Effectiveness of Stepped Care Psychological Interventions in Children and Adolescents: A Meta-Analytic Review

Stepped care has been proposed as an efficient and scalable framework for delivering pediatric psychotherapy. This meta-analysis examined the effectiveness, generalizability, and implementation characteristics of stepped care interventions for the prevention and treatment of mental health problems in children and adolescents. Across included studies, stepped care interventions demonstrated large significant overall pre–post improvements in health outcomes (d = 1.22, 95% CI [0.944; 1.50]). When compared with control conditions effects were small and non-significant (d = 0.09, 95% CI [-0.133; 0.313]) suggesting that stepped care yields outcomes comparable to standard care including intensive treatments rather than superior clinical effects. Moderator analyses indicated that stepped care effects were largely consistent across patient characteristics, outcomes and methodological qualities. Importantly, stepped care interventions were associated with significantly lower costs compared to control conditions, highlighting their economic advantage. Most studies combined relatively intensive steps, with limited use of self-directed, low-intensity, scalable interventions as initial treatment components. Stepping decisions were primarily based on disorder-specific symptom measures, although some studies incorporated shared decision-making involving clinicians, patients, and families. Exploratory analyses revealed that approximately 46% of the patients transitioned from the initial step, independent of age, and timing of the decision point. Overall, outcomes of stepped care in pediatric psychotherapy appear clinically comparable to usual care while offering substantial cost benefits. The findings support its promise as an efficient service delivery model while underscoring the need for further research on potential barriers and optimal implementation strategies in clinical practice.