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The effects of childhood trauma can be mitigated through care and treatment. Early intervention has significant impact. Trauma-informed treatment modalities treat the whole person, recognizing the impact of trauma on physical, psychological, and social health.

Reducing stress hormones (cortisol, adrenaline, testosterone) is a vital early step for effective treatment of complex childhood trauma.

At the present time, the evolving standard of care for the treatment of PTSD includes psychotherapy supplemented by psychopharmacology, where appropriate and used to relieve posttraumatic symptoms as well as associated symptoms of depression, anxiety, obsessive–compulsive disorder and, on occasion, psychosis, carefully applied according to the needs of the client. This is particular important because the overall cost of mental illness to the U.S. economy is staggering, with a 2008 report estimating costs over $300 billion, both the direct costs of mental health care and indirect costs including loss of income from unemployment (McCall-Hosenfield, Mukherjee, Lehman, 2014).

Despite demonstrated effectiveness of cognitive-behavioral psychotherapies for posttraumatic stress disorder (PTSD), there is limited research on the trajectory of PTSD symptom change during the course of these therapies. In addition, existent findings are mixed, making it difficult to know how individuals’ PTSD symptoms will change from week to week during psychotherapy (Schumm, Jeremiah, Kristen, Chard, 2013).

Cognitive behavioral therapy (CBT) is the psychological treatment of choice for PTSD and is recommended by best-practice treatment guidelines e.g. CBT typically involves confrontation with, and processing of, the trauma memory in a safe, gradual manner; identification and restructuring of problematic beliefs; and de-arousal skills. There is strong research evidence for use of these CBT techniques to treat PTSD in terms of magnitude of symptom reduction from pre-treatment levels, and diagnostic recovery. Associated treatment barriers include stigma, cost, geography and insufficient treatment availability (Allen, Newby, Smith and Andrews, 2015).

The treatment of CPTSD is cued to the diagnostic criteria that the seven areas of impairment described earlier: (a) alterations in the capacity to regulate emotions, (b) alterations in conscious- ness and identity, (c) alterations in self- perception, (d) alterations in perception of the perpetrator, (e) somatization, (f) alterations in perceptions of others, and (g) alterations in systems of meaning. The treatment approach that is most recommended at the present time is that of a meta-model that encourages careful sequencing of therapeutic activities and tasks, with specific initial attention to the individual's safety and ability to regulate his or her emotional state. By this reason psychopharmacology is another treatment for the related physical–psychological symptoms. A need to combine psychopharmacology and psychotherapy is usually recommended, including for CPTSD patients (Van Wesel, Alisic, Boeije, 2014).

The clinical relevance of recognizing the existence of complex PTSD in a patient is because the diagnosis is believed to merit a treatment plan that is different from that recommended by treatment guidelines for PTSD in adults (e.g., NICE, 2005). Treatment guidelines for PTSD in adults recommend trauma-focused treatment as a first line intervention for all patients with chronic PTSD. Trauma-focused treatment can be defined as treatment that focuses on "the patients' memories of their traumatic events and the personal meanings of the trauma". This consists of a first phase that focuses on safety, symptom reduction, and skills training; a second phase that focuses on processing of traumatic memories; and a third phase that focuses on social and psychological (re-) integration. Stand-alone trauma focused treatment is believed to carry a risk of psychologically overwhelming the patient and consequently of psychological de-compensation (Ter Heide, Mooren, Kleber, 2016).

A different approach is the Dialectical Behavior Therapy (DBT) which is well-established based on efficacy as well as effectiveness research and widespread acceptance by practicing clinicians, yet its primary benefits over and above community treatment by expert clinicians have been shown to be preventing self-harm and enhancing interpersonal functioning by reducing experiential avoidance and expressed anger (Ford, Courtois, 2014).

Structural and content-related features of trauma narratives of traumatic events may help explain the development of posttraumatic stress disorder (PTSD). In a sample of 35 female assault survivors, we examined the association between the structure and content of trauma narratives and PTSD and other trauma-related reactions (i.e., depression, anxiety, anger, dissociation, and guilt). When controlling for recounting style and recounting distress, narrative structure was not strongly associated with PTSD or other trauma-related reactions. In contrast, the content of the trauma narratives (more positive and negative emotion words, higher cognitive process, and less self-focus) was associated with lower symptomatology. Taken together, trauma narrative content rather than grammatical structure of the narrative may be more reflective of underlying emotional processing of the traumatic memory or lack thereof (Jaeger, Lindblom, Parker-Guilbert, Zoellner, 2014).

Another therapeutic option is the efficacy of Real Life Heroes (RLH) treatment was tested with 119 children in 7 child and family service programs, by (Kagan, James; Trinkle, LaFrenier, (2014), ranging from home-based family counseling to residential treatment. RLH is a sequential, attachment-centered treatment intervention for children with Complex PTSD that focuses on 3 primary components: affect regulation, emotionally supportive relationships, and life story integration to build resources and skills for resilience. Results included statistically significant decreases from baseline to 6 months in child behavior problems on the CBCL (Internalizing and Total Behavior), the Anger subscale of the TSCC, the UCLA PTSD Index-Parent Version (Re-experiencing, Avoidance, Hyper arousal, and Total Symptoms), and the UCLA PTSD Index-Child Version (Avoidance and Total Symptoms). Significant reductions were also found with repeated measures at 3-month assessments from baseline to 9 months on the CBCL, the UCLA Parent and Child Versions, and the PTSD subscale of the TSCC. Children receiving RLH did not have placements or psychiatric hospitalizations, a positive, but not significant trend, compared with trauma-informed "treatment as usual" provided by RLH-trained practitioners in the same programs. The study supported the efficacy of implementing trauma and resiliency-focused treatment in a wide range of child welfare programs and the importance of providing sequential attachment-centered treatment for children with symptoms of Complex PTSD.

The consensus or meta-model that is most in use in the contemporary treatment of CPTSD involves stages of treatment that are organized to address specific issues and skills (Courtois, 2004). A model consisting of three stages is widely adopted, following the recommendation made in Herman's influential and pioneering book on CPTSD, Trauma and Recovery (Herman, 1992). A model similar to this one was originally conceptualized and implemented for the treatment of chronic trauma by the French neurologist, Pierre Janet, at the end of the last century. The early stage of treatment is devoted to the development of the treatment alliance, affect regulation, education, safety, and skill-building. The middle stage, generally undertaken when the client has enough life stability and has learned adequate affect modulation and coping skills, is directed toward the processing of traumatic material in enough detail and to a degree of completion and resolution to allow the individual to function with less posttraumatic impairment. The third stage is targeted toward life consolidation and restructuring, in other words, toward a life that is less affected by the original trauma and its consequences (Courtois, 2004).

Research also covers the treatment of posttraumatic stress disorder (PTSD) among traumatized youth involved with the juvenile justice system. The first section presents the rationale for taking a family systems approach to respond to this problem and describes the ways in which family processes and parent–child relationships reciprocally affect one another in the aftermath of traumatic events. The second section outlines the key features of Functional Family Therapy (FFT) and makes the case for why this evidence-based intervention provides firm bedrock upon which to build a targeted trauma-focused adaptation. The third section of the article outlines the FFT-Trauma Focused model and describes the methods of its flexible and individualized implementation with families of traumatized delinquent youth (Kerig, Alexander, 2012).

Other option is the Narrative-Emotion Process Coding System (NEPCS) is a behavioral coding system that identifies eight client markers: Abstract Story, Empty Story, Unstoried Emotion, Inchoate Story, Same Old Story, Competing Plotlines Story, Unexpected Outcome Story, and Discovery Story. Each marker varies in the degree to which specific narrative and emotion process indicators are represented in one-minute time segments drawn from videotaped therapy sessions. As enhanced integration of narrative and emotional expression has previously been associated with recovery from complex trauma (Carpenter, Angus, Paivio, Bryntwick, 2015). On the other hand, the Attachment, Self-Regulation, and Competency (ARC) Framework is one of a handful of emerging treatment models being developed in partnership with the National Child Traumatic Stress Network (NCTSN) as an intervention for children and adolescents impacted by complex trauma. The ARC framework is a flexible, component-based intervention for treating children and adolescents who have experienced complex trauma. The ARC framework is theoretically grounded in attachment, trauma, and developmental theories and specifically addresses three core domains impacted by exposure to chronic, interpersonal trauma: attachment, self-regulation, and developmental competencies Attachment, self -regulation, competency, trauma experience integration, within those domains, the framework is organized around 10 core targets or building blocks of intervention (Arnsten, Raskind, Taylor, Connor, 2015).

Bush, Prins, Laraway, O’Brien, Ruzek, Ciulla, (2014) explored in a pilot study a non-concurrent, multiple-baseline single-case design to examine the impact of an online self-management posttraumatic stress (PTS) workshop on self-reported symptoms of PTS, depression, and functional impairment. Eleven student veterans with PTS first completed between three and five weekly baseline measures. Second, they took part in eight weekly online workshop sessions, each accompanied by symptom assessments. Third, they completed post intervention outcome measures. These researchers found statistically significant reductions in PTS from baseline across workshop sessions for four of 11 participants, and significant overall reductions in PTS between enrollment and post intervention for five participants. One participant also demonstrated significantly reduced depressive symptoms from baseline across the intervention, and two evidenced significant overall reductions from enrollment to post intervention. Three student veterans showed significantly improved general functioning across the sessions and one reported significant overall functional increase. Finally, five of six participants who completed extended measures of educational function showed significant improvements from enrollment to post intervention. Among secondary outcomes, more than 80% of those taking part said they would recommend the online PTS workshop to a colleague or fellow student with PTS issues.

This gap in services seems particularly unfortunate, in that there are a number of well-established treatments for PTSD. Cognitive behavioral therapy (CBT) for PTSD, in particular those interventions that include exposure therapy, has excellent empirical support in randomized control trials (Frueh, Anouk, Cusack, Kimble, Elhai, Knapp, 2009).



Introduction to Treatments

The effects of childhood trauma can be mitigated through care and treatment, with earlier interventions having a more significant impact. Trauma-informed modalities treat the whole person, recognizing the impact of trauma on physical, psychological, and social health ( National Center for Trauma-Informed Care).

At the present time, the evolving standard of care for the treatment of trauma includes psychotherapy supplemented by psychopharmacology, where appropriate and used to relieve symptoms of Post-traumatic Stress, Depression, Anxiety, Obsessive-Compulsive Disorder,  Personality Disorder such as Borderline Personality Disorder, and, on occasion, Psychosis, carefully applied according to the needs of the client.

Given the multitude of types of childhood trauma there are, many negative impacts can occur which can be hard to track during the process of therapy. However, there are a variety of psychotherapies that have found to be successful in reducing these negative impacts.

CBT

Cognitive behavioral therapy (CBT) is a popular psychological treatment for PTSD, Depression, Anxiety, and Psychosis which can all come from childhood trauma. CBT works towards identifying core negative beliefs/thoughts and collaborating to create positive replacements (cognitions), and increasing positive activities (behavioral). CBT typically involves confrontation with, and processing of, the trauma memory in a safe, gradual manner; identification and restructuring of problematic beliefs; and de-arousal skills. There is strong research evidence for use of these CBT techniques in terms of magnitude of symptom reduction from pre-treatment levels, and diagnostic recovery. In particular those interventions that include exposure therapy, have excellent empirical support in randomized control trials.

DBT

Dialectic Behavioral Therapy (DBT) which is well-established, effective, and widely utilized by practicing clinicians. DBT focusing on increasing distress tolerance skills, interpersonal effectiveness, radical acceptance, and use mindfulness skills. A focus and benefit of DBT is preventing self-harm and enhancing interpersonal functioning by reducing experiential avoidance and expressed anger. DBT has found to be effective in treating personality disorders due to childhood trauma as well as co-morbid disorder. Like CBT, DBT should be modified to fit the needs of the client to create positive change.

Real Life Heroes Treatment

Real Life Heroes (RLH) treatment is an attachment-centered therapy that has also been found to be an effective therapeutic option (https://www.nctsn.org/interventions/real-life-heroes). This approach has been tested in multiple settings with children and families to treat childhood trauma. This treatment works on promoting safety, an understanding of the traumatic event, attachment, coping skills, affect regulation, problem-solving, and was created for children who lack a safe home environment or supportive caregivers.

Functional Family Therapy

Functional Family Therapy (FFT) is a manualized evidence-based treatment found to be effective in treating a multitude of symptoms/problem. This therapy is used in a wide range of settings including community settings and in the juvenile justice system. The focus of FFT is to work with the youth as a whole person, working towards understanding and appreciating their struggles. FFT is able to be modified to fit the individuals and families needs.

Complex Post-Traumatic Stress Disorder

Those that experience chronic trauma or repeated traumatic events (such as violence, abuse, or neglect) may develop Complex Post-Traumatic Stress Disorder (CPTSD). Studies have seen that the symptoms of CPTSD are worse the earlier the trauma is experienced, the longer it lasts/number of events experienced, and whether the person causing the trauma is continually in the victims life or is a close figure in their life. CPTSD is still being studied in order to distinguish this from other disorders and create specific diagnostic criteria. The clinical relevance of recognizing the existence of complex PTSD in a patient is because the diagnosis is believed to merit a treatment plan that is different from that recommended by treatment guidelines for PTSD in adults. Many of the previous therapy mentioned can be modified and used in the treatment of CPTSD including strategies around emotion regulation, anxiety and stress management, interpersonal skills, mindfulness, narration of trauma, and cognitive restructuring

Attachment, Self-Regulation, and Competency (ARC) Framework

Attachment, Self-Regulation, and Competency (ARC) Framework is one of a handful of emerging treatment models being developed in partnership with the National Child Traumatic Stress Network (NCTSN https://www.nctsn.org/) as an intervention for children and adolescents impacted by complex trauma. The ARC framework is a flexible, component-based intervention for treating children and adolescents who have experienced complex trauma. The ARC framework is theoretically grounded in attachment, trauma, and developmental theories; addressing aspects impacted by exposure to chronic/interpersonal trauma such as attachment, self-regulation, and developmental competencies.

Narrative-Emotion Processing Therapy

Narrative-Emotion Processing Therapy is an integrative approach to help those that have experienced childhood trauma regulate their emotions through creating a narrative of their trauma. These techniques has been associated with recovery from complex trauma.