Cognitive Behavior Therapy in Treatment of Depression in Children - Literature review Example

Cognitive Behavior Therapy in Treatment of Depression in Children LINGZI JIN PSY424-730 LISA 06/04 The paper is a literature review ofCBT use in the treatment of children with depression, and the treatment is compared with conventional medicine therapies. Studies conducted on the efficacy of CBT show that it has a positive effect on treatment of children with the mental health condition. However, it is still not a perfect remedy because sustained cures may not always be guaranteed; it was suggested that booster sessions be considered to fix this problem. When compared to the use of medication, the literature review shows that drugs may possess some unwanted risks like suicide, yet their long-term ability to cure depression were slightly higher than CBT. Owing to the risks associated with drug-use, it was suggested that CBT be considered as a superior alternative on condition that it is augmented with booster sessions. 1. Overview of depression and Cognitive Behavior Therapy (CBT) Depression is a mental disorder not normally associated with children; even though, studies have shown that is now prevalent amongst them. Manifestation of depression in children is significantly different from how it occurs in adults; they are more likely to show masked behavior or equivalents that indicate prevalence of the condition. Such individuals may become sad, hopeless, unenthusiastic and withdrawn, with a number of them showing other aggressive symptoms such as anger, hostility, lack of sleep and alterations in eating habits. It is also common to find depressed children with somatic symptoms like headaches or stomachaches; these may sometimes be augmented by having an inability to concentrate, excessive feelings of guilt and too much sensitivity to rejection. In other cases, children may show self destructive behavior, contemplate suicide or demonstrate an affinity for dark drawings and tales during play (Forsell, 2007). Cognitive behavior therapy is a therapeutic approach in which clinicians attempt to reverse negative thought patterns that lead to depressive conditions. In Beck’s cognitive model, it is assumed that depressed candidates often engage in irrational thinking like attributing any negative events to themselves and positive ones to luck. These subjects simply have a negative view of their past experiences, their present situations and future occurrences, cognitive theories aim to change these thoughts in order to make them in tandem with reality. In this treatment process, therapists help people to understand that their distorted interpretation of their environment is causing their depression. Through the approach, it is possible to teach positive interpretations of experiences by working with patients in a number of sessions. During these encounters, which are often restricted to 20 sessions, therapists work with patients to expose certain contradictions in their thought processes. Each communicative process helps patients identify those thoughts and substitute them with positive ones, usually through verbalization of the problems (Peratikos-Kiritsis, 2010). When treating children with depression, it may be challenging for clinicians to get the child to talk about their problems freely, so a behavioral component may be imperative. When cognitive therapy is combined with behavior therapy, the clinician uses a child’s behavior rather than their words to identify instances of cognitive distortions. Thereafter, the person will apply cognitive models to reverse those negative patterns, usually in a setting that the child is comfortable with. Research to date suggests CBT is effective and successful in the management of childhood depression. 2. Common CBT treatment for depression In order to understand whether CBT is effective, it is necessary to familiarize oneself with treatment strategies; several treatment approaches for cognitive behavioral therapy are available, but this literature review will only focus on three primary approaches: The Penn Prevention Program, Adolescents Coping with Depression and, Cognitive Behavioral Play Therapy (CBPT). All treatment methods rely on identifying situations and problems that the child has experienced and attempt to draw lessons from them; they all have cognitive and behavioral components. In the Penn Prevention Program (PPP), youth between ten to fourteen years, who are susceptible to depression, are targeted for intervention. The method combines both problem-solving interventions as well as CBT by working with participants to determine self-talk and contemplate over the problems they experience. In the problem-solving category, individuals are able to become more assertive and relaxed; they also learn how to come up with ideas, as well as to make decisions on some of the stressors that they encounter daily (Peratikos-Kiritsis, 2010). The PPP therapy is implemented within a small group of participants consisting of teachers, clinicians, counselors and the subjects themselves. Currently, PPP has already been implemented among thousands of children in the country from different socioeconomic and cultural backgrounds. Studies on the efficiencies of the approach have also been conducted and been shown to work; as of now, 17 trials expound on whether the method of therapy works. Alternatively, clinicians may choose to utilize the coping with depression for adolescents model or CWD-A, which is also for adolescent children between the ages of twelve and eighteen. In this strategy, children attend 16 group sessions stretched over 8 weeks for 2 hours each session and get to interact with a clinician. Throughout the sessions, youth learn about their mood by monitoring it and identify some of the pleasant activities that may cause depression. Participants are challenged to rethink their distorted thoughts and to become better at dealing with certain interpersonal factors like conflict resolution or social skills. For slightly younger patients, it may be more effective to rely on CBPT, which is a modified version of CBT with additional features appropriate for young children. It assumed that CBT may not work on non-adolescents or very young children because they are at a stage in their development where their cognition is not sophisticated enough to respond to the therapy. These subjects may not have an effective way of thinking about their irrational thoughts because their superegos (the part of the personality responsibility for moral conscience) are still not well developed. Therefore, therapists ought to find ways of communicating with their subjects through methods that they can relate to in order to decipher how the child’s world is like (Peratikos-Kiritsis, 2010). When applied in a clinical setting, the therapist could try to work with stuffed animals or puppets when modeling the strategy. The child is usually encouraged to reenact problems or situations using this assistive tools, and find solutions using the same approach. Therefore, instead of relying on verbal methods of communication, children gain coping skills through mechanisms that are familiar to them. In the above therapeutic program, professionals do not focus on the negative outcomes that the child is experiencing; instead, the clinician ought to bring out their strengths. Professionals have numerous approaches to implementing the strategy as options can only be limited by their lack of creativity. One way of implementing it would be to read characters in a book; the child would then be asked to identify traits that are similar to theirs and ways that they would approach their own challenges. CBT combines both cognitive and behavioral approaches in therapy and this is prevalent in all of the above treatment approaches. Therapists using this method often attempt to correct how people think (which is the cognitive aspect) with how they act (the behavioral part). All strategies acknowledge the fact that people’s behavior changes depending on the physical and emotional components. 3. Comparison of CBT with medicine CBT may also be treated with medicine because analysts postulate that depression has biological links, which can be corrected with the right compounds. The first type of medication is commonly referred to as TCA, which is an abbreviation for tricylcin antidepressants. These medicines have shown minimal to no effects on patients in clinical trials, yet they have exhibited a number of side effects. It has been shown that children are more susceptible to cardiac arrest or toxic shock when exposed to these forms of therapy than when they are not. Furthermore, Lohoff (2010) indicates that a careful balancing act must occur in order to prevent accumulation of the drugs to toxic levels; the key limitation here was the study subjects were few. This often requires a thorough analysis of the blood concentrations of the drugs in the subject; in addition, the treatment may lead to constipation, blurred vision, dry mouth and drying of secretions from the bronchial region. For this reason, another treatment approach was used as lethal overdoses are too extreme for any treatment outcome. Selective serotonin reuptake inhibitors (SSRI) have become commonplace in many clinical treatment programs, and have been found to be less disruptive than TCAs. As the name suggests, these forms of medication work by inhibiting serotonin; it is one of the most significant neurotransmitters in mood determination. Therefore, depressive tendencies often reduce with continued application of the medicine without significant exposure to toxic conditions. However, the method is not without its side effects as some have been reported among adolescents and children alike. Peratikos-Kiritsis (2010) states that SSRIs cause nausea and diarrhea among 10% of the population; in other instances, they may lead to restlessness or the lack of sleep. These could also be accompanied by other relatively mature but prevalent conditions such as sexual dysfunction among adolescents. Perhaps one of the most disturbing issues about SSRIs is their linkage to increased suicide levels among adolescents and the youth. Weisz et. al. (2006) report that a link exist between suicide rates or ideation and the use of anti-depressive drugs among children. A number of stakeholders in the pharmaceutical industry such as the Food and Drug Administration authority and other regulatory agencies in Britain have backed these assertions. Some clinicians have shied away from this treatment alternative owing to those findings while some drug manufacturers have included those contraindications in the packet. It is because of this that in 2004, the FDA even issued a blanket warning against the use of antidepressants for children generally. Some studies have shown that the suicide link in medicine therapy may be minimal if not nonexistent while others have cast doubt on the strength of the association (Ryan, 2005). This last author found that most study designs in which a suicide link was found were based on individual findings and were not adjusted for geographical location. However, when all studies were combined, it was found that SSRIs actually matched with decreases in completed suicide across geographies. Ryan (2005) stated that these findings might be explained by the fact that completed suicides are rare as most adolescents only ideate about it. Furthermore, some individuals may be more predisposed to the risk of suicide than others hence may explain why they will show increased signs on a smaller scale. Weisz et. al. (2006) also did a meta-analysis in which they covered six studies on suicide; it was found that there was actually a reduction in suicidality among the respondents. The major problem with the research was that it relied on papers where a follow-up study could not be done. Regardless of the above findings, it is still not conclusive that medicine for depression in children is free from the risk of suicide, so it can only be taken at a patient’s own prerogative. Aside from the potential risks associated with medication, one must also consider the effectiveness of the drugs when prescribed for depression. Ryan (2005) also did a meta-analysis on the above subject and found that the key drug that was efficient in treatment of childhood depression was flouxetine. The major limitation here was too much reliance on other meta-analyses, such as one done by the FDA in 2004. Other drugs such as paroxetine and nefazodone were found to have minimal effect on treatment outcomes, and these assertions were augmented in other analyses. Shugart and Lopez (2002) also did an analysis that wanted to determine the short-term effects of anti-depressive drugs in patients taking flouxetine. It was found that among the 96 subjects, only 33% responded to treatment while the rest did not; in addition, remission occurred after a one-year follow-up. The key limitation was the geographical limitation of the study subjects, which may put into question its generalizability. This casts doubts on the long-term efficiency of the medication and its ability to eradicate depression without excess dependence on it. In comparison, cognitive behavior therapy has also elicited mixed reactions from analysts and therapists alike; some studies find that CBT is not effective while others do. Wesz et. al. (2006) did a meta-analysis of several studies that analyzed the effectiveness of cognitive behavior therapy among children and found that the treatment works. However, the key limitation of their study was statistical significance was relatively low in comparison to others thus showing that the method is not fail-safe. Additionally, they asserted that there were no lasting treatment effects; in comparison to medication, it appears that CBT does not offer a more superior alternative. Spirito et. al. (2012) also found that CBT was particularly preferable in handling certain depressive challenges like suicidality because treatment options can accommodate it. The key limitation of the above paper was that it did not focus on overall reduction of depression; its major concern was suicidality as a component of depression. A comparison of the two treatments together in some studies has shown that drugs yield 61% efficacy over a 12-week period while CBT only created 43% difference in outcomes. However, the remission rates had reverse outcomes among participants as the antidepressant flouetine has the highest percentage; that is 23%. Conversely, only 16% of patients remitted and 17% accounted for the placebo, which is a sign that drugs may only be effective in the short run (Rohde et. al., 2008). Furthermore, it was found that there were significant differences in outcomes over a period of 36 weeks and more among the above patients. Rohde et. al. (2008) stated that sustained response rates among depressed children remained at 62% for pharmacologically treated patients and 77% for cognitive behavior therapy alone. The key limitation in the above study is that its definition of long term follow-up was only 36 weeks – a 2 year or 5 year study may be preferable. 4. Long term benefits of CBT over medication Since a biological component exists in determining the causes of depression, it makes sense that pharmacological treatment would be considered. However, toxicity levels for children are highly alarming in comparison to adults, so their use should occur cautiously. Research on their effectiveness in the long-term is not conclusive thus putting stakeholders in a precarious position. One should note that these side effects or risks are completely absent in CBT; the only concern for CBT is that it may not work on the patient or might lack long-term effects. Conversely, the same is not true for a pharmacological approach as it may put subjects at a worse health risk than they were before they took the medication. The analysis has also shown that both forms of treatment do not appear to have a long-term impact thus proving that booster sessions later on may be appropriate. CBT may have a particular advantage over drugs in this regard because sustained response rates over medium periods seem to be much higher. If the substance or dose of CBT is increased, it may lead to improved results, yet when the same is done for drugs, some unwanted physical outcomes could result. For this reason, it may be plausible to consider CBT, as a superior alternative to medication for depression among young children. Clinicians may simply need to change the way they structure their programs or increase booster sessions later in order to make it long lasting. 5. Conclusion In the future, it would be insightful to study whether CBT has prolonged effects when booster sessions are increased; scientists should concern themselves with complementary combinations of CBT and drugs as well and see how effective this is. The major limitations among most of the paper was that they never followed up on patients for more than one year; aside from the meta-analyses, most studies were not spread across various geographies; they were not easily generalizable. Overall, the research has shown that CBT is an effective treatment for depression among children, and poses no physical or mental risk. Conversely, the same is not true for drugs which may have a suicide risk and some side effects on young patients, so their administration must be done with caution. In terms of prolonged cure of depression, CBT also has promising results; this can be improved if more if booster sessions are added. References Forsell, Y. (2007). A three-year follow-up of major depression, dysthymia, minor depression and subsyndromal depression: Results from a population-based study. Depression and Anxiety, 24, 62-65. Lohoff, F. (2010). Overview of the genetics of major depressive disorder. Curr. Psychiatry Rep., 12(6), 539-546. Shugart, M. & Lopez, E. (2002). Depression in children and adolescents: When moodiness merits special attention. Postgrad Med., 112(3), 53-6. Spirito, A., Esposito, C., Wolff, J. & Uhl, K. (2012). Cognitive-behavioral therapy for adolescent depression and suicidality. Child Adolescent Psychiatr. Clin. N. Am., 20(2), 191-204. Peratikos-Kiritis, A. (2010). Cognitive behavioral play therapy for children with depression: A manual for individual treatment. Connecticut: University of Hartford Rohde, P., Silva, S., & Tonev, S. (2008). 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