Corrected Grammar
The patient was apparently well and studying at a daycare center when, seven years prior to consultation (when he was four years old), he was coerced by his neighbors outside of their school to steal candies from a store. They threatened him that if he did not follow their instructions, they would hit him. Due to fear, he did as instructed. After getting the candies, he gave them what he stole and they shared some with him. This happened whenever he saw them in the neighborhood. According to his grandmother, during that time, she also noticed that her money was being taken.
Treatment and Management for Childhood Trauma with Coercion-Related Stealing
Primary Treatment Recommendation
Initiate trauma-focused cognitive behavioral therapy (CBT) immediately, specifically Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR), as these interventions demonstrate 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions and directly address both the traumatic coercion experience and subsequent behavioral problems without requiring a prolonged stabilization phase first. 1, 2
Understanding the Clinical Presentation
This 11-year-old presents with a complex history combining:
- Childhood trauma from coercion and threats (age 4), which meets criteria for a traumatic event involving threat to physical integrity and a fear-based response 1, 3
- Subsequent stealing behaviors that may represent trauma-related repetitive behaviors or posttraumatic reenactment 4
- Potential PTSD symptoms including anxiety, depression, and behavioral changes 1
The coercion experience at age 4 constitutes a Type I trauma (single, sudden event) with clear memories and trauma-specific fears, which typically responds well to direct trauma-focused treatment 4.
Evidence-Based Treatment Algorithm
Step 1: Immediate Trauma-Focused Psychotherapy
Begin with trauma-focused CBT without delay, as evidence demonstrates that children with trauma histories and behavioral problems benefit from direct trauma processing without requiring preliminary stabilization 1, 2. The specific modalities with strongest evidence include:
- Cognitive Processing Therapy (CPT): Addresses trauma-related guilt and self-blame, particularly relevant given this child may feel responsible for the stealing 1
- Prolonged Exposure (PE): Reduces trauma-specific fears and avoidance behaviors 1, 2
- EMDR: Equally effective alternative if exposure-based approaches are not tolerated 1, 2
Treatment should consist of 9-15 weekly sessions, with the therapist specifically addressing the coercion event, the child's fear response, and any guilt or shame about the subsequent stealing behaviors 2, 5.
Step 2: Address Stealing Behaviors Within Trauma Framework
The stealing behaviors should be conceptualized as trauma-related rather than primary conduct problems, as research shows that stealing in children often represents posttraumatic reenactment or trauma-specific repetitive behaviors 6, 4. The treatment approach should include:
- Motivational interviewing to explore the child's understanding of the stealing behaviors and their connection to the coercion experience 5
- Behavioral modification techniques integrated within the trauma-focused therapy to address current stealing 5
- Psychoeducation for the child and grandmother about trauma responses and how fear-based compliance can evolve into learned behavioral patterns 5
Evidence from a case report demonstrates successful treatment of adolescent stealing using a six-session individualized CBT protocol that included motivational interviewing, psychoeducation, behavioral modification, and imaginal desensitization, with Yale-Brown Obsessive Compulsive Scale scores dropping from 22 to 3 5.
Step 3: Screen for Comorbid Conditions
Assess for neurodevelopmental disorders, particularly ADHD and autism spectrum disorder (ASD), as these conditions are significantly associated with stealing behaviors in children and may require additional intervention 6. However, the presence of these conditions does not negatively affect trauma-focused treatment efficacy or increase dropout rates 1, 7.
Screen for abuse history beyond the coercion event, as multivariate analysis shows that ASD with abuse history and ADHD with abuse history have significantly increased odds ratios for stealing behaviors 6. If additional abuse is identified, this strengthens the indication for trauma-focused treatment 1.
Step 4: Consider Pharmacotherapy Only as Adjunct
Medication should be considered only if:
- Trauma-focused psychotherapy is unavailable or the family refuses it 1, 2, 8
- Residual symptoms persist after completing psychotherapy 8, 7
- Severe anxiety or depression symptoms interfere with the child's ability to engage in therapy 2, 7
If medication is indicated, use an SSRI (sertraline 25-50 mg daily for children ages 6-12, or fluoxetine) 2, 7, 3. SSRIs demonstrate 53-85% treatment response rates in controlled trials for PTSD 8, 7.
Absolutely avoid benzodiazepines, as evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo 1, 2, 8.
Family and Environmental Interventions
Engage the grandmother as a protective factor in treatment, providing psychoeducation about:
- How childhood trauma manifests as behavioral problems 1
- The connection between the coercion experience and subsequent stealing 4
- How to respond therapeutically rather than punitively to stealing behaviors 1, 5
Address safety and prevent re-traumatization by ensuring the child is no longer exposed to the neighbors who coerced him 1.
Follow-Up and Monitoring
Assess treatment response after 8 weeks of trauma-focused therapy, looking for:
- Reduction in PTSD symptoms (intrusive thoughts, avoidance, hyperarousal) 1, 2
- Decrease in stealing behaviors 5
- Improvement in anxiety and depressive symptoms 1
Screen for suicidal ideation and self-harm behaviors at each visit, as adolescent trauma victims are at increased risk 1.
Continue treatment for 6-12 months minimum after symptom remission to prevent relapse 2, 3.
Critical Pitfalls to Avoid
Do not delay trauma-focused treatment to first "stabilize" the child or address the stealing behaviors separately, as this approach lacks empirical support and prolongs suffering 1, 2. Evidence demonstrates that trauma-focused interventions directly reduce both behavioral problems and emotional dysregulation simultaneously 1.
Do not assume the stealing represents primary conduct disorder without addressing the trauma history, as this may lead to punitive rather than therapeutic interventions 6, 4. The temporal relationship between the coercion event and stealing onset suggests trauma-related etiology 4.
Avoid psychological debriefing or single-session interventions immediately after disclosure, as randomized controlled trials show this may be harmful 1, 2.
Do not use phase-based treatment requiring prolonged stabilization before trauma processing, as recent evidence shows this is unnecessary even for complex presentations and delays effective treatment 1, 2.
Expected Outcomes
With appropriate trauma-focused treatment, 40-87% of patients no longer meet PTSD criteria after completing 9-15 sessions 1, 2. Relapse rates are substantially lower after completing CBT compared to medication discontinuation (26-52% relapse with sertraline discontinuation versus lower rates post-CBT) 2, 8. The stealing behaviors should decrease as the underlying trauma is processed and the child develops healthier coping mechanisms 5, 4.