Brain Dev Trauma
Transcript of Brain Dev Trauma
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U.S. Department of Health and Human Services
Administration for Children and Families
Administration on Children, Youth and Families
Childrens Bureau
Child Welfare Information GatewayChildrens Bureau/ACYF1250 Maryland Avenue, SWEighth FloorWashington, DC 20024703.385.7565 or 800.394.3366Email: [email protected]://www.childwelfare.gov
BULLETIN FOR
PROFESSIONALS
August 2011Use your smartphone to
access this bulletin online.
Supporting Brain
Development
in Traumatized
Children and Youth
Whats Inside:
Understanding trauma andbrain development
Identication andassessment
Ages and stages Helping caregivers
promote healthy braindevelopment
Working with other serviceproviders
Creating a trauma-informedchild welfare system
References
As a child welfare professional, you may haveconcerns about the impact of maltreatment ona childs growth and development, and for goodreason: A growing body of evidence indicatesmaltreatment can alter brain functioning andconsequently affect mental, emotional, andbehavioral development (often called socio-emotional development). You and the families you
serve can benet from knowledge of childrensdevelopmental stages and the signs and symptomsof developmental delays. This bulletin summarizeswhat you can do to support the identication and
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assessment of the impact of maltreatment andtrauma on brain development; how to workeffectively with children, youth, and familiesto support healthy brain development; andhow to improve services through cross-systemcollaboration and trauma-informed practice.
This bulletin is a companion pieceto Information Gateways issuebriefUnderstanding the Effects ofMaltreatment on Brain Development(http://www.childwelfare.gov/pubs/issue_
briefs/brain_development). The issuebrief provides basic information on braindevelopment and helps professionalsunderstand the emotional, mental, andbehavioral impact of early abuse andneglect in children who come to theattention of the child welfare system.
Understanding Traumaand Brain Development
Research indicates that newborns brains havedeveloped enough to interact with the worldaround them, even in the earliest days oflife. They can recognize their mothers voiceand smell, and they have some capacity toself-regulate and self-soothe. As amazingas these early abilities are, the majority of
brain development occurs during the childsearly months and years, and higher functionscontinue to develop throughout adolescenceinto early adulthood. The brain developsin response to experiences with caregivers,
family, and the community, and the quality ofthose experiences affects whether the childwill develop a strong or weak foundationfor all future learning, behavior, and health(Center on the Developing Child at HarvardUniversity, 2007).
A traumatic experience such as abuse orneglect can profoundly impact a childs braindevelopment. Trauma may occur when achild feels intensely threatened by an event inwhich he or she is involved or witnesses, andit is often followed by serious injury or harm(National Child Traumatic Stress Network,2005). A child may experience a single
traumatic event or chronic trauma (occurringrepeatedly over time). Other types oftraumatic events include witnessing domesticor community violence; surviving a seriousillness, war, or terrorism; or grieving the deathof a loved one. A growing body of evidencedocuments that brain functioning is affectedwhen a child experiences trauma and thatcognitive, physical, emotional, social, health,and developmental problems can result.
Research overwhelmingly points to thebenets of supporting children and familiesat an early age to prevent maltreatment andits negative effects on brain developmentbefore they occur. In addition, cost-benetanalyses demonstrate the stronger return oninvestments that result from strengtheningfamilies, supporting development, andpreventing maltreatment during childhoodand adolescence rather than fundingtreatment programs later in life (Center on the
Developing Child at Harvard University, 2007).
http://www.childwelfare.gov/pubs/issue_briefs/brain_developmenthttp://www.childwelfare.gov/pubs/issue_briefs/brain_developmenthttp://www.childwelfare.gov/pubs/issue_briefs/brain_developmenthttp://www.childwelfare.gov/pubs/issue_briefs/brain_development -
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Identicationand Assessment
As a child welfare professional, you arein a unique position to identify childrensdevelopmental concerns early and helpfamilies receive the support they need toreduce any long-term effects. In working withat-risk children and families, you may assessrisk factors and indications of developmentaldelays resulting from maltreatment or traumaas well as protective factors and indicators of
resiliency that may help reduce the stressors.
Risk Factors
Research indicates that the following child,parent, and family factors may increase achilds risk for developmental delay. While thepresence of one risk factor does not mean thechild will have a developmental delay, multiplerisk factors should increase the cause forconcern:
Biomedical risk conditions in a child (suchas low birthweight, physical deformities, orchronic heart or respiratory problems)
Child maltreatment, particularly beforeage 3
Parental substance use or mental healthproblem
Single and/or teenage parent
Low educational attainment of parent
Four or more children in the home
Family poverty or domestic violence
Involvement with the child welfare system(Barth et al., 2007; Administration forChildren and Families, 2007)
Throughout this bulletin, the vignettes tellthe story of Billys traumatic experiencesin early childhood and the efforts of hisfamily, child welfare services, and relatedprofessionals to address the effects on hisbehavior and development.
Billy is a 6-year-old boy placed withhis maternal grandmother by the childwelfare system. Although his motherstated that she never used drugs
while she was pregnant, Billy was bornprematurely. His mother did not have ahome or regular income, and they movedfrom place to place for several years.Billy slept wherever he could nd a spot,and he ate only sporadically. Billy did notcause much trouble because he rarelyspoke.
BILLYS STORY: INTRODUCTION
Indications of Delay
During your interactions with families, observethe behaviors of children and youth for anyindications of developmental delay. (See theAges and Stages section later in this bulletin.)Because parents know their children best, askthem if they have concerns about their childsbehavior so they can help identify issues. Ifthere are causes for concern, refer the familyto early intervention services or to a health-
care provider or youth specialist so the childcan be fully assessed by a trained professional.
The Keeping Children and Families Safe Actof 2003 (P.L. 108-36) required State childwelfare agencies to develop provisions and
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procedures for referral of a child under age3 who is involved in a substantiated case ofchild abuse or neglect to early interventionservices funded under Part C of the Individualswith Disabilities Education Improvement Act( 106(b)(2)(A)(xxi)). Doing so helps ensurethat the developmental needs of childrenwho are abused or neglected are addressedand families receive the support they needto promote optimal child development. Formore information, see Information GatewaysAddressing the Needs of Young Children inChild Welfare: Part C Early InterventionServices(http://www.childwelfare.gov/pubs/
partc).
After Billy was removed from his motherscare due to abandonment, he was placedin foster care until his grandmother couldbe located. Billys grandmother becameconcerned about his behavior and
development while caring for him over thelast 6 months. Billy hid food in his pocketsand in his room, and his teacher reportedhe was stealing food at school. Billy alsoslept on the oor. Because he was soquiet, it took some time for Billys teacherto notice he had difculty speaking andinteracting in school.
BILLYS STORY: PART 2
ASSESSMENT TOOLS FOR CHILD
AND YOUTH DEVELOPMENT
Measures Review DatabaseNational Child Traumatic Stress Networkhttp://www.nctsnet.org/resources/online-research/measures-reviewPresents a database of tools measuringchildrens experiences of trauma and othermental health-related issues.
Trauma Assessment Pathway (TAP)ModelChadwick Center for Children and
Families, Rady Childrens Hospital, SanDiegohttp://www.taptraining.netOffers a framework to build and sustainan assessment-based treatment programand provides a guide for individualizedtreatment for children who suffer complextrauma.
Early Childhood Measures ProlesChild Trendshttp://aspe.hhs.gov/hsp/ECMeasures04Compiles assessment tools measuringlanguage and literacy, cognition,mathematics, social-emotionalcompetency, and approaches to learning.
Screening, Evaluation, and AssessmentNational Early Childhood TechnicalAssistance Centerhttp://nectac.org/topics/earlyid/screeneval.aspReferences numerous publications and
organizations professionals may consultregarding developmental assessments.
http://www.childwelfare.gov/pubs/partchttp://www.childwelfare.gov/pubs/partchttp://www.nctsnet.org/resources/online-research/measures-reviewhttp://www.nctsnet.org/resources/online-research/measures-reviewhttp://www.taptraining.net/http://aspe.hhs.gov/hsp/ECMeasures04http://nectac.org/topics/earlyid/screeneval.asphttp://nectac.org/topics/earlyid/screeneval.asphttp://nectac.org/topics/earlyid/screeneval.asphttp://nectac.org/topics/earlyid/screeneval.asphttp://aspe.hhs.gov/hsp/ECMeasures04http://www.taptraining.net/http://www.nctsnet.org/resources/online-research/measures-reviewhttp://www.nctsnet.org/resources/online-research/measures-reviewhttp://www.childwelfare.gov/pubs/partchttp://www.childwelfare.gov/pubs/partc -
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Ages and Stages
There are sensitive periods for developingcertain abilities (such as when infants formattachments with their parents) that, ifunachieved, could impair later development.Every child grows at his or her own pace,but most children achieve developmentalmilestones within the same general timeline.Keep in mind that the impact of abuse orneglect may cause children to develop at aslower rate (Perry, 2006) and that children bornprematurely may also achieve milestones at
different times, depending on the degree ofprematurity.
The chart on the next page provides generalguidance on developmentally appropriate
behavior in children, behaviors of the child orparent that may be a cause for concern, andpositive parenting strategies. You may wantto adjust your expectations according to thechilds needs and the parents situation. Inaddition, the presence of a cause for concerndoes not always mean the child is at risk fordevelopmental delay; however, the presenceof multiple concerns increases that risk.
Note: This chart should not replace amore thorough screening or assessmentby a qualied professional. Child welfareprofessionals may use this informationto observe the behaviors of children and
youth and refer families to a developmentalprofessional when appropriate.
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Child Development, Parenting Strategies, and Causes for Concern, 018 years1
1 Adaptedfrom:Chamberlain,2009;Gabriel,n.d.;Mayer,Anastasi,&Clark,2006;NationalCenteronBirthDefectsandDevelopmental
Disabilities,2010;NationalResearchCouncilandInstituteofMedicine,2009;NewYorkCityAdministrationforChildrensServices,2005;
ParentFurther,2010;ZEROTOTHREE,2007.
Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
03months
Reacts and turnstoward sound
Watches faces andfollows objects
Coos and babbles
Becomes moreexpressive anddevelops a socialsmile
Develops a generalroutine of sleep/wake times
Is unable tomove each limbseparately from theothers
Has difcultytracking light orfaces
Regularly cries forhours at a time and
is very hard to calm
Dont be afraid ofspoiling yourbaby; hold, cuddle,and comfort himoften
Respond to yourbabys cries andprovide the comforthe needs (rocking,feeding, diaperchanging)
Give the baby lotsof attention (talk,sing, read, play),and read the cuesto recognize whenhe needs a break
Have conversationswith your babyacting as if youunderstand each
other Allow the baby to
explore throughmovement, taste,and touch, but setsafe limits
Provide time onthe oor for sitting,rolling, and crawling
Does not knowwhen to feed ortries to keep thebaby on a rigidschedule
Feels too muchattention or holdingwill spoil the baby
Has trouble
knowing when thebaby is hungry,needs attention, orneeds quiet time
Gets upset everytime the baby cries
Allows the baby tocry for a long timewithout trying tocomfort
Doesnt enjoy timewith the baby or
feel the babyspersonality ts inwith family
47months
Babbles chains ofsounds
Responds to othersexpressions ofemotions
Grasps and holdsobjects
Regards ownhand and exploresobjects with handand mouth
Sits with, and thenwithout, support onhands
Cannot hold headup or roll over
Does not makesounds in responseto attention
Consistently resistsall efforts to hold orcomfort
Shows little interestin exploration
Strongly resists aroutine of sleep andawake time
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Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
812months
Changes tone whenbabbling
Says dada andmama and usesexclamations
Imitates sounds andgestures
Explores in manyways (shaking,
dropping, banging,poking)
Pulls self up tostand and may walkbriey without help
Is not able to calmhimself sometimes
Does not babbleor make simplegestures
Fails to respondto name or simpleverbal requests
Does not crawl or
explore the area
Has little or noreaction whenparent(s) leave theroom or return
Continued fromprevious page
Continued fromprevious page
2 years Says several singlewords and two- orthree-word phrases
Follows simpleinstructions
Points to things
when named Finds hidden
objects
Scribbles
Stands alone andwalks well
Knows no singlewords
Does not walkeasily
Does not seem toknow or respond to
family members Does not amuse
himself for shortperiods of time
Offer a variety ofsensory experiencesand follow thetoddlers lead inplay
Encourage, but
dont rush, motordevelopmentprovide plenty ofsafe, low places towalk and climb
Create predictableroutines and rituals
Is cold andunresponsivetoward the child
Rarely praises thechild or showsaffection
Has trouble dealingwith own or thechilds anger
Focuses more onthe childs negativebehaviors
Child Development, Parenting Strategies, and Causes for Concern, 018 years (Continued)
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Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
3 years Uses four- to ve-word sentences
Follows two-or three-partinstructions
Recognizes andidenties mostcommon objects
Draws simple
straight or circularlines
Climbs well, walksup and down stairs,runs
No two-wordspontaneousphrases
Has troubleexpressingemotions
Often refuses to dosimple tasks
Seems overly
fearful, even in safesituations
Continued fromprevious page
Be a safe, reliablebase as the childexplores the worldaround him
Tell stories and talkwith the child aboutwhat they see, hear,
and do Listen and try to
understand whatthe child is saying
Take the childsemotions seriouslyand help him makesense of them
Support interactionwith peers; providestructure butotherwise let him
negotiate playtimeon his own
Continued fromprevious page
Frequently yellsat the child orpunishes accidentsharshly
Describes the childas having hostileintentions, i.e., He
doesnt like me orHe knows better
Pushes the childtoo hard to do toomany activities and/or nds it hard tolet the child trythings by himself
Has trouble settingconsistent rules andsafe limits
4 years Uses ve- to six-word sentences,tells stories
Understandscounting andmay know some
numbers Identies four or
more colors
Copies or drawssimple shapes
Walks/runs forwardand backward withbalance
Is unable to run,jump, or climbeasily
Is extremelyaggressive andhostile toward
peers Clings and gets
very upset whenparent leaves
Child Development, Parenting Strategies, and Causes for Concern, 018 years (Continued)
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Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
5 years Speaks in fullsentences, tellslonger stories
Draws circles andsquares, begins tocopy letters
Climbs, hops,swings, and mayskip
Tries to solveproblems froma single point ofview and identifysolutions toconicts
More likely to agreeto rules
Does not speak fullsentences or speakclearly enoughfor strangers tounderstand
Seems shy and veryfearful with otherchildren
Never shares or
takes turns Regularly has
difculty caring forown toilet needs
Help child take onnew responsibilities
Teach reasonablerisks and safe limits
Handle angerconstructively
Create a safeenvironment whereyour child can feel
comfortable talkingabout a widerange of issues andemotions
Share feelingsand stories abouthow to deal withproblems and facefears
Support healthyfriendshipsand encourage
appropriate socialactivities
Regularly nds thechilds behaviorunmanageable
Does not see theneed for the childto socialize withothers
Thinks the child istoo aggressive or
too dependent Often criticizes or
blames the child
Seems excessivelyanxious about theresponsibilities ofbeing a parent
Leaves the childalone for extendedperiods of time
Is not involved with
school or with otherparents of childrenthe same age
67years
Reads short wordsand sentences
Draws person or
animal Takes pride
and pleasure inmastering new skills
Has more internalcontrol overemotions andbehaviors
Shows growingawareness of goodand bad
Is frequently sad,worried, afraid, orwithdrawn
Is easily hurt bypeers
Bullies otherchildren
Develops unrealisticfears (phobias)
Child Development, Parenting Strategies, and Causes for Concern, 018 years (Continued)
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Child Development, Parenting Strategies, and Causes for Concern, 018 years (Continued)
Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
810years
Reads well
Multiplies numbers
Expresses a uniquepersonality whenrelating to others
Solves conicts bytalking, not ghting
Is able to bounce
back from mostdisappointments
Returns to baby-likeor silly behaviors
Is preoccupied withviolent movies, TV,video games
Is fearful withfamiliar adults, ortoo friendly withstrangers
Continued fromprevious page
Continued fromprevious page
1114years
May have frequentmood swings orchanges in feelings
Gradually developsown taste, sense ofstyle, and identity
Has a hobby, sport,or activity
Learns to acceptdisappointmentsand overcomefailures
Has one or morebest friends andpositive relationshipswith others the sameage
Eats or sleeps less(or more) thanbefore
Has strong negativethoughts or opinionsof himself
Has an extremeneed for approvaland social support
Has highly conictedrelationships orregularly causesfamily conicts
Is alone most ofthe time and seemshappier alone thanwith others
Establish fair andconsistent rules
Provideopportunities fornew, challengingexperiences
Address thepotentialconsequences ofrisky behaviors
Help teensresolve conicts,solve problems,and understandchanging emotions
Encourage goalsfor the future andhelp create systemsfor time and taskmanagement
Discuss the physicalchanges in pubertythat affect height,weight, and bodyshape
Worries that thechild is maturingvery early or verylate
Doesnt setreasonable limits forthe childs behavior
Is uninterestedin helping thechild address
overwhelmingemotions orsituations
Expects the childto adhere to strictrules and severelypunishes mistakes
Often has conictsand loses temperwith the child
Frequently criticizes,nags, or judges thechild
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Child Development, Parenting Strategies, and Causes for Concern, 018 years (Continued)
Child Parent
AgeDevelopmentally
appropriatebehavior
Causesfor concern
Parentingstrategies
Causesfor concern
1518years
Begins to developan identity and self-worth beyond bodyimage and physicalappearance
Is able to calm downand handle anger
Sets goals and workstoward achieving
them Accepts family
rules, completeschores and otherresponsibilities
Needs time foremotions andreasoning skills tocatch up with rapidphysical changes
Feels hopeless,unable to makethings better
Withdraws fromfamily or friends
Often gives into negative peerpressure
Becomes violent or
abusive
Drives aggressively,speeds, drinks anddrives
Has a favorableattitude toward druguse
Diets excessively,even when notoverweight
Continued fromprevious page
Be available for helpand advice whenneeded
Tolerate (withinreason) teensdeveloping likes anddislikes in clothes,
hairstyles, and music
Continued fromprevious page
Doesnt provide thechild any privacyand nds it overlydifcult to let goas he becomes moreindependent
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Helping CaregiversPromote HealthyBrain Development
Most scientists agree that children needpositive relationships, rich learningopportunities, and safe environments tosupport their healthy brain development(Center on the Developing Child atHarvard University, 2007). As a professionalworking with children and youth affected
by maltreatment and with their parents orcaregivers, you can help to improve childrenschances for these positive experiences. Thoseopportunities exist at many points in the childwelfare continuum, including prevention,family strengthening, and treatment.
Preventing Trauma
Professionals who work with families can helpparents create safe and loving environments
for their children to prevent abuse or neglectbefore it occurs. Efforts to support optimalbrain development should start as early aspregnancy, when mother and child formtheir rst attachments. The babys prenataldevelopment is more than simple maturation;it involves complex interactions among themother, baby, prenatal environment, and earlyexperiences. Because babies begin to developall ve senses before birth, even experiencesin the womb can affect their development
(Klein, Gilkerson, & Davis, 2008). You can helpparents focus on their childs developmentbefore birth by teaching the mother to beaware of babys movements and to embracea positive lifestyle by avoiding alcohol, drugs,or cigarettes, eating nutritious meals, and
practicing good hygiene. You may also wantto link families to services such as homevisiting or Early Head Start programs designedfor at-risk expectant families.2
After the baby is born, parents can continueto receive help as needed through familysupport programs such as parent educationand home visiting. Recent prevention resourceguides from the U.S. Department of Healthand Human Services Childrens Bureau (ChildWelfare Information Gateway et al., 2011)encourage professionals to promote veprotective factors that strengthen families andhelp prevent abuse and neglect, which serve
to promote healthy brain development:
Nurturing and attachment
Knowledge of parenting and of child andyouth development
Parental resilience
Social connections
Concrete supports for parents
Parents can also support their babys brain
development by understanding and practicingthe strategies to promote healthy braindevelopment described below.
Building Relationships
One of the most important factors in a childsdevelopment is the support of a parent orcaregiver who gives consistent love andsupport. This importance is underscoredby the Centers for Disease Control and
Preventions (CDCs) effort to promote safe,stable, and nurturing relationships between
2 ReadaboutEarlyHeadStartservicesandlocateprogramson
theEarlyChildhoodLearningandKnowledgeCenterwebsite:
http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/Early%20
Head%20Start.
http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/Early%20Head%20Starthttp://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/Early%20Head%20Starthttp://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/Early%20Head%20Starthttp://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ehsnrc/Early%20Head%20Start -
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children and parents. Because youngchildren experience the world through theirrelationships with parents and caregivers,those relationships are fundamental to thehealthy development of the brain and ofphysical, emotional, social, behavioral, andintellectual capabilities (National Center forInjury Prevention and Control, 2009).
Researchers use the idea of serve andreturn, as in a game of tennis, to describeparent-child interactions. If a child attemptsto interact with a parent (for instance, bybabbling or making faces), but the parentdoes not respond appropriately, then
the childs learning process is incomplete(FrameWorks Institute, 2009). You can helpthe parent or caregiver recognize cueswhen the child wants to eat, sleep, play, orengage in other activities. Over time, thecaregivers awareness of and response to thechilds needs will lead to easier interactionsbetween the two and, ultimately, a strongerrelationship.
Whether a child is at home or has been placed
with a relative caregiver or foster parent,you should focus on ensuring the child has asecure relationship with at least one importantperson in his or her life. Training relativecaregivers and foster parents on meeting thechilds emotional and behavioral needs canhelp them form a healthy relationship thatsupports the childs growth. If the child mustbe placed in out-of-home care, strive to makethe rst placement the last. The importanceof stable attachment relationships for young
childrens healthy development cannot beoverstated. In addition, if the child has beenplaced in out-of-home care, you can supportparent-child attachment, when appropriate,by coordinating a visit soon after placement
and helping the parent maintain a schedule offrequent and extensive visits (Dicker, 2009).
Child Welfare Information Gatewaypartnered with the National ResourceCenter for Permanency and FamilyConnections, a service of the ChildrensBureau, to develop an online trainingon parent-child visits that may helpworkers enhance efforts toward familyreunication. View the free training on theInformation Gateway website:http://training.childwelfare.gov
Establishing Nurturing Routines
The predictability of a daily routine helpschildren understand the world is a safe placewhere they can learn and grow without fear.Routines also help establish and maintain anattachment between the child and caregiver(Hammond, 2010). You can help caregiversunderstand the importance of routines and
create a plan that meets the childs needs.
Children need to feel that their caregiver isin control. The caregiver should discuss anychanges to the routine with the child beforethey occur and give the child age-appropriateopportunities to make decisions about dailyactivities (Perry, 2002). Routines can alsohelp the caregiver establish clear and logicallimits for inappropriate behavior and developdisciplinary strategies that take the childs past
experiences into consideration. When caringfor a traumatized child, these rules should beapplied consistently but fairly (National ChildTraumatic Stress Network Schools Committee,2008).
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Enhancing Parent-Child Interactions
Research shows that babies prefer humaninteraction more than anything else (ZERO TO
THREE, 2008). The connections babies formwith their caregivers and the experiences theyshare are essential to promoting healthy braindevelopment. Because many parents worrythat they dont know how to support theirbabys development, you can teach them basicparenting skills (touching, holding, comforting,rocking, singing, and talking to) and explainthat these simple interactions are some of thebest stimulation a baby can receive (ZERO TOTHREE, 2008).
Prepare caregivers to support childdevelopment and provide appropriatelearning opportunities by describing thestages of child development and the timelinefor milestones they can expect their childrento achieve. Children build upon skills overtime as they accomplish increasingly difcultand varied tasks (National Scientic Councilon the Developing Child, 2007). Caregiversshould understand that children do not learn
faster if they are forced to attempt activitiesthey are not developmentally ready for yet. Inaddition, explain to caregivers of maltreatedchildren the negative developmentaloutcomes that may result from maltreatment.Because the childs developmental age maybe younger than his or her chronological age,the caregiver should adjust expectations andmodify learning activities to meet the childsdevelopmental needs (Perry, 2006).
Use the parent section of the chart beginning
on page 6 to guide a discussion of parentingstrategies with caregivers, or locate resourcesfor caregivers about UnderstandingDevelopmental Stages on the Child WelfareInformation Gateway website: http://www.childwelfare.gov/preventing/promoting/parenting/understanding.cfm
Billys grandmother asked for help fromhis caseworker, who referred him to amental health therapist for evaluation.After letting Billy speak openly abouthis past experiences, the therapistdetermined Billys tendencies to stealfood and sleep on the oor were adaptivebehaviors he developed while livingwith his motherskills that helped himsurvive but are no longer appropriategiven his current, more stable situation.
Building on the therapists advice andtaking Billys unique situation intoconsideration, the caseworker helped hisgrandmother establish regular routines,such as mealtimes and bedtimes, andgave her ideas for activities Billy and hisgrandmother could share to enhance thebond between them. The caseworker alsoconnected the grandmother to a supportgroup where she could meet othergrandparents raising their grandchildren.
BILLYS STORY: PART 3
Supporting Teenage
Brain Development
Trauma and its effects are not limited to youngchildren. Although the rst few years of lifeare critical to supporting brain development,it is important to remember that our brainscontinue growing into young adulthood.
Right before puberty, the adolescent brainexperiences a growth spurt in the areas thataffect planning, reasoning, impulse control,and emotions.
You can help caregivers and other importantadults in a teens life understand how theteenage brain develops and equip them with
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strategies to optimize that development.Teens benet from quality time with theircaregivers and adult mentors who help them:
Organize tasks and set priorities
Practice making decisions
Master new skills
Seek healthy adventures and take positiverisks
Minimize stress
Adopt healthy lifestyles and allow time forplenty of sleep (Chamberlain, 2009)
While all teens need adults in their lives whocan help them gain new experiences andsupport them through adolescence, teens whohave suffered from trauma caused by abuse orneglect can benet especially from caregiverswho encourage their growing independencewhile also offering a safety net when theyneed help.
Read more about adolescent and teen braindevelopment, as well as the impact of trauma,
in The Amazing Brain series on the Institutefor Safe Families website, which providesinformation for parents and caregivers:http://www.instituteforsafefamilies.org/the_amazing_brain_materials.php
Addressing the Effects of Trauma
No two children are affected by trauma inthe same way. Depending on the age atwhich a child experienced a traumatic eventor ongoing trauma, the initial response may
range from hyperarousal (ght or ight) todissociation (freeze and surrender), or acombination of the two (Perry, 2002). It isnormal for children to process their feelings
after a traumatic event. Common emotionalresponses include:
Making sense of the event
Creating memories
Re-experiencing the trauma
Avoiding reminders of the event
Experiencing anxiety or sleep problems
Acting impulsively (Perry, 2002)
Caregivers should not pressure the child totalk about the traumatic event but shouldbe prepared to discuss it when the child is
ready. Children who sense their caregiver isuncomfortable with or upset about the eventmay avoid talking about it. When the childbegins talking, the caregiver should listen,avoid overreacting, answer questions, andprovide comfort and support (Perry, 2002).
Children who continue to experienceheightened emotional responses forlonger than 1 month may be experiencingposttraumatic stress disorder (PTSD) (Perry,
2002).The next section discusses different types ofservices and how to access them for childrensuffering from trauma caused by maltreatment.
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Surviving Childhood: An Introduction tothe Impact of TraumaChild Trauma Academyhttp://www.childtraumaacademy.com/surviving_childhoodDiscusses the impact of negativeexperiences on the developing brain andreviews public policy and preventativeapproaches to address childrens healthand development.
PTSD in Children and AdolescentsNational Center for PTSDhttp://www.ptsd.va.gov/professional/pages/ptsd_in_children_and_adolescents_overview_for_professionals.aspProvides information on events that maycause PTSD, how many children areaffected, risk factors, symptoms, andtreatment.
PTSD IN CHILDREN AND YOUTH
Working With OtherService Providers
Because no single system can address all theissues a child and family may experience,child welfare professionals should strive toform collaborative relationships with otherservice providers to improve access to andcoordination of services. Key services forchildren affected by trauma and their familiesare summarized below.
Early Intervention
Each State has an early intervention program(EIP) that provides specialized health,
educational, and therapeutic services toinfants and toddlers who have an identieddevelopmental delay or disability and theirfamilies. Some States may also serve childrenwho are considered to be at risk of developingsubstantial delays (National DisseminationCenter for Children With Disabilities, 2010).EIPs are administered by lead agencies ineach State (including departments of health,developmental disability, social services,children and families, or education). As
described earlier, State child welfare agenciesare required to refer a child under age 3 whois involved in a substantiated case of abuse orneglect to the EIP.
Early intervention programs can serve as asource of support to help families addresstheir childrens development and, whennecessary, provide services to minimize oreliminate developmental delays. In addition,EIPs may provide a variety of services
to caregivers to help them support theirchildrens development, such as parenttraining, home visitation, or respite care.Once a family is referred to the EIP, an EIPservice coordinator will work with the familyto develop an Individual Family Services Plan(IFPS) and coordinate with the child welfaresystem to ensure the child and familys needsare being met. For more information, seeInformation Gateways Addressing the Needsof Young Children in Child Welfare: Part C
Early Intervention Services(http://www.childwelfare.gov/pubs/partc).
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Early Care and Education
Because children often spend time awayfrom home in early care and education (ECE)
settings, professionals serving very youngchildren are critical partners in supportinghealthy development. ECE programs thatprovide rich learning environments forchildren and work to strengthen familiescan reduce the effects of an unfavorablehome environment (Stepleton, Mcintosh, &Corrington, 2010). ECE professionals alsoobserve the childs behavior in a variety ofsocial and educational situations and maybe among the rst to recognize the signs
of developmental delay. ECE programsthat encourage regular communication withfamilies allow professionals to address anyconcerns as they arise and help connectfamilies to needed services.
When child welfare and ECE professionalsmaintain open communication with thefamilies they serve, everyone can contributeto the decision-making process to determinewhat actions are in the best interests of
the child. This collaboration also facilitatesthe familys ability to access services andallows limited resources to be used moreefciently and effectively (Stepleton et al.,2010). For more information, read the tutorialRecognizing and Addressing Trauma inInfants, Young Children, and Their Familiesfrom the Center for Early Childhood MentalHealth Consultation: http://www.ecmhc.org/tutorials/trauma
Health and NutritionA mothers nutrition during pregnancy affectsher babys birth weight and brain size, andthe quality of a childs nutrition continuesto affect brain development, especially
during the rst 2 years of life (ZERO TOTHREE, 2008). Helping a family gain accessto quality, affordable health care and makehealthy decisions regarding diet and nutritionare important for supporting a childs braindevelopment both before and after birth. Inaddition, when children regularly attend well-child visits, their primary care provider is betterable to assess growth over time, identifydelays early, and make referrals for treatmentor services (Center on the Developing Child atHarvard University, 2007). You should ensurefamilies follow the recommended schedule forwell-child visits and have the means to attend
those visits.The Federal Early and Periodic Screening,Diagnostic, and Treatment (EPSDT) programprovides comprehensive health services forindividuals under age 21 enrolled in Medicaid.Among other requirements, EPSDT programsmust provide services to children such ascomprehensive health and developmentalassessments, physical examinations, vision,hearing, and dental services, and diagnosisand treatment. A health-care provider can
assess the familys eligibility and help themaccess these services. For more information,visit the EPSDT Services in MedicaidKnowledge Path from the Maternal and ChildHealth Library:http://www.mchlibrary.info/knowledgepaths/kp_epsdt.html
Mental Health
When children are affected by a traumaticevent, they may experience a variety of
emotions or display behavioral problemsthat indicate the attention of a mental healthprofessional is needed. The nature of theevent, factors such as the age or sex of thechild, and the childs previous experiences canall affect how he or she responds to trauma
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(Perry, 2002). An assessment by a trainedprofessional can help determine if individualor group therapy would be benecial for thechild to address the impact of the trauma.
There are a number of points to considerwhen working with older youth who maybenet from mental health services:
Youth should be involved in decisions abouttheir mental health care whenever possible.
It is critical to keep the option open foryouth to request mental health servicesbecause they may be resistant initially butchange their mind later.
Workers should strive to reduce any stigmaattached to mental health services.
As with all clients, workers must respect andprotect the privacy of youth who may ormay not choose mental health services.
Keep in mind that parental stress andunresolved trauma from the parents childhoodmay lead to intergenerational traumaimpacting both the parent and childs mental
health. In such cases, services for both theparent and child may be necessary to fullyaddress the effects of trauma.
You can help families receive appropriatemental health services by explaining thebenets to caregivers, connecting them withservice providers that match their needs, andensuring they follow through with treatmentrecommendations. Visit the Mental Healthsection of the Child Welfare InformationGateway website for more information onmental health services for children, youth, andfamilies involved with the child welfare system:http://www.childwelfare.gov/systemwide/mentalhealth
To address Billys problems in school,his caseworker sought the help of theschools psychologist as well as a speechpathologist. Initial tests indicated Billyhad attention-decit/hyperactivitydisorder (ADHD); with parental consent,Billy was prescribed medicine to addressthe issue. The speech pathologist alsobegan working with Billy and gave hisgrandmother exercises to do with himat home. Several months later, when
Billys grandmother and teacher feltthe medicine was not working, Billysmental health therapist was consultedagain. The therapist advised that Billysproblems are more likely caused bysymptoms of posttraumatic stress disorder(PTSD) resulting from his earlier traumaticexperiences. Under the therapistssupervision, Billy stopped taking themedicine, and his treatment plan wasrevised to include more trauma-focusedtherapies, such as play and art therapy, tohelp Billy work through his feelings.
BILLYS STORY: PART 4
Schools and Communities
The physical and emotional distress thattraumatized children experience may leadto behavioral problems in school andpoor academic performance. Potentialdevelopmental delays may worsen thesituation as children fall behind their peersacademically and have difculty makingsocial connections. You can reach out to theeducators of the children you serve to informthem of each childs unique needs and support
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any accommodations necessary to ensurethe childs educational success. In particular,school professionals may benet from specialtraining on the impact of trauma and how towork with traumatized children and youth.The larger community and the opportunitiesit provides for social connections can alsoimpact the childs ability to recover fromtrauma.
The status of the childs emotional or physicalhealth may require the school to developan Individualized Education Program (IEP)in collaboration with the childs family andother professionals involved in the childs life.
The IEP should describe the specic servicesand support the childs needs to meet his orher educational goals. For more informationon the role of educators in supportingtraumatized children and youth, visit theNational Child Traumatic Stress NetworksChild Trauma Toolkit for Educators:http://www.nctsnet.org/resources/audiences/school-personnel/trauma-toolkit
Collaborating With Service Providers
Strategies to improve collaboration amongthese systems include:
Establish cross-training opportunities forprofessionals to understand the basicprinciples of other systems
Ensure adequate mechanisms for referralsto other systems and follow up on thosereferrals
Invite all providers serving the child
or family to regularly scheduled teammeetings
Engage community-based services andformal and informal community networks aspart of the support system for families
Involve related service systems duringsystemic performance reviews or qualityimprovement efforts (Stepleton et al., 2010)
The Child Welfare Information Gatewaywebsite offers resources for Collaboration forService Delivery at http://www.childwelfare.gov/management/practice_improvement/collaboration/service.cfm
Creating a Trauma-Informed ChildWelfare System
For children and youth involved withchild welfare, especially those who havebeen placed in out-of-home care, someexperiences with the child welfare system mayunintentionally cause additional trauma. Beinginterviewed as part of a child abuse or neglectinvestigation, separated from family members,or moved among multiple placements cancontribute to the trauma the child may have
already experienced. The key to makingchild- and youth-serving systems more trauma-informed is professionals who understandthe impact of trauma on child developmentand can address trauma and minimize anyadditional negative effects.
According to the National Child TraumaticStress Network (2008b), essential activities ofchild welfare trauma-informed practice are:
Maximize the childs sense of safety
Assist children in reducing overwhelmingemotion
Help children make new meaning of theirtrauma history and current experiences
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Address the impact of trauma andsubsequent changes in the childs behavior,development, and relationships
Coordinate services with other agencies
Use comprehensive assessment of thechilds trauma experiences and their impacton the childs development and behavior toguide services
Support and promote positive and stablerelationships in the life of the child
Provide support and guidance to the childsfamily and caregivers
Manage professional and personal stress,often called vicarious or secondary trauma
Child welfare agencies across the countryare realizing the benets of trauma-informedpractice for children, families, and theirworkforce, and are building upon existingpolicies and practices to make their servicesmore trauma-informed. For example, since itslaunch in 2007, the Multiplying Connectionsinitiative in Philadelphia has taken great strides
to improve public child and family servicesystems in ways that will promote higherquality connections between children andcaring adults that in turn lay the foundation foroptimal brain development. The following aresome strategies used by the initiative to createmore trauma-informed services:
Revise mission statements, policies andprotocols, and core competencies toinclude trauma-informed practices andvalues
Implement professional developmentactivities and create training cohorts amongstaff to promote collaboration and sharedlearning opportunities
Strengthen organizational partnerships byholding joint meetings and sharing fundingwhen possible
Incorporate trauma-informed practice goalsinto evaluation activities (Lieberman &Cairns, 2009)
For more information on trauma-informedpractice, access the National Child TraumaticStress Networks Child Welfare Trauma TrainingToolkit: http://www.nctsnet.org/products/child-welfare-trauma-training-toolkit-2008, orvisit the website of Philadelphias MultiplyingConnections initiative:
http://www.multiplyingconnections.org
Conclusion
To create an effective trauma-informedchild welfare system, it is critical that theprofessionals who regularly interact withfamilies are familiar with and can respond tothe issues surrounding trauma and its effecton brain development. Efforts should beginwith prevention, when families can learnparenting strategies to promote healthy brain
development and prevent abuse or neglect.Many of the same preventive strategies canalso be taught to parents involved with childwelfare, foster parents, relative caregivers,and other out-of-home care providers tosupport the development of a traumatizedchild or youth and minimize the effects oftrauma. Professionals who know the stagesof development and the warning signs fordevelopmental delays can work with familiesto identify concerns and connect them to
needed services. Ultimately, coordinated child-and youth-serving systems that are rooted intrauma-informed practices can have a positiveimpact on outcomes for children, youth, andfamilies involved in the child welfare system.
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BILLYS STORY: CONCLUSION
In order to improve communicationand avoid overlapping efforts, Billyscaseworker scheduled a multidisciplinaryteam meeting for the adults in Billys life.The long-term plan that resulted fromthe meeting included a number of actionitems:
Billys therapy sessions will continue; hisgrandmother will attend on occasionto support his progress and learn new
activities and exercises to do with himat home.
At school, Billys teacher will follow thenewly created individual education plan(IEP) to help him succeed academicallyand will create a weekly progress report.Billys speech pathologist scheduledseveral more sessions to track hisimprovements.
Billys grandmother will continue to
attend monthly grandparent supportmeetings to make connections andreceive support from other communitymembers.
Billys caseworker will help hisgrandmother become a foster parentand seek nancial support while shecares for Billy. If Billys father or motheris unwilling or unable to care forhim, the grandmother will apply for
subsidized guardianship to give Billy amore permanent home.
Suggested Citation:
Child Welfare Information Gateway(2011). Supporting brain development
in traumatized children and youth.Washington, DC: U.S. Department ofHealth and Human Services, ChildrensBureau.
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