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Of the many forms of psychotherapy offered to treat depression in youth, Cognitive Behavioural Therapy (CBT) has been shown to be efficacious. Nonetheless, a high degree of apparent non-responsiveness, failure to remit post-treatment, and lack of long term benefit are all problematic. Given that regular participation is critical to treatment success, child and family predictors of attendance were researched.
Twenty-nine depressed Canadian youth (aged 10–17) participated in a youth only or youth plus parent CBT group. Child and parent predictors of attendance were examined.
Youth who were younger, less anxious (by maternal report), and had more formally educated parents attended CBT more consistently. Further, mothers who perceived their children’s depressive symptoms as more severe, whose children reported more depressive and anxious symptoms, and who reported more life stressors attended more parent sessions.
This study identifies key factors influencing youth and parent attendance in group CBT for depressed youth. Addressing these factors at the outset of treatment may decrease attrition in this form of psychotherapy.
L’efficacité de la thérapie cognitivo-comportementale (TCC) dans le traitement de la dépression des adolescents n’est plus à démontrer. Toutefois, le taux élevé de non-réponse apparente au traitement, le fait que les symptômes subsistent après le traitement, et l’absence d’avantages à long terme sont problématiques. Cet article étudie les prédicteurs de participation, car la participation régulière de l’enfant et de sa famille est essentielle à la réussite du traitement.
Vingt-neuf jeunes Canadiens (âgés de 10 à 17 ans) ont participé à un groupe de TCC, seuls ou avec leur parents. Les prédicteurs de participation de l’enfant et de ses parents ont été analysés.
Les enfants plus jeunes, moins anxieux (d’après la mère) et dont les parents étaient plus éduqués assistaient plus régulièrement aux séances de TCC que les autres. Les sujets dont les symptômes dépressifs étaient plus sérieux (d’après la mère), ceux qui présentaient davantage de symptômes de dépression et d’anxiété et ceux qui avaient signalé un plus grand nombre de stresseurs dans leur vie assistaient à davantage de séances avec les parents que les autres sujets.
Cette étude définit les facteurs clés qui influencent la participation des enfants et des parents aux groupes de TCC. Aborder ces questions au début du traitement peut contribuer à réduire le nombre d’abandons en cours de thérapie.
It has been well established that depression in youth impacts their current functioning and has potential long lasting consequences well into adulthood (Costello et al., 2002). Of the many forms of psychotherapy offered to treat depression in youth, Cognitive Behavioural Therapy (CBT) is the most widely researched. Several meta-analyses have been published demonstrating the efficacy of CBT with depressed youth (Lewinsohn & Clarke, 1999; Michael & Crowley, 2002; Weisz et al., 2006). Each meta-analysis pointed to varying effect sizes, ranging from .34 to 1.27. Effect sizes differed because of the number of studies, inclusion criteria, and statistical methods utilized in the meta-analyses. Nonetheless, the literature also demonstrates a high degree of non-responsiveness to CBT, a very slow response in the absence of concurrent medication, high attrition rates, and frequent failure to remit post-treatment (TADS, 2004; Weisz et al., 2006). Moreover, the significant effects initially found at post-treatment were rarely maintained at follow-up (Weisz et al., 2006). A paucity of literature exists into mediators and moderators of effective treatment of depressed youth with CBT (Weisz et al., 2006).
Predictors of outcome in CBT for depressed youth included factors related to youth (e.g., age and comorbidity; Berman et al., 2000; Michael & Crowley, 2002), family (e.g., parental involvement in therapy and parental psychopathology; Lewinsohn et al., 1990), and study characteristics (e.g., attrition rates; Weisz et al., 2006). The present study was designed to ascertain which of several youth, family, and study factors are most predictive of consistent CBT attendance, a prerequisite for successful treatment. Existing research with respect to these factors in relation to youths’ recovery from depression is first reviewed. No studies have examined these factors in relation to CBT attendance.
With respect to age, a meta-analysis revealed that the overall effect size for adolescents (i.e., 13 and over) is better than children (i.e., 12 and under; Costello et al., 2002). Possible reasons include that older youth have better-developed cognitive skills and can thus benefit more from CBT (Weisz et al., 1997) or that younger children are more dependent on environmental influences to recover from depression. In contrast, another study found that younger age predicted better recovery from depression following CBT than older age (Clarke et al., 1992). A potential explanatory hypothesis is that younger children have less entrenched depression and are thus more amenable to therapy than older children.
Given that 25 to 50% of youth with a depressive disorder also have a co-morbid anxiety disorder (Axelson & Birmaher, 2001), evaluating the role of anxiety in CBT outcome trials for depression is critical. The presence of co-morbid anxiety predicted lower depression recovery (Clarke et al., 1992) and the presence of co-morbid depression predicted poorer anxiety recovery (Berman et al., 2000). However, a meta-analysis found that CBT utilized to treat depressed youth also reduced anxiety symptoms (Weisz et al., 2006). Specifically, anxiety acted as a moderator such that CBT had a stronger effect on depressive symptoms in those with co-morbid anxiety (Rohde et al., 2006).
Overall level of family functioning influences service utilization with this population (Velhurst & van der Ende, 1997). For example, one of the best predictors of youth depression is parental depression, particularly in mothers (Beardslee et al., 1998). Moreover, parental psychopathology affected treatment outcomes in youth with anxiety disorders and depression (e.g., Berman et al., 2000). Specifically, parents’ self reported psychopathology in general, and depression in particular, was higher for those children in the treatment “failure group” compared to those from the “success group” (Berman et al., 2000). Often associated with parental psychopathology is parent-child conflict, which itself has been related to the maintenance of depressive disorders in youth (e.g., Birmaher et al., 2000).
Parents’ perceptions of the severity of their children’s symptoms may influence their decision to seek services (Logan & King, 2002) and thus time to recovery among depressed adolescents treated with CBT (Rohde et al., 2006). Once parents seek treatment, it is widely believed that parental involvement is crucial in therapy (Clarke et al., 1999). However, research is equivocal as to the advantage of adding a parental component to CBT with depressed youth. On the one hand, Lewinsohn et al. (1990) found a trend for larger therapeutic effects with an adolescent plus parent group compared to an adolescent group alone or waitlist control. Similarly, self-rated adolescent depression scores were found to be lower in the adolescent plus parent group compared to the adolescent group alone (Clarke et al., 1992). Conversely, Clarke et al. (1999) found no significant difference between an adolescent alone and adolescent plus parent group.
Attrition rates vary greatly for CBT with this population, ranging from 0% to 71% with a mean of 12.8% and a median of 9.5% (Weisz et al., 2006). This is unfortunate, as participation in therapy is a prerequisite for response to CBT. No studies have evaluated whether attendance moderates treatment outcome.
The present study was designed to evaluate factors affecting attendance and thus potentially the efficacy of CBT treatment. Depressed youth participated in a youth only or youth plus parent CBT group. Youth and parent characteristics affecting participation were examined. The following were hypothesized: (1) parental attendance would predict youth attendance; (2) youth’s age and co-morbid anxiety symptoms would affect attendance; however, due to the equivocal literature, directionality was not predicted; (3) mothers who self-reported more parenting stress and depression would be less likely to attend; and, (4) mothers who reported more severe symptoms in their children would attend more groups.
A total of 29 Canadian youth (16 male and 13 female) ranging in age from 9.85 to 16.90 years (M age = 13.31 years) were recruited to participate in the study. All participants had been referred for treatment to an urban, outpatient, mood and anxiety program due to a primary diagnosis of Major Depressive Disorder (MDD) or Dysthymic Disorder (DD). Comorbid diagnoses were permitted, as long as MDD or DD was the most impairing condition. Diagnoses were confirmed by the Anxiety Disorders Interview Schedule for the DSM-IV (ADIS; Silverman & Albano, 1996) conducted with both the parents and youth by experienced clinicians trained for reliability. The ADIS is a well-validated semi-structured diagnostic interview that probes for internalizing disorders in detail and screens for externalizing disorders. The ADIS also assesses for clinical impairment. All youth were at least moderately impaired, based on initial clinician ADIS data. Excluded from the study were youth with developmental delays and those who lacked fluency in English or suffered from psychosis. To ensure representation of a broad spectrum of severity and consistent with the benefits demonstrated in the TADS study (2004) for combining CBT and medication, concurrent antidepressant medication was permitted as long as the dosage was stabilized at least one month prior to starting CBT. Participants were compensated for their travel.
All parents of participants under 16 years of age and all youth 16 years of age and older provided written, informed consent prior to their participation. Youth under 16 years of age provided assent to participate in the study. This study was approved by our Research Ethics Board.
Participating families were assigned to either a Cognitive Behavioural Therapy group with parent participation (CBT+P; n= 18) or without parent participation (CBT; n = 11). Groups were offered whenever four or more adolescents within a 3-year age range were available for participation. Randomization of the groups was attempted but not entirely successful due to slow rate of recruitment. Accordingly, group assignment depended upon the type of group offered at time of referral1. Due to the lack of randomization, participants in the two treatment conditions were compared on demographic characteristics and pre-treatment measures (see below). Group differences were addressed in subsequent analyses.
In both CBT groups, youth participated in a manualized program (of 15 sessions2) entitled “Getting Back on Track: A Group Cognitive Behavioural Therapy Program for Depressed Youth” (Monga & Shaw, 2005, unpublished manuscript available from the authors) developed from established, evidence-based CBT manuals. Components of the group included: psychoeducation around depression; learning how to identify one’s feelings; practicing relaxation techniques; discerning personal triggers for depressed mood; establishing new strategies for coping with low moods; understanding the importance of an active lifestyle; recognizing the connection between thoughts, feelings, and behaviour; how to challenge negative thoughts; as well as, how to care for yourself and build positive support systems.
Parents assigned to the CBT+P group participated in a manualized program (of 15 sessions2) based upon the book, “Helping Your Teenager Beat Depression” (Manassis & Levac, 2004 available from the authors) outlining an empathic, problem-solving approach for parents to help facilitate their children’s recovery. Components of the group included: helping parents understand the spectrum of their teenager’s mood (from sadness to suicidality); teaching parents problem solving techniques to use with their teenager; outlining healthy habits to instil in youth; discussing the comobidity of depression and anxiety, and how these disorders affect the whole family; and, helping parents cope with difficulties at school and with peers.
Therapists leading both youth and parent groups were seasoned clinicians of medical, nursing, and psychological backgrounds, each with several years of prior CBT experience with youth and parents. Parent and youth groups were independent, yet provided concurrently to facilitate attendance. Each session was 1.5 hours in length. Pre- and post-group measures were administered separately to the youth and their parents. Groups were audiotaped and a proportion of the tapes (10%) were scored by an independent rater for treatment fidelity, using a checklist for session content and important process elements. The adherence checklist was based upon DeRubeis and Feeley (1990), but modified for use with youth.
Youth completed paper and pencil questionnaires about their general functioning, as well as their depressive and anxious symptoms. Parents completed paper and pencil questionnaires about their children’s functioning, their own depressive and general psychological functioning, as well as their perceived parenting stress. Experienced, independent clinicians blind to treatment assignment or to pre- versus post-treatment status assessed the youths’ global functioning via the Children’s Global Assessment Scale (CGAS) from the DSM-IV (APA, 1994). The Wechsler Intelligence Scale for Children-III (WISC-III; Wechsler, 1991) was conducted to examine participants’ cognitive abilities. All measures chosen have demonstrated reliability and validity. Measures were administered to ensure comparability of subjects in the two treatment conditions, and to examine hypothesized predictors of attendance.
Youth self-report measures. Youth’s depressive symptoms were assessed with the Children’s Depression Inventory (CDI; Kovacs, 1992), a 27-item self-report inventory such that responses are rated on a 3 point scale ranging from 0 to 2, with higher scores indicating greater symptom severity. The Anhedonia subscale consists of 8 items with a Cronbach α = .66. Youth’s anxiety symptoms were evaluated with the Multidimensional Anxiety Scale for Children (MASC; March, 1997), a 39-item self-report measure (ranging from 0, i.e., never true about me, to 3, i.e., always true about me). The Anxiety Disorder Index (consisting of 10 items) was created to assess youth who would also probably be diagnosed with an anxiety disorder, and has internal reliability coefficients ranging from α=.60 to α=.64 depending upon the age and gender of the sample. The Social Anxiety subscale (consisting of 9 items) produced internal reliability coefficients ranging from α=.79 to α=.86 depending upon the age and gender of the sample. Youth completed the Youth Self Report (YSR; Achenbach & Rescorla, 2001), a 112 item self-report inventory of functioning (ranging from 0, i.e., not true, to 2, i.e., very true or often true). Factor analyses have revealed 2 broad-band (i.e., Internalizing and Externalizing Problems) and 8 narrow-band (e.g., Anxious/Depressed, Somatic Complaints, and Withdrawn/Depressed) dimensions of Behavioural disturbance.
Parent Measures. Parents completed the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) about their children’s general functioning. The 118-item inventory (ranging from 0, i.e., not true, to 2, i.e., very true or often true) is comparable to the YSR, with the same broad- and narrow-band scales. The Anxious/Depressed, Withdrawn/Depressed, DSM-Oriented Anxiety Problems and DSM-Oriented Somatic Problems subscales consist of 13, 8, 6, and 7 items, respectively; and, have Cronbach alpha’s equal to .84, .80, .72, and .75, respectively.
Parents completed The Brief Symptom Inventory (BSI; Derogatis, 1993) about themselves. The BSI is a 53 item self-report inventory to assess psychological symptom patterns (ranging from 0, i.e., not at all, to 4, i.e., extremely). Three global indices and 9 dimensions (e.g., Depression and Anxiety) can be obtained. Parents completed the Beck Depression Inventory-Second Edition (BDI-II; Beck et al., 1996) about their own depressive symptoms. The BDI contains 21 self-report items rated on a 4 point scale ranging from 0 to 3, with higher scores indicating greater symptom severity.
Parents completed the Parenting Stress Index (PSI; Abidin, 1995), a 101-item questionnaire developed to assess child and parent characteristics associated with stressors in the parent-child system. Parents rate 89 statements on a 5 point scale ranging from strongly agree to strongly disagree. The remaining 12 questions are based upon a 4 or 5 point scale, with higher scores indicating greater discord. From the Total score, Child and Parent Domains can be obtained. The Parent Domain consists of 54 items and has a reliability coefficient equivalent to .93.
Attendance indices. A youth attendance index was created after viewing the histogram of attendance such that they were classified as either low attendance (i.e., attended less than 2/3 of sessions; n = 14) or high attendance (i.e., attended 2/3 or more of sessions; n = 15).
With respect to parental attendance, some parents were not offered the parent group, some parents who were offered the group did not attend frequently, and some parents were consistent attendees of the group. Accordingly, an index of parental attendance was created and parents were classified according to 1 of 3 categories: (1) no parent sessions offered (n = 11), (2) low attendance (i.e., attended less than 2/3 of sessions; n = 10), and (3) high attendance (i.e., attended 2/3 or more of sessions; n = 8). When predicting parental attendance, only the latter 2 categories were used.
Based upon parent report, 48.3% of the youth were Caucasian, 24.1% were of a visible minority, and 27.6% did not report their racial or ethnic background. Sixty-nine percent of the participants’ parents were living together. Among mothers, 41.3% possessed a college/university degree, 13.7% completed some college/university, 10.3% completed some secondary school, 3.4% finished secondary school, and 31% did not report their education level. Among fathers, 27.6% possessed a college/university degree, 20.7% completed some college/university, 10.3% finished secondary school, and 41.4% did not report their education level. Among households, 27.6% reported an income over $60 000, 13.7% between $40 000 and $60 000, 6.8% between $20 000 and $40 000, 13.7% earned less than $20 000, and 37.9% did not report their family income. According to the Hollingshead classification system, the mean socioeconomic level of participants was Level III (e.g., skilled craftsmen, sales workers), and all classes were represented.
In order to ensure that no group differences existed pretreatment, t tests and −2 tests were conducted on key variables. There was no significant difference in attendance of youth between the CBT and CBT+P group (t (27) = 0.061, p = .95). On self-report measures, no differences in pretreatment measures were found between groups (CBT versus CBT+P) for the total CDI (t (25) = 0.054, p = 0.96), total MASC (t (17) = .247, p = .81), and YSR (total: t (10) = 0.24, p = .81; and, internalizing: t (10) = 0.17, p = .87). Additionally, no group differences in overall IQ was found (t (17) = 0.61, p = .55). On maternal reports, no differences between groups were found in the CBCL (total: t (12) = .317, p = .77, and internalizing: t (12) = 0.02, p = .98) and BSI (depression: t (14) =0.42, p = .68; and Global severity index: t (14) = 0.49, p = .64). Moreover, no pretreatment group differences were found on clinician rated CGAS (t (25) = 0.17, p = .87).
There was a significant group difference between female and male participants (−2 (1) = 5.58, p = .018), such that more males were assigned to the CBT+P. Youth’s age differed between groups such that those assigned to the CBT+P group (Mean = 12.53, SD = 1.53) were younger than those assigned to the CBT group (Mean = 14.58, SD = 1.54; t (27) = 3.50, p = .002).
Youth attendance. Separate independent sample t-tests were performed with youth’s attendance (high, low) as the independent factor for age, CDI, MASC, CBCL, and parent education. Please see Table 1 for details. The following significant differences were found for: (1) youth’s age, such that younger children attended more consistently; (2) mother’s CBCL-DSM Anxiety and Somatic Domain score, such that mother’s who reported less anxious symptoms in their children had higher attending children; and, (3) parents education, such that parents with more formal education had children who attended more frequently. Additionally, mothers who reported more anxious and depressed symptomatology (mother’s CBCL Anxious/Depressed Subscale) had children who tended to attend the group less frequently.
Parental attendance. Separate independent sample t-tests were performed with parental attendance (high, low) as the independent factor for age, CDI, MASC, CBCL, PSI, and parent education. Please see Table 2 for details. The following significant differences were found for: (1) youth CDI-Anhedonia subscale, such that youth who saw themselves as more anhedonic had parents who attended more frequently; and, (2) youth MASC-Anxiety Disorders index and Social Anxiety subscale, such that youth who reported more anxious symptoms had parents who attended more often. Additionally, the following trends occurred: (1) Mothers’ CBCL-Withdrawn/Depressed subscale, such that mothers who reported more symptoms of depression in their children were more likely to attend; and, (2) Mother’s PSI-Life Stress Index and Parent Domain, such that mothers who reported more life stresses and poorer general functioning were less likely to attend.
It has been well established that CBT is efficacious in treating depression in youth, though to variable degrees depending on the study. In some studies, a high degree of non-responsiveness is found, as well as very high attrition rates. The latter may account for some of the apparent non-responsiveness. Given that depression in youth impacts their current functioning and that attendance is needed for treatment to be effective, the present study sought to ascertain which characteristics are most predictive of youth and parental attendance. Although conclusions must be tempered by the small sample size and other limitations (see below), our main hypotheses were confirmed.
In predicting attendance, younger participants were found to attend more often. Potentially, the didactic approach used in CBT is more developmentally consistent with the school-focused attitudes of preteens, versus adolescents’ greater focus on peers and their own emerging autonomy. Alternatively, parents may be better able to influence their younger children to attend regularly, compared with their older children. Although age has not been investigated with respect to attendance in the CBT literature, better attendance may partially account for the finding that young age predicted better recovery from depression following CBT than older age (e.g., Clarke et al., 1992).
In the current study, youth whose mothers reported more anxious symptoms in their children attended less regularly. This finding is interesting in light of the existing literature which points to a lower recovery rate among depressed adolescents with co-morbid anxiety and anxious adolescents with co-morbid depression (Clarke et al., 1992). Perhaps participants with this co-morbid condition attended less frequently, were thus less likely to benefit from treatment, resulting in lower recovery rates. Alternatively, the group format may have been perceived as threatening by anxious youth, resulting in avoidance of sessions.
In contrast, children who saw themselves as more anxious had mothers who attended more often. Similarly, mothers who saw their children as more depressed pretreatment participated in the groups more frequently. This finding is consistent with the literature, which illustrates how parents’ perceptions of their children’s symptoms influence their help seeking behaviour (Logan & King, 2002). Perhaps mothers who saw their children as suffering more from depression and co-morbid anxiety felt more stressed in their parenting role and more helpless to aid their children. This may have led to greater recognition of the need for professional help and to attend the program more regularly.
In predicting youth attendance, we found that parents who reported more education had children who attended more often. Additionally, mothers who reported less life stress (independent of the parent-child relationship, e.g., death of a loved one and economic hardship) attended the group more frequently. More educated families may understand and thus value psychiatric or psychological intervention more than less educated families. Alternatively, these parents may have greater job flexibility. Further, lack of life stressors may have made it easier for families to focus on their child’s treatment. By offering all treatment free of charge and compensating families for the cost of travel to the clinic, we had hoped to offset this effect somewhat.
The generalizability of these findings is limited by the small sample size and underrepresentation of some racial groups. Studies with larger, more diverse samples are indicated to replicate these findings. The lack of a truly random design is also unfortunate, though it speaks to the challenges of engaging this highly impaired population in psychotherapy research. Studies in community (rather than academic) settings could further examine generalizability, and qualitative studies could better examine youths’ own perceptions of what helped and hindered their treatment participation.
This study identifies potential factors influencing attendance in group CBT for depressed youth. Should they be replicated in a larger study, may be confimed as key. Addressing these factors at the outset of treatment may decrease the attrition rates commonly found in this form of psychotherapy. For example, addressing parental stressors (e.g., the stress of parenting depressed youth and mental health factors) may help to increase both parent and child participation. Particular attention may be needed to engage older depressed youth, who appear less amenable to parental influences on participation. Methods to optimize treatment engagement in this population merit further study.
The authors wish to acknowledge the generous financial support of the Tremain Family for this research via the Centre for Addiction and Mental Health Foundation. Dr. Manassis and Ms. Levac receive royalties from the book “Helping Your Teenager Beat Depression.” The authors wish to thank the families who participated in this research project. Also, the authors are grateful to Tamara Arenovich for her invaluable statistical input.
1The first 2 groups were the CBT+P and the remaining groups alternated between the two types.
2Please note that due to SARS some groups had the content of some sessions condensed into 1 session. All material was equally presented. Moreover, participation scores were reflected as a percentage of attendance to account for number of sessions offered.