Trauma and Complex Trauma: its Implications for Children

1. Trauma and Complex Trauma: its Implications for Children Marjorie Withers, LCPC

2. Workshop dedicated • To children and families who have shared their stories: • Who have reached for their core of resilience and coped with feelings and memories: • And To those that have been their heroes whether it was an auntie, a teacher, a therapist, a fireman, another child, a DHHS worker. • NO ONE IS EXEMPT FROM THE AFTERMATH OF TRAUMA

3. Definition of Trauma • Horrific event beyond the scope of normal human experience. ( American Psychiatric Assoc., 1980) • Includes events that are perceived as life threatening. • Engenders: Fear, hopelessness, horror, helplessness. • Witnessing violence, and or being a victim of violence. • Being diagnosed with a life threatening disease. • Natural disasters, accidents, House fires loss caused by violence. • War, gang war. • Ongoing exposure to violence and or neglect

4. Definition of Complex Trauma • Repeated trauma over time • Trauma may include multiple types of traumatic experiences • Often includes neglect, abuse, and multiple parental issues that effect the ability of the family to parent the child and meet their developmental needs. • Child sustains multiple losses that upset their equilibrium and regulatory system.

5. Kinds of Trauma

6. Complex trauma: Onion effect • Child develops layers of trauma responses • Impact / effects all: Relationship Reactions Cognitive, emotional and social functioning. Ability to regulate behavior Brain chemistry and development.

7. Implications for the brain and its development. • Young children smaller cortex • Increased Coritsol • Problems with movement and sensation • Hypersensitivity to physical touch • Insensitivity to pain • Increased startle reaction • Constant fight or flight mode • Flashbacks: intrudes on reality

8. Effects of Trauma on Children • Effects cognition • Effects affect/feelings • Effects behavior • Effects neurophysiology • Effects physiology • Responses are coping adaptations

9. Impact on Physiology Traumatic event Prolonged Alarm Reaction Altered Neural System

10. Prevalence of Trauma in Children in United States • Over 5 million children a year experience trauma. • Estimated 2 million from sexual or physical abuse. • Unknown number more terrorized by Domestic Violence in their home • Natural disasters, car accidents, life threatening illnesses, community violence. • By age 18, one out of four will have been effected by family or community violence.

11. Trauma knows no age limits • In- Utero effects of trauma (increase cortisol levels). Anxious babies • Infant and toddlers exposed to violence towards a parent have changes in behavior. • Exposure to violence impacts child as much as violence to a child. • Pre-verbal children show signs and symptoms of trauma similar to those of older children.

12. Break: • Think of children you have known and the impacts trauma may have had on them. • What would you do differently? • What would be important for the child>

13. Children who have been exposed to trauma need: • Safety • Safety skills (exp. Whistle, safe people) • Reassurance • Information • Coping skills • Consistency and clarity • Reality checks with an adult

14. Implications for child • Effects all relationships • Effects Development • Effects ability to trust • Effects feelings and regulation of self • Effects ability to focus • Effects placement behavior • Effects school behavior • Requires intervention and understanding

15. Trauma interferes with: • Management of feelings including fear and aggression and anxiety. • Interferes with attention and problem solving. • Effects impulse control and physical responses to perceived dangers • Changes attachment and child’s feelings of safety

16. Changing how we interact with child to accommodate trauma: • Trauma informed (Lower stimuli) • Train and inform all adults involved with the child. • Establish relationships that stress safety • Create consistency • Have all adults on the same page with information. • Identify the child’s strengths and coping skills

17. Implications for child welfare and other interventionists: • Assessment of trauma: Through Child welfare trauma Referral Tool or form. • Assessing kinds of trauma for how long and when in the child’s life and by whom • Assessments of who tried to protect or intervene • Assessment of Losses that were sustained • Assessment of child’s reactions and behaviors. • Assessment of who in the community can be of help to the child.

18. Assessment must: • Connect through time line sequence of trauma. • Identify safety factors or safe people currently available as protective forces • Identify Impact on current development • Address Current Health • Identify Current behavioral issues • Identify Regressive behaviors • Identify fears and concerns of child.

19. A word about referrals • Know your resources • Does it fit the child’s needs? • Is the person skilled in trauma work with children? • Is the person going to use trauma assessment tools and if so which ones? • Is the person able to work with the foster placement on helping it to meet the child’s needs?

20. Tools for assessing • National Child Traumatic Stress Network: • Child Welfare Training Toolkit • UCLA PTSD Index for DSM IV • Trauma Symptom Checklist for children • Trauma Symptom Checklist for young children. (Biereres) • Child Sexual Behavior Inventory

21. Lunch: Break • How can you make your agency or office more trauma informed? • How can you create a feeling of safety. • (Bear and Back Packs, safety Plan)

22. When trauma occurs changes outcomes… • Pre-attachment: Worst outcome • Disruption of development: • Attachment as emotional foundation • Implications at different stages: >Review tasks of development • 0-2,2-5,5-7,7-10,10-13, 13-17. • Nature of abuse: • Follow up of abuse: • Treatment:

23. Placement for a traumatized child: • Trauma informed • Realistic about the child • Know the child’s history • Create a safety plan specifically for that child. • Have back up and respite • Have support from DHHS • Work in tandem with the department, school, child and others.

24. Most important factors • Loving • Consistent • Able to not over-personalize • Flexible • Calm and able to decrease stimulation • Understand the needs of the individual child. • Never make promises you cannot keep.

25. Resiliency Factors • Natural supports • Coping skills • Emotional foundation • Rescue or safe person • Mastery • Someone who believes in child and cares across time and trauma • Natural talents or resources • Acceptance of responsibility by abuser

26. Child needs to feel safe and be safe. • Establish control and safety for child both in terms of physical safety and psychological safety • Understand of the level of disruption to development and attachment which effects all behavior • Clear communication that is strength based and recognizes the child’s experience.

27. Break • Remember a child you have known, what would you do differently in terms of the placement, school, court and reunification? • Discuss on return:

28. Things that children need • Information • Comfort objects • Safety assurances and practices: night light, police whistle, etc. • Prepared placements where voices are not loud and environment is calm. • Knowing that they can get someone to be with them even in the middle of the night. • Strategies to feel safer.

29. More essentials • Clear communications • No promises that will not be kept • Space • Help label feelings and deal with them. • Outlets • Clarification of what they survived and help in ordering it cognitively • Reminder it was not the child’s fault.

30. Therapy as needed • Experienced Trauma therapist using best practice techniques such as: • Parent child interaction Psychotherapy (2-8). 14- 20 weeks of therapy. • Trauma Focused Cognitive Behavioral Therapy (older kids). Skill oriented.

31. Things that help • Creating a safe environment for child • Relaxation techniques • Calming skills • Breaks • Helping the child attend by using breathing skills before a task. • Outlets: Physical, arts, puppets, talking circles. • Order and calm in house and classroom.

32. Things to remember for traumatized children: • Stimulation that is sudden or overwhelming will overwhelm them. • Lower noises and voices helps • No yelling • Avoid Sudden transitions or crisis atmosphere • Avoid Exposure to violence (TV, Books etc.) • Warn and prepare child for court, for changes, for visits.

33. SAFETY in Homes • Quiet places (nest) • Clear rules about safety at home or in school. • Regular schedule/routine • Safe person developed and identified • Calming skills practices everyday • Discussions about feelings and what to do with different feelings • Breathing • Attention and planning before and after transitions

34. Role of a caring significant other • Children report the difference a caring adult makes: • “My aunt was always there after my mom died” • Someone made me feel safe and worthy. • “My worker was always there and would let me call her when I was feeling too much.” • “I had an angel it was my gym teacher”

35. Children taking the blame • Fear that they should have or could have • Protected • Saved • Avoided • Prevented Kept trauma from occurring (wish for control) Need for correction of untrue thoughts or assumption

36. Each Child needs: • Stress management skills • Coherent narrative of what happened • Changing misassumptions that they caused the experience…it happened because I was bad… • Change concept that bad things can happen even to good kids. • Involvement of parents or safe loving involved adult • Normalcy restoration

37. Summary • You can make a difference • Children are resilient when given tools • Mastery of soothing skills • Mastery of stress management skills • Time, love, reassurance, dependable environment that encourages safety planning. • Trauma reactions are not pathological. • Healing from wound to scar • I am a survivor…..I am Loved, loveable and I can soothe myself.

38. Vignettes: Chris 3 • Broken rib and dislocated shoulder • Old burns on his back • The youngest of three children. Mother has been in rehab and Chris was being taken care of by mother’s new boyfriend. Other kids are older and went to their Grandmother. Chris has no relatives in Maine other than his mom. Chris wants his mom and is scared of the foster mother who he had never met before. Mom called DHHS and said her boyfriend is not safe.

39. What would we do? • Placement? • Safety plan? • Inclusion of mother? • Inclusion of siblings? • What may be issues for 3 year old Chris?

40. Vignette: Chris • She wants a restraining order placed on him and wants to take her kids back to Vermont where she has a support system. • Her Mother is coming to Maine to get Chris if the department will let him go with her and she wants the other kids to go tom Vermont too. • Chris smiles when you ask about Nana and reaches out for her. He also asks for his siblings.

41. Jed 10 Years old • Placed in two foster homes and returned. He was in placement from ages 2-5 and went home. Mother was neglecting and also physically abusive. Jed returned to custody when he was 7 and his mom came back to Bangor. He was in Custody until he was 9 and returned. This time he reported to his teacher that there was no food in the house and he was taking care of his younger siblings and is scared because they are running out of food.

42. Jed Factors: • Wants to live with his Aunt (father’s side) forever on their farm near Waterville. • He is angry at his mother and sad that she makes promises and never keeps them. • He sleeps poorly and always looks worried. School is hard for him. • He wants to be in the same foster placement as his younger siblings one of whom is in a home that deals with medically fragile children and the other is with her godmother.

43. What might Jed need in a plan • Plan to see siblings • Goal of involving Aunt and Uncle • Work with school about trauma and impact on Jed.

44. Jenny age 8 history of SA • Jenny was taken by child welfare after two calls reporting that she had been sexually abused. The school called because Jenny was scared to go home and complained of physical symptoms daily. Her demeanor had changed since her mother started dating a younger boyfriend who takes care of Jenny after school since her mother got a job a month ago. • Jenny had told the nurse that Chuck hurt her and she could not tell mommy.

45. Jenny • Jenny’s mother, Lynn comes to the office and says Jenny is lying because she does not want to share her. She refuses to have her checked by a doctor. An immediate protection order is taken as Jenny has been clear about gross sexual abuse for the past month and her fear of Ed. She wants her Grandmother who the worker calls. Mrs. Johnson is very worried and believes Jenny. She states that Lynn

46. Jenny • Was their foster child whom they adopted when she was 13. Lynn had been sexually abused. Lynn has been angry at them because they do not like Chuck and find him inappropriate. They will do anything to help Jenny and are worried about Lynn whom they said seems much as she did when she was a teenager. She had a baby when she was 17 whom she gave up for adoption. Jenny has always spent much time with her grandparents.

47. Jenny Needs • Medical exam • To be with Grandparents • To be protected from Mother’s boyfriend • Therapy with grandparents if they are the family with whom she will be living.

48. Tamara • Tamara is 9 months and was taken at three days from her parents after her father shook her. Her mother (Lori) is addicted to opiates and is 19 and did not tell anyone she was pregnant. She says she loves Tamara but does not come for visits and is angry at her workers. She has been kicked out of several Substance Abuse programs. Her boyfriend has left and is expecting a baby with his old girlfriend.

49. Lynn factors: • Lynn believes that Tamara loves her even though she has not been present. • Lynn has little ability for postponing her own gratification. • Lynn has been involved with drugs since her accident at 15. • Lynn has little understanding of development and has never held a job or completed high school. • Lynn blames others for her issues.

50. Tamara • Tamara is with Lori’s older sister and husband who want to adopt her. Lori says she doesn’t want her to be there because they won’t let her visit when she wants. • Tamara is thriving and is very attached to Kim (her aunt) and Roy (her Uncle). They have two boys who are 8 and 11 who adore her. • Lori was in a serious car accident when she was 15 which everyone says changed her….