The present study compared PE-A, a directive, trauma-focused cognitive-behavioral treatment, with TLDP-A, a non-directive, non trauma-focused psychodynamic treatment, among adolescents with PTSD resulting from single event trauma. The TLDP-A treatment served as a credible active control condition. Both interventions were successful in reducing distress and increasing functioning at posttreatment and at 6- and 17-month follow-up. Importantly, in an intent-to-treat sample, PE-A was superior to TLDP-A in reducing symptoms of PTSD and depression, enhancing functioning, facilitating loss of diagnostic status, and increasing overall improvement (e.g., exhibiting good end-state functioning) at post-treatment and 6 months following treatment termination. The advantage of PE-A over TLDP-A was observed at post treatment and at 6-months follow-up, but was no longer significant at 17 months post-treatment.
Importantly, the greater efficacy of PE-A in reducing post-traumatic symptoms and increasing overall level of functioning was observed despite the fact that treatment expectancy, treatment satisfaction, and therapeutic alliance were similar for both treatments. In addition, the drop-out rates from both treatments were identical (21%). These (relatively) low drop-out rates and significant clinical gains were obtained by clinicians with modest experience in treatment of trauma. This suggests that PE-A can be effectively disseminated to real-world settings.37
The findings of the present study suggest that adolescents benefit from developmentally adjusted PE and that their clinical benefit from treatment is similar to that observed in adults in reduction of PTSD and depression, and increase in functioning.13,23
Moreover, using a stringent definition of good end-state functioning, we found that 63.2% of adolescents met good end-state criteria at 6-month follow-up. In sum, we found meaningful and significant clinical changes in distress and in global functioning in a highly comorbid adolescent sample, heterogeneous with respect to trauma type and gender.
The substantial reductions in both posttraumatic and depressive symptoms observed in PE-A are congruent not only with the adult literature, but also with many previous studies regarding the efficacy of CBT among traumatized youth.4,9–11
Taken together, these findings suggest that individually administered CBT, with the common components of psychoeducation, exposure to trauma-related reminders, and revisiting of the traumatic experience, are highly effective for reduction of distress and enhancement of functioning in pediatric populations suffering from diverse traumas.
Consistent with our prediction, TLDP-A, while not as efficacious as PE-A, resulted in significant reductions in posttraumatic and depressive symptoms, and significant increases in clinician rated functioning. The percent of individuals with loss of PTSD diagnosis in the TLDP-A group was relatively low, and similar to the somewhat unusual and exceptionally effective waitlist condition in the Smith et al.4
study. Importantly, there are some significant differences between our results and those of Smith et al. First, the pre-post effect size for TLDP and Smith et al.’s WL are 0.87 and 0.27, respectively. Second, the reductions in PTSD severity scores in the TLDP and waitlist were 10.8 and 3 points, respectively. Moreover, the effects of TLDP-A are consistent with previous studies examining psychodynamic–oriented therapy in general17,38
, and trauma related problems in adults.39
Some caveats should be noted. First, given our modest sample size, it is essential to replicate the efficacy of PE-A in a larger sample. Second, although our study employed a relatively long follow-up with a sub-sample of the participants, it is important to examine maintenance of treatment gains in an adolescent sample for a longer time as an early onset of anxiety and mood disorders is associated with a more pernicious course of psychopathology. In addition, future research should compare the effects of PE and TLDP with and without medication.
Several clinical implications emerged. First, both PE-A and TLDP-A were efficacious in reducing post-traumatic distress and increasing functioning for adolescent sufferers of PTSD following single-event traumas. Both treatments were well received by the patients and their families, and evinced positive pre-treatment expectancy, high therapeutic alliance and high satisfaction with clinical outcome. Second, directive trauma-focused intervention (PEA) showed superiority over psychodynamically oriented intervention immediately after treatment and at 6-months follow-up. Third, the interventions were efficacious even with highly comorbid, heterogeneous sample.