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CAC Director’s Guide to Mental Health Services for Abused Children
Part One
Why trauma focused interventions?Why expand mental health as a part of
the service component of CACs?
Presented byM. Elizabeth Ralston, Ph.D.
The Dee Norton Lowcountry Children’s CenterCharleston, SC
Primary Purpose of Guide
• To understand the issues and impact of childhood traumatic stress on children seen at CACs
• Support and expand the existing mental health services component within CACs to increase each child’s potential for recovering from identified abuse and to live a full and productive life.
Desired Outcome goals
• Improve awareness and understanding of CAC leaders of the impact of trauma on the children and non offending caregivers served through their CAC.
• Assist CAC directors in expanding MDT understanding of the impact of trauma and the need to expand trauma informed MH service components within their CAC.
•
Mental Health Standard
• Mental Health: Specialized trauma-focused mental health services, designed to meet the unique needs of the children and non-offending family members, are routinely made available as part of the Multidisciplinary Team Response.
Why trauma focused interventions for our clients?
• The most common factor that
brings children’s to the attention of
the CAC is some form of child
abuse or exposure to violence.
• Child abuse is the most common
form of trauma experienced by children.
Trauma is defined as an experience that threatens life
or physical integrity and that
overwhelms an individual’s
capacity to copeChild Welfare Committee, National Child Traumatic Stress
Network. (2008). Child welfare trauma training toolkit: Comprehensive guide (2nd ed.). Los Angeles, CA & Durham,
NC: National Center for Child Traumatic Stress
Definition of Trauma
Acute Traumatic Events
• Events are sudden, occur at a particular time and place and are usually time limited and create intense fear– School shootings– Gang related incidents– Terrorist attacks– Natural disasters– Serious accidents– Sudden or violent loss of a loved one– Physical or sexual assault (being shot or raped)
Chronic Traumatic Situations
Events may occur multiple times over
time and may create intense fear• Physical Abuse• Sexual abuse• Emotional or physical neglect• Domestic Violence• Wars or political violence• Chronic violence in the community• Exposure to drugs
Trauma and Children
• Children across the world experience many types of trauma
– Natural disasters– War– Community violence– Family violence
• Child abuse and neglect (CAN) is a common form of traumatic experience for children in all cultures.
• CAN may be overlooked in the wake of serious events. Download at:Download at:
http://ispcan.org/publications.htmhttp://ispcan.org/publications.htm
What does trauma informed mean?
• Understanding how trauma impacts children, behaviorally, emotionally, developmentally, socially and physically and considering that impact to inform the CAC respond to that child and their non offending caregiver.
What does trauma informed mean?
• To consider that children being seen at our CAC may have experienced a trauma which has resulted in traumatic stress that is playing a role in that child’s and their non offending caregiver’s response.
• Using our knowledge of trauma to expand our understanding of how trauma may impact the child’s presentation.
• Using standardized trauma screens and assessments to inform our interventions with a child and their non offending family.
What is Child Traumatic Stress?
• The physical and emotional responses a child has to a traumatic event or to witnessing a traumatic event occur to another person.
• Such events overwhelm the child’s capacity to cope, and elicit feelings of terror, horror, out-of-control physiological arousal, and powerlessness.
• The child’s reaction and the length of that reaction are related to the objective nature of the event and the child’s subjective response
Factors influencing the impact of traumatic events
• The child’s age and developmental stage
• The child’s perception of the danger faced
• Whether the child was the victim or a witness
• The child’s relationship to the victim or perpetrator
• The child’s past experience with trauma
• The adversities the child faces following the trauma
• The presence/availability of adults who can offer help and protection
Effects of Trauma Exposure on Children
• When trauma is associated with the failure of those who should be protecting and nurturing the child, it has profound and far-reaching effects on nearly every aspect of the child’s life.
• Children who have experienced the types of trauma that precipitate entry into the child welfare system typically suffer impairments in many areas of development and functioning, including:
Effects of Trauma Exposure on Children
• Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others.
• Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.
• Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.
Effects of Trauma Exposure on Children
• Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.
• Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.
• Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.
• Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.
The Influence of trauma on Developmental Stage
• Child traumatic stress reactions vary by developmental stage.
• Children who have been exposed to trauma use a great deal of energy responding to, coping with, and coming to terms with the event.
• This may reduce the child’s capacity to explore the environment and to master age-appropriate developmental tasks.
• The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways.
Effects of Trauma on Brain Development
• Brain development can be altered by the experience of abuse, resulting in negative impact on the child’s physical, cognitive, emotional and social growth.
• Chronic stress overdevelops regions of the brain involved in anxiety and fear and under develops other regions of the brain involved in complex thinking.
• Children who experience the stress of physical or sexual abuse or neglect will focus their brains’ resources on survival and responding to threats in their environment
Impact on environments
• Brain development in children who have been maltreated is often a very adaptive response to their negative environment and is maladaptive in other environments
• When a child lives in a world that ignores him, if not provided with appropriate stimulation for growth, his brain will focus on survival from day to day and may not fully develop healthy cognitive and social skills
• The child may have great difficulty functioning in an environment of kindness, nurturing and stimulation.
• Anxiety, fear, and worry about safety of self and others
• Worry about recurrence or consequences of violence
• Discomfort with feelings (such as troubling thoughts of revenge)
•Increased somatic complaints (e.g. headaches, stomachaches, chest pains)
What you might observe in children impacted by traumatic stress?
–Decreased attention and/or concentration–Increase in activity level–Impulsive behavior–Change in academic performance; reduced GPA; absenteeism–Irritability with friends, teachers, and events.–Angry outbursts and/or aggression (poor control of emotions)–Withdrawal from others or activities
What you might observe in traumatized children?
•Difficulty with authority figures•Resistance to transition or change•Over-or under-reacting to sounds, physical contact, doors slamming, sirens, lightening, sudden movements (startle response)•Repeatedly talking about the traumatic event with a focus on specific details of what happened (ruminating)
What you might observe in traumatized children? (continued)
•Re-experiencing the trauma (e.g., nightmares or disturbing memories during the day)•Hyperarousal (e.g., sleep disturbance, tendency to be easily startled)•Avoidance behaviors (e.g., resisting going to places that remind them of the event)•Emotional numbing (e.g., seeming to have no feeling about the event)
What you might observe in traumatized children? (continued)
What are potential effects of traumatic stress on a child?
• Behavioral Impact of victimization/trauma
• Psychological Effects of Trauma
• Potential Effects of Trauma on daily life
• Lifetime Effects of Trauma
Behavioral Impact of Childhood Victimization/Trauma
• Acting out behaviors such as inappropriate sexual behaviors, violent behavior (peer aggression, dating violence, spouse/partner violence)
• Delinquency and criminal behavior
• Other problems (future victimization, self-esteem, guilt, shame, self- blame, relationship difficulties, academic performance, occupational achievement)
Psychological Effects of Trauma
• Mental health disorders such as major depression and anxiety
• Posttraumatic stress disorder (PTSD) characterized by intrusive thoughts, avoidance and hyper arousal, and may include emotional numbing, irritability, trouble sleeping, trouble concentrating, withdrawal from activities and others.
Potential Effects on daily life
• Impact of PTSD symptoms on child’s daily life- School, inability to pay attention, sleepy,
angry, mood swings, avoidance of activities associated with triggers, withdrawn, acting out behaviors.
- Most common diagnosis for these behavioral problems experienced by traumatized children include ADHD, ADD, CD, and ODD.
Potential Effects on daily life
• Treatment for these behavioral diagnoses usually focuses on stopping the behaviors vs. treating the etiology
• Treatment of choice is usually medication• Child carries an incomplete behavioral diagnosis• May be defined as a “bad/problem child”• PTSD needs to be ruled in or out• Behavioral diagnoses may co exist with PTSD
and both need to be assessed and treated.
Potential Lifetime Effects of Trauma (ACE study)
• PTSD can negatively impact–Mental Health–Physical Health–School Performance–Employment Success–Economic Success–Relationship and Social Skill
What is a trauma informed CAC response?
• Having an understanding of how trauma impacts a child and what that means about the thinking, feeling and behavior of the traumatized child.
• Recognizing the signs and symptoms of child traumatic stress and how they vary in different age groups.
• Understanding the cumulative effect of trauma.
A trauma informed CAC response
• Gather and document psychosocial information regarding all traumas in the child’s life to make better-informed decisions (trauma screen).
• Consider the impact of traumatic stress on parents and caregivers who have traumatic experiences of their own.
• Integrate cultural practices and culturally responsive mental health services.
A trauma informed CAC response
– When a child is known to have experienced a trauma, consider the impact of traumatic stress on the child presentation.
– Understand that problematic behavior and emotion may be a response to traumatic stress vs. a bad child.
– Consider ruling out traumatic stress when considering other behavioral diagnosis.
– Use trauma screen/assessment in the development of treatment recommendations, treatment and referrals.
Role of CACs and child trauma
• CACs have accepted the role and responsibility of responding to child abuse and neglect issues.
• Initial focus of CACs has been on coordinating the investigation of allegations of CAN.
• CACs must now move beyond the investigation and be prepared to respond to the needs of the child and non offending family members to heal from any trauma experienced as a result of the CAN.
Mental Health Standard
• Mental Health: Specialized trauma-focused mental health services, designed to meet the unique needs of the children and non-offending family members, are routinely made available as part of the Multidisciplinary Team Response.
Mental Health Standard
• Specialized trauma focused mental health services for the child client include:– Crisis intervention services– Trauma-specific assessment including full trauma history– Use of standardized measures (assessment tools) initially
and periodically– Family/caregiver engagement– Individualized treatment plan that is periodically re-
assessed– Individualized evidence-informed treatment appropriate for
the children and family seen– Referral to other community services as needed– Clinical supervision
What is Trauma Focused?
• Treatment interventions designed to reduce any identified symptoms of trauma in the child and non offending caregivers seen at CACs.
• Designed to address specific problems and issues related to trauma and to result in measurable behavioral outcome goals, i.e. the reduction of trauma symptoms
A trauma informed MDT
• Investigation
• Caregiver’s response
• Safety considerations
• Family Engagement
• Developing Treatment plans
• Delivering treatment interventions
A Trauma informed MDT
The investigation of allegations of childabuse needs to be trauma informed• Dynamics of abuse• Child development• Impact of trauma on memory, emotion
and on the disclosure process• Depression, dissociation,
accommodation
A trauma informed MDT
• How children disclosure– Response of the child’s non offending caregiver
to disclosure– Impact of non offending caregiver’s response on
the child– Impact of trauma on the child’s caregiver– Dynamics of disclosure
• Relationship of the offender to victim• Role of child’s caregiver in outcome of the
investigation
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• Role of Mental Health in Investigation:– Educate MDT on Impact of Trauma on child’s
disclosure or lack of disclosure– Assess impact of other diagnosis, medication and
family history on investigation– Understand family dynamics– Develop multiple hypotheses regarding allegation– Expert witness in court hearing
Expanding the mental health role of CACs
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Expanding the Mental Health role of CACs
• Role of Mental Health in Developing and Monitoring Safety Plans:– Assess caregiver’s willingness and ability
to be a protective resource and identify any internal and external barriers to this outcome
– Pre-conditions of safety to family preservation, visitation and/or reunification.
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Expanding the Mental Health role of CACs
• Role of Mental Health in Family Engagement:– Assess and inform MDT about strengths and
supports in child and families life– Consistent communication between treatment
providers, MDT members, and family– Identify and remove any barriers to participation
in and completion of treatment– Identify needs and resources to support family in
treatment
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Expanding the Mental Health role of CACs
• Role of Mental Health in Coordinating Treatment Plans for Child and Family– Assess Caregiver’s need for treatment and
ability to engage in treatment for self and child
– Identify any risk factors to be addressed– Coordinate and communicate with MDT
regarding potential treatment issues– Utilize standardized assessments
including trauma assessments to inform treatment planning
Expanding the Mental Health role of CACs
• Role of Mental Health in Interventions:– With MDT, define Clear Measurable
Treatment Outcome Goals for Child and Non-offending Caregivers designed to reduce risk and trauma symptoms
– Match these goals with a specific trauma focused evidence supported treatment to include the child and non offending caregiver
– Provide or refer out for treatment, monitor progress and outcome for tracking purposes.
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Expanding the Mental Health role of CACs
• Role of Mental Health in Reunification:– Provide feedback to MDT about Child’s
Needs– Assess Caregiver’s Focus and
Ability/Willingness to Protect– Protection Clarification– Testify in court regarding permanency
plan, i.e. reunification, termination of parental rights, adoption.
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Expanding the Mental Health role of CACs
Mental Health Professionals support the MDT by:• Consider MH factors related to the forensic interview• Assess risk/safety issues for the child• Assess for and explaining the need for MH treatment for the
child and non offending caregiver including behavioral/measurable outcome goals designed to reduce risk
• Explain the recommended treatment and outcome goals and the need for attendance/participation by the child and non offending caregiver to support family engagement
• Identify barriers to treatment engagement by the family• Bring barriers to treatment participation to the MDT for
problem solving or modification of treatment plan• Track treatment progress• Provide necessary reports regarding treatment participation,
progress and outcome to MDT members as appropriate.• Celebrating and rewarding treatment completion.
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Your mission: To gain or maintain NCA Accreditation
1. What is the current role of Mental Health on your CAC’s MDT?2. Is MH a signatory on your CAC response protocol?3. Do you have linkage agreements with local MH professionals that
clearly define their role on the MDT?4. Do your on site MH professionals or those you refer to in the
community have the required training to provide evidence supported treatment?
5. What assessment tools are used to develop treatment plans?6. To what degree are these plans evidence based?7. Do these plans include the non offending caregiver?8. What level of cooperation in treatment planning and monitoring
exists in your CAC community now?9. Is MH a part of your MDT case review?10. Does your MDT case review process involve developing treatment
plans for the children and families served by your CAC?11. What are the needs of your CAC to ensure compliance with the NCA
Mental Health standard?
Questions
Part TwoMay 15, 2011
• What is evidence based treatment?
• How do you decide who needs treatment?
• What treatments are available to CAC clients and their non offending family members that are evidence based and trauma focused?
Remember Our Customers!
Contacts
Libby Ralston, Ph.D.,LISW-CP, LMFT
Dee Norton Lowcountry Children’s Center
