September 2013

Module 4Understanding the impact of

maltreatment, stress and separation on development

Module 4 Learning Objectives

Participants will:• Identify the impacts of maltreatment,

neglect and abuse on the physical, motor, language and communication, cognitive and social-emotional domains

• Understand how these negative impacts early in life can lead to lifelong challenges

• Understand the importance of access to consistent medical and dental care.

• Understand the importance of initial and ongoing developmental screening with referrals to early intervention as needed.

Modified by Children’s Administration 5/2014

Overview of this module

• There are often significant differences across all the developmental domains when we compare children who have been abused or neglected with children who have not

• The impacts of these early years will carry on long into adulthood, as we have learned from the ACE study

• What does this all mean for child welfare professionals?

Developmental comparison between a

typical and maltreated child

Physical

Motor

Language

Cognitive

Social emotional

Billy and Lucian

Video: First Person, Impressions of Being a BabyClip #1 Lucian: minutes 13:55-18:35

Video: Broken Child, Case Studies of Child Abuse

Clip #2: Billy (5:34-7:56)

Mom’s poor prenatal care put Billy on a lifelong trajectory for

health and emotional problems

Mom’s healthy prenatal care put Lucian on a trajectory of

optimal physical and emotional health

Transgenerational Transmission

“… the handing down of a susceptibility from parent to child.”

• Mothers who report experiencing stress during pregnancy are more likely to have babies who are hyperactive and developmentally delayed

• Newborns of depressed mothers are more irritable and harder to soothe, have more problems sleeping and have higher levels of the stress hormone cortisol in their blood

Physical Development

• Height and Weight• Nutrition• Physical Activity• Dental, Vision and Hearing

Physical Development

Lucian

• On target for height and weight

• Regular checkups

• Immunizations up-to-date

• Good teeth

• Excellent health

• Breastfed, so good immunities

Billy

• Malnourished and anemic

• Bottle mouth and rotten teeth

• Chronic untreated ear infections with possible hearing loss

• Compromised lung function from second-hand smoke

• No immunizations

• Bleeding diaper rash

Motor Development

• Gross motor development• Fine motor development• Development of self-help skills

Motor Development

Lucian

• Drinks unassisted from a cup

• Feeds self with spoon and fork

• Can undress self

• Can work puzzles and stack blocks

• Can turn on dad’s iPhone and play

Billy

• Prefers crawling but can run

• Drinks from bottle, not cup

• Eats with fingers

• Has never used spoon or fork

Language and Communication

• Receptive communication• Expressive communication

Left behind by kindergarten

By age 4, the average child in a poor family might have been exposed to 13 million fewer words than a child in a working class family and 30 million fewer words

than a child in a professional family.

Source: http://www2.ed.gov/programs/readingfirst/2008conferences/language.pdf

Speech and Language Development

Lucian

• Vocabulary of 300 words

• Can point and name correct animal in book “show me the dog”

• Carries out directions

• Initiates five-word sentences

• Asks for what he needs

• Knows songs, rhymes and fingerplays

Billy

• Points to get what he needs

• Ear infections make it hard to hear words

• No words

• No books in the house

• Watches TV

• Never been read to or sung to

Cognitive Development

• Eagerness and curiosity

• Persistence

• Creativity and problem-solving

• Vocabulary

Toxic stress from exposure to violence can impair healthy

development

One study revealed that exposure to relationship-based violence and trauma in the first two years of life resulted in lower IQ scores at 5 and 8 years of age.

Enlow MB, Egland B, Blood EA, Wright RO, & Wright RJ (April 4, 2012) Interpersonal trauma exposure and cognitive development in children

to age 8 years: a longitudinal study. Journal of Epidemiology and Community Health Online First.

Children learn through experiences

• Eagerness and curiosity• Persistence• Creativity and problem-solving

Cognitive Development

Lucian

• Creativity and problem-solving

• Plays make believe with stuffed animals

• Can name all his body parts

• Can count to 10

• Can work mechanical toy

• Vocabulary

Billy

• Creativity and problem-solving

• Curiosity

• Persistence-finds hidden food

• Imitates mom smoking with stick

• Minimum receptive language

Social and Emotional Development

• Trust and emotional security• Self-regulation• Self-concept

Consequences of Trauma

• Depression• Anxiety• Aggression• Conduct disorders• Sexualized behaviors• Eating problems• Substance abuse

Source: Harris, W.W., Putnam, F. W., and Fairbank, J.A. Mobilizing Trauma Resources for Children. January 8, 2004.

Social-Emotional Development

Lucian

• Range of emotions

• Happy, emotionally calm, balanced

• Expresses affection warmly

• Comforts other kids when hurt

• Uses Dad as secure base from which to explore world

• Reciprocity in relationship

Billy

• Plays with baby brother

• Flat affect

• Runs to mother

• Stays near mother

What has Billy learned about

relationships?

Who was their

secure base?

How did the adults in their life

help them regulate?

How will Billy react when

separated from his mother?

Trauma & Stress

Considering Trauma in Child Welfare

Modified by Children’s Administration 5/2014

Trauma and

Young Children

Child Welfare and Trauma

“Trauma can be a single event, connected series of traumatic events or chronic lasting stress.”

Diagnostic Classification: 0-3R

Children in the child welfare system almost by definition have suffered trauma, often multiple traumatic events, and 50-75% exhibit behaviors or symptoms that need mental health treatment.

Source: Landsverk, Burns, Stambaugh, & Rolls Reutz (2009). Psychosocial Interventions for Children

and Adolescents in Foster Care: Review of Research Literature. Child Welfare, 88 (1), 49-69.

Do you see signs of trauma?

Signs of trauma in toddlers:

• Lack of verbal skills to express emotions

• Biting, kicking, tantrums, unprovoked aggression

• Disengagement with others

• Disinterested in toys

• Indiscriminate preferences of caregivers

• Skill regression

• Vigilance

• Lack of exploration

Monitoring Health and Development

Modified by Children’s Administration 5/2014

American Academy of Pediatrics: Recommendations for health care of young children in foster care …

• Initial health screening

• Comprehensive medical and dental assessment

• Developmental and mental health evaluation

• Ongoing primary care and health monitoring

Modified by Children’s Administration 5/2014

WA POLICIES: HEALTH & MEDICAL NEEDS

Initial Health Screening – Five days of placement

Early Episodic Screening Diagnosis and Treatment (EPSDT) is required:

• Within the first thirty days of out of home placement. • Five exams during the first year of life • Three exams between 1 and 2 years of age• Annual exams between 3 and 20 years of age.

Health Care Services Policy

Modified by Children’s Administration 5/2014

WA POLICIES:DENTAL NEEDS

• Initial dental exam within 30 days of entering care (unless dental exam was received within 6 months of placement)

• Regular and ongoing dental exams every 6 months.

• Dental exams are recommended, for all children upon the first erupted tooth, 1st Birthday, or when referred by a medical professional.

Modified by Children’s Administration 5/2014

Early intervention matters

IDEA Part C: Ages 0-3

IDEA Part B: Ages 3-5

Sourcehttp://www.ideapartnership.org/index.php?option=com_content&view=section&id=51&Itemid=140

Unmet developmental needs of children investigated for maltreatment

A national study found that …

Only

13% had an IFSP or IEP indicating

services

32% of children age 0-

5 needed early intervention

Source: Casanueva, C. E., Cross, T. P., & Ringeisen, H. (2008). Developmental needs and individualized family service plans among infants and toddlers in the child welfare system. Child Maltreatment, 13, 245-258.

Early Support of Infants and Toddlers

• Early Support for Infants and Toddlers

www.del.wa.gov/esit • Please Ask video

www.youtube.com/watch?v=JoaFNGmSU5U • Guiding Concepts Videowww.youtube.com/watch?v=yGqAOZrvQQU&feature=youtu.be

Modified by Children’s Administration 5/2014

Early Support of Infants and Toddlers

• Family Health Hotline 1-800-322-2588• Contact Directorywww.del.wa.gov/publications/esit/docs/ContactsDirectory.pdf

• Practice Guide: Identifying the “Parent” for Infants and Toddlers in Foster or Out ‐ of‐Home Care (20U.S.C. §§1401(23) and 1439(a)(5)). – Participation in ESIT is voluntary.

www.del.wa.gov/publications/esit/docs/ESIT_practice_guide_foster_care.pdf

Modified by Children’s Administration 5/2014

CHILD HEALTH AND EDUCATION TRACKING SCREEN

• All children who remain in out-of-home placement longer than 30 days receive a Child Health & Education Tracking (CHET) Screen.

• CHET screens across five domains using validated and standardized tools to assess development.

• If a developmental delay is identified a referral must be made within two working days to Early Support for Infants and Toddlers (ESIT) for children birth to five. www.del.wa.gov/esit

• If a delay is identified for children three to five years of age a referral must be send to the Child Find Coordinator at the local school district.

• Children may have developmental concerns that emerge after the CHET screening and should be referred at that time by social worker or caregiver.

Modified by Children’s Administration 5/2014

Developmental Information

• Child Profilewww.doh.wa.gov/YouandYourFamily/Immunization/ChildProfileHealthPromotion.aspx

• Birth to 5: Watch Me Thrive

www.acf.hhs.gov/programs/ecd/watch-me-thrive • Center for Disease Control Developmental Milestone

Checklist

http://www.cdc.gov/ncbddd/actearly/milestones/index.html• Help Me Grow

Modified by Children’s Administration 5/2014

CHET ACTIVITY

• Identify any concerns documented in the report.

• Identify if the report has been provided to the FRC.

• As the identified social worker what are your next steps.

Modified by Children’s Administration 5/2014

Federal Mandate for Developmental Screening of Maltreated Children

CAPTA: 108-36 2003 Child Abuse Prevention & Treatment & Adoption Reform

Requires states to have procedures for the referral of children under 3 involved in substantiated cases of child abuse or neglect to early intervention services.

DOCUMENTING CAPTA IN WA

• The assigned investigator must make a referral to the local Family Resource Coordinator if they identify of suspect a developmental delay.

• The referral must be made within two working days to Early Support for Infants and Toddlers (ESIT). www.del.wa.gov/esit

• The referral must be discussed with the parent/caregiver.

• The parent/caregiver can request an extension of the referral timeline. This request should be documented on the referrals tab in the education record of the identified child’s person card in FamLink.

Modified by Children’s Administration 5/2014

Summary: Understanding the Impacts of Maltreatment

• Children who have been abused, neglected and/or maltreated are more likely to experience toxic stress

• The impacts of abuse, neglect and/or maltreatment can negatively influence all developmental domains

• These delays persist through a child’s life, making it harder for them to do well in school and adulthood

• Early and periodic medical, dental and developmental screening and referrals to appropriate interventions can change life trajectories.

• The “buffering” relationship with a loving, stable caregiver remains key to alleviating these negative impacts. It’s never too late!

Modified by Children’s Administration 5/2014