TheEffectsofPsychologicalTraumaonChildrenand Adolescents

ReportPreparedfortheVermontAgencyofHumanServices DepartmentofHealth DivisionofMentalHealth Child,AdolescentandFamilyUnit

by KathleenJ.Moroz,DSW,LICSW

June30,2005

...Ifcliniciansfailtolookthroughatraumalensandtoconceptualize clientproblemsasrelatedpossiblytocurrentorpasttrauma,they mayfailtoseethattraumavictims,youngandold,organizemuchof theirlivesaroundrepetitivepatternsofrelivingandwardingoff traumaticmemories,reminders,andaffects. (page12)

TableofContents
DefinitionofPsychologicalTraumaandPostTraumaticStressDisorder(PTSD)...........2 LimitsofDSMIVRDefinitionofPTSD ...........................................................................3 TheEffectsofPsychologicalTrauma ..............................................................................4 TraumaandAttachment..................................................................................................5 TraumaandBrainDevelopment.....................................................................................6 LongtermEffectsofTrauma...........................................................................................7 WhoisatGreatestRisk?................................................................................................8 StressOverloadfromTraumaandAccumulatedEffectsontheImmuneSystem......... 10 HowManyChildrenAreAffectedbyTraumainVermont? ............................................ 12 ProtectiveandRiskFactors .......................................................................................... 14 TheCostsofTrauma..................................................................................................... 15 TheImportanceofEarlyIdentificationandEarlyIntervention ....................................... 16 ImprovingtheStandardofCare .................................................................................... 17 PromisingandEvidenceBasedTreatmentApproaches............................................... 18 ReachingChildrenWhoNeedMentalHealthCare ....................................................... 19 TheNeedforaDevelopmental,MindBodySpiritApproachtoAssessmentand Treatment...................................................................................................................... 19 TheNeedforaStageBasedApproachtoTreatment ................................................... 20 InnovativeNCTSNTreatmentApproaches ................................................................... 22 DevelopingAPublicSystemofCareofChild/YouthVictimsofTrauma ....................... 25 TheNeedforOngoingTrainingandSupervision .......................................................... 27 FindingsfromRecentSurveysandTrainingNeedsAssessmentsinVermont............. 27 SummaryandRecommendations ................................................................................. 29 ResourcesandReferences........................................................................................... 32 Websites ....................................................................................................................... 39

DefinitionofPsychologicalTraumaandPostTraumaticStressDisorder(PTSD) Traumaisdefinedasaphysicalorpsychologicalthreatorassaulttoachildsphysical integrity,senseofself,safetyorsurvivalortothephysicalsafetyofanotherperson significanttothechild(VermontCUPSHandbook,p.170).Childrenmayexperience traumaasaresultofanumberofdifferentcircumstances,suchas: Abuse,includingsexual,physical,emotional Exposuretodomesticviolence Severenaturaldisaster,suchasaflood,fire,earthquakeortornado Warorothermilitaryactions Abandonment Witnesstoviolenceintheneighborhoodorschoolsetting,includingfights,drive byshootings,andlawenforcementactions Personalattackbyanotherpersonorananimal Kidnapping Severebullying Medicalprocedure,surgery,accidentorseriousillness. Posttraumaticstressistraumaticstressthatpersistsafteratraumaticincidenthas endedandcontinuestoaffectachildscapacitytofunction.Ifposttraumaticstress continuesandthechildsneurophysiologicresponsesremainchronicallyaroused,even thoughthethreathasendedandthechildhassurvived,thenthetermposttraumatic stressdisorder(PTSD)isusedtodescribethechildsenduringsymptoms.Because traumaaffectsthechildsabilitytoselfregulate,bothphysicallyandemotionally,post traumaticsymptomsininfantsandyoungchildrenmayencompassoneormoreofa broadrangeofbehaviors,includingthefollowing: Difficultysleeping,eating,digesting,eliminating,breathingorfocusing Aheightenedstartleresponseandhyperalertness Agitationandoverarousal,orunderarousal,withdrawalordissociation Avoidanceofeyecontactand/orphysicalcontact Terrifiedresponsestosights,soundsorothersensoryinputthatremindthechild ofthetraumaticexperience(s),(forexample,adog,policesirenorthesmellof alcoholonapersonsbreath) Preoccupationwithorreenactmentofthetraumaticexperience(forexample,a childsplaymaytakeonanurgent,rigidqualityandbedominatedbypeople shootingeachotherwithpolicecarsandambulancesarrivingatthescene). Psychologicaltraumamayoccurduringasingletraumaticevent(acute)orasaresultof repeated(chronic)exposuretooverwhelmingstress(Terr,1992).Childrenexposedto chronictraumagenerallyhavesignificantlyworseoutcomesthanthoseexposedto acuteaccidentaltraumas.Inaddition,thefailureofcaregiverstosufficientlyprotecta childmaybeexperiencedasbetrayalandfurthercontributetotheadversityofthe experienceandeffectsoftrauma.Traumaticstressmaybetransmittedbyparentsto theirchildren.Parentswhosufferfromuntreatedposttraumaticstressdisorderoften havedifficultyestablishingasecureattachmentwiththeirchildrentheymayviscerally

transmittheirownfeelingsofanxiety,rageandhelplessness,andinsodoing,colorthe childsinternalmodelofselfandtheworld. Whencaregiversarethreatening,hurtfulorfrightening,theintentionalhumantohuman qualityofthetraumacausesmoreseverenegativeconsequencesforthechildthan traumafromaccidentalcauses(forexample,aflood,fireorinjury).Intruth,however,all traumamayengenderfeelingsofvictimization,lossofcontrol,despairand hopelessnessandbeliefsthattheworldisunsafeandlifeunfair.

LimitsofDSMIVRDefinitionofPTSD VanderKolkandcolleaguesexploredthesignificanceofdissociation,affect dysregulation,andsomatizationasassociatedfeaturesofPTSD(vanderKolk, Pelcovitz,Roth,Mandel,McFarlane&Herman,1996b).Amongotherthings,theyfound thatassociatedfeaturesoftenpersistforyears,evenafterfullblownPTSDsymptoms subside.TheyconcludedthateventhoughacutePTSDsymptomsmaysubsidebelow criteriaforPTSD,longtermpervasiveandoftensomaticconsequencesofexposureto traumaticstresscontinue. Theseassociateddisordersmustbeviewedaspartofthe continuumofdiffusephysiologicalchangesinitiatedbyatraumaticevent,and associatedinitiallywiththesyndromeofPTSD.Inreallife,theexpressionoftraumais notrigidlyset,butcomposesacontinuumbasedonthetypeandseverityofthetrauma, thepastexperienceofthevictim,theprevalenceofdissociation,age,gender,andmany otherfactors(Scaer,2001,p.130).Ignoringsomaticsymptomsandthemany subsyndromalexpressionsoftraumacreatesaninappropriatelylimitedappreciationof thedisastrouseffectsoflifetraumaonindividualandsocietalhealth. AlthoughtheDSMIVdefinitionofPTSDmaybenecessaryforstandardizationof diagnosisandtreatment,itcreatesanartificialbarriertothediagnosisoftraumatization, especiallywhereinfantsandyoungchildrenareconcerned. Scheeringa,Zeanahandcolleagues(1995,2001,2003)haveassessedthreegroupsof preschoolchildrenwhosufferedseveretraumasandfoundtheDSMIVcriteriafor PTSDinadequateforthisagegroup.Theyhavedevelopedcriteriafordiagnosing PTSDthatareanchoredinobservablebehaviors,moreobjectivethantheDSMIV criteria,andsensitivetothedevelopmentaldifferencesofyoungchildren(the PosttraumaticStressDisorderSemiStructuredInterviewandObservationRecordfor InfantsandYoungChildrendevelopedbyScheringa&Zeanah,1994).Amongother differences,infantsandtoddlersarepreverbalorbarelyverbalandcannotdescribewith wordstheirfeelingsandthoughts.Adultsoftenspeculateaboutwhatisgoingonwitha childandmakeinferencesfromtheirbehavior,butthesearenecessarilysubjecttobias anderror.Certainitemsincludedinthesenewcriteriaappeartooccuronlyininfants andtoddlersandnotinolderchildrenoradults(suchaslossofacquireddevelopment skills,especiallylanguageregressionandlossoftoilettraining,separationanxietyand thedevelopmentofnewfears,includingfearofthedark,fearoftoiletingalone,fearof strangers,andnewaggressivebehaviors.Failuretorecognizethesesymptomsof traumamayleadtounderdiagnosisormisdiagnosisoftraumaininfantsandyoung

children.And,asNorris(1992)statedinreferencetoadults,itcertainlyappearstrue forchildrenthatthelimitationsandconstraintsoftheDSMIVcriteriaresultina definitionofPTSDthatrepresentsonlythetipoftheicebergintermsofexperienced distress(p.416).

TheEffectsofPsychologicalTrauma Severepsychologicaltraumacausesimpairmentoftheneuroendocrinesystemsinthe body.Extremestresstriggersthefightorflightsurvivalresponse,whichactivatesthe sympatheticandsuppressestheparasympatheticnervoussystem.Fightorflight responsesincreasecortisollevelsinthecentralnervoussystem,whichenablesthe individualtotakeactiontosurvive(eitherdissociation,hyperarousalorboth),butwhich atextremelevelscancausealterationsinbraindevelopmentanddestructionofbrain cells. Inchildren,highlevelsofcortisolcandisruptcelldifferentiation,cellmigrationand criticalaspectsofcentralnervoussystemintegrationandfunctioning.Traumaaffects basicregulatoryprocessesinthebrainstem,thelimbicbrain(emotion,memory, regulationofarousalandaffect),theneocortex(perceptionofselfandtheworld)aswell asintegrativefunctioningacrossvarioussystemsinthecentralnervoussystem. Traumaticexperiencesarestoredinthechildsbody/mind,andfear,arousaland dissociationassociatedwiththeoriginaltraumamaycontinueafterthethreatofdanger andarousalhassubsided. Developmentofthecapacitytoregulateaffectmaybeunderminedordisruptedby trauma,andchildrenexposedtoacuteorchronictraumamayshowsymptomsofmood swings,impulsivity,emotionalirritability,angerandaggression,anxiety,depressionand dissociation.Earlytrauma,particularlytraumaatthehandsofacaregiver,can markedlyalterachildsperceptionofself,trustinothersandperceptionoftheworld. Childrenwhoexperiencesevereearlytraumaoftendevelopaforeshortenedsenseof thefuture.Theycometoexpectthatlifewillbedangerous,thattheymaynotsurvive, andasaresult,theygiveuphopeandexpectationsforthemselvesthatreachintothe future(Terr,1992). Amongthemostdevastatingeffectsofearlytraumaisthedisruptionofthechilds individuationanddifferentiationofaseparatesenseofself.Fragmentationofthe developingselfoccursinresponsetostressthatoverwhelmsthechildslimited capacitiesforselfregulation.Survivalbecomesthefocusofthechildsinteractionsand activitiesandadaptingtothedemandsoftheirenvironmenttakespriority.Traumatized childrenlosethemselvesintheprocessofcopingwithongoingthreatstotheirsurvival theycannotaffordtotrust,relaxorfullyexploretheirownfeelings,ideasorinterests. Characterologicaldevelopmentisshapedbythechildsexperiencesinearly relationships(Johnson,19851987).Youngtraumavictimsoftencometobelievethere issomethinginherentlywrongwiththem,thattheyareatfault,unlovable,hateful, helplessandunworthyofprotectionandlove.Suchfeelingsleadtopoorselfimage,

selfabandonment,andselfdestructiveness.Ultimately,thesefeelingsmaycreatea victimstateofbodymindspiritthatleavesthechild/adultvulnerabletosubsequent traumaandrevictimization. TraumaandAttachment Childrenwholackasecureattachmentrelationshipareatgreaterriskforextreme dysregulationofaffectinthefaceoftraumaandthedevelopmentofenduringpost traumaticstresssymptoms.Conversely,thepresenceofasecureattachment relationshipcanbuffertheadverseeffectsoftraumaandprovidethesafetyand nurturingthatallowsthechildtoprocessthetraumaticeventsandreturntoasenseof safetyandwellbeing.Secureattachmentbondsserveasprimarydefensesagainst traumainducedpsychopathologyinbothchildrenandadults(Finkelhor&Browne, 1984).Inchildrenwhohavebeenexposedtoseverestressors,thequalityofthe parentalbondisprobablythesinglemostimportantdeterminantoflongtermdamage (McFarlane,1988,p.184). Caregiversplayacriticalroleinmodulatingchildrensphysiologicalarousalbyproviding abalancebetweensoothingandstimulationthisbalance,inturn,regulatesnormalplay andexploratoryactivity.Adequatecaregiversmaintainanoptimallevelofphysiological arousalunresponsiveorabusiveparentsoftenpromotechronichyperarousalinthese children.Chronichyperarousal,inturn,contributestoachildsinabilitytoselfsootheor modulatestrongemotions.Recentresearchhasshownthatasmanyas80%ofabused infantsandchildrenhavedisorganized/disorientedattachmentpatterns,including unpredictablealterationsofapproachandavoidancetowardtheirmothers,aswellas otherconflictbehaviors(e.g.,prolongedfreezing,stilling,orslowedunderwater movements)(LyonsRuth,1991).Inthisway,earlyattunementmaycombinewith temperamentalpredispositionstoseteachchildscapacitytoregulatearousal limitationsinthiscapacityarelikelytoplayamajorroleinlongtermvulnerabilityto psychopathologyafterexposuretotraumatizingexperiences. Childrenformaninternalworkingmodelofthemselvesandoftheworldaroundthem throughtheirexperiencesinprimaryattachmentrelationships.Selfandworldviewsare underminedbyviolence,hostilityandfear.Insecurelyattachedchildrenlackprotection intheirmostimportantrelationshipsandifexposedtotrauma,theirlimitedcoping abilitiesaremorelikelytobecompletelyoverwhelmedbystress.Copingalone,with fewoptionsorresources,childrenrespondwithhyperarousalordissociation.Perry (2001)hasfoundthatyoungerchildrenandgirlsaremorelikelytorespondtotrauma withdissociationwhileolderchildrenandboysaremorelikelytorespondwith hyperarousal.Aresponsepatternthatincorporatesbothdissociationandhyperarousal mayallowformoreimmediaterecoveryfromtraumaandaquickerreturntopretrauma functioning.Traumashocksthebodyanddysregulatestheparasympatheticand sympatheticnervoussystems.Thechildsinitialneurophysiologicresponseto overwhelmingstressestablishesapatternofrespondingthatwillbetriggeredagainand again,atlowerandlowerthresholdsofthreat.Inthiswayapatternedresponse,linked

tothechildssurvival,becomesembeddedinthechildsneurophysiology.Embedded responsepatternsbecomemoreembeddedwithuseandmoredifficulttochange. Ifitistruethattraumatizedpeopletendtobecomefixatedattheemotionaland cognitivelevelatwhichtheyweretraumatizedaswasobservedbyJanet,Kardiner, andmanysubsequentstudentsoftraumatheywilltendtousethesamemeansto dealwithcontemporarystressesthattheyusedatthestageofdevelopmentatwhich thetraumafirstoccurred.Sincereciprocal,supportiveinteractionswithinsecure attachmentrelationshipsappeartobetheprimaryvehiclethroughwhichchildrenlearn toregulateinternalstatechanges(Putnam,1988),thenegotiationofinterpersonal safetyneedstobethefirstfocusoftreatment(vanderKolk,etal.,1996,p.204). TraumaandBrainDevelopment Wenowknowthatbraindevelopmentcontinuesafterachildisbornandthatearly experiencesshapethedevelopmentofthecentralnervoussystemandthechilds senseofself.Thebrainmediatesthreatswithasetofpredictableneurobiological responses.Twopredominantadaptiveresponsepatternstoextremethreatoccuralong 1)thehyperarousalcontinuum(fightorflight)and2)thedissociativecontinuum (freezing,numbnessandsurrender).Dissociationisadefenseagainstfearorpain.It allowschildrentoescapementallyfromfrighteningorpainfulthingsthatarehappening tothem.Eachoftheseresponsepatternsactivatesauniquecombinationofneural systems.Theneurophysiologicactivationseenduringanacutestressresponseina childisusuallyimmediateandreversible.However,thisresponsepatterntendsto occuragainandagainatincreasinglylowthresholdsofstimulation,andthemorethe patternisactivated,themoreittendstobereactivated.Inthisway,anacutestress responsecanbecomealonglasting,posttraumaticpatternofrespondingtostress. Severetraumainearlychildhoodaffectsalldomainsofdevelopment,including cognitive,social,emotional,physical,psychologicalandmoraldevelopment.The pervasivenegativeeffectsofearlytraumaresultinsignificantlyhigherlevelsof behavioralandemotionalproblemsamongabusedchildrenthannonabusedchildren. Inaddition,childrenexposedtoearlytraumaduetoabuseorneglectlagbehindin schoolreadinessandschoolperformance,theyhavediminishedcognitiveabilities,and manygoontodevelopsubstanceabuseproblems,healthproblemsandseriousmental healthdisorders.Seriousemotionalandbehavioraldifficultiesincludedepression, anxiety,aggression,conductdisorder,sexualizedbehavior,eatingdisorders, somatizationandsubstanceabuse.Earlychildhoodtraumacontributestonegative outcomesinadolescence,includingdroppingoutofschool,substanceabuse,andearly sexualactivity,increasingtheoccurrenceofsexuallytransmitteddiseases,early pregnanciesandprematureparenting.Earlychildhoodtraumacontributestoadverse adultoutcomesaswell,includingdepression,posttraumaticstressdisorder,substance abuse,healthproblems(likelyrelatedtoincreasedstressandwearandtearonthe immunesystem)anddecreasedoccupationalattainment(Harris,Putnam&Fairbank, 2004).

Althoughtherelativeeffectsofchildabuseandneglectvs.familyenvironmentaland geneticfactorshavebeendebated,recenttwinstudiesconfirmasignificantcausal relationshipbetweenchildabuseandmajorpsychopathology(Kendler,Bulik,Silberg, Hettema,Myers&Prescott,2000).Severetraumainearlychildhoodseemstosetin motionachainofeventsanegativetrajectorythatplacesthosechildrenwhohavethe greatestexposureandthefewestpositivemediatingoramelioratingfactorsatgreatest riskofsignificantdebilitatingeffectondevelopmentandincreasedoccurrenceof psychopathology(Perry,1997,1999,2001Eth&Pynoos,1985Pynoos,1994). LongtermEffectsofTrauma VanderKolk,etal.,(1996b),describedthefollowinglongtermeffectsoftrauma: Generalizedhyperarousalanddifficultyinmodulatingarousal o Aggressionagainstselfandothers o Inabilitytomodulatesexualimpulses o Problemswithsocialattachmentsexcessivedependenceorisolation Alterationsinneurobiologicalprocessesinvolvedinstimulusdiscrimination o Problemswithattentionandconcentration o Dissociation o Somatization Conditionedfearresponsestotraumarelatedstimuli Lossoftrust,hope,andasenseofpersonalagency Socialavoidance o Lossofmeaningfulattachments Lackofparticipationinpreparingforthefuture ColeandPutnam(1992)proposedthatpeoplescoreconceptsofthemselvesare definedtoasubstantialdegreebytheircapacitytoregulatetheirinternalstatesandby theirbehavioralresponsestoexternalstress.Inchildrentraumatizedbyabuse,alack ofdevelopment,orloss,ofselfregulatoryprocessesleadstoprofoundandtragic problemswithselfdefinition,including1)disturbancesofthesenseofself,suchasa senseofseparateness,lossofautobiographicalmemories,anddisturbancesofbody image2)poorlymodulatedaffectandimpulsecontrol,includingaggressionagainstself andothersand3)insecurityinrelationships,characterizedbydistrust,suspiciousness, lackofintimacy,aggressionandisolation. Thelackorlossofselfregulationispossiblythemostfarreachingeffectof psychologicaltraumainbothchildrenandadults.TheDSMIVfieldtrialsforPTSD clearlydemonstratedthattheyoungertheageatwhichthetraumaoccurred,andthe longeritsduration,themorelikelypeopleweretohavelongtermproblemswiththe regulationofanger,anxietyandsexualimpulses(vanderKolk,Roth,Pelcovitz,& Mandel,1993,p.187).

Inaddition,childrenexposedtotraumahavebeenshownconsistentlytohave increasedvulnerabilitytoinfections,includingthecommoncoldvirus,respiratory infections,EpsteinBarr,hepatitisB,Herpessimplexandcytomegalovirus.Antibodies totheseviralinfectionshavebeenshownconsistentlytorisewithstress.Scaer(2001) hypothesizedthatexposuretohighlevelsofchronicstressmayincreasesusceptibility toinfectiousdiseasesduetoimmunesuppression(p.73).Acutetraumainchildren increasesvulnerabilitytoinfectiousdiseasewhenserumcortisoliselevated.However, inchronicPTSD,serumcortisollevelstendtobelow,astatewherethemodulating effectofcortisolontheimmunesystemisdecreased.Underthesecircumstances,the biologicaleffectsofprolongedandoverwhelmingstressmayunderminefunctioningof theHPA(hepaticpituitaryadrenal)axis,increaseimmunesystemactivityandultimately creategreatervulnerabilitytoautoimmunediseases.Additionaldatarelatedtothis hypothesisisneeded.However,acluetothisprocessmaybefoundinstudiesof chronicautoimmunedisordersinpopulationsofpatientswhosehistoriesinclude prolongedandsevereexposuretotraumaticstress(Scaer,2001,p.74). Childrenandyouthwhoexperienceoverwhelmingpsychologicalstress,particularly thosewiththegreatestnumberofvulnerabilitiesandthefewestnumberofprotective factors,aremostatriskforalterationsinbrainneurophysiology,imprintingoftrauma basedresponsepatterns(i.e.,dissociation,numbing,freezing,hypervigilance, hyperarousal),andcompromisedintegrationofbrainfunctioningthatadverselyaffects learning,characterdevelopment,selfesteemandimmunesystemfunctioning.

WhoisatGreatestRisk? InthreemajorstudiesofchildrenandyouthexposedtotraumaintheUnitedStates(i.e., theGreatSmokyMountainStudy[GSMS],theNewYorkCity[NYC]studyandthe NationalInstituteofJustice[NIJ]study),thenumberofchildrenidentifiedasvictimsof seriousinterpersonalviolencewasshockinglyhigh.Childrenunderage16represented overonequarterofthosemostexposedtoserioustraumaintheGSMSstudy.Sixty fourpercentofchildrenandyouthintheNYCstudyhadexperiencedatleast1 traumaticeventbyage16,andatleast1significanttraumaticeventpriortotheattack ontheWorldTradeCenters.IntheNationalInstituteofJusticestudy,4million Americanyoungpeoplebetweentheagesof12and17hadexperiencedaserious physicalassaultduringtheirlifetimeand9millionyouthhadwitnessedseriousviolence duringtheirlifetime. TraumaismorecommoninthelivesofAmericanchildrenandadolescentsthanis generallyunderstood.Childrenandadolescentsexperiencetraumainmoreforms. Millionsenduretheprofoundbetrayalofphysicalandsexualabuse,oftenfromtrusted caregivers.Manychildrenandadolescentsarevictimsofandwitnessestoviolencein theirfamiliesaswellascommunityandschoolviolence.AsurveyofAmericanyouth betweentheagesof12and17conductedbyDeanKilpatrick,Ph.D.(Crouch,J.L., Hanson,R.F.,Saunders,B.E.,Kilpatrick,D.G.,&Resnick,H.S.,2000)estimatedthat 1.9millionadolescentshadbeenvictimsofsexualassault,3.9millionhadbeenvictims

ofphysicalassault,and8.8millionhadwitnessedviolence.Inaddition,thousandsof childrenandadolescentseachyearendurenaturalandmanmadedisasters,automobile andotheraccidents,animalattacks,neardrownings,lifethreateningillnessesand invasivemedicaltreatments.ManyAmericanyouthslivesaremarkedbymultipleand repeatedtraumasandthesecondaryadversitiesthatmayfolloworaccompanytrauma. TheDepartmentofJusticeestimatedthatbetweenoneandoneandonehalfmillion childrenwereassaulted,robbed,orrapedin1992(FederalBureauofInvestigation,US DepartmentofJustice,1994).TheCentersforDiseaseControlandPrevention(CDCP) reportedthat8.7millionchildrenundertheageof15wereseeninhospitalemergency roomsforinjuriesin1992(Burt,1995).PandianiandGhosh(2003)reportedthat 15,012Vermontchildren(definedasVermontresidentsunderage18)received emergencyroomtreatmentforinjuriesduringJanuarythroughDecember2001.Injuries werecategorizedintofourbroadgroups:unintentionalinjuries,injuriesthatwerethe resultofassault,selfinjuries,andotherinjuries.Thetotalnumberofchildrenwithin eachcategoryandutilizationofcommunitymentalhealthserviceswereasfollows: UnintentionalInjury12,14110%AssaultVictims20315%SelfInjury5756% OtherInjury2,61116%. Inaddition,theU.S.DepartmentofHealthandHumanServices,Administrationfor ChildrenandFamiliesreportedthat896,000childrenintheUnitedStateswere confirmedvictimsofchildabuseandneglectin2002.Manyofthesechildren/youth sufferedmultipleformsofsevereabuseandneglectbutwereonlyreportedunderone category.Therefore,thesedatadonotfullyrepresenttheextentofabusesufferedby thesechildren.Infact,reportsfromtheChildrensBureauindicatethatonlyonethirdof theactualabuseandneglectofchildrenandyouthcomestotheattentionofchild protectionagenciesintheUnitedStates.Thismeansthattheactualnumberof childhoodvictimsoftraumaduetoabuseandneglectintheUnitedStatesmaybeas highas2,688,000.Infact,currentestimatesofthenumberofchildrenabused, neglectedorexposedtodomesticviolenceexceed3millioncasesannually(National ChildTraumaticStressNetwork,2004).Thereisasignificantoverlapbetweenfamilies wherechildabuseanddomesticviolenceoccursmanychildrenwhoexperiencedirect traumafromabusearealsotraumatizedbywitnessingtheabuseofothersintheir families.Inaddition,manychildrenaretraumatizedbyexposuretoviolenceathome butdonotcometotheattentionofchildprotectionauthorities. ResearchhasshownthataboutoneinfourgirlsintheUnitedStatesexperiences sexualabusebythetimesheis18,andover300,000Americanchildrenaresexually abusedeachyear.Sexualabuseisamongthemostcommonlytreatedformsoftrauma seenbyNationalChildTraumaticStressNetwork(NCTSN)sites.Researchhasalso shownthatchildhoodsexualabuseislinkedtonumerousnegativeconsequencesin childhood,adolescence,andadulthood(NCTSNChildrenandTraumainAmerica, 2004,p.38). Whileallchildrenhavestrengthsandvulnerabilities,protectivefactorsinachildslife areunderminedbychildabuseorneglect.Thereisevidencethattraumasignificantly

reducesIQ,whichmaybeoneofthesinglemostprotectivefactorsinachildslife.In addition,childhoodtraumaisasignificantriskfactorforanumberofmajorpublichealth problems,includingdepression,substanceabuse,sexuallytransmitteddisease,and increasedhealthrisksduetocigarettesmokingandobesity.Depressionisthreetimes morelikelyinadultswhowereabusedaschildrenthaninthegeneralpublic. Depressionisatophealthproblemintheworldwithanestimatedcostof$44billion dollarsintheUnitedStatesin2003duetolostoccupationalproductivity.Childhood abusevictimsexperiencemultipleandmultigenerationalhealthconcerns,including increasedratesofheartdisease,cancerandliverdisease.Inaddition,thechildrenof childabuseandneglectvictimsareatsignificantlyincreasedriskofbeingvictimized themselves. Emergingevidencehasimplicatedtraumaticeventsinmajorpublichealthproblems suchasviolenceandcriminality,substanceabuse,academicandvocational dysfunction,andmentalandphysicalillness(Pynoos,1994Cicchetti&Rogosche, 1997Pelcovitz,Kaplan,DeRosa,Mandel&Salzinger,2000).Arecentstudyof16,000 participantsconductedbytheCenterforDiseaseControlandPrevention(CDCP) implicatedexperiencesofchildhoodtraumawithoutcomessuchasrateof imprisonment,substanceabuse,HIVstatus,unemploymentstatus,anduseof psychiatricservices(Felitti,Anda,Nordenberg,Williamson,Spitz,Edwards,Koss& Marks,1998). StressOverloadfromTraumaandAccumulatedEffectsontheImmuneSystem Inadditiontotherelativelyimmediateconsequencesofchildhoodtrauma,includingthe developmentofposttraumaticstressdisorder,severetraumainchildhoodmayproduce astateofsensitization,vulnerabilityordiminishedreservecapacitytostressthatresults inanoverwhelmingphysiologicalstressresponsethatisnotrecognizeduntilamuch laterstressortriggersanacuteorprolonged(andseeminglyunrelated)stressresponse. Scaer(2001)assertsthatthedeterminingfactorfortraumatizationmustbebasedon theresponseoftheindividualvictimtoatraumaticallystressfuleventortothe individualshabitualandcumulativeresponsetostressoveranextendedperiodoftime. McEwen(2002)referstothehumantendencytowardstressoverload,orthe neurophysiologicstateofbeingstressedout,asacompromiseofthebody/minds naturalabilitytoestablishandreestablishallostasisorallostaticload.Thus,stress overloadearlyinachildslifeandfrequentoveractivationofthestressresponse afterwardcanoverwhelmthebodysabilitytomanagestresseffectively.Children traumatizedbyearlyabusesufferanincreasedriskofdepression,suicide,substance abuse,andearlierillnessanddeathfromawiderangeofdiseases(McEwen,2002,p. 59). Traumaticstressintheearlyyearscaninfluencethedevelopmentofthebrain,including thereactivityofthestressresponseitself.Inthelate1980s,MichaelMeaneyofMcGill UniversityandRobertSapolskyofStanfordUniversityshowedthatnewbornratswere

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abletoadaptsuccessfullytothestressofbeinghandledorseparatedfromtheir mothersforabout10minutesaday(overatwoweekexperimentalperiod).Infact, theseratshadlessreactivestresshormonesandslowerratesofbrainagingwhenthey grewupthanratswhowerehandledorseparatedmoreornotatallfromtheirmothers (McEwen,2002).Ontheotherhand,overwhelmingstressinearlylife,eveninthe periodbeforebirth,forratsaswellashumaninfants,seemstomakethehypothalamic pituitaryadrenal(HPA)axismorereactiveandtospeedupbrainaging. Theconsequencesoftheseveretrauma,suchaschildabuseanddomesticviolence, appeartogofarbeyondserotoninpathwaysanddysregulationoftheHPAaxis.Inone ofthelargestinvestigationsonchildhoodtrauma,the1998AdverseChildhood ExperiencesStudy(ACES),researchersmailedquestionnairestoover13,000people whohadrecentlyhadmedicalworkupsattheSouthernCaliforniaPermanenteGroup inSanDiego.Thesepatientswereaskedabouttheirexperienceswithanyofseven categoriesofchildhoodtrauma:psychological,physical,orsexualabuseviolence againstthemotherorlivingwithhouseholdmemberswhohadproblemswith substanceabuse,mentalillness,wereeverimprisonedorcommittedsuicide.Over 9,000patientsresponded.Amongthosewhoreportedevenonesuchexposure,there weresubstantialincreasesinastartlingarrayofdisorders,includingsubstanceabuse, depression,suicide,andsexualpromiscuity,aswellasincreasedincidencesofheart disease,cancer,chroniclungdisease,extremeobesity,skeletalfracturesandliver disease. Insummary,exposuretoextremetraumaticstressaffectspeopleatmanylevelsof functioning:somatic,emotional,cognitive,behavioral,andcharacteriological(e.g.,van derKolk,1988Kroll,Habenicht,&McKenzie,1989Cole&Putnam,1992Herman, 1992b,vanderKolketal.,1993).Childhoodtraumasetsthestageforavarietyof psychiatricdisorders,suchasborderlinepersonalitydisorder(Herman,Perry,&vander Kolk,1989Ogata,Silk,Goodrick,Lohr,Westen&Hill,1989)somatizationdisorder (Saxe,Chinman,Berkowitz,Hall,Lieberg,Schwartz&vanderKolk1994),dissociative disorders(Ross,Heber,Norton&Andreason,1990Saxe,vanderKolk,Hall,Schwartz, Chinman,Hall,Lieberg&Berkowitz,1993Kluft,1991Putnam,1989),selfmutilation (vanderKolk,Perry,&Herman,1991),eatingdisorders(Herzog,Staley,Carmody, Robbins,&vanderKolk,1993),andsubstanceabuse(Abueg&Fairbank,1992). Traumaleadstoavarietyofproblemswiththeregulationofaffectivestates,suchas anger,anxiety,andsexuality.Affectdysregulationmakespeoplevulnerabletoengage inavarietyofpathologicalattemptsatselfregulation,suchasselfmutilation,eating disorders,andsubstanceabuse.Extremearousalisaccompaniedbydissociationand thelossofcapacitytoputfeelingsintowords(alexithymiaandsomatization).Failureto establishasenseofsafetyandsecurityleadstocharacterologicaladaptationsthat includeproblemswithselfefficacy,shameandselfhatred,aswellasproblemsin workingthroughinterpersonalconflicts.Suchproblemsareexpressedeitherin excessivedependenceoritscounterpartsocialisolation,lackoftrust,andafailureto establishmutuallysatisfyingrelationships(vanderKolk,etal.,1996).

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Naveonetoonenotionsaboutthecausalrelationshipbetweentraumaandvarious mentalhealthdisordersoversimplifytheverycomplexinterrelationshipsamongspecific traumas,secondaryadversities,environmentalchaosandneglect,thenatureof preexistingandsubsequentattachmentpatterns,temperament,specialcompetencies, andothercontributionstothecreationoftheseproblems.However,ifcliniciansfailto lookthroughatraumalensandtoconceptualizeclientproblemsasrelatedpossiblyto currentorpasttrauma,theymayfailtoseethattraumavictims,youngandold,organize muchoftheirlivesaroundrepetitivepatternsofrelivingandwardingofftraumatic memories,reminders,andaffects(vanderKolk,etal.,1996). Theeffectsofearlytraumaarebecomingincreasinglyominousandclear.Atthesame time,weknowthathumanbrainsareresilientespeciallythebrainsofchildrenand thatmanylatersocialandemotionaldifficultiesandevenhealthproblemscanbe headedoffbyrecognitionandrathersimpleinterventionsearlyoninachildslife.

HowManyChildrenAreAffectedbyTraumainVermont? Itisdifficulttogetanaccurateestimateofthenumberofchildrenaffectedbytraumain Vermont.Variousdatasourcesprovidethefollowinginformation(July1,2003toJune 30,2004): NumberofchildreninVermont (Birthtoage18July1,2003)1

2 NumberofchildreninDCFprotectivecustody

148,135

male female NumberofDCFintakesinwhich domesticviolencewasidentified 3 asacontributingfamilyfactor

4 Numberofchildrenlinkedto1533intakes

2,148 1,029 (+/7) 1,119 (+/8)

1,533 (of12,397) 2,861

Numberofchildren/youthidentified ashavingbeenexposedtodomestic violenceintheirhomes(bymotherswhosoughthelp 5 fromaNetworkAgainstDomesticViolenceprogram)

1 2

6,922

VermontGovernmentwebsitewww.vermont.gov/statistics

Pandiani,J.&Ghosh,K.(February6,2004).VermontMentalHealthPerformanceIndicatorProject.YoungTraumaVictimsserved inMentalHealthPrograms. 3 Personalcommunication,EllieBreitmaier,MSW,Coordinator,DCFDomesticViolenceUnit.Thisnumberdoesnotincludecases thatmayhaveidentifieddomesticviolencefurtheralongintheassessmentprocess. 4 Personalcommunication,EllieBreitmaier,MSW,Coordinator,DCFDomesticViolenceUnit.The119additionalcases(overand abovethe1533intakes)representsnonDCFcasereferralsorcasestheDCFDVunitbecameinvolvedinpostintake. 5 VermontNetworkAgainstDomesticViolenceAnnualReport(2003).

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Numberofchildrenwhoreceived 6 CMHCservices male female TraumavictimsservedinCMHC 7 ChildrensServicesPrograms

8 EmergencyRoomInjuryChildVictims

8,713 (+/40) [5,026](+/32) [3.697](+/24) 1,516

15,012

EmergencyRoomInjuryChildVictims ServedbyCMHprograms (estimatedfrom 9 utilizationpercentages) ChildreninDCFcustody 10 byCMHprograms PercentageoftotalnumberinDCFcustody servedbyCMHprograms

1,349 515of2,148 (+/1.1)served

24%

ItisdifficulttodeterminehowmanychildreninVermontareaffectedeachyearby seriouspsychologicaltrauma.Weknowthatchildrentakenintoprotectivecustodydue toparentalabuseandneglectaremostvulnerable.Wealsoknowthatofthe2,148 childrenunderage18takenintoDepartmentforChildrenandFamilies(DCF)custodyin 2003/2004,only24%receivedservicesfromCommunityMentalHealthCenter(CMHC) programs.Whileitislikelythataportionoftheremaining76%ofchildrenreceived mentalhealthservicesthroughprivatepractitioners(eitherpaidforthroughCrime VictimsServices,privatepay,insuranceorMedicaid),thisinformationisnotreadily available.Thispercentagerepresents1633childrenwhodidnotreceivetreatment throughtheCMHcentersandwhomwemayconservativelyestimatehaveexperienced severetrauma,includingtraumaduetodomesticviolence. Inaddition,ofthe15,012childinjuryvictimsservedinEmergencyRooms,only1,349 receivedservicesfromcommunitymentalhealthprograms.Italsoshouldbenotedthat
6 Pandiani,J.&Ghosh,K.(February3,2004).VermontMentalHealthPerformanceIndicatorProject.TraumaVictimsservedin ChildrensServicesPrograms. 7 Pandiani,J.&Ghosh,K.(February3,2004).VermontMentalHealthPerformanceIndicatorProject.TraumaVictimsservedin ChildrensServicesPrograms. 8 Pandiani,J.&Ghosh,K.(February3,2004).VermontMentalHealthPerformanceIndicatorProject.TraumaVictimsservedin ChildrensServicesPrograms. 9 Pandiani,J.&Ghosh,K.(November21,2003).VermontMentalHealthPerformanceIndicatorProject.EmergencyRoomInjury VictimsservedbyCommunityMentalHealthPrograms 10 Pandiani,J.&Ghosh,K.(February6,2004).VermontMentalHealthPerformanceIndicatorProject.YoungTraumaVictims servedinMentalHealthPrograms.

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servicesfromcommunitymentalhealthprogramsincludecasemanagementand respiteservicesbutnotnecessarilyspecifictraumainformedortraumaspecific treatment. Exposuretodomesticviolenceconstitutesanothersourceoftrauma,andthenumberof Vermontchildrenwhoexperiencedomesticviolencemaybeasahighas7,000children ayear.Thereiscertainlysomeoverlapbetweenthechildrenwhoexperiencedomestic violenceandthosewhoareidentifiedasabusedorneglectedbythechildprotection system.Itislikelythatthereisalsooverlapbetweenbothgroupsandchildinjury victimsseeninEmergencyRooms.However,existingdatacollectionsystemsdonot allowustoaccuratelycountthenumberofchildrenwhoexperiencepsychological traumaacrosstheseandothersystems,norisanytraumascreeningconducted,sowe donotknowthesymptomsthesechildrenpresentwith,nordoweknowtheextentof theirtrauma.Forthesmallpercentageofthesechildrenwhodoreceivementalhealth services,wedonotknowthespecificservicestheyreceivedandiftheseservices includedmentalhealththerapyaimedatreducingoramelioratingtheirsymptomsof trauma.Wedonotknowhowmanyofthemrecoverfullyorpartiallyasaresultof mentalhealthservicesorontheirown,andweknowevenlessabouthowmany continuetoexperienceposttraumaticstresssymptomsorsufferlongtermadverse effectsoftraumanotonlyontheirpsychologicaldevelopmentbutontheircognitive, social/emotionalandphysicaldevelopmentaswell. AccordingtoPandiani,BanksandSchacht(2004)childrenundersevenyearsofagein Vermontaresubstantiallylesslikelytoreceivecommunitymentalhealthservicesthan youngpeopleinthe712or1317agegroups(14%vs.19%and28%).Girlswereless likelytobeservedthanboysineveryagegroup.Regardlessofcountry,raceorculture, girlsareconsistentlymorevulnerabletoPTSDthanboys.Agreaterpercentageofgirls willdevelopposttraumaticstressovertheirlifetimesroughly1012percentofthem, ascomparedwith5percentofboys.Anotheruniversalfindingisthatchildrenaremore vulnerabletoPTSDthanadults(Naparstek,2004).Theyoungerthechild,thegreater thelikelihoodofposttraumaticstressoccurring,andthemoreseverethesymptoms. Evenwithyoungchildren,themaletofemaledifferencesholdup,compounding vulnerabilityforyounggirlsandleavingtwostrikesagainstthem:oneforbeingachild andonceagainforbeingfemale(Naparstek,2004).Childrenwhowitnessor experienceviolenceareatincreasedriskforsignificanttraumaandposttraumatic stresssyndrome.

ProtectiveandRiskFactors Protectivefactorsarethoseassociatedwithresistancetostress.Protectivefactorscan occurinindividualsorenvironmentsandtheyarecorrelatedwith,orpredictiveof, positiveoutcomesforchildren.Incontrast,riskfactorsareassociatedwiththe increasedprobabilityofnegativeoutcomeseitherintermsofdebilitatingsymptomsor failurestoachievepotential.Riskfactorsmaybeattributedtotheindividual,including

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geneticvulnerabilities,aswellastotheenvironment.Bothprotectiveandriskfactors interactincomplexwaysinanygivenchild(Harris,etal.,2004). Protectivefactorsfoundtoameliorateorreducetheeffectsofchildhoodtraumainclude thefollowing: Intelligence Thecapacityforemotionalregulation Socialsupportfromgoodenough(competent,caring)parents Positivebeliefsaboutself Positivebeliefsabouttheworldassafe,predictable,fair Selfefficacyandmotivationtotakepositiveactionononesownbehalf. Riskfactorsassociatedwithgreaternegativeconsequencesofchildhoodtrauma includethefollowing: Geneticvulnerabilitiesorexposuretoinjury,illnessordeprivationthatmay adverselyaffectfetaldevelopmentand/orbirth Developmentaldisabilities Neglectandresultingstimulusdeprivation(institutionalorparental) Insecureattachment Caregivingbyanadultwhohasunresolved,untreatedtraumaandwhomay havedifficultywithaffectregulation,depression,anxiety,hostility,aggression and/orsubstanceabuse Exposuretoextremestressduetoabuse,violence,neglect,loss,illness,poverty andlackofresourcesincludinghealthcare,housing,nutrition. Variousfactorsinachildslifemaymediatetheeffectsofearlytrauma,includingthe following: Earlydetectionoftraumaandinterventiontoincreasesupportandreducethe childstraumarelatedsymptoms Earlyinterventiontostrengthentheparentscapacitytoprovidethechildwitha securebaseandasecureattachmentrelationship Earlyinterventiontoresolveuntreatedposttraumaticstressdisorderinparents sothattraumaisnottransmittedfromonegenerationtotheother Effectivetreatmentforyouthwhohavebeentraumatized,priortotheirparenting.

TheCostsofTrauma Psychologicaltraumaisoftenfollowedbymanynegativesequelae.Scaer(2001)and othershavereportedthatchildhoodtraumaisresponsibleforgreatlossesinhuman potentialandenormouscoststosociety.Theseadverseeffectsareseeninhealthcare (seriousadverseeffectstotheimmunesystem,cardiovascularsystem,chronicpain, somatizationleadingtoincreaseduseofmultiplehealthcareproviders,treatments, medications,surgeries,etc.)andmentalhealthcostsassociatedwithchronicmental

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healthdifficultiesovertheindividualslifetime. Inaddition,childhoodtraumacontributes tolostproductivityanddependenceaswellastothehugeandgrowingcostsof antisocialbehaviors,violence,victimization,legalandcourtinvolvement,incarceration, supervisionandrehabilitation. Childhoodtraumaisamajorpublichealthconcernworldwide.Traumanotonlyharms individualchildrenthemselves,ithasanadverseeffectonthelivesofthosearound themandonthelivesoftheirunbornchildren(Harris,etal.,2004). Thecostsof childhoodtrauma,unrecognizedanduntreated,areactuallymuchgreaterthanthe costsofpreventionandearlyinterventiontoeliminateorreducetheadverseeffectsof childhoodtrauma. TheImportanceofEarlyIdentificationandEarlyIntervention Itiswellestablishedthatsignificanttraumadisruptsnormaldevelopmentinways thataredetrimentaltomanyareasofadultfunctioningandoftenleadstocostly emotionalandphysicalproblemsthatcouldbeavoidedorminimizedbymuchearlier intervention(Harris,etal.,p.7).Fundamentaltoprimarypreventioneffortsisthe provisionofsafe,nurturingrelationshipsforallchildren.Secondarypreventionrequires earlyidentificationofyoungchildrenandyouthwhoareexposedtotraumaticevents andtimelypotentinterventiontocreateorreestablishsafetyandselfregulationandto promoteoptimaldevelopmentforeachindividual. Whileearlyidentificationofchildren/youthwhohaveexperiencedseverepsychological traumawouldpresumablyallowforearlytreatmentandrecovery,thereareprosand constoscreening.Screeninghasplayedacriticalroleinpublichealthadministration andhasbecomearoutinestandardpartofhealthcareinthisandothercountries.The costofscreeningisjustifiedwhentheincidenceofahealthproblemishigh,whenthe costsofitsoccurrencearegreatandwhenpreventionorremediationispossible. However,manywouldarguethatscreeningisnothelpful,ifimmediate,highquality, potentenoughtreatmentisnotreadilyaccessibletochildrenandfamiliesidentified throughscreening. Basicscreeningfortraumainthegeneralpopulationcouldbeaccomplishedaspartof routinepediatriccheckups,althoughtheadditionofscreeningfortraumawouldrequire extensivetrainingofhealthcareprofessionalsandconsiderablecost.Morecost effectivewouldbescreeningforvulnerablegroupsofchildrenwhoareknowntohave highratesoftrauma.Thesegroupswouldinclude:1)childrenwhohavebeenabused andneglectedagroupinwhichlittleornointerventionsfortraumatakeplace (Harris,etal.,p.13),2)childreninfostercareagroupofchildren/youthwhohave experiencedmaltreatmentoftenincludingneglect,abuseandexposuretoviolence,3) childrenwhowitnessdomesticviolenceand/ortheviolentdeathofaparent,siblingor friend,4)childvictimsofcatastrophicaccidents,naturaldisastersandcasualityevents, includingschoolviolence,5)youthinthejuvenilejusticesystem,6)childreninrefugee

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families,especiallyfromcountrieswhereextremedeprivationorarmedconflicthas takenplace,and7)childrenwhorequirepsychiatrichospitalization. Prioritiesincludetheearlydetectionofexposuretotraumaandearlyinterventionto alleviatesymptomsandeliminateorreducecausalfactors.Earlydetectionmaybe accomplishedbyscreeningforsymptomsoftraumainchildrenandfamiliesasapartof regular,routinepediatriccare,EarlyPrevention,Screening,DiagnosisandTreatment (EPSDT),IDEAPartCscreening,EarlyHeadStart/HeadStart,emergencymedical care,childprotectionandjuvenilecorrectionsintake.Asarule,screeningoftraumain infantsandyoungchildrenisbasedonadultobservationwhileadolescentscreeningis basedonselfreport.Anumberoftraumascreeninginstrumentsforchildrenandyouth havebeendevelopedbyNCTSNandothertraumaspecialists(reviewedinStrand, Sarmiento&Pasquale,2005).

ImprovingtheStandardofCare Clinicalexperienceandresearchhaverevealedthatmanychildrenandadolescents sufferingfromtraumaticstressfallthroughthecracks,neverbeingidentifiedastrauma victimsandneverreceivingtreatmentoronlyreceivingcareyearsafterfirst experiencingtraumaticevents.Toaddressthisproblem,NationalChildTraumatic StressNetworkprogramshavedevelopedeasytousescreeningtoolsthatcanbe implementedbynonmentalhealthprofessionalsintheplaceswherechildrenandyouth arefound.NCTSNscreeningtoolshavebeendesignedforuseinschoolsand pediatriciansofficesandbytheinstitutionsthatcomeintocontactwithchildrenincrisis, suchaschildprotectiveservices,thejuvenilejusticesystem,andresidentialtreatment programs(NationalChildTraumaticStressNetwork,ChildrenandTraumainAmerica, 2004). InstrumentsandinterventionsdisseminatedbyNCTSNreflectadevelopmental understandingoftraumaandthedirecttollittakesonachildslife,includingthe immediatedysregulatingsymptomsoftraumaaswellassubsequentandlongerterm impairmentoffunctioninganddisruptionofnormaldevelopment.Effectiveintervention mustnotonlyaddressthetrauma,itmustalsohelpachild/youthgetbackontrack developmentally. Forsomechildrentraumaticstressderivesfromasinglelifethreateningorhorrifying event,suchasanactofdomesticviolence,anaccidentorthetraumaticlossofa parent.Earlyinterventionisveryeffectiveforthesepatients,andyetresearchshows thatmostchildrenandadolescentswhosufferasingleextremeeventneverreceive traumafocusedcare.Weneedtomakesuretheyreceivethecaretheyneedassoon aftertheeventaspossible.Formanyothers,traumaoccursinrepeatedexposuresto communityviolenceand/orviolenceathome.Repairingthesechildrensand adolescentslivesrequiresrepairingtheenvironmentsinwhichtheylive.Bymaking thesechildrenslivessafer,wewillnotonlyimprovethestandardofcareforchild traumaticstress,wewillbegintopreventitsoccurrence.

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NCTSNinitiatedacoredatacollectionproject,whichisnowprovidingapictureofthe nationwidecharacteristicsofchildhoodtrauma,itsassessment,treatmentand outcomes.Theneedforthisknowledgewasdescribedinafederalgovernmentreport (EffectivenessofInsuranceCoverageandFederalProgramsforChildrenWhoHave ExperiencedTraumaLargelyUnknown,GAO02813,August22,2002),which concludedthattheeffectivenessoffederallyfundedprogramsfortraumatizedchildren waslargelyunknownbecauseofthelackofsystematicdocumentation.Thefinalreport ofthePresidentsNewFreedomCommissionalsoidentifiedtraumaasanareawhere moreknowledgeisurgentlyneeded. AllNCTSNprogramscompleteaCoreClinicalCharacteristicsFormforeverychild enteringtreatment.Inaddition,cliniciansinNCTSNprogramsemploythree standardizedmeasures:1)theChildBehaviorChecklist,ageneralmeasureofachilds problemsandfunctioningacrossawiderangeofareas,2)theTraumaSymptom Checklist,and3)theUCLAPTSDReactionIndexforDSMIV.Collectingdataonchild characteristicsandemployingthesestandardizedmeasuresofsymptomsallowsfor comparisonacrosssites,populations,traumatypesandoutcomemeasures.National ChildTraumaticStressNetworkprogramsarevalidatingexistingandnewlydeveloped traumascreeningmeasuresacrossawiderangeofchildrenandexaminingage, gender,culture,servicesectorandtypeoftrauma,includingmasscasualityeventsin 54programsin32states. PromisingandEvidenceBasedTreatmentApproaches TheNCTSNmissionhasfocusedonbuildinganetworktoservetraumatizedchildren, adolescentsandtheirfamilies,increasingavailabilityandaccesstoservices,improving thestandardofcareforidentifyingandtreatingyoungvictimsoftrauma,trainingand educatingthosewhohelpchildren/youth,sharingknowledgeaboutchildtrauma,and enhancingthenationalcapacitytorespondtoterrorismanddisaster.Thismission dovetailswithanumberofothernationalpriorities,suchasthemandatetoimprove overallacademicperformanceandthecallofthePresidentsNewFreedom CommissiononMentalHealthwhichcalledforthetransformationofmentalhealthcare andsingledouttraumainchildrenasanunderstudiedandcriticalareainthis transformationprocess. NCTSNeffortshaveincreasedpublicawarenessofthescopeandimpactofchild traumaticstressandcreatedimprovementsinaccesstoandqualityoftreatmentfor traumatizedchildrenandtheirfamiliesinNCTSNprograms.Todate,Vermontdoesnot haveanNCTSNprogramitishopedthatadditionalfederalfundingfornewprograms, includingfundingforaprograminVermont,willbeavailableinthenearfuture. Effective,evidencebasedassessmenttoolsandtreatmentsforchildhoodtraumatic stresshavebeendeveloped.Earlyinterventionwithsystematic,traumafocused treatmentcanfosternaturalresiliencyandcopingskills,enablingmostyoungpeopleto recoversignificantly.

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ReachingChildrenWhoNeedMentalHealthCare Veryyoungchildren,adolescents,childrenandyouthinrefugeefamiliesandthosewith developmentaldisabilitiesareespeciallyatriskfortraumaandlikelytobeunidentified astraumavictimsandunderserved. Earlyassessmentandinterventionarecrucialtopreventthelongtermdevelopmental consequencesoftraumaticstress.Multipleandcomplexfactorslimitaccesstoservices andcallforinnovativeandholisticsolutions.Toovercomeservicebarriers,many NCTSNprogramshaveprovidedservicesinsettingsoutsidepractitionersofficesand communitymentalhealthcenters.Suchprogramsarelocatedinhospitalemergency rooms,pediatricintensivecareunits,atthesceneofcrimes,innaturaldisastershelters, onIndianreservations,andinfamilieshomes. TheNeedforaDevelopmental,MindBodySpiritApproachtoAssessmentand Treatment Adevelopmental,mindbodyspiritapproachtotheclinicalassessmentandtreatmentof traumainchildrenisneeded.Thisapproachmustbebasedonanunderstandingof thecriticalroleofearlyrelationshipexperiences,attachmentandthe developmentofaffectregulation/dysregulation, theeffectsoftrauma,includingabuse,neglectanddisruptionoftheattachment process,onthechildsdevelopingbrainandcentralnervoussystem,both sympatheticandparasympatheticnervoussystems, thetransmissionoftraumaacrossgenerationsandtheneedfortraumaspecific treatmentforparentsandchildren, theimmediateandlongtermeffectsofstressoverloadonimmunesystem functioningandtheneedfortreatmentthatreducesneurophysiologicalarousal andincreasestheindividualsabilitytoselfsootheandselfregulate, theeffectsofearlytraumaoncharacterdevelopment, therelationshipbetweenchildhoodvictimizationandperpetrationofviolence and/orrevictimization, theeffectsofearlytraumaontheindividualscapacitytoprocesssensoryinput, storememories,regulateemotionsandorganizethoughts,includingtheabilityto uselanguagetomakesenseoforintegratetraumaticexperiences, thestorageoftraumaticexperiencesinthebodymindspiritoftheindividualand theneedfortreatmentthatrestoreswholenessofthebodymindspirit,and thehistoricalandcollectiveimpactofstoredtraumaonindividuals,familiesand societyasawhole,includingtheselfperpetuatingrelationshipbetweentrauma, aggressionandviolence.

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TheNeedforaStageBasedApproachtoTreatment Manyhavewrittenabouttheneedforspecificstagesorphasesoftreatmentforadult traumasurvivors.ThestagebasedapproachdevelopedbyJudithHermanand describedinhergroundbreakingbookTraumaandRecovery(1992),providesauseful templateforthetreatmentofadultsaswellaschildrenandyouthexposedtotrauma.As Hermanemphasized,atherapeuticandhealingrelationshipwithasafeandcompetent clinicianisthefoundationforthetreatmentoftrauma.Recoverythenunfoldsinthree stageswhich,basedonHermansandmorerecentresearchandpracticeinthemind bodyunity,traumaandattachment,include1)theestablishmentofsafetyforthe child/youth,2)remembrance,mourningandtheestablishmentorreestablishmentofan intactsenseofselfassafe,capableandlovable,and3)areconnectiontopeople,and lifeexperiencesthatsupportdevelopment,safety,creativityandjoyfulness. Itshouldberememberedthattheactualtreatmentprocessmustbeindividualizedand maynotadherepreciselytoanabstractconceptualizationofhowtreatmentshould proceed.Inaddition,theextraordinaryrecentandcontinuingexpansionofour understandingofthebrainandtheintegrationofonceseparatefieldsofstudyincluding attachment,trauma,stressandmindbodymedicineoffermuchpromiseinour understandingoftheeffectsoftraumaandhowtohelppeopleofallagestorecover fromit. Stage1: Thefirststageoftreatmentforeveryvictimoftraumaisestablishingorrestoringsafety. Inordertoknowwhatmustbedonetorestoreorcreateasenseofsafetyfora child/youth,athoroughassessmentoftheircurrentsituationmustbeconducted. Childrenandyouthwhoarelivinginchaotic,hostileorviolentsituationscannotheal fromtraumabecausethetraumaisongoing.Childrenbeingcaredforbyparentswhose traumaisunrecognizedanduntreatedarevicariouslyexposedtotheirparentsterror, rageanddespair.Thesechildrenalsoexperiencetheirparentsattemptstodealwith theirowntraumawhichoftenincludesboutsofemotionaldysregulation(angerand aggression,depressionandwithdrawal,poorimpulsecontrolandactingout), dissociationandtheuseofalcoholand/orprescriptionorillegaldrugs.Childrencannot experiencesafetyuntilandunlesstheirparentsexperiencesafety,oruntiltheyare separatedfromtheirparentsandplacedwithothersafe,nurturingcaregivers. Forchildvictimsofchronictraumachildrenandyouthwhoseearliestrelationship experienceshavebeencharacterizedbyhostility,insensitivity,neglect,physical, emotionaland/orsexualabuse,abandonmentorrejectiontheassuranceofasafe caregivingrelationshipisfundamentalandessentialtotreatment.Hopefully,the emotionalandphysicalavailabilityofasafe,sensitiveandnurturingcaregiverwillallow achildtodevelopasecureattachmentrelationship,butthosewhohavestrivedto rebuildorcreatesecurityandtrustinachildoryoungpersonwhohasbeenhurtknow howdifficultandslowthisprocesscanbe.

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Reestablishingsafetyorcreatingitforthefirsttimeinvolvessettingupanexternal structurethatprovidesapredictable,consistentroutineforachild/youthandmaking suretheirbasicphysical,emotionalandsocialneedsaremet.Establishingsafetyalso includeshelpingtheindividualtoestablishaninternalstructurethatallowsthemtofeel safeintheirownbodyandabletorecognizeandcopewithemotionsandsensory experiencesthatmayoverwhelmtheirabilitytothinkclearlyorcontroltheirresponses. Stage2: Thesecondstageoftreatmentremembranceandmourningisusuallyunderstoodto includethetellingofthestoryofthefrighteningandhurtfuleventsthathavederailedthe individualandtheexperiencingofsensitive,empatheticandattunedresponsesfroma personwhocanofferthechildasenseofsafety,nurturingandsecurity.Throughthe processoftellingtheirstory,andparticularlyforchildrenthistellingmayactuallyoccur throughplay,dramaorartwork,theindividualreleasesthetraumaticmemoriesalong withthetraumarelatedemotions,thoughtsandsensoryexperiences.Concurrently,the child/youthishelpednotjusttotellorinotherwaysexpresstheirstorybuttohavea transformativeexperiencethatenablesthemtoexperiencethemselvesdifferently.This transformationofthetraumaticexperienceandsenseofselfasshatteredbythe experienceisreplacedwithaneworrestoredsenseofself(body,mindandspirit)that isintact,lovable,abletobesafeandhappy,tomanagethechallengesofdailyliving andtoexperienceasenseofconnectiontoothersandoptimismaboutlife. Withthetransformationofmemorycomesreliefofmanyofthemajorsymptomsofpost traumaticstressdisorder,anditappearsthatthephysiologicalchangesinducedby traumacanactuallybereversedthroughtheuseofwordsorotherexpressionsofthe traumaticmemories.Thisstageoftreatmentinvolvesaneurophysiologicalresettingof thechildssympatheticandparasympatheticnervoussystem,whichismadepossible byinterventionsthatinvolvethebodyasmuchasthemindandwhichmayrequire borrowingneurochemicallyfrommedications(atleasttemporarily)thatreducearousal andincreasetheindividualssenseofrelaxationandwellbeing. Stage3: Thethirdstageoftreatmentinvolvessuccessfulentryorreentryofthechild/youthinto ageappropriatesocial,learningandcreativeexperiences.Throughtheseexperiences, thereinforcementofthechilds(oryouths)neworrestoredsenseofselfaslovableand capableandtheworldassafeandsupportiveisestablished.Dependingupontheage ofonset,durationandextentofthetrauma,therecoveringchildoradolescentisoften challengedbydelaysandgapsintheirowndevelopmentandtheneedtocatchupwith peerswhoseliveswerenotderailedbytrauma.Inadditiontotreatmentofthetrauma symptoms,thesechildrenandyouthoftenneedextrahelpwithcognitive,language, largeandsmallmotoraswellassocialandemotionaldevelopment.Theyneed scaffoldingfromadultswhocanpatientlysupporttheirunevenmaturation,especially socialandemotionaldevelopmentthatmaylagseveralyearsbehindchronological development.

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Treatmentproceedsinarecursiveratherthanalinearfashionandearlierstagesof treatmentwilltypicallyneedtoberevisitedandtreatmentaccomplishmentsreinforced. Treatmentthatskipsonestageoranotherisincompleteandnotlikelytocreatelasting changeandrecoveryfortheindividual. InnovativeNCTSNTreatmentApproaches InfantsandToddlers Manystillbelievethatinfantsandtoddlersareimpervioustotrauma,orifnot impervious,readilyabletorecoverfullyfromtraumaticevents.Researchandclinical experiencehavedemonstrated,however,thatthisisnotthecase,andwenowknow thatinfantsandveryyoungchildrenareprofoundlyaffectedbytrauma. NCTSNsEarlyTraumaTreatmentNetwork(ETTN)includesfourcentersandisheaded byAliciaLieberman,Ph.D.,andPatriciaVanHorn,Ph.D.,attheUniversityofCalifornia atSanFrancisco,ChildTraumaResearchProject.TheETTNalsoincludestheChild ViolenceExposureProgramatLouisianaStateUniversity,theChildWitnesstoViolence ProgramatBostonMedicalCenter,andtheTulaneUniversityJeffersonParishHuman ServicesAuthorityInfantTeam. ThetreatmentprotocoldevelopedbyDr.Liebermanandcolleaguesismanualizedand focusesonparentchildpsychotherapy.Althoughthenotionoftransgenerational traumamayseemabstract,theprocessbywhichtraumaiscommunicatedbetween parentandchildisnot.Parentswithunresolvedtraumafromtheirownchildhoodsare fearful,andtheycommunicatetheirfrightandviewoftheworldasfrighteningtotheir children.Somewhowereabusedthemselvesaschildrenreenacttheirabuseagainst theirownoffspring.Parentchildpsychotherapywithitsabilitytointerveneveryearlyin parentchildinteractionscanbreakthiscycleoftransgenerationaltrauma.Early interventioniscriticallyimportant.Traumahasameasurableimpactonbrain developmentandglobalcognitivefunctioningthatisreversiblewithearlyintervention. Preschoolerswhoreceivedparentchildpsychotherapyfollowingexposuretodomestic violencehadsignificantincreasesinIQ(performancescale,verbalscaleandfullscale) scorescomparedtotheirscoresbeforereceivingtreatment(p.29). Schoolbased CognitiveBehavioralInterventionforTraumainSchools(CBITS)isamanualized traumatreatmentprogramwithbroadapplicabilityforschoolbasedtraumatreatment programs.CreatedbytheLosAngelesUnifiedSchoolDistrict,itisbasedona10week programwith10groupand13individualsessions.Theprogramisdesignedforuseby existingschoolpersonnelandincludesamaintenancecomponenttosustainchildren oncetheformalinterventionends.

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Anotherschoolbasedprogram,theUniversityofCaliforniaatLosAngelesTrauma PsychiatryServicesTrauma/GriefFocusedGroupPsychotherapyProgram,hasalso beendisseminatedbyNCTSN.Thisisalsoamanualizedtreatmentprogramdesigned specificallyforadolescentsthatcanbedeliveredaseitheranindividualorgroup treatment.Theprogramaddressesbothtraumaandgriefandhasbeenextensively testedandshowntoreducesymptomsofdistressandimproveacademicperformance amongstudentssufferingfromposttraumaticstresstraumaticbereavement.Afteran extensivereviewofavailableevidencebasedprograms,theNewYorkOfficeofMental HealthselectedthisapproachforusewithadolescentsinNewYorkCityafterthe9/11 terroristattacks.ComprehensiveassessmentanddemographicdataontheNewYork Cityyouthrevealedthatmosthadextensivehistoriesofpasttraumaandlivedin environmentsthatcontinuedtobeunsafe.Evenso,preliminarydataindicatethatboth PTSDanddepressionwerereducedsignificantlyamongthosewhocompletedthe program.Theprogramisflexibleitcontainsthefollowingfourmodules:1)psycho educationandcopingskills,2)creationofthetraumanarrative,3)traumatic bereavementandissuesrelatedtogriefandloss,and4)thedevelopmentalprogression of,andprosocial,constructiveresponsesto,traumaandloss. TheMillerChildrensAbuseandViolenceInterventionCenter(MCAVIC)inLongBeach, Californiahasdevelopedastorefrontprogramforadolescentswhohavebeenexpelled fromschoolfordisruptiveorviolentbehavior.Notsurprisingly,theseyoungpeople havebeenfoundtobethemostseverelytraumatizedadolescentsintheschooldistrict, andmosthaveneverreceivedmentalhealthtreatmentbefore. TraumaSystemsTherapy ThisprogramwasdesignedtomeettheneedsofBostonsinnercityyouthaged618 yearsofage.Theprogramisbasedontheprinciplethattraumaticstressresultsfrom twofactors:1)atraumatizedchildoradolescentishavingdifficultyregulatingemotional states,and2)thechildssocialenvironmenteitherdoesnothelporunderminesthe childsabilitiestomanageemotions.TraumaSystemsTherapywasdevelopedwith NCTSNfundingbytheBostonMedicalCentersCenterforMedicalandRefugee Trauma.Theprogramismanualizedanddesignedbothtohelpchildrenand adolescentsregulateemotionsandmakeenvironmentsmoresupportiveandless stressful.Childreninthisprogrammayreceivehomebasedservices,legaladvocacy, officebasedpsychotherapy,and/orpsychotropicmedications. MedicalTrauma TheMedicalTraumaWorkingGroupoftheNCTSNhasdevelopedinnovative assessmentandinterventionapproachesforchildrenandfamiliesthatcanbeusedin settingswherepainful,invasiveandsometimeslifesavingmedicaltreatmentis deliveredclinics,emergencyrooms,pediatricintensivecareunitsandphysicians offices.PreviousstudiesatthePediatricIntensiveCareUnit(PICU)Projectofthe ChildrensHospitalinPhiladelphiasCenterforPediatricTraumaticStressrevealedthat onethirdofparentswhosechildrenwereadmittedtothePICUforatleasttwodays

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developedacutestressdisorder.Parentsymptomsincludedhyperarousal,increased startleresponses,anxietyandintrusivementalimagesoftheirchildinpainor undergoingpainfulprocedures.Whilemostparentsandchildrenrecoveredfairly quickly,oneoffiveparentswentontodevelopPTSDthatlingeredlongafterwardand adverselyaffectedparentchildinteractions.ResearchatthePICUhasalsoshownthat theparentssenseofthechildssituationaslifethreatening(evenwhenthisdegreeof threatisnotcorroboratedbytheattendingphysician)andtheaccompanyingfeelingsof fearandhelplessnessarecriticalfactorsintheriskofPTSD.PICUresearchisshowing thatwhenfamiliesfeelmoreincontrolofachildsmedicalcare,evenwhenthechilds medicalconditionmaybegrave,theyarelesslikelytoexperiencethepanicand helplessnessthatcontributetoPTSD. EvidenceBasedTreatmentforSexualAbuse TraumaFocusedCognitiveBehaviorTherapyisamanualized,evidencebased treatmentapproacheddevelopedinPennsylvaniaattheAlleghenyGeneralHospitals CenterforTraumaticStressinChildrenandAdolescents.Thetreatmentsynthesizes traumasensitiveinterventionswithcognitivebehavioralprinciplestotargetthe emotionalandbehavioralproblemsthatchildrendevelopinthewakeoftraumatic events.ThedevelopmentofatraumanarrativeiscentraltothisNCTSNmodelof treatment.AccordingtoJudithA.Cohen,MD,oneofthedevelopersofthistreatment approach,childrenmayparticipateintherapywheretheytalkandplayformonthsor evenyears,butiftheydonotgettotheheartofthematterthetraumaitselftheydo notgetbetter. Constructingacoherentnarrativeofwhathappenedandwhatitmeanscountersthe fragmentinganddisorganizingpulloftraumaticmemory.Bycreatingatraumanarrative withthetherapist,thechildmakessenseofwhathappenedandcorrectscognitive distortionssuchasbelievingallmenarebadbecausetheirabuserwasamanandhe wasbad.Throughthetraumanarrative,thechildintegratestheeventintothelarger narrativeofhisorherlife.Theabusenolongerdefinesthechildasvictimthechild developsalargeridentityinwhichbeingthevictimofabuseisonlyasmallpart.This modeloffersastepbystepframeworkforcreatingthetraumanarrativeand concurrentlyteachingthechildselfregulationtools.Thesetools,suchasrelaxation techniques,increasethechildssenseofcontroloverthedisturbingemotionsand physiologicalresponsesthatcomeupwhentheytalk(orexpressthemselvesinother ways,suchasartwork,puppetsorsandplay).Throughthiskindoftreatment,thechild oftenfindsaconstructivewaytorespondtowhathappenedtothem. ANeuronstoNeighborhoodsModelTreatmentProgram TheNeuronstoNeighborhoodsapproachtochildtraumaticstressisadaptedfromthe seminalreportfromtheNationalResearchCouncil/InstituteofMedicineentitled NeuronstoNeighborhoods:TheScienceofEarlyChildDevelopment(Shonkoff& Phillips,2000).DevelopedatBostonUniversity,SchoolofMedicine,thisNCTSN programintegratesourmostrecentunderstandingsabout1)thedynamicrelationship

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betweenbrainandenvironment,2)thecriticalroleofsocialcontext(andculture)for childdevelopment,3)theprimacyofrelationshipsforthedevelopingchild,and4)the ongoingdynamicinterplaybetweensourcesofriskandsourcesofresilienceacrossall levelsofthesocialenvironment(i.e.,individual,family,school,peergroup, neighborhood,andculture)(p.169170).Fivephasesofinterventionareoutlinedinthis modelwiththemaingoaloftherapybeingforthechildtoachieveemotionaland behavioralregulationandstability.Thecliniciandetermineswhichofsixpossible interventionmodulesshouldbeusedatwhichparticulartime,dependingontheneeds ofagivenchild/socialenvironment.Thesixtreatmentmodulesareasfollows: 1)BeyondTraumaEngagementofthechild,family,communityinattemptsto performactivities/ritualswhichwillcreatelastingmeaningoutofthetraumatic experience, 2)PreventativeEducationEngagementofchild,family,school,andcommunity inanticipatingtroublespotsforthechildtominimizetheriskofrelapse, 3)CognitiveReprocessingEngagementofthechildandfamilyin communicationaboutthetraumaticeventwithattempttoaddperspectiveswhich challengedebilitatingtraumarelatedcognitions, 4)EmotionalRegulationEngagementofthechildandfamilyinskillbased exercisestorecognize,label,andcontrolfeelings, 5)StabilizationOnSite(SOS)Communitybasedinterventionsdesignedto assessandremediateintractableproblemsinthechildssocialenvironment(home, school,peergroup,neighborhood,etc.)thatperpetuatetraumarelatedsymptoms,and 6)PsychopharmacologyAdministrationofpsychoactiveagentsdesignedto helpthechildregulateemotionsothatcognitiveprocessingcanoccur. DevelopingAPublicSystemofCareofChild/YouthVictimsofTrauma Thedevelopmentofaresponsiveandeffectivetraumainformedpublicsystemofcare forchildandadolescenttraumavictimsmustincorporatethefollowingelements: awarenessthattraumaisamajorcontributingfactortomentalhealth difficultiesinchildhoodandadulthoodandthattraumaisanunderlying causeofdysregulatedemotionsandbehaviorsinchildrenand adolescents recognitionofthesymptomsoftraumawhentheyarepresent availabilityofimmediatetraumaspecifictreatmentforvictimsofboth acuteandchronictraumaandtheirfamilies Thedevelopmentofatraumainformedstatewide,publicsystemofcarethatoffers traumaspecific,effectiveinterventionforadult,childandadolescentvictimsoftrauma shouldbeatoppriorityfortheVermontAgencyofHumanServices.Thedevelopment ofthissystemofcarewillrequireaninvestmentinthefollowing:

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o Increasingawarenessonthepartofthegeneralpublic,legislatorsand fiscalgatekeepersoftheurgentneedfortraumaspecificmentalhealth treatmentforvictimsoftraumainVermont,especiallyyoungchildren whoseneurophysiologyandbraindevelopmentmaybeunderminedby earlytraumaticexperiences. o Trainingofprovidersinchildcare,education,healthcare,childprotection, juvenilejustice,domesticandsexualviolenceandmentalhealthagencies (includingsubstanceabuseclinicians)onhowtorecognizeand understandtheeffectsoftraumaonchildren,youthandfamiliesandhow toconnecttraumavictimstoeffectivetreatment. o TrainingofVermontspublicmentalhealthprofessionalsstatewideto insurethatallaretraumainformedandcompetentinusingagreedupon traumaspecificassessmentandtreatmentapproachestoidentifyand treatchild/youthtraumavictims. o MakingtreatmentofVermontsmostvulnerablechildren/youthapriority (youngvictimswhosebraindevelopmentmaybealteredbytrauma, victimsofphysical/sexualabuseorwitnessestoviolenceathomeorinthe community). o Themaintenanceofthiscadreoftrainedmentalhealthprofessionals throughongoingandcontinuedtrainingandsupervision. o Thedevelopmentofadatabase(ortheenhancementandintegrationof existingdatabases)thatwouldmakeitpossibletoidentifychildand adolescenttraumavictims,recordtheuseoftraumaspecifictreatment methodsandmeasuretheeffectivenessoftreatment. o Thedevelopmentofafeedforward/feedbackloopthatwouldenable AgencyofHumanServicesprogramstoexamineandanalyze demographicdataaswellasassessmentandtreatmentdatatoimprove treatmentoutcomesfortraumavictimsinVermont. o FillingtheTraumaCoordinatorpositionwithintheAgencyofHuman Services. o MakingitaprioritytoseekfederalNCTSNorotherfundingto develop/enhanceastatewidesystemofcareforchild/youthtraumavictims inVermont.

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TheNeedforOngoingTrainingandSupervision Earlychildhoodcaregiversandeducators,mentalhealthprofessionalsandhealth providersneedacomprehensivetraumafocusedperspectivethatintegratestheir knowledge,clinicalthinkingandinterventions.Notonlyistrainingneededonevidence basedtreatmentapproachesandprovenpracticeswithchildrenandyouthwhohave beentraumatizedbutongoingsupportandfollowupiscriticaltothefullimplementation ofanytraining/treatmentmodel.Researchhasshownthatabriefoneortwoday trainingforcliniciansisnotenoughtoensuretheiruseofanewtreatmentapproach.If thesystemofcareasawholedoesnotsupporttheirnewperception,knowledgeand useoftraumainformedandtraumaspecificintake,assessment,andintervention,andif ongoingsupportandsupervisionarenotavailable,clinicianswilleithernotusean unfamiliarapproachatallorquicklyreverttooldpractices. FindingsfromRecentSurveysandTrainingNeedsAssessmentsinVermont Tworecentsurveys/trainingneedsassessmentsconductedinVermontrelated specificallytothementalhealthneedsofchildren/youthexposedtodomesticviolence (i.e.,theSurveyofCommunityMentalHealthCenterChildrensDirectors[February, 2005]andtheVermontNetworkAgainstDomesticViolenceSurveyofChild/Youth Advocates[July,2004]),provideinformationonscreeningoftrauma,provisionof treatmentfortraumavictims,especiallychildrenandyouthexposedtodomestic violence,andbarriersandgapsinservicesandtrainingneeds. TwoadditionalrecentsurveysoftrainingsneedsinVermont,oneconductedbythe ChildWelfareInteragencyTrainingCommittee(CWITCTrainingNeedsSurvey,Fall, 2004)andanotherconductedbytheCUPSTrainingTeam(2004)identifiedtraining relatedtotraumaasatrainingpriorityformentalhealthprovidersinVermont. ElevenCMHCdirectorscompletedtheSurveyofCMHCChildrensDirectors(February, 2005)andreportedthattheirCMHCprogramsroutinelyscreenforthepresenceof psychologicaltraumahistoryinchildren/youthreferredforservices.However,the validityoftheseresponsesmighthavebeenstrongeriftheterm screenhadbeen clearlydefined.AnexaminationoftheactualCMHCformsusedstatewideandrequired atintakedonotdirecttheintakeinterviewertoseekinformationabouttraumaorexplore thepossibilityofvarioustraumarelatedsymptomsortoviewpresentingproblemsasa reflectionoftrauma.TheIntakeform,aNarrativeDiagnosisandEvaluationformanda TreatmentPlanningformareallrequiredformsforMedicaidreimbursement,butonly datafromtheIntakeformisenteredintothestatewidedatabase.Thecategoryclosest totraumaontheIntakeform isabuse/assault/rapevictimbutthiscategoryisnot uniformlycheckedoffforchildrenoradultswhohaveexperiencedpsychologicaltrauma andisthereforenotaparticularlyvalidindicationofwhetherornottraumaispartofthe diagnosticpicture.

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UseofSpecificScreeningToolorInstrument OnlytwoCMHCcentersreportedusingaspecifictoolorinstrumenttoscreenfor traumainchildren/youthspecificallyidentifiedwere1)adevelopmentalandfamily assessment/familymatrixchart,and2)theChild&AdolescentFunctionalAssessment Scale(CAFAS)andtheAchenbachChildBehaviorChecklistinadditiontothecenters owninitialassessmentpackage. TheAchenbachChildBehaviorChecklist(CBC)isawellknownandwellresearched instrumentdesignedtogatherinformationaboutchildrensbehaviorsand competencies.Therearetwoversionsoftheinstrument,oneforchildrenages15 years,theotherforchildrenages618.Theinstrumentcanbefilledoutbyparents, teachersorstaff,andthereisaselfreportformforusebychildren618.The AchenbachCBCcanbeusedtomeasurechangesinbehaviorovertimeorinresponse totreatment.Thischecklistmeasuresaggression,hyperactivity,bullying,conduct problems,defianceandviolence. TheCAFASisdesignedtomeasureaggressionandconductproblemswithsubtests thatmeasureschool,home,community(delinquentlikebehavior),behaviortoward others,mood/emotions,selfharmfulbehavior,substanceuse,thinkingproblems, materialneedsandfamily/socialsupport. NeithertheAchenbachnortheCAFASisascreeninginstrumentfortraumaperse, althoughbothinstrumentscallfortheobservationandratingofachild/youthsbehaviors andcompetenciesthatmayhavebeenaffectedbytraumaticexperiences. Theuseofaspecificscreeningtoolwithinallthecommunitymentalhealthcenters wouldprovideamoreaccuratecountofthenumbersofchildren/youthaffectedby trauma.Inaddition,theuseofaspecifictoolstatewidewouldprovideinformationabout howchildrenandyouthhavebeenaffectedbytraumaticexperiencesandpointmore directlytowardthespecificinterventionsthatwouldincreasesafety,alleviatetrauma symptomsandpromoteemotionalregulationandimprovementsinfunctioningacross home,childcare,schoolandcommunitydomains. SpecializedTrainingNeeds TheCMHCChildrensDirectorsSurveyconductedinFebruary,2004focusedon trainingneedsrelatedtodomesticviolence.MostCommunityMentalHealthCenter childrensdirectorsindicatedtheneedforadditionaltrainingforCMHCstaffrelatedto understandingthesocialandinterpersonalcontextofdomesticviolence,screeningfor domesticviolenceinchildren/youth,assessingtheeffectsofdomesticviolenceon children/youth,ensuringthesafetyofchildrenandbatteredwomenduringscreening, assessmentandtreatment,understandingtheeffectsofdomesticviolenceonparent functioning(battererandvictim),andaccessinglocalandstatewidedomesticviolence resources.Inaddition,mostCMHCchildrensdirectorsindicatedtheneedforadditional trainingrelatedtothetreatmentofchildren/youthaffectedbydomesticviolence

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includingeffectiveinterventionapproachesforinfants/youngchildren,schoolaged childrenandyouthaswellastrainingoncomplextreatmentissuessuchas intergenerationaltrauma,substanceabuse,childabuse,mentalhealthand developmentaldisabilities.

SummaryandRecommendations Traumaininfancyandearlychildhoodaltersbraindevelopment.Childrenwhose parent(s)haveunresolvedtraumaareatextremeriskfortraumatizationthroughthe transmissionofinsecureandoftenchaotic/disorganizedattachmentrelationships. Childrenexposedtophysical/emotionalorsexualabuse,separationsandlossesof caregivers,exposuretoadultdrug/alcoholaddictionordomesticviolenceareatgreatest riskoftrauma.Withinthisvulnerablegroup,childrenwithdevelopmentaldifficultiesdue togenetic,environmentalorrelationshipbasedtraumaaredoublyatrisk. Unresolvedchildhoodtraumaaffectseveryaspectofdevelopmentandcontributesto behavioral,social,emotional,cognitiveandhealthdifficulties.Untreatedandunresolved traumacontributestomentalhealthdifficultiesinadolescencewhichinturnisrelated tovictimizationandperpetrationofviolenceamongyouth.Ifnottoosevereandif adequateprotectivefactorsarepresent,mostindividualsrecoverfullyfromasingle incidentoftrauma.However,manychildrenlacktheprotectionofasecureattachment relationshiporadequateparentalprotection,nurturingandappropriatestimulationof braindevelopment,andwhenexposedtotrauma(sometimesrepeated,evenchronic exposure),theydonotrecover.Thedysregulationoftraumamayalterneurochemistry ofthecentralnervoussystem,whichinturncanalterthestructuralandfunctional developmentandintegrationofthebrain,includingsensoryprocessing,focusingand regulationofactivity,arousalandemotion. Tocombattheseeffectsamultilayered,coordinatedandholisticapproachisneeded. Thedebilitatingeffectsoftraumaandtheoverallcoststosocietyconstituteatrue, seriouspublichealthemergency,warrantingimmediateactiononmanylevels: 1) improvingdatacollectionmethodstofacilitatethecollectionofuniformdata withinandacrossagencies,attheveryleastalteringexistingdatabasessothatdata canbeaggregatedtoprovidebetteridentificationoftraumavictimsandbetterrecording andspecificationoftreatmentapproachesutilizedandoutcomesachieved.Atpresent, separatemanagementinformationsystemsareusedindifferentbranchesofthe AgencyofHumanServices(e.g.,theDivisionofMentalHealth,theDivisionofFamily Services,theDepartmentofHealth,etc.)aswellastheDepartmentofEducation.At thispoint,itisimpossibletoascertainthenumberofVermontchildren,youthorfamilies whosehealth,includingmentalhealth,andabilitytofunctionproductivelyinsocietyis affectedbytrauma.Nordoweknowwhatservicestheseindividualsreceive,ifany,orif theimmediateorlongtermeffectsoftraumaarereduced,alleviatedorexacerbatedby existingsystemsofcareand/orbyothercausalormediatingfactorsintheirlives.

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2) developingandstrengtheningrelationshipsandpartnershipsbetweenand amongvariousproviderswhocomeincontactwithchildren/youthwhohave experiencedtraumaandtheirfamilies. 3) increasedidentificationandtreatmentoftraumatizedchildrenandyouthwhere theyare,inthechildprotectionandjuvenilejusticesystems,inschools,inemergency rooms,pediatriciansoffices,communitymentalhealthcentersandresidentialtreatment programs. 4) screeningandidentificationofchildrenaffectedbytrauma.Effortsareunderway inVermonttocomplywithFederalChildAbusePreventionandTreatmentAct(CAPTA) requirementsthatallchildrenunderage3substantiatedbythestatechildprotection agencyforabuseorneglectmustbescreenedfordevelopmentaldifficulties. 5) fullinvestmentinthecreationandmaintenanceofacommunitymentalhealth systeminVermontthatcanprovideimmediateaccesstoeffectivetraumaspecific servicestoallchildrenandyouthwhoarevictimsoftraumaandtheirfamilies. 6) reducingoreliminatinggapsinservicessothattraumavictimsareidentifiedand treatedearly. 7) incorporatingaholisticanddevelopmental,bodymindspiritapproachtothe treatmentoftraumainchildren/youthandtheirfamilies. 8) usinginnovativestrategiestoreachchildrenandfamilies.Forexample, partnershipsbetweenpoliceservicesandtreatmentprogramshaveresultedingreater identificationoftraumavictims(childrenandyouthwhowitnessviolenceathomeorin theircommunities)andincreasedreferralstotraumaassistanceprograms. 6) makingsmallchanges,atnoorlowcosts,toincreasepublicandinteragency awarenessoftheeffectsoftrauma,assessingchildrenandyouththroughatrauma lens,increasinginteragencycommunication,collaborationandpartnershiptoincrease safetyforchildrenandyouthandtoprovidethemwithimmediateandeffective interventionwhentraumaticeventshaveoccurred. 7) mobilizingeffortsinVermonttoprocureNCTSNorotherformsoffederalor privatefundingtodevelopafullrangeoftraumainformedandtraumaspecificservices forVermontchildren,youthandfamilies. 8) investinginpreventionandearlyinterventionprogramstheseprogramsreduce thecostsoftraumanotonlyintermsofthequalityofindividuallivesbutincommunity safety,productivityandwellbeing. 9) increasingpublicawarenessoftheepidemicnatureoftraumaandtheenormous relatedcoststoindividuals,familiesandsocietyasawhole.

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10) developingandimplementingtrainingprograms,includingtraumainformed trainingforabroadrangeofhealth,educationandhumanserviceprofessionals(health, education,childcare,mentalhealth,childprotectionandcorrections)aswellastrauma specifictrainingformentalhealthpractitionersinpublicandprivateagencies.

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UnitedStatesGeneralAccountingOffice,ReporttoCongressionalRequesters,(2002). EffectivenessofInsuranceCoverageandFederalProgramsforChildrenWhoHave ExperiencedTraumaLargelyUnknown,ChildTraumaandMentalHealthServices, GAO02813,August22,2002. vanderKolk,B.A.(1988).Thetraumaspectrum:Theinteractionofbiologicaland socialeventsinthegenesisofthetraumaresponse.JournalofTraumaticStress,1, 273290. vanderKolk,B.A.(1996a).Thecomplexityofadaptationtotrauma.InvanderKolk, B.A.,McFarlane,A.C.,&Weisaeth,L.(Eds.)(1996)Traumaticstress.NewYork:The GuilfordPress. vanderKolk,B.A.,Pelcovitz,D.,Roth,S.,Mandel,F.,MacFarlane,A.,Herman,J.L. (1996b).Dissociation,affectregulationandsomatization:Thecomplexnatureof adaptationttrauma.AmericanJournalofPsychiatry,153(Supplement),8393. vanderKolk,B.A.,Perry,C.,Herman,J.L.(1991).Childhoodoriginsofself destructivebehavior. AmericanJournalofPsychiatry,148,16651671. vanderKolk,B.A.,Roth,S.,Pelcovitz,D.,&Mandel,F.(1993).ComplexPTSD: ResultsofthePTSDfieldtrialsforDSMIV. Washington,DC:AmericanPsychiatric Association. Vogel,M.(1994).Genderasafactorinthetransgenerationaltransmissionoftrauma. Women&Therapy,15,3547. Winston,F.,KassamAdams,N.,GarciaEspana,F.,Ihenback,R.,&Craan,A.(2003). Screeningforriskofpersistentposttraumaticstressininjuredchildrenandtheir parents. JournaloftheAmericanMedicalAssociation,290,643649. Woods,D.(1996).Sexualabuseduringchildhoodandadolescenceanditseffectson thephysicalandemotionalqualityoflifeofthesurvivor:Areviewoftheliterature. MilitaryMedicine,161,582587. Wrtele,S.,Kaplan,G.,Keairnes,M.(1990).Childhoodsexualabuseamongchronic painpatients. TheClinicalJournalofPain,6,110113. Websites www.NCTSNet.org WebresourceofTheNationalChildTraumaticStress Network(NCTSN)

www.sanctuaryweb.com WebsiteoftheSanctuaryProgram,awholesystem approachtohealingtrauma)developedbySandraBloom, MDinPhiladelphia,PA

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www.ChildTrauma.org

WebsiteofBrucePerry,MD,Ph.D.articles,presentations, otherresources TheChildTraumaInstituteprovidestraining,consultation, informationandresourcesdevelopedbyRickyGreenwald, Psy.D.,EMDRtherapistandtrainer AmericanAcademyofChild&AdolescentPsychiatry (AACAP) ChildWelfareLeagueofAmerica.AACAPandCWLAare workingtogetheronaspecialinitiativetoimprovemental healthandsubstanceabuseservicesprovidedto children/youthinfostercare.

www.Childtrauma.com

www.aacap.org

www.cwla.org

http://gucdc.georgetown.edu GeorgetownUniversityCenterforChildandHuman Development http://gucdc.georgetown.edu/foster.html/ GeorgetownUniversityCenterforChildandHuman Developmentspecialreportsrelatedtomeetingtheneeds ofchildren/youth www.ncmhjj.com www.nccp.com NationalCenterforMentalHealthandJuvenileJustice NationalCenterforChildreninPoverty(NCCP) Reports: #1 BuildingServicesandSystemstoSupporttheHealthy EmotionalDevelopmentofYoungChildren #2 ImprovingtheOddsfortheHealthyDevelopmentof YoungChildreninFosterCare #3 ReadytoEnter:WhatResearchTellsPolicymakers AboutStrategiestoPromoteSocialandEmotional SchoolReadinessAmongThreeandFourYearOld Children http://www.zerotothree.org ZerotoThree:NationalCenterforInfants,Toddlers andFamilies,anonprofitorganizationwhosemission istopromotethehealthydevelopmentofinfantsand toddlersbysupportingandstrengtheningfamilies, communities,andthosewhoworkontheirbehalf. Books,videos,journalrelatedtoearlychildhood developmentandmentalhealth.

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http://www.traumapages.com/

DavidBaldwinsTraumaInformationPages,awebsite thatprovidesinformationforcliniciansand researchersinthetraumaticstressfield. TheFutureofChildrenisapublicationofthe WoodrowWilsonSchoolofPublic&International AffairsatPrincetonUniversityandtheBrookings Institute WebsiteoftheSidranFoundationPress,anonprofit organizationdevotedtoeducationandadvocacy regardingtraumaticstress,andtheSidranPressand ResourceCenter. TheNationalInstituteforTraumaandLossin Children. NationalCenterforPTSD,DepartmentofVeterans Affairs,hassectionontraumaandchildren.

http://www.futureofchildren.org

http://www.sidran.org

http://www.tlcinst.org

http://www.ncptsd.org

http://www.practicenotes.org/vol10_no3.htm TheJuneissueof"Children'sServicesPractice Notes"exploreswayschildwelfarepractitionerscan recognizePTSDandrespondinanappropriate, timelywaywhentheyencounterit. PracticeNotesis sponsoredbytheN.C.DivisionofSocialServicesand producedbytheFamilyandChildren'sResource Program,partoftheJordanInstituteforFamiliesat theUNCChapelHillSchoolofSocialWork. http://www.trainingmattersnc.orgThenewsletter"TrainingMatters"atthiswebsite offersresourcesforchildwelfareagencieswishingto learnmoreabouttraumaandPTSD.TrainingMatters issponsoredbytheN.C.DivisionofSocialServices andproducedbytheFamilyandChildren'sResource Program,partoftheJordanInstituteforFamiliesat theUNCChapelHillSchoolofSocialWork.

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