Understanding Childhood Trauma and its Lifelong Effects – A Systems Approach

1. Understanding Childhood Traumaandits Lifelong Effects – A Systems Approach Healthy People Stable Families Strong Communities Joanne Mooney and Carole Wilcox Child Safety and Permanency Division, MNDHS

2. Overview of Presentation • Adverse effects on healthy development due to toxic stress and trauma • Approaches to improving the odds • Development of a trauma informed Minnesota public child welfare system • Building hope from resiliency

3. Orientation What do we hope for our children?

4. MN Public Child Welfare System Hope for Children • Based on the child welfare practice model built form lessons learned over the last decade of reforms • Shift from “Family Bubble” or “Deficit Oriented Models” to Models that focus on strengths, health, & thriving. We work with parents and partners to ensure that children and families are supported to achieve equitable optimal development regardless of race, ethnicity, socioeconomic status or tribal status

5. Positive Adaptation – A Focus on Well-Being Child Well-Being includes: • Healthy social emotional functioning • Safe, secure and responsive environments for families • Conditions that allow children to be successful during childhood and into adulthood This means no child in Minnesota should ever experience extended hunger, be homeless, live in poverty or go without health care.

6. Equality or Parity?

7. Timing is Everything… When it Comes to Brain Development Health trajectories! Our healthy path is particularly affected during critical or sensitive periods. Early programming is key. • Critical or Sensitive Periods. While adverse events and exposures can have an impact at any point in a person’s life course, the impact is greatest at specific critical or sensitive periods of development. • Early Programming. Early experiences can “program” an individual’s future health and development.

8. Our Past Stays With Us Today's Experiences  Tomorrow's Health The lifecourse is an integrated continuum of risk and protective exposures, experiences and interactions Health pathways or trajectories are built –and modified– over the lifespan

9. Trauma and Early Brain Development • During the early period of life, a baby’s brain is forming 700 neural connections every second. The experience of trauma during this stage impacts healthy development. • Trauma is the experience of an event by a person that is emotionally painful or distressful which often results in lasting mental and physical effects. • Growing scientific knowledge links childhood toxic stress with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems.

10. Trauma and Early Brain Development • These disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health. • Disruption in Neural Development that concern child welfare • Failure to expose youth to appropriate experiences at the critical times (Neglect) • Overwhelming the brain’s alarm system (Abuse)

11. Adverse Childhood ExperiencesChange How Our Brains Work Toxic stress video: http://developingchild.harvard.edu/resources/multimedia/videos/three_core_concepts/toxic_stress/

12. Impact of Trauma Short Term • Eating • Sleeping • Toileting • Attention & Concentration • Withdrawal • Avoidance • Fearfulness • Re-experiencing/ • Flashbacks • Aggression; Turning passive into active • Relationships • Partial memory loss Long Term • Depression • Anxiety • PTSD • Personality • Alcohol or Other Drug Problems • Becoming Violent Towards Others

13. Trauma-informed worldview

14. Now Add…Child Poverty …Based on 3-year averages from the American Community Survey (ACS) for Minnesota 2007-2009 (children for whom poverty status is determined)

15. Poverty and Neglect • There is a relationship between neglect and poverty. Neglect is defined as the failure to provide for a child’s basic needs “when reasonably able to do so.” Disproportionate referrals occur by community reporters to the public child welfare system. • The Fourth National Incidence Study found families under the poverty level to be reported at 7 times the rate of families over the poverty level. • Conditions of poverty can create circumstances of a child being neglected due to parents’ lack of financial resources. When this occurs, public child welfare agencies should work to improve the conditions that influence neglect and meet protective needs while making no determination of maltreatment. • Families of color are more likely to be in poverty as an artifact of historical racism. • Therefore higher neglect rates of families of color can be tied in large part to higher poverty rates.

16. Historical Trauma • HISTORIC TRAUMA is the collective emotional and psychological injury both over the life span and across generations, resulting from a cataclysmic history of genocide. • Genocide is the intent to destroy a national, ethnic, racial or religious group (1948 Geneva Convention) • Historical trauma has a layering effect and is the "cumulative emotional and psychological wounding over the life span and across generations, emanating from massive group trauma." • Historical or intergenerational trauma is similar to that suffered by the Jewish people as a result of the Holocaust, Native Americans, the Japanese Americans interned in California at the beginning of World War II and African Americans suffering the aftermath of slavery. Maria Yellow Horse Brave Heart, Research Associate Professor, Graduate School of Social Work, University of Denver

17. Effects of Historic Trauma • First Generation • Post Traumatic Stress Disorder • Subsequent Generations – Historical Unresolved Trauma Survivor • Guilt, Depression, Anger • Psychic numbing • Victim identity/death identity • Thoughts of suicide • Nightmares • Preoccupation with trauma • Relational problems • Physical symptoms including diabetes and other disease associated with high stress hormones that wear out the body.

18. What is ACE?

19. High Individual and Public Costs of Trauma • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease (COPD) • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease (IHD) • Liver disease • Risk for intimate partner violence • Multiple sexual partners • Sexually transmitted diseases (STDs) • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of smoking • Early initiation of sexual activity • Adolescent pregnancy

20. (Graphic: R. Anda, 2011)

21. Slide from R. Anda (2011), used with permission

22. Slide from R. Anda (2011), used with permission

23. Magnitude of the solution A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experience. ACE reduction reliably predicts a decrease in all of these conditions simultaneously.

24. “Ten Tribes” StudyAdverse Childhood Exposures • Boarding School, Foster Care and Adoption perspectives added. • Cultural variables assessed. • 86% participants experienced one or more categories of exposure • 33% reported four or more categories. • Strong relationship between childhood sexual abuse and subsequent drinking problems among the general population similar in Native American population. • Combined sexual and physical abuse increased alcohol dependence for men. • Combined sexual abuse and boarding school attendance were significant for women. Source: Koss, M., Polacca, M., Yuan N., et al “Adverse Childhood Exposures and Alcohol Dependence Among Seven Tribes” American Journal of Preventative Medicine, 2003, pp. 238‐244

25. States Collecting ACE Data2009-2011 18 States 2009 2010 2011 No data Source: Behavioral Risk Factor Surveillance System, CDC.

26. HOPE • Children are vulnerable to risk – but also amenable to intervention • Human brains have the capacity to change - Plasticity • Focus for children must be on relationships that are: • Nurturing • Stable • Engaging

27. Resilience and Relationships “Resilience rests, fundamentally, on relationships” • None of us is perfect • Resilience is complex • We have the capacity to adapt • Resiliency and protective factors help during adversity • Recovery is individual and environmentally influenced Conclusion of SuniyaLuthar, in: Resilience in development: A synthesis of research across five decades. (2006, p. 780)

28. Key Components of Resilience How is your community nurturing these three components for resilience throughout the lifespan?

29. Discussion • How is your community nurturing these three components for resilience throughout the lifespan of the people you serve? • What do you need to do more of? • With whom?

30. Building Upon the Strengths of Families:The Protective Factors • Concrete Supports in Times of Need • Social Connections • Parental Resilience • Knowledge of Parenting and Child Development • Children’s Social and Emotional Competence

31. Embracing Culture • Culture is a system of shared actions, values and beliefs that guide behavior of families and communities • Recognizing importance and strength of cultural norms supports families and communities and helps them to flourish • Establishing shared leadership with diverse parents and caregivers improves supports and services for families and communities

32. Discussion Protective Factor Card How does this protective factor present itself in your personal life? How does this protective factor present itself in your professional life?

33. System Approach to Trauma Education Alcohol & Other Drugs System Child Welfare Health Care Trauma Mental Health Criminal Justice Community Violence

34. PEDIATRICS Volume 129, Number 1, January 2012

35. Working Across Systems in Partnership

36. Discussion Questions • How is the system you work within traumatizing children and families? • What will your system do to shift away from these policies, practices, or procedures?

37. Child Welfare System Perspective What has Minnesota’s Public Child Welfare System done to… Become trauma-informed? Improve the odds for children and their families?

38. Minnesota Public Child Welfare System Context • State-supervised/County-administered (87 counties) • Eleven federally recognized Tribes – 2 American Indian Child Welfare Initiative Tribes • State with highest share of local property taxes for child welfare

39. MN Children in Out-of-home Care per 1,000 in the Child Population by Race/Ethnicity, 2001–2010

40. What We Now Know • Relationships cause change • Leaders and partnerships impact change • Flexibility and adaptability • Employ strengths and engage capacities • Assure continuity of care and connections • Focus on well-being • Rely on professional, familial, community and cultural wisdom

41. Building Upon the Strong Foundation • Minimize trauma when a child enters the CW system • Engage parents as partners in safety planning • Parent Support Outreach Program • Family Assessment Response • Signs of Safety • Family Group Decision Making • If placement is necessary, make every effort to place children with relatives/kin • Conduct relative/kin searches early on • Continue to pursue available relative/kin resources • When placing children • keep them close to their homes • keep siblings together • maintain cultural connections and school stability • ensure frequent and quality visits with parents and children

42. Building Upon the Strong Foundation • Implement a systemic approach to creating trauma-informed child welfare system • Screen for trauma upon entrance to out of home care • Examine potential to integrate screening items into existing screening and/or assessment instruments. • Expand learning and training opportunities • Build knowledge of brain development and trauma-informed practice integrated into foundation training for social workers • Provide training to resource family providers

43. Building Upon the Strong Foundation • Improve capacity, access and availability for therapeutic services that are culturally sensitive and relevant • Coordinate with Children’s Mental Health Division and MN’s Ambit Network to build capacity for trauma-informed mental health practitioners • Encourage child welfare workers to make trauma-centered referrals to providers • Include parent leaders to inform policy, program and practice enhancements

44. Relationships Are the Difference • Trauma can be created by disruption in healthy relationships • Trauma can be healed by development of healthy relationships • Keep the focus on relationships for children that are: • Nurturing • Stable • Engaging

45. Building Hope:Resiliency and Change • How will YOU use your opportunities for integration and change?

46. Links to Sources • The Lifelong Effects of Early Childhood Adversity and Toxic Stress – American Academy of Pediatrics http://aappolicy.aappublications.org/cgi/reprint/pediatrics;129/1/e232.pdf • Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy – Dr. Jack P. Shonkoff http://steinhardt.nyu.edu/scmsAdmin/media/users/eez206/srb_conference/Building_a_New_Biodevelopmental_Framework_-_J__Shonkoff.pdf • Child Trauma Academy – Dr. Bruce Perry http://www.childtrauma.org/ • Adverse Childhood Experiences – Washington State Family Policy Council http://www.fpc.wa.gov/ • Strengthening Families  - A Protective Factors Framework – Center for the Study of Social Policy http://www.cssp.org/reform/strengthening-families • Chapin Hall Child & Family Policy Forum – Public Systems: Responding to Students Affect by Trauma http://www.chapinhall.org/sites/default/files/documents/Child_Family_Forum_Nov_1.pdf • Zero to Three: Supporting the Development of Infants and Toddlers in the Child Welfare System:  A Call to Action http://www.zerotothree.org/public-policy/webinars-conference-calls/supporting-the-development-of-infatns-and-toddlers-in-the-chld-welfare-system-a-call-to-action.html

47. JJoanne Mooney651.431.3879joanne.mooney@state.mn.usCarole Wilcox651.431.4977carole.wilcox@state.mn.us