Evidence-Based Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Abstract

The article reviews the current status (1993–2007) of psychosocial treatments for children and adolescents who have been exposed to traumatic events. Twenty-one treatment studies are evaluated using criteria from Nathan and Gorman (2002) along a continuum of methodological rigor ranging from Type 1 to Type 6. All studies were, at a minimum, robust or fairly rigorous. The treatments in each of these 21 studies also are classified using criteria from Chambless et al. (1996), and Chambless and Hollon (1998). Trauma-Focused Cognitive-Behavioral Therapy met the well-established criteria; School-Based Group Cognitive-Behavioral Treatment met the criteria for probably efficacious. All the other treatments were classified as either possibly efficacious or experimental. Meta-analytic results for four outcomes (i.e., posttraumatic stress, depressive symptoms, anxiety symptoms, and externalizing behavior problems) across all treatments compared to waitlist control and active control conditions combined reveal that, on average, treatments had positive, though modest, effects for all four outcomes. We also cover investigative work on predictors, moderators, and mediators of treatment outcome, as well as the clinical representativeness and generalizability of the studies. The article concludes with a discussion of practice guidelines and future research directions.

This project was supported in part by a cooperative agreement for the National Child Traumatic Stress Initiative, sponsored by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

We gratefully acknowledge the contributions of fellow members of the Learning From Research and Clinical Practice Advisory Group of the National Child Traumatic Stress Network for their chartering and guidance of this work: Charlene A. Allred, Joan R. Asarnow, Lucy Berliner, Kimberly E. Hoagwood, and Benjamin E. Saunders. We also are grateful for the assistance of Cybele M. Merrick of the National Center for Child Traumatic Stress (NCCTS), Linda Maultsby of the Services Effectiveness Research Program, and Armando Pina, at Arizona State University, as well as the support of John Fairbank and Robert S. Pynoos, Co-Directors of the NCCTS.

Notes

Note: Dashes indicate zero. NR = not reported.

^a Participants in Smith et al. (2007) listed as Black British.

∗Studies are classified by type using Nathan and Gorman's (2002) criteria.

¹The labels used by investigators to refer to the treatment have occasionally varied and have included individual Child Cognitive-Behavioral Therapy (Deblinger, Lippmann, & Steer, 1996), Cognitive-Behavioral Therapy for Sexually Abused Preschool Children (Cohen & Mannarino, 1996b), Sexual Abuse Specific Cognitive-Behavioral Therapy (Cohen & Mannarino, 1998), Cognitive-Behavioral Therapy (Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadi, 2004), Child Cognitive-Behavioral Treatment and Family Therapy (King et al., 2000), and Individual Child and Parent Cognitive-Behavioral Treatment (Kolko, 1996).

²RPT and EMDR both were classified as possibly efficacious rather than probably efficacious despite having been evaluated in two studies. With respect to RPT, improvements observed in this treatment were found in children who were maltreated as well as children who were not maltreated. Thus, whether the treatment approach shows treatment specificity effects, in terms of reducing reactions that follow child exposure to maltreatment, remains unclear. With respect to EMDR, although in Chemtob et al. (2002), the treatment was superior to a waitlist control condition (a necessary condition for probably efficacious), in the other EMDR study conducted by Jaberghaderi et al. (2004), which compared EMDR to CBT, the former was found to be statistically significantly superior over the latter on only one of the three measures administered (as well as there being several methodological limits including a sample size of 7 in each treatment condition).

Note: CBT = cognitive behavioral therapy; CBT-SAP = CBT for Sexually Abused Preschool Children; NST = Nondirective Supportive Therapy; C/ = child self-report; P/ = parent report about the child; CBCL- I, E, SC = Child Behavior Checklist–Internalizing, Externalizing, Social Competence; CSBI = Child Sexual Abuse Inventory (Friedrich et al., 1992); WBR = Weekly Behavior Reports; ICBT = Individual CBT; PT = Parent Training; STC = standard therapeutic care; STAIC-S, T = State-Trait Anxiety Inventory for Children–State, Trait; CDI = Child Depression Inventory; PPQ = Parenting Practices Questionnaire (Strayhorn & Weidman, 1988); CL/ = clinician report about the child; K-SADS = Schedule for Affective Disorders and Schizophrenia; PTSD-RI = Child Reaction Index; FT = Family Therapy; RCS = Routine Community Services; CTS = Child Tactics Scale (Straus, 1990); SAFE = Sexual Abuse Fear Evaluation Scales (D. A. Wolfe & Wolfe, 1986); CAPS = Children's Attributions and Perceptions Scale (Mannarino, Cohen, & Berman, 1994); YSR = Youth Self-Report (Achenbach, 1991); FQ = Friendship Questionnaire (Bierman & McCauley, 1987); CCI = Child Conflict Index; PS/ = parent self-report; CAPI = Child Abuse Potential Inventory (Milner, 1986); WRAI = Weekly Report of Abuse Inventory (Kolko, 1996); BSI = Brief Symptom Inventory (Derogatis & Melisaratos, 1983); BDI = Beck Depression Inventory; GAF = Global Assessment of Functioning Scale (American Psychiatric Association, 1987); POQ = Parent Opinion Questionnaire (Azar, Robinson, Hekimian, & Twentyman, 1984); CRI = Child Rearing Interview (Stouthamer-Loeber & Loeber, 1985); PPI = Parent Perception Inventory (Hazzard, Christensen, & Margolin, 1983); CP/ = child report about the parent; K-GAS = Global Assessment Scale for Children; SAS-CBT = Sexual Abuse Specific-CBT; CQ = Coping Questionnaire (King et al., 2000); RCMAS = Revised Children's Manifest Anxiety Scale; ADIS-C-IV = Anxiety Disorders Inventory for Children–Version IV; K-GAF = Global Assessment of Functioning for Children (American Psychiatric Association, 1987); TF-CBT = Trauma-Focused Cognitive-Behavioral Therapy; CCT = Child-Centered Therapy; PERQ = Parent's Emotional Reaction Questionnaire (Mannarino & Cohen, 1996); PSQ = Parental Support Questionnaire (Mannarino & Cohen, 1996); TSC-C = Trauma Symptom Checklist for Children (Briere, 1995); PTSS = posttraumatic stress symptoms; CBITS = Cognitive Behavioral Intervention for Trauma in Schools; CPSS-SR = PTSD Symptom Scale Self Report; PSC = Pediatric Symptoms Checklist (Jellinek, Murphy, & Burns, 1986); T/ = teacher report about the child; TCRS = Teacher-Child Rating Scale (Hightower et al., 1986); MHIP = Mental Health for Immigrants Program; RPT = Resilient Peer Treatment; AC = Attention Control; SSRS = Social Skills Ratings System (Gresham & Elliott, 1990); PPIC = Peer Play Interactive Checklist (Fantuzzo & Atkins, 1995); PIPPS = Penn Interactive Peer Play Scale (Fantuzzo, Coolahan, Mendez, McDermott, & Sutton-Smith, 1996); SGT = Support Group Therapy; GCBT = group CBT; WIST = What if Situation Test (Sarno & Wurtele, 1997); MBSS = Miller Behavior Style Scale (Miller, 1990); SCL-90 = Symptom Checklist-90 (Saunders, Arata, & Kilpatrick, 1990); IES = Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979); SSQ = Social Support Questionnaire (Zich & Temoshok, 1987); CPT = Cognitive Processing Therapy; PSS-SR = PTSD Symptom Scale- Self Report; EMDR = eye movement desensitization and reprocessing; DSRS = Depression Self-Rating Scale (Birleson, 1981); CROPS = Child Report of Posttraumatic Symptoms; PROPS = Parent Report of Posttraumatic Symptoms; RTS = Rutter Teacher Scale; CPP = Child–Parent Psychotherapy; DC: 0–3 = Semistructured Interview for Diagnostic Classification for Clinicians (Zero to Three: National Center for Clinical Infants Programs, 1994); SGT = Standard Group Therapy; FSSC-R = Fear Survey Schedule for Children–Revised (Ollendick, 1983); RAP = Recovering from Abuse Program; TAU = Treatment as Usual; CITES-R = Child Impact of Traumatic Stress Events (V. V. Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991); PAS = Parental Attribution Scale (Celano, Webb, & Hazzard, 1992); C-GAS = Children's Global Assessment Scale; SDQ = Strengths and Difficulties Questionnaire (Goodman, 1997); CBQ = Conflict Behavior Questionnaire.

Note: CBT = Cognitive Behavioral Therapy; K = number of independent samples that contributed an effect size; N = total sample size across the K samples; d = sample size weighted average effect size; SDd = sample size weighted standard deviation across the k effect sizes; SESD = sampling error associated with d; Res Sd = residual standard deviation; %VarSE = percentage of observed variance across the K effect sizes that can be attributed to sampling error; 95% CI = 95% confidence interval around the average effect size; Fail-safe N = number of samples with an average effect size of zero that should have been center out in our meta-analyses to lower the estimated effect size to .10; Q-Stat = variability among effect sizes (the Q-statistic is tested for significance at the .05 level; significant values suggest the presence of moderators); PTSS = posttraumatic stress symptoms.

∗Indicates significance at the .05 level.

³The 95% confidence interval is computed as d±1.96 (res SD). If the lower bound of the interval is positive, it can be said that the treatment was effective in 95% of the situations (or conversely, that there is a significant effect). A res SD of zero suggests that the treatment effect was constant across situations and samples. The smaller the res SD, the more generalizable the treatment effects are across the samples. An alternative way to look at this is to consider the percentage of observed variance accounted for by sampling error. If all the observed variance is because of sampling error (i.e., 100% of the variance accounted for by sampling error), then the treatment effect is constant across samples and situations. The Fail-safe N was computed as k((d/dc) − 1) where k is the number of effect sizes in that meta-analysis, d is the computed average effect size, dc is the critical value which was taken as .10 here. Q-stat was computed as k ∗Observed variance/sampling error variance and is a chi-square with k-1 degrees of freedom.

Note: K = number of independent samples that contributed an effect size; N = total sample size across the K samples; d = sample size weighted average effect size; SDd = sample size weighted standard deviation across the k effect sizes; SESD = sampling error associated with d; Res Sd = the residual standard deviation; %VarSE = percentage of observed variance across the K effect sizes that can be attributed to sampling error; 95% CI = 95% confidence interval around the average effect size; Fail-safe N = number of samples with an average effect size of zero that should have been left out in our meta-analyses to lower the estimated effect size to .10; Q-Stat = variability among effect sizes (the Q-statistic is tested for significance at the .05 level; significant values suggest the presence of moderators; PTSS = posttraumatic stress symptoms.