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Open Access Review

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention on Trauma in Schools (CBITS), and Other Promising Practices in the Treatment of Post-Traumatic Stress Disorder in Children and Adolescents: Evidence Evaluation

Ioannis Syros 1,2,*, Aggeliki Karantzali 3, Xenia Anastassiou-Hadjicharalambous 4

  1. Department of Child Psychiatry, School of Medicine, National and Kapodistrian University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece

  2. Child and Adolescent Psychiatry Unit, “Sotiria” General Hospital, Athens, Greece

  3. Society of Social Psychiatry, P.Sakellaropoulos, Athens, Greece

  4. Psychology Program, University of Nicosia, 46 Makedonitissas Avenue, P.O.Box 24005, 1700 Nicosia, Cyprus

Correspondence: Ioannis Syros

Academic Editor: Jeffrey Kibler

Received: April 11, 2022 | Accepted: October 11, 2022 | Published: November 15, 2022

OBM Neurobiology 2022, Volume 6, Issue 4, doi:10.21926/obm.neurobiol.2204146

Recommended citation: Syros I, Karantzali A, Anastassiou-Hadjicharalambous X. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention on Trauma in Schools (CBITS), and Other Promising Practices in the Treatment of Post-Traumatic Stress Disorder in Children and Adolescents: Evidence Evaluation. OBM Neurobiology 2022;6(4):43; doi:10.21926/obm.neurobiol.2204146.

© 2022 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

PTSD is a serious mental health condition with a lifetime prevalence of 1% to 14% in the general population. Several studies have evaluated evidence-based treatment approaches for children and adolescents. Interventions focusing on trauma are considered first-line treatments. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and a similar type of group intervention, the Cognitive Behavioral Intervention on Trauma in Schools (CBITS), have received the most empirical support from randomized controlled trials. Moreover, several other promising therapeutic CBT protocols are in the process of being applied and evaluated. This literature review highlights the common elements of CBT approaches for treating PTSD in children and adolescents, provides a detailed review of the therapeutic ingredients of TF-CBT and CBITS, and presents various other promising CBT protocols that are currently being used or evaluated. Future directions for the field are also discussed.

Graphical abstract

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Keywords

Post-traumatic stress disorder; cognitive behavioral therapy; children; adolescents; trauma; evidence-based interventions

1. Introduction

Psychological trauma is a debilitating mental health condition resulting from traumatic experiences. It causes overwhelming or underwhelming distress (in cases of neglect) that exceeds the person's coping ability, leading to serious long-term negative consequences [1].

Because experiences vary among individuals, people respond differently to a similar traumatic event. Therefore, not all individuals who experience a traumatic event become psychologically traumatized. Often traumatic events precede the current incident, making some people more vulnerable to having a later traumatic reaction [2].

In recent violent incidents at schools, universities, and other parts of the community, mental health professionals have focused on the symptoms and consequences of maladaptive traumatic stress and post-traumatic stress disorder (PTSD) in children and adolescents. Apart from single-event traumas, both childhood abuse and neglect are common in the United States [3] and worldwide; childhood abuse and neglect result in complex PTSD, which is further aggravated by relational trauma between caregiver and child [4].

A variety of psychological treatments are effective in treating post-traumatic stress symptoms and concomitant difficulties in children. These interventions are considered first-line treatment for children and adolescents. Treatments that specifically focus on the child’s traumatic experiences are superior to nonspecific or nondirective therapies in healing post-traumatic symptomatology. This is valid for children of all ages with PTSD and for therapies derived from various theoretical backgrounds, such as psychoanalytic, attachment, and cognitive-behavioral treatment models [5,6,7].

Trauma-focused-cognitive behavioral therapy (TF-CBT) is the most widely used and best-researched manual-based CBT protocol for PTSD [8,9,10], whereas Cognitive Behavioral Intervention for Trauma in Schools (CBIΤS) is the most-researched CBT protocol implemented in groups. Follow-up studies have demonstrated the sustainability of profits for 6 months, 1 year, and 2 years post-treatment [11,12]. Several other therapeutic CBT protocols are being applied and evaluated, leading to promising results in special populations of different origins and specificities in symptomatology.

Till now, the extensive analysis of both well-established and innovative interventions for PTSD remains limited, and the results of related studies are inconsistent. In addition, the factors affecting the outcomes of these programs require further evaluation [13,14].

This study is a systematic descriptive review with the following specific goals:

  1. To highlight the common elements of CBT approaches in treating children and adolescents with PTSD.

  2. To provide a detailed review of the therapeutic ingredients of TF-CBT and CBITS with substantial evidence of effectiveness. Previous studies on and the treatment process of these two approaches are described. Furthermore, the achievement of results and accessibility to different target populations are discussed. The review also presents several other promising CBT protocols that are currently being used and/or evaluated and have accumulated less evidence of effectiveness to date. Moreover, future directions of the field are discussed.

2. Conceptual Definition of Trauma, PTSD, and Acute Stress Disorder (ASD)

The definition of trauma varies depending on the context; however, in a broader sense, it includes both physical and psychological harm and injury [15]. According to a study, more than one out of four children experience a major traumatic event before reaching adulthood [16]. These traumas may include events that may occur over some time or at a point in time. Examples are child abuse; domestic, community, or school violence; disasters; vehicular or other accidents; medical traumas; war; terrorism; refugee trauma; the traumatic death of significant others; and other shocking, unexpected, or terrifying experiences. Although most children are resilient to trauma exposure, some of them develop substantial and potentially long-lasting mental health problems. Therefore, PTSD and ASD are diagnoses that refer to a set of psychological and physical symptoms following exposure to such a stressful traumatic event [17]. According to the International Classification of Diseases 11th Revision (ICD-11) diagnostic descriptions, in contrast to a single trauma event, prolonged or repeated trauma causes complex PTSD (C-PTSD), which has been diagnosed in many children participating in the treatment approaches. The type of trauma (relational trauma, single trauma, trauma caused by a man-made factor, or a natural disaster) affects the natural course of symptoms and the design of interventions, as well as their outcome [18].

3. Criteria for PTSD and ASD Diagnosis

In the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD is not categorized under “anxiety disorders,” but is included in a new section that groups the disorders related to trauma and stress (i.e., trauma-related and stressor-related disorders). PTSD is a mental disorder, with exposure to at least one or more traumatic events considered an essential diagnostic criterion. Diagnostic criteria in children aged 7 years and older comprise four clusters of symptoms that appear or worsen after exposure to actual or threatened death, severe injury, or sexual maltreatment by direct experience, direct observation, hearing of a traumatic experience that happened to a close friend or relative, or exposure to stressful reminders of the trauma.

These clinical features are required to occur for more than 1 month and be associated with distress and functional impairment. In children aged 7 years and younger, distinct PTSD criteria currently apply, which include developmentally specific phenomenology. ASD is a distinct psychiatric disorder that is diagnosed when traumatic stress or dissociative features occur within 3 days to 1 month of trauma exposure and last at least 3 days.

Changes in diagnostic semiology in the subsequent versions of the DSM indicate the increase in understanding and research on PTSD over the last two decades. The changes concern the stressor definition, the groups in whom the specific symptoms are classified, and the required number of symptoms for each group (the onset, duration, and requirements of clinical discomfort or functional impairment) [19].

4. Epidemiology and Prevalence

The lifetime prevalence of PTSD in the general population ranges from 1% to 14% [1,19,20,21]. In a recent study by Koenen et al. [21] with 71,083 individuals, the lifetime prevalence of PTSD was 3.9% among the participants and 5.6% among individuals exposed to trauma.

Giaconia et al. [22] reported that at the age of 18 years, more than 2 out of 5 adolescents in a community sample of working-class or lower-middle-class households met the criteria for at least one trauma according to DSM-III-R. Moreover, more than 6% fulfilled the criteria for PTSD diagnosis during their lifetime.

In a national sample of adolescents (12–17 years), 3.7% of male and 6.3% of female adolescents met the diagnostic criteria of PTSD [23]. In the National Comorbidity Survey Adolescent Supplement (NCS-A) study by Merikangas et al. [24], with approximately 10,000 adolescents aged 13–18 years in the U.S, the estimated lifetime prevalence of PTSD was 5.0%, with 1.5% having a severe impairment. The prevalence of PTSD among female adolescents (8.0%) was higher than in male adolescents (2.3%).

5. Trajectories of Post-Traumatic Adaptation: Risk and Protective Factors

Effects of traumatic stress exposure in children differ widely and can potentially vary over time. Cases with unfavorable outcomes are characterized by either initial severe reactions accompanied by persistent or episodic post-traumatic damage (chronic PTSD) or initial mild to moderate responses accompanied by intense damage (delayed-onset PTSD) [25].

Delayed-onset PTSD was assumed to be rare. However, a study revealed that 2 out of 10 young people, as well as adults, do not exhibit clinically significant symptoms for several months or even years after the initial exposure to traumatic events [26].

Negative prognostic factors for the development of chronic pediatric PTSD include the presence of pre-traumatic psychiatric disorders, problematic caregiver/family relationships, poverty, emotional distress, and exposure to relational trauma (e.g., maltreatment, sexual abuse, and domestic abuse). Moreover, post-traumatic reduced social support, withdrawal, psychiatric comorbidity, poor family adjustment to trauma, and post-traumatic cognitive distortions (distraction, rumination, thought suppression, and increased threat sensitivity) are included in the negative prognostic factors [27,28,29,30,31].

Some children, however, are resilient or without essential clinical manifestations of trauma exposure [32]. Therefore, they can adapt and preserve both the functioning and development of resilient behavior. In other cases, children show moderate to severe initial reactions during early-onset PTSD (i.e., within 3 months of exposure) but improve and retrieve normal functioning over time with or without therapy [25].

6. Assessment of PTSD Symptomatology in Children

For the assessment of post-traumatic symptomatology in children, the following should be performed: 1. the acquisition of a detailed history of traumatic event exposure as well as any previous traumas in the individual history of the child; 2. the clinical observation of the child (behavior, the content of speech/thoughts, emotional reactions, nonverbal communication, insight on difficulties, and cognitive functioning—attention, judgment, and orientation); 3. the usage of projective techniques, such as play and drawing; and 4. the application of general and special trauma assessment tests, such as Child Behavior Checklist (CBCL), Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA-5), and the UCLA children/adolescent PTSD reaction index [26].

The specialists ensure that a child’s evaluation always begins with a sensitive clinical interview. Children with undeveloped verbal skills can express their experiences through simple projective techniques, such as play, drawing, or storytelling. These often reveal their discomfort through repetitive and graphic representations of their experiences.

The routine evaluation of children in the group or community where the traumatic event, especially a natural disaster, took place constitutes a useful practice [33]. These procedures involve minimal clinical supervision and are economical and less time-consuming. In addition, in cases of traumatic experiences after natural disasters, group interviews with children, such as those conducted in classrooms or other smaller groups, could also be used. Therefore, a thorough individual assessment of these children with symptoms, such as increased arousal, sleep disorders, withdrawal, avoidance of reminders of the trauma, and intrusive thoughts related to their experience, is essential. Group interviews can be used to elicit children's cognitive and emotional responses, assess current adjustments, explore coping strategies, validate their emotions, and encourage support.

7. Brief Overview of the CBT

CBT provides a framework to help children understand the association between their thoughts, feelings, and behaviors. Therefore, children can acknowledge, challenge, and re-evaluate their negative thoughts in an optimal way. CBT comprises many behavioral techniques to facilitate changes in behavior, the important ones being positive reinforcement of supportive behaviors, contingency management, self-assessment of nonhelpful beliefs, and gradual exposure to traumatic memories [3,34,35,36]. The expected results of CBT relate to each of the following areas of the model:

A. Cognitive modification, resulting in reduced anxious or negative thoughts.

B. Improved emotional response, leading to a reduction in anxiety and depressive symptoms.

C. Changes in behavior that lead to improved self-efficacy; therefore, the child learns to overcome and face traumatic experiences and challenges [37,38,39].

8. CBT for the Treatment of PTSD in Children and Adolescents

Numerous studies have highlighted the effectiveness of CBT for PTSD in children and adolescents exposed to various traumatic experiences [5,10,17,40,41,42,43]. During CBT, therapists educate youths on stress reduction techniques, leading to the individual’s preparedness to gradually expose himself/herself to and, therefore, gain mastery over the trauma stimuli. CBT for individuals with PTSD is also effective when conducted in groups in various community or mental health clinics [44,45,46].

The bulk of empirical investigations have compared CBT with waitlist control groups; CBT was more effective even when compared with other well-known treatments, such as supportive [5,40] and narrative therapy [41]. CBT following appropriate developmental modifications is also effective in 3–6-year-old children who have experienced sexual abuse [47,48] or other traumas [49]. Therefore, as suggested by the UK National Institute for Clinical Excellence (NICE) guidelines, CBT is effective in the treatment of PTSD. Children and young people with PTSD should be offered a course of trauma-focused CBT suitably adapted to their age, circumstances, and developmental level [3,50].

As stated in the introduction, this study specifically provides an overview of two evidence-based preventive interventions, TF-CBT [8] and a similar type of group intervention, the CBITS [46]. Both have received the most empirical support through randomized controlled trials (RCTs).

Regarding these aforementioned interventions, the most important information on the RCTs, quasi-experimental, and open trials described in sections 8, 9, and 10 are listed in Table 1.

Table 1 CBT - oriented PROTOCOLS & CLINICAL TRIALS.

9. TF-CBT

TF-CBT is the most widely used and best-studied protocol that is based on CBT principles [8,9,11]. It is a "supported and effective" intervention and is based on the standards of evidence-based practice [56]. The protocol is designed for children with PTSD, comorbid depression, anxiety, and other trauma-related difficulties (shame, self-blame, etc.).

The TF-CBT model includes nine components that are described as follows by using the acronym, PRACTICE [8]:

(P) Psychoeducation regarding post-traumatic symptomatology: the education of a child/adolescent regarding the clinical manifestations of the disorder and the therapeutic options, as well as the formation of a therapeutic alliance.

Aid to (P) parental skills: on the basis of learning theories and behavioral techniques, parents are taught the utilization of effective parenting interventions, such as praise, positive attention, selective attention, time out, and contingency reinforcement procedures.

Teaching (R) relaxation skills: Children are taught how to use a range of relaxation techniques, such as focused breathing exercises, progressive muscle relaxation, and other personalized relaxation activities, to reverse the physiological manifestations of traumatic stress.

Enhancement of (A) affective modulation skills: children are taught emotional education skills, such as the identification of their feelings, the utilization of positive self-talk, thought interruption, and positive imagery. In addition, they learn problem-solving techniques, social skills, as well as, the recognition and self-regulation of their negative affective states.

The skills of cognitive coping (C) and processing and narration of the trauma (T): with the help of the therapist, children create a narrative of their traumatic experiences, repair cognitive distortions related to the traumatic nature of their experiences, and place those experiences within the context of their lives.

In vivo (I) control (mastery) over childhood trauma reminders: this is achieved with gradual exposure of the child to fearful stimuli.

Conduct of (C) combined child-parent sessions: these are joint sessions in which the child shares the narrative trauma with the parents; moreover, other family issues are addressed at the same time.

(E) Enhancement of the future safety and development of the child: with the help of the therapist, the child is able to deal with safety concerns associated with the prevention of future trauma, thereby returning to a normal developmental trajectory.

TF-CBT consists of 12–20 sessions, lasting 60–90 min each, and is suitable for children and adolescents aged 3 to 18 years [8]. It is delivered separately to children and their parents and is also provided in a group format. Gradual exposure is an important part of this intervention [13]. To address transportation barriers, various RCTs have evaluated the efficacy of TF-CBT in multiple settings (e.g., homes, foster homes, schools, and residential treatment facilities).

Studies on TF-CBT have included more than 900 youths, with over 16 randomized trials demonstrating clinically significant improvement. Follow-up studies have indicated profit sustainability for 6 months, 1 year, and 2 years after treatment. Therefore, TF-CBT is “supported and efficacious in PTSD, depressive and anxiety symptoms, conduct problems, sexualized behaviors, and shame, negative cognitions evoked by trauma, interpersonal trust, and social competence” [11,12,40,51,52,53,54,57,58,59].

TF-CBT has been evaluated in multiracial populations, such as American, Caucasian, African American, and Latino residents. Moreover, European, African, and Australian young people have demonstrated positive outcomes in multiple domains. To be more specific, TF-CBT was applied to English-speaking and Hispanic populations after the terrorist attacks of September 11, 2001, and was effective in reducing PTSD symptoms [55,60]. An adapted model in two studies has also revealed significant improvement in both PTSD and grief symptoms [5,53]. Moreover, parents have also reported a significant reduction in their distress and depressive symptomatology and significant gains in their ability to support and deal with their children’s behavioral difficulties [61].

10. CBITS

CBITS is the best-supported CBT protocol in a group intervention, especially for children with PTSD. CBITS is delivered in a group format (6 to 8 children per group), with 10-week sessions of 1 h each. CBITS has been delivered to adolescents from 5th to 12th grade, specifically to those who have witnessed or experienced traumatic life events, such as violence in the community and/or at schools. Moreover, it is suitable for individuals who have experienced or witnessed accidents and injuries, physical abuse, domestic violence, and natural or man-made disasters. It is usually provided inside the school environment but beyond the school schedule and includes all the elements of PRACTICE, except for the parent education component, which is limited and optional. However, a new component for teachers has been added to its design. This component educates teachers regarding the potential impact of trauma on students’ behavior and academic competence in the classroom. The trauma narrative component is mainly conducted during short one-to-one sessions in which children meet the group's primary caregiver.

CBITS was designed for trauma-impacted, recently immigrated students from Latino, Korean, Armenian, and Russian backgrounds; it was designed to be delivered in inner-city school mental health clinics. However, CBITS has been applied to a wide variety of populations in the US and worldwide. It was initially applied in two major studies in East Los Angeles in the US, primarily on Latino children exposed to violence in the community. Compared with waitlist control groups, more reduction in PTSD and depressive symptomatology was observed with CBITS intervention [42,43].

In the field trial by Jaycox et al. [44] that was conducted 15 months after Hurricane Katrina in Southern California, children with PTSD were randomly assigned to a group intervention at school (CBITS) or an individual intervention (TF-CBT). Both interventions resulted in reduced symptoms of post-traumatic stress; however, a larger percentage of children completed the whole intervention in the CBITS group [62].

11. Advantages and Disadvantages of TF-CBT and CBITS

The TF-CBT and CBITS interventions are flexible and easily adaptable to diverse populations. They are easy to learn in a short time and are specifically designed and evaluated in multicultural and multilingual populations. In addition, they can be applied to populations with different languages. Both interventions have been experimentally validated by RCTs that demonstrated their effectiveness in several traumatized youths.

CBITS is specially designed to be used by school-based clinicians with appropriate training and specifically focuses on the implementation of trauma services in school settings. Common obstacles in CBITS include transportation barriers, mental health stigma (which prevents someone from getting care), and the dependence on parents and families to seek and find proper care. CBITS is accessible to all eligible students, regardless of the parent's ability to be involved in the treatment.

These interventions, however, may not be appropriate or some parts of them may require modification in adolescents with externalized behavioral problems. In cases where trauma-induced behaviors interfere with therapeutic engagement, it would be more beneficial for the person to deal with the problematic behavior first and address his/her trauma afterward. In addition, in adolescents with active suicidal ideation or substance abuse, the part of the intervention focusing on trauma exposure could worsen the distress associated with these clinical conditions. In such cases, another intervention that does not prioritize trauma exposure but focuses on the practical management of the deviant behaviors would have advantages [13,63,64]. Finally, it is not clear whether the application of TF-CBT in the school environment ensures its accuracy because organizational (e.g., organizational culture and implementation climate) and individual factors of the providers (especially attitudes) can hinder its implementation and effectiveness [65,66,67,68].

12. Other Promising Treatment Practices and Protocols

This section describes protocols that have been used or are currently being evaluated to treat post-traumatic symptomatology but have not gained the evidence-based support of TF-CBT and CBITS. They are also designed to handle other crucial and essential components for achieving a positive therapeutic outcome; for example, new and promising practices for more comorbid situations, such as depression, externalizing behaviors, grief, and family social exclusion. Moreover, these practices are designed after considering particular cultural elements of the target population, such as grief symptoms in Latino immigrants. In some programs, trauma exposure, which is a necessary component for a positive outcome, is excluded. These promising protocols are presented in Table 2.

Table 2 PROMISING TREATMENT PRACTICES AND PROTOCOLS.

12.1 Support for Students Exposed to Trauma (SSET)

SSET is an adaptation of CBITS. It is provided by school staff without any clinical experience but with the support of a clinician in the situation of an urgent mental health issue. SSET is more like a "traditional" lesson plan, in which the individual and parental training sessions are eliminated. In this context, exposure to the imagination is applied in a more psychoeducational and academic structure and is formulated in a lesson plan format. In the study of Jaycox, Langley, Stein et al. [69], including 76 children with PTSD, the application of SSET resulted in the reduction of post-traumatic symptoms and concomitant depression. However, compared with CBITS, less improvement was observed. Furthermore, SSET intervention is mainly effective in young people with high levels of distressful symptoms before treatment sessions.

12.2 UCLA Trauma and Grief Component Therapy (TGCT)

UCLA TGCT was designed by the UCLA Trauma Psychiatry Service and was used in Armenia after the 1988 earthquake. Although it can be delivered in community mental health or other settings, UCLA TGCT has been primarily provided at schools. It mainly focuses on adolescents, with both individual and group sessions being available. It is used in addition to other empirically supported techniques and targets the alleviation of PTSD symptoms and traumatic grief. Therefore, youths restore their normal development course [70,71].

According to a study by Layne et al. [72], this intervention was beneficial in reducing PTSD, traumatic grief, and depressive symptoms in a sample of Bosnian adolescents. In addition, adolescents exposed to community violence and exhibiting PTSD symptoms also benefited from this intervention [103]. Moreover, it was effective in reducing PTSD symptoms in adolescents after a terrorist act [59,60].

In a study by Smith et al. in 2007 [43] including 24 young people (8–18 years) who experienced a single traumatic event, the intervention group exhibited a significant improvement in the symptoms of PTSD, depression, anxiety, and functionality compared with the wait list group; gains were maintained even after 6 months.

12.3 Surviving Cancer Competently Intervention Program (SCCIP)

SCCIP is an intervention model based on cognitive and family therapy. It is a 1-day program delivered through four sessions to a group of families. Compared with the waitlist group, the SCCIP group exhibited more relief in the symptoms of arousal and agitation in adolescent cancer survivors. The target groups are the survivors, siblings, and parents. Although the intervention provided favorable results in children, modifications in family functioning were more challenging [73].

12.4 Trauma Systems Therapy (TST)

TST is a systemic and CBT-influenced intervention inspired by Bronfenbrenner's social-ecological model [104]. It focuses on both post-traumatic stress symptoms and other comorbid symptoms of anxiety and depression [75]. In an open study, this intervention was applied to 110 children and adolescents aged 5–20 years [74]. The intervention focused on strengthening the ability of individuals to control uncomfortable emotions and deal with significant distress. Moreover, it promoted changes in the social context that perpetuates the symptoms. TST is an effective intervention for families who experience obstacles in completing a treatment, multiple injuries, and several issues related to the social environment of the families. Saxe et al. [74] demonstrated that participants exhibited significant improvements in PTSD symptoms. Moreover, family and school-related problems were relieved within a 3-month follow-up period.

12.5 Prolonged Exposure Therapy (PET)

PET teaches individuals to gradually approach trauma-related memories and emerged in a study by Foa et al. [76], which included 61 girls aged 13–18 years who had been sexually abused. Therapists were clinicians with no previous experience in behavioral therapy and who worked in community mental health clinics after receiving a short training in exposure therapy. The intervention included 14 individual sessions lasting 60 to 90 min and containing education on skills and in vivo exposure to the trauma. A significant improvement in PTSD symptoms was observed in the behavioral therapy group (n = 31) compared with the nonspecific counseling support group (n = 30, comparison group). Moreover, therapeutic gains were maintained during a 12-month follow-up. However, Foa's model has certain disadvantages. Some studies have indicated that exposure-based approaches can lead to higher dropout rates compared with nontrauma focused ones [105,106]. However, this finding was not confirmed in a subsequent meta-analysis regarding the RCTs of PTSD treatments, especially in children and adolescents [107].

12.6 Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

SPARCS is a 16-session group intervention. It is beneficial for chronically injured adolescents, aged 12–19 years, who live in or return to chaotic environments and exhibit post-traumatic symptoms and concomitant problems in various areas of functionality [77]. Weiner, Schneider, and Lyons [78] applied this intervention and observed a significant improvement in 33 adolescents who were of various origins, were aged 13–21 years, and experienced moderate to severe distinct traumatic experiences. The SPARCS methodology is mainly based on CBΤ techniques and also includes the components of dialectical behavioral therapy (e.g., mindfulness), Trauma Adaptive Recovery Group Education, and Therapy for Adolescents and Preadolescents (TARGET-A; e.g., emotion regulation and current PTSD symptom management skills), and TGCT (e.g., adaptive remembrance of the deceased and psychoeducation regarding grief). In contrast to trauma-focused interventions, direct exposure of the participant to the trauma is optional in SPARCS intervention and depends on the desire of the participant to discuss the traumatic experiences.

12.7 TARGET-Α

This intervention was specifically designed to address complex presentations of PTSD and also to focus on assisting juvenile delinquents involved in judicial procedures. It focuses on young people aged 12–19 years who have experienced interpersonal trauma (e.g., abuse), other chronic traumas (e.g., domestic violence and community violence), or other stressors [79]. Because of the manifestations of complex PTSD, the exclusive use of basic CBT skills in TARGET-A programs is not sufficient. Therefore, interventions from other psychotherapeutic backgrounds, such as emotion regulation and current PTSD symptom management skill acquisition, psychoeducation on trauma impact, training for nonprofessional helpers in implementation and reinforcement of the intervention, and substance abuse counseling and support, are also used. As in SPARCS intervention, the young person can choose to talk about previous traumatic events. Therefore, gradual exposure to traumatic ingredients is not a nuclear component of TARGET-A [80,81,108]. In addition, it is an approach designed for older children or adolescents who either refuse to narrate their trauma or their externalized behavioral problems hinder their commitment to therapy.

12.8 Combined CBT Approach for Children and Families at Risk of Physical Abuse (CPC-CBT)

CPC-CBT is implemented in families who are at risk of abuse or who have already been abused. Efficacy data for this intervention come from an RCT study [82] and a small open-label study [83].

It is specifically applied to young people with a history of harsh punishment and stressful parenting disciplinary techniques, leading to PTSD, depression, abuse-related negative beliefs, and externalized behavioral difficulties. CPC-CBT includes the elements of TF-CBT, mobilization interviews, recruitment of support services (e.g., facilitating the supervision & movement of children), and improvements in communication skills specifically aimed at preventing domestic violence. In this intervention, parents, and children participate in 16-week 2-hour sessions. Parental and child interventions are conducted concurrently for the first 75 min of the session by two therapists in each group. The rest of the 45 min comprise joint parent-child sessions.

12.9 Risk Reduction Through Family Therapy (RRFT)

RRFT is a CBT-oriented intervention consisting of 16–20 sessions (depending upon the intensity of symptoms) of 60–90 min each. The sessions are aimed at reducing risky behaviors and trauma-related symptoms in young people aged 13 to 18 years and who are victims of sexual assault or abuse. It comprises psychoeducation, problem-solving skills, family communication skills, substance abuse management, and PTSD symptom management. Moreover, it contains healthy sexual behavior lessons and techniques aimed at reducing the risk of re-victimization.

RRFT addresses a wide range of interrelated symptoms in a single intervention (i.e., symptoms and risk behaviors are not treated separately). Moreover, it addresses traditional barriers associated with this difficult-to-reach population. RRFT is tailored to individual adolescents’ and families’ requirements based on the family’s goals for treatment, needs, and strengths [84,85].

12.10 Intervention for Seeking Safety (SS)

SS is a CBT-oriented intervention designed for individuals and groups; it assists young individuals in coping with the comorbidity of PTSD and substance abuse [109]. Its methodology includes the modification of negative emotions, reduction of the risk of substance abuse, and correction of nonhelpful beliefs related to the trauma experience.

In a small pilot RCT by Najavits et al. [86], the intervention proved superior to the usual therapeutic interventions in a group of adolescent girls with PTSD and substance abuse.

12.11 Alternatives for Families—A Cognitive Behavioral Therapy (AF-CBT)

AF-CBT is an intervention with empirically substantiated data and has been designed to improve relationships between children and caregivers in families, whose relations are characterized by physical abuse or systematic conflicts. Some parents impose severe physical discipline or emotional neglect. Methodological adjustments have been implemented for children with comorbid externalized behavioral problems or developmental disabilities, especially in social communication. AF-CBT is based on the study by Kolko et al. [87,88,89,90,91], which is an RCT involving 55 people, mostly of American-African origin. The authors demonstrated a significant positive outcome in the target domains.

Since its introduction, AF-CBT has been delivered in English, Spanish, Japanese, and other languages. Therefore, the intervention has been appropriately applied to physically abusive parents and their school-age children. Moreover, it has been implemented both in community area services and mental health clinics. AF-CBT usually includes 20 sessions of 1–1.5 h each. The target population is young people aged 5–17 years from medium to low socio-economic status (SES) families. The intervention has not been designed for specific cultural groups. Its theoretical basis comprises learning/behavioral and cognitive theory, family systems, developmental victimology, and the psychology of aggression.

This intervention has several advantages. AF-CBT contains comprehensive material for children, parents, and families. It focuses on family conflicts, aggression, and the provision of alternative methods to set limits instead of overt physical punishment or child abuse. Moreover, it includes a structured session guide with handouts to facilitate implementation. Finally, the material can be adapted by clinicians to the requirements of the clients on the basis of their frequent decisions on what content to emphasize. However, this approach has certain disadvantages also. The treatment can sometimes be lengthy. Moreover, because of the difficult living conditions of treated families, it is sometimes complex to accommodate them and embrace their commitment to the treatment [89,91].

12.12 Bounce Back: An Elementary School Intervention for Childhood Trauma (BB)

BB is a group-based CBT-oriented intervention that educates elementary school children to cope with their traumatic experiences and to recover from them. It is often applied to children who have experienced or witnessed violence in the community, family, or school environment. Furthermore, children who have experienced natural disasters or traumatic separation from a loved one due to death, imprisonment, deportation, or placement in a childcare facility are referred to receive this intervention.

The intervention includes 10 group sessions where children learn and practice emotion modification, relaxation, helpful thinking, problem-solving, conflict resolution, positive activities, and social support. It also includes 2–3 individual sessions in which children recall their traumatic memory and the accompanying grief and share it with a parent/caregiver. Subsequently, children practice the skills acquired from these sessions. Moreover, BB contains materials for parent training sessions [93].

BB is developed by adapting CBITS for elementary school students and contains many of the same therapeutic elements. However, it is designed with additional elements and engaging activities, such as emotion recognition, behavioral activation, and social support. It also requires more parental involvement that is developmentally appropriate for children aged 5–11 years. It is designed to be applied in schools and to children from a variety of national and socioeconomic backgrounds and cultural levels. In the study by Langley et al. [92], BB was applied to 77 primary school children of various origins, with the intervention lasting 3 months. The outcome was positive for post-traumatic symptoms, comorbid depression, and anxiety in both groups (immediate intervention and delayed intervention).

The program is advantageous because its implementation at schools enables clinicians to reach underserved students who are not otherwise fortunate to receive mental health care. It reduces the barriers to health-care access, such as transportation. Moreover, BB is typically delivered at no cost to families. However, BB has some limitations, such as not all students are permitted by their parents to participate in screening or intervention groups at schools. Furthermore, some participants may require to receive further treatment beyond this early intervention group treatment. Therefore, clinicians who deliver BB need to link it with other mental health services and make appropriate referrals after the end of the BB process or in parallel.

12.13 Child and Family Traumatic Stress Intervention (CFTSI)

CFTSI is a brief intervention, consisting of 5 to 8 sessions. It is an empirically supported treatment for children aged 7 to 18 years and is designed to reduce the escalation of traumatic stress and PTSD occurrences. It has been successfully applied and evaluated in populations with varying ethnic and racial backgrounds. CFTSI is delivered within 30–45 days after traumatic events, such as physical or sexual abuse, domestic or community violence, rape, assault, and traffic accidents. The goal of CFTSI is to increase communication and family support. CFTSI highlights the importance of family support as a primary protective factor for children with trauma exposure [94,95,97,110,111,112].

12.14 Dialectical Behavior Therapy (DBT)

DBT is a complex and comprehensive intervention originally developed for chronically suicidal adults. After the developmentally appropriate adaptations since the publication of the original treatment manual, DBT now also targets adolescents with a history of trauma; moreover, it has already been implemented in individuals living in shelters or in hospital settings [113]. The DBT approach is based on the principles of CBT and focuses on two main aspects, problem-solving techniques (in conjunction with strategies based on acceptance of the individual) and other dialectical processes. The dialectic addresses issues related to the equilibrium between interventions of change versus interventions of acceptance of the individual. The DBT intervention consists of the following five components: (1) skills training; (2) a behavioral therapy plan; (3) the availability of therapists outside of clinical settings, including working at home with the adolescent and his family; (4) organization of the individual’s daily life by selectively enhancing mastery and providing pleasure through creative and enjoyable activities; and (5) inclusion of consulting team to the intervention therapist group. DBT highlights the balance between behavioral change, problem-solving, and emotional modification, with the validation of youth’s requirements, mindfulness techniques, and acceptance [98,114,115,116,117].

12.15 Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC)

MATCH-ADTC is an evidence-supported intervention based on CBT and designed for children aged 6 to 15 years. Unlike most treatment approaches that focus on a single diagnosis, this intervention overcomes barriers to therapists' use of empirically supported interventions through its transdiagnostic modular design.

The intervention is designed for multiple disorders and maladaptive states, including anxiety, depression, and post-traumatic stress, as well as for conduct problems. MATCH-ADTC was developed by Chorpita and Weisz [118] and assembles years of empirical studies on evidence-based treatments. Recent data [99,100,101,102,118,119] indicates that children treated with MATCH-ADTC exhibited significantly faster rates of improvement over time than did children in the usual community care. The outcomes regarding internalizing and total problems and the severity ratings on major problems were reported by children and parents. Compared with children in standard community care, children treated with this intervention spent less time in treatment, were less likely to require additional treatment services, and were less likely to be prescribed psychotropic medication.

13. Conclusions, Dilemmas, and Future Challenges

Effective and empirically supported intervention protocols for PTSD are available, with most of them, including CBT approaches [3,120,121]. CBT and psychoeducation can provide the necessary support for the child, youth, and family when post-traumatic stress and avoidance discourage trauma exploration. Most of the CBT treatments result in improvements in common concomitant difficulties, with the therapeutic gains maintained over time. These therapies have many modules in common with the well-established TF-CBT and CBITS interventions (e.g., psychoeducation, gradual exposure, and problem-solving skills). However, they also present innovative strategies to address the barriers to a positive therapeutic outcome.

In the last three decades, a rapid increase in knowledge regarding the development and management of PTSD in children and adolescents has been noted. However, many key issues remain unaddressed. Nevertheless, children with post-traumatic stress are increasingly being recognized, assessed, and treated.

The main benefits of the intervention programs included in the current review are summarized in the subsequent sentences: 1. They all comprise strategies and skills that are transdiagnostic; therefore, they are effective in treating not only PTSD but also various other coexisting diagnoses, such as depression, grief, and externalized behaviors. For example, exposure to feared stimuli is beneficial not only for treating post-traumatic symptoms but also for treating other comorbid anxiety disorders. Problem-solving techniques are essential not only in youth with post-traumatic symptoms but also in youths with internalizing disorders. 2. These intervention approaches can be provided not only by mental health professionals but also by other specialties (e.g., teachers). This possibility widens the perspective for dissemination in school settings in a cost-effective way. 3. The group interventions provide a protective environment in which children can practice a plethora of techniques. However, it is challenging to adapt these programs to the individual requirements of each child.

Whether these programs are practicable in various community settings (e.g., the school environment) remains controversial. Moreover, whether their efficacy is ensured when administered by different program leaders, for example, trained teachers and volunteers who are not mental health professionals, remains uncertain [122]. In some cases, the assessment of the intervention studies is not based on data from multiple sources (children, parents, and teachers), and in most cases, researchers do not use diagnostic interviews, which would increase the reliability of the outcome measures [123]. Finally, these group approaches may not be the most efficacious techniques for reducing post-traumatic stress in those children who have already experienced noteworthy symptoms or in those who exhibit complex presentations of PTSD due to multiple, repeated, and prolonged trauma. The TF-CBT and CBITS methods have been criticized for the management of children with multiple traumas. In such cases, it is recommended that the child be the one to choose, with the help of the clinician, which trauma will be the focus of treatment. Although a clinician may perceive a trauma as the largest significance for the child, the child may associate greater impact with another trauma [96,124].

The prevention programs have received much criticism from several researchers who argue that without demonstrating consistent efficacy across different types of traumas, study designs, and target populations, these programs cost money that could be invested in other forms of therapy. In addition, the detection process could create moral issues, as people deemed healthy may be false negatives because of inadequate screening procedures [125].

However, prevention programs have, gradually and internationally, established their presence in the treatment options of the specialist. Therefore, research is emerging, and the outlook is positive for the upcoming years. The necessity for early, selective, intensive, persistent, multifaceted, and participatory interventions is imperative.

Future challenges in the research and development of intervention programs include the following:

  1. An in-depth understanding of risk factors for the escalation of post-traumatic stress symptoms would benefit from prospective studies that may assist in the development of more targeted and selective prevention programs.

  2. Development of effective interventions for PTSD for particular populations, such as refugees and people with coexisting chronic diseases.

  3. The sustainability of treatment benefits over time should be explored. Sandler [126] suggested prevention programs should be judged on the basis of their long-term effects, instead of their immediate effects.

  4. The importance of including booster sessions and sessions with parents or primary caregivers should also be further highlighted. To achieve this, strategies must first be implemented to maximize parental participation.

  5. In many cases, evidence-based treatments were more effective in mental health settings, compared with school settings. This is because the mediation of both organizational and individual factors affects the program delivery by the school-trained clinician. Specifically, mental health interventions in school settings must fulfill the requirements of the school, e.g., the inclusion of teacher involvement, peer or group interventions, coordination between learning and mental health specialists, and coordination between school discipline and therapeutic interventions. Therefore, strategies that could enhance the training of mental health clinicians at schools should be explored to change the clinician’s perceptions, increase their sense of self-efficacy, and increase their motivation to faithfully apply protocols that have been proven effective, such as TF CBT and CBITS [66].

  6. The efficacy of these intervention programs in youth with high levels of post-traumatic stress symptoms must be further investigated.

  7. Further studies on the special elements that mostly “work” in prevention programs are required. Moreover, their importance in empowering young health professionals who are trained in these interventions should be highlighted.

  8. New CBT practices should be embraced to support trauma-impacted youths who might refuse to narrate their distressing experience thoroughly. Such practices should focus on affect dysregulation, education on the developmental impact of trauma, and cognitive restructuring regarding beliefs about oneself as diminished or worthless in relation to the traumatic events, as implemented in SPARCS and TARGET-A interventions. [127].

  9. Dissemination of the latest methods of these programs by using technology (telehealth programs).

  10. Additional research is required to improve current methodological issues associated with design, analysis, and descriptions of participation and dropout rates. Furthermore, whether researcher bias is factored into the outcome should be determined.

  11. These programs must be re-evaluated to include qualitative analyses supplementing the quantitative results. For this, the appraisal of the perspectives of children, parents, and educators must be performed.

Abbreviations

ASD

Acute Stress Disorder

APA

American Psychiatric Association

CBITS

Cognitive Behavioral Interventions for Trauma in Schools

CBT

Cognitive Behavioral Therapy

DSM-5

Diagnostic and Statistical Manual of Mental Disorders-5th Edition

NHS

National Health Service

NICE

National Institute for Health and Care Excellence

PTSD

Post-Traumatic Stress Disorder

RCT

Randomized Controlled Trial

TF-CBT

Trauma-Focused Cognitive Behavior Therapy

Author Contributions

Syros Ioannis conceived the original idea, wrote the manuscript and supervised the project. Karantzali Aggeliki and Anastassiou-Hadjicharalambous Xenia provided critical feedback and helped shape the manuscript.

Competing Interests

The authors have declared that no competing interests exist.

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