Trauma Informed Care

Effective Treatments for Child Traumatic Stress

Child and Family Traumatic Stress Intervention (CFTSI) 
Child FIRST
Creative Alternatives of New York (CANY)
Dialectical Behavior Therapy  (DBT)
Emergency Mobile Psychiatric Services   2-1-1
Essential Elements of a Trauma-Informed Child Welfare System
Eye Movement and Desensitization and Reprocessing (EMDR)
Functional Family Therapy (FFT)
Guiding Principles for Trauma-Informed Child Welfare Practice
Introduction
Parent Child Interaction Therapy (PCIT)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-CBT)
Trauma Matters - Spring 2020 Edition
Trauma Matters Ask the Experts Podcast
Trauma and Help After a Trauma
Understanding Child Trauma
Understanding How Trauma Affects Children and Caregivers
Why Trauma-Informed Care is Important to DCF

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Resources about Child Traumatic Grief are available:

• Child Traumatic Grief Speaker Series

If your child has symptoms such as sleep disturbances, regressive behaviors (i.e. bedwetting, thumbsucking, difficulties with separation from caregivers), or continued re-enactment of the trauma through play that last weeks or months after the tragedy and interfere with everyday activities, you may wish to contact one of the sixteen clinics listed below.  Each clinic has a team of trained clinicians who can provide a specialized trauma assessment to determine whether or not your child may be experiencing a traumatic stress reaction and need further specialized, effective trauma treatment, such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

TF-CBT is a clinic-based, short-term treatment (16 to 20 sessions) for children, ages 4 to 18 who have significant behavioral and emotional problems that are related to traumatic life events, even if they do not meet full diagnostic criteria for post traumatic stress disorder (PTDS).  TF-CBT is an evidence-based model of psychotherapy that combines trauma-sensitive interventions with cognitive behavioral therapy. Individual sessions with the child and parent as well as joint parent-child sessions are provided.  Treatment results in significant reduction in PTSD and depressive symptoms.

The clinics listed below have clinicians and supervisors who have completed the extensive training for TF-CBT through the TF-CBT Learning Collaborative, funded by the Connecticut Department of Children and Families and directed by the Connecticut Center for Effective Practice, in partnership with the National Child Traumatic Stress Network.   

Introduction

Children who receive DCF services have typically experienced or been exposed to traumatic events such as physical abuse, sexual abuse, chronic neglect, sudden or violent loss of or separation from a loved one, domestic violence, and/or community violence.  Often these children have emotional, behavioral, social and mental health challenges that require special care and treatment.  This has significant implications for the delivery of services.

Trauma awareness is acknowledging the presence of trauma symptoms in individuals with histories of trauma and understanding the role that trauma has played in their lives.   Trauma-informed care is an overarching framework, which incorporates trauma awareness and guides general practice with children and families who have been impacted by trauma.  The trauma-informed care system must promote healing environments and prevent re-traumatization by embracing "key" trauma-informed principles of safety, trust, collaboration, choice, and empowerment.  In addition, trauma-informed care systems require the availability of evidence-based trauma-specific services and treatments for individuals with trauma histories.

The DCF workforce must be both trauma-aware and trauma-informed to address the multiple challenges that traumatized children and their families bring with them when they enter the system.  A trauma aware and trauma-informed workforce seeks to change the paradigm from one that asks, "what's wrong with you?" to one that asks, "what has happened to you?"  

 

Understanding Child Trauma

Trauma occurs when a child experiences an intense event that harms or threatens harm to the child's physical or emotional well-being or to someone close to the child such as another family member or a friend.  Typically, this is an extraordinarily frightening event that overwhelms the child with feelings of terror and helplessness.

Some examples of traumatic events are:  physical abuse, sexual abuse, emotional abuse/psychological maltreatment, neglect, domestic violence, traumatic loss or separation from a loved one or bereavement, experiencing or witnessing violence in schools or neighborhoods, serious accidental injury/accident, serious illness/medical conditions, forced displacement such as loss of home or recent immigration, being exposed to a natural disaster such as a hurricane or flood, or exposed to events such as war, terrorism or political violence. Prolonged exposure to traumatic events may result in a toxic stress response.

There are different levels of exposure to traumatic events:

• Acute Trauma refers to a single traumatic event that is limited in time, such as an auto accident, a gang shooting, a parent's suicide, or a natural disaster.

• Chronic Trauma refers to repeated assaults on the child's mind and body, such as chronic sexual or physical abuse or exposure to ongoing domestic violence.

• Complex Trauma is a term used by some trauma experts to describe both exposure to chronic trauma, often inflicted by parents or others who are supposed to care for and protect the child, and the long-term impact of such exposure on the child (Cook et al, 2005). 

As a general rule, traumatic events overwhelm a child's capacity to cope and often result in intense emotional and physical reactions, referred to as Child Traumatic Stress.

Physical reactions may include:

• Rapid heart rate;

• Trembling;

• Dizziness; or

• Loss of bladder or bowel control.

Emotional reactions may include:

• Terror;

• Intense fear;

• Helplessness; and

• Disorganized or agitated behavior. 

Other Child Traumatic Stress symptoms and indicators may include depression anxiety, dissociation, substance abuse, self-injury, suicide, attachment/relationship challenges, and school problems.

In addition, children may develop adaptive responses at the time of the trauma, such as dissociation (i.e. feeling outside of their body or feeling that an actual event is not real) in order to cope with what is happening.  Unfortunately, these responses may become permanent, continuing long after the traumatic event is over and interrupting healthy development. 

Some, but not all children who experience a single significant trauma  or chronic, severe, and interpersonal trauma (i.e. trauma perpetrated by a family member or someone close to the child who should be a protecting adult) may develop a Post Traumatic Stress Disorder (PTSD).  This is a psychiatric condition characterized by specific symptoms that include:

• Re-experiencing the event through nightmares, flashbacks (which may include auditory hallucinations), or other symptoms for more than a month after the original experience;

• Avoidance and fear including not thinking about the event or having memory lapses, or new fears such as separation, being alone, or darkness;

Increased arousal such as nightmares, difficulty falling asleep or staying asleep, decreased attention or concentration, hyperactivity, irritability and mood changes, increased aggression, or hyper vigilance and easily startled; and

• Decreased responsiveness, numbing, and regression such as less interest in play or normal activities, social withdrawal, or peer difficulties.

Sometimes children who have had traumatic experiences are misdiagnosed.  It is essential that children who are exhibiting traumatic stress responses receive effective mental health screening, assessment and treatment to recover.

TRAUMA (and Help, After a Trauma) 

• Additional Topics

• After a loved one dies-how children grieve

• Connecticut Commission on Children

• How to help Children after a tragic event

• National Child Traumatic Stress Network:

  • Terrorism
  • Early Childhood Trauma
  • Psychological First Aid
  • Need to speak to someone? Call 2-1-1
  • Talking to a child after a Traumatic Event
  • Tips for Tots-Supporting Young Children
  • Trauma and how to help your child

A child's reaction to trauma can impact him or her in many ways. While some children "bounce back" after adversity, for many children traumatic experiences can result in a significant disruption of child or adolescent development and have profound long-term consequences. Repeated exposure to traumatic events can affect the child's brain and nervous system and increase the risk of difficulties at school, engagement in high-risk behaviors, health problems and difficulties in peer and family relationships.

Each child's reaction to traumatic experiences differs.  Not every child who experiences a traumatic event will develop symptoms of child traumatic stress. Whether or not the child does depends on a range of factors.  These can include the child's age and developmental state (although children of ANY age can be impacted by a traumatic event), his or her history of previous trauma exposure, the child's mental and emotional strengths and what kind of support the child has at home and in the community.  (For information on impact of trauma by ages and developmental stages, see the NCTSN website at: www.nctsnet.org/content/ages-and-developmental-stages-symptoms-exposure )

Traumatic experiences can impair a child's ability to function each day in the following ways.       

• Brain development - When children experience excessive stress for too long, too often, or too severely, the way brain cells connect and the way they influence each other may be altered.  These biological effects interfere with critical brain functions such as focusing, learning, self-regulation and decision-making.

• High Cortisol - Research has found that abused and neglected children have abnormally high levels of cortisol, even after they are removed from maltreating caregivers and placed in a safe environment.   Cortisol is a hormone associated with the stress response, emotion and memory.  Children may become stuck in a "fight, flee or freeze" response pattern.

• Attachment - When the caregiver who is supposed to provide protection and safety is the source of hurt and harm, the child feels helpless and abandoned and views the world as an uncertain, unpredictable place.  The child may be unable to trust and empathize with others, regulate emotions, and manage stress.

• Emotional Regulation - Children may have difficulty identifying and describing their feelings and internal states.  They may be unable to express emotions safely and to adjust or "regulate" internal experiences. For example, some children may appear quite, withdrawn, and unexpressive, whereas other children may show angry outbursts and aggression.  Some children may be unable to calm themselves when they are upset, to soothe themselves, to interact in appropriate ways with other people, and to learn from their behaviors  Children may not understand why they are acting in this way, particularly if they do so while re-experiencing or re-enacting traumatic events.

• Behavioral Regulation - Children may present with problematic behaviors relating to the trauma (e.g. aggression, self-injurious or sexualized behaviors), and these behaviors may serve as survival adaptations to overwhelming stress. 

• Cognition (Learning and School Performance) - Children may experience delays in language development, deficits in overall IQ, learning disorders, difficulty concentrating and completing tasks, failure to learn from past experiences, and an inability to anticipate and prepare for future events. These children are at risk for low academic performance, school drop-out, and later employment problems.

• Self-Concept - Maltreated children develop a sense of self as ineffective, helpless, deficient, and unlovable.  Children who perceive themselves as powerless may blame themselves for negative experiences and feel a sense of shame and guilt.

• Social development - Traumatized children may have poor social skills, fail to establish and maintain friendships, engage in unhealthy relationships, and become socially isolated.

Survivors of repeated and severe childhood trauma generally experience a common set of problems as adults when they do not receive effective treatment.  A decade-long scientific study, known as the Adverse Childhood Experiences Study (ACE Study - www.acestudy.org) found that these problems are serious and life altering including increased suicidal attempts and other mental health disorders, promiscuity, use of street drugs, heavy alcohol consumption, intractable smoking, and physical health problems such as diabetes, hypertension, obesity, strokes, heart disease, certain forms of cancer, chronic lung disease, and liver disease. 

Many birth parents have their own histories of child and/or adult trauma.  As described above, traumatic stress in childhood can impact the parent's ability to regulate emotion, maintain physical and mental health, engage in relationships, parent effectively, and maintain family stability.  Parents past or present experiences of trauma can also affect their ability to keep their children safe, work effectively with child welfare or juvenile justice staff, and engage in their own or their children's mental health treatment. First and foremost, DCF staff (especially the child welfare worker) must determine that the child and caregiver are safe, prior to referring for trauma-specific assessment and/or treatment.

Why Trauma-Informed Care is Important to DCF 

Exposure to child trauma is very high in the general population, and even higher in the child welfare population. Most children who enter the child welfare system have experienced significant trauma. For those who are placed out of their homes, the trauma of separation from their families and moves within the foster care system itself often lead to additional trauma.  These vulnerable and at-risk children have a high prevalence of mental health needs.

For the general population, many children are exposed to at least one, and often multiple, traumatic events by the time they reach seventeen years of age (Finklehor, Turner, Ormrod,& Hamby, 2009).

• 71% of youth up to age 17 reported trauma in the past year (most 3+ traumatic events )

• Child sexual abuse:  17% boys; 28% girls

• Domestic violence: 20 - 40% of all children

For the child welfare population,

• 60—80% of children served by DCF reported at least one traumatic event;

• 70% of children served by community agencies providing behavioral health services have reported exposure to at least one traumatic event; and

• Children receiving Trauma-Focused - Cognitive Behavior Therapy (TF-CBT) at 16 mental health clinics were exposed to an average of 8 different types of trauma.

Children served through the foster care system have a much higher rate of exposure. It was recently learned that one in four (25.2%) of foster care "alumni" had experienced PTSD.  Former foster children are twice as likely to suffer from PTSD as Iraq war veterans, according to the 2005 Northwest Foster Care Alumni Study. (Peter J. Pecora; Ronald C. Kessler, Jason Williams; Kirk O'Brien; A. Chris Downs; Diana English; James White; Eva Hirpi; Catherine Roller White; Tamera Wiggins; and Kate Holmes).  We also know that most trauma exposure is never reported!  The experience of trauma is so prevalent among the children and families that we serve, our work can only be improved by learning as much as we can about trauma and its effects on children and their families.

Trauma screening is the first step in indentifying children who have, or are at risk of, developing mental, emotional, or behavioral problems.  Children identified at risk of needing immediate attention, intervention or more thorough assessment through the screening process should be referred for a mental health assessment.

The responses by the DCF worker may either help the child to begin a healing process or further exacerbate the trauma.  When traumatic stress is left untreated, further harm is likely to occur.  Some actions or lack of actions that may cause System-Induced Trauma for the child include: 

• A child's trauma history is not identified;

• A child's trauma history is identified, but there is no referral and follow through regarding trauma-specific assessment and/or trauma-specific treatment;

• A child's traumatic stress is compounded by a failure to address ongoing safety needs of the child and adult survivor; and/or

• The child's traumatic stress is compounded by ongoing experiences of instability and uncertainty involving abrupt, unexplained removals from one's own home or multiple out-of-home placements in a short period of time.

Trauma screening is a critical function that:

• Supports the Strengthening Families Practice Model;

• Advances the federal goals of safety, permanency, and well-being;

• Supports achievement of the Program Improvement Plan under the federal Child and Family Services Review Program;

• Enables compliance of the Posit ive Outcomes for Children (Juan F. Exit Plan) - Needs Met; and

• Enables compliance with the Promoting Safe and Stable Families Act to monitor and treat emotional trauma associated with a child's maltreatment and removal from home.

Effective Treatments for Child Traumatic Stress

There is good news.  Traumatic stress in children is treatable and there are highly effective treatments available to help children and their families. There are different types of interventions that focus on acute (immediately following trauma), trauma-specific treatment (short-term and long-term) and intensive (in home, residential, hospital.)

• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) (http://tfcbt.musc.edu)

• Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-CBT) (http://tfcbt.musc.edu)

• Alternatives for Families Cognitive Behavioral Therapy (AF-CBT) ( www.afcbt.org)

• Dialectical Behavior Therapy (DBT) (http://www.dbtselfhelp.com)

• Eye Movement and Desensitization and Reprocessing (EMDR) (http://emdr.com)

• The Child and Family Traumatic Stress Intervention (CFTSI) (http://www.crimesolutions.gov)

• Parent Child Interaction Therapy (PCIT) (http://www.pcit.org)

• Child FIRST (http://www.childfirst.net)

• Creative Alternatives of New York (CANY) Drama Therapy (http://www.cany.org)

Other interventions to Help Children who are Victims of Trauma:

• Provide support so that the child and family feel safe and secure

• Advocate a supportive role by caregivers and others

• Maintain healthy relationships with the child's primary caregivers and other close relatives/friends

• Reduce unnecessary secondary exposures & separations

• Help the child to return to typical routines (such as school) as soon as possible

• Facilitate open but not forced communication with the child about his/her reactions to the traumatic event

• Focus on constructive responses

• Explain to child in developmentally appropriate terms

• Encourage and support help-seeking behaviors

• Create a supportive milieu for the spectrum of reactions and different courses of recovery

• Monitor and/or refer child for a clinical trauma evaluation

Essential Elements of a Trauma-Informed Child Welfare System

One of the Department's six cross-cutting themes is Trauma-Informed Practice.  This means delivering services to children and families with an understanding of the impact that trauma can have on their lives and using interpersonal skills to ensure that our work is supportive of trauma recovery and not re-traumatizing.  It requires a partnership with all those involved with the child (caregivers, providers and other stakeholders), using the best available science, to facilitate and support the recovery and resiliency of the child and family.  Trauma-informed practice aligns closely with principles already in practice by DCF staff.  Reflective of DCF's Strengthening Families Practice Model and the six Principles of Partnership, trauma-informed child welfare practice emphasizes the development of family-focused, strengths-based relationships with families to ensure the safety and well-being of their children.  The integration of trauma awareness into this practice underscores DCF's commitment to trauma-informed care as one of the department's six cross cutting themes.

The essential elements of a trauma-informed system include all of the following:  (Chadwick Center in San Diego, 2012)

1. Maximize the child's and family's sense of physical and psychological safety - Children need to be and feel physically and psychologically safe.  To be and feel safe, children need consistency, predictability, and nurturing, safe environments and caregivers. It is important to identify and understand both potential and perceived threats to safety, including trauma triggers that a child or parent may experience and to assure that the caregivers have tools to manage triggers and help children feel safe.

2. Identify the trauma-related needs of children and families - This involves a process for DCF staff to screen for trauma history and traumatic stress response, and to utilize this information to determine if a child should be referred for a more comprehensive trauma-focused assessment completed by a mental health clinician. Staff will complete the LINK Trauma Screening Measure for each child/family at the time of intake (including intake at facilities) or family assessment response, and re-screen using the same tool at the time of renewal of the Case Plan for ongoing services.  For positive screens, the Behavioral Health Referral Form will be used to refer a child/family to a mental health provider.   It is equally important to understand the birth parent's trauma history.  Some parents may need to work on their own trauma issues in individual therapy.  (Generic interventions that are not trauma-informed such as anger management or parenting classes will often be ineffective in addressing these needs.)  It is critical to find ways to engage with parents to begin the process of establishing trust and collaboration.  Explaining to parents that there is a connection between their traumatic events and their present reactions may be empowering and motivate the parents to make positive changes. 

3. Enhance the child's and family's well-being and resiliency - This element focuses on facilitating positive outcomes for children by providing appropriate support to enhance their well-being and resiliency, and their ability to form and maintain healthy relationships in the aftermath of trauma.  DCF staff assure that the child has access to evidence-based trauma treatments and services, as appropriate.  Also, the DCF staff support and promote positive and stable relationships in the life of the child.  DCF staff provide support and guidance to the child's family and caregivers about the impact of trauma on the child and family system, and recognizes that many of the child's adult caregivers may be trauma victims as well (recent and childhood trauma).  These individuals are referred to trauma-specific treatments and services too, as appropriate.  All of this work will enhance the protective capacities of caregivers, thus increasing the resiliency, safety, permanency and well-being of the child.

4. Partner with families and system agencies - DCF staff establish strong partnerships  with families and other child- and family-serving systems to create a continuum of  trauma-informed care. 

5. Enhance the well-being and resiliency of DCF staff - This element  recognizes the impact of exposure to trauma on professionals as well as on the climate and culture of the organizations within this system. This means implementing  organizational and individual strategies and practices to manage professional and personal stress, particularly to address the impact of secondary traumatic stress in a systematic way.