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 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: X 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. 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. 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 © 2010 American Academy of Sleep Medicine

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 Family-Service 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 This refers to the broader system, not just DCS/child welfare

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 Trauma-Informed 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.

Growth of Human Brain from birth to 20 years WHOLE BRAIN WEIGHT IN GRAMS 0-7 = 93% of brain growth (volume) has occurred.. We are learning more about the possibility of regeneration of the brain…

Child maltreatment reports 1989-2004 Note how neglect is prominent; Note that the early age group is prominent. Ages 0-7 comprise the majority, with the 0-3 the largest group affected. 3 million kids per year on maltreatment reports from 1989-present

Alters the Organized Brain 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. Neural imprinting: when an event occurs over and over, Long term potentiation occurs that causes synapses to strength in their connection to one another. LTP blazes a new trail along a series of neurons making it easier for subsequent messages to fire and travel along the same path. The more it is fired, the more permanent the new path becomes.

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). Red and blue need to be able to talk with each other in order to process whether or not the stressor creates a survival emergency or not. Kids with good affect regulatory development will be able to use their connections that got wired together to work back and forth regarding these decisions. Is it time to run or can I settle back down?

Survival Mode vs. Consultation Mode CORTEX THALAMUS Thalamus is the relay station… do I process this as an emergency and send the signal down to the amygdala for a survival response (fight, flight, freeze?) or can I use my cortex to figure out my next move and to decide how I will manage the stressor? 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 Now that you understand why children react to trauma the way they do, let’s talk about what those reacts may be

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 Does anyone here use trauma screening measures? Which ones?

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 Well-Being 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 Alison 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