Transdiagnostic Treatment Formats

In contrast to traditional single-diagnosis treatment protocols, transdiagnostic treatments focus on parallels and overlapping features across disorders, especially those from neighboring classes of diagnoses and those showing high levels of comorbidity. The early foundations of behavioral and cognitive therapies, as well as client-centered and psychoanalytic approaches, were intrinsically transdiagnostic (see Taylor & Clark, 2009). However, with major advances in affective neuroscience, underlying etiology, and latent structure of disorders (see Barlow, 2004; Wilamowska et al., 2010), research groups have been able to develop unifying, evidence-based protocols that can be applied flexibly across a range of diagnoses sharing common components and etiological mechanisms (Craske et al., 2009; Fairburn, Cooper, Shafran, & Wilson, 2008; Fairburn et al., 2009; Farchione et al., 2012; Norton, 2008; Norton & Hope, 2005; Sullivan et al., 2007).

A growing body of evidence supports the efficacy of transdiagnostic approaches in treating childhood disorders (Ehrenreich, Goldstein, Wright, & Barlow, 2009; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; Weersing, Rozenman, Maher-Bridge, & Campo, 2012). For example, instead of focusing on a single childhood disorder, the treatment protocol developed by Kendall (Kendall & Hedtke, 2006a, 2006b) applies cognitive restructuring, emotion awareness, problem-solving skills, and graduated exposure tasks to target the range of common childhood anxiety disorders. This transdiagnostic approach has undergone significant empirical examination—relative to wait lists, psychoeducation, support, pill placebo, active controls, and selective serotonin reuptake inhibitors—and has been associated with considerable clinical response across evaluations. Transdiagnostic protocols simultaneously targeting the range of anxiety and unipolar mood disorders in youth are also beginning to show strong promise (see Chu, 2012; Ehrenreich et al., 2009; Weersing et al., 2012).

Of course, additional research is necessary to clarify the clinical utility of transdiagnostic treatment protocols for children. However, research to date suggests that these recent advances hold the potential to meaningfully elevate the public health significance of the widespread availability of EBT practices. Specifically, by considerably reducing the number of supported protocols practitioners must learn and by introducing more parsimony into dissemination efforts, transdiagnostic protocols have the potential to increase the public health impact of our evidence-based interventions for children.

Modular Treatment Designs

Another approach to redressing the treatment manual proliferation barrier to broad dissemination in children’s mental health care is the development of modular approaches to care. Whereas traditional treatment manuals apply multiple treatment components in a more linear format, it is becoming increasingly apparent that not every child will benefit comparably from each and every treatment component in an indicated treatment protocol. And, of course, practitioners encounter a broad range of sometimes unrelated, comorbid disorders across internalizing and externalizing dimensions. Thus, many children may benefit from various treatment elements found across a range of single-diagnosis treatment protocols. For the heterogeneous cases that populate practice settings, employing a linear sequence of single-diagnosis manuals may not be optimal from either a treatment delivery or dissemination standpoint.

Relative to the theoretically based transdiagnostic formats, modular treatment formats take a more empirical approach to children’s mental health care and address the earlier-noted problems through strategic treatment redesign—procedures from supported protocols for specific identified problems are structured as free-standing modules, and decision flowcharts guide module selection and treatment component sequencing (Chorpita, 2007; Chorpita & Weisz, 2005; Harvey, Watkins, Mansell, & Shafran, 2004; Weisz et al., 2012). Modular approaches individualize treatment regimens to deliver supported components efficiently to each patient using evidence-based algorithms. Treatment is applied flexibly to address comorbidities by affording empirically informed sequencing of treatment elements to accommodate personalized tailoring of care for specific problems presenting in each child. Accordingly, modular approaches have the potential to address the needs of clinicians with caseloads marked by complex patterns of comorbidity and shifting clinical needs.

Modular approaches are already showing promise. For example, modular strategies and dynamic treatment regimens are distinguishing themselves from usual care for homogenous symptom classes in practice settings (Weisz et al., 2012). The MATCH (Modular Approach to Therapy for Children) program produced steeper improvement trajectories in a broad clinical child sample than usual care and standard linear manuals. At posttreatment, MATCH was also linked with significantly fewer children meeting criteria for diagnosis than usual care, whereas diagnostic outcomes of standard linear manuals did not differ from usual care outcomes (Weisz et al., 2012). Importantly, therapists trained in standard linear protocols held more negative views of manuals than did therapists trained in supported modular programs that incorporate potentially shifting treatment needs and tailor treatment sequences to individual child presentations (Borntrager, Chorpita, Higa-McMillan, & Weisz, 2009).

Intensive Treatment Formats

Whereas transdiagnostic and modular treatment formats offer opportunities to facilitate and improve broad dissemination efforts and the training of generalist mental health workers, dissemination and implementation efforts to generalists alone will not be sufficient to adequately address the incidence of children’s mental illness. As noted elsewhere (Comer & Barlow, 2013), our field needs to retain a role for specialty care in the delivery of psychological treatments, given that some EBTs prove too complex for universal dissemination and the time and expenses needed for quality dissemination and implementation typically preclude large-scale training in the treatment of low base-rate disorders. Regrettably, there are considerable geographic obstacles to the broad availability of specialty mental health care, and the limited availability of specialty care is understandable from a supply and demand standpoint.

To address local workforce shortages in specialty care and problems of treatment access, many specialty programs are increasingly offering intensive treatment formats, in which patients travel for brief (e.g., 1–3 week) periods of all-day sessions in treatment not offered in their local community. Intensive treatments deliver an entire course of a treatment in a shorter period of time through longer individual sessions (Albano, 2009). This condensed modification of traditional treatment has several advantages that may make intensive treatments an attractive option for families and mental health professionals. The massed nature of the treatment sessions may reduce the negative impact of the financial, logistic, and geographic barriers to treatment attendance and completion without requiring the content of treatment to vary significantly from a traditional therapeutic approach (Ehrenreich & Santucci, 2009). Intensive treatments may be more desirable than traditional weekly treatment with respect to the necessary time commitment, travel requirements, and reduction of stigma, and as a result they may be more marketable to families (Santucci & Ehrenreich-May, 2010). Intensive treatments may be conducted during times convenient for the family, such as summer or holiday breaks, during which children have fewer academic demands. The intensive format also may allow families without easy access to settings offering intensive treatments the option to travel to such a setting and spend a week devoted to treatment (Angelosante, Pincus, Whitton, Cheron, & Pian, 2009), ensuring that patients who would not otherwise receive EBT may benefit from such approaches. Moreover, the intensive delivery of treatment may benefit children for whom previous interventions have been ineffective (e.g., Storch, Geffken, Adkins, Murphy, & Goodman, 2007).

As with traditional weekly treatment approaches, intensive treatments afford opportunities for “flexibility within fidelity” (Kendall & Beidas, 2007), relying on clinical judgment to inform the appropriate delivery of individual treatment components as well as individually tailored homework assignments and out-of-session activities that are sensitive to the individual needs of each child (Santucci, Ehrenreich, Trosper, Bennett, & Pincus, 2009). This flexibility also extends to the format and delivery of intensive treatments. For example, intensive treatments may be delivered in both individual and group formats and can be modified to incorporate varying degrees of parental involvement. The group format of some intensive treatments may be both incrementally effective and attractive to youth, as children—particularly those with low base-rate disorders—may feel less isolated by their condition in the context of peers experiencing similar symptoms, and peer interaction may provide unique opportunities for modeling and practice. Research indicates that group cohesiveness may have the added benefit of augmenting treatment effectiveness (Marziali, Monroe-Blum, & McCleary, 1997). Given that interventions flexibly delivered using creative and interactive formats may increase engagement and understanding in younger populations (e.g., Beidas, Benjamin, Puleo, Edmunds, & Kendall, 2010; Kingery et al., 2006), “camp-based” intensive group treatments represent an innovative and developmentally appropriate format for children and adolescents that have demonstrated success in treating a range of mental health concerns. As participation in camp can be a standard and attractive activity for many youth, delivering intensive psychological treatment in a camp format may attenuate the stigma associated with the receipt of traditional mental health services.

Early evaluations of intensive treatment formats across childhood disorders have yielded preliminary promise. A number of intensive protocols for individual treatment of children and adolescents have demonstrated success for a range of conditions, including specific phobia (Ollendick et al., 2009; Öst, Svensson, Hellstrom, & Lindwall, 2008), obsessive-compulsive disorder (e.g., Grabill, Storch, & Geffken, 2007; Marien, Storch, Geffken, & Murphy, 2010; Storch et al., 2008; Whiteside, Brown, & Abramowitz, 2008), school refusal (Moffitt, Chorpita, & Fernandez, 2003; Tolin et al., 2009), and panic disorder with agoraphobia (Angelosante et al., 2009; Gallo, Cooper-Vince, Hardaway, Pincus, & Comer, in press; Pincus, Ehrenreich, & Mattis, 2008). A number of innovative group and/or camp-based approaches to intensive treatments have emerged as well. These include the Summer Treatment Program, which addresses attention-deficit/hyperactivity disorder in children and adolescents (e.g., Chronis et al., 2004; Coles et al., 2005; Pelham et al., 2010; Pelham & Hoza, 1996; Sibley, Smith, Evans, Pelham, & Gnagy, 2012); Emotion Detectives, a preventive camp-based intervention that teaches emotion-focused skills for coping with anxiety and depression (Ehrenreich-May & Bilek, 2011; Laird, Santucci, & Ehrenreich, 2009); Brave Buddies, a therapeutic summer program for the treatment of selective mutism in young children (Furr et al., 2011, 2012; Kurtz, 2009); and a 1-week summer treatment program targeting separation anxiety disorder in school-age girls (Santucci & Ehrenreich-May, 2010; Santucci et al., 2009).

Despite benefits that an intensive treatment approach may provide to affected youth, the implementation of intensive treatment programs within service provision settings presents many challenges. Service provision settings require adequate training, resources, and time in order to train and deliver intensive treatments with fidelity. Although intensive approaches may be more cost effective for some payers than weekly approaches, allocating staff time for intensive treatments may decrease the feasibility of this approach in certain settings, particularly for group settings where multiple therapists provide services to the group of patients enrolled in treatment. Moreover, insurance coverage for intensive treatments may be difficult to attain, given the nontraditional format and the necessity of covering up to 24 hours of billable therapist time in one block (Angelosante et al., 2009), potentially precluding the participation of families who are unable to pay out of pocket for services.