CHILD AND FAMILY TRAUMA

F R E D E R I C K H . ST R I E D E R , M S S A , P H DC L I N I C A L A S S O C I AT E P R O F E S S O R , U N I V E R S I T Y O F

M A R Y L A N D S C H O O L O F S O C I A L W O R KD I R E C T O R , FA M I LY C O N N E C T I O N S B A LT I M O R E

E L I Z A B E T H T H O M P S O N , P H DA S S I S TA N T V I C E P R E S I D E N T, D I R E C T O R

T H E FA M I LY C E N T E R AT K E N N E D Y K R I E G E R I N S T I T U T E

CHILD AND FAMILY TRAUMA

AGENDA

What is Child Traumatic Stress?Impact of Trauma on Child and

FamilyNational Child Traumatic Stress

NetworkTrauma Informed Organizational

PracticeTrauma InterventionsSecondary Traumatic Stress and the

WorkforceQuestions

What Is Child Traumatic Stress?

Artwork courtesy of the International Child Art Foundation (www.icaf.org)

What Is Child Traumatic Stress?

Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling).

Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal.

What Is Child Traumatic Stress, cont'd

A child’s response to a traumatic event may have a profound effect on his or her perception of self, the world, and the future.

Traumatic events may affect a child’s: Ability to trust others Sense of personal safety Effectiveness in navigating life changes

CONTEXT OF TRAUMA

Natural Disasters Illnesses and Injury Wars, Genocide, Terrorism Industrial and Nuclear Disasters Family and Intimate Partner

Violence Immigration Workplace and School threats and

violence Community/Neighborhood

Violence Institutional Victimization/Violation Child Maltreatment

Physical, Sexual, Emotional Abuse and Neglect

700 BCE documented in Homer’s Iliad 1800’s Freud “hysterical neurosis” WWI “shell shock”-weakness WWII “combat neurosis” 1960’s Recognition of Effects of

Trauma (Vietnam, Rape Crisis Centers) 1976 Chowchilla, CA (Lenore Terr) 1980-DSM III included PTSD as a

diagnosis for Adults 1987-DSM III-R Recognition of

differing PTSD symptoms in children 1994,2000- DSM IV TR Full

Recognition of Children

Types of Traumatic Stress

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

• Chronic trauma refers to the experience of multiple traumatic events. The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

• Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.

Prevalence of Trauma—United States

Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect.

In 2005, 899,000 children were victims of child maltreatment. Of these: 62.8% experienced neglect 16.6% were physically abused 9.3% were sexually abused 7.1% endured emotional or psychological abuse 14.3% experienced other forms of maltreatment (e.g., abandonment,

threats of harm, congenital drug addiction)

Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

U.S. Prevalence, cont'd

One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1

In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2

Four out of 10 U.S. children report witnessing violence;8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3

1. Costello et al. (2002). J Trauma Stress;5(2):99-112.2. Schwab-Stone et al. (1995). J Am Acad Child Adolescent

Psychiatry;34(10):1343-1352.3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.

http://www.ncjrs.gov/pdffiles1/nij/194972.pdf

Impact of Trauma on Child and Family


Variability in Responses to Stressors and Traumatic Events

The impact of a potentially traumatic event is determined by both: The objective nature of the event

The child’s subjective response to it

Something that is traumatic for one child may not be traumatic for another.

Variability, cont’d

The impact of a potentially traumatic event depends on several factors, including: The child’s age and developmental stage The child’s perception of the danger faced Whether the child was the victim or a witness The child’s relationship to the victim or perpetrator The child’s past experience with trauma The adversities the child faces following the trauma The presence/availability of adults who can offer help and

protection

Effects of Trauma Exposure on Children

When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far-reaching effects on nearly every aspect of the child’s life.

Children who have experienced the types of trauma that precipitate entry into the child welfare system typically suffer impairments in many areas of development and functioning, including:

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Effects of Trauma Exposure

Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others.

Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.

Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.

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Effects of Trauma Exposure

Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.

Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.

Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.

Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.

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Long Term Effects

In the absence of more positive coping strategies, children who have experienced trauma may engage in high-risk or destructive coping behaviors.

These behaviors place them at risk for a range of serious mental and physical health problems, including: Alcoholism Drug abuse Depression Suicide attempts Sexually transmitted diseases (due to high risk activity with multiple partners) Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease

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Source: Felitti et al. (1998). Am J Prev Med;14(4):245-258.

Childhood Trauma and PTSD

Children who have experienced chronic or complex trauma frequently are diagnosed with PTSD.

According to the American Psychiatric Association,1 PTSD may be diagnosed in children who have: Experienced, witnessed, or been confronted with one or more

events that involved real or threatened death or serious injury to the physical integrity of themselves or others

Responded to these events with intense fear, helplessness, or horror, which may be expressed as disorganized or agitated behavior

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Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

Childhood Trauma and PTSD

Key symptoms of PTSD Re-experiencing the traumatic event (e.g. nightmares, intrusive

memories) Intense psychological or physiological reactions to internal or

external cues that symbolize or resemble some aspect of the original trauma

Avoidance of thoughts, feelings, places, and people associated with the trauma

Emotional numbing (e.g. detachment, estrangement, loss of interest in activities)

Increased arousal (e.g. heightened startle response, sleep disorders, irritability)

Source: American Psychiatric Association. (2000). DSM-IV-TR ( 4th ed.). Washington DC: APA.

Childhood Trauma and Other Diagnoses

Other common diagnoses for children in the child welfare system include: Reactive Attachment Disorder Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Bipolar Disorder Conduct Disorder

These diagnoses generally do not capture the full extent of the developmental impact of trauma.

Many children with these diagnoses have a complex trauma history.

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Trauma and the Brain

Trauma can have serious consequences for the normal development of children’s brains, brain chemistry, and nervous system.

Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition.

Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans.

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1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193

Influence of Culture

People of different cultural, national, linguistic, spiritual, and ethnic backgrounds may define “trauma” in different ways and use different expressions to describe their experiences.

Child welfare workers’ own backgrounds can influence their perceptions of child traumatic stress and how to intervene.

Assessment of a child’s trauma history should always take into account the cultural background and modes of communication of both the assessor and the family.

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FITT Model

Family Processe

s

Sibling Relation

s

Adult Intimate Relations

Parenting Practices &

Quality

Parent-Child

Relations

Time* Acute and longer-term effectsIndividual developmentFamily life cycle

Child Respons

e

Adult/ParentalResponse

Adult Family of Origin Response

UrbanPoverty

Child

and

Family

Outcomes

Adapted from Kiser & Black, 2005

Trauma and Family Informed Principles*

National Child Traumatic Stress Network



The mission of the National Child Traumatic Stress Network (NCTSN) is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States.


• Funded in 2000 (Children’s Health Act) supported through funding from the Donald J. Cohen National Child Traumatic Stress Initiative, administered by the US Department of Health and Human Services (DHHS), Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA)

• Rapid Change – post 9/11/01• Innovative Collaborative Structure:

• UCLA-Duke University National Center for Child Traumatic Stress (Category I)

• Intervention Development and Evaluation Centers (Category II)

• Community Treatment and Service Centers (Category III)

• Alumni members

Trauma Informed Organizational Practice


The Paradigm Shift

Traditional Care

Trauma-Informed Care

Trauma Specific Intervention

Trauma-Informed Care

Universal understanding that nearly every individual seeking services in human service systems has a trauma history

Provision of care should be trauma competentBased on public health prevention concepts (with

emphasis on primary and secondary prevention)Commitment to strengths based beliefs and practices

(e.g. promoting resilience, collaborative working relationship with consumers and survivors)

Pre-requisites for Trauma Informed Service Delivery

Administrative commitmentUniversal screening for trauma

Assessment as neededOn-going staff training and education

Expert trauma consultation available to staffHiring practicesReview of organizational policies and procedures

Avoidance of re-traumatization practices Harris & Fallot (2001)

The Sanctuary® Model

Trauma exposure in individuals who seek services as well as the individuals who provide those services

Organizational stressors (e.g. fiscal pressures, regulatory compliance, workloads, etc.)

Active creation of trauma informed community7 Commitments

Nonviolence Emotional Intelligence Social Learning Democracy Open Communication Social Responsibility Growth and Change

Trauma Interventions


How can we sort out the good from the poor or even harmful interventions?

?A Good Question...

DevelopInterventionApproach

Use inPracticeSetting

ConductEfficacy Studies

ConductEffectiveness

Studies

DisseminateInterventionto the Field

The Ideal Clinical Science Process

Quality of Trauma Treatment

Practice Base

d Evidence

Emerging Practice

Good

Practice

Promising

Practice

Best Practice

Evidence

Informed Practice

Evidence

Supported Practice

Evidence

Based

Practice

Family Functioning

Child Response

Adult/ParentalResponse

Sibling Relations


Parenting Practices & Quality

Parent-Child Relations

TA-FC

LIVEGrandparent/caregiver Support GroupsSAFE

Family Processes

Child Response

Adult/Parental

Response

Sibling Relations


Parenting Practices &

Quality

Parent-Child Relations

AdultFamily of Origin

Response

Emotionally Focused TherapyFL

AF-CBTFLSFCRTF Parent Coaching

TF-CBTTG-CBTPCITAF-CBTCPPFLSFCR

AF-CBTSFCR

Cognitive Processing TherapyTG-CBTFLSFCR

FLSFCR

SOCIAL & SYSTEMS DEMANDS

SOCIAL AND PUBLIC INCIVILITIES

DAILY HASSLES

FINANCIAL INSTABILITY

RESIDENTIAL INSTABILITY Trauma

Trauma

Trauma

TF-CBTAF-CBTCFTSISFCR

Potential Family Interventions

What is the Common Elements approach?

Using elements that are found across several evidence-supported, effective interventions

“Clinicians ‘borrow’ strategies and techniques from known treatments, using their judgment and clinical theory to adapt the strategies to fit new contexts and problems” (Chorpita, Becker & Daleiden, 2007, 648-649)

An alternate to using treatment manuals to guide practice

Actual treatment elements become unit of analysis rather than the treatment manual

Treatment elements are selected to match particular client characteristics

Secondary Traumatic Stress and the Workplace


Potential for Personal Impact

Current Research

• Younger therapists experiences more burnout while more experienced therapists reported more compassion satisfaction.

• Implementing EBP’s generally reduced reported compassion fatigue and burnout.

Compassion Fatigue

• “a state of tension and preoccupation with the traumatized patients by re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e.g. anxiety) associated with the patient” (Figley, 2002)

• Often experienced as helplessness, confusion, sense of isolation from support

• Faster onset of symptoms than burnout or countertransference

• Faster recovery from symptoms• Highly treatable

Vicarious Trauma

• The process through which the clinician’s inner experience is negatively transformed through empathic engagement with the client’s trauma. (McCann & Pearlman, 1990)

• The cumulative transformative effect upon the professional who works with victims of trauma. (Pearlman & Saakvitne, 1995)

• Takes place over time• Responses unique to the person• Not specific to a particular client

Secondary Stress

• “the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1999, p.10)

• Those with enormous capacity for empathy for others tend to be more at risk

• Who can be affected?

Burnout• A state of physical, emotional, and mental

exhaustion caused by long term intervention in an emotionally-demanding situation

• Process, not an event• Positively associated with stressors (more

stressors more burnout) and negatively with social support (more social support less burnout)

Directly

Traumatized• Clinicians can also be directly experience

trauma in their work with families

• This can occur in many ways and the impact is dependent upon the individual

• Depending on clinician’s need, additional support may be needed

Traumatic Countertransferen

ce

• Emotional, physical or interpersonal reactions toward the client and can be a negative hindrance & inevitable occurrence; but often a positive opportunity for growth, building therapist’s intuition, self-awareness and perceptions (Burke, Carruth & Pritchard, 2006, pg. 287-288).

• Spontaneous response of professional regarding client’s information, behavior, emotions

• Professionals working with trauma often experience reactions to clients’ stories

• Reaction influence by practitioner’s own family history and experience

QUESTIONS???

Thank you!

CHILD AND FAMILY TRAUMA

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