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ESSAY COVER SHEET
Candidate number
RVHR7
Module
CHLDGMO6
Essay title
Factors influencing therapist’s choice for PTSD
in child and adolescent.
Word count
I confirm that this work is entirely that of my own, unless otherwise indicated and, where
indicated, I have provided full reference citations as to the origin of the material used. I also
confirm that I have read the departmental guidelines on plagiarism (below) and that I am aware
of UCL’s policy on plagiarism.
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PLAGIARISM
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software as though they were a student’s own. Any quotation from the published or unpublished
works of other persons must, therefore, be clearly identified as such by being placed inside
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series of short quotations from several different sources, if not clearly identified as such,
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Introduction
The treatment of post-traumatic stress disorder (PTSD) is wide-ranged, (Lieberman et al,2005)
and exemplifies the scenario where the therapist is influenced by various factors in the choice
of treatment (Agnes et al 2010). PTSD is a distressing mental health problem seen in some
children who have experienced traumatic injuries, actual or threatened, either to themselves or
others. It is characterized by intrusive thoughts and reminders of the traumatic experiences,
avoidance of traumatic reminders, negative mood and cognitions as a result of the exposure,
and physiological arousal resulting in significant impairment social, occupational or
interpersonal functioning (APA 2013). As PTSD in children and adolescents can be severe, it
often leads to chronic and impairing mental health disorders if not properly managed, ( Sadock
et al 2014) the therapist is usually careful in the selection of treatment that is most appropriate
for each patient. The treatment choice often lies between various psychotherapeutic
interventions such as Trauma-Focused Cognitive-Behavioural therapy (TF-CBT), Cognitive
Behavioural Interventions in Schools (CBITS), Trauma Affect Regulation: Guide for
Education and Therapy (TAEGET) and Psychopharmacological treatment options (Sadock et
al 2014), among others. The factors impacting on the final choice of treatment are varied, and
include evidence base for effectiveness, setting of traumas, nature of stress, age of patient and
presence of co-occurring substance use disorder (Gilles et al 2013). This essay will review the
evidence base for the choice of some of the above treatments, while considering the others.
Evidence base of effectiveness
The first factor influencing the therapist choice of treatment of PTSD in child and adolescent
is the evidence base of effectiveness. Accordingly, the treatment option recommended as firstline is Cognitive Behavioural Therapy (CBT), majorly in the form of Trauma Focussed
Cognitive Behavioural Thearpy or TF-CBT (NICE 2015). TF-CBT has the widest and strongest
evidence base of effectiveness (Cohen et al, 1996; Deblinger et al, 1999; Cohen et al, 2004;
Cohen et al, 2005; O'Callaghan et al, 2013; McMullen et al, 2013). In a comparative metaanalysis of all interventions for children and adolescents with posttraumatic stress disorder,
TF-CBT was found to be the most researched form of intervention (Morina et al, 2016). In fact,
in the 2016 Cochrane review of randomised clinical trials on psychological therapies for
children and adolescents exposed to trauma (Gilles et al 2016), of the 51 trials included in the
review, 17 used CBT, and another 14 included CBT. Apart from being the most widely
researched, TF-CBT was also found to be the most effective of all the interventions for child
and adolescent PTSD treatment (Cohen et al, 2011; Deblinger et al, 2015). In a review of
psychological therapies for the treatment of PTSD in children and adolescents, Gilles et al
(2013) included all the available randomised trials of psychotherapy where comparisons were
made to a control, pharmacotherapy and other treatments, and found that the psychological
therapy for which there was the best evidence of effectiveness was CBT. CBT showed
significantly better improvement for up to a month in two studies (Odds ratio [OR] 8.6, 95%
confidence interval [CI] 2.0 - 37.1), and even up to a year in one study (OR 8.0, CI 1.2 - 52.7),
and lowering of PTSD symptoms for up to a month in three studies, and a year in one study.
Similarly, depression scores were lowered for up to a month in three studies (mean difference
-0.80, 95% CI -1.47 to -0.13). Moreover, no adverse effects were identified with CBT. The
review is a high quality one because none of the trials were rated as high risk for selection
/detection bias. However, the findings are limited by the generally small size of the included
trials. But then, the largest randomized trial in the meta-analysis, a multi-site trial of 229
participants, showed that children randomised to TF-CBT group experienced reductions in the
PTSD symptoms compared to the control group. Therefore, based on the number of evidence
of efficacy, TF-CBT remains the first choice of therapy for children and adolescents with
PTSD.
Setting of traumas
TF-CBT is an individual rather than a group psychotherapy, hence, when trauma occurs in
congregant settings, especially among school children, it is more efficient to provide trauma
treatment in groups rather than individually (Stein et al 2003). While there exist many models
of group interventions with good evidence base of effectiveness, perhaps the most extensively
evaluated and widely accepted is Cognitive Behavioural Interventions for Trauma in Schools,
or CBITS (National Registry for Evidence-Based Programs and Practices, 2013). Stein and
colleague (2003) conducted a large randomized controlled trial to evaluate the effectiveness of
CBITS in reducing the symptoms of PTSD and depression in schoolchildren because of
exposure to violence. Sixty-one of them were randomised to the CBITS group for early
intervention, while the comparison group, the wait-list group, had 65 students. The main
outcome measures were child-reported symptoms of PTSD and depression, parent-reported
psychosocial dysfunction and teacher-reported classroom problems. The instruments used were
Child PTSD symptom scale, Child depression inventory, Pediatric symptom checklist and
Teacher-Child rating scale. The study demonstrated that after three months, schoolchildren in
the intervention (CBITS) group had significantly lower scores on symptoms of PTSD
compared to the no intervention (wait list) group (8.9 versus 15.5; adjusted mean difference 7, 95% confidence interval -10 to -3). The study is limited, however, by the fact the informants,
i.e. students, parents and teachers, were not blinded to the treatment conditions, thereby biasing
the assessment and treatment. Despite that, the study is a high quality one as the sample size is
large and when the delayed control group eventually received the CBITS after three months,
the students achieved similar score as the intervention group, lending a support for the choice
of CBITS as treatment for PTSD in school setting.
Complexity of trauma
While TF-CBT is non-specific, being applicable to a patient of broad age and trauma type, (De
Arenallo et al 2014) the need for a treatment approach tailored to teens with complex trauma,
such as maltreatment and/or chronic trauma such as community or domestic violence
influences the choice for customized treatment approach, such as Trauma Affect Regulation:
Guide for Education and Therapy (TARGET). (Sadock et al 2014) TARGET is administered
to adolescents aged between 13 and 19, and may have specific applicability for the juvenile
justice population (Ford et al, 2012). In a randomized clinical trial with 59 delinquent girls aged
13 to 17 years who met full or partial criteria for PTSD, authors demonstrated large
improvement in PTSD symptoms with both therapies, but for emotional changes, results favour
TARGET for change in PTSD (intrusive reexperiencing and avoidance) and anxiety
symptoms, posttraumatic cognitions, and emotion regulation (Ford et al, 2012). Thus,
complexity of trauma influences the therapist choice in that the proven choice lies with
TARGET rather than TF-CBT.
Age of patients
The choice of therapy for PTSD in CAMHS practice is heavily influenced by the age of the
patient. (Gilles et al,2016). This is because there are developmental differences in how PTSD
is manifested in young children(Sadock et al 2014). The PTSD manifestations are of basic fears
that young children have (eg body damage, abandonment, loss of care giver), and since young
children have limited verbal and cognitive abilities they are particularly trusting on
caregivers.(Sadock et al 2014) But when trauma occurs this trust is disrupted. Therefore, rather
than offer TF-CBT the therapist often chose CPP (Child-Parent Psychotherapy), particularly
for those aged 3 or less who are not expected to have any cognitive capability for a cognitive
behavioural therapy. The goal here is to rebuild the young child’s trust that the caregiver will
keep the child safe and the caregiver’s ability to do so. Thus, the therapist choice is CPP. A
randomized trial compared CPP with case management and community treatment referral for
75 preschool children with PTSD stemming from domestic violence (Lieberman et al, 2005).
After one year of weekly sessions monitored for fidelity, children receiving CPP experienced
greater improvement in PTSD symptoms (medium effect size), as well as for total behavior
problems (small effect size), relative to children receiving the comparison treatment. Mothers
receiving CPP also exhibited significantly greater decrease in avoidance symptoms and a trend
toward reduction in their own personal PTSD symptoms.
For preschoolers three to six years of age, CPP is suggested rather than other psychotherapies,
particularly for children with significant developmental delays since such children’s limited
cognitive ability would preclude effective cognitive-based interventions. Similarly, where
severe attachment-related difficulties form part of the PTSD symptomatology, CPP is preferred
due to its dyadic, attachment-based nature and longer duration. (Lieberman et al,2005).
Contraindications, non-responders, unavailability
The recommended first line treatment choice for PTSD is Trauma-focused cognitive behavioral
therapy (TF-CBT) (NICE, 2005) However, whenever trained specialist for TF-CBT are
unavailable, or where there is non-response to TF-CBT therapy, equally effective evidencebased treatment alternatives are pursued by the therapist. Eye movement desensitization and
reprocessing (EMDR) is an alternative PTSD treatment option often considered as its efficacy
has been proven in clinical settings (Diehle et al, 2015). For example, a randomized controlled
trial was conducted Diehle et al (2015) to compare the effectiveness and efficiency of both TFCBT and EMDR for the treatment of PTSD. In the trial, forty-eight children aged 8 through 18
years were randomly assigned to TF-CBT or EMDR groups, with each group undergoing 8
sessions of each treatment modality. The primary outcome was PTSD symptom measured with
Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). Secondary
outcomes measures were parent-reported status of PTSD, and comorbid problems. The result
showed that both TF-CBT and EMDR significantly reduce CAPS-CA scores (−20.2; 95 % CI
−12.2 to −28.1 and −20.9; 95 % CI −32.7 to −9.1) with little difference in rates of reduction
with each treatment modality (mean difference of 0.69, 95 % CI −13.4 to 14.8). Although
treatment duration was shorter with EMDR, this did not reach a statistically significant level
(p = 0.09). Thus, EMDR is an effective alternative to TF-CBT where the latter is not available,
contraindicated or not effective in the treatment of PTSD. It should be noted, however, that
parental report of reduction in comorbid emotional symptoms were higher with PTSD making
it the first treatment choice considered by the therapist.
Co-occurring substance use disorder (SUD)
In cases of co-occurring SUD, the therapist employs other models of therapy. A treatment
model to address PTSD and comorbid SUD is Seeking Safety (SS). A randomized, controlled
trial evaluated the efficacy of SS for thirty-three adolescent females with posttraumatic stress
disorder (PTSD) and co-occurring SUD (Najavits et al, 2006). This intervention group were
compared to treatment as usual (TAU) control group. Comparisons between groups were made
at intake, end-of-treatment, and 3-month follow-up. The result showed significantly better
outcomes with SS and the various domains assessed posttreatment, particularly in substance
use and associated problems, symptoms related to trauma, cognitions related to SUD and
PTSD. Other symptomatologies not designed to be measured in the study such as anorexia and
somatisation were also improved with SS intervention. This study therefore showed that SS
was effective at treating PTSD with co-occurring SUD. However, it should be noted that the
study was largely conducted in the fashion for adult population, with only some adaptations
for youths’ level of development. More clinical modifications for the adolescent population
and for gender is needed. Further the sample size appears too small to detect some outcome
measures. Despite these limitations, the effect sizes in the outcome measures were high, at least
moderate, thereby meriting some reliablity. Finally, some gains achieved by SS intervention
were sustained at follow-up, further lending support to the intervention's efficacy.
In conlusion, all current treatments have their strengths and limitations; therefore, the
therapist’s capacity to intervene flexibly with various psychotherapeutic techniques is key. No
one-size-fits-all approach is available; however, the care of each patient should be
individualized, carefully designed to suit the needs of patients which are always unique.
Hopefully, in the next few years, more homogenous studies specifically designed for children
will be conducted.
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fifth
Edition(DSM-5), American Psychiatric Association, Arlington,VA 2013.p272
BJ Sadock, VA Sadock, Ruiz P,eds.Kaplan & Sadocks’s Comprehensive Textbook of
Psychiatry.9 th .ed.Vol.ll.Philadelphia:LippincottWilliams Wilkins;2014:3636.
Deblinger E, Mannarino AP, Cohen JA. Theory, treatment development, and research. In:
Child Sexual Abuse: A Primer For Treating Children, Adolescents, and Their Non-Offending
Parents, 2nd ed, Oxford Press, New York 2015. p.19.
Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of
a randomized controlled trial. Child Abuse Negl. 2005 Feb;29(2):135-45.
Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for
children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry.
2004 Apr;43(4):393-402.
Cohen JA, Mannarino AP, Iyengar S Community treatment of posttraumatic stress disorder for
children exposed to intimate partner violence: a randomized controlled trial. Arch Pediatr
Adolesc Med. 2011 Jan;165(1):16-21.
Cohen JA, Mannarino AP. A treatment outcome study for sexually abused preschool children:
initial findings. J Am Acad Child Adolesc Psychiatry. 1996 Jan;35(1):42-50.
Deblinger E, Steer RA, Lippmann J. Two-year follow-up study of cognitive behavioral therapy
for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl. 1999
Dec;23(12):1371-8.
O'Callaghan P, McMullen J, Shannon C, Rafferty H, Black A. A randomized controlled trial
of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese
girls. J Am Acad Child Adolesc Psychiatry. 2013 Apr;52(4):359-69.
McMullen J, O'Callaghan P, Shannon C, Black A, Eakin J. Group trauma-focused cognitivebehavioural therapy with former child soldiers and other war-affected boys in the DR Congo:
a randomised controlled trial. J Child Psychol Psychiatry. 2013 Nov;54(11):1231-41.
National Registry for Evidence-Based Programs and Practices. Rockville, Md: Substance
Abuse and Mental Health Services Administration; 2013.
Najavits LM, Gallop RJ, Weiss RD. Seeking safety therapy for adolescent girls with PTSD and
substance use disorder: a randomized controlled trial. J Behav Health Serv Res.
2006;33(4):453.
Stein BD, Jaycox LH, Kataoka SH, Wong M, Tu W, Elliott MN, Fink A. A mental health
intervention for schoolchildren exposed to violence: a randomized controlled trial..JAMA.
2003 Aug;290(5):603-11.
Diehle J, Opmeer BC, Boer F, Mannarino AP, Lindauer RJ. Trauma-focused cognitive
behavioral therapy or eye movement desensitization and reprocessing: what works in children
with posttraumatic stress symptoms? A randomized controlled trial. Eur Child Adolesc
Psychiatry. 2015 Feb;24(2):227-36
Lieberman AF, Van Horn P, Ippen CG. Toward evidence-based treatment: child-parent
psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc
Psychiatry. 2005 Dec;44(12):1241-8.
Ford JD, Steinberg KL, Hawke J, Levine J, Zhang W. Randomized trial comparison of emotion
regulation and relational psychotherapies for PTSD with girls involved in delinquency. J Clin
Child Adolesc Psychol. 2012;41(1):27-37.
Morina N, Koerssen R, Pollet TV. Interventions for children and adolescents with
posttraumatic stress disorder: A meta-analysis of comparative outcome studies. Clin Psychol
Rev. 2016 Jul;47:41-54.
Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N. Psychological therapies for the treatment
of post-traumatic stress disorder in children and adolescents (Review). Evid Based Child
Health. 2013 May;8(3):1004-116.
Gillies D, Maiocchi L, Bhandari AP, Taylor F, Gray C, O'Brien L. Psychological therapies for
children and adolescents exposed to trauma. Cochrane Database Syst Rev. 2016 Oct
11;10:CD012371.
Agnes Van Minnen, Lotte Hendriks, Miranda Olff. When do trauma experts choose exposure
therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour
Research and Therapy 2010;48(4):312-320.
Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for
children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry.
2004 Apr;43(4):393-402.
De Arellano MA, Lyman DR, Jobe-Shields L, George P, Dougherty RH, Daniels AS, Ghose
SS, Huang L, Delphin-Rittmon ME. Trauma-focused cognitive-behavioral therapy for children
and adolescents: assessing the evidence. Psychiatr Serv. 2014 May 1;65(5):591-602.
Cary CE, McMillen JC. The data behind the dissemination a systematic review of traumafocused cognitive behavioral therapy for use with children and youth. Children and Youth
Services Review. 2012; 34:748–757.
NICE (2005). Post-traumatic stress disorder: management. Retrieved
https://www.nice.org.uk/guidance/cg26/chapter/1-Guidance#the-treatment-of-ptsd
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