Cognitive Behavioural Therapy for Children and Adolescents

Antonio Muñoz-Solomando; Tim Kendall; Craig J. Whittington

Disclosures

Curr Opin Psychiatry. 2008;21(4):332-337. 

In This Article

Recent Evidence for the Use of Cognitive Behavioural Therapy

The following narrative describes recent relevant systematic reviews retrieved from searches as described, either to update those undertaken for NICE guidelines or to fill in the gaps where guidelines have not been completed.

The NICE guideline for depression in children and young people[1] included evidence from a systematic search of CENTRAL, EMBASE, MEDLINE, and PsycINFO (to January 2004) and hand searches of relevant journals and the reference lists of previous reviews and studies. Five studies were included in the review of individual CBT compared with control (waitlist, nondirective supportive therapy, clinical management or another active treatment) in 9-year-olds to 18-year-olds (n = 501), and eight trials of group CBT compared with control (no treatment, waitlist control, ‘standard care’ or another active treatment) in 9-year-olds to 18-year-olds (n = 548). The data presented in the guideline suggest that the best evidence was for group CBT (8-16 sessions of 40-60 min duration for 5-8 weeks). At posttreatment, in three trials of adolescents, 50% of those receiving CBT no longer met DSM criteria for major depression compared with 36% of those receiving no treatment/waitlist [NNT = 7.1, 95% confidence interval (CI), 3.7-100].

Subsequently, Watanabe et al. [6•] published a meta-analysis of psychotherapies for depression in children and adolescents in comparison with no treatment, waitlist controls, attention placebos, and treatment as usual. Their search covered CENTRAL, CINAHL, EMBASE, LILACS, MEDLINE, PsycINFO, and PSYNDEX (to December 2004), and hand searches of relevant journals and the reference lists of previous reviews and studies. The review included 25 comparisons of CBT and two of other psychotherapies involving children and adolescents (aged 6-18 years; n = 1744). The authors suggest there are significantly improved outcomes with CBT; however, since this meta-analysis included trials that were excluded from the NICE guideline, some with ‘nonclinical’ populations who may well not have been depressed, we have not included outcomes reported.

The NICE guideline for obsessive compulsive disorder (OCD)[7] included evidence from a systematic search of CENTRAL, EMBASE, MEDLINE, and PsycINFO (November 2003). This is the first comprehensive national guideline developed in the UK examining the evidence base for a number of different treatment modalities. The guideline included one RCT (n = 77) of children and adolescents with OCD (mean age of 12 years), who were randomized to single family CBT with response prevention (ERP), multifamily CBT with ERP, or a 4-6 week waitlist control condition. The duration of the intervention was 14 weeks, with 3 and 6 months' follow-up. Strong evidence was found for both individual and group CBT when compared with waitlist control in terms of improved OCD symptoms (single family CBT: SMD = −2.73, 95% CI −3.55 to −1.91; multifamily CBT: SMD = −2.54, 95% CI −3.28 to −1.81), with no significant difference between modalities. Based on these results (and another 19 studies, open trials, case series, single case studies and case reports), the guideline suggests that there is evidence for the use of CBT that incorporates ERP in the treatment of OCD in children and young people. Furthermore, outcomes are better when parents are involved in the treatment of their children, especially in CBT protocols incorporating ERP.

In a Cochrane review, O'Kearney et al.[8] examined the overall efficacy of CBT or behavioural therapy in children and adolescents with OCD. Their search covered CCDANCTR-Studies and References, EMBASE, MEDLINE, PsycINFO (to August 2005), and hand searches of relevant journals and the reference lists of included studies. The authors identified four RCTs with a total of 222 participants aged 18 years or younger with a diagnosis of OCD. The studies compared standard behavioural and cognitive behavioural techniques, alone or in combination, with waitlist or pill placebo. The authors of the review suggest that the most reliable estimate for the efficacy of behavioural therapy/CBT relative to no treatment came from one RCT,[9] which was of higher quality than the other three trials. It was a small but significant trial that provided strong evidence that CBT/behavioural therapy is an effective treatment for OCD in children and young people. Using a cut-off of more than 10 on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the study showed that participants who received behavioural therapy/CBT alone (n = 28) were significantly less likely than those receiving the placebo (n = 28) to still have OCD posttreatment (61% compared with 96%; NNT = 2.8, 95% CI 1.8-6.3).

James et al.[10] authored a Cochrane review of CBT for anxiety disorders in children and adolescents. In this study, the authors provide strong evidence that CBT is a beneficial treatment for children and young people with anxiety disorders by combining results from 13 RCTs in a meta-analysis. Their search process included CENTRAL, EMBASE, MEDLINE, PsycINFO (to January 2004), and hand searches of relevant journals and the reference lists of identified studies. The review included 13 RCTs that aimed to determine whether CBT was an effective treatment for 6-year-olds to 18-year-olds with mild to moderate anxiety disorders [excluding OCD, posttraumatic stress disorder (PTSD) and simple phobia] (n = 498) in comparison with waitlist or attention controls (n = 311). The pooled response rate for remission of any anxiety diagnosis was 56% for CBT compared with 28.2% for controls (NNT = 3.0, 95% CI 2.5-4.5). The authors suggest that treatments administered using individual, group and family/parental formats appear to be equally effective.

The NICE guideline for PTSD[11] included evidence from a systematic search of CINAHL, EMBASE, MEDLINE, and PsycINFO (to mid-2004), and hand searches of relevant journals and the reference lists of previous reviews and studies. This national guideline examined a range of treatment options for adults and children with PTSD. Among other effective treatment options, CBT had evidence to support its use, although this evidence is more limited in children and young people than in adults. Seven studies were included in the review of CBT compared with controls (waitlist, nondirective supportive therapy, community care or another active treatment) in 2-year-olds to 16-year-olds (n = 658). In one trial (n = 67) of CBT for children under 7 years old and their parents/carers, there was evidence that, when compared with supportive therapy, CBT reduces the severity of externalizing behaviours (SMD = −0.79, 95% CI −1.29 to −0.28). There was also limited evidence from two trials (n = 212) suggesting that CBT for children over 7 years old and their parents/carers, when compared with supportive therapy, reduces the severity of PTSD symptoms (SMD = −0.55, 95% CI −0.83 to −0.28). There was also some evidence that CBT was better than community care and waitlist control at reducing PTSD symptoms.

In a Cochrane review of CBT for children and adolescents who have been sexually abused, Macdonald et al.[12] reviewed trials identified by searching CENTRAL, CINAHL, EMBASE, LILACS, MEDLINE, PsycINFO, SIGLE and the register of the Cochrane Developmental, Psychosocial and Learning Problems Group (to November 2005), as well as checking the reference lists of previous reviews and studies. Ten trials involving 847 children and adolescents (aged 2-17 years) were included in the review. The results of the meta-analysis showed that when CBT was compared with waitlist/nondirective supportive therapy, it produced benefits in terms of posttraumatic stress (SMD = −0.43, 95% CI −0.69 to −0.16) and anxiety (SMD = −0.21, 95% CI −0.40 to −0.02), which was sustained at a follow-up of at least 1 year. However, there were no statistically significant differences between the CBT and the control group with regard to depression, sexualized behaviour and externalizing behaviour. Overall, there is enough evidence to suggest that CBT in this context, perhaps directed at posttraumatic phenomena, particularly anxiety, would be worth further consideration and research.

NICE has recently published a consultation version of a clinical guideline on pharmacological and psychological interventions for attention deficit hyperactivity disorder (ADHD) in children, young people and adults.[13] The draft guideline includes evidence from a systematic search of CENTRAL, CINAHL, EMBASE, ERIC, MEDLINE, and PsycINFO (to December 2007), and the reference lists of included studies. Ten trials met the eligibility criteria, providing data on 549 participants. Of these, four RCTs assessed parent training interventions, two involving parents of preschool-aged children, and two involving parents of school-age children with ADHD, where the mean age of the child was less than 8 years. A further six RCTs were reviewed that examined interventions involving either just the child (two RCTs) or both the child and the family, where the mean age of the child was 8 or 9. For school-age children, CBT/social skills training interventions consisted of between eight and 12 sessions lasting 50-90 min for children and eight sessions lasting 50-120 min for parents, and were delivered by specifically trained facilitators. The evidence reported suggests that CBT interventions can have beneficial effects delivered in the absence of medication or as an adjunct to continued routine medication for children with ADHD. For example, in the two trials (n = 76) where participants were not receiving ADHD medication, parent-rated core ADHD symptoms at end of treatment favoured the psychological intervention over the control (SMD = −0.87, 95% CI −1.35 to −0.39). The draft guideline specifies that these findings come from RCTs evaluating the effects of CBT for children; therefore the conclusions do not necessarily apply to adolescent populations with ADHD.

In 2007, Armelius and Andreasson[14] conducted a Cochrane review looking at the use of various forms of CBT as an intervention for antisocial behaviour in young people in residential settings. Their search process included CENTRAL, Dissertation Abstracts International, ERIC, MEDLINE, and Sociological Abstracts (to May 2005). The review included 12 studies (five of which were RCTs) of CBT compared with a control condition (typically treatment as usual) in young people aged 12-22 years. The pooled estimate from 10 studies (n = 4441) was not clinically significantly in favour of CBT in terms of recidivism at 12 months' follow-up (37% compared with 41%; NNT = 25, 95% CI 14.3-100); moreover, the difference between CBT and control also failed to reach statistical significance at 6 or 24 months.

A Cochrane review conducted by Montgomery et al.[15] looked at the use of media-based CBT for behavioural problems in children. In this review, the treatment modality was of a behavioural or cognitive behavioural nature and could be delivered by book, video, audiotape or computer (including internet-based packages). The search process included Biosis, CENTRAL, CINAHL, EMBASE, MEDLINE, PsycINFO and Sociofile (to August 2005). Eleven RCTs (including quasi-randomized trials) with 943 participants aged 2-15 years with a wide variety of diagnoses (behavioural problems, learning disabilities, conduct disorder, ADHD and sleep problems) were included. Overall, the most robust evidence for improved behaviour with a media-based intervention came from the parent-rated Eyberg Child Behavior Inventory (intensity subscale) for which data from five trials (n = 285) could be pooled (mother rated: SMD = −0.67, 95% CI −1.36 to −0.42). Interestingly, significant improvements were made with the addition of up to 2 hours of a therapist's time.

There is a paucity of research examining the efficacy of CBT in children and adolescents with bipolar disorder, schizophrenia or related psychoses. The NICE guideline on bipolar disorder[16] failed to identify any formal evaluation of psychological interventions for children or adolescents, and the schizophrenia guideline had a lower age limit for intervention studies of 18 years.[17] Moreover, we found no other systematic reviews that examined the use of CBT in children or adolescents with psychotic symptoms.

The NICE guideline for Eating Disorders[18] included evidence from a systematic search of CENTRAL, CINAHL, EMBASE, MEDLINE, and PsycINFO (to December 2002), and hand searches of relevant journals and the reference lists of previous reviews and studies. Although the guideline applies to adults, adolescents and children aged 8 years and older, there were no suitable RCTs identified that only included children; most excluded participants younger than 18 years old (a few studies did not report exclusion criteria, but mean age was always over 20).

More recently, two reviews have examined the evidence for the treatment of bulimia nervosa[19] and anorexia nervosa.[20] However, no studies were identified (in searches to August 2005) that specifically examined these interventions in children or adolescents.

Recent epidemiological studies have shown an increase of prevalence in substance misuse among young people.[21] The NICE guidelines on psychosocial interventions for drug misuse[22] included evidence from a systematic search of CENTRAL, CINAHL, EMBASE, HMIC, MEDLINE, and PsycINFO (to May 2006), and hand searches of relevant journals and the reference lists of previous reviews and studies. The systematic search identified three RCTs of CBT compared with family and social-systems interventions in 458 participants aged 13-18 years with a DSM-IV diagnosis of cannabis misuse or dependence. The evidence suggested there was little difference between interventions in terms of the number incarcerated, hospitalized or with significant substance misuse problems at endpoint (relative risk = 0.97, 95% CI 0.88-1.07).

Finally, the NICE guideline on the management of self-harm[23] gives special consideration to children (aged over 8 years) and adolescents who self-harm. Following a systematic search of CENTRAL, CINAHL, EMBASE, MEDLINE, and PsycINFO (to December 2002), only two RCTs were included that compared CBT with treatment as usual. However, the meta-analysis included other problem-solving type therapies and the trials did not specifically examine the efficacy of CBT for children or adolescents. The guideline recommends that, for young people who have self-harmed repeatedly, developmental group psychotherapy should be offered.

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