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Counselling children and young people: A review of the evidence for its
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Article  in  Counselling and Psychotherapy Research · December 2006

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 Adding Value to Education through
Improved Mental Health: A Review of the
Research Evidence on the Effectiveness of
Counselling for Children and Young People

Sue Pattison
University of Newcastle upon Tyne

Belinda Harris
University of Nottingham

Abstract
This paper is set against the backdrop of an increasing number of strategies and
policies developed by the Department for Education and Skills in the U.K. regarding
the promotion of positive mental health in schools and the recognition of the value of
improving mental health in relation to children’s learning, achievement, attendance
and behaviour. The aim of the paper is to present the results from a systematic review
of the research evidence on counselling children and young people and discuss these
results in relation to the educational context and the added value to be gained in
addressing the mental health needs of children and young people. A systematic review
methodology is used to assess the outcome research literature. The review is structured
around a range of counselling issues and four groups of counselling approaches:
cognitive-behavioural, person-centred, psychodynamic and creative therapies. Results
indicate that all four approaches to counselling are effective for children and young
people across the full range of counselling issues. However, more high quality
published research evidence was located for the effectiveness of cognitive-behavioural
counselling than other approaches, identifying significant gaps in the evidence bases
for these approaches. Other gaps in the evidence include research into counselling for
school related issues and self-harm.

The Australian Educational Researcher, Volume 33, Number 2, August 2006 •97
SUE PATTISON AND BELINDA HARRIS

Introduction
Counselling and related interventions are aimed at improving the mental health of
children and young people. In the educational context they are linked to learning,
achievement, attendance and behaviour (DfES 2001, DfES 2003, Ofsted 2004). The
Department for Education and Skills (U.K.) has recognised the importance of mental
health in its Healthy Schools initiative (DfES 1999) and has published various resources
for teachers and other professionals on its website (DfES 2004a). The national
framework for working together (DfES 2004b) examines and promotes links between
schools and CAHMS (Child and Adolescent Mental Health Units) in order to improve
the mental health of children and young people.

The British Association for Counselling and Psychotherapy (BACP) publishes resources
for teachers and others working in the educational context on its website dedicated to
the Counselling in Education group (BACP 2004a). The BACP also convenes an annual
conference specifically related to counselling in education. Moreover, counselling and
associated interventions are provided as part of the curriculum for initial teacher
training in at least one university department in the U.K. (University of Newcastle upon
Tyne 2004a). Counselling is provided as continuing professional development for
teachers and other related professions at the Universities of Nottingham and Newcastle
upon Tyne (2004b). Counselling as an effective intervention for children and young
people in the educational context has been given more attention recently as
achievement, attendance and behaviour are increasingly linked to mental health.

The case for counselling linked to the school context is strengthened by legislation in
the form of the new Children Act (DfES 2004d). The results of a study carried out by
the Future Foundation (2004) show that counselling is more acceptable and sought
after in contemporary society than in the past. It is against this backdrop of increasing
recognition of the value of counselling and other psychotherapeutic interventions that
the BACP commissioned their series of systematic reviews.

The aim of this paper is to present the results from a systematic review of the research
evidence on counselling children and young people and discuss these results in
relation to the educational context and the added value to be gained in addressing the
mental health needs of children and young people (Harris and Pattison 2004). The
review was commissioned and funded by the British Association for Counselling and
Psychotherapy (BACP) in order to add to the evidence base for outcome research in
counselling and related therapies provided for children and young people from a
variety of contexts including schools and colleges. Although counselling processes
may be important in achieving a positive outcome, for the purposes of this review only
defined outcome research is included. Why and how particular counselling
approaches are effective would form a sound basis for further research.

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 ADDING VALUE TO EDUCATION THROUGH IMPROVED MENTAL HEALTH

Counselling and other psychological therapies are found to be useful in relieving

emotional and psychological problems in adults (DoH 2001, Fonagy 1999, Mellor-
Clark 1998). However, there may be difficulties in applying adult therapy research to
children and young people due to the nature of child and adolescent development
and perceptions of therapy (Fonagy 1999). The review aimed to address this issue and
provide more accessible relevant evidence for practice. The project proved
challenging in terms of the presentation required to produce a review that was both
relevant and accessible to counselling practitioners, service providers and policy
makers yet rigorous enough to be useful to other researchers in the field.

Counselling interventions
There are many types of counselling, which can be confusing for non-specialists.
According to the definition of counselling provided by the British Association for
Counselling and Psychotherapy (2004b):

Counselling takes place when a counsellor sees a client in a private and

confidential setting to explore a difficulty the client is having, distress
they may be experiencing or perhaps their dissatisfaction with life, or
loss of a sense of direction and purpose. It is always at the request of
the client as no one can properly be ‘sent’ for counselling.

In practice, counselling is concerned with prevention and de-escalation of problems

and focuses on enabling the child or young person to develop self-esteem and the
internal resources to cope with their difficulties more effectively. This includes the
remediation of mental health symptoms and problems.

Broadly speaking, therapies used with children fall into three categories. Each has
distinct philosophical underpinnings and underlying assumptions about the nature of
human behaviour and change. Cognitive-behavioural therapy (CBT) combines
techniques from cognitive therapy with behavioural therapy and is based on the
premise that cognition is related to mood and behaviour. It is one of the most widely
researched therapies for children and young people and CBT studies are published
in many high quality journals (Southam-Gerow and Kendal 2000). Moreover, CBT is
used widely within the National Health Service (NHS) in the U.K. and has been the
subject of many randomised controlled trials (RCTs), systematic reviews and meta-
analyses. This particular type of therapeutic intervention lends itself well to the
scientific method and is often carried out by psychologists trained in the quantitative
research paradigm. This enables such research to have more likelihood of being
included in the major evidence base for psychotherapeutic therapies, the Cochrane
Collaboration Database (Clarke and Oxman 2003). Cognitive-behavioural therapy
seeks to promote emotional and behavioural change in children and young people

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SUE PATTISON AND BELINDA HARRIS

by helping them to change their thinking in ways that are interactive and based on
problem-solving. Techniques and strategies are used to enhance self-control, increase
personal efficacy and rational problem solving. The aim is to develop more effective
social skills and increase the child’s participation in pleasurable, satisfying activities
(Freeman and Reinecke 1995).

In contrast to CBT, psychoanalytic and related therapies (originally founded by Freud

in 1909) focus on the dynamic between mental and emotional forces and how these
may affect behaviour, thoughts and emotions. When working with children, play is
often used as a means of establishing psychological contact, as a source of data, as a
medium for observation, and sometimes as a vehicle for interpretive communication.
The counsellor attempts to communicate the meaning of the child’s play in order to
increase the child’s understanding of their difficulties, thereby promoting emotional
adaptive resolution (Dearden 1998, Sherr et al. 1999).

Humanistic therapies emerged from humanistic psychology as an alternative to

psychoanalytical and cognitive-behavioural approaches (McLeod 2003a). These
therapies embrace a range of approaches including person-centred, existential and
gestalt (Clarkson 2004, Rogers 1959, van Deurzan 1997). Fundamental to the
humanistic approach is a concern to meet the deficiency and growth needs of the
child or young person (Maslow 1970). Placing an emphasis on the development of
the whole child (physical, intellectual, emotional, spiritual domains), the quality of the
therapeutic relationship is perceived as central to the efficacy of this approach. The
counsellor is responsible for creating an environment in which the child feels
cherished, contained and able to grow.

Creative approaches to therapy may be found mainly but not exclusively within
psychoanalytic and humanistic approaches to counselling children. They involve play,
art, clay modelling, movement, music and other forms of creative expression. The
major research paradigm for these therapies is qualitative. In research terms, the
psychoanalytic/dynamic approach has predominantly used the single case study and
focused on the processes taking place, whilst the humanistic therapies may focus on
the phenomenological world of the child or young person (McLeod 2003b). By
relying mainly on qualitative methods psychoanalytic and humanistic therapies are
placed at a disadvantage regarding the production of studies that can be rated as high
quality research evidence for inclusion in such databases as Cochrane. There are
parallels here with much of the educational research produced. Criticisms also have
been made about the quality of research in the educational arena (Tooley 2001).

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 ADDING VALUE TO EDUCATION THROUGH IMPROVED MENTAL HEALTH

Counselling approaches and cultural appropriateness

The BACP (2004) clarify what counsellors actually do: listening attentively and
patiently, perceiving difficulties from the individual’s point of view; helping people to
see things more clearly, possibly from a different perspective; reducing confusion and
facilitating choice and change. This focus on the individual may be experienced as
alien to those from different cultural backgrounds where collectivism may be the
traditional cultural approach (Pattison 2003). When adopting western approaches
counsellors help people to explore aspects of life and feelings; examine behaviour
and difficult situations; help people to initiate change and explore options. However,
advice giving, guiding and providing direction are not usually components of western
approaches to counselling. This contrasts with international perspectives on what
constitutes counselling, where advice and guidance may be expected as part of the
counselling process (Naidoo and Sehoto 2002, Nolte 2001, Pattison 2003, Trivasse
2002). Globally the diverse nature of counselling is more apparent, with counselling
encompassing many different activities. For example, Malindzsisa et al., (2001)
equates academic advice in distance learning with counselling. Nolte (2001) describes
counselling as guiding, enabling, facilitating, planning, organising, motivating,
educating and training the client in self-help skills. Naidoo and Sehoto (2002) point
out that another term for counselling in many African countries may be healing.
Counselling in the west has its roots in western theological, anthropological,
psychiatric and psychological literature/theory. On the other hand, a vast knowledge
base exists in oral form in African and other cultures (Naidoo and Sehoto 2002).
Moodley and West (2005) make a case for integrating traditional healing into
contemporary practice in order to address some of the issues and debates around
multi-cultural counselling.

Counselling issues in children and young people

The research literature examined for the review covered a wide range of issues
experienced by children and young people, identified through a preliminary scoping
search. These issues share some of the characteristics of adult issues such as
depression, anxiety, low self-esteem, sexual abuse, physical and emotional abuse,
eating disorders and difficulties with relationships. However, some issues are more
context-specific to the younger client, for example, school phobia, bullying and
behavioural problems.

Children and young people suffer a variety of psychological problems and difficulties.
Therefore, it is encouraging to note that most young people follow a relatively
untroubled psychological development and that a third of problems are intermittent
or temporary. However, 11% of young people have serious, chronic difficulties (Ebata

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and Moos 1990). Moreover, psychological problems are more common in adolescence,
with nearly half reporting difficulties in coping with situations at home or school.
Conflicts regarding the transitional nature of adolescence and the lack of control over
physical, social and physiological changes are more likely to lead to stress, depression,
alcoholism, drug misuse, eating disorders, self-harm and suicide amongst young people
(Steinberg 1996).

Depression in adolescence is related to youth suicide rates, which account for over one-
fifth of all deaths in young people. According to Steinberg (1996), one in three young
people have contemplated suicide with one in six actually making a suicide attempt.
Furthermore, figures from the Oxford Centre for Suicide Research (1998) estimate that
24,000 adolescents self-harmed in 1999 and that deliberate self-harm is more prevalent
amongst girls. Eating disorders are common amongst young people, particularly
adolescent girls and create challenges for teachers, support staff, counsellors and medical
practitioners (Abraham 2001) and the often catastrophic effects of bullying on children
and young people is well documented, particularly in relation to those who are already
vulnerable. For example, children with learning difficulties/disabilities (Norwich and
Kelly 2004) or other vulnerabilities based in gender or sexuality (Ellis and High 2004).

The systematic review

Evidence based practice is an increasing trend amongst a wide range of disciplines
(Cochrane Collaboration Database 2004, The EPI Centre, Centre for Evaluation of Health
Promotion and Social Interventions, Institute of Education 2004). The principles and
processes of evidence based practice have filtered into the education field (Evidence-
Based Education U.K., University of Durham 2004). They are increasingly used as the
basis for educational interventions and policy making, fitting in well with New Labour’s
research-led style of governance (Giddens 1999). Although counselling has strong
connections with education, traditionally as an intervention in child guidance clinics for
children with special educational needs, it is closely associated with psychology and
psychoanalysis/psychotherapy. This places it within the sphere of medicine and the
NHS, reflected in the status that the NHS has for being the largest single employer of
counsellors in the U.K. (DoH 2001). This link with the NHS is significant in terms of
evidence-based practice for counsellors and the type of research that carries the most
weight and contributes heavily to the evidence base (Clarke and Oxman 2003). The
randomised controlled trial (RCT) is accorded the highest respect in terms of research
evidence that forms the basis for good practice in the NHS and as such has infiltrated
other disciplines including education.

The British Association for Counselling and Psychotherapy (BACP) required the review
to be rigorous in order to be useful to researchers. At the same time, it was expected to

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 ADDING VALUE TO EDUCATION THROUGH IMPROVED MENTAL HEALTH

provide an accessible resource for counsellors, managers in education, health and social
care, along with others working in the mental health field. Therefore, the review was
designed and organised to present a variety of issues relevant to counselling children
and young people within a range of contexts. It covered issues such as behavioural
problems and conduct disorders, emotional problems including anxiety and depression,
post-traumatic stress, school-related issues, self-harming practices and sexual abuse. The
range of counselling issues included in the review is presented in figure 1.

Figure 1: Range of counselling issues included in the review

Counselling Issue Range of problems included

Behavioural and conduct disorders Anti-social and aggressive behaviours
Verbal and physical aggression
Impulsivity and hyperactivity
Emotional problems: Anxiety General anxiety symptoms
Post-traumatic stress symptoms
Obsessive-compulsive disorders
Separation anxiety
Agoraphobia
Emotional problems: Depression General symptoms of depression
Rate of progression of depressive symptoms
School-related issues Violent and aggressive behaviour at school
School refusal/phobia
Self-control and classroom behaviour
Aggression towards peers
Self-responsibility
Acting out
Distractibility and sociability in learning disabled children
Bullying
Self-harming practices Substance abuse
Repeated suicide attempts
Anorexia nervosa
Sexual abuse Psychological symptoms of sexual abuse
Depressive symptoms
Low self-esteem

The main aim of the research was to provide a systematic, replicable and
comprehensive review of the research on the effects of counselling for children and
young people. The purpose of adding this review to the evidence base was to enable
counsellors, policy makers and providers of services in education, health and social care
to base planning and delivery of counselling interventions on firm research evidence.

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SUE PATTISON AND BELINDA HARRIS

Review design, procedures and methodology

A systematic search of the research in counselling young people was carried out. This
was based upon pre-determined criteria to assess the quality and rigour of studies and
the effectiveness of therapies. The areas of: behaviour; anxiety; depression; self-
harming practices and sexual abuse across four main groups of therapy: cognitive-
behavioural therapy; psychodynamic/psychoanalytic, humanistic/interpersonal and
creative therapy were addressed. The following question was used to drive the
research process: Is counselling effective with children and young people? The
research was based upon a systematic approach that was recorded in detail in order
to provide transparency and accountability.

Three types of search were undertaken: electronic search, hand-search and

opportunistic search via professional networks and existing projects. The electronic
databases included: Cochrane (Systematic Reviews, Central Register of Controlled
Trials); PsycInfo; Medline; Cinahl; Science Direct and ERIC. The search strategy
involved search terms related to the child and adolescent population followed by a
second list of terms related to counselling and psychotherapy. Hand searching of
journals showed that although there were a huge number of published studies, many
were excluded by the search criteria. Review articles and meta-analyses were assessed
using quality criteria suggested by Oxman and Guyatt (1988):
• Were the questions and methods clearly stated?
• Were comprehensive search methods used to locate relevant studies?
• Were explicit methods used to determine which articles to include in the review?
• Was the validity of the primary studies assessed?
• Was the assessment of the primary studies reproducible and free from bias?
• Was variation in the findings of the relevant studies analysed?
• Were the findings of the primary studies combined appropriately?
• Were the reviewers’ conclusions supported by the data cited?

To define the scope of the review, a series of inclusion criteria were developed using
methodologies used in existing systematic searches (McLeod 2002) and the Cochrane
Reviewers Handbook (Clarke & Oxman 2003). Therefore, three further key questions
supplemented the main research question: Which types of counselling work? For
whom? For which issues? A range of characteristics was identified with regard to the
population, interventions, outcomes and study design. Inclusion and exclusion criteria
for studies incorporated in the review were devised to take account of children and
young people between the ages of 3-19 years, both male and female.

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 ADDING VALUE TO EDUCATION THROUGH IMPROVED MENTAL HEALTH

The BACP (2004b) definition of counselling was adopted, although it is

acknowledged that this definition may differ from that of other organisations,
particularly internationally. For example, in their review of school counselling
outcome research, Sexton et al. (1997) refer to the guidance model (Gysber and
Henderson 1994). This differs in nature to the BACP definition of counselling, yet
reflects a comprehensive model through which Sexton et al. (1997) organised and
examined the empirical literature for their review. Therefore counsellors, teachers and
other professionals may need to take differences in definition into account when
interpreting the results of this research in relation to their own context and practice.
The following exclusion criteria were applied to therapies researched in the studies
reviewed: behaviour therapy, social skills training and therapies based on behaviour
modification or social learning theory due to the emphasis on training as opposed to
counselling. Pharmacological treatments; psychiatric in-patient settings; family
therapy; bibliotherapy; computerised therapy; telephone counselling and peer
counselling were also excluded. Only counselling carried out by therapists with
formal training in the specific therapeutic approach investigated were included.
Regarding the assessment of outcomes of therapy from each research study, indicators
of change in young people involved examining improvement in the presenting
problem, behaviour, relationships, emotional well-being, raised self-esteem, improved
academic performance and increased self-awareness. In order to qualify for inclusion
in the review change indicators were required to be assessed by recognised
psychometric testing, pre/post-test and follow-up, along with qualitative indicators as
reported by the child, young person and therapist or significant other. The self-report
of the counsellor was not considered sufficient evidence of change in a child unless
it was supported by other data. A hierarchical approach was adopted when assessing
the quality and type of research studies (see figure 2).

Figure 2: Hierarchical approach to assessing studies

1. Systematic Reviews and Meta-analyses

2. Experimental Studies
(Randomised-controlled trials, controlled before and after studies)

3. Other Studies
(Simple before and after studies, qualitative designs)

This was deemed to be the most logical way of carrying out the review within the
constraints of available resources. Individual studies were categorised according to
criteria outlined in the Cochrane Reviewers Handbook (Clarke & Oxman 2003). Study

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SUE PATTISON AND BELINDA HARRIS

types were defined as reviews/meta-analyses; experimental (randomised controlled

trials, controlled before and after studies); other studies (simple before and after
studies and qualitative designs). Firstly, review articles and meta-analyses were
identified as best quality evidence in relation to the key counselling issues referred to
earlier. This represented the most efficient way of summarising a large number of
relevant studies and followed the methods used by the Department of Health Review
of Psychological Therapies (DoH 2001). High quality controlled trials not included in
such reviews and meta-analyses (generally studies carried out after the date of the last
review or meta-analysis) were located to add to the data, especially where review
evidence was sparse. Other sources of evidence (qualitative and process studies)
were included where they could offer valuable insights into therapies, issues or
populations that were under represented in the best quality evidence.

Reviews and meta-analyses were assessed for quality and rigour using criteria
developed by Oxman & Guyatt (1988). They were assigned to one of three Bands (A,
B, C) according to how many of the eight quality criteria each study met. Two
members of the research team rated a sample of 25% of the reviews and meta-
analyses and any differences were resolved through discussion. Fifty-five
review/meta-analyses were examined and formally reviewed with two studies falling
into Band A, ten in Band B and forty-one in Band C. Two studies did not meet the
review criteria and were excluded. The reviews and meta-analyses did not provide
enough evidence for the effects of counselling for each counselling issue. Therefore
supplementary evidence in the form of individual studies was included in the broad
categories of experimental and ‘other’. The research team were aware that mixed
methodologies may represent the best-fit research for real-world situations. The
collection of data from different sources using different methods was believed to
strengthen the findings.

All of the research studies included in this paper were published in the English
language medium. They are available in the public domain and were located in
libraries, through the Internet and as reports by organisations. The full list is available
in the original review document (Harris and Pattison 2004). Randomised controlled
trials were assessed through statistical significance, clinical significance and effect size.
The remainder were assessed through outcome measures and research
design/methodologies.

Results and discussion

Figure 3 provides a visual summary of the research findings related to the range of
variables. These include counselling issues, types of counselling and counselling
outcome studies providing research evidence for effectiveness. Full references for
each study are included in the reference section at the end of this paper.

106 •
 Figure 3: Summary of findings
Research studies reviewed

Counselling issues Effective therapies Meta-analyses and reviews Experimental studies Other studies

Behavioural and conduct disorders CBT Baer & Nietzel (1991) Ensink et al (1997) Fonagy & Target (1994)
Psychodynamic/analytical Bennett & Gibbons (2000) Schectman & Ben-Davis (1999)
Robinson et al (1999) Weiss, Catron & bb (2000)
Weisz et al (1987) Szapocznik (1989)

Emotional problems: Anxiety CBT Compton et al (2002) Mendlowitz et al (1999) Benazon et al (2002)
Psychodynamic/analytical Muratori et al (2002) Blos (1993)
Humanistic/interpersonal Pfeffer et al (2002) Dearden (1998)
Creative Salloumi et al (2001) Kaplan et al (1998)
March et al (1998)
McConnell & Sim (2000)
Ovaert et al (2003)
Racusin (2000)
Target & Fonagy (1994)
Thieneman et al (2001)

Emotional problems: Depression CBT Compton et al (2002) Birmaher et al (2000) Darcy et al (2001)
Humanistic/interpersonal Harrington, Whittaker & Shoebridge (1998) Kroll (1996) Weersing & Weisz (2002)
Merry et al (2004) Mendlowitz et al (1999)
Michel & Crowley (2002) Mufson et al (1999)
Reinecke, Rowley & Dubois (1998) Rossello & Bernal (1999)

School-related issues CBT Wilson et al (2003) English & Higgins (1971) Flitton & Buckroyd (2002)
Creative King et al (1998) Meredith (1993)
McArdle et al (2002) Sherr et al (1999)
Omizo & Omizo (1987) Squires (2001)

Self-harming practices CBT Kaminer et al (2000) Breslin et al (2002)

Humanistic/interpersonal Robin et al (2000) Paulson & Everall (2003)
Waldron et al (2001)
Wood et al (2001)

Sexual abuse CBT Finkelhor et al (1995) Cohen & Mannarino (2000) Berman (1995)
Psychodynamic/analytical Reeker et al (1997) Deblinger et al (1999) De Luca et al (1995)
Humanistic/interpersonal Nolan et al (2002) Trowell et al (2002)
Creative

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SUE PATTISON AND BELINDA HARRIS

The Office for National Statistics Health Survey (2001) found that the spectrum of
behaviour problems (from disruptive behaviour to autistic spectrum disorder) to be
present in 7.4% boys and 3.2% girls in the U.K. Ovaert et al. (2003) suggests links
between behaviour problems and mental health issues associated with post traumatic
stress. They assert that causative trauma may be overlooked or neglected in the face
of problems in school caused by the behaviour. School counselling in the U.K. can
be linked to the Key Stage 3 Behavior and Attendance Strategy (DfES 2003). Four
systematic reviews (Baer and Nietzel 1991, Bennett and Gibbons 2000, Robinson et
al. 1999, Weisz et al. 1987) and one experimental study (Ensink et al. 1997) provide
evidence for the effectiveness of CBT with behaviour and conduct problems. These
systematic reviews evidence a mild to moderate effect for antisocial behaviour,
hyperactivity and aggression and a significant effect for impulsivity. Bennett and
Gibbons (2000) found that CBT was more effective with pre-adolescents and younger
children when combined with parent training. This finding was supported by Ensink
et al. (1997). The studies were limited in that they either involved more female
subjects or failed to provide sufficient information to enable the differentiation of
gender. One primary study (Ensink et al. 1997) supported the medium term effect of
CBT for aggressive and defiant behaviour. One randomized controlled study
suggested that a combination of psychodynamic, humanistic and cognitive therapy
was successful in reducing aggression and developing a commitment to change in
children and pre-adolescents through self-awareness and self-understanding
(Schechtman and Ben-David 1999). Other supporting evidence indicated the potential
of psychoanalysis in resolving behaviour problems with children and adolescents
across the age-range (Fonagy and Target 1994). Two studies challenged the use of
individual therapies with ethnic minority children and adolescents with severe
behaviour problems (Szapocznik 1989, Weiss, Catron and Harris 2000).

Anxiety problems in children and young people can lead to poor school performance,
school refusal, social problems, family relationship problems, self-harm and suicide
attempts. The Office for National Statistics Survey (2001) identified levels of separation
anxiety as 0.9% in boys and 7% in girls in the U.K. Generalised anxiety was found to
be 0.5% in boys and 0.7% in girls. Anxiety may present with nightmares,
psychosomatic symptoms and difficulty in separating from parents or carers. Anxiety
can have far reaching effects on school attendance, learning, achievement and peer
relationships. One systematic review (Compton et al. 2002); two experimental studies
(Mendlowitz et al. 1999, Pfeffer et al. 2002) and five simple before and after studies
(Benazon et al. 2002, March et al. 1998, Kaplan et al.1995, Ovaert et al. 2003,
Thieneman et al. 2001) provided evidence of effectiveness of CBT counselling for
emotional problems related to anxiety. Compton et al. (2002) provided evidence of
effectiveness of CBT in the 6-13 years age group with generalized anxiety, separation
anxiety, social anxiety and avoidant disorder and showed effectiveness in reducing

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anxiety levels and increasing coping abilities and functioning. Mendlowitz et al.
(1999) found that parental involvement had an enhancing effect on therapeutic
outcomes. One experimental study (Muratori et al. 2002) found brief psychodynamic
therapy to be effective in reducing anxiety symptoms. A further study (SBA) also
found brief psychodynamic therapy to be effective (Racusin 2000), indicating
remission of anxiety symptoms and re-integration into school. Two further supporting
studies (SBA) provided evidence for the effectiveness of psychoanalytic work with
children and young people suffering anxiety problems (Blos 1993, Fonagy and Target
1994). Counselling was concluded to be more effective with children under 11 years
where parents were treated at the same time (Fonagy and Target 1994). Two
qualitative studies found humanistic/child-centred counselling to be effective with
anxiety with Dearden’s (1998) study showing a high level of child satisfaction and
benefit from counselling and McConnell and Sim (2000) identifying concerns by
children regarding levels of confidentiality. Salloumi et al (2001) provided evidence
in a simple before and after study for the effectiveness of a combination of
counselling approaches in a community group setting in relation to a significant
reduction of post-traumatic stress anxiety symptoms.

One systematic review (Wilson et al. 2003) found all included therapies to be effective
across the full age-range of school children with violent and aggressive behaviour
specifically in the school context. Four experimental studies (English and Higgins
1971, King et al. 1998, McArdle et al. 2002, Omizo and Omizo 1987) two simple
before and after studies (Sherr and Sterne 1999, Squires 2001) and two qualitative
studies (Flitton and Buckroyd 2002, Meredith 1993) specifically referred to school-
related issues and showed effectiveness for issues including bullying, behavioural
difficulties, emotional problems, school refusal/phobia, truancy and academic failure.
Three indicated that CBT (King et al. 1998, Omizo and Omizo 1987, Squires 2001)
was most effective. Three studies identify positive outcomes for creative therapy,
McArdle et al., (2002) evidenced drama group work, Sherr and Sterne (1999)
evidenced play therapy and Flitton and Buckroyd (2002) evidenced person-centred
art therapy. One study showed positive outcomes for humanistic/person-centred
counselling (English and Higgins 1971) and one found an eclectic problem-solving
approach to be helpful (Meredith 1993). The DfES (2001) highlighted counselling as
one of the most helpful interventions for children and young people with emotional
and behavioural difficulties and other problems related to bullying, truancy and
academic failure.

The review identified five systematic reviews (Compton et al. 2002, Harrington,
Whittaker and Shoebridge 1998, Merry et al. 2004, Michael and Crowley 2002,
Reinecke, Rowley and Dubois 1998); five experimental studies (Birmaher et al. 2000,
Mendlowitz et al. 1999, Mufson et al.1999, Rossello and Bernal 1999) and two simple

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before and after studies (Darcy et al. 2001, Weersing and Weisz 2002) showing
effectiveness of counselling for depression in children and young people. A Cochrane
review (Merry et al. 2004) found manual based CBT and personal growth groups to
be effective in reducing depressive symptoms in the short term. However,
improvements were not sustained in the longer term. Michael and Crowley (2002) and
Reinecke et al. (1998) recorded better results for the adolescent age range (13-18)
than are recorded for 6-11 year olds (Compton et al. 2002). Given that CBT was the
primary model of therapy in the review studies it is reasonable to assume that the
enhanced efficacy with the 13-18 age group may be related to the ‘fit’ between
cognitive based therapies and adolescents’ level of cognitive functioning. There is
some evidence that depressed female students benefit more from counselling than
their male counterparts. However, Michael and Crowley (2002) suggest that this may
be linked to the different social and emotional expectations of males and females
during adolescence. This places females at an advantage in a therapeutic culture that
values and nurtures emotional expressiveness. Primary studies not included in the
reviews provide supplementary evidence that CBT is effective in aiding children and
young people between 12-18 years with recovery from depression (Birmaher et al.
2000, Rossello and Bernal 1999) and depression co-morbid with anxiety (Mendlowitz
et al. 1999). However, the evidence for longer-term effectiveness is less convincing
unless booster sessions are provided to accelerate recovery and minimise recurrence
of symptoms (Birmaher et al. 2000). Mufson et al. (1999) and Darcy et al. (2001)
provided evidence that interpersonal counselling was effective in significantly
reducing depressive symptoms and improving global functioning in adolescents. Even
short-term benefits from counselling may be valuable in preventing self-harm and
suicide attempts in depressed children and adolescents by reducing isolation and
hopelessness and providing a space in which collaboration with other mental health
professionals can be organised to sustain the young person in the longer term. There
was no evidence to suggest that the benefits of therapies other than CBT are not
sustained over time. Depression in children and young people can cause difficulties
in general functioning, including relationships with peers, teachers and parents. This
can lead to isolation and marginalisation. The child may be further excluded from
academic life through the disruption of cognitive functioning (Michael and Crowley
2002). The evidence from this review indicated that counselling can be effective in
reducing depression and therefore helping children to re-engage in academic work
and school life.

Deliberate self-harm is one of the symptoms of anxiety and/or depression and is

common among young people, particularly girls (Hawton et al. 2002). Self-harm
includes cutting, head-banging, pulling out hair, eating disorders, drug and alcohol
abuse and attempted suicide. As a form of self-harm, eating disorders can lead to
withdrawal from education due to severe physical and psychological problems

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(Latner et al. 2005). Substance abuse can lead to extreme personal, social and
cognitive damage (Foster et al. 2003). Mortality from suicide is growing in the western
world and is the third highest cause of death among adolescents in the U.S. (AACAP
2001). The effects of suicide attempts upon the individual, their peers and teachers
have far reaching effects in schools. The research evidence indicated that CBT,
humanistic/interpersonal and psychodynamic/analytical forms of counselling are
effective for children and young people who engage in self-harming activities. This
evidence was provided by four RCTs (Kaminer et al. 2002, Robin et al. 1999, Waldron
et al. 2001, Wood et al. 2001), one simple before and after study (Breslin et al. 2002)
and one qualitative study (Paulson and Everall 2003). Research participants identified
the valuable aspects of counselling as enhanced self-understanding, communication
and creative expression through the therapeutic relationship and therapeutic
strategies (Paulson and Everall 2003). Two of the RCTs provided evidence for the
effectiveness of CBT in reducing alcohol and marijuana use with adolescents
(Kaminer et al. 2000, Waldron, 2001). A third study (Breslin et al. 2002) provided
evidence that brief CBT counselling was effective in reducing drug use and related
consequences. Robin et al. (1999) found ego-oriented psychodynamic counselling to
be useful in producing weight gain and a return to menstruation in anorexic
adolescent girls. Group CBT with longer term humanistic counselling work showed
promising results with adolescent girls who repeatedly self-harm (Wood et al. 2001).
Paulson and Everall (2003) indicated that a focus on self-development using a range
of counselling approaches can be a key factor in facilitating the recovery of suicidal
adolescents.

Sexual abuse is rather different in nature to other issues. It is an event or experience

that involves the child rather than a psychological condition. It can lead to a range of
symptoms such as substance abuse, nightmares, running away from home, anxiety,
depression, post-traumatic stress disorder, inappropriate sexual behaviour, self-harm,
behaviour and conduct problems and suicide (Finkelhor and Berliner 1995). A study
by the National Society for the Prevention of Cruelty to Children (Creighton 2004)
found that of 30,000 children on child protection registers in the U.K, 5,600 were
registered for sexual abuse with one per cent being abused by a parent or carer and
six per cent by another relative. Sexual abuse is more prevalent between the ages of
eight and twelve years (Bentovim 1987, Monck et al. 1993), having implications for
counsellors in primary schools. According to the findings from this review all four
types of counselling were found to be effective for children showing psychological
symptoms of sexual abuse. Evidence was to be found in one meta-analysis (Reeker
et al. 1997); one systematic review (Finkelhor and Berliner 1995); three experimental
studies (Cohen and Mannarino 2000, Deblinger et al. 1999, Nolan 2002); two simple
before and after studies (De Luca et al. 1995, Trowell et al. 2002) and one
observational study (Berman 1995). Outcome research can be difficult to evaluate in

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SUE PATTISON AND BELINDA HARRIS

relation to sexual abuse because some children may appear to have recovered well
or be asymptomatic, leading teachers and counsellors to believe they are coping.
However, distress may be suppressed until many years later, leading to the sleeper
effect (Briere 1992, Elliott and Briere 1994). This phenomenon can make it difficult
for researchers to establish a baseline in relation to measuring therapy outcomes.
Reeker et al. (1997) provided evidence for the effectiveness of group counselling
using CBT, drama therapy or play therapy. Finklehor et al. (1995) found that
counselling was more effective than no treatment at all. There was little difference
between the various approaches to counselling. There was evidence to show that the
beneficial effects of counselling for the psychological symptoms of sexual abuse were
maintained for up to two years (Deblinger et al. 1999). By improving the mental
health of children and young people who have been sexually abused there are likely
to be more positive outcomes in terms of education and learning.

Conclusion
The results of this systematic review have shown counselling to be a positive, useful
and effective intervention for children and young people across the full range of
issues. The greater body of evidence for CBT has indicated that this form of
counselling may be more effective for older children and adolescents. However, this
result needs to be interpreted with some caution due to the lack of high quality
research evidence published in support of other counselling approaches. Gaps in the
outcome research evidence base were also identified for school related issues and
research for the effectiveness of counselling for self-harming practices and self-injury
such as cutting, drug and alcohol abuse, eating disorders and attempted suicide was
minimal.

In the light of increasing evidence that promoting mental health in children and
young people can have positive effects upon learning, achievement, attendance and
behaviour (BACP 2004a, DfES 2001, DfES 2004b, Pettitt 2003) it seems that the
commissioning of a systematic scoping review of the counselling research evidence
by the BACP (Harris and Pattison 2004) was both timely and appropriate. The
resulting research report has been in high demand with practitioners, service
managers and Local Education Authorities for use as evidence in support of school
counselling provision. The broad scope of the review, examining the research
evidence across a range of issues and problems has made it useful to a wider
audience. This review has focused upon outcomes rather than how or why particular
types of counselling worked. However, empirical research into counselling processes
and how or why they work would be a useful direction for future research.

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 ADDING VALUE TO EDUCATION THROUGH IMPROVED MENTAL HEALTH

Acknowledgements
The authors wish to acknowledge the support given by the British Association for
Counselling and Psychotherapy, who commissioned and funded this project,
particularly the editors, Nancy Rowland and Fran Shall, along with Angela Couchman.
Thanks to Dr Peter Bowers for his useful and detailed feedback during the final stages
of the project.

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