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All children in the child welfare system have been neglected, abused, or abandoned. By definition these children have suffered trauma. They have been traumatized in their homes of origin and they suffer further trauma if they are moved about in foster care, neglected, abused or poorly placed. This experience of trauma increases vulnerability to stress, affects the capacity to problem solve, and results in a resistance to change. If these children are misunderstood as behavior disordered or mentally ill then their care and treatment will be ineffective in meeting their needs and possibly destructive to their development beyond the damage done by the trauma they experience.

“Unless caregivers [and professionals] understand the nature of trauma reenactments, they are likely to label the child as ‘oppositional’, ‘rebellious’, ‘unmotivated’, or ‘anti-social’.”

Bessel A. van der Kolk, M.D. Developmental Trauma Disorder.

 

Trauma Informed Practice Involves a Paradigm Shift

In order to ensure that children in the child welfare system receive effective care that meets their needs, a trauma informed practice involves a paradigm shift in how these children are treated.

  • The focus should be “What Happened to You?” not “What is Wrong with You?”
  • The child should be viewed as injured, not as behaviorally bad or emotionally ill or genetically flawed.
  • The child’s responses or behavior were adaptive in a neglectful/abusive environment.
    However, in a normal environment these responses may be seriously maladaptive.
  • The move to a safe environment, alone, may not change the child’s behavior.
  • Structural changes may have occurred in the child’s brain itself.
  • If the child is failing, the care and treatment is not providing what the child needs.
  • It is not the child failing the treatment program, it is the program failing the child.
  • Trauma-informed assessment, treatment, and environment are essential.

Jim Henry, Mark A. Sloane, Frank Vandervort: Building Resilience in Traumatized Children.  Power Point Presentation August 15, 2012.

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Operationalizing a Trauma-Informed Practice

The National Child Traumatic Stress Network, recognizing the importance of institutionalizing child trauma research, developed a trauma-informed child welfare model of practice, which includes:

  1. Support positive and stable relationships in the life of the child.
  2. Maximizing the child’s sense of safety.
  3. Services to the child should be guided by a thorough assessment of the child’s experiences and their impact on the child’s development.
  4. Assist children in reducing overwhelming emotion.
  5. Help children make new meaning of their trauma history and current experiences.
  6. Address the impact of trauma and subsequent changes in the child’s behavior, development and relationships.
  7. Provide support and guidance to the child’s family and caregivers.
  8. Coordinate services with other agencies.
  9. Manage professional and personal stress.

Connie Black-Pond, James Henry A Trauma-Informed Child Welfare Systems Practice: The Essential Elements. Michigan Child Welfare Law Journal. p 11- 23 Winter 2008.
See also http://www.nctsn.org/resources for resources on how to parent, train and/or educate children that have experienced trauma.

 

Trauma Informed Legal Practice

With regard to legal representation of children in foster care, trauma-informed legal practice can strengthen legal advocacy, improve attorney-client relationships, and ensure appropriate screening, in-depth assessment, and evidence-based treatment. In addition, awareness of secondary traumatic stress can improve prevention, identification, and self-care among legal professionals.  See "Trauma: What child welfare attorneys should know," National Child Traumatic Stress Network, Justice Consortium Attorney Workgroup Subcommittee (2017) informational guide released by the American Bar Association Center on Children and the Law.

 

Relationship - Based Therapy - One Significant Component

“This [case study] follows a five-year treatment of a little girl in foster care…It is full of enactments, demonstrating the pervasive nature of unprocessed trauma where felt experiences of the child’s history reverberate in unremembered form throughout the system. It focuses on the way children with multiple placements in long-term foster care repeatedly reenact their traumatic, disassociated experiences of early and recurring loss. The recurring reenactments take different forms as the child develops chronologically, but the undergirding theses of abandonment, destruction, and loss of self pervade. When these unformulated affective memories are triggered by way of environment, the child often reenacts in destructive and aggressive ways that neither they nor important others can understand…For many children in foster care the ever-changing environment is without continuity or memory.”  Chapter Nine, page 136.

For this and other illustrative case studies see: Treating Trauma: Relationship-Based Psychotherapy with Children, Adolescents, and Young Adults edited by Toni V. Heineman, June M. Clausen, and Saralyn C. Ruff, Jason Aranson (2013).

Connie Black-Pond and James Henry provide a helpful matrix of how various people may provide a child in the welfare system with positive and stable relationships:

BOX 1
Role Trauma-Informed Activity
Child Welfare Worker Frequent contact with child. Willingness to listen. Inform without making promises.
Court Provide orders to support contacts with important people in child’s life.
Resource Parents Respect child’s distrust. Build relationship through predictability.
Mental Health Relationship building as foundation to therapy
Medical Provide continuity in care. Obtain medical and trauma history.
Schools Develop relationships with children that provide safety and predictability

Connie Black-Pond, James Henry, A Trauma-Informed Child Welfare Systems Practice: The Essential Elements. Michigan Child Welfare Law Journal. p.16 Winter 2008.

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Traumatized Children Require a Comprehensive Trauma Informed Assessment, Trauma Informed Treatment and a Total Environment That Is Trauma Sensitive

“Most traumatized children now do not even receive a proper mental health assessment. Moreover, hundreds of thousands of them are numbed by powerful drugs that help control their “bad behavior,” but that do not deal with the imprint of terror and helplessness on their minds and brains. Drugs can sedate, but they do not help children deal with trauma – in fact, they may prevent recovery by interfering with learning and the formation of relationships, essential preconditions for becoming functioning adults.”

Bessel A. van der Kolk, M.D. Post-Traumatic Childhood. New York Times, May 10, 2011, page A-25.

“…we must first know how children are experiencing what they are exposed to if we want to determine what might be the most helpful and appropriate trauma-informed response….if the child’s experience involves terror, worry, guilt, feeling powerless, then that event may become traumatic.” p. 4, 7

“When we say someone is experiencing trauma, the one word that best describes that experience is terror. We define terror as feeling totally unsafe and powerless.” p.8

“Neuroscience has confirmed that trauma is experienced in the mid brain and lower brain, sometimes referred to as the “feeling” brain or the “survival” brain. Reason and logic, the ability to make sense of what has happened and act according simply are not accessible in trauma.” p.8

“Neuroscience documents that children in trauma are governed predominantly by the sensations associated with their traumatic memories – the sounds, smells, sensations of touch and visual memories. When these senses are triggered or activated by similar sensations associated with a real or even a perceived sense of impending danger, they don’t think but act on their senses.” p.9

“At this moment children need to experience something that is calming, soothing, familiar, safe; something they have engaged in previously that has allowed them to feel safe and in control…We can then verbalize we are there to help them. We can clarify what happened and what activated their survival response.” p. 10

It is therefore essential that the child’s entire environment – caregivers, school, after-school programs, child welfare system, and therapy — is trauma-informed.

Advancing Trauma-Informed Practices: Bringing Trauma-Informed, Resilience-Focused Care to Children, Adolescents, Families, Schools, and Communities The National Institute for Trauma and Loss in Children

 

Connie Black-Pond and James Henry provide a helpful matrix of how to ensure that a child in the welfare system has trauma-informed assessment:

BOX 3
Role Trauma-Informed Activity
Child Welfare Worker Obtain trauma history. Make referral for trauma-informed assessment.
Court Order trauma-informed assessments on all children entering foster care.
Resource Parents Participate in assessment, providing observations and support. Obtain results through consultation with evaluator/therapist.
Mental Health Conduct or refer for comprehensive trauma assessments.
Medical Coordinate with the assessment process and consider treatment options that maximize a child’s functioning.
Schools Provide input including classroom observations. Utilize findings to support safety plans, academic support, and social support in the child’s plan.

Connie Black-Pond, James Henry, A Trauma-Informed Child Welfare Systems Practice: The Essential Elements. Michigan Child Welfare Law Journal. p.17 Winter 2008.

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Comprehensive Assessment Is the Foundation

Assessment forms the foundation for effective practice with children and families.  Agency risk and safety assessment are often not sufficiently comprehensive.

Comprehensive Assessment Must include:

  • Mental functioning
  • History of maltreatment
  • Exposure to violence in the home and community
  • Loss of significant relationships
  • Medical needs
  • Educational status and needs
  • Neurodevelopmental functioning

Must be functional in nature – not just a paper and pencil test or I.Q. test.

Frank Vandervort, Mark A. Sloane, Building Resilience in Traumatized Children Power Point Presentation June 26, 2013.

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Assessment Guidelines for Infants and Young Children

  1. “Always use multiple sources of information: ‘Assessment must be based on an integrated developmental model; involves multiple sources of information and multiple components’, ‘formal tests or tools should not be the cornerstone of the assessment of an infant or young child’.
  2. The child’s primary relationship is the cornerstone of an assessment: ‘The child’s relationships and interactions with his most trusted caregiver should form the cornerstone of an assessment’.
  3. Do not separate child from parents: ‘Young children should never be challenged during assessment by separation from their parents or familiar caregivers’.
  4. The examiner should know the child: ‘Young children should never be assessed by a strange examiner’.”

S.I Greenspan and S.J. Meisels, (1996) Toward a New Vision for the Developmental Assessment of Infants and Young Children. pp. 17, 19, 23, 24 as cited in Connie Lillas and Janiece Turnbull Infant/Child Mental Health, Early Intervention, and Relationship-Based Therapies. (2009) W.W. Norton Co., Inc. New York, pp. 161-162.

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Trauma in Infancy and Early Childhood

"Social-emotional and other skills are interwoven from birth and develop together in the context of a child’s early experiences. Self-esteem, motivation, persistence, and self-regulation are key indicators of healthy social-emotional development, and result from positive early relationships and stable environments. Healthy social-emotional development also leads to improved academic performance and career prospects, as well as better adult health outcomes. By contrast, growing evidence suggests that poor social-emotional development may contribute to mental illness, obesity, drug dependence, and many other health challenges. It is not difficult to draw connections between how individuals with poor social-emotional skills are challenged personally, and the broader implications for their communities and our country." Leila Rock and Sarah Crow, "Not Just 'Soft Skills': How Young Children’s Learning & Health Benefit from Strong Social-Emotional Development" Whitepaper by Too Small To Fail.

“The causes and symptoms of infant trauma differ from that of older children and adults because very young children are upset or frightened by different things than adults and preverbal children cannot manage intense emotions independently…While chronic stress and trauma can change the adult brain they can seriously alter the organization of the infant brain.

[W]hen infants do not get a predictable response to their distress cues, as in situations of neglect, their stress response systems are activated with no resolution. Long term exposure to ongoing elevated stress results in large amounts of cortisol in the brain, which can be toxic to the developing brain and may cause permanent changes in brain structure.

When parents are frightening to infants, such as being physically or emotionally abusive to the infant, violent to one another or consistently unresponsive to their baby’s cues and signals of stress, as in situations of chronic or severe neglect, babies experience intense stress as described above. This type of trauma is referred to as ‘cumulative’ or ‘relational’ trauma and has been linked to significant lifelong psychological harm and in extreme cases, to substantial neurological harm.

Babies and young children who are afraid of their caregiver, or who haven’t developed the expectation of a comforting response to distress cues, often have problems with self-regulation. These difficulties can initially appear as problems with feeding…,erratic sleep, inconsolable crying…, extreme passivity or listlessness, primitive and persistent self-soothing behaviors…, and/or dissociation (distinct period of disorientation or freezing)

The most effective intervention for infant emotional trauma is exposure to high quality, stable, predictable caregiving relationships.”

Evelyn Witherspoon, Erinn Hawkins, Pamela Gough, Emotional Trauma in Infancy. (2009) Centre of Excellence for Child Welfare Information Paper #75E, Canada.

“Brain development is actually the process of creating, strengthening, and discarding connections, called synapses, among the neurons. Synapses organize the brain by forming pathways that connect the parts of the brain governing everything we do — from breathing and sleeping to thinking and feeling… By the age of 3, a baby’s brain has reached almost 90 percent of its adult size. The growth in each region of the brain largely depends on receiving stimulation, which spurs activity in that region… If the appropriate exposure does not happen, the pathways developed in anticipation may be discarded…If a child’s caretakers are indifferent or hostile, the child’s brain development may be impaired.

Babies are born with the capacity for implicit memory, which means they can perceive their environment and recall it in certain unconscious ways…In contrast, explicit memory, which develops around age 2, and is tied to language development…allows conscious recollections… children who have been abused or suffered other trauma may not retain or be able to access explicit memories…However, they may retain implicit memories…, and these may produce flashbacks, nightmares, or other uncontrollable reactions.

An enormous body of research now exists that provides evidence for the long-term damage of physical, sexual, and emotional abuse on babies and children…This chronic stimulation of the brain’s fear response means those regions of the brain are frequently activated. Other regions of the brain, such as those involved in complex thought and abstract cognition, are less frequently activated, and the child becomes less competent at processing this type of information…[E]motional abuse or severe deprivation…may permanently alter the brain’s ability to use serotonin, which helps produce feelings of well-being and emotional stability.

Neglect alone can be devastating…For children to master developmental tasks,…they need opportunities, encouragement, and acknowledgement from their caregivers. If this stimulation is lacking during children’s early years, the weak neuronal pathways that had been developed in expectation of these experiences may wither and die and the children may not achieve the usual developmental milestones…delays may extend to…cognitive-behavioral, socio-emotional, and physical development…severe global neglect can have devastating consequences… such as significantly smaller brains.

Intensive, early interventions are key to minimizing the long-term effects of early trauma on children’s brain development…In order to heal a damaged or altered brain, interventions must target those portions that have been altered. Because brain functioning is altered by repeated experiences that strengthen and sensitize neuronal pathways, interventions cannot be limited to weekly therapy appointments. Interventions must address the totality of the child’s life, providing frequent, consistent replacement experiences so that the child’s brain can begin to incorporate a new environment – one that is safe, predictable and nurturing.
Issue Brief. November 2009. Child Welfare Information Gateway.

 

The Bottom Line

The research on the most effective treatment to help child trauma victims might be accurately summed up this way: what works best is anything that increases the quality and number of relationships in the child’s life. Relationships matter. The currency for systemic change is trust, and trust comes through forming healthy relationships.

Bruce D. Perry and Maia Szalavitz: The Boy Who Was Raised As A Dog: What Traumatized Children Can Teach Us About Loss, Love, and Healing. (2006) Basic Books, p. 80.