In recent years, the media have focused on post-traumatic stress disorder among the nation's war veterans. Often overlooked are the high numbers of children who suffer from the condition, said speakers at a presidential symposium at APA's Annual Convention.

"As many as 50 percent of children experience trauma before their 18th birthdays," said Annette M. La Greca, PhD, a University of Miami psychology professor and the chair of APA's Task Force on PTSD in Children. "Unfortunately, estimates also indicate that very few children who are exposed to trauma actually receive any services."

As a result, children can experience nightmares, pervasive fears and other long-term consequences from a range of traumatic events, including sexual abuse, natural disasters, terrorism, even emergency room visits.

But by educating parents, developing early interventions and treatments, and tapping community resources, psychologists can do much to mitigate the negative consequences of trauma, presenters said.

Treatments that work

A new spin on cognitive behavioral therapy may be particularly effective for treating traumatized children, reported Anthony P. Mannarino, PhD, a psychiatry professor at Drexel University College of Medicine, in Pittsburgh. The treatment, called trauma-focused cognitive behavioral therapy (TF-CBT), takes 12 to 16 sessions, and, like all CBT, teaches participants to observe and change their thoughts and feelings. In TF-CBT, children also learn to manage their anxieties and fears about the traumatic incident, and they practice relaxation techniques such as deep breathing.

Therapists also bring in parents for occasional joint sessions, where they explore their own thoughts and learn to keep their children safe without being overprotective. These sessions are key to the success of the treatment, Mannarino said.

"One of the most consistent findings that we have come up with over and over again is that parental distress mediates outcome," he noted. "When the parents are doing better, their response seems to correlate with good outcomes with the kids."

Over the last decade, Mannarino and his colleagues have completed six studies that attest to TF-CBT's effectiveness for survivors of sexual abuse and those who witnessed terrorist attacks. One, published in 2004 in the Journal of the American Academy of Child and Adolescent Psychiatry (Vol. 43, No. 4), randomly assigned 229 children, age 8 to 14, to either TF-CBT or child-centered therapy, a common treatment for sexual abuse, where children and parents are encouraged to talk openly about their feelings and come up with their own strategies for behavioral change. At the beginning of the study, 89 percent of the children had PTSD. After receiving TF-CBT, that number had shrunk to 21 percent.

In comparison, 46 percent of the participants who had received child-centered therapy still had PTSD at the end of the study.

Therapists who are interested in learning more about TF-CBT can take an online course at http://tfcbt.musc.edu and gain 10 continuing-education credits, free of charge. So far, 10,000 people have completed the online course, Mannarino said.

ER terror

Accidents that land children in hospital emergency rooms, as well as treatments for cancer and other illnesses, can also lead to PTSD, said Nancy Kassam-Adams, PhD, co-director of the Center for Post-Traumatic Stress at the Children's Hospital of Philadelphia. In fact, 20 percent of injured children and 12 percent of ill children develop significant PTSD symptoms, according to a meta-analysis of 26 pediatric medical trauma studies, published in 2006 in the Journal of Pediatric Psychology (Vol. 31, No. 4). Interestingly, severely injured or ill children weren't especially likely to develop PTSD - rather, children's individual perceptions of their likelihood of dying predicted their distress.

"What is traumatic can be very different between individuals," said Kassam-Adams, a study co-author.

Children with previous traumatic experiences, who underwent painful procedures or who were separated from their parents during their ER visit were also at greater risk for PTSD, she said.

With that in mind, mental health-care providers and parents can keep an eye out for symptoms of trauma and address them through what is known as the "D-E-F" protocol, developed by Kassam-Adams and her colleagues.

In the first stage, "distress," adults assess and mitigate anguish by keeping children informed throughout medical treatments and by giving them a say in what's about to happen, if possible. In the second stage, "emotional support," parents encourage their children to talk about their worries and hopes, stay with their children in hospitals and help kids maintain contact with friends in the case of extended hospital stays. In the third stage, "family," medical professionals address parents' and siblings' needs, encouraging them to seek support from friends, therapists and clergy members, for example, and helping them get needed breaks from the hospital.

Parents, psychologists and medical professionals who want to learn more can visit www.nctsn.org/nccts and download pocket cards, presentations and tip sheets on helping children cope with medical trauma.

Culture's role

While there's been great progress in treating PTSD in children, many unanswered questions remain, noted Beth Boyd, PhD, a psychology professor at the University of South Dakota. In particular, researchers don't yet know how to tailor treatments to ethnic-minority children, who are more likely to live in poverty, have chronic health problems and have experienced previous traumas - all complicating factors in PTSD treatment, she said. As a result, ethnic-minority children may mask their fears and anxiety, presenting a facade of toughness, Boyd noted.

"Ethnic-minority children may not show signs of PTSD, especially if they have experienced trauma before in their lives," she said.

While research on helping ethnic-minority children cope with trauma is limited, studies suggest a few routes that can help, including:

  • Providing children with the chance to discuss their feelings.

  • Encouraging children to resume their normal lives and routines.

  • Minimizing children's exposure to upsetting media images after a terrorist attack or natural disaster.

Most of all, ethnic-minority children need culturally competent service providers who understand the culture of the children who have been traumatized and who can draw on sources of resilience within the community, including spiritual practices, oral traditions and cultural identity, Boyd said.

"Existing interventions must be adapted to the child's culture," she noted.

This session was sponsored by APA Divs. 16 (School), 27 (Society for Community Research and Action), 37 (Society for Child and Family Policy and Practice), 43 (Society for Family Psychology), 53 (Society of Clinical Child and Adolescent Psychology), 54 (Society of Pediatric Psychology), 56 (Trauma), and APA's Committee on Children, Youth and Families.