JACQUELYN G. BUICE, M.ED, LAPC, NCC, CTSCSCLINICAL BEHAVIOR AND TRAUMA THERAPIST

FOUNDER/EXECUTIVE DIRECTORCOLLABORATIONS FOR RESILIENCY IN CHILDREN

Juveniles and Trauma:Issues and Resolution

Agenda

Defining TraumaPrevalenceAdverse EffectsTrauma and Substance AbuseIssuesGuidelines for PTSD and Substance Abuse

TreatmentSolutionsHolistic Approach to Case Mgmt. – Judge PapeQ/A

Defining Trauma (SAMHSA)

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional or spiritual well-being.

Defining Trauma

Acute Trauma: a single event that is limited in time (Car accident, dog bite) A few weeks.

Chronic Trauma: multiple and varied events (exposed to domestic violence then car accident, then community violence)

Complex Trauma: exposure to chronic trauma usually caused by a caregiver and the immediate and long term impact of such exposure on the child

Defining Trauma

Events and circumstances may include being actually harmed or the threat of physical or psychological harm. Or the withholding of material or relational resources essential to healthy development. May occur as a single event or repeatedly over time.

Defining Trauma

The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event. How the individual labels, assigns meaning to, and is disrupted physically and psychologically by an event will determine if it is experienced as traumatic

Trauma Experiences

Individual reactions to trauma vary dramatically. What is devastating to one child may be less so for another.

Responses to a traumatic event depends on: - individual personality - coping style - cultural background - previous trauma - environment

Trauma in the context of community

Communities that are supportive and understanding facilitate healing and recovery.

Communities that avoid, overlook or misunderstand the trauma impact can re-traumatize or disrupt the healing process.

Example: (1) sexually abused child subjected to

restraints or seclusion. (2) Domestic violence victim harshly interrogated in a shelter

Prevalence

National Survey of Adolescents:One in four children experience at least one

traumatic event before they are 16.One in eight 17 year olds have experienced

PTSD.National Child Traumatic Stress Network: 75% of youth in the juvenile system are traumatic victims. 50% develop PTSD

Adverse Effects

Can occur immediately or over time

May not recognize the connection between the effects and the trauma event.

Adverse Effects

Re-experiencing the traumatic event through intrusive thoughts, dreams, or intense psychological distress when exposed to reminders. Dissociation can result.

Persistent avoidance of thoughts, feelings, images or locations that expose person to reminders.

Increased arousal (hypervigilance, irritability, exaggerated startle response and sleeping difficulties.

Adverse Effects

Inability to cope with normal stress of life school avoidance, loss of interest, sleep issuesInability to trust/benefit from relationshipsInability to manage emotions withdrawal, aggression, suicidal thoughts, disruptive/ risky behaviorsMemory/learning issuesAttention, focus and cognitive issues

(fight/flight/freeze)Inability to make good decisionsInability to regulate appropriate behavior

Adverse Effects

Altering of neuro-physiological make-up resulting in a constant state of arousal. Wears person down physically, emotionally, mentally

Risk for gang involvement. Gangs offer a sense of safety, control and structure that is often missing in their lives.

Adverse Effects

Juvenile justice youths have complex histories that contribute to their delinquency but present challenges for rehabilitation.

Poverty, violence, family instability, exposure to drugs, gangs, multiple relocations

Results: Loss of safety, powerlessness, fear, hopelessness

Leads to: lack of confidence, learning and cognitive issues and mental health problems.

Trauma is

the sum of the eventplus the experienceplus the effect

Trauma and Substance Abuse

Correlation is significant59% of traumatized adolescents develop

substance abuse problems.Adolescents with substance abuse disorders

are two times more likely to develop PTSD than non-abusing peers.

PTSD makes it difficult for these teens to stop using drugs due to exposure to trauma reminders.

Trauma and Substance Abuse

Teens experiencing physical or sexual abuse are three times more likely to engage in substance abuse.

Double sided sword: trauma increases the risk of substance abuse and for up to 66% of adolescents, substance abuse increases the likelihood that the adolescent will experience trauma due to risky behavior.

Stress and Substance Abuse

Trauma creates stress and we seek homeostasis.

Stress is a major contributor to substance abuse initiation, continuation and relapse.

Addicts identify stress and distress as reasons for abusing substances and for relapse

Stress and Substance Abuse

While providing immediate relief from anxiety or emotional pain, substances can actually make symptoms of trauma much more serious.

Alcohol and drugs actually intensify and exaggerate emotions. Long term use can cause emotional stagnation

Substances disrupt deep sleep and increase nightmares and makes them more vivid/believable.

Victimization and Substance Abuse

Very high correlation between sexual abuse and substance abuse.

Powerlessness: due to an inability to control sexual abuse, many continue to experience feelings of powerlessness into adulthood.

Substance use serves to increase feelings of personal power and self-esteem, increase confidence and decrease anxiety of normal social interactions.

Victimization and Substance Abuse

Shame- due to secrecy about abuse, feeling bad and at fault are common.

Substances can ease pain of feeling different and within the substance abuse environment one may feel accepted.

Betrayal- failure of adults to protect creates a sense of worthlessness, a perceived failure of self to protect the child-self.

Stimulants maintain hypervigilence allowing self protection from further violations.

Issues

Lack of awareness and training among support professionals.

Few validated adolescent treatment protocols for dual diagnosis.

Lack of trauma assessments in juvenile justice systems.

Treatment for Parents

Issue: Lack of Awareness and training Among Supporting Agencies

Deficits in professionals trained in both trauma specific and substance abuse treatment.

Few teens with co-occurring trauma and substance abuse problems receive integrated treatment services.

Few facilities offer integrated services and few professionals develop expertise in both trauma and substance abuse treatment.

Mental Health Professionals

Must become familiar with the patterns of substance abuse addiction and to recognize that similar patterns are at work in traumatic stress and addiction.

Both are characterized by emotional and behavior dysregulation and are expressed in a range of symptoms and behaviors.

Substance Abuse Professionals

Must look beyond the immediate circumstances of the youth’s substance use and pay attention to his or her trauma history and its relationship to the current emotional difficulties and coping patterns.

There are many commonalities between the way in which youth respond to substance abuse triggers and the way in which they respond to reminders of loss and trauma.

Judicial Staff

Judges are faced with the significant prevalence of trauma in the courtroom, placement concerns, lack of understanding about child trauma, assessment and treatment needs and the correlation of trauma to substance abuse issues and avoiding secondary traumatic stress to juveniles.

Judges need on going education and input from trained professionals for consultation on cases.

Guidelines for Working with PTSD and Substance Abuse

Know client’s interpersonal worldBe aware of client’s negative/positive re-inforcersBe aware of client’s social support systemBe aware of substance use of significant personsAssist with a decrease in associations with friends

who abuse substancesAssist with creation of new peer group (non-use)Be aware of client’s motivation for changeAssess client’s readiness for change.

Treatments

No standard protocol for treatment of PTSD and substance abuse.

Abstinence- once obtained PTSD can be treated.

Detoxification and Chemical Dependency Rehabilitation for co-occurring disorders

Medication – anti-depressants are helpful with co-occurring PTSD/Substance Use Disorders

Psychotherapy – cognitive behavioral, exposure therapy, family therapy. Look for dual trained professionals.

Essential Components of Integrated Treatment

Those with trauma-related substance abuse need: - Help to identify triggers and manage cravings - Counseling about healthier coping strategies - Relapse prevention strategies (role of stress/trauma) - Examine the impact of substance use on coping and learn drug refusal skills. - Motivational Interviewing/enhancement: focus on engagement/participation in treatment; safety (reduction of harm/risk, use, truancy, delinquency)

Essential Components of Integrated Treatment

Stress management skills – relaxation, positive self-talk

Emotional regulation skills – identification, expression, and modulation of negative affect

Cognitive Restructuring – recognizing, challenging, and correcting negative cognitions

Increasing problem solving, drug refusal and safety skills

Social skills trainingGradual exposure to achieve desensitization to

trauma reminders.

Essential Components of Integrated Treatment

Parental involvement in treatment - Parenting skills (behavioral management strategies, increase monitoring and limit setting, particularly around drug use and high risk behaviors)Family Psychoeducation (youth and their

families) substance use and trauma and the interaction between the two

Essential Components of Integrated Treatment

Random drug screeningsAdjunct psychopharmacologic treatmentsCase Management: schools, juvenile justice,

child welfare, substance abuse/MH treatment

Promising Therapy

Seeking Safety= adults/adolescents, 25 weekly sessions, evidenced based (www.seekingsafety.org)

Specific to dual diagnosis of substance use disorder and PTSD. Book: Seeking Safety: A treatment Manual for PTSD and Substance Abuse

Focus: understanding both disorders, teaching safe coping skills for both, exploring relationship between two disorders in present, e.g., substances to cope with flashbacks, healing requires attention to both disorders.

Focus on ideals: humanistic themes to restore hope for a better future. Honesty vs. denial, lying/Commitment vs.

irresponsibility. Emphasizes values- respect, care, integration and healing.Addresses interpersonal, cognitive, behavioral and case mgmt

Lack of Trauma Assessments in Juvenile Justice Systems

Few trauma specific assessments are being done for adolescents in juvenile justice settings.

Parents and adolescents do not connect life events with current struggles. Many do not recognize events as creating traumatic effects.

Provision for Parental Treatment is Limited

Most have no insuranceParents are often met through family provision for

child which depletes child benefitsFamily provision does not meet parental needsParents need provision for independent treatmentSuggested Solutions: - non profit partner - community support - grants/private donors - fee scale matches/scholarships

Solutions

Trauma Informed Approach Realizing the prevalence of trauma; Recognizing how trauma affects all individuals involved with the program, organization or system; Responding by putting this knowledge into practice.

Solutions

Trauma Specific Interventions Practitioners must be trained and use specific practices developed to address trauma experienced by individuals, families and communities and the knowledge to work with the substance abuse coping mechanisms.

Solutions

Trauma Specific and Substance Abuse Services

Providers must be able to offer integrated treatment programs that address co- occurring trauma and substance abuse with a continuum of interventions from screening to treatment to recovery supports.

Solutions

Promising ApproachHolistic Approach (Judge Pape) - Info gathering on life experiences (home, school, community) - Assessment - Treatment Plan - Implementation - Follow up with providers