TF-CBT for CYP with

PTSD
Trauma-focused Cognitive
Behavioural Therapy for
Children and Young People
with Post-Traumatic Stress
Disorder
David Trickey
Consultant Clinical Psychologist
[email protected]
Introduction
 • Mobile Phones
o Please answer, if necessary, in the least distracting
way
• Confidentiality
o Details of individual stories should stay in the room
Things you can o Lessons from those stories should leave the room
• Participation
do to help: o Don’t wait to be asked to ask questions
o Don’t feel you have to ask the perfect question
o Please do contribute your own examples
• Mutual Respect
o Of each other’s views and of each other’s time
 • I don’t know about your pasts or presents
• We will be talking about trauma, bereavement and
children, sometimes in detail, other times very
briefly
• As compassionate human beings, we should be
moved by the stories we hear
Looking after • Sometimes the impact can be greater when we are
with supportive colleagues, and have the
ourselves opportunity to reflect rather than when we are in
the thick of the actual work
• So if you start to feel overwhelmed, then do what
you need to do to look after yourself, for example:
o Take a break
o Talk it through
o Do it on another day
 Time’s up!

0 5 10

• Name
• Work context
Goal setting • If today turned out to be a good
Groups of 3-5, use of your time, how would
10 minutes you know? What would you
notice that was different next
week, next month or next year?
 • By the end of this session, you
should:
oBe familiar with, and understand, the
cognitive model of PTSD
oBe aware of how CYP commonly react
Learning to traumatic events and be familiar
with diagnostic criteria for PTSD
outcomes oUnderstand what is involved in CBT
(CBT for CYP with PTSD)
for CYP with PTSD, taking into account
developmental and systemic factors
oBe familiar with the evidence
supporting the use CBT for CYP with
PTSD
 Time’s up!

0 15
• Bring to mind some CYP who
have experienced traumatic
Making it events
relevant oWhat was it about the events that
Groups of 3-5, made them traumatic?
15 minutes oWhat has been the psychological
impact (e.g. behaviour, feelings,
thoughts and beliefs)?
 • Knowledge of best research
Evidence Based evidence
Practice • Individual clinical expertise
(Sackett et al., 1996;
APA, 2006)
• Client values (choice & voice)
Cognitive
Model of
PTSD
 • Trauma-focused CBT
(Cohen, Mannarino & Deblinger, 2016)
• Cognitive Therapy for PTSD
(Smith, Perrin, Yule & Clark, 2010)
“TF-CBT for • Prolonged Exposure Therapy (& Emotional
Processing)
PTSD”: (Foa, Chrestman & Gilboa-Schechtman, 2008)
• Narrative Exposure Therapy
A Very Large (Neuner et al., 2008)
• CBT-3M
Umbrella (Goodall et al., 2017)
• Cognitive Processing Therapy
(Resick & Schnicke, 1993)
• Abuse Focused CBT
(Kolko & Swenson, 2002)
The Cognitive Model of PTSD
(Meiser-Stedman, 2002)
Reactions
(e.g. PTSD)

Ehlers & Clark, Risk factors

2000
Memory
Assessment
Brewin et al., Meaning
2010 Helpful
support

Effective
interventions
Memories of normal events
Contextualised representations (C-reps)

Memory store

Event

Unconscious
Conscious
Different Types of Memories
Normal event memories Traumatic event memories
Contextualised representations (C-reps) Sensory-bound representations (S-reps)
Conceptual framework contains the Little conceptual framework to contain the
perceptual information perceptual information
Words and stories Vivid sensory information
Fluid, updateable, forgettable Static and frozen
Linked to other memories Isolated from other memories
Historical context – there and then No historical context – here and now
Organised into a coherent narrative Disorganised, incoherent, fragmented
Largely under conscious control Uncontrollable, easily triggered
Contextualised Standalone
 Sound Sight Smell
Fear Network Taste
Traumatic
Feeling
(Foa & Kozak, 1986) event

Touch Physiological
Thought
Memories of traumatic events
Sensory-bound representations (S-Reps)

Memory store

Unconscious
Traumatic
Conscious event
Maintenance cycle of internal avoidance

Memory
unprocessed

Memories and Memory and

thoughts suppressed thoughts intrude (e.g.
and avoided flashbacks, dreams)

Bringing original fear,

horror, helplessness
Maintenance cycle of external avoidance

Memory
unprocessed

Triggers and potential Memory easily

triggers avoided triggered

Bringing original fear,

horror, helplessness
 • “Fixed ideas” of traumatic
events, rather than usual
Pierre Janet’s memories
Description of • Sufferers are “unable to
make the recital which we
Traumatic call narrative memory and
Memories yet they remain confronted
by the difficult situation”
(1889, 1906)
• Continue to make efforts at
adaptation
 • Assesses the number of aspects
Trauma of a memory that are
Memory characteristic of traumatic
Quality memories
Questionnaire • Related to PTSD diagnosis
(TMQQ; Meiser-Stedman et
al., 2007)
• Related to severity of PTSD
symptoms
Memories and Brain Activity
(PET Scans; Rauch et al., 1996)

Areas activated during trauma memories, Areas activated during neutral

but not neutral memories memories, but not trauma memories
Evidence for Dual Memory Systems
(Holmes & Bourne, 2008)

Tap out a pattern

Decrease in visuo-spatial processing Fewer intrusions
during the film
Count backwards in
Decrease in verbal processing More intrusions
3s during the film
Answer questions
Increase in verbal processing Fewer intrusions
afterwards
Play Tetris within
Decrease in visuo-spatial processing Fewer intrusions
30 minutes
 • Multiple traumatic events may lead to
multiple traumatic memories
• What is perceived as the most distressing
Multiple is likely to change over time, even without
therapy (Panter-Brick et al., 2015)
events; • Repeated assessment (e.g. using a
questionnaire) needs to take that into
multiple account
memories • Memories may become conflated, which
may cause problems for criminal
prosecutions, but not necessarily for
therapy
 • Domains:
o Self (worthy, loveable)
o World (benevolent, makes sense, safe
enough)
o Others (trustworthy, worth relating to)
Meaning: • Usually unconscious, unarticulated,
taken for granted
Core Beliefs • People act as if their assumptions
were truths rather than constantly re-
examine them
• Often initially evident from people’s
actions
CBT Fundamentals
Systems (e.g. family, school, peers, community, agencies)

Beliefs Feelings

Physiological
Thoughts
reactions

Behaviour
Impact of Traumatic Events
“The trouble is, the rules have been broken” Joe, aged 8
Traumatised
Traumatic
Feelings
event

Trauma-based
Beliefs Traumatised
Trauma-based
Physiological
Thoughts
reactions

Traumatised
Behaviour

Avoidance of activities, places Beliefs confirmed not challenged

Avoidance of people Memory not processed
Avoidance of thoughts
Impact of Multiple Events

Traumatic Traumatic
event event

Traumatic Traumatic
event event

Beliefs
Traumatic Traumatic
event event
 • World
o Everywhere is dangerous
• Self
o I caused it
Common o I asked for it
o I’m only good for one thing
Traumatic o I should have stopped it
Misappraisals o I’m damaged
• Others
o Nobody cares about me
o Adults are dangerous, especially those
that are supposed to care for me
 • 25 statements (e.g. “Anyone could hurt
me), CYP indicates the extent to which
Child Post- they agree or disagree
• 10 item short form has good psychometric
traumatic properties (but less clinical potential)
Cognitions • Two subscales:
o Fragile person in a scary world
Inventory o Permanent and disturbing change
(CPTCI; • Related to PTSD diagnosis
Meiser-Stedman et al., 2009, • Related to severity of PTSD symptoms
McKinnon et al., 2016)
• Scores on both subscales higher if the
trauma was interpersonal
Formulation: Adam (16) – Assault, avoidance
“The only reason I’ve not been beaten up again, is that I’ve not left the house”

Physical Traumatised
assault feelings: S-Rep
Fear Memory
S-Rep Beliefs:
Memory I’m vulnerable, Trauma-based Traumatised
stop the world is thoughts: physiological
Friends inviting out dangerous, If I go out, Reactions:
^ people are violent I will be beaten Sweating,
up again Raised heart rate

Traumatised
behaviour:
Avoid leaving the
Beliefs confirmed home or carer
not challenged
Mother encourages
staying in
Formulation: Sue (8) – Abuse, misappraisals
“They don’t love me, she’s just doing it for the money, he’s gonna hurt me some time”

Abused by Traumatised
parents feelings: S-Rep
Fear & suspicion Memory
Beliefs:
S-Rep World is unsafe
Traumatised
Memory Trauma-based
Others are physiological
thoughts:
Amazing foster care dangerous Reactions:
(especially those They’re going
Hyper-vigilance
to hurt me
that are supposed Hyped-up
to look after you)
I’m un-loveable Traumatised
behaviour:
Kicks and bites
Placement
breaks down
Formulation: Ana (9) – Domestic violence, guilt
“People tell me I’m stupid, and I should stop thinking like that; so I’ve stopped telling people what I think”

Father killed Traumatised

S-Rep
mother feelings:
Memory
Guilt, sadness
Beliefs: Traumatised
Things happen for Trauma-based
Any negative physiological
a reason thoughts:
event Reactions:
I’m to blame It’s my fault
Lethargy, butterflies
S-Rep
Memory Traumatised
behaviour:
Avoid discussing or
thinking about it
Responsibility
not appraised Gran tells her to stop
more realistically thinking like that
Formulation: Matt (16) – Abduction, hypervigilance
“Most people my age are into parties; I’m into making sure that I don’t get hurt”

Traumatised S-Rep
Abduction as Memory
a young child feelings:
Beliefs: Fear, anxiety
I’m vulnerable,
The world is unsafe, Trauma-based Traumatised
People are potential thoughts: physiological
Leaving the house
threats I must be Reactions:
on my guard Hypervigilance
S-Rep
Traumatised
Memory
behaviour:
Scan for threats
Notice all
possible threats Constant reminders
not to worry
Formulation: Grace (14) – CSA, interpretation of
symptoms “I can cope with losing my virginity, I can’t cope with losing my mind”
Sexual Traumatised
abuse feelings:
Beliefs: Anxiety, panic
I’m damaged
S-Rep I can’t cope Traumatised
Memory Trauma-based
physiological
thoughts:
Reactions:
I’m going mad
Palpitations, sweating

Traumatised
behaviour:
Pushes the intrusive
thought away
Increases intrusions
Vicarious avoidance, may be endorsed by professionals
Traumatic
event Carer

Beliefs: Trauma-based
Opportunities
I’m not a thoughts: CYP
to discuss good parent, Talking about it Traumatic
events My child is might make event
or reactions
vulnerable things worse Beliefs:
I’m damaged
I can’t cope Trauma-based
Traumatised
thoughts:
behaviour:
I shouldn’t talk
Don’t mention it
about it
Don’t ask about
the impact
Traumatised
behaviour:
Don’t mention it
Don’t tell about
the impact
 • They may fill in the gaps
• They may over-generalise
Risks of not • They may hear it from a source that seeks
to sensationalise rather than re-assure
telling children (e.g. media)
and young • They may wonder whom they can trust
• They may assume that it’s not ok to talk
people enough about it, and so are left with whatever
account they stumble across
information
• They won’t know how to counter
inaccurate accounts
0 5 10 • How does the cognitive model (i.e. memory,
meaning and maintenance) apply to the CYP
that you brought to mind earlier?
Cognitive • If it’s helpful, consider the following questions:
model o What role did memory play in the person’s
difficulties?
o What role did meaning play in the person’s
formulations difficulties?
o Could you draw a formulation that represents this
Groups of 3-5, (some bits might be guesses that can be checked
out)?
10 minutes o Does the model help to understand how the
events lead to problems?
o Are there aspects of your client’s difficulties that
the model does not help to explain?
 • What difference might aspects of a
child or young person’s identity (e.g.
gender, race, religion, ability,
culture, ethnicity, sexuality) make
to:
Difference and oThe meaning CYP make of events
identity oThe way that they react to events
oThe way that those around them
react
oThe provision of services
oAccess to services
PTSD
 • What are your thoughts about
the advantages and
Diagnosis disadvantages of the existence
of a diagnostic label PTSD?
 • Mental health diagnoses are simply a list of symptoms that
often occur together; if someone has enough of them for
long enough, then the criteria for a diagnosis are fulfilled
• Diagnoses can be unhelpful:
o “Sub-threshold” ≠ no distress & no functional impairment
o No diagnosis may mean no access to services
o Diagnosis may over-simplify complex difficulties, leading to the

Mental health impression that the professional response is equally simple

o Diagnostic descriptions may be written based on adult
presentations with little or no adaptation for CYP
“diagnosis” • Diagnoses can be helpful:
o Clear definition makes it easier to study which contributes to
understanding which may help to decrease it
o Diagnosis can provide a framework of symptoms to consider
o May give CYP a way of understanding their difficulties
• PTSD in particular is a pretty broad collection of symptoms,
which may be academically imprecise, but may be a useful
description of post-traumatic distress
PTSD (DSM-5, 2013) PTSD (ICD-11, 2018)
A. Exposure to actual or threatened death, • Exposure to an extremely threatening
serious injury, or sexual violence or horrific event or series of events
B. Intrusions (1 of 5) • Re-experiencing (1 of 2)
C. Avoidance (1 of 2) • Avoidance (1 of 2)
D. Changes in cognitions and mood (2 of 7)
E. Arousal & reactivity (2 of 6) • Persistent perceptions of heightened
current threat (1 of 2)
F. Duration more than 1 month • Must last for at least several weeks
G. Clinically significant distress or • Significant impairment in personal,
impairment of function family, social, educational, occupational,
or other important areas of functioning
H. Due to event, not due to physiological
effects of a substance or medical condition
PTSD (DSM-5, 2013)
A. Exposure to actual or threatened death,
serious injury, or sexual violence
B. Intrusions (1 of 5)
C. Avoidance (1 of 2)
D. Changes in cognitions and mood (2 of 7)
E. Arousal & reactivity (2 of 6)

F. Duration more than 1 month

G. Clinically significant distress or
impairment of function

H. Due to event, not due to physiological

effects of a substance or medical condition
 Exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of the following ways:
• Directly experiencing the traumatic event(s)
• Witnessing, in person, the event(s) as it occurred to
others

Exposure • Learning that the traumatic event(s) occurred to a close

family member or close friend. In cases of actual or
(PTSD Criterion A; threatened death of a family member of friend, the
event(s) must have been violent or accidental
DSM-5, 2013)
• Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s) (e.g. first responders
collecting human remains; police officers repeatedly
exposed to details of child abuse)
Note: Criterion A4 does not apply to exposure through
electronic media, television, movies, or pictures, unless
this exposure is work related
 100

Percentage of
90

80
CYP (aged 13-17) 70

exposed to 60

potentially % 50
2+ events

traumatic events 40 1 event

“Actual or threatened death 30

or injury, or a threat to the 20

physical integrity of self or
10
others”
(DSM-IV; APA, 1994) 0
Landolt et al., McLaughlin et Copeland et al.,
2013 al., 2013 2007
 “Exposure to • Do any of the events that you
considered “traumatic” when
actual or bringing to mind traumatised
threatened children and young people, not
fulfill that criteria?
death, serious • Can you think of any events that
injury, or could be “traumatic” that would
not meet that criteria?
sexual • What happens to children who
violence” have symptoms of PTSD when the
(DSM-5, APA 2013)
event does not meet criterion A?
 • Intrusive memories
oOr repetitive play in which the event
or aspects or themes of the event are
expressed
Intrusion • Nightmares
symptoms oContent may not be recognisable
(PTSD Criterion B; 1 of 5: • Dissociative reactions (e.g.
DSM-5, 2013) flashbacks, reenactment)
• Psychological distress or
physiological reactivity in response
to reminders
 Avoidance of • Of internal reminders (e.g.
stimuli memories, thoughts, feelings)
associated • Of external reminders (e.g.
with the event people, places, conversations,
(PTSD Criterion C; 1 of 2: activities, objects, situations)
DSM-5, 2013)
 • Amnesia
• Exaggerated negative beliefs about self,
others or world
Negative • Distorted thoughts about causes or
alterations in consequences
• Persistent negative emotional state (e.g.
cognitions & fear, horror, anger, guilt or shame)
mood • Diminished interest or participation in
significant activities
(PTSD Criterion D; 2 of 7:
DSM-5, 2013) • Feelings of detachment or estrangement
• Inability to experience positive emotions
(e.g. happiness, satisfaction, love)
 • Irritable behavior and angry outbursts
(with little or no provocation) typically
Marked expressed as verbal or physical
aggression toward people or objects
alterations in • Reckless or self-destructive behaviour
arousal & • Hypervigilance
reactivity • Exaggerated startle response
(PTSD Criterion E; 2 of 6: • Problems with concentration
DSM-5, 2013) • Sleep disturbance (e.g. difficulty falling
or staying asleep or restless sleep)
Cardiovascular Lability (Perry, 1994)
150

140

130
Heart rate (bpm)

120
Control
110 PTSD 1
PTSD 2
100

90

80
1 2 3 4 5 6 7 8 9 10
Time Interval
PTSD Symptoms that overlap with other

GAD
ADHD
Phobia
Depression
Conduct
Psychosis
disorders

Hypervigilence (or “attending to the wrong thing”) x x

Problems with concentration x x x
Exaggerated negative beliefs about self, others or world x x x
Irritable, aggressive x x
Exaggerated startle response x x
Avoidance of specific stimuli x x
Exaggerated negative beliefs about self, others or world x
Persistent negative emotional state
Diminished interest / participation in significant activities
Feelings of detachment or estrangement
Inability to experience positive emotions
Dissociative reactions (e.g. flashbacks) x
 • <7: fewer re-experiencing symptoms
and little avoidance (Fletcher 1996)
• <4: Predominance of behavioural
PTSD in symptoms such as traumatic play and
aggression (Scheeringa et al., 2003)
Younger • Salmon & Bryant (2002) consider
Children developmental aspects of PTSD
• DSM-5 includes a separate diagnosis
of PTSD for children aged 6 and
younger
Rate of PTSD in CYP After a Potentially
Traumatic Event (Meta-analysis of 42 samples; Alisic et al. 2014)
30
Interpersonal
25.2
25

CYP only
20
%age with PTSD

17.5
15.9
15 Non-
interpersonal
9.7
10
Carer only
5.1
5

0
Overall Trauma type Informant
%age of trauma-exposed CYP showing
PTSD symptoms at different ages (Haag et al., 2019)
30

25 n.s.
p=0.002
n.s.
20
p=0.001
15

10

0
8 10 13 15
Female Male
 25

20

Recovery from

%age with PTSD

15

PTSD 10
(Meta-analysis of 18
samples; Hiller et al., 2016)
5

0
(k=18) (k=15) (k=17) (k=11)
1 3 6 12
Months
Recovery following accidental injury
(Le Brocque et al., 2010)
30

25
PTSD Symptoms (CRIES)

Chronic (10%)
20
Cut-off
15 Recovery (33%)
10 Average

5 Resilient (57%)
0
0 20 40 60 80 100 120 140 160
Days
Meta Analysis of Risk Factors for PTSD in
Adults (Brewin et al., 2000)
Lack of social support 0.40

Subsequent life stress 0.32

Trauma severity* 0.23 (significant variability)

0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50
 Meta Analysis of Risk Factors for PTSD in CYP (Trickey et al., 2012)
Distraction 0.47
Poor family functioning 0.46
After

Social withdrawal 0.39

Low social support 0.33
Parent psychological problem 0.29
Perceived life threat 0.36
During

Peri-traumatic fear 0.36

Trauma severity 0.29 (significant variability)
Pre-trauma life events 0.21
Low IQ 0.20
Before

Poverty 0.17
Female 0.15
Prior psychological problems 0.15
Age 0.03 (n.s.)
0.00 0.10 0.20 0.30 0.40 0.50
 • Perception trumps reality
o So it doesn’t really matter what we think
about whether an event was traumatic or
not; it matters what they think
• How well the carers are doing is as
important as the actual event
So what? • Some things that happen afterwards are
more important than how big or bad the
event actually was, especially:
o Lack of social support
o Social withdrawal
o Poor family functioning
o Distraction
PTSD (ICD-11, 2018) Complex PTSD additional symptoms
(ICD-11, 2018)
• Exposure to an extremely threatening or • … most commonly prolonged or repetitive
horrific event or series of events events from which escape is difficult or
impossible (e.g., torture, slavery, genocide
campaigns, prolonged domestic violence,
repeated childhood sexual or physical abuse)
• Re-experiencing (1 of 2) In addition… severe and persistent:
• Avoidance (1 of 2) • Problems in affect regulation
• Persistent perceptions of heightened • Beliefs about oneself as diminished, defeated
current threat (1 of 2) or worthless, accompanied by deep
pervasive feelings of shame, guilt or failure
• Must last for at least several weeks
related to the traumatic event
• Significant impairment in personal, • Difficulties in sustaining relationships and
family, social, educational, occupational, feeling close to others
or other important areas of functioning
 • Secondary analysis of data from a
RCT
• 155 CYP, with PTSD who received 12
sessions of TF-CBT
CPTSD vs PTSD • Latent Class Analysis supported two
in CYP discrete groups:
(Sachser et al., 2016) oPTSD symptoms plus low symptoms
of disturbances of self-organisation
(DSO) 60%
oPTSD symptoms plus high symptoms
of DSO 40%
Symptom endorsement – PTSD vs CPTSD
(Sachser et al., 2016)
 • Depression • Attachment
• Anxiety problems (e.g.
• Obsessive clinginess, rejection)
Compulsive • Omen formation
Other Disorder* • Sleep problems
• New fears • Regression
Reactions • Dissociation • Memory problems
(e.g. Fletcher, 1996; Bolton • Self-harm • School problems
et al., 2000, Dinn et al.,
1999; Heim et al., 2009)
• Chronic Fatigue • Medically
Syndrome Unexplained
• Psychosis Symptoms
• Eating Disorders • Ripple effects
• Substance abuse*
 • Very protective / Very controlling
• Overwhelmed / numb
Systemic • Avoidant
Reactions • Pre-occupied
(e.g. Families, schools,
organisations) • Breakdown in usual functioning
• Psychological problems of others
around the child
Assessment
 • If you don’t specifically ask they may not
mention it (e.g. McDonald et al., 2014; Frissa et
al., 2016)
o Avoidance
o Not realising the importance or relevance
• The “index” event(s) may not be the most
traumatic
Trauma History • Previous events may have set the scene for the
current reactions
• Use clinical judgement to determine:
o Whom you ask
o When you ask
o How you ask (e.g. Questionnaire (e.g. THQ, SLE,
UCLA PTSD RI), life line, rope)
 • Do mention it (the traumatic event)
o Don’t collude unnecessarily with unhelpful avoidance
o Make sure they know that you can talk about and hear
about the event
o Brief account (to assess nature of memory, avoidance)

Assessment: o But make sure that they come back!

• Assess changes in functioning and activity
specific o Pre-trauma functioning may be difficult to asses as their
report may be unreliable or tinted by the traumatic event

guidelines (1) o School reports often useful

• What meaning do they make of their symptoms and
the event (consider using the CPTCI)
• What is their motivation for attending or their goal:
o Increase functioning, decrease distress, problem
prevention, insurance or medico-legal
 • Ask about triggers
• Identify coping strategies, looking
particularly for avoidance
• Interview CYP and carers together,
Assessment: separately, then together
• Assessment of carers?
specific o Consider screening e.g. for PTSD, depression,
do they need their own intervention?
guidelines (2) o Are they avoidant, supportive
o What’s the impact on the CYP
• Consider using a standardised
questionnaire (e.g. CRIES-8, CRIES-13,
CPSS-5)
 • There are no short cuts to a good assessment
Standardised • But some measures can give a reliable(-ish)
indication of (perceived) symptom severity or
questionnaires frequency
• This can be a useful source of information:
and PTSD in o In addition to other sources information, to improve and
support our understanding of the young person (e.g.
CYP clinical practice, court assessments)
o To track change (in either direction) related to an
intervention (clinical practice or research)
List of measures are available: o To screen large numbers
www.nctsnet.org • Questionnaires can also:
www.ptsd.va.gov o Prompt useful discussions in therapy
Trickey & Meiser-Stedman (2018) o Promote communication between CYP and carer, leading
to improved support (e.g. Berkowitz et al., 2011)
 Self-report Questionnaires (8ish yrs old +)
Children’s Revised Impact of Children’s Revised Impact of Child PTSD Symptom Scale
Event Scale (CRIES-8) Event Scale (CRIES-13) (CPSS)
8 items 13 items 27 items
Subscales: Subscales: Subscales:
Intrusions Intrusions Intrusions
Avoidance Avoidance Avoidance
Arousal Arousal
Impact
CYP-IAPT & NHS-England MHSDS Also available as interview
Perrin et al., 2005 Perrin et al., 2005 Foa et al., 2017
Available from www.corc.uk.net Available from Available from author
or www.childrenandwar.org www.childrenandwar.org [email protected]
Date: / / 20 Time: h m
Below is a list of comments made by people after stressful life events. Please mark each item showing how frequently
these comments were true for you during the past seven days. If they did not occur during that time please mark the ‘not
at all’ box.

CRIES-8
Frequency during the last week: 0 1 3 5

1 Do you think about it even when you don’t mean to? Not at all Rarely Sometimes Often 3
2 Do you try to remove it from your memory? Not at all Rarely Sometimes Often 0
3 Do you have waves of strong feelings about it? Not at all Rarely Sometimes Often 1
4
Do you stay away from reminders of it
(e.g. places or situations)?
Not at all Rarely Sometimes Often 5
5 Do you try not to talk about it? Not at all Rarely Sometimes Often 3
6 Do pictures about it pop into your mind? Not at all Rarely Sometimes Often 3
7 Do other things keep making you think about it? Not at all Rarely Sometimes Often 3
8 Do you try not to think about it? Not at all Rarely Sometimes Often 3
TOTAL: 21
 Items from a When I am upset, it takes me a long time to calm down.
yet to be Sometimes I get really angry and cannot control my temper.
I get really upset by things that don’t bother other people.
evaluated My feelings get hurt easily.

Complex PTSD I feel like I am no good.

I feel guilty about lots of things.
questionnaire I don’t matter.
I am worthless.
for CYP: It is easier not to have friends.
Affective functioning I don’t feel close to anyone.
Self functioning I find it difficult to have good friends.
Relational functioning My friendships are always difficult and leave me feeling hurt.
(Meiser-Stedman)
 • Read instructions all the way through
before beginning.
• If names or events have particular
resonance for anyone, then change them
and choose roles carefully.
Guidance for
• If you would prefer to work on scenarios
all Skills specific to your own work, then please do
so, but pick a specific incident that is
Practices causing distress, and keep the objective of
the practice in mind.
• Therapist can <<PAUSE>> the client,
consult with the observer(s), then
<<UNPAUSE>>
 • Aim: to practice integrating a
questionnaire into assessment
• Group:
Skills practice: o2 x clients (Alex and parent)
CRIES-8 o1 x Therapist
o1 or 2 x Observer(s) / co-
therapist(s)
Self-care
0 5 10
• How does working with children
and families following a
traumatic event impact on us
Self-care (in terms of thoughts, feelings
Groups of 3-5, and behaviour)?
• How do we manage the
10 minutes impact?
• What could we do better to
manage the impact?
 • Research consistently identifies over-
involvement, or over-detachment as
pre-cursors to burnout
Detached Optimal Performance Over-involved

Over-involved
• Need to balance compassion and
or Too Distant? professionalism
• How do you know if you or someone
else is over-involved?
• How do you know if you or a colleague
is too detached?
“This article focuses on the mechanism by which real
or perceived distress of another in turn distresses us
and the process by which we become undistressed”

Secondary
trauma
(Ludick et al., 2016)
 • Members area of UKPTS website:
o Monthly research digests
o Slides from previous conferences and workshops

UK • Discounts for UKPTS events and associated

organisations
Psychological • Special interest groups and regional networks
• Automatic membership of ESTSS
Trauma Society • ESTSS Certificate in Psychotraumatology
www.ukpts.co.uk
• Discounted Journal of Traumatic Stress
subscription
• Membership £50 (£30 for students)
Guideline for the treatment and • To reduce the risk of vicarious
planning of services for traumatisation, services should
complex post-traumatic stress
encourage:
o Recognition of the early warning signs of
disorder in adults
traumatisation
o Regular supervision
o Peer support, team support, containing
management support, including self-care
groups within the workplace
o Limits on exposure to traumatic material
o Balancing of caseloads
o Balancing days and scheduling of breaks
o Good work-life balance
 • Be prepared to • Diet and exercise
witness, and • Be prepared to say
experience, “No” and “Why?”
extreme emotions
• Social support
• Self-monitoring
• Organisational
Self- • Process events
realistically and
support
preservation helpfully • Supervision
• Set realistic • Compassionate and
expectations professional
• Be clear about what
you are and are not
responsible for
Therapy
Key components and contexts
P s yc h o
ed uca
tion

s
ce
ur
so
re

S a f e ty &
al
Processing
id u

ofMemory
memory
d iv
In

stability
Cognitive
Meaning
Th

restructuring
er
ap
eu
tic

rk
co

wo
nt

ic
em
ex

st
Sy
t
 • Not all CYP require all key components
• Plan components based on the
formulation
Formulation o 14 year old boy who is not leaving the
house, but no intrusions, and no
based unhelpful beliefs – reduce avoidant coping
o 16 year old girl who believes that she
intervention “should have” died and therefore is more
likely to die – cognitive restructuring
o 8 year old boy with intrusive images –
narrative exposure
 • Surveyed experts in the treatment of PTSD and
complex treatment
• Both sets of experts agreed that treatment:
o Should be phased
o Should be tailored to symptoms
What about o Includes the following elements:
²Emotion regulation
complex PTSD ²Narration of trauma memory
²Cognitive restructuring
(Cloitre et al., 2011)
²Anxiety and stress management
²Interpersonal skills
• Did not agree on
o Prognosis
o Duration
 • Ensure basic needs are met
(including food, shelter, sleep)
Safety and • Safe environment (safe enough)
Stability • Families and schools can play a
crucial role in making the child
feel safe
 • It depends
• No hard and fast rules
• Should be based on the formulation for each
When are individual child or young person, and their personal
choice
things stable • Enable child or young person and their carers to
make well-informed decisions about the relative
enough to do “costs and benefits” of the symptoms and the
intervention
trauma- • Try it with difficult but not overwhelming
experiences
focused work? • Not during an acute psychotic episode
• But if the PTSD symptoms are contributing to
instability, things may never be stable without
trauma-focused work
 • Formulation factors:
o How vital is trauma-focused work to outcome?

Stability factors o How much do PTSD symptoms contribute to instability?

• Individual factors:
to consider o
o
How able and willing is the CYP to seek help out of sessions?
How much capacity does the CYP have regulate emotions?

when o
o
How motivated is the CYP?
What is the level of drug use – occasional cannabis to numb
the symptoms, or frequent cocaine use
approaching • Systemic factors:
trauma o How stable is the placement?
o How much support does the CYP have between sessions
(e.g. other professionals, family, friends)?
focused work o What is the legal context (e.g. Leave to Remain, care order,
criminal proceedings)?
Elaborated from the work of o Are there other current demands on the CYP (e.g. exams,
therapists attending TFCBT training young carer)?
by NHS Education for Scotland • Therapist factors:
o Is supervision adequate?
o How many sessions are available?
 • Education about traumatic
reactions, and normalisation
• Education about model
(memory, meaning,
Psycho- maintenance) and rationale for
Education treatment
• Sharing the formulation
• Could use handouts, videos,
quizzes
 Youtube
Psycho- Brain Model of PTSD

education
Videos
 • Aim: to practice explaining the
rationale for trauma focused
Skills Practice: work to children.
Rationale for • Group:
o2 x clients (Vic and foster-carer)
Trauma- o1 x Therapist
Focused Work o1 or 2 x Observer(s) / co-
therapist(s)
• Time: 25 minutes
 • Provides stability and predictability
• Parental psycho-education (reactions and
rationale)
• Existing relationships can enable
processing:
o Make events are talkable-about
Systemic work o Help re-appraisals & correct mis-perceptions
o Provide support to avoid avoidance
• Explore system’s avoidance (e.g.
protection, guilt)
• Carers may need individual treatment
• Family endorsement of the child’s therapy
 • No clear guidance from trials
• Depends on:
o Age
o Carers supportive of intervention
Extent of o Able to continue work between sessions
o Level of carer’s distress
involvement of o Extent to which CYP is protecting carer
• Reviewing each session with carers and CYP
carers o Common unless contra-indicated
o Helps them to support CYP with any between session
tasks and reduce avoidant coping
o Further opportunity to tell story to a trusted adult
and receive support and clarification (of any muddles)
 • Message of trauma might be “Don’t trust
others”
• Clients may be hyper-vigilant to
information that will support their
Therapeutic mistrust of you
• Trust is usually vital to narration of event
context and and exploration of meaning
relationship • Provides opportunity to undermine
unhelpful beliefs about lack of trust,
safety, or control
• May take time to ‘undermine’ the
assumption that others cannot be trusted
 • Starts with initial contact
• Explain what will happen
Therapeutic • Explain therapy may be different
context and to other interactions with adults
relationship • Give as much control as possible
(Calm, collaborative, confident, (e.g. time, place, seating, order,
containing, compassionate,
competent) agenda)
• Boundaries are even more
important
 • Enhancing social support
• Emotion regulation
oBreathing retraining
oRelaxation
Developing oImagery
individual oGrounding
oProblem solving
resources oUse of therapeutic relationship to
scaffold affect regulation
• Only as required, based on
formulation
 • Lack of social support and social
withdrawal are risk factors for PTSD
in CYP (Trickey et al., 2012)
• Most people do not develop PTSD,
What’s so good possibly because they find a way to
about social process the event by talking about it
within their social support
support? • Some limited evidence that just
Interpersonal Psychotherapy (IPT)
reduces PTSD (Markowitz et al.,
2015)
 Supportive
Others Literally
Change How • Hills are rated as less steep if you are
accompanied by a friend
You See the
• The longer you’ve known them, the less
World steep the hill seems
(Schnall et al., 2008)
• Hills seem less steep if you just think of
a friend rather than a neutral person or
someone that has betrayed you
 O = Safe X = 20% chance of an electric shock
Support From
Someone you
Know, Love and
Trust Changes
Brain Activity
(Coan et al., 2006)
Social Circles
Think about the
relationships that have an
impact on you at the
moment (positive,
negative or mixed).
Put their name, initial or a
picture on the diagram to • If you are comfortable to do so, have a conversation
indicate how involved with with the person next to you about your social circles,
them you are or how close use the questions on the instructions if you like.
Alternatively discuss with the person next to you
they are to you
how this could be adapted and used for your clients;
what would be the challenges and what would be
the possible benefits?
 Are you surprised by anything that you put in?
0 5 10
Is there any person, or group of people missing?
Who helps and supports you through difficult times?
Which relationships cause some difficulties or distress?
Social Circles Which ones rely on you to make contact?
Which ones offer you practical support?
questions to Which ones are two-way, and which ones are one-sided?
Which ones would you like to see more of?
aid discussion Which ones would you like to see less of?

if necessary How would you like things to be different and how could you begin
to make those changes?

Do you already use something similar?

How easy would it be to incorporate something like this into your
work?
Do you anticipate any challenges?
 • Development of emotional vocabulary and understanding
o By increasing day to day “emotional commentary”
o Including how people manage difficult emotions
• Help them put their emotions into words (e.g. by asking
about their “emotional” day i.e. not just “what did you do
Emotion today?”, but also “and how was that?”)
• Help them find a way to rate the strength of their feelings
regulation • Acknowledge and celebrate emotional successes
• Ensure they are surrounded as much as possible by good
emotional regulation models
• Important for many interventions, but trauma seems to
lead to particular imbalance in brain circuits (e.g. a single
sculler with one arm stronger than the other)
Putting Feelings into Words
(Lieberman et al., 2007)

When confronted with faces showing anger or fear, labelling the emotion (as
opposed to other tasks involving similar stimuli) reduces activity in the (left)
amygdala and increases activity in the prefrontal cortex
 • Structured focused guided relaxation may
be more useful than lots of silences and
just noticing what comes up
• “Traumatized individuals tend to have
difficulty tolerating unstructured
Relaxation meditation and do much better with an
instructor whose guidance helps them
maintain their focus on bodily sensation,
while modulating arousal with breathing
exercises” van der Kolk et al., 2014
• Be sure to seek feedback from client
 • Can be used in several ways:
oIf CYP gets too upset during the
work, they can signal and you can
Developing an help them to bring up their safe
place.
Imaginal “Safe- oCan be used at the end of sessions
Place” to make sure they feel better when
they leave
oCYP can use it between sessions if
something makes them feel bad
 • Aim: To practice helping
Skills Practice:
someone develop an imaginary
Safe Place safe place
Development • Group: In pairs – as yourselves
Where would be a good place to go to feel really safe and comfortable? It might be a real place or an imagined one.
What do you think would be a good safe place for you to think about being in?
If it seems right and if the person is happy to do so, invite them to close their eyes, take a few slow steady breaths
and imagine being there.
What is that place like – tell me about it?
(Allow the person to talk freely, if necessary encourage them to elaborate - the following questions might be useful)
What can you see there? What colours are things?
What can you hear? What can you smell? What can you touch? How does it feel?
What is around you?
Who is there with you? – Is there someone that you’d like to have there with you. Imagine walking around and
exploring your special place slowly with them.
What else can you tell me about this place?
How does it make you feel?
Where in your body do you feel that? What’s it like? Can you focus on it? Can you allow it to grow and get bigger?
At a suitable moment, let the person know that they can bring this place up whenever they want to or need to. And
then prepare them to leave it.
Now get ready to open your eyes and leave your special place for now. You can come back when you want. When
you are ready, in your own time, come back to room XXX in the YYY Centre, with me ZZZ and slowly open your
eyes
 • Identify triggers (understanding volatile nature
of traumatic memories reduces sense of being
out of control)
• Experiment with just letting intrusions come
Dealing with and go (riding the wave or let it wash over them
rather) rather than actively trying to inhibit
Intrusions • Can they take control of them, rather than just
try to avoid them (e.g. grab-hold-rewind-play-
Between eject)

Sessions • Remind them of the psychoeducation and

develop self-talk to help
o It’s just a memory
o I am safe
o It happened then but it isn’t happening now
 • Distinguish from substance abuse
• Identify triggers
• Notice the warning signs
• Develop emotional regulation strategies
• Consider distraction:
Dissociation o Focusing on something in the present and
describing it
²Pattern on carpet
²Number of right-angles
o Grounding word or phrase
o Grounding object
o Grounding image
 • Remind them of the formulation; avoidance is
understandable and may reduce distress in the
short-term, but may not work so well in the
medium term
• Avoid avoidance between sessions (e.g. persons,
Reducing places and things)
• “Reclaiming their life” (Smith et al. 2010)
Avoidant • Imaginal rehearsing (may need to come after
memory processing)
Coping • In-vivo exposure may be necessary to “cement” the
cognitive work
• Stimulus discrimination for site visits, and working
with triggers (e.g. letting the intrusion and distress
trigger, but discriminate between then and now)
 • Activate the whole memory within the safe
context of therapy breaks the link between
stimulus (memory) and response (fear)
• Not trying to control or suppress emotions, but
tolerate
Narrative • Use whatever method fits with you and the
child (e.g. reliving, play, video-analogy,
Exposure drawings, story book, media coverage)
• Stance should be supportive, containing but
quite matter of fact
• Graded
• Identify and target hotspots
 • Have the young person feedback their
level of distress before, during and after
(e.g. Subjective Units of Distress - SUDs,
thermometer, speedometer, ruler)
• Use relaxation, but not as avoidance
Narrative • Involve or share with carer where
appropriate
Exposure o But prepare them first, explain rationale, help
them to be supportive
• May spontaneously disrupt the
maintenance cycles outside of the session
• Quick gains are not uncommon, but it
usually needs to be repeated
 • Practice on non-traumatic event
• Plan start point (before event) and end point (when they
felt safe)
• Eyes closed, if they are comfortable
• Story
o Imagine back there
o Lots of detail, sensory information, thoughts, feelings
Imaginal o 1st person, present tense
• First time may be brief, but avoid too many prompts

Reliving • Feedback from CYP:

o
o
How was it?
As expected?
(Smith et al., 2010) o Any surprises or new things?
o How do you feel now you’ve done it?
• Praise
• Subsequent accounts
o More prompts for details, especially hotspots
o Occasional SUDs
o Rewind and hold to garner more information
o Use alternative perspective if helpful
Symptom levels session by session
10 year old girl – Road traffic collision (RCT participant)
50 TOTAL
Child PTSD Symptom Scale (CPSS)

Reliable Change Criterion: 14 (max) Intrusions

40 Avoidance
Hyperarousal
30

20
PTSD Cut-offs:
11, 16 (Total score)
10

0
1 2 3 4 5 6 7
n n n n n n n
s io s io s io s io s io s io s io
e s e s e s e s e s e s e s
S S S S S S S
Symptom levels session by session
14 year old boy – bereavement by suicide
50 TOTAL
Children’s Revised Impact of Event

Reliable Change Criterion: 13 Intrusions

40
Avoidance

30
Scale (CRIES)

20 PTSD Cut-off:
17 (Total score)
10

0
t
e n ion ion ion ion rge
s s s s
s m es es e s e s
c ha
s es S S S S is
s d
3r
d th th D
A 2n 4 5
Symptom levels session by session
16 year old girl – road traffic collision
40
Children’s Revised Impact of Event

Reliable Change Criterion: 13

35
30
Scale (CRIES-8)

25
20
PTSD Cut-off:
15 17 (Total score)

10
5
0
t 2 3 4 5 6 7 e
en arg
sm ch
s es is
D
As
 • Many CYP make “sudden gains” when
receiving trauma-focused interventions
• Aderka et al., 2011:
o Prolonged exposure for 63 x 8-17 year olds
with PTSD following RTC, terror attacks,
sexual assaults etc
o Sudden gain defined as:
Sudden gains ²Change in CPSS score of 4 or more and
²More than 25% of the pre-gain score and
²Statistically significant difference between
the scores of the 3 sessions before the gain
and the 3 sessions afterwards
o 49.2% of participants made “sudden gains”
o 48.6% of total reduction were “sudden”
Symptom levels session by session
12 year old boy, traumatic bereavement
40
Children’s Revised Impact of Events

Reliable Change Criterion: 13

35

30

25
Scale (CRIES)

20
PTSD Cut-off:
15 17 (Total score)

10

0
r il ay ne l y st er er e r er ry ry ch r il
Ap M u Ju gu b b b b a a a r
Ap
J
Au tem ct
o
em em
anu bru M
ov De c
ep O
N
J Fe
S
 Film strip
stories
(McIntyre & Hogwood, 2006)
My life before The worst part of it

My life since My hopes for my future

 • Aim: To help a client to put their
traumatic experience into words.
• Group (Split into smaller groups if you
wish):
Skills Practice: o 1 x client (Sam)
o 1 x main therapist
Trauma o remainder observers / co-therapist
• Time: 25 minutes
Narrative • Health warning:
o Please be extra careful; ensure that
everyone is completely happy with the
choice of traumatic event, if there is any
doubt, simply use a different traumatic
event(s)
 • Peri-traumatic cognitions may “spill over” in to
everyday life
o World
²Everywhere is dangerous
o Self
Common ²I caused it
²I asked for it
Traumatic ²I’m only good for one thing

Misappraisals ²I should have stopped it

²I’m damaged
o Others
²Nobody cares about me
²Adults are dangerous, especially those that are
supposed to care for me
 • Needs to be truly collaborative
• Important to validate and be curious rather than
“target and destroy”:
• “Hotspots” (moments in the memory of high
affect) may be related to the most troublesome
Trauma- cognitions
• CPTCI may help to identify ‘targets’
specific • Trauma related cognitions (the message of the
trauma) may change spontaneously, simply
cognitive work through narrative exposure because they can
‘benefit’ from a complete account including
corrective information and not just fragments
• May update memory with information from other
sources e.g. paper, friends, hospital, site visit,
engineer reports
 • If not, the memory may need to be
updated by CR within narrative
work to update the message of the
trauma stored in the memory e.g.:
Integrating CR oActivate the memory (e.g. through
and reliving reliving) to bring it “on-line” and
replace peri-traumatic cognitions with
restructured ones
oUse written re-scripting of the
narrative
 • Cannot change what happened
• But can thoroughly analyse it to ensure the interpretation is
fair and justified:
o Hindsight bias (e.g. Did you know that at the time?)
o Responsibility (e.g. Is that really your job?)
o All or nothing thinking

Guilt
o Prevention (e.g. Was it really preventable?)
o Cause (e.g. Help me understand that?)
• Consider alternative views, even if you do not agree with
them (e.g. What do others say?)
• Assess data that supports different views
• What would you say to a friend; why is it different for you?
• Allocation of responsibility (e.g. pie chart, lego tower)
 • May help reduce avoidant coping
• May assist elaboration and
processing of the memory
Site Visits
• May lead to changes in
cognitions
• Plan, support, wrap-up
 • Relapse is rare (e.g. Gutermann et al.,
2017)
• Identify possible future triggers (e.g.
anniversary, court case)
• How will they know if it’s becoming a
Endings and problem
Future • What have they learned that will help
them
• What other sources of support might
they have?
• Celebrate
 TF-CBT
Application
Single-incident PTSD Complex PTSD
Good attachment Poor attachment
Supportive family
Socially supported Unstable placement
Multiple,
inter-personal
incidents Unhelpful peer group
Single
incident
ADHD Dissociation
PTSD
DSH PTSD DSO
Depression Anxiety

16-25 x
8-16 x Risk of
TF-CBT
TF-CBT dropout
+ MDT

Symptom free, Statistically and

Post-traumatic clinically significant
growth (PTG) symptom reduction
Complex Trauma – more intervention (Cohen et al., 2017)
TF-CBT for CYP
with PTSD &
CPTSD • CPTSD group had higher PTSD scores than
(Sachser et al., 2016) PTSD group before and after intervention
• PTSD in both groups responded to TF-CBT
(statistically significant and large effect sizes)
• DSO symptoms in CPTSD group significantly
reduced, medium to large effect sizes
 • Three samples, from two studies (PE, CPT and CPT-
C)
• 18% of participants experienced symptom
exacerbation (defined as increase of > 6.15 points
Some (adults) on PSS or PDS)
• Most of those had a corresponding decrease by the
get worse following session
• Overall 2% (n=4) experienced exacerbation that did
before they get not subsequently improve at all
• Exacerbation was not related to pre-treatment
better severity
(Larsen et al., 2016) • Exacerbation was not related to non-completion
• Those who experienced exacerbation, tended to
not do as well as others, but overall they still
experienced significant improvements
 • Some research suggests high levels of
drop out of CYP receiving treatment
after trauma
o E.g. 69% finished before completion and
41% received less than an “adequate
Preventing dose” (12 sessions in 16 weeks) Wamser-
Nanney & Steinzor, 2016
drop out • Others have very low levels of drop
out
o E.g. 0% (Smith et al., 2007)
o 7% compared to 14% in WLC (Meiser-
Stedman et al., 2016)
Working with challenges
Elaborated from the work of therapists attending TFCBT training by NHS Education for Scotland

Questionnaires Assessment
Diagnosis

Inform professional system e.g. Formulation Inform intervention e.g.

• Manage expectations of timing & • When TF work not
timescales appropriate (e.g. not PTSD)
• Understand behaviour as symptoms • When TF appropriate (e.g. if
of PTSD (as opposed to ADHD) depression is secondary to
PTSD, or symptoms of OCD are
actually symptoms of PTSD)
Inform client’s system e.g.
• Help family to facilitate processing
• Help family to understand symptoms
 • Adhered to principles of TF-CBT
• More involvement of carers in treatment
(either joint sessions, or individual sessions
observed by carers)
o But some individual sessions for child are usually
Treatment for PTSD in helpful
Infants & Toddlers • More behavioural management components
(e.g. Scheeringa, 2011) for carers
• More relaxation
• More use of child-friendly visual aids (e.g.
cartoons of psycho-education)
• More drawing and playing for imaginal reliving
 • TF-CBT led to reduction in PTSD in
3-6 year olds
TF-CBT, • Also reduction in maternal
maternal depression
depression, • Evidence found that decreased
maternal depression influences
Child PTSD decreased CYP PTSD, and vice versa
(Neil et al., 2018)
• This adds to research that supports
TF-CBT for young children
 • Persistent deficits in the ability to
initiate and to sustain reciprocal
social interaction and social
ASD (ICD-11) communication
• Range of restricted, repetitive,
and inflexible patterns of
behaviour and interests.
ASD, trauma, PTSD & therapy (Adapted from Hoover, 2015)
Social communication difficulties

Harder to report Tend to under-

Interpret events
Social isolation, events and report on rating
differently,
less popular, reactions scales
especially inter-
more vulnerable
personal aspects
More reliance on parental report

Increased
Increased Reactions to trauma may be missed Find TF-CBT
exposure to
sensitivity to or misinterpreted as exacerbation of difficult to
potentially
traumatic events ASD symptoms access
traumatic events
 • Thinking about the young
person that you brought to
mind earlier:
Application oWhat is your formulation (use
diagrams if it helps)?
15 minutes - oWhat is likely to help and what is
small groups your role in that?
oWhat obstacles to that might you
predict, and how might you get
over them?
 • No real evidence of contra-indicators
• Comorbid condition is not automatically a
reason not to use CBT
o Most CYP with PTSD will have another diagnosis as
well
o Which might be secondary to the PTSD
Contra- o Return to formulation, involve team and supervision
• TF-CBT unlikely to be very helpful if:
indicators o On going significant threat
o Child or young person not signed up to intervention
o Family undermining
• Limited capacity to regulate emotions may lead
to focusing on resource development rather
than trauma
 • Trauma-focused therapy should not
be unnecessarily delayed or avoided
• But consider individual presentation
and risk
UKPTS CPTSD • Be careful when doing exposure
o Individualised
Guidelines o Incremental
• Recent self-harm or suicidality then
there will be more focus on
o Stabilisation
o Psycho-education
 Evidence to
Support CBT
for PTSD
 • Single case designs (e.g. Saigh, 1986 -
1989)
• Various uncontrolled experimental designs
Evidence (e.g. Feeny et al., 2004)
• 20+ Randomised controlled trials (RCTS)
supporting CBT o Including Cohen et al., 2004: multisite,
n=229, TF-CBT vs Child Centred Therapy
for CYP with • Several reviews (e.g. NICE, 2005; Dalgleish
PTSD et al., 2005; Stallard, 2006; Cohen et al.,
2009;)
• Several meta-analysis (e.g. Wethington et
al., 2008; Gutermann et al., 2016)
 • 31 studies; 7 different interventions (included
two EMDR studies as a form of CBT)
• PTSD, depression, anxiety, externalising, suicidal
Meta-analytic ideation, substance abuse
Support of CBT • Strong evidence showed that individual and
group CBT can decrease psychological harm
for CYP with among symptomatic children and adolescents
exposed to trauma
PTSD • Evidence was insufficient to determine the
effectiveness of play therapy, art therapy,
(Wethington et al., 2008) pharmacologic therapy, psychodynamic
therapy, or psychological debriefing in reducing
psychological harm
 More meta- • 135 studies; 150 interventions,
9,562 participants
analytic
• CBT, especially when conducted
Support of CBT in individual treatment with the
for CYP with inclusion of parents, is a highly
PTSD effective treatment for trauma
(Gutermann et al., 2016) symptoms
 • 47 studies; 56 interventions,
3767 participants, longest follow
Meta-analysis up 5 years
of long term • Treatment gains of psychological
interventions for young PTSD
treatment patients are maintained over
effects time, although more follow-up
(Gutermann et al., 2017) studies are needed to expand
and replicate these meta-
analytic results
 • Strengthens the support for TF-CBT
• Supportive counselling is not
Network Meta- effective
Analysis of • Emotional Freedom Technique
interventions (EFT), Child-Parent Psychotherapy
and Meditation showed large effect
for PTSD in CYP
(Mavranezouli et al., 2019) size, but based on very limited
evidence. Therefore further
research is needed
 TF-CBT with Complex Trauma
Feather & Ronan, 2009 Multiple abuse (emotional, physical, D.V.) TF-CBT 16
Runyon et al., 2009* Physical abuse, living with abuser CPC-CBT 16
Ahrens & Rexford, 2002 Detained young people CPT 12
Kataoka et al., 2003 Ethnic minority (Latino immigrants) G-CBT 8
Najavits et al., 2006 Comorbid substance misuse SS* 25
McMullen et al., 2013; Child soldiers G-TF-CBT 15
Ertl et al., 2011 NET 8
O’Callaghan et al., 2013 Sexually exploited, war-affected Congolese girls G-TF-CBT 15
rejected by families
Cohen et al., 2004 (etc.) Sexual abuse TF-CBT 12
Barron et al., 2013 War-affected Palestinian CYP (peri-traumatic) TRT 5
Ito et al., 2016 Severe symptom 3 yrs post-earthquake CT 1
 • A handful of RCTs (only 3 of
sufficient quality to be considered
by NICE)
Evidence for • 3 Meta-analyses (e.g. Gutermann et
al., (2016) - Small effect size
EMDR for CYP (g=0.49))
with PTSD • Currently only recommended by
NICE for CYP with PTSD, if the CYP
has not engaged with or responded
to TF-CBT
 • Medication
o Not supported by any RCTs for CYP (e.g. NICE, 2018)
o May have a role in symptom management (e.g.
Donnelly, 2009)
• Psychodynamic psychotherapy
Other o Better than group therapy (Trowell et al., 2002)
o Child-Parent Psychotherapy better than TAU for 3-5
Interventions year olds who had witnessed domestic violence
(Lieberman et al., 2005)
• Family therapy and non-directive creative
therapies are not supported by the evidence
o But CBT may involve family and should be adapted
to make it age-appropriate, so may make use of art,
play and drama
 NICE Guideline PTSD, 2018 (NG116)
1 – 3 Months
0 – 1 Month since event(s) since event(s) 3 Months + since event(s)

5–6 Consider TF-CBT

year olds
Do not offer
Consider
psychologically-
Active Consider
focused debriefing for Consider
Monitoring Consider TF-CBT
the prevention or EMDR only
or TF-CBT Group TF-
7 – 17 treatment of PTSD if they do
CBT for Offer
year olds not respond
large scale TF-CBT
to or
shared
engage with
trauma
TF-CBT
 Recommendations for Prevention and Treatment
(NICE PTSD Guideline, 2018; NG116)
1 – 3 Months
0 – 1 Month since event(s) since event(s) 3 Months + since event(s)

5–6
year olds

Do not offer drug treatments for the prevention or treatment of PTSD

in children and young people aged under 18 years
7 – 17
year olds
 1.3.1 Promote access to services for people with PTSD by:
• minimising the need to move between different services or
providers
• providing multiple points of access to the service, including
Promoting self-referral
• offering flexible modes of delivery, such as text messages,
access to email, telephone or video consultation, or care in non-
clinical settings such as schools or offices

services • offering a choice of therapist that takes into account the

person's trauma experience – for example they might
(NICE PTSD Guideline, 2018; prefer a specific gender of therapist
NG116) • using proactive person-centred strategies to promote
uptake and sustained engagement
• assessing the need for further treatment or support for
people who have not benefited fully from treatment or
have relapsed
 1.6.2 Be aware that people with PTSD
may be apprehensive, anxious, or
ashamed. They may avoid treatment,
Engagement believe that PTSD is untreatable, or
(NICE PTSD Guideline, 2018; have difficulty developing trust.
NG116) Engagement strategies could include
following up when people miss
appointments and allowing flexibility
in service attendance policies.
 • 1.1.6 Do not rely solely on the parent or carer for
information when it is developmentally appropriate
to directly and separately question a child or young
person about the presence of PTSD symptoms.
Specific • 1.1.7 When a child who has been involved in a
traumatic event is treated in an emergency
recognition department, emergency staff should explain to
their parents or carers about the normal responses
to trauma and the possibility of PTSD developing.
issues for Briefly describe the possible symptoms (for
example, nightmares, repetitive trauma-related
children play, intrusive thoughts, avoiding things related to
the event, increased behavioural difficulties,
problems concentrating, hypervigilance, and
difficulties sleeping), and suggest they contact their
GP if the symptoms persist beyond 1month.
 Five essential • Evidence-informed, rather than
elements of evidence-based
immediate and • Guidelines not a prescriptive manual
• Post crisis psycho-social interventions
mid-term mass should seek to promote:
trauma o Sense of safety
o Calming
intervention o Sense of self- and community-efficacy
(Hobfoll, Watson, Bell, Bryant, Brymer,
Friedman, Friedman, Gersons, de Jong, o Connectedness
Layne, Maguen, Neria, Norwood, Pynoos,
Reissman, Ruzek, Shalev, Solomon,
o Hope
Steinberg & Ursano, 2007)
Legal Issues
 • Therapy may decrease distress, which may decrease the
impact of evidence
• Developing narrative in therapy may be used to claim that
account was convincing not because it is true, but because
it has been “rehearsed” in therapy

Therapy and • Inconsistencies that come to light in therapy may be used

to cast doubt upon veracity of account

criminal • Benefits of pre-trial therapy should be weighed against

possible risk to trial

prosecutions • See:
o England & Wales - Provision of Therapy for Child Witnesses
Prior to a Criminal Trial available at
http://www.cps.gov.uk/publications/prosecution/therapychild.
html
o Scotland - Code of Practice to Facilitate the Provision of
Therapeutic Support to Child Witnesses in Court Proceedings
http://www.gov.scot/Publications/2005/01/20535/50112
 Further
information and
training

On-line training:
https://tfcbt.musc.edu