Psychiatric Times. Vol. 29 No.

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.
Stress also helps the development of our psychological well-being. Learning to
cope with adversity is an important part of develop-ing one’s 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
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
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
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.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
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
children exposed to trauma are at much greater risk for PTSD.
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 child’s 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
Although we use PTSD as a construct to understand children’s response to trauma, children with
subthreshold symptoms can also have the same degree of functional impairment. Alternative criteria
have been suggested for the diagnosis of PTSD in young children.
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
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
children’s 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
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
selecting an intervention. provides additional treatment considerations. (A complete review of Table 1
best-practice interventions can be found in Foa et al. )
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
acronym PRACTICE ( ). Trauma-focused (TF)-CBT combines individual and parent-child Table 2
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,
especially hyperarousal and avoidance in youths exposed to intimate partner violence.
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,
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
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,
victims of the Bosnian war, and victims of community violence have found that trauma/grief-focused
therapy resulted in significant reduction of PTSD symptoms.
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
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.
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.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
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
intervention for youths following motor vehicle accidents was successful in preventing depression and
behavior problems in preadolescent youths.
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
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
CCPT is a manualized treatment based on person-centered therapy that establishes unconditional
positive regard, genuineness, and empathy to facilitate children’s 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
reducing PTSD symptoms.
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
child’s difficulties to allow expression of feelings. In this form of therapy, the therapist rarely
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
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 child’s life; gradual
exposure to cues while replacing maladaptive behaviors with adaptive ones; and consolidation of
learned skills.
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.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
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
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
fluoxetine(Drug information on fluoxetine)
effective in improving earthquake-related PTSD symptoms in 26 youths. However, some studies have
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)
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 Children’s Global Assessment Scale. The
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
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)
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
sleep and neural integrity of the anterior cingulate, a brain region responsible for modulation of
emotional responses that is often impaired in PTSD.
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
risperidone(Drug information on risperidone)
effectively to stabilize mood in severe cases and to treat comorbid symptoms of childhood PTSD.
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.
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
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
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
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1. Kiecolt-Glaser JK, McGuire L, Robles T, Glaser R. Psychoneuroimmunology: psychological
influences on immune function and health. . 2002;70:537-547. J Consult Clin Psychol
Brewin CR, Holmes EA. Psychological theories of posttraumatic stress disorder. . 2. Clin Psychol Rev
McEwen BS. Allostatis and allostatic load: implications for neuropsychopharmacology. 3.
. 2000;22:108-124. Neuropsychopharmacology
Foy DW, Goguen CA. Community violence-related PTSD in children and adolescents. . 4. PTSD Res Q
De Bellis M, Baum AS, Birmaher B, et al. A.E. Bennett Research Award. Developmental 5.
traumatology. Part I: biological stress systems. . 1999;45:1259-1270. Biol Psychiatry
Gabbay V, Oatis MD, Silva RR, Hirsch G. Epidemiological aspects of PTSD in children and 6.
adolescents. In: Silva RR, ed. Posttraumatic Stress Disorder in Children and Adolescents: Handbook.
New York: WW Norton & Co; 2004:1-17.
Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the 7.
phenomenology of PTSD symptoms in youth. . 2002;41:166-173. J Am Acad Child Adolesc Psychiatry
Scheeringa MS. Developmental considerations for diagnosing PTSD and acute stress disorder in 8.
preschool and school-age children. 2008;165:1237-1239. Am J Psychiatry.
Bronfenbrenner U. . 9. The Ecology of Human Development: Experiments by Nature and Design
Cambridge, MA: Harvard University Press; 1979.
Freisthler B, Merritt DH, LaScala EA. Understanding the ecology of child maltreatment: a review of 10.
the literature and directions for future research. . 2006;11:263-280. Child Maltreat
Zielinski DS, Bradshaw CP. Ecological influences on the sequelae of child maltreatment: a review 11.
of the literature. . 2006;11:49-62. Child Maltreat
Bronfenbrenner U. Ecology of the family as a context for human development: research 12.
perspectives. . 1986;22:723-742. Dev Psychol
Foa EB, Keane TM, Friedman MJ, Cohen JA. 13. Effective Treatments for Posttraumatic stress
. 2nd ed. New Disorder: Practice Guidelines From the International Society for Traumatic Stress Studies
York: Guilford Publications; 2009.
Adler-Nevo G, Manassis K. Psychosocial treatment of pediatric posttraumatic stress disorder: the 14.
neglected field of single-incident trauma. . 2005;22:177-189. Depress Anxiety
Cohen JA, Mannarino AP. Trauma-focused cognitive behavioural therapy for children and parents. 15.
. 2008;13:158-162. Child Adolesc Ment Health
Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for 16.
children with sexual abuse-related PTSD symptoms. . J Am Acad Child Adolesc Psychiatry
Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of a 17.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
randomized controlled trial. . 2005;29:135-145. Child Abuse Negl
Scheeringa MS, Weems CF, Cohen JA, et al. Trauma-focused cognitive-behavioral therapy for 18.
posttraumatic stress disorder in three through six year-old children: a randomized clinical trial. J Child
. 2011;52:853-860. Psychol Psychiatry
Cohen JA, Mannarino AP, Iyengar S. Community treatment of posttraumatic stress disorder for 19.
children exposed to intimate partner violence: a randomized controlled trial. Arch Pediatr Adolesc Med.
Saxe GN, Ellis H, Fogler J, et al. Comprehensive care for traumatized children: an open trial 20.
examines treatment using trauma systems therapy. 2005;35:443-448. Psychiatr Ann.
Amaya-Jackson L, Reynolds V, Murray MC, et al. Cognitive-behavioral treatment for pediatric 21.
posttraumatic stress disorder: protocol and application in school and community settings. Cogn Behav
. 2003;10:204-213. Pract
March JS, Amaya-Jackson L, Murray M, Schulte A. Cognitive-behavioral psychotherapy for 22.
children and adolescents with posttraumatic stress disorder after a single-incident stressor. J Am Acad
. 1998;37:585-593. Child Adolesc Psychiatry
Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for schoolchildren exposed to 23.
violence: a randomized controlled trial. . 2003;290:603-611. JAMA
Goenjian AK, Karayan I, Pynoos RS, et al. Outcome of psychotherapy among early adolescents after 24.
trauma. . 1997;154:536-542. Am J Psychiatry
Layne CM, Pynoos RS, Saltzman WR, et al. Trauma/grief-focused group psychotherapy: 25.
school-based postwar intervention with traumatized Bosnian adolescents. Group Dynamics Theory Res
. 2001;5:277-290. Pract
Saltzman RW, Layne CM, Pynoos RS, et al. Trauma/grief-focused intervention for adolescents 26.
exposed to community violence: results of a school-based screening and group treatment protocol.
. 2001;5:291-303. Group Dynamics Theory Res Pract
Lieberman AF, Van Horn P, Ippen CG. Toward evidence-based treatment: child-parent 27.
psychotherapy with preschoolers exposed to marital violence. . J Am Acad Child Adolesc Psychiatry
Thomas R, Zimmer-Gembeck MJ. Accumulating evidence for parent-child interaction therapy in the 28.
prevention of child maltreatment. . 2011;82:177-192. Child Dev
Copping VE, Warling DL, Benner DG, Woodside DW. A child trauma treatment pilot study. 29. J Child
. 2001;10:467-475. Fam Stud
Adler Nevo G, Manassis K. An adaptation of prolonged exposure therapy for pediatric single 30.
incident trauma: a case series. . 2011;20:127-133. J Can Acad Child Adolesc Psychiatry
Kenardy J, Thompson K, Le Brocque R, Olsson K. Information-provision intervention for children 31.
and their parents following pediatric accidental injury. . 2008;17:316-325. Eur Child Adolesc Psychiatry
Zehnder D, Meuli M, Landolt MA. Effectiveness of a single-session early psychological intervention 32.
for children after road traffic accidents: a randomised controlled trial. Child Adolesc Psychiatry Ment
. 2010;4:7. Health
Gil E. . New York: Guilford Press; 1998. 33. Play Therapy for Severe Psychological Trauma
Nader K, Pynoos R. Play and drawing as tools for interviewing traumatized children. In: Schaeffer 34.
C, Gitlan K, Sandgrund A, eds. . New York: John Wiley; 1991:375-389. Play, Diagnosis and Assessment
Baggerly JN, Ray DC, Bratton SC, eds. 35. Child-Centered Play Therapy Research: The Evidence Base
. Hoboken, NJ: John Wiley & Sons; 2010. for Effective Practice
Kot S, Landreth GL, Giordano M. Intensive child-centered play therapy with child witnesses of 36.
domestic violence. . 1998;7:17-36. Int J Play Ther
Shen Y. Short-term group play therapy with Chinese earthquake victims: effects on anxiety, 37.
depression, and adjustment. . 2002;11:43-63. Int J Play Ther
Tyndall-Lind A, Landreth GL, Giordano MA. Intensive group play therapy with child witnesses of 38.
domestic violence. . 2001;10:53-83. Int J Play Ther
Schottelkorb AA, Doumas DM, Garcia R. Treatment for childhood refugee trauma: a randomized, 39.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012
controlled trial. 2012;21:57-73. Int J Play Ther.
Terr L. . New York: Basic Books; 1994. 40. Unchained Memories
Carrion VG, Hull K Treatment manual for trauma-exposed youth: case studies. 41. . Clin Child Psychol
. 2010;15:27-38. Psychiatry
Wilkinson J, Carrion VG. Pharmacotherapy in pediatric PTSD: a developmentally focused review of 42.
the evidence. . 2012;1:252-270. Curr Psychopharmacol
Seedat S, Stein DJ, Ziervogel C, et al. Comparison of response to selective serotonin reuptake 43.
inhibitor in children, adolescents, and adults with posttraumatic stress disorder. J Child Adolesc
. 2002;12:37-46. Psychopharmacol
Yorbik O, Dikkatli S, Cansever A, Sohmen T. The efficacy of fluoxetine treatment in children and 44.
adolescents with posttraumatic stress disorder symptoms [in Turkish]. . Klin Psikofarmakol Bulteni
Robb A, Cueva J, Sporn J, et al. Efficacy of sertraline in childhood posttraumatic stress disorder. In: 45.
Scientific Proceedings from the American Academy of Child and Adolescent Psychiatry; October
28-November 2, 2008; Chicago. Abstract P3.8.
Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized trial of combined trauma-focused 46.
CBT and sertraline for childhood PTSD symptoms. . J Am Acad Child Adolesc Psychiatry
Hammad TA. Results of the analysis of suicidality in pediatric trials of newer antidepressants. 47.
Presented at: US Food and Drugs Administration Psychopharmacologic Drugs Advisory Committee and
the Pediatric Advisory Committee; September 2004; Rockville, MD.
Mitka M. FDA alert on antidepressants for youth. . 2003;290:2534. 48. JAMA
Robert R, Blakeney PE, Villarreal C, et al. Imipramine treatment in pediatric burn patients with 49.
symptoms of acute stress disorder: a pilot study. . 1999;38:873-882. J Am Acad Child Adolesc Psychiatry
Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. 50. J Am Acad
. 1996;35:1247-1249. Child Adolesc Psychiatry
Perry BD. Neurobiological sequelae of childhood trauma: posttraumatic stress disorder in children. 51.
In: Murburg MM, ed. . Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts
Washington, DC: American Psychiatric Press; 1994:223-255.
De Bellis MD, Keshavan MS, Harenski KA. Anterior cingulate N-acetylaspartate/creatine ratios 52.
during clonidine treatment in a maltreated child with posttraumatic stress disorder. J Child Adolesc
2001;11:311-316. Psychopharmacol.
Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress 53.
disorder, acute type. A pilot study. . 1988;142:1244-1247. Am J Dis Child
Horrigan JP, Barnhill LJ. Risperidone and PTSD in boys. . 54. J Neuropsychiatry Clin Neurosci
Stoddard FJ Jr, Sorrentino EA, Ceranoglu TA, et al. Preliminary evidence for the effects of 55.
morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns. J Burn Care
. 2009;30:836-843. Res
Saxe G, Stoddard F, Courtney D, et al Relationship between acute morphine and the course of 56. .
PTSD in children with burns. . 2001;40:915-921. J Am Acad Child Adolesc Psychiatry
American Psychiatric Association. DSM-5 Development. DSM-5: The Future of Psychiatric 57.
Diagnosis. 2012. . Accessed September 24, 2012.
Psychiatric Times. Vol. 29 No. 11 October 29, 2012