1. Partnering to Serve Children and Families Following Potentially Traumatic Events
Yale Child Study Center Trauma Section
and Yale New Haven Hospital
Steven Marans, PhD, MSW Kirsten Bechtel, MD
Hilary Hahn, EdM, MPH
Kristen Hammel, LCSW

2. Psychological trauma as injury
Overwhelming, unanticipated danger that leads to:
Subjective experience of helplessness, loss of control and terror
Immobilization of usual methods for decreasing danger and anxiety (fight or flight)
Neuro-physiological dysregulation that compromises affective, cognitive and behavioral responses to stimuli

3. YCSC Trauma Section A specialty clinic of the Child Study Center
Section Chief: Steven Marans, MSW, PhD
Acute response and assessment – the Child Development Community Policing Program
Early intervention and treatment- the Child and Family Traumatic Stress Intervention
Longer-term trauma treatment- including Trauma- Focused Cognitive Behavioral Therapy
Complex evaluation, differential diagnosis and consultation
Acute Response and Assessment
CVTC clinicians work in collaboration with the New Haven Department of Police Services, the Yale New Haven Hospital and other agencies providing first responses to children and families exposed to violence or overwhelming events in their communities, neighborhoods or homes. With a call service that operates 24/7/365, CVTC clinicians are available to respond to the scene or follow-up with families within hours. Primary goals of the acute response are psychological stabilization and engagement into services after a potentially traumatic event (PTE) in an effort to prevent negative long term psychological reactions.
The Child and Family Traumatic Stress Intervention
A distinctive aspect of the CVTC clinic program is the focus on providing intervention early after a potentially traumatic event in an effort to prevent negative long term psychological reactions. CVTC clinicians are trained to provide the Child and Family Traumatic Stress Intervention (CFTSI), the early, brief intervention developed at the Childhood Violent Trauma Center. An early, brief treatment for children ages 7-18, implemented with the child and caregiver, CFTSI was designed to decrease post-traumatic stress reactions and onset of PTSD by strengthening communication and family support. CFTSI is implemented with children who have experienced a recent traumatic event within the past days or have disclosed physical or sexual abuse within the past days.
 Longer-term Trauma Treatment
The CVTC Trauma Specialty Clinic provides treatment for children with posttraumatic stress reactions following traumatic events, and for children with other disorders and functional difficulties that result from trauma exposure. Steeped in developmental perspectives, CVTC clinicians are fluent in psychodynamic perspectives and therapeutic approaches as well as other evidence-based trauma treatments. Determinations about modes of treatment are made on a case-by-case basis and in dialogue with a multidisciplinary professional team that includes senior clinicians. Longer- term trauma treatments provided through the CVTC Trauma Clinic include, Trauma-Focused Cognitive Behavioral Therapy, psychodynamic psychotherapy and family therapy. Regardless of the nature and type of treatment provided, caregivers are central partners in supporting children's recovery.
Complex Evaluation, Differential Diagnosis and Consultation
Making determinations about the emphasis on post-traumatic distress versus unfolding character pathology is critical to engaging children and families in appropriate treatment. Using a multi-disciplinary team approach, the CVTC Trauma Specialty Clinic provides evaluations that include psychological testing and psychiatric evaluation.

4. Phases of Traumatic Reactions: A Clinical Roadmap
Immediate/acute reactions
from within moments to first hours
Peritraumatic phase symptoms
up to 3 months after index event
Chronic PTSD and related disorders
3 months after index event
Delayed Onset
6 months after index event

5. Children’s Peritraumatic Responses to Trauma
Blunted emotions
Changes in social functioning
Social difficulties
Dissociation
Withdrawal
School difficulties/failure
Drug and alcohol abuse
Sleep disturbances/nightmares
Separation anxiety
Hyper-vigilance
Somatic complaints
Irritability and aggression
Re-experiencing of event
Impulsivity and distractibility
Regressive behaviors

6. Long-term Consequences
Without recognition, support and treatment early peri-traumatic reactions can persist and result in long-term outcomes
Can result in a variety of emotional, behavioral, social and psychiatric consequences
Examples of long-term sequelae:
Attachment and relationship problems
PTSD
School failure
Suicidal behavior
Anxiety disorders
Mood disorders
Substance abuse
Violent/ abusive behaviors
Somatic complaints and chronic illness
Personality disorders
NEXT SLIDE

7. CFTSI: What Is It? Model developed at the Yale Child Study Center by:
Steven Marans, MSW PhD
Carrie Epstein, LCSW-R
Steve Berkowitz, MD
Brief (5-8 session) evidence-based early intervention model for children that is implemented:
After recent exposure to a potentially traumatic event
After recent disclosure of earlier sexual or physical abuse
Serves children ages 3-18 years old, together with their caregivers
Based on a family strengthening approach

8. Goals of CFTSI CFTSI aims to:
Reduce traumatic stress symptoms and prevent chronic PTSD
Improve screening and initial assessment of children impacted by traumatic stress
Assess child’s need for longer-term treatment

9. CFTSI RCT Findings 112 study participants recruited from:
Forensic Sexual Abuse Program
Pediatric Emergency Department
New Haven Department of Police Service
Participants had experienced, on average, >6 trauma types prior to event that precipitated referral for CFTSI and the control treatment in the study

10. Major Findings
Children who received CFTSI were 65% less likely to meet full criteria for PTSD
Children who received CFTSI were 73% less likely to meet partial or full criteria for PTSD
Similar results in multiple chart review studies

11. CFTSI Outcomes Children Ages Receiving CFTSI in Child Advocacy Centers in North and South Carolina

12. Change in Child Trauma Symptoms

13. Change in Parent-Child Communication

14. Change in Parental Trauma Symptoms

15. Caregiver Survey Results

16. Caregiver Survey Results

17. Caregiver Survey Results

18. Caregiver Survey Results

19. YCSC and YNNH Collaboration
Partnering to identify, educate and refer children and families in the peritraumatic period
Children and families seen in the Sexual Abuse Clinic and Emergency Department
In the context of both emergency room treatment and forensic evaluations, YNNH colleagues are well-placed to introduce:
information about traumatic impact of events
referrals for clinical intervention addressing post-traumatic reactions
CSC colleagues engage, screen and treat referred children and families and “close loop” with YNNH colleagues
Kids who are continuously coming in for stomachaches or other physical complaints with no known cause might benefit from a closer look and from a consultation around whether history of traumatic exposure may be playing a role in the current symptom picture.

20. Roles in Identifying Cases for Trauma-informed Mental Health Treatment
Role of Medical Providers:
Identify children who have recently been exposed—as victims or witnesses—to potentially traumatic events
Identify children whose presenting problem may not be trauma (e.g. somatic complaints or psychiatric illness) but an underlying traumatic event is discovered
Introduce health and behavioral phenomena associated with traumatic experience and availability of clinical intervention
Role of Yale Child Study Center Trauma Section:
Screen for trauma symptoms
Engage children and families in trauma treatment or connect to other services as appropriate