Purpose of review: The aim is to summarize recent evidence from the National Institute for Health and Clinical Excellence clinical guidelines and high-quality systematic reviews for the use of cognitive behavioural therapy to treat children and adolescents with mental health problems.
Recent findings: Data from meta-analyses of randomized controlled trials suggest that the best evidence for the potential of cognitive behavioural therapy is in the treatment of children and adolescents with generalized anxiety disorder, depression, obsessive compulsive disorder and posttraumatic stress disorder. More limited evidence suggests that attention deficit hyperactivity disorder and behavioural problems may also respond to cognitive behavioural therapy. We found no or insufficient evidence to determine whether cognitive behavioural therapy is useful for the treatment of antisocial behaviour, psychotic and related disorders, eating disorders, substance misuse and self-harm behaviour.
Summary: Clinical guidelines and recent systematic reviews establish that cognitive behavioural therapy has a potentially important role in improving the mental health of children and adolescents.
The National Institute for Health and Clinical Excellence (NICE) guideline on Depression in Children and Young People recommended that pharmacological approaches should not be the first-line approach to the treatment of depression in this age group. Instead, the guideline recommends the initial use of psychosocial interventions, including cognitive behavioural therapy (CBT), for all severities of depression. If a child or adolescent with mild to moderate depression is unresponsive to a specific psychological intervention after four to six sessions, the addition of fluoxetine should be considered. The combination of CBT and fluoxetine appears to reduce the increased risk of self-harm associated with the use of this (and other selective serotonin reuptake inhibitors; SSRIs) for depressed children and adolescents. This is the first major national guideline in the UK on the treatment of depression in children and young people.
Prior to the publication of the Childhood Depression Guideline, it became apparent that the published evidence upon which most guidelines are based was overly positive, an effect resulting from the failure by the pharmaceutical industry to publish or make available data from the more negative trials. The systematic review of the published and unpublished trials of SSRIs in the treatment of depression in children and young people by Whittington et al. showed the powerful impact upon clinical decision making and guideline development of selective publishing by the pharmaceutical industry. (This paper was awarded the ‘Lancet Paper of the Year Award’ for 2004.) This finding of selective publishing of trials by the pharmaceutical industry has been recently confirmed in two publications looking at comparable data sets in adults.[3••,4•] Importantly, the meta-analysis of the full data set of randomized controlled trials (RCTs) submitted to the Medicines and Healthcare products Regulatory Agency (MHRA) on the use of SSRIs in childhood depression revealed that the balance of benefit and harm only favoured the use of fluoxetine.
In this context, it is particularly important to examine alternatives to pharmacological treatment, particularly among children, given the adverse reactions often associated with the treatment of this age group with drugs such as SSRIs, and the unknown longer term effects of these and other medicines used in the treatment of a wide range of mental health problems in children and young people.
This article therefore undertakes a narrative synthesis of systematic reviews addressing the use of CBT in the treatment of a range of child and adolescent mental health problems. In particular, we focus on depression, anxiety, externalizing disorders, disorders with psychotic symptoms and other disorders. Where NICE guidelines have been developed, systematic reviews (including meta-analyses) from these are used, and wherever possible confirmed by additional independent systematic reviews conducted since publication of the guideline. Where no guideline has been developed, other systematic reviews are used. We have limited this synthesis to systematic reviews so as to examine only the most reliable evidence currently available. The outcomes highlighted are those that provide relatively clear evidence of potential benefit (or not) for CBT in the treatment of children and young people with mental health problems.