Journal of Traumatic Stress

August 2014, 27, 1–5

Group Trauma-Informed Treatment for Adolescent Psychiatric

Inpatients: A Preliminary Uncontrolled Trial
Omar G. Gudiño,1 J. Rebecca Weis,2,3 Jennifer F. Havens,2,3 Emily A. Biggs,2,3 Ursula N. Diamond,2,3
Mollie Marr,2,3 Christie Jackson,2,4 and Marylene Cloitre2,5
1
Department of Psychology, University of Denver, Denver, Colorado, USA
2
Department of Child & Adolescent Psychiatry, New York University School of Medicine, New York, New York, USA
3
Department of Child & Adolescent Psychiatry, Bellevue Hospital Center, New York, New York, USA
4
Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
5
National Center for PTSD, Menlo Park, California, USA

Despite high rates of trauma exposure (46%-96%) and significant posttraumatic stress disorder (PTSD; 21%–29%) symptoms in adolescent
psychiatric inpatients, there is a dearth of research on effective interventions delivered in inpatient settings. The current report describes the
development of Brief STAIR-A, a repeatable 3-module version of skills training in affective and interpersonal regulation (STAIR) developed
for adolescents in inpatient care. An uncontrolled design was used to conduct a preliminary examination of the group intervention’s
effectiveness. Adolescent psychiatric inpatients (N = 38; ages 12 years–17 years) admitted to a public hospital participated in Brief
STAIR-A and attended a median of 6 sessions (range 3–36). They completed measures of PTSD and depressive symptom severity, coping
skill use, and coping efficacy upon admission and again prior to discharge. Participants reported significant reductions in symptom severity
(d = 0.65–0.67), no change in the absolute level of coping skills used (d = 0.16), but greater coping efficacy when discharged from care
(d = 0.75). Results from this pilot study suggest that this brief group treatment shows promise for treating adolescents’ trauma-related
difficulties in inpatient psychiatry settings, but additional research examining its effectiveness is essential.

Nearly one in three adolescent psychiatric inpatients has
clinically significant symptoms of posttraumatic stress disor-
der (PTSD) and 46%–96% are exposed to trauma (Allwood,
Dyl, Hunt, & Spirito, 2008; Havens et al., 2012). Despite these
rates, there is a dearth of research examining inpatient treatment
of trauma-exposed adolescents. We are aware of only one small
randomized trial that showed improved PTSD symptoms for
inpatients receiving 16 weeks of trauma-focused expressive art
therapy compared to treatment as usual (Lyshak-Stelzer, Singer,
St. John, & Chemtob, 2007).
Although not specific to adolescents, clinical guidelines sug-
gest that inpatient treatment of PTSD focus on present-day
functioning, safety, stabilization, symptom management, and
interpersonal relationships (Foa, Keane, & Friedman, 2000).
Whereas delivering a full-length trauma-focused treatment in-
cluding a trauma narrative may be challenging due to great
variability in treatment duration, brief skill-based treatments
targeting present-day functioning may provide an ideal model
for the psychiatric inpatient treatment of trauma-related difficul-
ties. Fortunately, clinical trials highlight the potential efficacy
of skill-focused treatment components for targeting such diffi-
culties (see Cloitre et al., 2010; Deblinger, Mannarino, Cohen,
Runyon, & Steer, 2011; Resick et al., 2008).
Skills training in affective and interpersonal regulation
(STAIR; Cloitre, Cohen, & Koenen, 2006) is a phase-based
intervention with demonstrated efficacy for reducing trauma-
related problems in adults in outpatient settings. An adolescent
version of STAIR has also previously been developed (STAIR-
A; Cloitre, Farina, Davis, Carr, & Brown, 2005; Gudiño,
Leonard, & Cloitre, 2014). We sought to develop Brief STAIR-
A, an adolescent and brief version of STAIR emphasizing skills
training, and to conduct a preliminary examination of its ef-
fectiveness for reducing PTSD and depression symptoms and
improving coping skill use and efficacy in adolescent inpatients.
Method

Correspondence concerning this article should be addressed to Omar Gudiño,
Department of Psychology, University of Denver, 2155 S. Race St., Denver,
CO 80210. E-mail: Omar.Gudino@du.edu
Copyright  C 2014 International Society for Traumatic Stress Studies. View
Participants and Procedure
Participants were 38 adolescents ages 12 years–17 years (M =
14.68, SD = 1.30), including 25 females (65.8%), 12 males

this article online at wileyonlinelibrary.com (31.6%), and one male-to-female transgender individual
DOI: 10.1002/jts.21928 (2.6%). Most were racial/ethnic minorities, with 44.7% being

1
2 Gudiño et al.

Table 1 study did not differ from the overall sample of 257 in terms of
Rates of Trauma Exposure, Discharge Diagnoses, and Discharge demographic and pretreatment clinical variables.
Medications by Type Intake assessments were conducted within 3 days of hospital-
ization and prior to participation in Brief STAIR-A. Both intake
Variable n %
assessments and participation in treatment groups throughout
Trauma type the hospitalization occurred as part of standard care for all pa-
Witness to community violence 32 82.1 tients. Discharge assessments occurred within the final week
Victim of community violence 26 66.7 of the 38 adolescents’ hospitalization. Given that groups were
Accident 17 43.6 offered as part of standard clinical care on the unit, voluntary
Physical abuse 15 38.5 treatment dropout was not possible. Adolescents were not com-
Disaster 11 28.2 pensated for participation. Study procedures were approved by
Domestic violence 10 25.6 the NYU School of Medicine’s Institutional Review Board.
Sexual abuse 9 23.1 Researchers and clinicians (M. Cloitre, C. Jackson, O.
Discharge diagnoses Gudiño, J. R. Weis, & J. Havens) identified three core treatment
Depressive disorders 20 52.6 components (described below) of STAIR (Cloitre et al., 2006)
ADHD 13 31.6 and condensed the treatment so that each component could
Disruptive behavior disorder 12 30.8 be delivered in one single-session module. To increase the fit
PTSD 12 30.8 with inpatient care, STAIR was distilled into three 90-minute
Mood disorder NOS 9 23.7 single-session modules offered each week, where adolescents
Other disorder 7 18.4 could start with any module and could attend groups repeatedly
Psychotic disorders 3 7.9 throughout their stay. In keeping with treatment guidelines (Foa
Bipolar disorder 2 5.3 et al., 2000), skills training interventions targeting stabilization,
Medications on discharge functioning, symptom reduction, and safety were prioritized; a
Antidepressants 25 65.8 trauma narrative was not included.
Antipsychotic 22 57.9 Brief STAIR-A is based on the notion that exposure to multi-
Stimulants 13 34.2 ple traumas affects the development of emotion regulation and
Mood stabilizer 3 7.9 interpersonal skills, which diminish an adolescent’s functional
Other 2 5.3 capacity. Thus, the intervention aims to enhance these abilities
through skills training.
Note. NOS = not otherwise specified; Depressive disorders = major depressive In Module 1, adolescents receive psychoeducation about
disorder and depression, NOS; ADHD = Attention deficit/hyperactivity disorder;
PTSD = posttraumatic stress disorder; Disruptive behavior disorder = conduct
trauma and emotions and they practice monitoring and labeling
disorder, oppositional defiant disorder, and disruptive behavior disorder, NOS; emotions. Module 2 focuses on coping with difficult feelings.
Other disorder = anxiety, adjustment, pervasive developmental, and impulse Group leaders first help adolescents identify and evaluate their
control disorders. current coping skills. Then, during the majority of the session,
adolescents learn skills to cope with challenging situations and
emotions. Experiential exercises are used throughout the ses-
Latino (n = 17), 44.7% African American (n = 17), 5.3% Asian sion to reinforce emotion regulation skills. Module 3 focuses
(n = 2), and 5.3% non-Hispanic White (n = 2). Most (74.4%) on developing skills for clear communication, with adolescents
qualified for public insurance. Diagnoses assigned upon dis- learning to identify barriers to effective communication, ac-
charge are detailed in Table 1. quiring new communication skills, and developing competence
Participants were drawn from an overall sample of 257 pa- and flexibility in interpersonal interactions. During this ses-
tients admitted consecutively to the adolescent psychiatric in- sion, adolescents refine new skills through role-playing activ-
patient unit of a New York City public hospital because they ities. Brief STAIR-A is trauma-informed, but emphasizes the
were deemed to be a danger to themselves/others, or were un- development of skills to improve current functioning.
able to function in the community. Adolescents were excluded Common elements across the three modules include a brief
from research if they were diagnosed with mental retardation, overview of the treatment (for adolescents new to the group), an
did not speak English, if acute psychotic/manic symptoms pre- opportunity to practice deep breathing as an emotion-regulation
vented participation, or if caregiver consent was not obtained strategy, and development of an individualized safety plan for
to conduct discharge assessments and to use the data from the each patient. These common elements account for approxi-
standard care delivered. For a variety of reasons, consent could mately 20% of each session. Adolescents use safety plans to
only be obtained for 38 adolescents—14.8% of the pool of pa- identify signals they display when feeling distressed and to list
tients who had a caregiver or legal guardian visit the unit during coping strategies that they find helpful. With help from group
a time when research staff was available to recruit the family leaders, adolescents revise safety plans as they develop new
and conduct informed consent procedures. Although the anal- skills and the plans facilitate communication among the ado-
ysis sample is small, the 38 adolescents participating in this lescent and unit staff.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Trauma-Informed Adolescent Inpatient Treatment 3

Brief STAIR-A groups included an average of six to eight Table 2

adolescents and were co-led by unit staff, including child psy- Paired-Samples t-Tests and Effect Sizes Assessing Change From
chiatrists, psychologists, social workers, nurses, activities ther- Intake to Discharge
apists, and trainees in these disciplines. All group leaders first
Intake Discharge
participated in a half-day training led by an experienced STAIR
trainer. Treatment adherence was maintained with 1 hour of Variable M SD M SD t(37) d
weekly group supervision provided by the trainer throughout
the study. Following each group, coleaders also completed an PTSD 24.76 13.49 16.55 10.30 4.07*** 0.67
adherence checklist (overall adherence of 83.4%). Although Depression 52.29 11.12 45.76 8.43 4.04*** 0.65
adherence to the protocol was high, clinicians noted that it was Coping skill use 9.16 2.76 8.74 2.32 1.03 0.16
sometimes not possible to deliver all session content due to Coping efficacy 1.09 0.50 1.41 0.30 −3.38** 0.75
unpredictable events that occur in an acute care setting (e.g., Note. PTSD = posttraumatic stress disorder.
groups having to be shortened when the daily unit schedule **p < .01. ***p < .001.
was impacted by patient safety concerns or when other unit
activities did not remain on schedule).
Graduate students in psychology administered measures
of variance (ANOVA) to examine if change from intake to dis-
upon hospitalization and at discharge. Given that this was an in-
charge was moderated by whether patients were started on a
patient setting, research assistants were aware that patients were
medication during the hospitalization. Change from intake to
receiving treatment and had participated in STAIR-A groups.
discharge was examined using paired-samples t tests and Co-
hen’s d (Cohen, 1988) was calculated to estimate effect size.
Measures
There were no missing data.
Diagnoses, medications, and demographics were obtained from
patient records. Exposure to traumatic events was assessed with
the NYU Child and Adolescent Stressors Checklist (Mullett- Results
Hume, Anshel, Guevara, & Cloitre, 2008), which produced an
Adolescents were exposed to an average of 3.08 trauma types
α of .75 in the current sample.
(SD = 1.58; see Table 1). Prior to hospitalization, 44.7% of
The UCLA PTSD Reaction Index for DSM-IV (Steinberg,
patients were already prescribed medication. On discharge,
Brymer, Decker, & Pynoos, 2004), a widely used measure with
92.1% of patients were prescribed medication (see Table 1).
excellent psychometric properties, was used to assess PTSD.
Participants attended a median of six groups over a median
In this sample, α for the total score was .85 at intake and .87 at
hospitalization of 19 days (range 8–130 days), with 7.7% at-
discharge. The Children’s Depression Inventory (Kovacs, 1992)
tending 3 groups, 43.5% attending 4–6 groups, 25.6% attend-
was used to assess symptoms of depression. It has demonstrated
ing 7–10 groups, 20.6% attending 11–18 groups, and one pa-
good internal consistency, test-retest reliability, and construct
tient (2.6%) attending 36 groups. Repeated measures ANOVAs
validity (Kovacs, 1992). In the current study, α for the total
comparing (a) adolescents who were prescribed psychotropic
score was .87 at both intake and discharge.
medications both prior to the current hospitalization and at dis-
Coping skill use and efficacy were assessed with the KID-
charge (52.6%) to (b) those who were only prescribed medica-
COPE (Spirito, Stark, & Williams, 1988). Participants first
tion as a result of the current hospitalization (47.4%) suggested
identified an interpersonal stressor in the past week and in-
that these groups did not differ on any outcome. Thus, paired-
dicated whether they used each coping skill (yes/no). They
samples t tests and Cohen’s d were used to examine change
then rated how helpful a skill was (0 = not at all, 1 = a
from intake to discharge. Adolescents reported significantly
little, 2 = a lot). Skills assessed included cognitive restruc-
lower levels of PTSD and depression symptoms at discharge
turing, problem solving, self-calming, social support, engaging
relative to intake. Although the number of coping skills used
in pleasurable activities, trying to forget, social withdrawal,
did not change significantly, patients did report improved cop-
wishful thinking, resignation, yelling/getting angry, and blam-
ing efficacy at discharge (see Table 2). These results suggest
ing others or oneself. We calculated an overall sum of coping
that Brief STAIR-A has promise for reducing clinical symp-
skills used and an average efficacy score across skills. Con-
toms and supporting an adolescent’s ability to apply coping
current validity has been supported by moderate to high cor-
skills effectively. Furthermore, there were no adverse events re-
relations with other coping scales (Spirito et al., 1988). In this
ported. Anecdotal evidence indicated that no patient or family
study, internal consistency ranged from .49 to .61 at intake and
refused participation in the Brief STAIR-A treatment, and that
discharge.
the groups are perceived as acceptable to both patients and staff.
The intervention continues to be delivered as part of standard
Data Analysis
clinical care on the inpatient unit more than 3 years after it was
Descriptive statistics were calculated to examine patient char- first implemented. Given that Brief STAIR-A was delivered as
acteristics. Subsequently, we used repeated measures analysis part of standard care on an inpatient unit, where dropping out

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
4 Gudiño et al.
entirely from treatment was improbable, these findings speak
more to the acceptability and feasibility of this treatment for
inpatient settings than to acceptability for individual patients
and families.
Discussion
This study addresses a critical research gap by examining the
effectiveness of a trauma-informed intervention for adolescent
psychiatric inpatients. By targeting stabilization and function-
ing, Brief STAIR-A may effectively address the unique clini-
cal needs of traumatized adolescents in inpatient care. Notable
strengths of the study include delivery of treatment by unit clin-
icians and reliance on a diverse sample of adolescents exposed
to various traumas.
Despite these strengths, this is only a preliminary trial with
several limitations. Perhaps most important, the study design
does not allow us to make definitive statements about the ef-
fectiveness of the intervention. Although results suggested that
starting medication during the hospitalization was not solely
responsible for the observed effects, we did not employ a con-
trol group and the relative effects of other interventions could
not be examined. Furthermore, high rates of medication use
and frequent changes in medication common during inpatient
hospitalization prevented us from conducting more sophisti-
cated analyses of medication effects in this small sample. Al-
though flexibility in the delivery of Brief STAIR-A modules
is a strength in terms of the treatment’s fit with inpatient care
settings, variability in the number of sessions participants re-
ceived and when in their hospital course they received it is a
limitation of the study. Conducting well-controlled studies in
inpatient settings presents formidable challenges and the liter-
ature on inpatient treatment has often failed to identify active
components of treatment (Lyman & Campbell, 1996). Nonethe-
less, future studies should examine the effectiveness of Brief
STAIR-A using controlled designs.
The convenience sample used in this study was small relative
to the number of eligible adolescents. Although it is reassuring
that the adolescents in this study did not differ from the overall
sample in terms of demographic or clinical variables, the ethical
recruitment of adolescents in inpatient care deserves attention
and future research should strive to enroll a higher proportion
of these vulnerable youth and families. All patient outcomes
were assessed using self-report and research assistants proctor-
ing the measures were aware that patients received treatment.
Future controlled trials should employ multiple methods of as-
sessment by assessors blind to condition. Therapist adherence
ratings were also assessed using self-report measures. Given
that consent was only obtained at discharge, it is also unclear
how this may have affected results. Finally, it is possible that
coping skills used on an inpatient unit may not generalize to
other settings, and we have no data on maintenance of gains
following discharge.
This study represents an important initial step for build-
ing knowledge about effective interventions for hospitalized
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
adolescents. Despite an increasing emphasis on community-
based treatment, inpatient treatment is a necessary part of the
continuum of care for youths with severe difficulties. Hos-
pitalization can present an opportunity to identify the effect
of trauma on these difficulties and to begin to address such
problems. Interventions like Brief STAIR-A may therefore
play an important role in the continuum of trauma-informed
care by targeting trauma-related difficulties, stabilization, and
functioning within a brief course of treatment. Brief STAIR-
A appears to be a promising intervention warranting further
study.
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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.