Stepped Care for Young Children After Trauma

Background: Young children are exposed to a wide range of traumatic events and many children are exposed to more than one type of victimization (Finkelhor et al., 2009). Approximately 25% of trauma-exposed young children will develop PTSD (Scheeringa et al., 2005). Due to barriers such as time, costs, limited trained clinicians, and accessibility, many young children do not receive treatment. Alternative service delivery methods, such as computer-based technology, telephone therapy or bibliotherapy that use evidence-based CBT methods, can be used as a first step in a Stepped Care model to address treatment barriers (Lovell & Richards, 2000; Salloum, 2010). The purpose of this study was to develop and test the preliminary feasibility of a novel first step treatment for young children with PTSD. The feasibility of treatment response to Step One was examined and feedback from parents was gathered.

Methods: The 6-week Step One protocol consisted of 3 CBT sessions, phone support, bibliotherapy and web-based information. Inclusion included ages 3 to 7, 5 or more PTSD symptoms, and no suicidal ideation. Exclusions included any condition that would limit the caregiver's understanding of CBT or the child's ability to follow instructions. Four cases were recruited at two mental health clinics. The children were ages 4, 5, 6, and 7; 2 boys, 2 girls; 2 Hispanic, 2 White children. Each child had been exposed to at least two traumatic events. All of the children had 10 to 12 PTSD symptoms at baseline. An independent evaluator administered measures at baseline, after Step One and at a 6-week follow-up. Standardized measures with strong psychometric properties were used. Primary outcome measures of PTSD symptoms included the DIPA and TSCYC. Secondary outcome measures of behavioral symptoms, severity and impairment included CBCL, CGI-S, and CGI. Client satisfaction and parental feedback was gathered. Data analysis included descriptive statistics, and qualitative content review.

Results: Three children (75%) responded to Step One. For the responders, (4, 5, and 6 yr. olds), there was a 92%, 70%, & 73% decrease in PTSD symptoms (DIPA). The frequency of PTSD symptoms (TSCYC) decreased 46%, 23%, & 47%. CBCL internalizing symptoms decreased 85%, 44%, & 57%. CBCL externalizing symptoms decreased 83%, 23%, & no change. Improvements in symptoms and impairment (CGI-S) were 80%, 25%, & 60%. The CGI rating was very much improved (4 yr. old) and much improved (5 and 6 yr. olds). The Step One non responder (age 7) had a 58% reduction in PTSD symptoms, but still had 5 PTSD symptoms. At follow-up, the 4 and 5 yr. olds maintained gains and the 6 yr. old had a slight increase in PTSD symptoms, but had reductions in other symptoms. Parents reported being very satisfied with Step One, and provided specific suggestions to improve the model.

Conclusions: Though results are limited in scope, the feasibility of this Step One model is quite promising. Findings suggest the need for continued development, refinement and testing of this innovative intervention which has the potential to increase access to treatment, thereby reducing childhood PTSD.