Outcome Research in Children and Adolescents

A growing number of randomized controlled trials (RCTs), reviews and meta-analyses for psychodynamic therapy with children and adolescents is available, including Abbass et al. (2013), Midgley et al. (2021) and Sleed et al. (2023). Compared to psychodynamic therapy with adults, the number of studies is still relatively small, and the quality of evidence is variable, with many of the studies being relatively small-scale.

With regards to evidence for specific clinical populations, the following provides a brief overview:

Emotional disorders

There have been a relatively large number of studies evaluating the outcome of psychodynamic therapies for children with emotional disorders: 21 studies, of which 12 are RCTs - 5 studies focused on mixed emotional disorders, 4 on depression, 2 on self-harm, 6 on anxiety disorders, and 5 on feeding and eating disorders. Taken together, the most recent review (Midgley et al., 2021) suggests that these studies indicate that emotional disorders respond well to psychodynamic therapy; with a number of studies suggesting that psychodynamic treatment is more effective for internalizing than externalizing symptoms.

Depression

Within the emotional disorders, the quality of research has been particularly high for the treatment of depression, where 3 RCTs have been conducted, including the IMPACT study (Goodyer et al., 2017). This was the largest study to date to include a psychodynamic treatment arm either in children or young people (n = 465). Taken together, these studies suggest that psychodynamic psychotherapy is equally effective to other psychological treatments such as cognitive behavioral therapy (CBT) or systemic family therapy, and that it can result in good outcomes across a range of domains, with those outcomes maintained beyond the end of treatment. For example, the IMPACT study found that 85% of adolescents receiving STPP no longer met criteria for depression one year after the end of treatment.

Bulimia Nervosa and Anorexia Nervosa

There is some evidence for the comparative effectiveness of psychodynamic therapies in the treatment of Bulimia Nervosa and Anorexia Nervosa. Two RCTs focused on Anorexia and one focused on Bulimia found psychodynamic treatment to be equally effective to an alternative treatment (Lock et al., 2010; Stefini et al., 2017).

Anxiety disorders

For the treatment of anxiety disorders, the number of studies has grown in recent years and a number of studies have now found psychodynamic treatment to be effective (Midgley et al., 2021). The best designed study of psychodynamic therapy for children with anxiety disorders was an RCT carried out by Salzer et al. (2018), which showed both active treatments were superior to a waitlist condition, with medium-to-large effects for CBT and medium effects for psychodynamic therapy. Overall, the evidence to date suggests that psychodynamic therapy, even when relatively short-term (<30 sessions) is effective in the treatment of anxiety disorders, and that these outcomes have been maintained at a 6-month follow-up period. One retrospective study showed that children with anxiety disorders did better than children with either depression or disruptive disorders (Horn et al., 2005).

Self-harm in adolescents

There is evidence to suggest that a contemporary psychodynamic therapy such as mentalization based treatment may be effective for treating self-harm in adolescents. Two RCTs have been conducted to date, and both demonstrated that a mentalization based intervention was equally or more effective than treatment as usual for the treatment of self-harm(Griffiths et al., 2019; Rossouw & Fonagy, 2012).

Externalizing (disruptive) disorders

Comparatively, the psychodynamic treatment of externalizing (disruptive) disorders has received less research attention, and this may partly be because the evidence-base for a range of parenting interventions in this area is well-established (Fonagy, 2015). There have been only 6 studies of psychodynamic therapies for this group of children, and only one of these was an RCT (see Midgley et al., 2021). However, despite the fact that behavioral-based parenting programmes are usually considered the treatment of choice for children with conduct problems (Fonagy et al. 2015), these studies show promising findings, particularly when the child also presents with some emotional difficulties. Research suggests that children with externalizing disorders may be difficult to engage, but those who remain in treatment can see significant symptom reduction. Although comparative studies are lacking, one study found psychodynamic therapy to be similarly effective to a behavioural intervention (Laezer, 2015). It may be, as with the feasibility study conducted by Edginton et al. (2018), that future studies of psychodynamic therapy should focus especially on those children with disruptive disorders who have not been responsive to a first-line treatment, including parenting interventions.

Emerging personality disorders

Some areas have received growing research interest in recent years, with more studies identified in more recent reviews (Midgley et al., 2021). Emerging personality disorders have been examined in 8 studies, of which 2 are RCTs. 5 of these 8 studies have been published since 2017. The two RCTs of borderline personality disorder (BPD) both showed the psychodynamic treatment to be equally effective to the control condition: cognitive analytic therapy (Chanen et al., 2008) and a group-based Mentalization Based Treatment (MBT-G; Bo et al., 2017). Given the high personal and social costs of PDs across the lifespan, and the evidence of the effectiveness of psychodynamic therapies for adults with personality disorders (Storebø et al., 2020), this may be an area where psychodynamic therapies have an especially important role to play.

Children impacted by parental conflict or domestic violence

Similarly, in recent years more studies have focused on children impacted by parental conflict or domestic violence – the most recent review found three studies, all published since 2017, of which two were RCTs (Midgley et al., 2021). These three studies were designed quite differently, such that it is difficult to draw together their findings. However, the study by Pernebo (2019) suggests that children experiencing trauma symptoms are particularly able to benefit from group psychodynamic therapy, suggesting a promising area for future research with children impacted by parental conflict.

Children who had experience trauma

A number of studies have evaluated the effectiveness of psychodynamic therapies with children who had experience trauma, including children in foster care and post-adoption. Midgley et al. (2021) identified eight studies, three of which are RCTs. These are promising and show that psychodynamic therapy is as effective as alternative treatments in the treatment of young people who have experienced trauma (Gilboa-Schechtman et al., 2010; Trowell et al., 2002). These findings support those of Pernebo (2019), who also found that children who have experienced trauma may benefit from psychodynamic therapy. Recent reviews of the work of psychodynamic child psychotherapists have highlighted the wide range of settings in which psychodynamic therapists work with children who have experienced maltreatment, especially those children who have been adopted or who are in care (Robinson et al., 2017, 2020). Therefore, there is an urgent need to build on the preliminary research in this area, with larger and better-designed studies.

Physical illness

The most recent review of the evidence-base for psychodynamic therapy with children and adolescents (Midgley et al., 2021)identified only 2 studies examining the effectiveness of psychodynamic therapy for physical illness, though these are both well designed. Moran and colleagues (Fonagy & Moran, 1990; Moran et al., 1991; Moran & Fonagy, 1987) show psychodynamic therapy to be effective in the treatment of adolescents with poorly controlled diabetes. There is also evidence from a pilot RCT that psychodynamic therapy can reduce symptom severity for young people experiencing idiopathic headache (Balottin et al., 2014). These findings suggest that further research should consider psychodynamic treatments for certain physical conditions, where symptoms or treatment adherence may have an important psychological component that could be treated with psychotherapy.

Autistic spectrum disorders (ASD) and obsessive compulsive disorder (OCD)

There are a number of areas where very little research has been carried out evaluating the effectiveness of psychodynamic therapies with certain clinical populations of children and adolescents. This includes research into the treatment of children and young people with autistic spectrum disorders (ASD) and obsessive compulsive disorder (OCD), where the most recent review identified few or no outcome studies (Midgley et al., 2021).  If psychodynamic therapy is to be offered to children with these clinical presentations, it is vital that more outcome research is carried out.

Children under five, including parents/caregivers and infants

In a systematic review and meta-analysis of the evidence for the effectiveness of psychodynamic interventions for children under 5 years of age and their caregivers, Sleed et al. (2023) identified 77 papers evaluating psychodynamic interventions with this age group. Most studies reported positive outcomes on a range of parent and infant domains. The meta-analyses of controlled studies found significant effects of psychodynamic interventions compared to control conditions on parental reflective functioning, maternal depression, infant behavior, and infant attachment. No significant differences between psychodynamic and control interventions were found for parental stress, and parent-infant interactions. Very few studies were rated as good quality and further high-quality research is needed.

1. Outcome research: open questions and future research of psychodynamic therapy in children and adolescents

Further RCTs and meta-analyses for both general emotional and behavioral difficulties and for specific mental disorders in children and adolescents required, e.g. in:

• depressive disorders

• anxiety disorders

• conduct and behavioral disorders

• personality disorders

• eating disorders

• ADHD

• Children with a diagnosis of ASD

Furthermore, in contrast to PDT in adults (Leichsenring et al., 2023), PDT for children and adolescents has not yet been evaluated according to the updated criteria of the American Psychological Association (Tolin et al., 2015). For this purpose a sufficient number of RCTs as well as meta-analyses are required (Tolin et al., 2015).

1. Process Research in Psychodynamic Therapy in children and adolescents

Process research - the empirical study of what actually takes place in a psychotherapy treatment - is the means by which we explore why and how change takes place as the consequence of a therapeutic intervention. Such research adds depth and understanding to the question of ‘what works for whom?’ (Fonagy et al., 2015) and has the potential to help identify the ‘active ingredients’ or change mechanisms that form the basis for a successful clinical intervention. As such, this approach to research can help develop a more clinically relevant research programme and, according to one review, is ‘probably the best short term and long-term investment for improving clinical practice and patient care’ (Kazdin & Nock, 2003, p. 1117).

Although the number of process studies of psychodynamic therapy with children and young people is increasing, the only review of such work to our knowledge was published more than 15 years ago (Kennedy & Midgley, 2007). There is an urgent need for a more updated review of work in this area.