I first met John at 4am on a cold morning. He was sitting on the front lawn of his friend’s apartment. He had been staying overnight with the friend and the friend’s mother had just attempted suicide by taking a broken glass to her wrists. John and his friend were awoken by the sound of glass smashing, and broke into the bathroom to stop the mother. When I arrived at the apartment there was a trail of blood through the apartment. John was sitting silently on the lawn. He talked about the event he had witnessed as if it had occurred to somebody else; he seemed numb, and disconnected. The police returned John to his parents’ home and I went back to visit with him in the weeks following the event. John taught me a lot about trauma, and its impact on children’s development. He was so ‘zoned out’ that he found himself unable to focus in school; he had had to repeated grades so many times that although he was 15 years old, he was only in the 6 th grade. His teachers despaired of him but felt that they barely knew him. They couldn’t decide what was wrong with him; at various points in his school career he was labeled as having ADHD, a learning disorder, a developmental disability – but never posttraumatic stress disorder. As the weeks unfolded, I learned much about John and learned that his 15 years were littered with more traumatic events that most 50 year olds had experienced: separation, loss, witnessing violence in the home and the community, severe illness of his mother, and the death of a sibling. These traumatic events, occurring early and with horrendous rapidity, conspired to render him vulnerable to later events. When I met him, after his friend’s mother’s suicide, he had retreated to what I realized was a pretty stable pattern of adaptation: he recalled little, of anything (including for example, the street he lived on even though he had moved weeks previously), he was very hyper-vigilant, and responded with alarm to noise, people walking down the street towards him, anything unexpected, and he reported constant intrusive thoughts and nightmares. He was convinced that he would not live to see age 21. For John, a saving grace was love and loyalty towards his mother and his surviving siblings. They were able to help him get into treatment to reduce his severe and debilitating trauma symptoms. As I learned more about John, he revealed something about that night at his friend’s house. He hadn’t wanted to stay there, but his friend had begged him to. His friend had shared with him his concerns about his mother’s mental state. John felt terribly guilty that he hadn’t suggested to his friend that they get help for her. He thought that maybe
In John’s case the secondary adversities were the academic challenges that resulted from his many missed days of school, and the inattention and difficulty in concentrating that led him to be very behind. This in turn, led to new challenges across development – such as being a 15 year old in a class of 12 yr olds.
Copeland et al., 2007) A majority of children (67.8%) were exposed to one or more traumatic events by age 16. Children exposed to trauma had almost double the
Standard deviation of Age is 3.7
Standard deviation of Anxiety at Baseline is 13.9 Standard deviation of Anxiety at 3 Months is 12.4 Standard deviation of Anxiety at 6 Months is 12.0 Standard deviation of Depression at Baseline is 12.3 Standard deviation of Depression at 3 Months is 13.4 Standard deviation of Depression at 6 Months is 11.0 Standard deviation of Anger at Baseline is 10.0 Standard deviation of Anger at 3 Months is 9.2 Standard deviation of Anger at 6 Months is 8.6 Standard deviation of PTSD at Baseline is 11.6 Standard deviation of PTSD at 3 Months is 11.5 Standard deviation of PTSD at 6 Months is 10.7 Standard deviation of Dissociation at Baseline is 11.3 Standard deviation of Dissociation at 3 Months is 11.4 Standard deviation of Dissociation at 6 Months is 10.3
Standard deviation of PTSD at Baseline is 13.4 Standard deviation of PTSD at 3 Months is 12.4 Standard deviation of PTSD at 6 Months is 13.9
Protecting their future: Finding and helping stressed children and families Abigail Gewirtz, Ph.D., L.P. firstname.lastname@example.orgJune 1st, 20122nd MN statewide conference on traumatic stressin children and families
Acknowledgments• Ambit Network and ADAPT teams & students – Dawn Reckinger – Chris Bray – Stephanie Morris• Our partners over the years – State partners (DHS, NG, MNDVA) – County and city partners – Multiple provider agencies• The families with whom we are privileged to work
• This conference is supported by SAMHSA NCTNSN grant #SM56177 to the University of MN• Thanks to our NCTSN collaborators and the National Center for Child Traumatic Stress• And to Senator Franken for his tireless advocacy on behalf of children and families
Overview• What are the common themes of traumatic stress? – Two examples – Core concepts – How are core concepts used in practice?• How can service providers respond to child traumatic stress?• How is Minnesota serving children and families affected by stress & trauma?
Core Concepts of Childhood Trauma (NCTSN, 2011)• Trauma can interact with and exacerbate pre- existing vulnerabilities across development – e.g., history of prior trauma, loss, or psychopathology.• Pre-existing protective and promotive factors can reduce the adverse impacts of trauma exposure across development. – e.g., positive attachment relationship with primary caregiver, family cohesion, social support, adaptive coping, social competence
Trauma affects the brain• Interventions with children and adolescents exposed to trauma and severe stress should address its neurobiological consequences.
Traumatic experiences are inherently complex• i.e., what occurs during the course of the event, including objective and subjective elements, moment-to-moment changes in appraisals of what is occurring, available protective actions, and acute emotional responses.
Traumatic events generate a variety of responses– These responses • fall on a continuum ranging from expectable transient distress, to more rigid entrenched disruptions that involve functional impairment, frank psychopathology, disruptions in self-regulatory capacities, and developmental disturbance. • can be misdiagnosed as other forms of psychopathology (e.g., bipolar disorder, ADD). • may reflect the specific type of traumatic event (including acute vs. serial or sequential trauma exposure)
Culture matters• Cultural factors and processes (including culturally dictated social roles, developmental tasks, developmental milestones, coping strategies, and meaning-making relating to the traumatic experience and to historical trauma) may profoundly influence trauma exposure and should be systematically considered at all stages of intervention.
Trauma exposure may generate adverse life events– Or circumstances that may continue to transmit the adverse effects of trauma over time and across development.– Trauma may generate secondary adversities, which may further tax coping resources and generate their own distress reactions and developmental challenges.– Trauma reminders are cues that may evoke renewed distress and maladaptive coping responses.
Interventions should address safety• Interventions with trauma-exposed children and adolescents should include promoting, where needed, the child’s or adolescent’s external (objective) safety and internal (psychological) safety.
Development matters!• Developmental factors and processes (including current developmental tasks, capacities, milestones, and cognitive/emotional characteristics of one’s particular developmental stage) may: – influence children’s and adolescents’ risk for exposure to trauma and associated reactions, and – Be influenced by exposure to trauma, and therefore should be systematically considered at all stages of intervention.
The caregiving environment is critical• Interventions should address the functioning of primary caregiving environments - the parent/caregiver, family unit, and their relationship with the child or adolescent. This includes: – Evaluating the influence of the family environment on the child’s or adolescents’ risk for exposure to trauma (e.g., risk for exposure to sexual abuse, physical abuse, neglect, and domestic violence).
Caregiving environment contd.• Evaluate the effects of trauma exposure on: – internal attachment systems (e.g., internal working models; development of secure/insecure/ disorganized attachment styles). – caregiving environments (e.g., immediate/extended family, peers, foster care, milieu). – interpersonal behaviors (e.g., ability to relate to other people; boundaries and trust; limit-setting; ability to approach people safely and appropriately; self-assertion; conflict resolution).
Ethical and legal issues• Interventions with trauma-exposed children and adolescents should address ethical and legal issues as these arise.
Secondary traumatic stress• Interventions with trauma-exposed children and adolescents should address the impact of working with these populations on the practitioner.
What do we know about traumatic stress?• No local epidemiological data on exposure to traumatic stress. – Reliance on national estimates that up to 68% children have experienced at least one traumatic event prior to age 16 (Great Smoky Mountains study; Copeland et al., 2007 ) – Children exposed to traumatic events had almost double the rates of psychiatric disorders than those who were not exposed
Minnesota data on children referred for trauma treatment• About 1000 children referred to mental health clinics across the state where clinicians were trained in trauma-focused cognitive behavioral therapy
Demographic Characteristics of Children Served*DemographicsGender (n= 1,257)Male 45.7%Female 54.3%Average Age (n=1,253) 11.9Age Group (n=1,253)Birth to 5 years 5.1%6 to 12 years 47.3%13 to 17 years 46.4%18 to 21 years 1.1%Race (n=872)American Indian or Alaska Native 12.4%Asian 1.3%Black/African-American 22.1%Native Hawaiian or Other Pacific Islander 1.5%White 75.3%Ethnicity (n=846)Hispanic Ethnicity 12.4%Not Hispanic or Latino 87.6%Country of Birth (n=660) n=659Children Born Outside US 3.6%*The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set.
Domestic Environment at Baseline* n=851*The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set. April 2012 MN Child Response 20 Center
Domestic Environment* Poverty LevelAnnual Family Income (n=65) Poverty categories are based on the U.S. Department of Health and Human Services poverty guidelines, which are available for the 50 States.Less Than $5,000 1.5%$5,000 - $9,999 10.8%$10,000 - $14,999 7.7%$15,000 - $19,999 15.4%$20,000 - $24,999 6.2%$25,000 - $34,999 18.5% n=65$35,000 - $49,999 6.2% Insurance$50,000 - $74,999 13.8%$75,000 - $99,999 12.3%$100,000 and Over 7.7% n=619*The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set.
Core Data SetClient Problems, Symptoms, and Types of Trauma
Top 10 Primary Problems/Symptoms Displayed by Children at Baseline n = 620*The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set.
Top 10 Problems at Baseline as Reported by Caregiver**The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set.**At home or in the community
Top 10 Types of Trauma* Has the child experienced... % Yes** Is this trauma a primary focus of treatment? (n = 856) Domestic Violence? (n=857) 67.7% 13.1% Emotional Abuse/Psychological Maltreatment? (n=863) 65.8% 9.0% Impaired Caregiver? (n=880) 62.7% 3.9% Physical maltreatment/assault? (n=870) 62.1% 15.7% Sexual maltreatment/assault? (n=863) 53.0% 26.1% Traumatic Loss or Bereavement? (n=889) 47.9% 14.5% Neglect? (n=854) 40.9% 4.9% Community Violence? (n=882) 20.2% 1.1% Serious Injury/Accident? (n=882) 18.4% 2.5% School Violence? (n=879) 17.1% 0.7%*The information reported on this slide is from questions on the General Trauma Information Form of the Core Data Set.**This includes percentage of children who either experienced the trauma or were suspected of experiencing the specific trauma.
Types of Trauma-Continued* Has the child experienced... % Yes** Is this trauma a primary focus of treatment? (n = 856) Other? (n=797) 16.9% 6.0% Illness/Medical? (n=891) 16.3% 1.1% Natural Disaster? (n=897) 9.8% 0.5% Extreme Interpersonal Violence? (n=864) 6.8% 0.7% Kidnapping? (n=891) 4.6% 0.1% Forced Displacement? (n=893) 2.8% 0.1% War/Terrorism/Political Violence Outside the U.S.? (n=899) 1.1% 0.4% War/Terrorism/Political Violence Inside the U.S.? (n=894) 0.8% 0.0%*The information reported on this slide is from questions on the General Trauma Information Form of the Core Data Set.**This includes percentage of children who either experienced the trauma or were suspected of experiencing the specific trauma. April 2012 MN Child Response 26 Center
Settings of Trauma Experience by Trauma Type**The information reported on this slide is from questions on the Trauma Detail Form of the Core Data Set.**Since trauma may have been experienced in multiple settings, the percentages will not add to 100%. April 2012 MN Child Response 27 Center
Top 10 Services Used at Baseline* Services received from NCTSN center or from other sector, clinician or % Yes setting in the past month Outpatient Therapy(n = 643) 63.0% Case Management or Care Coordination(n = 644) 46.7% School Counselor, School Psychologist, or School Social Worker(n = 605) 44.6% Child Welfare or Departments of Social Services(n = 624) 40.5% Special School or Special Class(n = 625) 35.5% Outpatient Treatment from a Psychiatrist(n = 636) 33.2% In Home Counseling or Crisis Services(n = 638) 31.2% Residential Treatment Center(n = 651) 21.2% Foster Care(n = 647) 17.2% Primary Care Physician/Pediatrician(n = 623) 16.1%*Services include those provided by the NCTSN Center as well as by other clinicians, agencies, sector or setting within the 30 days prior to intake. Theinformation reported on this slide is from questions on the Baseline Assessment Forms of the Core Data Set. April 2012 MN Child Response 28 Center
How do we serve children and families affected by traumatic stress in MN?• Identification – In mental health system – Through other child-serving systems• Screening and assessment – Mental health assessments – Screening for trauma in other systems• Treatment – Implementing evidence-based trauma treatment and trauma-informed practice
• This work has only been made possible with the vision, investment and hard work of MN’s DHS’ Division of Children’s Mental Health (particularly Glenace Edwall and Pat Nygaard).• And with the willingness to innovate on the part of all the agencies statewide that we have had the good fortune to collaborate with.
To date:• Identification: – Thousands of practitioners trained in identifying children affected by traumatic stress – in mental health and other child-serving systems like schools – In systems serving high risk children (e.g. child welfare), there have been significant efforts to pay attention to children’s trauma histories by asking the simple question: ‘what happened to you’ instead of ‘what did you do (wrong)’?
Screening and assessment– Efforts are underway to develop a statewide trauma screening for the highest risk children (e.g. those entering the child welfare system)– For mental health clinicians, assessment can provide important diagnostic information that can be fed back to the child and family • >1000 assessments done by TFCBT clinicians!
Treatment• 214 therapists in Minnesota trained in trauma-focused cognitive behavioral therapy, in 43 agencies across the state• Minnesota will be the first state to have a statewide rostering system that meets national certification criteria developed for TFCBT
Prevention and promotion• ADAPT (After Deployment Adaptive Parenting Tools) is one example of a family-focused resilience building program for military families that we have developed and are evaluating locally.• Minnesota’s leadership in supporting National Guard and Reserve families through Beyond the Yellow Ribbon make this a great state for this type of program.• And new legislation requiring VA to provide ‘family services’ means that children and families will also be able to receive services at VA medical centers.
Core Data SetClient OutcomesApril 2012 MN Child Response 37 Center
Average Level of Distress for Children Aged 8 to 16 as Measured by TSCC-A* at Baseline, 3 Months, and 6 Months Clinical threshold*The information reported on this slide is from questions on the TSCC-A measure of the Core Data Set. The sample reported here is restricted to thosewho have data at all reported data points.**The range for TSCC-A t score is 32-108. Scores 65 and above are in the clinical range. April 2012 MN Child Response 38 Center
Average UCLA PTSD Index for Children Aged 7 to 18 at baseline, 3 Months, and 6 Months* Clinical threshold n = 103*The information reported on this slide is from questions on the UCLA PTSD measure of the Core Data Set. The sample reported here is restricted to thosewho have data at all reported data points.**The range for the UCLA PTSD raw score is 0-68. The clinical cut-off for the PTSD Index is 38 or above. April 2012 MN Child Response 39 Center
We have a good start; what’s next?• Much remains to be done: – Helping systems come together on behalf of children and families affected by traumatic stress • E.g. screening that could be used across systems – Training more providers in evidence-based trauma treatment, and trauma-informed practice • And training should start in school, not when practitioners are already licensed. – Paying attention to our military families by increasing capacity of schools, healthcare providers, and others to ‘see’ military children and meet their needs.