Violence Prevention: Group Cognitive-Behavioral Therapy to Reduce Psychological Harm for Traumatic Events Among Children and Adolescents
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends group cognitive-behavioral therapy (CBT) for symptomatic youth who have been exposed to traumatic events based on strong evidence of effectiveness in reducing psychological harm.
The CPSTF has related findings for individual CBT (recommended).
The full CPSTF Finding and Rationale Statement and supporting documents for Violence Prevention: Group Cognitive-Behavioral Therapy to Reduce Psychological Harm for Traumatic Events Among Children and Adolescents are available in The Community Guide Collection on CDC Stacks.
Intervention
Cognitive-behavioral therapy (CBT) is used to reduce psychological harm among children and adolescents who have psychological symptoms resulting from exposure to traumatic events. Therapists administer CBT individually or in a group, and treatment may be accompanied by therapy sessions for or with parents.
A traumatic event is one in which a person experiences or witnesses actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Trauma may take the form of single or repeated events that are natural or human-made and intentional or unintentional. Traumatic exposures may have only temporary effects or result in no apparent harm. However, traumatic exposures may result in psychological harm and lead to long term health consequences.
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 10 studies (search period through March 2007).
Study Characteristics
- Studies assessed effects of group CBT on traumatized children and adolescents of varying ages, geographic locations, and traumatic exposures
- Index trauma included community violence and war, volcanic eruptions, sexual abuse, suicide of a family member, and juvenile cancer and treatment
- Most children in these studies were exposed to multiple traumas
- Number of group CBT sessions generally ranges from 8 to 12
- Some studies excluded children who were too disruptive or had severe mental health problems
Summary of Results
Ten studies qualified for the review.
- Summary-effect measures for ten studies were in the desired direction for all outcomes assessed: anxiety, depression, and PTSD
- Most children were exposed to multiple traumas, and group CBT effectively reduced psychological harm among these children
- Small number of studies made it difficult to determine whether effectiveness varied by principal trauma
Summary of Economic Evidence
An economic review did not find 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 traumatic exposure), found CBT had potential to be cost effective based on commonly used threshold values.
Applicability
Findings 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 had severe mental health problems, applicability to this subgroup is unknown.
Evidence Gaps
The following outlines evidence gaps from these reviews on reducing psychological harms from traumatic events: Individual CBT; Group CBT.
- 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.
Implementation Considerations and Resources
Other benefits of group CBT include preventing academic decline and improving parent child relationships.
Parents were participants in many programs; some studies indicated psychological benefits to parents themselves, and parental participation may be a mediator of effects on children.
Standardized group CBT requires relatively intensive efforts by providers. Specific training is necessary for those delivering this type of therapy.
Making it possible for a group of children to attend each session may pose scheduling challenges. Administration of group CBT in schools provides one potential solution.
Vicarious traumatization has been cited as a potential harm of group CBT, but no reviewed study assessed or reported evidence of such an occurrence. This potential harm may be avoided by having participants recount traumatic experiences with a therapist outside of the group setting.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.