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Violence: Psychological Harm from Traumatic Events Among Children and Adolescents – Cognitive-Behavioral Therapy (Individual)

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What the CPSTF Found

About The Systematic Review

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.

Context

  • 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

Summary of Results

Detailed results from the systematic review are available in the CPSTF finding pdf icon [PDF - 128 kB].

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.

Summary of Economic Evidence

  • 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).

Applicability

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.

Evidence Gaps

Each Community Preventive Services Task Force (CPSTF) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the CPSTF finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the CPSTF recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the CPSTF recommendation is based.

Identified 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.

Study Characteristics

  • 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.

Publications