Casación N° 3671-2014 LIMA (VII PLENO CASATORIO)

Nine factors were held as constant as possible between the target and control case of each pairing. These were sex, age, year of coming into treatment, type of treatment (intensive versus non-intensive), type of therapist (staff or trainee), 10, social class, category of diagnosis (neurotic,

psychotic, no diagnosis, learning difficulty or specific developmental disorder, habit disorder, conduct disorder), and whether the child's family was broken or intact. Chronicity of psychiatric diagnosis was, unfortunately, too seldom recorded to be usable. An attempt to include family size was only partially successful; 9 factors seemed the maximum number that could be adequately controlled. No pair was a perfect match but, overall, they were as close as it was possible to get w ith a limited number of cases from which to choose.

7 .6 .1.a The rationale for the selection of certain variabies

A) Sex

There is widespread recognition that sex differences play a major rôle in most aspects of human behaviour (Maccoby 1966, Bem 1974), including

psychiatric vulnerability (Kazdin 1988, Shepherd et al 1971) and response to treatment (Kazdin 1988).

B) Age

Anna Freud's emphasis on the importance of the developmental and

maturational aspects of childhood (1965) has been subsequently reinforced by the work of child psychologists and psychiatrists who stress the need for a child to be assessed according to age norms (Rutter et al 1970). It was decided that it was specially important to match children w ithin broad psychosexual stages - pre-latency, latency and adolescence. Younger children have been found to respond better than teenagers to treatments of all kinds (Kazdin 1988). Psychoanalysis, w ith its inherent regression and transference phenomena, is particularly difficult for older children to contend w ith (A. Freud 1965) and many drop out when they reach adolescence. To avoid an excess of premature terminations in any group, the sample subjects needed to be matched for age.

C) Social class

The literature varies in its assessment of the importance of social class to psychological disturbance and response to treatment. Rutter found only a

weak association although there is a stronger positive correlation w ith certain medical conditions such as asthma (Rutter et al 1970). In contrast, in their review of a number of studies which looked at social and cultural influences on psychopathology, Bruce & Barbara Dohrenwend found "considerable evidence of a high concentration of psychopathology in the lowest class compared to all other classes'. The most consistent result reported was an inverse relationship between overall rates of psychopathology and social class (Dohrenwend and Dohrenwend 1974). In many respects this seems a dubious finding, though, holding more for personality disorders than for neurotic and psychotic conditions and, again, there may be a confound of labelling and diagnostic practices. A re-analysis of the data suggested that the higher incidence of schizophrenia in lower social classes was balanced by increased rates of manic-depression higher up the social scale. The situation, then, is complicated. Nevertheless, it is possible that social class interacts w ith other factors to mediate treatment effects and, therefore, we decided to control for this.

More relevantly in terms of controlling appropriate variables for the present study, it is a feature of psychoanalysis as a treatment that it attracts mostly middle-class patients (Bachrach et al 1991) because they are generally supposed to be more articulate and disposed towards introspection and self- examination, attributes deemed necessary to make best use of intensive therapy. The families of our referred children therefore needed to be matched in terms of social class to control for the possible effect of social class on treatment outcome.

D) IQ

A low IQ rating is associated w ith an increased risk of psychiatric disorder (Rutter 1975). As high IQ may also interact w ith other factors such as social class which, in turn, may predict a beneficial response to psychoanalytic therapy (Bachrach et al 1991), it was necessary to match target and control children on their IQ ratings so that outcome ratings should not be

E) Year of starting treatment:

Nearly forty years of psychoanalytic assessment and treatment - from 1950 to 1989 - were represented and it was felt important that some attempt should be made to match children at least within a decade of starting treatment. Both psychoanalysis and, more especially, child-rearing and education, have changed dramatically over four decades and the child

coming into treatment in the 1980s and 90s would be a very different entity from his or her parent or grandparent'*'^.

F) Number of sessions

Heinicke (1965) and Heinicke and Ramsey-Klee (1986) reported that children seen in 4-times weekly psychoanalysis for a year improved on a variety of measures over children seen in once-a-week psychotherapy, even when the therapists used the same general approach. Although they only studied 12 subjects, their results suggested that our patients should be matched on intensity of treatment. A distinction was made between intensive treatment (4 or 5 psychoanalytic sessions per week) and non-intensive treatment (1-3 psychoanalytically-oriented psychotherapy sessions a week). Data had been recorded on both initial number of sessions and maximum sessions attended. Some children had started off in psychotherapy and increased attendance as they settled into treatment; for others the reverse occurred, and many

children reduced sessions towards the end of their therapy in preparation for final termination. Initial number of sessions was the variable controlled for as reductions and increases were seen to be largely a result of treatment

effects.

G) Type of therapist

Outcome studies on adult psychoanalysis have generally found greater benefit for patients treated by experienced staff therapists than by student candidates (Bachrach et al 1991) though this effect is often confounded by

'^For example, Martin Herbert has documented changes in the average age for starting toilet training with children (1974). In 1935 training was begun, on average, at 6 months of age. Twenty years later the mean age had risen to 11 months; in 1966 it was 18 months. In the 1990s training is often postponed until still later. Psychoanalytic theory predicts that such changes may have profound effects on personality and predisposition to psychological disturbance.

shorter analyses as candidates graduate and move away. It is recognised that treatment length correlates w ith more favourable outcomes (Erie in Bachrach et al 1991). Meta-analyses of child treatments have found that, whereas experienced therapists are equally successful w ith all client groups, student therapists are more effective w ith younger children (Weisz et al

1987a, 1992). Where possible, therefore, the subjects in the present study were matched for type of therapist.

H) Diagnosis

Psychoanalysis is often claimed to be of greatest use for patients w ith neurotic or psychosomatic conditions (Eissler et al 1977a, Bachrach et al

1991, W ittkow er and Warnes 1977) and of dubious merit, if not positively counter-indicated, in cases of psychosis and conduct disorders (Mannoni

1970). Clinicians differ considerably in their evaluation of conditions that can be appropriately treated w ith intensive psychotherapy but there is little

dispute over the assumption that diagnostic category is an important factor in determining response to treatment.

I) Family broken or intact:

There are a variety of family factors which may affect a child's overall level of functioning and his or her ability to use psychological intervention. Rutter found a slight positive association between psychiatric disorder in children and large families, broken homes and parents' emotional difficulties (Rutter et al 1970) These are all unknowns in terms of treatment outcome. No attempt was made to control for parental health, either physical or mental, as it was felt that this might be a factor of the child's illness or handicap and thus be regarded as a partly-independent variable. Efforts to control for family size were only partially successful although singletons were matched where possible. Family status in terms of broken and intact homes was taken into account in finding controls for the target children.

Besides parental pathology, length of treatment, reasons for termination, and parents' and children's GAP (global assessment of functioning) scores, were all variables that were not held constant but were assumed to be

contributory factors to relative success or failure of treatment.

7 .6.i.b Closeness of match on the selected variables A) Sex

The sex of all 81 target cases was appropriately matched w ith the controls.

B) Age

Ninety-three per-cent of cases were able to be matched w ithin broad age- groups (under 6, 6-11, over 11); 41 % were matched to w ithin one year. Taking the groups as a whole, the total mean age of subjects was within one year for targets and controls in all three groups (Table 7.11).

C) Social class

We recorded social class according to the Registrar-General's Classification of employment. This is by no means a very satisfactory way of

demonstrating the rather intangible differences between the social classes but is the best we could do w ith the retrospective information. Father's job was taken as indicative of the position of the family in the class hierarchy; if the father did not have a job, or the classification was unknown, mother's employment was considered.

Despite the Dohrenwends' review findings, cited above, that psychiatric disturbance is related to low social class, our families, consistent with psychoanalytic populations, fell into the top 4 categories on the RGC. Our intention was to match pairs of children within one class. That was achieved w ith 90% of the pairs - 56% of pairs where social class was known (70 out of 81) were matched exactly; a further 34% fell within one class. Table 7.12 shows the social class breakdown for all the target and control groups.

Overall, each medical subgrouping was matched to within .6 of a class.

D) IQ

10 scores proved fairly difficult to match as tests were not uniformly administered. Children, if assessed at all, might be tested before, during or after treatment, or any combination of this. Patients who had tw o or more

Mean Age in Years

Disabled III Somatic

Target Control Target Control Target Control

8.5 8.8 10.1 11.0 8.6 8.8

Table 7.11 Mean age of Target and Control groups

Social Class Disabled III Somatic All

T% C% T% C% T% C% T% C% 1 19 22 6 18 38 41 23 28 II 34 50 18 29 34 19 31 33 III 41 13 53 35 22 25 36 22 IV 3 9 18 6 3 0 6 5 Not Known 3 6 6 12 3 16 4 11

Mean Social Class 2.3 2.0 2.9 2.3 1.9 2.0 2.3 2.1

Table 7.12 Social class of Target and Control groups

Mean Year of coming

into freafenent

Disabled ill Somatic All

Target Control Target Control Target Control Target Control

1966 1967 1969 1974 1967 1968 1967 1969

separate testings sometimes obtained very different results. Often, only a verbal score or only a performance score was given. Evidence suggests that the verbal score is the more reliable of the tw o (Herbert 1974) and, if that is so, it may not be valid to compare tw o single scores, one verbal and one performance, from different children. Verbal ability is highly reliant on upbringing. Children whose upbringing is extremely verbal sometimes show considerable discrepancy between their verbal and performance scores (Griffiths 1981). Field (1960) reported that 25% of the lOVz year-old children he studied showed divergence between verbal and performance scores of at least 14 points and 10% of them deviated by at least 20 points. Other studies have not been able to confirm this but it is acknowledged that even a full IQ score is not an entirely stable indication of ability; over the course of his or her school career a child's 10 is known to deviate by about

15 points (Rutter 1975).

It therefore seemed adequate to attempt to match to within one standard deviation (16 10 points), and this was generally able to be achieved. 86% (N = 19) of the disabled children where the 10 of both members of the pair was available (N = 22) were matched to within 1 sd; similar matchings were obtained for 85% (N = 23) of the available Somatic group (N = 27) and 71% (N = 10/14) of the III children. The group mean of the scores was identical in the III sample and showed a difference of 3 and 4 points respectively for the Somatic and Disabled groups.

E) Year of treatment

We fulfilled our intention to match cases to w ithin a decade of beginning treatment for 85% of the target-control pairs. More than half the pairings (56%) started treatment within 5 years of one another. The mean year of beginning treatment differed between the Somatic target and

control children by just a year. The Disabled children showed a mean difference of tw o years and the III children five years (Table 7.13).

F) Initial number of sessions

More than two-thirds (68%) of the 81 pairs were matched exactly on initial number of sessions; a further 23.5% were matched for sessions w ithin one per week. Another 4 pairs (5%) were matched w ithin the non-intensive/ intensive dichotomy (1-3 sessions a week/4-5). This amounted to a total of 96.5% . Only 3 pairs (2 disabled and one somatic) were not able to be adequately matched. Taking the groups as a whole we can see from Table 7.14 that, w ithin each category, equal percentages of Disabled and III target and control children received intensive treatment (62% and 59%

respectively). The Somatic children differed from their controls by a couple of percentage points only (88% to 90%).

G) Type of therapist

74 of the 81 pairs (91 %) were matched correctly on whether initial

treatment was given by a staff or student therapist. Five pairs of subjects from the Disabled subgroup and one pair from both the III and Somatic categories were mis-matched. The Disabled category as a whole tended to even out so that all three categories had an over-all mismatch of one pair.

H) Principal diagnostic category

It was not possible for us to always match specific diagnosis for specific diagnosis. However, matching children within broad categories of neurosis (which included psychosomatic conditions, depression, habit disorders and learning problems), psychosis, conduct disorders and no diagnosis, proved feasible in most cases. This approach was justified on the grounds that research investigation has supported the validity of diagnostic lines of demarcation only w ith regard to wide-sweeping categories such as internalising emotional disturbance and externalising behaviour disorders. These account for the bulk of childhood disturbances (Rutter and Tuma

1988) and it is possible to distinguish between them but not so easily within them. The finer lines of division of classificatory systems such as DSM-III-R and ICD-X do not hold up under close examination (Rutter and Tuma 1988), although we matched many of the neurotic subdivisions, such as habit disorders, as closely as possible. We were not, unfortunately, able to control

Number of sessions