Toward More Effective Research on Child Psychotherapy

Toward More Effective Research on

Child Psychotherapy

Christoph M. Heinicke, Ph.D . and Larry H. Strassmann, Ph.D.

During the past 15 years, it has been repeatedly asserted that"there is no evidence to indicate that child psychotherapy is effective" (Levitt, 1957a; Eysenck, 1965; Robbins, 1972). In 1960, oneof us challenged both the form of the question that is implied andthe nature of the data analysis being used (Heinicke and Goldman,1960). We believe that the further data now available, althoughcertainly not extensive, justify reexamination of these issues.

The most basic point lies in the formulation of the research questions themselves. As long as the question is posed in such a waythat the answer is an emotion-laden "it works" or "it doesn't work ,"then the addition to ou r knowledge is likel y to be minimal. If, onthe other hand, we observe that, at least under certain conditions,individual psychotherapy is an essential factor in bringing aboutthe enhanced development of the child, then the further questionbecomes one of describing as exactly as possible the nature of thoseconditions. In this paper we shall first examine the results and interpretations that have been generated on th e basis of an inadequate question: does psychotherapy do an y good ? Next, we shallexamine what present research suggests as to the conditions orvariables that affect the outcome of the child and family who haveexperienced psychotherapy. We shall then describe two programsof carefully designed research that did demonstrate the significantimpact of a specified psychotherapeutic experience on specified

Dr. Heinicke is Associate Professor in the Department of Psychiatry. University of California. LO-lAngeles. Dr. Strassmann is a Senior Research P-Iychologist, Reiss-Dains Child Study Center in LosAngeles and Assistant Clin ical Professor in the Department of Psychiatry, University of California. LosAngeles.

We wish to acknowledge our gratitude to William Pollino M .D. of the N ./ .M .H . Research Task ForceGroup #4 on Mental Illness and Behavior Disorders who init iated the umting of this paper.

Reprints may be obtained from Dr. Heinicke, Department of Psychiatry, Uni"enity of Californ ia atLos Angeles. Los Angeles. Calif. 90024.

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562 Christoph M. Heinicke and Larry H. Strassmann

groups of children. Finally, we shall conclude by indicating whatwe believe to be promising possibilities for future research.

Before approaching these tasks, we shall make explicit two fociwhich one must be especially aware of in approaching the evaluation of any piece of treatment or intervention research with children: (I) What is the developmental status of the child being studied? (2) What is the nature of environmental and particularlyparental impact on that child?

Although it is important to clarify and be aware of certain symptoms and behavior manifestations, with children even more thanwith adults, we are trying to assess whether the overall development of the child is progressing in a manner consistent with hisown potential and the nature of the environment. There are, nodoubt, several different ways of using a multifaceted assessment toarrive at this basic diagnostic decision, but the Developmental Profile suggested by Anna Freud (1965) seems to us particularly useful. In a concluding section to the discussion of the Profile she distinguishes the following diagnostic guidelines: (I) the child whosebehavior disturbances fall within the range of normal variation; (2)the child whose pathological formations are of a transitory natureand can be classed as by-products of developmental strain; (3) thechild whose development has come to a considerable standstill(permanent drive regression and fixations), evidenced in neuroticand character disorders; (4) the child whose development is also ata standstill involving more pervasive regressions (drive, ego, andsuperego), evidenced in infantilisms, borderline, delinquent, orpsychotic disturbances; (5) the child who suffers from primary deficiencies of an organic nature or early deprivations which distortdevelopment and produce retarded, defective, and nontypical personalities; and (6) the child who is being influenced by destructiveprocesses of an organic, toxic, or psychotic origin.

Whether one agrees with the above psychoanalytic conceptualization, we believe it to be essential in psychotherapy research to determine which of these or similar broad categories a child falls into.For example, if we are dealing with a transitory symptom, thenpsychotherapy may indeed not make an easily demonstrable difference when compared with a nontreatment group.

Another major consideration is the child's psychologically significant environment, and especially his family environment. Whilethe above diagnostic conceptualization stresses that the child, quiteapart from his environment, has come to a standstill, to evaluatethe effect of therapy with him it is necessary to assess at least whatimpact the environment and changes in that environment are mak-

Toward More Effective Research on Child Psychotherapy 563

ing on the child. In some therapies with children, changing the environmental response is of course the focus of the therapeuticmode (e.g., behavior therapy).

The implication of these considerations on the questions askedwill be spelled out in subsequent sections. Moreover, we shall alsoexamine conditions. other than the nature of the child's difficultiesand the resources in his environment that affect the outcome andprocess of child psychotherapy.

I. RESEARCH RESULTS BASED ON

AN INADEQUATE QUESTION

Since the reviews of Eysenck (1952, 1965) and Levitt (1957a, 1963,1971) are still frequently quoted as providing evidence that "research fails to support the hypothesis that psychotherapy facilitatesrecovery from neurotic disorder" (Eysenk, 1952, p. 323), it is necessary to summarize these arguments and those of authors whohave commented on them.

Following a model suggested by Eysenck (1952), Levitt (1957a)derived mean figures of improvement as based on 18 studies ofchild psychotherapy. At closing, 67% were found to be improvedand 33% unimproved. At follow-up, the figures were 78% and22%.

To provide a baseline of child patients who were "similar totreated groups in every respect except for the factor of treatmentitself," those who were accepted for treatment but "voluntarily[broke] off the clinic relationship" were used (Levitt, 1957a,p. 190). Studies by Witmer and Keller (1942) and Lehrman et al.(1949) indicated a closing baseline figure of 72.5%. This rate of improvement was not significantly different from that for the treatedgroup, and thus the conclusion that while many child patients improve as a function of both their own resources and certain environmental facilitators, the child psychotherapeutic situation is notone of those facilitators.

Levitt (1957a) himself demonstrated that the results of the individual studies differed significantly, the rate of improvement atfollow-up ranging from 43% to 86%. In a further examination ofthese issues, Heinicke and Goldman (1960) reasoned that it wasmost appropriate to confine oneself to those treatment studieswhich also generated control groups as part of the total researchdesign. As did Levitt (1957a), these authors used the Lehrman etal. (1949) and Witmer and Keller (1942) "control" groups, but confined comparison of these with the treatment groups reported by


these same researchers. This again follows Levitt's (1971) own reminder that the treatment and control group should be selectedfrom the same population. Heinicke and Goldman further reasoned that if one is trying to test whether the psychotherapeutic situation is an important facilitator of development, then the distinction between successful adjustment and partial improvementbecomes very important.

Even though these two studies gave clear evidence that the control groups were favored in terms of the resources of the child andthe adequacy of the parents, and even though they received somehelp, the development of the treatment as opposed to controlgroups was a more adequate one. That is, despite this "favoring" ofthe control group, the evaluation of the treatment groups atfollow-up showed a significantly higher percentage of successfuladjustments as opposed to partial improvements, and a significantincrease in successful as opposed to partial improvements in theperiod from the end of treatment to the follow-up point. The moreprecise application of the model proposed by Levitt (1957a)seemed, therefore, to lend some support to the hypothesis thatchild psychotherapy is one of the facilitators of more successful development in a child. Heinicke and Goldman made it clear, however, that the model proposed by Levitt was at that point in the development of psychotherapy research no longer a useful one.

The first serious question was and still is in regard to the natureof the "control" used, and whether indeed the treatment and defector group were equivalent at the initial assessment point. In1960, and even following the further review by Levitt (1963), theevidence tended to be contradictory. Studies by Levitt (1957b,1958) tended to find no difference, whereas those by Lehrman etal. (1949), Witmer and Keller (1942), and Ross and Lacey (1961)found a great number of differences. One could continue to investigate this question, but other difficulties with the model make suchresearch of doubtful value. As in 1960, we would still conclude thata "family and child who wait and then pursue treatment are likelyto be a different family than one who does not" (Heinicke andGoldman, p. 491).

Insofar as one can find a control sample that has not soughttreatment and carefully match it with a group that does receivetreatment, then the comparison seems more convincing. Studies byShore and Massimo (1966), Shepherd et al. (1966), and Speer(1971) are examples of this approach. Unfortunately, the latter twostudies have to be seriously questioned because the only information on the child was given by the parents.


Another serious reservation about the nature of Levitt's (1971)review is raised by the reviewer himself. If the rate of improvementranges from 43% to 86%. there must be a number of importantvariables that account for such striking variation in effectiveness.Hood-Williams (1960) pointed out that the date of the studies reviewed by Levitt (1957a) correlated with effectiveness, and suggested that the more recent studies dealt with more severe pathology. and were therefore less successful.

Following Eisenberg and Gruenberg (1961), Levitt (1963) suggested an initial refinement of the research approach: that it wouldbe important to define carefully the different diagnostic groupingsinvolved in the psychotherapy research. He demonstrated that children with "special symptoms" show a significantly better rate of improvement than those placed in the "acting-out" category, and consequently should not be automatically combined into one group.

In a carefully reasoned review of some myths of psychotherapyresearch, Kiesler (1966) included the above consideration under adiscussion of misplaced uniformity assumptions, and specificallythe patient uniformity assumption. He further points out thatmuch research assumes that the therapist is also a uniform entity.Any adequate study must address itself to the fact that patientsvary greatly. and so do therapists.

Kiesler (1966) also questions the assumption of spontaneous remission: that psychoneurotics become better as a function of timeelapsed. Even if such improvement occurred without a definabletreatment, it would be important to define the nature of the patients involved and what actual or therapeuticlike experiences theyhave had. As we shall show later, a more relevant test of the outcome of psychotherapy is to find samples who, at the time pointbeing considered, have ceased to improve.

Under what conditions does improvement then occur? The question then changes from-does child psychotherapy do any good?to specifying the variables which affect the process and outcome ofthat therapy. The next section examines the available research andsuggests what variables should be studied further.

II. UNDER WHAT CONDITIONS Is PSYCHOTHERAPY MOST EFFECTIVE

IN FACILITATING DEVELOPMENT?

In surveying the literature on child therapy research, one is soonstruck by the paucity of well-designed and implemented studies.This state of affairs is even more surprising when one realizes thatas far back as 10-15 years ago, there were discussions as to what


kind of research was needed for a meaningful assessment of theefficacy of treatment with children, and too little has been donein the interim. Furthermore, in reading many of the child therapy research articles, one is often at a loss to make adequate inferences, since descriptions as to the exact nature of what constitutedtherapy, and the manner in which judgments were made, arefrequently missing, or so vague as to be of minimal utility. Giventhis rather disappointing situation, certain investigations have nevertheless yielded varying degrees of reliable, useful informationabout the conditions and circumstances pertaining to the utility ofpsychotherapy with children. These studies will be reviewed in thissection, and two of the more definitive, extensive, and carefullydesigned studies will be discussed in Section IV.

On a broad level, the most useful conclusions regarding theefficacy of treatment invariably come from studies utilizing welldefined control and/or contrast groups. Ideally, these are established a priori; however, at times it becomes possible to reanalyze previously gathered material out of which one can separatepatients with differing characteristics, and thereby establish contrast groups after the fact. In the paragraphs below we give examples of studies using control and/or contrast groups.

With the exception of the Heinicke (1969) and Shore and Massimo (1966) research (to be discussed later in greater detail), thereseem to be no comprehensive studies on long-term treatment withchildren which have incorporated carefully defined contrastgroups into the design. There have, however, been a number of investigations involving short-term therapy using contrast and control groups. It is noteworthy that in such instances there wasusually a demonstrable difference in results as a function of "groupmembership."

Exemplifying the use of controls who received no treatment, wehave the Shore and Massimo (1973) research on vocationallyoriented psychotherapy, which demonstrated that the benefits oftreatment with delinquents were maintained as long as 10 yearsafter therapy. In a study dealing with a similar population (Persons, 1967), institutionalized delinquents receiving group and individual therapy (4 hours per week over a period of 20 weeks) hadhalf as few reinstitutionalizations and fewer parole violations during the 9Y2 months after release as did the well-matched controlswho received no treatment. In a comparison of foster children withand without treatment, De Fries et al. (1964) found that treated foster children tended to improve more than those without treatment


(not statistically significant). However, there was apparently no indication that the foster homes (parents) were comparable.

With respect to the use of contrast groups, there have been aseries of investigations in which Eisenberg and his colleagues(1961) explored the differential effects of drugs and psychotherapy on various diagnostic groups. Cytryn et al. (1960) compared the combination of supportive psychotherapy, certain drugs,or placebo on neurotic, hyperkinetic, behavior disorder, and antisocial children. He found neurotics significantly more improvedthan the others under all treatment conditions, while revealing nobenefits to any of the drugs or placebo. Additionally, retrospectivejudgments were then made with respect to separating out thosechildren whose hyperkinesis was secondary to anxiety and thosewho were presumably constitutionally hyperkinetic. With these retrospectively established contrast groups, it was found that the anxiety-based hyperkinetics improved significantly more than did theconstitutionally based ones. A later, similar study (Eisenberg et al.,1961) found comparable results with no differential outcome according to drugs used, but a significantly higher frequency of improvement for neurotic as contrasted with hyperkinetic children.

While these studies show that there are clearly differential resultsaccording to the diagnostic groupings, the use of the term "psychotherapy" to define the nature of some of the interpersonal contactsinvolved seems questionable. In both studies the number of sessions and their duration are extremely small; e.g., 4 Y2- to %-hoursessions within 11 weeks for the Cytryn et al. (1960) study, 4 Y2hour sessions for the Eisenberg et al. (1961) study. Moreover, as isso often the case, there is no report as to the exact nature of thesecontacts. Further question as to the inferences possible from theCytryn et al. (1960) work is due to the fact that the therapy was administered by a pediatrician, albeit with special psychiatric training.Thus, one must be cautious in generalizing these findings to abroader category of what might be interpreted as psychotherapy.

In a somewhat different vein, Baymur and Patterson (1960) examined the effects of short-term client-centered counseling on underachieving high school students. Treatment groups includedthose having once-a-week individual sessions over a period of10-12 weeks, and those meeting for 9 weekly group sessions. Thecontrast groups included a no-treatment group and one receiving asession of "motivational" counseling. Following treatment, thecounseled groups (individual and group) had improved significantly more than the contrast groups in grade point average.


A study by Shepherd et al. (1966) is unique in that a randomlyselected control group was chosen from a large school population.The authors matched 50 consecutive cases seen in a child guidancecenter (excluding certain cases such as psychotics and epileptics)with 50 nonclinic children in local schools. Matching was done onthe basis of parent-rated forms, and the authors rerated both setsof children after 2 years on the basis of an interview with theparents. This time the groups did not differ significantly, havingimproved 65% and 61 % respectively. There are, however, variousfactors which severely limit the inferences which can be made fromthese results. Not the least of the difficulties is the reliance onparental ratings and on parents as sources of information abouttheir children. The control group parents, who originally saw theirchildren's problems as transitory, may well have felt the need toprove their judgment correct, and would in the follow-up see theirchildren in a more positive light. Additional questions arise interms of the initial comparability of the groups. The treatmentgroup showed a nonsignificant trend toward more disturbance inthe children and the parents. There were also striking differencesin the frequency of parental absence from the home (10 treated vs.3 nontreated had lost at least one parent permanently) and othersigns of family disruption (6 treated vs. 0 nontreated lost the fatherthrough desertion or divorce). It thus seems reasonable to suspectthat the clinic population did in fact consist of more disturbed families, and consequently the fact that the treated group wound upcomparable to the controls may well indicate that therapy overcame some of the detrimental factors.

Considering the fact that we have found few well-designed outcome studies, we should not be surprised that relatively little hasbeen done with respect to assessing the nature of factors related to,or influencing, the results of the treatment process. When they arephrased in the broadest terms, one quickly appreciates the verybasic level of the kind of questions which need to be answered.Thus, one would think few would argue with the statement thathow well a patient will do in treatment may have something to dowith the qualities and skills of the therapist, what the patient is like,what is "wrong" with the patient, what is the nature of the environmental impact, and what is the interaction between these variouselements. As already stressed, the family characteristics and thechild's developmental level are likely to be of particular importancein child as opposed to adult psychotherapeutic outcome. Regrettably, however, the level on which much psychotherapy research


has been done is somewhat analogous to giving a pharmacist sometraining in surgical techniques, having him do exploratory brainsurgery, and then generalizing the results of his operation to whatan experienced neurosurgeon might have accomplished with a specific disorder.

The Influence of the Initial Developmental Status

As was noted in the dis cussion on contrast groups, there is reasonto believe that children with different kinds of problems/diagnoses(levels of development) respond in a differential manner to treatment. In addition to the work of Eisenberg et al. (1961) and Cytrynet al. (1960) with neurotics and hyperkinetics , and the work of Persons (1967) and Shore and Massimo (1973) with delinquents, wecan point to the work of Brown (1963), who in the examination ofmaterial on childhood schizophrcnics/autistics found that of the 14children in the sample with grossly abnormal EEG (spike waves).only I did not eventually receive custodial care (it is unclearwhether they received treatment). As part of a similar kind of retrospective evaluation. Brown (1960) found that significantly moreof the "least improved" schizophrenic/autistic children had neverused toys properly when young. while the "more improved" hadtended to demonstrate the capacity to identify with animals whenyoung (both of which are suggestive of initially higher level development). In a similar vein. Hartmann et al. (1968). in their study ofadolescents treated in an inpatient facility. found positive relationships between aspects of developmental phase. initial state. andoutcome, Thus. factors such as good object relations. acute onset.normal handling of aggression. and defenses against infantile object ties were indeed definitely related to outcome. Yet. as if tohighlight the diffic .rlty of even feeling secure with such assumptions as "the more disturbed the child, the less likely the cure,"Kaufman et al. (1962) in their assessment of schizophrenic childrenfound no relationship between improvement and severity at timeof referral.

The importance of defining the nature of the diagnostic grouping into which the child falls, as well as supplementing these withmore descriptive criteria and indices of the severity of integrativedefects. can once more be stressed by reference to the review of themethodology of drug studies with children (Fish and Shapiro,1965). For' example, Fish (1971) concludes that hyperactivity is nota diagnosis or disease entity which can serve as a definition of thepretreatment state. Hyperactivity may appear in a neurotic child or


one suffering from schizophrenia or severe brain damage. Depending on the diagnostic assessment, the child's response to treatment with a drug like amphetamine will be very different.

The Nature of the Parental Impact

Few would doubt the significance of parental impact, and there areat least tentative indications to support this premise. Thus, in theiranalysis of work with school phobics, Coolidge et al. (1964) foundthe parents of the most severely limited children to be subjectivelydescribed as more disturbed than the others, while Kaufman et al.(1962) found that the most improved schizophrenic children camefrom homes in which there was family support for positive change.Cytryn et al. (1960), using retrospective assessments, arrived at theconclusion that the parents of the more improved children wereless disturbed at the beginning and were more responsive to casework, while 4 of the 12 "failures" in the work of Rodriguez et al.(1959) with school phobics were judged to be from families whichwere decompensating. Lessing and Schilling (1966) found improvement in children significantly associated with improvement intheir mothers, while Hartmann et al. (1968) found early separationfrom father or mother negatively related to outcome.

The Frequency ol Session and the Duration (!f Treatment

Turning to the general topic of the effects of "amount" of treatment, one finds it possible to approach the area in terms offrequency (intensity) of sessions (i.e., how many times a week thepatient is seen) and duration of treatment (i.e., for how long thepatient is seen over a period of time). With respect to the first variable of frequency, the only systematic research is a study by Heinicke (1969) who examined the effects of once-a-week and fourtimes-a-week psychoanalytic psychotherapy on boys with learningdisturbances. Details of this work will be discussed in a later section. In the present context, this study (and unpublished subsequent follow-up research) provides impressive support for thepremise that increased frequency of sessions has a long-range beneficial impact on a child's personality and academic functioning.Statements made in other studies with respect to the significance offrequency are invariably a by-product of the major research emphasis and typically have not included adequate methodologicalconsiderations of the sort needed to arrive at meaningful conclusions, In this vein we have the data-processing study of Lessing andSchilling (1966), who examined the data recorded on punch cardsfor children seen at a clinic over a 9-year period and, among other


results, concluded that frequency of treatment was unrelated tooutcome. However, in addition to the problems introduced by theiruse of such a heterogeneous sample, they note that 93% of thechildren were seen once a week, and so it is not surprising that withsuch a limited range of variability no positive results were found.

In terms of amount of treatment (in number of sessions), therehas been some preliminary work done by Rosenthal and Levine(1970) comparing the effects of brief therapy (maximum of 8hours with patient and/or family within a maximum of 10 weeks)with therapy the length of which was determined by the individualtherapist, on children of varying ages and with assorted problems.Using a variety of outcome measures, and assessing the entire sample, they found that the longer treatment group had 79% improved vs. 55% for the brief therapy. These figures include 8 brieftherapy subjects who the staff felt needed additional treatment, butone obviously cannot delete these subjects from the brief sample,or there would be a favorable bias in the direction of brief therapy.One must, nevertheless, view this study as tentative due to anumber of factors, including: the relative inexperience of the therapists, the heterogeneity of sample, and the variety of therapymethods used. In the data-processing study of Lessing and Schilling (1966), the number of interviews and time in treatment weresignificantly related to outcome. Since, however, cases in this clinicwere terminated when showing inadequate progress, the correlation of duration and outcome may well have been influenced bysuch a practice. Hartmann et al. (1968), working with adolescentinpatients, found no statistical relation between outcome andnumber of treatment hours or length of sessions. However, asthese authors point out, one cannot conclude such factors wereuseless because amount of treatment was not determined randomly, but undoubtedly was increased for those who had a poorerprognosis. Phillips (1960), using follow-up questionnaires sent toparents of children seen in "depth" therapy, as opposed to structured short-term therapy at a clinic, found the structured shortterm group significantly higher on a variety of dimensions. Thereare, though, various substantial methodological problems whichmake these results highly questionable. Foremost is the fact thatthere is strong reason to believe that the groups were not initiallycomparable, because it seems likely, especially in those days, thatthe clinic would have assigned the more disturbed cases to longterm treatment. The other major difficulty involves the dependence on parent ratings which may be unreliable. Thus, thoseparents who stayed with "long-term" may be more psychologically


sophisticated and see problems in behavior that the "short-termparents" might be satisfied with. Another study depending onparent-answered questionnaires (Shepherd et aI., 1966) found norelation between number of sessions and improvement. However,there are again the assorted difficulties of the questionable validityof such parent information, a heterogeneous sample, no notion ofthe conditions determining termination , and most notably, no figures as to the ratings and number of sessions involved. With respect to the last factor, the authors noted that the children rated"unchanged" had the largest average number of sessions, and thatwas only 15. Thus, with such a small range of sessions for such aheterogeneous group, it is not difficult to see why a statistical relationship might not emerge. It also appears reasonable to assumethat the failure to demonstrate a relationship between outcome andamount of treatment, with such a relatively small number of sessions, has little bearing on whether a relationship exists betweendegree of improvement and more substantial amounts of treatment.

Information pertaining to the impact of regularity and continuity was gathered by Kaufman et aI. (1962) . who found that themost improved schizophrenic children maintained more regularappointments. It is, however, impossible to state whether the moreregular appointments were a function of "becoming healthier" orthe cause of "gett ing better."

Therapeutic Outcome and the Age rif the Child

Evidence pertaining to the relationship between variations in thechild's age and the outcome of treatment gives a mixed picture. Intheir work with school phobics, Eisenberg (1959) and Rodriguez etal. (1959) found significantly more success with children aged IIand under, and Ashcraft (1971), investigating the later schoolachievement of treated and untreated emotionally handicappedchildren, found what appears to be a trend for greater improvement in the younger children. In contrast, neither Cytryn et al.(1960), working with neurotics, hyperkinetics, behavior disorders,and antisocial children, nor Brown (1960), evaluating schizophrenic children, found evidence of a relationship between ageand improvement.

Variations in the Therapist and the Nature cfOutcome

Turning to the potential impact of therapist variables, one findsagain relatively little information, and much which does exist seemscontradictory. In her examination of the work with schizophrenic


children, Brown (1960) found no relationship between improvement and the sex of therapists, their experience, or the number oftherapists a child had . In contrast, Kaufman et al, (1962) foundthat their most improved schizophrenics had fewer therapistchanges and that the therapists of the most improved were moreinvested in their patients, while the various serv ices for such children were better synchronized .

Several briefly reported studies are suggestive of the utility ofmatching therapist and patient along certain dimensions (e.g., personality). Levinson and Kitchener (1966) and Palmer (1973) claimimproved functioning for delinquents who worked with matchedcounselors. It is conceivable that such matching would also have abeneficial impact on other diagnostic groups.

Summary

Taking into consideration the assorted variables discussed, one caneasily begin to speculate on the possible meaning and significanceof these various factors . The validit y of man y of these findings is,however , so uncertain that they can only serve as guidelines in thedesign of more ca re fu lly executed research . The nature of thechild's initial development (or diagnosis) appears important. However, even such seemingly difficult groups as delinquents are,under certain conditions, amenable to treatment. The work onfrequency is promising, but needs replication and with other diagnostic groups. Various aspects of parental impact begin to appearas likely influencing factors on outcome , and there are positivesuggestions of the significance of certain th erapist-patient pairings.With respect to other variables, one can, at present , only concludethat there are no stud ies consistently revealing their potential impact on treatment with child ren . This is not to say that they are notrelevant, but merely to note that their relevance remains to bedemonstrated.

A repeatedly evident difficulty in much of the research lies in thefrequent failure to describe the specifics regarding what constitutestreatment, and so one is often unable to generalize from the resultsof research which is otherwise well designed. One frequently findsclear distinctions made between group, individual, and behaviortherapy. However, all too often each of these is dealt with as if itwere a homogeneous category, and the researchers do not takeinto account the wide diversit y of treatment approaches withinthese larger subdivisions. While there are obviously common elements, it is foolhard y to pool such approaches as psychoanalyticand directive therapy as if they were the same thing. Occasionally,


the difficulty appears to be just in the reporting, so that one is unsure as to what was, or was not done, but all too often one has theadditional uncomfortable feeling that such factors were not dealtwith as part of the overall design process. In the same vein, one isfrequently not told of the therapist's level of experience, or findsthat treatment was done by a pediatrician or a resident with twomonths of experience. While it is readily apparent that such factorsseriously reduce the meaningfulness of the results and/or severelylimit the generalizability of the findings, it is regrettable that one isfrequently confronted with situations in which the results are thenabstracted by others for further use, and conclusions are derivedfrom them without making note of such serious drawbacks.

In order to assess meaningfully the contribution of the differentvariables, it will undoubtedly be necessary to plan systematically fortheir examination, rather than to depend on chance findingsthrough retrospective analyses, as has so often been the case in thepast. In this light, one must also pay particular attention to the significance of follow-up assessments, both to determine whethergains made hold up, and to assess the possibility that improvementmay become apparent "later on," even though little or none mayhave been evident immediately upon termination.

II I. THREE METHODS OF ASSESSING OUTCOME

Since we are suggesting that the evaluation of changes that occur asa function of therapeutic intervention continue to rate a high priority, development of adequate and relevant methods of assessingsuch changes must also continue to be developed. We shall brieflydescribe three differing approaches that have been carefully developed as general tools of outcome evaluation.

The Behavior Problem Checklist (Peterson-Quay)

In 1961 Peterson stated that before the etiology and/or treatmentof children's behavior disorders can be sensibly examined, the disorders themselves must be defined. To allow both generalizationand descriptive efficiency, he concluded that the definitions shouldbe nonarbitrary, unitary, and independent. His basic approach wasto factor-analyze responses to behavior disorder descriptions.

The referral problems of 427 representative cases at a guidanceclinic were recorded and then reduced when there was overlap inmeaning. The randomly ordered checklist was submitted to 28teachers of 831 kindergarten and elementary school children. Rat-

Toward Mort, Effective Research on Child Psychotherapy 575

ings of 0 (no problem) , I (mild problem), or 2 (severe problem)were assigned.

Some of the items under the factor "Conduct Problems" weredisobedience , disruptiveness, boisterousness, and fighting. For thefactor "Personality Problem," the following items were loadedhighly: feelings of inferiority and lack of self-confidence.

In a further study by Quay et al. (1966) , the checklist was givento teachers of classes for the emotionally disturbed. In addition totwo previous factors, another one entitled "Inadequacy-Immaturity" was now defined by the factor analysis. This loaded on suchitems as sluggishness, laziness, and lack of interest.

Continuing analytic studies of the Behavior Problem Checklistsampling large numbers-a wide variety of children, adolescents,and different adult raters such as teachers and parents-have repeatedly yielded these three almost identical and independent factors (Speer, 1971): Conduct Disorder (externalizing, acting out,and antisocial symptoms); Personality Disorder (internalizing, neurotic, anxious-withdrawn symptoms); and Inadequacy-Immaturity.An additional scale, Subcultural (socialized) Delinquency, has beenadded (Quay and Peterson, 19(7).

While these factors 01' dimensions tend to appear consistentlywhen data from different populations are analyzed, the actual interrater reliability is not high; that is, adults have marked difficultyin agreeing on the problematic behavior of a given child.

Using the Behavior Checklist, Zold and Speer (1971) collecteddata on clinic, nonclinic, and siblings of clinic populations. Parentsfilled out the mailed checklist. It should first of all be noted thatthose who replied were in general more reliable, resourceful , andmotivated families . Moreover, the nature of the treatment receivedvaried greatly and is not adequately specified. Nevertheless, theirresearch seems to demonstrate that those patients who were assessed both before treatment and at some point after beginningtreatment (mostly 6-12 months after the close of treatment) didshow less deviance. Even though the patient population still differed significantly after treatment from the nonclinic population,the discrepancy was less than at the point of intake. The 30 patients who were in the sample, tested both at intake and some timeafter, and received no treatment, or only 4 appointments or less,showed less improvement than the 72 patients who received moretherapy.

The advantages of this checklist aloe: the ease of using it for largesamples, the applicability to a variety of treatment approaches, andthe consistency with which it taps certain dimensions .

576 Christoph M. Heinicke and Larry H. Stmssmann

The low interrater reliability is troubling, since the studies ofNovick et al. (1965) (see below) indicate that contrary to Quay et al.(1966), parents tend not to agree on the deviant behavior of theirchild.

The assignment of meaning to some of their results also presentsdifficulties, since the limited behavioral description may give littleclue as to why, for example, a nonclinical population should beconsistently rated more deviant by parents than the siblings ofclinic patients (Zold and Speer, 1971).

This in turn relates to the problem of the validity of the ratings,especially when done by parents. It is very possible that one is assessing changes in parent perception that are not related tochanges in the child in any simple way.

The Deviant Behavior Profile (Rosenfeld, Bloch, and Novick)

Partly in reaction to the limitations of the Peterson-Quay checklist,and in a continued effort to achieve a reliable and relevant tool forthe assessment of child psychotherapy, Novick et al, (1965) developed the Deviant Behavior Profile which consists of 237 items ofdeviant behavior. The mother, father, teacher, and a home andschool observer are asked to sort these into one of three piles:True, False, and Not Sure. Questions are then asked as tofrequency, intensity, pervasiveness, and chronicity. This gives someindication of the saliency of the behavior.

Several impressive findings resulted from the collection of Deviant Behavior Profiles on 7 patient families and 3 families whowere not treated. Thus, 10 sets of parents, each interviewed twice,endorsed a total of 1,624 items of which 1,039 (64%) were in disagreement. Using judges to establish whether a deviant behaviorwas or was not present, it was determined that the disagreement in60% of the cases was due to overreporting, and in 30% of the casesdue to underreporting. In only 10% of the cases was the differencelinked to true situational differences in the child's deviant behavior. It follows that wherever the outcome assessment tool is basedexclusively on data reported by the parents, great caution must beused in inferring what types of changes actually occurred in thechild (Novick et aI., 1965).

Changes in behavior profiles shown by a group of 6 children intreatment for a year were then analyzed (Rosenfeld, 1965).Changes in scores denoting presence and degree of severity ofeach of 237 deviant behaviors outside of therapy were made byjudges on the basis of the card-sorting and inquiry data from thefive different sources. The 6 children had been diagnostically clas-


sified as psychoneurotic (2), behavior disorders with neurotic traits(2), and borderline (2). The two psychoneurotic children showed asignificant decline in deviance, but no change in the severity ratings; the behavior disorders showed a decline in the severity, butnot in the number of deviancies; and the borderlines showed nosignificant changes.

Rosenfeld (1965) then examines what the profile of changes indeviant behavior means in terms of the development of the child.Three clinical judges-not the children's therapists-after examination of the initial profile had made judgments as to what they expected. At one year, they compared their expectations with thenew deviant behavior profile. These judges made statements aboutthe nature of change in each patient at one year, and it was suggested that these statements corresponded to test results derivedindependently by a psychologist. To our knowledge, the data havenot been published.

Despite this very extensive effort, one is left with the seriousquestion of whether clinical judges using only the deviant behaviorprofile information can make judgments which assess the child'schanges in the basic developmental trends. It is clear that the stepfrom empirically derived behavior descriptions to the formulationof constructs of mental health and developmental trends is a mostdifficult one.

The Developmental Profile (Anna Freud)

The Developmental Profile is the central piece in a book by AnnaFreud, subtitled "Assessments of Development" (1965). A carefullythought-out framework is used flexibly to capture a multifacetedpicture of the child and family. The diagnostician is guided by anoutline in considering the material from different points of view.He is asked to give specific descriptive clinical material, primarily todocument an inference about the quality and quantity of the child'sdevelopment in a given area. It is not a checklist to be filled, but aseries of headings are used to delineate the balance of progressiveover regressive forces.

Heinicke (1969) and his collaborators have used the Developmental Profile in the systematic study of the variable of frequencyof session. Profiles were constructed at the beginning, at the end,and one and two years after treatment. The following data wereavailable for each assessment point: (I) psychotherapeutic sessionswith the child; (2) psychotherapeutic sessions with both parents; (3)an interview with the school teacher; (4) results of a test batterygiven by a psychometrist not familiar with the other information;


(5) one or two diagnostic sessions between child and a psychiatristfamiliar only with the (Toss-sectional information; and (6) one ortwo diagnostic sessions between parents and a psychiatrist familiaronly with the cross-sectional information.

Profiles were constructed on each child at each assessment pointby both the therapist and the independent diagnostic psychiatrist.Both therapist and diagnostic psychiatrist also independently ratedthe children on 46 ratings at each assessment point. The reliabilityof these ratings was very adequate.

The advantage of this procedure was that two clinicians independently arrived at outcome assessments that related directly andwithout further extensive interpretation to the mental health statusof the child.

As a further step in the data analysis, the ratings were processedon an individual basis, or group trends computed. To facilitateanalysis of 46 ratings, a factor analysis seemed advisable. This wasnot an effort to reduce the ratings to one dimension, since all ratings were deemed valuable in order to insure in the individual casethat all relevant areas were covered; however, scores do make certain group comparisons more manageable.

We turn then to the use of this outcome assessment procedure inrelation to the study of the frequency of session in child psychotherapy.

IV. RESEARCH DEMONSTRATING THE IMPACT

OF A SPECIFIED PSYCHOTHERAPEUTIC EXPERIENCE

Frequency of Psychotherapeutic Session As a FactorAffecting Outcome and Process

In the previous section we have already indicated the importanceof frequency of session as one of the conditions affecting outcomeand process. It is perhaps the closest one can come to bringingabout a variation in "dosage" or "intensity." Here we wish to givefurther details of this study in order to provide one model of research, and to illustrate certain methodological points.

The first of two studies (Heinicke, 1969) compared two groupsof boys in terms of treatment and outcome variables. One groupwas seen once a week, the other four times a week. Two psychoanalytic child therapists with similar training and experience treatedthe children. All the mothers were seen on a once-a-week basis,and when appropriate, the fathers also had contact with a therapist. Using certain broad diagnostic considerations, cases were as-


signed to matched samples on a case-to-case basis. All treatmentswere terminated at the request of the parents and with the consentof the therapist. Information on the process variables was derivedfrom the record dictated by either the child's or the parent's therapist immediately after the sessions. Information on the outcomewas derived from multiple assessments at the beginning, at theend, and one and two years after the end of treatment.

From the outcome assessments we select two measures: (1) factorscores based on the correlational analysis of 46 clinical ratings madeby both the therapist and an independent clinician at the beginning, at the end, and one and two years after treatment; and (2)reading achievement test scores administered by a psychologist whohad no other information on the patient available to him. Thereading scores were of particular importance because all patientswere approximately 9 years of age and were suffering from alearning disturbance. The ratings reAect the Profile distinctionsand whit material had in fact been included in the Profiles: thus, alO-pumt rating entitled "The Extent to Which Child's DefensesAre Balanced" is directly related to Profile information on thechild's defensive organization, and specifically to the balance withwhich a variety of defenses is used. This rating turned out to becentral to a cluster called "Extent of Ego Flexibility." It should bestressed, however, that all the ratings were done in the context ofthe total material. It was also determined that all measures usedwere found to be reliable.

The factor analysis of the ratings revealed four factors entitled:Level of Ego Integration, Extent of Ego Flexibility, Capacity forPeer Relations, and Extent of Self-Reliance. Comparing the children seen once a week with those seen four times a week, we determined that there were no significant differences between the twogroups either at the beginning or end of treatment. However, inthe period following treatment, the children seen more frequentlyhad significantly higher scores on the first three factors. Moreover,looking at the within-group gains, we found that the children seenfour times a week showed the greatest gain in ego Aexibility fromthe beginning to end of treatment, the greatest gain in ego integration from the end of treatment to the first follow-up, and the greatest gain in peer relations from the first to the second follow-up.

Turning to another of the many outcome indices, the rate of improvement in reading, we found that because of the matchingthere were no differences in the period before treatment, but thechildren seen once a week improved at a faster rate during the firstyear of treatment. There was no difference in rate of improvement


in reading during the last period of treatment, but striking differences favoring the four-times-a-week children were demonstrated in the two years following the treatment.

These findings are placed into a clinical context by providing acomplete set of Profiles on one child seen once a week and anotherchild seen four times a week (Heinicke, 1965a).

Several aspects of these outcome results should be stressed inguiding the evaluation of future research.

I. In all instances there was ample evidence that despite considerable extra educational efforts before treatment was recommended, the child's rate of improvement was negligible. Neitherinner developments nor environmental facilitators were likely tobring about a change. Spontaneous remission had not occurred.The evaluation of the results of a treatment is likely to be clearer ifseen against baseline measures showing no, or minimal, changes inrelevant variables over a period of time.

2. The value of comparing two groups differing on the variableof interest, namely, frequency, is illustrated. Relevant knowledge isgained without getting into all the reservations of using a defectorcontrol group.

3. The results indicate clearly that the evaluation of the impactof frequency on outcome cannot be based on one outcome measure. Since we are using reliable measures, we are, through the different measures, tapping different facets of the developing child.The frequency of treatment clearly had a different pattern of impact. The less frequent led to a quicker consolidation, evidenced ina more immediate gain in reading during the first year. This consolidation did not, however, represent the kind of personalitychange that would sustain a progressive development after treatment. Similarly, within the group seen more frequently, certainchanges such as flexibility in ego functioning appeared first. Tostress, as Robbins (1972) did, that since the outcome indices of thisstudy did not always coincide in their assessment, they are therefore unreliable, is to miss the nature of the developing process oftreatment. If they did all agree, one would simply be dealing withone outcome measure, very likely getting a less complete picture ofthe changes.

4. Combining outcome measures that are clinically relevant (forexample, flexibility in ego functioning) with those that are easilyreplicable by a number of different investigators (for example,achievement test scores) makes it easier to develop both a clinicallymeaningful and testable interpretation. (See below for one suchtest.)

Toward More Effective Research on Child P!>ychotherapy 581

5. Perhaps even more important, these data emphasize the importance of follow-up evaluations and indicate that one is likely toget very different answers to the question of outcome, dependingon what time point one chooses. Had one stopped this study after ayear, one might have concluded that once-a-week psychotherapy ismore effective with learning disturbance in children. Or, using thisindex, at the end of treatment one might well have said frequencyis not an important variable.

Before turning to another feature of this research, its stress onthe importance of replication, we need to present some of the process data. Systematic content analysis of the process material of thepatient in the once-a-week and four-times-a-week therapy revealedmany differences. Most strikingly different, however, was the clarity of the transference phenomena, the resistances related to thesetransference phenomena, and the clarity with which the psychological events of the past could be reconstructed.

Given the small, even though carefully selected and matchedsamples, one might have decided simply to replicate the groupcomparison. Our experience suggests that carefully designed studies of small samples may yield much more valid information thanpoorly designed studies of large samples. Feeling that frequencywas indeed the most significant variable, we decided to vary it verydirectly by starting a child once a week, and then after a year increasing the frequency to four times a week (Heinicke, 1965b). Thenew sample was carefully matched with the two previous ones.Among the hypotheses were the following:

I. The rate of reading improvement would again increase during the first year.

2. This rate of improvement would be maintained and evenincrease slightly during the four-times-a-week frequency and during the follow-up period.

3. Comparison of process material of the patient before andafter the frequency shift at the end of the first year would reveal anoticeable increase in the clarity of the transference manifestation,the resistances related to it, and also make it easier to conceptualizeand interpret significant psychological events of the past.

This second study is now completed and provides considerablesupport for each of these hypotheses. What we wish to stress againis that the replication of findings through the naturalistic variationof the variable under focus may yield more reliable knowledgethan less precise studies based on large samples.

The next research program to be described is also instructive interms of planning future outcome research.


The Sustained Impact ofPsychotherapeuticIntervention on a PopulationOften Viewed As a Poor Treatment Risk

Shore and Massimo (1966, 1973), Shore et al. (1965, 1966, 1968a,1968b), and Massimo and Shore (1963, 1967) developed what theyhave referred to as a comprehensive, vocationally oriented, psychotherapeutic program for delinquent boys and carried out an extensive evaluative follow-up of their efforts. The basic study consistedof I() delinquents who received treatment and IO who did not.Subjects were included in the sample on the basis of havingdropped out of school or been expelled from it, and on other criteria, such as IQ and a history of antisocial behavior. After assigning subjects randomly to experimental and control groups andfinding no significant difference between the two in terms of age,IQ, or socioeconomic status, the treated group was seen for aperiod of 1O months. A possible methodological difficulty exists inthat there was no demonstration that the two groups were initiallycomparable in terms of severity of disturbance (e.g., frequency andnature of previous antisocial behavior). However, it is likely thatthe random assignment of subjects resulted in equivalent samples.A variety of elements characterized the program, the most crucialof which seemed to be the focus on reality-oriented factors relatingto getting and keeping a job, as well as the intense involvement ofthe therapist (i.e., available just about any time or any place). Otherhelp was provided when the patient requested it.

To evaluate the program, the authors had data from pretesting,posttesting, after 1O months, follow-up testing for half the sampleat 2 years, and the other half at 3 years, a 5-year follow-up, and alO-year follow-up. Assessment measures administered at thesevarious testing points included thematic stories to measure personality changes, Metropolitan Achievement Tests for academic progress, and descriptive statements of overt behavior (e.g., job performance, antisocial behavior).

On each of these indices, and most of their various subcategories, the treated group functioned in a demonstrably superiormanner, and this improved level of functioning tended to be sustained even 1O years after treatment. Most dramatically impressivewere the descriptive contrasts of overt behavior. Thus, most of thetreated group had good jobs and little if any antisocial behavior, incomparison with many more arrests and typically poorer employment records for the untreated group. Thus, of the treated group,at the 10-year follow-up, one subject had had four arrests since


January 1969, and was serving 3-5 years for armed robbery, whileanother subject had one arrest and suspended sentence for disorderly conduct. In contrast, seven of the control subjects had knownarrest records, not counting the one control subject whose whereabouts were unknown.

In addition to significant and maintained improvement in academic areas, the various analyses performed on the thematicstories supported the overt behavioral gains. Ratings pertaining toself-image, control of aggression, attitude toward authority, objectrelations, and guilt were made at various points. Illustrative of thekind of findings revealed was the increase in positive interactionwith people (object relations) for the treated group and the closeassociation between changes in self-image and academic achievement. Shore et at. (1966) concluded, "The changes noted in objectrelations are clearly not isolated changes but most certainly reHect agenerally higher level of over-all ego functioning and integration"(p. 103).

The series of studies assessing this treatment program serves as apotential model for psychotherapy research in various ways. Theselection of a population was determined on the basis of certainspecific theoretical assumptions so that a relatively homogeneousand specifiable sample was being examined (e.g., antisocial adolescents, just dropping out of or being expelled from school), and theform of treatment provided was also clearly delineated and usedbecause of the anticipated requirements of this particular population; e.g., the therapist saw the patients almost any time and anywhere and at a crisis point within the critical period of adolescence.Thus, one can begin to speak to the meaningful question of whatkind of treatment works with what kind of people. Especially impressive are the repeated long-term follow-ups which enable theauthors to demonstrate that the improvements brought about bytheir treatment program are not short-lived, but rather that therapy has initiated a growth process which continues.

The various indices of personality change (e.g., self-image, control of aggression, attitude toward authority, object relations) havepotential utility for further use as measures of change due to treatment. However, with the kind of problems and population beingdealt with here, it would seem necessary to place much of the focusof evaluative concerns on empirically relevant aspects. Thus, if antisocial subjects who receive treatment obtain and hold good jobswhile obeying the law, and nontreated subjects repeatedly get firedand arrested, we would seem to be dealing with critically relevantmeasures. The demonstration of inner psychological change is es-


sential in any evaluation of outcome; however, when confrontedwith "symptoms" like delinquency, it appears difficult to assess "improvement" without some eventual indication of decreased antisocial behavior. In this regard, it must be noted that more couldhave been done to assess empirically the overt behavior changes ofthe antisocial population. For example, one could have set up ascale of antisocial behavior such that more serious crimes wouldhave been weighted more heavily than lesser infractions.

In future research it would also be advantageous to use largersamples so that ongoing attrition would not be as serious a threat tothe ability to perform various analyses. In addition, it would be important to utilize various therapists for different subgroups inorder to separate out the effect of an individual therapist in contrast to the treatment per se-something that was not done in thepresent study. However, on the whole this is a rather impressiveresearch program, and one searches in vain for other examples ofsuch extensive follow-up.

CONCLUDING REMARKS AND SUGGESTIONS

Like other reviewers of the research on child psychotherapeuticprocess and outcome, we must conclude that there are indeed fewstudies which are clinically relevant, well executed, and clearly described. The distance between the convictions and results of the experienced clinician and those findings which publicly demonstratesuch experience and results is still vast.

Since a number of successful studies have been reported and arereviewed here, a strong recommendation is made for the furtherencouragement of such well-designed work. Initial focus mightcontinue to be placed on outcome studies, examining whether asignificant change in the child patient and his family can be demonstrated and, if so, what are the variables effecting such an outcome. Answering such questions will of course inevitably requireknowledge of the therapist-patient process. We believe it is indeednot possible to evaluate the meaning of outcome results withoutknowledge of the essential facets of the treatment. Since to ourknowledge, reliable methods of observing this process have not yetbe developed, and in any case are likely to be very complicatedanu time-consuming, it may well be most efficient in the next research strategies to rely on the daily reports of the therapist to capture the process and to expend more energies on the developmentof relevant and reliable measures of outcome. By relevant, we


mean relevant to the framework, techniques, and goals of the treatment. Some test measures may indeed be valuable in several different types of child treatment research. In Section III we summarized some of the efforts to develop various indices of outcome.

In our review we have stressed the importance of the child's initial status and the nature of the parental impact as a central contextwithin which all therapeutic efforts must be seen. The use of contrast and control groups is likely to be more powerful if variationsin these are specified. The treatment process is then seen as interacting with these variables. The concept of spontaneous remission is replaced by considerations of the internal and externalgrowth-promoting forces relevant to the child, and these are theneither facilitated or not by the treatment experience. The researchreviewed is indeed consistent with such a view, but much moreneeds to be learned about their role. For example, one would needto know if there are indeed instances when therapeutic intervention may not be necessary but may interfere with normal, eventhough stressful, growth processes. In addition, if the parent-childimpact is so important, can we not design treatment services aimedparticularly at helping the parent of the young child (Heinicke etaI., 1974)? Our review also suggested continued careful study focused on such variables as frequency of session, duration of treatment, and therapist-child matching.

Using the successful studies cited in this review as a guide, weconclude our review by listing certain characteristics of child psychotherapy research which are likely to be associated with additionsto our knowledge. Examples are drawn from the research on delinquents and learning disturbance in children cited in Section IV,but other examples could of course be given.

I. A population is chosen for which neither the developmentalforces within the child nor the normally available environmentalresources have insured average growth. For example, certain delinquents or children with serious learning disturbances are likely tofit such criteria.

2. Careful baseline assessment of the child and family impact aremade before the treatment intervention begins. For example, oneasks whether the learning disturbance is a transitional reaction toan environmental stress or whether it represents a more permanent standstill.

3. A variety of carefully selected, theoretically relevant outcomemeasures have been chosen. For example, a measure of the manner of relating to others and indices of legal arrest seem relevant to


changes in the delinquent. Likewise, assessment of ego integrationand actual achievement in reading seem relevant to changes in thechild with a learning disability.

4. Homogeneous treatment groups are formed and matchedwith contrast and control groups, in terms not only of the usualvariables like age, sex, and IQ, but of those factors particularly relevant to the goal of the treatment and the nature of the child beingtreated. For example, matching groups on the degree of ego integration may be particularly relevant in studies of learning disturbances.

5. Control and contrast groups are chosen to help answer specific questions. For example, if frequency of session is the focus, acontrast in frequency seems particularly relevant.

6. The type of treatment, experience of the therapist, and thenature of assignment of therapist to child are clearly described.

7. Cross-sectional assessments are made not only at the beginning and perhaps during treatment, but I, 2, 5, and even 10 yearsafter treatment.

8. The research is formulated in such a way that it can be replicated. For example, the rate of reading improvement during thefirst year of treatment of learning disability children was replicatedexactly in a second sample (see Section IV).

Clearly, there is much which can and should be done in terms ofdeveloping meaningful investigations of the efficacy of psychotherapy with children. While there remains room for substantialdebate with respect to the question of what constitutes adequateoutcome, there are nevertheless numerous methodological elements which can be controlled and thereby result in research whichyields meaningful inferences. Those studies which have already incorporated many of the control and methodological designs wehave suggested appear to support the contention that psychotherapy is an effective curative process under certain conditions.Further research might do well to follow similar guidelines inorder to yield "interpretable" and "generalizable" results.

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