A series of limitations render child psychoanalysis vulnerable to being seen as impractical, non-scientific, and uneconomical:
1. lack of operationalization in most descriptions of technical interventions, with the effectiveness of interventions supported almost entirely by evocative case illustrations;
2. inadequate specificity regarding technical interventions appropriate for children with a particular diagnosis or clinical presentation;
3. limited evidence of efficacy, particularly evidence derived from randomized controlled trials;
4. a rather loose relationship between theories of psychopathology (in turn poorly supported by empirical data), theories of technique, and technique as actually carried out in clinical practice;
5. lengthy treatment, with rather global goals, raising concerns about cost-effectiveness;
6. shortage of reliable procedures for evaluating ongoing clinical progress.
Child analysts thus face formidable challenges to their clinical and theoretical convictions, to their professional status, and, as evidence-based medicine and managed care relentlessly expands its control over reimbursement and denies payment for child therapy, to their livelihood. If child psychoanalysis is to have a future, its unique effectiveness for specific childhood disorders must be demonstrated in randomized controlled trials. We believe that children with severe disorders of personality and multiple psychiatric diagnoses are indeed well suited and dramatically benefit from a psychoanalytic approach. However, such faith now requires support from empirical investigations.
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