1. +
Trauma and Children
Brooke Goodwin, LICSW
Advanced Certificate in Forensic Social Work
December 14, 2013

2. +
What will be discussed…
 Trauma and its affects on children and adolescents
 The effects of witnessing Intimate Partner Violence (IPV) has
on children
 Posttraumatic Stress Disorder (PTSD) and the DSM
 Types of trauma informed assessment tools for children and
their appropriateness
 Trauma informed treatment for children with PTSD
 Efforts to assess the safety of children who witness IPV in the
Emergency Department

3. +
What is trauma?
 An event in which the person experienced, witnessed or was
confronted with an event or events that involved actual or
threatened death or serious injury or a threat to the integrity of
self or others.
 The response involved intense fear, helplessness or horror
 It may have many sources, including neglect, physical abuse,
psychological abuse, sexual abuse, witnessing of IPV and
other violence, traumatic loss, etc.
 The DSM IV ties trauma to two specific trauma-related
diagnosis: Acute Stress Disorder and Posttraumatic Stress
Disorder
 (Baker, 2007)

4. +
Child-Focused definition of Trauma
 Child trauma can result from any event or series of events that
overwhelms, overstimulates, or creates subtle or extreme fear
in a child that causes temporary or permanent interruption or
normal developmental processes or tasks that occur with or
without physical or psychological symptoms and behavioral
change. (Munson, 2001 as cited in Evidence-Based Treatment
or Traumatized and Abused Children)

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Effects of trauma on Preschoolers
 Secure attachment may be derailed
 Sleep and eating disturbances introduced
 Brain development may be altered
 Egocentricity leaves them susceptible to self blame for violent
events
 Less expression of emotion during play
 Ambivalence towards parents
 Acting out and whining
 Clinging and crying that may result from anxiety and post
traumatic stress
 (Stapleton, 2010)

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Effects of trauma on School-aged
Children
 Concern about the approval and disapproval of others as they
compare themselves to others in their discovery of self
 Guilt and shame
 Anxiety and symptoms of post traumatic distress
 Patterns of disability
 Poor school performance and peer relationships deteriorating
 Difficult concentrating due to intrusive thoughts
 Negative judgments as they go through gender socialization and
make judgments about fairness and appropriate means to having
their needs met
 (Stapleton, 2010)

7. +
Effects of trauma on Adolescents
 Depression and suicidal ideation
 Dating violence and use of violence as a control tactic
 Delinquency and substance abuse
 Anger for batterer and vengeance against batterer
 Responsibility for safety of younger siblings, which causes regret
 Lack of guidance leads to poor choices as they search for their
identity
 Sexual experience choices may be a factor of the results of their
own violence exposure
 (Stapleton, 2010)

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“Children who witness violence
between adults…are only the most
recent victims to become visible and
are called the ‘silent’ ‘forgotten,’ and
‘unintended’ victims of [intimate
partner violence].” (Groves, 1993)

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Intimate Partner Violence (IPV)
 A serious, preventable public health problem that affects
millions of Americans.
 It describes physical, sexual, or psychological harm by a
current or former partner or spouse
 This type of violence can occur among heterosexual or same-
sex couples and does not require sexual intimacy.
 (National Center for Children Exposed to Violence, 2003)

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How Do Children Experience IPV
 Most commonly defined as being within visual range of the
violence and seeing it occur
 Many children describe events that they have heard and not
seen
 Used within the direct events of violence
 Regardless of how the child experiences it, mother and children
describe the aftermath of the event as having a traumatic effect
on them

11. +
Examples
 In describing the event, she consistently placed her father at the
scene, described significant portions of the central action and
recounted her father’s efforts to clean up prior to leaving. Only after
the district attorney saw Julie stabbing a pillow, crying “Daddy pushed
mommy down,” did the district attorney become convinced that the
father indeed was the murderer. (Pynoos and Eth, 1984, p.100)
 I really thought somebody got hurt. It sounded like it. And I almost
started to cry. It felt really, I was thinking of calling, calling the cops or
something because it was really getting, really big banging and stuff
like that. (Peled, 1993, p.125)

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How Often Do Children Witness
IPV?
 It is estimated that 3 to 10 million children are exposed to intimate partner
violence each year in the United States. Straus, M. (1992). Children as
witnesses to marital violence: a risk factor. Columbus, OH: Ross
Laboratories.
 The National Survey of Children’s Exposure to Violence conducted Jan-
May 2008 measuring the past year and lifetime exposure to childhood
victimization on a national sample of 4549 children aged 0-17 (Finkelhor,
2009, Office of Justice Programs).
 More than half (60.6%) of the sample experienced or witnessed
victimization in the past year with almost half (46.3%) experiencing
physical assault, (10.2%) experienced child maltreatment and (25.3%)
witnessed domestic or community violence.
 In a second national study 4023 adolescents age 13-18 reported
experiencing physical assault (22%) and witnessing violence (39%).

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Impact of Witnessing Violence
 Children who witness severe or chronic violence are more likely
to develop symptoms of PTSD if they are younger, if the
violence is frequent and if it is perpetrated in close proximity to
them
 Evidence has shown that a child’s psychological reactions to
trauma are intensified if they know the victim or perpetrator
(Augstyn and Groves, 2005)
 With the increased research and awareness of intimate partner
violence and child witnessing violence, the reactions and
behaviors children are displaying are now being associated
with symptoms of posttraumatic stress disorder.

14. +
History of Posttraumatic Stress
Disorder (PTSD)
 Introduced as a psychiatric diagnosis in the DSM- II in 1980
and has been a source of controversy since
 One issue was an idea of a disorder that could be explained
entirely by an environmental event rather than by the
characteristics of a person or their interaction (Brewin ,2010)
 There was no specific reference to child trauma in the PTSD
until DSM III-R and there was a minimal increase in DSM-IV

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PTSD in Children??
 Rates of PTSD among children and youth have been primarily
restricted to groups of children who have been exposed to
maltreatment, war zones, natural disasters and single traumatic
events whether as victims or bystanders. (Arroyo, 2001)
 Some children meet the criteria for PTSD while others do not
meet the full criteria but still suffer with significant PTSD
symptoms

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Longstanding Issues with DSM IV
PTSD
 1. The alleged pathologizing of normal events
 2. The inadequacy of Criterion A
 3. Symptom overlap with other disorders
 4. Lack of age appropriate symptoms and criteria for children
 (Brewin, 2009)

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Alleged Pathologizing of Normal
Events
 It creates a medical condition out of normal distress
 That reactions to extreme stress are time limited and PTSD
symptoms will resolve on their own with no lasting harm to the
person
 Symptoms of PTSD are global reactions to stressful events
suffering from normal distress
 PTSD is not biologically distinguishable from normal distress

18. +
Inadequacy of Criterion A
 Trauma is not exclusively associated with PTSD
 It is too broad because it includes a events where a person
who is not personally and directly exposed to trauma but rather
learns about someone else being traumatized now qualifies as
having been exposed to trauma
 But is too narrow because qualification for PTSD diagnosis
relies on a qualifying Criterion A event but also a Criterion B
event (response with intense fear, helplessness or horror)

19. +
Symptom Overlap with Other
Disorders
 Depression and anxiety disorders serve as potential problems
with overlap
 Symptom B1 referring to any kind of intrusive memory, image
or thought are all symptoms common to many psychiatric
disorders
 Flashbacks and traumatic nightmares are seen as distinctive to
PTSD, although these symptoms are experienced in other
disorders, because they are relived in the present.

20. +
Lack of age/developmental appropriate
symptoms and criteria for children
 With the diagnostic criteria being centralized around
adults the lack of age-specific diagnostic criteria
accounting for fact that children express different
symptoms and at different intensities and
frequencies

21. +
Recommendations from
Scheeringa et al.
 Although PTSD has been widely reported in children and
adolescents, it was developed based on adult study samples.
 In study of 1420 children, 68% had experienced at least one
potentially traumatic event and 37% had been exposed to more
than one, showing that posttraumatic symptoms are common
following exposure to trauma
 Created the posttraumatic stress disorder alternative algorithm
(PTSD-AA) to argue the need for more behaviorally anchored
and developmentally sensitive criteria for children 6years and
younger

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Changes in PTSD Criteria for DSM V
 Pays more attention to the behavioral symptoms that accompany
PTSD
 Proposes for four diagnostic clusters instead of three: re-
experiencing, avoidance, negative cognitions and mood, and
arousal
 Re-experiencing- covers spontaneous memories of the event, recurrent
dreams related to it, flashbacks or other intense or prolonged
psychological distress
 Avoidance- distressing memories, thoughts, feelings or external
reminders of the event
 Negative cognitions and mood- myriad feelings, from a persistent and
distorted sense of blame of self or others, to estrangement from others
or markedly diminished interest in activities to an inability to remember
key aspects of the event
 Arousal-aggressive, reckless or self-destructive behavior, sleep
disturbances, hypervigilance or related problems.
 The “fight” reaction will be accounted for along with the “flight” aspect
currently acknowledged in DSM IV

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DSM V and PTSD Criteria for
Children 6 Years and Younger
 Essential feature: Significant reaction to serious traumatic event that involves actual or
threatened death, serious injury or sexual violation
 DSM-V lists the following diagnostic criteria:
 Presence of one or more specified intrusion symptoms in association with the traumatic event (s)
 Symptoms indicating either persistent avoidance of stimuli associated with the traumatic event (s)
or negative alterations in cognitions and mood associated with the event (s)
 Marked alterations in arousal and reactivity associate with the traumatic event (s)
 Duration of the disturbance exceeding one month
 Clinically significant distress or impairment in relationships with parents, siblings, peers or other
caregivers or in school behavior
 Inability to attribute the disturbance to the physiologic effects of a substance or medication
condition.

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Assessment tools: What do they
involve?
 Trauma informed assessment tools can identify a child’s
reactions, how his or her behaviors are connected to the
traumatic event and risk behaviors resulting for the traumatic
experience
 Trauma assessments usually involve conducting a detailed
trauma history
 This allows for all forms of traumatic events experienced or
witnessed by the child to be identified as well as the severity of
the symptoms
 Then the best type of treatment for the child can be determined

25. +
Assessments are not for everyone
 Not all children who have experience trauma need trauma
specific interventions
 Resiliency reigns true in some children and they are able to use
their support systems to cope with their experience

26. A “through trauma assessment
with children and adolescents is
a prerequisite to preventing the
potentially chronic and severe
problems in biospsychosocial
functioning that can occur when
PTSD and associated or co-
morbid behavioral health
disorders go undiagnosed and
untreated” (Wolpaw & Ford,
2004)

27. +
Definition of Trauma-Informed
Assessments
A more in-depth exploration of the
nature and severity of the traumatic
events, the impact of those events,
current trauma-related symptoms and
functional impairment (NCTSN, 2007)

28. +
Approaches to Assess Trauma
 Three approaches to assessment of trauma and post traumatic
stress in children via tools and instruments:
 Instruments that directly measure traumatic experiences or
reactions
 Broadly based diagnostic instruments that include PTSD subscales
 Instruments that assess symptoms not trauma specific but
commonly associated symptoms of trauma
 Wolpaw & Ford 2004

29. +
Types of Trauma Assessment
Measurement Tools
 Structured interviews
 Child and Adolescent Psychiatric Assessment: Life Events Section and PTSD Module (CAPA-
PTSD)
 Children’s PTSD Inventory (CPTSDI)
 Clinician administered scales
 Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV (CAPS-CA)
 Child Posttraumatic Stress Reaction Index (CPTS-RI)
 Patient self-report checklists
 Trauma Symptom Checklist for Children (TSCC)
 Caretaker self-reports
 Trauma Symptom Checklist for Young Children (TSCYC)
 Inventories
 Detailed Assessment of Posttraumatic Stress (DAPS)

30. + Child and Adolescent Psychiatric
Assessment: Life Events Section
(LES)and PTSD Module (CAPA-PTSD)
 Developed as an interviewer based measure that would detail
the timing of events and the onset of symptoms to better
assess causality and the relationship among other stress-
related disorders
 Measure additional non Criterion A stressors that might
contribute to psychiatric vulnerability and comorbidity
 Assess PTSD symptoms in excess of DSM-IV criteria that
might be of clinical and research interest
 Be considered suitable for clinical and research settings
 Children aged 9-17years

31. +
Children’s PTSD Inventory
(CPTSDI)
 Developed in 1988 by Saigh to correspond to the DSM-IV PTSD
diagnostic criteria
 Consists of five subtests: potential exposure/reactivity,
presence/absence of re-experiencing, avoidance and numbing
symptoms, increased arousal and significant distress
 Presents a series of items to establish the duration of distress for
endorsed symptoms
 Each item is scored on a dichotomous basis (1 for presence and 0
for absence)
 Yields diagnoses of PTSD Negative, Acute PTSD, Chronic PTSD,
Delayed Onset PTSD and No Diagnosis

32. +
CPTSDI Validity
 Yasik et al., 2000 demonstrates concurrent, convergent and
discriminant validity
 Concurrent: highly associated with diagnoses formulated by expert
clinicians, data derived highly associated with established and
frequently used PTSD structured interviews, true positives at a high
rate, high levels of agreement with symptom clusters of other
criterion measures
 Convergent: significantly associated with continuous psychological
variables that are theoretically and logically associated with PTSD
 Discriminant: indices effectively discriminated between groups of
youth with PTSD, those with simple phobia and nonclinical
comparison group

33. +
CAPS-CA
 Rates both the frequency and the intensity of PTSD symptoms
 Provides rating sheets with pictorial scales to help depict more
abstract concepts, including frequency (calendars marked with
X’s), intensity problems (cartoon figures with facial and somatic
expressions) and intensity –feelings (facial expressions).
 Also assess the frequency and intensity of PTSD associated
symptoms that are now apart of the DSM V
 The Life Events Checklist (LEC), an inventory of traumatic events,
is administered before the CAPS-CA to determine the presence
and number of traumas the child has experienced
 Up to three traumatic events can be investigated and recorded
using the LEC and CAPS-CA
 (Nadar, 1997)

34. +
Child Posttraumatic Stress Reaction
Index (CPTS-RI)
 20 item scale used in direct, semi-structured interview with children and adolescents 6-
17years
 Includes symptoms for Criterion B (re-experiencing trauma including fear), C
(numbing/avoidance) and D (physiological arousal) as well as guilt, impulse control,
somatic symptoms and regressive behavior
 Used to assess specific posttraumatic stress symptoms after exposure to violence and
disaster
 Only self direct report of symptoms are recorded
 Although the index does not provide a DSM PTSD diagnosis there is a scoring system (0-
80 that reflect the frequency of the symptoms)that establishes a level of PTSD
 Items are rated on a five point frequency scale (“none” to “most of the time”)
 Dept. of VA Affairs website

35. +
TSCC
 Developed using the criteria of the DSM-IV as a self-report measure of
posttraumatic distress and related symptoms, not as a stand-alone
diagnostic tool
 A 54-item self-report scale of posttraumatic symptomology in children and
adolescents (8-12 and 13-16, with normative adjustment for 17yr olds)
 Two validity scales, Under-response (UND) and Hyper-response (HYP)
 Six clinical scales: Anxiety (ANX), Depression (DEP), Posttraumatic Stress
(PTS), Sexual Concerns (SC), Dissociation (DIS) and Anger (ANG). Each
symptom item is rated according to its frequency, using a four-point scale
ranging from 0 (“never”) to 3 (“almost all of the time”)
 substantial normative base of the TSCC and its inclusion of validity scales
and reliability is often a welcomed addition to any clinical assessment of
PTSD

36. +
TSCYC
 a 90-item caretaker-report instrument used to assess PTSD symptoms in
children between 3-12 years old
 Items are rated on a 1 (“not at all”) to 4 (“very often”) scale
 Two validity scales to assess caretaker over-and under-report of the
child’s symptoms: Response Level (RVL) and Atypical Response (ATR) as
well as a norm referred item evaluating how many hours a week the
caretaker spends with the child
 Nine clinical scales: Posttraumatic Stress Intrusion (PTS-I), Posttraumatic
Stress Avoidance (PTS-AV), Posttraumatic Stress Arousal (PTS- AR),
Posttraumatic Stress Total (PTS-TOT), Sexual Concerns (SC), Anxiety
(ANX), Depression (DEP), Dissociation (DIS) and Anger/Aggression
(ANG) well as a summary PTSD scale
 It generates a probably diagnosis of PTSD with acceptable sensitivity and
specificity

37. +
Reliability and Validity of TSCYC
Briere et al., 2001
 Reports the clinical scales demonstrate good reliability and
association with exposure to maltreatment
 Findings regarding posttraumatic stress…support construct validity
because similar relationships have been documented in other
literature (Singer et al., 1995)
 The mood scales show reasonable face validity for these scales
 Although the findings in the study do not address convergent
validity, the data suggest requisite psychometric characteristics to
support use with
 Children too young to report on their own internal state or
symptomatology
 Instances where another sources of information is desired in children
who are able to provide symptom self-report

38. +
Correlation: TSCC and TSCYC
 Study by Lanktree looked at children’s scores on the TSCC and
Caretakers ratings on TSCYC in sample of 310 children at a
child abuse treatment center
 Too much convergence shows redundancy in measure from both
sources but at the same time demonstrates that any bias in one
measure might be replicated in the other
 A situation where the use of multiple measures, each with a different
reporting source might allow for more effective triangulation of
symptomatology [in potentially traumatized children]
 In situations were one informant is less reliable than the other (e.g.
a non-disclosing child or a psychologically compromised parent)
greater credence could be given to the other informants responses

39. +
Correlation: TSCC and TSCYC
(cont.)
 What this suggests:
 That the source of information on at least some psychological tests
may affect the outcome of psychological testing
 Specific to this study, there was moderate correlation on the child
and parent reports of trauma symptoms
 Concurrently, these disparate sources of information converged on
most of the underlying symptom dimensions reinforcing each
measures discriminant validity
 Overall, the simultaneous use of both child and parent report
measures when assessing trauma-related symptomatology in
children is supported

40. +
DAPSJohn Briere Ph.D.
 A 105 item inventory that provides detailed information on adult and
adolescents history of various types of trauma exposure including:
 Immediate psychological reactions (cognitive, emotional and dissociative)
 Enduring posttraumatic stress symptoms (re-experiencing, avoidance and
hyper arousal)
 Level of posttraumatic impairment in the context of a specific traumatic event
 Two validity scales for evaluation of under and over report of symptoms
 Three supplementary scales for evaluation of event-related dissociation,
substance abuse and suicidality often associated in PTSD
 Allows for a tentative diagnosis of PTSD and ASD
 Takes less time and has strong reliability and validity
 Computer Interpretive Report (DAPS-IR) is excellent for doing treatment
planning

41. “Since PTSD places children at increased
risk for other psychiatric and medical
conditions and may derail normal
developmental processes, it is important for
these children to receive early and effective
treatment” (American Academy of Child and
Adolescent Psychiatry, in press).

42. +
Evidence Based Trauma-Informed
Treatments
 Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
 Exposure/Direct Discussion Therapy
 Imaginal Flooding or In vivo
 Gradual Exposure
 Cognitive Processing and Coping
 Stress Management Techniques
 Muscle Relaxation
 Breathing Techniques
 Thought Stopping
 Thought Replacement
 Pharmacotherapy
 Play Therapy

43. +
Trauma Focused Cognitive
Behavioral Therapy (TF-CBT)
 Originally developed to treat child sexual abuse
 An empirically supported intervention based on learning and cognitive
theories
 Designed to reduce children’s negative emotional and behavioral
response, and to correct maladaptive beliefs and attributions related to the
abuse experiences
 Aims to provide support and skills to help non-offending parents cope
effectively with their own emotional distress and to respond optimally to
their abused children
 Has worked well for children exposed to a variety of traumas, male and
female and various ethnic and racial backgrounds
 Site: Cohen, et al. (2006). Treating Trauma and Traumatic Grief in
Children and Adolescents. New York: Guilford Press.

44. +
Trauma Focused Cognitive Behavioral
Treatment (TF-CBT) Components
P: Psycho-education (information about trauma and trauma reactions)
P: Parenting Skills (behavior management skills)
R: Relaxation Skills (managing physiologic reactions to trauma)
A: Affective Modulation Skills (managing affective response to trauma)
C: Cognitive Coping Skills (connections between thoughts, feelings and behavior)
T: Trauma Narrative and Processing (correcting cognitive distortions related to trauma)
I: In Vivo Mastery of Trauma Reminders (overcoming generalized fear related to trauma)
C: Conjoint Child-parent Sessions (variety of join child-parent activities)
E: Enhancing Safety and Future Developments (safety planning for future)

45. +
Exposure Therapy
 Involves ongoing exposure to stimuli that produce fear or
anxiety. Typically for traumatized individuals, these stimuli
represent specific aspects of the traumatic event
 The process of repeated exposure, remembering and
reminders of the trauma become less emotion-laden over time
 The unpairing of thoughts of the trauma and negative emotions
then decrease the intensity of the traumatic recollections and
need for avoidant behavior

46. +
Imaginal Flooding and Gradual
Exposure
 Imaginal Flooding:
 Involves the identification of specific anxiety-provoking scenes through clinical
interviews and several subsequent sessions during which the therapist instructs
the child to imagine the specific details of the anxiety-provoking scenes
 Child rates the degrees of emotional distress experienced (Saigh, 1998)
 Gradual Exposure
 Encourage the child to first describe a relatively less upsetting episode or aspect
of trauma and to gradually progress to describing more traumatic events that are
more emotionally difficult to verbalize and cope with
 Ultimately once the event has been described in detail, the child shares how it felt
to talk about he event and how stressful it was, which allows the therapist to
assess the child’s tolerability of increased exposure levels in the next session
(Deblinger and Heflin (1996), Cohen and Mannarino (1993) and March et al.
(1998).

47. +
Empirical Support
 Direct exposure treatment resulted in greater improvement in
PTSD symptoms when using gradual exposure and CBT
treatment but the effects of each could not be separated so the
efficacy could not be supported.
 There is no evidence that repeated retelling of the details of the
event produces successful treatment with or without PTSD
symptoms therefore, clear evidence of PTSD-like symptoms
should be identified before using repeated exposure

48. +
Cognitive Processing and Coping
 Cognitive Processing Therapy
 Looking at the idiosyncratic distortions internalized during the exposure
techniques such as responsibility for the event and regrets about doing
something that contributed to the event
 Steps to correct cognitive errors:
 Identify current cognitions
 Child and therapist evaluate reasoning for distorted cognitions
 Replace cognitive distortions with accurate cognitions
 Cognitive Coping
 Learning to identify the relationships between negative automatic
thoughts, negative affective states and dysfunctional behaviors
 This allows replacement of negative thoughts with more positive
alternative thoughts, resulting in ability to modulate affective and
behavioral states

49. +
Empirical Support
 Self blame for the trauma have been found to correlate with
emotional difficulties, general negative attributional style is
associated with greater internalizing symptoms
 There is suggestive evidence that cognitive interventions are
efficacious in resolving trauma related symptoms in children
exposed to various stressors
 Again because of additional treatment models used in CBT it is
not possible to ascertain the specific impact of cognitive
components in symptom resolution

50. +
Stress Management
 Strategies such as stress inoculation therapy (SIT) have shown
positive results in decreasing various symptoms in adult assault
victims dealing with PTSD, depression and anxiety
 SIT is used to help individuals cope with the aftermath of exposure
to stressful events and on a preventative basis to "inoculate"
individuals to future and ongoing stressors
 Relaxation interventions have decreased anxiety symptoms in
non-traumatized children

51. +
Muscle Relaxation and Breathing
Techniques
 Used to address the hyper vigilance and anxiety traumatized
children experience
 Ex. Tensing muscles from toes to head
 Ex. Focused breathing used during yoga-type meditation
 Can be used before or in combination with gradual exposure
components of CBT

52. +
Thought Stopping and Thought
Replacement
 Taught to enhance the child’s sense of control over negative
thoughts and resultant negative emotions and to manage
disturbing thoughts that occur outside of treatment
 Thought Stopping
 Interpret the upsetting thought and then using a verbal phrase to
interrupt the thought. Ex. Rubber band snapping
 Thought Replacement
 Having a child think about a positive memory and to mentally
describe the details of it
 Ex. Drawing a picture of positive event

53. +
Empirical Support
 Studies have shown effectiveness in exposure and stress
management therapy, but Field, Seligman, Scafedi and
Schanberg (1996) showed that massage therapy used on
children exposed to a hurricane resulted in the reduction of
salivary cortisol, which improved depressive and anxiety
symptoms in these children
 Due to the effects of relaxation interventions with those who
experienced a natural disaster, it is felt relaxation techniques
used along with other CBT components would be beneficial in
treating traumatized children.

54. +
Parental Involvement
 Parents are often included in mental health treatment for
information around the child’s functioning, clarification of
family/parental dysfunction and their involvement in interventions
and support of child through the process.
 Because of the difficulty of diagnosis of PTSD in young children,
parents information about symptomology can be critical in
identification of the disorder
 The goals for parental involvement are to resolve their own
emotional upset about the traumatic exposure, correct cognitive
distortions they may have and enhance effective parenting and
appropriate parental support for the children
 All of the same components used for child interventions for
treatment are used for parents

55. +
Empirical Support
 Parental emotional distress about the child’s traumatic exposure has a
great effect on the development of PTSD symptoms for the child
 Parental support is a significant factor in symptom resolution for the child
 Parental involvement in treatment resulted in notable improvement in
parenting practices, children’s acting out behaviors and children’s
depressive symptoms
 Oppositionaly, CBT treatment without parental involvement resulted in
decreased PTSD symptoms in children exposed to single-episode trauma
 Exploration of inclusion of parental treatment components and the benefits
regarding child stressors other than child sexual abuse continues

56. +
What About On-going Trauma?
 It is usually disclosed or detected after initiation of treatment
 Ex. Study where youth are receiving treatment for PTSD
symptoms related to mother’s IPV reported more frequent
contact with the perpetrators with 40% experiencing continued
trauma exposure during treatment (Cohen, Mannarino, &
Iyengar, 2011)
 The question stands “how youth can benefit from exposure-
based interventions that are supposed to de-sensitive youth to
their past traumatic memories and experiences if they have
repeated traumas…” (Cohen et al., 2011)

57. +
How to treat ongoing trauma..
 There is often little time to reflect upon experiences before the
next trauma occurs
 Creating a trauma narrative with adaptive cognitions and
contextualization
 Focus on the two “P’s”
 Psycho-education/Enhancing Safety
 Parental Engagement
 Breakdown the “T:”
 Parental acknowledgement of ongoing trauma experiences
 Perspective taking and contextualizing ongoing traumas
 Differentiating real danger for trauma reminders

58. +
There is evidence that “counseling
children very soon after a catastrophic
event may reduce some of the
symptoms of PTSD” (NIMH, 2001, p.5)

59. +
The Blatant Question
 Victims of IPV get lethality assessments done on the scene of a
first responder event to assess their safety
 What about the children who are there on the scene? Have
they witnessed the event? Has their safety been assessed like
the victim?
 Narrowing down this question to the pediatric emergency room
setting…what is done for children who live in a home with
IPV/witness IPV to assess their safety?

60. +
Hidden Victims Presenting to the
Emergency Room (ER)
 A child is brought to the ER for asthma by his mother who is
wearing sunglasses on a cloudy day. The nurse and doctor
both call the social worker due to the medical status of the child
and the concern around mothers unwillingness to take off her
sunglasses. Mom has a black eye and says it is not the first
time…it will go away in a couple days. SW has resources to
give mom but what about the child? What has he seen,
experienced, heard, etc.? Was this IPV incident one that he
intervened in? Did he get hurt?

61. +
Ethical Issues in the Assessment of
Traumatized Children
 A major but often unacknowledged reason children are not
assessed for trauma is because of the mandatory reporting law
to authorities
 To avoid this may professionals choose not to inquire about
traumatic experiences unless there is clear evidence of abuse
or neglect

62. +
What Research has said
 Accumulating research since Henry Kempe’s landmark
publication in 1962 on abused children, there has been
response to the need of recognizing and responding to children
who are traumatized through abuse or neglect
 Research has shown the critical vulnerability of young children
to traumatic experiences
 Witnessing their mothers being battered may be as traumatic
as being a direct victim of abuse, also called the most insidious
form of child abuse
 (Augustyn, 2005)

63. +
What the Barriers are…
 Time
 Inadequate training
 Powerlessness
 Patients and Families will be offended
 Presence of Children

64. +
Why it is important in the ED setting
 The ED is in a unique position to identify and respond to
battered mothers through their children, even though the
mother is not the primary patient. This in turn gives the
opportunity to intervene with the children who are secondary
victims as well as responding effectively to family violence.
(Wright, Wright and Isaac 1997)
 Women’s health studies have shown that IPV victims frequently
equate emergency care to “anonymous” care, because
emergency departments provide unscheduled evaluations and
treatments 24 hours a day by health professionals who rarely
have ongoing relationships with the patients. (Mother’s with
histories of DV in a pediatric emergency department)

65. +
Tools Currently Being Used
 The Initial Trauma Review: Adolescent/Young Adult Version
(ITR-A) is a tool used over several sessions with adolescents
ages 12-21, but some of the questions can definitely be used in
a quick assessment tool.
 1. “Have you ever seen someone else get killed, badly hurt or
sexually assaulted?
 2. “Has any other very bad or upsetting thing ever happened to
you?”
 When this happened did you feel very afraid, horrified or
helpless?
 Did you ever think you might be injured or killed?

66. +
Tools Currently Being Used
 Advocacy for Women and Kids in Emergencies (AWAKE)
developed at Children’s Hospital of Boston
 Trained physician identifies children reported for abuse and make
initial referral to interdisciplinary team
 Interdisciplinary team assesses the mother for IPV and assigns an
advocate to assist with resources
 Wright, 1997

67. +
Suggested Tools
 Child Behavior Checklist (Dehon and Scheeringa, 2006)
 A 20 item checklist that can screen for PTSD symptomology in
children following traumatic events
 Useful in medical settings
 Simple and requires no training
 Provides well-validated scales for elevations in other internalizing
and externalizing problems

68. +
Study Example
 Mount Sinai Medical Center’s pediatric emergency department
where child and primary caretaker were approached regarding
their stressors, the extent of PTSD and traumatic exposure
reported
 Self report questionnaires given: Brief assessment of reason for
ER visit, Posttraumatic Stress reaction index (PTSRI) and Impact
of Events Scale (IES)
 Results: Of 62 families, 56 reported at least one event for
emotional trauma according to DSM IV, the average number of
adverse life events per child was 3.14 (range 0-7) and 18 met the
criteria the threshold criteria for severity of PTSD symptoms
 Findings: Exposures to traumatic events and PTSD symptoms can
be reported in the pediatric ED setting and be well received.

69. +
Where Do We Go From Here?
 When a child discloses abuse or witnessed IPV and when IPV
is disclosed by a parent, is the family’s situation explored
further for safety?
 What Currently Happens?
 Social work is called to assess and provide resources to the
parent experiencing IPV
 What needs to happen?
 Doctor, who has received appropriate training, ask additional
questions to better understand the social situation
 Safety of the child needs to be acknowledged and assessed
 Further research on the aforementioned tools in attempt to
implement child safety efforts in the emergency room

70. +
Forthcoming…
Presenting to my ED team
Efforts to implement one of the
aforementioned tools in the ED
Work on a PTSD assessment initiative in the
ED