Taking a Trauma First Approach in Policy, Programs, and Practice Bryan Samuels, Commissioner Administration on Children, Youth and Families

Interpersonal Trauma “[Complex trauma – also referred to as “developmental trauma disorder” or “chronic interpersonal trauma”] refers to children’s experiences of multiple traumatic events that occur within the caregiving system – the social environment that is supposed to be the source of safety and stability in a child’s life. Typically, complex trauma exposure refers to the simultaneous or sequential occurrences of child maltreatment—including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence—that are chronic and begin in early childhood. Moreover, the initial traumatic experiences (e.g., parental neglect and emotional abuse) and the resulting emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues, often lead to subsequent trauma exposure (e.g., physical and sexual abuse, or community violence).” September 21, ATTACh Conference Southerland, D; Casaneuva, CE; & Ringeisen, H. (2009). Young adult outcomes and mental health problems among transition age youth investigated for maltreatment during adolescence. Children and Youth Services Review. 31(9):947.

Abusive or Neglectful Parenting Insecure Attachments, Emotional Dysregulation, Negative Internal Working Models Maladaptive Coping Strategies Poor Social-Emotional Functioning, Disturbed/Negative Relationships Psychological Distress Poor Adult Functioning/Outcomes Impact of Trauma on Healthy Development 3 September 21, 2012ATTACh Conference

Maltreatment Impacts How Youth Form Relationships with Adults Child maltreatment represents an extreme form of child–parent relationship disruption (Harden, 2004; Milan & Pinderhughes, 2000). Child maltreatment can be defined as a chronic interpersonal trauma, to which the child is exposed on a daily basis(Perry, 2008; van der Kolk, 2005). Children’s capacity to adequately cope with stress depends largely on the nature of the stress and on the attachment figure’s capacity to diminish or counter the effects (Lyons-Ruth et al., 1999). The developmental stage of the child at the onset of the abuse and neglect will influence the type and severity of the consequences (Frederico, Jackson & Black 2005; Perry 1995). Apr. 2, Ntl. Forum on Youth Violence Prevention

Relational Functioning as Well-being? Apr. 2, Ntl. Forum on Youth Violence Prevention Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31:211.

Relationships as Protective Factors ISLE OF WIGHT STUDY Study showed child abuse is linked with difficulties in interpersonal relationships. Adolescent psychiatric difficulties showed strong continuity of difficulties into adulthood. However, 45% of abused individuals reported no mental health problems in adult life. Half of those reporting abuse in adulthood had been rated as showing significant abnormalities in interactions with peers in adolescence. At the same time, peer relationships in adolescence emerged as one of the strongest predictors of no mental health problems in adult life. Some individuals in the abused resilient group showed evidence of isolated difficulties, but rates of difficulties were lower than for the rested of abused group. Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31: September 21, 2012ATTACh Conference

“DSM-IV psychiatric disorder connects with relationship functioning domains: high parental care; normal adolescent peer relationships; good adult friendships; supportive first partner, stable relationship history).” September 21, 2012ATTACh Conference 7 Collishaw, S; Pickles, A; Messer, J; Rutter, M; Shearer, C & Maughan, B. (2007). Resilience to adult psychopathology following childhood maltreatment: Evidence from a community sample. Child Abuse and Neglect. 31:211.

Study supports view: – impairments in interpersonal relationships are of crucial importance for understanding the effects of child abuse on mental health outcomes. – positive relationships should not be seen as good fortune arising from chance encounters with a supportive friend, peer or partner, but rather as an ongoing process of developing the competencies necessary to form, maintain and benefit from supportive interpersonal relationships. – individuals with good relationship experiences across different domains and across childhood, adolescence and adulthood who were particularly likely to demonstrate healthy adult outcomes. – understanding the processes whereby relationship competencies are developed and maintained constitutes an important goal for future research and target for clinical interventions. September 21, 2012ATTACh Conference 8 Relationships as Protective Factors ISLE OF WIGHT STUDY

Older Youth Entry into Foster Care September 21, 2012ATTACh Conference 9 Data Source: Adoption and Foster Care Analysis and Reporting System (AFCARS), U.S. Department of Health and Human Services

“Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.” National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu December 9, ZERO TO THREE National Training Institute

Programmatic Elements of Trauma- First Approach Trauma- First Child Welfare Approach Developmentally specific approach Knowledge building for staff and foster parents Addressing secondary trauma Build capacity to deliver EBPs; contract for externally- delivered EBPs Trauma- informed screening and mental health assessment Cross-system partnerships and collaboration September 21, ATTACh Conference

Practice Elements of Trauma-First Approach Trauma- First Child Welfare Approach Focusing on child- and family-level outcomes (as opposed to process outcomes alone) Monitor progress for reduced symptoms and improved child/youth functioning Promotion of healthy relationships Proactive approach to addressing social and emotional needs Trauma-informed case planning and management September 21, ATTACh Conference

Multi-Level Strategy to Address Trauma and Promote Well-Being Policy Promoting Safe and Stable Families – Trauma Screening and Treatment Information Memoranda: Well-Being, Psychotropics, CQI IM: Title IV-E Child Welfare Waiver Demonstration Projects CMS: Early and Periodic Screening, Diagnosis, and Treatment Workforce Program FOA: Screening, Assessment, and Services Array FOA: Regional Partnership Grants Protective Factors across Populations Ending Youth Homelessness (USICH) USAID Practice Permanency Innovations Initiative – Illinois Collaboration with SAMHSA Waiver Demonstrations in 6 States FOA: Integrating Trauma into Child Welfare Services FOA: Supportive Housing and Child Welfare Neuroscience and Child Maltreatment September 21, ATTACh Conference

A More Complete Picture of Well- Being Adapted from Impact Youth Services, 2011; ACYF-CB-IM-12-04: olicies/policy/im/2012/im1204.pdf olicies/policy/im/2012/im1204.pdf September 21, ATTACh Conference