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.27 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.28
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.29
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.30 Kenardy and colleagues31 conducted an information provision 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.31 Furthermore, a psychoeducational intervention for youths following motor vehicle accidents was successful in preventing depression and behavior problems in preadolescent youths.32
Play therapy . Posttraumatic play is defined as play activity that is driven, is serious, and has a morbid quality.33,34 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 trauma.35
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.36-38 In addition, a study of refugee children found that CCPT was more effective than TF-CBT in reducing PTSD symptoms.39
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.40 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.41 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.42 Psychotherapy is generally considered to be the first choice of treatment for childhood PTSD. 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 Carrion42 for a comprehensive review of all psychotropic medications that may be effective in treating childhood PTSD.)