- Charles Wilson, Charles WilsonChadwick Center for Children and Families, Rady Children Hospital, San Diego
- Donna M. PenceDonna M. PenceSan Diego State University
- and Lisa ConradiLisa ConradiChadwick Center for Children and Families, Rady Children's Hospital, San Diego
The concepts of trauma and trauma-informed care have evolved greatly over the past 30 years. Following the Vietnam War, professional understanding of post-traumatic stress disorder (PTSD) increased. The greater understanding of trauma and its effects on war veterans has extended to informing our comprehension of trauma in the civilian world and with children and families who have experienced abuse, neglect, and other traumatic events. This elevated insight has led to the development of evidence-based models of trauma treatment along with changes in organizational policies and practices designed to facilitate resilience and recovery. This paper highlights the concept of trauma-informed care by providing an overview of trauma and its effects, then providing a comprehensive description of our understanding of trauma-informed care across child- and family-serving systems.
- Children and Adolescents
- Clinical and Direct Practice
- Health Care and Illness
- Mental and Behavioral Health
The concepts of trauma-informed care have evolved over the past 30 years from a variety of streams of thought and innovation. They are now being applied in a wide range of settings, from mental health and substance-abuse treatment providers to child welfare systems and even schools and criminal justice institutions. In the simplest terms, the concept of trauma-informed care is straightforward. If professionals were to pause and consider the role trauma and lingering traumatic stress plays in the lives of the specific client population served by an individual, professional, organization, or an entire system, how would they behave differently? What steps would they take to avoid, or at least minimize, adding new stress or inadvertently reminding their clients of their past traumas? How can they better help their traumatized clients heal? In effect, by looking at how the entire system is organized and services are delivered through a “trauma lens,” what should be done differently? The answer can be used to guide practice, policy, procedures, and even how the physical caregiving environment is structured.
Foundations of Trauma-Informed Care
Long before anyone used the term “trauma-informed,” caring professionals and committed volunteers were instinctively acting in a trauma-informed manner. Much of this was influenced by the emergence of the feminist movement and the increasingly influential voice of survivors of interpersonal trauma, as seen in the rape crisis centers and the domestic violence movements of the 1970s (Burgess & Holmstrom, 1974) and the dramatic growth of child-advocacy centers and multidisciplinary teams in child abuse in the 1980s. These natural incubators for trauma-informed innovation and practice were “married” in the 1990s with the growing body of science and trauma-specific empirical research into how human beings respond in the aftermath of traumatic events, and how professionals and concerned activists could help them move toward recovery. That stream of research began with interest in combat-related post-traumatic stress after the Vietnam War. By the mid-1980s, the focus had expanded and was adopted by the wider mental health community as a relevant construct for understanding the cascade of symptoms often noted after rapes, shootings, and other major traumatic life events. In 1985, the International Society for Traumatic Stress was founded in the United States and served as a focal point for professionals searching for answers to support highly traumatized populations. By 1989, the United States Department of Veterans Affairs had created the National Center for Post-Traumatic Stress Disorder (www.ptsd.va.gov). In the 1990s, the Substance Abuse and Mental Health Administration (SAMHSA), within the U.S. Department of Health and Human Services, recognized the role of trauma in a significant number of women’s issues and gender-specific treatments. Over the next 20 years, a huge expansion of knowledge about trauma and traumatic stress occurred. This included not only better diagnostic criteria but also the development of empirically tested treatments for PTSD and other related trauma symptoms.
What Is Trauma?
Defining trauma is not without its controversies. Those who approach it from a clinical perspective tend to view trauma as a combination of a terrible event or series of events that involve real or perceived threats of death or serious injury, or threat to the physical integrity of the person or others, and from which that person experiences overwhelming fear, hopelessness, helplessness, or horror. This type of overwhelming stress, especially when it occurs over and over, as is common in many individuals served by the social work community, can create significant long-term impacts, including changes in the physiology of the brains of developing children. Some survivors of trauma, however, favor a definition that places greater emphasis on the subjective experience and the level of stress an individual perceives, independent of an event or series of events that threaten the individual with death, serious injury, or loss of their physical integrity such as a highly emotional argument with a family member (Substance Abuse and Mental Health Services Administration, 2012).
Prevalence of Trauma
Most individuals seeking public behavioral health services and other public services, such as homeless and domestic violence services, have histories of physical and sexual abuse, and witnessing or experiencing domestic violence, and they often live in neighborhoods where community violence is ever present. These individuals often present with co-occurring disorders such as chronic health conditions, substance abuse, eating disorders, and HIV/AIDS. In fact, 50% to 70% of women in psychiatric hospitals, 40% to 60% of women receiving outpatient mental health services, and 55% to 90% of women with substance abuse disorders report being physically or sexually abused, or both, in their lives ((Substance Abuse and Mental Health Services Administration, 2007). While trauma occurs throughout the lifespan, for many seeking the services of social workers and other helping professionals, the trauma began in childhood. Studies have reported high rates of trauma among children in the United States since the 1950s (Landis, 1956). For example, in one study, the authors found that 25% of their sample of nine- to 16-year-olds had recently experienced a potentially traumatic event (Costello, Erkanli, Fairbank, & Angold, 2002). Child abuse and neglect is an all-too-common form of trauma. In 2011, there were approximately 3.4 million reports of abuse or neglect that covered 6.2 million children (U.S. Department of Health and Human Services [DHHS], 2011. Another study found that approximately 15.5 million children were estimated to live in homes where they were exposed to at least one incidence of domestic violence in the previous year (McDonald, Jouriles, Ramisetty-Mikler, et al., 2006.). Anda and Felitti (2003) found that 21% of a 17,000-person sample drawn from adults enrolled in a San Diego Health Maintenance Organization reported being sexually abused; 26% were physically abused; and 13% lived in a home with domestic violence as a child. These and other studies reveal that a substantial number of children have experienced abuse or exposure to other traumatic events prior to their eighteenth birthday.
Not only are these forms of trauma common, they are among the most emotionally devastating and have been linked to a host of negative outcomes in childhood, from emotional and behavioral problems to impaired school performance (Conradi & Wilson, 2010; Ethier, Lemelin, & Lacharite, 2004). Without effective intervention, there is compelling evidence of long-term adverse consequences of untreated trauma lasting into adulthood that include substance abuse, suicidality, serious mental illness, and long-term physical health factors associated with early death (Felitti, Anda, Nordenberg, Williamson, et al., 1998; Anda, Dong, Brown, et al, 2009).
Whether children or adults, those who have experienced a traumatic event are likely to come into contact with multiple systems. Child welfare services alone come into contact with over 6 million children a year (US DHHS, 2011), and there are as many as 223,000 children placed in the protective custody of state or local governments at any one time (US DHHS, 2012). Youth involved in the juvenile justice system also present with high rates of trauma. In one study of a juvenile justice population, 92.5% of participants had experienced one or more traumatic events in their lifetime, and 11.2% of the sample met criteria for PTSD in the past year (Abram, Teplin, Charles, et al., 2004). By virtue of the events that brought the children into contact with these systems, and the additional traumas the system may impose (removal from the home, changes in placement, instability of relationships, use of seclusion and restraint, risk of re-abuse, inconsistent caregivers and caseworkers, separation of siblings, and so forth), virtually all have suffered major trauma.
Unique Response to Highly Stressful Events
Trauma, however, does not affect everyone in the same way. Some people experience a terrible event but suffer no long-term adverse emotional effects, while the same event have a devastating impact on the individual standing next to them. Traumatic response is highly individualized and shaped by a wide range of factors, from genetics, to previous life experiences, to support systems available in the aftermath of the event. How helping professionals respond also influences the long-term impact of traumatic events for the better, when delivered in a trauma-informed environment, or for the worse, if delivered in a trauma-insensitive manner, as has been the case for much of history.
The Emergence of Trauma-Informed Care
In 1994, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened the Dare to Vision conference, which explored the high prevalence of physical and sexual abuse among women served by the public mental health system. This event provided a forum for survivors to discuss their trauma histories and how trauma impacted their physical and mental health. It highlighted the re-victimization many experienced in residential or inpatient settings through the use of such practices as seclusion and restraint. By the late 1990s and early 2000s, a variety of professionals began to articulate the importance of the organizational context in the delivery of services to individuals who have experienced significant traumatic life events (Bloom, 1997; Harris & Fallot, 2001; Covington, 2002; Rivard, Bloom, & Abramovitz, 2003; Ko, Ford, Kassam-Adams N., et al., 2008; Bloom, 2010). The concepts at the core of “trauma-informed care” began to take greater shape and spread with the launch in 1998 of the Women, Co-Occurring Disorders and Violence Study, sponsored by SAMHSA (see www.wcdvs.com for more information), which integrated service system strategies for women with co-occurring mental health and substance abuse disorders who have also been victims of trauma. This study, carried out in 27 sites over five years in two phases (fourteen Phase One women sites, nine Phase Two women sites, and four Phase Two children’s sites), provided recommendations for “trauma-integrated services counseling.” This important study laid out a framework of principles for this population, complete with guidance for providers to be cognizant of their own practices and policies that might put women in danger physically and psychologically, add new traumatic experiences, or unnecessarily trigger memories of past traumatic events. The study highlighted the importance of “all service interventions [being] gender-specific, culturally competent, trauma-informed and trauma-specific, comprehensive, integrated, and [with] consumer/survivor/recovering women involved” (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2007, p.1). This study and others brought attention to the need for trauma-informed care in the adult world.
In 2001, the U.S. Congress and SAMHSA established the Donald J. Cohen National Child Traumatic Stress Initiative, and, through it, the National Child Traumatic Stress Network (NCTSN, www.nctsn.org). This national network, under the leadership of the National Center for Child Traumatic Stress at Duke University and the University of California–Los Angeles (UCLA), initially focused on the mission of raising “the standard of care and improve access to services for traumatized children, their families and communities throughout the United States.” Toward that end, the NCTSN concentrated on the identification and spread of empirically supported trauma-specific mental health interventions such as TraumaFocused Cognitive Behavioral Therapy (Deblinger, Lippmann, & Steer, 1996; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, & Staron, 2006) Deblinger, Mannarino, Cohen, & Steer (2006); Cohen, Mannarino & Iyengar (2011), and Child-Parent Psychotherapy (Lieberman, Weston, & Pawl, 1991; Cicchetti, Toth, & Rogosch, 1999; Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002; Lieberman, Ghosh Ippen, & Van Horn, 2006). By 2003, however, the NCTSN increasingly recognized that system issues could support or undermine effective trauma-specific treatments and began to explore the organization and system context in which trauma-specific interventions were being delivered, with the establishment of the Systems Integration Committee (Taylor & Siegfried, 2005). In short order, that effort was replaced by system-specific initiatives within the NCTSN designed to facilitate the NCTSN mission within the context of specific systems, including child welfare, juvenile justice, schools, and health care (Ko, Ford, Kassam-Adams, et al., 2008). In these efforts, the lessons learned in the Women with Co-Occurring Disorders Study and early adopters of trauma-informed care in the adult trauma world, along with the practical experience implementing trauma-specific interventions in child-serving environments, were integrated to create a trauma-informed perspective to serving traumatized children and their families.
As the term trauma-informed care took root in both adult- and child-serving worlds, distinctions began to be drawn between related, but discrete, perspectives. These ranged from “trauma-informed care” to “trauma-informed practice,” “trauma-informed organizations,” “trauma-specific treatments,” “trauma-informed systems,” and “trauma-informed approaches”; all linked by the concept of “trauma-informed.”
What Does It Mean to Be Trauma-Informed?
Many organizations and authors have offered definitions or a list of elements about what constitutes trauma-informed care or the related concepts of trauma-informed practice, organizations, and systems. In 2005, SAMHSA established the National Center for Trauma- Informed Care (NCTIC). The NCTIC suggested that every part of an organization seeking to be trauma-informed—its organizational structure, its management systems, and its service delivery—be
assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization. (National Center for Trauma-Informed Care, 2012)
Fallot and Harris (2009) suggest that trauma-informed care is built on five core values: (1) safety, (2) trustworthiness, (3) choice, (4) collaboration, and (5) empowerment. Here safety means both physical and emotional safety, while trustworthiness relates to the clarity of expectations, providing consistent service delivery across the organization, and maintaining boundaries. Fallot and Harris’s view of trauma-informed care emphasizes the active role of the person receiving the services or support. The concept of choice is important because it gives the consumer control over the services they receive. Control is significant because, as a victim of trauma, client control was taken from the during the traumatic event, whether through a rape, physical assault, or even a natural disaster. Collaboration emphasizes the need for client involvement and sharing of power, while empowerment relates to the development and enhancement of consumer skills.
In a working paper, US Department of Health and Human Servicese(USHHS/SAMHSA, 2012 suggests that a trauma-informed approach is guided by 10 principles:
Safety: throughout the organization, staff and the people they serve feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.
Trustworthiness and transparency: organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among staff, clients, and family members of people being served by the organization.
Collaboration and mutuality: there is true partnering and leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators; there is recognition that healing happens in relationships and in the meaningful sharing of power and decision-making.
Empowerment: throughout the organization and among the clients served, individuals’ strengths are recognized, built on, and validated and new skills developed as necessary.
Voice and choice: the organization aims to strengthen the staff’s, clients’, and family members’ experience of choice and recognize that every person’s experience is unique and requires an individualized approach.
Peer support and mutual self-help: are integral to the organizational and service delivery approach and are understood as a key vehicle for building trust, establishing safety, and empowerment.
Resilience and strengths based: a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma; builds on what clients, staff and communities have to offer rather than responding to their perceived deficits.
Inclusiveness and shared purpose: the organization recognizes that everyone has a role to play in a trauma-informed approach; one does not have to be a therapist to be therapeutic.
Cultural, historical, and gender issues: the organization addresses cultural, historical, and gender issues; the organization actively moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, geography, etc.), offers gender responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.
Change process: is conscious, intentional and ongoing; the organization strives to become a learning community, constantly responding to new knowledge and developments (What are the Key Principles of a Trauma-informed Approach? section)
Meanwhile, the National Child Traumatic Stress Network (NCTSN, 2012, What is a trauma-informed child- and family-service system? section, para. 1) defines the trauma-informed child-and family-serving system as one in which
all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to facilitate and support the recovery and resiliency of the child and family.
The NCTSN goes on to suggest that a service system with a trauma-informed perspective is one in which programs, agencies, and service providers (NCTSN, 2012):
routinely screen for trauma exposure and related symptoms;
use culturally appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptoms;
make resources available to children, families, and providers on trauma exposure, its impact, and treatment;
engage in efforts to strengthen the resilience and protective factors of children and families impacted by and vulnerable to trauma;
address parent and caregiver trauma and its impact on the family system;
emphasize continuity of care and collaboration across child-service systems; and
maintain an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress, and that increases staff resilience.
Some organizations, like the National Center for Children in Poverty (NCCP), have outlined a trauma-informed approach into a policy framework (Cooper, Masi, Dababnah, Aratani, & Knitzer, 2007). The NCCP advocates that:
All federal, tribal, state, and local policies should reflect a trauma-informed perspective. A trauma-informed response encompasses a fundamental understanding of trauma and how it shapes an individual who has experienced it.
Policies should support delivery systems that identify and implement strategies to prevent trauma, increase capacity for early identification and intervention, and provide comprehensive treatment.
Policies should support and require that strategies are designed to prevent and eliminate treatment practices that cause trauma or re-traumatization.
Policies should reinforce the core components of best practices in trauma-informed care: prevention; developmentally appropriate, effective strategies; cultural and linguistic competence; and family and youth engagement.
Policy and practice should be reflective of trauma-informed principles and be developmentally appropriate, based on a public health framework, and engage children, youth, and their families in healing.
Policies should focus on prevention of trauma and developing strategies to identify and intervene early for children, youth, and their families exposed to trauma or at risk of exposure to trauma.
Policies should focus on enhancing child, youth, and family engagement strategies to support informed trauma care delivery.
Policies should support strategies that encompass family-based approaches to trauma intervention.
Trauma-informed and related policies must include responsive financing, cross-system collaboration and training, accountability, and infrastructure development.
Policies should ensure that funding is supportive of trauma-informed care and based upon sound fiscal strategies.
Policies should make funding contingent upon eliminating harmful practices that cause trauma and re-traumatization across child-serving settings.
Policies should support comprehensive workforce investment strategies. (Cooper et al, 2007, pp. 1–2)
While the actual words vary considerably across definitions and perspectives on trauma-informed care, and the related topics of trauma-informed practice, trauma-informed approach, trauma-informed organizations and systems, some common themes emerge as the essential elements of trauma-informed care (Child Welfare Committee, National Child Traumatic Stress Network, & The California Social Work Education Center, 2012; Chadwick Trauma Informed Systems Project, 2013).
Maximize Physical and Psychological Safety
At its most fundamental level, recovery from trauma requires a sense of safety, and trauma-informed providers must recognize safety is both physical and psychological. Removing a child from an abusive home, for example, and placing him or her in a physically safe foster home where the child will not be maltreated may achieve physical safety but does not guarantee the child will feel safe. In fact, the very process of securing physical safety may intensify the child’s fears and insecurity and feelings of being out of control, helpless, and inherently unsafe. Without a sense of safety, not only will the client not progress, but the anxiety and stress it creates will add new trauma, amplify old trauma, and impact their behavior, often emerging as unhealthy maladaptive behaviors replayed long after the physical threat is gone.
The term psychological safety means a “sense of safety, or the ability to feel safe, within one’s self and safe from external harm” (Chadwick Trauma-Informed Systems Project, 2013, p. 13) This type of safety occurs on an emotional level and is not defined by objective observable reality. It has direct implications for physical safety and is critical for optimal functioning as well as physical and emotional growth. A lack of psychological safety can impact an individual’s and family’s interactions with all others, including those trying to help them, and can lead to a variety of maladaptive strategies for coping with the anxiety associated with feeling unsafe. These survival strategies may include high-risk and counterproductive behaviors, such as substance abuse, aggression and violence, high-risk-taking activities, and self-mutilation. The child (and his or her siblings) may continue to feel psychologically unsafe long after the physical threat has been removed or he or she has been relocated to a physically safe environment. In reality, the client may feel psychologically unsafe for a number of reasons. These may include factors the system can control, such as the placement environment and how professionals help the client regulate their emotions. Even after the client gains some degree of security, a trigger, such as a person, place, or event, may unexpectedly remind him or her of the trauma and draw his or her attention back to intense and disturbing memories that overwhelm his or her ability to cope, again creating a sense of fear and anxiety. At other times, a seemingly innocuous event or sensory stimulus like an odor, sound, touch, taste, or particular scene may act as a trigger and be a subconscious reminder of the trauma. In either of these situations, a physiological response is sparked due to the body’s biochemical system reacting as if the trauma were reoccurring. A trauma-informed provider understands that these pressures may help explain a client’s or family member’s behavior and can use this knowledge to help her or him better manage triggers and to feel safe.
As a result, trauma-informed care means considering not only how safe the service delivery environment actually is, but also how safe it is perceived to be by the clients being served; how trauma reminders and trauma triggers are managed; how the physical environment is structured to make the client feel safe; how culturally, developmentally, and linguistically congruent the service delivery system is with the client population served, and what can be done to maximize the sense of safety and security for both clients and service providers.
Partner with Clients
Consumers being served, and often their family members, who have been involved in the service system have a unique perspective. This experience can help the client and family guide their own services, and provide valuable feedback on how the system can better address trauma among those served, as well as others impacted by the experience. As articulated in the foundational work on trauma-informed systems by Fallot and Harris and advanced strongly by SAMHSA and the NCTIC, consumers should be given choices and an active voice in decision-making on both an individual and systemic level (choice and collaboration). This can help them reclaim the power (empowerment) that was taken away from them during the trauma, enhance their resilience, and provide important information to providers and the system. A sense of control and empowerment also helps build a sense of psychological safety as described above, and facilitates the client’s engagement and active participation in service delivery.
Identify Trauma-Related Needs of Clients
The first step in helping those that have been impacted by abuse, neglect, violence, and other trauma is understanding how trauma impacts them and their families on an individual level. Social workers and other helping professionals should use that knowledge to help educate the clients and their family, when appropriate, about the impact of trauma and how it influences their life and short- and long-term recovery. While much has been written on the subject, the NCTSN has done an excellent job of summarizing this in Core Concepts of Understanding Traumatic Stress Responses in Childhood. While written from a child trauma point of view, many of these concepts apply to adult trauma victims as well.
The 12 core concepts: Concepts for understanding traumatic stress responses in children and families. Core Curriculum on Childhood Trauma1
Traumatic experiences are inherently complex.
Every traumatic event—even events that are relatively circumscribed—is made up of different traumatic moments. These moments may include varying degrees of objective life threat, physical violation, and witnessing of injury or death. Trauma-exposed children experience subjective reactions to these different moments that include changes in feelings, thoughts, and physiological responses; and concerns for the safety of others. Children may consider a range of possible protective actions during different moments, not all of which they can or do act on. Children’s thoughts and actions (or inaction) during various moments may lead to feelings of conflict at the time, and to feelings of confusion, guilt, regret, and/or anger afterward. The nature of children’s moment-to-moment reactions is strongly influenced by their prior experience and developmental level. Events (both beneficial and adverse) that occur in the aftermath of the traumatic event introduce additional layers of complexity. The degree of complexity often increases in cases of multiple or recurrent trauma exposure, and in situations where a primary caregiver is a perpetrator of the trauma.
Trauma occurs within a broad context that includes children’s personal characteristics, life experiences, and current circumstances.
Childhood trauma occurs within the broad ecology of a child’s life that is composed of both child-intrinsic and child-extrinsic factors. Child-intrinsic factors include temperament, prior exposure to trauma, and prior history of psychopathology. Child-extrinsic factors include the surrounding physical, familial, community, and cultural environments. Both child-intrinsic and child-extrinsic factors influence children’s experience and appraisal of traumatic events; expectations regarding danger, protection, and safety; and course of post-trauma adjustment. For example, both child-intrinsic factors such as prior history of loss; and child-extrinsic factors such as poverty may act as vulnerability factors by exacerbating the adverse effects of trauma on children’s adjustment.
Traumatic events often generate secondary adversities, life changes, and distressing reminders in children’s daily lives.
Traumatic events often generate secondary adversities such as family separations, financial hardship, relocations to a new residence and school, social stigma, ongoing treatment for injuries and/or physical rehabilitation, and legal proceedings. The cascade of changes produced by trauma and loss can tax the coping resources of the child, family, and broader community. These adversities and life changes can be sources of distress in their own right and can create challenges to adjustment and recovery. Children’s exposure to trauma reminders and loss reminders can serve as additional sources of distress. Secondary adversities, trauma reminders, and loss reminders may produce significant fluctuations in trauma survivors’ post-trauma emotional and behavioral functioning.
Children can exhibit a wide range of reactions to trauma and loss.
Trauma-exposed children can exhibit a wide range of post-trauma reactions that vary in their nature, onset, intensity, frequency, and duration. The pattern and course of children’s post-trauma reactions are influenced by the type of traumatic experience and its consequences, child-intrinsic factors including prior trauma or loss, and the post-trauma physical and social environments. Post-traumatic stress and grief reactions can develop over time into psychiatric disorders, including post-traumatic stress disorder (PTSD), separation anxiety, and depression. Post-traumatic stress and grief reactions can also disrupt major domains of child development, including attachment relationships, peer relationships, and emotional regulation, and can reduce children’s level of functioning at home, at school, and in the community. Children’s post-trauma distress reactions can also exacerbate preexisting mental health problems including depression and anxiety. Awareness of the broad range of children’s potential reactions to trauma and loss is essential to competent assessment, accurate diagnosis, and effective intervention.
Danger and safety are core concerns in the lives of traumatized children.
Traumatic experiences can undermine children’s sense of protection and safety, and can magnify their concerns about dangers to themselves and others. Ensuring children’s physical safety is critically important to restoring the sense of a protective shield. However, even placing children in physically safe circumstances may not be sufficient to alleviate their fears or restore their disrupted sense of safety and security. Exposure to trauma can make it more difficult for children to distinguish between safe and unsafe situations, and may lead to significant changes in their own protective and risk-taking behavior. Children who continue to live in dangerous family and/or community circumstances may have greater difficulty recovering from a traumatic experience.
Traumatic experiences affect the family and broader caregiving systems.
Children are embedded within broader caregiving systems, including their families, schools, and communities. Traumatic experiences, losses, and ongoing danger can significantly impact these caregiving systems, leading to serious disruptions in caregiver–child interactions and attachment relationships. Caregivers’ own distress and concerns may impair their ability to support traumatized children. In turn, children’s reduced sense of protection and security may interfere with their ability to respond positively to their parents; and other caregivers’ efforts to provide support. Traumatic events—and their impact on children, parents, and other caregivers—also affect the overall functioning of schools and other community institutions. The ability of caregiving systems to provide the types of support that children and their families need is an important contributor to children’s and families’ post-trauma adjustment. Assessing and enhancing the level of functioning of caregivers and caregiving systems are essential to effective intervention with traumatized youths, families, and communities.
Protective and promotive factors can reduce the adverse impact of trauma.
Protective factors buffer the adverse effects of trauma and its stressful aftermath, whereas promotive factors generally enhance children’s positive adjustment regardless of whether risk factors are present. Promotive and protective factors may include child-intrinsic factors such as high self-esteem, self-efficacy, and possessing a repertoire of adaptive coping skills. Promotive and protective factors may also include child-extrinsic factors such as positive attachment with a primary caregiver, possessing a strong social support network, the presence of reliable adult mentors, and a supportive school and community environment. The presence and strength of promotive and protective factors—both before and after traumatic events—can enhance children’s ability to resist, or to quickly recover (by resiliently “bouncing back”) from the harmful effects of trauma, loss and other adversities.
Trauma and post-trauma adversities can strongly influence development.
Trauma and post-trauma adversities can profoundly influence children’s acquisition of developmental competencies and their capacity to reach important developmental milestones in such domains as cognitive functioning, emotional regulation, and interpersonal relationships. Trauma exposure and its aftermath can lead to developmental disruptions in the form of regressive behavior, reluctance or inability to participate in developmentally appropriate activities, and developmental accelerations such as leaving home at an early age and engagement in precocious sexual behavior. In turn, age, gender, and developmental period are linked to risk for exposure to specific types of trauma (e.g., sexual abuse, motor vehicle accidents, and peer suicide).
Developmental neurobiology underlies children’s reactions to traumatic experiences.
Children’s capacities to appraise and respond to danger are linked to an evolving neurobiology that consists of brain structures, neurophysiological pathways, and neuroendocrine systems. This “danger apparatus” underlies appraisals of dangerous situations, emotional and physical reactions, and protective actions. Traumatic experiences evoke strong biological responses that can persist and that can alter the normal course of neurobiological maturation. The neurobiological impact of traumatic experiences depends in part on the developmental stage in which they occur. Exposure to multiple traumatic experiences carries a greater risk for significant neurobiological disturbances, including impairments in memory, emotional regulation, and behavioral regulation. Conversely, ongoing neurobiological maturation and neural plasticity also create continuing opportunities for recovery and adaptive developmental progression.
Culture is closely interwoven with traumatic experiences, response, and recovery.
Culture can profoundly affect the meaning that a child or family attributes to specific types of traumatic events such as sexual abuse, physical abuse, and suicide. Culture may also powerfully influence the ways in which children and their families respond to traumatic events, including the ways in which they experience and express distress, disclose personal information to others, exchange support, and seek help. A cultural group’s experiences with historical or multigenerational trauma can also affect their responses to trauma and loss, their world view, and their expectations regarding the self, others, and social institutions. Culture also strongly influences the rituals and other ways through which children and families grieve over and mourn their losses.
Challenges to the social contract, including legal and ethical issues, affect trauma response and recovery.
Traumatic experiences often constitute a major violation of the expectations of the child, family, community, and society regarding the primary social roles and responsibilities of influential figures in the child’s life. These life figures may include family members, teachers, peers, adult mentors, and agents of social institutions such as judges, police officers, and child welfare workers. Children and their caregivers frequently content with issues involving justice, obtaining legal redress, and seeking protection against further harm. They are often acutely aware of whether justice is properly served and the social contract is upheld. The ways in which social institutions respond to breaches of the social contract may vary widely and often take months or years to carry out. The perceived success or failure of these institutional responses may exert a profound influence on the course of children’s post-trauma adjustment, and on their evolving beliefs, and attitudes and values regarding family, work, and civic life.
Working with trauma-exposed children can evoke distress in providers that makes it more difficult for them to provide good care.
Mental healthcare providers must deal with many personal and professional challenges as they confront details of children’s traumatic experiences and life adversities, witness children’s and caregivers’ distress, and attempt to strengthen children’s and families’ belief in the social contract. Engaging in clinical work may also evoke strong memories of personal trauma- and loss-related experiences. Proper self-care is an important part of providing quality care and of sustaining personal and professional resources and capacities over time.
A key to trauma-informed care is recognizing many, but not all, clients have trauma-related needs and would benefit from a trauma-specific intervention. To identify who would benefit from a trauma-specific intervention and to guide future interactions with those with a trauma history in a way that does not exacerbate past traumas or unnecessarily trigger trauma memories, a broad trauma-screening system is indicated. Where possible, a trauma-informed approach suggests the use of a reliable and valid screening tool for identifying the client’s trauma history and traumatic stress responses, and to make direct referrals for assessment and treatment when indicated (Conradi, Wherry, & Kisiel, 2011).
Enhance Client Well-Being and Resilience
Some individuals who have experienced maltreatment and subsequent trauma are more resilient than others; most often, these individuals have both internal and external resources, such as strong relationships; success in school, work, or other activities; and a temperament that helps them manage stress more readily. It is important for the social worker or other helping professional to recognize and build on the client’s existing strengths, while linking them to trauma-informed services when needed. Trauma-informed care seeks to support positive relationships in the client’s life and minimize disruptions of what is familiar, and to make sure that positive figures, including parents, children, teachers, neighbors, siblings, and other relatives, remain involved in client’s lives.
For many clients, recovery requires the support of specially trained mental health professionals who are schooled in evidence-based treatment models that are tailored to meet the needs of the clients. Any decision to treat a client with a history of significant trauma should be based on a thorough assessment that yields a clear picture of their unique strengths and needs. For children, this type of multidimensional assessment algorithm is exemplified by the Trauma Assessment Pathway (Chadwick Center for Children and Families, 2009; Taylor, Gilbert, Mann, & Ryan, 2005; Igelman, Taylor, & Gilbert, 2007) developed at the Chadwick Center for Children and Families at Rady Children’s Hospital in San Diego (www.chadwickcenter.org) with support from SAMHSA. The assessment should be designed to match the client to the evidence-based or evidence-informed treatment model best suited for their unique needs. It is important to remember that trauma often co-occurs with other major behavioral health disorders. In some cases, trauma serves as a precursor for another disorder like substance abuse. In other cases, another disorder, such as some forms of serious mental illness, may precede the trauma events or develop independently of the trauma history, and the assessment must explore those connections.
Recovery from trauma often requires the right evidence-based or evidence-informed mental health treatment, delivered by a skilled therapist, that helps the client reduce the overwhelming emotions related to the trauma, manage the behavioral and emotional symptoms of traumatic stress, address any traumatic grief issues the traumas produced, cope with trauma triggers, and make new meaning of his or her trauma history. The treatment also may need to address a second co-occurring disorder first, or a treatment model should be selected that addresses the co-occurring disorder in a trauma context, such as how Seeking Safety addresses substance abuse (Najavits, Weissbecker & Clark, 2007; Najavits, 2009).
There are numerous evidence-based treatment models now available that have been empirically tested with highly traumatized children and adults and fit well in a trauma-informed environment. Seeking out the empirical evidence on each possible model can be overwhelming for those actively involved in service delivery. Fortunately, there are multiple Internet-based clearinghouses that contain trauma-specific interventions in which the research reviews have already been conducted (see www.nrepp.samhsa.gov; www.cebc4cw.org; www.colorado.edu/cspv; and www.samhsa.gov/nctic).
Enhance Family Well-Being and Resilience
When it comes to child trauma victims and many adults, especially transition-age youths, families are a critical part of their recovery and enhance their natural resilience. However, families may find it difficult to be protective if they have been affected by trauma themselves, and they may need help and support in order to draw on their natural strengths.
Asking parents and other caregivers about their history of trauma provides critical information to social workers or other helping professionals about their behavior and needs, as well as helping inform service planning for all family members. It is common for the parents of traumatized children and young adults to share a significant trauma history. Sometimes that history is based in childhood experiences such as physical or sexual abuse, or it may be contemporary, such as ongoing intimate-partner violence.
Providing effective trauma-informed education and professionally delivered trauma-informed services to parents enhances their protective capacities, thereby increasing their children’s resilience and feelings of safety, permanency, and well-being. Additionally, educating other caregivers, foster parents, members of the child’s safety network and the parent’s support system enhances their protective capacities, thereby reducing the risk that the child will be inadvertently exposed to trauma triggers or have their behaviors, which may be trauma-related, misidentified as “bad” and subject the child to inappropriate and trauma-insensitive discipline or punishment.
Those working with these families must recognize that caregivers may also experience secondary traumatic stress related to their children’s trauma, and provide them with appropriate training and supports.
Enhance the Well-Being and Resilience of Those Working in the System
While the origins of trauma-informed care are clearly centered on the clients served, it is apparent that the professionals working with highly traumatized populations are also profoundly affected by the experience. Those experiences can influence their judgments on the job, invade their private lives, and shape their worldview at home as well as at work. Those working in a trauma-informed environment must be aware of this sometimes-insidious side effect of serving this population. Trauma-informed organizations must consider their staff’s physical and psychological safety. Actively working to increase staff resilience to secondary traumatic stress (STS) involves seeking ways to reduce the risk of STS among all personnel—from the receptionists, to transcriptionists, to the frontline professionals and their supervisors; identifying the early signs of STS among personnel; minimizing the impact of STS; and promoting effective interventions for secondary traumatic stress. Helping staff manage professional and personal stress and addressing the impact of secondary traumatic stress on both individuals and on the system as a whole is beneficial for all levels, from client to community.
Partner with Agencies and Systems that Interact with Clients
Because trauma can impact many aspects of an individual’s life, it is important that those aspiring to provide trauma-informed care partner with others in parallel service systems in identifying and addressing trauma. Working with allied professionals who know the clients and family can help in developing an appropriate service plan and prevent potentially competing priorities.
Failure to work together can not only undermine all the efforts to provide trauma-informed care, but actually can inadvertently add new traumas. Well-meaning agencies or professionals pursuing their own mission and goals independently can work at cross-purposes and trigger traumatic reactions, causing more harm. In fact, this was the genesis of the child-advocacy center movement (see www.nationalcac.org and www.nationalchildrensallaince.org) which began when the grandmother of an abused child in Huntsville, Alabama, protested to the district attorney how uncoordinated agencies in child protection, law enforcement, health care, and prosecution were not only operating independently, but were making things worse for her grandchild. The result was a national movement starting in the 1980s to create a multidisciplinary investigative team response to child-abuse allegations. This model was designed so that all aspects of the forensic investigation process were reconfigured to be child-centered, with tasks focused on providing all services in a single location, reducing unnecessary duplication of interviews, and having representatives from all involved agencies co-located. All this was done to enhance the possibility the system did not re-traumatize the child through lack of coordination and communication among the professionals.
A truly trauma-informed system is one in which all the disparate elements understand trauma, and, as articulated by the NCTSN, “infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policie” (NCTSN, 2012, What is a trauma-informed child- and family-service system? section, para. 1). To achieve this lofty goal, those aspiring to deliver true trauma-informed care need to establish strong partnerships with others serving the same clients and families. Service providers should develop common protocols and frameworks where possible for documenting trauma history, exchanging information, coordinating assessments, and planning and delivering services.
Moving to Trauma-Informed Care
Several organizations have developed formal self-assessment tools to help organizations and systems assess the degree to which they have become trauma-informed or are ready to move in that direction. Among the stronger assessments are Community Connections’ Creating Cultures of Trauma-Informed Care: a Self-Assessment and Planning Protocol (Fallot & Harris, 2009); the Chadwick Center’s Community Trauma-Informed Assessment Protocol (Hendricks, Conradi, & Wilson, 2011) and Trauma System Readiness Tool (Hendricks, Conradi, & Wilson, 2011); the National Center on Family Homelessness’s Trauma-Informed Organizational Toolkit (Guarino et al., 2009); and Western Michigan University’s Trauma-Informed System Change Instrument (Richardson, Coryn, Henry, Black-Pond, & Unrau, 2010). The NCTSN has developed training resources to support transformation efforts at the system level, with Caring for Children Who Have Experienced Trauma: A Resource Parent Curriculum, and Child Welfare Trauma Training Tookit (Child Welfare Committee, National Child Traumatic Stress Network, & The California Social Work Education Center, 2013). Early studies show these type resources show promise in practice change efforts (Kramer, Sigel, Conners-Burrow, Savary, & Tempel, 2013).
Trauma-informed care is not so much a new model of service delivery as it is an approach to service delivery. It weaves trauma knowledge and sensitivity into existing actions and models in a way that avoids or minimizes negative side-effects of intervention and increases the likelihood of meaningful engagement and effective implementation of other models. Effective trauma-informed care does rely on the capacity to deliver evidence-based and evidence-informed trauma-specific interventions when needed, but it goes further in viewing the whole service-delivery experience through a trauma lens. Trauma-informed care engages the customers and clients as partners, empowering them to help guide their intervention and seeking out the unique path to safety and resilience that will give the clients the capacity to face and overcome trauma triggers and new adversities in the future.
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