This document discusses protecting children affected by traumatic stress. It acknowledges that while there is no local data on childhood trauma exposure, national estimates find that up to 68% of children experience a traumatic event by age 16. The document then summarizes Minnesota's efforts to identify and serve children impacted by trauma, including training practitioners, implementing evidence-based trauma treatments, and screening children across systems. It recognizes progress made but more remains to be done to fully address childhood traumatic stress.
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
Gewirtz
1. Protecting their future: Finding and helping stressed
children and families
Abigail Gewirtz, Ph.D., L.P.
agewirtz@umn.edu
June 1st, 2012
2nd MN statewide conference on traumatic stress
in children and families
2. 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
3. • 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
4. 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?
5. 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
6. Trauma affects the brain
• Interventions with children and adolescents
exposed to trauma and severe stress should
address its neurobiological consequences.
7. 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.
8. 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)
9. 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.
10. 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.
11. 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.
12. 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.
13. 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).
14. 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).
15. Ethical and legal issues
• Interventions with trauma-exposed children
and adolescents should address ethical and
legal issues as these arise.
16. Secondary traumatic stress
• Interventions with trauma-exposed children
and adolescents should address the impact of
working with these populations on the
practitioner.
17. 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
18. 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
19. Demographic Characteristics of Children Served*
Demographics
Gender (n= 1,257)
Male 45.7%
Female 54.3%
Average Age (n=1,253)
11.9
Age 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=659
Children Born Outside US 3.6%
*The information reported on this slide is from questions on the Baseline Assessment Form of the Core Data Set.
20. 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.
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21. Domestic Environment*
Poverty Level
Annual 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.
23. 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.
24. 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
25. 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.
26. 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.
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27. 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%.
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28. 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. The
information reported on this slide is from questions on the Baseline Assessment Forms of the Core Data Set.
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29. 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
30. • 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.
31. 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)’?
32. 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!
33. 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
34.
35. 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.
38. 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 those
who 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.
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39. 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 those
who 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.
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40. 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.
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
