Psychiatric Annals

CME Article 

Psychosocial and Psychiatric Posttraumatic: Correlates and Treatment of Stress Disorder in Children and Adolescents

Elissa J. Brown, PhD

Abstract

Every year, millions of children and adolescents are witnesses to or direct victims of traumatic events, including community violence, domestic violence, child maltreatment, suicide of loved ones, war, terrorism, motor vehicle collisions, and natural and manmade disasters.1 The frequency with which youth are exposed to these events may vary by trauma type. A recent meta-analysis of child sexual abuse revealed a prevalence of 36%.2 Approximately 10% of teenagers are physically abused each year.3 Between 3.3 and 10 million children are living in households with domestic violence.4 Rates of witnessing community violence in urban environments may be as high as 70%.5 Motor vehicle collisions, the most common form of unintentional injury in children, are responsible for more than 1,500 deaths and 125,000 injuries per year.6

Given the large number of children and adolescents exposed to traumatic events, psychiatrists are likely to encounter these youth. By providing a review of the literature on the psychiatric sequelae of trauma and efficacious psychosocial and pharmacological interventions, this article aims to assist psychiatrists as they tackle a serious public mental health problem.

The mental health problems in children exposed to trauma vary and may be severe. The most commonly researched phenomenon is posttraumatic stress disorder (PTSD), found among survivors of community violence, domestic violence, child maltreatment, suicide, war and terrorism, motor vehicle collisions, and natural and manmade disasters.7–13

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),14 PTSD is consequent to a traumatic event in which actual or threatened death or serious injury is witnessed or experienced. Responses include intense fear, helplessness, or horror. In children, the response may also be disorganized or agitated behavior.

PTSD symptoms appear in three clusters: re-experiencing, avoidance, and arousal. Diagnosis requires one re-experiencing symptom, such as intrusive thoughts or nightmares. For young children, this may appear as repetitive play involving the traumatic event or generalized nightmares (versus dreams specifically about the traumatic event). Additionally, three symptoms of avoidance or numbing (eg, purposeful effort to avoid trauma cues, inability to remember elements of the traumatic event, and social detachment) are required. Finally, diagnosis also requires two symptoms of arousal, such as difficulty sleeping and hypervigilance. Psychosomatic symptoms (eg, stomach aches) are common among younger children. The re-experiencing, avoidance, and arousal symptoms must be present for at least one month and cause significant impairment (in social, school, or family arenas). PTSD can be acute or chronic (continuing for at least 3 months), with onset either immediate or delayed (more than 6 months after the trauma).

Incidence of PTSD may vary by type of trauma, study sample, and measurement tool. For example, research on child physical abuse reveals rates of PTSD ranging from 11% to 90%.3 Nevertheless, the majority of studies of motor vehicle collisions, sexual abuse, domestic violence, community violence, disaster, terrorism, and war found that 20% to 50% of children exposed to traumatic events experience PTSD.2,5,8,15 According to Fletcher,16 the average incidence rate of PTSD in children exposed to traumatic events is 36%. Given the high incidence of trauma exposure among children and adolescents, the number of children and adolescents with PTSD may reflect a serious public health crisis.

Even if they do not meet full criteria for PTSD, the majority of children exposed to trauma report some disabling symptoms of re-experiencing, avoidance, and arousal up to one year following the trauma.13,16 Children with subclinical PTSD symptoms may experience the same level of functional impairment as those who meet full criteria.17 This is particularly important for preschoolers, who are less likely than older children to meet the threshold for the avoidance and arousal clusters.18

The American…

Every year, millions of children and adolescents are witnesses to or direct victims of traumatic events, including community violence, domestic violence, child maltreatment, suicide of loved ones, war, terrorism, motor vehicle collisions, and natural and manmade disasters.1 The frequency with which youth are exposed to these events may vary by trauma type. A recent meta-analysis of child sexual abuse revealed a prevalence of 36%.2 Approximately 10% of teenagers are physically abused each year.3 Between 3.3 and 10 million children are living in households with domestic violence.4 Rates of witnessing community violence in urban environments may be as high as 70%.5 Motor vehicle collisions, the most common form of unintentional injury in children, are responsible for more than 1,500 deaths and 125,000 injuries per year.6

Given the large number of children and adolescents exposed to traumatic events, psychiatrists are likely to encounter these youth. By providing a review of the literature on the psychiatric sequelae of trauma and efficacious psychosocial and pharmacological interventions, this article aims to assist psychiatrists as they tackle a serious public mental health problem.

Nature of the Disorder

The mental health problems in children exposed to trauma vary and may be severe. The most commonly researched phenomenon is posttraumatic stress disorder (PTSD), found among survivors of community violence, domestic violence, child maltreatment, suicide, war and terrorism, motor vehicle collisions, and natural and manmade disasters.7–13

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),14 PTSD is consequent to a traumatic event in which actual or threatened death or serious injury is witnessed or experienced. Responses include intense fear, helplessness, or horror. In children, the response may also be disorganized or agitated behavior.

PTSD symptoms appear in three clusters: re-experiencing, avoidance, and arousal. Diagnosis requires one re-experiencing symptom, such as intrusive thoughts or nightmares. For young children, this may appear as repetitive play involving the traumatic event or generalized nightmares (versus dreams specifically about the traumatic event). Additionally, three symptoms of avoidance or numbing (eg, purposeful effort to avoid trauma cues, inability to remember elements of the traumatic event, and social detachment) are required. Finally, diagnosis also requires two symptoms of arousal, such as difficulty sleeping and hypervigilance. Psychosomatic symptoms (eg, stomach aches) are common among younger children. The re-experiencing, avoidance, and arousal symptoms must be present for at least one month and cause significant impairment (in social, school, or family arenas). PTSD can be acute or chronic (continuing for at least 3 months), with onset either immediate or delayed (more than 6 months after the trauma).

Incidence of PTSD

Incidence of PTSD may vary by type of trauma, study sample, and measurement tool. For example, research on child physical abuse reveals rates of PTSD ranging from 11% to 90%.3 Nevertheless, the majority of studies of motor vehicle collisions, sexual abuse, domestic violence, community violence, disaster, terrorism, and war found that 20% to 50% of children exposed to traumatic events experience PTSD.2,5,8,15 According to Fletcher,16 the average incidence rate of PTSD in children exposed to traumatic events is 36%. Given the high incidence of trauma exposure among children and adolescents, the number of children and adolescents with PTSD may reflect a serious public health crisis.

Even if they do not meet full criteria for PTSD, the majority of children exposed to trauma report some disabling symptoms of re-experiencing, avoidance, and arousal up to one year following the trauma.13,16 Children with subclinical PTSD symptoms may experience the same level of functional impairment as those who meet full criteria.17 This is particularly important for preschoolers, who are less likely than older children to meet the threshold for the avoidance and arousal clusters.18

Identification of Pediatric PTSD

The American Academy of Child and Adolescent Psychiatry (AACAP) has provided guidelines for the assessment and treatment of pediatric PTSD.19 Assessment of pediatric PTSD is a two-step procedure. First, a trauma history must be acquired. Second, an evaluation of the severity, duration, and frequency of the PTSD symptoms from each of the three clusters must be conducted. A number of semi-structured diagnostic interviews for DSM-IV disorders have sections that assess both trauma history and PTSD diagnosis (eg, Anxiety Disorders Interview Scale, child version, and Schedule for Affective Disorders and Schizophrenia, child version).20,21 Saigh and Bremner's22 Children's PTSD Inventory is a semi-structured diagnostic interview that was developed specifically for PTSD.

Trauma history and PTSD symptoms also can be assessed using questionnaires. Trauma history questionnaires, such as the Traumatic Events Screening Inventory,23 focus on the details surrounding a variety of traumatic events. PTSD questionnaires, such as the Child Posttraumatic Stress Reaction Index (Frederick CJ, Pynoos RS, Nader K, unpublished data, 1992), assess the severity of symptomatology, but they are not appropriate for assessing the presence or absence of the PTSD diagnosis. Trauma history and PTSD symptom scales can be administered as self- or parent-report instruments. The questionnaires can be completed as a survey or in an interview format with an evaluator.

Clinical Correlates and Differential Diagnosis

In addition to PTSD, symptoms of general anxiety, separation anxiety, and depression are common correlates of trauma in children.2,3,5,8,15,16 Aggression, oppositional behavior, and juvenile delinquency against parents, teachers, and peers in both home and academic settings have been reported following traumatic events. Somatic symptoms, such as gastrointestinal problems and headaches, may be common complaints among children who have been traumatized. Younger children may experience regressive behavior, such as enuresis. Attachment and social deficits include insecure attachments, misreading of social cues, lower peer status, fewer social skills, and more insular and negative social networks (eg, affinity with gangs). There is no research to support overall deficits in cognitive functioning following traumatic events, but children exposed to trauma may experience developmental delays, reading disabilities, and difficulties with comprehension and abstraction. Lastly, perhaps as a result of experiencing mental health, social, and intellectual deficits related to trauma exposure, children who have been traumatized often experience poor self-esteem.

Differential diagnosis of PTSD can be a challenge, particularly in relation to attention-deficit/hyperactivity disorder.14 Inattentiveness and intrusive thoughts may be hard to distinguish.24 Similarly, traumatized children may remain motorically active, mimicking hyperactivity, in an effort to keep their minds otherwise occupied (ie, avoidance). Clinicians also need to distinguish between psychotic intrusive thoughts and PTSD re-experiencing symptoms. Other than trauma-related content, children with PTSD have intact reality testing. Lastly, substance abuse and dependence may be common forms of self-medication to avoid thinking about the trauma or experiencing PTSD symptoms.

Prognosis

Years after the trauma, children may continue to exhibit high rates of PTSD diagnosis and symptoms.2,3,5,8,15,16 Chronic PTSD is associated with long-term changes in brain structure and function, with increased risk for suicide, substance abuse, and health problems.25 If untreated, and sometimes despite mental health interventions, the negative consequences of trauma may continue and worsen into adulthood. Adults with childhood histories of trauma exposure have reported suicidality, aggressive and violent behavior, nonviolent criminal behavior, substance abuse, interpersonal problems, and vocational difficulties.

Risk and Protective Factors for the Development of PTSD

Exposure to traumatic events is not a sufficient criterion for the development of PTSD. Researchers have investigated characteristics of the youth, their trauma and psychiatric histories, and their families as risk and protective factors.2,3,5,8,16 Studies evaluating the influence of age, gender, and race on PTSD diagnosis and severity have been equivocal. Similarly, previous negative life events may make children more vulnerable to developing PTSD following a subsequent trauma or may evoke coping skills that protect children during a subsequent trauma.15 In contrast, children's pre-trauma mental health problems frequently are associated with the likelihood of experiencing PTSD following a traumatic event.

Severity of the traumatic event, at times defined differently for different types of trauma, consistently has been predictive of PTSD severity.2,3,5,8,16 Higher physical injury and emotional proximity to the trauma (ie, death of a loved one during the traumatic event) are risk factors. Severity of child maltreatment (as defined by chronicity of the maltreatment and closeness of the relationship with the perpetrator) and severity of exposure to disasters, terrorism, and war (defined by closer physical proximity to the trauma, displacement, economic ramifications, and exposure to media coverage) are related to the severity of PTSD.

Some theorists have argued that it is not the traumatic event per se, but the cognitive processing of the event, which is related to later psychological functioning.3 In particular, the ways in which children process social information and attribute traumatic events (eg, by taking responsibility for the event or believing the world is a dangerous place) are cognitive processing variables that have been examined as predictors of symptom development among children exposed to traumatic events. Dodge et al.26 found social information processing patterns (eg, misperceiving other children's behavior as having a hostile intent) influenced the effect child physical abuse had on later conduct problems. In addition, children's attributions about their trauma (eg, blaming themselves) have accounted for a significant portion of the variance in the internalizing symptoms of PTSD, anxiety, depression, and externalizing behaviors.27 In fact, Brown and Kolko27 found that attributions about physical abuse accounted for variance in symptoms beyond that accounted for by the severity of the abuse.

In addition to characteristics of the children, characteristics of the ecological system in which children struggle following a traumatic event may influence their reaction to the event.2,3,5,8,16 Caregivers' mental health problems and family discord are both risk factors for PTSD. In turn, children's and caregivers' social support and coping skills are protective against the development of PTSD.

Neurobiological Correlates of PTSD

Recent research suggests that children have neurobiological responses to traumatic events that may be associated with PTSD. In a literature review, Cohen et al.25 summarized studies of neurobiological functioning in children with PTSD. Affect dysregulation patterns and memory deficits may reflect an over-reactivity of the amygdala and under-reactivity of the medial prefrontal cortex. Over-reactivity of the amygdala may account for re-experiencing symptoms (eg, intense fear in response to trauma cues, intrusive memories). High concentrations of dopamine in the medial prefrontal cortex may be responsible for its inhibition. This under-reactivity may account for the inability of trauma survivors to limit their fear responses to the specific traumatic incident, rather than generalizing to any stimulus that may remind them of the event. Increased activity of the norepinephrine/epinephrine (adrenergic) system may be related to hyper-arousal symptoms of PTSD. Elevated endorphin levels may be associated with avoidance symptoms, especially numbing. A dysregulation of the cortisol feedback loop in the hypothalamic-pituitary-adrenal (HPA) axis has been found with traumatized children; interestingly, the pattern (high versus low cortisol) appears to be a function of the length of time since the original trauma (acute versus chronic PTSD) and frequency of subsequent traumas. Similarly, duration of the trauma has been negatively correlated with hippocampal and corpus collosum size. Low levels of serotonin have been associated with clinical correlates of PTSD, including depression and aggression.

Empirically Supported Treatment of PTSD

Targets for Psychosocial Interventions

PTSD and other trauma sequelae are a combination of physiological symptoms and behavioral signs (eg, social withdrawal, aggression). These sequelae are mediated by maladaptive cognitive processing and caregiver functioning. Thus, traumatized children would benefit from a coping skills model that includes relaxation techniques to address physiological arousal, cognitive techniques to alter the maladaptive cognitions, and behavioral techniques to “face” rather than avoid people, places, and objects that remind them of the traumatic event, and address their oppositional, aggressive behavior. Cognitive-behavior therapy (CBT) is designed to provide the skills needed to intervene with traumatized youth. Given the potential impact of caregiver functioning on the children, an ideal psychosocial treatment model would involve caregivers. Conjoint parent-child CBT involves both the children and their caregivers in the intervention.

Efficacy of CBT

A number of randomized clinical trials have evaluated the efficacy of CBT for pediatric PTSD. Cohen and Mannarino28 conducted a randomized clinical trial of PTSD related to child sexual abuse (CSA) in children ages 8 to 14. They found that, among treatment completers, trauma-focused CBT was superior to nondirective supportive therapy (NST) in improving PTSD and dissociative symptoms at 12-month follow-up.29 In a parallel study, Cohen and Mannarino30 compared CBT to NST for CSA-related PTSD in pre-schoolers, and found that CBT was superior to NST in improving PTSD symptoms, and internalizing and externalizing behavior problems. These differences were maintained in a 1-year follow-up.31 In an examination of mediators of outcome, Cohen and Mannarino32 found that caregivers' emotional responses to the abuse (eg, shame, responsibility, sadness) were associated with children's behavior problems at post-treatment, revealing the potential importance of caregiver participation in treatment.

Extending Cohen and Mannarino's32 study of caregivers, investigators have evaluated the relative importance of caregiver involvement in treatment. Deblinger, Lippmann, and Steer33 compared the efficacy of CBT as a function of treatment participants (ie, CSA victims or caregivers). School-aged children who met full or partial criteria for PTSD subsequent to CSA were randomly assigned to child-exclusive CBT, caregiver-exclusive CBT, conjoint child and caregiver CBT, or community-referral control groups. The study found children who were randomly assigned to CBT in which they directly participated evidenced greater reductions in PTSD symptoms than children in the community referral control sample. Children assigned to CBT in which their parents directly participated evidenced greater reductions in externalizing behaviors and depression than children in the community referral control sample.

King et al.34 compared CBT provided to sexually abused children alone, CBT provided to children and parents, and a wait-list control condition. They found both CBT conditions to be superior to the wait-list control in improving PTSD and anxiety at post-treatment. At the 3-month follow-up evaluation, children in the parent-and-child CBT condition had fewer anxiety symptoms than children in the child-only CBT condition.

Emerging quasi-experimental research provides preliminary support for school-based, group CBT for pediatric PTSD. Goenjian and colleagues35 examined the efficacy of a brief trauma/grief-focused therapy for adolescents exposed to the 1988 earthquake in Armenia. Eighteen months after the earthquake, schools were randomly assigned to a treatment or a no-treatment control group. The children who received CBT improved regarding PTSD symptoms, whereas the untreated children reported more symptoms of PTSD at posttreatment than they had at pretreatment. In a study of community violence, Latino children were randomly assigned to a school-based group CBT or a wait-list control condition.36 Students receiving CBT experienced significantly greater improvement in PTSD and depressive symptoms than those in the control condition.

Stein et al.37 evaluated the efficacy of an intervention for symptoms of PTSD and depression resulting from exposure to a wide range of violent events. Participants were sixth-graders from a low socioeconomic status and predominantly minority, inner-city community. Students were randomly assigned to a 10-session, trauma-focused, early intervention group delivered by trained school mental health clinicians or to a wait-list control condition. At 3 months, the early intervention group demonstrated a significant reduction in symptoms of PTSD and depression as indicated by self-report measures, and in symptoms of psychosocial dysfunction as indicated by parent-report measures. Six months later, after both groups received the intervention, there were no significant differences between the groups on any symptom domains.

In the first multisite RCT for traumatized children, Cohen et al.7 demonstrated the superiority of CBT over child-centered therapy (CCT) in decreasing the likelihood of meeting criteria for PTSD and improving symptoms in each of the three PTSD symptom clusters in sexually abused children. The children receiving CBT also exhibited greater reductions in depression and anxiety symptoms, behavior problems and abuse-related attributions than the children receiving CCT. Compared with the caregivers attending CCT, caregivers who received CBT showed greater improvements in depression, emotional distress related to their children's abuse, support of the children, and positive parenting practices.

In sum, cognitive-behavior approaches to the treatment of PTSD and other trauma-related symptoms have been efficacious in children exposed to various traumatic events. The data suggest the importance of including both children and their caregivers in these treatments. These conclusions are strengthened by the methodological rigor of the reviewed studies, including large sample sizes, random assignment to treatment condition, measures administered to children and their caregivers, and monitored treatment integrity and satisfaction with treatment.

Targets for Psychopharmacologic Interventions

Neurobiological evidence, as reviewed by Cohen et al.,25 suggests that children with PTSD may experience over-reactivity of the amygdala, under-reactivity of the medial prefrontal cortex, elevated levels of dopamine, increased activity of the norepinephrine/epinephrine (adrenergic) system, elevated endorphin levels, dysregulation of the HPA axis, decreased hippocampal and corpus collosum size, and low levels of serotonin. Thus, children with PTSD may benefit from medications that minimize adrenergic transmission (beta blockers), and either decrease dopamine or increase serotonin (eg, selective serotonin reuptake inhibitors).

Pharmacologic Treatment

Unlike psychosocial interventions, pharmacotherapy appears to be guided by specific target symptoms rather than the disorder itself. Early studies of the efficacy of psychopharmacologic interventions focused on the treatment of nightmares and other re-experiencing symptoms that are particularly troubling for children with PTSD. An open trial by Faamularo, Kinscherff, and Fenton38 evaluated propanolol for the treatment of acute PTSD in 11 children ages 6 to 12. Results revealed a significant pre-post improvement in PTSD severity. Side effects include sedation and mildly lowered blood pressure and pulse.

Given the side effects of propanolol, later research on the treatment of re-experiencing symptoms in children evaluated alternative medications. Loof et al.39 reported results of the treatment of 12 girls and 16 boys ages 8 to 17 with a diagnosis of PTSD with carbamazepine during hospitalization in a state hospital. The 28 participants had histories of chronic sexual abuse and had symptoms of intrusive thoughts, flashbacks, hypnagogic phenomena (ie, sleep-induced hallucinations), and nightmares. The authors found that 22 out of the 28 patients became asymptomatic; the remaining six significantly improved (with rare abuse-related nightmares).

Harmon and Riggs40 investigated clonidine for symptoms of aggression, hyperarousal, and sleep disturbance in seven preschool children diagnosed with PTSD resulting from severe maltreatment. The children ranged in age from 3 to 6 and were receiving psychosocial treatment at a day hospital. Medication was provided for those children whose symptoms of hyperarousal, impulsivity, and aggression remained severe after 1 month in the day hospital. Most children experienced transient sedation for the first week. In addition, blood pressure levels declined in 10% of the sample. No other side effects were reported. Target symptoms, assessed weekly, were rated as moderately to greatly improved by both teachers and physicians. The findings were limited by the fact that no standardized assessment scales were used; instead, results were based on subjective clinical impressions.

Instead of focusing on a single PTSD symptom cluster, recent studies of pharmacologic interventions have evaluated the efficacy of medications for all three clusters of PTSD symptoms. Seedat and colleagues41 conducted a 12-week open trial of citalopram in adolescents with PTSD. The authors hypothesized that SSRIs might relieve intrusive, avoidant, and hyperarousal symptoms, as well as treat comorbid conditions. Based on support for this hypothesis from research in adults, Seedat's group conducted a trial of citalopram with eight adolescents (mean age = 14.8 years). Participants were diagnosed with moderate to severe PTSD. Comorbid anxiety or mood disorders were permitted as long as they did not precede the PTSD diagnosis. Six of the adolescents met criteria for mild major depression and one for panic disorder. They were given 20 mg of citalopram and administered a diagnostic measure of PTSD every 2 weeks over a period of 12 weeks. Seven of the adolescents completed the study, and all seven responded to citalopram, rated by clinicians as “much improved” or “very much improved” on PTSD. There was a 38% reduction in PTSD symptoms among the seven who completed the study. The citalopram was well tolerated with mild adverse effects reported, the most common being sweating, nausea, headache, and fatigue.

Seedat et al.42 continued their examination of citalopram in another open trial comparing response to treatment in children, adolescents and adults with PTSD. The authors conducted an 8-week trial that contrasted 24 children and adolescents whose ages ranged from 10 to 18 years (mean = 14.3 years) with 14 adults whose ages ranged from 20 to 52 years (mean = 33.5 years). The sample from the 2001 study was included in the group of children/adolescents. Biweekly assessments included an age-appropriate diagnostic interview and PTSD symptoms scales. Concomitant pharmacotherapy or psychotherapy was not permitted during this trial; however, supportive counseling was provided by the treating clinician. Participants were prescribed 20 mg to 40 mg of citalopram daily. Mean dose of citalopram was 27.9 mg for adults and 20 mg for children/adolescents.

In the child/adolescent group, 16 were responders, five were minimally improved, and five were minimally worse on the PTSD symptom measure, with a 54% mean reduction in PTSD severity. In the adult group, nine were classified as responders, four were minimally improved, and one was minimally worse, with a 39% mean reduction in PTSD severity. There were no significant differences between the two age groups, except for greater improvement on hyperarousal cluster symptoms in children/adolescents at week 8. Duration of symptoms, mode of onset, and presence of comorbidity did not affect treatment outcome for either age group. Most side effects were mild and self-remitting, including drowsiness, headache, nausea, sweating, yawning, insomnia, dizziness, tremor, and increased appetite.

In summary, research on the use of medication as treatment for PTSD is emerging and encouraging. Studies have moved from the treatment of a single symptom — nightmares — to the re-experiencing cluster, to the diagnosis of PTSD. Additionally, newer medications appear to have fewer side effects. In spite of the emerging work in the field, however, sample sizes remain small and no randomized trial has been conducted to establish the efficacy of a pharmacologic intervention for the treatment of PTSD. Further, no research has compared the efficacies of psychosocial and pharmacologic treatments directly. Nevertheless, pharmacologic interventions tend to be used with psychosocial treatment modalities25 to control intolerable and debilitating symptoms or to treat comorbid conditions.

Clinical practice would benefit from studies designed to assess the additive and comparative value of cognitive behavioral and pharmacological therapies. Each type of therapy may provide relief for different symptoms of PTSD. In addition, the order of implementing the two intervention modalities might affect their efficacy. Because exposure therapy can be an intimidating endeavor, medication as a first step may increase enrollment in or decrease drop-out from trauma-specific CBT. Alternatively, exposure therapy as a first step may prevent problems with medication adherence that stem from patients viewing the pills as traumatic reminders and thus avoiding them.

Needed Next Steps for the Treatment of Pediatric PTSD

Effectiveness Studies

In a recent study of children and adolscents in juvenile detention, Abram et al.43 found that more than 90% of the institutionalized children and adolescents had been exposed to at least one traumatic event, and on average, each had been exposed to 15 traumas. The incidence of PTSD in the sample was 11%. However, no study to date has investigated the efficacy of evidence-based, trauma-focused treatments for these youth. The field needs to move from efficacy to effectiveness, evaluating whether the findings of more controlled clinical trials can be generalized to more impaired, underserved children in inpatient and residential facilities, including psychiatric settings.

Community-based Interventions

Many traumatic events, such as war, natural disaster, terrorism, and community violence, affect entire communities. Thus, there is a need to develop and evaluate community-wide intervention models. Based on experiences following the 1995 Oklahoma City bombing and 2001 attacks on the World Trade Center, Brown and Bobrow44 and Gurwitch et al.45 made several recommendations:

  • Establish early community-based programs to establish a sense of safety and structure;
  • Develop collaborations among medical, educational, legal, and mental health systems;
  • Implement community-wide screening to identify children at risk;
  • Provide social support programs to support children's caregivers (eg, parents, teachers, clergy);
  • Disseminate information to normalize responses to an abnormal event;
  • Teach appropriate coping skills to address anxiety and fear;
  • Provide informal contact with mental health professionals; and
  • Provide evidence-based assessment and treatment services (as described above).

Although pieces of this intervention model have been investigated adequately, there have been no studies to date comparing various community-based intervention programs.

Preventive Interventions

Given the high prevalence of trauma exposure among children and adolescents and the likelihood that they will develop PTSD following traumatic events, there may be a psychological and economic benefit to investing in the study of preventive interventions. Silovsky and colleagues46 are conducting a pilot randomized clinical trial comparing a brief preventive CBT (an abbreviated four-session protocol consisting of physiological, cognitive, and behavioral coping skills), critical incidence stress debriefing (commonly used immediately following a traumatic event), and routine community care for children exposed to a variety of traumatic events. Replication and extension of this work is warranted.

Summary

Children in the United States are exposed to a variety of traumatic events. Psychosocial sequelae to these events vary in their nature and severity. PTSD is a common, debilitating response to traumatic events that may alter the normal developmental course for children. Risk and protective factors in the development of PTSD include child, caregiver, and family characteristics.

To date, empirical evidence reveals the efficacy of psychosocial treatments, especially cognitive-behavior therapy. Caregiver involvement in treatment is indicated. Aside from participation in psychosocial interventions, caregivers should be encouraged to convey belief of and empathy for their children, provide a forum for children to discuss the trauma if they choose, and promote coping skills that have been helpful following other stressful events.

Emerging studies suggest the potential adjunctive effects of pharmacologic treatments. Additional investigations of the efficacy of school-based group CBT, combined CBT and pharmacotherapy, and CBT for more severely impaired children are warranted. Children and families also might benefit from research on community-based interventions (eg, following disasters, terrorism, war, and community violence) and preventive interventions (designed to prevent the development of PTSD following traumatic events).

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Authors

Dr. Brown is associate professor, St. John's University, Queens, NY.

Address reprint requests to: Elissa J. Brown, PhD, Department of Psychology, St. John's University, Marillac Hall, 8000 Utopia Parkway, Queens, NY 11439.

10.3928/00485713-20050901-08

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