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Neurobiology of Trauma and Mindfulness for Hours

Children
Jaclyn Iacona, MSN, BS, RN ■ Stephanie Johnson, MSN, RN
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personal violence, maltreatment, neglect, natural disas-


ABSTRACT ters, accidents, medical illness, and grief (The National
Adverse child experiences (ACEs) have a significant impact
Child Traumatic Stress Network, 2017). Furthermore,
on developing children, both physically and psychologically,
trauma may be experienced as a single event or on pro-
with ongoing consequences that may manifest throughout
longed, multiple occasions, both of which can negatively
adulthood. These negative health consequences can be
affect the child in the same way (The National Child Trau-
mitigated if a child is given a supportive environment in
matic Stress Network, 2017).
which to develop healthy coping mechanisms. Those who
Understanding the neurobiology of youth who have
specialize in caring for children with ACEs must understand
undergone trauma is essential for those individuals pro-
the neurobiology of trauma to conceptualize how trauma
viding care and services to this vulnerable and at risk
triggers the brain and body when encountering stressful
population. When there is a traumatic event or ongoing
events. Mindfulness is an evidence-based practice that
situation in which the child is in danger, his or her brain
can be used as a healthy coping mechanism to develop
initiates neurochemical changes internally that result in
self-regulation and resiliency in children. The purpose of
external behavior and actions (Leitch, 2017). Consequen-
this article is to provide evidenced-based research on the
tially, some of these children have behavioral problems,
neurobiology of trauma and mindfulness intervention as a
trouble at school, and difficulty making and maintaining
recommended modality for use in children. Furthermore,
relationships—due in part to maladaptive, neurochemical
the content in this article was utilized in developing a
changes in their brain because of inflicted trauma (Chil-
training module for a suburban, youth organization that
dren’s Bureau, 2014).
provides residential housing, basic necessities, education,
When these children, who may be labeled as “troubled,”
and therapy for children with ACEs. The training module
disobey commands and/or do not follow rules, adults can
is intended to assist staff members in understanding the
become very frustrated after their attempts at correcting
neurobiology of trauma and mindfulness techniques in their
the situation are unsuccessful. The adult’s reaction, fueled
interactions with the children, thereby improving child–staff
by frustration and lack of understanding, may actually
relationships and encouraging the development of self-
trigger the child further. Adults who care for youth who
regulation and healthy coping mechanisms.
have undergone trauma need education on understand-
ing the internal neurobiology of trauma to comprehend
Key Words the external actions of the child and care for them ap-
Children, Mindfulness, Neurobiology of trauma
propriately. It is only then that the adult may be able to
effectively engage with the child and mitigate the poten-

A
ccording to the National Center for Mental Health tial for triggering the child into crisis mode (Leitch, 2017).
Promotion and Youth Violence, 60% of adults In addition to understanding the reasoning behind a
report experiencing abuse or other difficult fam- child’s behavior and actions, finding ways to respond to
ily situations during their childhood—also called the child who has experienced trauma in a calm, lov-
adverse child experiences (ACEs)—with 26% of ing, and supportive manner is important for the child’s
children witnessing or experiencing their own traumatic growth. Mindfulness, the human ability to be fully aware
event before the age of 4 years (Negrini, 2016). Traumatic of what is going on in the present moment, can be a tool
experiences for children may consist of community and that facilitates maturation in the ability to regulate emo-
tions and actions in an appropriate manner (Bethell, Gom-
bojav, Solloway, & Wissow, 2016). Children and adults
Author Affiliation: School of Nursing, Oakland University, Rochester, can use mindfulness in their daily life to effectively cope
Michigan.
when confronted with triggers. Numerous studies have
The authors declare no conflicts of interest.
statistically proven the efficacy of mindfulness programs
Correspondence: Jaclyn Iacona, MSN, BS, RN, School of Nursing, Oakland
University, 318 Meadow Brook Rd, Rochester, MI 48309 (iaconaja@ and modalities in the youth population to manage trig-
gmail.com). gers and provide resiliency in emotional regulation (Allen
DOI: 10.1097/JTN.0000000000000365 et al., 2012; Frewen, Rogers, Flodrowski, & Lanius, 2015;

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Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
Ortiz & Sibinga, 2017; Sanger & Dorjee, 2015; Sibinga, will be better equipped to care for the children, thereby
Webb, Ghazarian, & Ellen, 2016). Mindfulness is a safe, improving their mental, emotional, and physical health
low-cost, and beneficial modality that can be used as an outcomes.
adjunct with therapy and medication management to im-
prove the resiliency and emotional regulation of children
LITERATURE REVIEW
who have experienced ACEs or traumatic events (Ortiz &
Sibinga, 2017). Neurobiology of Trauma
Understanding the neurobiology of trauma can be helpful
PURPOSE for those who care for children who have experienced
The justification for training on the neurobiology of trau- trauma. Trauma is exceedingly stressful on the mind and
ma and mindfulness intervention was identified after con- body. Although mild or moderate stress can be positive
ducting a Needs Assessment as part of a master’s gradu- and beneficial to development, severe or chronic stress
ate nursing course in April of 2017 at a suburban, youth may be associated with physiological and psychological
organization that provides residential short- and long- negative health consequences (Hornor, 2017). ACEs can
term housing, education, basic necessities, and therapy lead to severe and/or chronic stress and thus the afore-
for children who are between household placement and mentioned negative consequences. With repeated stress,
have undergone traumatic situations with evidence of be- physical changes in the brain and hormonal imbalances
havioral issues. The authors first observed and informally throughout the body occur. Those effects and negative
interviewed both the adults (staff) and children (resi- consequences are a result of neurobiological changes, in-
dents) in the organization in an effort to collect data on cluding the peritraumatic recruitment of the body’s stress
perceived areas of improvement within the organization. system known as the hypothalamic–pituitary–adrenal
After this initial interaction, a survey was developed to (HPA) axis (Hornor, 2017).
elicit additional information from the adult staff members The HPA axis is responsible for the neuroendocrine
regarding the needs of the organization identified during adaptation component of the biological stress response
informal conversations. The survey asked the staff to rank (Nungent, Goldberg, and Uddin, 2016). When encoun-
the organization’s needs in order of importance in five tering trauma, the hypothalamus releases corticotropin-
areas and included increase the community’s awareness releasing hormone (CRH). This hormone then binds with
and knowledge of the services provided at the organiza- the CRH receptor on the pituitary gland to release adren-
tion; increase the training/education for staff on how to ocorticotropic hormone (ACTH). ACTH then causes the
care for children who have experienced trauma; increase adrenal cortex to stimulate the adrenal release of corti-
training/education opportunities for staff on providing sol (stress hormone). Cortisol can be released for several
medical care to children with physical health needs; in- hours after the traumatic event and binds to glucocorticoid
crease training/education opportunities for staff on how receptors until a certain blood concentration is reached
to participate in self-care strategies to improve stress man- (Nungent et al., 2016). This receptor serves as an impor-
agement and burnout; and increase training/education tant role in the negative feedback loop of the HPA axis.
for staff on how to engage in collaborative teamwork, The negative feedback loop allows for systemic homeo-
effective communication, and positive staff, work rela- stasis by deactivating the release of cortisol once the right
tionships. Survey results revealed that the majority of the blood concentration is reached (Nungent et al., 2016).
respondents felt that they needed a deeper understanding With frequent exposure to trauma, the HPA axis will
on the neurobiology of trauma and how this phenom- have repeated and sustained activation resulting in con-
enon can affect staff-child interactions. sistently high levels of stress hormones, thus chroni-
As a result of these findings, an evidence-based prac- cally affecting the immune and inflammatory processes
tice project was developed to educate staff at this organi- (Nungent et al., 2016). The repeated activation of the HPA
zation on care of youth who have experienced traumatic axis during critical periods of brain development in early
events or ACEs. The goal of this education is to provide childhood can lead to changes in gene expression that al-
staff with a better understanding regarding the neurobiol- ter the function of distinct parts of the brain that underlie
ogy of trauma and how it results in the child’s behavior adult emotional and cognitive behavior and functioning
and actions. Furthermore, the project will provide staff (Hornor, 2017).
with mindfulness interventions, tools, and resources that Studies have shown that chronic activation of the
have been proven successful coping mechanisms after HPA axis and an elevated level of cortisol can lead
trauma. The mindfulness modality was chosen specifical- to heightened reactivity to new stressors (Danese &
ly by the authors due to personal interest, feasibility of the Baldwin, 2017). Consequently, after enduring ACEs,
intervention, and demonstrated effectiveness in the child children are more likely to have triggers. A trigger is a
population. With the education and intervention, staff stimulus that causes the child to relive some aspect of

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Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
a traumatic experience. Although the reaction is to a Mindfulness has been well hypothesized to regulate
completely different situation, it reminds the child of changes in the brain through heightened self-awareness
the original traumatic event (Children’s Bureau, 2014). (Allen et al., 2012). In doing so, the brain generates new
This can cause children to react similarly to their previ- neurons (neurogenesis) that are reinforced (neuroplastici-
ous ACEs, activating their HPA axis once again. Their ty) during learning and practice, developing resiliency and
response to the trigger reflects a reflex that may have prosocial behaviors (Leitch, 2017). Specifically in the youth
been an important reaction for survival and what kept population, connections are made between relevant pre-
them alive in their past unsafe situation. Triggers may frontal structures that stabilize arousal and reduce harmful
include smells, sounds, tastes, visual, physical, signifi- risk-taking (Sanger & Dorjee, 2015). The changes in the
cant dates, stressful events, thoughts, behaviors, and brain impact top-down processing in early cognition con-
emotions (Children’s Bureau, 2014). trol and bottom-up processing in more extensive applica-
Facing these triggers, youth struggle with self- tion to increase affective sensitivity (Allen et al., 2012).
regulation and impulse control, oftentimes engaging in Changes on a neurobiological level negate the acute re-
risky behavior not considering the consequences of their sponse to trauma or ACEs and also inhibit the underlying
actions (The National Child Traumatic Stress Network, consequences (Ortiz & Sibinga, 2017). This permits a well-
2017). They may behave in ways that are unpredictable, rounded approach as both a preventive and therapeutic
oppositional, and volatile. Furthermore, feelings of pow- modality in ongoing, healthy brain development.
erlessness or fearing an abusive adult figure may cause In evaluating high-quality, structured, mindfulness
the child to respond defensively and aggressively, or al- programs implemented with youth, multiple positive
ternately be rigid or unusually compliant, in response to outcomes have emerged to encourage the application
perceived blame or attack (The National Child Traumatic of mindfulness (Ortiz & Sibinga, 2017). These outcomes
Stress Network, 2017). Although children may not have analyzed by Ortiz and Sibinga (2017) are compiled from
control over their emotions and reactions when confront- 11 studies conducted in the youth population from 2007
ed with their triggers, there are ways to help them regain to 2016. Outcomes include decreased anxiety, rumina-
control. Children are resilient and their brains are pliable tion, stress, somatization, depressive symptoms, suicidal
at a young age. Supportive relationships, responses of ideation, conflict avoidance, posttraumatic stress disorder
adults, and building a sense of hope and control over severity, and hostility. In addition, prosocial behaviors
their life through means such as mindfulness can facilitate such as effectiveness in social gains, improved attention,
physical and psychological growth in children who have and greater well-being have been identified. These stud-
been through ACEs (Hornor, 2017). ies validate a reduction in negative effect symptoms, with
improved adaptation, attention, and self-regulation in the
Mindfulness for Children youth population (Ortiz & Sibinga, 2017).
Mindfulness is not a new concept and has been practiced Mindfulness is a practical way to self-regulate and build
in some form since the beginning of human existence. resiliency in the youth population (Leitch, 2017). Through
It is a purposeful awareness of one’s presence through structured methods, there is a better capacity for problem-
breathing, thoughts, emotions, and sensations without solving and strategic thinking (Ortiz & Sibinga, 2017). This
judgment (Bethell et al., 2016). Mindfulness is commonly allows youth to choose responses instead of automati-
practiced and studied in the form of yoga, deep breathing, cally reacting (Ortiz & Sibinga, 2017). This change in the
meditation, biofeedback, guided imagery, and hypnosis, neurobiology and neuroplasticity develops an enhanced
but can be applied in almost every activity, whether in a mind–body connection in managing emotional regulation
structured or unstructured method (Bethell et al., 2016). from acute and chronic stressors stemming from ACEs
The key to mindfulness is an unbiased awareness that and trauma in children (Ortiz & Sibinga, 2017).
allows the individual to consciously choose to respond
to the situation or environment, instead of automatically Evidence-Based Project
reacting in a programed approach. It is well studied and An evidence-based project was developed in response
applied as a successful and effective intervention in the to the results of the aforementioned Needs Assessment
adult population; however, it is understudied and underu- conducted at the suburban, youth organization. The pro-
tilized in the youth population and only considered after ject was a PowerPoint presentation training module com-
complete failure of conventional modalities (Bethell et. al, posed of 33 slides with supplemental information in the
2016). notes section. This was the chosen format, as it allowed
Mindfulness has been studied diagnostically on mag- for both visual aids and written content to be presented
netic resonance imaging to evaluate concrete proof for in a practical, manageable way to staff.
changes in the brain with implementation and practice The first half of the module focuses on understand-
(Allen et al., 2012; Leitch, 2017; Sanger & Dorjee, 2015). ing the neurobiology of trauma, whereas the second

JOURNAL OF TRAUMA NURSING WWW.JOURNALOFTRAUMANURSING.COM 189


Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
half explains the mindfulness modality concept and DISCUSSION
implementation. The science of childhood trauma is ex- The training module was given to the organization’s di-
plained through a video courtesy of the Office of Justice rectors to e-mail staff members for viewing on their own
Programs (2016), through the definition supplied by The time. This indirect approach was convenient to the agen-
National Child Traumatic Stress Network (2017), through cy and will allow for a potential greater amount of staff
the neurobiology of trauma mechanism explained by to view the presentation. In addition, staff will be able to
Nungent et al. (2016), and through a video on toxic stress save the presentation on their computers and rereview at
courtesy of the Center on the Developing Child at Har- a later time. The additional material provided in the notes
vard University (2011). Thereafter, the physiological and section of the presentation, videos, and resources will as-
psychological effects during childhood as described by sist staff in furthering their own personal research from a
the Children’s Bureau (2014) and those manifested in basic foundation provided in the module.
adulthood described by the Centers for Disease Control Although an indirect method of presenting allowed
and Prevention (2016) are illustrated. Next, content is for convenience of the organization and ability for all
presented that focuses on understanding triggers identi- staff members to review the training on their own time,
fied by the Children’s Bureau (2014), Trauma Informed it did pose limitations in analysis of functional benefit. It
Care as explained by Leitch (2017), and Trauma-Based is unknown whether or not staff will actually receive and
Cognitive Behavioral Therapy explained by the National review the training module; however, the organization’s
Therapist Certification Program (2017). The first half of directors have reviewed the module themselves and are
the module ends with a summation of the information able to send to staff through a mass e-mail. The authors
presented to bridge to the next section on mindfulness did not have access to the organization’s employee e-
modality as a successful intervention. mails to e-mail themselves. Ideally, it would have been
The second half of the module explores the mindful- optimal to present the content in person to staff and be
ness definition, the mindfulness impact on trauma and able to answer questions and comments regarding the
ACEs, research studies on mindfulness in the youth popu- material. However, the authors added explanation of
lation, structured and unstructured methods, recommend- content in the notes section of the training module on all
ed techniques for staff, and additional resources. First, slides. This allows staff to review the training presenta-
the mindfulness definition as adopted by Bethell et al. tion and all notes the authors would have presented if
(2016) is utilized to lay the foundation. Next, the impact the module was delivered in person. Nonetheless, be-
of mindfulness on trauma and ACEs is illustrated in a flow cause of the results of the Needs Assessment findings,
chart by Ortiz and Sibinga (2017). Thereafter, concepts staff showed genuine interest in learning about the neu-
are introduced by Leitch (2017) such as self-regulation robiology of trauma from the demanding and stressful
and resiliency with image illustrations to examine the ef- interactions in their daily job. This training module offers
fect of mindfulness on the parasympathetic and sympa- staff an opportunity to review content that is research
thetic system. Then, evidence-based research studies are based, clear, and concise as a supplement to developing
presented by Ortiz and Sibinga (2017) to demonstrate the healthy, staff-child interactions.
efficacy of the mindfulness intervention. Once this link is
established and validated, various structured mindfulness
programs are introduced such as Jon Kabat-Zinn’s mind- Clinical Implications
fulness-based stress reduction (Sibinga et al., 2016), mind- Working with children who have encountered trauma
fulness and metta-based trauma therapy (Frewen et al., and ACEs is an arduous job. Although the majority of
2015), and mindfulness-based cognitive therapy and staff held master’s degrees, most lacked a concrete un-
mindfulness-based relapse prevention (Ortiz & Sibinga, derstanding of the neurobiology of trauma as applied in
2017). In addition, mindful-based, mind–body methods their youth population. With a better understanding of
as described by Bethell et al. (2016) are described. The how the brain processes and responds to trauma and trig-
authors chose recommendation of four mindful-based, gers, staff can better engage with the children in assist-
mind–body methods because of ease and practicality ing them to develop healthy, mindfulness techniques to
of the modality. The four methods chosen include the mitigate the effects of induced trauma. This will then ease
4-7-8 breathing technique (Gozenonline, 2012a), 3-min- the demands on staff while engaging with the children
ute meditation (Gozenonline, 2012b), I am meditation and promote a better atmosphere for both children and
(Gozenonline, 2017), and body scanning (Gozenonline, staff. This module can also serve as a mandatory training
2016). The training module ends with the author’s recom- for newly-hired staff in addition to current staff to ensure
mendations for future direction and desired outcomes, list proper education and training is implemented across the
of additional references, and all resources utilized. board.

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In summation, the developed training module was cre- from https://www.cdc.gov/violenceprevention/acestudy/journal
ated for utilization among adult staff members with an end .html
Children’s Bureau. (2014, November). Parenting a child who has
goal of improved child–staff interactions. Providing staff a experienced trauma. Retrieved from https://www.childwelfare.
basic foundation of the neurobiology of trauma will edu- gov/pubPDFs/child-trauma.pdf
cate them of the neurochemical response automatically Danese, A., & Baldwin, J. R. (2017). Hidden wounds? Inflammatory
occurring when a child is being triggered. This will help links between childhood trauma and psychopathology.
Annual Review of Psychology, 68, 517–544. doi:10.1146/
explain the behavioral issues they may be witnessing and annurevpsych-010416-044208
offer a successful, immediate intervention (mindfulness Frewen, P., Rogers, N., Flodrowski, L., & Lanius, R. (2015).
modality) they can teach children to promote self-regula- Mindfulness and metta-based trauma therapy (MMTT):
Initial development and proof-of-concept of an internet
tion and resiliency. This self-regulation and resiliency will resource. Mindfulness, 6(6), 1322–1334. doi:10.1007/s12671-
improve the overall health and well-being of the children 015-0402-y
from an enhanced mind–body connection that is able to Gozenonline. (2012a, December 4). 4-7-8 Breathing exercise by
mitigate the acute response to trauma or ACEs and also GoZen [video file]. Retrieved from https://www.youtube.com/
watch?v=Uxbdx-SeOOo
inhibit underlying consequences of chronic stressors both Gozenonline. (2012b, September 20). Mindfulness exercise for
physically and psychologically. kids: Still quiet place (gozen!) [video file]. Retrieved from
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Gozenonline. (2016, July 6). Body scan meditation by gozen! [video
KEY POINTS file]. Retrieved from https://www.youtube.com/watch?v=aIC-
Io441v4
• Understanding the neurobiology of youth who have Gozenonline. (2017, April 3). Mindfulness meditation: I am the
undergone trauma is essential for those individuals providing pond [video file]. Retrieved from https://www.youtube.com/
care and services to this vulnerable, at-risk population. watch?v=KfynZTaWiyI
Hornor, G. (2017, May). Resilience. Journal of Pediatric Health
• Mindfulness is a practical way to self-regulate and build
Care, 31(3), 384–390. doi:10.1016/j.pedhc.2016.09.005
resiliency in the youth population. Leitch, L. (2017). Action steps using ACEs and trauma-informed
• With a better understanding of how the brain processes and care: A resilience model. Health & Justice, 5(1), 5. doi:10.1186/
responds to trauma and triggers, staff can better engage with s40352-017-0050-5
the children in assisting them to develop healthy, mindfulness National Therapist Certification Program. (2017). Trauma-focused
cognitive behavioral therapy. Retrieved from https://tfcbt.org/
techniques to mitigate the effects of induced trauma.
about-tfcbt/
• A developed training module on the neurobiology of trauma Negrini, L. S. (2016, March). Trauma across the lifespan. Retrieved
and mindfulness-based modality for utilization in children from https://www.usfsp.edu/psychology/files/2015/12/Trauma-
will assist both current and prospective staff in optimal Across-the-Lifespan-Final.pdf
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Poulsen, P., ... Roepstorff, A. (2012). Cognitive-affective neural www.youtube.com/watch?v=jDOIBdsH8os
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Center on the Developing Child at Harvard University. (2011, Sibinga, E. M., Webb, L., Ghazarian, S. R., & Ellen, J. M. (2016).
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childhood experiences journal articles by topic area. Retrieved trauma-types/complex-trauma/effects-of-complex-trauma

For 2 additional continuing education articles related to the topic


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CE Test
Neurobiology of Trauma and Mindfulness for Children
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CE TEST QUESTIONS JTN0518B


General Purpose Statement: To provide evidence-based information about the 7. A purposeful awareness of one’s presence through breathing,
neurobiology of trauma and mindfulness intervention for children who have experienced thoughts, emotions, and sensations without judgment is how
traumatic events or adverse child experiences (ACEs). Bethell et al. (2016) defined
a. faith. b. consciousness.
Learning Objectives/Outcomes: After completing this continuing education c. mindfulness.
activity, you should be able to:
8. The key to mindfulness is
1. Summarize the review of the literature related to the neurobiology of trauma and a. a belief in a higher being.
mindfulness for children. b. an unbiased awareness.
2. Outline the evidence-based practice project developed to educate staff regarding the c. the ability to “let go.”
care of youth who have experienced traumatic events or ACEs. 9. Mindfulness allows an individual to
1. The body’s stress system is known as the a. consciously choose to respond.
a. positive feedback inhibition loop. b. react in a programmed approach.
b. hypothalamus–pituitary–thyroid axis. c. unconsciously respond with a successful approach.
c. hypothalamic–pituitary–adrenal axis. 10. What process described by Leitch (2017) occur during
2. Which hormone might be released for several hours after a periods of heightened self-awareness?
traumatic event? a. neurogenesis. b. differentiation.
a. somatostatin c. neurospecificity.
b. cortisol 11. With the application of mindfulness in youth, connections
c. vasopressin are made between relevant prefrontal structures in the
3. Repeated activation of the body stress system during brain that
critical periods of brain development can lead to alterations a. inhibit negative memories.
in parts of the brain that underlie which adult behavior and b. decrease inhibitions.
functioning? c. stabilize arousal.
a. emotional and cognitive 12. Outcomes of mindfulness in youth as analyzed by Ortiz and
b. motor and sensory Sibinga (2017) include
c. speech and comprehension a. improved school attendance and grades.
4. Danese and Baldwin (2017) found that chronic activation of b. decreased somatization.
the body’s stress system can lead to c. decreased drug use.
a. cognitive delays. 13. Leitch (2017) found that for youth, mindfulness was a
b. mood dysregulation in adulthood. practical way to self-regulate and build
c. heightened reactivity to new stressors. a. hope. b. resiliency.
5. According to The National Child Traumatic Stress Network, c. self-esteem.
when facing triggers, youth struggle with 14. Ortiz and Sibinga (2017) wrote that mindfulness allows
a. self-esteem and interpersonal relationships. youth to
b. self-perception and reality testing. a. choose responses.
c. self-regulation and impulse control. b. forget.
6. What did Hornor (2017) find could facilitate physical and c. take risks.
psychological growth in children who had been through 15. The format of the evidence-based project’s training module
ACEs? was a
a. education a. lecture and instructor-led discussion.
b. diet and exercise b. computer-based interactive simulation.
c. supportive relationships c. PowerPoint presentation.

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16. Mindfulness structured programs introduced in the second 18. How was the training module presented to the staff of the
half of the training module included mindfulness-based organization?
a. behavioral therapy. a. in person, with individual instruction
b. relaxation therapy. b. directly, during staff meetings
c. relapse prevention. c. indirectly via e-mail
17. What mindful-based, mind–body method was included in the 19. The training module was created for utilization among adult
training module? staff members with an end goal of
a. 3-min mediation a. enhanced professional development.
b. body–mind journal b. improved child–staff interactions.
c. I am mindful c. reduced neurochemical triggers.

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