Evaluation of Regulation Focused Psychotherapy for Children
Condition: Oppositional Defiant Disorder; Oppositional Defiant Disorder in Children
MeSH terms: Attention Deficit and Disruptive Behavior Disorders
Study type: Interventional

Summary: 
      The main objective of this project is to conduct a study of RFP-C for children with
      disruptive behaviors. Regulation Focused Psychotherapy for Children (RFP-C) is a twice a
      week, play therapy intervention.
    

Detailed description: 
      Background/Significance Currently, there are no empirically supported, manualized
      psychodynamic treatments for children and adolescents with disruptive behavior problems. Many
      barriers exist to providing effective treatment, including the large dropout rates in child
      psychotherapy, especially when multiple risk factors are present, such as maternal stress,
      greater symptom severity, and lower socioeconomic status. In order to remain viable and
      competitive, clinicians and researchers must demonstrate that psychodynamic approaches are
      valuable in terms of positive clinical outcomes, cost-effectiveness, and ease of
      implementation across a range of settings and disciplines.

      Externalizing behaviors are common in a wide range of child mental health problems, including
      oppositional defiant disorder, disruptive mood dysregulation disorder, and conduct disorder.
      These behaviors have high prevalence rates, ranging from 15 to 34 percent. These problems
      frequently result in the referral of young children to mental health providers and they are
      costly to the healthcare system overall . The current approach to these types of problems is
      to provide behavioral parent management training (PMT) to parents of the child in distress.
      These programs include Parent-Child Interaction Therapy, Triple P-Positive Parenting Program,
      or The Incredible Years. Behavioral parent training programs are widely used because the
      evidence shows they are efficacious for children with externalizing behaviors. PMT relies on
      traditional cognitive behavioral strategies in working with the parent, including behavioral
      modeling, rewards, reinforcement, and punishment. The parent is taught to set limits for the
      child and to direct and to shape behavior. A significant limitation associated with
      behavioral parent programs (and psychotherapy with children and adolescents in general) is
      elevated attrition rates for vulnerable populations due to factors such as low socioeconomic
      status, ethnic minority status, parental functioning, maternal stress, low parental
      motivation, and child symptom severity. Parental attrition in behavioral parent training is
      also due to parental attribution about where the problem resides - within the child. PMT is
      directed at the parent, which contradicts the parent's understanding of the cause and nature
      of the problem, thus sometimes further reducing motivation to seek and complete treatment.

      Regulation Focused Psychotherapy for Children (RFP-C) is a novel, manualized, time-limited
      psychodynamic treatment approach for children who manifest disruptive behaviors and emotional
      dysregulation. RFP-C conceptualizes children's externalizing behaviors as expressions of
      maladaptive defenses or impaired emotion regulation (ER). The child's behaviors are
      understood as products of developmental delays in implicit ER. This system has defined
      neurofunctional correlates which permit a targeting of the therapeutic work to brain-based
      deficits in the child's normative development. Externalizing behaviors are thus
      conceptualized both as biologically-driven products and as functional attempts to defend
      against painful emotions by protecting the child from disturbing feelings such as sadness,
      shame, and guilt. RFP-C relies heavily on the child being able to experience distressing
      affects through play and through the relationship with the therapist. Throughout the 16
      sessions of play therapy and several parent meetings, the clinician works with the parents
      and the child to increase understanding that all behavior, even disruptive behavior, has
      meaning in the service of emotional and behavioral regulation. This insight leads to a
      decreased need and reliance to act on the distressing emotions (e.g. less need for disruptive
      behaviors) and an increased ability to tolerate, work through, and talk about the feelings
      that previously needed to be warded off.

      This 16-session (plus four parent sessions) psychotherapy method operationalizes individual
      play therapy approaches for children with externalizing behaviors, including oppositional
      defiant disorder (ODD). Play therapy has long been the mainstay of community mental health
      with children and adolescents and has demonstrated efficacy, though no one has developed a
      play-based manualized treatment for children to date. Through iteratively addressing a
      child's disruptive behaviors as strategies to avoid painful affect, RFP-C is hypothesized to
      address developmental immaturity of the implicit ER system.

      Rationale There is a critical need for the development, evaluation, and implementation of
      evidence-based psychodynamic treatments for children and adolescents. Regulation Focused
      Psychotherapy for Children is a novel, manualized, time-limited psychodynamic treatment
      approach for children who manifest disruptive behaviors and emotional dysregulation. To date,
      we have only conducted a small pilot study of the RFP-C method. No clinical trial has been
      conducted to determine the outcomes associated with RFP-C in a larger sample. The immediate
      objective of this proposal is to conduct a randomized controlled trial with 20 children in
      order to evaluate comparable efficacy to a waitlist control group.
    

Intervention name(s): Regulation Focused Psychotherapy for Children
Intervention type(s): Behavioral
Intervention description(s): RFP-C is a manualized, psychodynamic psychotherapy that last 10 weeks. Children meet individually with a therapist for play therapy (twice a week for 16 sessions) and parents meet with the therapist for four full sessions (without the child).
Other intervention name(s): RFP-C
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Regulation Focused Psychotherapy for Children (RFP-C; Hoffman & Rice with Prout, 2015) is a novel, manualized, time-limited psychodynamic treatment approach for children who manifest disruptive behaviors and emotional dysregulation. RFP-C conceptualizes children's externalizing behaviors as expressions of maladaptive defenses or impaired emotion regulation (ER). The child's behaviors are understood as products of developmental delays in implicit ER (Rice & Hoffman, 2014). Externalizing behaviors are conceptualized both as biologically-driven products and as functional attempts to defend against painful emotions by protecting the child from disturbing feelings such as sadness, shame, and guilt. This 16-session (plus four parent sessions) psychotherapy method iteratively addressing a child's disruptive behaviors as strategies to avoid painful affect. RFP-C is hypothesized to address developmental immaturity of the implicit ER system.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: oppositional defiant disorder; regulation focused psychotherapy for children; emotion regulation; psychodynamic psychotherapy