Teaching kids to cope with stress


There’s no shortage of worldwide traumatic events impacting children. Most recently, a natural disaster in Nepal and protests-gone-violent in Baltimore took center stage. As traumatic as they are, disasters such as these tend not to be as mentally and physically damaging and prevalent as the chronic stressors many of America’s children experience.

There’s no shortage of worldwide traumatic events impacting children. Most recently, a natural disaster in Nepal and protests-gone-violent in Baltimore took center stage. As traumatic as they are, disasters such as these tend not to be as mentally and physically damaging and prevalent as the chronic stressors many of America’s children experience, according to Victor G. Carrion, MD, a pediatric psychiatrist and professor of psychiatry and behavioral sciences, and director of the Early Life Stress and Pediatric Anxiety Program, at the Lucile Packard Children’s Hospital, which is affiliated with Stanford University School of Medicine, Stanford, California.

We need some stress. If a teenager doesn’t care about tomorrow’s exam, there’s a good chance he or she will fail. Children need to be anxious or wary before crossing the street. They need to be hypervigilant if a truck is coming at them, according to Carrion. “The question here becomes: What happens when stress becomes way too much, when it’s too much for the capabilities of a young child?” he says. “We go from a state of homeostasis to a state of allostasis, where stress impacts the physiology of our bodies.”

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Fifteen years ago, Carrion began research to better understand how children fare when they feel, every day, as if a truck were coming at them.

“Everyday stress is going to impact how the brain develops,1 and how the brain develops is going to impact those symptoms of depression and anxiety and posttraumatic stress disorder (PTSD) that we see later in life. If we can understand it better, maybe we can treat it better. Our treatment can be more focused, more targeted,” he says.

Defining chronic stress in kids

There are natural disasters as well as man-made disasters such as terrorism and vandalism. However, much of Carrion’s research is focused on treatment, prevention, and systems approaches to the chronic exposure that some children have to interpersonal violence. Interpersonal violence is exposure to physical abuse, sexual abuse, domestic violence, and community violence. This type of exposure happens across socioeconomic groups and has no geographic boundaries, he says.

There are many terms to describe stress overload in children, including adverse childhood experiences, toxic stress, trauma, and traumatic stress. Carrion says he prefers a term coined in 1993 by McEwen and Stellar-allostatic load-that is the accumulation of all stressors throughout life.2

When it comes to how children deal with allostatic load, there is a common misconception, according to Carrion. Many think nothing happens-that children are resilient. They adjust. Their lives (good or bad) are their versions of normal. “Those generalizations cannot be further from the truth,” Carrion says.

Scientific data suggest children are more vulnerable than adults to traumatic events.3 That makes sense, according to Carrion. Children tend not to be armed with coping skills and defense mechanisms. Their brains and physiologies are developing.

Childhood resilience is a complicated matter. Research has shown, for example, that 70% of children who experience interpersonal violence are not going to develop PTSD.4 That means, 30% do.

“The literature tells us resilience is a mathematical formula with many different variables. We’re trying to figure out all of them, but one important factor that seems to be [important for resilience is] the presence of an adult that was there to give opportunity to listen, to reframe, to support, and to help,”5 Carrion says.

NEXT: What do studies have to say?


Studies expose need for effective treatment

Carrion says that giving children opportunities for education, life balance, and nutrition are integral in building children’s resilience.6

When evaluating children for his research on how the brain reacts to stress, Carrion says it became clear there was a need for new treatments. Commonly used treatments, such as prolonged exposure for PTSD and trauma-focused cognitive behavioral therapy for children experiencing allostatic load, help some but not all children.7

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“I was seeing a vacuum for kids that couldn’t even tell you what the trauma was. They were living a life of adversity that was so chronic that more experiences happened while they were receiving treatment. And it was clear that after therapy was over, things were going to continue,” Carrion says.

Cue-centered treatment

As a result of his research, Carrion developed the Cue-centered Treatment (CCT) for children experiencing ongoing adversity. The treatment allows children to be empowered and to become their own agents of change. In a randomized, controlled trial, CCT was shown to decrease anxiety, depression, and PTSD symptoms-interestingly, not only in children but also in their caretakers (who didn’t participate in the study).8

“We discovered the best way to empower children was through knowledge, through understanding of what trauma is and what PTSD is. Classical conditioning is one of the main ways that we learn. It’s the Pavlovian type of learning, where we associate a trigger with something that happens,”8 Carrion says.

The model in trauma is that trauma occurs and then the child has a response. That response tends to be adaptive-running out, getting under the bed, closing the door.3

A scenario: A child who has been experiencing domestic violence for a year has learned to react by running away. He’s in the classroom, and it’s noisy. The noise and chaos trigger his response, and he runs out of the classroom. The teacher, principal, and peers might see the behavior as bad, crazy, or weird.

The child is likely to label himself as a problem. However, the CCT protocol focuses on telling the child he is not crazy, bad, or a problem. In fact, anyone experiencing what he has would have learned an adaptive behavior. The aim is not to extinguish the learned response of running out, because that’s all the child has.

“What you do is, you work on developing new tools to empower these kids. So, the kid becomes an active participant in developing those tools and identifying those cues. The therapist is just there to guide the child,” Carrion says.

One of the important components of the treatment is that children tend to compartmentalize. They may know the history and trauma that occurred. They may have typical trauma-induced feelings of fear, sadness, and anger, and they may have the adaptive behavior, but they don’t see the connection among what happens, how it makes them feel, and what it makes them do, according to Carrion.8

Cue-centered treatment connects the dots and helps children find words to describe their life’s narrative. It’s important for them to encode the memory properly and for them to have words. The CCT helps them find that voice, which they retrieve when needed. That’s as opposed to retrieving a highly emotional response, which is how kids tend to encode memories when they don’t have words, according to Carrion.

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Carrion and colleagues have found that the model of referring children to a special clinic to develop coping skills falls short of reaching at-risk populations. The best approach, he says, is to go where kids live and go to school.

The researchers conducted pilot studies in areas where the exposure to violence is high. They studied third and fourth graders who received a mindfulness intervention with yoga and were getting good outcomes9 when CBS News picked up on the story.10 The Sonima Foundation partnered with Carrion’s program, as a result of that broadcast, to offer yoga-based intervention, which is a part of the school curriculum at some US schools. The intervention includes yoga, mindfulness, a nutritional component, and coping skills.

However, more data is needed for the US Department of Education to adopt the program. So, Carrion and colleagues have started a longitudinal study looking at cortisol, magnetic resonance brain imaging, and behavioral and academic outcomes among fifth and third graders participating in the program’s curriculum.

“In general, we’d like to see better emotional regulation and improved executive function among children in the intervention group,” Carrion says.

NEXT: Taking a systematic approach


A systematic approach

Lucile Packard Children’s Hospital is involved in 2 care models aimed at providing a systematic prevention and treatment approach for children chronically impacted by trauma.

A coalition, including Lucile Packard Children’s Hospital, the San Francisco (California) Child Abuse Prevention Council, the San Francisco District Attorney’s Office, and the Tipping Point Community (San Francisco) and other partners, launched the Center for Youth Wellness in San Francisco. The care model integrates primary pediatric care with mental health in a trauma-informed system, which means that everyone involved, from the receptionist to pediatricians and the chief executive officer, is aware of the struggles in the community, families, and children. They have been trained on the effects of trauma and how to support families that have gone through trauma. The concept is, children go to 1 place to get their primary care, mental health, and whatever social resources they may need.

Another integrated behavioral health services (IBHS) model at Ravenswood Family Health Center in Palo Alto, California, offers an in-house consultation service for pediatricians. Pediatricians don’t refer patients for a mental health assessment sometime in the future. Rather, they do what Carrion calls a “warm handoff.” They call trauma-trained therapists down to their offices while families are there, and introduce the mental health providers.

“We have data that says there is a significant increase in follow-up for care with this warm handoff,”11 Carrion says.

In a study published online in Clinical Pediatrics in January 2013, Aguirre and Carrion reported that pediatricians who worked with the IBHS team at the Ravenswood Center indicated they were highly satisfied with the availability and quality of services provided by the IBHS team.12

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“They recognize a significant need for behavioral health and described the short-term interventions and therapy as critical. The ability of IBHS clinicians to handle urgent cases and to assess risk was cited as an important asset. The IBHS clinicians described referrals from pediatrics as appropriate,”12 according to the study.

Screening tool in development

One of the goals at the San Francisco center has been to study and develop a screening tool for mental health providers, pediatricians, and others that helps identify at-risk children.

Carrion and the staff are adapting a screening instrument, the Advanced Childhood Experiences (ACE) Study, initially used by Kaiser Permanente for Kaiser’s study on adverse childhood experiences.

“It’s basically a checklist of adverse childhood experiences,” Carrion says. “We’re still studying the best way to use this, but have found we can actually identify those kids that may need that mental health intervention.”

The revised version of the ACE Form from the Center for Youth Wellness has not yet been disseminated. Researchers are working on consistency of use and data gathering before releasing it to pediatricians and others, according to Carrion.

In 1 study, Carrion and colleagues used the screening tool to evaluate data from more than 700 charts at the clinic that transformed into the Center for Youth Wellness and found that 12% of children have 4 or more adverse childhood experiences, and the average age in the sample was 7 years.13 Adverse childhood experience categories included significant trauma, such as having an incarcerated parent or experiencing sexual or physical abuse. They also found that exposure to 4 or more adverse event categories was associated with increased risk for learning and behavior problems, as well as obesity.

“That 12% has double the risk of obesity,” Carrion says.

It takes a team

The pediatrician plays an important role in not only identifying children who need help, but also as part of an integrated care team, according to Carrion.

“It’s very important that we talk about how our youth are all stressed. And it’s not only by violence. There’s stress by perfectionism. There’s stress by performance,” Carrion says. “The stressors are not minor. They really can make vulnerable children commit very serious acts.”



1. Carrion VG, Wong SS, Kletter H. Update on neuroimaging and cognitive functioning in maltreatment-related pediatric PTSD: treatment implications. J Fam Viol. 2013.28(1):53-61. Available at: http://link.springer.com/article/10.1007/s10896-012-9489-2]. Accessed June 4, 2015.

2. McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med. 1993;153(18):2093-2101. Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=McEwen%2C+BS%3B+Stellar%2C+E+(Sep+27%2C+1993).+%22Stress+and+the+individual.+Mechanisms+leading+to+disease.%22. Accessed June 4, 2015.

3. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry. 2002;41(2):166-173.

4. Kilpatrick KL, Williams LM. Post-traumatic stress disorder in child witnesses to domestic violence. Am J Orthopsychiatry. 1997;67(4):639-644.

5. Schneider SJ, Grilli SF, Schneider JR. Evidence-based treatments for traumatized children and adolescents. Curr Psychiatry Rep. 2013;15(1):332.

6. Carrion VG. Youth violence, posttraumatic stress symptoms and learning. California Education Supports Project, Brief Number 6. University of California San Francisco; 2011.

7. Carrion VG, Wong SS. Can traumatic stress alter the brain? Understanding the implications of early trauma on brain development and learning. J Adolesc Health. 2012;51(2 suppl):S23-S28.

8. Carrion VG, Kletter H, Weems CF, Berry RR, Rettger JP. Cue-centered treatment for youth exposed to interpersonal violence: a randomized controlled trial. J Trauma Stress. 2013;26(6):654-662.

9. Rettger JP, Fu MA, Chandler JM, Carrion VG. Developing a youth mindfulness program in a school-based setting: a two-year status report. Poster presented at: American Academy of Child and Adolescent Psychiatry 61st Annual Meeting, San Diego, California; October 20-25, 2014. Available at:  http://med.stanford.edu/elspap/pdfs/Mindfulness_in_Schools_AACAP_2014.pdf. Accessed June 4, 2015.

10. Sonima and Stanford University partner on yoga and mindfulness study. YouTube website. Available at: https://www.youtube.com/watch?v=lak6eJoMU1U. Published April 8, 2015. Accessed June 4, 2015.

11. Richter KP, Faseru B, Mussulman LM, et al. Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial. Trials. 2012;13:127.

12. Aquirre J, Carrion VG. Integrated behavioral health services: a collaborative care model for pediatric patients in a low-income setting. Clin Pediatr (Phila). 2013;52(12):1178-1180.

13. Burke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse Negl. 2011;35(6):408-413.

Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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