Psychological Trauma: Theory, Research,

Practice, and Policy

A Randomized Trial of Cognitive Behavior Therapy and
Cognitive Therapy for Children With Posttraumatic Stress
Disorder Following Single-Incident Trauma: Predictors and
Outcome at 1-Year Follow-Up
Reginald D. V. Nixon, Jisca Sterk, Amanda Pearce, and Nathan Weber
Online First Publication, September 26, 2016. http://dx.doi.org/10.1037/tra0000190

CITATION
Nixon, R. D. V., Sterk, J., Pearce, A., & Weber, N. (2016, September 26). A Randomized Trial of
Cognitive Behavior Therapy and Cognitive Therapy for Children With Posttraumatic Stress
Disorder Following Single-Incident Trauma: Predictors and Outcome at 1-Year Follow-Up.
Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.
http://dx.doi.org/10.1037/tra0000190
 Psychological Trauma: Theory, Research, Practice, and Policy © 2016 American Psychological Association
2016, Vol. 8, No. 6, 000 1942-9681/16/$12.00 http://dx.doi.org/10.1037/tra0000190

A Randomized Trial of Cognitive Behavior Therapy and Cognitive

Therapy for Children With Posttraumatic Stress Disorder Following Single-
Incident Trauma: Predictors and Outcome at 1-Year Follow-Up
Reginald D. V. Nixon, Jisca Sterk, Amanda Pearce, and Nathan Weber
Flinders University

Objective: The 1-year outcome and moderators of adjustment for children and youth receiving treatment
for posttraumatic stress disorder (PTSD) following single-incident trauma was examined. Method:
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Children and youth who had experienced single-incident trauma (N ⫽ 33; 7–17 years old) were randomly
This document is copyrighted by the American Psychological Association or one of its allied publishers.

assigned to receive 9 weeks of either trauma-focused cognitive behavior therapy (CBT) or trauma-
focused cognitive therapy (without exposure; CT) that was administered to them and their parents
individually. Results: Intent-to-treat analyses demonstrated that both groups maintained posttreatment
gains in PTSD, depression and general anxiety symptoms reductions at 1-year follow-up, with no
children meeting criteria for PTSD. A large proportion of children showed good end-state functioning at
follow-up (CBT: 65%; CT: 71%). Contrary to 6-month outcomes, maternal adjustment no longer
moderated children’s outcome, nor did any other tested variables. Conclusion: The findings confirm the
positive longer-term outcomes of using trauma-focused cognitive– behavioral methods for PTSD sec-
ondary to single-incident trauma and that these outcomes are not dependent on the use of exposure.

Keywords: posttraumatic stress disorder, cognitive behavior therapy, children and young people, single-
incident trauma

Supplemental materials: http://dx.doi.org/10.1037/tra0000190.supp

Exposure to traumatic events places children at risk of posttrau-
matic stress disorder (PTSD; Kenardy, Spence, & Macleod, 2006;
Nixon, Ellis, Nehmy, & Ball, 2010). A recent meta-analysis indi-
cates that a significant proportion of children (15.9%) will have
PTSD following trauma (Alisic et al., 2014). Fortunately we now
have a substantial evidence base from which it is clear that trauma-
focused cognitive behavior therapies (CBT) are an efficacious and
effective treatment for child PTSD (for reviews, meta-analyses and
guidelines, see Australian Centre for Posttraumatic Mental Health,
2013; Kowalik, Weller, Venter, & Drachman, 2011; National
Institute for Health and Clinical Excellence, 2005). Despite this,
we know somewhat less about the long-term prognosis after treat-
ment, especially with children whose trauma was not related to
sexual abuse or sexual assault trauma. We know even less about
the variables that moderate these longer-term outcomes.
Overall, there is reason to be optimistic about the maintenance
of treatment gains following trauma-focused CBT. With reference
Reginald D. V. Nixon, Jisca Sterk, Amanda Pearce, and Nathan Weber,
School of Psychology, Flinders University.
This research was supported by a Channel 7 Research Foundation
Research Grant awarded to Reginald D. V. Nixon. Reginald D. V. Nixon
has received consultancies for providing trauma-focused CBT training to
clinicians who work with children and adults. We thank the children and
families who participated in the study.
Correspondence concerning this article should be addressed to Reginald
D. V. Nixon, School of Psychology, Flinders University, GPO Box 2100,
Adelaide, SA 5001, Australia. E-mail: reg.nixon@flinders.edu.au
to children and youth who have experienced interpersonal trauma
including sexual abuse and assault, immediate symptom improve-
ment has been observed to be largely maintained at follow-ups
varying from 1-year posttreatment (e.g., Cohen, Mannarino, &
Knudsen, 2005; Deblinger, Mannarino, Cohen, & Steer, 2006;
Foa, McLean, Capaldi, & Rosenfield, 2013; Webb, Hayes, Grasso,
Laurenceau, & Deblinger, 2014) and up to 2-years posttreatment
(Deblinger, Steer, & Lippmann, 1999). Studies of single-incident
trauma that was largely nonsexual show similar maintenance of
gains albeit for generally shorter follow-up periods (6 months:
Nixon, Sterk, & Pearce, 2012; Smith et al., 2007; Stein et al., 2003;
10 –12 months: Chemtob, Nakashima, & Hamada, 2002). Gilboa-
Schechtman et al. (2010) obtained 17-month follow-up data on
their sample, 21% of whom had experienced a sexual assault. Thus
there remains a paucity of data on outcomes beyond 6-month
follow-up following treatment for single-incident trauma. This is
compounded by the fact that most child PTSD treatment studies
with long-term follow-up (i.e., of 1 year or more) report only on
reductions of symptoms. Often PTSD diagnostic and good end-
state outcomes (i.e., remission or minimal symptoms) that are
ideally indexed by structured (or semistructured) clinical inter-
views are not reported. This limitation is seen with all the afore-
mentioned studies, although Foa et al. (2013) reported response to
treatment at 12 months (but not 17 months) and Webb et al. (2014)
reported proportions of children who moved from the clinical to
nonclinical range on a PTSD interview measure (although only
54% of the sample were above the cut-off at baseline).
There are only a handful of studies that have examined predic-
tors of outcome for children who have received psychological

1
 2 NIXON, STERK, PEARCE, AND WEBER
PTSD treatment. Collapsing groups that had received CBT with
trauma focus and nondirective supportive therapy (NST), Cohen
and Mannarino (1996, 1998) reported more negative parent reac-
tion to their child’s sexual abuse predicted preschoolers posttreat-
ment outcomes on the Child Behavior Checklist (CBCL; Achen-
bach & Edelbrock, 1983), as did maternal depression. By 6- and
12-month follow-up, parental support of the child, and to a lesser
extent, support received by the mother, predicted these later out-
comes. Analyzing group data separately, Deblinger et al. (2006)
did not find significant predictors of outcome in children who
received trauma-focused CBT for sexual abuse trauma but did find
multiple trauma exposure and pretreatment child depression to
correlate positively with PTSD symptoms at 1-year follow-up in
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children who had received nontrauma focused child-centered ther-
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apy. Mannarino, Cohen, Deblinger, Runyon, and Steer (2012)
found parent report of child internalizing symptoms and children’s
own report of depression predicted PTSD caseness 1-year post-
treatment in a sample of sexual abuse survivors. These findings
collapsed groups who had varying treatment length as well as
those who did or did not receive a trauma narrative processing
component to their therapy (all received trauma-focused CBT).
Collapsing children who had received trauma-focused CBT or CT
(trauma-focused cognitive therapy without exposure), Nixon et al.
(2012) found that baseline maternal depression and unhelpful
trauma-related beliefs, but not maternal PTSD symptoms, moder-
ated children’s outcome at posttreatment and 6-month follow-up.
Specifically children high in baseline PTSD severity fared worse
when they had mothers with higher levels of depression and
unhelpful beliefs. In a similar vein, Weems and Scheeringa (2013)
found baseline maternal depression moderated preschoolers’
PTSD outcome following CBT with trauma focus. In contrast to
Nixon et al. (2012) who observed attenuated symptom reduction
in high symptom children in their analysis, Weems and Scheer-
inga documented a curvilinear trajectory that strongly sug-
gested a degree of relapse by 6-month follow-up for children
with mothers high in depression. Finally, when examining the
efficacy of trauma-focused CBT interventions delivered in the
school setting for children with PTSD as a consequence of
community violence, Santiago, Lennon, Fuller, Brewer, and
Kataoka (2014) observed that reductions in parents’ use of
inconsistent discipline predicted reductions in child PTSD and
depression, with increased parent involvement in the school
accounting for reductions in child depression.
Despite these initial promising attempts to document some of
the factors that might influence the success of trauma-focused
therapies for child PTSD, there is clearly a need for further
research in this area. It is particularly notable that the few studies
to date have largely examined baseline or pretreatment variables as
predictors, without reporting on the influence of subsequent vari-
ables. It is likely that most of these studies have continued to
measure some of the variables throughout each follow-up (e.g.,
caregiver symptoms) which can also change over time, yet is it
unknown whether they continue to exert an effect. When variables
have been collected at later assessments, they have been used to
predict children’s symptoms at the same assessment period (e.g.,
Cohen & Mannarino, 1998), thus the predictive utility of the
variable in question is unknown.
Accordingly, we examined the long-term effects (1-year follow-
up) and moderators of outcome for children who participated in a
previously reported trial of CBT following single-incident trauma
(Nixon et al., 2012). To date, there have been almost no disman-
tling studies of trauma-focused CBT for child PTSD, and our
initial findings found little difference between children who had
received CBT that included exposure components (imaginal and in
vivo) and children who received trauma-focused cognitive therapy
without exposure (CT). These findings were similar to those of
Deblinger, Mannarino, Cohen, Runyon, and Steer (2011). Al-
though children (child sexual abuse victims) who engaged in a
trauma narrative as part of their CBT showed greater improve-
ments in abuse-related fear and general anxiety relative to children
randomized to CBT that did not include such a narrative, this did
not apply across all outcome measures, including PTSD as mea-
sured by clinical interview. By 12-month follow-up (Mannarino et
al., 2012), all differences had disappeared, with no significant
group by time interactions observed. In addition to the need for
longer term follow-up studies, it is imperative that such assess-
ments report also on diagnostic and end-state functioning out-
comes and that moderators of outcome are not restricted to base-
line variables.
Based on our previous findings, as well as the meta-analytic
evidence that parental pathology and distress is one of the stronger
influences of child PTSD adjustment (Trickey, Siddaway, Meiser-
Stedman, Serpell, & Field, 2012), we expected baseline maternal
depression and unhelpful beliefs to continue to influence outcome.
Although maternal PTSD did not moderate initial treatment out-
come and 6-month posttreatment PTSD outcome in children, ma-
ternal PTSD was shown to moderate younger children’s separation
anxiety outcomes following PTSD treatment (Weems & Scheer-
inga, 2013). Parental PTSD has also predicted children’s PTSD in
longitudinal studies (De Young, Hendrikz, Kenardy, Cobham, &
Kimble, 2014; Landolt, Ystrom, Sennhauser, Gnehm, & Vollrath,
2012; Le Brocque, Hendrikz, & Kenardy, 2010). Thus we were in
a position to examine whether maternal PTSD moderated chil-
dren’s later outcomes. Over the course of follow-up we docu-
mented whether children experienced further traumatic events.
Surprisingly, longitudinal studies of child posttraumatic stress tend
to omit reporting whether this is measured and how it relates (or
not) to outcome. Therefore this, and maternal symptoms from each
assessment point (pre-, posttreatment, 6-month follow-up) were
tested as potential moderators of children’s 1-year PTSD out-
comes.
Method
Participants
Full details of the procedures and methods of the randomized
trial can be found in Nixon et al. (2012). Briefly, participants in the
original trial were 33 child and adolescent victims of single-
incident trauma whose families self-referred from mental health
centers, hospitals, and police. Children had to be aged 7–17 years
old and meet diagnostic criteria for PTSD relating to a single
traumatic event. PTSD caseness included those who met subsyn-
dromal status (as per Kenardy et al., 2006). Exclusion criteria for
the study comprised of an inadequate comprehension of English,
traumatic brain injury resulting in amnesia of the traumatic event,
developmental delay, sexual assault or chronic trauma (e.g., child
abuse). Supplementary Figure S1 summarizes the participant flow
 CBT FOR CHILD PTSD
into the trial (one child was withdrawn from the study when it
became apparent ongoing stalking was occurring during treatment,
and these data were not included in analyses). There were largely
negligible differences between the two treatment groups on base-
line and trauma characteristics. The original sample of children
consisted of 21 boys and 12 girls (Mage ⫽ 10.80) who were
predominantly Caucasian (85%), 64% (n ⫽ 21) of whom com-
pleted all therapy. One-third had been involved in a road traffic
accident, one third an assault or home invasion, with the remainder
experiencing a house fire or other event. Data was collected for 19
participants at the 1-year follow-up and reflected participation
rates of earlier assessment periods. Engagement in further treat-
ment was assessed at each follow-up. Three children in CT had
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received one therapy session, and one child in CBT had received
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six sessions. Two children in CBT had been prescribed a medica-
tion for a short period (e.g., ⬍3-months).
Measures
The following measures with established psychometrics and
validity were used. Child PTSD diagnosis and severity was as-
sessed using the Clinician-Administered PTSD Scale for Children
and Adolescents (CAPS-CA; Nader et al., 1998). We previously
reported excellent interrater reliability for diagnostic interviews.
At each assessment interviewers also determined whether the child
had experienced further trauma since the previous interview. This
was scored dichotomously (yes/no). Children completed the fol-
lowing self-report scales: the Child PTSD Symptom Scale (CPSS;
Foa, Johnson, Feeny, & Treadwell, 2001); the Children’s Depression
Inventory (CDI; Kovacs, 1992); the Childhood Post-Traumatic Cog-
nitions Inventory (CPTCI; Meiser-Stedman et al., 2009); and the
Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds &
Richmond, 1978). Mothers rated children on the Child Behavior
Check List (CBCL/6 –18; Achenbach & Rescorla, 2003), and rated
their own responses to the child’s trauma using the Posttraumatic
Stress Diagnostic Scale (PDS; Foa, 1995), Post-Traumatic Cogni-
tions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999)
and the Beck Depression Inventory-II (BDI-II; Beck, Steer, &
Brown, 1996). Good end-state was indicated by a score of below
20 (CAPS) or below 16 (CPSS; Nixon et al., 2013) and only
included children above the relevant clinical cut-off at pretreat-
ment who made reliable change to below the cut-off (Jacobson &
Truax, 1991).
Treatment Summary
The treatment protocols and treatment fidelity processes were
detailed in the original report, with treatments adapted from pre-
vious trauma-specific and general CBT resources (Deblinger &
Heflin, 1996; Rapee, Wignall, Hudson, & Schniering, 2000).
Briefly, participants received 9 ⫻ 1.5 hour sessions provided
individually on a weekly basis by Masters-level trainee clinical
psychologists trained and supervised by Reginald D. V. Nixon.
Children in CBT received psycho-education, relaxation training
and anxiety management, cognitive restructuring around unhelpful
trauma-related beliefs, imaginal exposure to the trauma memory,
and in vivo exposure. Children in CT received the same with the
exception of the exposure components. Although the time devoted
to the child and parents within each session varied depending on
3
the stage of treatment, over the course of therapy approximately
two thirds of contact time was spent with the child, whereas the
remaining third was spent with their parents. Both groups received
relapse prevention in the final session.
Procedure
Ethics approval was given by the university hospital ethics
committee. A telephone screening was first conducted to assess the
child’s eligibility for a full assessment at which point written
informed consent was obtained. After meeting inclusion criteria
children were allocated to one of the treatments via block random-
ization (generated independently of the researchers). Participants
were assessed at pretreatment, posttreatment, 6-month follow-up,
and 12-month follow-up. Assessments were conducted indepen-
dently by assessors unaware of the treatment condition and therapy
stage of participants. The assessors did not deliver treatment, did
not have any access to participant notes, and had not been involved
in any areas of the study previously (e.g., recruitment, administra-
tion, supervision). Honorariums were not used for participation in
assessments or therapy.
Data Analysis
We adopted a more sophisticated approach to missing data than
that used in the original treatment publication. Multiple imputation
was used employing fully conditional specification, otherwise
known as multivariate imputation by chained equations (MICE;
van Buuren & Groothuis-Oudshoorn, 2011; computed in R, a
statistical computing environment, R Development Core Team,
2011). The imputation model included all baseline symptom mea-
sures, treatment group, time since trauma, baseline variables that
had moderate or greater associations with dropout (e.g., prior
trauma history), and the primary PTSD and depression outcomes
for child and mother. This represented 29 variables in total. Rela-
tions between and within time were preserved and imputation
values were constrained to the range of observed values in non-
missing data. Simulations indicate that even with small samples
and substantial missing data (e.g., sample N ⫽ 50, 80% missing
data) five to ten imputed data sets demonstrate good performance
and efficiency of replacement (Rubin, 1987; Schafer & Graham,
2002). However we followed recommendations that number of
complete data sets equate to the proportion of missing data (White,
Royston, & Wood, 2011). Thus 50 complete data sets were com-
puted using 20 iterations. MICE uses Rubin’s (1987) rules for
pooling of statistical parameters (Raghunathan & Dong, 2013;
Rubin, 1987). SPSS 20.0 was used for remaining analyses. Ac-
cordingly, the analyses represent an intent-to-treat (ITT) approach.
Completer analyses were generally comparable to intent-to-treat
analyses (albeit with better good end-state being achieved), thus
are omitted due to space considerations.
Our analysis and interpretative approach focused on effect sizes
and the confidence intervals (CIs) around these effects. This was
due to it being increasingly recognized that traditional null hypoth-
esis significance testing (NHST) has substantial limitations.
NHST, with its resultant focus on p values, is unreliable and
uninformative with respect determining the magnitude (if any) of
differences in the two treatments under study (see Cumming, 2014
and Faulkner, Fidler, & Cumming, 2008, for detailed discussion of
 4 NIXON, STERK, PEARCE, AND WEBER

the superiority of effect sizes and CIs vs. NHST). Accordingly, we
report effect sizes (Cohen’s d, ␸, Cramer’s V) and CIs throughout,
with Cohen’s conventions, albeit relative, indicating that 0.2, 0.5,
and 0.8 reflect small, medium and large effects respectively for d,
and 0.1, 0.3, and 0.5 indicate the same for ␸.
For consistency with earlier research, we also report relevant
inferential statistics (Supplementary Table S1). We analyzed con-
tinuous measures (CAPS severity scores, CPSS etc.) in a series of
2 ⫻ 2 mixed analyses of variance (ANOVAs) to generate required
effect sizes and CIs, and pooled the results across imputed data sets
using Raghunathan and Dong’s (2013) formulae. Cohen’s ds were
calculated separately for each imputed dataset then pooled using
MICE’s pool scalar function. These pooled ds were treated as
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toms). Where differences occurred (e.g., higher RCMAS scores in
the CBT group), they did not correlate strongly with later outcome.
Of more relevance to the 12-month outcomes (and imputation
strategy) was the magnitude of difference between those who
completed therapy and those who did not, especially given that 11
of the 14 children who did not complete 1-year follow-up were
treatment dropouts. In general, effect size differences on baseline
variables between completers and dropouts were very small, and
most importantly, this included child PTSD severity (whether
measured with the CAPS or CPSS). However some medium-sized
differences or greater were observed, where children who did not
complete full therapy had mothers with higher PTSD (PDS: d ⫽
0.75, 95% CI [0.01, 1.48]), had more externalizing behavior prob-

standard effect size measures and the noncentrality interval esti- lems (CBCL-E: d ⫽ 0.62, 95% CI [⫺0.11, 1.34]), and were more
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mation approach (Cumming & Finch, 2001; Steiger & Fouladi,
1997), implemented in the MBESS package in R (Kelley, 2007), was
used to calculate 95% CIs. For analyses of covariance (ANCOVAs),
we calculated between-groups d as the adjusted mean difference
divided by the square root of the ANCOVAs within mean square
error (Smithson, 2002). Following the same approach for the
unadjusted ds above, these values were pooled and the CI calcu-
lated on the pooled value. We analyzed categorical outcomes
(PTSD status, good end-state function) by fitting a generalized
linear model with binomial distribution and logit link function (i.e.,
a logistic regression) and pooled using MICE. Tests of moderation
were analyzed using hierarchical multiple regression (and pooled
using MICE). Based on the imputed ITT sample size (N ⫽ 33) and
using a priori calculations within GⴱPower (Faul, Erdfelder, Bu-
chner, & Lang, 2009), we observed that there was only sufficient
power (set at 80%) to detect medium sized effects for ANOVAs,
large effects for ANCOVAs, and medium to large effects for
regression-based moderation analyses.
Results
As reported in the original study, there were few meaningful
differences between the groups at baseline (see Table 1 for symp-
likely to have experienced prior trauma (83% vs. 48%, ␸ ⫽ .35).
Accordingly the imputation model included these predictors to
create the dataset used for ITT analyses.
Symptom Severity Analyses
Repeated measures ANOVAs on imputed data showed a rela-
tively consistent pattern across the outcome measures. Imputed
descriptive statistics are presented in Table 1, pooled effect sizes in
Table 2, and pooled inferential statistics are available from the
online supplementary materials (Supplementary Table S1). Of
relevance was that at 1-year follow-up both groups continued to
show large and clinically meaningful reductions of PTSD relative
to pretreatment, with these effects ranging between 2.59 –3.30
(CAPS) and 2.03–2.67 (CPSS). Child self-reported depression
(CDI), unhelpful trauma beliefs (CPTCI), and general anxiety
(RCMAS) similarly showed large effect sizes (ranging between
1.47–2.68). Of interest is that these effect sizes were all larger for
the CBT group, although this must be qualified by the observation
that CIs were rather wide. Between group comparisons at 1-year
follow-up (controlling for pretreatment severity) generally indi-
cated only small differences in effect sizes. Mothers’ report of their
own symptoms as well as those of their children showed similar

Table 1
Outcome Measures (Imputed) at Each Assessment (N ⫽ 33)

Pretreatment Posttreatment 6-month FU 1-year FU

CBT CT CBT CT CBT CT CBT CT
Measure M SD M SD M SD M SD M SD M SD M SD M SD

Child
CAPS 58.41 20.56 50.00 21.79 17.15 20.83 13.72 14.97 10.27 7.26 7.91 8.48 6.90 6.11 8.09 7.17
CPSS 24.29 6.94 23.44 10.11 10.77 12.29 8.03 8.68 7.62 8.68 3.85 5.14 5.93 6.95 5.87 6.94
CDI 58.82 14.56 55.56 13.88 49.15 15.74 50.12 16.21 45.07 12.70 45.88 10.70 39.11 4.51 39.85 5.96
CPTCI 57.00 14.20 51.25 16.61 40.49 16.37 34.49 10.73 43.54 18.07 36.34 13.69 33.06 7.87 31.07 6.88
RCMAS 63.18 12.62 53.12 10.37 41.50 16.69 42.48 15.76 40.42 16.25 32.39 16.21 34.67 8.30 36.53 10.74
CBCL-I 67.53 9.97 62.50 10.74 52.32 14.51 48.45 13.63 57.37 15.39 49.24 14.44 50.65 12.19 48.68 13.29
CBCL-E 59.29 11.33 55.31 8.75 51.12 12.67 46.98 10.33 53.37 14.31 49.62 10.41 46.68 11.76 45.19 12.04
CBCL-T 64.12 9.53 59.75 11.60 51.05 15.85 46.79 14.81 55.96 15.78 48.03 15.42 47.59 15.49 44.46 16.16
Mother
PDS 18.82 16.35 14.69 15.04 9.24 13.95 6.74 9.56 11.00 14.55 8.42 11.00 5.56 7.18 5.87 6.26
BDI-II 12.88 13.81 12.81 12.27 8.07 12.13 7.53 11.17 11.68 14.06 7.86 11.89 5.28 7.41 5.47 7.20
PTCI 86.71 34.51 82.94 43.19 69.49 43.25 70.13 45.47 80.46 47.89 69.32 43.29 56.57 21.22 58.42 24.30
Note. CAPS ⫽ Clinician-Administered PTSD Scale for Children and Adolescents; CPSS ⫽ Child PTSD Symptom Scale; CDI ⫽ Children’s Depression
Inventory; CPTCI ⫽ Child Post-Traumatic Cognitions Inventory; RCMAS ⫽ Revised Children’s Manifest Anxiety Scale; CBCL-I ⫽ Child Behaviour
Checklist internalizing subscale; CBCL-E ⫽ Child Behaviour Checklist externalizing subscale; CBCL-Total ⫽ Child Behaviour Checklist total score;
PDS ⫽ Posttraumatic Diagnostic Scale; BDI-II ⫽ Beck Depression Inventory (2nd ed.); PTCI ⫽ Post-Traumatic Cognitions Inventory.
 CBT FOR CHILD PTSD 5

results. Mothers in both groups reported meaningful reductions of

Note. CAPS ⫽ Clinician-Administered PTSD Scale for Children and Adolescents; CPSS ⫽ Child PTSD Symptom Scale; CDI ⫽ Children’s Depression Inventory; CPTCI ⫽ Child Post-Traumatic

subscale; CBCL-Total ⫽ Child Behaviour Checklist total score; PDS ⫽ Posttraumatic Diagnostic Scale; BDI-II ⫽ Beck Depression Inventory (2nd ed.); PTCI ⫽ Post-Traumatic Cognitions Inventory.
Cognitions Inventory; RCMAS ⫽ Revised Children’s Manifest Anxiety Scale; CBCL-I ⫽ Child Behaviour Checklist internalizing subscale; CBCL-E ⫽ Child Behaviour Checklist externalizing
.51 [⫺.18, 1.21]
.20 [⫺.48, .89]
.00 [⫺.68, .68]
.21 [⫺.48, .89]
⫺.19 [⫺.87, .50]

.07 [⫺.62, .75]

.04 [⫺.64, .72]
⫺.02 [⫺.71, .66]

.16 [⫺.53, .84]

.03 [⫺.65, .71]
.11 [⫺.58, .79]
child behavior problems (CBCL) at 1-year follow-up with effects
1-year FU
between 0.97 and 1.52. Reductions of their own symptoms (PDS,
BDI-II, PTCI) were slightly more modest, but meaningful none-
Within- and Between-Group Pooled Effect Sizes (Cohen’s d) [and 95% Confidence Intervals] From Pre- to 1-Year Follow-Up on All Symptom Measures (N ⫽ 33)

theless (effect sizes ranging between 0.70 and 1.05). Overall for
both child and mother symptoms these reductions were greater
Between-group effect sizea

⫺.53 [⫺1.22, .17]

than those initially observed immediately after treatment or at
⫺.37 [⫺1.05, .33]

⫺.43 [⫺1.11, .27]

⫺.39 [⫺1.08, .30]

⫺.33 [⫺1.02, .36]

⫺.27 [⫺.95, .42]

.26 [⫺.43, .94]

⫺.28 [⫺.96, .41]

⫺.12 [⫺.80, .57]

⫺.07 [⫺.75, .61]

⫺.23 [⫺.91, .46]

6-month follow-up.
6-month FU

Diagnostic Outcome and Good End-State Functioning

The pooled results generally showed small differences between
the groups although due to a number of the imputed data sets
⫺.32 [⫺1.00, .37]
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including 0% or 100% for the proportion of children meeting a

⫺.07 [⫺.75, .61]
⫺.26 [⫺.94, .43]
.21 [⫺.48, .89]

⫺.29 [⫺.40, .97]

⫺.12 [⫺.81, .56]
⫺.17 [⫺.85, .52]
.09 [⫺.78, .59]

⫺.08 [⫺.77, .60]

⫺.06 [⫺.75, .62]
.08 [⫺.61, .76]
Posttreatment
This document is copyrighted by the American Psychological Association or one of its allied publishers.

particular criterion, some results (e.g., odds ratios [ORs] and

associated CIs) could not be calculated from the generalized linear
models. For the ITT sample, at posttreatment 72% and 68% of the
CBT and CT children no longer met criteria for PTSD (full or
subthreshold), OR ⫽ 1.20, 95% CI [0.18, 7.79], p ⫽ .84. At
.70 [⫺.02, 1.41]

6-month and 1-year follow-up this proportion had increased, with

2.59 [1.62, 3.52]
2.03 [1.16, 2.89]
1.47 [.68, 2.25]
1.59 [.78, 2.38]
1.58 [.77, 2.36]
1.16 [.40, 1.90]
.97 [.23, 1.70]
1.09 [.34, 1.83]

.77 [.04, 1.48]

.73 [.01, 1.45]

no children in either group meeting PTSD criteria.

Pre to 1-year effect size

A similar pattern was seen for good end-state functioning (i.e.,

CT

essentially complete remission) as measured with the CAPS. At

posttreatment on the CAPS 52% of CBT and 56% of CT children
met this criterion, OR ⫽ 1.19, 95% CI [0.21, 6.92], p ⫽ .84. This
.69 [⫺.01, 1.38]

rate rose at follow-ups, to 79% and 87%, respectively, at 6-month

3.40 [2.32, 4.45]
2.67 [1.72, 3.59]
1.83 [1.02, 2.63]
2.09 [1.23, 2.92]
2.68 [1.73, 3.61]
1.52 [.74, 2.28]
1.10 [.36, 1.81]
1.29 [.54, 2.02]

1.05 [.33, 1.76]

1.05 [.33, 1.77]

follow-up, and 95% and 87% for each group at 1-year. When good
CBT

end-state was measured by children’s self-report (CPSS) an initial

Positive values reflect CBT scores are lower than CT scores, effect sizes control for pretreatment score.

difference was observed although this disappeared by 1-year

follow-up. It should be recognized that large confidence intervals
were present. Thus at posttreatment 55% CBT and 77% CT chil-
dren reported good end-state functioning, OR ⫽ 2.79, 95% CI
.60 [⫺.11, 1.31]

.49 [⫺.22, 1.19]

.43 [⫺.28, 1.12]
.33 [⫺.37, 1.02]
2.55 [1.59, 3.48]
2.49 [1.54, 3.41]
.80 [.07, 1.51]
1.03 [.28, 1.77]
1.57 [.77, 2.36]
1.06 [.31, 1.79]

.87 [.14, 1.59]

[0.30, 26.15], p ⫽ .35. This discrepancy was maintained at

Pre to 6-month effect size

6-months: 67% (CBT), 86% (CT) meeting good end-state, OR ⫽

CT

2.86, 95% CI [0.25, 33.02], p ⫽ .38, but narrowed at 1-year

follow-up, 65% (CBT), 71% (CT), OR ⫽ 1.28, 95% CI [0.17,
9.80], p ⫽ .80. No children reported reliable worsening at 1-year
follow-up relative to their pretreatment scores (CPSS, CAPS). One
.46 [⫺.23, 1.14]
.63 [⫺.07, 1.31]

.51 [⫺.18, 1.19]

3.12 [2.10, 4.13]
2.14 [1.28, 2.98]

.09 [⫺.58, .76]

.15 [⫺.52, .83]
1.02 [.30, 1.73]
.84 [.13, 1.54]
1.57 [.78, 2.33]
.78 [.08, 1.48]

child from each group reported a reliable increase on the CPSS in

CBT

the 6-month to 1-year interval but these scores remained below

pretreatment levels.

Moderating Effects of Maternal and Child Variables

.39 [⫺.32, 1.09]

.65 [⫺.07, 1.36]

.46 [⫺.25, 1.16]
.30 [⫺.40, 1.00]
1.98 [1.12, 2.82]
1.71 [.88, 2.51]

1.25 [.48, 2.01]

.79 [.06, 1.51]
1.17 [.40, 1.91]
.88 [.15, 1.60]
.98 [.24, 1.71]

We conducted a series of analyses to examine which factors

interacted with children’s PTSD severity at pretreatment, posttreat-
CT
Pre–post effect size

ment, and 6-month follow-up to predict their later adjustment (i.e.,

PTSD severity at 1-year follow-up as measured by both the CAPS
and CPSS). In short, there were no meaningful or significant
moderators of children’s 1-year outcome. Unstandardized regres-
.66 [⫺.04, 1.35]

.68 [⫺.02, 1.37]

.64 [⫺.06, 1.32]

.38 [⫺.30, 1.06]
.46 [⫺.23, 1.13]
2.01 [1.16, 2.83]
1.37 [.61, 2.11]

1.08 [.35, 1.80]

1.47 [.69, 2.22]
1.23 [.48, 1.95]

1.00 [.28, 1.71]

sion coefficients for interactions were exceedingly small (e.g.,

typically between 0.002– 0.005, all ps ⬎ .38, with most ps ⬎ .60)
CBT

with full results available from Reginald D. V. Nixon on request.

These analyses not only examined whether maternal and child
pretreatment variables (e.g., depression, child behavior problems)
CBCL⫺E
CBCL⫺T

moderated the relationship between child pretreatment PTSD se-

CBCL⫺I
RCMAS
Measure

CPTCI

BDI-II

verity and 1-year PTSD severity, but also whether posttreatment

CAPS
Table 2

CPSS

PTCI
Mother
PDS
CDI
Child

and 6-month variables moderated this relationship, in addition to

whether posttreatment and 6-month variables, respectively, inter-
a
 6 NIXON, STERK, PEARCE, AND WEBER
acted with posttreatment and 6-month child PTSD severity to
predict children’s 1-year outcome. We were not able to test the
potential impact of further trauma that occurred after treatment as
only one child was exposed to such trauma. Accordingly, despite
a large number of analyses, we did not observe that any variables
moderated 12-month PTSD outcomes in the children.
Discussion
Our analysis of longer-term outcome in children who had re-
ceived a trauma-focused CBT or CT intervention showed that
posttreatment gains were maintained at 1-year follow-up. Specif-
ically, trauma-related symptoms (PTSD, unhelpful beliefs) and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
correlates of PTSD (general anxiety, depression) all demonstrated
This document is copyrighted by the American Psychological Association or one of its allied publishers.
significant reductions relative to pretreatment levels. These changes
were corroborated by maternal report on the CBCL, and mothers’
own symptom reduction was maintained. Over time, we observed
increasingly fewer differences in outcomes between the two treat-
ment groups for most measures. In general symptoms appeared to
improve over time and by 1-year follow-up, effect sizes of treat-
ment change for PTSD measures ranged between 2.03 and 3.40,
and most other measures showed large treatment effects (d ⬎ 1.0).
Diagnostically, no children met PTSD criteria at the last follow-up
and large proportions showed excellent good end-state functioning
that essentially reflects full remission (approximately 66% via
self-report on the CPSS, over 90% on interview using the CAPS).
Earlier treatment studies of CBT with a trauma focus for single-
incident trauma have also indicated the maintenance of treatment
gains, with two studies having similar (Chemtob et al., 2002) or
longer follow-up lengths (17 months for Gilboa-Schechtman et al.,
2010). However neither study comprehensively assessed PTSD
with a rigorous diagnostic measure at the last follow-up nor
reported on good end-state functioning. The present study offers a
valuable addition to the existing literature on this front.
In addition to providing further evidence of the longer-term
efficacy of trauma-focused CBT and CT interventions for child
PTSD, to our knowledge this is the first study to examine moder-
ators of longer term outcomes beyond those measured just at
baseline. Despite comprehensively testing multiple variables, we
did not observe any significant moderators. This was in contrast to
our earlier finding that maternal depression and unhelpful beliefs
influenced posttreatment and 6-month outcomes. We suspect that
this was largely due to the continued improvement of children such
that by 1-year follow-up, there were relatively low levels of PTSD
symptoms in both groups, allowing little variation for the role of
moderators to be detected. Our initial treatment study and that of
others (e.g., Cohen & Mannarino, 1996, 1998; Weems & Scheer-
inga, 2013) points to the idea that although parental adjustment
influences PTSD treatment outcome, this influence seems stron-
gest at posttreatment and over the next 6 months. This speaks to
the importance of achieving best possible gains by posttreatment.
There does remain a paucity of research on what predicts longer-
term outcomes. Although our findings initially seem in contrast to
other studies and meta-analyses that indicate parental adjustment
and other child factors influence children’s PTSD trajectory over
time (e.g., Trickey et al., 2012), it should also be noted that the
latter was not based on treatment samples. Given children who
require PTSD treatment have by definition not recovered naturally,
what accounts for their symptom trajectory, especially the persis-
tence of symptoms following treatment, might be different from
that which predicts symptom trajectory in nontreatment samples.
Limitations
Some of the limitations of the original study remain relevant
(e.g., lack of a waitlist control group, modest sample size and
missing data requiring multiple imputation, lack of father reported
symptoms). Although a strength of the study was the examination
of ongoing symptoms and further trauma as potential moderators
of longer-term outcome, we did not assess other potentially im-
portant factors including children’s perception of social support
support (known to influence child symptoms and outcomes; Cohen &
Mannarino, 1998; Hitchcock, Ellis, Williamson, & Nixon, 2015), nor
did we measure non-PTSD traumatic stressors (e.g., moving, family
financial stress). We did not assess possible mechanisms that would
shed light on our earlier finding of the moderating role of maternal
adjustment; that is, how this might operate to influence children’s
PTSD outcomes (e.g., possibly through parent– child interactions,
poor modeling of coping behaviors etc.).
Clinical Implications
There are several examples that demonstrate PTSD can be
treated with cognitive therapy approaches in adults (e.g., Bryant et
al., 2008; Resick et al., 2008; Tarrier et al., 1999). This has now
been shown for children who have experienced single-incident
trauma as in the present study, and TF-CBT without a trauma
narrative had comparable outcomes at follow-up as treatment that
did include such a narrative for children who had experienced
abuse (Deblinger et al., 2011; Mannarino et al., 2012). Together,
this suggests that exposure is not always a necessary prerequisite
for successful treatment, allowing clinicians to use this ap-
proach when children (or parents) may be unwilling to engage
in trauma-related exposure. Adult studies highlight the impor-
tance of changes in cognitions in driving changes in PTSD
symptoms (e.g., Kleim et al., 2013). Although we certainly
place value in the exposure components in trauma treatment
(with trauma narratives being a rich source of unhelpful cog-
nitions that can be targeted in therapy), our findings indicate
direct treatment of such cognitions is beneficial.
Our original report and that of Weems and Scheeringa (2013)
illustrate that maternal adjustment, especially depression, influ-
ences children’s PTSD outcomes. Although further replication is
required, the findings show that clinicians should assess parental
adjustment and be aware that this may signify attenuated treatment
response. At this time it is unclear what the optimal methods are to
address this issue. At a minimum, close monitoring of children’s
(and parent’s) adjustment during treatment appears sensible as it
will alert the clinician whether symptoms are not improving. It is
now common to monitor PTSD symptoms on a weekly basis
during therapy and we endorse that approach. Although a tentative
recommendation due to our limited understanding of the underly-
ing processes influencing children’s outcomes, we suggest that
when it is identified that parents have elevated depression levels,
parents are strongly encouraged to seek therapy for these issues
with the goal of optimizing both their and their children’s adjust-
ment.
 CBT FOR CHILD PTSD
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Received April 17, 2016
Revision received July 25, 2016
Accepted August 17, 2016 䡲