Treating child abuse related PTSD in adolescents. Is skills training helpful or needed?

'One in every classroom' is a regular statement to raise awareness for the size of child abuse, such as domestic violence, physical abuse and sexual abuse. Unfortunately, child abuse is a very common problem leading to a variety of medical and psychological symptoms, as well as social problems. Nowadays, the causal link between chronic stress in (early) childhood and later problems has been established in many (inter)national surveys. One of the most common sequelae as a result of child abuse is post traumatic stress disorder, or PTSD. Children with child abuse related PTSD suffer from intrusive flashbacks related to the traumatic events, and avoid thoughts or feelings related to the abuse. Additionally, they experience negative feelings about themselves, and the world, and because of hypervigilance, they have trouble sleeping and concentrating. In the adolescent phase, these children frequently referred to the practice of child and adolescent psychiatry for assessment and treatment. Because child abuse often has devastating effects on many aspects of a child’s life, treatment to deal with the consequences such as PTSD is extremely important. But, there are two problems with regard to the psychological treatment. Firstly, little is known about the effectiveness of treatment of adolescents with child abuse related PTSD. Secondly, recommendations of (international) guidelines on treating child abuse related PTSD proves contradictory. One group of colleagues advocates a ‘phase-based’ treatment of PTSD, whereas other colleagues suggest a direct 'trauma-focused treatment' without stabilization. According to the first group, a stabilization phase is of necessary to work on improving emotion regulation and interpersonal skills, which are hypothesized to be underdeveloped as a result of chronic stress in childhood. It is stated that adolescents need a skills training to benefit from standard PTSD treatment, such as eye movement desensitization and reprocessing (EMDR) or imaginary exposure (IE), also known as 'trauma-focused treatment'. According to the proponents of the inclusion of a 'stabilization phase', there is a significant risk that, if emotion regulation and interpersonal skills are not taught and integrated, the person will not benefit from the treatment or - even worse – symptoms may exacerbate, or treatment drop out may occur. The second group, on the other hand, consists of colleagues who have doubts about these assumptions, because the underlying empirical evidence is weak. Based upon recent treatment efficiency research in adults with PTSD due to childhood abuse, it has been suggested that emotion regulation and interpersonal regulation skills will automatically improve as a result of successful trauma-focused treatment. Adding a specific stabilization phase would, in their view, lead to unnecessarily long, expensive and unstructured treatment pathways, with less focus on the core problem, namely processing of the traumatic memories, thereby reducing post traumatic stress symptoms. With this project, the applicant intends to provide a scientific basis to this debate by conducting a randomized clinical trial (RCT) with adolescents (12-18 years). Two conditions will be investigated. In the first, adolescents will receive a phased-based trauma treatment consisting of 12 sessions STAIR-A (skills training phase) followed by 12 sessions of EMDR. In the second condition, adolescents will receive 12 sessions of EMDR without a skills training prior to EMDR. STAIR-A stands for Skills Training in Affective and Interpersonal Regulation for Adolescents, which is a cognitive behavioral therapy intervention specifically designed for adolescents with mental health problems as a result of child abuse. The RCT will be performed at Karakter Child and Adolescent’s Psychiatric Hospital and will be implemented at ten locations, spread out over three provinces in The Netherlands. The project aims are to: 1. determine the necessity and efficacy of a preparatory skills training in the treatment of patients suffering from abuse related PTSD. Therefore, this study will compare two treatment protocols in order to demonstrate that EMDR preceded by skills training (STAIR-A) is no better or worse than EMDR-only on the primary outcome measure the Clinician-Administered PTSD Scale for Children and Adolescents. If EMDR proves to be as effective as EMDR preceded by STAIR-A, it opens the way to a significantly reduced treatment duration. 2. identify of what subgroups of patients (adolescents with child abuse related PTSD with/without; depressive symptoms, intellectual disabilities, dissociative symptoms and other psychological factors) respond to either STAIR-EMDR or EMDR-only and which subgroups do not. 3. implement standard screening by using the Childhood Trauma Questionnaire (CTQ) to screen all referred adolescents for adverse childhood events in order to prevent misdiagnoses in the trauma related spectrum.