Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Melissa Alfaro

Bon Secours Memorial College of Nursing

Nursing Research 4122

On my honor, I have neither given nor received aid on this assignment, and I pledge that I am in

compliance with the BSMCON Honor System. Melissa Alfaro

AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to assess the literature concerning the effectiveness of

trauma-focused cognitive behavioral therapy compared to control groups in reducing

posttraumatic stress disorder and comorbid symptoms in the pediatric population. Posttraumatic

stress disorder and depression following traumatic events can lead to maladaptive behaviors in

youth; prompt and time-effective treatment is necessary in order to mitigate the illness. Trauma-

focused cognitive behavioral therapy, augmented from usual cognitive behavioral therapy by

direct addressment trauma symptoms, may reduce the morbidity of the illnesses. The following

research follows an integrative review design. Literature was collected using the online

databases, PubMed, EBSCO Discover, and psycNET. The search yielded 563 research articles. 5

met inclusion criteria. The findings analysis demonstrated inconclusive results pertaining to the

use of trauma-focused cognitive behavioral therapy for traumatized youth with PTSD. All

studies were effective in reducing posttraumatic stress symptoms; however, some were not

superior to the control group in doing so. Research limitations include the lack of research in the

past 5 years and a lack of experience on behalf of the researcher. Additional limitations include

the discrepancies in the delivery of trauma-focused cognitive behavioral therapy; time allotted

for treatment; the involvement of the caregiver in therapy; and inclusion of articles that may

contain bias. Implications for practice cannot be deduced from the integrative review due to the

inconsistencies across the research findings. There is an indication for future research that would

ensure the consistency on trauma-focused cognitive behavioral therapy, and consistent

measurement tools for variables.

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An Integrative Review

The purpose of this integrative review is to appraise literature pertaining to the use of

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in the pediatric population diagnosed

with posttraumatic stress disorder (PTSD). Cognitive behavioral therapy (CBT) has been used

with great remission rate with depressed children and adolescents; however, the history of

trauma in the adolescent tends to convolute the success of CBT (Shirk, DePrince, Cristostomo, &

Labus, 2013). Although children may create coping mechanisms in order to foster a sense of

normalcy, those coping mechanisms may lend themselves to unhealthy patterns, giving rise to

anxiety and depression (Konanur, Muller, Cinamon, Thornback & Zorzella, 2015). The aim of

this integrative review is to explore the literature pertaining to the researchers PICOT question:

In the pediatric population diagnosed with posttraumatic stress disorder (PTSD), what is the

effect of TF-CBT versus control in reducing PTSD and comorbid anxiety and depression? While

research is abundant in regards to the implementation of CBT for youth with posttraumatic

symptoms, there is limited evidence on TF-CBT that works specifically to address the trauma.

The researchers personal experience sparked interest in this topic; as a victim of intimate abuse

and violence, regular course of CBT was not effective for her.

Design and Search Methods

This integrative review focuses on five research articles. Three databases, PubMed,

EBSCO Discover, and psycNET, were used to search for articles. The terms included PTSD,

children, adolescents, trauma, and CBT. The research yielded 107 results from PubMed,

326 results from EBSCOhost and 130 articles from psycNET. To obtain recent articles, the

search was limited from 2011 to 2016. Filters were used to narrow down the articles to peer-

reviewed quantitative and qualitative nursing research articles in English, published in academic
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journals with full text. It was imperative that the articles pertained to the researchers PICO

question, In the pediatric population diagnosed with posttraumatic stress disorder (PTSD), what

is the effect of TF-CBT versus control in reducing PTSD and comorbid anxiety and depression?

The articles were then selected based on the following inclusion criteria: TF-CBT, and

examination of anxiety and depression. The research articles were screen based on inclusion

criteria and PICO question significance. Articles that did not meet the criteria were excluded

from the review. The screening produced 5 TF-CBT articles, all of which were quantitative.

Findings/Results

The results and findings of the research showed mixed results; 3 of the 5 articles

demonstrated a greater reduction in signs and symptoms of PTSD and associated comorbidities

compared to the controls (Jensen et al., 2014; Goldbeck et al., 2016; Konanur et al., 2015). Two

articles (Nixon et al., 2012; Shirk et al., 2014) did not, as TF-CBT did not outperform the

controls in that population in reducing symptoms of PTSD and comorbidities. A summary of the

research articles are in Table 1. This review is structured around the following themes in order to

categorize findings: use of TF-CBT as an intervention; differing dependent variables used for

analysis, and differing definitions of TF-CBT.

TF-CBT Interventions

Among all 5 studies, there was a consensus that the use of TF-CBT was effective in

reducing symptoms of PTSD (Jensen et al., 2014; Goldbeck et al., 2016; Konanur et al., 2015;

Nixon et al., 2012; Shirk et al., 2014). However, 2 of the studies did not outperform the control

group (Nixon et al., 2012, Shirk et al., 2014). In the quantitative study conducted by Konanur et

al. (2015), researchers examined the PTSD status outcomes of a randomized, controlled trial
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involving the use of TF-CBT versus a waitlist among 6 to 12-year-old Canadian children.

Employing a convenience sampling method, 113 children recruited from mental health clinics in

Canada were randomly assigned to a non-waitlist or waitlist (WL) condition. The non-waitlist

group completed a pre-waitlist data collection then immediately started receiving TF-CBT

treatment, whereas the waitlist group completed pre-waitlist collection data, waited three months,

then started TF-CBT treatment. For both WL and TF-CBT groups, data was collected pre-

therapy, post-therapy and six months following therapy using the Trauma Symptom Checklist for

Children or Trauma Symptom Checklist for Young Children. Data was analyzed with T scores

using raw scores obtained from child and caregiver reports of childrens PTS. A linear, mixed

model one-way ANOVA was used for repeated measures for statistical analyses. Significant

decreases in childrens PTS from pre-assessment to the six-month follow up were indicated in

the TF-CBT group versus WL condition. There was also a reduction in childrens and

caregivers report of associated arousal symptoms and intrusion symptoms. The effectiveness of

the study and statistical significant decrease in clinical variables among school-age children

contributes to the body of literature.

Goldbeck et al. (2016) sought to investigate the effectiveness of TF-CBT in German

children and adolescents compared to those in a WL condition. The single-blind stratified

parallel-group randomized control trial investigated the superiority of TF-CBT to WL groups in

terms of reducing posttraumatic stress syndromes (PTSS) assessed at 4 months. Also, additional

hypotheses sought to explore the following outcomes: remission of PTSD diagnosis, remission

of comorbid mental disorders, improvement of psychosocial functioning, reduction of self-

reported and caregiver reported PTSS, posttraumatic cognitions, general behavioral and

emotional symptoms, symptoms of anxiety and depression, and improvement of quality of life.
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Utilizing convenience sampling, 159 children and adolescents between the ages of 7-17 years old

who were symptomatic of PTSD per the Clinician-Administered PTSD Scale for Children and

Adolescents (CAPS-CA) were randomly assigned to 12 sessions of TF-CBT or a WL. The WL

received no treatment. Data was collected at baseline, 2 months and 4 months for both groups.

Data analysis was performed using raw data from the database and imported into the Statistical

Package for the Social Sciences, version 21 for Windows. The primary hypothesis was tested by

a repeated-measures ANOVA as assessed by blind evaluators. Analyses of secondary outcomes

were also performed by ANOVAs. Significant data was found in the number of youth receiving

treatment who had fulfilled the diagnostic criteria of PTSD at baseline who were no longer

diagnosed as having PTSD. Furthermore, there was a significant number of patients among the

treatment group who no longer filled the criteria for any comorbid mental disorder after 4

months. The significant data found in this study contributes to the body of literature.

The experimental trial conducted by Jensen et al. (2014) sought to evaluate whether TF-

CBT was superior to therapy as usual (TAU) in eight community clinics in Norway. Using

convenience sampling, 156 youth in between the ages of 10 and 18 were randomized to either

TF-CBT or TAU. Data collection occurred at baseline, mid-treatment after the 6th session, and

post-treatment after 15 sessions. Data collection included the measurement of PTSS using

CAPS-CA and Child Posttraumatic Symptom Scale (CPSS). Secondary outcomes were

measured using a battery of tests, assessing comorbid disorders, anxiety and depression. Data

analysis was performed using a mixed effects model on each of the outcome measures and

utilized the statistics program R and SPSS version 17. The study demonstrated a significant

decrease in PTSS values and depressive symptoms in the TF-CBT group than those in TAU

group. All groups showed significant reductions in PTSS between pre- and post-therapy
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assessments. There was no significant effect of treatment condition on child anxiety symptoms

in either group. In terms of diagnostic remission, significantly more participants in the TF-CBT

group lost their PTSD diagnosis. The significant data found in this article contributes to the

body of literature.

The randomized control trial conducted by Shirk et al. (2014) studied the initial

feasibility, acceptability, and treatment impact of modified CBT (m-CBT). The m-CBT was the

core CBT therapy augmented with mindfulness exercises targeted directly at trauma-related

emotions and cognitions. Adolescents were referred for outpatient treatment at a large mental

health center in the Rocky Mountains. The study followed 43 adolescents between the ages of

13 and 17. The m-CBT was a 12-session, manual-guided individual weekly therapy for

adolescents with a diagnosis of PTSD and a history of at least one interpersonal trauma. Data

was collected at sessions 1, 4, 8, 12 and at post-treatment at 16 weeks and for the primary

outcome, included Beck Depression Inventory II (BDI-II) scores. A battery of tests was used for

the secondary outcomes of feasibility and acceptability. Data analyses included assessing for

differences using t-tests for continuous variables and chi-squared for categorical variables. A

repeated measures linear mixed-effects model was applied to all outcomes. Results indicated

that results from both CBT and m-CBT indicated a significant reduction in PTSS and depressive

symptoms, though m-CBT did not outperform CBT. Diagnostic statuses did not differ between

groups. The contrasting outcome of this study drives the need for amelioration of research in this

area and contributes to the body of literature.

The experimental study by Nixon et al. (2012) examined the outcomes of a randomized,

controlled trial involving TF-CBT versus trauma focused cognitive therapy (CT) in the reduction

of PTSD in child following single-incident trauma. The researchers were also interested in the
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effects of caregiver pretreatment levels of PTS, unhelpful posttraumatic beliefs, and depression.

Using convenience sampling, 34 child and adolescent victims were referred from mental health

clinics, hospital and police in Australia. Children and adolescents were randomized to either TF-

CBT or CT. TF-CBT comprised of 9 sessions, pretreatment, posttreatment and a 6-month follow-

up; and included CAPS-CA as the measurement of the primary outcome. Secondary outcomes

were measured using participants self-reports of: The Child PTSD Symptom Scale (CPSS), the

Childrens Depression Inventory (CDI), the Childhood Post-Traumatic Cognitions Inventory

(CPTCI), and the Revised Childrens Manifest Anxiety Scale (RCMAS). Mothers rated their

children on the Child Behavior Check List (CBCL), and rated their own responses to their childs

trauma using the Posttraumatic Stress Diagnostic Scale (PDS), Post-Traumatic Cognitions

Inventory (PTCI), and the BDI-II. Repeated measures ANOVAs were used to determine

symptom change. X2 or Fisher exact test was used to determine differences in diagnosis, in

conjunction with Reliable Change Index (RCI), used to assess good end-state functioning.

Significant decreases in PTSD symptoms, associated trauma cognitions, and general anxiety

were reduced across both groups. Mothers of both groups reported significant reductions of their

own PTSD and depressive symptoms. Both youth across the two groups showed a significant

remission in their status of PTSD. The findings connote a need for further development in the

research of TF-CBT, and thus contributes to the body of literature.

Differing Dependent Variables Used for Analysis

All five of the research studies utilized quantitative variables to measure the effectiveness

of TF-CBT and compared the results with the control group (Jensen et al., 2014; Goldbeck et al.,

2016; Konanur et al., 2015; Nixon et al., 2012; Shirk et al., 2014). Albeit the tools chosen are

effective at measuring the intended variable, the consistency of measurements for every primary
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and secondary outcome is not the same tool. Thus, is difficult to extrapolate the true impact of

TF-CBT on PTSD and comorbidities. BDI-II was used for the primary outcome of reduction of

PTSD symptoms in the study conducted by Shirk et al. (2014). BDI-II was used as a

measurement in the secondary outcome of maternal PTSD of the child victimized (Nixon et al.,

2012).

Two of the studies used CAPS-CA and CPSS as a measurement of PTSD (Jensen et al.,

2014; Nixon et al., 2012); Goldbeck et al. (2016) only used CAPS-CA to measure PTSD. For

the primary outcome of PTSD symptoms, Konanur et al. (2015) used Trauma Symptom

Checklist for Children (TSCC) to measure trauma-related symptoms among children 8-16.

Trauma Symptom Checklist for Young Children (TSCYC) was used for caregivers to report the

trauma-related symptoms of their children up to age 12.

In terms of secondary variables, 4 of the studies included parental or caregiver

involvement and therapeutic treatment in conjunction with the child victim as part of the TF-

CBT protocol (Goldbeck et al., 2016; Jensen et al., 2014; Konanur et al., 2015; Nixon et al.,

2011). The differing variables highlight the need for consistency throughout the research.

Differing Definitions of TF-CBT

Across the studies, there was not one definitive amount of time allotted for amount of

sessions, nor was there a consensus on the definition of TF-CBT. All 5 studies explored the

benefit of addressing the trauma, which is the cornerstone of TF-CBT (Jensen et al., 2014;

Goldbeck et al., 2016; Konanur et al., 2015; Nixon et al., 2012; Shirk et al., 2014). The

execution of the core idea deviates among the studies. Shirk et al. (2014) enhanced CBT with

mindfulness techniques and targeting trauma-related beliefs over 12 individual therapy sessions,

and each session was not time limited. For 4 of the other studies, TF-CBT focused on
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psychoeducation, relaxation training, anxiety management, working through the trauma

narrative, cognitive errors and restructuring, and involved the caregiver or the parents to varying

degrees; the parents received parenting skills aimed at managing the childs illness (Jensen et al.,

2014; Goldbeck et al., 2016; Konanur et al., 2015; Nixon et al., 2012). In the study conducted by

Nixon et al. (2012), children received one and-a-half hour weekly sessions provided over nine

weeks, with two thirds of the session time dedicated to the children and the rest of the time

dedicated to the parents. TF-CBT sessions provided by Jensen et al. (2014) included 12 to 15

sessions, with sessions offered to the child and parent in either parallel and co-joint sessions.

Konanur et al. (2015) provided weekly therapy sessions that consisted of 45 minutes allotted to

the child and 45 minutes allotted to the caregivers. In the study conducted by Goldbeck et al.

(2016), 12 weekly 90-minute parallel or co-joint therapy sessions with the caregiver were spread

over 4 months.

Discussion/Implications

The findings of the integrative review address the effects of TF-CBT versus control

groups and the efficacy of reducing PTSD and comorbid disorders in the pediatric population.

Therefore, all the articles directly relate to the researchers PICOT question which asks about the

effect of TF-CBT versus control in reducing PTSD and comorbid anxiety and depression in the

pediatric population diagnosed with PTSD. Among all 5 studies, there was a consensus that the

use of TF-CBT was effective in reducing symptoms of PTSD (Jensen et al., 2014; Goldbeck et

al., 2016; Konanur et al., 2015; Nixon et al., 2012; Shirk et al., 2014). However, 2 of the studies

did not outperform the control group (Shirk et al., 2014; Nixon et al., 2012). Implications for

practice are difficult to extract from the evidence due to the inability to deem it superior to

controls. Furthermore, the existing literature does not agree on the definition of trauma-focused
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cognitive behavioral therapy. In order to demonstrate the true efficacy of TF-CBT, further

research is needed. Follow-up research necessitates the need for an absolute definition of TF-

CBT, and utilization of the same tools used consistently across trials for the same variables.

Limitations

Many limitations were imposed in regard to this integrative review. The topic is not

heavily researched, including only five articles within the past five years, so it is not an

exhaustive examination. Also, the researcher does not have adequate experience in completing

an integrative review, as this is a class exercise.

Because of the scant amount of literature on the topic, and a discord in the measurements

of the variables amongst the articles, the extraction of results is difficult to compare. Because of

the nature of the sampling method in all of the studies, all the studies included are prone to bias

(Coughlan et al., 2007, Jensen et al., 2014; Goldbeck et al., 2016; Konanur et al., 2015; Nixon et

al., 2012; Shirk et al., 2014). Also, 4 of the studies fail to explicitly mention the theoretical

framework (Jensen et al., 2014; Goldbeck et al., 2016; Konanur et al., 2015; Nixon et al., 2012).

Without a theoretical framework, a study is prone to a weak study design (Coughlan et al., 2007).

Conclusions

Findings from this integrative review are inconclusive. Three studies demonstrate the

significance of TF-CBT over controls in the reduction of PTSD and comorbidities (Jensen et al.,

2014; Goldbeck et al., 2016; Konanur et al., 2015); Two studies of TF-CBT do not outperform

the control groups (Nixon et al., 2012; Shirk et al., 201). Overall, it cannot be concluded if TF-

CBT is more effective than controls at reducing the symptoms of PTSD and anxiety and

depression in youth.
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References

Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1:

Quantitative research. British Journal of Nursing, 16(11), 658-663. doi:

10.12968/bjon.2007.16.11.23681

Goldbeck, L., Muche, R., Sachser, C., Tutus, D., & Rosner, R. (2016). Effectiveness of trauma-

focused cognitive behavioral therapy for children and adolescents: A randomized control

trial in eight German mental health clinics. Psychotherapy and Psychosomatics 85(1),

159-170.

Jensen, T.K., Holt, T., Ormhaug, S.M., Egeland, K., Granly, L., Hoaas, L.C., Hukkelberg, S.S.,

Indregard, T., & Shirley, D.S. (2014). A randomized effectiveness study comparing

trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of

Clinical Child and Adolescent Psychology, 43(3), 356-369.

Konanur, S., Muller, R.T., Cinamon, J.S., Thornback, K., & Zorzella, K.P. (2015). Effectiveness

of trauma-focused cognitive behavioral therapy in a community-based program. Child

Abuse & Neglect, 50(1), 159-170.

Nixon, R.D., Sterk, J., & Pearce, A. (2012). A randomized trial of cognitive behavior therapy and

cognitive therapy for children with posttraumatic stress disorder following single-incident

trauma. Journal of Abnormal Child Psychology 40(1), 327-337.

Shirk, S.R., DePrince, A.P., Crisostomo, P.S., & Labus, J. (2013). Cognitive behavioral therapy for

depressed adolescents exposed to interpersonal trauma: an initial effectiveness trial. American

Psychological Association, 51(1), 167-179. doi: 10.1037/a0034845

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First Author Shirk (2014) Department of Psychology, University of Denver, Denver,

(Year)/Qualificati Colorado
ons
Background/Prob Depression is an impairing condition, emerging usually in adolescents. Trauma
lem Statement convolutes the treatment of adolescents with trauma using cognitive behavioral
therapy (CBT)
Problem statement is the gap in CBT treatment that does not focus specifically on
trauma.
Conceptual/theor Deployment-focused approach
etical Framework
Design/Method/P Randomized Control Trial
hilosophical Initial effectiveness trial
Underpinnings evaluation of modified CBT (m-CBT) versus CBT in adolescents who experienced
interpersonal trauma.
Sample/ 43 adolescents referred for outpatient treatment between the ages of 13 to 17.
Setting/Ethical Large urban community mental health center in the Rocky Mountains.
Considerations Approved by an institutional review board at the University of Denver as well as
the community clinic review board.
Consent was provided by the parents of minors
No mention of confidentiality, autonomy protection
Major Variables Feasibility; Acceptability; Impact of the m-CBT; Control group = CBT as usual
Studied
Measurement Acceptability was measured by pre- and posttreatment of Treatment Evaluation
Tool/Data Inventory (TEI); Impact was measured by Beck Depression Scale II; Feasibility
Collection was measured by attendance/attrition.
Method
Data Analysis The inferential statistical tests used to analyze data were t-tests for continuous
variables and chi-
square for categorical variables. The Therapy Process Observational Coding
System-Strategies Scale
Findings/Discussi The results in terms of the studys feasibility were mixed; on average, adolescents
on completed only about half of the planned m-CBT treatment, with two adolescents
finishing the full protocol of m-CBT.
Despite poor attendance, adolescents reported high treatment satisfaction and
acceptability in both treatments, meaning that both treatments were reasonable,
appropriate and relevant per the adolescents, meaning the intervention was helpful
Impact - It was found that DBI-II scores changed by approximately one standard
deviation unit from pre- to post-treatment, a large effect
However, symptoms reduction did not differ across treatment groups nor did
diagnostic remission rates. It was found that approximately half of the adolescents
regardless of treatment type no longer met the diagnostic criteria for a depressive
disorder following treatment.
Appraisal/Worth CBT has great impact on depressive symptoms, regardless of trauma focused or
to practice not; Highlights the areas of improvement on implementing m-CBT.
First Author Goldbeck (2014) is affiliated with the Clinic for Child and Adolescent
(Year)/Qualificati Psychiatry/Psychotherapy in Germany.
ons
Background/Prob Many children who have been exposed to traumas exhibit post-traumatic stress
 AN INTEGRATIVE REVIEW 14

lem Statement symptoms (PTSS). Although trauma-focused treatments are available, many do
not receive the appropriate care.

This study aims to fill the current gaps in the literature and investigate the
effectiveness of TF-CBT in a range of different German child and adolescent
mental health services compared to a waiting-list group.
Conceptual/theor not discussed
etical Framework
Design/Method/P Quantitative Experimental
hilosophical Single blind stratified (by severity of PTSS) parallel-group randomized control
Underpinnings trial
Sample/ Eight German child and adolescent mental health clinics
Setting/Ethical 73 patients receiving TF-CBT; 84 patients allocated to waiting list.
Considerations All the legal guardians of the study participants gave their informed written
consent and the young patients gave their informed written assent.
The study received ethics approval from the IRB at the University of Ulm
Major Variables Experimental Group= Adolescents who received TF-CBT treatment. Outcomes
Studied (and their measured by: Remission of PTSD diagnosis, remission of comorbid mental
definition), if disorders, improvement of psychosocial functioning, reduction of self-reported
appropriate and care-giver reported PTSS, post-traumatic cognitions, general behavioral and
emotional symptoms, symptoms of anxiety and depression, and improvement of
quality of life

Whether TF-CBT in PTSD was equally effective 1. Independent of the patients

age, 2 in male and female patients 3. In patients with experience of interpersonal
and accidental trauma events 4. In patients with or without comorbid disorders, 5
whether delivered in the community or university clinics or 6 whether delivered by
therapists with versus without previous experience in TF-CBT.

Control Group= Patients on a waiting list

Measurement Primary outcome - Total Frequency and Intensity Score of PTSS assessed by the
Tool/Data Clinical-Administered PTSD Scale for Children and Adolescents (CAPS-CA),
Collection also used to establish the diagnostic status with regard to the DSM-IV criteria for
Method PTSA.
Presence of comorbid mental disorders according to the DSM-IV was determined
by the Schedule of Affective Disorders and Schizophrenia for School-Age
Children Revised for DSM-IV (K-SADS) administered to the child and the
caregiver.
Level of psychosocial functioning was assess using the Childrens Global
Assessment Scale (CGAS).
PTSS were reported on the child/adolescent and the caregiver version of the
UCLA-PTSD Reaction Index.
Patients cognitive distortions related to the trauma were assessed by self-reports
on the Child Posttraumatic Cognitions Inventory (CPTCI).
Symptoms of anxiety were assessed by self-reports and caregiver reports on the
Screen for Child Anxiety-Related Emotional Disorders (SCARED).
Symptoms of depression were assessed by self-reports on the Childrens
Depression Inventory (CDI). The Child Behavior Checklist was given to the
 AN INTEGRATIVE REVIEW 15

patients caregivers.
The patients quality of life was assessed by self-reports and caregiver reports on
the Inventory of Quality of Life for Children (ILK).
Data Analysis Descriptive Statistics frequencies, means, standard deviations, t-tests
Findings/Discussi Study demonstrates the superiority of TF-CBT to WL in terms of remission of
on PTSS and dysfunctional trauma-related cognitions, PTSD diagnoses and a broad
range of comorbid symptoms such as depression, anxiety and other internalizing
and externalizing symptoms.
TF-CBT was superior to WL in improving the patients psychosocial functioning.
Improvement of quality of life was not greater in the intervention group.
Findings showed that TF-CBT was effective independent to age, gender, trauma
type, level of specialization of the therapist, and the therapists individual
experience with the treatment model. Patients age and comorbidity were
significantly associated with treatment response, indicating that younger patients
and patients with fewer comorbid disorders are most susceptible to remission of
PTSS.
Appraisal/Worth TF-CBT improves symptoms of PTSD and comorbidities.
to practice The younger the patient is and the less comorbidities, the greater the outcome.
This experiment involved the parents in the therapy process.

First Author Tine K. Jensen (2014) Jensen is affiliated with the Norwegian Centre for
(Year)/Qualificati Violence and Traumatic Stress Studies and Department of Psychology at the
ons University of Solo, Norway
Background/Prob Traumatic events happen to children over the world. If untreated, it may lead to
lem Statement many mental health problems. There is an increase of anxiety and mood disorders
in those children who have experienced a traumatic event.
There is a gap in research whether TF-CBT is just as effective in community
clinics, in children with multiple trauma, or in comparison with usual care. They
also sought to examine whether TF-CBT is also applicable outside the United
States.
Conceptual/theor Not mentioned in the study
etical Framework
Design/Method/P Quantitative
hilosophical Randomized effectiveness study
Underpinnings

Sample/ 156 boys and girls between the ages of 10 to 18, from 8 community clinics for
Setting/Ethical children and adolescents with trauma-related symptoms in Norway.
Considerations
Study was approved by the Regional Committee for Medical and Health Research
Ethics. Written active consent to participate was provided by both the children and
their parents.
Major Variables TF-CBT versus care as usual
Studied (and their Primary outcome measure: PTSS
definition), if Secondary outcome measures: associated symptoms
appropriate
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Measurement PTSS measured using the CPSS (Self-report questionnaire) and the Clinician
Tool/Data Administered PSTD Scale for Children and Adolescents (CAPS-CA).
Collection Secondary outcomes measured using Mood and Feelings Questionnaire (MFQ);
Method the Screen for Child Anxiety-Related Disorders (SCARED) and the Strengths and
Difficulties Questionnaire (SDQ).

Data Analysis Power analysis; descriptive statistics to investigate the characteristics of the
sample; mixed effects model on the outcome measures; Intention-to-treat (ITT)
models. Statistics program R and SPSS version 17.
Findings/Discussi Youth in both treatment groups showed significant improvement from pre- to post
on therapy in terms of PTSS, depression, and anxiety and general mental health
functioning.
For the group that received TF-CBT the negative impact of PTSS on daily
functioning, depressive symptoms, and general mental health problems scored
significantly lower than those in the TAU group post treatment.
Significantly fewer participants that received TF-CBT met the diagnostic criteria
for full PTSD treatment.
TF-CBT may be more effective in reducing a wide range of symptoms than usual
care.
Appraisal/Worth Because PTSD often co-occurs with other disorders, it is important for clinicians
to practice to consider when treating for PTSD.

First Author Konanur, S. (2015) The author is affiliated with the Department of Psychology,
(Year)/Qualificati Faculty of Health, York University, Canada
ons
Background/Probl Research has documented the negative sequelae of trauma in children.
em Statement The provision of a timely and effective trauma-focused intervention, in this case,
TF-CBT
Conceptual/theore Not mentioned in the article
tical Framework

Design/Method/P Quantitative
hilosophical The researchers hypothesized a reported reduction in PTS following TF-CBT.
Underpinnings

Sample/ 113 children 10 to 12 years old, recruited from different community centers in
Setting/Ethical Canada.
Considerations Ethical considerations not mentioned
Major Variables TF-CBT vs. waiting list (no therapy)
Studied (and their Symptoms of PTS
definition), if Comorbid factors of PTS
appropriate

Measurement Trauma symptom Checklist for Children (TSCC)

Tool/Data Trauma Symptom Checklist for Young Children (TSCYC)
Collection
Method
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Data Analysis T scores, linear mixed model one-way ANOVA

Findings/Discussi Significant reduction in childrens PTS occurring from pre-assessment to post-
on therapy and follow-up, rather than during the treatment period alone, showed
symptomatic improvement beginning during the assessment.
Intrusion and avoidance arousal symptoms were found to increase during the
assessment period.
Appraisal/Worth Children waiting for clinical services do not experience an alleviation of PTS; it
to practice can be inferred that the passage of time does not decrease PTS.

First Author Nixon (2016) School of Psychology at Flinders University

(Year)/Qualificati
ons
Background/Probl Exposure to traumatic events places children at risk for posttraumatic stress
em Statement disorder.
Conceptual/theore Not mentioned in the article
tical Framework The researchers were interested in examining the long-term effects (1-year follow-
up) and moderators of outcome for children
Design/Method/P Quantitative
hilosophical Randomized control trial
Underpinnings The researchers hypothesized a reported reduction in PTSD following TF-CBT.
Sample/ 33 children and youth 7-17 years old suffering from PTSD following a single-
Setting/Ethical incident trauma.
Considerations Ethics approval was given by the university hospital ethics committee
Major Variables PTSD symptoms
Studied (and their Symptoms of anxiety, depression
definition), if Caregiver symptoms of anxiety, depression, PTSD
appropriate
Measurement CAPS-CA
Tool/Data CPSS
Collection CPTCI
Method CBCL
PTCI
BDI-II
Data Analysis Repeated ANOVAs, X2 Fishers test
Findings/Discussi Children who received a trauma-focused CBT or CT intervention showed that
on posttreatment gains were maintained at 1-year follow-up. Trauma related
symptoms and correlates of PTSD all demonstrated significant reductions relative
to pretreatment levels.

Appraisal/Worth Long-term efficacy is demonstrated in this study for TF-CBT, showing lasting
to practice reductions in PTSD and correlated symptoms.