“Child Trauma” will be published in the upcoming electronic newsletter, Briefings, for the California Psychological Association: Division I.

Trauma exposure is an unfortunate reality in the lives of today’s children, and the resulting symptomatology is markedly different from that seen in adults. Historically, Posttraumatic Stress Disorder (PTSD) was first introduced as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, when the third edition of the manual was released.  It was at this time, following the Vietnam war, that exposure to war and similar trauma was considered an etiological agent for the condition previously referred to as “battle fatigue” and “shell shock.”   The diagnosis of PTSD has since evolved into several criteria.  Firstly, a specific traumatic event, in which the victim is confronted with death, serious injury, or a threat to physical integrity, is required (Criterion A1).  Additionally, the victim must also have experienced intense fear, hopelessness, or horror at this exposure (Criterion A2).  If criteria is met for the trauma exposure and the individual’s psychological response, the individual must also demonstrate requisite symptoms from three clusters of symptomatology, including: reexperiencing the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma (Criterion C), as well as increased arousal (Criterion D).

The problem with PTSD

Many problems arise when attempting to apply the diagnosis of PTSD to children.  Criterion A2 stipulates that the individual must have experienced “intense fear, hopelessness, or horror” at the time of exposure.  Thus, subjective reporting of inner emotional experience is required.  While this may be feasible for some adolescents and adults, those children in earlier development lack the cognitive capacity for such self-reflection. Furthermore, pre-verbal children are at an even greater disadvantage.  While the DSM-IV-TR makes note that this symptom may be instead expressed as “disorganized or agitated behavior” in children, it may not always be possible for a caregiver to discern these qualities of behaviors in children during a traumatic event, especially if the child has a history of behavioral problems, or if the trauma occurs at the hands of the caregiver.  Additionally, both Criterions B and C also require subjective reporting of emotional experience, perception, and outlook.   The DSM-IV-TR again attempts to make developmental allocations, noting that children may instead express elements of the trauma through repetitive play, may have bad dreams without recognizable content, and may demonstrate trauma-specific enactment.  However, again the burden of diagnosis relies on observable behavior and accurate interpretation.  This behavioral interpretation is most problematic when examining the increased arousal criterion (D) of PTSD symptoms.  With requisite symptoms including: “difficulty falling or staying asleep, irritability of outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response,” (APA, 2000, p. 468) misdiagnoses of Attention-Deficit/Hyperactivity Disorder (AD/HD) and Oppositional Defiant Disorder (ODD) are common, especially for young boys.

Complex trauma in children

Diagnosing trauma in children is further complicated by the quality of the trauma exposure.  Unfortunately, children are more vulnerable to chronic forms of trauma exposure in the forms of child abuse and domestic violence.  Also termed “Developmental Trauma Disorder” (van der Kolk, 2005), “Complex Trauma” results from exposure to extreme stressors that are repetitive or prolonged, involve harm or abandonment by caregivers, and occur at developmentally vulnerable times in the victim’s life.  This interpersonal trauma prevents the victim from receiving the help they expect and need, and victimizes the child at the hands of the very people who are entrusted to protect them.  What occurs in these instances is almost doubly traumatizing – previously termed “second injury” (Symonds, 1975) and “betrayal trauma” (DePrince & Freyd, 2007) – the child experiences the traumatic event itself, in addition to the betrayal of trust in the caregiver.  Impairment found in children exposed to complex trauma include: difficulties in attachment, biological and mood lability, inability to regulate affect, dissociation, poor behavioral control, impaired cognitive appraisals, and distorted self concept (van der Kolk, 2005).

Treatment guidelines

The impact of trauma exposure in children is qualitatively different than in adults, due to the child’s developmental level and often times the interpersonal nature of the trauma.  As such, the core elements of trauma treatment must revolve around fundamental issues of safety and protection – both physical and psychological safety must be assured by the child’s caretaker as well as demonstrated in the therapy room.  The following core components of complex trauma treatment proposed by van der Kolk (2005) provide good guidelines for childhood trauma treatment.

  • Once safety is established, self-regulation must then be targeted through developmentally appropriate coping skills.
  • Following self-regulation of emotion, the clinician can begin to assist the child develop effective self-reflection and information processing – this includes exploring meta-cognitive abilities such as self-talk, automatic thoughts, and attribution errors.
  • Only when the child is equipped with both emotional and cognitive regulation skills and safety has been assured in the child’s life, then the treatment can begin attempting to integrate the traumatic experience, typically through the use of a developmentally appropriate trauma narrative.
  • Treatment should also address ongoing behavior problems and relationships between the child and peers, siblings, and parents, as needed.

Evidence-based treatments

The treatment with the most empirical support for childhood PTSD is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).  In TF-CBT, the clinician provides the child with stress management and cognitive skills prior to exposure-based interventions.  Originally designed for victims of childhood sexual abuse, the first three sessions are dedicated to feeling identification, stress management, and cognitive processing skills.  Sessions 4-6 begin gradual exposure, with session seven dedicated to cognitive processing.  Sessions 8-10 provide joint exposure/trauma narrative with a caregiver, followed by a session for psychoeducation and ongoing safety, with the 12th session dedicated to review and termination (Cohen, Deblinger, & Mannarino, 2005).  Cohen et al. (2005) offer the PRACTICE acronym to denote the following components of treatment: Psychoeducation and parent training, Relaxation, Affective Modulation, Cognitive coping and processing, Trauma narrative, In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing future safety. Recent research has found successful treatment with only eight sessions and no trauma narrative component, as well as in a 16-session treatment with a trauma narrative (Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011).

A well-researched group CBT protocol for childhood PTSD is Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; Stein et al., 2003).  The preferred group treatment for childhood PTSD, CBITS incorporates all of the treatment components described in TF-CBT’s PRACTICE acronym, with the exception of the parent component. Instead, it provides a teacher component to educate teachers on potential problematic classroom behavior.  CBITS typically follows an eleven-session format: Introduction and confidentiality; Education and relaxation training; Cognitive model; Combating negative thoughts; Avoidance and coping, construction of fear hierarchy; Exposure to stress or trauma memory through imagination/drawing/writing (two sessions); Introduction to social problem solving; Practice social problem solving; and Relapse prevention and graduation ceremony.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.

Cohen, J. A., Deblinger, E., & Mannarino, A. P. (2005). Trauma-Focused Cognitive- Behavioral Therapy for Sexually Abused Children. In E. D. Hibbs, P. S. Jensen, E. D. Hibbs, P. S. Jensen (Eds.) , Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (2nd ed.) (pp. 743-765). Washington, DC US: American Psychological Association.

Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28(1), 67-75. doi:10.1002/da.20744

DePrince, A. P., & Freyd, J. J. (2007). Trauma-induced dissociation. In M. J. Friedman, T. M. Keane, P. A. Resick, M. J. Friedman, T. M. Keane, P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 135-150). New York, NY US: Guilford Press.

Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., & Fink, A. (2003). A Mental Health Intervention for Schoolchildren Exposed to Violence: A Randomized Controlled Trial. JAMA: Journal of the American Medical Association, 290(5), 603-611. doi:10.1001/jama.290.5.603

Symonds, M. (1975). Victims of violence: Psychological effects and aftereffects. The American Journal of Psychoanalysis, 35(1), 19-26. doi:10.1007/BF01248422

van der Kolk, B. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408.