Presentation on theme: "CHILD AND FAMILY TRAUMA"— Presentation transcript:
1CHILD AND FAMILY TRAUMA Frederick H. Strieder, MSSA, PhDClinical Associate Professor, University of Maryland School of Social WorkDirector, Family Connections BaltimoreElizabeth Thompson, PhdAssistant Vice President, directorThe Family center at Kennedy Krieger Institute
2What is Child Traumatic Stress? Impact of Trauma on Child and Family National Child Traumatic Stress NetworkTrauma Informed Organizational PracticeTrauma InterventionsSecondary Traumatic Stress and the WorkforceQuestionsAGENDA
3What Is Child Traumatic Stress? Artwork courtesy of the International Child Art Foundation (www.icaf.org)
4What 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.
5What 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 othersSense of personal safetyEffectiveness in navigating life changes
6CONTEXT OF TRAUMA 700 BCE documented in Homer’s Iliad Natural DisastersIllnesses and InjuryWars, Genocide, TerrorismIndustrial and Nuclear DisastersFamily and Intimate Partner ViolenceImmigrationWorkplace and School threats and violenceCommunity/Neighborhood ViolenceInstitutional Victimization/ViolationChild MaltreatmentPhysical, Sexual, Emotional Abuse and Neglect700 BCE documented in Homer’s Iliad1800’s Freud “hysterical neurosis”WWI “shell shock”-weaknessWWII “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 Adults1987-DSM III-R Recognition of differing PTSD symptoms in children1994,2000- DSM IV TR Full Recognition of ChildrenThis is brief as next slides go in depth—shows various types of traumatic events as well as the development of post traumatic stress
7Types of Traumatic Stress Acute trauma is a single traumatic event that is limited in time.Chronic trauma refers 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 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.
8Prevalence 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 neglect16.6% were physically abused9.3% were sexually abused7.1% endured emotional or psychological abuse14.3% 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.
9U.S. Prevalence, cont'dOne in four children/adolescents experience at least one potentially traumatic event before the age of 16.1In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2Four out of 10 U.S. children report witnessing violence; 8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.31. Costello et al. (2002). J Trauma Stress;5(2):2. Schwab-Stone et al. (1995). J Am Acad Child Adolescent Psychiatry;34(10):3. Kilpatrick et al. (2003). US Dept. Of Justice.
10Impact of Trauma on Child and Family Artwork courtesy of the International Child Art Foundation (www.icaf.org)
11Variability in Responses to Stressors and Traumatic Events The impact of a potentially traumatic event is determined by both:The objective nature of the eventThe child’s subjective response to itSomething that is traumatic for one child may not be traumatic for another.
12Variability, cont’dThe impact of a potentially traumatic event depends on several factors, including:The child’s age and developmental stageThe child’s perception of the danger facedWhether the child was the victim or a witnessThe child’s relationship to the victim or perpetratorThe child’s past experience with traumaThe adversities the child faces following the traumaThe presence/availability of adults who can offer help and protection
13Effects 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
14Effects 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.1414
15Effects 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.1515
16Long Term EffectsIn 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:AlcoholismDrug abuseDepressionSuicide attemptsSexually transmitted diseases (due to high risk activity with multiple partners)Heart disease, cancer, chronic lung disease, skeletal fractures, and liver diseaseSource: Felitti et al. (1998). Am J Prev Med;14(4):1616
17Childhood 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 othersResponded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behaviorSource: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.17
18Childhood Trauma and PTSD Key symptoms of PTSDRe-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 traumaAvoidance of thoughts, feelings, places, and people associated with the traumaEmotional 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.
19Childhood Trauma and Other Diagnoses Other common diagnoses for children in the child welfare system include:Reactive Attachment DisorderAttention Deficit Hyperactivity DisorderOppositional Defiant DisorderBipolar DisorderConduct DisorderThese 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
20Trauma and the BrainTrauma 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;821:20
21Influence of CulturePeople 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
22FITT Model Urban Poverty Family Processes Child and Family Outcomes Trauma and Family Informed Principles*Child ResponseAdult/ParentalResponseAdult Family of Origin ResponseSibling RelationsAdult Intimate RelationsParenting Practices & QualityParent-Child RelationsUrbanPovertyChildandFamilyOutcomesFamilyProcessesHypothesized Pathways for the Impact of Chronic Trauma on Family ProcessesAs in any systems model, an event that impacts any member of the family influences every other family member as well as all other family relationships and also the family as a whole (Angell, Dennis, & Dumain, 1998; Dickstein et al., 1998; Figley, 1988; Kitzmann, 2000; Medalie, 1997) (refer to Figure 1). Accordingly, sorting out the effects of chronic trauma on family processes requires extrapolation from research on relationships among individual family members, dyadic or subsystem processes, and the family unit. Exposure to traumatic events creates emotional distress which can promote both physical and mental illnesses (Scheier, Botvin, & Miller, 1999). However, exposure does not necessarily lead to problems. Individual responses to trauma span positive growth experiences to chronic debilitating disorder. The solid lines in Figure 1 represent the hypothesis that exposure to chronic trauma directly effects individual family members.Individual family members form dyadic subsystems such as adult intimate partnerships, parent-child, and sibling relationships. The dotted lines in Figure 1 represent the multiple hypothesized pathways among chronic trauma and dyadic family subsystems. They also correspond to hypothesized indirect or mediated relationships at two different levels, for example, the effect of adult trauma reactions on intimate partnerships and the effect of parent-child interactions on siblings’ reactions.Strong empirical evidence demonstrates the impact of chronic trauma on individual family members and in turn, on multiple family subsystems. Thus, it seems inevitable that family processes would be altered. In Figure 1, In the model (as illustrated in Figure 2), the solid lines represent the effects of exposure to chronic trauma directly on individual family members. Individual family members form dyadic subsystems such as adult intimate partnerships, parent-child, and sibling relationships. The dotted lines represent the multiple pathways among chronic trauma and dyadic family subsystems. The dashed lines represent the pathways through which chronic trauma influences family processes and the bold, dashed line a direct causal relationship.Time* Acute and longer-term effectsIndividual developmentFamily life cycleAdapted from Kiser & Black, 200522
23National Child Traumatic Stress Network Artwork courtesy of the International Child Art Foundation (www.icaf.org)
24National 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.
25National 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 9/11/01Innovative 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
27Trauma Informed Organizational Practice Artwork courtesy of the International Child Art Foundation (www.icaf.org)
28Traditional Care Trauma-Informed Care Trauma Specific Intervention The Paradigm ShiftTraditional Care Trauma-Informed Care Trauma Specific InterventionTraditional services may trigger trauma survivors
29Trauma-Informed CareUniversal understanding that nearly every individual seeking services in human service systems has a trauma historyProvision of care should be trauma competentBased 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)Staff providing services also have trauma histories.Effects of trauma increase the risk of a range of emotional, behavioral and physical health problemsTrauma affects the way people approach potentially meaningful relationshipsTrauma often reoccurs in the service context itself
30Pre-requisites for Trauma Informed Service Delivery Administrative commitmentUniversal screening for traumaAssessment as neededOn-going staff training and educationExpert trauma consultation available to staffHiring practicesReview of organizational policies and proceduresAvoidance of re-traumatization practicesHarris & Fallot (2001)Need to assess every part of the organization and modify if needed to include a basic understanding of how trauma affects the life of an individual seeking servicesTrauma-informed mission and policies and procedures that reflect that missionResource Commitment so that what’s needed for system modification and performance improvement is availableValues that focus on empowerment and not power/control are minimized
31The Sanctuary® ModelTrauma exposure in individuals who seek services as well as the individuals who provide those servicesOrganizational stressors (e.g. fiscal pressures, regulatory compliance, workloads, etc.)Active creation of trauma informed community7 CommitmentsNonviolenceEmotional IntelligenceSocial LearningDemocracyOpen CommunicationSocial ResponsibilityGrowth and ChangeCost of these adversities is turnover, loss of productivity, poor communication, poor outcomes for children and families, limited capacity to deliver high quality services, and low employee morale. Transformational organizational change model created by Sandra Bloom that promotes safety and recovery from adversity through active creation of a trauma informed community. In addition to 7 commitments (changes how we relate to each other), the model uses a trauma-informed problem solving framework (changes how we use language) and a set of tools—Sanctuary Tool Kit (changes the way we practice). Improved outcomes for clients, improved staff retention and satisfaction, decreased violence (including non-verbal violence). Changing the organization changes client outcomes
32Trauma InterventionsOne of the hand-outs ed to you provides a good definition of trauma specific interventionsArtwork courtesy of the International Child Art Foundation (www.icaf.org)
33A Good Question...How can we sort out the good from the poor or even harmful interventions??So how do we sort out the good from the bad…..
34The Ideal Clinical Science Process Use inPracticeSettingDisseminateInterventionto the FieldConductEfficacyStudiesConductEffectivenessStudiesDevelopInterventionApproachThe stance we take in this presentation is that effective treatments (treatments that we know work) are ones that lend themselves to the clinical science process. This represents the ideal A lot of treatments out there skip steps two and three entirely. The ones that do have evidence should be used first with clients that are appropriate for them.Develop the intervention – intervention should have a manual so that it can be replicatedEfficacy studies involved testing the intervention in a very controlled research environment (with randonmization and comparison groups). Efficacious means positive results in a controlled setting.Effectiveness studies involve testing the intervention in real world setting (like the ones that each of you works in). Effective means positive results in a real world settingDisseminate the intervention into the field after both efficacy and effectiveness have been established. When the intervention is disseminated, important to measure outcomes and monitor adaptations or adjustments that need to be madeThe more common clinical practice is to go from a) use in clinical setting to dissemination in the field without any real evidence that it works or b) conducting efficacy studies to dissemination, without doing effectiveness studies in the real world.
35Quality of Trauma Treatment Practice Based EvidenceEmerging PracticeGood PracticePromising PracticeBest PracticeEvidence Informed PracticeEvidence Supported PracticeEvidence Based PracticeConcerning and/or blatant dangerous practices are not on the continuum, but they are out there—Avoid them?
36Potential Family Interventions TF-CBTAF-CBTCFTSISFCRChild ResponseChild ResponseFLSFCRSOCIAL & SYSTEMS DEMANDSSOCIAL AND PUBLIC INCIVILITIESDAILY HASSLESFINANCIAL INSTABILITYRESIDENTIALINSTABILITYTraumaSibling RelationsSibling RelationsAF-CBTSFCRFamilyFunctioningFamilyProcessesTA-FCCognitive Processing TherapyTG-CBTFLSFCRParent-Child RelationsParent-Child RelationsTF-CBTTG-CBTPCITAF-CBTCPPFLSFCRAdult/ParentalResponseAdult/ParentalResponseParenting Practices & QualityParenting Practices & QualityAdultFamily of OriginResponseAF-CBTFLSFCRTF Parent CoachingWent back and forth about whether or not to use this slide, but it gives some idea of the evidence supported practices that are appropriate for each of the family unitsAdult Intimate RelationsAdult Intimate RelationsLIVEGrandparent/caregiver Support GroupsSAFEEmotionally Focused TherapyFL
37What 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, )An alternate to using treatment manuals to guide practiceActual treatment elements become unit of analysis rather than the treatment manualTreatment elements are selected to match particular client characteristicsSchool of Social Work, University of Maryland
38Secondary Traumatic Stress and the Workplace Artwork courtesy of the International Child Art Foundation (www.icaf.org)
42Current ResearchYounger therapists experiences more burnout while more experienced therapists reported more compassion satisfaction.Implementing EBP’s generally reduced reported compassion fatigue and burnout.
43Compassion Fatigue“a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patient” (Figley, 2002)Often experienced as helplessness, confusion, sense of isolation from supportFaster onset of symptoms than burnout or countertransferenceFaster recovery from symptomsHighly treatableVicarious TraumaThe process through which the clinician’s inner experience is negatively transformed through empathic engagement with the client’s trauma. (McCann & Pearlman, 1990)The cumulative transformative effect upon the professional who works with victims of trauma. (Pearlman & Saakvitne, 1995)Takes place over timeResponses unique to the personNot specific to a particular clientSecondary Stress“the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1999, p.10)Those with enormous capacity for empathy for others tend to be more at riskWho can be affected?
44Traumatic Countertransference BurnoutA state of physical, emotional, and mental exhaustion caused by long term intervention in an emotionally-demanding situationProcess, not an eventPositively associated with stressors (more stressors more burnout) and negatively with social support (more social support less burnout)Directly TraumatizedClinicians can also be directly experience trauma in their work with familiesThis can occur in many ways and the impact is dependent upon the individualDepending on clinician’s need, additional support may be neededTraumatic CountertransferenceEmotional, physical or interpersonal reactions toward the client and can be a negative hindrance & inevitable occurrence; but often a positive opportunity for growth, building therapist’s intuition, self-awareness and perceptions (Burke, Carruth & Pritchard, 2006, pg ).Spontaneous response of professional regarding client’s information, behavior, emotionsProfessionals working with trauma often experience reactions to clients’ storiesReaction influence by practitioner’s own family history and experience