Healing the Invisible Wounds

1. Healing the Invisible Wounds Children Exposed to Violence in the Child Welfare System

2. Elena Cohen, Safe Start Center www.safestartcenter.org 240.645.4824 ecohen@jbsinternational.com

4. Children’s Exposure to Violence • Direct (child maltreatment) or indirect (exposure to home and community violence). • Physical and emotional response of a child to events that threatens life or physical integrity. • Events overwhelm child’s capacity to cope.

5. Exposure to violence • Other words used: exposure to violence, traumatic stress, complex trauma. • Interventions adapted from related mental health problems (PTSD, depression) • Prefer to use “exposure to violence”

6. Impact depends on: • Perception of danger (stress-to-trauma) • Risk and protective factors • Child’s age and developmental stage • Relationship to victim & perpetrator

7. Impact depends on: • Past experience with traumatic events (frequency, intensity, closeness) • Adversities faced before and after • Presence/availability of supports to protect (family and community)

8. Stress to Trauma Continuum • All children experience stressful events (directly or indirectly). • Positive stress fosters normal development. • Tolerable stress occurs during brief periods. • Toxic stress.

9. Stress-to-Trauma Continuum • Toxic stress is chronic, uncontrollable and experienced without adequate supports. • May actually interrupt child’s development. • Later in life may impact capacity to parent and to partner.

11. Protective Factors Characteristics that protect children from the damaging effects of negative life circumstances and events and build resiliency.

12. Risk Factors Characteristics and experiences that make it more challenging for a child to grow and develop skills that lead to success in life.

13. Resiliency The ability to recover readily or “bounce back” from adversity and stressful events.

14. Exposure to Violence and Developmental Tasks • Development is a cumulative process of maturation that occurs through life stages. • At each developmental stage, face different asks and build on previous completion of tasks. • Exposure interferes with resolution of tasks which affects development.

15. Secondary Adversities • Exposure to violence can impact many aspects of a child’s life (secondary issues). • Changes in the family system, disruption of routines, school problems. • It is critical to address these secondary issues.

16. Examples • Task of infant: form an attachment with caregiver(s) • Task for school-age children: making friends • Task of adolescents: increased sense of self and autonomy from family

17. Impact on Child Welfare Outcomes • Safety • Permanence • Well Being

18. Video: Children Are Watching

19. Common Symptoms Birth - 5 • Fussiness, uncharacteristic crying and neediness • Generalized fear • Startle response to loud or unusual noises • Regressive symptoms • Somatic symptoms • Helplessness—lack of usual responsiveness • Confusion

20. Common Symptoms (Birth – 5) • Somatic symptoms (stomachaches headaches) • Helplessness—lack of usual responsiveness • Confusion • Difficulty talking about event

21. Infants and Toddlers: Most Stressful Features • Separation from caregivers • Sudden and unpredictable changes • Distracted, tense, unhappy, socially isolated caregiver • Angry or inconsistent caregiver • Loud noises

22. Common Symptoms (6-11 years) • Feelings of responsibility and guilt • Repetitious play and retelling • Nightmares and other sleep issues • Concerns about being hurt • Aggressive behavior • Difficulty talking about event

23. School-Age Common Symptoms • Separation anxiety • Changes in eating and sleeping • Poor concentration • Inability to sit still or focus attention. • Hard to think straight or make decisions

24. School-Age Distressing Features • Chaotic change and unpredictability • Fear they may be injured • Disruption of routines • Feeling guilty about not being able to protect loved one • Separation for loved ones • Visitation

25. Adolescents: Common Symptoms • Use of violence to get what they want • Refusing to follow rules • Spend more time away from home (or do not want to leave house) • Nightmares • Lack of concentration

26. Adolescents: Common Symptoms • Unconcerned about appearance. • Do risky things (driving fast, jumping from high places). • Terrorized when thinking about event. • Say it did not happen.

27. Adolescents Distressing Features • Seeing caregiver upset, crying or bleeding • Seeing and hearing adults angry and yelling • Sounds and sights of first responders whey they secure the scene and assist on a call to the house. • Not being able to protect parent, friend. • Loss of friends, school, neighborhood

28. What can we do? Depends on child’s age • Understand children’s behavior • Encourage to talk about what they are thinking and feeling. • Help children feel safe and in control.

29. Video: Safe Havens

30. Young Children Express thinking and feeling • Holding and cuddling • Establish predictable routines • Ask questions that can help express feelings. • Use story books to help talk about feelings. • Drawings-ask questions

31. Young Children: Feeling Safe • Wrap in blanket • Follow their lead (i.e. pick up) • Allow child to show fear • Don’t let them watch violent TV shows • Don’t leave them with people they don’t know.

32. School-Age: Express Thoughts and Feelings • Listen without judging • Respond calmly: “I’m sorry you had to see me get hurt. It must have been hard for you.” • Help identify feelings What happened at school seems pretty scary. How did you feel?” • Admit when you don’t have an answer.

33. School-age: Feel Safe and In Control • Tell them what happened is not their fault. • Help them find a safe place they can go when they feel overwhelmed. • Don’t make promises you cannot keep. • Enroll them in a mentoring/after-school program. • Be careful what you say in front of them.

34. Safety Planning • As what child thinks would make her feel safe. Help her come up with ideas. • Make sure you agree and it suits age. • Be sure to explain it may not always work. • It’s not their fault if it fails. • Review plan periodically.

35. Sample Strategies • Dial 911 (if phone is in safe place). • Leave house—go somewhere else. • Don’t try to stop the violence.

36. Adolescents: Express Feelings • Reach out using conversation openings You haven’t seemed yourself lately. You seem kind of down. Is something bothering you? • Encourage to tell their side of the story and listen. • Expect difficult behavior but don’t let teens break the rules out of sympathy.

37. Adolescents: Safe and Control • Be extra patient if they are distracted and forget to do chores or turn in school work. • Give straightforward explanations, whenever possible. • Find out what’s making them feel unsafe and help them make a safety plan. • Provide them with safe and fun physical activities to release tension.

38. Keep in mind • Try to understand the behavior. • Look for how child’s issues are manifested. • Timing is important. • Think developmentally. • Acknowledge when the child needs professional help.

39. When to Seek Help: Birth to Preschool • Hard time calming down at bedtime; needs a lot of help to fall asleep • Abrupt changes in feeding or sleeping • Cries for long period at a time and is hard to calm • Does not respond when held or cuddle • Shows little interest in exploring surroundings • Is delayed (or does not) coo, babble, or speak

40. When to Seek Help: School Age • Showing declining performance in school. • Losing interest in things once enjoyed. • Experiencing unexplained changes in sleeping or eating patterns. • Avoiding friends or family and wanting to be alone all the time. • Daydreaming too much and not completing tasks.

41. When to Seek Help: School Age • Constant worry about being harmed, hurting others, or doing something "bad". • Racing thoughts that are almost too fast to follow. • Persistent nightmares.

42. Adolescents: When to Seek Help • Involvement in dating relationships • Drinking and using drugs • Skipping schools • Talking about death, suicide • Breaking the law

43. Promising Practices/Interventions • Home Visitation • Domestic Violence Shelter-Based Service • Motivational Interviewing • Kinship care /dyad therapy • Child Welfare-Domestic Violence Integrated Services • After School Support/Kids Club

44. Promising Practices/Interventions • Parent Child Interactive Therapy (PCIT) • Child Parent Psychotherapy (CPP-DV) • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) • Trauma Assessment Pathway (TAP) • Dyadic Therapy

45. Promising Practices/Interventions • In-home, family-centered services • Integrated case management (mental health/social services, family support) • Trauma-focused curriculum for teachers and parents • Medical home • Child advocacy center

46. Evidence-Based Practices • National Child Traumatic Stress Network www.nctsn.org • California Evidence-Based Clearinghouse for Child Welfare www.cebc.org • SAMHSA National Registry of Evidence-Based Programs and Practices www.nrepp.samhsa.gov

47. Difficulties/Barriers • I don’t know what to say • I’ve tried to talk; he won’t listen • I feel uncomfortable • I’m embarrassed • It may make things worse • It’s not a big deal

48. Difficulties/Barriers: Adolescents • Ignore you • Change subject (I’m hungry) • Blame others for violence • Say “don’t worry” try to cheer you up • Try to hit you • Listen quietly • Whatever

49. Systemic Barriers • Lack or awareness about impact of exposure and interventions • Fragmentation of services • Inadequate supply of trained providers • Inadequate attention to cultural competency

50. Systemic Barriers • Recognition of exposure to violence as a health issue for children • Limited resources in many communities • Limited resources of families (poverty) • Case management and advocacy are time consuming