Childhood Trauma Therapies

Research studies have shown that PTSD symptoms below the threshold can be effectively treated with trauma-focused psychotherapies. Individual and group treatments, as well as models adapted to the needs of specific subgroups, are all included in these interventions.

Treatment mechanism – PTSD is viewed as a disorder of conditioning of fear that is overgeneralized and cannot subside naturally. The development and maintenance of child PTSD are influenced by social, economic, environmental, learning, and biological factors, indicating the need for multifaceted treatment approaches.

Strong emotional reactions are elicited when someone has been through trauma (eg, anger, fear). When children are exposed to cues that remind them of the trauma, disordered behavior modification causes them to have strong negative emotional reactions to those stimuli. Children avoid trauma reminders in an effort to prevent these negative emotions.

Trauma-focused CBT (for individuals) –  A parallel treatment model for children and parents (or primary caregivers) that combines cognitive-behavioral therapy (CBT), family, attachment, neurobiological, psychological, developmental, and empowerment principles is trauma-focused cognitive-behavioral therapy (TF-CBT). Children and parents are taught coping techniques to help them recover from trauma. They are also taught how to overcome learned and overgeneralized avoidance of painful or traumatic memories. The next section details the effectiveness of TF-CBT. Children who exhibit trauma-related symptoms, regardless of whether they fulfill diagnostic criteria for PTSD, can benefit from trauma-focused psychotherapy.

Phases and components — TF-CBT is a multi-component treatment that is delivered in three phases. In each therapy session, counseling is provided to the kid and parent (or caregiver, hereafter “parent”) in separate, parallel sessions, as well as in conjoint child-parent group meetings as explained below.

• Psychoeducation, parental care, relaxation skills, affect regulation skills, and cognitive processing abilities are all included in the stabilization phase.
• Trauma narration and processing phase – Trauma narration and processing are included in this phase.
• Phase of integration and consolidation — Includes in-vivo mastering, collaborative child-parent sessions, and safety enhancement.

The following are brief descriptions of the constituents of these phases, which form the abbreviation “PRACTICE”:

Psychoeducation – Information is offered about the relationship between the child’s previous (or ongoing) exposure to traumatic events, trauma reminders, and current trauma symptoms, as well as the commonality of these responses to trauma.

Parenting skills – Parents are taught various effective parenting practices for dealing with their PTSD children. These include abilities such as praising, selective attention, and the use of functioning behavioral evaluation (e.g., altering antecedents and consequences) to manage behavioral trauma effectively.

Relaxation skills — Relaxation techniques (e.g.,  exercise, progressive muscle relaxation, focused breathing and visualization) are taught, tailored to the person, and practiced in order to reverse the physiological trauma effect, including reaction to trauma reminders.

Affect modification skills — Feeling recognition and modulation skills (e.g., vocal expression of unpleasant feelings, accessing support networks, positive diversion methods, and problem-solving) are offered, customized to the individual, and practiced, including in reaction to trauma reminders.

Cognitive processing abilities – Recognize relationships between general negative thought patterns (e.g., “I do not even have any peers”), negative emotions (e.g., anger), and behaviors (e.g., excessive competition with colleagues), and develop the ability to generate more accurate or beneficial thoughts (e.g., “Lisa enjoys my company”) in order to feel good (e.g., less angry) and act differently (e.g., ask Lisa to play at recess). These abilities enable children and parents in gaining control over a variety of unpleasant emotions and behaviors, so preparing them for more focused trauma-related cognitive processing in the subsequent phase.

Trauma narration and processing — Using the skills outlined above, the therapist helps the child in developing a thorough narrative of his or her personal trauma experiences and mentally processing these events. This component is a participatory, therapeutic process that takes place between the therapist and the child (as well as between the therapist and the parent, as the therapist communicates the content of the child’s narrative with the parent). It is believed that exposing trauma-related cognitions and resolving maladaptive thoughts associated with this cognitive information alleviates PTSD symptoms (e.g., cognitive distortions, negative emotions, avoidance, and negative behaviors).

In vivo mastering of reminders of traumatic events – For children who have an irrational fear of prolonged exposure to trauma-related stimuli in their environment (e.g., avoid the washrooms or living rooms where prior abuse took place but is now safe; resist going to the school where they were bullied earlier but are now safe), in vivo exposure is used to develop psychological adjustment.

Conjoint child-parent sessions — One or more mutual child-parent meetings are included to facilitate direct child-parent interaction about trauma (e.g., sharing the child’s trauma experience with the parent openly, safety planning, and other personalized difficulties).

Improving child welfare and safety – Trauma causes disruption of safety; re-establishing the child’s real and perceived sense of safety is essential for healing. It’s important to teach children safety skills that are appropriate for their age and living environment and to practice those skills with them.

Efficacy – A number of controlled clinical trials have found that TF-CBT was more effective at reducing PTSD symptoms in children than active treatments or controls for PTSD. Even though there has been some variation in findings of the improvement of associated symptoms (like mood changes, anxiety or depression, behavioral issues, difficulties with parenting, or cognitive dysfunctions), the overall trend has been positive. Three trials including 98 youth with PTSD found that CBT led to reduced PTSD symptoms one month after treatment in comparison with control groups. Children who have experienced sexual assault, domestic abuse, war, or multiple or complex trauma may benefit from these treatments, according to clinical trials.

For instance, the largest clinical trial involved 220 children (aged 8 to 14 years) who had symptoms in each cluster of the DSM IV-TR diagnostic criteria for PTSD, as well as a history of multiple traumas (average = 3.4), one of which was an index trauma of confirmed sexual abuse. Twelve sessions of either TF-CBT or Child-Centered Therapy (CCT) were given to the subjects at random, with the child and their parent attending each session. There was a reduction in PTSD symptoms and the proportion of patients meeting diagnostic criteria for PTSD in the TF-CBT group compared to the CCT group at the end of treatment; effect sizes ranged from medium to large.  In addition to the effect on ICD-11 complex PTSD and evidence of longer-term effects, there have been numerous international replications showing similar effect sizes. Research has shown that TF-CBT is effective in low-income countries, particularly for children grieving the death of a parent.

Mode of Administration — TF-CBT is commonly provided to individual children once weekly during hourly sessions for a period of 12 to 25 sessions. Depending on the child’s clinical presentation, the length and proportionality of treatment sessions vary from 12 to 25 sessions for children with typical PTSD and up to 40 sessions for those with complicated PTSD.

Children’s responses to treatment are typically monitored by clinicians based on self-reported ratings of PTSD symptom severity. For this, a self-report tool like the Child PTSD Symptom Scale or for young children, the parent-reported Young Children’s PTSD Checklist works best in clinical practice. Individual TF-CBT has been adapted for the treatment of PTSD in groups of children and for the treatment of children as young as three years old.

Training – In order to receive standard TF-CBT training, participants must complete the following requirements: successful execution of TF-CBTWeb2.0 course; two days of in-person training with an approved TF-CBT instructor; twelve consultation calls (generally twice monthly for 6 months); or involvement in an approved TF-CBT learning alliance. In the United States, training is accessible through the National Child Traumatic Stress Network, which may be found at www.nctsn.org. In addition to the dissemination of a validated methodology for educating lay counselors in low-resource countries, efforts are being made to introduce TF-CBT through the use of telemedicine.