Yesenia Aguilar Silvan & Lauren C. Ng
Section Editor: Antonella Bariani
Peer Reviewers: Linda Zheng & Molly Becker

Trauma Exposure Disparities for Latine Youth

By age 17, 46% of youth in the United States will have experienced at least one potentially traumatic event such as community violence or family separation (Sacks & Murphey, 2018). This major public health concern is associated with the development of mental health disorders, poor physical health, and early death in adulthood (Kalmakis & Chandler, 2015). Traumatic events have a dose-dependent relationship with health outcomes: as exposure to trauma increases, the severity of poor mental and physical health symptoms also increases. Among low-income, racial/ethnic, and immigrant minoritized groups, exposure to traumatic events is disproportionately higher (Haider et al., 2013; Sacks & Murphey, 2018). For example, Latine youth are more likely to witness violence in their neighborhood, have a guardian serve time in jail, and lack basic necessities like food and housing compared to non-Hispanic White adolescents (Sacks & Murphey, 2018). Despite having higher rates of traumatic exposure, racial/ethnic minority groups, such as Latine youth, are less likely to receive mental health services for trauma compared to non-Hispanic White patients (Haider et al., 2013; Zhang et al., 2021). Moreover, Latines with trauma initiate and stay in trauma treatment at lower rates than their White counterparts (McClendon et al., 2020; Youn et al., 2019). These inequalities disproportionately increase the risk of subsequent health problems among Latine youth.

Familismo as a Potential Mechanism for Increased Treatment Engagement

Familismo, a core value in Latine culture (Steidel & Contreras, 2003), may increase treatment engagement among Latine youth (Burrow-Sánchez et al., 2015). It mediates the relationship between trauma exposure and mental health symptoms (Dixon De Silva et al., 2020), and comprises multidimensional aspects, including the obligation to provide material and emotional support, use relatives as behavioral and attitudinal references, and rely on family members as sources of support (Steidel & Contreras, 2003). Substance use treatment research demonstrated that Latine youth with higher levels of familismo attended more treatment sessions and completed more practice worksheets (Burrow-Sánchez et al., 2015). According to a case study, familismo can be a mechanism to increase engagement in trauma treatment by reframing attendance and homework completion as evidence of the client’s dedication to seek help to provide for his family (López et al., 2014). This reframing improved his motivation to attend sessions and try challenging assignments (e.g., exposure hierarchy). Familial closeness, a component of familismo, is also a protective factor for Latine youth that can foster a supportive home environment and promote their trauma recovery (Dixon De Silva et al., 2020). These findings suggest that clinicians who can integrate familismo into the delivery of evidence-based trauma therapies may increase engagement among Latine youth by making treatment more relevant and appealing for those with this cultural value. A recent study found that across the most commonly used trauma therapies for youth, such as Trauma-Focused Cognitive Behavioral Therapy and Prolonged Exposure, there were common elements (i.e., techniques and mechanisms) (Kooij et al., 2022), that may be enhanced by integrating familismo.

Selective Adaptation

Clinicians often struggle with identifying whether trauma therapies should be culturally adapted. Clinicians working with Latine youth can use a selective adaptation approach to determine whether trauma therapies should be adapted by incorporating familismo. The selective adaptation model argues that data should be used to identify (a) clients who would benefit the most from adaptation (e.g., Latines with high level of familismo), and (b) problems (e.g., engagement challenges) that may be targeted through adaptation of the treatment content (Lau, 2006).

Identifying Latine Youth with High Familismo

Latine subgroups in the United States have distinct relationships with the United States, service utilization, and mental health (Keyes et al., 2012). For example, rates of psychological disorders and mental health service use among people from Puerto Rican origin are more similar to non-Latine Whites than other Latine subgroups. Therefore, it is crucial to consider the heterogeneity among Latine subgroups before culturally adapting trauma therapies. To assess within-group variance in familismo, clinicians can use the Cultural Formulation Interview (Jarvis et al., 2020) during the initial mental health intake or screening to assess the importance of familismo among Latine youth.

Clinicians can gauge cultural perceptions of support by asking youth how family support is affecting their symptoms and assessing cultural factors affecting past help-seeking behaviors (e.g., family commitments and stigma). It is also essential to understand how cultural factors can impact current treatment engagement and whether family members support the youth’s decision to seek mental health care. Indeed, assessing the role of familismo, such as the extent and obligation of family to serve as a source of emotional support, is critical as one of the most robust predictors of mental health outcomes among youth who have experienced traumatic events is the quality of support provided by family members (Trickey et al., 2012).

Identifying Engagement Challenges in Trauma Therapies

Effective treatment outcomes in trauma therapies are reliant on identifying and addressing engagement challenges. Although engagement challenges are often equated with attendance issues, such as missed appointments or tardiness (Lakind et al., 2022), it is important for clinicians to recognize that engagement in trauma therapy is multidimensional and encompasses several domains. By using the acronym REACH (Lakind et al., 2022), clinicians can assess if Latine youth are encountering difficulties with the Relationship (e.g., therapeutic alliance), Expectancy (e.g., beliefs about the helpfulness of trauma therapy), Attendance (e.g., missed appointments or being late for sessions), Clarity (e.g., agreement about treatment goals such as conducting the trauma narrative), or Homework (e.g., active participation of work assigned in and outside of sessions). By considering these different domains, clinicians can then develop tailored adaptations to improve treatment engagement.

Trauma Therapies Content Adaptations

Data from the Cultural Formulation Interview can be used to plan specific modifications that may make trauma therapies more engaging and appropriate for Latine youth and families with high levels of familismo. Specifically, clinicians can incorporate familismo throughout trauma treatment to foster positive cognitive-emotional regulation in caregivers and strengthen their role as behavioral and attitudinal references for their child. During the trauma narrative, which is a common element of trauma therapies, caregivers’ positive cognitive-emotional regulation of their own reactions and support for their child’s trauma-related reactions, reduced youth’s internalizing symptoms after treatment (Yasinski et al., 2016). Conversely, avoidance and blame from caregivers resulted in youth having higher internalizing and externalizing symptoms, and more problematic thinking patterns (e.g., generalized trauma beliefs). Thus, during trauma narration and processing, clinicians can help caregivers understand that many emotions and reactions will come up when learning about youths’ traumatic experiences, and that reactions such as avoidance or blaming the youth are harmful. Specifically, clinicians can highlight that youths need to feel supported to become healthier and that caregivers may meet their family obligation to provide emotional support (i.e., a component of familism) by practicing positive cognitive-emotional regulation skills. During the skill-building phase, another common element in trauma therapies, clinicians can also reframe parent modeling as being consistent with familismo by reminding caregivers that they are behavioral and attitudinal references for their child. Furthermore, when choosing coping skills to teach the youth, clinicians can prioritize teaching social coping skills that incorporate support from family members (i.e., a component of familismo) as social coping skills are associated with decreased mental health symptoms among Latine youth (Cardoso, 2018). Social coping skills that incorporate family members include activities such as talking to a trusted family member, attending family gatherings, watching something humorous with a sibling, or exploring their cultural identity with extended family.

Conclusion

Given the critical role of familismo among Latine culture (Steidel & Contreras, 2003) and evidence showing that this cultural factor mediates differential mental health outcomes among Latine youth who have experienced traumatic events (Dixon De Silva et al., 2020), it is critical for clinicians to understand and consider how to incorporate familismo in the delivery of trauma therapies. We believe that capitalizing on familismo as a way to optimize the role of family in treatment using selective adaptation might open opportunities to address the sociocultural context of Latine youth and increase initial and sustained engagement in evidence-based trauma treatments without undermining the therapeutic value of the original intervention.

YESENIA AGUILAR SILVAN is a doctoral graduate student at the University of California, Los Angeles (UCLA) Clinical Psychology program in the Treatment and Research for the Underserved with Stress and Trauma (TRUST) lab. Her research focuses on using implementation science frameworks to address mutable factors that contribute to documented mental healthcare disparities in care access and continuity for trauma-exposed communities. Yesenia’s clinical interest includes delivering evidence-based interventions to racial/ethnic minority youth in community settings and using strategies to help racial/ethnic minority and monolingual Spanish-speaking families engage in trauma-focused treatments.

LAUREN C. NG is a clinical psychologist and an Assistant Professor in the Department of Psychology at the University of California, Los Angeles (UCLA), where she is the lab director of the Treatment and Research for the Underserved with Stress and Trauma (TRUST) lab. Her research focuses on translational science as applied to developing, culturally adapting, and implementing evidence-based posttraumatic stress disorder (PTSD) interventions for underserved, minority communities in the US and low- and middle-income countries.

Citation: Aguilar Silvan, Y., & Ng, L. C. (2023). Integrating familismo into evidence-based trauma therapies to increase treatment engagement among Latine youth. Trauma Psychology News, 18(2), 26-30. https://traumapsychnews.com

By Eliana Gil
2017
The Guilford Press

Eliana Gil’s gentle and sensitive approach to children and their families is evident throughout her book on posttraumatic play therapy. She calls her approach Trauma-Focused Integrative Play Therapy (TFIPT). Dr. Gil aims her book towards clinicians, mainly focusing on complex, chronic, and ‘unrelenting’ Type II traumas, which include multiple types of abuse and perpetrators, rather than Type I traumas (e.g., related to natural disasters or situations such as terrorism).

Dr. Gil differentiates between therapeutic “dynamic” play and “toxic” play. Therapeutic play eventually helps the child to progress, and allows to experience less anxiety when confronted with stimuli that are reminiscent of the traumatic event. Toxic pla,; however, reflects the child’s being ‘stuck’ and unable to gain from the particularly repetitive and harmful type of play.

Dr. Gil describes children’s posttraumatic stress disorder (PTSD) symptoms differs from those expected in adult behaviors and symptoms, and include dreams of monsters, repetitive play in which the trauma is reexperienced, regression to previous developmental states (i.e., enuresis, encopresis), as well as difficulty concentrating in school, somnambulism, headaches, stomachaches, relentless anxiety, and other symptoms.

In her book, Gil states that there are four types of posttraumatic play:

• Literal (playing out the traumatic events as they occurred),
• Symbolic (the child does not call the items by real names but the story is readily seen),
• Individual posttraumatic behavioral reenactments (replaying the traumatic experience when the child does not include others), and
• Behavioral reenactments in which the child attempts to enlist others to join the reenactment.

Gil’s example of the fourth type was when a child gave her a ping-pong paddle to hit her, “You like me, don’t you?” (p. 30). This type of reaction is typical of successful play therapy – it reveals notions held by the child and allows for new definitions. Here, the child was showing that when someone likes you, they will inevitably hurt you, lashing out physically.

The book is structured neatly into two main sections. Part I: Understanding Posttraumatic Play describes Gil’s clinical approach. Part II: Clinical Illustrations gives clinical examples of children and their families and the techniques and interventions used by Dr. Gil. Although clinical examples are provided throughout the book, the examples given in Part II are described in great detail. These descriptions do not replace direct training in play therapy, but they do offer a close description of what clinicians do during play therapy.

There are little gems every so often in this book. In the discussion of dissociation, Gil seems to imply that children dissociate on purpose, but ultimately describes it as a sign of system overload. She writes that children may eventually learn to not dissociate as much through gaining more impulse control. Some of these changes also happen through elimination of destructive and repetitive toxic play, and use of more constructive dynamic play.

Gil is reminiscent of the kindly supervisor who calls children “Pumpkin” and is able to interact with children in a way that not all people can. It is for this reason that although the book is well-written, and Dr. Gil knows her subject, there are limits in transmissibility. One important caveat comes from an example of a 12-year-old girl, where Dr. Gil’s intervention was, “I simply stroked her back.” (p. 61). As clinicians, we do not need to resort to physical expression, especially in cases of PTSD (but also in other diagnoses, such as the Pervasive Developmental Disorders, various personality disorders, affective disorders, and diagnoses such as Intermittent Explosive Disorder). In fact, a seemingly simple touch may be misinterpreted and may undo much of the work we may have put into a case. Here, the question becomes, “Was it the therapist’s own need that drove her to touch the patient? Was there a more effective intervention available to her?” Luckily for Dr. Gil, her touch was not viewed as a threat, possibly due to her (previously described) gentle grandmotherly approach.

I recommend this book for clinicians who are unfamiliar with or would like to improve their play therapy skills and would like to get a behind-the-scenes view through the eyes of a soft, intelligent, non-threatening grandmotherly figure. Many clinicians who have practices that examine family dynamics, could also gain from including play therapy in their repertoire. Play therapy is one of many useful techniques for engaging and ultimately communicating with children, especially about uncomfortable or traumatic topics.

Review by June Shapiro
June Shapiro PhD is a Clinical Neuropsychologist working in private practice for over 25 years.

Stephany Pinales & Mariah Montgomery Stickley

In 2020, approximately 9% of adolescents between 13 and 17 years of age identified themselves as lesbian, gay, or bisexual, while nearly one percent of the population surveyed (.73%) identified as transgender (Bowleg, 2020). Considering the social, cultural, and spiritual influences placed upon youth in their development, these numbers should be used as an approximation. Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) adolescents experience higher rates of mental health disorders in comparison to their heterosexual peers (Russell & Fish, 2016). Literature indicates LGBTQ+ individuals also report higher adverse childhood experiences (ACEs) than their heterosexual peers (McCormick et al., 2018; Merrick et al., 2018) and experience higher lifetime rates of posttraumatic stress disorder (PTSD) as a result of their sexual or gender minority status (Alessi, 2013; National Resource Center for Mental Health Promotion and Youth Violence Prevention, 2019). Historically, the field of psychology has contributed to such stressors by pathologizing sexual and gender minority-identifying persons, increasing the importance of our commitment to affirming and culturally competent psychological services. In support of this aim, this article briefly reviews the available literature and future considerations for trainees and practitioners providing trauma care to LGBTQ+ youth.

A documented declining age of “coming out” among LGBTQ+ youth now overlaps with adolescence (Fish, 2020). Russell & Fish (2016) pose that coming out is associated with positive adjustment in adults but is a risk factor for youth. When considering contributions and unique challenges for youth, the 2015 National School Climate Survey report by the Gay, Lesbian & Straight Education Network (GLSEN) reported approximately 85% of LGBTQ+ adolescents have experienced verbal abuse, 27% were physically harassed, and 13% were physically assaulted while in high school (Pizmony-Levy & Kosciw, 2016). Sexual minorities are recognized as experiencing higher exposure to traumatization; LGBTQ+ people are exposed to traumatic life events such as hate crimes, violence, and sexual assaults at higher rates (Marchi et al., 2023). Similarly, internalized homophobia has been identified as predictive of PTSD symptom severity in LGBTQ+ persons with a trauma history (Gold et al., 2011). These findings are supported by foundational frameworks such as the minority stress theory (Meyer 1995, 2003), which posits that sexual minorities experience distinct chronic stressors related to their stigmatized identities.

In addition to interpersonal challenges, LGBTQ+ youth also navigate systemic barriers that exacerbate their vulnerability to potentially traumatic events as well as exposure to chronic stressors. Manifestations of these barriers are observed at national and state policy levels for sexual and gender diverse youth across cultures. This is evident through laws prohibiting same-sex marriage as well as the criminalization of same-sex acts, practices, and gender expression. Structural stigma can also be observed through policies prohibiting change of gender or sex on identification cards and legal requirements (Earnshaw et al., 2024). As such, pediatric providers must acknowledge the potential impact of increased opportunities for youth to experience rejection, stigmatization, and discrimination, in addition to other potentially traumatic events. These systemic and structural barriers to safety should also be considered in case conceptualization and treatment planning.

Recent studies have applied Meyer’s minority-stress theory (2003) to investigate the risk of developing PTSD in LGBTQ+ individuals, attributing increased risk to unique stressors linked to their minority identity (Binion & Gray, 2020). Constructs linked to minority stress, including rumination, perceived burdensomeness, and rejection sensitivity, are especially relevant in cases of trauma related to abandonment (Russel et al., 2016; Baams et al., 2015). Studies also highlight the mediating role of internalized heterosexism (IH) in this relationship, aligning with contemporary PTSD models emphasizing the significance of emotions like guilt and shame in the development and maintenance of the disorder (Budden, 2009; Straub et al., 2018; Stickley et al., 2023). While the majority of these studies were conducted with adult populations, they shed light on the minority stress process and potential points of intervention for pediatric providers.

In clinical application, practitioners are encouraged to consider the individual needs and experiences of traumatized LGBTQ+ youth when using manualized treatments. Providers can also leverage the constructs outlined in theories such as minority stress theory to bolster therapeutic outcomes (e.g., perceived burdensomeness and IH). For example, attempts to decrease perceived burdensomeness may include encouraging clients to increase their social involvement (e.g., joining clubs, sports, or other groups with peers that are a safe and affirming environment). Addressing IH may entail the integration of the patient’s unique socio-cultural values and beliefs (e.g., spirituality) into the provider’s conceptualization of trauma-related cognitive distortions (see Stickley et al., 2023 for an overview). The role of caretakers also plays a vital role in minority stress; a positive and supportive adolescent-parent relationship can significantly contribute to decreasing symptoms of depression and suicidality (Diamond et al., 2011). Practitioners must also caution against pathologizing or attempting to change clients of sex and gender minorities. McCormick and colleagues (2018) pose that the perception of physical and emotional safety is compromised when considering the trauma and secondary challenges (financial, social, and emotional) that often accompany traumatic experiences.

The use of trauma-informed practices can vary depending on the setting, structure, and organization. However, recommendations include protecting privacy and confidentiality, being aware of the client’s body language, considering the identity of adults interacting with youth, and considering cultural norms when greeting and questioning youth and their families (National Resource Center for Mental Health Promotion and Youth Violence Prevention, 2019). Practitioners should remain current with professional guidelines to minimize potentially traumatizing or re-traumatizing practices and ensure quality care. Practices and considerations within this realm include trauma around coming out or difficulty disclosing the traumatic event for those who have not yet disclosed their LGBTQ+ status (Stickley et al., 2023). Trauma-informed clinicians are encouraged to make use of banners, books, or other observable markers of support toward gender and sexual minority populations as a symbol of allegiance. Additionally, inquiring about preferred pronouns may allow youth to disclose and set a precedent for an accepting and affirming approach. Additional clinical techniques and considerations can be found through the National Resource Center for Mental Health Promotion and Youth Violence Prevention (2019).

The American Psychological Association (APA) has supported movements for treating clients with equity and respect. Specifically, gender and sexual minority topics in workshops and conventions have been included, and relevant resources and guidelines are available for APA members. To become accredited by APA, psychology doctoral programs must adopt a curriculum that fosters the development of the nine profession-wide competencies. Within these competencies, individual and cultural diversity, as well as legal and ethical standards, are especially relevant. However, it is essential to note that implementations of these standards are individual and subjective to each program. Additionally, students seeking a mental and behavioral health career may not be enrolled in an APA-accredited graduate program. These factors contribute to considerable variability in quality, preparedness, and understanding of appropriate services by providers.

In conclusion, the multifaceted challenges faced by traumatized LGBTQ+ youth underscore the critical need for tailored, comprehensive interventions and robust training in cultural competence. This article represents only a brief overview of the existing literature exploring mental health outcomes and treatment recommendations for LGBTQ+ youth. Practitioners are encouraged to adopt trauma-informed practices, protect privacy and confidentiality, and be mindful of cultural norms when interacting with LGBTQ+ youth and their families. By creating affirming environments and actively engaging with clients’ unique socio-cultural values and beliefs, practitioners can foster healing and resilience among traumatized LGBTQ+ youth.

STEPHANY PINALES (she/her/hers) is a bilingual master’s level school psychologist and doctoral student in the school psychology program at Texas A&M University. In her academic and professional career, Stephany has collaborated with multidisciplinary teams in schools, clinics, and behavioral health centers to provide culturally and linguistically diverse interventions to youth and their families. As a student, Stephany’s research and clinical interests include providing diverse trauma-based interventions to youth of minority backgrounds.

MARIAH MONTGOMERY STICKLEY, PhD (she/her/hers) is a licensed psychologist and assistant professor at Texas A&M University. Dr. Stickley specializes in the treatment of PTSD in adolescent populations. Her current research focuses on refining evidence-based PTSD treatments for greater accessibility, including the use of intensive/massed treatment models. In both her clinical and academic work, Dr. Stickley strives to provide culturally competent care that honors the unique experiences and stories of her patients and participants.

Citation: Pinales, S., & Montgomery Stickley, M. (2024). Creating connections: Training competencies for practitioners supporting traumatized LGBTQ+ youth. Trauma Psychology News, 19(1), 34-37. https://traumapsychnews.com

Elizabeth K. Lee

In the United States, approximately 1 out of 7 children is identified as having experienced child abuse within the past year (Centers for Disease Control and Prevention, 2022). In 2021, this equated to approximately 600,000 children (National Children’s Alliance, 2023). A recent report by UNICEF (2021), estimated that globally, around 80% of children aged 1 to 14 years, experienced some form of psychological aggression and/or physical violence by a caregiver within the past month. Moreover, perpetrators of child abuse are most often family members (Kurniawan et al., 2019), and maltreatment is often a pattern of repeated violence and/or neglect, rather than a single traumatic event (Warmingham et al., 2019). As such, chronic abuse and/or neglect can be conceptualized as complex trauma which, in children, has been associated with long-term mental health impacts such as PTSD and depression, low school engagement, and increased engagement in risky behaviors (Voisin & Berringer, 2015; Yearwood et al., 2021).

Child abuse and neglect are defined as physical and emotional mistreatment and/or lack of care, including physical and sexual violence, physical and emotional neglect, and forms of exploitation that result in harm or potential harm to a child’s health, survival, development, or dignity (World Health Organization, 2023). More recently, there is also an emerging consensus that witnessing domestic and family violence constitutes a form of emotional trauma that should be included under the umbrella of child maltreatment (e.g., UK Domestic Abuse Act, 2021). Of the different forms of abuse, emotional maltreatment and neglect are the most prevalent, and both have greater negative long-term impacts on victim-survivors compared to physical or sexual abuse (Naughton et al., 2017; Shi, 2013; Strathearn et al., 2020). In most US states, adults in specific professions (e.g., mental health providers, teachers, social workers, nurses) are, by virtue of their occupation, designated as mandated reporters, meaning that if they learn or suspect that a child is experiencing maltreatment, they are required by law to report it to child protective services (Child Welfare Information Gateway, 2022). In other states, all adults are required by law to report abuse or neglect. Laws regulating the responsibility of reporting also vary internationally.

Understanding perceptions of what constitutes maltreatment and the severity of its impact vary considerably across cultural groups (Nguyen-Feng et al., 2023). Cultural groups can be construed as individuals who share various identities that influence the way they view and interact with the world (Hook et al., 2017). This broad definition implies that multiple facets of identity influence perceptions of maltreatment, including socioeconomic status, educational status, immigration status, race, ethnicity, and religion, to name but a few. Throughout the world, sexual and physical victimization are generally considered to be the most severe forms of child abuse (Fakunmoju et al., 2013; Nguyen-Feng et al., 2023), although some studies also suggest that emotional maltreatment is as detrimental to development and mental health (Vachon et al., 2015). Furthermore, the degree to which the offender is viewed as responsible for the abuse, the offender’s relationship with the child, and the amount of harm inflicted on the child have also been found to shape perceptions of abuse (Qiao & Xie, 2017). For example, in a study examining public perceptions of child abuse conducted in China, Qiao and Xie (2017) found that it was only when a parent frequently caused serious physical injury to a child that it was perceived as physical abuse. This difference in definitions of physical abuse was also highlighted in a cross-cultural comparative study of mothers from the United States, Japan, and Korea (Son et al., 2017). Specifically, mothers from the US were more likely to view physical punishment as abuse than mothers from Japan and Korea. Interestingly, mothers from all three countries in this study agreed on definitions of emotional abuse and neglect. Within the United States, studies have shown that perceptions of what is considered as physical punishment vary by region, generation, socioeconomic status, and education level (Finkelhor et al., 2019; Hoffman et al., 2017). For example, Hoffman and colleagues (2017) found that older individuals of lower socioeconomic status and lower education levels endorsed the use of physical punishment more than younger individuals of higher socioeconomic status and higher education level. Moreover, regarding regional differences, those who live in southern US states have been found to approve of the use of physical punishment more than those who live in northeastern states (Finkelhor et al., 2019). Lastly, the use of corporal punishment as an educational tool was common and acceptable in most Western countries up until the 1970s, when it began to be denounced, leading to the enactment of gradual legal prohibitions (Zolotor & Puzia, 2010). However, it remains prominent in some cultures. For example, in a study of Korean immigrant mothers living in the US, Park (2001) found that although the participants reported negative attitudes towards physical abuse, they also indicated positive attitudes about physical punishment in the context of ‘correcting’ a child’s behavior. Furthermore, this was viewed by mothers as a form of showing love to their child, which the author suggests stems from the belief that using physical punishment for discipline helps children learn. Interestingly, the use of physical discipline in the context of child-parent conflict was not generally sanctioned by the mothers in this sample. Similarly, in a study examining the attitudes of Black mothers/caregivers regarding the use of physical punishment, Taylor et al. (2011) found that the majority of participants considered the use of at least some corporal discipline with their children to be both necessary and expected, particularly when the child compromised their safety, was disrespectful, or did not respond to other types of discipline. Furthermore, physical discipline was seen as both instrumental and effective, as well as culturally normative. Finally, in line with Park’s study of Korean mothers (2001), the Black mothers/caregivers in this study emphasized that they used physical punishment for the child’s own good, and that it was not intended to harm the child.

Given the complexity of the influence that culture has on the perceptions of, and the acceptability of child abuse, clinicians must be prepared to address child abuse in a culturally-informed manner. The first step in working with culturally diverse clients is adopting a multicultural orientation framework which includes cultural humility, cultural opportunities, and cultural comfort (Hook et al., 2017). Within this approach, the therapist does not simply attempt to achieve a finite level of cultural knowledge (i.e., competency) about the client’s cultural identity, but rather welcomes ongoing learning, and adopts an other-oriented perspective while working with clients (Hook et al., 2013; Hook et al., 2017). Cultural humility includes intrapersonal and interpersonal components. The interpersonal component is defined by the way in which the therapist maintains an open and curious stance regarding their client’s values and beliefs, especially when they differ from their own. Assuming a perspective of cultural humility in therapy is vital for therapists to be able to connect with their client’s most salient identities and to foster the therapeutic alliance. The intrapersonal component requires therapists to look inside themselves and reflect upon their own cultural identities including their biases, assumptions, and limitations. It is especially important for the therapist to consider their own perceptions of what constitutes child abuse and what parenting ‘should’ look like. Research has suggested that, despite their training, and research to the contrary (e.g., Vachon et al., 2015), mental health professionals tend to consider emotional abuse as less severe than physical and sexual abuse (Nguyen-Feng et al., 2023). Thus, part of adopting a cultural humility approach is recognizing that all the actors involved hold perceptions and values that are shaped by In sum, therapists who apply a cultural humility framework in their practice emphasize openness to their client’s beliefs and customs, as well as ongoing growth in themselves through self-reflection and autocritique (Hook et al., 2013). These are particularly important stances to adopt when working with culturally diverse clients who are engaging in child abuse, as they may feel judged and misunderstood by mental health providers, which could lead to a withdrawal from mental health and other supportive services, further jeopardizing the situation of the child. Moreover, refugee and migrant families may come from countries where the government does not get involved in family matters, and may already be reticent to work with healthcare professionals and the child welfare system (Earner, 2007). Studies support the effectiveness of adopting a cultural humility approach; for example, client’s perception of their therapist’s cultural humility has been shown to be a significant predictor of positive therapy outcomes (e.g., Owen et al., 2014).

Best practice recommendations for working with families and children who have experienced maltreatment include adopting a trauma-informed (SAMHSA, 2014) and strengths-based approach (Asay et al., 2014; Rashid, 2015). A trauma-informed approach is broadly defined by SAMHSA (2014) as consisting of six key principles: 1) safety, 2) trustworthiness and transparency, 3) peer support, 4) collaboration and mutuality, 5) empowerment, voice, and choice, and 6) cultural, historical, and gender issues. Therefore, when working with families, clinicians should consciously cultivate a sense of safety and trust, including by being transparent with their clients, approaching treatment as a collaboration and empowering their clients, as well as recognizing the cultural, historical, and gender issues that underpin their clients’ context. Moreover, a trauma-informed approach is based on four key assumptions wherein the clinician realizes the widespread impact of trauma (e.g., use of various coping strategies, distress and mental illness); recognizes the signs and symptoms of trauma (e.g., re-experiencing or avoidance); responds by integrating trauma knowledge into their practice (e.g., evidenced-based trauma practices); and actively resists re-traumatization of their client during the therapeutic process (e.g., triggering painful memories).

A strengths-based approach is based on the premise that everyone has talents, capabilities, and skills that can be harnessed to reach therapeutic treatment goals (Cox, 2006). Moreover, a strengths-based approach seeks to further foster existing family and child strengths, in order to improve well-being for the child and the family (Asay et al., 2014). When recognizing families’ strengths, it is also important to acknowledge how their culture has informed existing strengths, and how culture can be used to further enhance treatment. A specific culture focused tool that may be helpful in developing a working treatment plan in these contexts is Koramoa and colleagues’ (2002) continuum of child-rearing practices. This approach suggests that child-rearing practices and traditions can be viewed on a continuum comprising those that are undeniably harmful (e.g., female circumcision) to those that are beneficial (e.g., Inuit gentle parenting), and as such harmful practices can be targeted for elimination and those that are beneficial can be encouraged. One way a clinician may approach limiting harmful cultural practices is by suggesting alternatives, for example, age-appropriate time-outs could be suggested in lieu of physical punishments. The spectrum of child-rearing practices also includes harmless cultural practices, these should not be targeted for intervention as there is no justifiable reason to warrant their elimination. On the contrary, the therapist should work on understanding and respecting these practices as the objective of these interventions is the protection of children from maltreatment, not the homogenization of practices across cultures. Finally, Koramoa et al. (2002) also note that the clinician may engage in some evidence-based education in the case of practices that are potentially harmful (e.g., traditional scarification). Thus overall, a strengths-based approach, in conjunction with a trauma-informed framework is recommended as it consolidates what parents and children are already doing well, leading to increased self-efficacy, enhanced therapeutic alliance, and increased hope (Rashid, 2015).

In conclusion, clinicians working with children of diverse backgrounds should be aware of the various ways a child’s cultural context influences their well-being. Clinicians should adopt a cultural humility perspective by being aware of how their own culture influences their work and being open and non-judgmental with clients of different backgrounds. The continuum of child-rearing practices (Koramoa et al., 2002), in conjunction with the legal definitions of abuse in the clinician’s jurisdiction, may be beneficial in determining whether a child is being harmed. Finally, adopting a trauma-informed and strengths-based approach is recommended.

Biography/Positionality Statement

ELIZABETH K LEE: Mindful that this article provides suggestions on how to conceptualize cultural perceptions of childhood abuse, I wish to provide the reader with information on my background. I am a second-year Clinical Counseling Psychology Master’s student at the University of Minnesota Duluth, a Graduate Research Assistant, a Graduate Research Mentor, and the Research Team Coordinator in the Mind Body Trauma Care Lab. I was motivated to write this article because of my involvement in a past study exploring perceptions of childhood emotional abuse in the general public, psychologists, and college students, as well as my involvement in an ongoing study exploring perceptions of childhood emotional abuse across countries and cultures. I write this article as a White, heterosexual, cis-gender woman, born and raised in Minnesota, and a first-generation college student. I have six years of experience working with victim-survivors of interpersonal trauma, including youth, as an advocate, researcher, and practitioner. As a practitioner, I am drawn to trauma-informed, mindfulness-based, and embodiment-based approaches.

Citation: Lee, E. K. (2024).Navigating perceptions of child abuse with culturally diverse families in a trauma-informed a strengths-based way. Trauma Psychology News, 19(1), 18-22. https://traumapsychnews.com

Priscilla Dass-Brailsford & Rebecca Hage Thomley

Natural disasters occur suddenly and unexpectedly, but these relatively common events have the potential to cause severe community disruption, displacement, economic loss, property damage, death and injury, and profound emotional suffering. The traumatic consequences of disasters affect children psychologically, spiritually, cognitively, behaviorally, and socially with long-term impacts on their development, e.g., negative alterations of self, fostering perceptions of distrust, unpredictability, and worthlessness (Blake, & Fry-Bowers, 2018). Children who experience natural disasters have unique challenges and fears related to displacement and uncertainty (Szente, 2016). Other concerning issues are anxiety, depression, relational problems, sleep disturbances, withdrawal, and suicidal ideation (Kanewischer, 2013; Salloum, et al., 2015). Children who have had traumatic experiences tend to receive diagnoses of posttraumatic stress disorder (PTSD), oppositional defiant disorder (ODD), and/or attention deficit hyperactivity disorder (ADHD; Salloum et al., 2015). Despite their vulnerability, children can show remarkable resilience in the face of adversity. Unfortunately, their ability to bounce back and erroneous assumptions about caregivers and families always protecting them contribute to children being overlooked by disaster researchers and practitioners. In addition, most disaster professionals lack child development expertise to intervene appropriately. Thus, children’s needs are often ‘missed’ in disaster preparedness and disaster response planning (Blake, & Fry-Bowers, 2018).

Books for Disaster-Affected Children

Storytelling is a well-established psychosocial method to help children heal and develop practical coping skills after traumatic experiences (De Vries et al., 2017). This intervention modality may be less threatening and therefore encouraged for children who have experienced disasters; it facilitates social support, self-expression, and coping to promote a return to pre-disaster feelings of security and control (Szente, 2016).

Using literature promotes adjustment and provides opportunities to organize and sequence experiences, enhance understanding, and provide opportunities for self-reflection (Montgomery & Maunders, 2015). Reading is comforting and helps children cope with challenging experiences (Jensen, 2020). Stories educate children and address emotional challenges by building coping skills and supporting resiliency. When coupled with processing or discussion, research has found positive outcomes in children’s emotional, social, and cognitive functioning (Lucas & Soares, 2013; McCulliss & Chamberlain, 2013). Through the process of reading stories, children can identify and express feelings of loss and grief, self-blame and feelings of helplessness are reduced while safety and distance from the trauma increases; the story validates a child’s experience and enhances self-efficacy (Jensen, 2020; Montgomery & Maunders, 2015).

Priscilla Dass-Brailsford

Rebecca Hage Thomley

Citation: Dass-Brailsford, P., & Hage (2024). Storytelling to support children’s recovery from disasters. Trauma Psychology News, 19(2), 8-9. https://traumapsychnews.com

By Headwaters

Headwaters has authored several books to help children and families process disaster-related grief and loss and develop coping skills. The books have been translated into over 15 languages and have addressed the earthquake in Haiti, the typhoon in the Philippines, Ebola in West Africa, trafficking and girls’ empowerment in Nepal, earthquakes and hurricanes in Puerto Rico, and refugee children in Greece and Jordan. During the COVID-19 pandemic, the public health crisis was addressed by creating coloring books for children. The coloring books were widely distributed in South America, 9 European countries, and all 50 states in the US. Each book is accompanied by a caregiver guide that provides instruction on using the books to support children.

Books are generally written at a 4th to 6th-grade level. Although all the books developed by Headwaters are written for children, they can also be used with families and communities. By exploring normal reactions to abnormal events, such as earthquakes, individuals of any age can process and explore coping methods. The books are not available for public sale but are donated to the communities after training the community members and caregivers. The goal is that every book will get into the hands of a child in the community who may benefit from it.

Some examples of books developed by the organization are described and illustrated below.

• (1) When Haiti Shakes was the first book created by Headwaters in 2010 to help children understand earthquakes and learn what to do when they occurred. Reprints of the book (2011 & 2012) were completed in consultation with the Ministry of Education and translated into English, Creole, and French.
• (2) When Strong Winds Blow was created with consultation from Filipino volunteers after Typhoon Yolanda (Haiyan) in 2013. It is designed to assist children in coping with their trauma experience and empower them with techniques to cope with future unexpected events. The book features pictures of familiar animals showing their experiences of the event and their emotional expressions. It also has a caregiver guide.
• (3) When the Great Sickness Came was created by youth volunteers, writers, and artists in consultation with individuals from Sierra Leone, Guinea, and Liberia. The book explores the emotions and family losses related to the Ebola outbreak. A teacher/caregiver guide offers techniques to help children understand the virus and cope with loss while also providing suggestions for maintaining their physical and emotional health. Community partners in Sierra Leone have also developed the book into a play. The book has been read over loudspeakers, replacing drumming as a form of communication in the villages.
• (4) The Savage Wind helps children who experienced Hurricane Maria in Puerto Rico in 2017 understand their experiences. The coping techniques described can be applied to most traumatic events. A caregiver guide accompanies the book.
• (5) Together Again (Hami Sangai—in Nepali) discusses human trafficking and the harmful social and cultural practices that support it. This book has a preventative focus designed to educate children and their families about trafficking and how to work together to prevent it and support victims. Teachers, caregivers, and the community were trained on how to use the book with children.
• (6) Together We Stand was created in 2022 for children and families affected by war and the ongoing geopolitical disaster. The book and caregiver’s guide are written in Ukrainian and Russian, with translations in Polish and Hungarian. The book provides suggestions for adults on how to monitor their children carefully, risk factors, and some of the possible difficulties of working with displaced children. Volunteers worked with refugees-parents and children- who crossed the border to seek safety from the conflict. Non-governmental Organizations (NGOs) personnel were also taught how to use the books with the children.
• (7) The Night Our World Shook was created following the February 2023 earthquakes in Turkey and Syria. The book teaches children what to do when an earthquake happens and how talking to adults and processing feelings can help. A section for adults is designed to teach parents what physical and emotional reactions children may have after a traumatic event. This book was developed during political elections in Turkey, when differences in ideas and ideology due to culture proliferated, making disaster-related work more difficult, e.g., cultural issues centered around whether women should be mandated to wear a head covering in public places.

Headwaters seeks to inspire passion in serving others by forging connections among those being served, the Headwaters team, and the community. Regardless of age, background, skills, or experience, every volunteer feels valued and motivated to serve others. Volunteers learn to recognize, respect, and value differences, and by doing so, they build stronger communities and a better world for everyone.

For more information, reference this issue’s Feature article and/or visit https://headwatersrelief.org.

Reviewers: Priscilla Dass-Brailsford & Rebecca Hage Thomley