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| >>FROM THE EXPERTS CBT for Chronic Medical Illnesses in Children by eva szigethy, m.d., ph.d.  There is growing evidence of the benefit of integrating behavioral health into primary care settings as well as in pediatric clinics. Collaborative care approaches, careful joint monitoring of symptoms, and education have improved outcomes for both depressive and anxiety disorders. Among specific evidence-based psychiatric treatments, there is strong empirical evidence of the effectiveness of cognitive-behavioral therapy (CBT) with children and adolescents, across diverse psychiatric disorders. In addition, targeted CBT approaches have been shown to improve functioning in youth with a wide variety of chronic physical disease. Medication adherence, pain perception, sleep disturbances, and family issues can all significantly impact a child’s ability to cope with physical illness and are common across pediatric diseases. Both individual and family-based cognitive and behavioral approaches can target these domains. One such chronic pediatric disease, inflammatory bowel disease (IBD), which encompasses Crohn’s disease and ulcerative colitis, has high medical morbidity, unpredictable course, complicated treatment options including surgery, and substantial health care costs. In a subset of patients, standard medical care and episodic treatment have been ineffective in controlling these symptoms and can lead to medical resource overutilization. One potential reason for this misallocation of resources is the high rates of neuropsychiatric symptoms such as depression, anxiety, and functional abdominal pain reported in this population. The etiology of such brain effects of IBD is heterogeneous and may result from the physiological impact of the disease-related inflammation, premorbid psychopathology unrelated to IBD activity, and/or from an exaggerated stress response (either from concurrent life stress or the medical traumatization of having the disease or the associated surgical procedures). Each of these pathways to neuropsychiatric symptoms may benefit from individualized treatment algorithms that integrate medical, psychological, and surgical approaches. Adolescents with IBD report impaired health-related quality of life, poor self-esteem, fear of loss of control of bodily functions, and fear of pain and humiliation. Several studies have shown that adolescents with IBD have higher rates of depression compared with community controls and youth with other physical diseases. Our group has shown that depressed youth with IBD receiving CBT demonstrated improved depressive severity, improved functioning, and decreased medical utilization across two different pediatric gastroenterology settings. The CBT was based on a model developed by John Weisz and colleagues in 1997 known as Primary and Secondary Control Enhancement Training (PASCET). It postulates that depressive symptoms can be improved by teaching adolescents a more appropriate locus of control. The PASCET-CBT was modified to include: 1) a focus on illness perception and coping, 2) hypnosis for abdominal pain and immune functioning, 3) education about the relationship between IBD and depression, and 4) emphasis on maladaptive illness behaviors (e.g., disordered eating or medical nonadherence). In addition to content, the structure of this modified CBT was also adapted to the IBD population to include therapy sessions by phone and coupling face-to-face sessions with medical appointments. These changes greatly enhanced compliance with behavioral treatment. Although antidepressants are widely used as adjunctive treatment for severe psychopathology, psychotropic agents have not been systematically studied in randomized control trials in this pediatric population. Antidepressants may have negative synergistic side effects with IBD medications and may be poorly absorbed in patients with severe gastrointestinal pathology. While the initial outcomes of such an integrated psychiatric-medical model of care are promising, several challenges must still be overcome. These include educating both primary care providers about the importance of managing psychosocial issues and hospital administrators about the potential cost savings and improved overall quality of health care delivery. Given the pediatric onset of many chronic physical illnesses, early screening for psychopathology such as depression, easy access to behavioral care with little negative stigmatization, and collaboration with pediatrician and medical subspecialists in the context of a medical-home model may prevent both medical and psychiatric complications later in life. The targeted application of cognitive-behavioral interventions that incorporate a focus on the patient’s and family’s illness narrative offers the opportunity to change dysfunctional trajectories during the critical developmental window when there is optimal plasticity in brain circuitry and development. And as Hippocrates aptly stated, “It is far more important to know what person the disease has than what disease the person has” to achieve the best outcome.
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