1. September 2013

2. Module 4 Understanding the impact of maltreatment, stress and separation on development

3. Module 4 Learning Objectives Participants will: Identify the impacts of maltreatment, neglect and abuse on the physical, motor, language and communication, cognitive and social-emotional domains Understand how these negative impacts early in life can lead to lifelong challenges Understand the importance of access to consistent medical and dental care. Understand the importance of initial and ongoing developmental screening with referrals to early intervention as needed. Modified by Children’s Administration 5/2014

4. Overview of this module There are often significant differences across all the developmental domains when we compare children who have been abused or neglected with children who have not The impacts of these early years will carry on long into adulthood, as we have learned from the ACE study What does this all mean for child welfare professionals?

5. Developmental comparison between a typical and maltreated child Physical Motor Language Cognitive Social emotional

6. Billy and Lucian

7. Video: First Person, Impressions of Being a Baby Clip #1 Lucian: minutes 13:55-18:35

8. Video: Broken Child, Case Studies of Child Abuse Clip #2: Billy (5:34-7:56)

9. Mom’s poor prenatal care put Billy on a lifelong trajectory for health and emotional problems

10. Mom’s healthy prenatal care put Lucian on a trajectory of optimal physical and emotional health

11. Transgenerational Transmission “… the handing down of a susceptibility from parent to child.” Mothers who report experiencing stress during pregnancy are more likely to have babies who are hyperactive and developmentally delayed Newborns of depressed mothers are more irritable and harder to soothe, have more problems sleeping and have higher levels of the stress hormone cortisol in their blood

12. Physical Development Height and Weight Nutrition Physical Activity Dental, Vision and Hearing

13. Physical Development Lucian On target for height and weight Regular checkups Immunizations up-to-date Good teeth Excellent health Breastfed, so good immunities Billy Malnourished and anemic Bottle mouth and rotten teeth Chronic untreated ear infections with possible hearing loss Compromised lung function from second- hand smoke No immunizations Bleeding diaper rash

14. Motor Development Gross motor development Fine motor development Development of self-help skills

15. Motor Development Lucian Drinks unassisted from a cup Feeds self with spoon and fork Can undress self Can work puzzles and stack blocks Can turn on dad’s iPhone and play Billy Prefers crawling but can run Drinks from bottle, not cup Eats with fingers Has never used spoon or fork

16. Language and Communication Receptive communication Expressive communication

17. Left behind by kindergarten By age 4, the average child in a poor family might have been exposed to 13 million fewer words than a child in a working class family and 30 million fewer words than a child in a professional family. Source: http://www2.ed.gov/programs/readingfirst/2008conferences/language.pdfhttp://www2.ed.gov/programs/readingfirst/2008conferences/language.pdf

18. Speech and Language Development Lucian Vocabulary of 300 words Can point and name correct animal in book “show me the dog” Carries out directions Initiates five-word sentences Asks for what he needs Knows songs, rhymes and fingerplays Billy Points to get what he needs Ear infections make it hard to hear words No words No books in the house Watches TV Never been read to or sung to

19. Cognitive Development Eagerness and curiosity Persistence Creativity and problem-solving Vocabulary

20. Toxic stress from exposure to violence can impair healthy development One study revealed that exposure to relationship-based violence and trauma in the first two years of life resulted in lower IQ scores at 5 and 8 years of age. Enlow MB, Egland B, Blood EA, Wright RO, & Wright RJ (April 4, 2012) Interpersonal trauma exposure and cognitive development in children to age 8 years: a longitudinal study. Journal of Epidemiology and Community Health Online First.

21. Children learn through experiences Eagerness and curiosity Persistence Creativity and problem-solving

22. Cognitive Development Lucian Creativity and problem- solving Plays make believe with stuffed animals Can name all his body parts Can count to 10 Can work mechanical toy Vocabulary Billy Creativity and problem- solving Curiosity Persistence-finds hidden food Imitates mom smoking with stick Minimum receptive language

23. Social and Emotional Development Trust and emotional security Self-regulation Self-concept

24. Consequences of Trauma Depression Anxiety Aggression Conduct disorders Sexualized behaviors Eating problems Substance abuse Source: Harris, W.W., Putnam, F. W., and Fairbank, J.A. Mobilizing Trauma Resources for Children. January 8, 2004.

25. Social-Emotional Development Lucian Range of emotions Happy, emotionally calm, balanced Expresses affection warmly Comforts other kids when hurt Uses Dad as secure base from which to explore world Reciprocity in relationship Billy Plays with baby brother Flat affect Runs to mother Stays near mother

26. What has Billy learned about relationships?

27. Who was their secure base? How did the adults in their life help them regulate?

28. How will Billy react when separated from his mother?

29. Trauma & Stress

30. Considering Trauma in Child Welfare Modified by Children’s Administration 5/2014

31. Trauma and Young Children

32. Child Welfare and Trauma “Trauma can be a single event, connected series of traumatic events or chronic lasting stress.” Diagnostic Classification: 0-3R Children in the child welfare system almost by definition have suffered trauma, often multiple traumatic events, and 50-75% exhibit behaviors or symptoms that need mental health treatment. Source: Landsverk, Burns, Stambaugh, & Rolls Reutz (2009). Psychosocial Interventions for Children and Adolescents in Foster Care: Review of Research Literature. Child Welfare, 88 (1), 49-69.

33. Do you see signs of trauma? Signs of trauma in toddlers: Lack of verbal skills to express emotions Biting, kicking, tantrums, unprovoked aggression Disengagement with others Disinterested in toys Indiscriminate preferences of caregivers Skill regression Vigilance Lack of exploration

34. Monitoring Health and Development Modified by Children’s Administration 5/2014

35. American Academy of Pediatrics: Recommendations for health care of young children in foster care … Initial health screening Comprehensive medical and dental assessment Developmental and mental health evaluation Ongoing primary care and health monitoring Modified by Children’s Administration 5/2014

36. WA POLICIES: HEALTH & MEDICAL NEEDS Initial Health Screening –Five days of placement Early Episodic Screening Diagnosis and Treatment (EPSDT) is required: Within the first thirty days of out of home placement. Five exams during the first year of life Three exams between 1 and 2 years of age Annual exams between 3 and 20 years of age. Health Care Services Policy Modified by Children’s Administration 5/2014

37. WA POLICIES: DENTAL NEEDS Initial dental exam within 30 days of entering care (unless dental exam was received within 6 months of placement) Regular and ongoing dental exams every 6 months. Dental exams are recommended, for all children upon the first erupted tooth, 1st Birthday, or when referred by a medical professional. Modified by Children’s Administration 5/2014

38. Early intervention matters IDEA Part C: Ages 0-3 IDEA Part B: Ages 3-5 Source http://www.ideapartnership.org/index.php?option=com_content&vie w=section&id=51&Itemid=140

39. Unmet developmental needs of children investigated for maltreatment A national study found that … Only 13% had an IFSP or IEP indicating services 32% of children age 0- 5 needed early intervention Source: Casanueva, C. E., Cross, T. P., & Ringeisen, H. (2008). Developmental needs and individualized family service plans among infants and toddlers in the child welfare system. Child Maltreatment, 13, 245-258.

40. Early Support of Infants and Toddlers Early Support for Infants and Toddlers www.del.wa.gov/esit Please Ask video www.youtube.com/watch?v=JoaFNGmSU5U Guiding Concepts Video www.youtube.com/watch?v=yGqAOZrvQQU&feature=youtu.be Modified by Children’s Administration 5/2014

41. Early Support of Infants and Toddlers Family Health Hotline 1-800-322-2588 Contact Directory www.del.wa.gov/publications/esit/docs/ContactsDirectory.pdf Practice Guide: Identifying the “Parent” for Infants and Toddlers in Foster or Out ‐ of ‐ Home Care (20U.S.C. §§1401(23) and 1439(a)(5)). –Participation in ESIT is voluntary. www.del.wa.gov/publications/esit/docs/ESIT_practice_guide_foster_care.pdf Modified by Children’s Administration 5/2014

42. CHILD HEALTH AND EDUCATION TRACKING SCREEN All children who remain in out-of-home placement longer than 30 days receive a Child Health & Education Tracking (CHET) Screen. CHET screens across five domains using validated and standardized tools to assess development. If a developmental delay is identified a referral must be made within two working days to Early Support for Infants and Toddlers (ESIT) for children birth to five. www.del.wa.gov/esit www.del.wa.gov/esit If a delay is identified for children three to five years of age a referral must be send to the Child Find Coordinator at the local school district. Children may have developmental concerns that emerge after the CHET screening and should be referred at that time by social worker or caregiver. Modified by Children’s Administration 5/2014

43. Developmental Information Child Profile www.doh.wa.gov/YouandYourFamily/Immunization/ChildProfileHealthPromotion.aspx Birth to 5: Watch Me Thrive www.acf.hhs.gov/programs/ecd/watch-me-thrive Center for Disease Control Developmental Milestone Checklist http://www.cdc.gov/ncbddd/actearly/milestones/index.html Help Me Grow Modified by Children’s Administration 5/2014

44. CHET ACTIVITY Identify any concerns documented in the report. Identify if the report has been provided to the FRC. As the identified social worker what are your next steps. Modified by Children’s Administration 5/2014

45. Federal Mandate for Developmental Screening of Maltreated Children CAPTA: 108-36 2003 Child Abuse Prevention & Treatment & Adoption Reform Requires states to have procedures for the referral of children under 3 involved in substantiated cases of child abuse or neglect to early intervention services.

46. DOCUMENTING CAPTA IN WA The assigned investigator must make a referral to the local Family Resource Coordinator if they identify of suspect a developmental delay. The referral must be made within two working days to Early Support for Infants and Toddlers (ESIT). www.del.wa.gov/esit www.del.wa.gov/esit The referral must be discussed with the parent/caregiver. The parent/caregiver can request an extension of the referral timeline. This request should be documented on the referrals tab in the education record of the identified child’s person card in FamLink. Modified by Children’s Administration 5/2014

47. Summary: Understanding the Impacts of Maltreatment Children who have been abused, neglected and/or maltreated are more likely to experience toxic stress The impacts of abuse, neglect and/or maltreatment can negatively influence all developmental domains These delays persist through a child’s life, making it harder for them to do well in school and adulthood Early and periodic medical, dental and developmental screening and referrals to appropriate interventions can change life trajectories. The “buffering” relationship with a loving, stable caregiver remains key to alleviating these negative impacts. It’s never too late! Modified by Children’s Administration 5/2014