Cognitive-behavioural therapy (CBT) combines two well-established types of psychotherapy which have been shown to be very effective in treating anxiety and stress-related disorders: behaviour therapy and cognitive therapy. The CBT model explains the development of trauma symptoms based on principles of learning theories (e.g. classical and instrumental learning) and cognitive theories (e.g. dysfunctional thoughts, beliefs and assumptions about the traumatic event and oneself). CBT then aims at changing behaviours, thoughts and emotions of traumatised children and adolescents through specific treatment components.

Many variations of trauma-specific CBT exist; most of them, however, share the following components and combine both individual sessions with the child and the parent and conjoint parent–child sessions:

Not all CBT models for traumatised children include all of these components (e.g. trauma narrative or cognitive restructuring missing). Others, however, add additional components such as training of parental skills or standardised inclusion of important systems such as the school. As Dorsey et al. (2011) highlight, CBT treatment approaches also include common structural components, including modelling, coached practice of new skills during and in between sessions.

The most widely used and best researched CBT approach to treat PTSD in children and adolescents is the trauma-focused CBT (TF-CBT) protocol (Cohen et al. 2006) which has initially been developed for treating sexually abused school-age children and their nonperpetrating parents. In the last decade, the method has now successfully been applied to a wide variety of children with different traumatic experiences. Moreover, Scheeringa et al. have shown that TF-CBT with some minor adaptations is also effective in preschoolers (Scheeringa et al. 2011). TF-CBT has also been adapted for different cultural backgrounds and for childhood traumatic grief. Besides the TF-CBT, there are currently several other manualised CBT protocols for child PTSD being used and studied, among them, for example, Narrative Exposure Therapy for Kids (KIDNET) (Ruf et al. 2010), a childhood version of Prolonged Exposure Therapy (Aderka et al. 2011), Skills Training in Affect and Interpersonal Regulation for Adolescents STAIR-A (Gudiño et al. 2014) or the Seeking Safety Therapy (Najavits 2002). The website of the Child Traumatic Stress Network lists many of these protocols (www.​nctsnet.​org).

There are many randomised controlled trials showing that CBT, in particular TF-CBT, is highly effective in reducing symptoms of PTSD, depression and behaviour problems in children and adolescents after different types of single or multiple (complex) trauma in an individual or group setting (for an overview see Dorsey et al. 2011). TF-CBT has both proven to be superior to a child-centred, supportive treatment and to a waiting list control group. The current Cochrane Review (Gillies et al. 2012) and the current treatment guidelines for the treatment of child PTSD from the International Society of Traumatic Stress Studies (Foa 2009) and from the American Academy of Child and Adolescent Psychiatry (2010) all conclude that CBT has the highest level of evidence for the treatment of child PTSD. Therefore, the use of CBT to treat child and adolescent PTSD is highly recommended. However, evidence for preschool-age children, for specific ethnic minorities and for certain types of trauma (e.g. medical trauma) is still limited, and more research is needed.

Developed by Francine Shapiro in the 1980s, Eye Movement Desensitisation and Reprocessing (EMDR) is based on the premise that adaptive information processing following a traumatic event is adversely affected by emotions and dissociation, leading to incomplete processing of experience in memory. Through the use of a dual-attention task, recall of thoughts, images and sensation at the same time as attending to the visual stimulus of a moving finger or equivalent is the core technique in EMDR. The proposed mechanism of change is that the dual attention facilitates more complete information processing of the traumatic memory.

EMDR is usually delivered in the following eight phases: history taking and treatment planning, preparation, assessment, desensitisation, installation, body scan, closure and re-evaluation. The main part of the intervention involves moving through the assessment to the body scan phases repeatedly until the traumatic experience is processed.

EMDR has been applied with traumatised school-aged children. There are age-appropriate modifications to the method (Tinker and Wilson 1999), and the intervention is directed at the child without formal involvement of parents, although parents are provided with support and psychoeducation.

There is sufficient evidence to support EMDR as an evidence-based intervention for adults (Bisson et al. 2007, Chap.​ 11). This evidence comes from multiple randomised controlled trials and meta-analyses. However there is much less evidence supporting the application of EMDR with children. A recent meta-analysis (Rodenburg et al. 2009) identified studies that compared EMDR to a waiting list control, to treatment as usual and to CBT. Since then, there have been several other trials (e.g. Farkas et al. 2010; Kemp et al. 2010); however, the picture is still unclear. Overall, the evidence indicates that there is little or no support for the effectiveness of EMDR in reducing PTSD in those studies that compare it to waiting list or usual care controls. However, this may be due to the quality of the methodology of these studies. There is some support for EMDR, in that the two studies that compared EMDR and CBT directly (de Roos et al. 2011; Jaberghaderi et al. 2004) demonstrated equivalence between the two and, in the case of De Roos et al. (2011), with fewer sessions of treatment. However, neither study was of high quality nor provided support for clinically significant change as a result of EMDR, and this is a need in future research. There is also no available evidence on EMDR with preschool children.

The focus of psychodynamic treatment models are the emotional conflicts which are caused by the traumatic experience, particularly as they relate to the individual’s early life experiences. Psychodynamic therapies do not focus on the symptoms alone but on the meaning and the effects of the traumatic events for the individual child and his development. Importantly, trauma and its effects are considered as different across individuals and one has to understand the individual child to provide appropriate treatment. Therefore, modern psychodynamic therapies may include different modalities, such as talk therapy, trauma-focused play therapy, parental counselling and interventions in schools. In younger children, based on theories of attachment, the focus of intervention is the mother (parent)–child relationship. Psychodynamic therapists also conceptualise issues of transference and countertransference and consider them in the planning of their therapies (Terr 2013).

Procedures and components of psychodynamic treatment of traumatised youth differ enormously dependent on the specific protocol or manual used, making it impossible to describe a typical procedure. Usually, however, psychodynamic therapy has a longer duration compared to other methods and does not solely focus on the child’s symptoms.

The Child–Parent Psychotherapy (CPP; (Lieberman and Van Horn 2005), for example, is conducted over 50 weekly sessions in a dyadic setting with the parent and the child (>7 years). Based on the observation and modification of the child-parent interaction during the therapy sessions, CPP aims at strengthening the child–parent relationship in order to allow the child a healthy development. Parents are provided with assistance to better interpret their child’s behaviours and feelings and to provide age-appropriate emotional support. Because CPP is usually provided in the context of domestic violence, a joint child-parent trauma narrative is developed.

A quite different treatment protocol was described by Trowell et al. (2002) with sexually abused school-aged girls. These authors’ psychodynamic therapy involved 30 sessions consisting of three different phases: engagement, focus on issues relevant to the traumatised child and ending.

Lenore Terr, one of the pioneers of child psychotraumatology, who works with a strong psychodynamic background, describes three principles of healing in working with traumatised children (Terr 2013): abreaction (emotional expression), context (cognitive understanding) and correction (behavioural or fantasised change). Above all, attachment is seen as a crucial issue in traumatised children.

Efficacy of psychodynamic methods is supported by several randomised controlled trials as well as a high number of clinical case studies (American Academy of Child and Adolescent Psychiatry 2010; Foa 2009). Most of the controlled studies have examined the effects of long-term relationship-based interventions for traumatised young children and their caregivers affected by domestic violence. Currently, Child–Parent Psychotherapy (CPP) is the best studied method (Lieberman and Van Horn 2005). In sum, available studies show that CPP effectively reduces child and parent symptomatology and enhances the quality of attachment between child and parents.

Schools can serve a key role in assisting children during a traumatic stress. Schools are often the haven of consistency and safety in the lives of children who have been exposed to traumatic stress to the community such as disasters or interpersonal trauma such as abuse or violence. The routine and predictability of schools combined with the longer-term oversight and care of students by teachers provides an excellent opportunity to bolster and support existing coping and resilience but also to identify students in need of further care that may not be within the school’s capacity or capability. Schools provide a natural opportunity to engage, inform and resource children and their families in the face of community trauma. They also can act as the conduit to appropriate levels of care for children. However, in order for this process to be effective, there must be a close liaison between the school and specialist healthcare providers.

Schools have also been employed as the setting for intervention directly with children exposed to traumatic events with the goal of reducing the traumatic stress. This involves the direct delivery of psychological care within the school to students by therapists. Why should delivery within schools as opposed to other more usual settings be important? Jaycox et al. (2010) have demonstrated that following a community trauma an intervention delivered within a school is not only as effective as one delivered in a standard clinical setting, but more crucially the uptake rate of the school-based intervention was significantly greater than in the clinical setting.

Of interventions that have been delivered within schools for posttraumatic stress, those that have the most evidence are the ones based on trauma-focused CBT; however, a number of other interventions have been successfully applied employing CBT and other components. Typically the interventions are aimed primarily at students but can incorporate teachers, where the focus is on classroom management and support of students with posttraumatic stress. Jaycox et al. (2009) did demonstrate that teachers can be effective in helping to deliver the intervention in schools; however, the size of the effect of the intervention was considerably lower than those where a therapist was the primary treatment provider (Rolfnes and Idsoe 2011). Cognitive-Behavioural Intervention for Trauma in Schools (C-BITS) (Jaycox et al. 2009) is distinct from standard trauma-focused CBT in that it is largely offered in group format, does not include parents and can be slightly shorter in duration (10 sessions plus 1–3 individual sessions). As with trauma-focused CBT, C-BITS includes psychoeducation, relaxation, development of a trauma narrative and exposure to trauma reminders, anxiety and distress management skills.