24 Minutes

By THE BALANCE
Fact checked

Posttraumatic stress disorder (PTSD) that occurs as a result of childhood trauma is a serious, often prolonged, and disabling mental illness that affects children and adolescents. PTSD develops in some children (but not all) following exposure to traumatic experiences involving actual or threatened bodily harm or death. Physical abuse, accidents, natural catastrophes, and injuries are all examples of traumatic childhood experiences that can result in PTSD.

PTSD is defined by repeated thoughts and reminders of the traumatic experience, avoidance of trauma cues, poor mood and cognitions about the traumatic experiences, and physiologic hyper-arousal, all of which contribute to substantial social, educational, and interpersonal difficulties. Even toddlers can get PTSD. PTSD has a number of negative outcomes, including an increased risk of developing other mental disorders and an elevated risk of suicide, significant deterioration in role functioning, diminished social and economic opportunities, and an early development of chronic diseases, including cardiovascular disease.

The recommended first-line treatment is evidence-based, trauma-focused psychotherapy for the majority of children and adolescents with posttraumatic stress disorder (PTSD) secondary to childhood trauma or substantial PTSD symptoms without a known cause, including those with complex PTSD.

Numerous clinical trials have demonstrated the efficacy of trauma-focused psychotherapies in lowering PTSD symptoms in children and adolescents; by contrast, no medication for PTSD in this population has been firmly supported by randomized clinical findings. The US Food and Drug Administration (FDA) has not approved any drugs for the treatment of PTSD in children. Multiple small randomized trials in children have indicated that serotonin reuptake inhibitors (SSRIs), which are an effective first-line pharmacologic treatment for adults with PTSD, are ineffective.

Numerous trauma-focused psychotherapy methods place a greater emphasis on different aspects of PTSD symptoms related to childhood trauma and have been tailored to treat individuals with unique characteristics, clinical presentations, or in specific contexts. However, there is a lack of evidence to support the selection of one therapy over the other. Few clinical studies have evaluated psychotherapies directly, and those that have done so have found no differences in the outcomes of active treatments:

Forty-eight children with PTSD were randomly allocated to either eye movement desensitization and reprocessing (EMDR) group or the trauma-focused cognitive-behavioral treatment (TF-CBT) group in a clinical trial. Eight sessions of each intervention resulted in significant effect sizes for PTSD improvement; however, no difference in symptom reduction was seen. Parents and caregivers of children treated with TF-CBT reported improvement in child depression and hyperactivity symptoms, but not those treated with EMDR. A clinical investigation assessed the efficacy of two adult PTSD therapies in children by randomly assigning 103 participants to EMDR, cognitive-behavioral writing therapy, or ,affectswaitlist control. Both active conditions improved PTSD symptoms more than the waitlist condition, with substantial effect sizes for PTSD improvement and no difference between them.

Our preferences for trauma-focused psychotherapies differ according to age group and are mostly based on scientific trials comparing particular therapies to inactive controls, secondary data analysis, and our clinical experience. Numerous therapies have been demonstrated to be effective in treating adolescents with PTSD when compared to an inactive control. The intervention should be delivered by a therapist who has received the necessary training in the paradigm being employed. A course of therapy should be finished in its totality.

Trauma-focused psychotherapy can be delivered to individuals or groups. Group approaches are advantageous when budget constraints, a shortage of experienced therapists, or other hurdles to access preclude individual therapy, as with the Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Individual versus group therapy may also be determined by family preference, particular demographic needs (e.g., trauma and grief component therapy for adolescents with both PTSD and maladaptive grieving symptoms), or clinical presentation. Individual therapy, rather than group therapy, is preferred for children with severe PTSD symptoms. Specific therapy is recommended for subgroups of the population, including:

Children aged 7 years and above — For the majority of 7 years and older children who have PTSD or PTSD symptoms, TF-CBT is the intervention most firmly supported by clinical trial evidence. The findings have been repeated in a variety of populations of children who have experienced different sorts of childhood trauma.

Children aged 3 to 6 years — The recommended method is child-parent psychotherapy (CPP) over alternative psychotherapies. This is particularly advised who have:

  • Considerable cognitive or developmental delays, as involvement in cognitive-based therapies, is not required in this model.
  • Severe issues with attachment, owing to the realtional, attachment-based characteristics of CPP and its lengthier duration.

TF-CBT recommend over CPP for children with:

  • Sexualized behavior disorders, based on positive clinical trial findings
  • Increased prevalence of general internalizing or externalizing difficulties, as shown by a meta-analysis of several clinical treatments.

Children under the age of three — CPP rather than TF-CBT modified for preschoolers or other therapies are often suggested as per clinical and research-based evidence.

Optimizing psychotherapy includes evaluating the adherence of therapy to the evidence-based model, more cautious inquiry of potential trauma triggers, and dealing with unresolved medical concerns of the patients such as ongoing trauma, complex traumatic events, co-existing mental illness, and environmental stressors for patients who don’t respond well.

For patients who have not responded to an extensive trial of first-line psychotherapy, the following options may be considered by the clinician:

  • Interventions that are specifically tailored to the PTSD symptoms of the child
  • Changing to a different trauma-focused therapy that is supported by research
  • Incorporating supplemental medication.

When children with PTSD still have significant PTSD symptoms after completing trauma-focused psychotherapy (or when trauma-focused therapy was not warranted), guanfacine or clonidine medication is widely suggested. Treatment with prazosin is often recommended for children with PTSD who have considerable sleep disruption (or for whom trauma-focused therapy is not suitable).

Contraindications to trauma-focused psychotherapeutic approaches include acute clinical states requiring prompt stabilization (e.g., acute suicidal ideation,  mania, psychosis, or substance abuse); cognitive deficits or developmental delays are contraindications to cognitive-based psychotherapies.

Research studies have shown that PTSD symptoms below the threshold can be effectively treated with trauma-focused psychotherapies. Individual and group treatments, as well as models adapted to the needs of specific subgroups, are all included in these interventions.

Treatment mechanism – PTSD is viewed as a disorder of conditioning of fear that is overgeneralized and cannot subside naturally. The development and maintenance of child PTSD are influenced by social, economic, environmental, learning, and biological factors, indicating the need for multifaceted treatment approaches.

Strong emotional reactions are elicited when someone has been through trauma (eg, anger, fear). When children are exposed to cues that remind them of the trauma, disordered behavior modification causes them to have strong negative emotional reactions to those stimuli. Children avoid trauma reminders in an effort to prevent these negative emotions.

Trauma-focused CBT (for individuals) –  A parallel treatment model for children and parents (or primary caregivers) that combines cognitive-behavioral therapy (CBT), family, attachment, neurobiological, psychological, developmental, and empowerment principles is trauma-focused cognitive-behavioral therapy (TF-CBT). Children and parents are taught coping techniques to help them recover from trauma. They are also taught how to overcome learned and overgeneralized avoidance of painful memories. The next section details the effectiveness of TF-CBT. Children who exhibit trauma-related symptoms, regardless of whether they fulfill diagnostic criteria for PTSD, can benefit from trauma-focused psychotherapy.

Phases and components — TF-CBT is a multi-component treatment that is delivered in three phases. In each therapy session, counseling is provided to the kid and parent (or caregiver, hereafter “parent”) in separate, parallel sessions, as well as in conjoint child-parent group meetings as explained below.

  • Psychoeducation, parental care, relaxation skills, affect regulation skills, and cognitive processing abilities are all included in the stabilization phase.
  • Trauma narration and processing phase – Trauma narration and processing are included in this phase.
  • Phase of integration and consolidation — Includes in-vivo mastering, collaborative child-parent sessions, and safety enhancement.

The following are brief descriptions of the constituents of these phases, which form the abbreviation “PRACTICE”:

Psychoeducation – Information is offered about the relationship between the child’s previous (or ongoing) exposure to traumatic events, trauma reminders, and current trauma symptoms, as well as the commonality of these responses to trauma.

Parenting skills – Parents are taught various effective parenting practices for dealing with their PTSD children. These include abilities such as praising, selective attention, and the use of functioning behavioral evaluation (e.g., altering antecedents and consequences) to manage behavioral trauma effectively.

Relaxation skills — Relaxation techniques (e.g.,  exercise, progressive muscle relaxation, focused breathing and visualization) are taught, tailored to the person, and practiced in order to reverse the physiological trauma effect, including reaction to trauma reminders.

Affect modification skills — Feeling recognition and modulation skills (e.g., vocal expression of unpleasant feelings, accessing support networks, positive diversion methods, and problem-solving) are offered, customized to the individual, and practiced, including in reaction to trauma reminders.

Cognitive processing abilities – Recognize relationships between general negative thought patterns (e.g., “I do not even have any peers”), negative emotions (e.g., anger), and behaviors (e.g., excessive competition with colleagues), and develop the ability to generate more accurate or beneficial thoughts (e.g., “Lisa enjoys my company”) in order to feel good (e.g., less angry) and act differently (e.g., ask Lisa to play at recess). These abilities enable children and parents in gaining control over a variety of unpleasant emotions and behaviors, so preparing them for more focused trauma-related cognitive processing in the subsequent phase.

Trauma narration and processing — Using the skills outlined above, the therapist helps the child in developing a thorough narrative of his or her personal trauma experiences and mentally processing these events. This component is a participatory, therapeutic process that takes place between the therapist and the child (as well as between the therapist and the parent, as the therapist communicates the content of the child’s narrative with the parent). It is believed that exposing trauma-related cognitions and resolving maladaptive thoughts associated with this cognitive information alleviates PTSD symptoms (e.g., cognitive distortions, negative emotions, avoidance, and negative behaviors).

In vivo mastering of reminders of traumatic events – For children who have an irrational fear of trauma-related stimuli in their environment (e.g., avoid the washrooms or living rooms where prior abuse took place but is now safe; resist going to the school where they were bullied earlier but are now safe), in vivo exposure is used to develop psychological adjustment.

Conjoint child-parent sessions — One or more mutual child-parent meetings are included to facilitate direct child-parent interaction about trauma (e.g., sharing the child’s trauma experience with the parent openly, safety planning, and other personalized difficulties).

Improving safety – Trauma causes disruption of safety; re-establishing the child’s real and perceived sense of safety is essential for healing. It’s important to teach children safety skills that are appropriate for their age and living environment and to practice those skills with them.

Efficacy – A number of controlled clinical trials have found that TF-CBT was more effective at reducing PTSD symptoms in children than active treatments or controls for PTSD. Even though there has been some variation in findings of the improvement of associated symptoms (like mood changes, anxiety or depression, behavioral issues, difficulties with parenting, or cognitive dysfunctions), the overall trend has been positive. Three trials including 98 youth with PTSD found that CBT led to reduced PTSD symptoms one month after treatment in comparison with control groups. Children who have experienced sexual assault, domestic abuse, war, or multiple or complex trauma may benefit from these treatments, according to clinical trials.

For instance, the largest clinical trial involved 220 children (aged 8 to 14 years) who had symptoms in each cluster of the DSM IV-TR diagnostic criteria for PTSD, as well as a history of multiple traumas (average = 3.4), one of which was an index trauma of confirmed sexual abuse. Twelve sessions of either TF-CBT or Child-Centered Therapy (CCT) were given to the subjects at random, with the child and their parent attending each session. There was a reduction in PTSD symptoms and the proportion of patients meeting diagnostic criteria for PTSD in the TF-CBT group compared to the CCT group at the end of treatment; effect sizes ranged from medium to large.  In addition to the effect on ICD-11 complex PTSD and evidence of longer-term effects, there have been numerous international replications showing similar effect sizes. Research has shown that TF-CBT is effective in low-income countries, particularly for children grieving the death of a parent.

Mode of Administration — TF-CBT is commonly provided to individual children once weekly during hourly sessions for a period of 12 to 25 sessions. Depending on the child’s clinical presentation, the length and proportionality of treatment sessions vary from 12 to 25 sessions for children with typical PTSD and up to 40 sessions for those with complicated PTSD.

Children’s responses to treatment are typically monitored by clinicians based on self-reported ratings of PTSD symptom severity. For this, a self-report tool like the Child PTSD Symptom Scale or for young children, the parent-reported Young Children’s PTSD Checklist works best in clinical practice. Individual TF-CBT has been adapted for the treatment of PTSD in groups of children and for the treatment of children as young as three years old.

Training – In order to receive standard TF-CBT training, participants must complete the following requirements: successful execution of TF-CBTWeb2.0 course; two days of in-person training with an approved TF-CBT instructor; twelve consultation calls (generally twice monthly for 6 months); or involvement in an approved TF-CBT learning alliance. In the United States, training is accessible through the National Child Traumatic Stress Network, which may be found at www.nctsn.org. In addition to the dissemination of a validated methodology for educating lay counselors in low-resource countries, efforts are being made to introduce TF-CBT through the use of telemedicine.

Other trauma-focused therapies are based on cognitive and/or behavioral principles, with at least one clinical trial in children and adolescents with PTSD or PTSD symptoms supporting it. These therapies include:

Combined parent-child (CPC) CBT — CPC-CBT varies from TF-CBT in that it involves parents who have committed physical abuse against their children. In addition to the components of TF-CBT, CPC-CBT incorporates the following features as well:

  • A greater emphasis is placed on the development of non-confrontational parenting practices.
  • Joint parent-child meetings are held during each session of the program.
  • Abuse explanation – The abusive parent accepts full responsibility for prior abuse, absolves the child of any blame, and addresses the cognitive dysfunction of the child that has arisen as a result of the abuse.

In a clinical trial involving physically abused children and their abusive parents, CPC-CBT was delivered to both the child and the parent as compared to cognitive therapy delivered solely to the parents. When compared to the parent cognitive therapy group, the CPC-CBT group showed higher reductions in children’s PTSD symptoms and improved parenting practices at the conclusion of the study, with a medium effect size.

Trauma affect regulation: a guide for education and therapy (TARGET) —  TARGET is a particular type of trauma-focused cognitive behavioral therapy (TF-CBT) that was designed specifically for adolescents who have experienced complicated trauma. Complex trauma which is not included in DSM-5 but is proposed for inclusion in the International Classification of Diseases is different from non-complex PTSD in aspects such as the subject’s history of chronic trauma and involves the presence of notable features of affective impairment, low self-esteem, and interpersonal disruptions in addition to core PTSD characteristics. In some cases, TARGET may be particularly applicable to the juvenile justice population.

The treatment of adolescent females (aged 13 to 17 years) with full or partial PTSD was tested in a clinical experiment in which they were randomly assigned to either TARGET or relational supportive therapy.   Pertaining to the primary outcome, TARGET was proved to be better than relational supportive psychotherapy for improving PTSD symptoms (medium effect size), as well as anxiety symptoms (small effect size) in this population, whereas relational therapy was found to be superior for developing hope (medium effect size), and anger (small effect size).

Eye movement desensitization and reprocessing (EMDR) – The use of EMDR is different from TF-CBT in the following: 

  • EMDR includes the use of saccadic eye movements during the exposure phase.
  • A new method of closure is used in EMDR: the child imagines a scene from the trauma, concentrating on the accompanying cognition and arousal while following the movement of the therapist’s fingers in the child’s visual field, identical to how it is done in conventional therapies.
  • In EMDR, parental participation is optional.
  • The duration of treatment for EMDR is often shorter (about eight sessions) than the duration of treatment for TF-CBT (8 to 24 sessions).

Two well-conducted EMDR clinical trials in children yielded contradictory results:

33 kids aged 6 to 16 years old with DSM-IV PTSD from a variety of events were randomly assigned to either EMDR or a waitlist control condition in an open-label experiment. There was no difference in overall PTSD symptoms between the two groups; however, EMDR was significantly more effective in improving re-experiencing symptoms (medium effect size) when compared to the control group.

EMDR Therapy to Treat Mental Disorders

A clinical investigation involving 48 children with PTSD symptoms found no significant difference in treatment outcomes between EMDR and TF-CBT in terms of PTSD symptoms or efficiency; however, TF-CBT was found to be more effective in treating depressive and ADHD symptoms. In other clinical trials using EMDR in children, methodological limitations, such as limited sample sizes, have been identified. EMDR is discussed in further detail elsewhere.

Cognitive-based trauma therapy (CBTT) — CBTT varies from conventional trauma-focused cognitive behavioral therapy (TF-CBT) in that it does not include relaxation and instead places a strong emphasis on incorporating cognitive restructuring across the whole treatment process. Compared to a wait-list control condition, a small clinical trial in children and adolescents with a DSM-IV-TR diagnosis of PTSD with a single incident trauma discovered large effect sizes for improvement in anxiety, PTSD, and depressive symptoms with CBTT. The positive effects of CBTT were partly mediated by modifications in children’s maladaptive cognitions, which was expected by this cognitive-based model.

Somatic Experiencing Therapy to treat Traumas and PTSD

KidNET (kid narrative exposure therapy) – KidNET is a type of narrative exposure therapy for children. This treatment, which was adapted from adult narrative exposure therapy, varies from TF-CBT in that it focuses primarily on the trauma narration and cognitive processing elements, with only a little attention paid to the remaining treatment components. This treatment is especially beneficial for children who have been exposed to war, refugee, or migrant circumstances. A short clinical trial including 26 immigrant children with post-traumatic stress disorder (PTSD) discovered that KidNET was much more effective than a waitlist control condition in terms of decreasing PTSD symptoms and functional impairment, with substantial effect sizes.

It is more productive to deliver trauma treatment in groups rather than one-on-one in schools and other similar congregant settings.  There are several methods of trauma-focused group CBT that have been shown to be effective for children with PTSD symptoms. Among the most widely studied and disseminated interventions is Cognitive Behavioral Interventions for Trauma in Schools (CBITS). Another set of effective trauma-focused group CBT models has been developed and altered to meet various types of traumatic stress.

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) — CBITS is a group psychosocial therapy for those who are diagnosed with PTSD or have some of the PTSD symptoms. To help children cope with avoidance of trauma triggers and gain adaptive abilities, CBITS blends cognitive-behavioral principles with social support and resilience modeling. School-based group treatment has a significant impact on increasing access to mental health treatments.

CBITS is a program designed for school children aged ten to fifteen who have a history of one or more reported traumas as well as a resultant PTSD or substantial PTSD symptoms. The CBITS program for elementary school children is now being reviewed. A student is typically identified for inclusion in CBITS through school screening, which includes the administration of a PTSD self-report instrument, such as the Child Traumatic Stress Symptom Scale. Because some administrators and/or parents believe that these issues should not be addressed in the school setting, trauma of child abuse or domestic violence may be a contraindication for CBITS participation in some schools.

CBITS treatment is delivered over the course of ten group sessions held at schools. Weekly lessons with groups of six to eight children take place during school hours and last roughly one hour. The contents of CBITS have the same components as those of TF-CBT. During two additional individual “break out” sessions that take place separately from the group therapy sessions, the children develop personal trauma discourses about themselves. Parents of each kid are given the opportunity to participate in parent groups that are running concurrently. Teachers in educational contexts are educated on the effects of trauma and the management of trauma symptoms in their students. Self-report measures are commonly used to assess the severity of post-traumatic stress disorder (PTSD) and depressive symptoms before and after treatment.

Efficacy – The effectiveness of CBITS has been demonstrated in one large clinical study and two quasi-randomized trials when provided by trained school-based mental health practitioners. 126 sixth-grade students who reported exposure to violence and experienced PTSD symptoms were randomly assigned to either a 10-session CBITS group treatment or a wait-list control group in one randomized trial involving a total of 126 students. After three months of treatment, CBITS students experienced significantly greater reductions in PTSD symptoms than students assigned to the waitlist condition. After three months, mean scores for the CBITS group fell into the nonclinical range, whilst mean scores for the waitlist group stayed in the clinical range (large effect size). Depression and psychosocial dysfunction were also shown to be significantly reduced in the intervention group compared to the control group. The findings of the quasi-randomized studies were consistent with one another.

Training – Online training for clinicians is offered by the CBITS developers at http://cbitsprogram.org, and it is completely free of charge. There is a CBITS manual as well as additional materials for implementing the system. A variety of training options are available under the CBITS model, including face-to-face instruction, phone consultation, and participation in a CBITS learning consortium.

Even though CBITS has been widely spread to schools in the United States and around the world, many of these institutions do not have CBITS therapists on staff. A variant of CBITS, Supporting Students Exposed to Trauma, has been developed that may be offered by educators and, as a result, might be disseminated more simply than its more conventional counterpart. This approach appears to be feasible and acceptable according to preliminary findings, but further research into its efficacy is required.

Trauma grief components treatment (TGCT) — Trauma grief components treatment (TGCT) is a group cognitive behavioral therapy intervention that is slightly longer (17 sessions) and includes both trauma-focused and grief-focused designs that are intended to resolve PTSD and disordered grief responses, respectively. TGCT is particularly beneficial for adolescents who are experiencing PTSD symptoms and dysfunctional grief as a result of war, terrorism, or other situations involving tragic death.

With medium to large effect sizes, one clinical trial involving 127 war-exposed Bosnian youths with symptoms of PTSD, depression, or dysfunctional grief discovered that school-based TGCT was better compared to a school-based psychoeducation and skills comparison condition in terms of improving PTSD and undesirable grief responses.

ERASE-Stress — Extending and enhancing resilience amongst students experiencing (ERASE-) Stress is a 16-session resilience-building strategy provided by a teacher, and it is specifically created for children and adolescents who have been exposed to terrorism or war. While CBITS is a clinician-delivered intervention that is provided to children who are experiencing trauma-related symptoms, ERASE-Stress is a teacher-delivered intervention that is provided to all children who have been exposed to trauma, either to avoid the onset of symptoms or to treat symptoms after they have appeared.

Children assigned to receive ERASE-Stress showed greater improvement in PTSD symptoms (medium effect sizes), as well as in somatic complaints and anxiety, in two quasi-randomized controlled trials in Israel, comparing ERASE-Stress with waitlist control conditions for 142 children and 154 adolescents, respectively. There have been no randomized controlled studies done.

Group trauma-focused CBT. The group administration of CBT differs from the individual strategy only in that it is commonly provided in non-school settings, such as residential treatment centers, community or religious centers, or nongovernmental organizations.  The trauma narrative of the TF-CBT treatment phase is offered in individual “break out” sessions that are held in addition to the group sessions during the course of the treatment.

Two randomized clinical trials evaluated culturally tailored group TF-CBT to waitlist controls, in 52 Congolese sexually abused girls and in 50 Congolese adolescent boys exposed to the Congolese war, respectively. Both trials discovered that TF-CBT resulted in better improvement in PTSD, depression, and anxiety symptoms, as well as in conduct and pro-social behaviors when compared to control circumstances (large effect sizes for each result).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition describes developmental differences in how PTSD manifests itself in young children. Typical PTSD symptoms are indications of young children’s basic fears (eg, physical trauma, loss of caregiver, abandonment). Young children, who have limited verbal and cognitive abilities, are especially reliant on and trusting of their caregivers to keep them safe. When a traumatic event occurs, this sense of safety and trust is shattered.

To be effective, trauma treatments for young children must restore the young child’s confidence in the caregiver’s ability to keep him or her safe, as well as the caregiver’s own confidence in her or himself. These goals have been achieved through attachment-based models, which place a primary emphasis on the child-parent relationship, and through cognitive behavioral therapy (CBT) models, which place a primary emphasis on improving child-parent resiliency and communication skills, positive parenting, and the caregiver’s ability to promote safety.

Child-Parent Psychotherapy – For young children (birth to six years) who have been victimized and their parent(s) or caretaker adult, Child-Parent Psychotherapy (CPP) has been developed as relational attachment-based psychotherapy focused on the support and strengthening the parent-child relationship in order to heal the negative effects of interpersonal trauma. Despite the fact that CPP incorporates parts of cognitive-behavioral therapy, it is primarily focused on attachment and psychodynamic theories of human development. Parents who have young children who cannot vocally communicate their feelings but do so through play (e.g., those with developmental disabilities) will find that CPP is especially beneficial for helping parents understand and make more benign meaning of their children’s play, behaviors, and relationships.

For parents who have been traumatized by domestic violence, CPP may be especially beneficial because it offers more prolonged interventions for both the kid and the parent over the course of a year.

Interventions are aimed at a variety of issues, including:

  • Addressing maladaptive self and each other’s perception in children and their parents
  • Establishing and using a shared narrative of trauma to identify and address trauma triggers
  • Improve your social life by doing things you enjoy and setting goals you can achieve.

Efficacy – Seventy-five preschoolers with domestic violence-related PTSD participated in a randomized trial that contrasted CPP with case management and community therapy referral. PTSD symptoms (medium impact size), as well as overall behavior difficulties (small effect size), improved more in children receiving CPP than in children receiving the control condition after a year of weekly sessions assessed for fidelity. Additionally, mothers who received CPP reported lower levels of avoidance symptoms and a trend toward fewer personal PTSD symptoms.

Administration – There are 40 to 50 weekly relational child-parent sessions, with additional parent sessions provided as needed, in order to provide the CPP program. A developmentally appropriate tool (questionnaire, self-report scales, symptoms frequency scales) should be used by clinicians to systematically monitor young children’s PTSD and behavioral symptoms. If the child is receiving clinical care, the symptoms of the parents can be tracked as well.

Training – Handouts and other resources for CPP training are available, including treatment manuals provided by the treatment creators.  A year or more of regular dialogue calls or participation in a learning collaborative are required for training in the CPP paradigm, which also involves initial face-to-face instruction. The treatment creator and professional trainers offer training, and the National Child Traumatic Stress Network sponsors a learning collaboration (www.nctsn.org). The distribution of CBITS and CPP is spreading worldwide and within the US, with substantial state-wide dissemination efforts resulting in more than 10,000 trained therapists in each of these models across the US. There are plans to create a CPP certification program.

TF-CBT for Preschoolers – Psychotherapists who utilize TF-CBT with toddlers use structured play tactics to incorporate CBT components The effectiveness of TF-CBT in treating preschoolers has been studied in two clinical trials. Patients having at least five symptoms of posttraumatic stress disorder (PTSD) following an index trauma of sexual assault were given either TF-CBT or nondirective supportive treatment (NST) as part of a clinical experiment. When compared to the NST group, children who received TF-CBT showed significantly better improvement in PTSD symptoms, as well as internalizing and sexual behavior problems (medium effect size).

Clinical trials and deconstruction studies examined the effectiveness of four different TF-CBT versions in children with an index trauma of sexual abuse aged 4 to 11 years old: with the trauma narrative phase versus without; and over eight versus 16 sessions given. All four TF-CBT treatment groups demonstrated significant reductions in PTSD symptoms in the children who received them. For internalizing symptoms of fear and anxiety, children in the eight-session group with a trauma narrative phase improved more than those in other groups; for externalizing behavior symptoms, children in the 16-session group improved more than those in the eight-session group. The results were unaffected by younger (four to six-year-old) age groups. TF-tiered CBT’s core methodology has been adapted for preschoolers, allowing parents to handle much of the treatment themselves. This model’s results were comparable to those of the usual TF-CBT, although it was significantly less expensive.

Preschool PTSD Treatment (PPT) – PPT comprises all of the TF-CBT components but varies from TF-CBT in that the parent is actively involved during the entire treatment session. Preschool PTSD treatment. Children aged three to six years with at least five symptoms of PTSD following mixed traumas were randomly assigned to either PPT or a waitlist control condition in a controlled study Although PPT had a higher dropout rate, it had larger impact sizes on PTSD symptoms.

To deal with PTSD and co-existing substance use disorders (SUD) resulting from childhood trauma, two therapy strategies have been created and tested.

Seeking Safety – Adult CBT strategy for treating co-existing PTSD and substance use disorder (SUD) called Seeking Safety has been adapted for use with adolescents. However, trauma narrative and processing are omitted from this version of TF-CBT Practice. 

There are a few other differences between the therapy of Seeking Safety and TF-CBT.

  • Safety is the ultimate priority, not PTSD recovery.
  • Focus on values that have been eroded by substance misuse and post-traumatic stress disorder
  • To keep one’s attention on the present time

According to the results of a pilot clinical trial in which 33 adolescent females were randomly assigned to receive Seeking Safety, those assigned to usual treatment showed improvement on some subscales of the Trauma Symptom Checklist for Children and the Personal Experiences Inventory (for substance use). There was no change in the overall ratings for substance abuse or PTSD symptoms.

Risk Reduction Family Therapy (RRFT) – Reducing the risk of substance abuse through RRFT is an application of TF-CBT that incorporates extra components. 30 adolescents with histories of sexual abuse and substance abuse were randomly assigned to RRFT or usual treatment, with the results showing that participants assigned to RRFT improved more in PTSD, substance use, depressive and internalizing symptoms than participants assigned to usual treatment (medium effect sizes). At the beginning of the trial, the functioning of the groups was different.