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INTRODUCTION — Posttraumatic stress disorder (PTSD) in children and adolescents is a severe, often chronic, and impairing mental disorder. PTSD is seen in some children (and not others) after exposure to traumatic experiences involving actual or threatened injury to themselves or others.
PTSD is characterized by intrusive thoughts and reminders of the traumatic experience(s), avoidance of trauma reminders, negative mood and cognitions related to the traumatic experience(s), and physiological hyperarousal that lead to significant social, school, and interpersonal problems. PTSD can occur even in toddlers (one to two years old) [1,2].
This topic will address psychosocial treatment of PTSD in children, including early intervention to prevent the development of PTSD. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of PTSD in children are addressed separately, as are acute stress disorder and PTSD in adults. (See "Posttraumatic stress disorder in children: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" and "Psychotherapy for posttraumatic stress disorder in adults" and "Pharmacotherapy for posttraumatic stress disorder in adults" and "Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Treatment of acute stress disorder in adults" and "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis".)
TRAUMA-FOCUSED PSYCHOTHERAPIES — Several trauma-focused psychotherapy models have been found to be efficacious in the treatment of posttraumatic stress disorder (PTSD) or PTSD symptoms beneath the diagnostic threshold for the disorder [3,4]. These interventions include individual and group models, as well as models tailored to meet the needs of specific subgroups.
Mechanisms of treatment — PTSD is conceptualized as a disorder of fear conditioning that is both overgeneralized and fails to extinguish normally. Biological, learning, and social/environmental factors are implicated in the development and maintenance of child PTSD, suggesting the need for nuanced approaches to treatment.
Trauma elicits strong emotional responses (eg, fear, anger). Through operant conditioning, children associate other stimuli (eg, people, places, smells, or internal feelings) that were present at the time of the trauma ("trauma reminders") with those highly negative emotional responses. In an attempt to avoid these negative emotions, children avoid these trauma reminders .
Individual Trauma-Focused CBT — Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) for children and adolescents with PTSD is a parallel child and parent or primary caregiver treatment model that incorporates cognitive-behavioral, developmental, neurobiological, attachment, family, and empowerment principles. Goals include helping children and parents gain resiliency and coping skills, master learned and over-generalized avoidance of feared trauma memories, make more adaptive meaning of traumatic experiences, and resume optimal developmental trajectories. The efficacy of TF-CBT is described below. (See 'Efficacy' below.)
Children with trauma-related symptoms can benefit from trauma-focused psychotherapy whether or not they meet diagnostic criteria for PTSD.
Phases and components — TF-CBT is comprised of multiple components and is provided in three phases. Within each treatment session, therapy is provided in individual, parallel sessions to the child and the parent (or caregiver, hereafter "parent"), and in conjoint child-parent sessions as described below.
●The first, stabilization phase, includes the following components: psychoeducation, parenting skills, relaxation skills, affect modulation skills, and cognitive processing skills.
●The second, trauma narration and processing phase, includes only one component, which takes several sessions.
●The third, integration and consolidation phase, includes the following components: in vivo mastery, conjoint child-parent sessions, and enhancing safety.
The components of the three phases, which spell out the acronym "PRACTICE," are briefly described below:
●Psychoeducation – Information is provided about the connection between the child’s past (or ongoing) trauma experiences, trauma reminders, and the child’s presenting trauma symptoms, as well as information about the commonality of these responses following trauma.
●Parenting skills – Effective parenting strategies are provided and practiced with the parent. These include skills such as praise, selective attention, and using functional behavioral analysis (eg, changing antecedents and consequences) to effectively manage behavioral trauma impact.
●Relaxation skills – Relaxation strategies (eg, focused breathing, progressive muscle relaxation, exercise, visualization) are provided, individualized, and practiced to reverse physiological trauma impact, including in response to trauma reminders.
●Affect modulation skills – Feeling identification and modulation skills (eg, verbal expression of negative feelings, seeking social support, positive distraction strategies, problem solving) are provided, individualized, and practiced, including in response to trauma reminders.
●Cognitive processing skills – Identifying relationships among general negative thought patterns (eg, "I don’t have any friends"), negative feelings (eg, angry), and behaviors (eg, fighting with peers), and learning to generate more accurate or helpful thoughts (eg, "Jesse likes me") in order to feel better (eg, less mad) and behave differently (eg, ask Jesse to play at recess). These skills help children and parents to gain mastery over many negative feelings and behaviors and prepare them for more specific trauma-related cognitive processing in the next phase.
●Trauma narration and processing – During this phase, the therapist helps the child to develop a detailed narrative of his or her personal trauma experiences and to cognitively process these experiences using the skills described above. This component is an interactive, therapeutic process that occurs between the therapist and child (and between the therapist and parent, as the therapist shares the content of the child’s narrative with the parent). It is believed that PTSD symptoms (eg, avoidance, negative cognitions, negative feelings, and negative behaviors) are diminished through expressing trauma-related information and addressing maladaptive cognitions related to this material.
●In vivo mastery of trauma reminders – For children who have over-generalized fear of trauma-related stimuli in the environment (eg, avoid the bathroom or bedroom where past abuse occurred but that is now safe; avoid attending school where they were previously bullied but are now safe), in vivo exposure is used to gain adaptive functioning.
●Conjoint child-parent sessions – Several conjoint child-parent sessions are included to enhance direct child-parent communication about trauma (eg, sharing the child’s trauma narrative directly with the parent, safety planning, and other individualized issues).
●Enhancing safety – Trauma entails disruption of safety; reconstituting the child’s actual and sense of safety is critical for recovery. Safety skills appropriate to the child’s developmental level and living circumstances are provided and practiced with child and parent.
Efficacy — More than 15 clinical trials have compared TF-CBT with active treatments or controls for PTSD in children, with meta-analysis finding that TF-CBT reduced PTSD symptoms compared with controls [6-11]. Findings for improvement in associated symptoms (ie, depression, anxiety, behavior problems, maladaptive cognitions, and parental difficulties) have shown some variation but have been mostly positive. As an example, a meta-analysis of three trials with a total of 98 youth with PTSD found CBT led to reduced PTSD symptoms one month after treatment compared with controls (standard mean difference = -1.34, 95% CI -1.79 to -0.89) . Clinical trials have shown efficacy for children exposed to sexual abuse, domestic violence, war, and multiple or complex trauma [7-13].
As an example, the largest randomized trial was a multi-site trial of 220 children (ages 8 to 14 years) with symptoms in each cluster of DSM-IV-TR diagnostic criteria for PTSD, and a history of multiple traumas (mean = 3.4) including an index trauma of validated sexual abuse. Subjects were randomly assigned to receive 12 sessions of TF-CBT or Child Centered Therapy (CCT), both provided weekly to child and parent. At the end of treatment, the TF-CBT group experienced reductions in PTSD symptoms and in the proportion meeting diagnostic criteria for PTSD, compared with the CCT group; effect sizes were medium to large .
Administration — TF-CBT is typically provided once weekly during hourly sessions for a duration of 12 to 25 sessions. Other components are described above. (See 'Phases and components' above.)
Clinicians typically monitor children’s responses to treatment through children’s PTSD self-reports. This is best accomplished in clinical practice using a self-report instrument such as the Child PTSD Symptom Scale or, for young children, the parent report instrument Young Children’s PTSD Checklist.
Individual TF-CBT has been modified to treat groups of children with PTSD and to treat preschool-aged children. (See 'Other group CBT interventions' below and 'Therapies for preschool children' below.)
Availability — TF-CBT is available in all of the United States. It has been implemented internationally, yet availability varies widely and efforts to scale up dissemination and implementation continue.
Therapists certified as trained in the delivery of TF-CBT are listed at tfcbt.org.
Training — Materials for clinician training in TF-CBT include information online, books, and manuals [14,15].
A free introductory web-based course is available at www.musc.edu/tfcbt.
Standard TF-CBT training includes the following required elements: two-day face-to-face training with an approved TF-CBT trainer and 12 consultation calls (typically twice monthly for six months), or participation in an approved TF-CBT learning collaborative. Training in the United States is available from the National Child Traumatic Stress Network at www.nctsn.org.
Efforts are underway to disseminate a validated model for training lay counselors in low-resource countries .
Other individual trauma-focused therapies — Other trauma-focused therapies based on cognitive and/or behavioral principles and supported by at least one clinical trial in youth with PTSD or PTSD symptoms are described below:
●Combined Parent-Child Cognitive-Behavioral Therapy (CPC-CBT) – CPC-CBT differs from TF-CBT in that it includes parents who perpetrated physical abuse. CPC-CBT includes the following elements along with the components of TF-CBT :
•A stronger focus on developing noncoercive parenting skills.
•Joint parent-child meetings during every session.
•Abuse clarification – The abusive parent takes full responsibility for the past abuse, alleviates any child blame, and addresses other child’s maladaptive cognitions related to the abuse.
A clinical trial in physically abused children and their abusive parents compared CPC-CBT provided to child and to parent with cognitive therapy provided to parents alone. At the end of treatment, the CPC-CBT group had greater reductions in children’s PTSD symptoms and better parenting practices compared with the parent cognitive therapy group, with a medium effect size .
●Trauma Affect Regulation: Guide for Education and Therapy (TARGET) – TARGET differs from TF-CBT in that TARGET is specifically for teens with complex trauma, whereas TF-CBT is applicable for broader ages and trauma types. TARGET may have specific applicability for the juvenile justice population.
A clinical trial randomly assigned 59 delinquent girls (age 13 to 17 years) with full or partial PTSD to TARGET or relational supportive therapy . TARGET was superior to relational supportive psychotherapy for improving PTSD symptoms, the main outcome (medium effect sizes), as well as anxiety symptoms (small effect size) in this population, while relational therapy was superior for improving hope (medium effect size) and anger (small effect size).
●Eye movement desensitization and reprocessing (EMDR) – EMDR differs from TF-CBT in that :
•EMDR incorporates saccadic eye movements during exposure.
•The trauma narrative is completed differently in EMDR: The child imagines a scene from the trauma, focusing on the accompanying cognition and arousal, while tracking the movement of the therapist’s fingers in the child’s visual field.
•Parental involvement is optional in EMDR.
•The duration of treatment is generally shorter for EMDR (approximately eight sessions) than TF-CBT (8 to 24 sessions).
Two well-designed clinical trials of EMDR in children have shown mixed results:
•A clinical trial randomly assigned 33 youth ages 6 to 16 years with DSM-IV PTSD from mixed traumas to EMDR or a wait list control condition. No difference in overall PTSD symptoms was seen between the two groups; EMDR was superior in improving re-experiencing symptoms (medium effect size) compared with the control group .
•A clinical trial in 48 children with PTSD symptoms found no difference in outcomes between EMDR and TF-CBT .
EMDR is described further separately. (See "Psychotherapy for posttraumatic stress disorder in adults", section on 'Eye movement desensitization and reprocessing'.)
●Cognitive-Based Trauma Therapy (CBTT) – CBTT differs from TF-CBT in that it does not include relaxation and has a specific focus on integrating cognitive restructuring throughout treatment.
A small clinical trial in children and adolescents with a DSM-IV-TR diagnosis of PTSD following single incident traumas found large effect sizes for improvement in PTSD, anxiety, and depressive symptoms with CBTT compared with a wait list control condition . Positive effects of CBTT were partially mediated by improvements in children’s maladaptive cognitions as predicted by this cognitive-based model.
●Kid Narrative Exposure Therapy (KidNET) – Adapted from adult narrative exposure therapy, this treatment differs from TF-CBT in that it primarily utilizes the trauma narration and cognitive processing components, with relatively little focus on other treatment components. This treatment is particularly applicable for children exposed to war, refugee, or migrant conditions.
A small clinical trial in 26 refugee children with PTSD found that KidNET was superior to a wait list control condition for improving PTSD symptoms and functional impairment with large effect sizes .
Group therapies — In schools and similar congregant settings, it is more efficient to provide trauma treatment in groups rather than individually. There are a number of models of trauma-focused group CBT that have been found to be efficacious for children with PTSD symptoms. The most extensively evaluated and disseminated is Cognitive Behavioral Interventions for Trauma in Schools.
Cognitive Behavioral Intervention for Trauma in Schools (CBITS) — CBITS is a group psychosocial treatment for children with PTSD or PTSD symptoms . CBITS incorporates cognitive behavioral principles with peer support and resiliency modeling to help children overcome learned trauma avoidance and gain adaptive skills. School-based group treatment greatly expands access to mental health services.
CBITS has been developed for schoolchildren ages 10 to 15 years who have one or more disclosed traumas and PTSD or significant PTSD symptoms. Evaluation of CBITS for primary school children is underway.
Students are typically identified for inclusion in CBITS based on school screening using a PTSD self-report instrument, such as the Child PTSD Symptom Scale.
A primary trauma of child abuse or domestic violence may be a contraindication for CBITS participation in some schools, since some administrators and/or parents believe that these issues should not be addressed in the school setting.
CBITS treatment is provided over the course of 10 school-based group sessions. Groups of six to eight children meet for approximately one hour during school for weekly sessions. The contents of CBITS include the same components as TF-CBT. Children develop personal trauma narratives during two additional individual "break out" sessions that occur separately from the group sessions. Parents of each child are offered the opportunity to take part in parallel parent groups. Teachers receive education about trauma impact and management of trauma symptoms in educational settings. PTSD and depressive symptoms are typically monitored at pre- and posttreatment for improvement using self-report instruments.
CBITS has been shown to be efficacious when delivered by trained school-based mental health clinicians in one large clinical trial and two quasi-randomized studies [19,26,27]. In one randomized trial, 126 sixth-grade students who reported exposure to violence and had PTSD symptoms were randomized to receive a 10-session CBITS group treatment or to a wait list control . After three months, CBITS students had significantly greater improvement in PTSD symptoms than those assigned to the wait list condition; after treatment, the CBITS group mean scores were in the nonclinical range, whereas mean scores for the wait list group remained in the clinical range (large effect size). Significantly lower scores in the intervention group were also seen for depression and psychosocial dysfunction. Similar results were obtained in the quasi-randomized studies [26,27].
Clinician training via a free CBITS online course is available from the CBITS developers at http://cbitsprogram.org. A CBITS manual  and other implementation materials are available. Training in the CBITS model includes face-to-face training, phone consultation, or participation in a CBITS learning collaborative.
CBITS has been widely disseminated to schools in the United States and internationally, but many schools do not have CBITS therapists available. This has led to the development of a variant of CBITS, Supporting Students Exposed to Trauma (SSET) , which can be provided by educators, and thus could be disseminated more easily.
Other group CBT interventions — Other trauma-focused group CBT models found to be efficacious in clinical trials with children with PTSD symptoms have been adapted to address specific types of trauma, or for delivery to groups:
●Trauma Grief Components Treatment (TGCT) – TGCT differs from other group CBT interventions in that it is somewhat longer (17 sessions) and includes both trauma-focused and grief-focused treatment components that aim to address PTSD and maladaptive grief responses, respectively. TGCT is particularly appropriate for teens who have PTSD symptoms and maladaptive grief related to war, terrorism, or other circumstances of traumatic death.
A clinical trial in 127 war-exposed Bosnian adolescents with symptoms of PTSD, depression, or maladaptive grief found that school-based TGCT was superior to a school-based psychoeducation and skills comparison condition for improving PTSD and maladaptive grief responses with medium to large effect sizes .
●Extending and Enhancing Resiliency Amongst Students Experiencing (ERASE)-Stress – ERASE-Stress is a 16-session, teacher-delivered resiliency-building intervention designed specifically for children and adolescents who have been exposed to terrorism or war. While CBITS is a clinician-delivered intervention provided to children with trauma-related symptoms, ERASE-Stress is provided by teachers to all exposed children, either to prevent the emergence of symptoms or as treatment of symptoms when present.
Two quasi-randomized controlled trials comparing ERASE-Stress with wait list control conditions for 142 children and 154 adolescents in Israel, respectively, found that children assigned to receive ERASE-Stress experienced greater improvement in PTSD symptoms (medium effect sizes), as well as in somatic complaints and anxiety [30,31]. Randomized trials have not been conducted.
●Group Trauma-Focused CBT – The group application of TF-CBT does not differ from the individual modality except that it is often provided in nonschool settings, eg, residential treatment centers, community or religious centers, or nongovernmental organizations. The trauma narrative TF-CBT treatment phase is provided in individual “break out” sessions that are provided in addition to the group sessions. (See 'Other individual trauma-focused therapies' above.)
Two randomized trials have compared culturally modified group TF-CBT with wait list controls, one in 52 Congolese war-exposed sexually exploited girls and the other in 50 war-exposed Congolese teen boys, respectively. Both trials found that TF-CBT, compared with the control conditions, resulted in greater improvement in symptoms of PTSD, depression, and anxiety, as well as in conduct and pro-social behaviors (large effect sizes for each result) [12,13].
Therapies for preschool children — DSM-5 describes developmental differences in how PTSD is manifested in young children . Typical PTSD symptoms are manifestations of young children’s basic fears (eg, body damage, abandonment, loss of caregiver). With limited verbal and cognitive abilities, young children are particularly dependent on and trusting of caregivers to provide safety. When trauma occurs, this safety and trust is disrupted.
Effective trauma treatments for young children must rebuild the young child’s trust that the caregiver will keep the child safe and the caregiver’s ability to do so. This has been accomplished through attachment-based models that primarily focus on the child-parent relationship and by CBT models that focus on enhancing child-parent resiliency skills, communication, positive parenting, and the caregiver’s ability to promote safety.
Child-Parent Psychotherapy — Child-Parent Psychotherapy (CPP), developed for young children (birth to six years) who have experienced a trauma and their parent(s) or caretaking adult, is a dyadic attachment-based psychotherapy focused on supporting and strengthening the parent-child relationship as a way to heal the negative impacts of interpersonal trauma. Although CPP has some CBT elements, it is primarily based on attachment and psychodynamic theory. CPP is particularly valuable for very young children (birth to three years) and other young children (eg, those with developmental delays) who cannot express their emotions verbally but do so through play; the CPP therapist helps the parent to understand and make more benign meaning of the child’s play, behaviors, and interactions with the parent.
As a longer-term treatment approach (one year), CPP provides more sustained interventions to the child and parent and thus may be particularly helpful for parents who are highly dysregulated due to personal experiences of domestic violence. Targets of intervention include:
●Addressing parental and child maladaptive representations of self and each other
●Developing a joint trauma narrative to identify and address trauma triggers
●Developing more satisfying interpersonal relationships, activities, routines, and goals
A randomized trial compared CPP with case management and community treatment referral for 75 preschool children with PTSD stemming from domestic violence . After one year of weekly sessions monitored for fidelity, children receiving CPP experienced greater improvement in PTSD symptoms (medium effect size), as well as for total behavior problems (small effect size), relative to children receiving the comparison condition. Mothers receiving CPP also exhibited significantly greater decrease in avoidance symptoms and a trend toward reduction in their own personal PTSD symptoms.
CPP is provided in 40 to 50 weekly dyadic child-parent sessions with additional parent sessions provided as needed. Clinicians typically monitor young children’s PTSD and behavioral symptoms systematically; a developmentally appropriate instrument should be used, such as the YCPC described above. Parental symptoms may also be monitored if a subject of clinical attention.
CPP training materials, including published treatment manuals written by the treatment developers [33,34], handouts, and other resources, are available. Training in the CPP model includes initial face-to-face training and participation in one year or more of ongoing consultation calls or participation in a learning collaborative during which CPP cases are presented and discussed. Training is available from the treatment developer and expert trainers, as well as through learning collaborative sponsored by the National Child Traumatic Stress Network (www.nctsn.org). CPP has been disseminated to many programs across the United States and also in several international locations. A CPP certification program is under development.
Other psychotherapy models for preschoolers — Two CBT trauma-focused treatment models have been tested for preschool children with PTSD symptoms and found to be efficacious in a randomized controlled trial:
●TF-CBT for preschoolers – Two clinical trials have examined preschool children’s response to TF-CBT:
•A clinical trial compared TF-CBT with nondirective supportive therapy (NST) in 86 children ages three to six years with at least five PTSD symptoms following an index trauma of sexual abuse . Children receiving TF-CBT experienced significantly greater improvement in PTSD symptoms compared with the NST group (medium effect size), as well as in internalizing and sexual behavior problems.
•A clinical trial/dismantling study compared the efficacy of four different versions of TF-CBT in children ages 4 to 11 years old with an index trauma of sexual abuse :
-With the trauma narrative phase versus without
-Provided over 8 sessions versus 16 sessions
Children assigned to all four TF-CBT conditions showed improvement in PTSD symptoms with large effect sizes. Children assigned to the eight-session group with a trauma narrative phase showed greater improvement than other groups in internalizing symptoms of fear and anxiety, while children assigned to receive 16 sessions without the trauma narrative phase showed greater improvement in externalizing behavior symptoms. Younger age (four to six years) did not significantly moderate these results.
●Preschool PTSD Treatment (PPT) – PPT includes all TF-CBT components but differs from TF-CBT in that the parent fully participates throughout the entire treatment session. A clinical trial of 62 children ages three to six years with at least five PTSD symptoms following mixed traumas were randomized to PPT or wait list control condition . Despite high drop-out rates, PPT showed significantly greater improvement in PTSD symptoms with large effect sizes.
Therapies for PTSD and SUD — Two treatment models have been developed and tested to address PTSD and comorbid substance use disorders (SUD).
Seeking Safety — Seeking Safety is an adult CBT model for addressing comorbid PTSD and SUD that was modified for teens . It includes most TF-CBT PRACTICE components, but not trauma narration and processing. Other differences from TF-CBT include:
●Safety, not PTSD recovery, is the overarching goal
●A focus on ideals that have been lost through substance abuse and PTSD
●Several present focus/grounding components
A pilot clinical trial randomly assigned 33 adolescent females to receive Seeking Safety showed improvement on some subscale scores of the Trauma Symptom Checklist for Children and some subscales of the Personal Experiences Inventory (for substance use) compared with those assigned to treatment as usual . Changes in overall scores for substance use and PTSD symptoms were not reported.
Seeking Safety for adults with PTSD and SUD is discussed separately. (See "Treatment of co-occurring substance use disorder and anxiety-related disorders in adults", section on 'Integrated CBT'.)
Risk Reduction Family Therapy (RRFT) — RRFT is an application of TF-CBT that includes additional components for reducing risk of substance abuse. A pilot clinical trial randomly assigned 30 adolescents with histories of sexual abuse and substance abuse to RRFT or treatment as usual, finding that participants assigned to RRFT experienced greater improvement in PTSD, substance use, depressive, and internalizing symptoms compared with participants assigned to treatment as usual (medium effect sizes) . A limitation in the trial was a difference in functioning between groups at baseline.
Comparing psychotherapies — Comparisons in the efficacy of different types of trauma-focused psychotherapies in children are limited. Two clinical trials found little difference in primary PTSD outcomes between therapies. A much higher proportion of children made use of the more accessible school-based therapy compared with clinic-based therapy:
●A clinical trial in 48 children with PTSD symptoms compared EMDR with TF-CBT . Eight sessions of each intervention resulted in large effect sizes for PTSD improvement; no difference in reduction in PTSD symptoms was seen. Parents of children treated with TF-CBT, but not those treated with EMDR, reported improvement in child depressive and hyperactivity symptoms.
●A clinical trial compared CBITS and TF-CBT following Hurricane Katrina . One hundred and eighteen schoolchildren identified by screening to have significant PTSD symptoms were randomized to receive CBITS at their schools, or TF-CBT at community clinics. Students assigned to the school-based intervention were more likely to access treatment than students assigned to the clinic-based intervention (98 versus 37 percent). Both groups experienced reductions in PTSD symptoms, but no differences were seen between groups.
More trials are needed comparing the relative benefits of alternative trauma-focused psychotherapies for children with different presentations, comorbidities, and risk factors.
Contraindications — Contraindications for trauma-focused psychotherapies include:
●Acute clinical states that require immediate stabilization (eg, acute suicidality, psychosis, mania, or drug intoxication).
●For cognitive-based therapies, severe developmental or cognitive impairments.
●For group therapies, conditions that would interfere with participation (eg, severe behavioral dysregulation, severe attention deficit hyperactivity disorder).
TREATMENT SELECTION — For children with a posttraumatic stress disorder (PTSD) diagnosis or prominent PTSD symptoms, including those with complex PTSD, we suggest first-line treatment with an evidence-based, trauma-focused psychotherapy. The intervention should be provided by a therapist who has received appropriate training in that model. A full course of therapy should be completed.
Varied trauma-focused psychotherapy models have been developed, with emphasis on different components and/or customized to treat patients with specific characteristics, clinical presentations, or in certain settings. There is limited evidence, however, to inform selection among these therapies. Few clinical trials have directly compared psychotherapies, and these did not show differences in PTSD outcomes. Our suggestions stem largely from clinical trials comparing individual therapies with inactive controls, secondary data analyses, our clinical experience, and that of others with relevant expertise. Our suggestions are as follows (see 'Comparing psychotherapies' above).
Children seven years and older — For children seven years and over with PTSD or PTSD symptoms, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is most strongly supported by evidence from clinical trials in diverse populations of children with diverse types of trauma [39-41]. (See 'Individual Trauma-Focused CBT' above.)
Choice among treatments may be influenced by individual or family preference, specific population needs (eg, Trauma Affect Regulation: Guide for Education and Therapy [TARGET] for juvenile justice-involved youth) and/or local availability.
Where there are resource constraints, an absence of trained therapists, or other barriers to access that preclude individual therapy, we suggest first-line treatment with an evidence-based trauma-focused group CBT, such as CBITS [25-27]. The choice between individual and group modalities may also be influenced by family preference, by specific population needs (eg, TGCT for teens with both PTSD and maladaptive grief symptoms), or by clinical presentation (eg, we favor individual therapy for children with more severe PTSD symptoms ). (See 'Cognitive Behavioral Intervention for Trauma in Schools (CBITS)' above.)
Children three to six years — For children three to six years old with PTSD or PTSD symptoms, we suggest Child-Parent Psychotherapy (CPP) rather than other psychotherapies, particularly for children with:
●Significant developmental or cognitive delays, since this model does not require participation in cognitive-based interventions
●Severe attachment-related difficulties, due to the dyadic, attachment-based nature of CPP, and its longer duration
We suggest TF-CBT rather than CPP for children with:
●Sexualized behavior problems, based on findings of positive outcomes in a clinical trial 
●Higher levels of general internalizing or externalizing problems, based on the findings from a meta-analysis of multiple clinical trials 
Favoring the use of CPP and TF-CBT in this population are clinical trials showing improvement compared with active comparison conditions, and the availability of well-established training protocols and fidelity guidelines [39,40]. CPP and TF-CBT have not been compared in head-to-head clinical trials, nor have they been compared with other psychosocial interventions in this population. (See 'Therapies for preschool children' above.)
Children under three years — For children under three years old with PTSD symptoms, we suggest the use of CPP rather than TF-CBT or PPT. Children under three are typically too young to participate in cognitive-based interventions and would benefit more from attachment-based therapy. To date, no empirical data are available to guide decision making for this age group. (See 'Child-Parent Psychotherapy' above.)
NONRESPONSE TO PSYCHOTHERAPY — Research to date has not identified consistent predictors of nonresponse to trauma-focused psychotherapy in children. When children with posttraumatic stress disorder (PTSD) do not respond to psychotherapy, the clinician should reevaluate the therapy and the patient’s clinical presentation in view of the considerations below:
●Treatment fidelity – Treatment nonresponse may occur when an evidence-based treatment is provided with low fidelity, ie, the model is not provided as intended. If core treatment components are provided incorrectly or not at all, the treatment will likely be ineffective. In such cases, improved fidelity and outcomes can often be attained by ensuring that therapists receive appropriate training and consultation in the selected model, receive ongoing, model-specific supervision, and monitor their treatment fidelity over time. Certification or other documentation (when available) that therapists have completed all recommended training requirements for the chosen model can enhance the likelihood of children receiving treatment with high fidelity.
●Trauma reminders – Lack of response to cognitive-behavioral therapy (CBT) in children with PTSD should prompt more careful exploration of potential trauma reminders or triggers, further development of different coping strategies for these triggers, and/or helping the child to master the coping strategies identified (eg, during in-session practice). (See 'Mechanisms of treatment' above and 'Phases and components' above.)
●Ongoing trauma – Even with appropriate treatment, some PTSD symptoms may persist when trauma recurs during treatment; in this situation some trauma responses (eg, increased vigilance) might be adaptive. Clinical strategies include, for example, increasing the focus on child safety early in treatment, helping children differentiate between real danger and trauma reminders, and helping nonoffending parents collaborate with children to develop effective strategies for enhancing the child’s safety [9,42]. These strategies have been effective in reducing PTSD and anxiety symptoms in a clinical trial . (See 'Phases and components' above.)
●Complex trauma – Poor or delayed response to trauma-focused psychotherapy may suggest the presence of complex PTSD, which is seen in children who have experienced early, chronic interpersonal trauma. These children are particularly vulnerable to interpersonal trauma reminders (eg, arguments, real or perceived rejection or threatened attachment loss) [5,43] and experience severe dysregulation in multiple domains of functioning including affect, attachment, biology, self-concept, cognitions, perceptions . (See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis".)
Since youth with complex PTSD experience trauma within the context of close relationships, initiating a therapeutic relationship often serves as a trauma reminder for these youth. It is useful to contextualize these responses within a trauma framework rather than viewing such difficulties as "treatment nonresponse." Most treatments with efficacy for child PTSD have been successfully applied to the subgroup with complex trauma . These youth typically need somewhat lengthier treatment, with a longer initial stabilization phase, during which they can be expected to test the trustworthiness of the new therapist. Other treatments have been developed specifically for these youth [18,45,46].
●Co-occurring mental disorders – Co-occurring disorders are often seen in children with PTSD, including depression, generalized anxiety disorder, and obsessive-compulsive disorder. PTSD should not be considered nonresponsive to psychotherapy until the after the comorbid disorder is adequately treated. Many of these co-occurring conditions are treatable with CBT.
●Environmental factors – Many features of a traumatized child’s daily life (eg, family, health, educational, community, faith, legal, and child welfare) are likely to influence treatment response . Examples include changes in foster family placement or the arrest/incarceration or illness/death of a family member. These issues emphasize the critical importance of working collaboratively with caregivers to be proactively aware of potential changes that may occur in the child’s life and address perceived or real threats to the child’s safety that may occur as a result of these changes.
If after addressing these factors the clinician is convinced that the patient has not responded to an adequate trial of the first-line psychotherapy, the following steps may be helpful:
●Switching to another evidence-based psychotherapy that may be more helpful. As an example, a child who has not responded to trauma-focused group CBT may benefit from trauma-focused individual CBT .
●Tailoring the psychotherapy to the child’s specific PTSD symptoms, such as:
•For hyperarousal symptoms (eg, angry outbursts, irritability, and sleep disturbance) – A systematic CBT focus on parenting skills and behavioral regulation skills.
•For ongoing symptoms of re-experiencing, avoidance, fear, or anxiety – Trauma narration and/or cognitive processing of maladaptive cognitions that includes [11,48]:
-Increased coherence of trauma memories as the narrative progresses
-Focus on integrating meaning of past trauma experiences into more positive present and future
PREVENTION — Most children develop some psychological symptoms in the immediate aftermath following trauma exposure; these usually remit spontaneously. In a minority of children, these develop into posttraumatic stress disorder (PTSD), which is diagnosed if symptoms meeting a diagnostic threshold, accompanied by dysfunction or distress, persist for at least one month. Early interventions in the aftermath of a traumatic exposure have been developed and tested with the aim of preventing the subsequent development of PTSD.
Child and Family Traumatic Stress Intervention (CFTSI) — CFTSI is a CBT-based four- to six-session psychosocial intervention developed to begin within the first month after acute trauma exposure. The intervention includes psychoeducation, building awareness and parent-child communication about symptoms, and skill building to address prominent, mutually selected symptoms.
A clinical trial found that CFTSI prevented the development of chronic PTSD following trauma exposure in children. The trial randomly assigned 106 children within 30 days of traumatic exposure to receive CFTSI or supportive counseling . At follow-up 90 days after trauma exposure, participants who received CFTSI were 65 percent less likely to meet diagnostic criteria for PTSD compared with the control group.
Other interventions — Other models have been tested for early prevention of PTSD, but neither was found to be effective.
●Critical incidence stress debriefing (CISD) typically consists of a one-session debriefing session following trauma exposure, during which children describe and process their experiences with peers exposed to the same or similar experiences. A clinical trial comparing CISD with a wait list control in 132 children following road traffic accidents found no difference in preventing the development of PTSD .
●In a clinical trial with 132 children within 30 days of a road traffic injury, a two-session CBT-based intervention led to a subsequent rate of PTSD not significantly different from the proportion in the control group .
SUMMARY AND RECOMMENDATIONS
●Several trauma-focused psychotherapy models have been found to be efficacious in the treatment of posttraumatic stress disorder (PTSD) or PTSD symptoms beneath the diagnostic threshold for the disorder. These interventions include individual and group models, as well as models tailored to meet the needs of specific subgroups. (See 'Trauma-focused psychotherapies' above.)
●Components of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) and Cognitive Behavioral Intervention for Trauma in Schools (CBITS) include psychoeducation, parenting skills, relaxation skills, affect modulation skills, cognitive processing skills, trauma narration and processing, in vivo mastery of trauma, conjoint child-parent sessions, and enhancing safety. (See 'Phases and components' above.)
●Contraindications for trauma-focused psychotherapies include acute clinical states that require immediate stabilization (eg, acute suicidality, psychosis, mania, or drug intoxication); for cognitive-based therapies, severe developmental or cognitive impairments; for group therapies, conditions that would interfere with participation (eg, severe behavioral dysregulation, severe attention deficit hyperactivity disorder). (See 'Contraindications' above.)
●For children with PTSD who do not respond to trauma-focused psychotherapy, considerations should include treatment fidelity, further addressing trauma reminders, the possibility of ongoing trauma, the presence of complex trauma, co-occurring mental disorders, and/or environmental factors adversely affecting the child. (See 'Nonresponse to psychotherapy' above.)
●For children and adolescents with PTSD or prominent PTSD symptoms, including those with complex PTSD, we suggest first-line treatment with a trauma-focused psychotherapy rather than other psychotherapies (Grade 2C). Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) has the strongest basis in clinical trials for children seven years and older; other reasonable alternatives include Combined Parent-Child Cognitive-Behavioral Therapy (CPC-CBT) and Trauma Affect Regulation: Guide for Education and Therapy (TARGET). The intervention should be provided by a therapist who has received appropriate training in that model. A full course of therapy should be completed. (See 'Treatment selection' above.)
●Where there are resource constraints, an absence of trained therapists, or other barriers to access that preclude individual therapy, we suggest first-line treatment with trauma-focused group CBT, specifically with CBITS (Cognitive Behavioral Intervention for Trauma in Schools), rather than other psychotherapies for children seven years or older (Grade 2C). Other trauma-focused group psychotherapies that emphasize cognitive and behavioral principles, and are supported by clinical trials, are reasonable alternatives if preferred due to local availability, patient preference, and/or specific population needs. (See 'Cognitive Behavioral Intervention for Trauma in Schools (CBITS)' above and 'Children seven years and older' above and 'Other individual trauma-focused therapies' above and 'Other group CBT interventions' above.)
Children three to six years
●For children three to six years with PTSD or PTSD symptoms, we suggest Child-Parent Psychotherapy (CPP) rather than TF-CBT for children with significant developmental or cognitive delays, or severe attachment-related difficulties (Grade 2C). (See 'Children three to six years' above and 'Child-Parent Psychotherapy' above.)
●For children with sexualized behavior problems or higher levels of general internalizing or externalizing problems, we suggest TF-CBT rather than CPP (Grade 2C). (See 'Children three to six years' above and 'Other psychotherapy models for preschoolers' above.)
Children under three years
●For children under three years old with PTSD symptoms, we suggest the use of CPP rather than TF-CBT adapted to preschool children or other therapies (Grade 2C). (See 'Children under three years' above and 'Child-Parent Psychotherapy' above.)
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