User:James Cook Mental Health

Written by James Cook 2006

It is the opinion of Fonagy et al (2002) that recent reviews considering the effectiveness of psychological methods of treatment for child and adolescent psychiatric disorders identify cognitive behavioural therapy (CBT) as being the intervention which is best backed by research. Literature reveals that it is the work of Aaron Beck, Beck et al (1979) which gives CBT its theoretical underpinnings. Graham (2005) explains CBT can be defined as “interventions to alter cognitions with the aim of changing feelings” (page 57). CBT appears to work on the assumption that the way individuals feel and behave is largely due to the way they think. Graham (2005) goes on to explain that CBT looks at reducing and removing maladaptive behaviour and emotional distress by focusing on changing dysfunctional thoughts. However, Graham (2005) warns that this is a very simplistic definition of CBT, and in some ways could be misleading to the Mental Health Nurse. If consideration is given to the work of Teasdale & Barnard (1993), it becomes evident that recognition exists in favour of the concept that feelings can influence thoughts as well as thoughts influencing feelings.

Verduyn (2000) explains that “a major characteristic of cognitive behavioural therapies is that work takes place with the individual within their current social environment” (page 176). Verduyn (2000) points out that work within sessions is built around activities of everyday life, is collaborative with the client and is goal focused. It is also probable that sessions with children will also include another significant adult such as a teacher, parent or carer. It is well documented that CBT as been used with good effect for many years within adult services, but how does CBT work with children’s services?

It is possible that some within mental health services may question the applicability of CBT to children. After all, as pointed out by Verduyn (2000) the approach is verbal, generally on a one-to-one basis and primarily “developed on the basis of models of understanding of adult disorder” (page 176). Derisley (2004) claims there is a lack of empirical evidence, to either reject or support the applicability of CBT to children’s services, and asks us to consider facts such as concrete thinking and cognitive immaturity. However, Verduyn (2000) reminds us that CBT has “drawn extensively on developmental models” (page 176), and that as current research develops, similarities consistently show up between cognitions and behaviours in adult and children’s disorders. Another point made by Verduyn (2000) is that some within mental health services may suggest that to be able to participate effectively in CBT the child must be at a stage where they have the “ability to reflect on their own experience and communicate it verbally”.

Although in part this would appear to be an accurate assumption, Verduyn (2000) invites us to consider the therapeutic processes which are involved, and suggests that the “cognitive demands are those of practical problem solving” (page 176). Verduyn (2000) goes on to explain that provided the child can appropriately identify goals of work, then the “concrete practical problem solving skills of a child in mid-childhood years should be sufficient” (page 177). After review it appears that a large amount of literature supports the applicability of CBT in treating childhood disorders, but how effective is it, if at all? Graham (2005) claims that although there can be problems interpreting findings, random controlled trials (RCT’s) appear to provide the best evidence for effectiveness or lack of it. Harrington et al (1998) is considered by many to provide some of the best evidence supporting the use of CBT in depressive disorders of children. Harrington et al (1998) focused on the results of six RCT’s, during these trials children where randomly allocated to one of three areas. Some went directly to CBT, some to an alternative intervention i.e. (a relaxation session, placebo), or to a waiting list group. Harrington et al (1998) stated there was a significantly higher remission rate (62%) in the CBT group than in the comparison groups.

However, Graham (2005) points out some points for consideration regarding Harrington et al (1998). Firstly, it was noted the level of depressive disorders in the children participating were all considered to be mild or moderate. Secondly Graham (2005) states that there is still no quality evidence which supports the effectiveness of CBT in depressive disorders of children, which are considered to be severe in nature. However, Graham (2005) does acknowledge that there is evidence which suggest that used in combination with medication CBT may well be effective, in severe depression in older adolescents. A final point for consideration raised by Graham (2005) is that the six studies Harrington et al (1998) focused on where only considered to be of moderate quality.

Another useful area to consider when assessing the effectiveness of CBT is the RCT’s carried out in childhood anxiety disorders. Kendall (1994) was the first to carry RCT’s which examined the effectiveness of CBT in childhood anxiety disorders. Kendall (1994) used what is referred to as the ‘copy cat’ programme in which children, diagnosed with anxiety disorders where given CBT over a period of sixteen sessions, and again compared to a waiting list group. Kendall (1994) reported that 62% of the group who received CBT, no longer met the criteria for a diagnosis of anxiety disorder after the sixteen sessions, opposed to only 5% in the waiting list group. Reports suggested that this improvement was maintained at a one year review.

Derisley (2004) offers some very interesting views for consideration regarding the RCT’s discussed. Firstly, Derisley (2004) is of the opinion that much of the argument for the effectiveness of CBT is only estimated on the basis of it’s effectiveness with adults. Secondly, Derisley (2004) suggests that RCT’s do not provide us with consistent results and suggests that there is no strength in their support for the effectiveness of CBT, due to the fact they ultimately only suggest that CBT is the superior treatment when compared to no treatment at all. Derisley (2004) also wants us to consider the possibility that the non-specific affects of therapy, for example the therapeutic relationship, are the key to recovery rather than the cognitive elements.

To summarize, it becomes evident from reviewing literature that mixed opinions and heated debate surrounds the use of CBT in specialists CAMHS. Graham (2005) is of the belief that there is every indication that CBT is developing into the most promising therapeutic intervention for use in treating psychological disorders of childhood. Where as, Derisley (2004) feels that further research is needed to determine the effectiveness of CBT in treating psychological disorders of childhood, and acknowledges that current studies and research are still in their “infancy”. Derisley (2004) suggests that it is perhaps essential to continue to support the “development of CBT for young people, due to the fact it would provide therapeutic interventions guided by a clear theoretical basis” (page 19). Derisley (2004) also points out that as clinical experience and methods develop, the effectiveness of CBT will establish itself more clearly.

FONAGY, P. TARGET, M. COTTRELL, D. PHILLIPS, J. & KURTZ, Z. (2002) What Works for Whom? London: Guilford Press.

BECK, A. T., RUSH, A. J., SHAW, B. F., & EMERY, G. (1979) Cognitive Therapy of Depression. New York: Guilford Press.

DERISLEY, J. (2004) Cognitive Therapy for Children, Young People and Families: Considering Service Provision. Child and Adolescent Mental Health (9) 1. pp. 15-20.

GRAHAM, P. (2005) Jack Tizzard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay? Child and Adolescent Mental Health (10)2. pp 57-62.

HARRINGTON, R. WHITTAKER, J. SHOEBRIDGE, P. & CAMPBELL, F. (1998) Systematic review of efficacy of cognitive behaviour therapies in child and adolescent depressive disorder. British Medical Journal, 316, 1559-1563.

KENDALL, P. (1994) Treatment of anxiety disorders in children: A randomized control trial. Journal of Consulting and Clinical Psychology. (62) 100-110. in GRAHAM, P. (2005) Jack Tizzard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay? Child and Adolescent Mental Health (10) 2. pp 57-62

TEASDALE, J.D. & BARNARD, P.J. (1993) Affect, cognition and change. Hove: Lawrence Erlbaum. in GRAHAM, P. (2005) Jack Tizzard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay? Child and Adolescent Mental Health (10) 2. pp 57-62.

VERDUYN, C. (2000) Cognitive Behaviour Therapy in Childhood Depression. Journal of Clinical Child Psychology and Psychiatry. (5) 4 pp. 176-180