Study Review

Therapeutic interventions for children who have experienced trauma through abuse and neglect

Psychotherapeutic treatments to reduce symptoms of trauma, such as depression and anxiety, in children or young people following experiences of abuse and/or neglect.

Outcome	Overall effectiveness This rating shows how effective the intervention is at achieving the evaluated outcome. Click here for information about how effectiveness ratings are applied.	Strength of evidence This rating shows how confident we can be about a finding, based on how the research was designed and carried out.
Complex PTSD symptoms	Overall effectiveness: 1 (maximum 2)	Strength of evidence : 2 (maximum 3)

Headline points

This summary comes from the original systematic review: Leenarts, L. E., Diehle, J., Doreleijers, T. A., Jansma, E. P., & Lindauer, R. J. (2013). Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: a systematic review. European child & adolescent psychiatry, 22(5), 269-283.
This review looked at many different therapeutic interventions for children who displayed symptoms of complex post-traumatic stress disorder such as depression and anxiety following experiences of abuse and/or neglect. One intervention, trauma-focused cognitive-behavioural therapy (TF-CBT), had the largest evidence base.
TF-CBT has a low to medium positive effect in reducing the symptoms of complex PTSD for children, which means symptoms improved when the intervention was used.
However, all of the TF-CBT studies are from the USA and so we do not know how the findings relate to a UK context.
For children who had experienced sexual abuse, studies showed TF-CBT delivered ‘durable improvement’ in trauma symptoms. Encouraging findings were also seen in a study of children who had been exposed to domestic violence.
Use of a technique called a ‘trauma narrative’ produced larger improvements in symptoms and child safety skills as well as parenting skills.
All these studies included some level of parental/caregiver involvement in the intervention.
There were promising findings (but not yet enough high quality studies) for a range of other psychotherapeutic treatments which warrant further research.

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What is this?

This review sought to report on the effectiveness of treatments for children experiencing the symptoms of complex PTSD after exposure to abuse and/or neglect. The treatments were all psychotherapeutic and the review looked at diagnosed complex PTSD.

Complex PTSD is described by the authors as comprising ‘mental health problems, such as anxiety and depression, in addition to reduced capacity for affective and interpersonal self-regulation’. MIND state that complex PTSD may be diagnosed for people who have experienced trauma at an early age or if it lasted for a long time.

Thirty-three studies were included in the review, and the authors found great diversity in the nature and quality of these studies. Therefore, it was only possible to review one treatment in depth: trauma-focused cognitive behavioural therapy. However, promising results were found for a range of other psychotherapeutic treatments including: eye movement desensitisation and reprocessing, cognitive-behavioural therapy, treatments using art, child-parent psychotherapy, the youth relationships project and systematic training for effective parenting of teens; these promising findings warrant further research.

How is it meant to work?

Trauma-focused cognitive-behavioural therapy is a well-established treatment for children and adolescents based on trauma-specific cognitive-behavioural techniques. TF-CBT includes the teaching of coping skills, relaxation techniques and psycho-education. In addition, it includes gradual exposure aimed at developing the child’s management of fear and anxiety.

The review focused on effect and the authors note that there is strong theoretical evidence supporting the use of cognitive-behavioural therapy for children with trauma-related symptoms.

What are the evaluated outcomes?

Complex PTSD symptoms

How effective is it?

Overall, trauma-focused cognitive-behavioural therapy (TF-CBT) tends to show a low to medium positive effect on PTSD or PTSD symptoms, meaning that when TF-CBT is used PTSD symptoms improve. This statement is based on a moderate strength of evidence which means that there are three or more acceptable quality studies. However, the studies were not of a high enough quality to place strong confidence in the findings. Further, four of the five studies were undertaken by the developers of TF-CBT and so there is the potential for bias.

The conclusion is based on:

Five studies relating specifically to TF-CBT
Including 778 participants

Where has it been studied?

All of the trauma-focused cognitive-behavioural therapy studies included in this review were conducted in the USA. Thus, the applicability of the evidence to a UK context may be limited.

Who does it work for?

The study looked at TF-CBT for children from 3-18 years old, but the majority of children were between 8 and 15 years old. They were a mixture of males and females, 38% being male, with a mixture of ethnic backgrounds.

All studies included some level of parental/caregiver involvement. Due to the variation in the nature of parental inclusion, it is difficult to say with any certainty the most advantageous ways in which parents should be involved in these therapies.

One study looked at the effect of TF-CBT on children who have experienced sexual abuse. In a one-year follow up study, trauma-focused cognitive-behavioural therapy was shown to be superior to non-directive therapy in producing a ‘durable improvement’ in depressive, anxiety, sexual concern symptoms, PTSD and dissociative symptoms.

Another study looked at children who have been exposed to domestic violence. TF-CBT demonstrated a significantly larger improvement compared with child-centred therapy on measures for PTSD, depression, behaviour problems, shame and abuse-related attributions . Parents also showed improvements in depression, abuse-specific distress, support of the child and effective parenting practice.

A third study investigated the potential importance of the trauma narrative (TN) component of TF-CBT. Results showed some support for the use of TN within treatment.

When, where and how does it work?

Cognitive-behavioural therapy is widely delivered via the NHS in England for complex-PTSD.

The NHS states: ‘Trauma-focused CBT is usually recommended for children and young people with PTSD. This normally involves a course of 6 to 12 sessions that have been adapted to suit the child’s age, circumstances and level of development. Where appropriate, treatment includes consulting with and involving the child’s family. Children who do not respond to trauma-focused CBT may be offered EMDR (eye movement desensitisation and reprocessing)’.

The length of treatment in the five studies ranged from 8-20 weeks. However, the findings showed that eight sessions of trauma-focused cognitive-behavioural therapy with a trauma narrative (TN) produced larger improvements in symptoms, child safety skills as well as parenting skills than a comparative condition without TN.

Conversely, 16-sessions of TF-CBT without TN showed greater increases in effective parenting practices and fewer externalising child behaviours than a comparative condition with TN. This may be the result of the programme dedicating more time to parenting support.

What are the costs and benefits?

No economic analysis is included in the study and cost-effectiveness is not mentioned.

How is it implemented?

Trauma-focused cognitive-behavioural therapy is delivered by a therapist. The model involves a number of core components based on trauma specific cognitive behavioural techniques. Techniques include: coping skills, relaxation techniques, stress-management, and psycho-education. These aim to modify negative thoughts and behaviours and bring about a better understanding of body safety skills, for example.

Another fundamental element of the therapy is gradual exposure, which involves confrontation of any memories or distressing thoughts of the trauma experience. This is often referred to as creating a child’s ‘trauma narrative’ and aims to develop the child’s management of fear and anxiety. This element is gradually introduced as the programme progresses. In the early sessions, initial discussions of the traumatic event or memory is kept to a minimum and avoids thoughts that may be too anxiety provoking. As the programme progresses, discussion of the events becomes more detailed and specific. This is done via methods such as drawing and writing, for example.

Parental involvement is considered integral to the process, though its nature can vary. This often includes individual sessions and joint sessions with the child and involves elements such as parenting skills support and psycho-education.

In summary...

There is a vast range of therapeutic interventions which seek to alleviate symptoms of complex PTSD in children who have experienced abuse and/or neglect.
There is a vast range of therapeutic interventions which seek to alleviate symptoms of complex PTSD in children who have experienced abuse and/or neglect.
However, it is important to stress that all five of the TF-CBT studies included in this review were conducted in the USA; thus, we do not know how these findings relate to a UK context. Also, four of the studies were conducted by the developers of TF-CBT
Some other treatments currently have promising results, but lack a sound methodological base, which means we can’t yet draw conclusions about the effectiveness of these treatments, but further high quality research is warranted

Further resources

This summary comes from an original systematic review called:
Leenarts, L., Diehle, J. Doreleijers, T. A. Jansma, E. P. and Lindauer, R. J. 2012. Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: A systematic review. European Child & Adolescent Psychiatry 22(5), 269–283.