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This article is about the effects of trauma and the neurobiology behind it. Trauma can affect the body in many different ways. We are trying to understand it the best we can so we can help those get through it.

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White Rock Therapy - Trauma Counseling Texas & New Jersey

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Someone who has an avoidant attachment style is prone to withdraw or disconnect from others. They tend to keep their distance from others. They see others as too dependent, which frightens them. Those with an avoidant attachment style have fear of loss. As a result, it is masked as independence. They also reduce their own needs for connection.

Their behavior might look like an unwillingness to commit to a relationship. Or, being too particular or picky about another's habits, keeping secrets, and avoiding. They might even seem distant. For example, if you ask how their day was, they will answer with one word like "fine." People with this attachment style might also have trouble being emotionally available to others. They may also have an issue being emotionally intimate with others as they fear getting too close.

Much like the anxious attachment style, the avoidant attachment style is often due to early childhood experiences.

Trauma that could cause avoidant attachment includes neglect. This can explain why they fear getting too close to others. Or, why they feel they have to be so independent. This doesn't mean that they cannot learn to become more dependent on others. But, it will need a lot of extra work to develop a sense of trust and intimacy with others.

Because they have a fear of loss, if they experience trauma after their attachment style is formed, it could heighten their need for self-protection. They might become more isolated, dissociative, or angry with others. All in an attempt to keep themselves emotionally safe. This could mean that they will struggle to develop close, intimate relationships. Unless they seek to support and work on these issues.

Anxious-Avoidant (Disorganized) Attachment

For someone who has an anxious-avoidant attachment style (or disorganized attachment style), they face an internal battle of both anxious and avoidant tendencies. They desire closeness. But, once it's there, they become frightened or overwhelmed. Then they tend to push others away.

They want closeness, but it's also the thing that scares them the most. So, this can lead them into a cycle of nearness and distance. They may not even understand why. For example, they might pursue someone they are attracted to. But, once they get close, they become distant. Then they may repeat this cycle and not know why they are doing it.

The anxious-avoidant attachment style is often due to trauma that includes physical abuse, chaotic or scary environments, and/or inconsistent care. This can help explain why they are both attracted to and fearful of closeness. It can also help explain why they might have difficulty forming close, intimate relationships. They may fear getting close to others may result in them getting hurt, both emotionally and physically. Or, that the care/love they receive may be taken away.

What do Attachment Issues Look Like?

Attachment issues can look different for everyone and every attachment type. They often manifest in romantic relationships. But, it can show up in other types of relationships as well. Here are some examples:

Attachment issues can be difficult to manage. But, if you're struggling with them, know that you're not alone. It is common for children who have been placed for adoption or foster care to have attachment issues. And, it is common for people who have experienced trauma to have attachment issues. Because of this, they have attachment wounds that play out in adulthood. They can be difficult to overcome. But, with time, patience, and support, it is possible to develop healthier attachment styles.

Ways to Heal from Attachment Trauma

It may seem difficult or impossible to heal from attachment trauma. Yet, it is possible. Here are some ways that you can work on healing your attachment wounds:

These are just a few ways that someone can begin to heal their attachment trauma. It is important to seek out professional help if you feel like you're struggling to cope. Attachment issues can be difficult to overcome alone. With a therapist's support, you can begin to develop a more secure attachment style.

How do I Create a More Secure Attachment Style?

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​​Attachment Trauma: How Childhood Trauma Can Shape Your Attachment Style as told by a Therapist - White Rock Therapy - Trauma Counseling Texas & New Jersey

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Different forms of attachment can have cascading effects. Learn more about anxious and avoidant attachment and how to heal avoidant attachment style. Read this blog by a trauma therapist in Texas to learn more about how therapy can offer support today.

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This article talks about the "Fear Circuitry" Which is essentially the fight or flight response. This article also goes into detail about how the brain reacts and changes with trauma.

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Neurobiology of Trauma helps to explain many of the common behaviors and experiences of survivors of gender-based violence. Having an understanding of how trauma affects the brain helps to dismantle common misconceptions and victim-blaming statements about sexual violence. Please read the Myth vs Fact document below to learn more!

Key Concepts

The prefrontal cortex is the decision-making/choice-making part of the brain; it's the part of the brain responsible for rational thinking, planning effective responses, remembering important information, etc. When a person is experiencing a traumatic event or experiencing extreme fear, their " Fear Circuitry" may kick in and the prefrontal cortex begins to function less effectively. This means that in the midst of trauma, a person may not be able to think through the situation and make decisions such as calling for help. It is not a matter of choice--their brain is in survival mode and the fear circuitry is bypassing their prefrontal cortex entirely.

Many people are familiar with the concept of "fight or flight," but research shows that there is a third response called " freeze." A common example is a deer in the headlights, and humans have this same fear response--in fact, freezing is the most common reaction to trauma or fear, rather than fighting back or running away.

In addition to freezing, some survivors may experience extreme survival reflexes such tonic immobility or collapsed immobility. If you've ever seen a possum go limp when it is scared, you are familiar with this brain response. Going limp, feeling "sleepy" or passing out, or being completely unable to move or speak are survival mechanisms hard-wired into our brains--even apex predators like sharks have these responses! It is not a sign of weakness, nor is it a choice the person is making.

Survivors may also experience dissociation, which is a survival reflex where someone may feel disconnected from their body or may go into " auto-pilot" mode. In auto-pilot mode, a person is not using their prefrontal cortex to make decisions, but is instead relying upon habitual modes of being. Habitual responses are rooted in socialization--for example, women are socialized to be polite and pleasing, to "save face" or placate. This means that during an assault, a person might engage in sexual acts, say polite things, even smile, but they are not consenting; they are actually experiencing extreme fear and their brain is operating on auto-pilot as a survival mechanism.

Memories are encoded differently during a traumatic event. The brain does not encode memories in chronological order, there are gaps in memory, and whatever the "fear circuitry" in the brain focused attention on during the assault is more likely to be encoded into memory than periphery details. For example, a survivor may have a very clear memory of the smell of the perpetrator's cologne, but not have any memory of what the room looked like. Contextual information (e.g., the layout of a room) and time‐sequence information (e.g., the order in which sexual acts occurred) are often poorly encoded. Again, this is not a conscious choice a survivor is making about what to focus on or remember during an assault; it is a common impact on the brain when the "fear circuitry" survival response kicks in.

These are all based in normal brain processes that occur during extremely
stressful and traumatic situations. They can happen to police officers, soldiers - anyone who is attacked or fears for their life.

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Information about how trauma impacts the brain of victims and survivors, both during and after a traumatic event.

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This article kinda gives you more sources to look into. A certain doctor who has studied this goes into more detail in a book she wrote.

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Applied Neuroscience for Brain Change in the Treatment of Trauma, Anxiety and Stress Disorders | PES

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In this online course, Melanie Greenberg shows the use of applied neuroscience for brain change in the treatment of trauma, anxiety & stress disorders.

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This article really goes into detail about trauma. It goes into detail about what parts of the brain get affected and how. It really goes into detail about what happens to the brain during trauma.

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Understanding the Neurobiology of Trauma Recovery | Bay Area CBT Center

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Explore how trauma affects the brain, its implications for recovery, and practical insights for healing. Read the article for a deeper understanding.

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This article has a lot of other sources that can help.

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The body keeps the score: The neurobiological profile of traumatized adolescents - PubMed

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Trauma-related disorders are debilitating psychiatric conditions that affect people who have directly or indirectly witnessed adversities. Experiencing multiple types of traumas appears to be common during childhood, and even more so during adolescence. Dramatic brain/body transformations occurring …

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Now this article really gets down to it. This article even talks about physical effects that can be caused by trauma. I really liked this article because it had so much information.

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The Neurobiology Of Trauma: Understanding The Brain’s Response To Adverse Experiences 2025 - Kaplan

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This comprehensive guide explores the neurobiology of trauma, examining how adverse experiences reshape neural circuits, recovery and resilience.

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this article talks about the studies that have been done to show the effects of trauma on children

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Neurobiological studies of trauma-related psychopathology: a public health perspective

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The societal burden of psychiatric disorders that result after exposure to psychological trauma is enormous. The study of trauma-related disorders using neurobiological and public health approaches is often disjointed. It is critical to emphasize…

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Now this article talks about what neurobiology is as a whole. I didn't actually know what it was. This article was pretty interesting to read, as it really went into detail about what it was.

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Neurobiology Neurobiology is the study of the nervous system and how the brain works. The field studies nervous system functions, brain function and the related structures such as the spinal cord. Neurobiology is a subset of both physiology and neuroscience. Neurobiology FAQ’s What is Neurobiology? Neurobiology

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This article was kinda short. It really just breezed through a quick thing about how trauma affects the brain.

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The neurobiology of childhood trauma, from early physical pain onwards: as relevant as ever in today’s fractured world - PubMed

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Background: The situation in the world today, encompassing multiple armed conflicts, notably in Ukraine, the Coronavirus pandemic and the effects of climate change, increases the likelihood of childhood exposure to physical injury and pain. Other effects of these worldwide hardships include p …

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I guess this one was short and sweet. It was short little article about coping mechanisms for trauma

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Neurobiology of Trauma and Mindfulness for Children - PubMed

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Adverse child experiences (ACEs) have a significant impact on developing children, both physically and psychologically, with ongoing consequences that may manifest throughout adulthood. These negative health consequences can be mitigated if a child is given a supportive environment in which to devel …

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This article talks about what attachment is and the trauma that comes with it. There are different types of attachment. There are some good attachments and some bad.

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Attachment trauma comes from a rupture in the bonding process between a child and their primary caregiver. Its effects can last well into adulthood.

If you struggle with relationships, there's a dominant cultural narrative that assumes there is something wrong with you.

But science offers us a more expansive view: Our relationship challenges may be rooted in what's known as attachment trauma.

Attachment trauma is "a consistent disruption of physical and emotional safety in the family system. It is not what happens to you, but what happens inside you," says Heather Monroe, a licensed clinical social worker (LCSW) in Nashville, Tennessee, who specializes in treating relational trauma.

A child's early life experiences shape their adult life, and the relationship with their primary caregiver is among the most important for their development.

If a child doesn't have their early relational needs met, this can show up later in life in their mental health, relationships, and sense of self.

As we develop as children, we look to our caregivers for access to a variety of human needs, from shelter to affection. When those needs go unmet, some children can feel alone in highly charged emotional states.

Attachment trauma can occur when a caregiver is a source of overwhelming distress for the child. This is a form of relational trauma, which is trauma that occurs in the context of a relationship with another person.

It's also closely linked with complex trauma, which is trauma from repeated events, such as ongoing emotional abuse or childhood neglect.

While conversations around terms such as " attachment styles " and "attachment theory" are growing in popularity, what is less talked about is how attachment trauma can affect how we move through the world physically, mentally, and emotionally.

Attachment trauma can be felt physically. "Relationships can trigger your nervous system to go into fight, flight or freeze," explains Monroe.

Monroe, who is also a trauma educator, says relational trauma can be a constant, cumulative stress building up in the body over time in both visible and invisible ways.

Attachment trauma often leads to a "disoriented-disorganized" attachment - a pattern that, in turn, imparts an increased risk of further abuse and neglect.

In addition to relationship difficulties, attachment trauma is also linked to our overall mental health, according to a .

"Your nervous system is constantly learning how to be in connection with people. And the biggest thing around that is, is it safe to be in connection or not? There's all these overt ways that it can feel not safe, but also really covert ways that it can start feeling unsafe and shutting us down or revving us up," says Monroe.

Monroe explains there are overt and covert causes of attachment trauma.

Overt causes of attachment trauma include:

divorce in the family

loss in the family, such as death of a parent or sibling

postpartum issues

physical neglect, such as going without basic needs, like food or water

abuse, which could be physical, sexual, or emotional

caregiver(s) facing a life threatening illness

caregiver(s) having a substance use disorder

domestic violence

Covert causes of attachment trauma include a caregiver (or more than one caregiver) who:

is physically or emotionally unavailable

has mental health difficulties, such as depression, anxiety, post-traumatic stress disorder (PTSD), or eating disorders, that may make them less available to be present for their child

has inherited trauma they haven't processed yet and unknowingly pass on to their child

has poor boundaries and tends to treat child more like a friend

objectifies a child's body

uses psychologically controlling tactics, such as not being affectionate, shaming the child, making the child feel guilty, or not validating a child's feelings

may be controlling, which can remove a child's power and individuality

Relationship issues are one of the dominant aspects and often the most painful of attachment trauma. Attachment trauma, like other forms of childhood trauma, can affect adult relationships.

It can, for example, show up in avoiding relationships for fear of rejection, intense fears of intimacy, or being overly attached, such as ending up in codependent relationships.

Along with relationship difficulties, signs you may be facing attachment trauma include:

a tendency toward shame, guilt, and humiliation

hyper-reactivity to stress

hyperarousal

enmeshment

Like other forms of trauma, attachment trauma may be linked with mental health conditions, including:

There's a myth that if you face challenges in relationships, you will always find relationships difficult.

That simply isn't true.

"What attachment science shows us, especially the new attachment science and adults, is that we can change our attachment style at any point in our life, and we can actually change the wirings in our brain at any point in our life," Monroe says.

The process of healing from attachment trauma isn't easy, especially as we might not have immediate access to secure relationships.

It's important to remember that just as we have taken a lifetime to build our attachment style, changing our attachment style can also take time.

Here are some ways to recover from attachment trauma:

Find a connection that provides strength

Humans rely on connection for support and belonging. While one heals from attachment trauma, they don't have to work on their romantic relationships right away. They can start with a friendship, or a relationship with a therapist.

Monroe advises asking yourself which relationship gives you strength and security. Then, you can look at what traits make that happen, so you can better understand how a healthy relationship can function.

She says, "Think about relationships that give you resiliency. What are the qualities of those relationships? Usually, it has to do with being seen, feeling truly seen, feeling heard, and a person that is helpful in regulating your own nervous system."

Consider working with the body

"I look at the body as a vessel for healing, instead of looking at the mind as a way of thinking its way out of the problem," says Monroe, who works with her clients on mindfulness, breath, and grounding exercises.

Research from 2015 found that mindfulness can help treat PTSD.

While talk therapy can be a crucial part of the healing process, a behavioral component to healing such as walking, yoga, or other exercises can also help, according to a

It's common for people with a history of trauma to struggle with typical mindfulness sessions. If this applies to you, consider trauma-informed mindfulness.

What makes you feel calm? The answer to that question can be one way to start reprogramming your nervous system from trauma-response mode such as fight, freeze, flee, or fawn into a more grounded state.

Consider trauma-focused therapy

One of the best things you can do for healing attachment trauma is to try trauma-focused psychotherapy.
You can read about effective types of therapy for trauma here.
If you're looking for a therapist, consider checking out Psych Central's Find a Therapist resource for support in starting your therapeutic journey.

While there are many forms of trauma therapy to consider, here are two to look into:

"You are on a path of healing when your past becomes information with nonneutral energy, and it doesn't define you," says Monroe.

Here are some indicators you are on the right path:

You feel safe in your body.

You're practicing boundary setting.

You trust your intuition.

Your behavior is consistent with your values or beliefs.

You respond, rather than react.

There's no one approach to healing attachment trauma. It's important to take great care along your journey and make your healing process your own.

As you learn more about how your earlier childhood affected the patterns in your adult life, have patience with yourself. While it may take time, remember that healing is possible.

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Attachment Trauma: Effects, Examples, and How to Heal

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Attachment trauma comes from a rupture in the bonding process between a child and their primary caregiver. Its effects can last well into adulthood. If you struggle with relationships, there's a dominant cultural narrative that assumes there is something wrong with you.

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This article was very informative and interesting. I really enjoyed reading this. There was a lot of information to take in. There was a quiz and I did take it. I ended up getting Fearful/avoidant/ unorganized.

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Adoption Triad (2019, October). Attachment and Developmental Stages Throughout Childhood. Child Welfare.

Andersen, T. E., Ravn, S. L., Manniche, C., & O'Neill, S. (2018). The impact of attachment insecurity on pain and pain behaviors in experimental pain. Journal of Psychosomatic Research, 111, 127-132.

Andriopoulou, P. (2021). Healing attachment trauma in adult psychotherapy: The role of limited reparenting. European Journal of Psychotherapy & Counselling, 23(4), 468-482.

Cassioli, E., Rossi, E., Vizzotto, C., Malinconi, V., Vignozzi, L., Ricca, V., & Castellini, G. (2022). Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. The journal of sexual medicine, 19(2), 347-355.

Collins, N. L., & Feeney, B. C. (2004). Working Models of Attachment Shape Perceptions of Social Support: Evidence From Experimental and Observational Studies. Journal of Personality and Social Psychology, 87(3), 363-383.

Dagnino, P., Pérez, C., Gómez, A., Gloger, S., & Krause, M. (2017). Depression and Attachment: How do Personality Styles and Social Support Influence This Relation?. Research in psychotherapy (Milano), 20(1), 237.

Fearon, P., Bakermans-Kranenburg, M. J., Van IJzendoorn, M., Lapsley, A., & Roisman, G. I. (2010). The Significance of Insecure attachment and Disorganization in the Development of Children's Externalizing Behavior: A Meta-Analytic Study. Child Development, 81(2), 435-456.

Lahousen, T., Unterrainer, H. F., & Kapfhammer, H. P. (2019). Psychobiology of Attachment and Trauma-Some General Remarks From a Clinical Perspective. Frontiers in psychiatry, 10, 914.

Malekpour, M. (2007). Effects of attachment on early and later development. British Journal of Developmental Disabilities, 53(105,Pt2), 81-95.

Rees C. (2007). Childhood attachment. The British journal of general practice: the journal of the Royal College of General Practitioners, 57(544), 920-922.

Romeo, A., Tesio, V., Castelnuovo, G., & Castelli, L. (2017). Attachment Style and Chronic Pain: Toward an Interpersonal Model of Pain. Frontiers in psychology, 8, 284.

van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae. Development and psychopathology, 11(2), 225-249.

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Attachment Trauma: What is it? - Attachment Project

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What are the signs and how do we heal from attachment trauma? Read the article now to discover the ins and outs of attachment trauma.

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This article went through each attachment type. It broke everything down and gave some good information.

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Attachment
According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4].

Over time, attachment patterns become internalized and shape how individuals see the self and others in close relationships, which in turn influence how individuals perceive and cope with stress through the lifespan [4].

A researcher named Mary Ainsworth identified three categories of infant attachment styles: secure, insecure avoidant, and insecure ambivalent/resistant [20].

Securely attached babies and children "feel confident that the attachment figure will be available to meet their needs. They use the attachment figure as a safe base to explore the environment and seek the attachment figure in times of distress" [21].

Insecure avoidant children "do not seek contact with the attachment figure when distressed. Such children are likely to have a caregiver who is insensitive and rejecting of their needs. The attachment figure may withdraw from helping during difficult tasks and is often unavailable during times of emotional distress" [21].

Insecure ambivalent/resistant children fail to "develop any feelings of security from the attachment figure. When distressed they are difficult to soothe and are not comforted by interaction with the attachment figure. This behavior results from an inconsistent level of response to their needs from the primary caregiver" [21].

Research has also shown that trauma involving caregivers may significantly disrupt caregiver-child attachment, leading to insecure or disorganized attachment.

Insecure Attachment and Trauma

Inconsistent or unavailable caregivers disrupt children's formation of secure attachments and promote reliance on ineffective emotion regulation strategies, leading to the formation of insecure attachment [26].

Early life traumatic events, such as child maltreatment by caregivers, can disrupt the formation of secure attachment [4].

Longitudinal research suggests that insecure attachment may increase over time among individuals with severe trauma histories and disrupt the developmental process [27].

Insecure parental attachment may lead to negative consequences including increased levels of stress hormones, negative views of themselves and others, and poor regulation of emotion and and/or behavior [1].

Inconsistent and inadequate attachment relationships may also lead to externalizing behaviors (e.g., aggression, bullying) that are linked with subsequent conduct problems [1].

As a result of insecure attachment, feelings of fearfulness and helplessness are generally pervasive through the lifespan and are commonly demonstrated in infant and child behavior [16].

Research shows that fearfully attached individuals are more likely to perceive and interpret events as stressful, which in turn increases their vulnerability to experience adverse psychological symptoms and develop severe psychopathology [25].

The effects of trauma may also be transmitted within relational exchanges that occur between parents and children:

If a parent has untreated trauma, when the parent re-experiences states of terror or rage, the children may be traumatized by the parent's traumatized state and feel frightened by the parent, rather than soothed by them. Consequently, the children may become traumatized themselves [2].

Children may exhibit a tendency to block out or constrict feelings of vulnerability and painful experiences as modeled by attachment figures; over time, children may develop problems identifying and managing their own feelings [16].

Adult survivors of childhood maltreatment are more likely to have insecure rather than secure attachment styles [14]. Trauma survivors with insecure attachment report more trauma-related symptomatology in adulthood [4].

Insecure attachment predicts avoidance of memories of the abuse and avoidant, dependent, self-defeating, and borderline personality disorders in adulthood among incest survivors [12] [13].

Insecurely attached individuals also show higher depression, distress, and posttraumatic stress symptoms than traumatized people who exhibit secure-based attachment [4] [13].

Additionally, older adults who experienced their worst trauma in childhood or adolescence report a higher number of traumatic events through their lifespan compared to older adults who encountered their worst trauma in adulthood [24].

Disorganized Attachment, Trauma, and Dissociation

A fourth category of attachment style was later identified as the "disorganized/disoriented" type [22]. Children exhibiting disorganized behaviors did not fit into the other categories of attachment.

Behaviors coded as disorganized/disoriented included overt displays of fear of the caregiver, contradictory behaviors or affects, misdirected or jerky movements, or freezing and apparent dissociation when approaching the caregiver [23].

This classification has been found to be a risk factor for later developmental problems and tends to be associated with experiencing trauma such as maltreatment during infancy or childhood [23].

In normal, middle class families, about 15% of infants develop disorganized attachment behavior; however, in unhealthy social contexts and in clinical groups this percentage is 2 or even 3 times higher [15].

A meta-analysis revealed that 48% of infants classified as disorganized were assessed by social services as having experienced abuse or neglect [23].

Disorganized caregiver-child attachment is associated with increased vulnerability to later psychological difficulties, especially dissociative experiences [2].

Many dissociative patients may have had disorganized attachment with at least one attachment figure in childhood [8].

Longitudinal research demonstrates that disorganized attachment in infancy specifically predicts dissociation in childhood and early adulthood [7].

Experiencing trauma in infancy also has an enduring impact on the maturation of the right side of the brain [11].

Disorganized attachment may result from parental abuse, neglect, and/or frightening, intrusive, or insensitive behaviors [7].

Parental "frightened and/or frightening behavior" experienced in infancy also leads to an increased vulnerability to dissociative disorders [8].

Dissociative and helpless or withdrawing behaviors in parents have also been found to predict infants' disorganized attachment behaviors [23].

Parents' ongoing experiences of anxiety disorders or forms of social and economic disadvantage have additionally been found to predict disorganized attachment behaviors [23].

Although childhood abuse contributes to the development of dissociative identity disorder (DID), attachment difficulties also likely play a central etiological role in many cases [5].

Blizard (1997) states, "When a child is dependent for survival on a parent or caregiver who is abusive, the child faces an extraordinary dilemma in finding a way to preserve attachment to the caregiver while trying to survive terrifying abuse" [6].

Furthermore, parental loss or other severe life events within the first 2 years of a child's life are also risk factors for the development of dissociative disorders [10].

Severe life events may affect the parental relationship in the crucial period when attachment develops, and contribute to disorganized attachment, which may increase the likelihood of dissociation in later life [10].

[1] Anderson, S. M., & Gedo, P. M. (2013). Relational trauma: Using play therapy to treat a disrupted attachment. Bulletin of the Menninger Clinic, 77(3), 250-268.

[2] Brothers, D. (2014). Traumatic attachments: Intergenerational trauma, dissociation, and the analytic relationship. International Journal of Psychoanalytic Self Psychology, 9(1), 3-15.

[3] Zilberstein, K. (2014). Neurocognitive considerations in the treatment of attachment and complex trauma in children. Clinical Child Psychology and Psychiatry, 19(3), 336-354.

[4] Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2015). The relation between insecure attachment and posttraumatic stress: Early life versus adulthood traumas. Psychological Trauma: Theory, Research, Practice, and Policy, 7(4), 324-332.

[5] Barach, P. M. (1991). Multiple personality disorder as an attachment disorder. Dissociation: Progress in the Dissociative Disorders, 4(3), 117-123.

[6] Blizard, R. A. (1997). The origins of dissociative identity disorder from an object relations and attachment theory perspective. Dissociation: Progress in the Dissociative Disorders, 10(4), 223-229.

[7] Blizard, R. A. (2003). Disorganized Attachment, Development of Dissociated Self States, and a Relational Approach to Treatment. Journal of Trauma & Dissociation, 4(3), 27-50.

[8] Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation: Progress in the Dissociative Disorders, 5(4), 196-204.

[9] Lyons-Ruth, K. (2008). Contributions of the mother-infant relationship to dissociative, borderline, and conduct symptoms in young adulthood. Infant Mental Health Journal, 29(3), 203-218.

[10] Pasquini, P., Liotti, G., Mazzotti, E., Fassone, G., & Picardi, A. (2002). Risk factors in the early family life of patients suffering from dissociative disorders. Acta Psychiatrica Scandinavica, 105(2), 110-116.

[11] Schore, A. N. (2009). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P. F. Dell, J. A. O'Neil, P. F. Dell, J. A. O'Neil (Eds.). Dissociation and the dissociative disorders: DSM-V and beyond (pp. 107-141). New York, NY: Routledge/Taylor & Francis Group.

[12] Alexander, P. C. (1993). The differential effects of abuse characteristics and attachment in the prediction of long-term effects of sexual abuse. Journal of Interpersonal Violence, 8(3), 346-362.

[13] Alexander, P. C., Anderson, C. L., Brand, B., Schaeffer, C. M., Grelling, B. Z., & Kretz, L. (1998). Adult attachment and longterm effects in survivors of incest. Child Abuse & Neglect, 22(1), 45-61.

[14] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1989). Disorganized/disoriented attachment relationships in maltreated infants. Developmental Psychology, 25(4), 525-531.

[15] van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11(2), 225-249.

[16] Lyons-Ruth, K., Yellin, C., Melnick, S., & Atwood, G. (2005). Expanding the concept of unresolved mental states: Hostile/Helpless states of mind on the Adult Attachment Interview are associated with disrupted mother-infant communication and infant disorganization. Development and Psychopathology, 17(1), 1-23.

[17] Lyons-Ruth, K., Bronfman, E., & Parsons, E. (1999). Maternal frightened, frightening, or atypical behavior and disorganized infant attachment patterns. Monographs of the Society for Research in Child Development, 64(3), 67-96.

[18] Main, M., & Hesse, E. (1990). Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism?. In M. T. Greenberg, D. Cicchetti, E. M. Cummings, M. T. Greenberg, D. Cicchetti, E. M. Cummings (Eds.). Attachment in the preschool years: Theory, research, and intervention (pp. 161-182). Chicago, IL: University of Chicago Press.

[19] Bowlby, J. (1969). Attachment and loss, volume 1: Attachment. New York, NY: Basic Books.

[20] Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67.

[21] McLeod, S. A. (2014). Mary Ainsworth. Retrieved from www.simplypsychology.org/mary-ainsworth.html

[22] Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M.T. Greenberg, D. Cicchetti & E.M. Cummings (Eds.), Attachment in the preschool years (pp. 121-160). Chicago, University of Chicago Press.

[23] Duschinsky, R. (2015). The emergence of the disorganized/disoriented (D) attachment classification, 1979-1982. History of Psychology, 18(1), 32-46.

[24] Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2013). The impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults. Developmental Psychology, 49, 2191-2200.

[25] Pielage, S., Gerlsma, C., & Schaap, C. (2000). Insecure attachment as a risk factor for psychopathology: The role of stressful events. Clinical Psychology and Psychotherapy, 7, 296 -302.

[26] Goodman, G. S., Quas, J. A., & Ogle, C. M. (2010). Child maltreatment and memory. Annual Review of Psychology, 61, 325-351.

[27] Mikulincer, M., Ein-Dor, T., Solomon, Z., & Shaver, P. R. (2011). Trajectories of attachment insecurities over a 17-year period: A latent growth curve analysis of the impact of war captivity and posttraumatic stress disorder. Journal of Social and Clinical Psychology, 30, 960 -984.

[28] Kumar, S., & Mattanah, J. F. (2016). Parental attachment, romantic competence, relationship satisfaction, and psychosocial adjustment in emerging adulthood. Personal Relationships. doi:10.1111/pere.12161

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Trauma's Impact on Attachment - TeachTrauma

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Children who are traumatized are at risk for developing complications with attachment. Attachment According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4]. Over time, attachment patterns become internalized and...

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this article was kind of a view from a medical standpoint. I really liked reading this article as it gave some good insight and information.

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Psychobiology of Attachment and Trauma—Some General Remarks From a Clinical Perspective

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Attachment refers to a psychobiological principle that is deeply rooted in evolutionary development; it is thought to contribute a major advantage in the survival of the social group. Within individual development it indicates a primary motivational…

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This article went over the long-term effects of attachment issues. It went over what it would look like in adults.

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Early attachment ruptures can follow clients throughout their life. So how can we help them process the trauma and move forward?

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This article touched base on the effects on infants with attachment issues. it showed how it would affect early on in life.

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It's around 8 or 9 on a Saturday night and I'm on a 3-hour drive home. I'm returning from the field research I do every weekend in California's Central Valley as part of my graduate studies. I'm feeling horrible, but not because of any particular event or problem. The feeling might best be described as an overwhelming mix of self-loathing and despair. And it is quite familiar - I have felt this way most of my life.

I'm listening to talk radio as I often do on these drives. In this case, I have caught part of one of those psychologist radio shows where folks call-in and discuss their issues. She's talking about some new research that is just coming out about how important the first 2 years of life are in shaping the rest of our lives. It's when our core sense of self is formed, and how to operate in the world. The bonding and nurturing humans get within the first two years of life are essential to developing a sense that the world and people around us are safe and that we are, fundamentally, "ok". If we don't get that - and especially if we get the opposite - it has life-long impacts that are difficult to repair.

I have never heard these words before. They are literally stunning and revolutionary for me. I was in my early 30's and at that time my life was defined by a deep-seated belief that I am flawed and bad, coupled with a desperate effort to prove otherwise - to myself and to everyone around me. From my earliest memories, I had felt bad. But in hearing the words of this talk-radio host I entertained, for the very first time, the notion that maybe all of this was not really my fault. Maybe I wasn't born flawed, but rather something had happened to me to make me feel, and sometimes appear, so?

As a matter of fact, I knew from family history that the first two years of my life were, by any definition, a train wreck. My parents had been fighting while my mother was pregnant with me, during which she suffered some degree of physical abuse. Four months after I was born she fled my father and, with myself and my three older brothers, moved to live near her own mother. Then, when I was a year and a half old, she had a mental breakdown that led to her being hospitalized. My brothers and I were separated and placed in institutional children's homes for four months. Surely this was enough to have had the kind of impact this radio psychologist was speaking of?

This was the very beginning of a journey of healing that has taken decades. I am now in my early 60's and can now honestly speak of healing. I spend most of my days feeling at least "ok", and sometimes even "good". And though it may sound like a small thing, simply feeling "ok" is truly a blessed feeling. What I was struggling with, and am finally healing from, is what is now known as Attachment Trauma.

~~~

Attachment Trauma is the severe disruption or dysfunction of the infant-maternal bond. This can result from stress and dysfunction in the family, mental health problems in the mother, and/or extended separation from the mother. (I am referring to a "mother" here, but the same applies to whoever is serving the role of primary caregiver). These are traumatic experiences regardless of when they occur during childhood. However, when they occur during the first 2 years of life they have a uniquely damaging impact, leading to Attachment Trauma. The analogy I like to use is that of a house. When we experience trauma later in childhood or adolescence our house is damaged, sometimes severely, and it can be very hard to repair it. When we experience trauma during infancy the foundation itself is damaged, or simply not there. Without a solid foundation, even building a house is challenging, and whatever has been built is unstable and easily damaged. Also like a house's foundation, the damage is invisible because it occurs at a time we are unable to remember and during a period of life whose significance tends to be underestimated.

The key to understanding Attachment Trauma is to consider how and why we develop the foundational attributes and skills that make us healthy, functioning adults: the ability to manage our emotions, the ability to recognize and respond appropriately to social cues, a fundamental belief in one's worth and belonging, and a presumption that other people and the world itself is essentially safe.

These are all attributes and skills that most take for granted, but we are not born with them. Nor do they develop automatically according to some pre-programmed developmental process encoded in our DNA. Instead, these skills and attributes are learned through the experience of interacting with a reliable and responsive caregiver during the first 2 years of life. When the infant-maternal bond is dysfunctional or disrupted we enter childhood and grow into adults without the foundational skills and attributes that make possible all the rest of the learning and loving and resiliency essential for a happy and healthy life.

Attachment Trauma is not a stand-alone condition or diagnosis per se, but rather it is a core component of the most severe impacts of repeated traumatic experiences in childhood. The symptoms described below will be familiar to those struggling with CPTSD; however, these symptoms are likely to be most severe when the trauma includes attachment disruption and dysfunction during infancy. Developmental Trauma Disorder, which is closely related to CPTSD, includes early attachment disruption as one of its key criteria. Attachment Trauma is also at the core of the most serious mental health conditions associated with childhood trauma, including Borderline Personality Disorder, for which research has established a strong correlation with early attachment disruption; and Dissociative Identity Disorder (formerly called "multiple personality disorder") which results from the most extreme cases of Attachment Trauma and subsequent abuse.

When a traumatic childhood includes Attachment Trauma it leads to a consistent & recognizable constellation of challenges and symptoms later in life. I am going to describe them from the perspective of how I experienced them, but the precise way in which they show up is as variable as our individual childhood experiences. These symptoms include:

Toxic Shame

A deep-seated, pervasive belief that you are deeply and irredeemably flawed and unworthy. Life events and the behavior of others are interpreted through this lens, constantly reinforcing this sense of shame. The internal narrative is not that "I've done something bad", it's that " I am bad". The experience of intense shame is incredibly painful, like a gut punch, and we will go to great lengths to avoid it. For me, that translated into fear of doing or saying anything with which anyone could find fault; resulting in second-guessing every word or action, or taking no action whatsoever. Shame is difficult to regulate because it is difficult to recognize and name. I spent decades operating from this internal sense of shame without knowing what it was because the underlying premise that "I am bad" was unrecognized and unquestioned.

Emotional Dysregulation

Intense, often overwhelming, emotional reactions to simple everyday events - or sometimes seemingly coming out-of-the-blue for no apparent reason. These emotions can be intense sadness, or anger, or fear and anxiety. These intense emotions often lead to behaviors that are harmful to personal and professional goals and relationships.

Chronic Dysphoria & Depression

Underneath the shame and chaotic emotions lies a chronic, distressing mix of anxiousness and sadness called dysphoria. It is a persistent sense that something is very wrong, without being able to identify exactly what that "something" is. Frequently the dysphoria morphs into profound and relentless emotional pain; something I would describe as "a giant stone of grief sitting on my chest". The pain can be crushing and debilitating, and I have known it to last for days and weeks on end.

Unstable Self-Image & Goals

In the face of the intense shame and distressing emotions described above, having a clear and stable sense of ones values and goals is challenging at best. Decision-making tends to be guided by relieving the emotional distress, rather than by an internal compass. And when everything persistently feels "wrong" then no decision feels "right", leading to frequent, seemingly illogical, changes in jobs, career paths, and relationships. Additionally, the very effort of managing these intense emotions exacts a huge cognitive toll, making it hard to make good decisions and remain goal-oriented.

Relational Difficulties

Because we didn't experience a secure and healthy connection with our first caregiver, those with Attachment Trauma have difficulty forming and maintaining healthy relationships in adulthood. The cause of these difficulties can be insecurity and over-dependence on others, or it can be fear and aversion towards others. For many, it is a conflicting mixture of both, as it was for me. The insecurity and over-dependence led to a desperate, sometimes inappropriate, longing to connect with others. The fear and aversion led to social anxiety and discomfort, making it hard to even initiate relationships; upon forming relationships, it sometimes led to my pushing these friends and partners away. While I did establish a few close friendships, most of my early adulthood was spent in a recurring pattern of unrealistic attachments and unstable relationships against a backdrop of painful efforts to be "social".

Dissociation

An experience of being "disconnected from one's own self" that manifests in varying ways, both chronic and recurrent. When one's core is filled with shame, dysphoria, and chaotic emotions it is neither possible nor practical to "show up in the world" as your authentic emotional self. Instead, a separate self is created through which we operate in the world, while the turmoil continues underneath at the same time. For me, this separate-self served as a mask that hid my true self from those around me; I can recall many instances in which I was making jokes and laughing with others while at the same time, underneath, I was in profound pain. This is a chronic state of dissociation.

There are also recurring episodes of dissociation such as feeling cut-off from your emotions - apathetic or numb - or feeling like you are on autopilot and simply an observer of your actions. These episodes are a psychological defense mechanism that often occurs in response to intense emotion or to external stressors. Because interacting with others was inherently stressful for me, I frequently experienced dissociation in social gatherings and intimate interactions. This short-circuited the open and healthy communication needed to establish and navigate close relationships.

Substance Abuse & Self-harm

With the relentless emotional pain described earlier comes to a desperate urge to "make it stop". This can lead to many types of self-destructive behavior when the need to relieve the pain overrides healthy decision-making. For me, this took the form of secret binge drinking, but it can also show up as alcohol and drug addiction or other addictive behaviors. For some, it leads to "cutting", in an effort to replace the emotional pain with something else, anything else. Sometimes this desperation to relieve the emotional pain can lead to the one thing that is guaranteed to "make it stop": taking one's own life.

~~~

You may recognize yourself in the portrait of Attachment Trauma I have painted above. Like I did, you have likely blamed yourself and believed these symptoms reflect some flaw at your core. The first and most important thing to realize is that it is absolutely and emphatically not your fault. You were conceived with the same innate potential for love, joy, and connection as are all humans. But we are all shaped by the forces of biology and nurture, and your brain has developed in the only way it could given the trauma you experienced in infancy. I know from personal experience that the impact of Attachment Trauma is profound. I experienced, in varying degrees, all the symptoms described above for many years; they colored every aspect of my life and shaped every path. However, I also know that recovery and eventual healing is possible. Hopefully, understanding how and why your earliest experiences led to the challenges you face now will help you understand yourself better and facilitate your journey towards healing.
Guest Post Disclaimer: Any and all information shared in this guest blog post is intended for educational and informational purposes only. Nothing in this blog post, nor any content on CPTSDfoundation.org, is a supplement for or supersedes the relationship and direction of your medical or mental health providers. Thoughts, ideas, or opinions expressed by the writer of this guest blog do not necessarily reflect those of CPTSD Foundation. For more information, see our Privacy Policy and Full Disclaimer.

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Attachment Trauma: The Unique Impact of Trauma in Infancy

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It's around 8 or 9 on a Saturday night and I'm on a 3-hour drive home. I'm returning from the field research I do every weekend in California's Central Valley as part of my graduate studies. I'm feeling horrible, but not because of any particular event or problem.

# data[].attributes.body
This article gave resources in helping with getting over attachment issues in a healthy way. It gives so many resources and how to get help.

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The Better You Institute, LLC Therapy and Counseling in Philadelphia

# data[].attributes.attachment_link.title
Understanding the Link Between Trauma and Attachment

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Trauma impacts attachment, affecting emotions and relationships. Learn how childhood trauma disrupts attachment and discover ways to heal.

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It may have been a short article, but it gave some good information. It talked about issues with attachments.

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This article was from the point of view of a therapist. It gave some good information about how to help. It was nice to read about the information from a therapist. and what trauma can do to you with having attachment issues.

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White Rock Therapy - Trauma Counseling Texas & New Jersey

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Someone who has an avoidant attachment style is prone to withdraw or disconnect from others. They tend to keep their distance from others. They see others as too dependent, which frightens them. Those with an avoidant attachment style have fear of loss. As a result, it is masked as independence. They also reduce their own needs for connection.

Their behavior might look like an unwillingness to commit to a relationship. Or, being too particular or picky about another's habits, keeping secrets, and avoiding. They might even seem distant. For example, if you ask how their day was, they will answer with one word like "fine." People with this attachment style might also have trouble being emotionally available to others. They may also have an issue being emotionally intimate with others as they fear getting too close.

Much like the anxious attachment style, the avoidant attachment style is often due to early childhood experiences.

Trauma that could cause avoidant attachment includes neglect. This can explain why they fear getting too close to others. Or, why they feel they have to be so independent. This doesn't mean that they cannot learn to become more dependent on others. But, it will need a lot of extra work to develop a sense of trust and intimacy with others.

Because they have a fear of loss, if they experience trauma after their attachment style is formed, it could heighten their need for self-protection. They might become more isolated, dissociative, or angry with others. All in an attempt to keep themselves emotionally safe. This could mean that they will struggle to develop close, intimate relationships. Unless they seek to support and work on these issues.

Anxious-Avoidant (Disorganized) Attachment

For someone who has an anxious-avoidant attachment style (or disorganized attachment style), they face an internal battle of both anxious and avoidant tendencies. They desire closeness. But, once it's there, they become frightened or overwhelmed. Then they tend to push others away.

They want closeness, but it's also the thing that scares them the most. So, this can lead them into a cycle of nearness and distance. They may not even understand why. For example, they might pursue someone they are attracted to. But, once they get close, they become distant. Then they may repeat this cycle and not know why they are doing it.

The anxious-avoidant attachment style is often due to trauma that includes physical abuse, chaotic or scary environments, and/or inconsistent care. This can help explain why they are both attracted to and fearful of closeness. It can also help explain why they might have difficulty forming close, intimate relationships. They may fear getting close to others may result in them getting hurt, both emotionally and physically. Or, that the care/love they receive may be taken away.

What do Attachment Issues Look Like?

Attachment issues can look different for everyone and every attachment type. They often manifest in romantic relationships. But, it can show up in other types of relationships as well. Here are some examples:

Attachment issues can be difficult to manage. But, if you're struggling with them, know that you're not alone. It is common for children who have been placed for adoption or foster care to have attachment issues. And, it is common for people who have experienced trauma to have attachment issues. Because of this, they have attachment wounds that play out in adulthood. They can be difficult to overcome. But, with time, patience, and support, it is possible to develop healthier attachment styles.

Ways to Heal from Attachment Trauma

It may seem difficult or impossible to heal from attachment trauma. Yet, it is possible. Here are some ways that you can work on healing your attachment wounds:

These are just a few ways that someone can begin to heal their attachment trauma. It is important to seek out professional help if you feel like you're struggling to cope. Attachment issues can be difficult to overcome alone. With a therapist's support, you can begin to develop a more secure attachment style.

How do I Create a More Secure Attachment Style?

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​​Attachment Trauma: How Childhood Trauma Can Shape Your Attachment Style as told by a Therapist - White Rock Therapy - Trauma Counseling Texas & New Jersey

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Different forms of attachment can have cascading effects. Learn more about anxious and avoidant attachment and how to heal avoidant attachment style. Read this blog by a trauma therapist in Texas to learn more about how therapy can offer support today.

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This article really broke things down for me. It gave me some good information and some tips on how to help children who will need it.

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Many early childhood educators are likely to encounter young children who have experienced trauma on a daily basis.

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This article gave some good information on what trauma is and the abuse, and the effects it has on children. This really gave me some insight.

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Overcome past wounds with childhood trauma therapy at Honey Lake Clinic. Call 888.445.0535 to experience compassionate, faith-based care in Florida.

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This really gave some good information. It was a lot to take in. It gave me some good insights.

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This really gave me some good ideas on how to help children. I didn't know what I could do to help. I'm glad I'm finding these sources

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Trauma-Informed Practices in Early Childhood Education

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Implementing trauma-informed care in early childhood education can increase the chances that young traumatized children recover, thrive, and enter kindergarten ready to learn.

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This article really gave me some insight. Reading these stories really helped me understand how trauma affects children and how they grow up.

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Trauma and Learning: Connections and Learning 101 | AZAFAP

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I don’t want to bore you with stories from my childhood but, suffice it to say, there was plenty of trauma to go around for me and my 3 sisters. The 4th birth was even blessed with Fetal Alcohol Syndrome. Not fun.

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This article really broke things down for me. I'm glad I found this article. It gave me a lot of information and helped me understand.

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Explaining trauma informed practice and its benefits in early learning settings

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This foundation does some really wonderful work. I'm glad I found this. I'm hoping that I can do something like this and make a difference in a childs life.

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Child safety must come first: Why Trauma-Informed Practice is…

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Every child has the right to feel safe and supported - especially in environments designed for their learning, care and development. With over 1.4 million…

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This article gave some good information and a lot of ways to help

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Trauma-informed practices and pedagogies are valuable across educational contexts in providing care and ensuring safety for all children. In early childhood education (ECE), there is opportunity for teachers to invest in trauma-informed approaches to enhance and sustain their connections with children and families. This research review explores the philosophies, pedagogies, and resources which teachers can embrace when pursuing trauma-informed ways of working. It also explores the significant contribution that trauma informed practices can make in the short, medium, and long term for children, families, teachers, and communities.
What is trauma informed practice?

While trauma is often associated with abuse and life-threatening experiences, it can extend beyond this[1]. Martin and Berger provide the following definition along with some key examples:

Trauma results from an event, series of events, or circumstances that are physically or emotionally harmful, or life threatening.... Sometimes referred to as Adverse Childhood Experiences (ACEs), these events include child physical, sexual and emotional abuse, neglect and maltreatment, and household adversity, such as parent mental illness, family violence, substance abuse, incarceration, and separation and divorce.

Trauma-informed practice is characterised by an understanding of trauma and its impacts, a recognition of the indicators of trauma, and a preparedness to respond and to prevent re-traumatisation. This review will focus on trauma-informed practices and pedagogies relevant to the early years of children's lives (birth to eight years of age) and ECE settings.

Why is a trauma-informed approach important in ECE?

Trauma-informed approaches are also important in contributing to children's learning and achievement. Trauma and adverse experiences in the early years can impact learning and educational outcomes in a variety of ways[8]. For example, Cole and Camillo write:

When students feel unsafe or marginalised or are in a state of fear, their focus on survival can make their brain unavailable for learning at school. Trauma and overwhelming stress can affect memory, the ability to make logical inferences and to analyse stories, and the capacity to stay focused. Executive functions, such as planning and carrying out a learning task, can become disorganised. Moreover, children can lose trust in the adults and peers around them[9].

While trauma-informed approaches are holistically supportive and can serve the entire community within a centre or school, it is important to note how they may contribute to caring for and protecting vulnerable people and communities. For example, in a recent systematic review of research focusing on ACEs within Northern American Indigenous populations, it was evident that ACEs were higher in Indigenous populations and linked to increased suicidality and psychological distress. The authors noted protective factors to reduce these risks, including cultural identity and connectedness, education, and resilience[12].

Ultimately, it is critical for centres, schools, and their communities to collaboratively invest in trauma-informed approaches to ensure that all children and their families are cared for, and to safeguard the learning and development of young children.

What do teachers need to consider?

There are a number of core considerations which can help teachers build their awareness and preparedness with regards to trauma-informed practice in the early years. This includes centring children by honouring their identities, needs, rights, perspectives, and experiences and placing this at the heart of our practice. It also involves continuing to embrace play and play-based pedagogies, considering one's own wellbeing, and remaining attentive to how our knowledge around trauma-informed practice is developing and growing.

There are many elements of the natural world that can be challenging and/or rewarding for the traumatized child. Some children may be more sensitive to changes in temperature, to the sound or feel of a breeze, or to changes from direct sunlight to a shady area. Whether the exposure involves touching a squiggly, slimy earthworm or packing mud into 'clay bombs', play in nature requires children to take risks to experience and enjoy the natural environment[17].

Looking more broadly across children's rights, trauma-informed practice can potentially contribute to enacting social justice. For example, in a review of trauma-informed teaching frameworks, it was identified that the frameworks align to core social justice principles, support awareness of disempowerment and how education settings may perpetuate this, and provide the tools for teachers to reflect and evolve their practices to avoid continuation of disempowerment of students[20]. It is also worth considering the 'conceptual overlap' between trauma and children's rights, as noted by Bargemen and colleagues who write: 'While the language of trauma, itself, is not explicitly captured in the UN Convention on the Rights of the Child, it is clear that the overarching premise of the Convention identifies children's rights to be free from various types of trauma exposure'[21]. Article 19 is identified as one key example as it focuses on the protection of children from traumatising experiences such as violence, abuse, or neglect[22].

In terms of teachers' and leaders' own wellbeing, it is important to stay attentive to how staff engaged in trauma-informed approaches are coping. For example, there may be risks of increased stress, compassion fatigue, and vicarious trauma[23]. In writing around burnout and how it may lead to compassion fatigue, Nicholson, Perez and Kurtz write:

When early childhood teachers suffer from compassion fatigue they are at risk of losing their ability to have empathy, compassion, and desire to help the children and families they serve. Compassion fatigue can lead caring professionals to lose sight of the original reasons they entered into their work, to help others, and in the case of early childhood teachers, to love, care for, and support the development of young children and their families.

They step through personal and professional strategies for self-care which teachers can consider, noting that these strategies are individualised[24]. A recent study on the impact of trauma-informed attitudes on teachers and school staff indicated that such attitudes may serve as a protective factor against stress[25].

It is also essential to remain mindful that research about trauma and trauma-informed practice is ongoing. Remaining attentive to developing insights will help with sustaining a trauma-informed approach. For example, in a recent study[26] which sought to conceptually expand the list of ACEs, it was established that the original ten categories may not fully encompass all childhood adversity. The study also supported intervention or prevention approaches focused on whole-school mental health.

This is a key point for centre and school communities to embrace: trauma-informed practice should not exist in a 'micro' sense or in isolation. Rather, it is best established and sustained as a collective effort by all teachers and leaders that becomes integral to the culture and function of the setting as a whole. By working together to embrace trauma-informed practices in early childhood education and beyond, all children can be supported to thrive.
Recommended further reading
Hauser, M. D. (2020). How early life adversity transforms the learning brain. https://doi.org/10.1111/mbe.12277

Martin, K., & Berger, E. (2022a). Childhood trauma and its impact. https://theeducationhub.org.nz/childhood-trauma-and-its-impact-2

Martin, K. & Berger, E. (2022b). Trauma-informed practice in early childhood education. https://theeducationhub.org.nz/trauma-informed-practice-in-early-childhood-education/

Nicholson, J., Perez, L. & Kurtz, J. (2018). Trauma-informed practices for early childhood educators: Relationship-based approaches that support healing and build resilience in young children. Routledge. https://doi.org/10.4324/9781315141756
Endnotes
[3] Dobson, M. (2022). Social justice in early childhood. https://theeducationhub.org.nz/social-justice-in-early-childhood-education/

[7] MacLochlainn, J., Mallett, J., Kirby, K., & McFadden, P. (2022). Stressful events and adolescent psychopathology: A person-centred approach to expanding adverse childhood experience categories. Journal of Child & Adolescent Trauma, 15,327-340. https://doi.org/10.1007/s40653-021-00392-8

[8] Cole, S. F., & Camillo, J. E. (2021). Trauma sensitivity in early learning. School Administrator, 78(1), 28-32;

Hauser, M. D. (2020). How early life adversity transforms the learning brain. International Mind, Brain, and Education Society, 15(1), 35-47. https://doi.org/10.1111/mbe.12277

[9] Cole & Camillo, 2021.

[10] Barr, D. A. (2018). When trauma hinders learning. The Phi Delta Kappan, 99(6), 39-44. http://www.jstor.org/stable/44653420;

Hauser, 2020.

[11] Barr, 2018.

[12] Radford, A., Toombs, E., Zugic, K., Boles, K., Lund, J., & Mushquash, C.J. (2022). Examining Adverse Childhood Experiences (ACEs) within Indigenous populations: A systematic review. Journal of Child & Adolescent Trauma, 15, 401-421. https://doi.org/10.1007/s40653-021-00393-7

[13] Minne, E.P., & Gorelik, G. (2022). The protective role of trauma informed attitudes on perceived stress among teachers and school staff. Journal of Child & Adolescent Trauma, 15,275-283. https://doi.org/10.1007/s40653-021-00389-3

[15] Dobson, M. (2019). Recognising and respecting the right of all children to play. https://www.waier.org.au/recognising-and-respecting-the-right-of-all-children-to-play-benefits-of-play/

[17] Goodyear-Brown, 2019.

[18] Goodyear-Brown, 2019.

[23] Damian, A.J., Gallo, J., Leaf, P., & Mendelson, T. (2017). Organizational and provider level factors in implementation of trauma-informed care after a city-wide training: an explanatory mixed methods assessment. BMC Health Services Res earch. https://doi.org/10.1186/s12913-017-2695-0 ;

Nicholson, Perez, & Kurtz, 2018.

[24] Nicholson, Perez, & Kurtz, 2018.

[25] Minne & Gorelik, 2022.

[26] MacLochlainn, Mallett, Kirby, & McFadden, 2022.

By Dr Madeleine Dobson

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Trauma-informed practices and pedagogies for early childhood teachers - THE EDUCATION HUB

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A closer look at some of the ways that teachers can approach their practice in a trauma-informed way.

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This article really broke things down for me. It gave me some really good information.

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As early years practitioners, we play a crucial role in shaping the lives of young children. Our responsibility extends beyond simply teaching and caring; we must also be attuned to the emotional and psychological needs of the children in our care. This is where understanding Adverse Childhood Experiences (ACEs) and implementing trauma-informed care becomes essential.

What are ACEs?

Adverse Childhood Experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). These can include:

1. Physical abuse

2. Emotional abuse

3. Sexual abuse

4. Physical neglect

5. Emotional neglect

6. Witnessing domestic violence

7. Substance misuse within the household

8. Mental illness within the household

9. Parental separation or divorce

10. Incarceration of a household member

Research has shown that ACEs can have a profound impact on a child's development, health, and well-being, potentially leading to long-term negative consequences in adulthood.

The Impact of ACEs on Early Childhood Development

ACEs can affect children in various ways:

Brain Development: Trauma can alter brain structure and function, particularly in areas responsible for learning and behavior.

Emotional Regulation: Children may struggle to manage their emotions effectively.

Behavior: ACEs can lead to challenging behaviors, including aggression or withdrawal.

Learning: Trauma can impact a child's ability to concentrate and retain information.

Relationships: Children who have experienced ACEs may find it difficult to form secure attachments.

What is Trauma-Informed Care?

Trauma-informed care is an approach that recognizes the widespread impact of trauma and understands potential paths for recovery. It seeks to:

1. Realize the widespread impact of trauma and understand potential paths for recovery

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

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

4. Actively resist re-traumatization

Implementing Trauma-Informed Care in Early Years Settings
As early years practitioners, we can incorporate trauma-informed care into our daily practice:

Create a Safe Environment: Ensure your setting feels physically and emotionally safe for all children.

Build Trusting Relationships: Develop consistent, nurturing relationships with children to help them feel secure.

Promote Resilience: Teach and model coping skills, problem-solving, and emotional regulation.

Understand Behavior: View challenging behaviors as potential signs of trauma rather than willful disobedience.

Collaborate with Families: Work closely with families to understand each child's unique experiences and needs.

Practice Self-Care: Recognize that working with traumatized children can be emotionally taxing and prioritize your own well-being.

Continuous Learning: Stay informed about the latest research and best practices in trauma-informed care.

The Importance of Training
Understanding ACEs and implementing trauma-informed care requires specialized knowledge and skills. It's crucial for early years practitioners to receive proper training to effectively support children who have experienced trauma.

National Nursery Training offers an comprehensive course on "Understanding ACEs and Trauma-Informed Care" designed specifically for early years practitioners. This course provides in-depth knowledge about ACEs, their impact on child development, and practical strategies for implementing trauma-informed care in early years settings.

By participating in this course, you'll gain:

A thorough understanding of ACEs and their effects

Skills to recognize signs of trauma in young children

Practical strategies for creating a trauma-informed environment

Techniques for supporting children who have experienced trauma

Tools for working with families affected by ACEs

Methods for promoting resilience in young children

Investing in this training will not only enhance your professional skills but also significantly improve the quality of care you provide to the children in your setting. By understanding ACEs and implementing trauma-informed care, you can make a lasting positive impact on the lives of the children you work with.

To learn more about the "Understanding ACEs and Trauma-Informed Care" course and to register, visit the National Nursery Trainings website or contact their training department. Take this important step in your professional development and become a champion for trauma-informed care in early years education.

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Understanding ACEs and Trauma-Informed Care: A Guide for Early Years Practitioners – National Nursery Training

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As early years practitioners, we play a crucial role in shaping the lives of young children. Our responsibility extends beyond simply teaching and caring; we must also be attuned to the emotional and psychological needs of the children in our care. This is where understanding Adverse Childhood Experiences (ACEs) and implementing trauma-informed care becomes essential.

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This really gave some good information to help me out at work.

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The Importance of Trauma-Informed Care in Early Childhood Classrooms - post

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Explore the importance of trauma-informed care in early childhood classrooms to support children's growth and well-being.

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This article explains what trauma responses are and what can be done to help

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Trauma-Informed Care and Cultural Humility in the Mental Health Care of People From Minoritized Communities

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The prevalence and impact of trauma constitute a public health crisis that is complicated by the cultural heterogeneity of contemporary society and a higher rate of trauma among individuals from minoritized communities. A trauma-informed care…

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This Article talks about PTSD and what it does to the mind and things we can do to help

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Cultural Considerations in PTSD Treatment - iResearchNet

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This article delves into the critical intersection of cultural considerations and post-traumatic stress disorder (PTSD) treatment...READ MORE

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This article talks about how we can get proper help in the schools for those who need it.

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Embedding Culturally Responsive Practices into Trauma-Informed Schools | IES

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Educators can take concrete steps to identify and dismantle racist practices that may exist within schools and contribute to student racial trauma.

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This article talks about how minorities are affected.

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Cultural Adaptations to the Assessment and Treatment of Trauma Experiences Among Racial and Ethnic Minority Groups: A Mixed-Methods Systematic Review and Meta-Analysis - Lewis Benjamin, Steve Gillard, Jessica Jones Nielsen, Mariana Costa E. Silva, Jacqueline Sin, 2025

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A higher prevalence of post-traumatic stress disorder (PTSD) exists among racial and ethnic minority groups who experience trauma; however, little is known abou…

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This article talks about how to help those kids who need help with trauma.

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This article is really informative. It goes into detail about what happens to kids when they don't get the help they need to get through the trauma

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I think the title explains itself. It was a pretty good read actually. I got a lot of good information

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This article gave some good information. It also gave some good resources.

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Creating Accessible, Culturally Responsive, Trauma-Informed Services and Organizations - NCDVTMH

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Our Work Creating Accessible, Culturally Responsive, Trauma-Informed Services and Organizations NCDVTMH offers a unique, integrated approach to creating accessible, culturally responsive, and trauma-informed (ACRTI) domestic and sexual violence (DSV) services […]

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This article goes into detail about all the different backgrounds and different people

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It's not really an article per say but it has a lt of information about trauma responses.

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Culturally Responsive approaches to trauma - Bing

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Intelligent search from Bing makes it easier to quickly find what you’re looking for and rewards you.

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This article talks about the formative years and how they are important.

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They call them "the formative years" for a reason. A wealth of research has shown that stress and hardship in childhood-such as that caused by abuse, neglect, exposure to violence and mental illness in caregivers-can alter the brain architecture of a developing child. Those physiological changes, in turn, raise the risk of cognitive and developmental delays, physical health problems such as diabetes and heart disease, and behavioral and mental health problems such as substance abuse and depression.

Yet some people flourish despite those long odds, and psychologists are homing in on the factors that boost resilience.

Early on, resilience researchers focused on traits of resilient individuals, says University of Minnesota psychologist Ann S. Masten, PhD, who has studied the subject for 40 years and directs the Project Competence program of research on risk and resilience. More recently, the field has shifted toward looking at resilience from a systems perspective, she says. "The resilience of an individual depends on drawing resources from many other systems."

To be sure, some resilience factors are drawn from within, involving abilities such as problem solving, self-control, emotion regulation, motivation to succeed and self-efficacy. But external factors are important, too. Some of those influences are related to the attachment system, including having supportive parents or primary caregivers, close relationships with other caring adults and close peer relationships. Still others exist in systems beyond the family, such as effective schools and neighborhoods and the qualities of faith and hope embedded in spiritual and cultural beliefs.

"A child is embedded in interactions with friends, family, community. The way those other systems are functioning plays a huge role in the capacity of that child to overcome adversity," Masten says.

Those same resilience factors show up in research again and again, in many different populations. And that short list of protective systems also serves as a checklist of places to intervene to aim a child down a promising path.

Relationships foster resilience

Researchers agree that, of all the factors that boost resilience, good parenting is often the most significant. "The thing that makes the biggest difference, over and above one's genetic blueprint, is the relationship a child has with a primary caregiver," says Philip Fisher, PhD, a professor of psychology at the University of Oregon who studies early childhood interventions to improve the functioning of children from disadvantaged backgrounds. "The presence of a supportive, consistent and protective primary caregiver-especially when the underlying stress systems are activated-is the factor that makes the biggest difference in healthy development."

Many of the problems that stem from childhood adversity involve inadequate self-regulation, which has been linked to parents' behaviors and the home environment. As described in a detailed report from the U.S. Department of Health and Human Services Office of Planning, Research and Evaluation, children who have experienced maltreatment, harsh parenting and challenges such as poverty and food insecurity show poorer self-regulation in cognitive, emotional and behavioral domains. Yet parental warmth, responsiveness and sensitivity foster the development of self-regulation, and can buffer the effects of other stressors (Self-Regulation and Toxic Stress, OPRE Report #2015-30, 2015).

"Resilience rests, fundamentally, on relationships," says Suniya Luthar, PhD, a professor of psychology at Arizona State University who has studied vulnerability and resilience for more than three decades.

This year, she and her colleague Nancy Eisenberg, PhD, published a special section in the journal Child Development to highlight evidence-based interventions demonstrated to maximize resilience in families and children ( Child Development, Vol. 88, No. 2, 2017). Among those articles addressing diverse vulnerable populations, many highlight programs that support parents. "If you want a child to be functioning well, tend to the person who's tending the child," Luthar says.

In one paper, Amanda Sheffield Morris, PhD, and colleagues reviewed several programs designed to strengthen social support for parents and increase positive parent-child interactions to improve well-being for children living in poverty.

In one brief home-visit program, for instance, parents were helped to develop skills for becoming more positive and effective in their parenting, and were referred for additional family-based interventions as needed. Parents who participated in the program showed more positive parenting behaviors and fewer depressive symptoms. Their children showed fewer internalizing and externalizing problems.

Another program for mothers promoted their responsivity to their children, maternal feelings of support from their communities and maternal self-efficacy. The mothers attended weekly group sessions led by trained supervisors at early childhood agencies or pediatric primary-care sites. Compared with the control group, children whose mothers participated had fewer behavioral and socioemotional problems.

Increasing access to such programs could have a significant effect on public health by improving health and well-being in childhood and beyond, Morris and her co-authors conclude. By partnering with community sites-such as pediatric clinics and Head Start centers-the programs could be scaled up to reach large numbers of at-risk families, they say ( Child Development, Vol. 88, No. 2, 2017).

Better parenting

Other papers in the special section focus on specific subsets of parents. In one, Sherryl Goodman, PhD, and Judy Garber, PhD, explored evidence-based interventions for mothers with depression-a significant risk factor for maladjustment in young children. Depression can negatively affect parenting behaviors: Depressed mothers are more likely to be disengaged, harsh or critical with their kids.

But a variety of research has shown that treating maternal depression can trickle down to improve mental health in kids. Goodman and Garber reviewed programs that involved interpersonal therapy or cognitive-behavioral therapy (CBT) strategies to manage maternal depression and improve parenting, and found both in-home programs and those administered through sites such as child-care or community health centers improved parenting skills and reduced depression in mothers and their children ( Child Development, Vol. 88, No. 2, 2017).

In another example, Zoe E. Taylor, PhD, and Rand Conger, PhD, reviewed the evidence for enhancing the strength of single mothers. Several factors boost well-being and positive parenting behaviors for these mothers, including perceived social support from friends and family, as well as internal traits such as high optimism, self-efficacy and self-esteem, the authors say.

After reviewing the research, Taylor and Conger concluded that interventions that combine peer support for mothers and CBT are likely to improve single mothers' coping skills, increasing their well-being and that of their children. Group-based interventions are likely to be particularly effective, because they are both cost-effective and they encourage participants to form meaningful and lasting connections with one another, strengthening their social support networks ( Child Development, Vol. 88, No. 2, 2017).

When it comes to the role of fathers in a child's well-being, numerous studies have found associations between fathers' positive parenting and children's cognitive, social and emotional development and mental health, as Marsha Kline Pruett, PhD, and colleagues describe in another review in the special section. Unfortunately, interventions to increase fathers' involvement in low-income families have had mostly disappointing results, Pruett and her colleagues note. But their research suggests that focusing on couples, rather than fathers alone, can have positive effects. Through their Supporting Father Involvement project, Pruett and colleagues held weekly group sessions for low-income families that covered such topics as strengthening the couple's relationship, paternal involvement and finding help to deal with external stresses. Families who participated in the program reported increases in father involvement and decreased parenting stress. And while families in the control group reported increasing problem behaviors in their children, those who participated in the intervention reported no such increase ( Child Development, Vol. 88, No. 2, 2017).

Social-emotional schooling

Investing in children's development early pays off exponentially, Masten says. "The skills you need at one age are the platform for building future skills. If you establish a sound foundation early, you can build forward."

Yet research has shown that children raised in poverty are more likely to start school with fewer social-emotional skills. And such skills matter, says Roger Weissberg, PhD, a professor of psychology and education at the University of Illinois at Chicago, and board vice chair and chief knowledge officer at the Collaborative for Academic, Social, and Emotional Learning (CASEL), a national organization working to incorporate evidence-based social and emotional learning into education.

In a meta-analysis of more than 200 studies, Weissberg and colleagues found that children who participated in evidence-based social-emotional learning (SEL) programs had better social skills, behavior and attitudes, as well as academic achievement gains of 11 percentile points, compared with children who did not participate ( Child Development, Vol. 82, No. 1, 2011).

The earlier children develop those skills, the better, researchers agree. "Early adolescence is a period of rapid change in the brain, and it might be a good window to recover some functioning and recover to a good trajectory," Masten says.

Luthar agrees that adolescence is a critical period. But it's more than just an opportunity to correct for early adversities, she says. It's also a period when new developmental issues arise-and there's a need for more programs targeting adolescents and their parents. "The onset of adolescence presents its own set of unique challenges that must be directly addressed among at-risk populations," she says. "The needs, dilemmas and parenting challenges are entirely different for parents of at-risk adolescents as compared to at-risk toddlers-and so much is at stake as kids start to explore things like sex, drugs and delinquency."

The good news is that support for school programs that emphasize social and emotional learning is growing as educators and administers realize that such programs benefit all children, whether they're at risk of maladjustment or not. "Teachers and principals see these as critical strategies to enhance children's development," Weissberg says.

Social-emotional learning programs target many of the same skills that predict resilience: self-awareness, self-management, responsible decision-making, social awareness and relationship skills. Through CASEL, Weissberg and his colleagues review social-emotional learning interventions nationwide and help districts implement effective programs in their schools. So far, they've worked with 20 large urban districts, reaching about 2.5 million kids, he says.

"If you have kids who have experienced trauma and they're at risk, I think it's critical for them to have schooling that promotes their social, emotional and academic competencies. If you don't do that, you're not going to be able to meet their needs," Weissberg says.

Still, for some children whose brain development was derailed by hardship, school-based programs might not go far enough. They may need more tailored interventions-but to customize those interventions, it helps to know what's missing. New advances in neuroscience are helping to uncover those mechanisms and point toward interventions, says Fisher ( New Directions for Child and Adolescent Development, Vol. 2016, No. 153, 2016).

Children from high-adversity backgrounds often have trouble learning from their mistakes, for instance. Using neuroimaging, he and his colleagues showed that such children don't show normal patterns of brain activity after receiving corrective feedback when they make a mistake during a computer task. "It's not that the kids don't care. The information isn't getting through," he says.

But in a pilot study of foster children from high-adversity backgrounds, he and his colleagues demonstrated that those brain patterns could be changed through a family-based intervention that provided regular services from behavioral specialists, therapeutic playgroups and extensive support for foster parents.

With the right support, in other words, at-risk children can learn to make use of the information that can help them thrive. "Neuroscience measures allow us to understand more precisely the things that have been impacted [by adversity], and can help us tailor our interventions," he says.

Emerging findings from neuroscience can help researchers zero in on strategies that can help struggling children succeed. Yet, in the recent Child Development special section, the co-authors caution that for interventions intended for use on a large scale, it will be impractical to use biological measures to personalize interventions. Furthermore, when programs are known to be generally beneficial, it could be ethically questionable to plan to exclude some kids based on aspects of their biological or genetic profiles.

Following up on the Kauai Study

Some of the brain changes resulting from early-life hardships are likely to persist, Fisher says. Still, research shows it is possible to continue to develop skills related to resilience, even into adulthood. For proof, look to Hawaii.

In 1955, psychologists Emmy Werner, PhD, and Ruth Smith, PhD, launched the Kauai Longitudinal Study, which has followed all the children born on Kauai that year from birth into adulthood. Nearly a third of those children lived in impoverished or stressful conditions, such as in families with mental illness or alcoholism.

Many children developed mental health or behavioral problems in childhood, but about a third seemed to thrive despite those setbacks. They showed no signs of behavioral or learning problems and developed into competent, well-adjusted adults.

Werner and Smith identified common protective factors among those standouts. Resilient participants tended to have a well-developed sense of their own self-efficacy, and supportive relationships with at least one reliable family member and other caring adults such as teachers and community elders.

What was intriguing about the Kauai study, however, wasn't that a third of the kids thrived despite adversity. It was that among the two-thirds of at-risk children who did show signs of problem behavior in childhood and adolescence, the majority had turned things around by age 40, as Werner described in a report for Portland State University ( Focal Point: Research, Policy, and Practice in Children's Mental Health, Vol. 19, No. 1, 2005).

When she surveyed participants at 40, Werner found that the turning point usually came from forces that presented the participants with new opportunities: continuing education in adult high school or community college, joining the armed forces, marrying a stable partner, participating in a religious community, recovering from serious illness or accident, and in some cases, psychotherapy.

"There isn't a formula that dooms or blesses a child with success," says Laurie "Lali" McCubbin, PhD, a psychology professor at the University of Louisville who has since taken over as principal investigator of the Kauai study. "There are many pathways of resilience."

McCubbin recently followed up with the participants, now in their 60s. Many of those who have created stable, happy lives have drawn support from their cultural heritage, she says. One man, who had been abandoned by his mother as a child, drew purpose from his Hawaiian culture and his island, becoming involved in local conservation efforts and spending time on the water when something was troubling him. Another, who as a child had a difficult relationship with his father, took pride in caring for his dad in old age.

That experience of drawing meaning from adversity is something that clinical and counseling psychologists can help facilitate, McCubbin adds.

"What I love most about resilience is the creativity involved. It's wonderful as a clinician to help clients negotiate that experience in therapy," she says. "Resilience is a process, and we can help clients change at any point in the lifespan."

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They call them "the formative years" for a reason. A wealth of research has shown that stress and hardship in childhood-such as that caused by abuse, neglect, exposure to violence and mental illness in caregivers-can alter the brain architecture of a developing child.

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This was a great read. It really broke everything down for us

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Last fall, I spent a week with a friend I hadn’t seen in 40 years. To my great relief, what we loved about each other as teens survived the ensuing years of our very different lives. As we each told stories to “catch up”, I realized that in spite of great tragedy in her adult life (she buried two husbands and a baby, and went through bankruptcy as a newly single parent after “pre-existing conditions” nixed insurance coverage for the costs of her now-deceased husband’s heart failure treatment and hers for cancer) she had other stories to demonstrate her resilience and commitment to a joyful life (she had 10 tickets to the Rolling Stones stolen from her van only to have a friend replace them at no cost. She became the self-described “redneck Martha Stewart” with TV spots for her mosaic art and craft lessons). I feel honored to be privy to these stories and haven’t laughed that hard in years.

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This was a really good read. It gave some really good information about how things affect children and how it carries with them

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Safe, Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs)

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Protective factors can build resilience and potentially moderate the long-term impact of adverse childhood experiences (ACEs). To better understand the role of protective factors, this study examines the relationship of two protective factors…

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By Mental Health First Aid USA on January 18, 2022

According to the National Survey on Drug Use and Health, an estimated 52.9 million people, or 21% of adults ages 18 years or older, experience a mental health or substance use challenge each year. As the COVID-19 pandemic lingers, those numbers are likely to be higher, with roughly three out of four adults reporting that the pandemic has negatively affected their mental health. This means that someone you know may be facing a mental health challenge right now and needs your support more than ever before.

It's common to believe mental health challenges are simply periods of feeling 'down' or 'anxious.' Although these feelings are important to monitor and take care of, diagnosed mental health challenges are much more complex - and they can cause serious roadblocks in people's lives. "A mental health disorder may be present when patterns or changes in thinking, feeling or behaving cause distress or disrupt a person's ability to function" (Mayo Clinic, 2021). A mental health disorder can impact a person's ability to study, work, look after themselves and carry-on relationships with family and friends. In fact, mental health challenges are the leading cause of disability in the United States and Canada, accounting for 25% of years of life lost due to disability or early death.

Not all mental health challenges happen in a vacuum. They often occur simultaneously. For example, it is not unusual for a person with an anxiety disorder to also develop depression, or a person who is depressed to also have a substance use challenge. Episodes of co-occurrence or dual diagnosis are very common. Research shows that in a one-year period, 14.4% of adults in the United States with any mental health challenge have one disorder; 5.8% have two disorders; and 6% have three or more disorders. And according to the National Survey on Drug Use and Health, among adults aged 18 or older in 2020, 6.7% (or 17.0 million people) had both a mental illness and a substance use disorder.

A number of different factors - some biological or psychological, others social or environmental - can give people greater protection from or increase their risk of experiencing a mental health or substance use challenge. Effective reduction of mental health and substance use challenges focuses on bolstering protective factors and reducing risk factors.

Protective factors include individuals, families or communities that support resilience, help people more effectively manage stressful events, and strengthen other characteristics that minimize the risk of mental health or substance use challenges. They can include participation in group activities outside of work and school, supportive family relationships, religious or spiritual practices, other social support, physical exercise and healthy diet, positive emotions and hope for the future, and active coping skills, such as journaling, connecting with community clubs or groups, talking to a trusted person about how you're doing, using online support groups or chat rooms, writing, creating art or music, or developing a hobby.

Together, protective factors and coping skills can bolster resilience - a person's ability to "bounce back" or overcome adversity. Resilience involves behaviors, thoughts and actions that can be learned and developed in anyone over time.

It's common to think of resilience as optimism or a sunny disposition. While it may be true that some people seem to naturally be more happy, mental health challenges can impact anyone at any time. Being resilient doesn't keep you from experiencing difficulties or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma, and the road to resilience is likely to involve considerable emotional distress. But the combination of strong protective factors and managing emotional distress in a healthy way builds long-term resilience.

As a Mental Health First Aider, you can encourage specific resources and supports that can increase the protective factors a person has in their life. By understanding what protective factors are, you can actively support those in your life, improve their resiliency and lower their overall risk for any mental health and substance use challenges. You can also help people cope with any symptoms they may be feeling in a healthy and safe way.

For more information on how you can support those around you, check out other MHFA blogs:

1. Five Ways to Support a Loved One with Anxiety or Depression - Mental Health First Aid

2. ALGEE: How MHFA Helps You Respond in Crisis and Non-crisis Situations - Mental Health First Aid

3. You Can Support Someone's Journey to Recovery - Mental Health First Aid

4. How to Support a Loved One Going Through a Tough Time During COVID-19 - Mental Health First Aid

Sources:

Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 national survey on drug use and health. (HHS Publication No. SMA 18-5068, NSUDH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf.

U.S. Burden of Disease Collaborators. (2013). The state of US health, 1990-2010: Burden of diseases, injuries, and risk factors. JAMA, 310(6), 591-606.

Mayo Clinic. (2021, December 14). Mental health: What's normal, what's not. Mayo Clinic. Retrieved January 7, 2022, from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/mental-health/art-20044098

Mental Health First Aid USA. (2020). Mental Health First Aid USA for adults assisting adults. Washington, DC: National Council for Mental Wellbeing.

National Institute of Mental Health. (2017, Nov). Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154785

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H.-U. (2012). Twelve month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169-184.

SAMHSA. (2021, October). Key substance use and mental health indicators in the in the United States: Results from the 2020 National Survey on Drug Use and Health. SAMHSA. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

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How Protective Factors Can Promote Resilience

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According to the National Survey on Drug Use and Health, an estimated 52.9 million people, or 21% of adults ages 18 years or older, experience a mental health or substance use challenge each year. As the COVID-19 pandemic lingers, those

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This was a good read about how being positive can help children who really need it.

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Research

Open access

Published:

Child and Adolescent Psychiatry and Mental Health 17, Article number: 140 (2023) Cite this article

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Abstract

Introduction

The residuals approach, in which residual scores from regression models are used as a proxy for resilient functioning, offers great potential to increase understanding of resilience processes. However, its application in child and adolescent wellbeing research is limited to date. We use this approach to examine how adversity exposure impacts later wellbeing (life satisfaction, and internalising mental health difficulties) in the early-to-middle adolescence transition; whether gender and ethnic differences in resilience exist; which internal and external factors confer protective effects for resilience; and, whether the protective effect of these factors differs by gender and level of adversity exposure.

Method

Secondary analysis of the #BeeWell longitudinal data set (N = 12,130 adolescents, aged 12/13 at T1 and 13/14 at T2, representative of Greater Manchester, England) was undertaken, using a series of linear regressions to establish adversity indices for later wellbeing, before assessing the protective effects of internal and external factors on resilience.

Results

Multiple adversity factors (e.g., home material deprivation, sexuality discrimination, bullying) were found to impact later wellbeing. Girls and white adolescents presented lower levels of resilience than their peers. Internal psychological factors (self-esteem, emotional regulation, optimism) consistently conferred the strongest protective effects, but behavioural/activity factors (physical activity, sleep) also contributed to resilience. Among external factors, friendships and peer support were the most salient. Physical activity yielded stronger protective effects among boys (compared to girls). Effects of protective factors were stronger among those at lower (compared to higher) levels of adversity exposure.

Conclusion

The residuals approach can make a considerable contribution to our understanding of the interplay between adversity exposure and access to protective factors in determining adolescent wellbeing outcomes. Moreover, its application provides clear implications for policy and practice in terms of prevention (of adversity exposure) and intervention (to facilitate resilience).

Introduction

Use of the term 'resilience' has become so ubiquitous that some have argued that it has become, "an empty word that can be filled with almost any meaning" [ 1]. However, a review of key resilience theories [ 2] offers some specificity, noting that all contain two core tenets. The first is the presence of adversity (sometimes also referred to as risk, challenge, or stressors). The second is the demonstration of positive adaptation (sometimes also referred to as positive outcomes, adjustment, coping, or functioning). Adversity refers to factors operating at multiple systemic levels that threaten adaptation or development [ 3], representing threat (the presence of harmful inputs in the environment, such as bullying) and/or deprivation (the absence of expected inputs from the environment, such as neglect) [ 4]. Critically, positive adaptation must be demonstrated in spite of exposure to said adversity. Thus, resilience can be defined as, "the capacity of a dynamic system to adapt successfully to disturbances that threaten system function, viability, or development" [ 5].

What engenders resilience? In her seminal work, Masten concludes that it is built through ordinary rather than extraordinary processes (i.e., 'ordinary magic' [ 5]). In terms of how these processes operate, the adolescent resilience framework theorises that access to particular developmental assets moderates the relationship between exposure to adversity and developmental outcomes [ 6]. These assets are viewed as protective factors as their influence varies by levels of adversity exposure [ 3]. In both resilience theory [ 2] and the developmental assets framework [ 7], a distinction is drawn between those that are internal (e.g., self-esteem) and those that are external (e.g., parental support). Multiple reviews of the evidence base have identified a range of these protective factors that operate, like adversity factors, at multiple systemic levels [ 8, 9, 10]. None are particularly rare or special qualities, offering support for the ordinary magic thesis [ 9].

In the current study, we focus on adolescent resilience, with specific reference to wellbeing outcomes. Wellbeing has traditionally been conceptualized through two main theoretical lenses. First, in the hedonic/subjective framework, it comprises an affective component (positive and negative affect), and a cognitive component (life satisfaction, LS), and emphasizes 'feeling good' [ 11]. Second, in the eudaimonic/psychological framework, wellbeing is defined in terms of autonomy, purpose in life, environmental mastery, personal growth, optimism, self-acceptance, and/or positive relations with others, and emphasizes 'flourishing' [ 12]. Broader conceptualisations of wellbeing include symptoms of mental health (MH) difficulties and/or use the terms wellbeing and MH interchangeably (e.g., [ 13, 14]).

Measuring resilience: the residuals approach

As a concept that is inferred rather than observed, measuring resilience is challenging; a variety of approaches are evident in the current literature, none of which are considered to offer a 'gold standard' [ 21, 22, 23]. However, one very promising and innovative method that has emerged in recent years is the so-called 'residuals' approach. The basic premise is that a metric of resilience can be derived using standardised residual scores from models in which an outcome representing adjustment on a construct of interest (e.g., internalising symptoms) is regressed onto a series of adversity factors (e.g., exposure to discrimination) [ 23]. The standardised residual score for such a model represents the difference between actual adjustment and adjustment predicted by adversity. This enables us to identify those who are doing better than would be expected based on their exposure to adversity (i.e., those who are 'resilient') [ 22].

The residuals method is particularly attractive as it quantifies resilience using a continuous, meaningful metric from vulnerability (negative residual scores that fall below the fitted regression line) to resilience (positive residual scores that fall above the fitted regression line). It also enables analyses that offer specificity in terms of underpinning protective processes (i.e., the extent to which a putative protective factor predicts later resilience, and whether this varies by levels of adversity exposure) [ 22]. However, its application to date in the study of child and adolescent resilience is limited. The research which has been undertaken can be divided into studies that adopt a population health perspective (thereby drawing on large, representative cohort datasets), and studies that take a clinical approach (thereby drawing on targeted/indicated datasets, such as offspring of depressed parents [ 24], trauma-exposed adolescents [ 25], or those considered to be at-risk [ 26]. The current study is an example of the population health approach; accordingly, we review analogous research below.

Focusing on familial adversities, Miller-Lewis et al. [ 22] analysis of longitudinal data from Australian children used the residuals method to identify both internal (e.g., self-concept) and external (e.g., child-teacher relationships) factors associated with greater MH resilience in a two-year period between pre-school and school entry, while also noting those whose effects were amplified under conditions of high adversity (e.g., self-control). Also focusing on familial adverisities, but instead working with adolescents, Van Harmelen et al. [ 27] analysis of 1-year longitudinal data identified friendship support as a significant positive predictor, and (somewhat surprisingly) family support as a negative predictor, of later resilient functioning. Finally, Cahill et al. [ 23] drew on a range of factors spanning parent/familial (e.g., parental mental health problems), peer group (e.g., bullying), and neighbourhood (e.g., low neighbourhood satisfaction) adversities experienced during adolescence to examine MH resilience during emerging adulthood. The authors identified a number of protective factors, including self-esteem, positive sibling relationships, good temperament, and positive perceptions of school.

It is important to note that the interplay between adversity exposure and access to protective factors in determining adolescent wellbeing outcomes is not expected to be uniform across the adolescent population. First, we might reasonably expect effects to vary across gender, resulting from socialisation and intensification effects in relation to, for example, expectations and values pertaining to putative protective factors such as friendships and social support [ 28, 29]. Second, the social-ecological systems within which development occurs are not culturally neutral, and it has long been theorised that the mechanisms that support adjustment to adversity are, at least in part, culturally specific [ 30, 31], meaning we might reasonably expect ethnicity to moderate resilience. Finally, while protective factors are, by definition, those that confer advantage in the presence of adversity (operationalised in residuals studies through their association with the residuals score), it stands to reason that variability in levels of adversity exposure may moderate the magnitude of their effects, with some factors more (or less) potent in the context of increasing adversity [ 5].

The current study

In the current study, we use the residuals approach to identify internal and external protective factors for adolescent resilience at multiple system levels. We build upon the above evidence base and extend it in a number of important ways. First, we focus on the transition between early- and mid-adolescence (age 12-14), which immediately precedes the peak age-of-onset for lifetime cases of MH difficulties [ 33], thereby enabling insights into protective processes during a period of particular vulnerability. Second, we use data from a large sample collected after the Covid-19 pandemic (Autumn 2021 onwards). This is particularly critical given its impact on young people's MH [ 34], and consequent implications for the nature and extent of adversity exposure and access to protective factors [ 35]. Third, we use a longitudinal dataset. Doing so enables temporal precedence to be established (i.e., adversity exposure and access to protective factors preceding wellbeing outcomes). This is not possible in cross-sectional research, which remains predominant in the study of adolescent resilience research [ 8].

Fifth, we assess convergences and divergences in the influence of these factors on two important wellbeing outcomes: LS and internalising MH difficulties. Finally, we also consider socio-demographic differences in resilience and protective factors. The following research questions (RQs) drive our inquiry:

1. 1.
How does adversity exposure impact later wellbeing during the transition from early to middle adolescence?

2. 2.
Are there gender and ethnic differences in resilience in this period?

3. 3.
Which internal (sleep hygiene, physical activity, self-esteem, emotion regulation, and optimism), and external (parents/carer support, friendships and social support, and school staff support) factors confer protective effects for adolescent resilience?

4. 4.
Does the protective effect of these factors differ by gender and level of adversity exposure?

Our intended contribution to the broader field of adolescent mental health and wellbeing research in addressing these important questions is to provide insights into the often overlooked yet critical aspect of resilience processes in this population. The residuals approach not only sheds light on the impact of adversity exposure on later wellbeing, but also offers a novel lens through which to examine the protective effects of internal and external factors. By providing a nuanced exploration of the interplay between adversity exposure and access to protective factors in determining adolescent wellbeing outcomes, we hope to pave the way for informed policy and intervention strategies that promote adolescent wellbeing by addressing adversity exposure and fostering resilience factors.

Methods

Sample

Our secondary analysis draws on the first (T1) and second (T2) annual data points of the #BeeWell study in Greater Manchester [ 38]. #BeeWell's hybrid population cohort study design includes a truncated longitudinal study in which participants are surveyed with annual data points from age 12-15 (e.g. from Year 8 to Year 9 to Year 10 of secondary school; Sample 1) and a repeated cross-sectional study comprising annual data points for participants aged 14-15 (e.g. those in Year 10 of secondary school at a given data point; Sample 2). We consider all adolescents from the Sample 1 at T1 (2021) (Year 8, aged 12-13, N = 20,241) who took the survey in T2 (2022) when they were Year 9, aged 13-14 (N = 12,130).

Given the attrition rate observed between, we compared complete (T1 and T2) and incomplete (T1 only) cases (see Additional file 1: Table S1). Differences were small and trivial for socio-demographic variables (e.g., gender, ethnicity), candidate protective factors (e.g., physical activity), and adversity factors (e.g., bullying victimisation). Notable exceptions to this were the two socio-economic adversity indicators, where larger differences were observed (c.7% higher among incomplete cases), a point which we return to in the Discussion section.

Within our analytic sample, individual-level data were available on a wide range of wellbeing domains/indicators and drivers, in addition to multiple individual characteristics, from which we derive the adversity factors, wellbeing outcomes, candidate protective factors, and co-variates outlined in Table 1.

Measures

Study variables are detailed in Table 1. Data pertaining to adversity and protective factors and sociodemographic covariates were drawn from the T1 survey and linked administrative data provided by the 10 Greater Manchester Local Authorities. LS and MH data from T2 were used to estimate the residuals in the first step of our analysis, and to study protective factors in the second step (see Analytical Strategy). The correlation between the study variables is presented in Table 2.

Adversity (T1)

14 adversity variables were considered: bullying victimisation; free school meal eligibility (FSM); neighbourhood socio-economic disadvantage; home material deprivation; racial discrimination; gender discrimination; sexuality discrimination; disability discrimination; religious discrimination; special educational needs (SEN); feeling unsafe in local area; unhappy with home environment; caregiving responsibilities; and, suboptimal physical health. Each adversity factor was dichotomised (i.e., 0 = no exposure, 1 = exposure). All were derived from #BeeWell survey data, except for FSM, neighbourhood socio-economic disadvantage, and SEN, which were drawn from linked administrative data.

The above data were used to create two continous adversity exposure scales (for LS and MH, respectively) (see Analytical Strategy). Multiple regression models containing all 14 adversity variables indicated that there was no evidence of multicollinearity. Additional, categorical versions of these scales were created to distinguish between those facing high and low levels of adversity exposure (top third and bottom third in each scale, respectively).

Wellbeing (T2)

Our two (LS and MH) T2 wellbeing measures were used in step 1 of our analysis to derive the resilience metric using regression residuals, and in step 2 to assess the effects of candidate protective factors. The Office for National Statistics LS item ("Overall, how satisfied are you with your life nowadays?" [ 44]) provides a scale from 0 (most dissatisfied) to 10 (most satisfied). The emotional difficulites subscale of the Me and My Feelings questionnaire [ 45] provides a measure of internalising MH difficulties, operationalised through a 0-20 scale derived from responses (Never = 0, Sometimes = 1, Always = 2) to 10 items (e.g., "I worry a lot").

Resilience

A resilience metric was developed based on regression residuals using the procedures outlined below in Analytical Strategy. Values on this continuous scale range from vulnerability (negative residual scores that fall below the fitted regression line) to resilience (positive residual scores that fall above the fitted regression line).

Protective factors (T1)

Three external (school staff support, friendships and peer support, and family support) and five internal (sleep hygiene, physical activity, self-esteem, emotional regulation, optimism) candidate protective factors were used. For the internal factors, a distinction is drawn between those pertaining to behaviour/activity (e.g., physical activity) and those relating to psychological characteristics (e.g., optimism). All candidate protective factors were operationalised through standardised continuous scales (mean = 0, standard deviation = 1; see Table 1) with the exception of sleep hygiene, which was a dichotomous variable (0 = not getting enough sleep, 1 = getting enough sleep).

Covariates (T1)

T1 covariates considered in step 2 were gender (male, female), and ethnicity (categories enumerated in Table 1). For both, data were drawn from a linked administrative dataset.

Procedure

Ethical approval from the authors' host institution was sought and granted prior to the commencement of data collection (Ref: 2021-11133-18179). Opt-out parent/carer consent and student assent was used, leading to 1% of the overall #BeeWell sample being prevented from participation. Surveys were administered en masse to participants in school settings (typically in lessons or form time), supported by school staff (who provided standardised instructions), via a secure online survey platform (Qualtrics). Measures were presented in a random order to spread missing data due to item fatigue evenly across the survey.

Analytic Strategy

Our analysis involved two steps. In step 1, to address RQ1, we created the T1 LS and MH adversity scales described in the previous section. These scores were summed and weighted according to their predictive utility for T2 LS and MH, which was assessed using the co-efficient effect size in a series of individual regressions with T2 LS/MH as the response variable and each adversity variable as the only explanatory variable. The results of these regressions are presented in Table 3.

Next, to create the LS and MH resilience metrics, we regressed the T2 LS and MH data on to their respective T1 adversity scales. The standarized residuals from those regression models were used as the measures of resilience. For MH, the standardised residual score generated from the regression was reverse-coded so that, for both LS and MH, higher scores indicate greater resilience. In step 2, these resilience (residual) scores were treated as the outcome variable, and were regressed on the covariates and protective factors in a series of models. Model 1 (covariates only) included gender and ethnicity as the only explanatory variables in order to address RQ2. Model 2 (unique associations) included the 8 protective factors, introduced one at a time in 8 separate regression models (controlling for covariates) in order to address RQ3. In Model 3 (grouped associations), protective factors were introduced by groups in two separate models (internal and external protective factors) while controlling for covariates. In Model 4 (complete model) all protective factors and covariates were introduced simultaneously in the same model. Models 2 and 3 were considered as sensitivity analyses to assess the consistency of identified protective factors under differing model specifications. The results of Models 1 through 4 are presented in Table 4.

Following the above, several additional regression models were fitted to address RQ4. These models are presented in Table 5. First, to assess gender differences in the effect of protective factors, Model 5 (unique associations by gender) included as explanatory variables the interaction between gender and each of the 8 protective factors, introduced one at a time in 8 separate regression models that controlled for the other covariate (ethnicity). Second, to assess differences in the effect of protective factors by the level of adversity exposure, Model 6 (unique associations by the level of adversity exposure) included as explanatory variables the interaction between the categorical adversity variable (high vs low) and the 8 protective factors, introduced one at a time in 8 separate regression models that controlled for the covariates gender and ethnicity.

To account for missing data (see levels of missing data in the first column of Table 1), multiple imputation was used for all the study variables with missing data. We performed 20 imputations of the data set using multivariate normal regression approach. All analyses were conducted in STATA 15 [ 52].

Results

Adversity exposure and later wellbeing (RQ1)

Table 3 shows the results of the individual regressions to estimate the relative importance of each adversity variable to the two wellbeing outcomes. For LS, effect sizes ranged from -0.04 standard deviations (S.D.) (caregiving responsibilities) to - 0.80 S.D. (home material deprivation). For MH, effect sizes ranged from 0.08 S.D. (SEN) to 0.75 S.D. (sexuality discrimination). T1 neighbourhood socio-economic disadvantage and caregiving responsibilities were not statistically significant predictors of T2 MH. As a result, two distinct adversity indices were created as described in the previous section, for LS (min = 0, max = 5.71, mean = 0.77) and MH (min = 0, max = 5.32, mean = 0.73) respectively.

Resilience: socio-demographic differences across gender and ethnicity (RQ2)

Model 1 in Table 4 reveals gender differences in resilience. Specifically, girls are significantly less resilient than boys for both wellbeing outcomes (standardised effect size for LS − 0.33; for MH − 0.59). This is also evident in the complete model (Model 4), though the differences attenuate somewhat (for LS − 0.20; for MH − 0.46), indicating that gender disparities in protective factors explain part of the observed inequalities in resilience.

Ethnic differences in resilience are also observed in Table 4. Model 1 reveals that, compared to white adolescents, Asian and 'any other ethnic group' adolescents are significantly more resilient in terms of LS (0.13 and 0.14, respectively). In terms of MH resilience, compared to white adolescents, those of black, Asian and mixed race are significantly more resilient (0.32, 0.26 and 0.18, respectively). In the LS complete model (Model 4), the resilience gap between white and 'any other ethnic group' adolescents disappears, and the disparity between white and Asian adolescents, while still statistically significant, attenuates (0.06). In terms of the MH complete model (Model 4), all ethnic differences noted above remain statistically significant but shrink (white vs black 0.23; white vs Asian 0.19; white vs mixed race 0.16). As above, this indicates that disparities in protective factors explain part of the observed ethnic inequalities in resilience.

Protective factors for resilience (RQ3)

Table 4 shows that for all the internal and external factors studied, there is evidence of protective effects in one or several of the models. However, differences across model specifications are substantial in some cases.

Sleep hygiene is the only binary protective factor studied. Accordingly, effect sizes for this variable cannot be directly compared to those of the other (continuous) protective factors noted below. Model 2 (unique associations) shows that adolescents getting enough sleep show significantly higher LS and MH resilience than those who do not (for LS 0.30, for MH 0.26). When controlling for other internal protective factors in Model 3 (grouped associations), the protective effect of sleep hygiene is still evident but attenuates (for LS 0.08; for MH 0.06); this pattern is also evident when also controlling for external factors in the complete model (Model 4; for LS 0.07, for MH 0.08).

In Model 2 (unique associations), adolescents who are more physically active exhibit significantly higher resilience for both wellbeing outcomes (for LS 0.06, for MH 0.07). When controlling for other internal protective factors in Model 3 (grouped associations), the protective effect disappears for LS resilience, and reduces but remains statistically significant for MH resilience (0.03); this pattern is also evident when also controlling for external factors in the complete model (Model 4; no effect for LS, for MH 0.03).

In terms of the three internal psychological factors, the unique associations model (Model 2) reveals significant protective effects for each (self-esteem: for LS 0.22, for MH 0.20; emotional regulation: for LS 0.19, for MH 0.20; optimism: for LS 0.23, for MH 0.18). When controlling for other internal protective factors in the grouped associations model (Model 3), these protective effects reduce but remain statistically significant (self-esteem: for LS 0.10, for MH 0.09; emotional regulation: for LS 0.08, for MH 0.12; optimism: for LS 0.12, for MH 0.06); this pattern is also evident when also controlling for external factors in the Model 4 (self-esteem: for LS 0.09, for MH 0.09; emotional regulation: for LS 0.08, for MH 0.13; optimism: for LS 0.11, for MH 0.08).

With regard to the three external factors examined, the unique associations model (Model 2), reveals significant protective effects for each (school staff support: for LS 0.14, for MH 0.05; friendships and social support: for LS 0.15, for MH 0.14; family support: for LS 0.13, for MH 0.05). When controlling for other external protective factors in the grouped associations model (Model 3), these protective effects for LS resilience reduce but remain statistically significant (school staff support 0.07; family support: 0.06; friendships and social support: 0.10). In terms of MH resilience in Model 3, the protective effect remains the same for friendships and social support (0.14) but disappears for both school staff support and family support. When also controlling for internal protective factors in the complete model (Model 4), protective effects for LS resilience disappear for all three external factors. By contrast, protective effects for MH resilience reduce but remain statistically significant for friendships and social support (0.05), and reverse for school staff support (- 0.04) and family support (- 0.06).

Protective factors for resilience: differences by gender and level of adversity (RQ4)

In relation to gender differences in protective factors for resilience, Table 5 shows that there are no statistically significant differences between girls and boys in the protective effect of candidate factors for LS resilience. However, in terms of MH resilience, physical activity yields a stronger protective effect for boys than for girls (diff. - 0.09).

Table 5 also shows a clear pattern in which the protective factors studied have a stronger effect for those at lower levels of adversity exposure than for those at higher levels. In terms of LS resilience, this pattern is observed for all factors except emotional regulation (sleep hygiene diff. - 0.12; physical activity diff. - 0.06; self-esteem diff. − 0.07; optimism diff. - 0.07; school staff support diff. - 0.11; friendships and social support diff. - 0.15; family support diff. - 0.14). In terms of MH resilience, the pattern is observed for all factors except physical activity (sleep hygiene diff. - 0.11; self-esteem diff. - 0.07; emotional regulation diff. - 0.05; optimism diff. - 0.06; school staff support diff. - 0.11; friendships and social support diff. - 0.13; family support diff. - 0.13).

Discussion

In the current study, we sought to extend understanding of the interplay between exposure to adversity and access to protective factors in determining wellbeing outcomes during a particularly vulnerable period of adolescent development. Novelty and rigour are offered through our focus on the transition from early to middle adolescence (age 12-14); use of the residuals analytical approach; analysis of a large, longitudinal dataset, collected post-Covid-19; inclusion of a broad range of adversity and protective factors; consideration of socio-demographic disparities in protective factors and resilience; and, examination of two key wellbeing outcomes: life satisfaction (LS) and internalising mental health (MH) symptoms.

Adversity exposure and later wellbeing (RQ 1)

Consistent with resilience theory [ 2] and prior research [ 53], a range of adversity factors operating at multiple systemic levels predicted later reductions in wellbeing. Notably, being unhappy with home environment, home material deprivation, sexuality discrimination, suboptimal physical health, gender discrimination, and bullying were each associated with > 0.5 SD change in both later wellbeing outcomes. These findings offer valuable new insights as they emphasize the importance of certain harmful or abusive relationships, interactions, and experiences which are often neglected in research on child and adolescent adversity exposure (e.g., fewer than 10% of studies in Hughes et al. meta-analysis [ 54] of adverse childhood experiences on health outcomes included bullying, and no studies included experiences of discrimination).

Though many adversity factors were common to both outcomes, there was also clear evidence of differentiation for some, with disparities in relative magnitude (e.g. bullying more strongly associated with later MH than LS; contrastingly, home material deprivation more strongly associated with later LS than MH). Furthermore, two adversity variables (neighbourhood socio-economic disadvantage and caregiving responsibilities) predicted later LS but not MH. This pattern of findings is broadly consistent with the aforementioned characterisation of adversity factors representing threat and deprivation respectively, and the proposition that they result in distinct downstream consequences for later outcomes [ 4]. For example, it is noteworthy that threat factors (e.g. sexuality discrimination, gender discrimination, bullying) were consistently associated with larger changes in later MH than LS.

Socio-demographic differences in resilience (RQ2)

Girls displayed significantly lower levels of resilience than boys, particularly with regard to MH. This is consistent with previous findings focusing on gender differences in resilience among particular population subgroups (e.g. burns patients [ 55]; those affected by natural disasters [ 56]). However, studies on adolescence resilience using the residuals approach have so far provided mixed evidence [ 22, 23, 27, 32]. These contrasting findings may be the result of differences in the age group, wellbeing measure, and adversity factors considered in these studies, as well as further contextual considerations. Taken alongside consistent evidence of a significantly higher propensity for internalising MH symptoms and lower LS among girls during adolescence [ 57, 58], these findings prompt the need for further consideration of gender-specific resilience-related processes [ 59].

Turning to ethnicity, white adolescents displayed significantly lower levels of resilience than some minority ethnic groups; as above, this was particularly apparent with regard to MH. To our knowledge, the only adolescent residuals study to have considered ethnic differences in resilience is Cahill et al. [ 23], which found no evidence of ethnic differences using a binary approach to coding ethnicity data (i.e., White vs. ethnic minority). It is possible that these discrepancies may be explained by differences in the approach to categorise ethnic groups in the UK, as the approach in Cahill et al. [ 23] may have masked important differences across discrete ethnic minority groups. There is some evidence that young people from UK minority ethnic groups have similar or better MH than their white peers [ 60, 61], but findings are inconsistent [ 62]. However, there is more consistent evidence that Asian adolescents present better MH [ 63, 64] and higher subjective well-being [ 65] than white adolescents, which aligns with our findings (since their significantly higher levels of resilience identified here would predict comparable or better wellbeing outcomes). Furthermore, although research on ethnic differences in adolescent resilience in the UK is relatively scarce, our findings are in line with recent evidence indicating that adolescents from some ethnic minority groups displayed better MH adaptation to the covid-19 pandemic than white adolescents [ 66, 67].

Collectively, our analyses provide evidence that gender and ethnicity may be important moderators in the processes through which exposure to adversity and access to protective factors determine wellbeing outcomes. Further research is required to better understand why this is the case.

Protective factors for resilience (RQ3)

Evidence of the protective effects of all internal and external factors studied was found. However, protective effects attenuated (and in some cases disappeared) in the grouped associations and complete models, indicating some sensitivity to model specification. This was particularly evident in the case of external factors (e.g., school staff support). Nonetheless, adolescents who reported getting enough sleep displayed higher resilience across all models and outcomes, and higher levels of physical activity consistently predicted MH resilience specifically. These findings are in line with broader research on the links between these two health-related behaviours and wellbeing [ 68, 69], in addition to extant theory on how they could promote resilience during adolescence [ 70]. However, ours is the first study to empirically establish these protective effects. Sleep hygiene and physical activity offer particular promise as modifiable protective factors given their obvious tractability, with robust meta-analytic evidence of meaningful intervention effects in both cases [ 71, 72]. However, further work is required to consider effective intervention design for the adolescent population if the full potential of these health-related behaviours to promote resilience is to be realised.

The three external factors examined (school staff support, friendships and social support, and parents/carers support) generally yielded smaller and more variable (across outcomes and specifications) protective effects than the internal factors noted above. However, with one exception (complete model for LS), there was consistent evidence of friendships and social support as a protective factor for resilience. These findings mirror those of Van Harmelen et al. [ 27] aforementioned residuals study, and are supported by broader, meta-analytic evidence focusing on the association between peer social support and wellbeing in adolescence [ 76, 77]. By contrast, the protective effects of school staff support were smaller and more sensitive to model specification. This is somewhat consistent with Miller-Lewis et al. [ 22] finding, established through interaction effects as opposed to the residuals approach, of a very small protective effect of child-teacher relationships that varied by model. Interestingly, Cahill et al. residuals analysis identified protective effects of positive perceptions of school [ 23], and there is meta-analytic research evidence of the association between school connectedness and some aspects of adolescent wellbeing [ 78]. These findings indicate that young people's more general sense of attachment to school may be more important than the quality of their specific relationships with staff in conferring resilience. More broadly, the discrepancies speak to the 'two worlds' hypothesis [ 79, 80], which argues that young people would perceive their school life as involving two aspects rather than just one (learning-related aspects such as grades, attainment and relationships with school staff; and classmates-related aspects, such as bullying and relationships with peers). Evidence that classmates-related aspects tend to be more important to adolescents' wellbeing than learning-related aspects [ 80], alongside the contrasting findings noted above, prompts further empirical scrutiny of what specific aspects of school-related experiences may yield protective effects.

Finally, parent/carer support yielded the smallest and least consistent protective effects overall. Indeed, it is perhaps noteworthy that in the final, full model, the effect of this factor (and that of school staff support) actually reversed (i.e., predicted lower levels of MH resilience). While this could be a statistical artefact (e.g., overfitting), there are interesting parallels with Van Harmelen's aforementioned residuals study with adolescents [ 27], which similarly identified family support as a negative predictor of later resilient functioning. Like these authors, we are left to speculate that family involvement may not be adaptive in the context of adversity (which may, of course, include familial adversity factors). One reason why support from school staff and/or parents/carers could confer limited protection against adversity is that those adolescents who are more resilient are developing higher autonomy (i.e., lower dependency on this type of support), as might be expected in this developmental phase. Thus, we might hypothesize that school staff and parent/carer support would yield greater protective effects during childhood as opposed to adolescence. Further research is required to explore this issue in more detail. Collectively, though, our findings speak to the clear salience of peer social relations as conferring protection in the context of multiple adversities during the transition from early- to mid-adolescence.

Differences in the effects of protective factors by gender and level of adversity (RQ4)

We observed gender differences in protective factors for MH resilience (but not LS resilience) for physical activity, which presented stronger protective effects for boys than for girls. In line with this, existing evidence indicates that physical activity predict adolescent wellbeing, and levels tend to be higher among boys than girls [ 81, 82, 83]. To the best of our knowledge, this is the first to identify protective effects for MH resilience for physical activity levels.

We found a clear pattern across resilience outcomes in which protective factors yielded a stronger effect at low (compared to high) levels of adversity exposure. This may be indicative that they serve promotive rather than protective functions as they support resilience across the adversity spectrum, rather than specifically those at high adversity levels. Furthermore, these differences were more pronounced for external protective factors than for the internal protective factors. Our findings contrast sharply with Askeland et al., who found that goal orientation and self-confidence were particularly protective for Norwegian adolescents who experienced a higher number of negative life events [ 84], and Miller-Lewis et al., who found that greater self-control during preschool provided greater protection to children exposed to higher levels of familial adversity [ 22]. However, this could be explained by the conceptualisation and measurement of adversity, age of participants, and other differences between the studies. Collectively, these findings have clear implications for the design of interventions to promote resilience, as they indicate that a tailored, nuanced approach-which takes into account differing levels of adversity, as well as socio-demographic differences-may be more effective than a one-size-fits-all model. It is this issue to which we now turn.

Implications

Our findings confer three key implications for policy and practice. First, given that the effects of protective factors appeared to diminish at higher levels of adversity exposure, prevention and intervention efforts to reduce said exposure should be prioritised. Among the most influential adversity factors identified in the current study, some reflect broader structural inequalities (e.g., home material deprivation) that would require policy/governmental intervention [ 85], while other represent more immediately tractable issues (e.g., bullying) that could feasibly be targeted in localised school- and/or community-based interventions, for which there is a promising evidence base [ 86]. However, it is important to note that the above does not mean that universal interventions would not be beneficial, as our results indicate protective effects across the adversity spectrum for all the internal factors and friendships and social support. Second, resilience can be most effectively promoted through multi-faceted school- and/or community-based interventions intended to facilitate access to protective factors identified in the current study. In this vein, we note that there is robust evidence of the efficacy of interventions to promote sleep hygiene [ 87], physical activity [ 88], self-esteem [ 89], emotional regulation [ 90], optimism [ 91], school staff support [ 92], friendships and social support [ 93], and parent/carer support [ 94] in adolescence. Third, our finding that the protective effect of these factors differs by gender and level of adversity exposure indicates that a nuanced, tailored/targeted approach, alongside a universal offer, could optimise resilience promotion.

Our study also presents valuable insights for future research. First, our findings provide support to the call by Mesman et al. [ 8] on the need for and value of more longitudinal research using a multisystem approach and advanced assessment methods such as the residuals approach or network modelling [ 95]. Second, our findings highlight the need for nuanced approaches to assessing socio-demographic differences in protective factors for resilience. Third, our study also shows the importance of assessing resilience for distinct wellbeing constructs. Finally, the current study highlights the importance of assessing a wide range of adversity factors, beyond the 'usual suspects' (i.e., familial adversities).

Limitations

In considering the above implications, a number of limitations of the current study should be borne in mind, most of which pertain to the fact that we undertook secondary analysis of an existing dataset as opposed to a prospectively designed study. First, a number of key adversity factors (e.g., parental psychological distress, living in a single-parent family, household violence, etc.) were not included in our analyses. However, this is arguably counterbalanced by the inclusion of a number of new or relatively under-studied factors. Second, the analyses cover a relatively short period of time (1 year) and a limited age range (12-14). Nonetheless, this did of course enable insights into a particularly vulnerable period of adolescent development.

Third, while the composition of the study sample reflected that of the 11-16 population of the city-region (Greater Manchester) from which it was drawn very well, there are some noteworthy differences from the equivalent population in England (e.g., ethnic composition - somewhat higher proportion of Asian and lower proportion of white adolescents than is seen nationally) that suggest caution is required in terms of generalisation. Furthermore, we note that although complete and incomplete cases were generally very similar, the latter group were over-represented in two socioeconomic adversity indicators (FSM eligibility and neighbourhood socioeconomic deprivation) as is often observed in longitudinal studies [ 96]. More broadly, the study was conducted in a Western, high-income country using a population sample. Accordingly, and particularly in light of research that highlights differences in adversity and resilience processes across countries and cultures [ 30] that which has been reported here may not necessarily apply in other parts of the world -nor in clinical samples- where levels of exposure to adversity in the population studied may be different.

Finally, we must be mindful of the possibility of shared measurement variance due to the use of self-reported information in the assessment of both exposures and outcomes. This introduces a possible source of confounding in that an unmeasured factor could explain associations. However, it is important to note again the one-year lag between reporting of exposures and outcomes, and the fact that several exposures were not self-reported (e.g., FSM, neighbourhood socio-economic deprivation, special educational needs).

Conclusion

The current study has demonstrated that the residuals approach can make a considerable contribution to our understanding of the interplay between exposure to adversity and access to protective factors in determining adolescent wellbeing outcomes. Moreover, its application provides clear implications for policy and practice, in terms of prevention (of adversity exposure) and intervention (to facilitate resilience). Finally, the current study provides further support for Masten's [ 5] ordinary magic thesis. Getting enough sleep, being more physically active, experiencing support from friends, and other factors exerting protective effects for adolescents experiencing adversity epitomise the maxim that "resilience arises from ordinary resources and processes" [ 5].

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References

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Acknowledgements

The authors gratefully acknowledge the efforts of participating young people and their schools in this research.

Funding

The #BeeWell study is kindly funded by the University of Manchester, the Greater Manchester Combined Authority, The National Lottery Community Fund, BBC Children in Need, Big Change, the Gregson Family Foundation, the Paul Hamlyn Foundation, the Holroyd Foundation, the Oglesby Charitable Trust, and the Peter Cundill Foundation.

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Manchester Institute of Education, University of Manchester, Manchester, M13 9PL, UK

Jose Marquez, Louis Francis-Hew & Neil Humphrey

Authors

1. Jose Marquez

2. Louis Francis-Hew

3. Neil Humphrey

Contributions

All authors have made substantial contribution to conception and design, execution, or analysis and interpretation of data. Additionally, all authors were involved in drafting the article and revising it critically for intellectual content. All authors have read the enclosed manuscript and agree to the authorship and content of the manuscript.

Corresponding author

Correspondence to Jose Marquez.

Ethics declarations

Ethics approval and consent to participate

Ethical approval from the authors' host institution was sought and granted prior to the commencement of data collection (Ref: 2021-11133-18179). Opt-out parent/carer consent was used, leading to 1% of the overall #BeeWell sample being prevented from participation.

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Not applicable.

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The authors have no competing interests to declare.

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Marquez, J., Francis-Hew, L. & Humphrey, N. Protective factors for resilience in adolescence: analysis of a longitudinal dataset using the residuals approach. Child Adolesc Psychiatry Ment Health 17, 140 (2023). https://doi.org/10.1186/s13034-023-00687-8
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Protective factors for resilience in adolescence: analysis of a longitudinal dataset using the residuals approach - Child and Adolescent Psychiatry and Mental Health

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Introduction The residuals approach, in which residual scores from regression models are used as a proxy for resilient functioning, offers great potential to increase understanding of resilience processes. However, its application in child and adolescent wellbeing research is limited to date.

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Reading these articles are really helpful in giving me information on this subject

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Understanding resilience

To understand how to nurture resilience in children and youth, we need to first understand its link to mental health and mental health promotion. The following are key concepts used in the book.

Resilience

Resilience involves being able to recover from difficulties or change-to function as well as before and then move forward. Many refer to this as "bouncing back" from difficulties or challenges.

People who are resilient can effectively cope with, or adapt to, stress and challenging life situations. They learn from the experience of being able to effectively manage in one situation, making them better able to cope with stresses and challenges in future situations. In other words, dealing with challenges can make us grow and can make us stronger. Rather than merely bouncing back, we're better prepared than we were before to face challenges that lie ahead.

Resilient children tend to be empathic; that is, they can understand and sympathize with the feelings of others. They tend to be good communicators who are able to solve problems. They have a strong interest in school, and are dedicated to learning. They're driven to achieve goals. They're involved in meaningful activities. They're hopeful about the future. They have a solid relationship with one or more adults. And they live in safe and well-functioning families and communities.

Mental health

Part of being resilient is having good mental health. Mental health involves balancing the different aspects of life: the physical, intellectual, social, emotional and spiritual. It involves our ability to think, feel, act and interact in a way that we can enjoy our lives and cope with the challenges that arise. Mental health also involves how we think about and appraise ourselves, our lives and the people we know and care about. It involves our ability to make realistic sense of-and react meaningfully to-the world around us. It affects our ability to make choices and decisions.

Mental health promotion

As its name suggests, mental health promotion is about promoting mental health. Promoting mental health encourages the development of resilience. The reverse is also true: promoting resilience leads to better mental health. In fact, resilience is a central concept within the mental health promotion framework. According to the Centre for Health Promotion (1997), mental health promotion (MHP) improves the ability of people and the communities they live in "to take control over their lives and improve their mental health." MHP strategies nurture individuals and families and the communities they live in; build on their strengths; provide them with opportunities; create safe spaces for them; and support each to become resilient. More specifically, MHP strategies encourage cultural sensitivity and awareness, together with respect for people's differences, regardless of their age, gender, sexual orientation, culture, socio-economic situation or abilities.

MHP benefits everyone in his or her everyday life-whether the person is healthy; is at risk for developing difficulties (such as a substance use problem); or has an existing health problem (such as depression). That's because MHP is a holistic, or ecological, approach to health that focuses on the physical, mental, emotional and spiritual well-being of individuals, families and communities. And it does so in ways that create environments that are respectful to everyone and that enhance people's capacity to adapt and grow from challenges.

In using this book to take steps to building resilience in the children and youth in your life, you will also be involved in the exciting arena of mental health promotion.

Mental health problems and resilience

Can a resilient child or youth develop a mental health problem? And, conversely, can a young person with a mental health problem be resilient? The answer to both of these questions is yes. Not all health problems are avoidable, and even the most resilient young people can have mental health problems, such as anxiety or problems with aggression. Furthermore, being resilient does not guarantee that young people will always have happy and productive lives.

One in five children in Canada has a mental health problem. These problems can show up in different ways. Children may be frequently sad, anxious or rebellious; have difficulty paying attention; have problems eating, sleeping or getting along with schoolmates; or they may skip school. As adolescents, they may use alcohol or other drugs.

While these difficulties can lower a person's resilience, there are many things that can be done to help improve their resilience, as outlined in the tips listed at the end of each section on individual, family and environmental factors. These tips are strategies that parents, teachers and front-line workers can use in their interactions with young people: they are not meant to address more challenging issues that may require the help of a trained health care provider.

Risk and protective factors

Mental health professionals speak about risk and protective factors as the key to understanding resilience. Risk and protective factors are characteristics of individuals, their families and their communities or environments that either increase (protective factors) or decrease (risk factors) the likelihood that a young person will be resilient. In essence, protective factors help to protect children and youth from the negative effects of risk factors.

Human beings are complicated. For example, there likely isn't a simple reason as to why one person (or even one sibling) will be resilient, and another not so resilient, even though they are both brought up under the same circumstances.

Risk and protective factors do not occur in a vacuum, nor do they exist independently of one another. Young people's resilience is determined by the interplay of individual characteristics, the characteristics of the families within which they live, and the characteristics of their physical and social environments. For example, living with both parents is considered a protective factor for children and youth; however, if one parent is abusive to the child or to the other parent, then living with that parent could be a risk factor and not living with that parent could be a protective factor.

The tables of protective and risk factors presented at the end of chapters 3, 4 and 5 might give the impression that they are opposite sides of the same characteristic, and that they carry the same weight in a young person's life. Fortunately that's not the case. Even though there may be risk factors or challenges in young people's lives that cannot be changed, protective factors can be fostered or nurtured (if they're not already there) to help children and youth adapt and function better and become more resilient.

We can't always foresee how resilient someone will be based solely on risk and protective factors, because no formula exists for predicting human behaviour. What may be a risk factor for one child may be a protective factor for another. And what may be a risk factor for one youth in one situation or at one time may be a protective factor for the same youth in other situations or at other times.

For example, young people sometimes take on parental roles when the parent has a mental health or substance use problem. The challenge-of being confronted with adult problems, of having to take care of themselves, of having to take care of a parent, and of being denied a normal childhood-will be a risk factor for some young people who struggle to cope with roles they are not ready for. For other young people, however, taking on adult responsibilities may develop in them the ability to multi-task, organize, problem-solve and make decisions.

Some young people with many risk factors will be resilient. Other young people with many protective factors might not manage as well. For example, some youth live in troubled family situations in neighbourhoods where the sale of illegal drugs and other crimes are common. Yet they still manage to help raise brothers and sisters, make good friends, graduate from high school and contribute to their communities. Still other youth have loving parents and live in safe, well-resourced communities yet have low self-esteem and develop behavioural problems that compromise their resilience. Even within the same family, one child may be resilient while others are not.

Studies indicate that risk and protective factors are usually cumulative: the more protective factors in young people's lives, and the fewer risk factors, the greater the probability that these children or youth will be resilient. The reverse is also true: the more risk factors and the fewer protective factors in young people's lives, the greater the likelihood that they will not be resilient and will develop a range of problems. These problems can include failure at school, aggressive and criminal behaviour, injuring themselves or others, substance use problems and mental health problems.

The good news is that introducing even a few protective factors can shift the balance and help many children and youth flourish. For example, for young people growing up in families with low incomes, and with little money to pay for extra- curricular activities, the building of a neighbourhood recreation centre offering free or low-cost activities could serve as a protective factor. So could the launching of a youth choir or an amateur-theatre program in a small town or rural church.

The development of resilience

Young people are like trees. They come in various shapes and sizes and grow up in most parts of the world. Families can be thought of as the soil and water at the base of trees. Schools, neighbourhoods, communities and society at large can be compared to the sun, rainfall, insects, birds and animals. The different characteristics of trees, qualities of soils and weather conditions (such as the amount of sun and rainfall) can affect the health and growth of trees. In a similar way, the varying traits of young people, and the characteristics of their families and environments, can positively or negatively affect young people's health and growth.

Trees go through developmental stages as they mature from young saplings to full-grown specimens. Children also go through developmental stages on their way to adulthood, and what happens to them at various stages of development can affect their outcomes. Resilient children and youth grow, branch out and flower when systems supporting their healthy development (such as well-functioning families and environments) work together. Such young people are more likely to withstand and overcome challenges, learn from them, and develop and succeed in healthy ways.

No one can guarantee children and youth lives free from challenges. All young people need protective factors to help cushion them from problems they may encounter. Caring and socially responsible adults (such as parents, family members, neighbours, daycare workers, teachers and other school staff, spiritual leaders, health care providers, social service providers, police, storekeepers and coaches) can support and facilitate young people's resilience.

In the following chapters, we discuss ways to strengthen individuals, families and environments to build resilience in children and youth. We present ways to reduce the presence and impact of risk factors but put more emphasis on how to create and build protective factors that will nurture young people's strengths. We recognize that resilience is a complex concept and that we need to include multiple ways of promoting it.

Resilient children can be encouraged to become more resilient. And children who seem to have less resilience can be helped to develop it.

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Growing Up Resilient - Ways to Build Resilience in Children and Youth

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Resilience is one of the best life skills children and youth can develop. Growing Up Resilient is a way for adults to help children develop these skills.

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talking about how young children find ways to help them overcome everything they've been through is just wonderful

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Resilience in Children Exposed to Trauma, Disaster and War: Global Perspectives

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Offered by University of Minnesota. How do children overcome hazardous experiences to succeed in life? What can be done to protect young ... Enroll for free.

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This article talks about how programs can help trauma children

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51]

Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system. It requires a comprehensive and multi-pronged effort involving the many adults in children's lives. For example, in a school or afterschool program, TIC means increasing trauma-related knowledge and skills among program facilitators, school administrators, bus drivers, food service workers, classroom assistants, administrative staff, volunteers, teachers, leadership, special education professionals, school social workers and psychologists, families, and anyone else who comes into contact with children. However, increasing trauma knowledge is only one aspect of TIC, which also means that the individuals who care for children must be able to:

1. Realize the widespread nature of childhood trauma and how it impacts the child's emotional, social, behavioral, cognitive, brain, and physical development, as well as their mental health. In addition, adults must be aware of the influence of trauma on family members, first responders, service providers, and others who may experience secondary stress (trauma-related reactions to exposure to another person's traumatic experience).[52],[53] In some instances, adults endure the same traumatic events or circumstances as the child (e.g., a natural disaster, community violence, death of a community member) and may benefit from similar supports.

2. Recognize the symptoms of trauma, including how trauma reactions (i.e., symptoms of posttraumatic stress) vary by gender, age, type of trauma, or setting. In addition, the adults in children's lives must understand that a child's challenging behaviors are normal, self-protective, and adaptive reactions to highly stressful situations, rather than viewing that child as intentionally misbehaving. Children's trauma reactions are understood to be adaptive efforts to protect themselves in response to traumatic events. For example, a child may be hypervigilant to an adult's anger or disapproval because, in the past, he or she experienced physical abuse by a parent. Or, a child may disassociate or daydream as a learned response that enables them to avoid feeling or thinking about a traumatic experience.[54] In addition, TIC means recognizing that trauma may influence a child's engagement in activities and services, interactions with peers and adults, and responsiveness to rules and guidelines.[55]

3. Respond by making necessary adjustments, in their own language and behavior, to the child's environment; and to policies, procedures, and practices to support the child's recovery and resilience to trauma.[56]

4. Resist re-traumatization by actively shaping children's environments to avoid triggers (sounds, sights, smells, objects, places, or people that remind an individual of the original trauma) and protect children from further trauma, which can exacerbate the negative impacts of trauma and interfere with the healing process.[57],[58]

Training and professional development on child trauma is an important first step in TIC. Providing adults (staff, leadership, families, and community partners) with training and professional development on childhood trauma is an important component of implementing TIC.[59] It is essential that adults become aware of the prevalence and impact of trauma, and learn to apply a "trauma lens" (i.e., gain the capacity to view children's difficulties in behavior, learning, and relationships as natural reactions to trauma that warrant understanding and sensitive care).[60] In addition, adults can learn key strategies to manage trauma-related problems in childhood. These include creating environments that feel physically and emotionally safe; teaching children self-regulation, language and communication skills, and how to build healthy relationships; learning each child's trauma triggers and how both the child and adults can limit, anticipate, and cope with them; and supporting the development of healthy attachments with parents and other caregivers, as well as positive relationships with peers. Evaluations of TIC initiatives also indicate that when parents, service providers, and programs share a common language and view of trauma, they are better able to work together to meet children's needs.[61]

Training and professional development opportunities are also important for increasing the capacity of adults to attend to other aspects of TIC, including family engagement; practices that are responsive to culture, gender, and sexual orientation; collaboration with community service providers (e.g., mental health providers who can screen for childhood trauma and provide evidence-based treatment); developing and integrating emergency and crisis response protocols; and establishing trauma-informed policies that support positive youth development despite exposure to trauma. Building capacity and maintaining an ongoing commitment to TIC efforts are critical to sustainability.[62], [63] However, although it is a critical component of TIC, training staff and parents on the impact of childhood trauma is not sufficient and does not in and of itself constitute TIC. TIC must also include comprehensive, ongoing professional development and education for parents, families, school staff, out-of-school program staff, and community service providers on jointly addressing childhood trauma.

Parents and service providers who work with children who experience trauma require self-care to prevent and mitigate the effects of secondary traumatic stress. TIC also means attending to the psychological and physical safety and well-being of the adults who care for children who have experienced trauma.[64], [65] Professionals, parents, and other caregiving adults may suffer secondary traumatic stress (trauma-related reactions to exposure to another person's traumatic experience).[66],[67] Psychoeducation (helping others understand the impact of trauma, both on affected individuals and on their service providers, as well as pathways toward recovery),[68] skills training, high-quality supervision, and self-care (e.g., rest, exercise, social support, mindfulness and other stress reduction activities, engaging in pleasurable activities and hobbies, psychotherapy) are critical to ensuring adult well-being and providing sufficient personal resources to work effectively with children who are exposed to trauma. See Figure 4 for specific strategies recommended by the National Child Traumatic Stress Network to combat secondary traumatic stress and reduce related staff burnout and turnover.[69]

Further research is needed on TIC in child-serving programs, institutions, and systems to develop a sufficient evidence base to inform policy and practice. TIC is a relatively new framework for working with individuals who experience trauma, and the evidence base in support of its effectiveness is in the early stages of development. However, a number of promising TIC initiatives in early care and education, schools, child welfare, and behavioral health have demonstrated improvements in trauma-related knowledge and skills among service providers, foster parents, and family members; reductions in children's posttraumatic stress symptoms and problem behaviors; and increases in children's strengths and protective factors.[70],[71],[72],[73],[74] In addition, a growing number of clinical treatment models-including Trauma-Focused Cognitive Behavioral Therapy,[75],[76] Child-Parent Psychotherapy,[77],[78] Attachment and Biobehavioral Catch-up,[79],[80] and Parent-Child Interaction Therapy,[81],[82] -have undergone rigorous evaluation and shown positive outcomes for children from infancy to late adolescence. However, TIC is not limited to mental health professionals. Each child-serving program, institution, or service system can play a role in TIC, including referral to clinical treatment and follow-up with families.

Conclusion

Trauma-informed programs, institutions, and service systems are critical to promoting and fostering resilience in all children, and particularly those who have experienced trauma. TIC requires comprehensive, multi-pronged support from adults in all aspects of children's lives. It includes increasing adults' knowledge of childhood trauma and helping them recognize the symptoms, as well as giving them the resources to support and refer children who have experienced trauma to appropriate services. Additionally, as programs make their services more trauma-informed, it is important that they promote self-care to prevent or address secondary trauma among adults working with children who have experienced trauma.
Endnotes
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[3] Lieberman (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4), 336-351.

[5] Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS publication no. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[10] National Survey of Children's Health. (2011/12). Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved June 8, 2018 from www.childhealthdata.org.

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[12] McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Trauma exposure and posttraumatic stress disorder in a US national sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 815-830.

[13] U.S. Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2019).

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How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma - Child Trends

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51] Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system.

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this article talks about how trauma is formed. this goes into detail about what happens to get the trauma

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This page outlines risk and protective factors for child abuse and neglect.

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This article really went into detail about what it takes to help a trauma filled child

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Risk and Protective Factors in Child Development and the Development of Resilience

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Discover the groundbreaking research by Professor Sir Michael Rutter on risk and protective factors in child development. Learn how to create artificial protective conditions and promote resilience in children. Explore the Centre for Research into Parenting and Children’s 20-year study at the University of Oxford.

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This is a wonderful article about the power of healing. As someone who went through trauma, it was actually pretty nice reading it

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Laura Calderon de la Barca, Katherine Milligan & John Kania

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How recognizing trauma in ourselves, other people, and the systems around us can open up new pathways to solving social problems.

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This article really broke everything down for me. It went through everything, like what to look for, what you can do to help

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. Some individuals may clearly display criteria associated with posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.

This chapter begins with an overview of common responses, emphasizing that traumatic stress reactions are normal reactions to abnormal circumstances. It highlights common short- and long-term responses to traumatic experiences in the context of individuals who may seek behavioral health services. This chapter discusses psychological symptoms not represented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), and responses associated with trauma that either fall below the threshold of mental disorders or reflect resilience. It also addresses common disorders associated with traumatic stress. This chapter explores the role of culture in defining mental illness, particularly PTSD, and ends by addressing co-occurring mental and substance-related disorders.

TIC Framework in Behavioral Health Services-The Impact of Trauma

Sequence of Trauma Reactions

Survivors' immediate reactions in the aftermath of trauma are quite complicated and are affected by their own experiences, the accessibility of natural supports and healers, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Although reactions range in severity, even the most acute responses are natural responses to manage trauma- they are not a sign of psychopathology. Coping styles vary from action oriented to reflective and from emotionally expressive to reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding group or mass traumas, was the assumption that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual's style of coping and not valuing one type over another.

Foreshortened future: Trauma can affect one's beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won't occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work).

Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. Exhibit 1.3-1 outlines some common reactions.

Common Experiences and Responses to Trauma

A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social supports, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet criteria for trauma-related stress disorders, including mood and anxiety disorders.

The following sections focus on some common reactions across domains (emotional, physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria.

Emotional

Emotional reactions to trauma can vary greatly and are significantly influenced by the individual's sociocultural history. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They may associate strong feelings with the past trauma, thus believing that emotional expression is too dangerous or will lead to feeling out of control (e.g., a sense of "losing it" or going crazy). Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions.

Emotional dysregulation

Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness, and shame-this is more so when the trauma occurred at a young age ( van der Kolk, Roth, Pelcovitz, & Mandel, 1993). In individuals who are older and functioning well prior to the trauma, such emotional dysregulation is usually short lived and represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication-namely, substance abuse-is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation (e.g., substance-induced changes in affect during and after use). Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. In fact, some individuals find creative, healthy, and industrious ways to manage strong affect generated by trauma, such as through renewed commitment to physical activity or by creating an organization to support survivors of a particular trauma.

Traumatic stress tends to evoke two emotional extremes: feeling either too much (overwhelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating difficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. This will likely require learning new coping skills and how to tolerate distressing emotions; some clients may benefit from mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such as exposure therapy and eye movement desensitization and reprocessing (EMDR; refer to Part 1, Chapter 6, for more information on trauma-specific therapies).

Numbing

Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories. In the following case illustration, Sadhanna's numbing is evidenced by her limited range of emotions associated with interpersonal interactions and her inability to associate any emotion with her history of abuse. She also possesses a belief in a foreshortened future. A prospective longitudinal study ( Malta, Levitt, Martin, Davis, & Cloitre, 2009) that followed the development of PTSD in disaster workers highlighted the importance of understanding and appreciating numbing as a traumatic stress reaction. Because numbing symptoms hide what is going on inside emotionally, there can be a tendency for family members, counselors, and other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma as less severe than they actually are.

Case Illustration: Sadhanna

Sadhanna is a 22-year-old woman mandated to outpatient mental health and substance abuse treatment as the alternative to incarceration. She was arrested and charged with assault after arguing and fighting with another woman on the street. At intake, Sadhanna reported a 7-year history of alcohol abuse and one depressive episode at age 18. She was surprised that she got into a fight but admitted that she was drinking at the time of the incident. She also reported severe physical abuse at the hands of her mother's boyfriend between ages 4 and 15. Of particular note to the intake worker was Sadhanna's matter-of-fact way of presenting the abuse history. During the interview, she clearly indicated that she did not want to attend group therapy and hear other people talk about their feelings, saying, "I learned long ago not to wear emotions on my sleeve."

Sadhanna reported dropping out of 10th grade, saying she never liked school. She didn't expect much from life. In Sadhanna's first weeks in treatment, she reported feeling disconnected from other group members and questioned the purpose of the group. When asked about her own history, she denied that she had any difficulties and did not understand why she was mandated to treatment. She further denied having feelings about her abuse and did not believe that it affected her life now. Group members often commented that she did not show much empathy and maintained a flat affect, even when group discussions were emotionally charged.

Physical

Diagnostic criteria for PTSD place considerable emphasis on psychological symptoms, but some people who have experienced traumatic stress may present initially with physical symptoms. Thus, primary care may be the first and only door through which these individuals seek assistance for trauma-related symptoms. Moreover, there is a significant connection between trauma, including adverse childhood experiences (ACEs), and chronic health conditions. Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.

Somatization

Somatization indicates a focus on bodily symptoms or dysfunctions to express emotional distress. Somatic symptoms are more likely to occur with individuals who have traumatic stress reactions, including PTSD. People from certain ethnic and cultural backgrounds may initially or solely present emotional distress via physical ailments or concerns. Many individuals who present with somatization are likely unaware of the connection between their emotions and the physical symptoms that they're experiencing. At times, clients may remain resistant to exploring emotional content and remain focused on bodily complaints as a means of avoidance. Some clients may insist that their primary problems are physical even when medical evaluations and tests fail to confirm ailments. In these situations, somatization may be a sign of a mental illness. However, various cultures approach emotional distress through the physical realm or view emotional and physical symptoms and well-being as one. It is important not to assume that clients with physical complaints are using somatization as a means to express emotional pain; they may have specific conditions or disorders that require medical attention. Foremost, counselors need to refer for medical evaluation.

Advice to Counselors: Using Information About Biology and Trauma

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Frame reexperiencing the event(s), hyperarousal, sleep disturbances, and other physical symptoms as physiological reactions to extreme stress.

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Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms (e.g., therapy, meditation, exercise, yoga). You may need to refer certain clients to a psychiatrist who can evaluate them and, if warranted, prescribe psycho-tropic medication to address severe symptoms.

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Discuss traumatic stress symptoms and their physiological components.

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Explain links between traumatic stress symptoms and substance use disorders, if appropriate.

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Normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, being damaged, or going crazy.

Support your clients and provide a message of hope-that they are not alone, they are not at fault, and recovery is possible and anticipated.

Biology of trauma

Trauma biology is an area of burgeoning research, with the promise of more complex and explanatory findings yet to come. Although a thorough presentation on the biological aspects of trauma is beyond the scope of this publication, what is currently known is that exposure to trauma leads to a cascade of biological changes and stress responses. These biological alterations are highly associated with PTSD, other mental illnesses, and substance use disorders. These include:

Changes in limbic system functioning.

Hypothalamic-pituitary-adrenal axis activity changes with variable cortisol levels.

Neurotransmitter-related dysregulation of arousal and endogenous opioid systems.

As a clear example, early ACEs such as abuse, neglect, and other traumas affect brain development and increase a person's vulnerability to encountering interpersonal violence as an adult and to developing chronic diseases and other physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas ( Centers for Disease Control and Prevention, 2012).

Hyperarousal and sleep disturbances

A common symptom that arises from traumatic experiences is hyperarousal (also called hypervigilance). Hyperarousal is the body's way of remaining prepared. It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. It is also one of the primary diagnostic criteria for PTSD.

Hyperarousal is a consequence of biological changes initiated by trauma. Although it serves as a means of self-protection after trauma, it can be detrimental. Hyperarousal can interfere with an individual's ability to take the necessary time to assess and appropriately respond to specific input, such as loud noises or sudden movements. Sometimes, hyperarousal can produce overreactions to situations perceived as dangerous when, in fact, the circumstances are safe.

Case Illustration: Kimi

Kimi is a 35-year-old Native American woman who was group raped at the age of 16 on her walk home from a suburban high school. She recounts how her whole life changed on that day. "I never felt safe being alone after the rape. I used to enjoy walking everywhere. Afterward, I couldn't tolerate the fear that would arise when I walked in the neighborhood. It didn't matter whether I was alone or with friends-every sound that I heard would throw me into a state of fear. I felt like the same thing was going to happen again. It's gotten better with time, but I often feel as if I'm sitting on a tree limb waiting for it to break. I have a hard time relaxing. I can easily get startled if a leaf blows across my path or if my children scream while playing in the yard. The best way I can describe how I experience life is by comparing it to watching a scary, suspenseful movie-anxiously waiting for something to happen, palms sweating, heart pounding, on the edge of your chair."

Along with hyperarousal, sleep disturbances are very common in individuals who have experienced trauma. They can come in the form of early awakening, restless sleep, difficulty falling asleep, and nightmares. Sleep disturbances are most persistent among individuals who have trauma-related stress; the disturbances sometimes remain resistant to intervention long after other traumatic stress symptoms have been successfully treated. Numerous strategies are available beyond medication, including good sleep hygiene practices, cognitive rehearsals of nightmares, relaxation strategies, and nutrition.

Cognitive

Traumatic experiences can affect and alter cognitions. From the outset, trauma challenges the just-world or core life assumptions that help individuals navigate daily life ( Janoff-Bulman, 1992). For example, it would be difficult to leave the house in the morning if you believed that the world was not safe, that all people are dangerous, or that life holds no promise. Belief that one's efforts and intentions can protect oneself from bad things makes it less likely for an individual to perceive personal vulnerability. However, traumatic events-particularly if they are unexpected-can challenge such beliefs.

Cognitions and Trauma

The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress.

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier).

Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor's guilt, because others who experienced the same trauma did not survive.

Idealization: Demonstrating inaccurate rationalizations, idealizations, or justifications of the perpetrator's behavior, particularly if the perpetrator is or was a caregiver. Other similar reactions mirror idealization; traumatic bonding is an emotional attachment that develops (in part to secure survival) between perpetrators who engage in interpersonal trauma and their victims, and Stockholm syndrome involves compassion and loyalty toward hostage takers ( de Fabrique, Van Hasselt, Vecchi, & Romano, 2007).

Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore).

Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Whenever counseling focuses on trauma, it is likely that the client will experience some intrusive thoughts and memories. It is important to develop coping strategies before, as much as possible, and during the delivery of trauma-informed and trauma-specific treatment.

Let's say you always considered your driving time as "your time"-and your car as a safe place to spend that time. Then someone hits you from behind at a highway entrance. Almost immediately, the accident affects how you perceive the world, and from that moment onward, for months following the crash, you feel unsafe in any car. You become hypervigilant about other drivers and perceive that other cars are drifting into your lane or failing to stop at a safe distance behind you. For a time, your perception of safety is eroded, often leading to compensating behaviors (e.g., excessive glancing into the rearview mirror to see whether the vehicles behind you are stopping) until the belief is restored or reworked. Some individuals never return to their previous belief systems after a trauma, nor do they find a way to rework them-thus leading to a worldview that life is unsafe. Still, many other individuals are able to return to organizing core beliefs that support their perception of safety.

Many factors contribute to cognitive patterns prior to, during, and after a trauma. Adopting Beck and colleagues' cognitive triad model ( 1979), trauma can alter three main cognitive patterns: thoughts about self, the world (others/environment), and the future. To clarify, trauma can lead individuals to see themselves as incompetent or damaged, to see others and the world as unsafe and unpredictable, and to see the future as hopeless-believing that personal suffering will continue, or negative outcomes will preside for the foreseeable future (see Exhibit 1.3-2). Subsequently, this set of cognitions can greatly influence clients' belief in their ability to use internal resources and external support effectively. From a cognitive- behavioral perspective, these cognitions have a bidirectional relationship in sustaining or contributing to the development of depressive and anxiety symptoms after trauma. However, it is possible for cognitive patterns to help protect against debilitating psychological symptoms as well. Many factors contribute to cognitive patterns prior to, during, and after a trauma.

Feeling different

An integral part of experiencing trauma is feeling different from others, whether or not the trauma was an individual or group experience. Traumatic experiences typically feel surreal and challenge the necessity and value of mundane activities of daily life. Survivors often believe that others will not fully understand their experiences, and they may think that sharing their feelings, thoughts, and reactions related to the trauma will fall short of expectations. However horrid the trauma may be, the experience of the trauma is typically profound.

The type of trauma can dictate how an individual feels different or believes that they are different from others. Traumas that generate shame will often lead survivors to feel more alienated from others-believing that they are "damaged goods." When individuals believe that their experiences are unique and incomprehensible, they are more likely to seek support, if they seek support at all, only with others who have experienced a similar trauma.

Triggers and flashbacks

Triggers

A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience. Imagine you were trapped briefly in a car after an accident. Then, several years later, you were unable to unlatch a lock after using a restroom stall; you might have begun to feel a surge of panic reminiscent of the accident, even though there were other avenues of escape from the stall. Some triggers can be identified and anticipated easily, but many are subtle and inconspicuous, often surprising the individual or catching him or her off guard. In treatment, it is important to help clients identify potential triggers, draw a connection between strong emotional reactions and triggers, and develop coping strategies to manage those moments when a trigger occurs. A trigger is any sensory reminder of the traumatic event: a noise, smell, temperature, other physical sensation, or visual scene. Triggers can generalize to any characteristic, no matter how remote, that resembles or represents a previous trauma, such as revisiting the location where the trauma occurred, being alone, having your children reach the same age that you were when you experienced the trauma, seeing the same breed of dog that bit you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or anniversary of the event.

Flashbacks

A flashback is reexperiencing a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble the client's reactions during the trauma. Flashback experiences are very brief and typically last only a few seconds, but the emotional aftereffects linger for hours or longer. Flashbacks are commonly initiated by a trigger, but not necessarily. Sometimes, they occur out of the blue. Other times, specific physical states increase a person's vulnerability to reexperiencing a trauma, (e.g., fatigue, high stress levels). Flashbacks can feel like a brief movie scene that intrudes on the client. For example, hearing a car backfire on a hot, sunny day may be enough to cause a veteran to respond as if he or she were back on military patrol. Other ways people reexperience trauma, besides flashbacks, are via nightmares and intrusive thoughts of the trauma.

Advice to Counselors: Helping Clients Manage Flashbacks and Triggers

If a client is triggered in a session or during some aspect of treatment, help the client focus on what is happening in the here and now; that is, use grounding techniques. Behavioral health service providers should be prepared to help the client get regrounded so that they can distinguish between what is happening now versus what had happened in the past (see Covington, 2008, and Najavits, 2002b, 2007b, for more grounding techniques). Offer education about the experience of triggers and flashbacks, and then normalize these events as common traumatic stress reactions. Afterward, some clients need to discuss the experience and understand why the flashback or trigger occurred. It often helps for the client to draw a connection between the trigger and the traumatic event(s). This can be a preventive strategy whereby the client can anticipate that a given situation places him or her at higher risk for retraumatization and requires use of coping strategies, including seeking support.

Source: Green Cross Academy of Traumatology, 2010.

Dissociation, depersonalization, and derealization

Dissociation is a mental process that severs connections among a person's thoughts, memories, feelings, actions, and/or sense of identity. Most of us have experienced dissociation-losing the ability to recall or track a particular action (e.g., arriving at work but not remembering the last minutes of the drive). Dissociation happens because the person is engaged in an automatic activity and is not paying attention to his or her immediate environment. Dissociation can also occur during severe stress or trauma as a protective element whereby the individual incurs distortion of time, space, or identity. This is a common symptom in traumatic stress reactions.

Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive. At times, dissociation can be very pervasive and symptomatic of a mental disorder, such as dissociative identity disorder (DID; formerly known as multiple personality disorder). According to the DSM-5, "dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior" ( APA, 2013a, p. 291). Dissociative disorder diagnoses are closely associated with histories of severe childhood trauma or pervasive, human-caused, intentional trauma, such as that experienced by concentration camp survivors or victims of ongoing political imprisonment, torture, or long-term isolation. A mental health professional, preferably with significant training in working with dissociative disorders and with trauma, should be consulted when a dissociative disorder diagnosis is suspected.

Potential Signs of Dissociation

Sudden flattening of affect

Responses not congruent with the present context or situation

Excessive intellectualization

( Briere, 1996a)

The characteristics of DID can be commonly accepted experiences in other cultures, rather than being viewed as symptomatic of a traumatic experience. For example, in non-Western cultures, a sense of alternate beings within oneself may be interpreted as being inhabited by spirits or ancestors ( Kirmayer, 1996). Other experiences associated with dissociation include depersonalization-psychologically "leaving one's body," as if watching oneself from a distance as an observer or through derealization, leading to a sense that what is taking place is unfamiliar or is not real.

If clients exhibit signs of dissociation, behavioral health service providers can use grounding techniques to help them reduce this defense strategy. One major long-term consequence of dissociation is the difficulty it causes in connecting strong emotional or physical reactions with an event. Often, individuals may believe that they are going crazy because they are not in touch with the nature of their reactions. By educating clients on the resilient qualities of dissociation while also emphasizing that it prevents them from addressing or validating the trauma, individuals can begin to understand the role of dissociation. All in all, it is important when working with trauma survivors that the intensity level is not so great that it triggers a dissociative reaction and prevents the person from engaging in the process.

Behavioral

Traumatic stress reactions vary widely; often, people engage in behaviors to manage the aftereffects, the intensity of emotions, or the distressing aspects of the traumatic experience. Some people reduce tension or stress through avoidant, self-medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors), and/or self-injurious behaviors. Others may try to gain control over their experiences by being aggressive or subconsciously reenacting aspects of the trauma.

Behavioral reactions are also the consequences of, or learned from, traumatic experiences. For example, some people act like they can't control their current environment, thus failing to take action or make decisions long after the trauma (learned helplessness). Other associate elements of the trauma with current activities, such as by reacting to an intimate moment in a significant relationship as dangerous or unsafe years after a date rape. The following sections discuss behavioral consequences of trauma and traumatic stress reactions.

Reenactments

A hallmark symptom of trauma is reexperiencing the trauma in various ways. Reexperiencing can occur through reenactments (literally, to "redo"), by which trauma survivors repetitively relive and recreate a past trauma in their present lives. This is very apparent in children, who play by mimicking what occurred during the trauma, such as by pretending to crash a toy airplane into a toy building after seeing televised images of the terrorist attacks on the World Trade Center on September 11, 2001. Attempts to understand reenactments are very complicated, as reenactments occur for a variety of reasons. Sometimes, individuals reenact past traumas to master them. Examples of reenactments include a variety of behaviors: self-injurious behaviors, hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driving recklessly, or involvement in repetitive destructive relationships (e.g., repeatedly getting into romantic relationships with people who are abusive or violent), to name a few.

Self-harm and self-destructive behaviors

Self-harm is any type of intentionally self-inflicted harm, regardless of the severity of injury or whether suicide is intended. Often, self-harm is an attempt to cope with emotional or physical distress that seems overwhelming or to cope with a profound sense of dissociation or being trapped, helpless, and "damaged" ( Herman, 1997; Santa Mina & Gallop, 1998). Self-harm is associated with past childhood sexual abuse and other forms of trauma as well as substance abuse. Thus, addressing self-harm requires attention to the client's reasons for self-harm. More than likely, the client needs help recognizing and coping with emotional or physical distress in manageable amounts and ways.

Resilient Responses to Trauma

Many people find healthy ways to cope with, respond to, and heal from trauma. Often, people automatically reevaluate their values and redefine what is important after a trauma. Such resilient responses include:

Increased bonding with family and community.

Redefined or increased sense of purpose and meaning.

Increased commitment to a personal mission.

Increased charitable giving and volunteerism.

Case Illustration: Marco

Marco, a 30-year-old man, sought treatment at a local mental health center after a 2-year bout of anxiety symptoms. He was an active member of his church for 12 years, but although he sought help from his pastor about a year ago, he reports that he has had no contact with his pastor or his church since that time. Approximately 3 years ago, his wife took her own life. He describes her as his soul-mate and has had a difficult time understanding her actions or how he could have prevented them.

In the initial intake, he mentioned that he was the first person to find his wife after the suicide and reported feelings of betrayal, hurt, anger, and devastation since her death. He claimed that everyone leaves him or dies. He also talked about his difficulty sleeping, having repetitive dreams of his wife, and avoiding relationships. In his first session with the counselor, he initially rejected the counselor before the counselor had an opportunity to begin reviewing and talking about the events and discomfort that led him to treatment.

In this scenario, Marco is likely reenacting his feelings of abandonment by attempting to reject others before he experiences another rejection or abandonment. In this situation, the counselor will need to recognize the reenactment, explore the behavior, and examine how reenactments appear in other situations in Marco's life.

Among the self-harm behaviors reported in the literature are cutting, burning skin by heat (e.g., cigarettes) or caustic liquids, punching hard enough to self-bruise, head banging, hair pulling, self-poisoning, inserting foreign objects into bodily orifices, excessive nail biting, excessive scratching, bone breaking, gnawing at flesh, interfering with wound healing, tying off body parts to stop breathing or blood flow, swallowing sharp objects, and suicide. Cutting and burning are among the most common forms of self-harm.

Self-harm tends to occur most in people who have experienced repeated and/or early trauma (e.g., childhood sexual abuse) rather than in those who have undergone a single adult trauma (e.g., a community-wide disaster or a serious car accident). There are strong associations between eating disorders, self-harm, and substance abuse ( Claes & Vandereycken, 2007; for discussion, see Harned, Najavits, & Weiss, 2006). Self-mutilation is also associated with (and part of the diagnostic criteria for) a number of personality disorders, including borderline and histrionic, as well as DID, depression, and some forms of schizophrenia; these disorders can co-occur with traumatic stress reactions and disorders.

It is important to distinguish self-harm that is suicidal from self-harm that is not suicidal and to assess and manage both of these very serious dangers carefully. Most people who engage in self-harm are not doing so with the intent to kill themselves ( Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003)-although self-harm can be life threatening and can escalate into suicidality if not managed therapeutically. Self-harm can be a way of getting attention or manipulating others, but most often it is not. Self-destructive behaviors such as substance abuse, restrictive or binge eating, reckless automobile driving, or high-risk impulsive behavior are different from self-harming behaviors but are also seen in clients with a history of trauma. Self-destructive behaviors differ from self-harming behaviors in that there may be no immediate negative impact of the behavior on the individual; they differ from suicidal behavior in that there is no intent to cause death in the short term.

Advice to Counselors: Working With Clients Who Are Self-Injurious

Counselors who are unqualified or uncomfortable working with clients who demonstrate self-harming, self-destructive, or suicidal or homicidal ideation, intent, or behavior should work with their agencies and supervisors to refer such clients to other counselors. They should consider seeking specialized supervision on how to manage such clients effectively and safely and how to manage their feelings about these issues. The following suggestions assume that the counselor has had sufficient training and experience to work with clients who are self-injurious. To respond appropriately to a client who engages in self-harm, counselors should:

Screen the client for self-harm and suicide risk at the initial evaluation and throughout treatment.

Learn the client's perspective on self-harm and how it "helps."

Understand that self-harm is often a coping strategy to manage the intensity of emotional and/or physical distress.

Teach the client coping skills that improve his or her management of emotions without self-harm.

Help the client obtain the level of care needed to manage genuine risk of suicide or severe self-injury. This might include hospitalization, more intensive programming (e.g., intensive outpatient, partial hospitalization, residential treatment), or more frequent treatment sessions. The goal is to stabilize the client as quickly as possible, and then, if possible, begin to focus treatment on developing coping strategies to manage self-injurious and other harmful impulses.

Consult with other team members, supervisors, and, if necessary, legal experts to determine whether one's efforts with and conceptualization of the self-harming client fit best practice guidelines. See, for example, Treatment Improvement Protocol (TIP) 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment [CSAT], 2005c). Document such consultations and the decisions made as a result of them thoroughly and frequently.

Help the client identify how substance use affects self-harm. In some cases, it can increase the behavior (e.g., alcohol disinhibits the client, who is then more likely to self-harm). In other cases, it can decrease the behavior (e.g., heroin evokes relaxation and, thus, can lessen the urge to self-harm). In either case, continue to help the client understand how abstinence from substances is necessary so that he or she can learn more adaptive coping.

Work collaboratively with the client to develop a plan to create a sense of safety. Individuals are affected by trauma in different ways; therefore, safety or a safe environment may mean something entirely different from one person to the next. Allow the client to define what safety means to him or her.

Counselors can also help the client prepare a safety card that the client can carry at all times. The card might include the counselor's contact information, a 24-hour crisis number to call in emergencies, contact information for supportive individuals who can be contacted when needed, and, if appropriate, telephone numbers for emergency medical services. The counselor can discuss with the client the types of signs or crises that might warrant using the numbers on the card. Additionally, the counselor might check with the client from time to time to confirm that the information on the card is current.

TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a), has examples of safety agreements specifically for suicidal clients and discusses their uses in more detail. There is no credible evidence that a safety agreement is effective in preventing a suicide attempt or death. Safety agreements for clients with suicidal thoughts and behaviors should only be used as an adjunct support accompanying professional screening, assessment, and treatment for people with suicidal thoughts and behaviors. Keep in mind that safety plans or agreements may be perceived by the trauma survivor as a means of controlling behavior, subsequently replicating or triggering previous traumatic experiences.

All professionals-and in some States, anyone-could have ethical and legal responsibilities to those clients who pose an imminent danger to themselves or others. Clinicians should be aware of the pertinent State laws where they practice and the relevant Federal and professional regulations.

However, as with self-harming behavior, self-destructive behavior needs to be recognized and addressed and may persist-or worsen-without intervention.

Consumption of substances

Substance use often is initiated or increased after trauma. Clients in early recovery- especially those who develop PTSD or have it reactivated-have a higher relapse risk if they experience a trauma. In the first 2 months after September 11, 2001, more than a quarter of New Yorker residents who smoked cigarettes, drank alcohol, or used marijuana (about 265,000 people) increased their consumption. The increases continued 6 months after the attacks ( Vlahov, Galea, Ahern, Resnick, & Kilpatrick, 2004). A study by the Substance Abuse and Mental Health Services Administration ( SAMHSA, Office of Applied Studies, 2002) used National Survey on Drug Use and Health data to compare the first three quarters of 2001 with the last quarter and reported an increase in the prevalence rate for alcohol use among people 18 or older in the New York metropolitan area during the fourth quarter.

Interviews with New York City residents who were current or former cocaine or heroin users indicated that many who had been clean for 6 months or less relapsed after September 11, 2001. Others, who lost their income and could no longer support their habit, enrolled in methadone programs ( Weiss et al., 2002). After the Oklahoma City bombing in 1995, Oklahomans reported double the normal rate of alcohol use, smoking more cigarettes, and a higher incidence of initiating smoking months and even years after the bombing ( Smith, Christiansen, Vincent, & Hann, 1999).

Self-medication

Khantzian's self-medication theory ( 1985) suggests that drugs of abuse are selected for their specific effects. However, no definitive pattern has yet emerged of the use of particular substances in relation to PTSD or trauma symptoms. Use of substances can vary based on a variety of factors, including which trauma symptoms are most prominent for an individual and the individual's access to particular substances. Unresolved traumas sometimes lurk behind the emotions that clients cannot allow themselves to experience. Substance use and abuse in trauma survivors can be a way to self-medicate and thereby avoid or displace difficult emotions associated with traumatic experiences. When the substances are withdrawn, the survivor may use other behaviors to self-soothe, self-medicate, or avoid emotions. As likely, emotions can appear after abstinence in the form of anxiety and depression.

Avoidance

Avoidance often coincides with anxiety and the promotion of anxiety symptoms. Individuals begin to avoid people, places, or situations to alleviate unpleasant emotions, memories, or circumstances. Initially, the avoidance works, but over time, anxiety increases and the perception that the situation is unbearable or dangerous increases as well, leading to a greater need to avoid. Avoidance can be adaptive, but it is also a behavioral pattern that reinforces perceived danger without testing its validity, and it typically leads to greater problems across major life areas (e.g., avoiding emotionally oriented conversations in an intimate relationship). For many individuals who have traumatic stress reactions, avoidance is commonplace. A person may drive 5 miles longer to avoid the road where he or she had an accident. Another individual may avoid crowded places in fear of an assault or to circumvent strong emotional memories about an earlier assault that took place in a crowded area. Avoidance can come in many forms. When people can't tolerate strong affects associated with traumatic memories, they avoid, project, deny, or distort their trauma-related emotional and cognitive experiences. A key ingredient in trauma recovery is learning to manage triggers, memories, and emotions without avoidance-in essence, becoming desensitized to traumatic memories and associated symptoms.

Social/Interpersonal

A key ingredient in the early stage of TIC is to establish, confirm, or reestablish a support system, including culturally appropriate activities, as soon as possible. Social supports and relationships can be protective factors against traumatic stress. However, trauma typically affects relationships significantly, regardless of whether the trauma is interpersonal or is of some other type. Relationships require emotional exchanges, which means that others who have close relationships or friendships with the individual who survived the trauma(s) are often affected as well-either through secondary traumatization or by directly experiencing the survivor's traumatic stress reactions. In natural disasters, social and community supports can be abruptly eroded and difficult to rebuild after the initial disaster relief efforts have waned.

Survivors may readily rely on family members, friends, or other social supports-or they may avoid support, either because they believe that no one will be understanding or trustworthy or because they perceive their own needs as a burden to others. Survivors who have strong emotional or physical reactions, including outbursts during nightmares, may pull away further in fear of being unable to predict their own reactions or to protect their own safety and that of others. Often, trauma survivors feel ashamed of their stress reactions, which further hampers their ability to use their support systems and resources adequately.

Many survivors of childhood abuse and interpersonal violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers and family members or through significant relationships. This history of betrayal can disrupt forming or relying on supportive relationships in recovery, such as peer supports and counseling. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including behavioral health service providers. It is exceptionally difficult to override the feeling that someone is going to hurt you, take advantage of you, or, minimally, disappoint you. Early betrayal can affect one's ability to develop attachments, yet the formation of supportive relationships is an important antidote in the recovery from traumatic stress.

Developmental

Each age group is vulnerable in unique ways to the stresses of a disaster, with children and the elderly at greatest risk. Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches). School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worse school performance. Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, and sleep and eating disturbances ( Hamblen, 2001). Adults may display sleep problems, increased agitation, hypervigilance, isolation or withdrawal, and increased use of alcohol or drugs. Older adults may exhibit increased withdrawal and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b).

Neurobiological Development: Consequences of Early Childhood Trauma

Findings in developmental psychobiology suggest that the consequences of early maltreatment produce enduring negative effects on brain development ( De Bellis, 2002; Liu, Diorio, Day, Francis, & Meaney, 2000; Teicher, 2002). Research suggests that the first stage in a cascade of events produced by early trauma and/or maltreatment involves the disruption of chemicals that function as neurotransmitters (e.g., cortisol, norepinephrine, dopamine), causing escalation of the stress response ( Heim, Mletzko, Purselle, Musselman, & Nemeroff, 2008; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Teicher, 2002). These chemical responses can then negatively affect critical neural growth during specific sensitive periods of childhood development and can even lead to cell death.

Adverse brain development can also result from elevated levels of cortisol and catecholamines by contributing to maturational failures in other brain regions, such as the prefrontal cortex ( Meaney, Brake, & Gratton, 2002). Heim, Mletzko et al. (2008) found that the neuropeptide oxytocin- important for social affiliation and support, attachment, trust, and management of stress and anxiety-was markedly decreased in the cerebrospinal fluid of women who had been exposed to childhood maltreatment, particularly those who had experienced emotional abuse. The more childhood traumas a person had experienced, and the longer their duration, the lower that person's current level of oxytocin was likely to be and the higher her rating of current anxiety was likely to be.

Using data from the Adverse Childhood Experiences Study, an analysis by Anda, Felitti, Brown et al. (2006) confirmed that the risk of negative outcomes in affective, somatic, substance abuse, memory, sexual, and aggression-related domains increased as scores on a measure of eight ACEs increased. The researchers concluded that the association of study scores with these outcomes can serve as a theoretical parallel for the effects of cumulative exposure to stress on the developing brain and for the resulting impairment seen in multiple brain structures and functions.

The National Child Traumatic Stress Network ( http://www.nctsn.org) offers information about childhood abuse, stress, and physiological responses of children who are traumatized. Materials are available for counselors, educators, parents, and caregivers. There are special sections on the needs of children in military families and on the impact of natural disasters on children's mental health.

Subthreshold Trauma-Related Symptoms

Many trauma survivors experience symptoms that, although they do not meet the diagnostic criteria for ASD or PTSD, nonetheless limit their ability to function normally (e.g., regulate emotional states, maintain steady and rewarding social and family relationships, function competently at a job, maintain a steady pattern of abstinence in recovery). These symptoms can be transient, only arising in a specific context; intermittent, appearing for several weeks or months and then receding; or a part of the individual's regular pattern of functioning (but not to the level of DSM-5 diagnostic criteria). Often, these patterns are termed "subthreshold" trauma symptoms. Like PTSD, the symptoms can be misdiagnosed as depression, anxiety, oran other mental illness. Likewise, clients who have experienced trauma may link some of their symptoms to their trauma and diagnose themselves as having PTSD, even though they do not meet all criteria for that disorder.

Combat Stress Reaction

A phenomenon unique to war, and one that counselors need to understand well, is combat stress reaction (CSR). CSR is an acute anxiety reaction occurring during or shortly after participating in military conflicts and wars as well as other operations within the war zone, known as the theater. CSR is not a formal diagnosis, nor is it included in the DSM-5 ( APA, 2013a). It is similar to acute stress reaction, except that the precipitating event or events affect military personnel (and civilians exposed to the events) in an armed conflict situation. The terms "combat stress reaction" and "posttraumatic stress injury" are relatively new, and the intent of using these new terms is to call attention to the unique experiences of combat-related stress as well as to decrease the shame that can be associated with seeking behavioral health services for PTSD (for more information on veterans and combat stress reactions, see the planned TIP, Reintegration-Related Behavioral Health Issues for Veterans and Military Families; SAMHSA, planned f).

Case Illustration: Frank

Frank is a 36-year-old man who was severely beaten in a fight outside a bar. He had multiple injuries, including broken bones, a concussion, and a stab wound in his lower abdomen. He was hospitalized for 3.5 weeks and was unable to return to work, thus losing his job as a warehouse forklift operator. For several years, when faced with situations in which he perceived himself as helpless and overwhelmed, Frank reacted with violent anger that, to others, appeared grossly out of proportion to the situation. He has not had a drink in almost 3 years, but the bouts of anger persist and occur three to five times a year. They leave Frank feeling even more isolated from others and alienated from those who love him. He reports that he cannot watch certain television shows that depict violent anger; he has to stop watching when such scenes occur. He sometimes daydreams about getting revenge on the people who assaulted him.

Psychiatric and neurological evaluations do not reveal a cause for Frank's anger attacks. Other than these symptoms, Frank has progressed well in his abstinence from alcohol. He attends a support group regularly, has acquired friends who are also abstinent, and has reconciled with his family of origin. His marriage is more stable, although the episodes of rage limit his wife's willingness to commit fully to the relationship. In recounting the traumatic event in counseling, Frank acknowledges that he thought he was going to die as a result of the fight, especially when he realized he had been stabbed. As he described his experience, he began to become very anxious, and the counselor observed the rage beginning to appear.

After his initial evaluation, Frank was referred to an outpatient program that provided trauma-specific interventions to address his subthreshold trauma symptoms. With a combination of cognitive- behavioral counseling, EMDR, and anger management techniques, he saw a gradual decrease in symptoms when he recalled the assault. He started having more control of his anger when memories of the trauma emerged. Today, when feeling trapped, helpless, or overwhelmed, Frank has resources for coping and does not allow his anger to interfere with his marriage or other relationships.

Although stress mobilizes an individual's physical and psychological resources to perform more effectively in combat, reactions to the stress may persist long after the actual danger has ended. As with other traumas, the nature of the event(s), the reactions of others, and the survivor's psychological history and resources affect the likelihood and severity of CSR. With combat veterans, this translates to the number, intensity, and duration of threat factors; the social support of peers in the veterans' unit; the emotional and cognitive resilience of the service members; and the quality of military leadership. CSR can vary from manageable and mild to debilitating and severe. Common, less severe symptoms of CSR include tension, hypervigilance, sleep problems, anger, and difficulty concentrating. If left untreated, CSR can lead to PTSD.

Common causes of CSR are events such as a direct attack from insurgent small arms fire or a military convoy being hit by an improvised explosive device, but combat stressors encompass a diverse array of traumatizing events, such as seeing grave injuries, watching others die, and making on-the-spot decisions in ambiguous conditions (e.g., having to determine whether a vehicle speeding toward a military checkpoint contains insurgents with explosives or a family traveling to another area). Such circumstances can lead to combat stress. Military personnel also serve in noncombat positions (e.g., healthcare and administrative roles), and personnel filling these supportive roles can be exposed to combat situations by proximity or by witnessing their results.

Advice to Counselors: Understanding the Nature of Combat Stress

Several sources of information are available to help counselors deepen their understanding of combat stress and postdeployment adjustment. Friedman (2006) explains how a prolonged combat-ready stance, which is adaptive in a war zone, becomes hypervigilance and overprotectiveness at home. He makes the point that the "mutual interdependence, trust, and affection" (p. 587) that are so necessarily a part of a combat unit are different from relationships with family members and colleagues in a civilian workplace. This complicates the transition to civilian life. Wheels Down: Adjusting to Life After Deployment ( Moore & Kennedy, 2011) provides practical advice for military service members, including inactive or active duty personnel and veterans, in transitioning from the theater to home.

The following are just a few of the many resources and reports focused on combat-related psychological and stress issues:

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery ( Tanielian & Jaycox, 2008)

On Killing ( Grossman, 1995), an indepth analysis of the psychological dynamics of combat

Haunted by Combat ( Paulson & Krippner, 2007), which contains specific chapters on Reserve and National Guard troops and female veterans

Specific Trauma-Related Psychological Disorders

Part of the definition of trauma is that the individual responds with intense fear, helplessness, or horror. Beyond that, in both the short term and the long term, trauma comprises a range of reactions from normal (e.g., being unable to concentrate, feeling sad, having trouble sleeping) to warranting a diagnosis of a trauma-related mental disorder. Most people who experience trauma have no long-lasting disabling effects; their coping skills and the support of those around them are sufficient to help them overcome their difficulties, and their ability to function on a daily basis over time is unimpaired. For others, though, the symptoms of trauma are more severe and last longer. The most common diagnoses associated with trauma are PTSD and ASD, but trauma is also associated with the onset of other mental disorders-particularly substance use disorders, mood disorders, various anxiety disorders, and personality disorders. Trauma also typically exacerbates symptoms of preexisting disorders, and, for people who are predisposed to a mental disorder, trauma can precipitate its onset. Mental disorders can occur almost simultaneously with trauma exposure or manifest sometime thereafter.

Acute Stress Disorder

ASD represents a normal response to stress. Symptoms develop within 4 weeks of the trauma and can cause significant levels of distress. Most individuals who have acute stress reactions never develop further impairment or PTSD. Acute stress disorder is highly associated with the experience of one specific trauma rather than the experience of long-term exposure to chronic traumatic stress. Diagnostic criteria are presented in Exhibit 1.3-3.

The primary presentation of an individual with an acute stress reaction is often that of someone who appears overwhelmed by the traumatic experience. The need to talk about the experience can lead the client to seem self-centered and unconcerned about the needs of others. He or she may need to describe, in repetitive detail, what happened, or may seem obsessed with trying to understand what happened in an effort to make sense of the experience. The client is often hypervigilant and avoids circumstances that are reminders of the trauma. For instance, someone who was in a serious car crash in heavy traffic can become anxious and avoid riding in a car or driving in traffic for a finite time afterward. Partial amnesia for the trauma often accompanies ASD, and the individual may repetitively question others to fill in details. People with ASD symptoms sometimes seek assurance from others that the event happened in the way they remember, that they are not "going crazy" or "losing it," and that they could not have prevented the event. The next case illustration demonstrates the time-limited nature of ASD.

Differences between ASD and PTSD

It is important to consider the differences between ASD and PTSD when forming a diagnostic impression. The primary difference is the amount of time the symptoms have been present. ASD resolves 2 days to 4 weeks after an event, whereas PTSD continues beyond the 4-week period. The diagnosis of ASD can change to a diagnosis of PTSD if the condition is noted within the first 4 weeks after the event, but the symptoms persist past 4 weeks.

ASD also differs from PTSD in that the ASD diagnosis requires 9 out of 14 symptoms from five categories, including intrusion, negative mood, dissociation, avoidance, and arousal. These symptoms can occur at the time of the trauma or in the following month. Studies indicate that dissociation at the time of trauma is a good predictor of subsequent PTSD, so the inclusion of dissociative symptoms makes it more likely that those who develop ASD will later be diagnosed with PTSD ( Bryant & Harvey, 2000). Additionally, ASD is a transient disorder, meaning that it is present in a person's life for a relatively short time and then passes. In contrast, PTSD typically becomes a primary feature of an individual's life. Over a lengthy period, PTSD can have profound effects on clients' perceptions of safety, their sense of hope for the future, their relationships with others, their physical health, the appearance of psychiatric symptoms, and their patterns of substance use and abuse.

There are common symptoms between PTSD and ASD, and untreated ASD is a possible predisposing factor to PTSD, but it is unknown whether most people with ASD are likely to develop PTSD. There is some suggestion that, as with PTSD, ASD is more prevalent in women than in men ( Bryant & Harvey, 2003). However, many people with PTSD do not have a diagnosis or recall a history of acute stress symptoms before seeking treatment for or receiving a diagnosis of PTSD.

Case Illustration: Sheila

Two months ago, Sheila, a 55-year-old married woman, experienced a tornado in her home town. In the previous year, she had addressed a long-time marijuana use problem with the help of a treatment program and had been abstinent for about 6 months. Sheila was proud of her abstinence; it was something she wanted to continue. She regarded it as a mark of personal maturity; it improved her relationship with her husband, and their business had flourished as a result of her abstinence.

During the tornado, an employee reported that Sheila had become very agitated and had grabbed her assistant to drag him under a large table for cover. Sheila repeatedly yelled to her assistant that they were going to die. Following the storm, Sheila could not remember certain details of her behavior during the event. Furthermore, Sheila said that after the storm, she felt numb, as if she was floating out of her body and could watch herself from the outside. She stated that nothing felt real and it was all like a dream.

Following the tornado, Sheila experienced emotional numbness and detachment, even from people close to her, for about 2 weeks. The symptoms slowly decreased in intensity but still disrupted her life. Sheila reported experiencing disjointed or unconnected images and dreams of the storm that made no real sense to her. She was unwilling to return to the building where she had been during the storm, despite having maintained a business at this location for 15 years. In addition, she began smoking marijuana again because it helped her sleep. She had been very irritable and had uncharacteristic angry outbursts toward her husband, children, and other family members.

As a result of her earlier contact with a treatment program, Sheila returned to that program and engaged in psychoeducational, supportive counseling focused on her acute stress reaction. She regained abstinence from marijuana and returned shortly to a normal level of functioning. Her symptoms slowly diminished over a period of 3 weeks. With the help of her counselor, she came to understand the link between the trauma and her relapse, regained support from her spouse, and again felt in control of her life.

Effective interventions for ASD can significantly reduce the possibility of the subsequent development of PTSD. Effective treatment of ASD can also reduce the incidence of other co-occurring problems, such as depression, anxiety, dissociative disorders, and compulsive behaviors ( Bryant & Harvey, 2000). Intervention for ASD also helps the individual develop coping skills that can effectively prevent the recurrence of ASD after later traumas.

Although predictive science for ASD and PTSD will continue to evolve, both disorders are associated with increased substance use and mental disorders and increased risk of relapse; therefore, effective screening for ASD and PTSD is important for all clients with these disorders. Individuals in early recovery-lacking well-practiced coping skills, lacking environmental supports, and already operating at high levels of anxiety-are particularly susceptible to ASD. Events that would not normally be disabling can produce symptoms of intense helplessness and fear, numbing and depersonalization, disabling anxiety, and an inability to handle normal life events. Counselors should be able to recognize ASD and treat it rather than attributing the symptoms to a client's lack of motivation to change, being "dry drunk" (for those in substance abuse recovery), or being manipulative.

Posttraumatic Stress Disorder

The trauma-related disorder that receives the greatest attention is PTSD; it is the most commonly diagnosed trauma-related disorder, and its symptoms can be quite debilitating over time. Nonetheless, it is important to remember that PTSD symptoms are represented in a number of other mental illnesses, including major depressive disorder (MDD), anxiety disorders, and psychotic disorders ( Foa et al., 2006). The DSM-5 ( APA, 2013a) identifies four symptom clusters for PTSD: presence of intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. Individuals must have been exposed to actual or threatened death, serious injury, or sexual violence, and the symptoms must produce significant distress and impairment for more than 4 weeks ( Exhibit 1.3-4).

Case Illustration: Michael

Michael is a 62-year-old Vietnam veteran. He is a divorced father of two children and has four grandchildren. Both of his parents were dependent on alcohol. He describes his childhood as isolated. His father physically and psychologically abused him (e.g., he was beaten with a switch until he had welts on his legs, back, and buttocks). By age 10, his parents regarded him as incorrigible and sent him to a reformatory school for 6 months. By age 15, he was using marijuana, hallucinogens, and alcohol and was frequently truant from school.

At age 19, Michael was drafted and sent to Vietnam, where he witnessed the deaths of six American military personnel. In one incident, the soldier he was next to in a bunker was shot. Michael felt helpless as he talked to this soldier, who was still conscious. In Vietnam, Michael increased his use of both alcohol and marijuana. On his return to the United States, Michael continued to drink and use marijuana. He reenlisted in the military for another tour of duty.

His life stabilized in his early 30s, as he had a steady job, supportive friends, and a relatively stable family life. However, he divorced in his late 30s. Shortly thereafter, he married a second time, but that marriage ended in divorce as well. He was chronically anxious and depressed and had insomnia and frequent nightmares. He periodically binged on alcohol. He complained of feeling empty, had suicidal ideation, and frequently stated that he lacked purpose in his life.

In the 1980s, Michael received several years of mental health treatment for dysthymia. He was hospitalized twice and received 1 year of outpatient psychotherapy. In the mid-1990s, he returned to outpatient treatment for similar symptoms and was diagnosed with PTSD and dysthymia. He no longer used marijuana and rarely drank. He reported that he didn't like how alcohol or other substances made him feel anymore-he felt out of control with his emotions when he used them. Michael reported symptoms of hyperarousal, intrusion (intrusive memories, nightmares, and preoccupying thoughts about Vietnam), and avoidance (isolating himself from others and feeling "numb"). He reported that these symptoms seemed to relate to his childhood abuse and his experiences in Vietnam. In treatment, he expressed relief that he now understood the connection between his symptoms and his history.

Certain characteristics make people more susceptible to PTSD, including one's unique personal vulnerabilities at the time of the traumatic exposure, the support (or lack of support) received from others at the time of the trauma and at the onset of trauma-related symptoms, and the way others in the person's environment gauge the nature of the traumatic event ( Brewin, Andrews, & Valentine, 2000).

People with PTSD often present varying clinical profiles and histories. They can experience symptoms that are activated by environmental triggers and then recede for a period of time. Some people with PTSD who show mostly psychiatric symptoms (particularly depression and anxiety) are misdiagnosed and go untreated for their primary condition. For many people, the trauma experience and diagnosis are obscured by co-occurring substance use disorder symptoms. The important feature of PTSD is that the disorder becomes an orienting feature of the individual's life. How well the person can work, with whom he or she associates, the nature of close and intimate relationships, the ability to have fun and rejuvenate, and the way in which an individual goes about confronting and solving problems in life are all affected by the client's trauma experiences and his or her struggle to recover.

Posttraumatic stress disorder: Timing of symptoms

Although symptoms of PTSD usually begin within 3 months of a trauma in adulthood, there can be a delay of months or even years before symptoms appear for some people. Some people may have minimal symptoms after a trauma but then experience a crisis later in life. Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation. Survivors of abuse in childhood can have a delayed response triggered by something that happens to them as adults. For example, seeing a movie about child abuse can trigger symptoms related to the trauma. Other triggers include returning to the scene of the trauma, being reminded of it in some other way, or noting the anniversary of an event. Likewise, combat veterans and survivors of community-wide disasters may seem to be coping well shortly after a trauma, only to have symptoms emerge later when their life situations seem to have stabilized. Some clients in substance abuse recovery only begin to experience trauma symptoms when they maintain abstinence for some time. As individuals decrease tension-reducing or self-medicating behaviors, trauma memories and symptoms can emerge.

Advice to Counselors: Helping Clients With Delayed Trauma Responses

Clients who are experiencing a delayed trauma response can benefit if you help them to:

Create an environment that allows acknowledgment of the traumatic event(s).

Discuss their initial recall or first suspicion that they were having a traumatic response.

Become educated on delayed trauma responses.

Draw a connection between the trauma and presenting trauma-related symptoms.

Create a safe environment.

Explore their support systems and fortify them as needed.

Understand that triggers can precede traumatic stress reactions, including delayed responses to trauma.

Develop coping strategies to navigate and manage symptoms.

Culture and posttraumatic stress

Although research is limited across cultures, PTSD has been observed in Southeast Asian, South American, Middle Eastern, and Native American survivors ( Osterman & de Jong, 2007; Wilson & Tang, 2007). As Stamm and Friedman (2000) point out, however, simply observing PTSD does not mean that it is the "best conceptual tool for characterizing post-traumatic distress among non-Western individuals" (p. 73). In fact, many trauma-related symptoms from other cultures do not fit the DSM-5 criteria. These include somatic and psychological symptoms and beliefs about the origins and nature of traumatic events. Moreover, religious and spiritual beliefs can affect how a survivor experiences a traumatic event and whether he or she reports the distress. For example, in societies where attitudes toward karma and the glorification of war veterans are predominant, it is harder for war veterans to come forward and disclose that they are emotionally overwhelmed or struggling. It would be perceived as inappropriate and possibly demoralizing to focus on the emotional distress that he or she still bears. (For a review of cultural competence in treating trauma, refer to Brown, 2008.)

Methods for measuring PTSD are also culturally specific. As part of a project begun in 1972, the World Health Organization (WHO) and the National Institutes of Health (NIH) embarked on a joint study to test the cross-cultural applicability of classification systems for various diagnoses. WHO and NIH identified apparently universal factors of psychological disorders and developed specific instruments to measure them. These instruments, the Composite International Diagnostic Interview and the Schedules for Clinical Assessment in Neuropsychiatry, include certain criteria from the DSM (Fourth Edition, Text Revision; APA, 2000a) as well as criteria from the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; Exhibit 1.3-5).

Complex trauma and complex traumatic stress

When individuals experience multiple traumas, prolonged and repeated trauma during childhood, or repetitive trauma in the context of significant interpersonal relationships, their reactions to trauma have unique characteristics ( Herman, 1992). This unique constellation of reactions, called complex traumatic stress, is not recognized diagnostically in the DSM-5, but theoretical discussions and research have begun to highlight the similarities and differences in symptoms of posttraumatic stress versus complex traumatic stress ( Courtois & Ford, 2009). Often, the symptoms generated from complex trauma do not fully match PTSD criteria and exceed the severity of PTSD. Overall, literature reflects that PTSD criteria or subthreshold symptoms do not fully account for the persistent and more impairing clinical presentation of complex trauma. Even though current research in the study of traumatology is prolific, it is still in the early stages of development. The idea that there may be more diagnostic variations or subtypes is forthcoming, and this will likely pave the way for more client-matching interventions to better serve those individuals who have been repeatedly exposed to multiple, early childhood, and/or interpersonal traumas.

Other Trauma-Related and Co-Occurring Disorders

The symptoms of PTSD and other mental disorders overlap considerably; these disorders often coexist and in clude mood, anxiety, substance use, and personality disorders. Thus, it's common for trauma survivors to be underdiagnosed or misdiagnosed. If they have not been identified as trauma survivors, their psychological distress is often not associated with previous trauma, and/or they are diagnosed with a disorder that marginally matches their presenting symptoms and psychological sequelae of trauma. The following sections present a brief overview of some mental disorders that can result from (or be worsened by) traumatic stress. PTSD is not the only diagnosis related to trauma nor its only psychological consequence; trauma can broadly influence mental and physical health in clients who already have behavioral health disorders.

The term " co-occurring disorders " refers to cases when a person has one or more mental disorders as well as one or more substance use disorders (including substance abuse). Co-occurring disorders are common among individuals who have a history of trauma and are seeking help.

Advice to Counselors: Universal Screening and Assessment

Only people specifically trained and licensed in mental health assessment should make diagnoses; trauma can result in complicated cases, and many symptoms can be present, whether or not they meet full diagnostic criteria for a specific disorder. Only a trained assessor can distinguish accurately among various symptoms and in the presence of co-occurring disorders. However, behavioral health professionals without specific assessment training can still serve an important role in screening for possible mental disorders using established screening tools ( CSAT, 2005c; see also Chapter 4 of this TIP). In agencies and clinics, it is critical to provide such screenings systematically-for each client-as PTSD and other co-occurring disorders are typically under diagnosed or misdiagnosed.

People With Mental Disorders

MDD is the most common co-occurring disorder in people who have experienced trauma and are diagnosed with PTSD. A well-established causal relationship exists between stressful events and depression, and a prior history of MDD is predictive of PTSD after exposure to major trauma ( Foa et al., 2006).

Many survivors with severe mental disorders function fairly well following trauma, including disasters, as long as essential services aren't interrupted. For others, additional mental health supports may be necessary. For more information, see Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disaster ( Center for Mental Health Services, 1996).

Co-occurrence is also linked with greater impairment and more severe symptoms of both disorders, and the person is less likely to experience remission of symptoms within 6 months.

Generalized anxiety, obsessive-compulsive, and other anxiety disorders are also associated with PTSD. PTSD may exacerbate anxiety disorder symptoms, but it is also likely that preexisting anxiety symptoms and anxiety disorders increase vulnerability to PTSD. Preexisting anxiety primes survivors for greater hyperarousal and distress. Other disorders, such as personality and somatization disorders, are also associated with trauma, but the history of trauma is often overlooked as a significant factor or necessary target in treatment.

The relationship between PTSD and other disorders is complex. More research is now examining the multiple potential pathways among PTSD and other disorders and how various sequences affect clinical presentation. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c), is valuable in understanding the relationship of substance use to other mental disorders.

People With Substance Use Disorders

There is clearly a correlation between trauma (including individual, group, or mass trauma) and substance use as well as the presence of posttraumatic stress (and other trauma-related disorders) and substance use disorders. Alcohol and drug use can be, for some, an effort to manage traumatic stress and specific PTSD symptoms. Likewise, people with substance use disorders are at higher risk of developing PTSD than people who do not abuse substances. Counselors working with trauma survivors or clients who have substance use disorders have to be particularly aware of the possibility of the other disorder arising.

Co-Occurring PTSD and Other Mental Disorders

Individuals with PTSD often have at least one additional diagnosis of a mental disorder.

The presence of other disorders typically worsens and prolongs the course of PTSD and complicates clinical assessment, diagnosis, and treatment.

The most common co-occurring disorders, in addition to substance use disorders, include mood disorders, various anxiety disorders, eating disorders, and personality disorders.

Exposure to early, severe, and chronic trauma is linked to more complex symptoms, including impulse control deficits, greater difficulty in emotional regulation and establishing stable relationships, and disruptions in consciousness, memory, identity, and/or perception of the environment ( Dom, De, Hulstijn, & Sabbe, 2007; Waldrop, Back, Verduin, & Brady, 2007).

Certain diagnostic groups and at-risk populations (e.g., people with developmental disabilities, people who are homeless or incarcerated) are more susceptible to trauma exposure and to developing PTSD if exposed but less likely to receive appropriate diagnosis and treatment.

Given the prevalence of traumatic events in clients who present for substance abuse treatment, counselors should assess all clients for possible trauma-related disorders.

Timeframe: PTSD and the onset of substance use disorders

Knowing whether substance abuse or PTSD came first informs whether a causal relationship exists, but learning this requires thorough assessment of clients and access to complete data on PTSD; substance use, abuse, and dependence; and the onset of each. Much current research focuses solely on the age of onset of substance use (not abuse), so determining causal relationships can be difficult. The relationship between PTSD and substance use disorders is thought to be bidirectional and cyclical: substance use increases trauma risk, and exposure to trauma escalates substance use to manage trauma-related symptoms. Three other causal pathways described by Chilcoat and Breslau's seminal work ( 1998) further explain the relationship between PTSD and substance use disorders:

1. The "self-medication" hypothesis suggests that clients with PTSD use substances to manage PTSD symptoms (e.g., intrusive memories, physical arousal). Substances such as alcohol, cocaine, barbiturates, opioids, and amphetamines are frequently abused in attempts to relieve or numb emotional pain or to forget the event.

2. The "high-risk" hypothesis states that drug and alcohol use places people who use substances in high-risk situations that increase their chances of being exposed to events that lead to PTSD.

3. The "susceptibility" hypothesis suggests that people who use substances are more susceptible to developing PTSD after exposure to trauma than people who do not. Increased vulnerability may result from failure to develop effective stress management strategies, changes in brain chemistry, or damage to neurophysiological systems due to extensive substance use.

PTSD and substance abuse treatment

PTSD can limit progress in substance abuse recovery, increase the potential for relapse, and complicate a client's ability to achieve success in various life areas. Each disorder can mask or hide the symptoms of the other, and both need to be assessed and treated if the individual is to have a full recovery. There is a risk of misinterpreting trauma-related symptoms in substance abuse treatment settings. For example, avoidance symptoms in an individual with PTSD can be misinterpreted as lack of motivation or unwillingness to engage in substance abuse treatment; a counselor's efforts to address substance abuse-related behaviors in early recovery can likewise provoke an exaggerated response from a trauma survivor who has profound traumatic experiences of being trapped and controlled. Exhibit 1.3-6 lists important facts about PTSD and substance use disorders for counselors.

Case Illustration: Maria

Maria is a 31-year-old woman diagnosed with PTSD and alcohol dependence. From ages 8 to 12, she was sexually abused by an uncle. Maria never told anyone about the abuse for fear that she would not be believed. Her uncle remains close to the family, and Maria still sees him on certain holidays. When she came in for treatment, she described her emotions and thoughts as out of control. Maria often experiences intrusive memories of the abuse, which at times can be vivid and unrelenting. She cannot predict when the thoughts will come; efforts to distract herself from them do not always work. She often drinks in response to these thoughts or his presence, as she has found that alcohol can dull her level of distress. Maria also has difficulty falling asleep and is often awakened by nightmares. She does not usually remember the dreams, but she wakes up feeling frightened and alert and cannot go back to sleep.

Maria tries to avoid family gatherings but often feels pressured to go. Whenever she sees her uncle, she feels intense panic and anger but says she can usually "hold it together" if she avoids him. Afterward, however, she describes being overtaken by these feelings and unable to calm down. She also describes feeling physically ill and shaky. At these times, she often isolates herself, stays in her apartment, and drinks steadily for several days. Maria also reports distress pertaining to her relationship with her boyfriend. In the beginning of their relationship, she found him comforting and enjoyed his affection, but more recently, she has begun to feel anxious and unsettled around him. Maria tries to avoid sex with him, but she sometimes gives in for fear of losing the relationship. She finds it easier to have sex with him when she is drunk, but she often experiences strong feelings of dread and disgust reminiscent of her abuse. Maria feels guilty and confused about these feelings.

Sleep, PTSD, and substance use

Many people have trouble getting to sleep and/or staying asleep after a traumatic event; consequently, some have a drink or two to help them fall asleep. Unfortunately, any initially helpful effects are likely not only to wane quickly, but also to incur a negative rebound effect. When someone uses a substance before going to bed, "sleep becomes lighter and more easily disrupted," and rapid eye movement sleep (REM) "increases, with an associated increase in dreams and nightmares," as the effects wear off ( Auerbach, 2003, p. 1185).

People with alcohol dependence report multiple types of sleep disturbances over time, and it is not unusual for clients to report that they cannot fall asleep without first having a drink. Both REM and slow wave sleep are reduced in clients with alcohol dependence, which is also associated with an increase in the amount of time it takes before sleep occurs, decreased overall sleep time, more nightmares, and reduced sleep efficiency. Sleep during withdrawal is "frequently marked by severe insomnia and sleep fragmentation...a loss of restful sleep and feelings of daytime fatigue. Nightmares and vivid dreams are not uncommon" ( Auerbach, 2003, pp. 1185-1186).

Confounding changes in the biology of sleep that occur in clients with PTSD and substance use disorders often add to the problems of recovery. Sleep can fail to return to normal for months or even years after abstinence, and the persistence of sleep disruptions appears related to the likelihood of relapse. Of particular clinical importance is the vicious cycle that can also begin during "slips"; relapse initially improves sleep, but continued drinking leads to sleep disruption. This cycle of initial reduction of an unpleasant symptom, which only ends up exacerbating the process as a whole, can take place for clients with PTSD as well as for clients with substance use disorders. There are effective cognitive-behavioral therapies and nonaddictive pharmacological interventions for sleep difficulties.

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Trauma-informed care (TIC) involves a broad understanding of traumatic stress reactions and common responses to trauma. Providers need to understand how trauma can affect treatment presentation, engagement, and the outcome of behavioral health services. This chapter examines common experiences survivors may encounter immediately following or long after a traumatic experience.

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This was a good read. This one really broke things down for me

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Abstract

Oppression refers to systemic discrimination where the injustice targets or disproportionately impacts specific groups of people. The Trauma Symptoms of Discrimination Scale (TSDS) is a self-report measure designed to assess the traumatizing impact of discrimination broadly by measuring anxiety-related symptoms of trauma due to discriminatory experiences. This may include symptoms arising from racism, homophobia, sexism, poverty, or other forms of marginalization. Almost all studies of the TSDS have examined its use in marginalized ethnoracial groups, primarily African Americans. This paper will extend prior work to help us better understand racial trauma across groups by reporting and comparing TSDS mean scores across ethnoracial identities in a diverse national sample (n  =  923). It also explores trauma with other marginalized identities and demographic dimensions, including gender, sexual minority/LGBQ status, education, and income. The relationship of TSDS scores to clinical psychopathologies are examined, including stress, depression, anxiety, and PTSD. We also examine the unique risks associated with intersectionality, and how having multiple marginalized identities may increase traumatization. Clinical implications and future directions are discussed.

Keywords: oppression, intersectionality, minority stress, racism, homophobia, sexism

Introduction

Oppression-Based Stress and Trauma

Oppression describes an asymmetrical power dynamic characterized by domination and subordination of a group by restricting access to social, economic, and political resources. Subordinated groups experience fear, stress, and may develop negative views of themselves. As a chronic stressor, oppression can lead to poor mental health. Studies consistently link poverty and lower socioeconomic status (SES) with increased vulnerability to negative physical and mental health conditions, including schizophrenia, major depression, panic and phobic disorders, as well as antisocial personality disorder.

Oppression based on race, sexual orientation, and other identities predicts poor mental health. A meta-analysis of 66 studies concluded increased exposure to stress from racial discrimination was a stronger predictor of depression and anxiety for African Americans. Similar findings exist for intersectional oppressions based on class, sexual orientation and race. In a study of 376 Black, Latino, and multiracial sexual minority males, English and colleagues found gay rejection sensitivity, racial discrimination, and emotional regulation difficulties were significantly linked, which in turn predicted higher anxiety and depressive symptoms.

As chronic experiences, oppression can even be traumatizing. Although the DSM-5 conceptualizes traumatic experiences as discrete events, Holmes and colleagues argue this approach fails to capture the harm of chronic oppression-based experiences, such as racism, sexism, homophobia, and poverty. In support of this argument, Kira and colleagues found expanding trauma assessment models using Criterion A increased the predictive validity of chronic trauma on vulnerability to PTSD. Based on a cross-cultural combination of clinical and non-clinical samples experiencing political and economic oppression (total N  =  2754), chronic stressors such as collective identity trauma (eg, oppression and discrimination) along with attachment or betrayal trauma "increased the predictive model of PTSD six times over what Criterion A explained alone" (, p. 2672). As such, a more appropriate model of PTSD should include systemic discrimination along with secondary, abandonment, and betrayal traumas for more accurate and predictive assessment as well as effective treatment particularly for minoritized, non-Western communities.

Despite the growing evidence showing oppression-based stress can be traumatic and relates to symptoms of PTSD, research on oppression-based stress and trauma is limited. Specifically, one of the most widely-studied forms of oppression is racism, as racial discrimination is consistently linked with traumatization. Yet, a recent meta-analysis found a lack of validated psychological measures that adequately capture the distress associated with racism and an inability of the current literature to account for other forms of oppression-based trauma.

Trauma Symptoms of Discrimination Scale (TSDS)

The Trauma Symptoms of Discrimination Scale (TSDS) is a 21-item self-report measure that broadly assesses the traumatizing impact of discrimination by focusing on anxiety-related symptoms of trauma. Participants report the frequency of their experience of discriminatory distress regarding trauma (eg, "Due to the past experiences of discrimination, I often worry too much about different things") on a 4-point scale ranging from 0 (Never) to 3 (Often).

In the original paper introducing this measure, the psychometric properties of the TSDS were examined in 123 African American monoracial and biracial university undergraduates. The TSDS was found to have concurrent and predictive validity and excellent reliability (Cronbach's α  =  .94 for total score). It was positively correlated to measures of discrimination and psychopathology (eg, r  =  .48 for the Everyday Discrimination Scale, and r  =  .52 for the abbreviated Penn State Worry Questionnaire, p < .001 for both). This preliminary evidence supported the validity of the TSDS for the measurement of anxiety-related trauma symptoms due to racial discrimination but called for more studies to extend the findings to other marginalized groups.

The TSDS has been used in several subsequent studies of racism. For example, Maxie-Moreman and Tynes conducted a study of exposure to online racial discrimination and traumatic events in Black adolescents and young adults, centering the TSDS and its four subscales in its analyses. Reliability analysis indicated high internal consistency in the subscales (α's from .78 to .93), and the experience of online racial discrimination was significantly correlated to each subscale (r's from .35 to .49, p < .001 for all).

The TSDS was used as the primary outcome measure in a series of studies examining psychedelics and racial trauma. The retrospective study included 313 diverse Black, Indigenous, and other People of Color (BIPOC) in the U.S. and Canada who reported a memorable psychedelic experience that helped them cope with racial trauma. There was a significant decrease in symptoms, using the TSDS, before and after the psychedelic experience. Internal consistency reliability for the TSDS was excellent (α = 0.95), which was found with Asian American/Canadian (n  =  92; α  =  .94) and Indigenous/Native American (n  =  66; α  =  .97) subsamples as well.

In a nationwide survey study on racial trauma, the TSDS served as a benchmark for convergent validity for the Racial Trauma Scale (RTS 1;1). Diverse participants across the U.S. (n  =  923) were included in this racial trauma scale validation study. Of these, a subset completed clinical interviews of racial trauma, and the TSDS was found to reliably identify clinically relevant racial trauma, with a sensitivity of .77 and 1-specificity of .16 when using a cut-off score of 40.

Intersectionality and Oppression

Experiences of discrimination do not occur uniformly across marginalized groups. For example, Chou and colleagues found that African Americans experienced more discrimination than other major racialized groups. Further, multiple oppressed identities are theorized to be linked to more interactive discrimination and, in some cases, subsequent traumatization (eg, ). Root pointed to women of color's "double jeopardy" status, with many subsequent studies demonstrating their exposure to gender and racial discrimination and how it negatively affected their well-being in a variety of ways. Notably, Moody and Lewis found that a higher frequency of gendered racial microaggressions was significantly correlated with more severe traumatic stress symptoms in a national sample of Black women.

Research on LGBTQ populations and queer persons of color have also reflected parallel findings. In one of the largest national LGBTQ college campus studies to date with a sample size of over 5000 respondents, Rankin et al found that "multiple minoritized identities (eg, racial identity and sexual identity; racial identity and gender identity) lead to encounters of multiple forms of oppression" (p. 11). For example, while sexual orientation identity was indicated as the primary basis of observed harassment for both respondents of color and White respondents (75% and 76%, respectively), respondents of color were ten times more likely to attribute the perceived harassment to racial profiling. Moreover, trans- and gender-nonconforming respondents of color were more likely than cis-gendered respondents of color to experience on-campus hostility, exclusion, or harassment ( pp. 10-11). From their national online survey (n  =  200), Sutter and Perrin found that LGBTQ-based discrimination had a significant impact on the psychological functioning of sexual and gender minority persons of color, particularly suicidal ideation risk. Diaz et al's study of gay and bisexual Latino men demonstrated negative mental health outcomes (eg, depression, sleep issues, suicidal ideation) that were associated with both lifelong and current experiences of social discrimination based on their sexual orientation and racial/ethnic identity as well as financial hardship due to acute unemployment and poverty.

Purpose of This Study

Almost all studies of the TSDS focus on the experience of racism, primarily among African Americans. This paper will extend prior work to understand trauma across ethnoracial groups as well as other marginalized identities and several demographic dimensions, including gender, LGBTQ status, income, and education. We examine the TSDS and its relationships to clinical symptoms of depression, anxiety and stress, as well as PTSD using the data from Williams et al in a cross-sectional survey study. We also examine the unique risks associated with intersectionality, and how having multiple marginalized identities may increase traumatization.

Methods

Participants

Recruitment for this study was conducted online through Amazon Mechanical Turk (mTurk) Prime, now Cloud Research. Participants (Turk Workers) register to join the platform in exchange for opportunities to do online tasks for compensation. TurkPrime was designed as a research platform that integrates with MTurk and supports tasks that are common to social and behavioral sciences, such as survey data collection. Tasks that can be implemented with TurkPrime include selecting participants with specific characteristics and excluding participants on the basis of previous participation. For this study, eligibility criteria included: over 18 years of age; identify as African American/Black, Asian American, Latine/Hispanic American, or White/European American; spent most of childhood in the U.S.; and able to read and speak English.

Only eligible Turk Workers were able to view the posted recruitment invitation and, if they accepted the invitation, they were then able to complete the consent form and online battery containing the study surveys. The participant population of mTurk has similar demographics to the general U.S. population in geographical location and gender distribution, and participants were recruited to be a nationally geographically representative sample. The study was approved by the University of Connecticut's IRB. All participants were provided with local mental health resources in the event they felt distress from participating in the study. For the online survey, participants received $9 as compensation. The raw data consisted of a diverse sample of 1001 participants. For the purpose of validation, participants who were missing all the study measures (n  =  49) or their racial identity (n  =  11) were excluded.

In terms of demographics, the mean income level was somewhat lower than the U.S. national average. Demographic details of the sample are shown in Table 1.

Measures

Trauma Symptoms of Discrimination Scale. As noted, the TSDS ¹² is a 21-item scale that evaluates discriminatory distress for anxiety-related symptoms of trauma. The measure assesses uncontrollable arousal, feelings of alienation, worries about future negative events, and perceiving others as dangerous. Participants were asked to report the frequency of their experience of discriminatory distress regarding trauma on a 4-point scale ranging from 0 (Never) to 3 (Often). At the end of the scale, respondents divide the percentage of their discrimination across various sources (eg, racial/ethnic, gender, sexual orientation, religion, age, etc). This scale has excellent internal consistency and test-retest reliability and revealed good concurrent validity. ¹² Reliability was excellent (α  =  0.97). Most (97%) respondents of color indicated that some or most discrimination experienced was "Racial/Ethnic" in nature. Other sources of discrimination experienced by POC participants that contributed to traumatic distress included gender (36%), sexual orientation (81%), religion (68%), disability (86%), social class (38%), and age (56%).

General Ethnic Discrimination Scale. The GEDS was designed to evaluate the frequency and severity of discrimination in education, employment, the legal system, healthcare, or community settings due to one's race/ethnicity. It includes 17 multi-part questions wherein participants are asked to rate the frequency of a specific discrimination experience on a 6-point scale ranging from 1 (Never) to 6 (Almost all the time), and then rate the severity of their stress due to each experience on a 5-point scale ranging from 0 (Not at all stressful) to 4 (Extremely stressful). The sections are scored separately to provide a frequency and a stress score. For the past month and lifetime frequency as well as the stress scores had good reliability (α  =  0.96 for each).

Racial Microaggressions Scale. The RMAS was used to measure the frequency of ongoing racial microaggressions; these are small automatic/unintentional racist acts that are not clearly racially motivated and yet reinforce harmful stereotypes and communicate exclusion to POC. It contains 32 items, rated from 0 (Never) to 3 (Often/Frequently), with higher numbers indicating more frequent experiences of microaggressions. There are 12 categories of microaggressions included in the total scale, which correspond to several of Sue et al's taxonomy and include items about feelings of invisibility due to race, assumptions of criminality by others, being low-achieving or part of an undesirable culture, being a foreigner or not belonging, and environmental omissions, as well as additional categories such as erotization. For example, the item, "People act like they are scared of me because of my race" represents the microaggressive theme of criminality. The RMAS exhibited excellent reliability (α  =  0.95).

Race-Based Traumatic Stress Symptom Scale (Short Form). The RBTSSS-SF is a 22-item clinical tool for the assessment of distress in responses to experiences of racism. It consists of seven subscales: Depression, Anger, Physical Reactions, Avoidance, Intrusion, Hypervigilance/Arousal, and Low Self-Esteem. The measure begins with an open-ended section in which participants are asked about three memorable experiences with racism. In reference to their most memorable experience, participants answer a series of yes/no questions to assess psychological reactivity. In reference to the same event, participants rate a series of reactions on a 5-point Likert-type scale to assess emotional reactivity, which ranges from 0 (does not describe my reaction) to 4 (this reaction would not go away). We rated severity race-based discrimination by summing all items. The reliability for the RBTSSS-SF was excellent (α  =  0.96).

UConn Racial/Ethnic Stress & Trauma Survey. The UnRESTS is a clinician-administered interview for racial trauma. It includes 6 questions to assess ethnoracial identity development, a semi-structured interview to probe for a variety of racism-related experiences, and a checklist to help determine whether the individual's racial trauma meets DSM-5 criteria. The interview guides the clinician in asking questions about experiences with explicit and obvious racism toward them, racism experienced by loved ones, being vicariously impacted by racist experiences that were learned about, and experiences with subtle forms of racism or microaggressions. The checklist at the end provides a DSM-5 diagnosis for PTSD caused by experiences of racism. Interviews conducted on a subset of the sample, and 80 of these were used for analysis.

PTSD Civilian Checklist-5. The PCL-5 is a measure developed by the U.S. Department of Veterans Affairs National Center for PTSD that assesses for the presence and severity of symptoms of PTSD. The PCL-5 assesses re-experiencing of a traumatic event, avoidance, changes in cognitions and mood, arousal and reactivity, and distress and interference. The reliability for this measure was excellent (α  =  0.97).

Posttraumatic Cognitions Inventory. The PTCI is a questionnaire that is designed to assess negative cognitions about self, negative cognitions about the world, and self-blame. Participants are asked to rate the extent to which they agree or disagree with each item on a 7-point scale ranging from 1 (totally disagree) to 7 (totally agree). The PTCI has excellent internal consistency, good test-retest reliability, correlates well with other measures of trauma-related cognitions, and discriminates well between traumatized people with and without PTSD. The reliability was excellent (α  =  0.96).

Beck Anxiety Inventory. The BAI is a 21-item self-report measure used to assess anxiety in adults. The BAI focuses on somatic symptoms of anxiety, such as nervousness, dizziness, and inability to relax. Participants are asked to rate the extent to which they have been bothered by each symptom within the past week on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (severely). The BAI is psychometrically sound with good convergent validity, internal consistency, and test-retest reliability. 41, The reliability was excellent (α  =  0.96).

Beck Depression Inventory II. The BDI-II is a 21-item self-report measure that is designed to assess the severity of depression. Examples of items are, "I am sad all the time" and "I am disappointed in myself." The BDI-II has been validated through numerous studies across many different populations and ethnic groups. It has been used in a multitude of treatment outcome studies and with individuals with a history of trauma exposure. The reliability for this measure was good (α  =  0.95).

Analyses

A series of statistical tests were used to examine the relationship between racial trauma, microaggressions, racism, and psychopathology. Correlations were used to map the links between all the study variables. Group comparisons were made using t-tests and ANOVA. A t-test was used to compare TSDS between those with and without racial trauma. Regression analysis was used to examine the predictive relationship between racial trauma and other marginalized identities and various other demographic dimensions.

Marginalized identity values were computed based on demographic characteristics and identities associated with race, ethnicity, gender, sexual orientation, level of education, and income. Participants were coded as 0 if their identity represented a marginalized group and 1 if their identity represented a privileged group. Composite marginalization scores were computed by summing individual values for each demographic characteristic or identity and ranged from 0 to 5. Differences were compared using an ANOVA and Tukey's HSD post-hoc test.

Results

Relationship to Experiences of Racism

The bivariate relations between the trauma symptoms of discrimination (TSDS) and measures of frequency and stress related to ethnic discrimination (GEDS), experiences of microaggressions (RMAS), and race-based traumatic stress symptoms (RBTSSS-SF) were as expected and are found in Table 2. For general experiences of discrimination, TSDS related more strongly to lifetime (r  =  0.71) experiences than recent experiences (r  =  0.64). TSDS was also related to the amount of stress associated with experiences of discrimination (r  =  0.67). Similarly, TSDS was related to reports of microaggressions (r  =  0.65) and race-based traumatic stress symptoms (r  =  0.69).

Relationship to Psychopathology

The bivariate relations between the trauma symptoms of discrimination (TSDS) and measures of psychopathology, including PTSD symptoms (PCL-5), traumatic cognitions (PCTI), symptoms of anxiety (BAI) and depression (BDI) are shown in Table 3. The correlations show trauma symptoms of discrimination were associated with higher levels of depression (r  =  0.55) and anxiety (r  =  0.63) symptoms, traumatic cognitions (r  =  0.65), and PTSD symptoms (r  =  0.69).

An independent samples t-test was used to examine mean differences in TSDS in individuals with racial trauma (n  =  22, M  =  49.06, SD  =  14.09) and those without (n  =  58, M  =  29.10, SD  =  11.04) based on the UnRESTS interviews. The t-test revealed a significant mean difference between those with and without racial trauma, t(78) = -6.672, p < 0.001.

Comparisons of Ethnoracial Groups

Levels of discrimination and trauma differed across ethnoracial groups, as shown in Table 4. An analysis of variance (ANOVA) test was used to examine differences on the TSDS. There was a statistically significant difference between the ethnoracial groups, F(9154)  =  18.93, p < 0.001, suggesting mean levels of trauma symptoms of discrimination were not equal across the five groups. The Tukey's HSD test for multiple comparisons examined specific differences between pairs of means. The post hoc comparisons found the mean for White non-Hispanic was significantly lower than the means of the other four groups. Specifically the mean for Hispanic non-White (p < 0.001, 95% C.I.  =  8.85, 19.40) and Black non-Hispanic (p < 0.001, 95% C.I.  =  5.80, 12.76) were significantly higher than White non-Hispanic. To a lesser degree, White Hispanic was different from White non-Hispanic (p  =  0.035, 95% C.I.  =  0.25, 11.21). The mean for Hispanic non-White (p < 0.001, 95% C.I.  =  2.49, 13.48) was significantly higher than Asian non-Hispanic and this group (p  =  0.006, 95% C.I.  =  1.72, 15.06) was also higher than Hispanic White.

The remaining comparisons were not significantly different. There was no statistically significant difference between Hispanic non-White and Black non-Hispanic (p  =  0.07). There was no statistically significant difference between Asian non-Hispanic and both Black non-Hispanic (p  =  0.21) and White Hispanic (p  =  1.0). Lastly, Black non-Hispanic and White Hispanic were not different (p  =  0.42).

Participants varied in the proportion and type of discrimination they experienced. An independent sample t-test was used to examine mean differences in the percentage of traumatic racial discrimination BIPOC and White participants reported, with respect to all discrimination experienced. Specifically, BIPOC participants (M  =  55.10, SD  =  28.39) significantly differed from White participants (M  =  20.78, SD  =  26.87) in the percentage of racial discrimination they experienced with an average mean difference of −34.32, t(931) = −17.00, p < 0.001 [95% C.I.  =  -38.28, −30.36].

Gender and Sexual Orientation

T-tests were used to examine mean level differences on the TSDS related to discrimination for gender and sexual minority status. There were no statistical differences between male and female participants. However, the t-test results show a statistically significant difference based on sexual orientation, t(924) = -4.273, p < 0.001. The mean for those with LGBQ identities was significantly higher than those who identified as hetersexual.

T-tests were used to examine mean level differences in the percentage of discrimination experienced due to gender and sexual orientation. For gender, female participants significantly differed from male participants in the percentage of discrimination they experienced with an average mean difference of −19.03, t(931) = −14.32, p < 0.001 [95% C.I.  =  -21.65, −16.43]. For sexual orientation, LGBQ participants significantly differed from hetersexual participants in the percentage of traumatic discrimination they experienced with an average mean difference of −16.35, t (924) = −18.97, p < 0.001 [95% C.I.  =  -18.05, −14.66] ( Table 5).

Intersectionality and the TSDS

A marginalization index was computed by summing individual values for each marginalized demographic characteristic or identity. A point (value of 1) was given for each of the following dimensions: non-White, sexual minority, female, less education (less than or equal to highschool), and low income (less than $19,999 annually). The 3 trans/nonbinary people were omitted due to low numbers. As such, scores ranged from 0, not having any marginalized identity, to 5, identifying with all the marginalized identities. The majority of participants identified with at least one (n  =  353) or two (n  =  338) marginalized identities.

An ANOVA test was used to compare levels of trauma symptoms related to discrimination across multiple marginalized identities. There was a statistically significant difference between the number of marginalized identities, F(9284)  =  10.09, p < 0.001, suggesting mean levels of trauma symptoms are not equal across the groups. The Tukey's HSD test for multiple comparisons examined differences across marginalization scores. The mean level for those with no marginalizing identities were significantly lower than those with one (p < 0.001, 95% C.I.  =  -11.42, −2.10), two (p < 0.001, 95% C.I.  =  -14.48, −5.11), or three (p < 0.001, 95% C.I.  =  -17.01, −5.58) identities. ( Table 6).

A linear regression was used to predict trauma symptoms of discrimination based on marginalization scores. A significant regression showed F(1, 931) = 28.74, p < 0.001 with an R squared of .03. Participants' level of trauma symptoms due to discrimination increased by 3.06 for each additional identity of their marginalization score.

Discussion

Trauma Symptoms, Racism, and Psychopathology

This study shows trauma symptoms increased with recent and past experiences of discrimination, racial microaggressions, and multiple forms of psychopathology. Consistent with Williams and colleagues, ¹² this finding indicates both implicit and explicit acts of racism contribute to traumatization. This link is attributed to the fact that implicit acts, such as microaggression, occur more frequently. 12,44 Notably lifetime discrimination was more strongly related to trauma symptoms than recent (past year) experiences, underscoring the cumulative nature of trauma. For psychopathology, the TSDS was most strongly related to established measures of PTSD (PCL-5, PTCI) as well as measures of depression and anxiety. Williams, Kanter, and Ching also found a similar relationship between the TSDS and measures of anxiety. Anxiety and depression are separate disorders and often linked to discrimination, yet they both share symptoms with PTSD (eg, ).

Ethnoracial Groups Differ in the Degree of Symptoms

Ethnoracial groups clearly differ in their experiences of trauma symptoms with non-White Hispanic and Black Americans reporting the highest rates, followed by Asian Americans and White Hispanic Americans. The lowest symptoms were found among non-Hispanic White participants. This finding is consistent with a national study, Chou and colleagues found that African Americans reported a significantly higher degree of racial discrimination than Asian or Hispanic Americans, who did not differ significantly from each other in level of perceived discrimination. However, that study did not separate White and non-White Hispanics in their analysis. Similarly, a study by Lee and colleagues using data from the Pew Research Center, found when comparing Black, Hispanic, and Asian Americans, Black people reported the most racism among the groups analyzed.

Gender

In our analysis of gender differences, we found that being female alone does not increase the risk for trauma symptoms from discrimination, which is counterintuitive. One would assume that female gender would increase the risk of discrimination due to greater gender-based traumatization, as the literature tends to find greater trauma exposure and PTSD among women. Our findings could be a reflection of decreasing sexual harassment and abuse of women due to increased social appropriation of sexism, greater empowerment of women, and increased legal protections in the U.S. (cf, ). Notably, even current studies on trauma and gender differences often use datasets that are decades old, and do not show consistent gender differences for people of color. Newer studies show fewer gender differences in traumatization, such as among low-income African Americans (eg, ).

Our findings are somewhat consistent with McClendon and colleagues, who investigated ethnoracial and gender differences in discriminatory stress and PTSD severity in veterans. The authors found only small gender-related differences in discriminatory distress, despite large gender (and racial) differences in PTSD. Additionally, there were significant positive correlations between discriminatory stress and PTSD symptom severity for all ethnoracial groups but with small effect sizes.

Sexual Orientation

In our analysis of sexual orientation differences, we found being a sexual minority significantly increases the risk for trauma symptoms of discrimination. There is not much research on the connection between minority stress and trauma symptoms in LGBQ populations. Most of the literature focuses on minority stress and its connections to depression, suicidality, and substance use. Empirical studies about trauma focus on victimization and abuse. Nonetheless, there is emerging scholarship on LGBQ minoritization and trauma due to the cumulative nature of their identity-specific stressors. Cardona and colleagues conceptualize ongoing discriminatory stress as chronic and even traumatic invalidation that interferes with emotion processing when the environment prevents an individual's emotional needs from being met. This chronic invalidation results in greater sensitivity and avoidance. Eventually, the individual begins to feel their sexual minority related emotions are harmful and wrong, leading to internalization and the conclusion that something is wrong with them. It is clear being a sexual minority continues to be difficult in our society as evidenced by the greater levels of traumatization, and both implicit and explicit aspects of discrimination contribute to harms.

Intersectionality and Risk for Trauma Symptoms of Discrimination

We found intersectionality and multiple stigmatized identities increases risk for trauma symptoms, which is somewhat consistent with the literature. Currently, the generalizability of studies involving intersectionality with multiple marginalized identities poses a challenge due to basic data availability. More specifically, a "Catch-22" has yet to be truly surmounted regarding intersectional data collection on the most cross-marginalized populations, who are usually more invisibilized and less accessible to reach for sustained data collection. Others have similarly observed the paucity of available data involving dual minority status (eg, ethnicity-race/sexual orientation) and corresponding interventions.

Notwithstanding such limitations, research is mixed on the intersectional impact for sexual and gender minority POC populations. In Cochran et al's analysis of the National Latino and Asian American Survey (NLAAS) (n  =  4498), the LGB or same gender partner-identified subsample (n  =  245) reflected a lower prevalence of depressive, anxiety and substance use disorders as compared to sexual orientation minorities more generally speaking, mirroring prevalence rates reported by Latine and Asian Americans populations when compared to non-Hispanic Whites. At the same time, while male sexual minority participants were more likely to report a recent suicide attempt and less likely to report substance abuse or dependency than their heterosexual male counterparts, queer female participants were more likely than heterosexual females to have had recent drug use histories and depressive disorders.

Similarly, Meyer and colleagues found that Black and Latine sexual minorities reported a greater number of serious suicide attempts than White sexual minorities, while at the same time not exhibiting a higher prevalence of disorders. The observed lower prevalence rate was surmised in part to be due to the closer or tighter knit ethnoracial cultures of which Black and Latine LGB are a part. And while LGBTQ-based discrimination and racism were clearly associated with one another and exerted a direct impact on mental health, it was only the former (ie, LGBTQ discrimination) that demonstrated a significant indirect effect on suicidal ideation in another study. The researchers observed that LGBTQ discrimination tended to "overpower" the variable of racism, possibly due to both inter- and intra-cultural homophobia that queer persons of color confront in their ethnoracial and sexual minority communities. To sum up briefly, more work is needed to better understand how multiply marginalized individuals experience various forms of discrimination. As one example inquiry into multiple marginalization, greater attention must be paid to how being both a sexual minority and person of color shape discriminatory experiences differently than being a sexual minority or person of color separately.

Clinical Implications

People with more marginalized identities are more likely to have trauma symptoms, with the largest impact seen in non-White Hispanic Americans and sexual minorities. These identities alone were associated with comparable or greater discriminatory trauma than non-specific intersectional identities. Nonetheless, clinicians should be aware that greater intersectionality is more likely to signal cumulative trauma, and it also can be an impediment to treatment, as has been seen with other disorders as well (eg, ).

A culturally-informed approach to care is critical. Despite the increased availability of literature for cultivating practitioner cultural competency (eg, ), its practical application in the clinical field is still debated. Since the 1990s and earlier, the American Psychological Association (APA) has steadily supported initiatives tied to diversity and cultural awareness. The APA Ethical Code of Conduct includes standards surrounding the need for culturally responsive and respectful interventions that can mitigate risk of harm to diverse clients. Likewise, the 2014 American Counseling Association's (ACA) Code of Ethics calls for multicultural/diversity competence and social justice advocacy. Moreover, such guidelines recognize clinicians as cultural beings who bring their own beliefs and attitudes that influence clinical and empirical conceptualizations and their work with clients (, p. 26).

Social justice-oriented critics of clinical psychology, however, sharply rebuke the field for its lack of institutionalized support of an intersectional awareness competency, particularly its failure to integrate core diversity perspectives (eg, critical race, feminist, and social justice theories) and the role of structural inequalities to client pathology. Indeed, despite clear mandates for culturally-informed approaches, clinicians are not trained to assist clients experiencing distress due to marginalized identities. Many if not most clinical training programs do a poor job of preparing students to work with these clients on any dimension of diversity, much less intersectional identities (eg, ). To solve these problems, we must examine the larger structures that dictate which clinical issues are worthy of attention, and as such, this will require addressing the biases of faculty, supervisors, researchers, and administrators who wield power and privilege within these contexts.

Therapists should assess all minoritized clients for PTSD symptoms from discrimination. They may need to ask specifically about these experiences which may not be conceptualized as "traumas" by clients, who may be used to having these experiences dismissed by others as unrelated. ³⁷ Some recommended treatment approaches include empirically-supported PTSD treatments adapted to use with people with marginalized identities (eg, ) or evidence-based protocols specific to issues like racial trauma or minority stress (eg, ). Coping skills should be tailored to address the client's unique intersectional stressors, however coping should not be a substitute for empowerment, as treatment should also explore reducing discrimination in the person's daily environment.

Kira and colleagues also emphasize that proactive strategies can serve to inoculate against the effects of the cumulative buildup of abandonment/betrayal traumas and systemic discrimination. In building a therapeutic alliance with such clients, therapists can first assist with safety plans, working with clients to distinguish safe and unsafe behaviors as well as engage in any needed advocacy at systemic levels to address actual or emerging dangers. Identity threats can also be buttressed by innovations such as group-based emotional regulation (GBER), which works with stereotyping, self-esteem, and anxieties about identity annihilation. In-group and out-group studies from social psychology have demonstrated the tremendous influence that not only threats to personal identity but also those to social identity have on self-esteem and one's basic sense of self.

Limitations & Future Directions

In terms of demographics, there were not many participants in the lowest education or income brackets which impeded our ability to explore the traumatizing impact of poverty-related oppression. Likewise, there were not enough trans participants to explore this dimension of marginalization. Although the effects of multiple marginalized identities may compound traumatization, our index of marginalization is undoubtedly oversimplified. Confounding or effect modifying relationships may exist between certain demographic dimensions. Larger samples are needed to develop more precise predictors of traumatization. Trauma symptoms resulting from other forms of intersectionality also should be explored, such as sexual minority status and a stigmatized religious tradition. The TSDS and RTS may be equally good as a screener for racial trauma, but cut-off scores for the TSDS need to be established for other kinds of oppression-based trauma.

Conclusions

Our research found oppression in all its forms is traumatizing, although some dimensions of oppression are more traumatizing than others based on differing identities and intersectionalities. Clinicians should consider all of these in clinical practice, individually and in combination. Intersectionality may require unique treatment approaches, which is an area sorely in need of more research.

Author Biographies

Monnica Williams, PhD, ABPP is the Canada Research Chair for Mental Health Disparities at the University of Ottawa. A board-certified licensed psychologist, her work focuses on the mental health of underserved communities and innovative approaches to care. She has published over 150 peer-reviewed journal articles and has been awarded federal, local, and foundation grants.

Muna Osman holds a PhD in Psychology from the University of Ottawa. Her research areas include racism and its effects on marginalized groups in Canada.

Chrysalis Hyon, PhD, currently teaches research methods at the California Institute for Integral Studies and is a professional and academic coach. Through both her courses and academic coaching, she supports doctoral students around issues of methodology particularly for undertaking critical, interdisciplinary, and transdisciplinary qualitative research.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program, Canadian Institutes of Health Research (CIHR) grant number 950-232127 (PI M. Williams).

References

22. Stevens-Watkins D, Perry B, Pullen E, Jewell J, Oser CB. Examining the associations of racism, sexism, and stressful life events on psychological distress among African-American women. Cultur Divers Ethnic Minor Psychol. 2014;20(4):561-569. https://doi-org.ciis.idm.oclc.org/10.1037/a00367002014. [DOI] [PMC free article] [PubMed] [Google Scholar]

43. Beck AT, Steer RA, Brown GK. Beck Depression Inventory-II. San Antonio. 1996.

62. American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. 2017a.https://www.apa.org/ethics/code/ethics-code-2017.pdf.

64. American Psychological Association. Multicultural guidelines: An ecological approach to context, identity, and intersectionality. 2017b. http://www.apa.org/about/policy/multicultural-guidelines.pdf. [DOI] [PubMed]

Articles from Chronic Stress are provided here courtesy of SAGE Publications

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Understanding the Psychological Impact of Oppression Using the Trauma Symptoms of Discrimination Scale

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Oppression refers to systemic discrimination where the injustice targets or disproportionately impacts specific groups of people. The Trauma Symptoms of Discrimination Scale (TSDS) is a self-report measure designed to assess the traumatizing impact ...

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this was a good read.

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Learn about a few evidence-based treatments that might be able to mitigate trauma’s impact.

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this was a really good read. It broke things down really talked about how trauma effects everything

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How Systemic Oppression Perpetuates Trauma: A Call for Social Justice in Therapy

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Explore how social justice in therapy addresses systemic oppression’s impact on mental health. Discover healing through trauma therapy.

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This article broke everything down scientifically. what trauma goes to brain, the chemical reactions

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Abstract

This theoretical review proposes an integrated biopsychosocial model for stress recovery, highlighting the interconnectedness of intra- and interpersonal coping processes. The proposed model is conceptually derived from prior research examining interpersonal dynamics in the context of stressor-related disorders, and it highlights interconnections between relational partner dynamics, perceived self-efficacy, self-discovery, and biological stress responsivity during posttraumatic recovery. Intra- and interpersonal processes are discussed in the context of pre-, peri-, and post-trauma stress vulnerability as ongoing transactions occurring within the individual and between the individual and their environment. The importance of adopting an integrated model for future traumatic stress research is discussed. Potential applications of the model to behavioral interventions are also reviewed, noting the need for more detailed assessments of relational dynamics and therapeutic change mechanisms to determine how relational partners can most effectively contribute to stress recovery.

Keywords: Trauma, PTSD, Stress, Coping, Relationships, Social support

The Integrated Biopsychosocial Model for Posttraumatic Stress Recovery

The IBM-PSR assimilates the fundamental components of well-established theory in a unified framework that summarizes specific processes contributing to posttraumatic stress recovery in the interpersonal context (see Fig. 1). Posttraumatic stress recovery is a dynamic process involving transactions between biological and cognitive stress responses [ 14]. As such, the IBM-PSR presents inter- and intrapersonal coping strategies in the context of continuous, transactional, biopsychosocial processes inherent to an individual's intrinsic traumatic stress responses and recovery.

Fig. 1.

Conceptual model portraying the integrated biopsychosocial model of stress recovery as it relates to trauma. The curved line (w) represents feedback between the current response and a future latent stress response

Instead of viewing trauma as an insular mechanism, diathesis-stress frameworks assert that stressors are merely catalysts that prompt psychological reactions, which are governed by several pre-, peri-, and post-trauma susceptibility factors [ 22, 23]. These vulnerabilities have been conceptually divided into ecological diatheses (i.e., encompassing the self and environment), biological diatheses (e.g., genetic, neurological features), and catalyzing factors (e.g., trauma-related variables, residual stress [ 22]. Within a diathesis-stress framework, ecological predispositions (e.g., individual's developmental history and coping style) and biological predispositions (e.g., threat-response neural circuitry) interact with pathogenic triggers (e.g., trauma) to initiate a psychological stress reaction that can spur recovery or contribute to dysregulation and the emergence of psychopathology. The tenets of the diathesis-stress framework are used to organize the other major theoretical perspectives and domains of research that are referenced throughout presentation of the IBM-PSR.

The role of relational partners in providing social support is highlighted specifically in the posttraumatic stress recovery period and depicted as "Interpersonal Coping" in Fig. 1. Interpersonal coping is defined as any post-stressor behavior that centers on use of social relationships to facilitate recovery. Intrapersonal coping is presented as any self-initiated, post-stressor behavior enacted with the intention of facilitating recovery of the intrinsic stress response. By considering multiple, multilevel risk factors and pathogenic mechanisms, the IBM-PSR aims to provide a guiding model for understanding variance in posttraumatic recovery and explaining why some individuals develop significant mental health symptoms whereas others experience resilience and growth.

The full IBM-PSR conceptual model is discussed below. Discussions of relevant theory and empirical findings are intentionally succinct to maintain focus on the overarching model.

Latent Stress Response

The processing of an acute traumatic event is influenced substantially by cognitive and biological dispositions (i.e., endogenous, intrinsic factors) prior to the trauma, referred to herein as the "latent stress response" (referred to in other work as a component of "pre-traumatic factors") [ 24, 25]. Some individuals may have intrinsic factors that predispose them to respond adaptively post-stressor. Other individuals may have cognitive and biological dispositions that have been taxed by historical or co-occurring stressors, which may potentiate vulnerability for PTSD.

Paths A and B

The cognitive and biological components of the latent stress response work in a synergistic and dynamic fashion to set the stage for an individual's reactions to a potentially traumatic event. In line with the social cognitive theory for posttraumatic recovery [ 26], the cognitive component of the latent stress response consists of social-cognitive schemas that represent the individual and their world. Cognitive disposition and biological stress response proclivities within the latent stress response reciprocally influence one another [ 14], such that cognitive schemas resulting from an individual's past encounters with stressors influence the disposition of biological stress response systems (path A), which in turn influence cognitive disposition through neurocognitive functioning and biofeedback (path B). For example, an individual may be predisposed to experience exaggerated biological reactivity in response to a new stressor if the schema that informs their appraisal of a stressor is rooted in prior failed attempts to cope with similar stressors. Biological factors such as poor diet, excessively low/high activity levels, abnormal circadian rhythm, and physical illness also contribute to overall stress vulnerability [ 27].

Path C

Consistent with bioecological systems [ 28] and biopsychosocial-evolutionary frameworks [ 14], bidirectional associations exist between an individual's stress response system (i.e., latent, acute, recovery) and the environment. That is, factors within the environment (e.g., financial, interpersonal, cultural) [ 25] contribute to an individual's latent stress response [ 29, 30], which in turn, can affect interactions with their environment. As suggested by the stress generation hypothesis [ 31], individuals exposed to substantial stressors in their environment may develop negative cognitive styles and dysregulated affective states and, as a result, select into or contribute to challenging environmental contexts. This hypothesized transaction has been documented in particular for individuals living in low-income and impoverished communities [ 32], with poverty-related stressors and racial marginalization contributing to dysregulated biological and cognitive predispositions that manifest in future stress management difficulties [ 33, 34]. The IBM-PSR posits that the bidirectional relationship between an individual's intrinsic disposition and the environment (e.g., financial, cultural) is continually present within every phase of the posttraumatic stress response process, as denoted by all paths labeled C in Fig. 1. Given the focus of the current framework on interpersonal processes during posttraumatic recovery, transactions between the individual and the environment during the recovery phase are parsed more fully below (paths L-Q).

Acute Stress Response

Paths D, E, F, and G

The latent stress response influences the acute stress response in the face of a stressful event, as predisposing cognitive schemas are applied when appraising the level of threat presented by a current stressor (path D) [ 35]. Research in affective neuroscience suggests that preconceptions of threat/injury and self-efficacy are embedded in memory with affective cues that actuate biological stress responses accordingly in potentially harmful situations (path E) [ 36]. As such, pre-established schemas not only impact the evaluation of a future or current stressor, but also the degree to which biological stress response systems become activated in response to the stressor. Historical and co-occurring stressors also contribute to allostatic load - the cumulative toll of chronic or significant stressors on physiologic stress response systems [ 37]. Individuals with high allostatic load often show impaired and discordant functioning across multiple, interconnected biological stress response systems implicated in stress response and recovery. For instance, high allostatic load can contribute to sustained physiological arousal, systemic inflammation, dysregulated neuroendocrine function, aberrant brain connectivity, and adverse gene expression [ 38- 41]. Baseline biological stress response systems affected by prior stressors influence both perceptions of threat (path F) and how strongly the biological stress response system will react to perceived danger (path G). Individuals experiencing a heightened state of biological stress vulnerability are more likely to perceive an event as dangerous and experience more significant biological stress reactions [ 37].

Paths H and I

In the face of an acute stressor, cognitive and biological response processes influence one another in a reciprocal manner. As perceptions of danger increase and self-efficacy decreases, biological stress response systems are more likely to increase in activation (path H). In turn, increased activation provides physiological feedback that may increase perceptions of danger (path I). In other words, the more a person perceives danger, the more they feel stressed; and the more stressed a person feels, the more they perceive danger. In some situations, conscious cognitive evaluation of situational stressors may initiate a stress response. However, the "sudden" nature of trauma may lend itself more to involuntary stress responses that involve a greater degree of rapid subconscious processing reliant on pre-established schema.

Intrapersonal and Interpersonal Coping

Paths J and K

Strategies for intrapersonal coping are directly influenced by acute cognitive and biological stress responses, with indirect effects derived from latent responses. At the cognitive level, appraisals of stress and self-efficacy inform the individual's assessment and execution of intrapersonal coping strategies (path J) [ 19, 26]. The dynamic tension between initial threat and self-efficacy appraisal processes involves ongoing individual-environment transactions that unfold in the moment and eventuate in the individual's response to the stressor [ 19, 42, 43]. Thus, appraisal processes can recursively influence an individual's response to trauma reminders and subsequent stressor exposures. During the recovery phase, election of coping strategies is focused on maximizing self-efficacy. Self-efficacious individuals may implement a wide range of active intrapersonal coping strategies: cognitive restructuring (i.e., modifying appraisals of stressful events and one's ability to cope), emotion regulation, problem solving, and proactive reduction in stress vulnerability (i.e., reducing factors that influence overall stress levels such as financial problems, health conditions, and poor self-care [ 44, 45]. Coping research within the PTSD literature corroborates the importance of coping self-efficacy, showing that self-efficacious individuals who frequently use active, agentic intrapersonal coping skills show greater rates of posttraumatic recovery than those who do not [ 46]. Moreover, greater flexibility in utilizing active coping strategies has been shown to reduce the risk of PTSD following trauma [ 47].

Self-efficacy may be lower for novel trauma and also for trauma that bears strong similarity to stressful events that an individual had difficulty managing in the past. In these situations, the individual may need to explore new coping responses and seek out higher levels of social support to cope adaptively. Otherwise, the individual may resort to ineffective and iatrogenic coping behaviors, such as repressing undesirable aspects of the situation (avoidance), adjusting goals to better align with the situation (accommodation), or viewing their coping response to the situation as unimportant (devaluation) [ 48]. Less agentic forms of coping, such as these, maintain or amplify traumatic stress reactions and contribute to PTSD symptoms [ 49].

At the biological level, the selection and effective enactment of a coping response is supported by physiological resource mobilization and regulation of biological stress responses (path K) [ 50]. Unfortunately, traumatic stress exposure can adversely impact neurobiological systems needed to cope effectively. A full review of biological factors contributing to posttraumatic stress recovery is beyond our purview, but we briefly mention them here to note the importance of considering the complex and dynamic interactions that occur within and between biological systems affected by trauma exposure as contributors to one's coping capabilities [ 14]. The Hypothalamic-Pituitary-Adrenal (HPA) axis has been investigated extensively and shown to play a key role in trauma-related symptom emergence and maintenance [ 51, 52]. Individuals suffering from PTSD show dysregulated patterns of HPA activity throughout the day (i.e., diurnal fluctuations), compared to individuals who have not been exposed to trauma [ 53]. In addition, those with PTSD are known to exhibit a dysregulated HPA axis response to acute stressors (e.g., hypoactivation, hyperactivation) [ 53]. HPA hypoactivation fails to mobilize biological resources requisite for generating appropriate behavioral responses to manage acute stressors. Alternatively, HPA hyperactivation involves activation that exceeds what is warranted by the stressor, which cognitively incapacitates individuals and inhibits efficient use of executive resources for effective stressor management (e.g., regulatory interference) [ 54]. Overexposure to glucocorticoids (e.g., cortisol) that accompanies HPA hyperactivation is known to have neurotoxic effects brain regions implicated in affect regulation and executive functions (e.g., ventromedial prefrontal cortex) [ 55]. These findings are consonant with a burgeoning literature linking stressor exposure, acute and diurnal HPA dysregulation, and impaired prefrontal executive functioning (e.g., working memory, cognitive flexibility) involved in active coping (e.g., problem solving, cognitive restructuring) [ 56].

HPA dysregulation provides only one example of how trauma-related impairment of executive control, mediated by neurobiological disturbance, can compromise agency and ability to actively and effectively cope with stressors. Researchers have identified, and continue to identify, a variety of biological systems affected by trauma and biological mechanisms contributing to stress-related risk and resilience [ 22, 57, 58]. These include genetic and epigenetic factors, and their mediating relations with endophenotypes [ 59], levels of inflammatory markers [ 60], stress-reactivity neuroendocrine profiles (e.g., glucocorticoids, androgens) [ 51, 52], aberrant brain function and structure [ 61], and key regulators of sympathetic arousal and parasympathetic recovery, such as endogenous neurochemicals (e.g., norepinephrine, epinephrine, GABA) [ 62] and exogenous agents (e.g., propanalol) [ 63].

For individuals exhibiting an exaggerated biological reaction to trauma, behavioral responses may be characterized by psychobiological paralysis (i.e., freezing behavior), poor execution of active coping skills (e.g., problem solving), or more automatic, involuntary responses (e.g., aggression, avoidance, fight or flight) focused on quickly neutralizing the stressor. Such behavioral responses may lead to poor resolution of stress or even amplification of an individual's trauma response (i.e., make the situation worse and cause further emotional distress). Even more, an overall pattern of stress responding can emerge whereby dysregulated biological stress responses lead to ineffective behavioral responses, which decrease perceptions of self-efficacy. In turn, decreases in self-efficacy increase the likelihood of biological dysregulation and ineffective behavioral responses (see Fig. 2 for an illustration). Should such a pattern emerge, the risk of PTSD increases significantly.

Fig. 2.

Self-perpetuating cycle of maladaptive posttraumatic recovery

Paths L and M

Social relationships with relational partners hold the potential to positively or negatively influence intrapersonal coping processes. As such, we will forego the term social supports, in favor of the term relational partners 1 with due acknowledgment that not all relationships and interpersonal responses are inherently supportive.

Psychobiological impairment and reductions in self-efficacy resulting from trauma often pull for support from relational partners. In turn, partners are tested in their ability to rise to the occasion and meet the supportive needs of the trauma-exposed individual. The deleterious effects of trauma on biological and cognitive systems, lowered perceptions of self-efficacy, and less effective coping may result in more frequent support-seeking behavior [ 64], which increases demands on relational partners, who may not be well-equipped to provide effective psychological support. Although individuals with larger social support networks typically experience fewer negative outcomes post-stressor [ 65], vis-à-vis stress buffering [ 66- 68], more fine-grained research has suggested that the perceived helpfulness of one's social support network is more strongly associated with posttraumatic adjustment than the size of one's support network [ 69, 70]. This supports the position that functional, qualitative dimensions (i.e., emotional, instrumental) may better predict stress recovery than structural dimensions of social support (i.e., network size, frequency of social interactions [ 71, 72].

Social support may be offered in response to a direct or indirect solicitation for support by the stressed individual, or also based on deductive reasoning (i.e., based on the demands of the environment and known/inferred stress-managing capabilities of the individual) (path L). Trauma-exposed individuals can leverage relationships to help themselves more effectively use intrapersonal coping strategies (path M), but this assumes that relational partners' possess the ability to offer support that aligns with the individual's needs. The social cognitive theory for posttraumatic recovery emphasizes the connection between social support and agency, suggesting that support most effectively facilitates recovery from trauma-related stress when it enables a person to utilize existing, or develop new, intrapersonal coping skills. More self-efficacious individuals may use the relationship context as a "sounding board," while individuals with lower self-efficacy may require more involved assistance. Social supports may promote intrapersonal coping by either encouraging the utilization of specific strategies or actively modeling such strategies. Additionally, social support can serve to decrease avoidance and encourage other proactive actions that reduce risk for PTSD [ 73, 74]. For example, friends or family may encourage a trauma-afflicted loved one to resume daily activities, to confront trauma reminders, to discuss and process the traumatic event and their reactions, and to implement other effective coping strategies during high-stress periods.

Consistent with current models of differential susceptibility [ 75], posttraumatic growth (PTG) theory proposes a qualitative shift in the operationalization of posttraumatic adjustment, from a restricted focus on the reduction of negative affect, posttraumatic distress, and related sequelae (i.e., recovery) to further include increases in positive affect, appreciation of life, spiritual enrichment, and other adaptive potentialities (i.e., growth) [ 76]. PTG implicates the interplay of interpersonal (e.g., self-disclosure, social support) and intrapersonal (e.g., schema change) processes in postraumatic adjustment in ways that facilitate growth (e.g., sense of personal strength). PTG deviates from social cognitive theory in two notable ways. First, in social cognitive theory, social support-driven posttraumatic adjustment is achieved vis-à-vis self-efficacy, while in PTG theory such adjustment is achieved vis-à-vis self-discovery. In other words, social cognitive theory holds that social support fosters agency through encouraging use and socialization of coping skills. PTG theory, on the other hand, holds that social support fosters actualization through interpersonal self-disclosure and discourse, such that individuals co-construct novel self-narratives as well as re-construct schemas about one's character, meaning, and purpose. Second, in social cognitive theory, social support processes focus on remediating the individual, and once self-efficacy is bolstered and the trauma symptoms are alleviated, the individual terminates the use of support-driven coping strategies. In PTG theory, social support focuses on transcending the individual and continuing prosocial behavior-driven increases in hedonic, eudaimonic, and psychological well-being of the self-discovered individual. Posttraumatic growth (PTG) theory [ 76] suggests that continued dialogue with relational partners over time could aid in the generation of new self-narratives and a redefined understanding of one's character, meaning, and purpose (e.g., a newfound belief in one's abilities after managing reactions to traumatic event).

Relational partners who previously experienced trauma and were successful in effectively managing their posttraumatic stress reactions may prove to be a potentially important source of social support [ 77]. These partners may be knowledgeable about supportive strategies (e.g., emotional, instrumental) that foster adaptive intrapersonal coping. As an example, among parent-child dyads, children tend to have better psychological outcomes if their parents report lower levels of distress [ 78]. PTG theorists hold that stress-exposed individuals may be more willing to self-disclose to relational partners who can relate to their traumatic experiences, normalize their reactions, and assist in modifying problematic narratives and schemas about the trauma, given the credibility of their partner's perspective [ 76].

Despite the best efforts of relational partners, core symptoms of PTSD can make receiving social support difficult and negatively impact social relationships. For instance, trauma-affected individuals often withdraw from others and present as angry or irritable when they are socially engaged [ 79, 80]. Trauma-induced deficits in problem-solving, difficulties with intimacy, and aggressive behavior may impinge on relationship quality and the likelihood of receiving future relational support [ 81- 83]. Due to heightened stress levels and limited executive capacity, trauma-affected individuals may fail to attend to relational partners' emotional state or support them in times of need, resulting in a lack or reciprocity [ 84]. These interpersonal difficulties often lead to increased misunderstandings in the relationship, increased conflict, and decreased relationship satisfaction, all of which reduce the likelihood of relational partners offering continued support [ 85]. Work examining bidirectional associations between social support and health outcomes suggests that the stress buffering effects of social support may decrease over time as stress-related psychological symptoms and increased impairment place strain on relationships, thereby dampening the availability and quality of support [ 21]. A recent meta-analysis found that PTSD symptoms and social support were reciprocally connected over time such that greater social support predicted decreases in PTSD symptoms and greater PTSD symptoms predicted decreases in social support, which were more significant within closer relationships (family members, significant others, friends) [ 86].

Other problematic interpersonal dynamics can also occur in the context of trauma recovery. Relational partners who are less efficacious in active listening, managing their own stress reactivity, tolerating others' distress, or offering perspectives that can be incorporated into constructive schema change may be more dismissive or divert the conversation to avoid discussions about traumatic experiences (e.g., "That's not a big deal"). Some relational partners may respond to disclosures of trauma with harmful criticism (e.g., blaming, demeaning, or teasing comments), which can promote increased negative affect, diminish perceptions of self-efficacy, and reinforce existing harmful schemas (e.g., shame, guilt, failure). A recent meta-analysis determined that trauma-exposed individuals with relational partners who show greater negative affect towards them and make more negative social evaluations of them experience more severe PTSD symptoms; in fact, the effect size for "negative social reactions" in predicting PTSD symptom severity was significantly larger than those of more positive social support factors [ 87]. In addition to negatively influencing an individual's self-perceptions and serving as an additional source of stress following trauma, relational partners may model and encourage ineffective or harmful coping strategies, such as substance use, aggression towards others, or suicidal ideation [ 88, 89]. If relational partners actively avoid discussing traumatic events, respond punitively to disclosure, or otherwise encourage iatrogenic coping strategies, these behaviors could reinforce maladaptive coping and psychobiological dysregulation for the trauma-exposed individual, thereby increasing risk of PTSD symptoms [ 90, 91].

Relational partners may also provide precarious support - interpersonal behaviors that appear helpful and may offer some benefit (e.g., increased social connection, temporary distress alleviation) but may also be disadvantageous in promoting self-efficacy or self-discovery. Co-rumination, or a tendency to dwell on problems and negative affect in the interpersonal context [ 92], is one example of precarious support. Though examined predominantly in the depression literature, this dyadic interpersonal process has implications for posttraumatic stress recovery as well. While those who co-ruminate with a stress-exposed individual may demonstrate basic support skills such as responsiveness and validation, the process of co-rumination often fails to generate agentic ideas for adaptive coping. Thus, the trauma-affected individual may "feel" supported but remain stressed in the absence of a plan to actively manage their stress. Co-rumination may even serve as a mechanism that facilitates contagion of internalizing symptoms within relationships [ 93], thereby increasing risk of psychopathology for both the stressed individual and their relational partners. Of note, co-rumination is distinct from mutual cognitive processing [ 76], whereby relational partners engage with stress-exposed individuals in thinking that is conscious, instrumental in its focus, and not directly cued from the environment. Mutual cognitive processing can offer stress-exposed individuals additional opportunities for meaning making and positive reinterpretations of problematic trauma-related beliefs.

Other forms of precarious support may effectively reduce an individual's stress levels in the short-term but present problems in the long-term. For instance, relational partners may directly manage or remove environmental factors that contribute to stress levels (e.g., giving money to reduce financial distress; allowing the stressed individual to stay at their home to avoid marital strife; communicating with someone on behalf of the stressed individual to avoid conflict), but not address the underlying posttraumatic stress symptoms. Notably, these partner behaviors may be vital in supporting the immediate physical safety and security of recently stress-exposed individuals. However, in the long-term (presumably when the immediate threat has passed), they may promote avoidance, diminish agency, and thwart actualization for the trauma-exposed individual. In essence, precarious support can bypass the intrapersonal processes required for helping a stress-exposed individual strengthen their own coping self-efficacy and foster their own self-discovery. As such, precarious support can foster patterns of excessive reassurance-seeking and dependency on others for stress management [ 94]. The resulting perpetuation of low coping self-efficacy, lack of schema reconstruction, and maintenance of elevated traumatic stress levels has the potential to strain ties with relational partners who are overly relied upon.

Certain unhelpful dynamics may be more likely to occur with relational partners who are experiencing their own posttraumatic stress reactions due to direct or vicarious trauma exposure.

When an individual and their relational partner are both experiencing psychological symptoms, a reciprocally supportive relationship could be difficult to maintain due to competing needs and the limited availability of psychological resources required to provide effective support. As an example, if a relational partner was impacted by the same trauma (e.g., family members who experienced the same home invasion or car accident) and both partners are struggling to cope, the relationship could become non-supportive. This may take the form of mutual avoidance of disclosures about the trauma (due to fears of triggering one another), co-ruminative discussions, or joint engagement in harmful avoidant coping strategies (e.g., substance use, risk-taking). Given the strain that traumatic stress can place on relationship functioning, it is not surprising that PTSD symptoms prospectively predict decreases in social support in the years following a traumatic event [ 21, 95, 96].

Paths N and O

Supportive behavior may also focus on making modifications to the environment that facilitate intrapersonal coping (e.g., helping the individual meet immediate physical safety and security needs, removing or reducing stressors not directly tied to the trauma) (path N). However, relational partners who continue to provide excessive reassurance and accommodations even after the threat to physical safety and security has passed may miss opportunities to promote intrapersonal coping and consequently foster dependency in the trauma-affected individual. The quality and degree of support offered may also be influenced by environmental factors affecting the relational partner (path O). For instance, a relational partner may be able to provide only limited support if they are struggling to manage their own cognitive and biological stress reactions to chronic or multiple environmental stressors.

Paths P and Q

Intrapersonal coping can modulate the potentially deleterious impact of traumatic stressors in individuals' immediate environmental contexts (path P). Examples include an individual leaving or changing the situation (e.g., situation selection/modification) or using internal coping strategies (e.g., attentional deployment, cognitive restructuring) to reduce the influence of the environment on their ability to manage their stress response [ 97]. As noted by Tedechi and Calhoun [ 76], traumatic events happen not only to individuals, but also to relational partners, groups of people, and societies. When trauma is widespread, intrapersonal attempts at meaning-making and reconstructing narratives may generate new schemas that challenge existing social conventions (e.g., stigma) and seek to change problematic environmental structures (e.g., laws). Through transformative mutual support, stressor-exposed individuals' narratives can be integrated into socially shared schemas. As an example, a recent study using nationally representative sample of US veterans showed that, in addition to receiving social support, increases in altruistic behavior (e.g., provision of support to those in need) reduced internalizing symptoms, perhaps by reducing social isolation and loneliness but also by promoting a sense of meaning, direction and purpose in life [ 77].

Environmental factors also influence an individual's ability to cope intrapersonally (path Q), such as the continued presence of trauma cues, other environmental stressors, and accessibility of coping resources. Continued exposure to trauma cues and additional stressors could maintain or increase stress responses, thereby challenging an individual's ability to successfully utilize intrapersonal coping strategies. Environmental responses that address the trauma directly (e.g., justice delivered by the legal system) or reduce the likelihood of similar trauma in the future (e.g., revamped community safety measures) may positively impact intrapersonal efforts and further enhance recovery. Similarly, recent work has demonstrated that social identification with one's community, collective agency, and well-being stemming from expected support and shared goals in the wake of a common traumatic stressor can improve recovery (e.g., natural disaster) [ 98].

Stress Recovery

Paths R, S, T, and U

Intrapersonal coping mediates pathways from acute response to recovery through alterations in threat and injury appraisals, perceived self-efficacy, schema modification, narrative reconstruction, and regulation of biological stress response systems. Strategies that serve to change perceptions (e.g., cognitive restructuring), recalibrate biological arousal (e.g., relaxation), or modify environmental stressors (e.g., leaving the situation or making an environmental change) may all help to regulate stress responses (paths R and S) and facilitate efficient stress recovery. As perceptions of threat/injury decrease and perceptions of self-efficacy increase, biological stress vulnerability lessens (path T), and in turn, reductions in biological stress vulnerability increase appraisals of safety/wellness and self-efficacy (path U). Thus, intrapersonal and interpersonal coping contribute meaningfully to recovery through adjustments to one's appraisals of stress and self-efficacy, schema about the trauma, and ability to regulate biological stress responses and/or change the environment.

Environment and Time

Path V

Importantly, some environmental factors contributing to an individual's latent stress response will likely exert influence across the acute stress response and recovery phases. These ongoing environmental factors (path V) may include socioeconomic strain, maltreatment, pollutants, population density, and cultural oppression. Some environmental factors may remain consistent across each phase of the stress response (e.g., local culture) and, thus, maintain risk or promote resilience in an ongoing manner. However, as noted for paths N and P, intra- and interpersonal coping processes can also influence environmental factors and context.

Time

Time is an important concept within the recovery phase of the IBM-PSR. The timeline for recovery begins immediately following an acute traumatic experience. Importantly, we note that timelines for recovery are individual-specific, such that the length of time between the traumatic event and stress recovery is contingent on a multitude of factors, including intrinsic and learned coping abilities, as well as access to resources that support utilization of intra- and interpersonal coping strategies. Defining the end point to "recovery" is complex, given the varied indicators that could be used to operationalize recovery. For example, using "return to baseline" (biological or psychological state) assumes that baseline functioning was adaptive and healthy, and even if this assumption was upheld, "healthy" psychological functioning in the posttraumatic recovery phase may be qualitatively very different from healthy pre-trauma functioning (i.e., conceptualizations of recovery need to acknowledge posttraumatic growth).

The effectiveness of specific coping strategies in facilitating recovery may differ based on the phase of recovery (i.e., they may be time-dependent). For example, avoidance (e.g., running away) at the outset of trauma exposure (e.g., physical assault) may serve to mitigate cognitive and biological "wear and tear" that an individual might otherwise incur if they chose to remain proximal to the trauma and/or related stressors. Approach-oriented coping in the face of an immediate and uncontrollable trauma may compromise safety and psychobiological function that would otherwise have been preserved with more avoidant flight-oriented strategies. In the long-term, however, prolonged avoidance (e.g., difficulty leaving the house months after a traumatic event) may impede efficient stress recovery, whereas active coping strategies (e.g., leaving the house to run errands, returning back to work) may promote efficient stress recovery.

With regards to time-sensitive interpersonal coping, relational partners may be most helpful if they encourage the use of intrapersonal strategies that align with the phase-specific needs of the trauma-affected individual. Relational partners may help with practical challenges in the immediate aftermath of the trauma (e.g., filing a police report) and eventually transition to providing increased emotional support. Psychological First Aid [ 99] and Skills for Psychological Recovery [ 100] are trauma-centered prevention programs that emphasize the importance of tailoring support to individuals and their phase of recovery.

Recovery-informed Dispositions

Path W

The overall stress response (i.e., acute stress response plus stress recovery) to the traumatic event or trauma reminder informs the individual's future latent stress responses as a function of altered disposition (path W). An individual's perceived self-efficacy in managing their stress response and the impact of the stressor on their overall well-being are incorporated into social-cognitive schema. Similarly, the degree of activation caused by the stressor as well as the duration of sustained activation influences the set points for biological stress response systems, both with regard to diurnal (i.e., daily) and acute (i.e., stress-reactive) functioning.

Directions for Future Empirical Research

The literature reviewed and model proposed above underscore the need for nuanced research that addresses how interpersonal, biological, and cognitive processes operate together in governing posttraumatic stress recovery. As researchers continue to examine connections between social support and PTSD symptoms, the proposed theory could serve as a framework for identifying specific unilateral and transactional mechanisms that either confer risk or promote recovery. While social support has been widely regarded as protective, our review has illustrated that not all social support is created equal and studying the 'who, what, when, where, and how' of social support is critical for identifying interpersonal behaviors that promote and hinder efficacious coping following trauma. We provide recommendations for future research that may address remaining gaps in this field, emphasizing the need for multimodal, multidimensional, and prospective assessments of stress responses (latent, acute, recovery), intrapersonal and interpersonal coping processes, and environmental factors. Further, we note the importance of proper research designs and analytic techniques suitable for testing the proposed model and discuss implications of such research for prevention and intervention.

Intrapersonal Coping, Interpersonal Coping, and Post-Trauma Recovery

To adequately examine the interconnections between processes most relevant to post-trauma recovery, prospective, multimodal research designs are needed. Changes in concurrent functioning of neuroendocrine, physiological, and immunological stress response systems should be monitored simultaneously with longitudinal collection of biological samples (e.g., salivary cortisol, alpha-amylase, heart rate variability, inflammatory cytokines) to establish cross-system profiles of biological vulnerability. In particular, prospective work should aim to include experimental paradigms that examine functioning of these systems in relation to acute stress, threat, and reward (including for instance indices of cortisol reactivity, error-related negativity, reward positivity) over time and under specific conditions of intrapersonal coping (e.g., avoidance, distraction). Additionally, in vivo paradigms are needed that examine negative and positive valence systems specifically in the context of interpersonal stress processing, with consideration of varied relationship types (e.g., close friendships, romantic partnerships, caregiver-child relationships) and concomitant functioning of neurobiological systems most responsive to interpersonal processes (e.g., oxytocin system). Behavioral observation systems should examine connections of neurobiological systems with naturally-occurring interpersonal stress processing and across instructed conditions of support (e.g., active listening, validation, problem-solving, coping skills identification/expansion). Ecological momentary assessments (EMA) of coping behaviors, cognitive processes, trauma-related stressors (e.g., triggers), and posttraumatic symptoms administered in combination with the aforementioned experimental paradigms would allow for both micromomentary and situational-based examinations of trauma recovery. Extended measurement may be needed to capture growth indices (e.g., shifts in trauma-related self-perceptions/narratives) and other distal outcomes of trauma (e.g., tracking trauma-exposed children into late adolescence/adulthood to learn how early-life trauma affects relationships and mental health later in life). Data collected from multimodal, prospective research designs may benefit from use of multilevel, person-centered analyses and latent class analyses [ 101, 102] to identify individual differences in stress recovery processes and PTSD risk profiles that better indicate the level of intervention needed.

Intervention research specifically dedicated to the promotion of resiliency by modulating the links between social support and coping is warranted. The state of the science establishing the efficacy of trauma-related treatment across the lifespan is encouraging, with numerous randomized controlled trials demonstrating that trauma-exposed individuals with significant mental health symptoms recover with treatment [ 103- 105]. Recent advances in treatment research have demonstrated that relational partners play an important role in facilitating coping skill development. For instance, incorporating a caregiver to both model and promote coping has become an important element of empirically supported treatments for youth, such as Trauma-Focused Cognitive Behavior Therapy (TF-CBT) [ 106] and Risk Reduction through Family Therapy (RRFT) [ 107]. Similarly, cognitive-behavioral conjoint therapy for PTSD incorporates romantic partners to help support trauma-affected individuals in their recovery [ 108]. Recruiting relational partners to help provide encouragement, model coping skills, and support completion of exposure-based activities may be an effective way to increase treatment retention and positive treatment outcomes [ 109, 110].

However, incorporating relational partners into trauma treatment also comes with challenges. Partners may have difficulties hearing details of trauma involving gruesome injuries, death, or physical/sexual abuse, especially if they are close to a person who suffered during the trauma. These difficulties could manifest as a secondary or vicarious trauma response, which could decrease the likelihood that a trauma-affected individual will continue to process the trauma with their relational partner (i.e., promote avoidance) or reduce the quality of support received (e.g., partners struggling to manage their own reactions may not be able to provide helpful suggestions for coping). In some cases, relational partners may have experienced the same trauma and have difficulty supporting one another due to the impact of the trauma on their own stress regulating capacities. As noted earlier, posttraumatic stress and conduct problems are greater for children of caregivers who report high levels of distress after a traumatic event [ 78]. Carefully assessing a relational partner's readiness to provide support is essential for minimizing any potential problems that could arise should they be included as part of treatment planning.

Finally, the IBM-PSR provides opportunities for prevention efforts examining the utility of relational partners and intrapersonal coping strategies in mitigating mental health symptoms following exposure to traumatic stressors. Over 60% of individuals have experienced one or more adverse childhood experiences [ 111], which suggests that a significant proportion of the population have experienced a major stressor, or several, during their lifetime. Many of these individuals do not seek formal interventions and instead rely on their own intrapersonal coping mechanisms and relational support networks. However, as previously described, even well-intentioned support efforts can fall flat or foster maladaptive coping strategies. Dismantling research is needed to determine which aspects of social support most effectively reduce the impact of traumatic stress and improve one's capacity to cope. Specifically, research that closely examines the interpersonal components of intervention and prevention programs are needed to clarify whether providing psychoeducation about trauma and teaching constructive support (e.g., promoting self-efficacy, relaxation techniques, approaching trauma reminders) to relational partners reduces risk of psychological symptoms and bolsters the effectiveness of treatment. Further, research dedicated to understanding the timing of social support and the promotion of adaptive coping may be useful in uncovering empirically-informed answers to 'when' questions (e.g., "when are certain forms of social support most effective?;" "when is supplemental therapeutic support warranted / maximally effective?").

Conclusion

The Integrated Biopsychosocial Model for Posttraumatic Stress Recovery assimilates multiple theoretical perspectives relating to the interplay of intrapersonal and interpersonal coping processes following a traumatic event. As such, this novel conceptual framework connects fairly disparate domains of empirical inquiry in an effort to holistically articulate the complexities of posttraumatic risk and resiliency. In its reflection of the state-of-the-field, the framework emphasizes the need to consider a multitude of transactional processes, particularly those relevant to understanding how interpersonal coping influences intrapersonal recovery. Using the framework as a guide, investigators can fill gaps in knowledge with continued experimental and clinical research that centers on identifying specific mechanisms through which interpersonal processes may contribute beneficially and detrimentally to stress recovery.

Acknowledgements

Preparation of this manuscript was supported in part by National Institute of Mental Health grants T32 MH018869 (MPI: D. G. Kilpatrick & C. K. Danielson), T32MH015442 (PI: M. Laudenslager), T32 MH015755 (PI: D. Cicchetti), and the National Science Foundation Graduate Research Fellowship Program under Grant No. DGE-1540502 awarded to K.J. Stone. Views expressed in this article do not necessarily reflect those of the funding agencies acknowledged. NIMH and NSF had no role in drafting this manuscript.

Biographies

Casey D. Calhoun

is a practicing Licensed Psychologist and Adjunct Professor in the Department of Psychology and Neuroscience at UNC Chapel Hill. His research has largely centered on examining biopsychosocial mechanisms contributing to stress vulnerability and resilience, particularly in relation to depression and PTSD. Dr. Calhoun trains and supervises graduate students, psychology interns, and postdoctoral fellows in a school-based mental health clinic that offers trauma-focused care to youth and families.

Katie J. Stone

is a postdoctoral fellow in the Division of Clinical Behavioral Neuroscience at The University of Minnesota Medical School. She graduated from the University of Kansas with a PhD in Clinical Child Psychology. Her program of research is centered on understanding pathways of risk and resilience underlying adjustment outcomes for adversity-exposed youth, with a particular focus on biological, cognitive, behavioral, and self-regulation factors. In line with a systems-based approach, she examines individual and environmental factors that contribute to youths' functioning.

Adam R. Cobb

is a Clinical Assistant Professor in the Department of Psychology at the University of Texas at Austin, and an Adjunct Research Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina and Ralph H. Johnson VA Medical Center. His program of research aims to enhance treatments for anxiety, fear, and stress-related disorders using innovative augmentations, and by delineating mechanisms of change. A major secondary aim is to investigate how biological, behavioral, cognitive, and emotional factors contribute to the onset, maintenance, and amelioration of anxiety and stressrelated conditions with emphasis on individual difference and contextual factors that govern symptom expression.

Megan W. Patterson

is a postdoctoral fellow at the Developmental Psychobiology Research Group at the University of Colorado Anschutz Medical Campus. She received her PhD in Clinical Psychology from the University of Texas at Austin and completed her APA Internship at the Charleston Consortium - Medical University of South Carolina. Her program of research is focused on individual differences in biological and psychosocial factors during puberty that contribute to the development of psychopathology during adolescence, with a particular interest in transactions between biology, such as genetics and hormones, and human behavior. By focusing on the impact biological changes on adolescent mental health, Megan hopes to inform targeted adolescent intervention and prevention programs.

Carla Kmett Danielson, Ph.D.

is a Professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. Dr. Danielson's research interests focus on treatment and prevention with high-risk, trauma-exposed adolescents and traditionally underserved populations, including basic and translational science studies that inform clinical practice. Her particular areas of research and clinical expertise are in: 1) evaluating and disseminating integrated treatments for co-occurring PTSD and substance use problems, as well as HIV risk behaviors, among trauma-exposed adolescents, and 2) understanding the mechanisms and pathways from trauma and stress exposure to mental health problems. Of note, Dr. Danielson is the developer of Risk Reduction through Family Therapy (RRFT), an exposure-based integrative treatment for comorbid PTSD symptoms and substance use problems among adolescents with published RCT support.

Jason José Bendezú

is a postdoctoral fellow in the Department of Psychology at the University of Minnesota. They graduated from the Pennsylvania State University with a PhD in Clinical Child Psychology. Their program of research is dedicated to understanding psychobiological mechanisms (e.g., affective valence, immuno-endocrine, neurobiological) involved in stressillness pathways for at-risk youth, as well as identifying putative psychosocial buffers (e.g., identity/values, coping skills, social support) that may mitigate risk for the development of psychopathology by modifying those mechanisms. Their research aims to translate toward therapeutic routes to psychobiological system repair that might be leveraged in the design of more effective, person-centered prevention and intervention for at-risk youth.

Declarations

Informed Consent

The manuscript does not contain any studies with humans performed by the authors; therefore, informed consent was not obtained.

Research Involving Human Participants and/or Animals

This article does not contain any studies with humans or animals performed by any of the authors.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Footnotes

¹

For the current definition, relational partners encompass anyone within an individual's social circle (i.e., friends, family members, intimate partners, colleagues).

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Articles from The Psychiatric Quarterly are provided here courtesy of Nature Publishing Group

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The Role of Social Support in Coping with Psychological Trauma: An Integrated Biopsychosocial Model for Posttraumatic Stress Recovery

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This theoretical review proposes an integrated biopsychosocial model for stress recovery, highlighting the interconnectedness of intra- and interpersonal coping processes. The proposed model is conceptually derived from prior research examining ...

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This article went back to the beginning. It talked about how trauma started

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The impact of trauma systems on patient outcomes

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Trauma is a pressing public health epidemic. In 2016 alone, trauma accounted for 29.2 million emergency department visits and 39.5 million physician office visits in the United States.1 Trauma is the leading cause of death for those aged 46 years and younger in the United States; trauma-related mortality has increased by 23% between 2000 and 2010 across nearly all age groups.2 In particular, the growing elderly population—susceptible to injuries from even minor mechanisms such as ground-level falls—has seen a 56% increase in trauma-related deaths over the same decade.2 For those who survive, regaining health and returning to work requires substantial postacute care and rehabilitation. Accounting for medical expenditures and lost productivity, the annual burden of trauma care is approximately $670 billion in the United States.3 Traumatic injuries also remain an important cause of morbidity and mortality globally, for both developed and developing countries. In a recent update to the Global Burden of Disease study—the most comprehensive epidemiological study to date—973 million individual healthcare encounters and 4.8 million deaths were attributable to injuries in 2013 alone.4

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This article broke down what happens to children with trauma. It's interesting to see what happens and how children are affected

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This article talks about how to support those affected by this type of trauma. there are things that you can do to help, even it feels small

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Getting to the Root of the Problem: Supporting Clients With Lived-Experiences of Systemic Discrimination

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For many marginalized people, coping with discrimination is not a temporary condition. Rather it is endemic to living in a discriminatory society and a source of ongoing stress. In this paper, we explore the need to provide people struggling to cope…

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This is a really good website that breaks things down and how the body reacts to the different stressors

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Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy, to name a few) to localize and then eliminate the endogenous or exogenous source of the insult. It involves the release of acute-phase reactants, which are direct mediators of widespread autonomic, endocrine, hematological, and immunological alteration in the subject. Even though the purpose is defensive, the dysregulated cytokine storm can cause a massive inflammatory cascade leading to reversible or irreversible end-organ dysfunction and even death.

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I really like this website. It's more kid-friendly and breaks down things

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We tend to look at trauma as a problem that is strictly individual by nature (which may be, in part, due to the hyper-individualistic nature of our society as a whole). Sometimes an experience of trauma is very much individual, but often there is more going on beneath the surface. Systemic problems such as poverty, poor healthcare services and ineffective education can create conditions for traumatic situations to occur.

Though there usually is a specific person or situation that caused a traumatic event, and we must address that, often we neglect to see how deeply flawed systems are perpetuating the trauma.

For example, when a child is bullied in school. It is necessary for the child who is bullying to be accountable and experience consequences for their behaviour.

However, to make a lasting change we must also look at the child's homelife. Are they experiencing abuse? Are their basic needs being met? Are they living in a nurturing environment? Are they living in poverty? Is the family dealing with a systemic issue related to social determinants of health?

A systems approach is needed if we want the child who is bullying to recognize the harm in their behaviour. This means that the needs of the child's family must be addressed too.

The truth is that we are a traumatized nation-a traumatized world. Trauma gives rise to more trauma. It's cyclical and will continue to cycle until we are collectively much more deliberate about disrupting the cycles.

So what can be done about systemic trauma? Is there a way we can do our part? YES! Doing our own work to adopt a trauma-informed lens, building healing-centered connections, while integrating the core values of peer support into our work will make a difference in people's lives.

In general, as a society we are not good at addressing systemic trauma. The systems can seem so big, and the scale of the problem so overwhelming. So we create band-aid approaches to deal with the aftermath of trauma, but we tend not to focus on healing or prevention.

We live in an individualistic society that doesn't often consider the collective needs of people - we tend to each tree without recognizing the threats to the whole forest. In a more interconnected society, we would be working hard to change the systemic conditions that both create trauma and continue to retraumatize people.

Both as a society and as individuals, we need to learn to perceive and address trauma differently. It is essential that we learn to see and interact with the world through a trauma-informed lens. Unless we intentionally work to change these traumatizing systems, history will continue to repeat itself.
What are some ways you see systems creating or perpetuating cycles of trauma?
Media Attributions

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Post-Secondary Peer Support Training Curriculum

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We tend to look at trauma as a problem that is strictly individual by nature (which may be, in part, due to the hyper-individualistic nature of our society as a whole). Sometimes an experience of trauma is very much individual, but often there is more going on beneath the surface.

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talks about generational trauma and how it affects everyone down the line

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Intergenerational trauma refers to the apparent transmission of trauma between generations of a family. People who experienced adverse childhood experiences growing up, or who survived historical disasters or traumas, may pass the effects of those traumas on to their children or grandchildren, through their genes, their behavior, or both, leaving the next generation susceptible to anxiety, depression, hypervigilance, and other emotional and mental health concerns.

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This article talks about the effects of the trauma and what it does to the brain. It also talks about examples of the type of trauma.

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Intergenerational trauma: Examples, effects, and healing

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Intergenerational trauma can affect multiple generations of a family, and research suggests it may affect gene activity. Learn more here.

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This article talks about how far back trauma can go and what it does to the present generation

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Intergenerational Trauma: How It Affects Families

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Traumatic experiences your relatives lived through can sometimes be passed down and affect future generations. This is called intergenerational trauma.

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This article talks about how to break the cycle and what to do about healing

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Breaking the Chains of Generational Trauma

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We inherit more than just the shape of our bodies and the color of our skin; trauma itself can be passed down from one generation to the next. Here’s how to break the cycle.

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Black families are the primary effecting by intergenerational trauma as it dates all the way back to slavery

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This article talks a lot about trauma through legacy. Things happen all the time that we don't realize affect those in the future.

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In the mid- to late 2000s, Brent Bezo and his wife were living in Ukraine, when Bezo began noticing a kind of social hostility and mistrust among the population. It was subtle, "not necessarily something you'd pick up on if you'd spent only a short time there," says Bezo, a doctoral psychology student at Carleton University in Ottawa.

In his conversations with people, Bezo heard references to the Holodomor, the mass starvation of millions of Soviet Ukrainians from 1932 to 1933, considered by many to be an intentional genocide orchestrated by Joseph Stalin's regime.

Wondering if and how this horrific event continued to resonate with the people, Bezo conducted a qualitative pilot study of 45 people from three generations of 15 Ukrainian families: those who had lived through the Holodomor, their children and their grandchildren. People spontaneously shared what they saw as transgenerational impacts from that time, including risky health behaviors, anxiety and shame, food hoarding, overeating, authoritarian parenting styles, high emotional neediness on the part of parents and low community trust and cohesiveness-what many described as living in "survival mode" (Social Science & Medicine, Vol. 134, 2015).

"Each generation seemed to kind of learn from the previous one, with survivors telling children, 'Don't trust others, don't trust the world,'" says Bezo. He is now conducting a larger quantitative study to compare intergenerational effects among Ukrainians who remained in the country after the Holodomor, those who emigrated and a group of Ukrainians unaffected by the event. The work is part of an emerging line of research and clinical work in psychology and related disciplines that is exploring whether and how mass cultural and historical traumas affect future generations. Bezo's observations are compatible with those of researchers who are exploring the intergenerational effects of the Holocaust, the Khmer Rouge killings in Cambodia, the Rwandan genocide, the displacement of American Indians and the enslavement of African-Americans. The transgenerational effects are not only psychological, but familial, social, cultural, neurobiological and possibly even genetic as well, the researchers say.

But except for studies related mainly to the Holocaust, the field is still relatively young and has many unknowns. While trauma researchers have made great strides in understanding and treating single-episode present-life trauma, they are just beginning to explore the impact of intergenerational trauma and its expression, says APA Div. 56 (Trauma Psychology) President Diane Castillo, PhD, a former Texas A&M University associate professor of psychology who has studied and treated combat-related post-traumatic stress disorder (PTSD) for 30 years. The study of PTSD could benefit from the wider lens of an intergenerational perspective, she says, while the study of intergenerational trauma could learn from the systematic work that's been done on PTSD.

Continuing to explore intergenerational effects can help the field better understand and treat psychological pain at its roots, adds Yael Danieli, PhD, co-founder and director of the Group Project for Holocaust Survivors and Their Children in New York, where she has been a senior psychotherapist since the 1970s.

"Massive traumas like these affect people and societies in multidimensional ways," says Danieli, who is also the founder of the International Center for the Study, Prevention and Treatment of Multigenerational Legacies of Trauma. "It behooves us to study this area as widely as possible, so we can learn from people's suffering and how to prevent it for future generations."

A wider lens on symptoms

One of the first articles to note the presence of intergenerational trauma appeared in 1966, when Canadian psychiatrist Vivian M. Rakoff, MD, and colleagues documented high rates of psychological distress among children of Holocaust survivors ( Canada's Mental Health, Vol. 14). Since then, researchers have been assessing anxiety, depression and PTSD in trauma survivors and their progeny, with Holocaust survivors and their children the most widely studied and over the longest period of time.

Most of these studies have found atypically high rates of these disorders. However, in some cases they find little or no effect at all. A 2017 review of 20 studies of children of cultural and war trauma survivors by Cindy C. Sangalang, PhD, of California State University, Los Angeles, and Cindy Vang, of Arizona State University, for instance, found eight studies showing negative psychiatric, psychosocial and/or behavioral effects on survivors' offspring, three showing mixed results and two showing no differences between offspring and controls (Journal of Immigrant Minority Health, Vol. 19, No. 3).

Other researchers are taking a broader view of how survivors and their offspring might be affected. In the early 1980s, Danieli began writing about at least four adaptive styles that she and others observed among Holocaust survivors. Examples include "victim," people who have difficulty moving on from the original trauma and are emotionally volatile and overprotective, and "numb," those who are emotionally detached, intolerant of weakness in others and who maintain a "conspiracy of silence" within the family. (Other styles include "fighter" and "those who made it.")

In clinical, group and community work, Danieli also observed specific behavior patterns among children of Holocaust survivors, including an overly protective stance toward their parents, a high need for control, an obsession with the Holocaust and immature dependency. She called these reactions "reparative adaptational impacts" to highlight the notion that survivors' progeny use them to try to repair the world for their parents, their grandparents and themselves -largely unconsciously. Her related theory predicts a pathway between the initial trauma, the family's history and post-trauma sociocultural milieu, the adaptational styles of survivors, and the intensity of their children's and grandchildren's reparative reactions to them (American Journal of Orthopsychiatry, Vol. 86, No. 6, 2016).

In 2015, Danieli and colleagues started building an empirical foundation for her theory by creating the Danieli Inventory of Multigenerational Legacies of Trauma (Journal of Psychiatric Research, Vol. 68; American Journal of Ortho-psychiatry, Vol. 85, No. 3), a three-part questionnaire tailored to adult children of Holocaust survivors. It asks the children about their parents' parenting styles, their upbringing, the effects these influences had on their own lives and about their family history and demographics.

Research is starting to support the theory. In a study reported in Psychological Trauma: Theory, Research, Practice, and Policy (Vol. 9, No. S1, 2017), Danieli, Fran H. Norris, PhD, of Dartmouth College, and Brian Engdahl, PhD, of the University of Minnesota, first gave the Danieli inventory to 484 adult children and grandchildren of Holocaust survivors. Then, they conducted additional clinical interviews with a subsample of 191 of those offspring. Overall, 35 percent of the smaller sample had generalized anxiety disorder, 26 percent had a major depressive episode and 14 percent had PTSD. But when they compared those data with the inventory data, 46 percent of those with high reparative impact scores had a psychiatric diagnosis, compared with only 8 percent of those with low scores. In addition, children whose parents scored higher in "victim" and "numb" styles reported a higher intensity of reparative impacts, the team found.

Researchers studying Native American and Canadian populations are likewise finding broad effects among children and grandchildren of survivors of massive cultural oppression. In a 2014 review paper in Transcultural Psychiatry (Vol. 51, No. 3), psychologist Amy Bombay, PhD, an assistant professor at Dalhousie University in Halifax, Nova Scotia, Canada, and colleagues examined studies looking at intergenerational effects of Indian residential schools, institutions run by the Canadian government from the 1880s until the mid-1990s. Eliminating the "Indian problem" was the aim of the schools, according to original government texts. The schools provided a substandard education and taught native children to be ashamed of their languages, cultural beliefs and traditions.

Two large-scale national surveys included in the review-the First Nations Regional Longitudinal Health Survey and the Aboriginal Peoples Survey-found that children and in some cases grandchildren of those who attended the schools were more likely to report psychological distress and suicide attempts, to have learning difficulties and problems in school and to contract hepatitis C through drug use than controls whose parents had not attended such schools.

Less directly studied is the multigenerational impact of slavery on African-Americans. But an important line of related research studies the relationship between ongoing racial discrimination and trauma. Monnica Williams, PhD, of the University of Connecticut, who has extensively explored this topic, recently developed a measure to assess anxiety related to racial discrimination. Williams and colleagues found that of 123 African-American students who took the measure, those who reported high rates of perceived discrimination also had higher rates than others of uncontrollable hyperarousal, feelings of alienation, worries about future negative events and perceiving others as dangerous (Psychology of Violence, Vol. 8, No. 6, 2018).

While direct studies on intergenerational effects may be sparse, it's not difficult to spot such impacts in current generations of African-Americans, adds Alfiee Breland-Noble, PhD, who directs the AAKOMA (African American Knowledge Optimized for Mindfully Healthy Adolescents) Project at Georgetown University and studies mental health disorders and treatments in African-Americans.

A current example, she says, is the dread that many African-American parents face in talking with sons about potential police encounters. "It's traumatizing for parents and it's traumatizing for kids," she says.

The scenario is part of a legacy that she terms "shared stress"-the feeling that you have to manage everything within your own community because you don't know what you'll encounter in society at large.

"There is a sense among African-Americans and other marginalized people that our stressors are unique to us and not necessarily shared by people outside our groups," she explains. "So, we share stories of our lived experiences that help set the stage for how our loved ones encounter the world." In turn, that can lead to a general distrust of others outside the group-particularly those from historically oppressive groups-along with in-group insularity, she says.

Transmission mechanisms

Psychologists and others are also investigating how traumatic effects may be transmitted across generations. In a qualitative study that echoes Danieli's findings about the importance of family communication and milieu, Lidewyde H. Berckmoes, PhD, of the Netherlands Institute for the Study of Crime and Law Enforcement in Amsterdam, and colleagues spent five months observing and interviewing 41 mothers who lived through the 1994 Rwandan genocide and their teen children.

The team found direct effects of the genocide, including the ways that mothers communicated with their children about the trauma, such as maintaining silence or expressing hope that such an event would never occur again. The investigators also observed indirect effects, such as how the genocide affected the second generation through changes including heightened poverty, greater family work burden and compromised parenting. Meanwhile, teens discussed how they felt these factors affected their own lives. Many said poverty rendered them unable to attend school and forced them to work harder to help keep the family afloat (, Vol. 7, No. 3, 2017).

Trauma psychologist Elena Cherepanov, PhD, of Cambridge College in Boston, has been examining how survivors' initial reactions to an event may affect future generations-a topic outlined in her upcoming book, tentatively titled "Understanding the Transgenerational Legacy of Totalitarian Regimes: Paradoxes of Survivorship." Living under such difficult, oppressive circumstances, she surmises, can lead parents to formulate fear-based "survival messages" that they pass on to their children and grandchildren-ideas like "Don't ask for help-it's dangerous." While the messages may have initially helped people stay alive, in the present they are often irrelevant and may even increase people's interpersonal vulnerability. Fear of personal disclosure and not trusting mental health care providers, for example, "is exactly why it is so hard for trauma survivors to seek and accept support," says Cherepanov, who is comparing these messages in Russian and American samples.

Still another transmission vehicle may be the body itself. Researchers led by University of California, Los Angeles, economist Dora L. Costa, PhD, examined mortality and other Civil War-era data on 700 Union Army prisoners of war (POWs) and 2,500 of their children, along with data on 5,000 non-POW Union soldiers and 15,000 of their children. Starting from the time the sons of these soldiers turned 45, they found that the sons of Union POWs who had endured particularly harsh conditions while imprisoned died at younger ages overall than the sons of POWs who lived in camps under more favorable conditions or than the sons of non-POW soldiers (Proceedings of the National Academy of Sciences, Vol. 115, No. 44, 2018).

The researchers posit a potential transmission vehicle for these effects: epigenetics, environmentally driven molecular processes that can turn genes on or off. While the researchers' lack of ability to collect biological samples limited their ability to show a direct association between the earlier deaths and epigenetic changes, in a statistical "process of elimination," epigenetics emerged as a strong contender.

Taking a more direct look at possible epigenetic transmission is psychologist Rachel Yehuda, PhD, director of the Traumatic Stress Studies Division at the Icahn School of Medicine at Mount Sinai in New York. She and colleagues have found, for example, that children of Holocaust survivors with PTSD have lower rates of methylation-one type of epigenetic mechanism-in a particular stress-related glucocorticoid receptor, the GF-1F, than children of survivors who did not have PTSD (American Journal of Psychiatry, Vol. 171, No. 8, 2014).

More recently, the team has been looking directly at epigenetic changes across generations. In a well-known study comparing methylation rates in 32 Holocaust survivors and 22 of their children with those of matched controls, they found that Holocaust survivors and their children showed changes in the same location of the same gene-the FKBP5, a stress- related gene linked to PTSD and depression-while controls did not (Biological Psychiatry, Vol. 80, No. 5, 2016).

While admittedly small, the study is an important first step, Yehuda and others note, and epigenetics is a fruitful area for further research (World Psychiatry, Vol. 17. No. 3, 2018).

Promising interventions

Despite the many gaps in understanding the transgenerational effects of trauma, clinicians and researchers are delivering interventions based on recent findings, including at the community level.

One example is a long- running intervention being adapted to First Nation and Native American tribes in Canada and the United States called Strengthening Families. Based on a highly successful evidence-based program started at Iowa State University, it aims to prevent early substance use by improving family communication, reducing family conflict and teaching kids substance-use resistance skills. Working closely with the Ojibwe, Lakota, Dakota, Navajo, Pueblo and other tribes, researchers, including sociologist Melissa Walls, PhD, of the University of Minnesota Medical School, are adapting the program to resonate with each tribe.

"We hear a lot about the loss of a sense of community, the loss of generational ties," says Walls. "It really is a deep hurt, a deep pain-almost a longing for what used to be." The interventions help to address this chasm by bringing together families and the community as a whole, she says.

Two case studies of working with native groups to adapt the protocol are described in an article by Walls, Jerreed D. Ivanich, a doctoral student at the University of Nebraska-Lincoln, and colleagues (Prevention Science, online first publication, 2018). One version, called Bii-Zin-Da-De-Dah, Ojibwe for "listening to one another," has been revised over the years to include more culturally relevant material and to be tailored for young children. A fourth iteration of the program is now being tested in a five-year randomized controlled trial funded by the National Institute on Drug Abuse.

The results of these programs can be profound, says Walls, who describes a ceremony held at the end of each intervention. There, parents or caregivers give youngsters a blanket to symbolize their support of the next generation. "It's always powerful," says Walls. "It's a lot more than just a program, I think, for the people who get to do it."

In the clinical realm, Danieli recommends using her inventory to formulate questions and help treat clients. She also suggests that clinicians work with patients to construct multigenerational family trees that include details of a family's trauma history-an activity that can help families move beyond secrets and toward connection and growth.

In a similar vein, Cherepanov suggests the use of a "survival genogram," which adapts the genogram methodology-a pictorial version of a family tree used in psychotherapy to highlight family relationship, health and psychological patterns-to the transgenerational trauma experience. The methodology helps children and grandchildren of survivors to explore ancestral life lessons like "Never let your guard down" in their original context and to examine how such messages can help and hurt them in their present lives (The Journal of Psychodrama, Sociometry, and Group Psychotherapy, Vol. 63. No. 1, 2015).

Meanwhile, Breland-Noble encourages her African-American clients to use a few simple tools to address angry, overwhelmed or numb reactions to historical or present-day race-related injuries. One is simply to name the problem. "We're so used to living with racially oriented worry and fear that we don't necessarily recognize or name it as problematic," she says. "I want people to feel comfortable owning and naming our history."

She also encourages clients to embrace self-care practices, such as mindfulness, exercise or other nurturing activities. A third tool she emphasizes is prevention-reducing exposure to potential triggers such as news about race-based police shootings or other provocative race-related items.

Addressing present-day traumas like racism that relate to the original trauma is key to helping new generations heal and move on, agrees Bombay. Parents can help, she adds, by using the right communication tools.

"It's about finding an age-appropriate balance that provides children with the context of the original trauma," she says, "while at the same time providing them with cultural pride and coping strategies to deal with racism if they encounter it."

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In the mid- to late 2000s, Brent Bezo and his wife were living in Ukraine, when Bezo began noticing a kind of social hostility and mistrust among the population. It was subtle, "not necessarily something you'd pick up on if you'd spent only a short time there," says Bezo, a doctoral psychology student at Carleton University in Ottawa.

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This article talks about the study of the trauma and how it came about

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Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms

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This paper reviews the research evidence concerning the intergenerational transmission of trauma effects and the possible role of epigenetic mechanisms in this transmission. Two broad categories of epigenetically mediated effects are highlighted.…

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This article talks about the impact trauma has on generations and what can be done to help

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Intergenerational Trauma: What It Is & How to Heal

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Intergenerational trauma—sometimes called transgenerational trauma—is a term that is used to describe the impact of a traumatic experience, not only on one generation, but on subsequent generations after the event. Intergenerational trauma is a term that is often not talked about, resulting in a las…

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This article talks about the benefits of using therapy to help overcome the trauma

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Intergenerational Trauma - Center for Mindful Therapy

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When the traumatic experiences, stressors, or unresolved emotional wounds of one generation have a lasting impact on the mental, emotional, and even physical well-being of subsequent generations within a family or community.

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This article really breaks everything down. It talks about all aspects of the trauma. Starting with what it is, what it details, how it's passed down, examples, the affects, and what to do to help

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Intergenerational Trauma: How Trauma Can Be Inherited

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Learn about intergenerational trauma, its symptoms, and how to break the cycle and heal from inherited trauma.

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This article talks about how important it is to assess those who seem they might be in need of help

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Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders. Furthermore, behavioral health problems, including substance use and mental disorders, are more difficult to treat if trauma-related symptoms and disorders aren't detected early and treated effectively ( Part 3, Section 1, of this Treatment Improvement Protocol [TIP], available online, summarizes research on the prevalence of trauma and its relationship with other behavioral health problems).

Not addressing traumatic stress symptoms, trauma-specific disorders, and other symptoms/disorders related to trauma can impede successful mental health and substance abuse treatment. Unrecognized, unaddressed trauma symptoms can lead to poor engagement in treatment, premature termination, greater risk for relapse of psychological symptoms or substance use, and worse outcomes. Screening can also prevent misdiagnosis and inappropriate treatment planning. People with histories of trauma often display symptoms that meet criteria for other disorders.

Without screening, clients' trauma histories and related symptoms often go undetected, leading providers to direct services toward symptoms and disorders that may only partially explain client screening for trauma history and trauma-related symptoms can help behavioral health practitioners identify individuals at risk of developing more pervasive and severe symptoms of traumatic stress. Screening, early identification, and intervention serves as a prevention strategy.

Screening to identify clients who have histories of trauma and experience trauma-related symptoms is a prevention strategy.

Trauma-Informed Care Framework in Behavioral Health Services-Screening and Assessment

The chapter begins with a discussion of screening and assessment concepts, with a particular focus on trauma-informed screening. It then highlights specific factors that influence screening and assessment, including timing and environment. Barriers and challenges in providing trauma-informed screening are discussed, along with culturally specific screening and assessment considerations and guidelines. Instrument selection, trauma-informed screening and assessment tools, and trauma-informed screening and assessment processes are reviewed as well. For a more research-oriented perspective on screening and assessment for traumatic stress disorders, please refer to the literature review provided in Part 3 of this TIP, which is available online.

Screening and Assessment

Screening

The first two steps in screening are to determine whether the person has a history of trauma and whether he or she has trauma-related symptoms. Screening mainly obtains answers to "yes" or "no" questions: "Has this client experienced a trauma in the past?" and "Does this client at this time warrant further assessment regarding trauma-related symptoms?" If someone acknowledges a trauma history, then further screening is necessary to determine whether trauma-related symptoms are present. However, the presence of such symptoms does not necessarily say anything about their severity, nor does a positive screen indicate that a disorder actually exists. Positive screens only indicate that assessment or further evaluation is warranted, and negative screens do not necessarily mean that an individual doesn't have symptoms that warrant intervention.

Screening is often the first contact between the client and the treatment provider, and the client forms his or her first impression of treatment during this intake process. Thus, how screening is conducted can be as important as the actual information gathered, as it sets the tone of treatment and begins the relationship with the client.

Screening procedures should always define the steps to take after a positive or negative screening. That is, the screening process establishes precisely how to score responses to screening tools or questions and clearly defines what constitutes a positive score (called a "cut-off score") for a particular potential problem. The screening procedures detail the actions to take after a client scores in the positive range. Clinical supervision is helpful-and sometimes necessary-in judging how to proceed.

Trauma-informed screening is an essential part of the intake evaluation and the treatment planning process, but it is not an end in itself. Screening processes can be developed that allow staff without advanced degrees or graduate-level training to conduct them, whereas assessments for trauma-related disorders require a mental health professional trained in assessment and evaluation processes. The most important domains to screen among individuals with trauma histories include:

Depressive or dissociative symptoms, sleep disturbances, and intrusive experiences.

Past and present mental disorders, including typically trauma-related disorders (e.g., mood disorders).

Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences).

Social support and coping styles.

Availability of resources.

Risks for self-harm, suicide, and violence.

Assessment

When a client screens positive for substance abuse, trauma-related symptoms, or mental disorders, the agency or counselor should follow up with an assessment. A positive screening calls for more action-an assessment that determines and defines presenting struggles to develop an appropriate treatment plan and to make an informed and collaborative decision about treatment placement. Assessment determines the nature and extent of the client's problems; it might require the client to respond to written questions, or it could involve a clinical interview by a mental health or substance abuse professional qualified to assess the client and arrive at a diagnosis. A clinical assessment delves into a client's past and cu r-rent experiences, psychosocial and cultural history, and assets and resources.

Assessment protocols can require more than a single session to complete and should also use multiple avenues to obtain the necessary clinical information, including self-assessment tools, past and present clinical and medical records, structured clinical interviews, assessment measures, and collateral information from significant others, other behavioral health professionals, and agencies. Qualifications for conducting assessments and clinical interviews are more rigorous than for screening. Advanced degrees, licensing or certification, and special training in administration, scoring, and interpretation of specific assessment instruments and interviews are often required. Counselors must be familiar with (and obtain) the level of training required for any instruments they consider using.

Advice to Counselors: Screening and Assessing Clients

Ask all clients about any possible history of trauma; use a checklist to increase proper identification of such a history (see the online Adverse Childhood Experiences Study Score Calculator [ http://acestudy.org/ace_score] for specific questions about adverse childhood experiences).

Use only validated instruments for screening and assessment.

Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma.

Do not delay screening; do not wait for a period of abstinence or stabilization of symptoms.

Be aware that some clients will not make the connection between trauma in their histories and their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior).

Do not require clients to describe emotionally overwhelming traumatic events in detail.

Focus assessment on how trauma symptoms affect clients' current functioning.

Consider using paper-and-pencil instruments for screening and assessment as well as self-report measures when appropriate; they are less threatening for some clients than a clinical interview.

Talk about how you will use the findings to plan the client's treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions ( Fallot & Harris, 2001).

At the end of the session, make sure the client is grounded and safe before leaving the interview room ( Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client's plan is for maintaining personal safety, and what the client's plans are for the rest of the day.

For people with histories of traumatic life events who screen positive for possible trauma-related symptoms and disorders, thorough assessment gathers all relevant information necessary to understand the role of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and any ongoing diagnostic and treatment considerations, including reevaluation or follow-up.

Overall, assessment may indicate symptoms that meet diagnostic criteria for a substance use or mental disorder or a milder form of symptomatology that doesn't reach a diagnostic level-or it may reveal that the positive screen was false and that there is no significant cause for concern. Information from an assessment is used to plan the client's treatment.

The plan can include such domains as level of care, acute safety needs, diagnosis, disability, strengths and skills, support network, and cultural context. Assessments should reoccur throughout treatment. Ongoing assessment during treatment can provide valuable information by revealing further details of trauma history as clients' trust in staff members grows and by gauging clients' progress.

Timing of Screening and Assessment

As a trauma-informed counselor, you need to offer psychoeducation and support from the outset of service provision; this begins with explaining screening and assessment and with proper pacing of the initial intake and evaluation process. The client should understand the screening process, why the specific questions are important, and that he or she may choose to delay a response or to not answer a question at all. Discussing the occurrence or consequences of traumatic events can feel as unsafe and dangerous to the client as if the event were reoccurring. It is important not to encourage avoidance of the topic or reinforce the belief that discussing trauma-related material is dangerous, but be sensitive when gathering information in the initial screening. Initial questions about trauma should be general and gradual. Taking the time to prepare and explain the screening and assessment process to the client gives him or her a greater sense of control and safety over the assessment process.

Clients with substance use disorders

No screening or assessment of trauma should occur when the client is under the influence of alcohol or drugs. Clients under the influence are more likely to give inaccurate information. Although it's likely that clients in an active phase of use (albeit not at the assessment itself ) or undergoing substance withdrawal can provide consistent information to obtain a valid screening and assessment, there is insufficient data to know for sure. Some theorists state that no final assessment of trauma or posttraumatic stress disorder (PTSD) should occur during these early phases ( Read, Bollinger, & Sharkansky, 2003), asserting that symptoms of withdrawal can mimic PTSD and thus result in overdiagnosis of PTSD and other trauma-related disorders. Alcohol or drugs can also cause memory impairment that clouds the client's history of trauma symptoms. However, Najavits (2004) and others note that underdiagnosis, not overdiagnosis, of trauma and PTSD has been a significant issue in the substance abuse field and thus claim that it is essential to obtain an initial assessment early, which can later be modified if needed (e.g., if the client's symptom pattern changes). Indeed, clinical observations suggest that assessments for both trauma and PTSD- even during active use or withdrawal-appear robust ( Coffey, Schumacher, Brady, & Dansky, 2003). Although some PTSD symptoms and trauma memories can be dampened or increased to a degree, their overall presence or absence, as assessed early in treatment, appears accurate ( Najavits, 2004).

Conduct Assessments Throughout Treatment

Ongoing assessments let counselors:

Track changes in the presence, frequency, and intensity of symptoms.

Learn the relationships among the client's trauma, presenting psychological symptoms, and substance abuse.

Adjust diagnoses and treatment plans as needed.

Select prevention strategies to avoid more pervasive traumatic stress symptoms.

The Setting for Trauma Screening and Assessment

Advances in the development of simple, brief, and public-domain screening tools mean that at least a basic screening for trauma can be done in almost any setting. Not only can clients be screened and assessed in behavioral health treatment settings; they can also be evaluated in the criminal justice system, educational settings, occupational settings, physicians' offices, hospital medical and trauma units, and emergency rooms. Wherever they occur, trauma-related screenings and subsequent assessments can reduce or eliminate wasted resources, relapses, and, ultimately, treatment failures among clients who have histories of trauma, mental illness, and/or substance use disorders.

Creating an effective screening and assessment environment

You can greatly enhance the success of treatment by paying careful attention to how you approach the screening and assessment process. Take into account the following points:

Clarify for the client what to expect in the screening and assessment process. For example, tell the client that the screening and assessment phase focuses on identifying issues that might benefit from treatment. Inform him or her that during the trauma screening and assessment process, uncomfortable thoughts and feelings can arise. Provide reassurance that, if they do, you'll assist in dealing with this distress-but also let them know that, even with your assistance, some psychological and physical reactions to the interview may last for a few hours or perhaps as long as a few days after the interview, and be sure to highlight the fact that such reactions are normal ( Read et al., 2003).

Elicit only the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders. There is no need to probe deeply into the details of a client's traumatic experiences at this stage in the treatment process. Given the lack of a therapeutic relationship in which to process the information safely, pursuing details of trauma can cause retraumatization or produce a level of response that neither you nor your client is prepared to handle. Even if a client wants to tell his or her trauma story, it's your job to serve as "gatekeeper" and preserve the client's safety. Your tone of voice when suggesting postponement of a discussion of trauma is very important. Avoid conveying the message, "I really don't want to hear about it." Examples of appropriate statements are:

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"Your life experiences are very important, but at this early point in our work together, we should start with what's going on in your life currently rather than discussing past experiences in detail. If you feel that certain past experiences are having a big effect on your life now, it would be helpful for us to discuss them as long as we focus on your safety and recovery right now."

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"Talking about your past at this point could arouse intense feelings-even more than you might be aware of right now. Later, if you choose to, you can talk with your counselor about how to work on exploring your past."

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"Often, people who have a history of trauma want to move quickly into the details of the trauma to gain relief. I understand this desire, but my concern for you at this moment is to help you establish a sense of safety and support before moving into the traumatic experiences. We want to avoid retraumatization-meaning, we want to establish resources that weren't available to you at the time of the trauma before delving into more content."

Give the client as much personal control as possible during the assessment by:

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Presenting a rationale for the interview and its stress-inducing potential, making clear that the client has the right to refuse to answer any and all questions.

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Giving the client (where staffing permits) the option of being interviewed by someone of the gender with which he or she is most comfortable.

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Postponing the interview if necessary ( Fallot & Harris, 2001).

Use self-administered, written checklists rather than interviews when possible to assess trauma. Traumas can evoke shame, guilt, anger, or other intense feelings that can make it difficult for the client to report them aloud to an interviewer. Clients are more likely to report trauma when they use self-administered screening tools; however, these types of screening instruments only guide the next step. Interviews should coincide with self-administered tools to create a sense of safety for the client (someone is present as he or she completes the screening) and to follow up with more indepth data gathering after a self-administered screening is complete. The Trauma History Questionnaire (THQ) is a self-administered tool ( Green, 1996). It has been used successfully with clinical and nonclinical populations, including medical patients, women who have experienced domestic violence, and people with serious mental illness ( Hooper, Stockton, Krupnick, & Green, 2011). Screening instruments (including the THQ) are included in Appendix D of this TIP.

Barriers and Challenges to Trauma-Informed Screening and Assessment

Barriers

It is not necessarily easy or obvious to identify an individual who has survived trauma without screening. Moreover, some clients may deny that they have encountered trauma and its effects even after being screened or asked direct questions aimed at identifying the occurrence of traumatic events. The two main barriers to the evaluation of trauma and its related disorders in behavioral health settings are clients not reporting trauma and providers overlooking trauma and its effects.

Concerning the first main barrier, some events will be experienced as traumatic by one person but considered nontraumatic by another. A history of trauma encompasses not only the experience of a potentially traumatic event, but also the person's responses to it and the meanings he or she attaches to the event. Certain situations make it more likely that the client will not be forthcoming about traumatic events or his or her responses to those events. Some clients might not have ever thought of a particular event or their response to it as traumatic and thus might not report or even recall the event. Some clients might feel a reluctance to discuss something that they sense might bring up uncomfortable feelings (especially with a counselor whom they've only recently met). Clients may avoid openly discussing traumatic events or have difficulty recognizing or articulating their experience of trauma for other reasons, such as feelings of shame, guilt, or fear of retribution by others associated with the event (e.g., in cases of interpersonal or domestic violence). Still others may deny their history because they are tired of being interviewed or asked to fill out forms and may believe it doesn't matter anyway.

Common Reasons Why Some Providers Avoid Screening Clients for Trauma

Treatment providers may avoid screening for traumatic events and trauma-related symptoms due to:

A reluctance to inquire about traumatic events and symptoms because these questions are not a part of the counselor's or program's standard intake procedures.

Underestimation of the impact of trauma on clients' physical and mental health.

A belief that treatment of substance abuse issues needs to occur first and exclusively, before treating other behavioral health disorders.

A belief that treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of symptoms.

Not knowing how to respond therapeutically to a client's report of trauma.

Fear that a probing trauma inquiry will be too disturbing to clients.

Not using common language with clients that will elicit a report of trauma (e.g., asking clients if they were abused as a child without describing what is meant by abuse).

Concern that if disorders are identified, clients will require treatment that the counselor or program does not feel capable of providing ( Fallot & Harris, 2001).

Insufficient time for assessment to explore trauma histories or symptoms.

Untreated trauma-related symptoms of the counselor, other staff members, and administrators.

A client may not report past trauma for many reasons, including:

Concern for safety (e.g., fearing more abuse by a perpetrator for revealing the trauma).

Fear of being judged by service providers.

Shame about victimization.

Reticence about talking with others in response to trauma.

Not recalling past trauma through dissociation, denial, or repression (although genuine blockage of all trauma memory is rare among trauma survivors; McNally, 2003).

Lack of trust in others, including behavioral health service providers.

Not seeing a significant event as traumatic.

Regarding the second major barrier, counselors and other behavioral health service providers may lack awareness that trauma can significantly affect clients' presentations in treatment and functioning across major life areas, such as relationships and work. In addition, some counselors may believe that their role is to treat only the presenting psychological and/or substance abuse symptoms, and thus they may not be as sensitive to histories and effects of trauma. Other providers may believe that a client should abstain from alcohol and drugs for an extended period before exploring trauma symptoms. Perhaps you fear that addressing a clients' trauma history will only exacerbate symptoms and complicate treatment. Behavioral health service providers who hold biases may assume that a client doesn't have a history of trauma and thus fail to ask the "right" questions, or they may be uncomfortable with emotions that arise from listening to client experiences and, as a result, redirect the screening or counseling focus.

Challenges

Awareness of acculturation and language

Acculturation levels can affect screening and assessment results. Therefore, indepth discussions may be a more appropriate way to gain an understanding of trauma from the client's point of view. During the intake, prior to trauma screening, determine the client's history of migration, if applicable, and primary language. Questions about the client's country of birth, length of time in this country, events or reasons for migration, and ethnic self-identification are also appropriate at intake. Also be aware that even individuals who speak English well might have trouble understanding the subtleties of questions on standard screening and assessment tools. It is not adequate to translate items simply from English into another language; words, idioms, and examples often don't translate directly into other languages and therefore need to be adapted. Screening and assessment should be conducted in the client's preferred language by trained staff members who speak the language or by professional translators familiar with treatment jargon.

Common Assessment Myths

Several common myths contribute to underassessment of trauma-related disorders ( Najavits, 2004):

Myth #1: Substance abuse itself is a trauma. However devastating substance abuse is, it does not meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), criteria for trauma per se. Nevertheless, high-risk behaviors that are more likely to occur during addiction, such as interpersonal violence and self-harm, significantly increase the potential for traumatic injury.

Myth #2: Assessment of trauma is enough. Thorough assessment is the best way to identify the existence and extent of trauma-related problems. However, simply identifying trauma-related symptoms and disorders is just the first step. Also needed are individualized treatment protocols and action to implement these protocols.

Myth #3: It is best to wait until the client has ended substance use and withdrawal to assess for PTSD. Research does not provide a clear answer to the controversial question of when to assess for PTSD; however, Najavits (2004) and others note that underdiagnosis of trauma and PTSD has been more significant in the substance abuse field than overdiagnosis. Clinical experience shows that the PTSD diagnosis is rather stable during substance use or withdrawal, but symptoms can become more or less intense; memory impairment from alcohol or drugs can also cloud the symptom picture. Thus, it is advisable to establish a tentative diagnosis and then reassess after a period of abstinence, if possible.

Awareness of co-occurring diagnoses

A trauma-informed assessor looks for psychological symptoms that are associated with trauma or simply occur alongside it. Symptom screening involves questions about past or present mental disorder symptoms that may indicate the need for a full mental health assessment. A variety of screening tools are available, including symptom checklists.

However, you should only use symptom checklists when you need information about how your client is currently feeling; don't use them to screen for specific disorders. Responses will likely change from one administration of the checklist to the next.

Basic mental health screening tools are available. For example, the Mental Health Screening Form-III screens for present or past symptoms of most mental disorders ( Carroll & McGinley, 2001); it is available at no charge from Project Return Foundation, Inc. and is also reproduced in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c). Other screening tools, such as the Beck Depression Inventory II and the Beck Anxiety Inventory ( Beck, Wright, Newman, & Liese, 1993), also screen broadly for mental and substance use disorders, as well as for specific disorders often associated with trauma. For further screening information and resources on depression and suicide, see TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery ( CSAT, 2008), and TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a).

For screening substance use disorders, see TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ( CSAT, 1994); TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians ( CSAT, 1997a); TIP 31, Screening and Assessing Adolescents for Substance Use Disorders ( CSAT, 1999c); TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c); and TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d).

A common dilemma in the assessment of trauma-related disorders is that certain trauma symptoms are also symptoms of other disorders. Clients with histories of trauma typically present a variety of symptoms; thus, it is important to determine the full scope of symptoms and/or disorders present to help improve treatment planning. Clients with trauma-related and substance use symptoms and disorders are at increased risk for additional Axis I and/or Axis II mental disorders ( Brady, Killeen, Saladin, Dansky, & Becker, 1994; Cottler, Nishith, & Compton, 2001). These symptoms need to be distinguished so that other presenting subclinical features or disorders do not go unidentified and untreated. To accomplish this, a comprehensive assessment of the client's mental health is recommended.

Misdiagnosis and underdiagnosis

Many trauma survivors are either misdiagnosed (i.e., given diagnoses that are not accurate) or underdiagnosed (i.e., have one or more diagnoses that have not been identified at all). Such diagnostic errors could result, in part, from the fact that many general instruments to evaluate mental disorders are not sufficiently sensitive to identify posttraumatic symptoms and can misclassify them as other disorders, including personality disorders or psychoses. Intrusive posttraumatic symptoms, for example, can show up on general measures as indicative of hallucinations or obsessions. Dissociative symptoms can be interpreted as indicative of schizophrenia. Trauma-based cognitive symptoms can be scored as evidence for paranoia or other delusional processes ( Briere, 1997). Some of the most common misdiagnoses in clients with PTSD and substance abuse are:

It is possible, however, for clients to legitimately have any of these disorders in addition to trauma-related disorders. Given the overlap of posttraumatic symptoms with those of other disorders, a wide variety of diagnoses often needs to be considered to avoid misidentifying other disorders as PTSD and vice versa. A trained and experienced mental health professional will be required to weigh differential diagnoses. TIP 42 ( CSAT, 2005c) explores issues related to differential diagnosis.

Cross-Cultural Screening and Assessment

Many trauma-related symptoms and disorders are culture specific, and a client's cultural background must be considered in screening and assessment (for review of assessment and cultural considerations when working with trauma, see Wilson & Tang, 2007). Behavioral health service providers must approach screening and assessment processes with the influences of culture, ethnicity, and race firmly in mind. Cultural factors, such as norms for expressing psychological distress, defining trauma, and seeking help in dealing with trauma, can affect:

How traumas are experienced.

The meaning assigned to the event(s).

How trauma-related symptoms are expressed (e.g., as somatic expressions of distress, level of emotionality, types of avoidant behavior).

Willingness to express distress or identify trauma with a behavioral health service provider and sense of safety in doing so.

Whether a specific pattern of behavior, emotional expression, or cognitive process is considered abnormal.

Willingness to seek treatment inside and outside of one's own culture.

When selecting assessment instruments, counselors and administrators need to choose, whenever possible, instruments that are culturally appropriate for the client. Instruments that have been normed for, adapted to, and tested on specific cultural and linguistic groups should be used. Instruments that are not normed for the population are likely to contain cultural biases and produce misleading results. Subsequently, this can lead to misdiagnosis, overdiagnosis, inappropriate treatment plans, and ineffective interventions. Thus, it is important to interpret all test results cautiously and to discuss the limitations of instruments with clients from diverse ethnic populations and cultures. For a review of cross-cultural screening and assessment considerations, refer to the planned TIP, Improving Cultural Competence (Substance Abuse and Mental Health Services Administration, planned c).

Culture-Specific Stress Responses

Culture-bound concepts of distress exist that don't necessarily match diagnostic criteria. Culture-specific symptoms and syndromes can involve physical complaints, broad emotional reactions, or specific cognitive features. Many such syndromes are unique to a specific culture but can broaden to cultures that have similar beliefs or characteristics. Culture-bound syndromes are typically treated by traditional medicine and are known throughout the culture. Cultural concepts of distress include:

Ataques de nervios. Recognized in Latin America and among individuals of Latino descent, the primary features of this syndrome include intense emotional upset (e.g., shouting, crying, trembling, dissociative or seizure-like episodes). It frequently occurs in response to a traumatic or stressful event in the family.

Nervios. This is considered a common idiom of distress among Latinos; it includes a wide range of emotional distress symptoms including headaches, nervousness, tearfulness, stomach discomfort, difficulty sleeping, and dizziness. Symptoms can vary widely in intensity, as can impairment from them. This often occurs in response to stressful or difficult life events.

Susto. This term, meaning "fright," refers to a concept found in Latin American cultures, but it is not recognized among Latinos from the Caribbean. Susto is attributed to a traumatic or frightening event that causes the soul to leave the body, thus resulting in illness and unhappiness; extreme cases may result in death. Symptoms include appetite or sleep disturbances, sadness, lack of motivation, low self-esteem, and somatic symptoms.

Taijin kyofusho. Recognized in Japan and among some American Japanese, this "interpersonal fear" syndrome is characterized by anxiety about and avoidance of interpersonal circumstances. The individual presents worry or a conviction that his or her appearance or social interactions are inadequate or offensive. Other cultures have similar cultural descriptions or syndromes associated with social anxiety.

Sources: APA, 2013, pp. 833-837; Briere & Scott, 2006b.

Choosing Instruments

Numerous instruments screen for trauma history, indicate symptoms, assess trauma-related and other mental disorders, and identify related clinical phenomena, such as dissociation. One instrument is unlikely to meet all screening or assessment needs or to determine the existence and full extent of trauma symptoms and traumatic experiences. The following sections present general considerations in selecting standardized instruments.

Purpose

Define your assessment needs. Do you need a standardized screening or assessment instrument for clinical purposes? Do you need information on a specific aspect of trauma, such as history, PTSD, or dissociation? Do you wish to make a formal diagnosis, such as PTSD? Do you need to determine quickly whether a client has experienced a trauma? Do you want an assessment that requires a clinician to administer it, or can the client complete the instrument himself or herself? Does the instrument match the current and specific diagnostic criteria established in the DSM-5?

Population

Consider the population to be assessed (e.g., women, children, adolescents, refugees, disaster survivors, survivors of physical or sexual violence, survivors of combat-related trauma, people whose native language is not English); some tools are appropriate only for certain populations. Is the assessment process developmentally and culturally appropriate for your client? Exhibit 1.4-2 lists considerations in choosing a screening or assessment instrument for trauma and/or PTSD.

Instrument Quality

An instrument should be psychometrically adequate in terms of sensitivity and specificity or reliability and validity as measured in several ways under varying conditions. Published research offers information on an instrument's psychometric properties as well as its utility in both research and clinical settings. For further information on a number of widely used trauma evaluation tools, see Appendix D and Antony, Orsillo, and Roemer's paper (2001).

The DSM-5 and Updates to Screening and Assessment Instruments

The recent publication of the DSM-5 ( APA, 2013a) reflects changes to certain diagnostic criteria, which will affect screening tools and criteria for trauma-related disorders. Criterion A2 (specific to traumatic stress disorders, acute stress, and posttraumatic stress disorders), included in the fourth edition (text revision) of the DSM (DSM-IV-TR; APA, 2000a), has been eliminated; this criterion stated that the individual's response to the trauma needs to involve intense fear, helplessness, or horror. There are now four cluster symptoms, not three: reexperiencing, avoidance, arousal, and persistent negative alterations in cognitions and mood. Changes to the DSM-5 were made to symptoms within each cluster. Thus, screening will need modification to adjust to this change ( APA, 2012b).

Practical Issues

Is the instrument freely and readily available, or is there a fee? Is costly and extensive training required to administer it? Is the instrument too lengthy to be used in the clinical setting? Is it easily administered and scored with accompanying manuals and/or other training materials? How will results be presented to or used with the client? Is technical support available for difficulties in administration, scoring, or interpretation of results? Is special equipment required such as a microphone, a video camera, or a touch-screen computer with audio?

Trauma-Informed Screening and Assessment

The following sections focus on initial screening. For more information on screening and assessment tools, including structured interviews, see Exhibit 1.4-2. Screening is only as good as the actions taken afterward to address a positive screen (when clients acknowledge that they experience symptoms or have encountered events highlighted within the screening). Once a screening is complete and a positive screen is acquired, the client then needs referral for a more indepth assessment to ensure development of an appropriate treatment plan that matches his or her presenting problems.

Establish a History of Trauma

A person cannot have ASD, PTSD, or any trauma-related symptoms without experiencing trauma; therefore, it is necessary to inquire about painful, difficult, or overwhelming past experiences. Initial information should be gathered in a way that is minimally intrusive yet clear. Brief questionnaires can be less threatening to a client than face-to-face interviews, but interviews should be an integral part of any screening and assessment process.

If the client initially denies a history of trauma (or minimizes it), administer the questionnaire later or delay additional trauma-related questions until the client has perhaps developed more trust in the treatment setting and feels safer with the thoughts and emotions that might arise in discussing his or her trauma experiences.

The Stressful Life Experiences (SLE) screen ( Exhibit 1.4-3) is a checklist of traumas that also considers the client's view of the impact of those events on life functioning. Using the SLE can foster the client-counselor relationship. By going over the answers with the client, you can gain a deep understanding of your client, and the client receives a demonstration of your sensitivity and concern for what the client has experienced. The National Center for PTSD Web site offers similar instruments ( http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp).

In addition to broad screening tools that capture various traumatic experiences and symptoms, other screening tools, such as the Combat Exposure Scale ( Keane et al., 1989) and the Intimate Partner Violence Screening Tool ( Exhibit 1.4-4), focus on acknowledging a specific type of traumatic event.

Screen for Trauma-Related Symptoms and Disorders in Clients With Histories of Trauma

This step evaluates whether the client's trauma resulted in subclinical or diagnosable disorders. The counselor can ask such questions as, "Have you received any counseling or therapy? Have you ever been diagnosed or treated for a psychological disorder in the past? Have you ever been prescribed medications for your emotions in the past?" Screening is typically conducted by a wide variety of behavioral health service providers with different levels of training and education; however, all individuals who administer screenings, regardless of education level and experience, should be aware of trauma-related symptoms, grounding techniques, ways of creating safety for the client, proper methods for introducing screening tools, and the protocol to follow when a positive screen is obtained. (See Appendix D for information on specific instruments.) Exhibit 1.4-5 is an example of a screening instrument for trauma symptoms, the Primary Care PTSD (PC-PTSD) Screen. Current research ( Prins et al., 2004) suggests that the optimal cutoff score for the PC-PTSD is 3. If sensitivity is of greater concern than efficiency, a cutoff score of 2 is recommended.

Another instrument that can screen for traumatic stress symptoms is the four-item self-report SPAN, summarized in Exhibit 1.4-6, which is derived from the 17-item Davidson Trauma Scale (DTS). SPAN is an acronym for the four items the screening addresses: startle, physiological arousal, anger, and numbness. It was developed using a small, diverse sample of adult patients (N=243; 72 percent women; 17.4 percent African American; average age = 37 years) participating in several clinical studies, including a family study of rape trauma, combat veterans, and Hurricane Andrew survivors, among others.

The SPAN has a high diagnostic accuracy of 0.80 to 0.88, with sensitivity (percentage of true positive instances) of 0.84 and specificity (percentage of true negative instances) of 0.91 ( Meltzer-Brody, Churchill, & Davidson, 1999). SPAN scores correlated highly with the full DTS (r = 0.96) and other measures, such as the Impact of Events Scale (r = 0.85) and the Sheehan Disability Scale (r = 0.87).

The PTSD Checklist ( Exhibit 1.4-7), developed by the National Center for PTSD, is in the public domain. Originally developed for combat veterans of the Vietnam and Persian Gulf Wars, it has since been validated on a variety of noncombat traumas ( Keane, Brief, Pratt, & Miller, 2007). When using the checklist, identify a specific trauma first and then have the client answer questions in relation to that one specific trauma.

Other Screening and Resilience Measures

Along with identifying the presence of trauma-related symptoms that warrant assessment to determine the severity of symptoms as well as whether or not the individual possesses subclinical symptoms or has met criteria for a trauma-related disorder, clients should receive other screenings for symptoms associated with trauma (e.g., depression, suicidality). It is important that screenings address both external and internal resources (e.g., support systems, strengths, coping styles). Knowing the client's strengths can significantly shape the treatment planning process by allowing you to use strategies that have already worked for the client and incorporating strategies to build resilience ( Exhibit 1.4-8).

Preliminary research shows improvement of individual resilience through treatment interventions in other populations ( Lavretsky, Siddarth, & Irwin, 2010).

Screen for suicidality

All clients-particularly those who have experienced trauma-should be screened for suicidality by asking, "In the past, have you ever had suicidal thoughts, had intention to commit suicide, or made a suicide attempt? Do you have any of those feelings now? Have you had any such feelings recently?" Behavioral health service providers should receive training to screen for suicide. Additionally, clients with substance use disorders and a history of psychological trauma are at heightened risk for suicidal thoughts and behaviors; thus, screening for suicidality is indicated. See TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a). For additional descriptions of screening processes for suicidality, see TIP 42 ( CSAT, 2005c).

Concluding Note

Screenings are only beneficial if there are follow-up procedures and resources for handling positive screens, such as the ability to review results with and provide feedback to the individual after the screening, sufficient resources to complete a thorough assessment or to make an appropriate referral for an assessment, treatment planning processes that can easily incorporate additional trauma-informed care objectives and goals, and availability and access to trauma-specific services that match the client's needs. Screening is only the first step!

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Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders.

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This article talks about the importance of assessments and gives resources on things to help

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The National Child Traumatic Stress Network

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Trauma-informed screening and assessment practices help providers identify children's and families' needs early in the process and to tailor services to meet those needs.

Trauma Screening refers to a tool or process that is a brief, focused inquiry to determine whether an individual has experienced one or more traumatic events, has reactions to such events, has specific mental or behavioral health needs, and/or needs a referral for a comprehensive trauma-informed mental health assessment. Screening is a "wide-net" process.

Trauma-Informed Mental Health Assessment refers to a process that includes a clinical interview, standardized measures, and/or behavioral observations designed to gather an in-depth understanding of the nature, timing, and severity of the traumatic events, the effects of those events, current trauma-related symptoms, and functional impairment. Clinicians use the assessment to understand a child's trauma history and symptom profile; to determine whether a child is developmentally on target in the social, emotional, and behavioral domains; to inform case conceptualization and drive treatment planning; and to monitor progress over time.

The pages below provide more information about trauma-informed screening and assessment-including the types of tools that are available and strategies for engaging families-as well as considerations for implementation. In addition, the searchable NCTSN Measures Review Database provides easy access to comprehensive clinical and research information on a variety of measures important for the field of child traumatic stress.

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Trauma-informed screening and assessment practices help providers identify children's and families' needs early in the process and to tailor services to meet those needs.

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This article gives a lot of information about assessments and how they helps

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This article breaks down what it takes to have a calm and successful assessment to do the best

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This article breaks down everything that has to do with assessments and how it can help. It gave a lot of good information

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Overview

Trauma screening involves the use of a culturally competent, standardized, and validated trauma screening tool. A trauma screener is designed to be administered to every child within a given system.

Trauma screening tools are brief and should evaluate the presence of two critical elements: (1) exposure to potentially traumatic events/experiences, including traumatic loss, and (2) traumatic stress symptoms/reaction.

A trauma 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

Why Screen?

If you do not ask, they will/may not tell. Trauma-informed screening and assessment practices help providers identify children's and families' needs early in the intake/therapy process and to tailor services to meet those needs. Trauma exposure and its impact on a child can be varied and may occur over different developmental periods.

Trauma exposure has the potential to impact all domains of functioning, cognition, and emotional regulation. However not all children who experience a traumatic event(s) suffer posttraumatic or trauma-specific reactions as a result. Screening for exposure to trauma can help to gain a better understanding of what a child has experienced and identify or clarify other clinical presentations

The overall goal is for trauma to be factored into eligibility for services, service recommendations, and assessment and treatment planning. Screening for traumatic stress symptoms among those with a history of potentially traumatic experiences can identify children who may benefit from an evidence-based trauma treatment. Staff who administer the screening tool should be trained in the administration, scoring and interpretation of the results

For those mental health providers working in a CMHSP the MDHHS BHDDA Trauma Policy: Section IV states the following:

Screening for trauma exposure and related symptoms for each population. CMHSP, through direct service operations and provider network, shall use a culturally competent, standardized and validated screening tool appropriate for each population during the intake process and other points as clinically appropriate.

Trauma Screening is the first opportunity to normalize the effects of trauma. It is an opportunity for non-judgmental engagement and a transition to trauma treatment. The child and their caregiver can learn about common reactions to stress and normalize some of the reactions they may be experiencing. Trauma Screening can also provide a rationale for further trauma assessment and treatment.

Types of Trauma Screening Tools

What makes a good screening tool? The NCTSN states: 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.

There are a variety of screening tools, below are a couple of examples:

University of Minnesota's Traumatic Stress Screen for Children and Adolescents (TSSCA)

Juvenile Victimization Questionnaire (JVQ-R2)

What is a Trauma Assessment?

A trauma assessment typically occurs after a trauma screening has been completed and the child or caregiver has indicated trauma exposure. The assessment utilizes a formal, standardized measure to assess for a range of trauma exposures as well as behavioral reactions/coping skills that may have resulted from the trauma exposure. The assessment measure typically gathers information from both a child/youth and their caregiver.

Why is a Trauma Assessment Completed?

A trauma assessment typically occurs after a trauma screening has been completed and the child or caregiver has indicated trauma exposure. The assessment utilizes a formal, standardized measure to assess for a range of trauma exposures as well as behavioral reactions/coping skills that may have resulted from the trauma exposure. The assessment evaluates the ways in which a child/youth's current functioning might have been affected by the experience of trauma. The assessment measure typically gathers information from both a child/youth and their caregiver.

There are three dimensions of the trauma assessment:

1. Has the child/youth been exposed to potentially traumatizing events?

2. Does the child/youth display symptoms associated with posttraumatic stress?

3. Determining if the youth meets the criteria for a formal diagnosis of Posttraumatic Stress Disorder (PTSD) as per the DSM-IV or ICD-10 diagnostic manuals.
It should be noted a PTSD diagnosis is not required to receive TF-CBT or CPP.

Trauma assessments can help to determine, trauma responses that are currently occurring, whether a child is developmentally on target in their social, emotional, and behavioral functioning; as well as, inform case conceptualization and drive treatment planning. Treatment goals can also be established from the assessment, specifically targeting ongoing trauma responses and identifying any barriers to treatment. A trauma assessment can also monitor progress over time as the child, youth and family proceed through treatment.

Types of Trauma Assessments

What makes a good trauma assessment tool? When reviewing assessment tools the NCTSN states: providers using a trauma assessment 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.

There are a variety of trauma assessment tools, below are a couple of examples:

Young Child PTSD Checklist (YCPC) for children ages 1-6 years' old

UCLA Posttraumatic Stress Disorder Reaction Index for the DSM IV (UCLA-PTSD RI)

The NCTSN also has a database of searchable detailed reviews of screening and assessment measures utilized in the field of child traumatic stress, designed to allow comparison across measures.

Training Qualifications

Trauma Screening and Assessment Learning Collaboratives are provided on a regular basis throughout the year to Community Mental Health Services Programs (CMHSPs) and their provider agencies. To qualify for a Learning Collaborative in our Trauma Screening and Assessment program, you must be a licensed clinician employed by a CMHSP or provider agency.

Please speak with your agency supervisor if you are interested in participating in an upcoming Learning Collaborative.

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What is Trauma Screening and Assessment?

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Trauma screening involves the use of a culturally competent, standardized, and validated trauma screening tool. A trauma screener is designed to be administered to every child within a given system. Trauma screening tools are brief and should evaluate the presence of two critical elements: (1) exposure to potentially traumatic events/experiences, including traumatic loss, and (2) traumatic stress symptoms/reaction.

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this is actually a quiz about trauma. It helps break down what kind of trauma is affecting you and what kind of help you'd need

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PTSD (Post Traumatic Stress Disorder) Test

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The PTSD (Post Traumatic Stress Disorder) Test is for those who are bothered by a traumatic life event.

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This is a whole breakdown of everything. It's kind of a lecture of what to look for and how to help

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This article helps break things down on how to get families engaged and helping with the assessment process

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The National Child Traumatic Stress Network

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What is a Trauma-Informed Mental Health Assessment and Why is it Important?

Trauma-informed mental health assessment offers a structured framework for (1) gathering information across several key domains of functioning, (2) identifying and addressing the needs of children and families exposed to traumatic events, and (3) coding and summarizing this information, so that it can be communicated to families and other providers.

Engaging Families in the Assessment Process

The following practical strategies have been adapted from t he TAP training. Clinicians should facilitate child and family engagement in the process by addressing their concerns, answering their questions, validating their observations, and demystifying the process. When administering measures, describe for caregivers (and children, as appropriate), the purpose and importance of the assessment process and the various tools used to gather information.

Make time in the therapy session to complete measures with family members by putting it on the session agenda and explaining to caregivers how the measures can aid the treatment process and support the development of treatment goals and plans.

Allow the parent and child to choose the language in which they will complete the measures.

Describe the measures as a way you gather information on child and family functioning in order to help them as much as possible. This is not just more paperwork to complete.

Use developmentally appropriate strategies when completing measures with youth, including the following:

Have a dry erase board or chalk board, as an alternative to pencil and paper, for marking answers.

Let them decide the order in which they complete measures, when possible.

Select a fun pen or pencil to use when marking items.

Use visuals to clarify constructs such as frequency (e.g., calendar).

If the child opposes doing the measures, read aloud the items to him or her. This interviewing will allow you to collect additional "data," such as affective and physiological responses (Is he nervous completing the measure? Is she indecisive in responding? Does he fully understand the question?)

For youth, ask follow-up questions to probe more deeply after you have completed the measure.

Offer to complete the assessment over 1-3 sessions and give the child and caregiver some choice in this (e.g., complete all today or one today and one next week?).

Praise all children (and parents) for their "hard work" and patience completing questions.

Check the endorsement of critical items (e.g., hurting oneself) and develop a safety plan.

Take time to explain what will happen next (i.e., how the measures will be scored and how you will review the results with the youth and caregiver).

Clarify that you will re-administer the measures on an ongoing basis, share the results, and use those results as you develop and monitor the treatment plan.

Providing Feedback

Review the purpose of the measures with the child and caregiver.

When applicable, explain that the measures provide information on how the child is doing related to other children.

Highlight the strengths the child exhibits, whether indicated by a measure or domain related to resiliency, or strengths revealed as they were not identified as problematic (i.e., doing well in school). Explain to family members how you will integrate these strengths into the treatment plan to support recovery from trauma.

Assess the child and caregiver's level of interest in the feedback; you may want to provide more or less detailed information and assessment data.

Consider drawing diagrams or pictures to explain results on some measures (e.g., using bar graphs to indicate progress).

Highlight areas where the caregiver and child were consistent in their report on the measures (i.e., both agree the youth client is experiencing problems in school). If they are very consistent, this is a potential strength, indicating that they are "on the same page."

Highlight discrepancies between the child and caregiver report; explain that this suggests child and caregiver experience the same symptom very differently.

Ask the caregiver and child if the results are consistent with their experiences (Does this seem accurate? Does it provide any new information? If they disagree, why?). This helps reconcile differences between caregiver and youth responses or varying responses on different measures.

Share initial assessment results and use this information to engage in collaborative treatment planning with caregivers and youth as appropriate. Summarize the findings, noting two or three main points.

Use the feedback process to provide psychoeducation about trauma reactions with the child and caregivers (e.g., noting common responses to trauma or areas of need that are related to each other) and tie this information to the treatment selected (e.g., "This treatment can help reduce those physical reactions and improve your sleep.").

Remind the caregiver and child that you will re-administer the measures in the future, and that the results will show the progress of therapy, the areas where you may want to continue work, and how helpful the treatment has been for the child and family.

Examples of Trauma-Focused Mental Health Assessment Strategies

The following are three examples of tools and processes that can be used for trauma-informed assessment.

Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway Model. Developed by the Chadwick Center for Children and Families, with funding from the Substance Abuse and Mental Health Services Administration, the Trauma Assessment Pathway (TAP) was designed for children 0 to 18 years of age who have experienced any type of trauma and who may or may not be in the child welfare system. TAP is a multifaceted assessment process enabling clinicians to screen clients and, if appropriate for the treatment setting, to gain an in-depth understanding of the child, developmental level, traumatic experience, and the child's family, community, and cultural systems.

Child and Adolescent Needs and Strengths (CANS) - Trauma Comprehensive Version. The "CANS-Trauma" is a flexible, multi-purpose tool utilized in different capacities depending on the needs of a particular child-serving system (Kisiel, Lyons, et al., 2010). The CANS methodology is intended to gather information on a range of domains relevant to the functioning of the child and caregiving system (e.g., trauma experiences, traumatic stress symptoms, emotional and behavioral needs, risk behaviors, life domain functioning, strengths, and caregiver needs and strengths) and incorporate this information directly into individualized plans of care.

Transactional Model. Spaccarelli (1994) proposed a transactional or interactive model for understanding the effects of child abuse (and its associated events) on the presentation of symptoms. This model examines factors related to the abuse of the child, as well as those associated with the investigation (i.e., disclosure events) and related events that may occur subsequent to the investigation (e.g., placement outside the home and court hearings). This model also incorporates age, sex, and personality factors; social support; and previous coping styles and cognitive appraisal schemes (i.e., the way a child organizes and understands events in his or her world).

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Trauma-informed mental health assessment offers a framework for gathering information, identifying needs, and summarizing information.

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This really helped me understand stress and how we should help

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Trauma is one of the leading causes of death in young people worldwide. In the United States, trauma is the leading cause of death in young adults and accounts for ten percent of deaths in all men and women. In the U.S., there are approximately 50 million visits to the emergency department annually related to trauma. The most common causes of mortality in trauma victims include hemorrhage, cardiopulmonary arrest, and multiple organ dysfunction syndromes.[1]

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This is a really good article about trauma and the assessment process

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Child Therapy: 19 Counseling Techniques & Kids’ Activities

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What is child therapy? How does it differ from regular therapy?

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Help gives activities to help therapy

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Free Activities for Child & Adolescent Therapy — Child Therapy Guide

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Child Therapy Guide offers free printable therapy activities for kids! Our evidence-based worksheets are informed by CBT, DBT, and art/play therapy modalities.

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tons of videos

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Therapeutic interventions for young children - Bing

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Intelligent search from Bing makes it easier to quickly find what you're looking for and rewards you.

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ways to help kids calm down

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If you're a mental health professional working with children, you will probably agree that many of the calls you receive from parents have something to do with anxiety or stress. Child therapists have the amazingly important yet challenging task of educating and supporting kids in a therapeutic setting that is both productive and fun. When working with children as young as preschool age, it can be a very daunting task to keep things fresh and exciting week after week! So, how do we help children develop the coping skills they need while keeping them engaged (and not glancing at their watch)? Here are ten therapist (and child!)-approved, fun activities that address anxiety-based disorders and promote relaxation and stress reduction in children:

1 | Worry or "Reminder" stones

This activity is one that children will ask you to do again and again, and it will actually provide them with some comfort in their time spent away from you or their loved ones. Buy oven bake clay at your local craft store and have the children choose up to three colors that make them feel calm or happy. As they roll the colors into a ball and then gently push their thumb print into it, talk to the child about what this stone symbolizes for them; perhaps include a reminder to breathe, a positive thought, or a favorite mantra such as, "I can get through this". After it is baked for 30 mins at 250 degrees, it can be kept in their pocket and used in difficult moments as a reminder that they are safe an in control. Parents can even involve themselves in this activity and make a worry stone as a transitional object for kiddies who are having trouble separating. (Note: Most of the time, the stones are made in therapy, but baked at home).

2 | Calm down jars

Another fun activity that kids love to do is make "calm down jars". Throw some warm water, glitter glue and glitter in a glass (or even better, plastic) jar and have your kiddies shake up it up to watch the glitter slowly float to the bottom. It is incredibly soothing and relaxing to watch and kids can use it at home after a difficult or stressful moment. Encourage them to do some deep breathing as they watch as well incorporate some mindfulness. Smaller versions of the calm down jars can be made by using small plastic baby oil bottles and can be kept in the car or in Mom's purse for a quick relaxation tool on the go.

3 | Bibliotherapy

A great way to keep kids engaged while teaching them some important coping skills is to read age appropriate books on the topic with them. My favorite book to read with my anxious kiddos was written by yours truly and is called There's a Bully in My Brain. Children love that the main character, Justin, worries about the same things they do, and they are actually provided with some concrete and realistic cognitive behavioral strategies to use when they are experiencing anxious moments. As an added bonus, there are printable sheets at the end of the book for therapists to use as a tool in continuing the conversation about the physical sensations we feel in our body when anxious, and the benefit of breathing as a coping tool. Kids can also fill in what the bully in their own brain tells them as well as what they can say back to stand up to it. ( There's a Bully in My Brain is available on Amazon and Barnes and Noble.)

4 | Positive mantra bracelet

Making positive mantra bracelets is a simple but fun way to get kids talking about positive thinking and, more specifically, which mantras best apply to them and their worries. Start by opening up a discussion about the things they worry about most, and help them come up with three or four mantras they can repeat to themselves in an anxious moment, such as "I am safe", "Mom will always come back," or "My best is good enough". Assign each mantra to a different color bead, and have them string them onto a pipe cleaner or lanyard to be worn on their wrist as a daily reminder to think positive thoughts and breathe. The soft pipe cleaner and smooth, sliding beads also function as an awesome yet discreet fidget for our tactile seeking little ones.

5 | Worry box

Very often kids can feel as though they are controlled by their anxious thoughts and feel helpless in stopping them. Their parents will report that their child cannot stop talking about certain topics, and they often feel frustrated that they don't have enough time in their day to address their child's concerns. A great activity for kids struggling with Generalized Anxiety Disorder is creating a "worry box". This activity can be as simple or as elaborate as you would like. Children decorate a box however they like--with modge podge, glitter, markers, stickers, etc. As they are crafting their box, therapists can explain that the box will be a spot in which they keep their worries when they don't have the time to think about them. They write their worry on a piece of paper and place it in a box to be addressed at a later time. It gives kids a sense of control over their anxiety, and parents can set aside a certain time of day to talk to kids about their fears. When they no longer feel as though they need to address a certain worry that is in the box, the piece of paper can be ripped up and thrown in the garbage, which is a therapeutic activity in itself.

6 | Butterflies in the belly

This butterfly in my belly activity is an adorable and non-threatening way to open up discussions with kids about their worries or fears. The therapist draws and cuts out butterflies of all different sizes in advance and traces the child's head and torso on a large piece of oak tag. (For children with a history of physical and sexual abuse/trauma, it may be best to have an outline of a person traced out before the session starts). Talk to the child about the physical sensations they feel in their body when they feel worried, such as butterflies in their belly. Ask them to write down different things they stress about on the butterflies and use the various sizes for big or little worries. End with a discussion about what calm down strategies to use when the "butterflies in their belly" show up and write them down in a butterfly net to symbolize "catching the butterflies".

7 | Create a journal

Many of the kids we work with have a hard time expressing themselves verbally or do not have a parent or loved one they trust to talk to about their feelings. It's important to explain to these children that they do not have to talk about their worries or stress if these topics make them uncomfortable, but they do have to find an different outlet for expressing themselves. Have these children decorate a journal that is personal to them using stickers, markers, or even magazine cut-outs of positive phrases, and encourage them to journal when they first sit down with you as well as during times between sessions..

8 | Stress balls

Stress balls are a true fan favorite, and you'll be hard pressed to find a child who does not enjoy this activity. Fill a balloon with flour, rice, orbeez, or play dough using a small funnel, tie the end, and make sure to double wrap it into another balloon for extra security (Mom and Dad will thank you!). Stress balls make for a great fidget for our nervous kids and serve as a great distraction when working with kids with Trichotillomania.

9 | Slime

Slime is all the rage lately and a quick google search will produce hundreds of recipe variations. The cool part about making slime is that kids find the process super fun, but it is also an awesome therapeutic tool for our sensory seeking kids. Add some lavender oil into the slime as an additional bonus to calm them as they play. Just a few minutes of running the slime through their fingers can bring a child's baseline level of anxiety down a few notches.

10 | Put them all together and make a calm down "toolbox"

Our job as therapists is to provide children with the tools they need, and eventually get them to a point where they can regulate their own emotions in challenging moments. A great way to support and empower our kids to self soothe is to help them make a calm down "toolbox" with many of the items that have been mentioned in this article. It is important to explain that what may help to calm us down one day may not work the next, and using an analogy like "you wouldn't pick up a hammer to fix a leaky faucet" may help them to understand why we need many "tools" in our tool box. Have a realistic conversation with them about what helps them calm down when they are feeling anxious, and place those items in the box. Aside from their worry stone, journal, calm down jar, positive mantra bracelet, stress ball, and slime, kids may include bubbles for breathing, a photo album filled with happy memories, a stuffed animal, gum, an iPod for music, or coloring books and crayons. You can also make a list or key ring of strategy ideas that may not "fit" into the box, such as taking a bath or going for a walk.

Summary

Whatever activities you choose for your sessions, remember that the single most important part about your job is to create a safe and loving therapeutic space built on trust and free of judgement. Providing this environment for children can be life changing for them, and although they may not remember making a stress ball, they will always remember how you made them feel! Have fun!

About the Author

Kristin O'Rourke is a licensed clinical social worker and author of There's a Bully in My Brain, with over fifteen years of experience supporting children and families with anxiety disorders and behavioral issues. She is the owner of In-Home LCSW, PLLC, a private group practice that provides home and office based counseling services to children and families in New York and New Jersey. Find her on Facebook at In-Home LCSW, PLLC, on Instagram @inhomelcsw or on her website at www.inhomelcsw.com

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10 Therapist (and Child)-Approved Activities to Support Kids with Anxiety - Family Therapy Basics

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If you're a mental health professional working with children, you will probably agree that many of the calls you receive from parents have something to do with anxiety or stress. Child therapists have the amazingly important yet challenging task of educating and supporting kids in a therapeutic sett

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different kinds of therapy for helping

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Understanding the Different Types of Therapy for Children

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Exploring Therapeutic Strategies Enhancing Child Well-Being

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This is a great recourse to help

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This is a wonderful resource outlining what will help certain ages

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Great resource to help show what helps

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Cognitive-behavioural therapies:

Systemic interventions:

Psychoeducation

Group work with children

Psychotherapy (unspecified)

Counselling

Peer mentoring

Intensive service models:

Activity-based therapies

Cognitive-behavioural therapies

Cognitive-behavioural therapies are a group of interventions that draw on a number of theories of learning, both to account for, and address a range of, emotional, psychological and behavioural problems. They have a wide application, ranging from addressing health and mental health problems to more interpersonal and social problems, such as social skills deficits and delinquency. As such, they have considerable relevance to the problems associated with child maltreatment. Before describing the core features of a cognitive-behavioural approach, we briefly describe the therapeutic approaches associated with earlier behavioural and social learning theories, as these continue to form important components of complex cognitive-behavioural interventions.

Behavioural therapies

The earliest interventions were essentially behavioural, drawing on operant (instrumental) and classical (respondent) conditioning paradigms of learning, associated, respectively, with BF Skinner and I Pavlov. Operant conditioning focuses on how behaviour changes with changes in the environment, as when a child's antisocial behaviour increases as a result of adult attention (reinforcement). Classical conditioning focuses on associative learning, whereby a person learns to respond in a particular way (e.g. becoming anxious) to a neutral stimulus (e.g. a place) by dint of the pairing of the neutral stimulus with a traumatic event (e.g. sexual assault, humiliation).

Although now rarely viewed as adequate conceptualisations of human behaviour, operant and classical conditioning continue to inform the interventions required to address complex social and psychological problems, such as those associated with child maltreatment. Strategies drawing on both operant and classical conditioning are used in psychosocial treatments. The most commonly used classical or respondent-based technique is relaxation training. Children are trained to relax in the face of a hitherto stressful stimulus (e.g. a memory of sexual abuse) either as a way of neutralising the impact of the stimulus (where it forms part of an exposure therapy) or as the means of providing an opportunity to practise other ways of coping, such as 'reframing' (locating the responsibility for the maltreatment with the perpetrator rather than blaming themselves; practising positive self-talk). Some of the included studies evaluate a purely respondent approach to anxiety management. Operant techniques, such as differential reinforcement (essentially ensuring unwanted behaviour is not reinforced and positively reinforcing prosocial or wanted behaviour) form an important part of interventions that are designed to address the behavioural problems that are often associated with maltreatment, particularly for younger infants and children.

Modelling and skills training

Social learning theory, recognises that we are not simply the product of our environments: we do not simply respond to stimuli - we interpret them. What we think influences what we do and how we respond to other people and events, and our experiences lead us to expect certain outcomes from certain courses of action under certain circumstances. Furthermore, a large proportion of our behavioural repertoire (e.g. our social skills, our ability to problem solve) comes not from simple respondent or operant processes, but by learning from others. We learn how to do things and how to behave by watching other people or via processes of vicarious learning (e.g. by books or verbal instruction). Reinforcement will play a part in determining whether or not we adopt or use certain responses, and some may find it difficult to manage particular situations if they have not had the opportunity to develop the appropriate skills, including social skills. Social learning theory informs our understanding of how certain forms of maltreatment may be associated with the certain outcomes, for example in understanding how witnessing intimate partner violence can exert a 'modelling effect' on children, particularly boys, which - in the absence of opportunities to learn alternate ways of managing conflict or frustration (for example) - can lead to intergenerational cycles of violence. The understanding of the importance of modelling and behaviour rehearsal (with feedback and positive reinforcement) is used to inform a number of psychosocial therapies that aim to help individuals find more adaptive ways of responding to situations.

Cognitive-behavioural therapies

In contrast with traditional learning theory, cognitive theories afford the mind a central role in understanding behaviour, and in developing interventions designed to address psychosocial problems. Unlike the behaviour therapies, which emerged from laboratory-based experiments, cognitive therapies developed from clinical practice, largely in the field of depression, and thus predated the empirical data that have subsequently accrued. For example, Beck 1979 argued that depression resulted from the reciprocal interaction of three things: a negative way of viewing oneself, one's situation and one's prospects ( cognitive triad), rigid ways of thinking about the world ( schema) that often develop early in life or based on the interpretation of prior experience, and which result in negative, automatic thoughts, and biased and erroneous thinking ( faulty information processing). It is thought that children who have experienced maltreatment may well develop unhelpful ways of thinking about themselves, their situation and their prospects, which may cause them difficulties or prevent them overcoming associated problems. For example, children who have been maltreated may well blame themselves for what has happened to them; they may have internalised a negative self-image; they may have 'learned' that nothing they do can bring about a sought-after outcome (to be loved, thought well of), resulting in poor self-efficacy or indeed depression. Many of the psychosocial interventions designed to address the problems experienced by maltreated children are concerned to influence these cognitive sequelae. Cognitive-behavioural therapies seek to do so quite directly by helping individuals to identify maladaptive beliefs and ways of thinking, to challenge them (reality testing) and to replace them with more realistic and positive ways of thinking.

Trauma-focused cognitive-behavioural therapy

Trauma-focused CBT (TF-CBT) is a manualised intervention developed by Cohen, Mannarino and Deblinger. TF-CBT directly addresses traumatic symptoms, alongside other components that are typical of CBT interventions, such as coping skill training and symptom management, cognitive restructuring and gradual exposure. However, key differences are a greater focus on graded exposure, creating an appropriate account of the trauma [a trauma narrative (TN)] and cognitive processing of experiences. This focus builds on findings from research that support a model of trauma in which traumatic memories and related symptoms are maintained by cognitive biases and avoidance strategies. The TN component aims to address this in order to reduce symptomology and process traumatic memories. TF-CBT combines joint child-parent sessions and individual sessions for both child and non-offending parents. Parent involvement provides opportunities to address misperceptions and to validate parental reactions to their child's traumatic experiences, to train parents to support their child's therapeutic work and to provide a supportive environment at home (e.g. the studies by Cohen et al., and Cohen and Mannarino).

Eye movement desensitisation and reprocessing

We identified two controlled studies (both randomised trials) of EMDR. EMDR is a manualised intervention developed by Shapiro et al. Because its core features combine strategies from the learning theories outlines above, we have included it in the group of cognitive-behavioural interventions. EMDR involves the identification and processing of traumatic memories using bilateral stimulation, desensitisation through imaginal exposure, and challenging and replacing maladaptive beliefs about the trauma. The information processing model suggests that this helps to process traumatic memories into long-term memory, thereby reducing trauma-related symptoms, such as hypervigilance, as well as replacing unhelpful beliefs, related to the trauma, with more adaptive ones.

Relationship-based interventions

Attachment-orientated Interventions

Attachment describes an infant's strong disposition 'to seek proximity to and contact with a specific figure and to do so in certain situations, notably when . . . frightened, tired, or ill'. It is a behavioural system that is a product of human evolution, designed to trigger protection in the face of perceived danger and to alleviate its associated response, fear. Most infants develop an attachment to their primary carers, and, for most infants, the relationship with the mother is the first intimate relationship in which they engage. From these attachment relationships children start to form a sense of who they are, what they can expect from others, and what behaviour it is useful or dangerous to engage in. Infants whose primary carer provides sensitive and responsive care develop what is called a secure attachment. Carer sensitivity and responsiveness to their infant's needs helps to 'shape their physiological regulation and biobehavioral patterns of response' (p. 624), and, as infants develop a secure attachment (sometime towards the end of their first year), they use that attachment and associated feelings as a secure base from which to explore their worlds.

Emotional and physical neglect or abuse, and exposure to violence, can result in insecure attachments or sometimes disorganised attachments, which, if unresolved, will contribute to a wide range of problems in later development, including poor socioemotional development, self-regulation difficulties, maladaptive behaviour, sleep disturbance, language delays, poor peer relationships, school underachievement, and psychopathology and delinquency in later life.,, It has also been associated with a disturbed hypothalamic-pituitary-adrenal axis, which is important for self-regulation and stress management. Disorganised attachment styles develop when children are emotionally and physically depending on someone who is also a source of fear and anxiety. Unsurprisingly, disorganised attachments styles are prevalent among children living in families in which there is child maltreatment, parental depression, parental history of loss or trauma, parental dissociation, parental frightening behaviour or marital discord. The cascade of negative outcomes associated with a disturbed attachment has been referred to as 'toxic stress'.

There is a sizeable literature focused on interventions that are designed to promote maternal sensitivity and responsiveness (see van Ijzendoorn et al.). In this review, we included only those interventions that specifically focused on families when maltreatment was deemed to be an issue. Although these interventions might arguably also be viewed as secondary prevention (and therefore not appropriate for this review), the nature of attachment is such that interventions designed to promote secure attachments inevitably focus on the primary caregiver. Given the significant impact on subsequent development, these interventions were judged to meet the inclusion criteria of a psychosocial intervention dealing with the adverse consequences of maltreatment for children.

Attachment interventions generally involve caregiver-infant sessions, and aim to enhance parental sensitivity to emotional and behavioural cues in order to improve a child's attachment security (e.g. Moss et al.). This may involve child development training, parenting skills, coping strategies, developing social support networks, enhancing the caregiver's capacity to provide safety, child-caregiver joint narrative of trauma experiences, addressing negative maternal representational models in the parent-child interaction, providing a corrective emotional experience for caregivers or addressing a caregiver's own attachment difficulties stemming from childhood.,,⁻ In attachment-based interventions, the focus of the intervention is not the caregiver or the child but rather the caregiver-child relationship. This relationship is used as a vehicle to address a child's emotional, cognitive and social functioning difficulties. ⁻

Attachment and biobehavioral catch-up

Attachment and Biobehavioral Catch-up (ABC) is informed by both attachment theory and neurobiology., ABC focuses specifically on disorganised attachment styles, which are associated with frightening or frightened parental behaviour rather than purely a lack of attunement or insensitivity by the parent. This form of attachment has been found to mediate disrupted maternal behaviour and children's behavioural difficulties and dysregulation. Children's behavioural level and biobehavioural level dysregulation is characterised by externalising behaviour problems, conduct difficulties and disrupted cortisol patterns (which are associated with stress reactivity).,

Attachment and Biobehavioral Catch-up (ABC) is a manualised didactic intervention which was designed to decrease parental frightening behaviour and increase parental sensitivity. In contrast with more general attachment-based interventions, the focus of ABC is on parental behaviour change rather than changing parental internal representations. The aim of the intervention is to help children learn self-regulatory skills by changing the way parents interpret their children's behaviour, over-riding their own issues that interfere with their caregiving and providing an enabling environment for developing self-regulation skills.,

Parent-child interaction therapy

Parent-child interaction therapy (PCIT) was developed by Sheila Eyberg. PCIT draws on the work of Diana Baumrind (on parenting styles), as well as attachment theory and learning theory. In its original form it was designed to help parents to establish a secure and nurturing relationships with their child, and enhance prosocial behaviour while decreasing undesirable behaviour. Unlike parent training, PCIT involves in vivo child-parent dyadic sessions in which parents are taught behaviour management techniques, often being coached through a one-way mirror. To an extent, PCIT resembles a behavioural version of play therapy [Children's Depression Inventory (CDI)] and behavioural parent training (parent-directed interaction).

Most studies of PCIT seek to minimise the risk of maltreatment or future maltreatment and secure children's well-being by promoting nurturing parenting and reducing those parental practices that have been linked to maltreatment and attachment disorders, such as inappropriate discipline, coercive cycles of behaviour and negative communication.,

Dyadic developmental psychotherapy

Dyadic developmental psychotherapy (DDP) is designed to address the impairments associated with attachment disorders and complex childhood trauma., The intervention uses the child-therapist relationship to establish a relational context in which the child can learn how to engage with, and benefit from, relationships with others. The therapist seeks to establish a relationship that mirrors the general principles characteristic of parent-child relationships that facilitate secure attachments, for example attunement, reflecting back to the child his/her subjective experiences (including the trauma s/he has experienced) and helping him/her to make sense of these 'with acceptance, curiosity and empathy'. In the same way that attachments develop as a result of experience (preverbally), DDP emphasises the importance of healing experiences. In order to benefit from DDP, children need to be in a safe and secure environment (at home or in substitute care) and parents (or carers) are active participants in the therapy, either being with the child in the sessions or watching the therapy through a one-way mirror.

Child-parent psychotherapy

Child-parent psychotherapy (CPP) is a home-based, manualised intervention provided on a weekly basis for 1 year by trained master's level therapists. It is described as a 'supportive, non-directive, and nondidactic' intervention that 'includes developmental guidance based on the mother's concerns' (p. 794). When children are aged ≤ 1 year, this therapy is referred to as Infant-Parent Psychotherapy; when they are older, the intervention is called, alternately, Pre-School Parent Psychotherapy or Toddler-Parent Psychotherapy.

Parenting interventions

In general, parent training interventions aim to change unhelpful or maladaptive parenting practices in order to improve child development and well-being. As such, most parenting programmes that address maltreatment are concerned with secondary prevention, but we found three studies,, with a specific focus on improving outcomes for children who have been exposed to maltreatment, and these studies were included. One study evaluated the effectiveness of a parenting programmes designed to help foster parents and parents to co-parent children in foster care, with a view to ameliorating the child behaviour problems associated with, and return the children to, the care of their biological parents. A second assessed the impact of training maltreating mothers in elaborative and supportive reminiscing about positive and negative everyday past events with young children, as a means of addressing multiple sequelae of maltreatment. The third specifically examined the impact of the Webster-Stratton IY programme on children's autonomy, as well as positive parenting, recognising that autonomy is an important subjective state and a critical behaviour acquired in the early years, and which is related to the quality of parenting.

Systemic interventions

Systems theory posits that individuals are embedded in, and influenced by, a number of interacting systems, including - most importantly - the family. Within systems theory, the problems affecting an individual are conceptualised as a function of the relationships and patterns of interaction that surround him or her, with the resulting implication that effective interventions necessitate locating individual problems within that context and - in many circumstances - directing intervention at the family, rather than simply the individual. Systemic analyses can also be applied to other social systems, such as wider family networks, groups or organisations. Given the inclusion criteria, systemic interventions were included only when they directly focused on ameliorating the consequences of maltreatment for the children in the family (as opposed to halting it and creating a supportive family system that was capable of promoting optimal child development).

Systemic family therapy

There are many forms of FT, most of which are informed primarily by structural family systems theory and drawing on a wide range of techniques from other interventions, such as CBT. This can make assessing its effectiveness quite challenging, as some forms of therapy are essentially systems-focused cognitive-behavioural interventions.

Multisystemic therapy

Multisystemic therapy (MST) is a short-term, multifaceted intervention for children and young people with serous psychosocial and behavioural problems. It differs from FT in that it includes a combination of multiple systems in the treatment focus, such as family, peers, school, neighbourhood or community. Consistent with social ecological theories of human development, this broader focus is based on the view of the programme developers - that children's difficulties are caused and maintained by multiple factors within these systems and their interaction. The intervention therefore focuses on identifying and targeting these factors in order to reduce symptoms and distress, and promote health.

Group work with children

Group psychotherapies (or therapeutic groups) are interventions in which the group format is central. The group itself is deemed to be 'therapeutic', providing a number of essential components, such as a feeling of universality, reducing isolation, extending social networks, social skills practice, healthy relationship building and normalising.

The interventions' group content includes psychoeducation, as well as skills training and experiential learning. This may include assertiveness training, narrative therapeutic activities, such as storytelling or body image and self-esteem enhancement. Many of these interventions are based on social learning theory.

Psychotherapy/counselling

Common to all psychotherapeutic interventions that address individual, familial and community-level issues, is a non-judgemental, insight-orientated approach with a strong focus on the therapeutic alliance and dynamic relational processes with therapists or group members. Using these processes to work through past and current relationships, losses and disruptions, is thought to address underlying psychological processes in relation to traumatisation and to enable long-term change. Many the studies we identified provided only very general descriptions of these talking-based therapies (such as 'psychotherapy' or 'counselling'), often with little or no information on the underpinning theory of the approach used.

Intensive service provision

Treatment foster care

Enhanced Foster Care is designed specifically to meet the developmental, social and emotional needs of children in foster care with particularly challenging behaviour. A multidisciplinary team works with specially trained foster parents to reduce behavioural difficulties, increase regulatory abilities and increase a young person's secure attachment-related behaviour through a consistent and predictable environment. It involves high rates of positive reinforcement for desirable behaviours, clear limit setting, 24-hour crisis intervention for foster parents, support groups for foster parents, group therapeutic support for children and FT for relationships with biological family.

Therapeutic residential/day care

Like milieu therapy, therapeutic residential care entails creating a nurturing, stable and consistent environment and a predictable routine for children and young people who need specialist help, and whose problems make it difficult to provide that help in any other way. Indeed, for some maltreated children their experiences of maltreatment, combined with adverse care experiences, may mean they cannot be managed in substitute home-based care settings, such as adoption and fostering. A variety of specific interventions are used in the therapeutic residential care studies included in this review, among which are therapeutic parenting, life story work, trauma-focused psychological therapy, addressing cognitive distortions, improving impulse control, social skills training, risk management, sex education and behaviour modification, as well as preparation for independence for older adolescents.

Therapeutic day programmes aim to meet the developmental needs of children in terms of fine motor, language, and social and emotional skills. Therapeutic day programmes are held in classroom environments and usually run intensively over numerous full days per week. The programmes can include milieu therapy (see below), developmentally appropriate play and activities, structured interaction, individual and parent counselling, and education services, within a psychologically safe environment that is consistent and predictable.,,,

Milieu therapy is a therapeutically planned approach to a residential or day-care environment that is designed to provide a safe environment in which adults can assist children to address the consequences of maltreatment. Safety, containment, structure, support, involvement and validation are key therapeutic activities. Like therapeutic communities (the terms are sometimes used interchangeably), the aim is to provide a safe, nurturing environment that can engage the 'whole child' in processes of psychological change. Through multiple and repeated experiences that are carefully controlled (safe), children can learn about their behaviour and how to discuss distressing feelings and find alternative ways of expressing these. They can develop their self-esteem, learn to trust others, and learn to negotiate relationships and to acquire problem-solving skills. Milieu therapy draws on a range of theoretical frameworks, including attachment theory and object relations theory. Staff use their understanding of transference and countertransference to identify how a child's feelings and behaviour towards others reflect those with parents, siblings and significant others in their lives, and use this to facilitate change.

Co-ordinated care

Co-ordinated care refers to interventions designed to provide a single point of entry to services, combined with a seamless system of service delivery. It has much in common with initiatives designed to improve interagency working. It is designed to address some of the weaknesses that are inherent in a reliance solely on case management.

Activity-based therapies

Arts therapy

Children who have been maltreated can find it difficult to verbalise their experience, and may feel intimidated by the therapeutic environment and overwhelmed by the verbalisation of abuse experiences. Using a variety of media - such as paint, clay, photos, poems, storytelling or music - arts-based therapies are thought to help facilitate the non-verbal and verbal expression of thoughts, feelings and life narratives. In this way, arts can provide a non-verbal medium for therapeutic communication and cognitive processing for children for whom verbal forms of therapy are not possible. It can help to bridge the gap between the internal world and the limitations of verbal language, particularly in latency age children, and provide a mode of communication for children who are unwilling or unable to talk about what has happened to them.

Play/activity interventions

Play or activity interventions, depending on the age of the target population, are based on the premise that play and activity are vital for healthy development. Play therapy views play as a 'natural medium in which children express themselves' (p. 28). It therefore provides a way to communicate complex ideas that would be otherwise difficult, through verbal means and helps children make sense of their internal and external worlds. Furthermore, deficits in imaginative play have been observed in children who have experienced maltreatment that have been negatively associated with positive affect, peer interaction and problem-solving. Activity-based interventions, such as sports or game based interventions, view activity as an appropriate medium for adolescents because it is more enjoyable than one-to-one office-based therapy, requires the development of social skills and peer relations, has physiological benefits through physical exercise and requires cognitive skills, such as impulse inhibition and planning.

Interventions included under this category are those identified by the author as imaginative play training, challenge/initiative games and the sports-based intervention 'Do the Good'.

Animal therapy

Animal therapy (or animal-assisted therapy) uses animals as part of the therapeutic process. Animals (from dogs through to horses) are used to assist with the therapeutic process and strengthen treatment strategies. They are thought to aid the therapeutic environment through the provision of warmth, acceptance, empathy and unconditional love. Animal therapy is based on research that has found that the presence of animals has improved the communication skills of children participating in therapy, lowered anxiety while undergoing therapy and improved motivation for therapy, as well providing opportunities to teach boundaries and appropriate touch in maltreated populations.

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Cognitive-behavioural therapies: Systemic interventions: Psychoeducation Group work with children Psychotherapy (unspecified) Counselling Peer mentoring Intensive service models: Activity-based therapies Cognitive-behavioural therapies are a group of interventions that draw on a number of theories of learning, both to account for, and address a range of, emotional, psychological and behavioural problems. They have a wide application, ranging from addressing health and mental health problems to more interpersonal and social problems, such as social skills deficits and delinquency.

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this is great resource to help

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Recommending Evidence-based Interventions for Young Children and their Families | The Center of Excellence (CoE) for Infant and Early Childhood Mental Health Consultation (IECMHC)

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this website goes through what kinds of therapy can help

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Psychotherapy for Children and Adolescents: Different Types

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Psychotherapy is a form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family.

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Great resource on how domestic violence effects children

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Many children exposed to violence in the home are also victims of physical abuse.¹ Children who witness domestic violence or are victims of abuse themselves are at serious risk for long-term physical and mental health problems.² Children who witness violence between parents may also be at greater risk of being violent in their future relationships. If you are a parent who is experiencing abuse, it can be difficult to know how to protect your child.

What are the short-term effects of domestic violence or abuse on children?

Children in homes where one parent is abused may feel fearful and anxious. They may always be on guard, wondering when the next violent event will happen.³ This can cause them to react in different ways, depending on their age:

Children in preschool. Young children who witness intimate partner violence may start doing things they used to do when they were younger, such as bed-wetting, thumb-sucking, increased crying, and whining. They may also develop difficulty falling or staying asleep; show signs of terror, such as stuttering or hiding; and show signs of severe separation anxiety.

School-aged children. Children in this age range may feel guilty about the abuse and blame themselves for it. Domestic violence and abuse hurts children's self-esteem. They may not participate in school activities or get good grades, have fewer friends than others, and get into trouble more often. They also may have a lot of headaches and stomachaches.

Teens. Teens who witness abuse may act out in negative ways, such as fighting with family members or skipping school. They may also engage in risky behaviors, such as having unprotected sex and using alcohol or drugs. They may have low self-esteem and have trouble making friends. They may start fights or bully others and are more likely to get in trouble with the law. This type of behavior is more common in teen boys who are abused in childhood than in teen girls. Girls are more likely than boys to be withdrawn and to experience depression.⁴

What are the long-term effects of domestic violence or abuse on children?

More than 15 million children in the United States live in homes in which domestic violence has happened at least once.⁵ These children are at greater risk for repeating the cycle as adults by entering into abusive relationships or becoming abusers themselves. For example, a boy who sees his mother being abused is 10 times more likely to abuse his female partner as an adult. A girl who grows up in a home where her father abuses her mother is more than six times as likely to be sexually abused as a girl who grows up in a non-abusive home.⁶

Children who witness or are victims of emotional, physical, or sexual abuse are at higher risk for health problems as adults. These can include mental health conditions, such as depressionand anxiety. They may also include diabetes, obesity, heart disease, poor self-esteem, and other problems.⁷

Can children recover from witnessing or experiencing domestic violence or abuse?

Each child responds differently to abuse and trauma. Some children are more resilient, and some are more sensitive. How successful a child is at recovering from abuse or trauma depends on several things, including having:⁸

A good support system or good relationships with trusted adults

High self-esteem

Healthy friendships

Although children will probably never forget what they saw or experienced during the abuse, they can learn healthy ways to deal with their emotions and memories as they mature. The sooner a child gets help, the better his or her chances for becoming a mentally and physically healthy adult.

How can I help my children recover after witnessing or experiencing domestic violence?

You can help your children by:

Helping them feel safe. Children who witness or experience domestic violence need to feel safe.⁹ Consider whether leaving the abusive relationship might help your child feel safer. Talk to your child about the importance of healthy relationships.

Talking to them about their fears. Let them know that it's not their fault or your fault. Learn more about how to listen and talk to your child about domestic violence (PDF, 229 KB).

Talking to them about healthy relationships. Help them learn from the abusive experience by talking about what healthy relationships are and are not. This will help them know what is healthy when they start romantic relationships of their own.

Talking to them about boundaries. Let your child know that no one has the right to touch them or make them feel uncomfortable, including family members, teachers, coaches, or other authority figures. Also, explain to your child that he or she doesn't have the right to touch another person's body, and if someone tells them to stop, they should do so right away.

Helping them find a reliable support system. In addition to a parent, this can be a school counselor, a therapist, or another trusted adult who can provide ongoing support. Know that school counselors are required to report domestic violence or abuse if they suspect it.

Getting them professional help. Cognitive behavioral therapy (CBT) is a type of talk therapy or counseling that may work best for children who have experienced violence or abuse.¹⁰ CBT is especially helpful for children who have anxiety or other mental health problems as a result of the trauma.¹¹ During CBT, a therapist will work with your child to turn negative thoughts into more positive ones. The therapist can also help your child learn healthy ways to cope with stress.¹²

Your doctor can recommend a mental health professional who works with children who have been exposed to violence or abuse. Many shelters and domestic violence organizations also have support groups for kids.¹³ These groups can help children by letting them know they are not alone and helping them process their experiences in a nonjudgmental place.¹⁴

Is it better to stay in an abusive relationship rather than raise my children as a single parent?

Children do best in a safe, stable, loving environment, whether that's with one parent or two. You may think that your kids won't be negatively affected by the abuse if they never see it happen. But children can also hear abuse, such as screaming and the sounds of hitting. They can also sense tension and fear. Even if your kids don't see you being abused, they can be negatively affected by the violence they know is happening.

If you decide to leave an abusive relationship, you may be helping your children feel safer and making them less likely to tolerate abuse as they get older.¹⁵ If you decide not to leave, you can still take steps to protect your children and yourself.

How can I make myself and my children safe right now if I'm not ready to leave an abuser?

Your safety and the safety of your children are the biggest priorities. If you are not yet ready or willing to leave an abusive relationship, you can take steps to help yourself and your children now, including:¹⁶

If you are thinking about leaving an abusive relationship, you may want to keep quiet about it in front of your children. Young children may not be able to keep a secret from an adult in their life. Children may say something about your plan to leave without realizing it. If it would be unsafe for an abusive partner to know ahead of time you're planning to leave, talk only to trusted adults about your plan. It's better for you and your children to be physically safe than for your children to know ahead of time that you will be leaving.

Did we answer your question about the effects of domestic violence on children?

For more information about the effects of domestic violence on children, call the OWH Helpline at 1-800-994-9662 or check out the following resources from other organizations:

Sources

1. Modi, M.N., Palmer, S., Armstrong, A. (2014). The Role of Violence Against Women Act in Addressing Intimate Partner Violence: A Public Health Issue. Journal of Women's Health; 23(3): 253-259.

2. Gilbert, L.K., Breiding, M.J., Merrick, M.T., Parks, S.E., Thompson, W.W., Dhingra, S.S., Ford, D.C. (2015). Childhood Adversity and Adult Chronic Disease: An update from ten states and the District of Columbia, 2010. American Journal of Preventive Medicine; 48(3): 345-349.

3. Domestic Violence Roundtable. (n.d.). The Effects of Domestic Violence on Children.

4. Child Welfare Information Gateway. (2014). Domestic Violence and the Child Welfare System. Washington, DC: Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services.

5. McDonald, R., Jouriles, E.N., Ramisetty-Mikler, S., Caetano, R., Green, C.E. (2006). ). Estimating the Number of American Children Living in Partner-Violent Families. Journal of Family Psychology; 20(1): 137-142.

6. Vargas, L. Cataldo, J., Dickson, S. (2005). Domestic Violence and Children. In G.R. Walz & R.K. Yep (Eds.), VISTAS: Compelling Perspectives on Counseling. Alexandria, VA: American Counseling Association; 67-69.

7. Monnat, S.M., Chandler, R.F. (2015), Long Term Physical Health Consequences of Adverse Childhood Experiences. The Sociologist Quarterly; 56(4): 723-752.

8. Child Welfare Information Gateway. (2014). Protective Factors Approaches in Child Welfare. Washington, DC: Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services.

9. National Child Traumatic Stress Network. (n.d.). Interventions for Children Exposed to Domestic Violence: Core Principles.

10. Caffo, E., Belaise, C. (2003). Psychological aspects of traumatic injury in children and adolescents. Child and Adolescent Psychiatric Clinics of North America; 12(3): 493-535.

11. Deblinger, E., Mannarino, A. P., Cohen, J. A., & Steer, R. A. (2006). A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry; 45(12): 1474-84.

12. Kidshealth.org. (2013). Taking Your Child to a Therapist.

13. National Child Traumatic Stress Network. (n.d.). Interventions for Children Exposed to Domestic Violence: Core Principles.

14. Vargas, L., Cataldo, J., Dickson, S. (2005). Domestic Violence and Children. In Walz, G.R., Yep, R.K. (Eds.), VISTAS: Compelling Perspectives on Counseling. Alexandria, VA: American Counseling Association; 67-69.

15. Center for Domestic Peace. (2016). Calling the Police.

16. Loveisrespect.org (n.d.). I Have Children with My Abuser.

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Effects of domestic violence on children | Office on Women's Health

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Many children exposed to violence in the home are also victims of physical abuse.1 Children who witness domestic violence or are victims of abuse themselves

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great videos on domestic violence affecting children

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domestic violence effects on children - Bing

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Intelligent search from Bing makes it easier to quickly find what you're looking for and rewards you.

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great resource about domestic violence affecting children

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For victims of domestic violence -the physical attacks, emotional maltreatment, and other abuse endured are certain to take a toll on well-being.

However, while the horrors of abuse are apparent in primary victims-children who witness the abuse of their mothers, fathers, or other family members, are impacted.

This article will look into the lasting psychological and physical effects of a child's exposure to domestic violence. To reduce the risk of these effects, it is also important to highlight ways that children can be protected from harm's way.

Short-Term Effects of Witnessing Domestic Violence as a Child

As an all-too-common occurrence across the country, domestic violence is an uncomfortable feature of many American homes. An estimated 10 million people are affected by incidents of domestic abuse annually, a number that widens when silent victims, like children, are considered.

In 2010, 1 in 15 children were exposed to cases of intimate partner violence, with a worrying 1 in 3 children also experiencing acts of violence.

The effects of domestic abuse on children may be apparent within a short period of time, while other damages may be noticed in the long run. Some of the immediate effects that children experience after witnessing domestic violence are discussed below.

Children are likely to remain on edge if they are always surrounded by the abuse of one parent by the other. These children will live in bated breath for the next time physical or verbal assault might take place in their home. This can breed a state of perpetual anxiety.

For pre-schoolers who witness this, it isn't uncommon to revert to the habits of younger children. Thumb sucking, bedwetting, increased crying, and whining may result from observing abuse.

School-aged children can develop anti-social traits and may struggle with guilt over the abuse witnessed. These children typically take on the blame for the abuse their parent deals with, a belief that can strongly bruise their self-esteem.

Post-Traumatic Stress Disorder

One of the most devastating effects of domestic violence is its ability to cause post-traumatic stress disorder in children that are raised around it.

Despite being spared from physical abuse, the trauma of domestic violence is enough to cause dangerous changes in the developing brains of children. These changes may cause nightmares, changes in sleep patterns, anger, irritability, difficulty concentrating, and children may sometimes have the ability to re-enact aspects of the traumatizing abuse observed.

Physical Challenges

Mental health strains are a common result of witnessing the abuse of a parent. However, these consequences may sometimes be apparent in their physical well-being.

School-aged children may report headaches and stomach pains which are traceable to the tense situation back home. In infants, there is a higher risk of experiencing physical injury following the constant stream of abuse on a parent.

Aggressive Behavior

When teenagers witness domestic abuse, they tend to act out in reaction to the situation . They may fight, skip school, engage in risky sexual activities, or dabble in drugs and alcohol. These teenagers are also very likely to get in trouble with the law.

Physical Abuse

In many instances, children that live in abusive households are also likely to fall victim to this treatment themselves.

An abusive partner can very easily become an abusive parent or guardian-physically, verbally, and emotionally harming their children.

Long-Term Effects of Witnessing Domestic Violence as a Child

As helpful as distance might be, simply moving away from domestic violence isn't enough to undo the damage caused by witnessing it.

Children that grew up watching a parent experience abuse are likely to deal with effects that last well into adulthood. Some of the long-term effects that children experience after witnessing domestic violence are addressed below.

Depression

The anxious child raised in a toxic, abusive environment may grow to become a depressed adult. The trauma of routinely witnessing domestic violence places children at a high risk of developing depression, sadness, concentration issues, and other symptoms of depression into adulthood.

Health Problems

A poor diet or environmental risks may not always be the primary causes of conditions like heart disease, obesity, and diabetes in adulthood.

In some cases, these illnesses have direct links to the physical, emotional, and verbal abuse a child witnesses or is subjected to.

Repeating Abusive Patterns
While abusive behavior can be repetitive, it's important to note that abuse does not always occur in a cyclical pattern. In fact, assuming that violence occurs in cycles can lead to victim-blaming. Abuse can be unpredictable and is it never OK.
Feeling the pain and anguish of witnessing violence doesn't always guarantee that children will toe a different path. In some cases, early exposure to abuse simply sets the stage for children to walk that same line in adulthood.

In these cases, male children might physically abuse their partners after watching their fathers do the same. Likewise, women from homes that witness domestic violence are more likely to be sexually assaulted by their partners in adulthood.

Protecting Children from Domestic Abuse

Knowing that domestic violence can have lasting effects on the physical, mental, and later life of children-it's important to properly shield them from abuse. The following are ways to protect a child from domestic abuse.

Make Safety a Priority

One of the best ways to protect the interest and well-being of a child is for victims to receive the necessary support they need to leave the abusive environment.

By doing this, children are spared further exposure to violence and are given a chance to grow up within healthier structures.

Teach Children Healthy Relationship Dynamics

With a skewed view about romantic dynamics, talking to children about healthier interactions between partners can help to manage the damage caused after witnessing domestic violence.

Children should be taught healthy ways to resolve disputes in friendships. It's important that they learn wholesome ways that partners can relate with each other, taking care to share why violence has no place in relationships.

Educating Children About Boundaries

An effective way to manage the damage, and prevent a cycle of domestic violence is to teach children healthy boundaries.

Teaching children about autonomy (that no one has a right to touch their bodies or vice-versa) is a step in the right direction. Children should also be taught to always tell a trusted adult if another person is making them uncomfortable in any way.

A Word From Verywell

Domestic violence has the potential to leave lasting marks on direct and indirect victims. With psychological challenges like anxiety and depression likely to develop from domestic violence- receiving appropriate care from a mental health professional can help to manage these effects in children. Therapy can also help with navigating the emotional strain and trauma of living in a toxic environment.

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How Witnessing Domestic Violence Affects Children

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Domestic violence can have many negative mental and physical effects on children. Learn the short and long-term effects of witnessing domestic violence as a child.

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wonderful resource

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How Does Experiencing Domestic Violence Impact Children?

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Domestic violence negatively impacts children at all stages of their development in the key areas of life: physical, mental, behavioral, and relational.

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great resource on long term affects on domestic abuse of children

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The National Child Traumatic Stress Network

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Despite the high occurrence of childhood exposure to IPV, it is important to note that children are inherently resilient and can move forward from stressful events in their lives. One way children heal is by having adults who care about them provide guidance, attention, and support in the aftermath of IPV. While the number of children exposed to IPV remains staggering, services are available to those in need as the issue of childhood exposure to IPV becomes more visible.

Not all children exposed to IPV are affected equally or in the same ways. For many children, exposure to IPV may be traumatic, and their reactions are similar to children's reactions to other traumatic stressors.

Immediate Reactions and Long-term Effects

Children's immediate reactions to IPV may include:

Generalized anxiety

Sleeplessness

Nightmares

Difficulty concentrating

High activity levels

Increased aggression

Increased anxiety about being separated from a parent

Intense worry about their safety or the safety of a parent

Long-term effects, especially from chronic exposure to IPV, may include:

Physical health problems

Behavior problems in adolescence (e.g., delinquency, alcohol or substance abuse)

Emotional difficulties in adulthood (e.g., depression, anxiety, PTSD)

Exposure to IPV has also been linked to poor school performance. Children who grow up with IPV may have impaired ability to concentrate; difficulty completing school work; and lower scores on measures of verbal, motor, and social skills.

In addition to these physical, behavioral, psychological, and cognitive effects, children who have been exposed to IPV often learn destructive lessons about the use of violence and power in relationships. Children may learn that it is acceptable to exert control or relieve stress by using violence, or that violence is in some way linked to expressions of intimacy and affection. These lessons can have a powerful negative effect on children in social situations and relationships throughout childhood and in later life.

As with other trauma types, children's responses to IPV vary with age and developmental stage. In addition, children's responses depend on the severity of the violence, their proximity to the violent events, and the responses of their caregivers.

Reactions by Age Group

The table below shows a brief list of possible reactions or symptoms by age group.

Sleep and/or eating disruptions

Withdrawal/lack of responsiveness

Intense separation anxiety

Inconsolable crying

Developmental regression, loss of acquired skills

Intense anxiety, worries, and/or new fears

Increased aggression and/or impulsive behavior

Nightmares, sleep disruptions

Aggression and difficulty with peer relationships in school

Difficulty with concentration and task completion in school

Withdrawal and/or emotional numbing

School avoidance and/or truancy

Antisocial behavior

School failure

Impulsive and/or reckless behavior, e.g.,

School truancy

Substance abuse

Running away

Involvement in violent or abusive dating relationships

Depression

Anxiety

Withdrawal

It is important to remember that these symptoms can also be associated with other stressors, traumas, or developmental disturbances, and that they should be considered in the context of the child and family's functioning.

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Despite the high occurrence of childhood exposure to IPV, it is important to note that children are inherently resilient and can move forward from stressful events in their lives. One way children heal is by having adults who care about them provide guidance, attention, and support in the aftermath of IPV.

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great resource on long term effects of domestic violence on children and their development

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Long-term Effects of Domestic Violence on Child Development - Child Psychiatry Today

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When a child is exposed to domestic violence, the impact can be long-lasting and severe. Research has shown that witnessing violence in the home can have

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great resource on how to help those who need it. it breaks it down by age

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DVIS: Effects of Domestic Violence on Children

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Infants and Toddlers (0-2 ½ years) Developmental delay Failure to thrive – due to chaotic, loud and harmful environment Emotional withdrawal/low frustration tolerance Physical problems – frequent colds, ear infections, diarrhea Pre-schoolers (3-6 years) Developmental delay – especially in language …

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great resource on a different version of domestic violence, but still pretty close

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Intimate Partner Violence: Life-long Harm in Children

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Intimate partner violence (IPV) is very common and happens across all income levels and relationship types.

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talks about the development of children and how they are affected

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The Impacts of Domestic and Dating Violence on Children - CAWC

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In discussing domestic and dating violence, we often overlook their far-reaching impacts on the most vulnerable people involved: children. Young individuals who may witness or experience violence first hand endure profound consequences that ripple through every aspect of their lives. Highlighting domestic violence effects on children is crucial to understanding the full scope of domestic […]

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great resource on how the domestic violence affects children and development