Children With Long-term Conditions Could Benefit From CBT

Liam Davenport

May 24, 2019

Children and young people with long-term medical conditions who are suffering mental health issues could benefit from receiving cognitive behavioural therapy (CBT), say UK investigators in a review that points to the need for more research in the area.

Darren Moore, PhD of the Evidence Synthesis & Modelling for Health Improvement research group at the University of Exeter Medical School, and colleagues, conducted two systematic reviews of studies that examined the clinical and cost effectiveness of interventions, and their implementation.

The research was published in Health Technology Assessment on May 24th.

It showed that the evidence was strongest for the use of CBT in inflammatory bowel disease, chronic pain, and epilepsy, while there was also benefit seen with parenting programmes.

Lack of Evidence

In a news release, Liz Shaw, also from the University of Exeter, said that the studies they examined "highlighted the benefits of building good relationships and providing treatments in what feels like a 'safe space'".

However, it was notable that few of the studies, particularly those looking at the effectiveness of interventions, were of good quality, and there were no cost effectiveness studies that met the researchers full inclusion criteria.

Michael Nunns, PhD, from University of Exeter Medical School, said: "When we set out to do this research we were hoping to make recommendations about what works to support children and young people with long-term conditions, who are also having difficulties with their mental health.

"However, we were disappointed in the lack of good quality evidence available to guide treatment decisions for these children."

Stuart Logan, Professor of Paediatric Epidemiology at the University of Exeter, agreed, calling on investigators to do the high quality research to provide the necessary evidence to help these children.

He said: "The two things that are needed alongside managing a medical condition like this are something to help the family manage, and something to help with the children's emotional problems that so often go alongside these medical conditions.

"The exciting thing about this project is that it provides researchers with a roadmap for what to do next—we need to work sensibly with parents and children to carefully design treatments and test them in a way that helps us understand whether they actually work."

Children With Long-term Conditions

It is estimated that around 15% of children and young people have a long-term condition, while one survey revealed that up to 23% of secondary school pupils reported having such a condition.

Children and young people with a long-term condition are around four times more likely to be diagnosed with mental health problems than their healthy counterparts, which can place a strain on them and their families.

Moreover, mental health issues resulting from a long-term condition can themselves have an effect on the children and young people's physical condition by affecting treatment adherence and symptom severity.

There are numerous guidelines addressing the treatment of mental health disorders in children and young people, but few recommendations for their management in those with long-term conditions.

The researchers therefore conducted two systematic reviews to examine the clinical and cost effectiveness of interventions in this population, and the factors associated with the delivery of such interventions.

First Review

For the first review, they searched 13 electronic databases, including MEDLINE, EMBASE, PsycINFO, and the Cochrane Database of Systematic Reviews, which were supplemented by internet searches, among other strategies.

They defined a long-term condition as any diagnosed physical illness with an expected duration of at least 3 months, for which a cure is considered unlikely, that limits ordinary activities, and that requires medical care.

The search yielded 25 randomised controlled trials (RCTs) that examined 11 types of interventions in children and young people with 12 types of long-term condition.

Seven of the trials looked at the clinical effectiveness of CBT and provided "tentative evidence" that it could be beneficial for the mental health of children and young people with inflammatory bowel disease, chronic pain, epilepsy, and persistent functional somatic complaints.

However, CBT was not found to be effective in type 1 diabetes.

Parenting programmes that aimed to reduce behavioural problems in children and young people with acquired brain injury and/or cerebral palsy were also found to be beneficial.

The researchers note that, while other interventions such as group play therapy were assessed, there were relatively few studies and the quality was "generally poor".

There were also few opportunities for the researchers to perform a meta-analysis, and they were unable to locate any economic evaluations. Moreover, no studies had been conducted in the UK.

The findings therefore "point to the need for large, high-quality RCTs with consistency in intervention, design and outcome reporting", and that it would be "particularly useful" to test interventions across a range of conditions.

Second Review

For the second review, the researchers searched MEDLINE, PsycINFO and the Cumulative Index to Nursing and Allied Health Literature for qualitative studies that explored attitudes towards, and experiences with, interventions.

This resulted in 57 studies examining 21 interventions, with the most common long-term condition being cancer, alongside several studies looking at HIV-positive children and young people, and those with multiple conditions.

Unlike the studies in the first review, the interventions typically aimed at improving coping, self-esteem and emotional support, as well as symptoms related to the long-term condition.

Some interventions focused on increasing resilience and helping children and young people have a sense of hope for the future.

The children and young people themselves valued treatments that focused on a range of needs, not just mental health, as well as building supportive relationships with caregivers.

The researchers deemed that the quality of the studies in this review was generally good, although they note that there was only one study in which qualitative data collection and analysis was performed alongside an RCT.

They say that "there is a need for this type of mixed-methods evaluation to improve our understanding of how interventions are experienced and how this may link to effectiveness".

However, the team points out that none of the studies included children and young people with a diagnosed mental health disorder, and only two studies looked at the current mental health of participants on entry.

They nevertheless summarise that, alongside CBT, "there was evidence from both reviews that interventions that include family, particularly parents, may be beneficial".

In addition, interventions that enable children and young people "to meet peers with similar health needs also appears to have more benefits than disadvantages", the researchers say.

The research was funded by the National Institute for Health Research (NIHR) and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

No conflicts of interest declared.

Health Technol Assess 2019; 23. doi: 10.3310/hta23220

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