Trainings

Community based interventions have become a powerful new public-mental health tool to deliver heath and resiliency programs, recovery strategies from exposure to violence and adversity, and stigma free social change toolkits for community members with little to no resources for engaged and practical learning opportunities.

The International Trauma Center is a pioneer and now world leader in the design, development, dissemination and implementation of community based interventions assisting enterprises committed to supporting a community’s inherent leadership capacities and resiliency responses in the face of trauma and violence.

The International Trauma Center offers design, development, consultancy and training in a broad continuum of community based interventions and psychosocial interventions which include:

Suicide Prevention Frameworks

Posttraumatic Stress Management© (PTSM)

Psychological First Aid (PFA)

Trauma Informed Care (TIC) Seminars

Skills for Psychological Recovery (SPR)

Classroom-Community-Culture Based Intervention (CBI)

Suicide Prevention Frameworks

Primary Goal: Build Community Coalitions for the Prevention of Suicide and for the Implementation and Management of Suicide Cluster Contagion Containment

Introduction: Over the last 15 years research has clearly demonstrated that death by suicide creates powerful and long-lasting impact on families and communities and that death by suicide is preventable.

When communities are impacted by multiple teen and adult suicide deaths and attempts suicide prevention frameworks (SPF) are necessary and when possible should be put in place prior to multiple deaths by suicide. Multiple domains of research are now indicating that friends of both death by suicide and attempters may be at a significantly increased risk for suicidal behaviors.

Primary Factors that Underscore the Necessity for More Resources to Build SPF’s

“Youth play an important role in suicide prevention: Despite the support systems and safety nets that adults provide for teens and young adults, the first lines of defense in successful prevention efforts of youth suicide are youth themselves. Teens and young adults frequently bypass the adult world support systems and instead turn to their friends for help and understanding. Thus, it is imperative that youth be regularly trained in recognizing signs of depression or increased risk for suicide and know how to connect their friends with professional help. Teens should never be asked to be suicide counselors, but rather to be a peer to adult referral ‘system’.

Suicide is a public health problem: In 2017, there were 47,173 recorded suicides, up from 42,773 in 2014, according to the CDC’s National Center for Health Statistics (NCHS). On average, adjusted for age, the annual U.S. suicide rate increased 24% between 1999 and 2014, from 10.5 to 13.0 suicides per 100,000 people, the highest rate recorded in 28 years.

With over 47,000 suicides in the US each year and estimated suicide attempts minimally being 10 times that, suicide impacts on all aspects of our society. Preventing suicide is the responsibility of the whole community. Most youth prevention efforts are school based; however, this misses out on many youth and young adults who may have dropped out, or are homeschooled, or otherwise not connected with schools. This is particularly true for young adults in the 18-24 year old age group where suicide rates double. Suicide is a complex issue and preventing suicide will take a coordinated effort between law enforcement, mental health providers, educators, social service agencies, family, friends, neighbors, etc.

We are all “gatekeepers”: Gatekeepers is the term used for anyone who does not have a professional treatment relationship with teens and young adults. Gatekeepers are family, friends, relatives, neighbors, coaches, librarians, hairdressers, employers, etc. Regardless of what our professional role might be, we are all potential gatekeepers in our community. For the postvention protocols, a gatekeeper is anyone who has experienced the death by suicide of someone they know in their community. Or anyone who is regularly working with youth or adults at risk. Gatekeepers play an important role in the postvention and prevention process by assisting the immediate family/survivors grieve and ensuring that the community response to the death does not promote suicide contagion.  In addition, having gatekeepers trained to recognizewarning signs of suicide and how to connect with the youth and connectthe youth with help is an essential component to reducing risk for survivors of suicide.” From Frameworks Postvention Protocols

Goals of the Community Coalition

Communities may significantlystrengthen Community Coalitions to Prevent Suicide.Per the Frameworks Models, CDC and Post Traumatic Stress Management (PTSM) models,these programs strive to strengthen the development of the community coalition of elected officials, education leaders, service providers, parents, and youth. Please see examples below.

(1) CDC contagion containment protocols:

Please review CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters: MMWR Supplement (Circular) August 19, 1988 / 37(S-6); 1-12 at http://www.cdc.gov/mmwr/preview/mmwrhtml/00001755.htm

(See Article II-Elimination of Gaps in the Service Network and CDC Injury Center’s Circular Volume 37/NO. S-6 Article VII-At Risk Identification Protocols)

(2) PTSM suicide postvention protocols

Please review Robert D. Macy, et. al., Community-Based, Acute Posttraumatic Stress Management: A Description and Evaluation of a Psychosocial-Intervention Continuum;

Harvard Review of Psychiatry, Issue # 12.4, Taylor & Francis, September 2004 and Robert D. Macy, Issue Editor, Youth Facing Threat and Terror: Supporting Preparedness and Resilience; New Directions In Youth Development, No. 98, Jossey-Bass, June 2003

(3) Frameworks model

Please review https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01756/full

SPF coalitions can be developed and trained to support all stakeholders in their skill, ability and confidence to recognize youth and adults at risk and connect those people in an integrated, systematic and comprehensive way with help. This usually includes:

  • more gatekeeper training for community stakeholders-especially parents
  • specialized training and protocol development for the Police Department, First Responders and Medical Examiner and more training in both gatekeeper and suicide assessment for clinical service providers
  • funding to support a large-scale effort to train youth (18-12 year old) and adults in Signs of Suicide (S.O.S.) and in other appropriate gatekeeper functions
  • funding to support critically needed school based mental health service provision at schools, community centers and in First Responder Populations.

Communities need to identify clear system gaps that exist between the schools, hospitals, police, medical examiner, public health and mental health providers. The emphasis must be on coordination, communication, and connections between governance, local resources, providers, citizens, and youth. This can foster significantly increased help-seeking behaviors among our students and older youth.

Current Community Coalition Infrastructure-Membership/Stakeholders:

  • Community Gatekeepers
    • Board of Selectmen, Mayor’s Office or County Government
    • School-County Office of Education
    • Boys and Girls Clubs
    • YM/WCA’s
    • Parent Groups
    • Primary Care Doctors
    • Community Based Behavioral Health Organizations
    • Interfaith Clergy Councils
  • State Agencies
    • DMH
    • DPH
  • Social Service Agencies
  • Law Enforcement
  • Primary Care Providers
  • Teens/Students
  • Clergy
  • Judiciary
  • Schools/Educators
    • Public Schools
    • Private Schools
    • Mental Health and Substance Abuse Providers
    • Behavioral Health Services
    • Alliance for Substance Abuse Prevention
  • Emergency Medical Services
  • Emergency Departments
  • Funeral Directors 

SPF-Coalition Skill Building

County Behavioral Health Clinicians: Suicide Assessment Clinical Training

Provide advanced trainings in

(1) the Chronological Assessment of Suicide Events (C.A.S.E. Approach)

https://www.sprc.org/resources-programs/experiential-training-chronological-assessment-suicide-events-case-approach

School Containment: Gatekeeping, Casefinding, Screening & Suicide Prevention Programs

High Schools: Review Evidence-Based Gatekeeping, Casefinding and Screening Suicide Prevention Programs

Schools will need to review programming for their campuses that is deemed evidence based and appropriate for school. Several selections are fundamental to the SPF (see below). Both the Frameworks model and the PTSM contagion containment model indicate it will be necessary for the school to add additional programming to Counseling Centers and consider the SOS, SAP and Student Drop in Center programs given the level of possible risk at the school and in the community. This must include the development and consistent support of a student based S.O.S. ‘culture’.

School Based Mental Health

School Counselors and school staff working directly with students on a weekly basis to conduct treatment, stabilization, assessment and referrals is resource dependent (needs appropriate funding) and a critical foundation layer to the success of the SPF.

Signs of Suicide Program (S.O.S.)(Screening Component)

SOS trainings for school and non-school based gatekeepers is necessary with follow up post-SOS training to conduct small group work for identified at risk students, and the development and consistent support of a student based S.O.S. ‘culture’.

Student Assistance Program (SAP)

Schools and their community need to provide the funding to hire a 1.0 SAP specialist.

http://www.thepreventionnetwork.org/school-programs/sap/

Drop In Center at the Schools

The School Administration may need to consider the launch of a full-time student drop in center which will be staffed with School Counselor personnel. Clinicians who already known by staff and students should also be a consistent part of the drop-in center personnel.

Teacher/Parent Support

There is usually an immediate need to develop and practice a “buddy” system for teachers in case of another attempt or suicide death which can be implemented by the PTSM team members: the teacher group for “buddies” would be with them during the school day(s) immediately following the event to offer PTSM support to the teachers and their classroom. There is usually an immediate need for psychoeducation groups for the teachers on how suicide occurs-and how it is inhibited.

Resiliency Building Groups for students as part of School Health Curriculum

Schools may need to consider, in collaboration with DMH and Public Safety, using the newest evidence base from the psychosocial interventions used in the US and abroad to build a resiliency focused curriculum as part of the existing health curriculum.

Joint Incident Command System (ICS) Meetings

It is important to develop the possibility of building a School ICS collaborating with the  Town/County ICS managers to discuss how to share command during major high-risk behaviors or suicide deaths among residents. The the Town and School ICS should meet with some regularity to decrease any gaps in the level of understanding of shared command and agreed upon response protocols during a suicide crisis event. A good example of this is the arrest of students at risk for suicide. A protocol is in place that

all students who are arrested will be evaluated by a DHS-trained clinician prior to their release by the law enforcement.

Other suggestions for development and dissemination

(From Frameworks Model and PTSM Model)

  • Provided supports to survivors by convening a Survivors Committee
  • Consider a survivor newsletter with lists of support groups and County and State resources
  • Consider sending two residents to national training to become survivor support group facilitators
  • Consider the development and distribution of PSA’s with resource information to next of kin of suicide victims
  • Consider the development and funding of a Community Health and Healing fund to provide small grants for postvention activities
  • Consider the development and distribution to all Libraries of a bibliography of suggested books for suicide survivors.
  • Worked local and state media to promote responsible reporting of suicide events by distribution of CDC Media Recommendations to media outlets
  • Respond to various media outlets following sensational/inappropriate media coverage

And worked to decrease stigma and promote increased help seeking behaviors including:

  • Consider forming a workgroup to create messages that decrease stigma and promote help seeking behaviors
  • Consider Negotiated Memorandums of Understanding (MOU’s) between schools Police Chief, Medical Examiner, and clinical providers.

Our ITC partner, Emotion Technology, launches hotlines and other large scale suicide prevention and mental health programs that integrate mobile, social and interactive technology. These include:

Posttraumatic Stress Management© (PTSM)

For Residential, Agency, Schools, & First Responders

The PTSM development team, founded in 1995 and managed by the International Trauma Center and the Boston Childrens Foundation works closely with state Departments of Education, Mental Health, Youth and Family Services, and Federal agencies including DOE, SAMHSA, FEMA, DHS and the Red Cross to incorporate evidence-based and emerging practice models for psychological first aid and recovery phase protocols.

(See Robert D. Macy, et. al., Community-Based, Acute Posttraumatic Stress Management: A Description and Evaluation of a Psychosocial-Intervention Continuum; Harvard Review of Psychiatry, Issue # 12.4, Taylor & Francis, September 2004)*

*Please see PDF # 1

  • PTSM is a cognitive based (verbal) group intervention model for youth and adults 9 years old and older that has been developed through extensive field practice and research over the last 20 years in the US and abroad post adversity, trauma and violence exposure in schools and local communities; the PTSM design and development service continuum includes gender specific, developmentally specific, culturally and linguistically specific post-disaster psychological intervention, stabilization and resiliency augmentation protocols.
  • PTSM is a phase oriented series of highly structured, school, agency and community-based group interventions supporting the natural tendency of school and/or community peers to group together seeking safety and solace following traumatic incidents.
  • PTSM targets immediate reduction of traumatic stress sequelae with the concomitant augmentation of coping and resiliency and the identification of survivors who require higher levels of behavioral health or medical care.
  • PTSM focuses across the life span as well as specifically on impacted children, youth and their families and on the staff of schools and social service agencies supporting school trauma responses or exposed to ongoing traumatic events.

PTSM provides six basic interventions conducted by credentialed interventionists:

Post-trauma impact and needs assessments

Psychological first aid

Orientation sessions

Stabilization groups

Coping groups   

Ongoing psychosocial consultancy and technical assistance

  1. Post-trauma impact and needs assessments assisted by PTSM coordinators and implemented by community leaders
  2. Psychological first aid for one-to-one stabilization and immediate needs inventories
  3. Orientation sessions that provide ongoing accurate information about the event, the decedents, psychoeducation about survivor physical and emotional reactions following a trauma, resource installation and resiliency building. (Orientations are normally not more than 1 hour and are perfect for the school general assembly-if required and can accommodate any number of participants. Post 9/11 we did orientations for as many as 850 people at one time)
  4. Stabilization groups that accommodate 6-15 participants, normally with homogeneous exposure, A PTSM stabilization group has five phases (or core actions if using PFA terminology) lasting approximately 45 minutes, usually conducted on scene (0Hour/hot zone) or within the first 24 hours of the exposure, normally off scene. Stabilization groups focus on (a) psychological safety building, (b) grounding and mindfulness techniques and (c) self care and substance abuse information all aimed at the reduction of neurophysiological arousal secondary to the traumatic stress exposure and the development of a “safety plan” for now through the funeral services. Stabilization groups for school youth and their care giving adults have been customized for suicide, homicide, school shootings, and sudden death due to medical anomalies, ongoing violence exposures (violent gang activity), terrorism and natural disasters.
  5. Coping groups can accommodate 6-10 participants, normally with homogenous exposure, may last 90 to 120 minutes, and are provided usually after the funeral and up to 3-4 weeks after the event. A PTSM coping group has nine phases (or core actions if using PFA terminology) and focus on multiple cognitive and neurophysiological strategies for adapting to traumatic stress and normal bereavement without dwelling on (trauma processing) the incident narrative or sensory threat details. Coping groups for school youth and their care giving adults have been customized for suicide, homicide, school shootings, sudden death due to medical anomalies, ongoing violence exposures (violent gang activity), terrorism and natural disasters.
  6. Ongoing PTSM consultancy, technical support and assistance for the school or community leaders most impacted by the event to assist them with intermediate and long-term stabilization, recovery, and anniversary challenges. This phase may last from 3 weeks out through the first year anniversary.
  • Goal: The goal of the PTSM basic course is to credential acute trauma responders to be competent in the design, development and application of evidence-based and emerging practice models for psychological first aid and psychological trauma recovery protocols that are specific to school and community environments with a strength based, developmentally focused approach to all hazards exposure to adversity, violence and trauma.

101-Trauma Informed Care (TIC) Seminars

101- TIC begins with the Basic TIC Orientation and includes in depth didactic and experiential transformational learning to explore phenomenology contributing to the complexity of traumatic exposure and resulting reactions and the downstream development of survival behaviors. Particular attention is focused on how we were sanctioned and rewarded as a child and how our society is toxically dependent on the ‘mentalist model’ of human experience.

This seminar is an overview of Trauma Informed Care designed to address the specifics of the training population, their service recipients and their interaction with traumatized children and families. Didactic and experiential learning will focus on self-examination in the face of dysregulated children; how clients can cue your reactions and what that means for your ability to be guides for them to heal and recover. Seminar content and activities  examine social skill development, brain development and emotional development for the specific service recipient populations of the training group with the intent of developing customized concrete processes for healing and recovery.

Psychological First Aid (from the PFA Field Manual)

For citation: National Child Traumatic Stress Network and National Center for PTSD,

Psychological First Aid: Field Operations Guide, September, 2005

What is PFA?

Psychological First Aid (PFA) is an evidence-informed modular approach for assisting children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism.  PFA is designed to reduce the initial distress caused by traumatic events, exposure to adversity and violence and to foster short- and long-term adaptive functioning.  Principles and techniques of PFA meet four basic standards: (1) consistent with research evidence on risk and resilience following trauma; (2) applicable and practical in field settings; (3) appropriate to developmental level across the lifespan; and (4) culturally informed.

Who is PFA For?

PFA intervention strategies are intended for use with children, adolescents, parents/caretakers, families, and adults.  PFA is delivered in a 1:1 format normally, so it is NOT a group intervention model.

Who Delivers PFA?

PFA is designed for delivery by adult providers of social care and stabilization working with youth and their parents. PFA provides acute assistance to affected children and families as part of an organized stabilization response effort.

Basic Objectives & Goals of PFA

  • Understand your role as a PFA interventionist
  • Understand the other roles you may be bringing to the intervention and how to integrate or leave them at the door
  • Understand the identity and ‘role’ of the trauma survivor
  • Establish a human connection in a non-intrusive, compassionate manner.
  • Enhance immediate and ongoing safety, and provide physical and emotional comfort.
  • Calm and orient emotionally-overwhelmed/distraught survivors.
  • Help survivors to articulate immediate needs and concerns, and gather additional information as appropriate.
  • Offer practical assistance and information to help survivors address their immediate needs and concerns.
  • Connect survivors as soon as possible to social support networks, including family members, friends, neighbors, and community helping resources.
  • Support resilience, acknowledge coping efforts and strengths, and empower survivors; Encourage adults, children, and families to take an active role in recovery.
  • Provide information that may help survivors cope with the psychological impact of adversity and exposure to violence.

Skills for Psychological Recovery (SPR)

Skills for Psychological Recovery (SPR) (OR Skills for Personal Resiliency) is an evidence-informed modular approach to help children, adolescents, adults, and families in the weeks and months after disasters and terrorism, after the period where Psychological First Aid is utilized. Skills for Psychological Recovery is designed to reduce any ongoing distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. Principles and techniques of Skills for Psychological Recovery meet four basic standards.  They are: (1) consistent with research evidence on risk and resilience following trauma; (2) applicable and practical in field settings; (3) appropriate for developmental levels across the lifespan; and (4) culturally informed and delivered in a flexible manner.  Skills for Psychological Recovery does not assume that all survivors will develop severe mental health problems or long-term difficulties in recovery. Instead, it is based on an understanding that disaster survivors and others affected by such events will experience a broad range of reactions (for example, physical, psychological, behavioral, spiritual). Some of these reactions will cause enough distress to interfere with adaptive coping, and recovery may be helped by support from compassionate and caring counselors.

Skills for Psychological Recovery focuses on a few core empirically-derived skill sets that have been shown to help with a variety of post-trauma issues.  Research suggests that a skills-building approach is more effective than supportive counseling.  SPR is a skills-training model designed to accelerate recovery and increase self-efficacy, rather than a mental health model.

The SPR approach addresses the issue that many people will only being able to attend one or two contacts.  Expert Consensus suggests that there be at least 3-5 contacts that focus on skills-building to reliably change behavior.  However, SPR is set up to provide stand-alone contacts if 3-5 contacts aren’t practical.  Counselors should attempt to set an expectancy for what is most helpful (more than one contact).

SPR is not meant to be formal mental health treatment – it is intermediate, secondary prevention.  For many people it will be enough.  However, if SPR doesn’t help to alleviate distress as effectively as is needed, it is appropriate to refer to more intensive mental health intervention. SPR is meant to teach basic skills, but not to solve all problems.  The counselor may only be able to address one or two issues, then refer the survivor on.  Additionally, if serious issues are revealed in initial assessment, immediate referral is encouraged.

SPR is based on gathering information on client needs, and defining goals and priorities in a collaborative process – it should address the top needs identified by the client as well as what counselor perceives to be problems, considered in light of what is feasible in the time allotted.

Who are Skills for Psychological Recovery For?

Skills for Psychological Recovery intervention strategies are intended for use with children, adolescents, parents/caretakers, families, and adults exposed to adversity, trauma, violence, disaster or terrorism. Skills for Psychological Recovery can also be provided to teachers, residential staff, first responders and other social work recovery specialists.

Who Delivers Skills for Psychological Recovery?

Skills for Psychological Recovery is designed for delivery by mental health and other disaster response workers who provide ongoing support and assistance to affected children, families, and adults as part of an organized disaster response effort. These providers may be imbedded in a variety of services, school systems, residential treatment centers, community mental health settings, primary and emergency health care, school crisis response teams, faith-based organizations, Community recovery programs, Medical Reserve Corps, the Citizens Corps, and other social engagement–related organizations.

When Should Skills for Psychological Recovery Be Used?

Skills for Psychological Recovery is designed to be implemented in the weeks, months, and years following exposures to adversity, violence, and trauma, generally after psychological first aid (PFA) and/or supportive counseling have been attempted and more intensive support is indicated.

Where Should Skills for Psychological Recovery Be Used?

Skills for Psychological Recovery is designed for delivery in diverse settings. Mental health and other disaster response workers may be called upon to provide Skills for Psychological Recovery in general population shelters, special needs shelters, outreach settings such as schools, survivor support gatherings, memorial services, and community events, staging areas or respite centers for first responders or other relief workers, crisis hotlines or phone banks, disaster assistance service centers, family assistance centers, homes, businesses, and other community settings. However, for best results, the services should be provided in a private, quiet place that allows for at least 45 minutes of uninterrupted time together.

What are the SPR training modules?

Information Gathering

Problem Solving

Positive Activity Scheduling

Managing Traumatic Reminders

Helpful Thinking

Building Healthy Social Connections

Classroom-Community-Culture Based Intervention (CBI)

The CBI is a 4-week 12-session classroom-clinic-camp-based group intervention, involving a series of highly structured expressive-behavioral activities. The aim of these activities is to significantly reduce traumatic stress reactions, anxiety, fear and depressed moods, by allowing and guiding children to do what they do best: playing, learning and creative problem solving. The CBI structural design is derived from both old and new evidence-based research in the Classical Conditioning, Anxiety Disorders, Depression and Post Traumatic Stress Disorder (PTSD) literature. Prior studies indicate that the reduction of acute traumatic stress reactions coupled with the consistent reduction of arousal symptoms may significantly decrease overall the negative effects of extremely difficult or life threatening experiences.

The ultimate goal of the CBI is to bring about (1) immediate short-term reduction in potentially harmful traumatic stress reactions as well as (2) longer-term preventive effects such as increasing a child’s ability to problem solve, engage in social perspective taking[1] and sustain increased self-esteem and positive self and social concept. The expected (immediate) results include (1) a significant decrease in aggressive behaviors, sleep disturbances, concentration difficulties, and intrusive recall of the traumatic events, and (2) an increase in the sense of safety, self-esteem, hope, self-control, and willingness to sustain meaningful peer and adult relationships. In other words, CBI was not developed to prevent PTSD or other major behavioral health disorders but rather CBI aims to identify existing coping resources among children and youth facing difficult circumstances, and to sustain the utilization of those resources in the service of psychological and psychosocial recovery over time.

CBI was originated and continues to be developed by the Center for Trauma Psychology (CTP), which provides technical assistance and funding to The Children’s Trauma Recovery Foundation. CTP teams have designed, launched and currently manage child and youth trauma response networks, utilizing CBI as a psychosocial intervention program in the United States, Turkey, West Bank & Gaza, Israel, Jordan, Nepal, Indonesia, Sri Lanka, Eritrea, Afghanistan, Sudan, Uganda, and Burundi to assist with ongoing efforts to provide school, community and tribal based socioemotional and psychosocial interventions to successfully care for youth exposed to psychological trauma resulting from adversity, suicide, homicide and gang violence, armed conflict, ethnic cleansing, displacement and homelessness, terrorism, genocide, and natural disasters such as the hurricanes , storms, earthquakes.

CBI was especially designed and developed to be implemented in schools and community centers in order to assist teachers and administrators with stabilization and resiliency building during the school day or in after school time utilizing curriculum design similar to the current educational model.

The CBI method has been and will continue to be the application of state of the art psychosocial assessment and intervention programs targeting the impacted youth in regions requesting psychosocial stabilization and traumatic stress reduction programs.  These CBI® service continuum programs have been successfully implemented in 7 countries under extraordinarily difficult circumstances. As of August 2015, over 615,000 youth have completed the CBI® service continuum programs. Sponsored by multiple agencies such as the United States Agency for International Development, European Commission on Humanitarian Aid Organizations, United Nations, UNICEF, World Bank, FEMA, and the United Way, between August 2008 and December 2012 the ITC group and its partners have published nine  cluster controlled randomized trials of CBI® in leading peer reviewed journals indicating strong effect in multiple domains. These are the first school based psychosocial interventions for large scale trauma focusing on children and families to be published in the literature. Please see W. Tol, M.A.,  I. Komproe, Ph.D., D. Susanty, M.Psych., M. Jordans, M.A., R. Macy, Ph.D., J. De Jong, M.D., Ph.D.; School Based Mental Health Intervention for Children Affected by Political Violence in Indonesia: A Cluster Randomized Trial; JAMA, August 13, 2008, Vol 300, No.6 , 665**

*Please see PDF # 2

[1]  This essentially refers to a child’s capability to understand or take on somebody else’s perspective.