Help for Children (and Adult-children) Who Have Been Abused, Traumatized

The news of sexual abuse of children, particularly of boys by men, have been outpoured in the media. The Catholic priest scandals followed by the recent Penn State University and Syracuse University coaches accused of sexually abusing boys and young men are troubling. Sadly, research findings support that traumatic events are common in childhood. In one longitudinal study of more than 1,400 children 9 to 16 years of age, 68 percent of children reported at least one traumatic event (37 percent more than one), and 13.4 percent of those experiencing trauma developed some post-traumatic symptoms. This same study reported that 25 percent of its sample was exposed to or victimized by violence (excluding sexual violence), 11 percent was exposed to sexual trauma, and 32 percent was exposed to other types of trauma. 1

The Adverse Childhood Experiences Study showed high rates of childhood trauma exposure in a large adult population. 2 In this population, 65 percent recalled adverse childhood experiences, many of which could be defined as traumatic events (21% were sexual abuse). Trauma-exposed children can develop traumatic stress syndromes. Several risk and protective factors play a role in the development of traumatic stress syndromes, such as Post Traumatic Stress Disorder (PTSD). A variety of genetic and neurobiological factors may play a role in the development of PTSD. The developmental age, number of trauma exposures, family systems, and neighborhood factors may play a role in the development of PTSD after trauma.

Studies have indicated that childhood PTSD is associated with a high degree of impairment during childhood that can carry into adolescence and adulthood. For example, childhood PTSD increases the risk of several mental disorders such as depression, substance abuse, and conduct disorder. 3 Suicide is a particularly grave concern for children with PTSD. 3-5 Decreased functioning at home, school and in relationships by children and adolescents with PTSD also has been observed 6 .

Some current treatments available

For children already experiencing such symptoms, treatments are intended to result in remission of PTSD, a reduction of symptoms, and improved functioning. The same can be true for adults who have been traumatized when they were youth. Interventions other than pharmacotherapy may be carried out at an individual, family, or group level. They may be carried out in various settings (including the outpatient versus inpatient setting) or in the community, schools, or classrooms.

A number of different psychotherapeutic interventions, as reviewed by The Agency for Healthcare Research and Quality (AHRQ), may be used to address symptoms of traumatic stress; some of these interventions, or components of these interventions have the potential to be effective at preventing traumatic stress symptoms when implemented after exposure to a traumatic event:

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy used to treat many problems. CBT combines elements of cognitive therapy and behavioral therapy. In CBT, maladaptive thought patterns are identified and targeted through cognitive restructuring, and maladaptive behaviors are targeted through behavioral techniques that may include exposure/desensitization, relaxation skills, and stress inoculation training or teaching an individual how to reduce anxiety. Components of CBT may be appropriate for use with people exposed to traumatic events.

Trauma-Focused CBT (TF-CBT) is a psychotherapy technique that has specifically adapted CBT for use with children exposed to trauma and those presenting with symptoms of traumatic stress. In TF-CBT, children and parents learn skills to help process thoughts and feelings related to traumatic life events and to manage and resolve distressing thoughts, feelings, and behaviors also related to those same events. Components of treatment include psychoeducation about trauma; parenting skills; relaxation skills; coping skills to deal with trauma-related thoughts, feelings, and behaviors; and child exposure tasks via narratives, drawings, or other imaginal methods. Safety and social skills training may also be a component of treatment. 7

Skills Training in Affective and Interpersonal Regulation/Narrative Story-Telling (STAIR/NST) is a two-module treatment focused on reducing symptoms of PTSD and other trauma-related symptoms and on building and enhancing specific social and emotional competencies that are frequently disturbed in youths who have experienced multiple traumas and/or sustained trauma. This intervention might also be used to prevent the development of traumatic stress symptoms when implemented after exposure to a traumatic event. STAIR/NST includes 10 treatment sessions conducted in group or individual format that target social and emotional competency building. The sessions focus on developing emotional regulation and social skills, positive self-definition exercises, and goal setting and achievement. The NST phase of treatment is conducted in six individual sessions that focus on the emotional processing of traumas in detail while developing a positive life narrative and future plan.

Trauma and Grief Component Therapy (TGCT) is a group treatment program for traumatically bereaved older school-aged children and adolescents. The target population includes youths affected by community violence, school violence, gang violence, war/ethnic cleansing, and natural and man-made disasters. TGCT has several areas of focus, including the processing of traumatic experiences, coping with reminders of trauma and loss, coping with post-traumatic adversities, managing traumatic grief, and resuming developmental progression. This intervention may be appropriate for individuals exposed to traumatic events and for those experiencing traumatic stress symptoms. Psychotherapeutic interventions have also been developed specifically for use in the schools.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) is a skills-based, group intervention for children exposed to trauma who are typically between the ages of 10 and 15 years; it may be appropriate both for intervening early after exposure to a traumatic event but also for the treatment of traumatic stress symptoms. The CBITS program consists of 10 group sessions designed to provide education about reactions to trauma, teach relaxation skills, provide cognitive therapy to challenge upsetting thoughts, teach social problem solving, and work on processing traumatic memories and grief. These skills are learned through the use of drawings and by talking in both individual and group settings. Between sessions, children complete assignments and participate in activities that reinforce the skills they have learned. Parent and teacher education sessions are also included.

Dialectical Behavior Therapy (DBT) is a psychotherapeutic approach that helps clients learn to both regulate and tolerate their emotions and may be appropriate for the treatment of traumatic stress symptoms. Concrete skills are taught and practiced, including mindfulness practices from Eastern medicine. DBT combines standard cognitive behavioral techniques for emotion regulation with concepts of distress tolerance, acceptance, and mindfulness.

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) is based on DBT. SPARCS is a group intervention designed to address the needs of chronically traumatized adolescents who may be living with ongoing stress and is intended to take place in a variety of settings, including schools, agencies, and residential treatment centers; it has been shown to decrease PTSD symptoms. 8These adolescents may experience problems in several areas of functioning, including difficulties with affect regulation and impulsivity, self-perception, relationships, somatization, dissociation, numbing, and avoidance. SPARCS is predominantly cognitive-behavioral; key components of the program include mindfulness, problem solving, relationship building/communication skills, and distress tolerance.

Equine-Assisted Psychotherapy is a specialized experiential approach to psychotherapy that uses a horse as a therapeutic tool. The goal is to encourage client insight through horse examples, addressing self-esteem and personal confidence; communication and interpersonal effectiveness; trust, boundaries and limit setting; and group cohesion. Work performed through the horse supports and encourages the identification and expression of emotions. 9

Child-Development Community Policing (CD-CP). The CD-CP program is a collaborative early intervention program that targets individuals exposed to violence and is the product of a partnership between mental health professionals at the Yale University Child Study Center and the New Haven Police Department. The goals of the program are to help children cope with traumatic events and prevent the development of traumatic stress symptoms. 10

Trauma Systems Therapy (TST) is targeted toward children and adolescents who are having difficulty regulating their emotions as a result of the interaction between the traumatic experience and stressors in the social environment. TST is appropriate for individuals who are experiencing traumatic stress symptoms, but it might also be relevant for preventing traumatic stress symptoms when implemented after exposure to a traumatic event. Interventions include a focus on both the emotional regulation capacities of the traumatized child and the ability of the child’s social environment and system of care to help the child manage his or her emotions or to protect the child from threat. Treatment modules include Home and Community Based Services, Services Advocacy, Emotional Regulation Skills Training, Cognitive Processing, and Psychopharmacology.

Attachment, Self-Regulation and Competency (ARC) is designed to treat children and families who have experienced chronic trauma such as sexual abuse, physical abuse, domestic violence, but is also relevant for children exposed to community violence. ARC interventions focus on building secure attachments, enhancing the child’s self-regulatory capabilities, and increasing competencies across multiple domains.

Current child traumatic stress guidelines

Although there are no existing guidelines for other syndromes of childhood traumatic stress, three organizations-the American Academy of Child Adolescent Psychiatry (AACAP), the International Society for Traumatic Stress Studies (ISTSS), and the National Institute for Health and Clinical Excellence (NICE)-have published guidelines on the treatment of PTSD during childhood and adolescence. These guidelines largely stem from expert consensus based on existing evidence and clinical practice rather than on formal comparative effectiveness reviews. These guidelines use different categories of interventions to summarize evidence and don’t necessarily offer consistent recommendations.

More information is needed

The Agency for Healthcare Research and Quality is presently supporting two systematic reviews on children’s exposure to trauma. Their proposed systematic review will evaluate the comparative effectiveness of a broad array of interventions for benefits and harms. Their review will address the question of whether children without a formal diagnosis of PTSD, but with traumatic stress symptoms, may benefit from treatment. A comprehensive review will also help to identify a broad range of modalities, including those with limited dissemination, and may contribute to better uptake of effective interventions in areas with limited access to services for PTSD.

References

1. Copeland WE, Keeler G, Angold A, et al. (2007). Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry, 64(5), 577-84. PMID: 17485609.

2. Dube SR, Anda RF, Felitti VJ, et al. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA, 286(24),3089-96. PMID: 11754674.

3. Fergusson DM, Horwood LJ, Lynskey MT. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: II. Psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry, 35(10),1365-74. PMID: 8885591.

4. Brent DA, Oquendo M, Birmaher B, et al. (2002). Familial pathways to early-onset suicide attempt: risk for suicidal behavior in offspring of mood-disordered suicide attempters. Arch Gen Psychiatry, 59(9),801-7. PMID: 12215079.

5. Brown J, Cohen P, Johnson JG, et al. (1999). Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry, 38(12),1490-6. PMID: 10596248.

6. Saigh PA, Mroueh M, Bremner JD. (1997). Scholastic impairments among traumatized adolescents. Behav Res Ther, 35(5), 429-36. PMID: 9149452.

7. Cohen JA, Mannarino AP, Deblinger E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press.

8. Weiner DA, Schneider A, Lyons JS. (2009). Evidence-based treatments for trauma among culturally diverse foster care youth: treatment retention and outcomes. Child Youth Serv Rev, 31(11),1199-205.

9. Schultz PN, Remick-Barlow GA, Robbins L. (2007). Equine-assisted psychotherapy: a mental health promotion/intervention modality for children who have experienced intra-family violence. Health Soc Care Community, 5(3), 265-71. PMID: 17444990.

10. Berkowitz SJ, Marans SM. (2000). The child development-community policing program: a partnership to address the impact of violence. Isr J Psychiatry Relat Sci, 37(2),103-14. PMID: 10994294.

Debra has received training in CBITS, CBT, DBT, ARC approaches and is a former member of ISTSS.