Trauma reduction and Long Term Care planning for children and

adolescents

Michigan Association of Drug Court ProfessionalsAnnual Conference

March 11, 2014

Agenda Maltreatment:

Types of stress & trauma The Trauma Connenction:

Brain development, moral development, mental health and delinquency

Reducing the Harmful Effects of Trauma: Risk Reduction, Polices, Procedures, Home

Environment, Community Treatment & Safeguarding

Assessments, Interventions, Skill Building, Protective factors

Implications for Long Term Care: Ongoing Needs, Community, Outcome Evaluation

MALTREATMENT

Types of StressTypes of Trauma

Types of Stress• Learning how to cope with mild or moderate

stress is an important part of healthy child development– Increase our heart rate, blood pressure, stress

hormones– In young children when these stress responses are

activated within supportive relationships with adults, the physiological effects are buffered and return to baseline

• Healthy development can be derailed by excessive or prolonged activation of stress response in the body and brain– Of stress response is extreme or prolonged, and the

buffering relationships the child is unable to return to baseline and the child remains in a toxic state

Types of StressPositive stress – normal part of life and learning to adjust to it is an essential feature of healthy development (develop a sense of mastery)

Meeting new people Dealing with frustration Getting an shot Starting school

Tolerable stress – stress that has the potential to negatively the development of the brain but generally occur of periods of time that allows for the brain to recover and revere potentially harmful effects

Death Divorce Frightening accident

Types of Stress

• Adrenaline and Cortisol are both produced under normal circumstances and help the body for coping with stressors

• If the body fails to shut off the Adrenaline and Cortisol release, or experiences chronic stress, longer-term effects can include suppression of immune function, other types of memory, and can contribute to metabolic syndrome, bone mineral loss, and muscle atrophy (Sapolsky, R.M. Romero, L.M. & Munck, A. (2000).

Types of Stress

• Toxic Stress – strong, frequent or prolonged activation of the body’s stress management system – Chronic abuse, especially during early sensitive

brain development, the regions of the brain involved in fear, anxiety, and impulsive responses may overproduce while those regions of the brain dedicated to reasoning, planning and behavioral control may produce fewer neural connections

– Frequent or sustained activation of brain systems that respond to stress can lead to heightened vulnerability to a range of behavior and physiological disorders over a lifetime

Types of Trauma

• Acute Trauma – a single traumatic even that is limited in time. An earthquake, dog bite, or motor vehicle accident

• Chronic Trauma – multiple, varied and repeated events such as a child who is exposed to domestic violence at home, is involved in a care accident and then becomes a victim of community violence, or longstanding trauma such as physical abuse or war

Types of Trauma

• Complex Trauma – term used to describe both exposure to chronic trauma - usually caused by adults entrusted with the child’s care, such as parents or caregivers – and the immediate and long-term impact of such exposure on the child

• Hypervigilance: abnormally increased arousal, responsiveness to stimuli and scanning of the environment for threats. Hypervigilance is a symptom that adults and children can develop after exposure to dangerous and life-threatening events (4)

THE TRAUMA CONNECTION

Brain DevelopmentMoral DevelopmentMental Health Delinquency Substance Abuse

Child and Adolescent Brain Development

Normal Brain Development• Higher moral

development & decision making

• Learns coping skills to manage difficult situations

• Utilizes effective self-regulation skills

• Can maintain emotional stability

• Can utilize rational thinking

• Understands that life is lived in the “gray” area

Interrupted Brain Development• Makes decisions at lower

level of moral development

• Limited coping skills• Uses ineffective self-

regulation skills• Responds emotionally to

situations• Often appears irrational• Lives life in either “black”

or “white” & expresses “all or nothing” thinking

Child and Adolescent Brain Development

• Allen N. Shore in his article on “The Effects of Early Relational Trauma on Right Brain Development, Affect, Regulation, and Infant Mental Health” indicates that there is a direct relationship between traumatic attachment, inefficient right brain regulatory functions and both maladaptive infant and adult mental health. (Shore, INFANT MENTAL HEALTH JOURNAL, Vol. 22(1-2), 201-269 (2001) (1)

• There is evidence that severe/chronic trauma experienced by the mother during pregnancy can adversely effect fetal brain development (Dowling, Martz, Leonard, & Zoeller, 2000). (2)

Moral Development• Moral development appears to be obstructed

when the prefrontal cortex is damaged. The prefrontal cortex appears to be linked to social awareness, and its damage leads to social difficulties.

• When prefrontal cortex lobes are damaged, impulses for anger, lust, and greed can rage out of control. Damage to the prefrontal cortex, possibly from early neglect, later abuse, or exposure to environmental stress, may result in increased displays of disorganized and impulsive behavior, poor attention, and impaired behavioral regulation (Goldberg, 2002, p.153).

Moral Development

• Children & youth with damage to the Prefrontal Cortex there is often a disconnection between knowledge and action.. There is knowledge of rules of behavior but they do not follow them and instead act ineptly with little forethought or precision (Goldberg, 2002, p.153)..

• They have lost there “inner” guide to behavior

Mental Health• When a large amount of symptoms connected to

trauma are present themselves simultaneously, a person may be diagnosed with Post-Traumatic Stress Disorder (PTSD).

• In order to be diagnosed with PTSD a person must be exposed to a traumatic event and his or her response to that event must involve intense anxiety, powerlessness or terror. These symptoms must cause significant distress or disruption in important areas of functioning like: social interaction, job or school performance, relationships and daily functioning (National Center for PTSD, 2011).

Mental Health

Three categories are evaluated or assessed in those experiencing PTSD: intrusive recollection, avoidant/numbing behavior and hyper-arousal.

•Intrusive recollection = thoughts, images or recollections of the trauma exist. These may occur as “flash backs” or hallucinations and may result in physical responses to triggers that elevate heart rate, sweating, and increased breathing.

Mental Health• Avoidant or numbing behavior = includes avoidant

thoughts, feelings, or conversations associated with the trauma. This may include avoiding certain activities, places or people that arouse recollections of the trauma; an inability to recall important aspects of the trauma, detached or estrangements from others, markedly diminished interest in activities and a restricted range of affect which may result in inability to have loving feelings, set goals and plan for the future.

• Hyper-arousal = the existence of the following conditions not present before the trauma: difficulty falling asleep, difficulty concentrating, irritability and angry outbursts. Hyper-arousal is an abnormally increased arousal or response to stimuli and a scanning of the environment for threats.

delinquency• Traumatic events which result in conduct and behavior

issues place youth at risk for increased involvement with the juvenile justice system (Ford, Chapman, Hawke & Albert, 2007).

• Trauma can compromise the ability of youth to maintain emotional stability in times of crisis or perceived crisis, and make the youth more predisposed to aggressive, violent and sociopathic behavior (Adams, 2010).

• Youth may respond to additional trauma, crisis or mistreatment by choosing coping skills bordering on indifference, defiance and aggression as means of self-protection. Unfortunately these behaviors are often the reason a youth is in the juvenile justice system.

delinquency

• In 2010 the state of Minnesota published the Minnesota Student Survey (MSS). It is a 127 item questionnaire administered every three years to 6th, 9th and 12th graders in Minnesota public schools (including juvenile correctional facilities).

• The questions reflect a range of protective factors including connectedness to school, family and community as well as risk factors such as drug and alcohol use, violence and victimization (Swayze & Buskovick, 2010).

Delinquency

• MSS 2010 data found that over half of youth in correctional facilities (YCF) reported at least one form of trauma compared with just over one-quarter of a matched sample of mainstream students (MS).

• MSS data confirm that youth in correctional facilities who report 3-6 trauma indicators are statistically more likely than youth in correctional facilities with no trauma indicators to report the following: (Swayze & Buskovick, 2010).

Delinquency

• For the years 2011-2013, youth that received both the Massachusetts Youth Screening-Second Version (MASYI-2) and Michigan Juvenile Justice Assessment System (MJJAS) at Children’s Village were found to have a correlation between the acute reported trauma experiences and higher risk scores

– The MASYI-2 is a brief screening tool used to assess immediate mental, emotional and behavior difficulties.

– The MJJAS is a fourth-generation criminogenic risk assessment assess possible future criminal behavior.

Delinquency

• Between 2011 and 2013, youth at Children’s Village who took both the MASYI and the MJJAS Residential Tool and reported 0-1 trauma experiences also had the highest instances of falling into the low risk category for recidivism.

• Youth who reported between 2-5 trauma experiences were among the highest risk group for recidivism

Delinquency

Delinquency 2010 Minnesota Student Survey – Youth reporting 3-6 Trauma

Indicators

• Lower percentage of parent caring• Family member’s drug or alcohol use as problematic• Running away from home• Higher reports of victimization at school• Higher agreement with feelings of anger, depression,

nervousness and worry, stress and hopelessness• Increased difficulty with concentration, sleep, restless and

impulsivity• Self-injurious behavior, suicidal ideation and suicide

attempts• More chemical use and at an earlier age of first use• More reports of damaging property• More reports of victimizing a dating partner

Delinquency

• Research continually demonstrates that youth involved in the juvenile justice system experience trauma at a rate significantly higher rate than the general youth population.

• Youth who are exposed to severe and cumulative stressors are strongly associated with risk-taking behavior and delinquency (Zahn & Chesney-Lind, 2010).

REDUCING THE HARMFULL EFFECTS OF TRAUMA

Risk ReductionPolicesProceduresHome EnvironmentCommunity

Risk Reduction

Reduce the Risk for Re-Traumatizing Youth

Treatment must be designed with the awareness of the kinds of experiences the youth actually faced, and must be understood through their perspective (Steel & Kuban, 2012).

Information lacking in details of the experiences associated with the trauma places youth at greater risk when determining treatment.

Risk Reduction Understand their Story

Youth & Family HistoryLearn, understand and know their storyHow does the youth & family get their

needs met

Glasser’s five needs:– Survival – this is the need for food, shelter and safety. – Love & Belonging – this is the need for relationships, social connections, to give and receive

affection and to feel a part of a group.– Power – this is the need to achieve, to be competent, to be skilled and to be recognized for

our achievements and skills. This includes the need to be listened to and have a sense of self-worth.

– Freedom – this is the need for independence, self-sufficiency, to have choices and to be able to take control of the direction of your life.

– Fun – this is the need to find enjoyment, to play and to laugh!

Understanding Their StoryFamily Genograms

RelationshipsEmotional physical abuseSubstance abusePast family traumas

Collateral InformationFamily membersTherapistsTeachersCourt workersPsychiatrist

Policies and Procedures• Organizations, Treatment providers, Community

Partners must review their policies and procedures for evidence of practices that may contribute to re-traumatizing children and youth.

• Polices & Procedures that might be detrimental to children & youth who have trauma experiences:– Imposed Exclusion (for non-safety reasons)– “Breaking youth down”– Behavioral modification only approach– Non-evidence based programs– “We are the experts”– One size fits all approach – Physical Managements/Restraints

Home environment

• Review and evaluate how the house hold is being run on a day to day basis. What are the rules? Who sets the rules? What are the consequences and are they followed through on? Where is the power located, how are decisions made and what type message is being sent? How does the family get needs met?

• After reviewing and evaluating, determine the degree that how the households daily operation may contribute to a child or youth experiencing a sense of re-traumatization. .

Community• The more communities are engaged, the more

families are motivated to see their children succeed. Community involvement must also include services that extend beyond the family home, detention or treatment facility.

• Creating a collaborative partnership with community based organizations to begin new services, continue services and treatment provided in the facility and support treatment initiatives is vital to ensure a successful transition home for youth and reduce recidivism.

Community• This partnership should include: family, friends,

neighbors, mentors, existing community organizations, new service providers, psychiatrists, medical facilities, police departments, counseling centers, faith-based organizations, court systems, educational services and employment training and opportunities.

• Benefits of ongoing community support have demonstrated: (U.S. Substance Abuse and Mental Health Services Administration, 2011):– Positive effects on self-esteem– Buffers against stress– Increased educational, material and emotional support– A denser network of support which brings more support – A network of individuals with similar characteristics which also

brings more support

TREATMENT & SAFEGUARDING

AssessmentsInterventionsSkill BuildingProtective factors

Trauma Assessments

• The initial assessment or screening for trauma is particularly important because often behaviors associated with trauma look very comparable to: common delinquent behaviors ADHD, Depression and/or Bi-polar.

• Examples of trauma assessments include:– Massachusetts Youth Screening-Second Version

(MASYI-2)– Trauma Symptom Checklist for Children (TSCC)– Traumatic Events Screening Inventory (TESI)– PTSD Reaction Index (PTSD-RI)

Trauma Assessments

• In addition to the use of formalized assessment tools, assessment must also take place through a re-telling of the youth’s story. Frequently this must be accomplished through sensory based techniques and methods.

• Neuroscience documents that youth in trauma are governed predominately by the sensations associated with their traumatic memories…the sounds, smells, sensations of touch, and visual memories (NCTIC, 2011).

TraumaAssessments

• Trauma is not a cognitive experience but rather a combination of feelings, sensations and images, iconic or symbolic memories that defy logic, reason and common sense. And because of this trauma cannot be healed through cognitive process alone; attempts to gather, process and treat trauma cannot be solely accomplished through trying to talk a youth through his or her reactions. Therefore the youth’s story must often be told through sensory based assessment techniques (Malchiodi, 2011)

• In order to fully understand and evaluate sensory responses in young clients, sensory-based methods of assessment are necessary. These can include many types of action-oriented activities, but the most widely applied involve art and play-based protocols, many of which are found in the fields of art therapy and play therapy (Malchiodi, 2011).

Risk Assessments

• For youth on the verge of entering the Juvenile Justice System In addition to the use of trauma screening assessments and instruments, youth may need to be screened for future criminogenic risk through the use of actuarial needs and risk assessments.

• Actuarial risk and needs assessments provide objective information on an individual’s risk to engage in anti-social behavior based on measurement of risk and protective factors.

Risk Assessments

• Some of these risk factors are static such as criminal history, age of first contact with juvenile justice system and biological parents. Other factors are dynamic such as attitudes toward the criminal justice system, use of social skills and peer interaction.

• Case management plans can be based on high risk areas that are identified and intervention can be targeted to reduce risk levels. Evidence demonstrates that when interventions are targeted based on risk and needs, re-offending is reduced.

Risk Assessments

Examples of criminogenic risk assessments include:

•Michigan Juvenile Justice Assessment System (MJJAS)• Level of Service Inventory Revised (LSI-R)• Pride in Delinquency – criminal thinking•How I think – criminal thinking

Interventions

The Free Dictionary defines intervention as: “an act performed to prevent harm to a patient or to

improve the mental, emotional, or physical function of a patient.” http://medical-dictionary.thefreedictionary.com/intervention

Encyclopedia of Mental Disorders defines intervention as:– “Intervention may be any outside process that

has the effect of modifying an individual's behavior, cognition, or emotional state.” Read more: http://www.minddisorders.com/Flu-Inv/Intervention.html#ixzz2vDMD5lSn

InterventionsEvidence Based Best Practice

• Evidence-based practice (EBP) usually refer to program s or practices that are proven to be successful through research methodology and have produce consistently positive patterns of results.

• Evidence-based practices or model programs that have shown the greatest levels of effectiveness are those that have established generalizability (replicated in different settings and with different populations over time) through research studies.

InterventionsEvidence Based Best Practice

• Trauma-focused EBP include: Psycho-education, caregiver involvement and support, emotional regulation skills training, anxiety management, construction of a trauma narrative and personal empowerment training. Common elements include:– Emotional identification – Processing & leaning self-regulation – Anxiety management– Identification & altercation of maladaptive thoughts– Interpersonal skills & social problem solving skills– Self-mastery

InterventionsEvidence Based Best Practice

• Cognitive-behavioral interventions have been shown to be extremely effective treatment for addressing youth who have experienced trauma and are in the juvenile justice system. Problematic thought processes are replaced with more positive, accurate or pro-social thoughts (National Alliance on Mental Illness, 2011).

• Research has demonstrated that the most effective cognitive behavioral programs are highly structured, are strength based, emphasize the development of basic skills, and provide individual counseling to address behaviors, attitudes and faulty perceptions (Mahoney, Ford, Ko & Siegfried, 2004).

interventions

• Ballion (2002) explains that this sensory treatment approach is expected to assist children with relaxation, stresses reduction, emotional regulations, cognition, therapeutic relationships, symptoms of mental illness, sensory defensiveness, and restraint reduction (as cited in Moore, 2010).

• This kind of approach exclusively uses the human body to calm the mind. Thus, “sensory can be used to help calm the nervous system, even when cognitive techniques fail” (Moore, 2010).

InterventionsEvidence Based Best Practice

• Talk therapy treatment may not fully address all the symptoms that result from trauma experiences. Neuroscience has confirmed that trauma is experienced in the midbrain and lower brain, sometimes referred to as the “feeling brain” or “survival brain.” Reason, logic, rational talk, the ability to make sense of what has happened and act accordingly are not accessible in trauma (Shore, 2001).

Interventions Sensory based EBP

• Treatment must involve sensory based therapies to include art, music, body movement, audio, aromatherapy and experiential self-regulation/control exercises. Examples of EBP include:

– Structured Sensory Interventions for Traumatized Children, Adolescents and Parents (SITCAP)

– Trauma Affect Regulation: A Guide for Education and Therapy (TARGET)

– Trauma Recovery and Empowerment Model (TREM)– Brief Eclectic Therapy– Eye-Movement Desensitization and Reprocessing

Therapy (EMDR)– Skills Training in Affective and interpersonal Regulation

(STAIR)

Interventions must include Skill-building

• Mindfulness• Emotional regulation• Anger management • Communication• Interpersonal• Character development• Decision making• Problem-solving • Self-mastery

Interventions & Environment

• Environments conducive to change create an atmosphere that is safe, structured, caring and adults models appropriate behavior and may be helpful to be centered around “The Stages of Change Model.”

• Create environments that allow the child/youth to learn, practice, practice, practice, practice, practice and practice new skills. Environments need to allow for internal-evaluation and decision making…and allow for mistake and poor decisions!

• Create Sensory-based experiences and times of FUN!

• Allow for structured & impromptu time for the child and/or family to tell their story. Create environments that set rituals and expectations (must be followed through on)

Interventions & Environment• Allow for structured & impromptu time for the

child and/or family to tell their story. Create environments that set rituals and expectations (must be followed through on)

• Consequences work best if they are logical, reasonable and moderate. Consequences are most effective if they are designed in such a way that the child/youth is given the responsibility for changing their own behavior – Compliance is not proof of a change in behavior or a

pre-curser to a reduction in recidivism – Behavioral change becomes more real if what the

child/youth wants can be tied into the process• This is a transferable skill

Protective factors

• Those factors that insulate children/youth from trauma experiences and/or give them additional support and skills needed to transitional through a trauma experience– Schools– Relationships with caring adults– Sports– Positive communities & neighborhoods– Music– Extended family– Pets– Positive peers

IMPLICATIONS FOR LONG TERM CARE

Assessing Ongoing NeedsCommunity Outcome Evaluation

Assessing ongoing needs

• For youth removed for the community or for youth entering foster care, begin planning for reentry or aftercare from the start. – Exit upon Entry

• Assess strengths, needs, risks and barriers of youth and family to get an accurate picture of what is need in the community and who to partner with

• Continue to foster community relationships and educate the community

Assessing ongoing needs

•Staff & Community Training

–On-going training opportunities for staff and community partners regarding trauma exposure, strategies & interventions, maintenance and relapse

–Web-based education and training materials for use with youth, parents, community-based and government agencies

– Funding for sensory-based clinical training, materials and building space

community• The implementation of long range care planning

requires collaborative organizational partnerships with community service providers.

• ROCA’s 2009 report titled “Saving Young People with Interventions” points out that collaboration is vital in ensuring that young people living in harm’s way are supported as they try to change.

• Collaborations serve many purposes. They ensure that someone is “out there” at all times and surround young people so when things are out of their control; the strengths of the community can compliment and support families.

Community

•ROCA suggests that there are seven beneficial outcomes associated with community collaboration:

– Helps share risk– Improves knowledge– Information sharing– Keeps the message consistent– Shows young people how to work together– Allows for “give & take” among community members– Collaborative decision making leads to better

decisions

Outcome Evaluation

Outcome Data Throughout Treatment

– Develop a model of screening and assessment that evaluates outcomes for youth in all three stages of residential treatment and into the home:• Placement

– Intake, Detention, Residential Treatment and alternative placement

• Programming & Interventions• Re-entry into the community, remaining in home

and alternative placement

• How do we know things are improving?

• Information sharing– Review community and governmental

agencies’ policies and procedures for practices that may hinder healing opportunities or re-traumatize youth

– Case management system that allows community organizations & governmental agencies to share information without duplication of services