Journal of Traumatic Stress

October 2016, 29, 406–414

A Randomized Controlled Study of Cognitive–Behavioral Therapy

for Posttraumatic Stress in Street Children in Mexico City
Janet Shein-Szydlo,1 Denis G. Sukhodolsky,2 David Szydlo Kon,3 Miguel Marin Tejeda,4 Esteli Ramirez,5
and Vladislav Ruchkin2,6,7
1
Centro de Investigación en Psicoterapia Psicoanalı́tica AC, CIPPAC, Mexico City, Mexico
2
Child Study Center, Yale University Medical School, New Haven, Connecticut, USA
3
ABC Neurology Center, ABC Medical Center, Mexico City, Mexico
4
Universidad Nacional Autónoma de México, Mexico City, Mexico
5
Procuradurı́a de la Defensa del Menor y la Familia, Querétaro, Mexico City, Mexico
6
Child and Adolescent Psychiatry Unit, Division of Neuroscience, Uppsala University, Uppsala, Sweden
7
Säter Forensic Psychiatric Clinic, Säter, Sweden

The study aimed to evaluate cognitive–behavioral therapy (CBT) for posttraumatic stress (PTS), depression, anxiety, and anger in street
children by a randomized controlled trial of CBT versus a waitlist control. It was conducted in 8 residential facilities for street children in
Mexico City, with assessments at baseline, posttreatment, and 3 months later. Children who reported at least moderate posttraumatic stress,
and fulfilled the study requirement were enrolled in the study (N = 100, 12–18 years old, 36 boys). There were 51 children randomized to
CBT and 49 to the waitlist condition. Randomization was stratified by gender. CBT consisted of 12 individual 1-hour sessions administered
weekly by 2 trained, master’s-level clinicians. Outcome measures included self-reports of PTS, depression, anxiety, and anger; global
improvement was assessed by the independent evaluator. Compared to participants in the waitlist condition participants in CBT showed
a significant reduction in all symptoms, with effects sizes of 1.73 to 1.75. At follow up there was attrition (n = 36), and no change from
posttreatment scores. The study did find statistically significant improvement in symptoms in the CBT group compared to the waitlist
condition; symptoms remained stable at 3 months. The study found that CBT for trauma in a sample of street children provided a reduction
of a broad range of mental health symptoms.

High rates of exposure to domestic violence (Aichhorn
et al., 2008; Thompson, 2012), physical abuse (rates of ࣈ
40%, Khurana, Sharma, Jena, Saha, & Ingle, 2004), and sexual
abuse (15%–60%; Ahmadkhaniha, Shariat, Torkaman-Nejad,
& Hoseini Moghadam, 2007; Salem & Abd el-Latif, 2002)
contribute to mental health problems affecting children residing
or working on the streets. A street child is a minor for whom the
street has become a habitual abode, a source of living, or both,
and who is inadequately protected, directed, and supervised by
responsible adults (Inter-NGO, 1983). In Mexico, an estimated
1.5 million children live, work, or both on the streets. It is esti-
mated that more than 650,000 of those children live in Mexico
Funding for this study was provided by QUIERA, the Fundación de la Aso-
ciación de Bancos de México A.C., the American Express Foundation, and the
Fundación Banorte.
Correspondence concerning this article should be addressed to Vladislav
Ruchkin, Child and Adolescent Psychiatry Unit, Division of Neuro-
science, Uppsala University, Uppsala, S-751 85, Sweden. E-mail: vladislav.
ruchkin@yale.edu
Copyright  C 2016 International Society for Traumatic Stress Studies. View
City (Peralta, 2009). Over 80% of street youths are likely to
be repeatedly victimized (Stewart et al., 2004); 20%–30%
meet criteria for posttraumatic stress disorder (PTSD; Stewart
et al., 2004), and over 90% meet criteria for one or more other
psychiatric diagnoses (Whitbeck, Hoyt, Johnson, & Chen,
2007). Traumatic events and exposure to violence associated
with living in the streets may also trigger depression, anxiety,
and difficulties regulating anger and aggression (Pynoos et al.,
2009). All of these symptoms are commonly found in street
children with cumulative trauma histories (e.g., Aichhorn et al.,
2008) The prevalence rates of recent psychiatric disorders has
been found to be at least twice as high as for those among youth
from the community (for a review, see Kamieniecki, 2001).
Although the urgent need for interventions suitable for this
vulnerable population has been explicitly stated (Kidd, 2003),
treatment methods available in developing countries often do
not have a well-established evidence base of effectiveness.
Consequently, some have argued that there is a need to adjust
evidence-based treatments to the local context and environ-
ment (Patel, Chowdhary, Rahman, & Verdeli, 2011). There is

this article online at wileyonlinelibrary.com

evidence from randomized controlled studies conducted in the
DOI: 10.1002/jts.22124 Unites States that cognitive–behavioral therapy (CBT) is an

406
 CBT for PTSD in Mexico City
effective treatment in children and adolescents for symptoms
stemming from exposure to traumatic experiences (Cohen,
Mannarino, Deblinger, & Steer, 2004; Stein et al., 2003). This
treatment has also been implemented in challenging child
groups, such as children (a) in foster care, (b) in refugee
camps, (c) in war-affected zones (Cohen, 2013; O’Callaghan,
McMullen, Shannon, Rafferty, & Black, 2013), (d) who are
urban low-income youths (Rosselló & Bernal, 1999), and
(e) who are runaway adolescents (Hyun, Chung, & Lee,
2005). Studies of CBT for trauma in children have commonly
examined a wide range of outcomes, including posttrau-
matic stress (PTS), anxiety, depression, disruptive behaviors
(O’Callaghan et al., 2013; Smith et al., 2007), and anger
(Cahill, Rauch, Hembree, & Foa, 2003; Cohen, Mannarino, &
Knudsen, 2005; March, Amaya-Jackson, Murray, & Schulte,
1998). These studies suggested that CBT for the emotional
and behavioral difficulties following exposure to traumatic
events can be useful for street children. To date, however, we
are not aware of any study of CBT or any other treatment
for trauma exposure that has been conducted with this set of
children.
Thus, we conducted a randomized controlled study to test the
effectiveness of CBT for trauma in street children (CBT-TSC);
as far as we are aware, this was the first such study. Our first
goal was to evaluate the effect of CBT on symptoms of PTS,
depression, anxiety, and anger. Our second goal was to demon-
strate the feasibility of trauma-related mental health services
in a difficult to access population with significant residential
instability.
Method
Participants and Procedure
The study was conducted in Mexico City in eight facilities that
provide shelter, food, basic education, and medical care for
street children. These facilities varied in terms of number of
children served and the type of educational and medical ser-
vices offered; mental health services were not provided. Most
children came from environments with a high risk of victimiza-
tion and minimal or no family ties.
Attendance at institutions was voluntary. Many youths stayed
at an institution for several months, although some children
came only once or twice. Children intending to stay for at least
3 months were eligible to participate. Baseline and outcome
assessments were conducted in the institutions by independent
evaluators (IEs; psychologists with master’s-level degrees),
supervised by two experienced doctoral-level psychologists
(J.S.S. and D.S.K.) during weekly group supervision and indi-
vidual supervision on an as-needed basis. To ensure that ratings
at endpoint were blind to the study arm, the IEs were blind
to treatment assignment, and were not involved in any aspects
of CBT delivery or supervision. Because many children had
limited reading skills, the IEs read all items in the evaluation
forms to all children; they answered any questions as well.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
407
There were 350 children (12–18 years) in the eight partici-
pating facilities who completed the Child Posttraumatic Stress
Reaction Index (CPTS-RI; Pynoos et al., 1987) for screening.
Of those, 174 (49.7%) children received a score of ࣙ 24 (mod-
erate or higher level of PTS), and were approached regarding
participation in the study. Clinical psychopathology, including
diagnosis of PTSD, was assessed by the Diagnostic Interview
Schedule for Children (version 2.3; DISC; Shaffer et al., 1996)
conducted by the master’s-level clinicians who were trained
and supervised by one of the study investigators. These were
the exclusion criteria: (a) severe psychopathology, such as
psychosis or severe suicidal depression that would require
different and more immediate treatment; and (b) intellectual
disability.
There were eight children who refused to participate, 25 chil-
dren left the institutions before the beginning of the study, and
12 were unable to participate due to scheduling conflicts. Of the
remaining 129 children, 10 (7.8%) did not meet PTSD criteria
on the DISC, 9 (7.0%) received an intelligence quotient (IQ)
score < 70, and 10 (7.8%) met criteria for serious psychiatric
disorder that required other treatment. This left 100 children for
randomization.
The types and rates of traumatic events (according to the
DISC), were 56 subjects (56%) who were victims of sexual
abuse, 47 (47%) of physical abuse, 18 (18%) of witnessing a
violent event, and 17 (17%) of death of a family member. There
were 35 children (35%) who reported more than one type of
traumatic event. There were 14 participants who met criteria
for comorbid anxiety disorder and 28 for comorbid depression.
Participants were recruited from 2006 to 2008 until the pro-
posed group of N = 100 (36 boys) was achieved. The age range
was 12.0 to 18.8 years (M = 14.89, SD = 1.47); see Figure 1 for
details of subject flow and Table 1 for subject characteristics.
Baseline assessment, including self-report measures of PTS,
depression, anxiety, and anger, was conducted to confirm eli-
gibility, characterize study participants, and establish baseline
for outcome measures.
Children were randomly assigned to the CBT or waitlist (WL)
condition by a research assistant who was not involved in any
treatment or evaluation. The randomization list was constructed
using a random numbers generator and was stratified by gender
to assure equal numbers of boys and girls in each condition and
blocked in sequences in a way that prevented guessing the next
subject’s assignment. Subjects who were randomized to the WL
were offered CBT after completion of the endpoint evaluation.
No differences between the CBT and the WL conditions were
found on the demographic or baseline clinical characteristics.
Endpoint data collection was conducted by an independent
evaluator who was blind to treatment assignment. There was
remarkably low attrition in the study, with only 2 out of
100 children lost to endpoint evaluation, because they left the
institution. Children in the CBT condition were also evaluated
at a 3-month follow-up. Participants in the WL were not
followed up because they were offered CBT immediately after
the endpoint assessment. No other mental health services were
408 Shein-Szydlo et al.

Assessed for eligibility (n = 174)

Excluded (n = 74)
Refused to participate (n = 8)
Left residential facility (n = 25)
Enrollment
Scheduling conflicts (n = 12)
Did not meet PTSD criteria (n = 10)
IQ below 70 (n = 9)
Randomization Severe psychiatric disorder (n = 10)
(n =100)

Allocated to CBT (n = 51) Allocated to WL (n = 49)

Received CBT (n = 50) Allocation

Assessed (n = 49)
Lost to follow up (n = 1) End-point assessment Assessed (n = 49)

Assessed (n = 36) 3-month follow-up

Figure 1. Subject flow through the study. PTSD = posttraumatic stress disorder; IQ = intelligence quotient; CBT = cognitive–behavioral therapy; WL = waitlist.

available at the institutions at the time of the study, or after
the CBT trial ended, prior to 3-month follow-up. Children were
free to stay or go at their institutions at any time during the
study or after its completion. Because the follow-up of children
who were receiving CBT after the WL was not required
for testing our study hypotheses, we opted to maximize the
sample size rather than conduct additional assessments; hence,
our study had only a posttreatment assessment. Thus, the
study design had two time points; baseline and endpoint.
We collected 3-month follow-up data in 36 of 50 children
in the CBT condition. This 72% retention rate for 3-month
follow-up is similar to studies of behavioral interventions
conducted in the United States (e.g., Bearss et al., 2015). There
were no significant differences in age, gender, baseline PTS,
anxiety, depression, and anger symptoms between 36 subjects
available for follow-up and 15 subjects not available for
follow-up.
The study was approved by the institutional review board
of the Department of Postgraduate Research at the UNAM
(Universidad Nacional Autónoma de México), all subjects pro-
vided their assent, and their guardians (officials at the facilities
where the child was residing) signed an informed consent for
participation. None of the participants was compensated for
their participation in the study.
Measures
The Diagnostic Interview Schedule for Children (version 2.3;
DISC-2.3; Shaffer et al., 1996) is a structured diagnostic in-
strument that assesses most common psychiatric diagnoses of
children and adolescents. The DISC is designed for interviewer
administration, with administration time of approximately 1 hr,
and is a reliable and economical tool for assessing child psy-
chopathology (Shaffer et al., 1996). Interrater reliability of the
PTSD module of the DISC was evaluated in 13 children in the
sample by two raters (κ = .81). In the present study, a Spanish-
language version of the DISC-2.3 (Bravo, Woodbury-Farina,
Canino, & Rubio-Stipec, 1993) was used.
The Wechsler Intelligence Scale for Children (WISC-III;
Wechsler, 1991) and the Wechsler Adult Intelligence Scale
(WAIS; Wechsler, 1997) for those 17 years of age or older,
represent individually administered tests of intelligence and
cognitive ability. The measures take 45–65 min to administer.
A number of concurrent studies were conducted to examine the

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 CBT for PTSD in Mexico City 409

Table 1
Differences in Subject Characteristics at Baseline by Treatment Group
CBT (n = 50) WL (n = 49)
Variable n or M % or SD n or M % or SD t or χ2
Age (years) 14.75 1.71 15.05 1.78 0.87
IQ 95.75 14.24 95.53 14.29 0.75
Male 17 33.3 19 38.8 0.32
History of homelessness 14 27.5 9 18.4 1.16
Contact with family
Yes 29 56.9 31 63.3
No 22 43.1 18 36.7 0.43
Geographic origin
Urban 34 66.7 36 73.5
Rural 17 33.3 13 26.5 0.55
Type of traumatic event
Sexual abuse 23 45.1 21 42.9 0.05
Physical abuse 30 58.8 23 46.9 1.42
Witnessing violence 11 21.6 7 14.3 0.89
Death of a family member 5 9.8 12 24.5 Fisher exact
Anxiety disorder 9 17.6 5 10.2 Fisher exact
Depression 17 33.3 11 22.4 1.47
Note. There were 35 subjects who reported more than one traumatic event. CBT = cognitive–behavioral therapy; WL = waitlist; IQ = intelligence quotient;
ns = nonsignificant.

scales reliability and validity, and the measures are considered
the most widely used IQ tests, for both children and older ado-
lescents (Kaplan & Saccuzzo, 2005). Intelligence was evaluated
with the block design and vocabulary subtest of the Wechsler
Intelligence Scale for Children (WISC-III; Wechsler, 1991) or
the Wechsler Adult Intelligence Scale (WAIS; Wechsler, 1997)
for those 17 years of age or older.
The Child Posttraumatic Stress Reaction Index (CPTS-RI;
Pynoos et al., 1987) consists of 20 items, assessing the fre-
quency of PTS symptoms in the past month on a 5-point scale
(0 = none; 1 = a little; 2 = some; 3 = often; 4 = most of the
time), and has been used with the Spanish-speaking populations
(Goenjian et al., 2001). The total score ranges from 0 to 80 and
the degree of reaction is categorized as doubtful (score < 12),
mild (12–24), moderate (25–39), severe (40–59), or very severe
(ࣙ 60). In the present study, Cronbach’s α was .73.
The Child PTSD Symptoms Scale (CPSS; Foa, Johnson,
Feeny, & Treadwell, 2001) consists of 17 items assessing
the frequency of experiencing PTS symptoms over the past
2 weeks on a 0–3 scale (0 = not at all, 1 = once a week or
less/once in a while, 2 = 2 to 4 times a week/half the time, and
3 = 5 or more times a week/almost always), and has been used
with the Spanish-speaking children (Bustos, Rincón, & Aedo,
2009). The total score ranges from 0 to 51 and a score of ࣙ 11
has been suggested as the cutoff for probable PTSD (Foa et al.,
2001). Cronbach’s α was .79.
The Clinical Global Impression-Improvement Scale (CGI-I;
Guy, 1976), completed by the IEs, was used as another outcome
measure. The clinical global impression pretreatment score was
assigned based on the review of the PTSD symptoms during
the DISC interview. The same IE conducted the baseline and
endpoint evaluation. The CGI-I score reflected the indepen-
dent clinician’s assessment of overall change rated as 1 = very
much improved, 2 = much improved, 3 = minimally improved,
4 = no change, 5 = minimally worse, 6 = much worse, or 7 =
very much worse; hence lower scores corresponded to more im-
provement. By convention (Guy, 1976), ratings of either much
improved or very much improved defined positive response. All
other scores were classified as a negative response.
The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown,
& Steer, 1988) consists of 21 items measuring severity of
anxiety symptoms during the last 7 days on a 4-point scale
(0 = not at all; 1 = mildly, but it didn’t bother me much;
2 = moderately, it wasn’t pleasant at times; and 3 = severely,
it bothered me a lot). Although initially designed for use
with older populations, the measure has demonstrated valid-
ity with 12-to 17-year-old adolescents (e.g., Kumar, Steer, &
Beck, 1993). The instrument was validated with Mexican pop-
ulations (Robles, Varela, Jurado, & Páez, 2001). Cronbach’s
α was .75.
The Beck Depression Inventory (BDI; Beck, Ward,
Mendelsohn, Mock, & Erlbaugh, 1961) consists of 21 multiple-
choice items measuring severity of depressive symptoms during
the last 7 days. Although initially designed for individuals aged
13 and over, the measure has showed validity with 12-year-
old adolescents (Winter, Steer, Jones-Hicks, & Beck, 1999).

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
410
The validation for the Mexican population was conducted by
Jurado et al. (1998). Cronbach’s α was .81.
The Trait Anger Scale of the State Trait Anger Expression
Inventory (STAXI; Spielberger, 1988) consists of 10 items eval-
uating subjects’ general tendency to experience anger and de-
scribing how often a person becomes angry in a variety of
situations on a 4-point scale (1 = almost never, 2 = sometimes,
3 = often; 4 = almost always). The measure was developed
for adults, but has also shown reliability in adolescents (Reyes,
Meininger, Liehr, Chan, & Mueller, 2003). The measure was
validated in Mexico (Alcazar, Deffenbacher, & Byrne, 2011).
Cronbach’s α was .85.
The treatment consisted of 12 weekly, individually admin-
istered, 1-hr sessions that were organized in seven modules
and delivered according to a detailed manual. Similar to other
cognitive–behavioral interventions for trauma in children
(Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2013), the
treatment included learning to use emotion-regulation skills,
cognitive restructuring, relaxation, imaginary exposures to
traumatic memories, and in vivo exposures to avoidance. The
principles of narrative exposure for PTSD were adapted from
the evidence-based CBT approaches for trauma and violence
exposure (Cohen, Mannarino, & Devlinger, 2006; Jaycox,
2004). The components of psychoeducation about trauma and
safety were developed to address local and culture-specific
needs of street children in Mexico City. Cognitive restructur-
ing, emotion identification, relaxation, and problem-solving
modules were adapted from the training curriculum used by the
senior study investigators (J.S.S. and D.S.K.). The manual was
further developed by including case illustrations from clinical
work with children with PTSD conducted by J.S.S. and D.S.K.
and providing narrative scripts for clinicians. The draft of the
manual was then piloted with 10 street children (who were
not study participants). This resulted in enriching the manual
with additional examples brought to treatment by the street
children, as well as by the language that street children used to
describe their traumatic experiences. The manual also included
three additional themes that were addressed throughout the
treatment as clinically indicated: (a) safety issues, which were
discussed on the ongoing basis and information was provided
about residential and educational services available; (b) issues
of loss and separation from parents, addressed by building
supportive relationships in therapy and emphasizing values of
personal competencies; (c) social-problem solving to enhance
social relationships (Shein-Szydlo & Szydlo Kon, 2006).
Sessions were conducted by two master’s-level female psy-
chologists who were trained in uniform administration of the
CBT-TSC by an expert clinician (J.S.S.). During the plan-
ning stages of the study each therapist piloted CBT treatment
with 10 children under direct, session-by-session supervision
from J.S.S.
The sequence of treatment components was organized in
seven modules. Module 1 was an introduction to the treatment
and education about trauma and PTS symptoms. Module 2
was stress management and relaxation techniques. Module 3
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Shein-Szydlo et al.
was cognitive–behavioral strategies of feeling identification,
and techniques to counteract negative thoughts related to the
traumatic experience. Module 4 was exposure to trauma via
reconstruction of the traumatic experience through the narration
of the trauma and using tools, such as drawing and writing.
Module 5 was exposure to fears and avoidance of situations
related to trauma, with a focus on teaching that avoidance may
maintain anxiety and impede problem solving. Module 6 was
problem resolution and social skills for addressing excessive
anger, commonly associated with PTSD. Module 7 was a review
of the previous material and strategies for the prevention of
symptoms exacerbation.
In addition, three sessions were conducted with the child’s
case worker at the institutions to provide education about the
principles of CBT, to collect clinically relevant information
about the child’s background, and whenever feasible, to de-
velop exposure exercises that were conducted within the in-
stitutions with the assistance of the case worker. The thera-
pist met the case worker at the beginning, middle, and end of
treatment.
All treatment sessions were audiotaped for quality assur-
ance; 20% of the sessions were randomly selected for fidelity
ratings using a predetermined randomization scheme. A 6-item
treatment fidelity checklist was developed to rate the degree of
accomplishment of the session goals on a scale from 0 to 2 (0 =
poor, 1 = partial, 2 = complete). Consistent with other clinical
trials of behavioral interventions (e.g., Piacentini et al., 2010),
a psychologist who was not involved in treatment delivery
or outcome assessment rated each of the randomly selected
sessions using this checklist. Fidelity scores for the treatment
of each child were averaged across sessions and expressed as a
percent score. The mean level of treatment fidelity in this study
was 88% (SD = 8.8%, range = 66% to 100%).
Data Analysis
Two-way repeated measures analysis of variance (ANOVA)
was used for continuous measures. Using two treatment groups
(CBT vs. WL) and two time points (baseline vs. endpoint), the
ANOVA was used to test for a significant interaction between
the treatment group and time. To compare the results with those
of previous studies, the effect size (ES) for continuous measures
was calculated as the score change from baseline to endpoint in
CBT minus the change in WL divided by the pooled standard
deviation at endpoint. Categorical data used to characterize
subjects at baseline and the rates of positive response on the
CGI-I were evaluated by χ2 or Fisher’s exact test for cells with
n ࣙ 5. The two-tailed statistical significance was set at α =
.05. Follow-up scores in the CBT group were examined using
paired t tests for PTS measures and Fisher’s exact test for CGI-I
to test for change from endpoint to follow-up. All available data
were used in the analysis. Because two participants did not have
endpoint evaluations, these two subjects were not included in
the data analysis.
 CBT for PTSD in Mexico City 411

Table 2
Baseline, Endpoint, and Effect Size Values by Treatment Group
CBT (n = 50) WL (n = 49)
Baseline Endpoint Baseline Endpoint
Variable M SD M SD M SD M SD ES
CPTSD-RI 43.94 11.65 20.22 11.29 44.94 11.90 43.00 14.83 1.75
CPSS 28.18 9.68 12.00 8.69 26.31 8.70 26.65 11.12 1.73
BDI 28.39 11.60 10.82 8.56 28.00 11.89 27.37 13.56 1.48
BAI 19.49 10.91 8.71 8.16 18.94 9.87 18.53 10.47 1.05
STAXI 24.02 7.89 19.08 6.01 22.82 7.78 22.41 7.67 0.62
Note. All effect size values were statistically significant at p < .001. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CPSS = Child PTSD Symptoms
Scale; CPTS-RI = Child Posttraumatic Stress Reaction Index; ES = effect size (calculated as the difference between the change scores in CBT and WL divided by
pooled standard deviation); STAXI = State Trait Anger Expression Inventory.

Results
The levels of PTS symptoms both on the self-report measures
and on the IEs ratings for the CBT group decreased signifi-
cantly compared to the WL group (Table 2). The mean CPTS-
RI score decreased from M = 43.94, SD = 11.65 to M = 20.22,
SD = 11.29 in the CBT group, compared to M = 44.94, SD =
11.90 to M = 43.00, SD = 14.83 in the WL group, F(1, 97) =
73.04, p < .001; a large effect size of 1.75. The endpoint
CPTS-RI score in the CBT group was in the category of mild
PTS, whereas the baseline score was in the severe range. Simi-
larly (Table 2), the mean CPSS score decreased from M = 28.18,
SD = 9.68 to M = 12.00, SD = 8.69 in the CBT group compared
to change from M = 26.31, SD = 8.70 to M = 26.65, SD =
11.12 in the WL group, F(1, 97) = 69.18, p < .001, ES = 1.73.
On the CGI-I, 30 of 49 subjects (61.2%) in the CBT condition
were rated as much or very much improved compared with 2 of
49 (4.1%) in the WL condition, χ2 (1, N = 99) = 36.4, p < .001.
There was a significant reduction of anxiety, depression, and
anger symptoms. The BDI moved from M = 28.39, SD = 11.60
to M = 10.82, SD = 8.56 in the CBT group and from M = 28.00,
SD = 11.89 to M = 27.37, SD = 13.56 in the WL group, F(1,
97) = 51.56, p < .001. On the BAI, the CBT group decreased
from M = 19.49, SD = 10.91 to M = 8.71, SD = 8.16; the WL
group changed from M = 18.94, SD = 9.87 to M = 18.53, SD =
10.47, F(1, 97) = 25.43, p < .001. On the Trait-Anger subscale
of the STAXI, the mean score in the CBT group reduced from
M = 24.02, SD = 7.89 to M = 19.08, SD = 19.08, whereas
levels of anger in the WL group remained relatively stable,
M = 22.82, SD = 7.78 at baseline and M = 22.41, SD = 7.67 at
endpoint, F(1, 97) = 13.23, p < .001. These group differences
resulted in large ESs for the measures of depression (ES = 1.48)
and anxiety (ES = 1.05) and medium ES for anger (ES = 0.62).
Thirty-six children (71% retention rate) in the CBT group
still resided in the facility and were available for follow-up.
The follow-up scores on the CPTS-RI (M = 18.50, SD = 12.26)
and the CPSS (M = 11.87, SD = 9.63) were not statistically
different from the endpoint scores, t(35) = 0 .51, and t(37) =
−0.72, both nonsignificant (ns). Similarly, the follow-up scores
on the BDI (M = 10.97, SD = 10.07), the BAI (M = 7.08,
SD = 7.15), and the STAXI (M = 18.49, SD = 6.98) were not
different from the endpoint scores, t(35) = −0.69, t(35) = 0.06,
and t(34) = 0.50, all ns.
Discussion
CBT is considered to be the first choice of treatment for PTS in
children (Cohen et al., 2004; Silva et al., 2003). Our study found
a significant improvement in the symptoms of PTS compared to
the WL group after structured CBT in Mexican street children,
which remained stable at 3-month follow-up for those who
stayed at the institution. The study addressed the important
issue of generalizability of the methods with well-established
evidence of effectiveness to other cultures.
In addition to demonstrating efficacy of CBT for PTS in
street children, our study had broader implications for the treat-
ment of trauma in children in general. First, it showed that
CBT can be helpful even in the context of significant adver-
sity, when the children have been removed from the traumatic
environment. Although the issues of safety and daily living
skills were addressed as an auxiliary element of treatment, the
core component of CBT was focused on PTS, and demon-
strated that addressing mental health needs is feasible despite
persistent environmental stressors. The robust response to CBT
observed in our study showed that child-focused interventions
can be effective even in the absence of parental involvement;
these street children had little to no contact with their parents.
Third, significant decreases were found not only in symptoms
of posttraumatic stress, but also of anxiety and depression. This
suggested a need for transdiagnostic CBT approaches that could
address multiple emotional and behavioral problems of youth
with complex diagnostic profiles.
As noted above, anger and irritability are common problems
in children and adolescents with PTSD. There has been

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
412
emerging evidence that trauma-focused CBT may reduce
disruptive behaviors (Smith et al., 2007, Stein et al., 2003) and
the subjective experience of anger (e.g., Cahill et al., 2003;
Cohen et al., 2005; March et al., 1998). Our study expanded
the evidence base in support of positive effects of CBT on
self-reported anger in adolescents with PTS. Furthermore,
the magnitude of this effect (d = 0.62) was compatible with
the effects of CBT on anger and aggression in children with
disruptive behavior disorders (e.g., Sukhodolsky et al., 2004).
This underscored the view that anger and irritability can be
important treatment targets of CBT for individuals with PTS.
The stability of treatment gains at 3-month follow-up was
confounded by the children remaining at the institution at the
end of the study and being removed from continuous exposure
to a traumatic environment. Thus, future research should focus
on plans regarding future placement and follow-up of the child.
One limitation of the study was that the treatment included
both traditional CBT elements, and therapeutic strategies that
were developed to address specific needs of street children.
Future studies utilizing dismantling designs should investigate
which specific elements of CBT and ancillary therapeutic tech-
niques are differentially related to the treatment change. An-
other limitation of the study was reliance on self-reports, with
bias from self-report and single informant. Given the nature
of the sample, we did not attempt to collect information from
parents; however, the use of IEs enabled a more objective as-
sessment of PTS symptoms than self-report alone. A second
limitation of the study was the use of a WL as a compari-
son condition that controlled for the effects of the passage of
time, but did not control for nonspecific therapeutic factors
such as change agents, for example, being able to discuss one’s
symptoms with caring and sympathetic adults. The children
in our study were not receiving any mental health services
other than those provided in the study. Future studies should
test CBT-TSC against other active treatments to investigate
if treatment gains are indeed due to specific therapeutic tech-
niques of CBT. Our recruitment methods and study criteria
could have affected the generalizability of the sample, as street
children seeking services at the eight participating institutions
may not be representative of all street children in Mexico City.
In addition, limiting the study to children who expected to be
in the institution for 3 months and only following up those
who remained at the institution resulted in a highly select sam-
ple of children. The assent to participate was obtained from
children who reported that they planned to stay at the institu-
tions for the duration of the study; hence, it is unclear if this
study could speak to the feasibility of conducting this interven-
tion with most or all street children in Mexico City. No attempt
was made to assess those youth who returned to their families
or continued to live on the streets. Although these youth did
not differ from those who participated in the follow-up assess-
ment on any baseline variables, we knew that by the end of
the follow-up they differed significantly in terms of their living
situation; hence, the stability of the effects for those who left
the institution could not be ascertained.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Shein-Szydlo et al.
Street children have a wide range of clinical and educa-
tional needs that are best addressed with comprehensive pro-
gramming. The plight of homelessness, exposure to maltreat-
ment, and psychiatric symptomatology in this vulnerable group
is profound and interventions to ease distress and break this
cycle are rare. As a result of living in unstable and unsafe
environments, street children often have concrete and urgent
health needs (Zlotnick, Tam, & Zerger, 2012), which should be
addressed before introducing trauma-related interventions
(Kidd, 2003); ideally these children should be moved into sta-
ble, safe environments (Thompson, 2012). Once this has been
achieved, the opportunity to use CBT to treat symptoms after
trauma, as indicated by previous studies and the current study,
suggests that this should be a priority.
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