First-Line Treatment for Pediatric PTSD
Evidence-based trauma-focused psychotherapy is the first-line treatment for children with PTSD, specifically Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), which should be initiated immediately without a preceding stabilization phase. 1, 2
Primary Treatment Recommendation
TF-CBT is the gold standard for children ages 3-17 years with PTSD, demonstrating the highest level of evidence (Level Ia) with 10 randomized controlled trials showing large effect sizes in reducing PTSD symptoms. 2, 3
Individual forms of TF-CBT show consistently large effects, with cognitive therapy for PTSD demonstrating the strongest magnitude of effect (SMD -2.94) compared to waitlist controls in pediatric populations. 4
The treatment consists of eight components summarized by the acronym PRACTICE: Psychoeducation and Parenting skills, Relaxation skills, Affective modulation skills, Cognitive coping skills, Trauma narrative and cognitive processing, In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety. 2
Alternative Evidence-Based Options
Eye Movement Desensitization and Reprocessing (EMDR) is effective but demonstrates smaller effect sizes than individual TF-CBT in pediatric populations. 4
Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy are also effective alternatives for children and adolescents, though TF-CBT has the largest evidence base in this age group. 4, 5
Group TF-CBT can be considered when individual therapy is unavailable, though individual formats show superior outcomes. 4
Treatment Delivery and Access
TF-CBT can be effectively delivered via telehealth with equivalent outcomes to in-person treatment, expanding access to rural and underresourced communities. 1
Treatment typically requires 9-15 sessions to achieve significant symptom reduction, with 40-87% of patients no longer meeting PTSD criteria after completion. 6, 5
A "warm handoff" to mental health providers with direct communication is the most effective approach for pediatric primary care settings. 1
Critical Pitfalls to Avoid
Do NOT delay trauma-focused treatment with a prolonged stabilization phase—evidence shows immediate trauma processing is both safe and effective even in children with complex presentations, multiple traumas, or comorbidities. 1, 6
Avoid psychological debriefing within 24-72 hours post-trauma, as this single-session intervention is not supported by evidence and may be harmful. 7
Never use benzodiazepines for pediatric PTSD—evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo. 7
Role of Pharmacotherapy in Children
No medication is FDA-approved for PTSD in children and adolescents. 1
Medications may be judiciously considered only for specific comorbid symptoms (such as severe depression or anxiety) that interfere with the child's ability to engage in trauma-focused psychotherapy. 1
When medication is necessary, it should be used as an adjunct to—not a replacement for—trauma-focused psychotherapy. 1
Parental Involvement
One supportive caregiver should be regularly included in the therapeutic process, as this is a core component of effective TF-CBT for children. 2
Caregivers with their own trauma history should be referred for individual adult therapy, as untreated parental trauma can interfere with the child's treatment progress. 1