Creating a Trauma-Informed Child Welfare SystemStatement of

Statement of Need for Trauma-Informed Child Welfare While there is a considerable amount of literature and research documenting the long-term effects of adverse childhood experiences including abuse and neglect (Felitti et al., 1998), there has been a lack of exploration of how to integrate trauma-informed practice within the fabric of the child welfare system. Recognizing trauma and its potentially pervasive effects on children and families presents a critical challenge to the child welfare agency. Mismanagement of trauma reduces the likelihood of reunification (Rubin, OReilly, Luan & Localio, 2007), increases placement instability (Hartnett, Leathers, Falconnier & Testa, 1999), results in the application of increasingly more restrictive placements (Pecora et al., 2005), increases the likelihood of administration of strong psychotropic medicines (Raghavan et al., 2005), and increases the likelihood that the child will carry on an intergenerational cycle of abuse or neglect upon becoming a parent (Fang & Corso, 2007). Definition Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or someone critically important to the child (e.g., a parent or sibling). Exposure to a single traumatic event that is limited in time (e.g., an auto accident, a gang shooting, or a natural disaster) is called an acute trauma. Chronic trauma refers to repeated assaults on the childs body and mind (e.g., chronic sexual or physical abuse, exposure to ongoing domestic violence, emotional or physical neglect). Finally, complex trauma is a term used by some trauma experts to describe both exposure to chronic trauma, often inflicted by parents or others who are supposed to care for and protect the child, and the immediate and long-term impact of such exposure on the child (Cook et al., 2005). As a general rule, traumatic events overwhelm a childs capacity to cope and elicit intense emotional and physical reactions, such as those listed below, that can be as threatening to the childs physical and psychological sense of safety as the event itself. In addition, they may elicit adaptive responses, such as dissociation (i.e., feeling outside of your body or feeling that an actual event is not real) that may become fixed and interrupt healthy development. Trauma can refer to an isolated event, but the body responds to the developmental accumulation of traumatic stressors long after the event is over.

Types and prevalence of Child TraumaTypes and Prevalence of

Child

In 2010, child protective services (CPS) departments across the U.S. received 3.3 million referrals involving the alleged maltreatment of 5.9 million children (U.S. Department of Health and Human Services [DHHS], 2011). Children under age 6 are disproportionately exposed to trauma, particularly interpersonal violence (Chu & Lieberman, 2010; Ghosh Ippen & Lieberman, 2008). Of victims, 34% were under age 3, and 57% were under age 7 (U.S. DHHS, 2011). Further, infants are the fastest growing category of children entering foster care in the United States (Dicker, Gordon, & Knitzer, 2001). How Do Children Experience Trauma? Children are at increased vulnerability when compared to adults for developing negative outcomes after trauma. Separation and loss, although not lifethreatening, may be perceived as so to children, especially very young children. Child traumatic stress may manifest in destructive and maladaptive ways that can impair the childs ability to relate to others, to succeed in school, and to control his/her emotions and behaviors. A number of factors influence how a child experiences and reacts to traumatic events. A childs reactions to trauma can vary depending on the number and severity of traumatic episodes, and the time period of exposure to the event(s). A child is also affected by his/her proximity to the event (i.e., if it happened to a friend or family member), and the events personal significance for him/her. A childs responses to trauma are also shaped by the extent to which his/her support system is disrupted during and after the trauma. For instance, being separated from non-offending caregiver during or after the trauma can often affect a childs reactions. Other factors that can influence a childs responses to trauma include the following: The childs age and developmental stage Preexisting psychopathology The childs perception of the danger faced or sense of threat Whether the child was the victim or a witness The childs relationship to the victim or perpetrator Parental psychopathology and distress The adversities the child faces in the aftermath of the trauma The presence/availability of adults who can offer help and protection

Interactions with first responders and other helping professionals Genetic predisposition (Bradley et al., 2008) Previous history of traumatic experiences

Immediate, Delayed and Long-term Reactions to child Trauma Stress Childrens reactions to trauma are varied and complex, and may manifest at different periods following the event or their removal from the traumatic situation. Not all children who experience trauma are adversely affected. How a child responds and how long reactions linger are a result of the objective nature of the events plus the childs subjective response to those events. However, research has shown that trauma-related stress is associated with a varied group of shortand long-term adverse outcomes (Pecora et al., 2005; Fang & Corso, 2007). As explained below, responses immediately following the event may vary. Delayed reactions may include posttraumatic stress disorder (PTSD) or other disorders. In addition, long-term effects on learning and physical and psychological health can last into adulthood. The construct of PTSD is constantly evolving in order to be more accurate in reflecting the experience of children. For example, many professionals think of PTSD as an injury, rather than a disorder, since it reflects the over-sensitization of what otherwise is a normal fear response system (Scheeringa, Zeanah, Myers, & Putnam, 2003). Immediate Reactions to Traumatic Stress Childrens immediate reactions to traumatic stress may vary. A child who was not physically hurt, or who has no idea that what he/she experienced at the hands of others was wrong, may exhibit little or no immediate reaction. This may change when the child is placed in a safer environment; the new context may facilitate learning that helps the child understand what happened to him/her, and he/she may react behaviorally and emotionally. A child who experienced pain or knows that the abuse was wrong may, in the short-term, display intense reactions, such as: Expressed longing/concern for his/her non-offending caregivers Being easily reminded of the trauma Numbness Detachment Disbelief A frozen (deer in the headlights ) state 3

Intense anger Emotional lability (i.e., a condition of ex- cessive emotional reactions and frequent mood changes) Tearfulness Agitation Excitement Clinginess with caregivers These reactions can be normalized by reassurance from the caregiver. If reactions persist over time, professional intervention may be required. Cognitive distortions, which are inaccurate or unhelpful beliefs, are common among children who have experienced trauma, especially self-blame. Symptoms of Posttraumatic Stress Disorder (PTSD) and Other Disorders Not all children who have experienced traumatic events develop symptoms of PTSD. While many children may exhibit traumatic stress symptoms, only a small portion meet the criteria for PTSD. Full- scale PTSD is most common in children and adolescents who have experienced severe, chronic, or interpersonal and/or multigenerational trauma. Guilt resulting from cognitive distortions related to the traumatic event is a predictor of developing posttraumatic symptoms (Kletter, Weems, & Carrion, 2009). Symptoms of posttraumatic disorder are not only symptoms of anxiety, but also of mood and thought. Although most children who have experienced trauma do not develop full-scale PTSD, many will display one or more symptoms of the disorder. In addition, some children and adolescents with traumatic stress reactions may meet the criteria for other psychiatric disorders, such as acute stress or adjustment disorder. Looking at how a child is functioning is a better indicator of how he/she is doing than diagnosing the problem. Long-Term Reactions to Child Traumatic Stress It is important to recognize and understand the significant longer-term consequences of exposure to trauma. A major research project, called The Adverse Childhood Experiences (ACE) Study (Felitti, et al., 1998), investigated the relationship between adverse childhood experiences and adult health decades later. The authors found that adults who had experienced multiple adverse childhood experiences (e.g., recurrent physical abuse, recurrent emotional abuse, sexual abuse) were at increased risk of developing adverse health behaviors such as smoking, alcohol abuse, drug abuse, depression, suicide attempts, and having over 50 sexual partners. The authors infer that individuals who engage in these high-risk behaviors are at higher risk for

developing serious health problems, such as obesity, heart disease, cancer, and sexually transmitted diseases. Follow-up research suggests that individuals with a high number of adverse childhood experiences (six or more) have elevated prevalence of premature death relative to those without such experiences (Anda et al., 2009). Putnam (2003, p. 271) cites studies showing that among those who have suffered the trauma of sexual abuse as a child, there is a stronger likelihood of developing a psychological disorder later in life including major depression, borderline personality disorder, somatization disorder, substance abuse disorders, posttraumatic stress disorder (PTSD), dissociative identity disorder, and bulimia nervosa. Victims of child sexual abuse, says Putnam, also manifest many problematic behaviors and . . . neurobiological alterations (Putnam, 2003, p. 271). In addition to the aforementioned reactions to child traumatic stress, there are a few complicating factors that surface in the lives of these children in the child welfare system. These factors may increase the probability that a child will experience traumatic events due to increased stress in their birth homes. As a result, these children are more vulnerable to traumatic stress. Child Traumatic Stress and Substance Abuse A study from Chapin Hall in 2011 reported that almost 61 percent of infants and about 41 percent of older children in out-of-home care had a primary and/or secondary caregiver that reported active alcohol and/or drug abuse (Wulczyn, Ernst, & Fisher, 2011). Children who are exposed to homes with substance abuse experience: Chaotic and unpredictable home lives Inconsistent parenting and lack of supervision Inconsistent emotional responses from parents Parental abandonment Physical or emotional abuse (Breshears, Yeh, & Young, 2005) These experiences in the home can place the child at risk for traumatic stress.

Child Traumatic Stress and Learning Impairments Exposure to trauma can also impair a childs ability to learn. A study by Sullivan and Knutson (1998) found that maltreated boys were more likely to have impairments that would affect learning, see table below.

Type of Impairment

Maltreated Mltreated

Control Contrl

Language/Speech Mental Retardation Hearing Learning Disability Attention-Deficit Disorder (ADD)

12.6% 9.1% 9.0% 7.4% 3.9%

8.4% 1.3% 7.5% 2.6% 0.8%

For at least the mental retardation impairment, it is not known if the impairments put the boys at a higher risk for abuse or if the impairment is a result of the trauma. The impact on learning may be related to the role trauma plays in the development of the brain. In some cases of child abuse and neglect, areas of the brain fail to develop properly, which impairs physical, mental, and emotional development (Perry, 2002). In cases of chronic abuse, the stress experienced by the victim may result in the increased activation of certain areas of the brain, which may then facilitate anxiety, sleep disturbances, and hyperactivity. In behavioral terms, this increased activation renders children more vulnerable to developing PTSD, attention-deficit disorder (ADD), attention-deficit hyperactivity disorder (ADHD), conduct disorder, and learning and memory problems (Perry, 2001). Proper diagnostic assessment is essential for the most appropriate treatment Children involved in the child welfare system are particularly vulnerable to traumatic events, whether it is by virtue of the events that brought them into the system, or through the process of removal by child protective services and/or law enforcement and placement (sometimes several different placements) with substitute caregivers. Children who are seen in the child welfare system generally have experienced multiple traumatic events and are likely to have more complex symptom pictures (Kisiel, Fehrenbach, Small, & Lyons, 2009). While many children in the child welfare system have experienced traumatic events and may be exhibiting symptoms of traumatic stress, few of these children meet the full criteria for PTSD. In fact, recent research (Kolko et al., 2009) has found that, among children in the child welfare system, the prevalence of posttraumatic stress symptoms was only 11.7%. It is noteworthy, however, that children with no diagnosis of PTSD and fewer symptoms may be as functionally impaired, in terms of distress, personal relations, and schooling, as those with the full diagnosis (Carrion, Weems, Ray, & Reiss, 2002). For a younger child, separation from a caregiver may be considered a traumatic event when he/she is not emotionally developed enough. For many individuals, 6

contact with the child welfare system may serve as a trauma reminder and bring back memories of prior personal and family experiences with the child welfare system. Separation from a child is also likely to be traumatic for the caregiver. For individuals who are part of groups that have historically experienced the forced removal of children from parents (e.g., Native Americans, African Americans, and Alaska Natives), involvement with the child welfare system may serve as a reminder of historical trauma and may be associated with strong emotions and a reduced sense of safety. Trauma also often results in ruptured relationships. Within the child welfare system, there are likely to be both ruptures and conflicts among family members who are seeking to care for a child, resource parents, and child welfare workers. Of particular concern are youth who have a high number of placements, as each placement may strengthen the childs experience of rejection and lack of constancy and predictability. A trauma-informed child welfare system actively acts to reduce these conflicts and to help caregivers work jointly to create an environment that supports the childs relationship with all caregivers who are important to the childs life and development. While the effects of trauma highlighted above are prevalent and far-reaching among children in the child welfare system and impact casework practice at multiple levels, trauma and its effects have historically been overlooked or not well-understood in day-to-day child welfare practice. As a result, many children who have experienced trauma may not receive the types of supports and services that are necessary to help them achieve safety, permanency, and wellbeing. On the contrary, many well- meaning child welfare agencies may participate in actions that exacerbate a childs trauma, such as multiple placements or removing a child from his/her community or school. Researchers have recently started to identify the need to apply a traumainformed approach across child-serving systems, such as child welfare, juvenile justice, education, and others. The forerunners of this movement have been members of the National Child Traumatic Stress Network (NCTSN). In 2008, NCTSN colleagues introduced the concept of addressing the needs of children who have experienced trauma across multiple systems in an article that reviewed how various service systems approach trauma services differently. It also provided recommendations for how to make each of these service systems more trauma-informed (Ko et al., 2008). Adopting a trauma-informed approach to childserving systems provides benefits on multiple levels. It equips staff members and leadership with the tools and skills necessary to manage their own secondary traumatic stress and assist the children and families in their care. It also provides a framework for educating the workforce and affiliated stakeholders on the impact of trauma and provides them with strategies to manage a childs difficult behaviors and overwhelming emotions and ensuring that the child receives the services he/ she needs.

While child welfare has always had a focus on the physical safety of the child, a trauma -informed child welfare system must go further and recognize that psychological safety of both the child and his/her family is extraordinarily important to the childs and familys long-term recovery and social and emotional well-being. Psychological safety is a sense of safety, or the ability to feel safe, within ones self and safe from external harm. This type of safety has direct implications for physical safety and permanence, and is critical for functioning as well as physical and emotional growth. A lack of psychological safety can impact a childs and familys interactions with all other individuals, including those trying to help them, and can lead to a variety of maladaptive strategies for coping with the anxiety associated with feeling unsafe. These survival strategies may include high-risk behaviors, such as substance abuse and self-mutilation. The child (and his/her siblings) may continue to feel psychologically unsafe long after the physical threat has been removed or he/she has been relocated to a physically safe environment, such as a relatives or foster parents home. The childs parent(s) may feel psychologically unsafe for a number of reasons including his/her own possible history of trauma, or the uncertainty regarding his/ her childs well-being that emerges following removal. Even after the child and/or parent gains some degree of security, a trigger such as a person, place, or event may unexpectedly remind him/her of the trauma and draw his/her attention back to intense and disturbing memories that overwhelm his/her ability to cope again. Other times, a seemingly innocent event or maybe a smell, sound, touch, taste, or particular scene may act as a trigger and be a subconscious reminder of the trauma that produces a physical response due to the bodys biochemical system reacting as if the trauma was happening again. A trauma-informed child welfare system understands that these pressures may help to explain a childs or parents behavior and can use this knowledge to help him/her better manage triggers and to feel safe. The child welfare workforce should be educated on trauma and how it affects an individual at any stage of development and intersects with his/her culture. The system should screen everyone for traumatic history and traumatic stress responses that would assist the workers in understanding a childs and familys history and potential triggers and in creating a trauma-informed case plan. For those who screen positive for trauma, a thorough trauma-focused assessment by a properly trained mental health provider can identify a childs or parents reactions and how his/her behaviors are connected to the traumatic experience and help guide subsequent treatment and intervention efforts.

Enhancing Child Well-Being and Resiliency

development, and relationships, the child needs the support of caring adults in his/her life. It is common for a trauma-exposed child to have significant symptoms that interfere with his/her ability to master developmental tasks, build and maintain relationships with caregivers and peers, succeed in school, and lead a productive and fulfilling life. Case planning must focus on giving the child the tools to manage the lingering effects of trauma exposure and to help him/her build supportive relationships so that the child can take advantage of opportunities as he/she grows and matures. By helping him/her develop these skills in a clinical setting and build supportive relationships, mental health and child welfare professionals enhance the childs natural resilience (i.e., strength and ability to overcome adversity). Most birth families with whom child welfare interacts have also experienced trauma; including past childhood trauma, community violence, and domestic violence that may still be ongoing. Providing trauma-informed education and services, including:evidence-based or evidence-informed mental health interventions as needed, to birth parents enhances their protective capacities, thereby increasing the resiliency, safety, permanency, and well-being of the child. In addition, both birth and resource parents should also be offered training and support to help them manage secondary trauma related to caring for a child who has experienced trauma and his/her siblings.g the Well-Being and Resiliency Working within the child welfare system can be a dangerous business and professionals in the workforce may be confronted with threats or violence in their daily work. Adding to these stressors, many workers experience secondary traumatic stress reactions, which are physical and emotional stress responses to working with a highly traumatized population. When working with children who have experienced maltreatment, parents who have acted in abusive or neglectful ways, and systems that do not always meet the needs of families, feelings of helplessness, anger, and fear are common. A trauma-informed system must acknowledge the impact of primary and secondary trauma on the workforce and develop organizational strategies to enhance resilience in the individual members of it. Youth and family members who have experienced traumatic events often feel like powerless pawns in the system, reinforcing feelings of powerlessness felt at the time of the trauma. Treating youth and families as partners by providing them with choices and a voice in their care plays a pivotal role in helping them to reclaim the power that was taken away from them during the trauma and tap into their own resilience.

Youth and family members who have been involved in the child welfare system have a unique perspective and can also serve as partners by providing valuable feedback on how the system can better address trauma among children and families. These partnerships should occur at all levels of the organization, as

youth and families can help shape trauma-informed practices and policies. No one agency can function alone, and in a trauma-informed system, child welfare must reach out and coordinate with other systems so they too can view and work with the child and family through a trauma lens. This partnering includes: Teaming with law enforcement to minimize the number of front-end interviews a child must experience Working with mental health agencies to ensure therapists are trained in specialized trauma assessment and evidence-based or evidenceinformed trauma treatments Coordination with schools, the courts, and attorneys. Such coordination is necessary to prevent one part of the system undoing the good trauma-informed work of another part of the system.

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