|Practitioner Review: the Assessment and Treatment of Post-traumatic Stress Disorder (PTSD) in Children and Adolescents|
Perrin, S, Smith, P, Yule, W,
Reviewed by Dr. Jane Barlow,
No details are provided in the paper about the search strategy and it seems likely that this paper is an overview of the literature as opposed to a systematic review.
Significant studies may have been missed from this overview.
None of the primary studies in the review were critically appraised. However, the author clearly distinguishes between rigorous controlled, less rigorous uncontrolled, and single case studies. The results of single case studies have not been included in this summary and further information can be obtained from the original paper.
Five controlled studies have been conducted to evaluate the effectiveness of cognitive behavioural therapy (CBT) in children diagnosed with post traumatic stress disorder (PTSD) (Cohen and Mannarino, 1998; 1996; Coenian et al, 1997; Berliner and Saunders, 1996; Deblinger, Lippman and Steer, 1996). Two further non-controlled studies have been conducted to evaluate the effectiveness of CBT in the treatment of PTSD (March, Amaya-Jackson, Murray and Schulte 1998; Deblinger, McLeer, and Henry, 1990). Two controlled studies evaluated the effectiveness of non-exposure based psychosocial treatments such as family and psychodynamic therapy (Scarvalone, Cloitre and Difede, 1995; Brom, Kleber and Defres, 1989).
Two non-randomised studies (Galante and Foa, 1986; Yule, 1992) and one uncontrolled study (Foa and Meadows, 1997) have been conducted to evaluate the effectiveness of structured group therapy and crisis intervention (debriefing). Four studies (design unspecified) have provided preliminary data concerning the effectiveness of adrenergic blocking agents in the treatment of PTSD in children (Pynoos and Nader, 1993; Harmon and Riggs, 1996; Kinzie and Leung, 1989; Famularo, Kinscherff and Fenton, 1988).
Cognitive Behavioural Therapy
Five controlled studies have been conducted to evaluate the effectiveness of cognitive behavioural therapy in children diagnosed as having PTSD (Berliner and Saunders, 1996; Deblinger, Lippman and Steer, 1996; Cohen and Mannarino, 1996; 1998; Coenian et al, 1997).
Berliner and Saunders compared the effectiveness of a traditional treatment group which addressed abuse issues through the use of discussion, activities, games and role-play with a treatment group using the same techniques plus relaxation, cognitive restructuring and graduated exposure in the treatment of 80 sexually abused children. The results show marked improvements in both parent and child functioning, with no significant differences between the two groups. It is concluded that the addition of cognitive-behavioural interventions did not improve the effectiveness of the more traditional group therapy.
Diblinger et al (1996) compared the effectiveness of a community treatment control with one of three trauma-focused CBT conditions in the treatment of 100 sexually abused children – individual treatment, treatment with the parent and treatment through the parent alone. The two CBT treatments involving the child were found to be superior to all other treatments in reducing PTSD symptoms. The CBT condition involving both parent and child also produced significantly more improvement in externalising and depressive symptoms.
Cohen and Mannarino (1996) compared the effectiveness of a trauma-focused CBT intervention for the child and parent together with a nondirective supportive therapy condition involving the child only, in the treatment of 86 sexually abused preschoolers. The results show that the CBT was markedly superior to the nondirective therapy, and that the gains were maintained at 6- and 12-month follow-up. These findings were replicated in a subsequent trial with 49 children aged 7 – 14 years.
Goenjiaan et al (1997) compared the effectiveness of CBT to no treatment for traumatised children following an earthquake in Armenia. Children in two of four schools near the earthquake epicenter were provided with a school-based intervention involving group discussion about the trauma, relaxation and desensitization, grief work, and normalisation of responses. Children in the remaining two schools received no treatment. The results show that the treated children had better outcomes on self-report measures of PTSD and distress, than the non-treated children.
Two further non-controlled studies have been conducted to evaluate the effectiveness of CBT in the treatment of PTSD (March, Amaya-Jackson, Murray and Schulte 1998; Deblinger, McLeer, and Henry, 1990), and produced similar findings.
March et al, (1998) compared the efficacy of an 18-week, group-administered CBT package for PTSD in 14 older children and adolescents who had suffered a single traumatic incident. Post-intervention, 57% of subjects were free of PTSD symptoms and 86% was recovered at 6-month follow-up.
Deblinger et al, (1990) compared a 12-session CBT programme comprising coping skills training, gradual exposure and educative/preventive work for 19 sexually abused children. The results show improvement in every major category of PTSD symptoms, with no children still meeting diagnostic criteria post-intervention.
Other Psychosocial Treatments
Non-exposure based psychosocial treatments such as family and psychodynamic therapy have been evaluated in two controlled studies (Brom, Kleber and Defres, 1989; Scarvalone, Cloitre and Difede, 1995). Brom et al (1989) compared brief psychodynamic, hypnotherapy and trauma desensitation in the treatment of 112 adults with PTSD. The results show that the three treatment conditions were equally effective and superior to the wait-list control group in reducing trauma-related intrusion and avoidance.
Scarvalone et al (1995) compared an interpersonal process therapy group with a wait-list control group in the treatment of 43 sexually abused children. The results show greater improvement in the treatment group compared with the control group.
Structured group therapy and crisis intervention (debriefing) have been evaluated in two non-randomised studies (Galante and Foa, 1986; Yule, 1992) and one uncontrolled study (Foa and Meadows, 1997). Galente and Foa (1986) compared the effectiveness of structured group therapy with no-treatment controls in a sample of children exposed to an earthquake. The results showed that the group therapy produced significant improvements in teacher-rated behaviour compared with the control group. Yule (1992) compared the effectiveness of group debriefing meetings with a no-treatment control group in the treatment of children exposed to a shipping accident. The results show that the treatment children fared better on a range of measures of outcome. Foa and Meadows (1997) in an uncontrolled evaluation of crisis debriefing showed significant improvements on standardised self-report measures in a group of children involved in a road traffic accident.
Eye movement desensitisation and reprocessing (EMDR) employs saccadic eye movements during imaginal exposure to the traumatic event. This intervention has only been evaluated in uncontrolled case studies. [These have not been summarised here due to the unreliability of the study design. For further details, see the reference at the top of this abstract].
Many PTSD symptoms are thought to arise as a result of excessive activity of the central adrenergic system. Adrenergic blocking agents such as propanolol and Clonidine are therefore used in its treatment.
Four studies have provided preliminary data concerning the effectiveness of adrenergic blocking agents in the treatment of PTSD in children (Kinzie and Leung, 1989; Pynoos and Nader, 1993; Harmon and Riggs, 1996; Famularo, Kinscherff and Fenton, 1988). One study has shown that Clonidine significantly reduced symptoms of avoidance, startle responses and trauma-related depression in children children (Kinzie and Leung, 1989), and two further studies provide preliminary data suggesting that Clonidine may reduce persistent arousal in traumatised children Pynoos and Nader, 1993; Harmon and Riggs, 1996). A fourth study showed that Propanolol relieved arousal symptoms of children exposed to sexual assault (Famularo, Kinscherff and Fenton, 1988).
Overall, however, the above evidence was not obtained as part of placebo controlled studies, and there is currently limited empirical support for the pharmacological treatment of PTSD in children.
Implications for social work
There is preliminary evidence to support the use of cognitive-behavioural therapy in individual, parent and child, or group format, in the treatment of PTSD in children.
Effective treatments should include both the parents and child, psychoeducation about the nature of the disorder, exposure work, and restructuring of dysfunctional cognitions arising from the trauma.
There is limited evidence available to support the use of pharmacological agents, and further investigation is also needed into the use of EMDR, debriefing, psychodynamic and family interventions.
Implications for social policyCBT in the form of prolonged therapeutic exposure and cognitive restructuring should be available for children who have experienced trauma and for whom there is evidence of a diagnosis of PTSD.