Traumatized Children

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The lecture explores approaches for assessing and treating children, who have experienced any type of trauma focusing on the specific needs of each child, the impact of trauma , and development. A psychoanalytic perspective helps a therapist understand a child’s strengths and weaknesses, frustrations, and conflicts as well as those within a chaotic environment and social situation. This approach allows for flexible problem-solving strategies.

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1 Artwork courtesy of the International Child Art Foundation (www.icaf.org) Issues in Working with Traumatized Children Dr. Patricia A. Heisser Metoyer

Issues for Traumatized Youth : 

2 Issues for Traumatized Youth The workshop will explore approaches for assessing and treating children, who have experienced any type of trauma focusing on the specific needs of each child, the impact of trauma , and development. A psychoanalytic perspective helps a therapist understand a child’s strengths and weaknesses, frustrations, and conflicts as well as those within a chaotic environment and social situation. This approach allows for flexible problem-solving strategies.

Issues in Working With Traumatized Children : 

Issues in Working With Traumatized Children There are important implications for understanding the way the child is processing, learning, and reacting to a traumatic situation in treatment. A psychoanalytic orientation provides an important perspective for developing prevention, intervention and treatment for traumatized children and their families.

Trauma : 

4 Trauma 4 Artwork courtesy of the International Child Art Foundation (www.icaf.org)

What is trauma? : 

5 What is trauma? A traumatic experience: Threatens the life or physical integrity of a child or of someone critically important to that child (such as a parent or sibling) Causes an overwhelming sense of terror, helplessness, and horror Produces physical changes such as pounding heart, rapid breathing, trembling, dizziness, or loss of bladder or bowel control

Types of Trauma : 

6 Types of Trauma 6 Acute trauma is a single traumatic event that is limited in time. Chronic trauma refers to the experience of multiple traumatic events. The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

Types of Trauma: What about neglect? : 

7 Types of Trauma: What about neglect? Failure to provide for a child’s basic needs Perceived as trauma by an infant or young child completely dependent on adults for care Opens the door to other traumatic events May reduce a child’s ability to recover from trauma

Complex Trauma : 

8 Complex Trauma Complex trauma describes both exposure to chronic trauma (most often by a loved one) and the impact of such exposure on the child. Multiple interpersonal traumatic events Profound effects on nearly every aspect of a child’s development and functioning. Source: Cook et al. (2005). Psychiatr Ann,35(5):390-398.

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9 The Effects of Trauma Exposure on Children

National Statistics : 

10 National Statistics One out of every 4 children attending school has been exposed to a traumatic event. 1 out of 4 girls and 1 out of 6 boys will experience some form of sexual abuse before the age of 18. 1/3 of child sexual abuse cases are perpetrated by individuals under the age of 18. Nationally, 64.2 percent of child victims experienced neglect, 16.0 percent were physically abused, 8.8 percent were sexually abused, and 6.6 percent were emotionally or psychologically maltreated. U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006 (Washington, DC: U.S. Government Printing Office, 2008).

Prevalence of Traumain the Child Welfare Population : 

11 Prevalence of Traumain the Child Welfare Population A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%).1 Nearly 80% of abused children face at least one mental health challenge by age 21.2 1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at: http://www.casey.org/NR/rdonlyres/CEFBB1B6-7ED1-440D-925A-E5BAF602294D/302/casey_alumni_studies_report.pdf. 2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at: http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf.

Prevalence in Child Welfare Population : 

12 Prevalence in Child Welfare Population A study of children in foster care revealed that PTSD was diagnosed in 60% of sexually abused children and in 42% of the physically abused children.1 The study also found that 18% of foster children who had not experienced either type of abuse had PTSD,1 possibly as a result of exposure to domestic or community violence.2 1. Dubner et al. (1999). JCCPsych;67(3): 367-373. 2. Marsenich (March 2002). Evidence-Based Practices in Mental Health Services for Foster Youth. Available at: http://www.cimh.org/downloads/Fostercaremanual.pdf.

The Effects of Trauma Exposure on Children’s Behavior, Development, and Relationships : 

13 The Effects of Trauma Exposure on Children’s Behavior, Development, and Relationships Artwork courtesy of the International Child Art Foundation (www.icaf.org)

Symptoms and Psychological StrategiesPreschool through Second Grade : 

Symptoms and Psychological StrategiesPreschool through Second Grade Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesPreschool through Second Grade : 

Symptoms and Psychological StrategiesPreschool through Second Grade Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesThird through Fifth Grade : 

Symptoms and Psychological StrategiesThird through Fifth Grade Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesThird through Fifth Grade : 

Symptoms and Psychological StrategiesThird through Fifth Grade Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesThird through Fifth Grade : 

Symptoms and Psychological StrategiesThird through Fifth Grade Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesAdolescents (Sixth Grade and Up) : 

Symptoms and Psychological StrategiesAdolescents (Sixth Grade and Up) Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Symptoms and Psychological StrategiesAdolescents (Sixth Grade and Up) : 

Symptoms and Psychological StrategiesAdolescents (Sixth Grade and Up) Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Initial ConsultationFirst Stage: Opening : 

Initial ConsultationFirst Stage: Opening Establish the focus Free drawing and storytelling Traumatic reference Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Initial ConsultationSecond Stage: Trauma : 

Initial ConsultationSecond Stage: Trauma Reliving the experience - Emotional release - Reconstruction - Perceptual experience - Special detailing - Worst moment - Violence / physical mutilation Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Initial ConsultationSecond Stage: Trauma : 

Initial ConsultationSecond Stage: Trauma Coping with the experience - Issues of human accountability - Inner plans of action - Punishment or retaliation - Fears of counter-retaliation - Challenge to child’s impulse control - Influence of previous trauma - Traumatic dreams - Future orientation - Current Stresses Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Initial ConsultationThird Stage: Closure : 

Initial ConsultationThird Stage: Closure Recapitulation Underscore realistic fears Universalize the child’s responses Describe expectable course Acknowledge child’s courage in undertaking the interview Invite child critique of consultation Proper leave-taking Adapted from: Pynoos RS, Nader K: (1988) Psychological first aid and treatment approach to children exposed to community violence: Research implications. Journal of Traumatic Stress 1: 445-473.

Complex PTSD : 

25 Complex PTSD Problems with: Regulation of Affect & Impulses Cognitive Functioning/ Dissociation Somatization Sense of Self Relationships Systems of Meaning

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26 Emotions run high (angry, sad, afraid) Easily set off or triggered Difficulty calming down Self-destructive behavior Careless (realize later) vs. purposeful risk taking vs. not acknowledging the risks Problems with sexual involvement Suicidal preoccupation, parasuicide Regulating Affect and Impulses

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27 Attention or Consciousness Amnesia Dissociation Depersonalization

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28 Feel ineffective and permanently damaged Guilt, responsibility, shame Sense of alienation Minimizing the impact of trauma Self-Perception

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29 Difficulty Trusting Others - Reciprocity - Assertiveness Re-Victimization Victimizing Others Interpersonal Relationships

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30 Somatization Chronic Pain Digestive, Cardiopulmonary, Sexual, Conversion Symptoms

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31 Foreshortened future: education, work & love Problematic sustaining beliefs - Life has no meaning or there is no purpose to life - No justice in the world Systems of Meaning

Trauma and the Brain : 

32 Trauma and the Brain Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition. Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans. May affect the way these children respond to future stress in their lives, and may also influence their long-term health.1 1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193

Long-Term Effects of Childhood Trauma : 

33 Long-Term Effects of Childhood Trauma Alcoholism Drug abuse Depression Suicide attempts Sexually transmitted diseases (due to high risk activity with multiple partners) Heart disease, cancer, chronic lung disease, skeletal fractures, sexually transmitted diseases and liver disease Source: Felitti et al. (1998). Am J Prev Med;14(4):245-258.

So Why is this Important? : 

34 So Why is this Important? Children who have been exposed to trauma expend a great deal of energy responding to, coping with, and coming to terms with the event. This may reduce children’s capacity to explore the environment and to master age-appropriate developmental tasks. The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways.

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35 Trauma and Psychopathology Thompson et al., 2002

Childhood Trauma and PTSD : 

36 Childhood Trauma and PTSD PTSD may be diagnosed in children who have: Experienced, witnessed, or been confronted with one or more events that involved real or threatened death or serious injury to the physical integrity of themselves or others Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

Childhood Trauma and PTSD : 

37 Childhood Trauma and PTSD Reexperiencing nightmares, intrusive memories, trauma triggers, reenactment Avoidance thoughts, feelings, places, and people associated with the trauma Increased Arousal heightened startle response, sleep disorders, irritability, hypervigilance, poor concentration Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

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38 Children who have experienced trauma often exhibit extremely challenging behaviors and reactions. Avoid labeling as “good” or “bad”. Many of the most challenging behaviors are strategies that in the past may have helped the child survive. 38 Understanding Children’s Responses

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39 When faced with people, situations, places, or things that remind them of traumatic events, children may experience intense and disturbing feelings tied to the original trauma. These “trauma reminders” can lead to behaviors that seem out of place, but were appropriate—and perhaps even helpful—at the time of the original traumatic event. 39 Understanding Trauma Reminders

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40 Traumatized children may exhibit: Over-controlled behavior in an unconscious attempt to counteract feelings of helplessness Difficulty transitioning and changing routines, rigid behavioral patterns, repetitive behaviors, eating disorders, etc. Under-controlled behavior due to cognitive delays or deficits in planning, organizing, delaying gratification, and exerting control over behavior Impulsive behavior, disorganization, aggression, or other acting-out behaviors Understanding Children’s Responses

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41 Current Model

Proposed Model : 

42 Proposed Model Trauma Effects - Mind - Body - Family - Social Screen and Assess Trauma-Specific, Evidence-Based Treatment Refer

Model : 

43 Model Group Format Present-focused – not an exposure-based intervention Equip adolescents with tools for coping with current and future stressors 16 sessions – 60 minute sessions Manual based

Complex PTSD : 

44 Complex PTSD Regulation of affect and impulses Emotions run high Easily set off or triggered Self-destructive behavior Cognitive functioning Poor concentration Amnesia Dissociation Somatization Chronic pain Digestive, cardiopulmonary, sexual, and conversion symptoms

Complex PTSD : 

45 Complex PTSD Sense of self Feel ineffective and permanently damaged Guilt, responsibility, shame Relationships Difficulty trusting others Re-victimization Victimizing others Systems of meaning Foreshortened future Problematic sustaining beliefs, i.e. feeling life has no meaning/that there is no purpose in life, feeling there is no justice in the world

Key Concepts : 

46 Key Concepts “The Four C’s” Connect with others Cope more effectively in the moment Cultivate awareness Create meaning MUP’s and SOS – Cultivating awareness Mindfulness – Cultivating awareness Distress Tolerance – Coping more effectively in the moment LET’M GO – Problem solving skills MAKE-A-LINK – Communication skills

coping strategies that can : 

47 coping strategies that can Fighting Drinking/Smoking Cutting Over Eating Not Eating Enough Drugging Isolating Excessive Exercise MUPs Mess You UP Sleeping all the time Risky High Speed Activities Risky Sexual Behavior TV or Video Games constantly Toxic Relationships Constantly Taking Care of Others

SOS : 

48 SOS SLOW DOWN Take a time out; calm your body; one thought at a time ORIENT YOURSELF Bring your mind & body back to the present time and place SELF-CHECK Rate your level of personal distress and sense of control here and now Ford et al., 2001

Feeling Intensity Thermometer : 

49 Feeling Intensity Thermometer Personal Distress Right now I feel … Completely Calm 1 2 3 4 5 6 7 8 9 10 Most Distressed Ever Personal Control Right now I feel … In complete control 1 2 3 4 5 6 7 8 9 10 Totally out of control

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50 Paying attention in a particular way: On purpose, in the present moment, and nonjudgmentally Kabat-Zinn, 1994 Mindfulness

Distress Tolerance : 

51 Distress Tolerance Hanging in there – to get through the moment Self-Soothe Take a bath Light a candle Eat or Drink something enjoyable Distract Listen to music Exercise Do a crossword puzzle Play with Play-doh

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52 LET’M GO SOS BeMindful SOS BeMindful SOS BeMindful SOS BeMindful SOS BeMindful SOS BeMindful

MAKE-A-LINK : 

53 MAKE-A-LINK (be) Mindful Act confident Keep a calm & gentle manner Express interest Ask for what you want Let them know you get their point of view Include your feelings Negotiate—give to get Keep your self respect

Core Components : 

54 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

Core Components : 

55 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

Core Components : 

56 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

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Core Components : 

58 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

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59

Core Components : 

60 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

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61

Core Components : 

62 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

Core Components : 

63 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

Core Components : 

64 Core Components Psychoeducation and Parenting Skills Relaxation Affect Expression and Regulation Cognitive Coping Trauma Narrative Development and Processing In Vivo Gradual Exposure Conjoint Parent/Child Session Enhancing Safety and Future Development

Questions to Ask Therapists/Agencies That Provide Services : 

65 Questions to Ask Therapists/Agencies That Provide Services Do you provide trauma-specific or trauma-informed therapy? If so, how do you determine if the child needs a trauma-specific therapy? How familiar are you with evidence-based treatment models designed and tested for treatment of child trauma-related symptoms? How do you approach therapy with traumatized children and their families (regardless of whether they indicate or request trauma-informed treatment)? Describe a typical course of therapy (e.g., can you describe the core components of your treatment approach?).

The Importance of Early Mental Health Screening : 

66 The Importance of Early Mental Health Screening Not all children who have experienced trauma need trauma-specific intervention. Unfortunately, many children in the child welfare system lack natural support systems and need the help of trauma-informed care. Children exposed to traumatic events may or may not meet the full criteria for PTSD Following a mental health screen, all children should receive a comprehensive trauma assessment to determine which mental health intervention will be most beneficial.

Examples of Trauma Assessment Measures : 

67 Examples of Trauma Assessment Measures UCLA PTSD Index for DSM-IV Trauma Symptom Checklist for Children (TSCC) Trauma Symptom Checklist for Young Children (TSCYC) Child Sexual Behavior Inventory

Child Welfare Trauma Referral Tool : 

68 Child Welfare Trauma Referral Tool Purpose: This measure is designed to help child welfare workers make more trauma-informed decisions about the need for referral to trauma specific and general mental health services. Developed by the NCTSN Child Welfare Committee - March of 2008

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Section B: Current Traumatic Stress Reactions : 

71 Section B: Current Traumatic Stress Reactions Re-Experiencing Reenacting trauma through play, pronounced reactivity to trauma reminders, and nightmares Avoidance Avoiding anything connected to the trauma (people, places, activities, conversation, etc.) Numbing Often most difficult to assess in children Restricted range of emotion, minimizing the trauma, sense of foreshortened future, loss of previously acquired developmental skills, social withdrawal Arousal Difficulty with sleep, irritability, and/or extreme tantrums Newly proposed PTSD symptoms in young children New separation anxiety, new onset of aggression, new fears without obvious links to the trauma

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Now it is your turn… : 

78 Now it is your turn… Case Vignettes

Trauma Impact : 

Trauma Impact Severe distress almost universal Unresolved childhood trauma may lead to adult mental health problems Trauma impact may be long lasting Trauma impact varies; most children recover over time

Therapeutic Themes for Traumatized Children : 

Therapeutic Themes for Traumatized Children Anger Depression Anxiety Hopelessness Difficulty with affect regulation Low self esteem

Diagnoses : 

Diagnoses PTSD Depression Adjustment disorders Anxiety disorders

Complex PTSD : 

Complex PTSD Affective dysregulation Interpersonal problems Self esteem issues Self injurious behaviors

Treatment of Parents : 

Treatment of Parents Evidence to support treating parents: Deblinger, 1996 – showed decreased behaviors and depressive symptoms in child Cohen & Mannarino, 1996 – parents’ emotional reaction to trauma was the strongest predictor of positive treatment outcomes Cohen & Mannarino, 1997 – 12 month follow-up showed decreased symptoms in children when parents had support

Common Parental Concerns in Child Traumatization : 

Common Parental Concerns in Child Traumatization Over-protectiveness PTSD Symptoms Over-permissiveness Inappropriate child blame Inappropriate self blame & guilt

What is manualized treatment? : 

What is manualized treatment? It is not the treatment but guidelines to implement it Allows joint establishment of treatment goals Uses developmentally appropriate therapeutic interventions Therapeutic relationship is key Therapist creativity & judgment important

Cognitive Behavioral Interventions : 

Cognitive Behavioral Interventions Direct discussion of traumatic event Cognitive exploration and reframing Psychoeducation Feelings identification Self calming skills Joint parent/child sessions

Outline of Treatment : 

Outline of Treatment Individual sessions for both child and parent/caregiver Parent sessions – usually follow the same focus as the child’s Child and parent assigned to the same therapist

Psychoeducation : 

Psychoeducation GOALS: Normalize child’s and parent’s response to the traumatic event Identify and reinforce accurate cognitions about the traumatic event Educate regarding expected responses and diagnosis

Feelings Identificationand Expression : 

Feelings Identificationand Expression GOAL: To assist children and their parents in accurately identifying their feelings Includes feelings related and not related to the traumatic experience Should be started in the first session with the child

Stress Management Techniques : 

Stress Management Techniques GOAL: To reduce the physiological manifestation of stress and PTSD

Cognitive Coping : 

Cognitive Coping GOAL: To practice the skill of focusing on the positive instead of the negative aspects of any given situation Learn the relationship between thoughts, feelings and behaviors

Creating the Trauma Narrative : 

Creating the Trauma Narrative GOAL: Gradual desensitizing the child to their thoughts, feelings and reminders of the trauma Learn to recognize, anticipate and prepare for traumatic reminders Contextualize traumatic event

Discuss or not to discuss : 

Discuss or not to discuss Reasons we choose not to discuss: Child discomfort Parent discomfort Therapist discomfort Reasons we choose to discuss: Desensitization Address avoidance symptoms Correct inaccurate or unhelpful cognitions Model adaptive coping Prepare for traumatic reminders

Sharing Narrative with Parent : 

Sharing Narrative with Parent Therapist should remember: Parents may not know details of what happened Ask: what was your reaction? Discuss issues of confidentiality and any developmental concerns

Cognitive Processing : 

Cognitive Processing GOAL: Educate parents and children about the cognitive triangle; connection between thoughts, feelings and behaviors.

Cognitive Reframing : 

Cognitive Reframing GOAL: To decrease negative behavioral and psychobiological effects through developing appropriate cognitions about the traumatic event

Behavior Management : 

Behavior Management GOAL: Establish rapport and confidence in ability Create safety for the child

Joint Parent-Child Sessions : 

Joint Parent-Child Sessions GOAL: Share information about child’s experience Correct parents cognitive distortions Correct child’s cognitive distortions Encourage parent-child communication Prepare for future traumatic reminders Model appropriate responses Safety planning Healthy sexuality information

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