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Running head: EVIDENCE BASED TREATMENT

Evidence Based Treatments for Adolescents with Post Traumatic Stress Disorder
Elie Hays
Drake University
Bengu E. Tekinalp, PhD

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Efficacy of Post-Traumatic Stress Disorder (PTSD) Treatments for Adolescents


Post-Traumatic Stress Disorder (PTSD) is typically defined as incidents that are
perceived as terrifying, shocking, sudden, or that potentially pose a threat to ones life, safety, or
personal integrity (Gerson, Rappaport 2013). The National Institute for Mental Health (NIMH,
2010) estimates that approximately 4 % of individuals ages 1318 are diagnosed with PTSD
over their lifetime (NIMH). According to the DSM- 5, PTSD falls into four categories,
Intrusive symptoms such as flashbacks, avoidance of reminders, negative feelings and thoughts
such as guilt, fear and anger, and arousal and reactivity symptoms such anger, problems
concentrating and sleeping problems. PTSD in children ages 12-17 exhibit both internal
symptoms such as the flashback, depression, suicidal thoughts and guilt which often lead to
behaviors that include but are not limited to skipping school, aggression, and substance abuse.
Car accidents are the main cause of PTSD in children in industrial countries. Six months
after the trauma; 25%-30% of the children who survived the car accident meet the criteria for
PTSD (Stankovic, Grbesa, Kostic, , Simonovi, Milenkovic, Visnji, 2013). Traumatic stress
refers to physical and emotional reactions which caused by events which represent to threat a life
or disturbance of physical or psychological integrity of a child or a person of critical importance
to the child.
When Justin was 16 years old he quit football, started skipping school and smoking
marijuana daily. The link between traumas and substance abuse is been well-established and,
evidence has shown that the correlation between trauma and substance abuse is particularly
strong for adolescents with PTSD. Up to 59% of young people with PTSD subsequently develop
substance abuse problems (NIMH). Justin was unable to get past the car accident. His parents
had done what they thought was best and had put him in grief counseling. They believed that
over time he would be able to move forward and with counseling his flashbacks of the accident

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would start to diminish. After witnessing the death of his grandmother Justin had tried to move
on but continued to re-experience the accident and found that getting high on marijuana
would block the horrific memories
Justins symptoms of PTSD started almost immediately after the accident and last for
many years and early intervention would have been very beneficial(American Psychiatric
Association 2013). When treating PTSD the emphasis needs to be placed upon establishing a
feeling of safety. Picking the right treatment and counselor for Justin was critical. The following
are suggested treatments for PTSD in adolescents.
Educational and Therapeutic Approach, Trauma Affect Regulation: Guide for Education and
Therapy for Adolescents (TARGET)
Target is an educational and therapeutic approach for the prevention and treatment of
complex Post-Traumatic Stress Disorder (PTSD) The goal of TARGET is to help participants
shift the way they process memories and make sense of their memories. TARGET focuses on
PTSD related to trauma and seven core skills are taught through repeated coaching and guided
practice with one or two sessions per week. Sessions are 50-90 minutes and can be offered either
in a group setting with 3-10 sessions or 12 individual sessions (Ford 2012).
The TARGET Freedom steps are:
Focus to reduce anxiety and increase mental alertness
Recognize specific stress triggers and helps person being treated distinguish between a real
threats and a reminders
Emotions identify primary emotions both good and bad
Evaluate primary thoughts/self-statements and being able to move from reactive thoughts to
main thoughts and learning to balance thoughts.

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Define primary personal goal and start focusing on current hopes and dreams.
Option identify one choice that represents a successful step toward the primary goal that the
individual actually accomplished during a current stressful experience.
Make a contribution empower to be in control of the alarm reactions and be able to
recognize their unique contribution in life.
Reviewing the literature conducted by Marrow, Knudsen, Olafson, &Bucher (2012)
within a trauma informed juvenile setting, found that the participants had reduction in
depression, threats to staff, and the need to use physical restraints. The youth in the TARGET
program also reported greater hope and optimism. Limitations were the small sample size, lack
of follow up and lack of randomization.
In the review conducted by Ford and Hawke (2012) of 394 youth offenders ages ranging
from 11 to 16 who had experienced some form of PTSD found that after receiving TARGET for
14 days there were fewer disciplinary problems after treatment. A limitation was nonrandomization of participants.
Pharmacotherapy
Pharmacotherapy in the treatment of adolescents has increased in the last two decades,
promising medications tested on adults are now being used in conjunction with psychotherapy on
children (Huemer, Erhart & Steiner, 2010).
In a pilot randomized controlled trial of combined Trauma-Focused CBT and Sertraline
for Childhood PTSD Symptoms (Cohen, Mannarina, Perel, & Staron, 2007) Eighty subjects
ranging in age from 10-17 were equally split with one control group taking sertraline and using
TF-CBT and the other group doing treatment and given a placebo The study was inconclusive to

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whether the childrens improvements were due to the TF-CBT and the sertraline or just the TFCBT.
Conclusions: There is only marginal evidence to the benefits of adding sertraline to the TF-CBT.
Questions as to the improvement of adding sertraline was determining whether TF-CBT or
sertraline caused clinical improvement for children with depression (Keeshin, Strawn, 2014)
While some medications have proven to be effective in reducing the effects of PTSD,
most treatments for children and adolescents are still in the infancy stage. Pharmacological
therapy is limited and at this time it appears that most medication trials have been on adults. The
big concern when treating children and adolescents is the information that became available in
2003 warning that children may be experiencing increased suicidal ideation while taking SSRIs
(Mitka, 2003). Public warnings about antidepressant medication were issued by the U.S. Food
and Drug Administration and the eventual Black Box warnings were included on SSRI
medications in 2004 (U.S. Food and Drug Administration, 2004)

Eye Movement Desensitization and Reproducing for Children and Adolescents (EMDR)
EMDR was developed by Francine Shapiro in 1987 when she made an observation that
eye movement could reduce the disturbing thoughts that were stored at the time of the disturbing
event Shapiro continued to study this and in 1989 she reported her success in the Journal of
Traumatic Stress and claimed that EMDR was successful in treating individuals who had
experienced PTSD or other anxiety disorders (Shapiro).
EMDR is an eight phase psychotherapy treatment approach that uses eye movements to
alleviate symptoms of trauma. The target population is children and adolescents ages 2-17. The
first stage is discovery of the clients trauma history. The second stage client/therapist

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relationship building. The third stage is the identification of the experience and the client begins
to recreate images and this process involves therapist lead bilateral eye movement using auditory
tones, finger moving back and forth, or hand tapping. The fourth stage is the desensitization
phase and the memory is activated and the clinician asks the client to notice his/her experiences
while the clinician provides alternating bilateral stimulation. Phase 6 is the body scan and the
client works with the therapist to hold in mind both the target event and the new positive belief
and to mentally scan the body. In the closure phase the therapist orients the client back and
discussed the possibility that the processing might continue between session and finally the last
phase is three reevaluation phase and here the therapist looks for current triggers, anticipates
future challenges, and decides if phases three through eight should be repeated (EMDRIA).
Thomas Hensel investigated the effectiveness of EMDR while working in private practice
Hensel studied 36 children ages 1-18 with 14 of the children being under the age of 7 all
involved in a single incident trauma. The children symptoms ranged from separation, fear, sleep
disturbances, and nightmares. All participants were placed on wait list until treatment could
begin. Of the 36, 4 dropped out of the study. In initial findings showed there was improvement
after using EMDR. In the finding it was noted that children who had untreated trauma and were
put on a wait list or who did not immediately seek treatment showed more intense signs of PTSD
but could also profit more from the treatment. The study reported benefits from treatment and
the improvement was still there 6 months after treatment.
Limitations: Small number of participants and lack of randomized control group. (Hensel).
EMDR therapy is recognized as an effective form of treatment for PTSD by both the
American Psychiatric Association and the Department of Defence. Research in treating children

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and adolescents for PTSD appears to be unrepresented in literature. More than twenty
randomized studies support the effectiveness of the therapy in the treatment of PTSD
(EMDRIA).
Trauma Focused Cognitive-Behavioral Therapy (TF-CBT)
TF-CBT is a psychosocial treatment therapy model designed to help children after a
traumatic event. The model incorporates trauma interventions and works with the both
parent/caregiver and child to improve depressive and anxiety symptoms, help parents to better
support the child, improve the childs overall functioning, help in the reduction of guilt and
shame associated with the traumatic experience and improve behavioral problems. The program
also helps parents in their ability to support the child.
The essential components of TF-CBT according to the Sigel, Benton, Lynch, Kramer, (2013):
P-Psycho- education and parenting shills
R: Relaxation
A: Affective expression and regulation
C: Cognitive coping
T: Trauma narrative and processing
I: In vivo exposure
C: Conjoint parent and child sessions
E: Enhancing personal safety and growth
TF-CBT currently receives the most empirical support for treating adolescent PTSD. The
first session of the TF-CBT protocol focused on providing psychoeducation to normalize the
clients trauma reactions and was developed to work with children between the ages of 3 and

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18.The recommended durations is 8 to 20 individual sessions lasting between 30-45 minutes.


Parents and the adolescent both participate in treatment and do weekly homework.
TF-CBT compared to other treatments significantly reduces PTSD, depression and
behavioral problems and according to (Black, Woodworth Tremblay, & Carpenter (2012) PTSD
symptoms at the 12 month follow up are significantly reduced.

Seeking Safety for Adolescents


Seeking Safety is an evidence based treatment originally designed for adults. The treatment is
focused on coping skills.Seeking Safety for Adolescents has 25 topics which focuses on
numerous topics ranging from,vasking for help, setting boundaries, healthy relationship, selfnurturing, and discovery and recovery. The overall goal is to help client find safety in
relationships thinking, behavior and emotions (Najavitis 2006)
Seeking safety is often combined with substance abuse treatment and Najavitas, Gallop,
and Weiss in a randomized control trial evaluated Seeking Safety and found it to have positive
outcomes were indicated in many several domains including substance abuse and trauma related
symptoms (Navavitis).
Prolonged Therapy for Adolescents (PE-A)
PE-A emerged from a long tradition of Exposure Therapy for anxiety disorders. The goal
of PE-A is to have adolescents repeatedly approach situations or activities they are avoiding
because it reminds them of their trauma. Clients use vivo exposure and retelling or imagine
exposure to revisit the trauma with the help of a trained therapist. The goals of PE-A is to help
patients emotionally process the traumatic event with the goal that the event is confronted and in
time there will be a decrease in PTSD reminders and symptoms over time.
This program was developed by Edna Foa and her colleagues at the University of
Pennsylvania for treating adults with anxiety disorders. The PE-A program outlined in Prolonged

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Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences
and is specifically intended for adolescents aging between 12 and 18 who suffer from PTSD. PEA is used to treat adolescents and the program is structured into four phases: (1) pre-treatment
preparation, (2) psychoeducation and treatment planning; the beginning of treatment (3)
exposures, and (4) relapse prevention and treatment termination with the goal of diminishing
PTSD and other trauma related symptoms.
A randomized controlled trial, conducted by Aderka, Foa, Applebaum, Shafran, &
Gilboa-Schechtman, (2011) at the Schneider Childrens Medical Center of Israel looked at the
success PE-A in children and adolescents suffering from PTSD. As part of the study,
participants completed self-report measures of PTSD and depression before each session. The
outcomes were promising and showed significant decrease in PTSD as well as overall anxiety
and depression in participants after treatment.
Another study conducted by Aderka, Applebaum, Shafran, & Gilboa-Schechtman,(2011)
and again participants were test were assessed before each treatment session and sudden gains
were found among 49.2 % of the participants and constituted 48.6% of the total reduction in
posttraumatic symptoms. Limitations in both studies were small sample size, and lack of control
group, and lack of follow up.

When treating Justin for his diagnosed PTSD the best course of action was determined to
be the Trauma- Focused Cognitive Behavior Therapy. While many of the treatments showed
some reduction in symptoms the research suggested that TF-CBT as shown the most significant
improvement in not only PTSD symptoms but also in symptoms or anxiety and depression. The
current evidence supports psychotherapy for most children with PTSD. If symptoms persist of

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there is a reoccurrence of symptoms adding medication might be the next course of action as
well another treatment of TF-CBT.

References
Aderka, I. M., Foa, E. B., Applebaum, E., Shafran, N., & Gilboa-Schechtman, E. (2011).
Direction of influence between posttraumatic and depressive symptoms during prolonged

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exposure therapy among children and adolescents. Journal Of Consulting And Clinical
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Adler-Tapia, R., & Settle, C. (2009). Evidence of the Efficacy of EMDR With Children and
Adolescents in Individual Psychotherapy: A Review of the Research Published in PeerReviewed Journals. Journal Of EMDR Practice & Research, 3(4), 232-247.
doi:10.1891/1933-3196.3.4.232
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Black, P. J., Woodworth, M., Tremblay, M., & Carpenter, T. (2012). A review of trauma-informed
treatment for adolescents. Canadian Psychology/Psychologie Canadienne, 53(3), 192203. doi:10.1037/a0028441
Cohen, A, Mannarino, A, Perel,J.M., Staron, V. (2007) Controlled trail of combined traumafocused CBT and sertraline for childhood PTSD Symptoms . Journal of the American
Academy of Child & Adolescent Psychiatry, v46 n7 p811-819 Jul 2007. 9 pp.
EMDRIA - EMDR International Association. Retrieved May 1, 2014, from
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