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used gold standard mixed methodologies for developing locally validated assessment instruments. In companion RCTs, O’Callaghan, McMullen, and colleagues culturally modified TF-CBT for group delivery to youth with complex trauma in the Democratic Republic of Congo. Sexually exploited girls ages 12-17 were randomized to group TF-CBT provided in thrice weekly sessions over 5 weeks by trained lay counselors, or a wait list control group (WL; O’Callaghan et al., 2013). The TF-CBT group experienced significantly greater improvement in PTSD, depression, anxiety, conduct problems, psychosocial distress, and pro-social behaviors. Former boy soldiers and other war-affected boys ages 13-17 years were randomized to receive group TF-CBT provided by lay counselors or a WL control (McMullen et al., 2013). Youth receiving TF-CBT experienced significantly greater improvement in PTSD, depression, anxiety, conduct problems, psychosocial distress and pro-social behaviors compared to the WL group. In both studies treatment effects for the TF-CBT groups were maintained over a 3-month follow-up period. The cultural modifications to the TF-CBT model in the Congolese and Zambian studies were modest (e.g., using local folktales as metaphors during psychoeducation; incorporating the importance of witchcraft during cognitive processing; addressing cultural reluctance to discuss sexuality as prelude to education about healthy sexuality and developing trauma narration). Two quasi-randomized controlled trials conducted in schools evaluated interventions for children impacted by the conflict in the Middle East. Barron and colleagues (2013) randomized children in Nablus, Palestine ages 11-14 by classroom to receive Teaching Recovery Techniques (TRT), a CBT school-based group intervention, or a WL control condition. Children did not differ significantly on demographic or mental health variables at pre-treatment; Analysis of Covariance (ANCOVA) indicated significant group X time differences in favor of the TRT group with regard to PTSD, grief and depression, supporting the efficacy of the TRT model for children exposed to ongoing violence. In the second study, Berger and colleagues (2012) used a quasi-randomized controlled design to assign 154 7th and 8th graders in Sderot, Israel to receive Extended Enhancing Resiliency Amongst Students Experiencing Stress (ERASE-Stress), a manualized, universal teacher-delivered skills-based program that does not target traumatic memories, or a WL control group. At baseline, 43.5% of students had a likely diagnosis of PTSD. One month after the intervention, students in ERASE-Stress had statistically significantly greater reduction in PTSD, anxiety, somatic complaints, and functional impairment scores compared to the WL group. Finally, a Dutch team conducted a RCT to directly compare outcomes of Eye Movement Desensitization and Reprocessing (EMDR) and TF-CBT. This study also has relevance to complex trauma, which is discussed in more detail below. EMDR is widely used in many European countries and there is a strong belief that it is more efficient than other treatments for resolving PTSD symptoms. Diehle and colleagues (2015) randomized 40 traumatized Dutch children ages 8-19 years to TF-CBT or EMDR. Both treatments were highly effective for improving PTSD symptoms. However, contrary to the researchers’ hypothesis, there was no significant difference in efficiency between the treatments. As predicted, children receiving TF-CBT experienced significantly greater improvement in comorbid problems common in complex trauma than children receiving EMDR, including depressive and hyperactive symptoms. Back in the United States (US), lively discussion continues regarding the Diagnostic and Statistical Manual of Mental Disorders (DSM) PTSD diagnostic criteria for children and adolescents, and its impact on treatment outcome research. Specifically, since no single diagnosis or assessment instrument fully describes youth with complicated trauma presentations, researchers are using creative strategies to design treatment outcome studies for this population. Ford and colleagues (2012) evaluated Trauma Affect Regulation: Guide for Education and Therapy (TARGET), an emotion regulation therapy for complex trauma. This team randomized 59 delinquent girls ages 13-17 years who met full or partial PTSD diagnostic criteria to receive TARGET or enhanced TAU (ETAU), a relational supportive therapy. Almost half of these girls were in residential treatment during treatment, making this a very challenging study to conduct, since residential treatment facilities for adjudicated youth exist to address severe behavioral problems and typically are not focused on providing trauma services. Multiple instruments were used to assess diverse outcomes. Group X Time analyses showed significantly greater improvement in youth receiving TARGET for changes in PTSD, emotion regulation, anxiety and posttraumatic cognitions, but there was also improvement in the ETAU cohort with respect to hope and anger management. This study documented the promise of using evidence-based trauma treatments for traumatized youth within the juvenile justice system, and highlighted the importance of carefully evaluating how trauma impacts these youth’s complex clinical presentations. Studies like this
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