Child and Adolescent Mental Health Volume 11, No. 4, 2006, pp. 176184
A Review of PTSD in Children
Atle Dyregrov1 & William Yule2
1
Center for Crisis Psychology, Fabrikkgaten 5, 5059 Bergen, Norway. E-mail: atle@uib.no
2
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
Introduction
Although the diagnosis of PTSD, when first formulated
in 1980, was not believed to be relevant to children and
adolescents, Leonore Terrs studies (1979, 1983) of a
group of children who were kidnapped and held hostage
soon proved otherwise. It is now well accepted that
children and adolescents can develop PTSD following
life-threatening traumatic events, and the diagnosis of
PTSD has even encompassed some of Terrs findings i.e.
regarding a reduced future perspective.
The diagnosis of PTSD in children and adolescents is
almost isomorphic to the adult core criteria: 1) after
exposure to actual or threatened death or serious injury
instead of evidencing fear, helplessness or horror they
may respond with disorganised or agitated behaviour;
2) symptoms of re-experiencing, repetition and re-
enactments where children may manifest repetitive
behaviours, play re-enactments of the traumatic situ-
ation or frightening dreams without specific content; 3)
avoidance of stimuli associated with the trauma; be-
cause it is difficult for children to report diminished
interest in significant activities and constriction of af-
fect, these symptoms should be carefully evaluated,
with reports being sought from parents, teachers and
observers; 4) hyperarousal, where it is noted that chil-
dren may also exhibit physical symptoms such as
stomach-aches and headaches (APA, 1994).
Stress reactions in children
Although more thoroughly studied over the last decade,
there are few longitudinal studies on the natural history
of stress reactions in children. Clinically, we and others
(Eth & Pynoos, 1985) have found that young children
show less emotional numbing; they also have more
problems reporting avoidance reactions as they either
are not relevant or too complicated to put into words as
they require a rather complex cognitive introspection.
This makes it difficult for children to meet DSM criter-
ion for the avoidance criterion of the diagnostic
algorithm (although this does not apply so much to the
ICD-10 diagnosis).
Following exposure to traumatic stressors children
display a wide range of stress reactions. These vary with
age and to some extent by gender. Younger children
display more overt aggression and destructiveness, and
may also show more repetitive play (and drawing) about
the traumatic event, as well as behavioural re-enact-
ments. For preschool children there is less agreement
as to the range and severity of their stress reactions. For
this age group reactions are more determined by par-
ental reactions to the event. If parents respond in a calm
2005 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
doi: 10.1111/j.1475-3588.2005.00384.
manner, the child can feel protected and secure.
Scheeringa et al. (1995, 2003) have suggested an
alternative set of criteria to employ in making a diag-
nosis of PTSD in young children, but more research is
needed before these can be adopted.
Over the age of 8 to 10 years, childrens reactions are
more similar to those manifested by adults. The school
age child can understand more of the situation, is able
to see more of the long-term consequences of the trau-
matic event(s), and can reflect more on their own role in
what happened. Gender differences are often reported,
with more girls than boys qualifying for the diagnosis of
PTSD, while boys show higher rates of behaviour
symptoms (Yule, Perrin, & Smith, 1999). In adolescence
there is often a sense of foreshortened future in line
with their understanding of long-term perspectives, as
well as more social ramifications of trauma.
Regardless of age, children exposed to chronic and
repeated stressors, such as victims of physical and
sexual abuse, war or harassment, may develop per-
sonality changes, various self-injurious and suicidal
behaviours, depression or other psychiatric dis-
turbances. Exposure to trauma in these formative years
may also affect the maturation of the central nervous
system and the neuroendocrine systems. A review of the
neurobiologic sequelae can be found in van der Kolk
(2003), while clinical implications of such aspects for
PTSD are outlined in Cohen et al. (2002).
Family influences
As with other anxiety disorders, childrens trauma
reactions are influenced by parental reactions. In
addition to modelling their parents reactions (social
influence), there are probably also inherited disposi-
tions to react adversely to traumatic events (genetic
influence). This has not been adequately studied in
relation to PTSD in children.
Some traumatic events, such as the sudden loss of a
parent or sibling can dramatically impact the caring
environment surrounding the child, and can potentially
result in a complicated mix of trauma and grief with
both PTSD and complicated grief reactions as a result
(Dyregrov, 1993).
Children are very sensitive to their parents reactions
both to the event itself and to talking about it afterwards.
It is not uncommon that children will refrain from dis-
cussing a traumatic event and its consequences as they
soon register that doing so upsets their parent(s). This
may, in part, explain why parents underestimate the
degree of stress reactions experienced by their children.
Thus, one cannot rely solely on parental report when
making diagnoses or estimating prevalence.

An early study by McFarlane, Policansky and Irwin
(1987) claimed that in an Australian bush fire, the
childrens reactions to the event were fully accounted
for by the mothers own mental health, rather than by
the exposure to the fires. However, as mothers had
rated both their own adjustment and that of their chil-
dren, this finding was suspect. Subsequent studies
have found that direct exposure is usually a stronger
determinant of child reaction, with maternal reactions
having important modifying influences (Smith et al.,
2001).
Parents may avoid discussion of a traumatic event
because of their own distress involved in such discus-
sions; they may limit discussions as a means of pro-
tecting their child, or because of cultural taboos against
such discussions. From many studies it is also known
that adults underestimate the severity of childrens
reactions and they may therefore be unaware of chil-
drens need to process their experience. Parents own
symptoms may reduce their capacity to support chil-
dren as well as to avoid reminders. It has been found
that children of parents (especially mothers) who har-
bour an elaborative narrative style in contrast to a
restrictive narrative style provide more detailed narra-
tives of events (Harley & Reese, 1999). The parental
climate of communication may thus be instrumental in
helping the child cope following traumatic events. Sal-
mon and Bryant (2002) outline the following important
aspects that talking with adults can have for children; it
can a) reinstate the experience in memory and prevent
forgetting; b) help the child to appraise and interpret the
experience; c) correct misconceptions; d) help the child
manage and regulate his or her emotions; and e) pro-
vide information about coping strategies and facilitate
their enactment. It follows from this that loss and
trauma that impact parental communicative function-
ing can seriously reduce childrens coping potential if
such communication is not sustained by the childs
social environment.
Incidence of PTSD in children
Most epidemiological studies on PTSD have been of
older adolescents and adults. Giaconia et al. (1995)
report a life-time prevalence of 6% in a community
sample of older adolescents. Most commonly reported
traumatic experiences were witnessing injury to or
death of others, hearing news of others sudden death
or accident, and personally experiencing a sudden in-
jury or accident. Kessler et al. (1995) report a life-time
prevalence of 10% using data collected from older
adolescents and adults in the (United States) National
Comorbidity Survey. Elklit (2002) reported a 9%
estimated lifetime prevalence of PTSD among a national
Danish representative sample of eight grade students in
Denmark.
By contrast, the British National Survey of Mental
health of over 10,000 children and adolescents (Meltzer
et al., 2000) report that only 0.4% of 1115 year olds
were diagnosed with PTSD, with girls showing twice the
rate of boys. Below age 10, it was scarcely registered.
This lower rate is, of course, a point prevalence estimate
and is bound to be lower than a life-time prevalence
estimate. Moreover, the screening instrument was not
specifically developed to screen for PTSD.
PTSD in Children 177
Estimates of the incidence of PTSD are more frequently
reported after varying natural and man-made disasters.
Rates vary enormously, partly as a result of differing
methodologies, and partly as a result of different types of
traumatic events. In a review of studies on natural dis-
asters La Greca and Prinstein (2002) state that moderate
to severe symptoms of PTSD are evident by approxi-
mately 30 to 50% of youth, while 5% to 10% of children
and adolescents may meet criteria for a full diagnosis of
PTSD. Children exposed to gruesome aspects may evi-
dence very high rates of posttraumatic problems, as
found by Pynoos and co-workers (1993) when around
90% of youth reported severe PTSD symptoms following
the Armenian earthquake.
In various studies of the effects of Road Traffic Acci-
dents rates have varied from 29% at four weeks, 36% at
6 weeks, 6%25% at 1215 weeks through to 14% at
9 months post-accident (Stallard, Salter, & Velleman,
2004).
The study of 200 adolescent survivors of the sinking
of the cruise ship Jupiter (Yule et al., 2000) reported an
incidence of PTSD of 51%. Most cases manifested
within the first few weeks, with delayed onset being
rare. Other disorders such as anxiety and depression
were also common. Following a discotheque fire that
killed 63 adolescents, 25% of the 275 survivors met
DSM-IV criteria for PTSD (Broberg, Dyregrov, & Lilled,
2005) 18 months after the fire. Following another fatal
fire in a youth cafe in Volendam, Netherlands, Reijne-
veld, Verhulst and Verloove-Vanhorick (2003) were able
to examine pre-disaster mental health ratings with
post-fire ones as many of the adolescents had partici-
pated previously in an epidemiological study. The
findings indicate the need to look at disorders such as
anxiety, depression, aggression and alcohol abuse as
well as PTSD.
Studies of rates of childhood PTSD in warfare and
among child refugees from war torn countries find that
the incidence varies from 25% to 70%, depending on
exposure and type of warfare. Following sexual abuse,
the rates reported have also varied between 0% to 90%
(see Salmon & Bryant, 2002), but usually with high
rates. Similar rates have been found in children who
witness family violence or themselves suffer physical
violence (the two often go together). Peer victimisation is
also associated with posttraumatic stress, as is the
exposure to community violence (Mynard, Joseph, &
Alexander, 2000; Luthar & Goldstein, 2004). See Mar-
golin and Gordis (2000) for an overview of the effect on
violence on children.
Children with serious disease such as cancer and
children who undergo hospitalisation for paediatric in-
jury have also been shown to suffer from PTSD, al-
though rates usually are low (<15%). Parents of the
same children are evidencing much higher levels of
PTSD, indicating that a posttraumatic perspective on
the family can be an important added element in their
care (Kazak et al., 2004; Landolt et al., 2003).
In Fletchers (1996, reported in Salmon & Bryant,
2002) meta-analysis of 34 samples that included 2697
children who had experienced trauma, 36% of children
(comparable to the rate of 24% in adults) met criteria for
PTSD following a range of traumas, and the rates of
diagnosed PTSD did not differ markedly across develop-
mental levels.
178 Atle Dyregrov & William Yule
The different estimates across studies reflect meth-
odological differences regarding events studied, meas-
ures or method used, data collection variations, country
differences, time of assessment, and various other fac-
tors (composition of sample regarding gender, age and
socioeconomic and family status). Regardless of these
variations, the estimates show that many children suf-
fer from PTSD resulting from an array of different
events. On account of the documented childhood con-
sequences of trauma, significantly increased demands
will be made at all levels of primary and secondary child
and adolescent mental health services following trau-
matic events.
Natural history
The 57-year follow-up study of adolescents who sur-
vived the sinking of the cruise ship Jupiter found that
15% still met criteria for PTSD that long after the event
(Yule et al., 2000). More recently, a 33-year follow-up of
the children who survived the Aberfan land-slide dis-
aster found that 29% of those traced and interviewed
still met criteria for PTSD (Morgan et al., 2003). In other
words, in the absence of effective therapy, the long-term
effects of life threatening, traumatic events in childhood
can be severe.
Predictors of PTSD
Level of exposure has most consistently been associated
with later problems including PTSD following various
types of trauma (Pine & Cohen, 2002). Lack of social
support, problems in family cohesion, the female gen-
der, prior exposure to trauma, prior psychiatric pro-
blems, and a strong acute response have all been
associated with later posttraumatic problems (Pine &
Cohen, 2002; Meiser-Stedman, 2002). A less clear
relationship has been found between age and ethnicity
and posttraumatic reactions (Meiser-Stedman, 2002).
Ehlers, Mayou and Bryant (2003) have shown that 14%
of the variance in PTSD symptoms at 6 months after a
road traffic accident could be explained on the basis of
sex and stressor severity. The accuracy of the prediction
increased to 49% or 53% when cognitive variables
measured at initial assessment or 3 months, respect-
ively, were taken into account. The cognitive variables
included negative appraisal of intrusion and unfair-
ness, maintaining cognitive strategies such as rumin-
ation and thought suppression, and so-called
data-driven processing of the event i.e. how muddled or
confused they were during the accident. A review of
developmental factors that influence PTSD can be
found in Salmon and Bryant (2002) and Meiser-Sted-
man (2002).
Costello et al. (2002), in their study of exposure to
potentially traumatic events from middle childhood
through adolescence, found that exposure to such
events were far from rare. They also found that a family
history of mental illness doubled the risk of exposure.
Diagnostic and assessment measures
More is known about screening, assessment and diag-
nosis in children above the age of 7 years because
above that age many children can read independently
and can complete self-rating scales. It is much more
expensive to conduct standardised clinical interviews
with both parent and child to establish a diagnosis in
large groups of children. We will briefly mention some of
the instruments used.
There are several measures that assess the kinds of
exposure children have experienced. Usually these
scales measure domains of traumatic stressors, i.e. war
stressors (War-Trauma Questionnaire Macksoud,
1992), and physical abuse (Hunter et al., 2003), al-
though some try to measure across such domains
(Smith et al., 2002).
There are several scales that assess the effect of
trauma, of which some will briefly be mentioned here.
The most frequently used adult scale The Impact of
Event Scale (Horowitz, Wilner, & Alvarez, 1979) was
used and then adapted for use with children and ado-
lescents in its original 15-item version. Following two
large principal component analyses, a briefer 8-item
version was developed for children (Yule, 1997) and
subsequently expanded to a 13-item version to include
5 items attempting to measure arousal (see http://
www.childrenandwar.org). The 13-item version was
used with 2976 children aged 914 years in Bosnia
shortly after the war. Two principal components
emerged Intrusion and Arousal versus Avoidance. A
three-factor forced solution separated the intrusion and
arousal items (Smith et al., 2003). A similar finding
emerged from a study of over 290 Kosovan Albanian
refugee children (Yule et al., 2004). Thus, the 13-item
version for children seems to be a useful and robust
instrument.
Another frequently used instrument is the CPTS-RI
(Child Post Traumatic Stress Reaction Index) originally
rated following an interview by a clinician with the carer
and sometimes the child (Frederick, Pynoos, & Nader,
1992). More recently, it has been modified to be a self-
report instrument.
The CPSS (Child PTSD Symptom Scale), a 17-item
scale developed by Edna Foa and co-workers (Foa et al.,
2001), has been used both in initial diagnosis and in
monitoring progress. It contains a brief functional
impairment rating.
Greenwald and Rubin (1999) developed child and
parent versions of a rating scale that has now been
validated in a number of studies. Saigh et al. (2003) has
also updated a scale for measuring traumatic stress
reactions in children. More information on assessment
of trauma in children and adolescents can be found in
Newman (2002).
Structured interviews for PTSD in children and
adolescents
Several structural interviews for PTSD in children and
adolescents are in use. The CAPS-C (Clinician Adminis-
tered PTSD Scale for Children) (Nader et al., 1994) is
modelled on the adult CAPS and is widely regarded as
the gold standard measure to diagnose DSM-IV PTSD in
children. Another choice is the ADIS-C-PTSD Module
(Anxiety and Depression Interview Schedule for Chil-
dren) (Silverman & Albano, 1996) that has parallel
versions for parents and child and also has modules
assessing related anxiety disorders and depression.

In our experience it is both possible and helpful to
focus on the childs traumatic experience in the first
session. The use of systematic assessment of both the
childs trauma exposure and its effects, embedded in a
sensitive clinical encounter where the child or adol-
escent describes his or her experience, often gives a
wealth of clinical information that may determine the
clinical approaches chosen. For single-event trauma
we recommend that the child as early as the first
session is provided with some help (i.e. a simple
method for reducing intrusions) that help them with
their most bothersome symptom or problem. This will
increase their optimism and motivation for returning.
When meeting and assessing a child, drawing can be
used as a communication tool. If children are given
the opportunity to draw about an emotionally laden
event while talking about it, children between 3 and
9 years report more detailed verbal reports than if they
are required to give an account without drawing
(Gross & Hayne, 1998). This is achieved without loss
of accuracy in the childs story. Gross and Hayne
(1998) point to the following factors that may make
drawing beneficial: a) drawing may reduce the per-
ceived social demands of the situation making chil-
dren feel more comfortable than simply being asked to
tell; b) drawing may facilitate memory retrieval as they
may be reminded of other aspects of a situation while
drawing; and c) drawing may help children organise
their narratives, allowing for a better telling of their
story.
Psychological treatment for PTSD
There are very few randomised controlled trials of any
therapy with children, let alone therapies specifically
for PTSD. One has therefore to be cautious in drawing
conclusions solely by downward extension of results
from work with adults.
Early interventions
Whilst prevention is seen as better than cure, in respect
of PTSD this has to be seen as preventing the occur-
rence of traumatic events or childrens exposure to
them. Early intervention is attractive if it could be
shown that it prevented later development of PTSD or
other disorders but, as with adult studies, there have
been few published properly controlled trials of any
early intervention.
Although we still have next to no controlled studies of
early intervention, it is our clinical experience that by
intervening early it is possible to stimulate early family
communication around traumatic events and thus
clarify misunderstandings, prevent family secrets and
foster a good recovery environment for children (Dyre-
grov, 2001). In all early intervention the first and fore-
most principle is to ensure that the child feels safe and
secure, while secondly making sure that he or she is
provided with information and clarification about what
happened and the state of family members and friends.
Other principles of early intervention for children and
adolescents can be found elsewhere (Cohen, 2003), and
a thorough and balanced discussion of central issues
involved in the use of psychological debriefing for chil-
dren and young people can be found in Stallard and
Salter (2003).
PTSD in Children 179
Cognitive behavioural therapies
Parallel with increasing knowledge about PTSD in
children there has been an increase in the development
of both individual and group based therapy methods.
Partly this has consisted of adult therapeutic methods
being adapted for children and partly methods have
been developed directly for children. However, more
systematic evaluation of these methods has largely
been missing. The Practice parameters for the assess-
ment and treatment of children and adolescents with
posttraumatic stress disorders in 1998 stated: Very
limited empirical support exists for various treatment
interventions for children with PTSD (American Acad-
emy of Child and Adolescent Psychiatry, p. 145). The
situation today is somewhat better and in recent re-
views it is concluded that cognitive behavioural therapy
(CBT) is effective with children (Cohen et al., 2000,
2002; Pine & Cohen, 2002). However, in the various
studies reviewed, a variety of different methods within
the realm of CBT have been used, and the critical ele-
ments within the treatment remain to be identified.
Frequently practised treatments from orientations
other than CBT have not been evaluated sufficiently. In
addition, despite research based clinical trials, the
effectiveness of treatments as practised in clinical set-
tings has been shown to be modest (Ollendick & Davis,
2004).
Already back in the 1980s Philip Saigh documented
the use of exposure in the treatment of traumatised
children in a series of systematic single case design
studies of war exposed children in Lebanon (Saigh,
1987a, 1987b, c, d, 1989).
In recent years, many of the reactions children de-
velop following sexual abuse have been formulated as
part of a spectrum of post traumatic stress reactions.
Today this area has the majority of controlled studies
for treating PTSD reactions. Celano et al. (1996) com-
pared 15 girls in an abuse-specific programme, with 17
given a parallel set of 8 non-directive supportive ses-
sions. There were no differences on child scores in-
cluding on the Child Impact of Traumatic Events Scale
Revised (CITES-R). Deblinger, Stauffer and Steer (2001)
enrolled 67 children aged 28 years. Although only 44
completed all 11 sessions of treatment, 21 completed
group CBT and 23 completed a support group. There
was better outcome for CBT, but that group had had
higher scores to start with. Previously they used trau-
ma-focused CBT (TF-CBT) for sexually abused children,
with randomisation to four different groups where three
had various degrees of parental involvement and one
was a control group (Deblinger, Lippman, & Steer,
1996; Deblinger, Steer, & Lippman, 1999). In the two
treatment conditions where children were directly
treated, they evidenced significant improvement in
PTSD symptoms compared to the control group and the
group where only parents received treatment (also
CBT). Inclusion of parents resulted in improvement in
childrens externalisation symptoms and depression.
King et al. (2000) studied 36 sexually abused chil-
dren aged 517 years who met criteria for PTSD.
There were 12 children in each of 3 conditions: CBT
with child and family; CBT with child alone; waiting
list control. Treatment conditions consisted of 20
sessions. Using ADIS-C to assess PTSD, there was a
significant improvement on PTSD (p < .05) as well as
180 Atle Dyregrov & William Yule
on self reported anxiety scales. Both ways of delivering
CBT were equally effective compared to the control
group.
Cohen et al. (2004) showed that TF-CBT reduced
PTSD, depression and total number of behavioural
problems compared to a child-centred treatment for
sexually abused children. The TF-CBT included train-
ing in expressive techniques, understanding of the
relation between thoughts, feelings and behaviour,
gradual exposure, cognitive processing of the event,
joint sessions between parents and children, psycho-
education about sexual abuse or training of parents in
parent management skills. The child centred treatment
emphasised building a strengthening trusting relation-
ship before children and parents themselves chose how
and if they wish to approach the sexual abuse. The
therapist was actively listening, reflecting, showed em-
pathy and supported them in talking about feelings and
showed confidence in the childrens and adults coping
strategies. Although the work was client centred, writ-
ten psychoeducative information about sexual abuse
was provided and during two sessions the children were
prompted to share their feelings about the sexual
abuse.
Twice as many children aged 8 to 14 years receiving
the child centred treatment still met the criteria for
PTSD compared to those who received TF-CBT. For the
children in the TF-CBT group, their shame and negative
self-attribution also decreased. Parents of children in
the TF-CBT group reported less depression, more sup-
port of their children and better parent management
skills than parents in the other group. This was the last
in several well controlled studies that Cohen and
Mannarino (1996 1997) conducted comparing TF-CBT
with supportive therapy for sexually abused children of
various ages (Cohen and Mannarino, 1998). In all
studies TF-CBT shows the best results. This conclusion
was also reached in the review by Ramchandani and
Jones (2003).
For physically abused children the only randomised
controlled study has been undertaken by Kolko (1996).
He compared abuse-focused CBT conducted individu-
ally with children and parents, with both family therapy
and standard community care provided to children and
families. Results showed that both CBT and family
therapy were superior to standard care regarding
externalising symptoms, parental distress, risk of new
abuse and family conflict and cohesion.
Groups for children with PTSD or PTSD-symptoms
Goenjian and co-workers (1997) demonstrated a bene-
ficial effect of a trauma and grief focused treatment of
children in early adolescence following an earthquake
in Armenia. They combined classroom intervention
(four meetings) with two individual sessions empha-
sising five areas: 1) reconstruction and reprocessing of
the traumatic event; 2) handling of traumatic remind-
ers; 3) stress following the disaster and other negative
events; 4) grief and the interplay of grief and trauma; 5)
developmental progression. Discussions, drawings,
different activities, and training in relaxation and
problem solving were included in the intervention.
Individually, their experiences were processed by
working through traumatic moments. For the inter-
vention group, posttraumatic complaints were reduced
and there was no worsening of depressive symptoms. In
a control group not receiving this intervention both
posttraumatic problems and depression increased.
In a continuation of this group protocol, a programme
for children who experience war and children experi-
encing inner city violence has been developed by Layne
et al. (2001). In groups of 5 to 7, children at the age of 11
to 14 years met at school for 50 minutes over 20 con-
secutive weeks. Children were screened only to include
those who both had experienced trauma and evidenced
strong reactions to this. A manualised approach was
used, focusing on the same themes as mentioned
above. Participation resulted in significant improve-
ment in posttraumatic symptoms, complicated grief
reactions and school grades. Depression showed little
change.
Following the earthquakes in Turkey and Greece in
1999, a manualised group approach for children in
disasters, developed in collaboration by the Institute of
Psychiatry in London and Center for Crisis Psychology
in Bergen, Norway was used for children (Smith, Dyre-
grov, & Yule, 1999). A similar manual has been devel-
oped for war situations (Smith, Dyregrov, & Yule, 1998).
Through five group meetings children are taught self-
help strategies to reduce intrusive memories, handle
avoidance reactions and reduce bodily arousal. Pre-
liminary data indicate that both posttraumatic prob-
lems and depressive symptoms are significantly
reduced by the procedure (Giannopolou, 2000, see
http://www.childrenandwar.com).
A similar approach has been developed by Kataoka
and co-workers (2003) who work with refugee children
in California. They used CBT in groups of children
exposed to violence. The approach uses stories to
explain the treatment, provide information on trauma
and train children in various strategies including
relaxation. By using a control group waiting for
treatment they were able to show significantly better
results for PTSD and depression in the treatment
group compared to the control group. In another
study from the same group, Stein et al. (2003)
reported a randomised controlled trial in which 61
children who had been exposed to violence were given
10 sessions of CBT, with 65 children in a delayed
intervention group. At 3-months post treatment, the
treated group had significantly lower scores on the
Child PTSD Symptom Scale. Significant differences
were also found on measures of depression and
psychosocial dysfunction. Teacher rated behavioural
difficulties did not reflect improvement. The delayed
treatment group then made significant PTSD
improvement following treatment.
Another confirmation that CBT based groups can
lead to good results comes from March et al. (1998).
They used a variant of CBT that they called Multi-
Modality Trauma Treatment (MMTT). Over 18 weekly
meetings children evidencing high posttraumatic stress
from single event traumas at a school screening were
trained in handling anxiety and anger, and in grading
feelings. In addition, they told their trauma story
(exposure), reviewing the worst moment, correcting
dysfunctional thinking and so forth. Using a single case
across setting design they found that of those who
completed the groups there were 8 (57%) who no longer
met the criteria for PTSD at the end of treatment, and

12 of 14 (86%) who were without PTSD at 6-months
follow-up.
After Hurricane Iniki hit Hawaii, all elementary
school children were screened for serious stress reac-
tions and the high risk group of 248 children were
randomly assigned to one of three treatments (Chem-
tob, Nakashima, & Hamada, 2002). This consisted of
four sessions delivered either individually or in groups.
Their specially developed, manualised treatment had
many elements in common with other CBT approaches.
Both individual and group treatment had equally good
results compared to controls and achieved an effect size
of 0.50 on the Kaui Recovery Index. On the better
known Child Reaction Index completed on a sample of
children by clinicians, the effect size was 0.76. More
children dropped out of individual than group treat-
ment.
If any trend can be detected in the modern approa-
ches to groups for traumatised children it is charac-
terised by a reduction in number of sessions. Most
approaches seem to focus on the concrete experiences
of the children with some exposure involved in relating
their story orally or in writing. Another important as-
pect is the emphasis on teaching children strategies
that help them cope with the consequences of
the trauma, whether intrusive material, avoidance
reactions or a heightened arousal.
Other treatments for PTSD
Eye Movement Desensitisation and Reprocessing has
proven to be a potent technique for adults and there are
a number of case reports claiming effectiveness of
EMDR in treating PTSD in children. So far there is but a
dearth of published RCTs or even other group studies.
Chemtob, Nakashima and Carlson (2002) identified 32
children who still met criteria for PTSD after other at-
tempts at treatment. They achieved significant drops in
childrens CRI scores following three sessions of EMDR
with significant but lower drops on depression and
anxiety. The study had two groups immediate versus
delayed treatment.
Ribchester, Yule and Duncan (2004) treated 11 con-
secutive children who developed PTSD following RTAs.
One dropped out, but the other 10 no longer qualified
for a diagnosis on average after 2.4 sessions of EMDR.
This shows a promising potential for the method with
children and is being prepared for publication.
De Roos et al. (2004) report on an RCT involving 52
children following the Enschede fireworks disaster in
the Netherlands in 2000. EMDR compared very
favourably with CBT. Both treatments produced signi-
ficant lowering of stress symptoms, with EMDR doing
slightly better in fewer sessions.
Tiffany Field and co-workers (Diego et al., 2002;
Field, Kilmer, et al., 1996; Field, Seligman, et al., 1996)
have conducted several studies showing that massage
can reduce posttraumatic and other symptoms among
children. Although attention control groups have been
used, the methodological rigour is not to the standard of
the CBT studies.
A recent addition to the methods for treating trau-
matic stress reactions is a variant on narrative ther-
apy. This has its roots in part in South American
work on helping survivors of torture record their
stories and so stand testimony to the state violence
PTSD in Children 181
they had endured, and in part in developments within
CBT where clients are helped to write a fuller account
of their experiences, concentrating on the subjective
feelings. While this is seen as part of completing
otherwise fragmented memories, the technique is
emerging as a powerful one in its own right. Penne-
baker (1990 2004) has long demonstrated that writing
about emotional events can have very positive effects.
Neuner et al. (2004) have developed their narrative
exposure therapy technique (NET) and used it in an
RCT with adult refugees in the Sudan. The treated
group made significant improvements and the tech-
nique is now being used in a series of smaller studies
with children (Schauer et al., 2004).
Medication
Only one randomised controlled trial has been con-
ducted on the use of psychopharmacological agents for
children following traumatic exposure. Robert et al.
(1999) randomised 25 children suffering from burns to
either imipramine or chloral hydrate (control condition).
Children receiving imipramine showed lower rates of
acute stress disorder than children receiving chloral
hydrate. Cohen, Mannarino and Rogal (2001) found in
a US survey that child psychiatrists frequently used
alpha- and beta-adrenergic blocking agents, tricyclic
antidepressants, anticonvulsants and antipsychotic
medications for children with significant PTSD symp-
toms. Without more and better studies documenting
good effects and absence of serious side-effects, we urge
clinicians to exercise extreme caution in using psycho-
pharmacological agents for children, especially as
CBT-methods are available to reduce posttraumatic
symptoms and PTSD.
Conclusion
Although CBT and especially TF-CBT are the most well
documented intervention methods for traumatised
children, the samples involved in the studies are relat-
ively small. The sample size also makes it difficult to
study the effect of background variables. Most of the
well controlled studies have been undertaken with
sexually abused children and may not be as relevant for
children traumatised by other events. Taken together,
both the results from the individual and group therapy
domain should lead clinicians to choose CBT based
methods for helping children who have experienced
trauma. As clinicians we know that every child has to be
met as an individual and not treated by rigorous man-
uals. However, the material found in the treatment
manuals and the specific techniques imbedded in them
are the tools that we can apply and teach children.
Using these concrete tools we can help children make
full use of their potential, reducing the effect that
trauma will have on their life.
More research is needed to identify the active ingre-
dients in the therapeutic approaches, as well as learn-
ing more about what methods to use with which
children. How best to include family members in the
follow-up of children is another area that needs more
study. Likewise, we need to increase our understanding
of the children and adolescents who do not seek out
182 Atle Dyregrov & William Yule

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