Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: A review and meta-analysis

Abstract

Background and objectives

There is no clear gold standard treatment for childhood posttraumatic stress disorder (PTSD). An annotated bibliography and meta-analysis were used to examine the efficacy of cognitive behavioral therapy (CBT) in the treatment of pediatric PTSD as measured by outcome data from the Child Behavior Checklist (CBCL).

Method

A literature search produced 21 studies; of these, 10 utilized the CBCL but only eight were both 1) randomized; and 2) reported pre- and post-intervention scores.

Results

The annotated bibliography revealed efficacy in general of CBT for pediatric PTSD. Using four indices of the CBCL, the meta-analysis identified statistically significant effect sizes for three of the four scales: Total Problems (TP; −.327; p = .003), Internalizing (INT; −.314; p = .001), and Externalizing (EXT; −.192; p = .040). The results for TP and INT were reliable as indicated by the fail-safe N and rank correlation tests. The effect size for the Total Competence (TCOMP; −.054; p = .620) index did not reach statistical significance.

Limitations

Limitations included methodological inconsistencies across studies and lack of a randomized control group design, yielding few studies for meta-analysis.

Conclusions

The efficacy of CBT in the treatment of pediatric PTSD was supported by the annotated bibliography and meta-analysis, contributing to best practices data. CBT addressed internalizing signs and symptoms (as measured by the CBCL) such as anxiety and depression more robustly than it did externalizing symptoms such as aggression and rule-breaking behavior, consistent with its purpose as a therapeutic intervention.

Introduction

The diagnosis of posttraumatic stress disorder (PTSD) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 (American Psychiatric Association, 1980). Posttraumatic Stress Disorder is a complex disorder involving dysregulation of multiple neurobiological systems that affects cognitive, affective, and behavioral domains. Epidemiological studies report a prevalence rate of PTSD in the general adult population ranging between five and 14% (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Trauma is frequently experienced in the United States, with an estimated one-third of the adult population exposed on an annual basis. Of these individuals, approximately 10–20% will develop the clinical syndrome of PTSD (Solomon & Davidson, 1997).

The clinical impression is that, in contrast to the adult population, practitioners treating children and adolescents initially seemed reluctant to apply the diagnosis of PTSD to the pediatric age group. Data regarding trauma exposure as well as the subsequent development of PTSD in youth are more limited compared to adults. According to the National Child Traumatic Stress Network, 25% of children and adolescents experience a traumatic event by the time they reach 16 years of age (Copeland-Linder, 2008). A wide range of trauma rates has been reported in the literature, varying from as low as 16% (Cuffe et al., 1998) to as high as 40% in youth under the age of 18 (Boney-McCoy and Finklehor, 1996, Breslau et al., 1991, Giaconia et al., 1995, Schwab-Stone et al., 1995). The point prevalence of PTSD in youth remains unclear but lifetime prevalence estimates approximate 6% in the pediatric population (Giaconia et al., 1995). This number may be an underestimate, given that greater numbers of youth are now receiving the diagnosis as clinicians’ awareness of and comfort with diagnosing PTSD increases. Despite clinicians’ slow recognition of PTSD in younger age groups, it is now accepted as a frequently occurring disorder.

Posttraumatic stress disorder in children and adolescents is often severely disabling. Pediatric patients with PTSD present with a multitude of symptoms affecting functioning across different domains. Mueser and Taub (2008) reported a rate of PTSD as high as 20% among youth with severe emotional disorders who were involved in multiple systems of care. The authors also reported that adolescents with PTSD were more likely to engage in a variety of high-risk behaviors including running away from home, self-injury, and delinquency. Adolescents in their study reported higher levels of anxiety and depression and lower levels of optimal functioning in different settings (e.g., at home and at school) than did adolescents without PTSD.

Different treatment approaches have been applied to address the symptoms of pediatric PTSD. Currently, outpatient psychotherapy is the preferred initial treatment modality for PTSD, with pharmacotherapy used as an adjunctive intervention (Cohen, 1998). Clinicians use Cognitive Behavioral Therapy (CBT) to address associations between stimuli and conditioned fear responses, the influence of environmental factors on symptom expression, and cognitive and affective regulation; therefore, CBT lends itself to the treatment of symptoms of PTSD. For treatment of sexually abused children, for example, clinicians often use CBT to address sequelae of the trauma including internalizing, externalizing, and sexualized behaviors (MacDonald, Higgins, & Ramchandani, 2006). Taking into account economic factors, CBT provides a focused, time-limited treatment approach to address the effects of trauma and is a cost-effective way of treating a larger number of individuals.

Youth with PTSD often require a combination of treatment approaches (e.g., individual, group, and/or family psychotherapy along with pharmacotherapy) potentially in an array of treatment settings, with seamless transitions between levels of care. Treatment decisions are complicated by a lack of empirical data regarding outcomes of particular interventions. For these reasons, it remains difficult to recommend one particular treatment approach over another. Researchers have studied the use of psychotherapy in the pediatric PTSD population, with the majority of studies evaluating the efficacy of CBT approaches (Robertson, Humphreys, & Ray, 2004). Researchers have investigated trauma-focused CBT and found efficacy of this intervention in both individual and group therapy formats for sexually abused youth (Leserman, 2005). Pharmacological studies are fewer in number than studies of CBT, less rigorous in methodology and demonstrate less conclusive findings about efficacy and long-term outcomes (Nikulina et al., 2008).

The original purpose of this article was to review the overall efficacy of CBT in the treatment of pediatric PTSD as described in recent literature. This review did not intend to evaluate the efficacy of combinations of treatment interventions or treatment delivered across different clinical settings. It examines immediate rather than long-term outcomes of the intervention. This review explores published research studies and contributes to the understanding and establishment of evidence-based treatment interventions. Once it was observed that the Child Behavior Checklist (CBCL) was the only measure utilized with some consistency across studies of pediatric PTSD, the more focused purpose of the study became to examine the efficacy of CBT in the treatment of pediatric PTSD as measured by outcome data from the CBCL.

A quantitative approach that is well-suited for measuring the efficacy of interventions across multiple studies is meta-analysis. In this article, meta-analysis was used to evaluate outcomes from randomized clinical trials of CBT in which the comparison was to an active control group. For inclusion in a meta-analysis, it is recommended that studies all utilize the same measure of the construct in question in order to maximize comparability among studies (Littell, Corcoran, & Pillai, 2008). Among the studies identified and reviewed in this article, the Child Behavior Checklist (CBCL) was the most commonly used outcome measure for treatment of pediatric PTSD (Achenbach & Edelbrock, 1983). The ability of the CBCL to distinguish between clinical and non-clinical patient samples has been well-established (Kendall, 1994).

The CBCL was not designed to assess symptoms of PTSD in particular, and therefore is not considered a measure specific for PTSD phenomenology. It is a descriptive rating measure that assesses parent perceptions of their child’s behavior, adjustment, emotional functioning, and social functioning. Individual symptoms, but not the clinical syndrome of PTSD, are assessed by this measure; however, the CBCL provides composite indices that reflect how PTSD is expressed behaviorally by children and adolescents. The effects of trauma on children are varied and can be expressed in a number of ways. Symptoms can be categorized or conceptualized in ways that are similar to those used by the CBCL; these categories include internalizing, externalizing, and total competence. Some children who are exposed to traumatic experiences may react with internalizing symptoms (e.g., depression, anxiety, and/or somatic complaints as reflected by the Internalizing composite index of the CBCL), some with externalizing symptoms and behaviors (e.g., rule-breaking behaviors and/or aggression as assessed by the Externalizing composite index of the CBCL), and still others may manifest the effects of trauma with features that can be considered part of the “Total Competence” composite index of the CBCL (e.g., social challenges, diminished or limited participation in activities such as sports and hobbies, and school problems). These symptoms and signs are not specific to PTSD per se; however, the effects of trauma can be expressed in these different forms.