Feasibility and Preliminary Efficacy of School-Based Modular Psychotherapy

In February 2018, my students Christine Gonzales, Olivia M. Shipp, and Rachel L. Kininger presented the results of four case studies at the National Association of School Psychologists conference in Chicago, IL. In each case, we examined the feasibility and efficacy of modular therapy for depression, combined with elements of the Challenging Horizons Program, as a treatment for conduct problems when parent training was infeasible. The results suggest that this transdiagnostic approach is promising.

Background

Schools are the most common setting for child and adolescent mental health services. Unfortunately, evidence-based treatments (EBTs) are rarely implemented in these settings, partly because EBTs are typically developed for use in private practice settings (Langley et al., 2010). To improve the transportability of EBTs, researchers developed modular therapies by identifying the most commonly-used therapeutic techniques from hundreds of treatment manuals (Chorpita & Daleiden, 2009). Common techniques were then repackaged as standalone modules that allow clinicians to individualize treatment. Research suggests that school practitioners find modular therapy acceptable and children with internalizing disorders appear to benefit (Lyon et al., 2014). Research on modular therapy for chronic behavior problems, however, is less encouraging (cf., Weist et al., 2014). The purpose of this pilot study was to evaluate modular therapy used in combination with behavior interventions designed for use in schools (Challenging Horizons Program [CHP]; Evans et al., 2016; Schultz & Evans, 2015).

Method

Participants. We recruited four students from a Title 1 elementary school after advertising the study to all students and their families. Participants’ demographic information is summarized in Table 1. Depression (n = 3) and disruptive behavior (n = 1) were the main treatment targets, but we noted comorbid concerns in all cases.

Procedures. All participants received modular therapy for depression during one school semester, using the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC; Chorpita & Weisz, 2009), as well as elements of the CHP (Schultz & Evans, 2015) when indicated.

Measures. Feasibility was measured using the following:

•Adherence checklists based on the goals/objectives of each module (including the CHP elements)

•Parent satisfaction ratings using an 8-item Likert-type scale (1-4 response formats) used previously in the CHP with acceptable reliability (α = .96) (item M = 3.0, SD = .75).

Efficacy was measured using the following:

•Behavior Assessment System for Children, Third edition (BASC-3; Reynolds & Kamphaus, 2015), parent and teacher ratings

•Grade Point Average (GPA) on a 0-100 scale

Results

Feasibility: On average, participants received 10 sessions lasting approximately 34 minutes each. Clinician report of session adherence ranged from 33% to 100% (M = 80%), based on the goals and objectives checklists. One case (Michael) appeared to have a low level of overall adherence (62%), due in part to failed or incomplete therapeutic homework assignments between sessions (see Discussion), but all other cases met or exceeded 80% adherence. Parent satisfaction ratings (M = 3.7, SD = .12) exceeded previous studies of the CHP by nearly one standard deviation.

Treatment Outcomes: We calculated the reliable change index (RCI; Jacobson & Truax, 1991) in parent and teacher BASC-3 ratings from pre- to post-treatment. Given the exploratory nature of this study, we did not apply Bonferroni (or similar) corrections for multiple tests of significance, but instead estimated the proportion of clinically significant findings relative to the standard Type-I error rate (5%). In all, clinically significant change occurred in 25.9% of parent and 18.5% of teacher ratings. We also averaged grades across the four core courses (GPA) in each of four grading periods for each participant, then compared the fall semester (pre-treatment) to spring semester (treatment). Three of the four cases experienced improvement in GPA from the fall to spring semesters, with one case (Michael) experiencing a large improvement from 61.3 in the fall to 72.1 in the spring. It should be noted, however, that Michael started a stimulant medication during this time, so his results represent a mix of psychosocial and pharmacological intervention. Only one case (Anthony) experienced a drop in GPA, but this change was small (72.0 to 68.0).

Discussion

We assessed the feasibility and early efficacy of a school-based modular approach to conduct problems using depression modules alongside student-focused elements of the CHP (e.g., organization, assignment tracking). We found that clinicians were able to blend these elements to meet specific student needs, and the approach proved achievable at school and acceptable to parents. Below, we summarize lessons learned from each case.

•Anthony: Anthony rarely completed therapeutic homework assignments, so time was spent reviewing those materials at the beginning of each session. The therapist instituted a reward for homework completion (a snack of Anthony’s choice), but he completely only 1 of 7 assignments independently. Still, his parent reported a significant reduction in conduct problems and his teacher noted improvements in all externalized behaviors.

•Michael: Michael started a psychostimulant during the trial so his results are difficult to interpret. The clinician had difficulty maintaining adequate adherence to the planned treatment due to missed homework assignments and time constraints. Sessions typically occurred when Michael was in a “specials” class (e.g., art) and his backpack and binder were often locked in his homeroom and inaccessible to the clinician. Still, the parent’s effort to pursue medication and her reported satisfaction suggest that the experience of school-based treatment was positive.

•Kayla: All parent and teacher ratings on the BASC-3 were in the normal range at the start of treatment (despite meeting DSM criteria for depression using other measures). Still, it appeared that there was a significant reduction in somatization symptoms according to parent report, and a trend toward reduced anxiety according to her teacher. Kayla was engaged by the modules for depression and seemed eager to meet with the clinician.

•Eric: The CHP elements were well-suited for Eric’s needs (e.g., disorganization), but his response to the interventions was inconsistent. For example, the clinician often found that Eric had not written in his planner and some organizational elements were “lost.” If the intervention had been a part of class-wide expectations, with daily reminders, it may have improved his performance over time. Still, his parent reported significant reduction in aggression and somatization.

In short, all four students showed clinically significant gains in some (but not all) areas of concern, according to parent and/or teacher reports. We believe these findings underscore the promise of this hybrid modular approach for use in schools when parent training is infeasible, but more research is clearly needed.

References

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, 566-579.

Chorpita, B. F., & Weisz, J. R. (2009). MATCH-ADTC: Modular Approach to Therapy for Children with Anxiety, Depression. Trauma, or Conduct Problems. Sattelite Beach, CA: PracticeWise.

Evans, S.W., Langberg, J.M., Schultz, B.K., Vaughn, A., Altaye, M., Marshall, S.A. & Zoromski, A.K., (2016). Evaluation of a school-based treatment program for young adolescents with ADHD. Journal of Consulting and Clinical Psychology, 84, 15-30.

Jacobson, N.S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.

Lyon, A. R., Ludwig, K., Romano, E., Koltracht, J., Stoep, A. V., & McCauley, E. (2014). Using modular psychotherapy in school mental health: Provider perspectives on intervention-setting fit. Journal of Clinical Child & Adolescent Psychology, 43, 890-901.

Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior Assessment System for Children (3rd ed.). Bloomington, MN: Pearson.

Schultz, B. K., & Evans, S. W. (2015). A practical guide to implementing school-based interventions for adolescents with ADHD. New York: Springer.

Weist, M. D., Youngstrom, E. A., Stephan, S., Lever, N., Fowler, J., Taylor, L ... Hoagwood, K. (2014). Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health. Journal of Clinical Child & Adolescent Psychology, 43, 244-255.