectivity, this position is similar to that of Rogers and Vismara (2008), who stated that in the service of the public, it would be helpful for treatment givers to point out commonalities between the brandname interventions and others, and to document empirically the specific generic efficacious practices underlying the effects in the brand-name program (p. 31). Although some treatment family labels imply a particular method of delivery (e.g., Play ) or a particular treatment audience (e.g., Family ), our methods typically differentiated these treatment codes from format codes. For example, relaxation performed with a child and parents together would be coded in the Relaxation treatment family with Child and Caregiver(s) as the format and would not be coded as Family (which required explicit use of techniques related to that theoretical school). Similarly, not all treatments that used play were classified as Play ; rather, Play referred to treatments that used play as the primary therapeutic intervention strategy. Also, when specific treatments were judged to be unique from a family more generally, these protocols were classified into their own families (hence, some family therapy approaches are labeled differently from the default family therapy treatment family). EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 157

5 Table 2. iveness parameters (clinical utility) characterizing treatment families Ties Year Trainability Gender Age Ethnicity Therapist Frequency Duration Format Setting size The number of study groups in which a treatment performed better than one or more other study groups (a psychosocial treatment, medication, combined psychosocial and medication, placebo, waitlist, no treatment, or other control group) or had a qualifying tie with one or more evidence-based treatments in a randomized trial on the primary outcome measure in the target symptom domain. For leveling purposes, only one win tie was counted per treatment per study. The year of the most recent study producing a win or tie for an intervention in a particular treatment family. An estimate of the degree to which an intervention can be trained easily to others. High = manual available AND treatment was successfully used by nondoctoral-level practitioners; Moderate = manual available OR treatment was successfully used by nondoctoral-level practitioners; Low = no manual available AND treatment was successfully used by doctoral-level practitioners only. The average percentage of children who did not drop out of the group (or estimated from the study when not reported by group) (posttreatment n) (pretreatment n). For example, if 6 of 30 children drop out during treatment, compliance = 80%. Whether boys or girls (or both) were in the treatment group; if information was not reported for a specific treatment condition, the percentage was estimated using information for the entire study; when the lower percentage was greater than 30%, the term both was used. When the lower percentage was below 30%, the treatment was listed as representing the majority gender only (e.g., studies that had 75% boys would be displayed as boys ). Range in years since birth (or imputed when only grade level reported); when range was not reported, it was estimated by using the mean age plus or minus 1.5 SD (approximately 87% of a normal distribution); if no SD was reported, the mean was used as the minimum and maximum age; if information was not reported for a specific treatment group, these numbers were estimated using information from the entire study. Presence of each ethnic group within condition; if information was not reported for a specific treatment condition, this presence was estimated using information for the entire study under the assumption of the independence of ethnicity and treatment condition. The training, if reported, for the main provider(s) involved within each treatment condition. The highest and lowest observed frequency of contact with child family, reported in sessions per unit time (e.g., weekly ). The minimum and maximum length of time from pretreatment to posttreatment. Whether the treatment was group, individual, or some other format of therapy, including whether it included parents or family, etc. The primary location types in which treatment was delivered; when setting was not reported, it was sometimes inferred based on aspects of the treatment (e.g., teacher as therapist implied a school setting). The mean effect size of the treatment family, averaging across all study groups within that family (including those that did not win tie), where each group effect size is the difference between pre- and posttreatment group means divided by the pooled pre- and posttreatment standard deviations on the primary outcome measure. Indicators of iveness We again followed recommendations of the Task Force on Psychological Intervention Guidelines, American Psychological Association (1995) by examining the aspects of interventions that spoke to their feasibility, generalizability, and expected benefits (see Table 2). In our previous review, a number of diverse replications led to a higher rating on an index of robustness, which we no longer report here, owing to concerns over reliable interpretations of the specialized nature of a particular protocol. As a compromise, we now report for each treatment family the actual number of study groups in which a protocol from that family performed better than one or more other study groups or tied an evidence-based treatment in a randomized trial on the primary outcome measure in the target symptom domain (see Table 2, Ties ). Coding and Reliability All studies were coded by two reviewers plus a third validation judge using the PracticeWise Clinical Coding System (PracticeWise, 2005), which summarizes multiple variables pertaining to studies, study groups, and treatment protocols. A study was defined as a clinical research project in which participants were randomized to different study groups. A study group was defined as a set of participants who were randomized within a study to receive a defined protocol, such as a treatment group or a control group. Protocols were defined as the descriptions of the set of treatment operations in which members of a particular study group participated. A single publication could contain multiple studies (e.g., study 1, study 2 ), and a single study was sometimes summarized across multiple publications. Each study and protocol were coded by two raters who had undergone extensive training in the coding system, using a detailed coding manual (70 pp.). Once double coded, information from studies and protocols was entered into an application that compared all entries for discrepancies across raters. When the two raters agreed, these results were written automatically to a final record, and when raters disagreed, the problematic field was flagged as a discrepancy for an expert CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

6 reviewer (i.e., the first or second author), who was expected to resolve the discrepancy through a third coding of the relevant study or protocol code. Also, for the official coded record, all fields were given a final inspection for accuracy by an expert reviewer and were subjected to multiple data validation utilities to search for outliers or other offending values. Reliabilities for age, gender, ethnicity, problem, and leveling contrasts were previously reported by Chorpita and Daleiden (2009) and found to be good. We chose a random subset of the current sample for reliability comparisons, and for the new variables in this study (setting, therapist type, manual used, pre and post n, means, and SDs, etc.), the reliability coefficients were also good (j ranged from 0.84 to 1.0, and r ranged from 0.88 to 1.0). RESULTS Anxiety and Avoidance Review of the treatment outcome studies for childhood anxiety yielded 17 different treatment families with at least some level of empirical support (see Table 3). The vast majority of these studies supported Cognitive Behavior (CBT) and its variants as well as Exposure-based approaches. Not surprisingly, those two treatment approaches showed the greatest amount of diversity among participant characteristics, treatment format, treatment setting, and therapist background, and had some of the most up-to-date empirical support as well as large effect sizes. CBT and Exposure were also rated as highly trainable treatment approaches. Interestingly, a variety of non-cognitive-behavioral treatments were identified at the new level of minimal support, including hypnosis, psychodynamic therapy, biofeedback, and play therapy. Although this literature is now somewhat dated, these early, isolated successes suggest that further consideration on these diverse approaches may be warranted (cf. Weisz et al., 2004). Attention and Hyperactivity Review of the treatment outcome studies for childhood attention and hyperactivity yielded 16 different treatment approaches with at least some level of empirical support (see Table 4). The best support was evidenced by Self-Verbalization (rehearsed overt and then covert guiding self-statements) and by Behavior plus Medication, although the effect sizes for these treatments were relatively small. Notably, the support for these intervention approaches is not particularly recent, which may be in part because the effects of Self-Verbalization were largely measured on cognitive tasks, and there has been a shift in research emphasis to behavioral and diagnostic outcomes because of the emergence of structured diagnostic criteria and improved measurement of attention. Further, across all 16 identified and supported psychosocial and combined treatments for childhood attention problems, the number of clinical trials demonstrating the efficacy of each treatment is relatively low. Parent Management Training (alone) showed the largest number of successful studies. All treatments were relatively short term (i.e., ranging from 2 to 12 weeks), with the exception of Behavior plus Medication, which averaged over one year. The majority of treatments were tested mainly with boys, with only five having been tested in studies in which at least 30% of the sample was girls. There were also no studies that included youth above 13 years old. Strengths of the evidence base for attention problems, however, include that the various supported treatments for childhood attention problems span a variety of formats (e.g., group and individual) and settings (e.g., clinic, home, and school), and are also deliverable by a range of different therapist types (e.g., prebachelor s-level therapists, teachers, and doctors). Although our previous review found insufficient evidence supporting social skills training, the current review identified social skills training at the new level of minimal support. Autism Spectrum Review of the treatment outcome studies for childhood autism spectrum disorders yielded five different treatment families with at least some level of empirical support (see Table 5). The best support favored Intensive Behavioral Treatment and Intensive Communication Training, although the effect sizes were relatively small. Both of these treatment approaches were rated as highly trainable, tested among youths of various ethnic backgrounds, in various format types (e.g., individual and group) and settings (e.g., school, clinic, home, and community), as well as by different therapist types (e.g., prebachelor s-level therapists, master s-level therapists, EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 159

7 Table 3. Evidence-based treatments for anxiety and avoidance Treatment Family Level 1: Best Support Cognitive- Behavioral (CBT) High 94 Both 4 18 Aboriginal (Australia), American Indian or Alaska Native, Asian, Caucasian, Dutch, Hindu, Hispanic or Latino a, Indonesian, Multiethnic, Exposure High 97 Both 3 19 Asian, Latino a, Multiethnic, Modeling Moderate 100 Both 3 16 Caucasian Education Moderate 100 Both 9 13 Caucasian CBT plus Medication Level 2: Good Support CBT with Parents Moderate 94 Both 6 15 American Indian or Alaska Native, Asian, Caucasian, Hispanic or Latino a, Moderate 85 Both 4 14 American Indian or Alaska Native, Asian, Caucasian, Hispanic or Latino a, Multiethnic Pre-BA, MA, MD, PhD, Parent, Pre-BA, BA, MA, PhD, PhD, Teacher, MA, MD, Daily to Monthly Daily to Weekly Daily to * Daily to to Weekly MA, PhD Weekly to Biweekly Relaxation Moderate 89 * * BA, Daily to Assertiveness Training CBT for Child and Parent Family Psychoeducation 1 day to 24 weeks 1 day to 14 weeks 1 day to 6 months 1 day to 3 weeks Bibliotherapy, , Family, Group Client, Multifamily, Parent Group,, Self-Administered, Teacher Group, Telephone Call Group Client, Parent Group, Group Client, Individual Client Clinic, Community Field, Day Care, Home, Clinic, Community Field, Day Care, Hospital, Dental Clinic, Group Client weeks 12 to 14 weeks 1 month to 8 weeks Group Client, Multifamily, Parent Group * 1.06 Clinic 1.24 Group Client * Moderate 79 Both * * 2 weeks Group Client * Moderate 100 * 7 18 Caucasian MA, PhD Weekly 12 weeks Moderate 78 Both 7 12 Caucasian, MA, PhD * 16 weeks Clinic 0.81 Clinic 0.27 Hypnosis Moderate 100 Both * * Weekly 2 weeks Group Client 1.23 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

8 Table 3. (Continued) Treatment Family Level 3: Moderate Support Contingency * 100 Male 7 9 Caucasian MA, MD Weekly 20 weeks Group Client Clinic * Management Group * 100 Male 7 9 Caucasian Weekly 20 weeks Group Client Clinic * Level 4: Minimal Support Biofeedback * 96 * * 12 weeks * * Play Moderate 100 Both 6 11 * Teacher Weekly 17 weeks Individual Client * Psychodynamic Low 100 Both 6 15 PhD 8 weeks Individual Client Clinic 0.55 Caucasian Rational Emotive High 100 Both Caucasian BA Weekly 5 weeks Group Client 0.77 Notes. Train = Trainability. *Information could not be determined from the published reports. and doctors). The duration of both Level 1 treatments was at least a year. Another promising characteristic of these two approaches is that they were both tested on boys as young as one and two years old. None of the five treatment families, however, were successful among youth older than 13 years old, and girls were not well represented in any of the studies. Although there were three other treatments that demonstrated some support for treating children with autism, they were only assigned the level of minimal support. Depression and Withdrawal Review of the treatment outcome studies for childhood depression yielded 10 different treatment families with at least some level of empirical support (see Table 6). The best supported were Cognitive Behavior (CBT) and its variants (i.e., CBT plus Medication, CBT with Parents), which also showed the greatest amount of diversity among treatment formats (e.g., child parent individual, child parent group, telephone and selfadministered) and large effect sizes. Interestingly, Family also appeared in Level 1 for Best Support, based on studies in 2002 and 2007, despite having no support in our previous review (Chorpita et al., 2002). Among the four treatments at Level 1, only CBT was rated as highly trainable. The majority of treatment approaches were supported across multiple ethnicities, therapist types (e.g., prebachelor s-level therapists to doctors), and on both men and women. No studies reported successful tests of CBT with children younger than eight years old. The previous literature review did not find sufficient evidence in support of Self-Control Training and Self-Modeling, but these are now identified at the new level of minimal support. Disruptive Behavior Review of the treatment outcome studies for childhood disruptive behavior yielded 23 different treatment approaches with at least some level of empirical support (see Table 7). Across all of the problem areas reviewed, this was the area for which we identified the greatest number of supported treatments. Parent Management Training (PMT) was the only treatment supported at Level 1 in our previous review, whereas six treatments received that level of support in the current review. Nevertheless, the vast majority of positive findings EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 161

9 Table 4. Evidence-based treatments for attention and hyperactivity Treatment Family Level 1: Best Support Self-Verbalization Moderate 100 Both 7 13 Caucasian Daily to Behavior plus Medication Level 2: Good Support Parent Management Training (PMT) Moderate 86 Male 7 11 Caucasian, Hispanic or Latino a MA, MD, Teacher Daily to Biweekly 2 days to 2 weeks 12 weeks to 426 days Individual Client Clinic, 0.31 Group Client, Multifamily, Parent Group High 100 Male 2 12 * BA, Weekly 6 12 week Parent Group Physical Exercise High 97 Male 6 13 * MA to Weekly 3 4 weeks Group Client, Clinic, Community Field 0.09 Clinic, Home 0.92 Biofeedback Moderate 100 Male 7 12 * PhD * 12 weeks Individual Client weeks Group Client 2.00 Contingency Management PMT and Teacher Psychoeducation Social Skills plus Medication High 100 Both 6 10 Caucasian Pre-BA, Teacher Moderate 100 Both 5 12 Asian, Caucasian, Hispanic or Latino a, Multiethnic High 100 Male 8 13 * Pre-BA, MA MA, PhD Weekly weeks Fax to Teacher, Group Client, Multifamily, Parent Group Partial Hospital, 0.83 Clinic 0.80 Daily 2 weeks Group Client * Education Moderate 100 Male 6 12 Caucasian * Daily 3 5 weeks Computer Administered PMT and Problem Solving Relaxation and Physical Exercise Working Memory Training Level 4: Minimal Support PMT and Social Skills Moderate 100 Male 7 13 * * * Family, Individual Client * * Clinic, Home High 100 Male 6 8 * MA Weekly 3 weeks Group Client * High 85 Male 7 11 * * 5 6 weeks Self-Administered Home, Moderate 100 Both 8 10 Caucasian BA, PhD Biweekly 8 weeks Group Client, Parent Group Clinic 0.78 Relaxation Moderate 100 Male 8 9 * * * 3 weeks Individual Client * Self-Verbalization High 100 Male 8 9 Caucasian Teacher * * Group Client 0.87 and Contingency Management Social Skills Moderate 100 Both 8 10 Caucasian BA, PhD Weekly 8 weeks * Clinic 0.51 Notes. Train = Trainability. *Information could not be determined from the published reports. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

10 Table 5. Evidence-based treatments for autism spectrum Treatment Family 0.28 Clinic, Community Field, Day Care, Home, Group Client, Parent Group 5 weeks to 1,917 days Daily to Weekly Pre-BA, MA, MD, PhD, High 100 Male 2 12 Asian, Caucasian, Hispanic or Latino a, Level 1: Best Support Intensive Behavioral Treatment Clinic, 0.49 Group Client, Parent Group,, 152 days to 1 year Daily to Bimonthly BA, MA, Teacher, High 93 Male 1 10 Caucasian, Intensive Communication Training Clinic weeks Group Client, Parent Group Moderate 100 Male 8 13 * PhD Weekly to Monthly Level 4: Minimal Support Cognitive Behavior * weeks Parent Group, High 100 Male 2 9 * MA Weekly to Parent Management Training Peer Pairing Moderate 100 Male 3 4 * Teacher Weekly 13 weeks Group Client Day Care 1.48 Notes. Train = Trainability. *Information could not be determined from the published reports. continue to support PMT, which also demonstrated the largest effect size of any Level 1 treatment. Several treatment families were successful with both boys and girls as well as across a wide range of ethnicities, in contrast to our previous review for which the identified supported treatments were successful with samples that were primarily boys and limited in ethnic diversity. All six Level 1 treatments were also rated as highly trainable and were tested across a wide range of ages (i.e., ages 2 18), formats (e.g., family, parent group, individual client, and self-administered), and settings (e.g., clinic, home, hospital, and school). Interestingly, although group treatments for children have been shown to involve risks (e.g., Dishion, McCord, & Poulin, 1999), the majority of all 23 identified treatment families were successful with a group format component included. Eating Problems Review of the treatment outcome studies for childhood eating problems (e.g., anorexia and bulimia) yielded three different treatment approaches with empirical support indicated by one or two RCTs (see Table 8). All three treatments were supported at Level 2 ( Good Support ), involved either CBT or familybased interventions, and were rated as moderately trainable. The higher degree of specialized skill involved in treating youths with eating problems is suggested by the finding that the therapist type of the supported treatments were of master s level or above, in contrast to the range of therapists background for supported treatments of other problem areas. The specialized nature of this problem area is further highlighted by the findings that all three treatment types were tested in clinics only. CBT was only tested among Caucasian youth, demonstrating the need for CBT to be tested among youth from a wider range of ethnic backgrounds. All three supported treatments were successful primarily with girls, ranging from 10 to 20 years old. Substance Use Review of the treatment outcome studies for childhood substance use yielded eight different treatment approaches with some level of empirical support (see Table 9). The best support was evidenced by Family, which was found to be highly trainable, tested primarily on boys aged 6 21 from a variety of EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 163

11 Table 6. Evidence-based treatments for depression and withdrawal Treatment Family Level 1: Best Support Cognitive Behavior Cognitive Behavior plus Medication Cognitive Behavior with Parents High 94 Both 8 23 American Indian or Alaska Native, Asian, Latino a, Multiethnic, Puerto Rican National, Moderate 94 Both Asian, Latino a, Multiethnic, Pre-BA, BA, MA, PhD Moderate 95 Both Caucasian, BA, MA, MD, PhD Family Moderate 100 Both Asian, Caucasian, Level 2: Good Support Interpersonal Moderate 90 Female Hispanic or Latino a, Puerto Rican National Expressive Writing Journaling Diary * 100 Both Asian, Latino a, Multiethnic, to Weekly MA, MD, PhD to Weekly to Biweekly MA, PhD Weekly to Monthly 4 16 weeks Group Client, Self-Administered, Telephone Call, 12 weeks to 6 months 8 12 weeks Group Client, Parent Group 12 weeks to 9 months Family, Individual Client Clinic, MA, MD, PhD Weekly weeks Individual Client Clinic, * Weekly to Biweekly 3 4 weeks Individual Client Clinic, Home 0.87 Clinic 1.47 Clinic 0.95 Clinic 0.97 Relaxation Moderate 86 Both Caucasian MA, PhD 5 8 weeks Group Client 1.14 Pre-BA, MA Weekly 4 weeks Group Client 0.96 Client-Centered High 100 Both Asian, Latino a, Multiethnic, Level 4: Minimal Support Self-Control Training Moderate 100 Both 9 12 * MA, PhD 5 weeks Group Client 1.43 Self-Modeling Moderate 100 Both * MA, PhD 6 8 weeks Individual Client Notes. Train = Trainability. *Information could not be determined from the published reports. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

12 Table 7. Evidence-based treatments for disruptive behavior Treatment Family Level 1: Best Support Parent Management Training (PMT) Multisystemic High 93 Male 2 15 Asian, Australian, Australian Koori, Caucasian, Hispanic or Latino a, Multiethnic, Norwegian or Western European High 95 Male Asian, Latino a, Multiethnic Social Skills High 98 Both 4 19 American Indian or Alaska Native, Asian, Latino a, Cognitive Behavior Assertiveness Training PMT and Problem Solving High 100 Both 9 18 American Indian or Alaska Native, Asian, Latino a High 100 Both Latino a, Multiethnic High 89 Male 0 13 Caucasian Level 2: Good Support Problem Solving High 96 Male 5 17 Caucasian, Israeli (Jewish, Arab, and Druz) Communication Skills Contingency Management Pre-BA, BA, MA, PhD, Teacher, Parent, BA, MA, MD, Daily to Weekly Daily to Weekly MA, PhD Daily to Weekly MA, PhD, to Weekly 1 day to 2 years 5 weeks to 438 days Family, Group Client, Multifamily, Parent and Child, Parent Group, Parent Individual, Phone Sessions Videotape Instruction, Self-Administered Family, Individual Client, Parent and Child, Parent Individual Clinic, Home, Hospital, Playroom,, Undergraduate University Course Community Field, Home, Hospital, 3 22 weeks Group Client Clinic, Community Residential, Corrections, Day Treatment Center, 6 12 weeks Group Client Corrections, 2 4 weeks Group Client, Peer Hospital, 0.27 BA, MA Weekly to Biweekly BA, MA, PhD, to Weekly 12 weeks to 8 months 45 days to 20 weeks Family, Group Client, Parent Group, Bibliotherapy, Group Client, Individual Client Moderate 92 Male 6 16 * BA, MA, PhD Weekly 4 7 weeks Family, Multifamily,, High 100 Male 4 19 Caucasian Pre-BA, BA, MA, PhD, Teacher, to Weekly 4 20 weeks Group Client, Individual Client Clinic, Hospital 0.98 Home, Hospital, 0.52 Clinic 1.27 Clinic, Corrections, Hospital, 1.08 EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 165

13 Table 7. (Continued) Treatment Family Anger Control Moderate 87 Male 9 21 American Indian or Alaska Native, Asian, Latino a MA, PhD, to Weekly Relaxation Moderate 100 Both 9 18 * MA Daily to Therapeutic Foster Care Functional Family Parent Management Training and Classroom Contingency Management Rational Emotive Transactional Analysis Moderate 100 Both American Indian or Alaska Native, Asian, Latino a, 5 12 weeks Group Client, Individual Client 5 weeks to 80 days Corrections, Individual Client Corrections, Daily 174 days Family, Foster Care, Individual Client, Parent Group, Parent Individual Foster Home High 74 Both * MA * 5 6 weeks * * * * 100 Both 5 6 Asian, Latino a, High 100 Both Hispanic or Latino a Moderate 97 Male Latino a, Teacher, to Weekly 2 years Group Client, Parent Group 0.25 MA Daily 12 weeks Group Client 2.45 MA, 30 weeks Group Client Corrections * Level 3: Moderate Support Attention * 100 Female * * 3 months Group Client Corrections * Outreach Counseling Moderate 100 * * * MA, * * * Community Field Peer Pairing Moderate 100 Both * Teacher 7 weeks Group Client, Individual Client Self-Control Training Low 100 * Caucasian, Ethnicity : Puerto Rican, Hispanic or Latino a Level 4: Minimal Support Parent Management Training and Self-Verbalization Moderate 100 Both 6 12 Caucasian PhD Weekly to 4 weeks Group Client, Individual Client * * Group Client, Parent Individual * * Community Residential Community Field, Home, Physical Exercise * 91 Male 7 13 * * 4 weeks Group Client Partial Hospital * Stress Inoculation High 100 Male * MA 5 weeks Individual Client Corrections Notes. Train = Trainability. *Information could not be determined from the published reports. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

14 Table 8. Evidence-based treatments for eating problems Treatment Family Family Clinic year to 1.5 years MA, PhD Weekly to Bimonthly Level 2: Good Support Family Systems Moderate 100 Female Caucasian, Hispanic or Latino a Family * months to 1 year MD, PhD Weekly to Monthly Family Moderate 92 Female Caucasian, Middle Eastern Clinic months Parent and Child Moderate 70 Female Caucasian * Weekly to Monthly Cognitive Behavior Notes. Train = Trainability. *Information could not be determined from the published reports. ethnic backgrounds and associated with the largest effect size across all supported treatments for childhood substance use. The majority of the supported treatments were rated as highly trainable, demonstrating promise with respect to their implementation and effectiveness in nonclinic settings. In fact, a few of these treatments were successful in schools, and Motivational Interviewing Engagement demonstrated effectiveness in a community setting. Traumatic Stress Review of the treatment outcome studies for childhood traumatic stress yielded four different treatment approaches with at least some level of empirical support (see Table 10). The best support for treating childhood traumatic stress was evidenced by Cognitive Behavior (CBT) with Parents. The compliance rate was high for CBT with Parents, and this treatment was tested across a wide age range (i.e., youth ages 2 17). Notably, CBT with Parents was tested among samples that were primarily girls. Interestingly, as seen in the anxiety problems literature, two noncognitive behavioral treatments were identified at the new level of minimal support, including Play and Psychodrama. Each was supported by only one clinical trial, but suggests that further study of these approaches may be warranted. For instance, Play was tested only among Chinese nationals; clinical trials conducted on youth of other ethnicities and nationalities may further inform us. Notably, the CBT-based treatments supported at Level 1 and Level 2 were rated as highly trainable, whereas both Psychodrama and Play were rated as only moderately trainable. Lastly, it is worth noting that CBT (alone with parent involvement) demonstrated good support and was associated with the largest effect size. Although the inclusion of parents in CBT treatment for youth with traumatic problems has the most support, the present findings indicate that individual CBT would nevertheless be a reasonable course of action, particularly given its larger effect size and greater diversity of settings. DISCUSSION Overall, the literature points to an array of approaches for child and adolescent mental health concerns, even when individual protocols are aggregated into treatment EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 167

15 Table 9. Evidence-based treatments for substance use Treatment Family Level 1: Best Support Family High 100 Male 6 21 Asian, Latino a, Level 2: Good Support Cognitive Behavior Motivational Interviewing Engagement Contingency Management Family Systems Goal Setting Monitoring Purdue Brief Family High 62 Both Caucasian BA, MA, PhD High 100 Both American Indian or Alaska Native, Asian, Latino a, Multiethnic, Pacific Islander, High 100 Male Latino a High 78 * Latino a MA, PhD Weekly 3 weeks to 6 months Family, Individual Client, Parent Individual Clinic 0.71 Weekly 2 12 weeks Group Client 0.55 MA Daily 1 day Individual Client Community Field 0.13 BA, MA 6 months Parent and Child Clinic 0.48 MA Weekly 7 15 weeks Family Clinic * Moderate 100 Both Caucasian, * Weekly 3 weeks Moderate 100 Male * * * 12 weeks Family * * Level 4: Minimal Support Goal Setting Moderate 100 Both Caucasian, * Weekly 2 weeks Individual Client 0.34 Notes. Train = Trainability. *Information could not be determined from the published reports. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

16 Table 10. Evidence-based treatments for traumatic stress Treatment Family Clinic weeks to Weekly MA, PhD, High 94 Female 2 18 Caucasian, Hispanic or Latino a, Multiethnic, Level 1: Best Support Cognitive Behavior (CBT) with Parents 1.16 Clinic, Corrections, Group Client, Individual Client Weekly 8 20 weeks MA, PhD, Level 2: Good Support CBT High 93 Both 5 18 Caucasian, Hispanic or Latino a, Level 4: Minimal Support Play Moderate 100 Both 8 12 Chinese National 4 weeks Group Client * Psychodrama Moderate 92 Female Hispanic or Latino a, MA Weekly 20 weeks Group Client 0.52 Notes. Train = Trainability. *Information could not be determined from the published reports. family groupings as we have chosen to do in this report. This greater number of treatments is attributed to a number of factors, including the 128 new treatment outcome studies published since the year 2000, which included a growing body of international treatment outcome research. Methodological changes, including a new, lessstringent strength of evidence level (Level 4), added 19 new treatment families to the report. We see the current results as useful in guiding therapists to choose among treatment families, balancing consideration of both strength of evidence ratings and information related to the clinical utility of the approaches. Although behavioral and cognitive-behavioral treatments were successful across problem areas, proclaiming behavioral and cognitive-behavioral treatments as the clear winners may be too narrow and limiting, particularly in the contexts of promoting family choice, fitting treatment plans to specific family preferences and values, and when informing decisions about revising treatment plans in the face of poor outcomes with frontline approaches. These findings extend and complement recent reviews from APA Division 53 (Silverman & Hinshaw, 2008) in that (a) they organize specific treatments into broader categories (thus providing some evidence for the robustness of many of these approaches to minor variations), (b) they apply a single framework to catalog indicators regarding treatment effectiveness (i.e., feasibility, generalizability, and effect size), and (c) they identify overall a larger number of successful treatments both because of a larger number of RCTs reviewed as well as the expansion of leveling criteria to include promising treatments with less support (Levels 3 and 4) than would be identified by earlier standards. We continue to assert that there is more information in the treatment outcome literature than can be easily applied to decision making in applied contexts. Given the many details that characterize different treatments and the diverse client characteristics to which those treatments presumably must be matched, we see an increasing need for research on clinician judgment and decision making in the application of evidencebased treatments. Further, the results of this review represent only one view of that complex literature and, for example, do not address questions related to practice components or elements (Chorpita & Daleiden, 2009), risks and side effects associated with treatments, EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 169

17 generalizability of the literature to actual service populations (i.e., who is and is not covered by the literature and why; Schiffman, Becker, & Daleiden, 2001), idiographic outcomes found in experimental single-subject designs, or durability of treatments as reflected in reviews addressing long-term follow-up outcomes. Particularly given that the literature is still characterized by many gaps in terms of demonstrations of treatment applicability to specific groups (Kazdin, 2008), we feel that multiple, complementary views of the literature remain important, especially involving decisions about extending findings to new populations or contexts in the face of limited information (e.g., what to do with a 16-yearold child with hyperactivity). There is a constant tension between breadth and depth in review efforts, and there is clearly no single best way to focus the lens. Moreover, how these multiple views can best be incorporated into clinical decisions is not well understood and thus an important topic for future research. The methodology influencing this particular summary of the literature was developed primarily at a time when evidence-based practice was an emerging paradigm, and as such there are some aspects of this methodology that may warrant significant revision as the literature continues to grow. For example, the literature is now increasingly characterized by studies with stronger designs (i.e., tests against active treatments) and improved measurement. Thus, it may be that Level 4 treatments (those that outperformed waitlist) would add few if any new treatments over the next 10 years and thus could eventually become a historical category more than anything else. Relatedly, even in comparative outcome studies, the current methodology does not apply different strength of evidence levels based on the nature of the alternative treatment, and yet presumably our decisions in the future will be increasingly focused on those options that are likely to be more promising than treatment as usual, and not simply attentional, placebo, or other inert controls (see Weisz, Jensen-Doss, & Hawley, 2006). A specific limitation of our coding system in light of the evolving literature is the lack of coding of implementation-related variables, which are rarely reported in early studies but are increasingly described in more recent ones. Such information (inclusive of the availability of training resources, supervision requirements, and overall training demand) would presumably be helpful in serving the mission of selection and installment of evidence-based treatments. Another limitation was the use of a coded-nominated best measures to determine the outcome measure on which the leveling assignments were based. We know of no clear standard on how to operationalize a treatment outperforming a control group in terms of algorithms for inspecting significant contrasts among multiple measures (see Chambless & Hollon, 1998), although the trend appears to be to count studies in which at least one measure of the target construct demonstrated a statistically significant effect (e.g., Eyberg, Nelson, & Boggs, 2008; who also summarized the total number of measures tested to add useful perspective). In this review, we used a somewhat conservative criterion by agreeing a priori on a single measure per study to evaluate (i.e., our coding procedures prioritized those that are most widely used in the literature), but this conservatism had greater potential for subjectivity. Future research should evaluate the effects of various operational definitions of significant effects (e.g., sufficiency, best measure, and meta-analytic approaches) to determine the potential biases inherent in each. Another general limitation of this review is the lack of review of studies with single-subject designs. This decision stems from the trade-off between the practical considerations of identifying and coding such studies and the utility of the information obtained through review. We noted that in the series of reviews by APA Division 53 (Silverman & Hinshaw, 2008), some reviews included single-subject designs (Pelham & Fabiano, 2008; Rogers & Vismara, 2008), whereas other did not (e.g., Silverman, Pina, & Viswesvaran, 2008). These methodological decisions appeared to be tied to the same logic as our own: reviews with a greater number of RCTs were less likely to include single-subject designs, and reviews with a smaller number were more likely to include single-subject designs. Although the literatures with a high number of RCT provide sufficient information to provide reliable and sometimes plentiful treatment recommendations, they (as does our review) nevertheless may underrepresent the list of what treatments work. A comprehensive review of both randomized group and single-subject experimental designs albeit an enormous undertaking would be an CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE

18 important advance in summarizing more completely the scientific evidence supporting various treatment approaches. Regarding the noted improvements in measurement and other standards in more recent studies, we may need to reconsider for future reviews whether to aggregate newer, more precise findings with those from studies that may have used methods that would not be considered of sufficient quality today. Such an approach was taken in the reviews by APA Division 53 (Silverman & Hinshaw, 2008), which employed research quality standards by Nathan and Gorman (2002) in conjunction with Division 12 criteria for defining EBTs. This raises the kind of trade-offs common to the signal detection paradigm (i.e., filtering out the unwanted noise while filtering in the desired signal), with more conservative filters (i.e., those that prioritize filtering out over filtering in) yielding better quality, but fewer studies. As the 2008 Division 53 reviews demonstrate, no single standard is likely to fit all contexts (e.g., some reviews used studies only from Level 1 of the 6 levels outlined by Nathan and Gorman, 2002, whereas other reviews used Levels 1, 2, and 3), and less-developed literatures are likely to need more relaxed standards. We believe this problem is best handled through the application of multiple cutoffs (e.g., partially addressed by a 5-level system) that allow for higher standards to be enforced in well-developed areas of the literature and (temporarily) lower standards in others. The notion of an increasing standard of evidence raises the larger issue that most approaches to defining evidence-based treatment are confirmatory in nature that is, treatments can only move up and not down in strength of evidence levels. Given the lack of good information overall and the relatively small treatment outcome literature for children and adolescents, it seems a reasonable policy decision for now to err on the side of potentially overapplying existing findings rather than underutilizing available evidence because even given our best efforts, we still think that evidence is underutilized in applied settings. Nevertheless, it does raise the issue that the ability to select among treatments could eventually be complicated by an overly complex array of choices, and continued reviews that summarize features related to effectiveness (such as this review) as well as quantitative meta-analyses (e.g., Weisz et al., 1995) will become increasingly necessary in guiding choices among a list of evidence-based practices that can only get longer by current definitions. That said, at this point in time, we see the value of reviews that provide a balanced emphasis on efficacy and effectiveness that will lead to greater availability of information relevant to decisions about treatment selection and adaptation. This review presents mostly good news: there are hundreds of evidence-based practices that can be grouped into dozens of treatment families addressing a large array of common childhood mental health problems. Although notable gaps in the literature remain, there is a clear trend that those gaps are being filled and that both providers and families can look forward to a future involving even more choices guided by even richer information. The research community will need to continue to focus on analytic methods that will best organize and translate that ever-developing knowledge into practice. REFERENCES APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, Barkham, M., & Mellor-Clark, J. (2003). Bridging evidencebased practice and practice-based evidence: Developing a rigorous and relevant knowledge for the psychological therapies. Clinical Psychology and Psychotherapy, 10, Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, Chorpita, B. F., & Daleiden, E. L. (2009). Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77, Chorpita, B. F., & Regan, J. (2009). Dissemination of effective mental health treatment procedures: Maximizing the return on a significant investment. Behaviour Research and, 47, Chorpita, B. F., Yim, L. M., Donkervoet, J. C., Arensdorf, A., Amundsen, M. J., McGee, C., et al. (2002). Toward large-scale implementation of empirically supported treatments for children: A review and observations by the Hawaii Empirical Basis to Services Task Force. Clinical Psychology: Science and Practice, 9, Daleiden, E., & Chorpita, B. F. (2005). From data to wisdom: Quality improvement strategies supporting EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS CHORPITA ET AL. 171

19 large-scale implementation of evidence-based services. Child and Adolescent Psychiatric Clinics of North America, 14, Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behaviors. American Psychologist, 9, Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child and Adolescent Psychology, 37, Frenk, J. (2009). Globalization and health: The role of knowledge in an interdependent world. David E. Barmes Global Health Lecture. Bethesda, MD: National Institutes of Health. Graham, I. D., Logan, J., Harrison, M. B., Straus, S., Tetroe, J. M., Caswell, W., et al. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in Health Professions, 26, Kazdin, A. E. (2008). Evidence-based treatments and delivery of psychological services: Shifting our emphases to increase impact. Psychological Services, 5, Kazdin, A. E., & Bass, D. (1989). Power to detect differences between alternative treatments in comparative psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 57, Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives in Psychological Science, 2, Lonigan, C., Elbert, J., & Bennett-Johnson, S. (1998). Empirically supported psychosocial interventions for children: An overview. Journal of Clinical Child and Adolescent Psychology, 27, Nathan, P., & Gorman, J. M. (2002). A guide to treatments that work. New York: Oxford University Press. Pelham, W. E., & Fabiano, G. A. (2008). Evidence-based psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 37, PracticeWise. (2005). Psychosocial and combined treatments coding manual. Satellite Beach, FL: Author. Rodgers, J. L. (2010). The epistemology of mathematical and statistical modeling. American Psychologist, 65, Rogers, S. J., & Vismara, L. A. (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child and Adolescent Psychology, 37, Schiffman, J., Becker, K., & Daleiden, E. (2001). Evidencebased services in a statewide public mental health system: Do the services fit the problems? Journal of Clinical Child and Adolescent Psychology, 35, Silverman, W. K., & Hinshaw, S. P. (2008). The second special issue on evidence-based psychosocial treatments for children and adolescents: A 10-year update. Journal of Clinical Child and Adolescent Psychology, 37, 1 7. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, Stuart, R., & Lilienfeld, S. (2007). The evidence missing from evidence-based practice. American Psychologist, 62, Task Force on Promotion and Dissemination of Psychological Procedures, Division of Clinical Psychology, American Psychological Association. (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, Task Force on Psychological Intervention Guidelines, American Psychological Association. (1995). Template for developing guidelines: Interventions for mental disorders and psychosocial aspects of physical disorders. Washington, DC: American Psychological Association. Weisz, J. R., Hawley, K. M., & Jensen-Doss, A. (2004). Empirically tested psychotherapies for youth internalizing and externalizing problems and disorders. Child and Adolescent Psychiatric Clinics of North America, 13, Weisz, J., Jensen-Doss, A., & Hawley, K. (2006). Evidencebased youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. American Psychologist, 61, Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2006). A proposal to unite two different worlds of children s mental health. American Psychologist, 61, Weisz, J. R., Weiss, B., Han, S., Granger, D. A., & Morton, T. (1995). s of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, Received November 25, 2009; revised July 19, 2010; accepted July 20, CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V18 N2, JUNE