Katharine Halsey uses yoga to help her young patients relax mentally and physically. The Penn Center for Youth and Family Trauma Response and Recovery is part of Hall-Mercer Behavioral Health Services, located at Pennsylvania Hospital. (Photo by Dan Burke)
Children who come to the Penn Center for Youth and Family Trauma Response and Recovery carry heavy emotional loads from the dark pain of neglect, assault, or abuse. They have been hurt, outside and in. Their childhood innocence is in danger of being lost too soon.

Safe inside the Center, based at Pennsylvania Hospital, the children slowly allow their stories -–and their pain -- to unfold. Center social worker Kait Yulman, MSW, knows that the wooden dollhouse, colorful tubs of building blocks, toy cars, and pint-sized table and chairs in her office can help her young patients feel more comfortable.

“There are these moments of transition: You get a child who doesn’t want to look at you or talk to you when she first comes in. Then, the next time, she wants to play,” said Yulman. “It’s pretty special to see that. Children process the world through play and artwork -- those activities generate what they are able to express and feel willing to talk about. It is a huge triumph for them to better understand themselves and articulate what they are feeling.”

Child-artwork-1Child-artwork-2 Artwork can help children better express what they’re feeling. These drawings were created by (top) a child who witnessed a neighbor being shot, and (bottom) children who saw their mother die after being stabbed.

Following a potentially traumatic event – a car accident, a physical or sexual assault, a sports injury, witnessing violence – as many as 1 in 5 children develop Posttraumatic Stress Disorder (PTSD). A new approach to treating trauma, developed at the Center, successfully prevented full or partial chronic PTSD in 73 percent of children in a recent study.

“When I first started coming here, it was more murders and more on me,” said 9-year-old Nyla.* “But now it seems like it’s lighter. I don’t worry as much about it. I still think about it, but it’s not as much as it was when I first came here.”

Center director Steven Berkowitz, MD, associate professor of Clinical Psychiatry at the School of Medicine, developed the new Child and Family Traumatic Stress Intervention (CFTSI) based on the theory that trauma-related disorders such as PTSD might be best understood as a “failure of recovery.”

“Many of us have had potentially traumatizing experiences,” he explained. “After a car accident you might feel out of sorts, not quite yourself, and you may not sleep so well. After a couple of days, you return to a normal level of functioning. The memory hasn’t gone away, but it’s integrated. When the memory doesn’t get integrated, that’s when you develop trauma-related symptoms and disorders.”

PTSD symptoms can include reliving a traumatic experience, sleep disturbances, emotional numbness, angry outbursts or difficulty concentrating. The CFTS intervention teaches strategies to improve communication between child and parent/guardian, such as recognizing and managing traumatic stress symptoms and teaching coping skills, Berkowitz said. The intervention has successfully prevented chronic and sub-clinical PTSD in children and reduced others’ symptoms, and promoted recovery more quickly than a comparison intervention.

“CFTSI is the first preventative intervention to reduce the onset of post-traumatic stress disorder in children.”

“I feel that this experience for me has been very good,” said 14-year-old James. (Children's names have been changed to protect privacy.) “It’s allowed me to have somebody to tell how I feel and allowed me to know that it’s going to get better.”

CFTSI is the first preventative intervention to improve outcomes in children who have experienced a potentially traumatic event, and the first to reduce the onset of PTSD in children. “If this study is replicated and validated in future studies,” Berkowitz said, “this intervention could be used nationally to help children successfully recover from a traumatic event without progressing to PTSD.” The study appears online in the Journal of Child Psychology and Psychiatry.

The CFTS intervention begins with an initial assessment to measure the child’s trauma history and a preliminary visit with the parent or guardian, focusing on their essential role in the process. “By bringing them in, making them the center, engaging them in the process, we are demystifying therapy and treatment,” Berkowitz said. “We hope that in doing so, it opens the door to not only our treatment but referral to social service agencies and other support that they may have avoided in the past."

Then the clinician, parent/guardian and child develop a homework assignment to practice certain coping skills. These skills provide techniques to recognize and manage traumatic stress symptoms.

“As far as my thinking goes,” says 12-year-old Rosa, “I still always rush to the negative, but I’m trying to work on that each day.  I sometimes do it without realizing it. It’s very hard because you’re used to it, it’s a habit -- it’s hard to stop doing it.  I’m trying to change my way of thinking.”

”We want to provide [children] and their families with a sense of hope that things can be different.“- Katharine Halsey

It is not unusual for a child to present with a history of multiple traumas. In these cases, CFTSI can become a “starting point” for multi-modal treatment including behavioral therapy, medication and even yoga. Center social worker Katharine Halsey (above) is a certified yoga instructor who finds that yoga and its practice of mindfulness can help children relax mentally and physically. “These children have really, really horrifying stories,” she said. “We want to provide them and their families with a sense of hope that things can be different.”

That means providing tools for life. “Emotional support is a key protective factor and the lack of it increases the risk of poor outcomes tremendously,” Berkowitz said. “The CFTSI model helps provide emotional support directly to the children. We start by helping children communicate effectively about their symptoms and helping their parents and guardians listen and understand without judgment or recrimination. Then we provide strategies for coping and processing."

“What we teach our patients and what we hope to leave with them is a set of skills and coping strategies that aren’t so narrowly focused that they only work for the issue for which they came to see us. We hope to ingrain more open conversations and tools into their family lives,” said Yulman.

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