By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
- Seeking an early intervention for common mental health problems in children, before severity requires referral to specialist care, Jeppesen et al developed Mind My Mind (MMM), a form of cognitive behavioral therapy (CBT) designed to be used across diagnoses and in a community setting.
- Three hundred ninety-six youths ages 6 to 16 years participated in this multi-site Danish randomized clinical trial over a period of 18 weeks, with assessment at baseline, 18 weeks, and 26 weeks.
- Children and parents were randomized to nine to 13 weeks of weekly MMM with an additional “booster” session four weeks after completion of the main groups, or management as usual (MAU), which varied according to provider but included at least two care coordination visits.
- The main outcome (Strengths and Difficulties Questionnaire impact score) and multiple secondary outcomes (including anxiety and depressive symptoms) showed significant advantages for the MMM arm vs. MAU at the 18-week conclusion of the intervention, with maintenance of most gains at 26 weeks as well.
SYNOPSIS: This Danish randomized clinical trial compares a new form of cognitive behavioral therapy delivered in a community setting to “treatment as usual” for children and teens with emotional problems and shows advantages in multiple arenas, including parent-reported changes in child distress and impairment.
SOURCE: Jeppesen P, Wolf RT, Nielsen SM. Effectiveness of transdiagnostic cognitive behavioral psychotherapy compared with management as usual for youth with common mental health problems: A randomized clinical trial. JAMA Psychiatry 2021;78:250-260.
One in five Americans will have a diagnosable mental illness at some point in their lifetime. One-half of this group will have onset of symptoms before 14 years of age, and three-quarters will experience onset before 24 years of age. Accordingly, evidence-based studies have looked at early intervention in the treatment of mental illness.1,2
Demonstrating efficacy across a range of childhood emotional and behavioral disorders, cognitive behavioral therapy (CBT), a talk therapy delivered in a structured form and based on exercises to change dysfunctional thinking patterns, is increasingly seen as the “gold standard” in prevention and treatment efforts. However, access to this type of therapy and the availability of specialist care remain as barriers to effective and timely treatment worldwide.3
The problem with access to mental health care, and studies indicating that prevention during childhood can change the trajectory of mental illness in adults, spurred this study. Jeppesen et al designed a transdiagnostic CBT for use in a community setting with emotionally disturbed youth, with problems or symptoms not severe enough to require specialist care. “Transdiagnostic” refers to applicability across diagnostic categories, rather than specific for any one diagnosis. This characteristic provides flexibility to this intervention in addressing the needs of different communities.
Participants aged to 6 to 16 years were recruited from four diverse areas of Denmark. Referral sources included teachers, parents, and primary care providers (PCPs). Parents of referred children completed the Strengths and Difficulties Questionnaire (SDQ), including the related impact score — a brief screening tool for emotional disturbance in children that provides an estimate of impact on overall functioning.4
Inclusion criteria included age, a cut-off score on the SDQ, and a parent and child identified “top problem” of depressive and/or anxiety symptoms and/or behavioral problems. Exclusions from the study included children with a prior clinical diagnosis of mental illness or developmental disorder and families unable to commit to participation in weekly therapy sessions.
A total of 396 participants were randomized to receive either management as usual (MAU), which was enhanced by offering two care coordination sessions in addition to usual management, or Mind My Mind (MMM), the CBT program designed by Jeppesen et al. MMM consisted of nine to 13 weekly CBT sessions led by community-based psychologists and conducted at school or in a nearby office setting. Only 12.5% of these psychologists reported formal training in CBT prior to participating in this program. Training to administer MMM was accomplished within one week, with ongoing supervision throughout the treatment period. Notably, parents of children involved in the MMM arm were engaged in sessions, with specific parenting training being an integral part of the program for youth younger than 13 years of age. The MAU arm interventions varied, ranging from “no intervention” to educational support to psychological treatments.
All outcomes were measured at the conclusion of all sessions (week 18) and again eight weeks later (week 26) to determine maintenance of impact. The primary outcome was parent-reported SDQ impact score (five items; range 0-10, with higher scores reflecting more severe impacts of behaviors), while the secondary outcome measures included parent-reported changes in child anxiety levels, changes in depressive symptoms, school attendance, and child-reported well-being score. Potential harms, including suicidal thinking and poor quality of relationships (family and friends), were assessed at these same times.
RESULTS
In the baseline group (n = 396 children), the mean age was 10.3 years and there was a slight preponderance of boys (52%) vs. girls (48%). Parents identified anxiety as the top problem of concern in 58.3% of the participants, followed by “behavioral problem” in 25.5% and depression in 16.2%. The mean SDQ impact score was 4.16 (moderate impact); 80% of the children met criteria for a Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, diagnosis. At the study’s end, 88.8% of the MMM group had attended nine to 13 sessions (mean of 11.0 therapy groups attended). More than 80% of participants in both arms completed outcome assessments. Results are summarized in Table 1.
Table 1. Outcomes of Transdiagnostic Cognitive Behavioral Therapy in Young Patients |
Outcomes and Possible Side Effects |
18 Weeks |
26 Weeks |
Primary outcome (SDQ impact score in a range of 0-10)* |
- An improvement of 2.34 points in the MMM arm compared to an improvement of 1.23 in the MAU group
- The between-group difference is 1.10; 95% CI, 0.75-1.45; P < 0.01.
|
- An improvement of 2.54 in the MMM arm compared to an improvement of 1.34 in the MAU group
- The between-group difference is 1.20; 95% CI, 0.66-1.74; P < 0.01.
|
Secondary outcome (parent-reported level of child anxiety, depressive symptoms, school attendance, and child-reported well-being score) |
- Significant improvement in child levels of anxiety and depressive symptoms noted by parents,
with P < 0.001
- There was a significant difference in school attendance between the groups (P = 0.009). There was no significant difference in child-reported physical well-being (P = 0.51).
|
- Significant improvement in child levels of anxiety and depressive symptoms noted by parents, with
P < 0.001 continues
- There is no longer a detectable significant difference in school attendance between the groups; difference in child-reported physical well-being remains insignificant.
|
Possible side effects/potential harm** |
- No significant between-group difference in suicidal ideations reported by participants (13.2% in MMM vs. 18.2% in MAU; P = 0.26)
|
- Significant between-group difference in suicidal ideations reported by participants (4.7% in MMM vs. 16.7% in MAU; P = 0.03)
|
SDQ: Strengths and Difficulties Questionnaire; MMM: Mind My Mind; MAU: management as usual; CI: confidence interval *The SDQ impact score reflects the parent-reported functional impact of the child’s emotional problems in many areas, including home, school, and general relationships. **About 10% of the participating youth in each arm reported deteriorating relationships within the family and/or with friends at weeks 18 and 26 (no significant between-group difference). |
COMMENTARY
CBT is a known, effective treatment for children with disorders of mental health, but access to trained providers prevents implementation in many communities worldwide.3 Jeppesen et al present a unique solution to this dilemma, with significant promise for public health adaptation. A CBT program for use across a spectrum of mental health diagnoses, administered without onerous requirements for training and appropriate for children whose symptoms are under the threshold for specialist referral, has the potential to break barriers and reach a wide range of children in a variety of settings.
Before widespread implementation, several limitations of this study are important to examine and understand. Most of the outcome measures were fairly subjective, being contingent on parent-reported evaluation. However, parents played a role in the MMM therapy and, as such, may not have been objective observers of behavior. More concrete measures of behavioral impact and functioning (such as grades at school, number of disciplinary citations or corrections, numbers of hours of sleep) or an impartial observer of behavior blinded to the study intervention, could help in this regard. Of interest, school attendance — one objective outcome measure — did not continue to show significant difference between groups by week 26. This also bears further investigation.
Additionally, it is interesting to consider which aspects of MMM, as designed by Jeppesen et al, were the most significant in achieving outcome measure improvement. Parent involvement was noted to be an integral part of the program, with parents of younger children receiving regular parenting training. It will be important for future studies to identify whether this component alone is effective, or if other components of the intervention are necessary for full efficacy. It also is important to note that sessions were conducted at or near schools, that supervision was provided to psychotherapists, and that follow-up stopped at 26 weeks. These first two conditions may or may not be possible to meet in all communities and may not be fully generalizable.
A longer follow-up period in future studies will be helpful in assessing whether gains are maintained over time. Finally, the cost of MMM or a similar program must be weighed and evaluated. Cost may differ region by region, depending on a multitude of factors and conditions, including the cost of healthcare, space availability, and parent accessibility. One lesson of the COVID-19 pandemic has been that it may be prudent to evaluate the practicality of delivering interventions virtually. There are many promising studies regarding the efficacy of virtual delivery of psychotherapy, but a head-to-head comparison of specific therapies (virtual vs. in-person) is necessary for firm conclusions.
All in all, however, the Jeppesen et al study has the potential for widespread implementation in the future. For now, this investigation serves as a reminder to the primary care provider (PCP) of the importance of early intervention with children demonstrating a wide range of behavioral and/or emotional problems, even if symptoms are not severe enough to require specialist referral. Additionally, this study emphasizes the important role of parent involvement in such an intervention. Although this study leaves us with no specific findings for the PCP currently working with MAU, strengthening a parent component to an early intervention piece may be the most practical implementation of this work available at this time.
REFERENCES
- National Institute of Mental Health. Mental illness. Updated January 2021. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
- McGorry PD, Mei C. Early intervention in youth mental health: Progress and future directions Evid Based Ment Health 2018;21:182-184.
- David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry. Published Jan. 29, 2018. https://www.frontiersin.org/article/10.3389/fpsyt.2018.00004
- He J-P, Burstein M, Schmitz A, Merikangas KR. The Strengths and Difficulties Questionnaire (SDQ): The factor structure and scale validation in U.S. adolescents. J Abnorm Child Psychol 2013;41:583-595.
