Communicating with Children with Disabilities

Report
Trauma-Informed Child Welfare
Practice
TN CAC Connecting for Children’s Justice Conference
November 2014
Nashville, TN
Melissa L. Hoffmann, Ph.D.
UT Center of Excellence for Children in State Custody
University of Tennessee Health Sciences Center
Memphis, TN
Conflict of Interest Disclosures
1. I do not have any potential conflicts of interest to disclose, OR
X
2. I wish to disclose the following potential conflicts of interest:
Type of Potential Conflict
Details of Potential Conflict
Grant/Research Support
Substance Abuse and Mental Health Services Administration
(SAMHSA), National Child Traumatic Stress Initiative (NCTSI)
Category III Grant #1U79SM061152-01
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
X
4. This talk presents material that is related to one or more of these potential conflicts, and the
following objective references are provided as support for this lecture:
1.
De Bellis, M. D., Keshavan, M. S., Clark, D. B., Casey, B. J., Giedd, J. N., Boring, A. M., … Ryan, N. D. (1999). A. E. Bennett Research Award. Developmental
traumatology. Part II: Brain development. Biological Psychiatry, 45, 1271–1284.
2.
Griffin, G., McClelland, G., Holzberg, M., Stolbach, B., Maj, N., & Kisiel, C. (2012). Addressing the impact of trauma before diagnosing mental illness in child welfare.
Child Welfare, 90(6), 69-89.
3.
Reed, L. D. (2006). The role of risk factors, protective factors and resiliency in the psychological functioning of maltreated children. Retrieved from
http://www.denreed.com/documents/2dTheRoleofRiskfactorsprotectivefactorsandresiliency-Reed.pdf
Objectives
Participants will:
• 1) Understand the different types of trauma
• 2) Learn about the effects of trauma exposure on children
• 3) Become familiar with the Essential Elements of a
Trauma-Informed Child Welfare System
• Much of the information presented here is drawn from the National Child Traumatic
Stress Network (NCTSN) website and resources. Go to www.NCTSN.org for a wealth
of information.
Trauma-Informed Child- and FamilyService Systems
• 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;
• Infuse and sustain trauma awareness, knowledge, and skills into
their organizational cultures, practices, and policies;
• 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
• Utilization of trauma-informed practices will assist in
attaining the goals of:
• Safety
• Permanency
• Well-Being
• What impact does trauma have on these goals?
Child Welfare Trauma Training Toolkit
• NCTSN product
• Version 2.0
• released in 2013
• 14 modules
• This presentation is a
summary of the Toolkit
• In a trauma-informed child welfare system, the child
welfare worker:
• Understands the impact of trauma
• Can integrate that understanding into planning for the child and
family
• Understands his or her role in responding to child traumatic stress
The Essential Elements of a TraumaInformed Child Welfare System
• 1 - Maximize Physical and Psychological Safety for Children and Families
• 2 - Identify Trauma-Related Needs of Children and Families
• 3 - Enhance Child Well-Being and Resilience
• 4 - Enhance Family Well-Being and Resilience
• 5 - Enhance the Well-Being and Resilience of Those Working in the System
• 6 - Partner with Youth and Families
• 7 - Partner with Agencies and Systems that Interact with Children and
Families
The Essential Elements
• Implementation of each Essential Element must:
• Take into consideration the child’s developmental level and
• Reflect sensitivity to the child’s family, culture, and language
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 and
causes feelings of fear, helplessness or horror, which may
be expressed by disorganized or agitated behavior
Examples?
Types of Trauma
Acute Trauma
• Events that occur at a particular time and place and are
short-lived, and involve:
• (1) experiencing a serious injury to yourself or witnessing a serious
injury to or the death of someone else, or
• (2) facing imminent threats of serious injury or death to yourself or
others, or
• (3) experiencing a violation of personal physical integrity.
• During an acute event, children go through a variety of
feelings, thoughts, and physical reactions that are
frightening in and of themselves and contribute to a sense
of being overwhelmed.
Chronic Trauma
• Chronic trauma refers to the experience of multiple
traumatic events
• May be multiple and varied events (car accident and
domestic violence), or longstanding, repeated events
(ongoing sexual abuse)
• The effects of chronic trauma are often cumulative
Complex Trauma
• Complex trauma describes both exposure to chronic
trauma and the impact of such exposure on the child.
• The chronic trauma is usually caused by adults entrusted
with the child’s care
• 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
Other Types of Trauma
• Historical trauma
• Child traumatic grief
Child Traumatic Stress
What is Child Traumatic Stress?
• Child traumatic stress occurs when:
• children and adolescents are exposed to traumatic events or traumatic
situations, and
• this exposure overwhelms their ability to cope with what they have
experienced, eliciting feelings of terror, powerlessness, and out of control
physiological arousal
• Child traumatic stress refers to the physical and emotional responses
of the child
• 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 trust and sense of safety, and
may make them more vulnerable to current and future stressors
Responses to Stressors and Traumatic
Events
• A child’s response to a potentially traumatic event
depends on:
• Age and developmental stage
• Perception of the danger faced
• Whether the child was the victim or a witness
• Relationship to the victim or perpetrator
• Past experience with trauma
• Adversities faced after the trauma
• Presence or availability of adults who can offer help and protection
Effects of Trauma Exposure
• Attachment
• Biology
• Mood regulation
• Dissociation
• Behavioral control
• Cognition
• Self-concept
• Development
Maladaptive Coping Strategies
• Sleeping, eating, elimination problems
• High activity levels
• Irritability, acting out
• Emotional detachment, unresponsiveness, numbness
• Hyper-vigilance
• Unexpected and exaggerated response when told “no”
Trauma and the Brain
Trauma and Brain Development
Abuse and neglect have profound influences
on brain development. The more prolonged
the abuse or neglect, the more likely it is
that permanent brain changes will occur.
WHOLE BRAIN WEIGHT IN GRAMS
Growth of Human Brain
from birth to 20 years
Child maltreatment
reports
1989-2004
• Experience in Adulthood….
• Alters the Organized Brain
• Experience in Childhood….
• Organizes the Developing Brain
Neural Imprinting
• What Fires Together Wires Together
• The brain develops and modifies itself in response to experience.
Neurons and neuronal connections (i.e., synapses) change in an
activity-dependent fashion.
• The more an event occurs, the more a neural path is fired and
traveled, and the more permanent the message or new learning
becomes
• So, when you activate and repeatedly practice specific brain
activity you are wiring or rewiring the brain.
• During traumatic experiences children’s brains are in a
state of activation (due to fear, fight or flight).
• Chronic activation of this adaptive fear response can
result in the persistence of a fear state:
• Hypervigilance
• Increased muscle tone
• Focus on threat-related cues
• Anxiety
• Behavioral Impulsivity
• The neurohormones released during times of stress are
good for short periods – but can become harmful when in
the system for long periods of time.
• Trauma exposed children and adolescents display
changes in levels of stress hormones similar to those
seen in combat veterans.
• Young children who are neglected or maltreated have
abnormal patterns of cortisol production that can last even
after the child has been moved to a safe and loving home.
Normal Stress Response
• All affective
energy mobilized
in the limbic
system (red).
• Higher Cortical
areas less active
(blue).
CORTEX
THALAMUS
Survival Mode vs. Consultation Mode
•The path to thinking is longer than the path to action
•In times of danger/stress, chemicals are released that block the signal from going
to the cortex – adaptive, makes reactions automatic
•With enduring danger/stress/trauma, the brain becomes hard-wired from the
thalamus to the amygdala so the child is vigilant, over-reacts, or freezes
Brain Development in Infancy
• During the first few months after birth, only the brainstem
and midbrain are sufficiently developed to sustain and
alter basic bodily functions and alertness
• The primitive structures regulate the autonomic nervous system, mobilizing
arousal (sympathetic branch) and modulating arousal (parasympathitic
branch)
• Early deprivation of responsive caregiving (neglect,
maltreatment) can lead to lifelong reactivity to stress –
even mild stress later in life can elicit severe reactivity and
dysfunction
www.NCTSNet.org; Gunnar & Donzella, 2002
Brain Development in Early Childhood
• In toddlerhood and early childhood the brain actively
develops areas responsible for
• 1. Filtering sensory input to identify useful information
• 2. Learning to detect and respond defensively to potential threats
• 3. Recognizing information or environmental stimuli that comprise
meaningful contexts
• 4. Coordinating rapid, goal-directed responses
• In early childhood, trauma can be associated with
reduced size of the cortex
• The cortex is responsible for many complex functions, including
memory, attention, perceptual awareness, thinking, language, and
consciousness
Early Childhood
• During this time there is a gradual shift from right (feeling and
sensing) to left (language, abstract reasoning, planning)
hemisphere dominance
• The young child learns to attend to both the external and internal
environment, rather than responding reflexively to stimuli
• Trauma interferes with the integration of left and right
hemisphere brain functioning
• Under stress, traumatized children’s analytic capacities (left brain)
disintegrate, and their emotional reactions (right brain)take over, resulting
in uncontrolled emotions
• Proper categorizing of experiences is inhibited, resulting in fight-or-flight
reactions to non-threatening stimuli
• These changes may affect IQ and can lead to increased fearfulness and a
reduced sense of safety and protection
Trauma and the Brain: School-Age
Children
• In school-age children, trauma undermines the
development of brain regions that would normally help
children:
• Manage fears, anxieties, and aggression
• Sustain attention for learning and problem solving
• Control impulses and manage physical responses to danger,
enabling the child to consider and take protective actions
• As a result, children may exhibit:
• Sleep disturbances
• New difficulties with learning
• Difficulties in controlling startle reactions
• Behavior that shifts between overly fearful and overly aggressive
Trauma and the Brain: Adolescents
• In adolescents, trauma can interfere with development of
the prefrontal cortex, the region responsible for:
• Consideration of the consequences of behavior
• Realistic appraisal of danger and safety
• Ability to govern behavior and meet longer-term goals
• As a result, adolescents who have experienced trauma
are at higher risk for:
• Reckless and risk-taking behaviors
• Underachievement and school failure
• Poor choices
• Aggressive or delinquent activity
The Good News
• The brain is very plastic and therefore capable of
changing in response to experiences, especially repetitive
and patterned experiences.
• Early identification and intervention with abused and
neglected children has the capacity to modify and
influence development
Posttraumatic Stress Reactions
• Children who have experienced trauma often find it
difficult to:
• Trust other people
• Feel safe
• Understand and manage their emotions
• Adjust and respond to life’s changes
• Physically and emotionally adapt to stress
Posttraumatic Stress Reactions:
Young Children
• Become passive and quiet
• Easily alarmed
• Less secure about being provided with protection
• Become generally more fearful, especially in regard to
separations and new situations
Posttraumatic Stress Reactions:
Young Children
• May respond to very general reminders of the trauma, like
the color red or the sounds of another child crying
• Regression – begin wetting the bed, baby-talk
• Because a child's brain does not yet have the ability to
quiet down fears, the preschool child may have very
strong startle reactions, night terrors, and aggressive
outbursts.
Posttraumatic Stress Reactions:
School-age Children
• A wider range of intrusive images and thoughts, including what could
have stopped the event from happening and what could have made it
turn out differently. These thoughts can show up in "traumatic play”
• Respond to very concrete trauma reminders: someone with the same
hairstyle as an abuser; the monkey bars on a playground where a
child got shot.
• May develop intense specific new fears associated with the traumatic
event and "fears of recurrence" that result in the child avoiding doing
things they would usually like to do.
Posttraumatic Stress Reactions:
School-age Children
• May go back and forth between shy or withdrawn
behavior and unusually aggressive behavior.
• Normal sleep patterns may be disturbed, with restless
movements and vocalizations.
• The lack of restful sleep can interfere with daytime
concentration and attention, making studying more difficult
due to remaining on alert for things happening around
them.
Posttraumatic Stress Reactions:
Adolescents
• May interpret their own reactions as regressive or
childlike, or feel they are "going crazy," weak, or different
from everyone else.
• May be embarrassed by bouts of fear and exaggerated
physiological responses.
• May believe that they are unique in their pain and
suffering, resulting in a sense of isolation.
• May be very sensitive to the failure of family, school, or
community to protect or carry out justice.
Posttraumatic Stress Reactions:
Adolescents
• May respond to their experience through dangerous reenactment
behavior, such as reacting with too much "protective" aggression for a
situation.
• Response to reminders may involve reckless, dangerous behavior or
extreme avoidant behavior
• May try to get rid of emotions and physical responses through the use
of alcohol and drugs.
The Influence of Culture
• Children and adolescents from minority backgrounds are
at increased risk for trauma exposure and subsequent
development of PTSD
• Lesbian, gay, bisexual, transgender, or questioning
(LGBTQ) adolescents contend with violence directed at
them in response to suspicion about or declaration of their
sexual orientation and gender identity
• Immigrant and refugee families often face additional
traumas and stressors related to migration and/or traumas
in country of origin
The Influence of Culture
• Child welfare workers should work to understand that
social and cultural realities can influence children’s risk,
experience, and description of trauma;
• Recognize that strong cultural identity can also contribute
to the resilience of children, their families, and their
communities;
• Assess for historical trauma and events that may have
occurred in the family’s country of origin;
• Work with qualified interpreters
The Essential Elements
Essential Element 1: Maximize Physical and
Psychological Safety for Children and Families
• A sense of safety is critical for functioning as well as physical and
emotional growth
• Safety implies both physical and psychological safety
• When asking about emotionally painful and difficult experiences
and symptoms, workers must ensure that children are provided
with a psychologically safe setting
• Children and families should be helped to feel safer during
transitions
Maximize Physical and Psychological Safety for
Children and Families
• Let children and families know what will happen next.
• Give children control over some aspects of their lives.
• Help children maintain connections.
• Give a safety message.
Maximize Physical and Psychological Safety for
Children and Families
• When it is necessary to facilitate the removal of a child, ask the child
what personal items he or she would like to bring from home.
• Provide the child and parents with as much information as possible
about the new placement.
• Obtain information about the child’s schedules and preferences from
the birth parent and share this information with substitute care
providers.
• Be aware of how some practices in residential care settings can be
triggering and/or traumatizing and work to minimize triggers.
Essential Element 2: Identify Trauma-Related
Needs of Children and Families
• One of the first steps in helping trauma-exposed
children and families is to understand how they have
been impacted by trauma.
• Utilize trauma screening practices to identify children
who need trauma-focused therapy. Gather a full picture
of trauma exposure and impact.
• Identify immediate needs and concerns
• Assess the functioning of the caregiving system,
including the impact of parent trauma
Identify Trauma-Related Needs of Children and
Families
• It is important to consider trauma when making service
referrals and service plans.
• Refer children and families for culturally appropriate
therapy and other services as needed
• Ask questions of mental health providers regarding their
experience and training in assessing and treating trauma
Essential Element 3: Enhance Child Well-Being
and Resilience
• Professionals and caregivers can help children overcome trauma
by enhancing their natural strengths and resilience.
• Positive and stable relationships are vital to children’s ability to
overcome traumatic experiences.
• Children may need assistance to help them cope with
overwhelming emotions, begin to make sense out of what
happened to them, and express this to others.
• Trauma-informed treatments and services can effectively reduce
trauma impact and enhance child resilience.
Enhance Child Well-Being and Resilience
• Resilience is the ability to overcome adversity and thrive
in the face of risk.
• Neuroplasticity allows for rewiring of neural connections
through corrective relationships and experiences.
• Children who have experienced trauma can therefore
develop resilience.
• Factors that enhance resilience:
• Family support
• Peer support
• Spiritual beliefs
• School connectedness
• Self esteem/self efficacy
Essential Element 4: Enhance Family WellBeing and Resilience
• Many birth parents in the child welfare system have their
own histories of trauma that can impact their ability to
protect and support their children.
• Resource parents often struggle to understand and
manage children’s trauma-related reactions, leading to
frustration and possible placement disruption.
• Providing trauma-informed services to birth and resource
parents enhances family and child well-being and
resilience.
Enhance Family Well-Being and Resilience
• Facilitate partnership between birth and resource parents.
• Provide trauma education and trauma-informed parenting skills
to resource families.
• Help reframe children’s behaviors as trauma reactions to help
resource parents see that it’s not about them.
• Take the time to listen to resource parents and ask them what they
need.
• Engage resource parents as vital members of the team.
• Link resource parents to support groups, mentors, and other
community services.
• Ensure that resource parents have access to respite care and
encourage them to use it.
Essential Element 5: Enhance the Well-Being
and Resilience of Those Working in the System
• Child welfare is a high-risk profession in which workers
are exposed to trauma indirectly and sometimes directly.
• Child welfare workers are impacted by exposure to child
and family trauma; Secondary Traumatic Stress (STS)
reactions including feelings of helplessness, anger, and
fear are common.
• Workers, supervisors, and agencies can implement
strategies to build resilience and reduce the impact of
STS.
Sources of Secondary Trauma in Child Welfare
• The death of a child or adult on the worker’s caseload
• Investigating a vicious abuse or neglect report
• Frequent/chronic exposure to children’s detailed and emotional
accounts of traumatic events
• Photographic images of horrific injury or scenes of a recent serious
injury or death
• Helping to support grieving family members following a child abuse
death, including the siblings of the deceased child
• Concerns about the continued funding and adequacy of resources for
their agency
• Concerns about being publicly scape-goated for a tragic outcome when
they did not have the means or authority to intervene effectively
Source: Osofsky, J. D., Putnam, F. W., & Lederman, C. (2008). How to maintain emotional health when working with trauma. Juvenile and Family Court Journal,
59(4), 91-102.
(Osofsky et al, 2008)
Enhance the Well-Being and Resilience of
Those Working in the System
• Child welfare workers should work to be aware of how
trauma work impacts them and know their trauma signs
• Child welfare agencies can create a culture that
acknowledges and normalizes the impact of STS
• Agencies should engage in regular and reflective
supervision to address STS
• Develop and utilize self-care plans and advocate for
policies that promote self-care
Essential Element 6: Partner with Youth and
Families
• Youth and families involved with the child welfare system
have a unique perspective to be explored, respected, and
integrated into service delivery.
• Partnership provides a voice for families currently and
formerly involved in services.
• Strategies must be employed to engage youth and
families in partnerships and decision making.
Strategies for Partnering with Youth and Families
• Clear, honest, respectful communication
• Commitment to strengths-based, family-centered, and youth-driven
practice
• Shared decision making and participatory planning
• Praise and recognition for parents (birth, foster, kinship, and adoptive)
as resources
• Seeking feedback from youth and families on a regular basis
• Exit interviews with families
• Assessing your own practice and agency self-assessments
Essential Element 7: Partner with Agencies and
Systems that Interact with Children and Families
• Trauma-exposed children and their families are often involved with
multiple service systems
• Cross-system collaboration enables all helping professionals to see
the child as a whole person, thus preventing potentially competing
priorities and confusion for families.
• Service providers should try to develop common protocols and
frameworks for documenting trauma history, exchanging information,
coordinating assessments, and planning and delivering care.
Strategies for Cross-System Collaboration
• Cross-training on trauma and its impact
• Jointly developed protocols regarding child and family trauma and
collaborative services that promote resiliency
• Multi-disciplinary teams
• Family team meetings
• Co-location of staff in community “hubs”
• Cross-system assessment tools
• All systems engaged in shared outcomes
• Technology used for information exchange
• Integrated information sharing systems
Training in Trauma-Informed Practices
• NCTSN Child Welfare Trauma Training Toolkit
• 12-hour training for child welfare professionals to educate about
trauma, its effect on children, and how child welfare professionals
can help
• NCTSN Caring for Children Who Have Experienced
Trauma: A Workshop for Resource Parents
• 14-hour training for resources parents to educate about trauma, its
effect on children, and specific ways resource parents should
interact with children in their care

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