Cognitive Behavioral Therapies for Childhood Trauma

What Is Post Traumatic Stress Disorder (PTSD)?

Children exposed to the same traumatic event such as sexual assault/abuse, war, natural disasters, terrorist incidents, serious accidents, or violent personal assaults react differently.  Some will develop severe psychological distress while others will not.

PTSD is a serious psychological condition and the most common psychiatric disorder that can occur as a result of experiencing or witnessing a traumatic event. Typical symptoms of PTSD are: reliving the experience through nightmares and/or flashbacks, having difficulty sleeping, feeling numb or detached, avoiding situations which are reminiscent of the trauma; being jumpy, nervous or being "on alert" most of the time. The most common responses to trauma among children and adolescents are anxiety disorders and depressive disorders, and some children and adolescents will develop PTSD.  Most traumatized children suffer from a variety of post-traumatic symptoms such as anxiety, depression, sleep disturbances, preoccupation with words or symbols, or conduct problems but do not suffer from Post Traumatic Stress Disorder (Cohen, et al., 2000).  There appears to be a range of post-traumatic syndromes, one of which is defined as PTSD, but most of which is all kinds of mixed anxiety, depressive, and behavioral syndromes.

PTSD may arise weeks or months after a traumatic event and generally some form of therapy by a mental health professional is needed.  Children and adolescents who have PTSD are at increased risk of developing substance abuse disorders, becoming violent or self-injuring or engaging in unprotected sex.  These symptoms can be severe enough and last long enough to significantly impair the child's daily life at home and at school.  Sometimes, PTSD occurs in conjunction with other (or related) disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health.  A range of factors may contribute to the development of these conditions such as characteristics of the trauma exposure itself, characteristics of the individuals, and post-trauma factors such as the availability of social support. 

About 25% of persons who are exposed to catastrophic events will develop PTSD, and the disorder is often chronic.  It is possible that children diagnosed with severe mental illness have an elevated risk of PTSD if they are exposed to a traumatic event.  Recent estimates of lifetime prevalence of PTSD in the U.S. population range from eight to 12% (Rosenberg et al., 2001).  Among adults diagnosed with a serious mental illness, studies have found that at least 50% of the women and 25% of the men have experienced the significant trauma of childhood physical and/or sexual abuse (Rose, 1991).

Why Is PTSD Treatment Important?

Because of the prevalence of PTSD symptoms among children receiving mental health services, the New York State Office of Mental Health launched a Trauma Initiative in 1995 (Chassman, 2001).  The mission of the Trauma Initiative is to identify trauma issues among children diagnosed with serious emotional disturbance and adults diagnosed with mental illness and to provide effective treatments.  Anecdotal evidence suggests that trauma-related disorders are often overlooked during the psychiatric evaluation.  As a result, the treatment plan does not include trauma-based services.  Many assume that targeted trauma services will increase the rate of recovery among adults and children in public sector mental health programs who are trauma survivors (Tucker, 2002).

PTSD is a complex condition that can be associated with significant illness, morbidity, disability, and impairment of life functions.  There is a growing body of evidence about effective treatment of PTSD.  In response to the traumatic incidents of September 11, New York State has looked to these treatments as it expands its role in public mental health to meet the trauma-related needs of adults and children who have not traditionally been served in the public mental health system.  Treatment for PTSD typically begins with a detailed evaluation and development of a treatment plan that meets the unique needs of the survivor. Research has shown that one of the most effective interventions for PTSD is cognitive behavioral therapy.  Cognitive behavioral therapy involves working with the affected child to help her/him change her/his emotions, thoughts, and behaviors regarding the traumatic event. 

The World Trade Center terrorist attacks of September 11, 2001 affected us all- from families and friends of those who died, to the many thousands of New Yorkers who watched the towers fall over and over again on television. Research indicates that substantial symptoms of stress occur for children, adolescents, and adults even if they are not physically present at the attack location (Schuster et al., 2001).  Children and adolescents who have been exposed to traumatic events, such as the September 11, 2001 attack can develop a range of symptoms that, if left untreated can lead to longer-term problems. 

Clements (2001), Deering (2000), and Schuster et al. (2001) note that parental reactions impact the recovery of children who are traumatized. Clements (2001) encourages parents to be "proactive with discussing the attack and any related fears; to 'check-in'regularly with children to provide a conduit for exploration and discussion of any fears and concerns". 

Family, Youth, Cultural Perspectives

The development of the descriptions for these OMH Priority Evidence-Based Practices included extensive involvement from clinical experts, recipients of mental health, youth and family members, and people who represent culturally diverse viewpoints. Their perspectives are critical to the understanding of these important practices and programs in mental health.

Family Perspective

The proposals selected reflect attention to family values, family involvement in treatment or service planning and will reflect a range of culturally diverse populations.

Youth Perspective

Therapists need to be well-rounded in various therapeutic interventions including PTSD treatment. Furthermore, there needs to be experts in various areas of therapeutic interventions specific to children (such as Cognitive Behavioral Therapy for PTSD).

Cultural Perspective

Culture can influence how individuals and communities respond to experienced or witnessed traumatic events. In servicing children, care and attention needs to be paid to develop cultural knowledge as to family and community norms and values around help seeking and acceptance of assistance, secrecy and confidentiality, family roles, child rearing and spiritual practices. Differences in beliefs and values can shape engagement and sustained participation in treatment. Often there are misunderstandings about expressions of distress or the belief that distress is to be tolerated as a demonstration of strength. Therefore, people are unaware or underestimate mental health concerns, not recognizing the need or availability of assistance. Clinicians need to be aware of the cultural considerations impacting children and families-which include but are not limited to- ethnicity, gender, age, language, literacy, spirituality, sexual orientation, immigration status, acculturation, and the exposure to previous violence and trauma (experienced by the child, family, community at large or in a historical context).

In response to September 11, outreach included deliberate effort to reach people in their home communities facilitating connection to naturally occurring sources of support and information sharing. Materials were provided in the languages present in the community and using the media most familiar. In addition to raising awareness, these efforts provided a gateway to access trauma treatment services for those who needed it. Care was taken to assure written materials are not only translated, but were at a literacy level that did not raise additional barriers for the family members.

Cultural Competence and Evidence-Based Practices Fact Sheet
Cultural Competence: Maintaining the Asking Stance within the Coordinated Children's Services Initiative

Provider's ability to engage families, understand community roles and participation, and address the cultural considerations will impact the response to treatment. Mental health programs founded on individual, family and community strengths have the potential for both ameliorating risk and fostering resilience. Furthermore, culturally and linguistically relevant services are needed to educate families about the possibility of recovery, and the availability of services. (DHHS 2001)

Goals and Principles of Treatment for PTSD

There is a research base supporting the effectiveness of certain strategies to prevent comorbidity of other mental disorders including cognitive behavioral approaches for adolescents who are at high risk of developing major depression. Rollins (1997) reports that prevention measures to decrease mental and emotional developmental difficulties should include "protection and advocacy, and helping the child acknowledge and tolerate the realities of the traumatic event".  Lovrin (1999) reported that supportive psychotherapy for a traumatized child with clinical supervision for the caregiver showed evidence of a positive recovery process, thus decreasing likelihood of comorbidity in the long term. Strategies that consider preventive measures are likely to offset impairments associated with PTSD. Most importantly, Deering (2000), Rollins (1997) note that a child's reactions and responses to witnessing a traumatic event are directly impacted by their stage of development and mental health treatment needs to consider this important factor. Also, many children may develop post-traumatic symptoms, but it may not develop into full-blown PTSD.

Implementing PTSD Treatment in New York State

Project Liberty of the New York State Office of Mental Health provided free crisis counseling services, outreach and information to people in NYC and surrounding counties who were the most affected by the September 11 terrorist attacks.  The target population includes adults and children or adolescents with trauma-related mental health symptoms and functional impairments who are at high risk for developing one or more psychiatric disorders and who reside in the geographic area included in the Presidential Disaster Declaration issued subsequent to September 11, 2001 attacks. This includes the five boroughs of NYC and 10 surrounding counties including: Nassau, Suffolk, Westchester, Orange, Rockland, Putnam, Dutchess, Sullivan, Ulster, and Delaware.

The Child and Adolescent Trauma Treatments and Services Consortium (CATS), funded by SAMHSA, provides a range of evidence-based trauma treatments to school age children and adolescents throughout New York City. The CATS project offers both school and clinic-based assessments and trauma treatments free of charge. The services are provided by highly–trained clinicians who have received specialized training and supervision in evidence-based trauma therapies. This program augments the public mental health system's capacities by providing a range of clinical treatments and services to youth who have experienced significant traumatic events.

Children and Adolescent Service System Principles

All OMH Children's Initiatives are based upon the principles of the Child and Adolescent Service System Principles (CASSP). View the CASSP.

References

Chassman, J. (October 2001).  Frontline reports:  New york state office of mental health trauma initiative. Psychiatric Services, 52 (10), 1392-1393.

Clements, P.J. (2001).  Terrorism in America:  How do we tell the children?  Journal of Psychosocial Nursing, 39 (11), 8-10.

Cohen, J.A., Berliner, L., March, J.S. (2000). Treatment of children and adolescents. In Effective Treatment of PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. Foa, E.B., Keane, T.M., Friedman M.J. (eds), Guildford: New York.

Cohen JA, Mannarino AP. A treatment outcome study for sexually abused preschool children. J Am Acad Child Adolesc Psychiatry. 1996;35:42-50.

Deering, C. G. (2000).  A cognitive developmental approach to understanding how children cope with disasters.  Journal of Child and Adolescent Psychiatric Nursing, 13 (1), 7-16.

Foa, E.B., Dancu, C.V., Hembree, E.A., Jaycox, L.H., Meadows, E.A., Street, G.P. (1999).  The efficacy of exposure therapy, stress inoculation training and their combination in ameliorating PTSD for female victims of assault. Journal of Consulting and Clinical Psychology, 67, 194-200.

Layne, C. M., Warren, J. S., Saltzman, W. S., Fulton, J., Steinberg, A., & Pynoos, R. S. (in press). Contextual influences on posttraumatic adjustment: Retraumatization and the roles of revictimization, posttraumatic adversities, and distressing reminders. In Schein, L. A., Spitz, H. I., Burlingame, G. M., & Muskin, P. R., (Eds.), Group Approaches for the Psychological Effects of Terrorist Disasters. New York: Haworth.

Lovrin, M. (July- September 1999).  Parental murder and suicide:  Post-traumatic stress disorder in children.  Journal of Child and Adolescent Psychiatric Nursing, 12 (3), 110.

National Center for Post-Traumatic Stress Disorder, Department of Veteran Affairs. Treatment of PTSD. Retrieved January 3, 2001 from http://www.ncptsd.org

Rollins, J. A. (June 1997).  Minimizing the impact of community violence on child witnesses.  Critical Care Nursing Clinics of North America, 9 (2), 211-220.

Rose, S.M., Peabody, C.G., Sratigeas, B, (May 1991). Undetected abuse among intensive case management clients, Hospital and Community Psychiatry, 42 (5), 499-503.

Rosenberg, S.D., Mueser, K.T., Friedman, M.J., Gorman, P.G., Drake, R.E., Vidaver, R.M., et al. (2001). Developing effective treatments for posttraumatic disorders among people with severe mental illness. Psychiatric Services, 52 (11), 1453-1461.

Schuster, M.A., Stein, B.D., Jaycox, L.H., Collins, R.L., Marshall, G.N., Elliott, M.N., Zhou, A.J., et al. (November 15, 2001).   A national survey of stress reactions after the September 11. 2001, terrorist attacks.  New England Journal of Medicine, 345 (20), 1507-1512.

Tucker, W.M. (Summer 2002).  How to include the trauma history in the diagnosis and treatment of psychiatric inpatients. Psychiatric Quarterly, 73 (2), 135-144.

U.S. Department of Health and Human Services (2001). Mental health: Culture, race and ethnicity - A supplement to mental health: A report of the surgeon general. Rockville, MD:  U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.