children

Systematic Review
Clinical Efficacy of Psychotherapeutic Interventions for
Post-Traumatic Stress Disorder in Children and
Adolescents: A Systematic Review and Analysis
Evgenia Gkintoni 1, * , Elias Kourkoutas 2 , Vasiliki Yotsidi 3 , Pilios Dimitris Stavrou 4 and Dimitra Prinianaki 5

1 Department of Psychiatry, University General Hospital of Patras, 26504 Patras, Greece

2 Department of Primary Education, Research Center for the Humanities, Social and Education Sciences,
University of Crete, 74100 Rethymno, Greece; [email protected]
3 Department of Psychology, Panteion University, 17671 Athens, Greece; [email protected]
4 Department of Psychology, University of Athens, 15784 Athens, Greece; [email protected]
5 Department of Psychology, University of Crete, 74100 Rethymno, Greece; [email protected] or
[email protected]
* Correspondence: [email protected]

Abstract: Background: This systematic review aggregates research on psychotherapeutic interventions

for Post-Traumatic Stress Disorder (PTSD) in children and adolescents. PTSD in this demographic
presents differently from adults, necessitating tailored therapeutic approaches. In children and
adolescents, PTSD arises from exposure to severe danger, interpersonal violence, or abuse, leading
to significant behavioral and emotional disturbances that jeopardize long-term development. The
review focuses on describing PTSD within two age groups, children (6 to 12 years) and adolescents
(12 to 18 years), while evaluating the effectiveness of various clinical interventions aimed at this
condition. Methods: Utilizing the PRISMA guidelines, this review systematically examines studies
that assess clinical interventions for PTSD in the younger population. Results: Key symptoms of PTSD
in children and adolescents include avoidance, overstimulation, flashbacks, depression, and anxiety.
Citation: Gkintoni, E.; Kourkoutas, E.; The review identifies several effective treatments, including Cognitive Behavioral Therapy (CBT),
Yotsidi, V.; Stavrou, P.D.; Prinianaki, D. Trauma-Focused CBT (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), Systemic
Clinical Efficacy of Psychotherapeutic Therapy, Play Therapy, Exposure Therapy, Relaxation Techniques, and Psychodynamic Psychotherapy.
Interventions for Post-Traumatic Particularly, TF-CBT is highlighted as the most effective and commonly used method in treating
Stress Disorder in Children and childhood and adolescent PTSD, as supported by most of the studies reviewed. Conclusions: A
Adolescents: A Systematic Review significant outcome of this study is the short-term effectiveness of CBT in reducing PTSD symptoms in
and Analysis. Children 2024, 11, 579.
children and adolescents. The findings underline the importance of psychotherapeutic interventions
https://doi.org/10.3390/
and mark a substantial advancement in understanding PTSD in young populations. It is crucial for
children11050579
practitioners to integrate various psychotherapeutic strategies into their practice to improve patient
Academic Editor: Matteo Alessio outcomes and treatment efficacy.
Chiappedi

Keywords: PTSD; trauma; psychotherapy; intervention; children; adolescents

Received: 25 April 2024
Revised: 30 April 2024
Accepted: 9 May 2024
Published: 11 May 2024
1. Introduction
Trauma is a unique situation that can result in personal anguish and hopelessness.
Children may exhibit psychological responses to frightening situations that lead to imme-
Copyright: © 2024 by the authors.
diate, acute, and sometimes chronic disruptions. Post-Traumatic Stress Disorder (PTSD)
Licensee MDPI, Basel, Switzerland.
is a syndrome that occurs after experiencing a traumatic event that leads to intense fear
This article is an open access article
and feelings of hopelessness, abandonment, or terror. It is classified under the category of
distributed under the terms and
Disorders Induced by Trauma and Stressors [1–3]. PTSD is caused by a traumatic event
conditions of the Creative Commons
not typical of the human experience. Trauma is derived from the ancient Greek titrosko,
Attribution (CC BY) license (https://
which means to hurt. The medical definition of trauma is the “rapid or violent disruption
creativecommons.org/licenses/by/
4.0/).
of the continuity of the skin’s tissues, typically resulting in bleeding”. When the pressure

Children 2024, 11, 579. https://doi.org/10.3390/children11050579 https://www.mdpi.com/journal/children

Children 2024, 11, 579 2 of 33

exceeds the physiological tolerance limits of the body, physical damage occurs. When one
person experiences an extremely stressful event on a mental level, inner psychic powers
are mobilized to process it as efficiently as possible. If this procedure fails, internal cracks
are produced. A psycho-traumatic event is any event that endangers a person’s life and
causes severe psychological consequences and adjustment problems, even in those with no
history of psychopathology.
When one person experiences an extremely stressful event on a mental level, inner
psychic powers are mobilized to process it as efficiently as possible. If this procedure fails,
internal cracks are produced. A psycho-traumatic event is any event that endangers a
person’s life and causes severe psychological consequences and adjustment problems, even
in those with no history of psychopathology.
Nevertheless, not all individuals who experience such a situation inevitably develop
PTSD. PTSD is primarily a disorder characterized by the presence of multiple clusters of
symptoms. Traumatic memories, hyperarousal, and a negative disposition characterize
it. PTSD often occurs alongside melancholy or anxiety disorders [4]. Rapid transforma-
tions and extreme unpredictability characterize the modern era. Hence, it is common for
children and adolescents to encounter highly stressful situations, and in some cases, even
traumatic, thereby challenging their capacity to cope. These scenarios may encompass
natural and human calamities, victimization, acts of violence, or unforeseen accidents. The
aforementioned traumatic experiences have a significant impact on the physical, mental,
and emotional well-being of children and adolescents, thereby exerting a profound influ-
ence on their overall development, formation of personality, and the subsequent trajectory
of their future lives [5,6]. In addition to acute trauma, a series of other terms have been
introduced in clinical theory and research in order to capture and describe the variety of
child and adolescent traumatic experiences which may lead to PTSD. Depending on the
nature, conditions, and effects of traumatic experiences, terms such as developmental, rela-
tional/interpersonal trauma, complex, accumulated trauma, as well as covert and transgeneretional
trauma, refer to the complex nature of traumatic experiences in sensitive developmental
periods that may produce a PTSD condition [7,8].
PTSD is a debilitating mental health condition that can affect traumatized children and
adolescents. Among its symptoms are intrusive thoughts, nightmares, avoidance behaviors,
and hyperarousal. The advancement of psychotherapeutic interventions plays a crucial
role in addressing the symptoms of PTSD and facilitating the process of recovery among
individuals affected by this condition. CBT is one of the most extensively researched and
effective treatments for PTSD in children and adolescents. It involves identifying and
challenging negative thoughts and beliefs associated with the traumatic event, as well as
teaching coping skills to manage distressing symptoms. It has been demonstrated that
CBT is effective in reducing PTSD symptoms in a variety of populations, including refugee
children, those exposed to community violence, and those who have experienced single-
incident traumatic events. Eye movement desensitization and reprocessing (EMDR) is
another commonly used psychotherapeutic intervention for PTSD.
EMDR combines elements of exposure therapy and cognitive restructuring with
bilateral stimulation, such as eye movements or tapping, to help individuals process
traumatic memories and reduce distressing symptoms. EMDR has been found to be
effective in reducing PTSD symptoms in children and adolescents, and it is advantageous
for those who struggle to verbalize their traumatic experiences [9]. Other psychotherapeutic
interventions have shown promise in the treatment of PTSD in children and adolescents,
in addition to CBT and EMDR. Trauma-focused cognitive-behavioral therapy (TF-CBT)
is a form of CBT that employs trauma-focused interventions, such as exposure therapy
and narrative techniques, to address the effects of trauma on thoughts, emotions, and
behaviors [10]. It has been determined that TF-CBT is effective in reducing PTSD symptoms
and enhancing overall functioning in this population. Research has shown that it is
crucial to take into account the unique experiences and requirements of children and
adolescents when providing psychotherapeutic interventions for PTSD. Age, stage of
Children 2024, 11, 579 3 of 33

development, and cultural background can impact the efficacy of treatment approaches. For
instance, art-based interventions and group therapy have proven effective in reducing PTSD
symptoms in refugee children and adolescents, particularly when language barriers are
present. These interventions offer nonverbal means of expressing and processing traumatic
experiences, which can be especially beneficial for individuals who struggle with verbal
expression. Despite the availability of evidence-based psychotherapeutic interventions
for the treatment of PTSD in children and adolescents, there are still limitations to their
effective implementation [11].
In order to ensure the deliverance of effective interventions, it is also necessary to
consider issues pertaining to therapeutic adherence and competence [12]. In addition, it
is important to consider the effect of family factors, such as lack of parental support and
family conflict, on the development and perpetuation of PTSD symptoms in children and
adolescents [13]. Psychotherapeutic interventions are essential for the treatment of PTSD
in infants and adolescents. CBT, EMDR, and TF-CBT are proven effective interventions
for reducing PTSD symptoms and enhancing overall functioning in this population. Art-
based interventions and other culturally sensitive approaches should be considered to
address the unique requirements of individuals from diverse backgrounds. However,
additional research is required to investigate the influence of therapist traits, family factors,
and treatment adherence on treatment outcomes. Each intervention model brings unique
benefits, targeting specific aspects of PTSD symptomatology. Moreover, the effectiveness of
these interventions can be influenced by several factors, including the developmental stage
of the child or adolescent and cultural considerations. Understanding these influences is
crucial for tailoring interventions that are not only effective, but also culturally sensitive
and developmentally appropriate.
The aim of this study is to comprehensively evaluate the efficacy of various interven-
tion models for PTSD in children and adolescents, assessing their impact in ameliorating
symptoms and improving life quality and to delineate their effectiveness and highlight
factors contributing to successful outcomes, thereby informing practitioners about optimal
strategies for treating young individuals afflicted by trauma.

2. Literature Review
According to an increasingly number of findings [14,15] and research on kidnapped
and held hostage children indicated that these age groups could also develop PTSD fol-
lowing a traumatic event. Although the road to officially recognizing the disorder as
a disorder of childhood and adolescence was long, it became apparent during the 1987
revision of the DSM’s third edition that all age groups are susceptible to it. This observation
prompted a shift in attention towards the presentation of PTSD symptoms in children and
adolescents, as it is apparent that they employ psychological and cognitive processes that
differ from those observed in adults. The conventional perspective that a child’s reaction to
traumatic events is a transient adjustment has been supplanted by the concept that trauma
has enduring and profound developmental ramifications [16]. Currently, it is understood
that PTSD presents itself in various ways among different age cohorts and necessitates
distinct therapeutic approaches.

2.1. Clinical Signs and Symptoms of Trauma in Children and Adolescents

Psycho-traumatic events produce a variety of responses in children and adolescents.
A Traumatic experience can disorganize and disrupt children’s psychosocial functioning
and internal sense of cohesion, hindering their development if the traumatic experience is
too harmful or repetitive.
Delayed onset PTSD can occur months or years after a traumatic event [17,18]. In-
creased excitability and avoidance of trauma are the main reactions. Many people have
unwanted thoughts about the event. Random sounds can cause reliving. Images can enter a
child’s consciousness during quiet times, like before bedtime, disrupting sleep. Excitability
Children 2024, 11, 579 4 of 33

often causes irritability, concentration issues, insomnia, disturbed sleep, and hypervigilance.
Elevated arousal, memory, and concentration issues can hurt school performance [6].
Age and, to a lesser extent, gender predict trauma reactions. According to [16], random
trauma causes despair. Generalized anxiety and obsessions are common. Younger children
are more aggressive and destructive, and may play or draw with traumatic event content
and behaviors. Young children with chronic stress may develop behavioral or attachment
disorders. Younger children often regress to earlier developmental stages like bedwetting or
verbal loss [19,20]. After 8–10 years, adolescents’ responses resemble adults’. School-aged
children can understand and make sense of a situation, including the long-term effects of
trauma and their role in it. Adolescence emphasizes trauma’s long-term effects. Its social
effects are also emphasized [14].
Adults react to trauma with dread, horror, or despair, whereas children may display
disorganized and disturbed behavior. Avoidance behaviors are also more difficult to
observe in children because they are frequently not cognitively aware of their presence. Loss
of interest is another difficult-to-observe behavioral parameter in children, as it typically
manifests as listless play, daydreaming, or increased use of imaginary play. Physical distress
is common among children and adolescents who have experienced a traumatic event [16].
In addition to age-based differences, gender-based differences emerge as a growing number
of females are diagnosed with PTSD [14].
Regarding children (6–12 years old), previous research shows that school-aged children
rarely have visual “flashbacks” or amnesia after traumatic events. They seem to have a
disturbed sense of time (time asymmetry), where they cannot recall the correct temporal
order of trauma events, or “omen generation”, the belief that omens foretold the trauma.
They are constantly vigilant due to this perception. The above symptoms are rare in
adults [16]. Children are less emotionally detached than adults [6,14]. This age group
uses “post-traumatic play”, re-enacting psycho-traumatic events. This play is traumatic
and increases the child’s anxiety and tension, not helping him reduce negative emotions.
They depict the event in drawings, plays, and other verbal and nonverbal ways [21]. The
symptoms may appear at school and at home. They may cause nightmares, insomnia,
sleepwalking, or bedwetting at home. As the child expects these symptoms to occur outside
of bedtime, they may be afraid to sleep alone or have other problems. School issues may
include agitation, hyperactivity, inability to concentrate, and behavioral or academic issues.
These symptoms resemble ADHD, which is often misdiagnosed [16].
For adolescents (12–18), although their clinical picture is more like adults’, there are
still differences. Teens can develop dissociative symptoms, angry outbursts, self-harm,
and substance abuse after repeated trauma. Teens are especially vulnerable to trauma.
The importance of peer groups and this developmental period can increase risky behavior
and the disorder’s long-term adverse effects [16,17,21]. Teenagers, like younger children,
may act out trauma in daily life. After a traumatic event, this age group is more likely to
“dramatize” the trauma and incorporate it into their daily lives [20]. They have “survivor’s
guilt” when they feel partially responsible [16,19]. Trauma mainly affects adolescents
academically and socially. Teens with PTSD are three times more likely to attempt suicide
than those without PTSD [19].

2.2. Navigating the Complexity: Diagnosing PTSD in Children and Adolescents

The diagnosis of PTSD in children and adolescents is complicated in ways that are ab-
sent in the diagnosis of PTSD in adults. Difficulties arise at various stages of the diagnostic
procedure, such as when defining a psycho-traumatic event in children and adolescents
or anticipating the onset of symptoms. On the one hand, children may exhibit cognitive
deficits and limitations in expression or verbalization, which may hinder their compre-
hension of the psycho-traumatic event [16]. In the case of children, there are frequently
difficulties in reporting certain reactions; for instance, they frequently have trouble report-
ing correct instances of avoidance reactions because they may be too difficult to verbalize
or comprehend and require a more complex cognitive introspection [14]. It is also not
Children 2024, 11, 579 5 of 33

uncommon for them to avoid discussing the event out of fear of upsetting their parents or
out of concern that they will be rejected or not understood.
On the other hand, it is well known that infants have a vivid imagination, which they
use to embellish their accounts of their experiences. There is also a tendency to mistake
the actual for the ‘appearance’. A situation may not be particularly violent, threatening, or
traumatizing to adults, but it can still cause significant trauma to children, such as when
they are disoriented in a crowd of strangers or when they are sexually touched [16,19–21].
Given the complexity and individual variability in PTSD symptoms among youth,
this review critically examines a spectrum of approaches, including Cognitive-Behavior
Therapy (CBT), Trauma-Focused CBT, Prolonged Exposure Therapy, Eye Movement Desen-
sitization and Reprocessing (EMDR), Narrative Exposure Therapy, Play Therapy, Systemic
Trauma Therapy, and Psychodynamic Therapy. These interventions are evaluated based
on their theoretical foundations, empirical support, and adaptability to different ages,
traumas, and cultural backgrounds. Below is a very brief description of the conventional
psychotherapeutic approaches used to be applied for the treatment of PTSD.

2.3. Cognitive-Behavior Therapy (CBT)

CBT is the most studied psychotherapeutic intervention for PTSD in children and
adolescents, showcasing effectiveness across various trauma types. It combines behavioral
and cognitive techniques to modify dysfunctional thoughts and behaviors related to trauma.
Key strategies include psycho-education, relaxation, exposure to trauma in controlled
settings, and cognitive restructuring. Studies highlight the importance of factors such as
age, ethnicity, and parental involvement in treatment efficacy. School-based programs like
Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) have also been effective,
particularly in fostering social-emotional well-being in affected children.

2.4. Trauma-Focused CBT (TF-CBT)

TF-CBT, a variant of CBT specifically tailored for trauma, has shown superior efficacy,
particularly for victims of sexual abuse, but is also adaptable for other traumatic experi-
ences. This structured, brief model emphasizes skill development, trauma exposure, and
cognitive processing, often involving parents to enhance treatment stability and effective-
ness. The therapy spans approximately 12 to 18 sessions and utilizes a multi-component
approach including psycho-education, parenting skills, emotional regulation, and cognitive
coping strategies.

2.5. Prolonged Exposure Therapy

Since its development in 1982, prolonged exposure therapy, another form of CBT,
has been a prominent method for treating adolescent PTSD. It involves safe exposure to
traumatic content to reduce avoidance behaviors and emotional numbing associated with
PTSD. The approach is based on emotional processing theory, aiming to alter pathological
associations with trauma through repeated exposure sessions.

2.6. EMDR Therapy

Eye Movement Desensitization and Reprocessing (EMDR) therapy, developed by
Francine Shapiro, is used for children and adolescents with PTSD, utilizing rhythmic eye
movements to process and desensitize trauma. Despite limited randomized controlled trials
in children, EMDR has been effective, especially in settings that ensure a stable therapeutic
relationship and proper relaxation techniques.

2.7. Narrative Exposure Therapy

This therapy focuses on constructing a chronological narrative of the individual’s life
to contextualize and process traumatic events. It is particularly useful for individuals with
complex trauma histories, such as refugees, and typically lasts between 5 to 10 sessions.
The approach integrates psychoeducation and direct trauma processing.
Children 2024, 11, 579 6 of 33

2.8. Play Therapy

Play therapy provides a non-verbal medium for younger children to express complex
emotions and thoughts. It is adaptable to the child’s cultural and developmental needs,
often involving creative play, which helps children articulate and work through their
difficulties. Research supports its efficacy, particularly when integrated with caregiver
involvement.

2.9. Systemic Trauma Therapy

Focusing on the child’s social environment and emotional regulation, this therapy
addresses the broader systemic issues influencing a child’s trauma response. It includes
legal advocacy, home care, and psycho-education, emphasizing a comprehensive approach
to creating a stable, supportive environment for the child.

2.10. Psychodynamic Therapy

While traditionally less emphasized in empirical research compared to other therapies,
psychodynamic therapy focuses on resolving internal conflicts through understanding
past experiences and their impact on present behavior. This method involves exploring
unconscious conflicts, defense mechanisms, and the therapeutic relationship, and is shown
to be effective especially for internalizing and affective disorders.
The literature underscores a diverse array of effective psychotherapeutic interven-
tions for treating PTSD in children and adolescents, with cognitive-behavioral strategies
being the most prevalent. Factors such as therapy duration, parental involvement, and
adaptation to the child’s developmental stage play critical roles in the success of these
interventions. Specifically, the current research will focus on analyzing the effectiveness
of interventions across different developmental stages and cultural contexts, aiming to
identify tailored strategies that optimize treatment outcomes. The research questions based
on the systematic analysis revolve around understanding the clinical efficacy of psychother-
apeutic interventions for Post-Traumatic Stress Disorder in children and adolescents are
summarized below:
• [RQ1] How do various psychotherapeutic interventions, including TF-CBT, compare
in effectiveness for treating PTSD in different pediatric age groups (children aged 6–12
and adolescents aged 12–18)?
This question seeks to explore the comparative effectiveness of various psychotherapeutic
interventions, including TF-CBT, for treating PTSD in distinct pediatric age groups: children
aged 6–12 years and adolescents aged 12–18 years.
• [RQ2] What role does parental involvement play in the effectiveness of psychothera-
peutic interventions for PTSD in children and adolescents?
This question investigates the impact of family engagement in the therapeutic process, which
could provide insights into how treatment protocols might be enhanced by integrating family-
based support.
• [RQ3] How do cultural and developmental factors influence the efficacy of psychother-
apeutic treatments for PTSD in children and adolescents?
This question addresses the need to tailor psychotherapeutic interventions to the cultural
backgrounds and developmental stages of young patients to optimize treatment outcomes.
• [RQ4] What are the long-term effects of psychotherapeutic interventions on PTSD
symptoms in children and adolescents, and how sustainable are these effects over time?
This question focuses on the durability of treatment effects, crucial for understanding and
improving the long-term care and support strategies for young individuals affected by PTSD.
• [RQ5] What are the comparative effects of different psychotherapeutic interventions
(CBT, TF-CBT, EMDR, etc.) on PTSD symptoms reduction in children versus adolescents?
This question aims to explore how different psychotherapeutic interventions, such as CBT, TF-
CBT, and EMDR, differentially impact the reduction of PTSD symptoms in children compared
to adolescents.
Children 2024, 11, 579 7 of 33

• [RQ6] How do developmental stages affect the choice and success of psychotherapeutic
interventions for PTSD in children and adolescents?
This question seeks to understand how treatments should be adapted to match the developmental
needs of children at different ages for optimal effectiveness.

3. Materials and Methods

This paper focuses on English language articles, studies, meta-analyses, and reviews
published between 2016 and 2023. The exclusion of pre-2016 studies is justified for several
reasons. Firstly, psychotherapeutic interventions and methodologies evolve rapidly; thus,
studies conducted after 2016 are more likely to incorporate the latest advancements in psy-
chotherapy. These include new techniques or modifications to existing practices specifically
tailored to better serve children and adolescents, ensuring that the review captures the
most current evidence reflecting state-of-the-art practices.
Additionally, diagnostic criteria for PTSD and related conditions have likely been
updated, particularly with the revisions in the DSM-5. Also, the nature and impact of
traumatic experiences have evolved over the past five years due to various social, envi-
ronmental, and global factors. Recent studies more accurately reflect the current trauma
types experienced by children and adolescents, making the findings more applicable to
contemporary clinical practice. Such research also addresses the specific developmen-
tal needs and symptom presentation variations across different ages within the children
and adolescent populations, offering a nuanced understanding of how treatments can be
tailored for different age groups.
Furthermore, the study excluded reports that were not retrievable due to language
and publication restrictions. Specifically, studies not published in English or not accessible
through the primary databases searched—Scopus, PsycINFO, PubMed, Web of Science—
were omitted. This ensured that the review was limited to English language publications
accessible through these databases, prioritizing quality and reliability.
More emphasis is placed on quantitative research that seeks to demonstrate the efficacy
of therapeutic interventions used to treat childhood and adolescence PTSD and post-
analyses to determine which are deemed more effective. The search was conducted to
identify the most recent studies with adequate sample size and methodology. Preference
was given to empirical and randomized controlled trials.
However, their number is negligible as child–adolescent psychopathology is still in its
infancy. Studies conducted with a sample of adults or small sample size (e.g., case studies)
conducted before 2016 were disregarded. The PsycINFO, Scopus, PubMed, and Elsevier
databases were searched using Boolean logic, following the PRISMA guidelines which
outline the preferred reporting items for systematic reviews [22]: Children and adolescents
with Post-Traumatic Stress Disorder and Post-Traumatic Stress Disorder Clinical Interven-
tions for PTSD in Children and Adolescents, as well as PTSD in children and adolescents,
PTSD treatment, and PTSD interventions in English. In addition to the general search with
the terms listed above, a separate search was conducted for each intervention, such as
cognitive-behavioral therapy, systems therapy, trauma system therapy, etc. (Figure 1).
Children
Children2024, 11,11,
2024, 579x FOR PEER REVIEW 88ofof3332

Figure1.1.Flowchart
Figure Flowchartofofproposed
proposedresearch design.
research design.

At first, the investigation was carried out using broader criteria. Subsequently, exclud-
At first, the investigation was carried out using broader criteria. Subsequently, ex-
ing studies that failed to meet the predetermined, rigorous, and precise criteria commenced.
cluding studies that failed to meet the predetermined, rigorous, and precise criteria com-
The calculation of the survey date was a crucial factor. The holding date was strictly limited
menced. The calculation of the survey date was a crucial factor. The holding date was
to the period after 2016. The sample’s age range was also essential, as it had to fall between
strictly limited to the period after 2016. The sample’s age range was also essential, as it
5 and 17 years old. The permissible deviation from the specified age was either two years
had to fall between 5 and 17 years old. The permissible deviation from the specified age
or less. Nevertheless, most studies reviewed have a sample age range from 5 to 17 years.
was either two years or less. Nevertheless, most studies reviewed have a sample age range
The databases incorporated the primary keywords “PTSD” and “Clinical Interventions”,
from 5 to 17 years. The databases incorporated the primary keywords “PTSD” and “Clin-
as depicted in the flowchart provided (Figure 2). Quantitative research was prioritized
ical qualitative
over Interventions”, as depicted
research. in the flowchart
The rationale behind the provided (Figure
particular study2). Quantitative
was to initiallyresearch
collect
data on each approach, followed by a demonstration of their effectiveness. The study
was prioritized over qualitative research. The rationale behind the particular searchwas
wasto
Children 2024, 11, x FOR PEER REVIEWinitially collect data on each approach, followed by a demonstration of their effectiveness. 9 of 32
conducted in major databases including Scopus, PsycINFO, PubMed, and Web of Science,
The search
using a set ofwas conducted
specific keywordsin major databases
and filters including
to refine Scopus,
the search PsycINFO,
results. PubMed,
The keywords and
used
in the search were “PTSD” and “Clinical Interventions”. These keywords were chosen The
Web of Science, using a set of specific keywords and filters to refine the search results. to
ofkeywords
capture usedfor
interventions
the broad inscope
the search
teenage wereinterventions
PTSD.
of clinical “PTSD” and and
Consequently, “Clinical
most Interventions”.
reviews
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applied keywords
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ies,
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capture the broad
their consideration
and scope
whenofinterpreting
adolescents. clinical interventions
our findings.and psychotherapies ap-
plied within the field of PTSD in children and adolescents.
The use of Boolean operators (AND, OR, NOT) allows for the combination of these
keywords to refine search results effectively. The strategy used was the following based
on the query string:
TITLE‐ABS‐KEY (ptsd AND clinical AND interventions) AND PUBYEAR > 2015 AND
PUBYEAR < 2024 AND (LIMIT‐TO (PUBSTAGE, “final”)) AND (LIMIT‐TO (EXACTKEY‐
WORD, “adolescent”) OR LIMIT‐TO (EXACTKEYWORD, “child”) OR EXCLUDE (EXACT‐
KEYWORD, “adult”) OR EXCLUDE (EXACTKEYWORD, “depression”) OR EXCLUDE (EX‐
ACTKEYWORD, “procedures”) OR EXCLUDE (EXACTKEYWORD, “international classifica‐
tion of diseases)) AND (LIMIT‐TO (LANGUAGE, “english”)) AND (LIMIT‐TO (DOCTYPE,
“ar”)) AND (LIMIT‐TO (SUBJAREA, “psyc”)).
Out of the initial pool of 801 bibliometric sources, a subset of 31 sources was selected
for inclusion in this study. All subsequent evaluations encompassed qualitative and quan-
titative assessments of the effectiveness of the interventions. The clinical sample under-
went evaluation utilizing the diagnostic criteria outlined in the DSM-5 or ICD-11 for the
identification of Post-Traumatic Stress Disorder. An interview or questionnaire was typi-
cally conducted with either the infant or their caregiver. While a PTSD diagnosis was not
mandatory for inclusion in the sample, the presence of PTSD symptoms was a require-
ment in most studies. The conventional experimental design consisted of one or more ex-
perimental groups, which varied depending on the number of interventions in each study,
along with a control group that did not undergo the intervention. Typically, there was
only a preliminary sample preparation after commencing the research. However, in nu-
merous cases, subsequent studies were carried out to ascertain the long-term stability of
the interventions’ effects. There is a scarcity of meta-analytic studies, systematic reviews,
and randomized
Figure 2. Flowchart ofcontrolled trials that have been carried out to compare the effectiveness
PRISMA Methodology.

4. Results
Most of the literature on PTSD treatment focuses on CBT, particularly trauma-fo-
cused CBT.
Children 2024, 11, 579 9 of 33

The use of Boolean operators (AND, OR, NOT) allows for the combination of these
keywords to refine search results effectively. The strategy used was the following based on
the query string:
TITLE-ABS-KEY (ptsd AND clinical AND interventions) AND PUBYEAR > 2015 AND
PUBYEAR < 2024 AND (LIMIT-TO (PUBSTAGE, “final”)) AND (LIMIT-TO (EXACTKEY-
WORD, “adolescent”) OR LIMIT-TO (EXACTKEYWORD, “child”) OR EXCLUDE (EXAC-
TKEYWORD, “adult”) OR EXCLUDE (EXACTKEYWORD, “depression”) OR EXCLUDE
(EXACTKEYWORD, “procedures”) OR EXCLUDE (EXACTKEYWORD, “international classifi-
cation of diseases)) AND (LIMIT-TO (LANGUAGE, “english”)) AND (LIMIT-TO (DOCTYPE,
“ar”)) AND (LIMIT-TO (SUBJAREA, “psyc”)).
Out of the initial pool of 801 bibliometric sources, a subset of 31 sources was se-
lected for inclusion in this study. All subsequent evaluations encompassed qualitative
and quantitative assessments of the effectiveness of the interventions. The clinical sample
underwent evaluation utilizing the diagnostic criteria outlined in the DSM-5 or ICD-11
for the identification of Post-Traumatic Stress Disorder. An interview or questionnaire
was typically conducted with either the infant or their caregiver. While a PTSD diagnosis
was not mandatory for inclusion in the sample, the presence of PTSD symptoms was a
requirement in most studies. The conventional experimental design consisted of one or
more experimental groups, which varied depending on the number of interventions in
each study, along with a control group that did not undergo the intervention. Typically,
there was only a preliminary sample preparation after commencing the research. However,
in numerous cases, subsequent studies were carried out to ascertain the long-term stability
of the interventions’ effects. There is a scarcity of meta-analytic studies, systematic reviews,
and randomized controlled trials that have been carried out to compare the effectiveness of
interventions for teenage PTSD. Consequently, most reviews incorporate similar studies,
necessitating their consideration when interpreting our findings.

4. Results
Most of the literature on PTSD treatment focuses on CBT, particularly trauma-focused CBT.

4.1. Cognitive Behavioral Therapy (CBT) and Variants (TF-CBT, Group CBT)
Multiple studies indicate that trauma-focused cognitive-behavioral therapy (CBT) is
the most efficacious intervention for PTSD in infants and adolescents. Based on a meta-
analysis [21], trauma-focused cognitive-behavioral therapy (TF-CBT) is the most efficacious
and widely recognized treatment intervention for PTSD in adolescents. According to the
meta-analysis conducted by [23], TF-CBT emerged as the most efficacious intervention,
exhibiting a substantial effect size compared to the absence of any treatment. This re-
search aligns with the findings of previous studies, which also determined that TF-CBT
is the most efficacious intervention for childhood and adolescent PTSD. The findings of a
meta-analysis [23] indicate that EMDR therapy exhibited statistically significant effects in
the uncontrolled analysis. In contrast, the controlled studies included in the analysis re-
ported only minor to moderate impacts. Based on a study [24], CBT is the well-established
treatment for PTSD in infants and adolescents. In contrast, all other treatments are con-
sidered potentially sufficient or under investigation. TF-CBT is widely recognized as the
most productive and firmly established approach. Group CBT, commonly conducted in a
school environment, was considered sufficient. However, group CBT involving parental
involvement and EMDR therapy may yield positive results.
A study [25] identifies several shared characteristics among the practical approaches
that were identified: psycho-education on the frequency, effects, and management of
trauma; instruction in regulating emotions and employing problem-solving techniques;
exposure to simulated or real-life situations; and cognitive processing. Given the scarcity
of research on psychopharmacological interventions, mental health professionals should
exercise caution when employing medication. According to the study conducted by [26],
there is a negative relationship between the amount of medical information that children
Children 2024, 11, 579 10 of 33

are exposed to and their level of posttraumatic stress experienced several months after
a medical incident. There is a notable correlation between preschoolers and children of
school age. Furthermore, Ref. [21] has observed that six recent meta-analytic studies and
systematic reviews have assessed psychological interventions for post-traumatic stress
disorder (PTSD) in children and adolescents. The study supported CBT, EMDR, narrative
exposure therapy, and interventions implemented in a classroom setting. CBT and TF-CBT
have been recognized as established therapeutic approaches for PTSD in the pediatric
and adolescent population. Despite having a more limited evidence base, there was also
support for EMDR, narrative exposure therapy, and school-based interventions.
The study conducted by [27] presents several significant findings. First and foremost,
it showcases exercise training’s capacity to impact cortisol levels. Furthermore, it presents
a cost-efficient group intervention for individuals suffering from PTSD. Exercise training is
hypothesized to yield a distinct outcome compared to a placebo intervention.
The research findings [28] indicated that TF-CBT interventions exhibited greater ef-
ficacy compared to control conditions in terms of alleviating symptoms associated with
PTSD. Adolescents who have undergone traumatic experiences may manifest psychiatric
disorders, including affective, personality, and psychotic disorders, in addition to PTSD.
These disorders can arise due to the enduring and immediate consequences of intricate
traumatic incidents. These aforementioned factors have the potential to contribute to the
emergence of dissociative and somatic symptoms, which may exhibit more significant
debilitation compared to symptoms encountered after a traumatic incident. Personalized
and appropriate therapeutic interventions are required to address the demand for trauma
clinical interventions.
The research conducted by the authors [29] revealed that the implementation of a
focused preventive intervention resulted in a significant reduction in the intensity of symp-
toms associated with PTSD as time progressed. After three months, it was observed that the
intervention resulted in a more rapid decrease in post-traumatic stress symptoms (PTSS)
severity scores among children who received the intervention as compared to those in
the control group. The intervention demonstrated significant therapeutic outcomes in the
diagnosis of PTSD, evaluation of functional impairment, and management of behavioral
difficulties in young children who have experienced injury. The research provides promis-
ing preliminary findings regarding the efficacy of the targeted preventive intervention
in facilitating recovery from PTSS in young children who have sustained injuries. This
highlights the notable clinical ramifications associated with the provision of psychological
assistance to young children and their parents following a traumatic incident.
Moreover, an independent study [30] presents the main findings of the research, which
involve an analysis of variables that can forecast, assess, and manage PTSD in adolescents.
The investigation additionally examines the potential for reviewing distinct attributes
or domains, such as cognitive capacities, memory, and executive functioning, to enhance
comprehension of PTSD and its ramifications. In addition, the paper suggests implementing
a multidimensional methodology for examining PTSD and trauma.
TF-CBT can offer significant benefits in tackling the psychological and social diffi-
culties experienced by young individuals who are susceptible to or engaged in familial
sex trafficking and labor exploitation. TF-CBT has been found to effectively address the
psychosocial challenges encountered by children who have undergone childhood adversity
and trauma. Additionally, it has been suggested that TF-CBT may substantially impact
their resilience.
Cognitive therapy is an effective treatment for children and young individuals with
PTSD. Next, narrative exposure, play therapy, and other forms of individual TF-CBT are
implemented [31]. Furthermore, it has been acknowledged that both individual modalities
of TF-CBT and play therapy are cost-effective approaches for addressing PTSD in children
and young individuals who experience PTSD symptoms more than three months following
the traumatic incident. Furthermore, the cost-effectiveness of family therapy and supportive
counseling compared to alternative interventions is highly unlikely.
Children 2024, 11, 579 11 of 33

According to the research conducted by [32], it was observed that college students who
had previously encountered elevated levels of ADHD symptoms during their childhood
exhibited a notably greater prevalence of trauma exposure and symptoms associated with
PTSD. The implications of these findings extend to clinical interventions targeting children
and adolescents, high school counseling, and accessibility services related to psychological
well-being and academic adaptation. According to another study [33], interventions aimed
at preventing trauma, PTSD, and depression should be thorough and targeted at different
levels. These levels include the individual/interpersonal level, which involves reducing
abuse within households and immediate surroundings, and the community/societal level,
which consists of reducing crime rates in communities and improving conviction policies.
The initial findings of the first benchmarking study on TF-CBT are presented in
the study [34]. This study investigates the effectiveness and applicability of TF-CBT in
urban community settings that specifically target economically disadvantaged adolescents.
The research conducted by [35] unveiled significant disparities between the initial and
subsequent evaluations of symptoms related to depression and PTSD. Even though 62%
of the participants experienced negative life events while participating in the program
and were also going through the asylum process, this observation was made. A total of
six categories were identified through the qualitative interviews, namely social support,
normalization, valued tools, comprehensibility, manageability, and significance. The results
are consistent with the program theory of Trauma-Related Therapy (TRT), which suggests
that through the exchange of experiences in a safe and supportive environment, as well
as the acquisition of coping strategies such as trauma-specific exposure and behavioral
activation, the youth’s sense of coherence will be strengthened, leading to a reduction in
the intensity of depressive and PTSD symptoms. The results of the study indicate that TRT
exhibits potential as a preventative measure for individuals belonging to underrepresented
minority groups (URMs) who manifest symptoms associated with PTSD.
The research by [36] provides preliminary evidence regarding the cost-effectiveness
of cognitive therapy within this population. The intervention was conducted by clinical
researchers, and replicating the findings in a broader clinical setting may present difficulties.
From the perspective of the National Health Service (NHS) and personal social services,
CT-PTSD emerged as a financially efficient alternative to conventional care.
The publication referenced as [37] highlights the bidirectional impact of post-traumatic
stress symptoms (PTSS) on both adolescents and their parents after a catastrophic event.
The findings indicate that the PTSS of both mothers and fathers at 12 months can serve as a
predictor for the occurrence of PTSS in adolescents at 18 months. The presence of PTSS in
adolescents at 12 months was observed to be associated with maternal PTSS at 18 months,
while no significant association was found with paternal PTSS.
The predominant focus of the randomized controlled trials (RCTs) was directed to-
wards students and retirees residing in low- and middle-income countries (LMICs). These
trials consistently exhibited effectiveness in alleviating symptoms of anger, improving life
skills and overall functioning, as well as reducing the prevalence of post-traumatic stress
disorder (PTSD), depression, and anxiety. In low- and middle-income countries (LMICs),
there is significant potential for addressing mental health issues and other health-related
areas by implementing comprehensive programs focusing on enhancing parent–child
interactions and developing various life skills related to the individual and their social
environment [38].
TF-CBT and CBITS have demonstrated significant clinical enhancement and enduring
benefits. While there are empirically supported effective treatments for PTSD, most of them
involve cognitive-behavioral approaches [39].
Children 2024, 11, 579 12 of 33

Moreover, psychosocial interventions have been shown to have a significant and

beneficial effect on the outcomes of PTSD, depression, and anxiety in refugees and asy-
lum seekers who are undergoing distress. Most evidence confirms the effectiveness of
interventions based on cognitive behavioral therapies and incorporating a trauma-focused
component. Previous research has been suggested to develop evidence-based guidelines
and implementation packages [40].
Moreover, according to a study [41], TF-CBT is effective in reducing symptoms of
post-traumatic stress and improving psychosocial functioning over time.

4.2. Eye Movement Desensitization and Reprocessing (EMDR)

EMDR has demonstrated efficacy in mitigating symptoms of PTSD, depression, and
anxiety in comparison to alternative therapies and control treatments. Based on both
controlled and uncontrolled studies, the suitability and effectiveness of this interven-
tion are evident in its application to children and adolescents. The study conducted by
researchers [23] revealed a significant association between EMDR and a reduction in symp-
toms of PTSD, depression, and anxiety, in comparison to alternative therapies and control
treatments. Moreover, the systematic review reveals a growing body of empirical evidence
that substantiates the clinical efficacy of EMDR as a therapeutic approach for addressing in-
tricate childhood trauma across various age groups. The analysis encompassed six studies
that demonstrated favorable outcomes for EMDR compared to non-specific therapy, CBT,
fluoxetine, and control conditions. Nevertheless, the reliability of these findings exhibited
variability, with specific disparities failing to attain statistical significance.
In addition, the research conducted by [42] introduces alternative therapeutic ap-
proaches for the treatment of trauma. The treatment approach consisted of mindfulness-
based techniques, expressive arts, and group therapy utilizing EMDR. The results support
the use of this intervention as a possible short-term integrative/complementary measure
to reduce psychological distress in adolescents who have had multiple adverse childhood
experiences (ACEs). Although there was an observed improvement in psychological well-
being within the two months following release, the adolescents may require further group
or individual assistance to reinforce and consolidate the mental health benefits obtained
from this intervention.
According to a study conducted by researchers [43], Eye Movement Integration (EMI)
has been identified as a potentially advantageous temporary therapeutic intervention
for young children residing in resource-constrained environments. The study revealed a
noteworthy reduction in all symptoms associated with post-traumatic stress except for one
specific symptom.

4.3. Narrative Exposure Therapy (NET)

The efficacy of NET has been verified in clinical environments for children and ado-
lescents who have undergone multiple traumatic experiences. The primary objective of
this approach is to establish a cohesive life narrative encompassing various traumatic expe-
rience. The study’s main findings [44] demonstrate that both narrative exposure therapy
(NET) and treatment as usual (TAU) led to a decrease in PTSD and psychological distress.
Furthermore, an increase in resilience was observed within both groups. The reduction in
symptoms of PTSD was particularly noteworthy exclusively in the NET group, demon-
strating significant effect sizes. Similarly, there was a substantial decrease in the proportion
of participants with PTSD at clinical levels, observed explicitly in the NET group. The
study provides preliminary confirmation of the safety, effectiveness, and usefulness of
NET in clinical environments for children and adolescents who have undergone multiple
traumatic experiences.
Children 2024, 11, 579 13 of 33

Additionally, the study’s main findings [44] indicate that TF-CBT yielded a significant
reduction in symptoms of PTSD, with only 1 out of 16 participants meeting the diagnostic
criteria after the treatment. Furthermore, the utilization of self-report measures revealed
noteworthy improvements in the levels of PTSD, anxiety, and depression. While a minority
of participants encountered a transient worsening of symptoms during certain phases of
the treatment, all symptoms were wholly alleviated by the conclusion of the treatment.
Furthermore, a significant proportion of the participants reported that the intervention
yielded positive outcomes.

4.4. Specialized Interventions (PE-A, RRFT, and Systemic Therapy)

The study conducted by researchers [45] revealed that both Prolonged Exposure
Treatment for Adolescents (PE-A) and supportive counseling (SC) yielded significant
improvements in symptoms of PTSD and depression throughout treatment. However, it
was observed that the participants in the PE-A group maintained their progress in PTSD
and depression assessments throughout the 12-month follow-up period, indicating the
long-lasting effectiveness of PE-A. The study additionally demonstrated that the PE-A
protocol is applicable in a South African setting when implemented by novice counselors
within a school setting.
A study [46] found that prolonged exposure (PE-A) was more effective than support-
ive counseling in mitigating symptoms of PTSD in adolescents. A notable difference in
progress was observed between the two groups during the post-intervention, 3-month, and
6-month follow-up evaluations. In the aforementioned study, a significantly more signifi-
cant proportion of participants in the PE-A group exhibited a ‘good response’ compared
to those in the supportive counseling group, indicating a greater likelihood of favorable
treatment outcomes with PE-A. In the treatment of PTSD in adolescents, both Prolonged
Exposure Therapy for Adolescents (PE-A) and supportive counseling are effective. Never-
theless, PE-A resulted in a considerably more significant decrease in PTSD symptoms and
a greater likelihood of attaining remission in comparison to supportive counseling.
The study’s findings [47] showed that RRFT (risk reduction through family therapy)
yielded notably greater reductions in the duration of substance use at both the 12-month
and 18-month intervals compared to the control group.
Additionally, it is worth noting that both the RRFT and TAU groups demonstrated
significant reductions in symptoms of post-traumatic stress disorder (PTSD) at months 3, 6,
12, and 18 in comparison to their initial condition. Furthermore, no noticeable differences
were observed between the two groups. In neither condition was there any observed
evidence of a worsening of substance use issues.
Ultimately, the study [48] revealed that every child or adolescent has experienced at
least one traumatic event related to war, which is associated with increased mental health
and behavioral issues. The prevailing conditions require counseling programs tailored to
assist these families and children. The study’s findings suggest incorporating parental emo-
tional validation and invalidation as treatment objectives in clinical intervention practices
for this population could yield positive outcomes. Interventions propose that therapists
utilize emotional validation techniques to foster a more potent therapeutic alliance.

5. Discussion
The systematic review on PTSD in children and adolescents underscores the effective-
ness of several psychotherapeutic interventions, with a particular emphasis on the efficacy
of TF-CBT and EMDR. These interventions are highlighted for their robust outcomes in re-
ducing PTSD symptoms, improving emotional and behavioral functioning, and addressing
comorbid conditions such as anxiety and depression. The review also points to the potential
benefits of other therapeutic approaches, including play therapy, exposure therapy, and
relaxation techniques, underscoring the vast array of options available for treating PTSD in
young populations. The findings emphasize the necessity for interventions to be adaptable
Children 2024, 11, 579 14 of 33

to the individual’s specific needs, considering factors such as age, developmental stage,
trauma type, and cultural background to optimize treatment efficacy.
Furthermore, the present study indicates the importance of incorporating the child’s
social environment into the therapeutic process, noting the positive impact of family in-
volvement and school-based interventions on treatment outcomes. This holistic approach
supports not only the individual’s recovery from PTSD, but also their overall development
and well-being. However, the review acknowledges a notable gap in research on phar-
macological treatments for PTSD in this demographic, suggesting a cautious approach
to medication and a preference for psychotherapeutic interventions. The call for further
research highlights the need for long-term studies on the outcomes of these interventions,
their effectiveness across different cultural contexts, and the management of comorbid
conditions. Overall, the systematic review offers valuable insights into the current state
of treatment for PTSD in children and adolescents, advocating for evidence-based, tai-
lored, and accessible psychotherapeutic interventions to meet the diverse needs of this
vulnerable population.

5.1. Research Question 1 [RQ1]

The studies relevant to [RQ1] provide valuable insights into the effectiveness of
psychotherapeutic interventions for treating PTSD in children aged 6 to 12 years and
adolescents aged 12 to 18 years. In study [33], researchers conducted an analysis of
various psychotherapy forms, highlighting cognitive therapy as the most cost-effective
option across specified age groups. In the study [29] the research team conducted a
systematic review and meta-analysis specifically assessing TF-CBT, revealing its superiority
in reducing PTSD symptoms compared to control groups in children and adolescents.
Furthermore, the study [42] focused on Narrative Exposure Therapy (NET), demonstrating
significant reductions in PTSD symptoms and psychological distress, enhancing resilience
in multiply traumatized children and adolescents. Also, researchers in the study [26]
explored the impact of medical information exposure on post-traumatic stress in children,
offering insights into how different age groups respond to intervention methods. In the
study [40], the researchers analyzed the clinical efficacy of various interventions across a
broad age range, including children and adolescents, providing a comprehensive view of
their outcomes in treating PTSD.
Also, ref. [RQ1] delves into comparing TF-CBT with other psychotherapeutic ap-
proaches in reducing PTSD symptoms among children and adolescents who have experi-
enced traumatic events. The researchers in the study [29] conducted a systematic review and
meta-analysis focusing on TF-CBT, affirming its superiority in reducing PTSD symptoms
compared to control groups, suggesting a notable advantage over alternative therapeutic
methods. Researchers in the study [40] analyzed various interventions, including TF-CBT,
and highlighted its effectiveness compared to other therapies like EMDR and play therapy
across different age groups. Researchers in the research project [48] shed light on TF-CBT’s
efficacy alongside EMDR and narrative exposure therapy, particularly in reducing PTSD
symptoms among war-affected youth. Researchers in the study [42] contextualized TF-
CBT’s effectiveness within a broader therapeutic landscape by comparing its outcomes
with Narrative Exposure Therapy (NET) in clinical settings. Researchers in the study [39]
provided a comparative analysis, reinforcing TF-CBT’s significant improvement and sus-
tainability in benefits compared to other therapies. Researchers in the study [49] indirectly
contributed to the comparative landscape by evaluating Prolonged Exposure Therapy for
Adolescents (PE-A) against supportive counseling. Researchers in the study [47] added
insights into TF-CBT’s comparative benefits within a broader treatment context, despite
their primary focus on risk reduction through family therapy. Furthermore, researchers in
the study [33] provided a cost-effectiveness analysis, highlighting TF-CBT’s economic and
therapeutic advantages over other interventions. These studies collectively underscore the
effectiveness of TF-CBT in reducing PTSD symptoms in children and adolescents compared
to alternative approaches.
Children 2024, 11, 579 15 of 33

5.2. Research Question 2 [RQ2]

[RQ2] focuses on the role of parental involvement in psychotherapeutic interventions
for children and adolescents with PTSD. Danielson et al. (2020) demonstrated that family
therapy, which includes parental engagement, resulted in greater reductions in substance
use and significant decreases in PTSD symptoms over time. Their findings emphasized the
importance of involving parents in the therapy process to improve treatment outcomes in
adolescent populations. Additionally, the studies [37,50,51] also contribute to this aspect of
PTSD treatment. These studies collectively showcase the positive impacts of integrating
parental involvement into therapy for children and adolescents with PTSD, highlighting its
potential to enhance the efficacy of psychotherapeutic interventions.

5.3. Research Question 3 [RQ3]

[RQ3] delves into the influence of cultural and developmental factors on psychother-
apeutic interventions for treating PTSD in children and adolescents. Luoni et al. (2018)
emphasize the importance of individualizing trauma treatment by considering cultural
and developmental aspects, highlighting the complex psychiatric outcomes traumatized
adolescents may face. Researchers in the study [29] touch upon the necessity of adapting
interventions to the developmental level of the child or adolescent for effective treatment.
Furthermore, researchers in the study [49,52] showcase how cultural contexts can influence
treatment outcomes, demonstrating the effectiveness of trauma-focused interventions in
diverse settings like South African schools. Researchers in the study [42] stress the role of
cultural sensitivity in psychotherapeutic treatments, particularly for refugee children, sug-
gesting that incorporating non-verbal communication elements like art-based interventions
can be beneficial. The researcher in the study [39] discusses the need to tailor TF-CBT to the
specific developmental and cultural needs of patients for its efficacy. The research team in
the study [48] highlight the necessity of culturally sensitive interventions for children from
war-torn regions. Together, these discussions underscore the crucial role of cultural and
developmental considerations in tailoring psychotherapeutic interventions to maximize
efficacy in treating PTSD in children and adolescents, influencing not only therapy choices,
but also their implementation and expected outcomes.

5.4. Research Question 4 [RQ4]

[RQ4] investigates the long-term effects and sustainability of psychotherapeutic inter-
ventions on PTSD symptoms in children and adolescents, with several studies contributing
valuable insights. Researchers in the study [41], demonstrate the enduring benefits of
TF-CBT, showing sustained symptom relief and improved psychosocial functioning over
extended periods. Researchers in the study [42] find that narrative exposure therapy (NET)
provides long-lasting benefits, reducing PTSD symptoms and psychological distress while
enhancing resilience in multiply traumatized youth. Also, researchers in the studies [49,52]
highlight the sustained improvements in PTSD and depression symptoms with Prolonged
Exposure Therapy for Adolescents (PE-A) up to 12 months post-treatment. Researchers
in the study [30] discuss the sustained benefits of a targeted preventive intervention in
reducing PTSD symptom severity over time, particularly emphasizing early intervention
for young children. Furthermore, researchers in the study [29] affirm the sustainable long-
term benefits of TF-CBT in significantly reducing PTSD symptoms compared to control
treatments. Two studies [31,39] emphasize the importance of sustaining improvements in
PTSD symptoms over time through interventions like TF-CBT and Cognitive Behavioral
Intervention for Trauma in Schools (CBITS). Also, researchers in the study [36] provide
insights into the sustainable benefits and cost-effectiveness of Cognitive Therapy for PTSD
(CT-PTSD) in children and adolescents. Together, these studies underscore the enduring
effects of various psychotherapeutic interventions in reducing PTSD symptoms and en-
hancing overall psychological resilience and functioning in affected youth, highlighting the
importance of selecting therapies that contribute to long-term well-being.
Children 2024, 11, 579 16 of 33

5.5. Research Question 5 [RQ5]

[RQ5] aiming to determine the most effective psychotherapeutic interventions for
different age groups within the pediatric PTSD population is addressed by several studies.
Researchers in the study [34] assess TF-CBT’s effectiveness across various adolescent age
groups in real-world urban community settings, offering insights into its practical appli-
cation. Furthermore, researchers in the study [21] potentially cover the effectiveness of
psychological treatments for children and adolescents with PTSD, including an analysis by
age group, focusing on therapies like CBT and EMDR. Researchers in the study [45] delve
into TF-CBT within specific adolescent age ranges, evaluating its effectiveness in reducing
PTSD symptoms tailored to particular age groups. Moreover, researchers in the study [38]
explore life skills programs for adolescents, shedding light on their effectiveness for differ-
ent age groups within the pediatric population and demonstrating how psychotherapeutic
interventions can be adapted based on developmental stages. Although researchers with
their study [28] may not explicitly address different age groups, their study on trauma’s
differential impacts on children and adolescents following an earthquake could inform
tailored psychotherapeutic interventions for different ages. Researchers in the study [46]
investigate the impact of an integrative therapy program, including mindfulness and arts,
for adolescent girls, potentially providing insights into age-appropriate interventions ef-
fective for older children in the pediatric group. These studies collectively offer valuable
insights into the effectiveness of various psychotherapeutic interventions tailored to spe-
cific age groups within the pediatric PTSD population, encompassing cognitive-behavioral
strategies to more integrative techniques like mindfulness and arts.
Also, ref. [RQ5] pertains to the comparative long-term effects of EMDR versus CBT in
treating pediatric PTSD, along with factors influencing their sustainability. Several studies
from the provided list contribute to addressing this question. Specifically, researchers in the
study [21], while not explicitly focused on EMDR versus CBT, may offer insights into the
long-term effects of different psychotherapeutic interventions for pediatric PTSD and fac-
tors influencing sustainability. Similarly, researchers in the study [45] investigated TF-CBT,
closely related to CBT, potentially shedding light on the long-term effects and sustainability
of CBT-based interventions. Additionally, in the study [34], researchers, benchmarking TF-
CBT’s effectiveness in urban community settings, might provide insights into the long-term
effects of CBT-based interventions for pediatric PTSD and factors influencing sustainability.
The research project [35] explored the long-term effects of Internet-based CBT for children
with anxiety disorders, offering insights into CBT-based interventions’ long-term effects
and sustainability in pediatric populations. Additionally, in the study [38], researchers in-
vestigated life skills programs targeting mental health outcomes in adolescents, potentially
offering insights into the long-term effects and sustainability of psychotherapeutic interven-
tions tailored to pediatric populations. While these studies may not directly compare EMDR
and CBT, they provide valuable insights into the long-term effects of psychotherapeutic
interventions and factors influencing their sustainability in treating pediatric PTSD.

5.6. Research Question 6 [RQ6]

[RQ6] investigates how developmental stages affect the choice and success of psy-
chotherapeutic interventions for PTSD in children and adolescents. Several studies, found
in the list in Table 1 of the present study, contribute to addressing this question. Specifically,
the researchers in the study [21] may offer insights into how various psychotherapeutic
interventions are adapted to suit the developmental needs of children and adolescents
with PTSD, although not explicitly focused on developmental stages. Researchers in the
study [45], focusing on TF-CBT in reducing PTSD symptoms in adolescents, could shed
light on interventions tailored to the developmental stage of adolescents and their effec-
tiveness. Additionally, researchers in the study [35], although examining Internet-based
CBT for children with anxiety disorders, might offer insights into adapting interventions
for different developmental stages and their success in treating pediatric mental health
conditions. Similarly, in the study [38], researchers exploring life skills programs targeting
Children 2024, 11, 579 17 of 33

mental health outcomes in adolescents could provide insights into interventions tailored
to adolescents’ developmental needs and their effectiveness in improving mental health
outcomes. Additionally, researchers in the study [43], investigating the effectiveness of
narrative exposure therapy for children and adolescents with PTSD, might offer insights
into interventions’ adaptation for different age groups and their success in treating PTSD
symptoms. While these studies may not directly address the influence of developmental
stages on psychotherapeutic interventions for PTSD, they provide valuable insights into
how interventions are tailored to different age groups and their effectiveness in treating
PTSD symptoms.
The study of PTSD in children and adolescents has advanced significantly in recent
years. Several interventions can aid in symptom management. These may be psychological
or pharmacological. It is essential to mention that the specific requirements of clinical
or psychotherapeutic interventions addressing child and adolescent disorders linked to
traumatic experiences are different from those applied to adults. However, there is a
gradual increase in the quality and quantity of research on young individuals. It is now
evident that children and adults behave and think differently. This distinction will aid
in identifying and comprehending the unique requirements of each age group, resulting
in more effective treatment and prevention of their problems. Without doubt, child and
adolescent PTSD and psychopathology research has a long way to go.
As demonstrated by the preceding comparison, CBT, specifically trauma-focused CBT,
is the treatment of choice for pediatric and adolescent PTSD. Multiple researchers have
studied it, and it is now substantiated by evidence. CBT is a broad category encompassing
various methods and approaches, such as exposure therapy and relaxation techniques.
Numerous researchers support EMDR therapy, which is quite convincing. Systems therapy,
play therapy, psychodynamic psychotherapy, etc., are additional varieties of therapy. In
addition to psychological remedies, there are also pharmacological treatments, which are
widely available but should be used with caution.
One crucial challenge for the effectiveness of clinical psychological and psychothera-
peutic interventions is to systematically investigate the long-term effect of the treatment, as
well as to evaluate the global psychosocial thrive and development of subjects who have
suffered from a severe trauma, alongside symptom reduction. It also imperative to explore
the “what and why it works” in each intervention and analyze, for each psychotherapeutic
treatment, the specific factors that contribute to the therapeutic effect [53,54]. It could be,
for example, assumed that the efficacy of the CBT model does not exclusively lie in the
possibility of modifying the negative intrusive thoughts, but also in the fact of providing,
to a traumatized subject, a very structured model of intervention alongside the active
involvement of the therapist/clinical in the treatment process.
It should not, however, be overlooked the fact that the efficacy of the treatment
can be affected by multiple variables, including the duration and nature of the trauma,
the family environment and parental response to treatment, the age of the subject, the
previous psychosocial development, and personality traits (e.g., quality of defenses/coping
mechanisms, etc.), as well as factors related to specific conditions of applying treatment.
Typically, this factor is not considered when conducting research. The involvement of
parents and caregivers is an important facilitating factor that may impact the effectiveness of
treatment. According to [23,24], a meta-analysis, parental involvement improves treatment
efficacy. Individual therapies appear more efficient than group therapies.
Furthermore, the COVID-19 pandemic has exerted a substantial influence on the
mental well-being of children and adolescents, with specific subgroups being especially
susceptible to the psychological consequences of the pandemic [55]. This highlights the
necessity for comprehensive interventions to tackle PTSD and associated mental health
problems amid worldwide emergencies. Furthermore, there is a proposal to develop and
pilot test a traumatic stress screening tool specifically designed for adolescents in pediatric
primary care [56]. The goal of this initiative is to enhance the detection and treatment of
traumatic stress in this particular group [57].
Children 2024, 11, 579 18 of 33

Understanding the nuanced and complex nature of Post-Traumatic Stress Disorder

(PTSD) in children and adolescents necessitates a specialized approach to clinical inter-
ventions that takes into consideration not only the symptoms, but also the unique devel-
opmental, psychological, and social/family contexts of this population. This paper has
synthesized a broad spectrum of contemporary research findings, spanning from 2016
to 2023, to highlight the prevalence of PTSD among young populations, delineate the
distinguishing characteristics of PTSD symptoms across different age groups, and critically
assessed the efficacy of various therapeutic interventions.
Research unequivocally points to PTSD as a significant concern among children and
adolescents who have been exposed to traumatic events. The prevalence of PTSD within
these age groups suggests a distressing psychosocial phenomenon, with symptoms mani-
festing divergently based on developmental stages. For example, younger children, aged
6–12, might experience a disturbed sense of time, engage in post-traumatic play that re-
enacts the trauma, and suffer from sleep disturbances, such as nightmares. Adolescents, on
the other hand, tend to exhibit symptoms like dissociative behaviors, anger outbursts, self-
injurious actions, and substance abuse, reflecting a more complex cognitive and emotional
processing of trauma.
Diagnostic assessments of PTSD in younger populations also face unique challenges,
including difficulties in defining what constitutes a traumatic event for this demographic,
cognitive limitations that impede the expressive capability regarding their experiences, and
a general reluctance to discuss traumatic events due to fear or avoidance tendencies [58].
These diagnostic complexities necessitate therapeutic interventions that are not only ro-
bust and evidence-based, but are also flexible and sensitive to the individual needs and
developmental stages of children and adolescents.
Among the array of therapeutic interventions analyzed, CBT and specifically TF-CBT
emerge as the most effective and extensively employed methodologies for addressing PTSD
in children and adolescents. These approaches combine cognitive and behavioral strate-
gies to mitigate PTSD symptoms regardless of trauma type, with TF-CBT incorporating
additional elements like cognitive processing, family involvement, and exposure therapy.
Conversely, EMDR and Narrative Exposure Therapy (NET) offer alternative, yet compara-
bly effective, treatments that focus on desensitizing patients to traumatic experiences and
reconstructing personal narratives of trauma, respectively.
As for the psychodynamic treatment, it is worth noticing that in recent years, more
studies have focused on children who experience severe parental conflict and/or domestic
violence [35]. The study [59] suggests that children experiencing trauma symptoms are
mainly able to benefit from group psychodynamic therapy, suggesting a promising area for
future research with children impacted by parental conflict.
In addition, eight studies, including three RCTs, have evaluated the effectiveness of
psychodynamic therapies with children who had experienced trauma, including children in
foster care and post-adoption. These findings are promising and show that psychodynamic
therapy is as effective as alternative treatments [60]. However, the conclusion of the
systematic review [40] is that there is an urgent need to build on the preliminary research
in this area with more extensive and better-designed studies.
CBT has garnered significant recognition as an efficacious intervention for PTSD
among a diverse range of individuals. For the treatment of PTSD in children and adoles-
cents, trauma-focused CBT is effective [61]. Furthermore, there is substantial evidence
supporting the efficacy of TF-CBT delivered by therapists in the treatment of PTSD [62].
Additionally, Internet-delivered CBT and i-CBT are effective interventions for adults with
PTSD, according to studies [63]. Moreover, sleep disturbances among veterans with PTSD
have been effectively reduced through CBT [64].
Children 2024, 11, 579 19 of 33

CBT for PTSD is more effective than treatment as usual or unstructured therapy
modalities, according to empirical data [65], producing clinically significant outcomes.
Furthermore, empirical research indicates that CBT is efficacious when customized to
address specific concerns, solidifying its reputation as the treatment of choice for PTSD [66].
Consistent with the literature, CBT is a safe and productive intervention for acute and
chronic PTSD in children, adolescents, and adults [67].
Studies have shown that CBT is effective in the post-treatment phase of PTSD, indicat-
ing that its effects endure [68]. In addition, cognitive control network activity is increased in
patients with major depression and PTSD, suggesting that CBT may have a beneficial effect
on the severity of symptoms [69]. Additionally, research has demonstrated that cognitive-
behavioral therapy (CBT) is viable and correlated with ameliorations in symptoms and
associated results among people who also suffer from severe mental illness and borderline
personality disorder [70].
Additionally, multiple studies have established EMDR as an efficacious therapeutic
approach for PTSD. EMDR therapy employs eye movements to elicit orientation responses
(ORs), which assist individuals in forming adaptive associations between adverse experi-
ences and positive emotions and cognitions. This process ultimately results in a substantial
amelioration of symptoms associated with PTSD [71]. Scholarly investigations have demon-
strated that EMDR therapy exhibits a markedly superior efficacy in ameliorating symptoms
of PTSD in comparison to control conditions and alternative interventions, such as CBT [72].
Research has shown that EMDR is effective in alleviating symptoms of PTSD across
a range of populations, including adults and Syrian refugees [73,74]. In addition, EMDR
reduces the severity of PTSD symptoms more effectively than brief eclectic psychother-
apy [75], with a more pronounced decline in symptoms. In addition, when compared to
waitlist conditions, EMDR has demonstrated efficacy in mitigating symptoms of PTSD in
children, yielding results comparable to those of CBT [76].
Furthermore, the efficacy of EMDR therapy in mitigating symptoms of PTSD among
individuals with intellectual disabilities has been emphasized, implying that it might
surpass the effectiveness of verbal interventions tailored to this population [77,78]. Fur-
thermore, promising results in EMDR’s ability to alleviate PTSD symptoms have been
observed in a variety of settings, including the treatment of PTSD in pregnant women and
postpartum [79,80]. Further research indicates that EMDR therapy has the potential to treat
a variety of psychological conditions, including personality disorders that do not involve
PTSD [81,82].
Additionally, alternative therapies like art-based interventions and other culturally
sensitive approaches should be considered to address the unique requirements of individu-
als from diverse backgrounds. However, additional research is required to investigate the
influence of therapist traits, family factors, and treatment adherence on treatment outcomes.
The comprehensive systematic review of clinical interventions for PTSD in children
and adolescents reveals several critical insights regarding the quality of the studies in-
cluded and the potential heterogeneity among them. The review primarily focuses on
interventions like CBT, TF-CBT, EMDR, and various others. The quality of these studies
is generally essential, with many employing rigorous methodologies such as randomized
controlled trials (RCTs). This approach strengthens the reliability of the findings, sug-
gesting that therapies like TF-CBT and EMDR are effective for treating PTSD in children
and adolescents. Furthermore, including meta-analyses and systematic reviews further
enhances the quality of the evaluation by aggregating data from multiple studies, allowing
for more robust conclusions about the efficacy of various interventions. It is important to
note that the studies included in the review typically used established diagnostic criteria
(DSM-5 or ICD-11) and standardized outcome measures for PTSD, which adds to the relia-
bility of the findings. However, the variability in outcome measures across studies could
contribute to heterogeneity. Also, the review covers a wide range of psychotherapeutic
interventions (e.g., TF-CBT, EMDR, play therapy), which inherently differ in approach
and implementation. This diversity can lead to heterogeneity in outcomes, as different
Children 2024, 11, 579 20 of 33

treatments may be variably effective depending on the specific needs and backgrounds
of the children and adolescents treated. The age range of participants (5 to 17 years old)
encompasses a broad developmental spectrum from early childhood to late adolescence.
This broad age range can introduce heterogeneity due to developmental differences in un-
derstanding, processing, and coping with trauma. The review likely includes studies with
participants who have experienced different types and severities of trauma (e.g., abuse,
natural disasters, war). The heterogeneity in trauma experiences can affect treatment out-
comes, as some interventions may be more suitable for certain types of trauma than others.
Additionally, the studies included in the review may vary in their participants’ cultural
and socioeconomic backgrounds. These factors can influence the presentation of PTSD
symptoms and the effectiveness of interventions, contributing to heterogeneity in outcomes.
There may be variability in the duration of treatments and the mode of delivery (individual
vs. group therapy, in-person vs. online) across the studies. These differences can lead
to variations in treatment outcomes. Children and adolescents with PTSD often have
comorbid conditions (e.g., anxiety, depression, behavioral disorders). The presence and
treatment of comorbidities can introduce additional variability in outcomes. The quality of
the studies included in the review is generally high, providing valuable evidence for the
efficacy of various interventions for PTSD in children and adolescents. However, potential
heterogeneity among the studies can arise from differences in interventions, participant
characteristics, trauma types, cultural backgrounds, treatment modalities, and comorbid
conditions. Understanding this heterogeneity is crucial for tailoring interventions to meet
the individual needs of children and adolescents affected by PTSD.
Amplifying the complexity of treating PTSD in youth are factors such as gender
differences, with emerging evidence suggesting a heightened risk of PTSD diagnosis in
females and the crucial role of parental involvement in the therapeutic process. Treatment
duration, therapist characteristics, and the necessity for tailored interventions based on the
child’s cultural background further underscore the multifarious considerations required
for effective treatment.
As separate research on PTSD in children and adolescents began relatively recently, the
current literature on youth PTSD is insufficient. It would be beneficial to investigate various
types of trauma separately to determine whether specific treatments are more effective
for certain types of trauma. Most existing meta-analyses combine all forms of trauma,
obscuring potential differences in treatment outcomes. In addition to the form of trauma, it
would be beneficial to differentiate between PTSD resulting from a traumatic event and
PTSD resulting from chronic, repeated traumatic factors. The mechanisms implicated in
the two cases may differ, necessitating a different approach. Additionally, it would be
beneficial to contemplate more severe co-occurring disorders. According to the research,
PTSD frequently coexists with other disorders (anxiety, melancholy, etc.), which may hinder
the recovery of children. A more extensive survey sample could aid in consolidating and
generalizing the findings.
The present systematic review has some limitations that should be mentioned. First,
the review has not adequately addressed how cultural and geographical factors affect
the efficacy of different therapies, which is particularly important given the variability in
PTSD presentations across different cultural contexts. Second, there was no mention of
assessing for publication bias, which could influence the findings of studies with positive
outcomes more likely to be published than those with negative or inconclusive results.
Third, there was variability in intervention effectiveness. For instance, the excluded stud-
ies have explored different interventions, combinations of therapies, or have involved
diverse demographic groups. Discussing these limitations can help contextualize the find-
ings, acknowledge the scope of the review, and guide future research to address these
gaps effectively.
Children 2024, 11, 579 21 of 33

As previously stated, childhood and adolescence psychopathology research is limited

and has a long way to go. In addition to the limited quantity of empirical research, we
frequently encounter research of “low” quality. Most research is not grounded in empirical
evidence or randomized controlled trials. In addition, the majority of studies employ tiny
samples. Spontaneous remission, or “resolution”—improvement of the disorder’s clinical
symptoms without external treatment—has not been measured in most studies. This would
be beneficial in determining what proportion of the improvement is attributable to the
intervention used each time and what proportion is attributable to spontaneous remission
over time. Without doubt, there are significant gaps in childhood and adolescence psy-
chopathology research, particularly noting the scarcity and often low quality of empirical
studies. This shortfall is especially concerning when considering complex psychological
phenomena such as cognitive dynamics, trauma, psychosis, and personality disorders [83].
These elements are profoundly interlinked, influencing and exacerbating each other in
subtle and often unpredictable ways. For instance, trauma experienced in early life can
alter cognitive dynamics, potentially leading to the development of psychosis and person-
ality disorders as coping or defense mechanisms [84]. The lack of robust, large-scale, and
controlled studies makes it challenging to discern the natural course of these disorders
and the specific impacts of interventions. Furthermore, the failure to measure spontaneous
remission leaves a significant knowledge gap in our understanding of how these disorders
might resolve independently of interventions. This makes it difficult to evaluate the true
efficacy of treatments, thereby complicating clinical decisions and policy-making aimed at
effectively addressing these complex disorders in young populations.
To sum up, this paper underscores the imperative for an individualized, culturally
sensitive approach to treating PTSD in children and adolescents. It advocates for a holistic
understanding that integrates the symptomatic, developmental, and social dimensions of
the disorder, thereby paving the way for interventions that are not only effective, but also
empathetic to the unique challenges faced by young individuals recovering from trauma.
The ongoing research and refinement of therapeutic strategies remain crucial in ensuring
that all affected children and adolescents have access to evidence-based, developmentally
appropriate care.
Children 2024, 11, 579 22 of 33

Table 1. Main Results and Study Characteristics.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

Semi-structured interview
CBCL (child behavior checklist)
PTSDSSI (post-traumatic stress disorder
semi-structured interview) Medical information exposure inversely affects
Ben Ari et al. (2019) Prospective Children PCASS (the Preschool Children’s Assessment of post-traumatic stress in children months after a medical
[26] [RQ1] Study N = 151 Stress Scale) episode. The correlation is significant in preschoolers
UCLA-PTSD (University of California at Los Angeles and schoolchildren.
PTSD) reaction index: DSM-5 version
SCARED (the screen for child anxiety related
emotional disorders)
Exercise training may affect cortisol levels, introduce a
Budde et al. (2018) Adolescents aged 13–16 years Impact of an 8-week exercise training (ET) regime on
Quantitative cost-effective group intervention for PTSD patients, and
[27] [RQ5] N = 198 PTSD symptoms and changes in cortisol levels.
differ from a placebo.
- EMDR reduced PTSD, depression, and anxiety more
Chen et al. (2018) Adolescents aged 12–16 years than other therapies and controls.
Quantitative EMDR
[85] [RQ5] N = 251 - Clinical efficacy of EMDR in treating complex
childhood trauma in children and adults.
The intervention(s) that the study participants received
were Risk Reduction through Family Therapy (RRFT) - RRFT reduced substance-using days more than the
and Treatment-As-Usual (TAU) consisting primarily of control group at months 12 and 18.
Adolescents aged 13–17 years
Danielson et al. trauma-focused cognitive behavioral therapy. RRFT - RRFT and TAU groups showed significant PTSD
[RRFT: 61]
(2020) [47] [RQ1] Quantitative resulted in significantly greater reductions in symptom reductions from baseline to months 3, 6, 12,
[TAU: 63]
[RQ2] substance-using days at month 12 and month 18 and 18, with no between-group differences.
N = 124
compared to TAU. Significant reductions in PTSD - Neither condition showed worsening substance
symptoms were observed within the RRFT group at use problems.
months 3, 6, 12, and 18.
37 studies on PTSD, Six recent meta-analyses and systematic reviews
20 RCTs on PTSD, examined PTSD psychological treatments for children
41 RCTs of varied interventions Semi-structured interview and questionnaires and adolescents. CBT, EMDR, narrative exposure
Danzi & La Greca
for youth with PTSD, examining these parameters: Gender, Age, Ethnicity, therapy, and classroom-based interventions were
(2017) [21] [RQ5] Longitudinal
135 studies on psychological Domicile, Parent/Caregiver Factors, Trauma Types, supported. CBT and TF-CBT are well-established
[RQ6]
treatments for PTSS in youth Treatment Factors. treatments for youth PTSD. Despite limited evidence,
and found the largest effect sizes EMDR, narrative exposure therapy, and school-based
for CBT interventions gained support.
Children 2024, 11, 579 23 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

War-Traumatic Events Checklist (W-TECh),
Multicultural
El-Khodary et al. Children and Adolescents Events Schedule for Adolescents (M.E.S.A.) At least one war-traumatic event affected every child or
(2019) [48] [RQ1] Quantitative 11–17 years old Post-traumatic Stress Disorders Symptoms Scale adolescent, worsening mental health and behavior.
[RQ3] N = 1029 (PTSDSS) These families and children need counseling.
Strengths and Difficulties Questionnaire
Child Depression Inventory (CDI)
This population may benefit from clinical intervention
Child PTSD Symptom Scale
Ferrajão (2020) [50] Children goals like parental emotional validation and invalidation.
Quantitative Children’s Depression Inventory 2
[RQ2] N = 60 Therapy interventions suggest emotional validation to
Emotional Validation Experiences Questionnaire
improve therapist-patient relationships.
Children
and Adolescents 9–14 years UCLA PTSD-Index
Forresi et al. (2019) The findings suggest better clinical interventions for
Cross-sectional N = 682 Strengths and Difficulties Questionnaire (SDQ)
[28] [RQ5] earthquake-exposed children and adolescents.
Parents SCL-90
N = 1162
Grainger et al. Systematic
PROSPERO The results showed that TF-CBT reduced PTSD
(2022) [29] [RQ1] Review & 40 RCTs
TF-CBT interventions symptoms better than controls.
[RQ3] [RQ4] Meta-analysis
The targeted preventive intervention reduced
posttraumatic stress disorder (PTSD) symptom severity
Participant age: 1–6 years The intervention was a 2-session CBT-based
over time, with intervention children having a faster
Haag et al. (2020) [Intervention: 62] intervention for parents of children who screened
Quantitative PTSS severity score reduction than controls at 3 months.
[30] [RQ4] [Treatment-as-usual: 71] ‘high-risk’ for PTSD. The duration of the intervention
The intervention also improved PTSD diagnosis,
N = 133 was 2 sessions.
functional impairment, and behavioral issues in young
injured children.
The interventions that the study participants received The paper reviews predictors, assessment, and treatment
include psychoeducation about trauma reactions, options for youth with PTSD, suggests studying
Kolaitis, G. (2017) Systematic exposure to trauma-related cues and memories, coping phenotypes or domains like cognitive, memory, and
Children and Adolescents
[31] [RQ4] Review skills training for children, parental training, and executive functioning to understand PTSD and its
medications such as selective serotonin effects, and proposes a dimensional approach to PTSD
reuptake inhibitors. and trauma.
Children 2024, 11, 579 24 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

Wechsler Intelligence Scale for Children-IV
Traumatized adolescents can develop short- and
Minnesota Multiphasic Personality
long-term psychiatric diagnoses like affective,
Adolescents between Inventory–Adolescent Version
Luoni et al. (2018) personality, and psychotic disorders, as well as
Cross-sectional 12 and 18 years Trauma Symptom Checklist for Children
[86] [RQ3] dissociative and somatic symptoms that may be more
N = 107 (form TSCCA)
debilitating than PTSD. Trauma treatment requires
Child Behavior Checklist (Achenbach)
individualization.
Clinical Global Impressions-Severity of Illness Scale
Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT)
PRACTICE—Psychoeducation & Parenting skills, Youth at risk for familial sex trafficking and labor
Case Study
Márquez et al. Relaxation, Affective expression and exploitation may benefit from TF-CBT for psychosocial
Qualitative 14-year-old Guatemalan female
(2020) [32] [RQ1] modulation, Cognitive issues. TF-CBT can help traumatized children cope and
N=1
coping, Trauma narrative and processing, In vivo improve their mental health.
mastery, Conjoint sessions, and Enhancing safety and
future development
- Cognitive therapy for PTSD in children and youth is
the most cost-effective, followed by narrative exposure,
Cognitive therapy for PTSD, narrative exposure, play play therapy, and other individual TF-CBT.
Mavranezouli et al. Systematic therapy, other forms of individual TF-CBT, EMDR, - Individual TF-CBT and play therapy are cost-effective
Adolescent aged < 18 years
(2019) [33] [RQ1] Review parent training, group TF-CBT, family therapy, for children and youth with PTSD more than 3 months
supportive counselling. after trauma.
- Family therapy and supportive counseling may not be
cost-effective over other interventions.
Childhood ADHD symptoms were linked to trauma
UCLA PTSD Reaction Index, DSM-IV
exposure and PTSD in college students. Clinical
Miodus et al. (2021) College Students < 18 The Barkley Adult ADHD Rating Scale–IV
Quantitative interventions for children and adolescents, college
[44] [RQ1] N = 454 Beck Depression Inventory–Second Edition
counseling, and psychological and academic inclusion
Beck Anxiety Inventory
services are impacts.
Kiddie Schedule for Affective Disorders and
Interventions should address individual/interpersonal
Schizophrenia (K-SADS-PL)
(reducing home and environmental abuse) and
Nöthling et al. Adolescents Child PTSD Checklist (CPC)
Quantitative community/societal (reducing crime rates and
(2016) [87] [RQ1] N = 215 Childhood Trauma Questionnaire (CTQ)
strengthening conviction policies) levels to prevent
Child Exposure to Community Violence
trauma, PTSD, and depression.
Checklist (CECV)
Children 2024, 11, 579 25 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

The study found that narrative exposure therapy (NET)
and treatment as usual (TAU) reduced PTSD,
Children and Adolescents
Peltonen, K., & psychological distress, and rebuilt resilience. PTSD
9–17 years
Kangaslampi, S. symptoms and clinical-level PTSD rates decreased
Quantitative [NET: 29] NET Questionnaire
(2019) [42] [RQ1] significantly in the NET group only, with large effect
[TAU: 21]
[RQ3] [RQ4] sizes. The study suggests that NET is safe, effective, and
N = 50
useful for multiply traumatized children and
adolescents in clinical settings.
The study found that TF-CBT significantly reduced
PTSD symptoms, with only 1 out of 16 participants
meeting diagnostic criteria after treatment.
The self-report measures of PTSD, anxiety, and
Peters et al. (2021) Adolescents aged < 18 The intervention received by the study participants is
Quantitative depression improved significantly.
[45] [RQ5] [RQ6] N = 20 TF-CBT, with a mean of 15 sessions over 25 weeks.
Some participants experienced a brief exacerbation in
symptoms during certain phases of the treatment, but all
symptoms resolved by the end, and the majority of
participants rated the intervention as helpful.
The intervention included mindfulness, expressive arts,
and EMDR group therapy. This
Adverse childhood experience (ACE)
integrative/complementary short-term program may
Short PTSD Rating Interview (SPRINT)
Roque-Lopez et al. Girls aged 13–16 years reduce psychological burden in adolescents with
Quantitative Child PTSD Symptom Scale (CPSS)
(2021) [46] [RQ5] N = 44 multiple adverse childhood experiences. After 2 months,
Mindful Attention Awareness Scale—Adolescents
adolescents’ psychological functioning improved, but
(MAAS-A)
they may need group or individual follow-up to
maximize its mental health benefits.
The intervention(s) that the study participants received
were: Both PE-A and SC improved PTSD and depression
1. Prolonged Exposure Treatment for Adolescents symptoms during treatment, according to the study.
Adolescents aged 14–18 years
Rossouw et al. (PE-A): up to 14 weekly 60 to 90 min sessions, PE-A may be long-lasting because participants in the
[PE-A: 6]
(2016) [52] [RQ1] Quantitative comprising eight modules with specific activities and group maintained their PTSD and depression gains at
[SC: 5]
[RQ3] [RQ4] homework exercises. the 12-month post-treatment assessment. The study also
N = 11
2. Supportive Counselling (SC): up to 14 weekly 60 to showed that inexperienced school counselors in South
90 min sessions, focusing on client-centered therapy Africa can implement the PE-A protocol.
and establishing a trusting therapeutic relationship.
Children 2024, 11, 579 26 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

At post-intervention, 3-month, and 6-month follow-up
assessments, prolonged exposure (PE-A) reduced PTSD
symptoms in adolescents more than
Prolonged exposure therapy for PTSD: 7–14 weekly,
Adolescents aged 13–18 supportive counselling.
Rossouw et al. 60 min sessions with eight modules and
[PE-A: 31] - More PE-A participants had a ‘good response’ than
(2018) [49] [RQ1] Quantitative homework exercises.
[Supportive Counselling: 32] supportive counselling participants, indicating a higher
[RQ3] [RQ4] Supportive counselling: 7–14 weekly, 60 min sessions
N = 63 rate of positive treatment outcomes.
of client-centered therapy.
PE-A reduced PTSD symptoms and increased remission
rates in adolescent PTSD more than
supportive counselling.
Child PTSD Symptom Scale This study is the first benchmarking study of TF-CBT
Rudd et al. (2019) Children Ohio Mental Health Consumer Outcomes and provides preliminary findings on its efficacy and
Quantitative
[34] [RQ5] N = 114 System—Ohio Youth Problem, Functioning, and transportability to urban community settings serving
Satisfaction Scales poor youth.
Child maltreatment determined by substantiated The current study used a person-centered approach to
caseworker reports (a) identify subgroups of adolescent females with
Russotti et al. Longitudinal Adolescent Females 15–17 years Beck Depression Inventory-II distinct attachment quality with peers, fathers, and
(2023) [51] [RQ2] Cohort N = 514 Comprehensive Trauma Interview mothers and (b) determine if maltreatment affected
Inventory of Parent and Peer Attachment—IPPA depressive and PTSD symptoms differently by
Child’s Report of Parental Behavior Inventory attachment quality.
Despite 62% of participants experiencing negative life
events during the program and being in asylum, pre-
and post-measures showed significant differences in
depressive and PTSD symptoms. Six qualitative
interview categories were social support, normalization,
Sarkadi et al. (2017) Adolescent Teaching Recovery Techniques valuable tools, comprehensibility, manageability, and
Qualitative
[35] [RQ5] [RQ6] N = 139 (TRT)—6 week program meaningfulness. According to TRT’s program theory,
sharing experiences in a safe and supportive
environment and learning trauma-specific exposure and
behavioral activation will help youth feel more coherent
and reduce depression and PTSD symptoms. URMs may
benefit from TRT for PTSD.
Children 2024, 11, 579 27 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

Cognitive therapy for PTSD (CT-PTSD)—Individual
Children and Adolescents aged weekly sessions over 10 weeks delivered by trained Cognitive therapy is likely cost-effective compared to
Shearer et al. (2017)
Quantitative 8–17 years clinical psychologists. Average contact time: usual care for children and adolescents with PTSD,
[36] [RQ4]
N = 29 636.25 min. Average number of sessions: 8.3. Mean according to the study.
cost: £1463.
The study highlights the mutual impacts of adolescent
and parental PTSS after a disaster, with both maternal
Adolescents: 15.22 years Parents:
Shi et al. (2018) [37] and paternal PTSS at 12 months predicting adolescent
Quantitative 41.04 years PTSS Questionnaire
[RQ2] PTSS at 18 months. Adolescent PTSS at 12 months only
N = 688
predicted maternal PTSS at 18 months, not
paternal PTSS.
The study participants received life skills programs
targeting one or more mental health outcomes and Most RCTs on LMIC students and refugees reduced
co-occurring risk factors in school and community anger, improved life skills and functioning, and reduced
settings. The interventions were delivered by teachers PTSD, depression, and anxiety. LMICs may benefit from
Singla et al. (2020)
Quantitative Adolescents aged 10–19 years and specialist providers, focused on high-risk groups, comprehensive programs that address multiple life
[38] [RQ5] [RQ6]
and included comprehensive programs focusing on skills, the individual’s social environment, and
multiple life skills related to the individual, their social parent–child interactions to address mental health and
environment, and interventions promoting other health issues.
parent–child interactions.
TF-CBT:
- Demonstrated clinically significant improvement in
more than 900 children.
Child and Adolescent aged Most effective PTSD treatments include CB, and TF-CBT
Syros, I. (2017) [39] - Follow-up studies show sustainability of benefits for
Quantitative between 3–17 years and CBITS have shown clinically significant
[RQ1] [RQ3] [RQ4] 6 months, 1 year, and 2 years after treatment.
N = 900 improvement and sustained benefits.
CBITS:
- Superior to the waiting list in reducing PTSD and
depression cases.
Clinically significant psychosocial interventions improve
PTSD, depression, and anxiety in distressed refugees
NET, KIDNET, EMDR, music therapy, CETA, CBT,
Turrini et al. (2019) Children from 7 years and asylum seekers. Most evidence supports
Quantitative writing for recovery, IPT, TRT, CROP, FGI, need
[40] [RQ1] N = 1959 trauma-focused cognitive behavioral therapies.
satisfaction intervention.
Accordingly, develop evidence-based guidelines and
implementation packages.
Children 2024, 11, 579 28 of 33

Table 1. Cont.

Author (Year) Type of Study Sample (N) Assessment/Intervention Main Findings/Outcomes

Intervention:
- Trauma-focused cognitive-behavioral therapy
TF-CBT is effective in reducing posttraumatic stress
Tutus et al. (2017) Mean age: 12.66 years (TF-CBT).
Quantitative symptoms and improving psychosocial functioning over
[41] [RQ4] N = 76 - Additional interventions during the follow-up period:
the long term.
psychotherapy, counseling, rehabilitation, consultation
with a psychiatrist, and psychotropic medication.
Eye Movement Integration (EMI) reduced all but one
van der Spuy et al. Children aged 5–7 years Trauma Symptom Checklist for Young
Quantitative post-traumatic stress symptom in young children in
(2018) [43] [RQ6] N = 12 Children (TSCYC)
resource-constrained settings.
Children 2024, 11, 579 29 of 33

6. Conclusions
In conclusion, PTSD in children and adolescents is a complex mental health issue
requiring comprehensive clinical interventions. Post-traumatic Stress Disorder (PTSD) in
children and adolescents is a severe, potentially debilitating condition that can interfere with
their development and well-being as a whole. It is triggered by exposure to traumatic events,
which can be experienced directly or witnessed. Early identification and intervention
are essential for preventing the long-term mental, emotional, and even physical health
effects that this condition can have on children. The effectiveness of psychotherapeutic
interventions in treating PTSD in this population has been demonstrated. CBT, TF-CBT, and
EMDR are among the therapies with the most robust empirical support. They assist children
and adolescents in processing traumatic events, reducing distressing symptoms, and
enhancing coping mechanisms. Specifically, TF-CBT has been extensively studied and has
demonstrated remarkable efficacy in reducing PTSD symptoms and improving children’s
and adolescents’ functioning and quality of life. It integrates trauma-sensitive interventions
with cognitive behavioral therapy techniques to assist adolescents in comprehending and
managing their emotional reactions to traumatic events. Additionally, involving the parents
or caregivers in the therapeutic process is essential. Family support can substantially
improve treatment efficacy and facilitate the child’s recovery. However, treatment must be
tailored to the child’s age, developmental level, specific symptoms, and the nature of the
trauma. Not all children and adolescents respond the same way to treatment; therefore,
it is necessary to monitor and modify treatment plans. PTSD in children and adolescents
is a significant public health concern requiring trauma-informed, comprehensive care.
Psychotherapeutic interventions, in particular TF-CBT, are highly effective for symptom
management and reduction. However, additional research is required to ensure that
all affected children and adolescents have access to evidence-based treatment. Public
awareness and education about PTSD in adolescents and its treatment options are essential
for early detection and intervention.

Author Contributions: Conceptualization, E.K. and D.P.; methodology, E.K., E.G. and D.P.; soft-
ware, E.K. and E.G.; validation, E.K., E.G. and V.Y.; formal analysis, E.K. and E.G.; investigation,
D.P.; resources, E.K., E.G., D.P., V.Y. and P.D.S.; data curation, E.K., E.G., D.P., V.Y. and P.D.S.;
writing—original draft preparation, E.K., E.G. and D.P.; writing—review and editing, E.K. and E.G.;
visualization, E.K. and E.G.; supervision, E.K. and E.G.; project administration, E.K.; funding ac-
quisition, E.K., E.G., V.Y. and P.D.S. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflicts of interest.

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