Meta-Analysis of Trauma-Focused Cognitive Behavioral Therapy for Treating PTSD and Co-occurring Depression Among Children and Adolescents

Abstract

We evaluated the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) for treating posttraumatic stress disorder and co-occurring depression symptoms across 21 between-group studies representing the data of 1,860 children and adolescents (1,106 girls and 754 boys). Separate meta-analytic procedures were conducted for studies that implemented wait-list/no treatment and alternative treatment comparisons to estimate aggregated treatment effect of TF-CBT and moderators of effect size magnitude. Limitations of our findings and implications for counselors are discussed.

Keywords

TF-CBT PTSD depression research

Exposure to trauma is common in children and adolescents, which can have significant impact on their psychosocial functioning (Little & Little, 2013; Schoedl et al., 2010). Kilpatrick and colleagues (2013) reported that nearly 90% of adults in the United States have been exposed to a traumatic event at some point in their lives. Among these individuals, many of them may have been exposed to a traumatic event or stress-causing event prior to adolescence (Briggs-Gowan, Ford, Fraleigh, McCarthy, & Carter, 2010). Furthermore, survey researchers have detected that among children and adolescents, 41% had been physically assaulted within the past year and 22% had witnessed some form of violence (Finkelhor, Turner, Shattuck, & Hamby, 2013). Given the broad scope of incidence, identifying and evaluating interventions that support the mitigation of symptoms associated with trauma is a prudent task for counselors.

It is reasonable to infer that without primary intervention, exposure to traumatic events during childhood and adolescence may have deleterious effects on well-being across the life span. Although some children will demonstrate a natural, adaptive response to life following a traumatic event, others will exhibit intrusive re-experience, avoidance of associated stimuli, negative alterations in cognitions and mood, or marked alterations in arousal and reactivity that characterize posttraumatic stress disorder (PTSD). Although girls tend to report symptoms of PTSD to a greater degree than boys do (Merikangas et al., 2010), several negative disparities have been linked to unmitigated PTSD symptoms across genders such as academic dropout (Porche, Fortuna, Lin, & Alegria, 2011), vocational attainment (Sansonea, Leunga, & Wiederman, 2013), and physical heath (Maschi, Baer, Morrissey, & Moreno, 2013). Children who experience trauma are also more likely to display relational deficits such as persistent anger and poor conflict resolution skills with peers and families that tend to increase in severity and frequency as a function of the number of traumatic events the children have experienced (SAMHSA; Substance Abuse and Mental Health Services Administration, 2011).

As a result of these difficulties, many children are vulnerable to developing co-occurring psychiatric symptoms associated with disorders related to personality, anxiety, and depression (Howe, 2005). Major depressive disorder is one of the most commonly diagnosed disorders in combination with PTSD (American Psychiatric Association [APA], 2013), with researchers indicating that almost 40% of children and adolescents diagnosed with PTSD also met criteria for co-occurring major depressive disorder (Kar & Bastia, 2006; SAMSHA, 2011). Not only can the presence of co-occurring depressive symptoms complicate the treatment of PTSD (McLean, Morris, Conklin, Jayawickreme, & Foa, 2014), but some evidence has emerged that when clients exhibit co-occurring PTSD and depressive symptoms, they are at considerable risk for suicidality and behavioral problems when compared to others who have depression alone (SAMSHA, 2011). With this consideration in mind, interventions that mitigate both PTSD and depressive symptoms concurrently should be considered as a counselor’s first choice.

Target outcomes for treating PTSD among children and adolescents are commonly related to reducing the influence of thinking styles, affective responses, and ineffective behaviors that perpetuate the symptoms further (Cohen & Mannarino, 2008). Cohen, Mannarino, and Deblinger (2006) suggested that changes within these domains can promote positive developments related to emotional dysregulation, intrusive thoughts/memories/dreams, avoidance reactions, emotional numbing, and physical reactions. However, these symptoms can be resistant to mitigation in the presence of co-depression (SAMSHA, 2011). Although several approaches to counseling children and adolescents who experience the symptoms of PTSD have been presented (see Kendall, 2000; Lieberman, Van Horn, & Ippen, 2005; Najavits, Gallop, & Weiss, 2006), trauma-focused cognitive behavior therapy (TF-CBT; Cohen, Mannarino, and Deblinger, 2006) has emerged as a promising intervention for counselors to consider.

TF-CBT

TF-CBT was developed specifically for children and adolescents and has become one of the leading treatments for trauma and PTSD in this population (Cohen, Mannarino, Kliethermes, & Murray, 2012). TF-CBT utilizes trauma-sensitive interventions as well as CBT and is a relatively short treatment that takes place over 12–16 weeks. A core principle of TF-CBT is gradual exposure to the child’s traumatic experience through the various modes of treatment. Modes of treatment are described using the acronym PRACTICE and focus on coping skill development through activities that include psychoeducation, relaxation training, affective coping skills, cognitive reframing, trauma narration, in vivo exposure, conjoint child and parent sessions, and enhancement of future safety (Cohen et al., 2006).

Psychoeducation is implemented for the parent and the child and includes basic education regarding trauma responses and PTSD, including statistics regarding trauma and abuse. This can be helpful to reduce stigma regarding the situation for parents and children alike (Cohen & Mannarino, 2008). Relaxation skills entail a myriad of activities and serve to help the child feel equipped to handle stressful situations. Skills include mindfulness and breathing but also music, sports, and other recreational activities. Affective coping skills includes educating the child on emotions and then assessing where the child can use the most affective coping skills and engaging in individualized interventions. Cognitive reframing interventions facilitate the ability of child and parents to differentiate between thoughts, emotions, and behaviors and their ability to use that knowledge to effectively manage them. Once the child has completed the previous steps, the family is ready to engage in trauma narration, where the child tells the story of the trauma by writing it as a poem, song, book, or another creative venue for communication. This facilitates the child’s ability to overcome avoidance, identify any cognitive distortions, and view the trauma in the context of the rest of his or her life (Cohen & Mannarino, 2008). In vivo exposure is utilized with children who continue to struggle with life, interfering avoidance of a place or situation related to the trauma and entails gradual exposure to the situation to reduce anxiety and increase functioning. Conjoint parent and child sessions help increase communication and cohesiveness among family members. Finally, enhancing safety can include additional education for the child as needed, for example, education and discussion of healthy sexuality or safety regarding drug use (Cohen et al., 2006).

The efficacy of TF-CBT has been supported through several randomized trials and has received support from several government agencies as a best practice for treating child and adolescent PTSD (Cary & McMillen, 2012). Although this broad level of knowledge is useful to some degree, Wampold, Lichentenberg, and Waehler (2002) suggested that hypothesis testing alone is insufficient for making decisions related to what treatments work, for whom, and under what circumstances. This supposition was echoed by de Arellano et al. (2014) who called for further analysis over TF-CBT, especially in comparison to other evidence-supported treatments. Analysis of the available quantitative data regarding this treatment can supplement the current knowledge in the field regarding the best methods of treating children who have experienced trauma and increase favorable outcomes related to mental health counseling services.

Purpose of Study and Research Questions

The purpose of this study was to evaluate the effectiveness of TF-CBT for mitigating the symptoms of PTSD and co-occurring depression among children and adolescents with a history of traumatic experiences. Additionally, in the presence of heterogeneous findings across studies, we intended to identify visually observable associations between sample age, ethnic composition of the participant sample, and type of trauma as moderators of aggregated effect size. To accomplish this, we completed a meta-analysis of between-group outcome studies published between 2000 and 2014 to answer the following three research questions: (a) To what degree is TF-CBT effective for decreasing the symptoms of PTSD? (b) To what degree is TF-CBT effective for decreasing the symptoms of co-occurring depression among individuals with PTSD? and (c) What are the relationships between mean sample age, ethnic identity, reported trauma type, and domicile moderators and aggregated effect size?

Method

We searched for published and unpublished quantitative studies that estimated the efficacy of TF-CBT for treating the symptoms of PTSD and co-occurring depression among individuals who had been exposed to traumatic events. Data from identified studies that met our inclusion criteria were coded, collated, and synthesized using procedures to correct for small sample size bias and influence of study quality that resulted in an aggregated estimation of treatment effect for PTSD and depression symptoms.

Inclusion and Exclusion Criteria

Inclusion of studies within this meta-analysis was contingent on the following criteria: (a) studies implemented between-group quantitative research designs; (b) studies were published in peer-reviewed journals, dissertations, or theses; (c) the primary symptom treated among participants was PTSD as conceptualized within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (APA, 2000) or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, 2013); (d) eligibility for study participation was completed by a trained mental health practitioner; (e) TF-CBT was a therapeutic strategy implemented in the study; (f) researchers used standardized assessments prior to treatment (pretest) and at termination (posttest) to evaluate symptom severity; (g) mean and standard deviation data for pretest and posttest measures were reported; and (h) studies were published in English. Studies were excluded from our analysis if they reported findings from single-group, single-case, intent-to-treat analyses, or correlational research studies, did not assess features of pretest data, did not report information related to participant characteristics, or contained data reported across multiple publications. We established these standards a priori to support the presence of quality reports within our study sample while also reducing the influence of publication bias when estimating aggregated treatment effect.

Search Strategies

We implemented three search strategies to identify and include studies that reported changes in PTSD and co-occurring depression symptoms associated with participation in TF-CBT: (a) electronic database searches, (b) journal-specific searches, and (c) reviewing of reference lists. The first author independently searched PsycINFO, Pubmed, Academic OneFile, Web of Science, PsycARTICLES, Google Scholar, and Dissertations and Theses databases for articles within the time frame from 2000 to 2014. The key words TF-CBT and trauma-focused CBT were used to identify the intervention and trauma, posttraumatic, and PTSD to identify the target population. All database searches except Google scholar and dissertations and theses were screened through the databases peer-reviewed function to return relevant document abstracts.

We located eligible studies within relevant publication sources by completing journal-specific searches within the following periodicals: Behavior Therapy, Journal of Counseling and Development, Counseling Outcome Research and Evaluation, Journal of Mental Health Counseling, Journal of Trauma Practice, Journal of Traumatic Stress, The Counseling Psychologist, Psychological Trauma: Theory, Research, Practice, and Policy, and Journal of Aggression, Maltreatment, and Trauma. Reference lists of each eligible study were reviewed to detect any further studies for inclusion. All relevant articles, dissertations, theses, and abstracts that met inclusion criteria were pooled using the RefWorks database software program (www.refworks.com) and screened for redundancies using the check duplicates function.

Coding Procedures

The first author implemented guidelines detailed by Cooper, Hedges, and Valentine (2009) to code article information related to study features, participant characteristics, and contrasts needed to compute group gain scores. A coding guide was developed a priori by the first author, peer-reviewed to substantiate that target variables would be included within our sample of studies, and implemented throughout the data coding/verification processes.

Statistical Methods

Statistical analyses were completed using the Comprehensive Meta-Analysis, Version 2.0 software program. We computed standardized mean difference expressed with the Hedge’s g unbiased effect size metric to account for the influence of sample size and sampling error among studies (Erford, Savin-Murphy, & Butler, 2010; Lipsey & Wilson, 2001). We also attempted to control for the influence that larger studies may have on mean effect size by implementing a weighted invariance effect size procedure (Lipsey & Wilson, 2001). We evaluated null hypotheses for individuals and aggregated effect sizes by inspecting confidence intervals at the 95% level. Within our data set, negative effect sizes with greater magnitudes were representative of greater effectiveness of TF-CBT when compared to no treatment, wait-list, or alternative treatment comparisons. All effect sizes were interpreted using the suggestions submitted by Cohen (1988) for describing magnitudes as small (ES ≥ .20), medium (ES ≥ .50), and large (ES ≥ .80).

We evaluated publication bias by inspecting funnel plots that designated study effect sizes on the abscissa and standard error on the ordinate axes in which symmetrical distributions of effect sizes across standard errors represented a lesser degree of bias, whereas those that are skewed indicated potential publication bias. The fail-safe N (N_f ) metric was also computed to estimate the amount of unpublished studies reporting no treatment effect that would be needed to contradict our findings. When N_f is markedly low, it is reasonable to conjecture that the mean effect sizes may not characteristic of actual treatment effectiveness (Borenstein, Hedges, Higgins, & Rothstein, 2009; Erford et al., 2010).

Analysis of homogeneity

The homogeneity of effect size distributions were examined by inspecting values for Cochran’s Q and the inconsistency index (I ²). When the Q values are significant (i.e., p < .05) and I ² is greater than .50, heterogeneity is assumed and moderator variables should be evaluated (Borenstein et al., 2009; Erford et al., 2010).

Moderator analysis

Whereas inspection of moderator variables in large meta-analyses commonly relies on meta-regression analyses (Borenstein et al., 2009), evaluation of the features associated with effect size magnitudes within smaller samples may be most prudently completed through visual scrutiny. In the case of small sample of studies, we propose that the inferences of moderator analyses should be regarded as descriptive rather than based on statistically based predictive methods. Of interest within our analyses were the observable associations between participant age, ethnic composition of the sample, reported type of trauma, and domicile (domestic vs. international) within heterogeneous samples of effect sizes. We completed these analyses by plotting effect sizes graphically with magnitude represented on the ordinate axis and values of categorical moderating variables (age, ethnic composition of sample, type of trauma, and domicile) denoted along the abscissa. Subgroup means and confidence intervals were also computed and inspected in association with the moderator variable related to ethnic identity and type of trauma.

Results

Our search strategy yielded 49 candidate articles and 4 dissertations that warranted further inspection. After a detailed review of each candidate document and applying our inclusion/exclusion criteria, we selected 21 (21 peer-reviewed publications and 0 dissertations) for analysis (see Table 1). The total number of participants across studies was 1,860 with 1,009 of those having received TF-CBT as their primary intervention modality, 631 having received an alternative treatment, and 220 receiving no treatment or assigned to a wait-list condition. Participants across study samples were girls (n = 1,106; 59%) and boys (n = 711; 41%) with a mean age of 10.96 years (SD = 3.23), who were predominately residing in the United States (n = 1199; 63%) and receiving interventions for PTSD symptoms associated with multiple types of traumatic experiences (n = 996; 64%). All studies implemented a manualized TF-CBT protocol within the treatment condition and 17 (81%) of the 21 studies reflected data from studies conducted in community-based settings. Among the 21 studies included within our analyses, 13 (62%) implemented alternative treatment comparisons, 7 (33%) utilized wait-list/no treatment comparisons, and 1 (5%) implemented an alternative treatment and wait-list/no treatment comparison. Analyses that compared TF-CBT to a wait-list or no treatment group were based on the data of 585 participants across 7 studies, and analyses that compared TF-CBT to alternative treatments were based on the data of 1,287 participants across 14 studies.

Table 1.

Characteristics of Individual Studies Used in Meta-Analysis.

Study	Summary	N	Mean Age	Participant Characteristics	Type of Trauma	Type of Comparison
King et al. (2000)	Compared 20 sessions of TF-CBT to alternative treatment and a wait-list in a community-based setting	36	11.5	25 girls, 11 boys. Ethnicity not reported	Sexual assault	Family therapy and wait-list
Deblinger, Stauffer, and Steer (2001)	Compared 11 sessions of TF-CBT to alternative treatment in a community setting	44	5.4	17 girls, 27 boys who were White (n = 28), African American (n = 9), or other (n = 7)	Abuse/neglect	Supportive therapy
Kataoka et al. (2003)	Compared 8 sessions of TF-CBT to wait-list in a school setting	229	11.4	114 girls, 114 boys who were Latino/Latina	Abuse/neglect	Wait-list
Cohen, Deblinger, Mannarino, and Steer (2004)	Compared 12 sessions of TF-CBT to alternative treatment in a community setting	203	10.7	160 girls, 43 boys who were White (n = 122), African American (n ₌ 56), Latino/Latina (n = 9), or other (n = 16)	Sexual assault	Child-centered therapy
Cohen, Mannarino, and Knudson (2005)	Compared 12 sessions of TF-CBT to alternative treatment in a community setting	82	11.4	56 girls, 26 boys who were white (n = 49), African American (n = 30), or other (n =3)	Sexual assault	Supportive therapy
Lyshak-Stelzer, Singer, St. John, and Chemtob (2007)	Compared 16 sessions of art therapy-based TF-CBT intervention to treatment as usual within an inpatient setting	29	15	13 girls, 16 boys who were African American (n = 12), Latino/Latina (n = 5), White (n = 5), or other (n = 2)	Multiple types	TAU
Smith et al. (2007)	Compared 10 session of TF-CBT to wait-list in a school setting	24	13.8	12 girls, 12 boys who were White (n = 11), African American (n = 8), or other (n = 5)	Sexual assault	Wait-list
Berger, Pat-Horenczyk, and Gelkopf (2007)	Compared 8 sessions of TF-CBT to wait-list in a school setting	142	**	65 girls and 77 boys who were Israeli	Terrorism	Wait-list
Runyon, Deblinger, and Steer (2010)	Compared 16 sessions of TF-CBT to alternative treatment in a community setting	60	9.8	28 girls, 32 boys who were African American (n = 25) or other (n = 35)	Abuse/neglect	Parent training
Jaycox et al. (2010)	Compared 12 sessions of TF-CBT to an alternative treatment in a community setting	118	11.6	66 girls, 58 boys who were White (n = 56), African American (n = 54), or other (n = 8)	Natural disaster	Cognitive behavioral therapy
Deblinger, Mannarino, Cohen, Runyon, and Steer (2011)	Compared 8- and 12-session protocols of TF-CBT with alternative treatments without trauma component in a community setting	179	7.7	109 girls, 70 boys who were White (n = 102), African American (n = 22), Latino/Latina (n = 11), or other (n = 28)	Abuse/neglect	Cognitive behavioral therapy
Scheeringa, Weems, Cohne, Amaya-Jackson, and Guthrie (2011)	Compared 12 session of TF-CBT to wait-list in a community setting	64	5.3	22 girls, 42 boys who were African American (n = 38), white (n = 22), or other (n = 4)	Multiple types	Wait-list
Cohen, Mannarino, and Iyengar (2011)	Compared 8 sessions of TF-CBT to an alternative treatment in a community setting	124	9.6	61 girls, 63 boys who were white (n = 69), African American (n = 41), or other (n = 14)	Abuse/neglect	Child-centered therapy
Nixon, Sterk, and Pearce (2012)	Compared 9 sessions of TF-CBT to an alternative treatment in a community setting	33	11.5	12 girls, 21 boys who were European (n = 30) or other (n = 5)	Multiple types	Cognitive therapy
Schottelkorb, Doumas, and Garcia (2012)	Compared 17 sessions of TF-CBT to an alternative treatment among students referred from their school	31	9.1	17 girls, 14 boys who were of African (n = 21), Middle Eastern (n = 5) or other International origin (n = 5)	War-related	Child-centered play therapy
McMullen, O’Callaghan, Shannon, Black, and Eakin (2013)	Compared 15 sessions of TF-CBT to wait-list in a community setting	50	15.8	50 boys who were Congolese	War related	Wait-list
O’Callaghan, McMullen, Shannon, Rafferty, and Black (2013)	Compared 15 sessions of TF-CBT to wait-list in a community setting	52	16.1	52 girls who were Congolese	War related	Wait-list
Ormhaug, Jensen, Wentzel-Larsen, and Shirk (2014)	Compared 13 sessions of TF-CBT to treatment as usual in a community setting	156	15.1	123 girls, 33 boys who were Norwegian (n = 115), Asian (n = 17), or other (n = 34)	Multiple types	TAU
Jensen et al. (2014)	Compared 15 sessions of TF-CBT to treatment as usual in a community setting	156	15.1	124 girls, 32 boys who were Norwegian (n = 115), Asian (n = 17), or other (n = 34)	Multiple types	TAU
Diehle, Opmeer, Boer, Mannarino, and Lindauer (2014)	Compared 12 sessions of TF-CBT to an alternative treatment in a community setting	48	12.9	30 girls, 18 boys who were Dutch	Multiple types	EMDR

Note. ** indicates information was not included.

Is TF-CBT Effective for Decreasing the Severity of PTSD Symptoms?

Analyses of the effectiveness of TF-CBT for decreasing the severity of PTSD symptoms were based on 21 studies, yielding a total of 23 effect sizes (see Figure 1).

Figure 1.

Effect sizes, 95% confidence intervals, and p values for studies evaluating TF-CBT for decreasing PTSD symptoms using no treatment/wait-list and alternative treatment comparison groups. PTSD = posttraumatic stress disorder; TF-CBT = trauma-focused cognitive behavioral therapy.

TF-CBT versus wait-list

The seven studies included in the analysis of TF-CBT versus wait-list or no treatment comparisons (n = 554) yielded a mean effect size of −1.48 (CI 95 = [−2.13, −.83]), indicative of a large effect size and suggesting that the null hypothesis can be rejected.

The effect sizes within the distribution of studies were heterogeneous Q(6) = 51.73, p < .01 and I ² = 88.40, indicating that about 88% of the total variability were due to the between-study heterogeneity, thus exploration of moderating variables was warranted.

Scrutiny of moderating variables of interest revealed notable differences between studies in association with mean participant age in which older participant samples were associated with larger treatment effects. Inspection of the relationship between-sample ethnic identity and magnitude of effect size was not warranted, given that all included studies were composed of predominately minority participants. Evaluation of effect sizes in relation to the type of trauma that participants were receiving treatment for revealed no apparent differences based upon the type of trauma that participants were receiving treatment for. Examination of the relationship between domicile and effect size was substantial, revealing that studies from domestic samples yielded substantially lower treatment effects (g = −.76) when compared to international samples (g = −1.98). Taken together, it can be inferred that heterogeneity within this sample of studies may be associated with study characteristics related to the mean age and domicile of participants. This sample yielded an N_f of 233, indicating that 233 unpublished studies with an effect size of 0 would be needed to refute our findings.

TF-CBT versus alternative treatments

The 14 studies included in the analysis of TF-CBT versus alternative treatments (n = 1,267) yielded a mean effect size of −.28 (CI 95 = [−.44, −.11]), indicative of a small to medium effect size and suggesting that the null hypothesis can be rejected. The effect sizes within the distribution of studies were slightly heterogeneous, Q(14) = 28.98, p = .01 and I ² = 51.70, indicating that approximately 51% of the total variability was due to between study heterogeneity and that exploration of moderating variables was warranted.

Scrutiny of moderating variables of interest revealed differences between studies in which greater mean participant age was associated with larger effect sizes. Inspection of the relationship between sample ethnic identity, type of trauma experienced, and domicile and magnitude of effect size revealed no apparent differences between studies. Therefore, it can be conjectured that small amount of heterogeneity associated with this subset of studies may be associated with differences associated with the mean participant age within the studies. This sample yielded an N_f of 77, indicating that 77 unpublished studies with an effect size of 0 would be needed to refute our findings.

Is TF-CBT Effective for Decreasing the Symptoms of Depression?

Analyses of the effectiveness of TF-CBT for decreasing the symptoms of depression were based on 14 studies, yielding a total of 16 effect sizes (see Figure 2).

Figure 2.

Effect sizes, 95% confidence intervals, and p values for studies evaluating TF-CBT for decreasing symptoms of co-occurring depression using no treatment/wait-list and alternative treatment comparison groups. TF-CBT = trauma-focused cognitive behavioral therapy.

TF-CBT versus wait-list

The seven studies included in the analysis of TF-CBT versus wait-list or no treatment comparisons (n = 360) yielded a mean effect size of −.78 (CI 95 = [−1.41, −.15]), indicative of a medium to large effect size and suggesting that the null hypothesis can be rejected. The effect sizes within the distribution of studies were heterogeneous, Q(4) = 19.77, p < .01, and I ² = 79.77, indicating that about 79% of the total variability was due to between-study heterogeneity, thus exploration of moderating variables was warranted.

Scrutiny of moderating variables of interest revealed no notable differences between studies in association with mean participant age, ethnic composition, or type of trauma indicating that these characteristics were not associated with the degree that participants reported decreases in the symptoms of depression. Examination of the relationship between domicile and effect size was substantial, revealing that studies from domestic samples yielded substantially lower treatment effects (g = −.37) when compared to international samples (g = −1.39). Therefore, it can be inferred that heterogeneity within this sample of studies may be associated with study characteristics related to the domicile of participants. This sample yielded an N_f of 32, indicating that 32 unpublished studies with an effect size of zero would be needed to refute our findings.

TF-CBT versus alternative treatments

The 10 studies included in the analysis of TF-CBT versus alternative treatments for decreasing the symptoms of co-occurring depression (n = 1,109) yielded a mean effect size of −.25 (CI 95 = [−.39, .09]), indicative of a small effect size and scenario in which the null hypothesis can be rejected. The effect sizes within the distribution of studies were homogeneous, Q(10) = 14.66, p = .15, and I ² < 31.80, indicating that approximately 31% of the total variability was due to between-study heterogeneity and exploration of moderating variables was not warranted. This sample yielded an N_f of 30, indicating that 30 unpublished studies with an effect size of 0 would be needed to refute our findings.

Discussion

The findings of our meta-analysis of studies evaluating the efficacy of TF-CBT for decreasing the symptoms of PTSD and co-occurring depression produced some consistent and favorable findings. Mean effect sizes among the 21 studies assessing the efficacy of TF-CBT for decreasing PTSD indicated that TF-CBT was exceptionally superior to no treatment or wait-list comparisons and moderately superior to alternative treatments. These findings are hopeful when considering the potential for unmitigated PTSD symptomology among children and adolescents to carry into adulthood and be characterized by co-occurring psychiatric disorders (Howe, 2005; Schoedl et al., 2010). Inspection of the relationship between moderator variables and effect sizes indicated that whereas the findings are promising, they may be most descriptive of the experiences that adolescents have in treatment when compared to younger children. One possible explanation for this finding is that some components of the TF-CBT protocol may be more developmentally accessible for older clients when compared to younger ones. For example, families may be responsive to parent psychoeducation and relaxation skills training components regardless of client age; however, the ability to talk about traumatic events and work through trauma narrative components may be more successful when a greater degree of cognitive differentiation is present. Another explanation for this finding may be that older children may have more experience in communicating to caregivers and other collaterals about the type and amount of support that is helpful in their recovery from a traumatic event. Interestingly, participants across studies appeared to respond positively to treatment regardless of composite ethnic identity or type of trauma reported within the sample.

Inspection of our findings related to the effectiveness of TF-CBT for mitigating co-occurring depression symptoms across 17 studies revealed varied support in favor of TF-CBT over wait-list and alternative treatment comparisons. Among studies that implemented a wait-list or no treatment comparison, TF-CBT was notably more efficacious; however, the degree to which this effect is attributable to mean score gains among international participant samples when compared to domestic ones is uncertain. A possible explanation might be that culturally contextualized factors may have influenced the rate at which participant’s remediated associated depressive symptoms within treatment, but the nature of this information is not clear within our analysis. When inspecting differences between TF-CBT and alternative treatments for treating co-occurring depression, a modest treatment effect was detected. Within this analysis, effect sizes of individual studies were homogenous, indicating that change along the construct was likely not associated with moderating variables such as age, ethnic identity, type of trauma, or domicile. This finding is promising for counselors who wish to implement TF-CBT, especially when considering the findings that symptoms of depression commonly accompany PTSD among children and adolescents (SAMHSA, 2011) and that this co-occurrence can complicate the course of treatment (McLean et al., 2014).

Given the relatively equal distribution of girls and boys across study samples (59% girls and 41% boys) we submit that our findings may have a greater degree of generalizability than other evaluations of trauma-oriented practices that may be limited by the inclusion of predominately one gender. Furthermore, it appears that aside from age differences that were associated with treatment effect sizes, the results of our meta-analysis were mostly stable across the domains of ethnic identity and type of trauma receiving treatment for. When inspecting the differential influence of domicile on magnitude of treatment effect, we would like to highlight that although there was an apparent difference detected, both the domestic and international groups reported favorable change along symptom domains. It may be inferred from these findings that the composite elements within a TF-CBT protocol are suitable across demographic groups, with promising effects reported among individuals regardless of ethnic identity, type of trauma experienced, or geographic locale.

Implications for Counselors

Counselors interested in providing TF-CBT are encouraged to complete some degree of formal training and supervision to promote fidelity of treatment. Continuing education resources such as those at tfcbt.musc.edu provide didactic material and video demonstrations to support best practice when working with families. Formalized training will help set the foundation for counselors to enhance and implement ingenuity while implementing this intervention. Although the manual provides the groundwork, it is the obligation of the counselor to individualize and enhance the treatment through creative methods. In light of our findings, counselors should consider that this treatment may be better suited for older children and adolescents due to aspects of treatment such as the generation of the trauma narrative that require at least a moderate degree of insight. Finally, our analyses suggest that although some researchers used only the parent or child components of treatment, the full protocol that involves both children and parents were tended to be more efficacious. Therefore, despite some possible logistical complications, counselors should involve parents and children to optimize treatment outcomes.

Limitations and Recommendations for Future Research

Although meta-analyses provide an even-handed estimation of treatment effect that controls for many aspects of study characteristics and publication bias, some caveats are noted. First, our analysis of 21 PTSD studies was sufficient for inspecting the relationship of moderator variables using meta-regression analyses; the limited amount of studies inspecting co-occurring depression relegated our analyses to inspection of visually apparent relationships among graphical data. A greater sample of studies reporting these findings would have promoted more statistically robust analyses of these relationships. Next, three studies that were initially identified and met study characteristic criteria did not report adequate statistical information and contacting primary authors for this information was not fruitful. For this reason, we could not include those findings within our analysis and we encourage future researchers to report specific demographic frequencies, means, and standard deviations for scores rather than ranges or omitting demographic information that may promote generalization of findings to the larger population. Third, our analysis was based on comparisons of gain scores assessed at pretreatment and termination intervals. Although this practice provides useful information for clinicians to consider, the addition of studies that report follow-up data may help clarify the degree that treatment effects are sustained over time. Finally, when considering changes to the diagnostic criteria for PTSD within the Diagnostic and Statistical Manual, Fifth Edition (APA, 2013), it will be prudent for researchers to begin evaluating treatment effects using newer assessments of this new conceptualization.

Conclusion

Our analysis revealed that TF-CBT is a promising intervention for treating the symptoms of PTSD and co-occurring depression among children and adolescents when compared to no treatment or alternative treatments. In addition to having broad implications for effectiveness among children and adolescents, our findings suggest that treatment effects are likely to be noted when implementing this counseling approach across client populations regardless of age, ethnic identity, or type of trauma for which treatment is being sought. We suggest that counselors who wish to implement this approach seek formal education, training, and supervision but also keep in mind that the flexibility inherent within the protocol may contribute to favorable outcomes among in their setting. We regard our findings as both supportive and preliminary, conceding that greater understanding about the most efficacious applications of TF-CBT will require future investigations that accurately report procedures and outcomes within professional publication outlets.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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