Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can develop following exposure to various traumatic events. It consists of three core symptom clusters; re-experiencing of a traumatic event, emotional numbing or avoidance of reminders of that event and physiological hyperarousal. Children and adolescents may experience PTSD following exposure to a wide variety of traumatic events, including sexual or physical abuse, war, natural disasters, accidents and medical-related traumas. The trauma that triggers the development of PTSD may be either of a recurring nature (e.g., ongoing sexual or physical abuse), or it may be a single incident trauma (e.g., exposure to natural disaster, motor vehicle accident (MVA) or injury).
Approximately 25% of children and adolescents report experiencing a significant traumatic event by the age of 16 years [1
]. In Australia, accidental injuries (e.g. bicycle accidents, burns, sporting injuries) represent the most common type of traumatic event experienced by youth, with approximately 2,500 per 100,000 (2.5%) children and adolescents experiencing a serious accidental injury necessitating a hospital admission each year [2
]. Although the majority of youth demonstrate great resilience or appear to be only briefly affected by such traumatic events, a significant minority of young people will develop PTSD or other psychological difficulties following exposure to a traumatic event or ongoing trauma. A recent meta-analysis reported average prevalence rates ranging from 0% to 37.5% for children who have experienced any kind of accidental injury (including MVAs, but also other accidental injuries such as burns and sporting injuries), with an average prevalence of 19.82% [3
]. Prevalence rates appear to differ according to factors such as the type of injury sustained and in particular, the method of measurement used (e.g. self-report versus diagnostic interview and the use of full or partial diagnostic criteria). For instance, Aaron, Zaglul and Emery [4
] reported that 22.5% of participants met criteria for PTSD following a physical injury, although this increased to 47.5% when considering partial PTSD.
Importantly, recent research has indicated little difference in terms of distress and impairment between children meeting full and partial criteria for PTSD [5
]. Several alternative approaches have been proposed for the classification of PTSD in youth, which take into account developmental differences in youth experiencing posttraumatic stress. Specifically, Scheeringa and colleagues [6
] have proposed an alternative PTSD algorithm ("PTSD-AA algorithm"), which removes Criterion A2 (initial response of fear, helplessness or horror) and requires only one re-experiencing symptom, one symptom of avoidance (as opposed to three) and two of hyperarousal. The PTSD-AA algorithm has now been tested in several studies and has been demonstrated to be a better predictor than DSM-IV criteria of psychosocial functioning [7
]. This suggests that the number of children suffering emotional problems after a traumatic event may be much higher than the prevalence percentages suggested by studies requiring that full diagnostic criteria be met. It also highlights the importance of studying children and adolescents who meet criteria for not only the full PTSD diagnosis, but also the alternative algorithm (PTSD-AA). From this point onwards, the term PTSD will be used to refer to young people experiencing either full PTSD or meeting the PTSD-AA algorithm.
In terms of consequences, PTSD is a chronic and debilitating disorder that is associated with significant impairments in both social and academic functioning [9
]. When considering children who have experienced accidental injury specifically, PTSD is also associated with elevated rates of other emotional and behavioural problems (especially anxiety disorders), in comparison to community samples and children admitted to hospital for non-trauma related health reasons [10
]. Further, PTSD is also associated with poorer health-related quality of life for children (i.e., the impact of disease and therapy on a person's life situation), both in the short-term and the long-term, including poorer adherence to medical protocols [11
Interventions for childhood PTSD
Trauma-focused CBT (TF-CBT) has demonstrated the strongest level of empirical support as the treatment of choice for PTSD in adults. Specifically, models of the psychological impact of trauma suggest that the way in which people remember and recount threatening events significantly affects how well they manage and adjust to those experiences [12
]. Similar models of TF-CBT have also been described for childhood PTSD [13
]. In the child and adolescent literature, the evidence base is also strongest for TF-CBT interventions [14
], however the vast majority of research has examined a very narrow sub-group of traumatic events that may affect children and adolescents (e.g. sexual abuse). Unfortunately, accidental injuries represent a sub-group of traumatic events affecting children and adolescents that is far more commonly encountered and yet has received only very little scientific attention. It is possible that this group of sufferers may present with different symptoms to those experiencing ongoing sexual abuse or repetitive trauma and subsequently, may require different treatment approaches [17
In light of these important differences, it has been suggested that the generalization or application of knowledge gained from treatment outcome studies with young people who have experienced child sexual abuse to young people who have experienced trauma other than abuse may be highly problematic [18
]. In more recent years, Cohen and colleagues' TF-CBT has demonstrated efficacy for children who experience PTSD following traumatic events other than sexual abuse, including traumatic grief, domestic violence, terrorism, natural disasters and multiple traumatic events [15
]. However, a review of the literature indicates only a handful of controlled trials that have been published examining TF-CBT for children with PTSD following a single-incident trauma.
Chemtob, Nakashima and Hamada [19
] and Stein and colleagues [20
] provided school-based interventions to children experiencing trauma symptoms following a hurricane and exposure to violence respectively. Both studies concluded that the child-focused interventions evaluated resulted in significant reductions in self-reported PTSD scores. Although extremely important, neither of these studies included a WL condition, nor did they utilise diagnostic status as a primary outcome measure. In a more recent controlled trial, Smith and colleagues [21
] compared an individual child-focused CBT condition (in which joint parent-child sessions were carried out as deemed appropriate) to a WL condition, in a sample of 24 young people who met full criteria for PTSD following either an MVA or exposure to violence. They reported that individual TF-CBT was effective in reducing indicators of PTSD in children and adolescents who had experienced a single incident trauma. However, the number of participants was extremely small and the intervention evaluated does not appear to have been uniformly administered to all participants (this is particularly relevant when considering to what extent parents were involved in treatment). Importantly, none of the studies to date appear to have examined health-related outcomes such as physical functioning or adherence to medical protocols.
Overall, research has demonstrated strong support for TF-CBT in the treatment of childhood PTSD, however, controlled investigations of youth exposed to single-incident traumas are lacking. On the limited evidence available, it appears that trauma-focused CBT may be an effective treatment for PTSD in children and adolescents exposed to accidental injuries such as MVAs. However, more controlled trials and empirical evidence is required and several important questions remain unanswered, including the importance of parental involvement in treatment and optimal timing of interventions.
The role of parents in the treatment of PTSD in children and adolescents
The role of parenting behaviours and parental anxiety have long been recognised as crucial factors in the development and maintenance of childhood anxiety disorders [e.g. [22
]]. Recent research also supports the proposal that family-focused CBT results in significantly better long-term outcomes for children with anxiety disorders. For example, Cobham, Dadds, Spence, & McDermott [23
] reported that, 3 years after completion of treatment, anxiety-disordered children/adolescents who had received family-focused CBT were significantly more likely to be anxiety diagnosis-free (92%) compared with those who had received child-focused CBT (69%). Increasingly, it is being acknowledged that parental reactions, psychopathology and coping strategies all have the potential to play an important role in the development and maintenance of children's PTSD [e.g. [24
To date, very few treatment studies in this area have included a parental treatment component, with those that have concluding that a combined parent and child trauma-focused CBT condition results in the best outcomes for children. Although the recent pilot study conducted by Smith et al. [21
] did include some degree of parental involvement, this was not quantified and did not appear to be administered in a standardized fashion across participants. From the limited evidence available it is clear that an important direction for future research centres around the question of whether involving parents in treatment significantly enhances child-focused CBT for PTSD.
The importance of early intervention
Another issue which requires attention concerns the optimal timing for delivery of CBT interventions for childhood PTSD. In terms of the course of PTSD in children and adolescents, the current adult literature and the few existing prospective studies of children presenting with PTSD suggest that a steep decline in PTSD rates may be expected within the first year following the traumatic event [26
]. However, a significant proportion of children who initially present with PTSD following a traumatic event are highly likely to continue to experience PTSD over the long-term if they do not receive treatment. There is then a fine balance to be struck between the need to provide early intervention in order to prevent the development of emotional and behavioural problems after trauma, and the need to avoid treating young people who do not need treatment and would instead recover on their own.
Strategies for identifying those most at risk for the development or continuation of poor psychological adjustment after trauma may represent the best way forward. Kenardy and colleagues [10
] reported that early self-reported symptoms of PTSD in children injured in accidents (measured at 1-2 weeks post-injury) predicted the presence of PTSD symptoms at 4-6 weeks and 6 months post-injury. Using a specially developed scale (the Child Trauma Screening Questionnaire; CTSQ), the diagnosis of 91% of children was correctly predicted in this study. Thus, it is possible to identify those children most likely to be 'at-risk' of PTSD diagnosis within the first two weeks following the injury. Moreover, it is proposed that early intervention targeted at children who demonstrate the presence of PTSD symptoms at 4-6 weeks, will be effective in significantly reducing the longer-term prevalence of PTSD and anxiety disorder symptoms.
Thus, there is a pressing need for a controlled trial examining the efficacy of a trauma focused, CBT early intervention for the treatment of PTSD in children following exposure to accidental injury. Further, a controlled trial examining the impact of CBT on psychosocial as well as health related outcomes is necessary. A trial of this sort provides the opportunity to examine whether trauma-focused CBT interventions are suitable for PTSD resulting from accidental injury, as opposed to repetitive trauma such as sexual abuse or natural disasters. Given the importance of parental involvement in the treatment of other child anxiety disorders, yet the lack of examination of this issue in the treatment of youth PTSD (overall), there is also a need to examine whether CBT interventions can be enhanced through the addition of a parent-based component.
The study protocol presented here provides an overview of the present trial including a description of the methods, design, and current status of the trial as well as a discussion of the possible implications that may arise from the findings.