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How children rebound from their worst nightmares

Yale Medicine Magazine, 2014 - Autumn


A new intervention helps children who have seen, heard, and felt too much.

“Imagine that you are 10 years old, or 15, and you awake to the sound of your parents in a heated argument. Then imagine that the sounds turn to screaming as you enter the room where your mother is being beaten and your father is threatening to kill her. … Is your heart rate up? Are you actively trying to push away the images?” asks Steven Marans, M.S.W., Ph.D., professor of psychiatry and director of the Childhood Violent Trauma Clinic at the Yale Child Study Center.

Every year, Marans says, millions of children in the United States are exposed to community and domestic violence, natural and human-made disasters, and medical emergencies. “A traumatic event is the realization of your worst nightmare,” says Marans. “The worst has happened, and happened in a way that leaves one dysregulated and powerless.” Without help, too many children will be unable to fully wake up from the nightmare. Unable to recover, these children may suffer the scars of trauma over a lifetime.

Children with untreated trauma can grow up to become adults with a disturbing medley of mental and physical illnesses. But Marans and his colleagues at the Childhood Violent Trauma Clinic, Carrie Epstein, M.S.W., and Steve Berkowitz, M.D. (now at the University of Pennsylvania), have developed a brief early-intervention model. The Child and Family Traumatic Stress Intervention (CFTSI) is now helping children who have seen, heard, and felt too much.

As humans, we share a distinct set of fears: loss of life, limb, lucidity, and love. Children are particularly vulnerable to traumatic events. They depend on adults to see them through stressful events until they develop the cognitive and psychological maturity to handle such situations on their own. One of the most powerful predictors of outcome after trauma, says Marans, is the degree of external social support. Linda C. Mayes, M.D., FW ’85, the Arnold Gesell Professor of Child Psychiatry, Pediatrics, and Psychology in the Child Study Center, agrees that in order to be resilient, children need “to be protected and buffered from overwhelming stress—to have adults who care.”

Unfortunately, children may not have the skills to communicate their traumatic reactions, and their caregivers may not recognize the symptoms. Moreover, many of the children at the greatest risk of exposure to such traumatic events as domestic violence are often the least likely to receive support. One of the many ways the CFTSI aids in recovery is by bolstering communication and support between children and their parents or caregivers. The intervention teaches children how to talk about their mental and physical reactions to trauma and teaches caregivers to recognize when those reactions become symptoms of traumatic stress.

The CFTSI grew out of more than two decades of collaboration between the Child Study Center at Yale and the New Haven Department of Police Service. The collaboration between police officers and mental health professionals has brought many at-risk children from urban and economically disadvantaged families who have been exposed to violence to the attention of clinical service providers. It fills the gap between existing acute responses deployed at the time of the traumatic event, and longer-term treatments designed to address trauma symptoms and disorders that are already established. In as few as five sessions, the CFTSI can ease current suffering and symptomatology in children and prevent traumatic stress disorders from taking hold by returning a sense of control to both children and their caregivers.

Instead of leaving children alone with their traumatic terror and helplessness, a CFTSI-trained clinician coordinates with police, social services, and medical providers. They ensure safety while addressing post-traumatic reactions that so often follow overwhelming events. Over five to eight sessions, children and parents or caregivers are helped to identify and verbalize symptoms in ways that increase communication with and support from caregivers. They also learn such techniques as focused breathing, re-establishing routines, and recognizing what triggers post-traumatic reactions, with the aim of regaining control of their minds and bodies. As symptoms decrease, a sense of safety and competence can return, while the traumatic threat to developmental progress is diminished.

Children who received CFTSI services were 65 percent less likely to develop PTSD three months after a potentially traumatic event than children who received a standard intervention. And after the CFTSI sessions, caregivers seem to be more in tune with the trauma symptoms as they present in children. “CFTSI reduces the discrepancy between reports of symptoms by both parents or caregivers and children,” said Marans.

In addition, the CFTSI serves as an assessment tool, helping clinicians identify children in need of further psychotherapeutic treatment. While many children who receive CFTSI services experience significant reduction or resolution of post-traumatic symptoms, there are those children who will require longer-term trauma-focused or other mental health treatment provided by the Trauma Clinic and other clinical services of the Child Study Center. This work, Marans said, is supported by the Substance Abuse and Mental Health Services Administration, and is being disseminated to mental health clinicians and agencies around the country.

By capitalizing on a growing understanding of the factors that contribute to a healthy and happy human experience, the intervention decreases the likelihood that trauma will be damaging to a child’s future. It restores to children and their caregivers the sense of control that they often lose after traumatic events. Trauma doesn’t have to lead to lifelong afflictions, according to Marans, “It’s not a fait accompli.”

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