Posttraumatic stress disorder: the missed diagnosis

Damion J. Grasso MA is PhD Candidate, University of Delaware, Newark, Delaware.Joseph Boonsiri is Medical Student, Yale University School of Medicine, New Haven,Connecticut. Deborah Lipschitz MD is Associate Clinical Professor of Psychiatry, YaleUniversity School of Medicine, New Haven, Connecticut. Amanda Guyer PhD is Assis-tant Professor, University of California–Davis, Davis, California. Shadi Houshyar PhDis Vice President in Child Welfare Policy, First Focus, Washington, DC. Heather Douglas-Palumberi MA is Clinical Research Investigator, CARE Program, Yale University Schoolof Medicine, New Haven, Connecticut. Joan Kaufman PhD is Associate Professor of Psy-chiatry, Yale University School of Medicine, New Haven, Connecticut.

Posttraumatic Stress Disorder:The Missed Diagnosis

Damion Grasso, Joseph Boonsiri, Deborah Lipschitz,Amanda Guyer, Shadi Houshyar, Heather Douglas-Palumberi, Johari Massey, and Joan Kaufman

Posttraumatic stress disorder (PTSD) is frequently under -diagnosed in maltreated samples. Protective servicesinformation is critical for obtaining complete traumahistories and determining whether to survey PTSDsymptoms in maltreated children. In the current study,without protective services information to supplementparent and child report, diagnosing PTSD was missed in a significant proportion of the cases. Collaborationbetween mental health professionals and protectiveservice workers is critical in determining psychiatricdiagnoses and treatment needs of children involved with the child welfare system.

0009–4021/2009/0209157-176 CWLA 157

Address reprint requests to Joan Kaufman PhD, Yale University School of Medicine, Department of Psychiatry, Child and Adolescent Research and Education (CARE) Pro-gram, University Towers, 100 York Street, Suite 2H, New Haven, CT 06511. E-mail:[email protected].

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Diagnosing posttraumatic stress disorder (PTSD) requires ahistory of witnessing or experiencing a life-threatening orotherwise serious traumatic event. The criteria for PTSD are

outlined in Table 1 (American Psychiatric Association, 1994). Thesymptoms are divided into three main categories: reexperiencing,avoidance, and hyperarousal symptoms. In the absence of reportsof specific traumatic experiences, PTSD symptoms are not rou-tinely screened in research or clinical practice.

Prevalence of PTSD in Maltreated Children

While maltreated children are at elevated risk for a number of psy-chiatric disorders, PTSD is one of the most frequent diagnoses associated with a history of abuse (Kessler, Sonnega, Bromet,Hughes, & Nelson, 1995). Estimates vary substantially, however, instudies that have assessed the prevalence of PTSD in maltreatedpopulations. For example, in a study examining psychiatric diag-noses in 426 maltreated 6- to 18-year-old children living in out-of-home care, only 1.7% of the sample was reported to meet criteriafor PTSD (Garland, Hough, McCabe, Yeh, Wood, & Aarons, 2001).In a second study of 373 17-year-old youth in the foster care sys-tem, the rate of PTSD was estimated somewhat higher at 8%(McMillen, Zima, Scott, Auslander, Munson, Ollie, & Spitznagel,2005). PTSD rates in these two large-scale studies are notablysmaller than the rates of 26% to 67% reported in several smallerscale investigations (Ackerman, Newton, McPherson, Jones, & Dyk-man, 1998; Dubner & Motta, 1999; Famularo, Fenton, Kinscherff,& Augustyn, 1996; Famularo, Kinscherff, & Fenton, 1992; Kiser,

Acknowledgments: The authors wish to thank the children and families, and the staff atthe Department of Children and Families who facilitated this work. This research wasfunded by grants from NIMH 1R01MH65519-01 (JK) and K23 MH01789 (DL), moniesfrom the state of Connecticut (JK), support from the National Center for PTSD (JK), andthe Yale University Clinical Research Center Grant (MOIRR06022).

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TABLE 1Symptoms of Posttraumatic Stress Disorder

A. The traumatic event is reexperienced:1. Recurrent and intrusive distressing recollections of the event, including images,

thoughts, or perceptions (Note: In young children, repetitive play may occur inwhich themes or aspects of the trauma are expressed.)

2. Recurrent distressing dreams of the event (Note: In young children there may befrightening dreams without recognizable content.)

3. Acting or feeling as if reliving the traumatic event (e.g., illusions, hallucinations,flashbacks, etc.; Note: In young children, trauma-specific reenactment may occur.)

4. Intense psychological distress at exposure to internal or external cues5. Physiological reactivity to internal or external cues

B. Avoidance of stimuli and numbing of general response:1. Efforts to avoid thoughts, feelings, or conversations about trauma2. Efforts to avoid places or people that arouse memories of the trauma3. Inability to recall an important aspect of the trauma4. Markedly diminished interest or participation in significant activities5. Feeling of detachment or estrangement from others6. Restricted range of affect (e.g., unable to have loving feelings)7. Sense of foreshortened future

C. Increased arousal (not present before the trauma):1. Difficulty falling asleep or staying asleep2. Irritability or outbursts of anger3. Difficulty concentrating4. Hypervigilance5. Exaggerated startle response

Adapted from the American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders.(4th ed.). Washington, DC.

Heston, Millsap, & Pruitt, 1991; Linning & Kearney, 2004; Rug-giero, McLeer, & Dixon, 2000; Wolfe, Sas, & Wekerle, 1994). In thesesmaller scale studies, higher rates of PTSD were associated withrecent disclosure of sexual abuse (Wolfe et al., 1994), shelter place-ment (Linning & Kearney, 2004), and the occurrence of multipletypes of maltreatment (Kiser et al., 1991).In the majority of studies reporting higher rates of PTSD, in-

vestigators were familiar with children’s trauma histories beforeassessing psychiatric symptoms. The purpose of this report is todocument the importance of using multiple informants of traumaexperiences—especially input from protective service workers—when diagnosing PTSD in maltreated children. As knowledgeof past traumatic events is a prerequisite for the survey of PTSDsymptoms, determining the optimal method to assess trauma iscritical in assuring detection of this diagnosis in children.

Methods

Participants

The sample included 199 children (116 maltreated children re-moved from their homes in the six months prior to study entry and83 community-control children with no history of maltreatment ordomestic violence). Participants were 6 to 14 years old and part ofa larger study examining the efficacy of an intervention for chil-dren entering out-of-home care. As shown in Table 2, maltreatedand control children were comparable on age, sex, and ethnicity.

Procedures

The Institutional Review Board at Yale University and the Con-necticut State Department of Children and Families approved thestudy. Protective service caseworkers introduced the study to mal-treated children’s birthmothers and obtained permission for re-search staff to contact birthmothers. Community control familieswere recruited through advertisements and targeted mailings in

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TABLE 2Demographic Characteristics of the Sample

MALTREATED CONTROLS STATISTIC P-VALUE

N � 116 N � 83

Age 10.2 � 2.2 9.8 � 2.3 T � �1.2 ns

Sex (% male) 47% 47% �2 � 0.004 ns

Race by percentage* 20, 34, 24, 22 24, 28, 24, 24 �2 � 2.95 ns

*Caucasian, African American, Hispanic, biracial.

the communities that the maltreated children lived in. The absenceof a history of maltreatment in control children was confirmed byreviewing state protective services records and inquiring abouttrauma experiences with birthmother and child.The children’s legal guardian provided written consent. When

the children’s legal guardian was not their birthparent, written as-sent was also obtained from a birthparent if he or she was available.All children provided written assent for the study, and participa-tion required permission from all parties.Participants underwent baseline interviews at their current place

of residence. The baseline data were collected in one session with thechild, and two sessions with the parent/guardian. Both children andparents were compensated financially after each session.Approximately one month following the baseline interview,

all children attended a one-week summer day camp program es-tablished specifically for our research purposes. The camp, free ofcharge to all participants, included one to two hours of researchassessments per day. In the remaining time, children engaged inrecreational activities including art, sports, music, and outdoorwater games. This data collection procedure allows for naturalisticobservation and comprehensive assessments without overburden-ing children. The camps are fun for the children, are cost-effective,and promote strong collaboration among research staff, protective

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service workers, and birthparents (Kaufman, 1991; Kaufman,Yang, Douglas-Palumberi, Grasso, Lipschitz, Houshyar, Krystal, &Gelernter, 2006).In the first year of data collection, we experienced a delay in re-

ceiving permission to review state protective services records.Thus, psychiatric assessments were initially completed withoutprotective record data detailing the children’s maltreatment expe-riences. Approval to review records and obtain these data were ob-tained shortly before the planned six-month follow-up assessmentof cohort one. After examining protective service record data it be-came evident that children and parents failed to report a largenumber of maltreatment experiences during initial interviews, andconsequently, PTSD symptoms were not surveyed at baseline forapproximately half the children with a history of relevant trauma.Consequently, for cohort one, PTSD symptomatology was assessedat six-month follow-up visit.In years two and three of the study, we surveyed trauma expe-

riences at the visits using the same methods as in the first year, butreviewed children’s protective services records before camp. Dataobtained from parent, child, and protective service records weresubsequently used to determine the need to survey PTSD symp-toms with children.

Measures

Maltreatment Experiences

Multiple informants and data sources were used to obtain a bestestimate of children’s maltreatment experiences (Kaufman, Jones,Steiglitz, Vitulano, & Mannarino, 1994). As noted in the proceduressection, approval to review the protective service case records wasnot obtained until several months into data collection, providingan unexpected “experiment” that highlighted the importance ofcollecting this information to obtain complete trauma histories tofacilitate psychiatric assessment of children.Sources of information that were examined to assess mal -

treatment included (1) protective services computerized records,

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(2) child and parent reports of trauma included in the PTSD sec-tion of the schedule for affective disorders and schizophrenia forschool-age children—present and lifetime version (K-SADS-PL), asemistructured psychiatric interview (Kaufman, Birmaher, Brent,Rao, Flynn, Moreci, Williamson, & Ryan, 1997), (3) birthparents’ re-sponses on partner violence inventory (PVI), a 37-item measurethat assesses multiple dimensions of domestic violence includingemotional abuse, sexual exploitation, and physical abuse (Bern-stein, 1998), and (4) children’s reports on childhood trauma ques-tionnaire (CTQ), a 28-item measure that surveys experiences ofphysical abuse, sexual abuse, neglect, and emotional maltreatmentthat was individually administered at camp (Bernstein, Ahluvalia,Pogge, & Handelsman, 1997). As previously described (Kaufmanet al., 1994), data from the various sources were reviewed and syn-thesized to provide a “best estimate” of children’s history of phys-ical abuse, sexual abuse, neglect, emotional maltreatment, andexposure to domestic violence.

Diagnosis of PTSD

The K-SADS-PL, the semistructured child psychiatric diagnosticinterview (Kaufman et al., 1997), was administered to each childand one of the child’s biological parents or a relative caregiver. Thechild portion of the K-SADS-PL was administered at camp. A fos-ter parent or residential staff member completed the child behaviorchecklist (CBCL; Achenbach & Rescorla, 2001) when no biologicalrelative was available to complete the psychiatric interview (n �

40). The K-SADS-PL, like other standardized research diagnosticinterviews, has screen items which determine if the full criteria forthe diagnosis need to be surveyed. In the PTSD section, intervie-wees are first queried about trauma experiences. If none is en-dorsed, the remainder of the PTSD section is skipped.After the first year of the study, a review of protective services

records was routinely conducted before the child portion of theK-SADS-PL was administered. Parent/guardian interviews werealso routinely completed prior to administering the child portion ofK-SADS-PL to assure the most comprehensive available trauma

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data. If children were known to have experienced a trauma andfailed to acknowledge it during the interview, they were informedabout how we had learned about their past traumas. They weretold that they were not going to have to talk about the experiences,but would be asked about some common problems children oftenhave after going through the types of things they have experienced.In deriving best estimate psychiatric diagnoses, all clinical ma-

terial was reviewed during a multidisciplinary team meeting ledby two of the authors, who are a licensed child psychologist and aboard certified child psychiatrist. In addition to K-SADS-PL andCBCL data, clinical data obtained and reviewed to derive bestestimate diagnoses included the (1) the mood and feelings ques-tionnaire (MFQ; Angold, Costello, Messer, Pickles, Winder, & Sil-ver, 1995), a 33-item depression scale administered to children atbaseline; (2) screen for child anxiety-related emotional disorders(SCARED; Birmaher, Khetarpal, Cully, Brent, & McKenzie, 2003),a 41-item anxiety questionnaire also administered to children atbaseline; (3) child dissociative checklist (CDC; Putnam, Helmers,& Trickett, 1993), a 20-item parent-report scale; and (4) CBCL teach-ers report form (CBCL-TRF; Achenbach & Rescorla, 2001). For chil-dren with histories of trauma, the PTSD checklist (PTSD-CL;Amaya-Jackson, Newman, & Lipschitz, 2000), a 17-item measurethat assesses PTSD symptoms, was also administered at camp.Each of these measures has excellent psychometric properties andis widely used in child psychiatric research.

Social Supports

Studies of individuals with a history of abuse suggest that the avail-ability of a caring and stable parent or alternate guardian is one ofthe most important factors that distinguish abused individualswith good developmental outcomes from those with more deleteri-ous outcomes. For this reason, children also completed the Arizonasocial support interview (ASSI; Kaufman, 1991). During the inter-view, children are asked to name people they can (1) talk to aboutpersonal things, (2) count on to buy things they need, (3) share

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good news with, (4) get together with to have fun, and (5) go to ifthey need advice. Children provide information on their relation-ship to the people named (i.e., birthparent, foster parent, relative,friend), and the frequency with which they see each support.

Statistical Analysis

Descriptive statistics were utilized to report prevalence of PTSD trau-mas and diagnoses separately for each informant and for combina-tion of informants. Scores on clinical rating scales were examined forviolations in normality using the Shapiro-Wilks test prior to conduct-ing statistical analyses comparing scores of maltreated children withPTSD, maltreated children without PTSD, and community controls.Group differences on related continuous measures were first exam-ined with MANOVAs, with follow-up univariate tests completed asappropriate. The Student-Newman-Keuls multiple comparison testwas used to control for multiple group comparisons.

Results

Trauma Experiences

Trauma Experiences of Maltreated Children

Based on integrating the information from all data sources and in-formants, 20% of the children experienced sexual abuse, 62% phys-ical abuse, 68% emotional maltreatment, 70% witnessed domesticviolence, and 79% had histories of physical neglect. The majorityof children had multiple maltreatment experiences, with 47% ofthe sample having experienced three or more types of maltreat-ment. In addition, many of the children suffered extreme abuse,with 31% of the physically abused children requiring medical at-tention as a result of abuse, 90% of the sexually abused children ex-periencing genital contact, and 34% of the emotionally maltreatedchildren actually abandoned—either left unattended for severaldays on end while a parent was on a drug binge or forsaken by aparent in favor of a partner who sexually abused them.

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Trauma Experiences Not Reported by Parents or Children

Figure 1 shows the proportion of traumas experienced by childrenthat were reported by the various informants. When queried di-rectly about these types of experiences using the K-SADS-PL semi-structured diagnostic interview, parents and children reportedonly approximately 50% of substantiated incidents of physical and

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FIGURE 1Proportion of Traumas Reported by Each Informant

Legend: When interviewed, parents and children failed to report approximately half of substantiated incidents ofphysical and sexual abuse. Mothers were most likely to disclose domestic violence.

sexual abuse documented by protective services. Of the varioustypes of traumas, parents were most likely to report incidents ofdomestic violence. In addition, parents occasionally reported pastincidents of physical abuse that occurred when the family was liv-ing in another state that their protective services workers did notknow about. Utilizing only parent and child interview data, with-out access to the protective service information, we initially failedto identify 36% (n � 8) of the children with a history of sexualabuse, 39% (n � 29) of the children with a history of physicalabuse, and 32% (n � 26) of the children with a history of witness-ing domestic violence.

Interview Versus Questionnaire Data in Surveying Trauma Experiences

Interview (i.e., K-SADS-PL) and questionnaire (i.e., CTQ, PVI) meth-ods were used to assess physical and sexual abuse experiences withchildren and domestic violence histories with mothers. Neithermethod used independently had a clear advantage in facilitatingthe disclosure of trauma experiences. With children, interview andquestionnaire methods each resulted in disclosure of approximately50% of identified cases of physical and sexual abuse, and using bothmethods together resulted in disclosure of approximately 70% ofknown cases of physical abuse and 60% of known cases of sexualabuse. In assessing domestic violence experiences with parents, 74%of known cases were reported via interview, 62% via questionnaire,and 93% when both methods were employed. Overall, using bothmethods together resulted in more trauma experiences being re-ported, with this especially true with domestic violence.

Missed PTSD Diagnoses

Table 3 shows the number of children identified as having historiesof physical abuse, sexual abuse, or domestic violence using the dif-ferent informants to assess children’s trauma history, and the num-ber of these children who met criteria for PTSD. In using all availabledata (e.g., child, parent, and worker reports), 107 children withinthe maltreated sample were reported to have experienced one ormore of these significant traumas, and a total of 64 children, or 55%

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TABLE 3Trauma and PTSD Rates Utilizing Different Informants to Assess Children’sTrauma Histories (n � 116)

TRAUMA INFORMATION NUMBER OF CHILDREN NUMBER OF CHILDREN WITH

IDENTIFIED WITH HISTORIES TRAUMA HISTORIES MEETING

SOURCES OF PA, SA, OR DV CRITERIA FOR PTSD

Child report alone 64 39

Parent report alone 71 43

Both child and parent reports 80 48

Worker report alone 96 54

Child, parent, and worker 107 64reports

Note: PA � physical abuse, SA � sexual abuse, and DV � domestic violence.

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of the 116 maltreated children assessed, met diagnostic criteria forPTSD. Without using protective services information to supplementparent and child reports, there would have been many missedPTSD diagnoses.

Clinical Impairment Associated with PTSD Diagnosis

Maltreated children with PTSD scored significantly higher thanmaltreated children without PTSD and community control chil-dren on the self-report MFQ depression scale, and the teacher-rated CBCL-TRF total problem and externalizing behavior scales.Maltreated children with PTSD also scored significantly higher onthe self-report SCARED anxiety measure. As can be seen in Table 4,mean scores of maltreated children with PTSD were within theclinical range on these measures.

Predictors of PTSD

As indicated, the majority of children had multiple maltreatmentexperiences (e.g., physical abuse, sexual abuse, domestic violenceexposure, emotional maltreatment, neglect). As can be seen in Fig-ure 2, the proportion of children meeting criteria for PTSD grew

TABLE 4Child and Teacher Ratings of Psychopathology1

CBCL-TRF PTSD NO PTSD CONTROLS FN � 54 N � 49 N � 76

MFQ2 19.75 � 11.71a 14.47 � 9.67b 11.75 � 8.46b 11.26*

SCARED3 28.55 � 15.13a 24.3 � 14.29a,b 21.26 � 11.96b 3.97*

Internalizing4 58.98 � 10.45a 56.13 � 9.72a 52.26 � 11.43b 7.21*

Externalizing4 62.67 � 10.14a 57.63 � 9.76b 52.98 � 10.35c 16.33*

Total problem4 62.75 � 9.24a 57.89 � 8.85b 53.9 � 10.82b 14.33*

1 Values with different superscripts are significantly different from each other according to Student-Newman-Keulspost hoc tests, * p � .052 MFQ data was rank-transformed for analyses, raw scores are presented in the table. MFQ scores of greater than 14are considered clinically significant. Two maltreated children and one control child were excluded due to missingMFQ data.3 SCARED data was square root transformed for analyses, raw scores are presented in the table. SCARED scores ofgreater than 25 are considered clinically significant. Two maltreated children and one control child were excludeddue to missing SCARED data.4 13 maltreated children and 7 control children were excluded because of missing CBCL-TRF data. CBCL-TRF scoresare age and gender normed. TRF scores of greater than 60 are considered borderline, and scores greater than 63 areconsidered clinically significant.

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FIGURE 2Likelihood of Meeting Criteria for PTSD Increases as a Function of the Numberof Maltreatment Categories Children Experienced

Legend: Children who experienced three or four types of maltreatment experiences were approximately twice aslikely as children who had only one type of maltreatment experience to meet diagnostic criteria for PTSD.

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linearly with the number of different categories of maltreatmentexperienced by the children. While only about 30% of childrenwho experienced one form of maltreatment met criteria for PTSD,80% of children who experienced four different types of maltreat-ment met criteria for this diagnosis. Histories of physical abuse(�2 � 8.5, p � .02) and sexual abuse (�2 � 5.7, p � .05) were alsoindependent predictors of PTSD in children.

Factors Associated with Resiliency

Children who did not meet criteria for PTSD were more likely toidentify a primary support who they could rely on for more differ-ent categories of support than children who met definite or prob-able criteria for PTSD (F � 8.1, df � 2, p � .001). They were alsomore likely to name a birthfamily member—mother, father, or sib-ling—as their primary support, and they were more likely to haveat least weekly contact with their identified primary support (�2 �

20.5, p � .001) than children who met criteria for PTSD.

Discussion

The prevalence of PTSD in this chronically traumatized group of fos-ter care children was 55%. This rate is notably greater than the ratereported in two recent surveys of maltreated children in which noindependent source of information was used to determine children’strauma histories (Garland et al., 2001; McMillen et al., 2005), andwithin the range reported in several studies in which investigatorswere aware of children’s trauma histories prior to completing childpsychiatric assessments (Ackerman et al., 1998; Dubner & Motta,1999; Famularo et al., 1996; Famularo et al., 1992; Kiser et al., 1991;Linning & Kearney, 2004; Ruggiero et al., 2000; Wolfe et al., 1994).Collecting maltreatment information from the children’s pro-

tective service workers was critical in making many of the PTSDdiagnoses in the current report. If only parent and child interviewdata were used to assess children’s trauma experiences, 36% of thechildren with a history of sexual abuse, 39% of the children with ahistory of physical abuse, and 32% of the children with a history ofwitnessing domestic violence would not have been identified as

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having had these experiences. If the child were the sole reporter ofpast traumatic experiences, an even greater number of PTSD diag-noses would have been missed.While reports from protective service workers are critical to

obtain complete trauma histories, determining the presence of individual symptoms requires input from children and their care-givers. Collaboration between caseworkers, mental health profes-sionals, and caregivers is important in assuring proper psychiatricdiagnoses of maltreated children. The results of this study suggestthat multiple informants and multiple measures improve accuracywhen assessing children’s trauma histories and determining theappropriateness of surveying PTSD symptomatology. There doesnot appear to be any one best way to elicit trauma information.Questionnaire and interview format measures performed approx-imately equally well. In using both methods together, however,more traumas were identified, especially in the case of domesticviolence exposure. As several recent reviews have highlighted(Kaminer & Slesnick, 2005; Steinberg, Brymer, Decker, & Pynoos,2004; Stover & Berkowitz, 2005), multiple assessment tools can beused to facilitate proper assessment of PTSD symptoms in trauma-tized children. Practice parameters have also recently been draftedto guide the screening, assessment, and treatment of mental healthproblems of children in care (Pecora, Jensen, Romanelli, Jackson, &Ortiz, 2009; Romanelli, Landsverk, Levitt, Leslie, Hurley, Bellonci,Gries, Pecora, & Jensen, 2009).This study was not specifically designed to test rates of trauma

disclosure using different informants and different measures. Thepreliminary findings of this report suggest further systematic eval-uation of assessment methods will help to determine optimal pro-cedures for obtaining complete and accurate trauma histories andassessing the need to survey PTSD symptoms in children. As is ev-ident from the current study and other research, PTSD in childrenis associated with significant clinical impairment.Without knowledge of children’s trauma experiences, trauma-

related symptoms can appear to reflect manifestations of otherdiagnoses. For example, the teacher of one child who participated

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in our research reported that the child frequently initiated fightsand often bullied other children. While these symptoms are consis-tent with the diagnosis of conduct disorder, she noted that he wasmost apt to initiate fights with and bully girls, a likely “traumareenactment” symptom, as this child witnessed his mother bludg-eoned with a hammer by her boyfriend. This child did meet full di-agnostic criteria for PTSD, and the optimal treatment for this childwould likely involve trauma-focused interventions. Knowing thelink between children’s symptoms and their traumatic experiencesis critical for optimizing treatment outcomes, helping guardiansunderstand and empathize with children in their care, and mini-mizing exposure to trauma triggers that may elicit disruptive be-havior and jeopardize placement stability.Trauma-focused cognitive behavioral therapy (TFCBT) cur-

rently has the most empirical support for treatment of PTSD inchildren, from preschoolers to adolescents. Specific elements ofTFCBT include (1) psychoeducation about child maltreatment, po-tentially traumatic experiences, and traumatic stress; (2) emotionknowledge and expression skills; (3) cognitive coping skills; (4) grad-ual exposure centering on development of the child’s trauma nar-rative; (5) cognitive processing of the trauma experience(s); (6) jointchild-parent sessions; and (7) safety awareness. As children withPTSD frequently exhibit significant externalizing behaviors (Fa-mularo et al., 1996), TFCBT also utilizes standard behavioral ap-proaches to target these symptoms.The efficacy of TFCBT has been tested in a number of ran-

domized controlled trials. When compared to children in controltreatments, multiple studies have found significantly greater im-provements in PTSD, internalizing symptoms, dissociation, sexu-alized behavior, and social competence in sexually abused childrenwho received TFCBT (Cohen, Deblinger, Mannarino, & Steer, 2004;Cohen & Mannarino, 1998a, 1998b; Cohen, Mannarino, & Knud-sen, 2005), with the therapeutic effects of TFCBT sustained overtime (Cohen et al., 2005).Over the past decade, numerous studies have documented the

high prevalence of mental health problems of children in foster

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care, and the low rate of service delivery to this population (Lands -verk, Burns, Stambaugh, & Reutz, 2009; Levitt, 2009; Pecora et al.,2009). This growing body of research led to the establishment ofthe Child Welfare–Mental Health Best Practices group, whichpublished a series of articles outlining their recommendations.While there are significant gaps in the research available to guidepolicy and practice in the area of mental health services for chil-dren in foster care (Kemp, Marcenko, Hoagwood, & Vesneski,2009), this study highlights the importance of mental health pro-fessionals working collaboratively with protective service workersin psychiatric assessment and treatment planning for maltreatedchildren. Beyond formal clinical interventions, this study alsohighlighted the importance of optimizing the likelihood of mal-treated children having access to positive stable supports, as thisreduced risk for PTSD in children. Ongoing research in this areais needed to refine existing practice parameters and improve out-comes of children in care.

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