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Treating PTSD in Children
Using Cognitive Behavioral Group Therapy
Kurt D. LaRose, MSW LCSW
Stein et al. (2003) argue "no randomized controlled studies have been conducted to date on the effectiveness of psychological interventions for children with symptoms of posttraumatic stress disorder (PTSD)" (p. 603). The purpose of the research performed by Stein and his colleagues was to critically assess a PTSD treatment, particularly a Cognitive-Behavioral Therapy (CBT) based intervention, by applying the rigors of scientific methodologies to the evaluation. Supposedly, this research is the first of its kind in assessing psychological PTSD interventions for youth, using randomization. The researchers note that trauma in school aged children is a common phenomena and that mental health services for children have become increasingly a responsibility of school staff and personnel. As a result, the goal was not only to strenuously test an intervention but also to use a standardized treatment modality that, if found to be effective, can easily be learned and applied by schools who will possibly become treatment providers.
The population under study was sixth graders who were taken from two California schools. After the appropriate informed consents and assents were obtained, and with IRB approval, the children from each school were assessed for clinical determinants of PTSD symptomology (n=769). The students who had significant PTSD symptoms (N=126) were randomly assigned to an experimental group (n=61) and to a wait list control group (n=65). A standardized intervention was used, the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS), whereby clinicians were trained to provide the intervention to children following a manual based training program. The researchers, in an earlier pilot program, developed CBITS specifically for treating traumatized children in the academic setting.
Outlining the general topics of discussion for each of the 10 sessions operationalized the CBITS intervention. The researchers provided a clear diagram of the group topics that ranged from educational in nature (such as identifying common responses to trauma) to relaxation and problem solving techniques and ultimately the last session included a graduation ceremony. Groups ranged in size from 5-8 children, and clinicians introduced topics via games, worksheets, presentations and take home assignments; the specifics of the games, presentations, and assignments were not clearly discussed, but were presumably consistent with the manual based CBITS training program.
The research design used by Stein et al. (2003) is a partial cross over design with follow-up (as described by Fortune & Reid, 1999, p. 173). The benefits of using the cross over design is that all of the subjects received the intervention, which was believed to be helpful in reducing PTSD symptoms, depression, and hypothesized to reduce negative classroom behavior. The control group actually was a wait list group, who initially was not given the intervention, while the experimental group began treatment immediately. Both groups were assessed at pretest to establish a baseline, and at a three-month posttest the wait list control and experimental group were compared for anticipated changes. Next, after the three-month posttest, the control group was then given the intervention. Finally, both groups were assessed again with a follow-up (see Figure 1 for a diagram of the research design used by Stein and colleagues).
Figure 1. Partial Cross Over Design used by Stein et al. (2003)
Pretest Posttest Follow-up
O X O O
O O X O
R=Random Assignment, O=pretest, posttest and follow-up, X=CBITS intervention.
The researchers used psychometrically tested instruments (for example the Children's Depression Inventory and the Child PTSD Symptom Scale) for the pre and posttest assessments, and included evaluations from multiple informants: student self-reports, parental reports, and teacher reports. The use of psychometrically strong instruments, the use of a control group, in conjunction with multiple informants strengthens the findings of this study and helps to control for researcher bias, maturation and testing threats.
In a discussion of the CBITS technique the authors mention, "the groups most often met once a week" (Stein et al., 2003, p. 605) revealing fidelity and instrumentation threats. To help ensure fidelity the CBITS intervention was audio taped and randomly rated by the researchers for quality and consistency. Other threats to the study include a testing threat, a selection threat, attrition and maturation. Attrition is apparent in that the original sample numbered 126 subjects, however at the final follow-up 116 subjects were assessed. A maturation threat is evident in looking at two graphs that were used in the analysis of data, whereby the treatment group and the wait list control group both show improvements in reduced PTSD and depression symptoms at the three-month posttest.
In general however, and in spite of maturation, it is noteworthy to mention that when the intervention was applied to the treatment group, the rate of improved PTSD symptomology was greater when compared to the rate of improvements that were seen in the wait list group. Furthermore, when the intervention was applied to the wait list group, an improvement in PTSD and depression symptoms is noted, again at a faster rate than the improvement noticed by the experimental group from it's three-month and six-month follow-up. A less dramatic difference existed, although it was evident, when looking at depression symptoms between the experimental and control wait list groups throughout the course of the study.
Interestingly, the teacher reports of classroom behavior did not show improvements, even though PTSD and depression symptoms decreased. In looking at the data analysis graphs for classroom behavior, the treatment group showed improvements during treatment, while the wait list group actually got worse during the course of the intervention. The researchers address the behavior findings by suggesting that it is possible that the teachers monitored behavioral changes more closely in all of the children under study, partly because the teachers were aware of who was in the study and who was not. More simply, a researcher bias exists, and could be controlled for in a future study by making reporters blind to who is and is not getting the intervention.
Even as this study looked at a population that was primarily from a poor Latino area, and even though the PTSD was not particularly related to abuse (the school asked that abuse not be queried in the instruments used to identify the existence of PTSD), the findings indicate that a CBT group treatment is effective in reducing trauma related symptoms (PTSD and depression) in children. Because CBT is considered to be the treatment of choice for PTSD (Harvey, Bryant & Tarrier, 2003; Stein et al., 2003; Paunovic, 1999) and because a standardized method for treating children will help in the CBITS replicability, more research with other populations is needed. However, generalizability is improved in the Stein et al. (2003) study, because the researchers assessed all of the children from two different schools for PTSD symptoms, prior to random assignment.
The efficacy for practical uses of CBITS by clinicians makes sense, particularly in a school setting. The findings that show improvements in reduced PTSD and depression symptomolgy is impressive, however getting school personnel to implement such a treatment could be difficult given that classroom behavior may get worse during treatment. Duplicating this study with various other children who are in a school setting might also aid in the generalizability of CBITS, provided the findings of such a study are also favorable.
Fortune, A. E. & Reid, W. J. (1999). Research in social work (3rd ed.). New York: Columbia University Press.
Harvey, A. G., Bryant, R. A. & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 23, 501-522.
Paunovic, N. (1999). Exposure counterconditioning (EC) as a treatment for severe PTSD and depression with an illustrative case. Journal of Behavior Therapy and Experimental Psychiatry, 30, 105-117.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Ellitot, M. N., et al. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. The Journal of the American Medical Association, 290(5), 603-611.
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