Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH)

Scientific Rating:
NR
Not able to be Rated
See scale of 1-5
Child Welfare System Relevance Level:
High
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH) has been reviewed by the CEBC in the area of: Trauma Treatment - Client-Level Interventions (Child & Adolescent), but lacks the necessary research evidence to be given a Scientific Rating.

Target Population: School-age children between ages 6-12 and adolescents functioning developmentally at a latency-level in social, emotional, or cognitive skills who have experienced traumatic events (including losses, family violence, disasters, severe medical illness, neglect, and emotional, physical and sexual abuse), have a breakdown in emotionally supportive relationships, and show symptoms of traumatic stress/Complex Trauma including high risk behaviors that threaten the safety of children, families, and communities

For children/adolescents ages: 6 – 18

For parents/caregivers of children ages: 6 – 18

Brief Description

Real Life Heroes (RLH) provides practitioners with easy-to-use tools including a life storybook, manual, multi-sensory creative arts, mindfulness, yoga, and ‘improv’ activities, and psychoeducation resources to engage children and caregivers in trauma treatment in a wide range of child and family service programs. RLH can be used with children who have symptoms of Complex Trauma, children who have had frequent hospitalizations, and children who lack caregivers who are able or willing to participate in trauma treatment. Acknowledgement or validation of traumas is not required to begin use of RLH. RLH helps practitioners reframe referrals based on symptoms and blame into a shared ‘journey,’ a ‘pathway’ to healing and recovery focused on restoring (or building) emotionally supportive and enduring relationships and promoting development of affect regulation and co-regulation skills for children and caregivers. To do this, the model utilizes the metaphor of the heroic quest and stresses the importance of engaging caregivers and a collaborative team of caring adults working together with an integrated trauma and resiliency-centered framework to help children with Complex Trauma. Creative arts, mindfulness, yoga, and ‘improv’ activities and shared life story work provide a means for children and caregivers to develop the safety, attunement, emotional support, and self- and co-regulation skills needed for re-integration of traumatic memories and for strengthening a child’s and caregiver’s self-esteem.


Program Goals:

The program goals of Real Life Heroes (RLH): Resiliency-focused Treatment for Children with Traumatic Stress are:

  • Increased child and caregiver well-being
  • Increased child developmental abilities
  • Decreased high-risk behaviors including self-abuse, suicide attempts, and aggression to others
  • Decreased number and length of temporary placements
  • Decreased number of psychiatric hospitalizations
  • Treatment goals include:
    • Increased safety for children and caregivers (psychological, physical, and emotional)
    • Rebuilding (or building) of emotionally supportive relationships with caregivers committed to nurturing, guiding, and protecting children
    • Self- and co-regulation development for children and caregivers including cognitive, emotional modulation, focusing/concentration, and social skills
    • Trauma memory reintegration matched to the child and caregivers’ capacity
    • Development of a positive self-identity for child linked to child’s family and cultural heritage
    • Prevention and management of disruptions of important relationships

    Essential Components

    The essential components of Real Life Heroes (RLH): Resiliency-focused Treatment for Children with Traumatic Stress include:

    • Use of trauma-informed resources throughout model:
      • Incorporation of the ‘Core Components in Evidence-Based Trauma Treatment’ and the ‘Essential Elements of Trauma-Informed Child Welfare’ developed by the National Child Traumatic Stress Center (NCTSN)
      • Use of phase-based components outlined by the NCTSN Complex Trauma Workgroup and the 2009 recommended practice guidelines for treatment of Complex PTSD in children by Ford and Cloitre as a framework for Life Storybook chapters and session structure.
      • Use of strategies and step-by-step procedures and worksheets provided in the Practitioner’s Manual and training curricula to promote:
        • Safety for the child and child’s family (psychological, physical, and emotional)
        • Strengths and relationship-focused assessments and service planning
        • Self- and co-regulation development in all phases of treatment for the child and caregivers
        • Trauma memory re-integration matched to the child and caregivers’ capacity incorporating components from Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization Reprocessing (EMDR), and Progressive Counting
        • Prevention and management of disruptions of primary relationships and crises including trauma reactions using Youth and Caregiver Power Plans; interventions and activities prioritized based on the child’s level of self-regulation and the strength and availability of emotionally supportive relationships
      • Provision of a structured toolkit to promote relational healing for relationship-based traumas
      • Incorporation of tenets from desensitization therapies that have demonstrated that enabling children to remain safe and modulated with a trusted therapist during prolonged safe exposures to ‘tough times’ can lead to reduction in traumatic stress reactions
    • Four primary components for strengthening resiliency skills and resources:
      • Relationships (Emotionally Supportive Relationships with caregivers, family members, mentors, & peers)
      • Emotional self- and co-regulation (planning, calming, focusing)
      • Action Cycles (family interaction patterns)
      • Life Story Integration (desensitization and development of a positive identity)
    • Assessments and treatment including:
      • Developmentally based and resiliency-focused assessments
      • Service planning
      • Session structure
      • Fidelity
      • Evaluation
      • Real-time, in-session measures designed to guide session interventions
    • Integrated treatment sessions, review conferences and trauma-informed home, school, and clinic-based services involving:
      • Caregivers (e.g., birth, kinship, foster, and adoptive parents and residential counselors)
      • Educators
      • Family court workers
      • Child protective services workers
      • Home-based support workers
      • Other service providers
    • Real Life Heroes Session Structure, Life Storybook, and Toolkit Materials:
      • Engage children and caregivers to work together to:
        • Develop emotionally supportive relationships, and the self- and co-regulation necessary to make desensitization and life story reintegration possible
        • Learn to recognize clues in their own bodies and how to share these safely
        • Share feelings nonverbally on thermometers for stress, self-control, and feeling mad, sad, glad, and safe
        • Utilize movement, focusing, and mindfulness activities to learn and practice self- and co-regulation skills, to reduce stress, and to change family interaction patterns (Action Cycles)
        • Learn about heroes includes sharing stories of how family members and people with the child’s ethnic heritage have overcome hard times
        • Help children develop their own strengths, resources, and coping skills, building on increased emotional support and increased security and confidence from sharing stories of caring and overcoming ‘tough times’
        • Use shared activities that help children grow stronger than their fears and to change old ways of coping that got them into trouble
      • The Life Storybook helps children change how they see themselves from feeling hurt, unwanted, damaged, or hopeless, to feeling that they can move through the traumas of the past to experiences of security with emotionally supportive adults committed to helping children. This RLH activity-based workbook and an emphasis on creative arts help children and caregivers to:
        • Develop affect modulation skills with art, rhythm, music, movement, yoga, mindfulness, and ‘improv’, and movies
        • Build the skills and interpersonal resources needed to re-integrate painful memories, reduce the power of traumatic stress reactions that have led to high-risk behaviors, and to foster healing after serial traumatic experiences
        • Share both positive and stressful experiences as drawings and then develop drawings into ‘three- or five-chapter’ stories (or movies) with a beginning, middle, and an end so children learn they can move through both good times, and later ‘tough times,’ and make things better in their lives, instead of feeling helpless, stuck, ashamed, or overwhelmed
      • The Life Storybook chapters target recommended phase-based components of complex trauma therapy:
        • Chapter One: The Heroes Challenge; Trauma Psycho-education & Initial Safety Plans
        • Chapter Two: A Little About Me; Affect Recognition, Modulation & Expression
        • Chapter Three: Heroes; Restoring Hope, Inspiring Change
        • Chapter Four: Power Plans; Developing Resiliency-Centered Safety Plans
        • Chapter Five: My Family; Remembering People Who Cared
        • Chapter Six: Important People: Promoting Emotionally Supportive Relationships
        • Chapter Seven: Mind Power; Making Things Better with Mindfulness and Self-Regulation
        • Chapter Eight: Changing the Story; Changing Beliefs & Action Cycles to Achieve Goals
        • Chapter Nine: Timelines and Moves; Making Sense of the Past
        • Chapter Ten: Through the Tough Times; Desensitizing Traumatic Memories
        • Chapter Eleven: Into the Future; Identifying Goals and Important Relationships
        • Chapter Twelve: ‘My Story;’ Creating an Integrated Life Story with a Past, Present and Future

    Child/Adolescent Services

    Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH) directly provides services to children/adolescents and addresses the following:

    • High-risk behaviors; exposure to physical, sexual, or emotional abuse, neglect, or domestic violence; and symptoms of traumatic stress including emotional instability, avoidance, reenactments, lack of social skills, distorted beliefs, and shame

    Parent/Caregiver Services

    Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH) directly provides services to parents/caregivers and addresses the following:

    • Caregiver stress; lack of understanding of the impact of traumas on children’s behaviors and how to help children develop skills and change destructive cycles of family interactions; unavailability of emotionally supportive caregivers or neglect; and symptoms of traumatic stress including affect dysregulation, avoidance, reenactments, lack of social skills, distorted beliefs, and shame
    Services Involve Family/Support Structures:

    This program involves the family or other support systems in the individual's treatment: This program involves the family or other support systems in the individual's treatment: RLH emphasizes engaging and empowering caregivers to help their children (and themselves) heal after experiences of traumatic events. Parents, family members, resource parents, and other supportive adults are encouraged to become the heroes children need to restore safety, develop self- and co-regulation and other needed skills to increase resiliency, and succeed in school and areas of interest for children. Caregivers who meet safety criteria are involved in conjoint sessions to strengthen (or build) the attunement, nurture, guidance, and protection children need. Structured creative arts activities engage caregivers with both respect and fun to rebuild attunement and attachments with their children by sharing memories and experiences with art, rhythm, music and movement. Psychoeducation and activities help broaden the ‘window of tolerance’ for caregivers to share their own experiences of overcoming hardships, to share stories of strength from the family’s heritage, to link the child to strengths in their cultural heritage, to validate their child’s experiences, and to work together to become stronger than past traumas. Separate sessions are provided with caregivers who do not meet safety criteria with structured opportunities for children to share their work and rebuild safety and trust. RLH can also be used as a means to search for lost caring adults and to build new attachments with substitute caregivers when necessary as part of permanency work for children in placement.

    Delivery Settings

    This program is typically conducted in a(n):

    • Adoptive Home
    • Birth Family Home
    • Community Agency
    • Day Treatment Program
    • Foster/Kinship Care
    • Hospital
    • Outpatient Clinic
    • Residential Care Facility

    Homework

    Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH) includes a homework component:

    Children and caregivers are encouraged to practice self- and co-regulation and attachment-building activities between sessions that are related to each chapter (phase) of the treatment. For instance, to build affect recognition capacity (Chapter 2), children are encouraged to take pictures of family members and of themselves showing a wide range of emotions and then to use these in later sessions and games. Self-regulation skill building at home is encouraged through-out the treatment. Where ever possible, in-home support workers and case managers are involved in promoting RLH homework and assisting therapists in helping children and families develop skills matched to each chapter of the RLH Life Storybook.

    Languages

    Real Life Heroes: Resiliency-focused Treatment for Children with Traumatic Stress (RLH) has materials available in a language other than English:

    Chinese

    For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

    Resources Needed to Run Program

    The typical resources for implementing the program are:

    • A private room is needed for clinic, residential treatment, or home-based services.
    • The Real Life Heroes Practitioner’s Manual provides a wide range of tools and lists recommended inexpensive creative arts equipment (and low cost supplies) including:
      • Markers
      • Colored pencils
      • Paper
      • Two-octave xylophone
      • Materials useful for self-soothing, centering and mindfulness exercises such as peacock feathers
      • Drums for rhythm expression can be hand-made or purchased
      • Peacock feathers
    • A copy of the Real Life Heroes Life Storybook is needed.
    • Use of family-owned smart phones or an inexpensive digital camera or is also recommended.
    • Psychoeducational materials are included in the Practitioner’s Manual and additional recommended psychoeducational materials are available online from the National Child Traumatic Stress Network and from booksellers, e.g. guides to use of yoga and mindfulness with children.
    • Access to recommended therapeutic books in the HEROES Library linked to children’s reading level and cultural heritage is also encouraged.

    Minimum Provider Qualifications

    • Master's degree in psychology, social work, or related social services
    • Supervised experience working with children and families with traumatic stress
    • Training in treatment of Complex PTSD and application of the RLH treatment model
    • Participation in group and individualized consultation recommended

    Education and Training Resources

    There is a manual that describes how to implement this program, and there is training available for this program.

    Training Contact:
    Training is obtained:

    Training is obtained by contacting the model developer (above) and is typically provided on site and tailored to the needs of organizations or associations. Introductory workshops are presented at regional, national and international conferences.

    Number of days/hours:

    Training is developed to match organizational needs and resources and typically includes an initial two-day workshop, monthly one-hour small group content- and case-focused consultation using ‘reflective supervision’ for 10 months with video teleconferences, monthly supervisory consultation, and a follow-up 1-2 day workshop after 4-6 months. When possible, individualized consultation is also provided.

    Relevant Published, Peer-Reviewed Research

    This program has been reviewed and it was determined that this program lacks the type of published, peer-reviewed research that meets the CEBC criteria for a scientific rating of 1 – 5. Therefore, the program has been given the classification of "NR - Not able to be Rated." It was reviewed because it was identified by the topic expert as a program being used in the field, or it is being marketed and/or used in California with children receiving services from child welfare or related systems and their parents/caregivers. Some programs that are not rated may have published, peer-reviewed research that does not meet the above stated criteria or may have eligible studies that have not yet been published in the peer-reviewed literature. For more information on the "NR - Not able to be Rated" classification, please see the Scientific Rating Scale.

    Child Welfare Outcomes: Not Specified

    Show relevant research...

    Kagan, R., Douglas, A., Hornik, J., & Kratz, S. (2008). Real Life Heroes pilot study: Evaluation of a treatment model for children with traumatic stress. Journal of Child and Adolescent Trauma, 1, 5-22.

    Type of Study: One group pretest-posttest study
    Number of Participants: 41

    Population:

    • Age — Range: 8-15 years. Mean: 10.5 years
    • Race/Ethnicity — 65% European American, 26% African American, 22% Hispanic or Latino, and 9% Bi-racial
    • Gender — 59% male and 41% female
    • Status — Children in residential treatment centers, foster family, prevention or outpatient mental health clinic programs who had trauma histories

    Location/Institution: Albany, NY

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    This study evaluates the Real Life Heroes program, an integrated attachment and trauma therapy for children in child and family therapy program. Measures utilized include the UCLA PTSD Checklist, the Parent Report of Posttraumatic Symptoms, the Children’s Perceived Self-Control Scale, the Hopelessness Scale, Multidimensional Social Support Scale, the Trauma Symptom Checklist for Children, the Security Scale, the Working Alliance Inventory, and Connors Parent Rating Scale. Results showed significant levels of improvement on child-reports of trauma symptoms and fewer problem behaviors reported on caregiver checklists at 4-months and 12-month intervals. This study is limited due to lack of a control group and small sample size.

    Length of postintervention follow-up: None.

    Kagan, R., Henry, J., Richardson, M., & LaFrenier, A. (2014). Evaluation of Real Life Heroes treatment for children with complex PTSD. Psychological Trauma: Theory, Research, Practice, & Policy, 6(5), 588-596.

    Type of Study: One group pretest-posttest study and exploratory comparison study
    Number of Participants: 41

    Population:

    • Age — 6-18 years
    • Race/Ethnicity — 54 Caucasian/White, 41 African American, 18 multirace, and 6 not reported
    • Gender — 60 boys and 59 girls
    • Status — Participants were children who had trauma histories and were from outpatient mental health clinic, day treatment, home-based intensive counseling (to prevent placement), foster care, community residence, and residential treatment programs

    Location/Institution: Albany, NY

    Summary: (To include comparison groups, outcomes, measures, notable limitations)
    The efficacy of Real Life Heroes (RLH) treatment was tested with 119 children in seven child and family service programs, ranging from home-based family counseling to residential treatment, and compared to children receiving trauma-informed “treatment as usual” (TI-TAU) provided by practitioners trained in RLH in the same programs during the same time period Measures utilized include the Child Behavior Checklist (CBCL) 6-18, UCLA PTSD Index (Parent Version and Child Version), CDS Trauma History Profile Trauma Symptom Checklist for Children, and Resiliency Scales for Children and Adolescents. Results showed children receiving RLH treatment demonstrated significant improvements in trauma symptoms and behavior problems; however, the control group was not assessed with these same measures and no comparisons are made between the RLH and TI-TAU on these measures. Children receiving RLH did not have placements or psychiatric hospitalizations, a positive, but not significant trend, compared with youth in the TI-TAU. This study is limited due to lack of a randomly assigned control group and lack of comparison between the RLH and TI-TAU group on most outcome measures, and possible selection bias in the RLH sample.

    Length of postintervention follow-up: Not specified.

    References

    Kagan, R. (2016). Real Life Heroes: Toolkit for treating traumatic stress in children and families (2nd ed.). New York, NY: Routledge.

    Kagan, R. (2016). Real Life Heroes life storybook (3rd ed.). New York: Routledge.

    Kagan, R., & Spinazzola, J. (2013). Real Life Heroes in residential treatment; Implementation of trauma and attachment-focused treatment for children and adolescents with complex PTSD. Journal of Family Violence, 28(7), 705-715.

    Contact Information

    Name: Richard Kagan, PhD
    Agency/Affiliation: Parsons Child and Family Center
    Website: www.reallifeheroes.net
    Email:

    Date Research Evidence Last Reviewed by CEBC: December 2015

    Date Program Content Last Reviewed by Program Staff: October 2014

    Date Program Originally Loaded onto CEBC: September 2012