Hilit Kletter, PhD

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 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.

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 interventions.

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.

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.

 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 selecting an intervention. 

provides additional treatment considerations. (A complete review of best-practice interventions can be found in Foa et al.

 
Important factors to consider when choosing a treatment for childhood trauma 

 . 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 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.

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.

 . 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.

 . 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.

 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.

 Furthermore, a psychoeducational intervention for youths following motor vehicle accidents was successful in preventing depression and behavior problems in preadolescent youths.

 . 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 trauma.

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. 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 citalopram resulted in equivalent improvement.

An open trial of fluoxetine demonstrated that it was 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 and placebo in treatment outcome.

 A study that compared TF-CBT plus 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 compared with those who received chloral hydrate.

 However, 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 clonidine decreased basal heart rate, anxiety, impulsivity, and 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 has also been found effective in reducing reexperiencing and hyperarousal symptoms in children with PTSD.

 Novel antipsychotics such as risperidone have been used effectively to stabilize mood in severe cases and to treat comorbid symptoms of childhood PTSD.

 Finally, higher doses of morphine were found to prevent PTSD 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 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 family.

 Kiecolt-Glaser JK, McGuire L, Robles T, Glaser R. Psychoneuroimmunology: psychological influences on immune function and health. 

 Brewin CR, Holmes EA. Psychological theories of posttraumatic stress disorder. 

 McEwen BS. Allostatis and allostatic load: implications for neuropsychopharmacology. 

Articles

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.

Author | Hilit Kletter, PhD

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Treatment of Traumatic Stress Disorder in Children and Adolescents