Trauma Informed Care
becauseâ€Ś our children matter
Nicholas M. Neal
1-866 866--641 641--7181
Director, Family Services
Sanford R. Kauffman President, Geminus Corporation
PARTNERING FOR THE FUTURE
A Message about Trauma-Informed Care from the Director of Family Services, Geminus Corporation Family Services It is possible for children to be exposed to violence every day in their homes, schools, communities, and in the media daily. A child may be struck by a friend, assaulted by a mother’s boyfriend, bullied at school, abused by an adult or other authority figure, witness domestic violence regularly in the home, be witness to shootings on the street, or close to home, or be closely related to others that live with the reality of violence surrounding their everyday lives.
Nicholas M. Neal
This exposure to violence can cause physical, mental and/or emotional pain with harmful, long-term effects that may last well into adulthood.
It is of utmost importance to study the impact of violence in children’s lives, while developing methods of practice, evaluation, training, resources and outreach. It is so important for us to understand the nature and extent of children’s exposure to violence in order to combat its effects. It is even more important that we find methods to intervene so that developmental patterns in children are not negatively impacted into adulthood. More needs to be understood about how exposure to individual episodes of violence, repeated exposure to violence, and multiple types of exposure affects children and families, while providing effective treatment. Trauma-Informed Care is a systemic approach that integrates services across multiple systems to intervene in the lives of those most affected by violence. All too often, trauma survivors cycle in and out of various systems, without ever receiving appropriate services. Trauma-Informed Care is a step in the right direction of a care model in which federal, state and local communities, work together, to provide access to evidence-based services and supports, for children exposed to violence. We need to help survivors of violence by offering treatment programs that are survivor-driven, respectful, and empowering... Because...our children matter; and, isn’t that what’s most important?
Nicholas M. Neal Director, Family Services Geminus Corporation
PARTNERING FOR THE FUTURE
8400 Louisiana Street Merrillville, Indiana 46410
Nicholas M. Neal Director, Family Services
Sanford R. Kauffman President, Geminus Corporation geminuscommunitypartners.org firstname.lastname@example.org
Trauma-sensitive services are delivered regardless of which â€œdoorâ€? a survivor enters, or whether the survivor ever finds their way to a trauma-specific treatment program.
Trauma-Informed Care: What is It? While trauma-specific interventions are a piece of the puzzle, true trauma-informed care encompasses something much broader
We must develop trauma-informed systems of care to succeed in our organizational, community and national healthcare goals, we must adopt a systemic approach. The problems engendered by violence cut across multiple service systems
emergency services social services law enforcement mental health care primary healthcare housing substance abuse treatment domestic violence All too often, trauma survivors cycle in and out of various systems without ever receiving appropriate services. We need to help survivors of violence by the availability of treatment programs that are
survivor-driven, respectful, and empowering Trauma-informed care system services are survivor-driven respectful empowering A trauma-informed care system recognizes the developmental impact of trauma across domains physical emotional cognitive social occupational spiritual A trauma-informed care system appreciates the value of numerous behavioral health manifestations that many trauma survivors use as attempts to cope and survive such as disassociation substance use overeating acting out self-injury Trauma-informed care systems employ extreme care to ensure a relationally and environmentally safe environment of care This makes the possibility of inadvertent clinical retraumatization minimized
What happens when children are exposed to violence? What happens when children are exposed to violence? Children are very resilient-but they are not unbreakable. No matter what their age, children are deeply hurt when they are physically, sexually, or emotionally abused or when they see or hear violence in their homes and communities. When children see and hear too much that is frightening, their world feels unsafe and insecure. Each child and situation is different, but exposure to violence can overwhelm children at any age and lead to problems in their daily lives. Some children may have an emotional or physical reaction. Others may find it harder to recover from a frightening experience. Exposure to violence-especially when Elementary and middle school children exposed to it is ongoing and intense can harm children’s natural, healthy violence may show problems at school and at home. development unless they receive support to help them cope They may: and heal. Have difficulty paying attention What are some of the warning signs of exposure to Become quiet, upset and withdrawn
Children’s reactions to exposure to violence can be immediate or appear much later. Reactions differ in severity and cover a range of behaviors. People from different cultures may have their own ways of showing their reactions. How a child responds also varies according to age.
Be tearful and sad and talk about scary feelings and ideas Fight with peers or adults Show changes in school performance Want to be left alone Eat more or less than usual Get into trouble at home or school
Teenagers (13-18 years) Older children may exhibit the most behavioral changes as a result of exposure to violence.
Young Children (5 and younger)
Depending on their circumstances, teenagers may talk about the event all the time or deny that it happened and refuse to follow rules; they may talk back to their parents and authority figures with more frequency.
They may also: Young children’s reactions are strongly influenced by caregivers’ reactions. Children in this age range who are Complain of being tired all the exposed to violence may: Engage in risky behaviors Be irritable or fussy or have difficulty in calming Sleep more or less than usual
down Become easily startled Resort to behaviors common to being younger (such as thumb sucking, bed wetting, or fear of the dark) Have frequent tantrums Cling to caregivers Experience changes in level of activity Repeat events over and over in play or conversation
Increase aggressive behaviors Want to be alone, not even wanting to spend time with friends Experience frequent nightmares Use drugs or alcohol, run away from home or get into trouble with the law
Traumatic Events/Goals of Trauma-Informed Care
Examples of events that may be stressful or traumatic to children/adolescents Maltreatment (neglect, physical abuse, sexual abuse) Domestic/intimate partner violence/dating Peer violence Neighborhood violence Motor vehicle crashes Death/severe problems of a loved one Separation or removal from a parent or loved one Medical treatment Natural disasters War Terrorism Refugee experiences
Because abstinence education programs focus on groups that are most likely to bear children out-ofwedlock, these groups may also be at heightened risk for trauma.
Goals of Trauma-Informed Care What is the goal of trauma-informed care? The goal of trauma-informed care (traumainformed delivery, services, treatment, and systems) include aspects of:
Understanding trauma, and how it may affect lives;
Identifying current and past trauma experiences of the persons with whom one is working with;
Using this knowledge to adapt program delivery, design treatments and/or systems appropriate for trauma survivors.
In trauma-informed systems, all system components (programs, services, treatments, etc) have been reconsidered and restructured with the understanding of the role that trauma plays in the lives of the persons seeking assistance.
Reference: National Child Traumatic Stress Network.(n.d.) Scope of the problem. Available at htt://ww.nctsn.org/content/scope-problem
60% of U.S. children (age 0-17) experienced or witnessed at least one victimization in the past year including:
Direct physical assault Child maltreatment/sexual abuse Bullying Witnessing violence, etc.
39% experienced 2 or more direct victimizations 11% experienced 5 or more direct victimizations
Foster Care: 51% had been direct victims of violence
LGBTQ: LGBTQ youth contend with family rejection, school harassment, and physical, sexual and or emotional abuse in response to suspicion or declaration or their emerging sexual orientation and gender identity
Homeless/Runaway: Youth exposed to high rates of trauma both on the streets and prior to their becoming homeless
References: Gaetz, 2004; Killen-Harvey & Sterns-Ellis, 2006; Kidd, 2003; Stein et al., 2001 Reference: Finfelhor, Turner, Ormrod, Hamby, 2009
Trauma-informed Education System Trauma-informed Healthcare System Trauma-informed Child Welfare System/Foster Care
Prerequisite for a Trauma-Informed System is a Commitment to Change:
Those controlling the allocation of system resources must commit to using resources to integrate a trauma-informed approach
Staff interacting with persons receiving the programs or services should receive a general introduction to trauma and its effects including staff delivering programs
The goal is for all persons in the system to become sensitized to trauma so that they may help to make the system welcoming to trauma survivors and avoid inadvertent re-traumatization
Take Home Points
Universal Trauma Screening for Adolescents
Ideally all adolescents seen in the system (i.e, those receiving the program or services) should be screened Those screened positive should be provided with (or referred to) more comprehensive assessment and intervention if indicated One must make decisions concerning the best place within the system to conduct universal trauma screening
What to Expect, What to Do
Teens may talk about exposure to trauma all at once or in pieces and “test your responses”
Follow school or agency policies and procedures and refer the ten to specialized professionals such as the school counselor, social worker, or psychologist
Provide an opportunity to talk about what youth have witnessed and how they feel in an emotionally safe space with caring parents or adults who can listen
All state child welfare systems receive/respond to child abuse/neglect reports and offer services to teens/families State by state reporting requirements can be found at http://www.childrewelfare.gov/systemwide/ laws policies/state
It is important to consider the safety of the teen
Reporting is the shared responsibility of everyone with knowledge of the suspected abuse/neglect
Notify teens (and parents, if working with them) of this exception to confidentiality before disclosures happen.
Trauma is prevalent and far-reaching in its effects
Abstinence education and healing from trauma are possible for everyone, regardless of how vulnerable they may appear
When possible, adapt program delivery, design treatments, services and/or systems that are appropriate for trauma survivors (while maintaining fidelity of program core components)
Inform teens (and parents, when working with them) about your obligation to report some incidents
Make sure all program delivery staff and supervisors are aware of how to identify and respond to different type of incidents that may occur
Healing happens within safe, authentic and positive relationships
A poem about sisters traumatized by violence at home
The Story of Sisters Sasha and Leigh One was Six and the Other only Three My Name is Sasha my sister’s name Is Leigh; I am six and sister Leigh is three. Our dad is always mad he screams at us and yells; I don’t think he likes us much, It’s very easy to tell. Mom’s only kind to us when Dad's not around; and when he is home, Mom hardly makes a sound. Mom’s always out, she’s never home; Dads always drunk, we’re always all alone. As soon as we hear those jingly door keys; we run and we hide, we run and make a plea. We find a place and we curl up tight; I hold Leigh’s hand, and Leigh holds mine.
Soon enough Dad walks in; I think, “Leigh - don’t make a sound,” Don’t move, whisper or whim, I pray very quietly - deep within. But Leigh, she cannot help herself for her, the pain’s too much; "”Why? Oh Why?” she screams, "Why are you so mean?"
References: Arledge, E. & Wolfson, R. (2001). Care of the clinician. New Directions for Mental Health Services, 89, 91–98 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Champion, J. D. (2011). Context of sexual risk behavior among abused ethnic minority adolescent women. International Nursing Review, 58(1), 61-67. Child Welfare Information Gateway. (2009). Understanding the effects of maltreatment on brain development, Issue Briefs, Retrieved from: http:// www.childwelfare.gov/pubs/issue_briefs/brain_development/brain_development.pdf
He doesn't like what she’s just said, he beats her more and more; and with one last and hard blown hit, I scream,“What’d you do that for?”
Child Welfare Information Gateway. (2011). Supporting brain development in traumatized children and youth. Bulletins for Professionals, Retrieved from: http:// www.childwelfare.gov/pubs/braindevtrauma.pdf Finkelhor, D., Turner, H., Ormrod, R., & Hamby, S.L. (2009). Violence, abuse and crime exposure in a national sample of children and youth. Pediatrics. 125 (5), 1-13. Gaetz, S. (2004). Safe streets for whom? Homeless youth, social exclusion, and criminal victimization. Canadian Journal of Criminology and Criminal Justice, 46, 423–455.
Leigh takes one last big gasp of air, our hands still holding tight; her hand lets go, falls to the ground, her eyes are fixed in fright.
Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services , 89, 3-22. Haynie, D. L., Petts, R. J., Maimon, D., & Piquero, A. R. (2009). Exposure to violence in adolescence and precocious role exits. Journal of Youth and Adolescence, 38, 269286.
I stare at him with blaring tears, My eyes so blue, but red; he looks at me and points "O you!" “Your sister Leigh is dead.”
Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J., Marchbanks, P. A., & Marks, J. S. (2004). The association between adverse childhood experiences and adolescent pregnancy, long-term psychological consequences, and fetal death. Pediatrics, 113, 320-327.
"How dare you sisters have the gall to make me so very mad; “This is all your fault , not mine he said, Go ahead – go cry, be sad!" My name is Sasha, My sister’s name is Leigh; I am only six, My sister was only three
Hodas, G. R. (2006). Responding to childhood trauma: The promise and practice of trauma informed care. Retrieved from: www.nasmhpd.org Kidd, S. A. (2003). Street youth: Coping and interventions. Child & Adolescent Social Work Journal, 20 (4), 235–261. Killen-Harvey, A. , & Stern-Ellis, H. (2006). Trauma among lesbian, gay, bisexual, transgender, or questioning youth. Retrieved from: http://www.nctsnet.org/ nctsn_assets/pdfs/culture_and_trauma_brief_LGBTQ_youth.pdf 41
Ko, S. J., Ford, J. D., Kassam-Adams, N., Berkowitz, S. J., Wilson, C., Wong, M, Layne, C. M. (2008). Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39, 396-404. The National Child Traumatic Stress Network. (n.d.). Scope of the problem. Available at: http://www.nctsn.org/content/scope-problem
One day my Daddy murdered her; my best friend, my entire world.
National Institute of Mental Health (NIMH). (2012). Helping children and adolescents cope with violence and disasters: What parents can do. Retrieved from: http:// w.nimh.nih.gov/health/publications/helping-children-and-adolescents-cope-withviolence-and-disasters-parents/index.shtml Noll, J.G., Shenk, C.E., & Putman K.T. (2009). Childhood sexual abuse and adolescent pregnancy: A meta-analytic update. Journal of Pediatric Psychology, 34, 366-378.
We stuck together through thick and thin; because of him, now she’s gone, and I’m so lost within.
Office of Juvenile Justice and Delinquency Prevention. (n.d.). Trauma-informed care for children exposed to violence: Tips for pregnancy prevention programs. Retrieved from: http://www.safestartcenter.org/pdf/Tip%20Sheet%20-%20For%20Pregnancy% 20Prevention%20Programs.pdf
When I was six and my sister three my Daddy murdered my sister, my best friend, Leigh; Since that day I have not spoken - and I may not speak again, for speaking made my sister die, at the tender age of three.
Office of Juvenile Justice and Delinquency Prevention. (n.d.). Trauma-informed care
for children exposed to violence: Tips for Trauma-informed care for children exposed to violence: Tips for teachers. Retrieved from: http://www.safestartcenter.org/pdf/ Tip%20Sheet%20-%20For%20Teachers.pdf Office of Juvenile Justice and Delinquency Prevention. (n.d.). Trauma-informed care for children exposed to violence: Tips for pregnancy prevention programs. Retrieved from: http://www.safestartcenter.org/pdf/Tip%20Sheet%20-%20For%20Pregnancy% 20Prevention%20Programs.pdf Pearlman, L. A., & Saakvitne, K. W (Eds.). (1995). Trauma and the therapist: Counter-
because… our children matter
transference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton. Substance Abuse and Mental Health Services Association (2012). National Center for Trauma-Informed Care website. Retrieved from: http://www.samhsa.gov/nctic/ Schwartz, E. & Perry, B. (1994). The post-traumatic response in children and adolescents. Psychiatry Clinics of North America, 12, 311-326. Stein, B., Zima, B., Elliott, M. N., Burnam, M. A., Shahinfar, A., Fox, N.A., & Leavitt, L.A. (2001). Violence exposure among school-age children in foster care: Relationship to distress symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 588-594. Wilson, H. W., Woods, B. A., Emerson,E., & Donenberg, G. R. (2012). Patterns of violence exposure and sexual risk in low-income, urban African American girls. Psychology of Violence, 2, 194-207.
Trauma Informed Care
1-866 866--641 641--7181
becauseâ€Ś our children matter PARTNERING FOR THE FUTURE
8400 Louisiana Street Merrillville, IN 46410 geminuscommunitypartners.org email@example.com
Nicholas M. Neal, Director, Family Services Brandy Jania, Program Director, Geminus Community Partners