Question

Question: Among children and families treated for internalising and externalising problems within a randomised controlled trial (RCT) are sudden gains (rapid, sizeable changes between treatment sessions) associated with participant characteristics and longer term outcomes?

Participants: 161 children (aged 7–13 years; 70% male; 50% minority ethnic status) with anxiety, depression or conduct-disruptive disorders and their caregivers, who were participating in a multicentre RCT of three treatment modalities for internalising and externalising problems. Children and caregivers had initially sought outpatient treatment for the disorders and diagnoses confirming eligibility for the trial were made using the Children's Interview for Psychiatric Syndromes.

Setting: Community clinics, Massachusetts and Hawaii, USA.

Intervention: Modular treatment or standard manual treatment (not further described) compared with usual care. The therapist-completed consultation record was used to assess session content, which was broadly categorised into cognitive or behavioural content.

Outcomes: Internalising and externalising symptoms. The parent-reported and child-reported Brief Problem Checklist (BPC) were administered every 3 months during the first 18 months of the trial, which rates items from 0 (not true) to 2 (very true) with higher scores indicating greater symptom burden. Weekly phone calls in between sessions assessed past-week severity of the top three problems (identified at baseline using the Top Problems Assessment, TPA) on a scale from 0 (not a problem) to 10 (very, very much a problem). The Child Behaviour Checklist (parent report) and Youth Self-Report (child report) were used to assess symptoms at baseline, post-treatment and final assessments. Averages of each quarterly and weekly score were used to identify large sudden gains (SG). Linear regression models were used to examine associations between SG and final assessment scores and other participant and treatment characteristics.

Patient follow-up: Initial trial recruitment was 203 and 174 received treatment. Analysis was performed for the 161 children (80.5%) who had complete assessment data.

Main results

A total of 2946 sessions were assessed for SG. On the quarterly BPC, 1% of assessments were associated with SG, and 20% of participants had SG at some point during treatment. On the past-week TPA, 2% of assessments were associated with SG, and 33% of participants had SG at some point during treatment. The average size of SG was 0.64 points on BPC (3% of total score) and 3.75 on TPA (13% of total score). The median session associated with SG was sessions 4 for TPA and 5 for BPC. Presence of SG by parent or child report on either BPC or TPA was associated with improvement in overall symptoms at final assessment after controlling for baseline severity of scores and overall magnitude of pretreatment to post-treatment change (p<0.01). In children with depression and/or anxiety SG on BPC was not significantly associated with final assessment of parent-reported or child-reported internalising symptoms. In children with conduct disorder SG on BPC was associated with improvement in externalising symptoms, even after adjusting for baseline severity of scores and overall magnitude of pretreatment to post-treatment change (p<0.01). Early SG was not associated with overall, internalising or externalising symptoms. SG was not associated with gender, race, age, ethnicity, primary diagnosis, number of diagnoses, treatment modality or city. By content of modular and standard manual treatments, relaxation was more likely to be associated with SG than other session content.

Abstracted from

Dour HJ, Chorpita BF, Lee S, et al. Sudden gains as a long-term predictor of treatment improvement among children in community mental health organizations. Behav Res Ther 2013; 51: 564– 72.OpenUrlCrossRefPubMed