Pediatric Psychosomatic Department The Edmond and Lily Safra Children’s Hospital

1. Cognitive Behavioral Therapy of Depressive Disorders and Suicidality in Children and Adolescents Daniel Stein, M.D. Pediatric Psychosomatic Department The Edmond and Lily Safra Children’s Hospital The Chaim Sheba Medical Center, Tel Hashomer Affiliated with the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv

2. References Beck JS: Cognitive Therapy: Basics and Beyond. New York: Guilford Press, 1995 Beck JS: Cognitive Therapy for Challenging Problems. New York: Guilford Press,2005 Brent DA, Poling K: Cognitive Therapy Treatment Manual for Depressed and Suicidal Youth. Pittsburgh, PA: Services for Teen at Risk (STAR) Publications, 1997 Brent DA: Assessment and treatment of the youthful suicidal patient. Annals of the New York Academy of Science. 932:106-28; discussion 128-31, 2001 Sherrill JT, Kovacs M: Nonsomatic treatment of depression: Child and Adolescent Psychiatric Clinics of North America 2002 11:579-93, 2002 Butler AC, Chapman JE, Forman EM, Beck AT: The Empirical Status of Cognitive-Behavioral Therapy: A Review of Meta-Analyses. Clinical Psychology Review,26:17-31, 2006

3. References Vitiello B, Brent DA, Greenhill LL, Emslie G, Wells K, Walkup JT, Stanley B, Bukstein O, Kennard BD, Compton S, Coffey B, Cwik MF, Posner K, Wagner A, March JS, Riddle M, Goldstein T, Curry J, Capasso L, Mayes T, Shen S, Gugga SS, Turner JB, Barnett S, Zelazny J. Depressive symptoms and clinical status during the Treatment of Adolescent Suicide Attempters (TASA) Study. Journal of the American Academy of Child and Adolescent Psychiatry 2009;48(10):997-1004. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review 2009; 26 (1): 17-31.

4. References • דאי-גבאי א, מור נ. דכאון. מתוך: מור נ, מאיירס י, מרום צ, גלבוע-שכטמן א. טיפול קוגניטיבי התנהגותי בילדים. הוצאת דיונון, תל אביב, 2011, ע' 167-190 • סטארק קד, סטרייסנד ו, ארורה פ, פאטל פ. דיכאון בגיל הילדות. מתוך: טיפול בילדים ובמתבגרים. עורך קנדל פס, תרגום אבישי י', 2012, ע' -373302 • ספיריטו א, אספוסיטו-סמיתרס כ, ויסמור ג', מילר א. התנהגות אבדנית אצל מתבגרים. מתוך: טיפול בילדים ובמתבגרים. עורך קנדל פס, תרגום אבישי י', 2012, ע' 374-409

5. Lecture Plan Cognitive Behavioral Therapy (CBT) – Basic Principles Core Beliefs (Schemas) Intermediate Beliefs Automatic Thoughts Principles of CBT Structure of Therapeutic Session Treatment of Suicidal Adolescents TASA-CBT CBT in Children & Adolescents – Clinical Considerations Advantages Limitations

6. Lecture Plan TASA-CBT-Key Characteristics & Primary Techniques Safety Plan Chain Analysis Development of Adaptive Coping Skills Cognitive Restructuring Distress Tolerance Problem Solving Behavioral Family intervention Relapse Prevention Practical Considerations

7. Cognitive Behavioral Therapy (CBT) – Basic Principles Cognitive behavioral therapy (CBT) is defined in terms of the cognitive model rather than the specific set of techniques employed The CBT model emphasizes the importance of the individual’s perception of the world - primacy of meaning of event Psychopathological disorders are conceptualized in terms of persistent disordered thinking, derived from embedded dysfunctional beliefs Improvement results from evaluation and modification of dysfunctional thinking Evidence-based treatment

8. Principles of CBT in depression •  of non-depression related behaviors  the risk for the development of depression •  in dysfunctional depression-related cognitions may also  the risk for the development of depression

9. Principles of CBT in depression • These cognitions include: •  in competence;  in helplessness •  in hope;  in hopelessness •  in rumination of these negative cognitions  in the ability to distract from these cognitions & in the ability to problem-solve

10. Core Beliefs (Schemas) Core beliefs – early-onset, deep-seated (unconscious) & persisting beliefs concerning oneself, significant others, & the world around Characteristics in psychopathology: rigid, global, (always, never) ("ככה") considered absolute truth ,self-critical, negative irrational dysfunctional

11. Characteristic Core Beliefs Lack of self-esteem (eating disorders, narcissistic disturbances, depression) Beck’s cognitive triad in depression – negative perception of oneself (helpless, unlovable, worthless) the world around (inefficiency) the future (hopelessness) Insecurity, vulnerability, nothing is certain, catastrophic misinterpretation of sensations (anxiety disorders)

12. HELPLESSNESS CORE BELIEFS I am inadequate, ineffective, incompetent, can’t cope. I am powerless, out of control, trapped. I am vulnerable, likely to be hurt, weak, needy, a victim. I am inferior, a failure, a loser, not good enough, defective, don’t measure up.

13. UNLOVABLE CORE BELIEFS I am unlovable, unwanted, will be rejected or abandoned, will be always alone. I am undesirable, unattractive, ugly, boring, have nothing to offer. I am different, defective, not good enough to be loved by others.

14. WORTHLESSNESS CORE BELIEFS I am worthless, unacceptable, bad, crazy, broken, nothing, a waste. I am hurtful, dangerous, toxic, evil. I don’t deserve to live.

15. Intermediate Beliefs in Depression Core beliefs-worthlessness/helplessness/hopelessness General beliefs – People feel this way because nothing they do is good enough; as there is no way to change this condition, the best thing is not do anything, just wait till things are over, till something happens, although this will, likely, not be the case Personal rules/personal expectations– I expect nothing from myself or others; no one should expect anything from me

16. Intermediate Beliefs in Depression Conditional assumptions – If I do nothing, or if no one sees me, no one will criticize me. Self criticism will prevent/ compensate for criticism from others Compensatory strategies – rigid, dichotomous, prevailing, constant, avoidance, seclusion, self-criticism, self-blame (carried out to protect oneself, but only  cognitive distortions)

17. Characteristics of Automatic Thoughts Arise spontaneously Unnoticed (preconscious), associated emotions more often recognized Specific thoughts → specific affects: I am a failure → depression I do not know what will happen tomorrow → anxiety Individual unaware of presence, but easy to elicit

18. Characteristics of Automatic Thoughts Often brief & fleeting, in telegraphic form (I am worthless) Verbal and/or imagery Accepted as true, no reflection/evaluation Universal; evaluated according to validity & functionality In psychopathology - rigid, absolute truth, dysfunctional

19. Dysfunctional Automatic Thoughts (Cognitive Distortions) All or nothing (dichotomous) thinking Catastrophizing Emotional reasoning Mind reading Overgeneralization Personalization Discounting positive/magnifying negative

20. Eliciting Automatic Thoughts •   What thoughts, images, feelings went through your mind when the • specific event occurred (when thinking about the event) •    Ask question when noting a shift in affect during session • IF NEEDED •    Have the client describe a problematic situation. When noting • affective shift ask “what was going through your mind just then” • Focus on emotions (what were you feeling), then ask about connected • thoughts •    Imagine situation •    Role-playing

22. Principles of CBT Focus on present (here & now), problem-oriented Structured (each session, whole treatment process, homework, supervision) )Time-limited (improvement continues also after termination of treatment Psychoeducational (familiarizes client with the CBT model, emphasizes relapse prevention) )Importance of clients’ active role between sessions (homework Emphasizes therapist/client collaboration

23. Structure of Therapeutic Session 1. Setting agenda 2. Bridge from last session 3. Reviewing homework assignment from last session (e.g., mood check, activity chart, identification of dysfunctional automatic thoughts)

24. Structure of Therapeutic Session • Important to provide rationale for homework • Ensure that clientsees homework as meaningful, understands assignment, agrees to perform assignment & is able toperform homework (experience of success) • Give explicit instructions • Start & rehearseassignment in session • Insistence on completion ofassignment.

25. Structure of Therapeutic Session • Important to provide rationale for homework • Ensure that clientsees homework as meaningful, understands assignment, agrees to perform assignment & is able toperform homework (experience of success) • Give explicit instructions • Start & rehearseassignment in session • Insistence on completion ofassignment.

26. Principles of CBT Principles similar regardless of specific psychopathology Three stages 1. Psychoeducation on cognitive model, introduction of behavioral techniques to replace maladaptive with adaptive behavior Cognitive technique to modify dysfunctional cognitions .2 3. Maintenance of change, prepare patient for termination, relapse prevention

27. TREATMENT PLANNING 1. Initial Stage • Establishing the therapeutic relationship • Providing psychoeducation • Setting goals • Socializing patient with the cognitive model

28. Socializing patients with the process of therapy • Solving current problems/working toward goals • Eliciting, evaluating, responding to automatic thoughts • Modifying dysfunctional behaviors • Teaching coping strategies

29. 2. MIDPHASE • Continue previous activities • Identify/conceptualize/modify dysfunctional assumptions/beliefs • Identify and modify dysfunctional coping strategies

30. 3. Final Phase • Continue above activities • Prepare patients for termination • Problem-solving for predicted difficulties

31. 3. Final Phase • Teach self-therapy • Identify early warning signs of relapse/ recurrence • Develop (written) plans for relapse/recurrence

32. 3. Final Phase • Restart mood check, activity chart • Plan every day ahead • Plan alternative activities & social contacts at • times of risk • Confide in trustful others

33. CBT in depressed children and adolescents • Treatment of depression in children & adolescents includes two stages • 1. Amelioration of depressive symptoms in the acute stage • 2. Continuation of treatment to integrate the skills learned in the acute stage in the long-run

34. CBT in depression in children and adolescents - Principles • Definition of treatment goals: focused, limited (minimal), hierarchy, written plan • Psychoeducation for kid & parents: e.g., difference between anergia and laziness; written handouts • Self-monitoring of mood, hopelessness, suicidality, weekly goal checking

35. CBT in depression in children and adolescents - Principles • Behavioral activation & integration of enjoyable activities: structured time table of ADL with increasing hierarchy of challenge • Behavioral activation may  both depressive symptoms & negative dysfunctional cognitions • In severe depression, start with behavioral activation & maintain it until some improvement in depressive symptoms is achieved before moving to cognitive module

36. CBT in depression in children and adolescents - Principles • Development of problem solving & personal and interpersonal coping techniques • Cognitive restructuring: • Patient & therapist work together in the “court of thoughts” • What is the evidence supporting the dysfunctional cognition • Is there another possibility (raise doubts) • What is the evidence supporting the new, more functional cognition

37. CBT in depression in children and adolescents - Principles • Involvement of parents, goals for parents: depend on the developmental phase of the kid & the abilities of the family; individual or group parental consultation; goals can change during treatment •  social skills & social relations; solving social problems • Consolidation of change & relapse prevention; the importance of booster sessions

38. CBT in depression in children and adolescents - Principles • CBT in depressed children & adolescents usually requires 12-16 individual sessions • If required, specific modules may added for comorbid problems, e.g. anxiety, impulsivity, mood dysregulation, family & social problems

39. The Treatment of Adolescents with Depression Study (TADS, March, 2004, 2007) • 439 adolescents with varying severity of MDD • 12 CBT sessions, Fluoxetine, CBT + Fluoxetine, Placebo • Hierarchy of improvement • CBT + Fluoxetine (71%) • Fluoxetine (61%) • CBT (43%; not significantly different from placebo) vs. 60% in Brent et al’s (1997) study • Placebo (35%)

40. The Treatment of Adolescents with Depression Study (TADS, March, 2004, 2007) • No differences after 9 months (86% improved in the combined treatment; 81% in each separate treatment) • No depression after 9 months: • 55% Fluoxetine • 64% CBT • 60% CBT + Fluoxetine • SSRIs speed the reaction to treatment rather than enhance it • Suicidal attempts/ideation: Fluoxetine 14.7%; CBT 6.3%; CBT + Fluoxetine 8.4%

41. ACTION Model for the treatment of depressed young adolescents (NIMH; Stark et al, 2005a,b ) • 158 depressed girls age 9-13 • CBT  parents consultation vs. TAU (minimal contact) • 22 biweekly sessions; small groups in school settings • No post-treatment depression: • 84% in CBT • 81% percent in CBT + parents consultation • 46% in the control condition • Multiple specific CBT elements were associated with improvement (but not non-specific therapist-related factors)

42. Trials in Depressed Suicidal Adolescents Treatment trials for depressed adolescents typically exclude: Actively suicidal teens Often exclude those who are not acutely suicidal but have a history of suicidal behavior Analyzing data of “new occurrences” of suicidal behavior in the context of these trials is problematic

43. Treatment of Depressed Suicidal Adolescents: State of the Art Only a few psychosocial trials of existing therapies show efficacy data targeting suicidal behavior in teens, with decreased attempts as outcome Only a few empirically supported, accessible treatments for suicidal teens specifically target suicidal behavior (DBT is geared more for borderline personality disorder than for depression)

44. Treatment of Depressed Suicidal AdolescentsTASA-CBT David Brent, Kim Poling - Pittsburgh PA Greg Brown - University of Pennsylvania, PA John Curry, Karen Wells - Duke University, NC Betsy Kennard - Southwestern University, TX Barbara Stanley, Larry Greenhill - Columbia University, New York, NY

45. Modules of TASA-CBT Cognitive interventions - based on CT (Beck and colleagues) Behavioral interventions - based on dialectical behavioral therapy (DBT) (Linehan and colleagues) Family therapy with behavioral focus Psychoeducation about depression & suicide

46. Key Characteristics of TASA-CBT Treatment is brief & goal-oriented, narrow in focus and narrow in goals - prevention of future suicidal behavior Depressive adolescents have in addition multiple emotional problems, difficult family situations, frequent school difficulties & comorbid disorders, requiring other interventions in combination with TASA-CBT

47. Key Characteristics of TASA-CBT In a brief treatment, only the most important & immediate treatment goals are addressed The target suicide attempt is the centerpiece of the treatment Other problems are addressed primarily in the way that they relate to suicidality

48. Key Characteristics of TASA-CBT Case conceptualization Identify skills, deficits & dysfunctional thinking that led to the suicidal behavior Identify the adolescent’s strengths & natural approach to problem solving – e.g., cognitive vs. behavioral - and enhance these strengths first

49. Primary Techniques Safety plan: Emergency plan Chain Analysis: Awareness of circumstances that resulted in the attempt - “Behavior is understandable. Things do not just happen.” Development of skills to cope in the future with circumstances similar to those leading to present suicide attempt. How to cope with: a. immediate precipitants b. long term vulnerability factors Relapse prevention: Revisiting the suicidal event with the new skills developed in treatment

50. Safety Plan: What it is Hierarchically-arranged list of coping strategies for use during a suicidal crisis or when suicidal urges emerge Plan is a written document Uses a brief, easy-to-read, format Involves a commitment to the treatment process