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Intervention Summary

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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.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: August 2012
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 in 2004. 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, 2011), 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.

Quality of Research
Review Date: August 2012

Documents Reviewed

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.

Study 1

Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). 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.  Pub Med icon

Supplementary Materials

Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., & Angold, A. (2006). Test-retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child Adolescent Psychiatry, 45(5), 538-549.  Pub Med icon

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

The following populations were identified in the studies reviewed for Quality of Research.

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)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

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

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.

Study Weaknesses

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.

Readiness for Dissemination
Review Date: August 2012

Materials Reviewed

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.

Scheeringa, M. (2010, July). Adaptation checklist--Child (ACC). New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/ACC_version73110.pdf

Scheeringa, M. (2010, July). Therapist fidelity checklist (TFC). New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/TFC_version73110.pdf

Scheeringa, M. (2012, August). Young child PTSD checklist (YCPC): 1-6 years. New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/YCPC_Aug2012.pdf

Scheeringa, M. S. (2010, August). Diagnostic infant and preschool assessment (DIPA) manual. New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/DIPA_Manual.pdf

Scheeringa, M. S. (2010, November). Diagnostic infant and preschool assessment (DIPA). New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/DIPA_v111710.pdf

Scheeringa, M. S. (2011, February). Young child PTSD screen (YCPS). New Orleans, LA: Tulane University. Retrieved from http://www.infantinstitute.com/MikeSPDF/YCPS_versFeb2011.pdf

Scheeringa, M. S., Amaya-Jackson, L., & Cohen, J. (2010, October). Preschool PTSD treatment (Version 1.7). New Orleans, LA: Tulane Institute of Infant and Early Childhood Mental Health. Retrieved from http://www.infantinstitute.com/MikeSPDF/PPTversion7.pdf

Other materials:

  • Adaptation Checklist--Parent (ACP)
  • Parent Acceptance Checklist (PAC)
  • Research Diagnostic Criteria--Preschool Age

Program Web site, http://www.infantinstitute.com/index.html

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.3 2.8 2.5 2.8

Dissemination Strengths

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.

Dissemination Weaknesses

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.

Costs

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.

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
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
Michael S. Scheeringa, M.D., M.P.H.
(504) 988-2167
mscheer@tulane.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):