The opportunity to voluntarily participate in a debriefing discussion with a trained professional may be helpful for those who freely choose to discuss their traumatic experience. Treatment is designed to develop and maintain expectations of safety and predictability, reestablish self-control and self-direction, and build the child’s capacity for resilience in future experiences of adversity. A final goal of treatment is to help prevent the child from regarding himself with limited self-respect and self-regard.
The Table presents the 8 steps for treating traumatic stress. These steps are appropriate for acute treatment after traumatic injury, acute abuse, or natural disaster. They are also appropriate for children with PTSD and for those who have experienced repeated trauma and who evidence complex traumatic stress.
Step 1: Safety
The first step involves ensuring the child’s physical safety. Compassionate and caring involvement of police, rescue workers, health care professionals, and child protective workers maximize the likelihood that the child will feel psychologically supported. The clinician should ensure that a traumatized child feels safe at home and in the therapist’s office. Some abused children lack a sense of safety and may need to learn relaxation techniques to become comfortable with their therapist and to participate in therapy. The therapist can help the patient associate safety with the experience of calmness and begin to search out safety and avoid dangerous situations. In some cases of domestic or community violence, the therapist may need to help parents ensure their child’s safety.
Step 2: Basic needs
The next step is attention to the child’s basic needs for food, shelter, sleep, and medical care. After traumatic injury, this may include surgery and hospital care. After a natural disaster, this may include temporary housing and relief provisions. For children removed from abusive homes, the state is responsible for certifying that foster homes have the resources needed to care for the child.
Adequate nutrition and sleep are essential aspects of treatment for both acute and chronic traumatic stress. Psychopharmacology to assist with sleep, and to allay severe anxiety and significant hopelessness and withdrawal is also often useful. SSRIs are most commonly used with appropriate informed consent and monitoring. Use of these agents for children and adolescents with PTSD is currently off-label. However, sertraline(Drug information on sertraline) has been FDA-approved for children with other anxiety disorders, such as obsessive-compulsive disorder. Sertraline has also been approved for PTSD in adults. Both sertraline and fluoxetine(Drug information on fluoxetine) have been approved for use in depression in adolescents.
Depression is frequently comorbid with PTSD in children and adolescents. Informed consent by parents and consistent monitoring for suicidal ideation in youths treated with SSRIs are essential. When psychosocial treatments alone do not lead to recovery, I prescribe either sertraline or fluoxetine for children older than 10 years in conjunction with psychotherapy and parental involvement.
Step 3: Knowledge
It is essential that the child and family understand as fully as possible all aspects of trauma recovery. In acute situations, this involves providing information about treatment, recovery, and expectations for the future. The therapist must make sure that the family and child understand the psychological effects of trauma and how behavioral symptoms may be a response to traumatic experiences. Parents will need to learn the importance of validating their child’s emotional experience and to set consistent limits in a firm but caring manner.
Parents may feel guilty about their inability to protect their child. Accurate information may help them resolve their guilt and enable them to be available to support their child. Providing information is the first step in developing a recovery-oriented therapeutic collaboration with the child and family. By encouraging the family and child to ask questions and to build a thorough understanding of their situation and what can be expected in treatment, the therapist begins the process of empowerment and helps the child build self-control.