Introduction

Though previously believed to be disorders of adulthood, research suggests that pediatric mood and anxiety disorders are common and of significant public health concern. Depressive disorders (major depressive, disruptive mood dysregulation, and premenstrual dysphoric disorders; persistent and/or other specified/unspecified depressive disorders) are characterized by dysregulated mood (dysphoria/irritability) and/or anhedonia, vegetative changes (fatigue, sleep difficulties), and cognitive disturbances (feelings of worthlessness/guilt, thoughts of death/suicide). Though bipolar disorders (bipolar I, II, and cyclothymic disorders; other specified/unspecified bipolar and related disorders) often include depressive episodes, their hallmark lies in manic symptoms (elated and/or irritable mood, pressured speech, grandiosity, decreased need for sleep, risky behavior). Pediatric anxiety is comprised of a larger class of disorders (separation anxiety, generalized anxiety, social anxiety, and panic disorders; selective mutism; specific phobia; obsessive-compulsive disorder; acute/posttraumatic stress disorders), though all are characterized by: fear, anxiety, and/or worry; physiological arousal; and avoidance (or behaviors aimed at prevention) of feared stimuli/outcomes. See the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition for diagnostic criteria [1••].

Internalizing disorders in youth occur frequently and have high rates of comorbidity. A recent epidemiological study with adolescents reported prevalence of 31.9 % for any anxiety disorder and 14.3 % for any mood disorder (11.7 % for depressive disorders; 2.9 % for bipolar I and II disorders) [2]. For school-aged children, anxiety disorders affect 10–20 % of youth [3], while depression and bipolar disorders each impact 2 % of children [4, 5•]. Though comorbidity is the rule, rather than the exception, when it comes to pediatric psychiatric disorders, co-occurrence of mood and anxiety is particularly common [2, 4]. Development of internalizing disorders typically involves interaction between biological vulnerability and environmental stressors. Symptoms follow a waxing and waning course and cause considerable social, academic, and familial impairment.

Regarding intervention, pharmacotherapy is common in treating youth internalizing disorders. However, psychotherapy is vital for teaching coping skills and addressing psychosocial stressors, while healthy lifestyle changes can regulate nutritional/circadian rhythm imbalances. For depression, cognitive-behavioral therapy (CBT) and interpersonal therapy are well established, while attachment-based family therapy and parent-child interaction therapy show promise. Family psychoeducation plus skill building is recommended for bipolar disorders, though CBT, dialectical behavior therapy, and interpersonal and social rhythm therapy have mounting evidence. Healthy lifestyle changes (sleep, diet, exercise) are commonly emphasized in mood disorder treatments. Regarding anxiety, varying formats of CBT are efficacious for separation anxiety, generalized anxiety, and social anxiety disorders, selective mutism, and specific phobia; however, attention bias modification training is also impactful for anxious youth. Regarding disorder-specific interventions, research supports the use of: social effectiveness therapy for social anxiety; panic control treatment for panic disorder; CBT incorporating exposure/response prevention for obsessive-compulsive disorder; and trauma-focused CBT for acute/posttraumatic stress disorders. Below we offer a summary of interventions and evidence classification based on recent research (emphasizing randomized controlled trials [RCTs] and studies of youth with diagnosable internalizing disorders). The Journal of Clinical Child and Adolescent Psychology offers in-depth review of psychosocial treatment outcome studies for depression [6], bipolar disorders [7••], anxiety disorders [8], obsessive-compulsive disorder [9••], and acute/posttraumatic stress disorders [10].

Psychosocial treatments

Depressive disorders

Cognitive-behavioral therapy

  • Overview

    • CBT teaches cognitive restructuring (identifying and challenging negative thoughts/distortions), behavioral activation, problem solving skills, and emotion regulation strategies.

    • This approach may be particularly effective for youth with high levels of cognitive distortion and inactivity.

  • Empirical support

    • CBT has the most empirical support for treatment of adolescent depression, particularly when paired with pharmacotherapy (usually selective serotonin reuptake inhibitors [SSRIs]) [Class I]. For example, in the Treatment of Adolescent Depression Study (TADS), where adolescents were randomized to individual CBT (with parental component), fluoxetine, CBT + fluoxetine, or pill-placebo, combined treatment was associated with the most rapid and complete response [11, 12]. Similarly, in the Treatment of Resistant Depression in Adolescents study (TORDIA), switching antidepressants and adding individual CBT (with parental component) was superior to a medication switch alone [13]. However, according to other RCTs, combined treatment may not offer increased benefit over CBT monotherapy [14] or pharmacotherapy alone [14, 15]. Though the advantage of combined treatment over monotherapy seems to dissipate over time, these reasons are unclear (e.g., uncontrolled treatment usage during follow-up), and shortcomings of studies (e.g., attrition) limit interpretability of this finding.

    • Research also supports the use of CBT as a monotherapy in treatment of adolescent depression [Class I]. Numerous RCTs employing various CBT formats (group, individual, included parental component) and control conditions (waitlist; supportive, family, and relaxation therapies; life skills tutoring) demonstrated significant improvement in depressive symptoms, though between-group differences were not always maintained at follow-up assessments [e.g., 16–19]. One effectiveness study including children and adolescents using a usual clinical care control found significant improvement in depressive symptoms among both groups, though CBT was superior in terms of alliance, cost, length of treatment, and use of other services [20]. Finally, TADS monotherapy outcomes indicated that CBT did not differ from placebo and performed less well than fluoxetine in acute treatment, but monotherapy outcomes converged over time [11, 12].

    • Most psychosocial treatment outcome studies for childhood depression included samples of at-risk youth with elevated symptoms [6]. Though no RCTs focused exclusively on school-aged children with a diagnosable disorder, several RCTs with mixed age groups demonstrated efficacy of CBT for depressed youth [e.g., 19–22, Class I]. In addition, two open trials of CBT-based treatments for school-aged children with diagnosed depression reported promising results [23, 24]. One effectiveness RCT using a mixed sample of children with depression, anxiety, and/or conduct problems demonstrated superiority of a modular intervention (flexible application of CBT) over usual care and standard evidence-based treatments (separate, disorder-specific protocols) [25••]. This study adds to the evidence base for CBT in treatment of youth depression, and also suggests that a flexible approach may be more effective in practice settings.

Interpersonal therapy

  • Overview

    • Interpersonal therapy (IPT) aims to decrease interpersonal conflicts by teaching interpersonal problem-solving and communication skills. Targeted problem areas include grief, role transitions, role disputes, and interpersonal deficits.

    • This approach may be particularly effective for youth with conflictual familial and peer relationships, which often exacerbate depressive symptoms.

  • Empirical support

    • Four RCTs demonstrated the efficacy of IPT in treatment of adolescent depression [Class I]. Two studies found that individual IPT was superior to treatment as usual (TAU) and clinician monitoring in ameliorating depressive symptoms [26, 27]. RCTs of CBT versus IPT showed significant improvement in depressive symptoms overall, but mixed results regarding superiority of intervention [28, 29].

    • As with CBT, most studies of IPT used adolescent samples, though one open trial examining IPT with depressed, school-aged children showed promise, further supporting the use of IPT for depression across development [30, Class IV].

Attachment-based family therapy

  • Overview

    • Attachment-based family therapy (ABFT) aims to strengthen and/or rebuild secure parent–child relationships by targeting: parental criticism/hostility, distress, skills, and disengagement; and adolescent motivation, negative self-concept, affect regulation, and disengagement.

  • Empirical support

    • Though examined less rigorously than CBT and IPT, two small-scale RCTs of ABFT with adolescents using a waitlist control (WLC) and TAU comparisons demonstrated significant reduction in depressive symptoms [31, 32, Class II].

    • One RCT with children investigated a similar family-based treatment (systems integrative family therapy) versus focused individual psychodynamic psychotherapy, and also reported positive preliminary results [33, Class III].

Parent–child interaction therapy – emotion development

  • Overview

    • Parent–child interaction therapy – emotion development (PCIT-ED) was developed for depressed preschoolers and involves strengthening the parent–child relationship via teaching and in vivo coaching of: positive play techniques; effective commands and punishment; and emotional competence and regulation.

  • Empirical support

    • One RCT using a psychoeducation control demonstrated positive, significant results in both groups, though PCIT-ED showed significance in a greater number of domains. PCIT-ED was also superior for executive functioning and emotion recognition skills [34•, Class III].

Healthy diet and lifestyle

  • Overview

    • Eating balanced meals, maintaining a regular sleep cycle, and engaging in physical exercise can also alleviate depressive symptoms in youth by regulating nutritional, metabolic, and circadian rhythm functioning, and also by improving self-esteem and self-cognitions.

  • Empirical support

    • While diet and sleep interventions have not been studied in isolation, many of the aforementioned psychotherapies emphasize healthy lifestyle changes in treatment. In addition, aerobic exercise has shown promising preliminary results in an open study with depressed adolescents [35, Class IV], and is commonly targeted in psychosocial treatment of depression.

Bipolar disorders

Family psychoeducation plus skill building

  • Overview

    • Family psychoeducation teaches families about mood symptoms, course, and effective treatment, while skill building involves symptom management strategies (e.g., CBT, problem solving, communication, emotion regulation).

  • Empirical support

    • This intervention has the most empirical support in treatment of pediatric bipolar disorders [Class II]. It has been examined adjunctive to TAU and/or pharmacotherapy with both children and adolescents in individual-family and multiple-family formats in three large RCTs: multi-family psychoeducational psychotherapy + TAU versus WLC + TAU; family-focused treatment (FFT) + pharmacotherapy versus enhanced care control + pharmacotherapy; and FFT for youth at high-risk for developing bipolar disorders + pharmacotherapy versus family education control + pharmacotherapy. Results demonstrated significant improvement in mood and behavior symptoms following treatment and over time [36, 37, 38••, 39•].

Cognitive-behavioral therapy

  • Overview

    • CBT-based interventions for pediatric bipolar disorders are very similar to aforementioned family psychoeducation plus skill building treatments, differing mostly in their level of empirical support.

  • Empirical support

    • CBT + pharmacotherapy has been evaluated with children and adolescents in individual-family and multiple-family formats, as well as in an adolescent-only format (with limited familial involvement). Two open trials and one study with matched historical controls demonstrated improvement in mood and some comorbid symptoms following treatment [40–42, Class III].

Dialectical behavior therapy

  • Overview

    • Dialectical behavior therapy (DBT) involves individual therapy, family skills training, and as-needed telephone coaching to target problematic behaviors and replace them with effective coping skills (i.e., mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, walking the middle path).

    • This intervention may be particularly helpful for youth who exhibit suicidal thoughts/behaviors and/or non-suicidal self-injury.

  • Empirical support

    • Individual-family DBT + pharmacotherapy was evaluated in one published open trial with adolescents and demonstrated significant improvement in depression, emotion dysregulation, and suicidality [43, Class IV].

Interpersonal and social rhythm therapy

  • Overview

    • Perhaps most unique from the other treatments for pediatric bipolar disorders, interpersonal and social rhythm therapy (IPSRT) strictly targets medication nonadherence, interpersonal stress, and circadian rhythm dysregulation.

  • Empirical support

    • One open trial of individual IPSRT + pharmacotherapy with adolescents (and limited familial involvement) showed significant improvement in mania, depression, general psychiatric symptoms, and global functioning [44, Class IV].

Healthy diet and lifestyle

  • Overview

    • Similar to the pediatric depression literature, balanced diet, regular sleep schedule, and physical exercise can aid in mood stabilization among youth with bipolar disorders. Such diet and lifestyle changes help to regulate nutritional, metabolic, and circadian rhythm functioning, and improve self-esteem.

  • Empirical support

    • Though diet, sleep, and exercise interventions have not been examined as monotherapies, many of the aforementioned psychosocial interventions specifically target these healthy lifestyle changes in treatment.

Separation anxiety, generalized anxiety, and social anxiety disorders

Separation anxiety, generalized anxiety, and social anxiety are the most common anxiety disorders and frequently comorbid. Thus, they are often studied simultaneously in outcome trials and are reviewed together here. While selective mutism is also a common childhood anxiety disorder, no RCTs have exclusively examined treatment of this condition. However, youth with selective mutism have been included in several of the studies reviewed below.

Cognitive-behavioral therapy

  • Overview

    • In general, CBT for anxiety disorders targets physiologic, cognitive, and behavioral symptoms via psychoeducation, emotion identification, somatic management strategies, cognitive restructuring, exposure, familial involvement, and relapse prevention.

    • CBT for youth with separation anxiety disorder emphasizes identification of anxious, separation-related thoughts and feelings, recognition of physical arousal, and development of more effective coping skills (cognitive restructuring, relaxation strategies).

    • Key elements of CBT for generalized anxiety disorder involve identifying and challenging irrational fears and worries, and practicing exposure to feared outcomes via role plays, imagery, and in vivo exercises.

    • Important features of CBT for social anxiety disorder include cognitive restructuring of irrational thoughts related to social settings and exposure to avoided social situations.

  • Empirical support

    • CBT has the most empirical support for treatment of youth anxiety disorders [Class I]. Similar to the adolescent depression literature, combination of CBT + pharmacotherapy (usually SSRIs) offers added benefit for anxious youth. For example, the Child/Adolescent Anxiety Multimodal Study (CAMS) found that all active treatments (individual CBT with parental component, sertraline, CBT + sertraline) were superior to pill-placebo, though combined treatment was superior to either monotherapy alone [45].

    • CBT monotherapy has also demonstrated efficacy in improving anxiety symptoms in numerous RCTs with both children and adolescents [Class I]. These studies provide support for several formats of CBT (individual, group, included parental component, parent group only) in the treatment of pediatric anxiety disorders when compared with WLC, family-based education support, and group support + attention control [e.g., 46, 47•, 48–50, 51•]. Though an effectiveness trial using usual care control did not demonstrate significant between-group differences, clinical improvements across groups were evident, and youth receiving CBT used fewer additional services [52].

    • In addition, while a variety of CBT formats have demonstrated efficacy in treatment of pediatric anxiety disorders, group CBT is particularly effective for social anxiety disorder compared to WLC or attention control [53, 54, Class II].

    • Finally, CBT with computerized components may ameliorate anxious symptoms to a similar degree as clinic-delivered CBT [55, 56•, 57, Class II]. For example, recent studies demonstrated superiority of computerized and/or computer-assisted CBT over WLC and a computer-assisted education, support, and attention control. In addition, CBT with computerized components produced similar, comparable outcomes as clinic-based CBT. These studies further support use of CBT with anxious youth and also offer novel delivery formats to aid in transportability and dissemination of this treatment to real-world settings.

Social effectiveness therapy

  • Overview

    • Social effectiveness therapy (SET) is a behavioral group treatment specifically for social anxiety disorder involving psychoeducation, social skills training, peer generalization experiences, and in vivo exposure.

  • Empirical support

    • SET was effective in ameliorating childhood anxiety symptoms and improving social skills in an RCT using a study skills control [58]. SET also demonstrated significantly greater treatment response rates relative to fluoxetine and placebo, and greater improvements in social skills, among a sample including children and adolescents [59, Class II].

Attention bias modification training

  • Overview

    • Attention bias modification training (ABMT) for pediatric anxiety disorders is a novel treatment approach that teaches youth to shift their attention away from threat stimuli via computer training tasks.

  • Empirical support

    • The first RCT of ABMT reported significant reduction in youths’ anxiety symptoms compared with placebo attention training with threat and neutral stimuli [60••]. A second RCT examined a version of ABMT that trained attention towards positive stimuli (as opposed to solely away from threat) and demonstrated positive findings when compared with attention training control [61, Class II].

Parent–child interaction therapy

  • Overview

    • Parent–child interaction therapy (PCIT) combines elements of play therapy and behavioral principles, and teaches parents positive attention, problem solving, and effective communication skills via in vivo training with children.

  • Empirical support

    • One open trial PCIT for youth with varied anxiety disorders reported promising preliminary results [62, Class IV].

Specific phobia

Exposure

  • Overview

    • This CBT-based treatment focuses on graded, hierarchical exposure to stimuli via imaginal and/or in vivo exercises.

  • Empirical support

    • Exposure-based interventions have been evaluated in RCTs using several sessions or one session compared with WLC or educational control, with results demonstrating decreases in anxiety [e.g., 63, 64, Class II].

Panic disorder

Panic control treatment

  • Overview

    • Panic control treatment is a CBT-based intervention that involves psychoeducation, coping skills, physiologic symptom reduction, cognitive restructuring, interoceptive exposure, and relapse prevention.

  • Empirical support

    • One RCT of panic control treatment demonstrated reduction of panic, anxiety, and depression when compared with self-monitoring and therapist check-in control [65, Class III].

Obsessive-compulsive disorder

Cognitive-behavioral therapy

  • Overview

    • CBT for obsessive-compulsive disorder (OCD) includes psychoeducation, hierarchy building, exposure/response prevention, cognitive strategies, reward programs, family/parent training, and relapse prevention.

  • Empirical support

    • Similar to research on psychosocial interventions for pediatric depression and anxiety, individual CBT is the most efficacious treatment for youth with OCD, particularly when combined with medication (e.g., SSRIs) [66, 67••, Class II]. The Pediatric OCD Treatment Study (POTS I) demonstrated superiority of CBT + sertraline over either monotherapy alone in terms of symptom reduction, though remission rates were comparable for combined treatment and CBT alone [66]. POTS II also demonstrated superiority of CBT + pharmacotherapy over pharmacotherapy alone and pharmacotherapy + instructions in CBT [67••]. Two recent RCTs also found promising results when augmenting individual CBT with D-cycloserine, compared with individual CBT + placebo [68•, 69].

    • Other formats of CBT may also be effective in treatment of pediatric OCD. For example, family-focused individual CBT demonstrated equivalent, positive results as compared to family-focused group CBT, and superiority over WLC and relaxation control [70–72, Class II].

    • Group CBT also showed promise in several recent open trials [73, 74, Class III].

    • Finally, CBT delivery via webcam is also a promising modality, according to one RCT using WLC [75, Class III]. This delivery format can again aid in widespread dissemination of CBT.

Acute/posttraumatic stress disorders

Trauma-focused cognitive-behavioral therapy (and related interventions)

  • Overview

    • Trauma-focused CBT (TF-CBT) for acute and posttraumatic stress disorders (PTSD) involves psychoeducation, relaxation and coping skills, affective modulation strategies, cognitive coping processing, trauma narrative development, in vivo and/or imaginal exposure to trauma reminders, and parental involvement.

  • Empirical support

    • Numerous RCTs employing various control conditions (child-centered therapy, family therapy, routine clinical services, WLC) support the use of individual TF-CBT (commonly with parental involvement) in treatment of pediatric PTSD [e.g., 76, 77••, 78, 79•, Class I]. Interestingly, and unlike aforementioned examinations of combined psychosocial + pharmacological interventions for internalizing disorders, addition of medication to TF-CBT (TF-CBT + sertraline versus TF-CBT + placebo) does not offer added benefit [80]. However, for youth exposed to a single trauma, an RCT comparing TF-CBT with and without exposure found comparable symptom improvement, suggesting that exposure may not be necessary for treatment gains among less impaired youth [81].

    • Some of the treatments used as control conditions in the above-mentioned studies (child-centered therapy, family therapy) demonstrated some positive findings, though TF-CBT was typically superior [76, 78, Class III].

    • Interventions similar to TF-CBT, which emphasize some treatment components more than others, also show promise. For example, CBT (focusing mainly on cognitive factors) resulted in significant improvement in anxiety symptoms and functioning compared to WLC [82, Class III]. Also, in a study of narrative exposure therapy (brief intervention focusing on development of a narrative encompassing all experienced traumas) versus meditation-relaxation, both treatments were effective in ameliorating PTSD symptoms [83, Class III].

School-based cognitive-behavioral therapy

  • Overview

    • Though similar to TF-CBT, school-based CBT differs in the setting in which it occurs (school), and delivery format (group). The intervention includes psychoeducation, graded exposures, cognitive and coping strategies, and social skills.

  • Empirical support

    • One RCT reported comparable results for school-based CBT and individual TF-CBT [84]. A second study found support for school-based CBT + classroom psychoeducation/coping skills versus classroom psychoeducation/coping skills alone, though the active comparison condition also demonstrated some symptom reduction [85, Class II].

Eye movement desensitization and reprocessing

  • Overview

    • Eye movement desensitization and reprocessing (EMDR) involves graduated imaginal exposure while the child simultaneously visually tracks therapist hand movements. This tracking procedure is hypothesized to aid in cognitive processing of the traumatic event during exposure.

  • Empirical support

    • EMDR demonstrated nearly equivalent, positive results when compared with CBT [86]. A more recent RCT of CBT versus EMDR again showed significant symptom reduction in both groups, though treatment gains for EMDR were reached in fewer sessions [87, Class II].

Parent–child interaction therapy

  • Overview

    • Similar to PCIT for anxiety, PCIT for child maltreatment focuses on improving parent-child relations by teaching parents positive attention, problem solving, and effective communication skills via in vivo training with children.

  • Empirical support

    • In two RCTs using WLC, PCIT has shown positive results among families at risk for or with a history of child maltreatment [88, 89•, Class II].

Prolonged exposure

  • Overview

    • Prolonged exposure for adolescents, a form of CBT, focuses primarily on psychoeducation and exposure, while also incorporating case management and relapse prevention.

  • Empirical support

    • In an RCT of prolonged exposure versus time-limited dynamic therapy, both treatments resulted in symptom improvement, though effects were more pronounced in the prolonged exposure group [90, Class III].

Cognitive processing therapy

  • Overview

    • Cognitive processing therapy involves psychoeducation, cognitive strategies, and documentation of thoughts and feelings at the time of the traumatic event via taped or written narratives.

  • Empirical support

    • One RCT using a WLC illustrated promising findings [91, Class III].

Child–parent psychodynamic psychotherapy

  • Overview

    • This treatment uses clinical illustrations and strategies to address various domains of functioning (e.g., play, sensorimotor, biological rhythms, fear, reckless behavior, aggression, parenting).

  • Empirical support

    • One RCT comparing this intervention with case management demonstrated significant between-group differences [92, Class III].