Counseling Outcome Research

Counseling Outcome Research

and Evaluation
Meta-Analysis of Trauma- 2015, Vol. 6(1) 18-32
ª The Author(s) 2015
Focused Cognitive Behavioral Reprints and permission:
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DOI: 10.1177/2150137815573790
Therapy for Treating PTSD core.sagepub.com

and Co-occurring Depression

Among Children and Adolescents

A. Stephen Lenz1 and K. Michelle Hollenbaugh1

Abstract
We evaluated the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) for
treating posttraumatic stress disorder and co-occurring depression symptoms across 21 between-
group studies representing the data of 1,860 children and adolescents (1,106 girls and 754 boys).
Separate meta-analytic procedures were conducted for studies that implemented wait-list/no
treatment and alternative treatment comparisons to estimate aggregated treatment effect of
TF-CBT and moderators of effect size magnitude. Limitations of our findings and implications for
counselors are discussed.

Keywords
TF-CBT, PTSD, depression, research

Exposure to trauma is common in children and
adolescents, which can have significant impact
on their psychosocial functioning (Little &
Little, 2013; Schoedl et al., 2010). Kilpatrick
and colleagues (2013) reported that nearly
90% of adults in the United States have been
exposed to a traumatic event at some point in
their lives. Among these individuals, many of
them may have been exposed to a traumatic
event or stress-causing event prior to ado-
lescence (Briggs-Gowan, Ford, Fraleigh,
McCarthy, & Carter, 2010). Furthermore, sur-
vey researchers have detected that among chil-
dren and adolescents, 41% had been physically
assaulted within the past year and 22% had wit-
nessed some form of violence (Finkelhor,
Turner, Shattuck, & Hamby, 2013). Given the
broad scope of incidence, identifying and
evaluating interventions that support the miti-
gation of symptoms associated with trauma is
a prudent task for counselors.
It is reasonable to infer that without primary
intervention, exposure to traumatic events dur-
ing childhood and adolescence may have dele-
terious effects on well-being across the life
1
Early Childhood Education Center, Texas A&M Uni-
versityCorpus Christi, Corpus Christi, TX, USA
Submitted December 19, 2014. Revised January 26, 2015.
Accepted January 29, 2015.
Corresponding Author:
A. Stephen Lenz, Early Childhood Education Center, Texas
A&M UniversityCorpus Christi, Room 152, Corpus
Christi, TX 78412, USA.
E-mail: stephen.lenz@tamucc.edu

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Lenz and Hollenbaugh
span. Although some children will demonstrate
a natural, adaptive response to life following a
traumatic event, others will exhibit intrusive
re-experience, avoidance of associated stimuli,
negative alterations in cognitions and mood, or
marked alterations in arousal and reactivity that
characterize posttraumatic stress disorder
(PTSD). Although girls tend to report symp-
toms of PTSD to a greater degree than boys
do (Merikangas et al., 2010), several negative
disparities have been linked to unmitigated
PTSD symptoms across genders such as aca-
demic dropout (Porche, Fortuna, Lin, & Ale-
gria, 2011), vocational attainment (Sansonea,
Leunga, & Wiederman, 2013), and physical
heath (Maschi, Baer, Morrissey, & Moreno,
2013). Children who experience trauma are
also more likely to display relational deficits
such as persistent anger and poor conflict reso-
lution skills with peers and families that tend to
increase in severity and frequency as a function
of the number of traumatic events the children
have experienced (SAMHSA; Substance Abuse
and Mental Health Services Administration,
2011).
As a result of these difficulties, many
children are vulnerable to developing co-
occurring psychiatric symptoms associated
with disorders related to personality, anxiety,
and depression (Howe, 2005). Major depres-
sive disorder is one of the most commonly
diagnosed disorders in combination with
PTSD (American Psychiatric Association
[APA], 2013), with researchers indicating
that almost 40% of children and adolescents
diagnosed with PTSD also met criteria for
co-occurring major depressive disorder (Kar
& Bastia, 2006; SAMSHA, 2011). Not only
can the presence of co-occurring depressive
symptoms complicate the treatment of PTSD
(McLean, Morris, Conklin, Jayawickreme, &
Foa, 2014), but some evidence has emerged
that when clients exhibit co-occurring PTSD
and depressive symptoms, they are at consid-
erable risk for suicidality and behavioral
problems when compared to others who
have depression alone (SAMSHA, 2011).
With this consideration in mind, interven-
tions that mitigate both PTSD and depressive
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19
symptoms concurrently should be considered
as a counselor’s first choice.
Target outcomes for treating PTSD among
children and adolescents are commonly related
to reducing the influence of thinking styles,
affective responses, and ineffective behaviors
that perpetuate the symptoms further (Cohen
& Mannarino, 2008). Cohen, Mannarino, and
Deblinger (2006) suggested that changes within
these domains can promote positive develop-
ments related to emotional dysregulation, intru-
sive thoughts/memories/dreams, avoidance
reactions, emotional numbing, and physical
reactions. However, these symptoms can be
resistant to mitigation in the presence of
co-depression (SAMSHA, 2011). Although
several approaches to counseling children and
adolescents who experience the symptoms of
PTSD have been presented (see Kendall,
2000; Lieberman, Van Horn, & Ippen, 2005;
Najavits, Gallop, & Weiss, 2006), trauma-
focused cognitive behavior therapy (TF-CBT;
Cohen, Mannarino, and Deblinger, 2006) has
emerged as a promising intervention for coun-
selors to consider.
TF-CBT
TF-CBT was developed specifically for chil-
dren and adolescents and has become one of the
leading treatments for trauma and PTSD in this
population (Cohen, Mannarino, Kliethermes, &
Murray, 2012). TF-CBT utilizes trauma-
sensitive interventions as well as CBT and is
a relatively short treatment that takes place over
12–16 weeks. A core principle of TF-CBT is
gradual exposure to the child’s traumatic expe-
rience through the various modes of treatment.
Modes of treatment are described using the
acronym PRACTICE and focus on coping skill
development through activities that include
psychoeducation, relaxation training, affective
coping skills, cognitive reframing, trauma nar-
ration, in vivo exposure, conjoint child and par-
ent sessions, and enhancement of future safety
(Cohen et al., 2006).
Psychoeducation is implemented for the
parent and the child and includes basic educa-
tion regarding trauma responses and PTSD,
20
including statistics regarding trauma and abuse.
This can be helpful to reduce stigma regarding
the situation for parents and children alike
(Cohen & Mannarino, 2008). Relaxation skills
entail a myriad of activities and serve to help
the child feel equipped to handle stressful situa-
tions. Skills include mindfulness and breathing
but also music, sports, and other recreational
activities. Affective coping skills includes edu-
cating the child on emotions and then assessing
where the child can use the most affective cop-
ing skills and engaging in individualized inter-
ventions. Cognitive reframing interventions
facilitate the ability of child and parents to dif-
ferentiate between thoughts, emotions, and
behaviors and their ability to use that knowl-
edge to effectively manage them. Once the
child has completed the previous steps, the
family is ready to engage in trauma narration,
where the child tells the story of the trauma
by writing it as a poem, song, book, or another
creative venue for communication. This facili-
tates the child’s ability to overcome avoidance,
identify any cognitive distortions, and view the
trauma in the context of the rest of his or her life
(Cohen & Mannarino, 2008). In vivo exposure
is utilized with children who continue to strug-
gle with life, interfering avoidance of a place or
situation related to the trauma and entails gra-
dual exposure to the situation to reduce anxiety
and increase functioning. Conjoint parent and
child sessions help increase communication
and cohesiveness among family members.
Finally, enhancing safety can include addi-
tional education for the child as needed, for
example, education and discussion of healthy
sexuality or safety regarding drug use (Cohen
et al., 2006).
The efficacy of TF-CBT has been supported
through several randomized trials and has
received support from several government
agencies as a best practice for treating child and
adolescent PTSD (Cary & McMillen, 2012).
Although this broad level of knowledge is use-
ful to some degree, Wampold, Lichentenberg,
and Waehler (2002) suggested that hypothesis
testing alone is insufficient for making deci-
sions related to what treatments work, for
whom, and under what circumstances. This
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Counseling Outcome Research and Evaluation 6(1)
supposition was echoed by de Arellano et al.
(2014) who called for further analysis over
TF-CBT, especially in comparison to other
evidence-supported treatments. Analysis of the
available quantitative data regarding this treat-
ment can supplement the current knowledge in
the field regarding the best methods of treating
children who have experienced trauma and
increase favorable outcomes related to mental
health counseling services.
Purpose of Study and Research
Questions
The purpose of this study was to evaluate the
effectiveness of TF-CBT for mitigating the
symptoms of PTSD and co-occurring depres-
sion among children and adolescents with a his-
tory of traumatic experiences. Additionally, in
the presence of heterogeneous findings across
studies, we intended to identify visually obser-
vable associations between sample age, ethnic
composition of the participant sample, and
type of trauma as moderators of aggregated
effect size. To accomplish this, we completed
a meta-analysis of between-group outcome stud-
ies published between 2000 and 2014 to answer
the following three research questions: (a) To
what degree is TF-CBT effective for decreasing
the symptoms of PTSD? (b) To what degree is
TF-CBT effective for decreasing the symptoms
of co-occurring depression among individuals
with PTSD? and (c) What are the relationships
between mean sample age, ethnic identity,
reported trauma type, and domicile moderators
and aggregated effect size?
Method
We searched for published and unpublished
quantitative studies that estimated the efficacy
of TF-CBT for treating the symptoms of PTSD
and co-occurring depression among individuals
who had been exposed to traumatic events.
Data from identified studies that met our inclu-
sion criteria were coded, collated, and synthe-
sized using procedures to correct for small
sample size bias and influence of study quality
that resulted in an aggregated estimation of
Lenz and Hollenbaugh
treatment effect for PTSD and depression
symptoms.
Inclusion and Exclusion Criteria
Inclusion of studies within this meta-analysis
was contingent on the following criteria: (a)
studies implemented between-group quantita-
tive research designs; (b) studies were pub-
lished in peer-reviewed journals, dissertations,
or theses; (c) the primary symptom treated
among participants was PTSD as conceptua-
lized within the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition,
Text Revision (APA, 2000) or Diagnostic and
Statistical Manual of Mental Disorders, Fifth
Edition (APA, 2013); (d) eligibility for study
participation was completed by a trained
mental health practitioner; (e) TF-CBT was a
therapeutic strategy implemented in the study;
(f) researchers used standardized assessments
prior to treatment (pretest) and at termination
(posttest) to evaluate symptom severity; (g)
mean and standard deviation data for pretest
and posttest measures were reported; and (h)
studies were published in English. Studies
were excluded from our analysis if they
reported findings from single-group, single-
case, intent-to-treat analyses, or correlational
research studies, did not assess features of
pretest data, did not report information related
to participant characteristics, or contained data
reported across multiple publications. We
established these standards a priori to support
the presence of quality reports within our
study sample while also reducing the influence
of publication bias when estimating aggre-
gated treatment effect.
Search Strategies
We implemented three search strategies to
identify and include studies that reported
changes in PTSD and co-occurring depression
symptoms associated with participation in
TF-CBT: (a) electronic database searches, (b)
journal-specific searches, and (c) reviewing of
reference lists. The first author independently
searched PsycINFO, Pubmed, Academic
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21
OneFile, Web of Science, PsycARTICLES,
Google Scholar, and Dissertations and Theses
databases for articles within the time frame
from 2000 to 2014. The key words TF-CBT and
trauma-focused CBT were used to identify the
intervention and trauma, posttraumatic, and
PTSD to identify the target population. All
database searches except Google scholar and
dissertations and theses were screened through
the databases peer-reviewed function to return
relevant document abstracts.
We located eligible studies within relevant
publication sources by completing journal-
specific searches within the following periodi-
cals: Behavior Therapy, Journal of Counseling
and Development, Counseling Outcome
Research and Evaluation, Journal of Mental
Health Counseling, Journal of Trauma Prac-
tice, Journal of Traumatic Stress, The Counsel-
ing Psychologist, Psychological Trauma:
Theory, Research, Practice, and Policy, and
Journal of Aggression, Maltreatment, and
Trauma. Reference lists of each eligible study
were reviewed to detect any further studies for
inclusion. All relevant articles, dissertations,
theses, and abstracts that met inclusion criteria
were pooled using the RefWorks database soft-
ware program (www.refworks.com) and
screened for redundancies using the check
duplicates function.
Coding Procedures
The first author implemented guidelines
detailed by Cooper, Hedges, and Valentine
(2009) to code article information related to
study features, participant characteristics, and
contrasts needed to compute group gain scores.
A coding guide was developed a priori by the
first author, peer-reviewed to substantiate that
target variables would be included within our
sample of studies, and implemented throughout
the data coding/verification processes.
Statistical Methods
Statistical analyses were completed using the
Comprehensive Meta-Analysis, Version 2.0
software program. We computed standardized
22
mean difference expressed with the Hedge’s g
unbiased effect size metric to account for the
influence of sample size and sampling error
among studies (Erford, Savin-Murphy, & But-
ler, 2010; Lipsey & Wilson, 2001). We also
attempted to control for the influence that
larger studies may have on mean effect size
by implementing a weighted invariance effect
size procedure (Lipsey & Wilson, 2001). We
evaluated null hypotheses for individuals and
aggregated effect sizes by inspecting confi-
dence intervals at the 95% level. Within our
data set, negative effect sizes with greater mag-
nitudes were representative of greater effec-
tiveness of TF-CBT when compared to no
treatment, wait-list, or alternative treatment
comparisons. All effect sizes were interpreted
using the suggestions submitted by Cohen
(1988) for describing magnitudes as small (ES
 .20), medium (ES  .50), and large (ES 
.80).
We evaluated publication bias by inspecting
funnel plots that designated study effect sizes
on the abscissa and standard error on the ordi-
nate axes in which symmetrical distributions
of effect sizes across standard errors repre-
sented a lesser degree of bias, whereas those
that are skewed indicated potential publication
bias. The fail-safe N (Nf) metric was also com-
puted to estimate the amount of unpublished
studies reporting no treatment effect that would
be needed to contradict our findings. When Nf
is markedly low, it is reasonable to conjecture
that the mean effect sizes may not characteristic
of actual treatment effectiveness (Borenstein,
Hedges, Higgins, & Rothstein, 2009; Erford
et al., 2010).
Analysis of homogeneity. The homogeneity of
effect size distributions were examined by
inspecting values for Cochran’s Q and the
inconsistency index (I2). When the Q values are
significant (i.e., p < .05) and I2 is greater than
.50, heterogeneity is assumed and moderator
variables should be evaluated (Borenstein
et al., 2009; Erford et al., 2010).
Moderator analysis. Whereas inspection of
moderator variables in large meta-analyses
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Counseling Outcome Research and Evaluation 6(1)
commonly relies on meta-regression analyses
(Borenstein et al., 2009), evaluation of the fea-
tures associated with effect size magnitudes
within smaller samples may be most prudently
completed through visual scrutiny. In the case
of small sample of studies, we propose that the
inferences of moderator analyses should be
regarded as descriptive rather than based on
statistically based predictive methods. Of inter-
est within our analyses were the observable
associations between participant age, ethnic
composition of the sample, reported type of
trauma, and domicile (domestic vs. interna-
tional) within heterogeneous samples of effect
sizes. We completed these analyses by plotting
effect sizes graphically with magnitude rep-
resented on the ordinate axis and values of
categorical moderating variables (age, ethnic
composition of sample, type of trauma, and
domicile) denoted along the abscissa. Subgroup
means and confidence intervals were also com-
puted and inspected in association with the
moderator variable related to ethnic identity
and type of trauma.
Results
Our search strategy yielded 49 candidate arti-
cles and 4 dissertations that warranted further
inspection. After a detailed review of each can-
didate document and applying our inclusion/
exclusion criteria, we selected 21 (21 peer-
reviewed publications and 0 dissertations) for
analysis (see Table 1). The total number of par-
ticipants across studies was 1,860 with 1,009 of
those having received TF-CBT as their primary
intervention modality, 631 having received an
alternative treatment, and 220 receiving no
treatment or assigned to a wait-list condition.
Participants across study samples were girls
(n ¼ 1,106; 59%) and boys (n ¼ 711; 41%) with
a mean age of 10.96 years (SD ¼ 3.23), who
were predominately residing in the United
States (n ¼ 1199; 63%) and receiving interven-
tions for PTSD symptoms associated with mul-
tiple types of traumatic experiences (n ¼ 996;
64%). All studies implemented a manualized
TF-CBT protocol within the treatment condi-
tion and 17 (81%) of the 21 studies reflected
 Table 1. Characteristics of Individual Studies Used in Meta-Analysis.

Mean
Study Summary N Age Participant Characteristics Type of Trauma Type of Comparison

King et al. (2000) Compared 20 sessions of TF-CBT to 36 11.5 25 girls, 11 boys. Ethnicity not reported Sexual assault Family therapy and
alternative treatment and a wait-list wait-list
in a community-based setting
Deblinger, Stauffer, and Steer Compared 11 sessions of TF-CBT to 44 5.4 17 girls, 27 boys who were White (n ¼ Abuse/neglect Supportive therapy
(2001) alternative treatment in a community 28), African American (n ¼ 9), or
setting other (n ¼ 7)
Kataoka et al. (2003) Compared 8 sessions of TF-CBT to 229 11.4 114 girls, 114 boys who were Latino/ Abuse/neglect Wait-list
wait-list in a school setting Latina
Cohen, Deblinger, Mannarino, Compared 12 sessions of TF-CBT to 203 10.7 160 girls, 43 boys who were White (n ¼ Sexual assault Child-centered
and Steer (2004) alternative treatment in a community 122), African American (n ¼ 56), therapy
setting Latino/Latina (n ¼ 9), or other (n ¼
16)
Cohen, Mannarino, and Compared 12 sessions of TF-CBT to 82 11.4 56 girls, 26 boys who were white (n ¼ Sexual assault Supportive therapy
Knudson (2005) alternative treatment in a community 49), African American (n ¼ 30), or
setting other (n ¼3)
Lyshak-Stelzer, Singer, St. John, Compared 16 sessions of art therapy- 29 15 13 girls, 16 boys who were African Multiple types TAU
and Chemtob (2007) based TF-CBT intervention to American (n ¼ 12), Latino/Latina (n ¼
treatment as usual within an inpatient 5), White (n ¼ 5), or other (n ¼ 2)
setting
Smith et al. (2007) Compared 10 session of TF-CBT to 24 13.8 12 girls, 12 boys who were White (n ¼ Sexual assault Wait-list
wait-list in a school setting 11), African American (n ¼ 8), or
other (n ¼ 5)
Berger, Pat-Horenczyk, and Compared 8 sessions of TF-CBT to 142 ** 65 girls and 77 boys who were Israeli Terrorism Wait-list

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Gelkopf (2007)
Runyon, Deblinger, and Steer
(2010)
Jaycox et al. (2010)
wait-list in a school setting
Compared 16 sessions of TF-CBT to 60 9.8 28 girls, 32 boys who were African Abuse/neglect Parent training
alternative treatment in a community American (n ¼ 25) or other (n ¼ 35)
setting
Compared 12 sessions of TF-CBT to an 118 11.6 66 girls, 58 boys who were White (n ¼ Natural disaster Cognitive behavioral
alternative treatment in a community 56), African American (n ¼ 54), or therapy
setting other (n ¼ 8)

(continued)

23
 24
Table 1. (continued)

Mean
Study Summary N Age Participant Characteristics Type of Trauma Type of Comparison

Deblinger, Mannarino, Cohen, Compared 8- and 12-session protocols 179 7.7 109 girls, 70 boys who were White (n ¼ Abuse/neglect Cognitive behavioral
Runyon, and Steer (2011) of TF-CBT with alternative 102), African American (n ¼ 22), therapy
treatments without trauma Latino/Latina (n ¼ 11), or other (n ¼
component in a community setting 28)
Scheeringa, Weems, Cohne, Compared 12 session of TF-CBT to 64 5.3 22 girls, 42 boys who were African Multiple types Wait-list
Amaya-Jackson, and Guthrie wait-list in a community setting American (n ¼ 38), white (n ¼ 22), or
(2011) other (n ¼ 4)
Cohen, Mannarino, and Iyengar Compared 8 sessions of TF-CBT to an 124 9.6 61 girls, 63 boys who were white (n ¼ Abuse/neglect Child-centered
(2011) alternative treatment in a community 69), African American (n ¼ 41), or therapy
setting other (n ¼ 14)
Nixon, Sterk, and Pearce Compared 9 sessions of TF-CBT to an 33 11.5 12 girls, 21 boys who were European (n Multiple types Cognitive therapy
(2012) alternative treatment in a community ¼ 30) or other (n ¼ 5)
setting
Schottelkorb, Doumas, and Compared 17 sessions of TF-CBT to an 31 9.1 17 girls, 14 boys who were of African (n War-related Child-centered play
Garcia (2012) alternative treatment among ¼ 21), Middle Eastern (n ¼ 5) or therapy
students referred from their school other International origin (n ¼ 5)
McMullen, O’Callaghan, Compared 15 sessions of TF-CBT to 50 15.8 50 boys who were Congolese War related Wait-list
Shannon, Black, and Eakin wait-list in a community setting
(2013)
O’Callaghan, McMullen, Compared 15 sessions of TF-CBT to 52 16.1 52 girls who were Congolese War related Wait-list
Shannon, Rafferty, and Black wait-list in a community setting
(2013)
Ormhaug, Jensen, Wentzel- Compared 13 sessions of TF-CBT to 156 15.1 123 girls, 33 boys who were Norwegian Multiple types TAU

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Larsen, and Shirk (2014) treatment as usual in a community (n ¼ 115), Asian (n ¼ 17), or other (n
setting ¼ 34)
Jensen et al. (2014) Compared 15 sessions of TF-CBT to 156 15.1 124 girls, 32 boys who were Norwegian Multiple types TAU
treatment as usual in a community (n ¼ 115), Asian (n ¼ 17), or other (n
setting ¼ 34)
Diehle, Opmeer, Boer, Compared 12 sessions of TF-CBT to an 48 12.9 30 girls, 18 boys who were Dutch Multiple types EMDR
Mannarino, and Lindauer alternative treatment in a community
(2014) setting
Note. ** indicates information was not included.
Lenz and Hollenbaugh 25

Effect Size
Effect Size
Study Weight with 95% CI p TF-CBT vs. No Treatment

King et al. (2000) 13.31% -1.19 [-2.04, -.35] < .01

Kataoka et al. (2003) 16.45% -.29 [-.62, .03] .08
Smith et al. (2007) 11.77% -2.57 [-3.63, -1.51] < .01
Berger et al. (2007) 16.37% -1.05 [-1.40, -.70] < .01
Scheeringa et al. (2011) 13.70% -1.07 [-1.85, -.28] < .01
McMullen et al. (2013) 13.79% -2.64 [-3.41, -1.86] < .01
O’Callaghan et al. (2013) 14.61% -1.96 [ -2.61, -1.30] < .01

Mean Effect Size -1.48 [-2.13, -.83] < .01

-2 -1.5 -1 -.5 0 .5 1
Effect Size
Study Weight with 95% CI p TF-CBT vs. Alternative Treatments

King et al. (2000) 3.54% -.21 [-.99, .55] .58

Deblinger et al. (2001) 5.27% .06 [-.51, .64] .82
Cohen et al. (2004) 10.15% -.48 [-.76, -.21] < .01
Cohen et al. (2005) 7.33% -.22 [-.65, .20] .31
Lyshak-Stelzer et al. 3.22% -1.64 [-2.46, -.81] < .01
(2007)
Runyon et al. (2010) 6.07% -.61 [-1.12, -.09] .02
Jaycox et al. (2010) 8.52% -.38 [-.74, -.02] .03
Deblinger et al. (2011) 7.22% -.08 [-.51, .35] .72
Deblinger et al. (2011) 7.15% .25 [-.18, .69] .26
Cohen et al. (2011) 8.73% -.14 [-.49, .20] .40
Nixon et al. (2012) 4.40% -.02 [-.69, .64] .94
Schottelkorb et al. (2012) 4.18% .21 [-.48, .90] .55
Ormhauget al. (2014) 9.29% -.47 [-.78, -.14] < .01
Diehle et al. (2014) 5.54% -.06 [-.61, .50] .84
Jensen et al. (2014) 9.37% -.50 [-.81, -.18] < .01

Mean Effect Size -.28 [-.44, -.11] < .01

-2 -1.5 -1 -.5 0 .5 1
Note. Negative effect size values indicate that treatment outcomes favor TF-CBT; positive effect size values
indicate that treatment outcomes favor no treatment, waitlist controls, or alternative treatments

Figure 1. Effect sizes, 95% confidence intervals, and p values for studies evaluating TF-CBT for decreasing
PTSD symptoms using no treatment/wait-list and alternative treatment comparison groups. PTSD ¼ post-
traumatic stress disorder; TF-CBT ¼ trauma-focused cognitive behavioral therapy.

data from studies conducted in community-
based settings. Among the 21 studies included
within our analyses, 13 (62%) implemented
alternative treatment comparisons, 7 (33%)
utilized wait-list/no treatment comparisons,
and 1 (5%) implemented an alternative treat-
ment and wait-list/no treatment comparison.
Analyses that compared TF-CBT to a wait-
list or no treatment group were based on the
data of 585 participants across 7 studies, and
analyses that compared TF-CBT to alternative
treatments were based on the data of 1,287
participants across 14 studies.
Is TF-CBT Effective for Decreasing the
Severity of PTSD Symptoms?
Analyses of the effectiveness of TF-CBT for
decreasing the severity of PTSD symptoms
were based on 21 studies, yielding a total of
23 effect sizes (see Figure 1).

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26
TF-CBT versus wait-list. The seven studies
included in the analysis of TF-CBT versus
wait-list or no treatment comparisons (n ¼
554) yielded a mean effect size of 1.48 (CI
95 ¼ [2.13, .83]), indicative of a large
effect size and suggesting that the null hypoth-
esis can be rejected.
The effect sizes within the distribution of
studies were heterogeneous Q(6) ¼ 51.73,
p < .01 and I2 ¼ 88.40, indicating that about
88% of the total variability were due to the
between-study heterogeneity, thus exploration
of moderating variables was warranted.
Scrutiny of moderating variables of interest
revealed notable differences between studies
in association with mean participant age in
which older participant samples were associ-
ated with larger treatment effects. Inspection
of the relationship between-sample ethnic iden-
tity and magnitude of effect size was not war-
ranted, given that all included studies were
composed of predominately minority partici-
pants. Evaluation of effect sizes in relation to
the type of trauma that participants were receiv-
ing treatment for revealed no apparent differ-
ences based upon the type of trauma that
participants were receiving treatment for.
Examination of the relationship between domi-
cile and effect size was substantial, revealing
that studies from domestic samples yielded
substantially lower treatment effects (g ¼
.76) when compared to international samples
(g ¼ 1.98). Taken together, it can be inferred
that heterogeneity within this sample of studies
may be associated with study characteristics
related to the mean age and domicile of partici-
pants. This sample yielded an Nf of 233, indi-
cating that 233 unpublished studies with an
effect size of 0 would be needed to refute our
findings.
TF-CBT versus alternative treatments. The 14
studies included in the analysis of TF-CBT ver-
sus alternative treatments (n ¼ 1,267) yielded a
mean effect size of .28 (CI 95 ¼ [.44,
.11]), indicative of a small to medium effect
size and suggesting that the null hypothesis can
be rejected. The effect sizes within the distribu-
tion of studies were slightly heterogeneous,
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Counseling Outcome Research and Evaluation 6(1)
Q(14) ¼ 28.98, p ¼ .01 and I2 ¼ 51.70, indicat-
ing that approximately 51% of the total varia-
bility was due to between study heterogeneity
and that exploration of moderating variables
was warranted.
Scrutiny of moderating variables of interest
revealed differences between studies in which
greater mean participant age was associated
with larger effect sizes. Inspection of the rela-
tionship between sample ethnic identity, type
of trauma experienced, and domicile and mag-
nitude of effect size revealed no apparent dif-
ferences between studies. Therefore, it can be
conjectured that small amount of heterogeneity
associated with this subset of studies may be
associated with differences associated with the
mean participant age within the studies. This
sample yielded an Nf of 77, indicating that 77
unpublished studies with an effect size of 0
would be needed to refute our findings.
Is TF-CBT Effective for Decreasing the
Symptoms of Depression?
Analyses of the effectiveness of TF-CBT for
decreasing the symptoms of depression were
based on 14 studies, yielding a total of 16 effect
sizes (see Figure 2).
TF-CBT versus wait-list. The seven studies
included in the analysis of TF-CBT versus
wait-list or no treatment comparisons (n ¼
360) yielded a mean effect size of .78 (CI
95 ¼ [1.41, .15]), indicative of a medium
to large effect size and suggesting that the null
hypothesis can be rejected. The effect sizes
within the distribution of studies were hetero-
geneous, Q(4) ¼ 19.77, p < .01, and I2 ¼
79.77, indicating that about 79% of the total
variability was due to between-study heteroge-
neity, thus exploration of moderating variables
was warranted.
Scrutiny of moderating variables of interest
revealed no notable differences between studies
in association with mean participant age, ethnic
composition, or type of trauma indicating that
these characteristics were not associated with
the degree that participants reported decreases
in the symptoms of depression. Examination
Lenz and Hollenbaugh 27

Study Weight with 95% CI p TF-CBT vs. No Treatment

King et al. (2000) 18.67% -.28 [-1.05, .49] .47

Kataoka et al. (2003) 24.26% -.33 [-.66, -.01] .04
Smith et al. (2005) 18.38% -.70 [-1.50, .09] .08
Scheeringa et al. (2010) 18.98% -.62 [-1.37, .13] .10
McMullen et al. (2010) 19.72% -2.05 [-2.75, -1.35] .43

Mean Effect Size -.78 [-1.41, -.15] .01

-2 -1.5 -1 -.5 0 .5 1
Effect Size
Study Weight with 95% CI p TF-CBT vs. Alternative Treatments

King et al. (2000) 3.09% -.02 [-.78, .76] .96

Cohen et al. (2004) 14.73% -.29 [-.56, -.01] .04
Cohen et al. (2005) 8.27% -.51 [-.94, -.07] .02
Runyon et al. (2010) 6.60% -.05 [-.55, .45] .83
Jaycox et al. (2010) 10.82% .14 [-.21, .50] .43
Deblinger et al. (2011) 8.23% -.03 [-.47, .40] .86
Deblinger et al. (2011) 8.10% -.27 [-.71, .16] .22
Cohen et al. (2011) 11.16% -.15 [-.49, .20] .41
Nixon et al. (2012) 4.09% -.01 [-.67, .65] .98
Ormhaug et al. (2014) 12.35% -.52 [-.84, -.19] < .01
Jensen et al. (2014) 12.56% -.55 [-.87, -.23] < .01

Mean Effect Size -.25 [-.39, -.09] < .01

-2 -1.5 -1 -.5 0 .5 1
Note. Negative effect size values indicate that treatment outcomes favor TF-CBT; positive effect size values
indicate that treatment outcomes favor no treatment, waitlist controls, or alternative treatments

Figure 2. Effect sizes, 95% confidence intervals, and p values for studies evaluating TF-CBT for decreasing
symptoms of co-occurring depression using no treatment/wait-list and alternative treatment comparison
groups. TF-CBT ¼ trauma-focused cognitive behavioral therapy.

of the relationship between domicile and effect
size was substantial, revealing that studies from
domestic samples yielded substantially lower
treatment effects (g ¼ .37) when compared
to international samples (g ¼ 1.39). There-
fore, it can be inferred that heterogeneity within
this sample of studies may be associated with
study characteristics related to the domicile of
participants. This sample yielded an Nf of 32,
indicating that 32 unpublished studies with an
effect size of zero would be needed to refute
our findings.
95 ¼ [.39, .09]), indicative of a small effect
size and scenario in which the null hypothesis
can be rejected. The effect sizes within the dis-
tribution of studies were homogeneous,
Q(10) ¼ 14.66, p ¼ .15, and I2 < 31.80, indicat-
ing that approximately 31% of the total varia-
bility was due to between-study heterogeneity
and exploration of moderating variables was
not warranted. This sample yielded an Nf of
30, indicating that 30 unpublished studies with
an effect size of 0 would be needed to refute our
findings.

TF-CBT versus alternative treatments. The 10

studies included in the analysis of TF-CBT ver-
sus alternative treatments for decreasing the
symptoms of co-occurring depression (n ¼
1,109) yielded a mean effect size of .25 (CI
Discussion
The findings of our meta-analysis of studies
evaluating the efficacy of TF-CBT for decreas-
ing the symptoms of PTSD and co-occurring

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28
depression produced some consistent and
favorable findings. Mean effect sizes among
the 21 studies assessing the efficacy of
TF-CBT for decreasing PTSD indicated that
TF-CBT was exceptionally superior to no treat-
ment or wait-list comparisons and moderately
superior to alternative treatments. These find-
ings are hopeful when considering the potential
for unmitigated PTSD symptomology among
children and adolescents to carry into adult-
hood and be characterized by co-occurring psy-
chiatric disorders (Howe, 2005; Schoedl et al.,
2010). Inspection of the relationship between
moderator variables and effect sizes indicated
that whereas the findings are promising, they
may be most descriptive of the experiences that
adolescents have in treatment when compared
to younger children. One possible explanation
for this finding is that some components of the
TF-CBT protocol may be more developmen-
tally accessible for older clients when com-
pared to younger ones. For example, families
may be responsive to parent psychoeducation
and relaxation skills training components
regardless of client age; however, the ability
to talk about traumatic events and work through
trauma narrative components may be more suc-
cessful when a greater degree of cognitive dif-
ferentiation is present. Another explanation for
this finding may be that older children may
have more experience in communicating to
caregivers and other collaterals about the type
and amount of support that is helpful in their
recovery from a traumatic event. Interestingly,
participants across studies appeared to respond
positively to treatment regardless of composite
ethnic identity or type of trauma reported
within the sample.
Inspection of our findings related to the
effectiveness of TF-CBT for mitigating co-
occurring depression symptoms across 17 stud-
ies revealed varied support in favor of TF-CBT
over wait-list and alternative treatment compar-
isons. Among studies that implemented a wait-
list or no treatment comparison, TF-CBT was
notably more efficacious; however, the degree
to which this effect is attributable to mean score
gains among international participant samples
when compared to domestic ones is uncertain.
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Counseling Outcome Research and Evaluation 6(1)
A possible explanation might be that culturally
contextualized factors may have influenced the
rate at which participant’s remediated associ-
ated depressive symptoms within treatment, but
the nature of this information is not clear within
our analysis. When inspecting differences
between TF-CBT and alternative treatments for
treating co-occurring depression, a modest
treatment effect was detected. Within this anal-
ysis, effect sizes of individual studies were
homogenous, indicating that change along the
construct was likely not associated with moder-
ating variables such as age, ethnic identity, type
of trauma, or domicile. This finding is pro-
mising for counselors who wish to implement
TF-CBT, especially when considering the
findings that symptoms of depression com-
monly accompany PTSD among children and
adolescents (SAMHSA, 2011) and that this
co-occurrence can complicate the course of
treatment (McLean et al., 2014).
Given the relatively equal distribution of girls
and boys across study samples (59% girls and
41% boys) we submit that our findings may have
a greater degree of generalizability than other
evaluations of trauma-oriented practices that
may be limited by the inclusion of predomi-
nately one gender. Furthermore, it appears that
aside from age differences that were associated
with treatment effect sizes, the results of our
meta-analysis were mostly stable across the
domains of ethnic identity and type of trauma
receiving treatment for. When inspecting the dif-
ferential influence of domicile on magnitude of
treatment effect, we would like to highlight that
although there was an apparent difference
detected, both the domestic and international
groups reported favorable change along symp-
tom domains. It may be inferred from these
findings that the composite elements within a
TF-CBT protocol are suitable across demo-
graphic groups, with promising effects reported
among individuals regardless of ethnic identity,
type of trauma experienced, or geographic locale.
Implications for Counselors
Counselors interested in providing TF-CBT are
encouraged to complete some degree of formal
Lenz and Hollenbaugh
training and supervision to promote fidelity of
treatment. Continuing education resources such
as those at tfcbt.musc.edu provide didactic
material and video demonstrations to support
best practice when working with families. For-
malized training will help set the foundation for
counselors to enhance and implement ingenuity
while implementing this intervention. Although
the manual provides the groundwork, it is the
obligation of the counselor to individualize and
enhance the treatment through creative methods.
In light of our findings, counselors should con-
sider that this treatment may be better suited for
older children and adolescents due to aspects of
treatment such as the generation of the trauma
narrative that require at least a moderate degree
of insight. Finally, our analyses suggest that
although some researchers used only the parent
or child components of treatment, the full proto-
col that involves both children and parents were
tended to be more efficacious. Therefore, despite
some possible logistical complications, counse-
lors should involve parents and children to opti-
mize treatment outcomes.
Limitations and Recommendations for
Future Research
Although meta-analyses provide an even-
handed estimation of treatment effect that con-
trols for many aspects of study characteristics
and publication bias, some caveats are noted.
First, our analysis of 21 PTSD studies was
sufficient for inspecting the relationship of
moderator variables using meta-regression
analyses; the limited amount of studies inspect-
ing co-occurring depression relegated our
analyses to inspection of visually apparent
relationships among graphical data. A greater
sample of studies reporting these findings
would have promoted more statistically robust
analyses of these relationships. Next, three
studies that were initially identified and met
study characteristic criteria did not report ade-
quate statistical information and contacting pri-
mary authors for this information was not
fruitful. For this reason, we could not include
those findings within our analysis and we
encourage future researchers to report specific
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29
demographic frequencies, means, and standard
deviations for scores rather than ranges or omit-
ting demographic information that may promote
generalization of findings to the larger popula-
tion. Third, our analysis was based on compari-
sons of gain scores assessed at pretreatment and
termination intervals. Although this practice
provides useful information for clinicians to
consider, the addition of studies that report
follow-up data may help clarify the degree that
treatment effects are sustained over time.
Finally, when considering changes to the diag-
nostic criteria for PTSD within the Diagnostic
and Statistical Manual, Fifth Edition (APA,
2013), it will be prudent for researchers to begin
evaluating treatment effects using newer assess-
ments of this new conceptualization.
Conclusion
Our analysis revealed that TF-CBT is a promis-
ing intervention for treating the symptoms of
PTSD and co-occurring depression among chil-
dren and adolescents when compared to no
treatment or alternative treatments. In addition
to having broad implications for effectiveness
among children and adolescents, our findings
suggest that treatment effects are likely to be
noted when implementing this counseling
approach across client populations regardless
of age, ethnic identity, or type of trauma for
which treatment is being sought. We suggest
that counselors who wish to implement this
approach seek formal education, training, and
supervision but also keep in mind that the
flexibility inherent within the protocol may
contribute to favorable outcomes among in
their setting. We regard our findings as both
supportive and preliminary, conceding that
greater understanding about the most effica-
cious applications of TF-CBT will require
future investigations that accurately report
procedures and outcomes within professional
publication outlets.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
30
Funding
The author(s) received no financial support for
the research, authorship, and/or publication of
this article.
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Author Biographies
A. Stephen Lenz, PhD, LPC (TX), LPC-MHSP
(TN), is an assistant professor in the Department of
Counseling and Educational Psychology at Texas
A&M University—Corpus Christi. Dr. Lenz has
worked with children, adolescents, adults, and fami-
lies in community-based, private practice, and uni-
versity counseling settings. His research interests
include community-based program evaluation,
counseling outcome research, single-case research,
instrument development, and holistic approaches to
counseling, counselor education, and supervision.
K. Michelle Hollenbaugh, PhD, LPC-S, is an assis-
tant professor in the Department of Counseling and
Educational Psychology at Texas A&M University—
Corpus Christi. Her research interests include
dialectical behavior therapy, assessment, counselor
education pedagogy, & evidenced based interventions
in counseling.