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Understanding and Applying

Trauma-Informed Approaches Across

Occupational Therapy Settings

Claudette Fette, PhD, OTR, CRC

Texas Woman’s University, Denton, TX

Carol Lambdin-Pattavina, OTD, OTR/L

University of New England, Portland, ME

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

The Ohio State University, Columbus, OH

This CE Article was developed in collaboration with AOTA’s Mental Health

Special Interest Section.

ABSTRACT

Trauma and adverse childhood experiences can have lifelong

effects on emotional, behavioral, and physical health. Health

providers, along with state and federal policy makers, are calling

for increasing trauma-informed care and trauma-informed

approaches across health, social service, and education sec-

tors. Occupational therapy practitioners are likely to work with

individuals with a history of trauma across many settings, and

it is imperative to have a working knowledge of ways to support

these individuals. This article outlines basic principles related

to trauma, trauma-informed approaches, and research that may

assist practitioners in understanding how trauma-informed

approaches align with core tenets of occupational therapy and

how to facilitate best care for those they serve across all settings

and environments.

LEARNING OBJECTIVES

After reading this article, you should be able to:

1. Define basic principles of trauma and trauma-informed

approaches

2. Identify research-based outcomes of trauma-informed

approaches across practice settings

3. Identify application of trauma-informed approaches in occupa-

tional therapy

INTRODUCTION TO TRAUMA AND TRAUMAINFORMED APPROACHES

Formal recognition of trauma and its associated implications can

be traced back to the American Civil War, when the effects of

war on soldiers was described by terms such as soldier’s heart and

nostalgia. Terms such as shell shock and battle fatigue were used to

describe a similar phenomenon during World War I and World

War II. The term posttraumatic stress took hold after the Vietnam

War, when interest in developing more targeted interventions for

returning soldiers burgeoned. The third edition of the Diagnostic

and Statistical Manual for Mental Disorders (DSM-III) was released

in 1980 and, for the first time, trauma was officially recognized as

a significant event or series of events that could potentially have

long-standing implications for occupational functioning (Sub-

stance Abuse and Mental Health Services Administration [SAM-

HSA], 2014). Since that time, definitions of trauma and ways to

care for individuals who have experienced it have continued to

evolve.

Currently, trauma is defined as singular or cumulative

experiences that result in adverse effects on functioning and

mental, physical, emotional, or spiritual well-being (SAMHSA,

2018). Examples of trauma include exposure to violence, nat-

ural disasters, bullying, displacement, food insecurity, abuse,

neglect, sexual assault, terrorism, motor vehicle accidents, and

life-threatening military incidences. The original Centers for

Disease Control and Prevention (CDC)–Kaiser Permanente

Adverse Childhood Experiences (ACEs) Study was the first to ask

a large number of people (17,000) about their history of traumatic

experiences in childhood, and it found that childhood trauma is

common (CDC, n.d.). Two thirds of adults reported experiencing

least one ACE, and 1 in 5 reported three or more (Pardee et al.,

2017).

Because the original ACEs study was a retrospective survey of

adults, the National Survey of Children’s Exposure to Violence

was conducted in 2008 to collect data during childhood. Fin-

kelhor and colleagues (2013) highlighted the cumulative harm

experienced when children are exposed to multiple forms of

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childhood victimization. They conducted a regression analysis

and added ACE items based on the 2008 survey, including peer

victimization, property victimization, parents always arguing,

having no good friends, having someone close with a bad illness

or accident, low socioeconomic status, and exposure to commu-

nity violence.

The Office of Juvenile Justice and Delinquency Prevention

and the CDC conducted a national telephone survey of 3,392

school-aged children aged 5 to 17 years old regarding victim-

ization and violence exposure at school, and 74% reported

exposure to some form of victimization (Finkelhor et al., 2016;

Perfect et al., 2016). Finkelhor and colleagues (2016) stated

that 48% of those victimized reported at least one incident

at school. Furthermore, victimization at school increased the

likelihood that children would also be victimized elsewhere.

Children with disabilities reported higher rates of assault and

bullying.

Trauma contributes to mental health and functional difficul-

ties. Individuals with multiple ACEs are more likely to engage in

health risk behaviors and are more likely to be obese, and have

higher rates of heart disease, stroke, liver disease, lung cancer,

chronic obstructive pulmonary disease, and autoimmune disor-

ders than the general population (Oral et al., 2016).

People with posttraumatic stress disorder (PTSD) may also

present with disassociation and increased autonomic reactivity

and/or emotional under engagement, which causes difficulty

in relationships. Oral and colleagues (2016) also reported a

relationship between the number of ACEs and learning and

behavioral problems in children and adolescents, and in somatic

disorders, hallucinations, anxiety and obsessive compulsive

disorders, depression, and suicide attempts in adults. Although

trauma-informed approaches (TIAs) had their initial develop-

ment and implementation in mental health settings, the current

understanding of the effect that trauma has on all body systems,

in addition to the notion that the vast majority of people have

potentially experienced trauma, have made TIAs necessary best

practice in all settings.

SAMHSA (2018) states that a trauma-informed program,

organization, or system:

1. Realizes the widespread effect of trauma and understands

potential paths for recovery

2. Recognizes the signs and symptoms of trauma in clients,

families, staff, and others involved with the system

3. Responds by fully integrating knowledge about trauma into

policies, procedures, and practices

4. Seeks to actively resist re-traumatization

SAMHSA (2018) put forth six core trauma-informed principles:

1. Safety

2. Trustworthiness and transparency

3. Peer support and mutual self-help

4. Collaboration and mutuality

5. Empowerment, voice, and choice

6. Cultural, historical, and gender issues.

TIAS AND THE PUBLIC HEALTH MODEL

Researchers have called for all health care providers and staff

working with children, youth, and adults to apply TIAs and inter-

ventions (Perfect et al., 2016; Soleimanpour et al., 2017). Given

the long-term effects of adverse experiences in childhood, it is

particularly important that all disciplines working in health care

assess trauma; address safety in schools and the community; build

strengths and resilience; and provide opportunities for educa-

tional, economic, and social successes (Shonkoff et al., 2012).

Because trauma is widespread, a public health model is useful

in conceptualizing TIAs at various levels and across different

practice settings. A public health model divides care and health

initiatives into three tiers: universal, targeted, and intensive. In

the public health framework, universal (Tier 1) services are geared

toward universal promotion and prevention among large groups

of people. Targeted (Tier 2) services are directed at individuals

whose experiences place them at risk for developing mental,

emotional, and behavioral difficulties. Last, intensive (Tier 3)

services focus on intensive interventions for individuals with

identified disorders that notably affect function and participation.

A public health model seeks to efficiently allocate resources

by effectively addressing as much as possible at the lowest level

of care, beginning with trauma-informed “universal precau-

tions” applied at a whole population level. At a universal level,

occupational therapy practitioners can use person-centered care

practices, such as telling clients what is going to happen, asking

about their concerns, giving as much control as possible, and

asking what can be done to make them more comfortable (Raja

et al., 2015). All health care providers need to create safe envi-

ronments, recognize common symptoms of traumatic stress,

and shift their responses to better support individuals who are

in distress.

Next, targeted supports are provided to populations who are

at increased risk for behavioral and mental health difficulties,

such as those with disabilities, physical injuries, and chronic

life stressors. Bassuk and colleagues (2017) stated that within

systems serving high-risk, low-income populations, such as

people involved in child welfare and/or homelessness, trau-

matic stress may be nearly universal. They proposed that trau-

ma-informed care (TIC) be implemented in health care systems

serving these populations and recommended the following

guidelines:

1. Establish and disseminate a person-centered standard of

care.

2. Establish collaborative healing relationships between the

provider and the service user.

3. Establish SAMHSA’s six TIC principles as a foundation.

4. Respect all forms of diversity.

5. Understand the effects of trauma, mental health, and sub-

stance abuse conditions.

6. Promote belief that recovery is possible for all.

7. Ensure person-centered care is individualized and transpar-

ent, and be accountable.

8. Form collaborative, interdisciplinary teams that include peer-

to-peer roles.

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The third and highest level of care within a public health

model is intensive interventions. At this level, individuals

with histories of trauma may require expansive and interdis-

ciplinary care, much of which uses trauma-specific inter-

ventions by professionals with advanced trauma skills. See

Figure 1 for a list of TIC do’s, don’ts, and related principles in

action.

Raja and colleagues (2015) stated the importance of under-

standing the health effects of trauma, including coping styles

and behaviors, and the need to respectfully and collaboratively

discuss negative coping behaviors. They also stressed the

importance of knowing your own history and reactions, being

aware of the potential for secondary trauma, and knowing

how to care for yourself and practice “trauma stewardship,”

which is caring for patients without taking on their trauma

yourself.

Standard occupational therapy interventions that focus on

improving function, well-being, and health can support individu-

als with intensive needs. However, it is essential that practitioners

know the limits of their personal knowledge and skills and be

ready to refer when needed by maintaining collaborative relation-

ships with colleagues who have advanced trauma-specific skills.

REVIEW OF TIC LITERATURE ACROSS TREATMENT SETTINGS

Infancy and Early Childhood Settings

Sanders and Hall (2018) asserted the importance of the neuro-

ception of safety provided by a well-regulated nervous system,

beginning in the newborn intensive care unit. They emphasized the

importance of social engagement and shifting from “what is wrong”

with the infant and family to “what happened to them,” and align-

ing with SAMHSA’s six TIC principles: safety, trustworthiness, peer

support, collaboration, empowerment, and cultural competence.

Figure 1. Trauma-Informed Care (TIC) in Action: Do’s, Don’ts, and Associated Principles

Do Don’t Associated TIC Principle(s)

Ask, “What happened to you?” Ask, “What’s wrong with you?” Safety

Always ask preferred pronouns. Assume pronoun based on name or appearance. Cultural, historical, and gender issues

Ask permission for everything. Assume that individuals will be willing to say or do anything

you ask them to do.

• Safety

• Collaboration and mutuality

• Empowerment, voice, and choice

Provide TIC training for all providers and support

staff.

Provide training only for certain staff, based on title or role. • Safety

• Trustworthiness and transparency

• Peer support

• Collaboration and mutuality

• Empowerment, voice, and choice

• Cultural, historical, and gender issues

Administer an Adverse Childhood Experiences

screening to all clients.

Ignore the pervasiveness of trauma in all areas of practice. • Collaboration and mutuality

• Safety

• Trustworthiness and transparency

• Cultural, historical, and gender issues

Assess and follow up with trauma-related needs. Ignore trauma-related needs. • Collaboration and mutuality

• Safety

• Trustworthiness and transparency

Acknowledge that there may be aspects of the

environment that you cannot change to support

well-being, such as loud noises from machines.

Ignore those things over which you have no control. Trustworthiness and transparency

Recognize that trauma manifests in many different

ways, including ﬂat affect, defensiveness, and ag-

gressiveness, and that the individual is likely trying

to communicate with you.

Automatically attribute challenging behaviors to static

personality traits.

Safety

Recognize historical trauma. Dismiss the historical context in which a client is potentially

embedded.

Cultural, historical, and gender issues

Be cognizant of the type of information you are

trying to gather.

Forget that people may be re-traumatized by telling their

story and/or providing information.

• Safety

• Cultural, historical, and gender issues

• Trustworthiness, and transparency

Foster growth and positivity. Assume that individuals cannot change once they have

experienced trauma.

• Safety

• Empowerment, voice, and choice

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All health care providers must recognize the psychosocial

challenges that family members may face and collaborate with

them to build self-efficacy through positive caregiving expe-

riences and opportunities for independent decision making.

Practices to build infant and family adaptive responses include

making sure the mother sees the baby within 3 hours of birth,

skin-to-skin contact or kangaroo care, private rooms, and par-

ents as primary caregivers.

An essential component of trauma-informed practice is

collaboration with all key stakeholders. Watt (2017) stated that

caregivers avoid child welfare systems when those systems fail

to address trauma. Watt (2017) also cited that a trauma per-

spective is not congruent with the current system’s reliance on

diagnosis through the DSM and accompanying problem-ori-

ented focus. When working with children, collaboration means

involving families in making decisions about their children’s

care and the services, systems, policies, and practices that will

affect that care (Dayton et al., 2016).

Dayton and colleagues (2016) also cited training, confidenti-

ality concerns, scheduling, power imbalances, lack of family-ad-

vocate role clarity, and role imbalances as barriers. Clinicians

reported barriers to collaborating through family involvement

as recruiting families that represent patient demographics,

sustaining engagement, leadership buy in, and concerns about

re-traumatizing those families with a trauma history. Addition-

ally, families stated concerns related to the costs incurred, lack

of confidence, and logistics as barriers to collaboration.

Suggestions offered to prepare for successful family engage-

ment include:

1. Identify champions

2. Adopt a vision and specific goals

3. Deliberately build buy in with staff and management

4. Create the family-advocate role description

5. Orient staff

6. Identify a staff mentor and develop their role description

7. Establish compensation for family advocates

Dayton and colleagues (2016) also stressed the importance

of ongoing recruitment and support for family voice, ensuring

that family input is heard, creating meaningful roles, training the

whole team, mentoring and monitoring workloads, holding meet-

ings at convenient times, avoiding jargon, and recognizing and

celebrating family advocates at team and organizational levels.

School Settings

Occupational therapy practitioners need to put on their “trauma

glasses” and frame what they see in the classroom from a

perspective that recognizes common trauma-based responses

in children and youth to recognize potential triggers, so they

can help students feel safe and cope effectively. Perfect and

colleagues (2016) asserted that all school staff need to be

trauma informed, and schools should use trauma-informed

interventions. They stated that prolonged or repeated expo-

sure to trauma has negative effects on learning and behavior

and reported that common traumatic stress reactions include

intrusive thoughts, irritability, arousal, anxiety, fear, difficulty

concentrating, dysregulation, aggression against self and others,

dissociative symptoms, somatization, and character issues.

Wong and colleagues (2007) discussed the effects of trauma

on development and learning and their development of the

Cognitive Behavioral Intervention for Trauma in Schools

(CBITS) intervention, which is an established, evidence-based

intervention designed to reduce the negative effect of violence

on students. They reported exposure to violence can result in

psychological, behavioral, and academic problems. Students

exposed to trauma may demonstrate decreased concentration,

irritability and worry, avoidance behaviors, conduct problems,

and/or substance abuse. Chronic traumatic stressors may cause

developmental cognitive changes that reduce students’ ability to

focus, organize, and process information.

CBITS is a school-based individual and group intervention

and training program to support children exposed to commu-

nity violence (Wong, 2018). It aims to reduce PTSD symptoms,

depression, and behavioral problems, and to facilitate better

overall functioning, grades, attendance, support, and coping

skills (https://cbitsprogram.org).

The online Trauma Sensitive Schools Training package

is another recent addition to the resources available to sup-

port-trauma informed practice in schools (Guarino & Chagnon,

2018). Its resources walk through what trauma is, the stress

response system, the effect of trauma exposure, and how schools

can meet the needs of students (https://safesupportivelearning.

ed.gov/trauma-sensitive-schools-training-package).

After Hurricane Katrina, Cohen and colleagues (2009) ran-

domly assigned New Orleans students to test two types of inter-

ventions, CBITS or Trauma-Focused Cognitive Behavioral Therapy

(TF-CBT), during the next school year. They reported both CBITS

and TF-CBT were effective at reducing trauma symptoms but sug-

gested using CBITS as a Tier 2 or targeted intervention, and using

TF-CBT at Tier 3 with the students and their families participating

in collaboration with community mental health providers.

Whiting (2018) highlighted the distinct knowledge and skills

that occupational therapy practitioners can contribute to working

with children who have been affected by ACEs. Using a trau-

ma-informed, sensory, relationship-based approach, school-based

practitioners can help educate school staff on trauma and its

effect on children’s academic performance, and collaborate with

teachers and other school behavioral health team members. Their

role is to facilitate participation in childhood occupations, such as

education, social interaction, and play. They can identify problem

areas and support self-regulation strategies, and contribute their

skill in analysis of environment, tasks, and routines.

At a Tier 1 level, first author Claudette Fette facilitated dis-

trict-wide training using the Trauma Sensitive Schools Package

to frame a Trauma 101 session in a local in-service course in

preparation for the 2018–2019 school year. Participants included

all of that district’s occupational therapists (OTs) as well as many

speech-language pathologists, school psychologists, and teachers.

Next steps will be to reach out to schools that did not have staff

at the training, and to seek to support trauma-sensitive teams

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on individual campuses. At a Tier 2 level, therapists can provide

specific supports to classrooms or groups of children who are at

an elevated risk of having experienced trauma.

Primary Care Settings

Primary care includes health promotion, disease prevention,

health maintenance, counseling, patient education, diagnosis,

and treatment of acute and chronic illnesses, and is carried out

in various settings, including emergency care facilities, physi-

cian offices, and the home (American Academy of Family Phy-

sicians, n.d.). Primary care settings have begun to explore the

tenets of trauma, train staff, and address the potential for both

the physical and social environments to traumatize or re-trau-

matize individuals in these settings.

Most recently, the National Council for Behavioral Health

(2017) launched a 3-year initiative titled, “Trauma-Informed Pri-

mary Care: Fostering Resilience and Recovery” to better support

primary care settings in developing best practices for using TIAs

with their clients. Although still in its pilot stage, this initiative

includes developing screenings, evidence-based interventions,

trainings, and policy changes at the institutional level if nec-

essary. Literature in this area is growing as individuals, teams,

and systems attempt to balance the need to be trauma informed

and provide a trauma-sensitive environment with the need to

streamline services and maintain productivity standards, both of

which can depersonalize the health care experience.

In a study by Bruce and colleagues (2018), 147 medical

personnel in physical trauma–related roles completed a 38-item

survey related to their knowledge of TIC and injury-related

trauma, opinions of and competency with TIC, recent use of

TIC, and perceived barriers to TIC implementation. Although

most participants reported understanding aspects of inju-

ry-related trauma, most also indicated the greatest barriers to

using a TIA included decreased competence surrounding TIC

execution, being fearful of re-traumatizing individuals, time

constraints, and needing more training in TIC.

In another study, Green and colleagues (2016) recruited 30

primary care providers (PCPs) who then engaged in a 6-hour

continuing education program on trauma-informed medical

care. A total of 400 patients saw these PCPs either before or

after they received the training and completed a survey related

to perceptions of the patient–provider relationship. Those

respondents who saw the PCP after the training reported

improved partnerships with their PCP.

Additionally, training related to TIC was the central con-

cept of an elective course offered to first-year medical students

attending the Warren Alpert Medical School at Brown Univer-

sity. In a survey completed by 11 students at the conclusion of

the course, participants indicated that TIC should be a part of

medical education, with most indicating that TIC is important

to patient care (mean 4.91 on a 5-point Likert scale) and all

reporting moderate to high levels of competence in their ability

to manage their own vicarious trauma (Nandi et al., 2018).

Finally, another study highlighted the need for an efficient

tool that would enable identification of risk factors and adverse

experiences in the context of a young person’s life (Pardee et

al., 2017). They proposed using the event history calendar and

an expanded ACEs survey and stated the need to recognize the

effect of trauma on health and development when working with

young people in primary care.

Psychiatric Hospitals and Residential Settings

Hodgdon and colleagues (2013) asserted the need for applying

trauma-informed frameworks across staff roles and contexts

(e.g., schools, treatment milieu, individual treatment sessions),

and spoke to their development of trauma-informed capacity

in residential treatment for youth. They focused on teaching

self-regulation and building staff attunement skills to help

them shift from a behavioral orientation to trauma-focused

interactions that reset everyone to focus on building effective

self-regulation.

Even though it was not a focus of the intervention, restraints

were dramatically decreased. Outcomes included decreased

re-experiencing and hyperarousal, aggression and rule breaking,

anxiety, thought-disorder symptoms, somatic complaints; and

increased attention.

Although TIC effectively reduces restraint and seclusion in

inpatient psychiatric hospital settings, knowledge transfer and

implementation of training across entire systems can present

challenges. McEvedy and colleagues (2017) used a train-the-

trainer model to extend TIC and sensory modulation strategies

statewide. They reported that end users still wanted more expe-

riential training components.

Azeem and colleagues (2017) specifically cited occupational

therapy techniques in their discussion of restraint and seclusion

reduction tools in their implementation of the National Associa-

tion of State Mental Health Program Directors (NASMHPD) six

core strategies based on TIC.

The six strategies recommended by NASMHPD are:

1. Foster leadership to initiate and sustain focus, allocate

resources for change, and encourage role modeling.

2. Collect data on restraint and seclusion incidents and share

with staff.

3. Develop the workforce, using principles of recovery-ori-

ented care, person-centered care, respect, partnership, and

self-management.

4. Reduce restraint and seclusion through awareness of trauma,

safety plans, comfort rooms, occupational therapy tech-

niques, and de-escalation.

5. Involve patients and their families in safety plans.

6. Debrief in the moment with emotional support; include

patients and staff, and conduct formal problem-solving

debriefings to look for root causes.

Azeem and colleagues (2017) dramatically reduced

restraint/seclusion incidents in the pediatric unit of a state

hospital from 79 patients in 278 restraint/seclusion incidents

at baseline to 31 restraint/seclusion incidents during the final

6 months of the study.

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Community

Hopper and colleagues (2010) asserted the need for TIC in

homeless shelters and completed a literature review in which

they found the following themes as components of TIC: trauma

awareness, emphasis on safety, opportunities to rebuild control,

and use of strengths-based practices. They found that using TIC

with people experiencing homelessness resulted in increased

self-esteem and relationships, safety for children, cost effective-

ness, housing stability, and consumer satisfaction.

Halasz (2017) asserted the need for a trauma-informed lens

in primary care, especially when working with children in foster

care, to prevent confusing trauma symptoms with other behav-

ioral disorders and to limit inappropriate prescribing.

People who are homeless are more likely to have a history

of ACEs, and homelessness itself can involve trauma, such as

physical violence, sexual assault, and neglect in the form of

social exclusion. People who are homeless are at greater risk for

re-traumatization, but providers seeking to work with this pop-

ulation can facilitate supportive community connections and

opportunities to begin healing (Hopper et al., 2010).

In Canada, OTs work as part of a three-phase interdisciplinary

traumatic stress program in community mental health (Snedden,

2012). In the first phase, they facilitate safety planning, build

coping skills, and develop a Safety and Wellness Recovery Action

Plan. In the second phase, trauma therapists work with survivors

on losses, boundaries, self-esteem, guilt, and forgiveness. The

third phase focuses on engagement in meaningful occupation and

posttraumatic growth and resilience (Snedden, 2012).

Acceptance and commitment therapy focuses on building

psychological flexibility, which is understood as being present

and open to experience, and taking action guided by one’s values

(Harris, 2009). It has been used effectively to reduce symptoms

of PTSD in veterans (Shipherd & Salters-Pedneault, 2018) and

persons who have experienced domestic violence, and in loos-

ening the connection between traumatic events and the person’s

identity (Boals & Murrell, 2016).

Foster Care Populations

According to the Administration for Children and Families

(n.d.), nearly 500,000 children and youth are currently in the

foster care system in the United States. Nineteen percent of

these individuals self-identify as members of the lesbian-gay-bi-

sexual-transgender-queer (LGBTQ) community (Wilson et al.,

2014). Forge and colleagues (2018) researched the concerns

facing young adults experiencing homelessness who had prior

experiences with the child welfare system. Two-thirds of the

LGBTQ study participants reported having experienced child

abuse, and 95% of all study participants reported experiencing

some form of trauma, including sex trafficking, sexual violence,

and being robbed.

Caretakers, staff, and all professionals who work with children

in foster care systems need to have a firm understanding of TIAs.

As an example of a successful approach, the Atlas Project

focused on youth with intensive behavioral health needs in New

York City’s Treatment Family Foster Care and building trauma

knowledge and skills in caregivers and staff (Tullberg et al.,

2017). The Atlas Project developed a partnership between foster

care and a mental health provider, identified a lead champion,

and created a joint organizational plan. They used the Pediatric

Symptom Checklist (Jellinek et al., 1988) and the Child Stress

Disorder Checklist (Saxe et al., 2003) to screen children within

30 days of coming into foster care, then they implemented

trauma systems therapy as a phased treatment, beginning with

a focus on safety, then regulation, and finally maintenance.

Outcomes were increased staff and foster parent understanding

of trauma-related behavior, and their report of having the tools

to respond effectively.

TIAS AND OCCUPATIONAL THERAPY

As occupational therapy practitioners, we can begin by refin-

ing and highlighting areas of our practice that closely align

with TIAs. These include taking a non-pathological view of the

people we serve through respecting the person, seeing their

humanity, and empathizing with their experiences with pain.

Additionally, taking time and care in obtaining the occupa-

tional profile is essential when working from a TIA. Not only is

the profile a highlight of our professional identity and one that

allows us to deeply connect, but it also aligns with the principles

of TIAs, as occupational profiles allow us to build trust, collab-

orate with and empower our clients, and get to personal issues

that are unique to each person we work with.

CASE EXAMPLE: GEORGE

George was adopted into a supportive family in preschool, but

his early years were marked by extreme violence and neglect.

Chronic trauma in his early life changed the wiring of his brain

so that he was hardwired for fight-or-flight responses, which had

enabled his early survival. Even though George was in a support-

ive, loving home, those neurological efficiencies that helped him

survive persisted.

Fast forward to middle school. George was educated in a

behavioral adjustment classroom, where, at the beginning of the

school year, he was mouthing off in class and an aide jokingly

threatened to physically assault him. The remark triggered a

trauma response in George, who became verbally aggressive

and got into the aide’s face. This response prompted a restraint,

which acted as another trigger for George’s trauma.

After several days of multiple restraints per day, George was

suspended from school. He went into homebound education

and began wraparound care with the local mental health center.

His wraparound team included an OT, who functioned as a nat-

ural support for George and his family and worked to support

fidelity to wraparound principles and practices on the team.

After a few months, George began attending a couple of classes

in the school building. He added a couple more at a time until

a year later, at the start of the next school year, he was back in

school full time.

Although not a school district employee, the OT served on

the school team, planning accommodations, and providing trau-

ma-informed resources and encouraging their application. All

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this work supported George, his parents, and the wraparound

team, which met in the school setting.

For children like George, whose needs for intensive, indi-

vidualized supports present at the Tier 3 level, Whiting (2018)

suggested specific contributions that occupational therapy can

offer as part of a multidisciplinary school-based team. Thera-

pists can use task analysis to enable environmental accommo-

dations, teach self-regulation strategies and serve as a resource

to model regulation management strategies during instruction,

and facilitate the development of habits and routines. Whiting

(2018) advocated a sensory, relationship-based approach that

includes body-based interactive activities such as rhythmic,

patterned, repetitive activities that support self-regulation. Such

activities include mindful breathing, listening to music and sing-

ing, humming, doing yoga and other types of physical activity,

and playing circle games.

CONCLUSION

TIC and TIAs should cross the life span and environments. Given

the prevalence of ACEs, an understanding of trauma and the

capacity to respond appropriately is critical across practice settings

and populations. As occupational therapy practitioners who adhere

to holistic care and person-centered interventions, we have a duty

to understand the widespread nature and effects of trauma that are

likely to be part of the fabric of most clients we serve. Using TIAs

will make us better and more caring practitioners.

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Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-8 for details.

Continuing Education Article

CE Article, exam, and certificate

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Final Exam

Article Code CEA0519

Understanding and Applying Trauma-

Informed Approaches Across Occupational

Therapy Settings

To receive CE credit, exam must be completed by May 31, 2021.

Learning Level: Beginner

Target Audience: Occupational Therapists and Occupational Therapy

Assistants

Content Focus:

omain: Client Factors; mental health; Occupational

Therapy Process: Occupational Therapy Evaluation and

Interventions

1. A client is admitted to the emergency department complain-

ing of shortness of breath, feeling dizzy, and self-described

feelings of “nervousness.” Which of the following questions by

the attending physician would be most in concert with the core

principles of trauma-informed care (TIC)?

A. “What is wrong?”

B. “What is happening for you right now?”

C. “Why aren’t you feeling well?”

D. “What makes you think this is a physical problem?”

2. Which one of the following is no t typically considered

traumatic?

A. Witnessing death on the battlefield

B. Emotional neglect by a primary caregiver

C. Intimate partner violence

D. Caregiver arrives late to day care for pick up

3. A trauma-informed approach (TIA) should:

A. Be used with all clients, because anyone has potentially

experienced trauma

B. Be used only when you suspect the client has a history of

trauma

C. Be used in isolation and not combined with other models

or frames of reference

D. Not be used with client unless certification in TIC is

obtained

How to Apply for

Continuing Education Credit

A. To get pricing information and to register to take the exam online for the

article Understanding and Applying Trauma-Informed Approaches Across

Occupational Therapy Settings,

go to http://store.aota.org, or call toll-free

800-729-2682.

B. Once registered and payment received, you will receive instant email

confirmation.

C. Answer the questions to the final exam found on pages CE-8 & CE-9

May 31, 2021.

D. On successful completion of the exam (a score of 75% or more), you will

immediately receive your printable certificate.

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4. Administering an Adverse Childhood Experiences (ACEs) screen

yields which one of the following?

A. Sufficient information for the individual to be diagnosed

with a trauma-related disorder

B. Correlation between the score and potential risk level for

mental and physical health challenges

C. Information regarding the specific trauma-related

incidences

D. Nothing, because occupational therapy practitioners are

not qualified to administer the ACEs screen

5. A patient was admitted to your hospital floor after being

sexually assaulted in a dark corner of a bustling subway tunnel.

You read the electronic medical records and recognize that

she is at risk for being re-traumatized by the excessive sounds

and noises associated with a hectic hospital floor. Which of the

following would you do on first meeting her, given you are a

trauma-informed practitioner?

A. Nothing—she needs time and space to heal mentally and

physically

B. Ask her what aspects of the social and/or physical envi-

ronment might be re-traumatizing

C. Turn the lights off and put a sign on the door to whisper

when people enter the room

D. Develop trust by being with her and supporting her to

control the development of the therapeutic relationship

6. Members of the lesbian-gay-bisexual-transgender-queer

(LGBTQ) community are at greater risk for being traumatized in

the health care system than are their non-LGBTQ counterparts.

Which of the following actions taken by a health care profes-

sional would conform with TIC principles?

A. Make no assumptions and ask all individuals their pre-

ferred pronoun

B. Use pronouns based on how an individual looks and/or

dresses

C. Do not broach the subject of pronouns, as that is a pri-

vate matter

D. Use the pronoun “they” to reflect inclusivity

7. Which one of the following is not true of trauma?

A. Trauma has the potential to remodel the brain.

B. Trauma can be passed from one generation to another.

C. Trauma typically manifests as extreme emotionality.

D. Not all trauma is abuse, but all abuse is traumatic.

8. The hospital where you work has hired an individual with

a trauma history to inform development of policies and

procedures for the organization. This individual will also be

on call for patients when indicated. This reflects which of the

following TIC principles?

A. Cultural, historical, and gender issues

B. Safety

C. Peer support

D. Trustworthiness and transparency

9. An occupational therapist provides training for all staff at a local

community center regarding trauma and principles of using a

TIA. This would be considered what tier of intervention?

A. 1

B. 2

C. 3

D. Population

10. Which of the following was a finding of the original ACEs Study?

A. Trauma is uncommon.

B. Sixty percent of adults reported three or more ACEs in

childhood.

C. Twenty percent of adults reported three or more ACEs in

childhood.

D. Ten percent of adults reported three or more ACEs in

childhood.

11. You are retrieving a student from his classroom to take him to

the occupational therapy treatment room. Which is the best

thing to say or do if using a TIA?

A. “It’s time for our fun in the OT room! Let’s go!”

B. Inform the teacher you need to pull the student out and

then do so.

C. “You know if you go to therapy now, you won’t have to

keep missing class”

D. “Is it all right with you if we go to the OT room to work

on our goals together?

12. Trauma is not a new phenomenon, but the first official

acknowledgement of the experience came in the context of:

A. DSM-I

B. DSM-III

C. DSM-IV-TR

D. DSM-V

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