Assessing the Impact of Childhood Interventions on Subsequent Drug Use--Commissioned Papers

A systematic search for peer-reviewed empirical studies of childhood posttraumatic stress disorder (PTSD) was conducted using PsycINFO and Medline electronic databases. Studies that met the following criteria were included in the final report: (1) identified in the electronic database by one or more of the following study descriptors: treatment outcome study, clinical trial, controlled clinical trial, or randomized controlled trial; (2) included subjects between the ages of 6 and 12 as the primary treatment target population, although studies that included younger children and adolescents were not excluded; (3) published between 1985 and 1999; and (4) published in the English language. Reference lists from review articles and book chapters were also searched. This strategy identified 58 potential empirical peer-reviewed studies. This number was reduced by excluding studies that were not primarily concerned with treatment outcome and studies that had neither controlled nor quasi-experimental designs. This left five peer-reviewed controlled studies of psychosocial treatment for children with PTSD. No controlled psychopharmacological studies were found. These studies are presented in table 5.

In these five studies, treated children had either a PTSD diagnosis or PTSD symptoms. The identified trauma treated in three of the studies was sexual abuse; earthquake victims and a mix of trauma types (excluding abuse) were the subjects of the other two studies. The most common research design was an RCT and there were one each of a quasi-experimental and single case study series design. The interventions were time-limited, provided individual or group therapy, and were cognitive-behavioral in orientation. The largest study had a sample of 100 children, 2-year followup, and treatment arms that included parent treatment. In general, positive findings, such as decreased severity or number of PTSD symptoms, were reported. Manualized interventions were developed for several of these studies, creating the potential for replication.

Both the relatively recent recognition of PTSD in children and the measurement of it may partially account for the limited clinical research on this disorder. The psychosocial treatment literature for children with PTSD is at a very early stage, and pharmacological research is nonexistent. This limited evidence base, considering the small number of studies, is further characterized by relatively small sample sizes (a range of 15 to 100 subjects), precluding further analysis by gender or racial/ethnic group, despite diversity in these study samples. The current status of PTSD treatment research suggests both further treatment development and controlled replications of the two well-delineated interventions identified as cognitive behavior therapy as next steps.

Study Citation(s)	Study Design/ Description	Target Population	Demographic Characteristics	Outcomes	Notes
Table 5.1 Psychosocial Studies of Childhood Posttraumatic Stress Disorder
Berliner & Saunders, 1996	RCT; the final sample of 80 children were randomly assigned to 10-week index (n = 48) and comparison treatment group (n = 32); both received group sexual abuse treatment; the index group also received stress inoculation training and gradual exposure treatment	Children referred by parents, child protective services, juvenile justice, health and mental health providers; all with a history of sexual abuse and 81% with a chart diagnosis of PTSD	Age: 4 – 13 Gender: 11% boys 89% girls Race/Ethnicity: 74% White 11% African American 6% Hispanic 9% Other	Improvement over time on a variety of symptoms; no differences between groups in improvement on fear and anxiety symptoms; at the 2-year followup the majority of children in both groups reverted to baseline levels	One-third of recruited children did not complete treatment sessions; completers and noncompleters did not differ on key case variables; multiple statistical comparisons were conducted without correction for Type II error
Celano, Hazzard, Webb, & McCall, 1996	RCT; eight sessions, mostly conducted cojointly, with a nonoffending caretaker and a sexually abused girl; Recovering from Abuse Program (n = 15) vs. treatment as usual (n = 17) vs. supportive, unstructured psychotherapy	Girls who experienced sexual abuse in the past 3-year period recruited mostly from a pediatric emergency clinic in a public hospital; PTSD symptoms assessed, but no diagnosis reported	Age: 8 – 13 Gender: 100% girls Race/Ethnicity: 75% African American 22% White 3% Hispanic	PTSD symptoms decreased in both groups; abuse-related caretaker support increased; caretaker blame and expectations of negative impact on child decreased in the Recovering from Abuse Program at treatment termination	For the experimental condition, therapists received a 3-hour training session, had weekly supervision, and had access to a training manual; one-third of families dropped out of treatment; adjustment problems were greater at baseline in the control group
Deblinger & Lippman, 1996; Deblinger, Steer, & Lippmann, 1999	RCT; examined differential effects of child and nonoffending mother participation in a 12-session cognitive behavioral intervention; 100 families assigned to standard community care (n = 25), vs. child (n = 25), vs. nonoffending parent CBT (n = 25), and combined child and parent (n = 25)	School-aged sexually abused children were referred by child welfare agencies and presenting with at least three PTSD symptoms; 71% had a PTSD diagnosis based on standardized interview	Age: 7 – 13 Gender: 17% boys 83% girls Race/Ethnicity: 72% White 20% African American 6% Hispanic 2% Other	Posttreatment for children assigned to experimental conditions; PTSD and depressive symptoms and externalizing behavior decreased more than for control groups; greater use of effective parenting skills observed in the experimental groups; symptom findings held up through the 2-year followup	In addition to PTSD symptoms or diagnosis, other co-occurring disorders were common
Goenjian et al., 1997	Quasi-experimental design; assessed individual and group trauma/grief focused psychotherapy over 6 weeks among adolescents with PTSD who were victims of the 1988 earthquake in Armenia; students in two schools (n = 35) received psychotherapy vs. students at two other schools (n = 29) who did not	Students identified with posttraumatic stress and depressive reactions 1.5 years following an earthquake	Age: 11 – 13 Gender: 60% boys 40% girls Race/Ethnicity: 100% Armenian	Three years after the earthquake, students who received the intervention reported reduced severity of PTSD and depressive symptoms; those not receiving psychotherapy reported increased severity of PTSD and depressive symptoms; at baseline the rate of PTSD in the index group was 60% and 52% for controls; at followup, rates were 28% and 69%, respectively	Although small sample size, the direction of the findings for both groups underscore the importance of this brief intervention
March, Amaya-Jackson, Murray, & Schulte, 1998	Single case series across settings design; 18-session group-administered cognitive behavioral psychotherapy (n = 14)	Children in two elementary and junior high schools meeting criteria for a diagnosis of PTSD and considered suitable for treatment	Age: 10 – 15 Gender: 33% boys 67% girls Race/Ethnicity: 49% African American 49% White 1% Asian 1% American Indian	Among treatment completers, 57% no longer met criteria for PTSD at treatment termination; 86% were free of PTSD at the 6-month followup; improvement also observed for depression, anxiety, and anger symptoms	An initial efficacy study; children with chronic abuse-related PTSD were excluded because family and other relevant interventions not included; conducting a randomized clinical trial may be the next step for this intervention

Berliner, L., & Saunders, B. (1996). Treating fear and anxiety in sexually abused children: Results of a controlled 2-year follow-up study. Child Maltreatment, 1, 294-310.

Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic beliefs among sexually abused girls and their mothers: An evaluation study. Journal of Abnormal Child Psychology, 24, 1-17.

Deblinger, E., & Lippman, J. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310-322.

Deblinger, E., Steer, R. A., & Lippman, J. (1999). Two year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse and Neglect, 23, 1371-1378.

Goenjian, A. K., Karayan, I., Pynoos, R. S., Dzovag, M., Najarian, L. M., Steinberg, A. M., & Fairbanks, L. A. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154, 536-542.

March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998). Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single stressor incident. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 585-593.