Intervention Summary
Preschool PTSD Treatment (PPT)
Preschool PTSD Treatment (PPT) is a 12-session individual psychotherapy intervention that uses cognitive behavioral therapy (CBT) techniques to treat 3- to 6-year-old children with posttraumatic stress symptoms. The protocol is applicable to all types of traumatic events. PPT sessions are conducted one on one with each child, but caregivers are encouraged to participate by observing the sessions, either from another room using a video monitor or in person. PPT begins with a psychoeducation session in which the therapist and child discuss the concept of posttraumatic stress disorder (PTSD) and expectations for the remaining sessions. The second session is used to develop a discipline plan for oppositional behavior, in recognition of the comorbidity of oppositional defiant disorders with PTSD in very young children. The third session is used to practice the skills of identifying emotions. In the fourth session, therapists teach children three relaxation techniques. In the fifth session, children recount the narrative of their most distressing experience. Sessions 6 through 10 are used to expose the children to anxiety-provoking stimuli with drawings, mental imagery, and in vivo homework. In session 11, children are taught to deal with future distressing situations. Session 12 is used to review and consolidate autobiographical narratives. Caregivers' participation in PPT is designed to help them learn the material simultaneously with their children and increase their attunement to their children's issues. Caregivers also spend time alone with the therapists to help the therapists interpret the children's expressions and to discuss homework. All sessions are 45-60 minutes in duration and are delivered by licensed, trained mental health clinicians. It is optimal if the clinicians have some experience delivering CBT and working with young children. In the study reviewed for this summary, the participants were children who had experienced a life-threatening traumatic event, were between 36 and 83 months old at the time of the most recent trauma, and had four or more PTSD symptoms, including reexperiencing or avoidance. The majority of participants initially recruited for the study were 3- to 6-year-olds who had experienced acute single-blow trauma (recruited from a Level I trauma center) or chronic repeated events (recruited through battered women's programs). The study also included children who had experienced trauma related to the Hurricane Katrina disaster.
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted. Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52(8), 853-860. Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., & Angold, A. Test-retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child Adolescent Psychiatry, 45(5), 538-549.
The following populations were identified in the studies reviewed for Quality of
Research.
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
The outcome measure used in the study has strong psychometric properties. Attention was paid to assessing fidelity of the intervention. Therapists received extensive training and met with the principal investigator weekly during the study to watch their most symptomatic interviews on videotape to monitor for drift, critique technique, and correct coding errors. A treatment fidelity checklist was completed by therapists after every session. The four therapists' self-rated fidelity scores ranged from 93% to 97.5%. An independent rater scored 30.7% of the treatment sessions by reviewing videotapes and agreed with the therapists' self-ratings 97.1% of the time. Attrition rates were was high. One significant confounding variable is the effect of Hurricane Katrina, which occurred 5 months after the start of the study and forced the suspension of activities for 6 months. Because some participants could not be located after the storm, the study design was modified so that not all participants were randomized as planned. The study had a small sample size that may not have yielded enough statistical power, leading to the possibility that findings may be inconclusive.
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials. Other materials:
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria: For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
The treatment manual is easy to follow and written in user-friendly language. The treatment manual and all other program materials can be downloaded from the program Web site at no cost to implementers. The treatment manual clearly defines the target audience and identifies the conditions and situations in which this intervention should not be used. It also provides guidance on how to build rapport with clients (both children and their caregivers) and what to do if a child enrolled in the program experiences additional trauma once treatment has begun. Several checklists to support program fidelity are available. Posttraining support is available through optional phone and email consultation. There is no overview document to introduce implementers to the intervention and describe how the program materials should be used. The content and level of support offered after training is unclear. Although there are several tools to support fidelity, there is no written guidance on how to administer the tools and how the information should be used to improve program delivery.
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements. Descriptive Information
Areas of Interest
Mental health treatment
Outcomes
1: PTSD symptoms
Outcome Categories
Mental health
Trauma/injuries
Ages
0-5 (Early childhood)
6-12 (Childhood)
Genders
Male
Female
Races/Ethnicities
Black or African American
White
Race/ethnicity unspecified
Settings
Outpatient
Geographic Locations
Urban
Implementation History
Preschool PTSD Treatment was first implemented at Tulane University. It has since been implemented in approximately 20 sites in the United States and in London, England.
NIH Funding/CER Studies
Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: No
Adaptations
No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects
In the study reviewed for this summary (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie), among 46 children who attended at least 1 treatment session, there were 2 reports of possible adverse effects. A 5-year-old female reported on a brief Adverse Events Checklist during session 4 that her preexisting fear of the dark had worsened, but the phobia disappeared by session 8. A 6-year-old female developed enuresis (bed-wetting) by session 4, but the enuresis stopped by session 8.
IOM Prevention Categories
IOM prevention categories are not applicable.
Documents Reviewed
Study 1
Supplementary Materials
Outcomes
Outcome 1: PTSD symptoms
Description of Measures
Children's PTSD symptoms were assessed using the Preschool Age Psychiatric Assessment (PAPA), a structured interview used to diagnose psychiatric disorders in preschool children (ages 2-5). Derived from the Child and Adolescent Psychiatric Assessment, which is used with older children, the PAPA is tailored to feelings and behaviors pertinent to younger children. The PAPA has 26 sections focusing on a range of issues (e.g., play and peer and sibling relationships; elimination issues; sleep behaviors; separation anxiety; reactive attachment; PTSD, etc.). The PTSD section includes items dealing with acute reaction, intrusive recollections, nightmares, dissociative experiences, detachment or estrangement, and irritability. In the study, this measure was administered to caregivers by trained interviewers.
Key Findings
Participants in the study were 3- to 6-year-olds who were randomly assigned to the intervention group or to a 12-week wait-list control group. From pre- to posttest, mean scores on the PAPA in the intervention group showed substantial improvement in PTSD symptoms, whereas the control group had only slight improvement of PTSD symptoms (p < .005). This finding was associated with a large effect size (Cohen's d = 1.48).
Studies Measuring Outcome
Study 1
Study Designs
Experimental
Quality of Research Rating
2.8
(0.0-4.0 scale)
Study Populations
Study
Age
Gender
Race/Ethnicity
Study 1
0-5 (Early childhood)
6-12 (Childhood)
66% Male
34% Female
59.5% Black or African American
35.1% White
5.4% Race/ethnicity unspecified
Quality of Research Ratings by Criteria (0.0-4.0 scale)
Outcome
Reliability
of Measures
Validity
of Measures
Fidelity
Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: PTSD symptoms
3.5
3.3
3.3
2.0
2.0
2.5
2.8
Study Strengths
Study Weaknesses
Materials Reviewed
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3
2.8
2.5
2.8
Dissemination Strengths
Dissemination Weaknesses
Item Description
Cost
Required by Developer
Preschool PTSD Treatment Manual
Free
Yes
2-day, on-site training for up to 15 participants
$2,500 plus travel expenses
No
Phone and email consultation
$150 per hour
No
Diagnostic Infant and Preschool Assessment
Free
No
Diagnostic Infant and Preschool Assessment Manual
Free
No
Young Child PTSD Checklist
Free
No
Young Child PTSD Screen
Free
No
Research Diagnostic Criteria--Preschool Age
Free
No
Adaptation Checklists, Child and Parent Versions
Free
No
Therapist Fidelity Checklist
Free
No
Parent Acceptance Checklist
Free
No