Karina’s foster mom brought her to my office last year for irritability and “mood swings.” A soft-spoken fourteen year old, Karina (and her nine year old brother) had been with the family for three months, and her foster family reported that “little things” set her off into explosive anger. Sometimes she seemed tense or didn’t want to go out, but at other times she seemed fine, and she was eating and sleeping normally and doing okay in school. When talking to Karina, I learned that prior to being placed in foster care, she had beenphysically abused by her father after he relapsed on alcohol. In that first meeting, she insisted that she “never” thought about what happened and didn’t want to talk about it.

In the US, 60% of children report exposure to violence, abuse or other trauma in the past year (Finkelhor D et al, Pediatrics 2009;124:1–13). Traumatized children like Karina can present to treatment with a range of symptoms, including anxiety, irritability, disruptive behaviors, mood dysregulation, and developmental regression. Approximately one third develop posttraumatic stress disorder (PTSD). Without treatment, PTSD symptoms persist (Scheeringa MS et al, J Am Acad Child Adolesc Psychiatry 2005;44:899–906), and may increase risk for aggression and suicidality (Vivona JM et al, J Am Acad Child Adolesc Psychiatry 1995;34(4):434–44; Lipschitz DS et al, J Am Acad Child Adolesc Psychiatry 1999; 38:385–392), so recognizing and treating PTSD is critical.

Assessing Pediatric PTSD
While careful assessment is important for any pediatric disorder, it is particularly so for PTSD. Karina’s foster mother came in asking about depression or bipolar disorder; parents may be less likely to present asking about PTSD, because of its low profile and because often parents are unaware of their child’s traumatic experience.

Children are often afraid or embarrassed to disclose abuse or trauma, and their PTSD symptoms may be missed or mistaken for other disorders. Adding further complication, PTSD in children (particularly young children) looks different from that in adults.

Preadolescent children often are not sophisticated enough to recognize and report their own avoidance symptoms; instead they may just deny any trauma and refuse to speak about it. Re-experiencing symptoms in children can show up as trauma-themed play or as nightmares that are not specific to the traumatic event (PTSD Practice Parameter, J Am Acad Child Adolesc Psychiatry 2010;49(4):414–430). Children are also more likely than adults to present with reckless or self-destructive behaviors, cognitive distortions, guilt, anger, and shame (Cohen JA and Mannarino AP, Curr Op Pediatrics 2010;22:605–609).

But not all symptoms can be attributed to PTSD, and careful assessment of comorbidities is needed as well. In Karina’s case, her presentation was concerning for a mood disorder, so collateral was needed to confirm the absence of cyclic mood episodes and associated symptoms, and to discover that many of her outbursts were triggered by subtle reminders of her abuse.

Approaches to Psychotherapy for Pediatric PTSD
Once trauma is recognized, the first step is to ensure the child is safe. If not, that is the first priority. If so, treatment can begin. Psychotherapy is the first-line treatment for PTSD, and the best evidence is for cognitive behavioral therapy (CBT) specifically targeting trauma symptoms. Play therapy, art therapy, and psychodynamic psychotherapy have been tried, but there is not sufficient evidence to recommend them (Wetherington HR et al, Am J Prev Med 2008;35(3):287–313).

There are a number of CBT therapies for pediatric PTSD, but all share common features. The core components of CBT for pediatric PTSD include psychoeducation, teaching of coping and emotion regulation skills for managing stress, gradual exposure to trauma memories or reminders, and cognitive restructuring (Cohen JA et al, J Interpers Violence 2000;15:1202–1223).

Working with Young Children
While infant psychotherapy is daunting for many of us, child-parent psychotherapy (CPP) has proved effective in one randomized controlled trial and several non-randomized controlled studies of infants and young children exposed to family trauma, domestic violence, and traumatic loss (Lieberman AF, J Am Acad Child Adolesc Psychiatry 2005;44(12):1241–1248).

As suggested by the name, it is conducted jointly with parent and child, and helps parents to understand and interpret the child’s feelings and actions, improve empathy and emotional support between parent and child, model appropriate protective behavior, and develop a joint narrative about the family trauma.

For toddlers and preschoolers, trauma-focused CBT (TF-CBT) has been shown to work in children as young as three. TF-CBT is the most widely used CBT therapy for PTSD for kids and has been shown to be effective in several randomized controlled trials in kids aged three to 17 (PTSD Practice Parameter, J Am Acad Child Adolesc Psychiatry 2010;49(4):414–430). (For a detailed guide to TF-CBT, see this month’s interview with Judith Cohen, MD.) The version to use in young kids (age three to six) has several age-appropriate adaptations (including increased parent involvement) and can also be found free at www.infantinstitute.com.

School-Age Kids and Teens
For school-age kids and teens with PTSD, several well-studied treatments are available. For individual therapy, TFCBT is still the best choice, and in Karina’s case, that is what we chose. Other treatments with similar core features to TF-CBT have been specifically adapted for different kinds of trauma, such as single-incident trauma (CBT for PTSD) and traumatic loss (trauma and grief component therapy). For teens with substance use, the Seeking Safety protocol provides step-wise treatment for PTSD and risk reduction for the substance use (PTSD Practice Parameter, J Am Acad Child Adolesc Psychiatry 2010;49(4):414–430).

Group therapies are also useful in treating traumatized kids and teens. Some of the individual therapy protocols mentioned above, including trauma and grief component therapy and seeking safety, can also be used in a group format.

The most widely used group protocol, however, is CBITS (cognitive behavioral intervention for trauma in schools). Delivered in school settings, CBITS follows a model similar to TF-CBT and has been shown to be effective in multiple controlled trials. Exposure and trauma narrative are done in individual sessions, the other modules are covered in the group setting, and an additional component of trauma psychoeducation is added for teachers.

In schools where mental health professionals are not available, a modified version of CBITS called the support for students exposed to trauma (SSET) protocol can be used with kids by teachers, guidance counselors, or other school staff. SSET is not as well studied as CBITS, but pilot studies suggest it’s an effective option. SSET can be found free online at http://bit.ly/ubYrd3.

Engaging Families
The social environment of a traumatized child is often itself traumatic (through family or community trauma, or vicariously through the child’s experience) or traumatizing (dangerous or frankly abusive). If the child is not safe and/or the environment unable to protect and support the child, therapy is basically useless.

Trauma systems therapy (TST) is a step-wise treatment for traumatized children that shares many aspects of TF-CBT but also specifically targets environmental factors that may trigger the child’s symptoms. TST joins the mental health team with case managers, lawyers, families, and patients themselves for integrated and efficient care and stabilization of the child’s environment (Saxe GN et al, Psych Annals 2005;35(5):443–448).

Even in the most stable and supportive home, parents may not understand or know how to respond to the child’s PTSD symptoms, and may become overly permissive or protective because of guilt that their child experienced a traumatic event. It comes as no surprise then that involving parents in treatment has been shown to be more effective than treating the child alone (PTSD Practice Parameter, J Am Acad Child Adolesc Psychiatry 2010;49(4):414–430).

In Karina’s case, engaging her foster mother in treatment allowed the foster mother to better understand and respond to Karina’s symptoms at home. If parents have PTSD symptoms of their own (either from direct or vicarious trauma), they need treatment too, as their symptoms can trigger the child’s (Feldman R, Vengrober A, J Am Acad Child Adolesc Psychiatry 2011;50(7):645–658).

Special Populations
What do you do when you can’t protect a child from ongoing trauma, like children in war zones or neighborhoods with significant community violence? Stress inoculation training is a promising option in these cases, and while it is similar to the above CBT therapies, it aims not to directly treat PTSD symptoms but instead to promote resilience and enhance future coping.

For children who are refugees from war-torn or traumatized areas, eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (NET, or KIDNET) have been shown to be effective (Ehntholt KA and Yule W, J Child Psychiatry Psychology 2006;47(12):1197–1210). [For more on EMDR, see the article “EMDR for Children and Adolescents” in this issue.] For non-refugee children belonging to specific linguistic or cultural groups, several adaptations of TF-CBT and CBITS are available.

A final note of special consideration is needed for children who have undergone chronic maltreatment or developmental trauma. These children may present with more complex symptoms than those captured in the PTSD diagnosis, and may require more intensive, integrated, phase-based treatment than CBT alone can provide.

Trauma and PTSD in kids is common but can be hard to catch. Screen carefully, use an age-appropriate manualized CBT treatment, and involve parents and other caregivers whenever possible.

Psychotherapies for PTSD

• Child-Parent Psychotherapy (CPP): Proven effective in infants and young children; conducted jointly with parents and children.
• Trauma Focused Cognitive Behavioral Therapy (TF-CBT): Most widely used
  CBT; proven effective in ages three through 17.
• Seeking Safety: For teens with substance abuse.
• Trauma and Grief Component Therapy: Based on TF-CBT; can be used in group format.
• Cognitive Behavioral Intervention for Trauma in Schools (CBITS):Most widely used group therapy in schools; similar model TF-CBT.
• Trauma Systems Therapy (TST): Shares aspects of TF-CBT, but specifically targets environmental triggers for kids.
• Stress Inoculation Training: Best for kids who remain in stressful, traumatizing environments; promotes resilience and coping.
• Eye Movement and Desensitization and Reprocessing (EMDR): Type of CBT focused on exposure techniques; proven effective in adults, insufficient evidence in children.
• Not Well Supported: play therapy, art therapy, psychodynamic therapy.