Cognitive-Behavioral Therapy Shows Promise for Children With Mental IllnessCognitive-Behavioral Therapy Shows Promise for Children With Mental Illness

As growing numbers of children are diagnosed with mental illnesses, clinicians are struggling to identify, develop, and apply evidence-based therapies. Some practitioners are embracing cognitive-behavioral therapy, a treatment that has been successfully used in adults for decades. A growing body of evidence is demonstrating that this approach can be effective for children with some mental illnesses.

An estimated 20% of US children and adolescents aged 9 to 17 years has a mental or addictive disorder associated with at least some impairment; as many 4 million or 11% of children have a major mental illness with significant impairments (Shaffer D et al. J Am Acad Child Adolesc Psychiatry. 1996;35:865-877). Yet as few as 1 in 5 children with a mental illness or an addictive disorder receives treatment.

To meet the demand for evidence-based care, several studies have been conducted to determine whether children with mental illnesses may benefit from cognitive-behavioral therapy alone or in combination with psychoactive drugs. So far, there has been strong evidence that children with depression or anxiety disorders may benefit from these approaches, and there is emerging evidence that the treatment may be useful for treating children with other conditions, such as those who have been sexually abused.

The theoretical basis of cognitive-behavioral therapy was formed in the 1960s and 1970s, when Aaron T. Beck, MD, a psychiatrist at the University of Pennsylvania, recognized that depressed patients' beliefs, thoughts, or expectations often generated their distress. Beck's approach, which challenged the widely accepted psychoanalytic theory of depression, encourages patients to objectively assess the distorted views that underlie their distress and gives them techniques they can use to manage problems.

Beck, who received a Lasker Award in 2006 for developing cognitive-behavioral therapy and for other contributions to psychiatry, went on to rigorously test this therapy, and many randomized control trials of cognitive-behavioral therapy have been conducted. Such trials not only demonstrated the approach to be as good as or better than antidepressant drugs at treating depression in adults, they also showed that its long-term effectiveness is superior to drug therapy in preventing relapse (Evans MD et al. Arch Gen Psychiatry. 1992;49:802-808 and Hensley PL et al. Depress Anxiety. 2004;20:1-7). In addition, cognitive-behavioral therapy has also been proved effective as a treatment for a variety of other mental illnesses in adults, including anxiety disorders. Beck has also been credited with helping to raise the bar for the level of scientific evidence used to validate psychological treatments.

Extending and adapting this therapy to children with anxiety disorders was a logical next step, explained Jonathan S. Abramowitz, PhD, associate professor in the department of psychology at the University of North Carolina at Chapel Hill. And growing evidence supports its use in the pediatric population, with the strongest evidence pointing to the benefits for those with depression or anxiety disorders. Data on whether it might be an effective treatment for other disorders is still emerging.

In 2004, the Treatment for Adolescents with Depression Study (TADS), a multicenter randomized controlled trial of 439 patients aged 12 to 17 years with major depressive disorder, demonstrated that cognitive-behavioral therapy in combination with fluoxetine was highly effective (March J et al; Treatment for Adolescents With Depression Study Team (TADS). JAMA. 2004;292:807-820). After 12 weeks of treatment, there was a 71% response rate in children who received the combination treatment compared with a 60.6% response rate for fluoxetine alone and a 43.2% response rate for cognitive-behavioral therapy alone, which was not significantly different from the 34.8% response for placebo.

John S. March, MD, lead author of the study, explained that the response to cognitive-behavioral therapy alone may have been low in this study because the study patients had more severe illness. In addition, TADS assessed only the first 12 weeks of treatment, while studies that have found a stronger effect looked at 16 to 18 weeks of treatment. According to data presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry in Toronto in October 2005, the TADS investigators reexamined the data collected and found that after 18 weeks of treatment, children receiving cognitive-behavioral therapy alone had a response rate comparable with children receiving fluoxetine; after 36 weeks of treatment, those receiving cognitive-behavioral therapy alone had a response rate comparable with those who received both treatments.

Perhaps even more important, given the growing warnings of increased suicide risk associated with antidepressant use in children and adolescents, the trial found that cognitive-behavioral therapy had a protective effect against suicidal thoughts and actions. March said that 1 in 10 of the study participants had a suicidal event, as defined as suicidal thoughts or actions serious enough to require medical attention, and that twice as many suicidal events occurred in the children who took fluoxetine alone compared with the other three groups. In addition, the number of suicidal events among children receiving the combination therapy was roughly equal to the number seen in those receiving cognitive-behavioral therapy alone or the placebo.

“There's something about getting cognitive-behavioral therapy that not only helps you get better with respect to depression, but essentially eliminates excess risk of suicidal events that you would have from getting a selective serotonin reuptake inhibitor,” said March.

A Cochrane Library review that included 4 studies with a total of 222 participants that examined the efficacy of behavioral therapy or cognitive-behavioral therapy vs medication alone for treating obsessive compulsive disorder (OCD) in children and adolescents suggests combination therapy can lead to better outcomes than medication alone (O’Kearney RT et al. Cochrane Database Syst Rev. 2006;(4):CD004856).

One of the studies included in the Cochrane review was the Pediatric OCD Treatment Study (POTS), a multicenter randomized controlled trial of 112 patients with OCD (Pediatric OCD Treatment Study Team. JAMA. 2004;292:1969-1976). It found a remission rate of 53.6% with a combination treatment of cognitive-behavioral therapy and sertraline, 39.3% for cognitive-behavioral therapy alone, 21.4% for sertraline alone, and 3.6% for placebo. The study's authors concluded that combination therapy or cognitive-behavioral therapy alone should be offered as a first-line treatment for children and adolescents with OCD. The Cochrane review suggested that replicating the study would be helpful in determining the effectiveness of cognitive-behavioral therapy, alone or in combination with sertraline. While more data are collected, the report states that public health officials should consider making the therapy more widely available.

Another recent Cochrane Library review of 10 clinical trials with a total of 847 participants found that cognitive-behavioral therapy may have a positive effect on the negative psychological sequelae that result from child sexual abuse (MacDonald GM et al. Cochrane Database Syst Rev. 2006;(4):CD001930). However, the review notes that most of the studies' results were not significant and the review's authors concluded that more carefully conducted and better trials are needed.

Despite the evidence supporting the use of cognitive-behavioral therapy, there are many barriers to children receiving this treatment.

Because this approach in adults requires a lot of abstract thinking, practitioners have had to come up with creative ways to make the therapy more developmentally appropriate for children.

For example, therapists using this technique with children are likely to use metaphors, story, and play materials, explained Robert D. Friedberg, PhD, director of the cognitive-behavioral therapy clinic for children at Penn State Milton S. Hershey Medical Center in Hershey, Pa.

Treating children also requires that therapists, who may be psychiatrists, psychologists, social workers, or counselors, work with parents. Abramowitz explained that with anxiety disorders in particular, parents' behaviors may play a role in perpetuating the problem. For example, a parent may try to help a child who is anxious about going to bed alone by lying in the child's bed with the youngster until he or she is asleep. Such behavior “helps the problem persist; the child never has a chance to grow out of it because the parents are accommodating them,” he said.

Abramowitz and his former colleagues at the Mayo Clinic conducted a study to assess parents' attitudes about cognitive-behavioral therapy for the treatment of children with anxiety disorders (Brown AM et al. Behav Res Ther. doi:10.1016/j.brat. 200604.010). The study was sparked by parents seeking cognitive-behavioral therapy for their children who had left a previous clinician who offered only medication. Parents were not being informed of all the options, he said.

The study surveyed 71 parents seeking treatment for their child's anxiety disorders about the acceptability, believability, and effectiveness of cognitive-behavioral therapy or pharmacotherapy. Cognitive-behavioral therapy was the first choice of 54.5% of the parents compared with 7.3% who preferred medication and 38.2% who preferred a combination of the two. No parents indicated they would prefer not to have their children receive cognitive-behavioral therapy, 9 (15.3%) preferred their children not receive medication.

Abramowitz explained that the parents found it difficult to believe that a child's anxiety was biologically based, and that parents found the idea that the anxiety was learned and reinforced more believable. He noted that it is important for clinicians to take into account parent and patient preferences and the effect they can have on a treatment's effectiveness.

“Going with what a patient (or parent) prefers and what they believe to work is probably an important part of helping kids with anxiety disorders,” Abramowitz said. “It's not the whole answer, but we think it certainly has something to do with it.”

Even though cognitive-behavioral therapy has proven to be effective for certain disorders and is well accepted, most children simply do not have access to it. March explained that while the therapy is available at some academic medical centers, children in community settings often receive drugs alone. “Between one third and a half of the kids with OCD out in the world—if they are getting treated at all—are treated with selective serotonin reuptake inhibitors plus an atypical neuroleptic,” he said.

One reason access to this treatment is problematic is that too few psychologists and psychiatrists are trained in this technique, but this may improve over time because most child psychiatry residency programs now require some training in cognitive-behavioral therapy, Friedberg said. Several training centers also exist across the country, and the Academy of Cognitive Therapy offers information about training opportunities on its Web site, http://www.academyofct.org.

In addition, many clinicians may be unaware of this treatment option or may not inform their patients about alternatives to psychoactive medications. Because the treatment itself can be provided by a range of clinicians as long as they have adequate training, Abramowitz suggested that physicians learn about the technique and possibly train nurses to educate parents about the various treatment options and explain how cognitive-behavioral therapy works.

March said that he would like to see many stakeholders, including the psychiatric, psychological, and social work communities; insurance providers; and the pharmaceutical industry, commit themselves to making cognitive-behavioral therapy more available to children.

“Finding a way to take the treatments that we know work and put them in settings in which they are actually available to children with mental illnesses would have an enormous benefit,” he said.