Trauma refers to a normal response to an abnormal event. About 14% of the children exposed to a trauma develop PTSD. The probability of developing PTSD increase the longer and more severe the traumatic events are.

PTSD includes several symptoms:

• Intrusion symptoms (e.g. nightmares; flashbacks)
• Avoidance behaviour
• Negative alterations in cognitions and mood (e.g. the world is unsafe)
• Alterations in arousal and reactivity (e.g. poor concentration)

The symptoms need to last for at least a month. For late-onset PTSD, the symptoms need to have an onset of 6 months after the traumatic event. The intrusion symptoms in children are represented in pretend play (e.g. playing the traumatic experience). Regressive behaviour (e.g. going back a developmental step) is common in children with PTSD.

There are several risk factors to develop PTSD:

• Direct exposure to life threats.
• Being separated from parents during or shortly after the traumatic event.
• Serious bodily injury.
• Losing a loved one.
• Witnessing cruelties or violence.
• Experiencing the use of weapon.
• Violation of the physical integrity of a child.
• A known perpetrator.
• A negative intention of the perpetrator.

There are also several secondary sources of stress as a risk factor:

• Suffering great material losses.
• Lack of basic facilities.
• Moving houses.
• A shocking event with a long aftermath of stress.
• Pedagogical shortcomings in parents.

There are also several risk factors in children:

• Level of development.
• Temperament.
• Quality of attachment relationships.
• Guilt about the trauma.
• Previous traumatic experiences.
• Existing problems or psychopathology.
• Strong emotional reaction right after the traumatic event.

Ehler and Clarke’s cognitive model of PTSD states that persistent PTSD only occurs if individuals process the traumatic event and/or consequences in a way which produces a sense of serious, current threat. People with persistent PTSD are unable to see the trauma as a time-limited event that does not have global implications for their future. There are two key processes that lead to this sense of threat:

• Individual differences in the appraisal of trauma and its consequences.
• Individual differences in the nature of the memory for the event and its link to other autobiographical memories.

The perception of current threat is accompanied by intrusions and other re-experiencing symptoms when activated. This motivates a series of behavioural and cognitive responses that are intended to reduce perceived threat and distress in the short-term but prevent cognitive change. This maintains the disorder.

The emotional processing theory states that posttraumatic symptoms reflect the development of a problematic fear structure comprising many stimuli, responses and meaning representations. There are maladaptive responses when this is triggered.

The social cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. According to this theory, trauma-related feelings and thoughts should be reviewed to process the experience fully and correct dysfunctional beliefs and emotional reactions.

It is essential to treat children with PTSD because there may be stagnation of development and brain development may be influenced. They are at higher risk for developing comorbid problems when untreated. The goal of treating PTSD are processing the traumatic event so that the fear of traumatic events decreases. The sensory, fragmented memories are transformed into a meaningful, coherent story.

There are five steps from intake to treatment:

• Intake.
• Check the current safety of the child.
• Diagnostic process.
• Psychoeducation.
• Treatment.

Trauma-focused cognitive behavioural strategies (TF-CBT) involve a combination of coping skills training (1), cognitive restructuring (2), therapist- and client-led exposure (3) and parent interventions (4). This treatment has several goals:

• Mastering skills to manage stress and improve affective, behavioural and cognitive regulation early in treatment.
• Inclusion of parents whenever feasible.
• Mastering trauma reminders and traumatic avoidance.
• Making meaning and contextualizing traumatic experiences through affective and cognitive processing (i.e. moving beyond victimization).
• Enhance safety and optimize future development.

It aims to help children overcome traumatic avoidance (1), shame (2), sadness (3), fear (4) and other trauma-specific emotional and behavioural difficulties (5). It is not a first-line treatment but can help when children have stabilized. The treatment consists of several components named PRACTICE:

• Psychoeducation.
• Parenting skills.
• Relaxation skills.
• Affective expression and modulation skills (i.e. identifying and expressing feelings).
• Cognitive coping skills.
• Trauma narration and cognitive reprocessing of traumatic experiences.
• In vivo mastery of trauma reminders.
• Conjoint child-parent sessions.
• Enhancing safety and future developmental trajectory.

Each component builds on the previously mastered skills. It typically lasts for 8 to 20 sessions and is completed when all the components have been provided. Other intervention to consolidate the skills may be necessary.

The treatment is efficacious with a remission rate of 80 to 90%. It enhances parental support (1), effective parenting practices (2) and reduces parental levels of depressive and trauma-related symptoms (3). Parental emotional distress and parental support are good predictors of outcome. The treatment may be preferred for children with multiple traumas and those with more depressive symptoms.

Eye movement desensitization and reprocessing (EMDR) therapy is a brief treatment in which the patient holds a disturbing image from the trauma memory in mind while engaging in sets of saccadic eye movements. The rationale is that any form of distraction (e.g. tapping) overloads the working memory and prevents the negative emotion to be associated with the traumatic memory. This continued exposure eventually prevents the negative emotion to occur. The sessions consist of history taking (1), treatment planning (2), preparation (3), reprocessing (4), installation of a positive cognition (5), check for and processing any residual disturbing body sensations (6), positive closure (7) and evaluation (8).

EMDR story telling includes writing the story with the parents following the WRITEjunior structure. The story is then shared with the child while using EMDR techniques. This is done when the trauma occurred in the preverbal phase.

Cognitive behavioural writing therapy (CBWT) involves exposure to the trauma memory and restructuring of trauma-related beliefs through writing and updating of the trauma memory on a computer with the support of a therapist. The sessions include psychoeducation (1), imaginal exposure (2), cognitive restructuring (3), promoting healthy coping strategies (4) and enlisting support from loved ones (5).

Both EMDR and CBWT do not actively use parental involvement. Both treatments are efficacious and lead to reductions in child- and parent-reported symptoms of PTSD (1), anxiety (2), depression (3) and behavioural problems (4) and the results are maintained for 12 months. EMDR seems a bit more effective for PTSD symptoms.

WRITEjunior refers to a PTSD treatment where the client and the therapist write a story together. It includes cognitive restructuring (1), exposure (2), social sharing (3) and strengthening coping behaviour (4). It has a wide applicability as works for:

• Children with PTSD.
• Children of parents with psychiatric problems.
• Revealing secrets.
• Children with preverbal trauma.

The role of the therapist is directive and supportive. The therapist helps to find words to describe events, thoughts, feelings, bodily sensations and behaviour. They are well aware of the timeline and structure of the text.

The story has the following structure:

• Making a timeline.
• Title.
• Introduction.
• Rationale of the treatment (i.e. very explicit about what happened)
• Description of context or good memories.

The social sharing aspect of writing therapy may enhance social support. Written exposure may be effective through the same mechanisms as exposure in CBT. The goal of cognitive restructuring is to put the victim back in charge. There is a Socratic dialogue to prevent the client from going into the flight/fight/freeze response

Both EMDR and WRITEjunior are effective in reducing PTSD symptoms (1), anxiety (2), depression (3), physical problems (4) and behavioural problems (5). The parental PTSD symptoms also reduce when using these treatments. EMDR is effective in about 4 to 5 sessions, making it a bit quicker than WRITEjunior.

Narrative exposure treatment (NET) refers to a treatment for PTSD which only uses the trauma narrative. It aims to reduce symptoms by confronting the patient with memories to integrate the fragmented reports of traumatic experiences into a coherent narrative and bring about habituation of emotional responses to reminders of the trauma. It does not actively include cognitive restructuring and social sharing and is mainly focused on exposure.