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.
Quality of Research
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 1Scheeringa, 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.
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.
Outcomes
Outcome 1: PTSD symptoms |
Description of Measures
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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.
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Key Findings
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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).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.8
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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0-5 (Early childhood) 6-12 (Childhood)
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66% Male 34% Female
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59.5% Black or African American 35.1% White 5.4% Race/ethnicity unspecified
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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:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: PTSD symptoms
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3.5
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3.3
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3.3
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2.0
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2.0
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2.5
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2.8
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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.
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Readiness for Dissemination
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:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.3
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2.8
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2.5
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2.8
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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.
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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
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Cost
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Required by Developer
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Preschool PTSD Treatment Manual
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Free
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Yes
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2-day, on-site training for up to 15 participants
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$2,500 plus travel expenses
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No
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Phone and email consultation
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$150 per hour
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No
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Diagnostic Infant and Preschool Assessment
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Free
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No
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Diagnostic Infant and Preschool Assessment Manual
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Free
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No
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Young Child PTSD Checklist
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Free
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No
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Young Child PTSD Screen
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Free
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No
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Research Diagnostic Criteria--Preschool Age
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Free
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No
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Adaptation Checklists, Child and Parent Versions
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Free
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No
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Therapist Fidelity Checklist
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Free
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No
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Parent Acceptance Checklist
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Free
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No
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Replications
No replications were identified by the developer.
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