Overview of Post-Traumatic Stress Disorder and Other Trauma/Stressor-Related Disorders^[1]

Child trauma has received considerable attention since the publication of the ACES study, which highlighted the deleterious effects of traumatic exposure during childhood on long term health and wellness outcomes for adults. The National Child Traumatic Stress Network (NCTSN) was developed in 2000 to respond systematically to the epidemic of childhood trauma, and it offers clinicians and families with resources to promote healing and resilience after potentially traumatic events. NCTSN outlines that its mission is to raise the standards of care and access to services for children and families impacted by trauma.

So, what do we mean by trauma? For the purposes of client psychoeducation, it can be defined as a scary or upsetting event that can cause big changes in the way someone thinks, acts, and feels emotionally and physically. Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) sa)tates that “trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Additionally, trauma is defined by the three E’s: the event itself, the subjective experience of the event, and the effects of the event. Traumatic events tend to be of bigger magnitude, with examples including being assaulted, motor vehicle accidents, and natural disasters. The subjective experience matters; no two people experience an event in the exact same way. A traumatic experience is one that overwhelms someone, often immobilizing coping abilities or access to effective coping strategies. Lastly, the effects vary from changes in feeling, to avoidance of reminders of the event, to changes in sleep or eating patterns. It’s these effects that give us a window into Post-Traumatic Stress Disorder (PTSD).

Oftentimes, children bounce back from traumatic events. It’s much like physical injuries; there is a time for people to recover and heal. Caregivers and other important adults (grandparents, teachers, and mentors) play a critical role in the child’s recovery by supporting them in making meaning of their experiences and giving them time to heal. In PTSD, a child is stuck in their recovery process, and this is often where PTSD symptoms come into play. A person experiences intrusive thoughts about the trauma they were exposed to or have flashbacks or nightmares. These reactions perpetuate because someone is stuck in their recovery. Trauma exposure rates are high, and the good news is that some will bounce back without intervention, and some can receive timely, brief interventions to prevent the onset of PTSD. For those with PTSD, there are evidence-based treatments to promote full recovery.

Gaby’s experiences fall under the umbrella of traumatic events, with witnessing family violence and experiencing physical abuse. We would need to understand her experience of the event and the effects of the event from her reporting, but by impression, we can sense that she has been deeply impacted by these events. As Gaby has said, she hates starting over with new adults and caregivers, and she may identify this as the most “traumatic” part of her experience. As we will find later, there are particular types of events and experiences that will meet Criteria A for PTSD, and being in foster care would not technically fall under that category. Would we not then do treatment with Gaby? Of course not! As mentioned in her interview in this chapter, Dr. Cohen has said that we are here to help youth and families organize their experiences and to feel more in the driver’s seat with their lives and memories; so, clinicians will need to rely on the art of intervention.

Prevalence of Trauma and Stressor Related Disorders

Approximately two thirds of children in the United States are exposed to at least one potential traumatic event by the time they turn eighteen years old (CDC, 2019; SAMHSA, 2017). Although only about 5% of adolescents will meet PTSD criteria (Hamblen & Barnett, 2018), more often than not, traumatic events will cause stress that leads to functional impairment even if adolescents do not meet criteria for PTSD (Alisic et al., 2014). The National Center for PTSD reports that PTSD rates are higher in girls than boys, and rates tend to increase with age (Hamblen & Barnett, 2018).

Development of Trauma and Stressor Related Disorders in Youth

In clinical conversations, PTSD symptoms are considered normal reactions to abnormal events. The kind of event and the intensity of exposure to that event are known to be predictors of PTSD; essentially, the more intense an event and the closer someone is to the event, the higher the likelihood of PTSD (Hamblen & Barnett, 2018). For instance, a child who was violently assaulted is more likely to develop PTSD than a child who witnessed the violent assault. Moreover, researchers have found that factors such as pre-existing psychiatric disorders, parental psychopathology, being female, and low social support can increase the risk for PTSD (Hamblen & Barnett, 2018). Interventions to address PTSD tend to focus on cultivating protective factors such as parent observational capacity of child symptoms, supporting the child during recovery specific to the presenting symptoms, and developing adaptive coping skills (Hahn et al., 2019; Trickey et al., 2012). Gaby’s situation has many factors to consider; while she wasn’t directly assaulted by her parent when she witnessed intimate partner violence at home, she was still in close proximity to be affected by it. Also, her mother may have had her own stress symptoms from the intimate partner violence she sustained, which could impact her ability to be attuned to Gaby or to help co-regulate Gaby.

Developmental Systems Considerations for Trauma and Stressor Related Disorders

So how is trauma different for children? Development matters. Trauma has the potential to derail the child’s developmental trajectory, negatively impacting one or more domains of functioning (i.e., cognitive, emotional, and behavioral), which in turn may affect the child’s relationships with family and friends, school performance, self-concept, and more. The cumulative effects of trauma, especially severe and prolonged exposure, can change both the functioning and structure (Cohen, et al., 2017) of the child’s brain, considering that child organ development tends to resemble adults by age 15. With the brain, there have been studies that show that traumatic exposure affects grey matter and reactivity when viewed on an fMRI scan.

The family system is critical for recovery, starting with the child’s primary caregiver(s). Researchers and practitioners agree that the presence of a supportive caregiver significantly improves the likelihood of a positive treatment outcome for the child. There is the reciprocal interaction between child and caregiver. Studies find that caregiver attunement to the child’s needs and ability to assist the child are protective against development of PTSD after a traumatic exposure (Berkowitz et al., 2011). The Child and Family Traumatic Stress Intervention CFTSI is rooted in the idea that if there is increased observational capacity about symptoms, along with the ability for needs to get met and for proper coping skills to be employed, then the child will have a better prognosis in their recovery (Berkowitz et al., 2011). Caregivers can also have a reduction in their own stress symptoms as a result of their child getting treatment (Hahn et al., 2019), showing that intervention is mutually beneficial for the parent-child dyad.

Think of an example when a parent gets lost when they are driving a car. If the parent is flipping out and refusing to ask for directions, the child will react based on the parent’s reactions. If the parent is lost and remains calm, the child will not even know there is a problem. This example illustrates that caregiver stress can affect child symptomatology. Conversely, child symptomatology can affect parental stress; consider what it must feel like for the parent that has a child with hyperarousal, sleep problems, and oppositionality. It becomes a dance that leads to more frustration.

When external systems (e.g., school, community, and peer groups) are not healthy and healing for the child, they can either create more risk factors and more exposure to traumatic stressors, or they can delay recovery from any traumatic exposure. Complex trauma can emerge in such cases; complex trauma is defined by NCTSN (2011) as “both children’s exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure.” These are the events or series of events that impact the development of self-attachments with caregivers, with much of a child’s development relying on safety and stability offered from secure attachments (NCTSN, 2011). Gaby’s case can illustrate some of the disruptions in attachments that lead to complex trauma.

Other developmental systems factor to consider are the interplay of time and culture. How has systemic oppression influenced conditions leading to traumas? Have the parents themselves had a trauma history, as we know that intergenerational transmission of trauma is real? How much of caregiver stress is their own trauma reminders, as well as the stress of being a caregiver of an injured child? How much does racial stress serve as a vulnerability for PTSD?

Experiences Across Race and Ethnicity. In a previous chapter, we discussed racial trauma, and the core concepts from that chapter articulate both the structural conditions that create unique risk for trauma exposure and the experience of race-based traumatic stress. One of the other core elements of a trauma-informed approach includes attention to cultural, historical, and gender issues; for this section, we will consider specific cultural and historical factors. Part of the reality in writing this chapter is that there are disparities in the knowledge base and implementation of EBPs for child trauma for racial-ethnic minority populations. For example, consider the dearth of studies specific to Asian American trauma despite the known history of state-sanctioned internment camps and other discriminatory practices. Even with our best efforts to understand the unique traumas experienced by immigrant youth (Cleary et al., 2018), the knowledge base for responsive intervention is limited (Cardeli et al., 2020). With this in mind, we will present an overview of unique experiences of trauma across racial ethnic minority groups with some information related to specific care approaches.

Studies have shown that Black and African American people have higher exposure to certain trauma types, such as community violence, hate crimes, and pervasive racism (Cheng & Mallinckrodt, 2015; Williams, 2018; Roberts et al., 2011). Consequently, the rates of PTSD are higher in non-white racial/ethnic groups than in Whites, regardless of the number and type of traumatic events (Alegria et al., 2013). Another study elucidates that coping styles matter; avoidance coping creates greater symptom presentations in Black and African American people (Weiss et al., 2017). When working with Black and African American youth and their caregivers, it is important to be mindful of their distrust and hesitancy towards mental health providers based on previous atrocious historical events (e.g., Tuskegee Experiment) and previous negative experiences (i.e., providers call child welfare agencies at a much higher rate, and there is prejudice regarding inner city youth as “troubled” children, prone to violence and crime). Especially for White clinicians, it is paramount to open the floor for conversations regarding the visible and invisible wounds of racial trauma (Rich, J & T. Corbin, personal communication), and allow oneself to practice cultural humility and curiosity regarding both the group and individual level experience of that youth. What makes this worth mentioning is that stigma can create barriers to access to care for minority populations, and avoidance coping is what perpetuates symptoms.

As mentioned above, the experiences of immigrant youth are unique from other child groups because of their experiences before migration, during their migration, and after migration/during settlement. An approach that has some data is Trauma-Systems Therapy for Refugees (TST-R), an adaptation of Trauma Systems Therapy (TST; Saxe et al., 2006; Saxe et al., 2015). TST considers the individual/family, community, and macro systems of a client’s world, an approach that attempts to promote individual change but also to intervene at a social and structural level. In TST-R specifically, services are delivered in partnership with a cultural broker, much like a lay-counselor who is a community member with shared ethnic background with the client (Benson et al., 2018). This task-sharing approach has been used in delivery of other trauma EBPs outside of the United States (Dorsey et al., 2020). This team aims to enhance safety of the child’s social environment, reduce acculturative stress, and help the child with regulation skill building (Benson et al., 2018). Early findings from an ongoing, multi-site program evaluation of TST-R show that it is a promising intervention for refugee children and adolescents, in particular those who experience acculturative stress and traumatic stress (Cardeli et al., 2020).

Trauma-focused intervention has been studied in Japan, and the insights from these studies demonstrate the need to understand a child’s presentation through the lens of their culture. Kameoka et al. (2020) highlight that negative feelings such as fear, anger, guilt and shame are seen as undesirable and that Japanese folks avoid expression of these feelings; however, in the context of treatment, the families in the intervention study were engaged throughout the protocol. So, both points would be true; yes, avoidance of expression can be a cultural norm, but there is cultural flexibility that allows for engagement in trauma-focused treatments. Understanding culture can create better conditions for engagement of families and general uptake of the active ingredients of an evidence-based intervention.

As mentioned earlier, for more about considerations about racial trauma, please consult Chapter 2. In addition, there have been many current resources coming out of Dr. Metzger’s Empower Lab, where she investigates Engaging Minorities in Prevention, Outreach, Wellness, Education, & Research. Her lab’s work looks specifically at how to improve mental health treatment outcomes for Black and African American youth who are exposed to interpersonal and racial trauma. As you read the intervention section of our current chapter, reference the racial socialization strategies suggested in the article by Metzger et al. (2021).

Experiences of LGBTQ+ Youth. Sexual minorities will experience discrimination related to their sexual identities, and these affect external stressors and how those youth process those stressors (Russell & Fish, 2016). The LGBTQ+ community has been overlooked in mental health care that affirms their particular stressors, as a result of stigma or structural barriers. Roberts et al., (2012) report that sexual minorities have a risk of PTSD 1.6 to 3.9 times higher than heterosexuals, with child abuse victimization being a driver of traumatic exposure. Gender non-conforming youth tend to experience the most child abuse victimization among sexual minorities (Roberts et al., 2012).

Assessment of Trauma and Stressor Related Disorders

PTSD symptoms span intrusive and distressing memories of the event, avoidance of reminders related to the event, changes in mood and thought patterns such as negative emotional states like fear, anger, guilt, and shame, and hyperarousal (Spielman et al., 2020). For PTSD to be diagnosed, these symptoms must occur for at least one month. For Gaby, her symptoms map onto the criteria for PTSD: having nightmares every other day, feeling emotionally numb, avoidance of thoughts related to her traumas, and feeling irritable “all the time.” We would need to assess further to understand if Gaby meets full criteria for PTSD; for this list, consult this SAMSHA (2014).

Avoidance is a hallmark symptom of PTSD. Oftentimes, it is the avoidance symptom that perpetuates the entire constellation of PTSD symptoms. Think of the avoidance model of coping: if someone avoids a scary-looking dog as they walk down the street, they feel better in the moment, and that relief reinforces their appraisal that the dog was scary. What happens the next time the child sees a dog? They will have anxiety or arousal, followed by avoidance.

In addition to avoidance, youth who have experienced trauma may demonstrate many other symptoms. Intrusion symptoms like flashbacks involve distressing memories of the traumatic event. When a youth is experiencing intrusion symptoms, they may appear distractible or as though they are “spacing out.” Alternately, they may appear very scared in the absence of any identifiable stimuli in their environment. Young children may act out traumatic events in play.

Additionally, children who experience negative alterations in cognitions and mood may appear similar to children who are depressed. They may be forgetful about important events. They may present as pessimistic about themselves, other people, and the world. They may appear standoffish and have trouble connecting with others who are positioned to support them. Like Gabby, children with negative alterations in cognition and mood may appear numb and have difficulty experiencing positive emotions.

The symptom of “marked alterations in arousal and reactivity” may present in a wide range of ways. For example, some children who have experienced trauma are referred for behavioral issues and acting out. Without thoroughly assessing trauma history and PTSD symptoms, these youths may be misunderstood and mistreated.

Symptoms occur with developmental contexts. For adolescents, who are already vulnerable for at risk behaviors, trauma can increase risk taking even further. They may attempt to gain mastery over their symptoms or their situation. To borrow from the acquired capability theory of suicide (Joiner, 2005), being exposed to life threatening situations decreases the aversion that naturally comes to humans to avoid pain. For toddlers, tantrums become more frequent or more destructive. For school-aged children, there can be a withdrawal from generativity and social engagement, or externalizing behaviors because they maybe lack coping skills.

PTSD has various criteria, and it is important to note that because a person does not meet “Criteria A” which specifies the types of events that lead to PTSD, it does not mean that their experience is not meaningful or valid, or that it does not cause distress; however, to meet the official criteria for PTSD, Criteria A exposure must be evident. It is important to address that a child does not need to meet full PTSD criteria in order to benefit from trauma treatment (Cohen, 2017). The concept of post-traumatic stress symptoms (PTSS) helps us to consider other diagnostic constellations such as depression, anxiety, and behavior problems, when driven by trauma.

Assessment Tools

A child should have a semi-structured clinical interview conducted by a trained trauma clinician (someone who has worked with enough trauma-impacted youth to develop an expertise) and used self-report instruments to assess PTSD and other emotional problems that can accompany PTSD. Without a question, a clinical interview is essential and can be considered the “gold standard” in diagnosing PTSD and understanding a child’s unique challenges.

When interviewing the child, family members, or teachers, use language that is direct and specific to the problem. Ask questions about observable changes like, “How has your sleep been? Have there been any difficulties falling or staying asleep?” Internal changes like intrusive thoughts can be captured in questions like, “How often do pictures of the trauma pop in your head when don’t want them to?” Teachers can provide collateral in terms of classroom changes like disruptive behavior, withdrawal from peers, and drop in performance or attendance.

Measurement Tools and Rating Scales. NCTSN has a library of screeners for child trauma available for use, and they provide guidance on selecting an appropriate screener for your setting. The Child Trauma Screen (CTS) is a brief trauma screening measure for children (Lang & Connell, 2017), and it has been used in behavioral health, primary care, child welfare settings, and juvenile justice settings. It is a 10-item screener with excellent psychometric properties for use with children ages 6 to 17 (Lang et al., 2021; Lang et al., 2018). The CTS screens for potential trauma exposure and for trauma symptoms. The screener has cut points that maximize sensitivity and specificity (Lang et al., 2021; Lang et al., 2018). When choosing a screener for your setting, be sure to consider the age of child, whether parent or child report will be gathered, people/time resources to administer/score the screener.

A commonly used, open-access screener is the Child PTSD Symptom Scale (CPSS-5), a measure used for children ages 8 to18 to assess PTSD diagnosis and severity in the past month (Foa et al., 2001; Foa et al., 2017). The CPSS-5 has a trauma exposure screener to identify a Criterion A event, a set of 20 questions that assess for DSM-5 PTSD symptoms, and a set of 7 questions that assess for impact on daily functioning. The UCLA PTSD Reaction Index (PTSD-RI) is another measure that assesses for potential traumatic exposure and for the presence of DSM-5 criteria for PTSD among school age children and adolescents (Steinberg et al., 2004; Steinberg et al. 2013; Elhai et al., 2013). This measure requires a licensing agreement for use, and more information can be found here. For children ages 7 and younger, the Young Child PTSD Checklist (Scheering, S. & Haslett, 2010) is an appropriate measure to use, as it focuses on parental observation of child functioning. For youth ages 18 and older seen in a pediatric setting, the PTSD Checklist for the DSM-5 (PCL-5; Weathers et al., 2013) can be used and found on the National Center for PTSD website.

Intervention for Problems Related to Trauma and Stressor Related Disorders

The treatments with the best empirical support for youth exposed to trauma are individual cognitive-behavioral therapy (CBT) and group CBT (Dorsey et al., 2017). Cognitive-behavioral treatments have more than twice the effect size of non-CBT interventions for post-traumatic stress symptoms, depression, and externalizing behaviors (Dorsey et al., 2017). Common elements of effective trauma treatments are psychoeducation, emotion regulation skills, imaginal or in vivo exposure, cognitive processing, and/or problem solving (Dorsey, 2016). There are treatments that work such as Cognitive Processing Therapy (Bohus et al., 2020), Dialectical Behavior Therapy (Bohus et al., 2020), Trauma and Grief Component Therapy for Adolescents (Saltzman et al., 2001), and Trauma Focused Cognitive Behavioral Therapy (Cohen et al., 2017). Cognitive Behavioral Interventions for Trauma in Schools (CBITS) is a group model delivered in the school setting and shares the same core elements as TFCBT (Stein et al., 2003). It has been designated as an effective program (highest level of evidence) by the NCTSN. Bounce Back is a similar model, but it is designed for elementary school children ages 5 to11 (Langley et al., 2015).

Timing matters for intervention, there is a difference in the immediate aftermath of a trauma or disaster scenario, and the time that follows “after the dust settles.” Trauma recovery occurs in three phases, the acute phase (i.e., hours or days after the event); the peritraumatic phase (i.e., days to weeks after the event); and the post-traumatic phase (i.e., months after the event) (Epstein et al., 2017). Psychological First Aid occurs during the acute phase, addressing imminent safety concerns and connecting the child to resources (Brymer et al., 2006). The Child and Family Traumatic Stress Intervention is delivered in the peritraumatic phase, and it emphasizes increasing the effective use of coping skills and building parent-child communication about symptomatology (Berkowitz et al., 2011; Epstein et al., 2017). The post-traumatic phase may be the most common phase of treatment known to clinicians, in which focus shifts to adaptive coping and mastery over the thoughts and feelings related to the traumatic event, typically delivered through Trauma-Focused Cognitive Behavioral Therapy (Cohen et al., 2012).

With Gabby, she was amenable to TF-CBT. This intervention is grounded in a phase-based approach that incorporates gradual exposure. The PRACTICE acronym spans across the phases of stabilization, exposure, and safety. So how do we approach Gaby who has been through a lot and who has seen many providers and seems to be stuck? Predictability is the hallmark of trauma treatment. Engaging Gaby in a way that promotes transparency, safety, voice, and choice, provides a solid foundation for the therapeutic process. Psychoeducation about treatment lets the child know that we as clinicians have no tricks up our sleeves and that treatment is not a forever thing. After learning about TF-CBT and how it could be helpful, Gaby said, “I guess I can try this out.” Race and ethnicity can be a big factor in engagement, and part of psychoeducation can include discussing racial barriers in past treatment and validating negative experiences Gaby may have had (Metzger et al., 2021).

With psychoeducation and trauma reactions, Gaby learned about the relationship between physical abuse and trauma symptoms. It was important to not lecture her and to bring in her experiences of “regular stress.” She knows how she felt after arguments or if she had to run to catch the bus. Stress can be helpful, but too much of it can cause problems. The clinician could bring in the notion of racial stress in these sessions, and racial socialization strategies can help to foster racial pride messages (Metzger et al., 2021). As an aside, clinical support tools such as worksheets and videos should reflect the patient as best as they can to encourage this positive racial messaging. For examples specific to black youth, consult the C.A.R.E. Package for Racial Healing available through Dr. Metzger’s Empower Lab.

The rest of the “PRAC” skills were catered to her needs; what are soothing skills that are feasible and relevant for her? What were the core feelings she felt before, during, and after the trauma? Were any feelings being left out, for good or for bad? Gradual exposure throughout this phase included naming her trauma as abuse, then labeling it as violence or being assaulted. In the instances of communicated racial trauma, Metzger et al. (2021) suggest using racial socialization in sessions in order to address any experiences of racism and discrimination in order to encourage affective expression and identify effective coping strategies for potential future discriminatory encounters. For example, coping strategies for API children can target potential microaggressions like “Ascription of Intelligence” or more overt discriminatory behaviors like the exoticization of Asian American women (Sue et al., 2007). These strategies may also overlap with the Enhancing Safety module at the end of treatment. Consider the pain and stress non-white youth face when they are asked “Where are you from?” or “Where were you born?” or given comments like “You speak good English,” all of which communicate a sense of otherness and inferiority. As Dr. Cohen mentioned in her interview, we may not be able to cover all of the traumas a youth experiences, so our treatment should help to give a path forward.

Gaby was avoidant during the narrative. “Why should I write this if no one will read it?” This was an important point to join with her. “Who is an adult that you really care about that you feel like you have a bond with?” “I really like my case worker [child welfare], because she’s been there throughout all of this.” Gaby agreed that this person would be who she would share the story with, because reunification with her father was not a child welfare goal. The therapist acted as Gaby’s secretary, writing what Gaby said. She had some distortions around, “No one cares for me; I can’t trust anyone.” For an initial draft, that was something flagged for the clinician to return to. Cognitive processing consisted of going back to those clinical flags and using techniques like Socratic questioning to get down to whether these thoughts were helpful or accurate. Gaby’s narrative ended up covering themes of loss, the abuse itself, and the bouncing around from place to place.

“I would tell kids in my shoes to keep going; don’t give up. I really didn’t like doing this treatment to start, but I stuck with it, and it really has helped me. I sleep better and I don’t get as mad as I used to. Talking about it with someone you trust really works.”

Clinical Dialogues: Trauma and Stressor Related Disorder with Dr. Judy Cohen, MD

Sean E. Snyder, LCSW: Dr. Cohen, you are a hero to me and many of us in the child trauma world. Thank you for sharing your thoughts regarding child trauma; we will cover topics of engagement, assessment, and intervention. With engagement, we are curious about two things for your practice: a) the actual linkage to treatment when folks are referred to you and b) the strategies and practices of joining with the client in the therapeutic process. First, with linkage and access to trauma services, what does the process look like for your clinic from outreach to initial patient contact?

Judy Cohen, MD: Our clinic is somewhat different from the typical clinic that provides TF-CBT, as our clinic solely provides TF-CBT to children who have experienced trauma, whereas most clinics that provide TF-CBT probably are general outpatient programs that provide a broad scope of service. So, engagement will look a little different because we are taking a much more selective population from the beginning. We would screen them and only take kids into our clinic if we knew they had or if we’re sure they had experienced trauma. We are more of a specialty clinic as opposed to other programs that are taking kids, no matter what.

Snyder:  Great points. So readers should be aware that workflow will vary from place to place. I think there are many lessons to be generalized from your clinic, so we will start with your clinic and build out from there with these questions. I am thinking about the general process of assessments with children now. For instance, when we do ADHD assessments, before the parents come, they’ll complete rating scales like the Vanderbilt. For your child trauma clinic, do you have parents do some preliminary scales or other data collection measures?

Cohen: We’ve had two different clinics. In our current iteration, we’re a center for traumatic stress. We’ve been here for 26 years and prior to that, we were a specialty clinic and while we saw a lot of different traumas, we were focused more on sexual abuse. In both of those iterations, we spent a lot of time doing outreach, spent a lot of time educating our referral sources in the community about what we did, the kinds of services we provided, and what kinds of kids were appropriate to refer to us. As a clinic, it is important to engage families but also the other providers who have contact with families prior to referring to us. Thankfully, there are more clinics that provide trauma focused treatment or do a lot of education (NCTSN in particular). Nowadays, we focus less on engaging and educating the providers and have turned our attention more to family work.

But back then, hardly anybody did it, so we trained everybody from family court judges to pediatricians to police officers to family, social workers to other therapists about what kinds of kids were appropriate. And the multi-disciplinary teams, once they had developed child advocacy centers, we supported them around knowing what kinds of procedures needed to happen before it would be appropriate to refer kids to us. For example, if there was an allegation of sexual abuse, we wanted them to have a forensic evaluation before they came to us so that we could focus on the treatment; we’re not doing the forensic evaluations. In Esther’s program, for example, they have both a forensic program and treatment programs, so they can do both.

For that evaluation part, we would have them do that before they come to us for treatment. So that’s been a long educational process related to child protective services. After 30 years or so, the community knows what kind of kids to refer to us and at what point in the process. Occasionally we will get calls from families or even pediatricians, and we’ll have to provide that education. In the age of the COVID-19 pandemic, we do almost everything by telehealth. Sometimes we will send assessment tools and instruments to the family for them to fill out ahead of time, but we’re going to look at it during the assessment. It’s not screening before they come to us. That’s part of our assessment process, but our intake person is our outreach person. We have a very small clinic for everything we do, so it’s the same person. She goes out into the community virtually now but in normal times, she goes out into the community and is talking to different organizations to educate them about the kind of work we do, the kinds of kids to refer to us.

When families or referral sources call, she’s the one they talk to so she will get a lot of information on the phone about the kinds of traumatic experiences that child or teen has experienced if it’s a team. She’ll talk to the team as well, explain a little bit about the process, and get some information about the kinds of symptoms they’re having. We try to give them some hope and give them some information about what will happen during this process.

Snyder: You are taking the idea of trauma-informed care right from that initial screening, giving them the predictability of what to expect. So, with outreach and initial engagement, it’s less about clinical psychoeducation and more about telling them about the process, which can probably alleviate some of that anticipatory anxiety and increase some of the hope that you mentioned.

Cohen: And of course, we are assessing safety and evaluating if the child is safe, if it hasn’t been reported. Safety is part of trauma-informed care as well.

Snyder: It seems that there is a lot of education with the family, and there’s a lot of preparatory work and education you’ve done with communities. That highlights that systems need to work together even for just one family.

Cohen: I want to add that we collaborate. I’m a member of two different multi-disciplinary teams, and I’m familiar with different organizations in town. It can be a matter of referring to a child who is not appropriate for us. So, we are very collaborative. We’re not competitive; we want what’s best for the child.

Snyder: There are no trauma champions, where it’s just one person doing this kind of care; it really takes networks working collaboratively.

Cohen: Our goal over the last 30 some years is to try to develop a network in our community. There are unfortunately way too many children who need these services, so we’re reaching for a small number of children. There are always more children than can fill our services.

Snyder: And that points to the idea of scalability; with this intervention, how do we increase access and reach and penetration in care systems?

Cohen: Yes, and keep in mind, there are other interventions that work, for instance Child Parents psychotherapy or Alternatives for Family CBT.  So, there are a lot of different alternatives now, which is fantastic. And certainly, we’re also trying to identify children where trauma is not the first priority to address. Sometimes we don’t do that until the assessment or sometimes in the middle of treatment. If we can do that at the initial phone call or before the assessment, that’s going to save the family a lot of hassle and having to come in to spend two hours to do the assessment. If we can do that, immediately we can say, “It really sounds that although your child has had traumatic experiences, this other challenge probably takes precedence. Let us point you in the direction of doing this first, getting these behaviors under control.” Maybe they really need to get these medications sorted out first, or they’re suicidal, and they really need to address that first.

Snyder: That was very helpful to understand how families get to you and the nuances of that process. So, let’s kind of fast forward then. Families screen in, and they are appropriate for treatment after the assessment. What I see a lot of new trainees or students do is that sometimes they’re afraid of re-traumatizing the client by talking about the trauma itself. There’s a fear of exposure from the clinician at times. What would you say to folks that have that worry of re-traumatizing the client by talking about it?

Cohen: Well, that’s sort of the whole approach of TF-CBT, speaking the unspeakable, making new meaning and so forth, but it’s really important to help therapists understand that the trauma has already happened. The child has already gotten through that. And for some children, trauma is ongoing, but they’ve already survived at least one trauma experience. In many cases, they’ve survived many traumatic experiences, and in many cases, they’ve already had the courage to disclose it and tell somebody about it and go through a forensic evaluation.

But importantly, that experience, that memory is already there, and telling you, the clinician, about that is not going to be any harder than having survived that experience. They’ve already done the hardest part, which is going through it. I use the metaphor of cleaning out a closet. So, if you have a messy closet that’s stuffed full of stuff, and the door keeps slipping open, and the stuff falls on top of your head, that’s these disjointed trauma memories that are coming at you. The trauma reminders have not been sorted out; they have not been organized. They’re intrusive memories that you try to avoid, and you have maladaptive beliefs about them, and there’s negative cognition and hyperarousal. You’ve got all of these trauma symptoms because you haven’t addressed them, but you still remember them. It’s not that you don’t have those memories; you’ve had them. It’s just that they’re very disjointed and disorganized. They’re intrusive.

And that’s what children—or adults, for that matter—who have experienced trauma are dealing with. If we help them to make sense of that, if we give them skills and a way of mastering those memories or making sense of those experiences, it’s much like cleaning out that closet. You have a way of organizing that closet by going through it, throwing out the things that you don’t need, those maladaptive beliefs, and then organizing those memories and those reminders in a way that makes more sense.

Telling the story is a way of going through all of those things, retrieving those memories and describing them to someone who you can trust, who is not emotionally involved in it like your mother or your caregiver is, and being able to sort through them and then organize them in a way that is more helpful and more accurate. Then you can rearrange them, much like sorting through the stuff in the closet. Then you can open that closet or talk about those memories when you need to. And you might not always be able to control when you open the door; trauma reminders may come at times when you can’t control it.

But even if that door does open, at least you have reorganized those shelves, the things are going to fall on your head, and you can look at it. And you have some control over what’s in that closet and how it’s going to show up, so it’s not going to be any surprise. It’s going to be much more organized. So that’s a metaphor for families, but it’s also how we help young therapists or even experienced ones who are hesitant, who may be thinking, “If I do this, it’s going to be painful and difficult and very traumatizing.” The child already has those memories; the problem is they’re disorganized. They’re frightening and overwhelming. Well, we’re going to help them sort through them and speak about the unspeakable to make new meaning. But we’re not going to do it today or even the first time they come in. They need some skills; they need a pathway to follow.

And that’s what this treatment does: it gives you a pathway.

Snyder: A pathway decreases uncertainty to how to go about dealing with the memories. With the closet metaphor, I’m thinking of when adults ask kids to clean up their room, and the kids (and maybe this is more personal history) shove everything in the closet and the door is barely able to close. With it ready to burst, you don’t even want to touch it, and you spend a lot of time thinking about the door. And if you need to open the door, you just throw the stuff back in and hope for the best. Great metaphors.

Cohen: It’s like tidying up your room. It does take some work; it takes some organization at the beginning. At the end, you can see where everything is, and you can sort it out. You can find it when you need it, and it works better for you.

Snyder: Let’s take an example with our favorite age group. How do you approach adolescents or even kids in middle childhood that are so avoidant, and the last thing they want to do is be there, talk to you and certainly not talk about the exposure? I know that that exposure piece comes much later and that you do spend a lot of time focusing on skill building and rapport building. Do you have any particular strategies that you use with adolescents who may really present as if they just don’t want to be there at all?

Cohen: Sure. The typical scenario that we have is an adolescent who has experienced multiple traumas, who has been in multiple placements, who has a challenge with trusting you, and who does not want to talk about their trauma experiences and perhaps wants to go back to their birth parent or wants to go back to a prior placement and doesn’t want to tell you about what’s going on because they think it will be problematic if they disclose something about what’s going on because child protection or the judge or somebody will hold it against somebody if they’re honest with you.

One of the tips I share with trainees is, first of all, being transparent and starting with recognizing, “You don’t know me, I’m a stranger. There’s no reason for you to trust me. And asking why or how I can be helpful, or what do you want, what’s your goal? If I could help you with something, what would it be?” Sometimes kids will say, I just want to go back to my placement, or I want to go back and live with my parents. I’m really pissed about being here, whatever it is.

That might give an opening to either doing a really quick timeline about where you lived or what are these placements you’ve been in, and asking about “What’s your understanding of why you were removed from that place and put here?” Even if they give a story of “The judge is a jerk or “Child Protection Services have just fed me lies all my life,” that might open a door to at least asking, where did they get that information? What is it like for you to be away from your parents? So, you might tap into the traumatic separation aspects, even if you’re not going to get them to acknowledge or talk about the alleged domestic violence or physical abuse or whatever they don’t want to talk about. At least you could identify some legitimate problems they’re having with being taken away from their parents, which might be a starting point. And if they see that that’s valuable to them, it might be an engagement point for you to start some kind of working relationship with them.

Snyder: I think that you can apply that strategy to initial engagement but also throughout the course of treatment. Helpful things to think about if you’re going through a protocol, and you hit that plateau, or you hit that resistance. They are great ways to get to the function behind the behavior.

You mentioned great strategies for engagement, and there is a lot of great data coming from the engagement process; in a way, it’s a pre-assessment. When you formally do an assessment, what are some of your go-to instruments?

Cohen: We use free instruments, especially because we tend to train low resources or public mental health clinics. We use the Child PTSD symptom scale for DSM-5 because it’s free, and I think it’s very reasonable for kids from eight years old up to teenagers. When we do see transition age youth, we use the PCL-5, so for older teenagers and young adults. For the younger kids under seven, we have the parents fill out the Young Child PTSD Checklist, as it follows the DSM-5 criteria. These three are basically our go to instruments.

Clinical judgment is particularly important when considering avoidance. It could be avoidance of the trauma itself, or it could be they don’t want to talk to you at all. And that’s not so much avoidance, as their opposition, or they don’t want to be here. Maybe they don’t trust you at all. So, there can be a lot of iterations of why they’re not very talkative or not very cooperative or not very engaged in the process.

Part of good supervision is helping clinicians figure out why the child is not talking. Are they just not talking generally, or are they just not talking about trauma? There’s a difference. Depending on how avoidant they are and what they’re avoidant of, then you have to gauge clinically if they’re really avoiding trauma. If that’s the case, then that’s going to affect how they’re going to report certain symptoms.

And then even on the self-report instruments, obviously there’s overlap between what’s on the scale and general symptoms not specific to trauma. We talk about these as the “second page” symptoms (on the CPSS-5). A lot of those symptoms overlap with DMDD or depression or conduct behavior problems. So, consider if most of their score is racking up on the second page or on those overlapping with other disorders. We have to take that into consideration as opposed to the more trauma specific items. How much of this really is trauma specific versus other kinds of comorbid problems. And that’s where our history taking and clinical skills come into play.

Snyder: Very important point there, because more often than not, they’re probably not just dealing with a traumatic experience. Especially in our Community Mental Health clinics, there’s more than one presenting issue.

You’ve already mentioned a couple of treatments that can be helpful with youth and traumatic exposure such as TF-CBT and AF-CBT. Youth present with complexity of needs and some make quicker recoveries than others, and I’ve seen that firsthand with TF-CBT. How much is enough treatment, thinking about what dose of treatment is needed? I’ve had youth that do well with just psychoeducation and skill building; others need full protocols.

Cohen: Yeah, it’s a great question. Sean, you work in juvenile justice and for really profoundly complex traumatized youth, I would say probably most of those youth could benefit from the whole model, just because of the complexity of their experiences, how many they’ve had, how long it’s been going on, and the profound nature of how that’s changed the way they look at themselves and other people. I think they would get some benefit from the skills, and something is better than nothing. And don’t let the perfect get in the way of the good.

I do want to mention that after 9/11, there was a big study done with around 500 plus kids, most of them inner city, African American and Latinx kids. They were looking at exposure to 9/11, and youth reported that their main trauma were interpersonal traumas like child abuse, domestic violence, community violence, and other big hitters. So even though, yes, they were exposed to 9/11, that’s not what was bothering them. They had multiple traumas, and they were the private, typically interpersonal traumas.

So, among those children, the mental health response was looking at how to triage when we have a large-scale disaster, considering what level of treatments is going to be best, a matching algorithm basically. In terms of TF-CBT, they were investigating what level of symptoms would get just the practice skills (around four to six sessions) work versus the whole model for 12 to 15 sessions.

They found for children who had mild to moderate symptoms that they experienced an improvement of about nine points, which in the DSM-IV days was a reasonable improvement down to about normal levels. So that worked well, just the practice skills, about four to six sessions, whereas children who had more moderate to severe PTSD symptoms needed the whole model.

And that makes perfect sense because the more severe your symptoms are, the more likely you are not to get that much better with just the practice skills. But they did. And those kids with more severe levels of symptoms experienced twice as much improvement, but they had further to go.

Those findings would suggest that for kids who have lower initial symptoms, the practice skills alone can be good enough. Mid-treatment scores require ongoing conversations with the family. Even if they improve, my instinct says there are a lot of kids that they would be better off to continue and do the whole thing. Their real difficulties might not show up on their CPSS score. I think you would probably need to look a little deeper and see. Do they still have maladaptive cognition? Negative cognition can really do a lot of damage, and that doesn’t really get corrected until you do trauma narration and processing. So, I would say it depends on which items are elevated on the CPSS. It’s not just the score. An analogous example: let’s say a youth with depression is improving on measures and has suicidal ideation; that’s one item, but it could be a really important item.

Snyder: Yeah, this reminds me to think also where the child is developmentally because when we look at adolescence, their thinking is more complex, and they will need some processing to unpack more complex thoughts. But with youngsters whose thinking isn’t as complex I wonder if the cognitive coping PRAC skill could clear up some things for them. So, the theme of this part of our conversation is that small doses can make an impact, but consider the multitude of clinical factors in making treatment decisions, not just the scores.

Cohen: The other issue is, where’s their avoidance? Some kids after four to six sessions, if their avoidance has really improved because you’ve done such a great job of engaging them and they trust you more, their score is going to go up. But it really means they’ve improved, not that they’ve gotten worse. Whereas other kids, if they’re still really avoidant, their score might still be kind of low. That doesn’t mean they’re ready to start treatment. It means they really need more treatment. So, you have to be really clinically astute to figure out what does that treatment score mean.

Snyder: With the back end of TF-CBT, the narrative exposure, I immediately think of the youth with complex trauma or history of multiple placements or polyvictimization. They’ll have a lot to tell right and part of the technique in the narrative is to focus on themes so it’s not the whole life story. The question I have with these youth is how long is too long with doing the narrative work? In the protocol, typically six sessions are the maximum. How long is too long with narrative work?

Cohen: I think it’s really important to focus on the proportionality for those youth with complex histories, and one of the biggest mistakes that therapists make when working with a youth who has really complex traumas, really severe trauma types, or hundreds of episodes is, “I had to fit all this in. I have to give them a chance to talk about all these trauma types.” And the therapist is pretty overwhelmed. The kid is pretty overwhelmed, and the therapy is not structured enough. And I would say the more complex and profound the trauma is, the more that a youth needs that structure and guidance of, “we’re not going to do this forever. This is only going to be six or seven sessions.” Keep in mind the maximum is 24-25 sessions at the very most for the whole model. So let’s say you’ve taken 12 sessions for the practice skills and you take say eight sessions at the most for trauma narration and processing (it’s not right for the narrative). It’s a five or six for telling the story, and then you have three or two or three for the processing, you’re up to 20 sessions. Then you only have four sessions for conjoined sessions and in vivo work, and then enhancing safety, which is also going to take some time.

You have to look at the proportionality: how are you going to divide that up for sessions? More importantly, is eight sessions really the right amount for this youth? Are they going to be overwhelmed with that? And how can I help work with, as the copilot, structuring this narrative and this narration process so that it’s not overwhelming? If the kid looks at this as, we’re going to be doing this for two months, that’s eight weeks, that’s eight sessions, and they might start missing appointments. They might start saying I can’t do this for eight sessions; six might be a lot more palatable or even five. Five is just one more than one month.

So how can we structure it? Maybe it’s one session to talk about sexual abuse, it’s one for the domestic violence, then one for when my parent was murdered. That might be a lot more containable for this kid. You need to be thinking about not just how many things happen and how much time they need, but how much can they manage? What is a safe holding environment for them? They don’t have to tell you about everything they have to talk about, perhaps just the most striking example, and it will generalize. You don’t have to get everything in.

Snyder: Absolutely. And again, going back to the closet metaphor, we’re just trying to organize it to get something that they can actually use; that’s an adaptation. Like you said, eventually, they will probably generalize a lot of the learnings they get from processing those index events. Yeah, it can clear up some things later on in their own time,

Cohen: Yes, this is not prolonged exposure. They do not have to tell every detail about everything that ever happened. They have to speak the unspeakable, and they can choose this was the worst, or this is the thing that I’ve never told anybody about, or this is the thing I’m most ashamed about. It doesn’t have to be every single episode. So, on the whole, would say eight sessions of trauma narration and processing is too much for pretty much every kid. From experience, usually six is what the youth can tolerate.

Snyder: That makes sense. Generally, the kids that I have treated with complex trauma, and well most youth with any trauma history, they just want to be heard.  I think that part of the job of the clinician is to give them the space, and they will take it because they think “someone’s actually listening and not judging me.” There is a responsibility to open the space but to contain it, and I’m reminded of Carrie Epstein here: we don’t want venting because that shows the prefrontal cortex is disengaged and that is not helpful. They aren’t learning to regulate. So, your idea of proportionality is a great guide of how we contain that for them while still attending to them, of being empathetic and joining with them, without overwhelming them.

Cohen: And I think, giving them the context of what the purpose of this is, is really important. It’s to organize to give you a way of speaking about the unspeakable and making meaning and giving you a roadmap for how to do that. And you may, when you go home, or after therapy, you may be doing this for a lot more of the episodes that you’ve experienced. This is not the end of the road; you have the rest of your life. To do this, you don’t have to close the door on this and be finished with it forever, although a lot of people are. The idea is that it will generalize.

It’s really important that they take away that this is a process, and you learn how to do this, and you can continue to do this for your recovery.  Kids want to just say, “I’m done with this. I’m going to burn it. I’m finished with it. I can close the door on it. The closet is finished now.” But some kids will write things in their journal and do things outside of therapy, and they will see things differently as they age, where they see themselves developmentally. It’s like a slinky that unfolds: here I was at 15, 25, 55 years old. It takes a long time. And that’s life.  Life is a long time. And I think, if they trust you, which hopefully most kids will at this point in therapy, you are able to say this is enough processing or narrative.  I think sometimes they don’t trust themselves enough to say this is all you need.

Snyder: I’m thinking of what’s next or what’s outside of therapy with the kids that I see in detention. When they leave me, they’re going back a lot of times to the neighborhoods where it isn’t very safe. The likelihood of multiple exposure is very high for these kids, so if they are able to generalize lessons learned, they can have something protective in the face of new stressors. And that leads me to ask: what does the evidence look like for different populations?

Cohen: We do have some new data for Hispanic youth in Puerto Rico on that, and it shows effectiveness that’s very strong. We have the demographics in Pittsburgh and Stratford, New Jersey.  There haven’t been as many black and Latino kids in our randomized trials, but we had an overrepresentation relative to the general population of Black kids in our studies. We found no differences between African American and Caucasian kids in our outcomes. It’s equally effective. We had a pretty good representation, and all of our randomized control trials have African American kids, and so that’s probably 1000 kids out of all of our nine randomized control trials. We have international data as well. We have several studies in Africa, Japan, and European countries. So the model is pretty generalizable. We certainly have implementation manuals for American Indian/Native American kids and LGBTQ+ kids, and we have some pilot data for those populations as well.

Admittedly, we don’t have large samples of hundreds of kids in randomized control trials, yet we welcome those. While we don’t see a lot, we see some. Dr. Metzger, who is psychologist, has worked to incorporate racial socialization for Black families, and we’re hoping to work more with her on developing an implementation manual and gathering data for the racial injustice that Black families experience and specifically addressing those issues because it’s certainly an ongoing issue for many, if not most Black families in the US. But today, we don’t have any data specifically to address that particular pervasive kind of trauma.

Snyder: Dr. Metzger’s study is going to be very, very powerful in moving things forward. There’s a lot of promising things; it seems like a lot of excitement around making adaptations and being responsive.

Cohen: We’re so grateful to all 70 some trainers and many consultants and supervisors who are further advancing the data we have. And I know that you did a study in juvenile detention with TF-CBT. It’s so great that there are so many certified therapists that are doing such great work to further our knowledge and just our clinical wisdom about how to use our model in a variety of settings for different populations of youth and families experiencing different kinds of traumas. So, it’s really wonderful we’ve learned so much from all of you, and we hope that that continues to expand the ways that we can help children who experienced trauma.

In closing, I do want to mention just a little bit about our telehealth applications considering that is how a lot of people are operating these days. We have a small pilot that has less than 20 kids, but we just did publish a much larger pilot that has close to 80 kids using telehealth in schools and at home. It had really positive outcomes, and the best part of it is that it’s exactly what we’re finding in our clinic. There’s a much lower dropout rate and higher retention rate of course because families really enjoy it; they don’t have to even get dressed, and they don’t have to leave home. And we’re finding that in our clinic, the outcomes are comparable to what we found in our randomized trials, very good outcomes in terms of PTSD, but also higher retention rates in treatment, less than 10% drop out. So, it’s really getting very good for including minority families, and hopefully insurance will continue to pay for it.

The challenges, of course, for families, and we’re encountering this all the time, is when they have a loss of electricity, or they don’t have computers, or you can’t share your screen. It requires adaptation on the therapist’s part; you have to learn to send stuff ahead of time or be creative or talk them through stuff or just do without all of the creative nice neat things and just use your clinical skills. I mean, we’re basically doing therapy with some people just over the old-fashioned telephone. Because it is manualized, it lends itself to a balance of fidelity and flexibility.

On our certification website (which is TFCBT.org) you’ll find a telehealth implementation page, and the wonderful folks at MUSC developed a three-hour webinar to help people who don’t know much about how to use computers. It’s just a primer basically about how to do TFCBT by telehealth. There’s a lot of information on how to select a platform, how to share confidentiality, how to figure out privacy for kids of all ages, how to engage families, how to send materials, and how to go through each component and implement it via telehealth. So, it’s really great, a lot of great resources.

We’ve also worked with Sesame Street to figure out resources for younger kids and how to adapt what they have with Sesame Workshop. We are trying to figure this out to help our families.

Snyder: And that’s where the networks come into play, so we’re all doing it together to move things forward and be responsive.

Cohen: It’s just another example of how collaboration works better, and cooperation works better than competing, too. Our goal is just to help kids recover after trauma and share what we have learned. We are all in this together, and it takes us all cooperating to best help those families that need it.

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