Taking a Trauma First Approach in Policy, Programs, and Practice

Bryan Samuels, CommissionerAdministration on Children, Youth and Families

Interpersonal Trauma

“[Complex trauma – also referred to as “developmental trauma disorder” or “chronic interpersonal trauma”] refers to children’s experiences of multiple traumatic events that occur within the caregiving system – the social environment that is supposed to be the source of safety and stability in a child’s life. Typically, complex trauma exposure refers to the simultaneous or sequential occurrences of child maltreatment—including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence—that are chronic and begin in early childhood. Moreover, the initial traumatic experiences (e.g., parental neglect and emotional abuse) and the resulting emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues, often lead to subsequent trauma exposure (e.g., physical and sexual abuse, or community violence).”

September 21, 2012 2ATTACh Conference

Southerland, D; Casaneuva, CE; & Ringeisen, H. (2009). Young adult outcomes and mental health problems among transition age youth investigated for maltreatment during adolescence. Children and Youth Services Review. 31(9):947.

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Abusive or Neglectful Parenting

Insecure Attachments,

Emotional Dysregulation,

Negative Internal Working Models

Maladaptive Coping

Strategies

Poor Social-Emotional

Functioning, Disturbed/Negativ

e Relationships

Psychological Distress

Poor Adult Functioning/Outco

mes

Imp

act

of

Trau

ma

on

Hea

lth

y D

evel

op

men

t

September 21, 2012

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Maltreatment Impacts How Youth Form Relationships with Adults

• Child maltreatment represents an extreme form of child–parent relationship disruption (Harden, 2004; Milan & Pinderhughes, 2000).

• Child maltreatment can be defined as a chronic interpersonal trauma, to which the child is exposed on a daily basis(Perry, 2008; van der Kolk, 2005).

• Children’s capacity to adequately cope with stress depends largely on the nature of the stress and on the attachment figure’s capacity to diminish or counter the effects (Lyons-Ruth et al., 1999).

• The developmental stage of the child at the onset of the abuse and neglect will influence the type and severity of the consequences (Frederico, Jackson & Black 2005; Perry 1995). Apr. 2, 2012

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Relational Functioning as Well-being?

Apr. 2, 2012

Sexual or Severe Physical abuse

Duration of abuse (>1 year)

Age at onset of abuse (<10 years)

Normal peer relationships

Caring relationship w/ either parent

Supportive first intimate partner

Quality adult friendships

Stable relationship history

0% 10% 20% 30% 40% 50% 60% 70%

11%

20%

25%

53%

62%

40%

44%

53%

Correlates of Resilience to Adult Psy-chopathology

Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31:211.

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Relationships as Protective Factors ISLE OF WIGHT STUDY

• Study showed child abuse is linked with difficulties in interpersonal relationships.

• Adolescent psychiatric difficulties showed strong continuity of difficulties into adulthood.

• However, 45% of abused individuals reported no mental health problems in adult life.

• Half of those reporting abuse in adulthood had been rated as showing significant abnormalities in interactions with peers in adolescence.

• At the same time, peer relationships in adolescence emerged as one of the strongest predictors of no mental health problems in adult life.

• Some individuals in the abused resilient group showed evidence of isolated difficulties, but rates of difficulties were lower than for the rested of abused group.

Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31:211.

6

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“DSM-IV psychiatric disorder connects with relationship functioning domains: high parental care; normal adolescent peer relationships; good adult friendships; supportive first partner, stable relationship history).”

September 21, 2012

1 2 3 40%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Abuse

No Abuse

Number of Domains of Successful Relationship Functioning

Rate

of

Ad

ult

Psych

iatr

ic

Dis

ord

er

Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31:211.

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• Study supports view:

– impairments in interpersonal relationships are of crucial importance for understanding the effects of child abuse on mental health outcomes.

– positive relationships should not be seen as good fortune arising from chance encounters with a supportive friend, peer or partner, but rather as an ongoing process of developing the competencies necessary to form, maintain and benefit from supportive interpersonal relationships.

– individuals with good relationship experiences across different domains and across childhood, adolescence and adulthood who were particularly likely to demonstrate healthy adult outcomes.

– understanding the processes whereby relationship competencies are developed and maintained constitutes an important goal for future research and target for clinical interventions.

September 21, 2012

Relationships as Protective Factors ISLE OF WIGHT STUDY

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Older Youth Entry into Foster Care - 2011

September 21, 2012

17 Years

16 Years

15 Years

14 Years

13 Years

12 Years

11 Years

11,220

16,288

15,878

13,132

10,741

9,141

8,118

84,518 out of 252,320 Entries are Adolescents

Data Source: Adoption and Foster Care Analysis and Reporting System (AFCARS), U.S. Department of Health and Human Services

“Simply removing a child from a dangerous environment

will not by itself undo the serious consequences or

reverse the negative impacts of early fear learning. There

is no doubt that children in harm’s way should be

removed from a dangerous situation. However, simply

moving a child out of immediate danger does not in itself

reverse or eliminate the way that he or she has learned to

be fearful. The child’s memory retains those learned

links, and such thoughts and memories are sufficient to

elicit ongoing fear and make a child anxious.”

National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu

December 9, 2011

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Programmatic Elements of Trauma-First Approach

Trauma-First Child

Welfare Approach

Developmentally specific approach

Knowledge building for

staff and foster parents

Addressing secondary

trauma

Build capacity to deliver

EBPs; contract for externally-delivered

EBPs Trauma-informed

screening and mental health assessment

Cross-system partnerships

and collaboration

September 21, 2012

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Practice Elements of Trauma-First Approach

Trauma-First Child

Welfare Approach

Focusing on child- and family-level

outcomes (as opposed to

process outcomes alone)

Monitor progress for reduced

symptoms and improved

child/youth functioning

Promotion of healthy

relationshipsProactive

approach to addressing social

and emotional needs

Trauma-informed case planning and

management

September 21, 2012

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Multi-Level Strategy to Address Trauma and Promote Well-Being

PolicyPromoting Safe and

Stable Families – Trauma Screening

and TreatmentInformation Memoranda:Well-Being,

Psychotropics, CQIIM: Title IV-E Child

Welfare Waiver Demonstration

ProjectsCMS: Early and

Periodic Screening, Diagnosis, and

Treatment

Workforce

ProgramFOA: Screening, Assessment, and Services Array

FOA: Regional Partnership Grants

Protective Factors across Populations

Ending Youth Homelessness

(USICH)

USAID

PracticePermanency

Innovations Initiative – Illinois

Collaboration with SAMHSA

Waiver Demonstrations in 6

States

FOA: Integrating Trauma into Child Welfare Services

FOA: Supportive Housing and Child

Welfare

Neuroscience and Child Maltreatment

September 21, 2012

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A More Complete Picture of

Well-Being

WELL-BEING

Feeling safe and stable in the

living environment

Belonging and social

connectedness (permanency)

Self-efficacy based on

developing competencies

Has a positive self image

Able to sustain positive

interpersonal relationships

Able to manage emotions and

regain equilibrium when upset

Adapted from Impact Youth Services, 2011; http://impactyouthservices.com/goals.htm

ACYF-CB-IM-12-04: http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf

September 21, 2012