Effectiveness of CBT in private practice: Children

www.cbtaustralia.com.autania@cbtaustralia.com.auleigh@cbtaustralia.com.au

Pietrzak, T., Morgan, L., Collard, J., Gilson, K., Wong, G., Pope, G., O’Kelly, M.

Copyright Dr Tania Pietrzak CBT Australia 2015

7 Good Reasons to treat childhood disorders? 1. Globally 20% children suffer disabling mental illness. 2. Suicide 3rd leading cause of death among adolescents. 3. Up to 50% of adult mental disorders have origins in

childhood. 4. Child mental health problems common, serious and linked

to pre-mature death, serious adult dysfunction, school failure, criminality, drug/alcohol dependence, accidents, self harm, sexual risk taking.

5. Increased burden to family, community, government. 6. Unrecognized childhood disorders lead to harsh physical

punishment, abuse, stigmatization, exclusion. 7. Adolescence vulnerable time

Directive from Coalition

• Psychologists are directed to use focused psychological strategies: CBT

• ATAPS 12-18 & Better Access 10 sessions per calendar year, previously 16.

• Unclear future of Better Access

• Coalition has not yet stated its position on mental health funding nor contributed its mental health policy to APS on their key mental health issues.

Purpose of Study

To evaluate whether treatment of children using CBT in private psychology practice under government funded initiatives is effective.

Hypotheses1. Children would have a statistically significant

and meaningful decrease in total behavioral problems, anxiety & depression from pre to post test at time 1 (first review) and time 2 (second review)

2. Children would have a statistically significant and meaningful increase in outcome ratings (well being) and session ratings of therapeutic alliance from pre to post test at time 1(first review) and time 2 (second review).

•Seven psychologists – all with clinical endorsement•PhD – 3, D Psych – 2, M Clin Psych – 3•All completed advanced training course with CBT

Australia•Commenced associate fellowship training in REBT •Training at Beck institute – 3•One also trained at Albert Ellis Institute- fellowship

Method•Ethics approval obtained from Monash University

Human Research Ethics Committee•Data collection commenced Feb 2014 and

continued for 24 months• Client consent obtained for participation in study

at first session.•Uniform measures taken at 1st, 6th, 10th and final

sessions •CBT intervention .

Assessment

a) Centre For Epidemiological Studies Depression Scale for Children (CES-DC)

b) Spence Anxiety Scale (child version)

c) Child Behaviour Checklist

40-60% youth drop out of treatment (Kasdin, 2004)

Often mandated to come by parents

Little control over therapy process leading to poor engagement

Therefore to monitor and improve children’s effectiveness in treatment we included:

a) Child Outcome Rating Scale (measure of child’s self reported wellbeing) (Miller 2003; Duncan et al., 2006)

b) Child Session Rating Scale (self report measure of therapeutic alliance) (Miller; 2003; Duncan et al., 2006)

Giving children a voice

Me (How am I doing?) I----------------------------------------------------------------------I

Family (How are things in my family?) I----------------------------------------------------------------------I

School (How am I doing at school?) I----------------------------------------------------------------------I

Everything (How is everything going?) I----------------------------------------------------------------------I

Institute for the Study of Therapeutic Change _____________________________________ www.talkingcure.com © 2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks

ResultsClients N

Total number consenting 92

Children Retested on measures at T1: Range 27-58

Children Retested on measures at T2: Range 2-9

Demographic ResultsGender: Male – 46.48% Female – 56.52%

Age: Range 3 years -16 years Median 9.97 years SD 3.25

Education: Range Kinder - Year 11

Funding: Medicare – 76.09% Private – 2.17%

ATAPS – 13.04% TAC – 1.09%

Helping children with autism – 7.61%

Previous diagnosis: 64.13% had no previous diagnosis

Previous treatment: 51.09% had no previous treatment

Medication: 78.26% not on medication

CBCL: paired sample t-tests M

preM Post 1st Review

M change

SD t p Classification

Total n=33

62.4 50.06 12.42 22.2 3.2 .003 **

Borderline to normal

Demographic Predictors of change on CBCL : ANOVA• Education level predicted change (improvements) for

attention problems F 2.37 (df 9), p=04 and a trend towards reducing somatic complaints F 2.26 (df 9), p=0.056.

• Year 7s had greatest reduction

• Previous diagnosis predicted change (worse) for social problems F 4.34 (df 1 ), p=0.046

•Medication trend towards predicted change (improvement) on attention problems F 3.89 (df 1), p=0.057

Results: Depression paired sample t-testsClinical Cut off Score 15

M pre

M Post 1st Review

M change

SD t p Classification

CES-DC (n=29)

22.03

18.1 3.93 9.81 2.16

.004 **

Remains clinical

Spence (N=27)

36.19

29.48 6.7 11.14 11.11

P<0.0001***

Post test scores in normal range

Results: CORS & C-SRS

M pre

M Post 1st Review

M change

SD t p ClassificationORS cut off 32SRS cut off 36

ORS (n=58)

25.24 32.00 -6.7 8.24 -4.12 <.0001 Below to within range

SRS (n=51)

33.2 36.45 -3.24 5.63 6.19 <.0001 Below to within range

M Pre

M Post 2nd Review

M change

SD t p

ORS(n=9)

27.27 33.54 -6.27 5.9 -3.19 0.01 Below to within range

SRS(n=8)

32.79 38.77 -5.98 3.45 -4.9 0.002**

Below to within range

Effect Sizes- meaningful sizeable difference between pre- post test

Pre- Post T1

Pooled SD

Cohen’s D Effect Size

Pre -Post T2 Pooled SD

Cohen’s D Effect Size

*CBCL 31.22 0.398 (small) 17.99 1.19 (large)

CES-DC 12.05 0.33 (small) 15.92 0.38 (small)

*Spence 17.44 0.38 (small) 9.06 0.88 (large)

**ORS 8.13 0.83 (large) 6.32 0.99 (large)

*SRS 5.26 0.62 (medium)

2.87 2.08 (large)

Discussion

• For children aged 3 - 16 years, CBT has a statistically and clinically significant impact on reducing anxiety, depression & total behaviour problems as early as 6 sessions

• Preliminary data with small sample sizes at time 2 meant low statistical power

• Children’s anxiety on average moved from the elevated to normal range at the end of the sixth session.

• Depression – symptoms reduced, but remained within the elevated range, harder to treat within 1 cycle of therapy, consistent with literature.

Discussion

• Education Level (year 7) predicted reduction in attention problems over time. No effects were found for previous treatment, gender or previous diagnosis.

• A trend: medication predicted a reduction on attention problems.

• Implications for the use of medication with CBT to treat attention problems

Discussion

• The inclusion of the SRS and ORS provides valuable information for the clinician in relation to their understanding of the child’s well-being and feeding this back to the child to enhance effectiveness outcomes.

• Children’s ratings of therapeutic alliance improved longer they stayed in therapy.

•Many of the children may find it difficult to evaluate their own anxiety, but can more easily estimate their wellbeing on a scale

Limitations

• The nature of work with children can often be chaotic and therefore completing outcome measures can often be overlooked

• No follow-up data to assess whether change is maintained

• Greater sample sizes at time 2 needed… our difficulties reflected both attrition (we don’t know why some children stopped therapy just before or after 1st review) and difficulties obtaining & having feedback measures returned.

Future research

• This study did not evaluate the parent’s perception of the child’s anxiety or the impact of parenting interventions on child outcomes. • Inclusion of parent ratings of child wellbeing and parent

wellbeing on the C-ORS and ORS may be helpful to increase even greater effectiveness of child outcomes

• Evaluations at 3 and 6 months follow up to see how change is maintained.

• Do children with neurobiological disorders (ADHD and Autism) progress differently through treatment compared to children with other diagnoses?