Young People Who Experience Trauma: Identifying Strategies to Promote Resilience and Reduce Future Perpetration of Violence

April 2-3, 2012 Summit

Washington, DC

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Expert Panel

Dr. Sarah Oberlander (Facilitator)

Social Science Analyst, U.S. Department of Health and Human Services

Dr. Bradley Stolbach

Director, La Rabida Children’s Hospital Chicago Child Trauma Center; Associate Professor of Clinical Pediatrics, The University of Chicago Pritzker School of Medicine

Eric Lulow

Youth Involvement Associate, National Federation of Families for Children's Mental Health

Julia Silva

Director, Violence Prevention Office,                                                      American Psychological Association

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Trauma and Adverse Childhood Experiences

Dr. Bradley Stolbach

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Traumatic Stressors in Chicago Child Trauma Center Clients

Sexual abuse 						55%

Witnessed domestic violence 				39%

Physical abuse 						27%

Traumatic loss 						26%

Witnessed physical or sexual abuse 			26%

Witnessed community violence 				19%

Motor vehicle accident 					13%

Other medical trauma (other than burns) 			12%

Victim of extrafamilial violent crime 			7%

Burns 							7%

Fire 								7%

Witnessed homicide 					5%

Other (e.g., dog attack, school violence, abduction, torture, witnessing serious injury,  hurricane)  

      Source: Stolbach et al., 2009

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Other Adverse Experiences inChicago Child Trauma Center Clients

Impaired caregiver 						54%

Neglect 							37%

Placement in foster care 					30%

Death of significant other (not TL) 				26%

Unresolved trauma history in caregiver 			24%

Exposure to drug use or criminal activity in home		23%

Emotional abuse 						22%

Exposure to prostitution or other developmentally                  inappropriate sexual behavior in home 			18%

Substitute care (not foster care) 				17%

Incarcerated family member 				16%

Homelessness 						7%

       Source: Stolbach et al., 2009

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What is Complex Trauma?

Exposure to multiple forms of violence and other potentially traumatic stressors in the context of attachment behavioral systems that are unable to provide protection, care, and comfort.

Focus on cumulative trauma and the developmental context in which exposure occurs rather than on discrete episodes.

Individuals with a trauma history rarely experience only a single traumatic event.

Nearly 40% had experienced two or more types of direct victimization in the past year (Finkelhor et al., 2009).

Fewer than 24% had experienced only one type of trauma or adverse childhood experience; over 40% had experienced 4 or more (NCTSN Core Data Set, 2012).

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Proposed Developmental Trauma Disorder Criterion A:

A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:

A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and

A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse.

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Attachment Behavioral System

Attachment: an evolved behavioral system that functions to promote the protection and safety of the attached person.

Attachment system is activated strongly by internal and external stressors or threats.

It is through healthy attachment (i.e., a behavioral system that effectively protects and comforts the infant or child) that a child develops the capacity for emotional and behavioral self-regulation, as well as a coherent self.

These developmental capacities shape the way that individuals experience and respond to trauma.

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Some Basic Assumptions About             Psychological Traumatization

Traumatic experiences are those which overwhelm an individual’s capacity to integrate experience in the normal way (e.g., Putnam, 1985).

Following exposure to trauma, if integration does not occur, traumatic experience(s) are split off and an individual alternates between functioning as if the trauma is still occurring and functioning as if the trauma never occurred (e.g., Nijenhuis et al., 2004).

Although traumatic memories and associations remain inaccessible to consciousness much of the time, they have the power to shape an individual’s daily functioning and behavior (e.g., Allen, 1993).

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Key Developmental Capacities Affected by Complex Trauma

Ability to modulate, tolerate, or recover from extreme affect states (strong emotions)

Regulation of bodily functions (sleeping, eating, elimination)

Capacity to know emotions or bodily states 

Capacity to describe emotions or bodily states

Capacity to perceive threat, including reading of safety and danger cues

Capacity for self-protection

Capacity for self-soothing

Ability to initiate or sustain goal-directed behavior

Development of coherent self, identity

Capacity to regulate empathic arousal

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Example: “Marie Therese”

Fire 						1

Domestic violence 				5

Impaired caregiver 				5 - 20

Physical abuse 				5, 15, 16

Sexual abuse/assault 				7, 15, 16

Community violence 				10

School violence 				10 - 16

Extrafamilial violent crime victim 		12 - 20

Motor vehicle accident 			14, 19

Incarceration 					17 - 21

Traumatic loss 				18

Witnessing homicide 				18, 19

Homelessness 				19, 20

Employment in sex industry 			19, 20

Burn 						20

Total Types of Traumatic Stress 			12

Total Types of Other Adverse Experiences 		4

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Trauma History Timeline: “Marie Therese”

This graphic timeline shows traumatic and adverse experiences over the lifespan of Marie Therese.

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Why Prevention is Critical: Trauma and Adverse Life Events of Incarcerated Girls (n=10)

Trauma

100% had at least one form of family violence.

80% had at least one form of ongoing traumatic stress.

80% had at least one form of traumatic stress prior to age 6, including 30% who had exposure to violence from birth.

Mean = 8.5; Range = 3 - 15

Adverse Life Events 

70% had impaired caregiver, incarcerated significant other, and exposure to drug use/criminal activity in home

60% had neglect and death of significant other 

Mean = 4.8; Range = 2 – 8

Mean combined total types of traumatic stressors + other adverse childhood experiences = 13.3

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Personal Account of Trauma and Adverse Childhood Experiences

Eric Lulow

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Personal Account of Childhood Stressors and Impacts

Eric Lulow’s Traumatic and Adverse Life Experiences:

Witnessed domestic violence 			

Physical abuse 

Witnessed physical or sexual abuse 

Witnessed community violence 

Impaired caregiver 	

Neglect 		

Placement in foster care 	

Exposure to drug use or criminal activity in home

Emotional abuse 	

Incarcerated family member 

Homelessness 

“I was dealing with all of these trauma stressors while trying to develop appropriate relationships with friends and family, find/maintain housing and employment, and attend school.”  				

						       - Eric Lulow

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Trauma Informed Method of  Engagement (T.I.M.E.)

© Georgetown University National Technical Assistance Center for Children’s Mental         Health. Cady, D & Lulow, E. 

This graphic shows a circle split into four quadrants, Reflection, Relationship, Support, and Preparation. The Reflection quadrant has three bullet points: process/debrief, assess trauma triggers, and develop personal and professional skills. The Relationship quadrant is explained as: establish trust and rapport, identify trauma triggers, and develop a safety plan. The Preparation quadrant has three associated bullet points: provide standard training, target the task, and practice new skills. The Support quadrant is explained as: meets logistical needs, assess strengths, needs, and situation, and check in. This figure was developed by D. Cady and Eric Lulow and is distributed by the Georgetown University National Technical Assistance Center for Children’s Mental Health.

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Reflection

Relationship

Preparation

Provide Standard Training

Meet logistical needs 

Support

Establish Trust & Rapport

Identify Trauma Triggers

Develop a Safety Plan

Target the Task

Practice new skills

Process/Debrief

Assess trauma triggers

Develop Personal and Professional skills

Assess  strengths, needs, and situation

Check in

Building Capacity of Providers to Identify and Appropriately Treat Youth who are Victims

Julia Silva

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Victimized Children and Youth

What they need:

Help to Heal: be able to talk about the trauma on their own ways, have a sense that others believe them, that they are valued.

Help to Build Resilience: the capacity to bounce back and adapt.

Can help by providing access to organizations and providers that adopt: 

Scientifically-supported assessment tools for trauma symptoms and impact; and 

Effective trauma-focused evidence-based treatments.

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The Effective Providers for Child Victims of Violence Program (The EP Program)

A training program to increase the number of organizations and mental health and allied professionals informed about and prepared to adopt scientifically-supported assessment tools and family-centered, culturally sensitive, evidence-based treatments for children and youth who are victims of violence. 

The EP Program Principles: Effective trauma-focused treatments

Involve families/caregivers because they are central to treatment regardless of the child’s age.

Use evidence-based treatments because they were tested and we know they work.

Are provided by culturally competent providers because children and families come from diverse backgrounds.

Are based on collaboration among professionals and systems of care because violence is too complex for one field and one system to tackle. 

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The EP Program Rationale

Effective treatments help:

Organizations increase productivity

Professionals accomplish their mission

Decrease re-victimization rate

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The EP Program Model

Two-day workshops to train trainers to conduct 1-day community workshops. The curriculum addresses: 

Impact of exposure to violence on children and youth.

Review of six trauma-focused assessment tools.

Review of five trauma-focused evidence-based treatment models.

The role of culture on victimization and treatment.

A family-centered collaborative approach to treatment.

For more information, visit: www.apa.org/pi/prevent-violence/programs/child-victims.aspx

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Additional Information

Division of Violence Prevention, Centers for Disease Control and Prevention

http://www.cdc.gov/ViolencePrevention/index.html

National Child Traumatic Stress Network

http://www.nctsnet.org/

National Federation of Families for Children's Mental Health 

http://ffcmh.org/

American Psychological Association 

http://www.apa.org/pi/prevent-violence/index.aspx

The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, National Child Traumatic Stress Network, National Federation of Families for Children’s Mental Health, and the American Psychological Association.

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Discussion

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