In adolescents with chronic fatigue, cognitive behaviour therapy was more effective than remaining on a waiting list in reducing severity of fatigue, improving physical functioning, and increasing school attendance. Furthermore, treatment resulted in a greater proportion of patients with clinically significant change in these variables, more self reported improvement, and a significant reduction in several additional symptoms. These results endorse the findings of previous studies on the efficacy of cognitive behaviour therapy for adults with chronic fatigue syndrome.4,5
Passive and active patients showed equal improvements on all primary outcome variables. Furthermore, rates of improvement were larger than seen in the study by Prins et al, in which only one protocol was used to treat all patients.4
We tried to maximise inclusion by repeatedly informing general practitioners and paediatricians about the study and prolonging recruitment. Nevertheless, our final samples were still relatively small. This may be due to underdiagnosis because of unfamiliarity with adolescent chronic fatigue syndrome or may point to reluctance in doctors to diagnose this syndrome. Alternatively, chronic fatigue syndrome may be less common than previously estimated.3
We believe that our results can be generalised to other adolescents who fulfil the diagnostic criteria for chronic fatigue syndrome as our patients were referred from a large part of the Netherlands.
Six patients (19%) withdrew from therapy, which is higher than in most adult studies on cognitive behaviour therapy in patients with chronic fatigue syndrome.5
Most withdrawals occurred in the first half of the study, suggesting that therapists became more experienced in meeting the specific need for enhancing motivation of adolescent patients. As we did not have reference scores for activity pattern in adolescents, we used scores for adults. Fortunately, our results showed that mean activity levels and distributions of types of activity were similar to those in adults. Thus the use of reference scores for adults should not have led to misclassification.
Almost 60% of the patients in the immediate therapy group returned to full time education, an important indication of recovery. We consider that return to school is most difficult when adolescents lose contact with school and classmates and experience longstanding social isolation. In these cases other possibilities to guarantee education should be explored, such as considering a new school.
The prevalence of additional symptoms decreased significantly in immediate treatment group. Nevertheless, as in a previous report,21
many young people in both groups continued to report additional symptoms. Apparently, a complete resolution of additional symptoms is not a requirement of recovery, as has been suggested before.22
This study is the first randomised controlled trial to show that cognitive behaviour therapy can successfully be used to treat adolescents with chronic fatigue syndrome. As the prevalence of chronic fatigue syndrome seems to be lower than previously thought, we would not recommend widespread implementation of cognitive behaviour therapy but suggest that treatment should be centralised in specialised medical centres so that therapists can accumulate knowledge and maintain proficiency.
What is already known on this topic
Cognitive behaviour therapy is an effective treatment for chronic fatigue syndrome in adults, and one uncontrolled study has shown that it can reduce fatigue in adolescents
Chronic fatigue syndrome in adolescents can affect normal development
What this study adds
A cognitive behaviour therapy programme based on gradually increasing activity and challenging perpetuating beliefs helped adolescents with chronic fatigue syndrome
Relatively active patients as well as those with a passive physical activity pattern benefited from tailored therapy