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Here we can see different kinds of trauma which include: Bullying, community violence, complex trauma, disaster, early childhood trauma, intimate partner violence, medical trauma, physical abuse, race-based trauma, refugee trauma, sexual abuse, sex trafficking, terrorism and violence, and traumatic grief.

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The National Child Traumatic Stress Network

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When a child feels intensely threatened by an event he or she is involved in or witnesses, we call that event a trauma. There is a range of traumatic events or trauma types to which children and adolescents can be exposed.

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This site gives us an overview of what is child trauma, what it looks like, and what causes the child to have trauma.

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Fast Facts

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

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

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

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

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

Preschool Children

Fear being separated from their parent/caregiver

Cry or scream a lot

Eat poorly or lose weight

Have nightmares

Elementary School Children

Become anxious or fearful

Feel guilt or shame

Have a hard time concentrating

Have difficulty sleeping

Middle and High School Children

Feel depressed or alone

Develop eating disorders or self-harming behaviors

Begin abusing alcohol or drugs

Become involved in risky sexual behavior

The Body's Alarm System

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

Healthy Steps Kids Can Take to Respond to the Alarm

Recognize what activates the alarm and how their body reacts

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

Practice deep breathing and other relaxation methods

Impact of Trauma

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

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health and mental health services

Increase involvement with the child welfare and juvenile justice systems

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

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

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

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

Remember To:

Assure the child that he or she is safe.

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

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

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

Visit the following websites for more information:

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

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Within this website we can see what trauma looks like in a child and how we can help them.

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Key points

Children who experience neglect or abuse may grow up feeling emotionally "stuck" at the age in which they experienced trauma.

Many with histories of early trauma are desensitized to narcissistic partners and may find them "comfortable" if it's all they've known.

Red flags of nervous system dysregulation can include technology, social media, or exercise dependency or pathological behavior linked to love.

The U.S. Department of Veteran Affairs reports that approximately 15-43 percent of children and teens have experienced trauma, with estimates that as many as 6 percent of adolescents develop post- traumatic stress disorder ( PTSD). These statistics involve over 5.5 million children with reported cases of neglect or abuse.

Traumatic experiences are stored in our body and our subconscious mind, including attachment wounds that can begin as a result of developmental trauma in our formative years. Children who experience emotional and attachment wounding often become adults who hold onto this pain in their relational patterns, thoughts, feelings, self-beliefs, and choices in romantic partners as products of their early conditioning and attachment trauma.

Many of our earliest experiences are shadowed and highlighted by our parents' and caregivers' own level of self-awareness and where they are in their own healing journey. Caregivers who are attuned to their children's emotional needs are also typically attuned to their own needs. In this vein, emotionally healthy parents equal a shattering of inter- generational trauma.

Yet, as statistics report, many do not grow up with emotionally healthy parents. Children who experience neglect or emotional or physical abuse may grow up living in survival mode, where their inner child has become emotionally "stuck" at the age in which they experienced trauma or chronic trauma. These internalized messages a child receives may be subconsciously processed long before the child can developmentally understand their meaning, leaving the child at risk for emotional wounding.

Our inner child is a product of all of our positive qualities, including our joys, the free-spirited and positive parts of our sense of self, as well as things learned and conditioned that hold painful memories and traumatic experiences. It is during these formative years that we learn to identify our basic needs, including our need for safety, security, consistency, and a sense of belonging with those in our life.

Attachment trauma often shows up in a person's adult romantic relationships as toxic patterns, narcissistic adaptations, trust issues, difficulty with feeling vulnerable, and poor conflict resolution; problems may be avoided, dismissed, minimized, or exaggerated. Other common early wounds can include fears of abandonment or rejection, an unstable sense of self- identity, a harsh inner critic, an inability to be without a romantic relationship, or avoidance of romantic relationships.

Five areas of focus on healing our early emotional wounds include:

These can include drinking enough water throughout the day to ensure that you're hydrated, making healthy choices for snacks and meals, and getting enough exercise and fresh air. If a person was parented in a toxic or violent way, even the most basic needs, like getting enough sleep, may not have happened because of fears of the unknown when going to bed at night. Many kids who were raised in chaos were also raised in survival mode, so something as necessary and basic as getting a healthy amount of quality sleep may not have happened, leaving their body vulnerable for nervous system dysregulation.

Kids who experienced chaos and significant trauma often become adults with dysregulated nervous systems. Many may turn to distractions (like gaming, overusing technology or social media, over-exercising, or even pathological behaviors associated with love) as ways of trying to self-soothe and feel validated. Yet, these patterns of escape and avoidance perpetuate trauma; they don't heal it.

It's important to recognize if we need a break, need time to relax, or are becoming overstimulated. It is also important to recognize our motivations when it comes to our behavior patterns, as these provide clues into things like unmet needs or fears. As we begin reparenting ourselves, we also begin recognizing the messages our nervous system are telling us, so we can tend to our needs.

Safety being compromised is where many experience their first trauma in childhood. What some may not see is how not feeling safe in their childhood can affect their choices in friendships, self-beliefs, and their romantic relationships. For example, some may attract partners who are "exciting" where unpredictable or impulsive get confused as "fun." Or a person may be attracted to partners who are volatile, narcissistic, or unreliable because of their earliest experiences in feeling unseen or unheard. Establishing a safe space means having a safe, predictable, and reliable environment that fosters a sense of stability, trust, and consistency, which also includes the people we choose to bring into our lives.

Many with histories of attachment and developmental trauma have become desensitized to narcissistic behavior. Some may even find it "normal" or "comfortable" because it may be all they've known. Others may have developed survival responses that have left them vulnerable to more narcissistic friendships or romantic relationships. Identifying these patterns is important when doing healing work in order to identify what trauma responses have become "adaptive" (i.e., fight, flight, freeze, or fawn) and how to unlearn these patterns over time.

Reparenting ourselves and healing our early emotional wounds may include learning where boundaries need tightening or creating new boundaries. This may also include learning how to make difficult decisions, such as walking away from a toxic friendship, a "herd mentality," or a romantic relationship that has proven unhealthy. Other tough decisions may include choosing our self over what others think we should do, as well as learning how to say "no" in order to maintain a personal boundary we have set for ourselves.

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Children who experience neglect or abuse may grow up feeling emotionally "stuck" at the age at which they experienced trauma. This could help with the healing.

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This article allows us to gain a definition, of what types of traumatic experiences cause trauma, understand how children respond, and the effects, and gain resilience.

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This allows others to understand what trauma is and what trauma isn't.

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Key points

Relational, complex, and attachment trauma emphasize different aspects of the impact of trauma.

Developmental trauma and developmental trauma disorder are not the same.

Intergenerational trauma is not unavoidable for descendants of traumatized individuals.

From the specific situations that trigger trauma to the mechanisms underlying its effects, there exists a wide range of distinguishable forms of this complex phenomenon. Some authors concentrate on naming the different types of traumatic situations (e.g., betrayal trauma, childhood trauma) while others focus on the wide range of symptoms and syndromes that can unfold as a result (e.g., complex posttraumatic stress disorder [ C-PTSD], developmental trauma disorder [DTD]).

The growing list of "something trauma" now makes it very challenging to understand what each term means. Is "complex trauma" the same as C- PTSD? What exactly does "childhood trauma" encompass?

Consider that even people exposed to traumatic circumstances-even if they share the same living space and conditions-often display clear differences in how they adapted to the circumstances. This happens because, even when external factors appear similar, each of us deals with individualized internal traumatizing agents (like shame, fear, anger, rejection sensitivity, rumination, and social/familial factors) differently, which impact each one of us uniquely. Allow me to review some common myths surrounding different types of trauma to provide clarity on this important distinction:

Childhood trauma should not be equated with simply having had an imperfect or flawed childhood.

Myths About Different Types of Trauma

Myth 1: Developmental trauma is the same as childhood trauma. Developmental trauma (DT) is often mistakenly equated with childhood trauma (CHT), but they represent distinct concepts. DT specifically denotes exposure to prolonged stress or traumatic adversity during the early formative years, which may disrupt a child's cognitive, emotional, social, and/or physical development. This can include experiences such as domestic violence, neglect, abuse, or unstable living environments. In contrast, CHT encompasses a broader range of adverse experiences occurring during childhood, which can have lasting psychological, emotional, and physical effects. These experiences may range from one-time events like a car crash or the death of a pet to chronic stressors that persist throughout childhood, potentially causing developmental delays. It's important not to use CHT to label every aspect of an imperfect childhood. Remember that the exposure alone doesn't constitute trauma unless there are lasting consequences. As you can see in this illustration, DT is a subset of CHT.

Myth 2: Relational trauma, complex trauma, and attachment trauma are synonymous. These three terms refer to distinct experiences, with some overlapping. Relational trauma emphasizes the impact of harmful relationships (romantic, professional, familial, or social) on an individual's well-being at any age. Complex trauma underscores the effects of prolonged exposure to traumatic events at any age, encompassing a range of experiences beyond solely relational. Attachment trauma specifically concerns disruptions in early attachment relationships, occurring at birth and during the first few years of life, with caregivers and their enduring consequences.

Myth 3: Developmental trauma and DTD are the same. Here is a good place to clarify a big mistake most people make: There is a difference between terms that refer to the exposure to traumatic events versus the consequences of that exposure as a lasting set of symptoms. Developmental trauma refers to the exposure to experiences of prolonged stress or traumatic adversity during early formative years, typically encompassing the period from birth to early adulthood. These experiences can disrupt a child's cognitive, emotional, social, and physical development, leading to lasting effects on their well-being.

On the other hand, DTD refers to the consequences. This particular name is a proposed diagnosis in the field of psychiatry. It has been suggested to bring attention to the profound and pervasive impact of developmental trauma on an individual's functioning.

Myth 4: Developmental trauma's damage is irreparable. Trauma leaves its mark, but it does not break us irreparably. The way our system is designed causes us to get wounded when we are not able to emotionally handle some stressors or threats, but, like with a broken bone, our bodies have the remarkable ability to heal and become strong again. Scars from traumatic injuries may not disappear - the way scars also stay in our skin after a physical hurt - but we could see them as a life fully lived and also as proofs of our strength and resilience, not just the struggles we faced. This is where the mind needs to become our healing ally. In the aftermath of trauma, our scars may help us reevaluate priorities and gain a deeper appreciation for life.

Myth 5: Intergenerational trauma is unavoidable for those whose grandparents were traumatized. Intergenerational trauma has gained recognition as a term used to describe the effects of trauma transmitted from one generation to the next, often observed in families where ancestors have faced significant adversity or traumatic circumstances such as genocides, racism, and oppression. While epigenetic studies have shown that the effects of traumatization can reverberate through family systems, it is a misconception to believe that intergenerational trauma is inevitable for all descendants of traumatized individuals. These findings indicate that descendants may be prone to developing symptoms even without extreme exposure, but this does not mean they are destined to develop a disorder or that they cannot heal.

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The Myths About Childhood Trauma and Other Early Experiences

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In exploring different traumatic experiences, it becomes clear developmental trauma and childhood trauma, as well as relational, complex, and attachment trauma, are different.

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This article gives seven ways childhood trauma affects adulthood.

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Power of Positivity: Positive Thinking & Attitude

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The fact that childhood trauma - and the events that cause it - so prolifically exists is a tragedy. The fact that childhood trauma is so misunderstood, even by those responsible for the oversight of our social institutions is also a tragedy; this includes our law enforcement and criminal justice system.

Most people remain ignorant to the fact that childhood trauma, if not addressed, extends beyond childhood. This is also heartbreaking. Hence, the reason for this article. Besides the seven hidden ways that childhood trauma affects you as an adult, we'll go over other critical issues, including:

The state of affairs as it pertains to childhood trauma

What's being done about the increasing numbers of traumatized children and what needs to change.

Finally, we'll wrap things up by discussing how you can help prevent childhood trauma.

What is Childhood Trauma?

"The experience of an event by a child that is emotionally painful or distressful, which often results in lasting mental and physical effects." - The National Institute of Mental Health: definition of childhood trauma ( source)

Childhood trauma occurs when a child experiences or observes negative events during childhood. Due to the impression (e.g. shock) of the event, the child develops psychological trauma.

Interpersonal trauma is that which originates in the child's relationships. Examples of interpersonal trauma include emotional, physical, or sexual abuse; experiencing or witnessing violence within the family or at home, and experiencing or witnessing violence in a community (e.g. civil disturbances, armed conflict, asylum seeker trauma.) A child who is emotionally and/or physically neglected may develop trauma.

Trauma may also stem from a caregiver or parent trauma. Examples of this include:

A parent who is incarcerated

A parent who abuses alcohol or drugs

Parental ill-health

Parental separation (e.g. divorce)

Trauma may also be caused by natural disasters such as earthquakes, floods, or hurricanes; an act of violence (e.g. mass shooting or terrorist attack), and in other life-threatening conditions like a motor vehicle accident.

The 'ACE' Study

"We found a strong ... relationship between ... exposure to abuse or household dysfunction during childhood and multiple risk factors for ... the leading causes of death in adults." - Felitti, V.J., Et. Al ( source)

According to the 'ACE' study, there are ten different types of childhood trauma across two categories: personal and environmental. Trauma of the personal type includes emotional neglect, physical abuse, physical neglect, sexual abuse, and verbal abuse. Environmental trauma relates to family members and includes having an alcoholic parent, living with a mentally ill family member, having a mother that is the victim of domestic abuse, or the absence of a parent following abandonment, death, or divorce.

The Centers for Disease Control and Prevention (CDC) finds that children who experience Adverse Childhood Experiences, or 'ACEs,' are more likely to become future victims or perpetrators of violence. Researchers also found a strong correlation between ACEs and:

Disrupted neurodevelopment

Social, emotional, and cognitive impairment

Adoption of health-risk behaviors

Disease, disability, and social problems

Early death

How Trauma Manifests Into Adulthood

"Our study (suggests) that childhood trauma casts a long and wide-ranging shadow ... (including) important domains of functioning." - Copeland, W.E., Et. al ( source)

As the ACE study demonstrates, psychological trauma experienced during childhood continues to affect the victim. Here are seven of the many "hidden" ways that trauma affects you as an adult:

1. Anxiety and Depression

Studies show that the brain of an adult who experiences trauma during childhood differs from that of an adult who does not. Per a study published in the journal Proceedings of the National Academy of Sciences, the brain images of adults with a history of childhood trauma show "scar of prior trauma ... in functional dysconnectivity." These abnormalities appear to correlate with wide-ranging symptoms of major depressive disorder or MDD.

Other networks of the brain impacted include multiple areas of the resting-state network (RSN), attention and sensory systems, and the default mode network.

2. Substance Abuse

A probable link exists between the stress levels experienced during childhood and those experienced in adulthood. Maltreatment of a child heightens their reactivity to adverse stimuli. Over time, these responses may cause long-term changes in the brain's neural networks. A stress response that is easily triggered makes one susceptible to alcohol and drug dependency, as is seen in adult victims of childhood trauma.

3. Social Difficulties

It stands to reason that victims of childhood trauma. That's because those whose trauma stress from maltreatment like bullying, neglect, or physical abuse, have trouble in their relationships. We see these difficulties in common adult behaviors such as fear of commitment, separation anxiety, and social anxiety. Per a study published in the Journal of Trauma and Dissociation, "... a significant relationship [exists] between [childhood] trauma history [and] all aspects of social functioning."

4. Health Problems

As explained in the ACE study - and repeated again here - adult victims of childhood trauma are probably at a higher risk for multiple health problems. These ailments include cancer, heart disease, obesity, stroke, and others. Additionally, mental health problems include anxiety, depression, post-traumatic stress disorder (PTSD), and suicide.

5. Lost Opportunities

A link exists between victims of childhood trauma and career satisfaction, median income, and education levels. It appears that such adults have trouble with achieving or setting life goals long after their childhood has ended. Possible reasons for this include lack of adult guidance, cognitive underdevelopment, and poor socioeconomic conditions during childhood.

6. Low Self-Esteem

Emotionally neglected children will not receive the self-esteem that they require of their caregivers or parents. As a result of this neglect, the child will grow up with a poor self-image and a skewed sense of self-esteem. If not corrected via psychological intervention, self-care, or some other means, it is probable that the individual will live their entire life with a false sense of self. Tragic, indeed.

7. Lack of Direction

A child who isn't given direction by anyone will probably develop into an aimless adult. In fact, many smart and talented people who "waste" these traits never had a good role model or even a basic knowledge of their world. So how can we expect such poor souls to live to their potential?

Preventing Childhood Trauma and Seeking Help

As adults, we should take it upon ourselves to help children who may be suffering. In this regard, recognizing potential signs of trauma in children and adolescents is a critical part of prevention. Common childhood responses to trauma are classified according to three age groups: five and younger, six to 11, and 12 to 17.

Children at or below five years may:

Be excessively tearful or have crying fits

Cling to caregivers or parents

Complain often of headaches, stomachaches, or other physical symptoms

Display extreme irritability

Return to bed-wetting or thumb-sucking

Throw temper tantrums

Reenact the traumatic event during play

Between six to 11, children may:

Be unable to concentrate

Complain often of headaches, stomachaches, or other physical symptoms

Develop irrational fears (e.g. dying)

Distance themselves from family and friends

Experience sleep problems (e.g. inability to sleep, refusing to go to bed)

Have trouble with school and schoolwork

Lose interest in once-enjoyable activities

Spend a disproportionate amount of time alone

At the ages of 12 to 17, kids may:

Become angry or resentful

Complain often of headaches, stomachaches, or other physical symptoms

Lose empathy for others

Experience sleep problems

Lose interest in activities

Refuse any type of help for any personal problems

Use or misuse of alcohol, drugs, or tobacco

You can take the ACEs assessment for free here. Indeed, this is an outstanding resource for adult victims is the International Society for Traumatic Stress Studies or ISTSS. On the organization's homepage, you can find the following:

Trauma assessment tools

Options for treatment

Education and research

Meetups and events

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7 Hidden Ways Childhood Trauma Affects You As An Adult

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Most people remain ignorant to the fact that childhood trauma, if not addressed, extends beyond childhood. These 7 things often show up in adulthood if let go...

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This gives us a definition of what trauma is and also allows us to see if we had early childhood trauma with a simple quiz.

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Childhood trauma is an event, situation, or environment you experienced as a child that left you feeling vulnerable and like you couldn't count on the world or other people to keep you safe.

For many, childhood trauma has the unfortunate consequence of affecting your ways of thinking and of relating to the world and others as an adult. This can mean you find life at times challenging and difficult in ways that you might not be able to logically explain.
It's important to break any misconceptions that childhood trauma only involves physical danger or harm.
Anything that leaves a child feeling alone, vulnerable, overwhelmed or terrified is traumatic. Psychological trauma occurs not over the 'facts' of 'what really happened', but because of your personal experience and perspective of what happened to you.

Obvious vs hidden forms of childhood trauma

Experiences are traumatic because they are unexpected, unwanted, and you are powerless to stop them.

Obvious trauma that tends to affect all involved including children includes:
But there are other less obvious experiences in childhood can be just as traumatic for a child and have just as serious consequences for the long-term. These can environmental things like:

living in poverty

abruptly changing schools

going through an operation

living with parents who are always fighting

living in a violent or dangerous community

watching a parent being hurt

Or they might be emotional traumas such as:

a humiliating experience at school

being constantly put down and shamed by a parent figure

not getting proper attention from a caregiver

having to take care of a parent

being neglected

being abandoned by someone you love

Sadly, an all too common form of childhood trauma is sexual abuse. And many forms of sexual abuse go overlooked.

It is now understood that any form of inappropriate sexual behaviour can have long-lasting negative affects on a child. Being stripped down as a punishment for being 'bad', for example, or having a parent who makes constant inappropriate comments about your body, can both result in the long-term symptoms of trauma.

But aren't children resilient?

The idea that a child will not be affected by what they do not understand is incorrect. Even if a child does not comprehend the logistics of what is happening, they can understand danger and discord, and this is what causes trauma.

Research suggests that even infants are affected by the trauma around them, such as the suffering of their caregivers.

In fact a child can be more affected by trauma than adults as they can sense danger but not 'explain' it to themselves like an adult, meaning they feel more terrified and vulnerable.

Traumatic experiences also have a stronger impact on children when you take into account that children's brains are still developing and thus more vulnerable than those of adults. Trauma has been found to affect the growth of the brain cortex, which then affects learning, behaviour, and health, including things like memory, attention span, and your capacity to regulate your emotions and handle stress.

Did I suffer childhood trauma? Symptoms to look for

Not everyone reacts to trauma in the same way. Some people remember all details of what happened, many blank everything entirely from their mind and lose all memory of the experience.

Some people develop many symptoms from childhood onwards, and others have no symptoms of trauma but then suddenly, as an adult, something triggers them. This could be a stressful new job, a new relationship, or another life trauma like a bereavement or

In general, signs to look for as an adult that you suffered trauma as a child include but are not limited to:

Related mental health conditions to childhood trauma

If you suffered from childhood trauma, it's common to suffer from anxiety and depression as an adult until you seek help to uncover and process your experience.

Other common mental health problems include addictive behaviour, self-harm, repressed anger or anger management issues, and eating disorders.

Sexual abuse in particular has been connected to the development of borderline personality disorder.

Some people who experienced childhood trauma also exhibit symptoms of Sometimes these symptoms can manifest long after the trauma, although some victims of childhood trauma seem to spend their entire lives with the symptoms of emotional shock.

What do I do if I suspect I have experienced childhood trauma?

First of all, know that it is not your fault at all. What occurred was out of your control and it is unfortunate.

What is within in your control now is your ability to take steps to help yourself. The effects of childhood trauma are not known to magically resolve with time or age, but they do respond positively to focussed attention and support.

Information about recognising and resolving childhood trauma is now readily available on the internet, with forums you can connect with other sufferers on. There are also many books on the topic that can act as a starting point for exploring your experience, or bring a sense of relief to you just to know that you are not alone in your experience.

Be wary of playing the blame game when it comes to childhood trauma. Recognising you experienced a trauma can cause many emotions to rise up, including rage and anger. While it can be tempting to immediately contact family members or others who were involved and lash out, it's advisable to do this after you have processed your feelings around the matter, and are in a stable place to deal with the outcome of such conversations.

This is one of the many reasons that it is highly recommended if you were the victim of a childhood trauma that you seek professional support and help.

A trained counsellor or psychotherapist can help you go back and discover just what occurred, how you contended with the trauma then, and how it is affecting you today. They create a safe space for you to process your feelings and can teach you techniques for processing and letting go of old patterns and emotions so you can finally move forward with your life.
Have you successfully overcome a childhood trauma? Share your story below and inspire others.

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What is childhood trauma and did you experience it?

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Childhood trauma is an event, situation, or environment you experienced as a child that left you feeling vulnerable and like you couldn't count on the world or other people to keep you safe. For many, childhood trauma has the unfortunate consequence of affecting your ways of thinking and of relating to the world and others as an adult.

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Understanding Childhood Trauma and the Signs

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Understanding Childhood Trauma and the Signs

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This article gives us the signs we should look for in childhood trauma. This also talks about the health of one with trauma.

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Childhood trauma involve aversive, distressing experiences that can affect a child's ability to function and cope. Unfortunately, it is all too common. An estimated 46% of children experience trauma at some point in their young lives.

While kids are resilient, they're not made of stone. Adults often say things like, 'They were so young when that happened, they won't even remember it as an adult.' However, it is important to recognize that childhood trauma can have a lifelong effect.

"As children's brains develop, they are learning how safe or unsafe the world is through their experiences," says psychotherapist Yolanda Renteria, LPC. "A child has to develop a way to protect itself from what it deems unsafe; the ways in which a child protects itself shape their adult personality."

Because of this, it's important to recognize when a child may need professional help for dealing with their trauma. Early intervention can also prevent the ongoing effects of the trauma into adulthood.

What Is Childhood Trauma?

Childhood trauma is an event experienced by a child that evokes fear and is commonly violent, dangerous, or life-threatening. Also sometimes referred to as adverse childhood experiences or ACEs, there are many different experiences that can lead to trauma.

Physical or sexual abuse, for example, can be traumatic for children. One-time events like a car accident, natural disaster (like a hurricane), the loss of a loved one, or a major medical incident can take a psychological toll on children as well.

Ongoing stress, such as living in a dangerous neighborhood or being the target of bullying, can also be traumatic for a child-even if it just feels like daily life to an adult.

Childhood trauma doesn't even have to involve experiences that occur directly to the child. Watching a loved one endure a major health issue, for instance, can be extremely traumatic for children. Violent media can have this effect too.

Childhood Trauma and PTSD

As many as 15% of girls and 6% of boys develop post-traumatic stress disorder (PTSD) following a traumatic event. Children with PTSD may re-experience the trauma in their minds over and over again. They might also avoid anything that reminds them of the trauma or re-enact the trauma in their play.

Sometimes children believe that they missed warning signs predicting the traumatic event. In an effort to prevent future traumas, they become hypervigilant in looking for signs that something bad is going to happen again.

Children with PTSD may also:

Act younger than they are (such as by sucking their thumb)

Experience trouble focusing

Feel more depressed or anxious

Find it difficult to be affectionate with others

Have increased anger and aggression

Have issues in school

Have trouble sleeping

Lose interest in activities they once enjoyed

Lose touch with reality

Seem detached, numb, or non-responsive

Worry about dying young

Even children who don't develop PTSD may still exhibit emotional and behavioral issues following a traumatic experience. Here are some things to watch for during the weeks and months after an upsetting event:

Anger issues

Attention problems

Changes in appetite

Development of new fears

Increased concerns about death or safety

Irritability

Loss of interest in normal activities

Problems sleeping

Sadness

School refusal

Somatic complaints like headaches and stomachaches

Impacts of Childhood Trauma

Traumatic events can affect how a child's brain develops, which can have lifelong consequences for them physically, mentally, and socially.

Physical Health Impacts

When a child experiences a traumatic event, it can impair their physical development. The stress can impair the development of their immune and central nervous systems, making it harder to achieve their full potential.

Specifically, it notes that exposure to repeated trauma increases a child's risk of developing:

A 2019 review of 134 different research-based articles adds that exposure to adverse experiences as children increases the risk of developing several different conditions-such as autoimmune diseases, pulmonary disease, cardiovascular disease, and cancer-in adulthood, as well as increasing levels of pain.

Mental Health Impacts

Childhood trauma can also have an impact on mental health. Psychological effects of traumatic experiences can include:

Children exposed to complex traumas may even become disassociated. Dissociation involves separating themselves from the experience mentally. They might imagine that they are outside of their bodies and watching it from somewhere else or they may lose memory of the experience, resulting in memory gaps.

Research published in Psychiatric Times further notes that the prevalence of suicide attempts is significantly higher in adults who experienced traumas such as physical abuse, sexual abuse, and parental domestic violence as a child.

Relationship Impacts

A child's relationship with their caregivers-whether they be parents, grandparents, or other familial or non-familial adults-is vital to their emotional and physical health. The attachment children have with their caregivers can help them learn to trust others, manage emotions, and positively interact with the world around them.

When a child experiences a trauma that teaches them that they cannot trust or rely on that caregiver, they're likely to believe that the world around them is a scary place and people are dangerous. This lesson makes it incredibly difficult to form relationships throughout their childhood and into their adult years.

Children who experience trauma are also likely to struggle with romantic relationships in adulthood. A 2017 study in the Journal of Family Psychology found that spouses with a history of child abuse tend to have less satisfying marriages, even when still in the newlywed phase.

Renteria notes that the lasting effects of trauma often depend on the nature and severity of the event. In some cases, it may lead to feelings of anxiety or avoidance coping that some partners may find frustrating or confusion.

Yolanda Renteria, LPC

She also explains that some common relationship struggles that can stem from such trauma include:

Difficulty trusting

Being physically and verbally distant

Defensiveness

Difficulty being vulnerable

Difficulty giving their partner the benefit of the doubt

Difficulty with communication skills

Difficulty seeing their partner as their ally

Other Impacts

Sometimes the impact of childhood trauma extends beyond physical or mental health and relationships. For instance, some studies have connected adverse childhood experiences with an increased risk of becoming a criminal offender by the age of 35, oftentimes committing offenses that are serious and violent.

Additional impacts can include:

Being easily "set off" and having more intense reactions

Engaging in high-risk behaviors (such as driving at high speeds or unsafe sex)

Inability to plan ahead or prepare for the future

Increased risk of self-harm

Lack of impulse control

Low self-esteem

Trouble problem-solving or reasoning

Children experiencing traumatic events may also have a reduced ability to parent their own kids later in life.

Untreated Childhood Trauma

How to Help Children Who Have Experienced Trauma

Social support can be key to reducing the impact trauma has on a child, even as far as reducing their risk of suicidal ideation. Here are some ways to support a child after an upsetting event:

Encourage the child to talk about their feelings and validate their emotions.

Help them understand that they are not at fault.

Answer their questions honestly.

Reassure the child that you'll do everything you can to keep them safe.

Stick to a daily routine as much as possible.

Be patient as each child recovers at their own pace.

Depending on the child's age and needs, they may be referred for services such as cognitive behavioral therapy, play therapy, or family therapy. In some cases, such as when there is a diagnosis of PTSD, medication may also be an option to help treat their symptoms.

How to Heal From Your Own Childhood Trauma

If you experienced trauma as a child and still have some healing to do, there are several actions you can take to help you better cope. Among them are:

Talking to a mental health professional can also help you start to heal. Therapeutic options may include a number of trauma-informed therapies, such as cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), and acceptance and commitment therapy (ACT), among others.

You may also want to reach out to reputable organizations able to help childhood trauma survivors. The Disaster Distress Helpline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA) is one option. If you prefer to communicate via text, the Crisis Text Line is another.

A Word From Verywell

While it's normal to have some level of distress following a traumatic event, it's not out of the question that children can return to a healthy state of functioning-and some kids are less affected by their circumstances than others.

If childhood trauma has created negative effects, it is never too late to get help. Whether you've adopted a teenager who was abused over a decade ago or you've never received help for the traumatic experiences you endured 40 years ago, trauma treatment can still be effective and beneficial.

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The effects of childhood trauma can be debilitating and last a lifetime without early intervention. Here's how to recognize the signs of trauma and get help.

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This website allows us to understand why children with trauma have difficulty with school.

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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 4 th birth was even blessed with Fetal Alcohol Syndrome. Not fun.

I do, however, want to bring a few things to your attention that I know firsthand about being a kid with a trauma history in the classroom (public, private, or home school). I'm definitely smart enough to shine in the classroom but observing my 10-year-old self, you'd never know it. I was sleepy, cranky, ashamed, distracted, and just wanted to be left alone, preferably outside. I had trouble focusing on my work and following the rules about being quiet. Getting homework done and turned in was really beyond me. I couldn't learn to read music though I loved singing in the choir at my parochial school. For added context, let me point out that there were no more than 12 kids in my class so adequate attention was never an issue. I remember telling the teacher to "just leave me alone" one morning when he called on me to answer a question. I also remember going to a birthday party and sitting with a table full of moms instead of joining my peer group. I felt I was too mature to be silly with them.

Folks, I just didn't feel safe anywhere. School had always been a haven in my earlier years but by 5 th grade, it just wasn't enough to buffer the stress that enveloped me all day due to worry and fear.

I know, I know. The kids you live with aren't in stress anymore, right? Wrong. Many of them continue to worry about their moms. Many of them feel like they've abandoned her after years of taking care of her. Others have never felt safe with ANY adult at home or in school, even you.

I now suspect that the Minister of my parochial school, Carl Gaertner, approached a classmate's mom and asked her to invite me to spend weekends with them. I can't tell you I got close to Mrs. Steltzer; she was not a warm and cozy woman. But she offered me a break from whatever nightmare was going on at home. Her daughter, Mary, and I swam in the creek, walked to the movies and the nearby soda fountain, and generally got to be kids in the world. I can tell you I felt safe in their home.

Look, I share this with you to make a single point: You can over-control, "support", "guide", or "help" your kids to catch up or keep up in school. You can dedicate your entire day to helping them hold their own in the classroom but until they feel safe, they won't develop the skills they need to function without you at their shoulder. So, please, invest as much time and effort in your relationship with them as you have in their education. The sense of safety that comes with that connection with you just frees up what that little brain has to bring to the world.

I've even got some research to back all this up! "According to the National Child Traumatic Stress Network, chronic exposure to traumatic events, especially during a child's early years, can:

Adversely affect attention, memory, and cognition.

Reduce a child's ability to focus, organize, and process information.

Interfere with effective problem solving and planning..."

The executive functions that trauma can compromise:

"Inhibitory control - the capacity to inhibit or regulate strong emotional or impulsive behavioral responses voluntarily;

Cognitive flexibility - the ability to think about multiple concepts simultaneously or to switch quickly between concepts;

Working memory - the ability to hold new information in the mind, process it, and store it as a learned memory."

From http://www.kappanonline.org/barr-trauma-hinders-learning/

You can't be at their shoulder very long any way. They will eventually need to encounter the world on their own. And they need to be away from you to develop those executive function skills anyway.

Their challenges are not a reflection of your efforts. You have to know this deep down inside because the world, the teachers, the coaches, the Sunday School staff, the grocery store clerks, and the passersby will judge you harshly for any misbehavior your kid exhibits, and you have to rise above that. Your connection and the safe space that connection creates is your superpower. Don't let the uninformed world distract you from this reality.

Their education is important but feeling safe will open up their brain to their personal capacity for learning. Don't come in with that bear hug; let the child seek you. Respect how hard this path is; both yours and theirs. Do nice things for yourself. Be with friends. Laugh. Sleep well. Eat healthily. Restore yourself so you can bring what is needed: a calm, regulated, patient, responsive adult. Then you have to help the classroom teacher understand how to connect and restore regulation: Repetitive, rhythmic activities side by side throughout the day but especially before and after transitions.

You got this! But don't set a timer, it can take a while...
NEWS

1. Check out the AZAFAP Event Calendar at https://azafap.gnosishosting.net/Events/Calendar.

2. Our Friday night Happy Hour and Tuesday afternoon Coffee Chat continue. Some find me and a single other participant; others find a conversation among 4 to 12 people. The topics range from the silly to what hobbies have us in their grip to what life has thrown in our path. If you ever find yourself wanting a bit of grown-up conversation, consider joining us (check your email for the unchanging link).

3. The Caring for Caregivers project provides counseling sessions for those who do not have insurance to cover counseling services. Find the information and link at https://www.azafap.org/family-support-services/

4. Parent Mentor Partners: AZAFAP has trained volunteer parents as mentors who are ready to help support foster, kinship, and adoptive parents through one-to-one conversations. Interested? Fill out the form at https://www.azafap.org/family-support-services/

5. I encourage you to check out what Dr. Bruce Perry has to offer. Find his thoughts at https://youtu.be/uOsgDkeH52o?t=3 and at https://www.neurosequential.com .

Thanks for listening. Maintain yourself so you can be there reliably for others.

Cathy ( cathyt@azafap.org)

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Trauma and Learning: Connections and Learning 101

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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 4 th birth was even blessed with Fetal Alcohol Syndrome. Not fun.

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This video shows us how trauma affects our perspective on life. This allows us to have a stronger understanding of what a child may be feeling.

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How Childhood Trauma Distort Your Perception on Life

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This TED talk explains how trauma affects all forms of health.

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

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This gives us a list and ages for the children with the screening tool for trauma.

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The National Child Traumatic Stress Network

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Screening and Assessment Within Multiple Systems

Due to the particular developmental risks associated with young children's traumatic experiences, it is essential that vulnerable children be identified as early as possible after the trauma. Many community resources-including health systems, Early Intervention programs, child welfare agencies, Head Start, child care programs, and early education systems-play an important role in identifying children, and in linking them and their families with services.

Some of these systems now try to address possible traumatic experiences by including questions about specific traumas into their intake and/or assessment protocols. For example, both Head Start and Early Intervention intake protocols include questions about domestic violence in families. Other protocols may include targeted questions about accidents, loss of family members, and/or significant medical history. Most young children are seen at regular intervals by providers in the pediatric health care system, enabling repeated opportunities for identifying early childhood trauma. As such, medical providers can also play an important role in diminishing risks and in maximizing protective factors associated with young children's exposure to trauma. They can supply information to prevent accidents and can incorporate questions about stressful and traumatic experiences into their interviews with families.

Focus of Assessment for Young Children

Assessment of trauma in young children must focus on the presenting problem in the context of the child's overall development. This information can be gathered though interviews with the parents and significant caregivers in the child's life, observation of the parent/caregiver-child interaction, and standardized assessment tools. Clinical assessment should include review of the specifics of the traumatic experience including:

Reactions of the child and parents/caregivers

Changes in the child's behavior

Resources in the environment to stabilize the child and family

Quality of the child's primary attachment relationships

Ability of parents/caregivers to facilitate the child's healthy socioemotional, psychological, and cognitive development

When conducting an assessment of a young child, it is also important to assess developmental delays (e.g., gross/fine motor, speech/language, sensory processing), which may indicate that the child could benefit from evaluation and/or services from another professional (e.g., occupational therapist, speech/language therapist, physical therapist). It is often helpful to consult and to work collaboratively with these professionals.

Instruments for Assessing Traumatic Stress in Young Children

Below is a list of some of the standardized instruments used within the NCTSN to assess traumatic stress in young children.

Child Behavior Checklist (CBCL): Achenbach, and Rescorla (2001). Ages 1½-5

Posttraumatic Stress Disorder Semi-Structured Interview and Observation Record: Scheeringa and Zeanah (1994). Ages 0-4

Posttraumatic Symptom Inventory for Children (PT-SIC): Eisen (1997). Ages 4-8

Preschool Age Psychiatric Assessment (PAPA): Egger and Angold (1999). Ages 2-5

PTSD Symptoms in Preschool Aged Children (PTSD-PAC): Levendosky, Huth-Bocks, Semel, and Shapiro (2002). Ages 3-5

Traumatic Events Screening Inventory-Parent Report Revised (TESI-PRR): Ghosh et al. (2002). Ages 0-6

Trauma Symptom Checklist for Young Children (TSCYC): Briere et al. (2001). Ages 3-12

Violence Exposure Scale for Children-Preschool Version (VEX-PV): Shahinfar, Fox, and Leavitt (2000). Ages 4-10

Violence Exposure Scale for Children-Revised Parent Report (VEX-RPR): Shahinfar, Fox, and Leavitt (2000). For parents of preschool-aged children aged 4-10

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Due to the particular developmental risks associated with young children's traumatic experiences, it is essential that vulnerable children be identified as early as possible after the trauma. Many community resources-including health systems, Early Intervention programs, child welfare agencies, Head Start, child care programs, and early education systems-play an important role in identifying children, and in linking them and their families with services.

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This website gives us the screening tool for a child and an adult.

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Overview

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

Author/Publisher Details

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

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

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

Date

Description

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

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

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

Access

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

Scoring and Interpretation

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

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

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

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

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

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

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

Psychometrics

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

Key/Core References

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

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

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

Manual

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

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

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This gives us an up-to-date screening tool for 2024.

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Assessment

Child and Adolescent Trauma Screen (CATS) - Caregiver Report (Ages 3-6). Child and Adolescent Trauma Screen ... PTSD-Checklist-DSM5-(PCL-5)-Adult-(18+).pdf.

The Recent Traumatic Episode Protocol (R-TEP) - manuals.plus

following a trauma, in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) ... File Info : application/pdf, 30 Pages, 1.45MB.

Screening and Assessment of Child Trauma

Presents resources for professionals on screening and assessing trauma in children and youth. ... (opens in new window) (PDF - 1,334 KB) Wevodau (2016)

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Child trauma screening questionnaire pdf: Fill out & sign online | DocHub

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Edit, sign, and share child and trauma screen pdf online. No need to install software, just go to DocHub, and sign up instantly and for free.

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This website tells us the different ages of the screening tools and when to use them.

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Michigan's Women, Infants & Children program, providing supplemental nutrition, breastfeeding information, and other resources for healthy mothers & babies.

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Ages 1.5- five years old to find behavioral and emotional problems.

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Posttraumatic Symptom Inventory for Children checklist is on this website, it is used for children 4-8 years of age.

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Violence Exposure Scale for Children-Preschool Version

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Violence Exposure Scale for Children-Preschool Version

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This is the checklist for the child aged 4-10 for the children's exposure to violence.

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This is the trauma-informed screening tool that can be used, there are four phases.

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TIO | Trauma Informed Care Screening Tool

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TIO's Trauma Informed Care Screening Tool helps organizations identify their progress in the process of implementing trauma informed care.

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This is the questionnaire for adults to discover their aces in their lives.

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What a quick screening looks like for trauma.

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Conducting a Quick Screen for Trauma - Child Interview

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This explains PTSD and has many different screenings on the website one can do.

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Trauma and Stressor Exposure Measures

Below is an alphabetical list of trauma exposure measures. These assessment instruments measure the types of trauma a person has been exposed to, or the degree of severity of the traumatic event someone experienced. For each measure, a brief description, sample items, versions, and references are provided. Information on how to obtain the measure is also provided.

Measure availability: We provide information on a variety of measures assessing trauma and PTSD. These measures are intended for use by qualified mental health professionals and researchers. Measures authored by National Center staff are available as direct downloads or by request. Measures developed outside of the National Center can be requested via contact information available on the information page for the specific measure.

Other sources of information on measures and how to obtain them include:

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Apply for and manage the VA benefits and services you've earned as a Veteran, Servicemember, or family member-like health care, disability, education, and more.

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This website gives us the different types of interventions.

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The National Child Traumatic Stress Network

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As recognition has grown about the prevalence and impact of trauma on young children, more age-appropriate treatment approaches have been developed and tested for this population. These interventions share many of the same core components.

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Interventions for the Prevention of Post-traumatic Stress Disorder in Adults After Exposure to Psychological Trauma

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Interventions for the Prevention of Post-traumatic Stress Disorder in Adults After Exposure to Psychological Trauma

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This website states how to prevent PTSD.

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Background and Objectives for the Systematic Review

Studies suggest that individuals experience a broad range of traumatic events throughout their lives and that the frequency of these events may vary by the group studied, for example, civilian versus noncivilian samples. The fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR) defines a traumatic event as an event experienced, witnessed, or confronted by a person that involves (a) actual or threatened death, (b) serious injury, or (c) a threat to the physical integrity of self or others. ¹ The DSM-IV-TR diagnosis of PTSD also requires that the person's response to the event involve intense fear, helplessness, or horror. Traumatic events may include military combat, violent personal assault, being taken hostage, a terrorist attack, torture, natural or manmade disasters, and being diagnosed with a life-threatening illness. ¹ The full DSM-IV-TR criteria are listed in Table 1.

Criterion A: Trauma (both)

Traumatic event that involved actual or threatened death, serious injury, or threat to physical integrity

Intense response of fear, helplessness, or horror

Criterion B: Re-experiencing symptoms: (one or more)

Intrusive recollections of events

Recurrent distressing dreams of the event

Acting or feeling as if the traumatic event were recurring

Distress at internal or external reminders of the trauma

Physiological reaction to internal or external reminders

Criterion C: Persistent avoidance and numbing (three or more)

Avoidance of thoughts, feelings, or conversations associated with trauma

Avoidance of activities, places, or people that arouse recollections of trauma

Failure to recall an important aspect of trauma

Loss of interest or participation in significant activities

Detachment from others

Restricted range of affect

Lost sense of the future

Criterion D: Hyperarousal (two or more)

Difficulty falling or staying asleep

Irritability or outburst of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

Criterion E: Duration of disturbance

Duration of disturbance symptoms is more than 1 month

Criterion F: Clinically significant distress or impairment

Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of function

Prevalence of Traumatic Events

Studies conducted in the 1990s attempted to identify and describe the prevalence of traumatic events in nonclinical samples. Resnick et al. ² found that lifetime exposure to any type of traumatic event was 69 percent in a sample of 4,008 adult U.S. women. The National Comorbidity Survey ³ indicated that 60 percent of men and 51 percent of women reported experiencing at least one traumatic event in their lifetimes.

Most of the research has focused on assessing the burden of trauma in different populations. Not surprisingly, studies among groups at risk of occupational exposure to trauma, such as police officers, firefighters, and military service members, have shown high rates of trauma exposure. ⁴ Several studies have examined the prevalence of traumatic events among college students. These studies all showed that exposure to traumatic events was common, with lifetime prevalence ranging from 39 to 84 percent. ⁵⁻⁷

Development of Post-traumatic Stress Disorder and the Rationale for Preventing It With Early Intervention

Many theories focus on the role of disturbances in memory (i.e., problems with memory formation, retrieval, bias, saliency, etc.), and argue that alterations in the normal processes of memory are key to understanding the development and maintenance of PTSD. One of these theories suggests that when trauma-related memories are not properly integrated into memory, individuals may re-experience symptoms of PTSD. ⁸

Intense affect during a traumatic event and its accompanying physiological arousal have been associated with the development of PTSD. 9,10 Dissociation or detachment during the event has also been found to be a significant predictor of PTSD. ⁹ In extreme threat situations, strong affect can result in dissociation and prevent trauma-related information from being fully consolidated within memory. Incomplete memory consolidation may cause an individual to retain a limited amount of information about the event and/or may make the memory less accessible. The ability to access full or complete trauma-related memories is a core feature of several psychological theories of PTSD prevention and/or treatment.

Stress hormones released during exposure to a traumatic event have also been implicated in the development of PTSD. Some studies have shown that elevated levels of cortisol and adrenaline can disrupt the normal formation of memories, while others have found that stress hormones enhance memory consolidation. 11,12

Cognitive theories of PTSD are based on the concept that information associated with a traumatic event is inconsistent with the information contained in an individual's core cognitive schema. An individual exposed to a traumatic event tries to make sense of the experience but has difficulty fully integrating it into his/her existing schema. Over time, this disintegration manifests itself in the symptoms and behaviors classified as PTSD. Maladaptive beliefs related to the traumatic event have also been identified as a risk factor for the development of PTSD. ¹³

The implications of these various theories provide a rationale for a myriad of early intervention strategies, but they are only one part of the puzzle. Variability of types of trauma, contexts in which they occur, and individual differences of those exposed to traumatic events are likely to prohibit a one-size-fits-all model for preventive intervention.

Potential Preventive Interventions

Potential preventive interventions span a variety of psychological and pharmacological domains. These interventions have been used both separately and in combination with one another.

Psychological Interventions

Specific psychological interventions that have been studied for the prevention of adult PTSD are described below and include the following: psychological debriefing interventions, including critical incident stress debriefing (CISD) and critical incident stress management (CISM); psychological first aid (PFA); trauma-focused cognitive-behavioral therapy (CBT); cognitive restructuring therapy; cognitive processing therapy; exposure-based therapies; coping skills therapy (including stress inoculation therapy); psychoeducation; normalization; and eye movement desensitization and reprocessing (EMDR). These therapies are designed to prevent the onset of PTSD and development of trauma-related stress symptoms soon after exposure to a traumatic event.

Psychological Debriefing, Critical Incident Stress Debriefing, and Critical Incident Stress Management

Psychological debriefing interventions aim to educate victims about normal reactions to trauma and to encourage them to share their experiences and emotional responses to the event. Debriefing is typically offered in a single session within hours or days after the event to everyone exposed to the event. Although several variations of these single-session interventions have been tested, the most common form of psychological debriefing is CISD. ¹⁴

CISD is a secondary prevention intervention originally developed for use with individuals indirectly exposed to traumatic events because of their occupation, such as firefighters or emergency medical personnel. CISD is administered in a single 3- to 4-hour session by a team composed of individuals familiar with the organization (e.g., officers within a police department) and mental health professionals. 15,16 In addition to helping normalize the responses of individuals to stress and encouraging them to talk about their experiences and reactions, the team teaches coping skills and offers additional resources for those who may need it. ¹⁷ By design, the CISD approach is flexible and loosely structured. CISD was not designed to prevent PTSD; nonetheless, it has been applied directly to victims of trauma despite evidence that it may be ineffective for that purpose and actually may have harmful effects. ¹⁸⁻²⁰ A 2002 update of a previous 1997 Cochrane review assessed the effectiveness of brief, single-session psychological debriefing for the management of psychological distress after trauma and the prevention of PTSD. ²¹

CISD has expanded to become CISM, a multicomponent, comprehensive crisis intervention program that aims to reduce the severity of, and related impairment associated with, traumatic stress. ¹⁸ CISM incorporates additional methods such as pre-incident training for people with high-risk occupations, one-on-one individual crisis support, demobilizing (i.e., information about coping and stress to large groups of emergency workers as they rotate off duty), and defusing (small-group interventions during which participants are asked to explore and discuss the incident and their emotional reactions to it). ¹⁵ CISM also has a family support component whereby family members of the emergency personnel are debriefed. Lastly, there are additional procedures for referring people for psychological services. ¹⁸

PFA is a systematic set of helping actions aimed at reducing initial post-trauma distress and supporting short- and long-term adaptive functioning. PFA is designed as an initial component of a comprehensive disaster/trauma response, and it is constructed around eight core actions: (1) contact and engagement, (2) safety and comfort, (3) stabilization, (4) information gathering, (5) practical assistance, (6) connection with social supports, (7) information on coping support, and (8) linkage with collaborative services. ²² PFA is concept driven and its application requires assessment and clinical judgment by the provider given the complexity of presentations, variability of context, need, and logistical constraints. PFA is intended for use by disaster mental health responders, counselors, and others who may provide immediate support for trauma survivors. Two major advantages of PFA are that it is highly portable and designed for delivery anywhere recent trauma survivors can be found-such as shelters, schools, hospitals, homes, staging areas, feeding locations, family assistance centers, and other community settings. The principles of PFA can also be applied immediately after a traumatic event in nondisaster field settings, including hospital trauma centers, rape crisis centers, and war zones. ²³

CBT uses principles of learning and conditioning to treat disorders and includes components from both behavioral and cognitive therapy. In trauma-focused CBT, components such as exposure, cognitive restructuring, and various coping skills have been used either alone or in combination with one another. Most forms of trauma-focused CBT are brief and involve weekly sessions lasting 60 to 90 minutes, although the number of sessions varies across studies. CBT can be administered either as group or individual therapy. ²⁴⁻²⁶

Exposure-based therapy involves confrontation with frightening stimuli and is continued until anxiety is reduced. The exposure is based on mental imagery from memory or introduced in scenes presented by the therapist (imaginal exposure). In some cases, exposure is from the actual scene or similar events in life (in vivo exposure). The aim is to extinguish the conditioned emotional response to traumatic stimuli (for the subject to learn that nothing "bad" will happen during traumatic events), which eventually reduces or eliminates avoidance of feared situations and the affect associated with it. Exposure therapy is typically conducted for 8 to 12 weekly or biweekly sessions lasting 60 to 90 minutes. 24,25,27

Cognitive restructuring is based on the theory that the interpretation of the event, rather than the event itself, determines an individual's mood. It aims to facilitate relearning thoughts and beliefs generated from a traumatic event and increase awareness of dysfunctional trauma-related thoughts and correct or replace those thoughts with more adaptive and/or rational cognitions. Cognitive restructuring generally takes place over 8 to 12 sessions of 60 to 90 minutes. 24,25

Coping skills therapy may include components such as stress inoculation therapy, assertiveness training, biofeedback (including brainwave neurofeedback), or relaxation training. All may use techniques such as education, muscle relaxation training, breathing retraining, role playing, et cetera, to manage anxiety or correct misunderstandings conditioned at the time of trauma. The therapy is designed to increase coping skills for current situations. Most types of coping skills therapies require at least eight 60- to 90-minute sessions, while more comprehensive interventions such as stress inoculation therapy require 10 to 14 sessions. 24, 25

EMDR combines imaginal exposure with the concurrent induction of saccadic eye movements that are believed to help reprogram brain function so that emotional impact of trauma can be resolved. In the EMDR process, the client is instructed to imagine a traumatic memory, engage in negative cognition, and then articulate an incompatible positive cognition (e.g., personal worth). The clinician asks the client to contemplate memory while focusing on rapid movement of the clinicians' fingers. After 10 to 12 eye movements (back and forth), the clinician asks the client to rate the strength of the memory and his or her belief in the positive cognition. Although earlier versions of EMDR consisted of 1 to 3 sessions, current standards consist of 8 to 12 weekly sessions of 90 minutes each. 24, 28

Pharmacological Interventions

Various neurobiological pathways have been implicated in the development of PTSD. Accordingly, pharmacotherapy has been tried as a preventive intervention for PTSD. Several drugs have been studied for PTSD prevention including propranolol, morphine, glucocorticoids, and selective serotonin-reuptake inhibitors (SSRIs). 11,26

Propranolol

A significant body of research suggests that PTSD is associated with hyper-reactivity of the sympathetic nervous system, specifically the noradrenergic system. Studies have repeatedly shown that heart rates are elevated in the peritraumatic event period among persons exposed to trauma who develop PTSD, that stress-induced norepinephrine levels are higher among persons with PTSD, and that corticotrophin-releasing factor, which stimulates release of norepinephrine, is elevated among people with PTSD. ²⁹

Propranolol, a beta-adrenergic antagonist that crosses the blood-brain barrier, has been evaluated in several studies for its ability to prevent PTSD. ³⁰⁻³² So far results have failed to show any clear benefit of propranolol, when compared with placebo, in reducing physiological reactivity during traumatic imagery, severity of PTSD symptoms, or the rate of the PTSD diagnostic outcome. In addition, significant controversy exists about the use of propranolol for PTSD prevention because of its ability to attenuate the emotional response and memory of a traumatic event. Studies have shown that propranolol not only decreases emotional memory but also episodic memory for the traumatic event. ³³ This effect leads to various ethical concerns, considering that the long-term implications of emotional and episodic memories are not yet well understood.

Morphine

The opiate analgesic, morphine, has shown promise in preventing PTSD in persons experiencing physical injury from a traumatic event. In 155 adults hospitalized after traumatic injury, those prescribed higher doses of morphine had lower incidence of PTSD at 3-month followup. ³⁴ In 696 combat-injured U.S. military personnel serving in Iraq, the use of morphine during early trauma care was associated with significantly lower risk of a subsequent PTSD diagnosis. ³⁵ These studies highlight and support the importance of pain control in physically injured persons, but the potential role of opiates in prevention of PTSD after severe psychological trauma in the absence of painful physical injury remains unclear.

Cortisol

A substantial body of research has suggested that alterations in the hypothalamic-pituitary-adrenal (HPA) axis are associated with PTSD. Much of the research suggests increased sensitivity of the HPA negative feedback loop between the release of corticotropin-releasing factor (CRF) from the hypothalamus and release of cortisol from the adrenal cortex, resulting in high levels of CRF and low levels of cortisol among people with PTSD. ²⁹ This has led to the hypothesis that exogenous administration of cortisol shortly after trauma may prevent PTSD by preventing development of HPA axis dysregulation.

Several naturalistic studies have found that patients who were administered glucocorticoids either during or immediately after the trauma were significantly less likely to develop PTSD than those who were not. 36,37 These studies were conducted naturalistically in settings where multiple variables, including the administration of other medications and treatment procedures, could not be controlled.

Selective Serotonin-Reuptake Inhibitors

SSRI antidepressants are currently the drugs most widely used to treat PTSD. SSRIs have been shown to be modestly effective for civilian trauma-related PTSD, but no more effective than placebo for PTSD in military veterans. 38,39 As with beta-blockers such as propranolol, SSRIs may diminish the more severe clinical sequelae after a stress exposure, possibly through nonspecific effects on other monoamines, through neuroprotective effects in the brain, or through increases in neurotrophic factors that can block the down-regulation of brain-derived neurotrophic factors. ⁴⁰

Table 2 provides a summary of the medications studied for the prevention or treatment of PTSD.

Selective serotonin-reuptake inhibitors

citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline

Serotonin and norepinephrine reuptake inhibitors

duloxetine, desvenlafaxine, and venlafaxine

Other second-generation antidepressants

bupropion, mirtazapine, nefazodone, and trazodone

Tricyclic antidepressants

imipramine, amitriptyline, and desipramine

Monoamine oxidase inhibitors

phenelzine, isocarboxazid, selegiline, and tranylcypromine

Alpha-blockers

prazosin

Beta-blockers

propranolol

Benzodiazepines

alprazolam, diazepam, lorazepam, and clonazepam

Anticonvulsants

topiramate, tiagabine, lamotrigine, carbamazepine, divalproex, and gabapentin

Nonbenzodiazepine sedatives/hypnotics

zolpidem, eszopiclone, rozerem, and zaleplon

Second-generation (atypical) antipsychotics

olanzapine and risperidone

Narcotic medication

morphine

Steroids

hydrocortisone

Opioid antagonists

naltrexone

Emerging Interventions

In addition to traditional psychological and pharmacological interventions, there is a growing variety of emerging interventions and approaches derived from complementary and alternative medicine (CAM). Among these are dietary supplements, yoga, and guided imagery. ⁴¹ The use of CAM practices to prevent PTSD is novel, and as a result, their efficacy remains unclear.

Prevention Intervention Outcomes

One of the primary outcomes in the PTSD-prevention intervention literature is lack of trauma-related symptom development, which includes both clinician-rated and self-reported measures. In addition, we will consider other health outcomes such as symptom reduction; prevention/reduction of comorbid medical or psychiatric conditions (e.g., depressive symptoms, anxiety symptoms); improved quality of life; or ability to return to work or return to active duty. If we cannot find data on a particular health outcome of interest, we will include surrogate outcomes if evidence of a causal relationship between surrogate and health outcomes is available.

Summary of Existing Guidance

A recent review assessed the evidence base for existing guidelines for PTSD from seven respected organizations in the United States, Australia, and Europe. ⁴² These organizations include the American Psychiatric Association (APA), the U.S. Department of Veterans Affairs/Department of Defense (VA/DOD), the National Institute of Clinical Excellence (NICE), the National Health and Medical Research Council (NHMRC), the International Society for Traumatic Stress Studies (ISTSS), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Institute of Medicine (IOM). The review investigated whether each of the guidelines was based on existing evidence and concluded that the empirical data were insufficient to support many of the guidelines and recommendations put forth by these organizations.

Nonetheless, the clinical practice guidelines named above provide very similar recommendations regarding prevention of PTSD. Five of the seven sets of guidelines (VA/DOD, APA, NICE, NHMRC, ISTSS for adults, and ISTSS for children and adolescents) address early preventive interventions for populations exposed to trauma. They each warn against the use of psychological debriefing interventions to prevent the onset of PTSD, and four sets (APA, NICE, NHMRC, and ISTSS for adults) describe alternative approaches. ⁴² The NICE guidelines suggest offering "practical social and emotional support" to trauma survivors; whereas, the NHMRC guidelines suggest provision of psychological first aid based on expert consensus and the ISTSS guidelines support "practical, pragmatic psychological support and information." 42, p. 548 The APA guidelines state that the use of early supportive interventions, psychoeducation, and case management may be helpful for acutely traumatized individuals because they "promote engagement in ongoing care and may facilitate entry into evidence-based psychotherapeutic and psychopharmacological treatments [II]." 43, p. 13 In addition, the APA guidelines report that there is only minimal evidence that early supportive care alone can lead to long-term reductions in PTSD symptoms in populations of patients exposed to multiple recurrent traumas. On the other hand, there is no evidence of harms due to early supportive care.

Rationale and Objective of the Review

Psychological trauma is common and leads to PTSD in a substantial number of individuals exposed to trauma. Prevention of PTSD, therefore, has the potential to reduce a significant burden of individual and societal suffering. Unlike most psychiatric disorders, the precipitating cause of PTSD, psychological trauma, is an identifiable event that has a known time and place of onset. Therefore, the people at risk of developing PTSD (i.e., those exposed to trauma) can be identified, and preventive interventions can be offered to them shortly after exposure.

Despite evidence that some early interventions are not effective in preventing PTSD, or might even cause harm, they are still widely used. Such use indicates that uncertainty and controversy still exist within the field about providing an intervention that intuitively seems like it should help, and also that not enough consideration is given to scientific evidence when weighing intervention benefits and harms.

The objective of this review is to systematically evaluate the evidence on the general and comparative effectiveness and risk of harms of early interventions to prevent PTSD in people who have experienced psychological trauma. The report will also take into account the unique nature of different types of trauma and moderators affecting the impact of traumatic exposure. We will develop an analytic framework that will help conceptualize interventions to prevent PTSD.

This evidence review will be part of a collection of reports produced by the Agency for Healthcare Research and Quality (AHRQ) for a three-part series focusing on the treatment of PTSD in populations exposed to trauma. These reports will critically assess the comparative effectiveness of selected interventions aimed at treating symptoms of PTSD in adults and children and of interventions to prevent the development of PTSD in adults exposed to psychological trauma.

Note: This protocol includes revisions to the Key Questions (KQs) suggested by our Key Informants and revisions to the PICOTS (specifically the minimum sample size of 100 for prospective cohort studies, the addition of monoamine oxidase inhibitors and nonbenzodiazepine sedatives/hypnotics to the list of pharmacological interventions, and changing the name of the pharmacological interventions table) suggested by members of our Technical Expert Panel (TEP) and the project team. We posted the draft KQs for public comment on January 4, 2012. We received one comment on January 8, but it applied to another AHRQ-supported report in progress that addresses the psychological and pharmacological treatments for adults with PTSD.

Key Questions

KQ 1: For adults exposed to psychological trauma, what is the absolute effectiveness or comparative effectiveness of early interventions to prevent PTSD or to improve health outcomes?

KQ 2: For adults exposed to psychological trauma, does timing, intensity, or dosage of intervention have an impact on the effectiveness or harms of approaches to prevent PTSD or to improve health outcomes?

KQ 3: For adults exposed to psychological trauma, how does efficacy, effectiveness, or harms of early interventions to prevent PTSD differ for characteristics of traumatic exposure or subpopulations with respect to:

Demographic groups (defined by age, ethnic and racial groups, and sex);

Psychiatric comorbidities; or

Personal risk factors for developing PTSD (e.g., having a diagnosis of acute stress disorder vs. not having the diagnosis)?

KQ 4: For adults exposed to psychological trauma, what are the absolute risks or comparative risks of harms from early interventions to prevent PTSD?

PICOTS Criteria

The population, interventions, comparators, outcome measures, timing, and setting (PICOTS) criteria for the preceding KQs are:

Population(s):

Adults exposed to psychological trauma (to include interpersonal or domestic violence/abuse, sexual abuse/assault/rape, combat/military-related trauma, crime-related events, terrorism, natural disasters, injury, life-threatening illness or medical procedures, witnessing a traumatic event, being a refugee, and asylum seeking) at risk of developing PTSD.

Subgroups of interest include:

Demographic groups (defined by age, ethnic and racial groups, and sex)

Populations with psychiatric comorbidities

Populations with different personal risks of developing PTSD

Interventions

Psychological interventions including:

Trauma-focused CBT

Cognitive restructuring and cognitive processing therapy

Exposure-based therapies

Coping skills therapy (including stress inoculation therapy)

Psychological first aid

Psychoeducation

Normalization

EMDR

Psychological debriefing

CISD

CISM

Pharmacological interventions including:

SSRIs: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline

Serotonin-norepinephrine reuptake inhibitors (SNRIs: duloxetine, desvenlafaxine, and venlafaxine)

Other second-generation antidepressants (bupropion, mirtazapine, nefazodone, and trazodone)

Tricyclic antidepressants (imipramine, amitriptyline, and desipramine)

Monoamine oxidase inhibitors (phenelzine, isocarboxazid, selegiline, and tranylcypromine)

Alpha-blockers (prazosin)

Beta-blockers (propranolol)

Benzodiazepines (alprazolam, diazepam, lorazepam, clonazepam, and temazepam)

Anticonvulsants/mood stabilizers (topiramate, tiagabine, lamotrigine, carbamazepine, divalproex, and gabapentin)

Nonbenzodiazepine sedative/hypnotics (zolpidem, eszopiclone, rozerem, and zaleplon)

Atypical antipsychotics (olanzapine and risperidone)

Narcotic medication (morphine)

Steroids (hydrocortisone)

Opioid antagonists (naltrexone)

Emerging interventions
CAM (e.g., dietary supplements, yoga, guided imagery)

Comparators

Psychological treatments (listed above) with one another

Pharmacological treatments (listed above) with one another

Psychological treatments with pharmacological treatments (listed above)

Pharmacological treatments with placebo

Psychological treatments with waiting list assignment, usual care, or no intervention

Outcomes

Final outcomesa

Incidence of PTSD

Incidence and severity of symptoms: assessor-rated or self-rated symptoms (e.g., sleep disturbance, anxiety)

Incidence and severity of comorbid conditions (e.g., depression, anxiety disorders, substance use, abuse, or dependence)

Quality of interpersonal or social functioning

Quality of life

Return to work or duty, or ability to work

Incidence of self-injurious or suicidal thoughts, attempts, or behaviors (including suicide)

Incidence of aggressive or homicidal thoughts, attempts, or behaviors (including homicide)

Resilience

Perceived utility

Adverse effects of intervention(s)

Adverse effects (e.g., worsening of anxiety or agitation, increased distress, headaches, gastrointestinal effects, effects on blood pressure, heart rate, sexual side effects, sedation or insomnia, treatment-associated hypomania or mania, medication dependence or misuse)

Dropout rate (overall dropout rate, dropout because of adverse effects, dropout because of lack of efficacy)

Timing

Intervention must be administered any time ranging from immediately to 3 months after exposure to a traumatic event

No limit for duration of followup

Setting

a At least one PTSD-related outcome has to be addressed for a study to be eligible.

Analytic Framework

Figure 1 depicts the analytic framework for the comparative effectiveness of psychological and pharmacological interventions to prevent PTSD in adults. The KQs are displayed within the context of the population, intervention, comparator, outcome, timing, and setting described in the previous section. Beginning with a population of adults exposed to one or more traumatic events, the figure illustrates the absolute and comparative effects of early preventive interventions on incidence of PTSD or health outcomes, including incidence and severity of trauma-related symptoms, incidence and severity of comorbid conditions, quality of life, quality of interpersonal or social functioning, ability to return to work or military duty, incidence of self-injuries, suicidal thoughts, attempts, and behaviors, and incidence of aggressive or homicidal thoughts, attempts, and behaviors (KQ 1). Timing of an intervention as a potential mediator of these interventions is explored in KQ 2. Type of traumatic exposure and characteristics of subgroups as potential moderators of these interventions are explored in KQ 3. Subgroups within the overall population will be identified based on age, sex, race, and ethnicity, psychiatric comorbidities, and personal risk of PTSD.

KQ 4 addresses the absolute and comparative risks of harms and adverse events from these interventions.

Abbreviations: KQ = key question; PTSD = post-traumatic stress disorder

Methods

A. Criteria for Inclusion/Exclusion of Studies in the Review.

Table 3 presents the inclusion/exclusion criteria for this review. We do not repeat all of the PICOTS information related to the inclusion/exclusion criteria; Table 3 supplements the information outlined above in the PICOTS.

a Due to limited time and resources, we will only include studies published in English.

Abbreviations: KQ = key question; PICOTS = populations, interventions, comparators, outcomes, timing, and setting; PTSD = post-traumatic stress disorder; TEP = Technical Expert Panel.

Publication language

English

All other languages a

Admissible evidence (study design and other criteria)

Original research
For KQs 1-4, eligible study designs include:

Randomized controlled trials.

Prospective controlled cohort studies

For KQs 2-4 when outcomes of interest are focused on harms, additional eligible study designs are:

Retrospective controlled cohort studies

Case control studies

Case series

Case reports

Systematic reviews and meta-analyses

Nonsystematic reviews

Editorials

Letters to the editor

Studies rated high risk of bias during quality assessment

Studies with historical, rather than concurrent, control groups

Pre-post studies without a separate control group

B. Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies To Answer the Key Questions

We will systematically search, review, and analyze the scientific evidence for each KQ. We will take the following steps to perform the literature search.

1. To identify articles relevant to each KQ, we will begin with a focused MEDLINE® search using a variety of terms, medical subject headings (MeSH®), and major headings and limiting the search to English-language and human-only studies. Relevant terms are listed in Table 4. We will also search the Cochrane Library, the Cochrane Central Trials Registry, the Published International Literature on Traumatic Stress database, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®) database, PsycINFO®, the International Pharmaceutical Abstracts database, EMBASE®, and Web of Science® by using analogous search terms. We will conduct quality checks to ensure that known studies (i.e., studies included in the previous review on treatment of adult PTSD and those identified during topic nomination and refinement) are identified by the search. If they are not, we will revise and rerun our searches.

2. We will search the literature published in 1980 and later. We selected this 1980 search date based on the introduction/definition of PTSD as a clinical entity and based on the earliest publication date of relevant studies found in previous systematic reviews and expert opinion about when the earliest literature on this topic was published.

3. We will search the "gray literature" for unpublished studies relevant to this review and will include studies that meet all the inclusion criteria and contain enough methodological information to assess internal validity/quality. Sources of gray literature include ClinicalTrials.gov, the U.S. Food and Drug Administration Web site, and dossiers prepared by pharmaceutical companies for pharmacotherapies of interest. AHRQ's Scientific Resource Center will manage the process of submitting requests for scientific information packets, which contain information about pharmacotherapies of interest from relevant drug manufacturers.

4. We will review our search strategy with the Technical Expert Panel (TEP) and supplement it as needed according to their recommendations. In addition, to attempt to avoid retrieval bias, we will manually search the reference lists of landmark studies and background articles on this topic to look for any relevant citations that electronic searches might have missed.

5. We will also conduct an updated literature search (of the same databases searched initially) concurrent with the peer review process. We will investigate any literature the peer reviewers or the public suggest and, if appropriate, will incorporate them into the final review. Appropriateness will be determined by the same methods described above.

Population

"Traumatizing"[tiab] OR "Traumatising"[tiab] OR "Trauma"[tiab] OR "Traumatic"[tiab] OR "Traumas"[tiab] OR "Traumatization"[tiab] OR "Traumatisation"[tiab] OR "Traumatized"[tiab] OR "Traumatised"[tiab] OR "peritraumatic"[tiab] OR "Stress Disorders, Traumatic"[Mesh] OR "PTSD"[tiab] OR "post-traumatic stress disorders"[tiab] OR "post-traumatic stress disorder"[tiab] OR "posttraumatic stress disorders"[tiab] OR "posttraumatic stress disorder"[tiab] OR "Social Problems/psychology"[Mesh] OR "Life Change Events"[Mesh] OR "Stress, Psychological"[Mesh] OR "Wounds and Injuries/psychology"[Mesh] OR "Disasters"[Mesh] OR "survival/psychology"[Mesh]

Interventions

Psychological intervention terms:
"Psychotherapy"[Mesh] OR "Complementary Therapies"[Mesh] OR "Therapeutics/psychology"[Mesh] OR "Adaptation, Psychological"[Mesh] OR "Mental Health Services"[Mesh]OR "prevention and control" [Subheading] OR "prevention"[tiab] OR "prevent"[tiab] OR "preventive"[tiab] OR "preventative"[tiab] OR "early intervention"[tiab] OR "Emergency Treatment/psychology"[Mesh] OR "Crisis Intervention"[Mesh] OR "Resilience, Psychological"[Mesh] OR "Preventive Health Services"[MeSH] OR "Preventive Medicine"[Mesh] OR "immediate treatment"[tiab]Pharmacologic intervention terms:
"Anesthetics, Dissociative"[Pharmacological Action] OR "Opiate Alkaloids"[Mesh] OR "Benzodiazepines"[MeSH] OR "Tranquilizing Agents"[Pharmacological Action] OR "Antipsychotic Agents"[Pharmacological Action] OR "Adrenergic Agents"[Pharmacological Action] OR "Anticonvulsants"[Pharmacological Action] OR "Monoamine Oxidase Inhibitors"[Pharmacological Action] OR "Antidepressive Agents"[Pharmacological Action] OR "Psychotropic Drugs"[Mesh]

C. Data Abstraction and Data Management

Two trained research team members will independently review all titles and abstracts identified through searches for eligibility against our inclusion/exclusion criteria. Studies marked for possible inclusion by either reviewer will undergo a full-text review. For studies without adequate information to determine inclusion or exclusion, we will retrieve the full text and then make the determination. All results will be tracked in an EndNote® bibliographic database (Thomson Reuters, New York, NY).

We will retrieve and review the full text of all titles included during the title/abstract review phase. Two trained team members will independently review each full-text article for inclusion or exclusion based on the eligibility criteria described above. If both reviewers agree that a study does not meet the eligibility criteria, the study will be excluded. If the reviewers disagree, conflicts will be resolved by discussion and consensus or by consulting a third member of the review team. As described above, all results will be tracked in an EndNote database. We will record the reason why each excluded publication did not satisfy the eligibility criteria so that we can later compile a comprehensive list of such studies.

For studies that meet our inclusion criteria, we will abstract important information into evidence tables. We will design data abstraction forms to gather pertinent information from each article, including characteristics of study populations, settings, interventions, comparators, study designs, methods, and results. Trained reviewers will extract the relevant data from each included article into the evidence tables. A second member of the team will review all data abstractions for completeness and accuracy.

D. Assessment of the Risk of Bias of Individual Studies

To assess the risk of bias (internal validity) of studies, we will use predefined criteria based on guidance provided by AHRQ44 and the University of York Centre for Reviews and Dissemination. ⁴⁵ In general terms, results of a study with low risk of bias are considered to be valid. A study with medium risk of bias is susceptible to some bias but probably not sufficient enough to invalidate its results. A study with high risk of bias has significant methodological flaws (e.g., stemming from serious errors in design or analysis) that may invalidate its results. We will consider the risk of bias for each relevant outcome of a study.

Two independent reviewers will assess the risk of bias for each study. Disagreements between the two reviewers will be resolved by discussion and consensus or by consulting a third member of the team. We will rate studies that meet all criteria as having "low risk of bias." "Medium risk of bias" ratings will be given to studies that presumably fulfill all quality criteria but do not report their methods sufficiently to answer all of our questions. We will give a "high risk of bias" rating to studies that have a fatal flaw (defined as a methodological shortcoming that leads to a very high risk of bias) in one or more categories and will exclude them from our analyses.

E. Data Synthesis

If we find three or more similar studies for a comparison of interest, we will consider quantitative analysis (i.e., meta-analysis) of the data from those studies. We will also consider conducting mixed treatment comparisons meta-analysis using Bayesian methods to compare the pharmacological interventions with each other if we identify a sufficient number of studies with a common comparator (e.g., placebo). For all analyses, we will use random-effects models to estimate pooled or comparative effects. To determine whether quantitative analyses are appropriate, we will assess the clinical and methodological heterogeneity of the studies under consideration following established guidance. ⁴⁶ We will do this by qualitatively assessing the PICOTS of the included studies, looking for similarities and differences. If we conduct quantitative syntheses (i.e., meta-analyses), we will assess statistical heterogeneity in effects between studies by calculating the chi-squared statistic and the I ² statistic (the proportion of variation in study estimates due to heterogeneity). The importance of the observed value of I ² depends on the magnitude and direction of effects and on the strength of evidence for heterogeneity (e.g., p-value from the chi-squared test, or a confidence interval for I ²). If we include any meta-analyses with considerable statistical heterogeneity in this report, we will provide an explanation for doing so, considering the magnitude and direction of effects. We will also examine potential sources of heterogeneity by using sensitivity analysis or subgroup analyses. We plan to stratify analyses and/or perform subgroup analyses when possible and appropriate to examine clinical heterogeneity. Planned stratifications or categories for subgroup analyses include the subgroups listed in the analytic framework and geographic location of studies. When quantitative analyses are not appropriate (e.g., due to heterogeneity, insufficient numbers of similar studies, or insufficiency or variation in outcome reporting), we will synthesize the data qualitatively.

F. Grading the Evidence for Each Key Question

We will grade the strength of evidence based on the guidance established for the Evidence-based Practice Center Program. ⁴⁷ Developed to grade the overall strength of a body of evidence, this approach incorporates four key domains: risk of bias (includes study design and aggregate quality), consistency, directness, and precision of the evidence. It also considers other optional domains that may be relevant for some scenarios, such as a dose-response association, plausible confounding that would decrease the observed effect, strength of association (magnitude of effect), and publication bias.

Table 5 describes the grades of evidence that can be assigned. Grades reflect the strength of the body of evidence to answer KQs on the comparative effectiveness, efficacy, and harms of the interventions included in this review. Two reviewers will assess each domain for each key outcome, and differences will be resolved by consensus. We will grade the strength of evidence for the outcomes deemed to be of greatest importance to decisionmakers and those most commonly reported in the literature. We expect these to include PTSD symptom reduction, quality of life, disability/functional impairment, and adverse events.

High

High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.

Moderate

Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of the effect and may change the estimate.

Low

Low confidence that the evidence reflects the true effect. Further research is likely to change our confidence in the estimate of the effect and is likely to change the estimate.

Insufficient

Evidence either is unavailable or does not permit estimation of an effect.

G. Assessing Applicability

We will assess applicability of the evidence following guidance from the Methods Guide for Effectiveness and Comparative Effectiveness Reviews. ⁴⁴ We will use the PICOTS framework to explore factors that affect applicability. Some factors identified a priori that may limit the applicability of evidence include the following: age of enrolled populations; sex of enrolled populations (e.g., few women may be enrolled in the studies); race/ethnicity of enrolled populations; few studies enrolling subjects with exposure to certain types of trauma; or few studies distinguishing/reporting the type of traumatic exposure for a heterogeneous population.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.; 2000.

2. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 1993 Dec;61(6):984-91. PMID: 8113499.

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48. Substance Abuse and Mental Health Services Administration Web site. Resilience and Stress Management Resource Collection. Version 1.0. Resilience. Available at www.samhsa.gov/dtac/dbhis/dbhis_stress/resilience.htm. Accessed January 31, 2012.

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Definition of Terms

Absolute effectiveness: the effectiveness of an intervention relative to a nonactive control group, that is, either assigned to a waitlist group or receiving a placebo intervention

Absolute risk of harms: an intervention's risk of harms relative to a nonactive control group, that is, either assigned to a waitlist group or receiving a placebo intervention

Intensity: the length and number of treatment sessions for a psychological intervention; the equivalent of dosage for pharmacological interventions

Perceived utility: the extent to which recipients of an intervention subjectively find value in and/or express satisfaction with the intervention

Resilience: the ability to cope with adversity, such as traumatic exposures, and adapt to challenges or change ⁴⁸

Summary of Protocol Amendments

The original description of EMDR was outdated.

The last paragraph of Section Psychological Debriefing, CISD, and CISM has been revised as follows:

EMDR combines imaginal exposure with the concurrent induction of saccadic eye movements that are believed to help reprogram brain function so that emotional impact of trauma can be resolved. In EMDR, the patient is asked to hold the distressing image in mind, along with the associated negative cognition and bodily sensations, while engaging in saccadic eye movements. After approximately 20 seconds, the therapist asks the patient to "blank it out," take a deep breath, and note any changes occurring in the image, sensations, thoughts or emotions. The process is repeated until desensitization has occurred (i.e., patient reports little or no distress on Subjective Units of Distress Scales), at which time the patient is asked to hold in mind a previously identified positive cognition, while engaging in saccadic eye movements, and rating the validity of this cognition while going through the procedure as outlined above. The saccadic eye movements were initially theorized to both interfere with working memory and elicit an orienting response, which lower emotional arousal so that the trauma can be resolved. The eye movements, or other alternative parallel stimulation, have since been found in dismantling studies to be unnecessary in achieving desensitization. Although earlier versions of EMDR consisted of 1 to 3 sessions, current standards consist of 8 to 12 90-minute weekly sessions.24, 28

Investigators conducting a concurrent CER of treatments for adult PTSD used the same original description of EMDR in their project protocol and received suggestions during their public comment period to update its description. Following this guidance, the EMDR description is revised for this project's protocol to be consistent with concurrent CER of treatments for adult PTSD.

One of the drug classes listed in the description of PICOTS was "anticonvulsants/mood stabilizers".

The drug class is now listed as
"anticonvulsants".

One member of our Technical Expert Panel suggested removing "mood stabilizers" from the title of this drug class.

Review of KQs

For all EPC reviews, KQs are reviewed and refined as needed by the EPC with input from Key Informants and the TEP to assure that the questions are specific and explicit about what information is being reviewed. In addition, for Comparative Effectiveness Reviews, the KQs are posted for public comment and finalized by the EPC after review of the comments.

Key Informants

Key Informants are the end-users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Within the EPC program, the Key Informant role is to provide input into identifying the KQs for research that will inform health care decisions. The EPC solicits input from Key Informants when developing questions for systematic review or when identifying high-priority research gaps and needed new research. Key Informants are not involved in analyzing the evidence or writing the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Key Informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals are invited to serve as Key Informants, and those who present with potential conflicts may be retained. The Task Order Officer (TOO) and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Technical Experts

Technical Experts comprise a multidisciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes as well as identifying particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, study questions, design, and/or methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts provide information to the EPC to identify literature search strategies and recommend approaches to specific issues as requested by the EPC. Technical Experts do not perform analysis of any kind nor contribute to the writing of the report, and they have not reviewed the report, except as given the opportunity to do so through the public review mechanism.

Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts, and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Peer Reviewers

Peer Reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. Peer review comments on the preliminary draft of the report are considered by the EPC in preparation of the final draft of the report. Peer Reviewers do not participate in writing or editing of the final report or other products. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual Reviewers. The dispositions of the peer review comments are documented and will, for Comparative Effectiveness Reviews and Technical Briefs, be published 3 months after the publication of the Evidence report.

Potential Reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. Peer Reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.

Evidence-based Practice Center Team Disclosures

With the exception of the following, the team had no interests to disclosure:

Lead Clinical Investigator's Statement of Disclosure of Business and Professional Interest:
Member, Binge Eating Disorder Association Scientific Advisory Board

Co-Investigator A's Statement of Disclosure of Business and Professional Interest:
Editorial Board for Medscape Psychiatry and Mental Health, a continuing medical education organization

Role of the Funder

This project was funded under Contract No. 290-2007-10056-I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The TOO reviewed contract deliverables for adherence to contract requirements, including the objectivity and independence of the research process and the methodological quality of the report. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Appendix A. Post-traumatic stress disorder outcome measures

DSM = Diagnostic and Statistical Manual of Mental Disorders ¹

Clinician-Administered PTSD Scale (CAPS) 24, 49

Gold standard for post-traumatic stress disorder (PTSD) assessment and diagnosis for military and civilian trauma survivors.

30-item structured interview that corresponds to the DSM-IV criteria for PTSD.

Can be used to make a current or lifetime diagnosis of PTSD or to assess symptoms over the past week.

In addition to PTSD symptoms, CAPS assesses the impact of symptoms on social and occupational functioning, improvement in symptoms since a previous CAPS administration, overall response validity, overall PTSD severity, and frequency and intensity of five associated symptoms (guilt over acts, survivor guilt, gaps in awareness, depersonalization, and derealization).

Can be used to make a current or lifetime diagnosis of PTSD or to assess symptoms over the past week.

Administered in 45- to 60-minutes by trained (para)professionals.

Clinician-Administered PTSD Scale Part 2 (CAPS-2) ⁴⁹

Assesses 1-week symptom status.

Davidson Trauma Scale (DTS) 50, 51

17-item self-rating scale used to assess DSM-IV PTSD criteria (B-D).

Each item corresponds to a DSM-IV symptom of PTSD, and each symptom is rated in terms of frequency and severity.

Can be used to screen clients at initial evaluation, evaluate psychopathology in trauma victims, assess the effectiveness of treatment, and predict treatment success.

Scale covers the following types of trauma: accident, combat, sexual, criminal assault, natural disaster, torture, burns, loss of property, near-death experiences, and bereavement.

Administered in approximately 10 minutes.

Diagnostic Interview Schedule (DIS) ²⁴

Assesses DSM III-R/IV symptomatology and can be used for PTSD diagnosis.

Semistructured interview.

Requires patient to associate each symptom with a specific traumatic event.

Administered in 15 minutes by trained lay interviewers.

Impact of Events Scale (IES) ⁵²

15-item self-reported measure used to assess the frequency with which experiences of "intrusions," "avoidance," and emotional numbing related to stressful events occurred in the last week.

A total distress score is calculated by summing all 15 item responses.

Impact of Events Scale-Revised (IES-R) ⁵³

22-item self-report measure that assesses subjective distress caused by traumatic events.

Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD.

Los Angeles Symptom Checklist (LASC) ²⁴

43-item self-report measure used to assess PTSD symptoms and associated features, including signs of distress and functional problems.

Minnesota Multiphasic Personality Inventory (MMPI), Keane PTSD Scale ²⁴

Self-report questionnaire.

Originally composed of 29 items, revised for MMPI-2 by deleting three repetitious items.

46 MMPI items.

Norms available for different populations.

Mississippi Scale for Combat-related PTSD (M-PTSD) ²⁴

35-item self-report questionnaire used to assess DSM-III combat-related PTSD and related features (depression, suicidality, and substance abuse).

Administered in 10 to 15 minutes.

Modified PTSD Symptom Scale (MPSS-SR) ⁵⁴

17-item self-report measure that assesses the 17 DSM-III-R symptoms of PTSD.

This scale is a modification of the PTSD Symptom Scale.

The major modifications are that the items are not keyed to any particular traumatic event and that the MPSS-SR includes severity ratings in addition to the original measure's frequency ratings for each item.

It can be used to make a preliminary determination of the diagnosis of PTSD using DSM-III-R criteria or frequency, severity, or total score cutoff scores.

It can be scored as a continuous measure of PTSD symptom severity.

Penn Inventory for Posttraumatic Stress Disorder 24,55

26-item self-report questionnaire primarily used with male patients, including accident victims, veterans, and general psychiatric patients.

It does not assess all of the 17 DSM symptoms of PTSD and includes items that are not directly related to DSM criteria (e.g., self-knowledge).

Posttraumatic Diagnostic Scale (PTDS) ²⁴

17 questions, including a 12-item checklist of traumatic events used to assess DSM-IV PTSD criteria.

Assesses frequency of PTSD symptoms in the past month and self-ratings of impairment across nine areas of functioning.

Has been validated across several populations, including combat veterans and sexual and nonsexual assault survivors.

PTSD Checklist (PCL) ⁵⁶

17-item self-report measure of the 17 DSM-IV symptoms of PTSD.

The PCL has been used to screen individuals for PTSD, diagnose PTSD, and monitor symptom change during and after treatment.

There are three versions of the PCL: PCL-M (military), PCL-C (civilian), and PCL-S (specific).

Administered in 5 to 10 minutes.

PTSD Interview
(PTSD-I) 24,57

Structured clinical interview.

Patients given a copy of scale to read along with interviewer and asked to give subjective ratings for each symptom.

Administered by trained subprofessionals.

PTSD Symptom Scale-Interview (PSS-I) ⁵⁸

17-item semistructured interview that assesses the presence and severity of DSM-IV PTSD symptoms related to a single identified traumatic event in individuals with a known trauma history.

Each item is assessed with a single brief question.

Interviewees are asked about symptoms they have experienced in the past 2 weeks.

Administered in approximately 20 minutes.

PTSD Symptom Scale- Self-report Version (PSS-SR) ⁵⁹

17-item scale used to diagnose PTSD according to DSM-III-R criteria .

Assesses the severity of PTSD symptoms (consists of the same 17 items as the PSS-I).

Structured Interview for PTSD (SI-PTSD or SIP) ⁶⁰

Assesses the 17 PTSD symptoms, as well as survival and behavioral guilt.

For each item, the interviewer assigns a severity rating that reflects both frequency and intensity.

Item responses can be used to make a determination about whether a client's symptoms meet DSM criteria B, C, and D for PTSD.

Administered in 20 to 30 minutes.

Structured Clinical Interview (SCID) PTSD Module 24, 61

Semistructured interview used to assess the prevalence, absence, and subthreshold presence of PTSD across trauma populations.

It consists of separate modules corresponding to categories of diagnoses.

Administered in 25 minutes.

Symptom Checklist-90-Revised (SCL-90-R)24

90-item self-report questionnaire used to assess a broad range of psychological problems, symptoms of psychopathology, patient progress, and treatment outcomes.

Administered in 12 to 15 minutes.

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Interventions for the Prevention of Post-traumatic Stress Disorder in Adults After Exposure to Psychological Trauma

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Background and Objectives for the Systematic Review Studies suggest that individuals experience a broad range of traumatic events throughout their lives and that the frequency of these events may vary by the group studied, for example, civilian versus noncivilian samples.

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Kind of Traumas and What Intervention Best Fits

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Kind of Traumas and What Intervention Best Fits

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This article gives us details on different interventions and what is best for that kind of trauma.

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This website gives us different interventions but also the most popular kinds of interventions.

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

Trauma-Informed Approach

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

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

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

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

4. Seeks to actively resist re-traumatization."

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

Six Key Principles of a Trauma-Informed Approach

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

1. Safety

2. Trustworthiness and Transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice and choice

6. Cultural, Historical, and Gender Issues

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

Trauma-Specific Interventions

Trauma-specific intervention programs generally recognize the following:

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

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

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

Known Trauma-Specific Interventions

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

Addiction and Trauma Recovery Integration Model (ATRIUM)

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

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

Learn more about ATRIUM and Dusty Miller.

Essence of Being Real

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

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

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

Risking Connection

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

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

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

For more information, visit Risking Connection.

Sanctuary Model

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

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

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

For more information, visit The Sanctuary Model.

Seeking Safety

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

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

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

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

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

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

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

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

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

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

Read more about the TARGET model.

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

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

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

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

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

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This PDf gives us all the services one can get with trauma.

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This website shows the interventions for all ages.

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Child and Family Traumatic Stress Intervention (CFTSI)

Ages 7-18.

A four- to six-session secondary prevention approach for children and their families who have been exposed to violence and other traumatic events.

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

Ages 10+.

Educational and therapeutic approach for the prevention and treatment of post-traumatic stress disorders (PTSD).

Seeking Safety

Ages 12-17.

Present-focused counseling model to help people attain safety from trauma and/or substance abuse. It directly addresses both trauma and addiction, but without requiring clients to delve into the trauma narrative (the detailed account of disturbing trauma memories), thus making it relevant to a very broad range of clients and easy to implement. Any clinician can conduct it even without training as it is an extremely safe model; however, there are also many options for training.

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

Ages 18-55.

Group intervention for men and women that addresses a broad range of trauma symptoms and severe mental disorders and/or substance abuse problems.

Trauma Focused CBT (TF-CBT)

Ages 3-17.

Psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems.

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Trauma Specific Interventions 13 thru 21

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Child and Family Traumatic Stress Intervention (CFTSI) Ages 7-18. A four- to six-session secondary prevention approach for children and their families who have been exposed to violence and other traumatic events. Trauma Affect Regulation: Guide for Education and Therapy (TARGET) Ages 10+. Educational and therapeutic approach for the prevention and treatment of post-traumatic stress disorders (PTSD).

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This gives an overview, the benefits, and a formal definition.

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This gives us the history of trauma-specific interventions in addition to its benefits.

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Hae-Ra Han,

Hailey N. Miller,

Manka Nkimbeng,

Chakra Budhathoki,

Tanya Mikhael,

Emerald Rivers,

Ja'Lynn Gray,

Kristen Trimble,

Sotera Chow,

Patty Wilson

Subject Areas

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Abstract

Background

Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.

Methods

We performed database searches- PubMed, Embase, CINAHL, SCOPUS and PsycINFO-to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.

Results

More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).

Conclusions

There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Citation: Han H-R, Miller HN, Nkimbeng M, Budhathoki C, Mikhael T, Rivers E, et al. (2021) Trauma informed interventions: A systematic review. PLoS ONE 16(6): e0252747. https://doi.org/10.1371/journal.pone.0252747

Editor: Vedat Sar, Koc University School of Medicine, TURKEY

Received: July 1, 2020; Accepted: May 23, 2021; Published: June 22, 2021

Copyright: © 2021 Han et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: This is a systematic review. All relevant data were extracted from the published studies included in the review.

Funding: This study was supported, in part, by a grant from the Johns Hopkins Provost Discovery Award (HRH). Additional funding was received from the National Center for Advancing Translational Sciences (UL1TR003098, HRH), National Institute of Nursing Research (P30NR018093, HRH; T32NR012704, HM), National Institute on Aging (R01AG062649, HRH; F31AG057166, MN), Robert Wood Johnson Foundation Health Policy Research Scholar program (MN), and Substance Abuse and Mental Health Services Administration (5T06SM060559‐ 07, PW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.

Competing interests: The authors have declared that no competing interests exist.

Background

Despite the United States' commitment to health equity, health inequities remain a pressing concern among some of the nation's marginalized populations, such as racial/ethnic or gender minority populations. For example, according to the 2016 National Health and Nutrition Examination Survey (NHANES), 29.1% of Mexican Americans and 24.3% of African Americans with diabetes had hemoglobin A1C greater than 9% (the gold standard of glucose control with levels ≤ 7% deemed adequate), compared to 11% in non-Hispanic whites [ 1]. The 2016 survey also revealed that 40.9% and 41.5% of Mexican Americans and African Americans with hypertension, respectively, had their blood pressure under control, compared to 51.7% in non-Hispanic whites. In 2014, 83% of all new diagnoses of HIV infection in the United States occurred among gay, bisexual, and other men who have sex with men, with African American men having the highest rates [ 2].

Several factors have been discussed as root causes of health inequities. For example, Farmer et al. [ 3] noted structural violence-the disadvantage and suffering that stems from the creation and perpetuation of structures, policies and institutional practices that are innately unjust-as a major determinant of health inequities. According to Farmer et al., because systemic exclusion and disadvantage are built into everyday social patterns and institutional processes, structural violence creates the conditions which sustain the proliferation of health and social inequities. For example, a recent analysis [ 4] using a sample including 4,515 National Health and Nutrition Examination Survey participants between 35 and 64 years of age revealed that black men and women had fewer years of education, were less likely to have health insurance, and had higher allostatic load (i.e., accumulation of physiological perturbations as a result of repeated or chronic stressors such as daily racial discrimination) compared to white men (2.5 vs 2.1, p<.01) and women (2.6 vs 1.9, p<.01). In the analysis, allostatic load burden was associated with higher cardiovascular and diabetes-related mortality among blacks, independent of socioeconomic status and health behaviors.

Browne et al. [ 5] identified essential elements of promoting health equity in marginalized populations such as trauma-informed and culturally competent care. In particular, trauma-informed care is increasingly getting closer attention and has been studied in a variety of contexts such as addiction treatment [ 6- 8] and inpatient psychiatric care [ 9]. While there is a growing body of the literature on trauma-informed care, no prior review has systematically addressed trauma-informed interventions; one published review of literature [ 10] limited its scope to trauma survivors in physical healthcare settings. As such, the purpose of this paper is to conduct a systematic review and synthesize evidence on trauma-informed interventions.

For the purpose of this paper, we defined trauma as physical and psychological experiences that are distressing, emotionally painful, and stressful and can result from "an event, series of events, or set of circumstances" such as a natural disaster, physical or sexual abuse, or chronic adversity (e.g., discrimination, racism, oppression, poverty) [ 11, 12]. We aim to: 1) describe the types, setting, scope, and delivery of trauma informed interventions and 2) evaluate the study findings on outcomes in association with trauma informed interventions in order to identify gaps and areas for future research.

Methods

Five electronic databases-PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS and PsycINFO-were searched from the inception of the databases to identify relevant quantitative studies published in English. The initial literature search was conducted in January 2018 and updated in June 2019 using the same search strategy.

Review design

We conducted a systematic review of quantitative evidence to evaluate the effects of trauma informed interventions. Due to heterogeneity relative to study outcomes, designs, and statistical analyses approaches among the included studies, we qualitatively synthesized the study findings. Three trained research assistants extracted study data. Specifically, we used the PICO framework to extract and organize key study information. The PICO framework offers a structure to address the following questions for study evidence [ 13]: Patient problem or population (i.e., patient characteristics or condition); Intervention (type of intervention tested or implemented); Comparison or control (comparison treatment or control condition, if any), and Outcome (effects resulting from the intervention).

Eligibility

Inclusion criteria.

Articles were screened for their relevance to the purpose of the review. Articles were included in this review if the study was: about trauma informed approach (i.e., an approach to address the needs of people who have experienced trauma) or an aspect of this approach, published in English language and involved participants who were 18 years and older. Also, only quantitative studies conducted within a primary care or community setting were included.

Exclusion criteria.

Exclusion criteria were: studies in or with military populations, refugee or war-related trauma populations, studies with mental health experts and clinicians as research subjects or studies of incarcerated and inpatient populations. Conference abstracts that had limited information on study characteristics were also excluded.

Search strategy and selection of studies

Search strategy.

Following consultation with a health science librarian, peer-reviewed articles were searched in PubMed, Embase, CINAHL, SCOPUS and PsycINFO using MeSH and Boolean search techniques. Search terms included: "trauma focused" OR "trauma-focused" OR "trauma informed" OR "trauma-informed." We also searched for the term trauma within three words of informed or focus ((trauma W/3 informed) OR (trauma W/3 focused), or (traumaN3 (focused OR informed)). Detailed search terms for each database are provided in Appendix 1.

Study selection.

The initial electronic search yielded 7,760 references and the follow-up search yielded 5,207 which were all imported into the Covidence software for screening [ 14]. Screening of the references was conducted by 2 independent reviewers and disagreements were resolved through consensus. There were 4,103 duplicates removed from the imported articles and 8,864 studies were forwarded to the title and abstract screening stage. Eight thousand five hundred and twenty-one studies were excluded because they were irrelevant. Three hundred and forty-three abstracts were identified to be read fully. Following this, 311 articles were excluded for focusing on other psychological conditions (n = 120), were non-experimental studies (n = 78) and were in inpatient or incarcerated populations (n = 46). One additional companion article was identified during full text review. Therefore, thirty-three articles met the inclusion criteria and are reported in this review. Fig 1 provides details of the selection process and identifies the reasons why articles were excluded at each stage.

Quality assessment

We used the Joanna Briggs Institute quality appraisal tools [ 15] for randomized controlled trials (RCTs), quasi-experimental studies, and retrospective studies to assess the rigor of each study included in this review. The Joanna Briggs Institute quality appraisal tools [ 15] include items asking about methodological elements that are critical to the rigor of each type of study designs. In particular, one of the items for RCTs addresses participant blinding to treatment assignment. Due to the nature of trauma-informed interventions included in our review, it was decided that participant blinding is not relevant and hence was removed from the appraisal list for RCTs. No studies were excluded on the basis of the quality assessment. The quality assessment process was conducted independently by two raters. Inter-rater agreement rates ranged from 56% to 100% with the resulting statistic indicating substantial agreement (average inter-rater agreement rate = 77%). Discrepancies between raters were resolved via inter-rater discussion.

Results

Characteristics of trauma-informed interventions

Type of intervention.

Setting, scope, and delivery of intervention.

Effects of trauma-informed interventions

A select number of the studies found associations between trauma-informed interventions and other psychological outcomes such as attachment anxiety, attachment avoidance, psychiatric symptoms or dental distress. For example, the trauma-informed mindfulness-based reduction program implemented by Kelly and colleagues was associated with a greater decrease in anxious attachment, measured by the Relationship Structures Questionnaire, compared to the waitlist group [ 17]. Similarly, Masin-Moyer and colleagues found that TREM and an attachment-informed TREM (ATREM) were associated with significant reductions in group attachment anxiety, group attachment avoidance, and psychological distress in women with a history of interpersonal trauma [ 47]. Additionally, individuals in an outpatient substance abuse treatment program, consisting of psychoeducational seminars and trauma-informed addiction treatment, experienced significantly better outcomes of psychiatric severity, measured by the Global Appraisal of Individual Needs scale, compared to a control treatment group [ 19]. Doering and colleagues found that EMDR, compared to the control group, was associated with significantly greater improvement in dental stress, anxiety and fear in patients with dental-phobia [ 28].

There was a series of interpersonal, emotional and behavioral outcomes assessed in the included studies. For example, adult females that were sexually abused in childhood experienced a significant improvement in social interaction and social adjustment after receiving trauma focused group therapy [ 43]. Similarly, Dalton and colleagues found that couples that received emotion focused therapy experienced a significant reduction in relationship distress [ 23] and MacIntosh and colleagues found that individuals that received CBT reported lower interpersonal problems post-treatment [ 46]. Trauma-based interventions were also associated with emotional outcomes. Visual schema displacement therapy and EMDR both were superior to the control treatment in reducing emotional disturbance and vividness of negative memories [ 30]. In a separate study, CBT was found to reduce levels of emotional dysregulation in individuals that experienced childhood sexual abuse [ 46]. Lastly, trauma-informed interventions were associated with behavioral outcomes, including HIV risk reduction [ 26], decreased days of alcohol use [ 27], and improvements in avoidance of client condom negotiations, frequency of sex trade under influence of drugs or alcohol, and use of intimate partner violence support [ 40]. Interventions that were associated with these behavioral outcomes included trauma focused and present focused group therapy [ 26], CBT [ 27], and a trauma-informed support, validation, and safety-promotion dialogue intervention [ 40].

Publication bias

We analyzed three sets of outcome variables for publication bias: PTSD, depression, and anxiety. Based on Begg and Mazumdar test, there was no evidence of publication bias for PTSD (z = 1.55, p = 0.121) and anxiety (z = 0.29, p = 0.769). However, there was some evidence of publication bias for depression (z = 5.19, p<.001). The statistically significant publication bias for depression appears to be mainly due to large effect sizes in Nixon [ 24] and Bowland [ 35].

Discussion

Review limitations

Several limitations of this review should be noted. First, by using narrowly defined search terms, it is possible that we did not extract all relevant articles in the existing literature. However, to avoid this, we conducted a systematic electronic search using a comprehensive list of MeSH terms, as well as similar keywords, with consultation from an experienced health science librarian. Additionally, we hand searched our reference collections, Second, the trauma informed interventions included in this review were implemented to predominantly address trauma related to sexual or physical abuse among women. Thus, our findings may not be applicable to trauma related to other types of incidence such as chronic adversity (e.g., racism or discrimination). Likewise, there were insufficient studies addressing a wider range of trauma impacts such as emotion regulation, dissociation, revictimization, non-suicidal self-injury or suicidal attempts, or post-traumatic growth. Future research is warranted to address these broader impacts of trauma. We included only articles written in English; therefore, we limited the generalizability of the findings concerning studies published in non-English languages. Finally, we used arbitrary cutoff scores to categorize studies as low, medium, and high quality (quality ratings of 0-4, 5-8, and 9+ for RCTs and 0-3, 4-6, 7+ for quasi-experimental studies, respectively). Using this approach, each quality-rating item was equally weighted. However, certain factors (e.g., randomization method) may contribute to the study quality more so than others.

Conclusions

Our review of 33 articles shows that there is inconsistent evidence to support trauma informed interventions as an effective intervention approach for psychological outcomes (e.g., PTSD, depression, and anxiety). With growing evidence in health disparities, adopting trauma informed approaches is a growing trend. Our findings suggest the need for more rigorous and continued evaluations of the trauma informed intervention approach and for a wide range of trauma types and populations.

Acknowledgments

We would like to express our appreciation to a medical librarian, Stella Seal for her assistance with article search. Both Kristen Trimble and Sotera Chow were students in the Masters Entry into Nursing program and Hailey Miller and Manka Nkimbeng were pre-doctoral fellows at The Johns Hopkins University when this work was initiated.

References

1. 1. Health disparities data. 2020 May 28 [cited 28 May 2020]. In healthypeople.gov [Internet]. Available from: https://www.healthypeople.gov/2020/data-search/health-disparities-data/health-disparities-widget.

2. 2. HIV and AIDS. 2018 April [cited 28 May, 2020]. In: Agency for Healthcare Research and Quality [Internet]. Available from: https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/hiv.html.

3. 3. Farmer P, Kim YJ, Kleinman A, Basilico M. Introduction: A biosocial approach to global health. In: Farmer P, Kim YJ, Kleinman A, Basilico M, editor. Reimagining global health: An introduction. Berkeley and Los Angeles, CA: University of California Press; 2013. p. 1-14.

4. 11. National Institute of Mental Health. Helping children and adolescents cope with violence and disasters: What parents can do. U.S. Department of Health and Human Services; 2013.

5. 12. Trauma and violence. 2019 [Last updated on August 2]. [Internet]. Available from: https://www.samhsa.gov/trauma-violence.

6. 13. Evidence-based practice in health. 2020 Dec 21. [cited 21 December 2020]. [Internet]. Available from https://canberra.libguides.com/c.php?g=599346&p=4149722#s-lg-box-12888072.

7. 14. Covidence systematic review software, Veritas Health Innovation. 2019 [Last updated on February 4]. [Internet]. Available at: https://www.covidence.org/.

8. 15. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E MZ, editor. Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute; 2017.

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Trauma informed interventions: A systematic review

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Background Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions.

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This video shows us the professional point of view of trauma-specific intervention.

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Trauma Informed Interventions | Trauma Informed Care | Trauma Healing

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This TED talk allows one to hear about the personal experience one had with this intervention.

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How Trauma Informed Care Saved My Life  | Adrienne Rouan | TEDxDelthorneWomen

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This allows us to see the difference between trauma-focused and trauma-informed care.

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What is the Difference Between Trauma-Focused and Trauma-Informed Care? - TruHealing

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You may have heard the terms “trauma-focused” and “trauma-informed” care; though they sound similar, they are two different approaches to mental health and

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This gives us tips about how to create a trauma-sensitive classroom.

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You never know what all your students are going to be bringing into your classroom. Each one has a metaphorical backpack stuffed full of different items brought from home - from divorce to abuse to food insecurity to mental illness - and these weigh heavy on students even while they are at school. Although we wish we could have students leave their worries at the classroom door, this is not possible. Therefore, we must be aware of how trauma impacts our students' behavior and learning and learn to foster a trauma-sensitive classroom so that each student can be successful.

Is there trauma in my classroom?

Almost every student has experienced some trauma in their past. Repeated studies show that 45% of children have experienced at least one traumatic childhood event, commonly referred to as an Adverse Childhood Experience (ACE). One in ten children has experienced more than three ACE events. The most common examples of trauma include:

Physical, emotional, and sexual abuse

Physical, emotional, medical, and educational neglect

Mental illness in the household

Incarcerated family member

Divorced parents

Death of a loved one

Substance abuse in the home

Extreme poverty and food insecurity

Witnessing violent acts, particularly domestic abuse and acts resulting in death

Disaster and tragic accidents

As a teacher, what can I do To Help Traumatized Students?

Being able to identify the symptoms of a trauma-affected student is the first step to helping those students be successful.

Trauma manifests itself in many different ways and can have symptoms ranging from behavioral (social withdraw, drop in attendance, impulsive behavior), emotional (moodiness, jumpiness, inability to self-regulate or self-soothe), cognitive (poor memory and attention span, a drop in grades), and physical (headaches, stomach aches, excessive daytime sleepiness).

Once you are aware of how trauma may appear in your classroom, then you are more equipped to provide these students with a proper learning environment.

Here are seven ways you can foster a trauma-sensitive classroom:

1. Change your perspective

As educators, we must change our mindset about our students from "What is wrong with you?" to "What has happened to you?" It's easy to label a student a "troublemaker" or a "bad kid," but these quick judgments fail to consider the reasons behind their behaviors. Negative behaviors that students may exhibit, such as consistently being off-task, having angry outbursts or emotional meltdowns, and destructiveness likely stem from past trauma that has occurred outside the school walls. Instead of blaming the child for their misbehavior, become curious about the reasons behind their behavior.

2. Create a safe place

Because we never truly know what's going on at home, teachers must do everything they can to ensure their classroom provides a safe and learning-friendly environment for the students. School may very well be the only place where a student feels safe, protected, and loved. Make sure each student feels welcome in your classroom by greeting them warmly and by being sensitive to their individual needs.

3. Model healthy behaviors

While it can be challenging, it's essential not to take student behavior personally. It's not about you. It's a defense mechanism or avoidance technique they have maybe even subconsciously devised to protect themselves from what appears to be similar traumatic situations or feelings. It is crucial, then, to practice self-regulation in front of your students, modeling what healthy and mature actions and reactions look like and sound like. Students may not have positive role models outside of your classroom, so it's educational for them to witness an adult react in appropriate fashions and maintain composure and fairness in a world where much so much is out of their control.

4. Discipline the individual

Instead of having one predetermined, set plan for discipline regardless of the student, we need to remain flexible and remember that every student's situation is different. Some students respond well to certain types of discipline, while others may feel traumatized by the same thing. Students with trauma inherently have a distrust of adults, so you must discipline and enforce consequences while maintaining consistency and positivity. Don't discipline out of anger; discipline out of love.

5. Keep consistent routines

Life at home is anything but predictable for many of our students, so in the classroom, consistency is key. The routines and systems you set up in the classroom might provide the most stability they get in their everyday life. Keeping organized and predictable systems helps students by making their day feel a little less out of control. And when you know something's coming up that will change your normal direction, such as a fire drill or planned absence or assembly, let your students know ahead of time; when they know what is coming, they are in less of a reactionary state.

6. Keep them in the classroom

When a student acts out, it can seem so easy to just send them out in the hall or to another trusted teacher's classroom. Instead, create a safe and calm place within the classroom where the student can go to practice self-regulation skills. For younger kids, this could be a carpet square or special chair behind the bookcase or in the corner with some calming toys. For high schoolers, this could look like sitting at a table in the back with their head down or headphones on, or it might actually include letting them "take a walk" or go get a drink. By teaching them healthy ways to manage with unbearable feelings, students can learn to self-regulate on their own and join the class when they are ready.

7. Consider their physical needs

Trauma can create physical needs within your students that can be helped in the classroom. Students who experience food insecurity might be relieved to know that you have granola bars or fruit snacks available if they need them. Bright, fluorescent lights can be overstimulating to some students, so consider using lamps or more natural light in your classroom. Some students may need extra physical space to feel safe, so provide them a separate desk or keep fewer classmates at their table. Give frequent "brain breaks," or short periods of time where students can engage in physical activity such as stretching, yoga, jumping jacks, dancing, etc., to provide some relief after the impossible task of concentrating. And despite what anyone tells you, (and as long as it's done appropriately and with witnesses), there are some times when what a kid really needs, more than anything, is a simple hug.

Is your classroom a trauma-sensitive classroom?

Our students come to us with the world on their shoulders, and it's up to us, their teachers, to provide a safe and protected environment that can foster their learning success. Remember that many behaviors are a manifestation of the trauma, so look upon those students with sympathy and curiosity rather than animosity. Show them what it feels like to be loved and respected because you might be the only person in their life who does.

For more information on trauma-informed classrooms and teaching strategies, check out the course offerings from Credits For Teachers. We offer self-paced online Professional Development courses in topics such as effective discipline, Love & Logic, Safe Learning Environment, and Building Relationships with Students. These courses not only provide graduate credit through our university partners for salary advancement or license renewal, but they can give you the tools to create a more trauma-sensitive classroom. Learn more here.

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Ways to Create Trauma Sensative Classrooms

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You never know what all your students are going to be bringing into your classroom. Each one has a metaphorical backpack stuffed full of different items brought from home - from divorce to abuse to food insecurity to mental illness - and these weigh heavy on students even while they are at school.

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This website gives us clear examples of how to create a trauma-sensitive classroom.

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As an elementary teacher, you play a huge role in the emotional well-being of your students. For those who have experienced trauma, the classroom can be a safe place where they experience support and understanding. Use these 10 steps to build a trauma-sensitive classroom that fosters safety, connection, and optimal learning for your elementary students!

Statistics about Childhood Trauma

Trauma is an emotional response to any event that threatens or causes harm, usually things that cause a lot of stress on a person. The amount of stress that a child can process is different than what an adult can. According to a study completed by the National Institutes of Health in 2015, 34% of children have experienced one OR MORE traumatic events.

The most frequent types of traumatic events that children experience include witnessing or knowing of a family member being arrested or deported, witnessing physical violence or violence in their community, or personally experiencing physical violence.

Other types of childhood traumas:

Witnessing or being in a serious accident

Someone very close to the child being sick or hurt

Being separated from a caregiver

Experiencing the death of a close person

Being attacked by an animal

Threats of stealing or violence

Extreme poverty or homelessness

Experiencing a natural disaster

Common Signs of Trauma in Children

Approximately 75% of those children experienced moderate or higher levels of posttraumatic stress symptoms as a result.

Some of these symptoms can include:

Sudden drops in academic performance

New bullying behaviors

Decreased focus

New food aversions or desire to eat much more than usual

Falling asleep in class

Being aware of these signs is so helpful as a teacher. Don't hesitate to reach out to your school counselor for additional support!

Creating a Trauma-Sensitive Classroom

Once you are aware of these traumas and their signs, you can begin to build a classroom where all of your students can feel safe and truly blossom academically, socially, and emotionally!
Follow these 10 steps to easily create a trauma-sensitive classroom environment:
1. Establish a Safe and Predictable Environment

First thing first- create a daily routine with super clear expectations! When students know what to expect, they can feel secure. Predictability is key, especially on the days when unexpected changes happen like a school assembly or substitute teacher.

Prepare your students in advance when possible. Use resources like the substitute teacher social skills story to help maintain a sense of stability for students.

2. Build Positive Relationships

Greet your students warmly and show genuine interest in what is going on in their lives. This can make a world of difference for kids who have experienced trauma!

Foster positive one-on-one interactions with these students and special adults. Utilize other staff members in the school when needed. Anyone who has made a special connection with a student can be a good choice - the art teacher, librarian, kindergarten teacher, or registrar. There's no limit to positive relationships!

3. Teach Self-Regulation Skills

Incorporate activities that teach self-regulation like deep breathing, yoga, or mindfulness exercises. These techniques help empower your students to manage their stress and emotions effectively.

This emotional regulation bundle has everything you need for this important step in creating a trauma-sensitive classroom!

4. Provide Visual Supports

Visual schedules, charts, and cues help students understand and anticipate daily activities. They also enhance communication, help students know what to expect throughout the day, and reduce anxiety.

Set your students up for success to work independently and complete the tasks they are given with these FREE visual supports!

5. Offer Flexible Seating and Movement Breaks

Flexibility in seating and incorporating movement breaks into your daily schedule provides outlets for physical activity. These extra opportunities for movement help students release excess energy and improve focus.

6. Use Trauma-Informed Language

Mindful language is crucial in trauma-sensitive classrooms! Avoid shaming or punitive language and instead focus on positive reinforcement.

Provide students with clear and simple directions that encourage an added sense of security.

7. Promote a Sense of Ownership

Encourage students to take ownership of their learning environment by contributing to classroom rules, decorating the classroom, and choosing activities.

These choices will foster a sense of control and empowerment that children who have experienced trauma often lack.

8. Offer Sensory Supports

Recognize and address sensory needs in your students. Provide sensory-friendly tools and spaces such as bouncy bands on chair legs, sensory breaks, and fidget items to help meet these needs.

9. Provide Emotional Outlets

Incorporate activities like journaling, drawing, and personal emotions check-ins to allow students to express their emotions throughout the day as needed. By normalizing discussions about feelings, students can more confidently express and manage their feelings in your classroom and later in life!

Encourage students to share their worries with you in a classroom worry jar. Find everything you need to create this jar and so many other great ideas in the emotional regulation bundle.
*Read this post on feelings for even more ideas to teach students about their emotions!
10. Educate School Staff

And finally, take your trauma-sensitive environment beyond your classroom! Talk to your administration about offering professional development opportunities about childhood trauma so that all of the teachers and staff at your school are trained in trauma-informed practices.
Implementing these 10 steps will help you not only create a classroom that's sensitive to trauma but also cultivate a space that nurtures each student so that they can thrive emotionally and academically! Your dedication to creating a trauma-sensitive classroom environment for your students is an investment in the success of the next generation! So, thank you!
Creating a trauma-sensitive classroom environment is an ongoing process that will require adaptability and getting to know each of your students on a deeply personal level. Collaboration with caregivers and other school staff will help you support all students well.

Let me know if you have any questions about anything you see here. Don't forget to pin this post to refer to it later!

Gonzalez, A., Monzon, N., Solis, D., Jaycox, L., & Langley, A. K. (2016). Trauma exposure in elementary school children: Description of screening procedures, level of exposure, and posttraumatic stress symptoms. School Mental Health, 8(1), 77. https://doi.org/10.1007/s12310-015-9167-7
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10 PRACTICAL steps to build a trauma-sensitive classroom that fosters safety, connection, and optimal learning for your elementary students!

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These are the top five books to help children cope with their trauma.

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5 Children's Books to Help Kids Cope with Trauma - Best Kids' Books

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These five books -- from our curation 5 Best Picture Books to Help Address Trauma -- focus specifically on trauma accompanied by shocking events.

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Teaching Strategies to Help Create the Environment.

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Teaching Strategies to Help Create the Environment.

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This article breaks down each domain and how trauma effects it as well as how we can help the child within that domain.

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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 is for an educator when it comes to why we do trauma-informed teaching and how we do it.

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Working with trauma-affected students is a difficult balancing act.

We acknowledge the harmful impacts of the past, and hold out hope for a future of healing. We create a safe environment for students to share their lives, yet maintain professional boundaries. We provide our caring and our help to others, but have to pay attention to our own well-being, too. We work in our classrooms but depend on the support of our community.

These were the clear takeaways for teachers who participated in Edutopia's recent Twitter chat on the topic of trauma and social and emotional learning (SEL). Two parallel ideas emerged in the back and forth. First, as teachers we need to focus on the individual student and the strong, one-to-one relationships that support our trauma-affected kids. And second, creating these bonds requires a broader cultural adjustment and reprioritization, where the whole community works together to cultivate a space in which students, educators, and staff members thrive.

What about classrooms without a lot of trauma? It's risky to assume that our students haven't experienced trauma-according to a seminal study from the Centers for Disease Control and Prevention, childhood trauma is far more pervasive than previously believed and is often invisible. And chat participants asserted that trauma-informed and SEL practices benefit all children, building critical skills like self-awareness, self-regulation, empathy, and an openness to teamwork and cooperation. Adopt a "universal approach," suggested the nonprofit Zero to Three, and "assume all children are trauma-affected and need social and emotional learning instruction and support."

An emerging body of research backs that stance. A 2017 metastudy of over 97,000 K-12 students, for example, found that SEL practices boost academic success, decrease disruptive behavior, and reduce emotional distress in the long term.

So how do we balance the individual focus with a community commitment to trauma-informed SEL? Luckily, our Twitter chat participants had some great advice to share.

Know Your Students

To support students who have experienced trauma, start by flipping the traditional classroom paradigm: Relationships have to come before content, insisted dozens of educators.

It's a simple enough rule, but it runs against the grain and needs to be constantly reinforced: "If you're not addressing the trauma, and the students are distracted, checked out, and falling increasingly behind, even the best curriculum won't matter," explained Wendy Clark, reflecting on the order of events that drive real learning. If that point wasn't a settled matter by the end of the thread, Bill Waychunas cut straight to the heart of the issue by inverting the original proposition entirely: "Better question," he wrote, turning Edutopia's opening salvo around: "How do you teach academics WITHOUT having SEL embedded throughout your teaching and classroom?"

Excellent question. Wish we'd thought of it.

Still, if teachers agreed that one-to-one relationships were the critical building blocks of good SEL-and good trauma-informed practice-how can that effort be scaled to 20 or 30 unique students, each of whom experiences trauma differently? The good news is that it's not all on the individual teacher; system-wide supports are required to distribute the work and create a broader culture of belonging and mutual support (more on that below). Within that context, though, all educators need to row in the same direction: The trick, according to Mathew Portell, principal of the trauma-informed school Fall-Hamilton Elementary in Nashville, is to never lose sight of the individual student: "Trauma affects children in so many different ways. Some kids are reactive while others are reserved. It is key to know the students' stories in order to know how to support them."

With so much pain in the classroom, educators should be mindful that traumatic life experiences can sometimes emerge as behaviors that we might otherwise label as challenging. "Trauma can manifest in so many behaviors! Hypervigilance can masquerade as hyperactivity," offered Sarah MacLaughlin, recasting a child's nervous disposition as a possible response to a difficult home environment. "Fear can look like aggression: flight, freeze, or fight."

And it's not just very young children whose behavior may mask an underlying challenge. Math teacher Kareem Farah sees a connection between anger and trauma in his high school kids: "Students in poverty have been conditioned to suppress their pain. It often manifests as anger. It is critical to recognize that frustrated students are often those that have experienced the highest levels of trauma and need the most loving attention."

The Whole School Model

So relationship-building in the classroom is essential-the one-to-one with students is indispensable-but the impact of the work is amplified and reinforced only when it occurs within the broader contexts of the school and community.

Many teachers in the chat highlighted the need for a consistent, team-based approach. As Carmen Zeisler put it, "Being trauma-informed is not a checklist, but a mindset change. It is critical that everyone in the building is working towards being trauma-informed." Other educators agreed, adding that administration and school board support is needed to sustain these changes.

Teachers recommended ways to develop staff buy-in: Sarah Giddings shared that colleagues at her school meet in small groups to stay accountable to one another, and that extends to support staff like computer technicians. Lindsey Mattingly's school, Valor Collegiate in Nashville, engages all staff in restorative circles so teachers get firsthand experience of the social and emotional skills required of students in that model-with powerful results: "When teachers fully understand trauma and its manifestations, the mindset will shift from one more thing to do to THE thing we must do."

Understandably, there's bound to be pushback. Acknowledging that there is sometimes skepticism about broad, new programs is helpful-teachers and administrators won't all jump onboard enthusiastically. Several educators recommended connecting trauma-informed practices to the existing compassion and empathy among teachers: "You show them what they are already doing. Then they realize they are already partly there," says English teacher Alison Killy. And Joe LaCasse agreed that the foundations of trauma-informed practices were already embedded in many classrooms, and it was really a matter of emphasis: "Deep down, all teachers care about kids. So, this really gets at the core of being a teacher. It's not just something 'extra.'"

What About Me?

Well exactly. What about you?

The teaching profession is intellectually and emotionally challenging. Many educators in the chat recognized that the social and emotional work has to start with themselves. Educators who see the value of a practice in their own lives are more likely to be passionate advocates, and the learning ecosystem is only truly healthy when all members of the community are thriving. In other words, helping teachers feel emotionally grounded and supported is helping students, too. "Don't forget that teachers have SEL needs! Concentrate on teacher well-being and empower them to address their own needs," suggested the organization Move This World. In a school culture that focuses on wellness for all, teachers can practice and then model positive social and emotional skills for their students more authentically.

Social and emotional support for teachers also helps buffer the effects of secondary traumatic stress and vicarious trauma-when teachers experience symptoms similar to post-traumatic stress disorder because of the stress of bearing witness to others' trauma. Supportive peer connections are an important part of that prevention: "Don't let teachers with struggling students feel alone," recommended Rosa Derricott. "It should be a school-wide approach where everyone's supporting each other."

In the end, of course, we can't rely on our schools alone to address systemic issues of poverty, violence, or drug addiction. The net of responsibility must be cast more widely. "A trauma-informed approach to social emotional learning requires partnership between counselors, teachers, parents, and other trusted adults to help guide students through short and long-term challenge," suggested the chat participant Mom of All Capes. Not to put too fine a point on it, but perhaps it was user Belinda Talonia who said it all most succinctly: "SEL belongs to all of us."

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The How and Why of Trauma-Informed Teaching

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In an extraordinary Twitter chat, educators discuss building trauma-informed social and emotional learning environments.

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This video allows us to see what a trauma-informed school looks like and what practices are implemented.

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This article allows us to see what implementation looks like when it comes to the trauma-informed approach.

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Practical Guide for Implementing a Trauma-Informed Approach – The Recovery Process

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SAMHSA’s 2014 Concept of Trauma was a landmark publication that has influenced service provision beyond the areas of behavioral health and health care. In 2014, SAMHSA also released Treatment Improvement Protocol (TIP) 57, Trauma-Informed Care in Behavioral Health Services. Trauma continues to be a cross-SAMHSA priority, given its significant role in behavioral health prevention, treatment, and recovery. The primary goal of this practical guide is to expand the discussion presented in SAMHSA’s earlier resources, specifically focusing on tools and strategies for implementing a trauma-informed approach (TIA).

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This article helps to give tips about how to transition with a child who has trauma.

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Many children who have experienced trauma are sensitive to change. Their past relationships with adults may have been characterised by inconsistent and unpredictable responses to their needs, periods of emotional unavailability, separations and loss. Those children within the care system may have been faced with multiple changes in environment; some at very short notice. When a child's stress-response system is compromised by these persistent experiences of fear and uncertainty, they will need more support with managing the various transitions within the school day.

Providing warm and consistent routines

It's important that we help the child settle upon arrival to school in the morning. A familiar and consistent key adult could meet the child and act as a "secure base". There may need to be an explicit hand-over from the parent/guardian, with the use of a transitional object (e.g. a photograph, a key-ring, a scented tissue) as a concrete representation of their relationship. This can also be used if the key adult will not be present for the first classroom activity.

The child will benefit from encouraging messages about how happy you are to see them and how they are safe. We need to check in with their feelings - depending on the child's developmental age, this can be through verbal questions or visuals (e.g. a feelings thermometer or a choice of emotional faces). Asking about the night before or past weekend - and talking about how you've been thinking of them during that time - can be a good way of emphasising how you remain connected during these separations. Good home-school communication, via a daily diary or email system, can also give advanced warning of heightened emotions and the need to reduce demands on a particular day.

As the child may be anxious about the day ahead, a review of the daily timetable will help to add structure and predictability. A visual schedule should be considered as a concrete means of checking what is happening now and next. Some children may need dedicated time to play or perform a calming activity; such as drawing, building with Lego or performing rhythmic exercise. This can help to mitigate the emotional dysregulation caused by the large crowds in the playground and the higher levels of movement as everyone heads to their respective classroom. We also need to check in with the child at the end of the day, reflecting upon and empathising with the positives and negatives of their overall experience.

Getting ready to engage in a learning task

Let's first consider if the child is physiologically ready for engaging in the task. If it features prolonged sitting or listening, we may need to schedule a movement break or some form of proprioceptive input beforehand. This can help them maintain a calm and alert state. While such breaks should be part-and-parcel of the school day for a child with a background of trauma, we should take cues from the child's behaviour (e.g. increased restlessness, higher levels of inattention, seeking frequent reassurance) as a means of recognising when they need a calming activity before or after a more challenging academic task.

Clear communication about the task is vital. The child will need instructions to be simplified, reinforced and repeated. We may need to model organisational skills - such as retrieving specific equipment and taking out certain books and materials - and promote these skills using visual checklists and explicit labelling of nearby shelves and folders. Visual timers can be helpful in giving feedback to the child about how long they have to work. Tasks should be broken down into small and discrete steps.

We also need to think about the structure of the task. Memory and processing demands should be reduced where possible. For example, we can highlight key words for a comprehension activity, provide a vocabulary list for writing activities and show worked-out examples of a maths problem with arrows or colours to signify the processes. There may need to be an emphasis on quality over quantity and opportunities to demonstrate understanding without excessive writing. Multiple-choice answers or fill-in-the-blank sentences can remove the daunting prospect of the blank page.

Managing changes in activity

We must be mindful of a child's past experiences, where they may have been prevented from finishing something they enjoyed or lacked control over the beginning and ending of activities. Sudden changes may have been commonplace, leaving them hypervigilant to transitions in the school environment. We need to help them anticipate when a learning task is coming to an end.

For some children, verbal feedback may be sufficient in communicating how long is left or when they need to begin to tidy up. If this method proves to be stressful and is likely to escalate their emotions, visuals may be more appropriate. These could include periodically showing a 5 to 1 or coloured countdown strip, leaving a sand timer nearby for them to check or referencing a First/Then visual timetable. We may also have to model how to prepare for the next task.

If the child is transitioning from an activity which is highly enjoyable or motivating, we need to show empathy for how difficult this is. For example: "I know it's really annoying that we have to stop colouring in now. You're so good at it and I bet you wish you could colour in for another hour". It's important that we fully explain what is happening next and provide the opportunity to come back to the activity at a later point. We can provide physical reminders of this agreement, using post-it notes, bookmarks, a message on the whiteboard or a prompt in the Reminders or Notes apps on an iPad.

Coping with unstructured periods and changes to routine

While simple changes in activity can be tough for a child with attachment difficulties, just imagine what break and lunch time is like for them. Noisy and crowded dinner halls. Busy corridors as their peers gather their belongings. Stepping out into a big playground with lots of children playing tag or kicking footballs in every direction. All of this stimulation can be anxiety-provoking and trigger the fight/flight/freeze response which has been overly developed during experiences of trauma.

We need to increase the level of predictability at these times of the day. This could include having a designated seat in the dinner hall for the child. A key adult may need to get alongside the child to model what to say to the canteen staff and talk through the food which they are given. Clubs and group activities facilitated by an adult can be a great way of promoting social interaction in a structured and consistent manner. Social Stories can also be used to practice how to initiate play and conversations with peers in the playground.

Let's consider other times of the year which can be very challenging for these children. When they experience play rehearsals and parties in the lead-up to Christmas holidays, we may need to schedule more sensory breaks and opportunities for relaxation. On Sports Day, they may need a visual schedule for greater predictability about the various activities. Giving them a job to carry out may help them to cope with long waiting periods. When a familiar teacher or classroom assistant is absent from school, we need to explain this clearly and sensitively. It will be important to think out loud about how they may be feeling and empathise with these understandable emotions. The child will also benefit from reassurance that normal routines are being followed and that the familiar adult will be coming back.

Preparing for bigger transitions

School holiday periods can be stressful due to the change from the normal daily routine. As children who have experienced trauma may lack a reliable sense of time, we need to help them anticipate these larger breaks from the normal routine. It may be useful to have a big calendar in the classroom as a means of providing a visual countdown to the holiday. For older pupils in secondary school, we could use colourful marking in their homework planner to show this date approaching.

The end of the academic year poses many challenges; whether it's the child moving on to a new classroom and teacher in the same school or transferring to a new school entirely. We should consider providing photographs of the new classroom and the staff within it, so that the parents/guardians can discuss these changes with the child over the summer months. When moving to secondary school, photographs of the key areas of school (e.g. form room, PE hall, dinner hall, chill-out areas, etc) will help to demystify the new environment. Some settings now offer virtual tours on their websites, which I hope will become standard practice in the future.

Visits to these new environments with a key adult, in the months leading up to the summer, will be important in helping them safely explore the surroundings with the support of a secure base. I would also encourage communication with the child over the summer months or during the first term of secondary school. This could be a short letter, a postcard or even a scheduled visit to their new school once they have settled in. Going the extra mile to maintain contact during separations can show that we are keeping the child in our minds and that the positive relationship you shared continues to endure.

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Many children who have experienced trauma are sensitive to change. Their past relationships with adults may have been characterised by inconsistent and unpredictable responses to their needs, periods of emotional unavailability, separations and loss. Those children within the care system may have been faced with multiple changes in environment; some at very short notice.

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This article explains what activities with child play we can implement.

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How does play therapy work?

Children and adults communicate very differently, so it's not easy for kids to articulate what they're thinking or feeling to an adult. It can also be the case that adults don't pick up on a child's cues, from their speech to their body language.

Many children in foster care who have experienced trauma early in life have a lot of hurt and anger bottled up that they can't express appropriately. Some may be emotionally numb, tense and closed up while others can have bouts of aggression, throw tantrums and say things they don't mean.

That's why in play therapy, the therapist joins the child in their creative, imaginative and playful world to gain a better understanding of what issues the child has and works with them to resolve the trauma. Children use play to express themselves, act out feelings, solve conflicts and understand relationship dynamics. A play therapist will observe how the child uses toys, as they might be symbols for something deeper, and use therapeutic activities to explore emotions and work through past events.

Directive Vs Non-directive Play

Play therapy activities for trauma can be directive or non-directive, which is also known as 'free play'.

With free play, the child takes the lead. They choose the toys, crafts, books, games etc they want to play with and the therapist will pay close to attention to how the child interacts during the play session. They might notice dialogue between two action figures or troubling images in their paintings. By allowing the child free reign, this approach gives the therapist more room to uncover what the deep-rooted issues are.

With directive play, the therapist will have a clear goal in mind. Directive play therapy activities for trauma will be chosen by the therapist beforehand with the specific intention of guiding the child to discuss a particular topic or perhaps answer a sensitive and invasive question. The toys and games are predetermined and the child is gently guided throughout the session.

In both approaches to play therapy for trauma, the hope is that as the child continues to play, they'll put down their defensive walls and become more open to sharing what's on their mind, but it's all done at the child's pace. Helping young people with trauma doesn't happen overnight, so it's important that trust is established and the child doesn't feel pressured to discuss anything they're not ready for.

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Play Therapy Activities for a Child with Trauma

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Play therapy is an effective form of therapy that could give your foster child new coping mechanisms and a new outlook on life. Here's how it works.

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This article allows us to see how play can assist children when it comes to coping with their trauma.

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This article states how time heals children.

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"The path of least resistance is the path of the loser." H. G. Wells

Put more gently: The path of least resistance is rarely the path of wisdom.

"The path of least resistance leads to crooked rivers and crooked men." Henry David Thoreau

I remember getting new carpet once and noticing how fluffy the pile was in the doorways compared to the old stuff. I even went so far as to carefully place my steps further out near the door frame for a while, hoping to delay the inevitable crush that heavy traffic brings to pile carpeting. The practice didn't last long but the memory has persisted just like that carpet showed its "memory" of thousands of footfalls. The center of the doorway was just the easier path, the one that didn't take any intention to use. It took focus and persistence to place my feet anywhere else. My busy life just couldn't support that new habit and soon, my new carpet reflected what had happened to it. Again.

I've used this analogy for many years to help caregivers understand the neurological implications of childhood trauma. We sometimes seem to act as if neglect takes a backseat to physical or sexual abuse developmentally and legally but that is a mistake. Carelessness during pregnancy or neglect of the newborn's basic needs for comfort, company, or celebration in those first months and years of life creates neurological and physiological templates that guide the child's interactions with the world for a very long time. They don't need to "remember" what happened; they behave in ways that demonstrate what happened with no idea of why. Their brains have been shaped in a distinct way that determines how their senses experience everything.

This consequence is to be distinguished from the consequences of trauma experienced by adults. Healthy adults bring a complete history to the moment of their traumatic experience; children do not. Adult trauma has huge consequences for the ongoing functioning of the person, but it occurs in the context of years of foregoing experience from which the person can garner support, skills and strength. The adult knows something is "off"; that their usual functioning has taken a hit (hot temper or anxiety where once calm; disturbed sleep where once well rested; and/or isolation where once actively social, just to mention a few). A young child's entire perceptual schema is FORMED by their trauma. They know no other way to encounter the world. They may not even notice that their response styles are unusual compared to their peers. They just know they are in trouble a lot. They begin to believe they are unlovable, unworthy, or incapable of effective participation in life. But, just like adults, kids try to avoid the source, and anything similar to the source, of their trauma. Too often, because you are human, you are something to be avoided. As much as they still want connection, it is just too scary.

Conclusion: a child with an early trauma history needs the comfort of a caring adult but is too skeptical/afraid to accept the concern/attention/care offered by those in their sphere. What a rip-off! This now requires you, the caregiver, to hold off on the hugs, allow the child to approach first for comfort, and ride out any emotional display without judgement or any attempt to control or intervene. If your calm cannot de-escalate the situation yet it is probably because these wild displays of frustration, anger, or disappointment need to last until the child is "spent" because "spent" is the old, familiar pattern of coming down off strong feelings when there was no one there to provide comfort. What next? They clean up the mess and only then do you talk about what happened for the few minutes such conversation can be tolerated. No corrections, no other consequences, no moral lessons. Just patience and understanding that they are really doing the best they can with tragically limited resources based on such early trauma.

Then you do it all again tomorrow and the next day and the next day until an ember of trust begins to shimmer. Then you do it again and again until that ember has a chance to take hold. Careful: too much wind will blow it out so take it slow. In the meantime, take care of yourself in whatever way feeds your soul so you have the bandwidth to deliver the patience and curiosity this child needs from you and anyone else in their life. Maybe then they will have a chance to give and receive the kind of love you have been able to show them for oh, so long.
NEWS

1. Check out the AZAFAP Event Calendar at https://azafap.gnosishosting.net/Events/Calendar.

2. Our Friday night Happy Hour and Tuesday afternoon Coffee Chat continue. Some find me and a single other participant; others find a conversation among 4 to 6 people. The topics range from the silly to what hobbies have us in their grip to what life has thrown in our path. If you ever find yourself wanting a bit of grown-up conversation, consider joining us (check your email for the unchanging link).

3. Parent Mentor Partners: AZAFAP has trained volunteer parents as mentors who are ready to help support foster, kinship, and adoptive parents through one-to-one conversations. Interested? Fill out the form at https://www.azafap.org/family-support-services/

4. Registration is also open for new, regional Circles of Supportive Families. Reach out to find another parent who understands.

5. Though pandemic pressures are finally easing, reach out if you need an ear or even to share your thoughts about this or a past blog: cathyt@azafap.org.

6. I encourage you to check out what Dr. Bruce Perry has to offer. Find his thoughts at https://www.pcaaz.org/wp-content/uploads/2019/07/B21-Insightful-Caregiving-Intimacy.pdf and at https://www.neurosequential.com.

Thanks for listening. Maintain yourself so you can be there reliably for others.

Cathy

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Time, Trauma, and Healing: The Consequences of Trauma

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"The path of least resistance is the path of the loser." H. G. Wells Put more gently: The path of least resistance is rarely the path of wisdom. "The path of least resistance leads to crooked rivers and crooked men."

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This article gives us many different resources for families.

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Access a wealth of trauma-informed care resources for families at AAP's website. Explore articles, guides, and tools designed to provide support and understanding to families affected by trauma. Whether you're a parent, caregiver, or advocate, this platform offers valuable information to help navigate the challenges and promote healing in the aftermath of trauma.

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This video helps parents understand what their child is going through and how to assist them.

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Trauma For Kids - Coping With Childhood Trauma, Resilience, Self-Care, Grounding Techniques

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This article states the steps a parent can take to help themselves and their children.

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Need Help? - Attachment and Trauma Network

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Need help? You are not alone! Join ATN, the VOICE for traumatized children, empowring trauma-informed families, educators and communities.

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This article allows parents to get tips on how to parent a child with trauma.

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What is Trauma Informed Parenting

Trauma-informed parenting is an approach to raising children that acknowledges and addresses the potential effects of past traumatic experiences on a child's development, behavior, and emotional well-being. This parenting style is particularly relevant for children who have experienced trauma or adverse childhood experiences (ACEs).

Trauma in childhood occurs in various forms. The different types of trauma include physical abuse, emotional abuse, sexual abuse, neglect, loss of a parent, exposure to violence, sudden separation from the caregiver, dysfunctional families, and institutional racism.

Impact of childhood trauma on child development

Childhood traumas are strongly associated with the onset of psychiatric disorders among US adolescents. Childhood adversities, such as abuse, neglect, losing a parent, and economic adversity, are among the most consistently documented risk factors.

Across all DSM disorder classes, childhood adversities' risk proportions ranged from 15.7% for fear disorders to 40.7% for behavior disorders.

Multiple ongoing traumatic events are considered complex trauma that can result in complex post-traumatic stress disorder (PTSD)

This type of disorder is distinct from single trauma PTSD due to its earlier onset in development and often from the same person who is a source of both threat and safety.

Besides mental well-being, childhood adversities can affect a child's cognitive functioning.

Imaging studies show that the brain tissue of abused children exhibits a range of anomalies, including disturbances in circuitry, a reduction in brain volume, and reduced white matter in the prefrontal cortex. These children tend to suffer from memory problems and have lower academic performance.

Also See:
How Does Trauma Affect The Brain In Children

For more help on calming tantrums, check out this step-by-step guide

Trauma-Informed Parenting

Trauma-informed parenting is especially relevant for adoptive and foster parents (resource parents).

Children who have endured chronic trauma from caregivers during their early years often struggle with emotional and behavioral regulation. They also tend to have difficulties forming connections with others.

Parenting these children can be particularly challenging.

Effects of trauma may include severe behavior problems. These challenging behaviors are often maladaptive behavior developed to cope with the dangerous environments they were raised in or a lack of skills that have not been taught to them.

Supportive adults who adopt a trauma-informed approach recognize the impacts of trauma and take care to prevent retraumatization of the child.

Understand trauma and behavior

Behavior problems in traumatized children are often coping mechanisms developed in response to trauma rather than a deliberate act of disobedience, disrespect, or personal attack.

For instance, some children may act defiant when it comes to bedtime. Their intense fear for their own safety may result in the child trying to delay bedtime to escape frightening dreams.

Parents' empathy and patience when dealing with maladaptive behavior are essential for these children's healing and recovery.

Establish safety

Providing a safe and predictable environment so that children feel safe and supported is the first step in their recovery.

This can involve being responsive to their needs, setting clear boundaries and routines, and being consistent in parenting.

Build trust in relationships

Traumatic experiences often break children's trust in others.

Besides providing a predictable and safe environment, trauma-informed parents can build trust by using trust-based rather than fear-based discipline.

A child is more likely to listen when disciplined through reasoning, connecting, and preventing.

Reasoning - Teach them why some behaviors are proper while others are unacceptable.

Connecting - Focus on building relationships and solving problems rather than punishing the child.

Preventing - Take proactive steps to prevent disruptive behavior before it happens.

Trust can also be built and maintained by repairing ruptures in the relationship when they occur. When a relationship experiences a breach, trauma-informed parents prioritize making amends to repair the relationship and rebuild trust.

Develop emotional regulation

Many childhood traumas result from harm that occurs within a caregiver-child relationship. They are called attachment traumas. Betrayal in childhood disrupts many developmental processes, including those that lead to regulating emotion, attending to bodily signals, and developing trust.

There are several things parents can do to help children develop emotion regulation and trust in relationships.

- Parents demonstrate emotional regulation when facing difficulties, serving as a model for children to follow.

Validation - Acknowledge and validate their child's feelings, providing them with emotional support.

Co-regulate - Be attuned to and mirror their child's difficult emotions to co-regulate their intense feelings.

Emotion coaching - Teach children how to identify and understand different kinds of emotions, fostering emotional intelligence.

Coping skills - Teach children how to reframe unfavorable situations, problem-solve, and negotiate better solutions in different contexts.

Speak the Unspeakable

Making sense of their painful experiences is critical in the child's healing process.

Help the child process their childhood adverse experiences by encouraging them to disclose and discuss difficult topics, ask tough questions, and explore their sometimes overwhelming emotions.

Rather than encouraging them to forget their past, create a safe space for them to speak the unspeakable.

They can only move forward when they have processed the trauma and talked about it coherently.

Recovery and Self-care

A caregiver's mental well-being is one of the best predictors of a child's outcomes, not only for parents who have experienced trauma but also for other caregivers who have not experienced trauma themselves.

It is crucial to prioritize supporting all caregivers in practicing self-care and recovering from any stressors they may experience.

This approach can ultimately benefit the trauma recovery of the children in their care.

Advocate & coordinate

At times, trauma-informed parents may need to advocate on behalf of their children if clinicians who are not trauma experts misunderstand or misdiagnose the effects of trauma on their children. This may involve advocating for and getting involved with appropriate treatment.

They may also need to coordinate with schools and help others understand their children's upsetting behaviors through a trauma lens.

Also See: 23 Red Flags In Teenage Behavior

References

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Trauma-informed parenting is an approach that recognizes and addresses the impact of past trauma on a child's development, behavior, and emotions.

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This article allows a parent to know tips on how to help their child.

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Trauma and Mental Health | Guide For Parents

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If your child is struggling with the effects of trauma we have advice to help you support them to heal, and to find the right professional help if needed.

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This is a workshop the guardian can sign up for with their child to understand their child more and cope with the trauma together.

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Explore free, bilingual resources on traumatic experiences that caring adults can use to help children cope and boost their emotional well-being.

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This website is specifically for a clinic that works with child and their families with trauma.

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Beacon House offers a specialist trauma and attachment service for children, adolescents and parents/carers who have survived trauma, loss and disruption.
Our trauma therapists come with extensive experience of working sensitively and effectively with individuals who have been traumatised through their life experiences, and we draw on a range of creative and evidence-based interventions.

There are two forms of trauma that can affect us:

Post-traumatic Stress Disorder (PTSD)

Complex Developmental Trauma

What is Post-Traumatic Stress Disorder?

Post-traumatic stress disorder (PTSD) is a certain collection of symptoms that often develop following a one-off incident, such as a road traffic accident, a natural disaster or a sexual assault. PTSD can have a huge impact on an individual's life and relationships. The symptoms of PTSD can feel very strange and can often make children feel as if they have gone 'crazy'; but in fact, these are very normal reactions to abnormal events. PTSD can be treated very effectively using EMDR and other trauma focussed therapies.

When a child goes through a one-off traumatic incident there is a possibility that they will develop the symptoms of PTSD. Children under the age of six can also develop post-traumatic stress but it can look a little different to older children. Younger children are likely to show disturbed or repetitive play where there are themes of fear, anxiety and distress. Younger children are also likely to show anxiety at separating from their parents/carers, and other signs of distress such as bed wetting, disturbed sleep and challenging behaviour. Young children may not be able to put words to their feelings, but they can suffer with a post-traumatic stress reaction just as older children can.

PTSD develops because the traumatic event becomes 'frozen in time' for the child and they act and feel as if the threat is still ongoing. Therapy aims to help the child to process the trauma memory and re-learn that they are safe.

In our experience, once the core symptoms of PTSD have been addressed, the child and family often experience something known as 'post traumatic growth'. This is where the family feel even stronger, closer and wiser than had the traumatic event never happened.

How does Beacon House help PTSD?

We will first carry out a gentle and sensitive therapeutic needs assessment of how the trauma has impacted the child, which may include PTSD symptoms but may also include other difficulties impacting on home life and school life.

Our assessment will take into account the child's views and the parent's observations and, if helpful we can involve the school in building up a holistic picture of how the child is managing. Sometimes it can be helpful to use psychological measures to get a fuller picture of how the child is feeling and the coping strategies they have developed.

This usually takes place over one or two appointments. Following this, we will share with the parent and child our impressions of how the trauma is affecting them and family life, and what therapy plan is likely to be most effective.

We will then offer an evidence-based therapy to directly process the traumatic memories. This might include EMDR, Cognitive Behavioural Therapy or other approaches, For very young children, play is also brought in to the therapy. We often take what is known as a 'systemic' approach to the therapy, which means that we support the parents and the school to understand and help the child, as well as working directly with the child. We often also work 'dyadically' which means that the parent and the child are in the therapy room together, with the parent working alongside the therapist to support the child to feel safe and to enable the trauma processing.

Once the main trauma symptoms have reduced, we may bring in other therapeutic approaches to help the child and family develop a new story for themselves about how the trauma came, how they recovered and how they will take their experience positively into the future.

What is Developmental Trauma?

Complex Developmental Trauma (sometimes known as Complex PTSD) often develops after the child has experienced repeated, relational trauma such as sexual, emotional and physical abuse; neglect during childhood, or repeated loss and abandonment. Complex PTSD in childhood can also emerge when a child is removed as a young infant from their birth mother, and looked after by foster carers, special guardians or is adopted.

It is important to know that Developmental Trauma can also arise from early childhood experiences which, on the face of it, appear good enough. However, beneath the surface is an experience for the baby or child where their basic emotional needs were not met, or where there was a profound absence of attunement, empathy and emotional validation from the parent to the child, leaving a deep sense of emptiness within the child.

Children can experience Developmental Trauma when things happened that shouldn't have happened, or indeed when things didn't happen when they should have happened.

Developmental Trauma can also arise from experiences which are not relational, for example, in babies who have sensitive, dedicated parents but who undergo years of invasive medical procedures and life threatening illness.

When babies and children are faced with parenting that is either 'too much' and/or 'too little' time and time again; they naturally adapt to this threat to their sense of safety. In other words, they develop a wide range of behaviours and emotional survival strategies which have two simultaneous goals:

To reduce the likelihood of physical, emotional or sexual harm and

To bring key adults close enough to give comfort and protection, but not too close that it feels threatening

It is these very survival behaviours (otherwise known as 'adaptations to danger') that are often understandably described as 'symptoms' or 'challenging behaviours', and which leave parents and teachers feeling lost in a push-pull dance with the child. We like to re-frame these challenging behaviours and celebrate them as ways the child learnt to survive life's lessons - and thank goodness they did!

We invite all adults who are caring for, or working with, complexly traumatised children to shift from an individual perspective ("the problem is in the child and the child needs to change") to a relational perspective ("the child is relating to me as if the danger is still here, and I need to adapt my behaviours to create extra safety so that the child can over time, learn that she or he is now safe").

Click here for an image which helps to understand Developmental Trauma in children.

Click here for our comprehensive article on Developmental Trauma.

Take a look at our two animations about how to understand and support children who have suffered early trauma too:

Here - Window of Tolerance

Here - The Repair of Early Trauma, a Bottom Up Approach

You will find a rich range of resources about Developmental Trauma on our resources page.

How does Beacon House help Developmental Trauma?

Our team has an innovative and evidence-based approach to working with children and families who have experienced early trauma, separation and attachment disruption. Traumatised children are often driven by their primitive survival instincts, even when they are not in danger any more. They are frequently in fight/flight/freeze/collapse survival modes which we see through their 'too much' or 'too little' behaviours.

The feelings of fear and shame stored in the body often have no words. For therapy to be helpful, we must offer something which focusses on calming the primitive brain and the body first, before we invite the child to be reflective and to use sophisticated conversation in therapy. If we jump straight to the 'thinking brain' (which many standard treatments do), then well-meaning professionals are likely to be at best unhelpful, and at worst shame-inducing for the child.

We offer an integrative service where a variety of therapies are available to children and families, because no one single therapy is right for all traumatised children.

Our therapeutic plans are informed by the following values:

1. The therapy plan must be informed by a trauma-informed assessment with the child and his/her family, to embed the collaborative approach.

2. Therapy is long-term, often spanning a number of years but with breaks in between therapeutic chapters. The child is not 'cured', but instead learns, over time and with the attunement of their key adults, to love and let love in.

3. There is no one 'right' therapy. Different therapies are helpful at different times in the child's life. The key is that therapy must be relational, and in the right sequence, starting with calming the child's primitive fear response and building up, to enable them to reflect, think, learn and make choices.

4. Therapy might involve direct work with the child, but it almost always also includes working with the parents too. By building up the parents, we build up the child.

5. Therapy is only one small part of the child's world. For therapy to create change, the child needs to experience safety and compassion within their family, school and their wider community.

6. By building a therapeutic web around the child (filled with sensitive, attuned, informed adults), the child has a much greater chance of thriving.

What is involved in a Developmental Trauma Assessment?

Before we embark on a therapeutic plan for a chronically traumatised child, we always offer an extended Therapeutic Needs Assessment.

This involves:

A meeting the parent(s) only

A meeting with the child only (if they feel safe enough to be alone with a therapist)

A meeting with the child and parent(s) together

A conversation with other professionals supporting the child (e.g. school and social worker)

Administration of a range of questionnaires and psychological measures

Reading of all background reports and social care chronology, if available

Writing a Therapeutic Needs Letter, which is a comprehensive report

Feedback meeting and intervention planning

What are the assessment goals?

Our assessment goals vary, depending on the needs of the child and family. Generally, we work to the following aims throughout the assessment process:

To understand how the child's experiences have impacted his/her development

To understand the nature and extent of the child's Developmental Trauma, and whether there are also additional mental health or developmental difficulties

To understand the current home context and how this inter-relates with the child's needs and behaviours

To understand the school context, and how this inter-relates with the child's needs and behaviours

To understand the parents' own emotional well-being, resilience, strengths, resources and support needs

To identify the child's strengths, talents and resources

To support the child and the parents to identify their therapeutic goals

To identify what therapeutic intervention both the child and the parents are ready for, and able to tolerate

To make a series of recommendations about what interventions will help to create change, and in what order they should be offered in.

To make recommendations for parents, carers, schools and social workers which will build a therapeutic web around the child, and enhance the likelihood that therapy will be impactful.

What happens after the assessment?

After the feedback and therapy planning meeting, the child and parents are invited to begin the recommended therapy. Therapeutic goals vary greatly between families; and they also change over time. Common therapeutic goals include:

Stabilising the home environment for families at risk of breakdown

Creating better emotional stability for the child - so that they can regulate their senses, emotions and behaviour better

Promoting secure attachment between the parents/carers and the child

Improving the emotional resilience and sensitivity in the parent/carer

Improving communication and connection within the whole family

Increasing the confidence of parents to respond to very challenging behaviours in their child

Treating discrete mental health symptoms such as low mood, anxiety and post-traumatic stress

Stabilising school placements and enhancing the child's potential to learn

Building family resilience for the future

Here are the therapies available at Beacon House to heal and repair Developmental Trauma:

Dyadic Developmental Informed Psychotherapy

Attachment informed EMDR

Mentalization based treatment

Therapeutic Life Story Work

Dramatherapy

Sensorimotor psychotherapy

Non-violent resistance

Dyadic Art Psychotherapy

Sensory Attachment Intervention

Specialist Educational Psychology

Comprehensive Resource Model

How is my child's progress reviewed?

Therapeutic progress is something which is continually reviewed throughout the intervention. During the assessment, the therapist will make a plan with you about how many sessions should take place before a more formal 'pause and review' appointment is offered.

Alongside this, we have three main ways that we evaluate the therapeutic progress your child makes:

1. During your child's assessment, you will be asked to fill out a number of questionnaires, which will be re-administered at the end of each piece of work.

2. At the start of each piece of work, you and your child will be asked to identify three therapeutic goals, and scale them to show us how well you feel you are achieving those goals. We will review your goals and your scaling at the end of therapy.

3. At the end therapy, you and your child will be asked to tell us how satisfied you feel with your experience of coming to Beacon House, and whether you feel the difficulties you have been working on have improved.

What do other parents/carers and children say about Beacon House?

We understand that taking that step towards asking for help takes courage. We also understand that it can feel like a step into the unknown. Take a browse through our Testimonials and Young Person's page, where you can read what other parents and young people have said about their journey through therapy here at Beacon House. If your child is adopted or care for under a special guardianship, take a look at our services funded by the Adoption Support Fund here.
We also provide freely available resources so that knowledge about the repair of trauma and adversity is in the hands of those who need it. Please feel free to use our resources in your home or work setting, click here to view.

Getting in Touch

If you would like to get in touch with us for an information conversation about whether your child may benefit from our services, please get in touch with us on 01444 413 939 or admin@beaconhouse.org.uk.

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Beacon House offers a specialist trauma and attachment service for children, adolescents and parents/carers who have survived trauma, loss and disruption. Our trauma therapists come with extensive experience of working sensitively and effectively with individuals who have been traumatised through their life experiences, and we draw on a range of creative and evidence-based interventions.

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This video specifically is from a professional in which they talk about the role a parent needs to have for their child with trauma.

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Raising Trauma-Resilient Children Part 1: Secrets and Shame: PTSD and Trauma Recovery #5

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This article breaks down all the treatments and the benefits of both. This will allow parents to find the best care for them.

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Abstract

The period from birth to age six represents a time of significant risk for exposure to trauma. Following trauma exposure, children may experience significant negative and lasting psychological, cognitive, and physical effects. Over the last two decades, the demand for and availability of evidence-based treatments (EBTs) for children under the age of six who have experienced trauma has dramatically increased. Three of the most well-supported and widely disseminated EBTs for early childhood trauma are Trauma-Focused Cognitive Behavioral Therapy, Parent-Child Interaction Therapy, and Child-Parent Psychotherapy. Increasingly, clinicians are receiving training in more than one EBT. This paper provides an overview of each intervention; presents clinicians with various child, caregiver, and environmental factors to consider when deciding amongst these three EBTs; and applies these considerations to three composite cases.

Keywords: Early childhood trauma, Intervention, Toddlers, Preschoolers

Introduction

Early childhood presents an especially risky period of development with respect to exposure to trauma. Annual data from the National Child Abuse and Neglect Data System consistently indicates that children birth to age six are at the greatest risk for experiencing child abuse and neglect (U.S. Department of Health and Human Services 2018) with this age group accounting for 78.5% of all substantiated cases in 2016, the most recent year for which statistics are available. Furthermore, children birth to age six account for approximately 60% of children with direct exposure to domestic violence (Fantuzzo and Fusco 2007). Children birth to age five also are disproportionately more likely than children of other age groups to be hospitalized and die from injuries related to submersion and drowning, burns, falls, poisoning, suffocation and choking (Grossman 2000).

There are significant and lasting psychological, cognitive, and physical outcomes for young children following trauma exposure. Cross-sectional studies of infants, toddlers, and/or preschoolers suggest that traumatized children under age six are at increased risk for developmental delays, lower cognitive functioning, mental health difficulties, and trauma symptoms such as high levels of fussiness, increased crying, sleep disturbance, difficulty regulating emotions and behavior, clinginess and separation anxiety, posttraumatic play, restrictive play or environmental exploration, temper tantrums, and regression from previously acquired developmental skills (Mongillo et al. 2009; Pears and Fisher 2005; Scheeringa et al. 2003). These findings are consistent with prospective studies which find that infants, toddlers, and/or preschool age children exposed to trauma are at risk for deficits in social and daily living skills, internalizing and externalizing problems, cognitive deficits, and symptoms of posttraumatic stress disorder (PTSD; Enlow et al. 2013; Keiley et al. 2001; Scarborough and McCrae 2010).

Fortunately, over the last 20 years, the availability of evidence-based treatments (EBTs) for children under the age of six who have experienced trauma has surged. Along with increasing availability, demand has also increased as some states have recognized the specialized care that is required to work with very young children and their families. Increasingly, states are beginning to consider or implement infant mental health endorsements, certifications, and/or higher reimbursement rates for providers who use EBTs to treat children in this age group (Cohen et al. 2013; Zero To Three 2016). Three of the most well-supported EBTs for trauma in early childhood are Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al. 2017), Child-Parent Psychotherapy (CPP; Lieberman et al. 2015), and Parent-Child Interaction Therapy (PCIT; Funderburk and Eyberg 2011). Large-scale dissemination projects have been undertaken to disseminate TF-CBT (Sigel et al. 2013), PCIT (Scudder et al. 2017), and CPP (Joy Osofsky, personal communication, April 16, 2018).

Within our small, mostly rural state, we disseminate all three of these interventions statewide through the Arkansas Building Effective Services for Trauma (ARBEST), a program sponsored by the state legislature to improve outcomes of traumatized children throughout the state through collaboration among the University of Arkansas for Medical Sciences Psychiatric Research Institute; Commission on Child Abuse, Rape and Domestic Violence; and Children's Advocacy Centers of Arkansas. ARBEST, initiated in 2009, trains mental health professionals, child advocacy center advocates, child welfare staff and other stakeholders in evidence-based, trauma-informed practices including TF-CBT, PCIT, and CPP; helps coordinate and support mental health services provided in CACs and in the community for traumatized children; and monitors outcomes for traumatized children and their families. The authors of this manuscript are trainers in at least one of the EBTs disseminated by ARBEST and participate in training therapists throughout our state in TF-CBT, PCIT and/or CPP through in-person trainings and ongoing phone consultation throughout the duration of the training period.

Since 2013, when ARBEST began disseminating more than one EBT, 79 clinicians within our state have been trained in two or more EBTs for early childhood trauma, with many more having been placed on waiting lists to receive training in an additional EBT. Naturally, clinicians routinely inquire as to how to decide which trauma treatment to use. Osofsky and colleagues (Osofsky et al. 2017) have provided guidance for how clinicians may decide amongst CPP, PCIT and a home-based intervention called Attachment and Biobehavioral Catch-up (Dozier et al. 2014), but no such guidance exists for providers who may find themselves choosing amongst TF-CBT, CPP, and PCIT. Given that TF-CBT is the most widely disseminated EBT for childhood trauma with 20 randomized controlled trials completed to date (Cohen et al. 2017), this guidance is necessary. This paper first provides an overview of the three interventions, then offers considerations for clinicians when selecting amongst them, and then applies these case considerations to three composite cases. As such, client names and demographic information have been altered. We close by offering implications for training.

Trauma-Focused Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy (Cohen et al. 2017) is an evidence-based and manualized treatment for children ages three to 18 who present with posttraumatic stress symptoms related to any type of traumatic event they may have experienced or witnessed. However, it is not necessary for a child to have a full diagnosis of PTSD to participate in TF-CBT. TF-CBT is typically delivered in 12 to 16 weekly sessions. In reviews of research on treatment for children with posttraumatic stress symptoms (i.e., Chadwick Center for Children and Families 2004; Chadwick Center for Children and Families and Child and Adolescent Services Research Center 2018; Saunders et al. 2004; Silverman et al. 2008), TF-CBT was the only treatment given the highest rating (i.e., evidence-based practice) in all of the reviews. Due to TF-CBT's positive outcomes in children with a history of trauma and posttraumatic symptoms, large-scale dissemination is under way across the country through a variety of projects with differing funding sources (Sigel et al. 2013).

For children ages three through five, TF-CBT has demonstrated efficacy in reducing child PTSD symptoms, depression, anxiety, and behavior problems (Cohen and Mannarino 1996; Cohen and Mannarino 1997; Deblinger et al. 2011; Mannarino et al. 2012; Scheeringa et al. 2011). For this age range, TF-CBT has also been shown to improve parenting skills and parental support of the child, as well as reduce parental distress (Deblinger et al. 2011; Mannarino et al. 2012). The therapeutic components of TF-CBT include psychoeducation about trauma; parenting skills; development of relaxation and other coping skills; feelings identification; understanding the links among thoughts, feelings and behaviors; narration of the traumatic event(s) which have been witnessed or experienced by the child and verbally processing associated thoughts, feelings and behaviors; gradual exposure to reminders of the traumatic event(s) in an effort to teach the youth how to manage being exposed to such reminder(s); conjoint caregiver-child work; and enhancing safety/prevention skills. Most sessions are divided equally between the child and the caregiver with the therapist conducting a session with each person alone. However, some sessions are conducted as conjoint sessions in which the child, caregiver, and therapist are all present. TF-CBT is structured and directly focuses on the impact of traumatic stress. It is consistent with the principles of cognitive-behavioral, exposure, and parenting therapies that are widely accepted by mental health professionals.

Parent-Child Interaction Therapy

Parent-Child Interaction Therapy (Eyberg and Funderburk 2011) is an evidence-based, manualized treatment for children ages two to seven with disruptive behavior problems, including those with trauma histories and/or posttraumatic stress symptoms, and their caregiver(s). The Chadwick Center for Children and Families and Child and Adolescent Services Research Center's California Evidence-Based Clearinghouse for Child Welfare ( 2018) rates PCIT as "well supported by research evidence," its highest rating.

PCIT has consistently been shown to reduce disruptive behavior problems in children (Herschell et al. 2002; Ward et al. 2016). It has also been shown to improve parenting skills, increase the warmth of the caregiver-child relationship, and decrease parenting stress (Bjorseth and Wichstrom 2016; Danko et al. 2016; Timmer et al. 2005). Timmer et al. ( 2010) have shown that PCIT decreases both internalizing and externalizing symptoms in children exposed to trauma, indicating that PCIT can help reduce trauma reactions beyond disruptive behavior. Finally, Pearl and colleagues (Pearl et al. 2012) found that PCIT can reduce trauma-related symptoms without making any adaptations to the treatment model.

PCIT is conducted in two phases, both of which use directive therapist coaching to guide the caregiver toward skill mastery in real-time, play-based situations with the child. The first phase, Child-Directed Interaction (CDI), focuses on increasing the caregiver's positive attention skills and strengthening the warmth of the caregiver-child relationship. The second, Parent-Directed Interaction (PDI), focuses on increasing the caregiver's consistent, appropriate use of discipline, using a specialized form of time-out as the contingency for child noncompliance. Each phase is mastery-based rather than time-limited, resulting in varying lengths for PCIT across families, although a typical estimate is 12 to 16 weekly sessions (McNeil and Hembree-Kigin 2010). Each phase begins with a caregiver-only didactic session; all other sessions require both the child and the caregiver(s) to be present, as PCIT is based entirely on dyadic interactions. In addition, the dyad is assigned "homework" in the form of a daily, five minute play time in which the caregiver intensively practices the PCIT positive attention skills.

Child Parent Psychotherapy

Child Parent Psychotherapy (Lieberman et al. 2015) is a relationship-based, dyadic intervention that targets emotional and behavioral concerns in children birth through five years of age who have experienced trauma. It is listed as an evidence-based treatment on the Substance Abuse and Mental Health Services Administration National Registry of Evidence-Based Programs and Practices ( 2010) and designated as "Level 2, supported by research evidence" on the California Evidence-Based Clearinghouse for Child Welfare (Chadwick Center for Children and Families and Child and Adolescent Services Research Center 2018). CPP has demonstrated efficacy in improving attachment quality (Lieberman 1991; Toth et al. 2006); child cognitive development (Cicchetti et al. 2000); child posttraumatic stress symptoms, depressive symptoms, and behavior problems (Ghosh Ippen et al. 2011; Cicchetti et al. 2011); child physiological regulation (Lieberman et al. 2005); and caregiver depressive and posttraumatic stress symptoms (Ghosh Ippen et al. 2011).

CPP is typically delivered in 20-25 weekly sessions, can be practiced in a variety of settings (e.g., in home, in outpatient clinics, in school environments), and is divided into three phases: Foundational Phase - Assessment and Engagement; Core Intervention Phase; and Recapitulation and Termination (Lieberman et al. 2015). In the Foundational Phase, the clinician aims to build a collaborative working relationship with caregivers while simultaneously gathering information about the reason for treatment referral, demographic information, specific child and parent symptoms, and risk and protective factors that exist within the family system (Lieberman et al. 2015). In addition to gathering information, the therapist collaborates with the parent to incorporate a trauma-informed perspective regarding the child's presenting problems and treatment plan. The therapist and caregiver introduce CPP to the child in the first Core Intervention session in order to set the trauma frame for understanding behavior. They discuss how the trauma experience(s) and the child's behavioral and emotional reactions are connected, and give the child permission to tell or show how he or she feels (Lieberman et al. 2015). During the remainder of the Core Intervention Phase, the clinician uses "ports of entry" (Stern 1995) which are naturally occurring moments in session during which it is appropriate to use strategies to intervene in the parent-child system to promote therapeutic progress towards treatment goals. The primary goals of CPP include returning children's development to a typical trajectory, increasing the capacity of the dyad to realistically respond to threat, re-establishing trust in bodily sensations, restoring reciprocity within relationships, normalizing the traumatic response, increasing differentiation between reliving trauma and remembering it, and placing traumatic experiences in perspective (Lieberman et al. 2015). CPP clinicians rely on several strategies to realize these goals, including promoting developmental progress through play, physical contact, and language; offering unstructured reflective developmental guidance; modeling appropriate protective behavior; interpreting feelings and actions; providing emotional support and empathic communication; and providing crisis intervention, case management, and concrete assistance (Lieberman et al. 2015). The Termination and Recapitulation Phase involves shifting the focus from areas of problem to areas that have positively changed since treatment began, acknowledging that treatment is ending, and processing feelings associated with the end of treatment (Lieberman et al. 2015).

Considerations when Selecting an EBT

Considerations for EBT selection may be grouped into three main categories: child factors, caregiver factors, and environmental factors. Child factors include the child's age, developmental level (particularly with regard to speech and language), size, type of symptoms (trauma, behavioral, emotional, relational, etc.), timeline of symptoms, stability of symptoms, and the ability to verbalize aspects of the traumatic event. Caregiver factors include the availability of a supportive caregiver to participate in services, the offending status of the caregiver (i.e., whether the caregiver perpetrated abuse against the child), primary concern of the caregiver, and parent's level of impairment related to traumatic and/or other psychiatric symptoms. Environmental factors include the stability of the child's placement, case plan goal and visitation frequency (for children engaged in the child welfare system), and the use of other trauma treatment modalities within the same family. See Table ​Table1 1 for a list of sample questions clinicians may ask themselves when selecting amongst TF-CBT, PCIT, and CPP. Clinicians should consider all factors (child, caregiver, and environmental) simultaneously as they relate to a particular case prior to selecting a treatment. For some cases, different factors may become more salient and weighted more heavily in the decision-making process, as will be illustrated using the composite case descriptions below. Although a simple guidance system such as a flow diagram to help clinicians to select a treatment may initially appear most helpful, our work with these families has demonstrated that the multiple factors which must be considered simultaneously are too complex to be represented in this way.

Table 1

Consideration

Question

Child

What is the age of the child?

What is the developmental level of the child's speech and language functioning?

What is the physical size of the child?

What types of symptoms (e.g., posttraumatic stress, emotional, behavioral, relationship) are present? Which are most impairing?

Did the symptoms start before or after the trauma?

Has the symptom presentation changed over time? How?

Can the child verbalize memories of the trauma?

Caregiver

Is there a supportive caregiver available to participate in treatment with the child? Who?

Will an offending caregiver participate in treatment?

What is the primary concern of the caregiver(s)?

What is the level of impairment of the caregiver's symptoms? Is the caregiver able to hear the child's trauma?

Environmental

How stable is the child's placement?

What is the case plan goal?

How often does the child have visits with his or her biological parent(s)? What are these visits like? Does the child show symptoms before, during, and/or after these visits?

What other trauma treatments are being used in the family?

Considerations for Selecting TF-CBT

Child Factors

As mentioned previously, TF-CBT is an evidenced-based treatment for children ages three to 18 who have experienced any type of potentially traumatic event(s) and who are currently showing symptoms of posttraumatic stress, though a full diagnosis of PTSD is not necessary to proceed with TF-CBT. In order to implement TF-CBT, a child must have the verbal level of a two-and-a-half year-old child (Deblinger et al. 2017). TF-CBT may proceed with children of any size. Additionally, the child must have a memory of their traumatic experience(s) and, to some degree, be able to verbally express this memory and its impact (Deblinger et al. 2017).

A child may present with other emotional, behavioral, and/or social relatedness symptoms in addition to posttraumatic stress symptoms, as comorbidity is common for children with posttraumatic stress symptoms. For some children, comorbid symptoms of anxiety, depression, behavior problems, and/or social relatedness may have occurred after the traumatic events, and may be explained by a diagnosis of PTSD or the failure of the child's environment or support system following the traumatic event (i.e., a caregiver becomes so overwhelmed with his or her child having been sexually abused that he or she has significant difficulty setting limits so as to not cause the child further upset which has resulted in behavior problems). In order to proceed with TF-CBT, posttraumatic stress symptoms should be causing the greatest impairment and thus, are the primary treatment need (Cohen et al. 2017). Comorbid symptoms that occur in response to the trauma may be reduced when posttraumatic stress symptoms are effectively addressed with TF-CBT (Cohen and Mannarino 1996; Cohen and Mannarino 1997; Deblinger et al. 2011; Mannarino et al. 2012; Scheeringa et al. 2011).

Alternatively, if comorbid symptoms preceded the traumatic event(s), a child may continue to experience the comorbid symptoms after completing TF-CBT, although some improvement is possible. If the child has frequent or impairing comorbid symptoms which require immediate focus and prioritization, an alternative intervention may be appropriate prior to initiating TF-CBT (Cohen et al. 2017). For instance, a child who is showing significant disruptive behavior (e.g., frequent aggressive behavior, defiance, oppositionality) across settings, who experiences frequent daycare/school suspensions, and who is in danger of expulsion may need a treatment that primarily targets disruptive behaviors, such as PCIT, to increase daycare/school placement stability, and prosocial behaviors. Although, the parenting component of TF-CBT effectively reduces disruptive behavior, some children with high levels of disruptive behaviors may require a specialized treatment to reduce these symptoms (Cohen et al. 2017). After the disruptive behaviors decrease, the child may benefit from TF-CBT if impairing symptoms of posttraumatic stress remain.

Caregiver Factors

Some caregivers may be most concerned about the child's posttraumatic stress symptoms, whereas others may be most concerned about the child's emotional or behavioral symptoms and his or her ability to manage them. Certain components within TF-CBT may need to be emphasized to meet the needs of the family, based on the clinician's judgment (Cohen et al. 2017). For instance, parenting work may become a large focus early and frequently throughout TF-CBT for families most concerned about problem behaviors. However, when children present with extremely high levels of emotional or behavioral symptoms and the caregiver reports high levels of distress in managing these symptoms, an alternative effective treatment may be needed prior to initiating TF-CBT (e.g., PCIT; Cohen et al. 2017).

TF-CBT is not designed to be used with offending caregivers except in very rare cases (see Deblinger et al. 2017 for a detailed review). Therefore, offending caregivers are not typically included in TF-CBT treatment and never in instances where the caregiver physically abused, sexually abused, or neglected the child (Deblinger et al. 2017). In TF-CBT cases in which the child is in the custody of child welfare, treatment developers recommend that the child complete TF-CBT with a non-offending caregiver such as a foster parent (Deblinger et al. 2017). According to Deblinger and colleagues (Deblinger et al. 2017), if, after TF-CBT is complete and reunification with the offending caregiver is proceeding, the child and offending caregiver should be referred to an effective treatment designed to meet the needs of both the child and caregiver such as Alternatives For Families Cognitive Behavioral Therapy (AF-CBT; Kolko 1996), Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT; Runyon and Deblinger 2014), PCIT (Eyberg and Funderburk 2011), or SafeCare (Gershater-Molko et al. 2002). Additional implementation guidance for using TF-CBT with children in the custody of child welfare, such as how to proceed with TF-CBT when a child has visitation with an offending parent or under what circumstances a biological parent may participate in TF-CBT, is extensively described elsewhere (e.g., Deblinger et al. 2017).

Environmental Factors

In order to proceed with TF-CBT, the child's environment should also be fairly safe and stable (Deblinger et al. 2017). For instance, if a placement change is imminent, TF-CBT may be delayed until the child is in the new placement (Deblinger et al. 2017). However, in situations where a move may be possible but is not imminent, treatment developers recommend proceeding with TF-CBT because it may serve to stabilize the placement by giving the child concrete skills to manage his or her difficulties, and provide foster parents with skills for understanding what the child has experienced and how to manage the child's problem behavior (Deblinger et al. 2017).

If the child's current home, school, or community environment is unsafe prior to the initiation of TF-CBT, therapists should consider if and how to proceed with TF-CBT. For example, if the child is actively experiencing ongoing physical or sexual abuse prior to the start of TF-CBT, TF-CBT would be inappropriate to initiate. Clinicians should follow all mandated reporting laws and work with the family to increase safety. If posttraumatic stress symptoms are present after the traumatic event ends, then TF-CBT may be appropriate.

There may be occasions when implementing TF-CBT may be appropriate when there is a risk of further trauma, but abuse is not actively ongoing. For example, it is possible to implement TF-CBT in some instances of community or domestic violence when the threat of violence is present but violence is not ongoing (e.g., a parent and child have moved away from the abuser but the abuser has threatened to find them), because there may never be a time when the threat of violence ends entirely (Cohen et al. 2011; Murray et al. 2013). In situations such as this, TF-CBT may help the child and caregiver enhance safety, more accurately perceive danger, distinguish between true danger and generalized trauma reminders, acknowledge traumatic events, and process traumatic events (Cohen et al. 2011; Murray et al. 2013).

For children in the custody of child welfare, TF-CBT may proceed with a non-offending caregiver, often a foster parent, regardless of the case plan goal or visitation frequency (Deblinger et al. 2017). However, the manner in which TF-CBT is implemented may change depending on whether visitation is ongoing, the child's biological caregiver is meeting requirements of the case plan, and/or reunification is likely. For instance, the TF-CBT therapist should monitor the impact of the child's visits with biological parents on the child's functioning, help the child apply skills learned in TF-CBT during visits (as needed), discuss the impact of the visits with the child in session, and support the caregiver's ability to help the child use coping skills prior to, during, and after visits (Deblinger et al. 2017). As mentioned previously, there are special considerations for involving a biological parent in treatment when courts decide that reunification will occur during the course of TF-CBT (see Deblinger et al. 2017, for a review).

In situations in which multiple children from the same family are seeking treatment, it is important that clinicians consider other treatment models that may currently be used, or are proposed to be used in the family prior to selecting TF-CBT. For instance, TF-CBT takes a structured approach which directly addresses the impact of traumatic stress. This is similar to the structured approach used in PCIT which directly addresses disruptive behavior. However, this structured and directed approach differs from the non-directive and reflective approach used in CPP. Switching between these two approaches may be challenging for caregivers.

Considerations for Selecting PCIT

Child Factors

As described by McNeil and Hembree-Kigin ( 2010), PCIT was originally developed for children ages three to five, and is typically appropriate for children ages two to seven. However, the developmental level of the child, particularly with regard to speech and language, is a more important consideration than the child's chronological age. The skills taught in CDI, the first phase of PCIT, are appropriate for use with children beginning in infancy, and variations of PCIT for infants and toddlers have been developed (e.g., Kohlhoff and Morgan 2014). However, to implement PCIT as described in the manual (Eyberg and Funderburk 2011), children need the developmental capacity to understand "if-then" commands, which typically develops around 24-30 months of age (McNeil and Hembree-Kigin 2010). Therefore, children whose language development is similar to that of typically-developing two-year-olds are usually considered appropriate for PCIT. With older children, an additional consideration in PCIT is the size of the child. Because many children initially refuse to comply with the time-out procedure in PDI, it is frequently necessary for the parent to carry the child to the time-out chair or backup area. Therefore, the child should be small enough for the parent to lift and carry. Although rarely the case in the five-and-younger age range, some children may be too large to be transported in this way, particularly if parents have mobility difficulties. In these cases, PCIT may be more challenging, and the therapist's level of experience may be an important consideration. For example, it may be helpful for the therapist to be sufficiently experienced to implement PCIT with modifications as described by McNeil and Hembree-Kigin (e.g., a "hands-off time-out procedure").

Caregiver Factors

As noted above, PCIT requires a caregiver to participate in every session, typically scheduled once per week. "Caregiver" is defined broadly; in general, any adult who has a regular, long-term caregiving role in the child's life may participate in PCIT, including biological parents, foster and adoptive parents, and extended family members who provide day-to-day care for the child (e.g., grandparents). PCIT is most commonly conducted with a caregiver with whom the child lives full time. However, several other living situations are appropriate for PCIT as well. Examples include an extended family member who has care of the child while the parent is working or a non-custodial biological parent with regular visitation (see below for more details regarding visitation schedules).

PCIT is not recommended for use with sexually offending caregivers, but can be used with caregivers referred following physical abuse or neglect. Multiple studies (Chaffin et al. 2004; Kennedy et al. 2016) have found significant reductions in physical abuse risk factors or recidivism following PCIT. In addition, intergenerational trauma is not uncommon in families seeking treatment, including those receiving PCIT. Parental experience of trauma certainly does not preclude PCIT, and parents may derive secondary benefit from the increased stability and self-efficacy promoted by PCIT. However, because PCIT's primary focus is on child behavior management, as opposed to parental symptoms, highly salient caregiver posttraumatic stress reactions may impede PCIT progress and/or completion (Ware and Herschell 2010). Clinicians should consider whether an EBT with greater emphasis on caregiver trauma or shared caregiver-child trauma, such as CPP, may be more appropriate in these cases.

Finally, in situations in which multiple symptoms are present, such as both disruptive behavior and anxiety, the caregiver's greatest concern should be strongly considered when choosing a treatment. For example, a therapist may consider a child's separation anxiety to be more clinically significant than behavior problems, but if the caregiver views the behavioral difficulties as the greater problem, treatment is likely to be more effective if those difficulties are addressed first (e.g., Weisz et al. 2012). Adaptations of PCIT for comorbid conditions have been developed and are in various stages of dissemination (see Carpenter et al. 2014 for a review). Furthermore, because PCIT focuses on strengthening the parent-child relationship first, comorbid symptoms may be partially or fully addressed during the course of PCIT (Chase and Eyberg 2008).

Environmental Factors

Finally, several factors in the child's environment are relevant when choosing among PCIT and other EBTs. The stability of the child's placement is a very important factor. Because PCIT focuses on strengthening the caregiver-child relationship, it should not be conducted in situations in which the relationship is likely to end (e.g., a foster placement that is known to be short-term; Gurwitch et al. 2017). Similarly, in situations in which a parent has lost custody of the child, it would not be appropriate for that parent to participate in PCIT as it is only appropriate if there is a case plan goal of reunification (Gurwitch et al. 2017). However, a different caregiver (e.g., foster parent) may participate with the child. Even when the goal is reunification with the parent, the parent must have sufficient contact with the child to conduct and practice PCIT. At a minimum, the parent must be permitted sufficient unsupervised contact with the child so that weekly therapy appointments are possible (McNeil and Hembree-Kigin 2010). However, because outside-session practice is also a vital part of PCIT, Campbell et al. ( 2014) recommend that the parent have at least three visits per week in addition to the therapy session. Ideally, these visits should take place in the home environment so that the PCIT skills can be practiced in that context.

An additional environmental factor is the presence of siblings in the home who may also have experienced trauma or may be experiencing their own behavioral and emotional symptoms. Several factors should be considered when treatment is recommended for multiple siblings in a family. As delineated by McNeil and Hembree-Kigin ( 2010), PCIT is typically conducted with one child in a family at a time, but parents are directed to use the skills with other children within or near the two to seven age range who live in the home as reductions in behavior problems have been shown in siblings of children treated with PCIT (Brestan et al. 1997). PCIT is sometimes pursued for these children following completion of PCIT with the first identified child. In some situations, different children within the same family could participate in separate treatment models, such as conducting PCIT with one child while conducting TF-CBT with another, because the parenting component in TF-CBT uses similar strategies to those used in PCIT, and takes a structured approach. However, in most cases the same caregiver should not participate in both CPP and PCIT, because the differing styles of parent-child interaction and therapist stance (i.e., directive versus reflective) could cause confusion.

Considerations for Selecting CPP

Child Factors

CPP is evidence-based for children under the age of six. Due to its ability to treat children starting at birth, there are no minimum developmental requirements for participation. However, developmental considerations are made in the delivery of the intervention such that different techniques may be used depending upon the age of the child. CPP is designed to treat emotional and behavioral symptoms within children who have been exposed to trauma, with an additional treatment goal of returning children's development to a more typical trajectory if delays are noted (Lieberman et al. 2015). A timeline of symptom presentation and associated trauma exposure is often challenging to establish in young children, with many children experiencing potential trauma in-utero (e.g., maternal substance use while pregnant). Therefore, it is not necessary to establish that current mental health symptoms emerged subsequent to trauma exposure to pursue CPP. A fundamental tenet of CPP is that memory starts at birth and that pre-verbal memories have an impact on child functioning; therefore, a child does not need to have the ability to verbalize trauma memories in order to participate in CPP. Instead, caregivers and children learn to identify and respond to body-based dysregulation or other impacts of pre-verbal trauma (Lieberman et al. 2015).

Caregiver Factors

CPP is a dyadic intervention which necessitates the involvement of a caregiver within treatment. CPP is practiced within a relationship-based framework, and as such, the primary vehicle for change is the parent-child relationship (Lieberman et al. 2015). Therefore, parents and children typically participate in treatment sessions together. During the initial phase of CPP (Foundational Phase: Assessment and Engagement), the clinician assesses the needs of each caregiver-child relationship, understanding that child symptoms and attachment are relationship-specific. Indeed, a child often presents with different needs within different caregiver-child dyads. CPP can be conducted with one caregiver or multiple caregivers. If multiple caregivers are identified, initially they each typically participate with the child in separate dyadic sessions. Triadic work (e.g., sessions involving both caregivers and the child) may be considered at a later point in the intervention (Iwaoka-Scott and Lieberman 2015).

CPP may be contraindicated if a caregiver is not agreeable to the treatment model (e.g., dyadic sessions, the need to address the child's trauma history) or is experiencing unstable mental health difficulties that pose significant risk to the safety of the child (e.g., untreated psychosis, inability to present to sessions sober; Lieberman et al. 2015). If CPP is not deemed appropriate, alternative treatments or modifications may be pursued (e.g., starting with caregiver-only sessions to enhance safety and provide necessary case management, or focusing CPP on enhancing safety and building the caregiver-child relationship without trauma processing; Lieberman et al. 2015).

Environmental Factors

Finally, it is important to consider treatment needs for the entire family when making intervention decisions. There are significant differences among all three models discussed in this paper related to theoretical orientation regarding processes of change, therapist stance, requirements of treatment, and choice of strategies to address mental health symptoms that would likely make it challenging for a caregiver to participate in multiple interventions at the same time. For example, all three treatments address child disruptive behavior, but the therapist takes a structured, directive stance in PCIT and TF-CBT whereas a therapist takes a primarily non-directive, reflective stance in CPP. This may be confusing for a parent, whose experience of therapeutic intervention would vary vastly between the interventions. With regard to requirements, TF-CBT requires the presence of trauma memories that a child can verbalize and CPP does not, and therefore again could be confusing for a caregiver when providing the trauma framework needed for trauma processing. Finally, specific, in-the-moment approaches to address mental health symptoms can vary, in sometimes contradictory ways, between interventions. For instance, in response to minor, misbehavior, a PCIT therapist may coach a parent to remove his or her attention in order to avoid reinforcing the misbehavior, thereby reducing the frequency of the misbehavior. However, a CPP therapist may approach the same behavior by helping the parent and child to engage in a discussion about the meaning of the behavior and ways to use body-based regulation strategies to reduce the frequency of the behavior. In this example, the PCIT approach removes parental attention to the behavior, whereas the CPP approach would increase parental attention to the behavior with the purpose of improving regulation. If caregivers participate in multiple treatment interventions with their children, it may be difficult for them to discern when to use these differing in-the-moment approaches to misbehavior. Inconsistent responses to misbehavior may unintentionally serve to maintain the occurrence of the misbehavior.

Case Examples

Case 1

Thomas, age four-and-a-half years, was referred for treatment after he and his eight year-old sister were removed from their biological parents' care eight months ago. Removal occurred after a neighbor called the police when Thomas' sister asked her for food and disclosed that she had not eaten in two days. Both children are noticeably small for their age. The subsequent child welfare investigation found methamphetamine and drug paraphernalia in the home, very little available food, and squalid living conditions including animal and human feces on the floor. Both children later tested positive for methamphetamine in a hair follicle test. Upon removal, Thomas and his sister spent the first two weeks together in a shelter until a foster family could be identified. They have remained with the same foster family ever since.

Thomas' foster parents report that Thomas has intense bedtime crying episodes in which he calls for his biological mother and sister and is very difficult to soothe, wakes frequently in the night due to nightmares and has difficulty falling back to sleep, steals food, is irritable and easily upset, has frequent toileting accidents, has difficulty separating, and tantrums during the day. At daycare drop-off, he regularly clings to his foster mother and says "Don't leave me." His foster parents indicated they are most concerned about his nighttime crying episodes and nightmares due to the toll the sleep disruption is having on everyone in the household, although they note some improvement since he arrived in their home. Following supervised visits with his biological parents, his foster parents report an increase in bedtime tearfulness, nightmares, and poor sleep. His foster parents are eager to support Thomas and his older sister and are willing to participate in treatment with both children. With his foster parents' support, Thomas has already begun weekly speech and occupational therapy to address developmental delays. His language age equivalents are three years, four months for receptive language and three years, two months for expressive language. Although the child welfare case plan has been designated as reunification, Thomas' biological parents have not consistently attended once weekly supervised visits and have repeatedly tested positive for alcohol and methamphetamine despite both having completed inpatient substance abuse treatment. They have also failed to attend court-ordered family therapy. In the latest staffing, the team began discussing the possibility of recommending a change of the case plan goal to termination of parental rights at the next court hearing.

Case 2

Martinique, age three, was referred for treatment by her pediatrician after she was expelled from daycare for aggression including punching her teacher in the face, biting peers, and attempting to choke a peer. When she was 18 months old, Martinique's mother and father were in a physical altercation in which her father pushed her mother who was holding Martinique. Martinique and her mother both fell to the ground and her father continued to kick her mother while Martinique lay crying. Martinique's mother was bruised but did not sustain serious or lasting physical injuries. Martinique sustained bruises but was otherwise unharmed. After this incident, Martinique and her mother moved in with Martinique's grandmother in another state, and neither she nor her mother have had further contact with her father. Martinique's mother reported that initially, Martinique became clingy following the abusive episode, had difficulty separating, had nightly nightmares, and would say things such as "Mama boo boo, Daddy hurt" when she noticed her mother's bruises. However, her mother reported that these symptoms subsided a few weeks after she and Martinique began living with Martinique's grandmother. She noted that she would acknowledge the abusive incident and reassure Martinique that they were safe. A current thorough assessment of posttraumatic stress symptoms yielded no clinically significant symptoms of posttraumatic stress at this time other than occasional nightmares. Martinique's mother reported that she experienced posttraumatic stress symptoms initially as well, but that she had participated in individual therapy which effectively reduced them. Her mother reported that Martinique is currently aggressive towards her at home, is non-compliant, and has daily tantrums that last 30-60 min. These behavioral symptoms first started after the traumatic event occurred, when Martinique was two years old. Her mother and pediatrician believed that she would "outgrow" these symptoms as she grew older and matured, but they have intensified instead. She is of average size and has no known developmental delays. Her mother is concerned that she may lose her job because she has had to repeatedly leave work to care for Martinique when she has been suspended from daycare. She has had difficulty identifying another daycare that will accept Martinique due to her aggression. In addition, she reported feeling frustrated with herself because she was "always getting on to her" about her behavior.

Training Implications

In their 2011 call to improve the system of care for maltreated infants, toddlers, and preschoolers, Osofsky and Lieberman advocate for improved undergraduate and graduate training curricula in early childhood development and trauma for mental health practitioners. Graduate clinicians-in-training also need to be able to access trainings for EBTs for early childhood trauma so that upon graduation they may be appropriately equipped to work with families to address the effects of trauma in early childhood. Given their empirical support and widespread dissemination, clinicians-in-training may have the greatest access to trainings in TF-CBT, PCIT, and CPP. Therefore, the child, caregiver, and environmental considerations and applications of the framework offered above may be used as teaching tools within graduate programs and continuing education trainings to provoke discussion and enable clinicians to make informed decisions regarding which treatment to use. It is our hope that these considerations may also be helpful to use in trainings by TF-CBT, PCIT, and/or CPP trainers in states that disseminate more than one EBT to help clinicians make thoughtful, treatment-informed decisions about EBT selection. Such careful consideration of treatment selection may enable clinicians to select the treatment that may provide the best care for the child and family when multiple treatments are available.

Summary

Very young children under the age of six are disproportionately likely to be exposed to traumatic events. Fortunately, EBTs are available to help alleviate the ill effects of trauma exposure early in life. The increased availability of training in EBTs for children following early childhood trauma exposure has brought to light the need to provide clinicians with guidance regarding the treatment selection process. This paper highlights child, caregiver, and environmental factors that are important for clinicians to consider when making treatment selection decisions. The composite case descriptions offered illustrate the application of this decision making framework and may be used in graduate training programs and trainings for TF-CBT, PCIT and CPP to aid clinicians in making treatment selections.

Compliance with Ethical Standards

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Footnotes

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

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In the 1960s, there were very few professional counseling resources across Monroe County, particularly for our underserved and underprivileged population. Church Women United and the Monroe Council of Churches began to evaluate this service need and to explore the possibility of established a non-sectarian family counseling agency. In April of 1965, the Child and Family Services Board of Directors held their first formal organizational meeting. The Agency began providing services in 1966 and continues to serve hundreds of Monroe County residents each year.

In 1987, Shelter, Incorporated, which had provided emergency and advocacy services for survivors of domestic violence and their children, asked Child and Family Services to assume operation of the Domestic Violence Shelter Program due to financial issues. Following consideration by the Board of Directors, the merger of the two nonprofit agencies began in February of 1987. The merger was completed in 1989, and our Agency was renamed Family Counseling and Shelter Services (FCSS).

In February of 2006, the Agency opened the doors to the Children's Center of Monroe, its third facility, dedicated to serving the needs of our Monroe County children exposed to traumatic issues such as divorce, abuse and neglect, domestic violence, or substance abuse. The Children's Center provided Monroe County's first Supervised Visitation and Safe Exchange Program as well as child counseling and play therapy and parenting classes. In 2012, we relocated the Children's Center to our main office on LaPlaisance. The Center officially closed and our counseling office continued visitations by providing Therapeutic Visitations, instead of Supervised. Therapeutic Visitations are facilitated by licensed therapists, which enhances the visitation process.

In 2009-2010, FCSS diversified its services further adding a Domestic Violence Support Center (DVSS), Domestic Violence Legal Advocate, a Monroe County Domestic Violence Emergency Response Team (DVERT), Substance Abuse Assessments, Counseling, Groups, Parenting after Violence Classes, Supportive Visitations, Monroe County SMILE program for divorcing couples with minor Children, and our Batterer Intervention Program for women and men.

In December, 2014, the Child Advocacy Center (CAC) of Monroe was added to our DVSS Division. The CAC provides advocacy for children who have been sexually or physically abused as well as advocacy for their families. If requested, our Forensic Interviewer can conduct Forensic Interviews at our main office in order to help reduce any additional trauma that possibly could result for the child while they are going through the legal process. Beginning in 2016, we also expanded our DVSS Division to include Sexual Assault Support Services for all ages, and officially changing the division name to DSVSS. As of 2017, we added a full-time Sexual Assault Advocate to help support victims of sexual assault as well as a Volunteer Coordinator to build our direct service volunteer base.

In December, 2016, FCSS celebrated its 50th Anniversary of providing essential services all across Monroe County. Today, we continue to operate three key programs including Professional Counseling, Domestic Violence Emergency Shelter and Advocacy, and the Domestic and Sexual Violence Support Services (DSVSS) Division which provides advocacy for victims, and prevention/intervention for batterers. We continue to evaluate and respond to the growing and changing social service needs of our community and to meet our Agency mission and vision.

If you, or a family member, are in need of any of these services, we encourage you to contact us via email or telephone for information or an appointment.

Need Help? Contact us now (734) 242-7233 (SAFE)

We Facilitate Safe Spaces to Heal​

Our Mission:

"To provide programs and services essential to an individual's emotional well-being and the success of our community, as well as the protection and empowerment of survivors of domestic violence and sexual assault."

Our Vision:

"To be recognized throughout Monroe County as a full service child and family agency serving the underprivileged, while partnering within our community for those in need".

Over 50 years of providing professional and compassionate counseling services to the families, children, and individuals of Monroe County, with an emphasis on family preservation and services for those that might not otherwise have access.

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Lighting a path from the darkness that is domestic violence to a safe haven, empowerment, and a new and independent life.

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Assisting domestic violence batterers in changing behaviors and beliefs, reducing risk to women and children, and helping to break the chain of violence within our community.

Counseling and Support Center

14930 LaPlaisance Road, Suite 106
Monroe, MI 48161

(734) 241-0180

M-Th, 9am-8:30pm

Sunrise House Domestic Violence Shelter

*Location details upon acceptance.

(734) 242-7233 (SAFE)

Available 24 hours a day.

Domestic & Sexual violence support services staff

Lauren Lee

[email protected]
734-755-9709 (DV Advocate Cell)
734-625-7116 (SA Advocate Cell)

Domestic Violence Shelter Staff

Paige Fahringer, Sara Workman, Michelle Backus, Rita Wendler. (Not pictured: Kaitlyn Doute, Riann Webber)

Directors / Board Members

Kristian Bezeau

Drew Presto

Jason Linster

Timothy Stoddard

Ann Rothman

Brittney Calender

Barbara DiFlore

Gabriella Erdt

Michelle LaVoy

Linda M McDevitt

Ways to Give

Help By Supporting Positive Change Within Our Communities Today!

We greatly appreciate your help while we continue our mission to help those in need of mental health, domestic violence, and sexual assault services within our community.

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Who we are - Family Counseling and Shelter Services

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In the 1960s, there were very few professional counseling resources across Monroe County, particularly for our underserved and underprivileged population. Church Women United and the Monroe Council of Churches began to evaluate this service need and to explore the possibility of established a non-sectarian family counseling agency.

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This is the number if someone is having a crisis and needs assistance as soon as possible. You will be directed automatically to a counselor or someone who can assist you.

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Monroe Community Mental Health Authority

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Lighting the way:

The Monroe Community Mental Health Authority cares deeply about helping everyone in our community lead fuller, richer lives. That is why we are devoted to providing quality mental health services to all.

Am I eligible for services?

Monroe Community Mental Health Authority (MCMHA) serves anyone with a mental health or substance use disorder diagnosis, as well as individuals with intellectual/developmental disabilities (I/DD). MCMHA can provide services regardless of residence or ability to pay. Even if you do not qualify, we will connect you with the correct care agency.

The crisis team also provides 24/7 crisis mental health care to those in need. If you or someone you know is in a crisis, call 800-886-7340.

A Center for Community.

Our mission is to enhance and promote the mental health, well-being, and independence of members through a supportive environment based on respect, equality, acceptance, self-determination, and empowerment.

Become a Provider.

We are always looking for great new providers to help our consumers. If you're interested, take a look at our standard provider contract and then complete the application on our Provider page.

24-Hour Suicide Prevention
800.886.7340

24-hour Emergency Services ensure that help is available to anyone 24 hours a day, seven days a week. A mental health professional can be reached after regular business hours by calling: 800.886.7340 or 734.243.7340

Anyone, anywhere can be the one to make a difference in the life of someone with a mental health or substance use challenge - if they know what to do and what to say.

Mental Health First Aid See more about Mental Health First Aid under
Resources

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Monroe Community Mental Health Authority

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Lighting the way: The Monroe Community Mental Health Authority cares deeply about helping everyone in our community lead fuller, richer lives. That is why we are devoted to providing quality mental health services to all. Monroe Community Mental Health Authority (MCMHA) serves anyone with a mental health or substance use disorder diagnosis, as well as individuals with intellectual/developmental disabilities (I/DD).

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This article is from a trauma healing center. They assist in helping those with trauma and allowing those to heal.

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This website gives all forms of resources. For those with trauma, illness, and grief.

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The Consortium for Trauma, Illness & Grief in Schools (TIG) is a county-wide, multi-agency effort to prepare school districts to have appropriate mental health support in place during incidents of trauma, violence, illness and death that impact the school. TIG provides education, training opportunities and support to assist schools to effectively respond to the needs of children, parents, teachers, and other school personnel in times of crisis. The TIG website, has more detailed information as well as resources on grief, loss and trauma.
TIG Consortium Website The Monroe County Office of Mental Health contact for TIG is:
Elizabeth Kingsley-Curran, TIG Coordinator

Youth Risk Behavior Survey Analysis

Another activity that Monroe County Office of Mental Health has undertaken to support our local school districts is analysis of the Youth Risk Behavior Survey. To increase our efficacy in managing childhood adversity and trauma, our office has developed a cross-system partnership including local school districts, county government and community-based organizations to assess local Adverse Childhood Experiences (ACEs) data, resiliency factors and risk behaviors in youth. A summary of the results from the 2019 YRBS survey and suggestions on how everyone can help support our youth in overcoming the negative effects of ACEs is available below:

The dissemination of the results of this innovative analysis has driven a strategic plan accelerating change in schools, the service system and community. A summary of the steps we have and are undertaking to make a difference in Monroe County is available below:

Our work was presented at the Annual Staff Development Training Forum sponsored by the NYS Coalition for Children's Behavioral Health and the NYS Office of Mental Health at Saratoga, NY in November of 2018. The presentation slides are available below:

For more information on analysis work in this area, contact:

Resiliency Series - Dr. Ginsburg

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Consortium for Trauma, Illness & Grief & Related Resources

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The Consortium for Trauma, Illness & Grief in Schools (TIG) is a county-wide, multi-agency effort to prepare school districts to have appropriate mental health support in place during incidents of trauma, violence, illness and death that impact the school.

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In this article, there are all sorts of resources when it comes to medical care and dental.

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MCOP provides services to low-income individuals and families in Monroe County. We are able to meet the needs of our low-income community by administering millions of dollars of federal, state, local, and private funds to achieve our mission to reduce poverty, improve the quality of life, and promote self-sufficiency through community action.

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This article gives long-term help and short term for all sorts of situations one may be in.

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Search COVID-19/Coronavirus assistance programs in your ZIP code. Programs helping with food, paying bills, and more.