Protecting Their Future: Finding and Helping Stressed Children and Families

Chris Bray, Ph.D., LPAmbit Network University of Minnesota

www.ambitnetwork.org

Acknowledgements

• NAMI-MN

• Abi Gewirtz, PhD., LP, Professor and Director of Ambit Network, University of MN

• Monique Marrow, PhD., LP, Center on Trauma and Children, University of Kentucky

• National Child Traumatic Stress Network nctsn.org

Overview

An Overview of Child Traumatic Stress (CTS)

The Impact of CTS on Child Development

Working with Justice Involved Youth

Engaging Parents

Secondary Traumatic Stress

Institute for Translational Research in Children’s Mental Health

Abi Gewirtz, Institute DirectorDante Cicchetti, Research Director Gerry August, Training and Education DirectorAffiliated FacultyChris Bray, Administrative Director

Ambit NetworkUniversity of Minnesota

• Established in 2005 as a Community Treatment and Services Center through SAMHSA funding. Project Co-Directors: Drs. Abi Gewirtz and Chris Bray

• The MN National Child Traumatic Stress Network site: (ambit

network.org and nsctsn.org)

• A university-community partnership including a variety of nonprofit, government, and community agencies

• Purpose: to raise the standard of care for traumatized children by developing a Continuum of Care for Child Trauma

Ambit NetworkUniversity of Minnesota

• Train organizations (outpatient, inpatient, residential treatment, and therapeutic foster care facilities) across the state, and across the mental health continuum, in evidence-based treatments for trauma

• Connect “front door agencies” to trauma trained clinicians

• Emphasize subpopulations of traumatized children—those affected by parental military deployment, refugee and immigrant children, and American Indian children

• Served over 2,300 children and youth

Location Map Ambit Trained TF-CBT Providerswww.ambitnetwork.org

Ambit Trauma Informed Practice Regions

The truth about childhood is stored up in our bodies and lives in the depths of our souls. Our intellect can be deceived, our feelings can be numbed and manipulated, our perceptions shamed and confused, our bodies tricked with medication, but our soul never forgets. And because we are one, one whole soul in one body, someday our body will present its bill.

Alice Miller

What is your ACE Score?

The Adverse Childhood Experiences Study

Adverse Childhood Experiences and Maladaptive Coping Strategies

Dr. Felitti – Kaiser Permanente

Dr. Anda – Center for Disease Control and Prevention

Negative Coping MechanismsSmoking

Severe obesity

Suicide attempts

Alcoholism

Drug abuse

50+ sex partnersRepetition of original

traumaSelf Injury

Eating disorders

ACE Score Risk for these

ACEs and Maladaptive Coping

Early Death

Disease, disability, social

problems

High Risk Behavior

Childhood Adversity

Long Term Effects of Unaddressed Trauma

Disease and Disability• Ischemic heart disease• Autoimmune diseases• Lung cancer• Chronic obstructive pulmonary disease• Asthma• Liver disease• Skeletal fractures• Poor self-rated health• Sexually transmitted infections

SAMHSA Wellness Campaign

Social Problems• Homelessness

• Prostitution

• Delinquency, criminal behavior

• Inability to sustain employment

• Re-victimization

• Less ability to parent

• Teen and unwanted pregnancy

• Negative self-perception

• Intergenerational abuse

• Involvement in MANY services

Research on Psychological Trauma Over 40 years of research

• Lenore Terr: (1985) “Too Scared to Cry”• Judith Lewis Herman (1997): “Trauma

and Recovery”

Increasingly sophisticated• Are there underlying genetic mechanisms

that influence children’s responses to

traumatic events (e.g. Caspi & Moffitt, Cicchetti)

Research on Psychological Trauma

How are stress hormones modified as a function of exposure to trauma?

What is the relationship between heart rate immediately following a traumatic event and later propensity toward posttraumatic stress disorder?

What kinds of school-based interventions might buffer children from the effects of a traumatic event?

Prevalence

Up to 34% of all US children in the general population have

experienced at least 1 traumatic eventFelitti, Anda, Nordenberg, et al (1998)

Up to 25% of youth

between the ages of

9-16 have experienced at

least 1 traumatic eventCostello, E.J., Erkanli, A., Fairbank, J.A., & Angold, A. (2002).

Prevalence

• Over 1 million children will be affected by child abuse and neglect each year.

• $220 million per day—cost of child abuse and neglect in the US

• $80 billion to address child abuse and neglect in 2012

• $63,871= total yearly cost per abused and neglected childGelles, R.J. & Perlman, S, (2012). Estimated Annual Cost of Child Abuse and Neglect. Chicago IL: Prevent Child Abuse America.

Prevalence

60% of children can expect to have their lives touched by violence, crime, psychological abuse, and traumaAttorney General’s National Task Force on Children Exposed to Violence 2012

10-18% of all children witness family violence each year(Edleson et al., 2007)

Prevalence

• Frequent victimization more strongly predicts delinquency (Shaffer, Ruback, 2002)

• 75-93% of youth who enter the JJ system annually experienced some degree of traumatic victimization (Adams, 2010)

• In a Chicago detention center, over half of the youth experienced more than 6 traumatic events (Abram, et al. 2004)

Challenges Identifying Traumatized Children

• No way to know about children’s histories of traumatic eventso Particularly complicated by the shame and stigma

associated with many types of trauma

• Identifying ‘invisible’ witnesseso E.g. emergency room visitso E.g. police reports

• No national surveillance system

• Concerns about formal identification via official statistics leading to government involvement (e.g. CPS)

Child Traumatic Stress (CTS)

When I see the 10 most wanted list… I always have the thought: If they felt wanted earlier, they wouldn’t be wanted now.

~Edie Cantor

• Acute trauma is a single traumatic event that is limited in time

• Chronic trauma refers to the experience of multiple traumatic events

• 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 Sue Hoag-Babeau

Trauma

Trauma

Trauma

Impact of Exposure

Acute Trauma

Chronic Trauma

Complex Trauma

Types of Trauma

From “What Did You Do” to “What Happened To You”

NIMH Definition of Child Trauma

The experience of an event by a child that is emotionally painful or distressful which often results in lasting mental and physical effects*

• Event• Experience• Effects

*National Institute of Mental Health

Traumatic Events in the Lives of Youth Involved with the JJ System

• Physical, emotional, or sexual abuse

• Community violence and victimization

• Abandonment and neglect

• Domestic violence

• Traumatic loss

• Prostitution/Sex trafficking

• Serious accident

• Medical trauma, injury, illness

• Natural disaster

Traumatic Experiences

A subjective feeling about an objective event• Single incident or chronic incidents• Life threatening• Overwhelming• A subjective, internal state• Varies between people• Varies over time with the same person

(developmental level)

How Youth Respond to Trauma:

Effects/Symptoms

• Reexperiencing/Reenactment

• Hyperarousal/Reactivity

• Avoidance/Numbing

• Dissociation

Traumatic Stress Effects (Symptoms)

• Re-experiencing – Persistent Re-experiencing – “It keeps replaying in my head” – “Feels as if it’s happening again” (flashbacks)– “I keep dreaming about it” (nightmares)– “I can’t bear it when something reminds me of it”

• Avoidance – “I try not to think about it”– “I don’t go near places, people, or things that remind me of

(the event)”

Traumatic Stress Effects: Symptoms

• Hyperarousal– “I find it hard to sleep” (sleeplessness)– “Can’t focus on anything” (daydreaming, distracted)– “The smallest thing bugs me” (irritability)– “I jump at the slightest thing” (startle easily)– “I’m always scared that something bad will happen”

(hypervigilence)

• Dissociation– “I can’t even remember big chunks of it” (memory loss)– “It was like I was in a dream – unreal”

Short-term effects: Acute Disruptions in Self Regulation

• Eating• Sleeping• Toileting• Attention & Concentration• Withdrawal• Avoidance

• Fearfulness• Re-experiencing

/flashbacks• Aggression; Turning

passive into active• Relationships• Partial memory loss

Long Term Effects: Chronic Developmental Adaptations

• Depression• Anxiety• PTSD• Personality• Substance abuse

What Are the Behaviors Associated with CTS?

Behaviors You Often See: What Trauma Can Look Like

Anger

Hostility and coldness

Inability to trust other people

Perceiving danger everywhere

Problems with change and transitions

Acting guarded and anxious

(Kaplow, Dodge, Amaya-Jackson & Saxe, 2005; Shields & Cicchetti, 2001)

Behaviors You Often See: What Trauma Can Look Like

Difficulty being redirected

Physical and emotional reactivity

Difficulty calming down after outbursts

Difficulty letting go, holding onto grievances

Regressive behaviors (behaving much younger than his/her age)

Rejecting support from peers and adults

(Kaplow, Dodge, Amaya-Jackson & Saxe, 2005; Shields & Cicchetti, 2001)

Fight, Flee, or Freeze (to protect)

Hypothalamus

Release of adrenaline and cortisol

Heart rate and blood pressure increase

Breathing rate increases

Hippocampus

We Learn by Experience

We Learn by Experience

The Body Remembers Reminders/Triggers

• Sounds, places, people, smells, images all bring up memories and feelings.

• Does a memory come into mind, a person or time in your life?

• Do you experience any feelings?

• Do you feel a change in your body, heart rate, or energy level?

Complex trauma damages development

What’s Development Got to do With ItAdolescent development relies upon what is

learned in the course of relationships and through past experiences

PUBERTY/EARLY ADOLESCENCE11 – 14 Years

Expected Development:• Psychological in line with

physical changes

• Preoccupation with body

• Sense of distinctiveness

• Change in relationship with parents

• Peer pressure

PUBERTY/EARLY ADOLESCENCE11 - 14 Years

Child Development and Trauma

(Joan LaVoy, 2013, Anishinaabeg Today)

Stress and Trauma:• Feelings of inadequacy – why?

• Unrealistic feelings of guilt – why?

• Exaggerated preoccupation with body

• Somatic manifestations

• Acting out:• Unsafe sex, criminal and illegal activities, drugs, pregnancies,

etc.

PUBERTY/EARLY ADOLESCENCE11 - 14 Years

Child Development and Trauma

ADOLESCENCE14 - 18 Years

Expected Development:• Revival and culmination of

previous developmental issues

• Sexual and aggressive urges foster autonomy and independence

• Adult physical and cognitive maturation without the emotional component

• Identity definition and personality resolution (2nd opportunity)

ADOLESCENCE14 - 18 Years

Child Development and Trauma

(Gary W. Padrta, 2013,Anishinaabeg Today)

Stress and Trauma• Can act as younger children

• Inadequate solutions that can be physically dangerous to self and others

• 2nd opportunity for separation and individuation experienced as threatening

ADOLESCENTS14 - 18 Years

Child Development and Trauma

In response to trauma, adolescents may feel:• That they are weak, strange, childish, or “going crazy”• Embarrassed by their bouts of fear or exaggerated

physical responses• That they are unique and alone in their pain and

suffering• Anxiety and depression• Intense anger• Low self-esteem and helplessness

ADOLESCENCE contd.14 - 18 Years

Child Development and Trauma

Trauma helps shape adolescents’ beliefs and expectations:

The Invisible Suitcase

• About themselves

• About the adults who care for them

• About the world in general

“it’s all my

fault”“I am

bad”

“grownups

lie”

“I’m

stupid”“you’re going to hurt

me”“no one loves

me”

Trauma’s Impact on Emotional Development

• Difficulty with self-regulation• Difficulty describing feelings/internal states• Difficulty communicating wishes and desires

Youth who have experienced significant trauma may have difficulty

– Making realistic appraisals of danger and safety

– Governing behavior to meet longer-term goals

As a result, these adolescents may engage in:

– Reckless and risk-taking behavior or

– Become avoidant of any risk

51

Trauma’s Impact on Behavioral Development

52

The Influence of Developmental Stage

• Child traumatic stress reactions vary by developmental stage.

• Children who have been exposed to trauma expend a great deal of energy responding to, coping with, and coming to terms with the event.

HC-MC Well-Being Model©(BigFoot & Schmidt, 2008)

53

The Influence of Developmental Stage

• This may reduce children’s capacity to explore their environment and to master age-appropriate developmental tasks.

• The longer traumatic stress goes untreated, the

farther children tend to stray from appropriate developmental pathways.

Still Face Experiment

Helping Babies From the Bench: Using the Science of Early Childhood Development in Court: http://youtu.be/vmE3NfB_HhE?t=33

Pathways, Characteristics, Outcomes

Youth in the JJ System

Rates of Trauma in JJ Youth

93% of juvenile offenders

reported at least one or

more traumatic experiences.

The average number of different traumas reported was six.

Youth in the JJ population

have rates of PTSD

comparable to those of

service members returning from Iraq.

Pathways Persistent maltreatment (Ford, Cicchetti)

Involvement in the child welfare system (25 to 67%)

Placement instability (multiple placements)

Genetic influences

Severe family conflicts with mental illness involved

Racial inequality – Differential response

Mental health issues (70% vs 25% in the general population)

Inattentive, impulsive, defiant

Numb, disinterested

Social isolation

School failure

Special education issues

Mood disorders

Minority youth

Characteristics of Youth in JJ System

Long Term Outcomes•H

igher rates of substance use

•Higher rates of mental illness

•Higher rates of adult criminal involvement

•Higher rates of child welfare involvement as parents/perpetrators of maltreatment

Criminal Justice Policy: A Historical Perspective

Rehabilitation

1960’s

Just Deserts

1970’sSentencing Guidelines

Utilitarian:

1980’sMandatory

Minimums

Politicization:

1990’s

3 strikes

What Works

2000

60

The Research Foundation for EBP in Corrections

In the 1980’s research began to appear supporting the notion that treatment works to reduce recidivism

30+ years of over 500 quality research studies

Many sophisticated meta-analyses

Canada, Europe, and United States

61

What Works With Offenders?

Risk

Need

Responsivity

62

What Works with Offenders

Assess risks/needs

Enhance intrinsic motivation

Target interventions

Skill-train with directed practice (cognitive behavioral programming)

Increase positive reinforcement

Engage ongoing support in natural community

63

What Does Not Work with Offenders Targeting low-risk offenders

Deterrence alone without treatment

Targeting non-criminogenic needs; i.e., anxiety, depression, self-esteem

Scared straight approaches

Insight oriented, psychodynamic, non-directive, or client-centered therapies

Lack of direct training procedures with an absence of modeling and role-playing 64

What Do You Think Might Be Potentially Traumatizing

Events in JJ Settings?

Potentially Traumatizing Events in JJ Settings• Seclusion

• Restraint • Routine room confinement• Strip searches/pat downs• Placement on suicide status • Observing physical altercations • Fear of being attacked by other youth• Separation from caregivers/community

Effective Strategies

Helping Youth Get Back on Track

• Recognize the result of trauma or bad seeds

that have been planted.

• Begin to plant healthy seeds• Understand

that building resilience takes time

• Know you make a difference,

even if you don’t see the final result.

Coping Strategies

• Can be positive or negative• Are adaptive to a traumatic situation• Can be maladaptive when the situation

changes

An Intervention Framework to Supporting Children Following Child Trauma (NCTSN)

Tier III: Treatment required for PTS –

refer out

Tier II: Targeted services – some distress or risk factors

(anticipatory guidance, consultation-liaison, etc)

Tier I: Universal – distressed but coping well

Provide information, strategies to minimize PTS, screen for indicators of higher risk

SCREENING AND ASSESSMENT

The Maze of (Mis)Diagnosis

Oppositional Defiant Disorder? PTSD??

Depression? Substance Abuse?

ADHD? Conduct Disorder?OCD?

Anxiety?Bipolar Disorder?????

Personality Disorder??? Attachment Disorder?

Trauma Screening

Used to facilitate appropriate referrals

Brief and easy to administer

Doesn’t need to be done by a mental health professional

Can be incorporated into tools that are already being used

Mental Health Practices in Child Welfare Guidelines Toolkit

Effective Tier I and II Strategies for Traumatized Children

Tailor approaches to child’s developmental stage• Give information that child can understand• Provide options/simple choices where appropriate

(giving children some control)• Where possible, lay out the plan with the child and

parents • With older children, facilitate informed decision-

making

Parents are critical allies – (May need to address parent distress, fears, etc)

Effective Tier I and II Strategies for Traumatized Children

Enhance social support– Provide opportunities for children to get support from

parents & peers

Promote effective coping– Tell children what is going to happen (routines, etc)– Increase children’s control where possible– Help kids develop good coping resources: breathing,

meditation, yoga – that enhance emotional regulation

DEF Protocol

Medical Working Group, NCTSN

Creating a Trauma-Informed Safety Plan

1.Trauma history2.Trauma triggers3.Warning signs 4.Calming

behaviors

Safety plans include:

Tier III: Tertiary Interventions

Crisis Intervention Approaches

• Psychological first aid– Some emerging evidence for utility– Primarily psycho-educational

• Psychological debriefing– Group-based– No evidence for utility with children– May be harmful by increasing sensitivity to

trauma among non-symptomatic children

Trauma Treatment: one example

Trauma-focused cognitive behavior therapy– See http://tfcbt.musc.edu– Robust body of research (9 RCT’s plus 2 open trials)– Validated for 3-18 year olds– Essential components:

• Establishing and maintaining therapeutic relationship with child and parent

• Psycho-education about childhood trauma and PTSD• Emotional regulation skills• Individualized stress management skills

Trauma Informed Interventions for Youth in Justice System

Trauma Grief and Component Therapy for Adolescents (TGCTA) For ages 12-20 Laine, Saltzman, Pynoos

Trauma Affect Regulation: Guidelines for Education & Therapy for Adolescents and Pre-Adolescents (TARGET) For ages 10-18 Ford, Russo

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) For ages 12-21 Pelcovitz, Derosa, Habib

Commonalities Among Trauma Interventions for JJ Population

Psychoeducational component Problem solving skills Coping skills – old and new Self regulation and affect regulation skills Stress management – relaxation, deep breathing

Information processing Meaning making Narrative

Planning for the Future Safety planning

Caregiver Involvement

Module 1

•Foundation Knowledge and Skills

Module 2

•The Trauma Narrative

Module 3

•Working Through Grief Experiences

Module 4

•Preparing for the Future

Trauma Grief and Component Therapy for Adolescents

How Would You Cope with these Realities?

Survival Coping Strategies

What Supports Resilience?

Resiliency is the ability to recover from trauma.

Family Support

Peer Support

Competence

Self-efficacySelf-esteem

School Connectedne

ss

Spiritual Belief

You Don’t Have to be a Therapist To Be Therapeutic

Trauma-Informed Practice• Trauma-informed practice refers to the infusing and sustaining

of trauma awareness, knowledge, and skills into organizational cultures, practices, and policies (National Child Traumatic Stress Network [NCTSN]

• Includes: practitioner knowledge about impact of traumatic events on children, adults, and families

• Practitioner use of this knowledge in delivering care (skills)– E.g. ‘what happened to you?’ vs. ‘why did you do this?’

• Agency and system use of knowledge in training staff and implementing interventions

Trauma-Informed Practice Values

RELATIONSHIP

SAFETY

TRUST

CHOICE

EMPOWERMENT

Trauma and Systems

• Literature on integrating systems around trauma expertise and responses is scant to nonexistent.

• Survey conducted in 2005 by NCTSN assessedoWays agencies gather, assess, and share

trauma-related informationo Child trauma training that staffs receive

Taylor, Siegfried, NCTSN Systems Integration Working Group, 2005.

Trauma and Systems

• Many child and family serving agencies touch lives following traumatic experiences.

• The way these organizations work together is critically important.

• They can reduce the harmful impact of traumatic experiences OR …

Engaging Parents/Community

May Mental Health Month 2015 Events

Why be concerned with trauma and posttraumatic stress in parents?

• Associations between adult trauma and:o Child distress and child PTSDo Parenting impairments

• How might parents respond differently to other adults (e.g. service providers) when they are dealing with traumatic stress?

• And most important, how might they deal differently with their children?

Parent Trauma History

• Suffering from PTSD and related disorders (e.g., depression, anxiety)

• Using drugs to mask the pain

• Disempowered

• Parents of children who have become “parentified” (i.e. responsible beyond their years)

Parent Trauma History can:• Impair parents’ capacity to regulate their emotions

• Lead to poor self-esteem and the development of maladaptive coping strategies, such as substance abuse or abusive intimate relationships that parents maintain because of a real or perceived lack of alternatives

• Result in trauma reminders—or “triggers”—when parents have extreme reactions to situations that seem benign to others

• NCTSN, 2011http://www.nctsn.org/products/birth-parents-trauma-histories-and-child-welfare-system

Affects of Parent Trauma History on Parenting

A history of traumatic experiences may:• Compromise parents’ ability to make appropriate

judgments about their own and their child’s safety and to appraise danger; in some cases, parents may be overprotective and, in others, they may not recognize situations that could be dangerous for the child

• Make it challenging for parents to form and maintain secure and trusting relationships, leading to: o Challenges in relationships with caseworkers, foster

parents, and service providers and difficulties supporting their child’s therapy.

Traumatized parents may…

• Find it hard to talk about their strengths (or those of their children)

• Need support in managing children’s behavior

• Have difficulty labeling their children’s emotions, and validating them

• Have difficulty managing their own emotions in family communicationo When posttraumatic stress symptoms interfere with daily

interactions with children, parents should seek individual treatment.

Voices of Parents

Voices of ParentsSafety is in the Relationship

• Treat and value my child – when you’re good to my kid, that’s going to open the door

• When my child comes to me and says someone was bad to him, that closes the door

• When the Dr. requested my okay to speak to my child alone• Facial expressions• Respect and moving in slowly• Sensitive to each person• Never start with questions about trauma• No judgment – sitting and listening• Don’t create the question directly – if people talk long enough,

it will come out• Take the time to help me understand

What do therapists need from you?

What do you need from therapists?

102

There is a cost to caring.Charles Figley

Top 10 signs you’re too stressed

• You fake calls from your child’s school so you have an excuse to go home.• When you pull out your Blackberry for the tenth time your child threatens to throw

it out the window.• You listed Starbucks as your emergency contact.• You pencil in your bathroom breaks. • Case files have become “light bedtime reading.”• Your best friends think you have moved away because they have not heard from

you in so long.• You consider Red Bull part of a balanced diet.• You fall asleep during trips to the dentist’s office because it’s the only time you put

your feet up.• It takes you six days of vacation to begin to relax and six minutes in the office to

forget you took one.

Secondary Traumatic Stress can change our interactions with the world, our families, our friends.

What are the signs that you may be experiencing Secondary Traumatic

Stress?

Vicarious Trauma Warning Signs

Chronic

Exhaustion Disconnection

Social Withdraw

al

Insensitivity to

Violence or

Injustice

Loss of

Creativity

Avoidance

Poor

Boundaries

Anger/

Cynicism

Diminished Self-Care

Illness

Survival Coping

The A-B-C’s of Self--Care

• Awareness• Balance • Connection

Steps to Stress Reduction:Engage in Self -Care

Self-care is the ability to engage in helping

others without sacrificing other

important parts of one’s life.

Body

Personal life

Professional life

Awareness

Balance

Physical

Psychological

Emotional

Spiritual

Professional

Connection…

with your family

with your partner

Silence of

the Lambs

with your

friends

Organizational Stress

What do you think are someevents that can contribute to

organizational stress?

What are some of the events that can reduce organizational

stress?

It is unethical not to attend to your self care as a practitioner,

because self care prevents harming those we serve.

Charles Figley

Contact InformationChris Bray

Institute for Translational Research in Children’s Mental Health

University of Minnesota,

bray0021@umn.edu

612-624-3748