Effectiveness RCT of a CBT Intervention
for Youths Who Lost Parents in the
Sichuan, China, Earthquake
Ying Chen, M.D.
Wen Wu Shen, M.S.
Kamko Gao, M.A.
Chow S. Lam, Ph.D.
Weining C. Chang, Ph.D.
Hong Deng, M.D.
Objective: Many children who lost
parents in the 2008 earthquake in
Sichuan Province, China, experi-
enced symptoms of posttraumatic
stress disorder (PTSD) and depres-
sion. This randomized controlled
study compared the treatment ef-
fectiveness of short-term cognitive-
behavioral therapy (CBT) with a
general supportive intervention and
with a control group of nontreat-
ment. Methods: Thirty-two Chinese
adolescents were randomly assigned
to three treatment groups. Partic-
ipants were compared for psycho-
logical resilience (Connor-Davidson
Resilience Scale), symptoms of
PTSD (Children’s Revised Impact
of Events Scale), and depression
(Center for Epidemiologic Studies
Depression Scale) at baseline, af-
ter treatment, and three-month
follow-up. Results: CBT was effec-
tive in reducing PTSD and de-
pressive symptoms and improved
Dr. Chen, Mr. Shen, and Dr. Deng are with
the Mental Health Center, West China
Hospital, Sichuan University, Chengdu,
Sichuan, China. Mr. Shen is co-first author
and Dr. Deng is corresponding author
(e-mail:rhdeng88@hotmail.com). Ms. Gao
is with the Youth Development Foundation,
Hong Kong, China. Dr. Lam is with the
Department of Psychology, Illinois Institute
of Technology, Chicago. Dr. Chang is with
the Institute of Mental Health, Duke
University–National University of Singapore
Graduate School of Medicine, Singapore.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' February 2014 Vol. 65 No. 2
psychological resilience. General
support was more effective than
no intervention in improving psy-
chological resilience. Conclusions:
Short-term CBT group intervention
seems to be a robust intervention
for natural disaster victims. Short-
term CBT group intervention was
more effective than the general
supportive intervention and the no-
treatment group in enhancing psy-
chological resilience and reducing
PTSD and depression among ado-
lescents who had lost parents in the
earthquake. The general support-
ive intervention was effective only
in improving psychological re-
silience. (Psychiatric Services 65:
259–262, 2014; doi: 10.1176/appi.
ps.201200470)
A dolescents often experience post-
traumatic stress after natural dis-
asters (1,2) and posttraumatic stress
disorder (PTSD) is highly associated
with depression and suicide (3). The
literature has shown that, with proper
guidance, traumatic experiences can
strengthen psychological resilience, and
this in turn leads to effective coping (4).
Without early intervention, as much
as one-third of PTSD victims can de-
velop chronic psychological disorders
that may last a lifetime (5).
A 2011 meta-analysis of cognitive-
behavioral therapy (CBT) noted its
efficacy for the treatment of pediatric
PTSD (6). Smith and colleagues (7)
developed the manual Children and
Disaster: Teaching Recovery Techni-
ques, which integrates principles from
CBT, eye movement desensitization
and reprocessing (EMDR), and anx-
iety control training for treating chil-
dren after natural disasters. This
multifaceted approach successfully
helped child earthquake victims in
Turkey and Greece in 1999 (8) and in
Bam, Iran, in 2004 (9).
During and shortly after the May
2008 earthquake in Sichuan, China,
many adolescents were exposed to
horrific sights and sounds as their
school buildings collapsed with stu-
dents inside. A great number of the
survivors’ friends and classmates were
injured or died. Many volunteers from
China and the world came to provide
support and psychological interven-
tions to students. Most of the psycho-
logical interventions were based on
Western approaches, which have raised
questions as to their cultural appropri-
ateness and effectiveness. There has
not been a systematic evaluation of the
various intervention techniques that
were implemented, and reception of
these interventions varied. Furthermore,
in China there has never been a system-
atic documentation of the efficacy of
group psychological interventions for
adolescents exposed to natural disasters.
We developed a randomized con-
trolled trial (RCT) to compare the
effectiveness of a short-term CBT group
intervention (7) and a general support-
ive intervention for treatment of PTSD
259
and depression for adolescents who lost
at least one parent during the earth-
quake and who may be particularly
vulnerable to developing PTSD.
Methods
The study was conducted two years af-
ter the earthquake (2010–2011). Forty
adolescents from two secondary schools
were initially recruited to participate
in this study. Their mean6SD age was
14.506.71, with 13 boys (32%) and 27
girls (68%). Each adolescent had lost
at least one parent in the earthquake.
All of them scored $18 points on the
13-item Children’s Revised Impact of
Events Scale (CRIES-13) and thus
were considered to have PTSD symp-
toms. The parents or guardians and
schools provided written informed
consent on behalf of the youths. Ap-
proval of the study was obtained from
the institutional review board of West
China Hospital and Sichuan University.
The 40 adolescents were randomly
divided into three groups: the short-
term CBT group (N516), the general
support group (N512), and the non-
treatment control group (N512). Only
32 adolescents completed the entire
study. Six students were dropped from
the CBT group, and two students were
dropped from the general support
group.
Chinese versions of three psycho-
logical instruments were used to eval-
uate the outcomes of the interventions:
the CRIES-13 was used to assess
PTSD symptoms (10), the Center
for Epidemiologic Studies Depression
Scale (CES-D) (11) was used to assess
depressive symptoms, and the Connor-
Davidson Resilience Scale (CD-RISC)
(4) was used to measure psychological
resilience.
The CRIES-13 was designed for
children older than eight years who
have experienced traumatic events and
who can read independently. The
CRIES-13 assesses 13 trauma symp-
toms in three areas: flashback, avoid-
ance or numbness, and high vigilance.
Higher scores represent more severe
trauma.
In a pilot study with 252 students,
the Chinese version of CRIES-13
showed good internal consistency
(Cronbach’s a5.90). Using 18 points
as the cutoff for PTSD, the Youden
index was 58%, sensitivity was 81%,
260
specificity was 77%, and diagnosticity
was 81%.
The CES-D scale rates 20 symp-
toms of depression, with emphasis on
the affective component and depressed
mood. Each symptom is rated on a
Likert scale ranging from 0, never, to
3, often. Cronbach’s a5.94 was ob-
tained in this study.
The CD-RISC includes 25 items
spread across five factors: personal com-
petence, affect tolerance, acceptance of
change, sense of internal control, and
spirituality. Each symptom is rated on
a 5-point Likert scale (from 0, never, to
4, always). The range of possible scores
is 0–100, with the higher scores in-
dicating more resilience. Cronbach’s
a5.90 was obtained in this study.
Psychological assessments of the
adolescents in the three intervention
groups were conducted by trained
mental health professionals before
treatment, at the end of the last ses-
sion, and three months after treatment.
The short-term CBT program was
completed by ten youths. The CBT
group intervention offers participants
the opportunity to share their experi-
ences, develop a narrative, and learn
skills to cope with PTSD and de-
pression. We designed the CBT pro-
gram as a six-week intervention with
a one-hour session each week.
We adapted the program from the
manual Children and Disaster: Teach-
ing Recovery Techniques (7), basing our
revisions on Chinese cultural relevance
and on our experiences working with
earthquake victims. Specifically, two of
the sessions were modified from the
original technique. We omitted avoid-
ance for several reasons. Our previous
clinical experiences have shown that
PTSD symptoms are exacerbated when
avoidance is addressed, and to do so
usually takes longer than allowed for
with a six-week intervention. Also
Chinese cultures generally believe
that acceptance and avoidance are
the most adaptive approaches, and
school staffs are not trained to deal
with avoidance and are discouraged
from addressing this issue. The other
modification was to integrate cogni-
tive reframing throughout the CBT
program. Each session began with
a review and included a homework
assignment to practice the techni-
ques learned.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' February 2014 Vol. 65 No. 2
Sessions addressed participants’ fears
by providing training in relaxation and
coping techniques. Session 1 included
an introduction to normalization con-
cepts and relaxation training. Session
2 focused on helping participants to
establish a safe place in their imagi-
nations and included a guided medi-
tation on imagining a safe place that
was secure and trouble-free. Session 3
further developed imagery skills. It
included imagery exercises designed
to improve the adolescents’ control
over the intrusion of painful images,
thereby building coping skills. Session
4 included a dream intervention exer-
cise to help the adolescents cope with
and control nightmares. Session 5 fo-
cused on dual-attention therapy, which
included an exercise, similar to some
EMDR techniques, in which the pa-
tient moves his or her eyes back and
forth while concentrating on a prob-
lem. Session 6 engaged participants in
a group discussion and activity to look
ahead to the future.
The general support intervention
consisted of general support provided
on an individual basis by three local
volunteers who had received basic
training in counseling techniques such
as listening, reflection, and empathy.
The volunteers visited the ten adoles-
cents’ homes weekly for six weeks to
provide support and assistance to them
in dealing with problems at home and
at school.
No intervention or services were pro-
vided to the 12 students in the control
group.
The changes from baseline in
CRIES-13, CD-RISC, and CES-D
scores posttreatment and at the three-
month follow-up were analyzed with
repeated-measures analysis of variance
(ANOVA), with time as a within-group
factor and intervention as the between-
groups factor. The slope of lines (scores
as ordinate and time as abscissa) was
determined by subtracting the baseline
from the posttest (or subtracting the
baseline from the follow-up) to find
the change. The changes in CRIES-13,
CD-RISC, and CES-D scores across
groups were compared by one-way
between-factors ANOVA followed by
Scheffé’s post hoc tests. Three repeated-
measures ANOVAs were conducted
on dependent measures. In all three
analyses, Mauchly’s sphericity test
Table 1
Outcomes for 32 adolescent earthquake survivors who received six weeks of cognitive-behavioral therapy (CBT),
general support, or no intervention

Preintervention Postintervention Standardized rate (%) 3-month follow-up Standardized rate (%)

Measure M SD M SD M SD M SD M SD

CRIES-13a
CBT 41.20 11.80 27.20 13.30 –14.00b 8.25 18.40 4.90 –22.80c 11.55
General support 33.60 4.50 30.80 11.20 –2.80 10.18 27.10 13.80 –6.50 12.62
Control 31.20 13.60 32.75 9.74 1.58 13.06 29.00 11.37 –2.17 8.92
CES-Dd
CBT 23.40 14.20 19.70 13.00 –3.70 7.42 5.30 5.68 –18.10c 11.74
General support 13.50 10.00 17.40 10.10 3.90 16.86 8.70 6.15 –4.80 9.41
Control 15.60 16.90 18.40 10.20 2.38 12.50 15.20 10.80 –.42 11.62
CD-RISCe
CBT 51.80 13.20 60.50 13.80 8.70 8.50 70.80 19.80 19.00f 11.91
General support 49.30 6.50 60.30 11.10 11.00 8.54 70.10 12.60 20.80g 13.27
Control 52.70 17.90 54.00 14.10 1.33 16.66 53.10 12.70 .42 16.30
a
Children’s Revised Impact of Events Scale, 13-item Chinese version. Possible scores range from 0 to 65, with higher scores indicating more severe
trauma.
b
CBT versus control, p,.01
c
CBT versus general support, p,.05, versus control, p,.01
d
Center for Epidemiologic Studies Depression Scale. Possible scores range from 0 to 60, with higher scores indicating greater severity. A score of $18
indicates depression.
e
Connor-Davidson Resilience Scale. Possible scores range from 0 to 100, with higher scores indicating more resilience.
f
CBT versus control, p,.05
g
General support versus control, p,.01

(to validate the repeated-measures
ANOVA) was not significant, and there-
fore sphericity was assumed for in-
terpretation of results.
Results
Thirty-two students completed the
study (CBT, N510, including two
boys and eight girls 14.706.68 years
old; general support, N510, including
three boys and seven girls 14.606.70
years old; control group, N512, in-
cluding four boys and eight girls,
14.176.39 years old). There were no
significant differences among the three
treatment groups in terms of demo-
graphic characteristics and baseline
CRIES-13, CES-D, and CD-RISC
scores.
The CRIES-13, CES-D, and CD-
RISC repeated-measures ANOVAs each
showed a significant within-subject
main effect of time and a time 3
group interaction (CRIES-13: time,
F514.36, df52 and 95, p,.001, and
time 3 group, F55.54, df54 and 95,
p,.01; CES-D: time, F510.86, df52
and 95, p,.001, and time 3 group,
F53.48, df54 and 95, p,.05; and
CD-RISC: time, F517.97, df52 and
95, p,.001, and time 3 group,
F54.55, df54 and 95, p,.01).
Six one-way between-factor ANOVAs,
followed by Scheffe’s post hoc tests,
were conducted, one each for the slopes
created by the respective CRIES-13,
CES-D, and CD-RISC scores at post-
treatment and the three-month follow-
up (Table 1).
ANOVAs for the CRIES-13 scores
between baseline and posttreatment
and between baseline and three-
month follow-up showed a significant
difference among the three groups
(F55.82, df52 and 31, p,.01), espe-
cially between the CBT and control
groups at the end of treatment (p,.01).
There was also a significant difference
among the three groups (F510.31,
df52 and 31, p,.001), especially be-
tween the CBT and control groups
(p,.01) and between the CBT and
general support groups (p,.05) at the
three-month follow-up.
ANOVAs for the CES-D scores
between baseline and posttreatment
and between baseline and three-month
follow-up showed a significant differ-
ence among three groups (F57.40,
df52 and 31, p,.01), especially
between the CBT group and control
group (p,.01) and between the CBT
group and general support group
(p,.05) at the three-month follow-up.
Between baseline and posttreat-
ment and between baseline and three-
month follow-up, ANOVAs for the
CD-RISC scores showed a significant
difference among three groups (F57.18,
df52 and 31, p,.01), especially be-
tween the CBT group and control
group (p,.05) and between the gen-
eral support group and control group
(p,.01) at the three-month follow-up.
Discussion and conclusions
The findings of this first RCT of the
use of CBT for disaster-traumatized
youths dealing with parental loss
showed that the effect of short-term
group-based CBT in alleviating PTSD
symptoms was robust. Furthermore,
the group-based CBT intervention
was more effective than either general
support or nontreatment. Neither the
general support intervention nor non-
treatment had any effect in alleviat-
ing PTSD symptoms. Similar results
were obtained by Giannopoulou and
colleagues for children with PTSD
symptoms after the 1999 earthquake
in Athens, Greece (8). They used an
intervention based on the Children
and Disaster manual (7). Shooshtary
and colleagues (9) used the same inter-
vention to ameliorate PTSD symptoms

PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' February 2014 Vol. 65 No. 2 261
among adolescents after a catastrophic
disaster.
Children who are caught in a natu-
ral disaster often suffer from long-
lasting psychological problems such as
PTSD if no clinical intervention is
provided. Persons exposed often ex-
perience extreme fear, elicited by
stimuli associated with the traumatic
event. Naturally, to reduce pain and
suffering, adolescents may want to
avoid the scene of the event and
thoughts, feelings, or discussion about
the earthquake. However, avoiding
trauma-related stimuli may offer only
temporary relief and often creates
a barrier against successful long-term
recovery. Thus early confrontation
and management of intrusive fearful
memories are very important. Con-
fronting and learning to handle effec-
tively these intrusive images can help
adolescent trauma victims cope with
difficulties and gain an early recovery.
The short-term CBT intervention
in this study dealt with the fears of
these adolescents through relaxation
techniques and learning to establish
an imaginary safe place or refuge;
participants also learned to cope with
flashback symptoms through imagery,
dream intervention, and dual-attention
techniques. The findings of this study
showed that short-term CBT was ef-
fective in ameliorating PTSD symp-
toms of traumatized adolescents, and
it was significantly better than the
general support intervention.
Depression occurs frequently after
exposure to a traumatic experience (12).
This study showed that the short-term
CBT intervention not only reduced
PTSD symptoms but also ameliorated
depressive symptoms.
This study was limited by the small
sample size, and the use of multiple
ANOVAs for comparisons may have
inflated the alpha and led to a higher
type I error. Also, the differences in
262
treatment approach between CBT
(group based) and general support
(individual based) and differences in
training and preparation of providers
between the two groups could ac-
count for some of the variance of the
results. Furthermore, many other treat-
ments may have performed better than
the general support intervention pro-
vided in this study.
Psychological resilience is the ability
to adapt to and cope with change and
enables people to recover and thrive
against adversity (13). Among adoles-
cents, resistance to psychological injury
caused by negative events is enhanced
if the youths receive nurturing and
stable care from others (14). In this
study, the reliable structured care pro-
vided by CBT and general support in-
terventions improved the adolescents’
psychological resilience.
Acknowledgments and disclosures
The funding sources of the study included
grants CNTSP 2007BAI17B04 and CSCTP
2012SZ0139 and the Hong Kong Youth Foun-
dation. The authors express appreciation to all
adolescents who participated in this research. The
interpretation and conclusions of this report are
solely the authors’ and do not necessarily represent
those of the Chinese government or the Hong
Kong Youth Foundation.
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