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Problem-Solving Skills Training (PSST)

About this program.

Target Population: 7 to 14 year olds with behavioral problems, particularly children who struggle to handle disappointments, frustrations, or problems calmly

For children/adolescents ages: 7 – 14

Program Overview

PSST is aimed at decreasing inappropriate or disruptive behavior in children. The program teaches that problem behaviors arise because children lack constructive ways to deal with thoughts and feelings and instead resort to dysfunctional ones. It is designed to help children learn to slow down, stop and think, and generate multiple solutions to any given problem. The program uses a cognitive-behavioral approach to teach techniques in managing thoughts and feelings, and interacting appropriately with others. Specific techniques include modeling, role-playing, positive reinforcement of appropriate behavior, and teaching alternative behaviors. Children are typically given homework to help them practice implementing these skills. Most sessions are individual, but parents may be brought in to observe and to learn how to assist in reinforcing new skills.

Program Goals

The goals of Problem-Solving Skills Training (PSST) are:

  • Train the child to think differently about situations and behave differently in diverse situations
  • Help the child internalize the problem solving steps so that they are able to use them to evaluate potential solutions to problems occurring outside of therapy
  • Learn and generalize problem solving skills and how to apply problem solving skills using self-instruction
  • Learn how to generate positive solutions that would enable the child to avoid physical aggression, resolve the conflict, and keep themselves out of trouble

Logic Model

The program representative did not provide information about a Logic Model for Problem-Solving Skills Training (PSST) .

Essential Components

The essential components of Problem-Solving Skills Training (PSST) include:

  • Sessions that are fun for children as they play various games and have the opportunity to earn prizes as they learn the following:
  • The 5 Problem Solving Steps used to handle any problem situation
  • How to use these problem solving steps for hypothetical problems
  • How to use these problem solving steps for simple problems outside of session
  • How to use these steps to solve challenging hypothetical situations
  • How to ultimately use these steps to solve problems that come up in their own life
  • Individual treatment with one of the staff of certified clinicians who will keep the child's goals in mind throughout the therapy
  • A number of sessions with the parent before beginning with the child so that the parents will know how to encourage and maintain the child's growth

Program Delivery

Child/adolescent services.

Problem-Solving Skills Training (PSST) directly provides services to children/adolescents and addresses the following:

  • Oppositional behavior, aggressive behavior, antisocial behavior

Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Parents are involved sporadically during treatment to help support their child in implementing Problem-Solving Skills Training .

Recommended Intensity:

Weekly 50-minute sessions

Recommended Duration:

Approximately 8 to 14 weeks

Delivery Settings

This program is typically conducted in a(n):

  • Outpatient Clinic

Problem-Solving Skills Training (PSST) includes a homework component:

The child is given homework to help them learn to apply problem solving skills to everyday situations. Homework is a natural extension of treatment where learned problem solving skills are applied to real life situations.

Resources Needed to Run Program

The typical resources for implementing the program are:

PSST requires a standard clinical treatment room.

Manuals and Training

Prerequisite/minimum provider qualifications.

PSST providers must be Master's level mental health professionals.

Manual Information

There is not a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:

Training Type/Location:

Training is occasionally available either online or onsite.

Number of days/hours:

Total training time is about 8 hours.

Implementation Information

Pre-implementation materials.

There are no pre-implementation materials to measure organizational or provider readiness for Problem-Solving Skills Training (PSST) .

Formal Support for Implementation

There is no formal support available for implementation of Problem-Solving Skills Training (PSST) .

Fidelity Measures

There are no fidelity measures for Problem-Solving Skills Training (PSST) .

Implementation Guides or Manuals

There are implementation guides or manuals for Problem-Solving Skills Training (PSST) as listed below:

A comprehensive overview of Problem Solving Skills Training is available. For more information, please contact the program representative who is listed at the bottom of the page.

Research on How to Implement the Program

Research has not been conducted on how to implement Problem-Solving Skills Training (PSST) .

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Kazdin, A., Esveldt-Dawson, K., French, N., & Unis, A. (1987). Problem-Solving Skills Training and relationship therapy in the treatment of antisocial child behavior. Journal of Consulting and Clinical Psychology, 55 (1), 76–85. https://doi.org/10.1037/0022-006X.55.1.76

Type of Study: Randomized controlled trial Number of Participants: 56

Population:

  • Age — 7–13 years
  • Race/Ethnicity — 77% White and 23% Black
  • Gender — 45 Male and 11 Female
  • Status — Participants were inpatients at a psychiatric facility.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effects of cognitive-behavioral Problem-Solving Skills Training (PSST) and nondirective relationship therapy (RT) for the treatment of antisocial child behavior. Participants were randomly assigned to PSST , relationship therapy (RT), or a control group that had therapist contact with no directed focus on the elements of the two treatment conditions. Measures utilized include the Child Behavior Checklist (CBCL), Therapist Evaluation Inventory, and the Child Evaluation Inventory . Results indicate that children in the PSST condition had greater decreases in aggression, externalizing behaviors, and overall behavior problems and greater increases in pro-social behavior at follow-up than did the RT and control groups. Limitations include the use of a hospitalized sample and reliance on a small number and type of evaluations.

Length of controlled postintervention follow-up: 1 year.

Kazdin, A. E., Bass, D., Siegel, T., & Thomas, C. (1989). Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior. Journal of Consulting and Clinical Psychology, 57 (4), 522–535. https://doi.org/10.1037/0022-006X.57.4.522

Type of Study: Randomized controlled trial Number of Participants: 112

  • Race/Ethnicity — Not specified
  • Gender — 87 Male and 25 Female
  • Status — Participants were children receiving inpatient or outpatient treatment at a child conduct clinic.

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate alternative treatments for children referred for severe antisocial behavior. Participants were randomized to receive one of two Problem-Solving Skills Training (PSST) treatment conditions: standard PSST or PSST-P which included a set of planned activities and "homework" to be performed outside of therapeutic sessions, or to a relationship therapy (RT) control condition. Measures utilized include the Child Behavior Checklist (CBCL), the School Behavior Checklist, the Parent Daily Report, Interview for Antisocial Behavior, the Children's Action Tendency Scale,  and the Self-Esteem Inventory . Results indicate that both PSST groups showed significantly higher improvement in behavior than the RT group. Improvement in PSST-P children's school-related behaviors were shown to be stronger in comparison with standard PSST . Limitations include no direct assessment of the cognitive processes that problem-solving skills training were designed to change and relationship therapy may not have been well or fairly tested.

Kazdin, A. E., Siegel, T. C., & Bass, D. (1992). Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology, 60 (5), 733–747. https://doi.org/10.1037/0022-006X.60.5.733

Type of Study: Randomized controlled trial Number of Participants: 97

  • Race/Ethnicity — 69% White and 31% Black
  • Gender — 76 Male and 21 Female
  • Status — Participants were children referred for treatment to a psychiatric facility.

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effects of Problem-Solving Skills Training (PSST) and parent management training (PMT) on children referred for severe antisocial behavior. Participants were randomly assigned to receive PSST , PMT, or a combination of PSST + PMT. Measures utilized include the Child Behavior Checklist (CBCL), the Teacher Report Form (TRF), the Health Resources Inventory, the Interview for Antisocial Behavior, the Children's Action Tendency Scale, the Self-Report Delinquency Checklist, the Parent Daily Report, the Parenting Stress Index (PSI), the Beck Depression Inventory (BDI) (mothers), and the Family Environment Scale . Results indicate that children in all conditions showed significant improvement at home and school, which was maintained at follow-up. PSST + PMT had the greatest effects on children's aggressive, delinquent, and antisocial behavior; and was also associated with greater improvements in parental stress and depression. Limitations include lack of an untreated comparison group, large attrition rate, and the small sample size.

Bushman, B. B., & Gimpel Peacock, G. (2010). Does teaching problem-solving skills matter? An evaluation of Problem-Solving Skills Training for the treatment of social and behavioral problems in children. Child & Family Behavior Therapy, 32 (2), 103–124. https://doi.org/10.1080/07317101003776449

Type of Study: Randomized controlled trial Number of Participants: 26

  • Age — Mean=8.27 years
  • Race/Ethnicity — 23 Caucasian, 1 Asian, and 2 Biracial
  • Gender — 17 Male and 9 Female
  • Status — Participants were families with children with social and behavioral problems.

Location/Institution: Utah

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effectiveness of Problem-Solving Skills Training (PSST) for the treatment of social and behavioral problems in children. Participants were randomly assigned to either a PSST treatment group or a nondirective comparison group. Measures utilized include the Skills Rating System (SSRS), the Parent Daily Report (PDR), Child Behavior Checklist for Ages 6-18 (CBCL/6-18), Parenting Stress Index-Short Form (PSI-SF) , and a parent questionnaire at baseline, post-treatment, and at a 6-week follow-up. Results indicate that children in both the treatment and comparison group showed similar improvement, with PSST showing a minor advantage on several PDR and SSRS scales. Limitations include the small sample size and short-term follow-up.

Length of controlled postintervention follow-up: 6 weeks.

Additional References

Kazdin, A. E. (2010). Problem-Solving Skills Training and Parent Management Training for Oppositional Defiant Disorder and Conduct Disorder. In J. R. Weisz & A. E. Kazdin (Eds.). Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 211-226). Guilford Press.

Kazdin, A. E. (2011). Problem-Solving Skills Training for children and adolescents: Overview. Yale Parenting Center.

Kazdin, A. E. (2017). Parent Management Training and Problem-Solving Skills Training for child and adolescent conduct problems. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp.142–158). Guilford Press.

Contact Information

Date Research Evidence Last Reviewed by CEBC: December 2023

Date Program Content Last Reviewed by Program Staff: November 2021

Date Program Originally Loaded onto CEBC: April 2009

a child is receiving problem solving skills training as a treatment

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  • Provide Psychosocial Skills Training and Cognitive Behavioral Interventions

What to Know

Psychosocial skills training and cognitive behavioral interventions teach specific skills to students to help them cope with challenging situations, set goals, understand their thoughts, and change behaviors using problem-solving strategies.

Psychosocial skills training asks students to explore whether their behaviors align with their personal values. Cognitive behavioral interventions teach students to identify their own unhelpful thoughts and replace them with thoughts that are more helpful. Students might practice helpful coping behaviors and find positive activities to try. Doing these things can improve their mood and other symptoms of mental distress.

Districts and schools can deliver interventions in one-on-one settings, small groups, and classrooms. Some interventions focus on concepts that are also taught in social skill and emotional development programs, like self-control and decision-making. A counselor or therapist can lead these programs.

What Can Schools Do?

Promote acceptance and commitment to change.

Schools can help promote acceptance and positive behavior change for students through psychosocial skills training and dialectical behavior therapy. Psychosocial skills training asks students to explore whether their behaviors align with their personal values. Students who see that their behavior does not match their values can decide to make behavior changes. These trainings also help students accept what they cannot change and focus on what they can change. Dialectical behavior therapy teaches mindfulness, acceptance, and commitment skills.

Approaches using acceptance and commitment to change are associated with increases in students’ coping skills and decreases in depression and physical symptoms of depression.

Provide Cognitive Behavioral Interventions

Cognitive behavioral interventions for schools often include multiple sessions. They can be used for one student or a small group. Sessions often follow a standardized manual of activities to help students examine their own thoughts and behaviors. The interventions can include asking students to share what they learn about their thoughts and behaviors with their parents and other people. In some interventions, session leaders focus on a specific topic. Other interventions target mental health symptoms, like depression, anxiety, or post-traumatic stress.

Cognitive behavioral interventions can improve students’ mental health in many ways, including decreasing anxiety, depression, and symptoms related to post-traumatic stress.

  • LARS & LISA
  • Tools for Getting Along Curriculum—Behavior Management Resource Guide
  • Cognitive Behavioral Intervention for Trauma in Schools (CBITS )
  • Bounce Back
  • Brief Intervention for School Clinicians
  • Skills for Academic and Social Success
  • Building Confidence

Engage Students in Coping Skills Training Groups

Coping skills training groups use principles of cognitive behavioral intervention to teach students skills to help them handle specific problems. Students can also use these skills to help them cope when their lives are changing. Similar to social, emotional, and behavioral learning programs, coping skills training often focuses on building resilience, or being able to “bounce back” when bad things happen. Students can practice skills outside of the small group, like they would with social skills and emotional development lessons.

Coping skills training groups can increase coping skills for students and decrease anxiety and depression.

  • Journey of Hope
  • High School Transition Program

Focus on Equity

Students who have been exposed to trauma may receive trauma-focused or trauma-informed interventions in school. Cognitive behavioral interventions that are trauma-informed meet the unique needs of students exposed to traumatic experiences. These interventions teach problem-solving and relaxation techniques and help reduce trauma-related symptoms, including behavioral challenges. Trauma-informed interventions can also improve students’ coping strategies.

Implementation Tips

Cognitive behavioral interventions and psychosocial skills training help with many kinds of student needs. They can be used at multiple grade levels. Leaders can:

  • Work with school mental health staff to find ways for students to practice their new behaviors and coping skills.
  • Use the Multitiered Systems of Support (MTSS) framework to ensure that students are appropriately matched with classroom, small-group, or individual interventions that meet their needs.

Want to Learn More?

For more details on MTSS and providing psychosocial skills training and cognitive behavioral interventions, see Strategies for Promoting Mental Health and Well-Being in Schools: An Action Guide for School Administrators [PDF - 3 MB]

  • Increase Students’ Mental Health Literacy
  • Promote Mindfulness
  • Promote Social, Emotional, and Behavioral Learning
  • Enhance Connectedness Among Students, Staff, and Families
  • Support Staff Well-Being

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  • Open access
  • Published: 24 August 2021

Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

  • Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
  • Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
  • Benjamin W. C. Chan 4 ,
  • Sarah Bonato   ORCID: orcid.org/0000-0002-5174-0047 1 ,
  • Madison Aitken   ORCID: orcid.org/0000-0002-4921-5462 1 , 3 ,
  • Jacqueline Relihan 1 ,
  • Matthew Prebeg 1 ,
  • Karleigh Darnay   ORCID: orcid.org/0000-0002-0395-8674 1 ,
  • Lisa D. Hawke   ORCID: orcid.org/0000-0003-1108-9453 1 , 3 ,
  • Priya Watson   ORCID: orcid.org/0000-0001-9753-6490 1 , 3 &
  • Peter Szatmari   ORCID: orcid.org/0000-0002-4535-115X 1 , 3 , 5  

BMC Psychiatry volume  21 , Article number:  397 ( 2021 ) Cite this article

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10 Citations

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Metrics details

Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

Conclusions

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Peer Review reports

Depressive disorders are a common mental health concern in adolescence [ 1 , 2 , 3 ] and associated with functional impairment [ 4 ] and an increased risk of adverse mental health, physical health, and socio-economic outcomes in adulthood [ 5 , 6 , 7 , 8 ]. Early and effective intervention is needed to reduce the burden arising from early-onset depression. Several psychotherapies have proven modestly effective at reducing youth depression, including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) [ 9 , 10 ]. Room for improvement remains; around half of youth do not show measurable symptom reduction after an average of 30 weeks of routine clinical care for depression or anxiety [ 11 ]. One barrier to greater impact is a lack of understanding of which treatment ingredients are most critical [ 12 , 13 ]. Identifying the “active ingredients” that underpin effective approaches, and understanding when and for whom they are most effective is an important avenue for enhancing impact [ 13 ]. Distilling interventions to their most effective ingredients while removing redundant content may also help reduce treatment length and cost, freeing up resources to expand service provision. Given that youth frequently drop out of treatment early [ 14 ], introducing the most effective ingredients at the start may also help improve outcomes.

One common ingredient in the treatment of youth depression is problem-solving (PS) training [ 15 ]. Problem solving in real-life contexts (also called social problem solving) describes “the self-directed process by which individuals attempt to identify [ …] adaptive coping solutions for problems, both acute and chronic, that they encounter in everyday living” (p.8) [ 16 ]. Within a relational/problem-solving model of stress and well-being, mental health difficulties are viewed as the result of maladaptive coping behaviours that cannot adequately safeguard an individual’s well-being against chronic or acute stressors [ 17 ]. According to a conceptual model developed by D’Zurilla and colleagues ([ 16 , 17 , 18 , 19 ]; see Fig.  1 ), effective PS requires a constructive and confident attitude towards problems (i.e., a positive problem orientation ), and the ability to approach problems rationally and systematically (i.e., rational PS style ). Defeatist or catastrophizing attitudes (i.e., a negative problem orientation ), passively waiting for problems to resolve (i.e., avoidant style ), or acting impulsively without thinking through possible consequences and alternative solutions (i.e., impulsive/careless style ) are considered maladaptive [ 16 , 18 , 20 ]. Empirical studies suggest maladaptive PS is associated with depressive symptoms in adolescents and young adults [ 21 , 22 , 23 , 24 , 25 ].

figure 1

Dimensions of Problem-Solving (PS) Ability

Problem-Solving Therapy (PST) is a therapeutic approach developed by D’Zurilla and Goldfried [ 26 ] in the 1970s, to alleviate mental health difficulties by improving PS ability. Conceptually rooted in Social Learning Theory [ 27 ], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by helping them develop and internalize four core PS skills: (a) defining the problem; (b) brainstorming possible solutions; (c) appraising solutions and selecting the most promising one; (d) implementing the preferred solution and reflecting on the outcome ([ 16 , 17 , 18 , 19 ]; see Fig. 1 ). PST is distinct from Solution-Focused Brief Therapy (SFBT), which has different conceptual roots and emphasizes the construction of solutions over the in-depth formulation of problems [ 28 ].

PS training is also a common ingredient of other psychosocial depression treatments [ 15 , 20 ], such as CBT and Dialectical Behaviour Therapy (DBT) [ 15 , 29 , 30 , 31 , 32 ] that typically focus on strengthening PS skills rather than problem orientation [ 20 ]. In IPT, PS training focuses on helping youth understand and resolve relationship problems [ 29 , 30 , 33 , 34 ]. PS training is also a common component of family therapy [ 35 ], cognitive reminiscence therapy [ 36 ], and adventure therapy [ 37 ]. The extent to which PS training in these contexts follows the conceptual model by D’Zurilla and colleagues varies. Hereafter, we will use the term PST (“Problem-Solving Therapy”) where problem-solving training constitutes a stand-alone intervention; and we will use the term “PS training” where it is mentioned as a part of other therapies or discussed more broadly as an active ingredient of treatment for youth depression.

Meta-analyses considering over 30 randomized control trials (RCTs) of stand-alone PST for adult depression suggest it is as effective as CBT and IPT, and more effective than waitlist or attention controls [ 38 , 39 , 40 ]. PST has been applied with children, adolescents, and young adults [ 41 , 42 , 43 , 44 , 45 , 46 ], but dedicated manuals for different developmental stages are not readily available. In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, suggesting these skills are highly transferable and relevant to youth [ 47 ]. PS training can be brief (i.e., involve fewer than 10 sessions) [ 38 ], and has been delivered to youth by trained clinicians [ 45 ], lay counsellors [ 46 ], and via online platforms [ 44 ]. It can also be adapted for primary care [ 40 ]. In light of its versatility and of its effectiveness in adults, PS training is a prime candidate for a treatment ingredient that deserves greater scrutiny in the context of youth depression. However, no systematic evidence synthesis has yet examined its efficacy and effectiveness in this population.

This study had two sequential parts. First, we conducted a mixed-methods scoping review to map the available evidence relating to PS training as an active ingredient for treating youth depression. Youth were defined as aged 14 to 24 years, broadly aligning with United Nations definitions [ 48 ]. In a subsequent step, we conducted an exploratory meta-analysis to examine the overall efficacy of free-standing PST, based on clinical trials identified in the scoping review.

Scoping review

Scoping review methodology was used to provide an initial overview of the available evidence [ 49 ]. The review was pre-registered on the Open Science Framework [ 50 ] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews checklist [ 51 ] (Additional File  1 ). The review was designed to integrate four types of literature: (a) qualitative studies reporting on young people’s experiences with PS training; (b) controlled clinical trials testing the efficacy of stand-alone PST; (c) studies examining PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapeutic interventions (e.g., CBT); and (d) clinical practice guidelines (CPGs) for youth depression. In addition, the search strategy included terms designed to identify relevant conceptual articles that are discussed here as part of the introduction [ 52 ].

Search strategy

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for (a) empirical studies published from database inception through June 2020, and (b) CPGs published between 2005 and July 2020. Reference lists of key studies were searched manually, and records citing key studies were searched using Google Scholar’s “search within citing articles” function [ 52 ]. The search strategy was designed in collaboration with a research librarian (SB) and combined topic-specific terms defining the target population (e.g., “depression”; “adolescent?”) and intervention (e.g., “problem-solving”) with methodological search filters combining database-specific subject headings (e.g., “randomized controlled trial”) and recommended search terms. The search for CPGs built upon a previous systematic search [ 53 , 54 ], which was updated and expanded to cover additional languages and databases. A multi-pronged grey literature search retrieved records from common grey literature databases and CPG repositories, websites of relevant associations, charities, and government agencies. The search strategy is provided in Additional File  2 .

Inclusion and exclusion criteria

Empirical studies were included if the mean participant age fell within the eligible range of 14 to 24 years, and at least 50% of participants showed above-threshold depressive or emotional symptoms on a validated screening tool. Controlled clinical trials had to compare the efficacy or effectiveness of PST as a free-standing intervention with a control group or waitlist condition. Secondary analyses were considered for their assessment of PS ability as a predictor, moderator, or mediator of treatment response if they reported on data from controlled clinical trials of broader therapy packages. Records were included as CPGs if labelled as practice guidelines, practice parameters, or consensus or expert committee recommendations, or explicitly aimed to develop original clinical guidance [ 53 , 54 ]; and if focused on indicated psychosocial treatments for youth depression (rather than prevention, screening, or pharmacological treatment). Doctoral dissertations were included. Conference abstracts, non-controlled trials, and prevention studies were excluded. Language of publication was restricted to English, French, German, and Spanish.

All records identified were imported into the EPPI-Reviewer 4.0 review software [ 55 ], and underwent a two-stage screening process (Fig.  2 ). Title and abstract screening was conducted in duplicate for 10% of the identified records, yielding substantial inter-rater agreement ( kappa  = .75 and .86, for empirical studies and CPGs, respectively). Of studies retained for full text screening, 20% were screened in duplicate, yielding substantial agreement ( kappa  = .68 and .71, for empirical studies and CPGs, respectively). Disagreements were resolved through discussion.

figure 2

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

Data were extracted using templates tailored to each literature type (e.g., the Cochrane data collection form for RCTs). Information extracted included: citation details; study design; participant characteristics; and relevant qualitative or quantitative results. Additional information extracted from CPGs included the issuing authority, the target population, the treatment settings to which the guideline applied, and any recommendations in relation to PS training. Data from clinical trials and secondary analyses were extracted in duplicate, and any discrepancies were discussed and resolved. Data synthesis followed a five-step process of data reduction, display, comparison, conclusion drawing, and verification [ 56 ]. Scoping review findings were summarized in narrative format. In addition, effect sizes reported in PST trials for depression severity were entered into an exploratory meta-analysis (see below).

The Centre for Addiction and Mental Health (CAMH) implements a Youth Engagement Initiative that brings the voices of youth with lived experience of mental health difficulties into research and service design [ 57 , 58 , 59 ]. Two youth partners were co-investigators in this review and consulted with a panel of twelve CAMH youth advisors to inform the review process and help contextualize findings. Formal approval by a Research Ethics Board (REB) was not required, as youth were research partners rather than participants.

To incorporate a variety of perspectives, the review team convened for an inference workshop where emerging review findings and feedback from youth advisors were discussed and interpreted. The multidisciplinary team involved a methodologist; two child and adolescent psychiatrists with expertise in CBT, DBT, and IPT; a psychologist with expertise in parent-adolescent therapy; a research librarian; a family doctor; a biostatistician; a clinical epidemiologist; two youth research partners; and a youth engagement coordinator.

Exploratory Meta-analysis

Although meta-analyses are not typical components of scoping reviews [ 60 ], an exploratory meta-analysis was conducted following completion of the scoping review and narrative synthesis, to obtain an initial indication of the efficacy of stand-alone PST based on the clinical trials identified in the review. The PICO statement that guided the meta-analysis is shown in Table  1 .

Quality assessment

Risk of bias for included PST trials was appraised using the Cochrane Collaborations Risk of Bias (ROB) 2 tool [ 61 ]. Ratings were performed independently by two reviewers (KRK and MA), and consensus was formed through discussion. In addition, a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) appraisal was conducted (using the GRADEpro software; [ 62 ] to characterize the quality of the overall evidence. The evidence was graded for risk of bias, imprecision, indirectness, inconsistency, and publication bias [ 63 ]. A GRADE of “high quality” indicates a high level of confidence that the true effect lies close to the estimate; “moderate quality” indicates moderate confidence; “low quality” indicates limited confidence; and “very low quality” indicates very little confidence in the estimate. ROB ratings and GRADE appraisal results are provided in Additional File  6 .

Statistical analysis

The meta-analysis was conducted using the meta suite of commands in Stata 16.1. Effect sizes (Hedges’ g) and their confidence intervals were calculated based on the mean difference in depression severity scores between the PST and control conditions at the first post-treatment assessment [ 64 ]. Hedges’ g is calculated by subtracting the post-treatment mean score of the intervention group from the score of the control group, and by dividing the mean difference by the pooled standard deviation. Effect sizes between g = 0.2 and 0.5 indicate a small effect; g = 0.5 to 0.8 indicates a moderate effect; and g ≥ 0.8 indicates a large effect. Effect sizes were adjusted using the Hedges and Olkin small sample correction [ 64 ]. Pooled effect sizes were computed using a random effects model to account for heterogeneity in intervention settings, modes of delivery, and participant age and depression severity. The I 2 statistic was computed as an indicator of effect size heterogeneity. Higgins et al. [ 65 ] suggest that an I 2 below 30% represents low heterogeneity while an I 2 above 75% represents substantial heterogeneity. Investigations of heterogeneity are unlikely to generate valuable insights in small study samples, with at least ten studies recommended for meta-regression [ 65 ]. We conducted limited exploratory subgroup analysis by computing a separate effect size after excluding studies with high risk of bias. We inspected the funnel plot and considered conducting Egger’s test to examine the likelihood and extent of publication bias [ 66 ].

Selection and inclusion of studies

The search for empirical studies identified 563 unique records (Fig. 2 ), of which 148 were screened in full. Inclusion criteria were met by four RCTs of free-standing PST and four secondary analyses of clinical trials investigating PS-related concepts as predictors, mediators, or moderators of treatment response. No eligible qualitative studies that explicitly examined youth experiences of PS training were identified. The search for CPGs identified 9691 unique records, of which 41 were subject to full text screening, and 23 were included in the review. Below we present scoping review findings for all literature types, followed by the results from the meta-analysis for stand-alone PST trials.

Clinical trials of PST

Characteristics of the included PST trials are shown in Table  2 . Studies were published between 2008 and 2020 and included 524 participants (range: 45 to 251), with a mean age of 16.7 years (range: 12–25; 48% female). Participants had a diagnosis of major depressive disorder (MDD; k  = 1), elevated anxiety or depressive symptoms ( k  = 1), or various mild presenting problems including depression ( k  = 2). Treatment covered PS skills but not problem orientation (i.e., youth’s problem appraisals) and was delivered face to face ( k =  3) or online ( k  = 1) in five to six sessions. PST was compared with waitlist controls ( k  = 2), PS booklets ( k =  1), and supportive counselling ( k  = 1). Risk of bias was rated as medium for two [ 44 , 45 ], and high for one study [ 43 ] due to concerns about missing outcome data and the absence of a study protocol.

Eskin and colleagues [ 43 ] randomized 53 Turkish high school and university students with MDD to six sessions of PST or a waitlist. The study reports a significant treatment effect on self-reported depressive symptoms (d = − 1.20; F [1, 42] = 10.3, p  < .01.), clinician-reported depressive symptoms (d = − 2.12; F [1, 42] = 37.7, p  < .001), and recovery rates, but not on self-reported PS ability (d = − 0.46; F [1, 42] = 2.2, p  > .05). Risk of bias was rated as high due to 37% of missing outcome data in the control group and the absence of a published trial protocol.

Michelson and colleagues [ 46 ] compared PST delivered by lay counsellors in combination with booklets, to PS booklets alone in 251 high-school students with mild mental health difficulties (53% emotional problems) in low-income communities in New Delhi, India. At six weeks, the intervention group showed significantly greater progress towards overcoming idiographic priority problems identified at baseline (d = 0.36, p  = .002), but no significant difference in self-reported mental health difficulties (d = 0.16, p  = .18). Results were similar at 12 weeks, including no significant difference in self-reported emotional symptoms (d = 0.18, p  = .089). As there was no long-term follow-up, it is unknown whether reduced personal problems translated into reduced emotional symptoms in the longer term. Perceived stress at six weeks was found to mediate treatment effect on idiographic problems, accounting for 15% of the overall effect at 12 weeks.

Two trials found no significant effect of PST on primary or secondary outcomes: Hoek and colleagues [ 44 ] randomized 45 youth with elevated depression or anxiety symptoms to five sessions of online PST or a waitlist control; Parker and colleagues [ 45 ] randomized 176 youth with mixed presenting problems (54% depression) to either PST with physical activity or PST with psychoeducation, compared with supportive counselling with physical activity or psychoeducation [ 45 ]. Drop-out from PST was high in both studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ].

PS-related concepts as predictors, moderators, or mediators of treatment response

The review identified four secondary analyses of RCT data that examined PS-related concepts as predictors, moderators, or mediators of treatment response (see Table  3 , below). Studies were published between 2005 and 2014 and included data from 761 participants with MDD diagnoses, and a mean age of 15.2 years (range: 12–18; 61.2% female).

A secondary analysis of data from the Treatment for Adolescents with Depression Study (TADS, n  = 439) [ 79 ] explored whether baseline problem orientation and PS styles were significant predictors or moderators of treatment response to Fluoxetine, CBT, or a combination treatment at 12 weeks [ 70 ]. Negative problem orientation and avoidant PS style each predicted less improvement in depression symptom severity ( p  = .001 and p  = .003, respectively), while positive problem orientation predicted greater improvement ( p  = .002). There was no significant moderation effect. Neither rational PS style nor impulsive-careless PS style predicted or moderated change in depressive symptoms.

A secondary analysis of data from the Treatment of Resistant Depression in Adolescents (TORDIA) study [ 80 ] examined the impact of specific CBT components on treatment response at 12 weeks in youth treated with a selective serotonin reuptake inhibitor (SSRI) in combination with CBT ( n  = 166) [ 71 ]. Youth who received PS training were 2.3 times ( p  = .03) more likely to have a positive treatment response than those not receiving this component. A significant effect was also observed for social skills training (Odds Ratio [OR] = 2.6, p  = .04) but not for seven other CBT components. PS and social skills training had the most equal allocation ratios between youth who received them (52 and 54%, respectively) and youth who did not. Balanced allocation provides maximum power for a given sample size [ 81 ]. With allocation ratios between 1:3 and 1:5, analysis of the remaining seven components may have been underpowered. Of further note, CBT components were not randomly assigned but selected based on individual clinical needs. The authors did not correct for multiple comparisons as part of this exploratory analysis.

Dietz and colleagues [ 73 ] explored the impact of social problem solving on treatment outcome based on data from a trial comparing CBT and Systemic Behaviour Family Therapy (SBFT) with elements of PS training on the one hand, with Non-Directive Supportive Therapy on the other hand ( n  = 63). Both CBT and SBFT were associated with significant improvements in young people’s interpersonal PS behaviour (measured by coding videotaped interactions between youth and their mothers) over the course of treatment (CBT: b* = 0.41, p  = .006; SBFT: b* = 0.30, p  = .04), which in turn were associated with higher rates of remission (Wald z = 6.11, p  = .01). However, there was no significant indirect effect of treatment condition via youth PS behaviour, and hence, no definitive evidence of a formal mediation effect [ 82 ].

Kaufman and colleagues [ 72 ] examined data from a trial comparing an Adolescent Coping with Depression (CWD-A) group-based intervention with a life-skills control condition in 93 youth with comorbid depression and conduct disorder. The secondary analysis explored whether change in six CBT-specific factors, including the use of PS and conflict resolution skills, mediated the effectiveness of CWD-A. There was no significant improvement in PS ability in CWD-A, compared with the control, and hence no further mediation analysis was conducted.

PS training in clinical practice guidelines

We identified 23 CPGs from twelve countries relevant to youth depression (see Additional File  4 ), issued by governments ( k  = 6), specialty societies ( k  = 3), health care providers ( k  = 4), independent expert groups ( k  = 2), and others, or a combination of these. Of these 23 CPGs, 15 mentioned PS training in relation to depression treatment for youth, as a component of CBT ( k  = 7), IPT ( k  = 4), supportive therapy or counselling ( k  = 3), family therapy ( k  = 1), DBT ( k  = 1), and psychoeducation ( k  = 1).

None of the reviewed CPGs recommended free-standing PST as a first-line treatment for youth depression. However, five CPGs mentioned PS training as a treatment ingredient or adjunct component in the context of recommending broader therapeutic approaches. The World Health Organization’s updated Mental Health Gap Action Programme guidelines recommended PS training as an adjunct treatment (e.g., in combination with antidepressant medication) for older adolescents [ 83 ]. A guideline by Orygen (Australia) suggested that for “persistent sub-threshold depressive symptoms (including dysthymia) or mild to moderate depression”, options should include “6–8 sessions of individual guided self-help based on the principles of CBT, including behavioural activation and problem-solving techniques” [ 84 ]. The Chilean Ministry of Health recommended supportive clinical care with adjunctive psychoeducation and PS tools, or supportive counselling for individuals aged 15 and older with mild depression (p. 52) [ 85 ]. The Cincinnati Children’s Hospital Medical Centre recommended four to eight sessions of supportive therapy for mild or uncomplicated depression, highlighting “problem solving coping skills” as one element of supportive therapy (p. 1) [ 86 ]. Fifth, the American Academy of Child and Adolescent Psychiatry’s 2007 practice parameter suggested each phase of treatment for youth depression should include psychoeducation and supportive management, which might include PS training (p. 1510) [ 87 ]. CPGs did not specify whether PS training should incorporate specific modules, or whether the term was used loosely to describe unstructured PS support.

Meta-analysis

Each of the four RCTs of free-standing PST identified by the scoping review contributed one comparison to the exploratory meta-analysis of overall PST efficacy (see Fig.  3 ). Self-rated depression or emotional symptom severity scores were reported by all four studies and constituted the primary outcome for the meta-analysis. We conducted additional exploratory analysis for clinician-rated depression severity as reported in two studies [ 43 , 45 ]. The pooled effect size for self-reported depression severity was g = − 0.34 (95% CI: − 0.92 to 0.23). Heterogeneity was high ( I 2  = 88.37%; p  < .001). Due to the small number of studies included, analysis of publication bias via an examination of the funnel plot and tests of funnel plot asymmetry could not be meaningfully conducted [ 88 , 89 ]. The funnel plot is provided in Additional File  5 for reference (Fig. S3).

figure 3

Forest Plot: Random Effects Model with Self-Reported Depression or Emotional Symptoms as Primary Outcome (Continuous)

To achieve the best possible estimate of the true effect size and reduce heterogeneity we computed a second model excluding the one study with high risk of bias (i.e., [ 43 ]). The resulting effect size was g = − 0.08 (95% CI: − 0.26 to 0.10), with no significant heterogeneity ( I 2  = 0.00%; p  = 0.72; see Fig. S1 in Additional File 5 ). The pooled effect size for clinician-rated depression severity was g = − 1.39 with a wide confidence interval (95% CI: − 4.03 to 1.42) and very high heterogeneity ( I 2  = 97.41%, p  < 0.001; see Fig. S2 in Additional File 5 ).

Overall quality of the evidence

According to the GRADE assessment, the overall quality of the evidence was very low, with concerns related to risk of bias, the inconsistency of results across studies, the indirectness of the evidence with regards to the population of interest (i.e., only one trial focused exclusively on youth with depression), and imprecision in the effect estimate (Table S4 in Additional File 6 ).

This scoping review aimed to provide a first comprehensive overview of the evidence relating to PS training as an active ingredient for treating youth depression. The evidence base relating to the efficacy of PST as a stand-alone intervention was scarce and of low quality. Overall, data from four trials suggested no significant effect on depression symptoms. The scoping review identified some evidence suggesting PS training may enhance treatment response in CBT. However, this conclusion was drawn from secondary analyses where youth were not randomized to treatment with and without PS training, and where primary studies were not powered to test these differences. Disproportionate exposure to comparator CBT components also limits these findings. PST was not recommended as a stand-alone treatment for youth depression in any of the 23 reviewed CPGs; however, one guideline suggested it could be provided alongside other treatments for older adolescents, and four suggested PS training as a component of low-intensity psychosocial interventions for youth with mild to moderate depression.

Given the limited evidence base, only tentative suggestions can be made as to when and for whom PS training is effective. The one PST trial with a low risk of bias enrolled high-school students from low-income communities in New Delhi, and found that PST delivered by lay counselors in combination with PST booklets was more effective at reducing idiographic priority problems than booklets alone, but not at reducing mental health symptoms [ 46 ]. Within a needs-based framework of service delivery (e.g., [ 90 ]), PST may be offered as a low-intensity intervention to youth who experience challenges and struggle with PS—including in low-resource contexts. Future research could explore whether PS training might be particularly helpful for youth facing socioeconomic hardship and related chronic stressors by attenuating potentially harmful impacts on well-being [ 91 ]. If findings are promising, PS training may be considered for targeted prevention (e.g., [ 42 ]). However, at this time there is insufficient evidence to support PS training on its own as an intervention aimed at providing symptom relief for youth experiencing depression.

The PST manual suggests cognitive overload, emotional dysregulation, negative thinking and hopelessness can interfere with PS [ 16 ]. Youth whose depression hinders their ability to engage in PST may require additional support through more comprehensive therapy packages such as CBT or IPT with PS training. In the TORDIA study [ 80 ], where PS training was found to be one of the most effective components, it was generally taught alongside cognitive restructuring, behavioural activation, and emotion regulation, which may have facilitated youths’ ability to absorb PS training [ 71 ]. The focus of these other CBT components on changing negative cognitions and attributions may fulfil a similar function as problem orientation modules in stand-alone PST. Research that is powered to explore such mechanisms is needed. Future research should also apply methodologies designed to identify the most critical elements in a larger treatment package (e.g., dismantling studies; or sequential, multiple assignment, randomized trials) to examine the role of PS training when delivered alongside other components. While one trial focusing on CBT components is currently underway [ 92 ], similar research is needed for other therapies (e.g., IPT, DBT, family therapy).

The included PST trials provided between five and six sessions and covered PS skills but not problem orientation. Meta-analyses of PST for adult depression suggest treatment effectiveness may be enhanced by longer treatment duration (≥ 10 sessions) [ 38 ], and coverage of problem orientation alongside PS skills [ 39 ]. As per the PST treatment manual, strengthening problem orientation fosters motivation and self-efficacy and is an important precondition for enhancing skills [ 93 , 94 ]. In addition, only one youth PST trial assessed PS ability at baseline [ 43 ]. A meta-analysis of PST for adult depression [ 39 ] suggests that studies including such assessments show larger effect sizes, with therapists better able to tailor PST to individual needs. Future research should seek to replicate these findings specifically for youth depression.

Drop out from stand-alone PST was high in two out of four studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ]. Since its development in the 1970s, PST has undergone several revisions [ 16 , 93 , 95 , 96 , 97 ] but tailoring to youth has been limited. To contextualize the review findings, the review team consulted a panel of twelve youth advisors at the Centre for Addiction and Mental Health (without sharing emerging findings so as not to steer the conversation). Most had participated in PS training as part of other therapies, but none had received formal PST. A key challenge identified by youth advisors was how to provide PS training that is universally applicable and relevant to different youth without being too generic, rigid or schematic; and how to accommodate youth perspectives, complex problems, and individual situations and dispositions. Youth advisors suggested reviewing and reworking PS training with youth in mind, to ensure it is youth-driven, strengths-based, comprehensive, and personalized (see Fig. S4 in Additional File  7 for more detail). Youth advisors emphasized that PS training should identify the root causes underpinning superficial problems and address these through suitable complementary intervention approaches, if needed.

Solution-focused brief therapy (SFBT) has emerged as an antithesis to PST where more emphasis is given to envisaging and constructing solutions rather than analysing problems [ 28 ]. This may be more consistent with youth preferences for strengths-based approaches but may provide insufficiently comprehensive problem appraisals. Future research should compare the effectiveness and acceptability of PST and SFBT and consider possible benefits of combining the advantages of both approaches, to provide support that is strengths-based and targets root problems. More generally, given the effectiveness of PST in adults, future studies could examine whether there are developmental factors that might contribute to reduced effectiveness in youth and should be considered when adapting PST to this age group.

Strengths and limitations

This scoping review applied a broad and systematic approach to study identification and selection. We searched five bibliographic databases, and conducted an extensive grey literature search, considering records published in four languages. Nevertheless, our search may have missed relevant studies published in other languages. We found only a small number of eligible empirical studies, several of which were likely underpowered. As stated above, studies analysing PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapies were heterogenous and limited by design and sample size constraints.

Similarly, there was heterogeneity in recruitment and intervention settings, age groups, and delivery formats across the four RCTs of stand-alone PST, and the overall quality of the evidence was very low. As reflected in our GRADE appraisal, one important limitation was the indirectness of the available evidence: Only one PST trial focused specifically on youth with an MDD diagnosis, while the remaining three included youth with a mix of mental health problems. Although outcomes were reported in terms of depression or emotional symptom severity, this was not based on a subgroup analysis focused specifically on youth with depression. Impact on this group may therefore have been underestimated. In addition, the only PST trial with a low risk of bias did not administer a dedicated depression symptom scale. Instead, our exploratory meta-analysis included scores from the 5-item SDQ emotional problems subscale, which assesses unhappiness, worries, clinginess, fears, and somatic symptoms—and may not have captured nuanced change in depression severity [ 98 , 99 ]. Other concerns that led us to downgrade the quality of the evidence related to considerable risk of bias, with only one out of four studies rated as having a low risk; and imprecision with several studies involving very small samples. Due to the small number of eligible studies, it was not possible to identify the factors driving treatment efficacy via meta-regression. The long-term effectiveness of PS training, or the conditions under which long-term benefits are likely to be realized also could not be examined [ 38 ].

PS training is a core component of several evidence-based therapies for youth depression. However, the evidence base supporting its efficacy as a stand-alone treatment is limited and of low quality. There is tentative evidence suggesting PS-training may drive positive outcomes when provided alongside other treatment components. On its own, PS training may be beneficial for youth who are not acutely distressed or impaired but require support with tackling personal problems. Youth experiencing moderate or severe depressive symptoms may require more comprehensive psychotherapeutic support alongside PS training, as there is currently no robust evidence for the ability of free-standing PST to effectively reduce depression symptoms.

High-quality trials are needed that assess PST efficacy in youth with mild, moderate, and severe depression, in relation to both symptom severity and idiographic treatment goals or priority problems. These studies should examine the influence of treatment length and module content on treatment impact. Dedicated studies are also needed to shed light on the role of PS training as an active ingredient of more comprehensive therapies such as CBT, DBT, IPT, and family therapy. Future studies should include assessments of adverse events and of cost effectiveness. Given high drop-out rates in several youth PST trials, it is important to adapt PS training approaches and therapy manuals as needed, following a youth-engaged research and service development approach [ 57 ], to ensure their relevance and acceptability to this age group.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

  • Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

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Acknowledgments

We would like to thank the members of the Centre for Addiction and Mental Health (CAMH) youth advisory group for their valuable insights and suggestions. The systematic search for clinical practice guidelines presented in this review was based on a search strategy developed by Dr. Kathryn Bennett. We would like to thank Dr. Bennett for agreeing to the reuse of the strategy as part of this review. We would also like to thank the Cundill Centre for Child and Youth Depression for providing institutional support to this project.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” commission awarded to KRK, DBC and PS, and the Centre for Addiction and Mental Health, Toronto, Canada.

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Karolin R. Krause, Darren B. Courtney, Sarah Bonato, Madison Aitken, Jacqueline Relihan, Matthew Prebeg, Karleigh Darnay, Lisa D. Hawke, Priya Watson & Peter Szatmari

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Darren B. Courtney, Madison Aitken, Lisa D. Hawke, Priya Watson & Peter Szatmari

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Contributions

KRK, DBC and PS formulated the research questions and designed the study. SB conducted the systematic search for clinical practice guidelines and the grey literature search, and advised on the search for retrieving empirical studies, which was led by KRK. KRK, DBC and BWCC performed the screening of records for inclusion criteria. Data extraction was performed by KRK and BWCC. The risk of bias assessment for included randomized control trials was conducted by KRK and MA. The youth consultation was led by JR, MP and KD with input from LDH and KRK. Data analysis was led by KRK. All authors contributed to the interpretation of emerging findings through an internal findings workshop and through several rounds of feedback on the draft manuscript, which was drafted by KRK. All authors have reviewed and approved the final manuscript.

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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Krause, K.R., Courtney, D.B., Chan, B.W.C. et al. Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis. BMC Psychiatry 21 , 397 (2021). https://doi.org/10.1186/s12888-021-03260-9

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Increasing Effectiveness of Cognitive Behavioral Therapy for Conduct Problems in Children and Adolescents: What Can We Learn from Neuroimaging Studies?

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Cognitive behavioral therapy (CBT) is particularly relevant for children from 7 years on and adolescents with clinical levels of conduct problems. CBT provides these children and adolescents with anger regulation and social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Typically, CBT is combined with another psychological treatment such as behavioral parent training in childhood or an intervention targeting multiple systems in adolescence. The effectiveness of CBT, however, is in the small to medium range. The aim of this review is to describe how the effectiveness of CBT may be improved by paying more attention to a series of psychological functions that have been shown to be impaired in neuroimaging studies: (1) anger recognition, (2) the ability to generate situation appropriate solutions to social problems, (3) reinforcement-based decision making, (4) response inhibition, and (5) affective empathy. It is suggested that children and adolescents first become familiar with these psychological functions during group CBT sessions. In individual sessions in which the parents (and/or child care workers in day treatment and residential treatment) and the child or adolescent participate, parents then learn to elicit, support, and reinforce their child’s use of these psychological functions in everyday life (in vivo practice). In these individual sessions, working on the psychological functions is tailored to the individual child’s characteristic impairments of these functions. CBT therapists may also share crucial social-learning topics with teachers with a view to creating learning opportunities for children and adolescents at school.

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Introduction

According to the most recent large meta-analysis of psychological therapy for children and adolescents treated for mental health problems in the clinical range the mean post-treatment effect size (ES, Cohen’s d ) for conduct problems is 0.46 (Weisz et al., 2017 ). The effect sizes of several types of psychological therapy for conduct problems, however, differ from each other.

In the meta-analysis by McCart et al. ( 2006 ), the ES of cognitive behavior therapy (CBT) in children and adolescents with conduct problems is d  = 0.35 while the ES of behavioral parent training is d  = 0.47. According to a more recent meta-analysis of behavioral parent training, the ES for children aged 2–9 years is even larger: d  = 0.69 (Leijten et al., 2019 ). In the meta-analysis by McCart et al., there was a positive relationship between age and ES for CBT: as youth enter more advanced levels of cognitive development, they receive increased benefits from CBT. Yet in the meta-analysis by Armelius and Andreassen ( 2007 ), the ES of CBT in youths aged 12–22 for the treatment of antisocial behavior in residential setting is only d  = 0.25. According to British guidelines, group CBT for children aged 9–14 years with clinical levels of conduct problems is advised based on low-to moderate-quality evidence from randomized controlled trials (National Institute for Health and Clinical Practice (NICE), 2013 , 2017; Pilling et al., 2013 ). Clearly, attempts at increasing effectiveness of CBT as a psychological treatment for conduct problems in middle childhood and adolescence are appropriate.

One way might be to examine neuroimaging studies that investigate biological correlates of psychological functions targeted in CBT. In CBT, children and adolescents learn better ways to manage their anger and solve social problems by increasing emotion-regulation and problem-solving abilities (Lochman et al., 2019 ; Matthys & Lochman, 2017 ). In particular, children and adolescents learn to identify their level of anger as well as to use coping self-statements, distraction techniques, and brief deep-breathing relaxation methods as a means to handle arousal associated with their anger. They also learn and improve to adequately interpret social problems, generate possible solutions, and decide which solution will be implemented. We will currently review functional magnetic resonance imaging (fMRI) studies examining psychological functions that are targeted in CBT for conduct problems: anger recognition, the ability to generate situation appropriate solutions to social problems, reinforcement-based decision making, response inhibition, and affective empathy. For this, we use meta-analyses, reviews of neuroimaging studies and separate neuroimaging studies, and discuss results in the context of other studies of these five psychological functions. Thus, our non-systematic review of functional neuroimaging studies is motivated by increasing our understanding of psychological abilities that may improve CBT effectiveness. After presentation of the neuroimaging work of each psychological function, we will provide a conclusion as a theoretical statement and working hypothesis about the potential role of the psychological function in the maintenance of conduct problems and finally discuss possible implications for CBT.

Cognitive Behavioral Therapy

CBT is particularly relevant for children from 7 years on and for adolescents as CBT provides them with anger regulation and social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Anger management and social problem solving are core elements of evidence-based practice for children with conduct problems (Garland et al., 2008 ). Early CBT programs such as the Anger Control Program (Lochman et al., 1981 ) and Problem-Solving Skills Training (Kazdin et al., 1987 ) were developed as sole interventions for children with conduct problems. For example, Problem-Solving Skills Training was offered in cases when working with parents was not a viable option due to severe family dysfunction or parent psychopathology (Kazdin et al., 1987 ).

Over the years, developers of programs have combined CBT with other psychological treatments such as behavioral parent training in childhood or intervention targeting multiple systems in adolescence. Examples of programs for children aged 7–13 years that have been proven to be effective are Problem-Solving Skills Training combined with Parent Management Training (Kazdin et al., 1992 ); the Coping Power program, a more extended and comprehensive version of the Anger Coping program (Lochman et al., 1981 ), consisting of a child component and a parent component (Lochman et al., 2008 ; Wells et al., 2008 ; Van de Wiel et al., 2007 ; Zonnevylle-Bender et al., 2007 ); the Stop Now and Plan program consisting of several components including a child component and a parent component (Augimeri et al., 2007 ; Burke & Loeber, 2015 ). An example of a program developed for adolescents is the Aggression Replacement Training (Goldstein et al., 1998 ; Hornsveld et al., 2015 ) which involves network meetings between parents, teachers, friends, and social workers or other care providers. For adolescents with severe conduct problems interventions that target multiple environmental systems (e.g., family, peers, school) such as Multisystemic Therapy (Henggeler et al., 2009 ; Van der Stouwe et al., 2014 ) have been developed and may also include a CBT component. For more examples of evidence-based programs, see reviews by Kaminski and Claussen ( 2017 ) and McCart and Sheidow ( 2016 ).

Most psychological interventions for conduct problems that have been proven to be effective are based on operant learning principles (e.g., positive reinforcement) and cognitive learning principles (e.g., use of inner speech). In behavioral parent training, children and adolescents acquire appropriate behaviors and learn to refrain from inappropriate behaviors as a result of parents’ or caregivers’ giving positive instructions, praising appropriate behaviors, ignoring minor inappropriate behaviors, and using time-out for severe inappropriate behaviors (Kazdin, 2005 ). Likewise, in CBT, children and adolescents acquire anger management and problem-solving abilities (Lochman et al., 2019 ; Matthys & Lochman, 2017 ). The effectiveness of these social-learning-based behavioral therapies may depend on children’s and adolescents’ impairments in processing of punishment cues, reward cues, and cognitive control (Matthys et al., 2012 , 2013 ).

In the present review, we will focus on conduct problems in the clinical range, either because children and adolescents meet criteria of Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5 , American Psychiatric Association, 2013 ), Oppositional Defiant Disorder or Conduct-Dissocial Disorder according to the International Classification of Diseases (eleventh edition; ICD-11 , World Health Association, 2020 ), or because they show symptoms in the clinical range on a standardized measure of psychopathology. Finding ways to improve the effectiveness of psychological treatment of conduct problems is of utmost importance, especially given the range of short- and long-term negative outcomes of conduct problems in adulthood, including crime, substance use disorders, suicide attempts, low educational achievement, anxiety disorders, depressive disorders, manic episode, schizophreniform disorder, eating disorders (Fergusson et al., 2005 ; Kim-Cohen et al., 2003 ), as well as high costs in terms of service utilization across all three domains of criminal justice, health, and social welfare (Rivenbark et al., 2018 ).

Anger Recognition

Emotional dysregulation during anger is an important mechanism driving reactive aggression in children and adolescents (Hubbard et al., 2010 ). Based on clinical work with low-income aggressive children, Lochman et al. ( 1981 ) developed the Anger Control program that incorporated both the self-instruction training methods from Meichenbaum ( 1977 ) and the social problem-solving training methods from Spivack and Shure ( 1974 ). Anger management skills are crucial for children and adolescents with conduct problems in order to handle the surge in anger to a provocation or frustration before they can successfully begin to use problem-solving strategies. Therefore, in the Coping Power program (Lochman et al., 2008 ), anger coping precedes social problem solving. However, a precondition for children and adolescents with conduct problems to learn managing their anger is to become aware and recognize their own anger.

It might be that children and adolescents with conduct problems have difficulties recognizing anger in others and their own anger. These difficulties have been associated with hyporeactivity of the orbitofrontal and anterior cingulate cortex involved in the processing of angry expressions (Blair et al., 1999 ). Male adolescents and young adults with conduct problems displayed abnormally reduced brain responses of the amygdala, ventromedial prefrontal cortex, orbitofrontal cortex, and insula when viewing angry versus neutral faces relative to controls (Passamonti et al., 2010 ). Also, female adolescents with conduct problems demonstrated decreased medial orbitofrontal cortex functioning while viewing facial expressions among which anger relative to controls (Fairchild et al., 2014 ). In addition, reduced left anterior insula and inferior frontal gyrus responses have been observed in male adolescents with conduct problems and callous-unemotional (CU) traits relative to normal controls when participants were asked to judge their own emotional reactions to fearful and angry expressions of others (Klapwijk et al., 2016 ).

Several neuroimaging studies suggest that children and adolescents with conduct problems have difficulty in recognizing anger in others and their own feelings of anger. An efficacy study can test the hypothesis whether including anger recognition as a crucial first step in anger management improves anger management abilities and reduces reactive aggression, especially in those children and adolescents with clear difficulties in anger recognition.

In CBT, improving children’s and adolescents’ anger management abilities is an important topic. For example, in the Coping Power program, one session is devoted to identification of physiological cues of anger (e.g., feeling hot, faster heart rate, tightened muscles) and identification of various levels of anger (e.g., irritated, mad, furious) (Lochman et al., 2008 ). One may question whether one session is sufficient for children with conduct problems to recognize their anger in everyday life situations as this seems to be a major problem for them. In Coping Power trials, the effect sizes for proactive aggression have been as much as three times larger than the effect sizes for reactive aggression (Miller et al., 2020 ). From the viewpoint of enhancing the effects of the program by more precisely and intensively targeting the active mechanisms of reactive aggression, developers of Coping Power will start to include mindfulness in the program (Miller et al., 2020 ). But in their motivation the authors do not seem to consider anger recognition problematic for children and adolescents with conduct problems as no reference is made to psychological studies showing that anger recognition may be problematic for children and adolescents with conduct problems.

Male young offenders demonstrate difficulties in recognizing low intensity anger in others (Bowen et al., 2016 ). Likewise, boys and girls with disruptive behavior referred into a crime prevention program were impaired in anger recognition (Hunnikin et al., 2020 ). Anger recognition was disproportionally impaired in boys with early-onset CD (Fairchild et al., 2009 ). Also, both boys and girls with conduct problems compared to controls showed more difficulties in recognizing facial emotions among which anger (Kohls et al., 2020 ). In their study of social information-processing in aggressive and depressed children, Quiggle et al. ( 1992 ) included the emotions (e.g., anger, sadness) when children were read negative stories. Depressed children reported more inner experienced anger than controls, but surprisingly aggressive children did not. Likewise, a study by Van Rest et al. ( 2020 ) in adolescents with conduct problems did not show differences between these adolescents and controls in their anger after viewing videos depicting problem situations in which youths were disadvantaged by accident, while these adolescents generated more aggressive responses and selected more often an aggressive response among various responses shown. Apparently, these studies have been overlooked by researchers involved in CBT but results are in line with the previously discussed neuroimaging studies. How can anger recognition become a topic in CBT?

In CBT, child and parent components often are offered as separate components: therapists work with parents on their parenting skills and with children on their anger management and social problem-solving skills. Here, we propose that parents or foster parents should become actively involved in CBT; this also applies for child care workers in day treatment and residential treatment. For example, parents can observe their child and therapist working on anger recognition, including the recognition of physiological cues which signal that the child is becoming angry. Parents then learn to develop skills in prompting and praising their child’s use of anger recognition in everyday life (in vivo practice, Kazdin et al., 1989 ). For example, they learn to ask questions such as ‘It seems to me that something is bothering you’ or ‘It seems to me that you feel annoyed,’ and ‘Good of you that you recognize this in yourself.’ In our view, anger recognition in everyday life should become a major theme in CBT as it is a precondition for the next steps consisting of using the coping self-statements, distraction techniques, and brief deep-breathing relaxation methods as a means to handle arousal associated with anger by the child or adolescent.

Furthermore, CBT therapists may also want to inform teachers of the child’s or adolescent’s learning processes. The school is an ideal environment for children and adolescents with conduct problems to improve their anger management and social problem-solving skills given the amount of time they spend in school in a wide variety of social contexts. With regard to anger recognition, we assume that a lot of practice is needed for children and adolescents with conduct problems to actually recognize their anger in socially difficult situations. Like the parents, teachers may prompt and praise the child’s use of anger recognition in everyday life. In addition, teachers may warn the child that a difficult situation is coming for him or her. For example, the child quickly becomes angry when he receives a comment about his school work. The anticipation of a difficult situation may help the child to better recognize his anger and use the anger management skills he or she learns in CBT. Other potential difficult situations are when the child is teased by peers or when a peer outperforms in a game (Dodge et al., 1985 ). These are all problematic social situations that will be addressed in the next section.

The Ability to Generate Situation Appropriate Solutions to Social Problems

In everyday life, children continuously face social problems such as how to respond to situations in which the child is being disadvantaged or how to cope with competition (Dodge et al., 1985 ; Matthys et al., 2001 ). To deal with these challenges, children have at their disposal a set of cognitive skills including defining the problem or interpreting the situation, generating possible solutions, and deciding which solution will be implemented (see social information-processing models by Crick & Dodge, 1994 , and by Dodge et al., 1986 ). In social information-processing research emphasis is put on the aggressive children’s interpretation of the situation as being hostile (see meta-analyses by De Castro et al., 2002 , and by Verhoef et al., 2019 ). On the other hand, only few studies have focused on the quantity and the quality of the solutions generated. As for the number of solutions, boys with conduct problems have been found to generate fewer solutions to problems than their peers in situations in which they have to cope with competition (Matthys et al., 1999 ). With respect to the quality of the responses generated, aggressive children have been shown to offer fewer verbal assertive solutions than their peers (Lochman & Lampron, 1986 ). For treatment purposes, the latter finding is highly relevant: do children and adolescents with conduct problems have appropriate responses in their repertoire?

When individuals demonstrate problems with the processing of reward cues, they are less able to make accurate predictions about which kind of behaviors is beneficial for them (Blair, 2010 ). Reduced reward processing can impair social problem solving, in particular the generation of solutions that are beneficial for them, a topic that may have been underestimated in social information-processing research.

When looking at the brain, the amygdala is thought to be implicated in the formation of stimulus-outcome associations based on environmental feedback and closely interacts with the orbitofrontal cortex, which is implicated in the generation of reinforcement-related expectations (Averbeck & Costa, 2017 ; Costa & Averbeck, 2020 ; Rolls, 2004 ). The orbitofrontal cortex and striatum also play a role in error prediction during learning (Hare et al., 2008 ; O’Doherty et al., 2006 ). In a situation where the individual is choosing whether to make a response associated with a particular value, reinforcement expectancy information provided by the striatum on the basis of prior experience is critical (Blair et al., 2018 ). The striatum and anterior cingulate cortex are also important for prediction of error signals (i.e., detecting a discrepancy between the anticipated and actual outcome). Prediction error signals are thought to facilitate reward and punishment-related feedback learning in terms of error minimization routines. In addition, the ventromedial prefrontal cortex and orbitofrontal cortex represent reinforcement expectancies (Blair et al., 2018 ; Finger et al., 2011 ). Children and adolescents with conduct problems have been found to show reduced responses in the orbitofrontal cortex, ventromedial prefrontal cortex, and striatum during both anticipation and response to rewards (Cohn et al., 2015 ; Finger et al., 2011 ; Rubia et al., 2009 ; White et al., 2013 ).

Difficulties in making correct predictions about which behavior in a certain situation is most beneficial can interfere with children’s and adolescents’ ability to generate situation appropriate solutions. An efficacy study can test the hypothesis whether improving the generation of situation appropriate solutions improves social problem solving and ultimately reduces conduct problems, especially in those children and adolescents who do not show adequate responses in their cognitive repertoire.

In CBT programs, social problem solving is a core theme. Children and adolescents are encouraged to come up with as many solutions as possible which then are categorized into solution types such as help seeking, verbal assertion, compromise, verbal aggression, and physical aggression. One may question whether CBT therapists should work on this with children and adolescents independently of parents and teachers. Children’s learning to generate appropriate solutions is likely to be a slow process, require a lot of practice, and must, therefore also take place in everyday life situations (in vivo practice). The Fast Track study showed that a multiyear preventive intervention offered at schools including the promotion of children’s social-cognitive skills, children’s social skills, and parenting skills, among others, resulted in a decrease of antisocial behavior. This reduction was mediated by its impact on three social-cognitive processes: reducing hostile-attribution biases, increasing the generation of socially competent responses to social problems, and devaluing aggression (Dodge et al., 2013 ). This study not only demonstrates that increasing children’s generation of appropriate responses to social problems is feasible but is also a mechanism of change and as such constitutes an important aspect of cognitive-behavioral-oriented treatment approaches.

In order to strengthen children’s and adolescents’ ability to produce solutions, CBT therapists may teach parents or foster parents how to assist their child to come up with solutions that are beneficial to the child’s well-being (e.g., solutions resulting in a better relationship with parents, siblings, and peers). This also applies for child care workers in day treatment and residential treatment. Parents can ask their child questions about the social problem such as: ‘What can you do about it?’ And, if needed, parents can give suggestions about which behavior can bring benefits to the child or adolescent himself or herself on the short and long term. But children should also experience for themselves that socially appropriate solutions are rewarding, so that they can become part of their cognitive repertoire.

Therefore, in families where coercive interactions prevail over positive interactions between the child or adolescent and his or her parents and siblings, CBT therapists in their work with parents teach them how to elicit appropriate behaviors in their child by giving positive instructions as well as by relabeling problem behavior in its positive opposite and giving this opposite as an instruction (Kazdin, 2005 ). If these appropriate behaviors produce a rewarding effect on the child, these behaviors are more likely to re-occur in comparable situations and consequently have a higher likelihood that they become part of the child’s behavioral repertoire for dealing with social situations effectively. As a result, these solutions are stored in long-term memory and are accessible as a possible response to a social situation (i.e., they become part of their cognitive repertoire). Much repetition is needed here before associations between responses and reward are made due to problems in making these associations. CBT therapists may work with teachers in a similar way.

As a complement, collaborative discussions with parents may teach children how to generate mutually satisfactory solutions. This approach, called Collaborative and Proactive Solutions (previously referred to as Collaborative Problem Solving) (Greene, 1998 ), focuses on helping children and parents learn to proactively and collaboratively solve daily social problems. In a clinical trial in youth with ODD, the Collaborative and Proactive Solutions program was shown to be equivalent to a behavior parent training program (Ollendick et al., 2016 ).

Reinforcement-Based Decision-Making

The final step in social problem solving is deciding which alternative will be selected among the ones that have been generated (Crick & Dodge, 1994 ; Dodge et al., 1986 ), a step that has often not been included in social information-processing studies. As compared to typically developing boys, school-aged boys with conduct problems who were given the opportunity to select a response among a number of options shown in videos, including prosocial responses, more often selected an aggressive response, and less frequently a prosocial response in situations in which they are being disadvantaged (Matthys et al., 1999 ). Likewise, adolescents with conduct problems more often selected an aggressive response among the various response options as compared with their typically developing peers in accidental situations (i.e., situations in which they are being disadvantaged by accident) (Van Rest et al., 2020 ). It is interesting to note that children and adolescents with conduct problems even after an extensive assessment of the social information process in which examples of appropriate responses are shown and numerous questions about the various responses asked, are still inclined to select an aggressive response (Van Rest et al., 2020 ).

The response-decision process is assumed to be affected by outcome expectations and evaluations based on moral values (Crick & Dodge, 1994 ). Children and adolescents with aggressive behavior expect aggressive behavior to lead to favorable outcomes (Fontaine et al., 2002 ; Perry et al., 1986 ). In addition, children with aggressive behavior have been shown to have positive evaluations of aggressive outcomes (Zelli et al., 1999 ). Moreover, a stronger belief that aggressive retaliation is acceptable predicts more future aggressive behavior (Zelli et al., 1999 ).

In neurobiological research, reinforcement-based decision-making studies show that reduced neural responsiveness to reward puts an individual at risk of poor decision making because response choices are less guided by expectations that an action will result in reward relative to punishment (Blair et al., 2018 ). A meta-analysis of whole-brain fMRI studies showed that the most consistent dysfunction in children and adolescents with conduct problems involves the rostro-dorsomedial, fronto-cingulate, and ventral-striatal regions that mediate reward-based decision making (Alegria et al., 2016 ). In addition, anterior insular cortex, dorsomedial frontal cortex, and caudate nucleus of the striatum have been found to be implicated in avoidance-related behavior (Blair et al., 2018 ). Dysfunctions in these regions when making suboptimal choices as a function of expected value have been found in adolescents with conduct problems (White et al., 2014 ) and are correlated to increased risk for antisocial behavior (White et al., 2016 ).

Difficulties in decision making based on uncertainties about reward and punishment outcomes can impede children’s and adolescents’ ability to make decisions about appropriate solutions to social problems. An efficacy study can test the hypothesis whether improving decision making based on correct expectations will ultimately result in a reduction of conduct problems, especially in those children and adolescents who have difficulties anticipating that an action will result in a reward or punishment.

In CBT, after children and adolescents have come up with solutions, the therapist asks questions about the consequences of these solutions and about possible alternative solutions in view of making the decision of an appropriate response: ‘What do you think will happen if you do or say that? Will that help solve the problem? What is the direct effect for yourself and for the other? And what is the effect in a week or a month? Is that an appropriate thing to do? Are there other ways to solve the problem?’ Whether just discussing these topics in CBT is sufficient to change children’s and adolescent’s decision-making process remains an open question.

Here, we suggest two approaches that may facilitate the learning processes involved in making appropriate decisions in everyday life situations. First, children and adolescents with conduct problems need to actually experience that appropriate behaviors result in positive consequences. Therefore, therapists in their work with parents, foster parents, and child care workers teach them how to elicit and then reinforce appropriate responses in the child or adolescent. Second, therapists teach parents and other adults how they can assist the child or the adolescent in evaluating various responses and selecting the response for enactment that is most appropriate for him or her not only on the short term (e.g., in terms of reaching a goal for the child himself) but also on the long term (e.g., in terms of positive consequences for the relationship with the other person) (in vivo practice). Parents can learn to ask their child questions such as those previously mentioned. Children and adolescents with conduct problems, however, may have difficulty in making appropriate decisions because response choices are less guided by expectations that an action will result in reward relative to punishment. Therapists, therefore, remind parents, foster parents, and child care workers that much repetition is needed to improve the child’s or adolescent’s decision making. Likewise, CBT therapists may assist teachers in implementing this approach that includes both a behavioral and a cognitive component.

Response Inhibition

A precondition for using social problem-solving skills is that the tendency to respond impulsively is suppressed. Children with conduct problems are typically action oriented in their social thinking (Lochman & Lampron, 1986 ; Matthys et al., 1995 ). So becoming aware that they are encountering a social problem and should think before acting can be a difficult step for them to make in everyday life. In other words, response inhibition or inhibitory control of impulses which is one of the executive functions that regulate people’s thinking and behaviors (Diamond, 2013 ; Miyake & Friedman, 2012 ), can be a serious issue for children and adolescents with conduct problems. Impaired response inhibition can prevent them from starting the social problem-solving process and may affect social problem-solving steps such as deciding which response to select among the responses generated (Van Nieuwenhuijzen et al., 2017 ). While impaired response inhibition should not be expected in children and adolescents with conduct problems as impulsivity is a typical characteristic of Attention-Deficit/Hyperactivity Disorder (ADHD) and not of ODD or CD, the latter disorders and ADHD often co-occur (Angold et al., 1999 ).

Deficits in response inhibition have not only been found in elementary school children with ADHD, but also in children with conduct problems without comorbid ADHD (Oosterlaan et al., 1998 ). Similarly, impairments in inhibition were observed for both preschool children with ADHD and preschool children with conduct problems with and without ADHD comorbidity relative to typically developing children (Schoemaker et al., 2012 ). In contrast, adolescents with ADHD, conduct problems, and autism spectrum disorder show a high number of failed inhibitions on a Go/NoGo task relative to typically developing children. However, post hoc analyses suggest that ADHD symptoms may be in part driving the increased level of unsuccessfully inhibited no-go trials in the conduct problems group (Leno et al, 2018 ). Even if this would be the case, given the co-occurrence of ADHD symptoms and conduct problems at a greater than random rate (Waschbusch, 2002 ), impaired response inhibition is still relevant for the conduct problems group (see systematic review and meta-analysis by Bonham et al., 2021 ). In addition, when motivational factors such as reward and punishment are included in response inhibition tasks (e.g., the response perseveration task), impairments in these so-called ‘hot executive functions’ seem to be clearly associated with conduct problems (Matthys et al., 1998 , 2004 ), and even more than with ADHD (Van Goozen et al., 2004 ). For reviews of the neuroimaging literature, see Rubia ( 2011 ) and Noordermeer et al. ( 2016 ).

In a review of fMRI studies, Blair et al. ( 2018 ) conclude that studies examining different paradigms involving response inhibition (as a ‘cold executive function’) report no differences in recruitment of regions implicated in response control, including the inferior frontal gyrus, anterior insular cortex, and dorsomedial frontal cortex, between children and adolescents with conduct problems and controls. The authors note that several of these studies excluded youth with conduct problems with comorbid ADHD. A study that did not control for the presence of ADHD showed reduced anterior insular activity on a cognitive interference (Stroop) task. The extent of impairment did not particularly relate to severity of conduct problems but did positively correlate to ADHD symptom severity (Hwang et al., 2016 ). In our opinion, this does not make the finding any less relevant. As ADHD often is associated with conduct problems (Angold et al., 1999 ), impaired response inhibition may be a characteristic of the child or adolescent referred for the treatment of conduct problems. In sum, response inhibition may be impaired in children and adolescents with conduct problems either due to the association with ADHD (symptoms) or to motivational demands (reward and punishment) included.

With regard to social problem solving, impaired response inhibition can prevent children and adolescents with conduct problems from starting the thinking process before acting, especially those with either comorbid ADHD or associated ADHD symptoms. Impaired response inhibition may also affect these children’s and adolescents’ social problem solving such as generating solutions and making decisions. An efficacy study can test the hypothesis whether enhancing response inhibition through training programs (see further Kofler et al., 2018 , 2020 ) affects social problem solving in everyday life and ultimately results in a reduction of conduct problems, especially in those children and adolescents with either comorbid ADHD or associated ADHD symptoms. Likewise, an efficacy study can test the hypothesis whether enhancing response inhibition by psychostimulants in children and adolescents with conduct problems and ADHD comorbidity affects social problem solving in everyday life and ultimately results in a reduction of conduct problems.

In CBT, thinking prior to acting is a theme. In a study of the child component of Coping Power, effectiveness of group delivery was compared to individual delivery. According to teachers, children with low levels of inhibitory control appeared to profit more from individual delivery of Coping Power than children with high levels of inhibitory control, suggesting that individual delivery offers opportunities for tailoring CBT to children’s individual needs (Lochman et al., 2015 ).

Although thinking prior to acting is addressed by CBT, the issue of starting the thinking process when children and adolescents are facing a social problem in everyday life at home and at school probably may need more attention. We, therefore, suggest that CBT therapists instruct parents, foster parents, child care workers, and teachers to assist the child or adolescent in withstanding his or her impulsive urges by engaging into the thinking process of social problem solving that children and adolescents learn in CBT during daily life (in vivo practice). When children or adolescents ask for help when they face a social problem, parents and teachers assist the child or adolescent if necessary by asking questions like: ‘What is the problem? What are some solutions?’ etc. Likewise, when parents and teachers see the problem arise before their eyes, they can ask those questions. It is, however, complicated when the problem occurs out of sight of adults. It may help to discuss with the child and adolescent in CBT the type of social situation he or she finds particularly difficult to deal with. For example, when the child finds out that he or she has been left out of a group, game, or activity of peers or when a peer performs better than the child in a game (Dodge et al., 1985 ; Matthys et al., 2001 ). When children and adolescents know which social situation is problematic for them, this awareness can help them to engage in the thinking process and ask themselves questions on how to solve the problem.

In line with a conceptual framework for combined neurocognitive and skill-based treatment approaches for youth with ADHD (Chacko et al., 2014 ), we suggest that executive function training programs are included in the treatment of children and adolescents with conduct problems and poor response inhibition associated with ADHD. While training programs targeting working memory and response inhibition have been less successful than initially anticipated, results of recent studies on central executive training targeting working memory, with effects on response inhibition and hyperactivity, are promising (Kofler et al., 2018 , 2020 ). In a review of interventions and approaches for improving executive functions, Diamond and Ling ( 2016 ) suggest that while challenging of executive functions is necessary for improving them, benefits of improving executive functions will be greater if children’s and adolescents’ emotional, social, and physical needs are also addressed. For instance, stress, sadness, loneliness, not enough sleep, and lack of physical activity have a negative impact on executive functioning (Diamond & Ling, 2016 ). Parents can, therefore, create conditions (e.g., healthy life style) for their child to make optimal use of their executive functions among which response inhibition.

Affective Empathy

Empathy is the understanding of another’s emotional state (cognitive empathy) as well as the ability of sharing/feeling another’s emotional state (affective empathy). The cognitive aspect involves finding out or inferring and understanding another person's emotional state (e.g., sadness, fear, or pain). The affective aspect includes the emotional response to ourselves in perceiving the other person's feeling. In particular, this emotional response is appropriate to or congruent with another’s situation than to one’s own (Eisenberg & Fabes, 1990 ; Hoffman, 1984 ; Moul et al., 2018 ). Empathy is associated with prosocial behavior such as helping and comforting others and contributes to the inhibition of antisocial and aggressive behavior (Eisenberg & Miller, 1987 ; Miller & Eisenberg, 1988 ). However, systematic and meta-analytic reviews of empathy show considerable inconsistencies in the assumed association between empathy and conduct problems. Differences in the measures used and the conceptualization of empathy have been suggested to, at least in part, contribute to the heterogeneous findings (Moul et al., 2018 ).

Lack of empathy is one of cardinal features of callous-unemotional (CU) traits (Frick et al., 2014 ). In the DSM-5, CU traits are labeled as ‘limited prosocial emotions,’ a diagnostic specifier for individuals who meet full criteria for Conduct Disorder. Limited prosocial emotions include the following characteristics: lack of empathy, lack of remorse or guilt, shallow or deficient effect, and unconcerned about performance (American Psychiatric Association, 2013 ). Children and adolescents with both severe conduct problems and elevated CU traits are at risk for more severe and persistent antisocial outcomes (Frick et al., 2014 ). They also tend to be less responsive to psychological treatment (Frick et al., 2014 ).

Blair ( 1995 ) suggested that in humans, a victim’s pain and distress induce similar feelings of distress in the aggressor, which in turn stops further aggressive behavior. Children and adolescents with a deficit in this mechanism will be less likely to learn to avoid harming other individuals, because the distress of other individuals is less aversive for them. These children and adolescents are, therefore, more likely to continue displaying behaviors that harm others to achieve their goals.

Distress-related cues, particularly fearful expressions, play an important role in inhibiting antisocial behavior (Blair, 2001 ). A meta-analysis showed a strong association between antisocial behavior and deficits in recognizing fearful expressions (Marsh & Blair, 2008 ). Consistent with this, in an fMRI study, children and adolescents with conduct problems and CU traits showed reduced amygdala responsiveness during the presentation of fearful facial expressions in comparison to healthy controls and youth with ADHD. Interestingly, functional connectivity analyses demonstrated lower correlations between the amygdala and ventromedial prefrontal cortex in youth with conduct problems and CU traits as compared to healthy controls and youth with ADHD (Marsh et al., 2008 ). Impairments in amygdala-ventromedial prefrontal cortex connectivity are suggested to be associated with antisocial behavior as a result of instrumental behavior that is inappropriately modulated by others’ distress (Marsh et al., 2008 ). In addition, adolescents with conduct problems and psychopathic traits, including reduced empathy and guilt, showed reduced activity in the rostral anterior cingulate cortex, ventral striatum, and amygdala in response to observing increased pain in others (Marsh et al., 2013 ). Also, reduced activity in the insula while viewing others being harmed was related to children’s greater CD symptoms and CU traits (Michalska et al., 2016 ). Interestingly, reduced left anterior insula and inferior frontal gyrus responses in adolescents with conduct problems and CU traits relative to normal controls were found when participants were asked to judge their own emotional reactions to fearful and angry expressions (Klapwijk et al., 2016 ). These findings suggest that adolescents with conduct problems and CU traits resonate less with the feelings of others (Klapwijk et al., 2016 ). Impairments in affective empathy have also been demonstrated in children and adolescents with conduct problems without CU traits (Martin-Key et al., 2017 ) and in children aged 7–11 years with disruptive behavior referred into a crime prevention program (Hunnikin et al., 2020 ).

Difficulties in affective empathy in response to other’s distress can result in the maintenance of aggressive behavior. An efficacy study can test the hypothesis whether improving affective empathy, in particular in response to other’s distress, using virtual reality (see further Dellazizzo et al., 2019 ), affects aggressive behavior, especially in those children and adolescents with limited prosocial emotions.

Currently, in CBT, much attention is given to perspective taking, in particular understanding another person’s intentions as children and adolescents with aggressive behavior are inclined to attribute hostile intentions to others (De Castro et al., 2002 ; Verhoef et al., 2019 ). Attention is also given to better understand the emotions of others, but whereas cognitive empathy is a central theme, affective empathy is not. Here, we suggest that improving affective empathetic responding, in particular in response to other’s distress, should be a target in CBT. Children and adolescents with conduct problems, especially those with limited prosocial emotions, must learn to pay attention to the child’s distress towards whom they start displaying aggressive behavior and must experience themselves how it feels like if this is done to them, with a view to stopping this behavior. This requires a lot of practice, possibly adding virtual reality, as individuals tend to respond realistically to virtual simulations of real-life events (Dellazizzo et al., 2019 ), to the everyday life situations. Parents, foster parents, child care workers in day treatment and residential treatment centers, and teachers can learn how to help the child or adolescent in paying attention to peer’s distress when the child or adolescent starts showing behavior that physically and/or mentally harms others (in vivo practice).

Lack of remorse or guilt is another characteristic of limited prosocial emotions, related to lack of empathy. The amygdala plays a role in care-based moral judgements (Blair, 2007 ). As already discussed, reduced amygdala responsiveness to the distress of other individuals has been shown in children and adolescents with conduct problems and with CU traits (Marsh et al., 2008 ). In line with this, adolescents with conduct problems and psychopathic traits showed reduced amygdala activity when making judgements about legal/illegal actions; thus, psychopathic traits appear to be associated with these adolescents’ ability to attach the appropriate valence to actions of varying moral permissibility (Marsh et al., 2011 ). These findings suggest that for adolescents with conduct problems and limited prosocial emotions, it is appropriate to include moral reasoning in CBT (see Aggression Replacement Training; Goldstein et al., 1998 ), for example in the context of generating solutions to social problems. A slow learning process must be taken into account here as well.

The mean effect size of psychotherapy for conduct problems in children and adolescents has been shown to decrease over the last 50 years (1963–2016), suggesting that adjustments are needed in some of the approaches that have been followed thus far (Weisz et al., 2019 ). Most evidence-based CBT programs were developed during the last three decades of the previous century and only slightly updated in the present century. Results of neuroimaging research into a series of psychological functions have not been incorporated in this update: anger recognition, the ability to generate appropriate solutions to social problems, reinforcement-based decision making, response inhibition, and affective empathy. We propose that these psychological functions deserve more attention in CBT and that working on these psychological abilities only during CBT sessions is not sufficient. Children’s and adolescents’ use of these psychological abilities in everyday life, on the other hand, must be elicited, supported, and reinforced by parents, foster parents, or child care workers in day treatment and residential centers. Therefore, parents or other adults must be intensively involved in the CBT of their child, by participating in part of the sessions, but especially by finding out, with the help of the therapist, how the learning processes of which the first steps were taken in the sessions can be continued in everyday life.

In addition, the increased child’s and adolescent’s competence to use cognitive skills goes hand in hand with learning behavioral skills. For example, a prerequisite for generating an appropriate solution or for selecting an appropriate one between different solutions generated is that children and adolescents have experienced that appropriate solutions work for them and as a result become part of their behavioral repertoire. Thus, therapists and parents, foster parents and child care workers in day treatment and residential treatment centers, need also to work on the improvement of the child’s or adolescent’s behavioral repertoire using the typical parenting skills targeted in behavioral parent training such as giving positive instructions and praising. If these appropriate behaviors work for the child and the adolescent and are perceived as rewarding by them, they are stored in long-term memory, can be generated as possible responses, and finally chosen as the best response based on positive outcomes both on the short and long term. Much perseverance is needed here before associations between responses and reward are made due to problems in making these associations.

The developing brain of children and adolescents is plastic and exhibits greater learning capacity as compared to the adult brain. It is, therefore, not unreasonable to assume that psychological-based interventions at a relatively early age have a positive and lasting effect on brain maturation and neural organization (Ismael et al., 2017 ). There is, for instance, evidence that experience-based brain plasticity can have positive effects paralleled by associated functional as well as structural neuroanatomical changes in children with ADHD (Hoekzema et al., 2011 ). In addition to making use of these developmental windows of opportunity by promoting learning during CBT sessions as well as in the everyday life setting, promoting a healthy life style is likely to have positive effects as well (Diamond & Ling, 2016 ). For example, a balanced eating diet, sufficient amount of sleep, and physical activity (e.g., sports) may improve learning and executive functioning which, in turn, enhance psychological functions associated with anger regulation and social problem solving.

Just as children and adolescents with conduct problems differ in symptoms (e.g., reactive aggression and CU traits), so they differ in the psychological functions that need to be specifically addressed, such as anger recognition, generating appropriate solutions, or affective empathic responding. Therefore, CBT should be tailored to the individual psychological disabilities. In addition to working with the child or adolescent, engaging parents or other adults provide an opportunity for the therapist to personalize CBT. A modular approach as first used in CBT for anxiety disorders and subsequently for other types of psychopathology may be appropriate here (Chorpita et al., 2004 ; Evans et al., 2020 ). A modular approach preserves the benefits of standardization of manualized protocols, while, at the same time, modules can be flexibly arranged so that the content, order, and dose are adjusted to the child and adolescent characteristics. If deemed appropriate, the use of individual or group sessions can also be included in this approach.

Group format is engaging for children and adolescents and offers many opportunities for modeling. However, group formats can sometimes be unnecessarily long for individual children or adolescents if they already display specific anger management or social problem-solving skills in their repertoire. If this is the case, then the number of group sessions with the child or adolescent can be reduced to make room for individual sessions tailored to the individual characteristics of the child’s or adolescent’s psychological functions that need improvement.

For example, psychoeducational group sessions are aimed at introducing the set of anger management and social problem-solving skills that will be worked on in individual sessions later. Thus, children and adolescents first become familiar with the cognitive and behavioral skills during group psychoeducational sessions on anger management (one module) and social problem solving (another module). Subsequently, in individual sessions in which the parents or other adults (e.g., child care workers) and the child or adolescent participate, parents learn to elicit, support, and reinforce their child’s use of anger management skills (several modules) and social problem-solving skills (several modules) during everyday life. In these individual sessions, working on the psychological functions is tailored to the individual child’s characteristic impaired functions. Homework assignments are used to practice skills tailored to the individual child, adolescent, and parent at home. With regard to effectiveness of individual versus group delivery of CBT, according to parents, individual delivery of the child component of Coping Power was as effective as group delivery, whereas according to teachers, individual delivery was more effective (Lochman et al., 2015 ).

For the improvement of anger management and social problem-solving skills, a lot of practice is needed. The school offers unique opportunities for this. Indicated preventive interventions that also target children with clinical levels of conduct problems, have chosen the school as the social context for intervention, also for practical reasons. The Fast Track project has shown that the intervention’s impact on the prevention of later crime and to a lesser extent of general and mental health problems can be accounted for by improvements in self-regulation and problem-solving skills (Sorenson et al., 2016 ). Children and adolescents spend a lot of time at school in a wide variety of social contexts that may be a problem for them, such as situations in which the child is being disadvantaged or must cope with competition (Dodge et al., 1985 ; Matthys et al., 2001 ). Although the learning processes aimed at anger regulation and social problem solving are initiated in the CBT sessions, they must be given a chance to continue at school. Therefore, the CBT therapist shares crucial learning topics for the student with the teacher with a view to creating learning opportunities for the student. Just like parents, teachers may also have collaborative discussions with students how to proactively and collaboratively solve daily social problems (Greene, 1998 ; Ollendick et al., 2016 ).

Engaging families in psychological treatment for conduct problems is challenging (Acri et al., 2018 ). Data from 262 studies for example showed that at least 25% of the parents of children aged 2–12 years identified as appropriate for behavioral parent training do not start treatment, and an additional 26% begin, but drop out before completing treatment (Chacko et al., 2016 ). When behavioral parent training is the only psychological therapy suggested by the clinician who performed the clinical evaluation of the child or adolescent, parents may not start treatment because they think that their parenting skills are of a sufficient level and their child has to deal with his or her problems. These parents may be right as it has been shown that not all families benefit equally from behavioral parent training, in part because parenting skills in some families are not clearly inappropriate (Van Aar et al., 2019 ). Also, parents may drop out of treatment after a few sessions because they think their parenting skills have now reached an adequate level and the child now needs to work on his or her problems. So involving the child himself or herself in the treatment either from the start or after a series of behavioral parent training sessions in order to improve his or her anger regulation and social problem-solving skills may increase the likelihood that the treatment will start or be completed.

There is consensus among clinical researchers that children derive increasing benefit from CBT with increasing age (Fairchild et al., 2019 ). Adding CBT to behavioral parent training may increase the effect of behavioral parent training in children aged from 7 years on. Kazdin and colleagues examined whether the combination of Problem-Solving Skills Training (a CBT program) and Parent Management Training (a behavioral parent training program) generated an intervention that was more potent than either treatment alone in children with conduct problems aged 7–13 years (Kazdin et al., 1992 ). The combined treatment led to more marked changes in antisocial behavior of the child and in parental stress than Problem-Solving Skills Training only and Parent Management Training only. The effect was also evident in the proportion of children that the combined treatment placed within the normative range of functioning in comparison with either treatment alone (Kazdin et al., 1992 ).

For the treatment of adolescents with conduct problems, CBT can be added to family-based psychotherapy (e.g., Functional Family Therapy; Alexander et al., 2013 ) or may become part of interventions targeting multiple systems (e.g., Multisystemic Therapy; Henggeler et al., 2009 ). Increasing the effectiveness of CBT for adolescents is needed as a meta-analysis of Multisystemic Therapy, specifically indicated for adolescents with the most severe conduct problems such as violent offenders and conduct problems associated with substance abuse, showed small effect sizes: d  = 0.20 for delinquency and d  = 0.29 for psychopathology (Van der Stouwe et al., 2014 ). Likewise, as already mentioned, the ES of CBT in youths treated for antisocial behavior in residential settings is only d  = 0.25 (Armelius & Andreassen, 2007 ).

Finally, the perspective we adopted was a non-systematic review of the available neuroimaging literature to examine the neural basis of psychological functions that are implicated in the effectiveness of CBT programs. However, we acknowledge that the number of neuroimaging studies is limited. In addition to the five psychological functions discussed in the present review, other psychological functions, such as working memory, which are not included in the CBT programs may be relevant as well.

Although the literature on anger regulation and social problem solving is extensive, the present review of functional neuroimaging studies suggests that some psychological functions targeted in CBT may need more attention: anger recognition, the ability to generate situation appropriate solutions to social problems, reinforcement-based decision making, response inhibition, and affective empathy. Directly following from the observations that these psychological functions may be impaired in conduct problems, a number of suggestions to increase therapeutic effectiveness of CBT were made. While these require a close collaboration of the therapist with parents, teachers and child care workers in day treatment and residential centers, taking into consideration specific psychological dysfunctions may be beneficial to improving the effectiveness of CBT in the treatment of conduct problems.

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Matthys, W., Schutter, D.J.L.G. Increasing Effectiveness of Cognitive Behavioral Therapy for Conduct Problems in Children and Adolescents: What Can We Learn from Neuroimaging Studies?. Clin Child Fam Psychol Rev 24 , 484–499 (2021). https://doi.org/10.1007/s10567-021-00346-4

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Problem-solving skills training for parents of children with chronic pain: a pilot randomized controlled trial.

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Pain , 01 Jun 2016 , 157(6): 1213-1223 https://doi.org/10.1097/j.pain.0000000000000508   PMID: 26845525  PMCID: PMC4935529

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Problem Solving Skills Training for Parents of Children with Chronic Pain: A Pilot Randomized Controlled Trial

Tonya m. palermo.

1 University of Washington

2 Seattle Children’s Research Institute

Emily F. Law

Maggie bromberg, jessica fales.

3 Washington State University, Vancouver

Christopher Eccleston

4 University of Bath

Anna C. Wilson

5 Oregon Health & Science University

This pilot randomized controlled trial aimed to determine the feasibility, acceptability, and preliminary efficacy of parental problem solving skills training (PSST) compared to treatment as usual (TAU) on improving parental mental health symptoms, physical health and well-being, and parenting behaviors. Effects of parent PSST on child outcomes (pain, emotional and physical functioning) were also examined. Participants included 61 parents of children aged 10–17 years with chronic pain randomized to PSST (n = 31) or TAU (n = 30). Parents receiving PSST participated in 4–6 individual sessions of training in problem solving skills. Outcomes were assessed at pre-treatment, immediately post-treatment, and at 3-month follow up. Feasibility was determined by therapy session attendance, therapist ratings, and parent treatment acceptability ratings. Feasibility of PSST delivery in this population was demonstrated by high compliance with therapy attendance, excellent retention, high therapist ratings of treatment engagement, and high parent ratings of treatment acceptability. PSST was associated with post-treatment improvements in parental depression ( d = −0.68), general mental health ( d = 0.64), and pain catastrophizing ( d = −0.48), as well as in child depression ( d = −0.49), child general anxiety ( d = −0.56), and child pain-specific anxiety ( d = −0.82). Several effects were maintained at 3-month follow-up. Findings demonstrate that PSST is feasible and acceptable to parents of youth with chronic pain. Treatment outcome analyses show promising but mixed patterns of effects of PSST on parent and child mental health outcomes. Further rigorous trials of PSST are needed to extend these pilot results.

  • Introduction

Chronic pain is as prevalent in childhood as adulthood, with 8% of children reporting severe pain and disability [ 24 ]. Pediatric chronic pain is embedded in a broader context of parent and family factors that may directly or indirectly influence the child’s adjustment and coping with pain [ 36 ]. For example, higher levels of parental psychological distress [ 32 ] and less healthy family functioning [ 31 , 38 ] are associated with greater child pain-related disability. In addition, parents are themselves affected by caring for a child with chronic pain which may lead to changes in their own psychological and behavioral functioning. Many parents of children with chronic pain report clinically significant role stress, anxiety, and depressive symptoms [ 14 ]. Therefore, interventions that alleviate parent distress may also improve health and well-being for children with chronic pain.

Interventions have been developed and evaluated for parents of children with chronic medical conditions [ 3 , 13 , 30 ]. In a Cochrane review on this topic [ 15 ], problem-solving skills training (PSST) interventions were effective in reducing distress (i.e., improving parental mental health) in parents of children with chronic conditions (e.g., cancer, asthma). In contrast, there was no evidence for the effectiveness of cognitive-behavioral, family, or multi-systemic therapy in improving parental mental health or behavioral outcomes. PSST is based on the social problem-solving model of D’Zurilla and Nezu [ 8 , 9 ] and is hypothesized to change interpersonal interactions and behaviors associated with stress. Efficacy of PSST has been evaluated in caregivers of both adult and pediatric medical populations, gaining considerable empirical support, e.g., [ 41 , 43 , 44 ], but had not been applied to chronic pain. Thus, our research team adapted an existing PSST intervention developed for caregivers of children with cancer [ 43 ] for caregivers of children with chronic pain [ 37 ]. In line with prior studies of PSST, we also sought to evaluate the effects of PSST alone (without other interventions) in order to specifically test the preliminary benefits achieved by PSST.

Although parent interventions have been included in pediatric cognitive-behavioral pain interventions [ 20 ], their purpose has been to modify parent behavior that may inadvertently reinforce maladaptive coping (such as teaching parents to reward activity participation) based on social learning theory. Most typically, interventions directed towards parents have been brief (e.g., 1–2 sessions) and do not aim to modify parent distress [ 20 ]. Thus, applying interventions only to parents and directed toward reducing parental distress is novel in this population.

In this pilot RCT we aimed to determine feasibility, acceptability, and preliminary efficacy of PSST versus treatment as usual (TAU) for parents of children with chronic pain. We hypothesized that feasibility would be shown by high levels of participation, retention, and high ratings of intervention acceptability. We hypothesized that PSST would impact both parent and child outcomes at post-treatment and 3-month follow-up. Specifically, parents receiving PSST would report improved mental health symptoms, health and well-being, and more adaptive parenting compared to parents receiving TAU; children of parents receiving PSST would report decreased pain and improved physical and emotional functioning compared to children of parents receiving TAU.

Participants

Participants were 61 parents and their children aged 10–17 years with chronic pain. The clinical trial was registered and the full protocol is available (PSST; Problem Solving Skills Training for Parent Caregivers of Youth with Chronic Pain, ClinicalTrials.gov Identifier NCT01496378). Parent-child dyads were enrolled from May 2012 to October 2014 from two interdisciplinary pediatric pain clinics (Seattle Children’s Hospital and Oregon Health and Science University); follow up data were complete by May 2015. The study was approved by each site’s Institutional Review Board.

We have published one paper concerning adaptation and initial piloting of PSST for parents of youth with chronic pain [ 37 ]; however, that paper did not include any of the participants or outcome analyses of the pilot randomized controlled trial results presented here.

Inclusion/Exclusion Criteria

Inclusion criteria for the trial were: 1) parent of a child between the ages of 10 and 17 years with chronic pain, 2) child’s pain of a duration ≥ 3 months and interfering with daily functioning, 3) child received evaluation for chronic pain from one of the two pain clinics, and 4) parents were English-speaking. Exclusion criteria were: 1) child diagnosed with a serious comorbid health condition (e.g., cancer), 2) parent resided with child for < 1 year, and 3) parent had serious or life-threatening mental health issues (e.g., active psychosis, suicidal ideation).

Recruitment

Providers at the two pain centers gave potential participants a flyer about the study and asked if they would be willing to be contacted by study staff to learn more about the study and receive additional screening. Providers then sent potential participant’s contact information to study staff via secure email. Potential participants could also contact study staff directly by calling a phone number provided on the study flyer. Study staff screened for eligibility and held a consent conference with parents and children by telephone. Parents signed the consent forms and returned them to study staff. Children signed assent forms for their study participation.

Trial Design and Randomization

This pilot clinical trial used a balanced (1:1) randomized parallel group design. Assessments were sent to participants’ homes and were returned to study staff via postal mailings. Assessments were completed at pre-randomization (baseline), immediately post-treatment (6–8 weeks), and at 3-month follow-up. A fixed allocation randomization scheme was used. Order of randomization to the two treatment conditions was generated separately for each site with an online program (randomizer.org). A blocked method design was used, with blocks of 4 for each ID number. Using the output provided by the online program, study staff created a password protected electronic document that linked each ID number to a group assignment. Only the research coordinator had the password to the randomization table. Group assignment was concealed by formatting the document to block out group assignment until the time of randomization. Following completion of pre-treatment assessments, the research coordinator revealed participants’ group assignment. Interventionists were informed when participants were allocated to the active treatment group, and they contacted parents directly to schedule the first treatment session. Participants allocated to the TAU group were contacted by the research coordinator and were provided with instructions to continue with their usual care during the treatment phase. Thus, participants were not blinded to their group assignment. All study assessments were self-report measures completed in participants’ homes via mailings; children and parents were instructed to complete measures independently.

Figure 1 shows a CONSORT diagram depicting the flow of study participants through each phase of the study. Referrals were received from the two pain clinics for 151 families of youth with chronic pain. Of those families who were referred to participate, a total of 90 were excluded: 7 did not meet eligibility criteria because the child had a serious comorbid chronic medical condition, 58 declined participation due to lack of time and/or travel burden to the treatment center, 22 were unable to be reached during the recruitment period, and 3 were unable to be reached to complete pre-treatment assessments (passive refusals). The final sample consisted of 61 families. Demographics (child age and sex) did not differ between those families who did and did not choose to participate.

a child is receiving problem solving skills training as a treatment

The 61 eligible families were randomly assigned to PSST ( n = 31) or TAU ( n = 30). All 31 families who were randomized to PSST received the allocated intervention. One participant did not complete the immediate post-treatment assessment ( n = 0 PSST, n = 1 TAU). An additional participant did not complete the three-month follow-up assessment ( n = 0 PSST, n = 1 TAU) for an overall retention rate of 97%. All enrolled participants were included in final analyses, including 31 participants from the PSST group and 30 participants from the TAU group.

All child participants were patients who had received evaluation and treatment in one of the two collaborating interdisciplinary pain clinics. Resulting from this evaluation, participants may have received recommendations for treatment. These usual care recommendations were not altered for the clinical trial. All study-related procedures and interventions were adjunctive to the usual care participants received in their pain clinic. Parents and children were provided with study incentives (giftcards) following each completed assessment.

Participants completed all assessments in their homes and then returned the questionnaires to study staff via postal mailings. After study staff received the completed pre-treatment assessment, participants were randomized to PSST or TAU.

Parents assigned to the intervention condition received PSST as adapted for parents of children with chronic pain[ 37 ] in addition to the usual care their child received in pain clinic. This was a parent only intervention and the children did not participate. Our intervention was adapted from treatment materials developed by Sahler and colleagues [ 43 ] for caregivers of children with cancer (“ Bright IDEAS ”). Drawing from D’Zurilla and colleagues’ conceptualization of effective problem solving ability [ 8 , 9 ], Sahler et al.’s intervention emphasizes a positive problem-solving orientation characterized by optimism and problem-solving self-efficacy ( Bright ), as well as the major components of rational problem solving. These include problem definition and formulation ( I dentify the Problem ), generation of alternative solutions ( D etermine the options ), decision-making ( E valuate options ), solution implementation ( A ct ), and verification ( S ee if it worked ). Content was modified to be relevant to parents of children with chronic pain, including removal of references and examples specific to cancer and the addition of examples specific to chronic pain. Additional modifications included the creation of a list of common challenges faced by caregivers of youth with chronic pain and a booklet illustrating the problem-solving process using a vignette of a family with a child with chronic pain (see [ 37 ], for details).

In our initial pilot testing of the intervention [ 37 ], we found that parents learned problem solving skills quickly and were rated by therapists as ready to terminate within 4–6 sessions. In addition, we found that it was difficult for parents to schedule 8 sessions in an 8 week intervention period. Thus, we made the decision to shorten treatment to be delivered in 4 to 6 sessions, and telephone sessions were included as a mode of treatment delivery in an effort to increase feasibility of treatment. However, few parents made use of telephone sessions in the pilot RCT (24 out of 167 total sessions; 14%).

Sessions were designed to be delivered individually over one hour, and were conducted in the order prescribed by the treatment manual. The goal of the first session was to orient the caregiver to the intervention and establish rapport. Parents were asked to tell the story of their child’s pain, with follow-up prompts regarding how having a child with pain impacted various aspects of their lives (i.e., family functioning, emotional functioning, finances). They were provided with an overview of the intervention and a copy of the manual, which included the problem-solving vignette. Subsequent sessions focused on developing a positive problem solving orientation and learning how to enact the rational problem-solving skills. Therapists first presented a description and rationale for each skill and then encouraged the caregiver to enact the skill in session, with the aid of manualized worksheets. Training in positive problem solving orientation included education about the importance of a positive outlook when solving problems as well as instruction in cognitive restructuring when a negative problem solving orientation was identified. Parents completed a worksheet in which common problems experienced by families with chronic pain were listed (e.g., financial problems, lack of time for social activities, worry about their child, relationship problems). Therapists could use this worksheet to help parents choose problems to address in sessions. Example problems that parents worked on in sessions included dealing with sibling jealousy over time spent with the child with chronic pain, communication with school personnel about the child’s pain, and negative communications and interactions with their child.

The subsequent steps of problem solving were taught using behavioral rehearsal, role play, and positive reinforcement. Therapists could also provide brief training in abdominal breathing when parents generated a solution that involved the study therapist teaching them how to relax. At the end of each session, parents were provided with a take-home assignment, which was then closely reviewed and discussed in the following session. The full treatment manual can be obtained from the first author.

Treatment as Usual

Parents and children continued with the care that was prescribed by the pain clinic for their child’s pain problem. Care was not altered by participation in this pilot RCT. Clinical recommendations may have included physical therapy, psychological therapy, medication management, and/or complementary and alternative modalities such as acupuncture. Families may also have chosen to not pursue any other treatments. PSST is not a part of usual clinical care and was not offered to parents at either collaborating pain center.

Therapists, Supervision, and Treatment Fidelity

Four therapists were postdoctoral psychology fellows and two were licensed clinical psychologists, all of whom had formal training and experience in treatment of pediatric chronic pain. Therapists underwent a didactic training that was delivered in a group and individual format including review of treatment materials and role-play of treatment sessions with a trained therapist. All sessions were audio-recorded. After each session, therapists completed a fidelity record detailing the problems parents chose to address during the session, progress in acquisition of specific problem-solving skills, and tasks assigned for homework. Cross-site group supervision occurred weekly via conference call or individually with a licensed clinical psychologist (EL) who had experience in PSST to review sessions and compliance to the manual.

Treatment Acceptability and Satisfaction

At post-treatment and three-month follow-up, parents in the PSST group completed an adapted version of the Treatment Evaluation Inventory-Short Form [ 28 , 29 ], a 9-item scale designed to assess acceptability and satisfaction with the treatment process and outcomes. Select items were adapted to be specific to pediatric pain (e.g., “I find this treatment to be an acceptable way of dealing with children’s pain”). Items are rated on a 5-point Likert type scale, ranging from 1 ( Strongly Disagree ) to 5 ( Strongly Agree ). Items are summed to create a total score ranging from 9–45, with higher scores indicating greater treatment acceptability and satisfaction. “Moderate” treatment satisfaction and acceptability is indicated by a score of 27 or higher [ 28 ]. This measure has demonstrated good reliability and validity [ 29 ].

Treatment Feasibility

Feasibility of delivering PSST to parents with chronic pain was assessed by documenting the number of sessions completed by parents as well as therapist ratings of parent motivation to learn, receptivity to learning, understanding of the PSST process, and rapport. At the end of each session, therapists completed these ratings on 0–10 Likert scales, which were averaged across sessions.

Pre-treatment Measures

Demographics.

Parents completed an information form to assess their relationship to the child (i.e., biological mother, father), family composition, marital status, race, and education. Parents also provided information regarding their child’s age, sex, and race.

Psychological distress

The Brief Symptom Inventory 18 (BSI 18) [ 11 ] was used to screen for parent psychological distress and psychiatric disorders at pre-treatment. Parents rate their level of distress over the past week using a 5-point scale ranging from 0 ( not at all ) to 4 ( extremely ). Items are summed to create a Global Severity Index. The BSI 18 has demonstrated strong validity and reliability [ 11 ]. In the present study, Cronbach’s α was 0.84 for the global severity index score.

Selection of Outcome Measures

A goal of our pilot trial was to determine optimal measurement tools for parent behavior and mental health outcomes to inform a future larger definitive trial. To achieve this goal, where possible we administered two types of measures within each parent outcome domain: 1) general measures that have been used in previous trials of PSST with other caregiver populations, and 2) measures specifically developed for use with parents of children with chronic pain. Consistent with prior trials of PSST [ 41 – 43 , 48 ], our primary outcome used for estimating sample size was a general measure of parent depressive symptoms.

Parent Mental Health Outcomes

General parent mental health.

The primary outcome was parent depression as measured by the Beck Depression Inventory-II (BDI-II) [ 4 ]. The BDI-II is a 21-item questionnaire that assesses the presence and severity of depressive symptoms over the preceding two weeks. Items are rated on a 4 point scale, ranging from 0 to 3. Items are summed to create a total score, with higher scores indicating greater depressive symptom severity. The psychometric properties of the BDI-II have been extensively evaluated, with consistently strong support for its validity and reliability (e.g., [ 2 , 12 ]). In the present study, Cronbach’s α ranged from 0.85–0.94.

The Profile of Mood States-Standard (POMS) [ 34 ] was used as a secondary outcome to assess transitory mood. The POMS is a 65-item questionnaire that assesses transitory mood states (i.e., exhausted, relaxed). Items are rated on a 5 point Likert type scale ranging from 0 to 4, with higher scores indicating more intense mood during the past week. Items load onto six subscales: Tension-Anxiety, Anger-Hostility, Fatigue-Inertia, Depression-Dejection, Vigor-Activity, and Confusion-Bewilderment. Subscale scores are summed to create a Total Mood Disturbance score. In the present study, we report the effect of treatment on the Total Mood Disturbance score. The POMS has strong psychometric properties [ 35 , 40 ]. Cronbach’s α ranged from 0.91–0.92 in the present study.

Pain-specific parent mental health

Secondary pain-specific mental health outcomes included subscales from the Bath Adolescent Pain-Parental Impact Questionnaire (BAPQ-PIQ) [ 27 ] and the Pain Catastrophizing Scale for Parents (PCS-P) [ 21 ]. The BAPQ-PIQ is a 61-item questionnaire designed to assess the impact of caring for a child with chronic pain on parents’ functioning. Items are rated on a 5 point frequency response scale ranging from 0 ( Never ) to 4 ( Always ). Higher scores are indicative of more impaired functioning for all subscales. To reflect pain-specific mental health symptoms, we used scores on the Depression and Anxiety subscales. The BAPQ-PIQ has demonstrated good reliability and validity among parents of youth with chronic pain [ 27 ]. In the present study, Cronbach’s α ranged from 0.88–0.89.

The PCS-P is a 13-item questionnaire designed to assess catastrophic thoughts and feelings about the child’s pain [ 21 ]. Items are rated on a 5 point frequency response scale ranging from 0 to 4, and load onto three subscales: Rumination, Magnification, and Helplessness. Subscale scores are summed to create a Parent Pain Catastrophizing Total score, with higher scores indicative of greater catastrophizing. In the present study, we report the effect of treatment on the Parent Pain Catastrophizing Total score. The PCS-P has demonstrated good reliability and validity among parents of youth with chronic pain [ 21 ]. In the present study, Cronbach’s α ranged from 0.90–0.91.

General Parent Health and Well-being

General parent health and well-being was assessed with the Short Form Health Survey 12 (SF-12) [ 49 ], which is a brief health survey measure to assess functional health and well-being. Items ask about limitations and problems with emotions, health, and functional activities over the prior 4 weeks. The 12 items are combined to calculate physical and mental health summary scores. The SF-12 is a well-established health status measure that has demonstrated adequate content validity, discriminant validity, and test-retest reliability [ 49 ].

Exploratory Parenting Outcomes

General parenting stress.

The Parenting Stress Index-Short Form (PSI-SF) [ 1 ] is a 36-item questionnaire that assesses general parenting stress. Items are rated on a 5 point scale, ranging from 1 to 5, with higher scores indicative of greater difficulties related to parenting. Items load onto 3 subscales: Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child. Subscale scores are summed to calculate a Total Parenting Stress score. Raw scores were transformed to percentile scores for analyses. In the present study, we report on the Total Parenting Stress score. The PSI has demonstrated adequate reliability and validity [ 5 , 23 ]. Cronbach’s α ranged from 0.93–0.95 in the present study.

Pain-specific parent behaviors

Our primary measure of parent behavioral responses to pain was the Parent Behavior subscale of the BAPQ-PIQ [ 27 ]. This subscale contains 11 items about parent behaviors directed at encouraging or discouraging child activity. Items are rated on a 5 point frequency response scale ranging from 0 to 4. Higher scores are interpreted as more problematic parent behaviors. The BAPQ-PIQ has demonstrated good reliability and validity among parents of youth with chronic pain [ 27 ]. In the present study, Cronbach’s α was 0.88.

A secondary measure of parent behavioral responses to pain was the Helping for Health Inventory (HHI) adapted for chronic pain [ 18 , 22 ]. The HHI assesses miscarried helping, a maladaptive interactional process characterized by parents’ attempts to help their child that are met with resistance. Two versions (parent and child) are available that provide perceptions from each viewpoint. Example items include “The more my parents try to involve themselves in my pain, the more I resist their involvement,” and “I find that the more I try to help my child with his/her pain, the more he/she resists my involvement.” Items are rated on a 5 point scale, with higher scores indicative of greater miscarried helping. Items are summed to create an HHI Total score. In the present study, we report parent and child-reported HHI Total scores. The HHI has demonstrated good reliability and validity in pediatric populations, including in outpatient samples of youth with chronic pain [ 18 ]. In the present study, Cronbach’s α was 0.83 (parent) and 0.88 for child report.

Child Physical and Mental Health Outcomes

Pain intensity.

Pain intensity was assessed using a questionnaire previously validated with youth with chronic pain [ 39 ]. Children reported on their average pain intensity over the past month on an 11-point numerical rating scale (NRS), ranging from 0 ( No pain ) to 10 ( Worst pain ). The NRS is recommended for assessment of pain intensity in children and adolescents with chronic pain [ 47 ].

Emotional functioning and functional impairment

Youth completed the Bath Adolescent Pain Questionnaire (BAPQ) [ 16 ], a 61-item questionnaire that assesses the multidimensional impact of chronic pain on children’s functioning. Outcomes representing child emotional functioning outcomes were drawn from three subscales (Depression, General anxiety, Pain-specific anxiety). Child functional impairment was assessed by two subscales (Social functioning, Physical functioning). Items are rated on a 5 point scale, with higher scores indicative of more impaired functioning. The BAPQ was developed for use in clinical populations of youth with chronic pain to evaluate treatment efficacy and has demonstrated good validity and test-retest reliability in outpatient pain samples [ 16 ]. In the present study, Cronbach’s α = 0.85–0.88.

Adverse Events

Participants provided open-ended responses concerning any adverse events occurring during the study at post-treatment and follow up.

Process Measure

Problem-solving.

Parents completed the Social Problem-Solving Skills Inventory-Revised (SPSI-R) [ 10 ], a 52-item questionnaire that assesses a five dimensional model of social problem solving including two types of problem orientation (positive and negative) and three problem-solving styles (rational problem solving, impulsivity-carelessness, and avoidance). A dysfunctional problem solving score was constructed from negative problem solving, avoidance and impulsivity-carelessness scores, and a constructive problem solving score was calculated from positive problem orientation and rational problem solving scores. The SPSI-R total score is the weighted average of the five subscale scores, with higher scores indicating better problem solving skills. The SPSI-R has strong psychometric properties [ 10 ]. In the present study, Cronbach’s α ranged from 0.82–0.87. We report the effect of treatment on dysfunctional problem solving, constructive problem solving, and total problem solving.

Sample Size and Power Calculations

Data available from previous caregiver studies of PSST allowed us to conduct sample size calculations on parent depressive symptoms at post-treatment under the assumptions that the primary purpose of this pilot study is to examine feasibility and produce estimates of effect sizes to power a future larger scale trial. Therefore we sought to calculate estimates of effect sizes with confidence intervals less precise than for a definitive large-scale trial. Based on previous studies of PSST in caregivers [ 41 – 43 , 48 ] we calculated a standardized mean difference (SMD) across these trials for change in caregiver depressive symptoms to be −0.83 with 95% CI of −1.51 to −0.14. This effect size would be considered large per Cohen [ 7 ]. Using this estimate, the probability of detecting a true difference at a two-sided .05 significance level is 81% with a total sample size of 50. Based on estimates of sample attrition, we sought to enroll 61 parents to achieve a sample size of 50, which would allow us to test the primary study hypotheses with sufficient power and to create effect size estimates for a future larger scale trial.

Data Analysis Plan

Data analyses were conducted using IBM SPSS v21 [ 46 ]. Measures were scored and missing items addressed per the scoring manual for each measure. When scoring manuals did not include specific instructions to address missing items, mean imputation was used to replace missing items when at least 80% of items were completed. Overall missingness was very low. Descriptive statistics were used to summarize the demographic characteristics of the sample. For categorical variables frequency statistics are reported, and for continuous variables we report means and standard deviations. Table 1 shows demographic characteristics of the sample. Table 2 shows means and standard deviations for process and outcome variables at pre-treatment, post-treatment and three-month follow-up. Table 3 provides all coefficient estimates from the multilevel modeling analyses testing the group × time treatment effect for each outcome from baseline to post-treatment and baseline to 3-month follow-up.

Parent and child demographic characteristics at baseline (pre-randomization)

Unadjusted Descriptive Statistics on Primary and Secondary Treatment Outcomes by Treatment Condition

Linear Growth Models Testing Treatment Effects for Parent and Child Treatment Outcomes

Independent samples t -tests with Bonferroni correction and chi-square analyses were conducted to confirm that randomization produced equal groups. We also used independent samples t -tests to examine group differences on treatment expectancies at pre-treatment. For parents in the PSST group, we examined treatment engagement and treatment satisfaction/acceptability using descriptive statistics.

Multilevel modeling (MLM) procedures were used to test primary hypotheses for continuous outcomes. MLM accounts for repeated measures within subjects, accommodates missing observations, and includes all available observations in analyses. Procedures for linear growth model specifications were based on Shek and Ma [ 45 ]. Assessment wave (baseline, post-treatment, follow-up) was treated as a categorical variable and baseline values were specified as the reference point so that results were interpreted as change from baseline to immediate post-treatment and baseline to three-month follow-up. A full conditional model tested the effects of wave, treatment group, and a group × wave interaction. The group × wave interaction represents the change from baseline to post-treatment and the change from baseline to three-month follow-up for the PSST group relative to the TAU group. Separate linear growth model analyses were conducted for each outcome variable. In Table 3 , we report the beta and effect size for the group × wave interaction for each outcome variable at post-treatment and at three-month follow-up.

We calculated effect size estimates for the pre-post treatment design using recommendations put forth by Feingold [ 19 ]. Effect sizes (reported as Cohen’s d) were calculated for the group × wave interactions. Guidelines to interpret the effect size estimates are as follows: d = 0.20 indicates a small effect, d = 0.50 indicates a medium effect, and d = 0.80 indicates a large effect (Cohen [ 6 ]). Because this is a pilot RCT we provide 95% CI effect size estimates on all outcomes (see Table 3 ). For this pilot trial, a significance level of .05 was used for all analyses.

Descriptive Statistics

Participants included 61 parents and their children with chronic pain. Children were between the ages of 10 and 17 years (M = 14.3, SD = 1.9) and parents were between the ages of 32 and 67 years (M = 45.7, SD = 6.8). Parents and children were primarily female (98.4% and 80.3%, respectively), Caucasian (93.4%, 90.2%, respectively), and middle class as indicated by annual household income between 50 , 000 a n d 100,000 (38%). The majority of parents had completed a college education or higher (65.6%). Demographic characteristics for parents and children in each treatment group are presented in Table 1 . Children had pain on average for two years and reported various chronic pain conditions including musculoskeletal pain (41%), abdominal pain (29.5%), and headache (29.5%). Most children (70%) reported experiencing daily pain.

Tests of Group Equivalence

Independent samples t-tests and chi-square tests indicated that participants in the two groups did not differ on any demographic characteristics (see Table 1 ) or on the BSI Global Severity Index score ( p’ s > 0.05). The two groups were also similar on all outcome variables at pre-treatment ( p ’s > 0.05). Non-participants were similar to participating children on age and sex ( p ’s > 0.05). Only two participants dropped out of the study, and there were no differences from those who completed the study.

Treatment Expectancies

Independent samples t-test indicated there was no difference in treatment expectancies between groups, p > .05.

Treatment Satisfaction and Acceptability

Parents in the PSST group reported high satisfaction and acceptability for the intervention immediately post-treatment and at three-month follow-up. Mean ratings on the TEI were over 27 (post-treatment M = 33.9, SD = 7.3, follow up M = 34.5, SD = 6.1) indicating that treatment was rated as acceptable by parents. Treatment satisfaction and acceptability ratings were not completed by parents in the TAU group.

Parents in the PSST group completed an average of 5.23 treatment sessions ( SD = 0.72, range = 4–6). Therapists rated parents as highly motivated to learn ( M = 8.0, SD = 1.5, range = 6–10), receptive to learning ( M = 8.1, SD = 1.6, range = 3–10), and with good understanding of the PSST process ( M = 7.9, SD = 1.5, range = 4–10). Therapists rated their rapport with parents as generally strong ( M = 8.3, SD = 1.0, range = 5–10).

As shown in Table 3 , the PSST group demonstrated greater reductions in depression (BDI-II) compared to the TAU group at post-treatment that approached significance ( b = −4.91, p = 0.06, d = −0.68, 95% CI [−1.39, 0.03]) which was a medium effect. However, this difference was not maintained at 3-month follow-up. On the POMS total mood disturbance scale there were no effects of treatment on transitory mood through post-treatment or follow-up.

On the BAPQ-PIQ depression scale and the BAPQ-PIQ anxiety scale, there were no between-groups differences through post-treatment. However, through follow-up, the PSST group had greater reductions in both depression and anxiety symptoms compared to the TAU group and this approached significance ( b = −3.54, p = 0.07, d = −0.57, 95% CI [−1.17, 0.04]; b = −3.18, p = 0.05, d = −0.67, 95% CI [−1.33, −0.01], respectively), which were medium effects.

The PSST group had significantly greater reductions in pain catastrophizing (PCS-P) compared to the TAU group through post-treatment and follow-up ( b = −4.09, p = 0.03, d = −0.48, 95% CI [−0.92, −0.04]; b = −4.68, p = 0.02, d =−0.52, 95% CI [−0.95, −0.10], respectively), which were medium effects.

General Parent Health and Well-being Outcomes

On the SF-12 physical health scale, there were no treatment effects through post-treatment. However, through follow-up, the PSST group had greater improvement in physical health relative to the TAU group that approached significance ( b = 4.48, p = 0.08, d = 0.37, 95% CI [−0.04, 0.78]), which was a small effect. On the SF-12 mental health scale, the PSST group had significantly greater improvement in mental health symptoms compared to the TAU group through post-treatment ( b = 7.52, p = 0.01, d = 0.64, 95% CI [0.15, 1.14]), which was a medium effect. This effect was not maintained through follow-up.

On the PSI Total Parenting Stress scale, there were no between-groups differences through post-treatment or follow-up.

On the BAPQ-PIQ parent behavior scale, there was no between-groups difference through post-treatment. However, through follow-up, the PSST group had a significantly greater decrease in problematic parent behaviors compared to the TAU group ( b = −7.02, p < 0.001, d = −1.14, 95% CI [−1.72, −0.55]), which was a large effect.

On the HHI, the PSST group had a significantly greater decrease in child-report of miscarried helping through post-treatment compared to the TAU group ( b = −5.99, p = 0.05, d = −0.60, 95% CI [−1.19, 0]), which was a medium effect. This was not maintained through follow-up. On the parent-report HHI, there were no between-group differences through post-treatment or follow-up.

In examining downstream effects of PSST intervention on child outcomes, there were no between-groups differences through post-treatment or follow-up on children’s usual pain intensity scores or on child functional impairment (social functioning and physical functioning) through post-treatment and follow-up.

However, PSST was associated with improvements in child mental health outcomes. On the BAPQ depression scale and the BAPQ general anxiety scale, children whose parents received PSST had greater decreases in symptoms compared to children whose parents received TAU through post-treatment and this approached significance ( b = −2.56, p = 0.06, d = −0.49, 95% CI [−1.00, 0.02]; b = −3.18, p = 0.05, d = −0.56, 95% CI [−1.10, −0.01], respectfully), which were medium effects. There were not between-groups differences on either scale through follow-up. Similarly, children in the PSST group had a significantly greater decrease in pain-specific anxiety compared to the TAU group through post-treatment ( b = −4.54, p = 0.008, d = −0.82, 95% CI [−1.41, −0.22]), which was a large effect. There was no between-groups difference on BAPQ pain-specific anxiety scores through follow-up.

There were no study-related adverse events reported by participants during the course of the trial in either treatment group. When we collected adverse events at each assessment period, several participants reported major life events and stressors (e.g., hip replacement surgery). However, these were described by parents as being unrelated to study procedures.

The SPSI-R was used as a process measure. On dysfunctional problem solving, there were no between-groups differences through post-treatment or follow-up. However, PSST was associated with improvements in constructive problem solving and total problem solving scores. Parents in the PSST group had a greater increase in constructive problem solving compared to the TAU group through post-treatment that approached significance ( b = 6.09, p = 0.07, d = 0.34, 95% CI [−0.03, 0.72]), which was a small to medium effect. This was not maintained through follow-up. For total problem solving scores, there was no between-groups difference through post-treatment. However, at follow-up, the PSST group had a greater improvement in total problem solving relative to the TAU group that approached significance ( b = 0.67, p = 0.09, d = 0.29, 95% CI [−0.05, 0.62]), a small effect.

This is the first pilot RCT of problem solving skills training in parent caregivers of youth with chronic pain. Although our participation rate for entering the trial was only moderate, the families who agreed to participate stayed in the trial (97%) and were compliant with 4–6 individual sessions of PSST. Parents reported satisfaction with treatment, and were willing to complete outcome assessments. Taken together, these results indicate feasibility in delivering PSST to parents of children with chronic pain.

We also examined preliminary efficacy of PSST compared to usual care on parent and child outcomes. Our hypothesized effects on parent outcomes were partially supported. PSST was associated with improvements on our primary outcome of parent depression at post-treatment and in some other areas of general and pain-specific parent mental health, well being, and behavior. Although children were not involved in PSST treatment, several downstream effects of PSST on child outcomes were found. Specifically, children whose parents received PSST had improved emotional functioning (depression, general anxiety, and pain-specific anxiety) post-treatment compared to children whose parents received usual care. However, there were no effects found on children’s pain or daily functioning. Effect sizes ranged from small to large across outcomes, and confidence intervals for effect sizes were wide. Most changes were not maintained at follow-up.

In a recent Cochrane review of published trials of PSST in children with chronic medical conditions [ 15 ], treatment was also associated with improved parent mental health and behavior with similar small effect sizes; however there were no treatment effects observed on child outcomes. In contrast, our study found small improvements in child mental health outcomes. Although results from this pilot trial should be interpreted cautiously, our findings are consistent with Palermo and Chambers’ [ 36 ] conceptual model of parent and family influences on chronic pain in children. This model highlights the interrelationship between parent and child functioning, and suggests that downstream effects on child outcomes can be achieved by directly targeting parent distress. Existing behavioral interventions for this population focus primarily on cognitive-behavioral skills training for children and do not address parent mental health [ 20 ]. Treatment approaches such as PSST that directly target parent distress may contribute to positive outcomes for children with chronic pain and their families. Future research is needed to determine whether added benefit can be obtained from combining parent PSST with other effective child pain-focused CBT interventions where children are learning pain management skills concurrently. It is possible that synergy between the two interventions would produce more powerful sustained effects on relevant child and parent outcomes. Future trials should also document health services and cost of treatment to understand whether PSST is associated with improvements in health service use and cost reduction.

We examined parent problem solving abilities as a process measure in this pilot trial, and found that PSST produced only small effects. The process measure of problem solving abilities (SPSI-R) used does not have clinical cut-points, and so we are not able to determine whether parents had clinically significant impairments in problem solving skills at baseline that could have improved with treatment. In particular, because our sample had a high portion of college-educated parents the problem-solving skills may have been better than average at the start of the trial. Interestingly, despite the availability of a validated and standardized measure of problem solving abilities, this domain is not routinely assessed in clinical trials of PSST. For example, in a recent meta-analysis only 4 of 12 prior RCTs of PSST for parent caregivers of children with chronic medical conditions reported on change in parents’ problem solving abilities [ 15 ]. We encourage future research in this area to include assessment of parent problem solving abilities to further understanding of the mechanisms underlying this intervention. It will also be important to examine the effects of PSST in more socioeconomically diverse samples of parents.

There may also be other treatment mechanisms to consider in future trials of PSST. In particular, the support received from the therapist, normalization of the stress experienced by parents of children with chronic pain (e.g., via the “common problems” worksheet), or other non-specific therapeutic effects may contribute to positive outcomes. The PSST intervention might also serve to improve parent-child interaction patterns and increase psychological flexibility, which may be important for change in the context of chronic pain [ 33 ]. Future trials of PSST should include measurement of other key process variables.

In contrast to previous trials of PSST for parents of children with other chronic illnesses, we delivered treatment in just 4–6 sessions rather than 6–8 sessions. Although our initial adaptation of the intervention led us to determine that a shorter intervention would be more feasible to deliver [ 37 ], parents of youth with chronic pain differ in important ways from populations evaluated in these previous trials (e.g., children with newly diagnosed cancer; Sahler et al., 2005). In our sample, the children had chronic pain for an average of 2 years and most parents (56.6%) had clinically elevated symptoms of depression. Given the chronicity of problems faced by families of children with chronic pain, it is possible that these caregivers may actually require more rather than less treatment compared to other pediatric populations. Although additional or booster treatment sessions could result in larger effects on parent and child outcomes, the burden and demand of additional sessions may also have a negative impact on feasibility of treatment delivery. Further research is needed to determine the optimal dose of PSST treatment for parents of children with chronic pain.

A goal of our pilot RCT was to test a range of outcome measures in order to help define appropriate outcomes for a future large definitive trial. Prior studies of PSST have used various domains of measurement including health-related quality of life, parent mental health, child medical symptoms, parent behaviors, family functioning, and parenting skills. It is challenging to make direct comparisons between studies due to the variability in specific measures used and lack of consensus about outcome measures for PSST trials [ 17 ]. We included both general measures and pain-specific measures in order to determine change in particular areas of mental health and well-being that may be most relevant to our patient population. Indeed, some pain-specific variables (e.g., pain catastrophizing) demonstrated changes in parents receiving PSST compared to TAU. However, overall there was a lack of consistent pattern in findings observed in our pilot RCT. In future trials of PSST, investigators will need to select appropriate outcome domains and balance the issue of defining independent outcomes within each measurement domain. Based on our pilot RCT, in future definitive trials, we recommend inclusion of the outcome domains of parent mental health (with general parent depressive symptoms as a primary outcome), child mental health, child symptoms (e.g., pain), and behavior (e.g., parent behavior, child pain-related functioning).

The study sample was mostly comprised of mothers and thus our experience delivering PSST to fathers is limited. Although both parents were invited to be involved in PSST sessions, most often, mothers chose to attend treatment alone. Qualitative research with parents of youth with chronic pain involving mothers has emphasized the negative and burdensome experience of parenting a child with chronic pain [ 26 ]. However, fathers of youth with chronic pain [ 25 ] may have a different experience. In a larger trial, it is possible that participating adults may include a larger number of fathers. However, acquiring participation from fathers is a problem in the field and may need to be addressed with increased flexibility in timing and mode of treatment delivery (e.g., offering internet-based treatment).

Our findings should be interpreted in light of several study limitations. This was a pilot RCT and was only powered to detect medium to large effects. Thus we were underpowered to detect small effects. Fitting with our proof of concept pilot RCT design, we included a usual care rather than an attention control comparison arm, which limited our ability to determine the source of the treatment effect. Future studies are needed in larger, more definitive trials with attention control groups. The sample is small and may not be representative of the broader population of parents of children with chronic pain. Because we conducted only short-term follow up, durability of treatment effects are unknown. Children in our trial were not receiving a consistent form of pain treatment and therefore it is difficult to understand any potential synergy between PSST and other child-focused treatment interventions. This remains an important area for future research to understand whether parent treatment with PSST might enhance child or family-focused treatment.

Clinical implications of our findings highlight the importance of including parents in treatment of childhood chronic pain. Applying interventions to reduce parent distress and to support parent coping skills is feasible and parents desire this form of treatment. At this point, a definitive test of the efficacy of PSST on parent mental health and child pain outcomes is needed. Long term effects should be measured as maintenance of treatment gains is critically important in pediatric chronic pain management where children have symptoms for many years.

  • Acknowledgments

The authors thank the parents and youth who participated in the study. We are also grateful for the contributions of the late Dr. Robert Butler who advised on the treatment protocol and to Drs. Andrew Riley and Bonnie Essner who served as study therapists. Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD065180 (PI: Palermo). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of Interest . None of the authors have any conflicts of interest.

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Law EF , Fales JL , Beals-Erickson SE , Failo A , Logan D , Randall E , Weiss K , Durkin L , Palermo TM

J Pediatr Psychol , 42(4):422-433, 01 May 2017

Cited by: 13 articles | PMID: 27744343 | PMCID: PMC6075428

An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT.

Day C , Briskman J , Crawford MJ , Foote L , Harris L , Boadu J , McCrone P , McMurran M , Michelson D , Moran P , Mosse L , Scott S , Stahl D , Ramchandani P , Weaver T

Health Technol Assess , 24(14):1-188, 01 Mar 2020

Cited by: 2 articles | PMID: 32174297

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An intervention to improve the quality of life in children of parents with serious mental illness: the Young SMILES feasibility RCT.

Abel KM , Bee P , Gega L , Gellatly J , Kolade A , Hunter D , Callender C , Carter LA , Meacock R , Bower P , Stanley N , Calam R , Wolpert M , Stewart P , Emsley R , Holt K , Linklater H , Douglas S , Stokes-Crossley B , Green J

Health Technol Assess , 24(59):1-136, 01 Nov 2020

Cited by: 3 articles | PMID: 33196410

Psychological interventions for parents of children and adolescents with chronic illness.

Eccleston C , Palermo TM , Fisher E , Law E

Cochrane Database Syst Rev , (8):CD009660, 15 Aug 2012

Cited by: 30 articles | PMID: 22895990 | PMCID: PMC3551454

Review Free full text in Europe PMC

Eccleston C , Fisher E , Law E , Bartlett J , Palermo TM

Cochrane Database Syst Rev , (4):CD009660, 15 Apr 2015

Cited by: 76 articles | PMID: 25874881 | PMCID: PMC4838404

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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

a child is receiving problem solving skills training as a treatment

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

a child is receiving problem solving skills training as a treatment

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

  • Applying a positive problem-solving orientation to your life
  • Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

  • Knowing how to identify a problem
  • Defining the problem in a helpful way
  • Trying to understand the problem more deeply
  • Setting goals related to the problem
  • Generating alternative, creative solutions to the problem
  • Choosing the best course of action
  • Implementing the choice you have made
  • Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

  • Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
  • Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
  • Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
  • Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

  • Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
  • Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
  • Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

  • Chronic stress due to accumulating minor issues
  • Complications associated with traumatic brain injury (TBI)
  • Emotional distress
  • Post-traumatic stress disorder (PTSD)
  • Problems associated with a chronic disease like cancer, heart disease, or diabetes
  • Self-harm and feelings of hopelessness
  • Substance use
  • Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

  • Death of a loved one
  • Dissatisfaction at work
  • Everyday life stressors
  • Family problems
  • Financial difficulties
  • Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

  • Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
  • Confidence that you can handle problems that you face
  • Having a systematic approach on how to deal with life's problems
  • Having a toolbox of strategies to solve the issues you face
  • Increased confidence to find creative solutions
  • Knowing how to identify which barriers will impede your progress
  • Knowing how to manage emotions when they arise
  • Reduced avoidance and increased action-taking
  • The ability to accept life problems that can't be solved
  • The ability to make effective decisions
  • The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

  • Older adults
  • People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

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Problem Solving Skills Training for Parents of Children with Chronic Pain: A Pilot Randomized Controlled Trial

Tonya m. palermo.

1 University of Washington

2 Seattle Children’s Research Institute

Emily F. Law

Maggie bromberg, jessica fales.

3 Washington State University, Vancouver

Christopher Eccleston

4 University of Bath

Anna C. Wilson

5 Oregon Health & Science University

This pilot randomized controlled trial aimed to determine the feasibility, acceptability, and preliminary efficacy of parental problem solving skills training (PSST) compared to treatment as usual (TAU) on improving parental mental health symptoms, physical health and well-being, and parenting behaviors. Effects of parent PSST on child outcomes (pain, emotional and physical functioning) were also examined. Participants included 61 parents of children aged 10–17 years with chronic pain randomized to PSST (n = 31) or TAU (n = 30). Parents receiving PSST participated in 4–6 individual sessions of training in problem solving skills. Outcomes were assessed at pre-treatment, immediately post-treatment, and at 3-month follow up. Feasibility was determined by therapy session attendance, therapist ratings, and parent treatment acceptability ratings. Feasibility of PSST delivery in this population was demonstrated by high compliance with therapy attendance, excellent retention, high therapist ratings of treatment engagement, and high parent ratings of treatment acceptability. PSST was associated with post-treatment improvements in parental depression ( d = −0.68), general mental health ( d = 0.64), and pain catastrophizing ( d = −0.48), as well as in child depression ( d = −0.49), child general anxiety ( d = −0.56), and child pain-specific anxiety ( d = −0.82). Several effects were maintained at 3-month follow-up. Findings demonstrate that PSST is feasible and acceptable to parents of youth with chronic pain. Treatment outcome analyses show promising but mixed patterns of effects of PSST on parent and child mental health outcomes. Further rigorous trials of PSST are needed to extend these pilot results.

Introduction

Chronic pain is as prevalent in childhood as adulthood, with 8% of children reporting severe pain and disability [ 24 ]. Pediatric chronic pain is embedded in a broader context of parent and family factors that may directly or indirectly influence the child’s adjustment and coping with pain [ 36 ]. For example, higher levels of parental psychological distress [ 32 ] and less healthy family functioning [ 31 , 38 ] are associated with greater child pain-related disability. In addition, parents are themselves affected by caring for a child with chronic pain which may lead to changes in their own psychological and behavioral functioning. Many parents of children with chronic pain report clinically significant role stress, anxiety, and depressive symptoms [ 14 ]. Therefore, interventions that alleviate parent distress may also improve health and well-being for children with chronic pain.

Interventions have been developed and evaluated for parents of children with chronic medical conditions [ 3 , 13 , 30 ]. In a Cochrane review on this topic [ 15 ], problem-solving skills training (PSST) interventions were effective in reducing distress (i.e., improving parental mental health) in parents of children with chronic conditions (e.g., cancer, asthma). In contrast, there was no evidence for the effectiveness of cognitive-behavioral, family, or multi-systemic therapy in improving parental mental health or behavioral outcomes. PSST is based on the social problem-solving model of D’Zurilla and Nezu [ 8 , 9 ] and is hypothesized to change interpersonal interactions and behaviors associated with stress. Efficacy of PSST has been evaluated in caregivers of both adult and pediatric medical populations, gaining considerable empirical support, e.g., [ 41 , 43 , 44 ], but had not been applied to chronic pain. Thus, our research team adapted an existing PSST intervention developed for caregivers of children with cancer [ 43 ] for caregivers of children with chronic pain [ 37 ]. In line with prior studies of PSST, we also sought to evaluate the effects of PSST alone (without other interventions) in order to specifically test the preliminary benefits achieved by PSST.

Although parent interventions have been included in pediatric cognitive-behavioral pain interventions [ 20 ], their purpose has been to modify parent behavior that may inadvertently reinforce maladaptive coping (such as teaching parents to reward activity participation) based on social learning theory. Most typically, interventions directed towards parents have been brief (e.g., 1–2 sessions) and do not aim to modify parent distress [ 20 ]. Thus, applying interventions only to parents and directed toward reducing parental distress is novel in this population.

In this pilot RCT we aimed to determine feasibility, acceptability, and preliminary efficacy of PSST versus treatment as usual (TAU) for parents of children with chronic pain. We hypothesized that feasibility would be shown by high levels of participation, retention, and high ratings of intervention acceptability. We hypothesized that PSST would impact both parent and child outcomes at post-treatment and 3-month follow-up. Specifically, parents receiving PSST would report improved mental health symptoms, health and well-being, and more adaptive parenting compared to parents receiving TAU; children of parents receiving PSST would report decreased pain and improved physical and emotional functioning compared to children of parents receiving TAU.

Participants

Participants were 61 parents and their children aged 10–17 years with chronic pain. The clinical trial was registered and the full protocol is available (PSST; Problem Solving Skills Training for Parent Caregivers of Youth with Chronic Pain, ClinicalTrials.gov Identifier {"type":"clinical-trial","attrs":{"text":"NCT01496378","term_id":"NCT01496378"}} NCT01496378 ). Parent-child dyads were enrolled from May 2012 to October 2014 from two interdisciplinary pediatric pain clinics (Seattle Children’s Hospital and Oregon Health and Science University); follow up data were complete by May 2015. The study was approved by each site’s Institutional Review Board.

We have published one paper concerning adaptation and initial piloting of PSST for parents of youth with chronic pain [ 37 ]; however, that paper did not include any of the participants or outcome analyses of the pilot randomized controlled trial results presented here.

Inclusion/Exclusion Criteria

Inclusion criteria for the trial were: 1) parent of a child between the ages of 10 and 17 years with chronic pain, 2) child’s pain of a duration ≥ 3 months and interfering with daily functioning, 3) child received evaluation for chronic pain from one of the two pain clinics, and 4) parents were English-speaking. Exclusion criteria were: 1) child diagnosed with a serious comorbid health condition (e.g., cancer), 2) parent resided with child for < 1 year, and 3) parent had serious or life-threatening mental health issues (e.g., active psychosis, suicidal ideation).

Recruitment

Providers at the two pain centers gave potential participants a flyer about the study and asked if they would be willing to be contacted by study staff to learn more about the study and receive additional screening. Providers then sent potential participant’s contact information to study staff via secure email. Potential participants could also contact study staff directly by calling a phone number provided on the study flyer. Study staff screened for eligibility and held a consent conference with parents and children by telephone. Parents signed the consent forms and returned them to study staff. Children signed assent forms for their study participation.

Trial Design and Randomization

This pilot clinical trial used a balanced (1:1) randomized parallel group design. Assessments were sent to participants’ homes and were returned to study staff via postal mailings. Assessments were completed at pre-randomization (baseline), immediately post-treatment (6–8 weeks), and at 3-month follow-up. A fixed allocation randomization scheme was used. Order of randomization to the two treatment conditions was generated separately for each site with an online program (randomizer.org). A blocked method design was used, with blocks of 4 for each ID number. Using the output provided by the online program, study staff created a password protected electronic document that linked each ID number to a group assignment. Only the research coordinator had the password to the randomization table. Group assignment was concealed by formatting the document to block out group assignment until the time of randomization. Following completion of pre-treatment assessments, the research coordinator revealed participants’ group assignment. Interventionists were informed when participants were allocated to the active treatment group, and they contacted parents directly to schedule the first treatment session. Participants allocated to the TAU group were contacted by the research coordinator and were provided with instructions to continue with their usual care during the treatment phase. Thus, participants were not blinded to their group assignment. All study assessments were self-report measures completed in participants’ homes via mailings; children and parents were instructed to complete measures independently.

Figure 1 shows a CONSORT diagram depicting the flow of study participants through each phase of the study. Referrals were received from the two pain clinics for 151 families of youth with chronic pain. Of those families who were referred to participate, a total of 90 were excluded: 7 did not meet eligibility criteria because the child had a serious comorbid chronic medical condition, 58 declined participation due to lack of time and/or travel burden to the treatment center, 22 were unable to be reached during the recruitment period, and 3 were unable to be reached to complete pre-treatment assessments (passive refusals). The final sample consisted of 61 families. Demographics (child age and sex) did not differ between those families who did and did not choose to participate.

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The 61 eligible families were randomly assigned to PSST ( n = 31) or TAU ( n = 30). All 31 families who were randomized to PSST received the allocated intervention. One participant did not complete the immediate post-treatment assessment ( n = 0 PSST, n = 1 TAU). An additional participant did not complete the three-month follow-up assessment ( n = 0 PSST, n = 1 TAU) for an overall retention rate of 97%. All enrolled participants were included in final analyses, including 31 participants from the PSST group and 30 participants from the TAU group.

All child participants were patients who had received evaluation and treatment in one of the two collaborating interdisciplinary pain clinics. Resulting from this evaluation, participants may have received recommendations for treatment. These usual care recommendations were not altered for the clinical trial. All study-related procedures and interventions were adjunctive to the usual care participants received in their pain clinic. Parents and children were provided with study incentives (giftcards) following each completed assessment.

Participants completed all assessments in their homes and then returned the questionnaires to study staff via postal mailings. After study staff received the completed pre-treatment assessment, participants were randomized to PSST or TAU.

Parents assigned to the intervention condition received PSST as adapted for parents of children with chronic pain[ 37 ] in addition to the usual care their child received in pain clinic. This was a parent only intervention and the children did not participate. Our intervention was adapted from treatment materials developed by Sahler and colleagues [ 43 ] for caregivers of children with cancer (“ Bright IDEAS ”). Drawing from D’Zurilla and colleagues’ conceptualization of effective problem solving ability [ 8 , 9 ], Sahler et al.’s intervention emphasizes a positive problem-solving orientation characterized by optimism and problem-solving self-efficacy ( Bright ), as well as the major components of rational problem solving. These include problem definition and formulation ( I dentify the Problem ), generation of alternative solutions ( D etermine the options ), decision-making ( E valuate options ), solution implementation ( A ct ), and verification ( S ee if it worked ). Content was modified to be relevant to parents of children with chronic pain, including removal of references and examples specific to cancer and the addition of examples specific to chronic pain. Additional modifications included the creation of a list of common challenges faced by caregivers of youth with chronic pain and a booklet illustrating the problem-solving process using a vignette of a family with a child with chronic pain (see [ 37 ], for details).

In our initial pilot testing of the intervention [ 37 ], we found that parents learned problem solving skills quickly and were rated by therapists as ready to terminate within 4–6 sessions. In addition, we found that it was difficult for parents to schedule 8 sessions in an 8 week intervention period. Thus, we made the decision to shorten treatment to be delivered in 4 to 6 sessions, and telephone sessions were included as a mode of treatment delivery in an effort to increase feasibility of treatment. However, few parents made use of telephone sessions in the pilot RCT (24 out of 167 total sessions; 14%).

Sessions were designed to be delivered individually over one hour, and were conducted in the order prescribed by the treatment manual. The goal of the first session was to orient the caregiver to the intervention and establish rapport. Parents were asked to tell the story of their child’s pain, with follow-up prompts regarding how having a child with pain impacted various aspects of their lives (i.e., family functioning, emotional functioning, finances). They were provided with an overview of the intervention and a copy of the manual, which included the problem-solving vignette. Subsequent sessions focused on developing a positive problem solving orientation and learning how to enact the rational problem-solving skills. Therapists first presented a description and rationale for each skill and then encouraged the caregiver to enact the skill in session, with the aid of manualized worksheets. Training in positive problem solving orientation included education about the importance of a positive outlook when solving problems as well as instruction in cognitive restructuring when a negative problem solving orientation was identified. Parents completed a worksheet in which common problems experienced by families with chronic pain were listed (e.g., financial problems, lack of time for social activities, worry about their child, relationship problems). Therapists could use this worksheet to help parents choose problems to address in sessions. Example problems that parents worked on in sessions included dealing with sibling jealousy over time spent with the child with chronic pain, communication with school personnel about the child’s pain, and negative communications and interactions with their child.

The subsequent steps of problem solving were taught using behavioral rehearsal, role play, and positive reinforcement. Therapists could also provide brief training in abdominal breathing when parents generated a solution that involved the study therapist teaching them how to relax. At the end of each session, parents were provided with a take-home assignment, which was then closely reviewed and discussed in the following session. The full treatment manual can be obtained from the first author.

Treatment as Usual

Parents and children continued with the care that was prescribed by the pain clinic for their child’s pain problem. Care was not altered by participation in this pilot RCT. Clinical recommendations may have included physical therapy, psychological therapy, medication management, and/or complementary and alternative modalities such as acupuncture. Families may also have chosen to not pursue any other treatments. PSST is not a part of usual clinical care and was not offered to parents at either collaborating pain center.

Therapists, Supervision, and Treatment Fidelity

Four therapists were postdoctoral psychology fellows and two were licensed clinical psychologists, all of whom had formal training and experience in treatment of pediatric chronic pain. Therapists underwent a didactic training that was delivered in a group and individual format including review of treatment materials and role-play of treatment sessions with a trained therapist. All sessions were audio-recorded. After each session, therapists completed a fidelity record detailing the problems parents chose to address during the session, progress in acquisition of specific problem-solving skills, and tasks assigned for homework. Cross-site group supervision occurred weekly via conference call or individually with a licensed clinical psychologist (EL) who had experience in PSST to review sessions and compliance to the manual.

Treatment Acceptability and Satisfaction

At post-treatment and three-month follow-up, parents in the PSST group completed an adapted version of the Treatment Evaluation Inventory-Short Form [ 28 , 29 ], a 9-item scale designed to assess acceptability and satisfaction with the treatment process and outcomes. Select items were adapted to be specific to pediatric pain (e.g., “I find this treatment to be an acceptable way of dealing with children’s pain”). Items are rated on a 5-point Likert type scale, ranging from 1 ( Strongly Disagree ) to 5 ( Strongly Agree ). Items are summed to create a total score ranging from 9–45, with higher scores indicating greater treatment acceptability and satisfaction. “Moderate” treatment satisfaction and acceptability is indicated by a score of 27 or higher [ 28 ]. This measure has demonstrated good reliability and validity [ 29 ].

Treatment Feasibility

Feasibility of delivering PSST to parents with chronic pain was assessed by documenting the number of sessions completed by parents as well as therapist ratings of parent motivation to learn, receptivity to learning, understanding of the PSST process, and rapport. At the end of each session, therapists completed these ratings on 0–10 Likert scales, which were averaged across sessions.

Pre-treatment Measures

Demographics.

Parents completed an information form to assess their relationship to the child (i.e., biological mother, father), family composition, marital status, race, and education. Parents also provided information regarding their child’s age, sex, and race.

Psychological distress

The Brief Symptom Inventory 18 (BSI 18) [ 11 ] was used to screen for parent psychological distress and psychiatric disorders at pre-treatment. Parents rate their level of distress over the past week using a 5-point scale ranging from 0 ( not at all ) to 4 ( extremely ). Items are summed to create a Global Severity Index. The BSI 18 has demonstrated strong validity and reliability [ 11 ]. In the present study, Cronbach’s α was 0.84 for the global severity index score.

Selection of Outcome Measures

A goal of our pilot trial was to determine optimal measurement tools for parent behavior and mental health outcomes to inform a future larger definitive trial. To achieve this goal, where possible we administered two types of measures within each parent outcome domain: 1) general measures that have been used in previous trials of PSST with other caregiver populations, and 2) measures specifically developed for use with parents of children with chronic pain. Consistent with prior trials of PSST [ 41 – 43 , 48 ], our primary outcome used for estimating sample size was a general measure of parent depressive symptoms.

Parent Mental Health Outcomes

General parent mental health.

The primary outcome was parent depression as measured by the Beck Depression Inventory-II (BDI-II) [ 4 ]. The BDI-II is a 21-item questionnaire that assesses the presence and severity of depressive symptoms over the preceding two weeks. Items are rated on a 4 point scale, ranging from 0 to 3. Items are summed to create a total score, with higher scores indicating greater depressive symptom severity. The psychometric properties of the BDI-II have been extensively evaluated, with consistently strong support for its validity and reliability (e.g., [ 2 , 12 ]). In the present study, Cronbach’s α ranged from 0.85–0.94.

The Profile of Mood States-Standard (POMS) [ 34 ] was used as a secondary outcome to assess transitory mood. The POMS is a 65-item questionnaire that assesses transitory mood states (i.e., exhausted, relaxed). Items are rated on a 5 point Likert type scale ranging from 0 to 4, with higher scores indicating more intense mood during the past week. Items load onto six subscales: Tension-Anxiety, Anger-Hostility, Fatigue-Inertia, Depression-Dejection, Vigor-Activity, and Confusion-Bewilderment. Subscale scores are summed to create a Total Mood Disturbance score. In the present study, we report the effect of treatment on the Total Mood Disturbance score. The POMS has strong psychometric properties [ 35 , 40 ]. Cronbach’s α ranged from 0.91–0.92 in the present study.

Pain-specific parent mental health

Secondary pain-specific mental health outcomes included subscales from the Bath Adolescent Pain-Parental Impact Questionnaire (BAPQ-PIQ) [ 27 ] and the Pain Catastrophizing Scale for Parents (PCS-P) [ 21 ]. The BAPQ-PIQ is a 61-item questionnaire designed to assess the impact of caring for a child with chronic pain on parents’ functioning. Items are rated on a 5 point frequency response scale ranging from 0 ( Never ) to 4 ( Always ). Higher scores are indicative of more impaired functioning for all subscales. To reflect pain-specific mental health symptoms, we used scores on the Depression and Anxiety subscales. The BAPQ-PIQ has demonstrated good reliability and validity among parents of youth with chronic pain [ 27 ]. In the present study, Cronbach’s α ranged from 0.88–0.89.

The PCS-P is a 13-item questionnaire designed to assess catastrophic thoughts and feelings about the child’s pain [ 21 ]. Items are rated on a 5 point frequency response scale ranging from 0 to 4, and load onto three subscales: Rumination, Magnification, and Helplessness. Subscale scores are summed to create a Parent Pain Catastrophizing Total score, with higher scores indicative of greater catastrophizing. In the present study, we report the effect of treatment on the Parent Pain Catastrophizing Total score. The PCS-P has demonstrated good reliability and validity among parents of youth with chronic pain [ 21 ]. In the present study, Cronbach’s α ranged from 0.90–0.91.

General Parent Health and Well-being

General parent health and well-being was assessed with the Short Form Health Survey 12 (SF-12) [ 49 ], which is a brief health survey measure to assess functional health and well-being. Items ask about limitations and problems with emotions, health, and functional activities over the prior 4 weeks. The 12 items are combined to calculate physical and mental health summary scores. The SF-12 is a well-established health status measure that has demonstrated adequate content validity, discriminant validity, and test-retest reliability [ 49 ].

Exploratory Parenting Outcomes

General parenting stress.

The Parenting Stress Index-Short Form (PSI-SF) [ 1 ] is a 36-item questionnaire that assesses general parenting stress. Items are rated on a 5 point scale, ranging from 1 to 5, with higher scores indicative of greater difficulties related to parenting. Items load onto 3 subscales: Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child. Subscale scores are summed to calculate a Total Parenting Stress score. Raw scores were transformed to percentile scores for analyses. In the present study, we report on the Total Parenting Stress score. The PSI has demonstrated adequate reliability and validity [ 5 , 23 ]. Cronbach’s α ranged from 0.93–0.95 in the present study.

Pain-specific parent behaviors

Our primary measure of parent behavioral responses to pain was the Parent Behavior subscale of the BAPQ-PIQ [ 27 ]. This subscale contains 11 items about parent behaviors directed at encouraging or discouraging child activity. Items are rated on a 5 point frequency response scale ranging from 0 to 4. Higher scores are interpreted as more problematic parent behaviors. The BAPQ-PIQ has demonstrated good reliability and validity among parents of youth with chronic pain [ 27 ]. In the present study, Cronbach’s α was 0.88.

A secondary measure of parent behavioral responses to pain was the Helping for Health Inventory (HHI) adapted for chronic pain [ 18 , 22 ]. The HHI assesses miscarried helping, a maladaptive interactional process characterized by parents’ attempts to help their child that are met with resistance. Two versions (parent and child) are available that provide perceptions from each viewpoint. Example items include “The more my parents try to involve themselves in my pain, the more I resist their involvement,” and “I find that the more I try to help my child with his/her pain, the more he/she resists my involvement.” Items are rated on a 5 point scale, with higher scores indicative of greater miscarried helping. Items are summed to create an HHI Total score. In the present study, we report parent and child-reported HHI Total scores. The HHI has demonstrated good reliability and validity in pediatric populations, including in outpatient samples of youth with chronic pain [ 18 ]. In the present study, Cronbach’s α was 0.83 (parent) and 0.88 for child report.

Child Physical and Mental Health Outcomes

Pain intensity.

Pain intensity was assessed using a questionnaire previously validated with youth with chronic pain [ 39 ]. Children reported on their average pain intensity over the past month on an 11-point numerical rating scale (NRS), ranging from 0 ( No pain ) to 10 ( Worst pain ). The NRS is recommended for assessment of pain intensity in children and adolescents with chronic pain [ 47 ].

Emotional functioning and functional impairment

Youth completed the Bath Adolescent Pain Questionnaire (BAPQ) [ 16 ], a 61-item questionnaire that assesses the multidimensional impact of chronic pain on children’s functioning. Outcomes representing child emotional functioning outcomes were drawn from three subscales (Depression, General anxiety, Pain-specific anxiety). Child functional impairment was assessed by two subscales (Social functioning, Physical functioning). Items are rated on a 5 point scale, with higher scores indicative of more impaired functioning. The BAPQ was developed for use in clinical populations of youth with chronic pain to evaluate treatment efficacy and has demonstrated good validity and test-retest reliability in outpatient pain samples [ 16 ]. In the present study, Cronbach’s α = 0.85–0.88.

Adverse Events

Participants provided open-ended responses concerning any adverse events occurring during the study at post-treatment and follow up.

Process Measure

Problem-solving.

Parents completed the Social Problem-Solving Skills Inventory-Revised (SPSI-R) [ 10 ], a 52-item questionnaire that assesses a five dimensional model of social problem solving including two types of problem orientation (positive and negative) and three problem-solving styles (rational problem solving, impulsivity-carelessness, and avoidance). A dysfunctional problem solving score was constructed from negative problem solving, avoidance and impulsivity-carelessness scores, and a constructive problem solving score was calculated from positive problem orientation and rational problem solving scores. The SPSI-R total score is the weighted average of the five subscale scores, with higher scores indicating better problem solving skills. The SPSI-R has strong psychometric properties [ 10 ]. In the present study, Cronbach’s α ranged from 0.82–0.87. We report the effect of treatment on dysfunctional problem solving, constructive problem solving, and total problem solving.

Sample Size and Power Calculations

Data available from previous caregiver studies of PSST allowed us to conduct sample size calculations on parent depressive symptoms at post-treatment under the assumptions that the primary purpose of this pilot study is to examine feasibility and produce estimates of effect sizes to power a future larger scale trial. Therefore we sought to calculate estimates of effect sizes with confidence intervals less precise than for a definitive large-scale trial. Based on previous studies of PSST in caregivers [ 41 – 43 , 48 ] we calculated a standardized mean difference (SMD) across these trials for change in caregiver depressive symptoms to be −0.83 with 95% CI of −1.51 to −0.14. This effect size would be considered large per Cohen [ 7 ]. Using this estimate, the probability of detecting a true difference at a two-sided .05 significance level is 81% with a total sample size of 50. Based on estimates of sample attrition, we sought to enroll 61 parents to achieve a sample size of 50, which would allow us to test the primary study hypotheses with sufficient power and to create effect size estimates for a future larger scale trial.

Data Analysis Plan

Data analyses were conducted using IBM SPSS v21 [ 46 ]. Measures were scored and missing items addressed per the scoring manual for each measure. When scoring manuals did not include specific instructions to address missing items, mean imputation was used to replace missing items when at least 80% of items were completed. Overall missingness was very low. Descriptive statistics were used to summarize the demographic characteristics of the sample. For categorical variables frequency statistics are reported, and for continuous variables we report means and standard deviations. Table 1 shows demographic characteristics of the sample. Table 2 shows means and standard deviations for process and outcome variables at pre-treatment, post-treatment and three-month follow-up. Table 3 provides all coefficient estimates from the multilevel modeling analyses testing the group × time treatment effect for each outcome from baseline to post-treatment and baseline to 3-month follow-up.

Parent and child demographic characteristics at baseline (pre-randomization)

Unadjusted Descriptive Statistics on Primary and Secondary Treatment Outcomes by Treatment Condition

Linear Growth Models Testing Treatment Effects for Parent and Child Treatment Outcomes

Independent samples t -tests with Bonferroni correction and chi-square analyses were conducted to confirm that randomization produced equal groups. We also used independent samples t -tests to examine group differences on treatment expectancies at pre-treatment. For parents in the PSST group, we examined treatment engagement and treatment satisfaction/acceptability using descriptive statistics.

Multilevel modeling (MLM) procedures were used to test primary hypotheses for continuous outcomes. MLM accounts for repeated measures within subjects, accommodates missing observations, and includes all available observations in analyses. Procedures for linear growth model specifications were based on Shek and Ma [ 45 ]. Assessment wave (baseline, post-treatment, follow-up) was treated as a categorical variable and baseline values were specified as the reference point so that results were interpreted as change from baseline to immediate post-treatment and baseline to three-month follow-up. A full conditional model tested the effects of wave, treatment group, and a group × wave interaction. The group × wave interaction represents the change from baseline to post-treatment and the change from baseline to three-month follow-up for the PSST group relative to the TAU group. Separate linear growth model analyses were conducted for each outcome variable. In Table 3 , we report the beta and effect size for the group × wave interaction for each outcome variable at post-treatment and at three-month follow-up.

We calculated effect size estimates for the pre-post treatment design using recommendations put forth by Feingold [ 19 ]. Effect sizes (reported as Cohen’s d) were calculated for the group × wave interactions. Guidelines to interpret the effect size estimates are as follows: d = 0.20 indicates a small effect, d = 0.50 indicates a medium effect, and d = 0.80 indicates a large effect (Cohen [ 6 ]). Because this is a pilot RCT we provide 95% CI effect size estimates on all outcomes (see Table 3 ). For this pilot trial, a significance level of .05 was used for all analyses.

Descriptive Statistics

Participants included 61 parents and their children with chronic pain. Children were between the ages of 10 and 17 years (M = 14.3, SD = 1.9) and parents were between the ages of 32 and 67 years (M = 45.7, SD = 6.8). Parents and children were primarily female (98.4% and 80.3%, respectively), Caucasian (93.4%, 90.2%, respectively), and middle class as indicated by annual household income between $50,000 and $100,000 (38%). The majority of parents had completed a college education or higher (65.6%). Demographic characteristics for parents and children in each treatment group are presented in Table 1 . Children had pain on average for two years and reported various chronic pain conditions including musculoskeletal pain (41%), abdominal pain (29.5%), and headache (29.5%). Most children (70%) reported experiencing daily pain.

Tests of Group Equivalence

Independent samples t-tests and chi-square tests indicated that participants in the two groups did not differ on any demographic characteristics (see Table 1 ) or on the BSI Global Severity Index score ( p’ s > 0.05). The two groups were also similar on all outcome variables at pre-treatment ( p ’s > 0.05). Non-participants were similar to participating children on age and sex ( p ’s > 0.05). Only two participants dropped out of the study, and there were no differences from those who completed the study.

Treatment Expectancies

Independent samples t-test indicated there was no difference in treatment expectancies between groups, p > .05.

Treatment Satisfaction and Acceptability

Parents in the PSST group reported high satisfaction and acceptability for the intervention immediately post-treatment and at three-month follow-up. Mean ratings on the TEI were over 27 (post-treatment M = 33.9, SD = 7.3, follow up M = 34.5, SD = 6.1) indicating that treatment was rated as acceptable by parents. Treatment satisfaction and acceptability ratings were not completed by parents in the TAU group.

Parents in the PSST group completed an average of 5.23 treatment sessions ( SD = 0.72, range = 4–6). Therapists rated parents as highly motivated to learn ( M = 8.0, SD = 1.5, range = 6–10), receptive to learning ( M = 8.1, SD = 1.6, range = 3–10), and with good understanding of the PSST process ( M = 7.9, SD = 1.5, range = 4–10). Therapists rated their rapport with parents as generally strong ( M = 8.3, SD = 1.0, range = 5–10).

As shown in Table 3 , the PSST group demonstrated greater reductions in depression (BDI-II) compared to the TAU group at post-treatment that approached significance ( b = −4.91, p = 0.06, d = −0.68, 95% CI [−1.39, 0.03]) which was a medium effect. However, this difference was not maintained at 3-month follow-up. On the POMS total mood disturbance scale there were no effects of treatment on transitory mood through post-treatment or follow-up.

On the BAPQ-PIQ depression scale and the BAPQ-PIQ anxiety scale, there were no between-groups differences through post-treatment. However, through follow-up, the PSST group had greater reductions in both depression and anxiety symptoms compared to the TAU group and this approached significance ( b = −3.54, p = 0.07, d = −0.57, 95% CI [−1.17, 0.04]; b = −3.18, p = 0.05, d = −0.67, 95% CI [−1.33, −0.01], respectively), which were medium effects.

The PSST group had significantly greater reductions in pain catastrophizing (PCS-P) compared to the TAU group through post-treatment and follow-up ( b = −4.09, p = 0.03, d = −0.48, 95% CI [−0.92, −0.04]; b = −4.68, p = 0.02, d =−0.52, 95% CI [−0.95, −0.10], respectively), which were medium effects.

General Parent Health and Well-being Outcomes

On the SF-12 physical health scale, there were no treatment effects through post-treatment. However, through follow-up, the PSST group had greater improvement in physical health relative to the TAU group that approached significance ( b = 4.48, p = 0.08, d = 0.37, 95% CI [−0.04, 0.78]), which was a small effect. On the SF-12 mental health scale, the PSST group had significantly greater improvement in mental health symptoms compared to the TAU group through post-treatment ( b = 7.52, p = 0.01, d = 0.64, 95% CI [0.15, 1.14]), which was a medium effect. This effect was not maintained through follow-up.

On the PSI Total Parenting Stress scale, there were no between-groups differences through post-treatment or follow-up.

On the BAPQ-PIQ parent behavior scale, there was no between-groups difference through post-treatment. However, through follow-up, the PSST group had a significantly greater decrease in problematic parent behaviors compared to the TAU group ( b = −7.02, p < 0.001, d = −1.14, 95% CI [−1.72, −0.55]), which was a large effect.

On the HHI, the PSST group had a significantly greater decrease in child-report of miscarried helping through post-treatment compared to the TAU group ( b = −5.99, p = 0.05, d = −0.60, 95% CI [−1.19, 0]), which was a medium effect. This was not maintained through follow-up. On the parent-report HHI, there were no between-group differences through post-treatment or follow-up.

In examining downstream effects of PSST intervention on child outcomes, there were no between-groups differences through post-treatment or follow-up on children’s usual pain intensity scores or on child functional impairment (social functioning and physical functioning) through post-treatment and follow-up.

However, PSST was associated with improvements in child mental health outcomes. On the BAPQ depression scale and the BAPQ general anxiety scale, children whose parents received PSST had greater decreases in symptoms compared to children whose parents received TAU through post-treatment and this approached significance ( b = −2.56, p = 0.06, d = −0.49, 95% CI [−1.00, 0.02]; b = −3.18, p = 0.05, d = −0.56, 95% CI [−1.10, −0.01], respectfully), which were medium effects. There were not between-groups differences on either scale through follow-up. Similarly, children in the PSST group had a significantly greater decrease in pain-specific anxiety compared to the TAU group through post-treatment ( b = −4.54, p = 0.008, d = −0.82, 95% CI [−1.41, −0.22]), which was a large effect. There was no between-groups difference on BAPQ pain-specific anxiety scores through follow-up.

There were no study-related adverse events reported by participants during the course of the trial in either treatment group. When we collected adverse events at each assessment period, several participants reported major life events and stressors (e.g., hip replacement surgery). However, these were described by parents as being unrelated to study procedures.

The SPSI-R was used as a process measure. On dysfunctional problem solving, there were no between-groups differences through post-treatment or follow-up. However, PSST was associated with improvements in constructive problem solving and total problem solving scores. Parents in the PSST group had a greater increase in constructive problem solving compared to the TAU group through post-treatment that approached significance ( b = 6.09, p = 0.07, d = 0.34, 95% CI [−0.03, 0.72]), which was a small to medium effect. This was not maintained through follow-up. For total problem solving scores, there was no between-groups difference through post-treatment. However, at follow-up, the PSST group had a greater improvement in total problem solving relative to the TAU group that approached significance ( b = 0.67, p = 0.09, d = 0.29, 95% CI [−0.05, 0.62]), a small effect.

This is the first pilot RCT of problem solving skills training in parent caregivers of youth with chronic pain. Although our participation rate for entering the trial was only moderate, the families who agreed to participate stayed in the trial (97%) and were compliant with 4–6 individual sessions of PSST. Parents reported satisfaction with treatment, and were willing to complete outcome assessments. Taken together, these results indicate feasibility in delivering PSST to parents of children with chronic pain.

We also examined preliminary efficacy of PSST compared to usual care on parent and child outcomes. Our hypothesized effects on parent outcomes were partially supported. PSST was associated with improvements on our primary outcome of parent depression at post-treatment and in some other areas of general and pain-specific parent mental health, well being, and behavior. Although children were not involved in PSST treatment, several downstream effects of PSST on child outcomes were found. Specifically, children whose parents received PSST had improved emotional functioning (depression, general anxiety, and pain-specific anxiety) post-treatment compared to children whose parents received usual care. However, there were no effects found on children’s pain or daily functioning. Effect sizes ranged from small to large across outcomes, and confidence intervals for effect sizes were wide. Most changes were not maintained at follow-up.

In a recent Cochrane review of published trials of PSST in children with chronic medical conditions [ 15 ], treatment was also associated with improved parent mental health and behavior with similar small effect sizes; however there were no treatment effects observed on child outcomes. In contrast, our study found small improvements in child mental health outcomes. Although results from this pilot trial should be interpreted cautiously, our findings are consistent with Palermo and Chambers’ [ 36 ] conceptual model of parent and family influences on chronic pain in children. This model highlights the interrelationship between parent and child functioning, and suggests that downstream effects on child outcomes can be achieved by directly targeting parent distress. Existing behavioral interventions for this population focus primarily on cognitive-behavioral skills training for children and do not address parent mental health [ 20 ]. Treatment approaches such as PSST that directly target parent distress may contribute to positive outcomes for children with chronic pain and their families. Future research is needed to determine whether added benefit can be obtained from combining parent PSST with other effective child pain-focused CBT interventions where children are learning pain management skills concurrently. It is possible that synergy between the two interventions would produce more powerful sustained effects on relevant child and parent outcomes. Future trials should also document health services and cost of treatment to understand whether PSST is associated with improvements in health service use and cost reduction.

We examined parent problem solving abilities as a process measure in this pilot trial, and found that PSST produced only small effects. The process measure of problem solving abilities (SPSI-R) used does not have clinical cut-points, and so we are not able to determine whether parents had clinically significant impairments in problem solving skills at baseline that could have improved with treatment. In particular, because our sample had a high portion of college-educated parents the problem-solving skills may have been better than average at the start of the trial. Interestingly, despite the availability of a validated and standardized measure of problem solving abilities, this domain is not routinely assessed in clinical trials of PSST. For example, in a recent meta-analysis only 4 of 12 prior RCTs of PSST for parent caregivers of children with chronic medical conditions reported on change in parents’ problem solving abilities [ 15 ]. We encourage future research in this area to include assessment of parent problem solving abilities to further understanding of the mechanisms underlying this intervention. It will also be important to examine the effects of PSST in more socioeconomically diverse samples of parents.

There may also be other treatment mechanisms to consider in future trials of PSST. In particular, the support received from the therapist, normalization of the stress experienced by parents of children with chronic pain (e.g., via the “common problems” worksheet), or other non-specific therapeutic effects may contribute to positive outcomes. The PSST intervention might also serve to improve parent-child interaction patterns and increase psychological flexibility, which may be important for change in the context of chronic pain [ 33 ]. Future trials of PSST should include measurement of other key process variables.

In contrast to previous trials of PSST for parents of children with other chronic illnesses, we delivered treatment in just 4–6 sessions rather than 6–8 sessions. Although our initial adaptation of the intervention led us to determine that a shorter intervention would be more feasible to deliver [ 37 ], parents of youth with chronic pain differ in important ways from populations evaluated in these previous trials (e.g., children with newly diagnosed cancer; Sahler et al., 2005). In our sample, the children had chronic pain for an average of 2 years and most parents (56.6%) had clinically elevated symptoms of depression. Given the chronicity of problems faced by families of children with chronic pain, it is possible that these caregivers may actually require more rather than less treatment compared to other pediatric populations. Although additional or booster treatment sessions could result in larger effects on parent and child outcomes, the burden and demand of additional sessions may also have a negative impact on feasibility of treatment delivery. Further research is needed to determine the optimal dose of PSST treatment for parents of children with chronic pain.

A goal of our pilot RCT was to test a range of outcome measures in order to help define appropriate outcomes for a future large definitive trial. Prior studies of PSST have used various domains of measurement including health-related quality of life, parent mental health, child medical symptoms, parent behaviors, family functioning, and parenting skills. It is challenging to make direct comparisons between studies due to the variability in specific measures used and lack of consensus about outcome measures for PSST trials [ 17 ]. We included both general measures and pain-specific measures in order to determine change in particular areas of mental health and well-being that may be most relevant to our patient population. Indeed, some pain-specific variables (e.g., pain catastrophizing) demonstrated changes in parents receiving PSST compared to TAU. However, overall there was a lack of consistent pattern in findings observed in our pilot RCT. In future trials of PSST, investigators will need to select appropriate outcome domains and balance the issue of defining independent outcomes within each measurement domain. Based on our pilot RCT, in future definitive trials, we recommend inclusion of the outcome domains of parent mental health (with general parent depressive symptoms as a primary outcome), child mental health, child symptoms (e.g., pain), and behavior (e.g., parent behavior, child pain-related functioning).

The study sample was mostly comprised of mothers and thus our experience delivering PSST to fathers is limited. Although both parents were invited to be involved in PSST sessions, most often, mothers chose to attend treatment alone. Qualitative research with parents of youth with chronic pain involving mothers has emphasized the negative and burdensome experience of parenting a child with chronic pain [ 26 ]. However, fathers of youth with chronic pain [ 25 ] may have a different experience. In a larger trial, it is possible that participating adults may include a larger number of fathers. However, acquiring participation from fathers is a problem in the field and may need to be addressed with increased flexibility in timing and mode of treatment delivery (e.g., offering internet-based treatment).

Our findings should be interpreted in light of several study limitations. This was a pilot RCT and was only powered to detect medium to large effects. Thus we were underpowered to detect small effects. Fitting with our proof of concept pilot RCT design, we included a usual care rather than an attention control comparison arm, which limited our ability to determine the source of the treatment effect. Future studies are needed in larger, more definitive trials with attention control groups. The sample is small and may not be representative of the broader population of parents of children with chronic pain. Because we conducted only short-term follow up, durability of treatment effects are unknown. Children in our trial were not receiving a consistent form of pain treatment and therefore it is difficult to understand any potential synergy between PSST and other child-focused treatment interventions. This remains an important area for future research to understand whether parent treatment with PSST might enhance child or family-focused treatment.

Clinical implications of our findings highlight the importance of including parents in treatment of childhood chronic pain. Applying interventions to reduce parent distress and to support parent coping skills is feasible and parents desire this form of treatment. At this point, a definitive test of the efficacy of PSST on parent mental health and child pain outcomes is needed. Long term effects should be measured as maintenance of treatment gains is critically important in pediatric chronic pain management where children have symptoms for many years.

Acknowledgments

The authors thank the parents and youth who participated in the study. We are also grateful for the contributions of the late Dr. Robert Butler who advised on the treatment protocol and to Drs. Andrew Riley and Bonnie Essner who served as study therapists. Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD065180 (PI: Palermo). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of Interest . None of the authors have any conflicts of interest.

Evaluating social skills training for youth with trauma symptoms in residential programs

Affiliations.

  • 1 Child and Family Translational Research Center.
  • 2 Academy for Child and Family Wellbeing.
  • PMID: 32378925
  • DOI: 10.1037/tra0000589

Objective: Youth who receive services in residential programs have high rates of traumatic exposure and associated symptoms of Posttraumatic Stress Disorder (PTSD). Little information is available on specific social skills training that could be beneficial for youth in residential programs with PTSD. This study examined changes in behavioral incidents and psychopathology in youth receiving group home services based on training they received across three categories of social skills (i.e., self-advocacy, emotional regulation, problem-solving).

Method: The sample included archival data on youth ( N = 677) ages 10-18 years ( M = 15.7 years, SD = 1.53). Hierarchical Linear Modeling was used to examine the frequency of disruptive and self-injurious behaviors over 12 months as it relates to reported traumatic symptoms at admission and the presence of the three types of social skills objectives. Analysis of Covariance was conducted to test whether the social skill objectives differentially predicted changes in youth psychopathology from intake to discharge for youth with low and high trauma symptoms.

Results: Youth with high trauma symptoms who received training on problem-solving skills had significantly greater decrease in emotional problems from intake to discharge compared to youth with high trauma symptoms who did not receive problem-solving training ( d = -.54).

Conclusion: Problem-solving training could be further developed and tested to maximize the support youth with trauma symptoms receive in trauma-informed residential programs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

  • Emotional Regulation
  • Linear Models
  • Problem Solving
  • Psychopathology
  • Residential Treatment*
  • Self Concept
  • Social Skills*
  • Stress Disorders, Post-Traumatic / psychology*

Grants and funding

  • U. S. Department of Education; Institute for Education Sciences

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  1. Using Problem-Solving Skills Training and Parent Management Training

    Problem-Solving Skills Training (PSST), the treatment approach we consider in this chapter, is designed to teach aggressive youngsters to use their heads before using their fists. The children first learn basic steps of problem solving in the context of familiar games.

  2. CEBC » Program › Problem Solving Skills Training

    Problem-Solving Skills Training (PSST) directly provides services to children/adolescents and addresses the following: Oppositional behavior, aggressive behavior, antisocial behavior

  3. Evidence-based psychosocial treatments of conduct problems in children

    Parent training should be considered the first-line approach to dealing with young children, whereas cognitive-behavioral approaches have a greater effect on older youths.

  4. Provide Psychosocial Skills Training and Cognitive Behavioral

    Psychosocial skills training and cognitive behavioral interventions teach specific skills to students to help them cope with challenging situations, set goals, understand their thoughts, and change behaviors using problem-solving strategies.

  5. Parent management training for conduct problems in children: Enhancing

    For the standard treatment, 100% of the cases met criteria for standard treatment, i.e., they did not receive the described enhancements. ... Kazdin A.E. Parent management training and problem-solving skills training for child and adolescent conduct problems. In: Weisz J.R., Kazdin A.E., editors.

  6. Problem-solving training as an active ingredient of treatment for youth

    Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years. Five bibliographic databases (APA PsycINFO, CINAHL, Embase ...

  7. Problem‐Solving Skills Training

    Training in problem solving consists of learning and applying five, sequential steps: identifying a problem, generating a list of possible solutions, evaluating the strengths and weaknesses of each possible solution, choosing a solution to implement, and finally, implementing the solution and determining if the problem was solved, or if another ...

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    Cognitive behavioral therapy (CBT) is particularly relevant for children from 7 years on and adolescents with clinical levels of conduct problems. CBT provides these children and adolescents with anger regulation and social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Typically, CBT is combined with another psychological treatment such ...

  9. Parent management training and problem-solving skills training for

    Our intervention work has focused on disruptive behavior disorders among children and adolescents (ages 2-15) who are referred for inpatient or outpatient treatment. Our primary focus has been with children referred for extreme physical aggression and property destruction, but they evince the full range of behaviors included in the diagnosis of conduct disorder (CD). We have expanded our more ...

  10. Cognitive problem-solving skills training and parent management

    Evaluated the effects of problem-solving skills training (PSST) and parent management training (PMT) on 97 children (aged 7-13 yrs) referred for severe antisocial behavior. Children and families were assigned randomly to 1 of 3 conditions: PSST, PMT, or PSST and PMT combined. It was predicted that (1) each treatment would improve child functioning (reduce overall deviance and aggressive ...

  11. Problem-Solving Skills Training for Parents of Children With Chronic

    Problem-solving skills training is a cognitive-behavioral process by which parents can identify and create problem-focused strategies to buffer the outcomes of stressful events and improve coping, thus preventing episodes of negative affectivity by effectively solving various children's disease-related problems.

  12. Social Skills and Problem‐solving Training for Children with Early

    Families of 99 children with early-onset conduct problems, aged 4-8 years, were randomly assigned to a child training treatment group (CT) utilizing the Incredible Years Dinosaur Social Skills and Problem Solving Curriculum or a waiting-list control group (CON).

  13. PDF Parent Management Training and Problem-Solving Skills Training for

    The treatment uses learning -based procedures to develop behav ior and includes modeling, prompting and fading, shaping, positive reinforcement, practice and repeated rehearsal, extinction, and mild punishment. The treatment sessions develop skills that the parents use to implement behavior change programs in the home.

  14. Problem-solving skills training for parents of children with chronic

    Parents receiving PSST participated in 4 to 6 individual sessions of training in problem-solving skills. Outcomes were assessed at pretreatment, immediately after treatment, and at a 3-month follow-up. Feasibility was determined by therapy session attendance, therapist ratings, and parent treatment acceptability ratings.

  15. Problem-solving skills training for parents of children with chronic

    Problem-solving skills training for parents of children with chronic pain: a pilot randomized controlled trial. ... Children in our trial were not receiving a consistent form of pain treatment and therefore it is difficult to understand any potential synergy between PSST and other child-focused treatment interventions. This remains an important ...

  16. Basic Psychopathology

    A child is receiving problem-solving skills training as a treatment for conduct disorder. You can be reasonably sure that: the interventions used are cognitive-behavioral

  17. Problem-solving training as an active ingredient of treatment for youth

    PMCID: PMC8383463 PMID: 34425770 Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

  18. Bright IDEAS: Problem-Solving Skills Training

    Program Synopsis. Designed to reduce the emotional distress in mothers of children recently diagnosed with cancer, this coping skills training teaches a five-step problem-solving approach applicable to situations commonly encountered during pediatric cancer treatment. The study showed improvements in various problem-solving skills and mood and ...

  19. PDF In Childhood Cancer (Cr01)

    Maternal Problem-Solving Skills Training in Childhood Cancer (CR01): -5- Instructor's Manual. Establishing the parent-instructor relationship is the essential first step in conducting problem-solving skills training (PSST). Emulating warmth, empathy, trust, and genuineness sets the context for the parent's receptivity to learn the specific

  20. Problem-Solving Therapy: Definition, Techniques, and Efficacy

    Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions.

  21. Responsivity to Problem-Solving Skills Training in Mothers of ...

    Objective: Bright IDEAS (BI) is a problem-solving skills training (PSST) program that has been demonstrated in earlier randomized controlled trials (RCTs) to be an effective and specific intervention for improving problem-solving skills and reducing negative affect in caregivers of children with cancer.

  22. Problem Solving Skills Training for Parents of Children with Chronic

    This pilot randomized controlled trial aimed to determine the feasibility, acceptability, and preliminary efficacy of parental problem solving skills training (PSST) compared to treatment as usual (TAU) on improving parental mental health symptoms, physical health and well-being, and parenting behaviors.

  23. Evaluating social skills training for youth with trauma ...

    PMID: 32378925 DOI: 10.1037/tra0000589 Abstract Objective: Little information is available on specific social skills training that could be beneficial for youth in residential programs with PTSD.