Cognitive therapy as an early treatment for post‐traumatic stress disorder in children and adolescents: a randomized controlled trial addressing preliminary efficacy and mechanisms of action

Abstract

BackgroundFew efficacious early treatments for post‐traumatic stress disorder (PTSD) in children and adolescents exist. Previous trials have intervened within the first month post‐trauma and focused on secondary prevention of later post‐traumatic stress; however, considerable natural recovery may still occur up to 6‐months post‐trauma. No trials have addressed the early treatment of established PTSD (i.e. 2‐ to 6‐months post‐trauma).MethodsTwenty‐nine youth (8–17 years) with PTSD (according to age‐appropriate DSM‐IV or ICD‐10 diagnostic criteria) after a single‐event trauma in the previous 2–6 months were randomly allocated to Cognitive Therapy for PTSD (CT‐PTSD; n = 14) or waiting list (WL; n = 15) for 10 weeks.ResultsSignificantly more participants were free of PTSD after CT‐PTSD (71%) than WL (27%) at posttreatment (intent‐to‐treat, 95% CI for difference .04–.71). CT‐PTSD yielded greater improvement on child‐report questionnaire measures of PTSD, depression and anxiety; clinician‐rated functioning; and parent‐reported outcomes. Recovery after CT‐PTSD was maintained at 6‐ and 12‐month posttreatment. Beneficial effects of CT‐PTSD were mediated through changes in appraisals and safety‐seeking behaviours, as predicted by cognitive models of PTSD. CT‐PTSD was considered acceptable on the basis of low dropout and high treatment credibility and therapist alliance ratings.ConclusionsThis trial provides preliminary support for the efficacy and acceptability of CT‐PTSD as an early treatment for PTSD in youth. Moreover, the trial did not support the extension of ‘watchful waiting’ into the 2‐ to 6‐month post‐trauma window, as significant improvements in the WL arm (particularly in terms of functioning and depression) were not observed. Replication in larger samples is needed, but attention to recruitment issues will be required.

A core role for cognitive processes in the acute onset and maintenance of post‐traumatic stress in children and adolescents

“…These data support targeting negative appraisals in the psychological prevention and treatment of PTSD. When viewed alongside data from randomised controlled trials that have found a role for such appraisals in mediating treatment response (Jensen, Holt, Mørup Ormhaug, Fjermestad, & Wentzel‐Larsen, ; Meiser‐Stedman, Smith et al., ; Pfeiffer, Sachser, de Haan, Tutus, & Goldbeck, ), the case for making maladaptive appraisals a focus of psychological treatment is strong. A further implication is the need to recognise and address ruminative thinking styles in youth affected by trauma, rather than assuming that the sole cognitive style adopted by youth is avoidance.…”

Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations

“…Three studies were identified among children and adolescents. Among UK children and adolescents with singleincident trauma, Meiser-Stedman et al (2017;high quality) observed changes in rumination and safety-seeking behavior to associate with the effects of individual CT-PTSD on PTSS. When temporal order was established by only looking at changes from start of treatment to midway through it, only changes in safety-seeking remained a significant mediator of pre-post effects on PTSS.…”

“…Traumatic Memories and Centrality of Traumatic Event A single high-quality study was identified examining changes in traumatic memories as a mechanism of change. Meiser-Stedman et al (2017;high quality) found pre-post changes in self-perceived quality of traumatic memories to be associated with CT-PTSD effects on PTSS among children and adolescents. However, when changes from pretreatment to midway through only were included, in order to establish temporal precedence of changes, no significant mediation was observed.…”

A randomized waitlist‐controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism

“…Primary and secondary outcomes were examined first using intention-to-treat (ITT) analysis, followed by treatment completer analyses, as is common practice to provide results of those who complete the trial as well as those who have missing data as a result of dropping out (Luby, Lenze, & Tillman, 2012;Meiser-Stedman et al, 2017;Wood et al, 2009). A sample size of N = 60 was expected to be sufficient to detect large effects, given past studies of CBT interventions for children with ASD (e.g., Reaven et al, 2012), also supported by power analysis (GPower 3.1; with an alpha of .05 and power of 0.8; Cohen, 1988).…”