Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Separation

Child Abuse & Neglect 92 (2019) 179–195

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Child Abuse & Neglect journal homepage: www.elsevier.com/locate/chiabuneg

Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Separation

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Judith A. Cohena, , Anthony P. Mannarinob a Department of Psychiatry, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, 4 Allegheny Center, Pittsburgh, PA, USA b Department of Psychiatry, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, 4 Allegheny Center, 8th Floor, Pittsburgh, PA 15212, USA

A R T IC LE I N F O

ABS TRA CT

Keywords: Childhood Traumatic Separation Trauma-Focused Cognitive Behavioral Therapy Treatment Posttraumatic stress disorder Family separation Children Adolescents

Objectives: In light of the current U.S. family separation crisis, there is growing attention to Childhood Traumatic Separation, defined here as a significant traumatic stress reaction to a familial separation that the child experiences as traumatic. When living in a family setting, Childhood Traumatic Separation may interfere with the child's relationships with the current caregiver(s). Effective treatments for Childhood Traumatic Grief can be modified to address Childhood Traumatic Separation. This article describes current applications of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Childhood Traumatic Separation. Methods: Using two composite clinical cases, TF-CBT applications for Childhood Traumatic Separation are described. These include: (1) implementing the safety component first; (2) tailoring coping skills to address the uncertainty of Childhood Traumatic Separation; (3) integrating past traumas into trauma narration and processing of the traumatic familial separation; (4) providing Childhood Traumatic Separation-focused components to address challenges of committing to new relationships while retaining connections to the separated parent; and (5) addressing role changes. Results: These modifications have been implemented for many youth with Childhood Traumatic Separation and have anecdotally resulted in positive outcomes. Research is needed to document their effectiveness. Conclusions: The above practical strategies can be incorporated into TF-CBT to effectively treat children with Traumatic Separation. Practical implications: Practical strategies include starting with safety strategies; tailoring skills components to address the ongoing uncertainty of traumatic separation; integrating past traumas into trauma narration and processing of traumatic separation; providing traumatic separationfocused components to balance the challenges of committing to new relationships with retaining connections to the separation parent; and addressing role changes. Through these strategies therapists can successfully apply TF-CBT for Childhood Traumatic Separation.

1. Introduction: Childhood Traumatic Separation The United States is currently experiencing a family separation crisis as unprecedented numbers of asylum-seeking families are

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Corresponding author. E-mail addresses: [email protected] (J.A. Cohen), [email protected] (A.P. Mannarino).

https://doi.org/10.1016/j.chiabu.2019.03.006 Received 26 September 2018; Received in revised form 2 January 2019; Accepted 4 March 2019 0145-2134/ © 2019 Elsevier Ltd. All rights reserved.

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detained and separated at the border (Davis, 2018). There is concern that clinicians serving these children are not trained in evidencebased practices, and may be inadvertently engaging in not helpful and potentially harmful practices. It is therefore important for clinicians to understand how to recognize and treat Childhood Traumatic Separation. This article describes current applications of an evidence-based treatment, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Childhood Traumatic Separation. 1.1. Familial separation Children depend on attachment relationships for their sense of self, safety and trust. Children's first and primary attachments are typically with their parents. Some children experience permanent disruption of the child-parent attachment relationship due to parental death, while others experience temporary (albeit often prolonged and unpredictable) attachment disruption through familial separation. The term “familial separation” is used here to refer to situations in which children are separated from a birth parent or other primary caretaking adult; these situations may also involve separation from siblings, grandparents and other important attachment figures. Despite challenges inherent in attachment disruptions, many children adjust reasonably well when they continue to live with other supportive family members. For example, most children who experience a parental death, parental military deployment, or parental divorce adjust to these experiences without developing significant mental health problems. 1.2. Childhood Traumatic Separation However, familial death or separation can lead to potentially serious and long-lasting psychological problems. Following a parental or other familial death that the child perceives as shocking, sudden or frightening (“traumatic”), some children develop Childhood Traumatic Grief (CTG), a condition in which traumatic reactions interfere with the child's grieving process (Brown, Goodman, Falk, & Swiecicki, 2019; Cohen, Mannarinon & Knudsen, 2014). In CTG, children develop both trauma (posttraumatic stress disorder, PTSD) symptoms in response to the death; and maladaptive grief responses (Brown et al., 2019). Similar to CTG, after a traumatic family separation, many children develop trauma symptoms, and recent empirical research has documented the development of such symptoms in response to traumatic familial separations (Bryant et al., 2017; Rojas-Flores, Clements, Koo, & London, 2017). Traumatic familial separations typically occur under frightening, sudden, unpredictable, chaotic and/or violent circumstances (e.g., those related to familial immigration or deportation, parental incarceration; the child's move to kinship or foster care, or termination of parental rights). The resulting traumatic response has recently been referred to as Childhood Traumatic Separation (National Child Traumatic Stress Network [NCTSN], 2016, 2017, 2018a, 2018b). Childhood Traumatic Separation is thus similar to CTG in that both conditions include development of significant PTSD symptoms in response to the loss of an important attachment figure. However, in distinction from CTG, Childhood Traumatic Separation does not include maladaptive grief symptoms (because the separated family member is still alive); and does not require a unique assessment instrument (as described below). 1.3. Symptoms and detection of Childhood Traumatic Separation By definition, Childhood Traumatic Separation includes separation-related Posttraumatic Stress Disorder (PTSD) symptoms, although importantly, children do not need to meet full PTSD criteria in order to have Traumatic Separation. Clinicians should use a standardized assessment instrument e.g., Child PTSD Symptom Scale for DSM-5 (Foa, Asnaai, Yang, Capaldi, & Yeh, 2018) to assess these symptoms that include intrusive memories, dreams, and/or traumatic reenactment of the traumatic familial separation and/or related trauma experiences; avoidance of traumatic separation reminders or related reminders; negative changes in mood (e.g., worry, sadness, fearfulness, or anger); negative traumatic separation-related beliefs (e.g., about self, others, or the world); selfdestructive thoughts, plans or actions; hyperarousal behavior problems (e.g., aggression, irritability, or anger); problems sleeping, paying attention, concentrating; jumpiness, hyper-alertness to danger; or physical symptoms such as headaches, stomachaches or body pains (NCTSN, 2016). For children who are living in family settings, Childhood Traumatic Separation often also includes difficulties in the child's relationship with the current caregiver. These may include problems such as ongoing questions about the birth parent, the separation and/or reunification; fears about the birth parent's well-being; fear of separating from the current caregiver; excessive clinginess; lack of trust; refusal to interact with the current caregiver; anger at the current caregiver; refusal to accept the current caregiver's parental authority; and/or alternating trust and rejection of the current caregiver due to feelings of “split loyalty” to the birth parent (NCTSN, 2016, 2017, 2018a). These symptoms may manifest differently depending on developmental stage and cultural factors as described below. Before providing trauma-focused treatment, the clinician should conduct a thorough clinical assessment to determine whether the child has another medical or mental health diagnosis that should be the primary treatment focus. 1.4. Vulnerability to Childhood Traumatic Separation Neurobiological studies of children who have experienced traumatic familial separations have documented toxic impacts on brain stress response systems including increased cortisol output, amygdala hyperactivity, and decreased amygdala- pre-medial frontal cortex connectivity (Gee, 2018; Gee et al., 2013). Children's fear sensitization related to prior traumas (e.g., gang or domestic violence that may have led the family to migrate to the new country; child maltreatment that resulted in the child's removal from the parents’ care, etc.) likely increases these children's vulnerability to developing Childhood Traumatic Separation when exposed to familial separation, particularly if the separation occurs under circumstances that are frightening, unanticipated, chaotic, 180

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unpredictable and/or violent (McLaughlin & Lambert, 2017). Since traumatic separation may occur in the context of complex trauma experiences such as child maltreatment, domestic or community violence, some children with Child Traumatic Separation may have clinical presentations consistent with complex PTSD (Cohen, Mannarino, Kliethermes & Murray, 2012). The negative effects of traumatic separation may be long-lasting, and may impact the child's relationship with the birth parent even after family reunification (Zucker & Greene, 2018).

1.5. Developmental considerations Development plays a critical role in how children experience familial separation. Infants and toddlers are most biologically and emotionally dependent on parents for their survival. Upon separation very young children protest through inconsolable crying, rejecting attempts to be comforted by other caregivers, feeding and sleep difficulties, fussiness, and/or not being able to be soothed (Gee, 2018; Gee et al., 2013; NCTSN, 2018a, 2018b; Nelson et al., 2007). Over time they may respond to new caregivers, or may become apathetic and withdrawn, or even develop serious, potentially life-threatening failure to thrive. Preschoolers may cry, scream and cling to avoid separation, and develop traumatic reenactment with the new caregiver in which they develop separation difficulties, become clingy, refuse to separate, have difficulty sleeping alone, repeatedly ask for the parent, and/or cry upon reminders. These behaviors may alternate with irritability and inability to be comforted (Nelson et al., 2007; NCTSN, 2018a, 2018b). School aged children are often confused about the separation and may repeatedly ask about their parents, the separation, why it happened, and when they will be reunited; or these children may avoid the topic altogether. They may regress, become overly clingy and not want to separate from the current caregiver, or be worried, fearful, sad and/or tearful. Alternatively, they may be numb and withdrawn; or angry, distractible, inattentive and/or have behavior problems (Gee et al., 2014; NCTSN, 2016, 2018a, 2018b; Silburn et al., 2006). Teenagers are better able to understand the reasons for the separation, but also may be more likely to attribute blame for the separation (e.g., to the authorities, current caregiver, themselves, or the birth parent). Teens may also feel extreme sadness, depression, numbness, or detachment; feel guilty for becoming close to the new caregiver, or develop anger, fighting, substance abuse, or self-injury (NCTSN, 2016, 2018a, 2018b; Silburn et al., 2006).

1.6. Cultural factors related to Childhood Traumatic Separation Cultural factors may also contribute to children's manifestations of Traumatic Separation. When children are simultaneously separated from their families and other familiar and comforting aspects of their culture such as their own language, clothes, food, customs, religious practices, history, country of origin, and so forth, this will add to their feelings of being lost, alone, and alienated from those around them. Conversely, the degree to which their current caregivers and family speak their language, facilitate children being able to wear familiar clothing, have comfort toys or blanket, eat familiar foods, attend familiar religious services, follow familiar customs and maintain connections to their history and culture without serving as trauma reminders, will tend to facilitate children's adaptive functioning and minimize traumatic responses (NCTSN, 2017, 2018a, 2018b). One research team documented the long term impact of traumatic separation on very young children (Nelson et al., 2007). Romanian women were ordered by Communist rulers to bear at least five children, resulting in thousands of mothers abandoning their children (Sullivan, 2018). Most of these children experienced subsequent neglect while in state-run orphanages. Some were later adopted into families, while others grew up in state institutions. Researchers documented significant variability in children's impacts, with children who continued to live in institutions having the worst outcomes including significantly lower intelligence, greater levels of anxiety, depression, trauma symptoms and interpersonal problems; those adopted into homes had intermediate outcomes, and a community control group had the best outcomes. Adoption into a family setting by two years of age improved outcomes over adoption at an older age due to a “critical period” for attachment (Nelson, Fox, & Zeanah, 2014; Nelson, Furtado, Fox, & Zeanah, 2009; Nelson et al., 2007). To date no research has specifically evaluated the treatment of Childhood Traumatic Separation. The National Child Traumatic Stress Network suggests that, due to similarities in some clinical issues between Childhood Traumatic Separation and CTG (reviewed below), effective interventions for CTG can be used for Childhood Traumatic Separation with appropriate modifications (https:// www.nctsn.org/what-is-child-trauma/trauma-types/traumatic-grief/interventions). Three treatment models have empirical support for treating CTG: Trauma-Focused Cognitive Behavioral Therapy (Dorsey et al., 2018) Trauma and Grief Components Therapy (Layne et al., 2008); and Grief and Trauma Group (Salloum, 2004). Despite the lack of empirical research that has evaluated the efficacy of applying these treatment models for Childhood Traumatic Separation, given the current context, in which an unprecedented number of families are being separated, there is a pressing need to provide generalizable clinical guidance on how to treat children with Traumatic Separation. This article describes current clinical applications of one of these models, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Childhood Traumatic Separation.

2. Clinical issues in Childhood Traumatic Separation The NCTSN has described a number of relevant clinical issues for Childhood Traumatic Separation (NCTSN, 2016, 2017, 2018a). These have many parallels to CTG as described in the following section. 181

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2.1. Addressing safety concerns: Children with Traumatic Separation are often concerned about the safety of the parent from whom they have been separated (hereafter “the separated parent”), as well as the safety of other separated family members; and their own safety. The loss of parental protection may place some children with Childhood Traumatic Separation at heightened risk for experiencing child abuse, particularly those in immigration detention camps and other congregant care settings (e.g., National Public Radio, 2018). In common with CTG, children with Traumatic Separation also may worry about the safety of the current caregiver and have concerns that they will be separated from this new caregiver. In both conditions, the therapist must provide realistic information and reassurance related to the child's own safety; assure that there is a safety plan in place so that the child will be safe; and provide ongoing safety in light of ambiguity and uncertainty. Clinicians must recognize the cumulative importance of this issue for children with complex PTSD. 2.2. Resolving traumatic reactions In Childhood Traumatic Separation, as in CTG, PTSD symptoms are present both related to the traumatic loss of the parent and other prior traumas. Resolving these symptoms entails skills acquisition to manage biological, affective, behavioral, and cognitive trauma responses; recognizing trauma reminders related to both the traumatic loss and to prior traumas and learning to use the new skills in response to these reminders; and cognitively processing of these traumatic experiences, including maladaptive blame of self, current caregiver, the “system”, and/or the separated or deceased parent. In both conditions, the child may minimize prior traumas that led to the separation or death. For example, in Childhood Traumatic Separation the child may minimize or even deny parental sexual or physical abuse that led to the children's removal from the parent's care and subsequent foster placement. Helping the child to acknowledge and resolve trauma reactions related to these prior traumas is an important part of trauma-focused treatment. 2.3. Coping with separation pain and ongoing uncertainty Parallel to the pain of grief and coping with unanswered questions related to the death in CTG, in Childhood Traumatic Separation children must cope with the pain of separation from their parent (and often, other family members, their home, country, school, friends, language, culture, way of life, etc.). In distinction to most children with CTG, many children with Traumatic Separation simultaneously face ongoing uncertainty about why the separation happened, how long it will continue, when and if they will be reunited with the parent and other family members, and what will happen then. This ongoing uncertainty is often the greatest challenge to these children's adaptive functioning. 2.4. Committing to new relationships while retaining connections to the separated parent Unlike in CTG, in which children have no hope of reuniting with the deceased parent, children with Traumatic Separation live with ongoing hope of reunification; thus a common issue in Childhood Traumatic Separation is reluctance to form a relationship with the new caregiver (from whom children might also be suddenly separated), as well as the new caregiver's family members and new peers. If these children do start to form new relationships, they may struggle with feeling disloyal to their separated parent, family, culture, etc. Challenges include addressing loss of trust and emotional distance; the child's fear of repeated loss and/or sense of betrayal, and retaining the child's connection with a separated parent who may have little or no contact with the child and/or who may undermine the child in attempting to form new relationships. 2.5. Addressing role changes Traumatic Separation from a parent, similar to the traumatic death of a parent, may cause the child to abruptly lose or take on a new familial role. For example, older children with Traumatic Separation suddenly may be thrust into caretaking roles for younger siblings (or other young children in congregant care settings). Conversely, the child may suddenly lose a caretaking role for a younger sibling from whom they have been separated (Cohen, Mannarino, & Deblinger, 2017, p. 24). These role changes may disrupt the child's sense of identity and interfere with establishing a positive relationship with the current caregiver. 3. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Trauma-Focused Cognitive Behavioral Therapy (TF-CBT, Cohen, Mannarino & Deblinger, 2012; Cohen et al., 2017; https://tfcbt2. musc.edu/) is an evidence-based trauma-focused psychotherapy model for children ages 3–18 years and their non-offending parents or primary caregivers. Currently TF-CBT has the strongest evidence for treating traumatized children and adolescents, with 21 randomized controlled trials that document its efficacy in treating PTSD and related symptoms for a wide variety of traumatic experiences, including those that are often associated with traumatic separation such as child sexual abuse, domestic violence, complex trauma, commercial sexual exploitation, and children living in foster care (Cohen, Mannarino, & Iyengar, 2011; Cohen, Deblinger, Mannarinno & Steer, 2004; O’Callaghan, McMullen, Shannon, Rafferty, & Black, 2013; Weiner, Schneider, & Lyons, 2009). TF-CBT is a sequential model, with each component building on skills previously learned. Gradual Exposure is incorporated into every TF-CBT component, in order to help children gain mastery over their trauma reminders and memories. TF-CBT has been effective across a wide range of traumas, ages, settings and cultures. 182

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Table 1 TF-CBT for childhood traumatic grief vs. childhood traumatic separation. Childhood Traumatic Grief

Childhood Traumatic Separation

Trauma-Focused Components P: Psychoeducation re: grief, trauma, posttraumatic stress; relevant past traumas

Trauma-Focused Components E: Enhancing Safety: address specific concerns re: child's, separated parent's, and/or current caregiver's safety; introduce skills P: Psychoeducation: re: trauma, posttraumatic stress, uncertainty of traumatic familial separation; relevant past traumas

P: Parenting skills: manage traumatic behavioral problems

P: Parenting skills: manage traumatic behavior problems; with applications to ambivalent relationship with current caregiver

R: Relaxation skills: address physiologic hyperarousal to traumatic grief cues

R: Relaxation skills: address physiologic hyperarousal to traumatic separation cues

A: Affect modulation skills: manage negative affect in response to traumatic grief cues

A: Affect modulation skills: manage negative affect in response to traumatic separation cues; with applications to ambivalent relationship with current caregiver

C: Cognitive processing skills: cognitive triad, processing maladaptive cognitions re: traumatic grief and other traumas

C Cognitive processing skills: cognitive triad, processing maladaptive cognitions re: familial separation and other traumas

T: Trauma narration & processing: develop and process detailed personal narrative re: traumatic death and other prior traumas

T: Trauma narration & processing: develop and process detailed personal narrative re: traumatic separation and other traumas

I: In vivo mastery: master overgeneralized fears re: traumatic death

I: In vivo mastery: master overgeneralized fears re: traumatic separation

C: Conjoint Child-Parent sessions: share trauma narrative with caregiver; other joint activities as indicated

C: Conjoint Child-Parent sessions: share trauma narrative related to traumatic separation with current caregiver; other joint activities to improve communication/relationship with current caregiver

E: Enhancing safety: address safety concerns re: traumatic grief; practice skills.

E: Enhancing safety: continue to address safety concerns re: traumatic separation; practice skills

Grief-focused components Grief Psychoeducation: address grief, loss, death

Separation-focused components

Naming the loss: identify what has been lost through the death (good and bad qualities of the deceased), concretize permanence of death and changed nature of relationship with deceased

Naming the loss: acknowledge and validate what child misses (and may not miss) about separated family members, including personal qualities, culture, language, food, other aspects of communal identity

Preserving positive memories: remember sharing positive memories of the deceased

Preserving positive connections: Enhance positive connections with separated parent/other separated family members, culture, language, other parts of identity from which child has been separated

Committing to new relationships: develop meaningful new positive relationships with other adults and peers

Relating positively with current caregiver: Balance positive connections to separated family with developing positive relationships with current caregiver, family and peers Addressing role changes: Acknowledge changed roles, validate difficult emotions; ease transition to new roles.

Treatment closure issues: plan how to cope with future trauma, grief and loss reminders, end therapy

Treatment closure issues: plan how to cope with ongoing ambivalence of traumatic separation, trauma and loss cues, end therapy

For CTG, TF-CBT consists of sequential trauma-and grief- focused components provided to the child and surviving parent or current primary caregiver, in parallel individual sessions and conjoint child-parent sessions (Cohen et al., 2017). These have also been provided in parallel group child and parent sessions with conjoint child-parent sessions (Dorsey et al., 2018; O’Donnell et al., 2014). The trauma-focused components address immediate safety issues, and other trauma symptoms related to traumatic grief and other traumas. The grief-related components help the child engage more fully in grieving tasks and in relationships with the surviving parent or other current caregiver. The TF-CBT trauma-and grief-focused TF-CBT components are shown in Table 1. In the TF-CBT applications for Childhood Traumatic Separation, the trauma focused components similarly address safety issues, trauma symptoms related to traumatic separation and other traumas, but in distinction to the grief-focused components of CTG, the traumatic separation components described below help the child engage in addressing the pain and ambiguity of the separation, maintaining a connection with the separated parent while committing to the relationship with the current caregiver and other important new relationships, and addressing role changes (Table 1). These components address the clinical issues identified by the NCTSN as relevant for Childhood Traumatic Separation (NCTSN, 2016, 2017, 2018a) and are provided in parallel sessions to the child and current caregiver. Unfortunately, increasing numbers of children with Traumatic Separation are being placed in congregant care settings (NPR, 2018) including short-and long-term shelters, residential centers and detention centers. Such settings are particularly problematic for children with Traumatic Separation for a number of reasons, including that they (a) preclude the possibility of children forming attachment relationships with new caregivers and other family members that would be available in a family setting; (b) may place children at heightened risk for experiencing additional traumas; and (c) may not provide access to needed health or mental health services including trauma-focused therapy. Given these concerns, the priority should be on advocating for family reunification or 183

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alternative placement of these children in foster familial settings that could promote more optimal mental health recovery. Failing this, it may be feasible to provide TF-CBT for youth with Traumatic Separation if the setting is safe and if there is ongoing access to a trained mental health therapist. For example, for youth placed in trauma-informed residential treatment facilities, TF-CBT can be provided for Traumatic Separation using modifications for these settings described elsewhere (Cohen, Mannarino, & Navarro, 2012). Some youth with Childhood Traumatic Separation may have complex trauma (e.g., those who experienced familial separation related to foster care placement). TF-CBT has been modified for youth with complex trauma as described in detail elsewhere (Cohen, Mannarino, Kliethermes, & Murray, 2012; Kliethermes & Wamser, 2012). Relevant aspects of complex trauma TF-CBT applications are described in the following Childhood Traumatic Separation modifications. The status of separated parents often changes during the course of treatment; this may lead to the child unexpectedly returning to the separated parent's care and to premature treatment termination. Children placed in short-term shelters, residential settings or other custodial settings may also experience premature treatment disruption due to moves to a new placement. The model addresses issues such as safety, self-regulation, trauma mastery, and attachment throughout treatment, and although it is optimal to complete the entire model, children may experience significant improvement with even partial completion. 3.1. TF-CBT applications for Childhood Traumatic Separation The following section describes how the respective TF-CBT treatment components can be implemented for Childhood Traumatic Separation. It assumes familiarity with the basic TF-CBT model (Cohen, Mannarino, & Deblinger, 2012; Cohen et al., 2017). Two composite case examples are used to illustrate relevant clinical points. Marcus: Twelve year old Marcus experienced neglect related to his mother's substance abuse and physical abuse by her boyfriend Devin. Marcus often cared for his six year old half-brother Martin when his mother was on drugs. The police arrested his mother and Devin in a violent scene witnessed by both children; his mother and Devin were then incarcerated. Two days later the brothers were separated. Marcus, who lived with foster mother Ms. Tonya, had had no contact with Martin, who was living with a paternal aunt. Marcus said losing his family was his worst trauma. He was angry, had intrusive thoughts and blamed the police for the separation. He was disrespectful towards Ms. Tonya and had run away. His CPSS-5 score was 50 (severe PTSD). Elena: Seven year old Elena fled Guatemala with her mother following gang violence that had caused the death of her father. Coming to the US they experienced hunger and physical violence, and Elena witnessed her mother's sexually assault. At the US border as her mother asked about asylum, Elena was led away by a stranger and hasn’t seen her mother again. She was taken on a long bus ride with other children to a detention center where she stayed for several weeks. She was then placed with foster mother Mary and her teen daughters. Elena was frightened, confused, and clingy with Mary. She frequently asked questions about the separation and when she could see her mother. Her initial CPSS-5 (Spanish version) score was 35 (full PTSD). 3.2. Orientation to TF-CBT: engaging current caregivers in treatment At the start of treatment, the therapist orients the child and current caregiver, respectively, to TF-CBT, explaining that treatment will focus on the child's traumatic separation and related traumas. The therapist provides general information about TF-CBT, rather than a detailed description of specific TF-CBT components. The therapist also emphasizes the importance of including the current caregiver in treatment, with a focus on the child and current caregiver's relationship, and that approximately half of every treatment session will be spent with the current caregiver, with several conjoint child-caregiver sessions. Some children hesitate to include a new caregiver in treatment, due to the issues described above or because a caregiver inadvertently has served as a trauma reminder (e.g., used a loud or harsh voice to correct the child) or is insensitive and/or uninformed about the child's trauma history (e.g., has used judgmental language about the birth parent's decisions or behaviors, etc.) These need to be addressed in therapy, but are not necessarily reasons to prematurely exclude a caregiver from TF-CBT. Therapists should be familiar with and utilize effective strategies for engaging foster parents in TF-CBT treatment that have been described elsewhere (Dorsey & Deblinger, 2012; Dorsey et al., 2014). 4. Trauma focused components 4.1. Enhancing safety Children with Traumatic Separation often have real and immediate safety concerns. For these children the therapist begins TFCBT with the Enhancing Safety component and continues this component throughout treatment as needed. As always, the therapist evaluates immediate safety concerns and complies with mandated child abuse reporting requirements. Specifically, if children disclose new information about child maltreatment, the therapist reports this to the appropriate authorities and addresses this during TF-CBT as described in detail elsewhere (Cohen, Mannarino, & Deblinger, 2012; Cohen et al., 2017). The therapist should be particularly attentive to issues for children who served as caregivers to siblings and/or impaired parents prior to the familial separation. These children often have significant and well-founded concerns about the siblings and/or parent's safety, and need reassurance that they are receiving needed treatment and care, including for any underlying illness, mental illness, and/or addiction that required the child's care prior to the separation. For Childhood Traumatic Separation, unsafe behaviors often relate to the child's concern about the safety of the separated parent and/or other separated family members. Therefore the therapist explores the relationship between any immediate child unsafe behaviors, and the child's concerns about the separated parent or other family members. Modifications of complex trauma 184

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interventions in this regard for children with Traumatic Separation include: (1) identifying immediate safety issues, (e.g., running away, serious substance abuse, self-injury, suicidality, unsafe sexual behaviors, etc.); (2) providing information and realistic reassurance about the parent's safety (to the extent that this is feasible); (3) identifying and modifying trauma reminders that serve as antecedents to the child's unsafe behaviors; (4) developing and practicing specific skills to replace unsafe behaviors; and (5) tracking and tweaking these safety strategies over time. Marcus: Marcus acknowledged that ongoing worry about his brother's safety led him to run away. He was also worried about his mother's safety in prison. The therapist did not have any information about their status, so Marcus and therapist brainstormed about ways for him to feel okay. The therapist agreed to try to arrange for Marcus to have a phone call with Martin. Marcus said that when foster mother “yelled”, this made him want to run away. The therapist provided psychoeducation about trauma responses and reminders. The therapist introduced self- monitoring and basic relaxation skills. Marcus agreed to practice these skills when he worried about his mother's or Martin's safety. Therapist met with Ms. Tonya to help her understand Marcus’ safety concerns. The therapist also explained the role of trauma reminders and demonstrated, role-played and practiced using a soft voice instead of a loud one. Ms. Tanya said she would try to be more aware of using a calm, soft voice to minimize trauma reminders at home. She also agreed to practice the relaxation skills with Marcus regularly and help Marcus keep a daily log of how these strategies worked to improve his self-rating of safety and anxiety. She was amenable to facilitating Marcus’ phone calls to Martin once these were arranged. The therapist also ascertains what information the child has received about the separated parent's current safety; how often the child has direct contact or communication with the separated parent; other information (accurate or inaccurate) the child has received about the separated parent's situation that may be contributing to concerns about the separated parent's safety (e.g., from the media, other family members, or other separated children in congregant care, etc.), and information the child may have received related to family reunification (or lack thereof). Depending on the nature of the separation and other factors, there may be great variability in the available information or degree to which the therapist can realistically reassure the child of the separated parent's safety. In situations where no information is available about the parent's status or the potential for reunification, the therapist validates the extreme difficulty of coping with this uncertainty, and supports the child in developing safe coping strategies, using TFCBT coping skills as individually indicated. The therapist also ascertains whether the child is concerned about the safety of the current caregiver, and if so, assesses the nature of this concern. Elena: Elena had heard rumors from children in the detention center that her mother would be sent back to Guatemala without Elena. Elena was afraid that if this happened, her mother would be killed like her father had been, and that she would never see her mother again. The therapist validated that it was very confusing and scary to not know her mother's situation. She and Mary contacted an immigration advocacy group to arrange for Elena and her mother to have skype or phone contact on a more predictable schedule. This helped Elena to know when she would speak to her mother and to have ongoing updates about her safety. Mary continued to assure Elena that she would stay with Mary until she rejoined her mother. 4.2. Psychoeducation The therapist explores the child's understanding of the familial separation, and provides accurate information to the child and current caregiver about Childhood Traumatic Separation. This includes providing accurate information about the type of familial separation the child experienced, the frequency with which these separations occur, children's common traumatic responses, and how these impact the child's relationship with the birth parent and the current caregiver. This is done in a developmentally, linguistically and culturally competent manner. Information about Traumatic Separation related to immigration and refugee children for current caregivers is available in English and Spanish (NCTSN, 2018b). Information related to Traumatic Separation for children in foster care is also available (American Academy of Child & Adolescent Psychiatry [AACAP], 2018). The therapist also helps the child to make connections between the traumatic familial separation and prior traumas by providing psychoeducation about those traumas and relating them to the child's Traumatic Separation experiences and responses. For example, children whose families migrate have often left their home country under traumatic circumstances such as war, gang violence, domestic and or sexual violence, and may have experienced additional traumas during their migration (NCTSN, 2018a). Children whose parents are incarcerated have often experienced child abuse and/or neglect, domestic and/or community violence, as well as racism and historical trauma; these children may minimize past traumas in order to protect the birth parents that perpetrated the trauma and/or failed to protect them. Most children who enter foster care and those whose parental rights have been terminated have experienced prior child abuse or neglect, etc. (Administration for Children & Families, 2018). Providing psychoeducation about these prior trauma experiences is critical for helping children to fully understand and recover from Childhood Traumatic Separation. As appropriate, the therapist also provides psychoeducation about underlying parental mental health and/or substance abuse disorders (e.g., Sherman & Sherman, 2006). Current caregivers often do not have accurate information about the child's prior trauma experiences or the circumstances related to the traumatic separation (Dorsey & Deblinger, 2012; Dorsey et al., 2014). This can contribute to misunderstandings about the child's trauma symptoms. To the degree that the therapist has accurate information, it is helpful to share this information with caregivers in order to assist them in better understanding the child's trauma experiences and reactions. When information is lacking, the therapist validates how hard this is, and provides skills for coping with the uncertainty of not knowing. Marcus: Marcus’ therapist asked what he knew about the reasons for his mother's incarceration. Marcus said that his mother had a “problem with drugs”. The therapist provided psychoeducation about substance abuse as an illness for which his mother needed treatment, connecting this to his mother's inability to take care of Marcus and Martin (“neglect”), and her subsequent arrest and incarceration. The therapist also played the What Do You Know game (Deblinger, Neubauer, Runyon, & Baker, 2012) to provide psychoeducation about child 185

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physical abuse and connected this to his mother's substance abuse and inability to protect the children from Devin. During this game, Marcus disclosed that Devin also beat his mother frequently, and the therapist included psychoeducation on domestic violence. The therapist met individually with Ms. Tonya to provide psychoeducation about the different types of traumas that Marcus and his mother had experienced prior to her incarceration, and to help Ms. Tonya understand the severity of Marcus’ mother's addiction and personal abuse. Ms. Tonya was surprised to hear this, expressed empathy for what Marcus had been through, and for the first time expressed concern for Marcus’ mother. Elena: Elena's therapist asked her why people leave their countries to immigrate to another country. Elena said “To get away from bad people who hurt other people, like gangs.” The therapist provided information about community violence and common traumatic reactions to gang violence, highlighting that Elena's mother brought her to America to protect her from danger and to keep her safe. She said, “Countries allow people to move there if they are fleeing violence, but some of the people in the US government do not always follow the laws the way they are supposed to, which is why your mother is going through this difficult and unfair process and had to be separated.” The therapist validated Elena's sadness about this, and said that many children had trauma reactions to being separated from their parent. The therapist also said that many people were working hard to reunify families who had been separated. She assured Elena that she and Mary would tell Elena as soon as they learned more, and that Mary would keep Elena safe until she could return to her mother. 4.3. Parenting skills It can be quite challenging for the current caregiver to develop and maintain a nurturing, supportive relationship with the child, while also supporting and facilitating the child's ongoing primary attachment with the birth parent, who may have limited or no access to the child and/or whose decisions or behaviors may have contributed to the familial separation. Metaphors and analogies can be a useful therapeutic strategy for Childhood Traumatic Separation (NCTSN, 2018a). The therapist may use the Tug of War metaphor to help caregivers to conceptualize and communicate their role to the child. The child often thinks of the current caregiver as being on the “opposite side” from the child and separated parent in a Tug of War game. It is then little wonder that the child struggles to form a relationship with the current caregiver. The therapist can help the caregiver and child to instead view the current caregiver, the separated parent and the child as all being on the same side of the Tug of War, with the other side being negative outcomes of trauma. Another helpful metaphor for children with Traumatic Separation is that of the “Invisible String”, that connects the child and the separated parent and always maintains their loving connection despite physical distance and adversity (Karst & Stevenson, 2000). This same metaphor may also be helpful for those children who fear being separated from the current caregiver. Parenting skills used in TF-CBT for Childhood Traumatic Separation are similar to those for other traumatized children, with the therapist applying these with appropriate cultural and developmental consideration to the circumstances of each individual child with Traumatic Separation. Some of these strategies may include the therapist helping the caregiver to: (1) include the child in establishing predictable, soothing routines at home; (2) include the child in developing and participating in fun family activities; (3) give the child choices to reverse feelings of powerless and helplessness; (4) understand negative behaviors as manifestations of the child's traumatic separation rather than being “a bad child”; (5) implement effective parent management strategies to address and minimize these negative behaviors and trauma reminders; and (6) verbalize to the child connections between the child's behaviors and feelings (NCTSN, 2018a). The therapist also supports the caregiver in talking directly with the child about the traumatic separation, rather than avoiding these discussions (NCTSN, 2018a). The therapist guides the current caregiver in providing accurate, developmentally appropriate information to the child as this information becomes available. Resources are available in English and Spanish to help caregivers in this regard: (http://fsustress.org/pdfs/Traumatic_Separation_EN.pdf; http://fsustress.org/pdfs/Traumatic_Separation_SP.pdf). The caregiver should provide this information in a way that does not include graphic or frightening details, and supports the child's ongoing connection to the separated parent. The therapist guides the caregiver in refraining from making negative comments about the separated parent, or the parent's decisions or behaviors, especially if these are overtly problematic or cause the child distress (e.g., ongoing substance abuse, failure to attend scheduled visits with the child, etc.). The therapist models and practices with the caregiver focusing on the child's feelings and providing support to the child. The therapist also guides the caregiver in understanding that although children with Traumatic Separation need support from the current caregiver, they are often unable to ask for this directly or in appropriate ways due to the issues described above. The therapist assists the caregiver in recognizing the child's “approaches” to the caregiver, even if these are done in oblique or less than ideal ways, and how to encourage the child in continuing to try to form a positive relationship (e.g., consistent use of praise, selective attention, ignoring minor irritants and provocations, etc.) Helping the current caregiver to understand cultural factors also can be important in addressing traumatic responses. Providing the child with familiar foods, clothing, a comfort toy or blanket, and encouraging the child to adhere to familiar religious and/or cultural practices may help children to feel more comfortable in the current home (NCTSN, 2018a, 2018b). It is also possible that these actions could serve as trauma reminders, so the therapist and current caregiver should work closely with the individual child to determine what will be most helpful in this regard. Marcus: The therapist worked with Ms. Tonya to understand that Marcus was not a “bad” child but had learned aggressive and angry behavior from observing Devin. The therapist taught, role played and practiced with Ms. Tonya providing praise, selective ignoring, negotiating, and giving clear instructions with limited choices (e.g., It's time for bed. You can change into your PJs or brush your teeth first, which do you prefer?) The therapist continued to practice with Ms. Tonya minimizing trauma reminders (e.g., ignoring minor provocative comments rather than becoming angry; providing consistent limits in a quiet, calm voice rather than threatening negative consequences in a loud voice when Marcus became aggressive). The therapist also praised her for sticking with it and validated how hard it was to carry out these strategies 186

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consistently, while providing encouragement that the effort would be worth it. Ms. Tonya noted that Marcus’ anger and aggression markedly decreased over several weeks and he became more cooperative with family routines. Elena: The therapist encouraged Mary to include Elena's input in family routines (e.g., meals, bedtimes) that would reassure Elena about her safety and provide additional comfort while not serving as trauma reminders. For example, Mary asked Elena what her favorite games had been at home in Guatemala, and whether she would like to play those. Elena excitedly described playing hopscotch and jumping rope back home and showed these to Mary and her daughters. The therapist also guided Mary in helping to verbalize Elena's anxiety and fears. For example, when Elena clung onto Mary, Mary said to her, “You won’t let go of me because you’re afraid we’ll be separated like you were separated from your mother. It makes sense that you are afraid, but I will be here to take care of you until you can be together.” An In vivo Mastery program was also implemented to help Elena to gradually tolerate transitory separations from Mary. 4.4. Relaxation skills Similar to many children with complex trauma, some children with Traumatic Separation experience their own bodies as a trauma reminder. These children may have more difficulty initially utilizing internal body-focused relaxation strategies such as focused breathing or progressive muscle relaxation. The therapist may find that these children are more comfortable initially using more externally-focused strategies such as guided imagery, yoga, blowing bubbles, listening to music or other activities mutually agreed on by the child and therapist. As the child becomes more adept at using these skills on a regular basis, including with trauma reminders, the therapist can introduce more direct body-focused techniques and encourage the child to add these to the child's tool kit. As with all children, the therapist teaches, practices and role plays these and self-monitoring skills not only with the child, but also with the current caregiver, and encourages the caregiver to support the child in practicing these with the child every day for at least 20 minutes as well as in response to trauma reminders. Elena: The therapist instructed Elena in the use of belly breathing and practiced this with her to address her sleep problems and hypervigilance. Elena was familiar with the Muppet character Elmo, so the therapist showed her the Elmo Belly Breathe video (https://www. youtube.com/watch?v=_mZbzDOpylA), simultaneously translating it into Spanish. Elena loved this video and soon was successfully using belly breathing and reporting somewhat less anxiety. Mary bought Elena an Elmo stuffed animal, which became Elena's favorite toy and a transition object that she used during In vivo Mastery. 4.5. Affective modulation skills Children with Traumatic Separation typically have many negative emotions related to the traumatic separation, but similar to children with complex trauma, they may not sufficiently trust the therapist to express these feelings. Children with Traumatic Separation may particularly hesitate to express negative emotions for fear of jeopardizing the separated parent's or their own safety. This fear may have originated during the child's experiences of prior trauma (e.g., child maltreatment, domestic or gang violence, war, etc.) when negative affective expression could have further endangered the child's safety. This traumatic learning then overgeneralized to safe situations such as therapy. Depending on the child's living situation, there may a current realistic basis for this fear (e.g., a child in a detention center who expresses anger at detention staff may be at heightened risk for being punished including losing scheduled phone contact with the separated parent). The therapist encourages the child to express their full range of separation-related emotions through a variety of games or other activities as typically implemented in TF-CBT, with awareness of the above concerns that may limit affective expression. These may include sadness, fear and/or anger at the current caregiver, the authorities, the separated parent, and/or self-directed anger related to the separation. The child may also feel resentment, sadness and/or anger toward the perpetrators of the previous trauma(s) that led to or contributed to the traumatic separation, such as gang members that led the family to migrate to the US; criminal associates that led the parent to be incarcerated; a drug dealer who contributed to mother's substance abuse and child neglect, leading to the child's foster care placement, or the parents themselves for abusing the child that resulted in termination of parental rights. The therapist helps the child to identify these feelings, develop effective coping strategies described elsewhere (Cohen, Mannarino, & Deblinger, 2012; Cohen et al., 2017), practice these daily, and use these with trauma reminders. The therapist includes the current caregiver in learning and supporting the child in using affective expression and modulation skills. Often it is difficult for caregivers to tolerate children's expression of negative feelings, especially when anger is directed at the caregiver. The therapist validates that this is very difficult, especially when the caregiver and their family has opened their home to the child. The therapist helps the caregiver to practice and model personal affective modulation skills, and to continue to support the child in gradually gaining increased skills in managing difficult affective states over time. One of the most important strategies to encourage is reinforcing the child's seeking the caregiver's support. Since this is so difficult for many children with traumatic separation to attempt, they often do it unskillfully and in ways that will protect them from rejection (e.g., seeking the caregiver's attention through negative behaviors rather than asking for help). The therapist helps the caregiver to understand this as a “request for help” rather than simply bad behavior, and encourages the therapist to provide ample amounts of positive attention to the child at times when he or she is behaving in positive ways. Over time, the therapist encourages the child to directly seek the caregiver's help (e.g., by asking to talk, expressing negative feelings verbally rather than via negative behaviors, etc.), and supports the caregiver in responding immediately and supportively to the child when this occurs. Marcus: Marcus was mad at the police for his mother's arrest and incarceration and blamed Ms. Tonya for not being able to visit his mother in prison (which was several hours away and had limited visiting hours). The therapist reflected Marcus’ feelings (e.g., “I can see you are really mad. I understand why you are upset not be able to see your mother now, and I would be mad too.”) The therapist guided him in constructing 187

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an “anger pie” in which he listed all the people he was angry at, and dividing the percentage of anger in a “pie”, with the total adding up to 100%. He divided it as follows: police: 50%, Devin, 30%, Ms. Tonya, 20%. When he looked at it, he said he was also a little mad at his mother for using drugs, so changed it to his mother, 10%, Ms. Tonya, 10%. The therapist validated that Marcus had a right to be angry at what happened, not just about the separation, but about all the traumas in his life. She also said that Ms. Tonya understood that he was dealing with a lot of big and difficult feelings. She worked with Ms. Tonya to understand Marcus’ anger as reactions to his multiple traumas, and helped her practice not responding to his provocative behavior. The following week, Marcus asked if he could go with Ms. Tonya to the market, saying, “You’re not my mom, you don’t know what I like.” Keeping in mind what she had practiced with the therapist, Ms. Tonya realized that this was Marcus’ way of trying to approach her. They went to the market and Ms. Tonya invited Marcus to choose some meals for the family's supper the following week, as well as some snacks for himself. Elena: Elena initially denied being angry about the traumatic separation from her mother. After several weeks she told the therapist that she was angry, but the therapist must promise not to tell anyone or it would be very dangerous. Elena said that she was very angry at the lady who took her away from her mother, but if anyone found out how angry she was, “they would kick me and mama out; they hate angry people.” The therapist validated Elena's anger and assured her that she was safe to express this in therapy and with Mary. She then sadly said that she had no friends and no one liked her. These maladaptive cognitions were addressed during Cognitive Coping (described below). 4.6. Cognitive coping skills Children with Traumatic Separation often have inaccurate and/or unhelpful beliefs that contribute to their trauma symptoms. During this component, the therapist helps children and their current caregivers, respectively to learn to (1) identify non-traumatic negative (inaccurate or unhelpful) thoughts; (2) identify the relationship of these negative thoughts to negative feelings and behaviors; and (3) change negative thoughts to be more accurate and/or helpful. The therapist uses a variety of techniques to accomplish these goals, including the TF-CBT Triangle of Life game (freely available from Apple Store or Google Play), the cognitive triangle, and/or thought tracker activity in this regard. The therapist provides Cognitive Coping Skills to the current caregiver in a parallel fashion as described above. The therapist also shares the child's general maladaptive cognitions with the caregiver as well as the skills the child will use to cognitively process these inaccurate and unhelpful thoughts, and encourages the caregiver to support the child in using these skills. The therapist also supports the caregiver in identifying and processing his or her own maladaptive cognitions, both general and related to the child's traumatic separation and prior traumas. Elena: The therapist used the cognitive triangle with Elena. Starting with the thought, “I have no friends, no one likes me”, Elena said this made her feel sad and hopeless; when she felt that way, she stayed inside and cried or clung to Mary. The therapist asked her, “What would be a different thought you might tell yourself?” Elena did not know what she could say differently. The therapist suggested, “How about, I have no friends because I have not yet gone to school and haven’t had a chance to make any new friends here. If you told yourself that, how would you feel?” Elena said, “Better.” The therapist said, “What would you do if you feel better?” Elena said, “Try to make a friend.” She and Elena shared this with Mary, who praised Elena and suggested ways Elena might meet a new friend. 4.7. Trauma narration and processing As with children with complex trauma, it is often helpful for Childhood Traumatic Separation to start this component by developing a life timeline. This supports the child in including traumas and other significant experiences that occurred prior to and contributed to the traumatic familial separation; it also encourages the child to include positive family experiences and different caregivers with whom the child has lived. The therapist guides the child in an interactive process of developing a narrative about prior traumatic experiences related to the traumatic separation, the traumatic separation itself, events that have transpired since the separation, and processing the meaning of these experiences. During the process, the child describes his or her experiences, memories, thoughts, feelings and worst moments related to the traumatic separation and related traumas. The therapist then helps the child to identify inaccurate or unhelpful thoughts in the narrative, and use the earlier cognitive coping skills to develop more accurate or helpful thoughts related to the traumatic separation and related traumas. The therapist shares the child's narrative with the caregiver during individual caregiver sessions. The caregiver often learns new details about the child's trauma experiences and needs to process these him or herself during these individual sessions. It is often difficult and painful for the caregiver to hear about the full extent of trauma that the child has endured; yet this also helps to increase the caregiver's understanding and compassion for the child's behaviors and emotional reactions. Marcus: Marcus’ complex trauma theme was, “the people who should have protected me didn’t keep me safe, or they hurt me”. Marcus provided detailed descriptions of Devin's abuse of himself and his mother. Devin beat Marcus with his fist, belts, and other objects, including when Marcus tried to protect Martin. At these times, his mother was too impaired by drugs to protect them. Marcus described his mother abusing heroin for many years, and that he usually cared for Martin, feeding him, getting him to school, and keeping him away from Devin and his mother when they used drugs. He described the traumatic separation as follows: The boys were in their room while the adults partied. There was a loud noise and banging on the door, lots of confusion, yelling and hollering. Marcus and Martin stayed in their room until they heard their mother screaming for help. Marcus ran out of the room and Martin followed. They saw their mother and Devin struggling and fighting against several cops who were trying to restrain them. Marcus didn’t know what to do, but tried to go to his mother when a cop stepped between them and said, “Son, stay back. We don’t want anyone to get hurt.” He was confused and scared. He saw that Martin was crying and went to hold him. Then a lady from CPS came and took them to the other room. Mom was spitting and screaming and calling the cops bad names, 188

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saying, “Don’t take me away from my babies”. Martin and Marcus were in the bedroom when the cops took them away. The CPS lady took them to the shelter that night where they stayed for a few days. Then Martin was taken away crying and clinging onto him. Then he was all alone. Marcus said, “I knew my mom was getting worse. I should’ve made her get help before this all happened.” He felt mad and sad and it made him not listen and be rude. The therapist helped Marcus draw a suitcase to represent what his mother had control over, and a backpack to represent what he had control over. In his mother's suitcase Marcus put 1) mom's feelings; 2) mom's behavior. In his backpack Marcus put 1) My feelings; 2) my behavior; 3) my chores; 4) my homework; 5) what I think. The therapist then wrote down: 1) mom using drugs; 2) mom getting help for substance abuse; 3) taking care of Marcus and Martin; 4) buying food; 5) cooking meals; 6) paying bills. Marcus put them all in his mother's suitcase, but said “Mom couldn’t do those things because of drugs.” After a discussion about the illness of heroin addiction, his new thought was “Mom wanted to be a good mom but she couldn’t be because of addiction.” His new feeling was “sad” and his new behavior was to “never use drugs and become the man mom would want me to be, and hope she gets better and I can live with her.” Marcus added this as his last chapter. Elena: Elena described her memories of living in Guatemala and of the increasing gang violence during the final year of her life there. She described the night her mother told her that her father had been murdered by the gangs, and how her mother cried all the time and became afraid. Soon after, her mother told her that they were going on a trip and when they got to America they would be safe. Elena was sad to leave her friends and family but was excited to go on the trip. During the trip Elena was very hungry and thirsty. There were “bad men” who pulled off her mother's clothes and hurt her. Elena was afraid that the bad men would hurt her too but her mother told her not to be afraid. Her mother warned her to be respectful when they crossed the border and to listen to the adults, so that they would be allowed to stay. When they finally got to America, Elena and her mother were happy and believed their troubles were over. But when her mother was talking to the man about what they needed to stay in America, a woman took Elena to another room where there were other children. That was the last time she saw her mother. The therapist used the cognitive triangle to process Elena's maladaptive cognitions expressed earlier, “If anyone knew I was angry (about the separation) they would send me back. Americans only like happy kids.” Elena's feelings were “scared” that she would be sent back and never see her mother again; and her behavior was to “stay in the house, not tell anyone my true feelings, and not make friends because they might see my true feelings”. The therapist asked Elena how she might think about her story about traumatic separation differently. Elena thought for a while and then said, “If someone read my story, they might understand?” The therapist praised Elena for coming up with an alternative thought, and asked how she would feel if she told herself this instead of the previous thought. Elena said, “Less scared”, and her behavior would be “I might talk about my feelings more and not be scared to make friends. They might understand how I feel.” The therapist invited Elena to add these new ideas to her story. 4.8. In vivo Mastery The In vivo Mastery component is implemented only for children who have overgeneralized the associated fear and avoidance of trauma reminders with safe situations. In Childhood Traumatic Separation, transitory separations from the current caregiver (i.e., those that occur in the normal course of a child's day, such as going to school, going to sleep, going to the bathroom, etc.), are typically—and understandably—the most feared situation. The therapist assures that neither the child nor the current caregiver is at risk of being deported, arrested or otherwise separated from each other before starting this component. If there is any concern in this regard, the therapist should focus on Enhancing Safety. Elena: Elena overgeneralized the fear of the traumatic separation from her mother to safe, transitory separations from Mary, which she then feared and avoided. The therapist worked with Elena and Mary to develop a graduated fear hierarchy to enable Elena to be able to separate from Mary sufficiently to go to the bathroom and sleep alone, attend school, and allow Mary to go to work. They discussed the invisible string attaching Elena to her mother and to Mary. Mary took pictures of mother during Skype calls for Elena to keep with her in a locket, and she also took a picture of herself and Elena together for Elena to keep with her. Mary and the therapist repeatedly told Elena that her mother and Mary were always connected to Elena by the invisible string, even when they weren’t physically present. Mary and Elena practiced her relaxation strategies together, and together with the therapist, they developed a ladder to help Elena gradually feel safe even when Mary was not physically present with her. The plan included gradually increasing the amount of time when Elena could tolerate being separated from Mary, starting with Mary sitting in the room with Elena but not being physically in contact with her, while Elena used selfsoothing or relaxation strategies. Elena used the pictures of Mary and her Elmo doll to self-soothe and used the Elmo doll to help her use belly breathing when she got scared. These worked well for Elena and she was proud of her success in being able to relax. The next step was for Mary to sit outside the room but within eye contact from Elena; then outside of eye contact but down the hall; then outside the house but in the yard, etc. The amount of time away from Mary also increased. Over several weeks, Elena gradually began to tolerate slowly increasing increments of time separate from Mary, and eventually, she was able to go to school and Mary was able to return to work without Elena being frightened or clingy. 4.9. Conjoint child-caregiver sessions In this component, the therapist prepares the child and current caregiver, respectively, to share the child's trauma narrative and processing with the caregiver, and then the child shares the narrative during a joint child-caregiver session. Other joint activities may include ongoing safety planning, additional psychoeducation, and other joint activities that prepare the child and caregiver for the Separation-focused components. Some children with Traumatic Separation will not be willing to share the trauma narrative with the current caregiver, due to 189

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ongoing lack of trust in that caregiver and/or concern that disclosing details about the birth parent's prior abuse, neglect and/or substance abuse would be disloyal to that parent. In this case, the therapist might explore whether there are some parts of the narrative that the youth is comfortable sharing (e.g., first chapter re: “Who I am”; last chapter re: “How I’ve changed”, etc.). If the child refuses to share anything with the current caregiver, the therapist and caregiver respect that and move forward with the Separation-Focused components. Marcus: Marcus was initially hesitant to share details of his mother's substance abuse with Ms. Tonya, but was willing to tell her about Devin's abuse of mother. As Ms. Tonya expressed her concern and compassion for his mother during these interactions (Tonya became tearful when Marcus described the most severe abuse episode), Marcus gradually shared more information and eventually read his entire narrative to Ms. Tonya. She in turn became more empathic and supportive, offering again to drive Marcus and Martin to visit his mother when the prison allowed this. She shared with Marcus her own father's history of substance abuse and that she understood the struggles that his mother was going through.

4.10. Enhancing safety As noted above, the therapist provides this component at the start of TF-CBT for most children with Traumatic Separation, and continues to implement it as indicated throughout the model. As necessary, additional sessions may be provided at this or any other point in treatment using the same interventions as described above. Marcus: Around this time Marcus’ mother was released on parole. After one supervised visit his mother failed to appear for two subsequent ones. Marcus worried that his mother was using drugs again and he wanted to live with her to prevent that. However, she lived in a halfway house where children were not permitted. He ran away on one occasion but could not locate her; she did not answer his calls, so he returned to Ms. Tonya's house. The therapist, Ms. Tonya and Marcus brainstormed about ways that Marcus could enhance feelings of safety related to his mother, while remembering what was in his backpack and what was in his mother's suitcase. Marcus cried for the first time in therapy. He said that he all he had wanted was for his mother to get out of prison. Now that she was, she didn’t seem excited to be together as a family, but only seemed to want to get back to drugs. The therapist said that recovery was very hard, and that before he assumed this, he needed more information. Ms. Tonya said that she would pray for his mother and be there for Marcus and his family in any way she could. Marcus said he knew he could not control what his mother did. Marcus agreed that a visit with his brother would help him feel better. With CPS approval, Marcus had a visit with Martin, which went very well.

5. Separation-focused components 5.1. Naming the loss: what I miss (and don’t miss) During this component, the therapist encourages the child to discuss the things the child misses about the separated parent. In many cases, this also extends to other aspects of the child's culture, religion, language, foods, history, and other aspects of the child's identity that have been lost as part of the traumatic separation. The therapist can use many strategies for accomplishing this, including using a name anagram, colors, etc. to help the child describe different aspects of the separated parent that the child misses and has lost as a result of the separation. This often includes activities the child did with the separated parent (e.g., talk, play, sports, etc.), but can also include character traits of the parent (e.g., kind, funny, reliable, honest, etc.); things the parent taught the child (e.g., cooking together, playing basketball together, etc.); or physical attributes (e.g., strong, pretty, etc.). Some children simply say that they miss being with the parent, or miss the parent's love. Attachment is to a whole person, not only to their most perfect or positive qualities. Since there is a natural tendency to see the best in people from whom one is forcibly separated, it is important to facilitate the child in being allowed to acknowledge all aspects of the separated parent, not just the positive ones. As part of this component, the therapist asks “is there anything that you don’t miss about being with your parent?” as a way of providing children with an opportunity to verbalize what they may not miss about being with the separated parent. For many children, things the child does not miss will be minor annoyances (e.g., a quick temper, wearing unflattering clothes, or embarrassing the child in front of her friends.) But as a result of completing the trauma-focused components, many children may acknowledge significant things they do not miss about the separated parent, for example, the parent's substance abuse, domestic violence and/or child maltreatment perpetrated by the parent. Marcus: Marcus named many things he missed about his mother, including her humor, kindness (“she taught me to care about people who are smaller or weaker than me, and to always look out for Martin”), and fun (“before Devin, she told me stories and played games and we had the most fun together”). He also said that his mother made the best mac and cheese and mashed potatoes, and used to be “like a pit bull” protecting him, but that changed with Devin. Marcus said that the two things he did not miss about living with mom were “Devin, and drugs. When Devin moved in, mom started using drugs and everything changed. She didn’t cook or take care of us kids, and Devin abused us. When he was around, mom was using drugs. There was only one good thing about Devin, and that was Martin.” Elena: Elena described that she missed her mother's singing, cooking, playing with her, walking with her to the market, talking to her about their family and telling her stories, snuggling with her at night and in the morning, eating their favorite foods, and just being with her mother. She loved the sound of her mother's voice, the smell of her hair, and the feel of her arms around Elena when she told her stories at night. Her mother taught her to sew and cook, and always made her feel safe. Elena first said that she did not miss her mother's sadness after her father died, because it hurt so much to see her sad and crying all the time. Then Elena said that she wanted to be with her mother even if she was sad. 190

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5.2. Preserving positive connections During this component the therapist and child explore ways in which the child can preserve the child's connection to the separated parent, while also committing to other positive relationships and continuing on a healthy developmental trajectory. These are critically important in Childhood Traumatic Separation since it is unclear when (or if) family reunification will occur or if the separation will be permanent. The current caregiver's emotional and practical support will greatly contribute to the success of this component. The separated parent's circumstances; legal restrictions; lack of resources (time, money, legal representation, etc.); and other factors may determine the specific strategies that can be used in individual cases. For example, phone calls and in-person visits to separated parents may be restricted or impossible for parents who are incarcerated, migrant parents who are detained in undisclosed locations or who have been deported; parents who cannot be contacted due to ongoing substance abuse; parents who have court orders prohibiting or limiting visits with the child, or parents whose parental rights have been terminated. The therapist and child devise strategies with the current caregiver's involvement and support, to preserve the child's ongoing positive connections with the separated parent that take these factors into account. The therapist asks the child how he or she can hold on to the positive things in their relationship with the separated parent. It may be helpful to return to the list of attributes the child developed in the previous component about what they miss about the separated parent. If the child is able to have phone, Skype, and/or in-person contact with the separated parent, the therapist suggests that planning to do some of these activities during those contacts might be ways to preserve positive connections (while acknowledging that it would not be feasible to do other things on the list, like cooking a meal over Skype or playing soccer while visiting an incarcerated parent at the prison). However, in these situations, the child might draw a picture or write a few sentences about these activities to share with the parent during these interactions, that might help the child and parent to reminisce together about these happy times they have shared and thus cement their positive connection. If the child does not like these suggestions, the therapist solicits the child's suggestions for activities that appeal more to the child, for example, “What do you think would help you feel closest to your mom when you talk to her on your next phone call, and help you most to hold onto that closeness between calls?” The therapist helps the child to develop a plan for the next contact with the parent that includes ending the contact with something concrete (e.g., a drawing, a few sentences written down, or a cell phone photo, etc.) that the child can keep and return to in order to preserve a positive connection with the separated parent until their next contact. For children who have no contact with the separated parent, the therapist guides the child in developing imaginal strategies for preserving positive connections. This may consist of a journal, diary, a series of written or audio letters to the separated parent, videotaped messages, or other ways the child devises for preserving connections with the separated parent. Some children may choose to develop imagined responses back from their separated parent and the therapist encourages the child's creativity here. The therapist meets with the current caregiver to share the strategies that the child prefers for preserving positive connections with the separated parent. It is helpful for the therapist to practice and role-play these with the current caregiver. For some cases there will be a disconnection between the child's and current caregiver's perception of reality regarding the separated parent, and it is especially important for the current caregiver to support and validate the child's positive connections with the separated parent, even if the child expresses views of the separated parent that are not consistent with the current caregiver's perspective (for example, that the parent is fully recovered from mental health or substance abuse problems; that the parent was unfairly incarcerated, etc.) The therapist supports the caregiver to continue to maintain a non-judgmental stance towards the separated parent, and encourages the caregiver to share any concerns with the therapist rather than with the child. Marcus: The therapist explored with Marcus ways for him to maintain positive connections with his mother and Martin. He requested ongoing calls and visits with Martin. He also asked whether he could send a letter to his mother. The therapist encouraged him to write a letter to his mother. She encouraged him to include things that he missed about her, to let her know that he remembered many wonderful things about her. Martin wrote a letter expressing his love for his mother, telling her that he often thought about the good times they had shared together, with her telling him stories and jokes and cooking his favorite mac and cheese. He updated her on what he was doing as well as his desire to be reunited with her and Martin, and his hope that she was doing well and continuing with her treatment. He said that he had learned a lot about substance abuse and domestic violence and understood how hard it was to recover, and that if she needed more time before he could come home, it was okay. He ended by saying that it would mean a lot if he could talk to her or see her because he loved her so much. The therapist met with Ms. Tonya to suggest additional visits with Martin. Ms. Tonya supported this. With Marcus’ permission, the therapist shared the contents of Marcus’ letter to his mother, and Ms. Tonya supported his desire to contact her, although she was concerned that his mother was using drugs again and that Marcus would be badly hurt if she abandoned him. She said that she knew what that was like, having been repeatedly abandoned by her own father when she was growing up, and she did not want this to happen to Marcus. The therapist validated this and said that she knew that it was coming from desire to protect Marcus. Still, the therapist said that it would help Marcus if Ms. Tonya could continue to be positive about Marcus’ mother, and let Marcus discover the truth as it unfolded over time. Ms. Tonya agreed to this. She praised Marcus for his beautiful letter and during the coming week arranged for his regular visits with Martin and another visit with his mother. Elena: The therapist asked Elena how she could best hold onto her positive connections with her mother while they were apart, and how Mary could help with this. Elena had many ideas about this, including recording songs they sing together on calls, taking more pictures of her mother during calls, sending her a video, and making drawings to share. The therapist invited Mary to discuss how to implement these during Elena's calls and Mary enthusiastically agreed to help. During the next two calls with Elena's mother, Mary recorded them singing songs together for Elena to listen to during the week. Elena's mother did not have a cell phone, but Elena made pictures to share when she could communicate with her. These strategies helped Elena to feel closer to her mother.

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5.3. Committing to new relationships Children with Traumatic Separation naturally cling to the hope of family reunification. At the same time that the therapist and current caregiver support this hope and desire, for whatever period of time the child lives apart from the separated parent, it is important for the child to develop and maintain positive relationships with the current caregiver, other current family members, new peers, etc., and continue on (or regain) a healthy developmental trajectory. Throughout TF-CBT, the therapist has been implementing the parenting component with the current caregiver in order to enhance his or her understanding, compassion about and attunement to the child's traumatic separation experiences and responses, including when the child has displayed trauma-related emotional, behavioral and/or cognitive dysregulation. The therapist has also been assisting the caregiver in integrating the child into the new family, home, school, community, while maintaining a positive connection to the birth parent. Concurrently, the therapist has been implementing coping skills with the child to enhance the child's self-regulation abilities, and trauma narration and processing to gain mastery over trauma reminders and memories. This process has helped most caregivers to become more supportive, and most children to become more accepting of the caregiver's support. Thus for practical purposes, the therapist has been implementing this component throughout the treatment model. At this point in treatment many children already have a positive relationship with the caregiver, new family and peers. For these children the therapist implements this component by continuing to acknowledge that the child's relationship with the separated parent will always be the child's primary attachment, validate the child's desire to reunite with the separated parent, and address and tweak any ongoing problematic issues in the child's relationship with the caregiver and others, but also by describing the specific changes the therapist has seen in the relationship between the child and caregiver since the start of treatment, and praising the child's progress in this regard. The therapist particularly praises the child for making the commitment to having new relationships while still maintaining a primary one with the separated parent, validating that this is difficult but necessary for the child's ongoing healthy development, and is what the separated parent wants/would want for the child. Children who do not have a positive relationship with the caregiver and/or have not made new friends, etc., are often struggling with the fear of repeated loss and/or mistrust of CPS, immigration, prison or other system that caused the traumatic separation (i.e., “it already separated us once, why should I believe it won’t separate me again?”). These children often want to trust and have positive relationships, but are afraid that once they do, they will lose these new relationships too. Some children may have recently initiated a positive relationship with the current caregiver but changes in the separated parent's situation created complications (as described below). The therapist addresses this as clinically appropriate. One useful strategy for children who are afraid of repeated loss and mistrust of authorities is the wall analogy (Cohen et al., 2017, pp. 280–281). The therapist guides the child in drawing a wall made up of individual bricks, with a variety of positive and negative feelings behind the wall. The therapist helps the child to visually see that, while the wall protects the child behind the wall from all of the bad feelings like fear, hurt, and anxiety, it also keeps out good feelings like happiness, caring, closeness, and love. The therapist suggests that the child does not need to take the entire wall down at once, but can take one brick down at a time, and then one more brick, and one more, and let someone in a little bit at a time, as much as feels safe. A follow-up to this is to use cognitive processing in order to explore the full range of possibilities that could occur if the child began to trust and commit to new relationships. This could include the “worst case” scenario that the child fears, i.e., that the child would trust and care for someone and then traumatically lose that relationship also. However, there are many other possibilities, including the “best case” that the relationship would be positive, helpful and continue until the child returns to the separated parent; there are other “middle of the road” possibilities in between. The therapist thus encourages the child to recognize that the feared scenario is understandable based on the past traumatic separation, but is less likely than a more positive outcome. Treatment of more chronic issues of mistrust and/or emotional numbness related to complex trauma is described in detail elsewhere (Cohen, Mannarino, Kliethermes & Murray, 2012; Kliethermes & Wamser, 2012). Marcus: At Marcus’ next visit with his mother, she told Marcus that she had finished her substance abuse treatment and was ready to get custody of him and Martin. She asked Marcus to have Ms. Tonya tell CPS to let the children go home. Marcus asked Ms. Tonya to call CPS, but Ms. Tonya wanted to discuss it with his therapist first. Marcus was angry that Ms. Tonya did not immediately call CPS on his mother's behalf. He returned to his previous angry behavior, called Ms. Tonya rude names, and refused to interact with her, saying she broke his trust. That week in therapy, Marcus described the situation. The therapist explained that substance abuse treatment programs were six months long (his mother had been out of prison less than a month) and discussed with Marcus what his mother had to do to get custody. Marcus said, “Go to therapy and supervised visits, follow the rules at the halfway house, and stay off of drugs”. They then discussed why his mother might have misled Marcus about finishing treatment. He first defended her, saying that she really wanted to get custody of him. Then he said, “I know she has to do all those things, not me or anyone else. Why can’t she just DO it?” They then addressed Marcus’ anger at Ms. Tonya. He said that Ms. Tonya “broke my trust” (betrayal) by not calling CPS. The therapist validated Marcus’ feelings and reminded him that betrayal was his trauma theme, so it was understandable that he was highly sensitive to this. They carefully explored the situation and Marcus eventually said that maybe Ms. Tonya didn’t want to call CPS because she knew that his mother wasn’t being honest, but she didn’t want to hurt Marcus. The therapist said, “Ms. Tonya really cares a lot about you. She would rather not say something hurtful about your mother, even if it ended up being true.” Marcus agreed that this could be why Ms. Tonya didn’t call CPS, rather than breaking his trust. Marcus still hesitated to recommit to his relationship with Ms. Tonya. The therapist used the “best case”/“worst case” scenario to address this with Marcus, pointing out that Ms. Tonya had not “taken sides” against his mother in the recent episode. Marcus’ “best case” was that he resumed his positive relationship with Ms. Tonya and that she advocated for him to return to his mother when this was possible. His “worst case” was that he did not trust Ms. Tonya, and might end up in a much worse foster home. His “middle of the road” scenario was to stay with Ms. Tonya in a non-trusting relationship where they continued to have conflict as they had when he first came to live with her. He acknowledged that “for the time being”, until he could return to his mother's 192

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care, living with Ms. Tonya was what he wanted but he didn’t know how to get back to where they had been in their relationship. The therapist suggested having a joint session with Ms. Tonya to resolve this. During the conjoint session, Ms. Tonya listened to Marcus, shared her concerns about his mother but said that she had not made any assumptions about her without all the facts. Marcus was very relieved that Ms. Tonya did not judge his mother. Ms. Tonya validated that Marcus’ first loyalty should always be to his mother and that she understood why he was angry at her for not advocating for his mother with CPS. Marcus in turn said that he didn’t want Ms. Tonya or her family to be mad at him about what happened. Ms. Tonya said that they considered Marcus to be part of their family, and wanted him to stay with them until his mother can take him back. Marcus described his “best case” scenario and said that this was what he wanted too. Elena: Elena was committed to her relationships with Mary and her teen daughters, but was afraid to make new friends in school. Elena shared that she made a friend in the detention center, 9 year old Ana, who slept next to her and ate with her at meals. When she left the detention center she missed Ana and decided to not make new friends again. The therapist and Mary validated her sadness and fears about repeated loss, and encouraged her to talk about these feelings. The therapist used the wall exercise to help Elena see that she took the chance to make friends with Ana, and asked whether she wished she had never met Ana. Elena said she was glad she had met Ana even though she missed her. Elena agreed that she would like to have another friend, and Elena named two girls in school that she might like to have as friends. Mary suggested having play dates with each of them, and Elena agreed. 5.4. Addressing role changes Many children take on the care of siblings or other children, or lose the care of siblings and/or parents as a result of traumatic familial separations. As clinically appropriate, the therapist acknowledges the loss of this role, explores with the child ways in which this has impacted the child's self-identity and may be negatively impacting the child's relationship with the current caregiver and/or others, and how to clinically address these issues for the child's optimal functioning. Many of these interventions have likely already occurred during previous components. For example, during the Enhancing Safety component, the therapist provides assurance that the impaired parent is receiving needed interventions for health, mental health and/or addiction problems that required the child's caregiving prior to the traumatic familial separation. During Psychoeducation the therapist provides information about the impact of Childhood Traumatic Separation on children's relationships with separated family members including changing roles. During Trauma Narration and Processing the therapist guides the child in describing the child's relationship with family members before the familial separation, when these children often include details of caring for siblings and/ or impaired parents; the child also describes the traumatic separation which may include details of how younger siblings reacted to the loss of the caregiving child; and the child also engages in cognitive processing that often includes processing the loss of the child's role as caregiver. During the Naming the Loss component, some children may have described and processed having missed taking care of the parent and/or family. Additionally, the therapist may have addressed the child's changed caregiving role in some manner related to visitations with the separated parent and/or siblings. Thus, this issue has likely been addressed by this point in therapy with children and caregivers for whom it is relevant. Before ending therapy, it is often helpful for the therapist to review and summarize the change in the child's role. The therapist may find it helpful to use the metaphor of a “transformer” in this regard, i.e. the child has morphed from the caregiver into the child who is being cared for by the current caregiver. If the child was previously caring for younger siblings, they are likewise being cared for by adult caregivers who can keep them safe, and hopefully the child is able to see and/or speak with the siblings on a regular basis. If the child was previously caring for an impaired parent, that parent is in turn receiving care from professionals who can best provide this care, while the parent learns the skills to care for him or herself and hopefully to be able to care for the child(ren) when they are reunited in the future. Thus all members of the separated family are in a better position to live healthy lives when they are (hopefully) reunited. The child's appropriate role is to be a healthy child rather than an adult. Marcus: Marcus’ mother was rearrested for parole violations and returned to prison. This was very difficult and painful, but not a complete surprise for Marcus. The therapist discussed the change in Marcus’ role as a caretaker to his mother and Martin. Marcus said that he missed taking care of Martin, but since he had been able to visit him several times, he was able to see that Martin was safe and happy living with his aunt. Marcus said that it was a big change going from the oldest kid in the family and the one who was responsible for taking care of meals and getting to schools, etc., to the youngest one in Ms. Tonya's family, only having to be responsible for himself, and being taken care of instead of worrying about other people. He said he missed it in a way, but it was a relief too. He continued to worry about his mother, but realized that he could not control what she did and that it was not his job to take care of her. 5.5. Treatment closure issues Therapists who are treating youth with Childhood Traumatic Separation should be especially mindful of treatment closure issues. After experiencing sudden and traumatic separation from their primary attachment figures, these children are particularly sensitive to the loss of control over decisions related to when, how, and under what circumstances relationships change or end. The therapist should therefore openly address how and when treatment will end. As noted earlier, in some situations, TF-CBT treatment ends abruptly and unexpectedly, due to unanticipated changes in the separated parent's circumstances; in this case, the therapist does his or her best to meet or at least speak with the child in order to process the sudden termination in the therapeutic relationship. Specifically, the therapist explains the change in the separated parent's circumstances, the resultant change in the child's living situation (e.g., the child will be moving back to live with the separated parent), and why therapist will be ending (e.g., the separated parent lives too far to continue therapy here, etc.) In most 193

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cases the child will be so happy to return to the separated parent that ending the therapeutic relationship will not be very upsetting, but the child should have a chance to express any feelings related to this unanticipated loss and any associated feelings or trauma reminders that it elicits. For children who are nearing completion of TF-CBT, the therapist reminds the child that they only have a few more session (e.g., “we have 2 more sessions”, etc.), and verbalizes that for children with Traumatic Separation, ending any relationship may be a reminder of the traumatic familial separation they previously experienced. The therapist helps the child to recognize that there will be future reminders of trauma and separation, using a perpetual calendar or other strategies to identify personal reminders and to plan for these in the future (Cohen et al., 2017). The therapist then invites the child to plan how they would like this separation to go so that the child and therapist can say goodbye in a way that is not scary, chaotic or upsetting. The therapist can say that he or she will be sad to say goodbye, but also happy because the child is doing so much better than when they started treatment that the child no longer needs treatment for Traumatic Separation. The child and therapist may plan a small graduation “party” during the final session in which they review the child's progress during therapy and have small treats; the child and therapist may give each other pictures they take together or separately; and the therapist may prepare a graduation “diploma”. All of these (or other agreed upon activities) are ways for the child to gain mastery and a sense of control over separation experiences. The current caregiver is included in planning for the final session, and in planning and preparing for future trauma and separation reminders that may occur after the end of therapy. A final “graduation” session is held with the child and the current caregiver to say goodbye. Marcus: The therapist and Marcus discussed potential trauma and loss reminders that might occur in the future, and how he could prepare for these in the future. Marcus identified several dates on the perpetual calendar as well as unpredictable events (e.g., his mother getting out of or going into prison) that could be problematic, and ways to prepare for and cope with these. Marcus had a graduation session that Ms. Tonya attended to share cake and talk about his future plans. Marcus’ PTSD symptoms significantly decreased to a CPSS-5 score of18. Elena: Elena's mother's immigration status remained unresolved which was a source of ongoing trauma and loss reminders. The therapist, Elena and Mary worked together to plan for how to identify and respond to these as they occurred, using TF-CBT skills to manage these. Elena had adjusted to her current living situation. She was sleeping well, attending school and had made a few friends. The therapist, Elena and Mary had a graduation ceremony at a time when Elena's mother could briefly join them on the phone. They reviewed Elena's coping skills and Elena proudly demonstrated these for her mother during the call. Elena had a party and received a graduation certificate. Her PTSD symptoms significantly decreased to a CPSS -5 score of 14. 6. Discussion This paper describes clinical applications of TF-CBT for Childhood Traumatic Separation. Further training and consultation in these TF-CBT interventions are available to interested clinicians. Such training may be especially useful for clinicians who treat children in foster care, immigrant children, children of parents who have been deported or incarcerated, and/or other populations of children who experience familial separation, and includes TF-CBT Web2.0 (https://tfcbt2.musc.edu/), 2-day face-to-face training with an approved TF-CBT national trainer, consultation calls to implement TF-CBT with clinical cases, and advanced training specific to Childhood Traumatic Separation. More details are available at the TF-CBT National Therapist Certification website https://tfcbt. org. Therapists should be cautious about initiating TF-CBT in short-term shelters or detention centers where safety is a concern and where treatment has a high likelihood of being interrupted prematurely. The priority in these settings should be on advocating for family reunification or placing the child in a family-based setting. Research has shown that TF-CBT is effective for traumatized youth internationally, and cultural modifications are available for Hispanic and Native American families (Cohen, Mannarino, & Deblinger, 2012). It is likely that other evidence-based trauma treatments that include a strong focus on the child-parent relationship, such as Child Parent Psychotherapy (Lieberman & Van Horn, 2008) will also be effective for addressing Childhood Traumatic Separation. In addition to providing evidence-based trauma treatment, establishing and maintaining ongoing cross-system collaborations and communications with pediatric, educational, child welfare and other service providers are important to assuring optimal outcomes for children with Traumatic Separation. Knowing the relevant providers in the child's life, understanding the nature of the relationship the child has (or struggles to have) with each of these individuals, and assisting in bridging these gaps when necessary, can ease transitions and substantially improve services that these children receive across systems. Given the unprecedented number of immigrant families who are experiencing traumatic separation at the US border, it is critically important for mental health professionals to recognize and understand how to apply evidence-based treatment interventions for Childhood Traumatic Separation. 7. Conclusion Childhood Traumatic Separation occurs when children develop significant traumatic stress reactions in response to a traumatic familial separation. Evidence-based treatments for Childhood Traumatic Grief can be applied to help children with Childhood Traumatic Separation. Current clinical applications of one such treatment, TF-CBT, are described here as they have been used extensively in clinical practice for children with traumatic separation related to foster care placement, termination of parental rights, parental incarceration, immigrant and refugee children. Empirical research would contribute to documenting the effectiveness of these and other treatments for this population. Acknowledgments This manuscript was supported in part by a grant from the Substance Abuse and Mental Health Services Administration for the 194

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National Child Traumatic Stress Administration, Grant No. SM80056. We gratefully acknowledge the contributions of the National Child Traumatic Stress Network's Childhood Traumatic Grief and Traumatic Separation Committee with regard to Childhood Traumatic Separation conceptualization and product development (www.nctsn.org/trauma-types/traumatic-grief). References Administration for Children & Families (2018). Child maltreatment 2016. Retrieved from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2018. American Academy of Child & Adolescent Psychiatry (2018). Foster care facts for families. Retrieved from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_ Families/FFF-Guide/Foster-Care-064.aspx?utm_source=Informz&utm_medium=email&utm_campaign=Annual%20Meeting. Brown, E. J., Goodman, R. F., Falk, S., & Swiecicki, C. C. (2019). Psychometric of the PTSD and depression screener for bereaved youth. Death Studies, 43, 20–31. Bryant, R. 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