Transcript Trauma Screenings

Marisol Acosta, MEd, LPC-Supervisor , Project Director
April 17, 2015
Texas Children Recovering From Trauma Initiative
Department of State Health Services, Mental Health and Substance Abuse Division
Increase the understanding and importance of
trauma screenings: “why” screen, “what” to
screen, and “how” to screen
Differentiate Trauma Screenings vs Trauma
Assessment
Overview of different types of trauma screening
tools
• Trauma is widespread and pervasive
• Trauma does not occur on a vacuum, but within
the context of a community
•
SAMHSA, 2014
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Physical traumas are the leading cause of
death for individuals ages 1-44 (University Health System of
Bexar County, 2014)
70% of adults have experienced some type of
traumatic event at least once in their lives.
(National Council on Behavioral Health, 2014)
In the U.S. a woman is beaten every 15
seconds; and a forcible rape occurs every 6
minutes. (National Council on Behavioral Health, 2014)
Facts about children
25% of all children have experienced at least one
traumatic event (NCTSN, 2007)
Before age of four, 26% of all children have witnessed or
experienced a traumatic event (SAMHSA, 2011)
Children with disabilities are at least 2 times more likely
to be abused or neglected. (NCTSN, 2004)
83-93% of children living in neighborhoods with high
rates of violent crimes would have experienced trauma
(National Center for Children in Poverty, 2007)
Children in Texas
66,897 children/youth
were confirmed victims of
abuse and neglect
In 2009, 193,505 incidents
of family violence were
reported (Texas Council on Family
63% of them were
between the ages of
0-13 (DFPS, 2010)
In 2007, 369 children were
identified as victims of
human trafficking in Texas
The incidence of PTSD was
between 15-90%
depending on the type of
abuse (TexProtects, 2010)
In 2011, Texas became the
leading state of residence of
refugees in the U.S. and 34%
were younger than 18 (Martin
(DFPS, 2010)
Violence)
(THTTF, 2011)
& Yankay, 2011)
To Understand and Support
Develop a collaborative relationship
Prevent Adverse Effects
To Provide Appropriate Care and Services
Treat Adverse Effect
Address the impact of trauma and increase
functioning and coping mechanisms
Foster Resilience & Recovery
To Become A Trauma
Informed Organization
A system or program “informed”,
knowledgeable and sensitive to
the impact of trauma in the
individual/families’ lives and/or
the vulnerabilities of survivors of
traumatic events
Services are delivered in a way to
avoid re-traumatization
Fosters consumer/individual
participation
Addresses the vicarious impact on
the workforce
-
With Individuals That Receive Services:
Acknowledge history of trauma in
service planning: prioritize safety, focus
on recovery & wellness, incorporate’s
client’s voice and choice
-
Trauma Screenings
-
Understand client’s behavior or
interactions may be a reflection of they
trauma reactions and effects (not
“laziness”, not “lack of compliance” or
“attitude”)
It’s a Best Care Practice
National Association of State Mental Health
Program Directors (NASMHPD)
Substance Abuse and Mental Health Administration
National Center on Trauma Informed Care
National Child Traumatic Stress Network
National Council on Behavioral Health
Professional Associations
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Duration:
Short-Term
Long-Term
Adverse Childhood Events
(ACE) Study
Inability to cope with
normal stressors and
daily living
Impacts neurobiological
functions
CDC and Kaiser Permanente in CA from
1995 to 1997, and more than 17,000
participants
Trauma history is overlooked by
professionals in mental health settings.
Even when 1 event is has been reported, clinicians
overlook other forms of abuse or maltreatment
(Briere, 2004)
Studies have found that child abuse disclosure of
psychotic patients are often dismissed, ignored, or
marginalized under the belief that discussing the
issues will make them worse. (Hammersley, 2004)
Trauma is rarely reflected in primary or
secondary diagnosis
Study Findings
46% of women in psychiatric hospitals with a psychotic
disorder have history of incest (van der Kolk, 1987)
98 % of patients with serious mental illness
(schizophrenia and bipolar disorder) reported at least 1
traumatic event, only 2% had a diagnosis of PTSD in their
chart. (Mueser et al, 1998)
Trauma responses are often misdiagnosed
under symptoms of:
ADHD
Bipolar Disorder
Mood Disorder NOS
Psychosis NOS
Borderline Personality
- Tucker, 2002
Misdiagnosis
Inappropriate treatment plan
Increase vulnerability to substance use
Increases the probability of developing other serious
mental illness, physical illness and risk of early death
Increase chances of re-traumatization
Increase social isolation
Increase risk of suicide (in some traumatic events)
Creating cascading effect on the individuals life and
inappropriate care.
Underreporting of Trauma Survivors
Lack of Trust
Shame and Guilt
Memory problems
Avoidance of Reminders of Trauma
Cultural beliefs about trauma
Minimizing trauma events
Fear of retaliation by abuser (told to keep it a
“secret”)
Fear of loss
Inability to verbalize (children)
Underreporting by Provider
Lack of training
“It’s not required” /”No time”
Personal beliefs that the client will get worse
Lack of understanding and competency in how to
address, respond or treat trauma
Providers personal discomfort in talking about
abuse or trauma (e.g. sexual abuse)
Cultural/personal beliefs
Provider only asks about physical and sexual abuse
“Universal trauma screenings and specific
trauma assessment methods are necessary to
developing relationships with trauma survivors
and offering appropriate services”
Harris & Fallot 2001
What are we screening?
Shell Shock
Aftermath
Trauma
Traumatic Event
Childhood Traumatic Stress
Adverse Childhood Events
Toxic Stress
Stressors
Event or circumstances that created the
experience that caused an actual or extreme
threat of physical or emotional harm
(SAMHSA, 2014)
A common definition in the trauma field:
– A traumatic event is an experience that causes physical,
emotional, psychological distress, or harm. It is an event that
is perceived and experienced as a threat to one's safety or to
the stability of one's world.
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The person was exposed to: death, threatened death, actual
or threatened serious injury, or actual or threatened sexual
violence, as follows: (1 required)
Direct exposure.
Witnessing, in person , or
Indirectly
Repeated or extreme indirect exposure to aversive
details of the event(s), usually in the course of
professional duties
Diagnostic Statistical Manual -5 of Mental Health Disorders
(APA, 2013)
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…helps determine whether the event or
circumstances is a traumatic event
The experience and perception of a particular
event may be considered traumatic by one in
individual and not for another
How individuals labels, assigns meaning, and is
disrupted physically and psychologically by an
event will contribute to whether or not it is
experienced as traumatic
(SAMHSA, 2014)
Buddhist Swastika
Definitions of violence change through time
and vary according to culture of a particular
country or region
(Online Encyclopedia of Mass Violence, 2012)
Nazi Swastika
according to the World Health Organization (WHO)
"the intentional use of physical force or power,
threatened or actual, against oneself, another
person, or against a group or community, that
either results in or has a high likelihood of
resulting in injury, death, psychological harm,
maldevelopment, or deprivation.“
(World Report on Violence and Health: WHO, )
(World Health Organization)
Self- directed violence
Self abuse / “Self-harm” (self-mutilation, cutting, etc)
Suicide
Interpersonal violence (refers to violence between individuals)
Family/Partner (domestic: child, partner, elder)
Community violence: acquaintance, strangers
Collective violence
Refers to violence committed by larger groups
Social
Political
Economic
Direct Violence (hurting others physically)
VIOLENCE
Cultural Violence
(beliefs /cultural stories
that glorify and
normalize violence)
Structural Violence
(embedded into systems
restricting rights and access
to resources)
1.
Structural Violence
Unequal access to: water, food,
housing, services, health care,
terms of market trade
Discrimination Laws / Gender
Inequality/Institutionalized
Racism
2.
Symbolic Violence
Social beliefs against indigenous
population, against migrants,
beliefs of certain punishments
3.
Normalized Violence
“Normalizing the unthinkable”
Human rights violations
Justification for child abuse,
rape or domestic violence (as a
norm)
Separation of classes or groups
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Child traumatic stress occurs when children
and adolescents are exposed to traumatic
events or traumatic situations that overwhelm
their ability to cope.
These reactions interfere with his or her daily
life and ability to function and interact with
others.
-National Child Traumatic Stress Network
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Neglect
Accidents, Medical Procedures
Natural /Man-Made Disasters
Abuse: emotional, physical, sexual
Bullying
Exploitation/Human Trafficking
Domestic Violence/Community Violence
War/Torture
Historical Trauma
Military Life Transitions/Experiences
Witnessing an “event”
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Separation from parent or
caregiver/attachment
disruption
Abuse
Neglect
Hunger
Accidents/Physical Trauma
Witnessing Violence (Family
Violence)
Impaired Caregiver
Rapid developing brains
increase vulnerability.
Infants and Toddlers are
impacted by problems
affecting their parents.
(e.g. Post-Partum Depression,
substance abuse, disruptive bond
or lack of understanding)
•
•
•
•
Physical Responses
Mental Responses
Behavioral Responses
Social Responses
Re-experiencing the event in diverse manners
(Intrusions)
Avoidance
Negative alterations of cognitions (thoughts) and mood
(feelings) that began or worsened after the event
Alterations in arousal and reactivity
Exposure to traumatic events is related to the onset
of behavior changes in children/youth.
In some, it also increases the risk of onset of mental
disorders:
Depression*
Anxiety
Trauma-and-Stressor Related Disorders
Other
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Post Traumatic Stress Disorder (PTSD)
PTSD for Children 6 Years and Younger
Acute Stress Disorder
Adjustment Disorder
Other Specified Trauma-and-Stressor Related Disorder
DSM-5
How do you screen?
Trauma Screening
Brief and focused inquiry to
determine whether an
individual has experienced a
specific type of trauma
Trauma Assessment
An in depth exploration and
evaluation of the nature,
severity and impact of
traumatic events and its
sequelae in the individuals
functioning
History of traumatic event exposure (types of trauma
exposure)
Presence of Symptoms/responses to Trauma or Post
Traumatic Stress Disorder
Combines both history of exposure and presence of
symptoms
Multiple Symptoms of Trauma and Other related
diagnosis or life domains (e.g. depression, anxiety,
anger, trauma, PTSD, sexual concerns)
(Strand, Sarmiento, and Pasquale, 2005)
Prioritize and give clients choice and control
Explain clearly the reasons for screening
Provide the choice that they can refuse to answer any
questions, not answer a question
Provide the opportunity for them to stop the screening and
reschedule appointment
Provide the options for them to self-regulate and sooth
themselves if needed (e.g. allow to grab a pillow, toy,
blanket)
Explain that they can ask to take a break
If available, encourage the completion of a self-report
trauma screening tool
Best Practice:
Ask for exposure of all types of trauma
(like a checklist)
Other practice (not as effective)
Ask general question: “Have you ever or has your
child ever experience or have been exposed to an
event or incident that was actual or threatening
serious injury, violence or danger to you (child) or
someone else? Or an event that someone can
consider traumatic?”
How NOT to ask:
“Have you ever experienced a
traumatic event or witnessed trauma?
Universal Screenings (screen everyone/ all age groups
for all services)
Create a safe environment
Do the screening as early as possible in the Intake
Process or at least in the 1st Psychosocial Assessment
visit.
Use unambiguous and straightforward language (no
jargon, no abbreviations, call things by their name:
“rape”, “torture”, “penis”, “Vagina”. “abuse”
Briefly discuss self-regulation and coping skills and
provide a brief written handout in case person feels
distress by trauma reminders after the appointment.
1. Create a Safe Environment
• Provide adequate privacy (in particular for the child),
• Encourage to ask questions & provide assessment tools
• Review limits of confidentiality
2. Gather information using a variety of techniques and
approaches (clinical interview, standardized measures,
and behavioral observations.)
• Assess for wide range of traumatic events. Determine
when they occurred so that they can be linked to
developmental stages and onset of behavior problems.
• Assess for a wide range of symptoms risk behaviors,
functional impairments, and developmental derailments.
4. Gather information from Multiple perspectives
(child, caregivers, teachers, other providers, etc).
Talk to the child – start treatment with event child find more
stressful or threatening
5. Work with Family to Make Sense of Results and
Develop a Treatment/Service Plan
Try to make sense how each traumatic event might have
impacted developmental tasks and derailed future
development.
Try to link traumatic events to trauma reminders that may
trigger symptoms or avoidant behavior.
6. Assess Trauma Over Time (ongoing assessment)
(NCTSN, 2015)
Forensic Assessments for Victims of Crimes
(e.g. abuse)
Asylum Seekers Evaluation or Psychological
Evaluation for Special Visas
(e.g. human trafficking, domestic violence,
victims of crime, unaccompanied minors, etc.)
Trauma Screenings (Events
Only)
Brief Trauma Questionnaire (A)
Upsetting Events Survey (A)
Life Event Checklist (A)
Trauma Events Screening
Inventory (C)
Trauma Screenings (Symptoms
Only)
PTSD Checklist PCL (A)
Abbreviated PCL-Civilian Version
(A)
Child Post-traumatic Symptoms
Scale (CPSS)
Trauma Screening Questionnaire
(A)
Youth Outcome Questionnaire (Y)
Children’s Alexithymia Measure
Attachment Questionnaire for
Children
Both History & Symptoms
Harvard Trauma Questionnaire
(A) (Y)
UCLA PTSD Reaction Index (C)(Y)
Recognize Trauma – trauma
screening tool (C, Y)
Multiple symptoms
Beck Depression Inventory II
John Hopkins Depression &
Anxiety
CRAFFT (C)
Child Behavior Checklist for
Young Children (C) (Y)
Child & Adolescent Needs &
Strengths (CANS Trauma), (Texas
CANS)
Structured Interview for
Disorders of Extreme Stress (C, Y)
Trauma Symptoms Checklist for
Children (multiple versions)
National Child Traumatic Stress Network
http://www.nctsn.org/content/standardizedmeasures-assess-complex-trauma
SAMHSA
http://www.integration.samhsa.gov/clinicalpractice/screening-tools
National Center for PTSD
http://www.ptsd.va.gov/professional/assessme
nt/overview/index.asp
The Anna Institute
Aim:
Transform children’s mental health services in Texas into a trauma-informed care
system that fosters resilience and recovery.
How?
Creating a Category III Community Treatment Services Centers members of the National
Child Traumatic Stress Network (NCTSN) and their learning community:
Heart of Texas Region MHMR Center
Serves the following counties: Bosque, Hill, McLennan, Falls, Limestone and Freestone.
Target Population: Children ages 3 to 17 impacted by trauma or children of military
families.
Funded by: SAMHSA’s National Child Traumatic Stress Initiative
Grant No: 1U79SM061177-01
Funding Period Oct 2012-Sept 2016
Through Training:
Creating Community Partners
Creating of a Statewide Transformation Strategic
Plan
Statewide Summit on Transformation to TraumaInformed Care
ANNOUNCEMENTS:
TRAUMA INFORMED NETWORK OF TEXAS
(Join Us!)
TRAUMA INFORMED CARE SUMMIT
(August 2016)
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Marisol Acosta, MEd, LPC-Supervisor
Project Director , Texas Children Recovering From Trauma, Child &
Adolescent Services, MHSA Division Department of State Health
Services
Email: [email protected]
Phone: 512-206-4830
DSHS-MHSA Division
P.O. Box 149347, MC 2091
Austin, TX 78714-9347
Funded by SAMHSA NCTSI Initiative Grant #5U79SM061177-03