1. CHILD AND FAMILY TRAUMA
Frederick H. Strieder, MSSA, PhD
Clinical Associate Professor, University of Maryland School of Social Work
Director, Family Connections Baltimore
Elizabeth Thompson, Phd
Assistant Vice President, director
The Family center at Kennedy Krieger Institute

2. What is Child Traumatic Stress? Impact of Trauma on Child and Family
National Child Traumatic Stress Network
Trauma Informed Organizational Practice
Trauma Interventions
Secondary Traumatic Stress and the Workforce
Questions
AGENDA

3. What Is Child Traumatic Stress?
Artwork courtesy of the International Child Art Foundation (

4. What 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.

5. What 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 others
Sense of personal safety
Effectiveness in navigating life changes

6. CONTEXT OF TRAUMA 700 BCE documented in Homer’s Iliad
Natural Disasters
Illnesses and Injury
Wars, Genocide, Terrorism
Industrial and Nuclear Disasters
Family and Intimate Partner Violence
Immigration
Workplace and School threats and violence
Community/Neighborhood Violence
Institutional Victimization/Violation
Child Maltreatment
Physical, Sexual, Emotional Abuse and Neglect
700 BCE documented in Homer’s Iliad
1800’s Freud “hysterical neurosis”
WWI “shell shock”-weakness
WWII “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 Adults
1987-DSM III-R Recognition of differing PTSD symptoms in children
1994,2000- DSM IV TR Full Recognition of Children
This is brief as next slides go in depth—shows various types of traumatic events as well as the development of post traumatic stress

7. Types 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.

8. Prevalence 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 neglect
16.6% were physically abused
9.3% were sexually abused
7.1% endured emotional or psychological abuse
14.3% 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.

9. U.S. Prevalence, cont'd
One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1
In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2
Four out of 10 U.S. children report witnessing violence; 8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3
1. 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.

10. Impact of Trauma on Child and Family
Artwork courtesy of the International Child Art Foundation (

11. Variability in Responses to Stressors and Traumatic Events
The impact of a potentially traumatic event is determined by both:
The objective nature of the event
The child’s subjective response to it
Something that is traumatic for one child may not be traumatic for another.

12. Variability, cont’d
The impact of a potentially traumatic event depends on several factors, including:
The child’s age and developmental stage
The child’s perception of the danger faced
Whether the child was the victim or a witness
The child’s relationship to the victim or perpetrator
The child’s past experience with trauma
The adversities the child faces following the trauma
The presence/availability of adults who can offer help and protection

13. Effects 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

14. Effects 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. 14 14

15. Effects 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. 15 15

16. Long Term Effects
In 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:
Alcoholism
Drug abuse
Depression
Suicide attempts
Sexually transmitted diseases (due to high risk activity with multiple partners)
Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease
Source: Felitti et al. (1998). Am J Prev Med;14(4): 16 16

17. Childhood 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 others
Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior
Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA. 17

18. Childhood Trauma and PTSD
Key symptoms of PTSD
Re-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 trauma
Avoidance of thoughts, feelings, places, and people associated with the trauma
Emotional 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.

19. Childhood Trauma and Other Diagnoses
Other common diagnoses for children in the child welfare system include:
Reactive Attachment Disorder
Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Bipolar Disorder
Conduct Disorder
These 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

20. Trauma and the Brain
Trauma 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

21. Influence of Culture
People 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

22. FITT Model Urban Poverty Family Processes Child and Family Outcomes
Trauma and Family Informed Principles*
Child Response
Adult/
Parental
Response
Adult Family of Origin Response
Sibling Relations
Adult Intimate Relations
Parenting Practices & Quality
Parent-Child Relations
Urban
Poverty
Child
and
Family
Outcomes
Family
Processes
Hypothesized Pathways for the Impact of Chronic Trauma on Family Processes
As 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 effects
Individual development
Family life cycle
Adapted from Kiser & Black, 2005 22

23. National Child Traumatic Stress Network
Artwork courtesy of the International Child Art Foundation (

24. National 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.

25. National 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 9/11/01
Innovative 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

27. Trauma Informed Organizational Practice
Artwork courtesy of the International Child Art Foundation (

28. Traditional Care Trauma-Informed Care Trauma Specific Intervention
The Paradigm Shift
Traditional Care Trauma-Informed Care Trauma Specific Intervention
Traditional services may trigger trauma survivors

29. Trauma-Informed Care
Universal understanding that nearly every individual seeking services in human service systems has a trauma history
Provision of care should be trauma competent
Based 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 problems
Trauma affects the way people approach potentially meaningful relationships
Trauma often reoccurs in the service context itself

30. Pre-requisites for Trauma Informed Service Delivery
Administrative commitment
Universal screening for trauma
Assessment as needed
On-going staff training and education
Expert trauma consultation available to staff
Hiring practices
Review of organizational policies and procedures
Avoidance of re-traumatization practices
Harris & 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 services
Trauma-informed mission and policies and procedures that reflect that mission
Resource Commitment so that what’s needed for system modification and performance improvement is available
Values that focus on empowerment and not power/control are minimized

31. The Sanctuary® Model
Trauma exposure in individuals who seek services as well as the individuals who provide those services
Organizational stressors (e.g. fiscal pressures, regulatory compliance, workloads, etc.)
Active creation of trauma informed community
7 Commitments
Nonviolence
Emotional Intelligence
Social Learning
Democracy
Open Communication
Social Responsibility
Growth and Change
Cost 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

32. Trauma Interventions
One of the hand-outs ed to you provides a good definition of trauma specific interventions
Artwork courtesy of the International Child Art Foundation (

33. A 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…..

34. The Ideal Clinical Science Process
Use in
Practice
Setting
Disseminate
Intervention
to the Field
Conduct
Efficacy
Studies
Conduct
Effectiveness
Studies
Develop
Intervention
Approach
The 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 replicated
Efficacy 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 setting
Disseminate 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 made
The 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.

35. Quality of Trauma Treatment
Practice Based Evidence
Emerging Practice
Good Practice
Promising Practice
Best Practice
Evidence Informed Practice
Evidence Supported Practice
Evidence Based Practice
Concerning and/or blatant dangerous practices are not on the continuum, but they are out there—Avoid them?

36. Potential Family Interventions
TF-CBT
AF-CBT
CFTSI
SFCR
Child Response
Child Response FL
SFCR
SOCIAL & SYSTEMS DEMANDS
SOCIAL AND PUBLIC INCIVILITIES
DAILY HASSLES
FINANCIAL INSTABILITY
RESIDENTIAL
INSTABILITY
Trauma
Sibling Relations
Sibling Relations
AF-CBT
SFCR
Family
Functioning
Family
Processes
TA-FC
Cognitive Processing Therapy
TG-CBT FL
SFCR
Parent-Child Relations
Parent-Child Relations
TF-CBT
TG-CBT
PCIT
AF-CBT
CPP FL
SFCR
Adult/
Parental
Response
Adult/
Parental
Response
Parenting Practices & Quality
Parenting Practices & Quality
Adult
Family of Origin
Response
AF-CBT FL
SFCR
TF Parent Coaching
Went 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 units
Adult Intimate Relations
Adult Intimate Relations
LIVE
Grandparent/caregiver Support Groups
SAFE
Emotionally Focused Therapy FL

37. What 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 practice
Actual treatment elements become unit of analysis rather than the treatment manual
Treatment elements are selected to match particular client characteristics
School of Social Work, University of Maryland

38. Secondary Traumatic Stress and the Workplace
Artwork courtesy of the International Child Art Foundation (

40. Potential for Personal Impact

42. Current Research
Younger therapists experiences more burnout while more experienced therapists reported more compassion satisfaction.
Implementing EBP’s generally reduced reported compassion fatigue and burnout.

43. Compassion 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 support
Faster onset of symptoms than burnout or countertransference
Faster recovery from symptoms
Highly treatable
Vicarious Trauma
The 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 time
Responses unique to the person
Not specific to a particular client
Secondary 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 risk
Who can be affected?

44. Traumatic Countertransference
Burnout
A state of physical, emotional, and mental exhaustion caused by long term intervention in an emotionally-demanding situation
Process, not an event
Positively associated with stressors (more stressors more burnout) and negatively with social support (more social support less burnout)
Directly Traumatized
Clinicians can also be directly experience trauma in their work with families
This can occur in many ways and the impact is dependent upon the individual
Depending on clinician’s need, additional support may be needed
Traumatic Countertransference
Emotional, 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, emotions
Professionals working with trauma often experience reactions to clients’ stories
Reaction influence by practitioner’s own family history and experience

45. Thank you!
Questions???