Download Addressing Trauma in Children`s Health Homes

Addressing Trauma in Children’s
Health Homes
Yvette Kelly, LMHC
Meg Baier, LMSW
McSilver Institute for Poverty Policy and Research
AGENDA
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Welcome and Introductions
Complex Trauma defined
Trauma Informed Care defined
Why this matters:
▪ Why Complex Trauma is important for care managers
▪ Why Complex Trauma is important for improving
children’s outcomes
▪ Practical Steps for Care Managers
‣ Q&A
About the McSilver Institute for
Poverty Policy and Research
‣ The McSilver Institute for Poverty Policy and Research
at New York University Silver School of Social Work is
committed to creating new knowledge about the root
causes of poverty, developing evidence-based
interventions to address its consequences, and
rapidly translating research findings into action.
Community Technical Assistance Center
(CTAC) & Managed Care Technical
Assistance Center (MCTAC) Overview
‣ CTAC & MCTAC are training, consultation, and
educational resource centers that offer resources to all
mental health and substance use disorder providers
in New York State.
‣ MCTAC provides training and intensive support on
quality improvement strategies, including business,
organizational and clinical practices to achieve the
overall goal of preparing and assisting providers with
the transition to Medicaid Managed Care.
Basic Assumptions
• Children do well if they can
• Trauma may be an important factor in many of the
presenting problems that children and families bring
to mental health services
• Caregivers often want to participate in all processes
and do not know how or do not feel included
• Relationships are a critical element in healing
• Compliance is not the only important outcome
Exposure to Trauma
26% of children in the
United States will
witness or experience a
traumatic event before
they turn four.
There is considerable evidence that trauma
and abuse are of urgent concern;
consequently, trauma- informed policies
and services are needed along with
trauma-specific care.
National Center for Mental Health Promotion and Youth Violence Prevention,
"Childhood Trauma and Its Effect on Healthy Development," July 2012
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What is Trauma?
What is Trauma?
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‣ Individual trauma results from an event, series of
events, or set of circumstances that is experienced by
an individual as physically and emotionally harmful or
threatening and that has lasting adverse effects on the
individual’s physical, social, emotional, or spiritual
well- being.
~ SAMHSA, 2012
What is Trauma?
We become traumatized when our
ability to respond to a perceived
threat in some way is
overwhelmed.
Trauma is an experience, situation
or event that:
• Evokes fear
• Changes the individual’s
worldview
• Changes the individual’s view of
themselves.
The No More Shame Project, 2014
Trauma Ruptures Our Connections
 to ourselves
 physically
 emotionally
 mentally
 vitally

to others
family
social group
generation
culture

to nature
instinctually
environmentally
What is Complex Trauma?
Complex trauma results from the problem of an
individual’s exposure to multiple or prolonged
traumatic events. These events are typically of an
interpersonal nature, such as psychological
maltreatment, neglect, physical and sexual abuse (van der
Kolk 2005).
The events often begin in childhood (van der Kolk 2005) and
can extend over an individual’s life span (Giller 1999; Terr 1991).
What is Complex Trauma?
‣ Repetitive, chronic
‣ Cumulative
‣ Often in attachment relationships
• Entrapment & betrayal; second injury
‣ Often over the course of childhood
• Impacts development
‣ Other…
CMS/SAMHSA Definition*
This guidance on complex trauma draws upon the domains within the definition of serious emotional disturbance
(SED). While there may be similarities in the condition(s) and symptoms that arise in either complex trauma or
SED, the therapeutic approaches associated with the same diagnoses may vary significantly when the
symptoms arising from traumatic experiences are identified as such. Trauma experts indicate that with complex
trauma, the clinical diagnoses may be more severe and typically present as comorbidities or multiple diagnoses.
a. The term complex trauma incorporates at least:
i. Infants/children/or adolescents’ exposure to multiple traumatic events, often of an invasive, interpersonal nature,
and
ii. the wide-ranging, long-term impact of this exposure.
b. Nature of the traumatic events:
i. often is severe and pervasive, such as abuse or profound neglect;
ii. usually begins early in life;
iii. can be disruptive of the child’s development and the formation of a healthy sense of self (with self-regulatory, executive
functioning, self-perceptions, etc);
iv. often occur in the context of the child’s relationship with a caregiver; and
v. can interfere with the child’s ability to form a secure attachment bond, which is considered a prerequisite for
healthy social-emotional functioning
‣
*As updated by CMS on March 2, 2016
CMS/SAMHSA Definition*
c.Many aspects of a child’s healthy
physical and mental development
rely on this secure attachment, a
primary source of safety and
stability.
d.Wide-ranging, long-term adverse
effects can include impairments in:
i. physiological responses and related
neurodevelopment,
ii. emotional responses,
iii.cognitive processes including the ability to
think, learn, and concentrate,
iv.impulse control and other self-regulating
behavior,
v. self-image
vi.relationships with others, and
vii.dissociation
• SAMHSA recently updated the
definition to clarify that dissociation
should be included as a separate
impairment domain
• New York State will modify its State
Plan as well as its training materials
and Complex Trauma Eligibility
Determination Form to reflect this
change
* Dissociation was previously subsumed within “Cognitive Processes” in the initial NYS rollout and has been separated out into a
7th domain moving forward.
* As updated by CMS on March 2,2016
How Does Complex
Trauma Differ from PTSD?
PTSD vs. Complex Trauma
PTSD:
‣ Can occur after one
event
‣ 4 criteria/clusters
‣ Is a diagnosis in DSM-5
Complex Trauma:
‣ Multiple/chronic events
‣ 7 domains
‣ Not a diagnosis in DSM-5
‣ Is a determination for HH
eligibility in NYS
* As defined by SAMHSA
For more information on the domains of impairment, see the NCTSN Complex
Trauma Webpages: http://www.nctsn.org/trauma-types/complextrauma/effects-of-complex-trauma
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Prevalence of
Trauma
Exposure to Trauma
90% of public mental health clients have been exposed
(Muesar et al., in press; Muesar et al., 1998)
Most have multiple experiences of trauma (Ibid)
34-53% report childhood sexual or physical abuse
(Kessler et al., 1995; MHA NY & NYOMH 1995)
43-81% report some type of victimization (Ibid)
Trauma is Pervasive
‣ A report of child abuse is made every 10 seconds in the United
States (Childhelp, 2013).
‣ More than 2 million children in the US are victims of physical
and/or sexual abuse.
‣ Children with disabilities are more likely to experience neglect
than children without disabilities (Child Welfare Information
Gateway, 2006).
‣ The ACE (Adverse Childhood Experiences) Study reports the
effects of adverse child experiences before the age of 18 are
common and have lasting effects:
http://vetoviolence.cdc.gov/apps/phl/resource_center_infographic
.html
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Trauma has Long-lasting
Effects
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‣ Children who experience child abuse and neglect are 59% more likely
to be arrested as a juvenile, 28% more likely to be arrested as an
adult, and 30% more likely to commit violent crime (Child Welfare
Information Gateway, 2006).
‣ Research has found that early exposure to stress and trauma causes
physical effects on neurodevelopment which may lead to changes in
the individual's long-term response to stress and vulnerability to
psychiatric disorders.
‣ Children who experience trauma are often those with depressive,
disruptive behavior disorders and high anxiety.
‣ Exposure to trauma also affects children's ability to regulate, identify,
and express emotions, and may have a negative effect on the
individual's core identity and ability to relate to others.
Lubit R, Rovine D, Defrancisci L. et al. Impact of trauma on children. J
Psychiatry Pract. 2003;9:128-138
Trauma: A look across the
lifespan
‣ Violation of child’s sense of safety and trust, of self worth, with a loss
of a coherent sense of self, emotional distress, shame, grief, self and
other destructive behaviors;
‣ Un-modulated aggression, difficulty negotiating relationships with
caregivers, peers and (later in life) marital partners, clear link
between alcoholism and other drug misuse, sexual promiscuity,
physical inactivity, smoking, obesity suicide. Researchers have
noted a link between experiences of childhood trauma and suicide
(Pompili et al. 2011).
‣ More likely to develop heart disease, cancer, stroke, diabetes,
skeletal fractures, and liver disease (ABS 2006; Silburn et al 2011 van
de Kolk 2007).
‣ Victims/survivors of childhood trauma participate in high numbers in
the child welfare and juvenile justice systems (and later in life in the
adult criminal justice system. (Shaw 2010).
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Effects of Trauma
Trauma in Development
‣ Direct experiences of trauma in early childhood can
cause negative effects on cognitive, neurological, and
psychological development as well as attachment
distress.
www.aihw.gov.au/closingthegap
Brain development can be impaired
survival brain vs. learning brain
Trauma, neglect and brain
development
‣ Neglect is the absence of
critical organizing experiences
at key times during
development
‣ It can involve sensory
deprivation in a number of
domains such as language,
touch and social interactions
‣ Unlike a broken bone,
maldevelopment of neural
systems mediating empathy, is
not readily observable
Source: Perry, BD., 2002, Childhood Experience and the Expression of
Genetic Potential: What Childhood Neglect Tells Us About Nature and
Nurture, Brain and Mind Vol 3: pp 79-100.
How Trauma Can Impact
Development
Source: Perry, BD., 2002, Childhood Experience and the Expression of Genetic Potential: What
Childhood Neglect Tells Us About Nature and Nurture, Brain and Mind Vol 3: pp 79-100.
The Wonderful Brain: A Few
Brain Responsibilities
Left Hemisphere
‣ Motor (on the …)
‣ Language
‣ Memory creation
‣ Detail
‣ Sequence
‣ Logical thought based on
language
‣
‣
‣
‣
‣
‣
Right Hemisphere
Motor (on the…)
Emotional Processing
Memory retrieval
Spatial manipulation
Facial Recognition
Holistic Perception
What Will We See
Behaviorally?
Frontal Lobe Functions
‣ Impulse Control
‣ Organization
‣ Time Orientation
‣ Reading Social Cues
Corpus Callossum
‣ Not well integrated having
problems using words to
solve problems
Amygdala Functions
‣ Problems w/emotional
control
‣ Delays in cause and effect
thinking
‣ Difficulty w/empathy
‣ Inability to describe own
emotions
‣ Hyper-arousal, anxiety
What Will We See Behaviorally?
Hippocampus Functions
‣ Impaired learning
• Less ability to make
memories learning
• Less ability to retrieve
memories – recall
• More impulsiveness
‣ Children who have
experience trauma often
struggle with complex,
goals directed behaviors,
and have trouble adapting
to transitions, changes and
demands…
Trauma and Relationships
‣ Attachment/Relational Trauma
• occurs in attachment relationships with primary caregivers
◦ insecurity of response and availability
◦ mis-attunement, non-response
◦ lack of caring and reflection of self-worth
◦ caregiver as the source of both fear and comfort
• includes DV and child abuse of all types
◦ often “on top of”/in context of attachment insecurity
◦ neglect, abandonment, non-protection, non-response, sexual and physical abuse and
violence, verbal assault
Core Affects
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‣
‣
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‣
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Fear/terror
Anxiety
Depression
Anger/rage/outrage
Shame
Self-blame/guilt
Confusion
Grief/mourning/sadness
Alienation
Other…
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Engaging Children and Caregivers
in the Assessment Process – The
Importance of Trauma Informed Care
Families and Communities
Impact
Trauma experienced by one person will usually have a
ripple effect on other family members, extended family
and friends
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What Is
Trauma
Informed
Care?
(Hopper, Bassuk, & Olivet, 2010, p. 82)
Principles of a
Trauma-Informed Approach
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Safety
Trustworthiness and Transparency
Collaboration and Mutuality
Empowerment
Voice and Choice
(Fallot, 2008)
Safety
‣ Safety first: A Pillar of Healing
‣ A commitment to “Do No Harm”
‣ Create a sense of safety and security for the child and
family during the screen, assessment, and meetings
‣ Be welcoming to the child and family
‣ Express empathy and understanding
‣ Ask permission
‣ Create an opportunity for children and families to ask
questions
‣ Check in with families in between appointments
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Transparency
‣ Explaining the purpose and the process is important
for children and families to be an active part of the
screen and assessment
• Explain your role.Carefully introduce self, agency intake
process, and possible service options
• Discuss what is expected of the individual and what they
should expect from the process
‣ Attend to any barriers around participation in the
screen and assessment
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Collaboration
‣ Create closely knit collaborative relationships with
other public sector service systems
‣ Help children and families make informed decisions
about services and clarify the helping process
‣ Encourage shared decision-making in the process:
Create a collaborative working relationship
‣ Explain roles and responsibilities with the focus on
‘shared’ goals
‣ “We” is expressed and a partnership is built
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Empowerment
‣ Empower children and families by:
•
•
•
•
Instilling hope
Reinforcing strengths
Fostering resilience
Helping to identify barriers to participating in the process and help
problem-solve around those barriers
‣ Validate children and families and take time to
understand their perspective
• Don’t ask children and families to retell their stories or terrifying
experiences if you don’t have to.
• Provide positive feedback
• Attend to any concerns about privacy and confidentiality
◦ Children and families who do not trust the provider or feel the
information shared will not be held in confidence are also at a
greater risk for dropout
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Voice and Choice
‣ Provide choices for children and families
‣ Create a space for children and families to feel
comfortable to express their concerns and ask
questions
‣ Inform both the child and family about the next steps
and ask for their permission to move forward
‣ Give families and children control in the process of
screening and assessment
‣ Provide opportunities to discuss cultural and racial
differences between the provider and the child and/or
family to avoid any misunderstandings
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Healing from Complex Trauma
Anyone who interacts with a child who has
experienced any kind of trauma, including
complex trauma
in their home, school, and community can make
important contributions to healing
and growth.
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Systems without Trauma Sensitive
Characteristics
‣ Individuals/Families are labeled & pathologized as
“manipulative,” “needy,” attention seeking
‣ Misuse or overuse of displays of power - security,
demeanor
‣ Culture of secrecy- no advocates, poor monitoring of
staff
‣ High rates of Seclusion & Restraint & other restrictive
measures
(Fallot & Harris, 2002)
Systems without Trauma Sensitive
Characteristics
‣ Little use of least restrictive alternatives other than
medication
‣ Institutions that emphasize “patient compliance”
rather than collaboration
‣ Institutions that disempower and devalue staff who
then “pass on” that disrespect to service recipients
(Fallot & Harris, 2002)
Trauma Informed Care Management
Trauma informed care management is grounded in
and directed by a thorough understanding of the
neurological, biological, psychological and social
effects of trauma and violence on humans and the
prevalence of these experiences in persons who
receive mental health services.
Treatment Planning
for Complex Trauma
Treatment Principles
‣ Safety and protection
• Safety of self and others, to and from others
‣ Relationship issues
• Boundaries, limitations, respect
• Responsibilities of the therapist
◦ trustworthy/non-exploitive
‣ Informed consent/refusal; client rights
• professional privilege/limits of confidentiality
• right to seek consultation/2nd opinion
• rights to refuse and terminate treatment
Treatment Principles
‣ Treatment meets standard of care
‣ Treatment is individualized
• initial , ongoing, & collateral assessment
• not laissez-faire treatment: organized and planful
• ongoing review/adjustment of treatment plan
‣ Client empowerment/collaboration
• client engagement in the process, with responsibility for
progress
• client consulted on/understands treatment plan
• posttraumatic treatment philosophy and techniques
explained
Treatment Principles
Core Values
Ensure cultural competence
Support individual’s control
Share power and governance
Integrate care
Support relationship building
Enable recovery
Treatment Goals
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Educate about and de-stigmatize
Increase capacity to manage emotions
Reduce co-morbid problems
Reduce levels of hyperarousal
Re-establish normal stress response
Decrease numbing/avoidance strategies
Face rather than avoid trauma, process emotions,
integrate traumatic memories
Treatment Goals
‣ Restore self-esteem, personal integrity
• normal psychosexual development
• reintegration of the personality
‣ Restore psychosocial relations
• trust of others
• foster attachment to and connection with others
‣ Restore physical self
‣ Restore spiritual self
‣ Prevent re-victimization/re-enactments
Summary
‣ Trauma can vary dramatically, as can responses
‣ Treatment
• Is multimodal
• Is bio-psycho-social
• Must be individualized
◦ type of trauma response/disorder
◦ individual needs
Resources
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ISTSS.org
ISSTD.org--new name; formerly (ISSD.org)
NCTSN.org (child resources)
Ctacny.org/ComplexTrauma