Transcript Trauma Presentation - Maryland Department of Human Resources

CHILD AND FAMILY TRAUMA
FREDERICK H. STRIEDER, MSSA, PHD
C L I N I C A L A S S O C I AT E P R O F E S S O R , U N I V E R S I T Y O F
MARYLAND SCHOOL OF SOCIAL WORK
D I R E C T O R , FA M I LY C O N N E C T I O N S B A LT I M O R E
ELIZABETH THOMPSON, PHD
A S S I S TA N T V I C E P R E S I D E N T, D I R E C T O R
T H E FA M I LY C E N T E R AT K E N N E D Y K R I E G E R I N S T I T U T E
 What is Child Traumatic Stress?
AGENDA
 Impact of Trauma on Child and
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Family
National Child Traumatic Stress
Network
Trauma Informed Organizational
Practice
Trauma Interventions
Secondary Traumatic Stress and the
Workforce
Questions
What Is Child Traumatic
Stress?
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
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-ofcontrol physiological arousal.
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:
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Ability to trust others
Sense of personal safety
Effectiveness in navigating life changes
CONTEXT OF TRAUMA
 Natural Disasters
 Illnesses and Injury
 Wars, Genocide, Terrorism
 Industrial and Nuclear Disasters
 Family and Intimate Partner
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Violence
Immigration
Workplace and School threats and
violence
Community/Neighborhood Violence
Institutional Victimization/Violation
Child Maltreatment
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Physical, Sexual, Emotional Abuse
and Neglect
 700 BCE documented in Homer’s
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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
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.
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:
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62.8% experienced neglect
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16.6% were physically abused
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9.3% were sexually abused
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7.1% endured emotional or psychological abuse
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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.
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):99-112.
2. Schwab-Stone et al. (1995). J Am Acad Child Adolescent Psychiatry;34(10):1343-1352.
3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.
Impact of Trauma on Child
and Family
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
Variability in Responses to Stressors and
Traumatic Events
 The impact of a potentially traumatic event is determined
by both:
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The objective nature of the event
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The child’s subjective response to it
 Something that is traumatic for one child may not be
traumatic for another.
Variability, cont’d
 The impact of a potentially traumatic event depends on
several factors, including:
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The child’s age and developmental stage
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The child’s perception of the danger faced
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Whether the child was the victim or a witness
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The child’s relationship to the victim or perpetrator
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The child’s past experience with trauma
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The adversities the child faces following the trauma
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The presence/availability of adults who can offer help and
protection
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:
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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.
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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.
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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:
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Alcoholism
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Drug abuse
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Depression
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Suicide attempts
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Sexually transmitted diseases (due to high risk activity with multiple partners)
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Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease
Source: Felitti et al. (1998). Am J Prev Med;14(4):245-258.
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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:
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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.
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Childhood Trauma and PTSD
 Key symptoms of PTSD
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Re-experiencing the traumatic event (e.g. nightmares, intrusive
memories)
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Intense psychological or physiological reactions to internal or
external cues that symbolize or resemble some aspect of the
original trauma
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Avoidance of thoughts, feelings, places, and people associated with
the trauma
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Emotional numbing (e.g. detachment, estrangement, loss of
interest in activities)
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Increased arousal (e.g. heightened startle response, sleep disorders,
irritability)
Source: American Psychiatric Association. (2000).
DSM-IV-TR ( 4th ed.). Washington DC: APA.
Childhood Trauma and Other Diagnoses
 Other common diagnoses for children in the child welfare system
include:
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Reactive Attachment Disorder
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Attention Deficit Hyperactivity Disorder
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Oppositional Defiant Disorder
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Bipolar Disorder
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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.
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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;821:176-193
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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.
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FITT Model
Trauma and Family Informed Principles*
Child
Response
Sibling
Relations
Child
Family
Processes
Urban
Poverty
Parent-Child
Relations
Adult/
Parental
Response
and
Family
Outcomes
Parenting
Practices &
Quality
Adult Family of
Origin Response
Adult Intimate
Relations
Time*
Acute and longer-term effects
Individual development
Family life cycle
Adapted from Kiser & Black, 2005
National Child Traumatic
Stress Network
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
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.
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
Trauma Informed
Organizational Practice
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
The Paradigm Shift
Traditional Care
Trauma-Informed Care
Trauma Specific Intervention
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)
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)
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
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Nonviolence
Emotional Intelligence
Social Learning
Democracy
Open Communication
Social Responsibility
Growth and Change
Trauma Interventions
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
How can we sort out the good
from the poor or even harmful
interventions?
Use in
Practice
Setting
Conduct
Efficacy
Studies
Develop
Intervention
Approach
Conduct
Effectiveness
Studies
Disseminate
Intervention
to the Field
Quality of Trauma Treatment
Practice
Based
Evidence
Emerging
Practice
Good
Practice
Promising
Practice
Best
Practice
Evidence
Informed
Practice
Evidence
Supported
Practice
Evidence
Based
Practice
Potential Family Interventions
ChildChild
Response
Response
DAILY
HASSLES
SOCIAL & SYSTEMS
DEMANDS
Sibling
Sibling
Relations
Relations
Trauma
Trauma
FINANCIAL INSTABILITY
RESIDENTIAL
INSTABILITY
TF-CBT
AF-CBT
CFTSI
SFCR
Trauma
SOCIAL AND PUBLIC INCIVILITIES
TA-FC
FL
SFCR
Cognitive Processing Therapy
TG-CBT
Parent-Child
Parent-Child
FL
Relations
Relations
SFCR
Adult/
Adult/
Parental
Parental
Response
Response
Parenting
Parenting
Practices
Practices
&&
Quality
Quality
Adult
Family of Origin
Response
LIVE
Grandparent/caregiver
Support Groups
SAFE
Adult Intimate
Adult Intimate
Relations
Relations
AF-CBT
SFCR
Family Family
Functioning
Processes
TF-CBT
TG-CBT
PCIT
AF-CBT
CPP
FL
SFCR
AF-CBT
FL
SFCR
TF Parent Coaching
Emotionally Focused Therapy
FL
What is the Common Elements approach?
 Using elements that are found across several evidence
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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, 648-649)
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
Secondary Traumatic Stress
and the Workplace
Artwork courtesy of the International Child Art Foundation (www.icaf.org)
Potential for Personal Impact
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.
•
“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) •
•
•
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)
Compassion
Fatigue
Vicarious Trauma
•
•
Secondary Stress
Often experienced as helplessness, confusion,
sense of isolation from support
Faster onset of symptoms than burnout or
countertransference
Faster recovery from symptoms
Highly treatable
Takes place over time
Responses unique to the person
Not specific to a particular client
“the natural, consequent behaviors and
emotions resulting from knowledge about a • Those with enormous capacity for empathy for
traumatizing event experienced by a
others tend to be more at risk
significant other. It is the stress resulting
• Who can be affected?
from helping or wanting to help a
traumatized or suffering person” (Figley,
1999, p.10)
•
Burnout
Directly
Traumatized
•
•
Traumatic
Countertransferen
ce
A state of physical, emotional, and mental
exhaustion caused by long term intervention
in an emotionally-demanding situation
Clinicians can also be directly experience
trauma in their work with families
•
•
Process, not an event
Positively associated with stressors (more
stressors more burnout) and negatively with
social support (more social support less burnout)
•
This can occur in many ways and the impact is
dependent upon the individual
Depending on clinician’s need, additional
support may be needed
•
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. 287-288).
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
Thank you!
QUESTIONS???