Psychological therapies for children and adolescents exposed to trauma

Donna Gillies; Licia Maiocchi; Abhishta P Bhandari; Fiona Taylor; Carl Gray; Louise O'Brien

doi:10.1002/14651858.CD012371

. 2016 Oct 11;2016(10):CD012371. doi: 10.1002/14651858.CD012371

Psychological therapies for children and adolescents exposed to trauma

Donna Gillies ^1,^✉, Licia Maiocchi ², Abhishta P Bhandari ³, Fiona Taylor ⁴, Carl Gray ⁵, Louise O'Brien ⁶

Editor: Cochrane Common Mental Disorders Group

PMCID: PMC6457979 PMID: 27726123

Abstract

Background

Children and adolescents who have experienced trauma are at high risk of developing post‐traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents.

Objectives

To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event.

Search methods

We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status.

Selection criteria

All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event.

Data collection and analysis

Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random‐effects model. We analysed data as short‐term (up to and including one month after therapy), medium‐term (one month to one year after therapy) and long‐term (one year or longer).

Main results

Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life‐threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas.

Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive‐behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children.

The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) ‐0.42, 95% CI ‐0.61 to ‐0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term.

CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD ‐0.24, 95% CI ‐0.42 to ‐0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate.

We did not identify any studies that compared pharmacological therapies with psychological therapies.

Authors' conclusions

The meta‐analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High‐quality studies should be conducted to compare these therapies.

Plain language summary

Psychological therapies for preventing post‐traumatic stress disorder in children and adolescents

Why is this review important?

Children and adolescents who have experienced trauma are at high risk of developing post‐traumatic stress disorder (PTSD) and negative psychological and social outcomes.

Who will be interested in this review?

Children and adolescents who have undergone trauma and their families and caregivers will be interested in this review, along with healthcare professionals, particularly those working in mental health services for children and adolescents.

What questions does this review aim to answer?

• What are the effects of psychological therapies in preventing PTSD and other negative emotional, behavioural and mental health outcomes in children and adolescents exposed to a traumatic event?

• Which psychological therapies are most effective?

• Are psychological therapies more effective than pharmacological therapies or other treatments?

Which studies were included in the review?

Review authors searched databases to May 2015 to find all relevant trials. To be included in the review, studies had to be randomised controlled trials and had to include both children and adolescents exposed to trauma.

We included 51 trials with a total of 6201 participants. Participants had been exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three. In one trial each, participants had suffered a life‐threatening illness or had been physically abused or maltreated. Participants in the remaining trials were exposed to a range of traumas.

Most trials compared psychological therapy with a control condition such as treatment as usual, waiting list or no treatment; others compared different psychological therapies.

A total of 43 studies reported outcomes recorded within the first month after treatment; 27 studies reported outcomes from one month up to a year, and eight reported data for a year or longer after treatment.

What does evidence presented in the review tell us?

Children and adolescents receiving psychological therapies were less likely to be diagnosed with PTSD and had fewer symptoms of PTSD up to a month after treatment compared with those who received no treatment, treatment as usual or were on a waiting list. Our confidence in these findings is limited as the overall quality of evidence was very low to low. There was no evidence for the effectiveness of psychological therapies beyond one month. There was moderate quality evidence that cognitive‐behavioural therapy (CBT) might be more effective in reducing symptoms of PTSD compared to other psychological therapies for up to a month. Adverse effects were not reported. There were no studies which compared psychological therapies to drug treatments.

What should happen next?

Researchers should conduct high‐quality trials to further evaluate the effectiveness of psychological therapies for children and adolescents exposed to trauma. These trials should be designed to ensure that participants and their families are not aware of whether they are receiving psychological therapy, particularly when measures are completed by participants or their parents. In addition, efforts should be made to ensure high rates of follow‐up beyond one month after completion of therapy.

In addition, studies should compare different types of psychological therapy to give a better indication of whether children and adolescents exposed to different types of trauma are more or less likely to respond to these therapies.

Summary of findings

Summary of findings for the main comparison. Psychological therapies versus wait list, treatment as usual or no treatment for children and adolescents exposed to trauma (short‐term).

Patient or population: children and adolescents exposed to trauma  Setting: three hospitals and fourteen community/outpatient settings (including eight schools, a trauma clinic, child support services, foster care and youth support services) in the US (6), Australia (2), Democratic Republic of Congo (2), Israel (2), the Palestinian territories (2), Bosnia(1), Canada (1), and Indonesia (1).  Intervention: all psychological therapies  Comparison: control (short‐term)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	Number of participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Risk with control (short‐term)	Risk with all psychotherapies
PTSD diagnosis	Study population		OR 0.51  (0.34 to 0.77)	874  (5 studies)	⊕⊝⊝⊝  Very low^a,b,c
	367 per 1000	228 per 1000  (165 to 309)
	Moderate
	345 per 1000	212 per 1000  (152 to 288)
PTSD total symptoms	Mean PTSD total symptoms in the intervention group 0.42 standard deviations undefined fewer (0.61 fewer to 0.24 fewer)		Moderate effect size	2051  (15 studies)	⊕⊕⊝⊝  Low^d,e
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI)  CI: confidence interval; OR: odds ratio; RR: risk ratio
GRADE Working Group grades of evidence   High quality: We are very confident that the true effect lies close to that of the estimate of effect  Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect but may be substantially different  Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect  Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Outcome	Group	n	Mean	SD
PTSD symptoms One month	Exposure therapy	8	3.38	2.60
PTSD symptoms One month	Control	8	31.38	3.84
Avoidance One month	Exposure therapy	8	2.88	2.62
Avoidance One month	Control	8	20.25	2.38
Intrusion One month	Exposure therapy	8	0.50	0.50
Intrusion One month	Control	8	11.13	2.93

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis	5	874	Odds Ratio (M‐H, Random, 95% CI)	0.51 [0.34, 0.77]
1.1 CBT	3	769	Odds Ratio (M‐H, Random, 95% CI)	0.59 [0.43, 0.80]
1.2 EMDR	1	40	Odds Ratio (M‐H, Random, 95% CI)	0.2 [0.01, 4.44]
1.3 Family therapy	1	65	Odds Ratio (M‐H, Random, 95% CI)	0.11 [0.02, 0.56]
2 PTSD total symptoms	15	2051	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.61, ‐0.24]
2.1 CBT	6	1329	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.55, ‐0.19]
2.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.77 [‐1.61, 0.06]
2.3 Family therapy	2	95	Std. Mean Difference (IV, Random, 95% CI)	‐0.53 [‐0.94, ‐0.12]
2.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.26, 0.72]
2.5 Psychoeducation	2	215	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.69, 0.30]
2.6 Supportive therapy	2	272	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.95, 0.15]
2.7 CBT + narrative therapy	1	52	Std. Mean Difference (IV, Random, 95% CI)	‐1.96 [‐2.63, ‐1.29]
3 PTSD avoidance	2	205	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.29, 0.26]
3.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.27, 0.36]
3.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.80, 0.35]
4 PTSD hyperarousal	2	205	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.22, 0.32]
4.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.21, 0.41]
4.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.70, 0.45]
5 PTSD intrusion	2	205	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.16, 0.39]
5.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.15 [‐0.16, 0.46]
5.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.59, 0.55]
6 Anxiety total symptoms	7	959	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.26, 0.00]
6.1 CBT	2	557	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.30, 0.04]
6.2 Counselling	1	130	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.56, 0.16]
6.3 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.66 [‐1.30, ‐0.03]
6.4 Exposure	1	65	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.48, 0.51]
6.5 Narrative	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.58, 0.17]
6.6 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.21, 0.85]
7 Anxiety ‐ state	2	70	Std. Mean Difference (IV, Random, 95% CI)	‐0.64 [‐1.12, ‐0.16]
7.1 CBT	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.71 [‐1.31, ‐0.12]
7.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.51 [‐1.33, 0.31]
8 Anxiety ‐ trait	2	70	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.81, 0.14]
8.1 CBT	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.94, 0.22]
8.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐1.10, 0.51]
9 Depression	13	1569	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.30, 0.04]
9.1 CBT	6	1191	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.42, ‐0.00]
9.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.39 [‐1.41, 0.64]
9.3 Exposure	1	52	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.45, 0.65]
9.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.66, 0.77]
9.5 Narrative	2	176	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.52, 0.77]
9.6 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.43, 0.62]
10 Behaviour ‐ total	3	166	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.51, 0.42]
10.1 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐1.25, 0.37]
10.2 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.11, 0.80]
10.3 Family therapy	1	65	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.72, 0.26]
11 Behaviour ‐ internalising	10	719	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.20, 0.13]
11.1 CBT	2	162	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.44, 0.18]
11.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.57 [‐1.07, ‐0.07]
11.3 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.38 [‐0.08, 0.84]
11.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.40, 1.04]
11.5 Narrative	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.18, 0.41]
11.6 Psychoeducation	2	206	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.38, 0.17]
12 Behaviour ‐ externalising	12	1174	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.33, 0.14]
12.1 CBT	3	565	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.28, 0.06]
12.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐1.19, 0.10]
12.3 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.49 [0.03, 0.95]
12.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.49, 0.95]
12.5 Narrative	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.41, 0.81]
12.6 Psychoeducation	2	206	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.52, 0.46]
12.7 CBT + narrative therapy	1	52	Std. Mean Difference (IV, Random, 95% CI)	‐1.06 [‐1.64, ‐0.47]
13 Functional impairment	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
13.1 CBT	2	557	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.59, ‐0.24]
14 Quality of life	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
14.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Loss to follow‐up	26	3872	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.69, 1.39]
15.1 CBT	14	2913	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.47, 1.62]
15.2 Counselling	1	164	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.30, 1.03]
15.3 EMDR	2	92	Risk Ratio (M‐H, Random, 95% CI)	1.64 [0.48, 5.59]
15.4 Exposure	1	16	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
15.5 Family therapy	2	105	Risk Ratio (M‐H, Random, 95% CI)	1.44 [0.48, 4.30]
15.6 Narrative	2	280	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.32, 2.39]
15.7 Psychoeducation	3	274	Risk Ratio (M‐H, Random, 95% CI)	1.21 [0.75, 1.96]
15.8 Psychodrama	1	28	Risk Ratio (M‐H, Random, 95% CI)	1.5 [0.29, 7.65]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis	4	742	Odds Ratio (M‐H, Random, 95% CI)	0.66 [0.26, 1.69]
1.1 CBT	2	570	Odds Ratio (M‐H, Random, 95% CI)	0.49 [0.09, 2.61]
1.2 Debriefing	1	132	Odds Ratio (M‐H, Random, 95% CI)	1.31 [0.47, 3.68]
1.3 EMDR	1	40	Odds Ratio (M‐H, Random, 95% CI)	0.35 [0.01, 9.13]
2 PTSD total symptoms	12	2337	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.38, 0.05]
2.1 CBT	5	1701	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.72, 0.03]
2.2 Debriefing	2	231	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.22, 0.30]
2.3 Family therapy	2	141	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.39, 0.27]
2.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.26, 0.73]
2.5 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.65, 0.40]
2.6 Supportive therapy	1	144	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.54, 0.12]
3 PTSD ‐ avoidance	2	243	Std. Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.22, 0.29]
3.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.08 [‐0.42, 0.26]
3.2 Family therapy	1	111	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.20, 0.55]
4 PTSD ‐ hyperarousal	2	243	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.43, 0.17]
4.1 Debriefing	1	132	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.33, 0.35]
4.2 Family therapy	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.67, 0.09]
5 PTSD ‐ intrusion	2	243	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.29, 0.21]
5.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.39, 0.29]
5.2 Family therapy	1	111	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.40, 0.35]
6 Anxiety total symptoms	7	1470	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.20, 0.00]
6.1 CBT	3	1131	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.19, 0.04]
6.2 Debriefing	1	132	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.42, 0.27]
6.3 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.72 [‐1.36, ‐0.07]
6.4 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.73, 0.32]
6.5 Narrative	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.54, 0.21]
7 Anxiety ‐ state	1		Std. Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.1 CBT	1		Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Anxiety ‐ trait	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
8.1 CBT	2	101	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.45 [‐0.85, ‐0.05]
9 Depression	13	2191	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.22, 0.07]
9.1 CBT	8	1810	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.31, 0.07]
9.2 Debriefing	2	231	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.38, 0.14]
9.3 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.38, 1.06]
9.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.15, 0.84]
9.5 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.67, 0.38]
10 Behaviour ‐ total	3	281	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.43, 0.04]
10.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.28 [‐0.62, 0.06]
10.2 Family therapy	1	50	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.37 [‐0.93, 0.19]
10.3 Narrative	1	99	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.39, 0.39]
11 Behaviour ‐ internalising	4	291	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.25, 0.28]
11.1 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐1.13, 0.14]
11.2 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.72, 0.72]
11.3 Narrative	2	221	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.13, 0.40]
12 Behaviour ‐ externalising	5	694	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.32, 0.35]
12.1 CBT	1	403	Std. Mean Difference (IV, Random, 95% CI)	0.07 [‐0.13, 0.27]
12.2 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐1.66, ‐0.33]
12.3 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	‐0.01 [‐0.72, 0.71]
12.4 Narrative	2	221	Std. Mean Difference (IV, Random, 95% CI)	0.31 [0.05, 0.58]
13 Function	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
13.1 CBT	3	814	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.88, ‐0.05]
14 Quality of life	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
14.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Loss to follow‐up	20	3663	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.82, 1.21]
15.1 CBT	11	2856	Odds Ratio (M‐H, Fixed, 95% CI)	1.01 [0.81, 1.27]
15.2 Counselling	1	23	Odds Ratio (M‐H, Fixed, 95% CI)	7.0 [0.32, 152.95]
15.3 Debriefing	1	158	Odds Ratio (M‐H, Fixed, 95% CI)	0.76 [0.33, 1.76]
15.4 EMDR	1	65	Odds Ratio (M‐H, Fixed, 95% CI)	1.41 [0.52, 3.84]
15.5 Family therapy	1	75	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.48, 3.39]
15.6 Narrative	2	171	Odds Ratio (M‐H, Fixed, 95% CI)	0.70 [0.16, 2.99]
15.7 Psychoeducation	2	244	Odds Ratio (M‐H, Fixed, 95% CI)	0.77 [0.40, 1.47]
15.8 Other	1	71	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.29, 2.73]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis	2	160	Odds Ratio (M‐H, Random, 95% CI)	0.74 [0.29, 1.91]
1.1 EMDR	1	36	Odds Ratio (M‐H, Random, 95% CI)	1.0 [0.06, 17.33]
1.2 Supportive therapy	1	124	Odds Ratio (M‐H, Random, 95% CI)	0.71 [0.26, 1.95]
2 PTSD total symptoms	7	466	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.42, ‐0.05]
2.1 EMDR	2	62	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.44, 0.56]
2.2 Play therapy	1	26	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.56, 0.98]
2.3 Supportive therapies	4	378	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.53, ‐0.12]
3 PTSD avoidance	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 PTSD hyperarousal	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 PTSD intrusion	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
5.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Anxiety total symptoms	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
6.1 Supportive therapy	2	230	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.74, ‐0.22]
7 Depression	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
7.1 Supportive therapy	2	237	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.42, 0.14]
8 Behaviour ‐ total	3	182	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.27, 0.31]
8.1 EMDR	1	14	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐1.50, 0.63]
8.2 Supportive therapy	2	168	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.25, 0.36]
9 Behaviour ‐ internalising	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
9.1 Supportive therapy	3	235	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.79, 0.28]
10 Behaviour ‐ externalising	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
10.1 Supportive therapy	3	235	Std. Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.58, ‐0.05]
11 Function	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
11.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12 Loss to follow‐up	8	544	Odds Ratio (M‐H, Random, 95% CI)	0.69 [0.41, 1.18]
12.1 EMDR	2	64	Odds Ratio (M‐H, Random, 95% CI)	0.76 [0.23, 2.52]
12.2 Play therapy	1	31	Odds Ratio (M‐H, Random, 95% CI)	0.08 [0.00, 1.56]
12.3 Supportive therapy	5	449	Odds Ratio (M‐H, Random, 95% CI)	0.74 [0.38, 1.43]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD total symptoms	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
1.1 Supportive therapy	2	223	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.43, 0.11]
2 Anxiety total symptoms	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
2.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Depression	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Behaviour ‐ total	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Behaviour ‐ internalising	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
5.1 Supportive therapy	2	178	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.36, 0.26]
6 Behaviour ‐ externalising	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
6.1 Supportive therapy	2	178	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.37, 0.25]
7 Loss to follow‐up	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected
7.1 Supportive therapy	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Behaviour ‐ internalising	1	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
1.1 Supportive therapy	1	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Behaviour ‐ externalising	1	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
2.1 Supportive therapy	1	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Loss to follow‐up	1	Odds Ratio (M‐H, Random, 95% CI)	Totals not selected
3.1 Supportive therapy	1	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Methods	Randomised trial of individual vs group therapy
Participants	Included (n = 39) Adolescent females 13 to 17 years of age who had suffered contact sexual abuse validated by child protective services. Ethnicity: white 31, black 8. The girls were in the process of court proceedings or investigative procedures; 9 completed the court process during treatment Excluded Not reported Setting Counselling centre in a rural county in Delaware, USA
Interventions	Both therapies Therapists were instructed to use Rogerian techniques in both individual and group therapies. Therapists were given a list of topics to be introduced for discussion, including associated emotions and life changes, assertiveness and coping, family roles, support systems and resources, communication, court preparation and social concerns Individual therapy (n = 15) Individual therapy sessions of 1 hour were conducted for 10 weeks Group therapy (n = 24) Group therapy allowed sharing of experiences and information and provided feedback from other victims. Group sessions of 1 ½ hours were run with a maximum of 8 participants over 6 weeks Therapists All held master's level degrees in counselling disciplines, had received training in treatment of sexual abuse and were skilled in Rogerian techniques. Therapists were also provided with examples of Rogerian techniques (restatement, reflection of meaning, reflection of feeling, congruence, acceptance and reinforcement of positive feelings). Each of the 3 therapists led 1 group and saw 5 girls individually
Outcomes	Depression Scale: Institute for Personality and Ability Testing Depression Scale Rater: adolescent Anxiety Scale: Institute for Personality and Ability Testing Anxiety Scale Rater: adolescent When Post therapy
Notes	Depression and anxiety were in the normal range at pretest for both groups
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random assignment was achieved by having participants draw 1 slip of paper at a time from a box until all were assigned
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Outcome assessment could not be blinded, as all measures were self report
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Loss to follow‐up was not reported
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other apparent bias

Methods	Cluster‐randomised trial of teaching recovery technique vs wait list
Participants	Included (n = 140) The 10 students with the highest CRIES‐13 scores in each class of 11‐ to 14‐year‐olds. Female: 60. Mean age: 11.08 (range 11 to 14) years. Ethnicity: all Palestinian Excluded Students with incomplete pretest data Setting Nablus, Palestine; selected because of high levels of ongoing violence
Interventions	Teaching recovery technique (n = 90) This cognitive‐behavioural programme includes 5 sessions that focus on normalising trauma and strategies for intrusive memories, hyperarousal and avoidance symptoms of PTSD. The fifth session focuses on children’s response to loss. Sessions were delivered over 5 consecutive weeks. Each session lasted 1 hour and 30 minutes. Two counsellors were present during programme delivery ‐ one to present and the other to observe Wait list (n = 50) The wait list received the usual school health education curriculum (health and social issues) Therapists Counsellors received 3 days of training in programme delivery provided by 2 expert trainers from the Children and War Foundation, covering programme values, content and processes Programme fidelity was assessed by 18 observers who completed a fidelity questionnaire Observers reported that 60% of objectives were achieved and 74% of guidelines were followed
Outcomes	Diagnosis Scale: score ≥ 17 on the Children’s Revised Impact of Events Scale (CRIES‐13) Rater: child/adolescent Trauma symptoms Scale: CRIES‐13 Rater: child/adolescent Depression Scale: Depression Self‐Rating Scale for Children Rater: child/adolescent Behaviour Scale: Strength and Difficulties Questionnaire Rater: child/adolescent When Two weeks after intervention
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Counsellors trained in the intervention were randomly allocated to groups by the principal researcher, who 'blindly selected' their names from a container; however, counsellors then ‘identified’ classes
Allocation concealment (selection bias)	High risk	See above
Blinding of participants (performance bias	High risk	Participants were probably aware of whether they were in the active or wait list group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	'Questionnaires were translated to Arabic and then blind back‐translated to English from Arabic', but all measures were self reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Loss to follow‐up 5%
Selective reporting (reporting bias)	Unclear risk	All outcomes appear to have been reported
Other bias	Low risk	No other apparent bias

Methods	Cluster‐randomised trial of ERASE Stress Sri Lanka group therapy vs wait list
Participants	Included (n = 166) Children 9 to 14 years of age exposed to the 2004 tsunami Female: 73. Trauma exposure: physically hurt during the tsunami 139, knew someone close who had died during the tsunami 100, exposed to another major traumatic incident 148 Excluded Not reported Setting School in a small town that suffered a direct hit from the tsunami in Welligama Sri Lanka, 2006
Interventions	Group therapy (n = 84) Twelve weekly 90‐minute sessions of 12 to 16 participants (grouped by age and gender for the older 2 groups). Key components: CBT, psychoeducation, meditation, bioenergetic exercises, coping skills, narrative techniques including art therapy, planning for the future Wait list control (n = 82) Children in this group attended a religious class Therapists Teacher training was given to all 12 homeroom teachers over 3 days. Each teacher was responsible for 1 class only
Outcomes	Diagnosis Scale: score ≥ 3 on 1 item of the UCLA PTSD Index (17‐item) Rater: child Trauma symptoms Scale: UCLA PTSD Index Rater: child Depression Scale: Beck Depression Inventory (7‐item) Rater: child Functional problems Scale: Child Diagnostic Interview Schedule (7‐item) Rater: clinician When At 3‐month follow‐up
Notes	So they could be added to the meta‐analysis of function, functional impairment scores were converted to negative values
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	One class in each of the 6 age groups were randomised by coin toss to group therapy or wait list control
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the active or wait list group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Although 'volunteers blinded to the experimental condition administered questionnaires', all measures were self reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No loss to follow‐up: "we had no dropouts among those who completed the questionnaires. There were no missing data"
Selective reporting (reporting bias)	High risk	Only diagnosis was reported
Other bias	Low risk	No other bias was apparent

Methods	Cluster‐randomised trial of ERASE‐Stress vs wait list
Participants	Included (n = 154) 7th and 8th grade students from the largest Jewish governmental religious school in Sderot whose parents had participated in a psychoeducation session and had given informed consent. Females: 83 (53.9%). Age: mean 12.8 (range 11 to 13) years. 96% had been exposed to missile attacks Excluded Setting The largest Jewish governmental religious school with approximately 1200 students in Sderot, a town in Southern Israel exposed to ongoing and intense war‐related threat from daily rocket attacks and mortar shelling, 2007 to 2008
Interventions	ERASE‐Stress (n = 107) Covered cognitive‐behavioural techniques; psychoeducation on types and impact of stress, normative and non‐normative reactions; connections between sensations, thoughts and feelings; identification of personal resources and enhancement of coping strategies, affect modulation, emotional awareness, positive self talk and self affirmation techniques; and modalities to express feelings. The intervention consisted of 16 weekly 90‐minute classroom sessions. All sessions included homework review, warm‐up introduction, experiential exercises, psychoeducational material, learned skills and a closure exercise, followed by a new homework assignment Two major adaptations were made to the original ERASE Stress programme, extending the programme from 12 to 16 sessions. These included religious and spiritual practices, affect modulation strategies, self affirmations, a practice session on combating fears and additional social skills Wait list (n = 47) Homeroom teachers of wait list classes were instructed to delay the intervention for the following year Therapists Sessions were given in weekly social study classes traditionally taught by homeroom teachers All 6 seventh and eighth grade homeroom teachers participated in eight 3‐hour training sessions Fidelity assessments were done to ensure that the manual was followed. Teachers were aware that trainers would come and observe interventions but did not know when
Outcomes	Diagnosis Scale: UCLA PTSD‐I (17‐item) Rater: child/adolescent Trauma symptoms Scale: UCLA PTSD‐I (17‐item) Rater: child/adolescent Anxiety Scale: Screen for Child Anxiety‐Related Emotional Disorders (7‐item) Rater: child/adolescent Functional impairment Scale: Child Diagnostic Interview Schedule (4‐item) Rater: child/adolescent When At 1 month after training
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	‘we randomly (by picking paper slips out of a bag) assigned four of the six seventh and eighth grade classes (two in each grade level) to the experimental EES and two classes (one class for each grade level) to the waiting list (WL) condition’
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the active or wait list group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	‘Clinicians blinded to the experimental condition assisted students when necessary’, but all measures were self reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	All participants were followed up
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Block‐randomised trial of child and family traumatic stress intervention vs supportive therapy
Participants	Included (n = 106) Youth 7 to 17 years of age attending a paediatric emergency department and reporting ≥ 1 new distressing post‐traumatic stress symptom. Mean age: 12 years. Female: 52% Caucasian 32%, African American 37%, Hispanic 22%, multi‐ethnic 7%, other ethnicities 2%. Trauma exposure: motor vehicle accident 24%, sexual abuse 18%, witnessing violence 19%, physical assaults 21%, injuries 8%, threats of violence 5% Excluded Receiving counselling or mental health treatment, developmental delay, psychotic or bipolar disorder, caregiver or participant did not speak English Setting Trauma Section of the Yale Child Study Center, USA, 2006 to 2009
Interventions	Child and family traumatic stress intervention (n = 53) Four sessions involving child and caregiver used cognitive, behavioural and psychoeducational techniques. Identification of trauma responses, behavioural skills and communication between caregiver and child included Control (n = 53) Four sessions over 4 weeks involving child and caregiver included psychoeducation, relaxation training, coping strategies and supportive therapy Therapists Master's and doctoral level clinicians. Fidelity checked and weekly supervision provided
Outcomes	Trauma symptoms Scale: Trauma Symptom Checklist for Children (54‐item) Rater: child/adolescent Anxiety Scale: Trauma Symptom Checklist for Children Rater: child/adolescent When Post therapy and at 3‐month follow‐up
Notes	Standard deviations calculated from standard errors
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block‐randomised (block size of 10) using number containers
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Outcome assessment could not be blinded, as all measures were self report
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Analysis appears to be based on 'last observation carried forward', but loss to follow‐up was relatively high: post therapy 25%, 3 months 27%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Cluster‐randomised trial of stress inoculation training, gradual exposure and standard group therapy vs standard group therapy only
Participants	Included (n = 154) Child:ren 4 to 13 years of age reporting sexual abuse that child protection services or law enforcement professionals had substantiated or did not consider unfounded. Female 90%. Caucasian 73%. The index assault was rape in 49%; 75% were serially assaulted. The chart diagnosis was PTSD in 81% Excluded Those who did not complete a minimum 8 of 10 sessions Setting Two sexual assault clinics in a major metropolitan area, USA
Interventions	Stress inoculation training/Gradual exposure/Standard group therapy (n = 48) Experimental interventions were stress inoculation training and gradual exposure, in addition to standard group therapy Standard group therapy only (n = 32) The 10 sessions over 10 weeks covered feelings, family and friends, disclosure impact, self esteem and sexual abuse, body awareness and sexuality and prevention and termination Therapists Both treatment protocols were manualised. Therapists were trained in both protocols. Therapists completed a checklist describing the components covered in each session. Sessions were audiotaped and reviewed by the project co‐ordinator. As a result of these procedures, treatment integrity was excellent and was consistent with the written manuals
Outcomes	Behaviour Scale: Child Behavior Checklist (134‐item) Rater: parent Anxiety Scale: Revised Children’s Manifest Anxiety Scale (37‐item) Rater: child Depression Scale: Children’s Depression Inventory (27‐item) Rater: child When Post therapy and at 1‐ and 2‐year follow‐up
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Groups (stratified for age and gender) were randomly assigned to the treatment or comparison condition by a random number table
Allocation concealment (selection bias)	Low risk	Therapists and other staff were blind to the random assignment schedule and were not informed of the condition of the group they would be running until all children were referred
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Outcome assessment could not be blinded, as all measures were self reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Loss to follow‐up was high (48%), and only results for those completing were reported
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of a group psychosocial Intervention vs wait list control for war‐affected youth
Participants	Included (n = 436) Multi‐symptomatic war‐affected youth 15 to 24 years of age recruited through outreach centres and by referral from workers at youth‐serving agencies, religious leaders and community elders; wanted to continue education; psychological distress and impairment in daily functioning. Mean age 18 years. Female: 199. Type of trauma: separated from caregiver as the result of war 237: 54%; friend/family member died because of war: 219 (50%); exposure to armed conflict: 73 (17%); member of armed forces: 23 (5%). Mean UCLA PTSD‐RI: treatment 0.68; control 0.77 Excluded Active suicidality or psychosis Setting Six community‐based sites, Sierra Leone, 2012 to 2013
Interventions	Youth Readiness Intervention (n = 222) Based on stabilisation and skills‐focused, including elements from CBT and interpersonal therapy, to address symptoms and impairments related to emotion dysregulation, risky behaviour and functional impairments, including interpersonal deficits. Core components included psychoeducation, self regulation and relaxation, cognitive restructuring, behavioural activation, communication and interpersonal skills and sequential problem solving. Ten group sessions (mean, 6.3) with an average of 9 participants per group Wait list control (n = 214) Length of wait list unclear; it appears that both groups were randomised to EducAid intervention at 3 months Therapists Four male and 4 female counsellors who had a bachelor’s degree or diploma in social work completed intensive 2‐week training and achieved a high level of competency in the YRI after training. A senior local mental health worker provided weekly supervision, and clinical psychologists provided weekly phone supervision
Outcomes	PTSD symptoms Scale: UCLA PTSD‐RI Rater: child/adolescent Behaviour Scale: internalising and externalising items from the Oxford Measure of Psychosocial Adjustment (28‐item) Rater: child/adolescent Functional impairment Scale: functional impairment ‐ WHO Disability Adjustment Scale Rater: child/adolescent When Post treatment and at 6‐month follow‐up
Notes	After post‐treatment follow‐up, both groups were randomised to receive or not receive an educational intervention
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Stratified by gender and age; sequence generated in STATA
Allocation concealment (selection bias)	Unclear risk	Not described
Blinding of participants (performance bias	High risk	Wait list control
Blinding of outcome assessment (detection bias)   All outcomes	High risk	‘assessors were blinded', but outcomes were child/adolescent‐reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Imputation data were used; loss to follow‐up at end of treatment was 9.6%; at 6 months, 14.9%
Selective reporting (reporting bias)	Unclear risk	All data were reported
Other bias	High risk	PTSD scores were 10% higher in control group at baseline

Methods	Randomised trial of a psychodrama group vs wait list
Participants	Included (n = 28) Girls who were referred to a large school‐based mental health programme at the beginning of sixth grade by their teachers or parents for trauma‐related problems. Girls were screened for at least 7 of 10 listed traumatic experiences. Ages: 11 to 13 years; Latinas 14/26 who completed the intervention, African American 11, Haitian 1 Excluded Not reported Setting Middle school in an urban neighbourhood identified as having a high rate of community violence, poverty and social problems, USA
Interventions	Psychodrama group (n = 14) Psychodrama groups met for 20 weeks with the principal investigator. Groups covered 3 phases. The warm‐up phase introduced acting out feelings and learning to identify and share emotions. During the action phase, each child was helped to show or tell what had happened to him or her, and in the sharing phase, participants talked about their feelings during the action phase Wait list control (n = 14) The wait list control group could participate in an arts and crafts group over 20 weeks Therapists The therapist was a social worker 'well trained in psychodrama techniques and had extensive experience in group work and school‐based services'
Outcomes	Behaviour Scale: Youth Self‐Report (112‐item): withdrawn, aggressive subscales Rater: child When Post therapy
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the active or wait list group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Outcome assessment could not be blinded, as the only measure was self reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Data reported for completing participants; 18% loss to follow‐up
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of Stanford cue‐centred treatment vs wait list in children chronically exposed to violence
Participants	Included (n = 65) Individuals 8 to 17 years of age with a history of exposure to violence but no current exposure to perpetrators of violence and with a non‐abusing caretaker willing to participate. Mean age: 11.56 years. Female: 40%. Ethnicity: African American 50.7%, Hispanic/Latino 40.0%, Pacific Islander 1.5%, mixed ethnicity 7.7%. Type of trauma: All participants reported exposure to ≥ 2 traumatic events. The most common traumas were separation/loss (75.0%), witnessing violence (61.5%), homicide (51.9%), physical abuse (25.0%) and bullying (25.0%). Mean PTSD‐RI scores were 22.70 in the treatment group and 25.80 in the wait list group Excluded Significant medical illness, diagnosis of autism or schizophrenia, history of mental retardation or IQ < 70, substance dependency, lack of proficiency in English Setting 13 urban low‐income schools, USA, 2009 to 11
Interventions	Stanford cue‐centred treatment (n = 38) The primary goal is to empower the child through knowledge of trauma exposure and current affective, cognitive, behavioural or physiological responses. Children and parents learn about how adaptive responses become maladaptive, how to cope with rather than avoid ongoing stress and the importance of verbalising their life experiences. Also included skills training in how to reduce physical symptoms of anxiety, modify cognitive distortions and facilitate emotional expression. The manual also contained pictorial representations to assist the youth with understanding concepts. Therapy was delivered in 15 weekly individual sessions of approximately 50 minutes Two licensed therapists (PhD and MFT) with experience in the treatment of childhood trauma were trained in the cue‐centred treatment protocol over 3 months. Therapists received weekly supervision on the manual, phone consultation and case conferences. Fidelity to the treatment protocol in 25% of randomly selected audiotapes of sessions was assessed by 2 independent research assistants, who rated it as 91.2% Wait list (n = 27) Received cue‐centred treatment 3 months after randomisation
Outcomes	PTSD symptoms Scale: UCLA PTSD‐RI for DSM‐IV (48‐item) Rater: child/adolescent Scale: UCLA PTSD‐RI for DSM‐IV (48‐item) Rater: parent Depression Scale: CDI (27‐item) Rater: child/adolescent Anxiety Scale: RCMAS (37‐item) Rater: child/adolescent When Post treatment
Notes	Because loss to follow‐up was greater than 55% overall, only loss to follow‐up data are used in this review
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not described
Allocation concealment (selection bias)	Unclear risk	Not described
Blinding of participants (performance bias	High risk	Wait list control
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Self report measures used
Incomplete outcome data (attrition bias)   All outcomes	High risk	55.4% lost to follow‐up (63% treatment and 44.4% wait list)
Selective reporting (reporting bias)	Low risk	Protocol was not identified, but major measures were reported
Other bias	Low risk	No other biases were identified

Methods	Randomised trial of Recovering from Abuse Program vs supportive therapy
Participants	Included (n = 47) Girls 8 to 13 years of age who had experienced sexual abuse within the previous 3 years and had received no previous treatment and their non‐offending female caretaker. Mean age: 10.5 years; African American 75%, Caucasian 22%, Hispanic 3%. Abuse was substantiated by child protection authorities and had been disclosed within 1 to 26 months Excluded Children and/or female caretakers with mental retardation, psychosis or drug addiction Setting Outpatient Child Psychiatry clinic, USA
Interventions	Recovering From Abuse Program (RAP) (n = 25) A structured programme over 8 weekly 1‐hour sessions that used developmentally appropriate cognitive‐behavioural and metaphoric techniques. Issues covered were blame and stigmatisation, feelings of betrayal, traumatic sexualisation, feelings of powerlessness and anxiety and assertiveness skills. Two or 3 sessions were joint sessions with child and caretaker; remaining sessions were split individually between child and caretaker Supportive therapy (n = 22) Eight weekly 1‐hour sessions, primarily covering support education and discussion of child's symptoms, feelings and thoughts. Topics most frequently discussed with children in TAU were abuse‐related symptoms/feelings, other family issues, school issues, mother‐child communication, peer relationships and self esteem issues. Two or 3 sessions were joint sessions with child and caretaker; remaining sessions were split individually between child and caretaker Therapists Therapists for both interventions were 18 female psychiatrists, psychologists, social workers, nurses and trainees in psychiatry and psychology with prior education and experience in psychotherapy with children. RAP therapists participated in a 3‐hour training session and received weekly supervision in the manualised programme. Trainees providing TAU received 7 weekly supervision sessions highlighting clinical issues relevant to child sexual abuse. Professional clinicians participated in monthly group supervision sessions
Outcomes	PTSD symptoms Scale: Revised Children's Impact of Traumatic Events Scale (CITES‐R; 77‐item): symptom subscale Rater: child Behaviour Scale: Child Behavior Checklist (CBCL): internalising, externalising Rater: parent Function Scale: Children's Global Assessment Scale (C‐GAS) Rater: psychiatrist When Post therapy
Notes	CBCL PTSD subscale scores were also reported, but because these data were skewed, CITES‐R data were used Loss to follow‐up was greater than 40% in the therapy group post therapy for the outcome of function
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Assessment of the C‐GAS was blinded, but the other 2 measures were self reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Completer analysis reported. Loss to follow‐up: 32%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of Chapman art therapy vs standard hospital care
Participants	Included (n = 58) Children 7 to 17 years of age admitted for ≥ 24 hours to a level 1 trauma centre and scoring ≥ 12 on the PTSD‐I Scale. Mean age: 10.7 years. Female: 29%, Ethnicity: white 35%, black 29%, Asian 24%, Hispanic 12% Excluded Children with burns, head injuries or injuries resulting from child abuse; non‐English‐speaking children or caregivers Setting: level 1 trauma centre at a large urban hospital, USA
Interventions	Chapman art therapy (n = 31) A brief, trauma resolution method of approximately 1 hour designed to provide an opportunity for the child to sequentially relate and cognitively comprehend his or her medical trauma in a 1‐to‐1 session at the child's bedside Standard hospital care (n = 27) Therapists One of 2 art therapists
Outcomes	PTSD symptoms Scale: UCLA PTSD Index Rater: child/adolescent and parent When At 1 week after injury and at 1 month and 6 months after discharge
Notes	No means or variance values were reported. The only data were shown graphically; it appears that only scores for avoidance were reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the active or standard hospital care group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Outcome assessment could not be blinded, as the only measure was self reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Loss to follow‐up not reported
Selective reporting (reporting bias)	High risk	Only the subscore for PTSD avoidance was available. Six‐month follow‐up data were not reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of individual therapy vs group therapy or wait list
Participants	Included (n = 248) Children in grades 2 to 6 who met criteria for disaster exposure measured by a score at or above the 94th percentile for trauma symptom severity on the Kauai Recovery Index. Age: 6 to 12 years (mean, 8.2 years). Female: 61.4%. Hawaiian or part‐Hawaiian 30.1%; white 24.9%; Filipino 19.7%; Japanese 9.2%. 88% met DSM‐IV criteria for self reported PTSD Excluded Not reported Setting Ten elementary public schools on a Hawaiian island 2 years after a major hurricane, 1995 to 1996
Interventions	Individual therapy Therapists were provided a standard box of art and play materials, and therapy was guided by treatment manuals. The 4 weekly sessions covered safety and helplessness, loss, mobilising competence, issues of anger and ending and going forward. Themes were explored through a combination of play, expressive art and talk Group therapy As for individual therapy, except that co‐operative play and discussion were used in group sessions of 4 to 8 children Therapists Therapists were 3 school counsellors and 1 social worker experienced at working with children in schools who received 4 ½ days of training and 3 hours of supervision each week
Outcomes	PTSD symptoms Scale: Kauai Recovery Index (24‐item) Rater: child When At 1 and 12 months
Notes	Sample numbers were not reported, and these data could not be obtained from study authors
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	SPSS used to generate randomisation sequence. Randomised to 1 of 3 cohorts, then randomised to group or individual treatments
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they had been allocated to individual or group therapy or wait list
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Outcome assessment could not be blinded, as the only measure was self reported
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Loss to follow‐up not clear
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of Emotional Freedom Technique vs no treatment
Participants	Included (n = 16) Males 12 to 17 years of age who were removed by court order to a residential facility because of physical, psychological or sexual abuse, parental abandonment or negligence and could understand the instructions on the Impact of Events Scale. Average age: 13.7 years. All participants scored in the moderate clinical range on the IES Total, with an average score of 34.2 Excluded Organic or neurological conditions, prior clinical psychiatric diagnoses, concurrent pharmacological treatment Setting Residential facility in Trujillo, Peru
Interventions	Emotional Freedom Technique (n = 8) The Emotional Freedom Technique (EFT) is an exposure‐based therapy in which participants pair the memory of a highly traumatic event with a statement of self acceptance while tapping prescribed acupuncture points. The therapist asks the child to recall the most troubling specific incident of abuse as though it were a movie, give the movie a title and rate the level of distress associated with the trauma (subjective units of distress scale of 0 to 10). EFT was repeated until the distress level was at or near 0 over a single 1‐hour session Mean number of EFT was 2.47 (range, 2 to 4) Control (n = 8) No treatment Therapists Investigators providing therapy were trained with 'other psychologists in EFT'. Clinical supervisors monitored fidelity to the EFT manual
Outcomes	Trauma symptoms Scale: Impact of Events Scale (15‐item) ‐ intrusion, avoidance, total Rater: child/adolescent When At 1 month
Notes	Data were not added to meta‐analyses because the effect sizes were several times higher than the overall estimate and contributed substantial heterogeneity
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the active or no treatment group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	'Data [were] scored, offsite and blind, by a biostatistician', but data were collected by a therapy supervisor and measures were self reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No loss to follow‐up
Selective reporting (reporting bias)	Unclear risk	Only 1 outcome measure was reported
Other bias	Unclear risk	Potential differences between groups were not investigated

Methods	Randomised trial of CBT vs supportive therapy
Participants	Included (n = 86) Preschool children who had been sexually abused, with the most recent episode of sexual abuse reported within the previous 6 months with minimal symptoms defined as a Weekly Behavior Report score > 7 or any sexually inappropriate behavior reported on the Child Sexual Behavior Inventory. Mean age: 4.7 years. Female: 58%. Caucasian 54%, African American 42%, other 4%. Trauma: 25% abused once, 26% abused 2 to 5 times Excluded Children with mental retardation, pervasive developmental disorder, psychotic symptoms or serious mental illness or in short‐term care (< 12 months), or parents with a psychotic disorder or current substance abuse Setting Children were referred to the Center for Traumatic Stress in Children and Adolescents, Pittsburgh, USA
Interventions	Cognitive‐behavioural therapy for sexually abused preschool children (CBT‐SAP) (n = 39 completing treatment) A short‐term treatment model for sexually abused preschool children and their parents over 12 weekly sessions of 40 to 50 minutes with the child and 50 minutes with the parent. Specific issues addressed with the child were safety and assertiveness, ambivalence towards the perpetrator, behaviours, fears and anxiety. Interventions included cognitive reframing, thought stopping, positive imagery and contingency programmes. Issues addressed with parents included ambivalence to the perpetrator and their belief in the abuse, attributions, management of their fear and anxiety, their own history of abuse, feelings towards the child, legal issues and emotional support and behavioural management for the child Non‐directive supportive therapy (NST) (n = 28 completing treatment) Support from an understanding and concerned professional over 12 weekly sessions of 40 to 50 minutes with the child and 50 minutes with the parent designed to reduce isolation, loneliness, hopelessness and anxiety; improve understanding of their feelings; and validate these feelings. The therapist did not make interpretations or offer directive advice but could help identify alternatives through non‐directive suggestions Therapists Both therapists were master’s level clinicians who had worked with sexually abused children for several years. Two therapists were trained in both treatments before the study began. Detailed treatment manuals were provided for both therapies. Weekly individual supervision was provided. All treatment sessions were audiotaped, and scores for compliance with the treatment model were rated as greater than 90%
Outcomes	Behaviour Scale: Child Behavior Checklist Rater: parent When Post therapy and at 6‐ and 12‐month follow‐up
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Children and their parents were randomised by Efron's biased coin toss to ensure the 2 groups were balanced in terms of perpetrator, type of abuse, gender and age
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Outcome assessment could not be blinded, as all measures were self reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Overall loss to follow‐up at the end of treatment was 22% and 50% at 6 and 12 months and was > 50% for the supportive therapy group at 6 and 12 months
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

PERMALINK

Psychological therapies for children and adolescents exposed to trauma

Donna Gillies

Licia Maiocchi

Abhishta P Bhandari

Fiona Taylor

Carl Gray

Louise O'Brien

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings for the main comparison. Psychological therapies versus wait list, treatment as usual or no treatment for children and adolescents exposed to trauma (short‐term).

Summary of findings 2. CBT versus other psychological therapies for children and adolescents exposed to trauma (short‐term).

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Participant characteristics

Diagnosis

Co‐morbidities

Setting

Subset data

Types of interventions

Experimental interventions

Comparator interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Outcome scales

Timing of outcome assessment

Hierarchy of outcome measures

Search methods for identification of studies

Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR)

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Dichotomous data

Continuous data

Skewed data

Unit of analysis issues

Cross‐over trials

Cluster‐randomised trials

Studies with multiple treatment groups

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

11.1. Analysis.

11.2. Analysis.

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

'Summary of findings' tables

Results

Description of studies

Results of the search

1.

Included studies

Settings

Participants

Interventions

Outcomes

Data that could not be added to the meta‐analysis

1. Data from Church 2012.

Methods	Randomised trial of sexual abuse‐specific CBT vs non‐directive supportive therapy
Participants	Included (n = 82) Females 8 to 15 years of age who had experienced validated contact sexual abuse by someone ≥ 5 years older within the previous 6 months, had significant symptoms related to the abuse and had a non‐offending parent or primary caregiver able to participate in treatment. Participants were referred from a variety of sources. Mean age: 11 years. Female: 69%. Caucasian 60%, African American 37%, bi‐racial 2%, Hispanic 1%. Trauma exposure: 54% of participants experienced anal and/or vaginal intercourse, 33% were abused more than 10 times, and, for most, the abuse was accompanied by use of threatened or actual force Excluded Children with mental retardation, pervasive developmental disorder, active psychosis or substance abuse or serious medical illness, or whose caretaker was not long‐term (≥ 12 months) or had active psychosis or substance abuse Settting Urban outpatient child psychiatric programme specialising in the treatment of traumatic stress in children, USA
Interventions	Sexual abuse‐specific CBT (n = 41) CBT methods with the child focused on depression, anxiety and behavioural difficulties and with the parent focused on parental emotional distress, enhanced support for the child and management of behavioural difficulties. Major components for the child included identification of feelings, stress inoculation techniques, gradual exposure exercises, cognitive processing of the abuse, education about healthy sexuality and safety skill building. Parental components paralleled those for the child, with the addition of building parenting management skills. Each of the 12 weekly sessions consisted of 45 minutes with the child and 45 minutes with the parent Non‐directive supportive therapy (n = 41) Therapists did not provide specific suggestions or directive advice but encouraged exploration of alternative attributions, behaviours and feelings. Issues were addressed as they were raised by child or parent. Interventions provided a high degree of non‐judgmental empathy and support; encouraged identification, clarification and acceptance of upsetting feelings; and re‐established trust and positive interpersonal expectations. Each of the 12 weekly sessions consisted of 45 minutes with the child and 45 minutes with the parent Both therapies Appropriate referrals to non‐therapeutic ancillary care were made when indicated, and mothers in either group with a DSM‐III‐R diagnosis were also offered a referral for individual therapy Therapists Both therapists had received a master's level degree in clinical social work and were trained and experienced in both models. Halfway through the programme, therapists swapped to the other treatment model. Both therapies were manualised. Therapists received weekly supervision, and sessions were audiotaped and audited weekly to ensure adherence, which was rated at > 90%
Outcomes	Trauma‐related symptoms Scale:Trauma Symptom Checklist for Children (54‐item) Rater: child/adolescent Depression Scale: Children’s Depression Inventory (27‐item) Rater: child/adolescent Anxiety Scale: State‐Trait Anxiety Inventory for Children TSCC Rater: child/adolescent Behaviour Scale: Child Behavior Checklist Rater: parent When Post therapy and at 6‐ and 12‐month follow‐up
Notes	Because loss to follow‐up was greater than 54% in the supportive therapy group, only loss to follow‐up data were used in this review
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random number series generated by computer
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Outcome assessment could not be blinded, as all measures were child reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Last observation carried forward was used to account for missing data, but loss to follow‐up was greater than 54% for the NST group at all intervals and was high overall: post therapy 40%, 6 months 44%, 12 months 52%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of trauma‐focused CBT vs child‐centred therapy
Participants	Included (n = 124) Children of mothers attending a community women’s health service in the United States, 7 to 14 years of age with ≥ 5 interpersonal violence (IPV)‐related PTSD symptoms, including ≥ 1 symptom from each of the 3 clusters, who were fluent in English and had an English‐speaking mother who was a direct victim of IPV. Mean age: 9.64 years. Female: 63. Ethnicity: white 69, black 41, bi‐racial 14. Only 14.5% no longer had contact with the perpetrator Excluded Significant development disorder, IQ < 80, serious psychotic symptoms in parent or child, living in an IPV shelter Settting Community women's centre for victims of interpersonal violence, Pittsburgh, USA, 2004 to 2009
Interventions	Trauma‐focused CBT (n = 64) Develops a narrative of the child’s experiences, corrects maladaptive cognitions and includes mastery of trauma reminders. Treatment included psychoeducation about trauma, how to develop individualised relaxation skills, expression and modulation of upsetting feelings and development of cognitive coping skills. Some of the session time was given to joint child‐parent sessions in which the child was encouraged to discuss his or her IPV experience and safety plans. Child and parent each attended eight 45‐minute individual therapy sessions. The same therapist saw child and parent Child‐centred therapy (n = 60) Aimed at establishing an empowering and trusting relationship between therapist and client by encouraging the child and parent to direct the content of their own treatment. The therapist provided active listening, reflection, accurate empathy, encouragement to talk about feelings and belief in the client’s ability to develop positive coping strategies. Child and parent each attended eight 45‐minute individual therapy sessions. The same therapist saw child and parent Therapists Three master's‐level social workers providing child therapy at the Women’s Center and Shelter were trained in the TF‐CBT model and in distinctions between TF‐CBT and Child‐centred therapy models. Workers were supervised and adherence to therapy was checked, with a blinded rating of 25% of randomly selected sessions and ratings greater than 90%. A manual that differentiated the 2 therapies was also available
Outcomes	PTSD symptoms Scale: Schedule for Affective Disorders and Schizophrenia for School Age Children ‐ Present and Lifetime version (K‐SADS‐PL) Scores: change from baseline in total scores and in avoidance, hyperarousal and re‐experiencing subscores Rater: Trained research co‐ordinators interviewed child and parent Scale: UCLA PTSD Reaction Index Rater: child Depression Scale: Children’s Depression Inventory Rater: child Anxiety Scale: Screen for Child Anxiety‐Related Emotional Disorders (SCARED) Rater: child Behaviour Scale: Child Behavior Checklist Rater: parent When Post therapy
Notes	K‐SADS‐PL data were used for PTSD symptoms
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random assignment to treatment by computer‐generated random number series. However, 24 received the same treatment as the randomised sibling
Allocation concealment (selection bias)	Low risk	Randomisation lists were locked in therapists’ offices
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Two project co‐ordinators blinded to treatment assignment were trained in administration of the K‐SADS‐PL, but all other measures were child‐reported or parent report
Incomplete outcome data (attrition bias)   All outcomes	High risk	Last observation carried forward was used to account for missing data, but loss to follow‐up was 40%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of a Web‐based psychoeducation intervention vs no treatment
Participants	Included (n = 85) Children between 7 and 16 years of age recruited from paediatric surgical wards over 12 months, hospitalised overnight, who had acquired an accidental or unintentional injury including mild traumatic brain injury, with family Internet access. Mean age: 10.90 years. Female: 26. Type of injury: 41 falls, 13 sports, 12 MVA, 6 burns, 13 other. Mean injury severity score, 7 Excluded Parents' or child’s English was inadequate for completion of questionnaires, child had acquired a moderate to severe head injury, injury was the result of suspected intentional trauma Setting Children’s hospital in Queensland, Australia, 2007
Interventions	Web‐based intervention (n = 44) Consisted of a booklet for parents containing information regarding common child reactions, their likely time course and how parents can best assist their child’s emotional recovery, as well as a Website for children. Both aimed to normalise and relieve trauma reactions and incorporated practical tools based on cognitive‐behavioural and resiliency strategies including relaxation, coping skills, problem solving, identification of strengths and reflections on trauma Control group (n = 41) Assessed at each interval
Outcomes	PTSD symptoms Scale: Trauma Symptom Checklist for Children‐A (TSCC‐A; 44‐item) Rater: child/adolescent Scale: Impact of Events Scale‐Revised (IES‐R; 22‐item): intrusion, avoidance and hyperarousal Rater: parent Depression Scale: TSCC‐A: depression Rater: child/adolescent Anxiety Scale: TSCC‐A: anxiety Rater: child/adolescent When Post intervention (4 to 6 weeks) and at 6 months post injury
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computerised random number generator in Microsoft Excel
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they had been allocated to treatment or no treatment groups
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Outcome assessments could not be blinded, as all were self reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Analysis was based on last observation carried forward, but loss to follow‐up was 34% post therapy and 31% at 6 months
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of family therapy vs treatment as usual
Participants	Included (n = 30) Treatment‐seeking adolescents who could recollect ≥ 1 childhood unwanted/forced contact sexual abuse. Mean age: 14.8 years. Female: 88%. African American 46%, white 37.5%, Native American 4.2%, bi‐racial 8.3% and Hispanic 4%. Age at first/only abuse: 4 to 15 years. Mean time since most recent assault: 3.7 years; 23 reported other traumatic events Excluded Adolescents with mental retardation Setting Therapy was delivered through the outpatient clinic and by an outreach programme at an urban clinic specialising in treatment of trauma in the USA
Interventions	Risk reduction through family therapy (RRFT) (n =15) RRFT was developed to reduce the risk of substance use, other high‐risk behaviours and trauma‐related psychopathology in adolescents who had experienced child sexual abuse. RRFT was built upon the principles and interventions applied in multi‐system therapy (MST) and trauma‐focused cognitive‐behavioural therapy (TF‐CBT). The protocol has 7 components: psychoeducation, coping, family communication, substance abuse, PTSD, healthy dating and sexual decision making and re‐victimisation risk reduction. Strategic family therapy is utilised to help the family define problems and work together to find solutions. Weekly sessions of 60 to 90 minutes with the therapist were held, with adolescents and caregivers individually and as a family. The order of and time spent on each component was determined by the needs of each youth and family. A mean of 23 sessions were completed Treatment as usual (TAU) (n =15) No single treatment emerged as consistently delivered across youth and families assigned to the TAU group. The mean number of sessions was 13 Therapists Participants in both groups were treated by clinical psychology graduate students completing a predoctoral internship. RRFT adherence was assessed by review of randomly selected audiotaped sessions (2 per client per month), weekly individual supervision by the treatment developer (a licenced clinical psychologist) and an RRFT adherence checklist completed by therapists immediately after completion of each session. TAU therapists were supervised by other licenced psychologists in the clinic
Outcomes	Trauma symptoms Scale: UCLA PTSD Index Rater: adolescent, parent Depression Scale: CDI Rater: adolescent Behaviour Scale: Behavioral Assessment System for Children (BASC‐2) Rater: adolescent, parent When Post therapy and at 3‐ and 6‐month follow‐up
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Participants were randomly assigned by computerised block randomisation
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they had been allocated to treatment or no treatment groups
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Outcome assessment could not be blinded, as all were self‐reported or parent report
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Post therapy, 7% were lost to follow‐up, but imputed data appear to have been used, and none were lost to follow‐up at 3 months
Selective reporting (reporting bias)	Unclear risk	Parent‐rated BASC‐2 scores were not reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of CBT for child only, CBT for non‐offending mother only, CBT for non‐offending mother and child and standard community care
Participants	Included (n = 100) Children 7 to 13 years of age who had contact sexual abuse substantiated by the Division of Youth and Family Services or the prosecutor’s office with ≥ 3 symptoms of PTSD, including ≥ 1 avoidance or re‐experiencing symptom. Mean age: 9.8 years. Female: 83%. Caucasian 72%, African American 20%, Hispanic 6%, other 2%. Time since last abuse: ≤ 6 months 66%, 6 months to 2 years 16%, > 2 years 18% Excluded Children with severe developmental delay, psychosis, ongoing unsupervised contact with perpetrator, danger to self or others or mother unwilling to take part Setting Centre for Children's Support, USA
Interventions	CBT therapies (child only n = 25, mother only n = 25, combined n = 25) Therapies with the child focused on coping skills training, gradual exposure and processing, education and prevention skills training. Parent therapy concentrated on education, coping, communication, modelling, gradual exposure and behaviour management skills. Individual treatment sessions were 12 weekly treatments of 45 minutes each and 90 minutes for the combined child and parent group Control group (n = 25) Participants were given information about their children’s symptom patterns and were strongly encouraged to seek therapy Therapists Mental health therapists were intensively trained in the CBT intervention, including 1 pilot case. Treatment was manualised, and therapists were supervised weekly and monitored for adherence/fidelity
Outcomes	PTSD diagnosis Assessment: Schedule for Affective Disorders and Schizophrenia for School‐Aged Children (K‐SADS‐E) (DSM‐III‐R criteria) Rater: clinician PTSD symptoms Scale: K‐SADS‐E Rater: clinician Depression Scale: Child Depression Inventory (27‐item) Rater: child Anxiety Scale: State/Trait Anxiety Inventory for Children: state, trait (20‐item) Rater: child Behaviour Scale: Child Behavior Checklist: internalising, externalising (118 behaviour problem items) Rater: parent When Post therapy and at 3‐, 6‐, 12‐ and 24‐month follow‐up
Notes	Loss to follow‐up was greater than 40% in the control group for PTSD and behaviour at 3 and 12 months
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they had been allocated to treatment or no treatment groups
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Most measures were based on child or parent report
Incomplete outcome data (attrition bias)   All outcomes	High risk	Completer analysis reported, and follow‐up data reported only for those who were available at all 4 measurement intervals; loss to follow‐up 23%
Selective reporting (reporting bias)	Unclear risk	All outcomes were reported at all intervals, except anxiety and behaviour, which were reported only post therapy
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of a CBT group vs a supportive therapy group
Participants	Included (n = 44) Children 2 to 8 years of age referred to the Regional Child Abuse Diagnostic and Treatment Centre. All had credible disclosures of sexual abuse. Mean age: 5.45 years. Female: 27. Ethnicity: white 28, black 1, Hispanic 1, other 6 Excluded Children with, or children of parents with, psychotic disorders, severe developmental delay and/or behaviours that were dangerous to themselves or others Setting Regional Child Abuse Diagnostic and Treatment Centre, USA
Interventions	CBT (21 completers) Therapy consisted of 11 weekly sessions of 1 hour and 45 minutes with children and parents individually and 15 minutes for a joint parent and child activity. Sessions utilised an interactive format and a workbook. Parent sessions assisted parents to cope with their emotions, so they could support their children, provide education about communication skills and teach behaviour management skills. The main objectives were to help children communicate and cope with their feelings, identify okay and not okay touches and learn abuse response skills. An additional 15 minutes was used for a combined mother/child activity Supportive therapy (23 completers) The main objectives of supportive therapy with children were the same as with the CBT group but used a didactic approach. Parent sessions were based on self help models and were less structured than CBT sessions for parents. Eleven weekly sessions of 1 hour and 45 minutes of counselling were provided for children and parents Both Therapists for both groups were checked for adherence and were supervised weekly
Outcomes	PTSD symptoms Scale: Schedule for Affective Disorders and Schizophrenia for School‐Age Children ‐ Epidemiologic version (K‐SADS‐E) Rater: parent Behaviour Scale: Child Behavior Checklist Rater: parent When Post therapy and at 3‐month follow‐up
Notes	PTSD symptom scores were skewed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomly determined by computer programme
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Both groups received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Both measures were based on parent report
Incomplete outcome data (attrition bias)   All outcomes	High risk	Data were reported for completing participants, and loss to follow‐up was 30% at all intervals
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of trauma narrative therapy + trauma‐focused CBT vs trauma‐focused CBT
Participants	Included (n = 210) Children 4 to 11 years of age referred for verified contact sexual abuse with ≥ 5 PTSD symptoms, including 1 from each cluster. Mean age: 7.7 years. Female: 96/158 at follow‐up. Caucasian 103, African American 22, Hispanic 11, other 22 Excluded Children with an IQ < 70, with continued unsupervised face‐to‐face contact with perpetrator or with parent who had a serious medical or mental health illness that would impact participation Setting New Jersey and Pennsylvania, USA
Interventions	Trauma‐focused narrative therapy + CBT (n = 104) As for CBT + children, were encouraged to develop a detailed trauma narrative about the sexual abuse, which they processed and reviewed with the caregiver and therapist Trauma‐focused CBT (n = 106) Included psychoeducation and parenting, relaxation, affective modulation, cognitive coping, in vivo exposure, enhanced safety and future development, delivered as 8 or 16 weekly conjoint parent/child sessions of 90 minutes each. Mean number of sessions attended: 7.36 and 13.92, respectively Therapists Therapists had graduate degrees in psychology, clinical social work or a related field with ≥ 3 years of clinical experience. They were supervised weekly, and adherence to inclusion or non‐inclusion of trauma narrative was checked
Outcomes	PTSD symptoms Scale: Schedule for Affective Disorders and Schizophrenia for School‐Age Children ‐ Present and Lifetime version (K‐SADS‐PL) Rater: clinician administered individually to child and parent Depression Scale: Children's Depression Inventory (27‐item) Rater: child Anxiety Scale: Multidimensional Anxiety Scale for Children (39‐item) Rater: child Behaviour Scale: Child Behavior Checklist (120‐item) Rater: parent rating When Post therapy and at 6‐ and 12‐month follow‐up
Notes	Data for 8‐ and 16‐week groups were pooled
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Children were randomised to groups, but 17 siblings were allocated to the same intervention as the first randomised sibling
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Both groups were given a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	'The project coordinator who was blind to assignment conducted assessments'; however, most scales were child‐reported or parent report
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	ITT analysis was used, but follow‐up means and SDs were reported. Loss to follow‐up: 25%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Parallel RCT of trauma‐focused CBT vs EMDR in children and adolescents recruited from a trauma centre
Participants	Included (n = 48) Between 8 and 18 years of age; command of the Dutch language; exposure to ≥ 1 single traumatic event; last traumatic event occurred ≥ 4 weeks before the first measurement; partial or full PTSD. Mean age: 13 years. Female: 30. Majority were Dutch (77%): 46% with Dutch mothers and 33% with Dutch fathers. Types of trauma: accidents 23%, sexual assaults 17%, threats (with weapon) 13%, kidnapping 10%, serious illness 7%, other 30%. Exposure to domestic violence 44%, sexual assault 39%, multiple‐event trauma 17%. Seven children in the TF‐CBT condition were diagnosed with PTSD on the ADIS‐P: 6 fulfilled a partial diagnosis and 4 had no PTSD. EMDR condition: 9 children in the EMDR group fulfilled a PTSD diagnosis, 5 fulfilled a partial diagnosis and 1 had no diagnosis (Note: This accounts for only 32 participants) Excluded Children showing clinical signs of psychotic disorder, substance use disorder, pervasive developmental disorder (e.g. autism) or acute suicidality Setting Department of Child and Adolescent Psychiatry Trauma Centre, The Netherlands, 2009 to 2012
Interventions	Trauma‐focused CBT (n = 23) The following components were included in this programme: psychoeducation, relaxation, affective expression and regulation, cognitive coping, gradual exposure through creation of child’s trauma narrative, parent management skills, conjoint child/parent session, enhanced future safety and development. Children worked on their trauma narrative in sessions 4, 5 and 6 and shared the narrative with their parents in session 7 Parents were invited to also join sessions 1, 2, 3 and 8 or spent 15 minutes of a session alone with the therapist Therapy was delivered over 8 weekly sessions of 60 minutes but could be terminated earlier if all modules were administered, the child’s score on the CRIES‐13 was < 10 and the child and parent agreed EMDR (n = 25) The main components of this protocol include the following: psychoeducation about the trauma and therapy, preparation of the target memory, desensitisation of the memory, identification and processing of body sensations, re‐evaluation of the target. Desensitisation of the memory started in session 3 and was pursued until session 7. Children were asked to keep the target image in mind while simultaneously concentrating on the distracting stimulus (typically following the finger of the therapist). After episodes of 30 minutes, the child was asked to report what he or she had just experienced. This was repeatedly done until the target did not induce distress in the child. Parents were invited to join 15 minutes of each session, or to spend this time alone with the therapist. Therapy was delivered over 8 weekly sessions of 60 minutes Therapists Eight experienced CBT therapists were trained in both TF‐CBT and EMDR before the study. Four were EMDR practitioners, and 2 had competed advanced training. Supervision was provided weekly by an expert on EMDR for children and experts on TF‐CBT. Therapists filled out protocol‐specific checklists and recorded each session on video. A random selection of 25% of all videos was evaluated by therapists for treatment integrity (not clear which therapists). Treatment integrity was scored as 75% for EMDR and 73% for TF‐CBT
Outcomes	PTSD diagnosis Scale: ADIS‐P PTSD (47‐item) Rater: parent PTSD symptoms Scale: improvement on CAPS‐CA Rater: clinician Scale: CRIES‐13 Rater: child/adolescent Behaviour Scale: SDQ domains Rater: parent Anxiety Scale: Revised Child Anxiety and Depression Scale Rater: child/adolescent and parent When Post treatment
Notes	Starting date: 1 June 2009 Completion date: proposed completion December 2009 Contact information: Dr. R.J.L. Lindauer Academic Medical Center (AMC), Medical Research B.V.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	“A methodologist prepared the randomization list”
Allocation concealment (selection bias)	Low risk	"The researcher managing the randomization list directly communicated the assigned condition to the therapist”
Blinding of participants (performance bias	Low risk	Participants were not blinded, but both groups received therapy
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	“Assessors were blinded to the allocated treatment condition of the children”
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	“Multiple imputation” was used; overall loss to follow‐up was 25%, but 68% were lost to follow‐up for measures other than PTSD symptoms in the EMDR group
Selective reporting (reporting bias)	Unclear risk	CRIES‐13 scores not reported
Other bias	Low risk	No other biases were identified

Methods	Randomised trial of CBT or supportive therapy
Participants	Included (n = 32) Sexually abused children and adolescents 6 to 17 years of age referred to a Victims' Resource Institute. Mean age: 10 years. Female: 19. Caucasian 48%, Hispanic 40%, African American 8%, other 4% Excluded Children and adolescents with mental retardation, brain damage, psychotic or autistic behaviour, learning disabilities, perpetrators of violence or gang members, substance abusers and conduct‐disordered children Setting University of Houston, USA
Interventions	CBT (n = 22) Participants were taught to normalise their responses and skills to manage their affective, cognitive and behavioural responses to the traumatic event, and to identify and address deficits in interpersonal function. Therapy was based on 20 weekly sessions but could vary depending on participant need Supportive therapy (n = 10) The goal of therapy was to identify and encourage the participant's use of existing coping behaviours and to reflect on and validate their experiences and emotional reactions. A central component was the therapeutic relationship based on genuineness, unconditional positive regard for the participant and accurate empathic understanding. Therapy was based on 20 weekly sessions but could vary depending on need Therapists Therapists were 10 'upper level' graduate students in clinical psychology supervised weekly by PhD‐level clinical psychologists. Both therapies were manualised and all progress notes checked for use of CBT elements in CBT group and non‐use of CBT in supportive therapy group. CBT elements were used in 86% of CBT sessions and in 57% of supportive therapy sessions
Outcomes	PTSD symptoms Scale: Impact of Event Scale‐Revised: avoidance and intrusion (15‐item) Rater: clinician Depression Scale: Children's Depression Inventory (27‐item) Rater: clinician When Every second week during treatment
Notes	Only slope and intercept of outcome growth curves were reported. No significant differences were noted between the 2 treatments
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	Unclear risk	Participants could not be blinded, but all participants received a psychological therapy
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Clinician‐rated outcomes were used, but blinding of assessment was not reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Completer analysis reported. Loss to follow‐up: 22%
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	Low risk	No other bias was apparent

Methods	Randomised trial of motivation‐adaptive skills‐trauma resolution + EMDR vs wait list
Participants	Included (n = 65) Traumatised adolescents with conduct problems in Youth Protective Services reporting traumatic events with high impact on the Lifetime Incidence of Traumatic Events questionnaire. Participants were French‐speaking and 13 to 17 years of age; 25 were female. Participants were exposed to a mean 4.4 types of trauma Excluded Adolescents with psychosis, suicidal or mentally retarded Setting Youth Protective Services in Quebec, Canada, 2005 to 2006
Interventions	Motivation ‐ Adaptive Skills ‐ Trauma Resolution (MASTR) + EMDR (n = 33) Consisted of 12 weekly individual sessions. Sessions 1 to 4 aimed to establish rapport, assess history, identify goals, visualise a positive future and develop a case formulation and treatment plan. Sessions 5 to 8 covered self management skills, avoidance of high‐risk situations and imaginal rehearsal of behavioural choices. Sessions 9 to 12 were devoted to trauma resolution by EMDR. A manualised EMDR protocol with minor age‐appropriate modifications was used. Participants in the MASTR‐EMDR group continued to receive other types of therapy. Participants attended a mean 11 sessions over 8 months Wait list control (n = 32) Among the wait list group, 57% received another form of therapy and attended a mean 17 sessions over 8 months Therapists EMDR was provided by 2 licenced master's‐level therapists who together had 30 years of experience working with youth, had completed EMDR training and received ongoing supervision from the developer of MASTR. Treatment fidelity (of a random selection of 30% of sessions) was assessed as 94%
Outcomes	PTSD diagnosis Scale: Diagnostic Interview Schedule for Children Rater: not clear, appear to have been research assistants PTSD symptoms Scale: Trauma Symptom Checklist for Children (TSCC; 54‐item) Rater: adolescent Anxiety Scale: TSCC Rater: adolescent Depression Scale: Child Behavior Checklist (118‐item) Rater: parent When Post therapy and at 3 months
Notes	Although participants in the MASTR‐EMDR group continued to receive other types of therapy, this was not described
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants (performance bias	High risk	Participants probably were aware of whether they were in the wait list or therapy group
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Research assistants were not 'consistently blind to the treatment condition', and measures were self reported or parent reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Only data available for the 40 participants assessed post treatment and at 3 months follow‐up were reported (loss to follow‐up: EMDR 42%, control 34%)
Selective reporting (reporting bias)	Low risk	All outcomes appear to have been reported
Other bias	High risk	Twice as many males (48% vs 26%) were included; more came from low‐income families in the control group (75% vs 41%). Nearly twice as many had received a diagnosis of PTSD (37% vs 19%), and PTSD symptoms were greater (6.4 vs 3.7) in the treatment group