July 2021|Volume 9, Issue 3 |
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EVIDENCE IN ACTION
A quarterly research brief from the
Center on Trauma and Children
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Examination of Sex Differences in the PTSD Symptom Response of Polyvictimized Youth to Isolated Phases of Trauma-focused Cognitive Behavioral Therapy
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Ascienzo, S., Sprang, G., & Royse, D. (2021, February 22). Gender Differences in the PTSD Symptoms of Polytraumatized Youth During Isolated Phases of Trauma-Focused Cognitive Behavioral Therapy. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0001028
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While a great deal of research has focused on the differences in the experiences of male and female trauma survivors, existing studies have primarily looked at the types of traumatic events encountered and females’ increased likelihood of developing Posttraumatic Stress Disorder (PTSD). Conversely, there has been relatively little attention to how a person’s sex may play a role in patients’ responses to trauma-focused treatment. The limited number of studies that do focus on this vary too widely to draw any conclusions. Furthermore, trauma symptoms are typically assessed only at the beginning and end of treatment which fails to account for the possibility of fluctuation throughout the process. In order to better understand how to treat trauma survivors, which methods are effective, for whom, and under which circumstances, investigators have suggested isolating the components of the treatment process, thus allowing the opportunity to assess whether differences exist between males and females at various stages (Cary & McMillen, 2012; Knutsen & Jensen, 2017).
Building on prior knowledge and addressing the need for more research specifically on youth exposed to trauma, this study explores the progression of PTSD symptoms during treatment to assess how individual treatment phases impacted symptom reduction and to determine whether gender-based differences exist
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The Study
The study included 138 participants between the ages of 7 and 18 who presented with PTSD symptoms and received Trauma-focused Cognitive Behavioral Therapy (TF-CBT) at a university clinic. With the option to self-report their sex as male, female, transgender or other, all participants identified as male or female with
slightly more females (58%).
Trauma-focused Cognitive Behavioral Therapy (TF-CBT), one of the most widely used and empirically supported trauma-focused interventions for youth, was the treatment approach employed and is particularly well-suited due to its phase-based approach that allows for assessment at specific points throughout treatment (Cohen, Mannarino, and Deblinger, 2006; Cary & McMillan, 2012). It uses the PRACTICE acronym for its components: Psychoeducation and Parenting skills, Relaxation skills, Affective expression, Cognitive coping and processing I and II, Trauma narrative, In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety and future development (Cohen et al., 2006).
Symptom domains of PTSD (intrusion, avoidance, and arousal) as well as an additional overall PTSD score were measured using the University of California Los Angeles Post-traumatic Stress Disorder Reaction Index (UCLA-PTSD RI). The UCLA-PTSD RI is a child self-report instrument that assesses the diagnostic criteria of PTSD as well as two other associated symptoms: guilt and fear of traumatic events reoccurring (Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998). It includes 22 items that ask about the frequency of PTSD symptoms during the past month rated from 0 (none of the time) to 4 (most of the time).
Gender and sexual violence history were the two independent variables in this study that were analyzed alongside the scores in each phase of treatment.
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Findings
The study participants were polyvictimized with an average of 4.78 different trauma types, and 47% experienced sexual violence. A significantly larger number of girls (56.3%) reported experiencing sexual violence compared to 34.5% of boys in the study.
Consistent with prior research on TF-CBT, both males and females in this study had a reduction in symptoms from the beginning to end of treatment, and results suggested that this generally progressed in a similar way for both genders with certain exceptions. While females reported significantly higher levels of overall PTSD symptoms compared to males at baseline, this changed by the end of treatment due to the substantial symptom reduction reported by girls in the last phase, processing and integration. The marked decrease in symptoms for females was enough to lead to the absence of any significant gender-based symptom differences by the end of the study.
Although prior studies have shown sexual violence to have a great deal of impact on symptom severity regardless of sex (Tolin & Foa, 2006; Trickey et al., 2012), findings from this study were not consistent with that. However, it is possible this could be because of the polyvictimization of this study’s participants where the cumulative effect of multiple traumas could outweigh the heightened risk of PTSD for survivors of sexual violence.
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-TF-CBT is a highly effective treatment for trauma-exposed youth, both male and female.
-Processing and integration of trauma, while challenging, is an important part of treatment and may be particularly beneficial for female trauma survivors.
-Measurement-based care (aka outcome or process monitoring) can be a valuable tool throughout the treatment process to help determine a child’s individual needs and progress.
-Attending to individual PTSD symptom domains, not just overall PTSD severity, is important and can help focus treatment. A child who exhibits substantial arousal symptoms, for example, may benefit from an increased focus on relaxation strategies, whereas a child with highly distressing intrusive symptoms may need more gradual exposure to traumatic content in a manner they can tolerate.
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-TF-CBT significantly reduced PTSD symptoms for both boys and girls, although girls reported higher symptoms during some phases of treatment. Recognizing different pathways to recovery is important.
-When addressing gender differences, it is also important to make the distinction between sex, which refers to the biological characteristics of males and females, and gender, which is a more complicated set of social and psychological constructs (Lott & Maluso, 1993). Sex differences can account for some of the differences in trauma reactions of males and females, but the ways boys are girls are socialized differently and prescribed gender roles may also affect symptom expression and coping with trauma.
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References
Cary, C. E., & McMillen, J. C. (2012). The data behind the dissemination: A systematic review of trauma-focused cognitive behavioral therapy for use with children and youth. Children and Youth Services Review, 34(4), 748–757.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. Guilford Press.
Knutsen, Marie & Jensen, Tine. (2017). Changes in the trauma narratives of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress symptoms. Psychotherapy research: Journal of the Society for Psychotherapy Research, 29, 1-13.
Lott, B., & Maluso, D. (1993). The social learning of gender. In AE Beall & RJ Sternberg (Eds.), The psychology of gender, pp. 99-126.
Pynoos, Rodriguez, Steinberg, Stuber, & Frederick,C. (1998). UCLA PTSD Index for DSM-IV. Unpublished Manual.
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959–992.
Trickey D, Siddaway A, Meiser-Steadman R, Serpell L & Field A (2012) A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review, 32(2), 122-138.
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