2022 Children’s Mental Health Report

Treating Symptoms
of Trauma in Children
and Teenagers
 Table of Contents

The Child Mind Institute is dedicated to transforming the lives of children and
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the help they need to thrive. We’ve become the leading independent nonprofit
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INTRODUCTION

2 Treating Symptoms of Trauma

in Children and Teenagers
AUTHOR ONE

Hannah Sheldon-Dean, Child Mind Institute 4 What Is Trauma?

CONTRIBUTORS TWO

Rae Jacobson, Child Mind Institute

9 Treating Trauma in
Caroline Miller, Child Mind Institute Children and Adolescents
Sophia Van Iderstine, Child Mind Institute
THREE

SPONSORING PARTNER
�9 What Does It Mean to Be
Trauma-Informed?
The Child Mind Institute and Blue Shield of California are collaborating to share
the latest research on youth mental health as part of Blue Shield of California’s CONCLUSION
BlueSky initiative. Blue Shield of California is an independent member of the
Blue Shield Association. 22 Looking Ahead

CHILD MIND INSTITUTE STAFF REVIEWERS

Michael Milham, MD, PhD, Vice President of Research

Jamie Howard, PhD, Director, Trauma and Resilience Service

DESIGN

John Stislow, Stislow Design

Abby Brewster, Child Mind Institute

RECOMMENDED CITATION

Sheldon-Dean, H. (2022). 2022 Children’s mental health report:

Treating symptoms of trauma in children and teenagers. Child Mind Institute.

1
Introduction

Treating Symptoms of Trauma

in Children and Teenagers

Psychological trauma is a frequent topic of discussion these days, and for

good reason. From the ongoing devastations of the COVID-19 pandemic to
the harrowing realities of school shootings and war in Ukraine, the news
and even our own lives are filled with potentially traumatic experiences.

But what exactly is trauma, and how does it affect children and teenagers
in particular? And what can we do to lessen the impact of trauma on their
mental health? In the 2022 Children’s Mental Health Report, we seek to
answer those questions and review the evidence base for treatments aimed
at mitigating the impacts of trauma in young people.

Traumatic experiences can upend kids’ lives, but trauma doesn’t have to
be a life sentence. By increasing awareness of the effects of trauma and
the most promising ways to treat it, we can foster young people’s innate
resilience and get them — and their families and communities — the
support they need to thrive.

2 2022 CHILDREN’S MENTAL HEALTH REPORT 3

Chapter One Research indicates that
between 14% and 43%
of kids will go through at
Reactions to trauma can also depend in large part on the
least one traumatic event. child’s age and developmental stage. For instance, young
children may not be able to describe their feelings but will
simply avoid concrete reminders of the traumatic event,

What Is Trauma?
Kids with PTSD show a range of behavioral and emotional while older ones may experience more abstract fears
changes after going through a traumatic event, from about what happened. And very young children (ages zero
flashbacks and nightmares to fear, anger, or detachment. to five) who experience intense trauma may develop a set
As defined by the DSM-5, PTSD includes symptoms from of symptoms called reactive attachment disorder (RAD),
the following three categories: which is characterized by struggling to form supportive
bonds with caregivers.5 This kind of trauma response
Traumatic experiences are common and can have profound impacts on kids’ lives, but • Frequently thinking about, dreaming about,
looks different from the symptoms of PTSD that children
or acting out the traumatic event
it’s not always clear exactly what trauma is. This chapter will examine contemporary who experience trauma at a later age might develop.
• Feeling numb, having trouble focusing,
definitions of psychological trauma and how they apply to children and teenagers. and struggling to connect with other people In the United States, professional and governmental
guidance on trauma generally follows the criteria laid out
• Getting annoyed easily, acting constantly fearful
in the DSM-5, in particular its focus on a specific extreme
or hypervigilant, or having trouble sleeping
An experience and a response The DSM-5 is the manual used by psychiatrists and event as the cause. For example, the Centers for Disease
other mental health professionals to diagnose psychiatric Control notes that “traumatic events are marked by a
One of the challenges of discussing trauma is that the disorders, and it includes a detailed breakdown of the PTSD symptoms can begin right after an extremely sense of horror, helplessness, serious injury, or the
same term is often used to describe both an individual’s symptoms of post-traumatic stress disorder (PTSD) and upsetting event, or they can start months or even years threat of serious injury or death.”6
experience and their emotional and behavioral response other stressor-related disorders. later. To be diagnosed as PTSD, the symptoms must
to that experience. As trauma expert Bessel van der Kolk continue for at least a few months after the event, since it’s
PTSD was first introduced as a diagnosis to describe
puts it: “Trauma is not just an event that took place normal to be upset immediately after a very frightening
the symptoms of Vietnam War veterans, and it is still
sometime in the past; it is also the imprint left by that or life-threatening experience.
common among military veterans who have been
experience on mind, brain, and body.”1
through combat.3 But today, PTSD is also recognized
In this report, we’ll primarily use the term trauma to as a response to a wide range of disturbing and/or
describe the set of symptoms that a person might life-threatening events, including interpersonal or sexual
develop after going through a very frightening or violence, abuse, war, natural disasters, and serious
upsetting experience. For the experience itself, we’ll accidents. People who develop PTSD may have experi-
use the term traumatic event—although, as we’ll see, enced these events themselves or witnessed or heard
the experience may not always be one distinct event. about them happening to someone close to them.

PTSD occurs throughout the general population, including

Post-traumatic stress disorder in children. The U.S. Department of Veterans Affairs
and the DSM-5 notes that about 15% to 43% of girls and 14% to 43% of
boys go through at least one traumatic event, and “of
The most prevalent definition of trauma today comes those children and teens who have had a trauma, 3%
from the Diagnostic and Statistical Manual of Mental to 15% of girls and 1% to 6% of boys develop PTSD.”4
Disorders, Fifth Edition, commonly called the DSM-5.2

Trauma is not just an event that took place

sometime in the past; it is also the imprint left
by that experience on mind, brain, and body.”
The Body Keeps the Score, Bessel van der Kolk

4 2022 CHILDREN’S MENTAL HEALTH REPORT 5

 There is also an increasingly popular
understanding of trauma that takes into account
chronic, ongoing negative experiences as
opposed to single, extreme events. This kind of
trauma is often known as “complex trauma.”

Complex trauma is closely tied to the idea of Adverse Experts often note that children who have experienced
Childhood Experiences (ACEs), which are defined as complex trauma may meet the criteria for a range of
potentially traumatic experiences during childhood.12 different DSM-5 disorders, including PTSD, oppositional
The CDC reports that ACEs are fairly common in the defiant disorder (ODD), and reactive attachment disorder
U.S., with 61% of adults reporting that they experienced (RAD), but that there is no one diagnosis that captures
at least one ACE during childhood and 16% reporting their typical symptom profile.
four or more kinds of ACEs.13
The evidence base for these definitions of complex
There is no single definition of complex trauma, but trauma is growing, with research indicating that children
there is some broad agreement among experts about who have been through trauma that is ongoing and
the kinds of events and symptoms associated with it. interpersonal in nature tend to have more intense
symptoms and behavioral challenges than those who
The events underlying complex trauma are usually
have experienced other forms of trauma.16
characterized as:
Researchers are also learning more about the complica-
• Severe and chronic, such as abuse and neglect
tions of preventing, identifying, and treating complex
• Taking place over an extended period of time trauma. It can be challenging to treat because, unlike the
• Affecting a child’s ability to relate to others kind of traumatic event that is typical of PTSD, chronic
There is a broad and growing evidence base that illumi- Complex trauma and build trusting relationships with caregivers traumatic experiences (like abuse at home, poverty, or
nates the negative impacts that traumatic experiences
Beyond the DSM-5 definition, there is also an increas- and other authority figures14 stress due to experiencing racism) may be ongoing even
can have on children’s development and well-being.
Experiencing trauma as a child is linked to a heightened ingly popular understanding of trauma that takes into as the child is getting treatment.17 And though the
risk for developing mental health disorders (such as account chronic, ongoing negative experiences as evidence isn’t conclusive, complex trauma may affect
And the distinct set of symptoms that comes with
anxiety and depression) later in life.7 Research also opposed to single, extreme events. This kind of trauma is children of color more often than their white peers.18
complex trauma generally looks like the following:
indicates that childhood trauma is associated with often known as “complex trauma.” The concept of complex trauma reminds us that
impairments in cognitive functioning.8 There is even a • Challenges with attachment and relationships
After the introduction of the PTSD diagnosis, clinicians traumatic experiences and kids’ reactions to them
growing area of inquiry into how the impacts of trauma working with people who had experienced ongoing • Difficulty regulating emotions and behavior are closely linked to their communities and social
may be passed down across generations, perhaps traumatic events (such as survivors of child abuse) • Changes in attention span and contexts. Though this report focuses on understanding
through behavior patterns or changes to the genetic noticed that individuals’ reactions to such events were other cognitive abilities and treating trauma at an individual level, reducing
expression of those who experience it.9 often more varied than those listed in the DSM criteria the prevalence of childhood trauma in the long run will
• Dissociation from reality
The effects of going through a traumatic experience for PTSD.10 This distinct set of symptoms became known also require a large-scale commitment to improving
• Low self-esteem
can be profound. However, some researchers contend as “complex PTSD” (CPTSD) and later evolved into a the conditions (like poverty and discrimination) that
• Overall negative outlook on the world15 contribute to it.
that the DSM-5 definitions of trauma and PTSD don’t proposed diagnosis termed “developmental trauma
capture the whole picture of the way that many people disorder” (DTD).
— especially children — experience traumatic events The ideas of complex trauma and DTD have been
and their impacts. developed in large part through the work of the clinician
and author Bessel van der Kolk.11 DTD is not included in
the DSM-5 as a distinct diagnosis, but some of the PTSD
symptoms listed there were influenced by the research
of van der Kolk and his colleagues.

6 2022 CHILDREN’S MENTAL HEALTH REPORT 7

 Chapter Two IN THIS CHAPTER

Trauma-focused treatments
developed for children

Treatments originally
developed for adults

School-based group interventions

Group treatments for adolescents

Medication for trauma symptoms

Treating Trauma
in Children
and Adolescents
Despite the ongoing challenges of defining trauma and its impacts, there is
a substantial and growing body of evidence underlying clinical treatments
for kids who have experienced trauma.

As far back as 2010, the American Academy of Child Trauma-focused treatments

and Adolescent Psychiatry noted that psychotherapies
developed for children
specifically focused on children’s traumatic experiences
tended to show stronger outcomes than more general A number of the foremost treatments for trauma
forms of therapy.19 The evidence continues to bear out symptoms in kids were developed specifically for this
that trend, with a number of trauma-focused treatments population, rather than being adapted from treatment
becoming more prevalent and better understood.20 for adults. They frequently involve parents, caregivers,
and other family members participating in treatment
Overall, the treatments with the strongest evidence
alongside kids, and many are variations on CBT.
bases to date are trauma-focused treatments based
on cognitive behavioral therapy (CBT). The available
TRAUMA-FOCUSED COGNITIVE BEHAVIORAL
research shows that variations on CBT consistently help
THERAPY (TF-CBT)
reduce children’s trauma symptoms, often more quickly
or more thoroughly than other psychotherapies.21, 22
The leading trauma treatment for kids
There are also additional treatments with promising
evidence in their favor. Highly structured, with sessions involving both
children and caregivers
In this chapter, we look at some of the leading treatments
The available research shows that variations for symptoms of trauma in children and adolescents: Combines the core skills of cognitive behavioral
how they work, what the evidence for them is, and how therapy with exposure therapy via the trauma
on CBT consistently help reduce children’s they can help kids and families. narrative technique

trauma symptoms, often more quickly or more

thoroughly than other psychotherapies.

8 2022 CHILDREN’S MENTAL HEALTH REPORT 9

Trauma-focused cognitive behavioral therapy (TF-CBT) is educating children and caregivers about the impacts of THE ATTACHMENT, SELFggREGULATION, In part because it doesn’t take the form of one speci0c
broadly recognized as the first-line treatment for children trauma and helping them develop effective coping and AND COMPETENCY fiARCfl MODEL intervention, research on the ARC framework is less
and adolescents dealing with the effects of trauma. It relaxation skills. TF-CBT also includes practice in the robust than for some other trauma treatments. However,
has been studied in more depth than any other trauma- basic skills of cognitive behavioral therapy: distinguish- A 2exible intervention framework rather than a single preliminary data indicates that it is likely an effective
focused treatment for kids, and its effectiveness in reducing ing between thoughts, feelings, and actions, and learning structured treatment model for treating PTSD and related challenges in
symptoms of trauma and improving kids’ day-to-day how to manage the interactions between them. Later in Designed for children and families dealing with children and adolescents. One study of ARC-based
functioning has been validated in numerous randomized the treatment process, children create what’s known as complex trauma treatment in residential treatment programs found that
controlled trials.23 Recent meta-analyses have confirmed a trauma narrative (see sidebar for more), which is an participants saw reductions in PTSD symptoms and
that there is stronger evidence for TF-CBT’s effectiveness account of their traumatic experience that helps them Focuses on building skills and relationships across behavior issues,37 and another found that ARC treatment
than for that of any other trauma-focused intervention make meaning out of their experience and practice three main areas: attachment, self-regulation, decreased kids’ symptoms and caregiver stress in
for children and teenagers.24, 25 managing the upsetting emotions that memories of it and competency families of adoptive children who had experienced
bring up.29 complex trauma.38 There is also evidence that ARC can
There is also evidence that it is effective when applied in
Unlike many treatments for trauma, the attachment, be successfully applied to support culturally diverse
many different settings, including schools and residential Research indicates that TF-CBT is likely effective in
self-regulation, and competency A ( RC) model is not a groups of preschool- and school-aged children. 39
treatment centers, and for young people with a wide range reducing depression symptoms as well as PTSD
of racial and ethnic identities.26, 27 TF-CBT is often used symptoms30 and that it may even help kids develop speci0c set of steps. Rather, it is an intervention frame
-
as an individual treatment but can also be used in a stronger executive functioning skills.31 Although it is work for approaching both individual clinical treatment
and organization-level trauma-informed care. It is CHILDggPARENT PSYCHOTHERAPY fiCPPfl
group format.28 usually used with school-aged children and adolescents,
there is some evidence that, with modifications, TF-CBT designed for children and families who are coping with
TF-CBT takes place over the course of 12–16 weeks and For children ages zero to six
can help preschool-aged children with post-traumatic complex trauma.35
involves both the child and, when possible, one of their
stress as well.32 Child and caregiver both participate in treatment
caregivers. It is highly structured, with sessions falling ARC focuses on building coping skills, helping children
into distinct treatment phases. Early phases focus on handle emotions related to their trauma, and strengthening Focuses on the bond between child and caregiver
the children’s caregiving systems and other supports.
ARC is designed to be 2exibly applied across a wide range
Child-parent psychotherapy C ( PP) is unique in that it
of populations and service settings. The three p “ rimary
was speci0cally developed for use with children between
domains of intervention” in the ARC framework are:
the ages of zero and six. It focuses on strengthening the
The Trauma Narrative33 Attachment: Fostering strong connections
relationship between child and caregiver and is often
used with children who have been exposed to violence
One of the hallmarks of TF-CBT is the trauma narrative. This is a between kids and their caregivers and creating and with parents who have themselves experienced
form of therapeutic exposure in which the child, with a clinician’s a safe, supportive environment in which the family trauma. In CPP, the child and the caregiver participate in
guidance, develops a gradually more detailed account of their can recover from trauma. treatment together and the clinician adapts various
traumatic experience and the thoughts and feelings they experi- Self-regulation: Helping kids learn to identify, treatment components to the family’s speci0c needs. 40

enced during and after it. The narrative often takes the form of a express, and manage their emotions. As in other forms of trauma treatment that involve
story or book that the child creates gradually during treatment. caregivers, the parent participating in treatment must be
The trauma narrative is developed after the child has already Competency: Supporting kids’ self-esteem and
what’s called a n
“ onoffending caregiver” — that is, not
learned about the impacts of trauma, formed a trusting bond with sense of competence, as well as key developmental
someone who is the source of the child’s trauma or a
the clinician, and worked on coping skills to manage the painful tasks like executive functions and social skills.
36
perpetrator of abuse or neglect against them. It tends to
emotions that can emerge during the process. be implemented over a longer period of time than many
other types of treatment, sometimes up to a full year.
A primary goal of the trauma narrative, as outlined in the treatment
manual for TF-CBT, is “to unlink thoughts, reminders, or discussions
of the traumatic event from overwhelming negative emotions such as
terror, horror, extreme helplessness, avoidance, anger, anxiety, shame, or rage.”34 Through processing increasingly
in-depth memories of the event with a clinician’s support, the child gradually becomes able to encounter thoughts
or reminders of the trauma without being overwhelmed by those negative emotions.

10 2022 CHILDREN’S MENTAL HEALTH REPORT 11

 Several of the trauma treatments gaining
popularity for use in kids were originally
developed for use with adults with PTSD. Treatments originally So far, there have been eight randomized controlled
These treatments generally have strong developed for adults trials of EMDR as a treatment for children with trauma
symptoms. A recent systematic review of this evidence
evidence bases for use with adults, but less Several of the trauma treatments gaining popularity notes that, overall, EMDR does seem to reduce trauma
for use in kids were originally developed for use with symptoms in kids, though further research into its
evidence of effectiveness with kids. adults with PTSD. These treatments generally have efficacy is still needed.49 The same review finds that
strong evidence bases for use with adults, but less EMDR tends to require fewer sessions than comparable
evidence of effectiveness with kids. They are more often treatments, and it also seems to reduce symptoms of
used with teenagers than with younger children. depression and anxiety.

Research directly comparing EMDR with other trauma

treatments is minimal so far. The authors of one meta-
A number of studies have found that CPP can improve CFTSI is designed to be used in a variety of settings as EYE MOVEMENT DESENSITIZATION AND
analysis of various treatments conclude that the overall
outcomes for both children and caregivers, and much of an immediate way to prevent negative outcomes for kids REPROCESSING (EMDR)
evidence indicates that CBT is a more promising trauma
the available data includes participants from ethnically who have gone through something traumatic, and it can
treatment for kids and that more research into EMDR is
diverse groups. One randomized controlled trial of also be an intermediate step before the family moves on Short-term intervention designed to help
needed.50 A more recent meta-analysis of studies looking
preschool-aged children who had experienced multiple to longer-term treatment. It was originally developed for participants process memories of trauma
at the efficacy of EMDR and TF-CBT finds that TF-CBT
traumatic events found that CPP led to improvements in children aged seven or older, but it has also been Caregivers do not need to participate in treatment may be slightly more effective than EMDR.51 The authors
PTSD symptoms in both the children and their mothers.41 adapted for use with younger children.44
posit that the added effectiveness of TF-CBT over EMDR
CPP may even be helpful for fostering strong attachment Extensive evidence of efficacy in adults, with growing
Several studies indicate that CFTSI is effective at may be due to TF-CBT’s relatively flexible model and
between parents and very young infants under stress. evidence for use with kids
reducing symptoms of traumatic stress and preventing emphasis on including caregivers in treatment, but more
One small study found that using elements of CPP with
the development of PTSD. A randomized pilot study research is needed to understand the difference.
parents whose infants were hospitalized in neonatal EMDR is based on the idea that memories of traumatic
found that children who participated in CFTSI had
intensive care units seemed to help parents learn coping events are sometimes stored in the brain as isolated Despite the need for more evidence, EMDR is growing
reduced symptoms of anxiety and PTSD and were
strategies, reduce stress, and bond with their infants.42 incidents that disrupt the brain’s information processing more prevalent in trauma treatment for a number of
significantly less likely to meet the criteria for a PTSD
systems. The treatment is designed to help individuals reasons. Unlike many treatments for trauma in children,
diagnosis three months later.45 A later review of children
integrate memories of traumatic events into their EMDR does not involve homework or detailed descrip-
and caregivers treated with CFTSI after the child’s
CHILD AND FAMILY TRAUMATIC broader memory systems and process the negative tions of the traumatic event. It can be completed rela-
disclosure of sexual abuse found similar results,
STRESS INTERVENTION emotions, sensations, and beliefs associated with them. tively quickly, which makes it especially valuable as a
with both children and caregivers showing decreased
crisis intervention. It doesn’t require parental involve-
trauma symptoms.46 The therapy itself involves stimulating the individual’s
Short-term treatment used in a variety of settings ment, which can make it a good option in cases where
The same study found that while children and caregivers brain through eye movements, physical taps, or sounds, parents are unable to participate or an older child
Used right after a traumatic event to prevent complex which are thought to help the brain connect the isolated
often gave very different reports of the child’s symptoms prefers a more independent treatment.
trauma symptoms from developing memory of the trauma with broader, more adaptive
before the intervention, they tended to agree much
Prioritizes strengthening family communication and more afterward, which indicates that CFTSI seems to neural networks.48 With children, EMDR generally takes
building coping skills succeed in its goal of helping families communicate place over eight sessions. The therapist guides the child
more effectively and be more attuned to kids’ emotions through discussing the feelings and physical sensations
and needs. A large meta-analysis also found that associated with their trauma while simultaneously
The child and family traumatic stress intervention
caregivers who participated in CFTSI showed significant guiding their eye movements, often by asking the child to
(CFTSI) is a short-term treatment designed to prevent
reductions in their own traumatic stress, which likely follow the movement of their hands.
the development of complex trauma symptoms. It is
implemented soon after a child experiences a traumatic has the secondary effect of making them more able to
event or discloses physical or sexual abuse. It focuses on support their children.47
helping kids and caregivers communicate effectively
with each other so that the family can better support the
child. It also involves both children and caregivers
building coping skills that they can use to understand
and manage their reactions to the trauma.43

12 2022 CHILDREN’S MENTAL HEALTH REPORT 13

PROLONGED EXPOSURE THERAPY There isn’t yet much evidence to support the use of PE School-based group interventions Research on the effectiveness of CBITS is still somewhat
with younger children. Nonetheless, the evidence so far limited, but there are a number of studies indicating that
Reduces trauma symptoms by gradually exposing kids is promising, especially in that PE appears to work well In addition to broader initiatives for trauma-informed it can help kids recover from trauma. The first random-
to memories and situations that cause anxiety in a variety of service settings and can be delivered school communities, there are also treatments for kids ized controlled trial evaluating CBITS found that stu-
effectively by practitioners without extensive experience. dealing with trauma that are specifically designed to be dents who had been exposed to violence and participat-
Also involves building coping skills to handle chal-
delivered in schools. These interventions are usually in a ed in CBITS saw significant reductions in symptoms of
lenging feelings
group format and meet during the regular school day, PTSD and depression, and that those gains persisted six
Strong evidence of efficacy with adults, with some COGNITIVE PROCESSING THERAPY which means that they may be especially helpful for months later.64 Another randomized controlled trial of a
studies showing efficacy with kids children and teenagers who lack access to reliable, diverse group of middle school students found similar
Highly structured treatment based on correcting affordable mental health care. reductions in emotional and behavioral challenges, as
inaccurate beliefs well as evidence that these symptom reductions may be
Prolonged exposure therapy (PE) is a treatment that
gradually exposes participants to situations that cause Can include elements of exposure therapy connected to improved academic outcomes.65 Additional
COGNITIVE-BEHAVIORAL INTERVENTION FOR research has found evidence that CBITS remains
them anxiety. The idea is that by experiencing challenging
More evidence for use with adults than with kids TRAUMA IN SCHOOLS (CBITS) similarly effective when scaled up and implemented
emotions in a safe, supportive setting and processing
those feelings with a therapist, people with PTSD can across multiple schools66 and that the model can be
A leading school-based trauma intervention adapted for kids from ethnically diverse communities
confront their trauma-related fears rather than avoiding Cognitive processing therapy (CPT) is a highly structured
them. Over time, their fears and PTSD symptoms lessen. PTSD treatment that focuses on identifying and working Group treatment format around the country.67
Exposure in PE involves both recounting memories of the through inaccurate or dysfunctional beliefs about In addition to CBITS, promising school-based trauma
Focuses on skills drawn from cognitive
traumatic experience and dealing with real-world the traumatic event. It can include a written exposure interventions include Trauma Treatment Groups for
behavioral therapy
anxiety-provoking experiences. Participants also learn component in which participants recount their Students (which was developed by the Child Mind
about common trauma reactions and build coping skills traumatic experiences with a therapist’s support, and Institute), RAP Club,68 Bounce Back for elementary
to handle future challenges.52 it also includes education about PTSD and common One of the foremost school-based group interventions
school students,69 and Support for Students Exposed to
trauma responses.59 for kids who have experienced trauma is called CBITS
There are clinical guidelines for using PE with adoles- Trauma (SSET) for middle school students.70
(cognitive-behavioral intervention for trauma in schools).
cents specifically,53 but most of the research on this CPT is a well-established treatment for PTSD in adults
CBITS is used with middle and high school students who
treatment has been conducted with adults with PTSD. but it has not been widely studied for use with children
have experienced trauma and who are dealing with
One meta-analysis of PE found that it is highly effective or adolescents. One feasibility trial using a slightly
symptoms of PTSD. Over the course of ten group ses-
and had similar effect sizes compared to other treat- modified version of CPT for teenagers with PTSD found
sions, students learn skills drawn from cognitive behav-
ments, including EMDR and cognitive processing therapy that their symptoms of post-traumatic stress improved
ioral therapy to strengthen coping mechanisms, process
(see below).54 The studies analyzed included both adult significantly and that the improvement persisted after
memories of their trauma, and handle challenging
and adolescent participants, and the authors did not six months.60 And a larger randomized controlled trial
emotions more easily.63
report any differences in those results for adolescents. with teenagers who were experiencing PTSD due to
childhood physical or sexual abuse found similarly
More recently, a handful of randomized controlled trials
promising results.61 The authors report that the results
have found promising results for using PE for teenagers
of the larger trial “are comparable to effect sizes
with PTSD. One trial found that teenage girls who were
reported for CPT in adults and to overall effect sizes
treated with PE saw greater reductions in symptoms of
PTSD and depression than participants treated with
reported in meta-analyses on PTSD treatment for These interventions are usually
children and adolescents.”
supportive counseling did.55 Another found similar in a group format and meet
results even when the treatment was delivered by Comparable results in reducing symptoms were also
during the regular school day,
medical nurses who had no previous experience using found in one recent program evaluation study that
psychotherapy,56 and the participants who received PE compared outcomes for teenagers versus adults who which means that they may be
showed greater symptom reduction even two full years received CPT for PTSD.62 Additionally, teenagers were especially helpful for children
after their treatment ended.57 Another trial found that more likely than adults to complete the treatment. The
PE was also effective in treating suicidal ideation among authors interpret these findings as indicating that CPT and teenagers who lack access
teenagers with PTSD.58 is likely a helpful treatment especially for teenagers who to reliable, affordable mental
might not have the supportive caregiver necessary for
health care.
other evidence-based treatments like TF-CBT.

14 2022 CHILDREN’S MENTAL HEALTH REPORT 15

Group treatments for adolescents STRUCTURED PSYCHOTHERAPY FOR ADOLESCENTS Medication treatment Prazosin: Prazosin has been shown in several studies
RESPONDING TO CHRONIC STRESS (SPARCS) to be effective in adults diagnosed with PTSD, and it has
Trauma treatment groups for adolescents also take
for trauma symptoms
shown promise in case reports of kids taking it in the
more flexible forms that can be implemented in a SPARCS is a group intervention specifically developed to evening to reduce PTSD-related sleep disturbances
While trauma-focused psychotherapies are the
variety of settings. These interventions are often respond to the needs of young people who have experi- and nightmares. But there are no large, double-blind,
evidence-based choice for treatment of PTSD in
used in short-term settings such as inpatient treatment enced complex trauma. It combines techniques from a placebo-controlled trials that demonstrate safety or
children, medications also play a role, in combination
centers, residential programs, or detention facilities, number of evidence-based treatments. It can be used efficacy of prazosin in children.83
with therapy. In most cases, the recommendation is
though they may also be used in schools or outpatient both with adolescents who have been diagnosed with
that therapy be started first, and medication added Clonidine and guanfacine: Clonidine and guanfacine
treatment settings. PTSD and with those who have experienced trauma but
later if the child isn’t responding to therapy and are regularly used to treat symptoms of ADHD as well
do not meet the full criteria for PTSD.74
There is relatively little data from randomized controlled symptoms are severe. as aggression in children. They have been used to
trials to support these treatments, but the available Over the course of 16 sessions, participants in SPARCS reduce hyperarousal and sleep disruptions and
But in some cases, medication is needed from the start,
research shows promising results. These programs’ learn and practice coping skills, self-regulation, and nightmares in kids with PTSD, although there is little
when a child is too distressed to participate in therapy
potential for broad applications may make them a effective communication with others. Unlike many other evidence to support their use.84
without it. And medication may be needed when a child
valuable way to expand access to treatment for trauma. trauma treatments, there is no trauma narrative compo-
has a co-occurring disorder, such as depression or anxiety. Antidepressant medications: Several selective
We examine a few of the most prominent ones here. nent in SPARCS, but participants do discuss their
traumatic experiences in the context of understanding While several forms of medication have been shown to be serotonin reuptake inhibitors (SSRIs), including
how those experiences affect their thoughts, feelings, effective for reducing trauma-related symptoms in adults, sertraline and paroxetine, are FDA-approved for the
SKILLS TRAINING IN AFFECT AND INTERPERSONAL and behaviors in the present.75, 76 there is very little research on the effectiveness of these treatment of adults with PTSD. Results of studies
REGULATION (STAIR) medications for children. And what little research there is in children with PTSD are mixed:85 Two open-label
suggests that effectiveness in adults is often not replicat- studies of citalopram showed improvement in symp-
STAIR is a group intervention originally developed TRAUMA AFFECT REGULATION: GUIDE FOR
ed in children.80, 81 toms, but two randomized controlled trials showed no
to support adult survivors of childhood abuse. In a EDUCATION AND THERAPY (TARGET)
benefit with sertraline compared to placebo. In some
modified form, it is designed to help teenagers who have Here’s a look at the evidence for medications most
TARGET is a group intervention originally developed for children, SSRIs can lead to irritability, poor sleep,
experienced trauma build emotional and social skills. commonly used to treat trauma symptoms in kids:
adults that focuses extensively on building emotional or inattention, making them a poor choice for these
In settings that allow for longer-term treatment it can
regulation skills as a way to cope with trauma symptoms. children, since their PTSD already causes problematic
also include additional sessions focused on processing Anti-adrenergic medications: These medications
Through a sequence of 10 sessions, it teaches skills that hyperarousal.86
of the traumatic event and the creation of a trauma block receptors in the adrenergic system, which
narrative similar to those used in TF-CBT. STAIR can can help kids learn to manage challenging emotions and Antipsychotics: Atypical or second-generation
modulates the body’s fight-or-flight response. Also
also be delivered as an individual treatment.71, 72, 73 process memories of their traumatic experiences.77 It can antipsychotics like quetiapine and risperidone have
called adrenergic agonists, they are primarily used
also be delivered as an individual treatment.78, 79 been shown in open-label studies and case histories
to lower blood pressure. But they are also used to
There are small studies to support each of these group reduce some types of anxiety. to reduce trauma-related symptoms in young people.
interventions, but more research is needed to better They are used for kids who are experiencing aggres-
Propranolol: Propranolol, which is sometimes pre- sion, rage, ruminations, and dissociative episodes.
understand their effectiveness and how they might
scribed for the treatment of situational anxiety like But they are not recommended for other children
support kids in various settings.
stage fright, has been shown in one study to reduce with PTSD because of high rates of problematic side
PTSD symptoms in children. But other more rigorous effects, including significant weight gain and troubling
studies have had negative results, and randomized hormonal changes.87, 88
While several forms of medication have been shown clinical trials are needed.82

to be effective for reducing trauma-related symptoms in

adults, there is very little research on the effectiveness of
these medications for children. And what little research
there is suggests that effectiveness in adults is often
not replicated in children.

16 2022 CHILDREN’S MENTAL HEALTH REPORT 17

 Chapter Three

What Does It Mean

to Be Trauma-Informed?
It often seems like “trauma-informed” programs are showing up everywhere.
But like “trauma” itself, “trauma-informed” is a term and a concept without a single
clear definition or a conclusive evidence base. It can be hard to know what makes
a treatment provider, school program, or other setting trauma-informed — and
what that designation might mean for the kids involved.

One of the most common working definitions of what it These same guidelines also include principles for
means to be trauma-informed comes from the Substance developing trauma-informed practices across an
Abuse and Mental Health Services Administration organization, and they are often cited as a guiding
(SAMHSA) within the U.S. Department of Health and framework for specific trauma-informed programs.
Human Services. In 2014, SAMHSA published trauma
The National Child Traumatic Stress Network uses a
guidelines that define “four Rs” of a trauma-informed
similar definition to delineate how trauma-informed
approach. To qualify as trauma-informed, practitioners
systems can support children:
or organizations must:89
“A trauma-informed child and family service system
• Realize that trauma is prevalent and can have
is one in which all parties involved recognize and
profound impacts
respond to the impact of traumatic stress on those
• Recognize the signs of trauma who have contact with the system, including children,
• Respond with appropriate supports caregivers, and service providers. Programs and
• Resist retraumatization by avoiding practices agencies within such a system infuse and sustain
that could harm individuals with trauma histories trauma awareness, knowledge, and skills into their
organizational cultures, practices, and policies.
They act in collaboration with all those who are
involved with the child, using the best available
science, to maximize physical and psychological
safety, facilitate the recovery of the child and family,
and support their ability to thrive.”90

18 2022 CHILDREN’S MENTAL HEALTH REPORT 19

 Research into trauma-informed care among pediatric
practices is limited. But incorporating an awareness of
The basic idea of definitions like these is that trauma- Guidelines for providing trauma-informed mental health trauma into routine medical care for children could help
informed services don’t have to look any one way. care vary, but they often include taking steps like the practitioners spot children who may be experiencing
Rather, any organization, system, or setting can be following, which come from a SAMHSA guide for clinicians:
trauma-informed if it integrates an understanding of
• Conducting routine trauma screenings
trauma. Clinicians could play a positive role in helping
and responsiveness to trauma into all of its activities.
with all patients families get support when they need it.
Given the lack of agreement on definitions and stan- • Training all staff on the impacts and
dards,91 it’s not surprising that there is limited evidence signs of trauma
in the literature about how trauma-informed practices
• Considering how a patient’s cultural
work, how effective they are, and how to implement and
background and life experience might
evaluate them. At present, most of these practices are MEDICAL SETTINGS SCHOOLS
shape their understanding of trauma
essentially experiments responding to our growing
awareness of trauma’s significance, and it will take years • Aligning treatment goals with the patient’s Research into trauma-informed care among pediatric The movement for trauma-informed schools has grown
before there is a reliable body of evidence about what trauma symptoms, if any practices is limited. But incorporating an awareness of in recent years. Sometimes this can involve delivering
works and what doesn’t. • Prioritizing safety planning as an initial trauma into routine medical care for children could help trauma treatments at school, but it can also refer to
goal (for patients who are experiencing practitioners spot children who may be experiencing broader administrative and curricular practices. For
ongoing trauma) trauma. Clinicians could play a positive role in helping example, trauma-informed school programs can involve
Trauma-informed systems families get support when they need it. screening students for trauma, training staff to recognize
• Emphasizing autonomy, resilience, and
collaboration to rebuild the senses of signs of trauma and make appropriate referrals, offering
In practice, this can mean screening children for trauma
MENTAL HEALTH SETTINGS parent workshops on the effects of trauma, and imple-
personal competence and interpersonal during medical appointments and, when screening and
connectedness that trauma often interrupts menting disciplinary policies that consider trauma as a
One of the most obvious settings for trauma-informed assessment aren’t feasible (as during emergency care),
possible cause of behavior and avoid retraumatizing
services is mental and behavioral health providers. • Avoiding use of techniques that could defaulting to treating children as if they may have
students through punishments.
Providing trauma-informed mental health care doesn’t retraumatize patients (such as restraints, experienced trauma in the past.93 Additionally, some
necessarily mean treating symptoms of trauma directly isolation, or confrontation) approaches to trauma-informed care recommend an Again, there isn’t yet a clear standard of what makes a
or using a specific treatment protocol, but rather follow- • Providing support to help staff cope with emphasis on ensuring continuity of care across providers, school or school program “trauma-informed” and there’s
ing trauma-informed principles like those listed above secondary trauma (trauma-related symptoms involving the whole family in pediatric medical care, not a robust body of evidence about how trauma-in-
regardless of what kind of treatment is provided. that happen as a result of exposure to someone promoting self-care practices among medical staff, formed practices might impact student outcomes. The
else’s trauma)92 and providing the family with emotional support and available evidence is promising, but it’s still a relatively
connections to mental health care when appropriate.94 new field of study. A systematic review conducted in
2020 found documentation of several school-wide
Such practices may be especially helpful in medical
programs that meet the 2014 SAMHSA criteria for
settings that treat children who have experienced physical
trauma-informed practice and notes that these programs
trauma, which puts them at risk of developing PTSD.95
generally report positive outcomes.96 However, the
authors of the review conclude that the evidence base
for programs like these is weak overall, with few studies
available and issues of bias and other limitations present
in the studies that do exist.

20 2022 CHILDREN’S MENTAL HEALTH REPORT 21

 Parent Perspectives on Trauma

Trauma means something different for everyone who experiences it.

That’s why we initiated a new Child Mind Institute survey with data
Looking Ahead collection by Ipsos that complements the available research on
treatment and provides more personal insights into the ways that
trauma affects the lived experiences of American families. We asked
parents how their children have fared during the pandemic, how trauma
As clear as it is that trauma is a prevalent challenge Additionally, it is crucial to continue researching how
for children and families, it’s equally clear that its complex and chronic trauma differs from trauma that has impacted their families, and whether they have been able to get
effects are treatable. The available research across stems from a single experience. Some researchers have support when they need it.
the field is encouraging, with multiple interventions noted that TF-CBT, the leading treatment for trauma in
showing promise for reducing the impacts of traumatic children, may not fully meet the needs of kids who have To learn more about the survey and see its findings,
experiences and helping children and adolescents experienced complex trauma, especially when it isn’t
thrive through adversity. feasible for their caregivers to participate in treatment.97 visit childmind.org/2022report.
And a recent meta-review found that there is not, as yet,
At the same time, there is still so much that we don’t
any comprehensive analysis of the suitability of existing
know. As the analysis above makes clear, more work is
interventions when it comes to treating the impacts of
needed to identify workable strategies for preventing
complex trauma.98
and treating trauma. And more randomized controlled
trials are necessary to test promising approaches and Finally, as we continue to develop guiding principles and Learn More
understand whether they work for different populations practices for trauma treatments and trauma-informed
of children, including those of different racial and ethnic care, it’s also essential to work toward reducing the Visit childmind.org/2022report to download this report, learn how
backgrounds, socioeconomic groups, geographic groups, incidence of traumatic events themselves. Violence, the Child Mind Institute is helping kids who have experienced trauma,
and age groups. There is also limited data on how abuse, neglect, and other experiences that lead to
specific service delivery settings and other logistical trauma don’t happen in a vacuum. As the last few years
and find practical resources for parents and educators.
factors might impact treatment. have brought into especially stark focus, traumatic
experiences are intertwined with the public policies and
broader sociocultural systems that so often fail to meet
families’ material and psychological needs. Minimizing
the impacts of trauma on children requires not just
prevention and intervention on an individual level, but
also a commitment to making sure that all families and JOIN US CONNECT
communities have the resources and support they need
to raise healthy, thriving children. Millions of children with anxiety, depression, Follow, subscribe, and share our content
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22 2022 CHILDREN’S MENTAL HEALTH REPORT 23

Endnotes

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diverse youths: Examples from the Cognitive Behavioral Intervention
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& Steil, R. (2016). Psychological treatments for symptoms of post- adolescent girls: A randomized clinical trial. JAMA: The Journal of the
Trauma, 4(1), 34–51. https://doi.org/10.1080/19361521.2011.545046 tion for multicultural children exposed to traumatic events. Journal of
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84. Ibid.

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