The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds

The impact of trauma and how to intervene: a narrative review of psychotraumatology over the past 15 years

To mark 15 years of the European Journal of Psychotraumatology, editors reviewed the past 15-year years of research on trauma exposure and its consequences, as well as developments in (early) psychological, pharmacological and complementary interventions. In all sections of this paper, we provide perspectives on sex/gender aspects, life course trends, and cross-cultural/global and systemic societal contexts. Globally, the majority of people experience stressful events that may be characterized as traumatic. However, definitions of what is traumatic are not necessarily straightforward or universal. Traumatic events may have a wide range of transdiagnostic mental and physical health consequences, not limited to posttraumatic stress disorder (PTSD). Research on genetic, molecular, and neurobiological influences show promise for further understanding underlying risk and resilience for trauma-related consequences. Symptom presentation, prevalence, and course, in response to traumatic experiences, differ depending on individuals' age and developmental phase, sex/gender, sociocultural and environmental contexts, and systemic socio-political forces. Early interventions have the potential to prevent acute posttraumatic stress reactions from escalating to a PTSD diagnosis whether delivered in the golden hours or weeks after trauma. However, research on prevention is still scarce compared to treatment research where several evidence-based psychological, pharmacological and complementary/ integrative interventions exist, and novel forms of delivery have become available. Here, we focus on how best to address the range of negative health outcomes following trauma, how to serve individuals across the age spectrum, including the very young and old, and include considerations of sex/gender, ethnicity, and culture in diverse contexts, beyond Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We conclude with providing directions for future research aimed at improving the well-being of all people impacted by trauma around the world. The 15 years EJPT webinar provides a 90-minute summary of this paper and can be downloaded here [http://bit.ly/4jdtx6k].

Preliminary efficacy of eye movement desensitization and reprocessing for children aged 1.5-8 years with PTSD: a multiple baseline experimental design (N = 19)

Background: Trauma exposure is common in (pre) school-aged children and around one-fifth of exposed children meet the criteria for post-traumatic stress disorder (PTSD). These symptoms can cause severe impairment to a child's functioning and, if left untreated, have negative long-term consequences. Therefore, there is an urgent need for effective treatment to reduce the acute and long-term effects of trauma. However, currently, there are no established empirically validated treatments for PTSD in young children.Objective: To assess the efficacy of eye movement desensitization and reprocessing (EMDR) therapy for improving PTSD symptoms, behavioural and emotional problems in young children aged 1.5-8 years, and parenting stress in their parents.Method: A non-concurrent, multiple baseline experimental design was combined with standardized measures across 19 mostly chronically trauma-exposed children fulfilling DSM-5 PTSD diagnosis. Primary outcomes included effects on the severity of PTSD symptoms and the rate of diagnostic remission from PTSD. Secondary outcomes included emotional and behavioural problems and parenting stress at each assessment point (baseline, pre-treatment, post-treatment, and three-month follow-up). Participants received six 1-hour EMDR sessions.Results: At post-treatment 79% of the children no longer met the diagnostic criteria for PTSD. Further, a significant decline in the severity of PTSD symptoms, emotional and behavioural problems in children was found post-treatment (all effect sizes > 1.20), as well as a significant reduction of parenting stress in their parents (Cohen's d effect size 0.45). All gains were maintained at the three-month follow-up, including a 79% loss of PTSD diagnosis. There was no dropout (0%) and no adverse events were reported.Conclusions: The findings provide preliminary evidence of the safety, feasibility, and efficacy of six sessions of EMDR therapy for reducing paediatric PTSD and comorbidity in young children aged 1.5-8 years and, at the same time, decreasing parenting stress. Further trials are warranted.Trial Registration: International Clinical Trial Registry Platform (before National Trial Register, trial search/who/int: identifier: NL8426, EMDR for young children with PTSD).

Posttraumatic stress in infancy: The roles of cumulative trauma and caregiving context

Infants are exposed to traumatic events at higher rates than older children, potentially leading to posttraumatic stress symptoms. Despite this higher prevalence, posttraumatic stress responses in infancy have not been well researched due to conceptual, developmental, and methodological challenges. This study conducted in the United States investigated the responses of infants aged 3-18 months after exposure to a range of traumatic events. Caregivers reported on their infants' trauma exposure and posttraumatic stress symptoms using the UCLA PTSD Reaction Index for DSM-5 for Children Age 6 and Younger and reported on their own posttraumatic symptoms on the PTSD Diagnostic Scale for DSM-5 (PDS-5). Of 116 racially and ethnically diverse infants, 96 (82.8%) were exposed to at least one traumatic event (M = 1.6; SD = 1.2; range = 0-7). Infant trauma exposure and caregiver symptoms were significant predictors of the number and severity of caregiver-endorsed infant symptoms. These findings indicate that infants as young as 3 months of age may manifest posttraumatic stress symptoms after trauma exposure. Developmental context and caregiver functioning should be considered when assessing for posttraumatic stress symptoms in infants.

Systematic Review and Meta-Analysis: Imputing Response Rates for First-Line Psychological Treatments for Posttraumatic Stress Disorder in Youth

OBJECTIVE

Meta-analyses assessing psychological therapies for posttraumatic stress disorder (PTSD) in youth have demonstrated their effectiveness using standardized mean differences. Imputation of response rates (ie, 50% or greater reduction in symptoms) may facilitate easier interpretation for clinicians.

METHOD

We searched 4 databases (MEDLINE, PsycINFO, PTSDPubs, and Web of Science) and screened 1,654 records to include 60 randomized controlled trials (52 trauma-focused cognitive-behavioral therapy [TF-CBT], 8 eye movement desensitization [EMDR]) with a total of 5,113 participants, comparing psychological therapies for PTSD against control conditions in youth. Data from randomized controlled trials of EMDR and TF-CBT for PTSD were used to impute response rates, establishing how many patients display 50% reduction, 20% reduction, and reliable improvement and deterioration (using reliable change indices) in PTSD and depression.

RESULTS

The proportion of youth exhibiting a 50% reduction in PTSD symptoms was 0.48 (95% CI = 0.41-0.55) for TF-CBT, 0.30 (0.24-0.37) for EMDR, and 0.46 (0.39-0.52) for all psychological therapies, compared to 0.20 (0.16-0.24) for youth in control conditions. Reliable improvement was displayed by 0.53 (0.45-0.61; TF-CBT 0.55 [0.46-0.64], EMDR 0.42[0.30-0.55]) of youth receiving psychological therapies, compared to 0.25 (0.20-0.30) of youth in control conditions. Reliable deterioration was seen in 0.01 (0.01-0.02) of youth receiving psychological therapies, compared to 0.13 (0.08-0.20) of youth in control conditions. There was a high degree of heterogeneity in the included studies.

CONCLUSION

Psychological therapies, in particular TF-CBT, for young people with PTSD are effective and unlikely to cause deterioration, with around half of youth receiving TF-CBT exhibiting 50% symptom reduction.

Individual psychological interventions and therapies for posttraumatic stress disorder and posttraumatic stress symptoms in young children: a systematic review

Context: Treatments for posttraumatic stress disorder (PTSD) in young children (ages 0-6) should be adapted to their developmental characteristics: to their cognitive, social, and emotional abilities, to their specific trauma reactions and adjustments, and finally, to their degree of dependency on adults. Due to the lack of official recommendations for the treatment of PTSD in young children and considering the high prevalence of PTSD among this population, there is a growing need for targeted psychological interventions and psychotherapies for the youngest children with PTSD or posttraumatic symptoms.Objective: To provide an update on effective psychological interventions available for the treatment of PTSD and posttraumatic symptoms in young children (under the age of 6).Design: Systematic review of automated searches conducted using the search engines Google Scholar, Science Direct, PsycInfo, and PubMed.Results: This review identified 17 articles reporting on the efficacy of an individual therapy for treating PTSD or posttraumatic stress symptoms in young children. The therapies identified are TF-CBT, CPP, PCIT, DET, early pathway, EMI and EMDR.Conclusion: No treatment can currently be identified as a level-one evidence-based treatment (Well-Established Treatment) in children younger than 6 years old with PTSD or posttraumatic symptoms. Further research is essential to validate existing findings on the effectiveness of trauma-focused therapies in young children in order to establish internationally recognized recommendations.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

BACKGROUND

Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators.

METHODS

This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954.

FINDINGS

We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms.

INTERPRETATION

This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress.

FUNDING

Swiss National Science Foundation.

Psychotherapeutic interventions for childhood posttraumatic stress disorder: an update

PURPOSE OF THE REVIEW

We review treatment outcome studies and systematic reviews for childhood and adolescent posttraumatic stress disorder (PTSD) between January 2020 and August 2022, including studies involving younger children and different treatment delivery methods and models. We address predictors, moderators, treatment engagement, and attrition.

RECENT FINDINGS

Recent randomised controlled trials corroborate earlier trials documenting trauma-focused cognitive behaviour therapy (TF-CBT) as a highly efficacious treatment for PTSD. Evidence for treatment effects in complex PTSD in youth is still sparse. Research on moderators and predictors of treatment continues to be hampered by multiple factors, including a lack of sufficiently large homogeneous trauma samples.

SUMMARY

TF-CBT is a very effective treatment for children and adolescents with PTSD. Further work is needed to (i) demonstrate that task-shifting models utilising lay community health counsellors and peer counsellors can effectively and cost-effectively close the mental health treatment gap that exists world-wide in children and adolescents diagnosed with PTSD, but particularly within low- and middle income countries, and (ii) better understand moderators and predictors of treatment which remains a priority.

Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Complex PTSD is characterised by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships. Complex PTSD has been adopted as a new diagnosis in the ICD-11. Individuals with complex PTSD typically have sustained or multiple exposures to trauma, such as childhood abuse and domestic or community violence. The disorder has a 1-8% population prevalence and up to 50% prevalence in mental health facilities. Progress in diagnostics, assessment, and differentiation from post-traumatic stress disorder and borderline personality disorder is reported, along with assessment and treatment of children and adolescents. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions.