Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change

Systematic Review and Meta-analysis: Group-Based Interventions for Treating Posttraumatic Stress Symptoms in Children and Adolescents

OBJECTIVE

Trauma exposure in childhood is common and can lead to a range of negative mental health outcomes, including posttraumatic stress disorder (PTSD). In many settings, resources to address this distress are scarce. Group-based interventions require minimal resources and training, can be delivered by non-mental health specialists, and target larger numbers of children and adolescents. This meta-analysis sought to establish whether such an approach is an effective method for targeting PTSD symptoms and to identify potential moderators of effectiveness.

METHOD

PubMed, PsycNET, and PTSDPubs were searched for randomized controlled trials that used a group-based PTSD intervention with children and adolescents aged 6 to 18 years. Data were extracted for PTSD symptoms and depression symptoms. A random-effects meta-analysis was conducted to obtain between-group pooled effect size estimates. This study was registered on PROSPERO (CRD42020187214).

RESULTS

The initial search identified 9,650 studies, of which 42 were eligible for inclusion (N = 5,998). Children randomized to a group-based intervention had significantly lower PTSD symptoms after treatment compared with a control group, with a medium pooled effect (g = -0.55, 95% CI [-0.76, -0.35]). Group interventions were superior when compared with either active or passive controls, at follow-up, and for depression symptoms. There was a large amount of heterogeneity, but no evidence that this was explained by whether the intervention was delivered in a low- and middle-income or high-income country, included caregivers, or was universal or targeted.

CONCLUSION

Group PTSD interventions, particularly cognitive-behavioral therapy-based interventions, are effective at targeting posttrauma distress in children and adolescents. There was evidence of effectiveness when delivered in highly complex and resource-scarce settings and to a range of trauma-exposed groups, including groups exposed to war/conflict, natural disasters, and abuse.

Comparative effectiveness of psychological interventions for treating the psychological consequences of sexual abuse in children and adolescents: a network meta-analysis

BACKGROUND

Following sexual abuse, children and young people may develop a range of psychological problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and a range of behaviour problems. Those working with children and young people experiencing these problems may use one or more of a range of psychological approaches.

OBJECTIVES

To assess the relative effectiveness of psychological interventions compared to other treatments or no treatment controls, to overcome psychological consequences of sexual abuse in children and young people up to 18 years of age. Secondary objectives To rank psychotherapies according to their effectiveness. To compare different 'doses' of the same intervention.

SEARCH METHODS

In November 2022 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and two trials registers. We reviewed the reference lists of included studies, alongside other work in the field, and communicated with the authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing psychological interventions for sexually abused children and young people up to 18 years old with other treatments or no treatments. Interventions included: cognitive behavioural therapy (CBT), psychodynamic therapy, family therapy, child centred therapy (CCT), and eye movement desensitisation and reprocessing (EMDR). We included both individual and group formats.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias for our primary outcomes (psychological distress/mental health, behaviour, social functioning, relationships with family and others) and secondary outcomes (substance misuse, delinquency, resilience, carer distress and efficacy). We considered the effects of the interventions on all outcomes at post-treatment, six months follow-up and 12 months follow-up. For each outcome and time point with sufficient data, we performed random-effects network and pairwise meta-analyses to determine an overall effect estimate for each possible pair of therapies. Where meta-analysis was not possible, we report the summaries from single studies. Due to the low number of studies in each network, we did not attempt to determine the probabilities of each treatment being the most effective relative to the others for each outcome at each time point. We rated the certainty of evidence with GRADE for each outcome.

MAIN RESULTS

We included 22 studies (1478 participants) in this review. Most of the participants were female (range: 52% to 100%), and were mainly white. Limited information was provided on socioeconomic status of participants. Seventeen studies were conducted in North America, with the remaining studies conducted in the UK (N = 2), Iran (N = 1), Australia (N = 1) and Democratic Republic of Congo (N = 1). CBT was explored in 14 studies and CCT in eight studies; psychodynamic therapy, family therapy and EMDR were each explored in two studies. Management as usual (MAU) was the comparator in three studies and a waiting list was the comparator in five studies. For all outcomes, comparisons were informed by low numbers of studies (one to three per comparison), sample sizes were small (median = 52, range 11 to 229) and networks were poorly connected. Our estimates were all imprecise and uncertain. Primary outcomes At post-treatment, network meta-analysis (NMA) was possible for measures of psychological distress and behaviour, but not for social functioning. Relative to MAU, there was very low certainty evidence that CCT involving parent and child reduced PTSD (standardised mean difference (SMD) -0.87, 95% confidence intervals (CI) -1.64 to -0.10), and CBT with only the child reduced PTSD symptoms (SMD -0.96, 95% CI -1.72 to -0.20). There was no clear evidence of an effect of any therapy relative to MAU for other primary outcomes or at any other time point. Secondary outcomes Compared to MAU, there was very low certainty evidence that, at post-treatment, CBT delivered to the child and the carer might reduce parents' emotional reactions (SMD -6.95, 95% CI -10.11 to -3.80), and that CCT might reduce parents' stress. However, there is high uncertainty in these effect estimates and both comparisons were informed only by one study. There was no evidence that the other therapies improved any other secondary outcome. We attributed very low levels of confidence for all NMA and pairwise estimates for the following reasons. Reporting limitations resulted in judgements of 'unclear' to 'high' risk of bias in relation to selection, detection, performance, attrition and reporting bias; the effect estimates we derived were imprecise, and small or close to no change; our networks were underpowered due to the low number of studies informing them; and whilst studies were broadly comparable with regard to settings, the use of a manual, the training of the therapists, the duration of treatment and number of sessions offered, there was considerable variability in the age of participants and the format in which the interventions were delivered (individual or group).

AUTHORS' CONCLUSIONS

There was weak evidence that both CCT (delivered to child and carer) and CBT (delivered to the child) might reduce PTSD symptoms at post-treatment. However, the effect estimates are uncertain and imprecise. For the remaining outcomes examined, none of the estimates suggested that any of the interventions reduced symptoms compared to management as usual. Weaknesses in the evidence base include the dearth of evidence from low- and middle-income countries. Further, not all interventions have been evaluated to the same extent, and there is little evidence regarding the effectiveness of interventions for male participants or those from different ethnicities. In 18 studies, the age ranges of participants ranged from 4 to 16 years old or 5 to 17 years old. This may have influenced the way in which the interventions were delivered, received, and consequently influenced outcomes. Many of the included studies evaluated interventions that were developed by members of the research team. In others, developers were involved in monitoring the delivery of the treatment. It remains the case that evaluations conducted by independent research teams are needed to reduce the potential for investigator bias. Studies addressing these gaps would help to establish the relative effectiveness of interventions currently used with this vulnerable population.

Psychosocial interventions for responding to child sexual abuse: A systematic review

BACKGROUND

In this manuscript, we summarize the findings of a systematic review that informed the development of the World Health Organization's recommendations related to psychosocial interventions for child and adolescent sexual abuse.

METHOD

Systematic searches across 14 databases were conducted to retrieve any published randomized controlled trials of psychosocial interventions addressing mental health outcomes among children and adolescents exposed to sexual abuse who have experienced symptoms. We assessed study risk of bias using the Cochrane Risk of Bias tool and certainty of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twenty-four articles representing fifteen studies were included in the systematic review. Only two studies were conducted in low- or middle-income countries. Few studies could be pooled together because of differences in interventions and comparators. Due to the small numbers of participants and very serious concerns with risk of bias, we are very uncertain about the benefits of interventions provided to children alone and without the involvement of their caregivers. However, cognitive behavior therapy (CBT) with a trauma focus provided to children and involving their caregivers may reduce some mental health symptoms associated with sexual abuse experiences.

DISCUSSION

The findings suggest that more and larger studies are needed to evaluate the effects of psychosocial interventions for children and adolescents exposed to sexual abuse who preside in low- and middle-income countries. PROSPERO registration number: CRD42016039656.

The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis

Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people.

Psychological intervention with adult victims of sexual abuse: A comprehensive review

Child sexual abuse (CSA) is a phenomenon that is ubiquitous to all cultures and social classes. It has short- and long-term consequences, with specific treatment models that have been developed and adapted from psychological intervention models. A wide variety of studies have sought to evaluate the results of treatments with adult CSA survivors. This study presents an overview of research on the treatment of adult victims of CSA, by reviewing the existing literature on the types of treatment and the most studied psychotherapeutic avenues, and reports the findings related to the efficacy of these treatments. It is possible to conclude that psychological intervention exhibits benefits in the reduction of symptoms resulting from the experience of CSA and demonstrates the need to conduct further research on the effectiveness of intervention.

Psychodynamic Psychotherapy for Children as a Trauma-Informed Intervention

This article outlines the underpinnings of a psychodynamic approach for the treatment of childhood trauma through strengthening the implicit emotion regulation system. Childhood trauma impairs the functioning of the emotion regulation system, where deficits are common in children with post-traumatic stress disorder (PTSD). Difficulties with emotion regulation arise out of disruptions in the development of neurobiological pathways through the interaction of constitutional determinants with environmental factors, including the child's relationships with caregivers and the broader environment. We propose that a therapeutic focus on traumatized children's defenses can overcome the damaging reverberations of trauma. This approach may bypass the difficulties of high attrition rates, expense, and limited generalizability characteristic of skills training-based modalities. An illustration of an intervention to help children address unbearable emotions in traumatic experiences through defense interpretation is presented. The manualization and study of this approach within a project titled Regulation Focused Psychotherapy for Children (RFP-C) presents a unique opportunity to contribute to the evidence-based canon of treatments for children with histories of trauma.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluating the Reliability and Validity of the Arabic Version of the Parents Perceptions of Uncertainty Scale (A-PPUS)

BACKGROUND

Uncertainty often accompanies illness and may be a major aversive component of the patients' treatment process. There is evidence that parental uncertainty has a negative impact on their own and on their child's coping strategies and may affect family functioning. Key to the provision of competent care, to address uncertainty, is the use of an appropriate validated assessment tool to understand key parental concerns. The 'Parent Perception of Uncertainty Scale' (PPUS) has been widely used for this purpose.

AIM

This study reports on the validity and reliability testing of the Arabic version of the Parents Perception of Uncertainty Scale (A-PPUS).

METHODS

The scale was translated to Arabic using the translation-back-translation method. Appropriate statistical tests were performed including measurements of internal consistency, item to total scale correlation, and univariate and multivariate analyses.

RESULTS

The study included 240 parents of children with chronic illnesses. Cronbach's alpha coefficient of the whole scale was 0.93. All the items were positively correlated to the total score. The univariate and multivariate analysis supported the previous tests and the assertion that the Arabic version of the PPUS provided a relevant measure of the uncertainty level.

CONCLUSION

This study has identified that the A-PPUS is a reliable tool for parent report of their uncertainty, in the UAE and Arabic population.

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy

OBJECTIVE

This paper describes the evolution of methods of enquiry-through 25 years of work, with Professor Peter Fonagy and many other colleagues-of research and theorizing about child and adolescent therapy outcomes.

METHOD

The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities.

RESULTS

Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families.

CONCLUSIONS

Using the dilemmas, experiences, and findings ‌‌of our group as examples, growing points and well as growing pains for the field are suggested.

Psychological therapies for children and adolescents exposed to trauma

BACKGROUND

Children and adolescents who have experienced trauma are at high risk of developing post-traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents.

OBJECTIVES

To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random-effects model. We analysed data as short-term (up to and including one month after therapy), medium-term (one month to one year after therapy) and long-term (one year or longer).

MAIN RESULTS

Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life-threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas.Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive-behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children.The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) -0.42, 95% CI -0.61 to -0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term.CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD -0.24, 95% CI -0.42 to -0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate.We did not identify any studies that compared pharmacological therapies with psychological therapies.

AUTHORS' CONCLUSIONS

The meta-analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High-quality studies should be conducted to compare these therapies.

A Summary of Selective Experimental Research on Psychosocial Interventions for Sexually Abused Children

This study was conducted to explore current trends in psychosocial interventions for sexually abused children through a review of recent research. Our comprehensive review is limited to published (quasi) experimental studies in the English language over a period of 2000-2013. It provides a detailed analysis of the final 18 articles that met our inclusion criteria, from the 670 potentially relevant articles that were identified. Reviewers analyzed candidate articles to determine whether they met inclusion or exclusion criteria. The retrieved studies reported positive results with respect to improvements in the negative psychosocial sequelae of child sexual abuse following the use of a diverse set of treatment strategies. Of the various interventions, cognitive behavioral therapy was shown to be the most promising type of intervention for sexually abused children. In this review, we discuss some of the implications of psychosocial interventions for victims of child sexual abuse, citing both the methodological and ethical issues that should be considered.

Review of Randomized Controlled Trials on Psychological Interventions in Child Sexual Abuse: Current Status and Emerging Needs in the Indian Context

Child sexual abuse (CSA) is a critical, psychologically traumatic and sometimes life-threatening incident often associated with sequel of adverse physical, behavioral, and mental health consequences. Factors such as developmental age of the child, severity of abuse, closeness to the perpetrator, availability of medico-legal-social support network and family care, gender stereotypes in the community complicate the psychological trauma. Although the research on the effects of CSA as well as psychological intervention to reduce the victimization and promote the mental health of the child is in its infancy stage in India, the global research in the past three decades has progressed much ahead. A search was performed using MEDLINE, PubMed, PsycINFO, and Google Scholar from 1984 to 2015 and only 17 randomized controlled trials (RCTs) out of 96 potentially relevant studies were included. While nonspecific therapies covering a wide variety of outcome variables were prominent till 1999s, the trend changed to specific and focused forms of trauma-focused therapies in next one-and-half decades. Novel approaches to psychological interventions have also been witnessed. One intervention (non-RCT) study on effects on general counseling has been reported from India.

Interventions for children and adolescents with posttraumatic stress disorder: A meta-analysis of comparative outcome studies

This meta-analysis aimed at determining the efficacy of psychological and psychopharmacological interventions for children and adolescents suffering from symptoms of posttraumatic stress disorder (PTSD). A search using the Medline, PsycINFO, and PILOTS databases was conducted to identify randomized controlled trials (RCTs) for pediatric PTSD. The search resulted in 41 RCTs, of which 39 were psychological interventions and two psychopharmacological interventions. Results showed that psychological interventions are effective in treating PTSD, with aggregated effect sizes of Hedge's g=0.83 when compared to waitlist and g=0.41 when compared to active control conditions at posttreatment. Trauma-focused cognitive behavior therapy was the most researched form of intervention and resulted in medium to large effect sizes when compared to waitlist (g=1.44) and active control conditions (g=0.66). Experimental conditions were also more effective than control conditions at follow-up. Interventions were further effective in reducing comorbid depression symptoms, yet the obtained effect sizes were small to medium only. The findings indicate that psychological interventions can effectively reduce PTSD symptoms in children and adolescents. There is very little evidence to support use of psychopharmacological interventions for pediatric PTSD.

The Survivor Master Narrative in Sexual Assault

This article is based on data drawn from 90 Victoria Police operational files covering the period 2004-2008. Several thematic responses by sexual assault survivors are described as forming a master narrative of "identity shock." It is argued that the "minor/serious" sexual assault legal distinction is meaningless to survivors and conceals a shared felt experience. It is also argued that sexual assault is fundamentally a "public issue" of betrayal of citizen trust--not just a collection of "private troubles"--and that effective resolutions require more than individualized therapeutic and criminal justice measures.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents (Review)

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team. We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service. The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy. Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group. The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified. No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others. The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses. More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Making meaningful connections: assessing for clinical work in a child residential setting

Purpose

– The purpose of this paper is to discuss the clinical assessment of children and the development of a multi-disciplinary team in an established residential school for children aged five to 12.

Design/methodology/approach

– Using clinical examples the paper describes how assessment can identify different levels of therapeutic need, and then how the decision is made whether or not to offer milieu therapy, music therapy, dramatherapy or psychotherapy.

Findings

– The paper suggests that children who have early histories of abuse and trauma have differing clinical needs.

Practical implications

– The implication is that children will engage better with the therapy if the level of intervention is sensitive to their state of mind, which in turn will help them make better use of the environmental provision of the school.

Originality/value

– The paper offers an original perspective on the possibilities and limitations of psychotherapeutic work with extremely vulnerable damaged children in a residential therapeutic setting, the Mulberry Bush.

Psychodynamic psychotherapy for children and adolescents: a meta-analysis of short-term psychodynamic models

OBJECTIVE

Psychodynamically based brief psychotherapy is frequently used in clinical practice for a range of common mental disorders in children and adolescents. To our knowledge, there have been no meta-analyses to evaluate the effectiveness of these therapies.

METHOD

After a broad search, we meta-analyzed controlled outcome studies of short-term psychodynamic psychotherapies (STPP, 40 or fewer sessions). We also performed sensitivity analyses and evaluated the risk of bias in this body of studies.

RESULTS

We found 11 studies with a total of 655 patients covering a broad range of conditions including depression, anxiety disorders, anorexia nervosa, and borderline personality disorder. STPP did not separate from what were mostly robust treatment comparators, but there were some subgroup differences. Robust (g = 1.07, 95% CI = 0.80-1.34) within group effect sizes were observed suggesting the treatment may be effective. These effects increased in follow up compared to post treatment (overall, g = 0.24, 95% CI = 0.00-0.48), suggesting a tendency toward increased gains. Heterogeneity was high across most analyses, suggesting that these data need be interpreted with caution.

CONCLUSION

This review suggests that STPP may be effective in children and adolescents across a range of common mental disorders.

Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused

BACKGROUND

The sexual abuse of children and adolescents is a significant worldwide problem. It is associated with a wide variety of negative psychological, social and physical consequences for the victims. These effects can often be seen immediately following sexual abuse, but they may manifest later on and sometimes only in adult life. There are a number of different interventions aimed at helping children and adolescents who have been sexually abused, and psychoanalytic/psychodynamic psychotherapy has a long-established tradition of being used for such victims. In this review, we set out to find the evidence for its effectiveness specifically in children and adolescents who have been sexually abused.

OBJECTIVES

To assess the effectiveness of psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused.

SEARCH METHODS

We searched the following databases in May 2013: CENTRAL, Ovid MEDLINE, Embase, PsycINFO, CINAHL, Sociological Abstracts, Social Science Citation Index, Conference Proceedings Citation Index - Social Science and Humanities, LILACS and WorldCat. We also searched three trials registers, checked the reference lists of relevant studies and contacted known experts.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing psychoanalytic/psychodynamic psychotherapy with treatment as usual or no treatment/waiting list control for children and adolescents up to age of 18 who had experienced sexual abuse at any time prior to the intervention.

DATA COLLECTION AND ANALYSIS

The review authors (BP and WT) independently screened search results to identify studies that met eligibility criteria.

MAIN RESULTS

No studies were identified that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There are no randomised and quasi-randomised trials that compare psychoanalytic/psychodynamic therapy with treatment as usual, no treatment or waiting list control for children and adolescents who have been sexually abused. As a result, we cannot draw any conclusions as to the effectiveness of psychoanalytic/psychodynamic psychotherapy for this population. This important gap emphasises the need for further research into the effectiveness of psychoanalytic/psychodynamic psychotherapy in this population. Such research should ideally be in the form of methodologically high-quality, large-scale randomised controlled trials. If these are not conducted, future systematic reviews on this subject may need to consider including other lower quality evidence in order to avoid overlooking important research.

[Effectiveness of psychodynamic psychotherapy in children and juveniles - results of a pilot study]

QUESTION

The effectiveness of psychodynamic psychotherapy for children and adolescents has yet to be studied sufficiently in Germany. Because psychodynamic psychotherapy aims to reduce symptoms in both the short and long term - besides achieving other long-term goals - in this paper we present results focusing on whether symptoms and problem behavior can be improved within 25 h of outpatient psychodynamic psychotherapy taking place in a practice. Moreover, it addresses whether a positive change of life quality can be achieved in the same timeframe.

METHOD

Thirty children and juveniles with emotional, behavioral, and adjustment disorders who had received 25 h of psychodynamic psychotherapy were investigated. Parental reports on the Child Behavior Checklist and parental and expert opinions on the DISYPS-KJ were compared before and after therapy.

RESULTS

We found significant improvement on almost all measured CBCL scales, but not on the syndrome scales measured with the DISYPS. Predominantly medium-size effects were calculated. But parents did not report an improvement of general life quality of their children during the course of psychotherapy.

CONCLUSIONS

Our results indicate that there is an effective reduction of childhood emotional and behavioral symptoms following psychodynamic psychotherapy. The measured timeframe, however, seems to be too short to ensure significant improvements in specific childhood disorders from both parental and expert perspectives.

A comparative effectiveness review of parenting and trauma-focused interventions for children exposed to maltreatment

OBJECTIVE

To systematically review the comparative effectiveness evidence for interventions to ameliorate the negative sequelae of maltreatment exposure in children ages birth to 14 years.

METHODS

We assessed the research on pharmacological and psychosocial interventions (parent-mediated approaches or trauma-focused treatments) reporting mental and behavioral health, caregiver-child relationship, and developmental and/or school functioning outcomes. We conducted focused searches of MEDLINE (through PubMed), Social Sciences Citation Index, PsycINFO, and the Cochrane Library (1990-2012). Reviewer pairs independently evaluated the studies for eligibility using predetermined inclusion/exclusion criteria, evaluated studies for risk of bias, extracted data, and graded the strength of evidence (SOE) for each comparison and each outcome based on predetermined criteria.

RESULTS

Based on our review of 6282 unduplicated citations, we found 17 trials eligible for inclusion. Although several interventions show promising comparative benefit for child well-being outcomes, the SOE for all but one of these interventions was low. The results highlight numerous substantive and methodological gaps to address in the future research.

CONCLUSIONS

It is too early to make strong treatment recommendations, as comparative research remains relatively nascent in the child maltreatment arena. These gaps reflect, in large part, the Herculean demands on researchers involved in conducting high-quality clinical studies with this highly vulnerable population. The National Child Traumatic Stress Network and the Developmental-Behavioral Pediatrics Research Network (DBPNet) are two potentially powerful platforms to conduct large rigorous trials needed to move the field forward. More broadly, a paradigm shift among researchers and funders alike is needed to galvanize the commitment and resources necessary for conducting collaborative clinical trials with this highly vulnerable population.

Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: a systematic review

This is a systematic review of evidence-based treatments for children exposed to childhood maltreatment. Because exposure to childhood maltreatment has been associated with a broad range of trauma-related psychopathology (e.g., PTSD, anxiety, suicidal ideation, substance abuse) and with aggressive and violent behavior, this review describes psychotherapeutic treatments which focus on former broad range of psychopathological outcomes. A total of 26 randomized controlled clinical trials and seven non-randomized controlled clinical trials published between 2000 and 2012 satisfied the inclusionary criteria and were included. These studies dealt with various kinds of samples, from sexually abused and maltreated children in child psychiatric outpatient clinics or in foster care to traumatized incarcerated boys. A total of 27 studies evaluated psychotherapeutic treatments which used trauma-focused cognitive, behavioral or cognitive-behavioral techniques; only two studies evaluated trauma-specific treatments for children and adolescents with comorbid aggressive or violent behavior; and four studies evaluated psychotherapeutic treatments that predominantly focused on other mental health problems than PTSD and used non-trauma focused cognitive, behavioral or cognitive-behavioral techniques. The results of this review suggest that trauma-focused cognitive-behavioral therapy (TF-CBT) is the best-supported treatment for children following childhood maltreatment. However, in line with increased interest in the diagnosis of complex PTSD and given the likely relationship between childhood maltreatment and aggressive and violent behavior, the authors suggest that clinical practice should address a phase-oriented approach. This review concludes with a discussion of future research directions and limitations.

The state of the evidence base for psychodynamic psychotherapy for children and adolescents

This article reviews outcomes of psychodynamic psychotherapy (PP) for children and adolescents reported in articles identified by a comprehensive review of the literature on treatment evaluations of psychological and medical interventions for mental disorders in pediatric populations. The review identified 48 reports based on 33 studies. While there is evidence of substantial clinical gains associated with PP, in almost all the studies, when contrasted with family-based interventions, PP fares no better and appears to produce outcomes with some delay relative to family-based therapies. Further rigorous evaluations are needed, but evidence to date suggests that the context in which PP is delivered should be extended from the traditional context of individual therapy and parents should be included in the treatment of children.

Case study of cognitive behavioural therapy awareness educational programme using blended learning, UK

This paper examined the opportunities as well as challenges in relation to the use of cognitive behavioural therapy (CBT). The opportunities include the increased range of mental health conditions and other disorders where CBT (in isolation or with other interventions) could be effective to address them, as well as policies around workforce education and training that support the expansion of psychological therapies, particularly CBT services. The challenges include the urgent need of heightened awareness among the wider platform of health and social care workers about CBT principles, structure, framework, methods of delivery, wider applications, evaluation and appropriate referral of clients, and stepped model of care. In response to such needs, the paper described CBT awareness educational award at the University of Gloucestershire, UK: the Certificate of Professional Studies in Awareness of Cognitive and Behavioural Therapies Practice delivered at Level III and M level. The challenges associated with the initiation and running of such educational programmes are highlighted, as well as suggestions for the way forward considering the learners', employers' and educational providers' perspectives.

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents

BACKGROUND

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

OBJECTIVES

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

MAIN RESULTS

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy.Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group.The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified.No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

AUTHORS' CONCLUSIONS

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others.The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses.More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Posttraumatic stress disorder in children and adolescents: neuroendocrine perspectives

Posttraumatic stress disorder (PTSD) is a syndrome of distress that develops after exposure to traumatic life experiences. Dysregulation of both the hypothalamic-pituitary-adrenal (HPA) axis and the locus caeruleus/norepinephrine-sympathetic nervous system (LC/NE-SNS) is associated with the pathophysiology of the disorder. Studies have demonstrated a neuroendocrine profile unique to adults with PTSD, with centrally elevated corticotropin-releasing hormone (CRH), low cortisol in the periphery, and elevated catecholamines. Traumatic stress experiences in early life are strong predisposing factors for later PTSD development. In addition, early life stress programs the developing brain to overreact to future stressors. In children and adolescents involved in motor vehicle accidents, we found that high evening salivary cortisol and morning serum interleukin 6 concentrations were predictive of PTSD development 6 months later. We demonstrated a progressive divergence of the HPA and LC/NE-SNS axes of the stress system, which may be part of the pathophysiologic mechanism responsible for PTSD maintenance. An initial elevation of cortisol in the aftermath of the trauma, followed by a gradual normalization and finally low cortisol secretion, together with a gradual elevation of catecholamines over time, may represent the natural history of neuroendocrine changes in pediatric PTSD. Thus, the low cortisol concentrations found in adults with PTSD may reflect prior trauma and might represent a biologic vulnerability factor for later PTSD development.

Practice Parameter for psychodynamic psychotherapy with children

This Practice Parameter describes the principles of psychodynamic psychotherapy with children and is based on clinical consensus and available research evidence. It presents guidelines for the practice of child psychodynamic psychotherapy, including indications and contraindications, the setting, verbal and interactive (play) techniques, work with the parents, and criteria for termination.

Cost-utility analysis of different treatments for post-traumatic stress disorder in sexually abused children

BACKGROUND

Post-traumatic stress disorder (PTSD) is diagnosed in 20% to 53% of sexually abused children and adolescents. Living with PTSD is associated with a loss of health-related quality of life. Based on the best available evidence, the NICE Guideline for PTSD in children and adolescents recommends cognitive behavioural therapy (TF-CBT) over non-directive counselling as a more efficacious treatment.

METHODS

A modelled economic evaluation conducted from the Australian mental health care system perspective estimates incremental costs and Quality Adjusted Life Years (QALYs) of TF-CBT, TF-CBT combined with selective serotonin reuptake inhibitor (SSRI), and non-directive counselling. The "no treatment" alternative is included as a comparator. The first part of the model consists of a decision tree corresponding to 12 month follow-up outcomes observed in clinical trials. The second part consists of a 30 year Markov model representing the slow process of recovery in non-respondents and the untreated population yielding estimates of long-term quality-adjusted survival and costs. Data from the 2007 Australian Mental Health Survey was used to populate the decision analytic model.

RESULTS

In the base-case and sensitivity analyses, incremental cost-effectiveness ratios (ICERs) for all three active treatment alternatives remained less than A$7,000 per QALY gained. The base-case results indicated that non-directive counselling is dominated by TF-CBT and TF-CBT + SSRI, and that efficiency gain can be achieved by allocating more resources toward these therapies. However, this result was sensitive to variation in the clinical effectiveness parameters with non-directive counselling dominating TF-CBT and TF-CBT + SSRI under certain assumptions. The base-case results also suggest that TF-CBT + SSRI is more cost-effective than TF-CBT.

CONCLUSION

Even after accounting for uncertainty in parameter estimates, the results of the modelled economic evaluation demonstrated that all psychotherapy treatments for PTSD in sexually abused children have a favourable ICER relative to no treatment. The results also highlighted the loss of quality of life in children who do not receive any psychotherapy. Results of the base-case analysis suggest that TF-CBT + SSRI is more cost-effective than TF-CBT alone, however, considering the uncertainty associated with prescribing SSRIs to children and adolescents, clinicians and parents may exercise some caution in choosing this treatment alternative.

Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs

This paper reviews the literature on the nature and incidence of child sexual abuse, explores the link between child sexual abuse and later sexual exploitation, and reviews the literature on prevention strategies and effective interventions in child sexual abuse services. Our understanding of the international epidemiology of child sexual abuse is considerably greater than it was just 10 years ago, and studies from around the world are examined. Childhood sexual abuse can involve a wide number of psychological sequelae, including low self-esteem, anxiety, and depression. Numerous studies have noted that child sexual abuse victims are vulnerable to later sexual revictimization, as well as the link between child sexual abuse and later engagement in high-risk sexual behaviour. Survivors of child sexual abuse are more likely to have multiple sex partners, become pregnant as teenagers, and experience sexual assault as adults. Various models which attempt to account for this inter-relationship are presented; most invoke mediating variables such as low self-esteem, drug/alcohol use, PTSD and distorted sexual development. Prevention strategies for child sexual abuse are examined including media campaigns, school-based prevention programmes, and therapy with abusers. The results of a number of meta-analyses are examined. However, researchers have identified significant methodological limitations in the extant research literature that impede the making of recommendations for implementing existing therapeutic programmes unreservedly.

A meta-analysis of the effects of psychotherapy with sexually abused children and adolescents

This paper presents a meta-analysis of the psychotherapy treatment outcome studies for sexually abused children and adolescents. There were 39 studies included, most of which aimed to treat the psychological effects of childhood sexual abuse. Separate meta-analyses were conducted according to study design and outcome domain, in keeping with meta-analytic conventions. However, given heterogeneity across studies and the need for sufficient n in each category for meaningful moderator analyses, the study designs were pooled into a repeated measures meta-analysis. There were large effect sizes for global outcomes (g=1.37) and PTSD/trauma outcomes (g=1.12). More moderate effect sizes were evident for internalizing symptoms (g=0.74), self-appraisal (g=0.63), externalizing symptoms (g=0.52), and sexualized behavior (g=0.49), while small effects were found for measures of coping/functioning (g=0.44), caregiver outcomes (g=0.43), and social skills/competence (g=0.38). Effects were maintained at follow-up more than six months after treatment for some outcome domains but not others. Studies represented diverse treatment approaches, and most treatments were effective in symptom reduction. Presence of probable moderators of treatment outcome varied across symptom domains, reflecting importance of targeting therapy to individual needs.

Treatment manual for trauma-exposed youth: case studies

Witnessing community violence and experiencing abuse in the home are two examples of interpersonal trauma that can have a devastating impact on children and adolescents. Recent research on the treatment of children exposed to interpersonal violence has focused on cognitive-behavioral interventions, often delivered in school settings. We describe the application of a new manual-based psychotherapy protocol for treating pediatric trauma in a middle school. Two case studies illustrate the protocol application to children from an inner-city neighborhood. The Stanford Cue-Centered Therapy (CCT) is a short-term, multimodal therapy for youths who have experienced trauma, focusing primarily on exposure to trauma-related cues. These cases provide early data on the feasibility and effectiveness of providing CCT for high-risk youth within a school setting and training of school mental-health personnel in the use of the Stanford CCT Manual.

Posttraumatische Belastungsstörung

Bei der Posttraumatischen Belastungsstörung handelt es sich um eine vieldiskutierte Diagnose. Aktuell erörtert werden dabei die Unterschiede zwischen den beiden Diagnosesystemen DSM-IV-TR und ICD-10, deren Auswirkungen auf die klinische Praxis und spezifisch die Anwendbarkeit der Diagnosekriterien auf Kinder und Jugendliche. Außerdem werden Vorschläge zur Klassifikation im Bereich chronischer und schwerer Traumatisierung, der aktuelle Stand zur Berücksichtigung entwicklungspsychologischer Aspekte in der Modellbildung sowie Diskrepanzen zwischen Therapieforschung und Praxis dargestellt.

The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review

Children and adolescents in the U.S. and worldwide are commonly exposed to traumatic events, yet practitioners treating these young people to reduce subsequent psychological harm may not be aware of-or use-interventions based on the best available evidence. This systematic review evaluated interventions commonly used to reduce psychological harm among children and adolescents exposed to traumatic events. Guide to Community Preventive Services (Community Guide) criteria were used to assess study design and execution. Meta-analyses were conducted, stratifying by traumatic exposures. Evaluated interventions were conducted in high-income economies, published up to March 2007. Subjects in studies were <or=21 years of age, exposed to individual/mass, intentional/unintentional, or manmade/natural traumatic events. The seven evaluated interventions were individual cognitive-behavioral therapy, group cognitive behavioral therapy, play therapy, art therapy, psychodynamic therapy, and pharmacologic therapy for symptomatic children and adolescents, and psychological debriefing, regardless of symptoms. The main outcome measures were indices of depressive disorders, anxiety and posttraumatic stress disorder, internalizing and externalizing disorders, and suicidal behavior. Strong evidence (according to Community Guide rules) showed that individual and group cognitive-behavioral therapy can decrease psychological harm among symptomatic children and adolescents exposed to trauma. Evidence was insufficient to determine the effectiveness of play therapy, art therapy, pharmacologic therapy, psychodynamic therapy, or psychological debriefing in reducing psychological harm. Personnel treating children and adolescents exposed to traumatic events should use interventions for which evidence of effectiveness is available, such as individual and group cognitive-behavior therapy. Interventions should be adapted for use in diverse populations and settings. Research should be pursued on the effectiveness of interventions for which evidence is currently insufficient.

Post-traumatic stress disorder and its treatment in children and adolescents

This article reviews current concepts of and treatments for post-traumatic stress disorder (PTSD) in children and adolescents. We discuss the DSM-IV-TR diagnostic criteria and their applicability to children and adolescents. We also review the history of PTSD and the development of its diagnostic criteria. We present the concept of complex trauma and trauma's effect on the developing child and describe a new diagnosis labeled developmental trauma disorder that would better describe children and adolescents who have been exposed to abuse and neglect. Finally, we summarize psychotherapeutic and psychopharmacologic approaches to treating PTSD in children and adolescents. More research is needed on the diagnosis and treatment of PTSD in children and adolescents.

An exploratory study of group therapy for sexually abused adolescents and nonoffending guardians

Adolescent survivors of sexual abuse frequently report severe trauma, depression, anxiety, and low self-esteem. While cognitive-behavioral group interventions show promise, interpreting efficacy is problematic due to commonly high attrition. This article reports promising exploratory study findings relating to a 12-week multimodal abuse-specific group intervention with a nonoffending parent/caregiver component. Participants (aged 11 16 years) consisted of six adolescents with severe abuse histories, and their caregivers. Participants completed pre-, post-, and 1-month follow-up measures. The results were consistent with the possibility that the program produced clinically meaningful reductions in abuse-related psychological sequelae, the program had excellent face validity with participants, and there were no dropouts.

A meta-analytic investigation of therapy modality outcomes for sexually abused children and adolescents: an exploratory study

OBJECTIVE

The purpose of the current study was to investigate the independent effects of different treatment elements on a number of secondary problems related to childhood and adolescent sexual abuse, as well as investigate a number of different moderators of treatment effectiveness.

METHOD

Twenty-eight studies that provided treatment outcome results for children and adolescents who had been sexually abused were included in the meta-analysis. Different aspects of psychological treatment, such as specific treatment modalities (individual, cognitive-behavioral, etc.) or secondary problems (behavior problems, psychological distress, etc.) were investigated.

RESULTS

The overall mean weighted effect size for the meta-analysis was d=.72 (SE=.02). The results indicate that psychological treatment after childhood or adolescent sexual abuse tended to result in better outcomes than no treatment. There was significant heterogeneity in the effectiveness of the various psychological treatment elements. Play therapy seemed to be the most effective treatment for social functioning, whereas cognitive-behavioral, abuse-specific, and supportive therapy in either group or individual formats was most effective for behavior problems. Cognitive-behavioral, family, and individual therapy seemed to be the most effective for psychological distress, and abuse-specific, cognitive-behavioral, and group therapy appeared to be the most effective for low self-concept.

CONCLUSIONS

The choice of therapy modality should depend on the child's main presenting secondary problem. Further research should be conducted investigating other possible moderators and secondary problem outcomes.

Do all children need intervention after exposure to tsunami?

Children are uniquely vulnerable in the context of a major natural disaster like tsunami. Post disaster intervention studies in children are few, especially from developing countries like India. An intervention programme for children was developed and conducted at Srinivasapuram, a coastal hamlet in Chennai, a year after tsunami. Sixty-five children who participated in all the six intervention modules were compared to 70 children who did not participate in the intervention. All the children were assessed before and after intervention using the Youth Self Report (YSR) form of Child Behaviour Check List (CBCL) in addition to PTSD symptoms. Children in the two groups were comparable in socio-demographic factors and exposure to tsunami. Prevalence of family psychopathology was more in the intervention group. Only hyperactivity problems were significantly reduced after intervention (z = 2.41 p = 0.016). Children in the intervention group appreciated expression of positive emotions (F = 8.044 p = 0.005) and were also more likely to desist from smoking (F = 6.102 p = 0.003) compared to the control group. The majority of the children are likely to be resilient and only children with pre-existing vulnerability require specific and specialized interventions.

Psychosocial treatment of pediatric posttraumatic stress disorder: the neglected field of single-incident trauma

Despite the prevalence of childhood trauma, studies regarding psychotherapy for children suffering from posttraumatic stress disorder (PTSD) are scarce, especially regarding the treatment for pediatric PTSD following single-incident trauma. Treatment practices for this population rely mainly on the paradigms of therapy for adult PTSD and pediatric PTSD following sexual abuse. This review outlines the studies published in the last 10 years pertaining to the treatment of pediatric PTSD following single-incident trauma. This is done in the context of available literature on the paradigms mentioned above. Of 742 articles dealing with treatment of pediatric trauma, 10 were found relevant to the treatment of pediatric PTSD following single-incident trauma. The modalities of treatment most frequently reported in this context were cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and play therapy. As a whole, CBT studies were methodologically more rigorous, used manualized, reproducible treatment, and were group, school-based therapies. EMDR treatments were usually short and individual. Most studies showed statistically significant improvement but were still methodologically lacking. We conclude that research on the subject of treatment for pediatric PTSD following single-incident trauma constitutes a neglected part of the study of pediatric PTSD. This stands in contrast to the obvious prevalence of this type of trauma. We encourage future research that will address issues such as clarifying the role of pharmacotherapy, comparing different modes of treatment, dismantling treatment "packages," researching developmentally sensitive treatments, conducting long-term follow-up, and comparing different PTSD populations.

Psychological interventions for post-traumatic reactions in children and young people: a review of randomised controlled trials

Children exposed to a wide range of traumatic events suffer significant post-traumatic reactions. Randomised controlled trials assessing the effectiveness of interventions with traumatised children are described, the limitations of the current literature base identified and issues regarding the applicability of these findings and interventions to everyday clinical practice discussed. Methodological issues, variations in interventions, parental involvement, theoretical underpinning and outcomes will be discussed and implications for future studies highlighted.