Prolonged Exposure Therapy for Adolescents (PE-A)

Scientific Rating:
1
Well-Supported by Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
Medium
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Prolonged Exposure Therapy for Adolescents (PE-A) has been rated by the CEBC in the areas of: Anxiety Treatment (Child & Adolescent) and Trauma Treatment - Client-Level Interventions (Child & Adolescent).

Target Population: Adolescents who have experienced a trauma (e.g., sexual assault, car accident, violent crimes, etc). The program has also been used with children 6 to 12 years of age and adults who have experienced a trauma.

For children/adolescents ages: 12 – 18

Brief Description

PE-A is a therapeutic treatment where clients are encouraged to repeatedly approach situations or activities they are avoiding because they remind them of their trauma (in vivo exposure) as well as to revisit the traumatic memory several times through retelling it (imaginal exposure). Psychoeducation about common reactions to trauma as well as breathing retraining exercises are also included in the treatment. The aim of in vivo and imaginal exposure is to help clients emotionally process their traumatic memories through imaginal and in vivo exposure. Through these procedures, they learn that they can safely remember the trauma and experience trauma reminders, that the distress that initially results from confrontations with these reminders decreases over time, and that they are capable of tolerating this distress. Prolonged Exposure Therapy for PTSD for Adults (PE) is also highlighted on the CEBC website in the Trauma Treatment (Adult) topic area.

Program Goals:

The overall goal of Prolonged Exposure Therapy for Adolescents (PE-A) is:

  • Promote the client’s ability to emotionally process their traumatic experiences and consequently diminish posttraumatic stress disorder (PTSD) and other trauma-related symptoms

Essential Components

The essential components of Prolonged Exposure Therapy for Adolescents (PE-A) include:

  • Delivering rationales for the treatment program, as well as for the in vivo and imaginal exposure, to the client in order to increase understanding of the treatment components and how they will help diminish PTSD symptoms.
  • Creating an in vivo exposure hierarchy together with the client and guiding the client in implementing in vivo exposures to trauma reminders and situations that feel unsafe as a result of the trauma.
  • Conducting repeated and prolonged imaginal exposure to the trauma memory with the client, where the client is asked to recall and retell the trauma memory.
  • Delivering psychoeducation regarding common reactions to trauma.
  • Teaching breathing retraining exercise that can help patients to feel more calm.

Child/Adolescent Services

Prolonged Exposure Therapy for Adolescents (PE-A) directly provides services to children/adolescents and addresses the following:

  • PTSD and related symptoms
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: PE-A utilizes parent involvement in the psychoeducational sessions of the treatment, if parents are available and willing to participate. Parents may also help with in vivo exercises with the child.

Delivery Settings

This program is typically conducted in a(n):

  • Community Agency
  • Outpatient Clinic

Homework

Prolonged Exposure Therapy for Adolescents (PE-A) includes a homework component:

Clients are asked to do homework after each session of treatment. Homework consists of reading summaries of the information presented in the session and sharing it with parents, completing in vivo exercises, and completing imaginal exposure homework.

Languages

Prolonged Exposure Therapy for Adolescents (PE-A) has materials available in languages other than English:

Japanese, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

A quiet room with no interruptions or distractions is necessary to implement PE-A. DVD camcorders are necessary for conducting intensive individual and group supervision. Digital voice recorders are required for audio recording the treatment sessions which the client is required to listen as part of his homework. Clients can take the recorders with them or providers can use a CD burner to burn the audio recording onto a compact disc.

Minimum Provider Qualifications

Licensed mental health professionals or those working under the supervision of a licensed mental health professional. Psychology, social, work, and nursing staff can implement PE-A in their respective roles.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

Training can be provided onsite.

Number of days/hours:

4 full days (32 hours)

Implementation Information

Since Prolonged Exposure Therapy for Adolescents (PE-A) is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

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Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Prolonged Exposure Therapy for Adolescents (PE-A).

Formal Support for Implementation

There is no formal support available for implementation of Prolonged Exposure Therapy for Adolescents (PE-A).

Fidelity Measures

The program representative did not provide information about fidelity measures of Prolonged Exposure Therapy for Adolescents (PE-A).

Implementation Guides or Manuals

There are no implementation guides or manuals for Prolonged Exposure Therapy for Adolescents (PE-A).

Research on How to Implement the Program

Research has not been conducted on how to implement Prolonged Exposure Therapy for Adolescents (PE-A).

Relevant Published, Peer-Reviewed Research

This program is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The program must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. The article(s) below that reports outcomes from an RCT showing a sustained effect of at least 1 year has an asterisk (*) at the beginning of its entry. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

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*Gilboa-Schechtman, E., Foa, E. B., Shafran, N., Aderka, I. M., Powers, M. B., Rachamim, L., … Apter, A. (2010). Prolonged Exposure versus dynamic therapy for adolescent PTSD: A pilot randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1034-1042. doi:10.1016/j.jaac.2010.07.014

Type of Study: Randomized controlled trial
Number of Participants: 38

Population:

  • Age — 12-18 years
  • Race/Ethnicity — Israeli
  • Gender — 63% Female and 37% Male
  • Status — Participants were adolescents, fluent in Hebrew, with a primary diagnosis of PTSD related to a single traumatic event.

Location/Institution: Bar-Ilan University, Ramat-Gan, Israel

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study examined the efficacy and maintenance of developmentally adapted Prolonged Exposure Therapy for Adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas. Adolescents and their parents participated in a diagnostic interview and were randomly assigned to one of two treatment groups. Measures used included the Schedule of Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL), Children’s Global Assessment Scale (CGAS), Child PTSD Symptom Scale (CPSS), Beck Depression Inventory (BDI), Likert scales that assessed treatment expectancy and satisfaction with treatment, and the Working Alliance Inventory that measured therapeutic alliance. Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6 and 17-month follow-ups. Limitations include a small sample and reliance on self-reported measures.

Length of postintervention follow-up: 17 months.

Aderka, I. M., Foa, E. B., Applebaum, E., Shafran, N., & Gilboa-Schechtman, E. (2011). Direction of influence between posttraumatic and depressive symptoms during prolonged exposure therapy among children and adolescents. Journal of Consulting and Clinical Psychology, 79(3), 421-425. doi:10.1037/a0023318

Type of Study: One group pretest-posttest
Number of Participants: 73

Population:

  • Age — 8-18 years
  • Race/Ethnicity — Not specified
  • Gender — 56.2% Female and 43.8% Male
  • Status — Participants were children and adolescents with posttraumatic stress disorder (PTSD) who were fluent in Hebrew.

Location/Institution: Schneider Children’s Medical Center of Israel

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined the temporal sequencing of posttraumatic and depressive symptoms during Prolonged Exposure Therapy for Adolescents (PE-A) for PTSD among children and adolescents. Participants were children and adolescents. Participants completed self-report measures of posttraumatic stress and depression prior to every session. Measures included the Child PTSD Symptom Scale, Beck Depression Inventory, Schedule for Affective Disorders and Schizophrenia for School-Age Children—Revised (K-SADS), and Children’s Depression Inventory. Results showed changes in posttraumatic symptoms led to changes in depressive symptoms and vice versa. Posttraumatic symptoms accounted for 64.1% of the changes in depression, whereas depressive symptoms accounted for 11.0% of the changes in posttraumatic stress. Limitations include small sample size, lack of control group, and lack of follow-up.

Length of postintervention follow-up: None.

Aderka, I. M., Appelbaum-Namdar, E., Shafran, N., & Gilboa-Schechtman, E. (2011). Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 79(4), 441-446. doi: 10.1037/a0024112

Type of Study: One group pretest-posttest
Number of Participants: 63

Population:

  • Age — 8-17 years
  • Race/Ethnicity — Not specified
  • Gender — 37 Female and 26 Male
  • Status — Participants were children and adolescents with posttraumatic stress disorder (PTSD).

Location/Institution: Large public clinic in Israel

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined sudden gains during developmentally adjusted Prolonged Exposure Therapy for Adolescents (PE-A) for posttraumatic stress disorder (PTSD) among children and adolescents. Participants completed a developmentally adjusted protocol for the treatment of pediatric PTSD. Participants’ posttraumatic and depressive symptoms were assessed before each treatment session, as well as after treatment termination. Measures utilized include the Child PTSD Symptom Scale (CPSS), Schedule for Affective Disorders and Schizophrenia for School-Age Children—Revised (K-SADS), Beck Depression Inventory, and the Children’s Depression Inventory. Results indicate that sudden gains were found among 49.2% of participants and constituted 48.6% of the total reduction in posttraumatic symptoms. Compared to individuals who did not experience sudden gains, individuals who experienced sudden gains reported lower levels of posttraumatic symptoms. Differences in posttraumatic symptoms were maintained during both follow-up periods. Limitations include small sample size, lack of control group, and reliance on self-reported measures.

Length of postintervention follow-up: 3 and 12 months.

*Foa, E. B., McLean, C. M., Capaldi, S., & Rosenfield, D. (2013). Prolonged exposure vs supportive counseling for sexual abuse–related PTSD in adolescent girls: A randomized clinical trial. JAMA, 310(24), 2650-2657. doi:10.1001/jama.2013.282829

Type of Study: Randomized controlled trial
Number of Participants: 61

Population:

  • Age — 12-18 years
  • Race/Ethnicity — 56% Black, 18% White, 16% Hispanic, 3% Biracial, and 7% Other
  • Gender — 100% Female
  • Status — Participants were adolescent girls seeking treatment at a rape crisis center.

Location/Institution: Philadelphia, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study examined the effects of Prolonged Exposure Therapy for Adolescents (PE-A) compared with supportive counseling for adolescents with posttraumatic stress disorder (PTSD). Measures used included the Schedule of Affective Disorders and Schizophrenia for School-Age Children (K-SADS), the Child PTSD Symptom Scale–Interview (CPSS-I), the Child PTSD Symptom Scale–Self-Report (CPSS-SR), the Children’s Depression Inventory (CDI), The Children’s Global Assessment Scale (CGAS), and the Expectancy of Therapeutic Outcome for Adolescents (ETO-A). Results indicate that after treatment, participants who received PE-A showed greater improvement in PTSD symptoms and were more likely to lose their PTSD diagnosis and be classified as good responders than those who received supportive counseling. Limitations include the use of prerandomization preparatory sessions, which may reduce generalizability and introduce possible sample bias, and lack of generalizability to other types of trauma or to males.

Length of postintervention follow-up: 3, 6, and 12 months.

McLean, C. P., Yeh, R., Rosenfield, D., & Foa, E. B. (2015). Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents. Behaviour Research and Therapy, 68, 64-69. doi:10.1016/j.brat.2015.03.008

Type of Study: Randomized controlled trial (secondary analysis)
Number of Participants: 61

Population:

  • Age — 13-18 years
  • Race/Ethnicity — 56% Black, 18% White, 16% Hispanic, 3% Biracial, and 7% Other
  • Gender — 100% Female
  • Status — Participants were adolescent girls seeking treatment at a rape crisis center.

Location/Institution: Philadelphia, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study utilizes information from Foa, et al. (2013) to examine the effects of Prolonged Exposure Therapy for Adolescents (PE-A) to assess whether changes in negative trauma-related cognitions play an important role in reducing symptoms of posttraumatic stress disorder (PTSD) and depression. This study utilized secondary analysis of data from a randomized controlled trial comparing PE-A with client-centered therapy (CCT) for PTSD. Measures used included the Schedule of Affective Disorders and Schizophrenia for School-Age Children (K-SADS), the Child PTSD Symptom Scale–Interview (CPSS-I), the Child PTSD Symptom Scale–Self-Report (CPSS-SR), the Children’s Depression Inventory (CDI), The Children’s Global Assessment Scale (CGAS), and the Expectancy of Therapeutic Outcome for Adolescents (ETO-A). Results indicate that after treatment, participants who received PE-A showed that change in negative trauma-related cognitions mediated change in PTSD symptoms and depressive symptoms whereas change in PTSD and depressive symptoms did not mediate change in negative cognitions. Limitations include the use of prerandomization preparatory sessions, which may reduce generalizability and introduce possible sample bias, generalizability due to gender, and reliability on self-reported measures.

Length of postintervention follow-up: 3 months.

McLean, C. P., Su, Y. J., Carpenter, J. K., & Foa, E. B. (2015). Changes in PTSD and depression during Prolonged Exposure and Client-Centered Therapy for PTSD in adolescents. Journal of Clinical Child & Adolescent Psychology. Advance online publication. doi:10.1080/15374416.2015.1012722

Type of Study: Randomized controlled trial (secondary analysis)
Number of Participants: 61

Population:

  • Age — 12-18 years
  • Race/Ethnicity — 56% Black, 18% White, 16% Hispanic, 3% Biracial, and 7% Other
  • Gender — 100% Female
  • Status — Participants were adolescent girls seeking treatment at a rape crisis center.

Location/Institution: Philadelphia, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study utilizes information from Foa, et al. (2013) to investigate the relationship between changes in PTSD and depression during of Prolonged Exposure Therapy for Adolescents (PE-A) and client-centered therapy (CCT). Measures used included the Schedule of Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Beck Depression Inventory, and the Child PTSD Symptom Scale–Self-Report (CPSS-SR). Results indicate a reciprocal but asymmetrical relationship between changes in PTSD and depression during treatment in the overall sample. However, analysis showed that the reciprocal relation was observed only during PE-A. Reductions in PTSD led to reductions in depression to a greater extent than vice versa. For participants receiving CCT, reduction in PTSD led to reductions in depression but not vice versa. Limitations include the possible sample bias, generalizability due to gender, and lack of follow-up.

Length of postintervention follow-up: None.

References

Foa, E. B., Chrestman, K. R., and Gilboa-Schechtman, E. (2009). Prolonged Exposure Therapy for Adolescents with PTSD: Emotional processing of traumatic experiences: Therapist guide. New York, NY. Oxford University Press.

Contact Information

Name: Sandy Capaldi, PsyD
Agency/Affiliation: Center for the Treatment and Study of Anxiety at University of Pennsylvania
Website: www.med.upenn.edu/ctsa/workshops_pet.html
Email:
Phone: (215) 746-5705 or (215) 746-3311

Date Research Evidence Last Reviewed by CEBC: June 2016

Date Program Content Last Reviewed by Program Staff: March 2014

Date Program Originally Loaded onto CEBC: September 2011