Psychotherapy with Children and Adolescents with First Episode Psychosis: Limitations of the Research

Considerable difficulties occur in doing research with children and adolescents with severe psychiatric disorders, and studies of youth at high-risk for psychosis reveal variable outcomes. Early identification and prevention programs for children and adolescents at risk for psychosis investigate clinical characteristics, family history, and genetic, neurobiological and environmental risk factors while utilizing diverse preventative strategies. Assessments of the factors contributing to the conversion to psychosis indicate some salient predictor variables in first episode psychosis along with heterogeneous developmental trajectories with less than one third of high-risk youth developing persistent psychotic disorders [1]. However, few investigations have compared the impact of different forms of psychotherapy with each other in terms of their influence on the outcomes of children and adolescents who experience a first episode of psychosis even though studies have demonstrated that the combination of psychological and psychopharmacological interventions can have a positive effect on early-onset psychotic disorders [2]. This review aims to emphasize the need for studies that compare the impact of Cognitive Behavior therapy (CBT), psychodynamic psychotherapy and family therapy, and combinations of different forms of psychotherapy with psychopharmacological approaches in the treatment of children and youth who experience a first episode of psychosis.

Practice guidelines point to the importance of psychological therapy for individuals with a first episode of psychosis. Modestly effective results have been shown to derive from combinations of CBT and psychosocial interventions with children at risk for psychosis, but there have been few attempts to study very longterm benefits of CBT for the first episode of a psychotic disorder in childhood [3,4]. Reviews of typically cited databases, such as PubMed, PyschInfo, and Medline, note studies of the predictor variables, the diagnostic stability and the use of antipsychotic medication with first episode psychosis in children, adolescents and adults but an absence of investigations of different forms of psychotherapy with children and young adolescents who experience first episode psychosis [5-8].

The majority of children and adolescents who have brief psychotic symptoms will continue to experience later mental health problems, but most will not develop actual psychotic disorders [9]. One-year outcome studies of children and adolescents at high clinical risk who do develop non-affective psychosis indicate the predictive importance of both positive and negative symptoms and that more than half of the youth continue to be at high-risk while at least 20% develop schizophrenia [10]. The presence of psychotic symptoms is also associated with a greater severity of Major Depressive Disorder and a longer duration of episodes of illness in children and adolescents with Bipolar Disorder [11]. A study of adults with first episode psychosis revealed that for individuals who experience only one episode of psychosis the combination of prompt treatment and social and family support lowers the risk of future episode of psychosis [12]. Even among high-risk children and adolescents who have attenuated symptoms of psychosis, not all will develop a psychotic disorder [13], but there are few prospective studies or randomized trials that compare the potential long-term gains associated with different forms of psychotherapy with very high-risk children and adolescents who develop psychosis.

X, a nine-year-old Caucasian girl with deteriorating academic functioning, no prior psychiatric history or mental health treatment and no discernable history of trauma or psychiatric illness in the family, set a fire in her apartment in which a family member was severely burned. She reported that a voice told her to set the fire because the apartment had been invaded by demons and that burning the demons would be the only way to keep her parents and siblings safe from harm.

The findings from the influential Child and Adolescent First Episode of Psychosis Study (CAFEPS) indicate that for youth with a first episode of psychosis, aged nine to seventeen, Psychotic Disorder Not Otherwise Specified, Mood Disorder with Psychosis, and Schizophreniform Disorder are the most common diagnoses and that clinical assessments of symptom severity and negative symptoms are the most meaningful predictive outcome indicators [14]. Studies measuring the effect of CBT with individuals with first episode psychosis throughout the lifespan note either effective results when compared with treatment as usual or inconsistent findings [15]. For example, Addington et al. [4] reported no significant improvements with either the use of CBT or treatment as usual [16]. Early literature reviews of first episode psychosis studies revealed that psychosocial therapies, in general, in combination with psychopharmacology and the absence of a diagnosis of schizophrenia are associated with more positive outcomes [17]. More recent systematic reviews of preventative interventions and studies comparing the impact of psychological, psychopharmacological and combined treatments with children, adolescents and young adults with psychosis have found that antipsychotic medications have a modestly beneficial effect on psychotic symptoms and that family therapy in addition to CBT can be useful in delaying the onset of psychotic episodes, but no trials were found that compared psychotherapeutic interventions with youth under the age of eighteen [3,18].

Early investigations of the use of CBT with adults with schizophrenia who experience a first episode of psychosis often found little difference between CBT and supportive psychotherapy, but later studies placed a greater emphasis on the functional adaptations and quality of life issues that are associated with a persistent psychotic disorder [19]. Other early studies of CBT with first episode psychosis in adults showed that CBT has some efficacy in lowering psychotic symptoms and improving the individual’s quality of life but little influence on the reoccurrence of psychotic episodes [20]. Within the last ten years, the use of group CBT treatments with adults with first episode psychosis has been increasingly studied [21] with the caveat that the complexity of the clinical variables, such as comorbidity, and the limitations of the mental health care system can make it difficult to apply group CBT interventions effectively [22]. Gaynor and colleagues [22] reported that outpatient group CBT is more effective than individual CBT with relatively stable adults with first episode psychosis in reducing the presence of negative symptoms [23], while a 2018 investigation of group cohesion in cognitive behavioral group therapy with adults with first episode psychosis revealed that group participation and group cohesion are positively associated with both improved selfesteem and symptom reductions [24].

Studies of group cognitive behavioral therapy with adults with either first episode psychosis or a recent onset of psychosis also point to the value of groups in sustaining symptomatic improvements after there has been a stabilization of the psychotic symptoms [25], but as far as we know similar studies are lacking that assess the overall efficacy and long term outcome of individual or group CBT with children and young adolescents with a first episode of psychosis.

Psychodynamic psychotherapy, with its emphasis on the developmental roots of the individual’s subjective experience, the nuances of the therapeutic relationship, and scrutiny of therapistpatient mutual influences in transference-countertransference exchanges, has rarely been the subject of empirical studies with individuals who experience a first episode of psychosis. In one of the few prospective studies of psychodynamic psychotherapy with adults with a first episode of Schizophrenia Spectrum Disorder, a multisite, two year-long study was conducted that compared treatment as usual with supportive psychodynamic psychotherapy with a combination of both interventions; the combination of the two had a much stronger association with significant improvements in symptoms and global functioning [26]. Similar studies are lacking with children and young adolescents who are at very high risk for psychosis or are experiencing first episode psychosis.

Since its early origins, psychodynamic psychotherapy has been concerned with the intrapsychic sequalae of trauma as well as the relationship between difficulties in mental functioning and problems in forming and sustaining mental representations of self and others. Recent studies of psychodynamic and integrative psychotherapy approaches have examined such posttraumatic phenomena and object relations deficits as crucial aspects of psychotherapy with individuals who are suffering from early signs of psychosis or persistent psychotic disorders. Investigations of efforts to improve metacognition or metacognitive reflection ability in individuals experiencing early phases of psychosis have also been increasing in number [27,28]. Consumer oriented approaches to individual psychotherapy with people with psychotic disorders similarly emphasize the individual’s understanding and emotional experience of the illness and facilitating openness to accepting support and avenues for empowerment that can enhance social, cognitive and emotional functioning. In addition, psychodynamic approaches with their emphasis on psychological defenses and internalized relationship patterns are well suited for the exploration of adolescents’ and young adults’ concerns about identity, autonomy, intimacy and the experience of the self in the midst of struggles with psychotic illness [29]. There is a very long history of influential theoretical and clinical articles on psychoanalytic approaches to the treatment of childhood psychosis; some of the contributions are consistent with the steadily emerging literature about the relationship between trauma and psychotic symptoms [30]. However, in spite of the voluminous literature on the use of psychodynamic principles in understanding psychotic communication and attachment difficulties, a comprehensive 2017 survey of the growing empirical support for psychodynamic psychotherapy with children and adolescents found no empirical studies of the efficacy of psychodynamic psychotherapy with psychotic children and adolescents [31].

Family focused interventions are increasingly being recognized as critical aspects of the treatment of children and adolescents who are at risk for episodes of psychosis. Multi-Systemic Family Therapy and other family-based interventions that stress psychoeducation and family communication have been shown to reduce the frequency of psychotic episodes in very high-risk children and adolescents [32]. In a study of family-based interventions aimed at improving family communication, problem solving abilities and stress reduction strategies, Miklowitz et al. [33] similarly found reduced rates of psychotic symptoms in high risk adolescents [33] while other skills-based intervention programs have also noted both short-term and long-term benefits in very high risk youth [34]. Providing family support and ongoing training for therapeutic foster parents that helps to facilitate positive family communication patterns can likewise contribute to symptom reduction and behavioral improvements in high-risk adolescents [35].

Effective early intervention programs for high-risk children and adolescents provide psychoeducation and offer supportive services for both the child and the family while carefully considering family members’ explanations for and observations of youth who transition from premorbid and prodromal stages of an affective or nonaffective disorder to the full symptomatic expression of an episode of psychosis [36]. Individuals who have experienced a first episode of psychosis and their families report multiple benefits from family sessions that emphasize developing acceptance and enhancing mutually supportive communication [37]. Although family-based interventions and psychoeducation are typically included in the treatment of first episode psychosis with children and adolescents and are often combined with treatment as usual, studies are lacking comparing family treatments with CBT and psychodynamic psychotherapy with this very vulnerable population.

Since at least half of youth with first episode psychosis have histories of trauma and many have posttraumatic symptoms in addition to symptoms of psychosis, the integration of trauma informed care for the youth and the family with individual psychotherapy is of paramount importance [38]. At this point, although the positive impact of psychoeducational family approaches with first episode psychosis has been well documented, there is an absence of studies that compare a course of family-based therapy sessions with individual Trauma Focused CBT (TFCBT), other forms of cognitive therapy and psychodynamic psychotherapy [39].

Treatment studies are needed in order to assess the efficacy of different forms of individual psychotherapy and family therapy in combination with psychopharmacological interventions with children and adolescents with first episode psychosis. With the dual goals of reducing the likelihood of the transition to psychosis in high-risk youth and decreasing the vulnerability to repeated episodes of psychosis in youth who experience at least one psychotic episode, trials of combined treatments that compare the impact of CBT, psychodynamic psychotherapy and family therapy can help to facilitate beneficial treatment outcomes. In spite of the complexity and difficulty of conducting such studies, they can play a meaningful role in helping clinicians to expedite the restoration of age-appropriate levels of functioning.

James B McCarthy, PhD formulated the conceptual framework, reviewed the literature and drafted the manuscript. Ana J Figuereo, BA and Mali L Zaken, BA were also involved with the literature review and editing the manuscript.

The authors declare no financial or non-financial competing interests. No grant support was involved with this study.

No conflict of interest.

1. McCarthy J (2015) Psychosis in childhood and adolescence. New York, NY & London, UK: Routledge.
2. Schimmelmann BG, Schultze-Lutter F (2012) Early detection and intervention of psychosis in children and adolescents: urgent need for studies. Eur Child Adolesc Psychiatry 21(5): 239-241.
3. Stafford MR, Jackson H, Mayo-Wilson E, Morrison AP, Kendall T (2013) Early interventions to prevent psychosis: Systematic review and meta-analysis. BMJ 346: f185.
4. Addington J, Epstein I, Liu L, French P, Boydell KM, et al. (2011) A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res 125(1): 54-61.
5. Morris A, Nixon MK, Keyes R, Ashmore D (2009) Early Psychosis Intervention Service for Children and Youth: a retrospective chart review of the first four years. Early Interv Psychiatry 3(2): 99-107.
6. Castro-Fornieles J, Parellada M, Gonzalez-Pinto A, Moreno D, M Otero S, et al. (2007) The child and adolescent first-episode psychosis study (CAFEPS): design and baseline results. Schizophr Res 91(1-3): 226-237.
7. Stentebjerg-Olesen M, Pagsberg AK, Fink-Jensen A, Correll CU, Jeppesen P (2016) Clinical characteristics and predictors of outcome of Schizophrenia-Spectrum Psychosis in children and adolescents: A systematic review. J Child Adolesc Psychopharmacol 26(5): 410-427.
8. Vernal DL, Kapoor S, Al-Jadiri A, Sheridan EM, Bornstein Y, et al. (2015) Outcome of youth with early phase schizophrenia-spectrum disorders and psychosis not otherwise specified treated with second-generation antipsychotics: 12 week results from a prospective, naturalistic cohort study. J Child Adolesc Psychopharmacol 25(7): 535-547.
9. Tiffin PA, Welsh P (2013) Practitioner review: Schizophrenia Spectrum Disorders and the at-risk mental state for psychosis in children and adolescents-evidence-based management approaches. Journal of Child Psychology and Psychiatry 54(11): 1155-1175.
10. Armando M, Pontillo M, De Crescenzo F, Mazzone, L, Monducci E, et al. (2015) Twelve-month psychosis-predictive value of the ultra-high-risk criteria in children and adolescents. Schizophr Res 169(1-3): 186-192.
11. Geller B, Tillman R, Craney JL, Bolhofner K (2004) Four-year prospective outcome and early natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Arch Gen Psychiatry 61(5): 459-467.
12. Alvarez-Jimenez M, Gleeson JF, Henry LP, Harrigan SM, Harris MG, et al. (2011) Prediction of a single psychotic episode: a 7.5 year prospective study in first -episode psychosis. Schizophrenia Research 125(2-3): 236-246.
13. Corcoran CM, First MB, Cornblatt BA (2010) The psychosis risk syndrome and its proposed inclusion in the DSM-V: a risk-benefit analysis. Schizophr Res 120(1-3): 16-122.
14. Haddock G, Lewis S, Bentall R, Dunn G, Drake R, et al. (2006) Influence of age on outcome of psychological treatments in first-episode psychosis. Br J Psychiatry 188: 250-254.
15. Addington J, Epstein I, Liu L, French P, Boydell KM, et al. (2011) A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res 125(1): 54-61.
16. Menezes N, Arenovich T, Zipursky R (2006) A systematic review of longitudinal outcome studies of first-episode psychosis. Psychol Med 36(10): 1349-1362.
17. Stafford MR, Mayo-Wilson E, Loucas CE, James A, Hollis C, et al. (2015) Efficacy and safety of pharmacological and psychological interventions for the treatment of psychosis and schizophrenia in children, adolescents and young adults: a systematic review and meta-analysis. PLoS One 10(2): e0117166.
18. Addington J, Gleeson J (2005) Implementing cognitive-behavioral therapy for first-episode psychosis. Br J Psychiatry Suppl 48: S72-S76.
19. Penn DL, Waldheter EJ, Perkins DO, Mueser KT, Lieberman JA (2005) Psychosocial interventions for first-episode psychosis: a research update. Am J Psychiatry 162(12): 2220-2222.
20. Van der Gaag M, Nieman DH, Rietdijk J, Dragt S, Ising HK, et al. (2012) Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: a randomized controlled clinical trial. Schizophr Bull 38: 1180-1188.
21. Fanning F, Foley S, Lawlor E, McWilliams S, Jackson D, et al. (2012) Group cognitive therapy for first episode psychosis: who’s referred, who attends and who completes it? Early Interv Psychiatry 6(4): 432-441.
22. Gaynor K, Dooley B, Lawlor E, Lawoyin R, O’Callaghan E (2011) Group cognitive behavioral therapy as treatment for negative symptoms in psychosis. Early Interv Psychiatry 5(2): 168-173.
23. Lecomte T, Leclerc C, Wykes T (2018) Symptom fluctuation. Self-esteem, and cohesion during group cognitive behavioral therapy for early psychosis. Psychol Psychother 91(1): 15-26.
24. Chung YC, Yoon KS, Park TW, Yang JC, Oh KY (2013) Group cognitive- behavioral therapy for early psychosis. Cognitive Therapy and Research 37(2): 403-411.
25. Rosenbaum B, Harder S, Knudsen P, Koster A, Lindhardt A, et al. (2012) Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: Two-year outcome. Psychiatry 75(4): 331-341.
26. Hillis JD, Leonhardt BL, Vohs JL, Buck KD, Salvatore G, et al. (2015) Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder. J Clin Psychol 71(2): 125-135.
27. Leonhardt BL, Benson K, George S, Buck KD, Shaieb R, et al. (2016) Targeting insight in first episode psychosis: a case study of metacognitive reflection insight therapy (MERIT). Journal of Contemporary Psychotherapy 46(4): 207-216.
28. Davidson L, Strauss JS (1992) Sense of self in recovery from severe mental illness. Br J Med Psychol 65(2): 131-145.
29. Moe AM, Breitborde JK (2019) Psychosis in emerging adulthood: phenomenological, diagnostic, and clinical considerations. Evidence Based Practice in Child and Adolescent Mental Health 4(2): 141-156.
30. Arseneault L, Cannon M, Fisher HL, Polanczyk G, Moffit TE, et al. (2011) Childhood trauma and children’s emerging psychotic symptoms: a genetically sensitive longitudinal cohort study. Am J Psychiatry 168(1): 65-72.
31. Migdley N, O’Keefe S, Freuh L, & Kennedy E (2017) Psychodynamic psychotherapy for children and adolescents: an updated narrative review of the evidence base. Journal of Child Psychotherapy 43(3): 307-329.
32. Gerson R, Davidson L, Booty A, McGlashan T, Malaspina D, et al. (2009) Families’ experience with seeking treatment for recent-onset psychosis. Psychiatr Serv 60(6): 812-816.
33. Miklowitz DJ, O’Brien MP, Schlosser DA, Addington J, Marschall C, et al (2014) Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. J Am Acad Child Adolesc Psychiatry 53(8): 848-858.
34. O’Brien M, Zinberg J, Bearden CE, Daley M, Niendam TA, et al. (2007) Psychoeducational multi-family group treatment with adolescents at high risk for developing psychosis. Early Interv Psychiatry 1(4): 325-332.
35. Poulton R, Van Ryzin MJ, Harold GT, Chamberlain P, Fowler D, et al (2014) Effect of multidimensional treatment of foster care on psychotic symptoms in girls. J Am Acad Child Adolesc Psychiatry 53(12): 1279-1287.
36. Corcoran C, Gerson R, Sills-Shahar R, Nickou C, McGlashan T, et al. (2007) Trajectory to a first episode of psychosis: a qualitative study with families. Early Interventions in Psychiatry 1(4): 308-315.
37. Nilsen L, Frich JC, Friis S, Norheim L, Rossberg JL (2016) Participants’ perceived benefits of family intervention following a first episode of psychosis: a qualitative study. Early Interv Psychiatry 10(2): 152-159.
38. Tong J, Simpson K, Alvarez-Jimenez M, Bendal S (2027) Distress, psychotic symptom experience exacerbation, and relief in reaction to talking about trauma in the context of beneficial trauma therapy: perspectives from young people with post-traumatic stress disorder and first episode psychosis. Behav Cogn Psychother 45(6): 561-576.
39. Trotta A, Murray RM, Fisher HL (2015) The impact of childhood adversity on the presence of psychotic symptoms: a systematic review and meta-analysis. Psychol Med 45(12): 2481-2498.