Community-Based, Trauma-Informed Interventions

Capstone Final Document

Presented in Partial Fulfillment of the Requirements for the Degree Doctorate in Occupational
Therapy in the Graduate School of The Ohio State University

By

Shannon Mackenzie Joyce, B.S.

Graduate Program in Occupational Therapy

The Ohio State University

2020

Committee:

Lindy Weaver, PhD, MOT, OTR/L, adviser

Maria Baldino, OTD, MS, OTR/L

Erika Kemp, OTD, OTR/L, BCP

 Copyright by

Shannon Mackenzie Joyce

2020
 Abstract

Traumatic events and adverse childhood experiences impact roughly one-third of the pediatric

population across the United States. Research has identified countless negative effects that

trauma imposes on the mental, physical, and socioemotional health of individuals across the

entire lifespan. Efforts for intervention on the effects of trauma have been seen across the fields

of primary medicine and psychology, yet there is limited literature on these efforts being applied

at the local level in a community-based setting. The purpose of this capstone document is to

summarize the available literature pertaining to community-based interventions that address

psychosocial functioning for children exposed to a variety of traumatic events, as well as to

describe the process towards application of the concepts and recommendations identified in

literature. Components of this document include a clinical guideline, scoping review, and case

report. Research indicates that interventions should occur regularly over a course of about three

months, and should not only concentrate on psychology treatment, but also address the personal,

cultural, and environmental factors that influence the child’s mental functioning. Components of

intervention should focus on coping skills, self-regulation, and social skills development which

should be presented through weekly group sessions. Steps were taken to analyze the capacity for

implementation in which it was concluded that efforts need to be taken to strengthen

relationships between organization partners and local families before the intervention can be

successfully implemented. Recommendations presented in this final document are to aid in

effectively developing and implementing a sustainable intervention program in a community-

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based setting to support the psychosocial functioning of children exposed to traumatic

experiences.

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 Dedication

To all children longing to be sincerely known and loved.

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 Acknowledgements

I am indebted to the generosity of the Back2Back Cincinnati staff, especially Chris Cox, Katie
Evans, and Stephanie Powers, who not only embraced me as a capstone student and showed
great appreciation for the field of occupational therapy, but who also taught me immeasurable
amounts of knowledge on caring for children from hard places. I also wish to express my sincere
appreciation to my advisor, Dr. Lindy Weaver, for her continuous guidance and encouragement
throughout the entire research and writing process.

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 Vita

2013................................................................Hilliard Davidson High School

2017................................................................B.S. Health Sciences, University of Cincinnati

Fields of Study

Major Field: Occupational Therapy

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 Table of Contents

Abstract..................................................................................................................................i

Dedication..............................................................................................................................ii

Acknowledgements................................................................................................................iii

Vita.........................................................................................................................................iv

List of Tables.........................................................................................................................vi

List of Figures........................................................................................................................vii

Evidence-Based Clinical Guideline.......................................................................................1

Appendix A: Scoping Review...............................................................................................11

Appendix B: Needs Assessment............................................................................................55

Appendix C: Case Report......................................................................................................56

Appendix D: References........................................................................................................61

Appendix E: Supplemental Documents.................................................................................67

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 List of Tables

Table 1. Evidence Summary..................................................................................................22

Table 2. Cochrane Bias Assessment......................................................................................30

Table 3. Thematic and Numeric Analysis..............................................................................31

Table 4. Implementation Strategies.......................................................................................67

Table 5. Search Strategy........................................................................................................68

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 List of Figures

Figure 1. PRISMA Diagram..................................................................................................52

Figure 2. Concept Map..........................................................................................................53

Figure 3. Oxford Levels of Evidence.....................................................................................54

Figure 4. SIGN Methodology Checklist................................................................................70

Figure 5. LEGEND Evidence Appraisal Form......................................................................72

Figure 6. Google Survey........................................................................................................76

Figure 7. Strong Families Program........................................................................................80

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 Evidence-Based Clinical Guideline for Community-Based,
Trauma-Focused Interventions for Children to Improve
Psychosocial Functioning
Shannon M. Joyce, S/OT
Division of Occupational Therapy
School of Health and Rehabilitation Sciences
The Ohio State University

INTRODUCTION
The aim of this document is to give an overview of the available literature pertaining to
community-based interventions that address psychosocial functioning for children with histories
of trauma. Concepts and recommendations from this synthesis will be applied and summarized
through a site-specific case report as an analysis for implementation.

TARGET POPULATION
The programs of interest in this synthesis are recommended for any child who has experienced a
traumatic event or adverse childhood experience and is susceptible to psychological or
behavioral disturbances as a result of the event. It is not intended for children with primarily
physical traumas, or for children whose trauma is a product of terrorism, war-exposure, or
refugee movements. These programs may not be suited for individuals with severe or highly
complex presentations of trauma symptoms, who may be better served through intensive
psychiatric intervention.

Inclusion Criteria:
This pathway/program is designed to be used with:
 Population:
o Ages 2-18 years old
o History of traumatic event(s), including:
 chronic psychological stress
 abuse (physical, verbal, emotional, sexual, spiritual)
 drug/substance exposure
 poverty (homelessness, chronic hunger)
 neglect
 primary caregiver separation or death
 violence exposure (intimate partner, domestic, community)
 Setting:
o United States
o Community-based:
 after-school programs
 summer programs
 recreation centers
 local facilities
 non-profit organizations
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  community-partnerships
Exclusion Criteria:
 Setting:
o Hospital
o Clinic
o School
o private home
 Population:
o child-soldiers
o refugees
o actively in foster or out-of-home care
o parents/caregivers of a trauma-exposed child
 Trauma exposure:
o act of terrorism
o Outside of United States

TARGET USERS
 Behavioral specialists
 Mental health professionals
 Psychologists
 Community stakeholders
 Parents/caregivers
 Facilitators of community programming
 Occupational therapists

EVIDENCE SYNTHESIS
Background:
The effects of trauma on the individual’s health have been well researched over the years, where
it has been found that childhood traumatic events correlate with numerous health outcomes over
the lifespan, including: alterations in brain development, deterioration in cardiovascular
functioning, difficulties with behavioral and mental health, and pre-morbidity. A variety of
interventions have been implemented across settings to support the physical and mental healing
process from childhood traumatic events. The majority of these interventions are based in the
fields of psychology and medicine, and predominantly are offered through traditional medical
clinics. There currently is limited evidence on interventions being implemented by other allied
health professionals, such as occupational therapy and social work; and while there is a general
consensus across these professions that trauma-informed intervention is valid and beneficial for
vulnerable children, there is little research available on interventions that are being provided in
accessible settings outside of medical offices. It is known that the risk of exposure to a traumatic
event is high among those who are of low-income and uninsured (McCauley et al., 1997;
Medrano et al., 2004), as well as that impoverished children are twice as likely not to access any
form of health care (Institute for Research on Poverty, n.d.). It is also known that one in three
children in the United States will have at least one adverse childhood experience before they turn
eighteen (Health Resources & Services Administration [HRSA], 2019). With this in mind, it is
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critical to raise awareness and understanding of what communities and stakeholders can be doing
to intervene directly with children while in these vulnerable positions in order to provide more
proactive and effective treatment in the shadows of trauma. This synthesis is to help inform
individuals on the community-based interventions being implemented in effort to support the
healing process of children who have been exposed to traumatic events.

Synthesis of Evidence:
A scoping review was completed according to the Preferred Reporting Items for Systematic
Reviews (PRISMA or PRISMA-ScR). Five databases were searched within the time frame of
July 2019-September 2019: CINAHL, PubMed, Cochrane Library, Embase, and PsychInfo.
Search terms were P= child* OR youth OR adolescents OR teenager AND trauma-informed OR
traumatic event OR traumatic experience OR stress; C= intervention OR treatment OR therapy
OR program OR strategy OR approach; C= community*. Initial search strategies included:
(children OR adolescents OR youth OR child OR teenager) AND (trauma informed care or
trauma informed practice or trauma or trauma informed approach) AND (intervention or
treatment or therapy or program or strategy or approach) AND community-based; and on
CINAHL only: (children or adolescents or youth or child or teenager) AND (traumatic events or
traumatic experience or stress*) AND (intervention or treatment or therapy or program or
strategy or service* or approach) AND commun* NOT brain injur*. A second search strategy
was generated after recognizing the need to expand the population search terms to include
children who have been exposed to traumatic events, or adverse childhood experiences, that
would meet this review’s inclusion criteria for trauma. The following search strategy was
additionally applied to all five databases in September 2019: (child or youth or children) AND
(trauma OR adverse childhood experiences OR aces OR toxic stress) AND (intervention or
program or treatment) AND community.

Studies were all peer-reviewed, intervention-based, and conducted in the United States. Study
designs included: randomized control trials, quasi-experimental, prospective cohort studies, and
longitudinal studies. Participants were between the ages of two and 18 years old and presented
with either confirmed or reasonably assumed exposure to a traumatic event. Traumatic events
were defined as: chronic psychological stress, abuse (psychical, verbal, emotional, sexual,
spiritual), drug/substance exposure, poverty (homelessness, chronic hunger), neglect, primary
caregiver separation or death, violence exposure (intimate partner, domestic, community). All
studies were implemented through after-school programs, summer programs, recreation centers,
local facilities, non-profit organizations, or community-partnerships. Outcome measures of
included studies consisted of psychological functioning of the participant, problematic behaviors,
self-esteem, family and social engagement, and processing and/or expression of emotions.
Studies were excluded if 1) the intervention occurred in a hospital, clinic, school, or private
home setting, 2) participants of the intervention were child-soldiers, refugees, actively in foster
or out-of-home care, or parents/caregivers of a child, 3) the article was unavailable in English, 4)
trauma was a result of exposure to an act of terrorism, and 5) the primary outcome of the study
was feasibility or economic costs of intervention implementation.
A total of 1,837 articles were retrieved across the five databases and 395 duplicate articles were
removed. This left 1,442 articles to be screened, of which 1,346 were excluded for unmet criteria
or irrelevance. 96 articles underwent full-text review for eligibility. This included a detailed

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review of three systematic reviews, of which articles within the systematic review that met
inclusion criteria were included independently via hand-searching in this scoping review.
Additionally, three research poster abstracts were excluded during full-text review due to the
full-text study not being publicly available. A total of 16 articles met inclusion criteria and were
included in the final review. Information on the selection of evidence is summarized in Figure 1.
PRISMA Diagram (Appendix E, page 52).
Evidence from the 16 included articles was examined through thematic and numeric analysis.
Fourteen of the 16 included articles were rated by level of evidence, according to the Oxford
Centre of Evidence-based Medicine levels (OCEBM; Figure 3, Appendix A, page 54; n.d.),
utilized within the LEGEND evidence appraisal forms made available through Cincinnati
Children’s Hospital Medical Center (CCHMC; 2012). Two articles (Griese et al., 2018; and
Humensky et al., 2013) were not rated on level of evidence as these articles were descriptive in
nature and did not include study data. Of the fourteen articles, one article was at the 2a level
(Cohen et al., 2011), three articles at the 3a level (Beltran et al., 2016; Hoskins et al., 2018; and
Patterson et al., 2018), three articles at the 3b level (Allen & Solomon, 2012; Allen &
Hoskowitz, 2017; and Salloum et al., 2001), six articles at the 4a level (Becker et al., 2011;
Goodkind et al., 2012; Kiser et al., 2015; Vankanegan et al., 2019; Webb et al., 2014; and Young
et al., 2018), and one articles at the 4b level (Suarez et al., 2014).
Three broad types of interventions were identified across articles, including: psychotherapeutic
approaches, activity-based approaches, and local or culturally sensitive. The most numerous of
studies, as well as studies of the strongest evidence, utilized psychotherapeutic approaches to
intervention. Within the psychotherapeutic approaches, seven studies either implemented group
psychotherapy (for grief and healing, or yoga-based), or implemented trauma-focused cognitive
behavioral therapy (TF-CBT). There were four interventions classified as activity-based, which
included: adventure therapy, play, yoga, and educational entertainment. Eight studies
implemented culturally sensitive interventions, modeled specifically for the community. These
culturally sensitive interventions recognized American Indian customs, Native Hawaiian culture,
Latino/Hispanic communities, and multi-cultural dynamics on an urban neighborhood. A few
studies were accounted for under two different types of intervention as a result of complex
intervention design. A synthesis of results is described in relation to the themes identified
through the concept map and thematic analysis, reported in Figure 2. Concept Map (Appendix A,
page 53) and Table 3. Thematic and Numeric Analysis (Appendix A, page 31).

Critical appraisal of all studies for methodological quality was completed using the SIGN
methodology checklist and LEGEND evidence appraisal forms that corresponded with the
appropriate study design of each study (Appendix E, Figure 4, page 70; and Appendix E, Figure
5, page 72). Level of evidence was determined for fourteen of the sixteen included articles,
according to the OCEBM levels (Figure 3, Appendix A, Page 54; n.d.). Levels of evidence
across the review ranged from the 2a level to the 4b level, with six of the fourteen articles being
of level 3, and seven articles being of level 4. Information on the methodological quality of the
studies is summarized in Table 1. Evidence Summary (Appendix A and Page 22).
Individual bias assessments were completed for 14 articles, excluding Griese et al., 2018 and
Humensky et al., 2013, using the Cochrane Assessment of Bias table (Higgins et al., 2011). This
bias assessment rated each article either low or high in risk of bias based on the following
categories: random sequence generation, allocation concealment, blinding of participants and

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personnel, blinding of outcome assessments, incomplete accounting of outcome events, selective
outcome reporting, other potential biases, and overall bias. The risk of bias for individual
evidence sources is reported in Table 2. Cochrane Bias Assessment (Appendix A, page 30).
A synthesis of results is described in relation to the themes identified through the concept map
(All & Havens, 1997) and thematic analysis, reported in Figure 2. Concept Map and Table 3.
Thematic and Numeric Analysis (Appendix A, pages 53 and 31, respectively). Three broad types
of interventions were identified, including: psychotherapeutic approaches, activity-based
approaches, and local or culturally sensitive.

Overall, the literature is in support of community-based interventions for children with trauma
that are encompassing the unique characteristics and factors attributed to the targeted population,
are addressing psychological functioning, are structured in group settings, offer lessons that are
appropriate for the age and development of the individual, and are implemented for a pre-
determined length of time. The most frequented type of intervention included in this review
utilized a treatment approach that was culturally and locally responsive to a specific targeted
population. Although these populations varied both geographically and circumstantially, all
interventions were developed on a foundation of understanding of the population’s unique
characteristics. The next most populous of intervention type was the use of psychotherapeutic
approaches. Four studies extended further into psychotherapy to specifically utilize mindfulness-
based, yoga-based, or trauma-informed cognitive behavioral approaches. The third type of
intervention approach was activity-based, of which the four studies revealed promising results in
the overlap between active or physical engagement and psychological healing. When analyzing
intervention design, it is evident that the majority [12] of community-based interventions are
utilizing groups rather than individual treatment sessions. Analyzing the design further, half of
the interventions addressed only the child, while the other half of studies involved caregivers or
families into at least some component of the intervention. It should be noted that even those
programs incorporating caregivers and families utilized breakout sessions for age and
developmentally appropriate teaching lessons on trauma healing topics. The reasoning for
including families or not is unclear, and further research is recommended to determine if family
and/or caregiver involvement would be of further benefit. The strongest evidence was found
across interventions where all participants received a pre-determined number of treatment
sessions. The average length of intervention was 12.7 weekly sessions across the literature
available for implementing interventions with a blocked number of sessions.

Conclusions:
For children with histories of psychological trauma, there are a variety of community-based
intervention approaches that share in common factors, that support the healing and recovery from
traumatic events. The key elements of intervention include being locally and culturally sensitive,
psychotherapeutic approaches, group treatment settings, and consistent and scheduled sessions.
The key knowledge gaps lie in 1) High quality evidence (identifying and rigorously testing
programs with some evidence of success), 2) Benefit of incorporating families and caregivers,
and 3) Sustaining engagement of families and children for structured intervention in the
community setting.

NEEDS ASSESSMENT

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Pre-Experience Needs Assessment:
The experience setting is in Cincinnati, Ohio through the structure of Back2Back Ministries’
community-based programming. Back2Back Ministries is an international Christian non-profit
organization that has dedicated itself for over twenty years to addressing the spiritual, physical,
educational, emotional and social needs of orphaned and vulnerable children (Back2Back
Ministries, n.d.b) through what is referred to has the five-point holistic child developmental
model. International sites include: Monterrey, Mexico; Cancun, Mexico; Mazatlán, Mexico;
Hyderabad, India; Jos, Nigeria; and Port-Au-Prince, Haiti. Efforts have begun domestically in
Cincinnati as of 2018 as it was recognized that Cincinnati has one of the leading rates for
childhood poverty across the nation. Currently Back2Back Cincinnati engages in various
programming through partnership with other local operations, such as Boys and Girls Club, Bloc
Ministries, and Young Life Rising Leaders. Focus has currently been placed on establishing
partnerships with community partners who already have programming, resources, and facilities
in place in areas of need in order to strengthen and broaden the network of existing community-
based programs for children with trauma-inflicted histories. For the purpose of this capstone, the
primary program of interest is Bloc, which is owned and directed by Bloc Ministries; and is
designed to offer a safe space for after-school group activities, school tutoring, and reading
intervention for youth in the urban neighborhood of Price Hill located on the West side of
Cincinnati.
There is a pertinent need for trauma-informed interventions across Cincinnati, and particularly
within the community of Price Hill. According to the City of Cincinnati Health Department
(CHD), Price Hill was identified as one of the top three most vulnerable neighborhoods in
Cincinnati with the greatest health disparity and needs (2017). Approximately 44.5% of the
population in Price Hill lives at or below the poverty line (CHD, 2014). Additionally, nearly a
third (31.1%) of all children living in Cincinnati have experienced at least two adverse childhood
events, compared to the national average of 22.6% (Child & Adolescent Measurement Initiative,
2016). These factors are likely contributors to the fact that homicide is the leading cause of death
among adolescents in Cincinnati (CHD, 2017). It is evident that the children of Cincinnati are
not only surrounded by hard circumstances but are also early victims of various trauma
experiences such as poverty, abuse, and community violence. With extremely limited access to
trauma-informed health services, children in vulnerable neighborhoods of Cincinnati, like Price
Hill, have little opportunity to process and heal from their trauma which often leads to the child
continuing the cycle and inflicting more trauma.
During initial discussion with site mentors and key staff members at Back2Back Cincinnati,
Chris Cox (Cincinnati Director) and Katie Evans (Care and Compentency Coordinator) and
Stephanie Powers (Social Worker and Intern Coordinator), several priorities for intervention
were identified. Two in-person meetings and one phone call were completed for the purpose of
assessing the needs of the site and potential projects or involvements (Appendix B, page 54).
Areas of priority include: promoting self-regulation through environment adaptations and
activities in all programming, incorporating occupational therapy intervention recommendations
into the trauma-informed care training programs, designing a sensory-supportive education
center, performing a community analysis to better understand community needs and engage
families, and educating staff and stakeholders on evidence-based practice for trauma-informed
care. The largest area of concern in relation to intervention is self-regulation strategies in order
for children to be successful participants in program activities and educational tutoring.

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Participants are frequently dysregulated upon arrival to programming due to threatening school
environments and harmful or unsupportive home circumstances. Additionally, many participants
exhibit sensory seeking behaviors, particularly for touch and proprioception input. The expressed
needs of the site align well with the objective of implementing a trauma-informed intervention
designed to match the cultural priorities of Price Hill and be rooted in psychotherapeutic
approaches to promote mindfulness, coping strategies, and self-regulation.
As mentioned previously, Back2Back Cincinnati is currently targeting the Price Hill childhood
population through a partnership with Bloc Ministries at the Bloc after-school programming. The
facility is a repurposed multi-family housing unit that has been designed to have a relatively
open space (approximately 15’ by 30’), as well as a small “homework center” room and
bathroom. The second story of the facility is reserved for housing purposes for Bloc Ministries
staff. On Mondays, children with parental consent attend for one hour of reading tutoring which
is exclusively operated by Back2Back Cincinnati. From Tuesday through Thursday for two
hours per day every week, Bloc hosts after-school programming where children ages 4-18 are
able to play games, work on homework, socialize, and receive a hot meal. The majority of
attending children live within a two-block radius of the facility and typically walk to/from
programming. The structure of the program is relatively informal where no parental consent or
presence is required for participation, attendance is not monitored, and children are able to come
and go as they please. Bloc Ministries’ objective for the program is to offer a trusted and safe
space within the community of Price Hill for children to be nurtured. The current design and
structure of Bloc poses several barriers towards implementation of an intervention program.

Integration of Evidence Synthesis with Needs Assessment:

A trauma-informed intervention program was unable to be implemented at this time. There are
multiple factors impacting the ability for implementation, but the largest barriers are the infancy
of relationship forming with local parents and caregivers, and the dynamic standing partnership
that is not prepared to embrace a program with an organized approach and targeted treatment
goals at the Bloc facility.

Onsite Implementation Needs:

An in-depth implementation analysis is needed in order to further understanding the perceived
acceptability and feasibility of a structured trauma-informed intervention being offered for
vulnerable children in Price Hill and Cincinnati as a whole. Analysis will be completed via
informal communication with staff, objective surveys, and observational assessment of current
resources and space available. Since Back2Back Cincinnati staff represents a variety of
professions and backgrounds, there is likely great variance in the beliefs around how best to
intervene with children in a trauma-informed way. Results from the implementation analysis will
help guide recommendations in regard to potential partnership changes, new facility and staff
acquisition, and further education or training opportunities that may be essential for effectively
implementing this type of intervention.

CASE STUDY IMPLEMENTATION

The proposed intervention, guided by literature, is a twelve-week program in which caregivers
and children attend to explore relational factors, mindfulness techniques, and self-regulation
skills to promote the healing and prevention of psychological trauma caused by adverse events.

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Each session will begin with a family-style meal, followed by breakout education and activity
sessions, and concluded with group games to support social functioning. This community-based
trauma-informed intervention approach was not implementable at the facility during the time of
this capstone experience. Therefore, an implementation analysis was completed to examine
adoptability, appropriateness, and feasibility for future implementation of an adapted
intervention. A variety of roles contributed to the analysis, including: the Back2Back Cincinnati
site director, a care and competency coordinator, two social workers, a mental health counselor, a
child mentor, and an education specialist.

As part of preparing for future implementation of such an intervention, a neighborhood mapping

team was established to begin understanding the needs, values, and priorities of the local
community. Team members include a social worker, counselor, coach/mentor, and occupational
therapy capstone student. Through neighborhood mapping, the efforts of implementing a local
and culturally sensitive intervention will be more effective, while also making a conscious effort
to connect local families with valuable resources for sustained development and healing from
trauma.

OUTCOMES
An analysis of implementation was conducted to assess facilitators and barriers of successful
implementation of a community-based, family-centered intervention. Primary implementation
outcomes assessed were acceptability, appropriateness, and feasibility through the adoption of
the Weiner et al. psychometric assessment measures (2017). Overall, respondents were most
accepting of the proposed intervention, with an average score of 4.53 out of 5 which equates to
being between agree and strongly agree. Appropriateness of the intervention in relation to
matching the needs of community and fit to the setting was rated an average of 4.07 of 5,
indicating in general staff agreed with the appropriateness. The lowest scoring implementation
outcome was feasibility, with a score of 3.64 out of 5. This result can be interpreted as the staff is
undecided or apprehensive about the feasibility of implementing an intervention of this approach
at this time. To further analyze the facilitators and barriers towards implementation, a Google
form survey (Appendix E, Figure 6, page 76) was utilized to determine the perceived beliefs of
what factors are most greatly influencing the feasibility of implementation. Through multiple-
choice and/or fill-in response options, responding staff were encouraged to identify the top three
perceived facilitators and barriers. the three factors identified as the largest barriers to
implementation include attendance consistency of children and caregivers, Bloc Ministries
partnership buy-in or approval, and space limitations and/or facility access. Partnership buy-in
and facility access hold a strong association as the current facility is owned and operated by the
partner, therefore partnership support is critical for being able to utilize the facility. The three
largest facilitators towards implementation include access to resources and materials, available
staff, and staff education and/or training around the topic of trauma-informed care. Through
survey responses and additional informal interviews with staff members, it has been identified
that one of the main priorities towards implementation should be to continue furthering trust with
the Bloc partnership staff as well as local families for the purpose of establishing a collaborative
environment with a program driven by community support and motivation for change.
Additionally, it was identified that the pathway and objectives of implementing the proposed
intervention program aligned with the Back2Back Ministries’ system for implementing their
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international Strong Families Program (SFP). Back2Back’s SFP is designed to be a system of
holistic care and tools to work with families living in poverty in order to accomplish
developmental goals and establish healthier lives (Back2Back Ministries, n.d.a). Principles of
SFP include partnership, holistic care, asset-based community development, sustainability,
empowerment, and family ownership, which align closely with the proposal guided by literature
which emphasizes incorporating families, acknowledging the needs and desires of the local
community, and empowering children and families through self-regulation and trauma healing.
Therefore, recommendations and planning for implementation of the proposed program were
developed concurrently with recommendations for implementation of the SFP with the
likelihood that the proposed program will fall within the SFP overtime. Primary steps towards
implementation were taken through the neighborhood mapping team hosting the entire
Back2Back Cincinnati staff at a training event with the developers of the SFP. At this event, the
staff completed five modules of training and were educated on the two phases of program
implementation to ensure program development is asset-based and culturally-sensitive
(Appendix E, Figure 7, page 80).
RECOMMENDATIONS
Implementation strategies were derived from the implementation recommendations of Proctor,
Powell, & McMillen (2013). A detailed description of the strategy participants, timeline, and
justification are included in Table 4. Implementation Strategies (Appendix E, page 67).
Therefore, based upon the scoping review, needs assessment, and implementation analysis the
following implementation strategies are recommended for implementation in Price Hill through
Back2Back Cincinnati:
Family Engagement Strategy: In order to strengthen the acceptability, feasibility, and
sustainability of the intervention program, it is essential to increase family engagement
with staff members responsible for leading the program. Through increased engagement,
families will be more relationally invested which grows trust of the organization’s
members, as well as the intervention approaches the organization desires to implement.
Engaging families will be accomplished through walking children home after attending
Bloc after-school programming in order to meet and communicate with parents.
Invitation will be extended for parents to come to the Bloc facility during programming
hours in the effort to connect parents not only with staff members, but also with other
parents in a mutual setting. As a result of informal conversations and frequent face-to-
face touchpoints with local families, it is anticipated that caregivers and children will be
more invested and trusting of the program offerings by Back2Back staff members and
therefore will make greater effort to attend the intervention programming on a consistent
basis.

Facility Access Strategy: For the purpose of gaining facility access for implementation of
the program, this strategy targets the interorganizational relationship between Back2Back
Cincinnati and Bloc Ministries. Open and regular communication between the site
directors of both organizations is recommended in order to increase trust and
understanding of each other’s efforts. Through this communication, it is anticipated the
two organizations can come to a mutual agreement on utilizing the facility for the
implementation of program outside of current programming hours for the overall benefit

9
 of local families. The outcome of this strategy will increase feasibility of the intervention
within the operations of the current partnership within the Price Hill community.

SUMMARY AND CONCLUSIONS

The proposed intervention is a twelve-week program located in the community of Price Hill, in
which caregivers and children will attend to explore relational factors, mindfulness techniques,
and self-regulation skills to promote the healing and prevention of psychological trauma caused
by adverse events. Elements of the program include a family-style meal, breakout education and
activity sessions, and group games to support social functioning. Ultimately, the proposal for a
community-based intervention program that incorporates trauma-informed psychotherapeutic
approaches in a family-based context has the potential of meeting the needs of Back2Back
Cincinnati at the Price Hill site with the adoption of a few recommendations to overcome current
implementation barriers. The factors impacting implementation of the intervention program at
this time include the approval and willingness of the current partner organization to operate a
structured intervention, access to a facility to be used for the program, and participation and
consistency of attendance by local children and families. Throughout the implementation
analysis process, it was recognized that the Strong Families Program utilized internationally by
Back2Back Ministries aligned significantly with the objectives of the proposed intervention
program and is a probable forum for future implementation in Cincinnati. Therefore, it is
recommended that Back2Back Cincinnati continue to adopt the Strong Families Program at the
Cincinnati site and have appointed staff complete all training modules for implementation.
Recommendations towards implementation of the intervention program are written with respect
to the terminology and temporality of the phases for implementing the Strong Families Program
in its entirety, as it is anticipated that the intervention program will best fit under the umbrella of
this program model. Initial steps have been taken towards implementation through the formation
of a neighborhood mapping team, which is tasked with identifying available resources and
establishing networks between Back2Back Cincinnati, local residents, and community
stakeholders. Next steps should be to start engaging in conversations with these individuals in
order to more clearly identify the needs, values, and priorities of the community in order to mold
the intervention program to be local and culturally sensitive. Additional next steps are to invest
in more frequent, open communication with the site director at Bloc Ministries to further
determine the probability of gaining Bloc Ministries’ support and utilizing their facility for the
intervention program. The outcome of these conversations will determine the ability to move
forward with the current partnership, or if there is a need to pursue other partnerships in order to
implement the intervention. Although there are numerous steps and strategies to be completed
before the proposed program can fully be implemented, the overall value and benefits that this
program has to offer greatly outweigh the burden. Through the implementation of the
intervention program, children and families have the potential to grow in self-regulation and
mindfulness skills, improve family relationships, understand the causes and effects of trauma,
and invest in the overall health of themselves and their community.

10
 Appendix A: Scoping Review

Community-Based Interventions for Children with Trauma

Backgrounds: A Scoping Review
ABSTRACT
BACKGROUND: Psychological trauma as a result of traumatic events such as abuse, neglect,
violence, chronic stress, and poverty, has been found to negatively impact children’s
development in a variety of ways. Current interventions are primarily being implemented within
the field of psychology and occur in traditional medical settings. Although there is significant
research on the impact of trauma and effective medical trauma-informed interventions, less is
known about interventions that are being implemented in community-based settings that are
more accessible and supportive of trauma-exposed children navigating life within their natural
environment. OBJECTIVE: This scoping review aims to explore and summarize the evidence
found in literature on trauma-informed interventions for children that are being implemented
within communities across the United States. METHODS: A scoping review was completed
according to the Preferred Reporting Items for Scoping Reviews (PRISMA). Included studies
were critically appraised and assessed for methodological quality using the SIGN methodology
checklist and LEGEND evidence appraisal forms. Bias of studies was analyzed and documented
through the Cochrane Assessment of Bias table. A concept map was developed to analyze types
of intervention, design of intervention, length of intervention, and targeted populations, which
helped to guide the thematic and Numeric analyses of all studies. RESULTS: A total of 1,837
articles were retrieved across the five databases between July 2019 and September 2019. Sixteen
articles met inclusion criteria and were included in the final review. Three broad types of
interventions were identified, including: psychotherapeutic approaches, activity-based
approaches, and local or culturally sensitive. The majority of interventions were conducted in
group settings. Half of the interventions incorporated caregiver or families into the intervention,
yet most of these designs still utilized separate breakout sessions for treatment and education.
The average reported length of intervention across studies was 10.62 sessions. Quality of
available evidence remains weak largely due to the lack of randomized control trials, as well as
limited awareness of the importance of community-based approaches to intervention.
CONCLUSION: This scoping review indicates that interventions should occur regularly over a
course of about three months, and should not only concentrate on psychology treatment, but also
address the personal, cultural, and environmental factors that influence the child’s mental
functioning. Components of intervention should focus on coping skills, self-regulation, and
social skills development.

INTRODUCTION
One in three children in the United States have experienced at least one potentially traumatic
event, classified as an adverse childhood experience (ACE), before their eighteenth birthday
(HRSA, 2019). According to the 2018 National Survey of Children’s Health (NSCH), the most
11
prevalent ACE in children’s lives is the separation from or loss of a caregiver, followed by living
in a household with a drug or alcohol problem (NSCH, 2018). Additionally, approximately half
(50.3%) of all U.S. children received some form of mental health treatment or counseling over
the past two years (Data Resource Center for Child & Adolescent Health, 2018). Hundreds of
studies across numerous professions have investigated the impact trauma has on the developing
child, and the results are astounding. Exposure to violence, abuse, neglect, poverty, toxic stress,
and other forms of traumatic events can cause a series of health problems that have lasting
effects well into adulthood, including: altered brain development (Perry, 2006), onset of mental
health disorders (Herzog and Schmahl, 2018), hypertension, heart disease, other decline in
essential organ systems (American Academy of Pediatrics, 2014), and even pre-morbidity. But
not all outlooks for children exposed to traumatic events have to be negative. With the right
balance of protective factors, nurturing environments, and healing interventions, children can
learn techniques for overcoming the sentence trauma writes and grow into resilient individuals
with bright futures.

The term “trauma-informed” has become a buzz word across not only the medical profession,
but also educational systems, workplaces, and political platforms over the past several years. To
be trauma-informed means to acknowledge the variety of traumas that many people within the
organization may have experienced and target change in health, behavior, and environment in
order to promote resilience and empowerment for all individuals involved (Substance Abuse and
Mental Health Services Association, n.d.). According to the Substance Abuse and Mental Health
Services Association (SAMHSA), a system can be identified as trauma-informed when it
achieves all four R’s of the trauma-informed care (TIC) framework: Realize the impact of
trauma, Recognize the signs and symptoms of trauma, Respond by integrating knowledge of
trauma into policy, procedures, and practices, and actively Resist re-traumatization (2015). Many
school districts have embraced the trauma-informed approach to education by changing policies
and procedures that allow for the school setting to be more sensitive of trauma and for students
to feel more protected by staff and peers. School districts have implemented a variety of trauma-
informed elements, such as: self-regulation strategies throughout the school day, exploring
alternatives to suspensions or expulsions, and restructuring the classroom and overall school
environment to be more predictable and safer for all students (Ohio Department of Education,
2019). Medical settings are also transitioning to be more trauma-informed through the
incorporation of universal trauma-screenings, the utilization of trauma-sensitive communication
by staff, increased interprofessional collaboration for more well-rounded care, and adjustments
in the medical environment to reduce anxiety and stress (Raja et al., 2015). Because traumatic
events such as caregiver separation, abuse, neglect, and poverty are unfortunately not expected to
be eradicated any time soon, and with the rise in violence, poverty, terrorism, and refugee
immigration across the world, it is critical for us to continuously evolve into a trauma-informed
society and implement appropriate interventions in order to support the hundreds of thousands of
children victimized by trauma.

Current research on effective interventions for children with backgrounds penetrated by trauma
primarily rests within the field of psychology. Cognitive behavioral therapy (CBT), and more
specifically trauma-focused cognitive behavioral therapy (TF-CBT), have been recognized as
one of the most promising interventions for improving behavior and emotion regulation

12
following a traumatic event. According to the TF-CBT National Therapist Certification Program,
over twenty randomized-controlled trials have been conducted to assess the effectiveness of TF-
CBT, of which all studies found TF-CBT to produce superior results against comparison groups
for improving the symptoms and responses of trauma in children (n.d.). While this form of
cognitive behavioral therapy has been proven to be highly effective in improving the outcomes
of trauma, access to a certified mental health professional is limited, particularly for those
children who are most susceptible to trauma. Other promising interventions include child-parent
psychotherapy, attachment therapy, and integrative therapies (The National Child Traumatic
Stress Network, 2018). All of these intervention approaches share in the incorporation of
cognitive theories and target behavioral outcomes. Research has also revealed that beginning
prenatally, child development is a result of ongoing, inextricable interactions between biology
and ecology, that is one’s genetic and physiological predispositions and one’s social and physical
environments (Bronfenbrenner, 1979; Sameroff et al., 1975; and Shonkoff & Phillips, 2000).
While the effectiveness of the TF-CBT and other psychological interventions cannot be ignored,
it is clear that there lacks an approach that not only addresses the psychological healing of the
individual, but also takes into consideration the dynamic contexts of daily living, including one’s
physical and social environments which have been shown to influence development just as
significantly.

Because the majority of trauma-informed interventions are currently being implemented within
the realm of medicine and psychology, which often limits itself to traditional medical offices,
there is a lack of intervention expanding into the local communities and accessible by vulnerable
populations. According to the Institute for Research on Poverty, children experiencing poverty
are more than twice as likely not to access any form of health care compared to non-
impoverished children (n.d.); and the likelihood of experiencing a traumatic event is common
among low-income, uninsured patients (McCauley et al., 1997; Medrano et al., 2004).
Additionally, when considering the various types of traumatic events that children are exposed
to, most often these events occur within the child’s home or local neighborhood. This brings rise
the question, what is being done to support these children when they’re in their most vulnerable
environment? There is a need for trauma-informed interventions to be implemented within the
community in which these children are trying to navigate, as it is here that the child has become
victim to trauma, and it is here that the child is expected to grow and develop. If interventions are
being designed and implemented in order to help a child process and overcome the impacts of a
traumatic event, it is important that the intervention also takes into consideration the
environmental and social factors that communities present which significantly impact the
individual.

The purpose of this scoping review is to explore and summarize the evidence found in literature
on trauma-informed interventions for children that are being implemented within communities
across the United States. The hope for this review is to both highlight those interventions that are
transforming trauma-informed care out of the medical model and into a more holistic approach,
and to bring awareness to the needs in research and clinical practice for continued improvement
in the way society addresses trauma in the developing child.

METHODS

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Study design and research question
This study is a scoping review completed according to the Preferred Reporting Items for Scoping
Reviews (PRISMA). The objective of this review is to explore how organizations are taking
action to intervene and care for the children at the community level who are living with chronic
effects of psychological trauma. This, the PCC question which guided the review was: What
community-based interventions are being used to support children with history of trauma?

Eligibility criteria
Studies in this review met eligibility criteria as follows: 1) peer-reviewed, 2) intervention-based
articles, 3) participants ages 2-18 years old with confirmed or reasonably assumed exposure to a
traumatic event. For the purpose of this review, traumatic events were defined as: chronic
psychological stress, abuse (physical, verbal, emotional, sexual, spiritual), drug/substance
exposure, poverty (homelessness, chronic hunger), neglect, primary caregiver separation or
death, or violence exposure (intimate partner, domestic, community). All included studies were
conducted within the United States and were implemented through after-school programs,
summer programs, recreation centers, local facilities, non-profit organizations, or community-
partnerships. Outcome measures of included studies consisted of psychological functioning of
the participant, problematic behaviors, self-esteem, family and social engagement, and
processing and/or expression of emotions. Studies were excluded if 1) the intervention occurred
in a hospital, clinic, school, or private home setting, 2) participants of the intervention were
child-soldiers, refugees, actively in foster or out-of-home care, or parents/caregivers of a child,
3) the article was unavailable in English, 4) trauma was a result of exposure to an act of
terrorism, and 5) the primary outcome of the study was feasibility or economic costs of
intervention implementation.

Search strategy
The following five databases were searched within the time frame of July 2019-September 2019:
CINAHL, PubMed, Cochrane Library, Embase, and PsychInfo. Search terms were P= child* OR
youth OR adolescents OR teenager AND trauma-informed OR traumatic event OR traumatic
experience OR stress; C= intervention OR treatment OR therapy OR program OR strategy OR
approach; C= community*. Initial search strategies included: (children OR adolescents OR youth
OR child OR teenager) AND (trauma informed care or trauma informed practice or trauma or
trauma informed approach) AND (intervention or treatment or therapy or program or strategy or
approach) AND community-based; and on CINAHL only: (children or adolescents or youth or
child or teenager) AND (traumatic events or traumatic experience or stress*) AND (intervention
or treatment or therapy or program or strategy or service* or approach) AND commun* NOT
brain injur*. A second search strategy was generated after recognizing the need to expand the
population search terms to include children who have been exposed to traumatic events, or
adverse childhood experiences, that would meet this review’s inclusion criteria for trauma. The
following search strategy was additionally applied to all five databases in September 2019: (child
or youth or children) AND (trauma OR adverse childhood experiences OR aces OR toxic stress)
AND (intervention or program or treatment) AND community.

Selection of Sources

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Sources for evidence gathering were selected based on recommendation of advising faculty
members and prior knowledge of widely accessed sources for relevant research studies. The
author, who served as the primary investigator, was responsible for title and abstract screening,
as well as full text review of all obtained studies. When search strategy or articles were in
question for inclusion, the advisor overseeing the conduction of this review or one peer reviewer
were consulted.
Data charting and management
Articles were managed using Cochrane’s web-based research review platform, Covidence
(Covidence Systematic Review Software, n.d.). All articles retrieved using the search strategies
of the five databases were uploaded to Covidence for title and abstract screening and full-text
review. Following full-text review of studies, studies were critically appraised and assessed for
methodological quality using both the LEGEND evidence appraisal forms made available
through Cincinnati Children’s Hospital Medical Center (CCHMC; 2019) and the methodology
checklists provided by the Scottish Intercollegiate Guidelines Network (SIGN; 2007). The author
of this review independently completed data extraction and critical appraisal of all included
studies. As appraisals were being completed for studies meeting inclusion criteria following the
initial search, it was determined by the author that the inclusion of studies with participants who
could be reasonably assumed to have previous exposure to a psychologically traumatic event was
essential for best representation of the target population since trauma holds a vague and
subjective definition, much less an exact diagnosis. This resulted in a new search strategy to be
developed and applied to all five databases in September of 2019. A total of four more articles
were included in the final review following this secondary search.

Quality of studies and risk of bias

Methodological quality – Methodological quality and appraisal were completed using the SIGN
methodology checklist and LEGEND evidence appraisal forms that corresponded with the
appropriate study design of each study (Appendix E, Figure 4, page 70; and Appendix E, Figure
5, page 72).

Bias Assessment –Bias of all studies was analyzed and documented through the Cochrane
Assessment of Bias table (Appendix A, Table 2, page 30; Higgins et al., 2011).

Synthesis of information: A concept map was developed with the primary thematic arrangement
being characteristics of approach to intervention branching off the central spoke of community-
based supports for children with trauma. The main defining characteristics include: type of
intervention, intervention design, length of intervention, and target population. Types of
intervention branches further into: psychotherapeutic approaches, activity-based approaches, and
local/ culturally sensitive approaches. Subthemes beyond these broad intervention approaches
further categorized studies, such as yoga-based psychotherapy, or mindfulness-based culturally-
sensitive programs. Intervention designs include: group intervention, individual intervention,
child-only intervention, and family-based intervention. A few studies are represented multiple
times on this characteristic branch due to a multi-component design of intervention. Lengths of
intervention include: one-time session, blocked number of sessions, or continuous sessions as
needed by the child. Lastly, targeted populations specifically identified within studies include:

15
females only, males only, urban neighborhoods, Latino/Hispanic communities, African
American children, and American Indian children.

RESULTS
Included evidence sources
Selection of evidence sources: A total of 1,837 articles were retrieved across the five databases
and 395 duplicate articles were removed. This left 1,442 articles to be screened, of which 1,346
were excluded based on notable irrelevance or unmet criteria. 96 articles underwent full-text
review for eligibility. This included a detailed review of two systematic reviews, of which
articles within the systematic review that met inclusion criteria were included independently via
hand-searching in this scoping review. Additionally, two research poster abstracts were excluded
during full-text review due to the full-text study not being publicly available. A total of 16
articles met inclusion criteria and were included in the final review. Information on the selection
of evidence is summarized in Figure 1. PRISMA Diagram (Appendix A, page 52).

Characteristics of evidence sources: A descriptive analysis is presented of study population, year

of publication, journal of publication, and outcomes. The selected articles were published
between 2001 and 2019 (the criterion was publication from 2000-2019, but no articles published
in 2000 met inclusion criteria). All 16 articles were written by different authors. A few included
authors, such as J.A. Cohen and A. Salloum, have published multiple studies related to trauma-
informed care for children, but these additional publications did not meet inclusion criteria for
this review. Publication of articles was presented across 15 different journals: Alternative
Medicines, Archives of Pediatrics and Adolescent Medicine, Child and Adolescent Social Work,
Child Maltreatment, Couple and Family Psychology: Research and Practice, Death Studies,
Ethnicity and Inequalities in Health and Social Care, Hawai’i Journal of Medicine and Public
Health, Holistic Nursing Practice, International Journal of Play Therapy, Journal of the American
Academy of Child and Adolescent Psychiatry, Journal of Community Psychology, Journal of
Prevention & Intervention in the Community, Psychological Trauma: Theory, Research,
Practice, and Policy [2], and Social Work with Groups.

Interventions described in the articles were implemented across vastly different populations.
Geographical locations, by state, include: California [2], Colorado, Delaware, Hawaii, Illinois,
Louisiana, Maryland [2], New Mexico, New York, Pennsylvania [2], South Carolina, and Texas
[2]. The average reported age of participants in interventions ranged from 8.0- 15.4 years. Four
articles (Griese, Burns, & Farro, 2018; Humensky et al., 2013; Patterson, Stutey, & Dorsey,
2018; and Young, Minami, Aguilar, & Brown, 2018) did not report ages of the participants, but
rather indicated an age range of active or potentially appropriate participants. This range
stretched as young as three years old to as old as 18 years. Identified traumas targeted for
intervention include: bereavement of parent or sibling, community violence, intimate partner
violence, homicide exposure, sexual abuse, or a variety of adverse childhood experiences
(ACEs). Ethnic and cultural populations explicitly identified across studies include: African
American, Latino/Hispanic, American Indian, native Hawaiian, multi-cultural, urban
neighborhoods, low-socioeconomic status, and impoverished. Interventions addressed a variety
of behavioral and emotional outcomes, including: PTSD symptoms, externalizing behaviors,

16
internalizing behaviors, anxiety, depression, suicidal ideation, family functioning, and self-
esteem.

Methodological quality and risk of bias in included studies:

Fourteen of the 16 included articles were rated by level of evidence, according to the Oxford
Centre of Evidence-based Medicine levels (OCEBM; Figure 3, Appendix A, Page 54; n.d.),
utilized within the LEGEND evidence appraisal forms made available through CCHMC (2019).
Two articles (Griese et al., 2018; and Humensky et al., 2013) were not rated on level of evidence
as these articles were descriptive papers on an intervention program and did not include study
data. This review includes one article at the 2a level (Cohen et al., 2011), three articles at the 3a
level (Beltran et al., 2016; Hoskins et al., 2018; and Patterson et al., 2018), three articles at the 3b
level (Allen & Solomon, 2012; Allen & Hoskowitz, 2017; and Salloum et al., 2001), six articles
at the 4a level (Becker et al., 2011; Goodkind et al., 2012; Kiser et al., 2015; Vankanegan et al.,
2019; Webb et al., 2014; and Young et al., 2018), and one articles at the 4b level (Suarez et al.,
2014). Study designs include: randomized control trial [1], quasi-experimental [1], prospective
intervention cohort [4], and longitudinal [8]. Intervention approaches include: local/culturally
sensitive group psychoeducation [5], trauma-focused cognitive behavioral therapy [3], grief and
healing group therapy [2], adventure therapy [1], educational entertainment [1], family-centered
therapy [1], mindfulness-based psychotherapy [1], play therapy [1], and yoga-based group
psychotherapy [1]. Length of intervention ranged from a single 1.50-hour session (Educational
Entertainment, Allen & Solomon, 2012) to 27 weekly sessions (American Indian tribal
psychoeducation, Goodkind et al., 2012). The average length of intervention across all (12
reported) studies was 10.62 sessions. Information on the methodological quality of the studies is
summarized in Table 1. Evidence Summary (Appendix A and Page 22).

Individual bias assessments were completed for 14 articles, excluding Griese et al., 2018 and
Humensky et al., 2013, using the Cochrane Assessment of Bias table (Higgins et al., 2011). This
bias assessment rated each article either low or high in risk of bias based on the following
categories: random sequence generation, allocation concealment, blinding of participants and
personnel, blinding of outcome assessments, incomplete accounting of outcome events, selective
outcome reporting, other potential biases, and overall bias. 13 articles were rated with an overall
high risk of bias, and one article was rated an overall low risk of bias. The most commonly
identified biases were: blinding of participants and personnel, and blinding of outcome
assessment. Only one article (Cohen et al., 2011) performed random sequence generation and
allocation concealment when establishing treatment groups. Additionally, only two studies
utilized a control group for comparison of results. The risk of bias for individual evidence
sources is reported in Table 2. Cochrane Bias Assessment (Appendix A, page 30).

A synthesis of results is described in relation to the themes identified through the concept map
(All & Havens, 1997) and thematic analysis, reported in Figure 2. Concept Map (Appendix A,
page 53) and Table 3. Thematic and Numeric Analysis (Appendix A, page 31). Three broad
types of interventions were identified, including: psychotherapeutic approaches, activity-based
approaches, and locally or culturally sensitive. Seven of the sixteen studies, including the three
studies of the strongest levels of evidence, utilized psychotherapeutic approaches to intervention.
Within the psychotherapeutic approaches, studies either implemented group psychotherapy (for

17
grief and healing, or yoga-based), or implemented trauma-focused cognitive behavioral therapy
(TF-CBT). Group psychotherapy involves discussing specific problems within a group that can
all relate with the problem and is guided by a psychologist in order to offer guidance and support
(American Psychological Association, n.d.). TF-CBT is a psychotherapeutic intervention that
aims to help individuals overcome the impact of trauma through developing effective coping
strategies and reducing symptoms of depression or anxiety (TF-CBT National Therapist
Certification Program, Rivas-Hermina & Solano, 2014). Of the interventions that were identified
as activity-based, there were three studies that each implemented adventure therapy, yoga, and
edutainment, respectively. Adventure therapy is defined as “the prescriptive use of adventure
experiences provided by mental health professionals, often conducted in natural settings that
kinesthetically engage clients on cognitive, affective, and behavioral levels" (Gass et al., 2012).
Yoga is a Hindu discipline and widely utilized practice for health and relaxation that incorporates
controlled breathing, meditation, and body positioning (Lexico, n.d.).  Educational Entertainment
is defined as the use of dramatic arts are media to “engage the attention, interest, and curiosity of
audience members. Education entertainment involves presentations that purposely seek to
explain, demonstrate, define, and/or compare consequences of different life choices” (Glik et al.,
2002, p. 40). The most numerous of studies [8] implemented local or culturally sensitive
interventions, modeled specifically for the community. For the purpose of this review, local or
culturally sensitive elements are classified as routines, habits, or rituals that are valued by
community members and are passed down through generations. These interventions occurred at
a local site and incorporated cultural elements such as, but not limited to family meals, card
games, equestrian rides, and education on native practices. These culturally sensitive
interventions recognized American Indian customs, Native Hawaiian culture, Latino/Hispanic
communities, and multi-cultural dynamics of an urban neighborhood.

All psychotherapeutic approach studies reported a statistically significant decrease in targeted

outcomes, including: post-traumatic stress symptoms, anxiety, inter- and intra-personal
functioning, family involvement, and internalizing and externalizing behaviors. Studies that
implemented activity-based approaches also reported improvements in outcomes, although these
improvements were not as grossly applied to all outcomes being addressed. Statistically
significant (p < 0.05) improvements in anxiety, coping, and self-efficacy were found for
participants in the single session of Edutainment (Allen & Solomon, 2012), compared to
participants only in group discussion and the non-treatment group. For the adventure therapy
intervention (Vankanegan et al., 2019), significant improvements (p < 0.05) were found for
overall functioning, interpersonal relations, and critical items. Males in this study reported an
increase in social problems as a result of the study, while females reported a decrease. The yoga-
based psychotherapy group (Beltran et al., 2016), which was classified as being both
psychotherapeutic and activity-based approaches, reported statistically significant improvements
(p < 0.05) in all measured outcomes, including: inter- and intra-personal strength, family
involvement, school functioning, and affective strength. Analyzing the local/culturally sensitive
interventions, all studies again reported statistically significant improvements across numerous
outcomes, including: post-traumatic stress symptoms, anger, anxiety, depression, dissociation,
internalizing behaviors, externalizing behaviors, coping strategies, self-perception, quality of life,
school functioning, and self-esteem. Interestingly, Goodkind et al., 2012 also assessed
enculturation as an outcome of the intervention pertaining to American Indian culture, of which

18
it was found there was no change in the perception of enculturation among participants in this
culturally sensitive intervention.

DISCUSSION
The purpose of this scoping review was to summarize the current evidence from literature on
community-based interventions being utilized to support children who have a background in
psychological trauma. Trauma can manifest in many ways, including neglect, abuse, separation
from a caregiver, poverty, exposure to violence, or chronic stress. Intervening with this
population is essential for improving their quality of life and health outcomes, as it has been
found that adults who have endured adverse childhood experiences have elevated numbers of
health risk factors for the leading causes of death in adults (Felitti et al., 2019). A community-
based setting was selected for this scoping review as many children victimized by trauma live in
circumstances in which access to hospitals and medical systems offering trauma-related services
are unavailable due to geographical location, eligibility, payment restrictions, or other personal
factors.
In regard to type of intervention, half of the studies included in this review utilized a treatment
approach that was culturally and locally sensitive to the targeted population being addressed.
These populations varied both geographically and circumstantially, yet all interventions were
developed on a foundation of understanding of the population’s unique characteristics and daily
living priorities. While most numerous, it should be noted that level of evidence remained weak
for these study designs. The strongest evidence existed across the seven studies that utilized
psychotherapeutic approaches. Four studies extended further into psychotherapy to specifically
utilize mindfulness-based, yoga-based, or trauma-focused cognitive behavioral approaches. TF-
CBT was shown to be the most frequented and of the strongest evidence for psychotherapeutic
approaches, which is in agreement with prior research on effective trauma-informed
interventions. The third type of intervention approach was activity-based, of which the four
studies revealed promising results in the overlap between active or physical engagement and
psychological healing. While of moderate strength in evidence, the significantly limited quantity
of studies implementing each type of activity-based intervention makes it difficult to fully assess
the overall strength of these types of treatment. When analyzing intervention design, it is evident
that the majority [12] of community-based interventions are utilizing groups rather than
individual treatment sessions. Additionally, half of the interventions being implemented only
treat the child, in which caregivers or families played no active role in the intervention, while
half of the interventions described having a caregiver or family member involved for at least a
portion of intervention. Most interventions with family or caregiver involvement were designed
with a group activity and then separate breakout sessions for age-appropriate discussion on
trauma-related topics. The reasoning behind the decision for a child-only versus family involved
intervention design is unclear but may reflect the limitations of the community-based setting in
which it is more challenging to intervene at the family level. Within this review, the strongest
evidence was found across interventions that had a designated length of intervention, meaning
that all participants received a pre-determined number of treatment sessions. The average length
was 12.7 weekly sessions across the nine interventions with blocked sessions. Six other studies
were designed to have natural termination of intervention, in which treatment continued as long
as beneficial. Overall, the literature is in support of community-based interventions for children
with trauma that are encompassing the unique characteristics and factors attributed to the

19
targeted population, are addressing psychological functioning, are structured in group formats
and are implemented for a pre-determined length of time.

The majority of community-based interventions being utilized have been uniquely designed and
structured around a specific targeted population. While this type of intervention design limits
generalizability, it indicates a critical component to effective intervention for trauma. In order to
intervene with children presenting with trauma, it is essential to recognize and address the
cultural, personal, and community factors in which the individual resides. A child’s trauma
should not be treated in isolation. Research supports the need for proactive and preventative
interventions that address healthy biological development beginning prenatally, caregiver
support, community capacities, as well as public and private policies and programs, all of which
have the ability at strengthening the protective factors and building supportive environments
around children (Shonkoff et al., 2012). Additionally, several studies’ emphasis on
psychotherapy shows the importance of addressing psychosocial outcomes of trauma through
direct psychological intervention. Because traumatic events in childhood can alter brain
architecture, stress hormone levels, and neurological functioning such as learning, memory, and
executive functioning (Scientific Council, 2014), it is understandable why psychological
interventions that address the processing of and response to trauma are effective at improving
behaviors.

This review was interested in interventions being implemented in a relatively narrow setting,
however, it is known that evidence for trauma-informed interventions is available in broader
settings and should be taken into consideration when establishing an intervention plan. Several
programs have been developed in an effort to provide training and treatment for professionals,
caregivers, families, and children impacted by trauma. The Trust-Based Relational Intervention
(TBRI) is a recognized and promising intervention program, especially for “children and families
receiving child welfare services” (Karyn Purvis Institute of Child Development, n.d.). TBRI has
been utilized in clinical and private settings, as well as implemented through schools for at-risk
children. Additionally, the Neurosequential Model of Therapeutics (NMT) has been used in
treatment over the past two decades with thousands of children in child protective services,
juvenile systems, and more recently preschool programs (Perry, 2006). NMT addresses trauma
healing through the hierarchy of brain development and emphasizes the importance of
intervening at the appropriate neurodevelopment level of the child. Trauma-informed care is
expanding and now being applied across the settings of medicine, mental health, education,
child-welfare, first responders, and criminal justice (Ko et al., 2008). Recognizing that a wide
variety of settings and professions are contributing to trauma-informed care from all angles of a
child’s environment, it is clear that effective intervention is ultimately a result of a multi-faceted,
dynamic approach that is invested in the well-being of the child.

Several potential limitations need to be considered when interpreting the results of this scoping
review. During the data collection process, only two search strings were applied across all five
databases. It is possible that some applicable articles were missed if they did not include all the
applied search terms. Second, as analysis of the included articles proceeded, it was realized that a
key term “healing”, which was not used during data collection, may have yielded more evidence
as the word healing is commonly used to discuss trauma rather than treatment. Also, the validity

20
of this review is impacted by the fact that only one individual screened the articles and
determined eligibility for inclusion. Seven included articles were rated with a weak level of
evidence (level 4). This limits the validity and trustworthiness of the evidence made available in
these studies. Lastly, at the time of this study there is no published evidence on community-
based interventions being implemented within the field of occupational therapy. Occupational
therapy is a field that has begun to emphasize the importance of trauma-informed intervention
for children and is a pioneer in implementing interventions to address improvements in quality of
life and well-being for this population, yet at this time there are no publications for trauma-
informed occupational therapy interventions implemented within the community. This gives
great indication of future directions in which research and clinical practice should take.

In conclusion, there are a variety of interventions being utilized in the community to address
trauma-recovery for children exposed to traumatic events. While several different approaches to
treatment have been proven effective, it is clear that interventions must take into consideration
the complex and unique factors of each individual, even when implementing intervention in a
group setting. Literature indicates that interventions should occur regularly over a course of
about three months, and should not only concentrate on psychological treatment, but also address
the personal, cultural, and environmental factors that influence the child’s mental functioning.
Components of intervention should focus on coping skills, self-regulation, and social skills
development. Further research needs to be done to directly compare interventions that are
delivered in group versus individual formats in order to determine if one is more effective than
the other. Additionally, there is limited research assessing the effectiveness of caregiver or
family-based interventions, which may influence the recommendation of implementing child-
only or family-based interventions as research on this factor continues to grow. Continued
research, as well as implementation of research into evidence-based practice is critical in order
for this population of vulnerable children to develop into resilient and functioning individuals.

21
 Table 1. Evidence Summary

Study Objectives Rating/Design/ Intervention and Results Interpretation

Participants Outcome Measures
Allen & Solomon, To evaluate CEBM Level: 3b Intervention: The Edutainment Evidence to support that
2012 educational  Edutainment: attended play (Journey group had significantly Edutainment may be an
entertainment Design: CCT, quesi- of a Gun, 60min), then group higher self-efficacy effective intervention for
(edutainment) as experimental design discussion (20-30min) with audience scores than the control. improving violence avoidance
an intervention members, MSW, and cast Significant changes self-efficacy, anxiety, coping,
with Black N= 60 (35 females,  Group Discussion: 20-30min with pre/post for outcomes and stress levels among youth
adolescents 25 males) same MSW, format, agenda as edut. on anxiety (p=0.008), exposed to community
exposed to Group. coping (p=0.019), and violence.
community Edutainment: n= 20  Control: no intervention self-efficacy (p<0.001) Limitations: timing of group
violence. Group Discussion: were found only for discussion following play,
n=19 Outcome Measures: the Edutainment length of group discussions,
No intervention:  Spence Children’s Anxiety Scale group. There were no narrow time period between pre
n=21  Multicultural Events Schedule for significant changes for and post-test.
Adolescents the discussion or
 Children’s Coping Strategies control groups.
Checklist
22  Penn Violence Avoidance Self-
Efficacy Scale
Allen & Hoskowitz, To determine the CEBM Level: 3b Intervention: Significant reductions A greater use of structured
2017 impact of  Community-based TF-CBT, with in PTS, dissociation, CBT techniques may be more
integrating Design: prospective possible involvement of play anxiety, effective at improving
unstructured play intervention cohort components (average of 15.7 anger/aggression, symptoms for sexually-abused
techniques into sessions) depression, and sexual children.
trauma-focused N= 260 (51 male, concerns (p<0.001).
therapy, versus 209 female) Outcome Measures: Higher usage of Limitations: clinicians not
structured TF-  Treatment Techniques Scale structured CBT reporting data, varying
CBT for sexually  TSCYC Scale techniques wee experience of clinicians,
abused children associated with subjective outcome measures,
in the community significantly better control over sessions, number
setting. outcomes for PTS, of sessions
Dissociation, Anxiety,
and Anger/aggression,
while use of play
techniques was
associated with less
improvement.
Continued
 Table 1 Continued
Becker et al., 2011 To determine the CEBM Level: 4a Intervention: Statistically and The implementation of the
adaptability and  Fairy Tale Model Clinically significant Fairy Tale Model may be
implementation Design: Longitudinal gains were observed effective at treating traumatized
of a Greenwald across the IES, urban youth at a community
2005 phase model N= 59 (39 male, 20 Outcome Measures: CROPS, and PROPS level.
for trauma- female), dropout = 7  Impact of Events Scale outcome measures for
informed  Child Report of Post-Traumatic PTS (P<0.05). Limitations: generalizability,
treatment at a Symptoms Decrease in amount of lack of specific outcome
community level  Parent Report of Post-Traumatic special measures for youth’s presenting
for impoverished, Symptoms accommodations at problems, loss of 12 data points
multi-cultural  Family Empowerment Scale school. due to therapist noncompliance,
urban youth. non-blinded, no evaluation of
fidelity, no control group.

Beltran et al., 2016 to examine CEBM Level: 3a Intervention: Statistically significant Medium- large effects.
changes in  Yoga-based psychotherapy group (p<0.05) improvement A yoga-based psychotherapy
functioning Design: pro cohort (YBPG)- 14, 90 minute weekly in scores of the PRS, group for boys with trauma
following sessions (see Table 2). Family Involvement may be effective at improving
meetings of a N=10 (boys, ages 8- subscores increased areas of functioning, including:
yoga-based 12, 70% African Outcome Measures: significantly for both inter/intrapersonal strength,
23 psychotherapy American)  Behavioral and Emotional Rating parents and youth family involvement, school
group (YBPG) Scale (BERS-2) with parent, reports, all areas of functioning, and affective
for boys with a teacher/therapist, and youth rating functioning strength.
history of scales demonstrated
interpersonal statistically and Limitations: small sample size,
trauma exposure. clinically significant discrepancies between parent
differences. and child self-reports, no
control group, did not report of
TRS.
Continued
Table 1 Continued
Cohen et al., 2011 To evaluate CEBM Level: 2a Intervention: TF-CBT children had Strong Effect.
community-  TF-CBT group: 8 consecutive weeks significantly greater Preliminary evidence to show
provided trauma- Design: RCT of 45min individual session improvement in total that effectiveness of TF-CBT
focused cognitive  CCT: 8 consecutive weeks of 45min scores of the K-SADS- compared to CCT for youth
behavior therapy N= 124 (61 male, 63 individual sessions PL and RI, as well as with a history of IPV
(TF-CBT) female) hyperarousal and improving in PTS symptoms.
compared with TF-CBT group: n=64 Outcome Measures: anxiety (CI=95%).
usual community CCT group: n=60  K-SADS-PL diagnostic interview The number of Limitations: high attrition rate,
treatment for  UCLA PSTD Reaction Index children meeting the groups were not statistically
children with  Screen for Child Anxiety Related diagnosis for PTSD similar in race by end of
intimate partner Emotional Disorders decreased more treatment due to attrition,
violence (IPV)–  Children’s Depression Inventory significantly for those
related receiving TF-CBT
 Child Behavior Checklist
posttraumatic (P=0.03). More serious
 Kaufman Brief Intelligence Test
stress disorder adverse events were
symptoms reports in CCT youth.
Goodkind et al., To determine the CEBM Level: 4a Intervention: Statistically significant Findings indicate effectiveness
2012 feasibility,  Psycho-educational groups, 27 improvement was of intervention for treating AI
acceptability, and Design: Longitudinal sessions total, including 6 equine- found for self- youth with complex stress and
appropriateness assisted sessions. 3 evenings and 1 perception, coping trauma backgrounds in the AI
of a community- N=18 (14 female, 4 Saturday per month for 6 months. strategies, and quality community.
based, culturally- male) Youth and parents were in separate of life (p<0.05). No
sensitive mental breakout groups. change found over Limitations: high attrition, no
health time for enculturation. control, low generalizability
intervention Outcome Measures: Qualitative data due to cultural adaptations.
amongst  Recent Exposure to Violence Scale supports improvement
American Indian  Cognitive Behavioral Intervention for across all 5 outcomes.
youth. Trauma in Schools- adapted Life Results indicate this
Events Scale community-based
 Childhood PTSD Symptom Scale Native Indian
 Native American Enculturation Scale intervention is
 Harter Self-Perception Profile for effective at improving
Children cultural identity, self-
esteem, positive
 Rosenberg Self-Esteem Scale
coping skills, quality
 Children’s Coping Strategies
of life, and social
Checklist
adjustment for those
 Multidimensional Student’s Life youth who completed
Satisfaction Scale at least 9 session.
 Social Adjustment Inventory for More clinically
Children and Adolescents significant than
statistically.
Continued
Table 1 continued
Griese et al., 2018 To outlines the N/A. Intervention: N/A N/A
structure, process,  10 sessions, 50-90min/session
and content of Description of an  3 phases (getting started, telling our
Pathfinders: a intervention. stories, and moving forward
community-based
program to Outcome Measures: N/A
creatively address
the diverse needs
of bereaved
children and
families, prevent
complications of
grief and trauma,
and promote
healthy
adaptation.

Hoskins et al., 2018 To examine the CEBM Level: 3a Intervention: Clinically Significant Evidence to support PATH
acceptability and  10 week, 90min per session group symptoms of PTSD program as an effective
preliminary Design: prospective therapy model decreased from 56% to treatment for trauma-exposed
efficacy of intervention cohort  6 of the 10 sessions were split 0% pre/post treatment. Latino youth to improve PTSD,
Positive study caregiver and youth Youth endorsed depression, and anxiety
Adaptations for statistically and symptoms.
Trauma and N= 16 (6 male, 10 Outcome Measures: clinically significant
Healing (PATH), female)  The Child and Adolescent Needs and reductions in anger, Limitations: sample was highly
a manualized Strengths Comprehensive Assessment anxiety, depression, traumatized, no control group,
treatment for  Trauma History Questionnaire dissociation, and PTS niche community.
Latino youth and  Child Behavior Check List on the TSCC measure.
their caregivers.  Child Depression Inventory-short Significant decrease in
depressive symptoms
 Individual Protective Factors Index
(p=0.004). Significant
 Trauma Symptom Checklist for
reduction in
Children
externalizing
 UCLA PTSD Index (p<0.001) and
 Modified Positive and Negative internalizing (p<0.001)
Affect Scale behaviors. Stat
 Perceived Stress Scale significant increase in
 Skills Practice Scale negative emotions and
perceived stress.

Continued
Table 1 Continued
Humensky et al., to describe an N/A Intervention: N/A N/A
2013 academic-
community Description of an
partnership that intervention Outcome Measures:
has been created  Columbia Suicide Severity Rating
to evaluate the Design: quantitative Scale
LIP program ( a and qualitative  Suicidal Ideation Questionnaire
community-based components-  Reynolds Adolescent Depression
organization measures of Scale 2
operating in assessment given  Family Adaptation and Cohesion
Brooklyn and the 3x/year to track Scale
Bronx, has progress  Trauma Symptom Checklist for
developed a Children
comprehensive Population: Latina
suicide girls, ages 12-18
prevention
intervention for
Latinas) and
develop an
evidence-based
practice (EBP)
that can be
replicated in other
settings.
Kiser et al., 2015 To assess the CEBM Level: 4a Intervention: 48.25% of families Preliminary results indicate that
effectiveness of a  Manualized, skills-based attended at least 70% SFCR may be one of the first
new group-based Design: Longitudinal  Trauma Treatment (TT) Model- of sessions. family-centered trauma
intervention o 15, 2hr multifamily group sessions Significant reductions treatment programs to be
protocol, N= 185 families and o 30min family meal/session in PTSD symptoms of implemented and show
developed to children participated o Breakout groups the identified child. a significant positive impact on
meet an urgent across 13 sites, pre & o Module I, II, & III Children reported child symptoms
need for family post data collected on significant decreases and family functioning,
 High Risk (HR) Model-
centered trauma n=103 families and in overall and satisfying both key
o 10, 2hr multifamily group sessions
treatment; and too children (53 female, reexperiencing aims and expectations of the
o 30min family meal/session
examine whether 50 male) symptoms, and intervention.
SFCR would be o Breakout groups parents reported
associated with o Module I & II, NOT III significant decreases Limitations: not blinded,
decreased distress  Module I: concepts of ritual, routine, in children’s overall, possibility of evaluator bias,
at both the child storytelling, and shared mealtimes avoidance, and arousal various assessment batteries
and family levels.  Module II: building coping resources symptoms. On the utilized across sites, missing
 Module III: co-construct trauma CBCL, parents data on some participants (44%
narrative for communication and reported significant of sample was lost to follow-
understanding of traumas
 Continued
Table 1 Continued

Continued
Table 1 Continued
Salloum et al., 2001 To evaluate the CEBM Level: 3b Intervention: There was a Pilot study findings indicate
effectiveness of a  10-week community-based grief and statistically significant effectiveness of program at
community-based Design: prospective trauma group therapy model decrease in the PTSD improving PTSD symptoms in
time-limited intervention cohort Reaction Index score African American youth
psychotherapy study Outcome Measures: pre/post (p=0.001). exposed to homicide.
group model to  Child Postraumatic Stress Reaction The re-experiencing
decrease N= 45 (27 female, 18 Index and avoidance clusters Limitations: no comparison,
traumatic male) of youth showed convenience sampling method,
symptoms among statistically significant various relationships to
adolescent improvement in scores homicide victims, small sample
survivors of pre/post, while the size
homicide victims arousal cluster did not.
There was no
difference among
gender or length of
time since homicide.
Suarez et al., 2014 to describe the CEBM Level: 4b Intervention: Significant Findings indicate that
basic  System of Care approach improvements in youth participants in the PK program
demographic and Design: Longitudinal strengths (P=.024), are showing significant
clinical features Outcome Measures: competence (P=.027), improvements in overall
at intake of the N= 144 at intake,  Behavioral and Emotional Rating depression (P=.009), qualities and behavior related to
youth and n=69 female youth Scale, 2nd Edition impairment (P=.007), trauma. “The apparent
families served to who participated  Caregiver Information behavioral problems effectiveness of PK’s model of
date (2011-2014), Questionnaire, Revised: Caregiver- (P=.017), emotional intensive and peer-delivered
and preliminary Intake problems (P=.007), as community-based supports is
results regarding  Caregiver Strain Questionnaire well as caregiver strain likely to be the key lesson
clinical and  Child Behavior Checklist (P=.001) after 6 learned from this innovative
functional  Columbia Impairment Scale months of SoC service model implementation
outcomes as well intervention. for at-risk youth in Hawai’i”.
 Education Questionnaire–Revision 2
as participant
 Revised Children’s Manifest
satisfaction. Also, Limitations: low proportion of
Anxiety Scale, 2nd Edition
a cost analysis participants, unable to
compares the  Reynolds Adolescent Depression determine which elements of
level of mental Scale, 2nd Edition services are responsible for
health  Youth Services Survey improvement
expenditures for
PK participants
prior to and after
the
implementation
of PK services.
Continued
Table 1 Continued
Vankanegan et al., To explore the CEBM Level: 4a Intervention: minimum of 12 sessions, Youth reported Preliminary data shows AT in
2019 impact of an weekly or biweekly, 60-180 minutes/ significant the community setting may be
activity-based, Design: Longitudinal, session. Groups consisted of 5-6 youth and improvements in an effective approach for
adventure therapy pre-experimental 2 facilitators, grouped by treatment goals. overall functioning, treating youth with mental
group on youth in pretest/posttest Activities (Table 1). interpersonal relations health problems.
a community- design and critical items
based mental (p=0.05). Males Limitations: no control group,
health setting. N= 42 (27 male, 14 Outcome Measures: reported slight no follow-up data, low sample
females, 1  Youth Outcomes Questionnaire Self increase in social size, high attrition
transgender) Report, at intake & every 3 months problems, whereas
until discharge females reported a
large decrease. Race
was found to not affect
change.
Webb et al., 2014 To determine the CEBM Level: 4a Intervention: Weekly TF-CBT sessions, Significant decrease in Medium-Large effect.
effectiveness of 60-90 minutes in length, mean treatment PTSD symptoms on This study reveals that TF-CBT
trauma-focused Design: Longitudinal dose was 9.79 sessions the UPID over the first can be implemented and
cognitive 6 months and were effective in treating traumatized
behavioral N= 72 (46 females, maintained through the children at the community
therapy (TF- 26 males) ages 7-16 Outcome Measures: 12-month follow up level.
CBT) in treating years  The UCLA PTSD Reaction Index for (p<0.05). Decrease in
child traumatic DSM-IV (UPID) clinical PTSD Limitations: no control group,
stress when  The parent version of Child Behavior diagnosis from 54% to various number of treatment
implemented in Checklist 6-18 (CBCL), internalizing 9% over 12 months. A sessions, no restriction on
community and externalizing significant reduction in concurrent treatment unrelated
settings on a internalizing and to trauma
state-wide level externalizing
symptoms were found.
Young et al., 2018 To determine the CEBM Level: 4a Intervention: All participants rated Preliminary data reveals this
feasibility,  5-week intervention, “Taming the to be “highly or community-based mindfulness
acceptability, and Design: Longitudinal Adolescent Mind (TAM)” model, 1hr moderately satisfied” intervention to be effective at
preliminary weekly sessions. with the program. All improving perceived stress,
effects of a N= 7 (4 female, 3 participants rated the self-esteem, and depressive
mindfulness- male, 85% Outcome Measures: program to be symptoms for underserved
based Hispanic/Latino)  The Perceived Stress Scale somewhat or very Hispanic youth.
intervention with  Ruminative Responses Scale- helpful. Depressive
at-risk Brooding symptoms decreased Limitations: small sample size,
adolescents from  Child and Adolescent Mindfulness significantly no control, interventionist was
a predominantly Measure (P=0.018). Significant not formally trained in
Hispanic/Latino  Rosenberg Self-Esteem Scale Improvements were mindfulness instruction
community  Center for Epidemiologic Studies seen in self-esteem,
and perceived stress
Depression Scale for Children scores (p<0.05).
 Table 2. Cochrane Bias Assessment

Study Bias Risk Random Allocation Blinding of Blinding of Incomplete Selective outcome Other bias
Sequence Concealmen Participants Outcome accounting reporting (e.g. incomplete
Generation t and Assessment outcome stopping early statistical
Personnel events for benefit reporting)
Author et al., +, Low risk of bias +, Low risk of bias +, Low risk of bias +, Low risk of bias +, Low risk of bias +, Low risk of bias +, Low risk of bias +, Low risk of bias
year -, High risk of bias -, High risk of bias -, High risk of bias -, High risk of bias -, High risk of bias -, High risk of bias -, High risk of bias -, High risk of bias
? , Unclear ? , Unclear ? , Unclear ? , Unclear ? , Unclear ? , Unclear ? , Unclear ? , Unclear
Allen et al.,
2012 - - - - - ? + +
Allen &
Hoskowitz, - - - - - - + -
2017
Becker et al.,
2011 - - - - - - + +
Beltran et al.,
2016 - - - - - + + +
Cohen et al.,
2011 + + + - + - + +
Goodkind et
al., 2012 - - - - - + + -
31
Griese et al.,
2018
N/A N/A N/A N/A N/A N/A N/A N/A
Hoskins et
al., 2018 - - - - - - + -
Humensky et
al., 2013
N/A N/A N/A N/A N/A N/A N/A N/A
Kiser et al.,
2015 - - - - - - ? -
Patterson et
al., 2018 - - - - - + + -
Salloum et
al., 2001 - - - - - - + +
Suarez et al.,
2014 - - - - - - + +
Vankanegan
et al., 2019 - - - - - - + +
Webb et al.,
2014 - - - - - - + +
Young et al.,
2018 - - - - - + + +
Table 3. Thematic and Numeric Analysis
 Theme # of Studies / Sub-Themes Study Characteristics / Design Results Measures of Effectiveness Used
Strength of Evidence
Type of Intervention .
Psychotherapeutic 1 Level II Study TF-CBT (Allen, Allen 2017, Prospective Cohort Allen, 2017 Allen, 2017
Approaches (Cohen, 2011) 2017; Cohen, 2011; Design Higher usage of structured Treatment Techniques Scale:
Webb, 2014) N= 260 (51 male, 209 female) TF-CBT techniques were Paired sample t-tests- PTS (t=8.42,
3 Level III Studies This study compared TF-CBT associated with p<0.001), Dissociation (t= 6.35,
(Allen, 2017; Beltran, Yoga-based vs. unstructured play for significantly better p<0.001), Anxiety (t=6.06,
2016; Salloum, 2001) (Beltran, 2016) effectiveness at reducing stress outcomes for PTS, p<0.001), anger/aggression (t=
symptoms dissociation, anxiety, and 5.74, p<0.001), depression (t=8.42,
2 Level IV Studies Mindfulness-based anger/aggression. p<0.001), sexual concerns (t=5.63,
(Webb, 2014; Young (Young, 2018) p<0.001)
2018)
Psychotherapy for Cohen, 2011, Randomized- Cohen, 2011 Cohen, 2011
1 Descriptive paper grief & healing, Control Trial Significantly greater PTSD symptoms via K-SADS-PL
(Griese, 2018) homicide victims N= 124 (61 male, 63 female) improvement in total scores and SCARED
(Salloum, 2001) TF-CBT group: n=64, CCT on outcome measures, as ITT and LOCF analyses, 95% CI
group: n=60 well as hyperarousal and
Psychotherapy for Child and mother each had 8 anxiety for TF-CBT
bereaved children consecutive weeks of individual children. The number of
32 and families therapy sessions children meeting PTSD
(Griese, 2018) criteria decreased more
significantly for those
receiving TF-CBT.

Webb, 2014, Longitudinal Webb, 2014 Webb, 2014

design
N=72 (46 female, 26 male)
Weekly TF-CBT sessions with
both child and parent separately,
60-90 minutes in length, mean
treatment dose was 9.79
sessions.
Examined the effectiveness of
TF-CBT administered in the
community-based setting state-
wide.
Table 3 Continued
Significant decrease in
PTSD symptoms on the
UPID over the first 6
months and were
maintained through the 12-
month follow up.
Percentage of youth scoring
in the clinical range for
PTSD decreased from 54%
to 9% over 12 months.
Significant reduction in
internalizing and
externalizing symptoms.
Monte Carlo simulation analysis
for power: P> 0.90 for all three
outcome measures
Baseline  6 month = large effect
size (Cohen’s d = 0.92).
P value < 0.05.
Follow-up period = medium to
large effect size (d= 0.67)
Continued
 Psychotherapeutic Beltran, 2016, Prospective
Approaches Cohort Design
N=10 (boys, ages 8-12, 70%
African American)
Yoga-based psychotherapy
group (YBPG)
14, 90min weekly sessions.
Psychoeducation/therapeutic
components: explored and set
personal boundaries, increasing
awareness of self and
physiological sensations,
relaxation skills, social
interactions, and asserting
oneself.
Young, 2018, Longitudinal
Design
N=7 (57% female, 85%
Latino/Hispanic)
Taming the Adolescent Mind,
mindfulness-based group
33 therapy: 5-week, 1-hour weekly
sessions
Psychotherapeutic topics: (a)
regulate their attention, (b)
observe the present moment, (c)
accept all experiences, (d) be
mindful, and (e) mindfulness
and beyond.
Beltran, 2016 Beltran, 2016
Statistically significant Wilcoxon’s Signed Rank Test
improvement in scores for statistic for nonparametric analysis
both parents and youth t-test analysis
reports, all areas of Medium-large effect size
functioning 95% CI
(inter/intrapersonal P= 0.05
strength, family
involvement, affective
strength, school
functioning, strength index)
demonstrated statistically
and clinically significant
differences.
Young, 2018 Young, 2018
Descriptive results: all were Statistical analyses were conducted
“highly satisfied” or with SPSS version 22.0.
“moderately satisfied” with Nonparametric statistics (ie,
program. All found the Wilcoxon signed rank tests) were
program to be “very used to evaluate changes in study
helpful” or “somewhat variables
helpful.” A critical alpha for statistical
Statistical results: values significance was not identified a
for brooding, perceived priori due to the small sample size
stress, and depressive
symptoms decreased.
Mindfulness and self-
esteem increased.
Depressive symptoms had
greatest decrease (z=−2.37,
P=.018), followed by
improvements in self-
esteem (z=−2.20, P=.028)
Continued
Table 3 Continued
Psychotherapeutic Salloum, 2001, Longitudinal
Approaches Design
N= 45 (27 female, 18 male)
10-week community-based grief
and trauma group therapy model
Griese, 2018, Descriptive Paper
10 sessions, three distinct phases
within the intervention. Length
of the session may vary based on
setting and modality, ranging
from 50 to 90 minutes per
session.
Activity-based 3 Level III Studies Yoga-based Beltran, 2016, Prospective
(Allen, 2012; Beltran, (Beltran, 2016) Cohort Design
2016; Patterson, 2018) N=10 (boys, ages 8-12, 70%
Educational African American)
1 Level IV Study Entertainment Yoga-based psychotherapy
(Vankanegan, 2019) (Allen, 2012) group (YBPG)
14, 90-minute weekly sessions.
Adventure Therapy Activity-based components:
(Vankanegan, 2019) creating safe and trusting
environment among boys,
Play Therapy establishing expectations for
(Patterson, 2018) group interaction, practicing
teamwork and leadership skills
Allen, 2012, Quasi-experimental
design
N= 60 (35 females, 25 males)
Edutainment: n= 20, Group
Discussion: n=19, Control:
n=21
Edutainment: attended play
(Journey of a Gun, 60min), then
group discussion (20-30min)
Salloum, 2001 Salloum, 2001
Statistically significant Paired sample t-test
decrease in the PTSD P < 0.05
Reaction Index score
pre/post. The re-
experiencing and avoidance
clusters of youth showed
statistically significant
improvement in scores
pre/post, while the arousal
cluster did not.
Griese, 2018 Griese, 2018
N/A N/A
Beltran, 2016 Beltran, 2016
Statistically significant Wilcoxon’s Signed Rank Test
improvement in scores for statistic for nonparametric analysis
both parents and youth t-test analysis
reports, all areas of Medium-large effect size
functioning demonstrated P= 0.05
statistically and clinically
significant differences.
Allen, 2012 Allen, 2012
The Edutainment group had ANOVA analysis
significantly higher self- P<0.05
efficacy scores than the
control. Significant changes
pre/post for outcomes on
anxiety, coping, and self-
efficacy were found only
for the Edutainment group.
Continued
Table 3 Continued
Activity-based with audience members, MSW,
and cast
Group Discussion: 20-30min
with same MSW, format, agenda
as edut. Group.
Control Group: no intervention
Vankanegan, 2019, Longitudinal
Design
N= 42 (27 male, 14 females, 1
transgender)
Minimum of 12 sessions, weekly
or biweekly, 60-180 minutes/
session. Groups consisted of 5-6
youth and 2 facilitators, grouped
by treatment goals.
Patterson, 2018, Prospective
Cohort Design
N= 12 (African American)
6 weeks of individual CCPT
(1x/week, 50min)
6 weeks of group CCPT of 3-4
participants of similar age,
gender, and behavior (1x/week,
50min).
Local, Culturally 1 Level III Study Fairy Tale Model Becker 2011, Longitudinal
Sensitive (Hoskins, 2018) (adapted from Design
Greenwald phase N= 59 (39 male, 20 female)
5 Level IV Studies model), for urban Multi-disciplinary team
(Becker, 2011; minority youth conducted treatment in phases.
Goodkind, 2012; (Becker 2011) Evaluation, identification of
Kiser, 2015; Suarez, client goals/motivation, case
2014; Young, 2018) Positive formulation and treatment
Adaptations for contracting, stabilization,
2 Descriptive papers Trauma and Healing enhancement of coping and
(Griese, 2018; program, for Latino affect tolerance skills, resolution
Humensky, 2013) youth (Hoskins, of trauma memories,
2018) consolidation of gains,
anticipation of future challenges
Vankanegan, 2019 Vankanegan, 2019
Youth reported significant Repeated-measures ANOVAs
improvements in overall P < 0.05
functioning, interpersonal
relations and critical items.
Males reported slight
increase in social problems,
whereas females reported a
large decrease.
Patterson, 2018 Patterson, 2018
Internalized & externalized Repeated-measures ANOVA with
behaviors showed Greenhouse-Geisser corrections
significant decreases. P<0.20
Statistical significance was
found in the subtests for
generalized anxiety
disorder, obsessive–
compulsive disorder,
physical injury, and panic
disorder
Becker, 2011 Becker, 2011
Statistically and Clinically Two-tailed, paired t-test
significant gains were P=0.05
observed across outcome
measures for PTS. Decrease
in amount of special
accommodations at school.
Continued
Table 3 Continued
Local, Culturally American Indian Hoskins 2018, Prospective Hoskins, 2018 Hoskins, 2018
Sensitive comm., psycho- Cohort Design Symptoms of PTSD Paired t-tests
educational & N= 16 (6 male, 10 female) decreased from 56% to 0% 95% CI, P=0.05
equine therapy with 10 weeks, 90min per session pre/post treatment.
parents and children group therapy model, [see table Statistically and clinically
(Goodkind, 2012) 1] 6 of the 10 sessions were split significant reductions in
caregiver and youth anger, anxiety, depression,
Mindfulness-based: dissociation, and PTS.
Taming the Significant decrease in
Adolescent Mind depressive symptoms,
model, externalizing and
Hispanic/Latino internalizing behaviors.
community (Young, Stat significant increase in
2018) negative emotions and
perceived stress.
Family-based,
Strengthening Goodkind 2012, Longitudinal Goodkind, 2012 Goodkind, 2012
Family Coping Design Statistically significant Hierarchical linear modeling
Resources, urban N=18 (14 female, 4 male) improvement was found for P=0.05, 0.01, 0.001
families living in Psycho-educational groups, 27 self-perception, coping
trauma context sessions total, including 6 strategies, and quality of
(Kiser, 2015) equine-assisted sessions. 3 life. No change was found
evenings and 1 Saturday per over time for enculturation.
Gender responsive, month for 6 months. Youth and
system of care, parents were in separate
Hawaii natives breakout groups.
(Suarez, 2014)
Young 2018, Longitudinal Young, 2018 Young, 2018
(Griese, 2018) Design All participants rated to be SPSS version 22.0
N= 7 (4 female, 3 male, 85% “highly or moderately Wilcoxon signed rank tests
(Humensky, 2013) Hispanic/Latino) satisfied” with the program. P =0.05
5 weeks, 1 hr/week. Session All participants rated the
topics include: regulate their program to be somewhat or
attention, observe the present very helpful. Depressive
moment, accept all experiences, symptoms decreased
be mindful, and mindfulness and significantly (P=0.018).
beyond. Parents were invited, Significant Improvements
but not required to participate in were seen in self-esteem,
intervention and perceived stress scores

Continued
Table 3 Continued
Local, Culturally Kiser, 2015, Longitudinal Kiser, 2015 Kiser, 2015
Sensitive Design Significant reduction in Independent t-test and chi-square
N= 185 families, n= 103 PTSD symptoms; tests
children children’s Linear mixed model to assess
age 6 to 17 years (56.7% overall, avoidance, and change over time
female; M age: 10.7 years); arousal symptoms;
15, 2hr sessions, including a 30- anxious/depressed, social,
min family meal. attention, rule-breaking,
Module I introduces families to and aggressive behaviors.
the concepts of shared Significant improvements
mealtimes, ritual, routine, and in overall family
storytelling. functioning and in total
Module II builds constructive parenting stress
coping resources for family
stress management and to
protect family members from
further exposure.
Module III helps families
communicate about and
understand their traumas. With
the assistance of group
facilitators trained in anxiety
management, cognitive
reframing, and exposure,
families construct a trauma
narrative.

Suarez, 2014, Longitudinal Suarez, 2014 Suarez, 2014

Design Caregiver strain, and youth Pearson chi-squares, paired T-tests
N= 100, 69 youth & 31 impairment, emotional and ANOVA were calculated using
caregivers problems, depression, IBM SPSS Statistics for Windows,
Females, ages 11-18 behavioral problems, Version 22.0
System of Care model: intensive strengths, competence all
case management; community significantly improved
supports by paraprofessionals (P<0.05)
(ie, peer support for youth and
caregivers); structured group
activities; and evidence-based
treatments (eg, Trauma-Focused
Cognitive Behavioral Therapy
and Girls Circle psychoed
support groups).
Continued
Table 3 Continued
Local, Culturally Griese, 2018, Descriptive Paper Griese, 2018 Griese, 2018
Sensitive Pathfinders curricula: 10 N/A N/A
sessions, three distinct phases
within the intervention. Length
of the session may vary based on
setting and modality, ranging
from 50 to 90 minutes per
session.
curricula are designed for
children (3–11 years),
adolescents (12–to 18 years),
and adult caregivers

Humensky, 2013, Descriptive Humensky, 2013 Humensky, 2013

Paper N/A N/A
Latina girls, ages 12-18 years
old
After-school programming
provides a myriad of services,
including mental health
treatment, assistance with school
performance and family
relationships, art and music
therapy, gardening, and healthy
living initiatives.
Intervention Design
Family- 1 Level II Study Cohen, 2011, Randomized See above. See above.
based/Caregiver (Cohen, 2011) Control Trial
Involvement N= 124 (61 male, 63 female)
2 Level III Study TF-CBT group: n=64, CCT
(Beltran, 2016; group: n=60
Hoskins, 2018) Child and mother each had 8
consecutive weeks of individual
4 Level IV Studies therapy sessions
(Becker, 2011;
Goodkind, 2012; Beltran, 2016, Prospective
Kiser, 2015; Webb, Cohort Design
2014) N=10 (boys, ages 8-12, 70%
African American)
1 Descriptive paper Yoga-based psychotherapy
(Griese, 2018) group (YBPG)- 14, 90-minute
weekly sessions.
Continued
Table 3 Continued
Family- Parents attended 1st and 14th See above. See above.
based/Caregiver sessions, family meals provided,
Involvement parental psychoeducation and
relaxation exercises during 1st
session

Hoskins, 2019, Prospective

Cohort Design
N= 16 (6 male, 10 female)
10 weeks, 90min per session
group therapy model, [see table
1]
50% (5 of 10 sessions)
conducted together, 50% split
caregiver/youth

Becker, 2011, Longitudinal

Design
N= 59 (39 male, 20 female)
Multi-disciplinary team
conducted treatment in phases
Parents attended parent-training
and had parent-partner visit
home for follow-up. Child
participates in therapy
separately.

Goodkind, 2012, Longitudinal

Design
N=18 (14 female, 4 male)
Psycho-educational groups, 27
sessions total, including 6
equine-assisted sessions. 3
evenings and 1 Saturday per
month for 6 months. Youth and
parents completed some
education and activities together,
and some discussion and
activities in separate breakout
groups. Parents and youth
participated in all the same
themed sessions.
Continued
Table 3 Continued
Family- Kiser, 2015, Longitudinal See above. See above.
based/Caregiver Design
Involvement N= 185 families, n= 103
children
10-15, 2hr weekly sessions
Sessions include family-meals,
and breakout
groups that allow parents and
children of similar ages to share
their experiences, supporting one
another, and engaging in
developmentally appropriate
activities.

Webb, 2014, Longitudinal

Design
N=72 (46 female, 26 male)
Weekly 60-90min sessions
(mean 9.79 sessions)
Child and parent TF-CBT
sessions
are initially scheduled
separately, conjoint sessions
offered in later phases as
treatment progresses.

Griese, 2018, Descriptive Paper

10 sessions, three distinct phases
within the intervention. Length
of the session may vary based on
setting and modality, ranging
from 50 to 90 minutes per
session.
Sessions begin and end with
family meals/snack and ritual
activity, then participants attend
breakout groups according to
developmentally/age
appropriateness (child,
adolescence, caregiver).

Continued
Table 3 Continued
Child-only/no 4 Level III Studies Allen, 2012, Quasi-experimental See above. See above.
caregiver (Allen, 2012; Allen, Design
involvement 2017; Patterson, 2018; N= 60 (35 females, 25 males)
Salloum, 2001) Edutainment: n= 20, Group
Discussion: n=19, Control:
3 Level IV Studies n=21
(Suarez, 2014; Intervention and measures
Vankanegan, 2019; conducted at community center
Young, 2018) with adolescents

1 Descriptive paper Allen, 2017, Prospective Cohort

(Humensky, 2013) Design
N= 260 (51 male, 209 female)
This study compared TF-CBT
vs. unstructured play for
effectiveness at reducing stress
symptoms
Intervention was between
clinician and child.

Patterson, 2018, Prospective

Cohort Design
N= 12 (African American, ages
5-9)
6 weeks of individual CCPT
(1x/week, 50min)
6 weeks of group CCPT of 3-4
participants of similar age,
gender, and behavior (1x/week,
50min).
Play therapy between clinician
and participants.

Salloum, 2001, Prospective

Cohort Design
N= 45 (27 female, 18 male)
10-weekly sessions
community-based grief and
trauma group therapy model.
Group therapy provided to youth
ages 12-19

Continued
Table 3 Continued
Child-only/no Suarez, 2014, Longitudinal See above. See above.
caregiver Design
involvement N= 100, 69 youth & 31
caregivers
Females, ages 11-18
Model of intervention described
as “family-driven”, but all
intervention approaches
described with only clinician and
youth.

Vankanegan, 2019, Longitudinal

Design
N= 42 (27 male, 14 females, 1
transgender)
Minimum of 12 sessions, weekly
or biweekly, 60-180 minutes/
session.
Groups consisted of 5-6 youth
and 2 facilitators, grouped by
treatment goals.
Group adventure therapy for
middle school and high school
youth, average age 14.5.

Young, 2018, Longitudinal

Design
N=7 (57% female, 85%
Latino/Hispanic)
5-week, 1-hour weekly sessions
Taming the Adolescent Mind,
mindfulness-based group
therapy: 5 sessions were with
youth only. 1 parent information
session was offered at the
beginning, but not required.

Humensky, 2013, Descriptive

Paper
After-school programming
center for girls 12-18.

Continued
Table 3 Continued
Group intervention 5 Level III Studies Allen, 2012, Quasi-experimental See above. See above.
(Allen, 2012; Beltran, Design
2016; Hoskins, 2018; N= 60 (35 females, 25 males)
Patterson, 2018; Edutainment: n= 20, Group
Salloum, 2001) Discussion: n=19, Control:
n=21
5 Level IV Studies Intervention and discussion
(Goodkind, 2012; conducted in group setting.
Kiser, 2015; Suarez,
2014; Vankanegan, Beltran, 2016, Prospective
2019; Young, 2018) Cohort Design
N=10 (boys, ages 8-12, 70%
2 Descriptive papers 14, 90min weekly sessions.
(Griese, 2018; Yoga-based psychotherapy
Humensky, 2013) group (YBPG).

Hoskins, 2019, Prospective

Cohort Design
N= 16 (6 male, 10 female)
10, 90min weekly sessions of
group therapy. Groups
structured for youth to be with
others of similar age. Caregivers
participated partially in the same
group with youth, or in separate
groups.

Patterson, 2018, Prospective

Cohort Design
N= 12 (African American, ages
5-9)
12, 50min weekly sessions
6 weeks of individual CCPT
followed by
6 weeks of group CCPT of 3-4
participants of similar age,
gender, and behavior.

Continued
Table 3 Continued
Group intervention Salloum, 2001, Prospective See above. See above.
Cohort Design
N= 45 (27 female, 18 male)
10 weekly sessions
community-based grief and
trauma group therapy model,
broken into 6 smaller groups of
adolescents.

Goodkind, 2012, Longitudinal

Design
N=18 (14 female, 4 male)
27 weekly sessions over 6
months.
Psycho-educational groups;
including 6 equine-assisted
sessions. Each session had
discussion and activities for
youth and parents to do together,
as well as separate breakout
groups.

Kiser, 2015, Longitudinal

Design
N= 185 families, n= 103
children
10-15, 2hr weekly sessions
Multifamily groups: partially
completed together, partial
breakout groups for youth and
caregiver groups.

Suarez, 2014, Longitudinal

Design
N= 100, 69 youth & 31
caregivers
Females, ages 11-18
Opportunities to engage in
structured group activities, as
well as peer-to-peer mentoring.

Continued
Table 3 Continued
Group intervention Vankanegan, 2019, Longitudinal See above. See above.
Design
N= 42 (27 male, 14 females, 1
transgender)
Minimum of 12 sessions, weekly
or biweekly, 60-180 minutes/
session.
Groups consisted of 5-6 youth
and 2 facilitators, grouped by
treatment goals.

Young, 2018, Longitudinal

Design
N=7 (57% female, 85%
Latino/Hispanic)
5, 1-hour weekly sessions
Mindfulness-based group
therapy (TAM). Conducted in
small groups of up to 12
adolescents

Griese, 2018, Descriptive Paper

10, 50-90min sessions, three
distinct phases.
Combination of family, group,
and individual therapy
approaches. Groups designed for
age-appropriate intervention.

Humensky, 2013, Descriptive

Paper
Latina females, ages 12-18
After-school programming
offered in group format, of
approximately 8-10 youth for
group workshops, art, and music
therapy.

Continued
Table 3 Continued
One-on-One 1 Level II Study Cohen, 2011, Randomized See above. See above.
intervention (Cohen, 2011) Control Trial
N= 124 (61 male, 63 female)
2 Level III Studies TF-CBT group: n=64, CCT
(Allen, 2017; group: n=60
Patterson, 2018) Child and mother each had 8
consecutive weeks of individual
2 Level IV Study therapy sessions.
(Becker, 2011; Webb,
2014) Allen, 2017, Prospective Cohort
Design
N= 260 (51 male, 209 female)
TF-CBT vs. unstructured play
intervention conducted by
clinician with individual youth.

Patterson, 2018, Prospective

Cohort Design
N= 12 (African American, ages
5-9)
12, 50min weekly sessions
6 weeks of individual CCPT
followed by 6 weeks of group
CCPT of 3-4 participants of
similar age, gender, and
behavior.

Becker, 2011, Longitudinal

Design
N= 59 (39 male, 20 female)
Multi-disciplinary team
conducted treatment in phases.
Interventions with clinician(s)
and child only.

Webb, 2014, Longitudinal

Design
N=72 (46 female, 26 male)
Weekly 60-90min sessions
(mean 9.79 sessions)
Separate parent and child TF-
CBT sessions with clinician.
Continued
Table 3 Continued
Length of Intervention
One-time session 1 Level III Study Allen, 2012, Quasi-experimental See above. See above.
(Allen, 2012) Design
N= 60 (35 females, 25 males)
Edutainment: n= 20, Group
Discussion: n=19, Control:
n=21
1, 60min edutainment “play”,
followed by 20-30min group
discussion OR just 20-30min
group discussion
Blocked number of 1 Level II Study Cohen, 2011, Randomized See above. See above.
sessions (Cohen, 2011) Control Trial
N= 124 (61 male, 63 female)
4 Level III Studies TF-CBT group: n=64, CCT
(Beltran, 2016; group: n=60
Hoskins, 2018; 8 weekly sessions of individual
Patterson, 2018; therapy sessions for parent and
Salloum, 2001) child. No specific time indicated.

3 Level IV Studies Beltran, 2016, Prospective

(Goodkind, 2012; Cohort Design
Kiser, 2015; Young, N=10 (boys, ages 8-12, 70%
2018) African American)
Yoga-based psychotherapy
1 Descriptive paper group (YBPG)
(Griese, 2018) 14 consecutive weekly sessions,
occurring for 90 minutes.

Hoskins, 2019, Prospective

Cohort Design
N= 16 (6 male, 10 female)
10 consecutive weekly sessions,
group therapy occurring for
90min per session.

Continued
Table 3 Continued
Blocked number of Patterson, 2018, Prospective See above. See above.
sessions Cohort Design
N= 12 (African American)
12 consecutive weekly sessions,
occurring 50min per session
6 weeks of individual CCPT
6 weeks of group CCPT of 3-4
participants of similar age,
gender, and behavior

Salloum, 2001, Prospective

Cohort Design
N= 45 (27 female, 18 male)
10 consecutive weekly sessions
of community-based grief and
trauma group therapy. No time
per session provided.

Goodkind, 2012, Longitudinal

Design
N=18 (14 female, 4 male)
27 sessions total, occurring 3
weekday evenings and 1
Saturday per month for 6
months. No time per session
provided.

Kiser, 2015, Longitudinal

Design
N= 185 families, n= 103
children
age 6 to 17 years
Trauma Treatment group: 15
sessions, 2hr per session.
High Risk group: 10 sessions,
2hr per session.

Continued
Table 3 Continued
Blocked number of Young, 2018, Longitudinal See above. See above.
sessions Design
N=7 (57% female, 85%
Latino/Hispanic)
mindfulness group therapy
5 consecutive weekly sessions,
1hr per session.

Griese, 2018, Descriptive Paper

10 sessions, three distinct phases
within the intervention. Length
of the session may vary based on
setting and modality, ranging
from 50 to 90 minutes per
session.

Natural 1 Level III Study Allen, 2017, Prospective Cohort See above. See above.
Termination (Allen, 2017) Design
N= 260 (51 male, 209 female)
4 Level IV Studies Number of sessions dependent
(Becker, 2011; Suarez, on clinician recommendation.
2014; Vankanegan, Average number of sessions=
2019; Webb, 2014) 15.7 (ranged between 4-36
sessions)
1 Descriptive paper
(Humensky, 2013) Becker, 2011, Longitudinal
Design
N= 59 (39 male, 20 female)
Intervention continued until
successful termination, loosely
defined as elimination or
substantial reduction of the
presenting problem(s), such that,
by consensus of therapist,
child/teen, and parent(s),
treatment was no longer
warranted. Number of sessions
were not tracked or reported.

Continued
Table 3 Continued
Natural Suarez, 2014, Longitudinal See above See above
Termination Design
N= 100, 69 youth & 31
caregivers
Participants allowed to receive
services as long as needed
following enrollment.

Vankanegan, 2019, Longitudinal

Design
N= 42 (27 male, 14 females, 1
transgender)
Minimum of 12 sessions
recommended, weekly or
biweekly, 60-180 minutes/
session. Youth can continue on
beyond 12 sessions with
consultation between staff,
guardian, and youth.

Webb, 2014, Longitudinal

Design
N=72 (46 female, 26 male)
Followed TF-CBT protocol of
12-16 sessions, 60-90 minutes in
length. No data reported on full
completion beyond 11 sessions;
mean treatment dose was 9.79
sessions.

Humensky, 2013, Descriptive

Paper
Latina females, ages 12-18
Programming offered as long as
seen beneficial for the youth, or
until youth ages beyond 18
years.

Continued
Table 3 Continued
Targeted Population
Gender 1 Level III Study Male only (Beltran, Beltran, 2016, Prospective See above. See above.
(Beltran, 2016) 2016) Cohort Design
N= 10, average age 10.3 years
1 Level IV Study Female only Boys, ages 8-12 years, who were
(Suarez, 2014) (Suarez, 2014; receiving treatment at an urban,
Humensky, 2013) community-based, mental health
1 Descriptive paper center
(Humensky, 2013)
Suarez, 2014, Longitudinal
Design
N= 100, 69 youth & 31
caregivers
Females, ages 11-18

Humensky, 2013, Descriptive

Paper
Latina females, ages 12-18

Ethnicity 3 Level III Studies African American Allen, 2012, Quasi-experimental See above. See above.
(Allen, 2012; Hoskins, (Allen, 2012; Design
2018; Patterson, 2018) Patterson, 2018) N= 60 (35 females, 25 males)
African American adolescents,
2 Level IV Studies American Indian ages 9-15. Setting: community
(Goodkind, 2012; (Goodkind, 2012) center in Philadelphia, PA.
Young, 2018)
Latino (Hoskins, Patterson, 2018, Prospective
1 Descriptive paper 2018; Humensky, Cohort Design
(Humensky, 2013) 2013; Young, 2018) N= 12 (8 male, 4 female)
African American, ages 5-9.
Setting: nonprofit neighborhood
afterschool program for at-risk
children ages five to 15 in a
medium sized city in the
Southeastern United States.

Goodkind, 2012, Longitudinal

Design
N=18 (14 female, 4 male)
Sovereign American Indian
tribal nation in New Mexico.

Continued
Table 3 Continued
Ethnicity Hoskins, 2019, Prospective See above. See above.
Cohort Design
N= 16 (6 male, 10 female)
Latino youth, ages 8-16 years,
and their caregivers were
recruited from an urban
community in California.

Humensky, 2013, Descriptive

Paper
Latino females, ages 8-12, in
urban New York areas.

Young, 2018, Longitudinal

Design
N=7 (57% female, 85%
Latino/Hispanic)
Adolescents, ages 12-15,
English-speaking, 85%
Latino/Hispanic identifying. The
program was intentionally
designed to address the Latino
community.

Culture 1 Level IV study Urban (Becker, Becker, 2011, Longitudinal See above. See above.
(Becker, 2011) 2011) Design
N= 59 (39 male, 20 female)
Aimed to intervene with under-
served children in an
impoverished section of San
Diego. Participant ages 4-19.
Figure 1. PRISMA Diagram

Identification 1837 studies identified through 395 duplicates removed

database searching

1442 studies screened 1346 studies irrelevant

Screening

96 full-text studies assessed for eligibility 80 studies excluded

Wrong patient population (n=25)
Eligibility

Wrong outcome variables (n=12)

Wrong setting (n=13)
Wrong study design (n=19)
Results not available (n=4)
Wrong comparator (n=2)
Wrong intervention (n=3)
Systematic review- relevant articles hand-pulled (n=2)
Inclusion

16 studies included in final review

Figure 2. Concept Map
Figure 3. Oxford Levels of Evidence

55
 Appendix B: Needs Assessment

Format: Phone call interview

Date: November 19, 2019
Participants: Stephanie Powers and Shannon Joyce

Summary of phone call:

Potential involvements in programming through local partnerships:
 Villedge- adolescents in foster care system on verge of being incarcerated
o Partnership discontinued January 2020
 Bloc- tutoring and after-school program in neighborhood of Price Hill
o Approximately 20-30 kids come regularly (ages 2-15 years old)
o Education Program
 Education Coordinator- Maggie Hare
 Planning to expand to a refurbished education center
 Sensory-rich environment- desiring OT perspective
o Tutoring Room
 Assist students with homework after school
o Free-play activities
 Play with purpose
o Nurture Group
 On Thursdays from 5:00pm-5:30pm
 Interested in incorporating more self-regulation activities

Needs of Back2Back Cincinnati/programming:

 Self-regulation
 Emotion expression
 Family engagement
 Conflict resolution
 Educational support & advocacy
 Informing broader community of program offerings

Factors impacting occupational performance:

 Substance use
 Poverty
 Inconsistent housing
 Food insecurities
 Transportation (access & learning how to drive)
 Inadequate clothing (too big or too small impacting physical movement)
 Hygiene (awareness & access to resources)
56
 Appendix C: Case Report

Implementing a Family-Based, Trauma-Informed Intervention in a

Disenfranchised Urban Neighborhood: A Case Report
Key Words: adverse childhood experiences (ACEs), trauma-informed, community-based,
urban, family engagement
ABSTRACT
INTRODUCTION: Guided by literature, it is proposed to implement a twelve-week community-
based psychotherapeutic group intervention program for children and caregivers in a
disenfranchised urban neighborhood located on the western side of Cincinnati, Ohio. The
purpose of the intervention is to educate families on causes, consequences, and symptoms of
psychological trauma while simultaneously intervening for the purpose of healing from trauma
through the instruction of self-regulation and coping strategies. This intervention takes a family-
based approach to support sustainable healing from trauma with the ultimate goal of ending
generational trauma. INTERVENTION: The intervention approach supported by the literature
was not implementable at the targeted facility within the time frame of the capstone experience.
An implementation analysis was completed to examine adoptability, appropriateness, and
feasibility for future implementation of an adapted intervention. OUTCOMES: Feasibility scored
the lowest out of the three outcome measures, which may be explained via the primary
limitations of implementation being relationships with potential participants, partnership
endorsement, and facility access and/or limitations. CONCLUSION: Recommendations for next
steps include to further rapport with local families, investigate barriers to regular attendance, and
continue to strengthen partnership relationship to establish common goals for families and the
community.
INTRODUCTION
The targeted community of Price Hill is an urban neighborhood in Cincinnati stricken with
generational poverty and adversity. With a median household income of $13,355 per year, nearly
half of all Price Hill residents live in severe levels of poverty (Cincinnati Health Department
[CHD], 2017). Children across Cincinnati have elevated risk of exposure to adverse childhood
experiences, and 31% of Cincinnati minors report having at least two ACEs before the age of 18
years old (Child & Adolescent Measurement Initiative, 2016). The neighborhood of Price Hill is
one with almost constant adverse experiences, including poverty, substance abuse, neglect,
abuse, community violence and single-parent households, that are inflicting the holistic
development of children. Early intervention is essential to combat the lasting effects of childhood
adversity. Research has identified a dose-response relationship between ACEs and a large variety
of negative health outcomes beginning in early childhood and extending across the entire life
span, which in it of itself can be shortened due to trauma (Bucci et al., 2016). Further researched
has recognized that trauma caused by relationships can most effectively be healed through stable
57
and loving relationships (Purvis et al., 2013). Therefore, it is highly beneficial for trauma-
informed interventions to involve caregivers and/or trusted adults to promote healing through
healthy attachment. Currently there are just three health centers in Price Hill specializing in
behavioral and mental health. While these health centers are marketed to address the
psychological impacts of trauma, and even offer family psychotherapy, access to these clinics are
limited by insurance coverage, community knowledge of the need for trauma intervention, and
the broad stigma associated with seeking mental health services.
As a result of a scoping review on community-based trauma-informed intervention strategies, the
proposed intervention is as follows: twelve weekly parent-and-child hybrid sessions initiated by
a family meal, followed by breakout sessions for children and caregivers to address coping
strategies, self-regulation, and trauma-competent care strategies, and concluded with a group
activity selected by participants. The intended facility for the intervention is the Bloc Ministries
building where current after-school programming is conducted. This intervention is unique in
that it not only brings valuable resources directly into the community of Price Hill, but also into a
space that has already been recognized as being trusted and safe by residents. Additionally, the
intervention is designed to be culturally sensitive and supportive of family values through the
incorporation of family meals and group activities selected by participants. This intervention is
also imperative to bringing sustainable trauma healing to Price Hill as it enables parents and
caregivers to learn and heal from their own traumatic histories while simultaneously giving them
an opportunity to be a buffer for their children against further trauma.
BACKGROUND
Back2Back Cincinnati currently works in partnership with Bloc Ministries in Price Hill to run an
after-school program with homework assistance three days a week, and reading tutoring one day
a week, amounting to about seven hours of engagement with children who all exhibit symptoms
of chronic stress and trauma. Bloc Ministries’ main objective for the Bloc facility and
programming is for it to be a “safe haven” for children to escape from the traumatic realities of
daily life in Price Hill. The partnership between these two organizations was formally established
in early 2018 to bring more trauma-informed care into the programming, although Bloc
Ministries has been offering services in Price Hill since 2007. Decisions for any implementation
of new approaches or activities, as well as any alterations in programming operations must be
approved through the Bloc Ministries site director. On average, twenty children attend Bloc
after-school daily; and approximately fifty children and families are reached on a monthly basis.
The age range of attendees is between three and seventeen years old, with the average age of
approximately ten years old. While relationships with children are continuously growing,
establishing connections with parents has proved much more challenging. Currently there are
only a handful of established relationships with mothers and grandmothers of attending children,
and no identities of fathers are known by staff. The facility is the first floor of a repurposed
multi-family housing unit that has been renovated to have one open space (approximately 15’ by
30’) containing a snack station, foosball, carpetball, kitchen table for games and crafts, coloring
table, Xbox corner, as well as a single bathroom and a small “homework center” room equipped
with tables, bookshelves, and five laptops.
Problematic behaviors observed in children attending Bloc after-school include low frustration
tolerance, difficulty verbalizing wants and needs, verbal and physical aggression towards others,
and sensory processing deficits. The trauma histories of children vary and are generally more
58
suspected or assumed than directly confirmed through formal assessment. These trauma histories
of attendees noted by staff include unstable housing; unmet basic needs (nutrition, clothing,
hygiene); caregiver substance abuse; living with unsafe parent-figure or adult; verbal, emotional,
and physical abuse; exposure to community violence; and neglect. Back2Back Ministries has
developed a nine-module trauma-competent care training program which has been taught to
every Back2Back staff member and is offered nationwide for professionals and caregivers of
children with trauma backgrounds. These concepts for trauma-competent care have been
gradually implemented into the Bloc after-school program, such as: offering protein-rich meals
and water; supporting self-regulation with chewing gum, hard mints, and fidgets; enforcing the
practice of safe touch and physical boundaries; and utilizing scripts for social engagement. While
these concepts have been embraced at programming, to date, no formal or structured
interventions have been implemented with Bloc participants or families to support the
psychosocial healing from trauma.
ASSESSMENT
Assessment of the facility was completed through staff interviews and surveys, informal
observations, and conduction of psychometric assessments to determine the current status of
operation and potential for implementation of a psychotherapeutic intervention. Informal
observations were conducted by the author over a matter of six weeks to analyze interactions
amongst Back2Back Cincinnati and Bloc Ministries staff, as well as child participant behaviors,
trends in interests, and factors influencing participation in current programming. For
accessibility, a Google form (Appendix E, Figure 6, page 76) was utilized for obtaining survey
responses which incorporated both the psychometric assessments and other subjective opinions
of facilitators and barriers to intervention implementation. Three psychometric assessments were
used to assess three implementation outcomes: “acceptability (Acceptability of Intervention
Measure (AIM)), appropriateness (Intervention Appropriateness Measure (IAM)), and feasibility
(Feasibility of Intervention Measure (FIM))” (Weiner et al., 2017). The format of each of the
three assessments are the same in which respondents are asked five simple questions in which
they are to respond on a five-point Likert scale ranging from strongly disagree to strongly agree.
According to Weiner et al., 2017 acceptability is defined as the perception that the intervention is
agreeable, palatable, or satisfactory; appropriateness is defined as the perceived fit, relevance, or
compatibility of the intervention or evidence-based practice for a given practice setting, provider,
or consumer, and/ or perceived fit to address a particular issue or problem; and feasibility is the
extent to which the new intervention can be successfully used or carried out within a given
agency or setting.
Seven of the eight Back2Back Cincinnati staff involved in programming at Bloc after-school
participated in the survey for implementation analysis. Staff roles/titles of respondents include:
Cincinnati site director, care and competency coordinator, two social workers, mental health
counselor, education specialist, and student mentor. Across the AIM, IAM, and FIM
assessments, acceptability of the proposed intervention scored the highest, with an average
response score of 4.53 out of 5 on a five-point Likert scale. Appropriateness of the intervention
received an average score of 4.07 out of 5. Feasibility scored the lowest with a 3.64 out of 5
average score. More specifically, the lowest rated subcategory in the feasibility assessment was
“the described intervention seems easy to use”. Facilitators and barriers to implementation were
also assessed through multiple-choice responses to a variety of perceived factors. Additionally,

59
respondents were given the option to write in their own response for a facilitator or barrier that
they viewed to be highly influential on implementation. Of the responses, the three factors
perceived to be the largest barriers to implementation include attendance consistency of children
and caregivers, Bloc Ministries partnership buy-in or approval, and space limitations and/or
facility access. The three largest facilitators towards implementation include access to resources
and materials, available staff, and staff education and/or training around the topic of trauma-
informed care. A common theme across interviews with staff and conversations following the
survey consisted of concerns with establishing trust with families, especially with the intention of
using a multi-family group therapy structure for intervention. Others expressed the desire for the
intervention to be more strengths-based and empowering, where can families can learn from each
other, rather than be taught about trauma-informed caregiving from staff.
INTERPRETATION
Interpretations of these assessment results can conclude that while the proposed intervention is
agreeable and satisfactory amongst staff, as well as it is perceived to be fitting for the setting and
population, there is less confidence that the proposed intervention could be successfully
implemented within the current setting or within the current operations of programming at Bloc.
The three largest barriers of attendance consistency, partnership buy-in, and facility access give
reasonable explanation into the reduced feasibility of the intervention. The objectives of the
intervention of being community-based and producing longevity of psychosocial healing will be
unsuccessful without regular participation, support, or adequate space. Overall, it is perceived
that the proposed intervention, derived from current literature, is acceptable and appropriate in its
approach towards sustainable healing from trauma in the community of Price Hill, but the
current operations through partnership, reliance of Bloc Ministries facility, and fragile
relationships with local families limits the feasibility of implementation at this time.
RECOMMENDATIONS
With respect to the most pressing inhibitor towards implementation being consistent attendance
of children and caregivers, it is recommended that the most immediate step towards
implementation be to identify valued incentives and personal barriers among potential
participants that impact ongoing commitment to a program. One identified pattern of individuals
in generational poverty that is suspected to influence regular program attendance is that time
occurs only in the present and the concept of future-oriented thinking, planning, and scheduling
lacks significance (Payne et al., 2001). A system for reminding and recruiting families each week
to come to the program may be essential for increasing attendance rates. The two other
significant barriers, partnership buy-in and facility access, operate in tandem where increasing
the partnership’s acceptance and value of such an intervention could enable more flexible use of
the Bloc facility after programming hours for the purpose to implementing the intervention. It is
recommended that in-depth conversation continues with the site director of Bloc in order to
further the working partnership because it is of extreme value that Bloc Ministries already has an
established presence in the community of Price Hill and is connected with several familial
networks. Of great benefit to the implementation of the proposed intervention is the
qualifications and preparedness of the Back2Back Cincinnati staff to carry out a trauma-
informed, psychotherapeutic program. In addition to all staff members being certified in trauma-
competent care internally through Back2Back Ministries, a licensed mental health counselor has
recently been hired and is knowledgeable of evidence-based psychotherapeutic approaches

60
related to trauma healing which is a significant asset to both the fidelity and penetration of the
intervention implementation. Through this analysis of intervention implementation through
Back2Back Cincinnati in the neighborhood of Price Hill, it has been recognized the overt value
of solid relationships between facilitators, partners, and participants in order for all involved
parties to be committed to the objectives of the intervention. Literature provides evidence that it
is feasible to implement such interventions with similar populations and in comparable settings,
but it is necessary to first endure the gradual building of rapport with stakeholders and local
families who will ultimately benefit from this type of programming.

61
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 Appendix E: Supplemental Documents
Table 4. Implementation Strategies
Strategy: Family Engagement
Actor: Back2Back Cincinnati staff serving
on neighborhood mapping team
and/or involved in programming at
Bloc in Price Hill
Action: Staff engage in regular conversations
with families and build rapport
through: chaperoning children on their
walks home from program, offering
emotional support to caregivers,
inviting caregivers into the Bloc
space, connecting families to local
resources
Target of the action: Price Hill families and caregivers of
children who attend Bloc after-school
programming
Temporality: Communication between staff and
families should begin upon initiation
of Phase 1 of the Strong Families
Program model, at least one month
prior to the start of the program, and
be sustained throughout Phases 1 and
2 families should occur upon initiation
Dose: Staff completes at least one
touchpoint with each family on a
weekly basis, for at least 4
interactions prior to program initiation
Implementation outcomes: acceptability, feasibility, and
sustainability of intervention
Justification: Engagement of families and trust of
community partners are established
through being present in the
community, listening to community
members, acknowledging historical
context of the community, and being
upfront about intentions (Christopher
et al., 2008)
68
Strategy: Facility Access
Back2Back Cincinnati site director,
and support staff invested in program
implementation
Site director educates and collaborates
with Bloc Ministries director to
strengthen rapport, trust, and
understanding of the importance of
the program; and to establish schedule
of facility access, and agreement
between partners on facility use.
Bloc Ministries site director
Communication between site directors
focused on program implementation
should begin at least 6 weeks prior to
start of program. Education of
program elements and triad
communication with both partners and
of Phase 1 of the Strong Families
Program
Site directors to engage in 1 meeting
lasting at least 30 minutes on a weekly
basis to establish consistent and open
communication
Feasibility of intervention
Building trust between organizations
is done so through frequent and
proactive communication, early
establishment of mutual agreements,
and temporal investment in the
relationship (Vangen & Huxham,
2003)
 Table 5. Search Strategy
DOCUMENTING SEARCH STRATEGY WORKSHEET
1
Adapted from Murray Turner, University of Canberra, 2015. Designed for use with the PRISMA 2009 Flow Diagram.
# of Records
# of excluded after # of
Date of Records title/abstract Records
2
Database searched Search Search Terms Filters / Limiters applied retrieved screening3 included
BIBLIOGRAPHIC DATABASES:
((((chil dre n or adol escents or youth or child or te enage r)) AND Full text, publishe d date: 20000101-
(trauma informed care or trauma informed practice or trauma pre sent, humans, english, Age group:
70 66 0
informed approach)) AND (intervention or treatment or therapy child: birth-18 years
PubMed 2019-07-11 or program or strate gy or approach)) AND community-based
((((chil d* or youth) AND (trauma or adverse childhood Full text, publishe d date: 20000101-
experiences or aces or toxic stress))) AND (i nterve ntion or pre sent, humans, english, Age group: 2-
340
program or treatme nt)) AND community 18 years, Search fie ld: title/abstract
PubMed 2019-09-15
R e c o r d i d e n ti fi c a ti o n a n d S c r e e n i n g

( chil dren or adolesce nts or youth or child or te enager ) AND ( Publishe d date: 2000-2019, trial s
trauma informed care or trauma informed practice or trauma or
47 46 0
trauma informed approach ) AND ( intervention or treatment or
Cochrane 2019-07-12 therapy or program or strategy or approach) AND community-
(child or youth or children) AND (trauma OR adverse childhood Publishe d date: 2000-2019, cochrane
experiences OR ace s OR toxic stre ss) AND (i nterve ntion or reviews, i nclude word variations
8
program or treatme nt) AND community
Cochrane 2019-09-15
( children or adolescents or youth or child or t eenager ) AND ( trauma Peer Re viewed; Publ ishe d Date:
informed care or trauma informed pract ice or trauma or trauma 20000101-; Age Groups: All Child;
informed approach ) AND ( intervention or treat ment or therapy or 48 34 6
English Language; Human; Geographic
program or strat egy or approach) AND community-based 
CINAHL 2019-07-11 Subset: USA; Language : Engl ish.
( chil dren or adolesce nts or youth or child or te enager ) AND ( Peer Re viewed; Publ ishe d Date:
traumatic events or traumatic experience or stress* ) AND ( 20000101-; Age Groups: All Child;
729
intervention or treatment or therapy or program or strategy or English Language; Ge ographic Subset:
CINAHL 2019-07-12 servi ce* or approach ) AND commun* NOT brain injur* USA; Language: Engl ish
( chil d or youth or adol escents or children ) AND ( trauma or Peer Re view; Publishe d Date:
adve rse childhood expe rience s or aces or toxic stre ss ) AND ( 20000101-; Age Groups: All Child;
301
intervention or program or treatme nt ) AND community English Language; Ge ographic Subset:
CINAHL 2019-09-15 USA; Language: Enlgish, Expander:
( children or adole scents or youth or child or teenager ) AND ( Peer revie wed, published date: 2000-
trauma informed care or trauma informed practice or trauma or 2019, age groups: childhood (birth-
64 38 6
trauma informed approach ) AND ( intervention or treatment or 12yrs), school age (6-12 years),

69 PsycINFO 2019-07-11 therapy or program or strategy or approach) AND community-

( chil d or youth or adol escents or children ) AND ( trauma or
adol escence (13-17 years), engl ish,
Peer revie wed, published date: 2000-
2019, age groups: childhood (birth-
adve rse chil dhood experience s or aces or toxic stress ) AND ( 76
12yrs), school age (6-12 years),
interve ntion or tre atment or program ) AND community
PsycINFO 2019-09-15 adol escence (13-17 years), preschool
( children or adole scents or youth or child or teenager ) AND ( publication years: 2000-2019, Age
trauma informed care or trauma informed practice or trauma or groups: infant, child, preschool child,
62 59 1
trauma informed approach ) AND ( intervention or treatment or school child, adolescent, publication
Embase 2019-07-12 therapy or program or strategy or approach) AND community- types: article
publication years: 2000-2019, Age
(child or youth or children) AND (trauma OR adverse childhood
groups: child, preschool child, school
expe riences OR aces OR toxic stress) AND (intervention or 88
child, adolescent
program or tre atment) AND community
Embase 2019-09-15
OTHER SOURCES (Eg. handsearching,
etc):

AJOT 2019-07-12 Chil d trauma or stress and community Publication date: 2000-prese nt 1 1 0
I n c l u d eEdl i g i b i l i t y

RECORDS AFTER DUPLICATES REMOVED:4 191 dupl icates 942

STUDIES AFTER FULL-TEXT ASSESSED FOR ELIGIBILITY: 5 16

TOTAL STUDIES INCLUDED IN QUALITATIVE SYNTHESIS: 16

TOTAL STUDIES INCLUDED IN META-ANALYSIS:6 16

NOTES:
1 - PRISMA Statement and 2009 Flow Diagram available at: http://www.pri sma-statement.org/statement.htm
IOM Standard available at: http://iom.nationalacademie s.org/Reports/2011/Finding-What-Works-in-Health-Care-Standards-for-Systematic-Reviews/Standards.aspx
2 - Filters / Limite rs: Provide justifi cation for applyi ng fi lters / li miters to the se arch.
3 - Scre ening search results: Initial scree ning of records base d titl e and abstract information. Keep a log of re cords excluded.
4 - Duplicate record removal : easily achieved by citation manage ment software such as Zotero
5 - Exclusion of full-text articles: Final e xclusion of records based on pre-defi ned excl usion/inclusion cri teria applied to full-text.Add to log of re cords excluded.
6 - Optional step: Only required if including a synthe sis of quantitative data.

Continued
 Table 5 Continued

70
 DOCUMENTING SEARCH STRATEGY WORKSHEET
1
Adapted from Murray Turner, University of Canberra, 2015. Designed for use with the PRISMA 2009 Flow Diagram.
#o
# of exc
Date of Records titl
2
Database searched Search Search Terms Filters / Limiters applied retrieved sc
BIBLIOGRAPHIC DATABASES:
((((children or adolesce nts or youth or child or te enager)) AND Full tex t, published date: 20000101-
(trauma informed care or trauma informed practi ce or trauma present, humans, english, Age group:
70
informed approach)) AND (inte rve nti on or treatment or therapy child: birth-18 ye ars
PubMed 2019-07-11 or program or strategy or approach)) AND community-based
((((child* or youth) AND (trauma or adverse childhood Full tex t, published date: 20000101-
R e c o r d i d e n ti fi c a ti o n a n d S c r e e n i n g

e xpe riences or ace s or toxic stress))) AND (inte rve nti on or present, humans, english, Age group: 2-
340
program or tre atme nt)) AND community 18 years, Search fi eld: title/abstract
PubMed 2019-09-15
( childre n or adolesce nts or youth or child or tee nage r ) AND ( Published date: 2000-2019, trials
trauma informed care or trauma informe d practice or trauma or
47
trauma informed approach ) AND ( inte rve nti on or tre atment or
Cochrane 2019-07-12 therapy or program or strategy or approach) AND community-
(child or youth or children) AND (trauma OR adverse childhood Published date: 2000-2019, cochrane
e xpe riences OR ace s OR toxic stress) AND (inte rve nti on or re views, include word variations
8
program or tre atme nt) AND community
Cochrane 2019-09-15
( children or adolesc ents or y outh or child or teenager ) AND ( trauma Pe e r Revie we d; Publishe d Date:
informed c are or trauma informed practic e or trauma or trauma 20000101- ; Age Groups: All Child;
informed approac h ) AND ( intervention or treatment or therapy or 48
English Language; Human; Geographic
program or strategy or approac h) AND c ommunity-based 
CINAHL 2019-07-11 Subse t: USA; Language: English.
( childre n or adolesce nts or youth or child or tee nage r ) AND ( Pe e r Revie we d; Publishe d Date:
traumati c eve nts or traumati c ex perie nce or stress* ) AND ( 20000101- ; Age Groups: All Child;
729
inte rve nti on or tre atment or the rapy or program or strate gy or English Language; Geographic Subset:
CINAHL 2019-07-12 se rvice* or approach ) AND commun* NOT brain injur* USA; Language : English
( child or youth or adolescents or children ) AND ( trauma or Pe e r Revie w; Published Date:
adverse childhood ex pe rie nces or ace s or tox ic stre ss ) AND ( 20000101- ; Age Groups: All Child;
301
inte rve nti on or program or tre atme nt ) AND community English Language; Geographic Subset:
CINAHL 2019-09-15 USA; Language : Enlgish, Expander:
( children or adole scents or youth or child or teenager ) AND ( Pe e r revie wed, published date : 2000-
trauma informe d care or trauma informe d practice or trauma or 2019, age groups: childhood (birth-
64
trauma informe d approach ) AND ( interve ntion or treatment or 12yrs), school age (6-12 ye ars),
PsycINFO 2019-07-11 the rapy or program or strate gy or approach) AND community- adolescence (13- 17 years), english,
Pe e r revie wed, published date : 2000-
( child or youth or adolescents or children ) AND ( trauma or
2019, age groups: childhood (birth-
adve rse childhood ex perie nce s or aces or toxic stress ) AND ( 76
12yrs), school age (6-12 ye ars),
interventi on or tre atme nt or program ) AND community
PsycINFO 2019-09-15 adolescence (13- 17 years), pre school
( children or adole scents or youth or child or teenager ) AND ( publicati on years: 2000-2019, Age
trauma informe d care or trauma informe d practice or trauma or groups: infant, child, preschool child,
62
trauma informe d approach ) AND ( interve ntion or treatment or school child, adolescent, publicati on
Embase 2019-07-12 the rapy or program or strate gy or approach) AND community- types: article
publicati on years: 2000-2019, Age
(child or youth or children) AND (trauma OR adve rse childhood
groups: child, pre school child, school
e xperiences OR ace s OR toxic stre ss) AND (inte rve ntion or 88
child, adolescent
program or treatme nt) AND community
Embase 2019-09-15
OTHER SOURCES (Eg. handsearching,
etc) :

AJOT 2019-07-12 Child trauma or stre ss and community Publicati on date : 2000-prese nt 1
I n c l u d Ee ldi g i b i l i t y

RECORDS AFTER DUPLICATES REMOVED:4 191 duplicate s

STUDIES AFTER FULL-TEXT ASSESSED FOR ELIGIBILITY: 5

TOTAL STUDIES INCLUDED IN QUALITATIVE SYNTHESIS:

TOTAL STUDIES INCLUDED IN META-ANALYSIS: 6

NOTES:
1 - PRISMA Statement and 2009 Flow Diagram available at: http://www.prisma-stateme nt.org/state ment.htm
IOM Standard available at: http://iom.nationalacademie s.org/Reports/2011/Finding-What-Works-in-Health-Care-Standards-for-Systemati c-Re views/Standards.aspx
2 - Filters / Limite rs: Provide justi ficati on for applying fi lters / limiters to the se arch.
3 - Screening se arch results: Initi al scree ning of records base d title and abstract informati on. Ke ep a log of re cords e xclude d.
4 - Duplicate re cord re moval : easily achieved by citation manage ment soft ware such as Zote ro
5 - Ex clusion of full-te xt articles : Final exclusion of records based on pre -de fined e xclusion/inclusion criteria applied to full-te xt.Add to log of records exclude d.
6 - Optional step: Only re quire d if including a synthe sis of quanti tati ve data.

Figure 4. SIGN Methodology Checklist

Methodology Checklist 3: Cohort studies

SIGN

Study identification (Include author, title, year of publication, journal title, pages)

Guideline topic: Key Question No: Reviewer:

Before completing this checklist, consider:

1. Is the paper really a cohort study? If in doubt, check the study design algorithm
available from SIGN and make sure you have the correct checklist.
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population
Intervention Comparison Outcome). IF NO REJECT (give reason below). IF YES
complete the checklist..

Reason for rejection: 1. Paper not relevant to key question □ 2. Other reason □ (please
specify):
Please note that a retrospective study (ie a database or chart study) cannot be
rated higher than +.

71
 Section 1: Internal validity
In a well conducted cohort study: Does this study do it?

1.1 The study addresses an appropriate and clearly focused question. Yes □ No □
Can’t say □

SELECTION OF SUBJECTS
1.2 The two groups being studied are selected from source populations Yes □ No □
that are comparable in all respects other than the factor under
investigation. Can’t say □ Does not
apply □

1.3 The study indicates how many of the people asked to take part did Yes □ No □
so, in each of the groups being studied.
Does not
apply □

1.4 The likelihood that some eligible subjects might have the outcome Yes □ No □
at the time of enrolment is assessed and taken into account in the
analysis. Can’t say □ Does not
apply □

1.5 What percentage of individuals or clusters recruited into each arm of

the study dropped out before the study was completed.

1.6 Comparison is made between full participants and those lost to Yes □ No □
follow up, by exposure status.
Can’t say □ Does not
apply □
Continued
Figure 4 Continued
ASSESSMENT
1.7 The outcomes are clearly defined. Yes □ No □
Can’t say □

1.8 The assessment of outcome is made blind to exposure Yes □ No □

status. If the study is retrospective this may not be
applicable. Can’t say □ Does not apply □

1.9 Where blinding was not possible, there is some recognition Yes □ No □
that knowledge of exposure status could have influenced
the assessment of outcome. Can’t say □ □

1.10 The method of assessment of exposure is reliable. Yes □ No □

Can’t say □

1.11 Evidence from other sources is used to demonstrate that Yes □ No □

the method of outcome assessment is valid and reliable.
Can’t say □ Does not apply□

72
1.12 Exposure level or prognostic factor is assessed more than Yes □ No □
once.
Can’t say □ Does not apply □

CONFOUNDING
1.13 The main potential confounders are identified and taken into Yes □ No □
account in the design and analysis.
Can’t say □

STATISTICAL ANALYSIS
1.14 Have confidence intervals been provided? Yes □ No □

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize the risk of bias or High quality (++) □
confounding? Acceptable (+) □
Unacceptable – reject 0

2.2 Taking into account clinical considerations, your evaluation Yes  No 

of the methodology used, and the statistical power of the
study, do you think there is clear evidence of an association Can’t say 
between exposure and outcome?

2.3 Are the results of this study directly applicable to the patient Yes □ No □
group targeted in this guideline?

2.4 Notes. Summarise the authors conclusions. Add any comments on your own assessment of the
study, and the extent to which it answers your question and mention any areas of uncertainty
raised above.

73
Figure 5. LEGEND Evidence Appraisal Form

Continued
74
Figure 5 Continued

Continued

75
Figure 5 Continued

Continued
76
Figure 5 Continued

77
 Fi
gure 6. Google Survey

Program Implementation
The purpose of this survey is to help gain a better understanding of the acceptability and feasibility of
incorporating evidence-based practice methods for trauma-informed interventions in Back2Back Cincinnati’s
78
current model of operation. Results from this survey will help to guide recommendations for implementation of
strategies or programming.

In-depth research has brought the conclusion that the best evidence-based intervention for community-based
programming to support the psychological healing of children (ages 2-18) from trauma should be structured as
following: focused on psycho-therapeutic approaches, centered around local and culturally-appropriate
routines/activities, and provided through consistent and scheduled sessions. Current community-based
interventions are trending toward group-therapy sessions and about 50% of interventions are involving parents
or families for at least part of the sessions.

Proposed Intervention
A model of what this programming could look like is: a group of 5-8 children and their parent(s) are invited to
participate in 12 weekly sessions. Each week, the session begins with a 30-minute family-style meal for all
participants before breakout groups are formed for parents, female children, and male children. Parent breakout
groups would focus on 1 weekly topic around stress management, coping strategies, and trauma-competent
parenting techniques. Child breakout groups would consist of yoga-based group psychotherapy (through stretches,
yoga poses, and deep breathing) which is aimed to promote mindfulness, body awareness, and self-regulation.
Breakout groups would last 30-45 minutes. Lastly, parents and children would come back together to play a game
pre-selected by participants (such as Uno) before leaving.

1. Your Role *

Please answer the following questions related to the proposed intervention described above.
Answer the questions with the targeted population being the children and families of East Price Hill whom we serve at Bloc
after-school. Take into consideration the current status of partnership, facility, relationships, and resource access.

Continued
Figure 6 Continued
2. Acceptability of Intervention *

79
 Mark only one oval per row.

Neither
Completely Completely
Disagree agree or Agree
disagree agree
disagree
The described
intervention meets my
approval.

The described
intervention is appealing
to me.

I like the described

intervention

I welcome the described

intervention

3. Intervention Appropriateness *
Mark only one oval per row.

Neither
Completely Completely
Disagree agree or Agree
disagree agree
disagree

The described
intervention seems
fitting.

The described
intervention seems
suitable.

The described
intervention seems
applicable.

The described
intervention seems like a
good match.
Continued
Figure 6 Continued
4. Feasibility of Intervention *
80
 Mark only one oval per row.

Neither
Completely Completely
Disagree agree or Agree
disagree agree
disagree

The described
intervention seems
implementable.

The described
intervention seems
possible.

The described
intervention seems
doable.

The described
intervention seems easy
to use.

5. Barriers: What factors do you feel are MOST LIMITING to implementation of this type of
intervention? (please limit selection to no more than 3) *
Check all that apply.

Time
Space/facility access
Resources/Materials
Available staff
Funding
Partnership buy-in/approval
Training/Education on the topic
Attendance consistency of participants
Interest of the local families
Other:
Continued
Figure 6 Continued

81
6. Facilitators: What factors do you feel are currently MOST SUPPORTIVE of implementation
of this type of intervention? (please limit selection to no more than 3) *
Check all that apply.

Time
Space/facility access
Resources/Materials
Available staff
Funding
Partnership buy-in/approval
Training/Education on the topic
Attendance consistency
Interest of the local families
Other:

7. What other thoughts do you have about structured intervention and psychotherapy-
based programming being a part of Back2Back Cincinnati?

This content is neither created nor endorsed by Google.

Forms

82
Figure 7. Strong Families Program
Excerpts from the Strong Families Program participant guide (Back2Back Ministries, n.d.b)

Continued

83
Figure 7 Continued

Continued

84
Figure 7 Continued

Continued
85
Figure 7 Continued

Continued

86
Figure 7 Continued

87
88