National Child Traumatic Stress Network Research Articles

Service utilization among adolescents seeking trauma-related care: Differences by risk for suicide and ethnoracial background.

Adolescents from ethnoracially minoritized backgrounds increasingly report high rates of attempted suicide, trauma exposure, and limited access to mental healthcare services. However, less is known regarding their use of services across different youth-serving systems. This study examines the associations and interactions between self-injurious thoughts and behaviors (SITBs), race/ethnicity, and service sector utilization (mental healthcare, general healthcare, school, and social services) among a sample of trauma-exposed and treatment-seeking adolescents. Participants were treatment-seeking adolescents (N = 4406) ages 12-17 from the National Child Traumatic Stress Network Core Data Set who had available data for SITBs, race/ethnicity, services utilized, and other key variables. Mixed effects logistic regression was used to examine main and interactive effects for whether adolescents' race/ethnicity and SITBs were associated with service utilization in each of the identified service sectors. SITBs were associated with adolescents' utilization of mental healthcare (OR = 1.38 p < 0.001), general healthcare (OR = 2.30; p < 0.001), and school services (OR = 1.38 p < 0.001). NH Black adolescents reporting SITBs were less likely to use mental health services than other NH Black youths (OR = 0.53; p = 0.004). Hispanic adolescents reporting SITBs were more likely to utilize healthcare services than other Hispanic youths (OR = 1.51; p = 0.039). Trauma-exposed adolescents reporting SITBs are more likely to utilize mental healthcare, general healthcare, and school-based services than other trauma-exposed adolescents. However, NH Black adolescents experiencing SITBs may face additional barriers to utilizing mental healthcare services. Findings can be used to develop nursing practices and policies to address barriers faced by adolescents reporting SITBs.

Implementing the NCTSN Trauma-Informed Organizational Assessment (TIOA) for Improving Trauma-Informed Care in Inpatient Child Psychiatry.

Children and adolescents receiving inpatient psychiatric services have disproportionately high levels of exposure to trauma and adversity. The National Child Traumatic Stress Network Trauma-Informed Organizational Assessment (TIOA) is a comprehensive tool intended to guide implementation of trauma-informed care, but it has not yet been applied in inpatient settings. The purpose of this quality improvement project was to describe trauma-informed care in inpatient child/adolescent psychiatry with the TIOA, examine relatedness among trauma-informed care domains, and explore barriers or facilitators to applying trauma-informed care. This quality improvement project used mixed methods. We conducted a web-based survey in Summer 2022 with staff members (clinical and administrative) at two inpatient child/adolescent psychiatric units in California to assess trauma-informed care practices with the TIOA (87 items). Qualitative follow-up interviews were offered to interested participants. A correlation matrix and cluster analyses were used to examine relationships among TIOA domains; qualitative data were analyzed thematically. There were 69 survey respondents and seven qualitative interviews. TIOA domain scores ranged from a low of 2.3 to a high of 3.2, indicating that practices were occurring only "rarely" to "sometimes." There were two major themes identified from qualitive interviews: (a) barriers to trauma-informed care in an inpatient context that can be resource-constrained or coercive; and (b) discovering strategies to provide trauma-informed care despite structural barriers. Organizational interventions targeting any domains of trauma-informed care are needed in inpatient settings given limited uptake of trauma-informed care.

28.2 National Child Traumatic Stress Network (NCTSN) Learning Community for Integrating Trauma-Focused CBT and Racial Socialization

28.2 National Child Traumatic Stress Network (NCTSN) Learning Community for Integrating Trauma-Focused CBT and Racial Socialization

Building Preservice Teacher Resiliency with Trauma-Informed Case Based Instruction

At least one in four children in the United States has experienced one or more traumatic events (National Child Traumatic Stress Network Schools Committee [NCTSN], 2008). Children exposed to trauma bring a host of psychological and physical stressors to the classroom. Teachers can positively impact a student's ability to cope with these events and develop resilience (Brooks, 1994), but not without a physical and emotional toll on their well-being. This paper investigates one teacher education program's attempt to better support preservice teachers (PTs) in meeting these challenges by examining the impact of trauma-informed case-based instruction on PTs self-reported resilience and efficacy with Trauma Informed Instructional Practices (TIIP). Before partaking in a teacher education summer study abroad program, 26 PTs completed both the Conner-Division Resilience Scale-10 (CD-RISC) and Teacher Self-Efficacy Scale (TSES) to determine baselines for resilience and efficacy. During the program, eight PTs participated in a special topics course on trauma-informed practices utilizing case-based instruction (treatment group). At the completion of the program, all 26 PTs were reassessed on both scales. Results indicated that PTs made significant gains on both measures, but those who were in the trauma-informed case-based instruction group had significantly greater gains in resiliency than the control group. The findings support the use of case-based instruction for enhancing PTs&rsquo; resiliency. Implications are provided for embedding resiliency scaffolds for case-based reasoning through a trauma-informed lens. &emsp

Building Preservice Teacher Resiliency with Trauma-Informed Case Based Instruction

At least one in four children in the United States has experienced one or more traumatic events (National Child Traumatic Stress Network Schools Committee [NCTSN], 2008). Children exposed to trauma bring a host of psychological and physical stressors to the classroom. Teachers can positively impact a student's ability to cope with these events and develop resilience (Brooks, 1994), but not without a physical and emotional toll on their well-being. This paper investigates one teacher education program's attempt to better support preservice teachers (PTs) in meeting these challenges by examining the impact of trauma-informed case-based instruction on PTs self-reported resilience and efficacy with Trauma Informed Instructional Practices (TIIP). Before partaking in a teacher education summer study abroad program, 26 PTs completed both the Conner-Division Resilience Scale-10 (CD-RISC) and Teacher Self-Efficacy Scale (TSES) to determine baselines for resilience and efficacy. During the program, eight PTs participated in a special topics course on trauma-informed practices utilizing case-based instruction (treatment group). At the completion of the program, all 26 PTs were reassessed on both scales. Results indicated that PTs made significant gains on both measures, but those who were in the trauma-informed case-based instruction group had significantly greater gains in resiliency than the control group. The findings support the use of case-based instruction for enhancing PTs’ resiliency. Implications are provided for embedding resiliency scaffolds for case-based reasoning through a trauma-informed lens.

Evaluation of a Trauma-Informed Parenting Program for Resource Parents.

Child maltreatment impacts many young people involved in the child welfare system, and it is important that the resource parents supporting these youth have knowledge and skills in trauma-informed care. The current study is a preliminary evaluation of the Resource Parent Curriculum (RPC), an in-service, 8-module, group-based parenting program developed by the National Child Traumatic Stress Network. Youth and caregiver outcomes were examined by way of a quasi-experimental design that included 22 resource parents in the experimental group and 21 in the waitlist control group and involved baseline, post-program, and 2-month follow-up assessments. For learning outcomes, RPC resulted in improvements in resource parents' knowledge and beliefs about trauma-informed parenting. While not statistically significant, potential effects included improvements in resource parents' tolerance of challenging youth behaviors and parenting self-efficacy. For behavioral outcomes, several non-significant potential effects were noted, including improvements in resource parents' attachment relationships with their youth and increased social supports. This study was the first to evaluate RPC using a quasi-experimental design within a Canadian context and through a virtual delivery. Findings highlighted several benefits of the program and resource parents' ongoing training needs.

New guide developed to provide trauma‐informed care to youth

The National Child Traumatic Stress Network Multisystem Involved Youth Collaborative Work Group and Georgetown University's McCourt School of Public Policy Center for Juvenile Justice Reform have partnered to develop “A Trauma‐Informed Guide for Working with Youth Involved in Multiple Systems.” The purpose of this guide is to help those working with youth involved in multiple systems (YIMS) and their families to use a traumatic stress perspective and provide trauma‐informed care, the executive summary stated. YIMS are children and adolescents who are under the care or supervision of multiple child and family serving systems. They include “crossover youth” or “dually involved youth” who are involved in child welfare (CW) and in the juvenile justice (JJ) system. In addition to CW and JJ involvement, YIMS are also often simultaneously involved in an array of other service systems including immigration, legal, education, family services, physical and behavioral health systems and systems designed to serve those with developmental disabilities or those who experience homelessness.

6.1 The Hidden Impact of Psychological Maltreatment: Data From the National Child Traumatic Stress Network Core Data Set

6.1 The Hidden Impact of Psychological Maltreatment: Data From the National Child Traumatic Stress Network Core Data Set

Care of the Immigrant Child.

Care of the Immigrant Child.

19.3 TRAUMA-FOCUSED CBT FOR LGBTQ YOUTH OF COLOR WHO EXPERIENCE COMMERCIAL SEXUAL EXPLOITATION

LGBTQ youth of color are at heightened risk for experiencing commercial sexual exploitation (CSE) and developing complex traumatic stress reactions. This presentation describes tailoring applications of trauma-focused CBT (TF-CBT) for LGBTQ youth of color who experience CSE. Kelly Kinnish, PhD, and Judith Cohen, MD, describe TF-CBT modifications for LGBTQ youth of color who experience CSE developed through Project Intersect in Atlanta and a National Child Traumatic Stress Network (NCTSN) learning community. In addition to general TF-CBT modifications for youth who experience CSE, additional specific tailoring modifications include: 1) incorporating into youth and caregiver psychoeducation, trauma narration, and processing the impact of false societal stereotypes about LGBTQ youth of color on their trauma experiences, reminders, vulnerability to CSE, view of self, and relationship to others (eg, trust, intimacy); 2) integrating the impact of systemic racism, heterosexism, and/or cisgenderism into all TF-CBT components; and 3) enhancing caregiver support/advocacy related to intersectional trauma. Through describing composite cases, Drs. Kinnish and Cohen illustrate how TF-CBT is successfully tailored for LGBTQ youth of color who experience CSE. With appropriate applications and tailoring, TF-CBT can be helpful for LGBTQ youth of trauma who experience CSE.

Trauma-Informed Care in Child Health Systems.

Trauma-Informed Care in Child Health Systems.

Interpersonal Trauma Exposure and Interpersonal Problems in Adolescent Posttraumatic Stress Disorder.

Traumatic experiences have been differentiated as interpersonal (i.e., the direct result of actions by other people) or noninterpersonal (i.e., other life-threatening events, such as severe accidents). Interpersonal trauma exposure generally has been shown to be associated with more severe posttraumatic stress disorder (PTSD) symptoms than noninterpersonal trauma exposure. Interpersonal problems also tend to be associated with trauma exposure and PTSD symptoms, but it is unclear whether a mediating association exists between trauma type, interpersonal problems, and PTSD symptoms. A clinical sample of 4,275 adolescents (age range: 12-18 years) from the National Child Traumatic Stress Network Core Data Set were classified as having experienced interpersonal trauma, noninterpersonal trauma, or both. Interpersonal problems were operationalized by social problem behaviors (e.g., immature and dependent behaviors) and aggressive behaviors on the Child Behavior Checklist. The results of path analyses showed that cumulative interpersonal trauma exposure was both directly and indirectly associated with PTSD symptoms via social problem behaviors but not aggressive behaviors, total effect β = .20, 95% CI [.17, .23]. In a second model, path analyses showed that cumulative interpersonal trauma exposure was associated directly and indirectly via PTSD symptoms with social problem behaviors, total effect β = .15, 95% CI [.11, .18], and aggressive behaviors, total effect β = .13, 95% CI [.09, .17]. These findings suggest that during adolescence, interpersonal problems play an important role in the association between interpersonal trauma exposure and PTSD symptoms.

APA’s Government, Policy, and Advocacy Update

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy UpdateSearch for more papers by this authorPublished Online:30 Mar 2021https://doi.org/10.1176/appi.pn.2021.4.34APA Leaders Applaud Passage of the American Rescue Plan Act of 2021APA’s leaders praised the inclusion of several provisions related to mental health in the American Rescue Plan Act of 2021 (HR 1319). The legislation includes about $4 billion in funding for programs that support the prevention of and treatment for mental and substance use disorders.“We will not recover sufficiently from this pandemic long term unless we address our mental health with the same urgency and attention as our physical health,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “This package is a huge step in the right direction, and we look forward to working with Congress and the administration to implement policies and services that will help all our patients.”APA supported several provisions in the legislation, including funding for mental and substance use disorder services through programs including the Community Mental Health Services and Substance Abuse Prevention and Treatment block grants, Certified Community Behavioral Health Clinics, and the National Child Traumatic Stress Network, as well as expanded eligibility for premium assistance under the Affordable Care Act, increased Medicaid funding, and funding to promote mental health integration with pediatric primary care.“It is essential and heartening that Congress and the administration included funding for our nation’s mental health system in this wave of COVID relief,” APA President Jeffrey Geller, M.D., M.P.H., said in the news release.APA Urges Governors to Make Telehealth Flexibilities PermanentAPA and eight other medical organizations, representing more than 350,000 physicians, sent a letter to state governors urging them to support legislation and regulations to permanently retain the telemedicine rules that had been relaxed at the start of the COVID-19 pandemic. The letter was sent to the National Governors Association, the National Conference of State Legislators, and the National Association of Insurance Commissioners.“The ability to see a patient via telemedicine should be driven by clinical decision making over any other factors,” the letter stated. “When the public health emergency ends, telemedicine should remain an option for providing care.”ATTAIN Act Receives APA EndorsementLast month, Sens. Deb Fischer (R-Neb.) and Tina Smith (D-Minn.) reintroduced the Achieving Through Transparency and Accountability for Information Navigation (ATTAIN) on Mental Health Act. The legislation aims to create an online dashboard through which applicants, such as nonprofits, mental health treatment facilities, or state and local educational agencies, can identify federal grants that support mental health initiatives.APA supports the bill. In a news release, APA President Jeffrey Geller, M.D., M.P.H., said the bill is a “good first step” to ensure access to mental health funding for communities in need.“As the COVID-19 pandemic has continued, we have seen an increase in rates of anxiety, depression, suicide, and other mental illnesses,” Geller continued. “Providing states, localities, and other organizations with easy-to-access information regarding available federal funding for mental health programs will help them meet the increasing need for treatment faster.”APA, Partner Organizations Offer Recommendations to BidenIn a letter to President Joe Biden, APA and five of its partner organizations—collectively known as the Group of Six—outlined several health care issues that they urged the president to prioritize.The recommendations include implementing a science-based and public health approach to end the COVID-19 pandemic, expanding health care coverage and protecting access to care, expanding and strengthening Medicaid, improving health care for women, and ending interference in the patient-physician relationship, addressing physician workforce issues, addressing health disparities, and reducing the administrative burden in health care. ■ ISSUES NewArchived

Identifying Bereavement-Related Markers of Mental and Behavioral Health Problems Among Clinic-Referred Adolescents.

ObjectiveThis study examined bereavement‐related risk markers (number of deaths, cause of death, and relationship to deceased) of mental and behavioral health problems (suicidal thoughts or behaviors, self‐injury, depression, posttraumatic stress, and substance use) in a national sample of clinic‐referred bereaved adolescents.MethodParticipants included 1281 bereaved youth aged 12–21 years (M=15, SD=1.8; 62.1% female), from the National Child Traumatic Stress Network Core Data Set.ResultsGeneralized linear mixed‐effects regression models controlling for demographics and other traumas revealed that youth bereaved by multiple deaths had higher posttraumatic stress scores than youth bereaved by a single death (Estimated difference ±SE=3.36 ± 1.11, p=0.003). Youth bereaved by suicide were more likely to report experiencing suicidal thoughts or behaviors (AOR=1.68, p=0.049) and alcohol use (AOR=2.33, p<0.001) than youth bereaved by natural causes. Youth bereaved by homicide were at greater risk for substance use than youth bereaved by natural death (AOR=1.76, p=0.02). Compared to parentally bereaved youth, youth who lost a peer were more likely to use alcohol (AOR=2.32, p=0.02) or other substances (AOR=2.41, p=0.01); in contrast, parentally bereaved youth were more likely to experience depression compared to those who experienced the death of an adult relative or unrelated adult (range of AOR: 0.40 to 0.64, p‐values<0.05).ConclusionThese bereavement‐related contextual factors can serve as early markers of mental and behavioral health problems among bereaved youth.

The Role of School Psychologists in the Implementation of Trauma-Informed Multi-Tiered Systems of Support in Schools

The National Child Traumatic Stress Network has applied a trauma-informed (TI) lens to a multi-tiered systems of support framework, referred to as TI-MTSS. The NCTSN presents 10 Core Area guidelines to guide school personnel toward the implementation of TI-MTSS. The purpose of this paper is to connect the training and expertise of school psychologists to a rationale that school psychologists are ideally positioned to lead the efforts of TI-MTSS in schools. Framed in the 10 Core Area guidelines provided by the National Child Ttraumatic Stress Network, we operationalize the school psychologist’s role and skills within each of the 10 Core Area domains.

Implementing trauma-informed care through social innovation in residential care facilities serving elementary school children

Objectives: This article presents the theoretical basis, initial deployment strategies, and resulting preliminary findings of a program implemented in residential treatment centres (RCs) in child welfare. “Program Penguin” aimed to help workers develop trauma-informed attitudes and implement trauma-informed practices, make the workplace more responsive to the well-being of RC workers, and reduce the use of restraints and seclusion among school-aged children in RCs. Methods: Informed by the theories of complex trauma (National Child Traumatic Stress Network Complex Trauma Task Force, 2003), polyvicitimization (Finkelhor et al., 2007), Attachment, Self-Regulation and Competency (ARC; Blaustein &amp; Kinniburgh, 2018) and Positive Behavioural Interventions and Supports (PBIS; Sugai &amp; Horner, 2002), Program Penguin was developed and deployed using the social innovation approach (Fixsen et al. 2005). The key stages of social innovation will here be used to describe the implementation process. Results: Changes in practices were observed, RC worker attitudes towards trauma-informed care were assessed and showed strong effects between multiple covariables. RC worker support needs were identified, and a reduction in the use of restraints and seclusions was shown. Key strategies towards the development and maintenance of buy-in and meaningful change in practices are also described. Implications: Changes observed at all levels of this implementation suggest Programme Penguin is a promising approach, despite local issues that arose and the challenges inherent to program deployment within child protection settings. It appears a trauma-informed program using positive behavioural approaches and leveraging existing organizational strengths may impact intervention strategies, worker attitudes, and the use of restraints and seclusions against children in RCs.

Unseen Costs: The Direct and Indirect Impact of U.S. Immigration Policies on Child and Adolescent Health and Well-Being.

Shifts in migration and border control policies may increase the likelihood of trauma exposure related to child–parent separation and result in costs to the health system and society. In the present study, we estimated direct and indirect costs per child as well as overall cohort costs of border control policies on migrant children and adolescents who were separated from their parents, detained, and placed in the custody of the United States following the implementation of the 2018 Zero Tolerance Policy. Economic modeling techniques, including a Markov process and Monte Carlo simulation, based on data from the National Child Traumatic Stress Network's Core Data Set (N = 458 migrant youth) and published studies were used to estimate economic costs associated with three immigration policies: No Detention, Family Detention, and Zero Tolerance. Clinical evaluation data on mental health symptoms and disorders were used to estimate the initial health state and risks associated with additional trauma exposure for each scenario. The total direct and indirect costs per child were conservatively estimated at $33,008, $33,790, and $34,544 after 5 years for No Detention, Family Detention, and Zero Tolerance, respectively. From a health system perspective, annual estimated spending increases ranged from $1.5 million to $14.9 million for Family Detention and $2.8 million to $29.3 million for Zero Tolerance compared to baseline spending under the No Detention scenario. Border control policies that increase the likelihood of child and adolescent trauma exposure are not only morally troubling but may also create additional economic concerns in the form of direct health care costs and indirect societal costs.

Psychological First Aid in Time of COVID-19

Psychological First Aid in Time of COVID-19

Increased Risk for Family Violence During the COVID-19 Pandemic.

* Abbreviations: COVID-19 — : coronavirus disease CPS — : child protective services Although the public health benefits of social distancing, isolation, and quarantines are well-established and essential for reducing risk of transmitting the coronavirus disease (COVID-19), the disease caused by the novel coronavirus (severe acute respiratory syndrome coronavirus 2), there are also likely consequences for these practices when considering the impact of violence in the home. Reports of increased domestic violence after quarantine orders in China have revealed the interpersonal violence risks of isolation. Indeed, in a recent review of the psychological impact of quarantine published in The Lancet , the authors indicated increased anger, confusion, and posttraumatic stress symptoms, as well as evidence of increases in substance use, in those subjected to quarantine.1 These kinds of dysregulated emotions and substance use can increase violent behavior, especially within the family. Children’s exposure to intimate partner violence, whether directly witnessed or overheard, is harmful and may lead to posttraumatic stress disorder and other serious emotional and behavioral problems.2 Furthermore, intimate partner violence and child abuse often co-occur,3 … Address correspondence to Kathryn L. Humphreys, PhD, EdM, Department of Psychology and Human Development, Vanderbilt University, Nashville, TN 37203. E-mail: k.humphreys{at}vanderbilt.edu

Synergistic adversities and behavioral problems in traumatized children and adolescents

ObjectiveThis study investigated synergy of commonly co-occurring pairs of childhood traumas/adversities to determine: 1) if synergistic pairings differ by gender and/or age grouping; and 2) if some traumas/adversities were more synergistically reactive. MethodsA sample of 10,355 clinic-referred youth (1.5–18 years) from the National Child Traumatic Stress Network Core Data Set was divided by gender and categorized into salient age groups (1.5−5 years, 6−12 years, and 13−18 years). Attributable Proportion (AP), a biomedically relevant metric, was calculated to assess additive synergy for behavior problems on the CBCL. ResultsOverall, only four pairs of adversities were synergistic. Three involved sexual abuse with physical abuse, parental loss, and domestic violence. When the sample was analyzed by Gender X Age group, however, a more complicated picture emerges. Twelve of the twenty-one possible pairings (57 %) show additive synergy in one or more categories. The mean AP accounted for approximately 40 % of outcome variance. Males had more synergistic pairings (16) than females (7). The average synergistic effect was higher for males (42 % of variance) than females (36 % of variance). The vast majority of synergy occurs in the 6−12 and 13−18 age groups. Sexual abuse was the most synergistically reactive trauma, pairing most frequently (16) followed by physical abuse (10) or neglect (9). ConclusionSexual abuse was malignantly synergistic, frequently pairing with other adversities, followed by physical abuse, neglect, and domestic violence. The findings underscore that all ACEs are not equal in their contributions to commonly assessed outcomes. The findings also have considerable implications for prevention, intervention, and future research.