Clinical Child and Family Psychology Review

https://doi.org/10.1007/s10567-019-00305-0

Lost in Transition? Evidence‑Based Treatments for Adolescents

and Young Adults with Posttraumatic Stress Disorder and Results
of an Uncontrolled Feasibility Trial Evaluating Cognitive Processing
Therapy
Anna Vogel1   · Rita Rosner1

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Posttraumatic stress disorder (PTSD) is not uncommon among adolescents and young adults (AYAs). Left untreated, tran-
sition to adulthood might be especially challenging and/or prolonged for AYAs. However, it is unclear whether AYAs are
adequately represented in current PTSD treatment research and whether they benefit to the same degree as younger or older
individuals. In the first part of the paper, we reflect on developmental considerations in the treatment of AYAs and give an
overview of current age-specific results in PTSD treatment research. Furthermore, we review individual trauma-focused
evidence-based treatments that were examined in AYAs over the last 10 years. In the second part, we present data from an
uncontrolled feasibility trial evaluating cognitive processing therapy (CPT) with some age-adapted modifications and an
exposure component (written accounts). We treated 17 AYAs (aged 14 to 21) suffering from posttraumatic stress symptoms
(PTSS). At posttreatment, participants had improved significantly with respect to clinician-rated PTSS severity (d = 1.32).
Treatment gains were maintained throughout the 6-week and 6-month follow-ups. Results indicated that CPT, with only
minor adaptations, was feasible and safe in AYAs. The recommendations for future research focus on the inclusion of young
adults in trials with adolescents, more refined age reporting in clinical trials, and the encouragement of dismantling stud-
ies in youth. To conclude, clinical recommendations for caregiver involvement and the addressing of developmental tasks,
motivational issues and emotion regulation problems are discussed.

Keywords  Posttraumatic stress symptoms · Posttraumatic stress disorder · Adolescents · Young adults · Cognitive
processing therapy · Developmentally adapted treatment

Abbreviations CBT Cognitive behavioral therapy

A-DES Adolescent dissociative experiences scale CCT​ Stanford cue-centered therapy
ANOVA Analysis of variance CPT Cognitive processing therapy
AYAs adolescents and young adults CPT+A Cognitive processing therapy including
BDI-II Beck Depression Inventory written accounts
BSL-23 Borderline symptom list 23 CPTSD Complex posttraumatic stress disorder
CAED Clinician-assisted emotional disclosure CT-PTSD Cognitive therapy for PTSD in children
CAPS-CA Clinician-administered PTSD Scale for and adolescents
children and adolescents D-CPT Developmentally adapted cognitive pro-
cessing therapy
Electronic supplementary material  The online version of this DIA-X Expert system for diagnosing mental
article (https​://doi.org/10.1007/s1056​7-019-00305​-0) contains disorders
supplementary material, which is available to authorized users. DSM-IV Diagnostic and statistical manual of mental
disorders, fourth edition
* Anna Vogel
anna.vogel@ku.de EMDR Eye movement desensitization and
reprocessing
1
Department of Psychology, Catholic University Eichstätt-
Ingolstadt, Ostenstr. 25, 85072 Eichstätt, Germany

13
Vol.:(0123456789)

ICD-11 11th version of the International Classifi-
cation of Diseases
ITT Intent-to-treat
KIDNET Narrative exposure therapy for children
Kinder-DIPS Diagnostic interview for mental disorders
in children and adolescents
LOCF Last observation carried forward
LOCF Last observation carried forward
MANOVA Multivariate analysis of variance
NET Narrative exposure therapy
PE Prolonged exposure
PE-A Prolonged exposure for adolescents
PTSD Posttraumatic stress disorder
PTSS Posttraumatic stress symptoms
RCT​ Randomized controlled trial
RRFT Risk reduction through family therapy
SCID-I Structured clinical interview for DSM-IV
Axis I
SCID-II Structured clinical interview for DSM-IV
Axis II
STAIR-NT Skills training in affect and interpersonal
regulation narrative therapy
TARGET Trauma affect regulation: guide for educa-
tion and therapy
Tf-CBT Trauma-focused cognitive behavioral
therapy
UCLA University of California at Los Angeles
PTSD Reaction index
YSR Youth self-report
Introduction
Traumatic events are highly prevalent among adolescents and
young adults (AYAs), with an estimated rate of 21% who have
been exposed to any traumatic event. Of them, approximately
8% meet the diagnostic criteria for posttraumatic stress dis-
order (PTSD; Perkonigg et al. 2000). However, PTSD rates
varied considerably depending on the type of trauma and gen-
der in a meta-analysis of children and adolescents aged up to
18 (Alisic et al. 2014). The probability of PTSD is especially
high in adolescents after interpersonal trauma (e.g., 31% for
physical abuse and 41% for rape; McLaughlin et al. 2013). In
a meta-analysis, Hiller et al. (2016) showed that the prevalence
of PTSD diagnosis in children and adolescents aged 5–18 fell
by 53% in the first 6 months. In addition, a more stable PTSD
diagnosis was associated with higher age. We identified only
one study on longitudinal courses of posttraumatic stress
symptoms (PTSS) in the general population that included both
adolescents and young adults (Perkonigg et al. 2005). In this
study, on AYAs aged 14 to 24, 48% of all initial PTSD cases
showed no remission at 34–50-month follow-ups. This seems
13
Clinical Child and Family Psychology Review
comparable to the younger samples covered in Hiller et al.
(2016) despite considerable differences in follow-up periods.
Numerous studies document the detrimental consequences
of untreated PTSD for individual mental health as well as for
society (e.g., Kessler 2000). In addition to high rates of comor-
bid disorders (Perkonigg et al. 2000), adolescents with PTSD
have been shown to suffer from emotion regulation difficul-
ties (Villalta et al. 2018) and to be more likely to engage in
high-risk behaviors, such as self-harming behavior, suicidal
ideation, dissociation, substance use, and running away from
home (Davis and Siegel 2000; Mueser and Taub 2008; Reed
et al. 2007). The importance of affect dysregulation in some
cases of PTSD has been highlighted recently by including a
new category, Complex PTSD (CPTSD), in the 11th version
of the International Classification of Diseases (ICD-11; World
Health Organization 2018). CPTSD requires meeting the ICD-
11 PTSD symptoms as well as symptoms of three specific
symptom clusters that represent disturbances in self-organiza-
tion: affect dysregulation, negative self-concept, and interper-
sonal problems. While CPTSD has been shown to be applica-
ble to children and adolescents (Sachser et al. 2017), and more
specifically in a study of AYAs aged 14 to 24 (Perkonigg et al.
2016), its clinical utility has been a subject of critical debate
(ISTSS Guidelines Committee n.d.).
Late adolescence is a developmental phase characterized by
transition. This transition is characterized by developmental
milestones on the intrapersonal (e.g., self-sufficiency, educa-
tional attainment, employment), interpersonal (e.g., seeking
autonomy from parents, contributing to a household, relation-
ship changes), and community levels (e.g., changes in legal
status). To proceed developmentally, AYAs have to master sev-
eral tasks simultaneously: separation-individuation, identity
formation, and achieving intimacy in romantic relationships
(Martel and Fuchs 2017). As the transition to adulthood is
challenging for many young people in itself, these challenges
are amplified for AYAs with mental health disorders (Manda-
rino 2014; Skehan and Davis 2017).
The purpose of this article is to reflect on developmental
considerations regarding the treatment of AYAs and the cover-
age of AYAs in PTSD treatment research as well as age-related
findings in current meta-analyses. Furthermore, it reviews the
results of evidence-based treatments for PTSS in AYAs, and
finally, it presents the results of our uncontrolled feasibility
study on Cognitive Processing Therapy (CPT) with minor age-
related modifications for AYAs with PTSS after miscellaneous
traumatic events.
Clinical Child and Family Psychology Review
Developmental Considerations
in the Treatment of PTSD in Adolescents
and Young Adults
Adolescence constitutes an important opportunity for pre-
vention and intervention because of its inherent develop-
mental and reorganizational processes regarding biological,
psychological and social functioning (Cicchetti and Rogosch
2002). According to Arnett (1999), “many adolescents
exhibit a heightened degree of storm and stress compared
with other periods of life” (p. 324) because of three central
features of adolescence: mood disruptions, risk behaviors,
and conflict with parents. However, these features might
negatively impact the way young people and their caregiv-
ers engage in the treatment process. Many AYAs refrain
from seeking professional help despite having mental health
problems (Biddle et al. 2004; Zachrisson et al. 2006). Both
Sauter et al. (2009; for anxiety disorders in general) and
Matulis et al. (2014; for abuse-related PTSD) argue that
the developmental transitions in adolescence might impact
the willingness and the ability to engage in and to complete
treatment. This might be particularly relevant in the case of
individuals suffering from PTSD, who are at an increased
risk of dropping out of treatment (Imel et al. 2013), par-
ticularly in the case of elevated symptoms of PTSD-typical
avoidance (Zayfert et al. 2005).
Developmental neurobiology offers insights into limita-
tions in decision-making, impulsivity and emotion regula-
tion as well as increased risk taking, that may be related
to the developing adolescent brain in general (Casey et al.
2008; Giedd 2008). Consequently, the establishment of
emotion regulation techniques might be helpful (see also
Matulis et al. 2014). According to this rationale, several
treatment approaches for adolescents or AYAs with PTSD
include emotion regulation or skills training (e.g., Cloitre
et al. 2014; Cohen et al. 2006; Ford et al. 2012; Greenwald
2009; Matulis et al. 2014). However, at the present time,
there are no dismantling studies that examine the particu-
lar benefit of modules for emotion regulation in AYAs.
PTSD in adolescents has been shown to be associated
with poor school performance (Lipschitz et  al. 2000),
and a high risk of revictimization (Cuevas et al. 2010;
Pittenger et  al. 2019). Furthermore, adolescents with
emotional or behavioral difficulties show developmental
delays in all areas of psychosocial development (Skehan
and Davis 2017). Consequently, support in mastering
developmental tasks concerning career choice, vocational
training, individuation and romantic relationships might
be of importance in the treatment of AYAs suffering from
PTSD, as argued by Matulis et al. (2014).
This applies to young adults as well. According to Man-
darino (2014), in today’s society, the transition period to
adulthood has been extended to allow for completion of
education, financial independence, and individuation. This
should be even more the case if delays in psychosocial devel-
opment can be deemed to be a consequence of untreated
mental health problems (Skehan and Davis 2017). Some
authors, therefore, extend the adolescent phase in the case
of the presence of various mental health issues up to young
adulthood (some up to the age of 29) by referring to the term
of transitional aged youth (Mandarino 2014; Skehan and
Davis 2017). Arnett (2000, 2014) even argued in favor of a
new theory of a developmental stage between adolescence
and young adulthood, emerging adulthood, that includes
individuals aged 18 to 29, who have not yet reached the
developmental stage of adulthood—demographically, sub-
jectively, and in terms of identity formation. Even when they
have reached physical and sexual maturity, the educational
and occupational trajectories of individuals in their late
teens and early twenties are highly diverse. By contrast in
the case of adults in their thirties, most of the younger adults
experience a period of heightened instability without the
typical stable structure of an “adult life” with its associated
long-term commitments and responsibilities (Arnett et al.
2014). Neurodevelopment continues after adolescence and
is marked by enhanced prefrontal functioning, finally result-
ing in increased future-oriented (and, therefore, decreased
risky) behavior. Furthermore, important steps for social,
psychosexual, and moral development and identity forma-
tion also continue to be taken during emerging adulthood
(Skehan and Davis 2017). But this dynamic sensitive period
of ongoing development might also be associated with an
increased risk of mental health disorders. As a matter of fact,
prevalence rates for mental health disorders and substance
use problems spike during the late teens and early twenties
(Kessler et al. 2005; Martel and Fuchs 2017). This combina-
tion of a higher risk of mental health conditions and critical
developmental milestones means young adults run a higher
risk of not completing their educational and occupational
trajectories (Skehan and Davis 2017). It, therefore, seems
advisable to take a developmental framework into account,
not only when working with adolescents, but also when
working with young adults with their ongoing biopsycho-
social changes and challenges. As services offered within
the adult mental health system do not necessarily focus on
the needs of young adults, it remains unclear if they are
developmentally appropriate for these individuals (Manda-
rino 2014; Skehan and Davis 2017). Furthermore, the lack of
continuity between the child and adult systems concerning
mental health and social welfare in many countries might
lead to increased treatment attrition or disengagement from
services altogether, thus putting them at risk of “getting lost”
(Mandarino 2014; Skehan and Davis 2017). AYAs might,
therefore, benefit from specific motivational enhancement
approaches (e.g., Mistler et al. 2016).
13

Another important consideration in treatment planning
for adolescents is whether to include caregivers and, if so,
to what extent. Overall, meta-analyses on PTSD treatment
efficacy in children and adolescents produced inconclusive
results: Whereas in the meta-analyses by Gutermann et al.
(2016), Newman et al. (2014) and Sun et al. (2019), paren-
tal involvement was associated with a better treatment
outcome, the meta-analyses by Miller-Graff and Campion
(2016) and Morina et al. (2016) did not find any mod-
erating effect. These inconsistencies may stem from the
major variations in the degree, intensity and type of parent
involvement in the different interventions. Thus, while in
pre-school and school age children an equal distribution
of time for parents and children might be advisable (i.e.,
Cohen et al. 2006; Scheeringa 2015), this degree of car-
egiver involvement might not be adequate for adolescents.
Current interventions for adolescents include parents and
caregivers to a significantly lesser degree (e.g., Rosner
et al. 2019) or not at all (e.g., Foa et al. 2013), see below.
However, even in young adults, the inclusion of a caregiver
for single sessions might be helpful in terms of enhancing
social support or under specific circumstances (e.g., young
adult refugees in welfare institutions; Unterhitzenberger
et al. 2019; college students; Pedrelli et al. 2015).
Finally, therapists are sometimes confronted with some
complex ethical and legal issues that can potentiate when
working with victimized minors (Putnam et al. 1996). One
of the most difficult dilemmas is raised by the conflict
between the protection of therapeutic confidentiality and
the legal and ethical requirements to disclose confidential
information in specific circumstances, such as when the
patient or others may be at risk of harm (Fried and Fisher
2018). In adolescents suffering from PTSS, this might be
the case in conjunction with ongoing known or suspected
maltreatment or when the adolescent engages in poten-
tially risky behavior. In terms of child abuse, there is a
great variety of laws, regulations, and jurisdictions across
and within countries, concerning whether and what type
of maltreatment is subject to mandatory reporting (for an
overview, see Pietrantonio et al. 2013). In terms of poten-
tially risky behavior, therapists may need to take situation-
specific information into account, in addition to knowledge
of applicable laws and regulations, e.g., the severity, fre-
quency, and nature of the behavior and the implications
of disclosure (Fried and Fisher 2018). Another dilemma
is the issue of providing clinical services without the
consent of the legal guardian (Fried and Fisher 2018). In
most countries adolescents are allowed by law to indepen-
dently obtain medical treatments, but depending on the
country or state, initiating psychological treatment with
minors without the consent of the legal guardians may be
restricted to specific situations (Fried and Fisher 2018).
13
Clinical Child and Family Psychology Review
Results on PTSD Treatment Research
for Adolescents and Young Adults
Clinical Practice Guidelines for the Treatment
of PTSD
Clinical practice guidelines for the treatment of patients
with PTSD agree on trauma-focused interventions as first-
line treatments for PTSD (Australian Centre for Posttrau-
matic Mental Health 2013; Cusack et  al. 2016; ISTSS
Guidelines Committee 2019; National Institute for Health
and Care Excellence 2018b). Current evidence supports
the efficacy of trauma-focused cognitive behavioral ther-
apy (CBT) as well as Eye Movement Desensitization and
Reprocessing (EMDR; Shapiro 2001) for the treatment of
adults (Cusack et al. 2016; ISTSS Guidelines Committee
2019; National Institute for Health and Care Excellence
2018b).
In children and adolescents, trauma-focused CBT,
conducted either with the child alone or with the child
and caregiver, is recommended as the first-line treatment
(Australian Centre for Posttraumatic Mental Health 2013;
ISTSS Guidelines Committee 2019; National Institute for
Health and Care Excellence 2018a; Rosner et al. 2019).
Recommendations regarding EMDR are inconsistent.
Whereas the guideline of the International Society for
Traumatic Stress Studies made a strong recommendation
for EMDR in children and adolescents (ISTSS Guidelines
Committee 2019), the UK National Institute for Health
and Care Excellence (National Institute for Health and
Care Excellence 2018a) only recommended EMDR as
a second-line treatment. Two other guidelines recom-
mended further research examining EMDR for PTSD in
minors (Australian Centre for Posttraumatic Mental Health
2013; Rosner et al. 2019). Overall, CBT showed medium
(in controlled trials) to large (in uncontrolled analyses)
effect sizes (Gutermann et al. 2016; Morina et al. 2016).
EMDR showed large effects within uncontrolled analy-
ses but only small to medium effects in controlled studies
(Gutermann et al. 2016). Furthermore, in a more detailed
analysis by Gutermann et al. (2016), CBT treatments with
primarily cognitive- or exposure-based interventions, and
Trauma-Focused Cognitive Behavioral Therapy (Tf-CBT)
following the treatment manual of Cohen et al. (2006), all
showed larger effect sizes than CBT treatments with the
focus on coping and skills.
Group therapy is associated with substantially smaller
effect sizes in adults (e.g., Watts et al. 2013) and children
and adolescents (e.g., Brown et al. 2017; Gutermann et al.
2016; Miller-Graff and Campion 2016; Newman et  al.
2014), and higher dropout rates (Imel et al. 2013). This
is an indication that group therapy may be provided as an
Clinical Child and Family Psychology Review
adjunct, but is not to be seen as an alternative to individual
trauma-focused therapy (Australian Centre for Posttrau-
matic Mental Health 2013).
Overall, the results concerning the efficacy of trauma-
focused PTSD treatment are encouraging, as reflected in the
current treatment guidelines. However, the generalizability
of these results with regard to adolescents and to young
adults in particular is limited for the following reasons.
Coverage of Adolescents and Young Adults
in Meta‑Analyses
To gain an initial impression of how well AYAs are repre-
sented in clinical trials, we searched for explicit informa-
tion on age ranges in recent meta-analyses on psychological
PTSD treatment. It is indeed the case that some meta-analy-
ses do not report any information on the age of the included
samples. This is mostly the case in meta-analyses that do not
follow systematic search protocols. However, most meta-
analyses report the age means given in each of the included
primary studies.
On closer inspection, we found a high number of meta-
analyses that targeted adult samples with broad age ranges,
but with age means in the primary studies that were well
above 25 years (e.g., Cusack et al. 2016). This means that
probably only a few young adults under 25 were included in
these studies, and hence in each meta-analytic study pool.
However, we found several other meta-analyses targeting
studies with adults that included at least some primary
studies with age means between 18 and 25, that is, studies
with young adults. Mostly this was because of a specific
focus of the respective meta-analysis. For example, Brand
et al. (2018) and Sin and Spain (2016) both investigated the
effects of trauma-focused interventions in individuals with
psychotic disorders. The included primary samples with age
means under 25 consisted of individuals with a first epi-
sode of psychosis. Given this specific focus, the results of
these meta-analyses do not permit any conclusions about the
effects of trauma-focused treatments in young adults in gen-
eral. We also identified a meta-analysis targeting a specific
subgroup of young adults, i.e., college students (Huang et al.
2018). But when focusing specifically on studies examining
PTSS treatments, they found a non-significant overall effect
size based on only three trials.
Meta-analyses targeting youth typically include only chil-
dren and adolescents up to age 18 (e.g., Brown et al. 2017;
Gillies et al. 2016; Lenz and Hollenbaugh 2015; Miller-Graff
and Campion 2016; Morina et al. 2016; Newman et al. 2014;
Nocon et al. 2017). To our knowledge, to date only three
meta-analyses targeting youth have been published that also
included young adults (psychological treatments in general:
Gutermann et al. 2016; Gutermann et al. 2017; EMDR:
Moreno-Alcázar et al. 2017). Both in their meta-analysis of
psychological treatments in children and AYAs and in their
follow-up meta-analysis of long-term effects (Gutermann
et al. 2017) Gutermann et al. (2016) advocate including
studies with participants up to age 25 to take into account
studies conducted with AYAs in specific contexts (e.g., war
regions, student populations).
Of course, the age means given in the primary studies
do not necessarily reflect the proportion of young adults in
the respective samples due to the fact that the time span of
young adulthood is short compared to the general age ranges
included, for example, in treatment trials with adults (e.g.,
age 18 to 65). Still, we are confident in concluding that meta-
analyses so far only included a small proportion of young
adults and that there is a relative lack of primary studies
targeting young adults in particular. As a result, their specific
characteristics and needs have perhaps been overlooked up
to now. One might say, they “got lost” in between research
with children and adolescents and research with adults. To
take due account of studies in specific contexts, as argued by
Gutermann et al. (2016), and given the growing interest in
transitional aged youth (Mandarino 2014), the inclusion of
studies with young adults in meta-analyses of youth should
be encouraged, unless there are sufficient primary studies
to allow for an explicit focus on emerging adults. Choos-
ing a strategy of age stratification that more closely reflects
developmental tasks might better reflect the biological, psy-
chological, and social context of this age period (see also
Huỳnh et al. 2018).
Age as a Moderator of Treatment Outcome
Meta-analyses of PTSD treatment efficacy that analyze
age as a moderator of treatment outcome are scarce and
the results are inconclusive. However, as outlined above,
meta-analyses targeting adults usually include participants of
broad age ranges, so age effects for the comparatively small
group of young adults remain unclear.
When focusing on meta-analyses with young samples,
there seems to be a trend towards an association of higher
average age with better treatment outcomes (e.g., Gutermann
et al. 2016; Lenz and Hollenbaugh 2015; Miller-Graff and
Campion 2016; Morina et al. 2016; Newman et al. 2014). In
contrast, Brown et al. (2017) did not find age to be a signifi-
cant moderator of treatment effects in PTSS after man-made
and natural disasters in their meta-analysis. Gutermann et al.
(2016) cited, among other possible explanations, that the
positive association of age and treatment effect might be
explained by the improved capability to grasp cognitive
components of effective treatments. Yet again, the reported
information on age in the respective meta-analyses does not
allow conclusions on the distribution of age in each pri-
mary sample. For example, in Morina et al. (2016), 18 of
the 41 primary samples included only children, 18 included
13

children and adolescents and only 7 included only adoles-
cents older than 13. Based on this information, we do not
know how many adolescents contributed to the reported age
effects.
In contrast to these findings, there is some evidence that
older children and adolescents are more likely to terminate
trauma-focused treatment prematurely (Fraynt et al. 2014;
Jensen et al. 2014; Scheeringa and Weems 2014) and tend to
be less likely early-responders (Wamser-Nanney et al. 2016)
than younger individuals.
Evidence‑Based Treatments for Adolescents
and Young Adults
Several treatment manuals originally developed for older
(adult) or younger (child and/or adolescent) populations
have already demonstrated efficacy in adolescents or, to a
lesser degree, in young adults. In the following, we give
an overview of those trauma-focused interventions for indi-
vidual outpatient settings and their applicability to AYAs
reported so far. To our knowledge, there is only one review
that focuses on trauma-informed treatments for adolescents
in particular (Black et  al. 2012). In their review, Black
et al. (2012) reported on five trauma-informed treatment
approaches by summarizing the results of studies published
up to 2012, including both group treatment approaches and
case studies. We add to the results by Black et al. (2012)
by specifically focusing on randomized controlled studies
on individual psychosocial treatment approaches targeting
PTSS in AYAs that were published over the last 10 years
(i.e., since 2009). We searched for relevant publications by
reviewing primary studies included in recent meta-analyses
(Gillies et al. 2016; Gutermann et al. 2016; Morina et al.
2016) and by searching digital databases (PsycInfo, Med-
line, PTSDpubs) beyond the last search reported in these
meta-analyses for newer publications between April 2014
and March 2019 using the following terms: (treatment OR
therap* OR intervention OR psychotherap*) AND (adoles-
cen* OR teen* OR juvenile OR “young adult*” OR “tran-
siti* age* youth”) AND (PTSD OR posttrauma* OR post-
trauma* OR “post-trauma*”).
Because of the restriction to studies published in the last
10 years, some earlier published promising approaches, like
Seeking Safety, a program designed for individuals suffer-
ing from PTSD and substance use disorder that has been
adapted to adolescent girls (Najavits et al. 2006), were not
included in our overview. In addition, as we were interested
in trauma-focused interventions for PTSS in AYAs, we did
not include implementation (e.g., Cohen et al. 2016) or pre-
vention trials (e.g., Berkowitz et al. 2011) that targeted acute
stress disorder symptoms. Due to their higher effect sizes
in comparison to group treatments (e.g., Gutermann et al.
13
Clinical Child and Family Psychology Review
2016; Miller-Graff and Campion 2016), we focused in this
review on treatments for individual settings, even though
this excluded most of the school-based interventions (for
an overview, see Rolfsnes and Idsoe 2011) and one promis-
ing group treatment approach that was originally developed
for adults with PTSD after childhood abuse, Skills Training
in Affect and Interpersonal Regulation Narrative Therapy
(STAIR-NT; Cloitre et al. 2006), but has been adapted to
adolescents as well (Cloitre et al. 2014).
Altogether, we identified ten treatment approaches that
have been examined in adolescents or AYAs over the last
10 years. Table 1 gives an overview of the treatments, their
characteristics and age-specific adaptations, and the respec-
tive randomized controlled trials (RCTs) together with
their results. Three approaches were originally developed
for youth. While Stanford Cue-Centered Therapy and Tf-
CBT were originally developed for children and adoles-
cents in general, Risk Reduction through Family Therapy
specifically targets adolescents in particular. Among the
approaches originally developed for youth of a broader age
range, only one RCT reported specific adaptations for ado-
lescent patients (Madigan et al. 2015, for Tf-CBT). In con-
trast, adolescence-adapted modifications were reported for
most of the approaches that were originally developed for
adults but were evaluated in recent clinical trials targeting
adolescents and/or young adults.
Treatment Approaches Originally Developed
for Youth
Risk Reduction Through Family Therapy
Risk Reduction through Family Therapy (RRFT; Danielson
et al. 2010) is an integrative treatment approach that was
developed to reduce the risk of substance abuse and other
high-risk behaviors and trauma-related psychopathology in
adolescents who have experienced childhood sexual assault.
It is a family-focused treatment consisting of seven com-
ponents that integrates principles and interventions from
empirically supported treatments for adolescents with sub-
stance abuse, including multisystemic therapy (Henggeler
et al. 2002), and for PTSD, including Tf-CBT (Cohen et al.
2006). Therapists may administer single components in a
flexible order and may choose between prevention or treat-
ment approaches with regard to the substance abuse and
PTSD components of the treatment. This is determined by
the needs of each youth and family. The mean number of
sessions in the available studies of RRFT was 23 (Daniel-
son et al. 2012) and 24 (Danielson et al. 2010). The exact
amount of time spent together with the family or caregiver
was not reported. Adolescents who received RRFT reported
reduced substance abuse and better family functioning (Dan-
ielson et al. 2010; Danielson et al. 2012). Participants also
 Table 1  Randomized controlled trials since 2009 evaluating individual trauma-focused treatments including adolescents and young adults
Study Control condition Randomized sample, N (N in Age, range Between-group effect size Adaptations for adolescents
experimental condition/N in for PTSS at posttreatment,
control condition) Cohen’s d (measure)

Manuals Risk Reduction through Family

originally Therapy (Danielson et al.
developed 2010)
for youth
∙ Integrative approach: com-
bining elements from cogni-
tive, behavioral (including
exposure), and multisystemic
Clinical Child and Family Psychology Review

therapies
∙ 60- to 90-min sessions, flex-
ible number of sessions and
inclusion of caregivers
Danielson et al. (2012) TAU​ 30 (15/15) 13–17 nr, ns (UCLA) [was developed for adolescents]
Stanford Cue-Centered
Therapy (Carrion and Hull
2010)
∙ Integrative approach: com-
bining elements from cogni-
tive, behavioral (including
exposure), psychodynamic,
expressive, and family
therapies
∙ 15–18 50-min sessions,
inclusion of caregivers in 4
sessions
Carrion et al. (2013) WL 65 (38/27) 8–17 0.97 (UCLA) None
Tf-CBT (Cohen et al. 2006)
∙ Exposure, cognitive interven-
tions, coping skills/emotion
regulation
∙ 12–15 90-min sessions; up to
50% of the sessions are dedi-
cated to be parallel caregiver
or conjoint sessions
Diehle et al. (2014) EMDR 48 (23/25) 8–18 0.14, ns (CAPS-CA) None
Dorsey et al. (2014) Tf-CBT plus engagement 47 (22/25) 6–15 nr, ns (UCLA) None
strategies
Goldbeck et al. (2016) WL 159 (76/83) 7–17 0.50 (CAPS-CA) None

13


Table 1  (continued)
Study Control condition Randomized sample, N (N in Age, range Between-group effect size Adaptations for adolescents
experimental condition/N in for PTSS at posttreatment,

13
control condition) Cohen’s d (measure)

Jaycox et al. (2010) CBITS 118 (60/58) 9–16 nr, ns (CPSS-SR) None
Jensen et al. (2014) TAU​ 156 (79/77) 10–18 0.46 (CAPS-CA) None
Madigan et al. (2015) TAU​ 43 (21/22) 15–18 nr, ns (CPTSDI) ∙ No caregiver sessions
Murray et al. (2015) TAU​ 257 (131/126) 5–18 2.39 (UCLA) None
Nixon et al. (2012)a Trauma-focused cognitive 34 (17/17) 7–17 0.02, ns (CAPS-CA) None
therapy
Manuals Clinician-Assisted Emotional
originally Disclosure (Anderson et al.
developed 2001)
for adults
∙ Exposure, Emotion-focused
Therapy
∙ 4 30-min sessions
Anderson et al. (2010) No intervention 28 (15/13) 19.3b nr, ns (IES-R) None
Cognitive Processing Therapy
(Resick et al. 2016; Resick
and Schnicke 1993)
∙ Cognitive interventions;
CPT+A protocol additionally
includes exposure component
∙ 12 60-min sessions
Rosner et al. (2019) WL with treatment advice 88 (44/44) 14–21 0.90c (CAPS-CA) D-CPT (Matulis et al. 2014):
∙ Additional treatment mod-
ules to address motivational
issues, emotion management
techniques and developmental
tasks, resulting in a total of 30
50-min sessions
∙ Administering CPT+A at a
high frequency
∙ 6 optional sessions together
with caregiver
Cognitive Therapy (Ehlers
et al. 2003)
∙ Cognitive interventions,
exposure, stimulus discrimi-
nation techniques
∙ 12 60- to 90-minute sessions
Clinical Child and Family Psychology Review
 Table 1  (continued)
Study Control condition Randomized sample, N (N in Age, range Between-group effect size Adaptations for adolescents
experimental condition/N in for PTSS at posttreatment,
control condition) Cohen’s d (measure)

Meiser-Stedman et al. (2017)
WL 29 (14/15) 8–17 2.01 (CPTSDI) Cognitive Therapy for PTSD
(Smith et al. 2010)
∙ Age-appropriate techniques for
restructuring
∙ Flexible and optional inclu-
sion of caregivers, at least for
psychoeducation and at the
end of sessions to review treat-
Clinical Child and Family Psychology Review

ment progress and help to plan

EMDR (Shapiro 2001)
∙ Desensitization of trauma-
related images, beliefs, emo-
tions, and physical responses
during sets of bilateral
stimulation
∙ Flexible number of sessions
De Roos et al. (2011)
De Roos et al. (2017)
Diehle et al. (2014)
CBT
CBWT, WL
Trial compared EMDR and
a short form of Tf-CBT,
for results see above under
“Tf-CBT”
homework tasks
52 (26/26) 4–18 nr, ns (UCLA) EMDR with age-appropriate
modifications by Tinker and
Wilson (1999) and Greenwald
(1999):
Up to four sessions of parent
guidance
103 (43/42/18) 8–18 nr, ns vs. CBWT; 1.27 vs. WL EMDR with age-appropriate
(CRTI) modifications by Tinker and
Wilson (1999) and Greenwald
(1999):
∙ Involvement of caregivers for
10 min of each session
∙ Instructions for parents to
encourage their child to dis-
cuss the trauma or to confront
reminders
∙ Involvement of caregivers for
15 min of each session

13


Table 1  (continued)
Study Control condition Randomized sample, N (N in Age, range Between-group effect size Adaptations for adolescents
experimental condition/N in for PTSS at posttreatment,

13
control condition) Cohen’s d (measure)

Farkas et al. (2010) WL 65 (33/32) 13–17 nrd (DISC) MASTR/EMDR (Greenwald

2009):
∙ Preceding treatment phases for
motivational issues and self-
management skills training
∙ Minor age-adapted modi-
fications of EMDR, e.g.,
visual approaches of treatment
materials
∙ No involvement of caregivers
NET (Schauer et al. 2005,
2011)
∙ Exposure with life-span
perspective
∙ 90- to 120-min sessions, flex-
ible number of sessions
Ertl et al. (2011) Academic catch-up program, 85 (29/28/28) 12–25 0.72 vs. academic catch-up; None
WL 0.66 vs. WL (CAPS)e
Peltonen and Kangaslampi TAU​ 50 (29/21) 9–17 nr, ns (CRIES) None
(2019)
Ruf et al. (2010) WL 26 (13/13) 7–16 nr (UCLA) KIDNET (Neuner et al. 2008):
∙ Creative elements to help chil-
dren construct their story and
express their emotions
∙ Involvement of caregiver for
one session on psychoeduca-
tion
Schaal et al. (2009) Group ­IPTf 26 (12/14) 14–28 nr, ns (CAPS) None
Prolonged Exposure (Foa et al.
2007)
∙ Exposure
∙ 8–15 90-min sessions
(McLean and Foa 2011)
Clinical Child and Family Psychology Review
 Table 1  (continued)
Study Control condition Randomized sample, N (N in Age, range Between-group effect size Adaptations for adolescents
experimental condition/N in for PTSS at posttreatment,
control condition) Cohen’s d (measure)

Foa et al. (2013)
SC 61 (31/30) 13–18 1.01 (CPSS-I) PE-A (Foa et al. 2008):
∙ Flexible number and length
of sessions according to the
patients’ characteristics
∙ More extensive case manage-
ment and relapse prevention
components
∙ No caregiver sessions
Clinical Child and Family Psychology Review

Gilboa-Schechtman et al. Time-limited Dynamic 38 (19/19) 12–18 0.45 (CPSS-SR)

(2010) Therapy
Rossouw et al. (2016) SC 11 (6/5) 14–18 nr, ns (CPSS-I)
Rossouw et al. (2018) SC 63 (31/32) 13–18 1.22 (CPSS-I)
TARGET (Ford and Russo
2006)
∙ Emotion regulation
∙ 12 50-min sessions
Ford et al. (2012) Relational supportive therapy 59 (33/26) 13–17 0.53 (CAPS-CA) None

CAPS clinician-administered PTSD scale, CAPS-CA clinician-administered PTSD scale for children and adolescents, CBITS cognitive behavioral intervention for trauma in Schools, CBT cogni-
tive behavioral therapy, CBWT cognitive behavior writing therapy, CPSS-I Child PTSD symptom scale–interview, CPSS-SR Child PTSD symptom scale–self-report, CPT+A cognitive process-
ing therapy including written accounts, CPTSDI Children’s PTSD inventory, CRIES children’s revised impact of event scale, CRTI children’s responses to Trauma Inventory, D-CPT develop-
mentally adapted cognitive processing therapy, DISC diagnostic interview schedule for children, EMDR eye movement desensitization and reprocessing, IES-R impact of event scale–revised,
IPT interpersonal psychotherapy, KIDNET narrative exposure therapy for children, MASTR motivation–adaptive skills–trauma resolution, NET narrative exposure therapy, nr not reported, ns not
significant, PE-A prolonged exposure for adolescents, PTSD posttraumatic stress disorder, PTSS posttraumatic stress symptoms, SC supportive counseling, TARGET Trauma Affect Regulation,
Guide for Education and Therapy, TAU​treatment as usual, Tf-CBT Trauma-focused Cognitive Behavioral Therapy, UCLA University of California at Los Angeles PTSD Reaction Index, WL
wait-list
a
 Manual did not follow the manual by Cohen et al. (2006), but included similar components
b
 Only age mean of sample reported
c
 Hedges’ g reported
d
 Partial eta squared reported, η2p = .14
e
 Only Cohen’s d from pretreatment to 12-month follow-up reported
f
 Only n = 12 were randomly assigned

13

experienced reductions in PTSS and depression symptoms
(Danielson et al. 2012), although reductions in PTSS only
were significant with regard to parent-reported PTSS in the
RCT.
Stanford Cue‑Centered Therapy
Stanford Cue-Centered Therapy (CCT; Carrion and Hull
2010) is a short-term, multimodal therapy for youths who
have experienced trauma, focusing primarily on exposure to
trauma-related cues. Besides components like coping skills
training, narrative exposure, and cognitive restructuring,
several cue-centered treatment sessions focus on teaching
youth and caregivers about the conditioning process that
occurs through repeated exposure to trauma, on identifying
cues associated with this conditioning and on developing
more adaptive responses. CCT draws not only on cognitive
behavioral, but also on supportive, family, expressive and
insight-oriented techniques. The only existing RCT exam-
ining CCT (Carrion et al. 2013) was conducted in a school
setting, as CCT has been designed for implementation in
clinic or school settings. Compared to a wait-list condition,
CCT yielded significant reductions in PTSS, reported by
both parents and youth. Parents were asked to participate in
four of the 15–18 sessions. The proportion of adolescents
in the sample of Carrion et al. (2013) consisting of both
children and adolescents was not reported.
Trauma‑Focused Cognitive Behavioral Therapy
Tf-CBT (Cohen et al. 2006) is the most frequently investi-
gated treatment for children and adolescents suffering from
PTSD (de Arellano et al. 2014), with a total of 21 RCTs
published up to March 2018 ("Trauma-Focused Cognitive
Behavioral Therapy National Therapist Certification Pro-
gram: About Trauma-Focused Cognitive Behavior Therapy
(TF-CBT)," 2019). Tf-CBT is a short-term, component-
based intervention that emphasizes the involvement of car-
egivers. Although Tf-CBT was developed with children in
mind, most trials do not report on adaptations specifically for
adolescents. Only Madigan et al. (2015) adapted the number
of caregiver sessions in their sample of pregnant adolescents
by completely excluding caregiver sessions. Several trials
have studied Tf-CBT with populations up to the age of 16
or even 18 (see Table 1), but information about the percent-
age of participants older than 14 years is rarely given. The
results for age as a moderator of outcome were reported by
three studies, indicating that older patients benefitted less
from Tf-CBT (Goldbeck et al. 2016) and dropped out more
often (Murray et al. 2015; Ormhaug and Jensen 2018, for
a secondary analysis of the results by Jensen et al. 2014).
13
Clinical Child and Family Psychology Review
Treatment Approaches Originally Developed
for Adults
Clinician‑Assisted Emotional Disclosure
Clinician-Assisted Emotional Disclosure (CAED; Ander-
son et al. 2001) is an adaptation of two treatment modules
of Emotion-Focused Therapy (Elliott et al. 2004; Green-
berg et al. 1993) that focus on the elaboration of sexual
trauma narratives and their emotional focusing and pro-
cessing. With four sessions administered over a period of
approximately 10 days, the structure of CAED is derived
from Pennebaker (1997). The participants in the only
existing RCT were female college students, but the age
range was not reported (Anderson et al. 2010). Therefore,
we do not know if there were under-age participants as
well. With respect to PTSS, only avoidance symptoms
improved significantly compared to the control condition
at three months posttreatment.
Cognitive Processing Therapy
CPT is a predominantly cognitive treatment originally
designed to treat PTSS in adult sexual assault survivors
(Resick and Schnicke 1992). It has since been adapted for
a variety of other populations and trauma types and has
been proven to be effective in reducing PTSD and associ-
ated symptomatology in numerous controlled and uncon-
trolled trials (Asmundson et al. 2018; Holliday et al. 2018;
Lenz et al. 2014).
The CPT+A (CPT with written accounts) protocol for
adults consists of 12 weekly sessions, which can be deliv-
ered in group, individual or combined formats (Resick and
Schnicke 1993). Originally, CPT included written accounts
of the trauma, but after a dismantling study showed that their
inclusion did not yield better results (Resick et al. 2008),
Resick et al. (2016) encouraged the use of the name CPT
for the cognitive therapy-only version of CPT and decided to
give this version primacy. CPT+A is now used when written
trauma accounts are included. Sessions are highly structured
and can be divided into three components: education about
PTSD and CPT’s treatment rationale, exposure, and cogni-
tive therapy. The exposure component consists of writing
and reading detailed accounts of the most traumatic event.
The cognitive component includes writing an impact state-
ment about the personal meaning of the traumatic event,
identifying and challenging dysfunctional cognitions as a
result of the traumatic events (“stuck points”), and specific
modules for five areas of possible dysfunctional beliefs:
safety, trust, power/control, esteem, and intimacy (Resick
et al. 2016; Resick and Schnicke 1992).
Clinical Child and Family Psychology Review
Results on age as a moderator for outcome in CPT are
seldom reported. Based on results of their meta-analysis
on CPT trials, Lenz et al. (2014) reported lower effect
sizes in samples of adolescents and older adults. One CPT
trial with adults showed associations of younger age with
higher dropout rates (Rizvi et al. 2009), another with better
outcome (Butollo et al. 2016). However, the overall broad
age ranges (18–70 or 18–78, respectively) limit the gener-
alizability of these age effects to young adults in particular.
There is initial evidence that CPT is effective in ado-
lescents. Ahrens and Rexford (2002) showed a significant
reduction of PTSD and depression symptoms compared to
wait-list control in incarcerated male juveniles aged 15 to 18
after delivering short-term CPT, including written accounts
in a group format. Matulis et al. (2014) adapted CPT+A
specifically to the needs of AYAs after sexual and/or physi-
cal abuse by allotting more time to addressing motivational
issues, emotion management techniques and developmental
tasks as well as administering the CPT+A core of the thera-
peutic protocol at a high frequency. This Developmentally
Adapted CPT (D-CPT; Matulis et al. 2014) consists of 30
to 36 50-min individual sessions; it showed large pre-post
effect sizes with respect to PTSS, depressive and borderline
symptoms, and medium effect sizes with respect to disso-
ciative symptoms in an uncontrolled pilot trial. Recently,
D-CPT was shown to be superior to a wait-list condition
with treatment advice for AYAs with abuse-related PTSS
aged 14 to 21 in an RCT (Rosner et  al. 2019). Further
studies are needed to assess the efficacy of CPT in AYAs,
and to clarify whether preceding modules (e.g., emotion
regulation or skills training) are necessary before starting
trauma-focused interventions like CPT (see also the pilot
trial reported below), and whether the cognitive therapy-
only version of CPT yields comparable results in these age
groups as well.
Cognitive Therapy
Cognitive Therapy for PTSD in Children and Adolescents
(CT-PTSD; Smith et al. 2010) is a developmentally sensitive
intervention based on the cognitive PTSD model of Ehlers
and Clark (2000), and the respective treatment approach by
Ehlers et al. (2003). RCTs involving adults show that this
approach yields durable reductions of PTSS and related
symptoms relative to control conditions (Duffy et al. 2007;
Ehlers et al. 2003; Ehlers et al. 2014). CT-PTSD is a short-
term treatment that aims to develop a coherent narrative of
the trauma, to challenge unhelpful appraisals of the trau-
matic event and its sequelae, and to change dysfunctional
(cognitive and behavioral) coping strategies. Sessions with
the caregiver are used to modify parents’ unhelpful trauma-
related appraisals, and to engage them as co-therapists. In
a recent trial, CT-PTSD yielded greater improvement on
youth-reported questionnaire measures of PTSS, depression
and anxiety, clinician-rated functioning, and parent-reported
outcomes (Meiser-Stedman et al. 2017).
Eye Movement Desensitization and Reprocessing
EMDR is an eight-phase treatment approach originally
developed for adults that uses saccadic eye movements as
one treatment component to tap into images, beliefs, emo-
tions, physical responses, awareness, and interpersonal sys-
tems (Shapiro 2001). As stated by Shapiro and Maxfield
(2002), EMDR uses a free-association principle that does
not necessarily involve the patients concentrating for pro-
longed periods on the traumatic event or the challenging of
their beliefs. In addition, EMDR involves fewer homework
assignments (Shapiro and Maxfield 2002). Although earlier
versions of EMDR consisted of 1 to 3 sessions, current pro-
tocols consist of 8 to 12 weekly 90-minute sessions (Cusack
et al. 2016).
Most of the research on the effectiveness of EMDR was
conducted with adults (e.g., Chen et al. 2014; Chen et al.
2015; Khan et al. 2018; Lee and Cuijpers 2013). It showed
EMDR to be effective in reducing PTSS and associated psy-
chopathology. Despite this empirical support, the underly-
ing working mechanisms and the specific function of eye
movements in particular remain controversial in EMDR.
Two earlier meta-analyses of dismantling studies on EMDR
concluded that eye movements do not significantly contrib-
ute to treatment outcome (Cahill et al. 1999; Davidson and
Parker 2001). In contrast, Lee and Cuijpers (2013) showed
in their meta-analysis that eye movements had a moderate
additive effect in EMDR treatment studies and a large effect
in experimental studies. In any case and as argued in the
guideline of the Australian Centre for Posttraumatic Mental
Health (2013), EMDR has increasingly included more treat-
ment components that are comparable to the CBT interven-
tions. This makes differentiation between EMDR and CBT
difficult.
Meanwhile, several trials studied the efficacy of EMDR
therapy in children and adolescents as well. However, earlier
studies have been criticized in respect of methodological
shortcomings (Greyber et al. 2012), and in the meta-analy-
sis of Gutermann et al. (2016), EMDR demonstrated large
effects in uncontrolled studies but only small to medium
effect sizes in controlled studies. We identified four RCTs
evaluating EMDR in samples including adolescents over
the last 10 years. One of them only included adolescents
and adapted the treatment by adding preceding treatment
phases for motivational issues and self-management skills
training (Farkas et al. 2010). Developmental modifications
of EMDR therapy are generally recommended for children
such as adapting language and instructions, alternating the
method of bilateral stimulation, or involving caregivers in
13

treatment. In adolescents, Shapiro et al. (2017) recommend
targeting possible compulsive behavior in the processing
treatment phases. More preparation time may be needed for
both children and adolescents. As most RCTs on EMDR
in children and adolescents differ in how they apply these
developmental modifications (e.g., degree of caregiver
involvement, Shapiro et al. 2017), the specific benefit from
these modifications is unclear.
Narrative Exposure Therapy
Narrative Exposure Therapy (NET; Schauer et al. 2005,
2011) was originally developed for use in low-income coun-
tries (Robjant and Fazel 2010). NET focuses on exposure
and the elaboration of the autobiography, including inte-
gration of both the traumatic experiences and other highly
arousing events. Instead of focusing solely on an index
trauma, NET embraces a life-span perspective. Treatment
length may be adjusted, and trials in adults reported a range
of sessions from a minimum of four to a maximum of 17
sessions lasting for 90 to 120 min each (McPherson 2011;
Robjant and Fazel 2010). While NET was originally used in
adults, there also exists a child-friendly version with some
adaptations to the original model to help children construct
their story and express their emotions (i.e., NET for Chil-
dren: KIDNET). Although there is sound evidence of the
effectiveness of NET for adults (McPherson 2011; Robjant
and Fazel 2010), we only identified four recently published
RCTs with AYAs. Three trials reported significant reduc-
tions in PTSS at follow-up assessments (Ertl et al. 2011;
Ruf et al. 2010; Schaal et al. 2009), while one reported no
significant reductions in PTSS compared to treatment as
usual (Peltonen and Kangaslampi 2019). The actual scale of
developmental adaptations in these trials was not described.
Prolonged Exposure
Prolonged Exposure (PE; Foa et al. 2007) is a manualized
treatment package that focuses on exposure. PE has been
shown to be a highly effective treatment for reducing PTSS
and comorbid symptoms with treatment gains maintained
over time in many controlled studies that examined various
adult trauma populations (Powers et al. 2010).
The PE protocol was also adapted for adolescents (PE-
A; Foa et al. 2008). In PE-A no sessions are specifically
dedicated to working with caregivers. Four RCTs have
investigated the efficacy of PE-A in adolescents suffering
from PTSD after single-event trauma (Gilboa-Schechtman
et al. 2010), after sexual abuse (Foa et al. 2013), and after
interpersonal trauma (Rossouw et al. 2016; Rossouw et al.
2018). In the three trials with sufficient sample sizes (Foa
et al. 2013; Gilboa-Schechtman et al. 2010; Rossouw et al.
2018), PE-A exhibited a greater decrease in PTSD and
13
Clinical Child and Family Psychology Review
depression symptom severity and a greater increase in global
functioning compared to active control conditions. All of
them included adolescents not older than 18, so there are no
results specifically for young adults. In the studies included
in the meta-analysis by Powers et al. (2010), age as a mod-
erator of outcome or treatment attrition was seldom reported.
Trauma Affect Regulation: Guide for Education and Therapy
Trauma Affect Regulation: Guide for Education and Therapy
(TARGET) was originally developed for adults with PTSD
and co-occurring mental illness, for example, substance
abuse (Ford and Russo 2006). It can be employed in both
a group and an individual treatment setting. It teaches a
sequential set of self-regulation skills based on CBT strat-
egies. Exposure involves creating a “lifeline” including
traumatic and stressful events but does not involve repeated
retelling (Ford et al. 2012). We identified one RCT evaluat-
ing TARGET in a sample of adolescent girls involved in
delinquency who met the criteria for full or partial PTSD by
Ford et al. (2012). In terms of PTSS, results showed medium
effects favoring TARGET for change in reexperiencing and
avoidance symptoms. No developmental adaptations, e.g.,
involvement of caregivers, were reported in this study.
Summary of Evidence‑Based Treatments
for Adolescents and Young Adults
Several aspects of the various treatment approaches reported
above should be highlighted. First of all, the number of treat-
ment sessions varies considerably between different treat-
ment approaches as well as between different studies evalu-
ating the same approach. While some studies contained a
maximum of 10 sessions (e.g., 8 to 10 sessions in (KID)
NET, Ertl et al. 2011; Peltonen and Kangaslampi 2019; Ruf
et al. 2010; 10 sessions in CT-PTSD, Meiser-Stedman et al.
2017), most studies envisage 12 to 15 sessions (e.g., 12 ses-
sions for child and caregiver in Tf-CBT, Goldbeck et al.
2016; 12 sessions in TARGET, Ford et al. 2012; 14 ses-
sions in PE-A, Foa et al. 2013; 15 sessions in CCT, Carrion
et al. 2013), with a maximum of 30 to 36 sessions in D-CPT
(Rosner et al. 2019). Nonetheless, the treatment dose in the
different studies might be comparable, as session length var-
ies considerably as well (e.g., 90 to 120 min per session in
KIDNET, Ruf et al. 2010; 90 min per session in Tf-CBT,
Goldbeck et al. 2016; 60 to 90 min per session in PE-A,
Foa et al. 2013; 50 min per session in D-CPT, Rosner et al.
2019).
Even within one treatment approach, the number and
length of sessions (i.e., treatment dosage), and the degree
of caregiver involvement may vary considerably. For exam-
ple in studies of EMDR, de Roos et al. (2011) applied 4
individual 60-min sessions plus up to 4 sessions of parent
Clinical Child and Family Psychology Review
guidance, de Roos et al. (2017) administered 6 individual
45-min sessions without any caregiver involvement, Die-
hle et al. (2014) envisaged 8 60-min sessions with 15 min
of parental involvement in each session, and Farkas et al.
(2010) administered 12 individual 90-min sessions without
any caregiver involvement. Therefore, even within one treat-
ment approach, the results of the individual studies need to
be interpreted cautiously.
The involvement of caregivers also varied considerably
in other treatment approaches. Some studies of the reported
treatment approaches did not involve caregivers at all, e.g.,
TARGET (Ford et al. 2012), (KID)NET (Ertl et al. 2011;
Ruf et al. 2010; Schaal et al. 2009), or PE-A (Foa et al.
2013). Other studies provided optional and flexible numbers
of caregiver sessions, e.g., RRFT (Danielson et al. 2012),
or D-CPT (Rosner et al. 2019), while studies of Tf-CBT
(Cohen et al. 2006) usually dedicate up to 50% of the ses-
sions to parallel caregiver or conjoint sessions. These varia-
tions in the degree of caregiver involvement might account
for the above-mentioned inconsistent findings in meta-anal-
yses regarding its effects on outcome.
Given the positive results of a pilot trial (Matulis et al.
2014) and an RCT on abuse-related PTSD in AYAs (Rosner
et al. 2019), and bearing in mind that the interventions are
comparably long, we hypothesized whether a shortened ver-
sion of D-CPT—without the treatment modules to address
motivational issues, emotion management techniques and
developmental tasks—would be a feasible and sufficient
form of treatment. To date, most of the dismantling research
into the benefits of specific treatment components has been
conducted with adult samples and examined the need for
cognitive restructuring in the treatment of PTSD (e.g., Bry-
ant et al. 2008; Foa et al. 2005; Resick et al. 2008; Tarrier
et al. 1999). Only a minority of dismantling studies exam-
ined the specific benefit of certain components in young
populations, such as cognitive restructuring (e.g., Nixon
et al. 2012) or using a trauma narrative and a certain treat-
ment length (e.g., Deblinger et al. 2011). In the light of the
current discussion of the need for stabilization or emotion
regulation modules prior to trauma-focused treatment mod-
ules (de Jongh et al. 2016), dismantling trials focusing on the
need for stabilization modules are of major interest regard-
less of the treated age group.
Preparing a Dismantling Study: Are
Extensive Adaptations of Cognitive
Processing Therapy Necessary when Treating
Adolescents and Young Adults?
To set out a next step to the current literature in this field
and to illustrate a possible treatment approach for AYAs
with PTSS, we report on our uncontrolled feasibility study
in which we evaluated CPT+A with only minor age-related
modifications. We chose CPT+A because of its encourag-
ing results in a former trial in incarcerated male adolescents
delivered in a short-term (8 sessions) group setting (Ahrens
and Rexford 2002). Furthermore, our team has been involved
in three CPT trials so far (Butollo et al. 2016 with CPT for
adults; Matulis et al. 2014, and Rosner et al. 2019, with
D-CPT for AYA with abuse-related PTSD). Based on these
experiences and as a first preparation for a dismantling study
of D-CPT components, we decided to test the feasibility
of CPT+A for AYAs. Unlike D-CPT (Matulis et al. 2014;
Rosner et al. 2019) that was developed specifically to treat
abuse-related PTSD, we did not add further treatment mod-
ules and did not alter the session frequency. Age-adapted
modifications comprised revisions of treatment materials
and the option of offering optional sessions, e.g., to include
caregivers or for crisis intervention. The length of the proto-
col was similar to the original German CPT protocol (König
et al. 2012).
The overall aim of this uncontrolled study was to evaluate
the feasibility and safety of CPT+A, and to generate prelimi-
nary data on its efficacy for AYAs with full or subthreshold
PTSD after mixed traumatic events. We hypothesized that
participants would experience significant reductions in PTSS
(primary outcome) and associated psychopathological symp-
toms (secondary outcomes: depression, dissociation, border-
line symptoms, and behavior problems) after the interven-
tion and at the 6-week and 6-month follow-ups. Additionally,
the remission of PTSD diagnosis, reliable change in PTSS
and remission of comorbid mental disorders were examined.
Method
Participants
Participants were AYAs (aged 14-21). A primary diagnosis
of full or subthreshold PTSD was required for inclusion as
indicated by a total severity score of ≥ 24 and at least one
symptom in each of the clusters B, C, and D (see Kassam-
Adams and Winston 2004) of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; APA 2000) assessed
using the Clinician-Administered PTSD Scale for Children
and Adolescents (CAPS-CA; see below). We decided to
also include AYAs with subthreshold PTSD because of the
ongoing discussion about diagnostic criteria for PTSD in
children and adolescents (Cohen et al. 2010) and the docu-
mented associations of subthreshold PTSD with significant
impairment in both adults (Zlotnick et al. 2002) and chil-
dren (Cohen and Scheeringa 2009). The criteria for sub-
threshold PTSD in the current study corresponded to per-
centile rank ≥ 80 according to the German norm sample of
the CAPS-CA (Steil and Füchsel 2006). Moreover, to be
included, participants had to have sufficient cognitive ability,
13
 Clinical Child and Family Psychology Review

as indicated by an IQ of ≥ 75 in the Culture Fair Intelligence Table 2  Demographic variables of study participants in the feasibility
Test (Weiß 2006), sufficient proficiency in the German lan- trial of CPT adapted for adolescents and young adults
guage, and safe living conditions. The exclusion criteria Variable Intent-to-
were concurrent psychotherapeutic treatment, current severe treat sample
suicidality or suicide attempt or life-threatening self-harm (N = 17)
within 6 months prior to admission to the study, current Age, mean (SD) 17.12 (2.23)
or lifetime diagnosis of any psychotic or bipolar disorder Female, No. (%) 16 (94)
according to DSM-IV-TR as indicated by the Structured Nationality, No. (%)
Clinical Interview for DSM-IV Axis I (SCID-I; see below),  German 15 (88)
current drug or alcohol dependency according to DSM-IV  Other or dual citizenship 2 (12)
as indicated by the SCID-I, a documented diagnosis of a per- Immigration background, No. (%) 5 (29)
vasive developmental disorder, and initiation of or change in Living situation, No. (%)
psychotropic medication within the 3 weeks prior to admis-  With at least one parent 11 (65)
sion to the study. Any change in psychotropic medication  With other relatives 2 (12)
during the course of the study was continuously monitored.  Alone 3 (18)
The ITT sample consisted of 17 AYAs (16 females, one  With partner 1 (6)
male). Their ages ranged from 14 to 21, with n = 10 aged Occupation, No. (%)
under 18 (n = 4 aged 14 to 15; n = 6 aged 16 to 17). Accord-  Student 12 (71)
ing to CAPS-CA, the participants had experienced 4.5  In vocational training 3 (18)
(SD = 2.2) different types of traumatic events on average,  Unemployed 2 (12)
ranging from 1 to 9 types. Eight participants (47%) reported Type of traumatic e­ venta, No. (%)
single traumatic events. In 13 cases (77%), the criteria of  Sexual violence 9 (53)
PTSD according to DSM-IV were met at baseline.  Physical violence 3 (18)
In addition to PTSD, nine participants (53%) reported at  Murder/suicide/sudden death of a loved one 5 (29)
least one lifetime psychiatric disorder diagnosis according to  Accident 4 (24)
DSM-IV. At baseline, 12 participants (71%) fulfilled criteria Subthreshold ­PTSDb, No. (%) 4 (23)
of at least one comorbid psychiatric disorder with an average Comorbid disorder DSM-IVc, No. (%)
of M = 1.06 (SD = 1.2). Participants met an average of 1.35  None, No. (%) 5 (29)
(SD = 1.58) criteria of the borderline section of the SCID-II.  1 or 2, No. (%) 11 (65)
For further details, see Table 2.  3 or more, No. (%) 1 (6)
 Mood disorders, No. (%) 6 (35)
Treatment  Anxiety disorders, No. (%) 6 (35)
 Nicotine dependence, No. (%) 2 (12)
CPT followed the German version of the manual by König History of at least one suicide attempt before treat- 2 (12)
et al. (2012), consisting of 15 50-min sessions and includ- ment, No. (%)
ing a written account component (i.e., CPT+A). To adapt Histories of non-suicidal self-harm, No. (%) 10 (59)
CPT for AYAs, we made the following modifications: 1. Psychotropic medication, No. (%) 2 (12)
Following the example of Matulis et al. (2014) and based Support by youth welfare services, No. (%) 3 (18)
on modifications for cognitive deficits suggested by Resick
CPT cognitive processing therapy, PTSD posttraumatic stress disor-
et al. (2014), the worksheets were modified by: a) giving der
more detailed instructions, b) providing more examples, a
 According to the Clinician-Administered PTSD Scale for Children
and c) simplifying contents, especially regarding work- and Adolescents
sheets for the cognitive components of the intervention; b
 Subthreshold posttraumatic stress disorder was defined as having
see Table 5 in Online Resource 1. 2. We added additional a total severity score of ≥ 24 and at least one symptom per DSM-IV
sessions: one for administrative issues and for building clusters B, C, and D according to the Clinician-Administered PTSD
Scale for Children and Adolescents (all else according to DSM-IV)
up treatment motivation (see session 0 in Table 3), and c
 Including nicotine dependence and borderline personality disorder
up to four optional conjoint sessions with a significant
other (e.g., parent, other relative, girl- or boyfriend, social
worker; see sessions C1–4 in Table 3). 3. Up to three fur- according to the “stressor sessions” administered by Gal-
ther optional sessions were possible, e.g., to discuss the ovski et al. (2012). Altogether, a maximum of 19 therapy
implications of traumatic loss, to delve into specific top- sessions with the AYAs and four conjoint sessions with a
ics, e.g., by addressing specific developmental needs or significant other were possible according to the protocol,
cultural issues, or to address major psychosocial stressors see Table 3 for an overview.

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Clinical Child and Family Psychology Review

Table 3  Treatment protocol of CPT+A adapted for adolescents and young adults (Vogel and Rosner, based on the German manual by König
et al. 2012)
Session number Treatment strategies

0 Preparation session: addressing case management issues (e.g., safety concerns, administrative and motivational issues, parental
involvement)
1 Educating about PTSD symptoms and rationale for treatment
2 Discussing goals for the treatment; educating about dysfunctional cognitions (“stuck points”) and emotions
C1a Caregiver session 1: educating about PTSD symptoms and rationale for treatment
3 Discussing the meaning of the traumatic event (“Impact Statement”); examining connections between thoughts, feelings, and
behavior
C2a Caregiver session 2: discussing goals, expectations, and concerns about treatment; discussing ways of providing support during
treatment
4 Identifying connections between thoughts, feelings, and behavior; preparing a written trauma account as a practice assignment
C3a Caregiver session 3: challenging thoughts about trauma; challenging thoughts about dysfunctional parenting strategies
5 Remembering traumatic event via written account; identifying and challenging stuck points
6 Remembering traumatic event via second written account; challenging stuck points
7–9 Challenging stuck points and developing alternative beliefs
10–14 Challenging stuck points focusing on specific areas: safety, trust, power/control, esteem, intimacy
C4a Caregiver session 4: reviewing the course of treatment
15 Reviewing the course of treatment; identifying goals for the future; discussing the final Impact Statement

CPT+A cognitive processing therapy including written accounts, PTSD posttraumatic stress disorder
a
 Optional session

Procedure of the German treatment manual (Julia König, PhD). Thera-

The study was approved by the local institutional review
board. Recruitment was carried out between January 2014
and January 2017. Assessment and treatment were offered
at a university-based outpatient clinic. Written informed
consent was obtained from all adult participants and from
parents or guardians of minors; in addition, written assent
was obtained from all minor participants using the same
study information as for adult participants.
Participants were recruited by posting details of the study
on the clinic’s website, and by informing the local health
care and social/youth welfare community and schools. Eli-
gible participants were included consecutively in treatment.
The trial included assessments at baseline, posttreatment,
6-week and 6-month follow-ups each comprising the same
clinical interviews and self-ratings described below. All
assessments were conducted by trained clinical raters with
a minimum qualification of a bachelor’s degree in psychol-
ogy who were blind to participants’ baseline assessment
results and treatment progression. Participants received a
small financial compensation for taking part in follow-up
assessments (€10 for 6-week and €20 for 6-month follow
up); caregivers did not receive any financial compensation.
Treatment was administered by seven study therapists (six
female), who were master level or doctoral level psycholo-
gists and had on average 6.86 years (SD = 2.55; range: 5–11)
of clinical experience. All therapists attended a one-day per-
sonal training course in CPT+A run by one of the developers
pists were supervised bi-weekly by the last author, RR, and
had two case consultations with Patricia A. Resick over the
course of the trial.
Treatment adherence was assessed by two independent
raters, using an adherence rating scale specifically developed
for this study. The 10 items of this scale take the CPT+A
treatment protocol into account, and were drawn from either
the Therapeutic Adherence Scale (Gutermann et al. 2015)
or the CPT Therapist Adherence and Competence Proto-
col—Revised (Resick 2012), with slight modifications. The
last item assesses overall session adherence and is rated on
a 7-point Likert scale ranging from 0 (not at all adherent), 2
(major deviances), 4 (minor deviances) to 6 (very adherent).
We used this item as our adherence measure. A sample of 36
randomly chosen treatment tapes was evaluated, and 12 of
these sessions were doubly rated for the reliability analysis
and to avoid rater drift. The interrater-reliability for over-
all session adherence (ICC = .97) was excellent. The mean
therapeutic adherence rating was 3.77 (SD = 1.33), reflecting
acceptable treatment integrity based on the anchors of the
scale. The deviations from the intended interventions in the
specific sessions mainly involved postponing or repeating
CPT contents. For example, in order to address avoidance
behavior or motivational problems, the therapist spent more
time on repeating education on the rationale for treatment or
for practice assignments, when the participant did not com-
plete them. Furthermore, some therapists shifted contents
between specific sessions because of individual participants’

13

characteristics (e.g., experiencing extreme stuck points
regarding guilt, need for several written accounts because
of suffering from intrusions of multiple traumatic events).
There was only one case in which an intervention not
included in the treatment protocol was administered in one
session. In this specific case, the therapist taught relaxation
techniques in session 14, after all stuck points had been suc-
cessfully challenged. Given these results, we can assume that
the treatment protocol was delivered as intended.
Outcomes and Measures
With regard to all measures, DSM-IV criteria were used,
because no validated German versions for DSM-5 were
available for the targeted outcomes in 2014.
Primary Outcome
The primary outcome was the PTSS total severity score
as assessed by the CAPS-CA (Nader et al. 1996; German
version Steil and Füchsel 2006). The severity score is cal-
culated by summing all frequency and intensity scores of
the 17 symptom questions according to DSM-IV. Possible
scores range from 0–136. The total severity score of the Ger-
man version of the CAPS-CA has an interrater reliability of
κ = 0.68 and an internal consistency of α = 0.91 (Steil and
Füchsel 2006). In this study, the internal consistencies of
the total severity score (34 items; α = .95) and the reexperi-
ence subscale (10 items; α = .92) were excellent; internal
consistencies of the avoidance (14 items; α = .90) and the
hyperarousal subscales (10 items; α = .87) were good.
Secondary Outcomes
The CAPS-CA was also used to assess PTSD diagnostic
status as defined by DSM-IV as well as reliable change in
PTSS. According to Steil and Füchsel (2006), a symptom
was considered present if both the frequency and the inten-
sity scores were at least 1.
The presence of comorbid mental disorders according to
DSM-IV criteria was determined using the Structured Clini-
cal Interview for DSM-IV Axis I (First et al. 1997; German
version Wittchen et al. 1997), together with the borderline
section of the Structured Clinical Interview for DSM-IV
Axis II (SCID-II; First et al. 1994; German version Fydrich
et al. 1997). A range of studies has documented the reliabil-
ity of the SCID (e.g., Lobbestael et al. 2011; Zanarini et al.
2000). The presence of typical childhood mental disorders
which are not covered by the SCID-I, was determined using
specific modules of the Diagnostic Interview for Mental
Disorders in Children and Adolescents (Kinder-DIPS; Sch-
neider et al. 2009). We administered the modules for the
following disorders: attention-deficit/hyperactivity disorder,
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Clinical Child and Family Psychology Review
oppositional defiant disorder, conduct disorder, separation
anxiety disorder, tic disorder, mutism, enuresis, and enco-
presis. These modules have demonstrated high interrater
reliabilities between κ = 0.80 and κ = 1.00 (Neuschwander
et al. 2013). The current or lifetime comorbid diagnosis of
nicotine abuse was assessed using the corresponding mod-
ule of the Expert System for Diagnosing Mental Disorders
(DIA-X; Wittchen and Pfister 1997).
Self-reported PTSS were assessed using the adolescent
version of the University of California Los Angeles PTSD
Reaction Index (UCLA; Steinberg et al. 2004; German ver-
sion Arbeitsgruppe Psychotraumatologie KJP Ulm 2010).
This self-report measure explores the frequency of each of
17 PTSS according to DSM-IV. Total scores range from
0–68. The validation of the UCLA showed good psycho-
metric properties and has proven internal consistency of the
total scale with α = .90 (Steinberg et al. 2013). In the current
study Cronbach’s α was .94.
We used the Borderline Symptom List 23 (BSL-23;
Bohus et al. 2009) to measure the severity of emotion regu-
lation deficits. Scores of this self-report measure range from
0 to 92. Psychometric properties can be classified as good.
In the current study, the internal consistency (23 items;
α = .94) was excellent. Self-reported depressive symptoms
were assessed using the Beck Depression Inventory (BDI-
II; Beck et al. 1996; German: Hautzinger et al. 2006) with
scores ranging from 0 to 63. Cronbach’s alpha (21 items)
was .96 in the present study. The Adolescent Dissociative
Experiences Scale (A-DES; Armstrong et al. 1997; German:
Brunner et al. 2008) was used to measure the frequency of
dissociative symptoms. Scores range from 0 to 300, with sat-
isfactory psychometric properties (Farrington et al. 2001). In
the current trial, the internal consistency of the questionnaire
was good (30 items; α = .89). To evaluate behavior problems,
we asked participants to complete the Youth Self-Report
(YSR; Achenbach 1991; German version: Arbeitsgruppe
Deutsche Child Behavior Checklist 1993) consisting of 101
items. It resulted in a total problem score (range 0–202) and
scores regarding two broadband dimensions (internalizing
and externalizing behavior problems). Psychometric prop-
erties of the German version of the YSR can be classified
as good (Döpfner et al. 1994). In the current study, Cron-
bach’s alpha for the total symptom scale (101 items; α = .97)
and the internalizing symptom scale (32 items; α = .95) was
excellent, for the externalizing symptom scale Cronbach’s
alpha was good (30 items; α = .85).
Statistical Analysis
Single missing values in questionnaires (6-week follow-up
0.5%; 6-month follow-up 1.6%) were estimated using mean
substitution. All primary and secondary outcome analyses
were performed as intent-to-treat (ITT) analyses. We used
Clinical Child and Family Psychology Review
the last observation carried forward (LOCF) procedure to
replace missing values due to participants dropping out of
the study. To examine the effects of CPT+A on primary
and secondary outcomes, we conducted a repeated-measures
multivariate analysis of variance (MANOVA) with meas-
urement time points (t0, t1, t2, t3) as a within-subject fac-
tor. To assess the effects on each of the outcome measures,
repeated-measures analyses of variance (ANOVAs) were
performed with four measurement time points post hoc.
The Greenhouse–Geisser adjustment was used to correct
for violations of sphericity. The significance level for all
analyses was set to α = .05 (2-tailed). To avoid inflation of
type I error, a Bonferroni adjustment was applied for all post
hoc analyses. Cohen’s d effect size was calculated for within-
group pre-post comparisons. Cochran’s Q test, which is a
generalization of the McNemar test for more than two meas-
urement time points, was applied to investigate the change in
diagnostic status with respect to PTSD and comorbid mental
disorders (Cochran 1950).
Statistics were calculated using IBM SPSS Statistics 25
for Windows. The criterion for a clinically reliable change in
the CAPS-CA total score according to Jacobson and Truax
(1991) was calculated based on Cronbach’s α of the CAPS-
CA total severity score in the current study, as proposed by
Martinovich et al. (1996). Thus, clinically reliable improve-
ment was defined as a reduction of more than 10.32 points
in the CAPS-CA total score.
Results
Participant Flow
We screened 47 AYAs for eligibility; 30 of them did not
meet the study criteria. Figure 1 shows the participant flow
through the study. Five eligible candidates for treatment
declined, mostly because their current living circumstances
did not allow for regular participation in weekly sessions
(e.g., start of vocational training or university). Three par-
ticipants (18%) left treatment prematurely after session 1,
session 7 and session 13, respectively. In two of these cases,
treatment was terminated because of a lack of treatment
motivation. In one case, the legal guardians revoked their
consent to study participation after the first treatment ses-
sion. We were able to obtain further data from the two par-
ticipants who dropped out because of motivational issues at
the 6-month follow-up. Another participant did not complete
6-week follow-up self-report ratings.
Mean duration of treatment was 26.24 weeks (SD = 8.01),
with an average of M = 15.88 (SD = 4.44) sessions provided.
In seven cases (41%), participants decided to attend conjoint
sessions with their caregivers, with an average of M = 2.29
sessions (SD = 0.49). These participants were significantly
younger than participants who did not undergo conjoint
sessions, t(15) = 2.88, p = .01, and were less likely to have an
immigration background, p = 0.04, two-sided Fisher’s exact
test. Six participants had conjoint sessions with their moth-
ers, one participant had additional sessions with another
relative.
Neither suicidal crises nor other serious adverse events
occurred during the intervention or up to the 6-month
follow-up.
Treatment Outcome
The repeated-measures MANOVA of the primary (CAPS-
CA) and secondary outcome measures (UCLA, BSL-23,
BDI-II, A-DES, YSR) calculated based on the ITT sample
(N = 17), demonstrated a significant effect of time, F(30,
171) = 1.95, p = .004.
Primary Outcome Measure Repeated-measures ANOVA
revealed a significant large effect for the total severity
score of interview-rated PTSS from pre- to posttreatment
with d = 1.32. Improvements remained stable at the 6-week
follow-up, d = 1.39, and the 6-month follow-up, d = 1.59.
This was also true for each DSM-IV symptom cluster, see
Table 4 for results of respective ANOVAs and effect sizes.
Secondary Outcome Measures  At posttreatment and also at
both follow-ups, 9 of the 13 participants, who had fulfilled
the PTSD DSM-IV criteria at baseline, no longer met the
DSM-IV criteria. The four participants with subthreshold
PTSD at baseline did not meet DSM-IV criteria in any later
assessment. Three of the four cases who still met DSM-
IV criteria after treatment, were the participants who had
dropped out. Change in PTSD diagnostic status over time
was significant, Cochran’s Q(3) = 27.00, p < .001. At post-
treatment and the 6-week follow-up, 13 participants (77%)
met the criteria for reliable change according to the CAPS-
CA score, whereas 14 participants (82%) met the criteria
for reliable change at the 6-month follow-up. No clinically
relevant worsening of symptoms was observed.
There was also a significant change in diagnostic sta-
tus with respect to comorbid mental disorders over time,
Cochran’s Q(3) = 14.76, p = .001. Whereas 12 participants
(71%) met the criteria for any comorbid mental disorder
based on SCID, Kinder-DIPS, and DIA-X data at pre-treat-
ment, only six participants (35%) met such criteria at post-
treatment and the 6-week follow-up, and five participants
(29%) at the 6-month follow-up.
Results regarding self-reported PTSS (UCLA) revealed
a significant large effect from pre- to posttreatment with
d = 2.25, see Table  4. Effect sizes remained large at the
6-week follow-up, d = 2.09, and the 6-month follow-up,
d = 2.71.
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 Clinical Child and Family Psychology Review

Fig. 1  Flow diagram of study

47 Screened for participation
participants. ITT intent-to-treat,
LOCF last observation carried
forward, PTSD posttraumatic 11 Excluded
stress disorder
3 Refused to participate

3 Not fluent in German

1 Pervasive developmental disorder

2 No trauma according to DSM-IV

2 Negative PTSD screening

36 Enrolled for baseline assessment

(t0)
19 Excluded

10 Criteria for full or subthreshold

PTSD not fulfilled

5 No longer interested in treatment

(mostly because of time constraints)

1 Current substance dependency

1 Pervasive developmental disorder

17 Allocated to intervention 1 Psychotic disorder

(ITT sample using LOCF) 1 Involvement in alternative treatment

3 Dropout

14 Posttreatment assessment (t1)

14 6-week follow-up assessment (t2)

15 6-month follow-up assessment (t3)

In addition, participants improved significantly from pre- Discussion

to posttreatment and up to the 6-week and 6-month follow-
ups in all other dimensional secondary outcomes except for
the YSR externalizing subscale. Effect sizes for improve-
ments of depressive and borderline symptoms were large,
ranging from 0.85 to 0.98. There were medium effect sizes
with respect to improvements of general behavior problems
as well as internalizing problems (range from 0.53 to 0.76).
Small effects could be obtained with respect to the reduction
of dissociation as assessed by the A-DES.
This study investigated the feasibility of a short-term treat-
ment, CPT+A with only minor age-related modifications,
for AYAs suffering from PTSS after miscellaneous traumas.
While CPT previously had been evaluated only in specific
subgroups of adolescents (incarcerated male adolescents
in Ahrens and Rexford 2002; AYAs suffering from abuse-
related PTSD in Rosner et al. 2019) and with considerable
adaptations of the CPT+A protocol (delivered in a shortened

13
Clinical Child and Family Psychology Review

Table 4  Primary and secondary outcomes of study participants in the feasibility trial of CPT adapted for adolescents and young adults based on
intent-to-treat analyses with LOCF, N = 17
Outcome t0 t1 t2 t3 Time effect t0–t1 t0–t2 t0–t3
M (SD) M (SD) M (SD) M (SD) F df p d d d

Primary
 CAPS-CA total 51.12 (16.65) 21.65 (26.75) 20.76 (26.08) 17.00 (25.47) 31.23 1.47 < .001 1.32 1.39 1.59
  Reexperiencing 17.83 (7.25) 7.29 (10.00) 6.06 (10.09) 4.88 (9.45) 34.73 1.39 < .001 1.21 1.34 1.54
  Avoidance 18.47 (8.55) 6.94 (10.05) 7.00 (11.08) 6.71 (10.04) 20.57 1.76 < .001 1.24 1.16 1.26
  Hyperarousal 14.82 (6.23) 7.41 (8.63) 7.71 (9.14) 5.41 (7.72) 13.20 1.61 .003 0.99 0.91 1.34
Secondary
 UCLA 37.29 (9.69) 14.18 (10.82) 14.94 (11.59) 10.76 (9.90) 67.66 1.71 < .001 2.25 2.09 2.71
 BSL-23 26.82 (15.43) 13.88 (14.98) 13.00 (14.86) 11.88 (15.08) 13.00 1.49 .005 0.85 0.91 0.98
 BDI-II 22.12 (11.70) 11.94 (11.91) 11.12 (11.49) 10.76 (11.93) 12.42 1.59 .004 0.86 0.95 0.96
 A-DES 39.65 (29.80) 30.00 (33.49) 27.59 (32.90) 24.53 (34.17) 6.98 3 .006 0.30 0.38 0.47
 YSR total 56.65 (27.34) 41.82 (28.90) 41.12 (29.10) 35.77 (27.44) 13.63 1.72 .002 0.53 0.55 0.76
  Externalizing 12.24 (7.58) 9.47 (6.58) 9.82 (6.66) 8.26 (6.81) 5.21 2.14 .10 0.39 0.34 0.55
  Internalizing 22.82 (12.57) 15.76 (12.95) 15.65 (13.48) 13.83 (12.25) 11.27 1.73 .005 0.55 0.55 0.72

Greenhouse–Geisser corrected df values and Bonferroni-corrected p values are reported above

A-DES adolescent dissociative experiences scale, BDI-II beck depression inventory, BSL-23 borderline symptom list 23, CAPS-CA clinician-
administered PTSD scale for children and adolescents, CPT cognitive processing therapy, LOCF last observation carried forward, UCLA Uni-
versity of California at Los Angeles, PTSD reaction index, t0 baseline, t1 posttreatment, t2 6-week follow-up, t3 6-month follow-up, YSR youth
self-report

version in Ahrens and Rexford 2002; addition of further
treatments modules in Rosner et al. 2019), we were inter-
ested in the feasibility of CPT+A in AYAs with only minor
modifications to the treatment protocol.
We found significant pre- to posttreatment reductions in
PTSS as assessed by the CAPS-CA and the UCLA indices
with large effect sizes. According to the CAPS-CA score,
77% of participants showed clinically meaningful improve-
ment, and 69% of the participants who fulfilled criteria for
PTSD according to DSM-IV at baseline, achieved remission
from PTSD. Improvements remained stable at the 6-week
and 6-month follow-ups.
Regarding secondary outcome measures, significant
improvements from pre- to posttreatment were observed
with respect to depressive symptoms, borderline symptoms,
dissociative symptoms, and internalizing behavior problems
as assessed in self-report, with large pre-post effect sizes for
depressive and borderline symptoms and small to medium
effect sizes for dissociative symptoms and behavior prob-
lems (YSR total). Lower effect sizes might be explained by
dissociative symptoms and behavior problems within the
normal range at baseline.
The results regarding PTSS are comparable to the effect
sizes reported for CPT in adults (Asmundson et al. 2018;
Lenz et  al. 2014) and to pre-post effect sizes regarding
PTSS reported in meta-analyses of controlled and uncon-
trolled trials in children and adolescents (Gutermann et al.
2016; Morina et al. 2016; Newman et al. 2014). Compared
to medium pre-post effect sizes for depressive symptoms
reported in the literature (Gutermann et al. 2016), our results
for depressive symptoms with large pre-post effects seem to
be promising.
We also observed a large pre-post effect size for borderline
symptoms, which is comparable to the respective effect size
of the RCT of D-CPT (Rosner et al. 2019). This is surpris-
ing as borderline symptom severity at baseline in our study
was within the normal range and lower than in the sample
in Rosner et al. (2019). In D-CPT, an additional module pre-
ceding CPT+A and consisting of 6 sessions, is dedicated
to emotion regulation training. Although the results are not
fully comparable, as samples differ, for instance with regard
to trauma histories, and keeping its methodological short-
comings (uncontrolled design, small sample size) in mind,
the large effect sizes for borderline symptom severity in the
current trial are encouraging. To further discuss the need
for a stabilization phase or emotion regulation training prior
to trauma-focused treatment in AYAs, a dismantling study
examining the efficacy of an emotion regulation training
module prior to CPT would be of major interest.
Three participants dropped out of treatment (18%). In one
case, the legal guardians revoked their consent to study par-
ticipation after the first treatment session without giving any
further information. In two other cases, dropouts occurred after
sessions 7 and 13 because of motivational issues. Both dropouts
may be explained by the participants’ high pretreatment CAPS-
CA total scores (highest and third-highest baseline scores of
the sample). One of the dropouts also had the highest CAPS-
CA avoidance score. Research on PTSD treatment suggests a

13

positive association between dropout and PTSS severity (Gal-
ovski et al. 2012; Najavits 2015) as well as PTSD avoidance
(Zayfert et al. 2005). The dropout rate observed in our sample
is in line with the average dropout rate of about 20% in general
adult PTSD treatment samples (Imel et al. 2013) and lower
than dropout rates generally observed in child and adolescent
outpatient mental healthcare (de Haan et al. 2013). We did not
observe any exacerbation in PTSS from pretreatment to any
later assessment point, nor did any adverse event occur during
the trial. These results indicate that the intervention was well
received by the participants and was safe.
Limitations and Strengths
The generalizability of our study results is limited by the
small sample size and the predominantly female (94%) sam-
ple. A more general limitation is the lack of a control group,
which reduces the strength of the conclusions that can be
drawn from the findings. Hence, an RCT with a solid sample
size is necessary to test the efficacy of CPT+A for AYAs.
Furthermore, the psychometric properties of several out-
come measurements (e.g., CAPS-CA, BDI-II, and BSL-23)
have not been verified for the entire age range investigated
in our study. These limitations in the quality of assessment
instruments may influence internal validity of our results.
Finally, a follow-up more than 6 months after treatment
would have been advisable.
Despite these limitations, our study furnishes preliminary
evidence of the feasibility, efficacy, and safety of CPT+A
in AYAs aged 14 to 21 with PTSS after different types of
trauma. Unlike most studies in the field, we extended the par-
ticipants’ age range to 21. As the inclusion of young adults
up to 21 years is in accordance with the German healthcare
system, where youth up to 21 years may be treated by child
and adolescent therapists, extending the age range to 21, in
our opinion, strengthens external validity.
Implications and Conclusions
Future studies are needed to address the question of the effi-
cacy of CPT specifically in AYAs compared to adequate
control conditions. Furthermore, the need for specific treat-
ment components, such as written trauma accounts, or emo-
tion regulation modules, should be addressed in dismantling
studies targeting this age group.
General Discussion
In this article, we highlighted treatment for PTSD in AYAs.
As adolescents have to master unique developmental tasks
(Martel and Fuchs 2017) and suffer from specific symptoms,
especially regarding emotion regulation (Villalta et al. 2018),
13
Clinical Child and Family Psychology Review
aspects such as treatment motivation, emotion regulation, spe-
cific developmental tasks, but also ethical and legal aspects, as
well as the degree of caregiver inclusion are to be considered
when planning treatment. However, as we pointed out, these
aspects should be considered with regard to young adults as
well, as they are still in a dynamic sensitive period of ongo-
ing biopsychosocial development within an extended transi-
tion period to adulthood in today’s society (Mandarino 2014;
Skehan and Davis 2017) and PTSD may account for delays in
psychosocial development.
The generalizability of results from PTSD treatment
research to young adults remains unclear. We do not know if
young adults are underrepresented in research, because they
refrain from seeking professional help despite mental health
problems (Biddle et al. 2004; Zachrisson et al. 2006), or
because the number of young adults included and the specific
results concerning them just have not been reported in suf-
ficient detail in clinical trials so far. Furthermore, the incon-
clusive results about age as a moderator of treatment effects in
meta-analyses targeting youth have so far impeded conclusions
regarding the age-specific efficacy of trauma-focused treatment
in AYAs. Future research should focus on AYAs in particular
to avoid their specific characteristics and needs getting “lost”
between research targeting minors or adults, respectively.
We reviewed treatment approaches that have been examined
in AYAs in the last 10 years. In fact, there are some effective
treatments for PTSD that have been studied in adolescents,
and, to a lesser degree, specifically in young adults. Most of
the examined approaches were not originally tailored to ado-
lescents or AYAs, but were adaptations of treatment manuals
originally developed for older (adult) or younger (child and/or
adolescent) populations. In terms of the evidence base, there are
no empirical comparisons of developmentally adapted manuals
with not adapted manuals. Consequently, the specific benefit of
developmental adaptations for this age group is unclear.
To illustrate a possible next step to this field of research, we
presented the results of our feasibility trial on CPT with AYAs.
When preparing and conducting the trial, we encountered sev-
eral problems that might explain why research with this age
group is still scarce: there was not only a lack of measures
validated for the entire targeted age group, but recruitment was
also comparatively slow. This is consistent with reports from
other studies with adolescents and/or young adults (Foa et al.
2013; Rosner et al. 2019).
Conclusions
Conclusions for Future Research
Ideally, future research on age-specific trauma-focused
treatments for AYAs would focus on three key research
issues:
Clinical Child and Family Psychology Review
First, we encourage the inclusion of young adults in
studies with adolescents. To address the specific needs of
transitional aged youth it no longer seems appropriate to
draw a line at age 18, especially as young people of the
same chronological age may vary greatly in maturity. In
some countries, for instance in Germany, the healthcare
systems already account for this by allowing young adults
up to age 21 to be treated within the children and ado-
lescent healthcare system. Especially, in the implementa-
tion and dissemination trials conducted in these countries,
extending the participants’ age range up to 21 might make
sense to strengthen external validity.
Second, regarding the few and inconclusive results from
our review on age-specific findings of PTSD treatment
research, we encourage more refined age reporting in clini-
cal trials. Reporting of the proportions of age groups like
early, middle, late adolescence and young adulthood will
shed light on the possible generalizability of results and
the need for age-appropriate treatment procedures. More
data on age-specific dropout and treatment response rates
might also stimulate research regarding stepped care or
variable-length treatment models in AYAs suffering from
PTSD, which have been successfully examined in stud-
ies with young children (Salloum et al. 2016) and adults
(Galovski et al. 2012).
Third, dismantling trials tailored to youth, and specifi-
cally AYAs, should be encouraged. Knowledge about the
necessary components of PTSD treatment in AYAs is cru-
cial for the adequate implementation and dissemination of
effective as well as economic treatments.
Clinical Recommendations
In the following, we give some clinical recommendations
for therapeutic work with AYAs. Given the small evidence
base for the actual need for age-specific adaptations, these
considerations should be understood as recommendations
stemming from clinical practice. However, based on our
clinical experience, consideration of the following aspects
is crucial when working with AYAs suffering from PTSS.
Attention to motivation for treatment is vital when
working with AYAs. The interaction between strivings
for autonomy on the one hand, and PTSD-typical avoid-
ance on the other, can lead to ambivalence toward the
therapeutic process. A developmentally appropriate way
of addressing this ambivalence may be the most effec-
tive way of facilitating the engagement of AYAs in treat-
ment. For example, in a session with a teenage girl on
the verge of dropping out, we strengthened her autonomy
by explicitly discussing with her the short- and long-term
advantages and disadvantages of discontinuing treatment.
With a young woman, who recurrently did not complete
homework assignments, frequent repeating of psychoedu-
cation and challenging maladaptive thoughts on therapy
(e.g., “Only weak persons need to see a therapist.”) early
in treatment was crucial to build up motivation.
The caregiver may still play a supportive role in treat-
ment, but given the striving for autonomy and privacy dur-
ing the adolescent period, the number of caregiver sessions
should be reduced compared to treatment with children. In
our experience, the degree of caregiver involvement when
treating AYAs varies greatly depending on actual maturity
but also living circumstances. In the above-reported pilot
study, conjoint caregiver sessions took place in 7 cases. In
the remaining 10 cases both the therapist and the participant
did not deem them to be necessary after having discussed
the issue (n = 5) or, in fact, the participants actively decided
not to involve their parents or caregivers in treatment (n = 5).
Several developmental tasks have to be mastered in
adolescence, for instance career choice, vocational train-
ing, individuation and romantic relationships (Martel and
Fuchs 2017). Mastering these tasks might be challenging
for adolescents with mental health issues (Mandarino 2014;
Skehan and Davis 2017). Therefore, establishing social or
institutional support in mastering these tasks early on in the
treatment process might be of importance and might further
facilitate the transition to “adult” mental health systems if
necessary. We assume that the aforementioned develop-
mental tasks remain important for young adults as well.
Therefore, we encourage the design and implementation
of developmentally appropriate services offered within the
adult mental health system, e.g., vocational counseling tar-
geting specifically young adults or sexual education. In fact,
some young people greatly benefit from education in and the
fostering of daily living or leisure-time skills, for example
as add-on group training alongside inpatient or outpatient
psychotherapy. We sometimes find ourselves providing edu-
cation on seemingly simple things that the youth apparently
did not learn at home. This is especially true of AYAs who
suffered from childhood neglect.
As many AYAs will probably go to college or univer-
sity, these institutions have the potential to be a key setting
for the prevention and treatment of mental health disorders
in this age period. Pedrelli et al. (2015) outlined the impor-
tance of enhancing motivation, of considering the degree
of parental involvement, of including case management
services, and of ensuring continuous care during school
breaks when treating college students. However, when
implementing services, it will be important to choose
evidence-based treatment approaches.
There are indications that AYAs suffer from spe-
cific symptoms regarding emotion regulation (Villalta
et al. 2018). Still, the specific benefit of extra modules
with regard to emotion regulation/skills training before
trauma-focused treatment components is unclear. For
13

adult treatment, de Jongh et al. (2016) discuss the hypoth-
esis that long stabilization phases may result in a delay
of access to effective trauma-focused treatments. Fur-
thermore, delaying the trauma-focused treatment compo-
nent might considerably reduce treatment motivation, as
patients might get the impression that they are not ready to
discuss their traumatic memories. From our point of view,
this might be especially true for AYAs, whose treatment
motivation needs to be encouraged in particular.
The work of mental health professionals often involves
complex choices between confidentiality policies and
disclosure decision-making, which might be even more
challenging in the case of minors. Therefore, open and
developmentally tailored discussion and description of pri-
vacy, confidentiality, and disclosure policies and practices
with the adolescent, the caregivers, and legal guardians are
inevitable at the beginning of treatment—and sometimes
they need to be repeated later on (Fried and Fisher 2018).
When the need for disclosure arises, Fried and Fisher
(2018) recommend strategies that attribute an active role
to the adolescent in the disclosure process, by preparing
the adolescent in advance, and by scheduling joint sessions
with the caregiver/legal guardians or other relevant par-
ties. Furthermore, monitoring of the consequences of the
disclosure at follow-up meetings is encouraged.
To summarize the above, we do think that addressing
confidentiality issues, treatment motivation and develop-
mental tasks, discussing emotion regulation problems (to
an appropriate extent), and the degree of caregiver involve-
ment are important aspects when starting treatment with
an adolescent or young adult who suffers from PTSS. We
hope that our suggestions may serve as a first guide for
researchers involved in the development and empirical
evaluation of age-specific treatment approaches and for
clinicians working with AYAs suffering from PTSD.
Acknowledgements  We thank all the patients who participated in this
trial, and all therapists and raters who administered the interventions
and assessments. We also thank proFOR+ , a funding program run by
the Catholic University of Eichstätt-Ingolstadt, for funding parts of this
research. Finally, we thank Dr. Maria Hagl for her helpful suggestions
and comments on earlier drafts of the manuscript.
Funding  Parts of the study were funded by proFOR+ , a funding pro-
gram run by the Catholic University of Eichstätt-Ingolstadt.
Compliance with Ethical Standards  55(5), 469–480. https​://doi.org/10.1037//0003-066X.55.5.469.
Conflict of interest  RR was paid fees for workshops and presentations
on PTSD treatment and has co-authored a book on Cognitive Process-
ing Therapy. AV has no conflict of interest.
Ethical Approval  All procedures were in accordance with the ethical
standards of the institutional review board of the Catholic University
of Eichstätt-Ingolstadt, Germany (approval given on 04.06.2013), and
13
Clinical Child and Family Psychology Review
with the 1964 Helsinki Declaration and its later amendments or com-
parable ethical standards.
Informed Consent  Informed consent was obtained from every partici-
pant included in the study and from the participant’s parents or guard-
ian in the case of minors.
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