Psychiatric Times. Vol. 29 No.

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CHILD AND ADOLESCENT PSYCHIATRY
Treatment of Traumatic Stress Disorder in
Children and Adolescents
Assessment and Treatment Strategies
By Victor G. Carrion, MD and Hilit Kletter, PhD | October 29, 2012
Dr Carrion is Professor in the department of psychiatry and behavioral sciences and Director of the
Stanford Early Life Stress Program. Dr Kletter is Master Clinician and Lab Director of the Stanford
Early Life Stress Program at Stanford University School of Medicine in California. The authors report
no conflicts of interest concerning the subject matter of this article.
We all experience stress throughout our lives; this can be beneficial because
stress inoculation aids in the development of many of our biological systems.
1
Stress also helps the development of our psychological well-being. Learning to
cope with adversity is an important part of develop-ing ones sense of
effectiveness and coping. Our bodies are built to manage stressful events and, in
fact, our performance may improve, in certain situations, when we are stressed.
However, this applies only up to a certain point. That point differs for each
individual and depends on genetic and environmental factors, which influence
stress vulnerability. When stressors are overwhelming and activate our fear
mechanism in a way that over-sensitizes it to future stress, that is traumatic
stress. Different events in our life can act as trauma: natural and man-made
2
disasters, accidents, and traumatic loss.
For some individuals, traumatic stressors can be acute: a bushfire, a shooting. For others, they may be
more chronic: ongoing war, child abuse. Acute trauma can lead to secondary stressors, initiating a
chronic process of adjustment. Traumatic events and other stressors may accumulate in an allostatic
load to our systems. When the load overwhelms our coping mechanisms (psychological and
3
physiological), PTSD may develop.
The effects of traumatic stress on development
Traumatic stress in children can lead to difficulties in social, emotional, and cognitive development.
Approximately 25% to 30% of children who experience inner-city violence develop symptoms of
PTSD. Although a number of children are resilient to traumatic experiences, there are no methods to
4
identify and measure what constitutes true resilience. Problems may develop in some children not
shortly after a traumatic event; however, the allostatic load may be building, pushing them closer to a
threshold where specific vulnerabilities may eventually manifest clinically.
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Preventive interventions for youths exposed to chronic stressors or at risk for traumatic stress are
critical. Many people believe that being a child by itself constitutes a protective factor against the effects
of trauma; however, there is no evidence to support this. In fact, the evidence points toward the contrary:
children are particularly vulnerable to the effects of trauma. Epidemiological studies indicate that
5
children exposed to trauma are at much greater risk for PTSD.
6
The impact of trauma on cognitive processing, as demonstrated by difficulties with learning and
memory, renders many children with posttraumatic symptoms to be less successful in school. Emotional
regulation, social development, and behavior can also be affected. The phenomenology differs
depending on the childs developmental age.
What new information does this article provide?
The authors discuss the different manifestations of traumatic stress; treatment considerations for
childhood PTSD; and the existing interventions, including a new hybrid psychotherapy.
What are the implications for psychiatric practice?
Clinicians will be better informed about diagnosis of childhood PTSD and selection of appropriate
interventions.
Although we use PTSD as a construct to understand childrens response to trauma, children with
subthreshold symptoms can also have the same degree of functional impairment. Alternative criteria
7
have been suggested for the diagnosis of PTSD in young children.
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Therapeutic interventions
Trauma affects youths on multiple levels, including individual, family, community, society, and culture.
These levels act as either risk or protective factors and may influence the child directly and through
interaction with each other. Thus, to fully comprehend the effects of trauma on the child, treatment
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models ought to consider each of these levels. There is growing support in the childhood trauma
literature for a comprehensive treatment model within an ecological context. Bronfenbrenner
10,11 9,12
conceptualized such an ecological framework that takes into account environmental influences on
childrens development. This framework consists of 4 nested systems around the individual child:
Microsystem: direct environmental experiences of the child (family, school)
Mesosystem: interrelations among 2 or more of these environments (relationship between child and
peer group)
Exosystem: community influences (neighborhoods, peers, schools)
Macrosystem: societal beliefs and values (public policy)
Treatments for childhood trauma include individual, group, family, school-based, and biological
interventions. Some treatments enhance resiliency and prevent symptom development, while others
reduce symptoms and improve functioning. Although a variety of treatments exist, it is important to use
evidence-based interventions because they provide clear guidelines about what treatment components
are necessary and help determine treatment efficacy. Consider cultural and linguistic factors when
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selecting an intervention. provides additional treatment considerations. (A complete review of Table 1
best-practice interventions can be found in Foa et al. )
13
Table 1
Important factors to consider when choosing a treatment for childhood trauma
Cognitive-behavioral therapy . CBT is the most widely used and researched treatment for childhood
trauma. Various trauma-oriented CBT interventions exist and all share components summarized by the
14
acronym PRACTICE ( ). Trauma-focused (TF)-CBT combines individual and parent-child Table 2
15
sessions. TF-CBT has proved to be efficacious in numerous randomized controlled trials for reduction of
PTSD symptoms, depression, and other emotional and behavioral difficulties for single-event and
multiple-event traumas. It is superior to child-centered therapy in reducing PTSD symptoms,
16-18
especially hyperarousal and avoidance in youths exposed to intimate partner violence.
19
Trauma systems therapy (TST) is an individual treatment that addresses trauma-related symptoms and
the environmental factors that perpetuate them. TST has shown improvements in PTSD symptoms,
20
environmental stability, and functioning.
Table 2
Trauma-focused CBT components
Many CBT interventions for youths are school-based. The multi-modality trauma treatment (MMTT)
protocol, an intervention that uses developmentally sensitive methods, has been successfully
implemented in school and community mental health settings. The Cognitive-Behavioral
21,22
Intervention for Trauma in Schools (CBITS) is a 10-session treatment that has been shown to improve
psychosocial functions in youths exposed to violence. Finally, several studies of earthquake survivors,
23
victims of the Bosnian war, and victims of community violence have found that trauma/grief-focused
therapy resulted in significant reduction of PTSD symptoms.
24-26
Psychodynamic therapy . Child-parent psychotherapy (CPP) is a dyadic treatment in which play and
other expressive methods are used to repair attachment and regulate traumatic stress. Young children
27
exposed to domestic violence who received CPP had greater reductions in total behavior problems and
traumatic stress symptoms, and mothers had greater reductions in avoidance than controls. These gains
were maintained at 6-month follow-up. Parent-child interaction therapy has also been found to improve
social, emotional, and behavioral functioning through play therapy and live coaching aimed at
improving attachment.
28
The intergenerational trauma treatment model, an intervention aimed at monitoring dysfunctional family
patterns and altering them, has resulted in improvements in social functioning in traumatized children.
29
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Psychoeducation . A key component of trauma treatment involves providing information on the
prevalence of trauma and the nature and course of posttraumatic stress reactions. Treatment goals are
normalization of responses, identification of trauma reminders, and strategies for managing distress. In
youths exposed to a single-incident trauma, PTSD symptoms were significantly reduced following the
psychoeducation phase of treatment. Kenardy and colleagues conducted an information provision
30 31
intervention in youths and their caregivers following a pediatric accidental injury. The intervention
resulted in a decrease of anxiety in the child at 1-month follow-up; at 6-month follow-up, parental
intrusion and overall posttraumatic symptoms were decreased. Furthermore, a psychoeducational
31
intervention for youths following motor vehicle accidents was successful in preventing depression and
behavior problems in preadolescent youths.
32
Play therapy . Posttraumatic play is defined as play activity that is driven, is serious, and has a morbid
quality. It is characterized by repetitive, unresolved themes; increased aggression and/or
33,34
withdrawal; fantasies linked with rescue or revenge; reduced symbolization; and concrete thinking.
DSM-IV includes repetitive play with traumatic themes as a symptom of reenactment (cluster B) in
children. Child-centered play therapy (CCPT) is the most researched form of play therapy for childhood
trauma.
35
CCPT is a manualized treatment based on person-centered therapy that establishes unconditional
positive regard, genuineness, and empathy to facilitate childrens communication of feelings, thoughts,
and desires. This form of play therapy utilizes culture-specific toys and includes parent consultation for
each of the play sessions. Studies of youths exposed to domestic violence and natural disaster found
CCPT to improve self-concept and significantly reduce anxiety, depression, aggression, and suicidal
risk. In addition, a study of refugee children found that CCPT was more effective than TF-CBT in
36-38
reducing PTSD symptoms.
39
Release play therapy is a directed psychotherapy in which the therapist selects a few toys related to the
trauma to encourage the child to play out traumatic themes or may re-create the event that triggered the
childs difficulties to allow expression of feelings. In this form of therapy, the therapist rarely
40
interprets the play.
Cue-centered therapy (CCT): a hybrid intervention . The Stanford CCT is a manual-based treatment that
combines elements of CBT and psychodynamic, expressive, and family therapies and enhances them
with psychoeducation on classic conditioning and trauma-related reminders (cues). Therapy focuses on
how these cues are linked to current behaviors, emotions, thoughts, and physiological reactions. CCT
41
emphasizes the importance of collaboration among the therapist, child, and caregiver to increase a sense
of efficacy and empowerment through knowledge.
CCT is divided into 4 parts: psychoeducation and coping strategies; incorporating traumas into life
narratives involving expression of emotions, filling of memory gaps, identification of cues, correction of
cognitive distortions, and integration of the traumas into the greater context of the childs life; gradual
exposure to cues while replacing maladaptive behaviors with adaptive ones; and consolidation of
learned skills.
Pharmacology
While use of psychotropic medications in adults with PTSD is common and algorithms exist to guide
clinicians in which medications to choose, research on pharmacotherapy for childhood PTSD is lacking.
Psychotherapy is generally considered to be the first choice of treatment for childhood PTSD.
42
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However, pharmacotherapy has been indicated when the severity of symptoms impedes engagement in
psychotherapy, to treat comorbidity, or when the clinical presentation is marked by the severity of one
of the symptom clusters (frequent dissociation or hyperarousal). A review of all psychotropic
medications that may be effective in treating childhood PTSD is beyond the scope of this article, thus
only a select few are discussed here. (Please see Wilkinson and Carrion for a comprehensive review of
42
all psychotropic medications that may be effective in treating childhood PTSD.)
Data on the efficacy of SSRIs have been mixed. A study that compared 24 youths with PTSD with 14
adults with PTSD found that resulted in equivalent citalopram(Drug information on citalopram)
improvement. An open trial of demonstrated that it was
43
fluoxetine(Drug information on fluoxetine)
effective in improving earthquake-related PTSD symptoms in 26 youths. However, some studies have
44
found SSRIs to be of no benefit in treating childhood PTSD.
A randomized controlled trial of children with PTSD found no difference between sertraline(Drug
and placebo in treatment outcome. A study that compared TF-CBT plus information on sertraline)
45
sertraline with TF-CBT plus a placebo in sexually abused youths with PTSD found that all youths
improved with no group-by-time differences except on the Childrens Global Assessment Scale. The
46
study concluded that while use of sertraline combined with psychotherapy may benefit some children, it
is generally better to start psychotherapy alone and add an SSRI only if symptom severity or lack of a
response indicates the need.
SSRI use is also associated with certain risks in youths. For some children, SSRIs may be overly
47,48
activating and may lead to irritability, poor sleep, and inattention. In addition, there is an FDA black box
warning for increased suicidal ideation or behaviors for all antidepressant medications in individuals
younger than 24 years.
Other medications that have been researched for use in treatment of children with PTSD include
non-SSRI antidepressants, blocking agents, novel antipsychotics, mood stabilizers, and opiates. A study
of hospitalized children with acute stress disorder secondary to burns found that PTSD was less likely to
develop after 6 months in patients who received imipramine(Drug information on imipramine)
compared with those who received . However, chloral hydrate(Drug information on chloral hydrate)
49
TCAs are associated with rare but serious cardiac adverse effects and therefore are not recommended as
a first-line treatment for children with PTSD.
Adrenergic blocking agents have also been used with some success in youths with PTSD. Two studies
found that decreased basal heart rate, anxiety, impulsivity, and clonidine(Drug information on clonidine)
hyperarousal symptoms. In addition, a case study of a child with PTSD found clonidine to improve
50,51
sleep and neural integrity of the anterior cingulate, a brain region responsible for modulation of
emotional responses that is often impaired in PTSD.
52
Propranolol(Drug information on propranolol)
has also been found effective in reducing reexperiencing and hyperarousal symptoms in children with
PTSD. Novel antipsychotics such as have been used
53
risperidone(Drug information on risperidone)
effectively to stabilize mood in severe cases and to treat comorbid symptoms of childhood PTSD.
54
Finally, higher doses of were found to prevent PTSD morphine(Drug information on morphine)
secondary to burns in hospitalized preschool children, school-aged children, and adolescents.
55,56
Conclusions
Although treatments exist for children who experience traumatic stress, the heterogeneous manifestation
of symptoms supports the need for development of further treatments. Children who experience trauma
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need an ecological approach during assessment and a biopsychosocial approach to their treatment. The
role of prevention of trauma and prevention of functional impairment after trauma is paramount, because
this may disrupt the accumulated physiological and psychological effect of stressors in the individual.
Treatments should be tailored to the specific circumstances and characteristics of the particular child or
family.
Photo by Flickr/PotatoJunkie
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