More than half of children and young people are exposed to potentially traumatic events,1,2 and a significant minority of those exposed go on to develop post-traumatic stress disorder (PTSD).3 Because PTSD can be chronic, it can have a notable impact on child development, as well as social, academic and occupational function – it is therefore imperative that effective treatments are identified and prioritized.
The current consensus is that trauma-focused cognitive behavioural therapy (TF-CBT)4 is the most effective PTSD treatment, followed closely by eye movement desensitisation and reprocessing (EMDR).5 Many other treatments based on, for example, emotional freedom technique, child–parent psychotherapy, combined TF-CBT/parent training and meditation, have been proposed but their relative effectiveness has not been properly addressed.
In 2019, researchers in the UK performed a systematic review and network meta-analysis (NMA) of such psychological and psychosocial interventions for children and young people with PTSD. The implementation of this NMA approach meant that the researchers could make both direct and indirect treatment comparisons and thus estimate the relative effects of different treatments even if they were not directly compared in previous randomized controlled trials.6 The study included ~2,000 participants from 32 eligible studies that together assessed 17 interventions. The NMA allowed the researchers to rank PTSD interventions versus waitlist controls in terms of their descending magnitude of effect as follows: cognitive therapy for PTSD, combined somatic/cognitive therapies, child–parent psychotherapy, combined TF-CBT/parent training, meditation, narrative exposure, exposure/prolonged exposure, play therapy, Cohen TF-CBT/cognitive processing therapy, EMDR, parent training, group TF-CBT, supportive counselling and family therapy.
Based on the amount of evidence available for each treatment approach, the researchers concluded that TF-CBT, particularly individual TF-CBT, is most effective for managing PTSD and achieving remission in affected youth. Consistent with previous reports, they also found that EMDR seems to be effective, but to a lesser extent than TF-CBT. Most importantly, they found no significant difference between supportive counselling and waitlist controls, suggesting that this intervention should be avoided. Going forward, the researchers propose the routine use of TF-CBT for children and young people with PTSD, and EMDR as an alternative treatment option. Although emotional freedom technique, child–parent psychotherapy, combined TF-CBT/parent training, and meditation showed positive effects in reducing PTSD symptoms, further research is still required to determine their true efficacy.
Referring to:
Mavranezouli, I., Megnin-Viggars, O., Daly, C., Dias, S., Stockton, S., Meiser-Stedman, R., Trickey, D. & Pilling, S. (2019), Psychological and psychosocial treatments for children and young people with post-traumatic stress disorder: a network meta-analysis. J. Child Psychol. Psychiatr. doi: 10.111/jcpp.13094.
Glossary:
Post-traumatic stress disorder (PTSD): PTSD is included in the DSM-5 chapter on Trauma- and Stressor-Related Disorders. The trigger to PTSD is defined as exposure to actual or threatened death, serious injury or sexual violation. The individual may be exposed to the event directly or witness the event, learn of a traumatic event that occurred to a close family member or close friend, or experience first-hand repeated or extreme aversive details of a traumatic event. The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.
Trauma-focused cognitive behavioural therapy (TF-CBT): a form of CBT that is specifically adapted for PTSD. This short-term intervention typically requires between eight and 25 sessions, and uses cognitive behavioural techniques to modify distorted or unhelpful thinking and negative reactions and behaviours.
Eye movement desensitization and reprocessing: a brief, trauma-focused treatment whereby the patient visualizes a disturbing image from the trauma in their memory while engaging in sets of saccadic eye movements. These rapid eye movements are intended to create a similar effect to the way the brain processes memories and experiences during sleep. In this way, the brain appropriately re-processes distressing memories and eliminates emotional distress.
Network meta-analysis: a meta-analysis where more than three treatments are compared by both directly comparing the interventions within randomized controlled trials and by indirectly comparing the interventions across trials based on a common comparator or control group. This approach can answer more relevant clinical questions and can make treatment estimates for an entire treatment network than multiple, separate pair-wise analyses.
References:
(1) Landolt, M.A. et al. (2013), Trauma exposure and posttraumatic stress disorder in adolescents: a national survey in Switzerland. J. Trauma Stress. 26, 209-216. doi: 10.1002/jts.21794.
(2) McLaughlin, K.A. et al. (2013), Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J. Am. Acad. Child Adolesc. Psychiatry. 52, 815-830. doi: 10.1016/j/jaac.2013.05.011.
(3) Alisic, E. et al. (2014), Rates of posttraumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. Br. J. Psychiatry. 204, 335–340. doi: 10.1192/bjp.bp.113.131227
(4) Cohen, J. A., Mannarino, A. P. & Deblinger, E. (2017). Treating Trauma and Traumatic Grief in Children and Adolescents (2nd Ed.).: New York, NY: Guilford.
(5) Shapiro, F. et al. (2014), The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences. Perm. J. 18: 71-77. doi: 10.7812/TPP/13-098.
(6) Lu, G. et al. (2004), Combination of direct and indirect evidence in mixed treatment comparisons. Stat. Med. 23, 3105–3124. doi: 10.1002/sim.1875