Efficacy of psychological interventions for multiple‐event‐related <scp>PTSD</scp> in children and adolescents: a network meta‐analysis
Authors: Thole H. Hoppen, Lena Wessarges, Marvin Jehn, Julian Mutz, Ahlke Kip, Pascal Schlechter, Richard Meiser‐Stedman, Nexhmedin Morina
Journal: World Psychiatry (2025)

About a third of children and adolescents in the general population report the experience of one or multiple traumatic events1. A substantial minority of traumatized young people develop post-traumatic stress disorder (PTSD) in the aftermath1, with an increased risk following multiple exposures2. Given the large individual and societal disease burden of pediatric PTSD1, its effective treatment constitutes a public health priority. Treatment guidelines for pediatric PTSD recommend psychological interventions, with trauma-focused cognitive behavior therapies (TF-CBTs) regarded as first-line treatment. Two previous network meta-analyses on psychological interventions for pediatric PTSD reported good treatment efficacy3, 4. Yet, neither differentiated between single- and multiple-event-related PTSD. Consequently, the efficacy of psychological interventions for multiple-event-related pediatric PTSD remains unknown. Increased knowledge about treatment efficacy in this condition is crucial, since many clinicians working with it are reluctant to address trauma for fear of destabilizing patients5. Clinicians, patients and caregivers need to be well informed about the efficacy of psychological treatments for multiple-event-related pediatric PTSD to draw evidence-based treatment decisions. The present work reports on the first network meta-analysis on the efficacy of psychological interventions for multiple-event-related pediatric PTSD. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2015 guidelines6 were followed. All data were extracted independently by at least two authors, and discrepancies were discussed until consensus was reached. The main research question of interest was: in children and adolescents with full PTSD or PTSD symptoms, how do psychological interventions, compared to either passive or active control conditions, or with each other, perform in terms of reducing PTSD symptom severity in randomized controlled trials (RCTs) in which most participants (i.e., ≥50%) reported PTSD related to at least two traumatic events? Inclusion criteria were as follows: a) RCT investigating psychological treatment for pediatric PTSD compared to a control condition; b) all participants presented with full or sub-threshold PTSD; c) sample mean age <19 years; d) outcome data reported for ≥10 participants per arm. We searched PsycINFO, MEDLINE, Web of Science and PTSDpubs from inception to April 18, 2023 with all-field searches by means of various terms for PTSD and treatment (see supplementary information). We also searched 71 qualitative and quantitative reviews on psychological treatment of pediatric PTSD (see supplementary information), the reference lists of included trials, Google Scholar, and ResearchGate. Risk of bias was independently assessed by two reviewers using the eight quality criteria reported by Cuijpers et al7. We distinguished three assessment periods: short-term (i.e., treatment endpoint); mid-term (i.e., up to 5 months after treatment endpoint); and long-term (i.e., longest follow-up beyond 5 months after treatment endpoint). The primary outcome of interest was the standardized mean difference in PTSD symptom severity between two arms at a given timepoint as measured with Hedges' g. Random effect network meta-analyses were performed in R (version 4.1.1) using the netmeta package8. Analyses were run only in the light of sufficient accumulated evidence (i.e., at least four direct comparisons per psychological intervention category). Hedges' g was interpreted as small (0.20), medium (0.50) or large (0.80) effect size. Various assumption checks9 were performed. Inconsistency was checked with the net splitting procedure. Outliers were defined as effect sizes scoring at least 3.3 standard deviations above or below the pooled g, but no outliers were present in any of the analyses. Potential influence of small-study effects was checked with the Egger's test. Psychological interventions were ranked by efficacy using surface under the cumulative ranking (SUCRA) based on 50,000 resamples. The systematic literature search yielded 67 eligible RCTs (N=5,297 patients) (see supplementary information). Psychological interventions were subdivided into five categories: TF-CBTs, eye movement desensitization and reprocessing (EMDR), other trauma-focused psychological interventions (i.e., not based on TF-CBTs or EMDR), multi-disciplinary treatments (MDTs), and non-trauma-focused psychological interventions. In total, 44 RCTs (66% of eligible RCTs) involved ≥50% participants with multiple-event-related PTSD, whereas 14 RCTs (21% of eligible RCTs) involved mainly single-event PTSD, and the other nine RCTs did not report sufficiently on the matter (see also supplementary information). The current analyses were conducted on the 44 RCTs having ≥50% participants with multiple-event-related PTSD. TF-CBTs, MDTs and non-trauma-focused psychological interventions had a sufficient number of direct comparisons for synthesis. TF-CBTs could be analyzed throughout (i.e., short-, mid- and long-term efficacy); MDTs for short- and mid-term efficacy; and non-trauma-focused psychological interventions for short- and long-term efficacy. EMDR and other trauma-focused psychological interventions did not have sufficient data and could not be included in any analysis. At treatment endpoint, TF-CBTs (g=1.24, p<0.001), MDTs (g=1.00, p<0.001), and non-trauma-focused interventions (g=1.02, p<0.001) produced large short-term effects compared to passive control conditions. Compared to active control conditions, however, only TF-CBTs produced a significant (moderate-sized) treatment effect (g=0.56, p<0.001). No outliers and no inconsistencies were detected. Heterogeneity in outcomes was large (see supplementary information). At mid-term (up to 5 months following treatment), compared to passive control conditions, TF-CBTs produced a large effect (g=0.84, p<0.001) and MDTs a moderate effect (g=0.67, p=0.027). Compared to active control conditions, only TF-CBTs yielded a significant (moderate-sized) effect (g=0.56, p<0.001). At long-term (6-24 months after treatment endpoint), relative to passive control conditions, both TF-CBTs (g=0.74, p=0.004) and non-TF interventions (g=0.71, p=0.019) produced a moderate-to-large treatment effect. Compared to active control conditions, however, only TF-CBTs (g=0.45, p=0.004) produced a significant effect. TF-CBTs were the highest-ranking psychological intervention across all assessment periods in SUCRA (see also supplementary information). Thus, TF-CBTs are currently the most extensively evaluated treatment for multiple-event-related PTSD in children and adolescents, with high efficacy found relative to passive controls and moderate efficacy relative to active controls in the short-, mid- and long-term. While several trials examined MDTs (short- and mid-term data) and non-trauma-focused psychological interventions (short- and long-term data), these treatments did not produce significant effects compared to active controls in any of the assessment periods. Insufficient data regarding multiple-event-related PTSD were available for EMDR and other trauma-focused interventions. The finding that multiple-event-related PTSD responds well to TF-CBTs has important implications for the provision of treatments for pediatric PTSD, for therapist training, and for future research, and should guide decision-making in clinical practice.