Trauma Informed Care
If you need immediate assistance, the following resources are available.
Resources about Child Traumatic Grief are also available:
If your child has symptoms such as sleep disturbances, regressive behaviors (i.e. bedwetting, thumbsucking, difficulties with separation from caregivers), or continued re-enactment of the trauma through play that last weeks or months after the tragedy and interfere with everyday activities, you may wish to contact one of the sixteen clinics listed below. Each clinic has a team of trained clinicians who can provide a specialized trauma assessment to determine whether or not your child may be experiencing a traumatic stress reaction and need further specialized, effective trauma treatment, such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).
TF-CBT is a clinic-based, short-term treatment (16 to 20 sessions) for children, ages 4 to 18 who have significant behavioral and emotional problems that are related to traumatic life events, even if they do not meet full diagnostic criteria for post traumatic stress disorder (PTDS). TF-CBT is an evidence-based model of psychotherapy that combines trauma-sensitive interventions with cognitive behavioral therapy. Individual sessions with the child and parent as well as joint parent-child sessions are provided. Treatment results in significant reduction in PTSD and depressive symptoms.
The clinics listed below have clinicians and supervisors who have completed the extensive training for TF-CBT through the TF-CBT Learning Collaborative, funded by the Connecticut Department of Children and Families and directed by the Connecticut Center for Effective Practice, in partnership with the National Child Traumatic Stress Network.
Children who receive DCF services have typically experienced or been exposed to traumatic events such as physical abuse, sexual abuse, chronic neglect, sudden or violent loss of or separation from a loved one, domestic violence, and/or community violence. Often these children have emotional, behavioral, social and mental health challenges that require special care and treatment. This has significant implications for the delivery of services.
Trauma awareness is acknowledging the presence of trauma symptoms in individuals with histories of trauma and understanding the role that trauma has played in their lives. Trauma-informed care is an overarching framework, which incorporates trauma awareness and guides general practice with children and families who have been impacted by trauma. The trauma-informed care system must promote healing environments and prevent re-traumatization by embracing "key" trauma-informed principles of safety, trust, collaboration, choice, and empowerment. In addition, trauma-informed care systems require the availability of evidence-based trauma-specific services and treatments for individuals with trauma histories.
The DCF workforce must be both trauma-aware and trauma-informed to address the multiple challenges that traumatized children and their families bring with them when they enter the system. A trauma aware and trauma-informed workforce seeks to change the paradigm from one that asks, "what's wrong with you?" to one that asks, "what has happened to you?"
Understanding Child Trauma
Trauma occurs when a child experiences an intense event that harms or threatens harm to the child's physical or emotional well-being or to someone close to the child such as another family member or a friend. Typically, this is an extraordinarily frightening event that overwhelms the child with feelings of terror and helplessness.
Some examples of traumatic events are: physical abuse, sexual abuse, emotional abuse/psychological maltreatment, neglect, domestic violence, traumatic loss or separation from a loved one or bereavement, experiencing or witnessing violence in schools or neighborhoods, serious accidental injury/accident, serious illness/medical conditions, forced displacement such as loss of home or recent immigration, being exposed to a natural disaster such as a hurricane or flood, or exposed to events such as war, terrorism or political violence. Prolonged exposure to traumatic events may result in a toxic stress response.
As a general rule, traumatic events overwhelm a child's capacity to cope and often result in intense emotional and physical reactions, referred to as Child Traumatic Stress.
Physical reactions may include:
Emotional reactions may include:
Other Child Traumatic Stress symptoms and indicators may include depression anxiety, dissociation, substance abuse, self-injury, suicide, attachment/relationship challenges, and school problems.
Sometimes children will re-experience these intense and disturbing feelings that are tied to the original trauma if they are reminded of any person, situation, sensation, feeling or thing that reminds the child of a traumatic event. These are referred to as Traumatic Reminders or Triggers. An example is an anniversary date that may serve as a strong reminder. A child may not be consciously aware of having been reminded, therefore it is important for caregivers and DCF staff to help a child recognize and learn to cope with the reminders.
In addition, children may develop adaptive responses at the time of the trauma, such as dissociation (i.e. feeling outside of their body or feeling that an actual event is not real) in order to cope with what is happening. Unfortunately, these responses may become permanent, continuing long after the traumatic event is over and interrupting healthy development.
Some, but not all children who experience a single significant trauma or chronic, severe, and interpersonal trauma (i.e. trauma perpetrated by a family member or someone close to the child who should be a protecting adult) may develop a Post Traumatic Stress Disorder (PTSD). This is a psychiatric condition characterized by specific symptoms that include:
Re-experiencing the event through nightmares, flashbacks (which may include auditory hallucinations), or other symptoms for more than a month after the original experience;
Avoidance and fear including not thinking about the event or having memory lapses, or new fears such as separation, being alone, or darkness;
Increased arousal such as nightmares, difficulty falling asleep or staying asleep, decreased attention or concentration, hyperactivity, irritability and mood changes, increased aggression, or hyper vigilance and easily startled; and
Decreased responsiveness, numbing, and regression such as less interest in play or normal activities, social withdrawal, or peer difficulties.
A child's reaction to trauma can impact him or her in many ways. While some children "bounce back" after adversity, for many children traumatic experiences can result in a significant disruption of child or adolescent development and have profound long-term consequences. Repeated exposure to traumatic events can affect the child's brain and nervous system and increase the risk of difficulties at school, engagement in high-risk behaviors, health problems and difficulties in peer and family relationships.
Each child's reaction to traumatic experiences differs. Not every child who experiences a traumatic event will develop symptoms of child traumatic stress. Whether or not the child does depends on a range of factors. These can include the child's age and developmental state (although children of ANY age can be impacted by a traumatic event), his or her history of previous trauma exposure, the child's mental and emotional strengths and what kind of support the child has at home and in the community. (For information on impact of trauma by ages and developmental stages, see the NCTSN website at: www.nctsnet.org/content/ages-and-developmental-stages-symptoms-exposure )
Traumatic experiences can impair a child's ability to function each day in the following ways.
- Brain development - When children experience excessive stress for too long, too often, or too severely, the way brain cells connect and the way they influence each other may be altered. These biological effects interfere with critical brain functions such as focusing, learning, self-regulation and decision-making.
- High Cortisol - Research has found that abused and neglected children have abnormally high levels of cortisol, even after they are removed from maltreating caregivers and placed in a safe environment. Cortisol is a hormone associated with the stress response, emotion and memory. Children may become stuck in a "fight, flee or freeze" response pattern.
- Attachment - When the caregiver who is supposed to provide protection and safety is the source of hurt and harm, the child feels helpless and abandoned and views the world as an uncertain, unpredictable place. The child may be unable to trust and empathize with others, regulate emotions, and manage stress.
- Emotional Regulation - Children may have difficulty identifying and describing their feelings and internal states. They may be unable to express emotions safely and to adjust or "regulate" internal experiences. For example, some children may appear quite, withdrawn, and unexpressive, whereas other children may show angry outbursts and aggression. Some children may be unable to calm themselves when they are upset, to soothe themselves, to interact in appropriate ways with other people, and to learn from their behaviors Children may not understand why they are acting in this way, particularly if they do so while re-experiencing or re-enacting traumatic events.
- Behavioral Regulation - Children may present with problematic behaviors relating to the trauma (e.g. aggression, self-injurious or sexualized behaviors), and these behaviors may serve as survival adaptations to overwhelming stress.
- Cognition (Learning and School Performance) - Children may experience delays in language development, deficits in overall IQ, learning disorders, difficulty concentrating and completing tasks, failure to learn from past experiences, and an inability to anticipate and prepare for future events. These children are at risk for low academic performance, school drop-out, and later employment problems.
- Self-Concept - Maltreated children develop a sense of self as ineffective, helpless, deficient, and unlovable. Children who perceive themselves as powerless may blame themselves for negative experiences and feel a sense of shame and guilt.
- Social development - Traumatized children may have poor social skills, fail to establish and maintain friendships, engage in unhealthy relationships, and become socially isolated.
Survivors of repeated and severe childhood trauma generally experience a common set of problems as adults when they do not receive effective treatment. A decade-long scientific study, known as the Adverse Childhood Experiences Study (ACE Study - www.acestudy.org
) found that these problems are serious and life altering including increased suicidal attempts and other mental health disorders, promiscuity, use of street drugs, heavy alcohol consumption, intractable smoking, and physical health problems such as diabetes, hypertension, obesity, strokes, heart disease, certain forms of cancer, chronic lung disease, and liver disease.
Many birth parents have their own histories of child and/or adult trauma. As described above, traumatic stress in childhood can impact the parent's ability to regulate emotion, maintain physical and mental health, engage in relationships, parent effectively, and maintain family stability. Parents past or present experiences of trauma can also affect their ability to keep their children safe, work effectively with child welfare or juvenile justice staff, and engage in their own or their children's mental health treatment. First and foremost, DCF staff (especially the child welfare worker) must determine that the child and caregiver are safe, prior to referring for trauma-specific assessment and/or treatment.
Effective Treatments for Child Traumatic Stress
There is good news. Traumatic stress in children is treatable and there are highly effective treatments available to help children and their families. There are different types of interventions that focus on acute (immediately following trauma), trauma-specific treatment (short-term and long-term) and intensive (in home, residential, hospital.)
Treatments that research shows can reduce child traumatic stress are called “evidence-based treatments." One of these evidence-based treatments available in Connecticut is called, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). TF-CBT is a 16-20 session treatment model for children. TF-CBT targets children ages 4-21 and their caregivers who have experienced a significant traumatic event and are experiencing chronic symptoms related to the exposure to the trauma. TF-CBT is a time limited intervention, which usually lasts five to six months and involves outpatient sessions with both the child and caregiver. There has been strong evidence to support its ability in reducing symptoms of Post-Traumatic Stress Disorder (PTSD) and depression in both children and their caregivers. The intervention is a manualized, phased intervention that helps the child develop and enhance their ability to cope with and regulate their responses to troubling memories, sensations and experiences. Over time, through the course of treatment, the child develops a trauma narrative that helps them tell their story in a safe, supportive setting.
Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-CBT) (http://tfcbt.musc.edu)
TG-CBT is an adaptation of TF-CBT for children and teens aged 6-18 who have experienced childhood traumatic grief through the loss of a loved one. TG-CBT involves the same steps as TF-CBT with additional sessions focused specifically on working through the grieving process in a healthy manner with both the child and the caregiver.
Alternatives for Families Cognitive Behavioral Therapy (AF-CBT) ( www.afcbt.org)
AF-CBT is an intervention that targets individual child and parent characteristics related to the abusive experience and the family context in which abuse or aggression occurs. This approach emphasizes training in interpersonal skills designed to build self-control and reduce violent behavior. During AF-CBT, school-aged children and parents (or caretakers) participate in separate but coordinated therapy sessions, often using parallel treatment materials. In addition, children and parents attend sessions together at different times throughout treatment. This approach tries to address individual and parent-child issues in an integrated way.
Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment approach with two key components: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. "Dialectical" refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) skills training; (2) individual behavioral treatment plans; (3) access to a therapist outside a clinical setting, homework, and inclusion of family in treatment; (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) therapist team consultation group. DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual.
EMDR is a form of psychotherapy that uses a structured eight-phase approach to address the past, present, and future aspects of a traumatic or distressing memory that has been stored in the mind of the victim as a dysfunctional memory. The goal of EMDR therapy is to process these distressing memories, reducing their lingering influence and allowing clients to develop effective coping mechanisms.
CFTSI is a 4-6 session preventative model for children aged 7-18 in the days and weeks following a traumatic event or disclosure of a past traumatic event. The goals of CFTSI are to reduce traumatic stress symptoms, increase caregiver and child communication, provide skills for the child to cope with trauma reactions, reduce other external stressors on the child and assess the child's need for longer-term treatment. Currently this treatment is offered at the Yale Child Study Center in New Haven
PCIT is a parent-child treatment program that helps parents of children aged 2-7 years old with behavioral problems (aggression, non-compliance, defiance, and temper tantrums). PCIT focuses on promoting positive parent-child relationships and interactions while teaching parents effective child management skills. PCIT has been adapted as an intervention for many different types of families (child welfare population, at-risk families, adoptive families, foster families, and other languages including Spanish and Chinese).
Child FIRST is an innovative evidence-based model which effectively decreases emotional and behavioral problems, developmental and learning problems, and abuse and neglect among very vulnerable young children (prenatal through age six years) and families. Child FIRST directly addresses these risks through 1) comprehensive, integrated services and supports to the whole family, which decreases risk and increases the capacity of the parent to nurture and support the child, and 2) home-based, parent-child intervention, which builds the nurturing relationship, protects the developing brain and optimizes child emotional development, learning, and health. The effectiveness of the Child FIRST model has been rigorously researched through a randomized clinical trial, demonstrating markedly improved outcomes in child mental health and language, parental stress and depression, protective service involvement, and access to community-based services.
Drama therapy is the intentional use of drama and/or theater processes to achieve therapeutic goals and facilitate personal growth. CANY groups support the safe exploration of feelings and thoughts, build self-esteem increasing cooperation and peaceful conflict resolution as well as foster creative self-expression in an appropriate and empowering way. Groups focus on helping young participants give voice to their unique life experience, exploring their needs, both now and in the future, striving to help them feel both heard and seen. This approach provides clients with the chance to tell their stories, set goals, solve problems, express feelings, achieve insight and develop life skills.
Other interventions to Help Children who are Victims of Trauma:
- Provide support so that the child and family feel safe and secure
- Advocate a supportive role by caregivers and others
- Maintain healthy relationships with the child's primary caregivers and other close relatives/friends
- Reduce unnecessary secondary exposures & separations
- Help the child to return to typical routines (such as school) as soon as possible
- Facilitate open but not forced communication with the child about his/her reactions to the traumatic event
- Focus on constructive responses
- Explain to child in developmentally appropriate terms
- Encourage and support help-seeking behaviors
- Create a supportive milieu for the spectrum of reactions and different courses of recovery
- Monitor and/or refer child for a clinical trauma evaluation
Essential Elements of a Trauma-Informed Child Welfare System
One of the Department's six cross-cutting themes is Trauma-Informed Practice. This means delivering services to children and families with an understanding of the impact that trauma can have on their lives and using interpersonal skills to ensure that our work is supportive of trauma recovery and not re-traumatizing. It requires a partnership with all those involved with the child (caregivers, providers and other stakeholders), using the best available science, to facilitate and support the recovery and resiliency of the child and family. Trauma-informed practice aligns closely with principles already in practice by DCF staff. Reflective of DCF's Strengthening Families Practice Model and the six Principles of Partnership, trauma-informed child welfare practice emphasizes the development of family-focused, strengths-based relationships with families to ensure the safety and well-being of their children. The integration of trauma awareness into this practice underscores DCF's commitment to trauma-informed care as one of the department's six cross cutting themes.
- Maximize the child's and family's sense of physical and psychological safety - Children need to be and feel physically and psychologically safe. To be and feel safe, children need consistency, predictability, and nurturing, safe environments and caregivers. It is important to identify and understand both potential and perceived threats to safety, including trauma triggers that a child or parent may experience and to assure that the caregivers have tools to manage triggers and help children feel safe.
Content Last Modified on 9/9/2016 10:40:56 AM