Trauma informed care: Implications for child mental health services

1. Trauma informed care: Implications for child mental health services John Briere, Ph.D. MCAVIC-USC Child and Adolescent Trauma Program National Child Traumatic Stress Network Psychological Trauma Program Keck School of Medicine, University of Southern California

2. Common problems of children in care Emotional distress Posttraumatic stress Anxiety, depression, anger, social withdrawal Posttraumatic stress, dissociation �Acting out� behaviors Directly self-injurious behavior Self-mutilation Suicidality Risky behavior Substance abuse Excessive/inappropriate sexual behavior Entrapment in exploitive or dangerous relationships Eating disorders Aggression

3. All of these symptoms/behaviors are associated with childhood abuse, neglect, or other victimization Especially child abuse and neglect Sexual, physical, and psychological abuse Emotional neglect Witness to violence (domestic and neighborhood) But also: Peer physical or sexual assault Community violence (including gang activity) The vicious circle: Revictimization

4. How these abuse/trauma effects may be misinterpreted The delinquent/bad kid Juvenile justice issues Conduct disorder Borderline (in late adolescence) ADHD Problems in attention, concentration, and activity level, versus hyperarousal symptoms of PTSD Manic depression/bipolar

5. What helps?Empirically-validated core interventions(irrespective of treatment model) Individualized, assessment-based treatment planning Customized according to client characteristics Age Ethnicity/culture Level of posttraumatic stress Level of affect regulation capacity Comorbidities Trauma-focused treatment Outcomes exceed that of generic care

6. Components Relationship development Treatment outcome data Activation and processing of attachment schema Psychoeducation Trauma symptoms Substance abuse issues Basis and antecedents for self-injury Endangering behavior and revictimization HIV/AIDS risk

7. Components Titrated exposure and emotional processing within the �therapeutic window� Formal verbal trauma therapy Play therapy Journaling Therapeutic conversations

8. Components Cognitive processing Normalizing and reframing of experiences and symptoms during session Cognitive reconsideration Development of a coherent, nonpathologizing narrative

9. Components Affect regulation training Breath training Relaxation Emotion identification and discrimination Moving in and out of emotional activation Interference in TRBs

10. Components Working with triggers Learning the difference between triggered thoughts, feelings, and behaviors versus current perception Learning to identify triggers as they occur Learning what to do when triggered to reduce the impacts and forestall behavior

11. Components Medication Incorrect medication Overmedication Staff overreliance on medication Limits of medication Dangers of non-medication

12. Suggestions Multiple staff in-services regarding the relationship between �problem� behaviors, mental health issues, and trauma Regular trauma evaluations (events and symptoms) upon intake Trauma input during case conferencing or treatment planning Train and supervise staff therapists in trauma therapy Referrals to qualified outside clinicians and agencies