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Treatment of Posttraumatic Stress Disorder in Children and Adolescents

Patrick, Smith; Perrin, Sean; Tim, Dalgleish; Richard, Meiser-Stedman; David M, Clark;William, YulePublished in:Current Opinion in Psychiatry

DOI:10.1097/YCO.0b013e32835b2c01

2013

Link to publication

Citation for published version (APA):Patrick, S., Perrin, S., Tim, D., Richard, M-S., David M, C., & William, Y. (2013). Treatment of PosttraumaticStress Disorder in Children and Adolescents. Current Opinion in Psychiatry, 26(1), 66-72.https://doi.org/10.1097/YCO.0b013e32835b2c01

Total number of authors:6

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REVIEW

CURRENTOPINION Treatment of posttraumatic stress disorder in

children and adolescents

www.co-psychiatry.com

a a,b c c

Patrick Smith , Sean Perrin , Tim Dalgleish , Richard Meiser-Stedman ,David M. Clarkd, and William Yulea

Purpose of review

We review recent evidence regarding risk factors for childhood posttraumatic stress disorder (PTSD) andtreatment outcome studies from 2010 to 2012 including dissemination studies, early intervention studiesand studies involving preschool children.

Recent findings

Recent large-scale epidemiological surveys confirm that PTSD occurs in a minority of children and youngpeople exposed to trauma. Detailed follow-up studies of trauma-exposed young people have investigatedfactors that distinguish those who develop a chronic PTSD from those who do not, with recent studieshighlighting the importance of cognitive (thoughts, beliefs and memories) and social factors. Such findingsare informative in developing treatments for young people with PTSD. Recent randomized controlled trials(RCTs) confirm that trauma-focused cognitive behaviour therapy (TF-CBT) is a highly efficacious treatment forPTSD, although questions remain about effective treatment components. A small number of disseminationstudies indicate that TF-CBT can be effective when delivered in school and community settings. One recentRCT shows that TF-CBT is feasible and highly beneficial for very young preschool children. Studies of earlyintervention show mixed findings.

Summary

Various forms of theory-based TF-CBT are highly effective in the treatment of children and adolescents withPTSD. Further work is needed to replicate and extend initial promising outcomes of TF-CBT for very youngchildren. Dissemination studies and early intervention studies show mixed findings and further work isneeded.

Keywords

children and adolescents, posttraumatic stress disorder, trauma, treatment

aDepartment of Psychology, King’s College London, Institute of Psychia-try, London, UK, bInstitutionen for Psykologi, Lund University, Lund,Sweden, cMRC Cognition and Brain Sciences Unit, Cambridge anddDepartment of Experimental Psychology, University of Oxford, Oxford,UK

Correspondence to Patrick Smith, PhD, Department of Psychology,King’s College London, Institute of Psychiatry, London SE5 8AF, UK.Tel: +020 7848 0506; e-mail: patrick.smith@kcl.ac.uk

Curr Opin Psychiatry 2013, 26:66–72

DOI:10.1097/YCO.0b013e32835b2c01

INTRODUCTION

Traumatic events are defined in the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV) [1]as (1) involving ‘actual or threatened death orserious injury, or a threat to the physical integrityof self or others’; and (2) the person’s response atthe time involved ‘fear, helplessness or horror’(or disorganized or agitated behaviour in children).In the DSM-V, it is proposed that the second part ofthe definition be dropped because it has little utilitywith adults or children. Recent epidemiologicalstudies in the United States have confirmed thatexposure to a range of traumatic events defined inthis way is very common among adolescents [2,3].However, community prevalence of posttraumaticstress disorder (PTSD) is low, at about 5% [4]. Inthe Great Smokey Mountain Study [5], the con-ditional probability of developing subclinical PTSD

following exposure to traumatic events was about3%. The relative rarity of PTSD among childrencompared with adults is likely to be due in part tothe developmental insensitivity of the DSM-IV diag-nosis. It has been known for some time [6] thatsubsyndromal PTSD is associated with significantdistress and functional impairment among young

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KEY POINTS

� Trauma-Focused CBT (TF-CBT) is a highly effectivetreatment for PTSD in children and young peopleexposed to a range of traumatic events.

� TF-CBT is feasible to deliver to young preschoolchildren and their parents, and initial trial evidence forits efficacy is very encouraging.

� Dissemination studies suggest that delivery of TF-CBTprogrammes in schools can be both acceptable toyoung people and effective.

� Single-session early intervention for all trauma-exposedchildren has not been shown to be helpful, but screen-and-intervene approaches to early interventionappear promising.

Treatment of posttraumatic stress disorder Smith et al.

people, and a recent review [7&&

] argues that theoptimal algorithm for PTSD in children may requirefewer symptoms than specified in the DSM-IV. Thisis especially true for young preschool children (seebelow). Nevertheless, it is now clear that mosttrauma-exposed young people do not developchronic PTSD. In this context, recent research hasinvestigated factors that might distinguish theminority of trauma-exposed young people whodevelop persistent PTSD from the majority whoare resilient. Identification of potentially modifiablemaintaining factors can inform the development ofeffective treatments.

RISK AND MAINTAINING FACTORS

The recent meta-analysis of risk factors by Trickeyet al. [8

&&

] brings some clarity to a growing literature.Sixty-four studies of PTSD among 32 238 youngpeople (6–18 years old) were included, and 25 riskfactors were examined. Broadly, and in line withprevious meta-analyses of risk factors in adults, itwas found that peritraumatic and posttraumaticfactors showed larger effect sizes on persistent PTSDthan pretrauma demographic factors and theseverity of exposure. Specifically, demographic fac-tors such as age, sex and ethnicity showed smalleffects, whereas peritraumatic factors such as fearand the perception of life threat during the eventshowed large effects. A number of posttrauma fac-tors showed large to medium effect sizes, includingcognitive factors (thought suppression, blamingothers, distraction); social and family factors (poorsocial support, social withdrawal, poor family func-tioning); and psychological factors (severity ofinitial PTSD symptoms and comorbid psychologicalproblems). Some caution is needed in interpretingthese findings, given the relatively small number of

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included participants for some variables (e.g.N¼115 for thought suppression). However, in termsof clinical application, it is encouraging that themost significant maintaining factors are those thatcan in principle be targeted and modified intherapy.

For example, as predicted by cognitive theory[9], the recent longitudinal study by Nixon et al.[10

&

] extended earlier work [11,12] to show thatcognitive misappraisals of children who had beenexposed to a wide range of single event traumasplayed a greater role in their adjustment than bio-logical factors. Misappraisals also appear to beimportant to the adjustment of children who havebeen repeatedly maltreated, abused or neglected[13]. Cross-cultural support for the role of negativetrauma-related appraisals was found in a verylarge study of Chinese adolescents exposed to theWenchuan earthquake in China [14]. As predictedby cognitive models, the particular characteristicsof trauma memories – specifically their degree ofdisorganization – have recently been found to dis-tinguish trauma-exposed children with acute stressdisorder (ASD) from those without ASD [15]. Emerg-ing evidence suggests that social support [16

&&

] andsocial connectedness [17] are strongly related topersistent PTSD, but not to ASD [18].

From a treatment point of view, it is helpful toidentify factors that influence the maintenance ofpersistent PTSD over time, because modifying suchfactors may lead to reduction in symptoms. There isneed for further well-designed prospective studies oftrauma-exposed young people that can delineatePTSD trajectories over time and distinguish clearlybetween onset and maintaining factors [19,20

&

].Nevertheless, increased understanding of childhoodPTSD has already led to the development of theory-driven treatments, which have in turn been rigor-ously evaluated. We review recently published(2010–2012) treatment evaluation studies below.

TREATMENT

Trauma-focused cognitive behaviour therapy (TF-CBT) is based on clearly articulated and empiricallysupported theories, and has the most empiricalsupport of all treatments for childhood PTSD.Recent practice parameters from the USA [21] arein line with earlier UK guidelines [22]: both recom-mend TF-CBT as a first-line treatment for youngpeople with PTSD. Recent treatment outcome stud-ies have supported these recommendations.

Exposure to the trauma memory is a keycomponent of most forms of TF-CBT. Gilboa-Schechtman et al. [23

&&

] directly compared 12–15 sessions of prolonged exposure (a form of CBT)

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with 15–18 sessions of psychodynamic therapy in arandomized controlled trial (RCT) for adolescents(N¼38) who had developed PTSD as a primarydiagnosis following exposure to single-incidenttrauma. Both treatments were associated withreductions in PTSD and depression at posttreatmentand at follow-up. However, prolonged exposure wassuperior to psychodynamic therapy in reducingPTSD symptoms (P<0.05) and depression symp-toms (P<0.05). At posttreatment, 68% of thosewho started prolonged exposure were free ofPTSD posttreatment compared with 37% of thosewho started psychodynamic therapy (P¼0.05). At6-month follow up, the equivalent figures were 63%(prolonged exposure) and 26% (psychodynamictherapy) (P<0.01). Of those who completed thetreatment, 87% (prolonged exposure) and 47%(psychodynamic therapy) were free of PTSD diag-nosis posttreatment.

In contrast, the RCT by Nixon et al. [24&&

]showed that a form of cognitive therapy, whichexplicitly precluded exposure, was highly effica-cious for adolescents suffering from PTSD.Adolescents (N¼33) who had developed PTSD orsubsyndromal PTSD (i.e. at least one symptom fromeach of the three DSM clusters) after exposure tosingle-incident trauma such as road traffic accidentsand assaults were included. They were randomlyallocated to either nine sessions of cognitivetherapy (including anxiety management, cognitiverestructuring and working with parents) or to ninesessions of TF-CBT (including the same componentsas well as imaginal and in-vivo exposure). In thecognitive therapy arm, 90% of completers (N¼10)and 56% of the intention-to-treat samples (N¼16)were diagnosis-free at posttreatment. In the CBTarm, 91% of completers (N¼11) and 65% of theintention-to-treat samples (N¼17) were diagnosis-free at posttreatment. Differences between cogni-tive therapy and TF-CBT were not significant. Thissuggests that techniques aimed at modifyingtrauma-related misappraisals and dysfunctionalbeliefs may be as important as therapist-guidedexposure in reducing symptoms of childhood PTSD.Indeed, an earlier study [25] found that changes intrauma-related misappraisals mediated the effect ofTF-CBT (relative to a waiting list control condition)on PTSD symptoms in children and adolescentswho had been exposed to assaults and accidents.The relative contribution of exposure techniquesand cognitive techniques to symptom reductionis not yet clear, but it may be that their carefulintegration is important to successful outcome.Although TF-CBT is a powerful treatment, furtherinvestigations of mediators and moderators willhelp to refine and enhance future protocols for

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young people who develop PTSD after a single-event trauma.

Deblinger et al. [26&&

] also investigated therelative importance of exposure-based therapy com-ponents in an evaluation of TF-CBT for childrenwho developed PTSD symptoms following sexualabuse. In an extension and replication of earlierwork, they tested directly whether the developmentof a trauma narrative was necessary for symptomreduction. Children (N¼210, 4–11 years old) andtheir parents were randomized to one of four con-ditions: eight sessions with or without a traumanarrative component, or 16 sessions with or withouta trauma narrative. As well as replicating theirprevious findings of a large effect for TF-CBT acrossall treatment conditions (effect size across all out-come measures and all treatment arms, d¼0.94),some specific main effects and interactive effectswere observed. For example, children allocated tothe conditions that included a trauma narrativecomponent reported less fear associated with think-ing or talking about the abuse, and less generalanxiety, compared with children in the conditionsthat did not include a trauma narrative component.Many of the children in the trauma narrative con-ditions reported that talking about the abuse specifi-cally was the most important part of therapy.However, parents assigned to the 16-session, notrauma narrative condition reported greaterincreases in effective parenting practices and fewerexternalizing child behavioural problems. Thisstudy is therefore an important step towards thedelivery of psychological therapies that are tailoredtowards young children’s specific profile of post-trauma difficulties.

To date, the majority of RCTs evaluating psycho-logical treatment for childhood PTSD have beencarried out in academic centres. There is also a smallbut growing literature suggesting that TF-CBT can beeffective when delivered by education professionalsin schools, or by community-based clinicians forpatients referred via standard clinical pathways.For example, Jaycox et al. [27

&&

] screened nearly700 schoolchildren in the aftermath of HurricaneKatrina and identified 195 with elevated symptomsof PTSD. These children were then invited either toparticipate in a school-based group CBT programmeor to attend a local mental health clinic and receiveTF-CBT. Both treatments were effective in reducingPTSD symptoms, with TF-CBT showing marginallybetter outcomes. Importantly, 98% of the childrenwho were offered the school-based programmeaccepted treatment, and 91% completed treatment.In contrast, only 37% of children offered TF-CBT atthe clinic started treatment, and only 9% com-pleted. Treatment location as opposed to treatment

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type appeared to have a large influence on treatmentuptake, and some families asked for the TF-CBT to bedelivered at the school. School-based treatment maybe more convenient and/or less stigmatizing forsome families.

Rolfsnes and Idsoe’s [28] review and meta-analysis of school-based treatment programmesfor childhood PTSD included 19 studies thatused either a randomized design (N¼9) or a quasi-experimental design with a control condition(N¼10). Sixteen studies (six RCTs) evaluated CBT;the other RCTs evaluated play therapy, eye move-ment desensitization and reprocessing (EMDR) andmind–body techniques. Medium to large effects werefound in 11 of the CBT evaluations, and small tomedium effects in four of the CBT studies. One verylarge quasi-experimental study of war-affected chil-dren in Lebanon did not find any effect of CBT onPTSD symptoms. The two school- based RCTs of playtherapy and EMDR (vs. wait list control) also showedmedium to large effect sizes. The weight of evidencesuggests that school-based programmes delivered byeducation professionals can be effective, althoughfurther RCTs are required. Delivery in schools maysignificantly improve access and uptakeof treatment,and may be especially helpful in situations in whichmany young people have been traumatized, such ascan occur after disasters or accidents.

However, some caution is warranted. Wonderlichet al. [29] developed a multiphase programme toidentify therapists in community clinics who wereinterested in (but not already using) evidence-basedtreatment approaches for adolescents exposed torepeated abuse. Therapists were trained in twoevidence-based treatments for PTSD, and local super-vision groupswere established. The authors detail notonly the significant uptake of the training pro-gramme but also the obstacles involved in encourag-ing community clinicians to record routine clinicaloutcome data. In a subsequent uncontrolled pilotevaluation phase of the programme, adolescents(N¼79, aged 8–18 years) who had been exposed tomultiple traumas received either individual TF-CBTor a group-based CBT approach. Youth in both treat-ment conditions experienced reductions in symp-toms of PTSD, anxiety and depression, althoughthese reductions were modest.

EARLY INTERVENTION

The growing evidence for the powerful effect ofTF-CBT on chronic PTSD has stimulated efforts tointervene earlier so that persistent PTSD can beprevented.

Zehnder et al. [30] randomly allocated a con-secutive series of 99 children (7–16 years old) either

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to a one-off debriefing session (comprising psycho-education and reconstruction of the accident) or tostandard medical care, 10 days after a road trafficaccident. At assessment 2 and 6 months later, therewas no difference between the groups in terms ofPTSD symptoms (although younger children in theintervention group showed improvement in depres-sion and behaviour problems). This result is consist-ent with two earlier reports of negative findingswhen a one-off, early intervention was offered toall trauma-exposed children [31,32], and with thenegative findings for psychological debriefing inadults [33,34].

An alternative early intervention approach wastrialled by Kassam-Adams et al. [35]. Hospitalizedinjured children (N¼290, 8–17 years old) werescreened for PTSD symptoms, and those abovecut off (N¼85) were randomly allocated to a two-session intervention, which was contrasted withusual care. At assessment 6 weeks and 6 monthsafter injury, there was no difference between thegroups in terms of PTSD symptoms.

A similar design was employed by Berkowitzet al. [36

&&

], using a more intensive intervention thatextended over a longer time period. Children(N¼176, 7–17 years old) exposed to a variety oftraumatic events were screened, and those endors-ing at least one symptom of PTSD (N¼106) wererandomly allocated either to a four-session inter-vention, which was delivered within the first2 months after exposure, or to a supportive com-parison intervention. The intervention, The Childand Family Traumatic Stress Intervention (CFTSI),was flexibly delivered to parents and children, andincluded psychoeducation, techniques to improvefamily communication and behavioural and cogni-tive skills teaching (coping enhancement). Assess-ment after intervention and at 6-month follow-upshowed significant and meaningful improvementsin PTSD in the CFTSI group relative to the com-parison group.

Taken together, these studies show that,although universal single-session early interven-tions have not been helpful, screen-and-interveneapproaches appear feasible and promising. Verybrief early interventions of one or two sessions areunlikely to be beneficial, whereas approachesinvolving at least four sessions, delivered flexiblyto children and families, seem highly promising.Studies are very few and further work is needed.

YOUNG CHILDREN

The studies reviewed above include childrenfrom about 7 years old through to late adole-scence. What is known about the presentation

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and treatment of PTSD in infants and veryyoung children?

Very young children are certainly exposed topotentially traumatic events. However, communitysurveys and studies of trauma-exposed childrengenerally show very low rates of PTSD diagnosisaccording to the DSM-IV criteria. For example, Saighet al. [37] found that none of their sample of veryyoung children who were exposed to the September11 attacks in New York met criteria for a DSM-IVPTSD diagnosis. This may arise either because youngchildren are especially resilient (due, for example,to cognitive immaturity) or because the DSM-IVcriteria are developmentally insensitive. To addressthis important question, Scheeringa et al. [7

&&

] for-mulated an alternative algorithm for diagnosingPTSD in preschoolers. This alternative algorithm(PTSD-AA) reduces the threshold for diagnosis bydropping the required number of avoidance symp-toms and by refining some of the existing DSMsymptoms to make them more developmentallysensitive. A series of studies by Scheeringa’s groupand others [7

&&

] has reported promising findingswith respect to the criterion, convergent, discrim-inant and predictive validity of PTSD-AA. Thealternative algorithm approach is now widely usedby research groups and has been incorporated intothe DSM-V proposal for a subtype of PTSD in chil-dren younger than 6 years. This new DSM-V pre-school subtype is consistent with the overall DSM-Vapproach, which includes four symptom clusters,but otherwise appears to match Scheeringa’s PTSD-AA very closely. A recent report of posttraumaticstress reactions among very young (1–6 year old)burn victims [38] found that PTSD-AA and theDSM-V preschool subtype identified nearly identicalchildren and provided developmentally sensitiveand valid measures of PTSD. At 1 month post-trauma, PTSD-AA and the DSM-V preschool subtypediagnosed 25% of young children, far more than theincidence of 5% according to DSM-IV.

Alongside this growing consensus on the differ-ing presentation of PTSD in infants and preschoolchildren, advances have been made in treatment.Scheeringa et al. [39

&&

] conducted an RCT of TF-CBTfor preschool children (N¼64, 3–6 year olds). Thefundamental principles of TF-CBT were adhered to,but important adaptations were made for workingwith younger children. These included greaterparental involvement (sessions were observed bymothers, or joint sessions carried out), greateremphasis on behavioural management trainingand relaxation training, the use of visual aids (e.g.cartoons for psych-education) and the use of draw-ing and playing to complete imaginal reliving. Theintervention was feasible to deliver and showed

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large effect sizes relative to a wait list control con-dition. This is highly promising for the treatmentof very young traumatized children, but requiresreplication and extension.

COMPLEX POSTTRAUMATIC STRESSDISORDER IN CHILDREN

The term complex PTSD is used to refer to thepotential sequelae of exposure to multiple, repeatedor prolonged traumatic events. There is little con-sensus on the phenomenology of complex PTSD inadults. Some authors find that the construct is notuseful and that it has little empirical support as adistinct entity [40

&&

]. Others note that the dis-tinguishing feature is affective dysregulation along-side PTSD symptoms [41]. There are very fewempirical studies of young people and complexPTSD. In our clinic, we see adolescents who havebeen exposed to multiple traumas as young chil-dren. Trauma histories typically involve repeatedwitnessing or suffering abuse and interpersonalviolence at home. These young people may presentwith very clear, severe, chronic PTSD symptoms,alongside marked mood dysregulation. Mood labil-ity may include intense anger and aggressive violentoutbursts, or episodes of very low mood accom-panied by hopelessness, suicidal ideas and self-harm. Mood changes may be short lived and oftenappear to be triggered by interpersonal difficulties orsensitivities. Young people with this sort of presen-tation can present diagnostic challenges and arevariously referred to trauma services, depressionservices or services for young people with emergingunstable personality disorders. We have found thatyoung people with such difficulties can benefit froma trauma-focused intervention. Before engaging intrauma-focused work, treatment components aimedat increasing affective stability are necessary. Thesemay include arousal reduction (relaxation training),functional analysis of triggers and responses tomood shifts (chain analysis), and coping skills teach-ing of adaptive responses to triggers and moodshifts, including behavioural activation approaches.Further coping skills training around trauma-specific symptoms, such as image manipulationtechniques, may also be needed prior to engagingin memory-focused work. When memory-focusedwork is started, this often takes a narrative approach,constructing a timeline to contextualize multipleexposure to trauma. Typical TF-CBT techniques canbe used for each of the young person’s traumaticexperiences if necessary, although in our experiencea few memories are often particularly prominentand problematic, and these are likely to be focusedon during therapy. To our knowledge, there are no

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treatment outcome studies for young patients whopresent with these sorts of difficulties.

CONCLUSION

Various forms of TF-CBT have been shown to behighly effective for young people who develop PTSDfollowing single-incident trauma: remission rates ofaround 90% have now been reported in several well-designed trials [23

&&

,24&&

,25]. Three recent trialshave highlighted the importance of both exposureand cognitive techniques in treatment. Our clinicalexperience is that the careful integration of thesetwo central components is tolerated well by youngpatients and is beneficial. Recent trials were ofmodest size, and further large-scale evaluations withbroad inclusion criteria are now needed. Never-theless, on the basis of trials to date, clinicians canbe confident in recommending TF-CBT for youngpatients with PTSD. Recent findings on the effectsof adapted TF-CBT for PTSD in preschool children arehighly encouraging, although replication and exten-sion are now needed. Further work is also required todevelop early intervention approaches: current evi-dence suggests that a move towards developingscreen-and-intervene approaches rather than univer-sal single-session debriefing will be productive.School-based delivery of TF-CBT may improve uptakeand accessibility, but further work is needed to ensurethat protocols are effective when implemented inthese settings. Complex PTSD is a contentious con-struct when used with adults, and research withchildren is currently lacking.

Acknowledgements

None.

Conflicts of interest

There are no conflicts of interest.

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& of special interest&& of outstanding interest Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (pp. 128–129).

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27.&&

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30. Zehnder D, Meuli M, Landolt MA. Effectiveness of a single-session earlypsychological intervention for children after road traffic accidents: a rando-mised controlled trial. Child Adolesc Psychiatry Mental Health 2010; 4:1–10.

31. Stallard P, Velleman R, Salter E, et al. A randomized controlled trial todetermine the effectiveness of an early psychological intervention with chil-dren involved in road traffic accidents. J Child Psychol Psychiatry 2006;47:127–134.

32. Kenardy J, Thompson K, Le Broque R, Olsson K. Information provisionintervention for children and their parents following pediatric accidental injury.Eur Child Adolesc Psychiatry 2008; 175:316–325.

33. Bisson JI, Jenkins PL, Alexander J, Bannister C. Randomised controlled trial ofpsychological debriefing for victims of acute burn trauma. Br J Psychiatry1997; 171:78–81.

34. Mayou RA, Ehlers A, Hobbs M. Psychological debriefing for road trafficaccident victims: three year follow-up of a randomized controlled trial. Br JPsychiatry 2000; 176:589–593.

72 www.co-psychiatry.com

35. Kassam-Adams N, Garcia-Espana JF, Marsac ML, et al. A pilot randomizedcontrolled trial assessing secondary prevention of traumatic stress integratedinto pediatric trauma care. J Trauma Stress 2011; 24:252–259.

36.&&

Berkowitz SJ, Stover CS, Marans SR. The child and family traumatic stressintervention: secondary prevention for youth at risk of developing PTSD.J Child Psychol Psychiatry 2011; 52:676–685.

An important study that trials a screen-and-intervene approach to early interven-tion.37. Saigh PA, Yasik AE, Mitchell P, Abright AR. The psychological adjustment of a

sample of New York City preschool children 8–10 months after September11, 2001. Psychol Trauma 2011; 3:109–116.

38. de Young AC, Kenardy JA, Cobham VE, Kimble R. Prevalence co-morbidityand course of trauma reactions in young burn injured children. J Child PsycholPsychiatry 2011; 53:56–63.

39.&&

Scheeringa MS, Weems CF, Cohen JA, et al. Trauma-focused cognitivebehavioural therapy for posttraumatic stress disorder in three through six yearold children: a randomized clinical trial. J Child Psychol Psychiatry 2011;52:853–860.

This trial examines feasibility and efficacy of developmentally adapted TF-CBT forvery young children.40.&&

Resick PA, Bovin MJ, Calloway AL, et al. J Trauma Stress 2012; 25:241–251.

An important position paper in this special edition devoted to complex PTSD,followed by invited commentaries.41. Bryant RA. Simplifying complex PTSD: comment on Resick et al. (2012).

J Trauma Stress 2012; 25:252–253.

Volume 26 � Number 1 � January 2013