Cognitive-behavioral therapy for depression in youths

Depression is one of the most common psychological disorders in children and
adolescents. Prevalence rates vary between 2% and 8% (AACAP, 1998; Birmaher
e.a., 1998; De Wit & Kroesbergen, 1992). Cumulative prevalence rates are about
35% for females and 19% for males at the age of eightteen (Lewinsohn & Clarke,
1999). These numbers plea for the development of effective treatments of
depression in youths. In 2005, the National Institute for Clinical Excellence
(NICE) has produced guidelines with respect to psychological treatments of
depression in children and adolescents (see for a summary Murray &
Cartwright-Hatton, 2006). According to these guidelines, cognitive-behavioral
therapy (CBT), interpersonal psychotherapy, and short-term family therapy are
among the evidence-based treatents, which have proven its effectiviness in
randomized controlled trials for moderate to severe depression in children and
adolescents.

CBT in children and adolescents can be divided into an operant part and a
cognitive part. The operant part of the treatment is inspired by the work of
Lewinsohn et al. (1984) as well as of Martell et al. (2001), and consists of
gradual increase of pleasurable and satisfying events, excercising social
skills, and teaching problem-solving techniques. The content of the cognitive
part is less strictly defined in the literature. In many protocols, negative
automatic thoughts are traced and challenged by the therapist according to the
methods described by Beck et al. (1979). Additionally, elements form rational
emotive therapy (Ellis, 1962) and increasing coping skills are subsumed under
the heading 'cognitive'.

Research aimed at examining the effectiviness of CBT for depression in children
and adolescents has started in the eighties by means of case studies (see for
example Frame et al., 1982; Petti et al., 1980). These case studies were the
first step towards randomised controled studies examining the effectiveness of
CBT in children and adolescents (see for example Reynolds & Coats, 1986; Stark
et al., 1987; Lewinsohn et al., 1990; Lerner & Clum, 1990; Kahn et al., 1990;
Vostanis et al., 1996; Wood et al., 1996). A meta-analsis in which the
aforementioned studies are included showed a medium effect size (d=0.68) in
reducing symptoms of depression in chilren and adolescents and that long-term
effects are favorable (Reneicke et al., 1998). The effectiviness of CBT can be
increased by involving the parents in the treatment.

One of the recommendations of NICE for future research is comparing the effects
of various psychological treatments for depression in youths. In particular,
there is a need for studies in which parents are involved in the treatment
(Birmaher et al., 1996; Kaslow & Racusin, 1994). This research proposal is a
pilot study (in preparation to a multi-centre trial), in which individual
cognitive therapy for the child is compared to individual cognitive therapy for
the child added by emotion coaching of the parents (Gottman, 1997). The most
important primary goals of this study are to finetune both treatment protocols
on the basis of experiences from therapists and to compute an effect size of
both treatments in order to be able to conduct a power calculation for the
multi-center trial. In addition, the secundary goal of this study is to
evaluate the reduction in depressive symptoms as well as to evaluate the role
of some important process variables. These evaluations will be done in a
descriptive way (will not be statistically tested) due to the limited numbers
of participants.

This study is an intervention study in which youths aged between 10 and 17
diagnosed with depressive disorder are randomly allocated to indidivual CBT or
individual CBT with emotion coaching of the parents. Random allocation to each
of the two treatment arms is done after participants have received information
and signed the consent form. As this study examines the added effect of emotion
coaching, and the effectiveness might depend on the age of the child, we choose
to stratify on age. Youths are divided in two groups: 10 to 12 and 13 to 17
years old. Within these strata, randomisation to either of the two treatment
arms occurs. In all participants, a baseline measurement, measurement after
treatment is completed as well as two follow-up measurements will take place.

The construction of individual CBT is derived from the treatment protocol used
in adults (Boelens, 2004). The CBT is adapted to the perception of the
environment of children and adolescents. The CBT consists of 12 sessions with
the child in which the first six sessions are devoted to operant techniques
(increase pleasurable activities, exercising social skills), whereas the
remaining six sessions are devoted to cognitive techniques according to the
method of Beck (Beck et al., 1979), in which negative automatic thoughts are
being traced and challenged in a way that suits children and adolescents. In
the protocol, there is also room for tracing and challenging anxious
cognitions. The end of the treatment is focused on the prevention of relapse.
Parents are seen three times during the treament: sessions one, six and twelve
(last session).

For emotion coaching, parents are seen four times apart form their child (in
addition to the three times in the CBT protocol). These four sessions are
devoted to emotion coaching. In the first session, a meta-emotion interview
takes place with the purpose of letting parents become aware of their own
emotions. In the remaining sessions, parents learn how to respond to the
emotions of their child (anxiety, depressed mood, and anger). Whit the approval
of the child and the parents, all sessions are taped so that treatment
adherence can be examined. Every session has homework. Both CBT and emotion
coaching have been carefully checked by a group of well experienced therapist.

The burden is minimal and risks are neglectable.