not for 10th annual maryland casa...

10th Annual Maryland CASA Conference

NOT FOR REPRODUCTION

Trauma‐Informed Care: What Does It Mean?Frederick H. Strieder, MSSA, PhD

Clinical Associate ProfessorDirector, Family Connections Baltimore

University of Maryland School of Social Work


Objectives• Participants will recognize the impact of trauma on the development and behavior of children and families.

• Participants will understand the components of intervening in a trauma‐sensitive manner.

• Participants will identify the role of the advocate in facilitating trauma‐informed care.


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Child Welfare Trauma Training Toolkit

The National Child Traumatic Stress Network


Definition of Trauma‐Informed Child‐and Family‐Service System

A trauma‐informed child‐ and family‐service system is one in which all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to facilitate and support the recovery and resiliency of the child and family.

5Source: National Child Traumatic Stress Network. Retrieved from http://www.nctsn.org/resources/topics/creating‐trauma‐informed‐systems


Why is this important?

The research is clear that the experience of abuse or neglect leaves a particular traumatic fingerprint on the development of children that cannot be ignored if the child welfare system is to meaningfully improve the life trajectories of maltreated children, not merely keep them safe from harm.

‐ Bryan Samuels, Commissioner for the Administration on Children, Youth and Families,Testimony to House Ways and Means Subcommittee on Human Resources, Congress on 6/16/2011

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Why is this important?(continued)

Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.

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Source: National Scientific Council on the Developing Child. (2010). Persistent fear and anxiety can affect young children’s learning and development: Working Paper No. 9. Retrieved from www.developingchild.harvard.edu.

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Addressing Trauma Requires an Integrated Approach

• Trauma has biological and psychological effects that impact behavioral, social, and emotional domains.

• The impact of trauma can hinder development and interfere with children’s functioning in relationships, school, and life.

• Complex challenges of children who have experienced trauma may not be addressed by the system and services as they are currently designed.

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Source: U.S. Department of Health and Human Services (DHHS), Administration for Children Families, Administration on Children, Youth and Families, Children’s Bureau. (2012). Information memorandum (Log No: ACYF-CB-IM-12-04). Available from

http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf


VIDEO OF CHILD TRAUMATIC STRESS

HTTP://WWW.YOUTUBE.COM/WATCH?V=Z8VZXDA2KPM

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Child Welfare Trauma Training Toolkit

Child Trauma and Child Traumatic Stress


What Is Child Trauma?

• Witnessing or experiencing an event that poses a real or perceived threat.

• The event overwhelms the child’s ability to cope.

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SITUATIONS THAT CAN BE TRAUMATIC

Can you name some?

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Types of Trauma

• Acute trauma is a single traumatic event that is limited in time.

• During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening.


Types of Trauma(continued)

• Chronic trauma refers to the experience of multiple traumatic events.

• These may be multiple and varied events, such as:– the child’s being exposed to domestic violence, involved in a serious car accident, and then becoming a victim of community violence, or

– longstanding trauma such as physical abuse, neglect, or war

• The effects of chronic trauma are often cumulative.14



• Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.

• Children who have experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.

• Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

15Source: Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., ... van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5),

390‐398.



• Historical trauma is a personal or historical event or prolonged experience that continues to have an impact over several generations. Examples include:

‐ Slavery‐ Removal from homelands‐ Relocation‐Massacres, genocides, or ethnocides‐ Cultural, racial, and immigrant oppression‐ Forced placement in boarding schools

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Types of Trauma: What About Neglect?

• Failure to provide for a child’s basic needs• Perceived as trauma by an infant or young child who is

completely dependent on adults for care• Opens the door to other traumatic events• May interfere with a child’s ability to recover from trauma

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Child Traumatic Grief• When someone important to the child dies in a sudden or

violent manner that is perceived as traumatic to the child.• Child’s trauma symptoms interfere with his/her ability to

grieve.• Symptoms of child traumatic grief include:

– Being overly preoccupied with how the loved one died– Reliving or re‐enacting the traumatic death– Showing signs of emotional and/or behavioral distress when reminded of the loss

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Racial Injustice

• Racism includes interpersonal, internalized, institutional and systemic experiences, events and exposures.


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Medical Trauma in the Child Welfare Population

• Medical trauma (related to ongoing or chronic illness or injury) is a special concern for children in foster care due to their higher rates of chronic health conditions.

• Medical illness, injury, and treatment can be traumatic. • Medical exams can be invasive and may trigger past

traumas or uncover conditions requiring painful or prolonged treatment.

Source: U.S. Department of Health and Human Services (DHHS), Administration for Children Families, Office of Planning, Research and Evaluation. (2007). NSCAW, No. 7: Special health care needs among children in child welfare, Research brief, Findings from the NSCAW study Retrieved from

http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf


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Medical Trauma in the Child Welfare Population

For children in foster care, medical trauma may become “layered” onto previous traumatic experiences:

• Children are at risk for additional traumatic stress reactions related to their healthcare experience.

• The same risk factors for persistent traumatic stress in ill and injured children are particularly relevant for children in foster care who:

– Experience severe levels of pain during illness or injury– Are exposed to scary sights and sounds in the hospital– Are separated from parents or caregivers during treatment– Have experienced prior medical trauma or had previous trauma reactions


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Other Sources of Ongoing Stress• Children in the child welfare system frequently face other sources of ongoing stress:

– Poverty

– Discrimination

– Separations from parent/siblings

– Frequent moves

– School problems

– Traumatic grief and loss

– Refugee or immigrant experiences


Potentially Traumatizing Events in Juvenile Detention and Other Residential Settings

• Seclusion

• Restraint

• Routine room confinement

• Strip searches and pat‐downs

• Placement on suicide watch

• Witnessing physical altercations

• Fear of being attacked by other youth

• Separation from family and community23Source: National Child Traumatic Stress Network [NCTSN]. (n.d.). The trauma‐informed juvenile

justice system resource. Retrieved from http://learn.nctsn.org/course/category.php?id=6


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What Is Child Traumatic Stress?

• Child traumatic stress refers to the physical and emotional responses of a child to threatening situations.

• Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out‐of‐control physiological arousal.


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What Is Child Traumatic Stress?(continued)

• Post‐traumatic stress reactions include re‐experiencing the event, avoidance, hyper‐arousal, and persistent difficult thoughts and emotions.

• A child’s response to a traumatic event may have a profound effect on his or her perception of self, others, the world, and the future.

• Traumatic events may affect a child’s:

– Ability to trust others– Sense of personal safety– Effectiveness in navigating life changes


Prevalence of Trauma in the United States

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Trauma Exposure in Children Served in the National Child TraumaticStress Network

Single vs. Multiple Trauma Types

NCTSN Core Data Set September 2010

23.2%

76.9%

100%90%80%70%60%50%40%30%20%10%0%

Single MultiplePercen

tage

ofCh

ildren&Ado

lescen

ts

SingleMultiple


Percentage of Children Experiencing Cumulative Traumas

N= 11, 138Mean= 3.60%S.D= 2.4Range= 0-15

© 2012 Briggs-King

5%

10%

15%

20%

25%

1 2 3 4 5 6# of Trauma Types

7 8 9 10+

23.2%

18.0%

14.6%12.8%

10.1%8.3%

5.4%

3.4%2.1% 2.2%


Percentage of Children in the NCTSN Core Data SetExperiencing Cumulative Traumas

Per

cent

© 2011 by Fairbank & Briggs-King


30%

25%

20%

15%

10%

5%

0%1 2 3 4 5 6 7

Total # Types of Traumatic Stressors ExperiencedMean = 2.59 70.9% Experienced 2 or More

Stolbach et al., 2009

Trauma Exposure in Children Served at theChicago Child Trauma CenterNOT FOR REPRODUCTION

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What Can I Do?• Remember that most children and families involved in the child welfare

system have been exposed to multiple traumatic events.• Learn about the different types of trauma that can impact children and

families.• Seek information about the particular types of traumas and stressors that

affect the families with whom you work.


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Child Welfare Trauma Training

Toolkit

How Does Trauma Affect Children?


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Variability in Responses to Stressorsand Traumatic Events

• The impact of a potentially traumatic event is determined by both:– The objective nature of the event

– The child’s subjective response to it

• Something that is traumatic for one child may not be traumatic for another.


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Variability in Responses to Stressorsand Traumatic Events

• The impact of a potentially traumatic event depends on several factors, including:

– The child’s age and developmental stage

– The child’s perception of the danger faced

– Whether the child was the victim or a witness

– The child’s relationship to the victim or perpetrator

– The child’s past experience with trauma

– The adversities the child faces following the trauma

– The presence/availability of adults who can offer help and protection


Effects of Trauma Exposure

• Attachment • Biology• Mood regulation• Dissociation

• Behavioral control• Cognition• Self‐concept• Development

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Trauma and Overwhelming Emotion

• Trauma can elicit such intense fear, anger, shame, and helplessness that the child feels overwhelmed.

• Overwhelming emotion may interfere with the development of age‐appropriate self‐regulation.

• Emotions experienced prior to language development may be very real for the child but difficult to express or communicate verbally.

• Trauma may be “stored” in the body in the form of physical tension or health complaints.


Overwhelming Emotion and Behavior

• Trauma‐exposed children may also exhibit:

– Over‐controlled behavior in an unconscious attempt to counteract feelings of helplessness and impotence

– Under‐controlled behavior due to cognitive delays or deficits in planning, organizing, delaying gratification, and exerting control over behavior

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• Maladaptive coping strategies can lead to behaviors including:

– Sleeping, eating, or elimination problems– High activity levels, irritability, or acting out– Emotional detachment, unresponsiveness, distance, or numbness– Hyper‐vigilance, or feeling that danger is present even when it is not– Increased mental health issues (e.g. depression, anxiety)– An unexpected and exaggerated response when told “no”

Overwhelming Emotion and Behavior(continued)


Key Developmental Capacities Affected byComplex Trauma

Ability to modulate, tolerate, or recover from extreme affect states

Regulation of bodily functionsCapacity to know emotions or bodily states

Capacity to describe emotions or bodily states

Capacity to perceive threat, including reading of safety and danger cues

Capacity for self-protection

Capacity for self-soothing

Ability to initiate or sustain goal-directed behavior

Coherent self, Identity

Capacity to regulate empathic arousal


Some Basic Assumptions AboutPsychological Traumatization

Traumatic experiences are those which overwhelm an individual’s capacity tointegrate experience in the normal way. (e.g., Putnam, 1985)

Following exposure to trauma, if integration does not occur, traumatic experience(s)are split off and an individual alternates between functioning as if the trauma isstill occurring and functioning as if the trauma never occurred. (e.g., Nijenhuiset al., 2004)

Although traumatic memories and associations remain inaccessible toconsciousness much of the time, they have the power to shape an individual’sdaily functioning and behavior. (e.g., Allen, 1993)


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Long‐Term Effects of Childhood Trauma• High‐risk or destructive coping behaviors

• These behaviors place children at risk for a range of serious mental and physical health problems, including:– Alcoholism– Drug abuse– Depression– Suicide attempts– Sexually transmitted diseases (due to high risk activity with multiple partners)– Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease

Source: Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245‐258.


Adverse Childhood Experiences Household dysfunction:

• Emotional abuse

• Physical abuse

• Sexual abuse

• Emotional neglect

• Physical neglect

• Mother treated violently

• Household substance abuse

• Household mental illness

• Parental separation/divorce

• Incarcerated household member

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Source: Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245-258.


Adverse Childhood Experiences

• Abuse and Neglect (e.g., psychological, physical, sexual)• Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)

Impact on Child Development

• Neurobiological Effects (e.g., brain abnormalities, stress hormone dysregulation)• Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy)

• Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)

Long‐Term ConsequencesDisease and Disability• Major Depression, Suicide, PTSD• Drug and Alcohol Abuse• Heart Disease• Cancer• Chronic Lung Disease• Sexually Transmitted Diseases• Intergenerational transmission of abuse

Social Problems• Homelessness• Prostitution• Criminal Behavior• Unemployment• Parenting problems• Family violence• High utilization of health and social

services

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Source: Putnam, F.,& Harris, W. (2008). Opportunities to change the outcomes of traumatized children: Draft narrative. Retrieved from

http://ohiocando4kids.org/Outcomes_of_Traumatized_Children


Long‐Term Effects of Trauma Activity• Think about a child with whom you have worked:

• Which of the trauma effects that we have reviewed were true for them?

• What are the relevant long‐term risk factors?

• Share with your small group and discuss strategies to prevent long‐term trauma effects.

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Childhood Trauma and PTSD• Children who have experienced chronic or complex trauma may be

diagnosed with Post‐Traumatic Stress Disorder (PTSD).

• According to the American Psychiatric Association, PTSD may be diagnosed in children who have:

– Experienced, witnessed, or been confronted with one or more events that involved real or threatened death or serious injury to their physical integrity or that of others

– Responded to these events by experiencing symptoms of PTSD

Source: American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM 5). Washington, DC: Author.


Childhood Trauma and PTSD(continued)

• Key symptoms of PTSD:

– Re‐experiencing the traumatic event (e.g., nightmares, intrusive memories)

– Intense psychological or physiological reactions to internal or external cues that symbolize or resemble some aspect of the original trauma

– Avoidance of thoughts, feelings, places, and people associated with the trauma

– Negative changes in thoughts and mood (e.g. inability to recall aspects of the trauma, feelings of fear, guilt, sadness, shame or confusion, loss of interest in activities)

– Increased arousal (e.g., heightened startle response, sleep disorders, irritability)• Many children show signs of post‐traumatic stress but do not meet full diagnostic criteria for

PTSD.

46Source: American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM 5). Washington, DC: Author.


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Childhood Trauma and Other Diagnoses

• Other common diagnoses for children in the child welfare system include:

– Attention deficit hyperactivity disorder

– Oppositional defiant disorder

– Conduct disorder

– Bipolar disorder

– Reactive attachment disorder• These diagnoses generally do not capture the full extent of the developmental impact of

trauma.

• The symptoms leading to these diagnoses may in fact be a child's reaction to a trauma reminder, which can result in withdrawn, aggressive, reckless or self‐injurious behaviors.

• Many children with these diagnoses have a complex trauma history.


Target Symptoms of Trauma‐ExposedChildren and Teens

• Affective arousal (irritable or angry mood)• Sleep problems• Fear and anxiety• Depression and sadness• Aggression• Impulsivity and attention problems

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What Can I Do?• Understand that children can react to trauma in different ways.

• View the child’s reactions and behaviors through a trauma lens and help other service providers and caregivers to do the same.

• Refer appropriate children for trauma treatment to reduce long‐term impacts.

• If you are concerned that a child is being overly or unnecessarily medicated, advocate for a second opinion.

• Assure that medications are only used as part of a comprehensive treatment plan.

What can you begin doing right away?

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What Is the Impact of

Trauma on theBrain and Body?


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Traumatic Stress Response Cycle

52Source: Georgetown University Center for Child & Human Development. (n.d.). Stress and the developing brain: The stress response. Retrieved from Center for Early Childhood

Mental Health Consultation website: http://www.ecmhc.org/tutorials/trauma/mod2_1.html


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Trauma and the Brain

• Trauma can have serious consequences for the brain.

• Trauma‐induced alterations in biological stress systems can adversely affect brain development.

• Trauma‐exposed children and adolescents display changes in their levels of stress hormones similar to those seen in combat veterans.

• Plasticity means the brain continues to change in response to repeated stimulation.

– Risk and opportunity: impact of trauma but also corrective experiences

Source: Pynoos, R. S., Steinberg, A. M., Ornitz, E. M., & Goenjian, A. K. (1997). Issues in the developmental neurobiology of traumatic stress. Annals of the New York Academy of Sciences, 821,

176‐193.


Brain Diagram

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Limbic System

Prefrontal Cortex

Brain Stem


Brain Structure: Three Main Levels• Prefrontal cortex – abstract thought, logic, factual memory,

planning, ability to inhibit action

• Limbic system – emotional regulation and memories, “value” of emotion

• Brainstem/midbrain – autonomic functions (breathing, eating, sleeping)

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Trauma and the Brain

• Structural Brain Differences

– Maltreated children present with a smaller corpus callosum, which affects how the brain’s hemispheres communicate about arousal, emotion, and cognition.

– Adults who were maltreated as children show reduced volume of the hippocampus (learning and memory) and prefrontal cortex (behavior, cognition, emotional regulation).

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Trauma and Memory

• Implicit memory: babies can perceive their environment and retain unconscious memories (e.g., recognizing mother’s voice)

• Explicit memory: conscious memories are created around age two and tied to language development

• Children with early trauma may retain implicit memories of abuse:

– Physical or emotional sensations can trigger these memories, causing flashbacks, nightmares, or other distressing reactions

57SSource: Applegate, J. S., & Shapiro, J. R. (2005). Neurobiology for clinical social work theory and practice. New York: W.W. Norton & Company.


Trauma and Development in Children and Youth• Developmental delays are common (50%, according to NSCAW) among

children in the child welfare system:– Cognitive

– Gross and fine motor skills

– Speech and language

– Sensory

– Emotional/behavioral dysregulation

• Developmental screenings are needed for all young children in the child welfare system.

58Source: Stahmer, A. C., Leslie, L. K., Hurlburt, H., Barth, R. P., Bruce Webb, M., Landsverk, J., & Zhang, J. (2005). Developmental and behavioral needs and service use for young

children in child welfare. Pediatrics, 116(4), 891 -900. doi: 10.1542/peds.2004-2135


Factors that Enhance Resilience

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Sources: Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227‐238.

National Child Traumatic Stress Network, Juvenile Justice Treatment Subcommittee. (in preparation). Think trauma: A training for staff in juvenile

justice residential settings. Will be available from http://www.nctsnet.org/resources/topics/juvenile‐justice‐system


Protective Factors

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Individual characteristics:Cognitive abilitySelf‐efficacy

Internal locus of control (asense of having control over

one’s life and destiny)TemperamentSocial skills

Family characteristics:1

Family cohesionSupportive parent-child

interactionSocial support (e.g., extended

family support)

Community characteristics:2

Positive school experiencesCommunity resources

Supportive peers and/ormentors

Cultural protective factors:Strong sense of cultural identity

SpiritualityConnection to cultural community

Protective beliefs and valuesCultural talents and skills

1 Benzies, K., & Mychasiuk, R. (2009). Fostering family resiliency: A review of the key protective factors. Child & Family Social Work, 14, 103‐114.2 Koball, H., Dion, R., Gothro, A., Bardos, M., Dworsky, A., Lansing, J., … Manning, A. E. (2011). Synthesis of research and resources to support at‐risk youth. Retrieved from

Administration for Children and Families Office of Planning, Research, and Evaluation website: http://www.acf.hhs.gov/programs/opre/fys/youth_development/reports/synthesis_youth.pdf


Examples of Evidence‐Based Treatments

• Trauma‐Focused Cognitive Behavioral Therapy (TF‐CBT)• Eye Movement Desensitization Reprocessing (EMDR)• Child‐Parent Psychotherapy (CPP)• Prolonged Exposure Therapy for Adolescents (PE‐A)• Trauma Adapted Family Connections (TA‐FC)

There are many different evidence‐based trauma‐focused treatments. A trauma‐informed mental health professional should be able to determine which treatment is most appropriate for a given case.

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Family Protective Factors• Nurturing and attachment

• Knowledge of parenting and child development

• Parental resilience

• Social connections

• Concrete supports for parents

62Source: U.S. Department of Health and Human Services (DHHS), Administration for Children Families, Child Welfare Information Gateway. (n.d.). Enhancing protective factors.

Retrieved from http://www.childwelfare.gov/preventing/promoting/protectfactors/


Trauma and Birth Parents

• Parents whose children have experienced trauma often experience secondary traumatic stress reactions.

• Many birth parents who are involved in the child welfare system have their own histories of trauma.

• Past and recent traumas can impact parents’ ability to keep their children safe, to work effectively with child welfare staff, and to respond to child welfare system requirements.

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Child Welfare Trauma Training

Toolkit

Enhance the Well‐Being and

Resilience of Those Working in the System


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Impact of Working with Victims of Trauma • Trauma experienced while working in the role of helper has been

described as:

– Compassion Satisfaction

– Compassion fatigue

– Secondary traumatic stress

– Vicarious traumatization

• STS is the stress of helping or wanting to help a person who has been traumatized.

• Vicarious can disrupt child welfare workers’ lives, feelings, personal relationships, and overall view of the world.


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Experience


What is a Trauma-Informed System?


“Trauma-informed” refers to all of the ways in which a service system is influenced by having an understanding of trauma, and the ways in which it ismodified to be responsive to the impact of traumaticstress. A program that is “trauma- informed” operateswithin a model or framework that incorporates anunderstanding of the ways in which trauma impactsan individual’s socio- emotional health. Thisframework should, theoretically, decrease the risk of retraumatization, as well as contribute more generallyto recovery from traumatic stress. (Harris & Fallot,2001)


Key Principles

Trauma awareness

Emphasis on safety

Opportunities to rebuild control andempowerment

Strengths-based approach


Building Trauma-Informed Systems


7 Steps Toward Success1. Identify Stakeholders

2. Conduct Needs Assessment

3. Facilitate Team Building

4. Provide Training

5. Implement Evidence Based Practice

6. Evaluate Effectiveness

7. Support Sustainability


Core TI Topics for Training

1. Understanding Traumatic Stress: “What is Trauma”?

2. Understanding the Impact of Trauma on the Brain and theBody: The Human Danger Response and Triggers

3. Understanding the Impact of Trauma on Development

4. Understanding the Impact of Trauma on Self Regulation

5. Tools to Help Individuals Impacted by Trauma


Lessons Learned: Strategies to Overcome Barriers

• Buy-in from the top

• Incorporating Trauma-Informed goals into program goals,objectives, outcomes, etc

• Bottom-Up vs. Top-Down Training Approach

• Creating a Safe Environment

• Build Internal Sustainability

• One Size Doesn’t Fit All

• Staff Self Care

• Consumer Involvement


The Trauma-Informed Organizational Self-Assessment

This was designed to help programs evaluate their practices.

There are 5 key areas to assess:• Supporting Staff Development• Creating a Safe and Supportive Environment• Assessing and Planning Services• Involving Consumers• Adapting Policies


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