Violence Prevention: Group Cognitive-Behavioral Therapy to Reduce Psychological Harm for Traumatic Events Among Children and Adolescents

The CPSTF finding is based on evidence from a systematic review of 10 studies (search period through March 2007). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

Ten studies qualified for the systematic review.

• Summary-effect measures for the ten studies were in the desired direction for all outcomes assessed anxiety, depression, and PTSD.
• Most children in these studies were exposed to multiple traumas, and group CBT effectively reduced psychological harm among these children.
• Because of the small number of studies, it was difficult to determine whether the effectiveness of group CBT varied by principal trauma.

• An economic review of this intervention did not find any studies specific to this review.
• However, evidence from two studies that evaluated a CBT intervention for children and adolescents with depression (not necessarily related to a traumatic exposure), found CBT had the potential to be cost effective based on commonly used threshold values (Haby et al. 2004; Lynch et al. 2005).

Findings of this review are likely applicable to children and adolescents who have developed symptoms following traumatic exposures (e.g., anxiety, PTSD, depression, and externalizing and internalizing symptoms). Because studies excluded children who were too disruptive or had severe mental health problems, the applicability to this subgroup is unknown.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps from these reviews on reducing psychological harms from traumatic events: Individual CBT; Group CBT; Play Therapy; Art Therapy; Psychodynamic Therapy; Pharmacological Therapy; Psychological Debriefing.

• Identification of robust predictors of transient and enduring symptoms following traumatic events would allow for better screening of exposed children and adolescents and more efficient allocation of treatment resources.
• The optimal timing of cognitive behavioral therapy (CBT) intervention following the exposure and the onset of symptoms is important to assess.
• It would be useful to stratify the outcomes of CBT treatment by the severity of patient PTSD symptoms and history. For example, it would be useful to know whether children and adolescents with multiple traumatic exposures require more intensive or longer treatment.
• One study with long term follow-up indicates that it may take a year after the end of the intervention for benefits to appear. This outcome should be replicated. If confirmed, it suggests that follow-up periods of less than one year are not adequate and may erroneously indicate intervention ineffectiveness.
• The cost effectiveness and differential cost effectiveness of individual and group CBT among children and adolescents should be explored.
• The effectiveness of individual and group CBT among minority populations, especially in communities in which violence is prevalent, should be further explored.
• Adaptations of CBT involving the recruitment, training, deployment, and supervision of nonprofessionals should be evaluated, and their applicability to low-income countries should also be explored.

• The studies reviewed assessed the effects of group CBT on traumatized children and adolescents of varying ages, geographic locations, and traumatic exposures.
• Index trauma varied and included community violence and war, volcanic eruptions, sexual abuse, suicide of a family member, and juvenile cancer and treatment.
• Most children in these studies were exposed to multiple traumas.
• The number of group CBT sessions generally ranges from 8 to 12.
• Some studies excluded children who were too disruptive (per mental health clinician) or had severe mental health problems (e.g., psychotic disorders, severe developmental delays, or behaviors that were dangerous to themselves or others).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of individual CBT; group CBT; play therapy; art therapy; psychodynamic therapy; pharmacological therapy; psychological debriefing

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Ahrens J, Rexford L. Cognitive processing therapy for incarcerated adolescents with PTSD.Journal of Aggression, Maltreatment & Trauma 2002;6:201 16.

Berliner L, Saunders BE. Treating fear and anxiety in a sexually abused children: results of a controlled 2-year follow-up study. Child Maltreat 1996;1:294 309.

Deblinger E, Stauffer LB, Steer R. Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreat 2001;6:332 43.

Ehntholt KA, Smith PA, Yule W. School-based cognitive-behavioural therapy group intervention for refugee children who have experienced war-related trauma. Clin Child Psychol Psychiatry 2005;10:235 50.

Goenjian AK, Karayan I, Pynoos RS, et al. Outcome of psychotherapy among early adolescents after trauma, Am J Psychiatry 1997;154:536 42.

Goenjian AK, Walling D, Steinberg AM, Karayan I, Najarian LM, Pynoos RS. A prospective study of posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after a catastrphic disaster. Am J Psychiatry 2005;162:2302 8.

Kataoka SH, Stein BD, Jaycox LH, et al. A school-based mental health program for traumatized Latino immigrant children. J Am Acad Child Adolesc Psychiatry 2003;42: 311 8.

Kazak AE, Alderfer MA, Streisand R, et al. Treatment of posttraumatic stress symptoms in adolescent survivors of childhood cancer and their families: a randomized clinical trial. J Fam Psychol 2004;18:493 504.

Pfeffer CR, Jiang H, Kakuma T, Hwang J, Metsch M. Group intervention for children bereaved by the suicide of a relative. J Am Acad Child Adolesc Psychiatry 2002;41: 505 13.

Ronan KR, Johnston DM. Behaviourally-based interventions for children following volcanic eruptions: an evaluation of effectiveness, Disaster Prevention and Management 1999;8:169 76.

Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA 2003;290: 603 11.

The following outlines the search strategy used for these reviews on reducing psychological harms from traumatic events: Individual CBT; Group CBT; Play Therapy; Art Therapy; Psychodynamic Therapy; Pharmacological Therapy; Psychological Debriefing.

Effectiveness Review

Electronic searches for literature were conducted in the MEDLINE; EMBASE; ERIC; NTIS (National Technical Information Service); PsycINFO; Social Sciences Abstracts; and NCJRS (National Criminal Justice Reference Service) databases for all dates up to March 2007. Search terms included the generic and specific terms for treatments, different forms of trauma, and terms such as evaluate, effective, and outcome. Also reviewed were the references listed in all retrieved articles; researchers also consulted with experts on the systematic review development team and elsewhere for additional studies. Studies published as journal articles, government reports, books, and book chapters were considered.

1. (THERAPY OR THERAPIES OR COUNSELING OR DEBRIEFING OR (CRITICAL()INCIDENT(2W)MANAGEMENT) OR SCREENING OR INTERVENTION? OR CISD OR CISM)/TI,AB
2. (CHILD? OR TODDLER? OR YOUTH? OR ADOLESCENT? OR INFANT? OR BABY OR BABIES OR PEDIATRIC? OR TEEN OR TEENS OR TEENAGER?)/TI,AB
3. (VIOLENCE OR VIOLENT OR DISASTER? OR FIRE OR CHILD()ABUSE? OR SEXUAL()ABUSE? OR RAPE OR WAR OR TRAUMA? OR TERRORIST OR TERRORISM OR CRISES OR CRISIS OR PTSD OR POST()TRAUMATIC OR POSTTRAUMATIC OR POST-TRAUMATIC OR DROWNING OR BOMBING …
4. (EVALUAT? OR EFFICACY OR EFFECTIVE? OR ASSESSMENT? OR OUTCOME?)/TI,AB
5. S1(20N)S2
6. S1(20N)S3
7. S1(20N)S4
8. S5 AND S6 AND S7
9. (ADULT? OR BLOOD OR XRAY? OR X-RAY? OR BRAIN()INJUR? OR PERSONNEL OR MANPOWER OR CRANIOCEREBRAL OR HEAD()TRAUMA OR ASTHMA OR BRONCHODILATOR OR KIDNEY? OR LUNG? OR CRIMINOLOGY OR COUPLE?()THERAPY OR CHILD()ABUSE()PREVENTION)/DE
10. 10 S8 NOT S9
11. (ADULT? OR BLOOD OR XRAY? OR X-RAY? OR BRAIN()INJUR? OR PERSONNEL OR MANPOWER OR CRANIOCEREBRAL OR HEAD()TRAUMA OR ASTHMA OR BRONCHODILATOR OR KIDNEY? OR LUNG? OR CRIMINOLOGY OR COUPLE?()THERAPY OR CHILD()ABUSE()PREVENTION OR SURGER? …
12. S8 NOT S11
13. (RISK? OR SCREEN?)/TI
14. S12 NOT S13
15. RD (unique items)
16. (ADULT? OR WOMAN OR WOMEN)/TI
17. S15 NOT S16
18. (CHILD? OR TODDLER? OR YOUTH? OR ADOLESCENT? OR INFANT? OR BABY OR BABIES OR PEDIATRIC? OR TEEN OR TEENS OR TEENAGER?)/TI
19. S17 AND S18
20. (VIOLENCE OR VIOLENT OR DISASTER? OR FIRE OR CHILD()ABUSE? OR SEXUAL()ABUSE? OR RAPE OR WAR OR TRAUMA? OR TERRORIST OR TERRORISM OR CRISES OR CRISIS OR PTSD OR POST()TRAUMATIC OR POSTTRAUMATIC OR POST-TRAUMATIC OR DROWNING OR BOMBING …
21. S19 AND S20

Haby M, Tonge B, Littlefield L, Carter R, Vos T. Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents. Aust NZ J Psychiatry 2004;38:579 91.

Lynch F, Hornbrook M, Clarke G, et al. Cost-effectiveness of an intervention to prevent depression in at-risk teens. Arch Gen Psychiatry 2005; 62:1241 8.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Other benefits of group CBT include preventing academic decline and improving parent child relationships.
• Parents were participants in many of the programs included in this review; some studies indicated psychological benefits to the parents themselves, and parental participation may be a mediator of effects on children.
• Standardized group CBT requires relatively intensive efforts by providers.
• Specific training is necessary on the part of those delivering this type of therapy.
• Making it possible for a group of children to attend each session may pose scheduling challenges. The administration of group CBT in schools provides one potential solution to this challenge.
• Vicarious traumatization (i.e., traumatization by exposure to reports of the traumatic events experienced by others and shared in the group setting) has been cited as a potential harm of group CBT, but no reviewed study assessed or reported evidence of such an occurrence. This potential harm may be avoided by having group CBT participants recount their traumatic experiences with a therapist outside of the group setting.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of children and adolescents with symptoms of trauma who get treatment — AH-D02
• Increase the number of children and adolescents with symptoms of trauma who get treatment — MHMD-D01