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2018 | OriginalPaper | Hoofdstuk

12. Evidence-based behandeling voor kinderen en adolescenten: aandachtspunten en commentaar

Auteurs : Prof.dr. Th. H. Ollendick, prof.dr. N. J. King

Gepubliceerd in: Methoden en technieken van gedragstherapie bij kinderen en jeugdigen

Uitgeverij: Bohn Stafleu van Loghum

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Samenvatting

Dit hoofdstuk geeft een overzicht van de inspanningen die zijn geleverd om te komen tot een evidence-based psychosociale behandeling voor kinderen en adolescenten. Eerst wordt opgemerkt dat deze ontwikkeling onderdeel is van een grotere beweging die als evidence-based geneeskunde of evidence-based praktijk bekendstaat, wat in wezen een kennismethodiek en een strategie is om het functioneren te verbeteren. Geconcludeerd wordt dat sommige behandelingen effectiever zijn dan andere, dat protocollisering geen struikelblok is voor het geven van effectieve therapie in een klinische of onderzoekssetting en dat de overdraagbaarheid van behandeling van laboratorium naar klinische praktijk haalbaar en veelbelovend is. Er zijn nog weinig psychosociale behandelingen met de status goed onderbouwd in een onderzoekssetting, laat staan in de klinische praktijk. Toch is dit een spannende tijd, omdat er veel behandelingen worden ontwikkeld die vermoedelijk werkzaam zijn. We staan voor de uitdaging om onze onderzoeksresultaten in een klinisch gevoelige praktijk om te zetten.
Voetnoten
1
Voor de meest recente overzichten verwijzen we naar de rubriek ‘Evidence based update for Psychosocial treatments’ van uiteenlopende problemen als trauma, ADHD, angst, disruptieve gedragsproblemen, etc. in het Journal of Clinical Child and Adolescent Psychology (vanaf Volume 42, 2013). Voor de Nederlandse situatie bieden ook de Databank Effectieve Jeugdinterventies van het Nederlands Jeugdinstituut (NJI, www.​nji.​nl) en de website www.​richtlijnenjeugd​hulp.​nl relevante informatie.
 
2
Verwijzen naar de klinische praktijk is hier een goede suggestie, maar onder voorwaarde dat de therapeut de behandeling voortdurend evalueert met herhaalde metingen. Kortom, dat de behandeling wordt opgezet en uitgevoerd als een goede, bij voorkeur gecontroleerde N = 1 (zie Bosch en Prins 2017).
 
3
De Databank Effectieve Jeugdinterventies van het Nederlands Jeugdinstituut gebruikt voor de beoordeling van interventies een effectiviteitsladder. Interventies kunnen op verschillende sporten van de ladder staan, afhankelijk van hun empirische onderbouwing. Hoe sterker empirisch onderbouwd, des te hoger op de ladder.
 
4
Zie voetnoot 2.
 
5
In grote lijn komt de recente meta-analyse van Weisz et al. (2017) tot dezelfde conclusie, maar wel met enkele nuanceringen. De gemiddelde effectgrootte is op de nameting 0.46 en op de follow-up elf maanden later 0.36; de kans dat jongeren in de behandelgroep meer profiteren dan jongeren in de controleconditie is 63 %. Vijf decennia psychotherapieonderzoek laat zien dat psychotherapie gunstige, maar bescheiden effecten heeft die relatief stabiel zijn. Deze effectgrootte is wel kleiner dan die in eerdere meta-analyses werd gevonden. Meest waarschijnlijke verklaring is volgens Weisz et al. een statistische; in vorige analyses werd niet gecontroleerd voor steekproefgrootte.
Uit de meta-analyse van Weisz et al. (2017) komt CGT weliswaar relatief sterk, maar niet over de hele linie als beste naar voren. Het ligt genuanceerder. De gemeten effectiviteit is afhankelijk van informant (wie het effect rapporteert: kind, ouders of therapeut) en type uitkomstmaat. Met andere woorden, de dominantie van CGT als effectieve bewezen werkzame behandelvorm boven andere behandelvormen dient genuanceerd te worden (zie verder Weisz et al. 2017).
 
6
In hun meest recente, geactualiseerde meta-analyse over de effecten van psychotherapie bij kinderen en jongeren komen Weisz et al. (2017) echter tot de vaststelling dat treatment as usual in recente studies effectiever blijkt te zijn dan in hun vorige meta-analyses werd gevonden. Weisz et al. concluderen dat treatment as usual zeker gebruikt kan worden als een standaard controleconditie waarmee nieuwe behandelvormen moeten worden vergeleken. Zie voor onderzoek in Nederland op dit punt bijvoorbeeld Stikkelbroek et al. (2013).
 
7
Zie in dit verband het belangrijke initiatief van de Nederlandse onderzoeksorganisatie ZonMw om in het kader van de vraag ‘wat werkt in jeugdprogramma’s?’ binnen het onderzoeksprogramma ‘Effectief werken in de jeugdsector’ in te zetten op onderzoek van ‘werkzame elementen’ (www.​zonmw.​nl).
 
8
Voor recent onderzoek hierover van Kendall en zijn collega’s, zie Podell et al. (2013) en Marker et al. (2013).
 
9
Na deze modulaire behandeling voor kinderen met verschillende angststoornissen hebben Chorpita c.s. ook kinderen met angst en depressie op deze manier behandeld. Meest recent is hun transdiagnostische benadering en het onderzoek rond het modulaire programma MATCH (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems), zie Weisz et al. (2012).
 
10
De term ‘werkzaamheid’ (efficacy) verwijst naar de effectiviteit van een interventie, aangetoond in een onderzoekssettting met een RCT. De term ‘doeltreffendheid’ (effectiveness) verwijst naar de uitkomsten van dezelfde behandeling in een klinische praktijksetting.
 
11
Zie voor een recente publicatie over dit onderwerp: Smith et al. (2017).
 
12
In het verlengde van deze scheidslijn tussen werkzaamheids- en doeltreffendheidsonderzoek en met betrekking tot het vierde analyseniveau over systeemevaluatie dienen ook de recente ontwikkelingen rond ‘implementatieonderzoek ’ genoemd te worden. Goede, bewezen werkzame protocollen kunnen dikwijls niet zomaar geïmplementeerd worden; er moet ook steeds rekening worden gehouden met specifieke omgevingscondities (zie Proctor et al. 2011).
 
13
Goed voorbeeld hiervan in de Nederlandse situatie is de systematische verspreiding van de oudertrainingsprogramma’s ‘Pittige Jaren’ (Incredible Years) en Triple-P, zie Nederlands Jeugdinstituut (www.​nji.​nl).
 
14
Ook in Nederland en Vlaanderen worden onverminderd grote inspanningen geleverd om de klinische praktijk van de psychotherapie bij kinderen en jongeren nóg meer evidence-based te maken. De Databank effectieve jeugdinterventies van het Nederlands Jeugdinstituut (NJI) geeft actuele informatie over de stappen die op dit punt zijn gezet, welke resultaten er zijn geboekt en welke vragen nog beantwoord moeten worden.
 
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Metagegevens
Titel
Evidence-based behandeling voor kinderen en adolescenten: aandachtspunten en commentaar
Auteurs
Prof.dr. Th. H. Ollendick
prof.dr. N. J. King
Copyright
2018
Uitgeverij
Bohn Stafleu van Loghum
DOI
https://doi.org/10.1007/978-90-368-1972-5_12