Psychological risk factors and PTSD in trauma-exposed children

Focal Issues America-based population research reveals that sudden death in the family constitutes one of the most commonly-cited traumatic experiences, rendering the psychological effects of a sudden demise a major public health issue. According to epidemiologic study findings, most American children have been exposed to PTEs (potentially traumatic experiences/events). One of the latest population surveys revealed that 68 percent of children surveyed had suffered a minimum of one PTE in their life, with over 50% percent experiencing multiple events (Stahmer et al., 2018).
Trauma-exposed persons each have their unique reactions to such events, depending on a complicated set of protective and risk factors. Several kinds of stressors are capable of triggering post-traumatic stress disorder (PTSD), such as natural catastrophes (e.g., earthquakes, tsunamis, etc.) and human-made catastrophes (e.g., civilian violence, war, etc.). Certain events more strongly precipitate PTSD as compared to others. Prior studies suggest that rogue civilian shootings, mass violence, terror attacks, and similar human-made calamities were more potent as compared to technological or natural disasters. Interpersonal trauma experienced in childhood will more likely be linked to complex PTSD when compared with disaster, adulthood onset, or accidental trauma (Farooqui et al., 2017). Contributing Factors Risk factors under the compensatory model (like stresses and genetic susceptibility) may add to and potentiate one another. Generally, several risk factors together hinder development and not anyone risk factor alone. However, this doesn't mean risk factors are all equally influential – this is not always likely. For instance, the genetic risk might be a more attributable schizophrenia risk factor in comparison to others. But multiple risks often potentiate one another. Sameroff's (1987) research findings reveal that children hailing from households characterized by a minimum of seven risk factors had an IQ score of 30 points lower than children from no-risk-factor households. Babyhood risk factors are seemingly magnified synergistically in case of negative household climates or if children experience stressful events in life (Haggerty & Mrazek, 1994). 
Individual childhood risk factors may result in susceptibility, with other kinds of risk factors potentially having a greater impact. For instance, low-birthweight, preterm babies might be at greater risk compared to healthy, full-term siblings within a suboptimal household atmosphere. Gender also forms a key genetic factor. Prenatally as well as from birth until the age of ten years, boys will more likely be susceptible to psychosocial as well as physical stressors when compared with girls. From 10-20 years, the opposite phenomenon is observed (i.e., girls tend to display greater vulnerability to psychosocial factors), while early adulthood witnesses males are again becoming more susceptible. Some familial factors posing as major risk factors when it comes to greater childhood psychopathology are severe discord among parents, maternal psychological issues, low social class, large or overcrowded household, admission to local child welfare service, and paternal criminality (Haggerty & Mrazek, 1994). 
Community determinants impacting children include being socially disadvantaged, especially if the child hails from a welfare household, and not merely because of low income. After controlling for income, impairment rates are substantially higher in the case of children belonging to lower-income welfare households as compared to low-income households, not on state welfare. Further, hailing from a subsidized living/housing arrangement situated in a locality with high community disorganization rates also increases childhood psychological disorder risks. Schools and other community institutions have the potential to both improve and undermine social and intellectual progress, thereby serving as either a protective setting or community risk in the case of youngsters (Haggerty & Mrazek, 1994). 
While research on protective factors has progressed by leaps and bounds, it isn't as developed as that on risk factors, with numerous methodological and conceptual problems still not adequately resolved. But evidence exists of a core collection of support sources and individual traits buffering the influence of psychosocial as well as biological childhood risk factors. Social skills, a positive attitude, and superior intelligence may play a part in individual resilience (Haggerty & Mrazek, 1994). 
Receptive and even-tempered children evoke the best actions and experiences from their educators, parents, other adults, and fellow students. Superior intelligence levels facilitate the child's academic performance as well as problem-solving skill development, besides perception and emotional differentiation from his/her community or family, promoting individuality and self-sufficiency vital to optimal functioning in adulthood. Social skills encompass effectively getting along with other people. A protective element at the teenage stage is rationality and an inner control orientation locus (or a personal feeling of effectively taking controlling one's own life) (Haggerty & Mrazek, 1994). 
Community-level protective elements encompass relationships forged outside of the family (i.e., with friends and significant adult others), as well as external support systems like the school, church, recreation, and youth groups that all help develop competence, contributing to child success (Jones and Offord, 1989; Werner, 1989; Werner and Smith, 1982). A good secondary school will positively influence the child's academic performance and, as a result, occupational outcome. Moreover, it will lower absenteeism, juvenile court appearance, and dropout rates in case of children hailing from disadvantaged communities (Haggerty & Mrazek, 1994).  Motivation and Stage of Change The motivator for change among clients is frequently a topic of both frustration and interest in clinician circles. Motivation is considered a precondition for therapy; therapists seldom enjoy any success with an unmotivated client. The absence of motivation accounts for individuals not commencing, continuing, sticking to, and completing treatment. Until quite recently, this factor was perceived to be a static quality or inclination either possessed or not possessed by a client. Consequently, the client was to blame for not being motivated to change his/her behavior. Indeed, motivation to undergo therapy implied a readiness to follow the prescription set for recovery by the therapist or intervention ("Center for Substance Abuse Treatment," 1999).
Clients appearing to be open to clinical guidance or accepting that they abused drugs or alcohol were regarded as motivated clients; meanwhile, those who disliked diagnostic testing, declined treatment, or didn't comply with it, were branded 'unmotivated.' Additionally, motivation was typically a burden to be borne by the client and not the clinician. Jim admitted to hiding empty cans of compressed air and bottles of beer in his room, claiming he had no disorder and had only once or twice attempted to drink or huff. This suggests that he acknowledged this behavior and didn't have any problem changing ("Center for Substance Abuse Treatment," 1999).
All addicts realize the need for change at some stage of life. Motivation is what distinguishes those who succeed at making the necessary changes from those who fail. As motivation proves crucial for recovery, both clients and counselors must understand change motivators. This encompasses a grasp of the kind and extent of motivation and different ways of increasing motivation. An adequately motivated individual is capable of successfully changing. It is a generally known fact that the process of change doesn't happen overnight; it occurs gradually, and as it slowly unfolds, the motivation of the individual changes (Monti, 2002). 
While the SOC model has five stages, proactive drug/alcohol testing in trauma facilities often identifies only those who are in the initial three stages (i.e., pre-contemplation, contemplation, and preparation). Those in the last two stages of action (having recently effected change) or maintenance (sustaining change), have either totally given up drinking or, at least, moderated it. Hence, they will most likely not test positive. The client in question, Jim, is at stage I (Pre-Contemplation). Those on this stage, though potentially understanding the drawbacks of addiction, might perceive them to be trivial when compared with the benefits. However, some might perceive the situation in a different light. This stage is characterized by disinterest in changing, and no intent or plan to change. Such an individual may be labeled as 'unaware' (Monti, 2002).  Case Formulation The hypothesis addressed the link between Change Stage (Pre- Contemplation, Contemplation, Action or Maintenance), Therapeutic Barriers (Treatment Problems, Demands, and Perceived Therapy Relevance), Treatment Attendance (the period of treatment and number of therapy sessions the client participated in), and CBCL (Total Problems Scale). An analysis of data indicated a major positive association between scores of CBCL total problems and the Contemplation stage, a major negative linkage between scores of CBCL total problems and the Action stage, a major positive association between scores of CBCL total problems and the Maintenance stage, and a major positive link between scores of CBCL total problems and the treatment time. In indicating links between willingness to change and therapeutic barriers in a community outpatient mental health facility, this study constitutes an attempt at promoting a more comprehensive understanding of therapy (Sliter, 2009).

Treatment TF-CBT (trauma-focused cognitive behavior therapy) represents a conjoint parent-child psychotherapy model-based cognitive-behavioral approach mostly adopted in the treatment of traumatized children between 3 and 17 years of age. It comprises several key therapeutic elements like trauma-related psycho-education, distressing thoughts, emotions, and action management approaches; enhancement of child safety and parenting capability; and processing and experiencing trauma-linked memories by developing a trauma narrative. Non-offending/trauma-causing caregivers and children are first made to visit separately. After both are perceived to be ready, they may visit together to allow the child to share his/her trauma story with the caregiver (Weiner et al., 2009).
To select a therapeutic plan for Jim, ensuring a safe treatment relevant to his symptoms and capable of improving his health outcomes was crucial. Other factors like child age, traumatic occurrence recall, and cultural and familial background were also taken into account to select the ideal treatment to meet the client and his family's preferences and needs. This was performed with the aid of Jim's extant comprehensive evaluation for ascertaining the therapeutic approach best suited in his case (Weiner et al., 2009).
The therapy's first phase entails developing competency and stabilization, encompassing psycho-education, improving cognitive coping capability, skills for facilitating impact modulation, and parenting and relaxation skills. The second phase entails trauma narrative development and its processing and experiencing. The third phase encompasses closure and consolidation, with emphasis given to mastering trauma reminders, improving safety, relapse resistance, and joint parent-child therapeutic sessions. An expanded chapter on TF-CBT studies analyzes multisite researches and covers research works that entail a multicultural setting. Several international randomized controlled researches have been performed, with some encompassing therapeutic provisions within war zones (Nadeem & Ringle, 2016).
Akin to several similar CBT initiatives, TF-CBT commences with psycho-education about trauma, therapy protocol, and trauma-linked grief, remarking that this kind of psycho-education is kick-started with the foremost phone call in which the caller gets informed of the program's potential positive result and the experience of providers when addressing the problem. Psycho-education forms a component of evaluation in which normalization of parental as well as child reactions may be combined with data on common trauma results and its impact on several functioning elements. Particularly while treating children suffering from multiple comorbidities, accurate identification of comorbidities while taking care to emphasize the positive effect of therapy is recommended. About grief, psychoeducational data nature is contingent on reasons underlying loss (e.g., a random murder) as against purposeful terrorism (Nadeem & Ringle, 2016).
In the initial stages of the therapeutic protocol, parents receive training on applying functional analysis as well as its antecedents (the behavior-impact chain). Selective focus and utilizing reinforcement are described, coupled with Time Out application. The competencies required for dealing with children differ from those involving teenagers. Strategic disparities are explained. Therapists familiarize clients with focused breathing, meditation, and mindfulness, with useful scripts offered for progressive diaphragmatic breathing and muscle relaxation (Nadeem & Ringle, 2016).
The parent, as well as child, are taught the enhancement of proper effective expression. Another preliminary element of the initiative is using positive images and self-talk, accompanied by improving social and problem-solving capabilities. All this is performed within a setting focusing on a better sense of security and safety. The cognitive feeling-thought-behavior triangle is provided and, subsequently, awareness of incorrect, adverse, and obstructive thoughts. Client Engagement Following trauma narrative session completion with the child, the therapist introduces his/her parents to the narrative. A perpetual fear persists that stressing on the child's trauma narrative can trigger and even aggravate PTSD symptoms, particularly within at-risk populations suffering from comorbidities like the history of multiple trauma or depression. However, the opposite is true. The client's trauma narrative helps therapists highlight and aid the child (as well as his/her parents) in correcting incorrect or negative cognitions. Catastrophization, inability to trust others, and feeling they can't go on living are a few common thoughts that need addressing. The client's trauma narrative forms part of an exposure and desensitization strategy supplementing in-vivo exposure and desensitization to things triggering trauma (Cohen, Mannarino, & Deblinger, 2017).
About loss, children must necessarily be told the truth linked to their demise. This must be performed within a developmentally-sensitive setting. Keeping facts from children might subsequently erode their trust once they finally learn the actual truth. Some examples of words understandable by children for ensuring they can comprehend loss, sickness, accident, overdose, murder, or taking one's own life are provided. Again, slow, though direct, experiencing of events linked to the death of a family member are illustrated. Public websites to aid parents coping with loss are identified. Intriguingly, concerning the loss, the therapist will frequently find him/herself having to handle the client's family's religious values. Strategies for sensitive handling of religious differences between the family and counselor are studied. Again, therapists are urged to stick to an empathetic, frank, straightforward, and sensitive presentation style (Cohen, Mannarino, & Deblinger, 2017).
It is imperative to address the personal safety concept following any traumatic event. Safety Skills Training encompasses the ability of directly and explicitly communicating while focusing on physical "gut" feelings, awareness of safe zones and individuals, learning and effectively enforcing personal boundaries when it comes to one's body, body space, and touching, understanding the need to refrain from concealing things, and supporting the ability to seek assistance and sustain one's requests until the arrival of relevant aid (Cohen, Mannarino, & Deblinger, 2017).
Therapy cessation involves the following 3P's: prediction, planning, and permission. Adults as well as children must realize the fact that grieving is no instantaneous process having a definite, lucid endpoint. It can recur any time, triggered by stimuli like holidays, anniversaries, and other trauma/loss-linked triggers. One element of cessation is reviewing coping abilities to allow adults and children to explain what they will do, should such events transpire. The last "permit" part entails accepting our humanity and permitting the child as well as others to express their emotions rather than perceiving them as a mark of ongoing pathology (Cohen, Mannarino, & Deblinger, 2017).
PART III
I employ this very same principle in treatment, particularly trauma treatment. I make sure never to force clients to evoke traumatic memories until we are both certain that they can contain, whenever and however desired, the flow of memories, feelings, physical sensations, and anxiety. That is, I make sure they never press the accelerator before knowing where the brake is. This approach ensures trauma treatment is both safe and easily controllable, besides making clients braver as they get closer to this daunting stage. They may dig deeper after being certain that they can cease their distress whenever they wish to. Usually, the very first time, the development of such "trauma brakes" helps clients control traumatic memories, instead of memories controlling them. (Stahmer et al., 2018)
A therapist doesn't become friends with the client; the client-therapist relationship isn't intended to be forged from commonalities between them. Self-disclosure constitutes a capability needing clinical determination, dexterity, and sensitivity. For developing trust, therapists must never stray to irrelevant subjects such as vacations or hobbies which don't fall within the client's concern. The client-therapist relationship invariably aims at clients' clinical wellbeing promotion. Whatever action therapists take needs conceptual intent as well as dedication to client wellness (Wilkinson et al., 2017).
Among the foremost goals of a therapist in therapeutic sessions with clients is forging trust, to some extent, at least. A client not confident in the therapeutic relationship will probably not be open about the issues he/she is encountering, especially when it comes to discussing them with the therapist. But one point that therapists must bear in mind is: trust cannot be developed all of a sudden. Developing rapport in any professional therapeutic relationship needs commitment, efforts, and planning (Wilkinson et al., 2017).
Therapists find it tricky to give clients the chance to take therapeutic sessions wherever they desire and at a comfortable pace for them; nevertheless, learning to do this is vital, and calls for the therapist to challenge his/her intrinsic tendency of wishing to guide sessions. Rather, they should broach certain issues only if they find the client explicitly opening the door for their discussion. Active listening proves crucial to connecting with clients. This proves critical in helping therapists gather the required details for commencing therapy as well as in demonstrating a sincere desire to grasp the other person's perspective and feelings. When therapists listen actively while connecting with clients, the latter feel they are being heard and, consequently, trust develops (Wilkinson et al., 2017).
However, in some instances, despite attempts at being respectful and providing space and validation, the therapist-client relationship simply does not click. One must remember, here, that every client is unique, and some like taking it slow. We might be very solution-focused in our job, but if we make the mistake of being too fast (in the client's opinion), a problem-focused client might feel their problem is 'stolen' from them. In case of all clients who come to me, irrespective of their resistance or their overt feelings of dislike towards me, I attempt at developing excitement in the relationship – I make them feel I simply cannot wait for the next session, to understand them better, because I find them and their thoughts and opinions interesting; I am genuinely interested and genuinely excited to discuss things with them. In Jim's case, I can assess a better and different way if afforded the opportunity, as I will be able to understand his ideas more comprehensively.

References Center for Substance Abuse Treatment. (1999). Enhancing motivation for change in substance abuse treatment. https://www.ncbi.nlm.nih.gov/books/NBK64972/ Cohen, J. A., Mannarino, A. P. & Deblinger, E. (2017). Treating Trauma and Traumatic Grief in Children and Adolescents. Second Edition. New York: Guilford, xviii +356 pp., $45.00. (hardbound). Farooqui, M., Quadri, S. A., Suriya, S. S., Khan, M. A., Ovais, M., Sohail, Z., & Hassan, M. (2017). Post-traumatic stress disorder: a serious post-earthquake complication. Trends in Psychiatry and Psychotherapy, 39 (2), 135–143. Haggerty, R. J., & Mrazek, P. J. (Eds.). (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. National Academies Press. Monti, P. M. (Ed.). (2002). Treating alcohol dependence: A coping skills training guide. Guilford Press. Nadeem, E., & Ringle, V. (2016). De-adoption of an evidence-based trauma intervention in schools: A retrospective report from an urban school district. School mental health, 8(1), 132–143. https://doi.org/10.1007/s12310-016-9179-y Sliter, H. M. (2009). Treatment barriers and stages of change among adolescents in psychotherapy. ETD Archive. 271. https://engagedscholarship.csuohio.edu/etdarchive/271 Stahmer, A. C., Suhrheinrich, J., Schetter, P. L., & McGhee Hassrick, E. (2018). Exploring multi-level system factors facilitating educator training and implementation of evidence-based practices (EBP): a study protocol. Implementation science: IS, 13(1), 3. https://doi.org/10.1186/s13012-017-0698-1 Weiner, D. A., Schneider, A., & Lyons, J. S. (2009). Evidence-based treatments for trauma among culturally diverse foster care youth: Treatment retention and outcomes. Children and Youth Services Review, 31(11), 1199-1205. Wilkinson, C., Von Linden, M., Wacha-Montes, A., Bryan, C., & O'Leary, K. (2017). Cognitive processing therapy for post-traumatic stress disorder in a University Counselling Center: an outcome study. The Cognitive Behaviour Therapist, 10.