This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with children, adolescents and their families, experience of psychological trauma, and a supervision framework. It replaces neither your clinical judgement, nor your professional responsibility, nor the legal child protection obligations that apply in your country. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is written neither for children nor for their families: if a child is in danger today, contact your country's emergency services or child protection services.
1. The programme at a glance
Indication. Post-traumatic stress disorder, or clinically significant post-traumatic symptoms, in children and adolescents aged 3 to 17, more than a month after one or several traumatic events: physical or sexual abuse, domestic violence witnessed by the child, assault, accident, disaster, war, frightening medical care, the violent death of someone close. In a child who is protected today, and with at least one non-offending adult who can take part. The protocol is described for 7- to 17-year-olds; the adaptations for younger children are in sections 5, 35 and 39.
Reference model. The trauma-focused cognitive behavioural therapy of Cohen, Mannarino and Deblinger (2017), whose efficacy is established by several controlled trials, among them the multisite trial by Cohen and colleagues (2004), and the cognitive therapy for PTSD in children of Smith and colleagues (2007), derived from Ehlers and Clark's cognitive model. Both share the same framework: understanding, regulating, going back over the memory, revising what it led the child to believe, taking back what has been avoided, and involving those around the child. This manual describes them through their published components, without reproducing their materials.
Format. Fourteen weekly sessions of 75 to 90 minutes, each divided between child time and parent time of about 35 minutes, with a few minutes of joint time at the end. The twelfth session is entirely joint. Two booster sessions, at one month and at three months. For repeated and prolonged trauma, the same protocol is extended to twenty sessions or more (section 39).
Mechanism targeted. That the memory becomes a memory — something past, which can be told, drawn or written in full without setting off the alarm. That what it led the child to believe about themselves, about adults and about the world is revised. That the child takes back what they avoid. And that the non-offending parent becomes the person the child can talk to about it.
| Session |
Focus |
Session output |
| 1 |
Assess and protect |
Protection checked, framework and confidentiality announced, baseline measures |
| 2 |
Understanding what is happening |
Model explained to the child and to the parent |
| 3 |
The body and the alarm |
Two regulation tools tried in session |
| 4 |
Feelings |
Thermometer calibrated, the event named out loud |
| 5 |
Thoughts |
The link between thought, feeling and action understood |
| 6 |
My story, the beginning |
First chapter and start of the narrative |
| 7 |
My story, the worst moment |
The hardest moment told |
| 8 |
What the story makes me think |
Two or three thoughts examined in writing |
| 9 |
The last chapter |
Full narrative, parent prepared to hear it |
| 10 |
Then and now |
Reminders listed, ladder of situations built |
| 11 |
Taking things back |
First challenge done, plan for school |
| 12 |
Joint session: sharing the story |
Narrative shared with the parent |
| 13 |
Safety and the future |
Written safety plan, three adults named |
| 14 |
Review, relapse, what comes next |
Measures repeated, plan written in the child's own hand |
| Session |
What the parent works on, in their own time |
| 1 |
Their account, protection, their own distress |
| 2 |
The model, and what their support changes |
| 3 |
Positive attention, routines, sleep |
| 4 |
Difficult behaviour and meltdowns |
| 5 |
Their own thoughts: guilt, anger, the child's future |
| 6 to 9 |
Hearing the narrative, step by step, and preparing for it |
| 10 and 11 |
Supporting the challenges, no longer going along with avoidance, school |
| 12 |
The joint session |
| 13 |
The family safety plan |
| 14 |
Warning signs, dates, what comes next |
What the child and the parent take away. Nine printable worksheets, listed in section 42: what is happening to me, my thermometer and my tricks, what I tell myself, my story, then and now, my safety, two worksheets for parents — what helps at home, and you —, and my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things. The section on safeguarding, which comes before everything and can suspend the whole programme. The place of the non-offending parent, who has time in every session and who hears the narrative before receiving it from their child. And a trauma narrative that changes form with age — play, drawing, a book, writing, telling in the present tense — without changing its principle.
2. Before you begin
Who this programme is for
This text is written for psychologists, child and adolescent psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy with children and adolescents, with experience of psychological trauma, knowledge of the child protection system in their country, and access to supervision. It assumes that you can hear a nine-year-old tell what an adult did to them, several times and in detail, without changing the subject and without your face forbidding it.
It is written neither for children nor for parents. It contains reporting procedures, criteria for non-response, and a discussion of what parents sometimes do, which a family would read as an accusation.
The five preliminary decisions
Is the child protected today? That is section 3, and it is the only question that can stop the programme.
Is there a non-offending adult available? A parent, a grandparent, a foster family, a key worker. Without one, the programme loses one of its two legs; section 33 says what is done then.
Are proceedings under way? An investigation, an investigative interview of the child, a trial, a protective measure, a custody dispute. They change the timing of the narrative. Sections 3 and 39.
Is there suicide risk or self-harm, in adolescents above all? Section 11.
And what trauma are we talking about? A single event — an accident, an assault, a disaster — or repeated violence, often within the family, that started early. The format is not the same. Section 39.
What this programme does not treat
It does not treat a child who is still exposed. Section 3.
It does not treat the reactions of the first weeks. Most of them resolve spontaneously, and section 4 says what is done instead.
It does not on its own treat an attachment disorder linked to deprivation of care, nor a behaviour disorder established well before the event. They often coexist with trauma and they need their own work. Section 9.
It does not treat grief without trauma. Traumatic grief has its place in this manual (section 39); grief in children falls under Treating grief in children and adolescents: a therapist's manual.
And it is not an investigative tool. The trauma narrative is an instrument of care. It serves neither to establish facts, nor to identify a perpetrator, nor to produce evidence.
How to use it
Read the whole text before the first session, in particular sections 3, 7, 33 and 35: safeguarding, the model, the non-offending parent, and the narrative according to age. These are the four places where the treatment turns.
Each session is described with the same framework: the aim, child time and parent time in steps, what you say, common errors, and the criterion for moving on.
Three warnings specific to this presenting problem.
Adults avoid more than the child does. The parent who does not want to "make them relive it", the teacher who advises "moving on", the therapist who spends three months drawing feelings: the child understands very quickly that what happened to them cannot be spoken of, and falls silent. If you still do not know, at session 7, what happened at the hardest moment, the protocol has gone off the rails.
The child will not ask for this work. They are brought along, they have asked for nothing, and they would rather talk about something else. That is to be expected. It is worked on through play, structure and gradation, not by waiting.
And supervision is not optional. Hearing what is done to children has a cost, often heavier than with adults' accounts. Section 43.
3. Safeguarding the child, above all
Why this section is placed here
Because it governs everything else, and because it is the only one that can suspend the programme. You do not treat the post-traumatic stress disorder of a child who is still undergoing what caused it. Exposure to the memory in a child who will be back with the perpetrator this evening is not a treatment: it teaches the child to lower their guard in the face of a real danger. An abused child does not first need therapy. They need to be protected.
The situations to identify
Violence or abuse that is continuing. The alleged perpetrator lives in the home, comes back to it, looks after the child, or has contact with them that is not supervised.
Ongoing domestic violence that the child witnesses, even if the child is not hit themselves. Exposure to violence between parents is recognised as a form of child abuse in many legal systems, and it is a trauma in itself.
A parent who does not protect. They do not believe the child, ask the child to keep quiet or to retract, maintain contact, or are themselves under the perpetrator's control.
Serious neglect. Care, food, supervision, schooling.
Violence outside the family that is continuing. Bullying at school, violence in a club or an institution, exploitation, violence in a teenage romantic relationship, online contact with an adult who has approached them.
And a danger the child is putting themselves in. Suicidal ideas, self-harm, running away. Section 11.
How the question is asked
Of every child, alone, from the first session, and again as soon as something changes. With simple, open words: "is anyone making you scared at the moment?", "is there a place or a person you don't like going to?", "is anyone hurting you, or asking you to do things you don't want to do?"
Of the parent, alone: current contact with the alleged perpetrator, court or protective decisions under way, what has already been reported, by whom, and what followed.
What you do when a child discloses something
You listen, calmly. Your face counts more than your words. A child who sees the adult fall apart retracts, and protects the adult by keeping quiet.
You do not ask questions that suggest an answer. Never "was it your uncle who did that?". Open prompts, few in number — "tell me about it", "and then what?" —, and you stop as soon as you know enough to know that the child is in danger. The detail is not your job at that moment: it belongs to those who will conduct the investigative interview, and each additional questioning weakens the child's account.
You write down their exact words, the date, the context, and what led to the disclosure. In quotation marks, without interpretation, without rephrasing.
You do not promise secrecy. You announced this at the first session (section 17), and you say it again: "what you have just told me is very important. I have to talk about it with people whose job is to protect children. I am going to explain to you what will happen."
You thank the child. "You were right to tell me." The child has often been threatened, or ordered to keep quiet; they need to hear that they did nothing wrong by speaking.
And you do not confront the alleged perpetrator. Nor do you warn them. When it is a parent, the usual rule of informing parents does not apply to them: warning them can expose the child to pressure or reprisals, or compromise the investigation. How to proceed with each parent is decided with the relevant services.
Reporting
Obligations vary from country to country, and you must know yours before you need them. In some countries, any professional who becomes aware of abuse is required to report it. In others, the law allows professionals to set aside confidentiality to protect a minor without formally requiring them to do so. Almost everywhere, there are two routes: a referral to child protection services when the child is at risk, and a referral to the judicial authorities or the police when the danger is serious or immediate. Almost everywhere, too, doing nothing about a child in danger engages the professional's liability.
You do not have to be certain. A well-founded suspicion is what justifies the referral; establishing the facts belongs to others. Waiting for certainty means waiting too long.
You do not decide alone. A colleague, your supervisor, the doctor of your service, and in many countries an advice line for professionals. Record that you consulted, whom, and what was decided.
You let the child know, and, unless it is dangerous to do so, the non-offending parent. What is going to happen, who is going to come, what is expected of them. Before, not after.
You remain the therapist. You do not conduct the investigation, you do not pronounce on whether the facts are true, and you do not become the expert on the case. What goes into a referral is what you have observed and heard, in the child's words, and what you cannot assert.
What is done while protection is not secured
There is no trauma narrative and no exposure to the memory.
You keep in contact. The child has often just spoken, and the worst thing would be for them to lose, at the same time, the adult they spoke to. "Come back when it's sorted out" is never said.
You work on what can be worked on. Regulation, sleep, general psychoeducation, support for the non-offending parent, coordination with services, and preparation for the investigative interview when the framework allows it — explaining how it takes place, never talking about the facts.
And you know your network. Child protection services, specialist paediatric units for child victims where they exist, victim support organisations, helplines for children. Having them to hand changes the conversation.
When protection is enough to begin
Absolute safety does not exist. What counts is that the child is no longer exposed to what traumatised them. Three markers.
No more unsupervised contact with the alleged perpetrator. Organised, supervised contact decided by an authority is not in itself a contraindication; it is prepared for, and the narrative is conducted taking each meeting into account.
A protective adult who believes the child, or who at least does not ask the child to retract.
And proceedings that will not be compromised. If an investigative interview of the child is planned, it is prudent to wait until it has taken place before starting the detailed narrative, and to coordinate with those involved when your framework provides for it. Sessions 1 to 5 can start before.
Contexts where safety will never be complete
War, a refugee camp, a neighbourhood where violence is daily. Waiting for complete safety here amounts to never treating. You then distinguish the danger aimed at the child personally, which suspends the narrative, from the diffuse danger of the environment, which requires in vivo exposure to be adapted but does not prevent work on the memory. And you never ask a child to resume a behaviour that would genuinely expose them.
4. Four pictures not to confuse
Four situations present after a serious event, and they do not call for the same approach.
1. The normal reaction of the first weeks
What you observe. New fears, restless sleep, the need to stay close to a parent, games that replay the event, repeated questions, irritability, tummy aches. This is the rule, not the exception.
What points the way. The trajectory. Most children exposed to a traumatic event do not develop PTSD (Alisic et al., 2014), and, without intervention, the frequency of the disorder falls by about half between the first and the sixth month after the event (Hiller et al., 2016).
What it implies. Information for parents, resumption of routines, a quick return to school, availability, and a reassessment at one month. No trauma narrative, no debriefing.
2. Post-traumatic stress disorder
What you observe. Beyond one month, an organised picture: re-experiencing — memories, nightmares, repetitive play —, avoidance, lasting changes in mood and thinking, hyperarousal.
What points the way. Persistence, the organisation of avoidance, and the impact on school, sleep, relationships and play.
What it implies. This is the programme described here. Beyond six months, the frequency of the disorder barely falls any further without intervention (Hiller et al., 2016), and waiting is no longer an option.
3. Another disorder that appeared after the event
What you observe. Separation anxiety, a specific phobia — after a dog bite, for example —, depression or a behaviour disorder, appearing after the event, without re-experiencing.
What points the way. The absence of intrusive memories and of avoidance of reminders specific to the event.
What it implies. The protocol specific to that disorder. See Treating anxiety in children: a therapist's manual.
4. Traumatic grief
What you observe. After the violent or sudden death of someone close, images of that death that invade every memory of the person who died.
What points the way. Two intertwined processes: missing the person, which belongs to grief, and the images, which belong to trauma.
What it implies. You first treat what prevents the child from thinking about the person who died. Section 39.
The three other things to have ruled out
A current danger. Hypervigilance in a child who is genuinely under threat is not a symptom. Section 3.
A head injury, after an accident or physical violence. It changes how difficulties with concentration and mood are interpreted.
And a medical cause for regression, sleep problems or somatic complaints, which is looked for before attributing everything to trauma.
The three screening questions
"Do pictures, thoughts or dreams of what happened come back without you wanting them to?" With young children, you ask the parent: "does he replay what happened, or talk about it all the time?"
"What have you stopped doing, or not wanted to do any more, since then?" It isolates avoidance, which is the engine.
"For how long, and is it getting less?" It separates the normal reaction from the established disorder.
5. Presentations by age
The disorder is the same at every age. What changes is the way it shows itself, and who is able to put it into words.
Young children, up to about six
What dominates. What is seen rather than what is said. Post-traumatic play first: the child replays the event, repetitively, without pleasure, and without the play bringing relief. Ordinary play invents and transforms; this play repeats. Drawings that keep returning to the same motif. Nightmares, often without recognisable content. Regressions: toileting, language, sleep, going back to the bottle or the dummy. Marked separation anxiety. New fears with no apparent link to the event — the dark, monsters, the toilet. Tantrums that are more frequent and last longer. Withdrawal from play and from other children.
What misleads. The child does not say that they are reliving the event, and does not say what they think of themselves. Criteria designed for adults underdiagnose them, which justified a specific form in the DSM (section 8).
Who provides the information. The parent, first of all, and observation of play. The parent has often lived through the same event, or is deeply shaken by it, and their own distress colours their description — in both directions.
What it changes. Treatment goes through the parent and through play, with the parent present in the room for a large part of the work. Section 39.
School-age children
What dominates. Re-experiencing starts to be described, often as thoughts or pictures that "come into my head", in class or at bedtime. Repetitive play and drawing persist in the younger ones. Somatic complaints, tummy aches and headaches, especially in the morning. Difficulties concentrating, which show first at school. Specific fears linked to reminders. Guilt, and the feeling of being different from others.
What is specific to this age. Omens, described by Terr (1991) after a single trauma: the conviction, built after the fact, that there had been warning signs and that the child should have seen them — then watching out for new signs, which keeps the alarm going. Errors in the order and duration of events. And re-enactments: the child reproduces the scene, or plays the role of the aggressor with a smaller child.
What misleads. Inattention, restlessness and irritability, which point towards ADHD or oppositional disorder (section 9).
Adolescents
What dominates. A picture close to that of adults: re-experiencing, avoidance, hypervigilance, and very heavily charged beliefs about oneself — shame, the feeling of being damaged, the impression of having no future.
What is specific to this age. Risk-taking behaviour: substance use, dangerous outings, risky sexual behaviour, running away. Self-harm and suicidal ideas. Revenge fantasies. Withdrawal into the peer group or, conversely, a break with peers. A complicated sexuality after sexual abuse. And an increased risk of revictimisation, which makes section 37 essential.
What misleads. Opposition, insolence and withdrawal, put down to adolescence. And shame, which silences what matters most for months.
What it changes. Longer time alone, confidentiality announced with care (section 17), and a narrative that can take the adult form: in the present tense, in the first person, repeated.
Single event and repeated trauma
Terr (1991) distinguished single, unexpected trauma, of which the child often keeps a precise memory, from repeated, anticipated trauma — typically violence within the family —, which produces more denial and numbing, self-hypnosis and dissociation, and anger. This distinction partly overlaps with the one ICD-11 makes between PTSD and complex PTSD (section 8), and it changes the format of the programme (section 39).