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.
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.
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.
■ Clinicians will be better informed about diagnosis of childhood PTSD and selection of appropriate interventions.
Trauma-focused CBT components
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
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
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.