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Effect of Developmentally Adapted Cognitive Processing Therapy for Youth With Symptoms of Posttraumatic Stress Disorder After Childhood Sexual and Physical AbuseA Randomized Clinical Trial

Educational Objective
To examine whether developmentally adapted cognitive processing therapy (D-CPT) is more effective than a wait-list condition with treatment advice (WL/TA) among adolescents with posttraumatic stress disorder (PTSD) related to childhood abuse.
1 Credit CME
Key Points

Question  Is developmentally adapted cognitive processing therapy more effective than a wait-list condition with treatment advice in adolescents and young adults with posttraumatic stress disorder related to childhood sexual and/or physical abuse?

Findings  In a multicenter, randomized clinical trial of 88 participants (aged 14-21 years), developmentally adapted cognitive processing therapy resulted in greater improvement in blinded, rater-assessed posttraumatic stress disorder severity and in self-reported secondary outcomes than a wait-list condition with treatment advice. Treatment success was greatest during the trauma-focused core phase and remained stable to the 3-month follow-up.

Meaning  Developmentally adapted cognitive processing therapy is more effective than a wait-list condition with treatment advice and well tolerated in adolescents and young adults with abuse-related posttraumatic stress disorder.

Abstract

Importance  Despite the high prevalence, evidence-based treatments for abuse-related posttraumatic stress disorder (PTSD) in adolescents have rarely been studied.

Objective  To examine whether developmentally adapted cognitive processing therapy (D-CPT) is more effective than a wait-list condition with treatment advice (WL/TA) among adolescents with PTSD related to childhood abuse.

Design, Setting, and Participants  This rater-blinded, multicenter, randomized clinical trial (stratified by center) enrolled treatment-seeking adolescents and young adults (aged 14-21 years) with childhood abuse–related PTSD at 3 university outpatient clinics in Germany from July 2013 to June 2015, with the last follow-up interview conducted by May 2016. Of 194 patients, 88 were eligible for randomization.

Interventions  Participants received D-CPT or WL/TA. Cognitive processing therapy was enhanced by a motivational and alliance-building phase, by including emotion regulation and consideration of typical developmental tasks, and by higher session frequency in the trauma-focused core CPT phase. In WL/TA, participants received treatment advice with respective recommendations of clinicians and were offered D-CPT after 7 months.

Main Outcomes and Measures  All outcomes were assessed before treatment (baseline), approximately 8 weeks after the start of treatment, after the end of treatment (posttreatment), and at the 3-month follow-up. The primary outcome, PTSD symptom severity, was assessed in clinical interview (Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV [CAPS-CA]). Secondary outcomes were self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation.

Results  The 88 participants (75 [85%] female) had a mean age of 18.1 years (95% CI, 17.6-18.6 years). In the intention-to-treat analysis, the 44 participants receiving D-CPT (39 [89%] female) demonstrated greater improvement than the 44 WL/TA participants (36 [82%] female) in terms of PTSD severity (mean CAPS-CA scores, 24.7 [95% CI, 16.6-32.7] vs 47.5 [95% CI, 37.9-57.1]; Hedges g = 0.90). This difference was maintained through the follow-up (mean CAPS-CA scores, 25.9 [95% CI, 16.2-35.6] vs 47.3 [95% CI, 37.8-56.8]; Hedges g = 0.80). Treatment success was greatest during the trauma-focused core phase. The D-CPT participants also showed greater and stable improvement in all secondary outcomes, with between-groups effect sizes ranging from 0.65 to 1.08 at the posttreatment assessment (eg, for borderline symptoms, 14.1 [95% CI, 8.0-20.2] vs 32.0 [95% CI, 23.8-40.2]; Hedges g = 0.91).

Conclusions and Relevance  Adolescents and young adults with abuse-related PTSD benefited more from D-CPT than from WL/TA. Treatment success was stable at the follow-up and generalized to borderline symptoms and other comorbidities.

Trial Registration  German Clinical Trials Register identifier: DRKS00004787

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Article Information

Accepted for Publication: November 20, 2018.

Corresponding Author: Rita Rosner, DPhil, Department of Psychology, Catholic University Eichstätt-Ingolstadt, Ostenstr 25, 85072 Eichstätt, Germany (rita.rosner@ku.de).

Published Online: April 10, 2019. doi:10.1001/jamapsychiatry.2018.4349

Author Contributions: Dr Rosner was the principal investigator and wrote the first draft of this report. Drs Rosner and Frick had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rosner, Frick, Steil.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rosner, Rimane, Frick, Hagl, Steil.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rosner, Rimane, Frick.

Obtained funding: Rosner, Steil.

Administrative, technical, or material support: Rosner, Rimane, Gutermann, Renneberg, Vogel, Steil.

Supervision: Rosner, Renneberg, Steil.

Conflict of Interest Disclosures: Dr Rosner reported being paid fees for workshops and presentations on posttraumatic stress disorder (PTSD) treatment and coauthoring a book on cognitive processing therapy. Dr Steil reported being paid fees for workshops and presentations on PTSD treatment. No other disclosures were reported.

Funding/Support: The study was supported by grants 01KR1204A and 01KR1204C from the German Federal Ministry of Education and Research.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank all patients who participated in this trial and all therapists who administered the interventions. Simone Spranz, Dr Rer Nat, a private practitioner in Frankfurt, Germany, supported the trial with case consultation, and Maja Steinbrink, Dr Rer Nat, Department of Clinical Psychology and Psychotherapy, Freie Universitaet of Berlin, Berlin, Germany, provided study coordination in Berlin. Both were compensated for their work.

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