Development of a Differential Assessment Guide to Improve Engagement with Youths & Families Living with Chronic Trauma

Abstract

Youths and parents/caregivers who have experienced multiple forms of severe interpersonal trauma may demonstrate severe and persistent symptoms of complex trauma including high-risk behaviors. Engagement, and sustaining engagement, of these youths and parents/caregivers in evidence-supported trauma treatment is a critical challenge, especially when youths or parents/caregivers have experienced chronic traumas that may be expected to continue into the foreseeable future. An extensive literature review was conducted leading to development of an assessment framework that could increase engagement of youths and parents/caregivers in trauma treatment based on research on chronic trauma, complex trauma, Developmental Trauma Disorder (DTD), and factors that promote engagement. A multi-dimensional assessment guide was developed to enable clinicians to differentiate types of chronic trauma based on a continuum of past, current and expected exposure over time and then to use this guide collaboratively with youths and parents/caregivers to develop priorities for treatment and service planning that matches their needs and strengths. The assessment guide incorporates exposure to intra-familial and community forms of interpersonal trauma, attachment disruptions, established symptoms of PTSD, Complex PTSD and DTD, as well as social-emotional development. The assessment and treatment planning guides proposed in this article expand applicability of evidence-supported trauma-informed therapy to youths and families who have not been engaged by programs offering treatments that are focused on past or single incident traumas or do not address disrupted attachments, multi-generational experiences of adversity, discrimination and community violence, life-threatening dangers or the impact of chronic trauma on youth, parent/caregiver and family development.

Introduction

For many youths and families, traumatic experiences persist from generation to generation with no clear beginning and no expected end. This includes those living with recurrent threats of severe physical or psychological harm to themselves or their families, fears of deportation, life-threatening illnesses, ‘ambiguous losses’ (Boss, 1999), armed conflict, community violence, and multi-generational racism or violence based on ethnicity, religion or sexual orientation. Given the nuances of chronic trauma exposure, widely varying conceptualizations in the literature, and the range of symptomatic presentation in youths and families, it can be difficult for therapists to select interventions that are both effective and engaging. Based on our literature review, clinicians do not have access to a systematic guide to frame engagement and treatment planning strategies for youths & families experiencing very different types of chronic trauma. In addition, most intervention models, including many trauma-informed evidence-based treatments (EBT’s), emphasize Post Traumatic Stress Disorder (PTSD) symptom decrease or elimination, traumatic memory reprocessing, and recovery from past trauma exposures (Amaya-Jackson & DeRosa, 2007; Murray et al., 2013). This focus on past experiences has proven efficacy for youths who are currently living in safe homes and communities with supportive relationships with concerned parents/caregivers but may appear unhelpful for those living with persistent and pervasive trauma exposure (Kagan, 2021; Smith & Patton, 2016). Current assessment practices, diagnoses and treatment of PTSD may inadvertently divert services from addressing how youths and families need to find ways to cope with real and present dangers (Diamond et al., 2013).

Common treatment plans and programs stressing ‘overcoming’, ‘healing’, ‘recovery,’ eliminating hypervigilance and hyperreactivity’, and talking about past traumas may appear out of touch, antithetical, or, even dangerous to youths and parents/caregivers focused on surviving persistent threats, especially on-going interpersonal and systemic traumas that disrupt youths’ primary attachments. Emphasis on ‘stabilization’ of youths’ behaviors may appear to be of little value to youths who experience family members in danger or when youths are experiencing on-going abuse, violence, or neglect. Hypervigilance and hyperreactivity may be essential for surviving familial or community violence, and ‘recovery’ may seem like a fantasy when a community or society has been overtly or covertly persecuting, discriminating against, or oppressing a youth’s family for generations. Systems of care can inadvertently contribute to increased disenfranchisement and disengagement by clients, by utilizing diagnostic labels that are experienced as stigmatizing, along with treatment plans that are experienced as continuing neglect of basic needs or punitive for youths attempting to escape on-going trauma and secure better lives. The mismatch of diagnostic assessments, treatment plans and services offered may be a primary factor in why engagement can be so challenging for youths and parents/caregivers who have been, and may continue to be, experiencing complex interpersonal trauma.

Differential Guide for Prioritizing Engagement Strategies by Types of Chronicity

This article introduces a differential guide to assessment and treatment planning that can be used by therapists to expand and sustain engagement with diverse youths and families living with varying forms of chronic trauma, attachment insecurity and recurrent periodic or pervasive risk of severe harm. This assessment guide builds on the framework of complex trauma and Developmental Trauma Disorder (DTD) (Cook et al., 2005; Ford et al., 2018) as well as research about the effects of living with on-going familial or community violence, terrorism, prejudice and racism and research on engagement. The assessment guide can help therapists and trauma treatment programs by:

1. Providing a practical multi-dimensional assessment tool for youths and families using the components of DTD (Ford et al., 2018; van der Kolk, 2005) in addition to symptoms listed by the DSM-5 and ICD-11 for PTSD and by the ICD-11 for Complex PTSD.

2. Highlighting the value of including assessment of time (past, present & future) for traumatic experiences, predictability of on-going traumatic events and possibilities for prevention or ending recurrent traumas in selection of engagement strategies and in collaborative treatment planning.

3. Incorporating understanding of the developmental impact of complex trauma into treatment planning. This includes how youth, parent/caregiver and family development continues to be shaped by living with on-going trauma exposure from early childhood through adolescence, often blocking possibilities for youths and families to develop or renew attachments, increase capacity for self and co-regulation, and for parents/caregivers to support youths to develop life skills to become successful as young adults.

4. Moving beyond the predominantly western and ethnocentric perspective typical of many assessment models by building on the strengths of other cultures and a collectivist orientation and by addressing experiences of adversity, e.g. poverty, racism, historical oppression.

5. Utilizing engagement strategies and treatment planning that minimizes dropouts by keeping treatment focused on what is most important for youths and parents/caregivers and how that is often shaped by how family members are grappling with different types of chronic trauma.

Search Methodology

Research and practice literature were surveyed using the Primo discovery tool to search across databases such as PsycINFO, PubMed, and Galileo. Key terms included complex trauma OR DTD OR continuous stress OR continuous traumatic stress OR chronic stress OR chronic trauma OR pervasive risk OR pervasive trauma OR engagement OR barriers OR attrition. Peer-reviewed articles, especially meta-reviews, published within the last 10 years were prioritized along with seminal articles and books that provided foundational concepts and addressed cultural diversity e.g. socio-economic status, oppression, racial/ethnic minorities. Research studies from different countries were included in order to provide a broad perspective on what is working and what may be missing in efforts to increase engagement in treatment for chronic trauma. Altogether, eighty-nine publications were utilized to develop a practical framework to differentiate types of chronic trauma and prioritize engagement strategies and service planning matched to chronicity and symptoms of PTSD, complex trauma and DTD.

Findings from Literature Search

Research on Chronic Trauma

The assessment guide builds on research from a wide range of chronic trauma experiences including families with multi-generational abuse and violence, refugee communities escaping war and genocide and Black and Latinx communities systemically trapped in marginalized and disenfranchised communities with high poverty and violence (Stevens et al., 2013). Multiple descriptive terms have been used to denote exposure to chronic trauma including: ‘continuous trauma’ (Straker & The Sanctuaries Counseling Team, 1987, Thomson, 2006), ‘on-going trauma’ (Cohen et al., 2011; Zaghrout-Hodali et al., 2008), ‘on-going traumatic stress’ (Diamond et al., 2010), ‘chronic threat’ (Dickstein et al., 2012), and ‘continuous traumatic stress’ (Eagle & Kaminer, 2013; Straker, 2013). Diamond et al. (2013) conceptualized living with ‘on-going trauma’ from external sources as ‘On-going Traumatic Stress Response’ (OTSR) which reflects adaptive reactions to real and present dangers, rather than a disorder resulting from internal processes stemming from past traumas.

Smith and Patton (2016) described survivors of community violence needing to stay “on point” with enduring hypervigilance. When trauma exposure is ongoing, avoidance behaviors and intrusive thoughts can protect in many ways against distress from real and current threats. Treatment recommendations for PTSD typically focus on the individual, conceptualize avoidance as reducing distress from reminders of past threats, emphasize psychoeducation on internal reactions to trauma, and call for building affect regulation skills, exposure strategies and emotional processing of past traumas. In contrast, individuals coping with ongoing traumatic exposure have been shown to benefit from psychoeducation for on living with on-going stressors, building and enhancing coping capacity (e.g. distraction and distancing), and building community support (Bodkin et al., 2007).

For youths growing up in a community or family context with persistent threat, there is often insufficient experience of safety for recovery, stabilization and deactivation of the stress response (Eagle & Kaminer, 2013). Smith and Patton (2016) described survivors of community violence emphasizing their need to stay “on point” with enduring hypervigilance. A substantial body of research has documented the destructive consequences of a constantly engaged stress response system (e.g., higher mental health symptoms, compromised immune system, impaired executive functioning, higher illness and disease, etc.; Kalmakis & Chandler, 2015; Perry, 2002). Individuals who demonstrate anger, aggression, pessimism, distrust, hypervigilance, and functional difficulties in school, community, and home are frequently misperceived as displaying symptoms of psychopathology leading to referral to psychiatric facilities, child welfare systems, and criminal justice systems (Diamond et al., 2013; Ford et al., 2000). These behaviors can be better understood as adaptive and normal responses to ongoing risk and trauma (Straker, 2013).

The Challenge of Engagement

Engagement and sustaining engagement are primary challenges for trauma treatment, especially for high-risk youths and families who have experienced multiple, chronic trauma exposure with no foreseeable relief (Becker et al., 2011; Gopalan et al., 2010). Low rates of engagement of children and adolescents in psychotherapy have been cited as a significant public health concern, as poor engagement has been found to be associated with poor outcomes (Danko et al., 2016; Haine-Schlagel & Walsh, 2015; Karver et al., 2006; Kazdin & Wassell, 1999). An estimated 50% of youth identified as needing therapy were found in a national survey to not have begun treatment (Merikangas et al., 2010). No-show rates for youth psychotherapy have ranged from 48–62% for initial appointments (Harrison et al., 2004; McKay & Bannon, 2004) and drop-out rates have been reported to range from 20–75% (Armbruster & Kazdin, 1994; Olfson et al., 2009; Wierzbicki & Pekarik, 1993).

Studies of dropouts from trauma treatment are very limited but appear similar to those from youth psychotherapy (Gillies, 2013). For instance, dropout rates before completion of TF-CBT have been described as ranging between 33 and 77% (Wamser-Nanney & Steinzor, 2017; Yasinski et al., 2018). In a study of exposure-based CBT treatment for youth victims of violence, 40% of those who stopped participating before treatment completion dropped out after the initial session (Chasson et al., 2013). Dropout rates from randomized controlled trials (RCT’s) have been noted to be lower than less restricted, ‘real world’ studies (de Haan et al., 2013) and this has been associated with RCT exclusion criteria that limit comorbidity or complexity (Schottenbauer et al., 2008). A meta-analysis of 40 RCT studies for children with PTSD (Simmons et al., 2021) found a high degree of variability in ‘dropout’ rates across studies but little difference in dropout rates between trauma-focused EBT’s using exposure protocols (11.2%) and non-trauma-focused treatments or controls (12.8%). Sixty percent of these studies did not define ‘dropouts’ and definitions of ‘dropouts’ in the remaining 16 studies varied widely with some studies only requiring participation in a few sessions, e.g., 3 sessions out of a possible 8, 12 or 16, to qualify as completion while others required participation in all offered sessions in a brief and limited treatment program, e.g., 8 out of 8 sessions (Simmons et al., 2021).

Findings of studies on engagement and sustaining engagement also appear limited by challenges of accessibility and inclusion in populations included in studies. The ongoing impact of poverty, insufficient housing, community violence, and chronic caregiver adversity are all variables that have been identified as barriers to treatment engagement (Davis et al., 2008; Haine-Schlagel & Walsh, 2015; Ofonedu et al., 2017). Engagement can be especially difficult with youths and families in communities with high rates of poverty and institutional racism, lack of accessibility to resources, and where the risk of violence is higher (Self-Brown et al., 2006; Smith & Patton, 2016). The American Psychological Association’s Guidelines for Psychological Practice for People with Low-Income and Economic Marginalization (Juntunen et al, 2022) calls for practitioners to address the intersecting biases and stigma that exacerbate experiences of low and limited economic status including difficulty accessing services, multiple forms of social injustice and therapists’ own implicit and explicit biases.

Research on Increasing Engagement

Client engagement has been identified as the most robust predictor of change in decades of research investigating process variables contributing to psychotherapy efficacy (Constantino et al., 2010; Karver et al., 2005). Families dealing with ongoing environmental stressors such as poverty and insufficient housing can be challenging to engage in psychotherapy (Gopalan et al., 2010; Ofonedu et al., 2017). Similarly, parents coping with their own depleted internal resources can be challenging to engage in youth and family treatment (Haine-Schlagel & Walsh, 2015), particularly caregivers dealing personally with chronic depression or substance use disorders (Ofonedu et al., 2017). Clients identifying multiple family-level problems and overall elevated family stress are less likely to complete treatment (Attride-Stirling et al., 2004; Thompson et al., 2007). For youths and families of color struggling with emotional distress or chronic adversity, engagement in mental health services has been identified as a public health crisis (Angold et al., 2002; Garland et al., 2005). Fraynt et al. (2014) identified disparities in treatment completion specifically with African American and Latino youths and families seeking services for trauma-related intervention as compared to their White family counterparts. Youths of color who do receive service are more likely to drop out prematurely, attend fewer treatment appointments, and receive services that poorly match their needs (Flores, 2010).

Empirical studies have identified critical factors for engagement including attitudinal, behavioral, social domains, while also considering the importance of treatment preparation and engagement through all stages of intervention (Buckingham et al., 2016; Lindsey et al., 2014). Attitudinal factors include emotional investment, commitment to treatment, and belief that treatment is worthwhile (Nock & Ferriter, 2005; Staudt, 2007). Youth and caregiver data suggest interpersonal disconnection in the early stages of the therapeutic alliance as a significant factor in premature dropout (Buckingham et al., 2016). Youths have identified failures in the therapeutic relationship as the most frequent reason for treatment discontinuation (Constantino et al., 2010; Garcia & Weisz, 2002). Studies surveying treatment dropout have reported low engagement related to youths feeling poorly understood, disrespected, and disempowered by providers (Becker et al., 2011; Buckingham et al., 2016; Snell-Johns et al., 2004).

Primary recommendations in the engagement literature to improve sustained treatment success with vulnerable populations include:

• Focusing on the therapeutic relationship (Amaya-Jackson & DeRosa, 2007; Becker et al., 2011; Buckingham et al., 2016).

• Collaborative assessment of family needs (Becker et al., 2018; Buckingham et al., 2016).

• Youth and caregiver preparation for therapy and continuous exploration of family expectations throughout treatment (Becker et al., 2011; Snell-Johns et al., 2004).

• Youth and family psychoeducation related to symptoms, recovery, and the expected process of psychotherapy (Becker et al., 2018; Lindsey et al., 2014).

• Acknowledgment of cultural differences, needs, and expectations related to treatment assumptions and process (Buckingham et al., 2016; Snell-Johns et al., 2004).

• Support and intervention provided for caregiver stressors, including individual and partner stressors (Haine-Schlagel & Walsh, 2015; Snell-Johns et al., 2004).

• Building on and enhancing youth and family strengths rather than focusing on decreasing symptoms (Gopalan et al., 2010; Snell-Johns et al., 2004).

• Proactively brainstorming around logistical barriers to treatment (Becker et al., 2018; Buckingham et al., 2016; Lindsey et al., 2014; Snell-Johns et al., 2004).

• Flexibility in application of EBT treatment components (Lyon et al., 2014).

These recommendations highlight the importance of relational engagement with parents/caregivers, including information provision and emotional support. Increased parent/caregiver participation has been linked to improved treatment outcomes and strategies designed to increase parent participation are essential (Haine-Schlagel & Walsh, 2015). Buckingham et al. (2016) stress the importance of therapeutic rapport-building from the start of treatment and both youth and family empowerment. Youth and family treatment outcomes are more likely to succeed when therapy can address couples’ relational distress, caregiver social isolation and therapeutic attunement to the realistic parental stress levels for families coping with chronic adversity (Snell-Johns et al., 2004).

Multiple studies on engagement have recommended prioritization of collaborative family assessment, psychoeducation, and proactive exploration of treatment barriers as paramount to intervention success (Becker et al., 2018; Lindsey et al., 2014). Assessment can be approached through collaborative dialogue, in which the therapist seeks to understand the youth and family narrative, and their experiences are validated. This helps youths in particular to learn to perceive themselves as experiencing trauma not because of what they have done, but how they have learned to survive adversity. This process can be integrated into treatment-related psychoeducation, using developmentally appropriate language, checking on client understanding, and coherence with client beliefs (Becker et al., 2011; Becker et al., 2018).

Research has also explored the challenges of applying EBTs that are often based on studies utilizing narrow inclusion criteria for participants and therapists (Gopalan et al., 2010; Southam-Gerow et al., 2003; Spinazzola et al., 2005). There have been longstanding questions as to how well psychotherapy EBT research results generalize to the challenges of engaging under-resourced families facing multiple forms of adversity in’real-world’ mental health programs (Huey & Jones, 2013).

Building a Bridge to Youths and Parents/Caregivers That Validates Different Types of Chronic Trauma Experiences

Youths referred to child and family services, juvenile justice, and intensive behavioral health programs for high-risk behaviors have frequently been involved in multiple previous treatment programs with little improvement or increased risk of harm. During the assessment phase for new programs, youths have complained that previous programs and clinicians didn’t ‘get’ them, and many youths reject platitudes that this next treatment program will help them or their families (Henry, J. Personal Communication, June 21, 2021). Many youths also reject going to another therapy program where they will be asked to talk about their trauma or any kind of ‘trauma therapy.’ As one youth put it, “They’re trying to fix me.” Another youth complained, “I had it when she (the clinician) said it’s going to be okay.”

Engagement can be promoted during the clinical assessment by helping children and adolescents who have lived with chronic traumas and disrupted attachments feel understood, sometimes for the first time, so they don’t feel so alone. This can be enhanced by sharing what other youths have communicated about how chronic traumatic stress has impacted family relationships, their internal perceptions of themselves and others and how extreme stressors may continue into the future. Therapists’ validation of experiences of chronic traumatic stress creates a ‘bridge’ upon which youths, parent/caregivers, and therapists can meet to share experiences and begin trauma treatment (J. Henry, personal communication, June 21, 2021). This bridge can be enhanced by therapists sharing an acknowledgement of what it is like to live with different types of chronic trauma and how these experiences shape perceptions of what is necessary to survive the present, what is possible for the future and what services or treatment youths and parents/caregivers may find useful.

Multi-Dimensional Assessment Guide

The Multi-Dimensional Assessment Guide for Youths and Families Experiencing Chronic Trauma (see Table 1) differentiates five primary types of complex traumatic stress that can be readily identified by clinicians and linked to practical strategies for enhancing and sustaining engagement in trauma-informed treatment, increasing safety where possible, building resilience skills and resources, and reducing the impact of traumatic stress on youths, families, and communities. The Multi-Dimensional Assessment Guide incorporates level and type of risk, timing and chronicity of traumatic experiences (past/present/future), predictability and possibilities for preventing or ending further exposure, strength of attachments and emotionally supportive relationships, interpersonal violence and ongoing external threats and violence, such as community violence, racism, oppression, and armed conflict. This is integrated with criteria for PTSD denoted in the ICD-11 and DSM-5 as well as symptoms of DTD (Ford et al., 2018) including disruptions to attachment relationships, impaired caregiving system, and interpersonal victimization, along with dysregulation symptoms across various domains: affective and somatic, attentional and behavioral, self and relational. The DTD framework identifies symptoms for trauma-impacted youth similar to the adult-focused diagnosis of Complex PTSD in the ICD-11: significant problems with affect regulation, self-concept, and interpersonal relationships in addition to symptoms of PTSD. In the proposed assessment guide, DTD symptom areas have been expanded to help practitioners tailor interventions to each youth and parents/caregivers. Regulation strategies include co-regulation with primary parents/caregivers, mentors, educators. Self and relational dysregulation includes development of a resiliency-centered life story, with traumatic experiences integrated into a youth’s multi-generational family heritage including how family members have coped with adversity and the family’s cultural heritage. Level of emotional support is linked to acknowledgement, validation, and support in processing past trauma, as well as protection from future traumatic exposure by parents/caregivers and other important people in a youth’s life (e.g. extended family, educators, mentors, clergy).

Table 1.

Multi-Dimensional Assessment Guide for Youths and Families Experiencing Chronic Trauma

The Multi-Dimensional Assessment Guide was designed to be used with evidence-supported assessment measures for complex trauma (Briere & Spinazzola, 2009) and assessment-driven treatment models such as Integrative Treatment of Complex Trauma (Lanktree et al., 2012), Attachment Regulation Competence (Arvidson et al., 2011), Real Life Heroes; Resiliency-Focused Therapy for Complex Trauma (Kagan et al., 2014), Trauma Systems Therapy (Ellis et al., 2012). The Multi-Dimensional Assessment Guide provides a practical tool for therapists to pull together critical elements in complex trauma assessment. Key elements include severity of risk over time (past, present & future), uncertainty of safety, single versus multiple types of trauma, and hope for change. In addition, clinicians are encouraged to assess ongoing vulnerabilities and potential resources in a youth’s caregiving system: whether families are living in poverty, history of or ongoing trauma impact on parents/caregivers, presence of caring adults in the family or community who can support treatment implementation, strengths in the family’s cultural heritage and presence of family or community members willing and able to maintain safety plans to reduce risk of recurrence of traumas experienced.

The Multi-Dimensional Assessment Guide differentiates pervasive trauma from experiences of chronic traumas which could be prevented and from traumatic experiences that are on-going but are predictable with transient periods of safety (C. Lanktree, personal communication, October 20, 2020). Preventable traumas are defined as adverse experiences that could be blocked or significantly reduced by changes made by family members and/or school and community authorities and service providers. Pervasive traumatic stress includes factors involved in ‘cumulative trauma’ (Kira et al., 2015) including the impact on youth development. Both pervasive traumatic stress and recurrent, predictable traumatic stress often include coping strategies linked to survival amid on-going dangers that become habitual response patterns of the youth, adolescent, family, and community. These are differentiated from normal reactions to on-going traumatic events denoted as ‘ongoing traumatic stress’ response (adapted from Diamond et al., 2013) that do not involve internalized and persistent traumatic stress, and that would likely decrease to non-clinical levels after children and families escape dangerous environments or threats of recurrent trauma ended.

Developmentally Guided Treatment Planning

The Multi-Dimensional Assessment Guide incorporates youths’ social and emotional developmental level as a critical element in guiding strategies for engaging youths with interventions that match their developmental level. The effects of neglect, abuse, impaired or disengaged caregivers and family violence on development have been well-documented for young children (Briere et al., 2017; D’Andrea et al., 2012; Perry, 2002; Puetz et al., 2020; Spinazzola et al., 2018). Children who experience polyvictimization, coupled with disrupted or impaired relationships with their primary caregivers and familial or community violence, appear to have the greatest risk of developmental delays and impaired self and relational functioning (Musicaro et al., 2019; Spinazzola et al., 2018).

DTD (Ford et al., 2018) highlights the impact of disrupted attachment relationships and caregiving systems, and the importance of assessing chronicity of trauma over time through a youth’s and family’s development (past, present, and future). Chronicity over a youth’s lifetime exacerbates the impact of trauma especially when children and families expect traumas to extend into the foreseeable future. Chronicity diminishes hope for a better life and this can have especially deleterious effects as youths enter adolescence. At that developmental juncture, youths become much more aware of the impact of community, cultural and societal forces on their families’ well-being. While school-age children may be able to cling to hopes and fantasies, particularly if there is some source of support or nurturance, adolescents appear especially vulnerable to becoming hopeless, depressed, or enraged when their worldview remains constricted by the necessity to survive, fight, or protect the people they love from seemingly endless traumas (Kagan, 2021). Opportunities for youths entering adolescence to use maturing perspectives and life skills may be diminished when support from primary attachment figures becomes tenuous or when youths are living with on-going injustice, racism, terrorism or oppression. Adolescents may come to believe that the chaotic and traumatic environment in which they live is “just life”, that change is impossible, or that maintaining hope for change is too painful to bear when your deepest wishes are repeatedly crushed. Chronic interpersonal trauma has been associated with high-risk behaviors that appear to be reactions to underlying despair and unspeakable terror (Cook et al., 2005; D’Andrea et al., 2012).

Differential Treatment Planning Guide

The Multi-Dimensional Assessment Guide helps increase engagement of youths and parents/caregivers by identifying resiliency-centered interventions to increase skills and resources needed for identified components of complex trauma and DTD. The Differential Treatment Planning Guide (See Table 2) promotes collaborative treatment planning by engaging youths and parents/caregivers to begin work on developing skills and resources linked to the reality of living with different types of chronic trauma. The Differential Treatment Planning Guide provides therapists with an easy-to-use resource for prioritizing treatment planning for each type of chronic trauma identified including common indicators, youth and family examples, strategies to implement core components of complex trauma treatment, and pitfalls to avoid. Strategies listed include services to youths and families who are not seeking or refuse trauma-focused treatment and families who have not acknowledged or validated traumatic experiences.

Table 2.

Differential Treatment Planning Guide for Youths and Families Who Have Experienced Chronic Traumas

Multiple Past Traumas with Complex Traumatic Stress
Indicators:
•Initial experiences with accompanying feelings of terror and helplessness
•Patterns of ‘what happens’ leading up to traumas are often identifiable
•Appear safe from past trauma but youths or parents/caregivers continue to be ‘triggered’ by trauma reminders & living as if traumas could happen again
Examples:
•A parent stayed with a perpetrator endangering youth but has since separated and now blames self for past abuse and neglect of youth
•Sex abuse by a relative or parent/caregiver who is no longer allowed to have contact with youth
•Violence experienced in previous community or school but family has moved to a safe environment
Strategies to Engage & Implement Complex Trauma Core Components
Safety for Youths & Parents/Caregivers
•Reinforce and strengthen safety resources as needed
•Help children & parents/caregivers set up, practice and test warning monitors and safety responses with youth, parents, extended family, community resources, pets, technology, and other resources that build confidence after repeated practice
Relational Engagement
•Building on cultural/community/collectivist strengths
•Increase level of emotional support including acknowledgement, validation, and support in processing past traumas by parents/caregivers and other important people in youth’s life e.g. family members, mentors, educators, clergy
Self and Co-Regulation
•Increase co-regulation and skill development for children and parents/ caregivers with modeling, guidance, and practice with primary parents/ caregivers, mentors, educators and other caring adults
•Increase affect regulation capacity to best cope with real threats e.g. mindfulness, yoga and other creative arts
Self-Reflective Information Processing
•Psychoeducation to understand and normalize trauma reactions
•Differentiate between past, present and future. Help youth and parents/caregivers see how they can be safe now compared to past
Positive Affective Enhancement
•Build on youth talents, and family and cultural strengths
•Augment or engage youth to help others using special sensitivity and skills developed from coping with traumas, e.g., younger children experiencing similar types of traumas
•Use creative arts, humor and emotional re-engagement
Traumatic Experience Integration
•Develop a youth and family life story and trauma narrative that highlights youth, family and cultural strengths including coping with external threats e.g. community violence, racism, persecution, armed conflict
•Reinforce strength-oriented identity for youth and family linked to cultural heritage including reducing traumatic stress reactions to reminders of past traumatic events
•Help youths and parents/ caregivers reduce feelings of shame or blame for not preventing or for contributing to past traumas including acknowledgement, apologies, and restitution where appropriate
•Help youths and parents/ caregivers acknowledge and grieve losses
Pitfalls to Avoid
•Focusing primarily on a youth’s internalized PTSD or developing regulation skills without addressing relational traumas and highlighting importance of validation and support by parents/caregivers, caring adults and authorities
•Focusing on one identified trauma when children and families have experienced many types that may not be revealed at the time of referral
•Not addressing collective traumas, such as poverty, racism, xenophobia, etc

On-going Preventable Complex Traumatic Stress
Indicators:
•Initial experiences with accompanying feelings of terror and helplessness
•Patterns of ‘what happens’ leading up to traumas are often identifiable
•Not safe from recurring trauma but could become safe or reduce trauma impact significantly with implementation of safety steps, policies & practices by youth, parents/caregivers, extended family & community
Examples:
•Living with ‘continuous traumatic stress’ but approved by UNHCR for refugee status and awaiting documentation needed to emigrate to safer country
•Living with multiple deaths or severe illness from pandemic but able to get vaccine or other preventive medication to prevent future severe illness/deaths
•Parent/caregiver continues to become violent but disclosure led to CPS ‘indication’ and court validation of DV, abuse or neglect with change mandates
Strategies to Engage & Implement Complex Trauma Core Components
Safety for Youths & Parents/Caregivers
•Changes in community policies, practices, courts & systems of care to prevent traumas, validate youths and families, and restore security if threats or patterns of behavior linked to past traumas recur
•Practice and test safety plans to re-assure they can prevent recurrence and build trust
•Reinforce and strengthen safety resources as needed
•Help children & parents/caregivers set up, practice and test warning monitors and safety responses with youth, parents, extended family, community resources, pets, technology, and other resources that build confidence after repeated practice
Relational Engagement
•Building on cultural/community/collectivist strengths
•Increase level of emotional support including acknowledgement, validation, and support in processing past traumas by parents/caregivers and other important people in youth’s life e.g. family members, mentors, educators, clergy
•Increase protection of relationships from any future traumas
•Promote validation of what happened by parents/caregivers, caring adults and community authorities wherever needed
Self and Co-Regulation
•Increase co-regulation and skill development for children and parents/ caregivers with modeling, guidance, and practice with primary parents/ caregivers, mentors, educators and other caring adults
•Increase modulation capacity to best cope with real threats e.g. mindfulness, yoga and other creative arts
•Learn and practice how and when to use of self- and co-regulation to keep safe, e.g. mindfulness, yoga
Self-Reflective Information Processing
•Psychoeducation to normalize reactions to on-going threats and reminders of past traumas
•Differentiate what makes the present and future different. Help youth and parents/caregivers see how they are safe now compared to the past
Positive Affective Enhancement
•Build on youth talents, and family and cultural strengths
•Augment or engage youth to help others using awareness and skills developed from coping with traumas, e.g., younger children experiencing similar types of traumas
•Use creative arts, humor and emotional re-engagement
Traumatic Experience Integration
•Develop a youth and family life story, including their traumatic experiences, that highlights youth, family and cultural strengths including coping with external threats (community violence, racism, persecution, armed conflict) and reducing traumatic stress reactions to reminders of traumatic events
•Reinforce strength-oriented identity for youth and family linked to cultural heritage including reducing traumatic stress reactions to past and present traumatic events
•Help youths and parents/caregivers reduce feelings of shame or blame for not preventing or for contributing to past and present traumatic events,, including acknowledgement, apologies, and restitution where appropriate
•Help youths and parents/ caregivers acknowledge and grieve past and present losses
Pitfalls to Avoid
•Focusing on a youth’s internalized PTSD or developing skills without repairing relational traumas, and highlighting importance of validation, support, and preventing recurrence by parents/caregivers, caring adults and authorities
•Not addressing collective traumas, such as poverty, racism, xenophobia, etc
•Requiring youth to work on re-integration of traumas when level of self and co-regulation and strength of emotionally supportive relationships are low compared to distress reactions and danger
•Asking youth to use relaxation skills that create safety risks with current or future traumas

Recurrent Complex Traumatic Stress with Transient Safety
Indicators:
•Initial experiences with accompanying feelings of terror and helplessness
•Patterns of ‘what happens’ leading up to traumas are often identifiable
•Periodically unsafe with expectation that safety can be re-established after traumatic event. Trauma impact can be reduced despite chronicity
Examples:
•Alcohol abuse and DV by primary parent/caregiver after getting biweekly paycheck; financial dependence on perpetrator, other parent/caregiver unwilling to leave perpetrator, no mandates from CPS, or courts; multi-generational history of similar problems
•Violence in community and school. Parents/caregivers unable/unwilling to move or may initially not validate youths’ experiences as parents/caregivers managed same community and believe children can do the same
•Multigenerational sexual abuse of females in family beginning in adolescence; however, parents/caregivers willing to acknowledge this and hear how this affects children in family
Strategies to Engage & Implement Complex Trauma Core Components
Safety for Youths & Parents/Caregivers
•Changes in community policies, practices, courts & systems of care to prevent traumas, validate families and restore security if threats linked to past traumas recur
•Help families set up warning monitors to detect and prevent recurrent dangers including cycles of behaviors
•Develop, practice and test safety plans for recurrent dangers that at least partially prevent traumas and restore safety, regulation, relationships and increase trust and confidence after recurrent adversity
•Differentiate times of risk from times of safety and over-sensitized reactions
•Reinforce and strengthen safety resources as needed
Relational Engagement
•Building on cultural/community/collectivist strengths
•Increase level of emotional support including acknowledgement, validation, and support in processing past traumas by parents/caregivers and other important people in youth’s life e.g. family members, mentors, educators, clergy
•Increase protection of relationships from any future traumas
•Promote validation of what happened by parents/caregivers, caring adults and community authorities wherever needed
•Prioritize building a caring, loving network for children and parents/caregivers that can withstand periodic crises and stressors
Self and Co-Regulation
•Increase affect modulation skill development for children and parents/ caregivers with modeling, guidance, and practice with primary parents/ caregivers, mentors, educators and other caring adults
•Learn and practice how and when to use of self- and co-regulation to keep safe, e.g. mindfulness, yoga
Self-Reflective Information Processing
•Psychoeducation to normalize reactions to on-going threats and reminders of past traumas
•Differentiate what makes the present and future different. Help youth and parents/caregivers see how they are safe now compared to the past and identify situations where safety is maximized
•Learn from past traumas to increase ability of youth, family and community to protect themselves when predictable traumatic events recur
•Accentuate what can be changed from what can’t
•Promote acceptance of what can’t be changed and addressing what can be changed to achieve youth and parent/caregiver goals
Positive Affective Enhancement
•Build on youth talents, and family and cultural strengths
•Augment or engage youth to help others using special sensitivity and skills developed from coping with traumas, e.g., younger children experiencing similar types of traumas
•Use creative arts, humor and emotional re-engagement
Traumatic Experience Integration
•Utilize transient periods of safety to reduce stress reactions for past and recurrent traumas
•Develop a youth and family life story that includes traumatic experiences and highlights youth, family and cultural strengths including coping with external threats (community violence, racism, persecution, armed conflict), and reducing traumatic stress reactions
•Reinforce strength-oriented identity for youth and family linked to cultural heritage, including reducing traumatic stress reactions to past and present traumatic events
•Help youths and parents/caregivers reduce feelings of shame or blame for not preventing or for contributing to past and present traumas including acknowledgement, apologies, and restitution where appropriate
•Help youths and parents/ caregivers acknowledge and grieve past and present losses
Pitfalls to Avoid
•Focusing primarily on a youth’s internalized PTSD or developing regulation skills without repairing relational traumas, and highlighting importance of validation and support by parents/caregivers, caring adults
•Focusing on one identified trauma when children and families have experienced many types that may not be revealed at the time of referral
•Not recognizing repeated types of traumas or collective traumas, such as poverty, racism, xenophobia, etc
•Emphasizing treatment goals for eliminating hypervigilance, processing past traumas, recovery, or healing for a youth when family members remain at high risk

Pervasive Complex Traumatic Stress
Indicators:
•Initial experiences with accompanying feelings of terror and helplessness
•Patterns leading up to traumas are often not identified or acknowledged by family
•Family members have not been safe in the past or present time and do not appear able to become safe for any extended period in the foreseeable future
•Family members have often experienced multiple types of traumas, some of which have repeated over generations e.g., sexual abuse or racism. Traumas have disrupted primary attachments and relationships for children, families and often communities including youth’s or family’s link to their own cultural heritage
•Traumas experienced have been predominantly unpredictable, severe or life-threatening before referral and family members remain at high risk with limited capacity for change at this time
Examples:
•Multi-generational family violence (emotional, physical & sex abuse) without any family, community or authority validation or protection from recurrence. Disclosures by children may have been dismissed in investigations followed by continued violence or abuse
•Multi-generational community violence including harm to family members with no hope of change by family, e.g. experiences of bias, restrictions or violence linked to race, ethnicity, or religion. Expectation of deportation to previous country where they experienced life-threatening violence with no expectation of change by family
•Life-threatening illness for family member(s) with compromised systemic support
Strategies to Engage & Implement Complex Trauma Core Components
Safety for Youths & Parents/Caregivers
•Changes in community policies, practices, courts & systems of care to prevent traumas, validate families and restore security if threats linked to past traumas recur
•Help families set up warning monitors to detect recurrent dangers including feelings and behaviors
•Develop, practice and test safety plans to prevent or reduce the impact of recurrent dangers and increase trust and confidence
•Differentiate times of risk from times of partial safety and over-sensitized reactions
•Advocate for increased safety resources to match risks, e.g., guard dogs, alarm systems, technology, etc
Relational Engagement
•Uncover hidden openings to promote connections in families and communities: caring, hope for supportive & protective relationships, legacies of strength from past generations, curiosity, faith, possibilities for small & significant changes in community policies, procedures & institutions
•Prioritize building a caring, loving network for families that can withstand periodic crises and counter isolation, shame and fear
•Increase level of emotional support including acknowledgement, validation, and support in protecting from current dangers and processing past traumas by parents/caregivers and other important people in youth’s life e.g., family members, mentors, educators, clergy
Relational Engagement Cont’d
•Prioritize protection of emotionally supportive relationships from future traumas
•Promote validation by parents/ caregivers, caring adults and community authorities whenever possible for on-going dangers as well as what has happened
Self and Co-Regulation
•Increase affect modulation skill development for children and parents/caregivers with modeling, guidance, and practice with primary parents/caregivers, mentors, educators or other caring adults
•Increase coping skills for managing stressful situations including mindfulness, relaxation, and yoga
•Promote acceptance of what can’t be changed and addressing what can be changed to achieve youth and parent/caregiver goals. Acceptance in this context refers to recognition and capacity to address what can be done about real dangers without trying to control what cannot be controlled, reliance on minimization or denial or preoccupation about unfairness
•Develop or strengthen strategies for reducing both normal and excessive stress reactions. Learn and practice how and when to use of self- and co-regulation to keep safe, e.g. mindfulness, yoga
Self-Reflective Information Processing
•Psychoeducation to understand Pervasive Trauma Reactions and normalize reactions to recurrent threats and unpredictable experiences of traumas including normal stress responses and cycles
•Learn from past traumas to increase abilities of children, families and community to protect themselves when traumatic events occur
•Differentiate what makes the present and future different. Help youth and parents/caregivers see how they can become safer now compared to the past
Positive Affective Enhancement
•Build on youth talents, family and cultural strengths
•Augment or engage youth to help others using special sensitivity and skills developed from coping with traumas e.g., younger children experiencing similar types of traumas
•Use creative arts, humor and emotional re-engagement
Traumatic Experience Integration
•Develop a youth and family life story including traumatic experiences that highlights youth, family and cultural strengths including coping with external threats e.g., community violence, racism, persecution, armed conflict
•Reinforce strength-oriented identity for youth and family linked to cultural heritage including reducing traumatic stress reactions to reminders, recurrence of past traumatic events and experiences of new potentially traumatic events
•Help youths and parents/caregivers reduce any feelings of shame or blame for not preventing or for contributing to past or present traumas including acknowledgement, apologies, and restitution where appropriate
•Life Story work that reinforces a strength-oriented perspective of youth, family, and cultural heritage including reducing traumatic stress reactions to recurrent traumatic events, reminders of past traumatic events and other potential traumas
•Search for and accentuate little bits of certainty in an uncertain world
•Help youths and parents/ caregivers acknowledge and grieve past and present losses as much as possible
Pitfalls to Avoid
•Focusing primarily on a youth’s internalized PTSD or developing regulation skills without repairing relational traumas and highlighting importance of validation and support by parents/caregivers, caring adults and authorities
•Focusing on one identified trauma when children and families have experienced many types that may not be revealed at the time of referral
•Not recognizing repeated types of traumas or collective traumas, such as poverty, racism, xenophobia, etc
•Emphasizing treatment goals for eliminating hypervigilance, processing past traumas, recovery, or healing for a youth when family members remain at high risk
•Overemphasizing processing of specific traumatic events in the absences of sufficient intervention supporting safety and affect regulation

‘On-going Traumatic Stress Response’
Indicators:
•Initial experiences with accompanying feelings of terror and helplessness and patterns of what happens leading up to traumas are often not identifiable
•Behaviors and reactions match need to maintain safety from on-going and real threats and are neither excessive nor generalized to safe situations
•Hypervigilance, intrusive thoughts, avoidance, and arousal levels are linked to present and future dangers not past traumatic events. Avoidance and intrusive thoughts linked to real threats and dangers. Trauma responses stop when safety of youth and family is restored
Examples:
•Families living with armed conflict who demonstrate normal behaviors when able to escape conflict situations or when safety is established
•Families living in violent communities or children going to schools and experiencing violence or persecution with trauma reactions that stop after moving to safe environments
Strategies to Engage & Implement Complex Trauma Core Components
Safety for Youths & Parents/Caregivers
•Community interventions including school-based programs and pediatric-linked services
•Optimize and practice safety plans
Relational Engagement
•Optimize and reinforce emotionally supportive relationships
Self and Co-Regulation
•Increase coping skills for managing stressful situations (outlined above)
•Learn and practice how and when to use of self- and co-regulation to keep safe, e.g. mindfulness, yoga
•Regulation of stress including mindfulness, relaxation, and acceptance as well as avoidance of dangers where possible
Self-Reflective Information Processing
•Psychoeducation to normalize reactions to real threats including fears about real threats, need to watch out for danger and react quickly when danger recurs as well as increased sensitivity and fear responses to real dangers that recur and increased likelihood of developing PTSD
Positive Affective Enhancement
•Build on youth talents, family and cultural strengths with mentoring, classes, etc
•Augment or engage youth to help others using special sensitivity and skills developed from coping with adversity
Traumatic Experience Integration
•Life Story work that reinforces strength-oriented perspective on youth and family linked to cultural heritage including successes and coping with traumas
Pitfalls to Avoid
•Pathologizing responses by children, parents/caregivers and families that are not excessive given real risks
•Ignoring need for community leaders to validate risks and improve safety
•Requiring remembering, talking about or repeatedly emotionally reprocessing past traumas

Strategies were developed to expand inclusion and engagement of youths and families while ensuring implementation of evidence-supported components of complex trauma treatment. The National Child Traumatic Stress Network Complex Trauma/DTD Committee proposed six core components of complex trauma treatment (Cook et al., 2005): Safety, Relational Engagement, Self-regulation, Self-reflective Information Processing, Positive Affect Enhancement and Traumatic Experiences Integration. These components include strategies for alleviating the symptoms of DTD (Ford et al., 2018) and Complex PTSD (ICD-11) and are utilized in the Differential Treatment Planning Guide to provide therapists with options to offer to youths and families in collaborative treatment planning.

Strategies described recognize the adaptive function of trauma symptoms, including avoidance and dissociation for youths and families living with chronic trauma. Suggested activities focus on building sufficient relational supports and both self and co-regulation capacity. This planning guide acknowledges the critical goal of enhancing youth and family ability to manage distress, including triggered reactions to externally-induced adversity, before seeking to reduce trauma symptoms (Briere, 2021).

Discussion

For youths and parents/caregivers living with chronic traumas, engagement begins by respecting the reality of their lived experiences as well as the legacy of their multi-generational heritage and the impact of community or cultural neglect, discrimination, and disenfranchisement. Opportunities and risk factors for youths and parents/caregivers are very different depending on whether traumatic experiences have ended with safety re-established, traumas are continuing but could be prevented, traumas are on-going but predictable with periods of safety, or traumas are persistent and unpredictable with no expectation of safety.

For many families living with persistent adversity, primary attachments have been disrupted during years or generations of trauma exposure, and family relationships may be chaotic and disorganized, leaving youths to grow up without guidance, nurture and protection. Adults including family members, teachers, clergy, and service providers may appear uncaring, unreliable, shaming, or violent to youths. This can make it hard for youths to know who to trust, how to cope with stressors, how to improve their situation, or even retain hope for change.

For youths who have grown up with chronic traumas, the greatest challenge is often to find, strengthen, or foster sustainable relationships with caring and safe adults who can and will work to restore the ‘protective shield’ of safety, nurturing, and guidance that youths need to develop and thrive. These caring adults can include caregivers and family members who may previously have been overwhelmed or emotionally incapable of supporting youths but can become important supports for youths through individualized, empathically attuned, and culturally appropriate interventions including opportunities to process their own traumas. Rebuilding trust and committed emotionally supportive relationships are primary antidotes to the core experiences of disrupted attachments seen in studies of DTD. At the same time, engaging caring adults is often the hardest challenge in complex trauma treatment.

Assessments and service planning can promote engagement through experiences that help youths and parents/caregivers feel understood and see that their experiences are normalized for the types of traumas that they have experienced and may continue to experience. The Multi-Dimensional Assessment and Differential Treatment Planning Guides facilitate this process by providing practical tools that identify timelines of relational trauma experiences (past, present, future), predictability and preventability of relational traumas and developmental impact on youths, parents/caregivers and families. Therapists can increase engagement by validating ongoing or pervasive traumas and collaboratively developing treatment plans that restore the caring, validation and emotionally supportive relationships that youths need to return to a normal developmental trajectory while living with chronic trauma.

Conclusion

Findings from this literature review highlight the critical challenge of engagement of youths and parents/caregivers who have experienced, and may continue to be experiencing, chronic traumas as well as the importance of acknowledging and validating very different experiences of chronic trauma in order to develop collaborative treatment plans and sustain engagement in trauma treatment. The Multi-Dimensional Assessment Guide for Youths and Families Experiencing Chronic Trauma and the Differential Treatment Planning Guide for Youths and Families Who Have Experienced Chronic Traumas were developed to help clinicians match treatment priorities and service planning to youths and families presenting with very different trauma experiences over time within families and communities, attachments, social-emotional developmental levels, and symptoms of PTSD, complex trauma and DTD. Research studies and further literature analyses are needed to determine the value of augmenting existing trauma assessments with differentiation of types of chronicity (i.e., frequency, duration, severity), the impact of community violence and cultural oppression, attachment disruptions, and developmental levels as well as the efficacy of the proposed assessment and treatment planning guides to increase and sustain engagement in treatment programs for diverse youths and families with complex trauma and DTD.

Declarations

Conflict of Interest Statement

On behalf of all authors, the corresponding author states that there is no conflict of interest.