Because children with ADHD often have difficulty monitoring and managing their own behavior and following through with plans, a series of one-hour visits with a psychotherapist may not be so helpful to them. Insights gained and skills practiced with the therapist may be forgotten soon after the child returns to real life. Even if the insights are recalled, their power to govern behavior may be swamped by the force of impulses and distracting events. As noted in the introduction to this section, ADHD may not involve deficits in insight and understanding so much as deficits in performance that have their impact on child functioning in important life settings. What may be needed to address these performance deficits for the ADHD child is intervention that is located in those life settings, present on a daily basis, and monitored and managed by significant others in the setting. In one of the most extensively studied approaches to treatment, those significant others are the child's parents, and the setting is home.

Most approaches to behavioral parent training involve helping parents learn to design and implement contingency management programs. A number of such programs have been used with parents of youths diagnosed with ADHD. A common sequence is that parents are assigned readings on behavioral principles, they have a series of group sessions to learn and practice standard behavioral procedures, and they apply the procedures with their child and receive corrective feedback until the child's behavior shows desired change.

Like all of us, troubled children and teens are embedded within complex social systems. Each youngster's behavior reflects his or her own attributes interacting with characteristics of the family, peer group, neighborhood, school, and so forth. With antisocial and delinquent youths, there are often problems at (and between) multiple levels of the social system. Yet most of the tested treatments for conduct problems focus on only one or two of the layers. Anger management programs, for instance, focus treatment mainly on the individual youths who have problems in self-control (see Chapter 8). Other programs emphasize parent training and the parent-child relationship (see Chapters 9, 10, and 11). Still other programs focus on the family system (see Chapter 9) or pair youth training with parent training (see Chapter 12). In contrast to these approaches, multisystemic therapy (MST), to which we now turn, is an attempt to reach out and touch most of the major social systems that envelop antisocial and delinquent youth.

Included in the purview of MST are such social systems as the youth's family, family support network, school, neighborhood, peer group, and in many cases, probation officer and juvenile justice system. The MST therapist has a complex job, one that may not include much time in a clinic office and may not entail waiting for troubled clients to come in seeking help. Instead, much of the therapist's work day is spent in the settings where the young clients live their lives, and the people with whom the MST therapist talks include many of those who touch the young clients’ lives.

In this book, we have examined a variety of evidence-based psychotherapies for children and adolescents. The therapies encompass the four broad clusters of problems and disorders that account for most referrals for outpatient child and adolescent mental health care: anxiety, depression, ADHD, and conduct problems and conduct disorder. The descriptions and critiques in each of the chapters have revealed several strengths and several limitations in each of the specific treatments and in the evidence base bearing on each of them. In this final chapter, I adopt a broader focus, describe some important strengths and gaps in the literature more generally, and highlight some issues that need special attention in future treatment development and in future treatment research. I also propose a specific model for treatment development and testing, one that I believe could contribute significantly toward bridging the gulf that still exists between clinical research and clinical practice.

Strengths of the Evidence on Youth Psychotherapy Effects

The broad evidence base on youth treatment, surveyed in Chapter 1, and the specific treatments and the research on them, discussed in subsequent chapters, shows substantial strengths – strengths that represent good news for all of us who care about youth mental health care.

Overall Magnitude and Durability of Treatment Effects. First, the meta-analytic findings we reviewed in Chapter 1 showed that the average effect of youth treatments tested in peer-reviewed studies is quite respectable, falling between commonly used benchmarks for medium and large effects (Cohen, 1988). Treatment effects have also proven to be durable, with little drop-off in benefit over the five to six months that is common in posttreatment follow-up assessments.

One way to construe aggression and antisocial behavior is that they are ineffective ways of solving problems. Jared pushes Alex in the lunch line. Alex solves this problem by punching Jared in the face. This may seem effective in the short run, but it may also earn Alex an enemy for the rest of the school year, and it may cause some of Alex's peers to avoid him. Most likely it will get Alex into serious trouble at school. If he could suspend time for 15 minutes and think through all this before acting, Alex might come up with some alternative responses that are less risky. Unfortunately, Alex doesn't have 15 minutes to think it over, so he does what comes naturally, and fists fly.

Problem-Solving Skills Training (PSST), the treatment approach we consider in this chapter, is designed to teach aggressive youngsters to use their heads before using their fists. The children first learn basic steps of problem solving in the context of familiar games. The steps include defining the problem, identifying response options, and evaluating them. Then they learn to apply these steps to interpersonal situations, eventually including the kinds of situations that have led to aggressive behavior and prompted referral. If all goes well, the youngsters learn to apply their cognitive training during real-life stressful encounters, identifying and using increasingly prosocial solutions to their interpersonal problems.

PSST relies heavily on children's capacity to learn how to generate their own prosocial solutions to problems, although parents are also trained to help their children use the problem-solving steps.

For many children and adolescents, fears seem to develop one at a time. One child is frightened by a dog's loud bark and fears dogs thereafter. Another is afraid to be alone in the dark. Another won't take swimming lessons for fear of the water. Even for children like Sean, introduced at the beginning of this section, a cluster of fears that coexist at one point in time may actually have developed in serial fashion. For the focused treatment of specific fears, whether they occur solo or within a complex tapestry, four tested treatment approaches have evolved out of four somewhat different theoretical traditions. We focus on these four treatments in this chapter. First we consider how fears and avoidance take shape and become entrenched.

Across some rather different theoretical perspectives, one can piece together an account of how fears and the avoidance of feared objects and situations come to be such a potent force in the lives of many boys and girls (see e.g., Bandura, 1971; Ollendick & Cerny, 1981). Here is part of the thinking in some accounts: Through a combination of biological vulnerability and learning experiences, the fearful child comes to anticipate that carrying out certain actions (e.g., approaching a dog) or being exposed to certain situations (e.g., being in the dark alone) will lead to frightening consequences (e.g., being attacked by the dog, or grabbed by a monster in the dark). The prospect of engaging in the behavior or being in the feared situation stimulates aversive physiological arousal in the child, in such forms as increased heart rate, tense muscles, a tight feeling in the stomach, or various other bodily changes.

Behavioral parent training is a potent treatment for child conduct problems, as discussed in Chapters 6, 9, and 10. For some therapists, though, the challenge of becoming a behavioral expert and finding time to structure individual interventions, one family at time, can discourage efforts to try behavioral approaches - particularly under the productivity pressures of managed care. Fortunately, there is a cost-effective approach that relieves therapist burden to some degree, and has unusually strong empirical support. The approach uses videotaped illustrations to convey behavioral principles through observational learning, one of the most efficient ways to build skills.

The most thoroughly tested video modeling approach has been developed by Webster-Stratton (e.g., 1981a,b, 2001) and her colleagues. In the parent component of their Incredible Years Training Series, a therapist shows brief videos of parent-child interactions to groups of mothers and fathers and leads discussions on themes illustrated in the videos. In this chapter, we describe some of the videos, some of the themes, and some of the evidence on treatment effects.

The Incredible Years BASIC Parent Training Program: Conceptual Basis and Procedural Overview

Advantages of teaching parents child behavior management skills were discussed in Chapter 9. Teaching parents via video illustrations may offer further advantages. One is that the video approach employs modeling, a highly efficient form of learning that outpaces, for example, the trial and error process involved in operant conditioning (see e.g., Bandura, 1971, 1986). The video-guided approach is also more engaging for many parents than didactic learning in a classroom format, or being required to read a book and take a test on it.

Megan

Megan, age 13, seems both miserable and angry. She mopes around the house, complaining that she has no friends, and that other kids are laughing at her behind her back. She is irritable with her parents and she objects bitterly when asked to help with housework. She resents family rules, and she recently told her mother, “When I'm at home, I feel like a prisoner. All I ever do here is work.” At meal times, she is sullen and withdrawn, uninterested in communicating with her parents or her younger sister. She has taken to wearing black and using black lipstick, and she has developed an interest in grunge music and reading about Kurt Cobain, the grunge musician who committed suicide in 1996. She listens to his music late into the night, seemingly unable to sleep.

Megan also overeats. She raids the refrigerator late at night, trying to cope with a pervasive empty feeling. The snacking gives her moments of pleasure, but that feeling subsides with the last bite of each snack and is quickly replaced by shame and guilt about the eating and about her noticeable weight gain. In fact, some of Megan's social isolation stems from embarrassment about her appearance. She hates to have peers see how “fat” she is now. She has been skipping PE class because she thinks she looks “disgusting” in her gym outfit – shorts and a T-shirt. Of course, skipping PE means less calorie burning and even more weight gain. Megan is aware of this causal chain, and she sees the situation as “hopeless.”