Washington State Institute for Public Policy
Cognitive Behavioral Therapy (CBT)-based models for child trauma
Children's Mental Health: Trauma
Benefit-cost estimates updated May 2017.  Literature review updated April 2012.
Treatments include several components, such as psycho-education about post-traumatic stress disorder (PTSD), relaxation and other techniques for managing physiological and emotional stress, the gradual desensitization to memories of the traumatic event (also called exposure), and cognitive restructuring of inaccurate or unhelpful thoughts. In the studies included in this review, weekly treatments provided 9 to 15 therapeutic hours per client in individual or group settings. This review includes studies of Trauma-Focused CBT, Cognitive Behavioral Intervention for Trauma in Schools (CBITS), Narrative Exposure Therapy for traumatized children (Kid-NET), Enhancing Resiliency Among Students Experiencing Stress (ERASE), and Trauma and Grief Component Therapy.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $1,913 Benefits minus costs $6,523
Participants $3,189 Benefit to cost ratio n/a
Others $648 Chance the program will produce
Indirect $436 benefits greater than the costs 100 %
Total benefits $6,185
Net program cost $338
Benefits minus cost $6,523
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $5 $0 $14 $3 $21
K-12 grade repetition $6 $0 $0 $3 $9
K-12 special education $18 $0 $0 $9 $27
Labor market earnings associated with PTSD $1,380 $3,038 $0 $0 $4,418
Health care associated with PTSD $516 $168 $639 $258 $1,581
Costs of higher education ($12) ($17) ($5) ($6) ($40)
Adjustment for deadweight cost of program $0 $0 $0 $169 $169
Totals $1,913 $3,189 $648 $436 $6,185
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $730 2009 Present value of net program costs (in 2016 dollars) $338
Comparison costs $1,035 2009 Cost range (+ or -) 10 %
We estimated the per-participant cost by computing the weighted average therapeutic hours for this sample of studies (average hours of group and individual therapy reported in the studies), multiplied by the average Regional Support Network costs (for 2009) for group and individual therapy.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Anxiety disorder 8 403 -0.124 0.069 13 -0.057 0.035 14 -0.141 0.041
Externalizing behavior symptoms 6 172 -0.103 0.131 13 -0.049 0.071 16 -0.125 0.409
Global functioning^ 3 81 -0.249 0.153 13 0.000 0.024 14 -0.581 0.001
Internalizing symptoms 5 118 -0.150 0.268 13 -0.109 0.213 15 -0.199 0.545
Major depressive disorder 14 846 -0.239 0.051 13 0.000 0.020 14 -0.375 0.001
Post-traumatic stress 21 1311 -0.370 0.058 13 -0.370 0.058 14 -0.559 0.001
Suicidal ideation^ 1 26 -0.106 0.283 13 0.000 0.025 14 -0.294 0.301
Citations Used in the Meta-Analysis

Berger, R., & Gelkopf, M. (2009). School-Based Intervention for the Treatment of Tsunami-Related Distress in Children: A Quasi-Randomized Controlled Trial. Psychotherapy and Psychosomatics, 78(6), 364-371.

Berger, R., Pat-Horenczyk, R., & Gelkopf, M. (2007). School-based intervention for prevention and treatment of elementary-students' terror-related distress in Israel: A quasi-randomized controlled trial. Journal of Traumatic Stress, 20(4), 541-551.

Berkowitz, S. J., Stover, C. S., & Marans, S. R. (2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry and Allied Disciplines, 52, 6, 676-685.

Berliner, L., & Saunders, B.E. (1996). Treating fear and anxiety in sexually abused children: Results of a controlled 2-year follow-up study. Child Maltreatment 1(4), 294-309.

Burke, M.M. (1988). Short-term group therapy for sexually abused girls: A learning-theory based treatment for negative effects. Dissertation Abstract International, 49: 1935.

Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic beliefs among sexually abused girls and their mothers: An evaluation study. Journal of Abnormal Child Psychology, 24(1), 1-17.

Cohen, J.A., Deblinger, E., Mannarino, A.P., & Steer, R.A. (2004). A multisite, randomized controlled trial for children with sexual abuse- related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

Cohen, J.A., Mannarino, A.P., & Iyengar, S. (2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: A randomized controlled trial. Archives of Pediatrics and Adolescent Medicine, 165(1), 16-21.

Cohen, J.A., Mannarino, A.P., & Knudsen, K. (2005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29(2), 135-145.

Cohen, J., Mannarino, A. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child Adolescent Psychiatry, 35(1), 42–50.

Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually Abused Children Suffering Posttraumatic Stress Symptoms: Initial Treatment Outcome Findings. Child Maltreatment, 1(4), 310-321.

Deblinger, E., Stauffer, L.B., & Steer, R.A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment 6(4), 332-343.

Ertl, V., Neuner, F., Pfeiffer, A., Elbert, T., & Schauer, E. (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda: A randomized controlled trial. Journal of the American Medical Association, 306(5), 503-512.

Goenjian, A.K., Karayan, I., Pynoos, R.S., Minassian, D., Najarian, L.M., Steinberg, A.M., & Fairbanks, L.A. (1997). Outcome of Psychotherapy Among Early Adolescents After Trauma. American Journal of Psychiatry, 154(4), 536-542.

Jordans, M. J D., Komproe, I.H., Tol, W.A., Kohrt, B.A., Luitel, N.P., Macy, R.D., & De Jong, J.T.V.M. (2010). Evaluation of a classroom- based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial. Journal of Child Psychology and Psychiatry, 51 (7), 818-826.

Kataoka, S., Stein, B.D., Jaycox, L.H., Wong, M., Escudero, P., Tu, W., Zaragoza, C., & Fink, A. (2003) A school-based mental health program for traumatized Latino immigrant children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 311- 318.

King, N.J., Tonge, B.J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., . . . Ollendick, T.H. (2000). Treating sexually abused children with postraumatic stress symptons: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 39(11), 1347-1355.

Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M., Pa+íali-ç, A., Durakovi-ç, E. et al. (2008). Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 1048-1062.

Ruf, M., Schauer, M., Schauer, E., Elbert, T., Neuner, F., & Catani, C. (2010). Narrative exposure therapy for 7- to 16-year-olds: A randomized controlled trial with traumatized refugee children. Journal of Traumatic Stress, 23(4), 437-445.

Shooshtary, M.H., Moghadam, J.A., & Panaghi, L. (2008). Outcome of Cognitive Behavioral Therapy in Adolescents After Natural Disaster. Journal of Adolescent Health, 42(5), 466-472.

Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish, T., & Clark, D.M. (2007). Cognitive-behavioral therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46(8), 1051-1061.

Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong, M., Tu, W., Elliott, M.N., & Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. Journal of the American Medical Association, 290(5), 603-611

Tol, W. A., Komproe, I.H., Susanty, D., Jordans, M.J.D., Macy, R.D., & De Jong, J.T.V.M. (2008). School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial. Journal Of The American Medical Association 300(6), 655-662.

For more information on the methods
used please see our Technical Documentation.