(Saving Private Ryan &) Saving James

Promoting Successful Futures By Addressing Child Traumatic Stress

Kristine Buffington, MSW, LISW-Skbuffington46@hotmail.com

Acknowledgements

• Presentation based on Technical Assistance Bulletin entitled: Ten Things Every Juvenile Court Judge Should Know About Trauma and Delinquency. [Available from NCJFCJ or NCTSN]

• Buffington, K., Dierkhising, C. B., Marsh, S. C. (2010). Ten things every juvenile court judge should know about trauma and delinquency. Reno, NV: National Council of Juvenile and Family Court Judges.

• Collaborative project between NCTSN and NCJFCJ.

• Supported by funding from the Office of Juvenile Justice and Delinquency Prevention [Grant No. 2007-JL-FX-0007 awarded to NCJFCJ]

#1

A traumatic experience is an event that

threatens someone’s life, safety, or well-

being.

Trauma overwhelms one’s capacity to cope.

• Acute Trauma: A single traumatic event limited in time.

• Chronic Trauma: Multiple, consistent, or varied exposure to traumatic events.

• Youth in JJ typically have experienced chronic trauma.

• Child maltreatment

• Witnessing violence

• Interpersonal victimization

• Terrorism/War• Natural disasters • Loss of loved ones • Serious accidents• Medical trauma

Examples of Traumatic Events

#2

Child traumatic stress can lead to Post Traumatic Stress Disorder (PTSD).

Characteristics of the event:

Nature and intensity of the event

Child or family member’s experience of direct harm

Proximity to event Pattern and duration of

the event Parent’s and other’s

reaction to the event Exposure to the event

through media and other mechanisms

Characteristics of the child:

Subjective experience of the event

Prior history of exposure to trauma

Prior psychiatric history Coping style Strengths & supports Family relationships Cultural issues Gender Age

PTSD

Avoidance Re-experiencing Hyperarousal

“Abnormally increasedarousal, responsiveness to stimuli, and scanning

for threats” (1)

Nightmares, Intrusive memories

Avoiding Traumatic Reminders

Trauma and PTSD are prevalent in the Juvenile

Justice System • 92% of youth incarcerated had experienced one or more

traumas (Teplin et al., 2002)

• 92% of incarcerated adolescents knew someone who had been killed; 57% saw someone being killed; 72% report being shot or shot at; 29% report having been sexually assaulted (Wood et al., 2002)

In a study of youth in the California Youth Authority facilities, Steiner and colleagues (1997) found:

• 32% of boys met full criteria for diagnosis of PTSD• 49% of girls met full criteria for diagnosis of PTSD

“Rates of PTSD in juvenile justice involved youth are estimated between 3% 50% (Wolpaw & Ford, 2004) making it comparable to the PTSD rates (12%-20%) of soldiers returning from deployment in Iraq (Roehr, 2007).” –Buffington et al. 2010

#3

Trauma impacts a child’s development

and health throughout his or her life.

Trauma Impacts Various Domains of Child and Adolescent

Development

Biopsychosocial Impact of Trauma

• Altered Biological Stress Systems and Neural Circuitry/Structure

• Disruptions in Attachment Behavior • Changes in Social Development and

Understanding of Social Stimuli

Neurodevelopment: Body’s Natural Alarm System

Danger Evaluate Respond or

Relax

Trauma changes our biology, including brain development which can result in very well-developed emergency response systems in the brain at a cost to the executive functions of our brain that enhance learning and self-regulation…

*Buffington, Dierkhising, Marsh, 2010

Social Development

– Social Information Processing: • Hostile attribution bias• Larger repertoire of aggressive

responses• Aggression as an acceptable response

• The Court’s Role: – Prevent further trauma– Assess for trauma – Provide interventions (treatment works!)

“It is essential for court’s and communities to work together to prevent traumatic events where

possible (such as child abuse and neglect) and to provide early

interventions to treat traumatic stress before a youth becomes entrenched in

a pattern of maladaptive and problematic behavior.”

ACE Study Findings

People with 4 or more ACEs were:

• Nearly 2 times more likely to smoke cigarettes, or have heart disease, cancer, obesity

• 7 times more likely chronic alcoholism; engage in sex with > 50 partners.

• 11 times more likely to engage in IV drug use• 19 times more likely to attempt suicide

Higher Utilizers of Mental Health Study (Oregon Dept. of Mental Health, 1999)

During a 3 year time period in the mid 1990’s a group of 69 adults used 3.1 million dollars in mental health services; Over 90% of these adults had experienced childhood sexual and/or physical abuse.

#4

Complex trauma is associated with risk of

delinquency.

Courtesy of Western Michigan University Child Assessment Clinic

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Types of Traumatic Stress,cont'd

• Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.

• Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.

• Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

Source: Cook et al. (2005). Psychiatry Ann,35(5):390-398.

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Effects of Trauma Exposure on Children

When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far-reaching effects on nearly every aspect of the child’s life.

20

2. Trauma shapes the survivor’s basic beliefs about identity, world view and

spirituality

2. Trauma shapes the survivor’s basic beliefs

Why did this happen? (“Abuse is inevitable)

Why did this happen to me? (“It was my fault”)

What does this experience mean? (“Nothing I do will make any difference”)

Healing involves transformation of harmful overgeneralized negative beliefs about self, others, world, and spirituality

Julian Ford, University of Connecticut

“Post Traumatic Stress is responding to normal stressors and life events as if they are threats to your survival…”

24

Post Traumatic Stress Biased Perception

People who have experienced child traumatic stress…

• Often distrust people in authority and see them as threats because of being abused or harmed by adults that are supposed to protect them…

• Abuse perpetrated by adults violates our social contract with children

• Police, Teachers, Principals, bosses, etc…can be perceived as threats

• So, there are some situations where using a forceful or intimidating or authoritative manner might evoke stronger violence or increase resistance

Responses to people in PTSD Mode

• Be aware of traumatic reminders and PTSD bias• Work to establish a sense of safety as a way to

achieve a safe outcome for all involved• Know when authoritarian responses are needed and

when they are not• Help the person calm down and focus• Help them explore safe options to work through the

situation at hand• Follow what is taught in CPI training

#5

Traumatic exposure, delinquency, and school

failure are related.

Youth who are exposed to chronic trauma often must learn to function in a constant state of alert and preparedness for threats and danger… a state a hyperarousal or in chronic alarm mode… This survival ability conflicts with the focus and self control needed for youth to succeed in school…

Trauma changes our biology, including brain development which can result in

very well-developed emergency response systems in the brain at a cost to the executive functions of our brain that

enhance learning and self-regulation…

Normal v. Abused Brain

(As cited by Felitti & Anda,

Normal Child

Abused/Neglected Child

Triggers and False Alarms

• Triggers include seeing, feeling, or hearing something that reminds us of past trauma.

• Triggers activate the alarm system.• When there is actually no current

danger, it is a false alarm.• But the person reacts as if there is

current danger….PTSD, ASD, DTD

Copyright 2007 WSU Area Health Education Center

Impact: School Failure

• At least half of all maltreated children will experience serious school problems, especially conduct issues. (Putnam)

• Maltreated children have 3x the drop out rate of the general population (Focal Point, 2007)

• Children with emotional and behavioral disorders who are also in special education classes have the highest school drop out rate of any disability group--50%

Copyright 2007 WSU Area Health Education Center

Complex Trauma May Disrupt Cognition• Difficulty learning

and processing verbal information

• Difficulty using language to communicate

• Difficulty organizing and retrieving information

• Difficulty understanding cause and effect

• Difficulty focusing on and completing tasks at hand

• Disrupted orientation in time and space

• Tend to have poor problem solving skills

• Difficulty planning and anticipating

System issues also can increase a youth’s risk of school failure…

• Missing school because of changes in foster or adoptive home placements or placement in detention centers

• Delays in transferring records from one school to the next

• Delays in receiving special education services

• Moving to a new school district• 70-95 % rates of school failure and drop out

for youth in child welfare and/or juvenile detention or incarceration

What can a the court and community professionals do?

• Put meeting a youth’s educational needs a top priority—it is life saving!!!

• Find ways to link youth with educational advocates and programs that support youth educational success

• Judging it essential that youth who must transfer schools have very timely record transfers, access to school assistance, and extra support!

#6

Trauma assessments can reduce

misdiagnosis, promote positive outcomes, and

maximize resources.

• Many youth come to the attention of the court with previous diagnoses.

• Risk for misdiagnosis (and inappropriate treatment)– Behaviorally, trauma can present as

ADHD, ODD, CD, and/or RAD

• Proper assessment = Proper treatment – Child Welfare Trauma Screening Tool– Traumatic Events Screening Inventory – UCLA PTSD Reaction Index– Trauma Symptom Checklist for Children

Courtesy of Western Michigan University Child Assessment Clinic

Purpose of Assessment

• Thorough assessment can identify a child’s reactions and how his or her behaviors are connected to the traumatic experience.

• Thorough assessment can also predict potential risk behaviors and identify interventions that will ultimately reduce risk.

• Use assessment results to determine the need for referral to appropriate trauma-specific mental health care or further comprehensive trauma assessment.

*Adapted from the NCTSN Child Welfare Toolkit

• James is a 13 year old Caucasian male who had been living in a battered women’s shelter for 4 months.

• Mom had just left her boyfriend Don after living with him for 6 years. Don nearly killed mom on 4 occasions through strangulation. He threatened to kill James and his mom with a gun from his extensive gun collection. Don physically abused James and his mom. Mom admits she has been with abusive men all of James’ life.

• James visits his dad who for 3 years has been living with an angry women who abuses alcohol. She emotionally abuses James and his dad.

• James has been suspended from school for stabbing a kid with a pen, cussing out his teacher, refusing to follow rules, and fighting.

• He has nightmares, is afraid to sleep alone, and worries someone will kill mom or dad.

• Between the ages of 2-4 years old, James’ mom was actively drug addicted and dropped James off at his dad’s house and disappeared for two years. James was in foster care for 4 months at the age of 3 years old.

• Mom has a very out of control Bipolar disorder and gets easily angered and yells and cusses at James.

What if all you knew was…?

James cusses at his teachers, starts fights with other youth, and he recently stabbed a classmate at school?

“For years our court treated these cases as “bad

behavior” and “lack of self control.” It is only in the

last several years that we, as a court, have educated

ourselves about trauma. As a result, we now know that it is important to ask about trauma. Indeed, we often

discover a history of trauma that has gone undetected, despite

attempts to help the child through traditional

counseling services.”

– Judge Michael L. Howard & Robin R. Tener, PhD.

#7 There are mental health

treatments that are effective in helping youth

who are experiencing child traumatic stress.

• Effective mental health treatments must address the trauma’s and adversities that youth have experienced.

• We no longer have to do guess work to find the highest quality treatments…

Key components of evidence-based trauma-focused treatments include:

• Randomized controlled studies proving their effectiveness

• Manualized treatment, specialized training, and supervision

• Structured and clear treatment components that comprehensively address the developmental impact of trauma on youth, including traumatic reminders

Trauma-Focused Cognitive Behavioral Therapy

Judith Cohen, MD., Anthony Mannarino, Ph.D. & Esther Deblinger, Ph.D.)

• Psychoeducation about impact of trauma, coping and parenting

• Relaxation techniques• Affect modulation work: recognizing, expressing, and

managing emotions• Cognitive Coping: addressing the traumatic

perspectives• Trauma Narrative: a safe, structured, protocol for

developing and sharing the trauma story• In-vivo Desentization: the trauma no longer controls

them• Conjoint and family sessions• Enhancing Safety and Social Skills

TARGET-A ModelDr. Julian Ford, Ph.D., University of

Connecticut• Addressing the emotional and behavioral

dysregulation resulting from complex trauma• Addresses managing alarm reactions• Uses the FREEDOM Steps as skill development areas• Being evaluated and implemented in juvenile justice

and residential settings and outpatient settings

Child Parent PsychotherapyAlicia Lieberman, Ph.D., and Patricia

Van Horn, Ph.D., UCSF• Primary designed for youth ages 0-6 and their non-

offending caregiver• Assists in addressing the trauma of both the

caregiver and the child• Helps the caregiver to support their child in regaining

momentum and progress in their healthy development

• Studies have shown an increase in IQ scores of the youth completing this treatment

Treating Traumatic Stress in Children and Adolescents:

How to Foster Resilience through Attachment, Self-

Regulation, and Competency

By Margaret E. Blaustein & Kristine M. Kinniburgh

As summarized by Kristine Buffington, MSW

Blaustein & Kinniburgh, 2010

What is ARC?

• A components-based model• Three core domains of intervention for youth

exposed to trauma and their caregiving system:– Attachment– Self-Regulation– Competency

Blaustein & Kinniburgh, 2010

What is ARC?

Blaustein & Kinniburgh, 2010

Resources• www.nctsn.org Treatments that Work and

specialized resources for juvenile court professionals.

• Training curriculums for child welfare workers, juvenile court detention centers, foster and adoptive parents, second responders to disasters, and much more…

#8

There is compelling need for effective family

involvement.

• Supportive and involved families have the potential to promote healing, rehabilitation, and resiliency.

• Families of court-involved youth may also need support to cope with their own traumatic experiences so that they can provide support and guidance to their children.

• Obstacles to Effective Family Involvement: – Feeling shame and/or feeling judged – Feeling intimidated in a large and confusing

system– Previous bad experiences in the past by human

service professionals and public systems– Language barriers– Lack of financial and transportation resources

especially when a youth is placed a far distance from home

– Restrictive definitions of family– Assumptions that all family systems are

negative

What can a the judicial and other systems dodge do?

• Set a culture within his/her court that priorities positive family engagement

• Ask families what supports they need so they can be more involved in their child’s treatment and rehabilitation

• Make sure referrals for mental health services are to providers who are trauma-informed and who are accessible and respectful to families

• Help families access resources so they may visit with and communicate with their child

• Train court professionals to be able to communicate in culturally competent and respectful ways with families

# 9 Youth are Resilient!!!!

• Resiliency is the capacity to thrive in the face of adversity.

• Function of risk and protection.• Risk and protective factors exist across

ecological domains.– Individual– Family– Peer– School– Community

• Goal: reduce risk factors and increase protective factors.

• Take home message: Children and youth CAN get better.

What can a child welfare, judicial, and treatment professionals do?

Deficit Model Positive Youth Development

• Ask about protective factors – not just risk (i.e., avoid a “deficit model”)

• Consider risk and protection in multiple domains (i.e., don’t focus just on the individual and family)

• Encourage connection with prosocial adults (i.e., facilitate connections with “persons of character”)

• Promote youth’s strengths instead of focusing on weaknesses/problems

• Reframe problems to highlight personal competencies and strengths

#10 The juvenile justice system needs to be

trauma-informed at all levels.

Trauma affects behavior in detention

• In a study by DeLisi and colleagues at the CYA, researchers found those with higher levels of traumatization; – Had higher levels of institutional misconduct, – 3x the suicidal activity, – 3.5x the sexual misconduct, – Upon intake, greater scores for depression,

anxiety, suicidal ideation, substance abuse, and anger compared to their offender counterparts with low or no traumatization.

*DeLisi, Drury, Kosloski, Caudill, Conis, Anderson, Vaughn, & Beaver, 2010

• Work to ensure a sense of safety for youth.

• Monitor for and reduce exposure to traumatic reminders.

• Collaboration across stakeholders.• Involve family.• Nurture culture of respect, honesty,

and humility.• Collect and evaluate data.• Draw on existing resources and

“lessons learned”.

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Essential Elements of Trauma-Informed Child Welfare Practice

1. Maximize the child’s sense of safety.2. Assist children in reducing overwhelming emotion.3. Help children make new meaning of their trauma

history and current experiences.4. Address the impact of trauma and subsequent

changes in the child’s behavior, development, and relationships.

5. Coordinate services with other agencies.

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Essential Elements of Trauma-Informed Child Welfare Practice

6. Utilize comprehensive assessment of the child’s trauma experiences and their impact on the child’s development and behavior to guide services.

7. Support and promote positive and stable relationships in the life of the child.

8. Provide support and guidance to child’s family and caregivers.

9. Manage professional and personal stress.

The Science of Implementation

Fixsen, Dean L.; Blase, Karen A.; Naoom, Sandra F.; & Wallace, Frances. “Lessons Learned From Research on Implementation.” National Implementation Network, Oregon RTI Meeting, 2007.