Child psychotherapy dropout

Abstracts

OBJECTIVE: To compare a sample of 24 children who completed 12 months of psychoanalytical psychotherapy with a sample of 38 children who dropped out from treatment before 12 months of intervention. METHOD: Quantitative study involving two groups of children. Quasi-experimental treatment of single measure before the beginning of individual psychoanalytical psychotherapy. RESULTS: Statistically significant differences were found in the following variables: gender, symptoms, frequency of sessions, child's impulse and emotion control (measured using the Rorschach test and sociability scales), somatic complaints and internalizing behaviors, such as anxiety and depression (measured using the Child Behavior Checklist). CONCLUSIONS: CThe results revealed that child psychoanalytical psychotherapy is effective in the treatment of female children with internalizing disorders, such as anxiety and depression, who have little control of impulses and emotions and attend at least 12 months of psychoanalytical psychotherapy twice a week.

Child psychoanalytical psychotherapy; outcome research; psychoanalysis; effectiveness and dropout

OBJETIVO: Comparar uma amostra de 24 crianças que completaram 12 meses de psicoterapia psicanalítica com uma amostra de 38 crianças que interromperam prematuramente o tratamento. MÉTODO: Trata-se de um estudo quantitativo em dois grupos de crianças; tratamento quase-experimental de medida única antes do início da psicoterapia psicanalítica individual. RESULTADOS: Foram encontradas diferenças estatisticamente significantes nas seguintes variáveis: sexo, sintomas, frequência dos atendimentos, capacidade da criança de controlar as emoções e os impulsos, medida pelo teste Rorschach e nas escalas de sociabilidade, queixas somáticas e comportamentos internalizantes, tais como ansiedade e depressão, medidas pelo Child Behavior Checklist. CONCLUSÕES: Este estudo revelou que a psicoterapia psicanalítica é efetiva no tratamento da criança do sexo feminino que apresenta transtornos internalizantes, tais como ansiedade e depressão, tem maior descontrole de emoções e impulsos e recebe atendimento com uma frequência de duas vezes por semana por pelo menos 12 meses.

Psicoterapia psicanalítica com crianças; pesquisa de resultados; psicanálise; efetividade e abandono

ORIGINAL ARTICLE

Child psychotherapy dropout

Elisabeth Kuhn Deakin^I; Maria Lucia Tiellet Nunes^II

^IPhD in Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

^IIPhD in Psychology, Free Berlin University, Berlin, Germany, Coordinator, Graduate Program in Psychology, PUCRS

This study was conducted at the Graduate Program in Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

Correspondence

ABSTRACT

OBJECTIVE: To compare a sample of 24 children who completed 12 months of psychoanalytical psychotherapy with a sample of 38 children who dropped out from treatment before 12 months of intervention.

METHOD: Quantitative study involving two groups of children. Quasi-experimental treatment of single measure before the beginning of individual psychoanalytical psychotherapy.

RESULTS: Statistical significant differences were found in the following variables: gender, symptoms, frequency of sessions, child's impulse and emotion control (measured using the Rorschach test and sociability scales), somatic complaints and internalizing behaviors, such as anxiety and depression, measured using the Child Behavior Checklist.

CONCLUSIONS: CThe results revealed that child psychoanalytical psychotherapy is mostly effective in the treatment of female children with internalizing disorders, such as anxiety and depression, who have little control of impulses and emotions and attend at least 12 months of psychoanalytical psychotherapy twice a week.

Keywords: Child psychoanalytical psychotherapy, outcome research, psychoanalysis, effectiveness and dropout.

INTRODUCTION

Psychotherapy dropout is a very important problem for professionals who provide psychotherapy treatment to children, adolescents and their families. Longitudinal studies have suggested that child psychiatric diseases are precursors of a wide range of negative outcomes, that is, if a child has a psychiatric disease and does not receive treatment, he/she is at higher risk of developing other emotional disorders throughout his/her adulthood.¹ In that sense, it is very important to have an empirical understanding of the phenomenon involving early dropout from child psychotherapy treatment so that appropriate preventive measures can be taken and, thus, more children can be treated.

In order to meet this demand, we conducted the present study, whose objective was to compare 62 children who sought psychological care due to several emotional problems at an outpatient clinic in Porto Alegre, state of Rio Grande do Sul, Brazil. Of the 62 children, one was discharged after 7 months of treatment, and 23 completed 12 months of psychoanalytical psychotherapy. The other 38 children dropped out from treatment, which amounted to an early dropout rate of 61.3%

Early treatment dropout

In the present study, we defined early treatment dropout as the interruption of psychoanalytical psychotherapy before 12 months of treatment as a consequence of a unilateral decision made by the patient and/or his/her family, without reaching an agreement with the therapist, who considered that the treatment should not be interrupted.

The literature presents many factors related to early dropout. Namely: a) child and /or his/her family's perception that the treatment is not relevant; b) weak therapeutic alliance between therapist and child and his/her family in the beginning of the treatment; c) socioeconomic disadvantage; d) high stress level and family dysfunction, etc. As a matter of fact, the larger the number of factors, the higher the risk of early dropout. Studies have suggested that, in most cases, the reason for dropping out is related to family difficulties, instead of being related to the child who needs treatment.^2-4

In that sense, child psychotherapy is different from adult psychotherapy, since children do not seek treatment by themselves and, therefore, treatment maintenance depends on parents' motivation. Therefore, a positive therapeutic alliance with the parents is often more important for treatment maintenance than a good therapeutic alliance with the child.⁵ In most cases, parents actively participate in their children's psychotherapy treatment. The more they avoid participating, the higher the risk of early dropout.^3,5

Objectives

To compare the group of children that continued to be treated with psychoanalytical psychotherapy for 12 months and adhered to the treatment until being discharged by the therapist (G1) with the group of children which dropped out from treatment earlier than expected (G2). We also tried to associate the sociodemographic and clinical variables and the test results with adherence to treatment.

METHOD

This is a quantitative study involving two groups (G1 vs. G2); quasi-experimental treatment of single measure before the beginning of individual psychoanalytical psychotherapy. Sociodemographic and clinical data, as well as test results, were associated with psychoanalytical psychotherapy for 12 months and adherence to treatment until being discharged by the therapist and with psychotherapy dropout before 12 months or due to discharge.

Sample

Our sample included 62 children who sought psychotherapy treatment in the Center of Childhood and Adolescence Studies, Care and Research (CEAPIA) in Porto Alegre, state of Rio Grande do Sul, Brazil, in 2005 and 2006, and who agreed to participate in this study. The sample was then divided into two groups: G1, including those children who continued to be treated for 12 months and adhered to treatment and/or were discharged by the therapist, totaling 24 children, and G2, which included those children who dropped out from treatment, totaling 38 children. The sociodemographic characteristics of the sample are shown in Table 1.

The analysis of frequencies indicates that, when the children first sought treatment, the sample included 37.1% of females and 62.9% of males. In spite of being the minority at the baseline of the present study, females were the majority (62.5%) in the group who continued to be treated with psychotherapy during 12 months and did not drop out from treatment. Males, in turn, were the majority in the group with early treatment dropout (78.9%).

With regard to age, the largest number of children in both groups was between 8 and 10 years old. Children's educational level was in agreement with their ages, since there were almost no children who repeated grades.

The clinical characteristics of the sample are shown in Table 2.

Our results suggest that school was responsible for the largest number of referrals in both groups followed by health professionals. In relation to the reasons for seeking treatment, internalizing behaviors, such as anxiety (70.8%) and depression (33.3%), were the most prevalent in G1, being present in a large number of cases. On the other hand, externalizing behaviors, such as behavioral problems, were the most prevalent in G2, being present in 39.5% of the cases.

The initial diagnostic hypothesis for most cases in both groups is related to anxiety disorders, which may be connected to the reasons for seeking treatment in G1, but not in G2. Most G1 patients were seen twice a week (54.8%). On the other hand, most G2 patients only underwent the psychological assessment (36.8%) or were seen once a week (47.4%). The psychological assessment in this study consisted of approximately two sessions with the parents, two sessions with the child, and one feedback session with the parents, during which the treatment plan was discussed, amounting to five sessions. Our findings also demonstrate that 86.8% of the children in G2 did not receive other concomitant treatments apart from psychotherapy. This rate was 66.7% in G1. With regard to the year of the psychotherapy training course being taken by the therapists when the patient sough treatment, 20.8% of the therapists of G1 were in the first year and 58.3% were in the second year. On the other hand, in G2, 26.3% of the therapists were in the second year, and most of them were concentrated in the first year of the course (44.7%). The service offers a 3-year child and adolescent psychotherapy course.

Instruments

The following instruments were used to assess the children: a) child's sociodemographic and clinical data form; b) Bender Visual Motor Gestalt test;⁶ c) Wechsler Intelligence Scale for Children (WISC III), Brazilian adaptation by Figueiredo;⁷ d) Rorschach technique; and d) Child Behavior Checklist (CBCL).

Data analysis procedure

Two scales were used for score reporting in the Bender-Gestalt test: maturity scale according to age based on Koppitz⁸ and maturity scale according to age based on Kroeff.⁹ In the WISC III, the scale used to assess the results was the adaptation and standardization of this instrument based on a Brazilian sample prepared by Vera Lúcia Marques de Figueiredo.⁷ On the other hand, using the Rorschach technique, the results were obtained and interpreted based on a comprehensive system for children proposed by Exner.⁹ And, finally, the CBCL score was achieved based on a software that shows the scores and divides them into clinical, borderline, and non-clinical.¹⁰

In relation to the data form filled out by the therapists, the survey was conducted based on information provided by the therapists regarding sociodemographic and clinical data.

The results of each test and data forms for each child were entered in the Statistical Package for the Social Sciences (SPSS) 11.0. The chi-square test was then used for heterogeneity with Yates' correction or Fisher’s exact test to associate the categorical variables. Student's t test was used for the association of the quantitative variables. This was done with the purpose of associating the sociodemographic and clinical variables and the test results with psychoanalytical psychotherapy for 12 months and with treatment dropout.

RESULTS

The chi-square test was used to analyze the differences in the sociodemographic and clinical variables. The results are shown in Table 3.

The analysis of the sociodemographic and clinical variables demonstrate that there was statistically significant differences in the following variables: sex (0.001), with prevalence of females in the group that was treated for 12 months; reasons for seeking treatment: anxiety, lack of self-confidence, fears (0.005) and depression (0.001), all of them being prevalent in G1, and behavioral problems (0.003), more prevalent in G2; frequency of sessions, prevalence of sessions twice a week in G1 and once a week in G2. All the other variables did not show statistically significant difference.

With regard to the variables related to the results of the Bender test, WISC III, Rorschach technique, and CBCL, p value is shown in Table 4.

Our results demonstrate statistically significant differences in the variables of the Rorschach technique, which assess the individual's ability to control his/her emotions, using the percentage of responses with color formless determinants (% CF) (p = 0.041), and his/her impulses, using the percentage of formless determinants with inanimate movements, plus those with a defined form (% m + mF) (p = 0.013). Both results suggest a difficulty in controlling impulses and emotions in the individuals who continued to be treated. We also found differences in the following scales: sociability (p = 0.045), anxiety and depression (p = 0.019), somatic (p = 0.021), and introversion (p = 0.046) in the CBCL. With regard to the variables measured in the Bender and WISC III tests, we could not find statistically significant differences, as well as in the other variables of the Rorschach technique and CBCL.

DISCUSSION

Research conducted so far on child psychotherapy dropout have provided a better definition of early dropout, enabling the identification of factors that lead to dropout, as well as methods to prevent it and improve the psychotherapy treatment offered to children.^3,4 However, there few studies on child psychotherapy dropout , and such limitation seems to be related to the difficulty in contacting the patients with early treatment dropout, since they seldom agree to participate in longitudinal studies, which prevents researchers from acquiring a dynamic understanding of the topic.

Kazdin¹¹ highlights the relevance of defining the characteristics of the moderators that have an influence on the results of an intervention for the referral of patients to the most effective treatment according to their needs. Specifically, in the present study, the analysis of the results showed, by means of the comparison between G1 and G2, that most children who continued to be treated were females, had anxiety symptoms, lack of self-confidence, fears, depression, somatic complaints, and difficulty in socializing when they sought treatment – all these symptoms are typical of internalizing disorders – and were treated with two sessions a week. Furthermore, the children in G1 had statistically significant differences in some variables measured using the Rorschach technique, suggesting a higher difficulty in controlling impulses and emotions than G2.

These findings demonstrate that those children who have such sociodemographic characteristic (female), clinical characteristics (internalizing disorders and higher frequency of sessions) in the test results are the ones who have a higher chance of being treated with psychoanalytical psychotherapy for a longer period, benefiting from the treatment and not dropping out earlier than expected. G2, on the other hand, was characterized by a large number of boys who had behavioral problems and attention deficit when they sought treatment – there was a prevalence of externalizing behaviors – being treated with sessions once a week or only undergoing psychological assessment before dropping out from treatment. Such findings suggest that children who have the characteristics mentioned above are at a higher risk of not benefiting from psychoanalytical psychotherapy and dropping out at the beginning of the treatment.

Our results also confirm the high dropout rate found in child psychotherapy treatments.⁵ It is important to highlight, however, that high dropout rates are also found in psychotherapy treatments involving different age groups, diagnostic groups, and treatment methods (30-60%), showing that this is not a problem related only to children treated with psychoanalytical psychotherapy. Some studies conducted in Brazil about this topic found dropout rates ranging from 35 to 68.7% in the facilities providing psychological care.^12-14 A recent sample investigated in Porto Alegre, state of Rio Grande do Sul, Brazil, regarding the effectiveness of psychoanalytical psychotherapy with adults reported even higher dropout rates, between 76.4 and 94.12%.¹⁵ In spite of that fact, 88.24% of the patients of this sample reported that they had a satisfactory experience with the treatment. These findings corroborate data from other studies about the psychotherapists' tendency to underestimate treatment discharges and overestimate dropouts.

In the present study, we attempted to carry out a longitudinal investigation by administering the CBCL to dropouts, but few families returned for follow-up, which confirms the evidence mentioned in the literature.³ However, we believe that it would be possible to find similar results regarding the patients' satisfaction with the treatment: despite the dropouts, the satisfaction rate would be high. Such assumption is based on the results found in an informal survey conducted with parents during 2006 at the same service: almost 100% of the parents whose children were being treated at the moment the survey was conducted reported being fully satisfied or satisfied with the psychoanalytical psychotherapy offered to their children (Deakin EK, Dian S, Satisfação dos pais com a psicoterapia dos filhos, unpublished study, 2006).

A study on the characteristics of the children who drop out from treatment concluded that treatment maintenance does not depend much on the child's characteristics, but it depends on background factors not related to the psychotherapy, such as race and social class.^16,17 However, some factors related to the psychotherapy can be detected, like parents' motivation, and they may be used to plan the treatment to be offered to the child.

Some hypotheses about the reasons why this sample had a high dropout rate deserve to be mentioned. Firstly, as mentioned above, psychoanalytical psychotherapy seems to be more effective in the treatment of female children with internalizing disorders. These results confirm the findings of a study conducted at the Anna Freud Center, in London, United Kingdom.¹⁸ It was a retrospective study of 763 medical records and demonstrated that child psychoanalysis and methods based on psychoanalysis are more effective to treat emotional disorders such as anxiety and depression, being less effective for behavioral disorders. There is also evidence suggesting that male children are prone to have higher psychotherapy dropout rates.¹⁹

The initial sample of the present study comprised mainly boys with behavioral problems, that is, externalizing disorders. For such population, some studies have suggested that behavioral psychotherapies are more appropriate, and the high dropout rate reinforces the evidence that psychoanalytical psychotherapy is not as effective as behavioral psychotherapy.^18,20

Secondly, it is worth emphasizing that most therapists involved in the present study were beginners and lacked experience in providing child psychotherapy. Other studies have reported a positive correlation between treatment duration and outcomes.²¹ Beginner therapists usually tend to have ideal expectations instead of real expectations regarding their work. They wish to deliver a flawless treatment, exceeding the patient's expectations.²²

Nevertheless, it is worth mentioning that most therapists who base their work method on psychoanalysis or psychodynamic psychotherapy, either beginners or experienced professionals, are focused on providing more than the simple relieve of the symptoms that motivated the patient to seek treatment, their goal is to cause a structural change in the child by establishing a new object relation.²³ In order to achieve these goals, higher frequency of sessions and longer treatment are often required. However, parents not always wish to implement these changes, with their main focus being to normalize the child's behavior. When such goal is reached, even if the therapist has other goals, parents might feel satisfied and choose to interrupt the treatment, which they do not regard as an early dropout because their expectations have been met.²⁴ In addition, it is important to highlight that those professionals whose work method is based on psychodynamic psychotherapy, such as psychoanalytical psychotherapy, tend to interpret the end of treatment as resistance or lack of motivation of the patients and/or their families. The families, in turn, tend to blame the interruption of treatment on factors not related to psychotherapy, such as lack of time, transportation or financial problems.²⁵ Plunkett²⁶ highlights that when parents' expectations are in disagreement with the expectations of the institution where the child is being treated there is a higher chance that the family will interrupt the treatment and/or have difficulties to get involved. The author mentions some methods to prevent early dropout, such as understanding the goals and expectations of parents and children with regard to the treatment, as well as establishing a strong therapeutic alliance with them, since for child psychotherapy, the therapeutic alliance with the parents is more important than the one established with the child.²⁷

It is important to clarify that we did not carry out an initial analysis of the parents' expectations, and maybe this issue should be emphasized in future studies on effectiveness and dropout of child psychotherapy. A recent study²⁸ demonstrated that children/adolescents' satisfaction is associated with the therapist's positive expectations. On the other hand, a higher rate of parents' satisfaction was associated with a larger number of sessions and improvement of the child's global functioning. However, it is important to point out that the constructs related to parental expectations and satisfaction with regard to psychotherapy are still vague and need to be well defined so that they can be used in studies assessing child therapeutic interventions.

We should also keep Gabbard & Western's point of view in mind.²⁹ According to these authors, the modern theory of therapeutic action is related to the use of strategies (either psychoanalytical or not) that will facilitate the changing process suggested in the treatment plan of a specific patient. Based on that, the authors suggest that the therapist should be focused on the fact that a certain technique is therapeutic for the patient instead of considering whether it belongs to the theoretical line adopted by the therapist. According to the same line of thought, Tryon & Kane²⁷ suggested that the same type of treatment should not be offered to all children regardless of the situation, because when the individual characteristics of each case are not taken into consideration, there is higher risk of treatment dropout.

Other factors that may also be related to a higher dropout rate from long-term psychotherapy treatments, such as those proposed by psychoanalytical psychotherapy, are the need of immediate reward, children and parents' little reflective ability, and the search of quick and inexpensive solutions. Furthermore, there is a constant pressure from health insurance companies, which want to reduce costs at any price and, as a consequence, impair the quality of the treatment offered. The distance between the real treatment and the ideal treatment for a specific patient seems to be increasingly longer, compromising outcomes and leading to higher dropout rates. The professionals who deliver treatment in this area should join efforts to understand current typical demands so that, this way, they are able to keep effectively treating those children with psychological problems. Finally, the integration between clinical therapists and universities, where researches are conducted, is essential so that the important concepts developed by child psychoanalysis throughout the last century can be effectively used with current patients, therefore, preventing early treatment dropout.

REFERENCES

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Publication Dates

• Publication in this collection
  24 May 2010
• Date of issue
  Dec 2009

History

• Accepted
  09 Mar 2009
• Received
  09 Oct 2008