Understanding and Addressing Trauma within Systems:

Key Issues and Ways to Support Trauma-Informed Practices

Cassandra Kisiel, Ph.D.

Center for Child Trauma Assessment and Service Planning

Northwestern University Feinberg School of Medicine

The National Child Traumatic Stress Network (NCTSN) www.nctsn.org

• Mission: To raise the standard of care and increase access to services for traumatized children and their families across the US

• Established by Congress in 2000• National collaboration of multiple academic and community-

based service centers • Serves as a national resource for disseminating evidence-

based interventions, trauma-informed services, and public and professional education

• Emphasis on transforming trauma-focused services throughout child-serving systems of care across the U.S.

• Currently comprised of 176 member centers - including 79 currently funded Centers and 98 affiliate members

Prevalence and Impact of Trauma• More than 67% of children/adolescents experience at least

one potentially traumatic event before the age of 16.• 4 out of 10 U.S. children report witnessing violence; 8%

report a lifetime prevalence of sexual assault; 17% report being physically assaulted.

• The majority of traumatized children experience multiple, co-occurring, and often chronic forms of trauma or adverse experiences.

• More than 60% of American males and 51% of females report lifetime exposure to one or more traumatic events; about 1 in 3 women will experience sexual assault in their lifetime.

• Trauma impacts a broad range of areas for youth and adults: emotional, behavioral, interpersonal, physiological, and cognitive functioning.

• Chronic interpersonal trauma in childhood has a differential impact on adults compared to acute or interpersonal traumas in adulthood.

• Strengths have an important role in buffering the effects of trauma.

A Common Theme for Systems

Child Welfare Juvenile Justice

Mental and Physical Health

Education

Substance Abuse

Trauma

The Impact of Trauma within Systems

• Rates of maltreatment are significantly higher in juvenile detention and child welfare than in the general population.

• Many youth and adults with trauma histories and current symptoms are never assessed or fully assessed.

• Many youth with trauma symptoms never receive appropriate treatment.

• Children and adults in both systems are sometimes “blamed” or labeled as “bad” = potential stigma

• Both systems are largely comprised of already oppressed individuals who are often exposed to several other ongoing stressors.

Based on Kisiel et al. (2009). J Child and Adoles Trauma, 2:143-160

Neglect

Family

Violence

Traumatic G

rief/S

eparation

Physica

l Abuse

Emotional A

buse

Witness

Criminal A

ctivity

Medica

l Trauma

Sexu

al Abuse

Community Violen

ce

School V

iolence

Natural Disa

ster

War A

ffected

Terro

rism Affecte

d0

5

10

15

20

25

30

35

40

45

50

Significant Traumatic Experiences for Youth entering Illinois Child Welfare (N=16,474)

Trauma Symptoms

Life Domain Fu

nctioning

Accultu

ration

Emotional/Behavio

ral Needs

Risk Behavio

rs0

5

10

15

20

25Single/Non-CG Trauma Complex Trauma

Frequency of Significant Clinical Needs (N = 16,474)

Complexly Traumatized Youth Entering IL Child Welfare

All differences sig. at p=.000

Based on Kisiel et al. (2009). JCAT, 2:143-160

*Complex Trauma Exposure = 2 or more significant caregiver traumas on the CANS

Placement Disruptions by Type of Trauma Exposure:Two Years Following Entry into CW System (N=14, 264)

Illinois child welfare system, Incident Rate Ratios, **=p<.001

Single

Type

(Viol

ent)

Single

Type

(Non

-Viole

nt)**

Multipl

e/Com

plex T

rauma**

5%

15%

26%

Kisiel et al., 2012

Children’s Posttraumatic Reactions:

Risk for Misdiagnosis and MislabelingChildren presenting with posttraumatic symptoms

are at risk of being misdiagnosed with a variety of disorders and functional difficulties particularly when a trauma assessment is not conducted

ADHD Depressive Disorders Oppositional Defiant Disorder Conduct Disorder Reactive Attachment Disorder Psychotic Disorders Specific Phobias Learning/ academic difficulties Juvenile Delinquency

Challenges in the Assessment of Trauma Responses and within Service Systems-

Misunderstood or Mislabeled?

Trauma: A

Missing Link?

Willful defiance/n

on-complianc

e

Conduct Disorder/

‘Sociopathic’

behaviors

Problems with

Attention and

Learning

Psychotic Sympto

ms

Intensely Reactive

behaviors/Sexually

aggressive behaviors

What is a Trauma-Informed Service System?

• All programs/providers involved in a particular system recognize and respond to the impact of traumatic stress on all those who have contact with their system.

• Programs and agencies within this system infuse and sustain trauma awareness, knowledge and skills to their organizational cultures, practices and policies

• Programs and agencies act in collaboration with all those involved (using best available evidence) to facilitate and support resiliency of the child/adult and family.

www.nctsn.org

Trauma-Informed PracticeThe trauma-informed professional:

• Understands the impact of trauma on a child or adult’s behavior, development, relationships, and survival strategies

• Can integrate that understanding into planning for the child, adult, and family

• Understands his or her role in responding to child traumatic stress

NCTSN Child Welfare Trauma Training Toolkit, 2008

Resilience

“The process of, the capacity for, or outcome of successful adaptation despite challenging or threatening circumstances.”

(Masten, Best, & Garmezy, 1990)

Protective Factors

Protective factors can:

1. Buffer individuals from exposure to additional traumas or adversities

2. Increase the likelihood of positive outcomes following exposure to trauma.

Protective Factors or Factors Promoting Resilience

Individual Factors Developmental Competencies (language, cognitive skills) Personality and temperament Positive Beliefs/Self-efficacy Internal Locus of Control External Attributions for Blame Special Talents/Creativity Spirituality/Meaning-Making

Environmental Factors

Ongoing Social Support – within and outside of family

Secure Attachments –Positive attachment with emotionally supportive adult

Family Cohesion/Ties to Extended Family

Community Involvement (recreational, religious)

What can I D0 in my work?

Helping to Support Trauma-Informed Practices across

Settings

General Guidelines and Implications for Practice:

How to Support Staff, Youth, and Caregivers• Recognize that exposure to trauma is often the

rule, not the exception, among youth and adults in child welfare and justice settings.

• Recognize the cumulative effects of trauma – the range of signs and symptoms stress and how they vary across different age groups.

• Recognize that an individual’s “bad” behavior is sometimes an adaptation to trauma or a result of them not having developed age-appropriate regulation capabilities.

Utilizing a Trauma-informed Perspective: Practical Recommendations (www.nctsn.org)

1. Routinely screen for trauma exposure and related symptoms2. Conduct a comprehensive assessment – gathering

information on all traumas and range of reactions to make better-informed decisions.

3. Integrate culturally appropriate and responsive evidence-based practices

4. Engage in efforts to strengthen the resilience and protective factors of children/families and adults impacted by trauma

5. Address parent trauma and its impact on the family system6. Enhance communication/share resources with youth, adults,

and providers on trauma exposure, its impact and treatment7. Promote effective family involvement in counseling/rehab

services.8. Emphasize continuity of care and collaboration and training

for ALL relevant professionals across child or adult service systems

9. Maintain an environment of care that addresses and minimizes secondary trauma and increases staff resilience

Promoting resilience and building competence in the context of treatment

and services• Strengthen ties to other

adult/community resources• Teach flexible problem-solving skills

– Communication skills– Self-help skills

• Foster independence and responsibility• Strengthen and support individual

competencies• Model/reward acts of cooperation and

helpfulness

June is National PTSD Awareness Month

Why take time to learn about PTSD?

• Because taking the step to help someone you care about (even yourself), or your clients, starts with knowing the basics.

• No matter how much you already know about PTSD and trauma responses, there is always more to learn.

• Initial step - connect with materials to help you learn more about PTSD, including the latest research and tools to manage symptoms

See www.ptsd.va.gov for more information

Provider Resources in Illinois: Statewide Provider Database (SPD) –

https://illinoisoutcomes.dcfs.illinois.gov • Program Type

– Mental Health– Substance Abuse– Domestic

Violence– Parenting– Non-clinical– Early Childhood– General Medical

• Target Population– Deaf/hard-of-

hearing– Developmentally

disabled– Young Children– Teen parents– Sexual offenders– Trauma survivors– GLBTQ– Foster care

Information and Resources on Addressing Trauma:

Helpful Organizations and Websites• National Child Traumatic Stress Network:

www.nctsn.org (child)• National Center for PTSD: www.ptsd.va.gov (adult)• International Society for Traumatic Stress Studies:

www.istss.org• American Professional Society on the Abuse of

Children www.apsac.org

• International Society for the Prevention of Child Abuse and Neglect www.ispcan.org

• Illinois Statewide Provider Database https://illinoisoutcomes.dcfs.illinois.gov

•

Thank You!

Contact Information:

Cassandra Kisiel, Ph.D.c-kisiel@northwestern.edu