Beyond behavior

A new type of therapy takes its cues from trauma

Illustration of a girl with two faces, one looking inward and one looking outward Fall 2015

Hannah Blomdal stood in her darkened front yard, trying to surmount her fear. Her family’s suburban home looked calm, even bucolic, on the April evening. But the 17-year-old’s thoughts were agitated.

A few months earlier, the Redwood City, California, front yard had been the scene of an assault that sent Hannah to the hospital with a broken jaw, a skull fracture and bleeding on her brain. She had almost no memory of the attack, yet felt profoundly unsafe in the yard, especially at night. Her vigil alone there, plotted in advance with her psychotherapist at Lucile Packard Children’s Hospital Stanford, was part of a treatment program intended to help her brain exercise control over the danger signal.

Subconscious tripwires such as Hannah’s fear of her front yard are a long-recognized feature of post-traumatic stress disorder, but we are just beginning to understand the damage inflicted by living with these internal alarms. That’s especially true when intense stress starts early in life. People traumatized in childhood, research now shows, can suffer decades of harm to their physical and mental health.

“Some people think kids are protected by virtue of being kids. In fact, the opposite is true,” says Victor Carrion, MD, director of the Stanford Early Life Stress and Pediatric Anxiety Program and a leader in understanding the long-term effects of childhood trauma. Children are more likely to be harmed by traumatic experiences than adults, scientists have found, and the wounds do not heal without help. Instead, the effects of untreated trauma worsen with time, casting a long shadow over young people’s futures. Yet many pediatricians and psychiatrists aren’t aware that they should ask about children’s experiences of trauma. Absent such information, doctors can easily misdiagnose traumatized children with other psychiatric conditions, such as attention-deficit hyperactivity disorder, which has symptoms similar to PTSD but different origins and treatments.

However, there is good news in the form of a growing movement to get the word out about childhood trauma, coupled with effective new therapies for childhood PTSD. One such approach, a method Carrion developed called cue-centered treatment, was the technique that led Hannah Blomdal to stand in her front yard that spring evening, confronting her fears.

Awakening to trauma

When Carrion was a pediatric psychiatry fellow at Stanford in the mid-1990s, he noticed a curious phenomenon.

“Kids were coming to see me with little notes from their teachers that said, ‘This child has ADHD. Please place on Ritalin,’” Carrion says. Chuckling slightly, he recalls his half-facetious reaction to these missives: “Wow: A diagnosis has been made; there’s a treatment plan; there’s not much for me to do here.”

But after carefully obtaining life histories for several patients, he realized that although some had ADHD, many others had been traumatized by such experiences as abuse, neglect or witnessing violence in their homes or communities. Their reactions — a triad of self-protective behaviors that experts summarize as “freeze, fight or flee” — were being misinterpreted as ADHD’s signature inattentiveness, hyperactivity, aggression and poor cooperation.

“Teachers don’t realize that these out-of-control behaviors are manifestations of fear and helplessness,” says Alicia Lieberman, PhD, a professor of psychiatry at the University of California-San Francisco who studies trauma’s effects on very young children. Like Carrion, she sees many untreated trauma sufferers labeled as problem kids.

Trauma during childhood is widespread. Experts estimate that about a third of U.S. children experience some form of trauma before they become adults, and of those, 3 to 15 percent of girls and 1 to 6 percent of boys develop full-fledged PTSD. But PTSD rates are much higher for kids who experience the worst traumas. More than a quarter of girls who are physically assaulted develop PTSD, as Hannah did. And researchers are also finding that childhood trauma can manifest in other ways, not just as full-blown PTSD.

The worrying realization that signs of childhood trauma were widely misunderstood led Carrion to wonder what trauma really did to his patients. Starting in the early 2000s, he launched a series of studies to track children’s levels of cortisol, a key stress hormone.

Chronic or unresolved trauma changes the body’s cortisol levels, he and other researchers found. The perturbations harm developing nerve cells, according to animal studies. In children, Carrion’s team linked the changes to impaired development and smaller structures in brain centers that form memories, make decisions, and register rewards and pleasure. These areas line up with trauma symptoms: memory, emotion regulation and decision-making are all hindered in people with PTSD.

At the same time that Carrion was studying cortisol and kids’ brains, the question of trauma’s lasting effects was also catching the attention of researchers studying adults. In the mid-1990s, scientists noticed that risk factors for chronic ailments such as heart disease were not randomly distributed in the population, instead concentrating in certain groups. Could childhood trauma help explain the discrepancy?

In 1998, the first of several scientific papers was published from the Adverse Childhood Experiences study, a survey of more than 17,000 adults enrolled in a large California HMO. The researchers tracked 10 types of childhood adversity: emotional, physical or sexual abuse; emotional or physical neglect; seeing domestic violence toward one’s mother; having a parent who was alcoholic or abused drugs, had a mental illness or was incarcerated; and parental separation or divorce. More than 60 percent of survey participants had experienced at least one of these forms of trauma and 12 percent had experienced four or more.

The ACE study connected adverse childhood experiences to a stunningly long list of physical illnesses in adults — ischemic heart disease, liver disease, obesity and sleep disturbances, among others — as well as many mental health issues, such as depression, illicit drug use and suicide attempts. Throughout the studies, researchers consistently found that adults who experienced more types of childhood trauma were at higher risk for each disease or bad outcome.

In 2011, Carrion and San Francisco pediatrician Nadine Burke Harris, MD, published a similar study that focused on Harris’ patients who lived in a violent, low-income San Francisco neighborhood. Risk for learning and behavior problems and for childhood obesity rose with increasing trauma exposure, they found.

The emerging evidence provides a startling contrast to the traditional narrative of why people with rough childhoods don’t do very well, the idea that bad role models and tough circumstances leave them without a map. The old story boils down to kids simply making bad choices. The new story is a lot more complicated: Children exposed to toxic levels of trauma have brains that aren’t well-equipped to handle fear or frustration; to remember things or exhibit the self-control needed for success in school; to avoid self-medicating their bad feelings with illicit drugs; in short, to make good choices. And even when they do make good choices as they mature, these long-traumatized adults are still at greater risk for physical illness than their peers who did not grow up with toxic levels of stress.

In 2012, the American Academy of Pediatrics issued a technical report that summarized much of this evidence and suggested that “many adult diseases should be viewed as developmental disorders that begin early in life.”

“We need to address trauma because it impacts health, period,” Carrion says. “Not just mental health; it impacts physical health as well.”

Building a new treatment

When Carrion began studying trauma, researchers had already scientifically validated more than a dozen trauma therapies, including several variations on play-based therapy for young children and cognitive behavioral therapy for older kids and teenagers. Medications sometimes help alleviate specific symptoms of trauma, but aren’t effective on their own, research has shown. But even with everything that was known about treatment, many young patients still weren’t helped sufficiently by it.

“I realized that what we call ‘PTSD kids’ is a really heterogeneous group,” Carrion says. The existing therapies worked best for children who had experienced a single horrible event in an otherwise stable life. “They could say, ‘Yes, I went through a fire; I have symptoms and when I talk about them, I get better,’” he says. “With other kids, when you ask about traumatic events, they look at you like you have two heads. For them, it’s always happening.”

‘A lot of treatments start by asking, “What are the problem behaviors? Let’s fix them.” But we know that there’s a reason these maladaptive behaviors develop: It’s protective.’

Carrion and his colleagues began developing cue-centered treatment with these kids in mind. Though its techniques overlap with many other trauma therapies, two features set CCT apart. It can address all traumas a child has experienced, rather than asking him or her to pick a single bad event as the focus of treatment. Even more important, it gives kids insight into the “freeze, fight or flee” response. And in CCT, children work with a therapist to develop a tool kit of healthy coping skills that can replace the “problem” behaviors, such as using deep breathing and meditation techniques instead of running away from a setting that makes them panicky.

“Many kids see themselves as bad, a problem, crazy,” Carrion says. “We teach them that their response to trauma is something that was adaptive, and hence it was learned really well by their bodies as a good response. But when the response is maintained and triggered by reminders, it becomes maladaptive.”

“A lot of treatments start by asking, ‘What are the problem behaviors? Let’s fix them,” says Hilit Kletter, PhD, a clinical instructor in psychiatry and behavioral sciences who worked with Carrion to develop CCT. “But we know that there’s a reason these maladaptive behaviors develop: It’s protective.” Taking away a child’s sole defense without providing a healthy alternative can backfire, Kletter says. “They’re going to fight you to keep their one tool, so we don’t try to take it away; we offer alternatives.”

In the first randomized controlled trial of the treatment, published in 2013, Carrion and Kletter studied 65 children who had each experienced at least two and an average of five traumatic events. After 15 weekly counseling sessions, the kids had fewer PTSD symptoms. Their caregivers, who attended four of the sessions, also had less anxiety and depression. The scientists are now sharing the method: A manual for therapists describing how to conduct the treatment is in press. And although CCT was developed for children with ongoing adversity, it’s also proving useful for kids who experienced a single trauma.

Carrion is optimistic that the treatment will make a durable improvement in kids’ lives.

“Kids get it,” he says. “They can say, ‘That’s what’s happening to me,’ and become their own agents of change.”

Portrait of Hannah Blomdal
A year after a brutal attack, Hannah Blomdal has returned to the softball field.

A surprise attack

Unlike many traumatized children, Hannah Blomdal was not raised in a milieu of disaster. Before she was attacked in late 2014, she was an accomplished high school senior who was preparing to apply to a half-dozen top universities. She loved playing catcher and outfielder on her competitive softball team and adored her family’s four dogs. Her parents, Kim and John, had made their suburban home a welcoming place not only for Hannah and her older sister, Meghan, but also for the girls’ friends. Two months earlier, Hannah’s best friend, Caitlin, had even moved in with the family, and the friends were so close that Hannah thought of her as another sister.

On Oct. 31, Hannah, Meghan, Caitlin and another friend, a young man who also lived with the Blomdal family, went to a parade in San Francisco for the Giants baseball team, which had won the World Series two days earlier. Later that evening, still dressed in their Giants gear, Hannah and Caitlin left the Blomdal house together to visit a local street known for its over-the-top Halloween celebrations.

After a few hours, the two girls came home. Hannah can recall almost none of what happened next.

Sometime later, the young man returned to the Blomdal house. He texted Hannah’s phone for help, saying he had lost his keys. But when she answered the front door, he attacked her. The Blomdals still aren’t sure if he used a weapon; Hannah remembers only her urge to scream.

When Hannah opened the front door, Kim and John were asleep in their room in the back of the house. At night, John uses a continuous positive airway pressure machine to help him breathe, and the noisy device at first masked Hannah’s screams. However, a neighbor heard her yelling, came outside to investigate and found Hannah in the street. The attacker assaulted the neighbor too. (The attacker later pled guilty to charges associated with both assaults and is now serving a prison term.)

Hannah’s injuries were severe. She was rushed in an ambulance to Lucile Packard Children’s Hospital Stanford for emergency surgery. Her surgeon, Gerald Grant, MD, used eight titanium plates and 64 surgical staples to put her skull back together.

Her jaw had been broken in two places, but Grant decided to let that heal on its own. He stitched up a large cut in her face.

After surgery, she spent a few days in a medically induced coma.

“It’s almost surreal, watching your daughter go through something like that,” Kim says. “You just put one foot in front of the other, hold your spine straight and walk through it; you can’t fall apart.”

When Hannah was discharged from the hospital on Nov. 5, her family was not sure what to do next.

“We were concerned for her physical and emotional health,” Kim says.

“And mental health, too,” adds John.

They are having this conversation sitting in their living room on a warm May afternoon, with Hannah in an armchair near both of them. Hannah looks healthy, and she is — she has just finished her spring season of softball, playing with as much enthusiasm as ever. The only visible remnant of the attack is a thin, white scar, perhaps 3 inches long, on her right cheek.

But John looks pained, as though his worry about his daughter’s recovery is still fresh. Using Hannah’s childhood nickname, he articulates what he was thinking when she first came home from the hospital: “How can we get Hootie as close back to where she was as possible?”

A 15-week road map

“I was kind of in shock,” says Hannah, recalling the weeks after the attack. Exhausted and struggling to recover from her injuries, she missed more than a month of school. In late November, she began cue-centered treatment with Kletter.

“I didn’t realize how out of tune with myself I was,” she says. “It was not until I started to sit down for an hour once a week, talking with Dr. Kletter, that I was able to have a full thought about it.”

“She was vacillating between being overwhelmed and feeling numb,” Kletter recalls. Because Hannah couldn’t remember the assault, it seemed unreal, like something that had happened to someone else. Although she lacked a conscious memory of the attack, certain things related to it sparked intense fears, such as standing in her family’s front yard. The fact that her attacker had lived with her family left her feeling especially vulnerable, wondering how she could ever again suss out others’ motives. And she wasn’t sure how to ask family and friends for help in handling her feelings, or even if she should.

“She’s very competent,” Kletter says. “She places a lot of expectation on herself that she should be able to do things, and not rely on others.”

Worst of all, she had lost her sense of momentum.

“When Dr. Kletter started to ask me what I thought about my priorities now, and where I could see myself going, that was a really big surprise,” Hannah says. “It wasn’t on my radar. I was taken aback.” Before the assault, she had never questioned her desire to go away to college; now “it was a really big question.” Maybe instead, she thought, she should just “stay at home and lay low.”

‘PTSD doesn’t disappear by itself. It feeds on avoidance. If you don’t recognize it, or if a family tries to hide their big secret, or if a child doesn’t have words to describe what happened, it gets worse.’

In this context, the road map Kletter described for 15 weeks of cue-centered treatment was a relief to the Blomdals, reassuring them that Hannah was expected to make clear, measurable progress.

The therapy began with a few sessions for Hannah and her parents about the trauma reaction, as well as an assessment of Hannah’s entire medical history. Kletter helped Hannah list her existing coping tools — meditation, exercise and listening to music — and figure out what new strategies she needed. They talked about how she could reframe her negative thoughts and how to manage panic before it got out of control.

Then, Kletter had Hannah tell the story of the attack. They also charted major events of Hannah’s life, rating each as positive, negative or neutral.

“The trauma, even though it felt like everything, was one point on the giant graph that was my life,” Hannah says. Seeing the chart helped her give more weight to positive events such as starting softball, which “sparked this big love, this passion I had for the game for so long.”

Next, Kletter and Hannah identified the triggers of Hannah’s strongest fears: being in her front yard, especially alone and at night; answering the front door; being home alone at night; Halloween; and scary movies. Between therapy sessions, Hannah practiced changing her response to each trigger, first imagining herself dealing with each scenario and then exposing herself to it in real life. As she did so, she rated her anxiety on a scale of 1 to 10. If it rose above a 3, she used one of her coping skills to handle it.

Her family helped. Her parents arranged for surprise visitors so that Hannah would have to answer the front door at unexpected times, and Meghan and Caitlin stood with her in the front yard as she worked up to the spring evening when she was first able to stand there alone. Gradually, she also figured out how to tell everyone what she needed: when she wanted to talk about the trauma; when she wanted them to stop tiptoeing and just treat her like her old self.

“Coming back to school, it felt like people weren’t looking at me; they were looking at my story,” she says. “They were not really making eye contact. It was, ‘She’s had a rough year.’” She tried to help her friends understand that she had not been eclipsed by one terrifying, random event: “I do appreciate your support, but I’m still here!” she says now.

“I could really see a shift in her energy,” says Kim. “There were glimpses of her confidence coming back.”

As Hannah’s treatment progressed, her confidence and momentum grew. She started hearing back from colleges to which she had reluctantly applied. She had been admitted to five schools, and decided to attend the University of California-Santa Cruz.

Trauma-informed care

Carrion sees stories like Hannah’s as a hopeful contrast to the directions that PTSD can take someone if it’s never addressed.

“Let me tell you, PTSD doesn’t disappear by itself,” he says. “It feeds on avoidance. If you don’t recognize it, or if a family tries to hide their big secret, or if a child doesn’t have words to describe what happened, it gets worse.

“And the pity is that it is so treatable. But if we don’t recognize our own traumas, they don’t just go away.”

Today, he’s focusing his work on two key areas: helping the health-care system recognize trauma, and boosting children’s resilience.

In the mid-2000s, Carrion was one of several experts who helped found a trauma-informed clinic in San Francisco’s impoverished Bayview neighborhood, where he had done much of his cortisol research. (San Francisco pediatrician Nadine Burke Harris, the San Francisco Child Abuse Prevention Council, the Tipping Point Community Foundation and then-district attorney Kamala Harris were also involved.) The Center for Youth Wellness, as the clinic is now called, has become a model for how to care for traumatized kids.

A key step in this caregiving, Carrion says, is eschewing the traditional, singular focus on checklists of a child’s symptoms or “bad behaviors.”

Lieberman, at UCSF, puts it this way: “Doctors don’t ask, ‘What happened to this child?’ Instead they think, ‘What’s wrong with this child?’”

Parents, too, may not want to look at what’s really going on, especially if a parent is causing the problem. “Many times the parents don’t put two and two together; they have defenses against understanding the impact of the child’s experience on the child,” she says.

Government officials are turning resources toward child trauma. In February, Kamala Harris, now California’s attorney general, launched the Bureau of Children’s Justice to advocate for disadvantaged children, including those in foster care, in the juvenile justice system and living with a lot of trauma.

Nonprofit efforts are taking shape, too. Futures Without Violence, a nonprofit public benefit corporation that led work to pass the federal Violence Against Women Act in 1994, is now at the forefront of a movement to stop violence against children. Carrion has been involved in both efforts, and also serves on the California Mental Health Services Oversight and Accountability Commission. “To address childhood trauma, we need broad solutions that extend from neuroscience to advocacy and policy,” he says. “Our program’s activities span the whole spectrum.”

The challenge of resilience

One of the more puzzling features of childhood trauma is its ability to elicit extremely varied reactions: Some survivors are badly debilitated, while others respond with great strength and creativity, a phenomenon known as post-traumatic growth.

“People who are highly traumatized have become extraordinarily creative and successful, but may also have episodes of deep depression and maladaptive relationships, and as parents they might be perpetuating the same problems with their children,” Lieberman says. “But because they’re so successful, nobody’s looking behind the façade.” She recalls a throwaway lecture comment by the late Norman Garmezy, a pioneer of resilience research: “But of course, when you talk to these very resilient people who have overcome great difficulty, they tell you how much they suffer when they are alone, when they’re not trying to show their successful persona to the world.”

Carrion’s next project aims to prevent that suffering. He’s leading a large study of teaching yoga and mindfulness meditation to children in schools throughout the Ravenswood City School District, which includes East Palo Alto and parts of Menlo Park. These schools, in a low-income community near Stanford, are full of students who live with the sorts of stresses he has studied. In the study, sponsored by the Sonima Foundation, his team is providing its curriculum to 3,400 students from kindergarten to eighth grade, and testing the program’s effects in a subset of third- and fifth-graders. They will assess the kids’ behavior and study their cortisol levels, sleep patterns and brain scans. The team hopes the training will give kids better ability to handle stressors that could derail them, ranging from everyday frustrations to full-blown trauma. So far, their pilot data look promising.

Coming to terms

At the end of Hannah’s therapy, she retold the story of the Halloween night attack, giving Kletter a fresh take on the narrative she related at the start of her treatment. Together, they compared the two versions.

“It was easy to see that not only the way I was describing it, but also my emotions, thoughts and body feelings were less anxious than before,” Hannah says.

In the first telling, Hannah worried about what she should say. Would it be believable? Would it be enough?

In the retelling, Hannah took charge but also viewed her story from a wider lens, Kletter says. “She was coming to terms with, ‘This happened, but it’s not the defining point in my life; I have something to look forward to and focus on,’” she adds. “I was seeing a sense of hope in her.”

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Erin Digitale

Erin Digitale is the pediatrics senior science writer in the Office of Communications. Email her at

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