1. A Trauma-Informed Children’s Intervention Norma Finkelstein, PhD Executive Director, Institute for Health and Recovery Lisa Russell, Ph.D. Senior Scientist, ETR Associates Sixth Annual Conference on Co-Occurring Disorders: One Person, One Team, One Plan for Recovery February 8, 2008 Long Beach, CA

2. Possible Impact of Family Substance Abuse/Mental Illness and Violence on Children Sleep disturbances – nightmares, trouble waking up, trouble falling asleep Aggressive behavior and angry feelings A very high activity level Constant worry about possible danger Forgetting how to do things they have mastered Child Witness to Violence Project, Boston Medical Center, Boston, MA

3. Children Need: Safety Developmentally appropriate information about addiction and recovery To express their feelings about their experiences in a safe place Emotional skill-building Time to re-establish trust in the parent-child relationship

4. Protective Factors to Increase Resiliency in Children Caring Relationships Safety, basic trust, listening High Expectation Messages Guidance, structure, challenge Opportunities for Meaningful Contributions Making decisions, giving voice, being heard

5. WCDVS Children’s Subset Study Primary Goals Generate empirical knowledge about the effectiveness of trauma-informed, age-specific intervention models Identify models of care that will prevent or reduce intergenerational perpetuation of violence For children of mothers with co-occurring mental health and substance use disorders & histories of violence:

6. Target Population Children (aged five to ten years) of women enrolled in the Women, Co-Occurring Disorders and Violence Study Woman must be caregiver to child (not necessarily primary) Must have at least weekly contact with child (can be in person or via telephone) Siblings can participate in a group, but only one child can be in study (most accessible or by birth date closest to program entry date)

7. SAMHSA Women Co-occurring Disorders & Violence: Children’s Sub-Study Four sites: Cross site study with common protocol Each site has: 30 Intervention 30 Comparison Dates: October 2000 – September 2003

8. WCDVS Children’s Study Sites Allies Project Prototypes New Directions for Families W.E.L.L. Project

9. Intervention Development Interventions developed through national steering committee process Active participation on steering committee of Consumer/Survivor/Recovering (CSR) women

10. Critical involvement of CSR in design and evaluation CSR letter to participants –Concerns regarding: child abuse reporting, trust Use of CSR advocates, group leaders, resource coordinators Intervention Development

11. The Children’s Study Was Guided by the Following Core Values Children Are Entitled To: 1.Having their voices heard 2.Being physically safe 3.Experiencing consistency 4.Having a sense of dignity & self-worth 5.Having control over their bodies 6.Receiving respect, understanding, compassion, & support 7.Having nurturing relationships with adults in their lives 8.Having confidentiality respected, except when issues of safety arise 9.Connecting to community & natural supports

12. Core Interventions Screening / Assessment Service Coordination / Advocacy Skill building / Resiliency promoting group –Includes safety planning

13. Clinical Assessment Strengths and interests Significant life events Parent and child substance abuse Medical concerns Mental health needs Educational and developmental issues Parenting and discipline

14. Resource Coordination and Advocacy Parent and child self-determination and empowerment Strengths-focused rather than pathology- focused Resource coordinators as “resiliency mentors” Focused on resiliency-building activities Teaching parents advocacy skills

15. Primary Goals of the Group Intervention Learn self-protection skills Develop skill in self-soothing Enhance interpersonal relationships Strengthen self-esteem and self identity

16. Groups divided into four separate age groups: 5-7 and 8-10 Individual assessment with mother and child separately prior to child joining group Groups required co-leadership

17. Children’s Group Intervention Week 1: Getting to know each other / message: it’s ok to feel and express feelings* Week 2: What is abuse? Week 3: Anger Week 4: It’s not always happy at my house Week 5: Sharing personal experience with violence *Adopted from Groupwork with Children of Battered Women, Peled & Davis, Sage Publications, 1995. Orientation – with mothers and children

18. Children’s Group Intervention Week 6: Touch Week 7: Assertiveness Week 8: Protective Planning Week 9: Review and good-bye Booster Session (1): 30 days post – review week 2 (abuse) Booster Session (2): 60 days post – review week 8 (safety planning)

19. Children’s Group Intervention Message of the week –Example: “Abuse and violence are not okay” Check-in Feeling of the day –Example: “Sad” Activities and process Personal affirmation Pass the squeeze Snack Reward / reinforcement

21. Characteristics of Children Average age – 7.28 years In legal custody of mother – 74.3% Involved in child welfare system – 39% Experiencing emotional or behavioral problems – 67.5 % Parent convicted of a crime – 79.8% Parent treated for substance abuse – 98% National Trauma Consortium.

22. Evidence of Impact Primary research question of the Children’s Study: Are trauma-informed, age-specific interventions for children more effective than usual care conditions in leading to increases in safety, self-care, positive interpersonal relationships and self-identity?

23. Study Sample N=253 at Baseline N=209 at 6 months (82.6%) N=217 at 12 months (85.8% retention) N=195 (77.1%) received Baseline, 6 month and 12 month interviews Intervention and comparison groups are statistically equivalent on demographic characteristics across follow-ups

24. Age (N = 253)

25. Prevalence of Victimization

26. Short Term Effects (6 months past baseline) Mother’s positive change (improvement) in symptomatology strongest predictor of child’s positive change in emotional and behavioral strengths & competencies Children whose mothers had positive outcomes did well regardless of treatment assignment Children in intervention group showed general improvement regardless of mother’s 6-month outcomes

27. Short Term Effects (6 months past baseline) At 6 months, while involvement in standardized intervention did not predict children’s overall improved short-term outcomes, it did lead to significant improvement in specific domains of positive interpersonal relationships, positive self- identity, and increases in safety knowledge

28. Longer-Term Effects (12 Months past baseline) Mother’s outcomes no longer played significant role in predicting children’s positive outcomes Involvement in intervention was significant predictor of children’s positive change in emotional & behavioral strengths, regardless of mother’s outcomes

29. Longer-Term Effects (12 Months past baseline) Younger children showed more improvement regardless of condition Children in intervention group performed consistently better across all age groups

30. Substance abuse/mental health programs have a unique opportunity to intervene to address inter-generational impact of violence/trauma Any setting where parents receive substance abuse and/or mental health services should be capable of providing, at the very least, screening and referral services for children Implications

31. For these children, early intervention services can reduce the possibility of more serious childhood and adult disorders Children’s study showed treating parents had clear benefits for children, but may not be enough in itself Specific services to children provide additional benefits Implications

32. Lessons Learned Children can be the motivator for women to seek treatment Treatment of the woman offers an opportunity to provide services to the children Traumatic childhood experiences influence the ability to parent Victimization of children triggers memories in the parent Motherhood is both a major source of identity and self-worth, and a source of shame and guilt

33. Lessons Learned Extreme guilt and shame must be addressed in order to build healthy parenting relationships The support of a parent who has experienced similar challenges is critical to overcoming fear and guilt Must have well developed working relationships with child welfare agencies System related issues of confidentiality and privacy must be addressed in order to promote healthy boundaries

34. WELL Child “I learned how to have fun with my children. I learned how to, you know – children love to play outside, alright? I didn’t like to go outside. I learned to play kickball, ride bikes, take a walk. [The WELL Child Clinician] would walk with us. In the beginning I wouldn’t have done that it if [the WELL Child Clinician] wasn’t doing it.” “Through the WELL Project, I was able to get connected with [the WELL Child Clinician] who in turn was able to help me with [my child]…The purpose of your program is to help women that use and maybe have had children under a certain age and [my child] fell in that category so it made me be more aware of the damage that I may have caused [my child]. Like I said, by me getting hooked up with [the WELL Child Clinician], she was able to do some things with me that I guess otherwise I would have just not worried about. Or some gifts in [my child] that I would have ordinarily not seen, you know, had I not been connected with this program and somebody showing interest to my child.”

35. WELL Child “You know, [the WELL Child Clinician] was a god-send. She really was. She spent a lot of time, talking with me, and I would watch her interact with my children, and play basketball and play soccer and she let me come into it slowly, you know? They never made me say anything or do anything I didn’t want to do. I got a lot of support from [the WELL Integrated Care Facilitator (ICF)]. She used to meet with me, I think it was every week, and we would talk and see where the kids were at. I went through a lot of things in that house [substance abuse residential]. As of today, my children and I have such a bond. It’s like when I said I didn’t want to parent, it took me, with the help of other people but today that’s untouchable. They’ve learned to trust again, you know? And that, again, meeting with [the WELL Child Clinician], and knowing [the WELL Child Clinician] going to show up at the same time every week or whatever she did, it built consistency in their life. And they learned to trust. I think [my child] trusted [WELL Child Clinician] before [my child] really trusted me.”

36. How was the children’s intervention different from what women in treatment historically experienced?

37. Within substance abuse treatment, focus on children was historically related to accessing: Child care Residential treatment for mothers Some referral for existing outside services

38. As more programs began including children of all ages, became clear how many services were needed andPrograms have embraced treatment for women and children but most have not designed clinical and milieu interventions for the children

39. Underlying assumption has been that a mother’s recovery will positively impact her children (and will be enough) Needs of children have not been addressed independently of the parent-child relationship (e.g., parenting classes)

40. A Woman’s Reflection on Her Residential Treatment with Children “Children weren’t making it there because there’s nothing for those [older] children to do. They were so isolated, and they couldn’t do anything. I mean it was like the children were being punished also for what their parents were doing. It was bad enough that they were having to live the lifestyle they were living with their parents, but now their parents are in recovery it was like they were still being punished.”

41. A Woman’s Reflection on Her Residential Treatment with Children “You come in and a counselor assesses you and your needs and your problems, but there’s nobody to assess the children and their needs and their problems. These kids have a lot of needs and a lot of problems because they’ve lived in this lifestyle for a long time. They don’t do that. They don’t have anybody assess the children and see what’s going on with them until they see them trying to jump off the balconies and biting kids…”

42. A Woman’s Reflection on Her Residential Treatment with Children “One thing I think they need to do is hire more staff…have someone there who is a behavioral psychologist or something similar, just for children.”

43. The Children’s Intervention and Systems Change What did we learn about the process of integrating the children’s intervention in adult substance abuse treatment settings?

44. Incorporating Children’s Services: Key Elements of a Paradigm Shift Family- centered Trauma- informed Prevention & Early Intervention

45. Incorporating Children’s Services: Cross-Cutting Dimensions Philosophy and goals Primary clients Staff skills and roles Interventions Administrative and systems issues

46. Family-Centered: Philosophy and Goals Relationships are central to recovery Parent and child well-being are intertwined, whether they live together or apart Treatment is to promote well-being of entire family

47. Family-Centered: Primary Client Family as client rather than single individual as client Each family member is a primary client, e.g., children are not solely collateral clients

48. Family-Centered: Staff Skills and Roles Skilled in working with children and mothers as family Acts as coach and mentor vs. distanced professional Not aligned primarily with either mother or child Recognizes legitimacy of child welfare concerns Has vehicle to address own attitudes and biases about recovery, parenting and related cultural issues Acts as a positive role model

49. Family-Centered: Interventions Are strengths-based and focus on resiliency building Are aimed at relationship strengthening Value families having meaningful voice and choice Are inclusive, flexible, responsive, and culturally relevant Are individualized based on screening and assessment for physical/behavioral health/violence exposure in family Include parenting, family counseling, partner/marital counseling, children’s mental health services and substance abuse treatment Reflect multi-system collaboration with child services agencies – schools, health clinics/pediatricians, recreational programs, juvenile justice, child welfare, behavioral health, etc.

50. Family-Centered: Administrative and Systems Issues Commitment to family-centered services approach Policies, procedures, staffing, funding, and physical space that support: –positive parent-child, inter-staff, & staff-family interactions, –developmentally appropriate and safe activities for children, –recruitment and retention of qualified staff –ongoing staff development and promotion –consistent, high quality clinical supervision Clear policies and training on child abuse reporting, confidentiality of records Funding streams that support direct child and family services and cross-system collaboration

51. Prevention: Philosophy and Goals Strengths based Treatment for parent is a preventive intervention for the family Value family preservation Strengthen family functioning, nurturing parenting practices Build resiliency and protective factors to prevent future substance abuse, mental illness, and violence

52. Prevention: Primary Client Child: increase protective factors, decrease risk factors Parent: treatment, parenting skills

53. Prevention: Staff Skills and Roles Emphasize resiliency building for child Skills in strengths based approach, including assessing protective and risk factors Provide consistent, caring, positive role model to child client Knowledge of child development and resiliency building Experience accessing and linking community-based children’s services Skills in modeling and supporting positive parenting

54. Prevention: Interventions Assessment of risk and protective factors for child Focus on developing child resilience: coping skills, self-care, safety skills, constructive ways to express feelings, healthy relationships, help-seeking Advocate for child with community-based resources of interest (e.g., sports, music, art, drama) Guide and support parent’s ability to support child’s school work and to advocate for child at school Work with parents to reduce child’s exposure to risk factors

55. Prevention: Administrative and Systems Issues Staff training on strengths based approaches, child resiliency, and child development Address organizational and staff barriers to prevention work with families Address tensions that may develop between parent/adult staff and children’s staff, if these are separate Develop funding mechanisms to cover early identification and intervention (e.g., SCHIP or Medicaid/EPSDT)

56. Trauma-Informed: Philosophy and Goals Trauma is often central to recovery from substance abuse and mental disorders Parental/child trauma exposure puts children at risk for emotional, behavioral & interpersonal problems Coping skills learned to survive violence may be maladaptive in other contexts Many aspects of program environments and procedures can feel unsafe for survivors of violence & trigger distress

57. Trauma-Informed: Primary Client Child as survivor and/or witness to violence or child of a survivor Parent as survivor and/or witness

58. Trauma-Informed: Staff Skills and Roles Knowledge about how trauma impacts child development and family relationships and dynamics Skills in recognizing and addressing trauma in children of different ages and intergenerational trauma in families Have addressed own trauma recovery, if applicable Are supportive and non-confrontational with parents Able to recognize and change program procedures that may be retraumatizing

59. Trauma-Specific: Interventions Assessment of child and parent exposure to violence and trauma-related symptoms Prevention/early intervention with child, aimed at defining violence, understanding the impact of trauma, non-violent ways of dealing with needs and conflicts, development of safety plans and healthy coping mechanisms Mental health services are selected and coordinated to reflect assessed strengths and needs of child and family Use of evidence-based cognitive behavioral approach

60. Trauma-Informed: Administrative and Systems Issues Commitment to evidence-based trauma interventions and ongoing clinical support for them Training in confidentiality and CPS reporting issues Trauma-informed policies, procedures, and physical setting Expanded funding mechanisms for trauma specific services

61. Summary Cannot simply add services for children into existing adult programs –Requires changes in both ideology and practice Paradigm shift needed: Towards trauma- informed, trauma-specific family treatment which includes resilience building and strengths based prevention and treatment services for children

62. “Do no harm” A Woman’s Reflection on Her Residential Treatment with Children “The treatment center I entered is for women and children, but I saw a lot of things while I was there that made me wonder, you know, whether they were really trying to help the children or what they were doing was in the best interest of the children.”

63. Contact Information Norma Finkelstein, PhD Executive Director Institute for Health and Recovery 349 Broadway, Cambridge, MA 02139 (617) 661-3991, normafinkelstein@healthrecovery.org Lisa Russell, Ph.D. Senior Scientist ETR Associates 4 Carbonero Way Scotts Valley, CA 95066 (831) 438-4060, lisar@etr.org