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Complex Trauma and Children Exposed To Domestic Violence. How innocent lives are shaped by disrupted beginnings. Phil Wells. My Hopes and Dreams (What I think you can get out of this workshop).

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complex trauma and children exposed to domestic violence

Complex Trauma and Children Exposed To Domestic Violence

How innocent lives are shaped by disrupted beginnings

Phil Wells

my hopes and dreams what i think you can get out of this workshop
My Hopes and Dreams (What I think you can get out of this workshop).

An informed discussion of trauma, complex trauma and traumatic stress as well as the effects on children exposed to Domestic Violence.

Understanding and accepting the responsibility of our role as interventionist, clinician, healer and human being.

Validation of all our efforts to help kids and families lead less hectic lives.

trauma informed services
Trauma Informed Services

Trauma-informed services are not designed to treat symptoms or syndromes related to abuse or trauma. Instead, the primary purpose is to deliver mental health, and other services, etc., in a manner that acknowledges the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services.

what trauma survivors need to know jane middelton moz
What trauma survivors need to KnowJane Middelton-Moz
  • What happened to you is not normal, but you are normal
  • Healing takes time, be good to yourself
  • You survived the experience and you have many strengths
  • Continually validate yourself
  • You need people to help you heal. There are steps to healing, don’t rush it.
slide7
With the gift of listening comes the gift of healing, because listening to your brothers or sisters until they have said the last words in their hearts is healing and consoling. Someone has said that it is possible “to listen a person’s soul into existence.”

Catherine de Hueck Doherty

triggers and flashbacks
Triggers and Flashbacks

An event, symbol, reminder of something unfavorable that causes you to feel, act or respond in a certain way.

It can set off a memory transporting a person back to the event of the original trauma.

A flashback can take the form of pictures, sounds, smells, body sensations, feelings, or numbness. An event or circumstance that happens before something else.

definition of a traumatic event
   Definition of a traumatic event

A traumatic event is any event or events, which overwhelms our core capacity to cope. It results in an experience of personal threat to our safety and/or the integrity of our identity.

Exercise:(traumatic event)

complex trauma
Complex Trauma
  • Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child.
  • Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age.
  • Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

Source: Cook et al. (2005). Psychiatry Ann,35(5):390-398

what is child traumatic stress
What Is Child Traumatic Stress?
  • Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling).
  • Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal.
types of traumatic stress
Types of Traumatic Stress
  • Acute trauma is a single traumatic event that is limited in time. Examples include:
    • Serious accidents
    • Community violence
    • Natural disasters (earthquakes, wildfires, floods)
    • Sudden or violent loss of a loved one
    • Physical or sexual assault (e.g., being shot or raped)
  • During an acute event, children go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.
types of traumatic stress14
Types of Traumatic Stress
  • Chronic trauma refers to the experience of multiple traumatic events.
  • These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war.
  • The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.
domestic violence
Domestic violence

Domestic violence (also known as domestic abuse,spousal abuse, or intimate partner violence) occurs when a family member, partner or ex-partner attempts to physically or psychologically dominate another. Domestic violence often refers to violence between spouses, or spousal abuse but can also include cohabitants and non-married intimate partners.

domestic violence in vermont
Domestic violence in Vermont
  • In 2008, it was estimated that 7,835 children/youth (a conservative estimate) were identified through the Network’s 15 domestic violence programs as experiencing or having experienced domestic violence between July 1, 2007 and June 30, 2008. In 2008, The Department for Children and Families, Family Services, Domestic Violence Unit consulted on 1,892 child abuse reports that had co-occurring domestic violence.
slide18

Where one form of family violence exists,

there is a likelihood the other

A survey of more than 6,000 American families found

that 50% of men who frequently assaulted their wives

also frequently abused their children.

Slightly more than half of female victims of domestic

violence live in households with children under age 12

Studies suggest that as many as 10 million children

witness domestic violence each year.

how does domestic violence affect children
How does domestic violence affect children?

No standard response to living with domestic violence and all children may react differently. Many children are very resilient and do overcome significant problems

However children may experience a wide range of physical, emotional, behavioural and social problems as a result

slide20

Youth who witness domestic violence are more likely to:

  • Exhibit behavioral and physical health problems
  • including depression, anxiety, and violence
  • towards peers
  • Attempt suicide
  • Abuse drugs and alcohol
  • Run away from home
  • Engage in teenage prostitution
  • Commit sexual assault crimes
risks posed to children by exposure to batterers
Risks Posed To Children By Exposure To Batterers

Risk of exposure to threats or acts of

violence towards their mother.

Risk of undermining mother-child

relationships.

Risk of physical abuse of the child by

the batterer.

Risk of sexual abuse of the child by the

batterer

risks posed to children by exposure to batterers22
Risks Posed To Children By Exposure To Batterers

Risk to children of the batterer as a role

model.

Risk of rigid, authoritarian parenting.

Risk of neglectful or irresponsible

parenting.

Risk of psychological abuse and

manipulation.

Risk of abduction.

Risk of exposure to violence in the

batterer’s new intimate relationships.

what do children say
What do children say?

Children describe being abused or neglected and being afraid

They may take on more physical or emotional responsibility for family members / household tasks

DV affects children’s schooling, educational and play opportunities and friendships

Emotional and physical symptoms (e.g. nightmares) may not go away after they are away from the violence

how do children say domestic violence makes them feel
How do children say domestic violence makes them feel?
  • Terrified and afraid - “walking on eggshells”
  • Love and loyalty Loss
  • Sadness, isolation and depression
  • Anger and aggression - “I’d like to kill him”
  • Guilt and shame - “I’m really sorry I didn’t stand up for you when daddy used to hit you but I was only little and I was afraid.” (McGee, 2000)
  • Stigma
jane middelton moz children of trauma copyright 1986
Jane Middelton-Moz

Children of Trauma

Copyright: 1986

Jane Middelton-Moz

From Legacy to Choice

shame exercise
Shame exercise

Jane Middelton-Moz

guilt and shame
Guilt and Shame

Guilt

Feeling responsible for an event, outcome, situation that maybe real or imagined

Shame

A feeling of disappointment about something inside of us.

“ We feel guilt about what we do or don’t do, and we feel shame for what we are”.

shame compulsion to repeat
SHAMECompulsion to repeat:
  • The one who is humiliated becomes the one who humiliates.
  • The one who is humiliated hurts and humiliates themselves
  • The one who is humiliated seeks out relationships where humiliation continues
  • Talking it out and feeling it out ends acting it out

Jane Middelton-Moz

Shame and Guilt the Master of Disguise

slide30

3 Million Reports of Child Abuse Annually

  • 1 Million Reports are Substantiated
  • Child Abuse World-Wide
  • 73 million boys
  • 150 million girls
  • Sexually abused annually
  • 53,000 children are murdered each year
  • World Health Organization
prevalence of trauma united states
Prevalence of Trauma—United States
  • Each year in the United States, more than 1,400 children—nearly 2 children per 100,000—die of abuse or neglect.
  • In 2005, 899,000 children were victims of child maltreatment. Of these:
    • 62.8% experienced neglect
    • 16.6% were physically abused
    • 9.3% were sexually abused
    • 7.1% endured emotional or psychological abuse
    • 14.3% experienced other forms of maltreatment (e.g., abandonment, threats of harm, congenital drug addiction)

Source: USDHHS. (2007) Child Maltreatment 2005; Washington, DC: US Gov’t Printing Office.

u s prevalence
U.S. Prevalence
  • One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1
  • In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2
  • Four out of 10 U.S. children report witnessing violence;8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3
  • 1. Costello et al. (2002). J Traum Stress;5(2):99-112.
  • 2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc Psychiatry;34(10):1343-1352.
  • 3. Kilpatrick et al. (2003). US Dept. Of Justice. http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.
vermont children affected by trauma
Vermont Children Affected by Trauma
  • Number of children in DCF protective custody (FY’04)
    • 2,148
  • DCF intakes w/ domestic violence identified
    • 1,533 ( of 12,397)
  • Children exposed to domestic violence
    • 9119
  • Emergency Room Injury Child Victims
    • 15,012 (10% referred to CMH)
  • Percentage in DCF custody served by CMH
    • 24%

Personal communication, Ellie Breitmaier, MSW, Coordinator, DCF Domestic Violence Unit.,

J. & Ghosh, K. (February 6, 2004).Vermont Mental Health Performance Indicator Project. Young Trauma Victims served in Mental Health Programs.

Network Against Domestic Violence

prevalence of trauma in vermont
Prevalence of Trauma in Vermont
  • In 2005, 1,436 children in Vermont lived apart from their families in out-of-home care, compared with 1,432 children in 2004. In 2005, 18.3% of the children living apart from their families were age 5 or younger, and 30.2% were 16 or older. 1.
  • Of the children in out-of-home care in 2005, 95% were white, 2.7% black, 1% Hispanic, 0.2% American Indian/Alaskan Native, and 1.1% children of other races and ethnicities. 2.

1.Child Welfare League of America. (2007). Special tabulation of the Adoption and Foster Care Analysis Reporting System. Washington, DC: Author. 

2."Other races and ethnicities" includes Asian, Pacific Islander, Illinoisan Native, unknown or unable to determine, missing data and two or more races. CWLA (2007) Special AFCARS tabulation. 

prevalence of trauma in the child welfare population
Prevalence of Traumain the Child Welfare Population
  • A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%). This was higher than rates of PTSD in American war veterans.1
  • Nearly 80% of abused children face at least one mental health challenge by age 21.2
  • 1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at: http://www.casey.org/NR/rdonlyres/CEFBB1B6-7ED1-440D-925A-E5BAF602294D/302/casey_alumni_studies_report.pdf.
  • 2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at: http://www.astho.org/pubs/Childmaltreatmentfactsheet4-05.pdf.
prevalence in child welfare population
Prevalence in Child Welfare Population
  • A study of children in foster care revealed that PTSD was diagnosed in 60% of sexually abused children and in 42% of the physically abused children.1
  • The study also found that 18% of foster children who had not experienced either type of abuse had PTSD,1 possibly as a result of exposure to domestic or community violence.2

1. Dubner et al. (1999). JCCPsych;67(3): 367-373.

2. Marsenich (March 2002). Evidence-Based Practices in Mental Health Services for Foster Youth. Available at: http://www.cimh.org/downloads/Fostercaremanual.pdf.

impact of child abuse
Impact of Child Abuse

Children who have experienced a traumatic event show an increased incidence of:

Ischemic heart disease

Cancer

Chronic Lung disease

Skeletal fractures

Liver disease

slide38

Temporal Lobe Epilepsy

    • Developmental Disabilities; 10-25%
    • 3-6% of abused children will have a permanent disability as a result of the abuse
    • Between 20-50% of abused children suffer mild to severe brain damage.
    • The vast majority of all child abuse occurs within the family system.
  • (Office of Trauma Services, Department of Mental Health, Mental Retardation and Substance Abuse Services, Augusta, Maine)
slide39

Impact of Child Abuse

  • Early abuse and neglect negatively effect the maturation of the developing brain.
  • 80% of traumatized children have disorganized attachment patterns
  • During adolescence traumatized children have a 300% greater chance to engage in substance abuse, self-mutilation and aggressive behavior
  • The Neurobiology of Childhood Trauma and Abuse, Bessel van der Kolk, M.D.
slide40

Impact of Child Abuse

  • Childhood trauma is associated with increased rates of:
  • Imprisonment
  • Substance abuse
  • HIV status
  • Unemployment status
  • Use of psychiatric services
  • Impaired Health Status
  • (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss & Marks, 1998).
slide41

Impact of Traumatic Stress

  • A child’s response to a traumatic event may have a profound effect on his or her perception of self, the world, and the future.
  • Traumatic events may affect a child’s:
    • Ability to trust others
    • Sense of personal safety
    • Effectiveness in navigating life changes
slide42

“It was the worst part of my life – constantly being shouted at, frightened, living in fear. You will never know what it’s like, thinking that every day could be your last.”16 year old South Asian girl quoted in Mullender et al., 2002

the pain we carry around everyday
The pain we carry around everyday

Always going last/

being put aside

Being violent

Being beaten up while parents are drunk

Family violence

Child abuse

No encouragement

Always talking about mistakes

Anger

Blame

Being judged

Under estimated

Adults aren’t paying attention

Being lied to

Sexual abuse/assault

Not feeling respected

Self destructive

Shame

Guilt

Self hatred and hatred to others

Mistissini,2009

Afraid of our own anger and violence

effects of trauma exposure
Effects of Trauma Exposure

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.

effects of trauma exposure45
Effects of Trauma Exposure

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.

traumatic reaction
Traumatic Reaction

Exposure to Trauma

Post-Traumatic Stress Disorder

Avoidance/Numbing

Hyperarousal

Re-Experiencing

Traumatic event

post traumatic stress syndrome
Post Traumatic Stress Syndrome
  • Persistent re-experiencing of the event (i.e., distressing dreams, distressing recollections, flashbacks, or emotional and/or physiological reactions when exposed to something that resembles the traumatic event).
  • Persistent avoidance of things associated with the traumatic event or reduced ability to be close to other people and have loving feelings.
slide49
Persistent symptoms of increased arousal (i.e., sleep difficulties, outbursts of anger, difficulty concentrating, constantly being on guard, extreme startle response).

Duration of at least one month of symptoms.

Disturbance produces clinically significant distress or impairment in social, occupational or other important areas of functioning

PTSD
childhood trauma and other diagnoses
Childhood Trauma and Other Diagnoses
  • Other common diagnoses for children in the children’s Mental health system include:
    • Reactive Attachment Disorder
    • Attention Deficit Hyperactivity Disorder
    • Oppositional Defiant Disorder
    • Bipolar Disorder
    • Conduct Disorder
  • These diagnoses generally do not capture the full extent of the developmental impact of trauma.
  • Many children with these diagnoses have a complex trauma history.
trauma and the brain
Trauma and the Brain
  • Trauma can have serious consequences for the normal development of children’s brains, brain chemistry, and nervous system.
  • Trauma-induced alterations in biological stress systems can adversely effect brain development, cognitive and academic skills, and language acquisition.
  • Traumatized children and adolescents display changes in the levels of stress hormones similar to those seen in combat veterans.
    • These changes may affect the way traumatized children and adolescents respond to future stress in their lives, and may also influence their long-termhealth.1

1. Pynoos et al. (1997). Ann N Y Acad Sci;821:176-193

trauma and the brain52
Trauma and the Brain
  • In early childhood, trauma can be associated with reduced size of the cortex.
    • The cortex is responsible for many complex functions, including memory, attention, perceptual awareness, thinking, language, and consciousness.
  • Trauma may affect “cross-talk” between the brain’s hemispheres, including parts of the brain governing emotions.
    • These changes may affect IQ, the ability to regulate emotions, and can lead to increased fearfulness and a reduced sense of safety and protection.
trauma and the brain53
Trauma and the Brain
  • In adolescents,trauma can interfere with development of the prefrontal cortex, the region responsible for:
    • Consideration of the consequences of behavior
    • Realistic appraisal of danger and safety
    • Ability to govern behavior and meet longer-term goals
  • As a result, adolescents who have experienced trauma are at increased risk for:
    • Reckless and risk-taking behavior
    • Underachievement and school failure
    • Poor choices
    • Aggressive or delinquent activity

Source: American Bar Association. (January 2004). Adolescence, Brain Development and Legal Culpability. Available at: http://www.abanet.org/crimjust/juvius/Adolescence.pdf

long term effects of trauma
Long-Term Effects of Trauma
  • Generalized hyper- arousal and difficulty in modulating arousal
    • Aggression against self and others
    • Inability to modulate sexual impulses
  • Problems with social attachment – excessive dependence or isolation
  • Alterations in neurobiological processes involved in stimulus discrimination
    • Problems with attention and concentration
    • Dissociation
    • Somatization
effects of trauma
Effects of Trauma
  • Conditioned fear responses to trauma-related stimuli
  • Shattered meaning propositions
    • Loss of trust, hope, and sense of agency
    • Loss of “thoughts as experimental action”
  • Social avoidance
    • Loss of meaningful attachments
    • Lack of participation in preparing for the future
maximize the child s sense of safety
Maximize the child’s sense of safety
  • Traumatic stress overwhelms a child’s sense of safety and can lead to a variety of survival strategies for coping.
  • Safety implies both physical safety and psychological safety.
  • A sense of safety is critical for functioning as well as physical and emotional growth.
  • While inquiring about emotionally painful and difficult experiences and symptoms, workers must ensure that children are provided a psychologically safe setting.
assist children in reducing overwhelming emotion
Assist children in reducing overwhelming emotion
  • Trauma can elicit such intense fear, anger, shame, and helplessness that the child feels overwhelmed.
  • Overwhelming emotion may delay the development of age-appropriate self-regulation.
  • Emotions experienced prior to language development maybe be very real for the child but difficult to express or communicate verbally.
  • Trauma may be “stored” in the body in the form of physical tension or health complaints.
help children make new meaning of their trauma history and current experiences
Help children make new meaning of their trauma history and current experiences

Trauma can lead to serious disruptions in a child’s sense of safety, personal responsibility, and identity.

Distorted connections between thoughts, feelings, and behaviors can disrupt encoding and processing of memory.

Difficulties in communicating about the event may undermine a child’s confidence and social support.

Staff must help the child feel safe, so he or she can develop a coherent understanding of traumatic experiences.

61

address the impact of trauma
Address the impact of trauma

Traumatic events affect many aspects of the child’s life and can lead to secondary problems (e.g., difficulties in school and relationships, or health-related problems).

These “secondary adversities” may mask symptoms of the underlying traumatic stress and interfere with a child’s recovery from the initial trauma.

Secondary adversities can also lead to changes in the family system and must be addressed prior to or along with trauma-focused interventions.

62

support and promote positive and stable relationships in the life of the child
Support and promote positive and stable relationships in the life of the child
  • Separation from an attachment figure, particularly under traumatic and uncertain circumstances, is highly stressful for children.
  • Familiar and positive figures—teachers, neighbors, siblings, relatives—play an important role in supporting children who have been exposed to trauma.
  • Minimizing disruptions in relationships and placements and establishing permanency are critical for helping children form and maintain positive attachments.
provide support and guidance to the child s family and caregivers
Provide support and guidance to the child’s family and caregivers
  • Caregivers have some of the most challenging roles in the children’s mental health system.
  • Caregivers must be nurtured and supported so they, in turn, can foster safety and well-being.
  • Relatives serving as caregivers may themselves be dealing with trauma related to the crisis that precipitated child welfare involvement and placement.
manage professional and personal stress
Manage professional and personal stress
  • Mental health work is a rewarding but stressful profession, and workers may be confronted with danger, threats, or violence.
  • Mental health workers may empathize with victims; feelings of helplessness, anger, and fear are common.
  • Mental health workers who are parents, or who have histories of childhood trauma, might be at particular risk for experiencing such reactions.
key elements of children s healing
Key Elements of Children’s Healing

A close relationship w/their non-abusive

parent

Safety

Good relationships w/siblings

Connection to other loved ones, peers,

self

key elements of children s healing64
Key Elements of Children’s Healing

Opportunities to talk about events and express feelings

Opportunities to release distressing feelings

Good information about abuse

empowering children
Empowering Children

Teach critical thinking skills

Understand and support children’s

emotional and physical survival strategies

Talk to children about safety planning

narratives jane middelton moz
Narratives Jane Middelton-Moz
  • “Stories make available perspectives on the emotional themes of our implicit memory that may otherwise be consciously unavailable to us. This is why narratives (story telling has such a powerful effect on the mind. They allow us to modulate our emotions and make sense of the world. The narrative process also enables interpersonal integration and healing.” Segal, “the Developing mind”
fairy tale legend the story of your life
Fairy Tale, Legend, The Story of Your Life

Jane Middelton-MozShame and Guilt the Master of Disguise

  • Include:“Once upon a Time”
  • The shame and hurt you have experienced in childhood, youth, or adult years
  • The way you have protected yourself from the pain examples, (
  • shut down ,denial, became invisible)
  • What you know about the shame and pain experienced by your caregivers in their childhoods and how that shame was passed on to you.
  • How the shame in your childhood or youth is affecting you today.
  • Gifts from your pain and your vision for the future.
  • “and they lived…ever after”.
slide69
C.L.E.A.R.E.D.

Create something (food, art, photography….)

Love your family, spouse, and pets and spend lots of time with them

Exercise at least 3 times per week

Avoid excess in anything (food, caffeine, alcohol, exercise, work…)

Relax with a good book, and schedule “nothing” time

Eat healthy food

Dream about your goals and envision the future you want for yourself and your family

slide70
Sometimes the only thing we can do to help is to be a witness to the child's struggle.

Phil Wells