This document discusses various interventions for children and adolescents exposed to trauma. It covers several key considerations for treatment, including safety, the therapeutic relationship, and using a strengths-based approach. Two evidence-based trauma-focused therapies are described in detail: trauma-focused cognitive behavioral therapy (TF-CBT) and child-parent psychotherapy (CPP). TF-CBT uses psychoeducation, parenting skills, relaxation techniques, cognitive processing, and exposure. CPP focuses on improving the relationship between the child and caregiver through play and dyadic sessions.

1. Trauma: Assessment
and Intervention
TRAUMA FOCUSSED INTERVENTION FOR
CHILDREN AND ADOLESCENTS

2. Interventions with Trauma Exposed Children
and Adolescents: Foreword
Important considerations when working with children and adolescents
Evidence based treatments must be used with children and adolescents
 Treatment should be developmentally appropriate (child’s age or level
of development where delays are evident)
 Treatment must be specifically designed for children and adolescents
 It is not appropriate to simply adapt treatments developed for adults to
children or adolescents
Regardless of one’s professional background clinicians must have
specialist training, knowledge and competencies in all areas of assessing
and treating children and adolescents exposed to trauma

3. Interventions with Trauma Exposed Children
and Adolescents: Key Considerations, Safety
Safety risks include;
self-harm and suicidality
substance abuse or psychopathology
ongoing exposure to traumatic events/situations e.g. family
violence, abuse, neglect
behaviour that places the child or adolescent at risk for
sexual victimisation
community violence
life-threatening illness
legal problems and incarceration

4. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Safety
It is inappropriate to conduct any form of trauma focussed
therapy while the child/adolescent is at risk of, is under
imminent threat of or, is currently being re-traumatised
If threats to safety are identified, the focus of therapy
becomes the safety and stabilisation of the child or
adolescent. This may mean engaging other services such as
child protection services, helping the child or parent(s) with
connecting to other resources such as legal services or
community based and government based services relevant to
their immediate safety needs

5. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Safety and
Multi-Systemic Therapy (MST)
The Multi-systemic therapy (MST) program is an in home
intensive family-based intervention for severe behavioural
disorders in young persons aged 10-16 years. The program
lasts four to six months
The primary focus of MST is on behaviour change within
the family through:
 improved communications styles
 promotion of school engagement
 promotion of positive social activities with peers

6. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Safety and
Multi-Systemic Therapy (MST) (con)
One adaptation in the Australian context of implementing MST is the use
of cultural advisors (or cultural supervisors). Generally, the role of the
cultural advisor includes;
“providing clinical staff with information to increase their awareness and
knowledge of relevant norms, treatment expectations, and behaviours
within particular cultural groups, provide advice about how to adjust
MST training and clinical support protocols to better conform to local
teaching standards, provide a liaison with culturally appropriate natural
supports in the community, facilitate the family’s engagement with the
MST therapist by accompanying the therapist to select initial meetings,
and when indicated, assisting the therapist with interventions to ensure
that they are being implemented in a culturally appropriate manner.”
(Schoenwald, Heiblum, Saldana, & Scott Henggele p. 219).

7. Interventions with Trauma Exposed Children
and Adolescents: Key Considerations, Safety
TARGET
A young person identified as abusing substances in conjunction with
posttraumatic stress symptoms or disorder may benefit from the
intervention of TARGET
Interventions for addiction such as TARGET should be a priority of
treatment.
TARGET is an intervention designed to help clients identify their
personal strengths by developing a new skill set that is applied when
experiencing stress reactions in their current lives
TARGET has shown evidence of effectiveness in rigorous research
studies in reducing PTSD and psychiatric symptoms and trauma-related
beliefs, sustaining sobriety-related self-efficacy and improving emotion
regulation skills, with adolescents’ and adults with chronic PTSD and
SUD.

8. Interventions with Trauma Exposed Children
and Adolescents: Key Considerations, the
Therapeutic Relationship
The foundations for the therapeutic relationship begin in the assessment
stage
Initial treatment sessions are instrumental in establishing and
strengthening the therapeutic relationship
The therapeutic relationship is maintained throughout treatment
The caregiver may also be traumatised and quite distressed about the
traumatisation of their child. This has the potential of leading to
difficulties in establishing and maintaining secure and responsive
relationships between the caregiver and child and caregiver/child with
the therapist

9. Interventions with Trauma Exposed Children
and Adolescents: Key Considerations, the
Therapeutic Relationship (con)
The caregiver may also be traumatised and quite distressed about the
traumatisation of their child. This has the potential of leading to
difficulties in establishing and maintaining secure and responsive
relationships between the caregiver and child and caregiver/child with
the therapist
Ford and Cloitre, (2009) suggest that in therapeutic treatment for
“children with PTSD the therapeutic relationship should be viewed as
triadic rather than dyadic: bridges linking the child, caregiver and
therapist affectively to each other such that the therapist provides co-
regulation for the child and caregiver, empowering the caregiver to
assume this role with the child while secure in the therapist’s
unconditional, non-intrusive, non-competitive empathy and guidance”
(p.61)

10. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Treatment with
Children and Families is Always Relational
Within this therapeutic setting, goals for treatment must be
identified with caution. The psychoeducation phase of
treatment provides the therapist with an opportunity to learn
the child’s and caregivers’ goals as well as to teach them
about PTSD and recovery
It is important that the goals set (e.g. complete recovery,
elimination of avoidance behaviours, time frames etc.) are
realistic and are of immediate personal relevance to the child
and caregiver(s)

11. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Treatment is
Always Strengths-Based
Consider treatment approaches that are inclusive of
comorbid disorders and behaviour and emotional symptoms
as well
Identify the child’s existing or former, strengths, resources
and resilience, including the economic resources available to
the child
The child/adolescent is part of a micro culture of the family
and the family is a potentially powerful source of support
and healing for the traumatised individual

12. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Treatment is
Always Strengths-Based
Sometimes the impact of traumatic and adversarial events
stretch the family’s resources and the traumatised child/
adolescent along with caregiver(s) may need treatments that
involve strengthening the family ties, relationship dynamics,
and attachments, as well as treatment associated with the
trauma. Such treatments (for example Attachment Self-
Regulation Competencies Framework (ARC)) help the
therapist maintain a consistent strengths-based approach in
treating traumatised children and adolescents

13. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Preventing and
Managing Crises
The child or adolescent my currently live in safe and stable
environments within the protection of safe and stable
relationships. Furthermore, the child adolescent may have a
supportive network within their primary relationships such
as immediate and extended family members, peers and or
other available role models (social support systems). All of
these factors are strengths to be drawn upon during
treatment, in preventing crises

14. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Preventing and
Managing Crises (con)
Many children also enter therapy who have a history of any
number of losses due to deaths, out-of-home placements,
institutionalisation, family abandonment and, neglect and
abuse due to parental and familial psychopathology,
substance use disorders, violent or antisocial lifestyles, or
severe socioeconomic adversities . For these children and
adolescents further rejection, losses and disappointment
come to be expected
Caring adults and peers are viewed as undependable.
Consequently, for these children and adolescents both
negative and positive situations can lead to an increase in
trauma symptoms

15. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Preventing and
Managing Crises (con)
Distress and dysregulation is predictable when traumatic
memories are provoked by and re-enacted in times of
relational uncertainty. The best approach to preventing or
managing crises or deterioration is to provide the child and
all caregivers to the child with psychoeducational assistance
that helps them to understand the behaviours the child
engages in, and anticipate and, address predictable
manifestations of dysregulation
Sometimes crises cannot be prevented, in such instances
provision of, reassurance, immediate safety, structure and
limits will be useful

16. Interventions with Trauma Exposed Children and
Adolescents: Key Considerations, Preventing and
Managing Crises (con)
Crisis de-escalation with traumatised children generally
requires the use of several focal interventions and strategies
that include re-establishing a sense of emotional connection
In the post- crises stage, therapeutic processing includes a
strengths based approach whereby the child /adolescent is
encouraged to identify and acknowledge the techniques of
self-regulation they used in resolving the crisis

17. Interventions with Trauma Exposed Children
and Adolescents: Key Considerations,
PRACTICE
The key elements in psychotherapy for children with PTSD are
summarized by the acronym PRACTICE:
Parenting skills and Psychoeducation
Relaxation skills
Affect modulation (helping the child and caregivers manage emotional
distress)
Cognitive coping skills
Trauma narrative reconstruction
In vivo application of skills (practicing skills and confronting reminders
of traumatic experiences in daily life)
Conjoint parent child sessions (treatment sessions with the parent and
child together)
Ensuring safety and post therapy adjustment

18. Interventions with Trauma Exposed Children
and Adolescents: Trauma Focussed-Cognitive
Behaviour Therapy ( TF-CBT )
The most extensively validated psychotherapy approach for sexually or
physically abused or traumatically bereaved children with PTSD is
trauma-focused cognitive behaviour therapy, and adaptations of the
measure for traumatised toddlers and pre-schoolers, have shown
promise. Note: TF-CBT is also effective for other types of trauma
exposure
TF-CBT is a short-term, three phase treatment typically provided in 12 to
18 sessions of 50 to 90 minutes, depending on treatment needs. The
intervention is usually provided in private therapeutic sessions, but it has
been used in group settings (e.g. hospitals, schools). The duration of
therapy will vary between individual and group settings

19. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT
Prior to focussing on the therapeutic interventions of phase
one, the child/adolescent must be assessed as being safe
from potential dangers and stable (from themselves e.g.
suicidality, self-harm, substance use etc.) and within their
environments (e.g. ongoing family violence etc.) Note:
Identifying and addressing threats to the child or family’s
safety and stability are the first priority of treatment

20. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase One
Psychoeducation: This the first component of phase one.
The aim of this component of phase one is to normalise and
validate the responses of the child and parent(s).
Providing descriptions of available treatments and
discussing the strong empirical support for the treatment of
choice provides reassurance and confidence in the model,
outlining specifically TF-CBT
A final aspect of psychoeducation is to provide strategies to
the child and parent to manage current symptoms
Component two of phase one relates to the development or
increased development of parenting skills

21. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase One (con)
Relaxation skills are taught to both the child and parent(s) and
encouraging engaging in physical exercise as this may help to alleviate
symptoms of depression
Affective expression and modulation addresses affect dysregulation
Depending on the child (appropriateness e.g. age) techniques such as
thought interruption, positive self-talk, personal safety skills, and
problem solving, and social skills are developed
The same skill set is taught to parent(s) with the addition (if required) of
thought interruption and positive distraction.
Cognitive coping and processing. This involves assisting the child and
parent(s) in making a connection between thoughts, feelings, and
behaviours, thus enabling them to identify inaccurate attributions in
every day events

22. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase Two
Creation of a trauma narrative (also referred to as gradual
exposure or GE) is primary to this phase
“One of the goals of creating the trauma narrative is to
unpair thoughts, reminders, or discussions of the traumatic
event from overwhelming negative emotions such as terror,
horror, extreme helplessness, shame, or rage” (Foa, 2006, p.
119).
This unpairing occurs in a carefully regulated manner as
guided by the therapist over several sessions.
 The trauma narrative is shared with the parent, therapists
collaborate to ensure the child’s stress management skills are
not being exceeded

23. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase Two (con)
Once the child has completed the process of creating the
trauma narrative, trauma related cognitive errors are
identified
Once identified, new cognitions and understandings about
the event are explored, developed, and corrected. These, are
then practiced and reinforced as more accurate and helpful
thoughts
The same process is undertaken with parent(s) who may
have also developed parental cognitive errors about the
child’s or their own response to the traumatic event

24. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase Two (con)
When narrative techniques are insufficient in resolving
generalised avoidant behaviours techniques such as in vivo
exposure may be introduced
Fears of innocuous trauma reminders (e.g., trauma
memories, darkness) most often can be resolved through
trauma narrative and processing work or through in vivo
exposure tasks. However, other realistic safety concerns may
best be addressed through education and training in safety
skills

25. Interventions with Trauma Exposed Children
and Adolescents: TF-CBT, Phase Three
As the end of therapy approaches, the therapist should
assess how the child and parent are progressing in treatment.
The final session should be spent, in part, discussing the
joint session experiences, including thoughts and feelings of
the child and parent experienced during these interactions
If the therapist believes that either needs ongoing therapy,
this recommendation should be discussed and appropriate
referrals and arrangements made prior to treatment
termination

26. Interventions with Trauma Exposed Children
and Adolescents: Child Parent Psychotherapy
(CPP)
In some instances it is not appropriate to plan treatments that involve
exposure therapy. In such cases other evidence based treatments are
available. One such treatment was developed by Van Horn and
Lieberman (2008) Child Parent Psychotherapy (CPP) for traumatised
infants and toddlers and a parent/caregiver
CPP is an integrative treatment approach developed on the theoretical
principles of attachment theory, developmental psychopathology, stress
and trauma, cognitive behavioural and social-learning theories
CPP has also been recognised as an evidence-based, culturally sensitive
treatment for maltreated children and their caregivers

27. Interventions with Trauma Exposed Children
and Adolescents: Child Parent Psychotherapy
(CPP) (con)
Within this therapeutic setting, rather than the child being
the client, the relationship between the child and caregiver is
considered the client. What this means in the process of
therapy, through dyadic sessions, the therapist observes the
natural caregiver/child interactions in order to identify
maladaptive relational patterns
Therapy is conducted via the child’s spontaneous play with
the role of therapist encouraging reciprocally enjoyable
interactions between the parent and child. When required,
the therapist interprets and conveys the needs of the child to
the parent

28. Interventions with Trauma Exposed Children
and Adolescents: Child Parent Psychotherapy
(CPP) (con)
Psychoeducation is provided to help the caregiver
understand how traumatic stress is affecting their child
Parental knowledge and skills are developed to assist the
caregiver in developing developmentally appropriate
expectations of the child as well as providing consistent,
sensitive and nurturing assistance to the child in playing and
doing tasks of daily living
Helping the caregiver to understand their own relational
experiences that now influence their interactions with their
own child. From an attachment perspective Bowlby (1951)
proposed that attachment relations are acquired via
intergenerational transmission

29. Interventions with Trauma Exposed Children
and Adolescents: Child Parent Psychotherapy
(CPP) (con)
One of the goals in CCP is to help the caregiver gain
develop insight into their own patterns of relational
interaction in an effort to break the intergenerational
transmission of maladaptive relational representations from
parent to child
Fundamental to this therapy, is the therapeutic relationship
between therapist and child and therapist and caregiver
The therapist/ parent therapeutic relationship is based on
unconditional positive regard and a nonjudgmental,
empathic stance. The role of the therapist is to build a strong
therapeutic relationship with the caregiver

30. Interventions with Trauma Exposed Children
and Adolescents: Child Parent Psychotherapy
(CPP) (con)
It is through these interventions that the therapist can begin to foster
more positive and consistent interactions between parent and child. Thus,
enhancing the security of attachment bonding between the traumatised
child and their caregiver, preventing or remediating insecure attachment
that can occur when traumatic stressors disrupt the development of
infant/toddler-caregiver attachment bonds
A final component of this model is that the therapist may be required to
provide additional support to the family to ensure or improve their safety
needs. For example the therapist may be required to liaise between the
family and governmental agencies, in regards to the family’s basic needs
such as, housing, food, and financial resources