儿童和青少年创伤后应激障碍的心理治疗(综述)

Evidence-based child health : a Cochrane review journal Pub Date : 2013-05-16 DOI:10.1002/ebch.1916

Donna Gillies, Fiona Taylor, Carl Gray, Louise O'Brien, Natalie D'Abrew

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The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the <i>Cochrane Central Register of Controlled Trials</i>) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.</p>\n </section>\n \n <section>\n \n <h3> Selection criteria</h3>\n \n <p>All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.</p>\n </section>\n \n <section>\n \n <h3> Data collection and analysis</h3>\n \n <p>Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.</p>\n \n <p>We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.</p>\n </section>\n \n <section>\n \n <h3> Main results</h3>\n \n <p>Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.</p>\n \n <p>The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). 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引用次数: 123

摘要

背景创伤后应激障碍(PTSD)在经历过创伤的儿童和青少年中非常普遍，并且有很高的个人和健康成本。尽管广泛的心理疗法已被用于治疗创伤后应激障碍，但这些疗法在儿童和青少年中的应用还没有系统的综述。目的探讨心理治疗对诊断为创伤后应激障碍的儿童和青少年的疗效。检索方法我们检索了Cochrane抑郁、焦虑和神经症回顾组的专业注册(CCDANCTR)至2011年12月。CCDANCTR包括来自以下书目数据库的相关随机对照试验:CENTRAL (Cochrane CENTRAL Register of controlled trials)(所有年份)、EMBASE(1974 -)、MEDLINE(1950 -)和PsycINFO(1967 -)。我们还查阅了相关研究和综述的参考文献。我们没有使用日期或语言限制。选择标准所有的随机对照试验，将心理治疗与对照、药物治疗或其他治疗方法在暴露于创伤性事件或诊断为PTSD的儿童或青少年中进行比较。数据收集和分析两名评审小组成员独立提取数据。如果发现了差异，则通过协商一致或提交给审查小组来解决。我们使用固定效应模型计算了二元结果的比值比(OR)，连续结果的标准化平均差(SMD)以及两者的95%置信区间(CI)。如果发现异质性，我们使用随机效应模型。本综述纳入14项研究，758名受试者。参与者所遭受的创伤类型包括性虐待、民事暴力、自然灾害、家庭暴力和机动车事故。大多数参与者都是创伤相关支持服务的客户。这些研究中使用的心理疗法包括认知行为疗法(CBT)、暴露疗法、心理动力学疗法、叙事疗法、支持性咨询以及眼动脱敏和再加工疗法(EMDR)。大多数人将心理治疗与对照组进行比较。没有研究将心理治疗与单独的药物治疗或作为心理治疗的辅助疗法进行比较。在所有心理治疗中，改善明显更好(3项研究，n = 80, OR 4.21, 95% CI 1.12至15.85)，PTSD(7项研究，n = 271, SMD -0.90, 95% CI -1.24至-0.42)、焦虑(3项研究，n = 91, SMD -0.57, 95% CI -1.00至-0.13)和抑郁(5项研究，n = 156, SMD -0.74, 95% CI -1.11至-0.36)的症状在完成心理治疗一个月内明显低于对照组。最有效的心理疗法是认知行为疗法。治疗后长达一年的改善明显更好(长达一个月:两项研究，n = 49, OR 8.64, 95% CI 2.01至37.14;最长1年:1项研究，n = 25, OR 8.00, 95% CI 1.21 ~ 52.69)。PTSD症状评分在长达一年的时间内也显著降低(长达一个月:3项研究，n = 98, SMD -1.34, 95% CI -1.79至-0.89;长达一年:一项研究，n = 36, SMD -0.73, 95% CI -1.44至-0.01)，与对照组相比，CBT组抑郁评分降低长达一个月(三项研究，n = 98, SMD -0.80, 95% CI -1.47至-0.13)。未发现不良反应。没有研究被评为选择或检测偏倚的高风险，但少数研究被评为流失、报告和其他偏倚的高风险。大多数纳入的研究在选择、检测和损耗偏差方面被评为风险不明确。作者的结论:有证据表明心理疗法，尤其是CBT，在治疗儿童和青少年创伤后应激障碍后长达一个月的时间内是有效的。在这个阶段，没有明确的证据表明一种心理治疗比其他心理治疗更有效。也没有足够的证据表明，患有特定类型创伤的儿童和青少年比其他人更容易或更少地对心理治疗产生反应。本综述的结果受到方法学偏差的潜在限制，以及确定的研究数量少且通常规模小。此外，有证据表明，在一些分析中存在实质性的异质性，这无法用亚组或敏感性分析来解释。治疗后一个月以上所有心理治疗的有效性需要更多的证据。需要更多的证据来证明不同心理治疗的相对有效性，或者心理治疗与其他治疗相比的有效性。在未来的试验中，需要更多的细节来研究PTSD诊断之前的创伤类型，以及创伤是单一事件还是持续发生的。未来的研究还应旨在确定最有效和可靠的创伤后应激障碍症状的测量方法，并确保所有分数，总分和分值的报告一致。儿童和青少年创伤后应激障碍的心理治疗创伤后应激障碍(PTSD)在经历过创伤且个人和健康成本高的儿童和青少年中非常普遍。本综述的目的是检查所有心理疗法治疗儿童和青少年创伤后应激障碍的有效性。我们检索了所有随机对照试验，比较心理疗法与对照组、其他心理疗法或其他治疗3至18岁儿童和青少年创伤后应激障碍的疗法。我们确定了14项研究，共有758名参与者。与创伤后应激障碍相关的创伤类型为性虐待、民事暴力、自然灾害、家庭暴力和机动车事故。大多数参与者都是创伤相关支持服务的客户。纳入研究中使用的心理疗法包括认知行为疗法(CBT)、暴露疗法、心理动力学疗法、叙事疗法、支持性咨询以及眼动脱敏和再加工疗法(EMDR)。大多数纳入的研究将心理治疗与对照组进行了比较。没有研究将心理治疗与药物或药物与心理治疗相结合进行比较。有充分的证据表明，心理疗法，尤其是认知行为疗法，在治疗后长达一个月的时间里，对儿童和青少年的创伤后应激障碍有治疗效果。需要更多的证据来证明心理治疗的长期有效性，并能够比较一种心理治疗与另一种心理治疗的有效性。本综述的结果受到以下因素的限制:纳入研究的潜在偏倚、无法确定的研究之间可能存在的差异、确定的研究数量较少以及大多数研究的参与者人数较少。

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Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents (Review)

Background

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.

Objectives

To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.

Search methods

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.

Selection criteria

All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.

Data collection and analysis

Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.

We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed-effect model. If heterogeneity was found we used a random-effects model.

Main results

Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.

The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy.

Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD -0.90, 95% CI -1.24 to -0.42), anxiety (three studies, n = 91, SMD -0.57, 95% CI -1.00 to -0.13) and depression (five studies, n = 156, SMD -0.74, 95% CI -1.11 to -0.36) were significantly lower within a month of completing psychological therapy compared to a control group.

The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD -1.34, 95% CI -1.79 to -0.89; up to one year: one study, n = 36, SMD -0.73, 95% CI -1.44 to -0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD -0.80, 95% CI -1.47 to -0.13) in the CBT group compared to a control. No adverse effects were identified.

No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.

Authors' conclusions

There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others.

The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses.

More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub-scores, are consistently reported.

Plain Language Summary

Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents

Post-traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. The aim of this review was to examine the effectiveness of all psychological therapies for the treatment of PTSD in children and adolescents.

We searched for all randomised controlled trials comparing psychological therapies to a control, other psychological therapies or other therapies for the treatment of PTSD in children and adolescents aged 3 to 18 years. We identified 14 studies with a total of 758 participants. The types of trauma related to the PTSD were sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma-related support service.

The psychological therapies used in the included studies were cognitive behavioural therapy (CBT), exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most included studies compared a psychological therapy to a control group. No study compared psychological therapies to medications or medications in combination with a psychological therapy.

There was fair evidence for the effectiveness of psychological therapies, particularly CBT, for the treatment of PTSD in children and adolescents for up to a month following treatment. More evidence is required for the effectiveness of psychological therapies in the longer term and to be able to compare the effectiveness of one psychological therapy to another.

The findings of this review are limited by the potential for bias in the included studies, possible differences between studies which could not be identified, the small number of identified studies and the low number of participants in most studies.

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来源期刊

Evidence-based child health : a Cochrane review journal

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