ETHICAL CONSIDERATIONSIN THE TREATMENT OF

CHILD TRAUMA Valerie McClellan, LCSW, ACSW

Diane Braman, LCSWMatt Anderson, LMSW

Miracle Paige, NCC, Ed.S, PCMHT

Rules of conduct governing a group or individual.

The discipline dealing with what is right and wrong and with moral duty and obligation.

Merriam

Webster

What are ethics?

A complex situation that will often involve an apparent mental conflict between moral imperatives, in which to obey one would result in violating another.

Ethical Dilemma

National Association of Social Workers

Ethical Responsibilities to Clients

• Informed Consent

• Competence

• Conflict of Interest

• Privacy and Confidentiality

Ethical Principals – NASW

American Psychological Association

Ethical Principals of Psychologists & Code of Conduct

• Competence• Privacy & Confidentiality• Assessments• Informed Consent• Multiple Relationships

Ethical Principles – APA

How does the code of ethics apply to trauma treatment of children & adolescents?

Why does it matter if we are trauma informed?

Why are we talking about being trauma informed care in an ethics seminar?

Is it ethical to treat trauma if we aren’t trauma informed?

Questions to Consider

Informed ConsentCompetenceConflict of InterestPrivacy & ConfidentialityUse of AssessmentsClarification of Roles

Examples of Ethical Dilemmas

An emotional and/or behavioral reaction resulting from severe mental or emotional stress.

Merriam-Webster

What is Trauma?

Features: sudden or unexpected events death or threat to life or bodily integrity subjective feeling of intense terror, horror or

helplessnessAmerican Psychiatric Association

Examples: child physical & sexual abuse, witnessing/a victim of violence severe accident life threatening illness natural/man made disasters

Features & Examples of Trauma

an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma.

emphasizes physical, psychological and emotional safety for both consumers and providers

helps survivors rebuild a sense of control and empowerment.

Trauma Informed Care

Adverse Childhood Experiences study: examined the health and social effects of adverse

childhood experiences over the lifespan, 18,000 participants. Kaiser Permanente and CDC.

ACEs-sexual & physical abuse, psychological abuse, exposure to DV, substance abuse or mental illness by caregiver, incarcerated caregiver, separation or divorce by parents.

ACEs-strongest predictor of physical and mental health problems in adulthood.

ACEs determine the likelihood of 10 most common causes of death in U.S.

Why be trauma informed? Why does TIC matter?

Nat’l Survey on Child & Adolescent Well-Being II:

Examined impact of ACEs on child mental health.

5872 children/adolescents, 2 follow-up interviews at 18 month intervals with caregivers, caseworkers and children, use of standardized measures.

Findings-Caregiver mental illness was only ACE predictive of child mental health problems in all age groups. Accumulation of ACEs may have latent effects on mental and physical health. Studies found dose-response relationships in early adolescents but not in young children.

Why be trauma informed? Why does TIC matter? pg 2

If you have an ethical dilemma that you would

like feedback from the group on, please

write it down and give it to one of the

presenters. We will discuss them tomorrow at

the end of the session.

Ethical Dilemmas

What does trauma look like behaviorally and/or emotionally?

ADHD Oppositional Defiant Disorder Bipolar Disorder Anxiety Disorders Depressive Disorders High Blood Pressure Sleep Disorders Addiction Issues Etc.

We possibly end up treating the symptoms instead of the core issue.

What happens if we aren’t trauma informed or don’t screen?

Become Trauma Informed- read, on-line trainings, outside trainings by

certified trainers.

Screen for trauma & refer: Child Trauma Screening Questionnaire, Brief

Trauma Questionnaire, Child Stress Disorder Checklist, Trauma Symptom Checklist, etc. or simply DMH Initial Assessment.

(Google “child trauma screeners”)

How do we screen & treat child trauma?

Exert from the DMH Initial Assessment:

Traumatic Event or Exposure History: Serious accidents Natural disaster Witness to a traumatic event Sexual assault Physical assault (with or without a weapon) Childhood sexual molestation Close friend or family member murdered Homeless Victim of stalking or bullying Other (specify)

Trauma Screening Questionnaire

• Google: Certified TF-CBT Therapist:

https://rtfweb.wpahs.org/tfcbt/

• Email: valerie.mcclellan@ccjackson.org

(I can guide you in searching for either a TFCBT or EMDR therapist.)

Who do you refer to?

Trauma Treatment-designed to help a child/adolescent process a trauma/traumas he/she experienced and learn how to cope with the thoughts and feelings associated with the experience.

Evidence-Based Practice: a combo of

(1) best research evidence

(2) best clinical experience

(3) consistent with family/client values

Treating Child Trauma

Ensures families are referred to & receive the most effective & efficacious treatment available.

Empowers families in crisis to resolve their own conflicts, using well-tested programs.

May cause families to make a greater commitment to treatment.

Help providers understand what is available & make informed choices when referring

Used for resource development (grant writing), program development, policy development and advocacy.

Helps identify outcomes Payment sources are beginning to require

Why is using an EBP important?

• Well-Supported by Research Evidence: 2 studies in different settings, effects last at least 1 yr:-Trauma Focused Cognitive Behavioral Therapy-Eye Movement Desensitization Reprocessing

• Supported by Research Evidence: 1 study , effects last 6 months:- Child Parent Psychotherapy- Prolonged Exposure Therapy for Adolescents

Based on California Evidence-Based Clearinghouse for Child Welfare

Evidence-Based Practices for Child Trauma

Break into groups

Take your case study

Brainstorm how you would address the ethical dilemma & what ethical standard it

Present to the larger group

Ethical Dilemmas

Ethical Principles (that pertain to clients)NASW Informed Consent Competence Conflict of Interest Privacy &

Confidentiality

APA Informed Consent Competence Privacy &

Confidentiality Assessments Multiple

Relationships

An 8 year old child had been a victim of neglect and sexual abuse while in the mother’s care. Upon entering treatment, the child was in the care of the maternal grandmother while the father was serving in Afghanistan. The family completed treatment. The father was able to come to the termination session. The family then moved on to their home in another state. A month or so after termination, the grandmother emailed the therapist and let the therapist know that the child was transitioning well into her home with her father and thanked the therapist for services provided and the support she’d needed to care for her grandchild. She went on to say “and when you’re ready to schedule a message therapy session just let me know. (The therapist, prior to treating the child, had been referred to this message therapist from several colleagues who spoke highly of the quality of her services. In addition, this massage therapist is the only one in the area who has specialized therapeutic training to work with folks who’ve suffered various physical medical problems.)

• What ethical standards come to mind? • How would you handle this situation?

Ethical Dilemma #1

Two children; 9 year old female and 11 year old male, they live with their biological mother. The mother and the children's father are separated . The client's father has been verbally and physically abusive towards mother.Before the case is even open, the father comes to the agency twice demanding to talk to the assigned therapist and see the clinical documentation.Upon opening the case and beginning the assessment process, the clinician learns that there has been no court order regarding legal or physical custody. The children are fearful of their father but have not reported any abuse that could be considered dangerous or required to be reported. On one occasion, while in a vehicle, he did pull a gun out and put it on the seat. He did not threaten the children with it. Mother would like the children to participate in therapy to help with their reaction to their parents' separation and divorce. The children are obviously traumatized by the parents' arguments during their marriage and separation. The mother is aligned and engaged with treatment. Mother upon intake request the therapist not disclose any information about the children's treatment nor report on any progress within treatment. to their father By this, she meant for the therapist to make no notes nor document any contact with the children in case the father requests copies of their charts. After a temporary hearing, the children’s mother has physical custody and both parents have legal custody. Mother has also been referred for treatment for her own traumatic needs related to her abuse from her husband.

• What ethical standards come to mind? • How would you handle this situation?

Ethical Dilemma #2

KC is a 13 year old female who was raped by an older male. KC’s case was a statutory rape case. KC also reported molestation as a child. KC was removed from mother's home and placed with father. KC’s treatment consisted of trauma focused therapy. As time passed, KC revealed that she was over her cousin's house and had sex with a male her age. According to the law, she was not old enough to consent to sex.

What ethical standards come to mind?

How would you handle this situation?

Ethical Dilemma #3

A 35 year old Hispanic female presents for therapy upon referral from Catholic Charities Migrant Support Services program. She was encouraged by them to get counseling to address her exposure to 10 plus years in a domestic violence relationship. She presented for her first session with a friend to provide interpretation services for her since she has limited English speaking abilities. During the screening and assessment process it was discovered that she was exposed to multiple traumatic childhood events including child sexual abuse. Other details discovered in this family include: the client is undocumented; she has been separated 6 months from the man with whom she was in a domestic violence relationship. This man continues to harass her by coming by her house in the middle of the night, drunk, knocking on her door, trying to get her to take him back, threatening to call immigration services if she doesn’t take him back. Sometimes he’ll threaten to hurt himself also.They have 2 children together and she doesn’t want him to take the kids because sometimes he acts like he’s been drinking and other times the kids come back home saying that daddy has been talking bad about their mother.

• What ethical standards come to mind?

• How would you handle this situation?

Ethical Dilemma #4

A Hispanic mother and her 14 year old daughter presented for therapy upon referral from the MS Child Advocacy Center. The daughter had disclosed to a friend that an 21 year old male, a close friend of the family, had been sexually abusing her. This friend’s mother then told the client’s mother who called the police and reported it which initiated the investigation process. Additional information gained at intake: 14 year old is smoking marijuana. Mom is undocumented. She makes money by cleaning houses. She shares a home with another single mother and kids in order to pay the bills. Mom has been in the US for 15 years, the client was born here. Mom’s extended family, maternal grandmother & maternal aunt families, also live in the area, in the same housing development as this family. The mom has been very close to the aunt and maternal grandmother – until the sexual abuse was disclosed. The maternal grandmother, aunt and other family members reportedly don’t believe the sexual abuse happened. In addition, the extended family is reportedly blaming the client because she had recently reportedly started dressing sexy & seductively, and had been found trying to meet guys in texting and over the internet and facebook. As a result of the extended family’s reactions, the mother has had to cut off all contact with these family members.

• What ethical standards come to mind?

• How would you handle this situation?

Ethical Dilemma #5

Discussion:

your ethical dilemmas