Dr. Hilit Kletter directs the clinical arm of the Early Life Stress and Resilience Program. She is head of the Stress and Resilience clinic which provides assessment, consultation, and treatment for youth with a wide range of traumas including physical and sexual abuse, neglect, community and domestic violence, medical trauma, sudden/violent death, and emotional abuse. She is leading the trauma training rotation within the clinic which provides supervision to medical fellows and residents as well as psychology graduate students. She was part of the development team for Cue-Centered Therapy (CCT), an intervention for youth exposed to chronic trauma, and is the director of the CCT training and dissemination program. She has experience doing assessments as well as individual, group, and family psychotherapy utilizing evidence-based practices such as cognitive behavioral therapy, exposure, and behavioral management to treat anxiety disorders including posttraumatic stress
disorder, generalized anxiety, obsessive-compulsive disorder, and phobias. She has worked in a variety of settings such as community
mental health, day-treatment programs, schools, a domestic violence shelter, and outpatient clinics. She provides teaching and training both within Stanford and to the community, nationally and internationally. Dr. Kletter received her BA in anthropology from the University of Washington and was a Koret Foundation Fellow while completing her PhD studies at Pacific Graduate School of Psychology. She completed her pre-doctoral internship at the Child and Family Guidance Center in Northridge, CA and her post-doctoral fellowship at Kaiser Permanente Child Psychiatry in Milpitas, CA.

Clinical Focus

  • Posttraumatic Stress Disorder
  • Anxiety Disorders
  • Clinical Child and Adolescent Psychology

Professional Education

  • PhD Training: Pacific Graduate School of Psychology (2008) CA
  • Fellowship: Kaiser Permanente (2009) CA
  • Internship: Child and Family Guidance Center (2008) CA

Current Research and Scholarly Interests

Risk and resiliency factors of childhood posttraumatic stress and development and improvement of treatment interventions.

All Publications

  • Cortical activation predicts posttraumatic improvement in youth treated with TF-CBT or CCT. Journal of psychiatric research Espil, F. M., Balters, S., Li, R., McCurdy, B. H., Kletter, H., Piccirilli, A., Cohen, J. A., Weems, C. F., Reiss, A. L., Carrion, V. G. 2022; 156: 25-35


    BACKGROUND: Identifying neural activation patterns that predict youths' treatment response may aid in the development of imaging-based assessment of emotion dysregulation following trauma and foster tailored intervention. Changes in cortical hemodynamic activity measured with functional near-infrared spectroscopy (fNIRS) may provide a time and cost-effective option for such work. We examined youths' PTSD symptom change following treatment and tested if previously identified activation patterns would predict treatment response.METHODS: Youth (N=73, mean age=12.97, SD=3.09 years) were randomly assigned to trauma-focused cognitive behavioral therapy (TF-CBT), cue-centered therapy (CCT), or treatment as usual (TAU). Parents and youth reported on youth's PTSD symptoms at pre-intervention, post-intervention, and follow-up. Neuroimaging data (N=31) assessed at pre-intervention were obtained while youth engaged in an emotion expression task. Treatment response slopes were calculated for youth's PTSD symptoms.RESULTS: Overall, PTSD symptoms decreased from pre-intervention through follow-up across conditions, with some evidence of relative benefit of TF-CBT and CCT over TAU but significant individual variation in treatment response. Cortical activation patterns were correlated with PTSD symptom improvement slopes (r=0.53). In particular, cortical responses to fearful and neutral facial stimuli in six fNIRS channels in the bilateral dlPFC were important predictors of PTSD symptom improvement.CONCLUSIONS: The use of fNIRS provides a method of monitoring and assessing cortical activation patterns in a relatively inexpensive and portable manner. Associations between functional activation and youths' PTSD symptoms improvement may be a promising avenue for understanding emotion dysregulation in clinical populations.

    View details for DOI 10.1016/j.jpsychires.2022.10.002

    View details for PubMedID 36228389

  • Cue-Centered Therapy for Youth Experiencing Posttraumatic Symptoms. Current treatment options in psychiatry Kletter, H., Matlow, R., Tanovic, S., Carrion, V. 2021: 1–16


    Purpose: Few of the existing evidence-based interventions for child trauma exposure were specifically designed to address experiences and outcomes of complex developmental trauma. Stanford's cue-centered therapy (CCT) was designed to address this gap by offering a flexible, integrative, and insight-oriented treatment approach that is grounded in principles of neuroscience, developmental trauma, client empowerment, and allostasis. This article reviews the CCT rationale, treatment components, evidence base, and training approach.Recent findings: Studies demonstrate promising outcomes indicating CCT effectiveness in reducing child and caregiver posttraumatic stress, and in improving child functioning. Further research, however, is needed to identify which clients are best-suited for CCT (versus other available child trauma treatments) and to identify which components of CCT are most critical for addressing complex developmental trauma.Summary: CCT advances the field of child trauma treatment by offering an intervention approach focused on addressing complex developmental trauma. Positive treatment and training outcomes indicate utility of CCT for clients and clinicians. Innovations in research and training approaches are needed to further dissemination and implementation of CCT and other related child trauma interventions for complex developmental trauma.

    View details for DOI 10.1007/s40501-021-00241-3

    View details for PubMedID 33898161

  • Cue-Centered Therapy ASSESSING AND TREATING YOUTH EXPOSED TO TRAUMATIC STRESS Kletter, H., Carrion, V. G. 2019: 207–21
  • Cue-Centered Treatment for Youth Exposed to Interpersonal Violence: A Randomized Controlled Trial JOURNAL OF TRAUMATIC STRESS Carrion, V. G., Kletter, H., Weems, C. F., Berry, R. R., Rettger, J. P. 2013; 26 (6): 654-662


    This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13 schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4 discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression.Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility,adherence, and efficacy in treating youth with a history of interpersonal violence.

    View details for DOI 10.1002/jts.21870

    View details for Web of Science ID 000328566900002

    View details for PubMedID 24490236

  • A Prospective Study on the Association Between Caregiver Psychological Symptomatology and Symptom Clusters of Pediatric Posttraumatic Stress Disorder JOURNAL OF TRAUMATIC STRESS Wong, S. S., Kletter, H., Wong, Y., Carrion, V. G. 2013; 26 (3): 385-391


    This study investigated the influence of caregiver psychological symptoms on posttraumatic stress disorder (PTSD) symptoms in traumatized children. One-hundred eleven children and caretakers were assessed in this study. Children (N = 59) with a history of exposure to interpersonal violence were evaluated for reexperiencing, avoidance/numbing, and hyperarousal symptom clusters using the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). The 52 primary caregivers were evaluated using the Symptom Checklist-90-Revised (SCL-90-R) on 9 domains of psychological symptomatology: anxiety, depression, hostility, interpersonal sensitivity, obsessive-compulsive disorder, paranoid ideation, phobic anxiety, psychoticism, and somatization. At 14-month follow-up, 45 of the children were re-evaluated with the CAPS-CA. Caregiver psychological symptoms in the domains of anxiety, depression, interpersonal sensitivity, obsessive-compulsive disorder, and paranoid ideation were associated with less improvement in total pediatric PTSD symptoms. Analysis of PTSD symptoms by cluster showed that greater caregiver symptomatology in the domains of anxiety, depression, interpersonal sensitivity, and obsessive-compulsive disorder were associated with less improvement in the hyperarousal symptom cluster. These results suggest caregiver symptomatology may be specifically associated with hyperarousal symptoms in pediatric trauma.

    View details for DOI 10.1002/jts.21816

    View details for PubMedID 23737297

  • Working with youth exposed to war and violence: recommendations for future research and interventions Child & Youth Care Forum Kletter, H., Rialon, R. A., Laor, N., et al 2013; 42: 371-388
  • Posttraumatic Stress Disorder Shifting Toward a Developmental Framework CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA Carrion, V. G., Kleffer, H. 2012; 21 (3): 573-?


    This article reviews the current classification of posttraumatic stress disorder and its limitations when applied to youth. Distinctions are made between single-event and multiple-event traumas. Diagnosis, neurobiology, treatment development, and treatment outcomes are presented. A summary of current empirical interventions is provided. The authors present implications for future research and for clinical practice.

    View details for DOI 10.1016/j.chc.2012.05.004

    View details for PubMedID 22800995

  • BRAIN ACTIVATION TO FACIAL EXPRESSIONS IN YOUTH WITH PTSD SYMPTOMS DEPRESSION AND ANXIETY Garrett, A. S., Carrion, V., Kletter, H., Karchemskiy, A., Weems, C. F., Reiss, A. 2012; 29 (5): 449-459


    This study examined activation to facial expressions in youth with a history of interpersonal trauma and current posttraumatic stress symptoms (PTSS) compared to healthy controls (HC).Twenty-three medication-naive youth with PTSS and 23 age- and gender-matched HC underwent functional magnetic resonance imaging (fMRI) while viewing fearful, angry, sad, happy, and neutral faces. Data were analyzed for group differences in location of activation, as well as timing of activation during the early versus late phase of the block. Using SPM5, significant activation (P < .05 FWE [Family-Wise Error] corrected, extent = 10 voxels) associated with the main effect of group was identified. Activation from selected clusters was extracted to SPSS software for further analysis of specific facial expressions and temporal patterns of activation.The PTSS group showed significantly greater activation than controls in several regions, including the amygdala/hippocampus, medial prefrontal cortex, insula, and ventrolateral prefrontal cortex, and less activation than controls in the dorsolateral prefrontal cortex (DLPFC). These group differences in activation were greatest during angry, happy, and neutral faces, and predominantly during the early phase of the block. Post hoc analyses showed significant Group × Phase interactions in the right amygdala and left hippocampus.Traumatic stress may impact development of brain regions important for emotion processing. Timing of activation may be altered in youth with PTSS.

    View details for DOI 10.1002/da.21892

    View details for PubMedID 22553009

  • Treatment of Traumatic Stress Disorder in Children and Adolescents Psychiatric Times Carrion, V. G., Kletter, H. 2012; 29: 1-8
  • Posttraumatic stress disorder: shifting towards a developmental framework Child and Adolescent Psychiatric Clinics of North America Carrion, V. G., Kletter, H. 2012; 21: 573-591
  • Update on neuroimaging in maltreatment-related pediatric ptsd: treatment implications Journal of Family Violence Carrion, V. G., Wong, S. S., Kletter, H. 2012; 28: 53-61
  • Guilt and posttraumatic stress symptoms in child victims of interpersonal violence. Clinical child psychology and psychiatry Kletter, H., Weems, C. F., Carrion, V. G. 2009; 14 (1): 71-83


    Our objective was to examine the relationship between guilt and posttraumatic stress disorder (PTSD) symptoms in children with a history of interpersonal violence. Eighty-seven children between the ages of 5 and 16 years (mean age = 11.70 years) were administered the Clinician-Administered PTSD Scale for Children and Adolescents to assess for PTSD symptoms and associated features. Multiple regression analysis found that guilt over acts of commission or omission (behaviors the child performed or failed to perform during the event or to prevent it) was highly associated with PTSD severity. Derealization and changes in attachment were also significantly related to PTSD symptoms. Findings suggest that it may be important for clinicians to assess for associated features in traumatized children as these are associated with greater PTSD severity. Posttraumatic interventions may benefit from targeting these symptoms.

    View details for DOI 10.1177/1359104508100137

    View details for PubMedID 19103706

  • Dissociation in PTSD Dissociation and the Dissociative Disorders: DSM-V and Beyond Waelde, L. C., Silvern, L., Fairbank, J., Carlson, E., Kletter, H. Rutledge. 2008: 447–453