Professional Psychology: Research and Practice Copyright 2007 by the American Psychological Association

2007, Vol. 38, No. 6, 620 – 628 0735-7028/07/$12.00 DOI: 10.1037/0735-7028.38.6.620

Posttraumatic Stress in Children and Adolescents Exposed to Family

Violence: II. Treatment
Katrina A. Vickerman and Gayla Margolin
University of Southern California

Interventions for youth exposed to family violence recently have incorporated a trauma focus with the
objective of reducing posttraumatic stress disorder symptoms along with alleviating other wide-ranging
childhood disorders. This article describes generally agreed-upon treatment components for youth
exposed to violence in the home (specifically, children who are physically abused or witnesses to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

interparental violence), including reexposure interventions, education about violence and cognitive
This document is copyrighted by the American Psychological Association or one of its allied publishers.

restructuring, processing of emotional cues, social problem-solving skills, and parenting interventions.
Information is drawn from clinical intervention descriptions, expert consensus, and empirical treatment
outcome evaluations. Empirically evaluated treatment programs for different developmental stages
(preschool, school-age, and adolescence) are summarized, and remaining questions about how to best
focus treatment efforts for youth traumatized by family violence are presented.

Keywords: child and adolescent intervention, posttraumatic stress disorder (PTSD), child physical abuse,
domestic violence, cognitive behavioral interventions

Family violence exposure as a potential precipitant of posttrau- This article details selected treatment components for children
matic stress disorder (PTSD) in children and adolescents involves traumatized by family violence, specifically child physical abuse
unique features (see Margolin & Vickerman, in press) that raise and exposure to interparental aggression. Our focus here is on
important considerations for treatment. For instance, can therapeu- these forms of family violence, which are distinct from and more
tic reexposure procedures be used as part of treatment if there is a common than child sexual abuse, but have received less attention
high likelihood of reexposure in real life? What is the role of as trauma stressors. First, we discuss important considerations and
parents in treatment if one or both parents have perpetrated the targets in treatment. In the second half of this article, we review the
violence? To what extent does treatment for traumatic stress gen- existing empirically supported treatment programs that have spe-
eralize to other comorbid symptoms associated with family vio- cifically examined efficacy in trauma reduction for youth who
lence exposure? Cognitive behavioral treatments are increasingly have been physically abused or exposed to domestic violence.
recognized as the preferred treatment for childhood PTSD related Because of the limited number of such programs, we also highlight
to natural disasters, medical procedures, and sexual abuse (Feeny, several interventions for traumatized youth that have led to treat-
Foa, Treadwell, & March, 2004). It is only in the past several ment gains in areas other than PTSD, and several trauma-focused
years, however, that posttraumatic stress has emerged as a unifying treatments that appear promising but have yet to be tested with this
direction for conceptualizing and treating problems associated population.
with child physical abuse and domestic violence exposure
(Graham-Bermann, 2001; Wekerle, Miller, Wolfe, & Spindel, Treatment Considerations and Targets
2006).
The treatment modalities specifically developed for children
exposed to family violence are varied (individual, group, family,
KATRINA A. VICKERMAN received her MA in clinical psychology from the
University of Southern California, where she is currently a doctoral stu-
and school). One-on-one treatment permits attention to individu-
dent. Her research interests include mental and physical health correlates of alized traumatic cues, distorted thoughts, and behavioral interac-
intimate partner violence and longitudinal patterns of emotional and phys- tions. Group treatments, which typically are administered in
ical partner aggression, as well as family violence, sexual assault, and schools, community settings, and domestic violence shelters, target
trauma. general beliefs and attitudes about violence, reactions to violence,
GAYLA MARGOLIN received her PhD in psychology from the University of and social problem-solving skills. Although many children benefit
Oregon and is professor of psychology at the University of Southern from the positive, fun atmosphere where they feel validated and
California. Her research examines the impact of family and community appreciated (Suderman, Marshall, & Loosely, 2000), group treat-
violence and other serious stressors on youth and family systems. ment may be counterindicated for children with particularly poor
PREPARATION OF THIS ARTICLE was supported in part by National Research
social skills who are at risk for further rejection (Friedrich, 2002).
Service Award 1F31 MH74201, awarded to Katrina A. Vickerman, and
National Institute of Child Health and Human Development Grant 5R01
A number of treatments are designed for violence-exposed youth
HD046807, awarded to Gayla Margolin. at specific developmental stages, typically preschool children,
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Gayla school-age children, or adolescents. Interventions with younger
Margolin, Department of Psychology-SGM 930, University of Southern children frequently incorporate play, whereas interventions with
California, Los Angeles, CA 90089-1061. E-mail: margolin@usc.edu adolescents draw on adult-oriented treatments but attend to the

620
 FAMILY VIOLENCE AND YOUTH PTSD: TREATMENT 621

unique challenges of adolescents regarding risk taking and social relationship, the child can review and integrate the fragmented
pressures. Some treatments focus on specific adjustment problems impressions of the trauma into a coherent story, increase his or her
related to the violence exposure (e.g., aggression or conduct dis- tolerance for negative emotions associated with the event, learn
orders related to child abuse), whereas others provide preventive what to expect in terms of future traumatic reactions, and address
strategies to address the wide-ranging risks of living in violent the personal meanings of the event. Silvern, Karyl, and Landis’s
families. Some treatments are designed to assist children and (1995) “straight talk” model of the trauma interview emphasizes
families at specific transitions—for instance, as the mother and the need for direct rather than polite questions in eliciting salient
children leave a battered women’s shelter. details about the child’s response to a traumatic event. Silvern et
Nonetheless, despite variability in treatment modalities, targeted al. recommend reframing, normalizing, or offering comfort when
clients, and symptom presentation, there is considerable consensus the child reveals behaviors that she or he finds embarrassing or
across the clinical literature and empirically tested treatments on shameful; for example, “if a child laments his or her failure to take
important intervention objectives and strategies for children trau- action, the therapist might assert that staying out of the batterer’s
matized by family violence. Trauma-focused treatments are pre- way was smart” (p. 56). This example also illustrates the impor-
dominantly based on cognitive behavioral models, which aim to tance of reinforcing strategies that are effective toward the goal of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

optimize adaptive functioning in youth. These interventions typi- safety.

cally use a combination of the following treatment components: In Cohen, Mannarino, and Deblinger’s (2006) trauma narratives,
trauma reexposure, violence education and cognitive restructuring, children write a trauma story, dictate the story to the therapist, or
emotion expression and regulation, social problem solving, safety enact the story through play activities. In developing the narrative
planning, and parent training. As noted (Margolin & Vickerman, in of the traumatic event, the child first writes an account of the
press), before beginning treatment, clinicians should do a compre- details and facts, then elaborates that story with thoughts and
hensive assessment of all salient domains, including the child’s feelings, and eventually adds the worst part that previously was too
symptoms, strengths, family context, and broader environment. difficult to discuss. When young children enact the narrative
through dolls or puppets, or by drawing, the therapist needs to
Reexposure Interventions actively direct the play and interrupt repetitive enactments of the
trauma. Play also can provide behavioral rehearsal of adaptive
The overall goals for exposure interventions in response to ways of coping with violence exposure—for example, telephoning
trauma are to help the child (a) separate the thoughts, cues, and someone for help.
other reminders surrounding the trauma event from overwhelming
and incapacitating negative emotions; (b) make sense of reactions Education About Violence and Cognitive Restructuring
during and subsequent to the traumatic event; and (c) discuss and
rehearse alternative responses (Cohen, Mannarino, & Deblinger, Education about violence and cognitive restructuring typically
2006; Kerig, Fedorowicz, Brown, & Warren, 2000). Theoretically, focus on changing cognitions about aggression and gaining control
reexposure is thought to work as an informal desensitization pro- over the intrusive reexperiencing of symptoms. Cognitive inter-
cess. By discussing the event and the conditioned aversive stimuli ventions have several goals in common with reexposure—namely,
surrounding the event without retraumatization, conditioned re- thinking about the violence from a new perspective and developing
sponses between the aversive stimuli and the painful emotional different coping strategies to respond to violence— but often are
reactions are extinguished. If there is a reduction in the physio- conducted in group settings to allow children to learn from one
logical and psychological reactions to trauma cues and intrusive another.
thoughts, then the child no longer will need to avoid those cues or Cognitive interventions are used to help children understand
suppress the thoughts and will be able to engage in normal activ- connections between violence exposure and violence reactions,
ities. and also to highlight the nonnormative nature of aggression and
For reexposure interventions to be therapeutic and not retrau- violence in relationships (Graham-Bermann, 2001; Peled & Edle-
matizing, the clinician needs to carefully guide the intervention so son, 1995). Children typically experience considerable relief as
that the child maintains control and ultimately obtains mastery they learn that their seemingly out-of-control symptoms actually
over the experience (Cohen, Mannarino, & Deblinger, 2006; Kerig are quite normal, given the circumstances of violence exposure.
et al., 2000). As contrasted with one-time trauma exposures, which Group leaders also help children develop vocabularies to describe
may be accompanied by unrealistic fears, the repeating and ongo- violent events. As children tell their stories of abuse, they receive
ing nature of violence in the home makes it important to use support and validation from others and come to realize that they
reexposure techniques to prepare youth for coping with future are not alone in living with violence.
episodes. The objective is to assist youth in developing a personal A related goal is to undo the lessons learned from growing up in
story with new strategies of coping with the violence, or respond- a violent home, specifically, messages that aggression is an ac-
ing even to less dangerous but still threatening anger and conflict- ceptable way to deal with conflict. These interventions convey
related cues. three unambiguous messages: that violence and abuse are unac-
One commonly used form of reexposure is the trauma interview, ceptable, that violent behavior is a choice, and that children are not
which allows the child to disclose and review details of the responsible for parents’ aggression and violence. With respect to
traumatic event in a safe, accepting environment where the danger child abuse, Kolko and Swenson (2002) recommend helping the
cannot reoccur. Pynoos and Eth (1986) developed a widely used child distinguish between discipline and harm, and explaining that
interview protocol to engage children ages 3 to 16 in a discussion there are laws to protect children from harm. Interventions with
of the traumatic event. Within the safe confines of the therapeutic children exposed to domestic violence often address gender role
 622 VICKERMAN AND MARGOLIN

beliefs that foster aggression (Graham-Bermann, 2001) and, with apy, etc.), or if additional abusive incidents are discussed in
adolescents, help youth develop strategies to combat societal mes- therapy. As part of ongoing safety assessments, the therapist must
sages about power and control in relationships, sex role stereo- be alert for changes in the family situation that could elevate
types, and gender-based attitudes (Wolfe et al., 1996). chronic states of tension and stress to a crisis level with the
Thought-stopping, self-talk, and positive imagery are strategies potential of serious injury to the youth or another family member.
to help children interrupt intrusive, distressing thoughts (Kerig et Children who remain in family environments with the potential
al., 2000; Wekerle et al., 2006). The important component is that for violence need to learn to recognize and plan for future in-
children learn they have control over their thoughts. When a stances of family aggression. Distinctions are needed between not
child’s new perspectives on violent episodes translate into self- being responsible for the violence but being responsible for acting
statements such as “I am not responsible for my parents’ fright- to protect one’s own safety. Protecting one’s own safety includes
ening behaviors,” or “I did the best I could under the circum- anticipating the cues of dangerous situations at home or elsewhere
stances,” that child may have less need to mentally replay the and identifying people who can be helpful (Kolko & Swenson,
violent episodes. 2002). The consistent message is that children should “break the
silence” and disclose situations that pose a danger to themselves or
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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Emotion Recognition and Expression others (Peled & Edleson, 1995). Although it is important to praise
children for their previous responses to the violence so that they do
Interventions that address the processing of emotional cues have not feel as though they failed to act responsibly, children under-
several important objectives. Attending to and expressing one’s stand the message they can always expand their options for re-
own emotions can lead to improved emotional regulation. Recog- sponding to family violence (Cohen, Mannarino, & Deblinger,
nizing emotions in others can facilitate the development of empa- 2006).
thy. Learning to interrupt anxiety gives youth a sense of control
over unpleasant emotions. Identifying connections between emo- Parenting Interventions
tions, automatic thoughts, and behaviors enables youth to respond
in a more intentional manner to ambiguous or stressful situations. Even when one or both parents are the source of the child’s
An important step toward these objectives is developing an exposure to violence in the home, parents are important in the
emotional vocabulary. By learning the full range of emotions, both child’s recovery from PTSD (American Academy of Child and
positive and negative, youth can better distinguish between anger Adolescent Psychiatry, 1998). Involving the nonoffending parent
and other negative emotions—such as sadness, disappointment, in some portion of treatment is quite standard. It is less clear to
and fear—and then express more nuanced emotions (Suderman et what extent and under what circumstances the offending parent
al., 2000). Identifying connections between bodily sensations and should be included, although some investigators recommend in-
emotions can help youth identify specific emotions, such as anx- volving offending parents who continue to interact with the child
iety. Deep breathing, relaxation, guided imagery, and visualization on a day-to-day basis (Runyon, Deblinger, Ryan, & Thakkar-
are often taught so that youth have strategies to interrupt anxiety Kolar, 2004). When engaging parents in the therapeutic process, it
and short-circuit the common occurrence of fear escalating into is important not to underestimate the parents’ fundamental desire
anger (Kolko & Swenson, 2002; Wekerle et al., 2006). to do what is best for the child, despite evidence that they have, at
least on certain occasions, created or contributed to a dangerous,
Social Problem Solving and Social Interaction Skills threatening home environment. One reason to include parents is to
convey the essential message that familial risk to the child must be
Social problem solving teaches children new ways of interacting reduced. Another reason is to inform parents about the therapeutic
and working out conflicts, once they have developed nonviolent interventions with the youth and have them prompt and reinforce
cognitions and emotion recognition skills. Behavioral rehearsal is the child’s efforts toward mastery. Formalized parenting interven-
the primary strategy for learning new interaction skills. Interven- tions typically focus on stopping aggressive parenting, improving
tions with school-age children emphasize how to open conversa- constructive and positive parenting skills, and lessening parents’
tions, take turns, listen to one another, be polite to others, and use own distress and isolation.
assertive rather than aggressive or passive behaviors for conflict One important parent intervention is communicating the mes-
resolution (Graham-Bermann, 2001; Kolko & Swenson, 2002). sage that physical aggression in parenting is not an effective
Wolfe et al.’s (1996) adolescent intervention addresses assertive- discipline strategy and actually promotes negative child behavior
ness versus aggressiveness in dating relationships with role-play and adverse child outcomes (Kolko & Swenson, 2002; Runyon et
exercises to help youth learn how to handle conflict, respond to al., 2004). Straus (1994) has argued that corporal punishment itself
abuse in their own relationships, and develop positive social skills is “deeply traumatic for young children” (p. 9), leading to high
such as giving compliments. levels of aggression and low empathy for others’ distress. When a
child is already traumatized by family violence, the further use of
Safety Planning and Coping With Violence physical punishment, even commonly used corporal punishment,
can retraumatize that child. It is often difficult to overcome par-
Safety must be a primary and continuing concern when working ents’ resistance to relinquish physical punishment, because of its
with children who are exposed to domestic violence or have been accepted legitimacy in parents’ viewpoints. However, parents tend
the victim of child abuse. Child abuse reporting may be necessary, to be more likely to consider other strategies if the therapist
depending on how the child is brought to the attention of a recognizes and commends the parents’ well-meaning intentions.
therapist (e.g., child protective services referral, individual ther- Prioritizing problem behaviors based on discussion of age-
 FAMILY VIOLENCE AND YOUTH PTSD: TREATMENT 623

appropriate expectations is an important step. Parents also need manual (see entries in the reference list marked with a † for
alternatives to physical punishment, such as effective ways of treatment manuals or component descriptions), except the Learn-
doing “time out,” contingency management, withdrawal of rein- ing Club, which has a manual for the mother advocacy intervention
forcement, and communication skills (Patterson & Forgatch, 2005; but not the child intervention. Several expert panels have rated the
Wekerle et al., 2006). Parents often benefit from rehearsing the level of empirical support of treatments for youth PTSD or for
new skills and from assistance as they incorporate new behaviors victims of child abuse. The final column in Table 1 includes
into their lives, for example, through home visits so that the ratings, when available, on treatments for PTSD from the National
therapist can help resolve specific obstacles to carrying out non- Child Traumatic Stress Network (NCTSN, 2005), treatments for
aggressive discipline strategies. Parents also benefit from knowing child physical and sexual abuse from the National Crime Victims
in advance that their initial attempts at nonaggressive discipline Research and Treatment Center and Center for Sexual Assault and
strategies may result in immediate, albeit short-term, spikes in
Traumatic Stress (Saunders, Berliner, & Hanson, 2004), and treat-
undesirable child behaviors.
ments for child abuse from the Kauffman Best Practices Project
Treatments also aim to lessen coercive interactions by empha-
(Chadwick Center for Children and Families, 2004).
sizing more positive and supportive parenting techniques, some-
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times through direct coaching during observed parent-child inter-

actions (Urquiza & McNeil, 1996). Kolko (1996) worked with the Violence Exposure Treatments Targeting Youth PTSD
entire family to promote identification and reduction of coercive
behaviors and to replace them with constructive problem solving Child–parent psychotherapy (CPP) for preschoolers exposed to
and positive communication skills. marital violence. Lieberman and Van Horn (2005) have devel-
Violence-prone families are affected by many contextual stres- oped an intervention for preschoolers exposed to partner violence
sors, including poverty, single parenthood, and racism, as well as toward their mother. CPP builds on attachment, social cognitive,
parents’ own trauma symptoms, substance abuse, and psychopa- psychodynamic, and cognitive behavioral theories and targets the
thology. In light of the ample evidence that parents’ own distress
mother– child relationship during joint mother– child and mother-
is a risk factor for youth PTSD symptoms, treatments aimed at
only sessions. The goals of CPP include creating a joint trauma
reducing parents’ distress through stress management and anger
narrative for the mother and child, increasing maternal responsive-
modulation can have added benefits for youth (Kolko & Swenson,
ness, addressing developmentally appropriate interactions and
2002; Wekerle et al., 2006). Parenting interventions include
knowledge about child development, in-home visits to identify the nonaggressive parenting, and decreasing maladaptive behaviors. A
ways that parents express anger toward the child, and opportunities randomized clinical trial (RCT) evaluating CPP versus case man-
to discuss their parenting concerns and worries (Graham-Bermann, agement and community treatment referral found significant re-
2001). These parenting interventions are bolstered by other types ductions in children’s traumatic stress (Lieberman, Van Horn, &
of instrumental assistance (e.g., helping the mother to interact with Ippen, 2005). It is notable that these children often had multiple
the school and obtain transportation, employment, and housing) traumas and exposure to other types of violence, including child
and emotional support through a system of one-on-one advocacy physical abuse, child sexual abuse, and community violence. Im-
or a supportive group environment. provements in children’s behavior problems and mother’s distress
were maintained at a 6-month follow-up assessment, although no
Empirically Evaluated Treatments information is provided about PTSD in the follow-up study
(Lieberman, Ippen, & Van Horn, 2006).
Of the empirical studies that have examined treatments for child The Kids’ Club and The Preschool Kids’ Club for children
physical abuse or exposure to domestic violence, some focus on exposed to partner violence. Graham-Bermann and colleagues
posttraumatic stress, whereas others focus on other types of youth designed group interventions for school-aged (The Kids’ Club)
outcomes. In the following section, we first discuss four interven- and preschool children (The Preschool Kids’ Club) that have been
tions that have examined the impact of treatment on PTSD symp- used in shelter and community settings (Graham-Bermann, 1992;
toms or diagnoses in youth who have been physically abused or Graham-Bermann & Follett, 2002). These psychoeducational
exposed to domestic violence. Our focus is on published outcome groups help children recover from traumatic exposure to intimate
research; we did not include case studies in this review. Next,
partner aggression and aim to prevent future problems through
because of the dearth of interventions that evaluate PTSD as an
learning about and discussing feelings and concerns related to
outcome, we review several select treatments for physically abused
violence, increasing coping skills and resilience, and addressing
children and children exposed to partner aggression that show
assumptions and cognitions about violence in intimate relation-
treatment gains in other problem areas but have not evaluated
PTSD as an outcome. Finally, we refer to several treatments that ships. Treated mothers participated in a group that provided em-
deserve mention because they effectively address PTSD in chil- powerment, parenting support, and discussion about the impact of
dren exposed to other forms of interpersonal violence, or because violence exposure on children. An efficacy study comparing fam-
they have some preliminary data on youth exposed to family ilies sequentially assigned to child only, mother and child, or
violence. wait-list control groups showed that children in both treatment
Table 1 summarizes treatment details, targets, and outcomes for conditions (child only, and mother and child) received fewer PTSD
empirically supported treatments that either specifically target diagnoses after treatment than did control children (Graham-
PTSD or that target other important outcomes for youth exposed to Bermann & Hughes, 2003). Only the mother and child treatment
family violence. Each child intervention is based on a treatment showed significant improvement in other outcomes (externalizing
 624 VICKERMAN AND MARGOLIN

Table 1
Selected Treatments for Youth Exposed to Child Physical Abuse (CPA) and Domestic Violence Between Intimate Partners (DV)

Age CPA/ PTSD Length of Other youth Empirical

Treatment range DV targeted? treatment PTSD outcome outcomes Parent/mother outcome ratings

Child-Parent Psychotherapy 3–5 DV Yes 1 year, weekly 2 symptoms 2 behavior 2 distress 1a, 3b
(Lieberman et al., 2005) 2 diagnoses problems 2 PTSD avoidance,
reexperiencingd,
hyperarousald
symptoms
The Kids’ Club (Graham- 5–13 DV Yes 10 weeks 2 diagnoses 2 externalizing none reported
Bermann, 2000; Graham- symptoms
Bermann et al., 2007) • improved violence
attitudes
Trauma-Focused Cognitive- 8–14e CPA, Yes 12–16 weeks 2 symptoms 2 depression 2 depression 1a, 1b
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Behavioral Therapy DV 2 diagnoses 2 behavior 2 distress about abuse BPc

This document is copyrighted by the American Psychological Association or one of its allied publishers.

(Cohen et al., 2004) problems

2 shame 1 support to child
• improved abuse- 1 parenting
related attributions effectiveness
The Youth Relationships 14–16 DV No 18 weeks 2 symptoms 2 dating abuse- not applicable
Project (Wolfe et al., physical &
2003) emotional
Abuse-Focused Cognitive- 6–13 CPA Yes 12–16 weeks 2 externalizing 2 parent-to-child 2a, 3b,
Behavioral Therapy symptoms violence BPc
(Kolko, 1996; Kolko & 2 child-to-parent 2 distress
Swenson, 2002) violence 1 family cohesion
2 family conflict
2 belief in need for
punishment
Parent-Child Interaction 4–12 CPA No Motivation 2 internalizing 2 CPA re-report risk 2a, 3b
Therapy (Chaffin et al., enhancement symptomsd 2 negative parent BPc
2004) ⫹ 12–14 2 externalizing behavior (coded)
sessions ⫹ symptomsd
4 weeks
group
(6 months)
The Learning Club 7–11 DV No 10 weeks 1 feelings of 2 depression
(Sullivan et al., 2002) competency 1 self-esteem
• quicker 2 in child
witnessing DV
Project SUPPORT (Jouriles 4–9 DV No M ⫽ 23 2 externalizing 1 child management
et al., 2001; McDonald sessions symptoms & skills
et al., 2006) over 8 diagnoses 2 aggression toward
months 2 internalizing child
diagnoses 2 return to abusive
1 happiness and partner
social relationship
functioning

Notes. Empirical ratings coded as 1 ⫽ well-supported and efficacious, 2 ⫽ supported and probably efficacious, 3 ⫽ supported and acceptable. PTSD ⫽
posttraumatic stress disorder; 2 ⫽ decrease; 1 ⫽ increase.
a
National Child Traumatic Stress Network’s (2005) Empirically Supported Treatments and Promising Practices for treatment of youth PTSD. b Child
Physical and Sexual Abuse: Guidelines for treatment from the National Crime Victims Research and Treatment Center and the Center for Sexual Assault
and Traumatic Stress (Saunders et al., 2004). c BP ⫽ best practice designation for treatment of child abuse by Kauffman Best Practices Project in
collaboration with field leaders (Chadwick Center for Children and Families, 2004). d Treatment compared to an active treatment (rather than a
no-treatment condition) and symptoms decreased in both groups. e Age range ⫽ 4 –18 for child sexual abuse.

behaviors and violence attitudes) compared to the wait-list control involves psychoeducation, skills training, and community involve-
(Graham-Bermann, Lynch, Banyard, DeVoe, & Halabu, 2007). ment in antiviolence efforts. Youth are encouraged to recognize
The Youth Relationships Project promoting teenagers’ nonvio- that being aggressive is a choice; to examine social attitudes and
lent relationships. Wolfe et al. (1996) created a group “compe- power dynamics that foster relationship violence; to increase as-
tency enhancement approach” for at-risk adolescents that is in- sertiveness, respect, and safety in romantic relationships; and to
tended to prevent intimate violence victimization and to promote develop coping skill sets for dealing with relationship aggression.
healthy relationships. This approach was originally created for Although this program is preventive in nature, it can be seen as
teens with a history of violence exposure and risk factors for abuse, potentially derailing a trajectory of prior intimate violence expo-
but it has also been used in general school populations. The group sure leading to an increased risk of revictimization. An RCT
 FAMILY VIOLENCE AND YOUTH PTSD: TREATMENT 625

involving 14 –16-year-olds with child maltreatment histories (in- risk of physically abusive parents re-abusing their child; moreover,
cluding abuse, neglect, and domestic violence exposure) found that children in both conditions had significant decreases in internal-
youth receiving the intervention showed a greater decline in as- izing and externalizing symptoms (Chaffin et al., 2004). Posttrau-
pects of posttraumatic stress compared to control condition youth matic stress outcomes have not been evaluated for physically
(Wolfe et al., 2003). These groups were not meant to address abused children treated with PCIT, and PCIT still needs evaluation
problems related to past abuse, and the authors noted that it was for parents who have engaged in severe physical abuse of their
unclear whether posttraumatic stress improvement was directly children.
related to treatment or indirectly related to treatment through Two interventions show treatment gains for children and moth-
decreased involvement in aggressive relationships. ers leaving domestic violence shelters: The Learning Club (Sulli-
Trauma-focused cognitive– behavioral therapy (TF-CBT) for van, Bybee, & Allen, 2002; Sullivan, Campbell, Angelique, Eby,
child abuse victims. Cohen, Mannarino, and Deblinger (2006) & Davidson, 1994) and Project SUPPORT (Jouriles et al., 2001;
have done extensive research on treatment for child sexual abuse McDonald, Jouriles, & Skopp, 2006). Both involve advocacy and
victims with PTSD using TF-CBT. They use the acronym PRAC- mentoring components for the mother that include modeling of
TICE to identify the key treatment components in order of use:
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

appropriate child management strategies, empowerment and sup-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

“psychoeducation, parenting skills, relaxation, affective modula- port, and assistance in acquiring resources. The Learning Club
tion, cognitive coping and processing, trauma narrative, in vivo pairs the community advocacy intervention with a psychoeduca-
mastery of trauma reminders, conjoint child-parent sessions, and
tional group to educate children about feelings, safety, and respect
enhancing future safety and development” (p. 57). The developers
for themselves and others (Sullivan et al., 2002). In Project SUP-
promote phase-oriented treatment with the belief that knowledge
PORT, children with clinical levels of aggressive or oppositional
of one component facilitates work on the next component. Ses-
behavior work with a supportive mentor, while mothers work with
sions are initially conducted with the parent and child individually,
a therapist on child management skills and nurturing behaviors
and later as joint parent– child meetings. RCTs with TF-CBT have
(Jouriles et al., 2001). Neither of these treatments mentions post-
repeatedly shown improvements in PTSD and other outcomes for
traumatic stress as an outcome.
youth who have been sexually abused. Notably, TF-CBT was
effective with child victims of sexual abuse exposed to multiple
types of trauma; specifically 26% had also been physically abused, Other Promising Interventions For PTSD in Youth
and 58% had witnessed domestic violence (Cohen, Deblinger,
Exposed to Interpersonal Violence
Mannarino, & Steer, 2004). Additional research is examining
PTSD outcomes in TF-CBT compared to child-centered therapy Several other treatments targeting PTSD in youth deserve men-
for children exposed to domestic violence (Cohen, Mannarino, tion. The Cognitive Behavioral Intervention for Trauma in Schools
Murray, & Igelman, 2006). (CBITS; Jaycox, 2004) is a group-based school intervention and
has successfully reduced PTSD symptoms in violence-exposed
Violence Exposure Treatments Evaluating Other Child youth (Stein et al., 2003). This treatment uses education about
Outcomes trauma, relaxation and imaginal exposure, thought stopping, pos-
itive imagery and distraction, and social problem solving. This
Abuse-focused cognitive– behavioral therapy (AF-CBT) for
project primarily focuses on community violence exposure, but the
physically abused children incorporates behavior therapy and cog-
NCTSN (2006) suggests that CBITS can also target PTSD result-
nitive behavior therapy principles (Kolko & Swenson, 2002). An
ing from physical abuse. Combined Parent–Child Cognitive–
RCT with abused and maltreated children found that compared to
Behavioral Approach (CPC-CBA) for children and families at risk
community parent training groups, AF-CBT had greater efficacy in
for child physical abuse incorporates principles from TF-CBT and
multiple child domains, including fewer externalizing symptoms,
AF-CBT; preliminary findings evidence decreases in PTSD
and in family outcomes—most notably lower parent-to-child vio-
lence risk. PTSD is addressed in the AF-CBT treatment compo- (NCTSN, 2005; Runyon et al., 2004). Similarly, preliminary find-
nents through anxiety management techniques. However, PTSD ings on the Community Outreach Program (COPE; de Arrellano et
was not directly evaluated in clinical trials, perhaps because very al., 2005), which incorporates components from TF-CBT, PCIT,
few children met full criteria for PTSD at pretreatment. The and intensive case management, show trauma symptom improve-
investigators indicated that their study participants typically expe- ment for physically abused children. With little research on PTSD
rienced minor types of abuse, and they noted the need for further in physically abused children, data from CPC-CBA and COPE are
evaluation of AF-CBT with children who experience severe phys- promising and have been rated as “supported and acceptable” by
ical abuse (Kolko, 1996). the NCTSN. Finally, for adolescents with significant affect regu-
Parent– child interaction therapy (PCIT) was originally devel- lation and risk-taking problems, the use of dialectical behavior
oped for children with externalizing behavior problems (Eyberg, therapy (Linehan, 1993) has been suggested prior to TF-CBT or
1988) but has now been suggested for physically abusive parents other CBT treatment (Chadwick Center on Children and Families,
and their children (Urquiza & McNeil, 1996). PCIT is based on 2004; Wekerle et al., 2006). Skills training in affective and inter-
behavioral parenting principles and involves step-by-step live personal regulation/narrative story-telling (Cloitre, Koenen, Co-
coaching of parent– child interactions. It aims to stop coercive hen, & Han, 2002) employs this approach by coupling group affect
interactions that may escalate children’s behavior problems, and to regulation and social skills training with individual sessions fo-
teach parents appropriate child management techniques. One RCT cused on emotional reprocessing of trauma; it is rated “supported
found that PCIT, compared to community treatment, decreased the and acceptable” by the NCTSN.
 626 VICKERMAN AND MARGOLIN

Treatment Summary depression or other problems (Yule, 2003). To what extent do we

rely on trauma-focused versus standard treatments for these other
Several promising empirically supported treatments that di- problems?
rectly target PTSD symptoms are available for traumatized 4. It has been suggested that treatments targeted at one type of
child victims of physical abuse or witnesses to domestic vio- violence exposure (e.g., child sexual abuse or community vio-
lence. Treatments for preschoolers (CPP) and school-aged chil- lence) are likely effective for other types of exposure (e.g., family
dren (The Kids’ Club) show decreases in posttraumatic stress. violence; Cohen, Mannarino, Murray, et al., 2006). However,
The Youth Relationship Project prevention program also has empirical evaluations are needed to test this hypothesis and deter-
shown reductions in PTSD symptoms for adolescents. Consid- mine whether adjustments are necessary.
erable data support TF-CBT for reducing PTSD symptoms and 5. Children also can be multiply traumatized when they have a
other problems in children and adolescents traumatized by history of family violence and then experience a nonfamilial
interpersonal aggression, although, as yet, limited outcome data adverse event, such as a natural disaster. Interventions related to
are available for child physical abuse victims and children the new traumatic event should consider how preexisting family
exposed to intimate partner violence. CBITS also shows reduc- context may impact children’s reactions to an external trauma and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tions in PTSD symptoms for young adolescents exposed to

This document is copyrighted by the American Psychological Association or one of its allied publishers.

parents’ abilities to be supportive following the new stressor

community violence, but its generalizability to violence in the (Proctor et al., 2007).
home as the primary trauma exposure is untested. Other treat- 6. In light of the potentially disabling nature of PTSD symptoms
ments for youth exposed to family violence, most notably and the strong psychobiological impact, information is needed on
AF-CBT and PCIT, have successfully targeted problem areas the benefits and risks of psychopharmacological interventions spe-
for youth who have been physically abused or exposed to cifically for children and adolescents with PTSD (Cohen, Perel,
domestic violence, but have not evaluated PTSD as an outcome. DeBellis, Friedman, & Putnam, 2002). Results from adult clinical
trials cannot be generalized to youth but are likely to prompt future
Conclusion and Future Directions studies on the use of psychopharmacological agents with youth as
an adjuvant treatment.
Current thinking about the assessment and treatment of chil- Future work should address these questions with continued
dren exposed to child abuse and domestic violence reflects two attention to the salience of developmental stage and the potential
important advances— developmentally informed perspectives for impact across multiple domains in youth traumatized by family
on PTSD and recognition that violence in the home can be a violence.
traumatic experience. Treatment manuals provide excellent
guidelines for integrating a trauma focus into clinical work with
these youth. Recently published and ongoing investigations
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This document is copyrighted by the American Psychological Association or one of its allied publishers.