Treatment of Traumatic Stress Disorder in Children and Adolescents

October 29, 2012

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.

We all experience stress throughout our lives; this can be beneficial because stress inoculation aids in the development of many of our biological systems.1 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.2 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.3 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.4 Although a number of children are resilient to traumatic experiences, there are no methods to identify and measure what constitutes true resilience. Problems may not 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.5 Epidemiological studies indicate that children exposed to trauma are at much greater risk for PTSD.6

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.7 Alternative criteria have been suggested for the diagnosis of PTSD in young children.8

Therapeutic interventions

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.9 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.10,11 Bronfenbrenner9,12 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. Table 1provides additional treatment considerations. (A complete review of best-practice interventions can be found in Foa et al.13)

Table 1


Important factors to consider when choosing a treatment for childhood trauma

Cognitive-behavioral therapy . CBT is the most widely used and researched treatment for childhood trauma.14Various trauma-oriented CBT interventions exist and all share components summarized by the acronym PRACTICE (Table 2).15 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.16-18 It is superior to child-centered therapy in reducing PTSD symptoms, especially hyperarousal and avoidance in youths exposed to intimate partner violence.19

Trauma systems therapy (TST) is an individual treatment that addresses trauma-related symptoms and the environmental factors that perpetuate them.20 TST has shown improvements in PTSD symptoms, environmental stability, and functioning.

Table 2


Trauma-focused CBT components

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.21,22 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.23 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.24-26

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.

Pharmacology

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.)

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.43 An open trial of fluoxetine demonstrated that it was effective in improving earthquake-related PTSD symptoms in 26 youths.44 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.45 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.46 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.47,48 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.49 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.50,51 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.52 Propranolol has also been found effective in reducing reexperiencing and hyperarousal symptoms in children with PTSD.53 Novel antipsychotics such as risperidone have been used effectively to stabilize mood in severe cases and to treat comorbid symptoms of childhood PTSD.54 Finally, higher doses of morphine were found to prevent PTSD secondary to burns in hospitalized preschool children, school-aged children, and adolescents.55,56

Conclusions

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.

References:

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References

1.

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

J Consult Clin Psychol

. 2002;70:537-547.

2.

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

Clin Psychol Rev

. 2003;23:339-376.

3.

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

Neuropsychopharmacology

. 2000;22:108-124.

4.

Foy DW, Goguen CA. Community violence-related PTSD in children and adolescents.

PTSD Res Q

. 1998;9(4):1-6.

5.

De Bellis M, Baum AS, Birmaher B, et al. A.E. Bennett Research Award. Developmental traumatology. Part I: biological stress systems.

Biol Psychiatry

. 1999;45:1259-1270.

6.

Gabbay V, Oatis MD, Silva RR, Hirsch G. Epidemiological aspects of PTSD in children and adolescents. In: Silva RR, ed.

Posttraumatic Stress Disorder in Children and Adolescents: Handbook.

New York: WW Norton & Co; 2004:1-17.

7.

Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth.

J Am Acad Child Adolesc Psychiatry

. 2002;41:166-173.

8.

Scheeringa MS. Developmental considerations for diagnosing PTSD and acute stress disorder in preschool and school-age children.

Am J Psychiatry.

2008;165:1237-1239.

9.

Bronfenbrenner U.

The Ecology of Human Development: Experiments by Nature and Design

. Cambridge, MA: Harvard University Press; 1979.

10.

Freisthler B, Merritt DH, LaScala EA. Understanding the ecology of child maltreatment: a review of the literature and directions for future research.

Child Maltreat

. 2006;11:263-280.

11.

Zielinski DS, Bradshaw CP. Ecological influences on the sequelae of child maltreatment: a review of the literature.

Child Maltreat

. 2006;11:49-62.

12.

Bronfenbrenner U. Ecology of the family as a context for human development: research perspectives.

Dev Psychol

. 1986;22:723-742.

13.

Foa EB, Keane TM, Friedman MJ, Cohen JA.

Effective Treatments for Posttraumatic stress Disorder: Practice Guidelines From the International Society for Traumatic Stress Studies

. 2nd ed. New York: Guilford Publications; 2009.

14.

Adler-Nevo G, Manassis K. Psychosocial treatment of pediatric posttraumatic stress disorder: the neglected field of single-incident trauma.

Depress Anxiety

. 2005;22:177-189.

15.

Cohen JA, Mannarino AP. Trauma-focused cognitive behavioural therapy for children and parents.

Child Adolesc Ment Health

. 2008;13:158-162.

16.

Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms.

J Am Acad Child Adolesc Psychiatry

. 2004;43:393-402.

17.

Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of a randomized controlled trial.

Child Abuse Negl

. 2005;29:135-145.

18.

Scheeringa MS, Weems CF, Cohen JA, et al. Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: a randomized clinical trial.

J Child Psychol Psychiatry

. 2011;52:853-860.

19.

Cohen JA, Mannarino AP, Iyengar S. Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: a randomized controlled trial.

Arch Pediatr Adolesc Med.

2011;165:16-21.

20.

Saxe GN, Ellis H, Fogler J, et al. Comprehensive care for traumatized children: an open trial examines treatment using trauma systems therapy.

Psychiatr Ann.

2005;35:443-448.

21.

Amaya-Jackson L, Reynolds V, Murray MC, et al. Cognitive-behavioral treatment for pediatric posttraumatic stress disorder: protocol and application in school and community settings.

Cogn Behav Pract

. 2003;10:204-213.

22.

March JS, Amaya-Jackson L, Murray M, Schulte A. Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor.

J Am Acad Child Adolesc Psychiatry

. 1998;37:585-593.

23.

Stein BD, Jaycox LH, Kataoka SH, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial.

JAMA

. 2003;290:603-611.

24.

Goenjian AK, Karayan I, Pynoos RS, et al. Outcome of psychotherapy among early adolescents after trauma.

Am J Psychiatry

. 1997;154:536-542.

25.

Layne CM, Pynoos RS, Saltzman WR, et al. Trauma/grief-focused group psychotherapy: school-based postwar intervention with traumatized Bosnian adolescents.

Group Dynamics Theory Res Pract

. 2001;5:277-290.

26.

Saltzman RW, Layne CM, Pynoos RS, et al. Trauma/grief-focused intervention for adolescents exposed to community violence: results of a school-based screening and group treatment protocol.

Group Dynamics Theory Res Pract

. 2001;5:291-303.

27.

Lieberman AF, Van Horn P, Ippen CG. Toward evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence.

J Am Acad Child Adolesc Psychiatry

. 2005;44:1241-1248.

28.

Thomas R, Zimmer-Gembeck MJ. Accumulating evidence for parent-child interaction therapy in the prevention of child maltreatment.

Child Dev

. 2011;82:177-192.

29.

Copping VE, Warling DL, Benner DG, Woodside DW. A child trauma treatment pilot study.

J Child Fam Stud

. 2001;10:467-475.

30.

Adler Nevo G, Manassis K. An adaptation of prolonged exposure therapy for pediatric single incident trauma: a case series.

J Can Acad Child Adolesc Psychiatry

. 2011;20:127-133.

31.

Kenardy J, Thompson K, Le Brocque R, Olsson K. Information-provision intervention for children and their parents following pediatric accidental injury.

Eur Child Adolesc Psychiatry

. 2008;17:316-325.

32.

Zehnder D, Meuli M, Landolt MA. Effectiveness of a single-session early psychological intervention for children after road traffic accidents: a randomised controlled trial.

Child Adolesc Psychiatry Ment Health

. 2010;4:7.

33.

Gil E.

Play Therapy for Severe Psychological Trauma

. New York: Guilford Press; 1998.

34.

Nader K, Pynoos R. Play and drawing as tools for interviewing traumatized children. In: Schaeffer C, Gitlan K, Sandgrund A, eds.

Play, Diagnosis and Assessment

. New York: John Wiley; 1991:375-389.

35.

Baggerly JN, Ray DC, Bratton SC, eds.

Child-Centered Play Therapy Research: The Evidence Base for Effective Practice

. Hoboken, NJ: John Wiley & Sons; 2010.

36.

Kot S, Landreth GL, Giordano M. Intensive child-centered play therapy with child witnesses of domestic violence.

Int J Play Ther

. 1998;7:17-36.

37.

Shen Y. Short-term group play therapy with Chinese earthquake victims: effects on anxiety, depression, and adjustment.

Int J Play Ther

. 2002;11:43-63.

38.

Tyndall-Lind A, Landreth GL, Giordano MA. Intensive group play therapy with child witnesses of domestic violence.

Int J Play Ther

. 2001;10:53-83.

39.

Schottelkorb AA, Doumas DM, Garcia R. Treatment for childhood refugee trauma: a randomized, controlled trial.

Int J Play Ther.

2012;21:57-73.

40.

Terr L.

Unchained Memories

. New York: Basic Books; 1994.

41.

Carrion VG, Hull K

.

Treatment manual for trauma-exposed youth: case studies.

Clin Child Psychol Psychiatry

. 2010;15:27-38.

42.

Wilkinson J, Carrion VG. Pharmacotherapy in pediatric PTSD: a developmentally focused review of the evidence.

Curr Psychopharmacol

. 2012;1:252-270.

43.

Seedat S, Stein DJ, Ziervogel C, et al. Comparison of response to selective serotonin reuptake inhibitor in children, adolescents, and adults with posttraumatic stress disorder.

J Child Adolesc Psychopharmacol

. 2002;12:37-46.

44.

Yorbik O, Dikkatli S, Cansever A, Sohmen T. The efficacy of fluoxetine treatment in children and adolescents with posttraumatic stress disorder symptoms [in Turkish].

Klin Psikofarmakol Bulteni

. 2001;11:251-256.

45.

Robb A, Cueva J, Sporn J, et al. Efficacy of sertraline in childhood posttraumatic stress disorder. In: Scientific Proceedings from the American Academy of Child and Adolescent Psychiatry; October 28-November 2, 2008; Chicago. Abstract P3.8.

46.

Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms.

J Am Acad Child Adolesc Psychiatry

. 2007;46:811-819.

47.

Hammad TA. Results of the analysis of suicidality in pediatric trials of newer antidepressants. Presented at: US Food and Drugs Administration Psychopharmacologic Drugs Advisory Committee and the Pediatric Advisory Committee; September 2004; Rockville, MD.

48.

Mitka M. FDA alert on antidepressants for youth.

JAMA

. 2003;290:2534.

49.

Robert R, Blakeney PE, Villarreal C, et al. Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: a pilot study.

J Am Acad Child Adolesc Psychiatry

. 1999;38:873-882.

50.

Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children.

J Am Acad Child Adolesc Psychiatry

. 1996;35:1247-1249.

51.

Perry BD. Neurobiological sequelae of childhood trauma: posttraumatic stress disorder in children. In: Murburg MM, ed.

Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts

. Washington, DC: American Psychiatric Press; 1994:223-255.

52.

De Bellis MD, Keshavan MS, Harenski KA. Anterior cingulate N-acetylaspartate/creatine ratios during clonidine treatment in a maltreated child with posttraumatic stress disorder.

J Child Adolesc Psychopharmacol.

2001;11:311-316.

53.

Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress disorder, acute type. A pilot study.

Am J Dis Child

. 1988;142:1244-1247.

54.

Horrigan JP, Barnhill LJ. Risperidone and PTSD in boys.

J Neuropsychiatry Clin Neurosci

. 1999;11:126-127.

55.

Stoddard FJ Jr, Sorrentino EA, Ceranoglu TA, et al. Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns.

J Burn Care Res

. 2009;30:836-843.

56.

Saxe G, Stoddard F, Courtney D, et al

.

Relationship between acute morphine and the course of PTSD in children with burns.

J Am Acad Child Adolesc Psychiatry

. 2001;40:915-921.

57.

American Psychiatric Association. DSM-5 Development. DSM-5: The Future of Psychiatric Diagnosis. 2012.

www.dsm5.org

. Accessed September 24, 2012.