Trauma systems therapy

Last updated August 17, 2024

Trauma Systems Therapy (TST) is a mental health treatment model for children and adolescents who have been exposed to trauma, defined as experiencing, witnessing, or confronting "an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others".^[1] TST focuses on the child's emotional and behavioral needs as well as the environments where the child lives (home, school, community). The treatment model includes four components (skill-based psychotherapy, home and community-based care, advocacy, and psychopharmacology) that are fully described in a published manual.^[2] A clinical trial showed that TST is effective in improving the mental health and well-being of children who have been traumatized.^[3] TST has also been successfully replicated.^[4]

When referring to TST, therapists analyze four categories: the reason a child may need TST, the signs and symptoms expressed by the child, the management and treatment methods and the results of children who have gone through TST. A look at what causes emotional trauma, the families involved, and how therapy can heal the child as well as the adult are also important factors.

Reasons for treatment

Traumatic events that affect children are seen in households where sexual, mental, or physical abuse is present. The inability to regulate self-emotions either directly or indirectly is a clinical sign that a traumatic event has affected the child. According to child psychiatrist Dr. Glenn Saxe, “TST is a comprehensive model for treating traumatic stress in children and adolescents that adds to individually based approaches by specifically addressing the child’s social environment and/or systems of care”.^[6] This may include children or adolescents having social problems in school or in their home secondary to rape, physical abuse, neglect, death of a caregiver and/or any significant life altering emotion trauma. Sexual, physical, or mental traumatic events can affect present, past memory, and the anticipated future. Saxe's theory in “The March of the Moments: Traumatic Stress in the Past, Present, and Future,” begins with “survival-in-the-moment” which causes severe emotions, unexplained personality changes, erratic behavior due to a sudden trigger that reminds the child of the event.^[2] Second, “Past memory” refers to “laying down of the present, conscious moments in the brain so that they can be accessible if we need them”.^[2] This causes significant long-term trauma because if a child is not able to understand what has happened to him or her in the past, then he or she will go through life with a band-aid on this wound instead of healing mentally and physically. Finally, “marching into the future” refers to one of the most detrimental causes of traumatic stress, its effect on the child's ability to think into the future. Saxe states, “If consciousness is about the present, and memory is about the past, then planning and anticipation are about the future”.^[2]^: 40 One's ability to see into the future is part of the human cognition, when a child starts to “calculate survival-related risk”;^[2]^: 40 this causes significant stress by continuously reliving the trauma. When a child or adolescent plans their future around what might happen, this never allows the cause of the problem to be resolved, insuring they will never mentally or emotional heal. In addition to the black and white causes of Traumatic Stress, there are also secondary causes that are directly related to these events. So TST not only addresses the event at hand but also the associated problems that come along with it.

Diagnosis

The treatment for TST is based on professional finding. PTSD is an umbrella diagnosis that includes many children and adolescents who show the basic problem of the inability to regulate their emotions.^[2]^: 62 When evaluating a child for TST, therapists look for awareness, affects, and actions when faced with a stressful event or unfamiliar situation.^[2]^: 62 Children who have been exposed to traumatic events show secondary symptoms such as the following: self modulation, self-destructive behavior, disassociation, feeling shameful, sadness, anger, hostility, social withdrawal, poor relationship skills, or changes in personality.^[2]^: 63 In many children, these symptoms can show up long after the event has occurred, during puberty or even the transition into adulthood.

There are three main groups used to categorize a child's trauma: awareness (elements of attention, sense of self, orientation),^[2]^: 65 affect (mood disorders, personality disorders), and action (conduct disorders, personality, mood disorders, eating disorders, or substance abuse).^[2]^: 65 The disorders listed are usually first seen by family members, teachers, counselors, or other adults in the child's life. Children who show signs of depression may also be affected by some sort of PTSD and would benefit from TST. Once children are clinically depressed, they tend to show changes in their thinking about themselves, their view of the world and how they see the future.^[2]^: 61 Signs and symptom associated with the event spill over into the home life, social life, academics and extracurricular activities.

Management

Management of such intense emotional stress has to include the child affected, as well as his or her social surroundings. TST treats the home and proved community based care, provides a service advocacy, helps with emotional regulation skills training and uses psychopharmacology to treat patients.^[6] Knowledge of the child's trauma, what stage he or she is at in the recovery phase, and willingness to seek treatment is all part of the healing process for the child and his or her family.

Therapy starts with the home environment. The caregiver has to understand the core problem by addressing if his or her child is sad a lot, destructive, or maybe the school keeps calling CPS (child protective services).^[2]^: 158 Understanding why the child is acting in such a manner is crucial in the healing process. Treatment for family, teachers and social workers is done so all the adults are on the same page with the problem at hand; they understand the course for treatment and can all be tools for the child to use during TST. Next, everyone in the child's life must become a service advocacy, which means holding “Family Collaborative Meetings”.^[2]^: 156 This offers education and information to the adults so they know what to expect from TST. Dedication from the adults to meet at the scheduled times, have adequate transportation to therapy, ability to overcome language barriers, and put their children's needs before their own are all essential to success. Emotional regulation skills training is very important to therapy. The process starts with assessment, and then going through the course of treatment. Coping skills are stable and healthy ways to overcome stress and manage a child's emotions and emotional identification, giving the child tools so he or she can better deal with the strategies, and communication about feelings, emotions, fears and concerns.^[2]^: 225 This is especially important as children who experience trauma face a loss of emotional and mental control because of emotional numbing, flashbacks, and a higher probability for many mental health issues.^[7] An example of a coping technique that could be used is therapy through creating music. Music helps stimulate feel-good hormones in the brain, and could help re-establish a sense of balance and mental tranquility.^[8] Finally, psychopharmacology is medication used to help a person's emotional state. To reach the best therapeutic effect for a child, all of these concepts have to be integrated. The medication approach starts with SSRIs (Selective Serotonin Reuptake Inhibitors); these help with anxiety, depression and impulsivity.^[2]^: 212 The second-line medications are Benzodiazepines, Tricyclic antidepressants and Antipsychotic medication. These are very strong and are used as a last-ditch effort to prevent a child from having severe emotional problems. Occasionally, sleeping medication is prescribed but all are under careful supervision for harmful side effects. TST is an ongoing process that attempts to heal the child, not band-aid the problem; thus, medication is used sparingly and patients are weaned to lower therapeutic doses over time.^[2]^: 214

Results

TST patients showed a much longer committed enrollment time versus the patient in basic therapy by almost 90%.^[9] The key to success is preventing dropout; this is a long process and significant evidence-based treatment needs at least eight sessions.^[9] Children with emotional trauma tend to come from substance abuse families and lower income. This makes it hard for parents to be committed to TST, particularly if they struggle with addiction or abuse themselves. Children have shown significant progress just by the one-on-one attention during TST; a child's social environment is crucial to his or her success in treatment. Results vary in different social levels of the country, different families and what each child has experienced and its severity.

Related Research Articles

Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Physical abuse is any intentional act causing injury or trauma to another person or animal by way of bodily contact. In most cases, children are the victims of physical abuse, but adults can also be victims, as in cases of domestic violence or workplace aggression. Alternative terms sometimes used include physical assault or physical violence, and may also include sexual abuse. Physical abuse may involve more than one abuser, and more than one victim.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is used in assessing mental health and developmental disorders in children up to age five.

Developmental disability is a diverse group of chronic conditions, comprising mental or physical impairments that arise before adulthood. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, especially in "language, mobility, learning, self-help, and independent living". Developmental disabilities can be detected early on and persist throughout an individual's lifespan. Developmental disability that affects all areas of a child's development is sometimes referred to as global developmental delay.

Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Emotional dysregulation is characterized by an inability flexibly to respond to and manage emotional states, resulting in intense and prolonged emotional reactions that deviate from social norms, given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Neurological reparative therapy (NRT) is a new model of treatment synthesized from a compilation of literature and research on how to better the lives of individuals who have a wide range of mental, emotional, and behavioral disturbances – particularly children and adolescents. Although the term "neurological reparative therapy" is new, the foundation of this model is not.

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary mode of transmission is the shared family environment of the infant causing psychological, behavioral and social changes in the individual.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.

Early childhood trauma refers to various types of adversity and traumatic events experienced during the early years of a person's life. This is deemed the most critical developmental period in human life by psychologists. A critical period refers to a sensitive time during the early years of childhood in which children may be more vulnerable to be affected by environmental stimulation. These traumatic events can include serious illness, natural disasters, family violence, sudden separation from a family member, being the victim of abuse, or suffering the loss of a loved one. Traumatic experiences in early childhood can result in severe consequences throughout adulthood, for instance developing post-traumatic stress disorder, depression, or anxiety. The effects of this trauma can be experienced very differently depending on factors such as how long the trauma was, how severe and even the age of the child when it occurred. Negative childhood experiences can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. However, not all children who are exposed to negative stimuli in early childhood will be affected severely in later life; some children come out unscathed after being faced with traumatic events, which is known as resilience. Many factors can account for the invulnerability displayed by certain children in response to adverse social conditions: gender, vulnerability, social support systems, and innate character traits. Much of the research in this area has referred to the Adverse Childhood Experiences Study (ACE) study. The ACE study found several protective factors against developing mental health disorders, including mother-child relations, parental health, and community support. However, having adverse childhood experiences creates long-lasting impacts on psychosocial functioning, such as a heightened awareness of environmental threats, feelings of loneliness, and cognitive deficits. Individuals with ACEs are more prone to developing severe symptoms than individuals in the same diagnostic category.

Conflicts and emergencies around the world pose detrimental risks to the health, safety, and well-being of children. There are many different kinds of conflicts and emergencies, for example, violence, armed conflicts, war, and natural disasters. Some 13 million children are displaced by armed conflicts and violence around the world. Where violent conflicts are the norm, the lives of young children are significantly disrupted and their families have great difficulty in offering the sensitive and consistent care that young children need for their healthy development. One impact is the high rates of PTSD seen in children living with natural disasters or chronic conflict.

Out-of-home placements are an alternative form of care when children must be removed from their homes. Children who are placed out of the home differ in the types and severity of maltreatment experienced compared to children who remain in the home. One-half to two-thirds of youth have experienced a traumatic event leading to increased awareness and growing literature on the impact of trauma on youth. The most common reasons for out-of-home placements are due to physical or sexual abuse, violence, and neglect. Youth who are at risk in their own homes for abuse, neglect, or maltreatment, as well as youth with severe emotional and behavior issues, are placed out of the home with extended family and friends, foster care, or in residential facilities. Out-of-home placements aim to provide children with safety and stability. This temporary, safe environment allows youth to have their physical, mental, moral, and social needs met. However, these youth are in a vulnerable position for experiencing repeated abuse and neglect.

Sexual trauma therapy is medical and psychological interventions provided to survivors of sexual violence aiming to treat their physical injuries and cope with mental trauma caused by the event. Examples of sexual violence include any acts of unwanted sexual actions like sexual harassment, groping, rape, and circulation of sexual content without consent.

References

↑ Diagnostic and Statistical Manual of Mental Disorders (Fourth ed.). American Psychiatric Association. 2000.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Saxe, GN; Ellis, BH; Kaplow, JB (2007). Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. Guilford Press. ISBN 9781593853150.
↑ Saxe, GN; Ellis, BH; Fogler, J; Hansen, S; Sorkin, B (May 2005). "Comprehensive Care for Traumatized Children". Psychiatric Annals. 35 (5): 443–448. doi:10.3928/00485713-20050501-10.
↑ Hansen, S.; Saxe, G. (2009-02-17). "Trauma systems therapy: A replication of the model, integrating cognitive behavioral play therapy into child and family treatment". In Drewes, Athena A. (ed.). Blending play therapy with cognitive behavioral therapy: Evidence-based and other effective treatments and techniques . Hoboken, NJ: John Wiley & Sons. pp. 139–164. ISBN 9780470495520.
↑ TST Development Team. "TST Basics". Trauma Systems Therapy: Transforming the lives of traumatized children. Retrieved 2 October 2011.
1 2 Saxe, Glenn N. "TST Basics". Trauma Systems Blog. Retrieved 24 April 2012.
↑ "NCTSN Activities: NCTSN Indian County Child Trauma Center Sponsors American Indian Training". PsycEXTRA Dataset. 2004. doi:10.1037/e416582005-007 . Retrieved 2020-04-16.
↑ Hussey, David L.; Reed, Anne M.; Layman, Deborah L.; Pasiali, Varvara (2008-09-30). "Music Therapy and Complex Trauma: A Protocol for Developing Social Reciprocity". Residential Treatment for Children & Youth. 24 (1–2): 111–129. doi:10.1080/08865710802147547. ISSN 0886-571X. S2CID 144488049.
1 2 Saxe, Glenn N.; Heidi Ellis, B.; Fogler, Jason; Navalta, Carryl P. (2012). "Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout". Child and Adolescent Mental Health. 1. 17 (1): 58–61. doi: 10.1111/j.1475-3588.2011.00626.x . PMID 32847314.

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[DSM4-1] Diagnostic and Statistical Manual of Mental Disorders (Fourth ed.). American Psychiatric Association. 2000.

[Saxe2007-2] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Saxe, GN; Ellis, BH; Kaplow, JB (2007). Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. Guilford Press. ISBN 9781593853150.

[Annals-3] Saxe, GN; Ellis, BH; Fogler, J; Hansen, S; Sorkin, B (May 2005). "Comprehensive Care for Traumatized Children". Psychiatric Annals. 35 (5): 443–448. doi:10.3928/00485713-20050501-10.

[Drewes-4] Hansen, S.; Saxe, G. (2009-02-17). "Trauma systems therapy: A replication of the model, integrating cognitive behavioral play therapy into child and family treatment". In Drewes, Athena A. (ed.). Blending play therapy with cognitive behavioral therapy: Evidence-based and other effective treatments and techniques . Hoboken, NJ: John Wiley & Sons. pp. 139–164. ISBN 9780470495520.

[TSTWeb-5] TST Development Team. "TST Basics". Trauma Systems Therapy: Transforming the lives of traumatized children. Retrieved 2 October 2011.

[saxe-blog-6] 1 2 Saxe, Glenn N. "TST Basics". Trauma Systems Blog. Retrieved 24 April 2012.

[7] "NCTSN Activities: NCTSN Indian County Child Trauma Center Sponsors American Indian Training". PsycEXTRA Dataset. 2004. doi:10.1037/e416582005-007 . Retrieved 2020-04-16.

[8] Hussey, David L.; Reed, Anne M.; Layman, Deborah L.; Pasiali, Varvara (2008-09-30). "Music Therapy and Complex Trauma: A Protocol for Developing Social Reciprocity". Residential Treatment for Children & Youth. 24 (1–2): 111–129. doi:10.1080/08865710802147547. ISSN 0886-571X. S2CID 144488049.

[Saxe2012-9] 1 2 Saxe, Glenn N.; Heidi Ellis, B.; Fogler, Jason; Navalta, Carryl P. (2012). "Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress-trauma systems therapy approach to preventing dropout". Child and Adolescent Mental Health. 1. 17 (1): 58–61. doi: 10.1111/j.1475-3588.2011.00626.x . PMID 32847314.

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