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Cognitive behavioral therapy (CBT)-based models for child trauma

Children's Mental Health: Trauma
Benefit-cost methods last updated December 2018.  Literature review updated August 2017.
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Cognitive behavioral therapy (CBT) for trauma includes psycho-education about post-traumatic stress disorder (PTSD), relaxation and other techniques for managing physiological and emotional stress, the gradual desensitization to memories of the traumatic event (also called exposure), and cognitive restructuring of inaccurate or unhelpful thoughts. In programs in this analysis, 5 to 27 therapeutic hours per client were provided in individual or group settings, with duration of treatment ranging from one to five months. This review includes studies of trauma-focused CBT, cognitive behavioral intervention for trauma in schools (CBITS), narrative exposure therapy for traumatized children (Kid-NET), enhancing resiliency among students experiencing stress (ERASE), trauma and grief component therapy, and Teaching Recovery Techniques (TRT).
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2017). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $7,758 Benefits minus costs $23,875
Participants $11,881 Benefit to cost ratio n/a
Others $2,732 Chance the program will produce
Indirect $1,391 benefits greater than the costs 100 %
Total benefits $23,763
Net program cost $112
Benefits minus cost $23,875
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $28 $0 $74 $14 $117
K-12 grade repetition $6 $0 $0 $3 $9
K-12 special education $84 $0 $0 $42 $126
Labor market earnings associated with PTSD $5,065 $11,153 $0 $0 $16,218
Health care associated with PTSD $2,575 $728 $2,658 $1,278 $7,239
Mortality associated with depression $0 $0 $0 ($1) ($1)
Adjustment for deadweight cost of program $0 $0 $0 $56 $56
Totals $7,758 $11,881 $2,732 $1,391 $23,763
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,037 2016 Present value of net program costs (in 2017 dollars) $112
Comparison costs $1,035 2009 Cost range (+ or -) 30 %
Per-participant costs are based on weighted average therapist time, as reported in the included studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer, 2015, Behavioral Health Data Book for the State of Washington for Rates Effective January 1, 2016). For comparison group costs we use 2010 Washington State DSHS data to estimate the average reimbursement rate for treatment of child and adolescent post-traumatic stress disorder.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Anxiety disorder 12 18 999 -0.166 0.047 12 -0.066 0.051 13 -0.307 0.001
Disruptive behavior disorder symptoms 12 3 102 -0.324 0.150 12 -0.178 0.119 15 -0.759 0.016
Externalizing behavior symptoms 12 10 528 -0.008 0.077 12 -0.004 0.046 15 0.064 0.636
Global functioning^ 12 4 165 0.239 0.141 12 n/a n/a n/a 0.490 0.038
Internalizing symptoms 12 9 296 -0.181 0.085 12 -0.181 0.085 14 -0.261 0.026
Major depressive disorder 12 25 1483 -0.308 0.054 12 0.000 0.310 14 -0.581 0.001
Post-traumatic stress 12 35 2187 -0.449 0.064 12 -0.449 0.064 13 -0.733 0.001
Suicidal ideation^ 12 1 26 -0.147 0.283 19 n/a n/a n/a -0.294 0.301

Citations Used in the Meta-Analysis

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Berger, R., Pat-Horenczyk, R., & Gelkopf, M. (2007). School-based intervention for prevention and treatment of elementary-students' terror-related distress in Israel: A quasi-randomized controlled trial. Journal of Traumatic Stress, 20(4), 541-551.

Berkowitz, S.J., Stover, C.S., & Marans, S.R. (2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry and Allied Disciplines, 52(6), 676-685.

Berliner, L., & Saunders, B.E. (1996). Treating fear and anxiety in sexually abused children: Results of a controlled 2-year follow-up study. Child Maltreatment, 1(4), 294-309.

Burke, M.M. (1988). Short-term group therapy for sexually abused girls: A learning-theory based treatment for negative effects. Dissertation Abstract International, 49, 1935.

Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic beliefs among sexually abused girls and their mothers: An evaluation study. Journal of Abnormal Child Psychology, 24(1), 1-17.

Cohen, J.A., Deblinger, E., Mannarino, A.P., & Steer, R.A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

Cohen, J.A., Mannarino, A.P., & Knudsen, K. (2005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29(2), 135-145.

Cohen, J.A., Mannarino, A.P., & Iyengar, S. (2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: A randomized controlled trial. Archives of Pediatrics and Adolescent Medicine, 165(1), 16-21.

Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310-321.

Deblinger, E., Stauffer, L.B., & Steer, R.A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6(4), 332-343.

Ertl, V., Neuner, F., Pfeiffer, A., Elbert, T., & Schauer, E. (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda: A randomized controlled trial. Jama - Journal of the American Medical Association, 306(5), 503-512.

Goenjian, A.K., Karayan, I., Pynoos, R.S., Minassian, D., Najarian, L.M., Steinberg, A.M., & Fairbanks, L.A. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154(4), 536-542.

Goldbeck, L., Muche, R., Sachser, C., Tutus, D., & Rosner, R. (2016). Effectiveness of trauma-focused cognitive behavioral therapy for children and adolescents: A randomized controlled trial in eight German mental health clinics. Psychotherapy and Psychosomatics, 85(3), 159-170.

Jensen, T.K., Holt, T., Ormhaug, S.M., Egeland, K., Granly, L., Hoaas, L.C., . . . Wentzel-Larsen, T. (2014). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology, 43(3), 356-369.

Jordans, M.J.D., Komproe, I.H., Tol, W.A., Kohrt, B.A., Luitel, N.P., Macy, R.D., & De Jong, J.T.V.M. (2010). Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial. Journal of Child Psychology and Psychiatry, 51(7), 818-826.

Kataoka, S., Stein, B.D., Jaycox, L.H., Wong M., Escudero, P., Tu, W., . . . Fink, A. (2003). A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311-318

King, N.J., Tonge, B.J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., . . . Ollendick, T.H. (2000). Treating sexually abused children with postraumatic stress symptons: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 39(11), 1347-1355.

Langley, A.K., Gonzalez, A., Sugar, C.A., Solis, D., & Jaycox, L. (2015). Bounce back: Effectiveness of an elementary school-based intervention for multicultural children exposed to traumatic events. Journal of Consulting and Clinical Psychology, 83(5), 853-65.

Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M., Pasalíç, A., Durakoviç, E. . . . Pynoos, R.S. (2008). Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 47(9), 1048-1062.

McMullen, J., O'Callaghan, P., Shannon, C., Black, A., & Eakin, J. (2013). Group trauma-focused cognitive-behavioural therapy with former child soldiers and other war-affected boys in the DR Congo: a randomised controlled trial. Journal of Child Psychology and Psychiatry, 54(11), 1231-1241.

Murray, L.K., Skavenski, S., Kane, J.C., Mayeya, J., Dorsey, S., Cohen, J.A., Michalopoulos, L.T.M., . . . Bolton, P.A. (2015). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia. Jama Pediatrics, 169(8), 761.

O'Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., & Black, A. (2013). A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. Journal of the American Academy of Child and Adolescent Psychiatry, 52(4), 359-369.

Pityaratstian, N., Piyasil, V., Ketumarn, P., Sitdhiraksa, N., Ularntinon, S., & Pariwatcharakul, P. (2015). Randomized controlled trial of group cognitive behavioural therapy for post-traumatic stress disorder in children and adolescents exposed to tsunami in Thailand. Behavioural and Cognitive Psychotherapy, 43(5), 549-61.

Qouta, S.R., Palosaari, E., Diab, M., & Punamäki, R.L. (2012). Intervention effectiveness among war-affected children: a cluster randomized controlled trial on improving mental health. Journal of Traumatic Stress, 25(3), 288-98.

Ruf, M., Schauer, M., Schauer, E., Elbert, T., Neuner, F., & Catani, C. (2010). Narrative exposure therapy for 7- to 16-year-olds: A randomized controlled trial with traumatized refugee children. Journal of Traumatic Stress, 23(4), 437-445.

Shein-Szydlo, J., Sukhodolsky, D.G., Ruchkin, V., Kon, D.S., Tejeda, M.M., Ramirez, E., Ruchkin, V., . . . Ruchkin, V. (2016). A randomized controlled study of cognitive-behavioral therapy for posttraumatic stress in street children in Mexico City. Journal of Traumatic Stress, 29(5), 406-414.

Shooshtary, M.H., Moghadam, J.A., & Panaghi, L. (2008). Outcome of cognitive behavioral therapy in adolescents after natural disaster. Journal of Adolescent Health, 42(5), 466-472.

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Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong, M., Tu, W., Elliott, M.N., & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. Journal of the American Medical Association, 290(5), 603-11.

Tol, W.A., Komproe, I.H., Susanty, D., Jordans, M.J.D., Macy, R.D., & De Jong, J.T.V.M. (2008). School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial. JAMA: The Journal of The American Medical Association, 300, 655-662.