Evidence-Based Support of Children in the Immediate Aftermath of Traumatic Stress Exposure

Sept 1, 2022 By Hannah Bowen, LCSW

The word trauma originates in the Greek language and translates to “wound.” Only in recent decades has the field of Psychology created a framework and research body that allows us to understand the nature and treatment of the psychological wounds resulting from traumatic stress exposure. In fact, it was just in the 1980’s when trauma or traumatic events were first understood through a mental health framework, and these early definitions of trauma still only included impact from “catastrophic stressors,” such as war or natural disasters.

We have learned an incredible amount in the intervening decades about the vastness and complexity of human experience and impacts of childhood traumatic stress exposure in particular. At present, the American Psychological Association defines trauma as an, “emotional response to a terrible event like an accident, rape, or natural disaster” and notes both short-term and long-term reactions that may impact emotions, cognitions, behaviors, relationships and overall functioning (American Psychological Association, n.d.). We also understand more about risk and resiliency factors that help to explain why two people can go through the exact same potentially traumatic experience and have drastically different reactions, both short-term and longer-term.

Much of what we have learned about the long-term impacts of childhood trauma over the past four decades can be traced to a revolutionary study conducted by the CDC in the early 1990’s, known as the “ACE Study” or Adverse Childhood Experiences Study. The study aimed to explore the links between adult health risk behaviors and childhood abuse and/or household dysfunction. This initial ACES study offered compelling evidence that:

1. More adults than expected experience some form of childhood adversity
2. Childhood adversities often compound to form chronic or complex trauma
3. Childhood trauma exposure is linked longer-term to a variety of both mental health challenges and adverse physical health outcomes, including chronic diseases, social difficulties, and decreased life expectancy

We now know that more than two thirds of children report at least one traumatic event by age 16 (SAMHSA, n.d.). We also now understand that a vast range of adverse experiences may be considered traumatic stressors, including: medical trauma, gun violence, systemic oppression, physical, sexual, and psychological abuse, identity marginalization, bullying, war, domestic violence exposure, betrayal traumas, natural disasters, unexpected injuries, secondary media or workplace exposure to traumatic events, and many other events that can overcome our perceived or actual capacity to cope in the moment.

In spite of the prevalence of traumatic stress in today’s world, there is also hopeful data about the resilient nature of children and the potential of young brains to “bounce back” from or grow through traumatic stress, particularly with the right supports in place. Neuroplasticity, or the capacity of the brain to engage in new learning and form new connections, peaks during our first 25 years of life (American Psychological Association, n.d.). Our evolved understanding of both childhood mental health and trauma provides opportunities for more effectively integrating a trauma-informed lens into the settings that most heavily influence child development, from homes, to schools, to healthcare settings. The more we understand about the ways in which we can buffer against the negative impacts of traumatic stress exposure and respond effectively following trauma, the better we can equip ourselves, our institutions, and our children for resilience in the face of trauma.

What we now know about traumatic stress, brain development, and potential long-term consequences highlights the importance of early intervention following traumatic stress exposure. For instance, in the immediate 30-45 days after a potentially traumatic event (or following disclosure of a past event), traumatic stress symptoms are typically at their highest (Marans et al 2012). Trauma symptoms may initially appear as disruptions to basic biological and cognitive functioning, such as difficulties eating, sleeping, concentrating, engaging with others or pursuing one’s interests – and many other variations of impairment to the normal rhythms of life.

At present, the front-line therapeutic intervention created for supporting children and families in the weeks following trauma exposure (the “peritraumatic period”) is an intervention called Child and Family Traumatic Stress Intervention (CFTSI). This intervention focuses on “increasing family support for the child, enhancing communication between the child and caregiver about the child’s symptoms, and providing skills to help children and families cope with and master trauma reactions” (Epstein et al., 2017). In addition, the clinician and parents often interface with collateral systems in a child’s life (e.g., school, healthcare systems, law enforcement, and/or other community supports) to help reestablish a sense of safety and to secure the child’s basic needs, creating a foundation of security that allow the child and family to address the core trauma symptoms. This therapy could include discussing safety plans openly, allowing children to share any information about what happened, validating and normalizing the feelings around the incident, and offering developmentally appropriate information about what happened. Developing shared language for the posttraumatic experiences, and reestablishing routine as best as possible is critical to restoring a sense of security and predictability for children. Routines help us return to a semblance of predictability and control – both of which are typically disrupted by the experience of trauma. Additionally, shared language around the event(s) often leads to greater potential for connection between family members, and is another key component in healing through posttraumatic experiences. In fact, shared language alone and having a common understanding what happened significantly reduces long-term trauma symptoms, depression, and overall impairment (Oransky et al., 2013).

Another large part of a collateral response in CFTSI is parental support. It is important for parents and caregivers to honestly acknowledge their own immediate responses, which may include parental traumatic stress reactions, and to seek family, community, and/or professional support for themselves. The trauma treatment literature consistently shows that parents or caregivers identifying and managing their own traumatic responses facilitates regulation and healing for their children (e.g., Oransky et al 2013). Furthermore, studies have shown that participation in CFTSI reduces both child and parental post-traumatic stress symptoms (Hahn et al., 2019).

The developers of CFTSI found that children who completed the CFTSI intervention were 73% less likely to meet partial or full criteria for PTSD in a three month follow up appointment, compared to those in a comparison condition that focused primarily on trauma-related psychoeducation (Berkowitz et al 2011). CFTSI was born out of research that points to family support as the primary protective factor for developing PTSD. This support includes increasing communication between caregivers and children, especially around identification of traumatic stress symptoms, and development of a shared framework and vocabulary for discussing the traumatic stressor. The next focus in treatment is working together to master coping strategies that are often relaxation-based in nature. These include daily practice of diaphragmatic breathing, progressive-muscle relaxation, guided imagery or meditation, cognitive coping, etc. The primary focus of this phase is supporting children to feel safe, soothed, and connected.

A significant piece of the CFTSI treatment is focusing on the present, unfolding post-traumatic experience, to stabilize any potential acute trauma responses. During this phase, parents often wonder if communication should include processing the details of the traumatic incident. The focus on present symptoms in the CFTSI intervention is based on research showing that restabilizing the family system and reducing dysregulation are critical areas of focus during the peritraumatic period, and premature processing of a trauma narrative may lead to exacerbation and/or reemergence of traumatic stress symptoms. Prior to engaging in any longer-term trauma-based therapies or trauma narratives, children need to first reestablish a sense of safety/security, build up awareness around potential trauma stressors or “triggers,” and have effective tools for coping with the inevitable trauma reminders (Alexander, 2012).

As a clinician working in the field of traumatic stress, I’m routinely taken aback by the sheer courage and resilience of children, their families, and communities. While parents and caregivers typically do their best to shield their families from potentially traumatic events, adversity and even trauma are often unavoidable. I have found hope in bearing witness to the capacity of children and their families to move through these traumatic experiences and ultimately experience meaningful growth, recovery, and connection, allowing new and more hopeful chapters of a family’s story to unfold.

References

• Ace Response. (n.d.). Who we are: Ace Study . ACE Response. Retrieved August 26, 2022, from http://aceresponse.org/who_we_are/ACE-Study_43_pg.htm
• Alexander, P. C. (2012). Retraumatization and revictimization: An attachment perspective. In M. P. Duckworth & V. M. Follette (Eds.), Retraumatization: Assessment, treatment, and prevention (pp. 191–220). Routledge/Taylor & Francis Group
• American Psychological Association. (n.d.). Trauma. Retrieved August 26, 2022, from https://www.apa.org/topics/trauma/
• Berkowitz, S. J., Stover, C. S., & Marans, S. R. (2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry, 52(6), 676-685.
• Marans, S., Smolover, D., & Hahn, H. (2012). Responding to child trauma: Theory, programs, and policy. In Handbook of juvenile forensic psychology and psychiatry (pp. 453-466). Springer, Boston, MA.
• Merriam-Webster. (n.d.). Trauma definition & meaning. Merriam-Webster. Retrieved August 26, 2022, from https://www.merriam-webster.com/dictionary/trauma
• Oransky, M., Hahn, H., & Stover, C. S. (2013). Caregiver and youth agreement regarding youths’ trauma histories: Implications for youths’ functioning after exposure to trauma. Journal of Youth and Adolescence, 42(10), 1528-1542.
• SAMHSA. Understanding child trauma. (n.d.). Retrieved August 26, 2022, from https://www.samhsa.gov/child-trauma/understanding-child-trauma
• Veterans Affairs. PTSD History and Overview. (2007, January 31). Retrieved August 26, 2022, from https://www.ptsd.va.gov/professional/treat/essentials/history_ptsd.asp