Mental health problems (MHP) for children and young people (CYP) are on the rise. As many as one in six school-aged children experience a MHP, which has increased from one in nine in 2017 (NHS Digital, 2020). Additionally, up to 75% of MHPs are first experienced before the age of 25 (McGorry et al., 2007).
Cognitive Behavioural Therapy (CBT) is at the forefront of treatment for MHP. CBT involves managing thoughts and behaviours to positively impact on our mood (Beck, 2011). There is extensive literature reporting the safety and effectiveness of CBT in adults, as well as the treatment satisfaction felt by patients (Zhang et al., 2019; Craske, 2017). However, the literature is scarce in reporting the satisfaction of children and young people who receive CBT. This is important to discover, as patient-centred care and satisfaction are primary drivers for healthcare delivery (Pellicano et al., 2014; Batbaatar et al., 2017). Moreover, they underpin the NHS constitution.
Choque-Olsson and colleagues (2021) investigated this issue in their research. Their primary aim was to “investigate the reporting quality of treatment satisfaction in identified studies” in a systematic review. Their secondary aim was to “investigate the level of treatment satisfaction with CBT among children and adolescents with anxiety and depression”.
The researchers conducted a systematic review, searching four electronic databases and conducting a meta-synthesis of the studies they found and included.
The methodologies of the studies included were randomised controlled trials (RCTs), experimental, quasi-experimental, and observational studies. All studies were published in English, focusing on treatment satisfaction with CBT among children and adolescents (0-21 years old) between 1948-2019.
The eligibility of the data was initially reviewed independently by three individuals, and four reviewers assessed the full text papers. Any disagreements were resolved by a consensus discussion. A sensitivity analysis was conducted, and a checklist used for reliability.
The heterogeneity of the data meant a strict meta-analysis could not be conducted. To investigate treatment satisfaction, a meta-synthesis was performed using studies with a defined point-scale.
The initial literature search yielded a total of 1,825 articles. After screening, 35 articles reached the criteria for quality assessment. This included 22 RCTs, 12 quasi-experimental, and 1 semi-structured interview.
The sample included 6,631 participants. The majority of the studies included male and female participants. The age range of the sample was 4-17 years old.
The reporting quality on treatment satisfaction was found to be moderate to good. The analysis found that only four studies described patient satisfaction as a primary objective. Other papers focused on efficacy, feasibility and acceptability, using satisfaction as a secondary objective.
- The majority of studies reported high satisfaction with CBT, with five reporting moderate to high satisfaction, and three reporting moderate satisfaction.
- The pooled mean and standard deviation was 28.2 (SD = 2.9) on a total mean 1-32 point scale, and 2.9 (SD = 0.2) on a 1-5 point scale.
- In the ten studies using percentages, the proportion meta-analysis level of satisfaction was high, RE (k=10) = 0.84 (CI 0.79-088).
The authors concluded that:
The results of the review showed moderate to good reporting quality of data, measure, informants and results.
The majority of the studies showed a moderate to high treatment satisfaction with CBT among children and adolescents with anxiety and depression.
Strengths and limitations
To the authors’ knowledge, treatment satisfaction with CBT for children and young people has not been systematically reviewed before. They addressed this gap in the literature using a clearly focused question and appropriate research design.
The broad definition used in the search strategy allowed for a large sample of papers to be identified. The use of a consensus method mitigated selection bias.
There are some limitations:
- The review included studies with multiple research designs. For the quality of the analysis to be enhanced, future research may use a homogenous design, as the authors acknowledge.
- Publication bias is another limitation. Only studies published in English were included. Studies with positive findings are more likely to be published in an English-language journal than studies with inconclusive findings (Bigby, 2014). This, along with only four databases used in the search, means that valid studies may have been omitted from review.
- Lastly, the search strategy did not extend to grey literature. Grey literature can reduce publication bias by including studies with null or negative results that might not otherwise be disseminated. It can therefore lead to a more balanced picture of the available evidence. This may limit the validity of the claims made.
Implications for practice
The variable definition of treatment satisfaction suggests that a consensus is required for measuring treatment satisfaction, e.g. a ‘checklist’. This would strengthen the reliability of future studies.
This review has found that CBT is accepted by many children and young people, which has clinical practice implications. This corroborates with studies showing the effectiveness of CBT, and validates the position that CBT currently has as a leading treatment option for children and young people. It won’t work or be acceptable by all, but that’s true of all treatments.
The review found that only four of the 35 studies explored treatment satisfaction as a primary objective. This brings into question whether patient-centred care is truly at the forefront of research and practice. Seeking perspectives from CYP using CBT is an important avenue for future research, as this could facilitate knowledge regarding treatment preferences. This would avoid shoe-horning CYP into a CBT ‘box’, instead offering personalised care to meet individual needs.
Statement of interest
Choque-Olsson, N., Juth, P., Högberg-Ragnarsson, E., Lundgren, T., Jansson-Fröjmark, M., & Parling, T. (2020). Treatment satisfaction with cognitive-behavioral therapy among children and adolescents with anxiety and depression: A systematic review and meta-synthesis. Journal of Behavioral and Cognitive Therapy, 31, 147-191.
Batbaatar, E., Dorjdagva, J., Luvsannyam, A., Savino, M., & Amenta, P. (2017). Determinants of patient satisfaction: A systematic review. Perspective in Public Health, 137, 89-101.
Beck, J. (2011). Cognitive behavior therapy: Basics and beyond. (2nd ed.), New York: The Guildford Press.
Bigby, M. (2014). Understanding and evaluating systematic reviews and meta-analyses. Indian Journal of Dermatology, 59, 134-139.
Craske, M. (2017). Evaluation. In Craske, M. (Ed.) Cognitive Behavioural Therapy (pp. 127-139). American Psychological Association.
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Zhang, A., Borhneimer, L., Weaver, A., Franklin, C., Hang-Hai, A., Guz, S., & Shen, L. (2019). Cognitive behavioural therapy for primary care depression and anxiety: A secondary meta-analytic review using robust variance estimation in meta-regression. Journal of Behavioural Medicine, 42, 1117-1141.