Violence Prevention: Individual 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 11 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.

• CBT is often administered by doctoral-level professionals or other clinicians with graduate degrees, such as social workers.
• CBT for traumatized children combines the following:
  • Exposure techniques such as review of the past traumatic event
  • Learning of stress management/relaxation techniques
  • Correction of inaccurately remembered events
  • Reframing counterproductive perceptions of the trauma

Detailed results from the systematic review are available in the CPSTF finding.

Eleven studies qualified for the systematic review.

• The summary effect measures indicated that the CBT intervention group had a higher reduction in the rate of psychological harm than the comparison group.
• Although summary effects were of similar magnitude for all of the outcomes assessed, those for PTSD and anxiety were statistically significant, whereas those for internalizing behavior, externalizing behavior, and depression were not (primarily due to differences in the number of studies reporting each outcome).
• The reviewed studies assessed the effects of individual CBT on traumatized children and adolescents of varying ages, geographic locations, and for varied traumas, such as physical abuse and sexual abuse. Studies excluded children who were too disruptive or seriously suicidal.

Detailed results from the systematic review are available in the CPSTF finding.

• 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 seriously suicidal, the applicability to this subgroup is unknown.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help 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.

Furthermore, the finding of insufficient evidence to determine the effectiveness of several of the interventions reviewed highlights the need for additional well-controlled studies of these interventions. Because CBT has been found to be an effective intervention, and because research funds are limited, it would be useful to adopt CBT as a comparison in future evaluations. Because of harms reported for psychological debriefing among adults, caution should be taken in research on this intervention with children and adolescents.

• The number of individual CBT sessions ranged from 2 to 20.
• Study populations included children and adolescents of varying ages and geographic locations who developed symptoms following traumatic exposures (e.g., physical abuse, sexual abuse).
• Five studies included parents in some of the of treatment sessions.
• Youth in the included studies were predominantly white or black.
• Studies were conducted in the U.S. (9 studies), Australia (1 study), and The Netherlands (1 study).
• Studies excluded children who were too disruptive or seriously suicidal.

Wethington HR, Hahn RA, Fuqua-Whitley DS, et al. The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review. American Journal of Preventive Medicine 2008;35(3):287-313.

Task Force on Community Services. Recommendations to reduce psychological harm from traumatic events among children and adolescents. American Journal of Preventive Medicine 2008;35(3):314-6.

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

No content is available for this section.

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

Barbe RP, Bridge JA, Birmaher B, Kolko DJ, Brent DA. Lifetime history of sexual abuse, clinical presentation, and outcome in a clinical trial for adolescent depression. J Clin Psychiatry 2004;65:77 83.

Celano M, Hazzard A, Webb C, McCall C. Treatment of traumagenic beliefs among sexually abused girls and their mothers: an evaluation study. J Abnorm Child Psych 1996;24:1-17.

Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry 2004;43:393 402.

Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse Negl 2005;29:135 145.

Cohen JA, Mannarino AP. A treatment study for sexually abused preschool children: outcome during a one-year follow-up. J Am Acad Child Adolesc Psychiatry 1997;36: 1228 35.

Deblinger E, Steer RA, Lippmann J. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl 1999;23:1371 8.

King NJ, Tonge BJ, Mullen P, et al. Treating sexually abused children with posttraumatic stress symptoms: a randomized clinical trial. J Am Acad Child Adolesc Psychiatry 2000;39:1347 55.

Kolko DJ. Individual cognitive behavioral treatment and family therapy for physically abused children and their offending parents: a comparison of clinical outcomes. Child Maltreat 1996;1:322-42.

Lange A, van de Ven JP, Schrieken B, Emmelkamp PMG. Interapy, treatment of posttraumatic stress through the Internet: a controlled trial. J Behav Ther Exp Psychiatry 2001;32:73 90.

Lytle RA, Hazlett-Stevens H, Borkovec TD. Efficacy of eye movement desensitization in the treatment of cognitive intrusions related to a past stressful event. J Anxiety Disord 2002;16:273 88.

Scheck MM, Schaeffer JA, Gillette C. Brief psychological intervention with traumatized young women: the efficacy of eye movement desensitization and reprocessing. J Trauma Stress 1998;11:25 44.

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

Economic Review

No content is available for this section.

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.

• The benefits of individual CBT reported in the literature were decreased shame, improved trust, and enhanced emotional strength and parenting ability of the caretaking parent.
  • The effects of CBT on participating parents may be a mediator of effects on children.
• No potential harms of individual CBT were noted.
• Standardized individual CBT requires relatively intensive efforts by providers.
• Specific training is necessary for those delivering this type of therapy.

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