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1 Polyvictimization and Child Trauma: Identifying and Addressing Client Needs Howard Davidson, JD [email protected] Lisa Conradi, PsyD [email protected] Lisa Pilnik, JD, MS [email protected] 2 Presentation Agenda • • • • • • Background on Polyvictimization Child Trauma Causes and Symptoms Screening Tools and Interventions Practice Tips for Attorneys Additional Resources Questions? The materials in this presentation is for informational purposes only and is not meant to constitute legal advice. Please consult an attorney for opinions regarding specific facts, cases or legal issues. National Survey of Children’s Exposure to Violence “Children’s exposure to violence, whether as victims or witnesses, is often associated with long-term physical, psychological, and emotional harm. Children exposed to violence are also at a higher risk of engaging in criminal behavior later in life and becoming part of a cycle of violence.” Finkelhor, D., Turner, H., Ormrod, R., Hamby, S., and Kracke, K. 2009. Children’s Exposure to Violence: A Comprehensive National Survey. Bulletin. U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention • Children exposed to violence are more likely to abuse drugs and alcohol; suffer from depression, anxiety, and post-traumatic disorders; fail or have difficulty in school; and become delinquent and engage in criminal behavior. • 60 percent of American children were exposed to violence, crime, or abuse in their homes, schools, and communities. • Almost 40 percent of American children were direct victims of two or more violent acts, and one in ten were victims of violence five or more times. • Children are more likely to be exposed to violence and crime than adults. • Almost 15 percent of children experienced an assault with a weapon and were injured as a result. • Almost 1 in 10 American children saw one family member assault another family member, and more than 25 percent had been exposed to family violence during their life. • 10 percent suffered some form of child maltreatment. • A child’s exposure to one type of violence increases the likelihood that the child will be exposed to other types of violence and exposed multiple times. Advocating for Victimized Youth • preventing further victimization and trauma; • treating the underlying child and family vulnerabilities • broadening what child protective and child welfare services agencies should be providing to these children; and • advocacy for building the supervision and protective capabilities of those adults who are, or will be, caring for them. Recommendations • Every child advocacy legal training should now be including a section on recognizing and responding to traumatized children, regardless of what part of the juvenile court they’re involved in. • Look at childhood victimization more broadly – how to identify and address it – even if it appears unrelated to the incident that brought the child client before the court. • Court appointed child advocates should be more aware of their clients’ victimization and trauma history -- and most importantly how they can effectively advocate for services their clients need to address the adverse consequences of that history. What does the word “trauma” mean? 9 A traumatic experience . . . Threatens the life or physical integrity of a child or of someone important to that child (parent, grandparent, sibling) Causes an overwhelming sense of terror, helplessness, and horror Produces intense physical effects such as pounding heart, rapid breathing, trembling, dizziness, or loss of bladder or bowel control Types of Trauma Acute trauma: A single event that lasts for a limited time Chronic trauma: The experience of multiple traumatic events, often over a long period of time Complex trauma is used to describe a specific kind of chronic trauma and its effects on children: Multiple traumatic events that begin at a very young age Caused by adults who should have been caring for and protecting the child How Children Respond to Trauma Long-term trauma can interfere with healthy development and affect a child’s: Ability to trust others Sense of personal safety Ability to manage emotions Ability to navigate and adjust to life’s changes Physical and emotional responses to stress How Children Respond to Trauma (Continued) A child’s reactions to trauma will vary depending on: • Age and developmental stage • Temperament • Perception of the danger faced • Trauma history (cumulative effects) • Adversities faced following the trauma • Availability of adults who can offer help, reassurance, and protection Long-Term Effects of Childhood Trauma • In the absence of more positive coping strategies, children who have experienced trauma may engage in high-risk or destructive coping behaviors. • These behaviors place them at risk for a range of serious mental and physical health problems, including: ▫ Alcoholism ▫ Drug abuse ▫ Depression ▫ Suicide attempts ▫ Sexually transmitted diseases (due to high risk activity with multiple partners) ▫ Heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease Source: Felitti et al. (1998). Am J Prev Med;14(4):245-258. The Adverse Childhood Experiences Study (ACE) Trauma and Behavior Problems in Children • Children who have been traumatized stay in chronic states of fear and anxiety leading to hypervigilance and a heightened sense of threat • Traumatized children often misinterpret the behavior of others as hostile and respond with aggression • Past victimization can lead to survival strategies that are often anti-social and/or self-destructive • Adolescents may respond to their experience through dangerous reenactment behavior or recklessness. Common Diagnoses • Some common diagnoses for children experiencing traumatic stress include: ▫ Posttraumatic Stress Disorder ▫ Reactive Attachment Disorder ▫ Attention Deficit Hyperactivity Disorder ▫ Oppositional Defiant Disorder ▫ Bipolar Disorder ▫ Substance Abuse ▫ Conduct Disorder • These diagnoses generally do not capture the full extent of the developmental impact of trauma. • Many children with these diagnoses have a complex trauma history. How does trauma Acting out? Victimization Survival Coping Victim Coping Loss of personal integrity and control Dysregulation of emotions and info processing; Rigid, distrustful, callous on outside; Damaged, hopeless, empty inside Taking any means necessary to avoid revictimization; Loss of empathy and impulse control; Diminished sense of future Defiance as a desperate attempt to redress injustice and regain sense of control (Ford, Chapman, Mack, & Pearson, 2006) Screening and Assessment Psychological Evaluation *Designed to answer a specific referral question Trauma Assessment *If a child has a history of trauma and is currently displaying trauma symptoms, referral for a trauma mental health assessment is warranted Trauma Screening *Universally administered to determine a child’s trauma history and related symptoms Trauma Screening • Trauma-informed screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events or reactions to trauma and if they need traumafocused mental health treatment. • Done by front-line workers, such as Child Welfare and, in some cases, mental health. • Usually includes questions regarding a child’s exposure to trauma and his/her symptoms Trauma-Informed Assessment • Trauma assessment is a more in-depth exploration of the nature and severity of the traumatic events, the impact of those events, current trauma-related symptoms and functional impairment. • Usually done by a mental health provider to drive treatment planning. • A good trauma assessment usually occurs over at least 2-3 sessions of therapy and includes a clinical interview, use of objective measures, behavioral observations of the child, and collateral contacts with family, caseworkers, etc. • Domains covered include: ▫ Basic demographics ▫ Family history ▫ Trauma history (comprehensive, including events experienced or witnessed) ▫ Developmental history ▫ Overview of child problems/symptoms. Who Needs Trauma-Focused Treatment? • Children who have experienced extreme trauma, such as a penetrating injury (gun shoot, stabbing, etc) or sexual assault • Children who are “re-experiencing” the traumatic events in their nightmares, in flashbacks, repetitive play, or those who react strongly to reminders of their trauma • Children who are actively avoiding reminders (people, places, sounds, smells, etc) of the trauma What are the Core Components of Evidence-Based Trauma Treatment? • Building a strong therapeutic relationship • Psycho-education about normal responses to trauma • Parent support, conjoint therapy, or parent training • Emotional expression and regulation skills • Anxiety management and relaxation skills • Cognitive processing or reframing Core Components of Trauma-Focused Treatment, cont’d • Opportunity for trauma integration • Strategies that allow exposure to traumatic memories and feelings in tolerable doses so that they can be mastered and integrated into the child’s experience • Personal safety training and other important empowerment activities • Resilience and closure How Do These Core Components Fit Together to Create EvidenceBased Practices? Treatment Triage: Examples of Evidence-Based Treatments for Children • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) • Child-Parent Psychotherapy (CPP) • See www.cebc4cw.org for more information on other modalities that exist • There are many different evidence-based trauma-focused treatments. A trauma-informed mental health professional should be able to determine which treatment is most appropriate for a given case. Practice Tips • Ensure children and youth receive appropriate screenings, assessments and treatments for traumatic stress as appropriate • Ask about follow-up and request that ongoing assessments, where appropriate. • Request that parents and caregivers receive services as well, when appropriate. Practice Tips (cont.) • Ensure that biological and foster families learn about the effects of victimization and warning signs for dangerous symptoms of traumatic stress. • Help youth stay in the least restrictive setting possible. (e.g., their own homes, when safe and possible, or therapeutic or family foster homes, rather than group facilities, when necessary). Practice Tips (cont.) • Help build long-term sustaining relationships (e.g., connecting youth to mentoring organizations or faith-based groups, supporting relationships with extended family members) • Ensure the child or youth is both physically and psychologically safe (e.g., working with a provider who is respectful, non-judgmental, and allows the youth to explore his/her history in a safe and supportive manner) 30 New Resources Coming Soon Resources being developed by the Safe Start Center, ABA Center on Children and the Law and Child & Family Policy Associates • Issue Brief on Trauma Informed Legal Advocacy • Identification Tool and Resource Guide on Polyvictimization and Trauma among CourtInvolved Youth Will be available at www.safestartcenter.org or e-mail [email protected] to receive when available Issue Brief: Trauma-Informed Advocacy • Part of Safe Start Center’s “Moving from Evidence to Action” series • Prevalence and impact of exposure to violence • Symptoms of traumatic stress • Evidence-based assessments and interventions • Practice tips for attorneys and others • State/local initiatives • Special considerations/ethical issues • Policy recommendations Identification Tool and Resource Guide • • • • “Information Integration Tool” Questions about experiences and symptoms No “score” Flowchart on referrals for services Guidance on how to use the tool, understanding child trauma, policy/practice considerations • Resources on prevalence/impact, traumafocused assessments and intervention, and trauma-informed advocacy Other Resources Polyvictimization: Children’s exposure to multiple types of violence, crime, and abuse www.unh.edu/ccrc/pdf/jvq/Polyvictimization%20OJJDP%20bulletin. pdf Understanding Children's Exposure to Violence http://safestartcenter.org/pdf/IssueBrief1_UNDERSTANDING.pdf National Child Traumatic Stress Network Child welfare trauma training toolkit www.nctsn.org/products/child-welfare-trauma-training-toolkit-2008 Other Resources cont. Birth parents with trauma histories and the child welfare system: A guide for judges and attorneys www.nctsn.org/sites/default/files/assets/pdfs/birth_parents_trauma _guide_judges_final.pdf CAC directors’ guide to mental health services for abused children www.nctsnet.org/sites/default/files/assets/pdfs/CAC_Directors_Guid e_Final.pdf Healing invisible wounds: Why investing in traumainformed care for children makes sense www.justicepolicy.org/images/upload/1007_REP_HealingInvisibleWounds_JJ-PS.pdf 35 Questions? 36 Contact • Howard Davidson, JD ABA Center on Children and the Law [email protected] • Lisa Conradi, PsyD Chadwick Center/Rady Children’s Hospital [email protected] • Lisa Pilnik, JD, MS Child & Family Policy Associates [email protected]