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4 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013What is Traumatic Stress?Lucy Berliner, MSWWhat is a Trauma?Traumas are events involving threat or danger.They do not have to be actually violent.The perception that something terriblecould happen can make the event traumatic.Traumas may be directly experienced,witnessed or happen to a close loved one.They include child abuse, rape, violent crime,witnessing DV or community violence,serious accidents or natural disasters, and theviolent or sudden death of a loved one. Notall bad experiences are traumas. Neglect, notbeing loved, foster care, parental incarcerationand mental illness are adversities that can havenegative effects.The Prevalence of Traumatic EventsExposure to trauma is very common.According to Finkelhor (Finkelhor et al,2009) each year about 60 % of childrenexperience at least one trauma. A subset,about 22%, has four or more different typesof traumas. Traumas can range from the lessserious, being hit by a sibling occasionally,to the extremely serious such as being rapedor witnessing a parent murdered. Traumaexposure is almost universal among childrenin the child welfare system (CWS). Forexample, even though neglect comprises themajority of all CWS cases, many neglectedchildren have witnessed DV or communityviolence.What is Post-Traumatic StressDisorder (PTSD) and How Does itDiffer from PTS?A minority of children will experiencepersisting or worsening traumatic stress thatbecomes Post-Traumatic Stress Disorder.PTSD and altered brain structures and stressresponse systems. It is not clear whetherthese biological differences create increasedsusceptibility to PTSD or are the biologicalexplanation of PTS (Neigh, Gillespie, &Nemeroff, 2009). Overall, research showsthat the accumulated burden of multipleFinding out that a child has been exposed to trauma creates theopportunity for all involved in child serving settings to actively contributeto the child’s recovery from the impact.OverviewWhat is Posttraumatic Stress(PTS) and How Does it Differ fromTrauma?Being exposed to a trauma is almost alwaysupsetting. Trauma-specific reactions are calledposttraumatic stress (PTS). PTS is unwantedand upsetting memories or dreams of thetrauma and intense emotional and physicalreactions when thinking about or beingreminded of the traumas. Avoidance copingstrategies decrease the negative emotionalstates when thinking about the traumas. PTSalso includes heightened physical arousalresponses such as jumpiness, irritability,difficulty concentrating, and trouble sleeping.Traumatic stress is a normal reaction to a verybad experience; most children exposed totraumas have at least some symptoms. PTSis not the only consequence of exposure to atrauma observed in children. Symptoms ofgeneral anxiety, depression, and behavioraldisruption are also seen following traumas.Some children do not show distress followingtraumas, and for most the PTS will subsideover time without treatment.Occasionally, children develop PTSD after aperiod of appearing to be fine. To make thediagnosis, a qualified professional conductsa systematic assessment to find out if thesymptoms required by the Diagnostic andStatistical Manual (DSM) are present.The diagnosis requires a certain number ofsymptoms of intrusive memories, avoidanceor numbing reactions, and hyperarousalsymptoms and that symptoms have persistedfor at least a month and interfere withfunctioning. Just being exposed to a traumaor being upset about the trauma does notmean PTSD.Predictors of PTSD in ChildrenCertain factors place children at greater riskfor developing PTSD. The main predictorsare more serious traumas, perception of lifethreat, prior traumas or psychiatric problems,and being female. A negative reactionfrom others also is associated with PTSD.Recent biological research demonstrates anassociation between child abuse and neglect,and different bad experiences (traumas andadversities) is more important than thespecific type of trauma in predicting PTSD.Immediate Responses to TraumaWe now have strategies to help children whohave experienced trauma and have PTS.Psychological First Aid (PFA) (NationalChild Traumatic Stress Network, www.nctsn.org) is an approach for acute situationswhere the trauma has just occurred. Itwas originally designed for disasters, thepsychological field response accompanyingother rescue efforts. The main ingredientsare focusing on here and now concerns,providing psychoeducational informationand normalization, support, reinforcement ofcoping skills, and, when needed, facilitatingaccess to ongoing services. With children,engaging caregivers is key. PFA usuallyinvolves one or two sessions. This type ofapproach can be used in emergency rooms,during child welfare investigations, in ChildAdvocacy Centers, and DV shelters. A
CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 5slightly more intensive approach is the Childand Family Traumatic Stress Intervention(Berkowitz, Stover, & Marans, 2011). Thisfour session intervention is delivered withina month of the traumatic event and cansignificantly lower PTS and PTSD.Screening for PTS and PTSDRoutine screening is the best way to identifychildren who have high levels of PTS orPTSD and would benefit by trauma-specifictherapy. It is most important in childserving settings where children have highrates of exposure and are most likely to besignificantly affected by their experiences,such as child welfare, mental health andjuvenile justice. Experience shows thatchildren are not distressed at being askedabout traumas and are more likely to reportwhen asked. There are checklists for screeningfor a trauma history (see the article byConradi in this publication for more detailedinformation on screening). Screening is thefirst step to insure that children are assessedfor mental health needs and to facilitateaccess to evidence-based therapy such asTrauma-Focused CBT (Cohen, Mannarin,& Deblinger, 2006). Professionals operatingwithin the best practice multidisciplinarymodel or a Child Advocacy Center are wellequipped to seamlessly facilitate access totrauma-specific assessment and therapy.Providing SupportSimply asking about abuse and trauma is notsufficient since the children already knowwhat they have experienced. The key is tolearn about children’s reactions and respondin a supportive way. Professionals and otherssuch as foster parents can provide nonclinicalinterventions that are immediatelyhelpful, such as normalizing PTS reactions,offering support and giving comfort. Evenchildren who do not have significant PTSmay have been affected by their experiencesand appreciate acknowledgement that thetrauma was bad, frightening or wrong. CPSinvestigators or forensic interviewers may berequired to take care in the degree to whichthey validate children’s reports of abuse, butthey can still express appreciation and offersupport.PTS is a common reaction to exposureto trauma. Finding out that a child has beenexposed to trauma creates the opportunityfor all involved in child serving settings toactively contribute to the child’s recoveryfrom the impact. Simple steps such asacknowledgement, normalizing reactions,and providing support can reduce stress andpotentially avert the development of longertermconsequences. It is also the platform forfacilitating access to assessment and evidencebasedtrauma-specific treatment whennecessary. The key to making a differenceis not avoiding the trauma but rathercommunicating directly about the trauma andmaking sure there is access to needed care.Lucy Berliner, MSW is Director ofHarborview Center for Sexual Assaultand Traumatic Stress, University ofWashington at Harborview MedicalCenter. She can be reached at lucyb@u.washington.edu.OverviewEmail us at info@childwelfare.gov orcall toll-free at 800.394.3366Stay connected to child welfare information and resourcesFrom child abuse and neglect to out-of-home careand adoption, Child Welfare Information Gatewayis your connection to laws and policies, research,training, programs, statistics, and much more!Go to www.childwelfare.gov:- Sign up for FREE subscriptions- Order publications online- Chat live with our Information SpecialistsUse your smartphone toaccess the Gateway website.
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