The Programs That Work series edited by David H. Barlow aims to disseminate evidence-based treatment manuals. These two volumes represent the first in the series to be devoted to PTSD in young people. Prolonged Exposure (PE) has a substantial evidence base for use as a treatment in adults with PTSD. There is also extensive evidence in support of the conditioning models that originally underpinned PE. However, the evidence base for PE in children and adolescents, while extremely promising, is less clear.

Therapeutic exposure (not necessarily the same as PE) to the trauma memory and trauma-related stimuli have been used alongside a variety of supportive (non-specific), behavioural (coping skills training and parenting strategies) and cognitive interventions in youth with PTSD symptoms arising from a range of traumatic events in more than 10 randomized and controlled trials (RCTs). Effect sizes for these multi-component CBT packages vary widely (~0.5–1.1). This range of effect sizes must also be viewed within the context that the majority of participants in these RCTs were recruited by advertisement and were not active treatment seekers; nor did the majority of participants meet diagnostic criteria for PTSD. To date, no published RCT of children or adolescents with a DSM-IV diagnosis of PTSD has evaluated the effect of PE applied in the rigorous manner described in these manuals. However, in the introduction to the Therapist Guide the authors cite their own ongoing open trial of 45 treatment-seeking adolescents with DSM-IV PTSD arising from a variety of traumas, all of whom completed a course of PE based on the current manuals and administered by community-based, child mental health therapists. After an average of 13 treatment sessions the mean reduction in self-reported PTSD symptoms was 71%, corresponding to a within-subject treatment effect size of 2.13 (very large effect). The authors note that this effect size is within range of those obtained in carefully controlled trials of adults with PTSD receiving 9–12 sessions of PE. The findings from this open trial suggest that “purer” treatments comprised entirely of active ingredients drawn from evidence-based models of PTSD may be more effective than the package CBT approaches currently available for childhood PTSD. In support of this suggestion, only one other published RCT involving children and adolescents has achieved the high effect sizes reported by Foa et al. in their Therapist Guide. Smith et al. (Reference Smith, Yule, Perrin, Tranah, Dalgleish and Clark2007) compared the cognitive therapy approach developed by Ehlers and Clark (Reference Ehlers and Clark2007) to wait-list in a clinic-based sample (n = 24) of 8–18 year-olds with a current diagnosis of PTSD linked to a single traumatic event (most had a history of multiple traumas). Using the same self-report measure of PTSD outcome as Foa et al. in their open trial, Smith et al. (Reference Smith, Yule, Perrin, Tranah, Dalgleish and Clark2007) obtained a controlled (intent-to-treat) effect size of 2.48 (the effect size for wait-list was 0.27) for 10 sessions of cognitive therapy involving imaginal reliving of the traumatic event, stimulus discrimination, and restructuring of trauma-related appraisals.

The therapist guide is written in clear language such that those without extensive experience of CBT can access and deliver this treatment under supervision from an experienced CBT therapist. Therapists with extensive experience of trauma focused cognitive and CBT approaches will also find the manual useful for delivering PE treatment as it was intended, and supervising others to do the same. The Therapist Guide is divided into 13 chapters covering: Motivational Interviewing (an optional component); Case Management; Treatment Rational; Gathering Information (assessment); Common Reactions to Trauma (overview of common post-traumatic presentations); Real-Life Experiments (confronting trauma-related stimuli along a hierarchy of distress both in-session and as homework); Recounting the Memory (imaginal exposure to the trauma memory); Worst Moments (focusing attention on the most upsetting moments of the trauma memory); Relapse Prevention; Final Session (termination); and Tailoring Treatment to the Individual. There are several helpful forms in the appendices, including a Crisis Coping Plan (for dealing with suicidal and self-destructive urges); Trauma Interview Form (open-ended questions to assist the therapist in obtaining a detailed account of the trauma, physical and emotional effects (guilt and shame), any changes in beliefs about the self and interpersonal relationships, and difficulties associated with talking about the trauma. Handouts are included for parents describing PTSD and its treatment and how the parents can help the child overcome the effects of the trauma. Finally, two brief case examples are included that are suitable for handing out to the client; and Common Reaction Cards, which the client can be asked to sort to help increase their understanding of the effects of trauma.

The Teen Workbook is comprised of 10 chapters covering the same topics as in the Therapist Guide. Chapters are very brief (4–10 pages) in an easily-readable double-spaced font, with lists to complete that help deepen understanding of the topic under discussion. The overall presentation and language is clear and concise and clearly targeted at and would be understandable by most adolescents. It is completely free of the cartoon and graphical images found in most CBT workbooks for children and adolescents. As such the presentation and language may be more difficult for children under 12 years of age to read and understand without a therapist or parent present to explain various words and concepts. At the end of the workbook are forms for the adolescent to create their own hierarchies of feared situations (trauma-related), to record their traumatic memories and the worst moments therein. The Therapist Guide and Teen Workbook represent a valuable contribution to the literature and will aid therapists in the successful treatment of this all too common and yet largely undiagnosed and untreated condition in teens.