Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education

Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Helping Young Children
             Who Have Experienced
             Trauma: Policies and Strategies
             for Early Care and Education

April 2017
Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Authors                                                  Acknowledgments
    Jessica Dym Bartlett, MSW, PhD                           We are grateful to our reviewers, Elizabeth Jordan,
    Senior Research Scientist                                Jason Lang, Robyn Lipkowitz, David Murphey,
    Child Welfare/Early Childhood Development                Cindy Oser, and Kathryn Tout. We also thank
    Child Trends                                             the Alliance for Early Success for its support of
                                                             this work.
    Sheila Smith, PhD
    Director, Early Childhood
    National Center for Children in Poverty
    Mailman School of Public Health
    Columbia University

    Elizabeth Bringewatt, MSW, PhD
    Research Scientist
    Child Welfare
    Child Trends

    Copyright Child Trends 2017 | Publication # 2017-19

Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Table of Contents
                        Executive Summary..............................................................1
                        What is Early Childhood Trauma?.................................. 4
                        The Impacts of Early Childhood Trauma.......................5
                        Meeting the Needs of Young Children Who Have
                        Experienced Trauma............................................................7
                        Putting It Together: Trauma-Informed Care for
                        Young Children......................................................................8
                        Promising Strategies for Meeting the Needs of
                        Young Children Exposed to Trauma...............................9
                        Recommendations............................................................. 12
                        Conclusion............................................................................ 14
                        Appendix A......................................................................... 24

Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Executive Summary
  Many young children are exposed to traumatic
  life events.1,2 Almost half of children in the United
  States—approximately 35 million—have experienced
  one or more types of trauma,3 and young children
  are at especially high risk compared to older
  children. Over one quarter of all children with
  confirmed cases of child abuse and neglect are
  under age 3, and victimization is most common
  for children under 12 months old.4 Unintentional
  injuries, such as drowning, falls, burns, choking,
  and poisoning, also occur most frequently among
  children ages 5 years and younger.5 In addition,
  children who experience domestic violence are
  disproportionately young, with 60 percent under
  age 6 at the time of exposure.6

  Early childhood trauma occurs when a young child
  experiences an event that causes actual harm or
  poses a serious threat to the child’s emotional           In this report, we describe early childhood trauma
  and physical well-being. These events range from          and its effects, offer promising strategies for ECE
  experiencing abuse and neglect to having a parent         programs and systems to help young children
  with substance abuse issues or being separated            who have experienced trauma, and present
  from a parent.7 Trauma is different from regular life     recommendations for state policymakers and other
  stressors because it causes a sense of intense fear,      stakeholders looking to support trauma-informed
  terror, and helplessness that is beyond the normal        ECE for this vulnerable group.
  range for typical experiences.8

  Trauma has been shown to negatively impact early          Promising strategies for trauma-
  brain development, cognitive development, learning,       informed care in early care and
  social-emotional development, the ability to develop
  secure attachments to others, and physical health.9
  However, each child’s reaction to trauma is               To address the needs of young children who have
  unique and depends on the nature of the trauma,           been exposed to trauma, ECE programs and
  characteristics of the child and family, and the          systems can provide trauma-informed care (TIC).
  overall balance of risk and protective factors in the     TIC supports children’s recovery and resilience
  child’s life. While almost all children experience        using approaches that have been shown, through
  distress immediately after a traumatic event, most        evaluation, to work—that is, TIC uses evidence-based
  return to their typical functioning over time with        approaches.12
  supports from parents and other caregivers.10
  Generally, trauma that begins early in life, takes        Although TIC is a relatively new approach, several
  multiple forms, is severe and pervasive, and              promising approaches to TIC have emerged:
  involves harmful behavior by primary caregivers
  has been linked to the most serious symptoms of           •   integrating trauma-informed strategies into
  posttraumatic stress and negative child outcomes.11           existing ECE programs to support children in
                                                                those programs who have experienced trauma,
  Despite trauma being widespread and detrimental
  to the well-being of infants, toddlers, and               •   building partnerships and connections between
  preschoolers, few early care and education (ECE)              ECE and community service providers to
  programs and state systems are prepared to offer              facilitate screenings of and service provision to
  care that is trauma-informed—with all adults able             children and families,
  to recognize and respond to the impact of trauma
  on young children, and to infuse trauma awareness,
                                                            •   implementing professional standards and
                                                                training for infant and early childhood mental
  knowledge, and skills into program culture,
                                                                health consultants that emphasize TIC, and
  practices, and policies.

1 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
•    supporting the professional development                    3. Provide children who have experienced
       and training of the ECE workforce in working                  trauma with high-quality, stable early care and
       with and supporting young children who have                   education and strong early learning supports.
       experienced trauma.
                                                                      a.   Establish policies for ECE programs that
                                                                           promote continuity of care and participation
  Recommendations                                                          in ECE for children who have experienced
  Policies can play an important role in developing                        trauma.
  and supporting the programs and professionals in
                                                                      b. Establish policies that promote the
  the lives of young children who have experienced
                                                                         placement of young children who have
  trauma. The following recommendations would
                                                                         experienced trauma in high-quality ECE
  increase the availability of and access to high-
  quality, trauma-informed ECE and related supports
  for young children’s healthy development. These                     c.   Develop policies that severely limit or
  recommendations have direct relevance to state-                          prohibit the suspension and expulsion of
  level policymakers, but also apply to program                            young children, and require appropriate
  directors, community, state, and federal leaders in                      interventions for children who have
  the field of early childhood, as well as advocates                       experienced trauma and have social-
  for other aspects of high-quality ECE programming                        emotional or behavioral difficulties.
  (e.g., Quality Rating and Improvement Systems,a
   infant and early childhood mental health                           d. Establish screening and educational support
  consultationb).                                                        policies that respond to both the social-
                                                                         emotional and early learning needs of
  1.   Strengthen the early care and education                           children who have experienced trauma.
       workforce by increasing early care and
       education professionals’ capacity to provide               Historically, society has overlooked the impact
       trauma-informed care.                                      of early childhood trauma, perhaps due to
                                                                  misconceptions that very young children do not
       a.   Incorporate strategies that benefit children          fully perceive traumatic events, or that they will
            who have experienced trauma into ECE                  always “bounce back” from them. In reality, the first
            professional development.                             few years of life constitute a period during which
                                                                  children are highly sensitive to trauma—more so
       b. Increase the capacity of infant and early
                                                                  than during any other time of life.
          childhood mental health consultants to
          incorporate trauma-informed approaches.

       c.   Increase support to ECE professionals who
            experience high levels of stress at work as a
            result of working with children who exhibit
            challenging behaviors related to trauma.

  2. Expand initiatives that help early care and
     education programs connect families with
     community services.

       a.   Invest in initiatives that help ECE programs
            connect families with children who have
            experienced trauma to screening and
            services that can address their needs.

    The U.S. Department of Health & Human Services’ Office of Child Care defines QRIS as “a systemic approach to assess,
  improve, and communicate the level of quality in early and school-age care and education programs. Similar to rating systems
  for restaurants and hotels, QRIS award quality ratings to early and school-age care and education programs that meet a set of
  defined program standards.” See
    The Substance Abuse and Mental Health Services Administration defines IECMHC as “an evidence-based approach that pairs
  mental health professionals with people who work with young children and their families.” See

2 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
  In almost every early care and education (ECE)            challenges of children who experience trauma, of
  program across the country, there are children            their families, and of their teachers. It is equally
  who have experienced trauma or who will, during           important to identify features of programs (both
  their early childhood, experience traumatic events.       center-based and in homes) that help these children
  Trauma in early childhood takes many forms,               form positive relationships, feel safe and secure,
  including abuse or neglect, witnessing violence,          and enjoy learning and playing with their peers and
  and having prolonged separation from or loss              caregivers.
  of a parent. An extensive body of research has
  documented the negative impacts of trauma on              This report includes:
  young children’s behavior, learning, and other long-
  term school- and health-related outcomes.
                                                            •   a definition of early childhood trauma, including
                                                                different types, and its prevalence;
  The prevalence of early childhood trauma is
  difficult to establish, as researchers typically focus
                                                            •   the impacts of early childhood trauma on the
                                                                child, family, and ECE programs;
  on specific forms (e.g., child abuse and neglect).
  However, one study found that 70 percent of               •   the special needs of young children who have
  children endure three or more adverse childhood               experienced trauma;
  experiences—highly stressful or traumatic events—
  by the time they reach 6 years old.13 The high            •   a description of trauma-informed care;
  prevalence of trauma and the potential magnitude
  of its effects underscore a critical mandate for ECE      •   promising program strategies to support the
  programs and associated systems: to identify and              healthy development and learning of young
  implement promising strategies for supporting the             children in ECE; and
  healthy development of children who are victims of
                                                            •   recommendations of policies that could increase
                                                                the capacity of ECE providers to help children
  Children in families at all economic levels experience        who have experienced trauma learn and thrive.
  trauma, but early childhood trauma occurs more
  often in families facing financial hardship.14 Because
  many young children spend long hours in ECE
  programs,15 it is important to understand the

3 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
What is Early Childhood                                   Young children also are more likely to be victims
                                                            of abuse and neglect,23 drowning, burns, falls,
  Trauma?                                                   suffocation, and poisoning,24 and to live in homes
                                                            with domestic violence.25 For example, over one
  Early childhood trauma occurs when a young child          quarter of all children with confirmed cases of
  (here, birth to age 6) experiences an event that          child abuse and neglect are under age 3, and
  causes actual harm or poses a serious threat to           victimization is most common among children
  the child’s emotional and physical well-being.16          under 12 months old.26 Unintentional injuries (e.g.,
  Trauma is different from regular life stressors,          drowning, falls, burns, choking, poisoning) occur
  because it causes a sense of intense fear, terror, and    most frequently among children 5 years and
  helplessness that is beyond the normal range of           younger.27 Children who are exposed to domestic
  typical childhood experiences.17 Common types of          violence also are disproportionately young, with 60
  trauma during this developmental period include:          percent under 6 years old.28

  •   abuse and neglect;                                    Research on adverse childhood experiences (ACEs)
                                                            suggests that many young children also endure
  •   serious, untreated parent mental illness or
                                                            complex trauma. Approximately 70 percent of
      substance abuse;
                                                            children experience three or more ACEs by the
  •   witnessing domestic violence;                         time they reach 6 years old.29 Certain types of
  •   prolonged separation from or loss of a loved          trauma are especially likely to co-occur in young
      one; and                                              children’s lives. For example, between 30 and 60
                                                            percent of maltreated children live in homes with
  •   incurring serious injuries or undergoing painful      domestic violence,30 and as many as 79 percent of
      medical procedures.                                   children in foster care have experienced both child
  Some children face multiple types of trauma               maltreatment and parental substance abuse.31
  simultaneously or over time. Trauma exposure that         The prevalence of trauma exposure among children
  begins early in life, takes multiple forms, is severe     who are enrolled in ECE programs is not well
  and pervasive, and involves the caregiving system         understood. However, one national study of children
  (parents and other primary caregivers) is referred to     who have experienced child abuse and neglect
  as complex trauma.18                                      found that almost 30 percent of child-welfare-
  Historically, society has overlooked the impact           involved children were in child care programs, with
  of trauma on young children, perhaps due to               21 percent in Head Start.32
  misconceptions that infants, toddlers, and
  preschoolers are not capable of perceiving or             Early childhood trauma is unique.
  remembering such circumstances or events.19
                                                            Research shows that early childhood trauma differs
  Another myth is that young children always “bounce
                                                            from trauma that occurs later in life.33 Not only
  back” from adversity. In fact, research demonstrates
                                                            is it especially prevalent in early childhood, but
  that the first few years of life constitute a period
                                                            young children have different responses to trauma
  during which children are highly sensitive to trauma,
                                                            than do older children and adults. Infants and
  and more vulnerable to its negative effects than
                                                            toddlers cannot verbalize their feelings, talk about
  during any other period of life.20 Children are aware
                                                            frightening events, or describe their nightmares.
  of traumatic experiences when they occur and can
                                                            Preschoolers have not yet fully developed the skills
  show signs of distress beginning in the first weeks of
                                                            to express feelings of being afraid, overwhelmed,
  life; long-lasting trauma symptoms have been found
                                                            or helpless. As a result, young children exhibit a
  to begin in infants as young as 3 months old.21
                                                            range of behaviors that adults may not recognize
                                                            as reactions to trauma (e.g., excessive crying,
  The prevalence of trauma in early                         distress, regression, aggression, withdrawal, physical
  childhood is high.                                        symptoms, acting out traumatic events during
  Trauma is common in early childhood. Almost 35
  million children in the United States (approximately      Some of these behaviors may look similar to
  48 percent) have been exposed to one or more              those of their peers, yet may not be amenable
  types of trauma,22 and young children are at              to typical approaches that adults use to address
  disproportionate risk compared to older children.         challenging behavior (e.g., redirection, helping a

4 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
child express feelings    Impact on brain development. Early experiences
Early childhood trauma             in a constructive way,    influence brain development, and trauma can
generally refers to the            removing a child          interfere with brain in several ways, including
traumatic experiences that         from the situation).      interfering with executive function and self-
occur to children ages             Sometimes, even           regulation, and limiting brain volume (which is
zero to 6.                         strategies that           critical to emotion regulation, cognition, and
                                   normally work well        behavior).41 Executive function and self-regulation
Because infants’ and
                                   to promote positive       skills are the mental processes that allow individuals
young children’s reactions
                                   behavior (e.g., praise,   to engage in planning, focus our attention,
may be different from
                                   a gentle touch on the     remember instructions, and balance multiple tasks
older children’s, and
                                   shoulder, a reward)       at once.42 Traumatic stress can reduce children’s
because they may not
                                   increase a child’s        ability to cope with stress effectively, leading them
be able to verbalize their
                                   stress, because they      to overreact or fail to respond appropriately.43
reactions to threatening
                                   remind the child of a     Moreover, chronic trauma (e.g., neglect) is linked to
or dangerous events,
                                   traumatic event.35        smaller brain volume; poor information processing,
many people assume
                                                             self-regulation (the ability to control impulses, focus
that young age protects            Because early             attention, solve problems, and organize behavior),
children from the impact           childhood trauma          and attention; and mental health disorders later in
of traumatic experiences.          can be both difficult     life.44
However, young children            to identify and to
are affected by traumatic          address successfully,     Impact on cognitive development and learning.
events, even though they           it is essential that      Young children who experience trauma show
may not understand what            the adults who care       cognitive and language delays that place them at
happened.                          for young children—       risk for early learning difficulties and later academic
                                   including ECE             challenges.45 One study found that over one quarter
Source: National Child             professionals—learn       of maltreated children had serious language
Traumatic Stress Network.          how to recognize          delays.46 A fifth of maltreated children had very low
Available at http://www.nctsn.     trauma reactions          scores on a measure of attention, understanding
org/trauma-types/early-            and respond               of concepts, and other cognitive skills that
childhood-trauma                   appropriately.36          predict school readiness. Without intervention,
                                                             early difficulties with language or attention, or
                                                             other delays, can persist and undermine school
   The Impacts of Early                                      performance among young victims of trauma.47

   Childhood Trauma                                          Impact on social-emotional development. Early
                                                             trauma is associated with myriad social-emotional
   Impact on children                                        problems in childhood, adolescence, and adulthood.
                                                             Short-term consequences include difficulties coping
   Trauma takes a toll on children, parents, families,       with stress, feelings of helplessness, worthlessness,
   workers in ECE programs, and society generally.           and hopelessness, low self-esteem, and feeling
   Many children return to functioning normally after        responsible for bad things that happen.48 Behavior
   a traumatic event, particularly if it was a single        problems are also common,49 and may lead to more
   incident. Others, especially those who experience         serious behavior problems and poor social skills.50
   complex trauma, suffer serious and long-lasting           Post-traumatic stress disorder (PTSD) also can occur
   consequences.37 Generally speaking, more severe           in early childhood. Approximately 39 percent of
   and chronic trauma leads to more problematic child        preschoolers develop PTSD following a traumatic
   outcomes.38 However, the particular impact—and a          event,51 and PTSD has been described in infants
   child’s ability to recover—depends on the age of the      as young as 12 months old.52 Young children who
   child, the nature of the trauma, and the presence         experience trauma also are at high risk for anxiety
   of other risk factors (e.g., parental mental illness,     and depression, difficulty with social situations, and
   poverty, community violence, social isolation) and        trouble accepting praise later in life.53
   protective factors (e.g., a nurturing caregiver, social
   support, concrete supports).39 For instance, young        Impact on attachment. Trauma threatens young
   children who live in poverty and are exposed to           children’s ability to form and maintain secure
   trauma are more vulnerable to its negative effects        attachment relationships.54 Problems with
   than are children living in higher-income families.       attachment can stem from issues in relationships

 5 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
with primary caregivers (e.g., loss of a parent, abuse,    develop. In some cases, family members endure
  neglect, domestic violence) and create a blueprint         enforced separations and dangerous circumstances,
  for relationships later in life. Children may show         such as those associated with domestic violence
  mistrust, withdrawal, or aggression with others. They      or child maltreatment.65 Finally, adults may miss
  may also have difficulty developing and maintaining        time at work because ECE programs have difficulty
  healthy friendships, romantic relationships, and           managing children’s challenging behaviors and may
  positive interactions with authority figures.55 Thus,      suspend or expel children, or send them home early.66
  it is critical when working with young children who
  have experienced trauma to support their primary           Impact on early care and education
  attachment relationships.56
  Impact on physical health and development. Some
                                                             ECE programs are impacted by early childhood
  traumatic events can cause immediate physical harm
                                                             trauma through children’s challenging behaviors,
  (e.g., a car accident, physical abuse). In other cases,
                                                             and the strain they place on ECE professionals who
  physical effects appear over time. For example, early
                                                             must manage them. Young children’s externalizing
  childhood trauma can have long-lasting effects by
                                                             (acting out) behaviors, in particular, have negative
  causing biological disruptions that lead to health
                                                             effects on ECE teachers and classrooms.67 ECE
  problems in adulthood, including heart disease,
                                                             teachers may experience high levels of stress,
  cancer, alcoholism, depression, drug abuse, obesity,
                                                             burnout, and turnover. Other negative effects of
  and smoking.57
                                                             early childhood trauma on ECE programs include
                                                             disruptions to routines, activities, and learning
  Impact on parents and families                             among other children.
  Caring for a child affected by trauma can be
                                                             Impact on preschool suspension and expulsion.
  challenging for parents and other primary caregivers
                                                             Some young children entering ECE programs have
  (e.g., grandparents, other family members and
                                                             problems severe enough to limit their ability to
  kin; hereafter referred to as “parents”). A child’s
                                                             participate in routine activities, and thus to reap the
  trauma can have a strong influence on other family
                                                             full benefit of ECE.68 Families of these children may
  members and their relationships.58 Parents are most
                                                             even be asked to leave ECE programs. In fact, the
  often children’s source of support after a traumatic
                                                             national rate of preschool expulsion in state-funded
  event. A parent’s warm response following a child’s
                                                             pre-kindergarten programs is over 3 times the rate
  trauma exposure is associated with fewer symptoms
                                                             of expulsion in kindergarten to 12th grade (6.7 versus
  of PTSD,59 whereas their overprotectiveness or
                                                             2.1 per 1,000 children enrolled).69 In private child
  avoidance may increase a child’s risk for PTSD.60
                                                             care programs, the rate of preschool expulsion has
  Impact on parents. Caring for a young child who is         been found to be even higher.70 Black children and
  a victim of trauma is stressful, which may negatively      boys are at especially high risk for expulsions and
  affect parenting. For instance, parents’ distress may      suspensions, due in part to implicit bias by teachers
  interfere with their ability to respond sensitively,       and programs.71
  contributing to further distress in the child.61 Parents
                                                             Impact on teacher stress, burnout, and turnover.
  and other caregivers may also have been involved
                                                             Job stress reduces the capacity of ECE professionals
  in the same traumatic event as their children (e.g.,
                                                             to work effectively with children who have emotional
  domestic violence, natural disaster, war).62 In such
                                                             and behavioral problems.72 For example, high levels
  instances, negative reactions from either the parent
                                                             of workplace stress have been shown to lead to
  or the child may intensify symptoms in the other.63
                                                             teacher-child conflicts in Head Start.73 Many ECE
  A child’s trauma may be an emotional trigger for a
                                                             professionals feel unprepared to cope with these
  parent who has been a victim of trauma. In some
                                                             children, and may feel torn between attending to a
  cases, parents may be overwhelmed by these
                                                             particular child’s needs or focusing on the group.74
  triggers, and may respond to their own needs before
                                                             The demands of managing children with severe
  those of their children.64
                                                             emotional and behavior needs, especially in the
  Impact on families. Caring for a young child who           absence of adequate training, support, and self-care,
  has experienced trauma also affects other aspects          often leads to secondary traumatic stress (feeling
  of family life. When families are stressed and their       mentally, emotionally, or physically exhausted or
  emotional resources are limited, daily routines            overwhelmed by working with children affected by
  may become more difficult, and conflicts within            trauma), burnout, and turnover among staff.75
  the parenting couple or sibling relationships may

6 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Such stressors, in combination with other factors                   •   protect children from re-traumatization, and
  (e.g., insufficient compensation, limited support
  from leadership) may contribute to high rates of                    •   promote children’s self-regulation skills.84
  teacher turnover. Each year an estimated 25 to 50
  percent of preschool teachers leave their jobs,76                   ECE professionals have a critical role in helping
  and almost one fifth of center-based staff leave                    young children recover from trauma. Many young
  the field entirely.77 Turnover disrupts teacher-child               children spend much of their day in ECE programs
  attachments, adversely impacts children’s learning,                 (in 2011, approximately 60 percent of children under
  and threatens the emotional well-being of all                       age 5 were in child care; preschoolers spend an
  children in ECE programs.78                                         average of 33 hours per week in care).85 Children
                                                                      benefit from relationships with ECE professionals
                                                                      who care for them in trauma-sensitive ways. To
  Impact on society
                                                                      provide this type of care, ECE professionals need
  Early childhood trauma places a heavy burden on                     adequate training on the impact of trauma on young
  society. The behaviors and conditions associated                    children, on effective strategies for identifying and
  with early trauma can lead to dependence on a wide                  addressing trauma, and on helping families access
  range of systems, such as child welfare, juvenile and               community services. To prevent secondary traumatic
  criminal justice, and physical and behavioral health.               stress86 (the experience of feeling mentally,
  In addition, trauma that goes unaddressed early                     emotionally, or physically exhausted or overwhelmed
  in life can manifest in later behaviors that disrupt                by working with children affected by trauma), ECE
  school and work environments.79 Moreover, there are                 professionals also need reflective supervision—a
  financial consequences. For example, in the United                  collaborative relationship between supervisors and
  States, the estimated total lifetime cost to society                program staff that promotes professional growth
  associated with one year of confirmed cases of child                and improves program practices and quality.87 And,
  maltreatment is $124 billion.80                                     they need time for self-care.

                                                                      Children benefit when ECE staff also promote
  Meeting the Needs of                                                parents’ well-being. When parents’ physical, mental,
                                                                      and emotional needs are met, they are more likely to
  Young Children Who Have                                             give sensitive care. A positive alliance between ECE
                                                                      professionals and parents, in which staff recognize
  Experienced Trauma                                                  families’ strengths and values, encourage families
                                                                      to participate in children’s education, and engage
  All children benefit from stable, safe, and nurturing               family members in planning to make progress
  relationships and environments.81 However, these                    toward their goals, is essential to children’s social-
  relationships and environments are particularly                     emotional well-being. ECE programs can help young
  important for young children who have experienced                   victims of trauma by working with parents and other
  trauma. Their presence and stability can help                       caregivers to help them gain access to concrete
  children recover from past trauma and develop the                   supports (e.g., medical, mental health, educational,
  skills to cope and thrive.82                                        and legal services), emotional supports (e.g., social
                                                                      support, self-care), and other community services
  Presence and continuity of a nurturing caregiver.
                                                                      (e.g., evidence-based trauma treatment and other
  An extensive body of research shows that children
                                                                      mental health services, primary medical care,
  who do well despite adversity have at least one
                                                                      supports from child welfare, Early Intervention,c
  stable and nurturing adult caregiver in their lives.83
                                                                       home visitingd).
  Adults who serve in this role can:
                                                                      Environments that promote safety and trust.
  •   facilitate children’s coping with trauma by
                                                                      Environments that promote safety and trust, both
      helping them process events and giving meaning
                                                                      at home and in ECE programs, help young children
      to experiences,
                                                                      heal from traumatic experiences by restoring a
    Early Intervention are services for children, birth to age 2 with disabilities, and their families provided through The Program for
  Infants and Toddlers with Disabilities (Part C of IDEA). See for additional information.
    Home visiting consists of services that are offered on a voluntary basis to pregnant women, expectant fathers, and parents and
  caregivers of children from birth to kindergarten entry, that target outcomes including maternal and child health; prevention
  of child injuries; reduction in/prevention of child abuse, neglect, and emergency department visits; school readiness and
  achievement; reduction in domestic violence; parenting skills; and referrals to community resources and supports. See https://

7 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
feeling of control and predictability. Consistent         informed is
  routines and appropriate expectations are also            challenging, due
                                                                                     A trauma-informed child- and
  important. In addition, ECE professionals can             to variations in
                                                                                     family-service system is one
  identify and limit those experiences that may re-         interpretation of
                                                                                     in which all parties recognize
  trigger a child’s trauma (e.g., smells, sounds, sudden    its components.
                                                                                     and respond to the impact of
  movements).88 They can prepare children to cope           The National
                                                                                     traumatic stress on those who
  with these triggers, provide a safe space for verbal      Child Traumatic
                                                                                     have contact with the system,
  children to talk about their experiences and feelings,    Stress Network’s
                                                                                     including children, caregivers,
  and offer opportunities for parents, too, to learn        definition of a
                                                                                     and service providers.
  these skills and create safe environments at home.        trauma-informed
                                                                                     Programs and agencies within
                                                            service system is
  Environments that promote self-regulation and                                      such a system infuse and
                                                            a helpful starting
  social-emotional skills. Promoting children’s self-                                sustain trauma awareness,
                                                            point (see text
  regulation skills can help them heal from trauma.89                                knowledge, and skills into
  Young children’s experiences in the first years of life                            their organizational cultures,
  affect their ability to calm themselves, communicate      TIC includes all         practices, and policies. They act
  effectively, get along well with peers and adults,        of the people in         in collaboration with all those
  take pride in their accomplishments, and become           young children’s         who are involved with the child,
  more aware of their feelings and behaviors. ECE           lives. For an ECE        using the best available science,
  providers also can help children by practicing co-        program, TIC             to facilitate and support the
  regulation—nurturing interactions in which they           means increasing         recovery and resiliency of the
  model and coach self-regulation skills when children      knowledge and            child and family.
  face stressful situations or trauma triggers. They        skills among bus
                                                                                    Source: National Child
  can also work with families to learn how to support       drivers, classroom
                                                                                    Traumatic Stress Network
  children’s self-regulation skills.                        assistants,
                                                            teachers, family
  Environments that promote early skills needed to                                  resources/topics/creating-
                                                            service workers,
  succeed in school. To avoid serious delays in the                                 trauma-informed-systems
  language skills that promote self-regulation and          leaders, families,
  success in school,90 children who have experienced        mental health
  trauma are particularly in need of environments in        consultants, and anyone else who comes into
  which adult caregivers, including ECE professionals,      contact with young children.
  actively promote their language development
  through conversations, interactive book reading,          In TIC, training ECE staff and increasing their
  and activities that help build vocabulary and the         awareness about early childhood trauma is critical,
  ability to understand and use increasingly complex        but it is not enough.93 TIC also requires collaboration
  language.91 Similarly, these children benefit from        with other community service organizations
  environments that offer strong supports in the            to address the needs of traumatized children
  social-emotional, early math, and language domains,       proactively and to establish program, local, and
  so that they enter school ready to learn.92               state policies that address their unique needs.94
                                                            Successful TIC requires coordinated efforts at all
  Putting It Together:
                                                            If we overlook the impact of trauma on young
  Trauma-Informed Care for                                  children, we may inadvertently prolong their
                                                            exposure, cause re-traumatization, and impede
  Young Children                                            their process of recovery. ECE programs that
                                                            become trauma-informed and trauma-responsive
  Researchers, practitioners, and policymakers
                                                            settings, and that collaborate with other service
  recognize that addressing childhood trauma will
                                                            systems, support the optimal development of
  take more than any single individual, service,
                                                            all children, including children with and without
  or intervention. Thus, helping young children
                                                            formally documented trauma. Fortunately, there
  overcome traumatic experiences cannot be the sole
                                                            are a number of promising TIC strategies for young
  responsibility of parents, the mental health system,
                                                            children that can be effective in ECE systems.
  or ECE staff. Rather, a systemic approach, often
  called trauma-informed care (TIC) or a trauma-
  informed approach, is needed. Defining trauma-

8 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Promising Strategies for                                         Kids in Transition to School (KITS) is a curriculum
                                                                   for ECE programs that promotes psychosocial
  Meeting the Needs of                                             and academic school readiness among children in
                                                                   foster care and/or at high risk for school difficulties.
  Young Children Exposed                                           Delivered during the transition from preschool to
                                                                   kindergarten, KITS includes playgroups to enhance
  to Trauma                                                        children’s social-emotional skills and literacy, and
                                                                   parent workshops to promote involvement in early
  Despite the fact that the majority of ECE professionals          literacy and positive parenting practices. Evidence
  work with traumatized children every day, promising              from RCTs indicates that children in KITS had lower
  strategies within ECE programs and systems for                   levels of oppositional and aggressive behaviors
  addressing the needs of those children have only                 compared to children in the control group;96 KITS
  recently begun to emerge. Moreover, few strategies               also had positive effects on early literacy and self-
  have been rigorously evaluated. Nevertheless, (though            regulation skills.97
  not all of these have been evaluated), a number of
  innovative approaches, including initiatives within              Let’s Connect (LC) is an intervention that promotes
  existing ECE programs, have been implemented.                    resilience and well-being among caregivers and
                                                                   children who have experienced stressful life events
  Here, we review some of these promising practices.               such as trauma. LC includes teacher training,
  See “Appendix A” for more detailed descriptions of               modeling positive interactions with children and
  these strategies and evidence of their effectiveness.            their caregivers, live coaching of teachers, and
                                                                   ongoing consultation with teachers by a therapist.
  Integrating trauma-informed care into                            It can be integrated with evidence-based parent
  early care and education programs                                treatment (e.g., Trauma Focused Cognitive-
                                                                   Behavioral Therapyf). LC has been used in Head
  Several early childhood trauma strategies have                   Start programs and schools. Pilot studies indicate
  been designed to be integrated into existing                     that LC activities are feasible to implement, and
  ECE programs. Some take the form of curricula                    are viewed positively by caregivers. They also
  emphasizing evidence-based or evidence-informed                  found improvement in caregivers’ communication
  approaches to meeting the needs of young, trauma-                of positive emotions and their connection and
  impacted children and their families. Others focus on            emotion-support skills with family members, and
  establishing partnerships between ECE and mental                 reductions in their communication of negative
  health. Still others offer services in a wide range of           emotions with family members from pre- to post-
  settings that include ECE. Below are a few examples of           treatment.98 An RCT of LC in Head Start is underway.
  promising approaches to the integration of TIC in ECE.
                                                                   Safe Start was developed by the U.S. Office of
  Trauma Smart (TS) is an early education/mental                   Juvenile Justice and Delinquency Prevention
  health partnership designed for Head Start                       (OJJDP) to mitigate the negative consequences
  classrooms. The goals of TS are to reduce the stress             of children’s exposure to violence and to enhance
  of chronic trauma, support children’s social and                 the well-being of children and adolescents through
  cognitive development, and develop an integrated,                preventive interventions. Programs use different
  trauma-informed culture for young children, parents,             approaches: some provide services only to children;
  and staff. TS includes training, classroom consultation,         others serve children and their families. All include
  intensive evidence-based clinical treatment, and peer            a therapeutic component, and many offer case
  mentoring of teachers. An evaluation of TS found                 management and/or service coordination for
  that teachers reported significant improvements in               families. Intervention sites vary (e.g., homes, clinics,
  children’s externalizing behavior (including defiant and         shelters, child centers, Head Start classrooms).
  oppositional behavior) and attention. Parents reported           An RCT of Safe Start in a Michigan Head Start
  significant reductions in externalizing behaviors,               program found significant improvements in reported
  internalizing behaviors (depression, anxiety), and               symptoms of child PTSD, and in social-emotional
  inattention/hyperactivity.95 A rigorous evaluation               competence and academic achievement.99
  (a randomized controlled trial [RCT]e) is currently
    An RCT is a study in which participants are assigned by chance to different groups. See
    For additional information about Trauma-Focused Cognitive Behavioral Therapy, see

9 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
Therapeutic early care and education                            Partnerships between early care and
  programs                                                        education and community service
  Some licensed child care programs provide a                     providers
  specialized therapeutic environment for children
                                                                  To meet the needs of young children who have
  who have experienced trauma. This approach
                                                                  experienced trauma and their families, some
  differs from those that emphasize general inclusion
                                                                  ECE programs develop close partnerships with
  of young children with disabilities, including
                                                                  community agencies that can provide additional
  social-emotional disabilities such as PTSD, in high-
                                                                  services. Examples include trauma screening,
  quality early childhood programs.100 The programs
                                                                  referral, and service coordination, including linking
  described below have demonstrated positive
                                                                  children and families to evidence-based trauma
  outcomes for children, and use specific strategies
                                                                  treatments and practices. ECE programs also can
  that may be applicable to inclusive classrooms and
                                                                  help connect families to court and legal services that
  to the broader field of ECE.
                                                                  are trauma-focused. Below are several promising
  Childhaven Childhood Trauma Treatment (CCT)                     initiatives in these areas.
  provides therapeutic child care and optional
                                                                  The Centralized Referral System (CRS; “LINK-
  specialized services for maltreated and/or drug-
                                                                  KID”) provides free statewide trauma screening,
  affected children and their families. Treatments
                                                                  referral, and follow-up services to evidence-based
  focus on the child and caregiver together, using
                                                                  treatments for children in Massachusetts exposed
  evidence-informed approaches. Results of an RCT
                                                                  to trauma through a toll-free number staffed by
  showed that families in CCT showed more parental
                                                                  master’s-level social workers. An initial evaluation
  responsiveness and a more positive emotional
                                                                  found that the average wait for a first appointment
  climate compared to families in the control group.
                                                                  was 25.5 days, compared to 180 to 360 days for
  Children displayed less aggression, fewer physical
                                                                  children seen in area local mental health agencies.104
  complaints, less anxiety/depression, fewer social and
  attentional problems, fewer internalizing behaviors,            Help Me Grow (HMG) promotes early identification
  and a greater degree of social acceptance by                    of and supports for children at risk for
  peers.101                                                       developmental and behavioral problems. Core
                                                                  components include (1) outreach to child health
  Children’s Relief Nurseries (CRN) offer services to
                                                                  care providers to support their use of screening
  families with young maltreated children and those
                                                                  and HMG resources; (2) a centralized telephone
  at high risk for child welfare system involvement.
                                                                  line that a parent, early childhood professional,
  Services are free, and include therapeutic ECE in
                                                                  pediatrician, or other concerned person can call to
  classroom settings, home visits, parent education
                                                                  obtain information about screening and services
  and support groups, respite care, case management
                                                                  for a family; (3) community outreach to encourage
  and assistance accessing basic resources and other
                                                                  service providers to use HMG and network to
  community services. Some nurseries focus on
                                                                  coordinate services; and (4) data collection that
  responding to trauma. For example, Portland’s CRN/
                                                                  helps identify gaps in services for families that can
  LifeWorks NW provides Child-Parent Psychotherapy
                                                                  inform policy initiatives. Implementation research
  (CPP),102 adult mental health treatment, and other
                                                                  on HMG showed that 85 percent of children and
  intensive programming. A recent evaluation found
                                                                  families referred were connected with community-
  that CRN parents read more frequently to children,
                                                                  based programs and services, and that services were
  family functioning improved, and parent-child
                                                                  associated with an increase in protective factors.105
  interactions were more positive. Parents had fewer
  risk factors (out of 23 targeted by the intervention;           Safe Babies Court Teams (SBCT) is an initiative
  e.g., child welfare and foster care involvement,                in which courts coordinate with child welfare
  mental and physical health, poverty, and family                 agencies and other organizations to facilitate service
  violence) and reported high levels of satisfaction              delivery to infants and toddlers in the child welfare
  with services.103                                               system. SBCTs have been replicated across the
                                                                  country. Each team is a public–private collaboration
                                                                  between ZERO TO THREE,g local courts, community
                                                                  leaders, child and family advocates, child welfare

   ZERO TO THREE is an organization that uses the science of early development to develop resources, tools, and policies to
  ensure that infants and toddlers have a strong start in life.

10 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
agencies, ECE providers, government agencies,              guide development for professionals who work with
  private philanthropies, nonprofit and private service      infants and their families. Such systems can help
  providers, and attorneys committed to improving            equip ECE providers to work with young trauma
  community response to child maltreatment.                  victims. However, the majority of professional
  Evaluation findings show that SBCT is associated with      development and training efforts have not yet been
  significant gains in key child welfare outcomes (safety,   rigorously evaluated. Below are several examples of
  permanency, well-being).106 A second study found that      promising approaches to professional development
  children in SBCT reached permanency 2 to 3 times           and training.
  faster and exited the foster care system one year
  earlier than did children in a matched comparison          The Michigan Association of Infant Mental
  group, and they were more likely to find a permanent       Health (MI-AIMH) Competency Guidelines and
  home with a member of their biological family.107          Endorsement offers a guide for individuals working
                                                             with pregnant women and families with children
                                                             from birth to age 5, and for those who provide
  Infant and early childhood mental
                                                             training to those workers, on culturally sensitive,
  health consultation                                        relationship-focused practices that promote infant
                                                             mental health. Practitioner skills and knowledge in
  Currently operating in more than half the states,
                                                             child trauma are a key component at all four levels
  early childhood mental health consultation
                                                             of endorsement.113 As of 2016, 27 states and 18 state
  (IECMHC) is a multi-level preventive intervention
                                                             infant mental health associations were using the MI-
  where mental health professionals work with ECE
                                                             AIMH Competency Guidelines.
  professionals, programs, and families to improve
  children’s social, emotional, and behavioral               The Child Trauma Training Toolkit for Educators
  health and development. The approach includes              provides resources on child trauma for educators
  observations, individualized strategies, and early         and parents working with different age groups,
  identification of children with and at risk for            including preschool-aged children. It also includes
  mental health challenges.108 Most IECMHC does not          information on traumatic grief (an intense response
  specifically focus on child trauma. However, Project       to grief following the death of a loved one), and
  Play in Arkansas has a trauma focus, prioritizing          on self-care for educators to address secondary
  consultation services to ECE programs that serve           traumatic stress.114
  children in foster care, helping staff understand
  children’s behavior in relation to trauma, and             Trauma Informed Care: Perspectives and Resources
  placing a particular emphasis on working with ECE          is a web-based, video-enhanced resource tool that
  professionals to strengthen features of care that          offers eight modules designed to enhance federal-,
  are important for children who have been exposed           state-, local-, and provider-level work to become
  to trauma (e.g., continuity of care, and a nurturing       trauma-informed. Each module includes an issue
  relationship). A review of 14 studies that used            brief, a video, and a resource list.115
  rigorous methods reported generally positive results
  for key outcomes, including an increase in positive        High-quality early care and education
  child behaviors and a reduction in challenging
  behaviors.109 Studies also show that IECMHC                High-quality ECE is an essential foundation
  prevents preschool expulsion,110 reduces parental          for trauma-informed care. ECE programs that
  stress and missed work time,111 and decreases              meet high quality standards have the potential
  teacher stress and turnover.112                            for both immediate and lifelong benefits for
                                                             all young children, but particularly those from
  Professional development and                               disadvantaged backgrounds, such as children
                                                             who have experienced trauma. For example,
  training                                                   maltreated children in ECE programs with better
                                                             quality have better school readiness outcomes,116
  Accompanying increasing recognition of the
                                                             compared to children in ECE programs with lower
  mental health needs of very young children has
                                                             quality. Moreover, a recent analysis of two well-
  been interest in related professional development
                                                             known high-quality ECE programs—the Carolina
  and training opportunities for ECE professionals.
                                                             Abecedarian Project and the Carolina Approach to
  A number of web-based trainings on child trauma
                                                             Responsive Education—found significant benefits for
  show promise. In addition, endorsement systems
                                                             disadvantaged children across multiple life-domains
  for competence in infant mental health have helped

11 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
(health, quality of life, education, employment,           Increase the capacity of infant and early childhood
  crime), and found a return on investment in high-          mental health consultants to incorporate trauma-
  quality early childhood programs of up to 13.7             informed approaches. As a widely embraced,
  percent per year.117                                       evidence-based, ECE program capacity-building
                                                             strategy,121 infant and early childhood mental health
  Recommendations                                            consultation (IECMHC) is well-positioned to promote
                                                             a trauma-informed ECE workforce. States have
  This section presents recommendations of policies          increasingly invested in IECMHC, which has been
  and practices that can help increase access to high-       shown to decrease teacher stress and turnover,122
  quality, trauma-informed early care and education.         prevent preschool expulsion,123 and reduce problem
  While these recommendations have particular                behaviors among children.124 To increase the return
  relevance to state-level policymakers, they also           on their investments and reach young children
  apply to program directors, community, state, and          affected by trauma, states should implement
  federal leaders in the field of early childhood, as well   professional standards and training for IECMHC
  as advocates of other aspects of high-quality ECE          consultants that emphasize TIC.
  programming (e.g., Quality Rating and Improvement
                                                             Increase support for early care and education
  Systems, infant and early childhood mental health
                                                             professionals who experience high levels of stress
                                                             at work. The stress commonly experienced by
  Some of these recommendations emphasize                    ECE professionals who care for children who have
  increased state and federal funding to expand              experienced trauma is not only detrimental to the
  supports for ECE programs, while others focus on           well-being of ECE staff, but also can interfere with
  state program standards, professional competencies,        positive teacher-child interactions.125 A recent report
  and administrative policies, such as states’ plans for     of the National Research Council, Transforming
  the Child Care and Development Fund (CCDF), the            the Workforce for Children Birth Through Age
  largest source of funding for child care assistance        8,126 discusses several potential strategies for
  for low-income families.118 Because individual ECE         reducing teacher stress, including training on self-
  programs cannot be expected to meet all the needs          care and mindfulness. As the evidence base for
  of these children and families, the recommendations        stress reduction strategies grows, states should
  also call for policies that help ECE programs connect      promote their use through professional competency
  families to other community services.                      standards and training. This will ensure that infant
                                                             and early childhood mental health consultants
  Recommendation: Strengthen the                             and professional development specialists acquire
                                                             the skills they need to support the well-being of
  early care and education workforce by                      ECE professionals who work with children who
  increasing professionals’ capacity to                      experience trauma.

  provide trauma-informed care.                              Recommendation: Expand initiatives
  Incorporate strategies that benefit children who           that help early care and education
  have experienced trauma into ECE professional
  development. Although research evidence is lacking         programs connect families with
  for specific models in ECE programs that benefit           community services.
  children who experience trauma, professional
  development (PD) is a component of a number of             Invest in initiatives that help early care and
  promising interventions that help ECE professionals        education programs connect families with children
  acquire trauma-informed knowledge, skills, and             who have experienced trauma to screening and
  practices.119 State CCDF plans and professional            services that can address their needs. Many
  development offered through quality rating and             ECE programs do not have the capacity to meet
  improvement systems should include strategies used         the many unique needs of children who have
  in these interventions that help ECE professionals         experienced trauma. Some need specialized
  implement trauma-informed practices.120 In addition,       treatment, and many live in families facing
  as the evidence base for particular strategies grows,      challenges that pose ongoing risks to young
  states should promote their use through professional       children, such as parental depression, housing
  competency standards and training, and by ensuring         and food insecurity, and social isolation. State and
  that state professional development plans include TIC.     federal investments in linkage systems, such as

12 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
The Centralized Referral System (LINK-KID) and                  Establish policies that promote the placement of
  Help Me Grow, can help ECE programs connect                     young children who have experienced trauma in
  families to child and family services, including                high-quality early care and education programs.
  trauma screening, evaluation, and evidence-based                Children who have endured trauma show more
  treatment, that complement the supports provided                learning and social-emotional growth when ECE
  in the ECE classroom. These systems also can                    programs meet high quality standards. Examples of
  help families obtain services, such as treatment                high-quality programs include Head Start Programs
  for parents’ mental health problems or financial                and Early Head Start (HS/EHS), ECE programs with
  assistance, that can help reduce stress and increase            their state’s highest quality ratings, and programs
  the odds of resilience among these children and                 accredited by the National Association for the
  their families.                                                 Education of Young Children. Currently, children in
                                                                  foster care are categorically eligible for HS/EHS,
  Recommendation: Provide children                                regardless of family income.128 The new Child Care
                                                                  and Development Block Grant Acth regulations
  who have experienced trauma with                                encourage states to provide vulnerable children,
  high-quality, stable early care and                             including children who are homeless and in foster
                                                                  care, with access to child care.129 Several states use
  education and strong early learning
                                                                  contracts to create slots in HS/EHS and other high-
  supports.                                                       quality child care for vulnerable children, including
                                                                  those who have experienced trauma.130 In addition,
  Establish policies for early care and education
                                                                  increased state and federal investments in initiatives
  programs that promote continuity of care and
                                                                  such as Safe Babies Court Teams, that promote
  participation in early care and education for
                                                                  collaboration among the courts, ECE programs,
  children who have experienced trauma. Children,
                                                                  and other child-serving organizations, would help
  particularly those who have experienced trauma,
                                                                  improve access for this population to high-quality
  need and benefit from stable, nurturing care in ECE
                                                                  ECE programs.
  programs. QRIS and other ECE program standards
  should require that all infants and toddlers, including         Develop policies that severely limit or prohibit the
  those who have experienced trauma, have a primary               suspension and expulsion of young children, and
  caregiver. When there is one adult who consistently             require appropriate interventions for children who
  cares for an infant or toddler, the child can develop           have experienced trauma and have social-emotional
  a close, trusting relationship.127 States also should           or behavioral difficulties. Children who have
  promote continuity of program participation.                    experienced trauma are at higher risk for expulsion
  Federal Child Care Development Fund regulations                 than other children because they often demonstrate
  require states to provide 12 months during which                challenging behavior as a symptom of their distress;
  the family is continuously eligible (according                  behaviors such as hitting, biting, or behaving
  to state guidelines for eligibility) for subsidized             recklessly may result in ECE programs’ refusing to
  child care. If a parent experiences permanent                   serve some children and families. Recent federal
  job loss or the end of an education or training                 guidance directs states to establish prevention
  activity, the state must give families a minimum                strategies, including infant and early childhood
  of 3 months of extended child care assistance if it             mental health consultation and professional
  elects to terminate families’ assistance under these            development, that help ECE professionals address
  circumstances. However, states have the option of               challenging behavior, and policies that eliminate
  extending assistance beyond this 3-month period                 preschool suspension and expulsion.131 The need
  or not terminating assistance before 12 months. In              for such policies is critical for children who have
  addition, CCDF rules offer a graduated 12-month                 experienced trauma and would endure further harm
  phase-out for parents whose incomes rise above the              by losing the social-emotional and learning supports
  state’s income eligibility threshold. State policies            provided through high-quality ECE.
  that offer extended assistance to provide continuity
  of participation in ECE could greatly benefit this              Establish screening and educational support
  population of young children, who might otherwise               policies that respond to both the social-emotional
  experience disruptions in care.                                 and early learning needs of children who have
                                                                  experienced trauma. Young children who are victims
                                                                  of trauma have a heightened risk for delays in
   CCDGB is the main source of federal funding for child care subsidies provided to low-income working families and for
  improvements in child care quality.

13 | Helping Young Children Who Have Experienced Trauma: Policies and Strategies for Early Care and Education
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