CHILD AND FAMILY TRAUMA

1. CHILD AND FAMILY TRAUMA Frederick H. Strieder, MSSA, PhD Clinical Associate Professor, University of Maryland School of Social Work Director, Family Connections Baltimore Elizabeth Thompson, Phd Assistant Vice President, director The Family center at Kennedy Krieger Institute

2. What is Child Traumatic Stress? • Impact of Trauma on Child and Family • National Child Traumatic Stress Network • Trauma Informed Organizational Practice • Trauma Interventions • Secondary Traumatic Stress and the Workforce • Questions AGENDA

3. What Is Child Traumatic Stress? Artwork courtesy of the International Child Art Foundation (www.icaf.org)

4. What Is Child Traumatic Stress? • Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling). • Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal.

5. What Is Child Traumatic Stress, cont'd • A child’s response to a traumatic event may have a profound effect on his or her perception of self, 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

6. CONTEXT OF TRAUMA • Natural Disasters • Illnesses and Injury • Wars, Genocide, Terrorism • Industrial and Nuclear Disasters • Family and Intimate Partner Violence • Immigration • Workplace and School threats and violence • Community/Neighborhood Violence • Institutional Victimization/Violation • Child Maltreatment • Physical, Sexual, Emotional Abuse and Neglect • 700 BCE documented in Homer’s Iliad • 1800’s Freud “hysterical neurosis” • WWI “shell shock”-weakness • WWII “combat neurosis” • 1960’s Recognition of Effects of Trauma (Vietnam, Rape Crisis Centers) • 1976 Chowchilla, CA (Lenore Terr) • 1980-DSM III included PTSD as a diagnosis for Adults • 1987-DSM III-R Recognition of differing PTSD symptoms in children • 1994,2000- DSM IV TR Full Recognition of Children

7. Types of Traumatic Stress • Acute trauma is a single traumatic event that is limited in time. • Chronic traumarefers to the experience of multiple traumatic events. The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact. • Complex traumadescribes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.

8. Prevalence of Trauma—United States • Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect. • In 2005, 899,000 children were victims of child maltreatment. Of these: • 62.8% experienced neglect • 16.6% were physically abused • 9.3% were sexually abused • 7.1% endured emotional or psychological abuse • 14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction) Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

9. U.S. Prevalence, cont'd • One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1 • In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2 • Four out of 10 U.S. children report witnessing violence;8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3 • 1. Costello et al. (2002). J Trauma Stress;5(2):99-112. • 2. Schwab-Stone et al. (1995). J Am Acad Child Adolescent Psychiatry;34(10):1343-1352. • 3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.

10. Impact of Trauma on Child and Family Artwork courtesy of the International Child Art Foundation (www.icaf.org)

11. Variability in Responses to Stressors and 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.

12. Variability, cont’d • 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

13. Effects of Trauma Exposure on Children • When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far-reaching effects on nearly every aspect of the child’s life. • Children who have experienced the types of trauma that precipitate entry into the child welfare system typically suffer impairments in many areas of development and functioning, including: 13

14. Effects of Trauma Exposure • Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others. • Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems. • Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states. 14

15. Effects of Trauma Exposure • Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal. • Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others. • Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development. • Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt. 15

16. Long Term Effects • In the absence of more positive coping strategies, children who have experienced trauma may engage in high-risk or destructive coping behaviors. • These behaviors place them 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 et al. (1998). Am J Prev Med;14(4):245-258. 16

17. Childhood Trauma and PTSD • Children who have experienced chronic or complex trauma frequently are diagnosed with PTSD. • According to the American Psychiatric Association,1 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 the physical integrity of themselves or others • Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA. 17

18. Childhood Trauma and PTSD • 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 • Emotional numbing (e.g. detachment, estrangement, loss of interest in activities) • Increased arousal (e.g. heightened startle response, sleep disorders, irritability) Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

19. Childhood Trauma and Other Diagnoses • Other common diagnoses for children in the child welfare system include: • Reactive Attachment Disorder • Attention Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Bipolar Disorder • Conduct Disorder • These diagnoses generally do not capture the full extent of the developmental impact of trauma. • Many children with these diagnoses have a complex trauma history. 19

20. Trauma and the Brain • Trauma can have serious consequences for the normal development of children’s brains, brain chemistry, and nervous system. • Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition. • Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans. 1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193 20

21. Influence of Culture • People of different cultural, national, linguistic, spiritual, and ethnic backgrounds may define “trauma” in different ways and use different expressions to describe their experiences. • Child welfare workers’ own backgrounds can influence their perceptions of child traumatic stress and how to intervene. • Assessment of a child’s trauma history should always take into account the cultural background and modes of communication of both the assessor and the family. 21

22. FITT Model Trauma and Family Informed Principles* Child Response Sibling Relations Child and Family Outcomes Urban Poverty Family Processes Parent-Child Relations Adult/ Parental Response Parenting Practices & Quality Adult Family of Origin Response Adult Intimate Relations Time* Acute and longer-term effects Individual development Family life cycle Adapted from Kiser & Black, 2005

23. National Child Traumatic Stress Network Artwork courtesy of the International Child Art Foundation (www.icaf.org)

24. National Child Traumatic Stress Network The mission of the National Child Traumatic Stress Network (NCTSN) is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States.

25. National Child Traumatic Stress Network • Funded in 2000 (Children’s Health Act) supported through funding from the Donald J. Cohen National Child Traumatic Stress Initiative, administered by the US Department of Health and Human Services (DHHS), Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA) • Rapid Change – post 9/11/01 • Innovative Collaborative Structure: • UCLA-Duke University National Center for Child Traumatic Stress (Category I) • Intervention Development and Evaluation Centers (Category II) • Community Treatment and Service Centers (Category III) • Alumni members

27. Trauma Informed Organizational Practice Artwork courtesy of the International Child Art Foundation (www.icaf.org)

28. The Paradigm Shift Traditional Care Trauma-Informed Care Trauma Specific Intervention

29. Trauma-Informed Care • Universal understanding that nearly every individual seeking services in human service systems has a trauma history • Provision of care should be trauma competent • Based on public health prevention concepts (with emphasis on primary and secondary prevention) • Commitment to strengths based beliefs and practices (e.g. promoting resilience, collaborative working relationship with consumers and survivors)

30. Pre-requisites for Trauma Informed Service Delivery • Administrative commitment • Universal screening for trauma • Assessment as needed • On-going staff training and education • Expert trauma consultation available to staff • Hiring practices • Review of organizational policies and procedures • Avoidance of re-traumatization practices Harris & Fallot (2001)

31. The Sanctuary® Model • Trauma exposure in individuals who seek services as well as the individuals who provide those services • Organizational stressors (e.g. fiscal pressures, regulatory compliance, workloads, etc.) • Active creation of trauma informed community • 7 Commitments • Nonviolence • Emotional Intelligence • Social Learning • Democracy • Open Communication • Social Responsibility • Growth and Change

32. Trauma Interventions Artwork courtesy of the International Child Art Foundation (www.icaf.org)

33. A Good Question... How can we sort out the good from the poor or even harmful interventions? ?

34. The Ideal Clinical Science Process Use in Practice Setting Disseminate Intervention to the Field Conduct Efficacy Studies Conduct Effectiveness Studies Develop Intervention Approach

35. Quality of Trauma Treatment

36. DAILY HASSLES SOCIAL & SYSTEMS DEMANDS Trauma Trauma FINANCIAL INSTABILITY RESIDENTIAL INSTABILITY Trauma SOCIAL AND PUBLIC INCIVILITIES Potential Family Interventions TF-CBT AF-CBT CFTSI SFCR Child Response Child Response FL SFCR Sibling Relations Sibling Relations AF-CBT SFCR Family Processes Family Functioning TA-FC Cognitive Processing Therapy TG-CBT FL SFCR Parent-Child Relations Parent-Child Relations TF-CBT TG-CBT PCIT AF-CBT CPP FL SFCR Adult/ Parental Response Adult/ Parental Response Parenting Practices & Quality Parenting Practices & Quality Adult Family of Origin Response AF-CBT FL SFCR TF Parent Coaching Adult Intimate Relations Adult Intimate Relations LIVE Grandparent/caregiver Support Groups SAFE Emotionally Focused Therapy FL

37. What is the Common Elements approach? • Using elements that are found across several evidence-supported, effective interventions • “Clinicians ‘borrow’ strategies and techniques from known treatments, using their judgment and clinical theory to adapt the strategies to fit new contexts and problems” (Chorpita, Becker & Daleiden, 2007, 648-649) • An alternate to using treatment manuals to guide practice • Actual treatment elements become unit of analysis rather than the treatment manual • Treatment elements are selected to match particular client characteristics

38. Secondary Traumatic Stress and the Workplace Artwork courtesy of the International Child Art Foundation (www.icaf.org)

40. Potential for Personal Impact

42. Current Research • Younger therapists experiences more burnout while more experienced therapists reported more compassion satisfaction. • Implementing EBP’s generally reduced reported compassion fatigue and burnout.

45. Thank you! Questions???