Protecting Their Future: Finding and Helping Stressed Children and Families Chris Bray, Ph.D., LP Ambit Network University of Minnesota www.ambitnetwork.org.
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Protecting Their Future: Finding and Helping Stressed Children and Families Chris Bray, Ph.D., LP Ambit 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 Director Dante Cicchetti, Research Director Gerry August, Training and Education Director Affiliated Faculty Chris Bray, Administrative Director Ambit Network University 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 Network University 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 Providers www.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. What is your ACE Score? Adverse Childhood Experiences and Maladaptive Coping Strategies The Adverse Childhood Experiences Study Dr. Felitti – Kaiser Permanente Dr. Anda – Center for Disease Control and Prevention Negative Coping Mechanisms Smoking Severe obesity Suicide attempts Alcoholism Drug abuse 50+ sex partners ACE Score Repetition of original trauma Self Injury Eating disorders 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 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 SAMHSA Wellness Campaign 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 event Felitti, Anda, Nordenberg, et al (1998) Up to 25% of youth between the ages of 9-16 have experienced at least 1 traumatic event Costello, 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 child Gelles, 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 trauma Attorney 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 events o Particularly complicated by the shame and stigma associated with many types of trauma • Identifying ‘invisible’ witnesses o E.g. emergency room visits o 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 Types of Trauma • • • 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- Acute Trauma Trauma Trauma Trauma Chronic Trauma Impact of Exposure Babeau Complex 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) Hippocampus Hypothalamus Heart rate and blood pressure increase Breathing rate increases Release of adrenaline and cortisol 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 It Adolescent development relies upon what is learned in the course of relationships and through past experiences PUBERTY/EARLY ADOLESCENCE 11 – 14 Years Child Development and Trauma PUBERTY/EARLY ADOLESCENCE 11 - 14 Years Expected Development: • Psychological in line with physical changes • Preoccupation with body • Sense of distinctiveness • Change in relationship with parents • Peer pressure (Joan LaVoy, 2013, Anishinaabeg Today) Child Development and Trauma PUBERTY/EARLY ADOLESCENCE 11 - 14 Years 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. ADOLESCENCE 14 - 18 Years Child Development and Trauma ADOLESCENCE 14 - 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) (Gary W. Padrta, 2013, Anishinaabeg Today) Child Development and Trauma ADOLESCENTS 14 - 18 Years 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 Child Development and Trauma ADOLESCENCE contd. 14 - 18 Years 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 The Invisible Suitcase Trauma helps shape adolescents’ beliefs and expectations: • About themselves • About the adults who care for them • About the world in general Trauma’s Impact on Emotional Development • Difficulty with self-regulation • Difficulty describing feelings/internal states • Difficulty communicating wishes and desires Trauma’s Impact on Behavioral Development 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 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 52 the event. HC-MC Well-Being Model© (BigFoot & Schmidt, 2008) The Influence of Developmental Stage • This may reduce children’s capacity to explore their environment and to master ageappropriate developmental tasks. • The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways. 53 Still Face Experiment Helping Babies From the Bench: Using the Science of Early Childhood Development in Court: http://youtu.be/vmE3NfB_HhE?t=33 Youth in the JJ System Pathways, Characteristics, Outcomes 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 Characteristics of Youth in JJ System 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 Long Term Outcomes • Higher 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 What Works 2000 Politicization: 1990’s 3 strikes Just Deserts 1970’s Sentencing Guidelines Utilitarian: 1980’s Mandatory Minimums 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, selfesteem Scared straight approaches Insight oriented, psychodynamic, non-directive, or client-centered therapies Lack of direct training procedures with an absence of modeling 64 and role-playing 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 •• Know you make a difference, Begin to plant • Recognize the see result of trauma or bad seeds even if you don’t the healthy seeds that have been planted. final result. • Understand that building resilience takes time 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? Depression? ADHD? PTSD?? Substance Abuse? 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 University of Minnesota’s Traumatic Stress Screen for Children and Adolescents (TSSCA) Name of Child/Adolescent: _________________________ DOB: _______________ G ender: M F Interviewer Name/ID: _____________________________ Assessment Date: ____________________ Below is a list of problems that people sometimes have after experiencing a bad or upsetting event. Bad or upsetting events might include being threatened or hurt, seeing someone else threatened or hurt, or feeling like your life was in danger. Have you ever experienced a bad or upsetting event? Yes No If yes, what was the bad or upsetting event? Feel free to list more than one. _________________________________ _______________________________ _______________________ _______________________________________________________________________________________ _____________________________________________ _________________________________ _________ When thinking about your bad or upsetting event, how often have the following problems happened to you during the past month? DURING THE PAST MONTH, HOW OFTEN HAVE YOU… 1. Had upsetting thoughts, images, or memories of the event come into your mind when you didn’t want them to? 2. 3. 4. 5. Never Sometimes Often 0 1 2 Felt afraid, scared, or sad when something reminded you about the event? 0 1 2 Tried to stay away from people, places, or activities that reminded you of the event? 0 1 2 0 1 2 0 1 2 Had trouble feeling happiness, enjoyment, or love? Been on the lookout for danger or other things that you are afraid of (for example, looking over your shoulder when nothing is there)? + + TOTAL © Ambit Network, University of Minnesota, 2015, Minneapolis, MN. [email protected]. This form may be reproduced and used for free with permission from the Ambit Network. . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! 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 decisionmaking 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 Safety plans include: 1. Trauma history 2. Trauma triggers 3.Warning signs 4. Calming behaviors 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 Trauma Grief and Component Therapy for Adolescents Module 1 Module 2 Module 3 Module 4 • Foundation Knowledge and Skills • The Trauma Narrative • Working Through Grief Experiences • Preparing for the Future How Would You Cope with these Realities? Survival Coping Strategies What Supports Resilience? Family Support Spiritual Resiliency from Belief is the ability to recover Peer Support trauma. School Connectedness Self-esteem Competence Self-efficacy 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 assessed o Ways agencies gather, assess, and share trauma-related information o 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 PTSD o 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-parentstrauma-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 communication o When posttraumatic stress symptoms interfere with daily interactions with children, parents should seek individual treatment. Voices of Parents Voices of Parents Safety 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 The A-B-C’s of Self--Care 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. Awareness Balance Professional Physical Psychological Spiritual Emotional Connection… with your family Organizational Stress What do you think are some events 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 Information Chris Bray Institute for Translational Research in Children’s Mental Health University of Minnesota, [email protected] 612-624-3748