in Child Welfare - The Trauma Center

More documents

Recommendations

Info

8 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013The Heart of the Matter: Complex Trauma in Child WelfareJoseph Spinazzola, Ph.D., Mandy Habib, Psy.D., Angel Knoverek, Ph.D., LCPC, Joshua Arvidson, MSS, LCSW, JanNisenbaum, MSW, Robert Wentworth, MSW, Hilary Hodgdon, Ph.D., Andrew Pond, LICSW, and Cassandra Kisiel, Ph.D.OverviewComplex trauma involves chronic or repeated,typically early-onset exposure to two or moreof the following forms of trauma exposure:sexual, physical or emotional abuse, domesticviolence, or neglect, as well as severe caregiverimpairment and school/community violence(Kisiel et al., 2009). A national sample of over2,200 children in child welfare found thatover 70% met exposure criteria for complextrauma (Greeson et al, 2011). A substantialsubset of children—typically those withthe fewest social and economic resources,and those living amidst poverty, crime orcultural minority status (Cohen, 2007)—haveexperienced all of these forms of exposure.Complex trauma impacts multiple coredomains of functioning: children’s physiologyand brain development; their ability toidentify, tolerate, control and appropriatelyexpress emotions, impulses and bodilysensations; to concentrate, learn and engage ingoal-directed behavior; to form a positive andcohesive sense of self, meaningful values andhopeful future outlook; to cultivate secure andhealthy attachment bonds, sustain intimaterelationships, safely negotiate conflict andcommunicate their needs; and to interpretsocial cues accurately, set healthy personalboundaries and differentiate safe fromthreatening situations and interactions withpeers and adults (Cook et al, 2005; Kisielet al, 2009; Spinazzola et al, 2005). By thetime they reach adolescence, many complexlytraumatized youth are already caught in avortex of intense somatic, behavioral andemotional dysregulation in which dailylife is fraught with an ever-expanding hostof traumatic reminders and subtle falsealarms that activate extremes of hyper- andhypo-arousal. Like “live wires,” complexlytraumatized youth can become chargedwith heightened vigilance and physiologicalreactivity at levels that are emotionallyoverwhelming and debilitating to the immunesystem. Like “walking dead,” they canretreat or slip into extended periods of severewithdrawal, emotional constriction, avoidanceand numbing of consciousness induced viacoping strategies that include dissociation,binge eating or substance dependence.The legacy of unresolved complex traumais staggering, and has been causally linkedwith increasingly dire outcomes across thelifespan that collectively place an enormouseconomic burden on society, conservativelyestimated at over $200,000 per impactedchild and over 100 billion per year (Fang et al,2012). Long-term outcomes include scholasticfailure, dropout and unemployment; earlypregnancy, sexually transmitted disease,rape and domestic violence; chronic mentaland physical illness, health risk behaviors,The legacy of unresolved complex trauma is staggering, and has beencausally linked with increasingly dire outcomes across the lifespanthat collectively place an enormous economic burden on society,conservatively estimated at over $200,000 per impacted child and over100 billion per yeardisability and premature mortality (Edwardset al, 2004; Felitti et al, 1998, Ford et al,2010).Psychological maltreatment: Thesleeping giant of complex traumaPsychological maltreatment has beenrecognized by the American PediatricAssociation as the most prevalent form ofchild maltreatment and thus far the mostoverlooked despite substantial evidence ofits deleterious impact at levels comparableto more readily recognizable forms ofmaltreatment such as physical and sexualabuse (Hibbard et al, 2012). Psychologicalmaltreatment is comprised of various overtand subtle forms of chronic emotional abuseand neglect, including prolonged verbalabuse, terrorizing, shunning, and socialisolation. A recent study on a large sampleof over 5,000 children and adolescents fromthe Core Dataset of the NCTSN revealedpsychological maltreatment to have equal orsignificantly greater association than physicalor sexual maltreatment to 27 out of 30frequency and severity symptom, diagnosticand risk indicators assessed (Spinazzola etal, 2011). Psychologically maltreated youthwere the most likely to exhibit significantinternalizing, attachment and substanceabuse problems and the most likely todevelop anxiety and depressive disorders. Alsonotable was that exposure to psychologicalmaltreatment resulted in equal levels of PTSDsymptom severity compared to physical orsexual abuse. The child welfare system canserve as a critical gatekeeper of suspectedThe term complex trauma wasintroduced by a special taskforceof the National Child TraumaticStress Network (NCTSN) to helpmultidisciplinary service providersbetter understand and respondto the multifaceted relationshipbetween children’s exposure tomultiple traumatic events and thewide-ranging, long-term impactof this exposure (Complex TraumaTaskforce, Cook et al, 2003, 2005,2007). The complex trauma constructdiffers in important ways fromother conceptual frameworksof child maltreatment. Whereas“polyvictimization” addresses thecircumstances of children’s exposureto multiple, often inter-relatedtraumatic forms of trauma (Finkelhoret al., 2007, 2009), complex traumaspeaks to the cascading interplaybetween trauma exposure, impactand (mal)adaptation. Moreover,unlike “Complex PosttraumaticStress Disorder,” introduced in anattempt to characterize a broaderand more pronounced symptom-setexhibited in a subset of traumatizedadults (Herman, 1992), the complextrauma construct was formulated inrealization that the PTSD diagnosisneither typically nor sufficientlycaptures the cardinal featuresof disturbance observed in youthexposed to prolonged and severemaltreatment, violence, and neglect(Ackerman et al., 1998; Spinazzola etal., 2005).and reported psychological maltreatmentin children and families with its power andauthority to open the door to thoroughinvestigation of its presence and impact inreported youth.
CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 9What lies beneath: The need forcomprehensive assessmentChildren impacted by complex trauma are notonly at high risk for revictimization but aremore vulnerable than other youth to exposureto other forms of acute, non-interpersonaltrauma. For example, chronically neglectedchildren are at significantly increased riskof exposure to accidents and burns in thehome. The aberrant socialization thatfrequently accompanies familial incest oremotional abuse can increase children’ssusceptibility to school bullying and lead tojuvenile delinquency, substance abuse andhigh-risk sexual behaviors. In turn, chronicphysical abuse often underlies and fuelsconduct problems and social aggression.Comprehensive evaluation that includesa thorough caregiving and trauma historyand integrates developmental, psychiatric,behavioral, scholastic and interpersonalstrengths and difficulties is essential. The childwelfare system can play a pivotal role notonly through early screening and assessment,triage, and trauma-informed referral butin working with providers to connect allthe dots. “Unpacking” these exposure, riskand protective trajectories for youth inthe child welfare system is the critical firststep toward rerouting pathways to healthyoutcomes, fostering resilience, and disruptingintergenerational cycles of complex trauma(Layne et al, 2008).Placement instability: The sine quanon of complex trauma?Children in child welfare with complextrauma have been found to have significantlyhigher rates of placement disruption (Kisielet al., 2009). A child’s risk for poor outcomescan increase exponentially in child welfareas a result of cycles of impaired caregivingfollowed by periods of separation fromprimary caregivers, potential incidents ofplacement instability, revictimization in thenew home, failed reunification attempts,or ultimate loss of primary caregivers.For children whose sense of self, intimateattachments, material possessions, access tofriends and siblings—in effect, their entireworld—hangs in the balance of the successor failure of these placements, each juncturecan be experienced as another complextrauma exposure irrespective of the effortsand intentions of child welfare personnel andfoster, kinship, or biological parents. Thechild welfare system can play a pivotal rolein mitigating this risk by: a) recognizing thecritical importance of placement stabilityin altering risk trajectories for complexlytraumatized children, b) prioritizing carefuldeliberation around the timing and nature ofplacement decisions, c) establishing structuresto support emotional regulation of childrenfacing unavoidable placement transitions, andd) delineating proactive strategies to preventor rapidly respond to child decompensationassociated with abrupt placement disruption.Helping the most vulnerable:Complex trauma andresidential carePlacement in a residential treatment facilitycan be a common outcome for those childrenmost severely and chronically impacted bycomplex trauma. In turn, complex traumais heavily over-represented in youth inresidential care. Analysis of the NCTSN CoreDataset revealed that when compared withtraumatized youth receiving outpatient orcommunity-based services, those receivingresidential services had the highest rates oftrauma exposure and associated impairment(Briggs et al, 2012). While the majorityof outpatient youth no longer exhibitedsymptoms by the end of treatment, asubstantial percentage of complexlytraumatized youth in residential carecontinued to manifest impairment indicatingthe need for more extensive services. Thehighly structured, predictable and consistentenvironment and caregiving offered withintrauma-informed residential settings mayprovide these children with a sufficient senseof safety and emotional containment to beginto shift from a survival-based preoccupationwith threat detection and avoidance to amore present and future-oriented focus onskill acquisition and identity development. Aresidential placement can afford child serviceproviders a unique window of opportunityto guide complexly traumatized children inthe development of internal capacities forself-control and affect management, in therehearsal of effective problem-solving andcommunication skills, and in the delineationof interpersonal boundaries and cultivationof safe and healthy relationships. The childwelfare system can provide leadership oninitiatives that ensure maximal treatmentgains for complexly traumatized children bymaking purposeful, collaborative, treatmentgoaldriven decisions about the timing,duration and type of residential placementsto which complexly traumatized childrenare assigned, extended, transitioned anddischarged.Complex trauma requirescomplex solutionsTraditional treatment of PTSD in childrenhas focused on processing and resolving vividand painful memories, beliefs, and emotionsassociated with one or more specific traumaticexperiences. Intervention models designedto treat complex trauma of necessity attendto the broader array of deficits and domainsof maladaptive functioning. Of the overtwo dozen evidence-based and empiricallysupported interventions created or advancedby members of the NCTSN over the pastdecade (NCTSN, 2012), several have beenspecifically developed to treat complextrauma by addressing six core componentsidentified in complex trauma intervention:safety; self-regulation; attachment; identitydevelopment; trauma experience integration;and strength-based cultivation of self-worth,positive affect, personal competencies andmastery experiences (Cook et al, 2005).Treatment models are predicated upon ashared recognition that training is insufficientto achieve successful intervention withcomplexly traumatized children; responsibletreatment of complex trauma entails ongoingtraining, supervision, fidelity assessmentand careful adaptation responsive to uniquecultural, setting and developmental needs ofContinued on page 37Overview
Page 1 and 2: Center for Advanced Studiesin Child
Page 3 and 4: CW360 o Trauma-Informed Child Welfa
Page 10 and 11: 10 CW360 o Trauma-Informed Child We
Page 12 and 13: 12 CW360 o Trauma-Informed Child We
Page 14: 14 CW360 o Trauma-Informed Child We
Page 17: CW360 o Trauma-Informed Child Welfa
Page 29 and 30: A Birth Parent’s Perspective: Wha
Page 33 and 34: Recent studies show that as many as
Page 35 and 36: and will learn regulation in the da
Page 41 and 42: Lieberman, A. F. (2004). Traumatic

in Child Welfare - The Trauma Center

Create successful ePaper yourself

Delete template?

Save as template?