Research Review: Psychological and psychosocial treatments for children and young people with post‐traumatic stress disorder: a network meta‐analysis

Abstract

Background Post‐traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder that affects a significant minority of youth exposed to trauma. Previous studies have concluded that trauma‐focused cognitive behavioural therapy (TF‐CBT) is an effective treatment for PTSD in youth, but the relative strengths of different psychological therapies are poorly understood. Methods We undertook a systematic review and network meta‐analyses of psychological and psychosocial interventions for children and young people with PTSD. Outcomes included PTSD symptom change scores post‐treatment and at 1–4‐month follow‐up, and remission post‐treatment. Results We included 32 trials of 17 interventions and 2,260 participants. Overall, the evidence was of moderate‐to‐low quality. No inconsistency was detected between direct and indirect evidence. Individual forms of TF‐CBT showed consistently large effects in reducing PTSD symptoms post‐treatment compared with waitlist. The order of interventions by descending magnitude of effect versus waitlist was as follows: cognitive therapy for PTSD (SMD −2.94, 95%CrI −3.94 to −1.95), 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 (CPT), eye movement desensitisation and reprocessing (EMDR), parent training, group TF‐CBT, supportive counselling and family therapy (SMD −0.37, 95%CrI −1.60 to 0.84). Results for parent training, supportive counselling and family therapy were inconclusive. Cohen TF‐CBT/CPT, group TF‐CBT and supportive counselling had the largest evidence base. Results regarding changes in PTSD symptoms at follow‐up and remission post‐treatment were uncertain due to limited evidence. Conclusions Trauma‐focused cognitive behavioural therapy, in particular individual forms, appears to be most effective in the management of PTSD in youth. EMDR is effective but to a lesser extent. Supportive counselling does not appear to be effective. Results suggest a large positive effect for emotional freedom technique, child–parent psychotherapy, combined TF‐CBT/parent training, and meditation, but further research is needed to confirm these findings as they were based on very limited evidence.

Cost‐effectiveness of psychological interventions for children and young people with post‐traumatic stress disorder

“…It can be seen that, with the exception of cognitive therapy for PTSD, the next most cost‐effective interventions up to (and including) parent training have probabilities of being cost‐effective among remaining options that do not exceed 0.40, although increasingly fewer interventions are included in the analysis, indicating the uncertainty characterising the results for high‐to‐middle rankings. Notably, supportive counselling had a higher mean NMB but worse mean ranking than no treatment and, also, a .49 probability of being cost‐effective when compared with no treatment alone, suggesting considerable uncertainty around its cost‐effectiveness; these findings are attributable to the skewed distributions of NMBs, combined with the fact that, according to the NMA that informed the economic analysis (Mavranezouli et al, ), the 95% credible intervals around the mean effect of supportive counselling versus no treatment crossed the line of no effect, indicating uncertainty in its clinical effectiveness. The cost‐effectiveness plane (Figure ) depicts the mean incremental costs and QALYs of all psychological interventions versus no treatment (placed at the origin).…”

“…Our analysis utilised effectiveness data derived from a systematic review and NMA of changes in PTSD symptoms (Mavranezouli et al, ). This methodology enabled us to consider information from both direct and indirect comparisons between interventions, and allowed simultaneous comparisons across all options while preserving randomisation (Caldwell, Ades, & Higgins, ).…”

“…The psychological interventions considered in the economic analysis were selected amongst interventions that were considered in a systematic review and NMA of randomised controlled trials (RCTs) of psychological, psychosocial and other non‐pharmacological treatments for children and young people with PTSD (Mavranezouli et al, ; see Appendix of that paper for the study protocol and the inclusion criteria for the NMA). For the economic analysis we considered only interventions that had been tested on at least 40 individuals across RCTs included in the NMA of changes in PTSD symptoms at treatment endpoint, as this was deemed the minimum size of evidence base that could support a practice recommendation.…”

Using Behavioral Insights to Design Implementation Strategies in Public Mental Health Settings: a Qualitative Study of Clinical Decision-Making

“…Of these treatments, trauma-focused cognitive behavioral therapy (TF-CBT) has been a particular focus (29). Over twenty randomized controlled trials show that TF-CBT is effective for youth with posttraumatic stress disorder (31)(32)(33). Despite its strong research base, TF-CBT is not regularly implemented in public mental health settings (34).…”

Cultural adaptation and feasibility of trauma-focused cognitive behavioural therapy in China

“…Extensive work has been done to develop and test EBTs for PTSD, including trauma-focused cognitive behavioural therapy (TF-CBT), eye movement desensitization and reprocessing, child-parent psychotherapy and parent training (Mavranezouli et al, 2019). However, these are mostly found in Western countries (Ennis et al, 2019).…”