This meta-analysis is aimed to assess the efficacy and acceptability of exposure therapy in the treatment of PTSD in children and adolescents. To our knowledge, this is the first time that exposure therapy for PTSD in children and adolescents have been compared in a metaanalysis. We found that exposure therapy showed better efficacy than control groups at post-treatment/follow-up and depressive symptom, but the acceptability did not perform better. Subgroup analysis showed that patients with single type of trauma may benefit more from exposure therapy. And PE showed a significantly advantage. This meta-analysis may provide some new sights for the clinical treatment of PTSD in children and adolescents.
It has been proved that ET showed a significant advantage40,47 and was recommended as the first-line therapy for adults’ PTSD16,40. The present study showed a similar result in terms of PTSD in children and adolescents. Owing to the mechanisms of ET, it can active the traumatic memory and inserted the safe components15,48, so that ET can have good efficacy of PTSD. Besides, subgroup analysis showed a signiଁcantly advantage for PE. The possible reasons for could be the following: Firstly, PE was an exposure-based CBT of PTSD and has been in development since 198216. Therefore, PE was the widely studied psychotherapy with more comprehensive evidence for PTSD. Secondly, PE is an extensively studied form of individual CBT, the adaptation emphasizes developmental sensitivity, modularity, and flexibility16. In addition to core ET components of psychoeducation and exposure, PE included more extensive case management and relapse prevention component, those could contribute to the beneficial of PE16. While for NET, the fear structure needed to be activated in a safe environment to decrease maladaptive associations19. However, during re-experiencing of the traumatic events (such as through nightmares, intrusive thoughts, or flashbacks), the fear network became reinforced because of the additional layer of emotional distress, and the memory was thus more susceptible to being triggered later19. On the other hand, subgroup analysis showed that exposure therapy was more effective for children and adolescents with single type of trauma. But due to the low number of studies, the results should be treated with caution. The trauma types of patients in the present study were more comprehensive compared with the previous study49. Four out of six studies in the meta-analysis included patients with multiple types of trauma. For example, one of our studies44 included the teenagers who suffered natural disasters, traffic accidents, or sexual assault. These results were consistent with previous studies50,51. Since patients who experienced multiple types of trauma, had more possibility to have complex PTSD including (in addition to the core PTSD symptoms of re-experiencing, avoidance, and hyperarousal) disturbances in affect regulation, dissociation, self-concept, interpersonal relationships, somatization, and systems of meaning52. Complex mental illnesses may have a negative impact on the treatment results of PTSD patients53, leading to unhealed trauma, and uncured trauma was a common cause of refractory depression and obsessive-compulsive disorder54.
Our analysis suggest that ET may generally result in better outcomes than control conditions in long-term follow-up. When treating children and adolescents with trauma, it may be important not only to tackle one event in their traumatic history, but to process all events that still cause PTSD symptom. The clinical model of repeated traumatization underlying ET drew on dual representation theories of PTSD and emotional processing theory and the idea of fear networks55. ET constructed a narrative that covers the patient's entire life, while giving a detailed account of past traumatic experiences, which could contribute to the long-term efficacy16. For acceptability, no significant different was observed between ET and control groups. However, from the patient's perspective, especially for children and adolescents, exposure therapy was challenging and its treatment process was relatively painful15, it required the patient to reproduce the traumatic experience, and may cause adverse effects on the patient. The treatment cycle was also relatively long16.
Because PTSD patients usually had comorbidities, such as depression and anxiety56,57, we also considered the efficacy of exposure therapy for PTSD comorbidities. This study showed that exposure therapy can significantly improve patients' depressive symptoms. Regarding the mechanism of its effect on depression symptoms, despite the lack of Socratic questioning, specific instruction about cognitive errors, and assigned practice, ET may change depression through cognitive shifts, or the mechanism may be the emotional arousal via exposure58. The specific mechanism was still unclear. However, those could provide some signs that ET could be an efficacious choice for PTSD patient comorbidity with depressive symptoms in children and adolescents. The patient's quality of life at the end of treatment has not been greatly improved. We speculated that this may be related to the relatively painful process of exposure therapy and further researches are needed.
Overall, our results provided some new perspectives on exposure therapy for PTSD in children and adolescents. We have tried to reduce heterogeneity by omitting RCTs that may cause significant bias in the results due to article characteristics (such as unreasonable research design, non-RCT, sample size less than 10, etc.). However, due to the following limitations, the results of this meta-analysis should be interpreted with caution. First of all, this study included a small sample size. The scope of our literature search was as wide as possible, but after screening in strict accordance with the standards, only 6 studies were included. Reasons for the low number of studies include: 1) for the high drop-out rate, there were not many RCTs for children and adolescents with PTSD, however, the mental health of children and adolescents was essential to the sustainable development of society, which is why we adhered to this theme. The reasons of high drop-out rate may include: a. either the child’s/adolescent’s or his or her parents’ decision not to continue the treatment because they felt that the treatment was no longer needed 24. b. Some NET clients reported that it was too hard to go through the traumatic events and wanted to quit24. c. Many times the child populations in wars are on the move. ‘Home’ is often a Displaced People’s Camp, a Cross border Transit or Refugee Camp. It is challenging to extend individual services, which last several weeks if not months. 44; 2) psychotherapy for children and adolescents required systematic and standardized training, which was more difficult than better quantitative evaluation of drug therapy; 3) exposure therapy can evoke traumatic memories in children and adolescents. Secondly, most of the analysed outcomes presented with moderate to high heterogeneity. Those could come from the clinical and methodological characteristics. Some subgroup analyses were conducted to explore the potential sources of heterogeneity, however, other important parameter such as symptom severity, gender, age, country of patients couldn’t not be addressed due to the limitation of original data. Thirdly, the ROB 2.0 showed most of the risk of bias of the included studies was rated as low risk and some concerns. These mainly came from the deviations from intended interventions, for the blinding. However, it was difficult to conduct with double-blinding in psychotherapies.