The impact of exposure to trauma and adversity during early development (i.e., developmental adversity) has been well documented, including a range of post-trauma reactions that can later develop into varied behavioral health disorders (e.g., posttraumatic stress disorder [PTSD], anxiety disorders and depressive disorders) and negative effects on the family and broader caregiving systems (NCTSN Core Curriculum on Childhood Trauma Task Force, 2012). A recent, extensive review of science-based treatments for PTSD in children and adolescents outlined and summarized four clinical cornerstones of effective treatment: 1) psychoeducation on the prevalence and impact of trauma exposure and treatment of trauma-related problems; 2) coping skills; 3) exposure and cognitive restructuring; and 4) parenting support and skills (Jensen et al., 2020). Given the decades of scientific findings in support of parent training models for the treatment of psychopathology in children and adolescents (Shaffer et al., 2001), their effective clinical application to the field of developmental adversity is unsurprising. However, might we be missing the mark or, at the very least, underutilizing a trauma-informed lens to maximize the intervention’s effectiveness?
The overarching purpose of parent training (also known as parent management training or behavioral parent training) is to teach caregivers effective parenting strategies to improve their ability to manage child behavior problems and increase functional behavior. Typically, parent training is recommended when behavior problems are severe enough to impair a child's functioning, which are often labelled as “disruptive,” “inappropriate” and/or “unacceptable.” Parent training has been most successful for disruptive behavior problems (Chorpita et al., 2011; Coates et al., 2015), although some empirical support exists for internalizing symptoms (Eckshtain et al., 2017; Gonzalez & Jones, 2016). Clinical wisdom and scientific evidence, however, do not indicate that behavior problems of children and youth affected by trauma and adversity exposure are the same as those who aren’t negatively impacted by such adverse experiences (e.g., attention-seeking, tangible reward-seeking, and escape-motivated behavior). Rather, the manifest behaviors are expressions of the child’s emotion dysregulation. Directly addressing this deficient regulatory process would thus arguably make parent training truly trauma-informed (Navalta, 2022).
The Substance Abuse and Mental Health Services Administration developed a framework for trauma-informed care relevant to public health agencies and service systems (Substance Abuse and Mental Health Services Administration, 2014). Two mnemonics were crafted to highlight the key features: The Three “Es” and The Four “Rs”. First, trauma is defined as an event that is experienced by a person with lasting adverse effects. Second, a trauma-informed approach realizes the widespread impact of trauma; recognizes the associated signs and symptoms; responds integratively and seeks to actively resist re-traumatization. This concept of trauma incorporates key trauma principles into organizational culture within the context of trauma-specific clinical practices. As such, innovating parent training by altering its clinical focus to children’s dysregulated emotions aligns with a trauma-informed approach to care.
Emotion dysregulation is hypothesized to be a central mechanism that links exposure to developmental adversity to later behavioral health problems (McLaughlin et al., 2015). Such dysregulation typically leads to internalizing symptoms when the problem is less severe but results in highly disruptive and potentially risky or dangerous behavior when the dysregulation is more problematic (D’Andrea et al., 2012). Because the problems can be many and varied, an alternative, albeit consistent, premise is that such dysregulation is a transdiagnostic risk factor or pathway for multiple behavioral health conditions (Werner & Gross, 2010). This transdiagnostic perspective has a direct bearing on trauma-informed parent training in that the clinical focus isn’t on the differing psychopathological outcomes that the children can have but rather on an underlying process for the onset and maintenance of clinical problems (Chu, 2012). In other words, emotion dysregulation is that very process that trauma-informed parent training ought to primarily concentrate on. This newer therapeutic strategy has been called the core dysfunction approach (Marchette & Weisz, 2017).
At its essence, parent training that is trauma-informed should address the children’s emotion dysregulation that, in turn, should lead to improvements in their behavioral health. Such treatment would seem to be especially germane in circumstances when trauma and adversity impact the family system, the parents’ responsiveness to the child and their capacity to engage in treatment. For very young children, parent-guided approaches to address these issues for improving the child-parent relationship are well-established (e.g., Child-Parent Psychotherapy; Toth et al., 2018). Given that emotion regulation development is largely dependent on how parents respond to their children’s emotions (Thompson & Goodman, 2010), treatment that focuses on caregivers aligns with a fundamental truism—parents are our children’s best and most important teachers.
About the Author
Carryl P. Navalta, PhD, Clinical Associate Professor of Psychiatry and Graduate Medical Sciences, Boston University Chobanian & Avedisian School of Medicine
References
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