Effect of Developmentally Adapted Cognitive Processing Therapy for Youth With Symptoms of Posttraumatic Stress Disorder After Childhood Sexual and Physical Abuse

Abstract

IMPORTANCE Despite the high prevalence, evidence-based treatments for abuse-related posttraumatic stress disorder (PTSD) in adolescents have rarely been studied. OBJECTIVE To examine whether developmentally adapted cognitive processing therapy (D-CPT) is more effective than a wait-list condition with treatment advice (WL/TA) among adolescents with PTSD related to childhood abuse. DESIGN, SETTING, AND PARTICIPANTS This rater-blinded, multicenter, randomized clinical trial (stratified by center) enrolled treatment-seeking adolescents and young adults (aged 14-21 years) with childhood abuse-related PTSD at 3 university outpatient clinics in Germany from July 2013 to June 2015, with the last follow-up interview conducted by May 2016. Of 194 patients, 88 were eligible for randomization. INTERVENTIONS Participants received D-CPT or WL/TA. Cognitive processing therapy was enhanced by a motivational and alliance-building phase, by including emotion regulation and consideration of typical developmental tasks, and by higher session frequency in the trauma-focused core CPT phase. In WL/TA, participants received treatment advice with respective recommendations of clinicians and were offered D-CPT after 7 months. MAIN OUTCOMES AND MEASURES All outcomes were assessed before treatment (baseline), approximately 8 weeks after the start of treatment, after the end of treatment (posttreatment), and at the 3-month follow-up. The primary outcome, PTSD symptom severity, was assessed in clinical interview (Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV [CAPS-CA]). Secondary outcomes were self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation. RESULTS The 88 participants (75 [85%] female) had a mean age of 18.1 years (95% CI, 17.6-18.6 years). In the intention-to-treat analysis, the 44 participants receiving D-CPT (39 [89%] female) demonstrated greater improvement than the 44 WL/TA participants (36 [82%] female) in terms of PTSD severity (mean CAPS-CA scores, 24.7 [95% CI, 16.6-32.7] vs 47.5 [95% CI, 37.9-57.1]; Hedges g = 0.90). This difference was maintained through the follow-up (mean CAPS-CA scores, 25.9 [95% CI, 16.2-35.6] vs 47.3 [95% CI, 37.8-56.8]; Hedges g = 0.80). Treatment success was greatest during the trauma-focused core phase. The D-CPT participants also showed greater and stable improvement in all secondary outcomes, with between-groups effect sizes ranging from 0.65 to 1.08 at the posttreatment assessment (eg, for borderline symptoms, 14.1 [95% CI, 8.0-20.2] vs 32.0 [95% CI, 23.8-40.2]; Hedges g = 0.91). CONCLUSIONS AND RELEVANCE Adolescents and young adults with abuse-related PTSD benefited more from D-CPT than from WL/TA. Treatment success was stable at the follow-up and generalized to borderline symptoms and other comorbidities. TRIAL REGISTRATION German Clinical Trials Register identifier: DRKS00004787

Challenges in recruiting and retaining adolescents with abuse-related posttraumatic stress disorder: lessons learned from a randomized controlled trial

“…This is especially the case when focusing on child sexual and/or physical abuse-related PTSD in adolescents and/or young adults despite a growing body of evidence that PTSD, after histories of multiple traumas in childhood, tends to be associated with higher levels of symptom complexity [52,53] or severity [54]. To our knowledge, only two RCTs have been conducted that were tailored specifically to adolescents suffering from abuse-related PTSD [55,56]. Furthermore, sample sizes were small given the respective timescales for screening in both RCTs (N = 61 in 6 years, [55], N = 88 in 2 years, [56]).…”

“…To our knowledge, only two RCTs have been conducted that were tailored specifically to adolescents suffering from abuse-related PTSD [55,56]. Furthermore, sample sizes were small given the respective timescales for screening in both RCTs (N = 61 in 6 years, [55], N = 88 in 2 years, [56]). These numbers also indicate that research with adolescents suffering from abuse-related PTSD might be challenging.…”

“…Participants aged 14 to 21 years suffering from PTSD after sexual and/or physical abuse were recruited for a multicenter RCT to evaluate developmentally adapted Cognitive Processing Therapy [D-CPT, 24] in comparison to a wait-list condition with treatment advice (WL/ TA) at three university outpatient mental health clinics in Germany from July 2013 to June 2015 [56]. Health insurance covered the psychotherapy costs.…”

Behandlung der posttraumatischen Belastungsstörung bei Kindern und Jugendlichen – ein Fallbeispiel

“…Für die Altersgruppe zwischen 14 und 18 Jahren liegen aktuell nur wenige Studien vor. Einzeluntersuchungen existieren für die Prolongierte Exposition [9] und die Cognitive Processing Therapy (CPT) [10] und zeigen eine hohe Wirksamkeit. Da sich in Metaanalysen v. a. für kognitive Interventionen die höchsten Effektstärken ergeben [11], lohnt es sich, der CPT mit ihrem kognitiven Fokus auch bei der Behandlung von Jugendlichen Aufmerksamkeit zu widmen.…”

“…Eine Besonderheit der CPT ist, dass zusätzlich die 5 Bereiche Sicherheit, Vertrauen, Macht und Kontrolle, Wertschätzung sowie Intimität besonders thematisiert werden.Es gibt bereits Hinweise, dass die CPT auch bei Jugendlichen wirkt. So wurde beispielsweise eine entwicklungsangepasste Form der CPT für Jugendliche speziell nach sexuellem und körperlichem Missbrauch entwickelt und erfolgreich evaluiert[10][15], bei der die CPT in zeitlich intensivierter Form u. a. in Kombination mit einem vorgeschalteten Emotionsregulationstraining erfolgt.TherapieprogrammMit dem Ziel der Entwicklung einer Form der CPT für Jugendliche und junge Erwachsene mit einer PTBS, die auf unterschiedliche traumatische Ereignisse zurückzuführen ist, erprobte unsere Arbeitsgruppe in den letzten Jahren eine jugendangepasste Form der CPT, die vom zeitlichen Umfang her der ursprünglichen CPT entspricht. Die vorund nachgeschalteten Module zur Behandlungsmotivation, Emotionsregulation und jugendspezifischen Themen, wie wir sie für die Behandlung von missbrauchten und misshandelten Jugendlichen entwickelt haben, werden hier nicht angeboten.…”