Van der Oord, Lucassen, van Emmerik, & Emmelkamp (2010). Treatment of post-traumatic stress disorder in children using cognitive behavioural writing therapy

PTSD symptoms may persist into adulthood if children are not treated adequately. Cognitive behavioural treatment is more effective than a waitlist condition (1), community treatment (2), supportive therapy (3) or child-centred therapy (4) on short- and long-term outcomes. However, there is no consensus regarding essential aspects of the treatment (e.g. should anxiety management procedures be added?). Furthermore, most studies focus on a single traumatic event rather than complex trauma (i.e. multiple traumatic events).

Imaginal exposure and cognitive restructuring of trauma-related dysfunctional cognitions are seen as essential to CBT. Written exposure may be effective through the same mechanisms as exposure in CBT. Cognitive behavioural writing assignments produce materials which can be shared with partners or parents (i.e. social sharing). Social sharing may promote social support which reduces PTSD symptoms.

The narrative exposure treatment (NET) only uses the trauma narrative. It aims to reduce PTSD symptoms by confronting the patient with the memories of the traumatic event. The goal is to integrate the fragmented, gap-filled reports of traumatic experiences into a coherent narrative and bring about the habituation of emotional responses to reminders of the trauma. Cognitive restructuring and social sharing are not explicitly included in NET. NET seems to be effective in reducing PTSD symptoms.

The most important elements of cognitive behavioural writing therapy (CBWT) are psychoeducation (1), exposure (2), cognitive restructuring (3), promoting adequate coping (4) and social sharing (5). It does not include relaxation training. In the case of multiple traumas, a timeline is constructed and the most distressing trauma is then described into more detail. The written account of the traumatic event is further integrated into a complete storyline during the course of treatment.

Sessions are individual but joint parent-child sessions can be provided when necessary. The first session is devoted to the rationale of the treatment and psychoeducation. The therapist helps the child write by asking explicit questions and giving examples of what other children may feel. During the writing, the therapist helps the child to restructure the maladaptive thoughts (i.e. cognitive restructuring) and learns the child how to identify and restructure maladaptive thoughts.

In each therapy session, the child rereads the story of the trauma as this serves as exposure and then continues describing the remainder of the story. At the end of the story, the therapist and the child generate potential coping strategies for the future. Afterwards, the story is shared with important people.

CBWT leads to a decrease of PTSD symptoms (1), depressive symptoms (2) and internalizing and externalizing behavioural problems (3). This was maintained at 6-months follow-up. The results are comparable to other evidence-based interventions. However, there was no control condition so it is difficult to compare to other treatments.

CBWT uses a computer and this may be especially motivating for children. The use of a storyline facilitates the child to make a coherent story of the traumatic event with a beginning and an end. This may facilitate processing of the traumatic event.