Childhood Trauma and Trauma-Informed Systems of Care

1. Childhood Trauma and Trauma-Informed Systems of Care Molly Lopez, Ph.D. Texas Institute for Excellence in Mental Health Center for Social Work Research University of Texas at Austin

2. Types of Traumatic Events • Physical abuse • Sexual abuse • Domestic violence • Community violence • Traumatic loss • Car accidents • Bullying • Accidental injuries • Animal attack • Fires • Natural disaster • Life-threatening medical emergencies

3. Prevalence out of every

4. Some Trauma Facts • Trauma is almost universal for boys (93%) and girls (87%) in the JJ System • Children in the child welfare system almost by definition have suffered trauma, often multiple traumatic events and 50-75% exhibit symptoms that need mental health treatment(Landsverk et al, 2009). • Trauma increases the risk of further trauma (most survivors have at least 2 distinct trauma incidents).

5. The Stress Response Surge in adrenaline, epinephrine, & cortisol Increased metabolism Faster heart rate Faster respiration Increased blood sugar Increased blood pressure Suppression of other systems

6. Normal vs. Sensitized Response following Trauma Arousal Sensitized Normal Time

7. The Role of Reminders Reminders of past trauma sight smell taste feeling sound Alarm system is activated triggers Respond as though there is current danger

8. DSM-IV PTSD • Criterion A: Stressor • Criterion B: Intrusive Recollection (1) • Criterion C: Avoidance or Numbing (3) • Criterion D: Hyperarousal (2) Only about 3 to 15% of children who experience a significant trauma meet full criteria for PTSD.

9. Endorsement of Trauma Symptoms van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola (2005). Journal of Traumatic Stress

10. Coping with Trauma • Trauma survivors adopt a set of survival skills that have helped them manage their trauma in the past. • These strategies make sense given what people have experienced, even if they are confusing to others or are seen as getting in the way of current goals.

11. The Adverse Childhood Experiences (ACE) Study • Collaboration between Centers for Disease Control and Prevention (CDC) and Kaiser Permanente HMO in California • Largest study ever that determined both the prevalence of traumatic life experiences in the first 18 years of life and the impacts on later well-being, social function, health risks, disease burden, health care costs, and life expectancy • 17,000 adult members of Kaiser Permanente HMO participated • Subsequent 5-state study in 2010

12. Types of Adverse Childhood Experiences (Birth to 18) • Abuse of Child • Emotional abuse, 11% • Physical abuse, 28% • Contact sexual abuse, 22% • Neglect of Child • Emotional neglect, 19% • Physical neglect, 15% • Trauma in Child’s Household • Alcohol or drug use, 2% • Depressed, emotionally disturbed, or suicidal household member, 17% • Mother treated violently, 13% • Imprisoned household member, 6% • Loss of parent, 23%

13. Impacts of Childhood Trauma (ACE Study) • Neurobiological Impacts • Disrupted development • Anger–rage • Hallucinations • Depression/other mental health challenges • Panic reactions • Anxiety • Somatic problems • Impaired memory • Flashbacks • Dissociation • Health Risks • Smoking • Severe obesity • Physical inactivity • Suicide attempts • Alcohol and/or drug abuse • 50+ sex partners • Repetition of trauma • Self injury • Eating disorders • Violent, aggressive behavior

14. Impacts of Childhood Trauma (ACE Study) • 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- and other perception and loss of meaning • Intergenerational abuse • Involvement in MANY services • HIV/AIDS

15. ACE Model

16. Trauma-Informed Care Incorporates proven practices into current operations to deliver services that acknowledge the role that violence and victimization play in the lives of most of the children entering our systems.

17. Trauma-Informed Care (TIC) provides a new paradigm under which the basic premise for organizing services is transformed. From: To: From:To: What is wrong with you? What happened to you? Control Collaboration

18. Trauma Informed Systems… • educate children, families, and providers on trauma exposure, its impact, and treatment; • engage in efforts to strengthen the resilience and protective factors of children and families; • routinely screen for trauma exposure and related symptoms; • use culturally appropriate evidence-based assessment and treatment; Adapted from NCTSN definition

19. Trauma Informed Systems… • address parent and caregiver trauma and its impact on the family system; • emphasize continuity of care and collaboration across child-service systems; and • maintain an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress, and that increases staff resilience. Adapted from NCTSN definition

20. A Culture Shift: Core Principles of a Trauma-Informed System • Safety: Ensuring physical & emotional safety • Trustworthiness: Maximizing trustworthiness, making tasks clear, & maintaining appropriate boundaries • Choice: Prioritizing child & family choice & control • Collaboration: Maximizing collaboration & sharing of power with child and family • Empowerment: Prioritizing empowerment and skill-building

21. Trauma-Specific Treatments Interventions intended to increase coping skills and reduce trauma-related emotional and behavioral symptoms

22. Trauma Specific Treatments • Examples of Evidence-Based Trauma Treatments • Trauma-Focused Cognitive Behavioral Therapy • Parent Child Interaction Therapy • Real Life Heroes • Seeking Safety • Cognitive Behavioral Intervention for Trauma in Schools (CBITS) • TF-CBT (Grief)

23. Key Components in Effective Trauma Interventions • Focus on relationship with caregiver • Psychoeducation on the effects of trauma on children • Building affective expression and modulation skills • Relaxation and anxiety management skills • Building cognitive coping skills • Safety planning • Retelling of trauma/exposure

24. Resources • National Child Traumatic Stress Network (http://www.nctsnet.org/) • National Center for Trauma Informed Care (http://www.samhsa.gov/nctic/) • Child Welfare Information Gateway (http://www.childwelfare.gov/responding/trauma.cfm) • THRIVE Maine’s System of Care Inititiative (http://thriveinitiative.org/)