J. Behav. Ther. & Exp. Psychiat.

42 (2011) 405e413

Contents lists available at ScienceDirect

Journal of Behavior Therapy and

Experimental Psychiatry
journal homepage: www.elsevier.com/locate/jbtep

Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress

disorder: A review and meta-analysis
Joanna Kowalik a, *, Jennifer Weller a, Jacob Venter a, David Drachman b,1
a

University of Arizona College of Medicine Phoenix Campus, Maricopa Integrated Health System/District Medical Group, Desert Vista Behavioral Health Center,
570 West Brown Road, Mesa, AZ 85201, USA
b
Maricopa Integrated Health System, Maricopa Medical Center, 2601 E. Roosevelt Street, Phoenix, AZ 85008, USA

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 25 August 2010
Received in revised form
18 January 2011
Accepted 2 February 2011

Background and objectives: There is no clear gold standard treatment for childhood posttraumatic stress
disorder (PTSD). An annotated bibliography and meta-analysis were used to examine the efcacy of
cognitive behavioral therapy (CBT) in the treatment of pediatric PTSD as measured by outcome data from
the Child Behavior Checklist (CBCL).
Method: A literature search produced 21 studies; of these, 10 utilized the CBCL but only eight were both
1) randomized; and 2) reported pre- and post-intervention scores.
Results: The annotated bibliography revealed efcacy in general of CBT for pediatric PTSD. Using four
indices of the CBCL, the meta-analysis identied statistically signicant effect sizes for three of the four
scales: Total Problems (TP;
.327; p .003), Internalizing (INT;
.314; p .001), and Externalizing (EXT;

.192; p .040). The results for TP and INT were reliable as indicated by the fail-safe N and rank
correlation tests. The effect size for the Total Competence (TCOMP;
.054; p .620) index did not reach
statistical signicance.
Limitations: Limitations included methodological inconsistencies across studies and lack of a randomized
control group design, yielding few studies for meta-analysis.
Conclusions: The efcacy of CBT in the treatment of pediatric PTSD was supported by the annotated
bibliography and meta-analysis, contributing to best practices data. CBT addressed internalizing signs
and symptoms (as measured by the CBCL) such as anxiety and depression more robustly than it did
externalizing symptoms such as aggression and rule-breaking behavior, consistent with its purpose as
a therapeutic intervention.
2011 Elsevier Ltd. All rights reserved.

Keywords:
PTSD
CBT
Pediatric
Annotated bibliography
Meta-analysis

1. Introduction
The diagnosis of posttraumatic stress disorder (PTSD) rst
appeared in the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) in 1980 (American
Psychiatric Association, 1980). Posttraumatic Stress Disorder is
a complex disorder involving dysregulation of multiple neurobiological systems that affects cognitive, affective, and behavioral
domains. Epidemiological studies report a prevalence rate of PTSD
in the general adult population ranging between ve and 14%
(Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Trauma is
frequently experienced in the United States, with an estimated one-

* Corresponding author. Tel.: 1 480 344 2026; fax: 1 480 344 0219.
E-mail addresses: Joanna_Kowalik@dmgaz.org (J. Kowalik), Jennifer_Weller@
dmgaz.org (J. Weller), Jacob_Venter@dmgaz.org (J. Venter), David.Drachman@
mihs.org (D. Drachman).
1
Tel.: 1 602 344 5161; fax: 1 602 344 1974.
0005-7916/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbtep.2011.02.002

third of the adult population exposed on an annual basis. Of these

individuals, approximately 10e20% will develop the clinical
syndrome of PTSD (Solomon & Davidson, 1997).
The clinical impression is that, in contrast to the adult population, practitioners treating children and adolescents initially
seemed reluctant to apply the diagnosis of PTSD to the pediatric age
group. Data regarding trauma exposure as well as the subsequent
development of PTSD in youth are more limited compared to
adults. According to the National Child Traumatic Stress Network,
25% of children and adolescents experience a traumatic event by
the time they reach 16 years of age (Copeland-Linder, 2008). A wide
range of trauma rates has been reported in the literature, varying
from as low as 16% (Cuffe et al., 1998) to as high as 40% in youth
under the age of 18 (Boney-McCoy & Finklehor, 1996; Breslau,
Davis, Andreski, & Peterson, 1991; Giaconia et al., 1995; SchwabeStone et al., 1995). The point prevalence of PTSD in youth remains
unclear but lifetime prevalence estimates approximate 6% in the
pediatric population (Giaconia et al., 1995). This number may be an

406

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

underestimate, given that greater numbers of youth are now

receiving the diagnosis as clinicians awareness of and comfort with
diagnosing PTSD increases. Despite clinicians slow recognition of
PTSD in younger age groups, it is now accepted as a frequently
occurring disorder.
Posttraumatic stress disorder in children and adolescents is
often severely disabling. Pediatric patients with PTSD present with
a multitude of symptoms affecting functioning across different
domains. Mueser and Taub (2008) reported a rate of PTSD as high as
20% among youth with severe emotional disorders who were
involved in multiple systems of care. The authors also reported that
adolescents with PTSD were more likely to engage in a variety of
high-risk behaviors including running away from home, self-injury,
and delinquency. Adolescents in their study reported higher levels
of anxiety and depression and lower levels of optimal functioning
in different settings (e.g., at home and at school) than did adolescents without PTSD.
Different treatment approaches have been applied to address the
symptoms of pediatric PTSD. Currently, outpatient psychotherapy is
the preferred initial treatment modality for PTSD, with pharmacotherapy used as an adjunctive intervention (Cohen, 1998). Clinicians
use Cognitive Behavioral Therapy (CBT) to address associations
between stimuli and conditioned fear responses, the inuence of
environmental factors on symptom expression, and cognitive and
affective regulation; therefore, CBT lends itself to the treatment of
symptoms of PTSD. For treatment of sexually abused children, for
example, clinicians often use CBT to address sequelae of the trauma
including internalizing, externalizing, and sexualized behaviors
(MacDonald, Higgins, & Ramchandani, 2006). Taking into account
economic factors, CBT provides a focused, time-limited treatment
approach to address the effects of trauma and is a cost-effective way
of treating a larger number of individuals.
Youth with PTSD often require a combination of treatment
approaches (e.g., individual, group, and/or family psychotherapy
along with pharmacotherapy) potentially in an array of treatment
settings, with seamless transitions between levels of care. Treatment decisions are complicated by a lack of empirical data
regarding outcomes of particular interventions. For these reasons, it
remains difcult to recommend one particular treatment approach
over another. Researchers have studied the use of psychotherapy in
the pediatric PTSD population, with the majority of studies evaluating the efcacy of CBT approaches (Robertson, Humphreys, & Ray,
2004). Researchers have investigated trauma-focused CBT and
found efcacy of this intervention in both individual and group
therapy formats for sexually abused youth (Leserman, 2005).
Pharmacological studies are fewer in number than studies of CBT,
less rigorous in methodology and demonstrate less conclusive
ndings about efcacy and long-term outcomes (Nikulina et al.,
2008).
The original purpose of this article was to review the overall
efcacy of CBT in the treatment of pediatric PTSD as described in
recent literature. This review did not intend to evaluate the efcacy
of combinations of treatment interventions or treatment delivered
across different clinical settings. It examines immediate rather than
long-term outcomes of the intervention. This review explores
published research studies and contributes to the understanding
and establishment of evidence-based treatment interventions.
Once it was observed that the Child Behavior Checklist (CBCL) was
the only measure utilized with some consistency across studies of
pediatric PTSD, the more focused purpose of the study became to
examine the efcacy of CBT in the treatment of pediatric PTSD as
measured by outcome data from the CBCL.
A quantitative approach that is well-suited for measuring the
efcacy of interventions across multiple studies is meta-analysis. In
this article, meta-analysis was used to evaluate outcomes from

randomized clinical trials of CBT in which the comparison was to an

active control group. For inclusion in a meta-analysis, it is recommended that studies all utilize the same measure of the construct in
question in order to maximize comparability among studies (Littell,
Corcoran, & Pillai, 2008). Among the studies identied and
reviewed in this article, the Child Behavior Checklist (CBCL) was the
most commonly used outcome measure for treatment of pediatric
PTSD (Achenbach & Edelbrock, 1983). The ability of the CBCL to
distinguish between clinical and non-clinical patient samples has
been well-established (Kendall, 1994).
The CBCL was not designed to assess symptoms of PTSD in
particular, and therefore is not considered a measure specic for
PTSD phenomenology. It is a descriptive rating measure that
assesses parent perceptions of their childs behavior, adjustment,
emotional functioning, and social functioning. Individual symptoms, but not the clinical syndrome of PTSD, are assessed by this
measure; however, the CBCL provides composite indices that reect
how PTSD is expressed behaviorally by children and adolescents.
The effects of trauma on children are varied and can be expressed in
a number of ways. Symptoms can be categorized or conceptualized
in ways that are similar to those used by the CBCL; these categories
include internalizing, externalizing, and total competence. Some
children who are exposed to traumatic experiences may react with
internalizing symptoms (e.g., depression, anxiety, and/or somatic
complaints as reected by the Internalizing composite index of the
CBCL), some with externalizing symptoms and behaviors (e.g., rulebreaking behaviors and/or aggression as assessed by the Externalizing composite index of the CBCL), and still others may manifest the
effects of trauma with features that can be considered part of the
Total Competence composite index of the CBCL (e.g., social challenges, diminished or limited participation in activities such as
sports and hobbies, and school problems). These symptoms and
signs are not specic to PTSD per se; however, the effects of trauma
can be expressed in these different forms.
2. Method
To evaluate the outcomes of CBT treatment studies of pediatric
PTSD, the authors conducted a systematic search of data sources for
relevant scientic publications. Articles were identied via a search
of both Ovid MEDLINE and PsycINFO databases between 1966 and
2010. The following search terms were used: (PTSD OR posttraumatic stress disorder OR sexual abuse) AND (CBT OR cognitive
behavioral therapy). The search was subsequently limited to the
pediatric population (0e18 years) and the English language.
The search identied 21 randomized controlled trials using CBT
in the treatment of pediatric PTSD (Celano, Hazzard, Webb, &
McCall, 1996; Cohen & Mannarino, 1996, 1998; Cohen, Deblinger,
Mannarino, & Steer, 2004; Cohen, Mannarino, & Knudsen, 2005;
Cohen, Mannarino, & Staron, 2006; Cohen, Mannarino, Perel, &
Staron, 2007; Deblinger, Lippman, & Steer, 1996; Deblinger,
Mannarino, Cohen, & Steer, 2006; Deblinger, Stauffer, & Steer,
2001; Deblinger, Steer, & Lippman, 1999; Feather & Ronan, 2006;
Giannopoulou, Dikaiakou, & Yule, 2006; Jaberghaderi, Greenwald,
Rubin, Zand, and Dalatabadi, 2004; Kazak et al., 2004; King et al.,
2000; Kolko, 1996; March, Amaya-Jackson, Murray, & Schulte,
1998; Smith et al., 2007; Stein et al., 2003). Of the 21 studies, two
were secondary analyses and therefore were excluded from further
review. To be included in the meta-analysis, studies not only had to
be randomized, but also had to use the same outcome measure
before and immediately at conclusion of the intervention. Only
studies comparing CBT to an active control group were included.
Among the therapeutic approaches used in the active control
groups were supportive unstructured psychotherapy, nondirective
supportive treatment, and child-centered therapy. The CBCL was

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

407

Table 1
Annotated bibliography of studies of CBT in pediatric PTSD included in the meta-analysis.
1. Celano et al. (1996) in J Abn Child Psychology
Objective
Method
Participants
Interventions

Measures

Outcomes

Comments

To evaluate and compare the efcacy of two short-term individual therapy interventions for sexually abused girls and their non-offending
female caretakers
Randomized Controlled Trial
Participants included 32 sexually abused girls aged 8e13 years and their caretakers from low-income African American families.
Participants were randomly assigned to the experimental program (using CBT and metaphoric techniques) or control group
(supportive unstructured psychotherapy).
Both interventions consisted of eight 1-h sessions.
In the experimental group, 30 min were spent with the child and 30 min with the caretaker per session. Two to three sessions included
conjoint sessions.
In the control group, 40e70% of the session time was with the child, 15e50% was with the caretaker, and 0e25% was with both parties.
Out of 56 initial referrals, seven did not meet eligibility criteria, 17 dropped out, and 32 completed treatment.
1. CBCL: INT, EXT, PTSD subscale
2. Childrens Impact of Traumatic Events Scales e Revised (CITES-R)
3. Childrens Global Assessment Scale (CGAS)
4. Parent Reaction to Incest Disclosure Scale (PRIDS)
5. Parental Attribution Scale (PAS)
Both treatment programs decreased PTSD symptoms and traumagenic beliefs reecting self-blame and powerlessness, and increased overall
psychosocial functioning.
The experimental intervention was more effective than the comparison program in increasing abuse-related caretaker support of the child and in
decreasing caretaker self-blame and expectations of undue negative impact of the abuse on the child.
Length of the intervention was not specied

2. Cohen and Mannarino (1996) in J Am Acad Child Adolesc Psychiatry

Objective
Method
Participants
Interventions
Measures
Outcomes
Comments

To assess treatment outcomes for sexually abused preschool-age children and their parents by comparing the effectiveness of CBT to nondirective
supportive treatment (NST)
Randomized Controlled Trial
Participants included 67 sexually abused preschool children and their parents.
Children were randomly assigned to either CBT adapted for sexually abused preschool children (CBT-SAP) or to nondirective supportive therapy.
Child Measure: The Preschool Symptom Self-Report (PRESS)
Parent Measures: CBCL-Parent Version, Child Sexual Behavior Inventory, Weekly Behavior Report
Within-group comparison of pre- and post-treatment outcome measures demonstrated that the NST group did not change signicantly with regard
to symptomatology, but the CBT group showed signicant improvement in symptoms.
None

3. Deblinger et al. (1996) in Child Maltreatment

Objective

To examine the differential effects of child and non-offending mother participation in CBT designed to treat PTSD and other behavioral and emotional
difculties in school-aged sexually abused children
Method
Randomized Controlled Trial
Participants Participants included 100 families, of which 90 completed the pre-treatment and post-treatment assessment. Of the child group (aged 7e13 years), 83%
were female, 17% were male, and 71% had a PTSD diagnosis.
Interventions Children were randomly assigned to a control group or to one of three experimental treatment conditions: child only, mother only, or mother and child.
Measures
1. Structured Background Interview (SBI)
2. Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-E)
3. PTSD section of the K-SADS-E
4. CBCL
5. STAIC
6. CDI
7. Parenting Practice Questionnaire (PPQ)
Outcomes
Results of ANCOVAs showed signicant main effects for the CBCL Externalizing scale, CDI, PTSD section of K-SADS-E, and PPQ. Children assigned to
experimental treatment (child only or child and parent) reported fewer PTSD symptoms than children in the parent only or control groups.
Treated children showed fewer externalizing behaviors.
Only six of 38 children in the experimental group met PTSD criteria after the treatment.
Comments
Heterogeneity of community treatment; low sensitivity of instruments used to assess trauma
4. Cohen and Mannarino (1998) in Child Maltreatment
Objective

To evaluate treatment outcomes for recently sexually abused children who received either sexual-specic CBT (SAS-CBT) or nondirective supportive
therapy (NST).
Method
Randomized Controlled Trial
Participants Participants included 82 children (7e14 years), but only 49 participants competed treatment and post-treatment evaluation.
Interventions Children were randomly assigned to SAS-CBT or NST.
Measures
1. CBCL
2. STAIC
3. CDI
4. CSBI
Outcomes
At post-treatment, children receiving SAS-CBT reported fewer depressive symptoms on the CDI than did children receiving NST.
There was a group by time interaction on the CBCL Social Competence scale; the signicant pre-treatment difference between groups suggested that
the differential improvement of the SAS-CBT group represented regression to the mean.
There was no signicant difference between treatment groups at post-treatment evaluation, and no signicant group by time interaction with regard to
sexually inappropriate behaviors.
Comments
High drop-out rate
5. Deblinger, Steer, and Lippmann (1999) in Child Abuse and Neglect
Objective
Method

To determine if the 12 session pre- and post-intervention therapeutic gains found by Deblinger et al. (1996) were sustained two years after treatment
Randomized Controlled Trial

408

Participants
Interventions
Measures

Outcomes

Comments

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

The 1996 sample included 100 participating families. Only 90 completed the pre- and post-treatment assessment. Of the children (aged 7e13), 83%
were female, 17% were male, and 71% had a PTSD diagnosis.
Children were randomly assigned to community comparison (control), a child-only treatment group, a mother-only treatment group, or a
mother-and-child treatment group. Participants were assessed three, six, 12, and 24 months after treatment.
1. SBI
2. PTSD section of the K-SADS-E
3. CBCL
4. STAIC
5. CDI
6. PPQ
A series of repeated MANCOVAs was conducted, controlling for pre-test scores. Results indicated that, for the measures of psychopathology on which
symptoms decreased in the original study (i.e., externalizing problems, depression, and PTSD symptoms), scores on these measures
at 3-month, 6-month, 1-year, and 2-year follow-ups were comparable to post-treatment scores.
Incomplete data from measures at follow-ups

6. King et al. (2000) in J Am Acad Child Adolesc Psychiatry

Objective
Method
Participants

To evaluate the efcacy of child and caregiver participation in the CBT treatment of sexually abused children with PTSD symptoms
Randomized Controlled Trial
Participants included 36 sexually abused boys and girls aged 5e17 years with symptoms meeting criteria for PTSD or considered at high-risk for PTSD.
Only 28 children completed the study.
Interventions Intervention groups included two experimental groups and one control group with 12 children in each group.
Group 1 received child CBT consisting of 20 50-min sessions targeting abuse-related PTSD symptoms.
Group 2 received family CBT consisting of 20 50-min sessions focused on parent training for behavior management and communication.
Group 3 was a wait-list control group that received no contact for 24 weeks.
An additional 10 children were screened but not included in the study. Eight more children dropped out during treatment (two from the control group,
three from Group 1, and three from Group 2).
Measures
1. From the Child Behavior Checklist (CBCL), the Internalizing and Externalizing composite scores and the PTSD subscale
2. Anxiety Disorders Interview Schedule (ADIS, Child Version), PTSD section
3. Childrens Depression Inventory (CDI)
4. Fear Thermometer for Sexually Abused Children (FT-SAC)
5. Revised Childrens Manifest Anxiety Scale (RCMAS)
6. Coping Questionnaire for Sexually Abused Children (CQ-SAC)
7. Global Assessment Functioning Scale (GAF)
Outcomes
Comparing Group 1 and Group 3, children receiving treatment reported signicant improvement in PTSD symptoms and fear/anxiety.
No difference was detected between child CBT and family CBT treatment groups.
Results were still evident at 12-week follow-up.
Comments
Small study sample
7. Cohen et al. (2004) in J Am Acad Child Adolesc Psychiatry
Objective

To examine the differential efcacy of trauma-focused cognitive behavioral therapy (TF-CBT) and child-centered therapy for treating PTSD and related
emotional and behavioral problems in children who suffered sexual abuse
Method
Randomized Controlled Trial
Participants Two hundred twenty-nine children (8e14 years) who experienced contact sexual abuse that was conrmed by CPS, law enforcement, or a professional
independent evaluator were included in the study.
Interventions Children were randomly assigned to the TF-CBT or the child-centered therapy group.
Measures
1. Schedule for Affective Disorders and Schizophrenia for School-Aged Children e Present and Lifetime Version (K-SADS-PL) to assess DSM-IV psychiatric
disorders
2. Childrens Depression Inventory (CDI)
3. State-Trait Inventory for Children (STAIC)
4. Childrens Attributions and Perceptions Scale (CAPS)
Outcomes
A series analyses of covariance indicated that children in TF-CBT, compared to those in child-centered therapy, demonstrated signicantly more
improvement with regard to PTSD, depression, behavior problems, shame, and abuse-related attributions.
Comments
Lack of non-treatment control group; small diversity of the sample group
8. Cohen et al. (2005) in Child Abuse and Neglect
Objective
Method
Participants
Interventions
Measures

Outcomes
Comments

To measure the durability of improvement in response to two treatments for sexually abused children
Randomized Controlled Trial
Participants included 82 sexually abused children (8e15 years) and their primary caretakers
Children were randomly assigned to either TF-CBT or NST delivered over 12 sessions.
1. CDI
2. Trauma Symptom Checklist for Children (TSCC)
3. STAIC
4. CSBI
5. CBCL
The intent-to-treat group indicated signicant group  time effects in favor of TF-CBT on measures of depression, anxiety, and sexual problems.
Among treatment completers, the TF-CBT group showed greater improvement in anxiety, depression, sexual problems, and dissociation.
Outcome measures lacked sensitivity for PTSD symptoms; high drop-out rate, especially in the NST group

the most commonly used outcome measure. Nine studies used

a variety of scales as outcome measures other than the CBCL, and
were excluded. Other outcome measures included but were not
limited to the Weekly Behavior Report, the Post-Traumatic Stress
Disorder Reaction Index, the State-Trait Anxiety Inventory for
Children, the Revised Childrens Manifest Anxiety Scale, the Child
Report of Post-Traumatic Symptoms, and the Subjective Units of

Distress Scale. The remaining studies of CBT utilized the CBCL;

however, two did not include pre- and post-intervention assessments and were also excluded from the meta-analysis, leaving
eight studies total for the meta-analysis. To obtain a comprehensive
impression of the studies included in the meta-analysis, the
authors compiled an annotated bibliography of each of the eight
CBT studies (Table 1).

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

409

In an attempt to enable the CBCL to provide a more specic

measure of PTSD symptoms, Wolfe, Gentile, and Wolfe (1989)
derived a PTSD scale comprised of a subset of CBCL items. The
authors illustrated that the PTSD scale has high discriminant validity, as sexually abused youth scored much higher than did
a normative sample. The Wolfe PTSD scale was calculated in only
two of the eight studies included in the meta-analysis. In the
remaining six studies, scores on the set of items utilized to
construct the PTSD scale were not available; therefore, scores for
this scale could not be calculated for the remaining studies.
The CBCL includes a number of composite indices, of which up
to four were utilized to measure outcomes in the eight studies
selected for meta-analysis: Total Problems (TP), Internalizing (INT),
Externalizing (EXT), and Total Competence (TCOMP). Although the
authors were not able to assess a measure specic for PTSD in the
meta-analysis, the CBCL-based PTSD scale scores correlate very
strongly with the CBCL TP, INT and EXT measures (Ruggiero &
McLeer, 2000). Table 2 indicates which CBCL indices were reported in each study included in the meta-analysis. The purpose of the
meta-analysis was to calculate an aggregate effect size for the CBT
intervention for each of these four CBCL indices. The four metaanalyses were performed with the Comprehensive Meta-Analysis
software application, Version 2.2.046 from Biostat, Inc., 2007.

2.3. Publication bias

2.1. Measure of effect size

3.1. Effect sizes

A commonly utilized measure of effect size is Cohens d which is

simply the standardized difference between the mean outcomes in
two experimental groups (Cohen & Yang, 2008). Because several
studies included in this meta-analysis had small-sample sizes, Hedges g was used to correct for small-sample bias in the Cohens
d measure and to express the effect size for each study (Hedges,1981).
These effect sizes were then aggregated with each effect size
weighted using the inverse variance method. This method provides
effect sizes with smaller condence intervals greater weight in the
aggregated estimate of effect size (Littell et al., 2008). A negative
effect size indicates a lower score on the CBCL index, suggesting
improvement in the CBT group compared to the control group.

Fig. 1 and Table 3 report the effect sizes of each CBCL index.
For the CBCL TP, INT and EXT indices, effect sizes were statistically signicantly in favor of CBT over active control conditions. For
the TCOMP index, the average effect size was not statistically
signicantly different across CBT and control groups. In other
words, CBT interventions improved scores on the TP, INT and EXT
indices relative to control groups but not on the TCOMP index.
For all outcome measures assessed, the I2 statistic indicated
substantial homogeneity among the eight studies. To verify the
homogeneity assumption, both a xed effects model (homogeneity
assumed) and a random-effects model (heterogeneity assumed)
were calculated. The results were exactly the same for TP, EXT, and
TCOMP indices, and very similar for the INT index. These ndings
conrmed the appropriateness of using the xed effects model in
this study. Consequently, the xed effects model was used to
calculate the average effect sizes for each study included in the
meta-analysis. (Figs. 2e5)

2.2. Heterogeneity
To accurately estimate overall effect sizes for each CBCL index, it
is important to know if the differences between calculated effect
sizes for each study included in the meta-analysis can be explained
by sampling error, or if the variation among effect sizes is due to
systematic differences in study characteristics (e.g., such as differences in sample or treatment characteristics). The latter situation is
referred to as heterogeneity. For each outcome index included in
the meta-analysis, the I2 statistic was used to assess heterogeneity
among the studies utilizing that specic measure (Huedo-Medina,
Sanchez-Meca, Marin-Martinez, & Botella, 2006).

Studies without signicant ndings (i.e., null ndings) are less

likely to be submitted and/or accepted for publication than are
studies that nd statistically signicant results. If unpublished,
well-conducted studies with null ndings were included in the
meta-analysis, the effect size would be reduced. Therefore, it was
important to determine if publication bias could have been a factor
in the ndings. One strategy for detecting publication bias in metaanalyses is to calculate the fail-safe N. The fail-safe N is the
number of studies with null ndings that would have to be added to
the meta-analysis to reduce the effect size to a non-signicant
value (Littell et al., 2008).
The rank correlation test can also be used to examine publication bias (Begg & Mazumdar, 1994). When publication bias exists,
small studies are more likely to be included when they show
a relatively large treatment effect, and more likely to be absent
when they show a relatively small treatment effect. The result
would then be an inverse correlation between study size and effect
size. In this meta-analysis, both the fail-safe N and the rank
correlation test were used to assess publication bias.
3. Results

3.2. Publication bias

Table 2 reports the fail-safe N for each measure. The fail-safe N
for both the TP and INT analyses was four studies. Therefore, it is

Table 2
CBCL Indices reported in studies included in both the annotated bibliography and
meta-analysis.
Authors
Celano et al. (1996)
Cohen and Mannarino (1996)
Deblinger et al. (1996)
Cohen and Mannarino (1998)
Deblinger et al. (1999)
King et al. (2000)
Cohen et al. (2004)
Cohen et al. (2005)
TOTAL

TP

INT

EXT

X
X
X
X

X
X
4

X
X
X
7

X
X
X
X
X
X
X
X
8

TCOMP

PTSD
X

X
X
X
X
X
4

2
Fig. 1. Average effect sizes and condence intervals.

410

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

Table 3
Results of meta-analysis of each CBCL index.
Index

Number of studies

Condence interval

Average effect size

Z statistic

p value

I2

Fail-safe N

Rank correlation

TP
INT
EXT
TCOMP

4
7
8
4

.541

.505

.376

.267

.327

.314

.192

.054

2.297

3.550

2.051

.496

.003
.001
.040
.620

0.0%
20.3%
0.0%
0.0%

4
4
0
0

.167a
.571a
.179a

.167a

to
to
to
to

.113

.122

.008
.159

Test for a negative correlation was not signicant.

unlikely that publication bias affected the ndings for these two
CBCL indices. On the other hand, the fail-safe N for the EXT and
TCOMP indices was so small (zero) that ndings on these two
indices should be viewed with caution.
None of the rank correlation tests for each of the four CBCL
outcome indices showed a signicant inverse correlation. These
results provided further evidence that publication bias did not
signicantly affect the ndings.
4. Conclusions
4.1. Study strengths and implications
The annotated bibliography in Table 1 supported the efcacy in
general of CBT for treatment of pediatric PTSD. The meta-analysis of
eight randomized trials of CBT, comparing CBT to active control
groups and using both pre- and post-intervention assessments,
provided strong evidence that CBT is effective in the treatment of
childhood PTSD. In particular, Total Problems, Internalizing, and
Externalizing indices of the CBCL showed favorable outcomes as
reected by greater effect sizes of the CBT treatment groups versus
comparison groups. The ndings for the effects of CBT on the Total
Competence index of the CBCL were not statistically signicant.
Participants in the comparison groups in the studies included in
this meta-analysis received active treatment as opposed to no
treatment at all. This fact strengthens the signicance of our
conclusion that CBT is efcacious for the treatment of pediatric
PTSD. The fail-safe N for both the Total Problems and Internalizing
indices was four studies. Therefore, despite the small number of
studies available for inclusion in the meta-analysis, the authors can
be condent that neither publication bias nor the small number of
studies suitable for inclusion signicantly affected the ndings
reected by these two CBCL indices. In contrast, the fail-safe N for

the Externalizing and Total Competence indices was zero, casting

doubt on the validity of effect sizes observed for these dimensions
of functioning.
Results for the Total Problems and Internalizing indices
provided support for the effectiveness of CBT in addressing symptoms specically measured by these two CBCL indices. Statistically
signicant positive change occurred in these two indices in
response to CBT, and the fail-safe N for these indices indicated that
the ndings were reliable. Although the Externalizing index
showed statistically signicant improvement in response to CBT,
the fail-safe N of zero indicated that the results should be interpreted with caution. The Total Competence index did not change
following CBT and had a fail-safe N of zero; these ndings could not
be explained satisfactorily and require further exploration. It is
possible that CBT interventions for pediatric PTSD do not address
externalizing and Total Competence constructs or behaviors as
measured on the CBCL to the same degree as they do internalizing
symptoms. It would seem that CBT better addresses internalizing
symptoms such as anxiety and depression (as the intervention was
originally intended to do) than it does externalizing symptoms such
as aggression and/or rule-breaking behaviors as they are measured
by the CBCL. Externalizing symptoms often lead parents to seek
treatment for their children with PTSD, due to signicant effects of
aggression and rule-breaking behavior on overall social functioning. In addition to CBT, other treatment approaches may be
helpful specically targeting externalizing signs and symptoms
that manifest in response to PTSD.
4.2. Study limitations
For inclusion in a meta-analysis, studies must utilize similar (or
ideally, identical) outcome measures and must use a randomized
control group design. The current meta-analysis was limited by

Most Recent

Earliest

Cohen & Mannarino Jan 1996*

Cohen & Mannarino Feb 1998

Each line represents the

effect size for the indicated
study and all studies
occurring before it

Cohen et al. Apr 2004*

Cohen et al. 2005*

-1.0

Effect Size

-0.8

-0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

Average Effect Size

Favors CBT Group

95% Confidence Interval

Favors Control Group

* Statistically significant

Fig. 2. Cumulative evidence chart: CBCL total problems (TP).

0.8

1.0

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

411

Earliest

Celano et al. Jan 1996

Cohen & Mannarino Jan 1996*
Deblinger et al. Nov 1996

Each line represents the

effect size for the indicated
study and all studies
occurring before it

Most Recent

Cohen & Mannarino Feb 1998*

King et al. Nov 2000
Cohen et al. Apr 2004*
Cohen et al. 2005*
-1.0

-0.8

-0.6

-0.4

Effect Size

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

Average Effect Size

Favors CBT Group

Favors Control Group

* Statistically significant

95% Confidence Interval

Fig. 3. Cumulative evidence chart: CBCL internalizing (INT).

the diversity of outcome measures utilized across studies, and the

absence of randomized control group designs. Some of the
outcome measures were designed specically to measure childhood traumatic experiences, while others tapped emotional and/
or behavioral problems that may be a result of trauma more
generally. The CBCL was used most often as an outcome measure
among CBT treatment studies; therefore, only studies that utilized
this measure were included in the meta-analysis. The use of
diverse measures across studies revealed the lack of a gold
standard instrument for use in the assessment of pediatric PTSD.
With respect to use of a randomized control group design, most
studies of the treatment of pediatric PTSD using CBT approaches
did not utilize such a research design.
A further limitation due to the relatively low number of studies
that could be included in the meta-analysis was that it limited the
generalizability of the ndings. A greater number of studies of CBT
utilizing the same outcome measure(s), and that were more
specically aimed at assessing PTSD symptoms, would have yielded
more robust ndings.
Inconsistencies across studies in methodology further limited
the results of the meta-analysis. Variables such as the type and
delity of CBT used to address pediatric PTSD (e.g., trauma-focused

CBT, combining traditional CBT with metaphorical techniques, etc.),

participant characteristics (e.g., child only receiving intervention
versus child and parent receiving intervention), therapist sophistication or training in the intervention(s), and number of sessions
and the length of the treatment intervention period all could have
affected study ndings. Additional clinical characteristics such as
age, sex differences, sample sizes, differences in drop-out rates, and
severity of symptoms in the study samples could affect the generalizability of ndings.
4.3. Future directions
Given that this review provided support for the use of CBT to
treat symptoms of pediatric PTSD, a next step would be to
deconstruct the components of CBT to determine which symptoms of PTSD respond best to particular aspects of this treatment
approach. Doing so would allow clinicians to select the ideal
combination of treatment components for their pediatric patients
who have been exposed to traumatic experiences. Additionally,
future studies of the use of CBT in pediatric PTSD would benet
from use of a randomized control group design to enhance
scientic merit.

Earliest

Celano et al. Jan 1996

Cohen & Mannarino Jan 1996*
Deblinger et al. Nov 1996*

Each line represents the

effect size for the indicated
study and all studies
occurring before it

Most Recent

Cohen & Mannarino Feb 1998

Deblinger et al. 1999
King et al. Nov 2000
Cohen et al. Apr 2004*
Cohen et al. 2005*
-1.5

Effect Size

-1.0

-0.5

0.0

0.5

Average Effect Size

Favors CBT Group

95% Confidence Interval

Favors Control Group

* Statistically significant

Fig. 4. Cumulative evidence chart: CBCL externalizing (EXT).

1.0

1.5

412

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

Most Recent

Earliest

Cohen & Mannarino Jan 1996

Cohen & Mannarino Feb 1998

Each line represents the

effect size for the indicated
study and all studies
occurring before it

Cohen et al. Apr 2004

Cohen et al. 2005

-1.0

-0.8

-0.6

Effect Size

-0.4

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

Average Effect Size

Favors CBT Group

95% Confidence Interval

Favors Control Group

* Statistically significant

Fig. 5. Cumulative evidence chart: CBCL total competence (TCOMP).

References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, D.C.: American Psychiatric Press. (DSM-III).
Achenbach, T., & Edelbrock, C. (1983). Manual for the child behavior checklist and
revised child behavior prole. Univ Vermont/Dept Psychiatry.
Begg, C. B., & Mazumdar, M. (1994). Operating characteristics of a rank correlation
test for publication bias. Biometrics, 50(4), 1088e1101.
Boney-McCoy, S., & Finklehor, D. (1996). Is youth victimization related to trauma
symptoms and depression after controlling for prior symptoms and family
relationships? A longitudinal, prospective study. Journal of Consulting and
Clinical Psychology, 64(6), 1406e1416.
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and
postrraumatic stress disorder in an urban population of young adults. Archives
of General Psychiatry, 48(3), 216e222.
Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic
beliefs among sexually abused girls and their mothers: an evaluation study.
Journal of Abnormal Child Psychology, 24(1), 1e17.
Cohen, J. A. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37(10 Suppl.), 4se26s.
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. (2004). A multisite,
randomized controlled trial for children with sexual abuse-related PTSD
symptoms. Journal of the American Academy of Child and Adolescent Psychiatry,
43(4), 393e402.
Cohen, J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually
abused preschool children: initial ndings. Journal of the American Academy of
Child and Adolescent Psychiatry, 35(1), 42e50.
Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children:
initial treatment outcome ndings. Child Maltreatment, 3(1), 17e26.
Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually abused
children: 1 year follow-up of a randomized controlled trial. Child Abuse and
Neglect, 29(2), 103e105.
Cohen, J. A., Mannarino, A. P., Perel, J. M., & Staron, V. (2007). A pilot randomized
controlled trial of combined trauma-focused CBT and sertraline for childhood
PTSD symptoms. Journal of the American Academy of Child and Adolescent
Psychiatry, 46(7), 811e819.
Cohen, J. A., Mannarino, A. P., & Staron, V. R. (2006). A pilot study of modied
cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG). Journal of
the American Academy of Child and Adolescent Psychiatry, 45(12), 1465e1473.
Cohen, J., & Yang, F. (2008). Progress in applied mathematical modeling. Nova Science
Pub Inc.
Copeland-Linder, N. (2008). Posttraumatic stress disorder. Pediatrics in Review, 29,
103e104.
Cuffe, S. P., Addy, C. L., Garrison, C. Z., Waller, J. L., Jackson, K. L., McKeown, R. E., et al.
(1998). Prevalence of PTSD in a community sample of older adolescents. Journal
of the American Academy of Child and Adolescent Psychiatry, 37(2), 147e154.
Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering
posttraumatic stress symptoms: initial treatment outcome ndings. Child
Maltreatment, 1(4), 310e321.
Deblinger, E., Mannarino, A. P., Cohen, J. A., & Steer, R. A. (2006). A follow-up study
of a multisite, randomized, controlled trial for children with sexual abuserelated PTSD symptoms. Journal of the American Academy of Child and Adolescent
Psychiatry, 45(12), 1474e1484.
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efcacies of
supportive and cognitive behavioral group therapies for young children who

have been sexually abused and their nonoffending mothers. Child Maltreatment,
6(4), 332e343.
Deblinger, E., Steer, R. A., & Lippmann, J. (1999). Two-year follow-up study of
cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse & Neglect, 23(12), 1371e1378.
Feather, J. S., & Ronan, K. R. (2006). Trauma-focused cognitive-behavioural therapy
for abused children with posttraumatic stress disorder: a pilot study. New
Zealand Journal of Psychology, 35(3), 132e145.
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E.
(1995). Traumas and posttraumatic stress disorder in a community population
of older adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 34(10), 1369e1380.
Giannopoulou, I., Dikaiakou, A., & Yule, W. (2006). Cognitive-behavioural group
intervention for PTSD symptoms in children following the Athens 1999
earthquake: a pilot study. Clinical Child Psychology and Psychiatry, 11(4),
543e553.
Hedges, L. V. (1981). Distribution theory for Glasss estimator of effect sizes and
related estimators. Journal of Statistics Education, 6(2), 107e128.
Huedo-Medina, T., Sanchez-Meca, J., Marin-Martinez, F., & Botella, J. (2006).
Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychological
Methods, 11(2), 193e206.
Jaberghaderi, N., Greenwald, R., Rubin, A., Zand, S. O., & Dalatabadi, S. (2004).
A comparison of CBT and EMDR for sexually-abused Iranian girls. Clinical
Psychology & Psychotherapy, 11(5), 358e368.
Kazak, A. E., Alderfer, M. A., Streisand, R., Simms, S., Rourke, M. T., Barakat, L. P., et al.
(2004). Treatment of posttraumatic stress symptoms in adolescent survivors of
childhood cancer and their families: a randomized clinical trial. Journal of
Family Psychology, 18(3), 493e504.
Kendall, P. C. (1994). Treating anxiety disorders in children: results of a randomized
clinical trial. Journal of Consulting and Clinical Psychology, 62(1), 100e110.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General
Psychiatry, 52(12), 1048e1060.
King, N. J., Tonge, B. J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., et al. (2000).
Treating sexually abused children with posttraumatic stress symptoms:
a randomized clinical trial. Journal of the American Academy of Child and
Adolescent Psychiatry, 39(11), 1347e1355.
Kolko, D. J. (1996). Individual cognitive behavioral treatment and family therapy for
physically abused children and their offending parents: a comparison of clinical
outcomes. Child Maltreatment, 1(4), 322e342.
Leserman, J. (2005). Sexual abuse history: prevalence, health effects, mediators, and
psychological treatment. Psychosomatic Medicine, 67(6), 906e915.
Littell, J., Corcoran, J., & Pillai, V. (2008). Systematic reviews and meta-analysis. USA:
Oxford University Press.
MacDonald, G. M., Higgins, J. P. T., & Ramchandani, P. (2006). Cognitive-behavioural
interventions for children who have been sexually abused (review). Cochrane
Database of Systematic Reviews, 4. CD001930.
March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998). Cognitivebehavioral psychotherapy for children and adolescents with posttraumatic
stress disorder after a single-incident stressor. Journal of the American Academy
of Child and Adolescent Psychiatry, 37(6), 585e593.
Mueser, K. T., & Taub, J. (2008). Trauma and PTSD among adolescents with severe
emotional disorders involved in multiple service systems. Psychiatric Services,
59(6), 627e634.
Nikulina, V., Hergenrother, J. M., Brown, E. J., Doyle, M. E., Filton, B. J., &
Carson, G. S. (2008). From efcacy to effectiveness: the trajectory of the

J. Kowalik et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 405e413

treatment literature for children with PTSD. Expert Review of Neurotherapeutics, 8(8), 1233e1246.
Robertson, M., Humphreys, L., & Ray, R. (2004). Psychological treatments for posttraumatic stress disorder: recommendations for the clinician. Journal of
Psychiatric Practice, 10(2), 106e118.
Ruggiero, K. J., & McLeer, S. V. (2000). PTSD scale of the child behavior checklist:
concurrent and discriminant validity with non-clinic-referred sexually abused
children. Journal of Traumatic Stress, 13(2), 287e299.
Schwab-Stone, M. E., Ayers, T. S., Kasprow, W., Voyce, C., Barone, C., Shriver, T., et al.
(1995). No safe haven: a study of violence exposure in an urban community.
Journal of the American Academy of Child and Adolescent Psychiatry, 34(10),
1343e1352.

413

Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish, T., & Clark, D. M. (2007).
Cognitive-behavioral therapy for PTSD in children and adolescent: a preliminary randomized controlled trial. Journal of the American Academy of Child and
Adolescent Psychiatry, 46(8), 1051e1061.
Solomon, S. D., & Davidson, J. R. (1997). Trauma: prevalence, impairment, service
use, and cost. Journal of Clinical Psychiatry, 58(9), 5e11.
Stein, B. D., Jaycox, L. H., Katoaka, S. H., Wong, M., Tu, W., Elliott, M. N., et al. (2003).
A mental health intervention for schoolchildren exposed to violence:
a randomized controlled trial. Journal of the American Medical Association, 290
(5), 603e611.
Wolfe, V. V., Gentile, C., & Wolfe, D. A. (1989). The impact of sexual abuse on
children: a PTSD formulation. Behavior Therapy, 20(2), 215e228.