Trauma-Informed Care: Effects of Childhood Trauma on the Family and Adulthood

Transcription

1 Trauma-Informed Care: Effects of Childhood Trauma on the Family and Adulthood Karen Mallah, Senior Director, Quality Management August 3, 2016 Presentation Goals Review types of traumatic/adverse/stressful experiences that can affect: Children and youth Caregivers/adults Families Review effects/responses following those experiences Discuss ways to incorporate this information into treatment that facilitates resilience and recovery 2

2 Types of Childhood Trauma Physical abuse Sexual abuse Emotional abuse Physical neglect Emotional neglect Domestic violence exposure Community violence exposure (including criminal victimization) Medical trauma/illness Traumatic loss Accidents/fires Natural disasters War/combat 3 Adverse Childhood Experiences Growing up with: Family member who had mental health challenges Family member who had substance use challenges Family member who spent time in a correctional facility Parents who separated or divorced Exposure to domestic violence Physical abuse Emotional abuse Sexual abuse 4

3 Historical/Multigenerational Trauma Legacy of oppression Slavery Genocide Forced relocation Institutionalization Institutional racism Housing discrimination Educational discrimination/inequity Health disparities/history of experimentation Justice system inequities Child protection/service system differences 5 Cultural and Environmental Stress Racism Microaggressions/prejudice Stereotyping/invisibility syndrome Profiling/discrimination Immigration stress Language Loss Guilt Chronic anxiety Acculturation Decreased feelings of selfworth Decreased hope Poverty Increased trauma risk 6

4 NCTSN Core Concepts 1. Traumatic experiences are inherently complex 2. Trauma occurs within a broad context that includes children s personal characteristics, life experiences, and current circumstances 3. Traumatic events often generate secondary adversities, life changes, and distressing reminders in children s daily lives 4. Children can exhibit a wide range of reactions to trauma and loss 5. Danger and safety are core concerns in the lives of traumatized children 6. Traumatic experiences affect the family and broader caregiver systems 7 NCTSN Core Concepts 7. Protective and promotive factors can reduce the adverse impact of trauma 8. Trauma and post-trauma adversities can strongly influence development 9. Developmental neurobiology underlies children s reactions to traumatic experiences 10. Culture is closely interwoven with traumatic experiences, response, and recovery 11. Challenges to the social contract, including legal and ethical issues, affect trauma response and recovery 12. Working with trauma-exposed children can evoke distress in providers that makes it more difficult for them to provide good care 8

5 Trauma and the Child Children who have experienced trauma feel: Fear/terror Guilt/shame Sadness Anxiety Anger Alterations in their views of self, others, society Hopelessness 9 Trauma and the Child Young children who have experienced trauma may show: Behavioral regression Sleep problems Separation anxiety Generalized fears Stranger anxiety Rigid, repetitive posttraumatic play Preoccupation with trauma-related words, items, symbols 10

6 Trauma and the Child Latency-aged children who have experienced trauma may show: Sleep problems Problems with concentration and learning Somatization Over reactive or aggressive behavior Impulsive or reckless behavior Inaccurate recall of the traumatic event Beliefs/omens/superstitions about the trauma Compulsive, repetitive posttraumatic play, drawings, writing 11 Trauma and the Child Adolescents who have experienced trauma may show: Posttraumatic behavioral reenactment Withdrawal Concern about others perceptions Revenge fantasies Self-destructive behaviors Substance use Accident-prone behaviors Impulsivity/aggression 12

7 Frequent Diagnoses Given Anxiety Disorders (Separation Anxiety, Social Phobia, Specific Phobia) Externalizing Behavior Disorders (ADHD, Conduct, ODD) Thought/Psychotic Disorders Mood Disorders (Depression, Bipolar, Schizoaffective) Personality Disorders (Borderline, Antisocial) Substance Use Disorders 13 Trauma-Specific Diagnoses Acute Stress Disorder Posttraumatic Stress Disorder (PTSD) Dissociative Disorders Complex PTSD, Developmental Trauma Disorder Clinical frameworks for treatment planning, not in DSM Due to early adversity (insecure attachment, multiple placements), family abandonment, interpersonal trauma/maltreatment and/or other history of multiple/chronic trauma Diagnosis guides assessment, treatment, conceptualization and sometimes hopefulness about change 14

8 Complex PTSD Can affect multiple domains including: Attachment Biology Affect Regulation Dissociation Behavioral Regulation Cognition Self-concept 15 Attachment Uncertainty about reliability/predictability Problems with boundaries Distrust and suspiciousness Social isolation Interpersonal difficulties Difficulty attuning to other s emotions Difficulty with perspective taking Difficulty enlisting other people as allies 16

9 Biology Sensorimotor development problems Hypersensitivity to physical contact Analgesia (numb to pain) Problems with coordination, balance, body tone Somatization Increased medical problems 17 Affect Regulation Difficulty with emotion regulation Difficulty describing feelings and internal experience Problems knowing and describing internal states Difficulty communicating wishes and desires 18

10 Dissociation Distinct alterations in states of consciousness Amnesia Depersonalization and derealization Two or more distinct states of consciousness with impaired memory for state-based events 19 Behavioral Regulation Poor modulation of impulses Self-destructive behavior Aggression against others Inappropriate self-soothing behavior Sleep disturbance Eating disorders Substance use Excessive compliance Oppositional behavior Difficulty understanding and complying with rules Trauma reenactment in day-to-day behavior or play 20

11 Cognition Difficulties in attention regulation and executive functioning Lack of sustained curiosity Problems with processing novel information Problems focusing on and completing tasks Problems with object constancy Difficulty planning and anticipating Problems understanding own contribution to situations Learning difficulties Problems with language development Problems with orientation in space and time Acoustic and visual perceptual problems Impaired comprehension of complex visual-spatial patterns 21 Self-concept Lack of a continuous, predictable sense of self Poor sense of separateness Disturbances of body image Low self-esteem Shame Guilt 22

12 Trauma and the Family: Siblings Event(s) may also be traumatic for sibling(s) Domestic violence Traumatic death Natural disaster Community violence Accident/illness: siblings may experience vicarious trauma symptoms May trigger trauma reactions in siblings Sibling may have similar traumatic history Sibling(s) may develop vicarious trauma including fear/anxiety Siblings may feel responsible or overprotective Exacerbation of environmental and/or cultural stressors 23 Trauma and the Family: System Parenting may change More lenient due to guilt Stricter due to fear/anxiety Increased parental vigilance/decreased child independence Changed/curtailed family activities/plans May strain parents relationship May strain sibling relationship(s) May strain relationships with extended family or community supports May decrease family hopefulness for the future Family resources may be limited and/or strained due to needs/expenses following traumatic event(s) Exacerbation of environmental and/or cultural stressors 24

13 Trauma and the Family: Caregivers Event(s) may be traumatic for caregiver/adult as well Domestic violence Traumatic death Natural disaster Community violence Accident/illness Caregiver/adult stress may rise Caregiver/adult coping skills may decrease May trigger trauma reactions in adult/caregiver(s) Parent may have similar traumatic history Long terms physical and behavioral health effects Exacerbation of environmental and/or cultural stressors 25 The ACE Study (Anda & Filetti) 26

14 Resilience in the Face of Trauma Positive attachment/connections with supportive, competent adults Cognitive mastery skills Effective self-regulation and coping skills Positive beliefs about self Sociability Easy going, positive temperament Internal locus of control and external attributions for blame Special talents, creativity, spirituality 27 Components of Trauma Treatment Establish safety Teach/increase self-regulation/coping skills Establish/increase sense of personal narrative Processing/integration of the trauma through gradual exposure and re-interpretation/new understanding Building on strengths, resiliency, and new learning Preparing for the future 28

15 Family Trauma Treatment Promote safety for all family members and prevent exposure to further traumas (help family create safety/crisis plan) Encourage use of natural, cultural, spiritual supports Link families to relevant community resources and services Comprehensive assessments to determine individual treatment needs Facilitate family discussion and education about the traumatic event(s) and their effects Strengthen/rebuild family relationships Strengthen/rebuild family structures and roles 29 Culture and Trauma Culture is a system of shared beliefs, values, customs, behaviors, and artifacts that the members of a society use to cope with their world and with one another, and that are transmitted from generation to generation through learning (Bates and Plog, 1990) 30

16 Cultural Considerations Cultural differences within a family Deaf, hard of hearing and hearing children of Deaf adults (CODAs) Children of immigrants Interracial adoptees LGBT youth 31 Cultural Considerations Language needs for treatment What language Would each family member prefer? Does the youth use with peers/at school? Is used between various family members? How well do the family member communicate? Emotional vs. Functional language 32

17 Cultural Considerations Chronic cultural stressors Widening cultural gap within the family Assimilation with peers Effects of prejudice, oppression, racism, stigmatization and social misunderstandings Stress/learning of bicultural roles Role shifts within the family Decreased incidental learning Communicative isolation Decreased access to services/supports 33 Cultural Considerations Increased risk of trauma Deaf: higher risk and incidents of maltreatment and crime victimization Immigrants/Refugees: survivors of war, violence, poverty, migration trauma, loss Language barriers increase vulnerability and decrease support seeking Paucity of culturally/language-adapted safety or abuse prevention curricula 34

18 Increasing Cultural Connection Meet individual language needs Explain your role and obligations; what you are not obligated to do Acknowledge, value and discuss cultural differences Understand or learn about the culturally-specific historical trauma Acknowledge and validate cultural and environmental stressors Explore culturally-specific and family-driven understandings of trauma and the child s specific challenges Encourage culturally-based connections and supports Use culturally-specific role models in trauma treatment work 35 References National Child Traumatic Stress Network Information re: Adverse Childhood Experiences National Center for Traumatic Stress 36