Long-Term Effects of Combined Cognitive Behavior Therapy and Parent Training for Childhood Depression: 2-3 Year Follow-U

1. Combined Individual Cognitive Behavior Therapy and Parent Training for Childhood Depression: 2- to 3-Year Follow-Up Catherine Lennox EDPS 635 Summer 2016

2. Guiding Questions • Should Cognitive Behaviour Therapy combined with Parent Training be considered an evidence-based treatment for childhood depression? • What is the long-term evidencethat these treatments are efficacious in treating childhood mood disorders?

3. Study rationale • Depressive disorders prevalent and impairing pediatric conditions (American Academy of Child and Adolescent Psychiatry, 2007) • Up to 2% of children experience depression (Health Link BC, 2015) • Children diagnosed with Major Depressive Disorder (MDD) during childhood were 2-4x more likely to develop depression as young adults (Wagner, Ambrosini, Rynn, Wohlberg, Yang, Greenbaum, Childress, Donnelly, Deas, 2003).

4. Study rationale • Parent training programs have been shown to be effective in improving children’s mental health and parental competency • Webster-Stratten & Herman (2008): Incredible Years (IY) Parent Training (PT) program reduced internalizing symptoms in children compared to wait-list control • De Graaf, Speetjens, Smit, de Wolff, Tavecchio (2008): Triple P Level 4 interventions reduced dysfunctional parenting styles in parents and improved parental competency.

5. study: Rationale • Cognitive behavioral treatment (CBT) the most frequently evaluated and best supported psychosocial treatment for children with depression (Curry, 2001) • CBT superior to no treatment or non-CBT alternative programs in almost all studies for school-age children with depressive symptoms (Curry, 2001) • CBT superior to alternative psychosocial interventions during acute treatment but not at longer term follow-up (Curry, 2001) • Benefits for children with depression modest and short-lived; heterogeneity in treatment response (ex. 36% did not improve) (Eckshtain & Gaynor, 2012)

6. study: Purpose & HYPOTHESIS • PURPOSE: Provide data on the long-term effects of combined CBT and parent training treatment conducted by Eckshtain & Gaynor (2012). • HYPOTHESES: • Maternal caregivers will report positive relations with children compared to pretreatment assessment • Children will report positive relations with caregivers compared to pretreatment assessment • Report of poor caregiver-child relations at pretreatment and post-treatment would be related to higher levels of child depressive symptoms 2-3 years later

7. study: Sample • 14 children and their caregivers • Elementary or middle school; semi-rural community • Average age: 10.27; 9 females, 5 males; 12 Caucasion; 2 multiracial • Referred by school professionals after scoring 11+ on Children’s Depression Inventory • 80% had received psychotherapy; 46.7%- psychiatric medications • If receiving psychiatric medication, stable dose for at least 2 months at time of enrollment • Caregivers: 4- both caregivers; 1- paternal only; 9- maternal only

8. Study: PROCEDURE • Parental consent; child assent • Caregivers and children: self-report inventories • Treatment: • 23 sessions over a 3- to 4- month period • CBT: Primary and Secondary Control Enhancement Training Manual (PACSET) • Sixteen 45 minute sessions • Parent training: Caregiver-Child Relationship Enhancement Training (C-CRET); PASCET manual • Seven 60 minute sessions • Long-term treatment assessment: • 4: 2 years post-treatment • 4: 2.5 year post-treatment

9. Study: MEASUREs Children’s Depression Inventory (CDI): • 27 items • 3 choices (0,1, or 2) • Higher scores  greater severity • Test-retest reliability= 0.67; acceptable internal consistency • http://www.mhs.com/product.aspx?gr=edu&id=overview&prod=cdi2 Strengths and Difficulties Questionnaire (SDQ) • 25 items • 3 point scale; scores range from 0-40; abnormal (16-40); borderline (12-15); normal (0-11) • Reliability= 0.70-0.85; internal consistency= 0.51-0.76 • https://www.cafcass.gov.uk/media/215237/child_aged_11-16.pdf

10. Study: MEASURES • Parent-Child Relationship Questionnaire (PCRQ) • Warmth, closeness, positive disciplinary strategies, parental power assertion, and possessiveness • Children: 40-item youth version • Caregivers: 57-item version • 5-point scale: 1(hardly at all)  5 (extremely much) • Higher totals  better parent-child relationship • http://www.midss.org/content/parent-adult-child-relationship-questionnaire-pacq

11. STUDY: RESULTS at 2- to 3- year follow up • CDI: • No statistically significant changes in scores between post-treatment scores and follow-up scores  gains were maintained across long-term follow up period • SDQ: • No statistically significant change in scores between post-treatment scores and follow-up scores  gains were maintained across long-term follow up period

12. STUDY: RESULTS at 2- to 3- year follow up • Parent–Child Relationship Questionnaire: Maternal Caregiver Report (N = 13): • Significant worsening of relations • Relationships still significantly better than pre-treatment scores  some endurance of improved relations Parent–Child Relationship Questionnaire: Child Report (N = 14): • No significant changes in relationships with maternal caregivers compared to pre-treatment • No significant changes in relationships with paternal caregivers compared to pre-treatment • Significant worsening of relationships compared to immediately post-treatment

13. Study: limitations • Small sample size • Open clinical trial design  differences in when follow-up data was collected • Longitudinal design  subject attrition, time • Absence of control group  were changes due to treatment or other factors (ex. concurrent psychotherapy, medication)?

14. Study: conclusions • Preliminary evidence supporting the positive long-term effects of combined individual CBT with parent training for the treatment of childhood depression • Importance of targeting caregiver–child relations • CBT and parent training should both be considered evidence-based treatments supported by research and viable options for treating childhood depression

15. Discussion questions: 1. What outside factors could account for the deterioration in the parent-child relationship over the course of the study? 2. How valid are child self-reports? 3. In your opinion, how important is parent involvement in the treatment of childhood psychological disorders (i.e. anxiety, depression)?

16. References: • American Academy of Child and Adolescent Psychiatry. (2007). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11), 1503– 1526. • De Graaf, I., Speetjens, P., Smit, F., De Wolff, M., & Tavecchio, L. (2008). Effectiveness of the Triple P Positive Parenting Program on Parenting: A Meta-Analysis. Family Relations, 57 (5), 553-566. • Curry, J.F. (2001). Specific psychotherapies for childhood and adolescent depression. Biological Psychiatry, 49:12, 1091–1100. • Eckshtain, D., & Gaynor, S. T. (2012). Combining individual cognitive behavioral therapy and caregiver-child sessions for childhood depression: An open clinical trial. Clinical Child Psychology and Psychiatry, 17(2), 266–283. doi:10.1177/1359104511404316

17. References: • Eckshtain, D., & Gaynor, S.T. (2013). Combined individual cognitive behaviour therapy and parent training for childhood depression: 2- to 3- year follow-up. Child & Family Therapy, 35(2):132-143. • Health Link BC (2015). Depression in Children and Teens. Retrieved July 29, 2016 from http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=ty4640 • Wagner, K.D., Ambrosini, P., Rynn, M., Wohlberg,C., Yang, R., Greenbaum, M.S., Childress, A., Donnelly, C., Deas, D. (2003). Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder two randomized controlled trials. Journal of the American Medical Association, 90(8):1033-1041. • Webster- Stratton, C.W., & Herman, K.C. (2008). The impact of parent behavior- management training on child depressive symptoms. Journal of Counseling Psychology, 55(4): 73–484.