A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents

• Author: Larissa M. Hoogsteder,Geert Jan J. M. Stams,Eveline E. Schippers,Lotte ten Thije
• Published date: 01 May 2022
• Date: 01 May 2022
• DOI: http://doi.org/10.1177/0306624X211010290
• Subject Matter: Articles

https://doi.org/10.1177/0306624X211010290

International Journal of

Offender Therapy and

Comparative Criminology

2022, Vol. 66(6-7) 735 –757

© The Author(s) 2021

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DOI: 10.1177/0306624X211010290

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Article

A Meta-Analysis of the

Effectiveness of EMDR and

TF-CBT in Reducing Trauma

Symptoms and Externalizing

Behavior Problems in

Adolescents

Larissa M. Hoogsteder1, Lotte ten Thije2,

Eveline E. Schippers1, and Geert Jan J. M. Stams2

Abstract

This multi-level meta-analysis tested if evidence-based trauma treatment was effective

in reducing trauma symptoms and externalizing behavior problems in adolescents.

Based on eight independent samples and 75 effect sizes, results indicated that Trauma

Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization

Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on

reducing trauma symptoms and externalizing behavior problems. Trauma treatment

significantly decreased trauma symptoms (large effect) and externalizing behavior

problems (medium effect). Age and type of control group moderated treatment

effects. Treatment was more effective in older adolescents. Trauma treatment for

adolescents with externalizing behavior problems had a larger effect compared to no

treatment, but not compared to treatment as usual. It seems important to provide a

broad treatment offer for adolescents with severe externalizing behavior problems,

in which, besides trauma treatment, attention is paid to reducing relevant individual

risk factors for behavior problems.

Keywords

meta-analysis, externalizing behavior, trauma treatment, trauma symptoms,

adolescents

1Forensic Care Specialists, Utrecht, The Netherlands

2University of Amsterdam, The Netherlands

Corresponding Author:

Larissa M. Hoogsteder, Forensic outpatient treatment center de Waag, Forensic Care Specialists,

Postbus 1362, Utrecht 3500 BJ, The Netherlands.

Email: LHoogsteder@dewaagnederland.nl

1010290IJOXXX10.1177/0306624X211010290International Journal of Offender Therapy and Comparative CriminologyHoogsteder et al.

research-article2021

736 International Journal of Offender Therapy and Comparative Criminology 66(6-7)

Worldwide, about 23% of the adolescents are exposed to traumatic events, such as

physical or sexual violence, severe accidents, natural disasters, or chronic illnesses

(Costello et al., 2002; Felitti et al., 1998; Putnam, 2003). One out of six adolescents

(15.9%) develops Post-Traumatic Stress Disorder (PTSD) as result (Alisic et al.,

2014). Adolescents who have been exposed to traumatic events may experience trauma

symptoms that influence various developmental areas (Cloitre et al., 2009; D’Andrea

et al., 2012). These developmental areas often relate to internalizing behavior prob-

lems, such as mood disorder symptoms, anxiety symptoms, or a negative self-image

(Campbell et al., 2007; Green et al., 2010; McLaughlin et al., 2012). Recently, it has

become increasingly evident that trauma symptoms relate to externalizing behavior

problems as well, including violent behavior and other types of delinquency (e.g.,

Gold et al., 2011; Greenwald, 2014; Kerig & Becker, 2012; Mersky & Reynolds,

2007). Traumatic experiences may affect the development of executive functioning,

such as behavioral control and inhibition (Cohen et al., 2011; Polak et al., 2012;

Tarullo, 2012), which shows a clear relation to aggression problems and delinquent

behavior (Tonnaer et al., 2016; Van Nieuwenhuijzen et al., 2017).

Trauma Relates to Externalizing Behavior Problems

A recent meta-analysis indicated that individuals who experienced childhood abuse

had a greater chance of committing violence than individuals without such experi-

ences: 17% of the abused individuals ended up committing violent acts compared to

10% of the non-abused individuals (Fitton et al., 2020). Another study showed that

the extent of trauma symptoms in detained adolescents was related to the number of

arrests and severity of their delinquent behavior (Becker & Kerig, 2011). Also, using

a sample of 417 male and 170 female juvenile offenders, research showed that ado-

lescents with PTSD recidivated more often within 3 years than adolescents without

this diagnosis (Becker et al., 2012). Girls with PTSD were more likely to recidivate

than boys with PTSD.

Given the clear connection between traumatic experiences and externalizing behav-

ior problems, trauma treatment seems to be a sensible addition to treatment for adoles-

cents with externalizing behavior and trauma symptoms. Therefore, it is necessary to

investigate if trauma treatment is effective in reducing trauma symptoms in adoles-

cents with externalizing behavior problems, and to investigate if a reduction of trauma

symptoms leads to a reduction of externalizing behavior problems. The current meta-

analysis examines the overall effect of trauma treatment on trauma symptoms and

externalizing behavior problems in adolescents.

Trauma among Adolescents with Externalizing

Behavior Problems

Thus far, it is clear that adolescents with severe externalizing behavior problems

have relatively often experienced traumatic events (Hamerlynck et al., 2006; Maschi

et al., 2008; Steiner et al., 2011). Studies in the USA showed that 90% to 95% of