Gillies, D., Maiocchi, L., Bhandari, A. P., Taylor, F., Gray, C., O'Brien, L.

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 support ve 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. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Cochrane Database of Systematic Reviews, 2016(10) : CD012371

Barron, I., Abdallah, G., Heltne, U.

Randomized control trial of Teaching Recovery Techniques in rural occupied Palestine: Effect on adolescent dissociation

This study assessed the effect of a cognitive behavioral group intervention, Teaching Recovery Techniques (TRT), for adolescents with high levels of posttraumatic stress (n = 154), from villages in occupied Palestine. A randomized control trial involved standardized measures to assess war stressors, posttraumatic stress, depression, and dissociation. Program fidelity was measured by presenter and observer ratings and program delivery cost was calculated per adolescent. High levels of traumatic exposure, dissociation, and posttraumatic stress were found. In comparison to a wait list group (n = 75), TRT adolescents reported significantly fewer posttraumatic stress symptoms postintervention. Depression and dissociation remained stable for TRT adolescents, but worsened for those on the wait list. Given the high returns and low costs, this cost-benefit analysis makes a clear case for TRT to be delivered throughout the West Bank. Longitudinal evaluation is needed to assess adolescent traumatization and the impact of TRT within a context of ongoing violence. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Journal of Aggression, Maltreatment & Trauma, 25(9) : 955- 973

Fayyad, J. A.

Resilience-building for children exposed to war trauma: A controlled classroom-based intervention [conference abstract]

Objectives: The goal of this study is to build resilience among children exposed to war trauma and childhood adversities using a controlled classroom- based, teacher-mediated intervention. There is a need to collect evidence for universal interventions in developing countries where children experience war and trauma to reach the largest number of students possible. Methods: Students (N= 2,031), their mothers, and teachers (N= 42) from 17 schools completed pre- and postintervention questionnaires on war exposure, home stressors, coping strategies, depression, anxiety, posttraumatic stress, and externalizing symptoms. Teachers delivered a manual-based, classroom-based intervention over 13 weekly sessions using cognitive behavioral and mind-body techniques to students in grades 3-7. Sessions were tape-recorded and reviewed by supervisors to rate for quality and adherence to intervention procedures. Results: Clear differences emerged in classroom atmosphere among intervention students compared with control subjects. Pre-postclinically and statistically significant differences in teacher-rated ADHD and impulsivity scores were noted, and these were substantiated by nonintervention teachers as well. In logistic mixed models, depression improved in intervention students compared with control subjects [effect size (ES)= 0.51, P= 0.003], in addition to self-confidence scores in the universal sample group (ES= 0.48, P= 0.043), cognitive distraction scores among war-exposed children (ES= 0.51, P= 0.002), and anxiety scores among war-exposed children (ES 0.24, P= 0.05). Results remained significant after Bonferroni corrections. Conclusions: Meaningful changes took place in internalizing and externalizing symptoms, as well as in personal competencies based on self-confidence and cognitive distraction measures using a universal classroom-based intervention targeting war- exposed children. Dissemination and replication of such models are needed.

Journal of the American Academy of Child and Adolescent Psychiatry, 55(10 (Suppl 1)) : S11

Cohen, J. A., Mannarino, A. P., Jankowski, K., Rosenberg, S., Kodya, S., Wolford-II, G. L.

A randomized implementation study of trauma-focused cognitive behavioral therapy for adjudicated teens in residential treatment facilities

Adjudicated youth in residential treatment facilities (RTFs) have high rates of trauma exposure and post-traumatic stress disorder (PTSD). This study evaluated strategies for implementing trauma-focused cognitive behavioral therapy (TF-CBT) in RTF. Therapists (N = 129) treating adjudicated youth were randomized by RTF program (N = 18) to receive one of the two TF-CBT implementation strategies: (1) web-based TF-CBT training + consultation (W) or (2) W + 2 day live TF-CBT workshop + twice monthly phone consultation (W + L). Youth trauma screening and PTSD symptoms were assessed via online dashboard data entry using the University of California at Los Angeles PTSD Reaction Index. Youth depressive symptoms were assessed with the Mood and Feelings Questionnaire-Short Version. Outcomes were therapist screening; TF-CBT engagement, completion, and fidelity; and youth improvement in PTSD and depressive symptoms. The W + L condition resulted in significantly more therapists conducting trauma screening (p = .0005), completing treatment (p = .03), and completing TF-CBT with fidelity (p = .001) than the W condition. Therapist licensure significantly impacted several outcomes. Adjudicated RTF youth receiving TF-CBT across conditions experienced statistically and clinically significant improvement in PTSD (p = .001) and depressive (p = .018) symptoms. W + L is generally superior to W for implementing TF-CBT in RTF. TF-CBT is effective for improving trauma-related symptoms in adjudicated RTF youth. Implementation barriers are discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Child Maltreatment, 21(2) : 156-167

Wald, I., Fruchter, E., Ginat, K., Stolin, E., Dagan, D., Bliese, P. D., Quartana, P. J., Sipos, M. L., Pine, D. S., Bar-Haim, Y.

Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial

BACKGROUND: Efficacy of pre-trauma prevention for post-traumatic stress disorder (PTSD) has not yet been established in a randomized controlled trial. Attention bias modification training (ABMT), a computerized intervention, is thought to mitigate stress-related symptoms by targeting disruptions in threat monitoring. We examined the efficacy of ABMT delivered before combat in mitigating risk for PTSD following combat. METHOD: We conducted a double-blind, four-arm randomized controlled trial of 719 infantry soldiers to compare the efficacy of eight sessions of ABMT (n = 179), four sessions of ABMT (n = 184), four sessions of attention control training (ACT; n = 180), or no-training control (n = 176). Outcome symptoms were measured at baseline, 6-month follow-up, 10 days following combat exposure, and 4 months following combat. Primary outcome was PTSD prevalence 4 months post-combat determined in a clinical interview using the Clinician-Administered PTSD Scale. Secondary outcomes were self-reported PTSD and depression symptoms, collected at all four assessments. RESULTS: PTSD prevalence 4 months post-combat was 7.8% in the no-training control group, 6.7% with eight-session ABMT, 2.6% with four-session ABMT, and 5% with ACT. Four sessions of ABMT reduced risk for PTSD relative to the no- training condition (odds ratio 3.13, 95% confidence interval 1.01-9.22, p < 0.05, number needed to treat = 19.2). No other between-group differences were found. The results were consistent across a variety of analytic techniques and data imputation approaches. CONCLUSIONS: Four sessions of ABMT, delivered prior to combat deployment, mitigated PTSD risk following combat exposure. Given its low cost and high scalability potential, and observed number needed to treat, research into larger-scale applications is warranted. The ClinicalTrials.gov identifier is NCT01723215.

Psychological Medicine, 46(12) : 2627- 2636

Rossouw, J., Yadin, E., Mbanga, I., Jacobs, T., Rossouw, W., Alexander, D., Seedat, S.

Prolonged exposure treatment for PTSD in a Third-World, taskshifting, community-based environment (conference abstract)

Background. Empirical support for cognitive behaviour therapy (CBT) treatment of adults is now quite robust. Despite the high rate of trauma exposure and PTSD in children and adolescents the literature contains surprisingly few outcome studies. The available paediatric and adolescent randomised control trial (RCT) studies will be reviewed. South Africa (SA) is a country with high rates of trauma exposure. In a study conducted in SA and Kenya, 14.5% of students met criteria for PTSD within SA. Given the extremely limited access to public health psychological services, it is crucial to address the gap between need and availability of psychological interventions by making them more readily available to a broader population. In the first step towards that goal, a pilot RCT study was initiated with registered nurses trained to provide adolescents with either Prolonged Exposure for Adolescents (PE-A) PTSD treatment or Supportive Counselling (SC). Pilot data from our adolescent study will be presented. Objectives. To compare the effectiveness of two treatments, PE-A and SC, in reducing PTSD symptom severity over 10 - 14 weeks of treatment, as administered by counsellors; to assess maintenance of PE-A treatment gains on PTSD symptom severity by conducting follow-up assessments at 12-month follow-up. Method. The pilot study in 11 adolescents with PTSD utilised a singleblind, randomised, permuted block design. Recruitment of participants and administration of the interventions were undertaken within school settings. Primary outcome measures were the Child PTSD Symptom Scale - Self Report (CPSS) and the Beck Depression Inventory (BDI). Results. Data were analysed as intent-to-treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvements, as determined on the CPSS and the BDI. At the 12-month post-treatment assessment, there was a significant group difference in the maintenance of effects, with the PE-A group retaining post-treatment PTSD and depression scores indicative of subclinical symptoms (p<0.05). Conclusion. Our results indicate that either intervention, administered by registered nurses who are trained in their delivery, can lead to significant improvements in PTSD and depression symptoms immediately post-treatment. However, only adolescents in the PE-A group maintained treatment gains at 12-month follow-up. These preliminary findings and the challenges and opportunities encountered with the training and delivery of trauma- focused interventions in Third-World community-based settings will be discussed.

South African Journal of Psychiatry, 21 (3) : 127

Nguyen-Feng, V. N., Frazier, P. A., Greer, C. S., Howard, K. G., Paulsen, J. A., Meredith, L., Kim, S.

A randomized controlled trial of a web-based intervention to reduce distress among students with a history of interpersonal violence

Psychology of Violence, 5(4) : 444

Culver, K. A., Whetten, K., Boyd, D. L., O'Donnell, K.

Yoga to Reduce Trauma-Related Distress and Emotional and Behavioral Difficulties among Children Living in Orphanages in Haiti: A Pilot Study

Objectives: To measure trauma-related distress and evaluate the feasibility, acceptability, and preliminary efficacy of an 8-week yoga intervention (YI) in reducing trauma-related symptoms and emotional and behavioral difficulties (EBD) among children living in orphanages in Haiti. Design: Case comparison with random assignment to YI or aerobic dance control (DC) plus a nonrandomized wait-list control (WLC) group. Setting: Two orphanages for children in Haiti. Participants: 76 children age 7 to 17 years. Intervention: The YI included yoga postures, breathing exercises, and meditation. The DC group learned a series of dance routines. The WLC group received services as usual in the institutional setting. After completion of data collection, the WLC group received both yoga and dance classes for 8 weeks. Outcome measures: The UCLA PTSD Reaction Index and the Strengths and Difficulties Questionnaire were used to indicate trauma-related symptoms and EBD, respectively. A within-subject analysis was conducted to compare pre-and post-Treatment scores. A post- Treatment yoga experience questionnaire evaluated acceptability of the YI. Results: Analyses of variance revealed a significant effect (F[2,28]=3.30; p=0.05) of the YI on the trauma-related symptom scores. Regression analyses showed that participation in either 8 weeks of yoga or dance classes suggested a reduction in trauma-related symptoms and EBD, although this finding was not statistically significant (p>0.05). Respondents reported satisfaction with the yoga program and improved well-being. Conclusions: Children with trauma-related distress showed improvements in symptoms after participation in an 8-week yoga program compared to controls. Yoga is a feasible and acceptable activity with self-reported benefits to child mental and physical health. Additional research is needed to further evaluate the effect of yoga to relieve trauma-related distress and promote well-being among children.

Journal of Alternative & Complementary Medicine, 21(9) : 539-545

Diab, M., Peltonen, K., Qouta, S. R., Palosaari, E., Punamaki, R-L.

Effectiveness of psychosocial intervention enhancing resilience among war-affected children and the moderating role of family factors

The study examines, first, the effectiveness of a psychosocial intervention based on Teaching Recovery Techniques (TRT) to increase resiliency among Palestinian children, exposed to a major trauma of war. Second, it analyses the role of family factors (maternal attachment and family atmosphere) as moderating the intervention impacts on resilience. School classes in Gaza were randomized into intervention (N = 242) and control (N = 240) groups. The percentage of girls (49.4%) and boys (50.6%) were equal, and the child age was 10-13 years in both groups. Children reported positive indicators of their mental health (prosocial behaviour and psychosocial well-being) at baseline (T1), post-intervention (T2) and at a six-month follow-up (T3). At T1 they accounted their exposure to war trauma. Mothers reported about their willingness to serve as an attachment figure, and the child reported about the family atmosphere. Resilience was conceptualized as a presence of positive indications of mental health despite trauma exposure. Against our hypothesis, the intervention did not increase the level of resilience statistically significantly, nor was the effect of the intervention moderated by maternal attachment responses or family atmosphere. (PsycINFO Database Record (c) 2015 APA, all rights reserved) (journal abstract).

Child Abuse & Neglect, 40 : 24-35

Diehle, J., Opmeer, B.C., Boer, F., Mannarino, A. P., Lindauer, R. J.

Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: What works in children with posttraumatic stress symptoms? A randomized controlled trial

To prevent adverse long-term effects, children who suffer from posttraumatic stress symptoms (PTSS) need treatment. Trauma-focused cognitive behavioral therapy (TF-CBT) is an established treatment for children with PTSS. However, alternatives are important for non-responders or if TF-CBT trained therapists are unavailable. Eye movement desensitization and reprocessing (EMDR) is a promising treatment for which sound comparative evidence is lacking. The current randomized controlled trial investigates the effectiveness and efficiency of both treatments. Forty-eight children (8-18 years) were randomly assigned to eight sessions of TF-CBT or EMDR. The primary outcome was PTSS as measured with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). Secondary outcomes included parental report of child PTSD diagnosis status and questionnaires on comorbid problems. The Children's Revised Impact of Event Scale was administered during the course of treatment. TF-CBT and EMDR showed large reductions from pre- to post-treatment on the CAPS-CA (-20.2; 95 % CI -12.2 to -28.1 and -20.9; 95 % CI -32.7 to -9.1). The difference in reduction was small and not statistically significant (mean difference of 0.69, 95 % CI -13.4 to 14.8). Treatment duration was not significantly shorter for EMDR (p = 0.09). Mixed model analysis of monitored PTSS during treatment showed a significant effect for time (p < 0.001) but not for treatment (p = 0.44) or the interaction of time by treatment (p = 0.74). Parents of children treated with TF-CBT reported a significant reduction of comorbid depressive and hyperactive symptoms. TF-CBT and EMDR are effective and efficient in reducing PTSS in children. (PsycINFO Database Record (c) 2015 APA, all rights reserved) (journal abstract).

European Child & Adolescent Psychiatry, 24(2) : 227- 236

Allan, N. P., Short, N. A., Albanese, B. J., Keough, M. E., Schmidt, N. B.

Direct and Mediating Effects of an Anxiety Sensitivity Intervention on Posttraumatic Stress Disorder Symptoms in Trauma-Exposed Individuals

Anxiety sensitivity (AS), or fear of anxious arousal, is a higher-order cognitive risk-factor for posttraumatic stress disorder (PTSD) composed of lower-order physical, cognitive, and social concerns regarding anxiety symptoms. Brief and effective interventions have been developed targeting AS and its constituent components. However, there is limited evidence as to whether an intervention aimed at targeting AS would result in reductions in PTS symptoms and whether the effects on PTS symptoms would be mediated by reductions in AS. Furthermore, there is no evidence whether these mediation effects would be because of the global or more specific components of AS. The direct and indirect effects of an AS intervention on PTS symptoms were examined in a sample of 82 trauma-exposed individuals (M age = 18.84 years, SD = 1.50) selected based on elevated AS levels (i.e., 1 SD above the mean) and assigned to either a treatment (n = 40) or an active control (n = 42) condition. Results indicated that the intervention led to reductions in Month 1 PTS symptoms, controlling for baseline PTS symptoms. Furthermore, this effect was mediated by changes in global AS and AS social concerns, occurring from intervention to Week 1. These findings provide an initial support for an AS intervention in amelioration of PTS symptoms and demonstrate that it is primarily reductions in the higher-order component of AS contributing to PTS symptom reduction.

Cognitive Behaviour Therapy, 44(6) : 512- 524

Boals, A., Murrell, A. R., Berntsen, D., Southard-Dobbs, S., Agtarap, S.

Experimentally reducing event centrality using a modified expressive writing intervention

Event centrality, the extent to which one perceives a stressful or traumatic event as central to one's identity, has been shown to be one of the predictors of PTSD symptoms. Boals and Murrell (in press) found that an Acceptance and Commitment Therapy (ACT)-based, therapist-led treatment resulted in significant decreases in event centrality, which in turn led to decreases in PTSD symptoms. In the current study, a version of this treatment was administered using a modified expressive writing intervention. Participants were randomly assigned to learn core components about either ACT, cognitive-behavioral therapy (CBT), or baseball (control) via audio analogs. The ACT and CBT groups then attempted to apply what they learned in two subsequent expressive writing sessions, while the baseball group wrote about a neutral topic. The results revealed that participants in the ACT and CBT conditions evidenced significant decreases in event centrality, if they followed the writing instructions correctly, in comparison to the control group. However, there were no group differences in changes in PTSD symptoms. These results suggest that principles of ACT and traditional CBT expressed using a modified expressive writing intervention hold great promise to help individuals recover from stressful experiences. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Journal of Contextual Behavioral Science, 4(4) : 269- 276