Pediatric Trauma Exposure Influences the Efficacy of Brief Behavioral Therapy

Keypoint: Current behavioral therapies may not be effective for anxious-depressed pediatric patients with a history of trauma.

Brief behavioral therapy (BBT) is broadly effective for pediatric patients with depression and anxiety. However, BBT does not outperform assisted referral to outpatient community care (ARC) among children and adolescents with pediatric trauma exposure. These findings were published in NPJ Mental Health Research.

Although anxiety and depression are the most common psychiatric disorders among children and adolescents, these disorders frequently go untreated before adulthood.

Recently, evidence-based transdiagnostic psychotherapies have been developed in the hopes of increasing access to treatment among pediatric patients. However, little is known about whether these therapies are effective in children and adolescents who have been exposed to trauma. Therefore, researchers conducted a study to determine if trauma exposure and clinically significant depression were moderators of BBT treatment outcomes among pediatric patients with anxiety.

In this randomized controlled trial, the researchers recruited pediatric patients with an anxiety disorder and/or depression who were not currently receiving treatment for their disorder(s). Clinical diagnoses were confirmed at baseline using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime

Version (K-SADS-PL), the Children’s Depression Rating Scale-Revised (CDRS-R), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV), criteria.

Participants who were experiencing suicidality, did not speak English, and/or had other comorbid disorders were excluded from the study. The researchers used the Clinical Global Impressions severity scale (CGI-S), the Children’s Global Assessment Scale (CGAS), and the Pediatric Anxiety Rating Scale (PARS) to evaluate clinical response, functioning, and anxiety symptoms at 16-week and 32-week follow-up appointments.

A total of 175 children and adolescents (aged 8 to 16 years) were included for analysis and the researchers randomly assigned participants to BBT (n=89) or ARC (n=86). At baseline, 46.3% of participants reported exposure to at least 1 traumatic event. Among participants with a history of trauma, 48.1% were exposed to more than 1 type of traumatic event. The most common single types of traumatic events were car/other accidents (32.1%), domestic violence (25.9%), natural disaster (18.5%), fire (14.8%), physical abuse (8.6%), violent crime (6.2%), and victim or witness to sexual abuse (2.5%).

At the 16-week follow-up, the researchers found a significant main effect of the treatment group favoring BBT over ARC for treatment response (P =.031) and anxiety symptoms (P =.013). However, there was also a significant 3-way interaction between treatment group, comorbid depression, and trauma exposure. These findings indicated that a history of pediatric trauma exposure ameliorated the significant effect of BBT over ARC for treatment response and anxiety.

At 32 weeks, BBT again outperformed ARC for treatment response (P =.013) and anxiety (P <.001). The researchers also observed a significant 3-way interaction between treatment group, comorbid depression, and trauma exposure for anxiety symptoms, in which BBT was not significantly different than ARC for anxiety symptoms.

The researchers noted, “Although there were differences in outcomes across the patterns of comorbid depression and trauma exposure, the significant positive effect of BBT over ARC was generally robust, except for [patients] who were anxious, depressed, and endorsed a history of trauma exposure.” Study authors concluded, “This is a critically important subgroup of youths, given the high prevalence of trauma exposure in the community, the strong overlap between trauma exposure and the presence of depression, and the high comorbidity of anxiety and depression.”

Study limitations include an underpowered sample size for analyses of 3-way interactions and the use of a binary variable for trauma exposure.