Since any problem in children and adolescence is closely associated with the family, it is warranted to consider family-based therapies for IA. Though there is not enough evidence to support for efficacy of such interventions, overall improvement in communication in the family and better monitoring of the Internet use are some of the benefits noticed [68, 69].

Many enthusiastic and innovative therapies based on behavior therapy have been put to practice to bring about a positive change in Internet addictive behaviors, such as Reality therapy (RT) [70] and Acceptance & Commitment Therapy (ACT) [71] with varying results.

Simple educational programs for children in real life or ironically online are considered to combat problem use of the Internet. One such online program follows the 12 steps self-help treatment approach used for alcoholic anonymous [60].

Some suggests that there is an important place for physical exercise in helping adolescents to reduce the use of the Internet. Sports believed to be compensating for the reduced dopamine levels in brain resulted in the decreased online use. Further, sports can be a part of CBT programs [72].

## **15.2. Pharmacological treatments**

A few types of medications have been used, and there are some studies looking into the effectiveness of them. However, there are no adequate randomized controlled trials to derive definitive guidance to treatments.

There are several reports on the use of selective serotonin-reuptake inhibitors (SSRIs) particularly when Internet addiction is comorbid with depression and anxiety for which SSRIs have an established place as an effective treatment [73, 74]. The SSRI, escitalopram [75], nontricyclic antidepressants, bupropion [76], psycho-stimulant, methylphenidate [77], mood stabilizers [22], antipsychotic, quetiapine [78] and opioid receptor antagonist and naltrexone [79] have been trialed as treatments. However, most of these studies were quite short term and some are case reports. Hence, no pharmacological medication can be recommended for IA per se in children and adolescents at present.

#### **15.3. Multimodal treatments**

IA being a complicated phenomenon involving many aspects of life as biological, psychological and sociocultural, a combined or a multimodal treatment approach is increasingly considered by the concerned scientific community. There are reports on group CBT, parental training, teacher education, family therapy, medication, case management and brief intervention therapies, which are combined according to the necessity [80–85]. A widely inclusive IA recovery program with mindfulness-based relapse prevention, digital detoxification and animal-assisted therapy among many other different multidisciplinary approaches is proposed in 2012 [86].

## **16. Tips on sensible Internet use**

behaviors, as a component in treatment plans for IA (19). MI has not been used so far in the

Since any problem in children and adolescence is closely associated with the family, it is warranted to consider family-based therapies for IA. Though there is not enough evidence to support for efficacy of such interventions, overall improvement in communication in the family

Many enthusiastic and innovative therapies based on behavior therapy have been put to practice to bring about a positive change in Internet addictive behaviors, such as Reality therapy

Simple educational programs for children in real life or ironically online are considered to combat problem use of the Internet. One such online program follows the 12 steps self-help

Some suggests that there is an important place for physical exercise in helping adolescents to reduce the use of the Internet. Sports believed to be compensating for the reduced dopamine levels in brain resulted in the decreased online use. Further, sports can be a part of CBT

A few types of medications have been used, and there are some studies looking into the effectiveness of them. However, there are no adequate randomized controlled trials to derive

There are several reports on the use of selective serotonin-reuptake inhibitors (SSRIs) particularly when Internet addiction is comorbid with depression and anxiety for which SSRIs have an established place as an effective treatment [73, 74]. The SSRI, escitalopram [75], nontricyclic antidepressants, bupropion [76], psycho-stimulant, methylphenidate [77], mood stabilizers [22], antipsychotic, quetiapine [78] and opioid receptor antagonist and naltrexone [79] have been trialed as treatments. However, most of these studies were quite short term and some are case reports. Hence, no pharmacological medication can be recommended for IA per

IA being a complicated phenomenon involving many aspects of life as biological, psychological and sociocultural, a combined or a multimodal treatment approach is increasingly considered by the concerned scientific community. There are reports on group CBT, parental training, teacher education, family therapy, medication, case management and brief intervention therapies, which are combined according to the necessity [80–85]. A widely inclusive IA recovery program with mindfulness-based relapse prevention, digital detoxification and animal-assisted therapy among many other different multidisciplinary approaches is

and better monitoring of the Internet use are some of the benefits noticed [68, 69].

(RT) [70] and Acceptance & Commitment Therapy (ACT) [71] with varying results.

treatment of Internet addiction according to available information.

treatment approach used for alcoholic anonymous [60].

programs [72].

154 Child and Adolescent Mental Health

**15.2. Pharmacological treatments**

definitive guidance to treatments.

se in children and adolescents at present.

**15.3. Multimodal treatments**

proposed in 2012 [86].

Author suggests, after reviewing available solutions on the Internet (You tube, Ted Talks, etc.) by activists as well as scientific reports, some simple techniques based on behavior therapy with or without cognitive component that can be utilized to use the Internet sensibly (Box 1).

**Box 1.**Tips on sensible Internet use.

## **17. Clinical course and prognosis**

Not much is known about the natural history of the condition as the concept of IA itself is at a very preliminary level. We need follow-up studies.

The experience from highly affected countries suggests that the problem of IA is quite a complex one. With the ubiquity of the Internet and its innate qualities of urging individuals to misuse despite harm, the course of IA is seemingly long term and resistant to treatment.

Prognosis of the highly addicted adolescent seems poor in general given the available information. However, clinicians should not be pessimistic in attempting to treat IA of an affected individual patient as multimodal treatment approached though not tested adequately offers some hope.

## **18. Prevention**

IA is considered at different intensity by different countries depending on how affected their population by it. Asian countries are undoubtedly most affected and hence have come up with most solutions too.

Most of the Internet-based activities are promoted among children and adolescents. Case is particularly so in online gaming which seemingly is the most prevalent type of Internet addiction disorder that could even reach DSM-5 at least at a warning stage.

A mass awareness program on the concept of IA is important. It has to be carefully planned and implemented as a total aversion from the Internet even before it reaches most of the children and adolescents in some parts of the world would be a shame given the unbeatable wonderful positive aspects of the Internet on education, business and recreation. The reader is also reminded at this point, of the accusation by some, that a normal phenomenon is being pathologized by introducing the concept of Internet addiction.

Primary prevention is encouraged by developing a sensible Internet culture starting from the individual household. Adults should set living examples and have controlled access to the Internet following a discussion and agreement in the family upon the way of the Internet use (Box 1).

Secondary and tertiary prevention may call for drastic methods if a nation is seriously affected. For example, total ban of the Internet in certain time of the day for under 18-yearolds, developing a system to slow down the Internet if played more than a certain number of hours (South Korea) [8], restricting Internet gaming among youth by demanding a "game fatigue system" from the game operators (China) [8].

## **19. Summary**

The Internet use is increasingly becoming an integral part of day-to-day life of all age groups around the world. The concept of "Internet addiction" remains controversial and at a fetal stage waiting to be evolved into maturity with better quality research. While IA has not reached DSM-5 or probably the future ICD 11, we cannot ignore the numbers or the seriousness of cases reported in Asian countries, neither can we ignore the individual families seeking help for problematic Internet users, children and adolescents. An internationally consensual multicenter attempt to define the concept, look into etiology, develop valid and reliable diagnostic criteria and come up with effective management strategies that involve prevention is warranted. We are gifted with the technology of Internet, and it has come to stay and will expand in new horizons we may only see in science fictions today. The children should be taught to use it with respect in a moderated and controlled but positive way. Such an approach only will win the cooperation of today's children and adolescents who are growing up with the Internet as a daily commodity.

## **Acknowledgments**

**18. Prevention**

156 Child and Adolescent Mental Health

(Box 1).

**19. Summary**

with most solutions too.

IA is considered at different intensity by different countries depending on how affected their population by it. Asian countries are undoubtedly most affected and hence have come up

Most of the Internet-based activities are promoted among children and adolescents. Case is particularly so in online gaming which seemingly is the most prevalent type of Internet addic-

A mass awareness program on the concept of IA is important. It has to be carefully planned and implemented as a total aversion from the Internet even before it reaches most of the children and adolescents in some parts of the world would be a shame given the unbeatable wonderful positive aspects of the Internet on education, business and recreation. The reader is also reminded at this point, of the accusation by some, that a normal phenomenon is being

Primary prevention is encouraged by developing a sensible Internet culture starting from the individual household. Adults should set living examples and have controlled access to the Internet following a discussion and agreement in the family upon the way of the Internet use

Secondary and tertiary prevention may call for drastic methods if a nation is seriously affected. For example, total ban of the Internet in certain time of the day for under 18-yearolds, developing a system to slow down the Internet if played more than a certain number of hours (South Korea) [8], restricting Internet gaming among youth by demanding a "game

The Internet use is increasingly becoming an integral part of day-to-day life of all age groups around the world. The concept of "Internet addiction" remains controversial and at a fetal stage waiting to be evolved into maturity with better quality research. While IA has not reached DSM-5 or probably the future ICD 11, we cannot ignore the numbers or the seriousness of cases reported in Asian countries, neither can we ignore the individual families seeking help for problematic Internet users, children and adolescents. An internationally consensual multicenter attempt to define the concept, look into etiology, develop valid and reliable diagnostic criteria and come up with effective management strategies that involve prevention is warranted. We are gifted with the technology of Internet, and it has come to stay and will expand in new horizons we may only see in science fictions today. The children should be taught to use it with respect in a moderated and controlled but positive way. Such an approach only will win the cooperation of today's children and adolescents who are grow-

tion disorder that could even reach DSM-5 at least at a warning stage.

pathologized by introducing the concept of Internet addiction.

fatigue system" from the game operators (China) [8].

ing up with the Internet as a daily commodity.

**1.** Dr. Sampath Tennakoon, Senior Lecturer, Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka.

**2.** Dr. Helani Alahakoon, Temporary Lecturer, Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Sri Lanka.

**3.** Dr. Rangana Kuruwita, Temporary Lecturer, Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Sri Lanka.

**4.** Miss. H.G Devika Malkanthi, Temporary Lecturer, Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Sri Lanka.

## **Author details**

Pabasari Ginige

\*Address all correspondence to<EMAIL_ADDRESS>
Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.

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**Treatment in Transition. Giving What is Needed**

## **Peer Bullying in Schools: A Cognitive Behavioral Intervention Program**

Füsun Gökkaya

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66701

### **Abstract**

Students face few problems in schools. Some of these conflicts may be defined with the bullying concept. The concept of bullying is defined as "to repetitively expose a student/ students to negative effects of another student or students." "Negative effects" includes students getting disturbed as well as getting hurt from the same kind of negative behavior; it also may be done by attempting to hurt someone, deliberately harming someone verbally or physically. Bullying behavior should include an "inequivalent power" between opponents and this needs to be "permanent" and "intentional." Bullying at school affects lots of students around the schools who witness bullying behavior in different dimensions; thus, it is an important problem that needs to be prevented. While some of the studies encompass interventions toward the whole school system, some studies were conducted by determining separate groups and working on those. In this paper, first, some whole school approach–based prevention programs and the effectiveness of these programs and then intervention programs for groups, which are provided to reduce and intervene bullying, will be explained. Second, cognitive behavioral therapy and its use in preventing bullying will be briefly explained. Finally, the context of a cognitive‐behavioral based peer bullying intervention program.

**Keywords:** peer bullying, intervention program, cognitive behavioral therapy, school bullying, prevention program

## **1. Introduction**

Students encounter various problems in the school environment and some of those are experienced among friends. Cases termed as "bullying," which is one of the problems encountered among friends, have certain characteristics that differ from cases of violence. This concept is defined as "a student/students repeatedly exposing another student/students to negative

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

effects multiple times" [1]. This "negative effect" may range from disturbance to actual injury and can be done verbally or physically in order to attempt to do harm or deliberately harm another. In bullying behavior, certain characteristics should be present, such as an "unequal power relationship" between the sides, the situation having a "continuous" characteristic and the acts being carried out "on purpose" [1].

Research has shown that approximately 15–20% of all students are affected by peer bullying at school [2–6]. Peer bullying can be performed directly or in an indirect manner. While direct bullying is performed openly against the bullied student, indirect bullying may well range into the realm of purposeful exclusion from the social group because of discrimination [1]. Generally, peer bullying has been grouped into physical bullying, verbal bullying and social exclusion. While physical and verbal bullying are elements of direct bullying, social exclusion is in the scope of indirect bullying. Physical bullying encompasses behavior such as hitting, pushing, spitting, kicking, pulling hair and tripping, whereas verbal bullying encompasses behavior such as use of foul language, giving nicknames and insulting. Social exclusion encompasses behavior that aims to harm the social relations of the students such as gossiping, exclusion from the friend group, ignoring and not accepting the student into games. The shape of peer bullying has changes throughout the years. In recent years, the developing Internet and communication technologies have created the concept of cyber bullying [7]. Writing various things under the photographs of friends in social network sites through the Internet, spreading unfounded rumors on them, disturbing them thorough phone messages and E‐mails, taking inappropriate pictures via cameras and spreading them through the Internet are all defined as cyber bullying. Additionally, although these behaviors are conducted in environments outside the school, their effects are more pronounced at school. Sexual harassment/disturbance behavior has also been discussed as a type of peer bullying with a different motivation. For this reason, sexual bullying, which encompasses sexual behavior (lifting skirts, taking pictures under skirts, pulling down pants, etc.), has been defined as a separate category.

While discussing peer bullying, students are generally grouped into bullies, victims, bully‐victim and bystanders [1, 8]. Bullying at school affects bullies, victims and bystanders who witness bullying behavior in different dimensions. Victims of bullying encounter problems such as anxiety, feelings of anger and desperation, unhappiness, ostracism and loneliness [9–11]. Alongside possibilities such as disciplinary action and exclusion from academic life, children who exhibit bullying behavior during school years have high risks of having their experiences affect their adult life negatively and carry their behavior into adulthood. Longitudinal studies have shown that children and adolescents who exhibit bullying behavior at school get mixed up in acts of violence in adulthood, have impulsive behavior, lead unsuccessful lives with lower job positions and have substance abuse problems [12–15]. These findings have made interventions to prevent and reduce bullying gain importance.

In many countries (Australia, Finland, the UK, Ireland, Sweden, Italy, Norway), it can be seen that programs toward preventing peer bullying have been applied for years and country wide studies on the subject have been performed [16, 17]. Stopping bullying behavior at school can be carried out through prevention or intervention programs [16, 18, 19].

Studies researching the reasons behind bullying behavior at school have shown that the personal characteristics of the students, parental attitudes, family relationships, school atmosphere, teacher attitudes, friendship relations and cultural factors may all have effects on the subject [20–22]. For this reason, studies on reducing bullying at schools can be said to have different focal points. While some of the studies encompass interventions toward the whole school system, some studies were conducted by determining separate groups and working on those.

In this chapter first, some whole school approach‐based prevention programs and the effectiveness of these programs then intervention programs for groups, which are provided to reduce and intervene bullying will be explained. Second, cognitive‐behavioral therapy and its use in preventing and intervening bullying will briefly explain. Finally, the context of a cognitive‐behavioral based peer bullying intervention program.

## **2. Whole school approach studies to prevent peer bullying at schools and their effectiveness**

Whole school approach programs to prevent peer bullying at schools are applied on school, classroom and individual levels [1]. Interventions toward bullying aim at all of the students at the school developing an attitude against bullying and are applied to decrease bullying events within the school. Interventions at the school level are student and teacher questionnaires, school conference days aimed at developing a positive school environment, parent‐teacher meetings, telephone interviews with parents and the regulation of school playgrounds. Classroom efforts include forming classroom rules against bullying, information being given to raise awareness, the formation of a positive environment and meetings with parents and teachers. Programs applied on an individual level include interventions such as having serious meetings with bullies and victims, having meetings with the parents of children involved in bullying, receiving help from unbiased children, providing help and support for parents, forming discussion groups with the families of bullies and victims and changes in schools and classrooms [1]. The programs summarized in this section are some of the most widely used studies.

### **2.1. Olweus bullying prevention program (BPP)**

effects multiple times" [1]. This "negative effect" may range from disturbance to actual injury and can be done verbally or physically in order to attempt to do harm or deliberately harm another. In bullying behavior, certain characteristics should be present, such as an "unequal power relationship" between the sides, the situation having a "continuous" characteristic and

Research has shown that approximately 15–20% of all students are affected by peer bullying at school [2–6]. Peer bullying can be performed directly or in an indirect manner. While direct bullying is performed openly against the bullied student, indirect bullying may well range into the realm of purposeful exclusion from the social group because of discrimination [1]. Generally, peer bullying has been grouped into physical bullying, verbal bullying and social exclusion. While physical and verbal bullying are elements of direct bullying, social exclusion is in the scope of indirect bullying. Physical bullying encompasses behavior such as hitting, pushing, spitting, kicking, pulling hair and tripping, whereas verbal bullying encompasses behavior such as use of foul language, giving nicknames and insulting. Social exclusion encompasses behavior that aims to harm the social relations of the students such as gossiping, exclusion from the friend group, ignoring and not accepting the student into games. The shape of peer bullying has changes throughout the years. In recent years, the developing Internet and communication technologies have created the concept of cyber bullying [7]. Writing various things under the photographs of friends in social network sites through the Internet, spreading unfounded rumors on them, disturbing them thorough phone messages and E‐mails, taking inappropriate pictures via cameras and spreading them through the Internet are all defined as cyber bullying. Additionally, although these behaviors are conducted in environments outside the school, their effects are more pronounced at school. Sexual harassment/disturbance behavior has also been discussed as a type of peer bullying with a different motivation.  Bullying at school affects bullies, victims and bystanders who witness bullying behavior in different dimensions. Victims of bullying encounter problems such as anxiety, feelings of anger and desperation, unhappiness, ostracism and loneliness [9–11]. Alongside possibilities such as disciplinary action and exclusion from academic life, children who exhibit bullying behavior during school years have high risks of having their experiences affect their adult life negatively and carry their behavior into adulthood. Longitudinal studies have shown that children and adolescents who exhibit bullying behavior at school get mixed up in acts of violence in adulthood, have impulsive behavior, lead unsuccessful lives with lower job positions and have substance abuse problems [12–15]. These findings have made

In many countries (Australia, Finland, the UK, Ireland, Sweden, Italy, Norway), it can be seen that programs toward preventing peer bullying have been applied for years and country wide studies on the subject have been performed [16, 17]. Stopping bullying behavior at school can

interventions to prevent and reduce bullying gain importance.

be carried out through prevention or intervention programs [16, 18, 19].

the acts being carried out "on purpose" [1].

168 Child and Adolescent Mental Health

defined as a separate category.

The first school‐based program to prevent bullying, the BPP aims to change the social norms that see bullying behavior as acceptable. Within the context of this goal, it first tries to create awareness on bullying. First, the rates of bullies, bully‐victims, victims, bystanders and exposure to bullying are determined through a scanning effort in the school. Then, school wide conferences, meetings with school staff, teacher trainings, family trainings, small group efforts with the families, classroom studies and individual meetings with bullies and victims are performed [1].

Alongside many studies where Olweus' program was applied and its effectiveness was researched, Olweus himself has made effectiveness evaluations regarding the application. The results of the first studies found a 50% decrease in bullying behavior [1] and later evaluations have shown the change to be between 21 and 38% [23, 24].

## **2.2. Creating a peaceful school learning environment (CAPSLE)**

The program, developed in 1994, aims to prevent bullying and create a positive school environment through ensuring that students learn ways to solve their problems without aggression and the social skills necessary to communicate positively [14]. The program consists of four basic and two supporting elements. The first basic element is to create a positive atmosphere at school by "zero" tolerance to all bullying. The second element is the formation of a disciplinary plan to provide appropriate behavior. In the process of doing this, the importance of social skills not only among the students but also with adults in the school was stressed. The third element is a classroom management plan. For this, the aim is to raise awareness on the dynamics of bullying and develop the appropriate disciplinary measures to ensure the change of these behaviors. The fourth basic element is a unique physical training program. In this program, the focus is on self‐defense sports that may help students develop self‐regulation skills. Additionally, in this stage, the aim is to provide counseling in a manner that will help to prevent bullying through an appropriate counseling program for children and adults. The first supportive element of the program is changing the language used at school to increase cognitive skills and the awareness of a person of his/her role in the bullying phenomenon. The second supportive element is to focus on psychopathology instead of penalty applications in the bully‐victim‐bystander triangle to direct toward treatment and making the necessary referrals [9, 25]. In the program, study groups with families as well as the children are arranged to increase their awareness on the subject.

Twemlow et al. [26], who developed and applied the program, which was generally found to decrease victimization, aggressiveness and aggressive bystanders, performed a longitudinal study with a control group. The applications were performed by showing zero tolerance to bullying at the school where the program was applied. In the control group, only regular psychiatric consultation was provided. The results were evaluated by taking data on disciplinary cases and school success from those two schools. The increase in academic success and the decrease in disciplinary events in the school where the program was applied were found to be significantly different compared to the school in the control group [26].

#### **2.3. Steps to respect**

The program consists of three stages: the first stage starts with building a school bullying management team that encompasses the whole school. This team makes observations regarding bullying behavior. The antibullying strategies and procedures and the consequences that those who apply bullying behavior will face are determined and the expectations on the subject are communicated to the whole school. In the second stage, the whole school staff is trained according to the reports of the students. During school personnel training, counselors, classroom teachers and foreign personnel are all trained for awareness on the subject. Some selected school personnel are trained to work directly with children involved in bullying. The families are included in this stage. In the third stage, classroom efforts where the classroom teachers give skill trainings last 11 hours. Classroom level efforts are aimed toward increasing the socioemotional skills of the students so that they can form positive relationships. Emotion regulation, recognizing emotions, resisting certain emotions and reporting bullying behavior are all among skills taught during training. Additional aims include being able to enter a group, being able to discern bullying behavior from others and adding responsibility to bystanders [27].

The results of studies on the effectiveness of the program have shown a significant decrease in the bullying approval behavior of bystander students in the intervention group compared to the control group. Additionally, an improvement in the taking responsibility to stop bullying behavior of the bystanders in the intervention group was reported [28]. According to the results of another study, students have reported 33% less physical bullying, teachers have reported 35% decrease in fights and 20% of school staff stated that the school environment had a more positive atmosphere [29].

## **2.4. Bully busters**

**2.2. Creating a peaceful school learning environment (CAPSLE)**

are arranged to increase their awareness on the subject.

**2.3. Steps to respect**

170 Child and Adolescent Mental Health

significantly different compared to the school in the control group [26].

The program, developed in 1994, aims to prevent bullying and create a positive school environment through ensuring that students learn ways to solve their problems without aggression and the social skills necessary to communicate positively [14]. The program consists of four basic and two supporting elements. The first basic element is to create a positive atmosphere at school by "zero" tolerance to all bullying. The second element is the formation of a disciplinary plan to provide appropriate behavior. In the process of doing this, the importance of social skills not only among the students but also with adults in the school was stressed. The third element is a classroom management plan. For this, the aim is to raise awareness on the dynamics of bullying and develop the appropriate disciplinary measures to ensure the change of these behaviors. The fourth basic element is a unique physical training program. In this program, the focus is on self‐defense sports that may help students develop self‐regulation skills. Additionally, in this stage, the aim is to provide counseling in a manner that will help to prevent bullying through an appropriate counseling program for children and adults. The first supportive element of the program is changing the language used at school to increase cognitive skills and the awareness of a person of his/her role in the bullying phenomenon. The second supportive element is to focus on psychopathology instead of penalty applications in the bully‐victim‐bystander triangle to direct toward treatment and making the necessary referrals [9, 25]. In the program, study groups with families as well as the children

Twemlow et al. [26], who developed and applied the program, which was generally found to decrease victimization, aggressiveness and aggressive bystanders, performed a longitudinal study with a control group. The applications were performed by showing zero tolerance to bullying at the school where the program was applied. In the control group, only regular psychiatric consultation was provided. The results were evaluated by taking data on disciplinary cases and school success from those two schools. The increase in academic success and the decrease in disciplinary events in the school where the program was applied were found to be

The program consists of three stages: the first stage starts with building a school bullying management team that encompasses the whole school. This team makes observations regarding bullying behavior. The antibullying strategies and procedures and the consequences that those who apply bullying behavior will face are determined and the expectations on the subject are communicated to the whole school. In the second stage, the whole school staff is trained according to the reports of the students. During school personnel training, counselors, classroom teachers and foreign personnel are all trained for awareness on the subject. Some selected school personnel are trained to work directly with children involved in bullying. The families are included in this stage. In the third stage, classroom efforts where the classroom teachers give skill trainings last 11 hours. Classroom level efforts are aimed toward increasing the socioemotional skills of the students so that they can form positive relationships. Emotion regulation, recognizing emotions, resisting certain emotions This program was prepared by Newman et al. [30]. The "Bully Busters" program is a teacher training focused psychoeducational intervention program aimed at preventing violence. The program includes both individual and environmental factors regarding a child. The aim is to ensure that especially teachers learn bullying and victimization prevention and intervention strategies, skills and techniques. The training, which starts with high priority awareness training on bullying, continues by teaching bully and victim recognition, bully and victim intervention, stress management, relaxation and coping skills. Through teacher support groups, trainings on activities to be applied in the classroom are taught to teachers. The teachers are given handbooks and CDs. The special aims of the program are increasing the coping skills of the students through strong role models, decreasing aggressive behavior and creating a more positive school atmosphere. Additionally, the program forms a discussion environment in the classroom so that students understand factors regarding being bullies and victims and aims at the provision of the necessary alternative social skills for conflict resolution.

Study results have shown that the Bully Busters program increases the knowledge of teachers on the subject and their intervention skills [31, 32], increases their personal sufficiency regarding bullying prevention [31], and decreases the bullying events among students and disciplinary problems [31, 33].

#### **2.5. Bully prevention in positive behavioral interventions and supports: BP‐PBIS**

The BP‐PBIS is a school‐based prevention program focused on the positive behavior of students and school staff. It is a program where bullying behavior is followed for the prevention of gossiping, inappropriate behavior and cyber bullying that encompasses the whole school curriculum and aims at providing social responsibility awareness. It was prepared using a developmental approach [30].

BP‐PBS teaches all of the students in a school the concept of "being respectful" and aims at adopting a three‐stage response (do not talk, stop, walk) when they encounter disrespectful behavior. The program is designed to train the personnel to make the correct interventions to the problematic behavior of students by teaching the correct behavior after the three‐stage response is used.

Around the school, the PBS is organized around a three‐layered prevention model. In the first layer, the aim is to make the school a safe and positive environment for students around the clock. For this reason, the behavior expected from them is taught to all of the students in the form of structured rules, the appropriate behaviors are ensured to be accepted in social environments, the results of problematic behavior are made to be predictable and the punishments to be met are made clear. In the second layer, the students under risk who do not receive enough support in the first layer are provided additional support. This layer includes interventions made to the students in small groups. Bullying is tried to be eliminated using social rewards. Last, the third layer includes students who do not respond to the first and second layers and consistently act negatively to be examined and worked with separately [34].

This program is supported, in addition to subjects included in the school curriculum, activities performed by students on the Internet. The effectiveness of the program is evaluated through questionnaires and the observations of supervisors [30].

Studies evaluating the effectiveness of the program have shown that children in the schools where the program was applied encountered less peer rejection and bullying compared to schools where the program was not applied [35], and that there was a decrease in problematic behavior, especially 65% decrease in physical and verbal aggression [34].

## **2.6. Kiusaamista Vastaan: against bullying: KiVa**

This program, which was developed in Finland, has international characteristics. In the program, it is suggested that teachers and students should form group norms in their schools through individual and group discussion. Content is presented through various materials prepared for teachers, students and parents. For example, in order to make students develop antibullying attitudes, antibullying video games are used. The whole of the program takes 20 hours and the courses are given by the teachers. In the courses, discussions, group studies, short films on bullying and role playing techniques are used to conduct the program. After each course, a classroom rule appropriate for the theme of the subject of the day is adopted. Another important factor of the program is teacher training. Teachers supervise during play time in the school playground. In the teacher training, they are taught to recognize the signals of bullying, which starts at the playground and reflects into the school and intervene appropriately. Additionally, an electronic forum environment where teachers from different schools can communicate is formed. In this electronic environment, teachers inform each other on the bullying events and interventions they encounter and make suggestions. Additionally, support groups for bullying victims are formed. Last, families are sent a handbook containing information on bullying and what they can do to prevent bullying [13].

When the effectiveness of the KiVa program was evaluated, 79.4% of the students stated that bullying stopped completely, 18.5% stated that it decreased, 0.9% stated that it stayed the same and 03% stated that it increased, while an increase in liking school and decreases in depression and anxiety were found [36]. Additionally, bullying was found to decrease in groups where bullies where characterized as having medium or little popularity [37].

## **3. Group studies toward intervening in peer bullying and their effectiveness**

Around the school, the PBS is organized around a three‐layered prevention model. In the first layer, the aim is to make the school a safe and positive environment for students around the clock. For this reason, the behavior expected from them is taught to all of the students in the form of structured rules, the appropriate behaviors are ensured to be accepted in social environments, the results of problematic behavior are made to be predictable and the punishments to be met are made clear. In the second layer, the students under risk who do not receive enough support in the first layer are provided additional support. This layer includes interventions made to the students in small groups. Bullying is tried to be eliminated using social rewards. Last, the third layer includes students who do not respond to the first and second layers and consistently act negatively to be examined and worked with

This program is supported, in addition to subjects included in the school curriculum, activities performed by students on the Internet. The effectiveness of the program is evaluated

Studies evaluating the effectiveness of the program have shown that children in the schools where the program was applied encountered less peer rejection and bullying compared to schools where the program was not applied [35], and that there was a decrease in problematic

This program, which was developed in Finland, has international characteristics. In the program, it is suggested that teachers and students should form group norms in their schools through individual and group discussion. Content is presented through various materials prepared for teachers, students and parents. For example, in order to make students develop antibullying attitudes, antibullying video games are used. The whole of the program takes 20 hours and the courses are given by the teachers. In the courses, discussions, group studies, short films on bullying and role playing techniques are used to conduct the program. After each course, a classroom rule appropriate for the theme of the subject of the day is adopted. Another important factor of the program is teacher training. Teachers supervise during play time in the school playground. In the teacher training, they are taught to recognize the signals of bullying, which starts at the playground and reflects into the school and intervene appropriately. Additionally, an electronic forum environment where teachers from different schools can communicate is formed. In this electronic environment, teachers inform each other on the bullying events and interventions they encounter and make suggestions. Additionally, support groups for bullying victims are formed. Last, families are sent a handbook containing information on bullying and what they can do to prevent

When the effectiveness of the KiVa program was evaluated, 79.4% of the students stated that bullying stopped completely, 18.5% stated that it decreased, 0.9% stated that it stayed the same and 03% stated that it increased, while an increase in liking school and decreases in depression and anxiety were found [36]. Additionally, bullying was found to decrease in

groups where bullies where characterized as having medium or little popularity [37].

through questionnaires and the observations of supervisors [30].

**2.6. Kiusaamista Vastaan: against bullying: KiVa**

behavior, especially 65% decrease in physical and verbal aggression [34].

separately [34].

172 Child and Adolescent Mental Health

bullying [13].

Some of the programs toward intervening in peer bullying are conducted in a classroom level while some are only toward the target student group [13]. Target‐focused programs are intervention efforts made toward bullies, victims, bully‐victims, or mixed groups. Since peer bullying is not a psychological disorder that is evaluated and classified according to certain diagnosis criteria, the studies performed with students with high bullying inclination were named not as therapeutic applications but as preventive group efforts in this section. In this section, although the number of the group studies made with high bullying tendencies is not much in the literature, especially the studies made with these bully students will be evaluated. For example, effort to increase the self‐respect of victims, similar victim‐based intervention studies and classroom‐based training studies will not be discussed.

In a study performed with male adolescents displaying bullying behavior [38], the aim was to decrease bullying by using behavioral techniques. The experimental study was conducted with 54 male bullies at age 16 studying at 3 middle schools in South Africa in three groups. The results of the study were evaluated using pretest, posttest and follow‐up measurements (1 month). The program was based on the social interactive model which explains the development of aggression in its theoretical basis and the behavioral approach, which is thought to be appropriate for the prevention of bullying. The program was performed by psychology students at school during school hours twice a week in nonconsecutive 10 weeks with sessions that took a total of 20 hours. In the behavioral program applied, the homework, self‐monitoring, role‐playing and token economy methods were used to provide positive behavior. For behavior change in rewarding nonbullying behavior, the "Wonderland Game" tokens, chocolates and movie tickets were used to utilize token economy. In each session, a topic was discussed in a manner allowing feedback on the behavior of students and role‐playing, drawings and games were utilized. During role‐playing, each member chose a "partner" to use the observations of the partner in "self‐monitoring sessions." With the program, a small decrease in bullying behavior that was not statistically significant was achieved. The nature and shortness of the program were thought to be the reason.

In another study, the aim was to provide outpatient treatment to young people with demonstrating bullying behavior, decrease the anger of young people and to improve their interpersonal relationships and health behavior related to quality of life [39]. For this reason, 22 young people received 6 months of family therapy and 22 young people were included in the control group. Weekly sessions for 90 min were held in the first 2 months and these sessions were made once a fortnight in the following months. In the sessions, elements of systematical therapy, dynamic therapy, gestalt therapy, psychodrama therapy and behavioral therapy were used. The therapy focused on interfamilial relationships. Topics such as communication, interfamilial rules and the freedoms of family members were discussed and "family games" changing familial balance were used to raise awareness and form new family rules. Two trained therapists conducted the sessions. Once every 2 weeks, the scales used in the study were applied to the members to evaluate improvement. A year after the study, follow‐up measurements were taken. The results of the study showed that the family therapy decreased the aggression and bullying behavior of young males with bullying behavior in a statistically significant manner and that the therapies increased health behavior related to quality of life.

In another study conducted with male students who engaged in bullying behavior, short‐term strategic family therapy was conducted [40]. The anger and health behavior related to quality of life of male adolescents who engage in bullying were tried to be changed. Of 72 students demonstrating bullying behavior, 36 were assigned to 12‐week short‐term strategic family therapy and 36 were assigned to the control group. After 12 weeks of treatment, decreases in the bullying behavior of the study group, increases in anger control and increases in health behavior related to quality of life were all found to be statistically significant.

In a study where art was used to decrease bullying, the effectiveness of an opera watched by the students in decreasing bullying was evaluated using pretest and posttest measurements [41]. The opera, named Elijah's Kite, was found to be more effective compared with the results of previous studies through social‐emotional learning, improving both social skills and life skills. The subject of the opera, which tried to emerge emotions through music, movement, order and dance, was the recognition of bullying, understanding the feelings of the victim and giving information on what to do in event of bullying. The study was performed with fourth and fifth graders formed from 57 males and 47 females and the opera was staged 6 weeks (3 schools) after the pretest measurements. In the results, the information of the students regarding bullying was found to be increased and reports of victimization were found to significantly decrease. Alongside these, while reports of bullying decreased with time in males, it increased in females.

In a study conducted in Turkey (Konya), the pressure exerted by high school students exerting peer pressure was tried to be decreased [42]. The study was conducted with 24 male students from among freshmen from a high school. In the study, the group psychological counseling applications developed by the researchers with an eclectic approach took 8 weeks. In the sessions, the subjects of having information on peer pressure and understanding basic concepts, sharing experiences regarding peer pressure, what the group members considered peer pressure, why they acted as such, what they feel when they exert or receive pressure, coping methods for feelings of anger, communication skills, conflict resolution training, emotion training and what the situations and automatic negative thoughts were when exerting or receiving peer pressure in daily life and how these could be changed, in respective order. As a result of the application, the program was found to be effective in decreasing peer pressure.

In another study, the elements of cognitive behavioral therapy were used in a program for bullying intervention [43]. The effects of contingency management and cognitive self‐instruction on bullying behavior were examined. The sample of the study consisted of 120 randomly selected bully students from 3 schools in 3 settlements in Nigeria. The study was conducted with 2 study (self‐instruction and contingency management) and one control group and each group consisted of 40 people (20 male and 20 female). The intervention groups took 1‐hour trainings once a week for 6 weeks. In each session, 15 min were allocated to the discussion of the previous session, 30 min to discussion/lesson and 15 min to summarizing and assigning homework for the next session. In the intervention group that received self‐instruction training, the method of using positive self‐concepts instead of negative ones such as "I should overcome bullying" and "I should think twice before bullying" was used. In the contingency management group, reinforcers for positive behavior were given. In the placebo control group, trainings on subjects such as time management and the importance of keeping notes were given. Results based on pretest and posttest evaluation showed that contingency management and self‐instruction had significant effects in decreasing bullying behavior. Self‐instruction was found to be more effective than contingency management. The effectiveness of the treatment did not show difference according to the religion or age of the participants.

the aggression and bullying behavior of young males with bullying behavior in a statistically significant manner and that the therapies increased health behavior related to quality of life. In another study conducted with male students who engaged in bullying behavior, short‐term strategic family therapy was conducted [40]. The anger and health behavior related to quality of life of male adolescents who engage in bullying were tried to be changed. Of 72 students demonstrating bullying behavior, 36 were assigned to 12‐week short‐term strategic family therapy and 36 were assigned to the control group. After 12 weeks of treatment, decreases in the bullying behavior of the study group, increases in anger control and increases in health

In a study where art was used to decrease bullying, the effectiveness of an opera watched by the students in decreasing bullying was evaluated using pretest and posttest measurements [41]. The opera, named Elijah's Kite, was found to be more effective compared with the results of previous studies through social‐emotional learning, improving both social skills and life skills. The subject of the opera, which tried to emerge emotions through music, movement, order and dance, was the recognition of bullying, understanding the feelings of the victim and giving information on what to do in event of bullying. The study was performed with fourth and fifth graders formed from 57 males and 47 females and the opera was staged 6 weeks (3 schools) after the pretest measurements. In the results, the information of the students regarding bullying was found to be increased and reports of victimization were found to significantly decrease. Alongside these, while reports of bullying decreased with time in males, it increased in females. In a study conducted in Turkey (Konya), the pressure exerted by high school students exerting peer pressure was tried to be decreased [42]. The study was conducted with 24 male students from among freshmen from a high school. In the study, the group psychological counseling applications developed by the researchers with an eclectic approach took 8 weeks. In the sessions, the subjects of having information on peer pressure and understanding basic concepts, sharing experiences regarding peer pressure, what the group members considered peer pressure, why they acted as such, what they feel when they exert or receive pressure, coping methods for feelings of anger, communication skills, conflict resolution training, emotion training and what the situations and automatic negative thoughts were when exerting or receiving peer pressure in daily life and how these could be changed, in respective order. As a result of the application, the program was found to be effective in decreasing peer pressure. In another study, the elements of cognitive behavioral therapy were used in a program for bullying intervention [43]. The effects of contingency management and cognitive self‐instruction on bullying behavior were examined. The sample of the study consisted of 120 randomly selected bully students from 3 schools in 3 settlements in Nigeria. The study was conducted with 2 study (self‐instruction and contingency management) and one control group and each group consisted of 40 people (20 male and 20 female). The intervention groups took 1‐hour trainings once a week for 6 weeks. In each session, 15 min were allocated to the discussion of the previous session, 30 min to discussion/lesson and 15 min to summarizing and assigning homework for the next session. In the intervention group that received self‐instruction training, the method of using positive self‐concepts instead of negative ones such as "I should overcome bullying" and "I should think twice before bullying" was used. In the contingency

behavior related to quality of life were all found to be statistically significant.

174 Child and Adolescent Mental Health

## **4. A general overview of cognitive behavioral therapy (CBT) and peer bullying preventions with CBT**

According to cognitive model, the ways people interpret the events affect their emotions and actions. Cognitive behavioral therapy is based on two principles: one of them is our cognitions (thoughts) that determine our emotions and actions and the other one is the way we act that shows some strong effects on our thoughts and feelings. According to CBT, every single psychological disorders and problematic behaviors have an underlying mechanism as distortional and dysfunctional thoughts that affect people's psychological mental health and their actions. Evaluation and changing them cause some improvements and recruitments on emotions and actions. Briefly, fundamental assumption of CBT is changing emotions and actions by finding the negative automatic thoughts and reframing them. Cognitive and behavioral techniques are used while working on changing thoughts and emotions.

Examination of peer bullying prevention and intervention programs reveals that cognitive and behavioral techniques are frequently used although not all components of the cognitive behavioral therapy methods are employed. For instance, Olweus' [1] bullying prevention program aims to alter bullying‐related cognitions at schools. Attempts at altering bullying‐ related cognitions involve changing these cognitions with positive thoughts, such as "children are okay with this" versus "bullying must be stopped/no child can be educated like this" or "bullying is a great opportunity" versus "I can stop bullying when I confront it."

In the Bully‐Busters bullying prevention program, components of cognitive behavioral therapy are used. The program's manual teaches children to change their negative bullying‐ related cognitions with positive alternatives and to plan various actions against bullying. Anger management, emotion training, empathy training, cognitive training, social skills training, problem solving skills training and conflict resolution training are among other cognitive behavioral elements used in the Bully‐Busters program [44].

In a bullying prevention program which used behavioral techniques involved self‐monitoring, role playing and token economy [38]; while in another program which used cognitive behavioral techniques involved self‐instruction and contingency management [43]. During the studies, the researchers employed the cognitive reframing technique and tried to establish positive thoughts such as "I must overcome bullying" and "I should think twice before bullying someone."

In conclusion, despite the abundance of efficacy studies on cognitive behavioral therapy programs aimed at reducing aggression among youth, studies that use cognitive behavioral interventions in youth who bully peers are limited [38, 43]. As explained above from a cognitive behavioral approach, it can be postulated that psychological disorders derive from dysfunctional thought patterns or the lack of positive‐appropriate behavioral coping strategies. In this treatment approach, it is aimed to restructure effective coping strategies and problem solving skills as well as reducing cognitive bias or distortions [45].

In this context, an intervention program which included cognitive behavioral therapy elements was prepared for middle school students with high bullying tendencies. The efficacy of the program was tested in an experimental study which investigated the pretest, posttest and follow‐up measures of experiment, placebo control and control (no intervention) groups. It was found that this cognitive behavioral therapy program that aimed to reduce bullying tendencies was effective in changing bullying related cognitions and in reducing bullying behavior [46].

## **5. Introduction of a cognitive Behavioral intervention program aimed at decreasing bullying**

The cognitive behavioral intervention program was prepared according to the principles of cognitive behavioral therapy. In summary, it consists of certain techniques, namely psychoeducation, which entails understanding what bullying behaviors are, the difference between joking and conflict, how bullying harms people in the short and long terms (to encourage change and motivate the group) and feelings and thoughts that accompany bullying behavior; self‐awareness training, which helps a person recognize their valuable aspects and supports positive self‐perception; cognitive restructuring, which entails changing the thoughts accompanying bullying; coping techniques, which entail stopping bullying behavior and replacing them with alternative behavior; self‐instruction, which entails finding slogans and internal discourses to remind of stopping bullying and repeating them to oneself; and role‐playing, which is applied to use the techniques learned in hypothetical situations. Additionally, a reward system to reinforce positive behavior was used.

#### **5.1. The process of the program, duration and content**

The group application consisted of 13 120‐min sessions, once a week. The first 15 min of each session is allocated to forming connections to the previous session and the discussion of homework, if present. Later, the daily subject was discussed for 20–30 min. After a 15‐min break, the second half of the session was started and the subject was reinforced with an appropriate game (table game, enactment) (15–20 min). Later, free play time was given (15–20 min). At the end of the games, the reward schematics were recorded. Last, a review of the day was performed, feedback on the session was received and the session was ended.

#### *5.1.1. Environment*

The applications were made in an empty room seen appropriate by the school management (library, counselor's room, etc.). An environment where the students could comfortably sit in a circle, come to a table when needed, which was wide enough that free games and role plays could be played and which would not be used during group hours for other reasons was tried to be ensured. To use rewards, sometimes the schoolyard was also used. In each session, the pages of the program handbook were given to the students as written materials and written‐ table games were prepared for the subjects.

Use of rewards: in order to support members' participation, compliance with group rules, completion of assignments and positive interaction, the use of rewards is very important. In this study, a reward table was used for rewards. The reward table was recorded at the end of each session. These rewards were arranged as individual and group rewards.

## *5.1.2. The content of the sessions*

According to the plan outlined above, the goals and general summary of each session was given below.

## *<IP_ADDRESS>. Sessions 1–3: psychoeducation*

## *<IP_ADDRESS>.1. Introduction*

In conclusion, despite the abundance of efficacy studies on cognitive behavioral therapy programs aimed at reducing aggression among youth, studies that use cognitive behavioral interventions in youth who bully peers are limited [38, 43]. As explained above from a cognitive behavioral approach, it can be postulated that psychological disorders derive from dysfunctional thought patterns or the lack of positive‐appropriate behavioral coping strategies. In this treatment approach, it is aimed to restructure effective coping strategies and problem

In this context, an intervention program which included cognitive behavioral therapy elements was prepared for middle school students with high bullying tendencies. The efficacy of the program was tested in an experimental study which investigated the pretest, posttest and follow‐up measures of experiment, placebo control and control (no intervention) groups. It was found that this cognitive behavioral therapy program that aimed to reduce bullying tendencies was effective in changing bullying related cognitions and in reducing bullying behavior [46].

**5. Introduction of a cognitive Behavioral intervention program aimed at**

The cognitive behavioral intervention program was prepared according to the principles of cognitive behavioral therapy. In summary, it consists of certain techniques, namely psychoeducation, which entails understanding what bullying behaviors are, the difference between joking and conflict, how bullying harms people in the short and long terms (to encourage change and motivate the group) and feelings and thoughts that accompany bullying behavior; self‐awareness training, which helps a person recognize their valuable aspects and supports positive self‐perception; cognitive restructuring, which entails changing the thoughts accompanying bullying; coping techniques, which entail stopping bullying behavior and replacing them with alternative behavior; self‐instruction, which entails finding slogans and internal discourses to remind of stopping bullying and repeating them to oneself; and role‐playing, which is applied to use the techniques learned in hypothetical situations. Additionally, a

The group application consisted of 13 120‐min sessions, once a week. The first 15 min of each session is allocated to forming connections to the previous session and the discussion of homework, if present. Later, the daily subject was discussed for 20–30 min. After a 15‐min break, the second half of the session was started and the subject was reinforced with an appropriate game (table game, enactment) (15–20 min). Later, free play time was given (15–20 min). At the end of the games, the reward schematics were recorded. Last, a review of the day was

The applications were made in an empty room seen appropriate by the school management (library, counselor's room, etc.). An environment where the students could comfortably sit in

performed, feedback on the session was received and the session was ended.

solving skills as well as reducing cognitive bias or distortions [45].

reward system to reinforce positive behavior was used.

**5.1. The process of the program, duration and content**

**decreasing bullying**

176 Child and Adolescent Mental Health

*5.1.1. Environment*

The leader started by introducing themselves. The reason for the group gathering and the group process was explained to the students and an introduction game was played. Group rules were discussed and the contracts on compliance with group rules were given as two copies to the students to be signed. Then the aims of the study, rewards, study type and study days were explained. In order to ensure group motivation, the students were told to think of a group name until the nest session.

## *<IP_ADDRESS>.2. Awareness on bullying behavior*

In order to make peer bullying more understandable, examples of bullying and nonbullying behavior were given in hypothetical situations and the differences between these behavior types were discussed. What peer bullying is was explained.

#### *<IP_ADDRESS>. Sessions 4 and 5: emotional training*

In order to recognize emotions, understanding someone else's emotions by bodily cues and the fact that more than one emotion can be experienced in an event were studies using emotion posters and emotion guessing games. In order to make students realize that emotions can change, different people having different emotions in various situations and the emotions that occur during bullying were studied using the experiences of the students recorded at home by homework and the prepared worksheets.

#### *<IP_ADDRESS>. Sessions 6–10: cognitive restructuring*

In these sessions, the concepts of thought, connections between thought‐emotion‐behavior, recognizing thoughts related to bullying, making the connections between thoughts and emotions related to bullying behavior and replacing thoughts that cause bullying with new thoughts were studied. Card games prepared beforehand were used to reinforce the subject.

In this process, awareness training was given so that group members could recognize their own positive characteristics. The needs underlying one's bullying behavior were checked, the needs for perceiving oneself as strong, valuable and leading were identified and positive personality characteristics that would make one such a person without bullying were emphasized. Additionally, what the alternatives to bullying behavior could be was discussed.

## *<IP_ADDRESS>. Session 11: self‐instruction training*

Finding slogans and internal discourses to change the thought that may cause bullying and remind of the alternative behavior and rewarding oneself when bullying behavior is stopped were studied. In order to replace bullying behavior with new behavior, behavioral experiments that would remind one of the slogans were performed. In this stage, self‐instruction and role playing techniques were used.

## *<IP_ADDRESS>. Sessions 12 and 13: reviewing all of the techniques and conclusion*

In these sessions, all of the techniques that were learned were reviewed and alternative behavior to stop bullying behavior and slogan reminding were reinforced through role playing. The efforts of the students to reward themselves when they stopped bullying behavior were supported.

## **6. Discussion**

In the prevention of peer bullying, whole school approach programs that encompass all groups whether bully, victim, or bystander and that are applied to the school system as a whole are known to be effective [1, 13]. These programs generally contain education efforts done in large groups. However, when the risks exhibited by bullying children regarding their adult lives are considered, it was thought that these children should be the subject of separate interventions with more comprehensive techniques and thus a cognitive behavioral intervention program aimed at reducing or eliminating these behavior was prepared and its effectiveness was tested [46]. This program is not thought to be an alternative approach to prevention programs toward the school system as a whole, but as an additional application that may lead to more effective results in the reduction of bullying.

## **Author details**

Füsun Gökkaya Address all correspondence to<EMAIL_ADDRESS>Ministry of Education, İzmir, Turkey

## **References**

In this process, awareness training was given so that group members could recognize their own positive characteristics. The needs underlying one's bullying behavior were checked, the needs for perceiving oneself as strong, valuable and leading were identified and positive personality characteristics that would make one such a person without bullying were emphasized. Additionally, what the alternatives to bullying behavior could be

Finding slogans and internal discourses to change the thought that may cause bullying and remind of the alternative behavior and rewarding oneself when bullying behavior is stopped were studied. In order to replace bullying behavior with new behavior, behavioral experiments that would remind one of the slogans were performed. In this stage, self‐instruction

In these sessions, all of the techniques that were learned were reviewed and alternative behavior to stop bullying behavior and slogan reminding were reinforced through role playing. The efforts of the students to reward themselves when they stopped bullying behavior were

In the prevention of peer bullying, whole school approach programs that encompass all groups whether bully, victim, or bystander and that are applied to the school system as a whole are known to be effective [1, 13]. These programs generally contain education efforts done in large groups. However, when the risks exhibited by bullying children regarding their adult lives are considered, it was thought that these children should be the subject of separate interventions with more comprehensive techniques and thus a cognitive behavioral intervention program aimed at reducing or eliminating these behavior was prepared and its effectiveness was tested [46]. This program is not thought to be an alternative approach to prevention programs toward the school system as a whole, but as an additional application that may lead

was discussed.

178 Child and Adolescent Mental Health

supported.

**6. Discussion**

**Author details**

Füsun Gökkaya

Ministry of Education, İzmir, Turkey

*<IP_ADDRESS>. Session 11: self‐instruction training*

and role playing techniques were used.

*<IP_ADDRESS>. Sessions 12 and 13: reviewing all of the techniques and conclusion*

to more effective results in the reduction of bullying.

Address all correspondence to<EMAIL_ADDRESS>

[30] Serwacki M, Nickerson AB, editors. Guide to School Wide Bullying Prevention Programs, Alberti Center for Bullying Abuse Prevention. Graduate School of Education University at Buffalo, the State University of New York. [Internet]. 2012. Available from: http:// gse.buffalo.edu/gsefiles/documents/alberti/Bullying%20Prevention%20Program%20 Guide%20‐%20FINAL%203.16.12\_0.pdf [Accessed: 2016‐08‐15]

[15] Olweus D. Bullying at school and later criminality: findings from three Swedish community samples of males. Criminal Behaviour and Mental Health. 2011; 21: 151–156. [16] Rigby K, Smith PK, Pepler PK, Smith D, Pepler K. Working to prevent school bullying: key issues. In: Rigby D, editors. Bullying in Schools: How Successful can Interventions

[17] Smith PK, Brain P. Bullying in schools: lessons from two decades of research. Aggressive

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[19] Rigby K. What can schools do about cases of bullying? Pastoral Care in Education. 2011;

[20] Doğan A. Ecological systems model as a framework for bullying. Turkish Journal of

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[24] Black S. Evaluation of the Olweus bullying prevention program: how the program can work for inner city youth. In: Proceedings of Persistently Safe Schools, The 2007 National

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[29] Brown EC, Low S, Smith BH, Haggerty KP. Outcomes from a school randomized controlled trial of steps to respect: a school bullying prevention program. School Psychology

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to respect program. Developmental Psychology. 2005; 41(3): 479–491.

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Behavior. 2000; 26: 1–9.

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180 Child and Adolescent Mental Health

## **Use of Antidepressants in Children and Adolescents**

[41] Haner D, Pepler D, Cummings J, Vaughan AR. The role of arts‐based curricula in bullying prevention: Elijah's kite—a children's opera. Canadian Journal of School Psychology.

[42] Sargın N, Çetinkaya B. The effectiveness of group counseling in reducing peer pressure.

[43] Eweniyi G, Adeoye A, Ayodele K. O, Raheem A. The effectiveness of two psycho‐social behavioural interventions on adolescents' bullying behaviour among Nigerian adoles-

[44] Doll B, Swearer SS. Cognitive behavioral interventions for participants in bullying and coercion. In: Mennuti R, Freeman A, Christner R, editors. Cognitive‐Behavioral

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182 Child and Adolescent Mental Health

Psychiatry. 2005; 4(9): 123–125.

Isabel Hernández-Otero, Carlos Gómez Sánchez-Lafuente and Cecilia Hernández González

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68994

## **Abstract**

Depression is a serious disorder that can cause significant problems in mood, thinking, and behavior at home, in school, and with peers. It is estimated that major depressive disorder (MDD) affects about 5% of adolescents. Research has shown that, as in adults, depression in children and adolescents is treatable. Certain antidepressant medications, called selective serotonin reuptake inhibitors (SSRIs), can be beneficial to children and adolescents with MDD. Certain types of psychological therapies also have been shown to be effective. However, our knowledge of antidepressant treatments in youth, though growing substantially, is limited compared to what we know about treating depression in adults. The U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. However, SSRI medications are considered to have an improvement over older antidepressant medications and they have been shown to be safe and effective for adults. In this chapter we provide an updated and well-documented review of the current scientific evidence on this topic.

**Keywords:** antidepressants, children, adolescents

## **1. Overview**

Major depressive disorder (MDD) is one of the most common mental disorders in children and adolescents [1, 2]. Although the estimated prevalence is 5–6% in adolescents aged 13–18 years and 5–6% in children aged 6–12 years, there are fewer studies to understand how antidepressants work in this age group [1]. Children and adolescents present with undifferentiated depressive symptoms, like irritability, school refusal, and aggressive behavior [3], which is

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

possible the main reason why major depressive disorder is still under diagnosed and untreated comparing to adults. Depression often impaired social functioning and it may cause suicidal ideation and attempts as a symptom of low mood [4]. Use of antidepressants is wide, in spite of the recommendations of psychotherapy as first-line treatment in most clinical trials [5]. In 2004, the US Food and Drug Administration (FDA) practitioners set a black-box warning relating the use of antidepressants in children and adolescents to an increased risk of suicide [7]. Since then, the use of antidepressants in this group of age remains controversial [3].

The European Medicines Agency has completed its review of two classes of antidepressants and concluded that they should not be used in children and adolescents except in their approved indications [4, 6]. The review of serotonin-selective reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medicines looked at the potential risk of suicidal behavior in children and adolescents treated with these products [13].

The Agency's scientific committee, the Committee for Medicinal Products for Human Use (CHMP), concluded at its April 19–22, 2005 meeting that suicide-related behavior (suicide attempt and suicidal thoughts) and hostility (predominantly aggression, oppositional behavior, and anger) were more frequently observed in clinical trials among children and adolescents treated with these antidepressants compared to those treated with placebo [13].

The Agency's committee is therefore recommending the inclusion of strong warnings across the whole of the European Union to doctors and parents about these risks. Doctors and parents will also be advised that these products should not be used in children and adolescents except in their approved indications [13].

Most of these products are approved for the treatment of depression and anxiety in adults in the European Union, but are not licensed Europe-wide for the treatment of these conditions in children or adolescents. Some of these products are however licensed for pediatric use for the treatment of obsessive-compulsive disorder and one of them for the treatment of attention deficit/hyperactivity disorder [13].

The efficacy of antidepressants is well documented among adults with major depressive disorder, however, in children and adolescents there are fewer studies and they tend to have worse methodology and more risk of bias [8, 9]. Randomized controlled trials (RCT) have shown that antidepressants agents have positive risk-benefit ratio in children and adolescents, but their clinical use should balance the potential risk and the clinical need. Young people should be closely monitored for suicidal ideation and behaviors, especially when starting an antidepressant and at dosage adjustments [7].

A recent network meta-analysis has proved antidepressants to be well-tolerated in major depressive disorder in children and adolescents [9], although they do not seem to offer a clear advantage against psychotherapeutic interventions. These trials include use of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine [8]. Only fluoxetine showed statistically significant differences with placebo. In terms of tolerability, fluoxetine was better than duloxetine and imipramine. According to these results, fluoxetine should be considered the best option when considering medication to treat moderate-to-severe depression in children and adolescents, when they do not have access to psychotherapy or have not responded to nonpharmacological interventions. Evidence suggests a significantly increased risk for suicidality (suicidal behavior or ideation) in young people given venlafaxine for the treatment of major depressive disorder [10].

## **2. Selective serotonin reuptake inhibitors (SSRIs)**

## **2.1. Fluoxetine**

possible the main reason why major depressive disorder is still under diagnosed and untreated comparing to adults. Depression often impaired social functioning and it may cause suicidal ideation and attempts as a symptom of low mood [4]. Use of antidepressants is wide, in spite of the recommendations of psychotherapy as first-line treatment in most clinical trials [5]. In 2004, the US Food and Drug Administration (FDA) practitioners set a black-box warning relating the use of antidepressants in children and adolescents to an increased risk of suicide [7].

The European Medicines Agency has completed its review of two classes of antidepressants and concluded that they should not be used in children and adolescents except in their approved indications [4, 6]. The review of serotonin-selective reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medicines looked at the potential risk of

The Agency's scientific committee, the Committee for Medicinal Products for Human Use (CHMP), concluded at its April 19–22, 2005 meeting that suicide-related behavior (suicide attempt and suicidal thoughts) and hostility (predominantly aggression, oppositional behavior, and anger) were more frequently observed in clinical trials among children and adoles-

The Agency's committee is therefore recommending the inclusion of strong warnings across the whole of the European Union to doctors and parents about these risks. Doctors and parents will also be advised that these products should not be used in children and adolescents

Most of these products are approved for the treatment of depression and anxiety in adults in the European Union, but are not licensed Europe-wide for the treatment of these conditions in children or adolescents. Some of these products are however licensed for pediatric use for the treatment of obsessive-compulsive disorder and one of them for the treatment of attention

The efficacy of antidepressants is well documented among adults with major depressive disorder, however, in children and adolescents there are fewer studies and they tend to have worse methodology and more risk of bias [8, 9]. Randomized controlled trials (RCT) have shown that antidepressants agents have positive risk-benefit ratio in children and adolescents, but their clinical use should balance the potential risk and the clinical need. Young people should be closely monitored for suicidal ideation and behaviors, especially when start-

A recent network meta-analysis has proved antidepressants to be well-tolerated in major depressive disorder in children and adolescents [9], although they do not seem to offer a clear advantage against psychotherapeutic interventions. These trials include use of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine [8]. Only fluoxetine showed statistically significant differences with placebo. In terms of tolerability, fluoxetine was better than duloxetine and imipramine. According to these results, fluoxetine should be considered the best option when considering medication to treat moderate-to-severe depression in children and adolescents, when they do not have access to psychotherapy or have not responded

cents treated with these antidepressants compared to those treated with placebo [13].

Since then, the use of antidepressants in this group of age remains controversial [3].

suicidal behavior in children and adolescents treated with these products [13].

except in their approved indications [13].

184 Child and Adolescent Mental Health

deficit/hyperactivity disorder [13].

ing an antidepressant and at dosage adjustments [7].

## *2.1.1. Pharmacodynamics*

## *2.1.2. Pharmacokinetics*

Fluoxetine is absorbed in gastrointestinal tract and metabolized by the liver. The active metabolite, norfluoxetine, has a half-life of 2 weeks. The original drug has a half-life of 2–3 days. Inhibits cytochrome P450 2D6 (CYP2D6) and cytochrome P450 3A (CYP3A).

## *2.1.3. Drug and food interactions*

## *2.1.4. Side effects and toxicology*

The appearance of these side effects by itself does not need the withdrawal of the drug, but the decision should be individualized. Sometimes these adverse effects could be very disturbing por the patient, so if this happens we recommend to decrease the dose and wait, being able to rise again progressively in case of improving the symptoms. In case of persistent effects despite decreasing the dose, consider withdrawing the drug.

In high risk bleeding patients, consider prescribing another antidepressants (nonSSRIs). In patients taking antidepressants with high affinity for serotonin receptors, it is advised to avoid or decrease the use of nonsteroidal anti-inflammatory drugs or aspirin.

#### *2.1.5. Use in children and adolescents*

## **2.2. Sertraline**

• It could increase concentrations of pimozide and produce dangerous QTc prolongation and

• Patients diagnosed with bipolar disorder, psychotic disorder, or bipolar or psychotic disorder undiagnosed may be more vulnerable to the pharmacological actions of SSRIs on the

The appearance of these side effects by itself does not need the withdrawal of the drug, but the decision should be individualized. Sometimes these adverse effects could be very disturbing por the patient, so if this happens we recommend to decrease the dose and wait, being able to rise again progressively in case of improving the symptoms. In case of persistent effects

In high risk bleeding patients, consider prescribing another antidepressants (nonSSRIs). In patients taking antidepressants with high affinity for serotonin receptors, it is advised to

• Posology: fluoxetine has been approved for depression and obsessive-compulsive disorder (OCD). Teens usually receive the same dose as adults, children receive slightly lower dose. They should be administered in a single dose, usually in the morning. The liquid solution

• How to start treatment: you have to gradually increase the drug. The starting dose is 10 mg/ day for anxiety disorders and depressive disorders; gradually increase the dose to achieve therapeutic range (usually 20 mg/day). In bulimia nervosa, the dose is 60–80 mg/day in

• Phase maintenance dose should be carefully adjusted: it is recommended that treatment should be maintained between 6–12 months after reaching the clinical improvement.

• Treatment withdrawal: no need to taper the dosage as fluoxetine alone is removed gradu-

ally due to the long half-life that has and shares with its active metabolites.

avoid or decrease the use of nonsteroidal anti-inflammatory drugs or aspirin.

• Tramadol increases the convulsion risk in patients taking antidepressants.

• Decreased appetite, nausea, diarrhea, constipation, and dry mouth.

• Insomnia, sedation, agitation, tremors, headache, and dizziness.

despite decreasing the dose, consider withdrawing the drug.

cardiac arrhythmias.

186 Child and Adolescent Mental Health

*2.1.4. Side effects and toxicology*

• Hematomas and rarely bleeds.

central nervous system (CNS).

*2.1.5. Use in children and adolescents*

facilitates management in children.

adolescents and in children slightly lower.

• For long-term use: it is safe for an extended period.

• Sexual dysfunction.

• Sweating.

#### *2.2.1. Pharmacodynamics*

## *2.2.2. Pharmacokinetics*

The original drug has a half-life of 22–36 hours. The half-life of the metabolite is from 62 to 104 hours. Also, inhibits CYP2D6 and CYP3A4 (weakly).

## *2.2.3. Drug and food interactions*

#### *2.2.4. Side effects and toxicology*

As we discuss with fluoxetine, the appearance of these adverse effects alone does not need withdrawal of the drug, but the decision should be individualized. If these adverse effects are very annoying to the child, we recommend decreasing the dose and wait, being able to rise again progressively in case of improving the side effects. In case of persistent effects despite decreasing the dose, consider withdrawing the drug.

Note: Patients with diagnosed or bipolar disorder or psychotic disorders may be more vulnerable to the pharmacological actions of SSRIs.

Toxicology: It is rare to be lethal in overdose alone; vomiting, sedation, abnormal heart rhythm, mydriasis, agitation; deaths have been reported with overdoses of sertraline, in combination with other drugs or alcohol.

#### *2.2.5. Use in children and adolescents*

#### **2.3. Citalopram**

#### *2.3.1. Pharmacodynamics*

#### *2.3.2. Pharmacokinetics*

The original drug has a half-life of 23–45 hours. It is a weak inhibitor of CYP2D6.

## *2.3.3. Drug and food interactions*

• Hyponatremia is rare. • Hypotension is rare.

188 Child and Adolescent Mental Health

decreasing the dose, consider withdrawing the drug.

able to the pharmacological actions of SSRIs.

one can start the adult dose of 50 mg daily.

• Long-term use: it is safe for an extended period.

months after clinical improvement.

desensitizes, especially, 5-HT1A.

bination with other drugs or alcohol.

*2.2.5. Use in children and adolescents*

fective dose.

complete withdrawal.

*2.3.1. Pharmacodynamics*

*2.3.2. Pharmacokinetics*

**2.3. Citalopram**

As we discuss with fluoxetine, the appearance of these adverse effects alone does not need withdrawal of the drug, but the decision should be individualized. If these adverse effects are very annoying to the child, we recommend decreasing the dose and wait, being able to rise again progressively in case of improving the side effects. In case of persistent effects despite

Note: Patients with diagnosed or bipolar disorder or psychotic disorders may be more vulner-

Toxicology: It is rare to be lethal in overdose alone; vomiting, sedation, abnormal heart rhythm, mydriasis, agitation; deaths have been reported with overdoses of sertraline, in com-

• Posology: for children aged 6–12 years, the initial dose is 25 mg/day. From the age of 13,

• How to start treatment: gradual increase in dose, 25 mg/7 days to reach the minimum ef-

• Maintenance phase: the dose should be carefully adjusted and maintain the drug for 6–12

• Treatment withdrawal: the dose should be gradually reduced to avoid withdrawal symptoms (dizziness, nausea, stomach cramps, sweating, tingling, and dysesthesia). Some patients tolerate a decrease of 50% of the dose in 3 days, another 50% over the next 3 days to

• Action mechanism: blocking reuptake pump 5-HT, serotonin neurotransmission increasing. • Pharmacological profile: receptor affinity. Increases concentration of 5-HT receptors and

The original drug has a half-life of 23–45 hours. It is a weak inhibitor of CYP2D6.

#### *2.3.4. Side effects*

The advice for action in case of appearance of side effects is the same as that discussed in previous SSRIs.

#### *2.3.5. Toxicology*

## *2.3.6. Use in children and adolescents*

## **2.4. Escitalopram**

### *2.4.1. Pharmacodynamics*

## *2.4.2. Pharmacokinetics*

The elimination half-life is 27–36 hours. Stable mean plasma concentrations are reached within weeks. It has no effect on the CYP450.

#### *2.4.3. Drug and food interactions*

#### *2.4.4. Side effects*

The advice for action in case of appearance of side effects is the same as that discussed in previous SSRIs.

### *2.4.5. Toxicology*

*2.3.6. Use in children and adolescents*

single dose in the morning or evening.

• For long-term use: it is safe for an extended period.

symptoms. Restart the reduction more progressively.

• Action mechanism: enhanced release of 5-HT reuptake inhibiting pump.

• Tramadol increases the risk of convulsion in patients taking antidepressants.

to 10–20 mg/day.

190 Child and Adolescent Mental Health

**2.4. Escitalopram**

*2.4.1. Pharmacodynamics*

autoreceptors.

*2.4.2. Pharmacokinetics*

*2.4.4. Side effects*

• Sexual dysfunction.

*2.4.3. Drug and food interactions*

within weeks. It has no effect on the CYP450.

MAOI up to 14 days after it is suspended.

• Posology: the right dose in children is 5–10 mg/day. In adolescents it may be administered

• Phase maintenance: carefully adjust the dose. You can increase the dose to 5 mg/day after one or two weeks. In adolescents it can be increased to 10 mg/day after one or more weeks until the desired effectiveness. The maximum is 60 mg/day. It can be administered as a

• Treatment withdrawal: no progressive reduction of the drug is needed. However, it is advisable to avoid potential withdrawal symptoms. Most patients tolerate doses decreased 50% in 3 days; another 50% reduction in 3 days, and then the dose may be suspended. If withdrawal symptoms appear during reduction, the dose should be increased to stop

• Pharmacological profile: receptor affinity. Desensitize 5-HT receptors, especially 1A

The elimination half-life is 27–36 hours. Stable mean plasma concentrations are reached

• Can cause a fatal "serotonin syndrome" when combined with MAOIs; not starting an

• It could theoretically cause weakness, incoordination hyperreflexia, and when combined with sumatriptan or other triptans, so careful monitoring of the patient is necessary.

• It can increase the risk of bleeding, especially when combined with anticoagulants.

• Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, and dry mouth).

Mortality is rare to the overdose of escitalopram alone or in combination with other drugs. Symptoms associated with overdose are nausea, vomiting, sedation, sweating, tremor, and rarely amnesia, coma, and convulsions.

#### *2.4.6. Use in children and adolescents*

**There are other antidepressants such as paroxetine and fluvoxamine that have not demonstrated superior efficacy to placebo in children and adolescents with depression**.

## **3. Serotonin and norepinephrine reuptake inhibitors (SNRIs)**

Although none of them is approved by European Medicines Agency or US FDA, some antidepressants not related with SSRI have also been used to children and adolescents for childhood and juvenile depression and anxiety disorders.

## **3.1. Venlafaxine**

#### *3.1.1. Pharmacodynamics*

Venlafaxine is a selective serotonin and norepinephrine reuptake inhibitors (SSNRIs). Although, the exact mechanism of action is not well known, venlafaxine and its metabolite, O-desmethylvenlafaxine (ODV) inhibit the reuptake of serotonin at low doses, serotonin and norepinephrine (NE) at higher doses, and have a weak inhibitory effect on the reuptake of dopamine at even higher doses. Venlafaxine has little affinity for histaminergic, cholinergic, and alpha-adrenergic receptors, not clinically significant.

## *3.1.2. Pharmacokinetics*

Venlafaxine is well absorbed. Food does not affect the absorption of venlafaxine. Bioavailability is 45% following oral administration. Venlafaxine is metabolized by cytochrome P450 2D6 and cytochrome P450 2C19 to ODV, the major metabolite, which is clinically active. Renal elimination is the main route of excretion. The half-life is about 5–11 hours.

### *3.1.3. Drug and food interactions*

Venlafaxine is a moderate inhibitor of cytochrome P450 2D6. Tramadol increases the risk of seizures in patients taking antidepressants. Venlafaxine could inhibit the metabolism of tramadol, reducing his analgesic efficacy and increasing the risk of serotonin syndrome.

### *3.1.4. Side effects and toxicology*

#### *3.1.5. Use in children and adolescents*

Venlafaxine is FDA approved for major anti-inflammatory in adults; meanwhile extendedrelease venlafaxine is approved for the treatment of adults with generalized anxiety disorder, panic disorder, and social phobia besides major depressive disorder.

Two multicenter, randomized, double-blind, and placebo-controlled trials have evaluated the efficacy and tolerability of venlafaxine extended release (ER) for children and adolescents with major depressive disorder. The primary main outcome was the Children's Depression Rating Scale-Revised (CDRS-R) total score. Analysis of each trial independently showed no statically significance between venlafaxine ER and placebo. In the age subgroup analysis, the pooled data showed greater improvement with venlafaxine ER among adolescents (ages 12–17) but not among children (ages 7–11). This study also found that hostility and suiciderelated events were more common in venlafaxine ER-treated participants than in placebotreated participants. There were no completed suicides.

The treatment of resistant depression in adolescents (TORDIA) study was a RCT of treatment resistant adolescents (ages 12–18) with major depressive disorder, who had not responded to a 2-month treatment with an SSRI. Then they were randomized to another SSRI alone, alternate SSRI plus cognitive behavioral therapy (CBT), venlafaxine alone, or venlafaxine plus CBT. Combination of CBT and a switch to another antidepressant had a higher rate of clinical response than medication alone. Changing to an alternate SSRI or venlafaxine had no different response rates. Venlafaxine groups have shown increase in blood pressure and frequency rate, rarely of clinical impact.

Venlafaxine ER has been also studied for anxiety disorders. An RCT of 320 youth (ages 6–17) diagnosed with generalized anxiety disorder shown statistically significant improvement in both the primary outcome and the response rate compared to placebo. Statistically significant changes in weight, blood pressure, pulse, and cholesterol levels were observed in the venlafaxine ER group.

#### *3.1.6. Dosage and administration in children and adolescents*

#### **3.2. Desvenlafaxine**

O-desmethylvenlafaxine (ODV) inhibit the reuptake of serotonin at low doses, serotonin and norepinephrine (NE) at higher doses, and have a weak inhibitory effect on the reuptake of dopamine at even higher doses. Venlafaxine has little affinity for histaminergic, cholinergic,

Venlafaxine is well absorbed. Food does not affect the absorption of venlafaxine. Bioavailability is 45% following oral administration. Venlafaxine is metabolized by cytochrome P450 2D6 and cytochrome P450 2C19 to ODV, the major metabolite, which is clinically active. Renal

Venlafaxine is a moderate inhibitor of cytochrome P450 2D6. Tramadol increases the risk of seizures in patients taking antidepressants. Venlafaxine could inhibit the metabolism of tra-

• Sustained elevation of blood pressure is dose-dependent (rarely occurs below 255 mg/day doses) related to inhibition of NE reuptake. In patients with sustained blood pressure raises during venlafaxine therapy, dose reduction, or discontinuation should be considered. Monitoring blood pressure and heart rate is recommended when using venlafaxine.

• Gastrointestinal: nausea, dry mouth, constipation. Consider reducing the dose if these

• Central nervous system: sedation, dizziness, nervousness, anxiety, insomnia, somnolence,

• While all antidepressants have the black-box warning about increased suicidal behaviors, venlafaxine is the only one that have demonstrated in RCT and meta-analysis to be associated with higher rates of self-harm events in patients with higher levels of suicidal thoughts. Close monitoring of suicidal ideation and behaviors is necessary during treat-

Venlafaxine is FDA approved for major anti-inflammatory in adults; meanwhile extendedrelease venlafaxine is approved for the treatment of adults with generalized anxiety disorder,

and tremor. Consider reducing the dose if these symptoms are annoying.

• Mydriasis: patients at risk of angle-closure glaucoma should be monitored.

panic disorder, and social phobia besides major depressive disorder.

• In young people, venlafaxine could lead to decrease appetite and weight loss.

madol, reducing his analgesic efficacy and increasing the risk of serotonin syndrome.

elimination is the main route of excretion. The half-life is about 5–11 hours.

• Sexual dysfunction, especially abnormal ejaculation and orgasm.

and alpha-adrenergic receptors, not clinically significant.

*3.1.2. Pharmacokinetics*

192 Child and Adolescent Mental Health

*3.1.3. Drug and food interactions*

*3.1.4. Side effects and toxicology*

symptoms are annoying.

ment with this drug.

*3.1.5. Use in children and adolescents*

#### *3.2.1. Pharmacodynamics*

Desvenlafaxine (O-desmethylvenlafaxine), the major metabolite of venlafaxine, is a selective serotonin and norepinephrine reuptake inhibitor. As venlafaxine and desvenlafaxine inhibit the reuptake of serotonin at low doses, serotonin and norepinephrine at higher doses, and have a weak inhibitory effect on the reuptake of dopamine at even greater doses. Desvenlafaxine has no clinically significant affinity for histaminergic, cholinergic and alpha-adrenergic receptors.

## *3.2.2. Pharmacokinetics*

Bioavailability is approximately 80% and is unaffected by food. Desvenlafaxine undergoes simple metabolism via conjugation mediated by UGT isoforms and oxidative N-demethylation via cytochrome P450 3A4 to a minor extent. CYP2D6 is not involved. Approximately 45% of the total oral dose is excreted by urine as unchanged desvenlafaxine. The half-life is about 11 hours.

## *3.2.3. Drug and food interactions*

Compared to other SSNRIs, desvenlafaxine has a low risk of drug-drug interactions since there is minimal metabolization by cytochrome P450 pathway.

### *3.2.4. Side effects and toxicology*

#### *3.2.5. Use in children and adolescents*

Desvenlafaxine is FDA approved for the treatment of major depressive disorder in adults. There is no clinical study in the literature about the use of desvenlafaxine in the pediatric population.

#### *3.2.6. Dosage and administration in children and adolescents*

#### **3.3. Duloxetine**

the reuptake of serotonin at low doses, serotonin and norepinephrine at higher doses, and have a weak inhibitory effect on the reuptake of dopamine at even greater doses. Desvenlafaxine has no clinically significant affinity for histaminergic, cholinergic and alpha-adrenergic receptors.

Bioavailability is approximately 80% and is unaffected by food. Desvenlafaxine undergoes simple metabolism via conjugation mediated by UGT isoforms and oxidative N-demethylation via cytochrome P450 3A4 to a minor extent. CYP2D6 is not involved. Approximately 45% of the total oral dose is excreted by urine as unchanged desvenlafaxine. The half-life is about 11 hours.

Compared to other SSNRIs, desvenlafaxine has a low risk of drug-drug interactions since

• Sustained elevation of blood pressure, dose-dependent, related to inhibition of NE reuptake. Monitoring blood pressure and heart rate is recommended when using desvenlafaxine. In patients with sustained blood pressure raises during desvenlafaxine therapy, dose

• Central nervous system: sedation, dizziness, nervousness, anxiety, insomnia, somnolence,

Desvenlafaxine is FDA approved for the treatment of major depressive disorder in adults. There is no clinical study in the literature about the use of desvenlafaxine in the pediatric

• Maintenance phase: the dosage can be increased by 50 mg daily every 4–7 days. Clinical studies have not observed additional efficacy with dosages greater than 50 mg but side effects were more common. A total of 200 mg daily is the maximum dose recommended. Maintaining treatment is recommended 6–12 months produced clinical improvement.

there is minimal metabolization by cytochrome P450 pathway.

reduction or discontinuation should be considered.

• Gastrointestinal: nausea, dry mouth, constipation.

*3.2.6. Dosage and administration in children and adolescents*

• Sexual dysfunction, especially abnormal ejaculation and orgasm.

• Mydriasis: patients at risk of angle-closure glaucoma should be monitored.

• Desvenlafaxine is presented in 50 and 100 mg extended-release tablets.

• Home treatment: the recommended initial dosage is 50 mg as a single dose daily.

*3.2.2. Pharmacokinetics*

194 Child and Adolescent Mental Health

*3.2.3. Drug and food interactions*

*3.2.4. Side effects and toxicology*

and tremor.

population.

*3.2.5. Use in children and adolescents*

## *3.3.1. Pharmacodynamics*

Duloxetine is another selective serotonin and norepinephrine reuptake inhibitor (SSNRIs). The major difference to venlafaxine is that duloxetine has comparable binding affinity to both norepinephrine and serotonin transport sites. Duloxetine has no significant affinity for dopaminergic, histaminergic, cholinergic, and alpha-adrenergic receptors.

## *3.3.2. Pharmacokinetics*

Duloxetine is well absorbed and unaffected by food. Protein binding is greater than 90%. Duloxetine is metabolized by cytochrome P450 2D6 and 1A2 to the metabolites, which are not active. Renal elimination is the main route of excretion (70%) followed by fecal excretion (20%). The half-life is about 12 hours [8–17].

#### *3.3.3. Drug and food interactions*

Duloxetine is a moderate inhibitor of cytochrome P450 2D6. Tramadol increases the risk of seizures in patients taking antidepressants. As result of a pharmacokinetic interaction, duloxetine could increase plasma levels of thioridazine, which may result in increased risk of ventricular arrhythmias.

#### *3.3.4. Side effects and toxicology*

#### *3.3.5. Use in children and adolescents*

Among adults, duloxetine is usually used for the acute and maintained treatment of major depressive disorder, acute treatment of anxiety disorders, fibromyalgia, and neuropathic pain, especially when is associated with peripheral neuropathy.

Two multicenter, randomized, double-blind, and placebo-controlled trials have evaluated the efficacy and safety of duloxetine for children and adolescents with major depressive disorder and compared to fluoxetine. The primary main outcome was the Children's Depression Rating Scale-Revised (CDRS-R) total score. In these studies, neither duloxetine nor fluoxetine demonstrated a statistically significant improvement compared with placebo. Headache and nausea were the main treatment-emergent adverse events. Weight decrease was more common among duloxetine and fluoxetine groups compared to placebo. Suicidal behavior did not occur in acute treatment, while seven cases occurred during extended treatment. There were no completed suicides. No patients had sustained elevation in systolic or diastolic blood pressure during the 36-week study.

Another randomized, double-blind, and placebo-controlled trials have evaluated duloxetine for children and adolescents with generalized anxiety disorder. They found that duloxetine was statistically better than placebo on Pediatric Anxiety Rating Scale (PARS).

## *3.3.6. Dosage and administration in children and adolescents*

## **4. NaSSRI**

#### **4.1. Mirtazapine**

#### *4.1.1. Pharmacodynamics*

Mirtazapine is a piperazinoazepine with an anxiolytic effect. Mirtazapine acts as an antagonist at central presynaptic alpha-2-receptors. This antagonism inhibits negative feedback to the presynaptic nerve and enhances the release of both norepinephrine and serotonin. Mirtazapine is also a weak antagonist of 5-HT1 receptors and a potent antagonist of 5-HT2 (particularly subtypes 2A and 2C) and 5-HT3 receptors. Mirtazapine could also cause sedation through H1 receptor antagonism. It has minimal activity at dopaminergic and muscarinic receptors and NE and 5-HT reuptake are not affected.

## *4.1.2. Pharmacokinetics*

Two multicenter, randomized, double-blind, and placebo-controlled trials have evaluated the efficacy and safety of duloxetine for children and adolescents with major depressive disorder and compared to fluoxetine. The primary main outcome was the Children's Depression Rating Scale-Revised (CDRS-R) total score. In these studies, neither duloxetine nor fluoxetine demonstrated a statistically significant improvement compared with placebo. Headache and nausea were the main treatment-emergent adverse events. Weight decrease was more common among duloxetine and fluoxetine groups compared to placebo. Suicidal behavior did not occur in acute treatment, while seven cases occurred during extended treatment. There were no completed suicides. No patients had sustained elevation in systolic or diastolic blood

Another randomized, double-blind, and placebo-controlled trials have evaluated duloxetine for children and adolescents with generalized anxiety disorder. They found that duloxetine

• Home treatment: the recommended initial dosage is 30 mg as a single dose daily in the

• Maintenance phase: the target dose is 30–60 mg in both adolescents and children. Clinical studies have not observed additional efficacy with dosages greater than 60 mg but side effects were more common. A total of 120 mg once a day is the maximum dose recommended. Maintaining treatment is recommended 6–12 months produced clinical improvement.

• Treatment withdrawal: the dosage should be gradually decreased over at least 2 weeks to prevent withdrawal symptoms like gastrointestinal discomfort, headache, nervousness, or agitation. If withdrawal symptoms appear during the gradual decline of the drug, the dose

Mirtazapine is a piperazinoazepine with an anxiolytic effect. Mirtazapine acts as an antagonist at central presynaptic alpha-2-receptors. This antagonism inhibits negative feedback to the presynaptic nerve and enhances the release of both norepinephrine and serotonin. Mirtazapine is also a weak antagonist of 5-HT1 receptors and a potent antagonist of 5-HT2 (particularly subtypes 2A and 2C) and 5-HT3 receptors. Mirtazapine could also cause sedation through H1

should be increased until they disappear and then start the reduction again.

was statistically better than placebo on Pediatric Anxiety Rating Scale (PARS).

*3.3.6. Dosage and administration in children and adolescents*

• Duloxetine is presented in 20, 30, and 60 mg capsules.

• Long-term use: it is safe for an extended period.

pressure during the 36-week study.

196 Child and Adolescent Mental Health

morning.

**4. NaSSRI**

**4.1. Mirtazapine**

*4.1.1. Pharmacodynamics*

Mirtazapine is completely absorbed but, due to first-pass metabolism, bioavailability is about 50%. Protein binding is about 85%. Duloxetine is metabolized by cytochrome P450 3A4, 2D6 and to a lesser extent by 1A2 to many different metabolites, several of whom are active, but plasma levels are low. Kidneys excrete about 75% of mirtazapine. Half-life is about 20–40 hours.

## *4.1.3. Drug and food interactions*

Mirtazapine is a weak CYP2D6 inhibitor. CYP3A4 potent inhibitors could increase plasma levels of mirtazapine. Adding another serotonin antidepressant may produce serotonin syndrome

### *4.1.4. Side effects and toxicology*

## *4.1.5. Use in children and adolescents*

Mirtazapine is an FDA approved for the acute and maintenance treatment of major depressive disorder in adults.

Few studies till date have evaluated mirtazapine in children and adolescents. There is not strong data with double-blind and placebo-controlled trials. In a recent network meta-analysis, Cipriani and colleagues reported two randomized, placebo-controlled trials funded by a pharmaceutical company in 170 patients aged 7–17. Mirtazapine was not significantly different to placebo on any outcome rating.

## *4.1.6. Dosage and administration in children and adolescents*

## **5. MAOI**

## **5.1. Nonselective**

*5.1.1. Tranylcypromine*

## *<IP_ADDRESS>. Pharmacodynamics*

#### *<IP_ADDRESS>.1. Action mechanism*

Tranylcypromine irreversibly blocks monoamine oxidase (MAO) from breaking norepinephrine, serotonin, and dopamine. This presumably boosts noradrenergic, serotonergic, and dopaminergic neurotransmission. As the drug is structurally related to amphetaine, it may have some stimulant-like actions due to monoamine release and reuptake inhibition [14].

#### *<IP_ADDRESS>.2. Pharmacological profile*

Tranylcypromine is a nonhydrazine monoamine oxidase inhibitor with a rapid onset of activity. It increases the concentration of epinephrine, norepinephrine, and serotonin in storage sites throughout the nervous system and, in theory, this increased concentration of monoamines in the brain stem is the basis for its antidepressant activity [14].

#### *<IP_ADDRESS>.3. Pharmacokinetics*

Tranylcypromine achieves an initial peak within approximately 1 hour and a secondary peak within 2–3 hours. It has been suggested that this apparent biphasic absorption in some individuals may represent different absorption rates. Following discontinuance of tranylcypromine, the drug is excreted within 24 hours. On withdrawal of tranylcypromine, MAO activity is recovered in 3–5 days (possibly in up to 10 days). Concentration of urinary tryptamine, an indicator of MAO-A inhibition return to normal, however, within 72–120 hours [14].

#### **5.2. Selective**

#### *5.2.1. Moclobemide*

Moclobemide is a reversible inhibitor of monoamine-oxidase-A (RIMA) and has been extensively evaluated in the treatment of a wide spectrum of depressive disorders and less extensively studied in anxiety disorders.

There is a growing evidence that moclobemide is not inferior to other antidepressants in the treatment of subtypes of depression, such as dysthymia, endogenous (unipolar and bipolar), reactive, atypical, agitated, and retarded depression as with other antidepressants limited evidence suggests that moclobemide has consistent long-term efficacy.

### *<IP_ADDRESS>. Pharmacodynamics*

• Long-term use: it is safe for an extended period.

**5. MAOI**

**5.1. Nonselective**

*5.1.1. Tranylcypromine*

198 Child and Adolescent Mental Health

*<IP_ADDRESS>. Pharmacodynamics*

*<IP_ADDRESS>.1. Action mechanism*

*<IP_ADDRESS>.2. Pharmacological profile*

*<IP_ADDRESS>.3. Pharmacokinetics*

**5.2. Selective**

*5.2.1. Moclobemide*

sively studied in anxiety disorders.

• Treatment withdrawal: the dosage should be gradually decreased over at least 2 weeks to prevent withdrawal symptoms like gastrointestinal discomfort, headache, nervousness, or agitation. If withdrawal symptoms appear during the gradual decline of the drug, the dose

Tranylcypromine irreversibly blocks monoamine oxidase (MAO) from breaking norepinephrine, serotonin, and dopamine. This presumably boosts noradrenergic, serotonergic, and dopaminergic neurotransmission. As the drug is structurally related to amphetaine, it may have some stimulant-like actions due to monoamine release and reuptake inhibition [14].

Tranylcypromine is a nonhydrazine monoamine oxidase inhibitor with a rapid onset of activity. It increases the concentration of epinephrine, norepinephrine, and serotonin in storage sites throughout the nervous system and, in theory, this increased concentration of mono-

Tranylcypromine achieves an initial peak within approximately 1 hour and a secondary peak within 2–3 hours. It has been suggested that this apparent biphasic absorption in some individuals may represent different absorption rates. Following discontinuance of tranylcypromine, the drug is excreted within 24 hours. On withdrawal of tranylcypromine, MAO activity is recovered in 3–5 days (possibly in up to 10 days). Concentration of urinary tryptamine, an

Moclobemide is a reversible inhibitor of monoamine-oxidase-A (RIMA) and has been extensively evaluated in the treatment of a wide spectrum of depressive disorders and less exten-

indicator of MAO-A inhibition return to normal, however, within 72–120 hours [14].

amines in the brain stem is the basis for its antidepressant activity [14].

should be increased until they disappear and then start the reduction again.

## *<IP_ADDRESS>.1. Action mechanism*

Moclobemide is a substrate of CYP2C19. Few clinically significant drug interactions between moclobemide and teother drugs have been reported in spite of the fact that it acts as an inhibitor of CYP1A2, CYP2C19, and CYP2D6. Switch to another antidepressants could be quick as its half-life in plasma is short, 24 hours. As it is well-tolerated, therapeutic doses can be reached rapidly upon onset of treatment. After one week following dose adjustment plasma levels are reached. Patients with severe hepatic impairment require dose adjustment, not those with renal dysfunction.

## *<IP_ADDRESS>.2. Pharmacological profile and pharmacokinetics*