I was extremely honored to receive the 2012 ISTSS Sarah Healy Memorial Award for Clinical Excellence. ISTSS has been very important to me and I appreciate this opportunity to reflect on how child trauma treatment has changed in the past 30 years.
Child trauma treatment has moved into the mainstream: Child trauma treatment was on the outer fringes of child psychiatry when I completed training in 1984. Aside from a small group of child abuse colleagues, mental health professionals generally ignored child trauma—except when they disparaged it. When I decided to focus on child trauma treatment I was asked “Why don’t you study something important?” Attitudes changed after the September 11, 2001 terrorist attacks killed more than 3000 people and dramatically raised public and professional awareness about trauma. A few weeks later, the Substance Abuse and Mental Health Services Administration funded the National Child Traumatic Stress Network
(NCTSN) to raise the standard of care for traumatized children and families, providing sustained national attention on child trauma and the need for effective treatment. High profile disasters such as Hurricane Katrina and the recent school shootings in Connecticut continue to maintain public awareness about the importance of child trauma treatment. Child trauma treatment is now in the mainstream of child mental health, hopefully to stay.
Effective child trauma treatments are available: No child evidence-based treatments (EBT) existed until 1996. Throughout the 1990’s and 2000’s, funding from federal and other agencies including the National Center of Child Abuse and Neglect and the National Institute of Mental Health supported randomized controlled trials for a growing number of child trauma treatment models. We now have more than 20 EBTs for child Posttraumatic Stress Disorder (PTSD) and associated conditions
. These include interventions for traumatized children across the developmental spectrum from infancy through transition age adolescents, provided in individual, family and group formats as well as in schools or residential treatment settings; and treatments for diverse traumas including the multiple and complex traumas often experienced by children in usual clinical care settings.
EBT for child trauma are being implemented in usual care: Perhaps most importantly, these child trauma EBTs are being implemented in routine settings. The NCTSN has applied the Institute for Healthcare Improvement’s
learning collaborative methodology to support child trauma EBT implementation by thousands of clinicians in communities across the United States. NCTSN data indicate that children receiving EBTs experience significant improvement across a variety of clinical domains. The NCTSN-funded Medical University of South Carolina has provided free training to more than 130,000 mental health providers in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) through its distance learning course TF-CBT Web
. Increasingly EBTs are becoming the standard of care in community settings. For example, the Los Angeles County Department of Mental Health now requires clinicians to provide EBTs to traumatized children in order to receive reimbursement, while insurers such as Community Behavioral Health of Philadelphia are considering providing higher reimbursements for child trauma EBTs than for usual care. In some cases, non-mental health providers have been able to provide EBTs with positive child outcomes. This is particularly crucial in settings where highly trained providers are unavailable and suggests new possibilities for future implementation.
Future directions for child trauma treatment: Despite these transformations in child trauma treatment, a lot of work remains. For example, relative to adults we have almost no information about whether pharmacologic treatments are effective for traumatized children; we will need well designed multi-site studies in order to answer questions such as which medications should be used for whom, in what dosages, and under what circumstances? Putting aside important diagnostic issues that are beyond the scope of this column, how should we best treat comorbid conditions that commonly occur in traumatized children? For example, is there an optimal way to sequence current EBTs for children who have co-occurring major depression and PTSD; do these EBTs need to be modified or are novel treatments needed for these children? We are just starting to use exciting new genetic, neuroimaging and other methodologies with the potential for early identification of children in need of trauma treatment and to tailor EBTs for individual needs.
From a personal perspective, some things have remained constant. I have been blessed to share a long partnership with the smartest, nicest and most excellent clinicians I know, Esther Deblinger, PhD and Tony Mannarino, PhD; and to collaborate with many other dear friends in the child trauma field. I have had the good fortune of working with dedicated child trauma therapists around the world who are committed to helping traumatized children recover, and of seeing children and families transcend trauma every day. I feel very fortunate to have had all of these opportunities, and look forward to the future of child trauma treatment.
Judith A. Cohen, MD is a board certified child and adolescent psychiatrist, Professor of Psychiatry at Drexel University College of Medicine and Medical Director of the Allegheny General Hospital Center for Traumatic Stress in Children and Adolescents. She is a co-developer of Trauma-Focused Cognitive Behavioral Therapy and a former member of the ISTSS Board of Directors.