Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Addressing Trauma in Children’s Health Homes Yvette Kelly, LMHC Meg Baier, LMSW McSilver Institute for Poverty Policy and Research AGENDA ▪ ▪ ▪ ▪ 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 14 What is Trauma? What is Trauma? 15 ‣ 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 26 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 27 Trauma has Long-lasting Effects 29 ‣ 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). 28 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 ‣ ‣ ‣ ‣ ‣ ‣ ‣ ‣ ‣ ‣ Fear/terror Anxiety Depression Anger/rage/outrage Shame Self-blame/guilt Confusion Grief/mourning/sadness Alienation Other… 56 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 57 What Is Trauma Informed Care? (Hopper, Bassuk, & Olivet, 2010, p. 82) Principles of a Trauma-Informed Approach 58 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 59 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 60 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 61 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 62 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 63 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. 64 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 ‣ ‣ ‣ ‣ ‣ ‣ ‣ 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 ‣ ‣ ‣ ‣ ISTSS.org ISSTD.org--new name; formerly (ISSD.org) NCTSN.org (child resources) Ctacny.org/ComplexTrauma