Beyond Trauma Basics: Being Prepared to Assess and Meet Children’s Needs

1. Beyond Trauma Basics:Being Prepared to Assess and Meet Children’s Needs Presented by Amanda K. Janner, Psy.D. Psychological Affiliates, Inc. February 20, 2019

2. Objectives • Define trauma, trauma-informed care, and treatment interventions • Explore cognitive development and implications for working with children of various ages • Discuss children’s testimony – the 4 W’s • Explore motivation for children’s expressed wishes (e.g., returning to their parents’ care)

3. What does it mean to be trauma informed?

4. Foundational Steps • Building awareness • https://www.traumainformedcare.chcs.org/trauma-informed-care-in-action/ • Incorporate trauma trainings regularly • Supporting a culture of staff wellness • Acknowledge and understand concepts like vicarious trauma and compassion fatigue • Recruiting a workforce that embodies values of trauma-informed care • Creating a safe physical, social, and emotional environment • Assess the individual’s needs

5. Key Principles • Safety – what does it mean to that child • Trustworthiness and transparency • Peer support – debrief when needed • Collaboration and Mutuality • Empowerment, voice, and choice • Cultural, historical, and gender issues – what else about this child’s experience of the world is at play?

6. Key Assumptions • Realization – understand how trauma can affect families and groups as well as individuals • Recognize – know the signs of trauma; may be gender, age, or setting-specific • Respond – promote a culture based on beliefs about resilience, recovery, and healing from trauma • Traumatic growth – positive learning from the experience • Resist re-traumatization – avoid recreating the environment that was initially traumatic

7. Trauma • Defined as the sum of the event, how it is experienced, and its effect on a person • Witness or experience actual or threatened death or serious injury • Adverse experiences do not automatically equate to trauma • 3 E’s – Event(s), Experience, Effect • Caution – vicarious trauma and need for self-care • Viewing self as not just a witness but a participant in the system

8. ACE Studies • 4 or more adverse experiences increases likelihood of medical and psychological issues in adulthood

9. Topics for Consideration • Assessing family dynamics – who is involved in the family and what is their role • Identifying all forms of maltreatment • Determine the child’s baseline of functioning – children with special needs are more vulnerable to abuse and neglect • Attachment prior to DCF involvement • Culture/social

10. Factors to Consider • Length of Dependency Cases • Children’s age – cognitive development, expressive and receptive language skills • Family’s prior DCF involvement • Type and number of professionals involved • General legal knowledge • Children are more likely to convey traumatic memories through play

11. Treatment • Critical incident stress debriefing • Play therapy • Cognitive-behavioral therapy • Trauma-informed therapy • Narrative therapy • Medication Resource: SAMHSA

12. Stats • Rates of physical, sexual, and psychological abuse declined most since 2000, less so with neglect. • In 2014, more than 1500 children died from abuse or neglect. • Women who are survivors of childhood abuse are twice as likely to be victims of physical assault. • Younger children (3 and under) are more likely to be victims of maltreatment.

13. Reactions to Trauma • Mood symptoms – depression, irritability • Anxiety – varies in degrees • Aggression/defiance • Substance use • Somatic complaints • Emotional dysregulation • Disrupted attachments • Behavioral regression • Suicidal ideation/self-harm

14. Cognitive Development Piaget studied how children acquire knowledge • Schema – cognitive structures used to interpret experiences • Organization – combining existing schemas with new, more complex ones • Adaptation – process of adjusting to the environment • Assimilation – interpreting new experiences in terms of existing schemas • Accommodation – modifying existing schema to better fit new experiences

15. Stages • Sensorimotor – birth to 2 years, learn by interacting with the environment, object permanence, attachment • Preoperational – 2-7 years old, egocentric, think symbolically (pretend play) • Concrete Operational – 7-11 years old, begin using reasoning although still concrete and literal • Formal Operational – 12 and up, abstract thought, deductive logic

16. Why do they want to return? • Strength of early attachment – Harlow’s monkeys clinging to surrogate despite unpleasant results • Norepinephrine is released in massive amounts at birth and during bonding with the mother as well as when in pain • Infant brain wired for survival – presence of the mother suppresses activity of amygdala (involved in emotionally charged memories) and do not release stress hormone corticosterone • Epigenetics – influence of outside-world factors on genes explains why effects of abuse aren’t seen until adolescence and may explain why they become abusers

18. To Testify or Not To Testify Considerations for Involving your child in court proceedings

19. Can/Should the Child Testify? • Conceptualize it like a criminal competency • Assess language skills • Consider suggestibility • Cognitive ability • Accuracy of recall • Family dynamics

20. The key to good testimony is anxiety management. Confrontation with the alleged abuser and adversarial nature of cross-examination can significantly interfere with the child’s memory and capability to accurately and effectively testify.

21. Qualitative Research • 54% of children in the study did not know the outcome after Court regarding placement • 37% did not feel listened to or believed in Court • 61% indicated feeling positive about seeing their parent (s) • 75% reported not hearing new information about their family

22. Knowledge • With age, knowledge improves significantly • Greater contact with the legal system does not improve knowledge • Children have difficulty applying general legal knowledge to specific situations • Maltreated children are more likely to be cognitively delayed • Gaps in knowledge remain until at least early adolescence

23. More Knowledge • Attorneys surveyed about children’s understanding consistently over estimated older children’s understanding • Children need assistance understanding decisions made on their behalf throughout the process Remember: Knowledge is power!

24. Child Factors • Younger children (5-6 years old) can define more general terms (i.e. role of the Judge) • Children as old as 12 may get confused about more legalese (petition, competence, motion) • Lack understanding of the roles of the professionals • Developmental constraints • Attitude toward Court/testifying

25. Older Children • Have more negative reaction to Court • Are treated more harshly • Have a better appreciation of the shame and guilt associated with the dependency system • Can foresee the possibility of permanent separation from parents

27. Estimated 100,000 children testify a year • 6 million children referred to CPS in 2010 • 78% of maltreatment cases involved neglect so testimony from the child was not needed • Offers the opportunity to regain control • Sense of empowerment • Feeling of retribution for abuse

28. Distress • Children are more anxious when they do not know what will happen to them • Benefits of education are seen in children as young as 4 • Better when given information directly relevant to their experiences – give them a context • Greater distress negatively impacts communication skills • Attending to emotions and attempting to regulate them distract from understanding the proceedings

30. Maslow’s Hierarchy of Needs

31. Talking to Kids Let’s play! • Set the stage - safety • Engage them in an activity - rapport

32. Guidelines for Questions • Open-ended • Triggers recall memory • Focused or Direct • Recognition memory • Should only include information the child provided • Forced Choice • Minimize new information, provide alternatives • Avoid tag questions – highly suggestive

33. Suggestions • Encourage truthfulness • Minimize your authority – acceptable to say “I don’t know” or “I don’t remember” • Get an idea of their language development • Younger children don’t understand prepositions as well • Limit “how” and “why” questions to older children • Resource: Washington State Child Interview Guide

34. Disclosures • Most disclosure begin with a friend • 30-80% do not purposefully disclose • Studies found a mean delay of 3 to 18 years • Assess for points in time when contamination may have occurred • Look for consistency and possible explanations for a lack thereof • Remain as neutral as possible

35. The more closely related to the perpetrator the less likely to disclose • Disclosures may be inhibited in families whose cultures hold taboos and negative attitudes toward sexuality and place a premium on preservation on family • Obedience to authority and discouragement of discussing family matters are deterrents

36. Recantation • 25% recantation rate in corroborated cases • Influenced by: • Child’s age • Caregiver supportiveness of recantation • Family (other than non-offender) belief • Child placement – more likely if remain in home where disclosed vs. foster care • Visitation with the alleged perpetrator

37. Supporting Coping • Comfort objects • Testimony in Chambers • Emotional support animals • Therapist present • Building resiliency • Consider grief process

38. Interventions • Education • Reframing • Relaxation skills • Explore experience of self and the world in general • Active listening • Validation and support of emotions • Normalize • Refocus on more productive thinking

39. Testimony Anxiety • Facing the parents • Not knowing where they will be staying • Embarrassment about crying or not knowing answer • Postponements • Testifying more than once associated with long-term mental health issues • Testifying about more severe abuse had higher levels of trauma-related problems

40. Assessing Emotional Abuse

41. APSAC Definition • Most common type of abuse because it is embedded in other forms of maltreatment • Psychological maltreatment: • A symbolic, sometimes verbal, communication • Affects the thoughts and feeling the child has in response to abuse or neglect • Child then interprets actions, which shapes efforts to have their needs met • Includes acts of commission and omission • Psychological maltreatment: “A repeated pattern or extreme incident(s) of caretaker behavior that thwart the child’s basic psychological needs (e.g., safety, socialization, emotional and social support, cognitive stimulation, respect) and convey a child is worthless, defective, damaged goods, unloved, unwanted, endangered, primarily useful in meeting another’s needs, and/or expendable.”

42. Forms • Spurning – belittling, degrading • Exploiting/Corrupting – encourages inappropriate behaviors and attitudes • Terrorizing – threatens, willing to place child, child’s loved ones, or objects in danger • Emotional Unresponsiveness – ignoring child’s attempts and needs to interact • Isolating – denying opportunities to meet needs for interacting with others • Mental Health, Medical, and Educational Neglect

43. Effects • Intrapersonal problems – anxiety, depression, negative self-concept • Emotional – instability, substance use, eating disorders • Social competency – lack of empathy, isolation, dependency, aggression • Learning problems – lower achievement, non-compliance, lack of impulse control • Physical – risky behaviors, asthma, allergies

44. Assessing Severity • Intensity/extremeness, frequency, and chronicity of caregiver behavior • Degree to which PM pervades the caregiver-child relationship • Number of forms perpetrated • Influences that may mitigate effects (caregiver nurtures too) • Salience of the maltreatment based on development • Extent to which negative development outcomes exist, are developing, or are likely

45. Aspects to Consider • Caregiver-child relationship – observations, interviews, records • Child characteristics – deviation in functioning • Caregiver competencies and risk factors – childcare views, resources, stressors • Social/Cultural context

47. Building Resilience • Involves a conscious effort to move forward in an insightful, integrated, and positive manner • Making meaning out of experiences – gives a sense of hope despite the apparent chaos • Effort to sustain dignity rather than alleviate misery • An individual’s resilience is highly dependent on intervention at multiple levels

48. Questions?