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Someone that is in a domestic violence relationship has a hard time getting out because the other partner makes the person feel trapped and have no place to go. This article gives you a lot about facts and statistics of violence. The Safe House is a wonderful organization for resources.

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This is an hour long webinar with great information. It goes step by step on how to create a trauma sensitive classroom and why it is so important in society today.

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Webinar: Creating Trauma Sensitive Classrooms

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More than one of these hits home personally. I see more of the big "T" traumas and have experienced more than the others. This resource puts them in 3 areas that are easy to identify. The Somatic Center is a place where you use body awareness approach to healing trauma.

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Trauma is commonplace—it’s a by-product of living in today’s world. Somatic Experiencing® is a body-awareness approach to healing trauma developed by Peter Levine Phd.

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Domestic violence is such a hard subject to address to someone you love. This is a great resource to get a point across. The facts and myth differences and how serious this issue is.

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The article is about gun violence is domestic disputes. Legislation is taking steps to help protect women during this violence. The numbers are astounding!

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Domestic Violence does not discriminate by race, gender or sexuality. These are the statistics from the whole United States. It's unbelievable to think that the numbers are that high.

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The effects of trauma are life lasting and hard to deal with most times without outside help. Everyone has some kind of trauma at least one time in their life that they live with. The event is important but it's the way you respond to the experience how the outcome will be. Everyone is different.

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I like this resource because I found useful information about bullying trauma. My daughter experience this along with online bullying. The is a great resource! It has the impacts of childhood trauma, mental health impacts, how to help children cope, therapy options, medication and when to seek help.

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In every case healing is possible. Any trauma depends on many things including on how you cope with it. Signs and symptoms and PTSD are the emphasis in this article.

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Sometimes the things we experience as kids stay with us through adulthood. That is the case with trauma.

Childhood trauma can affect everyone differently. For some, it can have significant mental health effects. For others, it might mean the development of chronic physical health conditions.

How trauma affects you depends on many things, including your temperament, resources, and environment. In every case, healing is possible.

Childhood trauma, also known as developmental trauma, is any significant experience that overwhelms a child's ability to function and cope.

Trauma usually involves circumstances that are perceived as highly threatening - physically, emotionally, or both. But what's traumatic for you may not be for someone else, and vice versa.

Childhood trauma isn't a formal diagnosis in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).

Instead, it's listed as a possible contributing factor for several mental health conditions, including anxiety and mood disorders.

Because of this, there isn't a formal list of causes or symptoms of trauma.

What may affect one child may not have the same impact on another.

In general, traumatic experiences for a child may include:

Abuse

Neglect

Medical trauma

chronic illnesses

hospitalizations

medical procedures

emergency transport

accidents

other experiences involving pain or injury

Household challenges

difficult divorce

family mental illness

exposure to domestic violence and intimate partner violence

family substance use disorder

incarcerated relatives

loss of a loved one, sudden or anticipated

Environmental adversity and social influences

natural disasters (witnessing, experiencing, or losing loved ones to one)

homelessness

poverty and other economic challenges

racism

bullying

acts of violence, including hate crimes and terrorism

discrimination

Childhood trauma may have long-term effects that affect how you live your life as an adult. A multitude of trauma effects can be experienced long after the initial shock has faded away.

For instance, research from 2010 indicates childhood trauma is linked to significantly higher rates of chronic physical and mental health conditions among adults.

Long term effects of childhood trauma

On the side of mental health, one of the most common diagnoses associated with trauma is post-traumatic stress disorder (PTSD).

PTSD is often a result of exposure to a traumatic event during childhood or adulthood. This event may be a one-time incident or a repetitive occurrence.

Approximately 3.5% of adults in the United States experience symptoms of PTSD every year, and an estimated 1 in 11 will receive a PTSD diagnosis in their lifetime.

Symptoms of PTSD include:

But not all traumatic events result in PTSD.

Other mental health conditions may also develop from experiencing childhood trauma. They're not mutually exclusive. Sometimes, you may live with symptoms of two or more of these conditions.

Some of the most common ones include:

Your long-term physical health may also change as a result of what you've experienced as a child.

Childhood trauma has been linked to increased chances of:

Symptoms that aren't a formal diagnosis

Sometimes, experiencing a traumatic childhood event doesn't result in a diagnosable condition.

Protective factors, such as certain types of temperament or a strong support network, may buffer some of the effects of trauma.

It's possible that some people may not experience significant lasting, adverse effects of trauma.

Sometimes, the results of trauma are less noticeable or impairing but still present. This will look different for every person.

Maybe you developed a bird phobia, or you may rely on manipulation tactics in your relationships.

Other effects can be more disruptive to your adult life.

Childhood trauma can impact how you:

Build bonds in relationships. You may be afraid to trust anyone fully or be afraid to commit in a relationship.

Express or regulate your emotions. You may have difficulty saying what you're thinking without emotional outburst.

Respond to authority figures. You may have an intense dislike or mistrust of authority figures.

Handle stressful situations. You may become more easily overwhelmed in times of stress or have lower tolerance to frustration.

Behave socially. You may avoid certain types of social events or speaking with certain people.

Perform at school or work. You may be absent-minded or unable to focus clearly.

Envision your future success. You may doubt you have the ability to go far in life.

When you've experienced childhood trauma, you may not realize how it impacts your life as an adult.

The effects can be subtle, like locking yourself into a job you hate, for example. Deep down, this choice might be due to self-doubt as a result of the trauma you experienced.

Only a mental health professional can help you explore and identify how childhood trauma has affected you.

Like adults, children can develop PTSD and other mental health conditions as a result of trauma.

According to research published in 2019, trauma can double the chances a child will develop a mental health condition.

The symptoms of trauma in children, however, are often complex. Age plays an important role - children in preschool won't have the same opportunities for expressing themselves as children in middle school.

Age-related symptoms of childhood trauma may include:

Preschool children

excessive crying and screaming

language development delays

aggression

hypervigilance or alertness

recurrent nightmares

loss of appetite

weight fluctuations

clinginess or separation anxiety from adult caregivers

avoidance of some adults

acting out the trauma during play

physical symptoms, like headaches and tummy aches

hyperactivity

restlessness

impaired social skills

sudden changes in behavior

Elementary children

difficulty sleeping

nightmares

changes in concentration and school performance

fearfulness

anxiety

expressing guilt or shame

constantly talking about the event

sudden changes in behavior

Middle school and high school children

substance use

self-harm behaviors

eating disorders

hazardous sexual activity

impulsivity

anger outbursts

behaviors that put them in jeopardy

depression and anxiety

not typical social withdrawal

PTSD in children

The symptoms of PTSD in children are similar to those in adults.

Children may particularly experience:

acting out the traumatic incident in play

sudden changes in behavior

episodes of intense irritability and anger

distrust or fear of others

symptoms of depression

clinginess

event denial

absence of positive emotions

avoidance of places and people

changes in sleep patterns

bed wetting

reluctance to stay alone even for a moment

Children may exhibit these behaviors for several reasons, including other mental health conditions, physical conditions, or everyday stress responses.

It's common to have days where they feel overwhelmed, exhausted, or down.

When symptoms persist, or if there's no apparent acute cause (school test stress, performances), a traumatic event may be a possibility.

It's highly advisable to seek the support of a mental health professional. Only they can diagnose and treat a condition accurately.

Symptoms of childhood trauma in both children and adults can range in severity. It depends on protective factors, resources, as well as the event itself.

Even when the effects of trauma aren't as evident to you, speaking with a mental health professional can help process unresolved emotions.

As a coping mechanism, you may not be fully aware of the impact childhood trauma has had on your life.

In every case, trauma symptoms can be managed, and healing is possible.

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Childhood Trauma: Effects and Symptoms in Children and Adults

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Trauma can impact your life in many ways. Sometimes, you may not be aware. These are some of the possible effects it has on childhood and adulthood.

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Understanding childhood trauma in children is very important to me being an educator. Early signs to be aware of for sooner intervention. Being aware of our bodies alarm system, healthy steps to respond and things to remember to do to help the child.

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Fast Facts

At least 1 in 7 children have experienced child abuse and/or neglect in the past year, and this is likely an underestimate. In 2019, 1,840 children died of abuse and neglect in the United States.

Each day, more than 1,000 youth are treated in emergency departments for physical assault-related injuries.

In 2019, about 1 in 5 high school students reported being bullied on school property in the last year.

8% of high school students had been in a physical fight on school property one or more times during the 12 months before the survey.

Each day, about 14 youth die from homicide, and more than 1,300 are treated in emergency departments for violence-related injuries.
It's important to recognize the signs of traumatic stress and its short- and long-term impact.
The signs of traumatic stress may be different in each child. Young children may react differently than older children.

Preschool Children

Fear being separated from their parent/caregiver

Cry or scream a lot

Eat poorly or lose weight

Have nightmares

Elementary School Children

Become anxious or fearful

Feel guilt or shame

Have a hard time concentrating

Have difficulty sleeping

Middle and High School Children

Feel depressed or alone

Develop eating disorders or self-harming behaviors

Begin abusing alcohol or drugs

Become involved in risky sexual behavior

The Body's Alarm System

Everyone has an alarm system in their body that is designed to keep them safe from harm. When activated, this tool prepares the body to fight or run away. The alarm can be activated at any perceived sign of trouble and leave kids feeling scared, angry, irritable, or even withdrawn.

Healthy Steps Kids Can Take to Respond to the Alarm

Recognize what activates the alarm and how their body reacts

Decide whether there is real trouble and seek help from a trusted adult

Practice deep breathing and other relaxation methods

Impact of Trauma

The impact of child traumatic stress can last well beyond childhood. In fact, research has shown that child trauma survivors may experience:

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health and mental health services

Increase involvement with the child welfare and juvenile justice systems

Long-term health problems (e.g., diabetes and heart disease)

Trauma is a risk factor for nearly all behavioral health and substance use disorders.
There is hope. Children can and do recover from traumatic events, and you can play an important role in their recovery.
A critical part of children's recovery is having a supportive caregiving system, access to effective treatments, and service systems that are trauma informed.

Get Help Now
SAMHSA Behavioral Health Treatment Services Locator The National Child Traumatic Stress Network: Get Help Now Healthcare Toolbox: Basics of Trauma-Informed Care
Not all children experience child traumatic stress after experiencing a traumatic event. With support, many children are able to recover and thrive.

As a caring adult and/or family member, you play an important role.

Remember To:

Assure the child that he or she is safe.

Explain that he or she is not responsible. Children often blame themselves for events that are completely out of their control.

Be patient. Some children will recover quickly while others recover more slowly. Reassure them that they do not need to feel guilty or bad about any feelings or thoughts.

Seek the help of a trained professional. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope and move toward recovery. Ask your pediatrician, family physician, school counselor, or clergy member for a referral.

Visit the following websites for more information:

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Recognize the signs of child traumatic stress and the impact that trauma may have on children. The infographic developed by SAMHSA's National Child Traumatic Stress Initiative (NCSTI) provides information on the prevalence and impact of traumatic events on children, and what actions can be taken to support children who experience traumatic events.

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This video Pediatrician Nadine Burke Harris talks about the way the brain develops differently when parents struggle with mental health, substance abuse or neglect regularly. How if you suffer from these traumas you are more likely to develop health problems when you are older. She also talks about a proactive approach to trauma treatment and prevention.

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How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

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This video is Liz Mullinar the founder of Heal for the Life foundation. Liz was awarded a Humanitarian of the year award. She talks about the core problems regarding childhood trauma. How in psychiatric hospitals have patients who all suffer from some for of trauma.

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TEDxNewy 2011 - Liz Mullinar - Treating the core problem of childhood trauma.

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In this article they talk about the landscape of childhood trauma and the consequences it can have on your mental, emotional and physical wellbeing.

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Childhood Trauma & Its Lifelong Impact: 12 Resources

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By better understanding childhood trauma, therapists can recognize its signs and guide clients on a path toward healing and resilience.

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The Gateway Foundation is a wonderful organization that helps trauma patients with programs all over Illinois. They have inpatient and outpatient programs for drugs and alcohol.

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Gateway Foundation
Gateway Foundation is a recognized leader in evidence-based addiction treatment proven to get results. Our experts in Addiction Medicine-including highly educated clinical and medical professionals and expert psychiatrists and nurses-deliver care that never stops. For over 50 years, Gateway Foundation has been helping individuals and their families recover from addictions and behavioral health issues and is the only provider that covers the entire state of Illinois with 16 facilities from the Wisconsin Border to the Kentucky Border. Gateway has specific programs focusing on substance use disorders, trauma, depression, anxiety, and other co-occurring issues. We're licensed by the state of Illinois and accredited by the Joint Commission. We are in-network with all the major commercial insurance plans. Gateway Foundation: Addiction medicine, saving lives.

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Why Trauma Often Leads to Addiction | Gateway

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Traumatic situations as an adult or child can change how you see the world & how you view yourself. Learn how trauma can lead to an addiction.

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This article is about the data from a recent national survey of adolescents. This is a resource that can be handed out to parents. It is very informative.

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This video was very informative. It talks about Addiction how it's not a brain disorder due to genetic reasons or a choice. It's because of human needs of attachment. when there is trauma that attachment gets broken. We need to reconnect with ourselves to heal from trauma.

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How Childhood Trauma Leads to Addiction - Gabor Maté

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This article talks about trauma, affecting the brain, types of trauma, how different types of trauma link to addiction, signs and symptoms of trauma and treatment. This article also has resources at the end.

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This video is very powerful. It has a lot of information about the power of addiction. We need to find our power from within ourselves. Our brain gets wired different from every trauma we endure.

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The Power of Addiction and The Addiction of Power: Gabor Maté at TEDxRio+20

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This article is about forming healthy relationships in your life. How counseling is so important in healing. The community impact and integrated care is also important in the global increase approach in addressing these issues. Helping with transportation to come to get help.

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The intersection of childhood trauma and addiction

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In being aware of the vulnerability to addiction for those affected by adverse childhood experiences, professional counselors can play a pivotal role in prevention and early intervention.

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This help guide is very informative. It talks about how parents substance abuse affects the children, the dependency affects the entire family, long term effects, the seven c's and what is the first step to recovery.

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Sana Lake - Missouri Alcohol & Drug Rehab

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Children of Parents with Addiction: A Help Guide - Sana Lake - Missouri Alcohol & Drug Rehab

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Being the child of parents in addiction can feel like a war zone instead of a typical household. Children of individuals who suffer from substance dependence

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This article is all about alcohol abuse in a family and the effects it has on them. What is the trauma of having an alcoholic parent, why it is traumatic, neglect, caos, shame, parenting a parent, the long term effects, treatment,recovery and healing.

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What Is the Trauma of Having an Alcoholic Parent?

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If you’re an adult child of an alcoholic, you might describe your childhood as traumatic. Many such people do. But many don’t realize that their alcoholic

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This article is about what is behind your trauma to make you turn to alcohol and drug use.Aspects that contribute to the trauma and addiction. You have to open old wounds to heal and healing is possible. this website has a lot of resources for different therapy programs to fit different needs.

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Is Trauma Behind Your Alcohol or Drug Use?

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For those struggling with trauma, substances such as drugs and alcohol can seem to offer a way to cope with emotional pain. It’s a false promise, of

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This site talks about what is trauma, how it affects the brain, PTSD, signs and symptoms of addiction, dangers of self medicating and developmental issues. This site also talks about inpatient vs. outpatient treatment options and how to look for programs for you.

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Making the Connection: Trauma and Substance Abuse | No Matter What Recovery

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Decades of research have found a strong link between experiencing a traumatic event and developing an addiction. Contact us today to learn more and get help.

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This video talks about different ways children cope with grief. When traumatic bereavement events happen to children they all handle it differently because of the situation they went through. Some do not manage well.

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Traumatic Bereavement: Helping children and young people who are struggling in schools & colleges

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I didn't know domestic violence was a hidden crisis in our community. The United Way organization is wonderful and does great things for our community. The United Way helps with shelter, counseling for children and families, legal aide and a lot more. I encourage everyone to donate to this cause. I have money taken out of my paycheck every month that goes directly to our community.

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Please be advised, the below article might mention trauma-related topics that include abuse which could be triggering to the reader. If you or someone you love is experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7.
Domestic violence is a pervasive issue that affects millions of individuals and families across the United States. Shockingly, nearly 20 people per minute experience physical abuse at the hands of an intimate partner in this country, amounting to over 10 million survivors each year. Beyond its criminal implications, domestic violence has far-reaching public health consequences that impact the physical, mental, and financial well-being of survivors. It's a problem that not only requires urgent attention but also demands a collective effort from our society. This article explores the health implications of domestic violence, delves into local statistics from Michigan and even deeper into the Michigan Lakeshore, and sheds light on the critical role of nonprofits in combating this issue.

The Health Implications of Domestic Violence

Domestic violence leaves deep and lasting scars on its survivors, affecting their physical and mental health in profound ways. Here are some critical health implications:

1. Lack of Medical Care: Shockingly, only about one-third of those injured by a partner seek medical care for their injuries. This means that many survivors suffer in silence, without the necessary medical attention to heal physically and emotionally.

2. Mental Health Disorders: Survivors of domestic violence are at a higher risk of developing mental health disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD). The trauma they experience can have long-lasting effects on their psychological well-being.

3. Chronic Diseases and Infections: Domestic violence survivors are more vulnerable to chronic diseases and infections due to the stress and physical trauma they endure. These health issues can have lasting consequences on their quality of life.

4. Enormous Financial Costs: The annual financial cost of domestic violence is staggering, estimated to be in the trillions of dollars. This includes lost productivity, healthcare expenses, and law enforcement efforts to address the issue.

5. Adverse Impact on Children: Children who grow up in violent homes are particularly vulnerable to both social and physical problems. Witnessing violence at home can lead to emotional trauma and behavioral issues. Moreover, when children learn that violence is a normal way of life, it increases the likelihood that they may become the next generation of victims or abusers.

Local Data and Information from Michigan

Domestic violence is not just a national issue; it is a pressing concern in communities across the United States. In Michigan, recent statistics from the Michigan Incident Crime Report (MICR) shed light on the situation:

There was a 2.9% decrease in incidents of domestic violence from 2021 to 2022 in Michigan.

Survivor Statistics:

Among survivors in Michigan, 15.4% were in the age group between 30-34.

70.7% of survivors were women.

52.8% of survivors were white, and 42.8% were Black/African American.

Alarmingly, 43% of incidents resulted in serious injuries.

Offender Statistics:

Among offenders in Michigan, 18.1% were in the age group between 30-34.

71.1% of offenders were men.

49% of offenders were white & 43% were Black/African American.

Statistics Broken Down on the Lakeshore (Muskegon, Newaygo, and Oceana Counties)

There were 1,665 domestic violence incidents reported to police (1,311 in Muskegon County, 134 in Newaygo County, and 220 in Oceana County) in 2022. Of these incidents, 823 resulted in injuries (51% in Muskegon County, 38% in Newaygo County, & 43% in Oceana County).

Relationships of Offenders to Survivors

A majority of domestic violence incidents are between dating couples (boyfriend/girlfriends). 28% of all incidents shared a dating relationship. Other high percentages of relationships included parents, siblings, and spouses. See below for a break down of percentages of survivor/offender relationships.

Offender to Survivor Relationship Chart for 2023 (MI Incident Crime Report)

These statistics underscore the urgency of addressing domestic violence within local communities. It is important to remember that the information above only displays the statistics for what HAS BEEN reported. According to the Bureau of Justice Statistics survey (published October 5, 2021), only about half of all domestic violence incidents are reported to law enforcement.

Raising Awareness and Support

One of the challenges in combating domestic violence is that it often goes unreported, and survivors may find it difficult to share their experiences. We must raise awareness and provide support to those affected. October is Domestic Violence Awareness Month, but we need to engage in open and continuous conversations throughout the year.

Supporting Survivors

We often get asked how someone can support a friend or loved one who discloses violence or trauma to them. It can be difficult for a survivor to disclose any part of their experience with others. If someone comes to you for support, start by believing them. You can't take away what happened to someone, but you can listen to them, believe them, and be a source of comfort.
Some things you can say to someone who has been impacted by domestic or sexual violence:

"I believe you." The most important thing to do when supporting a survivor is validate their experience. Let them know you believe them.

"It wasn't your fault." It is essential that a survivor understand they are not responsible for their assault or abuse. Be a supportive voice and remind them that they are not to blame.

"I'm sorry this happened to you." Mindful language is key: let survivors know that what happened was unacceptable, and that you take their experience and feelings seriously.

"Can I help?" Let survivors know you are there to support them without being forceful. This allows survivors power of choice on whether to seek out your help.

"What do you need most right now?" Give the survivor space to decide what comes next; there is no single right or wrong way for a survivor to respond to an assault or abuse.

It takes a lot of courage for a survivor of domestic violence or sexual assault to share their story with anyone. Never underestimate your power to affect the course of a survivor's healing journey! The 24-Hour Domestic Violence Hotline is always available at 1-800-799-SAFE (7233).

Local Nonprofits Taking Action

Several Lakeshore nonprofits are actively working to combat domestic violence, providing critical support, intervention, and counseling services. These organizations include:

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Domestic Violence: A Hidden Crisis in Our Communities | United Way of the Lakeshore

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Content Warning: Please be advised, the below article might mention trauma-related topics that include abuse which could be triggering to the reader. If you or someone you love is experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7.

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This article is about ACE's also known as Adverse Childhood Experiences. Adverse childhood experiences have long term effects on our health and well being. ACE's are traumatic events that happen between the ages of 0-17. This article gives facts and stats, outcomes and prevention information.

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Overview of adverse childhood experiences, the latest data, and CDC’s approach to prevention.

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The Early Childhood Learning and Knowledge Center is a great source of information. It talks about the link between stress and health, limitations and strengths of the ACE score, factors that increase trauma, strategies to reduce the effects of trauma and supporting children.

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Trauma and Adverse Childhood Experiences | ECLKC

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In this overview, learn about the impact of trauma and adverse childhood experiences on children’s development.

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This is a great informational video to watch. In the mid 1990s that the higher the ace score the higher the persons was prone to health, emotional and mental problems. Ten ACE's were discovered.

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Adverse Childhood Experiences (ACEs) Study

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This video explains what ACE's are and the effects of toxic stress that is released in the brain. It explains when you are continually in that state how your brain is damaged because of the constant trauma.

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Office of the California Surgeon General

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Understanding ACEs: What are Adverse Childhood Experiences (ACEs)?

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This video is very good. It explains more in-depth about ACE's. One in 8 people had 4 or more experiences with some kind of ACE's in their childhood. This video talks about the key factors leading to childhood trauma.

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Office of the California Surgeon General

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Understanding ACEs with Dr. Nadine Burke Harris

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This is a great resource to print out and give to my co workers to help explain some of the things they are seeing in their own classrooms.

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This video talks about ACE's and their consequences can be prevented. In some cases community helpers help people find jobs to help families relieve some stress. It talks about how things can be different if more people get involved.

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Centers for Disease Control and Prevention (CDC)

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Muskegon County

Resilience Muskegon

Contact Name: Lauren Meldrum
Address: Health West 376 E. Apple Ave Muskegon, 49442
Email: lauren.meldrum@healthwest.net
Phone: 231-332-3812
Website: https://1in21.org/resilience-information/
Geographic Area: Muskegon County
Primary Activities: Public awareness, Professional education/development, Identification of trauma-informed services & resources, Promoting/facilitating adoption of trauma-informed practices & policies, Providing ACE and Resilience information across the community
Populations Served: Children & youth, Young adults, Parents/caregivers, Human service professionals
Child welfare (CPS; public/private foster care), Community members, Education - Pre K - 12, Health care, Local government, Mental health, Public health

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Muskegon County

Resilience Muskegon

Contact Name: Lauren Meldrum
Address: Health West 376 E. Apple Ave Muskegon, 49442
Email: lauren.meldrum@healthwest.net
Phone: 231-332-3812
Website: https://1in21.org/resilience-information/
Geographic Area: Muskegon County
Primary Activities: Public awareness, Professional education/development, Identification of trauma-informed services & resources, Promoting/facilitating adoption of trauma-informed practices & policies, Providing ACE and Resilience information across the community
Populations Served: Children & youth, Young adults, Parents/caregivers, Human service professionals
Child welfare (CPS; public/private foster care), Community members, Education - Pre K - 12, Health care, Local government, Mental health, Public health

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This is a great article with a ton of information. It asked what traumatic grief is, what are the effects on families and communities, national crises, strategies for mental health and so much more. This article also talks about the differences and similarities between grief and traumatic grief.

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When a traumatic event occurs, the first emotions we tend to experience are shock and horror. Reality itself may seem to be suspended temporarily, but once we realize the magnitude of the trauma, our shock may give way to grief. As devastating as traumatic grief can be, it's the first stage in the healing process.

Even our grief has been transformed by the trauma the COVID-19 pandemic has inflicted. Safety measures to prevent the deadly coronavirus have disrupted the normal grieving process in some of the following ways:

Understanding the connection between unexpected trauma and grief helps mental health practitioners provide the guidance and support that will help families and communities heal from the ravages of COVID-19. Never before has social support and the role of mental health counselors been more needed to help people learn and implement the coping strategies for traumatic grief.

What Is Traumatic Grief?

What is traumatic grief? It's a reaction to a traumatic event that lasts longer than is typical or that affects the person who is coping after a death or other event more deeply than is typical.

Emotional and psychological trauma strikes people in the aftermath of exceptionally stressful occurrences. Trauma is described as evoking feelings of insecurity and helplessness. People who are traumatized experience a jumble of emotions and memories that may leave them feeling anxious, numb, disconnected or distrustful.

Traumatic grief occurs after an unexpected loss, such as the sudden death of a loved one. The typical grieving process may be accompanied by post-trauma survival mechanisms that could complicate and prolong the healing process. The mechanisms may include fear, fight-or-flight (hyper) responses or freeze (hypo) responses.

How Traumatic Grief Differs from Other Forms of Grief

Grief is an unfortunate but natural part of life. We grieve when we lose a loved one, when a long-term relationship ends and when experiencing other forms of loss. In most cases, the loss is expected or foreseeable, such as the loss of an aged parent to illness. However, when the loss is unexpected, we experience trauma as well as grief, which can interrupt, exacerbate and prolong the usual grieving process. Overcoming traumatic grief often requires counseling from a mental health professional or other professional assistance.

Effects of Traumatic Grief on Individuals, Families and Communities

In the aftermath of a disaster such as the COVID-19 pandemic, most people can return to the way they functioned before the event. However, many people will experience negative feelings and emotions immediately after the calamity. In some cases, the ill effects on the mental health of survivors will persist for an extended period.

Common reactions adults and children experience after a disaster include:

Having trouble falling or staying asleep

Feeling sad, depressed, moody, irritable or hyperactive

Feeling numb

Feeling tired

Having trouble eating or overeating

Having trouble focusing

Avoiding social contacts and usual routines

Misusing alcohol or other drugs

Very young children may cling tighter to their parents and caregivers, be frightful or throw tantrums. School-age children sometimes become more combative or isolated; they may struggle with schoolwork.

There are many ways COVID-19 has strained the usual grieving process along with resources communities can tap to mitigate the damage:

Fact sheets and video presentations are available from many sources to help mental health counselors and other health professionals assist clients struggling with COVID-19 issues.

Traumatic Grief Resulting from National Crises

Traumatic grief due to the pandemic is unlike that experienced by people who have lost a loved one in other natural disasters or national crises. Deaths from tornadoes, hurricanes, earthquakes, wildfires and other natural events are typically accompanied by massive damage to property. The full scale of the economic, social and public health damage resulting from the slow-moving catastrophe of the pandemic won't be known for many years. Communities across the country may respond to the mental health repercussions of COVID-19 for years afterward.

How COVID-19 Impacts Mental Health

The pandemic has affected everyone, but in many cases, the added stress and uncertainty the outbreak has caused has worsened existing mental and physical health conditions. Adults and children can easily be overwhelmed by these feelings. Being concerned about the safety and well-being of our loved ones is natural, but sometimes that worry can get out of control.

In the months after the pandemic struck, 1 in 3 adults in the U.S. experienced symptoms of anxiety or depressive disorder.

The Challenges of Providing Mental Health Care in Times of National Crisis

Following are some of the challenges faced in combating COVID-19 and other natural disasters:

Strategies for Building Mental Health Resilience During a Crisis

There are many simple ways for people to cope with COVID-19 stress and tend to their emotional health during this time.

For health care professionals, be aware of the potential for vicarious trauma or compassion fatigue as a consequence of witnessing the trauma and distress from COVID-19.

For workplaces and businesses, be aware of the symptoms of stress, and communicate health and safety information clearly and frequently.

For parents helping children and young adults, try to maintain routine and continuity in learning and health care; take every opportunity to make children feel safe and secure.

Resources on Traumatic Grief

What Is Mass Trauma?

Mass trauma occurs when a group of people is affected psychologically after experiencing a shared traumatic event. The impact of the COVID-19 pandemic constitutes mass trauma in that it causes people to feel the world they live in isn't safe. The outbreak has taken a physical and mental toll on much of the population that hasn't been infected by the virus, causing symptoms mirroring those of PTSD and other mental illnesses.

How Mass Trauma Relates to COVID-19

The APA states COVID-19 will worsen existing mental health conditions for many people and cause new mental health problems for many others. The organization recommends medical researchers and clinicians prepare mental health diagnostics, prevention and outreach efforts coordinated with local health care providers. The goal is to quickly develop and test interventions for mental distress due to COVID-19.

How Mass Trauma Affects Mental Health

The following are among the conditions that mass trauma and concern about COVID-19 may cause in people:

Short-Term Impact of Mass Trauma on Mental Health

In the immediate aftermath of mass trauma, all witnesses are likely to experience stress reactions that eventually subside, usually within weeks or months, according to the U.S. Department of Veterans Affairs (VA). However, people with specific risk factors are more susceptible to severe responses, including depression, anxiety and PTSD.

The VA lists the risk factors that may cause serious short-term mental health problems following mass trauma:

Long-Term Impact of Mass Trauma on Mental Health

The type of social isolation and loneliness resulting from COVID-19 restrictions have been linked to increases in mental and physical illnesses, as well as reduced life spans. Mental health risks are also associated with increased worry and stress in older adults. More workers report high stress levels due to potential job loss and income insecurity.

Adapting to and coping with COVID-19 in the long term requires resilience that protects against depression, anxiety, traumatic stress and other mental health conditions. The National Alliance on Mental Illness (NAMI) describes tactics that have proven effective in building mental health resilience:

Effects of Mass Trauma on Community Health

Following an event that causes mass trauma, the rise in mental illness affects entire communities, not just the people who experienced the event firsthand. Higher levels of PTSD, depression and other mental conditions are reported throughout the impacted community.

The situation is made worse by repeated media reports and social media posts about the traumatic event. The challenge for all communities in protecting the mental health of residents is to make sure resources such as the National Suicide Prevention Lifeline (800-273-8255) are readily available to people in crisis.

How Mass Trauma Affects Children and Vulnerable Communities

A World Health Organization (WHO) survey on the impact of COVID-19 on the provision of mental health services found poor people and other vulnerable populations will suffer the most serious disruptions in the delivery of essential services.

Impact of Trauma on Children

The trauma many children experience as a result of the COVID-19 pandemic will have deep and long-lasting effects on their mental health. Witnessing the death of loved ones and community members lost to COVID-19 is only one reason for concern about the mental health impact of the outbreak on children.

Vicarious Trauma in Health Care Workers Due to COVID-19

Mental health counselors and other health care professionals have to be aware of the physical and mental risks of treating patients during and after the pandemic. A study found vicarious trauma in health care workers treating COVID-19 patients was lower in nurses on the front line than nurses not on the front line and the general public; the level of pandemic-related vicarious trauma was about the same in the latter two groups.

Symptoms of vicarious trauma include loss of appetite, tiredness, sleep disturbances, irritability, lack of focus, fear and interpersonal conflict. The researchers note most of these symptoms remain relatively minor in affected health care providers. The studies reported in Frontiers in Psychology identified specific groups of health care providers who appear to be at greater risk of vicarious trauma from treating COVID-19 patients. For example, unmarried nurses tend to have fewer severe symptoms of vicarious trauma than nurses who are married, divorced or widowed.

The higher level of vicarious trauma in nurses not on the front line and the general public is the result of two factors, according to the researchers:

Most nurses on the front line volunteered to work in COVID-19 wards and received the psychological preparation to prevent vicarious trauma.

Nurses not on the front line and the general public are concerned about COVID-19 patients and the professionals who are caring for them, while nurses on the front line are able to better sympathize with their patients and benefit from their experience with the pandemic.

Resources on Mass Trauma

How Do Trauma and Grief Relate to Each Other?

Psychology Today points out traumatic grief results from unexpected events, while other causes of grief are foreseeable, such as losing a loved one after a long illness. What is uncertain is the degree of unexpectedness leading to the trauma. Fear plays a greater role in traumatic grief because the event comes by surprise and causes a person's world to be thrown off its axis.

Differences and Similarities of Grief and Traumatic Grief

Many of the physical and mental responses to grief and traumatic grief are the same:

However, when trauma complicates grief, a person's symptoms may include feeling a loss of safety or security. A fixation on the loss can dominate the person's thoughts. The person may become bitter and envy those not affected by the loss, or may no longer find enjoyment in some favorite activities.

How an Unexpected Death Triggers Traumatic Grief

The four types of problems that may arise after the unexpected death of a loved one include:

The Connection Between Traumatic Grief and PTSD

People who suffer a traumatic loss are especially susceptible to PTSD. They may also experience panic disorder and depressive episodes that persist long after the usual grieving period. These are among the symptoms of PTSD:

Anger, tension and irritation

Heart palpitations, sweating and hyperventilation

Flashbacks to the traumatic event

Avoiding any reference to and emotions surrounding the event

Feelings of guilt or self-blame

Persistent negative thoughts

What Is Complicated or Prolonged Grief?

Prolonged grief differs from depression in that the person typically becomes fixated on the lost loved one. Also called complicated grief, the condition occurs in about 1 in 10 people who suffer the traumatic loss of someone close to them. If left untreated, the grief can last indefinitely, causing sleeplessness, substance abuse, suicidal thoughts and impaired immune-system response.

How to Distinguish Traumatic Grief from PTSD

While traumatic grief and PTSD share some characteristics, such as disbelief and avoidance behaviors, the two conditions differ primarily in the former's focus on personal loss.

Resources on Trauma and Grief

Stages of Grief

The model for the five stages of grief that Elisabeth Kübler-Ross developed in 1969 was based on her work with terminally ill patients, but it also applies to the grief people experience following a traumatic event such as the COVID-19 pandemic. The model has been used to help people recover from such traumatic events as substance dependency, divorce or the end of a long-term romantic relationship in addition to overcoming the traumatic grief caused by the death of someone close.

Five Stages of Grief

While most people going through the grieving process will experience all five stages in order, others may not feel all five or may experience them in a different order. Mental health counselors must be aware everyone processes grief uniquely, so the stages of grief should be considered as guidelines to help determine the best course of care for an individual.

Denial

Someone who experiences grief may initially refuse to believe what happened. For example, after receiving a terminal diagnosis, a patient may insist the lab results were mixed up or when learning of a loved one's death, the patient may hold out hope the victim was misidentified. This is a natural defense mechanism that can help people cope in the short term, but the healing process can't begin until the person acknowledges the reality of the situation.

Anger

The initial response after acknowledging the event is to feel upset about the unfairness of it. People may look for others to blame as their grief is transformed into anger at loved ones or caregivers. As with denial, anger can be an important part of the grieving process in the short term, allowing people to process the news at their own pace and to express their legitimate emotion rather than suppressing it.

Bargaining

Once the anger subsides, the person may attempt to make a deal with God under the false hope a way to negotiate out of the situation exists. Much of the bargaining is motivated by guilt because the event results from something the person did or didn't do.

Depression

Grief and depression go hand in hand; the feeling of emptiness that follows the realization of the traumatic event's consequences may lead to a sense of numbness or vagueness. The person may avoid contact with friends and family and may retreat from their normal routines. Suicidal thoughts may also arise at this stage of the grieving process.

Acceptance

The grieving person ultimately finds acceptance in the final stage of the process, i.e., the event was traumatic but the person has learned to live with it. At this point, the person acknowledges the new, post-traumatic reality not as a good thing, but as something that allows for putting the traumatic event in the past while adjusting to a new life without the lost loved one.

Resources on the Stages of Grief

The Five Stages of Grief explains the emotions that are part of the healing process and compares the Kübler-Ross model to other models of grief and bereavement.

There are several therapy worksheets related to grief, including ones for caregivers of grieving children, the tasks involved in mourning and an education printout on the stages of grief.

Symptoms of Grief

Diagnosing patients who experience symptoms of grief to a greater extent or over a longer period than would be considered typical begins by identifying the symptoms they exhibit or express to caregivers. In particular, complicated grief, which is sometimes called persistent complex bereavement disorder, can have serious consequences for people in mourning and their families.

How Traumatic Grief Symptoms Differ from Other Types of Grief

The symptoms of traumatic grief and other forms of grief are as follows:

Symptoms of Traumatic Grief in Children

While children who are suffering grief will experience many of the same symptoms as adults, they may also exhibit distinct changes in behavior:

Children may cling to adults more, be anxious or feel abandoned.

Children may experience regression in their development, such as small children wanting to drink from a bottle or use baby talk.

Children may act out or fall behind in their schoolwork.

The way children play may change to focus on pretend dying and coming back to life.

Children sometimes feel guilty during grief, believing the loss is their fault.

Older children and teenagers may adopt risky behaviors, such as drinking alcohol or taking drugs.

Other Techniques for Identifying People Affected by Traumatic Grief

The APA distinguishes the symptoms of people with prolonged grief from sadness and depression:

However, prolonged grief shares some symptoms with PTSD:

Resources on the Symptoms of Grief

Coping with the Loss of a Loved One offers a guide to identifying complicated grief, including advice for helping people who are grieving.

The U.S. National Library of Medicine's bereavement directory including links to information on grief and loss related to COVID-19 and journal articles on prolonged grief disorder.

Coping Strategies for Grief

Recovering from the trauma of losing a loved one requires a platform for examining and understanding what has happened and how the person's life has changed. Coping strategies for grief are intended to allow people who have suffered trauma to be introspective and thoughtful about their loss. The goal is to channel the flood of emotions that are a natural part of grieving to let thoughts be considered from a different perspective. This helps prevent negative thoughts from looping through the person's mind.

Common Strategies for Coping with Grief

The following five skills can help people work through the grieving process:

Eat a healthy diet and drink plenty of water. Even when you don't have an appetite, preparing simple foods such as soup or tea can bring comfort by feeling familiar.

Let people know how you feel. It's common for people in mourning to avoid talking about how they feel, but finding a sympathetic ear can be a therapeutic release.

Start a journal. If you hesitate to open up to others, express your emotions in a private journal. This helps you mark progress over time and make note of small accomplishments.

Stay active. Swimming, weightlifting, bicycling and other forms of exercise help relax tense muscles. Even short walks and simple activities such as sweeping the walk can have benefits.

Try using relaxation techniques. Many people who are grieving find comfort in meditation, prayer and other mindfulness practices. A technique as simple as slow, deep breathing can help calm anxiety or worry.

Explaining the Grieving Process

No two people grieve the same way. The following factors can affect how a person grieves:

People in mourning must identify behaviors that indicate the need for professional help in overcoming their grief. These behaviors include being unable to maintain a routine, having trouble completing everyday tasks, missing work, incessantly blaming themselves, and feeling worthless or that life isn't worth living. These feelings aren't part of the normal grieving process.

Counteracting the Emotional and Physical Symptoms of Grief

These steps can help overcome the physical and emotional effects of the grieving process:

Reaching the Stage of Acceptance and Remembrance

In the last stage of grief, people who are grieving allow feelings of sadness, anger, regret or depression. They have reached the point of understanding their emotions and have accepted their new world. Unfortunately, not everyone who grieves can reach the acceptance and remembrance stage due to being unable to get past one of the stages, like anger or depression.

Sources of Support for Coping with Overcoming Grief

As personal as the grieving process is, no one needs to or should go through it alone. Social support and good eating habits help people recover more quickly from a traumatic loss. The APA recommends five ways for people in mourning to reach out for assistance to help ease their pain:

Talk about your loss with friends and family to help them understand and remember the person.

Don't deny any of the emotions you feel; all of them are part of the normal grieving process.

Take care of your physical health and make sure others who may be grieving are doing likewise.

Help others who are experiencing the same feelings; this is one of the best ways to overcome feelings of loss.

Take every opportunity to celebrate the life and memory of the person you lost.

Family and Friends

The following tips and advice can help family and friends of people in mourning understand the best way to help them through the grieving process:

Acknowledge the person's loss and express your concern.

Give the person a chance to talk about the loss, including how the loss occurred.

Ask how the person is feeling, but avoid comparing the person's grief with anyone else's.

Accept the emotions the person expresses without judgment or criticism.

If the person doesn't want to talk, sitting with the person in silence for a while is OK.

Community Support Services

The American Medical Association (AMA) guidelines for managing mental health patients during COVID-19 recommend planning for increased workloads as the conditions of existing patients are exacerbated and new patients experience symptoms.

Social Media and Other Online Services

Consider the following when using social media as part of the grieving process:

The Importance of Self-Care for People Who Are Grieving

A personalized self-care plan can help with the grieving process:

Tips for Facing and Expressing Your Feelings

People who are grieving should make the effort to reach out to friends and family rather than waiting for them to make the call. While it can be helpful to tell them about how you're feeling, relaxing conversation on nearly any topic can be therapeutic.

In some instances, the best way to communicate how you feel about your grief is by joining a support group or by seeking the help of a mental health counselor. Keep in mind there is no single best way to go about expressing how you feel, so don't hesitate to experiment until you find the best method for you.

The Importance of Returning to a Daily Routine

The new routine will likely vary in some ways from your previous habits and activities, but it should be designed with your health and well-being in mind. If necessary, make appointments to take part in favorite activities, such as listening to music, reading a book or simply taking a bath. Be sure to include shared activities and visits with friends and family in your new routine.

Encouraging Healthy Habits and Discouraging Unhealthy Ones

A little self-indulgence can help overcome the pain of grieving, but not so much the indulgence becomes a crutch. Grieving requires you to address and process the pain you're feeling rather than running away from it. Friends, family and co-workers can play important roles in reminding you to maintain a healthy lifestyle despite the pain and sorrow you feel.

Resources on Coping Strategies for Grief

In Times of Crisis, Look to the Helpers

National traumas are typically associated with a specific date, such as Dec. 7, 1941, or Sept. 11, 2001. The COVID-19 pandemic sometimes feels like it's happening in slow motion, but the devastation resulting from this ongoing disaster has been made all too real to millions of Americans and tens of millions of people around the world. Grieving after a national crisis the scope of COVID-19 will be widespread, long and painful.

These are the times when our attention naturally turns to the people who are dedicated to the care and comfort of others who are suffering and in need. The work of counselors and other mental health professionals will be needed in the coming months and years more than ever before in our lifetimes.
Infographic Sources: American Psychiatric Association, "Coping After Disaster" Mayo Clinic, "Complicated Grief"

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Managing Traumatic Grief and Coping After National Crises

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When a traumatic event occurs, the first emotions we tend to experience are shock and horror. Reality itself may seem to be suspended temporarily, but once we realize the magnitude of the trauma, our shock may give way to grief. As devastating as traumatic grief can be, it's the first stage in the healing process.

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This diagram shows how traumatic grief affects people's brain after the event and what types of things they turn to as a result.

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Fading Fast: Cognitive Controls and The Wrenching Struggle to Subdue Traumatic Grief, Guilt and Fear - Center for Family & Personal Growth Venice FL

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An Accredited CE Seminar for the Health Professions (Includes real-client video accounts of violent and non-violent trauma) Go to Seminar Schedule and Registration Infograph found at missecoglam.com Program Outline & Objectives: Distinguish simple/incidental, developmental, complex and epigenetic trauma development Cumulative Adverse Childhood Experience and the elegance of the extended Pavlovian model Describe the neurobiology of […]

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This article has a lot of great information on traumatic grief. It tells you what it is, what typical grief vs. traumatic grief is, common symptoms, signs, how to cope and when to get help. It also gives resources.

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Emma McSkelly talks about her trauma and loss of her mom to a drug overdose that changed her life. She talked about the fear that is so strong it takes over your body. Fear of loss, abandonment, rejection, sense of self left her in a trauma state of grief that she eventually overcame.

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Turning Childhood Loss & Trauma into a Superpower | Emma McSkelly | TEDxDoncaster

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This article is about traumatic grief is a form of grief that happens in response to a sudden and unexpected loss. It causes prolonged grief disorders and PTSD.

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Traumatic grief is a form of grief that happens in response to a sudden, unexpected loss.

Grieving is always difficult. And when a loss is sudden, coping in the aftermath can feel impossibly hard.

Everyone grieves at some point in their life, and it affects people in all sorts of ways. When grieving, you may find it difficult to move forward.

But while it can feel tough right now, there are ways to heal and manage the grief you're feeling.

Traumatic grief can happen in response to a sudden, unexpected loss.

For example, maybe you lost a child, or experienced the violent death of someone close to you. It might also involve losing your support system.

Traumatic grief is different from the grief that happens from an expected loss, such as when someone passes away after a long chronic illness.

That doesn't mean that other forms of grief are any less difficult to deal with. In some people, it may even lead to prolonged grief disorder, also called complicated grief.

Traumatic grief is more likely to lead to complicated grief. And the feelings that come with traumatic grief are also much more intense.

"The shock and unexpected nature of the loss can be traumatizing and trigger intrusive, preoccupying thoughts or bodily responses that are essentially distorted survival mechanisms in addition to the mourning of whatever was unexpectedly lost," says Michael Roeske, PsyD and executive director at Newport Healthcare Connecticut.

Traumatic grief is also related to prolonged grief disorder, says Roeske. Sometimes, people use the terms interchangeably. Prolonged grief disorder involves a deep longing for the lost loved one and constant thoughts about them, which can interfere with your everyday life.

Evidence suggests that people are more likely to develop complicated grief disorder if the circumstances of the loss are traumatic in some way, like an accident or natural disaster. For many people, the loss of a child may be the most traumatic form of family loss.

According to Roeske, finding out about an unexpected death can also cause grief that leads to post-traumatic stress disorder (PTSD), a mental health condition that causes disturbing, intrusive thoughts related to the initiating traumatic event.

Research involving adults who lost someone during 9/11 found that about 43% had what could be categorized as complicated grief with PTSD 3 years after the event.

PTSD relating to grief is also especially likely if you have an existing mental health condition at the time you experience a traumatic loss, adds Roeske.

If you're living with depression, for example, you may have a more pronounced reaction to a loss.

We all experience grief differently. There's no right or wrong way to grieve a loss. But if you're experiencing traumatic grief, it may look different from other forms of grieving. Symptoms can include:

According to Roeske, people experiencing traumatic grief may also feel angry and that what's happened is unfair. They may also feel like they have unfinished business or something they need to work on.

The symptoms are more intense, pervasive, and persistent than regular grief. "Those experiencing traumatic grief are also more likely to feel fear for themselves and/or others," adds Roeske.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), physical symptoms may also include:

shakiness or trembling

nausea

loss of appetite

dry mouth

problems sleeping

trouble breathing

muscle weakness

People deal with grief in different ways, but some things may be more helpful than others in getting you through this difficult time.

Focus on routine and maintaining structure

"It is best to first stabilize the trauma by focusing on how to regulate emotions and calm the nervous system before trying anything else," says Roeske.

Soothing the nervous system looks different for everybody, but doing things that you enjoy is a good place to start. For some people, grounding exercises help them feel more connected to their bodies and surroundings.

Following a routine helps people to feel safe and cared for. Keeping regular mealtimes and prioritizing sleep may give you a greater capacity to regulate your emotions throughout the day.

Know that your feelings are not uncommon

Everyone deals with grief at some point and handles it differently. There's nothing wrong with you if you're experiencing traumatic grief that's impacting your usual activities. You just might need extra support.

Acknowledge how you're feeling

By understanding and identifying traumatic grief, you're better equipped to deal with and manage those feelings, adds Roeske.

Think about it

Avoid trying to ignore your pain and grief. "Allow yourself to think about what happened instead of numbing or blocking it out," Roeske says.

Express yourself

If you're finding it tough to make sense of your feelings, journaling about your grief may help. It may even be a good first step before opening up to others.

Lean on others

Share how you're feeling with people around you. Some people find it particularly helpful to talk with people who have experienced the same type of loss by joining grief support groups.

If you're supporting someone who has experienced a sudden loss, try being a good listener. It can help to let the person talk about their loved one and grief.

In a 2021 study on forms of support for traumatic grief, responders commonly said that they appreciated it when people let them mention the name of the person they lost without being made to feel awkward.

"Grief is different for every person and every loss. It can last for weeks, months, or even years. This is why working with a mental health professional can be so important and beneficial in healing," says Roeske.

He recommends seeing a mental health professional if your grief is having a negative impact on your life. If you're having trouble eating, sleeping, or otherwise taking care of yourself, that's a sign it's time to talk with someone about how you're feeling.

If you're looking for extra support, these resources may help:

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Traumatic Grief: What it Is, Symptoms, and How to Cope

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Traumatic grief can happen after a sudden or unexpected loss. Learn about ways to cope here.

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This article is small but a lot of information that gets right to the point. It talks about the hidden mental illness struggle with childhood PTSD, gives you symptoms of the childhood PTSD and the reality of it.

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Childhood PTSD - Get Help From South Coast Community Services

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Childhood trauma is not something that can go away immediately. If you suffer from childhood PTSD, turn to South Coast Community Services for the help you need.

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This article talks about how many children have develop PTSD, what causes it,how it can be treated. Its talks about the effects on children and teens, outward signs and which children are at a higher risk. There are treatments and how to explain PTSD to young children.

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More than one of these hits home personally. I see more of the big "T" traumas and have experienced more than the others. This resource puts them in 3 areas that are easy to identify. The Somatic Center is a place where you use body awareness approach to healing trauma.

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Trauma is commonplace—it’s a by-product of living in today’s world. Somatic Experiencing® is a body-awareness approach to healing trauma developed by Peter Levine Phd.

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This is a great short video that explains a lot about PTSD and what things can trigger you. How important it is to talk to someone to find things to help you deal with PTSD.

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Post Traumatic Stress Disorder and Teens

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This is a great video about how the brain changes with trauma and PTSD. The video goes through all 4 parts of the brain and talks about what each one does and how they all work together. The video gives different ways of treatment.

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Leah's told her story of her childhood trauma that lead her to live and being adopted from her Aunt and Uncle. Leah talked about her depression and the help she receives.

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Depression and Childhood Trauma: Leah's Story

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This video talks in detail on the signs and symptoms of depression in young children. It is important to look for theses signs and symptoms to catch early before it gets to suicide and they can get professional help as soon as possible.

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This website has a ton of information about conscious discipline. There are things you can buy for your classroom, parent information, trainings you can take online etc. This is a great site for teachers who want to use it in their classrooms.

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Are you struggling with Children with big emotions. . . Overwhelmed administrators. . . Teachers burning out. . . Students feeling unsafe. . . Teachers

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This section on the website has a video with Dr.Becky Bailey about Healing hurting hearts-Trauma informed strategies to transform behaviors. Its has tools for parenting and in different languages.

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Visit Shubert at Home and School!

Practical, Hands-On Examples of Conscious Discipline Structures

Shubert's Home and School in Bug Valley offers practical, room-by-room examples of Conscious Discipline implementation. Discover tips, tools, videos and more that model how families, educators, administrators and helpers can put the principles and practices into action and bring safety, connection and problem solving to life.

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This article talks about the unpredictable environment that has a impact on anxiety in children. When children who suffer from anxiety it changes the brain structure and function. There are coping skills children can learn through counseling. They need to explore the past to see what triggers them.

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This article talks about how everything is intertwined. The childhood trauma experiences lead to ways of how they deal with it. It is not uncommon for children to develop behavioural and emotional symptoms.

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When bad experiences trigger anxiety: childhood trauma and PTSD

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Shockingly, up to 80% of children are exposed to trauma by the age of 18 in the UK. With the theme of World Mental Health Awareness Week being ‘anxiety’, we have an opportunity to unpack how…

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The article talks about what makes us anxious, when anxiety becomes a problem for children, what are the signs of anxiety in children, why is my child anxious and ways to ease anxiety in children. This article is very informative.

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Just like adults, children and young people feel worried and anxious at times.
But if your child's anxiety is starting to affect their wellbeing, they may need some help.

What makes children anxious?

Children can feel anxious about different things at different ages. Many of these worries are a normal part of growing up.

From the age of around 6 months to 3 years it's very common for young children to have separation anxiety. They may become clingy and cry when separated from their parents or carers. This is a normal stage in a child's development and should stop at around age 2 to 3.

It's also common for preschool-age children to develop specific fears or phobias. Common fears in early childhood include animals, insects, storms, heights, water, blood and the dark. These fears usually go away gradually on their own.

There may also be other times in a child's life when they feel anxious. For example, many children feel anxious when going to a new school or before tests and exams. Some children feel shy in social situations and may need support with this.

When is anxiety a problem for children?

Anxiety becomes a problem for children when it starts to get in the way of their everyday life.

If you go into any school at exam time, all the children will be anxious, but some may be so anxious that they do not manage to get to school that morning.

Severe anxiety like this can harm children's mental and emotional wellbeing, affecting their self-esteem and confidence. They may become withdrawn and go to great lengths to avoid things or situations that make them feel anxious.

What are the signs of anxiety in children?

When young children feel anxious, they cannot always understand or express what they are feeling. You may notice that they:

become irritable, tearful or clingy

have difficulty sleeping

wake in the night

start wetting the bed

have bad dreams

In older children you may notice that they:

lack confidence to try new things or seem unable to face simple, everyday challenges

find it hard to concentrate

have problems with sleeping or eating

have angry outbursts

have a lot of negative thoughts, or keep thinking that bad things are going to happen

start avoiding everyday activities, such as seeing friends, going out in public or going to school

Find out more about the symptoms of anxiety on our page about anxiety disorders in children.

Why is my child anxious?

Some children are more likely to have worries and anxiety than others.

Children often find change difficult and may become anxious following a house move or when starting a new school.

Children who have had a distressing or traumatic experience, such as a car accident or house fire, may have anxiety afterwards.

Family arguments and conflict can also make children feel insecure and anxious.

Teenagers are more likely to have social anxiety than other age groups, avoiding social gatherings or making excuses to get out of them.

Find out more about social anxiety.

How to help an anxious child

If a child is experiencing anxiety, there are things that parents and carers can do to help.

First and foremost, it's important to talk to your child about their anxiety or worries. Reassure them and show them you understand how they feel.

If your child is old enough, it may help to explain what anxiety is and the physical effects it has on our bodies. It may be helpful to describe anxiety as being like a wave that builds up and then ebbs away again.

As well as talking to your child about their worries and anxiety, it's important to help them find solutions.

For example, if your child is worried about going to a sleepover, it is natural to want to tell them not to go. However, this could mean your child feels that their anxiety will stop them from doing things.

It's better to recognise their anxiety and suggest solutions to help them, so they can go to the sleepover with a plan in place.

Other ways to ease anxiety in children

teach your child to recognise signs of anxiety in themselves

encourage your child to manage their anxiety and ask for help when they need it

children of all ages find routines reassuring, so try to stick to regular daily routines where possible

if your child is anxious because of distressing events, such as a bereavement or separation, look for books or films that will help them to understand their feelings

if you know a change, such as a house move, is coming up, prepare your child by talking to them about what is going to happen and why

try not to become overprotective or anxious yourself

practise simple relaxation techniques with your child, such as taking 3 deep, slow breaths, breathing in for a count of 3 and out for 3.

distraction can be helpful for young children. For example, if they are anxious about going to nursery, play games on the way there, such as seeing who can spot the most red cars

turn an empty tissue box into a "worry" box. Get your child to write about or draw their worries and "post" them into the box. Then you can sort through the box together at the end of the day or week

Find out more

When should we get help?

If your child's anxiety is severe, persists and interferes with their everyday life, it's a good idea to get some help.

A visit to a GP is a good place to start. If your child's anxiety is affecting their school life, it's a good idea to talk to their school as well.

Parents and carers can get help and advice about children's mental health from Young Minds' free parent helpline on 0808 802 5544, from Monday to Friday, 9.30am to 4pm.

Find out more about treatments on our page about anxiety disorders in children.

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How to help your child deal with anxiety about things such as going to school or socialising with friends. Also, how to tell when it's time to get medical help.

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This is a great video! This video gives you diagrams and is very easy to follow. It gives you great examples of normal anxiety and the differences of normal and a anxiety disorder. It shows you what parts of your brain react to the anxiety and how it works.

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What’s Normal Anxiety – and What’s an Anxiety Disorder? | Body Stuff with Dr. Jen Gunter | TED

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This video gives you breathing techniques to help your body calm when having anxiety. I use these when I'm feeling stressed and anxious during the day.

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This resource gives you an idea of what a child will do when feeling anxious. I would give this to my parents if their child was showing any of these signs.

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This article talked about a research done and they found that trauma in childhood predicted lower prefrontal-hippocampal connectivity in females and males and lower prefrontal- amygdala connectivity in females. These alterations in connectivity influences the development of internalizing symptoms of depression and anxiety.

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Childhood Trauma and Depression - Shier Private Practice

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We know that events that occur in early childhood are important for healthy brain development and mental wellbeing. Research suggests that these events may be specifically relevant to depression in adulthood. Traumatic events in childhood, such as death, divorce, abuse and/or serious illness have the ability to

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This is a good video. It explains in detail on how the brains hippocampus and amygdala react to trauma and depression. It talks about how it can heal from it also by making more cells in the hippocampus.

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This is a pamphlet you could print out and give to someone with key points on what to look for to help someone you love that is showing these signs of depression.

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National Institute of Mental Health (NIMH)

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Being a teenager can be tough, but it shouldn't feel hopeless. If you have been feeling sad most of the time for a few weeks or longer and you're not able to concentrate or do the things you used to enjoy, talk to a trusted adult about depression.

Do I have depression?

Do you often feel sad, anxious, worthless, or even "empty"?

Have you lost interest in activities you used to enjoy?

Do you get easily frustrated, irritable, or angry?

Do you find yourself withdrawing from friends and family?

Are your grades dropping?

Have your eating or sleeping habits changed?

Have you experienced any fatigue or memory loss?

Have you thought about suicide or harming yourself?

Depression looks different for everyone. You might have many of the symptoms listed above or just a few.
How do I get help for depression?

Talk to a trusted adult (such as your parent or guardian, teacher, or school counselor) about how you've been feeling.

Ask your doctor about options for professional help. Depression can be treated with psychotherapy (also called "talk therapy"), medication, or a combination of medication and talk therapy.

Try to spend time with friends or family, even if you don't feel like you want to.

Stay active and exercise, even if it's just going for a walk. Physical activity releases chemicals, such as endorphins, in your brain that can help you feel better.

Try to keep a regular sleep schedule.

Eat healthy foods.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIMH Identification No. OM 22-4321

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The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

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Teen Depression: More Than Just Moodiness

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This fact sheet is intended for teens and young adults and presents information about how to recognize the symptoms of depression and how to get help.

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This video is about the repeating your trauma. It explains 20 different ways trauma affects your life during childhood and then what happens when you are older when you haven't gotten treatment.

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The Real Reason It's So Hard to Recover from Childhood PTSD

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This article talks about the differences in PTSD and CPTSD. It has a diagram of the overlapping symptoms. Also talks about the treatments.

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PTSD vs CPTSD According To A Trauma Therapist In Pennsylvania

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Understanding the differences and the similarities between PTSD and CPTSD can help you find the right kind of support for your recovery from trauma. Read more here!

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This is just a great diagram that I found. It's easy to understand.

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This site is a treatment place that helps teens deal with PTSD. How it is so important as a parent to get your child help early instead of waiting until they are adults. This site also has videos in it to help with more answers. I really like this website.

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This article is about uncovering the causes of the depression and that is the most important thing so you can recover from it. It talks about how childhood trauma can lead to adult depression and how they can help you overcome it.

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Uncovering the causes of your depression is one of the most critical things you can do to recover. There are indeed biological factors that could contribute to your depression. But there are several other potential causes too. There may be things in your past you don't even associate with your symptoms.

One major factor that could contribute to depression is experiencing childhood trauma. Several studies have revealed a strong link between childhood trauma and depression.

Of course, if you experienced childhood trauma, that doesn't necessarily mean you'll develop adult depression. However, because trauma and depression are so closely linked, experts agree that you may be at higher risk.

Whether or not you remember your childhood trauma or if you've chosen to block it out of your mind, your body still remembers. To truly heal, you must partner with a qualified mental health professional to discover the root causes of your depression. While working with your clinician, you may uncover some causes of depression from childhood trauma.

What is Childhood Trauma?

Childhood trauma comes in many different forms. There may even be events in your past that you've shrugged off as "unfortunate" when, in reality, they were traumatic. Some examples of childhood trauma include the following:

witnessing or experiencing domestic violence

sudden or violent loss of a loved one

physical assault

sexual assault

neglect

psychological abuse

physical abuse

sexual abuse

bullying

serious accidents

life-threatening illness

community violence

Why You Need a Strong Support System
Unfortunately, childhood trauma is more common than you may think. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), over two-thirds of children report at least one traumatic event by the time they turn 16.

The Stop Abuse Campaign focuses on protecting children from Adverse Childhood Experiences (ACEs). In other words, they aim to help avoid childhood trauma by recognizing the signs and symptoms that something may be going on at home. One of the most significant indicators of childhood trauma is a high ACE score. According to the Stop Abuse Campaign, those with a score of four or more are at three times the risk of developing depression. ( Take the ACEs test here!)

How Childhood Trauma Can Lead to Adult Depression

The link between childhood trauma and depression is complex. But the bottom line is although it's not a certainty if you experience childhood trauma, you're more likely to develop depression later in life.

Childhood trauma and depression are linked in many unseen ways, affecting your mind and body in ways you may not realize. These include the following:

Biologically: Childhood trauma has been linked to a change in stress hormone systems that impact your body's ability to handle stress. Biological changes like this could contribute to your risk of developing depression.

Cognitively: Experiencing trauma in your childhood could play a part in your developing negative cognitive patterns like guilt, self-blame, and feeling worthless. Such profound cognitive changes can contribute to your depression.

Socially: Childhood trauma and depression are also linked because if you've experienced trauma, you may have trouble forming healthy relationships or interacting with others. You may also isolate yourself more, which could lead to depression.

Experiencing trauma in your childhood may also impact your:

Emotional regulation: The development of healthy emotional regulation skills may be interrupted due to childhood trauma. This could lead to difficulties coping with stress and challenging emotions, which, in turn, may increase your risk of depression.

Coping mechanisms: If you've experienced childhood trauma, you are more at risk for developing maladaptive coping mechanisms like substance abuse to cope with the pain. These unhealthy coping skills could contribute to depression.
Cyberbullying and Teenagers: Psychiatrists Address the Psychological Effects
How Untreated Childhood Trauma May Look in Adulthood

Childhood trauma makes a long-lasting impact on your mental health. Of course, how it manifests as an adult varies based on specific traumas and your individual characteristics. You were likely forced into survival mode if you felt unsafe, neglected, unloved, or abused in your childhood.

As a result, you may exhibit some of the following negative impacts of childhood trauma:

Mental health concerns: Not only are you more likely to develop depression from childhood trauma, but you also have an elevated risk of developing anxiety, post-traumatic stress disorder (PTSD), and personality disorders.

Substance abuse: In an attempt to cope with the challenging emotions associated with childhood trauma, you are more likely to turn to drugs or alcohol.

Mood swings: Because childhood trauma affects emotional regulation, you may be more prone to intense mood swings and experiencing emotional numbness.

Relationship issues: As mentioned earlier, childhood trauma may negatively impact your social skills. You may experience trust issues and have a fear of intimacy.

Low self-esteem: Not only are trauma and depression closely linked, but childhood trauma can also damage how you feel about yourself. You may struggle with feelings of inadequacy and self-doubt.

Physical health problems: Unaddressed childhood trauma can manifest in physical symptoms like chronic pain, autoimmune disorders, and stress-related illnesses.

Depression in Older Adults: The Importance of Therapy

Dissociation: This common coping mechanism aims to disconnect yourself from your traumatic memories and challenging emotions.

Self-Harm: If you've experienced childhood trauma, you are more at risk for committing self-harming behaviors in an attempt to deal with emotional pain.

Perfectionism: You may feel driven to perfectionist tendencies as a way to gain a sense of control over your life.

Again, not everyone who experiences childhood trauma will exhibit these behaviors, but if you're a victim of trauma, there's a good chance you can relate to many. Depression from childhood trauma requires the help and support of a qualified mental health professional. With the right clinician by your side, you can heal and move forward to live a more fulfilling life.
Understanding Depression in Adolescents: Signs, Symptoms, and Treatment Options
We Can Help You Overcome Depression From Childhood Trauma

At BOLD Health, we offer high-quality, individualized depression treatment in San Diego tailored to your individual needs. When you partner with us, you'll receive compassionate, understanding, comprehensive mental health care. We'll help you get to the root of your mental health concerns and walk with you through the negative impacts of childhood trauma.

When determining the proper depression therapy in San Diego for yourself or a loved one, you want a team you can count on. Because our facility is physician owned and operated, we can help you on several levels. Our options for depression treatment in San Diego include the following:

individual therapy

group therapy

family therapy

medication management

intensive outpatient program (IOP in San Diego)

ketamine treatment

The circumstances that brought you to our door are unique. We take the time to understand not only your experiences but also your genetic, structural, biological, and medical makeup so we can tailor the perfect depression treatment in San Diego specifically to you.

Contact us to learn more about how we can help you get to the root cause of your depression through depression therapy in San Diego so you can live the life you deserve.

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Understanding the Link Between Childhood Trauma & Depression

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Depression from childhood trauma is not uncommon. Unaddressed trauma could manifest in ways you don't associate with your painful experiences.

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This video is a great source of a quick reference on who and what a mandated reporter does.

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This site talks about how you keep Michigan children safe. It has hotline resources, trainings and online reporting resources.

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Important documents and links for people that have established relationships with children based on their profession.

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This web site has a lot of information not only for mandated reporting, but about all the laws for child welfare, foster care, adoption, etc.. This site talks about who are mandated reporters, training requirements for mandated reporting, institutional responsibility to report, standards for making a report, privileged communications, inclusion of reporters name and disclosure of their identity.

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We’re sorry, we can’t find the page you’re looking for. It might have been removed, changed its name, or is otherwise unavailable.

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This is a site that you can take a mandated reporting training class in. Also if you are looking for a refresher on the subject.

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I found this poster that I thought was a great resource for my job in the office and in each of our classrooms.

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I found this poster that I thought was a great resource for my job in the office and in each of our classrooms.

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This was given to all of us teachers after we experienced a death of a child in our preschool program. This has a lot of great information for parents to help their child with death.

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This article talks about the brain states we go through when we are going a traumatic event. Understanding the internal brain-body states that produces certain behaviors in children and ourselves.

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Conscious Discipline- The Three Brain States - Carmel Mountain Preschool

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The Conscious Discipline Brain State Model becomes a framework for us to understand the internal brain-body states that are most likely to produce certain behaviors in children and in ourselves

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Understanding trauma and to be able to teach children with trauma you have to reach them first. This is a webinar you can take that Dr. Becky Bailey does for teachers on how to reach their children in the classroom. It talks about connection and resilience interventions.

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Understanding Trauma: Reaching and Teaching Children with Trauma

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To access this content, you must purchase Understanding Trauma Webinar Series, Site License or Understanding Trauma Webinar Series, Individual.

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The effects of trauma are life lasting and hard to deal with most times without outside help. Everyone has some kind of trauma at least one time in their life that they live with. The event is important but it's the way you respond to the experience how the outcome will be. Everyone is different.

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This video talks about the survival state of the brain and what its function is when you are in fight,flight or freeze state. It talks about ways to cope and how to help someone in this state.

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VIDEO 1 Conscious Discipline Mini Session 1 Intro: Survival State

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This conscious discipline mini session video was about the emotional state. It talks about what we know when we are stressed and how your brain reacts in those moments. None of us are immune to stress and trauma. We can only learn when we are physical and emotionally safe. We draw on our knowledge to figure out what our next steps are and we need to learn how to recognize it first. I love conscious discipline not only for myself and in my family but to use it in my classroom has done wonders to connect with my children every year and to help families.

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VIDEO 2 Conscious Discipline Mini Session 2 : Emotional State

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This is a great resource to give to parents. It is very informative.

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Childhood bullying is very common. This article talks about how common it is and gives the statistics of bullying in childhood. It talks about the psychological effects it has on our brains in adulthood. The effects are just as bad as any other abused in childhood.

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Childhood bullying is so common that it may not seem like a big deal. Up to 35% of people are estimated to have experienced it at some point. By adulthood, we are generally expected to have "got over" it. But the mental health effects of being bullied can be serious and last a lifetime. One study has even suggested that, when it comes to mental health, bullying is as harmful as child abuse, if not worse.

Approximately 20% of people who have been bullied experience some kind of mental health problems later in life, even at the age of 50. While some of these, such as post traumatic stress disorder (PTSD), are easy to spot, others may be more difficult to recognise. These can range from inexplicable bouts of anger to a lifetime of feeling inferior to other people.

Although there has been an immense amount of research on bullying, most of it has focused on immediate effects, intervention and prevention. So we need more research on long-term effects and new forms of bullying, such as online abuse.

That said, severe long-term effects of bullying are relatively well documented. Research has shown that victims of bullying report more severe anxiety symptoms than others. Being bullied is also linked to social anxiety, which often lasts into adulthood and increases the risk of developing personality disorders.

Depression is another negative consequence of bullying , which might lead to suicidal ideation and even suicide attempts. So if you are struggling with depression or anxiety and have a history of being bullied, there may be a link.

Dom Ernest L Gomez/Shutterstock

One of the most severe consequences is post traumatic stress disorder (PTSD). Research has shown that 40.5% of girls and 27.6% of boys show PTSD symptoms at the time of being bullied. These individuals' torment can sometimes follow them into later life. This can be triggered by just remembering the bullying incident or by related stimuli, such as visiting their school as adults or by encountering their bully in a different environment.

Trust and self-esteem

While people with severe depression, anxiety or post traumatic stress disorder may actually seek help and uncover that bullying could have played a part in their mental health problems, for many other people the signs are more subtle.

Self-esteem is an aspect that is both a risk factor and a consequence of bullying. It is not hard to see that children who are suffering from repetitive bullying at school, at a time when they are still in the process of developing their personalities, could suffer a serious and lasting decline in self-esteem.

On the other hand, high self-esteem has been linked to bullying others. However, this effect seems to be moderated by other factors - high self-esteem is only linked to high bullying rates in schools which the students perceive to have a poor climate.

Another distinctive example is anger, which is a prerequisite of aggression and has been associated with both victimisation and perpetration of bullying. For the bullies, it is well recognised that, behind their abusive behaviour, lies the intention to hurt another individual - usually motivated by negative emotions such as aggression, anger and hostility. But repeated bullying can also make victims more angry, which in turn maintains the cycle of bullying. The main difference between bullies and victims is that bullies exhibit higher levels of proactive aggression (behaviour that anticipates a reward), whereas victims exhibit higher levels of reactive aggression (anger in response to a threat).

Bullying can also lead to health problems, alcohol and drug abuse, social withdrawal and severe trust issues. For many victims who are trying to overcome the experience, the loss of trust is perhaps the most challenging consequence. But if nobody stands up for you at the time of being bullied, you begin to lose trust in your peers - and that may be for life.

It is also important to note that bullying effects are often related. In other words, low self-esteem is related to depression, depression is related to suicidal ideation, and so on. Such relationships lead victims to experience not one, but multiple bullying effects during their victimisation period and in their adulthood.

Dealing with the past

So what should you do if you suddenly realise that bouts of anger or low self-esteem may have resulted from bullying that happened decades ago? One option is talking therapy or cognitive behavioural therapy. The latter involves training yourself to change your thinking and behaviour, tackling for example negative thinking, social phobia or low self-esteem.

hikrcn/Shutterstock

When it comes to anger, various studies have indicated that restorative justice techniques - a mediation between the victim and the offender while promoting discussion and forgiveness - could help. However, such practices can only benefit victims and bullies respectively if applied in a controlled environment, such as the school, by a trained member of staff.

Some individuals take their own initiative to face their bully or victim in adulthood and either apologise for their past behaviour or seek answers for their victimisation. However, they must keep in mind that such an encounter might have the exact opposite results. Research shows that bullies often maintain an aggressive behaviour in adulthood. Therapy or counselling are usually therefore much better ways to deal with the consequences.

Perhaps the most important thing in order to get over traumatic bullying experiences is to stop blaming yourself. There have been numerous studies indicating that this is very common and a result of wrongfully developed perceptions. For example, it is well established that overweight children suffer higher levels of bullying than others. Such individuals may view their body mass or inability to "stand up for themselves" as the reason they were picked on. If these victims do not accept their individuality and stop self blaming, it can be very hard to heal the wounds.

Being bullied as a child in school, which is such a huge part of an individual's world, is clearly a traumatic experience - it should come as no surprise that it may leave lasting scars. Luckily, there is plenty of help out there. And even if you don't want to embark on getting therapy, just identifying the negative thinking patterns and behaviour that the bullying may have triggered can ultimately help you change them and move on.

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Childhood bullying can cause lifelong psychological damage - here's how to spot the signs and move on

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Childhood bullying is so common that it may not seem like a big deal. Up to 35% of people are estimated to have experienced it at some point. By adulthood, we are generally expected to have "got over" it. But the mental health effects of being bullied can be serious and last a lifetime.

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Healthwest has youth and family services such as autism programs, disability services, medical, dental,pharmacy, lab, mental health services, substance abuse,veteran services and respite services.

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HealthWest offers youth and family services through a variety of approaches and strategies to better serve our community.

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This is a great article with a ton of information about childhood bullying. It talks about the research that is being done and what they have learned. The bullying statistics, in schools,cyberbullying,the types,suicide and the laws that are made to protect the ones being bullied.

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This section pulls together fundamental information about bullying, including:

Definition of Bullying

In 2014, the Centers for Disease Control and Department of Education released the first federal definition of bullying. The definition includes three core elements:

unwanted aggressive behavior

observed or perceived power imbalance

repetition or high likelihood of repetition of bullying behaviors

This definition helps determine whether an incident is bullying or another type of aggressive behavior or both.

Research on Bullying

Bullying prevention is a growing research field that investigates the complexities and consequences of bullying. Important areas for more research include:

Prevalence of bullying in schools

Prevalence of cyberbullying in online spaces

How bullying affects people

Risk factors for people who are bullied, people who bully others, or both

How to prevent bullying

How media and media coverage affects bullying

What We've Learned about Bullying

Bullying affects all youth, including those who are bullied, those who bully others, and those who witness bullying. The effects of bullying may continue into adulthood.

There is not a single profile of a young person involved in bullying. Youth who bully can be either well connected socially or marginalized, and may be bullied by others as well. Similarly, those who are bullied sometimes bully others.

Solutions to bullying are not simple. Bullying prevention approaches that show the most promise confront the problem from many angles. They involve the entire school community-students, families, administrators, teachers, and staff such as bus drivers, nurses, cafeteria and front office staff-in creating a culture of respect. Zero tolerance and expulsion are not effective approaches.

Bystanders, or those who see bullying, can make a huge difference when they intervene on behalf of someone being bullied.

Studies also have shown that adults can help prevent bullying by talking to children about bullying, encouraging them to do what they love, modeling kindness and respect, and seeking help.

Bullying Statistics

Here are federal statistics about bullying in the United States. Data sources include the Indicators of School Crime and Safety: 2019 (National Center for Education Statistics and Bureau of Justice) and the 2017 Youth Risk Behavior Surveillance System (Centers for Disease Control and Prevention).

How Common Is Bullying

About 20% of students ages 12-18 experienced bullying nationwide.

Students ages 12-18 who reported being bullied said they thought those who bullied them:

Had the ability to influence other students' perception of them (56%).

Had more social influence (50%).

Were physically stronger or larger (40%).

Had more money (31%).

Bullying in Schools

Nationwide, 19% of students in grades 9-12 report being bullied on school property in the 12 months prior to the survey.

The following percentages of students ages 12-18 had experienced bullying in various places at school:

Hallway or stairwell (43.4%)

Classroom (42.1%)

Cafeteria (26.8%)

Outside on school grounds (21.9%)

Online or text (15.3%)

Bathroom or locker room (12.1%)

Somewhere else in the school building (2.1%)

Approximately 46% of students ages 12-18 who were bullied during the school year notified an adult at school about the bullying.

Cyberbullying

Among students ages 12-18 who reported being bullied at school during the school year, 15 % were bullied online or by text.

An estimated 14.9% of high school students were electronically bullied in the 12 months prior to the survey.

Types of Bullying

Students ages 12-18 experienced various types of bullying, including:

Being the subject of rumors or lies (13.4%)

Being made fun of, called names, or insulted (13.0%)

Pushed, shoved, tripped, or spit on (5.3%)

Leaving out/exclusion (5.2%)

Threatened with harm (3.9%)

Others tried to make them do things they did not want to do (1.9%)

Property was destroyed on purpose (1.4%)

State and Local Statistics

Follow these links for state and local figures on the following topics:

International Statistics

According to the UNESCO Institute of Statistics:

One third of the globe's youth is bullied; this ranges from as low as 7% in Tajikistan to 74% in Samoa.

Low socioeconomic status is a main factor in youth bullying within wealthy countries.

Immigrant-born youth in wealthy countries are more likely to be bullied than locally-born youth.

Bullying and Suicide

The relationship between bullying and suicide is complex. The media should avoid oversimplifying these issues and insinuating or directly stating that bullying can cause suicide. The facts tell a different story. It is not accurate and potentially dangerous to present bullying as the "cause" or "reason" for a suicide, or to suggest that suicide is a natural response to bullying.

Research indicates that persistent bullying can lead to or worsen feelings of isolation, rejection, exclusion, and despair, as well as depression and anxiety, which can contribute to suicidal behavior.

The vast majority of young people who are bullied do not become suicidal.

Most young people who die by suicide have multiple risk factors.

For more information on the relationship between bullying and suicide, read "The Relationship Between Bullying and Suicide: What We Know and What it Means for Schools" from the CDC.

Anti-Bullying Laws

All states have anti-bullying legislation. When bullying is also harassment and happens in the school context, schools have a legal obligation to respond to it according to federal laws.

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This section pulls together fundamental information about bullying.

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This article gives a clear picture of the brain when someone is being bullied. It talks about the long - term changes that leads to cognitive and emotional deficits as serious as child abuse. This is a vicious circle that needs to be fixed.

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Brain research is revealing that bullying is more than just an unfortunate part of growing up. It can cause long-term changes to the brain that leads to cognitive and emotional deficits as serious as the harm done by child abuse.

Being bullied is a stressful experience. Victims of bullying often struggle with anxiety, depression, poor self-esteem, and drug abuse - during the bullying and well into adulthood.

It turns out that long-term changes to the brain may be behind these behavioral issues. Bullying can leave a lasting mark on the developing brain, and brain science is starting to show how devastating and persistent the scars of bullying can be.

Stressed Out

Bullying can alter levels of stress hormones, and research in animals and people shows how this can affect brain function.

Chronic stress in humans is a known risk factor for drug abuse, and scientists want to know if being a victim of bullying poses a similar risk. To study this, scientists like Klaus Miczek, a psychologist at Tufts University, model bullying in rodents, often by putting an older, more aggressive rat or mouse in the cage of a juvenile animal. The dominant animal pushes the younger one around, maybe even biting it to show it who's boss.

Miczek has found that bullied animals have higher amounts of the stress hormone corticosterone in areas of the brain that process rewarding stimuli, like drugs of abuse. He also saw that too much of the hormone can remain in these brain areas long after the stress has ended, possibly leading to a propensity to abuse drugs. When given access to drugs like cocaine and alcohol, Miczek's bullied rodents took more of the drugs than non-bullied animals, even months later when they were adults.

The most interesting aspect of this research, Miczek says, is how little social stress it takes to lead to a persistent, long-lasting effect. "In rats, it only requires four episodes of social stress, which are five minutes long each," he says. "And the effects of that are seen into adulthood."

Bullying can also alter stress hormones in humans. In a long-term study of teenagers, Tracy Vaillancourt, a psychologist at the University of Ottawa, found that bullied boys and girls have abnormal levels of cortisol compared to their non-bullied peers. Abnormal cortisol levels can weaken the immune system and can even kill nerve cells in the hippocampus, a brain region involved in memory. In fact, Vaillancourt has found that bullied teens perform more poorly on memory tests designed to examine hippocampal functioning compared to their non-bullied peers, suggesting that their abnormal cortisol levels might be affecting their brains.

Immune to Stress

Social stress also has a dramatic effect on immune system functioning, which in turn can negatively affect brain function.

When exposed to stress, our bodies produce more white blood cells, which in turn produce and release more pro-inflammatory substances that normally function to help the body fight off infection. In the case of chronic stress, scientists think the body produces too many white blood cells, resulting in sustained production and release of pro-inflammatory substances.

"When you experience chronic social stress, you have the immune response, but it doesn't turn off properly," says Scott Russo, a neuroscientist at the Icahn School of Medicine at Mount Sinai. "The immune system ramps up and doesn't shut down, and that then causes damage such as nerve cell death. In vulnerable individuals, these changes can last for months following the stress."

However, Russo found that some animals are resilient in the face of social stress. When exposed to an aggressive adult, these individuals had fewer white blood cells and pro-inflammatory substances. Russo thinks there is some mechanism by which resilient individuals dampen negative inflammatory responses to stress.

To illustrate the connection between the immune system and behavioral resilience, Russo and his colleagues took immune system cells from resilient mice and injected them into stressed mice. They found that, following the injections, stressed mice showed less social avoidance and anhedonia, the inability to feel pleasure. In effect, the stressed animals received the benefits of the resilient animal's immune system.

The results show that social stress can lead to a heightened immune response which, in turn, can lead to changes in behavior. Russo's research suggests that dysregulation of the immune system, like that linked to chronic social stress, can lead to psychiatric disorders, such as depression and anxiety.

A Vicious Circle

Not only do victims of bullying experience heightened stress and immune responses, but research in animals suggests that they might also be more likely to become bullies themselves.

Researchers at the University of Texas at Austin studied social stress in hamsters and found that juvenile hamsters who were bullied by an adult became more aggressive toward smaller animals, while being fearful and subordinate with hamsters of similar size or larger.

"Basically, a bully victim becomes a victimizer," says Yvon Delville, who led the study.

Delville also examined the hamsters' brains and found that socially-stressed hamsters showed changes in the levels of the neurotransmitters vasopressin and serotonin. In people, high levels of vasopressin are associated with increased aggression, while serotonin is known to inhibit aggression.

Bullied hamsters had lower levels of vasopressin and higher levels of serotonin than their non-bullied littermates. Delville is currently determining how these changes in neurotransmitter levels lead to enhanced aggression, and he suspects the aggression is secondary to changes in brain areas that govern more general features of behavior, such as impulse control.

Delville's results suggest adolescence may be a sensitive period for the development of aggressive behavior in adulthood, with chronic social stress making it more likely that victims will become bullies themselves. He says his results support what is often observed in humans: where you have violence against children, you'll find children becoming violent.

"People argue that bullying is a rite of passage or it builds character, but that idea is so misguided," Vaillancourt says. "Our work supports the idea that bullying is actually a seriously harmful event in a child's life. It's a public health issue, because it affects so many children adversely and the biological evidence supports that it confers a risk for future health problems."

Not all bullied kids have long-term damage to their brains or changes in their behavior, but those who do may carry these neurological scars for a lifetime. Brain research is helping to recast bullying as a serious form of childhood trauma with the potential to cause long-term chemical and structural damage to the brain.

About the Author

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Brain research is revealing that bullying is more than just an unfortunate part of growing up. It can cause long-term changes to the brain that leads to cognitive and emotional deficits as serious as the harm done by child abuse. Being bullied is a stressful experience.

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This video gives you the basics about bullying and what it looks like in all levels. Cyber, verbal, physical and social. This is a good video to start with for kids for their level of understanding.

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This article talks about what bullying is, the types,the signs of someone being bullied, what makes us vulnerable to bullying, the causes and that you're not alone!

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Bullying is repetitive, intentionally aggressive behavior that causes hurt or discomfort to another person. Learn more about bullying with JED.

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This article talks about cyberbullying. The general statistics are discussed along with school and adult statistics. This article has how to recognize and to prevent cyberbullying.

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15 Alarming Cyberbullying Statistics - Panda Security

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Explore key cyberbullying statistics and prevention strategies for adolescents, adults and schools. Learn how to combat online harassment effectively.

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This is a quick video on how bullying affects the brain and how we as parents can help our child with the effects it has them. It shows how our brain is shaped like our fist and the parts that bullying effects.

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This site is great because it gives you step by step on how to report child abuse, neglect and exploitation of children. It gives you a reporter's guide and what happens after you report.

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Reporting Abuse | Support & Resources | Children’s Advocacy Center of Suffolk County

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Anyone who suspects a child is being abused can and should file a 51A Report with the Massachusetts Department of Children and Families (DCF), but professionals who have been designated as mandated reporters are required by law to do so.

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I loved this site because it really put things in perspective on the statistics on child abuse in all aspects. This is only in 2021 but the numbers are astounding. More than 600,000 children are abused each year. It talks about the most vulnerable is the youngest being children in the first year of life. It goes through every type of abuse.

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I found this poster that I thought was a great resource for my job in the office and in each of our classrooms.

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This site is for mandated reporters or others such as family members to go to for an online option to report child abuse.

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Online Option for Mandated Reporters

For mandated reporters, it can be difficult to call and make a report of suspected abuse or neglect knowing it could take up to 30 minutes or more to complete the process by phone.

Thanks to a new online program, those reports can now be completed online. If you are a mandated reporter, please register at your earliest convenience. It doesn't take long and will save you time later if you have to make a report. The website is available at all hours, every day.

When filing online, reporters have no obligation to file an additional written report (DHHS-3200) or to call the hotline. The hotline remains open for oral reports, especially emergencies. Online reporting is simply a second option.
To register for the Michigan Online Reporting System, click here.
Additional information about the Michigan Online Reporting System or reporting suspected child abuse and neglect in Michigan, mandated reporters is available here.

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Online Option for Mandated Reporters - Michigan Education Association

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For mandated reporters, it can be difficult to call and make a report of suspected abuse or neglect knowing it could take up to 30 minutes or more to complete the process by phone. Thanks to a new online program, those reports can now be completed online.

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In this article they talk about the landscape of childhood trauma and the consequences it can have on your mental, emotional and physical wellbeing.

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Childhood Trauma & Its Lifelong Impact: 12 Resources

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By better understanding childhood trauma, therapists can recognize its signs and guide clients on a path toward healing and resilience.

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This is a CATS assessment stands for Child and Adolescent Trauma Screen. There are 3 different ones on this site.

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Overview

The Child and Adolescent Trauma Screen (CATS) questionnaire is a brief, freely accessible screening instrument based on the DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). It is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS).

Author/Publisher Details

The developers are Prof. Lutz Goldbeck (Ph.D.) & Prof. Lucy Berliner (Ph.D.)

The CATS Consortium consists of Prof. Lucy Berliner (Ph.D.), Cedric Sachser (Ph.D.), Elisa Pfeiffer (Ph.D.), Prof. Tine Jensen (Ph.D.), Prof. Elizabeth Risch (Ph.D.), Prof. Rita Rosner (Ph.D.), Prof. Lutz Goldbeck (Ph.D.)

Corresponding Author: Cedric Sachser, Ph.D., cedric.sachser@uniklinik-ulm.de

Date

Description

The CATS is based on the DSM-5 and is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS). The CATS can be administered as a self-report or as an interview and is appropriate for pre-schoolers, children and adolescents. There is a self-report measure for 7-17 year old children/youth, and two caregiver versions; one for 3-6 year old children and one for 7-17 year old children/youth. The younger child version conforms to the DSM-5 3-6 year old PTSD symptom criteria. The interview format may be preferable with younger children or youth with reading comprehension challenges.

The CATS has 15 items measuring traumatic events, 20 items measuring DSM-5 PTSD symptoms, and 5 items measuring psychosocial functioning, and can be administered in approximately 15 minutes.

The CATS is available in several languages, including German, Norwegian, Spanish, Swedish, Arbabic, Dari, Farsi, Paschtu, Tigrinya, Turkish. Please contact the corresponding author for further information on these translations.

Access

The measure can be freely accessed by clicking below. There are no copyright or licensing fees associated with the assessment. Feel free to contact the corresponding author for other versions of the CATS.

Scoring and Interpretation

The CATS is a screening instrument for posttraumatic stress symptoms (PTSS) in children and adolescents. A clinical diagnosis of PTSD should not be based on completion of the CATS alone. Positive results on the CATS should be followed up with a semi-structured clinical interview.

To score the CATS, respondents need to verify whether they have experienced at least one potential traumatic event (PTE) (A-criterion). For those without any reported PTE the assessment is finished. Those respondents with at least one endorsed PTE indicate their (child's) most distressing event and rate their (child's) stress symptoms (criteria B, C, D and E) on page 2. Additional items describe any restrictions of functioning in different domains. The 4-point symptom response scales indicate the reported frequency/severity of each symptom. There are differences in calculating the scores for children from age 7 and adolescents vs. preschool children (see below).

Using the DSM-5 algorithm:
You can use the stop light sheet or scoring sheet to guide you through the process.

Using the total symptom score:
The determination of preliminary cutoff scores was done based on an estimation derived from the validation of a previous DSM-IV based questionnaire (see below).

Ages 3-6: The total symptom score is calculated by summing up the items 1-16 (possible range = 0-48). We recommend to use a cut-off ≥ 16 as indication of a clinically relevant level of symptoms in preschool children.

Ages 7-17: A total symptom score is calculated by summing up the raw scores of items 1-20 (possible range = 0-60). We recommend to use a cut-off ≥ 21 as indication of a clinically relevant level of symptoms.

Include scoring for total scores and subscale scores as well as information on diagnostic or severity cut offs (if any).

Psychometrics

An international validation study (Sachser et al., 2017) proved good to excellent reliability with α ranging between .88 and .94. The convergent-discriminant validity pattern showed medium to strong correlations with measures of depression (r = .62-.82) and anxiety (r = .40-.77) and low to medium correlations with externalizing symptoms (r = −.15-.43) within informants in all language versions. Using CFA the underlying DSM-5 factor structure with four symptom clusters (reexperiencing, avoidance, negative alterations in mood and cognitions, hyperarousal) was supported (n = 475 for self-report; n = 424 for caregiver reports).

Key/Core References

Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jungbluth, N., Risch, E., ... & Goldbeck, L. (2017). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of affective disorders, 210, 189-195.
https://pubmed.ncbi.nlm.nih.gov/28049104/

Nilsson, D., Dävelid, I., Ledin, S., & Svedin, C. G. (2020). Psychometric properties of the Child and Adolescent Trauma Screen (CATS) in a sample of Swedish children. Nordic Journal of Psychiatry, 1-10. https://www.tandfonline.com/doi/full/10.1080/08039488.2020.1840628

Akkuş, P. Z., Serdaroğlu, E., Kömürlüoğlu, A., Asena, M., Bahadur, E. İ., Özdemir, G., ... & Özmert, E. N. (2021). Screening traumatic life events in preschool aged children: cultural adaptation of Child and Adolescent Trauma Screen (CATS) Caregiver-report 3-6 years version. Turkish Journal of Pediatrics, 63(1). http://www.turkishjournalpediatrics.org/abstract.php?id=2262

Manual

Administration of the CATS should be conducted as a clinical encounter. The CATS may be part of routine assessment procedures and/or occur at a later point with the assigned clinician. It may be used as a stand-alone screening or be part of a larger assessment and clinical interview. The Clinical Guide for administering the CATS is available here

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The Child and Adolescent Trauma Screen (CATS) questionnaire is a brief, freely accessible screening instrument based on the DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). It is a measure of potentially traumatic events and of posttraumatic stress symptoms (PTSS). The developers are Prof. Lutz Goldbeck (Ph.D.) & Prof. Lucy Berliner (Ph.D.)

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This article talks about what is a trauma screening or process. It talks about if this screening tool types and engaging the families in the screening process.

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The National Child Traumatic Stress Network

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What is a Trauma Screening Tool or Process?

Trauma screening is designed to be able to be administered to every child within a given system (such as child welfare) to determine whether he or she has experienced trauma, displays symptoms related to trauma exposure, and/or should be referred for a comprehensive trauma-informed mental health assessment. Trauma screening can include a particular tool or a more formalized process. Trauma screening should evaluate the presence of two critical elements: (1) Exposure to potentially traumatic events/experiences, including traumatic loss, and (2) Traumatic stress symptoms/reactions.

Not all children who experience negative events suffer posttraumatic or trauma-specific reactions as a result. Trauma screening should measure a wide range of experiences and identify common reactions and symptoms of trauma (e.g., PTSD, dissociation), as well as other commonly reported difficulties (e.g., anger, behavior problems, depression, anxiety). With proper training, professionals or paraprofessionals from various child-serving systems-healthcare, schools, home visiting programs, and domestic violence shelters-can administer the screening.

Screening typically covers the following types of traumatic stress reactions:

Avoidance of trauma-related thoughts or feelings

Intrusive memories of the event or nightmares about the event

Hyper-arousal or exaggerated startle response

Irritable or aggressive behavior

Behavioral problems

Interpersonal problems

Other problems based on the developmental needs and age of the child

Types of Screening Tools

Providers may administer trauma screening in a number of ways depending on the age and developmental stage of the child and on the child's relationship with the caregiver and other collateral informants in his or her life. For example, with very young children, it is difficult to screen specifically for "trauma symptoms." Rather, a provider may screen for exposure to traumatic events and social and emotional difficulties, such as attachment difficulties or mood dysregulation. As the child gets older, it may be more appropriate to screen specifically for trauma symptoms.

Most screening tools are developed for use by professionals with a range of training and experience. Providers using a screening tool should consider (1) factors such as the child's age, language skills, and cognitive capabilities; (2) whether the child is among the populations for which the tool has been validated and normed; and (3) if there are other factors that might affect the reliability and validity of the tool for this particular child.

Child-Completed Tool (Self-Report). Child-completed tools are appropriate for children, typically ages eight and above, who are able to read and complete the questions. These measures provide the child with an opportunity to verbalize his or her responses aloud or in writing.

Caregiver-Completed Tool. For infants, toddlers, young children (ages 0-8), or children with developmental delays, it is more appropriate to have a caregiver complete the trauma screening either by providing written responses to the items or through an interview by the provider.

Provider-Completed. The caseworker, clinician, or other professional can administer certain tools while reviewing and integrating available information on a child (e.g., court reports, interviews with caregivers and teachers, other questionnaires, and behavioral observations). These tools can be useful in consolidating a range of information in one place so that it is readily accessible.

Engaging Families in the Screening Process

To engage families in the screening process, the individual administering the tool should consider the following:

Explain the purpose and use of the screening tool and process. Say why you need to know this information, how you will use what you gather, how it may benefit the child and family, and who will have access to the information in the future. Emphasize that the information is confidential in most cases, unless the child endorses harm to self or others or the clinician has concerns regarding child abuse.

After the child or family has completed the trauma screening, share the results and show how you are using the information. For example, "It's clear from the forms that you filled out that your daughter is having a really hard time with nightmares and fear of things that remind her of her brother getting hurt. We call this Posttraumatic Stress. To help her, I would like to refer you to a therapist who specializes in treating children with these problems."

Make sure to thank the child for completing the tool or process, particularly if he or she disclosed a new trauma. Explain that the child's feelings and trauma reactions are normal and expected, given what he or she has lived through.

Consider the potential burden of the trauma screening to family members in terms of time and effort, and highlight the potential benefits, such as helping to link them to appropriate providers and services. Some families may be discouraged by the process; others may be comfortable with it. When providers explain the purpose and use of the screening tools and share the results, they enhance the benefits to families.

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Trauma screening should measure a wide range of experiences and identify common reactions and symptoms of trauma.

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This article is a screening tool to identify children who need help. It has a downloadable screener on this site.

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The Child Health and Development Institute of Connecticut, Inc.

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Many children suffer from trauma in silence and alone. Screening is a way to identify children that are experiencing high levels of distress and may need additional support to overcome trauma exposure. Screening is also important to facilitate discussions with youth and caregivers about trauma, to provide factual information about traumatic stress, and to offer a range of resources to families, including evidence-based treatment when indicated.
CHDI joined with the Connecticut Department of Children and Families and Yale to develop a brief trauma screening measure for children called the The Child Trauma Screen (CTS) Child Trauma Screen (CTS; formerly called the Connecticut Trauma Screen).
The CTS is being used by behavioral health providers, pediatricians, school staff, child welfare workers, and juvenile justice staff to identify children who may be suffering from trauma exposure and need more comprehensive assessment or treatment.

The CTS is:
Validation

1. Brief (10 items)

2. Free to use

3. Based on research and evidence

4. Available for children age 6-17 (a version for children 3 to 6 is under development)

5. Intended for use by intake staff, clinicians, child welfare workers, juvenile probation officers, pediatric providers, school personnel, case managers, care coordinators, or other professionals interesting in screening children for trauma.

The CTS is NOT a comprehensive screening tool or a clinical assessment, and does not screen for all types of trauma exposure or all traumatic stress reactions. Those using it should be trained in child trauma and screening, including managing disclosures and requirements for mandated reporting of suspected child abuse and neglect.
Additional Resources
The CTS is supported by three peer-reviewed studies that indicate that the CTS is reliable and has good to excellent psychometric properties as a brief screen. Cut points maximizing sensitivity and specificity are available. Additional details are in the CTS Information & FAQ below, and copies of the CTS forms may be downloaded at the link below.
CTS development was funded in part through the Department of Human Services, Administration for Children and Families, Children's Bureau, Grant #90CO1069.

Lang, J. M., Connell, C. M., & Macary, S. (2021). Validating the Child Trauma Screen Among a Cross-Sectional Sample of Youth and Caregivers in Pediatric Primary Care. Clinical Pediatrics, 60(4-5), 252-258. (View Abstract)

Lang, J. M., & Connell, C. M. (2018). The Child Trauma Screen: A Follow-up Validation. Journal of Traumatic Stress. doi:10.1002/jts.22310 (View Abstract)

Lang, J. M., & Connell, C. M. (2017). Development and Validation of a Brief Trauma Screening Measure for Children: The Child Trauma Screen. Psychological Trauma: Theory, Research, Practice, and Policy, 9(3), 390-398. doi:10.1037/tra0000235 (View Abstract)

For more information about the CTS, please contact Jason M. Lang, Ph.D. ( jalang@uchc.edu) and/or Christian M. Connell, Ph.D. ( cmc128@psu.edu ​).

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Child Trauma Screen (CTS; formerly called the Connecticut Trauma Screen) is a brief trauma screening measure for children used by behavioral health providers, pediatricians, school staff, child welfare workers, and juvenile justice staff to identify children who may be suffering from trauma exposure and need more comprehensive assessment or treatment.

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This is a great site for various checklists and screening tools. It includes life events checklist, ACES study and checklist, trauma screening checklist, children's hope scale and a trauma stress screening.

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The Michigan Domestic & Sexual Violence Prevention and Treatment Board administers state and federal funding for domestic violence shelters and advocacy services, develops and recommends policy, and develops and provides technical assistance and training.

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This article has a lot of information. It talks about the evidence for screening for trauma, the recommended approach to screening and data. It has a road map of care for pediatric traumatic stress in a primary care setting from 6-18 years.

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Screening for Trauma in Pediatric Primary Care

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Provided the high prevalence of trauma exposure in childhood as well as the risk for morbidity, this article examines evidence, a recommended approach, and key implementation factors relevant to screening for trauma in pediatric primary care. A…

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This is a trauma screening questionnaire.

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This is a questionnaire for childhood trauma. It tells you what it is used for, how to use it,, when who can use it.

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What is the Childhood Trauma Questionnaire?

The Childhood Trauma Questionnaire is a nifty tool that allows mental healthcare professionals and trauma experts to get to know their patients better to help structure their discussions with them as they progress through their treatment program.

This questionnaire is the revised version of what David P. Bernstein and his group created before. It used to be a seventy-item questionnaire, but this one is the twenty-eight-item version.

The questions revolve around five different types of childhood trauma, which are: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Here are some of the items that need to be answered by the patient:

I did not have enough to eat when

I was hit so hard that I had to see a doctor

My parents were too drunk/too high to take care of me

I was punished with a belt, board, cord, or another hard object

My family said hurtful or insulting things to me

Someone molested me

Someone tried to make me do sexual things or watch sexual things

Someone in my family hated me

Most of these items are emotionally challenging, so do not be surprised if your patient has a hard time answering this questionnaire.

Printable Childhood Trauma Questionnaire

Download this Childhood Trauma Questionnaire and develop a better understanding of your client's childhood experiences.

How to use the Childhood Trauma Questionnaire

Administer this questionnaire to your patient.

There are two ways to go about administering this questionnaire to your patient:

You can conduct this like an interview during your first appointment with them. If you opt for this, do not expect them to answer. Given that childhood trauma is a difficult subject to talk about, even among close family/friends, it's even more complicated when talking about it to professionals and strangers. Before anything, you have to make them feel they can trust you and that your clinical space is safe for them.

The second choice is to hand them a copy of the questionnaire and have them answer it on time. This gives them the distance, space, and time to think about their childhood traumas and answer accordingly. Just make sure to agree as to when you should receive a fully-accomplished questionnaire.

Now, how do they answer the items? It's simple. They just have to select any one of the following per item:

Some items have the inverse, though. These specific items are Items 2, 5, 7, 13, 19, 26, and 28. So, "Never true" is equal to 5, and "Very often true" is equal to 1.

Calculate the scores.

Physical Abuse: Items 9, 11, 12, 15, and 17

Emotional Abuse: Items 3, 8, 14, 18, and 25

Sexual Abuse: Items 20, 21, 23, 24, and 27

Physical Neglect: Items 1, 2, 4, 6, and 26

Emotional Neglect: Items 5, 7, 13, 19, and 28

Once you receive a fully-accomplished questionnaire, it's time for you to calculate the scores. You will be tallying the scores per childhood trauma type, and they are arranged as such:

Don't forget the Items with the inverse scoring!

Besides those five categories, there is another one called "Minimization/Denial," which tries to measure if the patient is still positing that their family is great despite having answered items related to family that would say otherwise.

For that section, you only need to look at Items 10, 16, and 22. For each of these, if the patient answers "Very often true," it's equivalent to 1 point. If they picked other answers, then it's equivalent to 0. The maximum score that they can get for Minimization/Denial is 3.

As for interpreting the scores, here are the cut-off scores and designations per type:

Just so you know, if the level of abuse is "None" for the particular childhood trauma type, it doesn't mean that they don't have trauma. Always refer to their answers. There might be something there beyond what the number tries to say.

Determine the next steps based on the scores.

Once you have calculated the scores, the next thing is to determine what you can do for your patient to help them work through their childhood traumas. For example, suppose they scored high regarding emotional abuse and neglect. In that case, you might want to create a plan where you provide the necessary worksheets and discussions needed to help them develop skills related to regulating their emotions. Maybe you would like to give them self-esteem exercises. Again, what you will do will be based on their scores. Tailor-fit your care plan to your patient.

Childhood Trauma Questionnaire Example

Now that you know all there is to know about the questionnaire, it's best that you see what it generally looks like, so here is an example of a filled-out Childhood Trauma Questionnaire sample. Do note that the answers that you see in this example are based on a fictional patient. This is merely for educational and demonstrative purposes. If you like what you see here and would like to add the Childhood Trauma Questionnaire to your roster of assessments, then we recommend that you visit the Pearson official website to purchase an official Childhood Trauma Questionnaire kit.

When does one typically issue the Childhood Trauma Questionnaire?

The Childhood Trauma Questionnaire is normally used during a patient's initial assessment. This is when the healthcare professional doesn't know anything about the patient, so to find ways to help them work through their trauma, professionals tend to issue assessments for them to answer to get to know the patient and have them open up.

The questionnaire is not just used to get the patient to open up during discussions. This questionnaire is also used when healthcare professionals are at the point where they are supposed to develop a care plan for their patients. This is one of the best times to issue this questionnaire to their patients because the scores they will get will help shape what goes into their respective care plans.

Who can use the Childhood Trauma Questionnaire?

The following healthcare professionals can use the Childhood Trauma Questionnaire for their work:

(Clinical) Psychologists

Psychiatrists

Counselors

(Mental Health) Therapists

So long as the healthcare professional is highly trained in dealing with and caring for patients who have had childhood traumas as well as those with PTSD, they are more than welcome to use this questionnaire.

Psychometricians and researchers can also use fully-accomplished questionnaires to determine the commonalities and outcomes of childhood trauma regarding how people think, act, and what they feel like years after going through traumatic experiences. This can also be used by them to evaluate the efficacy of care plans implemented by professionals.

What are the benefits of using the Childhood Trauma Questionnaire?

It can help patients open up to healthcare professionals.

Getting to know the patient is the first step for any healthcare professional focusing on helping patients work through their problems, especially traumas. But that first step may not be easy. Depending on the patient, it might just be a massive mountain to climb, given that traumas are not exactly things people are normally willing to discuss.

Using assessments such as the Childhood Trauma Questionnaire helps them open up because having them answer assessments is a way to get to know patients, even if only you'll get a simple background of them. The Childhood Trauma Questionnaire can frame discussions with the patient moving forward and get them to elaborate on their traumatic experiences. Just make sure to assure them that everything will be kept confidential, there won't be any judgment, and that you can be trusted.

It gives the professional a comprehensive look at the patient's background.

Concerning the Childhood Trauma Questionnaire being a good assessment to help you get to know the patient, the questionnaire looks at five childhood trauma types. This means that the questionnaire will help you understand your patient better by giving you perspective on different aspects of life that were impacted by their traumatic experiences.

Were they sexually abused? Were they emotionally hurt by their loved ones or by other people? Were they physically harmed by their loved ones or by other people? By learning about these things, especially during subsequent appointments where they elaborate on their answers, you'll be able to have a better understanding of your patient, their traumatic experiences, how these experiences have impacted their view of themselves, and how they cope.

It helps professionals create tailor-fitted treatment plans.

To jump off the point about getting a comprehensive understanding of the patient, this leads to making a comprehensive care plan that is tailor-fit for the patient. By having a well-rounded view of the patient, you can determine what the patient needs to do.

Do they need to take self-esteem exercises? Do they need to learn skills related to managing their emotions? Do they need anger management and related programs to combat anger episodes, crying episodes, etc.?

These are just some of the questions you might be able to answer when you consider the scores for the five types of childhood trauma on the questionnaire and the conversations you have had with your patient.

Why use Carepatron for trauma-related software?

If you work in psychology and mental health, especially if you specialize in caring for patients who are trying to work through their trauma, then you'd be elated to know that Carepatron is a treasure trove of tools that streamline your work.

From guides about assessments (like this one for the Childhood Trauma Questionnaire) to actual assessments, from worksheets to general treatment plans, we have a wide variety of instruments and documents that should help you with your work!

Not only that, Carepatron has a highly secure storage system that you can take advantage of! The storage system allows you to store your files in a HIPAA-compliant manner and you can nominate the people who can access them besides you!

If you have purchased the Childhood Trauma Questionnaire from Pearson, you may store fully-accomplished questionnaires through us! You can even store blank questionnaires that you can whip out anytime, anywhere, on any capable device you might have, so long as you have internet access. This is especially great if you are conducting appointments outside your hospital or clinic!

Convenience. Accessibility. Security. You get all three with Carepatron.

I plan on using this for my practice. May I know how old the patient must be for me to use this?

I plan on using this for my practice. May I know how old the patient must be for me to use this?

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Childhood Trauma Questionnaire & Example

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Before you can help your patient work through their trauma, you need to understand them first. Issue this Childhood Trauma Questionnaire to your patient to get a bit of their background, then work on getting to know them from there during subsequent sessions!

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This is a trauma screening checklist from the Michigan Department of Health and Human Services for ages 6-18 years of age.

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This is a trauma screening checklist for ages 0-5 identifying children at risk.

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This article has great information about trauma interventions in a classroom, creating a sensitive classroom, 6 key principles, interventions and the essence of being real.

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The six key principles of a trauma-informed approach and trauma-specific interventions address trauma's consequences and facilitate healing.

Trauma-Informed Approach

According to the concept of a trauma-informed approach, "A program, organization, or system that is trauma-informed:

1. Realizes the widespread impact of trauma and understands potential paths for recovery;

2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4. Seeks to actively resist re-traumatization."

A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing.

Six Key Principles of a Trauma-Informed Approach

A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific:

1. Safety

2. Trustworthiness and Transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice and choice

6. Cultural, Historical, and Gender Issues

From this perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma. Consistent with this definition of recovery, services and supports that are trauma-informed build on the best evidence available and consumer and family engagement, empowerment, and collaboration.

Trauma-Specific Interventions

Trauma-specific intervention programs generally recognize the following:

The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery

The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety

The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

Known Trauma-Specific Interventions

Following are some well-known trauma-specific interventions based on psychosocial educational empowerment principles that have been used extensively in public system settings. Note that these interventions are listed for informational and educational purposes only. MentalHealth.org does not endorse any specific intervention.

Addiction and Trauma Recovery Integration Model (ATRIUM)

ATRIUM is a 12-session recovery model designed for groups as well as for individuals and their therapists and counselors. The acronym, ATRIUM, is meant to suggest that the recovery groups are a starting point for healing and recovery. This model has been used in local prisons, jail diversion projects, AIDS programs, and drop-in centers for survivors. ATRIUM is a model intended to bring together peer support, psychosocial education, interpersonal skills training, meditation, creative expression, spirituality, and community action to support survivors in addressing and healing from trauma.

Dusty Miller, author and creator of ATRIUM, is available for training, consultation, workshops, and keynote presentations. She works with groups that address issues of self-sabotage, traumatic stress, trauma re-enactment, substance abuse, self-injury, eating disorders, anxiety, body-based distress, relational challenges, and spiritual struggles.

Learn more about ATRIUM and Dusty Miller.

Essence of Being Real

The Essence of Being Real model is a peer-to-peer approach intended to address the effects of trauma. The developer feels that this model is particularly helpful for survivor groups (including abuse, disaster, crime, shelter populations, and others), first responders, and frontline service providers and agency staff.

The developer feels that this model is appropriate for all populations and that it is geared to promoting relationships rather than focusing on the "bad stuff that happened."

The Sidran Institute provides educational materials, training, and implementation support.

Risking Connection

Risking Connection is intended to be a trauma-informed model aimed at mental health, public health, and substance abuse staff at various levels of education and training. There are several audience-specific adaptations of the model, including clergy, domestic violence advocates, and agencies serving children.

Risking Connection emphasizes concepts of empowerment, connection, and collaboration. The model addresses issues like understanding how trauma hurts, using the relationship and connection as a treatment tool, keeping a trauma framework when responding to crises such as self-injury and suicidal depression, working with dissociation and self-awareness, and transforming vicarious traumatization.

The Sidran Institute provides educational materials, training, and implementation support.

For more information, visit Risking Connection.

Sanctuary Model

The goal of the Sanctuary Model is to help children who have experienced the damaging effects of interpersonal violence, abuse, and trauma. The model is intended for use by residential treatment settings for children, public schools, domestic violence shelters, homeless shelters, group homes, outpatient and community-based settings, juvenile justice programs, substance abuse programs, parenting support programs, acute care settings, and other programs aimed at assisting children.

The developer indicates that the Sanctuary Model's approach helps organizations create a truly collaborative and healing environment that improves efficacy in the treatment of traumatized individuals, reduces restraints and other coercive practices, builds cross-functional teams, and improves staff morale and retention.

The Sanctuary Leadership Development Institute provides on-site assessment, training, and implementation support.

For more information, visit The Sanctuary Model.

Seeking Safety

Seeking Safety is designed to be a therapy for trauma, post-traumatic stress disorder (PTSD), and substance abuse. The developer feels that this model works for individuals or with groups, with men, women or with mixed-gender groups, and can be used in a variety of settings, such as outpatient, inpatient, and residential.

The developer indicates that the key principles of Seeking Safety are safety as the overarching goal, integrated treatment, a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse, knowledge of four content areas (cognitive, behavioral, interpersonal, and case management), and attention to clinical processes.

Seeking Safety provides on-site training sessions and telephone consultation. For more information, visit Seeking Safety.

Trauma, Addiction, Mental Health, and Recovery (TAMAR)

Developed as part of the first phase of the SAMHSA Women, Co-Occurring Disorders and Violence Study, the TAMAR Education Project is a structured, manualized 10-week intervention combining psycho-educational approaches with expressive therapies. It is designed for women and men with histories of trauma in residential systems. Groups are run inside detention centers, state psychiatric hospitals, and in the community.

The TAMAR Education Project provides basic insights on trauma, its developmental effects on symptoms and current functioning, symptom appraisal and management, the impact of early chaotic relationships on healthcare needs, the development of coping skills, preventive education concerning pregnancy and sexually transmitted diseases, sexuality, and help in dealing with role loss and parenting issues.

Contact:
Darren McGregor, MS, MHS, LCMFT
Maryland Behavioral Health Administration
410-402-8467
darren.mcgregor@maryland.gov

Trauma Affect Regulation: Guide for Education and Therapy (TARGET)

TARGET is a model designed for use by organizations and professionals with a broad range of experience with and understanding of trauma. The developer feels that TARGET works with all disciplines and can be used in all levels of care for adults and children.

The developer indicates that TARGET is an educational and therapeutic approach for the prevention and treatment of complex Post Traumatic Stress Disorder. The developer suggests that this model provides practical skills that can be used by trauma survivors and family members to de-escalate and regulate extreme emotions, manage intrusive trauma memories experienced in daily life, and restore the capacity for information processing and memory. The University of Connecticut's Research and Development Corporation is creating a behavioral health service company to provide training and consultation in the TARGET model which will include training, long-term small group consultation, quality assurance, and program evaluation.

Read more about the TARGET model.

Trauma Recovery and Empowerment Model (TREM and M-TREM)

The Trauma Recovery and Empowerment Model is intended for trauma survivors, particularly those with exposure to physical or sexual violence. This model is gender-specific: TREM for women and M-TREM for men. This model has been implemented in mental health, substance abuse, co-occurring disorders, and criminal justice settings. The developer feels this model is appropriate for a full range of disciplines.

Community Connections provides manuals, training, and ongoing consultation in TREM and M-TREM.

For more information, visit Community Connections.
Last Updated: Nov 12, 2015

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The six key principles of a trauma-informed approach and trauma-specific interventions address trauma's consequences and facilitate healing.

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This article has a lot of information. It covers various treatment approaches designed to treat trauma and related disorders. It talks about immediate interventions,basic needs, core actions, breathing exercises, couple and family therapy and mindfulness.

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This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively. The chapter begins with a section on trauma-specific treatment models, providing a brief overview of interventions that can be delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the immediate crisis. The second segment focuses on integrated care that targets trauma-specific treatment for mental, substance use, and co-occurring disorders. Even though entry-level, trauma-informed behavioral health service providers are unlikely to be in a position to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease out the most important ingredients of early interventions and their role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review of selected emerging interventions that have not been covered elsewhere in this Treatment Improvement Protocol (TIP).

Introduction

Trauma-specific therapies vary in their approaches and objectives. Some are present focused, some are past focused, and some are combinations ( Najavits, 2007a). Present-focused approaches primarily address current coping skills, psychoeducation, and managing symptoms for better functioning. Past-focused approaches primarily focus on telling the trauma story to understand the impact of the trauma on how the person functions today, experiencing emotions that were too overwhelming to experience in the past, and helping clients more effectively cope in the present with their traumatic experiences. Clients participating in present-focused approaches may reveal some of their stories; past-focused approaches emphasize how understanding the past influences current behavior, emotion, and thinking, thereby helping clients cope more effectively with traumatic experiences in the present.

Trauma-Informed Care Framework in Behavioral Health Services-Trauma-Specific Services

The distinction between these approaches lies in the primary emphasis of the approach. Depending on the nature of the trauma and the specific needs of the client, one approach may be more suitable than the other. For instance, in short-term treatment for clients in early recovery from mental illness and/or substance abuse, present-focused, cognitive-behavioral, or psychoeducational approaches are generally more appropriate. For clients who are stable in their recovery and have histories of developmental trauma where much of the trauma has been repressed, a past-focused orientation may be helpful. Some clients may benefit from both types, either concurrently or sequentially.

This chapter discusses a number of treatment models, general approaches, and techniques. A treatment model is a set of practices designed to alleviate symptoms, promote psychological well-being, or restore mental health. Treatment techniques are specific procedures that can be used as part of a variety of models. Some models and techniques described in this chapter can be used with groups, some with individuals, and some with both. This chapter is selective rather than comprehensive; additional models are described in the literature. See, for example, the PILOTS database on the Web site of the National Center for PTSD (NCPTSD; http://www.ptsd.va.gov) for treatment literature related to trauma and posttraumatic stress disorder (PTSD). For an overview of models for use with both adult and child populations, refer to Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services ( Center for Mental Health Services, 2008).

Some treatments discussed in this chapter are described as evidence based. Because research on integrated treatment models is so new, many have only been examined in a few studies. Given these circumstances and the fact that an outcome study provides only limited evidence of efficacy, the term "evidence based" should be interpreted cautiously. Additional scientific study is needed to determine whether some treatments discussed herein are, in fact, evidence based. A good resource for evaluating evidence-based, trauma-specific treatment models is Effective Treatments for PTSD ( Foa, Keane, Friedman, & Cohen, 2009). Although evidence-based interventions should be a primary consideration in selecting appropriate treatment models for people with symptoms of trauma that co-occur with mental and substance use disorders (see Allen, 2001, for an indepth discussion of trauma and serious mental illness), other factors must also be weighed, including the specific treatment needs of the client; his or her history of trauma, psychosocial and cultural background, and experiences in prior trauma treatment; the overall treatment plan for the client; and the competencies of the program's clinical staff. Although behavioral health counselors can prepare to help their clients address some of the issues discussed in Chapter 5, specialized training is necessary to provide treatment for co-occurring substance use and mental disorders related to trauma.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has created the National Registry of Evidence-Based Programs and Practices (NREPP) as a resource for reviewing and identifying effective treatment programs. Programs can be nominated for consideration as co-occurring disorders programs or substance abuse prevention or treatment programs, and their quality of evidence, readiness for dissemination, and training considerations are then reviewed. For more detailed information, including details about several evidence-based co-occurring trauma treatment programs, visit the NREPP Web site ( http://www.nrepp.samhsa.gov). Program models for specialized groups, such as adolescents, can also be found on the NREPP Web site. For specific research-oriented information on trauma-specific treatments, refer to Part 3 of this TIP, which provides a literature review and links to select abstracts (available online).

Federal Agencies

Both the American Red Cross and the Federal Emergency Management Agency (FEMA) respond to disasters. Behavioral health service providers should understand the basics about these major emergency response agencies. For example, the Red Cross can respond rapidly with funding for food, shelter, and immediate needs, whereas FEMA assistance requires a period of gearing up but provides for longer-term needs. SAMHSA, along with other Federal agencies, assists FEMA in a number of areas of emergency response planning activities. See also SAMHSA's Disaster Technical Assistance Center Web site ( http://www.samhsa.gov/dtac) and Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health Treatment Programs ( SAMHSA, 2013).

Trauma-Specific Treatment Models

Immediate Interventions

Intervention in the first 48 hours

The acute intervention period comprises the first 48 hours after a traumatic event. In a disaster, rescue operations usually begin with local agencies prior to other organizations arriving on the scene. Law enforcement is likely to take a primary role on site. Whether it is a disaster, group trauma, or individual trauma (including a trauma that affects an entire family, such as a house fire), a hierarchy of needs should be established: survival, safety, security, food, shelter, health (physical and mental), orientation of survivors to immediate local services, and communication with family, friends, and community ( National Institute of Mental Health, 2002). In this crucial time, appropriate interventions include educating survivors about resources; educating other providers, such as faith-based organizations and social service groups, to screen for increased psychological effects including use of substances; and use of a trauma response team that assists clients with their immediate needs. No formal interventions should be attempted at this time, but a professionally trained, empathic listener can offer solace and support ( Litz & Gray, 2002).

"One day I was called out of bed at 5:00 a.m. to go to a town approximately 30 miles away because a levee had broken.... By 6:00 a.m., my colleagues and I were there with many of the townspeople, with helicopters flying overhead, with trucks going in and out by the main road trying to empty the factories. When we got there, as far as you could see was farmland. By 11 a.m., you could see a 'lake' in the distance. By 2 p.m., the water was on the edge of the town. Being there, at that town, before, during, and after the water came was probably the most valuable function we performed. We were able to share in the grief of the hundreds of people as we stayed with them while their fields, houses, and workplaces were flooded. We witnessed the death of a town, and the people reacted with disbelief, anger, sadness, and numbness. Each person had a different story, but all grieved, and we provided many an opportunity to express it. People cried as the water started rising into their houses. Some had to watch. Some had to leave. At times it was utterly silent as we all waited. There was a woman whose parents sent her away during the floods of '43 and she had been angry for 50 years about it. She was determined that her children and grandchildren would see everything. I spent 12 hours that day just giving support, listening, giving information, and sometimes shedding a tear or two myself."
-Rosemary Schwartzbard, Ph.D., responder to floods along the Mississippi River in 1993

Source: Schwartzbard, 1997.

Basic needs

Basic necessities, such as shelter, food, and water, are key to survival and a sense of safety. It is important to focus on meeting these basic needs and on providing a supportive environment. Clients' access to prescribed medications may be interrupted after a trauma, particularly a disaster, so providers should identify clients' medication needs for preexisting physical and mental disorders, including methadone or other pharmacological treatment for substance use. For example, after September 11, 2001, substance abuse treatment program administrators in New York had to seek alternative methadone administration options ( Frank, Dewart, Schmeidler, & Demirjian, 2006).

Psychological first aid

The psychological first aid provided in the first 48 hours after a disaster is designed to ensure safety, provide an emotionally supportive environment and activities, identify those with high-risk reactions, and facilitate communication, including strong, reassuring leadership immediately after the event. The primary helping response of psychological first aid is to provide a calm, caring, and supportive environment to set the scene for psychological recovery. It is also essential that all those first responding to a trauma-rescue workers, medical professionals, behavioral health workers (including substance abuse counselors), journalists, and volunteers-be familiar with relevant aspects of traumatic stress. Approaching survivors with genuine respect, concern, and knowledge increases the likelihood that the caregiver can ( NCPTSD, 2002):

Answer questions about what survivors may be experiencing.

Normalize their distress by affirming that what they are experiencing is normal.

Help them learn to use effective coping strategies.

Help them be aware of possible symptoms that may require additional assistance.

Provide a positive experience that will increase their chances of seeking help if they need it in the future.

Clinical experience suggests that care be taken to respect a survivor's individual method of coping; some may want information, for example, whereas others do not. Similarly, some may want to talk about the event, but others won't. An excellent guide to providing psychological first aid is available online from the Terrorism and Disaster Branch of the National Child Traumatic Stress Network ( http://www.nctsn.org/content/psychological-first-aid).

Critical incident stress debriefing

Initially developed for work with first responders and emergency personnel, critical incident stress debriefing (CISD; Mitchell & Everly, 2001) is now widely used and encompasses various group protocols used in a variety of settings. This facilitator-led group intervention is for use soon after a traumatic event with exposed people. The goal is to provide psychological closure by encouraging participants to talk about their experiences and then giving a didactic presentation on common stress reactions and management.

The widespread use of CISD has occurred despite the publication of conflicting results regarding its efficacy. Claims that single-session psychological debriefing can prevent development of chronic negative psychological sequelae are not empirically supported ( van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Some controlled studies suggest that it may impede natural recovery from trauma ( McNally, Bryant, & Ehlers, 2003). Other research suggests emphasizing screening to determine the need for early interventions. Mitchell and Everly (2001) point out that many of the studies showing negative results were not conducted with first responders; that is, CISD may be appropriate for some, but not all, groups. A recent study of 952 U.S. peacekeepers and CISD by the U.S. Army Research Unit-Europe ( Adler et al., 2008) found mixed results.

Advice to Counselors: Evidence Related to Immediate Interventions

Evidence related to immediate interventions suggests that:

Early, brief, focused psychotherapeutic intervention provided in an individual or group format can reduce distress in bereaved spouses, parents, and children.

Selected cognitive-behavioral approaches may help reduce the incidence, duration, and severity of acute stress disorder (ASD), PTSD, and depression in trauma survivors.

A one-session individual recital of events and expression of emotions evoked by a traumatic event does not consistently reduce risk of later developing PTSD. In fact, it may increase the risk for adverse outcomes. Perhaps CISD hinders the natural recovery mechanisms that restore pretrau-ma functioning ( Bonanno, 2004).

The focus initially should be upon screening with follow-up as indicated.

Interventions Beyond the Initial Response to Trauma

In the interest of increasing your overall familiarity with relevant approaches, the following sections review several traumatic stress treatment approaches that counselors will most likely encounter when collaborating with clinicians or agencies that specialize in trauma-specific services and treating traumatic stress.

Cognitive-behavioral therapies

Most PTSD models involve cognitive-behavioral therapy (CBT) that integrates cognitive and behavioral theories by incorporating two ideas: first, that cognitions (or thoughts) mediate between situational demands and one's attempts to respond to them effectively, and second, that behavioral change influences acceptance of altered cognitions about oneself or a situation and establishment of newly learned cognitive-behavioral interaction patterns. In practice, CBT uses a wide range of coping strategies.

There are many different varieties of CBT. CBT originated in the 1970s ( Beck, Rush, Shaw & Emery, 1979; Ellis & Harper, 1975) and has expanded since then to address various populations, including people who use substances, people who experience anxiety, people with PTSD or personality disorders, children and adolescents, individuals involved in the criminal justice system, and many others. CBT has also been expanded to include various techniques, coping skills, and approaches, such as dialectical behavior therapy (DBT; Linehan, 1993), Seeking Safety ( Najavits, 2002a), and mindfulness ( Segal, Williams, & Teasdale, 2002). Traditional CBT emphasizes symptom reduction or resolution, but recent CBT approaches have also emphasized the therapeutic relationship, a particularly important dynamic in trauma treatment ( Jackson, Nissenson, & Cloitre, 2009).

A widely accepted framework in treating trauma, substance use disorders, and mental illness categorizes therapies as single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

CBT has been applied to the treatment of trauma and has also been widely and effectively used in the treatment of substance use. A review of efficacy research on CBT for PTSD is provided by Rothbaum, Meadows, Resick, and Foy (2000). Najavits and colleagues (2009) and O'Donnell and Cook (2006) offer an overview of CBT therapies for treating PTSD and substance abuse. In addition, a free online training resource incorporating CBT for traumatized children within the community, Trauma-Focused CBT, is available from the Medical University of South Carolina ( http://tfcbt.musc.edu/).

Cognitive processing therapy

Cognitive processing therapy (CPT) is a manualized 12-session treatment approach that can be administered in a group or individual setting ( Resick & Schnicke, 1992, 1993). CPT was developed for rape survivors and combines elements of existing treatments for PTSD, specifically exposure therapy (see the " Exposure Therapy" section later in this chapter) and cognitive therapy. The exposure therapy component of treatment consists of clients writing a detailed account of their trauma, including thoughts, sensations, and emotions that were experienced during the event. The client then reads the narrative aloud during a session and at home. The cognitive therapy aspect of CPT uses six key PTSD themes identified by McCann and Pearlman (1990): safety, trust, power, control, esteem, and intimacy. The client is guided to identify cognitive distortions in these areas, such as maladaptive beliefs.

Advice to Counselors: Relaxation Training, Biofeedback, and Breathing Retraining Strategies

Relaxation training, biofeedback, and breathing retraining strategies may help some clients cope with anxiety, a core symptom of traumatic stress. However, no evidence supports the use of relaxation and biofeedback as effective standalone PTSD treatment techniques ( Cahill, Rothbaum, Resick, & Follete, 2009). Both are sometimes used as complementary strategies to manage anxiety symptoms elicited by trauma-related stimuli. Breathing retraining uses focused or controlled breathing to reduce arousal. Breathing retraining and relaxation, along with other interventions when necessary, can help clients with ASD. An important caution in the use of breath work with trauma clients is that it can sometimes act as a trigger-for example, given its focus on the body and its potential to remind them of heavy breathing that occurred during assault. Biofeedback, which requires specialized equipment, combines stress reduction strategies (e.g., progressive muscle relaxation, guided imagery) with feedback from biological system measures (e.g., heart rate, hand temperature) that gauge levels of stress or anxiety reduction. Relaxation training, which requires no specialized equipment, encourages clients to reduce anxiety responses (including physiological responses) to trauma-related stimuli; it is often part of more comprehensive PTSD treatments (e.g., prolonged exposure and stress inoculation training [SIT]).

Results from randomized, placebo-controlled trials for the treatment of PTSD related to interpersonal violence ( Resick, 2001; Resick, Nishith, Weaver, Astin, & Feuer, 2002) support the use of CPT. CPT and prolonged exposure therapy models are equally and highly positive in treating PTSD and depression in rape survivors; CPT is superior in reducing guilt ( Nishith, Resick, & Griffin, 2002; Resick et al., 2002; Resick, Nishith, & Griffin, 2003). CPT has shown positive outcomes with refugees when administered in the refugees' native language ( Schulz, Marovic-Johnson, & Huber, 2006) and with veterans ( Monson et al., 2006). However, CPT has not been studied with high-complexity populations such as individuals with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. CPT requires a 3-day training plus consultation ( Karlin et al., 2010). Resick and Schicke (1996) published a CPT treatment manual, Cognitive Processing Therapy for Rape Victims: A Treatment Manual.

Exposure therapy

Exposure therapy for PTSD asks clients to directly describe and explore trauma-related memories, objects, emotions, or places. Intense emotions are evoked (e.g., sadness, anxiety) but eventually decrease, desensitizing clients through repeated encounters with traumatic material. Careful monitoring of the pace and appropriateness of exposure-based interventions is necessary to prevent retraumatization (clients can become conditioned to fear the trauma-related material even more). Clients must have ample time to process their memories and integrate cognition and affect, so some sessions can last for 1.5 hours or more. For simple cases, exposure can work in as few as 9 sessions; more complex cases may require 20 or more sessions ( Foa, Hembree, & Rothbaum, 2007). Various techniques can expose the client to traumatic material. Two of the more common methods are exposure through imagery and in vivo ("real life") exposure.

Advice to Counselors: Steps for Introducing a Breathing Exercise

Use the following statements to lead clients through a breathing exercise:

Place your hands on your stomach. As you inhale, breathe deeply but slowly so that your hands rise with your stomach. As you exhale slowly, practice breathing so that your hands drop with your stomach.

Inhale slowly through your nose with your mouth closed; don't rush or force in the air.

Exhale slowly through your mouth with your lips in the whistling position.

Breathe out for twice as long as you breathe in.

The effectiveness of exposure therapy has been firmly established ( Rothbaum et al., 2000); however, adverse reactions to exposure therapy have also been noted. Some individuals who have experienced trauma exhibit an exacerbation of symptoms during or following exposure treatments. Even so, the exacerbation may depend on counselor variables during administration. Practitioners of exposure therapy need comprehensive training to master its techniques ( Karlin et al., 2010); a counselor unskilled in the methods of this treatment model can not only fail to help his or her clients, but also cause symptoms to worsen.

Exposure therapy is recommended as a first-line treatment option when the prominent trauma symptoms are intrusive thoughts, flashbacks, or trauma-related fears, panic, and avoidance. However, counselors should exercise caution when using exposure with clients who have not maintained stability in managing mental illness symptoms or abstinence from substance use disorders. Studies and routine use of exposure have consistently excluded high-complexity clients such as those with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. The only trial of exposure therapy with a substance dependence sample found that it did not outperform standard substance abuse treatment on most variables ( Mills et al., 2012).

Prolonged exposure therapy for PTSD is listed in SAMHSA's NREPP. For reviews of exposure therapy, also see Najavits (2007a) and Institute of Medicine (2008). In addition to prolonged exposure therapy, other therapies incorporate exposure and desensitization techniques, including eye movement desensitization and reprocessing (EMDR; Shapiro, 2001), cognitive processing, and systematic desensitization therapies ( Wolpe, 1958).

Eye movement desensitization and reprocessing

EMDR ( Shapiro, 2001) is one of the most widely used therapies for trauma and PTSD. The treatment protocols of EMDR have evolved into sophisticated paradigms requiring training and, preferably, clinical supervision. EMDR draws on a variety of theoretical frameworks, including psychoneurology, CBT, information processing, and nonverbal representation of traumatic memories. The goal of this therapy is to process the experiences that are causing problems and distress. It is an effective treatment for PTSD ( Seidler & Wagner, 2006) and is accepted as an evidence-based practice by the U.S. Department of Veterans Affairs (VA), the Royal College of Psychiatrists, and the International Society for Traumatic Stress Studies ( Najavits, 2007a); numerous reviews support its effectiveness (e.g., Mills et al., 2012). EMDR values the development of "resource installation" (calming procedures) and engages in exposure work to desensitize clients to traumatic material, using external tracking techniques across the visual field to assist in processing distressing material. Training in EMDR, available through the EMDR Institute, is required before counselors use this treatment. It is listed in SAMHSA's NREPP ( EMDR Network, 2012). Thus far, there is no study examining the use of EMDR with clients in substance abuse treatment. See Part 3 of this TIP, available online, to review empirical work on EMDR.

A Brief Description of EMDR Therapy

Treatment involves three main concentrations (past memories, present disturbances, future actions) and eight phases. Counselors may work with several phases in one session. Each phase is meant to be revisited either in every session or when appropriate (e.g., the closure process is meant to be conducted at the end of every session, in preparation for the next).

Phase 1: History and Treatment Planning (1-2 sessions)

Phase 3: Assessment and Reprocessing

Source: EMDR Network, 2012.

Narrative therapy

Narrative therapy is an emerging approach to understanding human growth and change; it is founded on the premise that individuals are the experts on their own lives and can access their existing intrapsychic and interpersonal resources to reduce the impact of problems in their lives. Developed for the treatment of PTSD resulting from political or community violence, narrative therapy is based on CBT principles, particularly exposure therapy ( Neuner, Schauer, Elbert, & Roth, 2002; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). This approach views psychotherapy not as a scientific practice, but as a natural extension of healing practices that have been present throughout human history. For a trauma survivor, the narrative, as it is told and retold, expresses the traumatic experience, puts the trauma in the context of the survivor's life, and defines the options he or she has for change. Narrative structure helps clients connect events in their lives, reveals strings of events, explores alternative expressions of trauma, evokes explanations for clients' behaviors, and identifies their knowledge and skills. The use of stories in therapy, with the client as the storyteller, generally helps lessen suffering ( McLeod, 1997; White, 2004).

In the substance abuse treatment field, many clients will see a connection between narrative therapy and the process of telling their stories in 12-Step programs, in which reframing life stories of feeling trapped, despairing, and hopeless leads to stories of strength, joy, and hope. Key storytelling points at a 12-Step speaker meeting include describing what an experience was like, what happened, and what it is like now.

Skills training in affective and interpersonal regulation

Skills training in affective and interpersonal regulation (STAIR) is a two-phase cognitive-behavioral model that adapts therapies developed by others into a new package ( Cloitre, Koenen, Cohen, & Han, 2002). Phase 1 consists of eight weekly sessions of skills training in affect and interpersonal regulation derived from general CBT and DBT ( Linehan, 1993) and adapted to address trauma involving childhood abuse. Session topics are labeling and identifying feelings, emotion management, distress tolerance, acceptance of feelings, identifying trauma-based interpersonal schemas, identifying conflict between trauma-generated feelings and current interpersonal goals, role-plays on issues of power and control, and role-plays on developing flexibility in interpersonal situations. Phase 2 features eight sessions of modified prolonged exposure using a narrative approach.

STAIR Steps

Phase 1, tailored to individual clients, is called Skills Training in Affect Regulation and consists of the following components:

Psychoeducation: Describe the symptoms of PTSD and explain the treatment rationale.

Training in experiencing and identifying feelings, triggers, and thoughts, as well as training in mood regulation strategies.

Learning history: Ask the client the following questions-How did the client deal with traumas past and present? How did the client's family deal with feelings? How did the client's family life affect his or her present difficulty experiencing and identifying feeling?

Emotion regulation skills: Identify the cognitive, behavioral, and social support modalities for coping. Use data gathered with self-monitoring forms to identify strengths and weaknesses in each coping modality. Teach skills such as breathing retraining, self-statements to reduce fear, and social skill training to improve social support.

Acceptance and tolerance of negative affect: Motivate clients to face distressing situations related to the trauma that are important to them. Review negative repercussions of avoidance. Discuss tolerating negative affect as a step toward achieving specific goals.

Schema therapy for improved relationships: Identify relevant schemas learned in childhood. Suggest alternative ways of viewing self and others in current relationships. Use role-playing to teach assertiveness, emphasizing response flexibility based on relative power in each relationship.

Once Phase 1 of STAIR is well learned, clients move to Phase 2, which involves exposure therapy.

Source: Mollick & Spett, 2002.

Cloitre and colleagues (2002) assigned women with PTSD related to childhood abuse randomly to STAIR or a minimal attention wait-list, excluding clients with current substance dependence as well as other complexities. STAIR participants showed significantly greater gains in affect regulation, interpersonal skills, and PTSD symptoms than the control participants. These gains were maintained through follow-up at 3 and 9 months. However, it is not clear from this study whether DBT and exposure were both needed. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the importance of establishing a strong therapeutic relationship and emotion regulation skills before conducting exposure work with people who have chronic PTSD.

Stress inoculation training

SIT was originally developed to manage anxiety ( Meichenbaum, 1994; Meichenbaum & Deffenbacher, 1988). Kilpatrick, Veronen, and Resick (1982) modified SIT to treat rape survivors based on the idea that the anxiety and fear that rape survivors experience during their trauma generalizes to other objectively safe situations. SIT treatment components include education, skills training (muscle relaxation training, breathing retraining, role-playing, guided self-talk, assertiveness training, and thought stopping [i.e., actively and forcefully ending negative thoughts by thinking "STOP" and then redirecting thoughts in a more positive direction]), and skills application. The goal is to help clients learn to manage their anxiety and to decrease avoidant behavior by using effective coping strategies. Randomized controlled clinical trials have indicated that SIT reduces the severity of PTSD compared with waitlist controls and shows comparable efficacy to exposure therapy. At follow-up (up to 12 months after treatment), gains were maintained ( Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991).

SIT has been used to help individuals cope with the aftermath of exposure to stressful events and on a preventative basis to "inoculate" individuals to future and ongoing stressors ( Meichenbaum, 1996). This practice as a preventive strategy is similar to promoting disease resistance through immunizations.

Advice to Counselors: SIT Phases

SIT is a prevention and treatment approach that has three overlapping phases. It is often seen as a complementary approach to other interventions for traumatic stress.

Phase 1: Conceptualization and education. This phase has two main objectives. The initial goal is to develop a collaborative relationship that supports and encourages the client to confront stressors and learn new coping strategies. The next objective is to increase the client's understanding of the nature and impact of his or her stress and awareness of alternative coping skills. Many cognitive strategies are used to meet these objectives, including self-monitoring activities, Socratic questioning, identifying strengths and evidence of resilience, and modeling of coping strategies.

Phase 2: Skill acquisition and rehearsal. This phase focuses on developing coping skills and using coping skills that the individual already possesses. This process includes practice across settings, so that the individual begins to generalize the use of his or her skills across situations through rehearsal, rehearsal, and more rehearsal.

Phase 3: Implementation and following through. The main objective is to create more challenging circumstances that elicit higher stress levels for the client. By gradually increasing the challenge, the client can practice coping strategies that mimic more realistic circumstances. Through successful negotiation, the client builds a greater sense of self-efficacy. Common strategies in this phase include imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure.

Source: Meichenbaum, 2007.

Other therapies

Numerous interventions introduced in the past 20 years focus on traumatic stress. For some interventions, the evidence is limited, and for other others, it is evolving. One example is the traumatic incident reduction (TIR) approach. This brief memory-oriented intervention is designed for children, adolescents, and adults who have experienced traumatic stress ( Valentine & Smith, 2001). Listed in SAMHSA's NREPP, the intervention is designed to process specific traumatic incidents or problematic themes related to the trauma, including specific feelings, emotions, sensations, attitudes, or pain. It involves having clients talk through the traumatic incident repeatedly with the anticipation that changes in affect will occur throughout the repetitions. TIR is a client-centered approach.

Integrated Models for Trauma

This section covers models specifically designed to treat trauma-related symptoms along with either mental or substance use disorders at the same time. Integrated treatments help clients work on several presenting problems simultaneously throughout the treatment, a promising and recommended strategy ( Dass-Brailsford & Myrick, 2010; Najavits, 2002b; Nixon & Nearmy, 2011). Thus far, research is limited, but what is available suggests that integrated treatment models effectively reduce substance abuse, PTSD symptoms, and other mental disorder symptoms. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment, 2005c), offers a detailed description of integrated treatment. In contrast with integrated models, other model types include single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

Similar to single models, integrated treatment models are designed for use in a variety of settings (e.g., outpatient, day treatment, and/or residential substance abuse and mental health clinics/programs). Most models listed are manual-based treatments that address trauma-related symptoms, mental disorders, and substance use disorders at the same time. Additional approaches and further details on the selected approaches can be found at NREPP ( http://www.nrepp.samhsa.gov).

Addiction and Trauma Recovery Integration Model

The Addiction and Trauma Recovery Integrated Model (ATRIUM; Miller & Guidry, 2001) integrates CBT and relational treatment through an emphasis on mental, physical, and spiritual health. This 12-week model for individuals and groups blends psychoeducational, process, and expressive activities, as well as information on the body's responses to addiction and traumatic stress and the impact of trauma and addiction on the mind and spirit. It helps clients explore anxiety, sexuality, self-harm, depression, anger, physical complaints and ailments, sleep difficulties, relationship challenges, and spiritual disconnection. It was designed primarily for women and focuses on developmental (childhood) trauma and interpersonal violence, but it recognizes that other types of traumatic events occur.

The ATRIUM model consists of three phases of treatment. The first stage, or "outer circle," consists of the counselor collecting data from the client about his or her trauma history, offering psychoeducation on the nature of trauma, and helping the client assess personal strengths. ATRIUM actively discourages the evocation of memories of abuse or other trauma events in this phase. The second stage, or "middle circle," allows clients and counselors to address trauma symptoms more directly and specifically encourages clients to reach out to and engage with support resources in the community. The middle circle also emphasizes learning new information about trauma and developing additional coping skills. The third stage of the program, the "inner circle," focuses on challenging old beliefs that arose as a result of the trauma. For instance, the concept of "nonprotecting bystander" is used to represent the lack of support that the traumatized person experienced at the time of the trauma. This representation is replaced with the "protective presence" of supportive others today.

ATRIUM was used in one of the nine study sites of SAMHSA's Women, Co-Occurring Disorders and Violence Study. Across all sites, trauma-specific models achieved more favorable outcomes than control sites that did not use trauma-specific models ( Morrissey et al., 2005). There has not yet been a study of ATRIUM per se, however. A manual describing the theory behind this model in greater depth, as well as how to implement it, is published under the title Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit ( Miller & Guidry, 2001).

Beyond Trauma: A Healing Journey for Women

Beyond Trauma ( Covington, 2003) is a curriculum for women's services based on theory, research, and clinical experience. It was developed for use in residential, outpatient, and correctional settings; domestic violence programs; and mental health clinics. It uses behavioral techniques and expressive arts and is based on relational therapy. Although the materials are designed for trauma treatment, the connection between trauma and substance abuse in women's lives is a theme throughout. Beyond Trauma has a psychoeducational component that defines trauma by way of its process as well as its impact on the inner self (thoughts, feelings, beliefs, values) and the outer self (behavior and relationships, including parenting). Coping skills are emphasized; specific exercises develop emotional wellness.

Concurrent Treatment of PTSD and Cocaine Dependence

Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) is a 16-session, twice-weekly individual outpatient psychotherapy model designed to treat women and men with co-occurring PTSD and cocaine dependence ( Coffey, Schumacher, Brimo, & Brady, 2005). CTPCD combines imagery and in vivo exposure therapy (in which the client becomes desensitized to anxiety-producing stimuli through repeated exposure to them) for the treatment of PTSD with elements of CBT for substance dependence. To balance the dual needs of abstinence skill building and prompt trauma treatment, the first five sessions focus on coping skills for cocaine dependence. Session six transitions into exposure therapy, which begins in earnest in session seven and is combined with CBT for the treatment of substance abuse.

CTPCD helps reduce substance use and PTSD symptoms. The use of any illicit drug, as measured by urine screens, was quite low during the 16-week treatment trial and didn't escalate during the second half of treatment-when most exposure sessions occurred. PTSD symptoms dropped significantly over the course of treatment, as did self-reported depressive symptoms; however, the dropout rate was high ( Coffey, Dansky, & Brady, 2003). CTPCD was reformulated into Concurrent Prolonged Exposure (COPE; Mills et al., 2012), which was compared with treatment as usual in a high-complexity clinical sample of individuals who had PTSD and substance dependence. Both treatment conditions resulted in improvements in PTSD with no difference at 3 months (though COPE showed significantly greater improvement at 9 months); moreover, the two conditions did not differ in impact on substance use outcomes, depression, or anxiety.

Integrated CBT

Integrated CBT is a 14-session individual therapy model designed for PTSD and substance use. It incorporates elements such as psychoeducation, cognitive restructuring, and breathing retraining ( McGovern, Lamber-Harris, Alterman, Xie, & Meier, 2011). A randomized controlled trial showed that both integrated CBT and individual addiction treatment achieved improvements in substance use and other measures of psychiatric symptom severity with no difference between the treatments.

Seeking Safety

Seeking Safety is an empirically validated, present-focused treatment model that helps clients attain safety from trauma and substance abuse ( Najavits, 2002a). The Seeking Safety manual ( Najavits, 2002b) offers clinician guidelines and client handouts and is available in several languages. Training videos and other implementation materials are available online ( http://www.seekingsafety.org). Seeking Safety is flexible; it can be used for groups and individuals, with women and men, in all settings and levels of care, by all clinicians, for all types of trauma and substance abuse.

Seeking Safety covers 25 topics that address cognitive, behavioral, interpersonal, and case management domains. The topics can be conducted in any order, using as few or as many as are possible within a client's course of treatment. Each topic represents a coping skill relevant to both trauma and substance abuse, such as compassion, taking good care of yourself, healing from anger, coping with triggers, and asking for help. This treatment model builds hope through an emphasis on ideals and simple, emotionally evocative language and quotations. It attends to clinician processes and offers concrete strategies that are thought to be essential for clients dealing with concurrent substance use disorders and histories of trauma.

More than 20 published studies (which include pilot studies, randomized controlled trials, and multisite trials representing various investigators and populations) provide the evidence base for this treatment model. For more information, see SAMHSA's NREPP Web site ( http://www.nrepp.samhsa.gov) as well as the "Outcomes" section of the Seeking Safety Web site ( http://www.seekingsafety.org/3-03-06/studies.html). Study samples included people with chronic, severe trauma symptoms and substance dependence who were diverse in ethnicity and were treated in a range of settings (e.g., criminal justice, VA centers, adolescent treatment, homelessness services, public sector). Seeking Safety has shown positive outcomes on trauma symptoms, substance abuse, and other domains (e.g., suicidality, HIV risk, social functioning, problem-solving, sense of meaning); consistently outperformed treatment as usual; and achieved high satisfaction ratings from both clients and clinicians. It has been translated into seven languages, and a version for blind and/or dyslexic individuals is available.

The five key elements of Seeking Safety are:

1. Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions).

2. Integrated treatment (working on trauma and substance abuse at the same time).

3. A focus on ideals to counteract the loss of ideals in both trauma and substance abuse.

4. Four content areas: cognitive, behavioral, interpersonal, and case management.

5. Attention to clinician processes (addressing counter transference, self-care, and other issues).

Substance Dependence PTSD Therapy

Substance Dependence PTSD Therapy ( Triffleman, 2000) was designed to help clients of both sexes cope with a broad range of traumas. It combines existing treatments for PTSD and substance abuse into a structured, 40-session (5-month, twice-weekly) individual therapy that occurs in two phases. Phase I is "Trauma-Informed, Addictions-Focused Treatment" and focuses on coping skills and cognitive interventions as well as creating a safe environment. Phase I draws on CBT models, anger management, relaxation training, HIV risk reduction, and motivational enhancement techniques. Phase II, "Trauma-Focused, Addictions-Informed Treatment," begins with psychoeducation about PTSD followed by "Anti-Avoidance I," in which a modified version of stress inoculation training is taught in two to four sessions. Following this is "Anti-Avoidance II," lasting 6 to 10 sessions, in which in vivo exposure is used.

Trauma Affect Regulation: Guide for Education and Therapy

Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford & Russo, 2006; Frisman, Ford, Lin, Mallon, & Chang, 2008) uses emotion and information processing in a present-focused, strengths-based approach to education and skills training for trauma survivors with severe mental, substance use, and co-occurring disorders across diverse populations. TARGET helps trauma survivors understand how trauma changes the brain's normal stress response into an extreme survival-based alarm response that can lead to PTSD, and it teaches them a seven-step approach to making the PTSD alarm response less distressing and more adaptive (summarized by the acronym FREEDOM: Focus, Recognize triggers, Emotion self-check, Evaluate thoughts, Define goals, Options, and Make a contribution).

TARGET: The Seven-Step FREEDOM Approach

Focus: Being focused helps a person pay attention and think about what's happening right now instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate environment and to use a simple scale to measure stress and control levels.

Recognize triggers: Recognizing trauma triggers enables a person to anticipate and reset alarm signals as he or she learns to distinguish between a real threat and a reminder. This step helps participants identify personal triggers, take control, and short-circuit their alarm reactions.

Emotion self-check: The goal of this skill is to identify two types of emotions. The first are "alarm" or reactive emotions such as terror, rage, shame, hopelessness, and guilt. Because these emotions are the most noticeable after trauma, they are the alarm system's way of keeping a person primed and ready to fend off further danger. The second type of emotion, "main" emotions, include positive feelings (e.g., happiness, love, comfort, compassion) and feelings that represent positive strivings (e.g., hope, interest, confidence). By balancing both kinds of emotions, a person can reflect and draw on his or her own values and hopes even when the alarm is activated.

Evaluate thoughts: When the brain is in alarm mode, thinking tends to be rigid, global, and catastrophic. Evaluating thoughts, as with identifying emotions, is about achieving a healthier balance of positive as well as negative thinking. Through a two-part process, participants learn to evaluate the situation and their options with a focus on how they choose to act-moving from reactive thoughts to "main" thoughts. This is a fundamental change from the PTSD pattern, which causes problems by taking a person straight from alarm signals to automatic survival reactions.

Define goals: Reactive goals tend to be limited to just making it through the immediate situation or away from the source of danger. These reactive goals are necessary in true emergencies but don't reflect a person's "main" goals of doing worthwhile things and ultimately achieving a good and meaningful life. This step teaches one how to create "main" goals that reflect his or her deeper hopes and values.

Options: The only options that are available when the brain's alarm is turned on and won't turn off are automatic "flight/fight" or "freeze/submit" reactive behaviors that are necessary in emergencies but often unhelpful in ordinary living. This step helps identify positive intentions often hidden by the more extreme reactive options generated by the alarm system. This opens the possibility for a greater range of options that take into consideration one's own needs and goals as well as those of others.

Make a contribution: When the brain's alarm is turned on and reacting to ordinary stressors as if they were emergencies, it is very difficult for a person to come away from experiences with a feeling that they have made a positive difference. This can lead to feelings of alienation, worthlessness, or spiritual distress. The ultimate goal of TARGET is to empower adults and young people to think clearly enough to feel in control of their alarm reactions and, as a result, to be able to recognize the contribution they are making not only to their own lives, but to others' lives as well.

Source: Advanced Trauma Solutions, 2012.

TARGET can be presented in individual therapy or gender-specific psychoeducational groups, and it has been adapted for individuals who are deaf; it has also been translated into Spanish and Dutch. TARGET is a resilience-building and recovery program not limited to individual or group psychotherapy; it is also designed to provide an educational curriculum and milieu intervention that affects all areas of practice in school, therapeutic, or correctional programs. TARGET is listed in SAMHSA's NREPP ( http://www.nrepp.samhsa.gov).

Trauma Recovery and Empowerment Model

The trauma recovery and empowerment model (TREM) of therapy ( Fallot & Harris, 2002; Harris & Community Connections Trauma Work Group, 1998) is a manualized group intervention designed for female trauma survivors with severe mental disorders. TREM addresses the complexity of long-term adaptation to trauma and attends to a range of difficulties common among survivors of sexual and physical abuse. TREM focuses mainly on developing specific recovery skills and current functioning and uses techniques that are effective in trauma recovery services. The model's content and structure, which cover 33 topics, are informed by the role of gender in women's experience of and coping with trauma.

TREM can be adapted for shorter-term residential settings and outpatient substance abuse treatment settings, among others. Adaptations of the model for men and adolescents are available. The model was used in SAMHSA's Women, Co-Occurring Disorders and Violence Study for three of the nine study sites and in SAMHSA's Homeless Families program, and it is listed in SAMHSA's NREPP. This model has been used with clients in substance abuse treatment; research by Toussaint, VanDeMark, Bornemann, and Graeber (2007) shows that women in a residential substance abuse treatment program showed significantly better trauma treatment outcomes using TREM than they did in treatment as usual, but no difference in substance use.

TREM Program Format

Each session includes an experiential exercise to promote group cohesiveness. The 33 sessions are divided into the following general topic areas:

Part I-empowerment introduces gender identity concepts, interpersonal boundaries, and self-esteem.

Part II-trauma recovery concentrates on sexual, physical, and emotional abuse and their relationship to psychiatric symptoms, substance abuse, and relational patterns and issues.

Part III-advanced trauma recovery issues addresses additional trauma issues, such as blame and the role of forgiveness.

Part IV-closing rituals allows participants to assess their progress and encourages them to plan for their continued healing, either on their own or as part of a community of other survivors.

Part V-modifications or supplements for special populations provides modifications for subgroups such as women with serious mental illness, incarcerated women, women who are parents, women who abuse substances, and male survivors.

Source: Mental Health America Centers for Technical Assistance, 2012.

Triad Women's Project

The Triad Project was developed as a part of SAMHSA's Women, Co-Occurring Disorders and Violence Study. It is a comprehensive, trauma-informed, consumer-responsive integrated model designed for female trauma survivors with co-occurring substance use and mental disorders who live in semirural areas. Triad integrates motivational enhancement for substance use disorders, DBT, and intensive case management techniques for co-occurring mental disorders. This program is a 16-week group intervention for women that uses integrated case management services, a curriculum-based treatment group, and a peer support group ( Clark & Fearday, 2003).

Emerging Interventions

New interventions are emerging to address traumatic stress symptoms and disorders. The following sections summarize a few interventions not highlighted in prior chapters; this is not an exhaustive list. In addition to specific interventions, technology is beginning to shape the delivery of care and to increase accessibility to tools that complement trauma-specific treatments. Numerous applications are available and evolving. For more information on the role of technology in the delivery of care, see the planned TIP, Using Technology-Based Therapeutic Tools in Behavioral Health Services (SAMHSA, planned g).

Couple and Family Therapy

Trauma and traumatic stress affects significant relationships, including the survivor's family. Although minimal research has targeted the effectiveness of family therapy with trauma survivors, it is important to consider the needs of the individual in the context of their relationships. Family and couples therapy may be key to recovery. Family members may experience secondary traumatization silently, lack understanding of traumatic stress symptoms or treatment, and/or have their own histories of trauma that influence their willingness to support the client in the family or to talk about anything related to trauma and its effects. Family members can engage in similar patterns of avoidance and have their own triggers related to the trauma being addressed at the time. A range of couple and family therapies have addressed traumatic stress and PTSD, but few studies exist that support or refute their value. Current couple or family therapies that have some science-based evidence include behavioral family therapy, behavioral marital therapy, cognitive-behavioral couples treatment, and lifestyle management courses ( Riggs, Monson, Glynn, & Canterino, 2009).

Mindfulness Interventions

Mindfulness is a process of learning to be present in the moment and observing internal experience (e.g., thoughts, bodily sensations) and external experience (e.g., interactions with others) in a nonjudgmental way. Mindfulness challenges limiting beliefs that arise from trauma, quells anxiety about future events, and simply helps one stay grounded in the present. It plays a significant role in helping individuals who have been traumatized observe their experiences, increase awareness, and tolerate uncomfortable emotions and cognitions.

To date, mindfulness-based interventions appear to be valuable as an adjunct to trauma-specific interventions and in decreasing arousal ( Baer, 2003). It may also help individuals tolerate discomfort during exposure-oriented and trauma processing interventions. Overall, mindfulness practices can help clients in managing traumatic stress, coping, and resilience. In a study of firefighters, mindfulness was associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems when controlling for other variables ( Smith et al., 2011).

Becoming an Observer and Learning To Tolerate Discomfort: The Leaf and Stream Metaphor

The following exercise, "leaves floating on a stream," is a classic. Many clinicians and authors provide renditions of this mindfulness practice. The main objectives are to stand back and observe thoughts rather than get caught up in them. Simply stated, thoughts are just thoughts. Thoughts come and go like water flowing down a stream. We don't need to react to the thoughts; instead, we can just notice them.

Conduct the mindfulness exercise for about 10 minutes, then process afterward. Take time to allow participants to visualize each sense as they imagine themselves sitting next to the stream. For example, what does it look like? What do they hear as they sit next to the stream? Don't rush the exercise. As you slowly make the statements detailed in the following two paragraphs, take time in between each statement for participants to be in the exercise without interruption; simply offer gentle guidance.

Begin to sit quietly, bringing your attention to your breath. If you feel comfortable, close your eyes. As you focus on breathing in and out, imagine that you are sitting next to a stream. In your imagination, you may clearly see and hear the stream, or you may have difficulty visualizing the stream. Follow along with the guided exercise; either way, it will work just as well.

Now begin to notice the thoughts that come into your mind. Some thoughts rush by, while others linger. Just allow yourself to notice your thoughts. As you begin to notice each thought, imagine putting those words onto a leaf as it floats by on the stream. Just let the thoughts come, watching them drift by on the leaves. If your thoughts briefly stop, continue to watch the water flow down the stream. Eventually, your thoughts will come again. Just let them come, and as they do, place them onto a leaf. Your attention may wander. Painful feelings may arise. You may feel uncomfortable or start to think that the exercise is "stupid." You may hook onto a thought-rehashing it repeatedly. That's okay; it's what our minds do. As soon as you notice your mind wandering or getting stuck, just gently bring your focus back to your thoughts, and place them onto the leaves. Now, bring your attention back to your breath for a moment, then open your eyes and become more aware of your environment.
Facilitated Questions:

What was it like for you to observe your thoughts?

Did you get distracted? Stuck?

Were you able to bring yourself back to the exercise after getting distracted?

In what ways was the exercise uncomfortable?

In what ways was the exercise comforting?

For clients and practitioners who want to develop a greater capacity for mindfulness, see Kabat-Zinn's books Wherever You Go, There You Are: Mindfulness Meditation In Everyday Life ( 1994) and Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness ( 1990). For clinical applications of mindfulness, see Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse ( Segal et al., 2002) and Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors ( Marlatt & Donovan, 2005).

Pharmacological Therapy

Pharmacotherapy for people with mental, substance use, and traumatic stress disorders needs to be carefully managed by physicians who are well versed in the treatment of each condition. Medications can help manage and control symptoms; however, they are only a part of a comprehensive treatment plan. There are no specific "antitrauma" drugs; rather, certain drugs target specific trauma symptoms. Clients receiving pharmacotherapy need careful assessment. Some clients with preexisting mental disorders may need further adjustment in medications due to the physiological effects of traumatic stress. In addition, sudden withdrawal from a pattern of self-administered substances can not only lead to dangerous levels of physical distress, but also exacerbate the emergence of more severe PTSD symptoms. Distress after trauma often lessens over time, which can sometimes make the use of medications unnecessary for some individuals. Some trauma survivors do not develop long-term psychological problems from their experiences that require medication; others may simply refuse the initiation of pharmacotherapy or the use of additional medications.

Concluding Note

Behavioral health counselors can best serve clients who have experienced trauma by providing integrated treatment that combines therapeutic models to target presenting symptoms and disorders. Doing so acknowledges that the disorders interact with each other. Some models have integrated curricula; others that address trauma alone can be combined with behavioral health techniques with which the counselor is already familiar.

In part, the choice of a treatment model or general approach will depend on the level of evidence for the model, the counselor's training, identified problems, the potential for prevention, and the client's goals and readiness for treatment. Are improved relationships with family members a goal? Will the client be satisfied if sleep problems decrease, or is the goal resolution of broader issues? Are there substance use or substance-related disorders? Is the goal abstinence? Collaborating with clients to decide on goals, eliciting what they would like from treatment, and determining what they expect to happen can provide some clues as to what treatment models or techniques might be successful in keeping clients engaged in recovery.

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This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively.

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