Skip to main content
Log in

Trauma in Context: an Integrative Treatment Model

  • Treatment approach
  • Published:
Journal of Child & Adolescent Trauma Aims and scope Submit manuscript

Abstract

Evidenced based trauma treatments benefit children, but they rarely suffice for youth with multiple and complex comorbidities. After the completion of standard treatments, many children continue to show residual social, behavioral, and emotional difficulties. Part of the difficulty is that while the literature on trauma describes numerous facets that contribute to the severity, expression, and outcomes of trauma exposure, clinical assessments and interventions do not sufficiently reflect that literature. Clinicians thus have little guidance on how to integrate the intricacies of client’s circumstances into a trauma-informed framework. To expand the scope and efficacy of treatments and guide clinicians in selecting appropriate interventions, this paper explores factors associated with pretreatment traumatic responses and proposes an integrative treatment model that includes the trauma experience, itself, combined with pre- and post-trauma factors that are both internal and external to the child and family. Pre-trauma experiences influence the severity of traumatic responses, while post-trauma factors impact a person’s ability to cope and recover. Both are important targets for direct intervention.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  • Alisic, E., Zalta, A. K., Van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G. E. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. British Journal of Psychiatry, 204(5), 335–340.

    Article  Google Scholar 

  • American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders, fifth edition (DSM–5). Author.

    Book  Google Scholar 

  • Anandi, M., Mullainathan, S., Shafir, E., & Zhao, J. (2013). Poverty impedes cognitive function. Science, 341, 976–980.

    Article  Google Scholar 

  • Ascienzo, S., Sprang, G., & Royse, D. (2021). Gender differences in the PTSD symptoms of polytraumatized youth during isolated phases of Trauma-Focused Cognitive Behavioral Therapy. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

  • Augusti, E., Baugerud, G., Sulutvedt, U., & Melinder, A. (2018). Maltreatment and trauma symptoms: Does type of maltreatment matter? Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 396–401.

    Article  Google Scholar 

  • Austin, A., Berkoff, M., & Shanahan, M. (2020). Incidence of injury, maltreatment, and developmental disorders among substance exposed infants. Child Maltreatment online first.

  • Behnke, M., Smith, V., Committee on Substance Abuse, & Committee on Fetus and Newborn. (2013). Prenatal substance abuse: Short- and long-term effects on the exposed fetus. Pediatrics, 131(3), e1009–e1024.

    Article  PubMed  Google Scholar 

  • Bennett, R., Denne, M., McGuire, R., & Hiller, R. (2020). A systematic review of controlled- trials for PTSD in maltreated children and adolescents. Child Maltreatment, online first.

  • Blake, J., Lund, E., Zhou, Q., Kwok, O., & Benz, M. (2012). National prevalence rates of bully victimization among students with disabilities in the United States. School Psychology Quarterly, 27(4), 210–222.

    Article  PubMed  Google Scholar 

  • Blakemore, S., & Mills, K. (2014). Is adolescence a sensitive period for sociocultural processing? Annual Review of Psychology, 65, 187–207.

    Article  PubMed  Google Scholar 

  • Blaustein, M., & Kinniburgh, K. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. Guilford Press.

    Google Scholar 

  • Briere, J., Kaltman, S., & Green, B. (2008). Accumulated childhood trauma and symptom complexity. Journal of Traumatic Stress, 21(2), 223–226.

    Article  PubMed  Google Scholar 

  • Bryant, R. (2021). A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder. Clinical Psychology Review, 85, 101981.

  • Choi, J., Jeong, B., Polcari, A., Rohan, M., & Teicher, M. (2012). Reduced fractional anisotropy in the visual limbic pathway of young adults witnessing domestic violence in childhood. NeuroImage, 59(2), 1071–1079.

    Article  PubMed  Google Scholar 

  • Cloitre, M. (2015). The ‘“one size fits all”’ approach to trauma treatment: Should we be satisfied? European Journal of Psychotraumatology, 6, 27344.

    Article  PubMed  Google Scholar 

  • Cohen, J., Mannarino, A., & Deblinger, E. (2016). Treating trauma and traumatic grief in children and adolescents, second edition. Guilford Publications.

  • Colvonen, P., Glassman, L., Crocker, L., Buttner, M., Orff, H., Schiehser, D., Norman, S., & Afari, N. (2017). Pretreatment biomarkers predicting PTSD psychotherapy outcomes: A systematic review. Neuroscience and Biobehavioral Reviews, 75, 140–156.

    Article  PubMed  Google Scholar 

  • Colvonen, P. J., Straus, L. D., Acheson, D., & Gehrman, P. (2019). A Review of the relationship between emotional learning and memory, sleep, and PTSD. Current Psychiatry Reports, 21(1), 2.

    Article  PubMed  PubMed Central  Google Scholar 

  • Comas-Diaz, L. (2016). Racial trauma recovery: A race-informed therapeutic approach to racial wounds. In A. Alvarez, C. Liang, & H. Neville (Eds.), The cost of racism for people of color (pp. 249–272). American Psychological Association.

    Google Scholar 

  • Contractor, A., Layne, C., Steinberg, A., Ostrowski, S., Ford, J., & Elhai, J. (2013). Do gender and age moderate the symptom structure of PTSD? Findings from a national clinical sample of children and adolescents. Psychiatry Research, 210, 1056–1064.

    Article  PubMed  Google Scholar 

  • Cicchetti, D. (2013). Research review: Resilient functioning in maltreated children— Past, present and future perspectives. Journal of Child Psychology and Psychiatry, 54(4), 402–422.

    Article  PubMed  Google Scholar 

  • Danese, A., Moffit, T., Arseneault, L., Bleiberg, B., Dinardo, P., Gandelman, S., Houts, R., Ambler, A., Fisher, H., Poulto, R., & Caspi, A. (2017). The origins of cognitive deficits in victimized children: Implications for neuroscientists and clinicians. American Journal of Psychiatry, 174(4), 349–361.

    Article  PubMed  Google Scholar 

  • de Jongh, A., Resick, P., Zoellner, L., van Minnen, A., Lee, C., Minsin, C., Foa, E., Wheeler, K., ten Broeke, E., Feeny, N., Rauch, S., Chard, K., Mueser, K., Sloan, D., van der Gaag, M., Rothbaum, B., Neuner, F., de Roos, C., Hehenkamp, L., & Bicanci, I. (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33, 359–369.

    Article  Google Scholar 

  • Dempsey, K., Butler, S., & Gaither, L. (2016). Black churches and mental health professionals: Can this collaboration work? Journal of Black Studies, 47(1), 73–87.

    Article  Google Scholar 

  • Emdad, R., Sondergaard, H., & Theorel, T. (2005). Learning problems, impaired short-term memory, and general intelligence in relation to severity and duration of disease in post-traumatic stress disorder patients. Stress, Trauma, & Crisis, 8, 25–43.

    Article  Google Scholar 

  • Ennis, N., Shorer, S., Shoval-Zuckerman, Y., Freedman, S., Monson, C., & Dekel, R. (2019). Treating posttraumatic stress disorder across cultures: A systematic review of cultural adaptations of trauma-focused cognitive behavioral therapies. Journal of Clinical Psychology, 1–25.

  • Eslinger, J., Sprang, G., & Otis, M. (2014). Child and caregiver dropout in child psychotherapy for trauma. Journal of Loss and Trauma, 19, 121–136.

    Article  Google Scholar 

  • Finkelhor, D., Ormrod, R., & Turner, H. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7–26.

    Article  Google Scholar 

  • Finzi-Dottan, R., Dekel, R., Lavi, T., & Su’ali, T. (2006). Posttraumatic stress reactions among children with learning disabilities exposed to terror attacks. Comprehensive Psychiatry, 47, 144–151.

    Article  PubMed  Google Scholar 

  • Flouri, E., Midouhas, E., & Hoshi, H. (2014). The role of urban neighbourhood green space in children’s emotional and behavioural resilience. Journal of Environmental Psychology, 40, 179–218.

    Article  Google Scholar 

  • Ford, J. (2009). Neurobiological and developmental research: Clinical implications. In C. Courtis & J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 31–58). Guilford Press.

    Google Scholar 

  • Ford, B., & Mauss, I. (2015). Culture and emotion regulation. Current Opinion in Psychology, 3, 1–5.

    Article  PubMed  PubMed Central  Google Scholar 

  • French, B., Lewis, J., Mosley, D., Adames, H., Chavez- Dueñas, N., Chen, G., & Neville, H. (2020). Toward a psychological framework of radical healing in communities of color. The Counseling Psychologist, 48(1), 14–46.

    Article  Google Scholar 

  • Fujisawa, T., Shimada, K., Takiguchi, S., Mizuzhima, S., Kosaka, H., Teicher, M., & Tomoda, A. (2018). Type and timing of childhood maltreatment and reduced visual cortex volume in children and adolescents with reactive attachment disorder. NeuroImage: Clinical, 20, 216–221.

  • Goodman, L., Wilson, J., Helms, J., Greenstein, N., & Medzhitova, J. (2018). Becoming an advocate: Process and outcomes of a relationship-centered advocacy training model. The Counseling Psychologist, 46(2), 122–153.

    Article  Google Scholar 

  • Goslin, M., Stover, C., Berkowitz, S., & Marans, S. (2013). Identifying youth at risk for difficulties following a traumatic event: Pre-event factors are associated with acute symptomatology. Journal of Traumatic Stress, 26, 475–482.

    Article  PubMed  Google Scholar 

  • Gunnar, M., & Quevedo, K. (2007). The neurobiology of stress and development. Annual Review of Psychology, 58, 145–173.

    Article  PubMed  Google Scholar 

  • Hart, S. (2011). The impact of attachment: Developmental neuroaffective psychology. New York, NY: W.W. Norton & Co.

  • Haselgruber, A., Solva, K., & Lueger-Schuster, B. (2020). Validation of ICD-11 PTSD and complex PTSD in foster children using the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 141(1), 60–73.

    Article  PubMed  Google Scholar 

  • Henry, J., Sloane, M., & Black-Pond, C. (2007). Neurobiology and neurodevelopmental impact of childhood traumatic stress and prenatal alcohol exposure. Language, Speech, and Hearing Services in Schools, 38, 99–108.

    Article  PubMed  Google Scholar 

  • Hiller, R., Meiser-Stedman, R., Elliot, E., Banting, R., & Halligan, S. (2021). A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care. The Journal of Child Psychology and Psychiatry, 62(1), 48–57.

    Article  PubMed  Google Scholar 

  • Holmes, J. (1997). ‘“Too early, too late”’: Endings in psychotherapy– an attachment perspective. British Journal of Psychotherapy, 14(2), 159–171.

    Article  Google Scholar 

  • Horn, S., Roos, L., Beauchamp, K., Flannery, J., & Fisher, P. (2018). Polyvictimization and externalizing symptoms in foster care children: The moderating role of executive function. Journal of Trauma and Dissociation, 19(3), 307–324.

    Article  PubMed  Google Scholar 

  • Howie, H., Rijal, C., & Ressler, K. (2019). A review of epigenetic contributions to post-traumatic stress disorder. Dialogues in Clinical Neuroscience, 21(4), 417–428.

    Article  PubMed  PubMed Central  Google Scholar 

  • Johnson, S., Riis, J., & Noble, K. (2016). State of the art review: Poverty and the developing brain. Pediatrics, 137(4), e20153075.

  • Karatzias, T., & Cloitre, M. (2019). Treating adults with complex posttraumatic stress disorder, using a modular approach to treatment: Rationale, evidence, and directions for further research. Journal of Traumatic Stress, 32, 870–876.

    Article  PubMed  Google Scholar 

  • Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Roberts, N., Shevlin, M., Hyland, P., Maercker, A., Ben-Ezra, M., Coventry, P., Mason-Roberts, S., Bradley, A., & Hutton, P. (2019). Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis. Psychological Medicine, 1–15.

  • Kirmayer, L., Dandeneau, S., Marshall, E., Phillips, M., & Williamson, K. (2011). Rethinking resilience from indigenous perspectives. The Canadian Journal of Psychiatry, 56(2), 84–91.

    Article  PubMed  Google Scholar 

  • Kisiel, C., Fehrenbach, T., Liang, L., Stolbach, B., McClelland, G., Grffin, G., Maj, N., Briggs, E., Vivrette, R., Layne, C., & Spinazzola, J. (2014). Exploring child sexual abuse in relation to complex patterns of trauma exposure: Findings from the National Child Traumatic Stress Network. Psychological Trauma: Theory, Research, Practice, and Policy, 6(S1), S29–S39.

    Article  Google Scholar 

  • Kohl, P., Jonson-Reid, M., & Drake, B. (2011). Maternal mental illness and the safety and stability of maltreated children. Child Abuse & Neglect, 35(5), 309–318.

    Article  Google Scholar 

  • Koponen, A., Kalland, M., & Autti-Rämö, I. (2009). Caregiving environment and socio-emotional development of foster-placed FASD-children. Children and Youth Services Review, 31, 1049–1056.

    Article  Google Scholar 

  • Kumsta, R., Kreppner, J., Kennedy, M., Knights, N., Ruttter, M., & Sonuga-Barke, E. (2015). Psychological consequences of early global deprivation: An overview of findings from the English & Romanian Adoptees Study. European Psychologist, 20(2), 138–151.

    Article  Google Scholar 

  • Lewis, T., McElroy, E., Harlaar, N., & Runyan, D. (2016). Does the impact of child sexual abuse differ from maltreated but non-sexually abused children? A prospective examination of the impact of child sexual abuse on internalizing and externalizing behavior problems. Child Abuse & Neglect, 51, 31–40.

    Article  Google Scholar 

  • Lieberman, A., & van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachments. The Guilford Press.

    Google Scholar 

  • Maguire-Jack, K., & Wang, X. (2016). Pathways from neighborhood to neglect: The mediating effects of social support and parenting stress. Children and Youth Services Review, 66, 28–34.

    Article  Google Scholar 

  • Marusak, H., Etkin, A., & Thomason, M. (2015). Disrupted insula-based neural circuit organization and conflict interference in trauma-exposed youth. NeuroImage: Clinical, 8, 516–525.

  • Mattson, S., Bernes, G., & Doyle, L. (2019). Fetal alcohol spectrum disorders: A review of the neurobehavioral deficits associated with prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 43(6), 1046–1062.

  • McGeough, B., & Sterzing, P. (2018). A systematic review of family victimization experiences among sexual minority youth. The Journal of Primary Prevention, 39, 491–528.

    Article  PubMed  PubMed Central  Google Scholar 

  • National Institute for Health and Care Excellence. (2018). Post-traumatic stress disorder:Management [NG116]. Retrieved from. http://www.nice.org.uk/guidance/ng116

  • Nievergelt, C., Maihofer, A., Klengel, T., Atkinson, E., Chen, C., Choi, K., Coleman, J., Dalvie, S., Duncan, L., Gelenter, J., Levey, D., Logue, M., Polimanti, R., Provost, A., Ratanantharathorn, A., Stein, M., Torres, K., Aiello, A., Almi, L., Armstadter, A., & Koenen, K. (2019). International meta-analysis of PTSD genome-wide association studies identifies sex- and ancestry- specific genetic risk loci. Nature Communications, 10, 4558.

    Article  PubMed  PubMed Central  Google Scholar 

  • O’Connor, T., & Sefair, A. (2019). Stress and physiology in clinical research with risk-exposed children: From mechanism to application. Adoption & Fostering, 43(3), 340–350.

    Article  Google Scholar 

  • Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240–255.

    Article  Google Scholar 

  • Price, M., Higa-McMillan, C., Kim, S., & Frueh, B. (2013). Trauma experience in children and adolescents: An assessment of the effects of trauma type and role of interpersonal proximity. Journal of Anxiety Disorders, 27, 652–660.

    Article  PubMed  Google Scholar 

  • Rijkers, C., Schoorl, M., van Hoeken, D., & Hoek, H. (2019). Eating disorders and posttraumatic stress disorder. Current Opinion in Psychiatry, 32(6), 510–517.

    Article  PubMed  Google Scholar 

  • Roberts, A., Gilman, S., Breslau, J., Breslau, N., & Koenen, K. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41(1), 71–83.

    Article  PubMed  Google Scholar 

  • Roberts, A., Rosario, M., Corliss, H., Koenen, K., & Austin, S. (2012). Elevated risk of posttraumatic stress in sexual minority youths: Mediation by childhood abuse and gender nonconformity. American Journal of Public Health, 102(8), 1587–1593.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ross, S., Sharma-Patel, K., Brown, E., Huntt, J., & Chaplin, W. (2021). Complex trauma and Trauma-Focused Cognitive-Behavioral Therapy: How do trauma chronicity and PTSD presentation affect treatment outcome?. Child Abuse & Neglect, 111(1), 104734.

  • Roubinov, D., Hagan, M., Boyce, W., Adler, N., & Bush, N. (2018). Family socioeconomic status, cortisol, and physical health in early childhood: The role of advantageous neighborhood characteristics. Psychosomatic Medicine, 80(5), 492–501.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sachser, C., Keller, F., & Goldbeck, L. (2017). Complex PTSD as proposed for ICD-11: Validation of a new disorder in children and adolescents and their response to Trauma-Focused Cognitive Behavioral Therapy. The Journal of Child Psychology and Psychiatry, 58(2), 160–168.

    Article  PubMed  Google Scholar 

  • Salmon, K., & Bryant, R. (2002). Posttraumatic stress disorder in children: The influence of developmental factors. Clinical Psychology Review, 22, 163–188.

    Article  PubMed  Google Scholar 

  • Shapiro, B. (2020). Assessing trustworthiness: Marginalized youth and the central relational paradox in treatment. Children and Youth Services Review, 116, 105178.

  • Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). The Guilford Press.

    Google Scholar 

  • Shimada, K., Takiguchi, S., Mizushima, S., Fujisawa, T., Saito, D., Kosaka, H., Okazawa, H., & Tomoda, A. (2015). Reduced visual cortex grey matter volume in children and adolescents with reactive attachment disorder. NeuroImage: Clinical, 9, 13–19.

  • Somers, J., & Luecken, L. (2021). Socioemotional mechanisms of children’s differential response to the effects of maternal sensitivity on child adjustment. Parenting Science and Practice, 21(3), 241 - 275.

  • Strelau, J., & Zawadzki, B. (2005). Trauma and temperament as predictors of intensity of posttraumatic stress disorder symptoms after disaster. European Psychologist, 10(2), 124–135.

    Article  Google Scholar 

  • Teicher, M., & Samson, J. (2016). Annual research review: Enduring neurobiological effects of childhood abuse and neglect. The Journal of Child Psychology & Psychiatry, 57(3), 241–266.

    Article  Google Scholar 

  • Walsh, C., MacMillan, H., & Jamieson, E. (2003). The relationship between parental substanceabuse and child maltreatment: Findings from the Ontario Health Supplement. Child Abuse & Neglect, 27, 1409–1425.

    Article  Google Scholar 

  • Wamser-Nanney, R., & Campbell, C. (2020). Sexual behavior problems among sexually abused children. Associations with co-occurring symptoms. Child Maltreatment, Advance online.

  • Wamser-Nanney, R., & Vandenberg, B. R. (2013). Empirical support for the definition of a complex trauma event in children and adolescents. Journal of Traumatic Stress, 26(6), 671–678.

    Article  PubMed  Google Scholar 

  • Wamser-Nanney, R., & Steinzor, C. (2016). Characteristics of attrition among children receivingtrauma-focused treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 8(6), 745–754.

    Article  Google Scholar 

  • Weissman, D. G., et al. (2020). Altered neural processing of threat-related information in children and adolescents exposed to violence: A transdiagnostic mechanism contributing to the emergence of psychopathology. Journal of the American Academy of Child & Adolescent Psychiatry, 59(11), 1274–1284.

    Article  Google Scholar 

  • Wherry, J. (2014). The role of assessment in evidence-based treatment with trauma-exposed children. In B. Allen & M. Kronenberg (Eds.), Treating traumatized children: A casebook of evidence-based therapies (pp. 26–46). Guilford Press.

    Google Scholar 

  • Wilhoit, L., Scott, D., & Simecka, B. (2017). Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Mental Health Journal, 53, 711–718.

    Article  PubMed  Google Scholar 

  • World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). World Health Organization.

  • Yasinski, C., Hayes, A., Alpert, E., McCauley, T., Ready, C., Webb, C., & Deblinger, E. (2018). Treatment processes and demographic variables as predictors of dropout from trauma-focused cognitive behavioral therapy (TF-CBT) for youth. Behaviour Research and Therapy, 197, 10–18.

    Article  Google Scholar 

  • Yearwood, K., Vliegen, N., Chau, C., Corveleyn, J., & Luyten, P. (2019). When do peers matter? The moderating role of peer support in the relationship between environmental adversity, complex trauma, and adolescent psychopathology in socially disadvantaged adolescents. Journal of Adolescence, 72, 14–22.

    Article  PubMed  Google Scholar 

  • Youssef, N., Lockwood, L., Su, S., Hao, G., & Rutten, B. (2018). The effects of trauma, with or without PTSD, on the transgenerational DNA methylation alterations in human offsprings. Brain Sciences, 8, 83.

    Article  PubMed Central  Google Scholar 

  • Zeanah, C., Gunnar, M., McCall, R., Kreppner, J., & Fox, N. (2011). Sensitive periods. Monographs of the Society for Research in Child Development, 76(4), 147–162.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zilberstein, K. (2014). Neurocognitive considerations in the treatment of attachment and complex trauma in children. Clinical Child Psychology and Psychiatry, 19(3), 336–354.

    Article  PubMed  Google Scholar 

Download references

Funding

No funding.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Karen Zilberstein.

Ethics declarations

Research Involving Human and Animal Participants

This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of Interest

Author declares that she has no conflict of interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zilberstein, K. Trauma in Context: an Integrative Treatment Model. Journ Child Adol Trauma 15, 487–500 (2022). https://doi.org/10.1007/s40653-021-00416-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40653-021-00416-3

Keyword

Navigation