Polyvictimization and Child Trauma: Identifying and Addressing Client Needs

1
Polyvictimization and Child Trauma Identifying
and Addressing Client Needs

• Howard Davidson, JD
• Howard.Davidson_at_americanbar.org
• Lisa Conradi, PsyD
• lconradi_at_rchsd.org
• Lisa Pilnik, JD, MS
• lisa_at_childfamilypolicy.com

2
Presentation Agenda

• Background on Polyvictimization
• Child Trauma Causes and Symptoms
• Screening Tools and Interventions
• Practice Tips for Attorneys
• Additional Resources
• Questions?
• The materials in this presentation is for
  informational purposes only and is not meant to
  constitute legal advice. Please consult an
  attorney for opinions regarding specific facts,
  cases or legal issues.

3
National Survey of Childrens Exposure to
Violence

• Childrens exposure to violence, whether as
  victims or witnesses, is often associated with
  long-term physical, psychological, and emotional
  harm. Children exposed to violence are also at a
  higher risk of engaging in criminal behavior
  later in life and becoming part of a cycle of
  violence.
• Finkelhor, D., Turner, H., Ormrod, R.,
  Hamby, S., and Kracke, K. 2009. Childrens
  Exposure to Violence A Comprehensive National
  Survey. Bulletin. U.S. Department of Justice,
  Office of Justice Programs, Office of Juvenile
  Justice and Delinquency Prevention

4

• Children exposed to violence are more likely to
  abuse drugs and alcohol suffer from depression,
  anxiety, and post-traumatic disorders fail or
  have difficulty in school and become delinquent
  and engage in criminal behavior.
• 60 percent of American children were exposed to
  violence, crime, or abuse in their homes,
  schools, and communities.

5

• Almost 40 percent of American children were
  direct victims of two or more violent acts, and
  one in ten were victims of violence five or more
  times.
• Children are more likely to be exposed to
  violence and crime than adults.
• Almost 15 percent of children experienced an
  assault with a weapon and were injured as a
  result.

6

• Almost 1 in 10 American children saw one family
  member assault another family member, and more
  than 25 percent had been exposed to family
  violence during their life.
• 10 percent suffered some form of child
  maltreatment.
• A childs exposure to one type of violence
  increases the likelihood that the child will be
  exposed to other types of violence and exposed
  multiple times.

7
Advocating for Victimized Youth

• preventing further victimization and trauma
• treating the underlying child and family
  vulnerabilities
• broadening what child protective and child
  welfare services agencies should be providing to
  these children and
• advocacy for building the supervision and
  protective capabilities of those adults who are,
  or will be, caring for them.

8
Recommendations

• Every child advocacy legal training should now be
  including a section on recognizing and responding
  to traumatized children, regardless of what part
  of the juvenile court theyre involved in.
• Look at childhood victimization more broadly
  how to identify and address it even if it
  appears unrelated to the incident that brought
  the child client before the court.
• Court appointed child advocates should be more
  aware of their clients victimization and trauma
  history -- and most importantly how they can
  effectively advocate for services their clients
  need to address the adverse consequences of that
  history.

9
What does the word trauma mean?
10
A traumatic experience . . .

• Threatens the life or physical integrity of a
  child or of someone important to that
  child (parent, grandparent, sibling)
• Causes an overwhelming sense of terror,
  helplessness, and horror
• Produces intense physical effects such as
  pounding heart, rapid breathing, trembling,
  dizziness, or loss of bladder or bowel control

11
Types of Trauma
Acute trauma
A single event that lasts for a limited time
Chronic trauma

• The experience of multiple traumatic events,
  often over a long period of time

Complex trauma is used to describe a specific
kind of chronic trauma and its effects on
children

• Multiple traumatic events that begin at a very
  young age
• Caused by adults who should have been caring for
  and protecting the child

12
How Children Respond to Trauma
Long-term trauma can interfere with healthy
development and affect a childs

• Ability to trust others
• Sense of personal safety
• Ability to manage emotions
• Ability to navigate and adjust to lifes changes
• Physical and emotional responses to stress

13
How Children Respond to Trauma(Continued)
A childs reactions to trauma will vary depending
on

• Age and developmental stage
• Temperament
• Perception of the danger faced
• Trauma history (cumulative effects)
• Adversities faced following the trauma
• Availability of adults who can offer help,
  reassurance, and protection

14
Long-Term Effects of Childhood Trauma

• In the absence of more positive coping
  strategies, children who have experienced
  trauma may engage in high-risk or destructive
  coping behaviors.
• These behaviors place them at risk for a range of
  serious mental and physical health problems,
  including
• Alcoholism
• Drug abuse
• Depression
• Suicide attempts
• Sexually transmitted diseases (due to high risk
  activity with multiple partners)
• Heart disease, cancer, chronic lung disease,
  skeletal fractures, and liver disease
  

Source Felitti et al. (1998). Am J Prev
Med14(4)245-258.
15
The Adverse Childhood Experiences Study (ACE)
16
Trauma and Behavior Problems in Children

• Children who have been traumatized stay in
  chronic states of fear and anxiety leading to
  hypervigilance and a heightened sense of threat
• Traumatized children often misinterpret the
  behavior of others as hostile and respond with
  aggression
• Past victimization can lead to survival
  strategies that are often anti-social and/or
  self-destructive
• Adolescents may respond to their experience
  through dangerous reenactment behavior or
  recklessness.

17
Common Diagnoses

• Some common diagnoses for children experiencing
  traumatic stress include
• Posttraumatic Stress Disorder
• Reactive Attachment Disorder
• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Bipolar Disorder
• Substance Abuse
• Conduct Disorder
• These diagnoses generally do not capture the full
  extent of the developmental impact of trauma.
• Many children with these diagnoses have a complex
  trauma history.

18
How does trauma ? Acting out?
Victimization Loss of personal integrity
andcontrol
Survival Coping Dysregulation of emotions and
info processing Rigid, distrustful, callous on
outside Damaged, hopeless, empty inside
Victim Coping Taking any means necessary to
avoid revictimization Loss of empathy and
impulse control Diminished sense of future
Defiance as a desperate attempt to redress
injustice and regain sense of control (Ford,
Chapman, Mack, Pearson, 2006)
19
Screening and Assessment
20
Trauma Screening

• Trauma-informed screening refers to a brief,
  focused inquiry to determine whether an
  individual has experienced specific traumatic
  events or reactions to trauma and if they need
  trauma-focused mental health treatment.
• Done by front-line workers, such as Child Welfare
  and, in some cases, mental health.
• Usually includes questions regarding a childs
  exposure to trauma and his/her symptoms

21
Trauma-Informed Assessment

• Trauma assessment is a more in-depth exploration
  of the nature and severity of the traumatic
  events, the impact of those events, current
  trauma-related symptoms and functional
  impairment.
• Usually done by a mental health provider to drive
  treatment planning.
• A good trauma assessment usually occurs over at
  least 2-3 sessions of therapy and includes a
  clinical interview, use of objective measures,
  behavioral observations of the child, and
  collateral contacts with family, caseworkers,
  etc.
• Domains covered include
• Basic demographics
• Family history
• Trauma history (comprehensive, including events
  experienced or witnessed)
• Developmental history
• Overview of child problems/symptoms.

22
Who Needs Trauma-Focused Treatment?

• Children who have experienced extreme trauma,
  such as a penetrating injury (gun shoot,
  stabbing, etc) or sexual assault
• Children who are re-experiencing the traumatic
  events in their nightmares, in flashbacks,
  repetitive play, or those who react strongly to
  reminders of their trauma
• Children who are actively avoiding reminders
  (people, places, sounds, smells, etc) of the
  trauma

23
What are the Core Components of Evidence-Based
Trauma Treatment?

• Building a strong therapeutic relationship
• Psycho-education about normal responses to trauma
• Parent support, conjoint therapy, or parent
  training
• Emotional expression and regulation skills
• Anxiety management and relaxation skills
• Cognitive processing or reframing

24
Core Components of Trauma-Focused Treatment,
contd

• Opportunity for trauma integration
• Strategies that allow exposure to traumatic
  memories and feelings in tolerable doses so that
  they can be mastered and integrated into the
  childs experience
• Personal safety training and other important
  empowerment activities
• Resilience and closure

25
How Do These Core Components Fit Together to
Create Evidence-Based Practices?
26
Treatment Triage Examples of Evidence-Based
Treatments for Children

• Trauma-Focused Cognitive Behavioral Therapy
  (TF-CBT)
• Child-Parent Psychotherapy (CPP)
• See www.cebc4cw.org for more information on other
  modalities that exist
• There are many different evidence-based
  trauma-focused treatments. A trauma-informed
  mental health professional should be able to
  determine which treatment is most appropriate for
  a given case.

27
Practice Tips

• Ensure children and youth receive appropriate
  screenings, assessments and treatments for
  traumatic stress as appropriate
• Ask about follow-up and request that ongoing
  assessments, where appropriate.
• Request that parents and caregivers receive
  services as well, when appropriate.

28
Practice Tips (cont.)

• Ensure that biological and foster families learn
  about the effects of victimization and warning
  signs for dangerous symptoms of traumatic stress.
  
• Help youth stay in the least restrictive setting
  possible. (e.g., their own homes, when safe and
  possible, or therapeutic or family foster homes,
  rather than group facilities, when necessary).

29
Practice Tips (cont.)

• Help build long-term sustaining relationships
  (e.g., connecting youth to mentoring
  organizations or faith-based groups, supporting
  relationships with extended family members)
• Ensure the child or youth is both physically and
  psychologically safe (e.g., working with a
  provider who is respectful, non-judgmental, and
  allows the youth to explore his/her history in a
  safe and supportive manner)

30
New Resources Coming Soon

• Resources being developed by the Safe Start
  Center,
• ABA Center on Children and the Law and Child
  Family Policy Associates
• Issue Brief on Trauma Informed Legal Advocacy
• Identification Tool and Resource Guide on
  Polyvictimization and Trauma among Court-Involved
  Youth
• Will be available at www.safestartcenter.org or
  e-mail lisa_at_childfamilypolicy.com to receive when
  available

31
Issue Brief Trauma-Informed Advocacy

• Part of Safe Start Centers Moving from Evidence
  to Action series
• Prevalence and impact of exposure to violence
• Symptoms of traumatic stress
• Evidence-based assessments and interventions
• Practice tips for attorneys and others
• State/local initiatives
• Special considerations/ethical issues
• Policy recommendations

32
Identification Tool and Resource Guide

• Information Integration Tool
• Questions about experiences and symptoms
• No score ? Flowchart on referrals for services
• Guidance on how to use the tool, understanding
  child trauma, policy/practice considerations
• Resources on prevalence/impact, trauma-focused
  assessments and intervention, and trauma-informed
  advocacy

33
Other Resources

• Polyvictimization Childrens exposure to
  multiple types of violence, crime, and abuse
• www.unh.edu/ccrc/pdf/jvq/Polyvictimization20OJJDP
  20bulletin.pdf
• Understanding Children's Exposure to Violence
• http//safestartcenter.org/pdf/IssueBrief1_UNDERST
  ANDING.pdf
• National Child Traumatic Stress Network Child
  welfare trauma training toolkit
• www.nctsn.org/products/child-welfare-trauma-traini
  ng-toolkit-2008

34
Other Resources cont.

• Birth parents with trauma histories and the child
  welfare system A guide for judges and attorneys
• www.nctsn.org/sites/default/files/assets/pdfs/birt
  h_parents_trauma_guide_judges_final.pdf
• CAC directors guide to mental health services
  for abused children
• www.nctsnet.org/sites/default/files/assets/pdfs/CA
  C_Directors_Guide_Final.pdf
• Healing invisible wounds Why investing in
  trauma-informed care for children makes sense
• www.justicepolicy.org/images/upload/10-07_REP_Heal
  ingInvisibleWounds_JJ-PS.pdf

35

• Questions?

36
Contact

• Howard Davidson, JD
• ABA Center on Children and the Law
• Howard.Davidson_at_americanbar.org
• Lisa Conradi, PsyD
• Chadwick Center/Rady Childrens Hospital
• lconradi_at_rchsd.org
• Lisa Pilnik, JD, MS
• Child Family Policy Associates
• lisa_at_childfamilypolicy.com