Therapeutic Interventions

1. Gather information from the parents regarding the traumatic incident and the effects on themselves, the child, and other family members.

2. Assess the child's current level of anxiety by administering an anxiety scale designed for children (e.g., the Revised

2. Debrief the child regarding the traumatic incident. (3, 4, 5)

3. Reassure the child about personal and family well-being. (6, 7, 8)

Children's Manifest Anxiety Scale [RCMAS], the Trauma Symptom Checklist for Children by Briere) or obtain an evaluation from the child's counselor or therapist.

3. Teach the parents to debrief their child regarding the anxiety-producing trauma using an open-ended, nonjudgmental, and supportive conversational style that is accepting of all expressed feeling and opinions.

4. Instruct the parents to encourage the child to express anxieties, feelings and reactions to the trauma through drawings, unstructured play, and mutual storytelling.

5. Assign the parents to play therapeutic games with their child (e.g., Talking, Feeling and Doing Game from Creative Therapeutics, or the Ungame from the Ungame Company)

to discover unexpressed thoughts and feelings that may be contributing to the elevated anxiety.

6. Advise the parents to reassure the child of their ongoing unconditional love and support throughout and beyond the posttraumatic adjustment period.

7. Instruct the parents to work together to provide for the emotional and physical needs of all family members despite the unsettling effect of the traumatic experience.

8. Refer the parents to private and community organizations that

4. Encourage open communication of fears, feelings, and trauma-related thoughts. (9, 10, 11)

5. List the effects of trauma-induced stress on the daily functioning of self and the child. (12, 13)

6. Teach the child problemsolving and decision-making skills to manage stress and anxiety. (14, 15)

offer relief for families experiencing trauma (e.g., Red Cross, church relief groups, hospitals, mental health organizations).

9. Role play with the parents to prepare them for responding to the child's ongoing feelings of stress and anxiety in a nurturing, supportive, nondefensive manner.

10. Discuss and role play with the parents the techniques of using "I" statements and active listening to use when discussing the anxiety-producing situation. (See Parent Effectiveness Training by Gordon.)

11. Assign parents to read material that will help them develop skills for positive communication with the child (e.g., How to Talk so Kids Will Listen and Listen so Kids Will Talk by Faber and Mazlish).

12. Brainstorm with the parents an extensive list of posttrauma reactions and prioritize them from greatest to least troubling, eliminating duplications, and consolidating overlapping items.

13. Assign the parents to draw therapeutic pictures with their child entitled "What stress looks like to me," and "What serenity looks like to me," and place the drawings in their parent/child therapeutic portfolio.

14. Assign the parents to assist the child in coping with a traumatic experience (e.g., a fire) by taking proactive measures to

7. Teach skills for managing an emergency situation. (16, 17)

8. Assist child in differentiating threatening and non-threatening circumstances. (18)

9. Implement strategies that reduce the child's anxiety when interacting with others.

prevent a future fire (e.g., buy smoke alarms, create an escape plan, arrange for a fire safety inspection).

15. Ask the parents to brainstorm with the child possible remedies to an anxiety producing situation, choose an option most likely to reduce the level of concern, agree to implement the strategy and follow up with an evaluation of the effectiveness of the plan.

16. Instruct the parents and school personnel to establish procedures for dealing with emergency situations (e.g., dial 911, fire drills, tornado plans, school lockdown process) that are explained in detail and practiced frequently.

17. Assign the parents to discuss, define, and role-play with the child strategies for mitigating inappropriate adult/child interactions (e.g., how to say "no" to inappropriate touch, never go with strangers, how to get immediate help).

18. Council the parents to brainstorm with the child a list of situations that create anxiety and to differentiate those that pose a danger from those that are harmless (e.g., stranger offering candy versus classmate passing out a birthday treat).

19. Instruct the parents to enroll the child in a social skills or anxiety-reduction therapeutic group offered by the school or a counseling agency.

10. Reframe trauma-related feelings of guilt that affect the child and other family members. (21, 22)

11. Identify anxiety-induced physical symptoms evidenced by the child. (23, 24)

12. Teach the child relaxation techniques to use during

20. Assign the parents to use activities from Peacemaking Skills for Little Kids (Schmidt, Friedman, Brunt, and Solotoff) to encourage the child to develop social assertiveness and conflict management skills.

21. Council the parents to help the child reframe feelings of guilt related to the trauma by discussing events rationally and logically and pointing out that the child's reaction and behavior was normal and appropriate given the circumstances.

22. Teach the parents to use rational emotive techniques to help the child deal with chronic worry and anxiety (or assign the "Reframing My Worries" activity from the Parenting Skills Homework Planner by Knapp).

23. Assign the parents to note in a personal journal all incidents of elevated stress and related physical symptoms evidenced by themselves and the child, (e.g., rapid heart beat, headache, stomach or bowel distress) and refer to a physician for possible anti-anxiety medication if the symptoms appear excessive.

24. Instruct the parents to compare their own physical receptors of stress to those of the child (or assign the "Physical Receptors of Stress" activity from the Parenting Skills Homework Planner by Knapp).

25 Assign the parents to practice deep and even breathing with periods of posttraumatic stress. (25, 26)

13. Increase the frequency of the child reporting a sense of safety, calm, and well being. (27, 28)

14. Reestablish a consistent, positive, and loving system of discipline. (29, 30)

15. Teach the child techniques for reducing nighttime terrors. (31, 32)

the child during periods of stress and elevated anxiety.

26 Encourage the parents to engage the child in an aerobic exercise for one half-hour, three to four times per week to release the accumulated physical effects of stress.

27. Advise the parents to adopt a "one day at a time" philosophy for overcoming the effects of trauma on the family and to expect small steps toward reclaiming a feeling of calm and well being rather than sweeping changes.

28. Assign the parents to engage in family nurturing and bonding activities (e.g., family prayer, reading together, singing, storytelling) on a daily basis to restore a sense of well being for themselves and the child.

29. Instruct the parents to help the child regain a sense of personal control by using choices to encourage responsible behavior (e.g., "Will you do your homework before or after dinner?").

30. Assign the parents to reestablish positive discipline with the child by using consequences with empathy to modify inappropriate behavior ("I'm so sorry that you're not finished with the video but it's bedtime now.").

31. Council parents to provide the child with an environment conducive to peaceful nighttime sleep and to develop and enforce a bedtime routine.

16. Acknowledge and affirm the child's development of confidence and ability to deal with personal stress and anxiety. (33)

17. Verbalize to the child a personal optimism toward the present and future. (34)

32. Assist the parents and child in developing a plan to deal with distressing dreams and periods of wakefulness during the night (e.g., stay in bed, play soft music, read a calming book, draw a picture).

33. Council the parents to affirm the child for any progress demonstrated in reducing the influence of stress and anxiety on daily behavior and participation in routine activities.

34. Advise the parents to hold family discussions focusing upon positive plans for the future (e.g., vacation plans, college and career decisions, holiday arrangements, social gatherings, community projects) to emphasize the reestablishment of optimism and normalcy in the family life.

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