January 01, 2015

Supporting the Mental Health of Trauma-Exposed Children in the Child Welfare System

Lisa Conradi

The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association, and accordingly, should not be construed as representing the policy of the American Bar Association.

You are an attorney working in the dependency court system representing an adolescent with severe behavior problems. You are doing your best to help this adolescent, but she continues to be oppositional, blowing out of placements repeatedly. You are concerned she will cross into the juvenile delinquency system. The adolescent has experienced significant abuse and neglect and you wonder if those experiences could be related to her current behavior? What mental health interventions could help stabilize and put her on a healthy developmental path?

The prevalence of potentially traumatic events in court-involved children and adolescents is high (see the first article in this series, “Understanding Trauma and Its Impact on Child Clients,” in the September 2014 CLP for definitions of types of trauma and information on its prevalence in court-involved children and adolescents).  As a result, they may display challenging behaviors and reactions that may be related to the trauma they have experienced. Therefore, it is critical that court professionals understand the impact of trauma on the child’s reactions, behaviors, and relationships. This article highlights these behaviors and how they impact relationships and functioning. 

Understanding Emotional and Behavioral Responses to Trauma

Know how a child’s trauma history influences behavior. 

Trauma-exposed children may exhibit a range of complex emotional and behavioral responses to events they have experienced. When working with a child or adolescent who has experienced trauma, it is important to be sensitive to the ways in which a child’s trauma history affects the child’s current behavior. The behavior of a child exposed to trauma can reflect his efforts to adapt to overwhelming stress and may be difficult to identify and manage. For example, a child may reenact aspects of his trauma (e.g., aggression, self-injurious behaviors, or sexualized behaviors) in response to a reminder of a previous traumatic event, or as an attempt to gain mastery or control over her experiences. 

Be aware of the child’s trauma triggers. 

A trauma reminder is any person, place, situation, sensation, feeling, or thing that reminds a child of a previously experienced traumatic event. When faced with these reminders, a child may re-experience the intense and disturbing feelings tied to the original trauma. These trauma reminders can lead to behaviors that seem out of place in the current situation but were appropriate—and perhaps even helpful—at the time of the original traumatic event. For example, a child may be triggered by events as conscious as seeing a person or place connected to the trauma, or as subconscious as certain smells, lights, or sounds that are reminiscent of the trauma. (Sidebar 1 highlights traumatic responses by age.) 

Understand how a child’s behavior is often a coping mechanism. 

In some cases, a child may be aware of his reaction and its connection to the traumatic situation. However, often the child is unaware of the root cause of his feelings and behaviors and may exhibit increased behavioral problems as a way of coping with trauma and traumatic stress. These behaviors can be difficult to understand and cope with for the court professional. For instance, in the absence of more adaptive coping strategies, a trauma-exposed child or adolescent may use drugs and/or alcohol to avoid experiencing overwhelming emotions. Similarly, in the absence of appropriate boundaries and interpersonal skills, a sexually abused child may revert to sexual behaviors with others because that is the only way he has ever experienced any degree of acceptance or intimacy. 

Understand how trauma relates to controlling behaviors. 

Trauma-exposed children may also exhibit over-controlled behavior in an unconscious attempt to counteract feelings of helplessness, and impotence may manifest as difficulty transitioning and changing routines, rigid behavior patterns, repetitive behaviors, etc. At the other extreme, due to cognitive delays or deficits, some children who have experienced trauma display under-controlled behavior in terms of planning, organizing, delaying gratification, and exerting control over their behavior. This may manifest as impulsivity, disorganization, aggression, or other acting-out behaviors. Trauma-exposed children’s maladaptive coping strategies can lead to behaviors that undermine healthy relationships and establishing positive connections, including:

  • Sleeping, eating, or elimination problems
  • High activity levels, irritability, or acting out
  • Emotional detachment, unresponsiveness, distance, or numbness
  • Hypervigilance, or feeling that danger is present when it is not
  • Increased mental health issues (e.g., depression, anxiety)
  • An unexpected and exaggerated response when told “no”

Know the child’s mental health diagnoses and clinical/educational services. 

Court-involved children and adolescents have often been diagnosed with many different mental health diagnoses through their interactions with various child-serving systems. The most common of these include attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, bipolar disorder, and reactive attachment disorder. 

Many of these children also receive special education services (see Sidebar 2 for more information on the interface between trauma, special education, and disabilities). Neither the diagnoses nor the clinical and/or educational interventions provided capture or address the full extent of the developmental impact of trauma. The symptoms leading to these diagnoses may in fact be a child’s reaction to a trauma reminder, which can result in withdrawn, aggressive, reckless, or self-injurious behaviors. Court professionals should understand how a child or adolescent’s diagnosis may result from behaviors associated with coping with trauma rather than a statement about his personality structure overall.

Screening, Assessment, and Evaluation

Know the difference between screening, assessment, and evaluation. 

When thinking about mental health evaluations and reports, it is important to distinguish between screening, assessment, and evaluation (see Sidebar 3 ). Information from the screening and assessment process can help courts understand a child’s history and behaviors and make decisions about placement. Integrating information from the trauma screening process into court reports is one strategy some jurisdictions are using to create more trauma-informed courts that understand the impact of trauma on a child’s behavior and use that information to make case-planning decisions. Regardless of whether this information is strategically integrated into a court report process, a comprehensive trauma-informed mental health assessment should be conducted by an experienced mental health professional and that information should be shared with the court and used to inform case-planning efforts.

In general, the purpose of a comprehensive assessment is NOT to provide recommendations regarding placement and visitation within the child welfare context. An assessment conducted as part of an intervention is usually very different from one conducted as part of a placement resource. For example, an evaluator generally interviews all relevant caregivers, lets the caregivers know they are being evaluated, and informs them that the assessment will be shared openly with the court. On the other hand, therapists may work with only some family members and may not be in a position to make unbiased placement recommendations as they have not observed the child with the other caregivers.

Improving Resiliency and Well-Being

Enhance the child’s resilience. 

Many children are naturally resilient, and can get through the difficult experiences they have had and even flourish. Resilience is the ability to overcome adversity and thrive in the face of risk. Neuroplasticity (i.e., the ability of the brain to rewire neural connections) allows for resilience to be developed through corrective relationships and experiences. Factors that can enhance resilience include: 

  • Supportive relationships
  • Family support
  • Having a strong relationship with at least one competent and caring adult
  • Feeling connected to a positive role model/mentor
  • Peer support
  • Competence
  • Having talents/abilities nurtured and appreciated
  • Self-efficacy
  • Self-esteem
  • School and community connectedness
  • Spiritual belief

Court professionals can play an important role  supporting these factors by serving as a corrective relationship for the child. For example, court professionals can verbally identify areas of competence and strength that the child exhibits throughout the process, and identify areas of talent or ability that they may witness, no matter how small or seemingly insignificant. 

Acknowledging challenging situations, while also mirroring healthy coping responses can also provide a child or adolescent with language to manage a difficult situation. Court professionals can also encourage court-involved children and adolescents to maintain connections to their friends and school and support any spiritual beliefs or connections they may hold.

Build the child’s relational capacity. 

There are several ways in which child-serving professionals can promote a child’s well-being and resilience. A key to promoting well-being and resilience is by developing a child’s relational capacity. This may occur through informal supports, such as participating in mentorship programs, sports, and other activities. It can also occur through the referral to a trauma-informed evidence-based practice. The Institute of Medicine (IOM) defines “evidence-based practice” as a combination of the following three factors: (1) best research evidence, (2) best clinical experience, and (3) consistent with patient values.  Current research on treatment models for child traumatic stress suggests several common elements found in effective evidence-based trauma treatment (see Sidebar 4). Court professionals working with court-involved children and adolescents should be able to identify these elements in any proposed treatment plan for children presenting with primary trauma issues. 

 

Advocate for evidence-based treatments. 

A number of evidence-based trauma treatments are available that include these components and research supports their efficacy with children and families who have experienced trauma. When working with court-involved children and adolescents, be aware of treatment practices in your region that serve children who have experienced trauma and provide referrals as needed. (Sidebar 5 lists evidence-based trauma treatment programs for children and/or adolescents rated by the California Evidence-Based Clearinghouse for Child Welfare. See www.cebc4cw.org for more information).

Seek trauma-informed therapists. 

Many therapists who treat trauma-exposed children lack specialized knowledge or training in trauma and its treatment. When you have a choice of providers, select a therapist who is most familiar with the available evidence and has the best training to evaluate and treat the child’s symptoms. (Sidebar 6 provides 10 questions court professionals can use to advocate for trauma-informed mental health services for court-involved children and adolescents.) 

Parent Trauma

Many parents involved in the child welfare system have histories of trauma and substance abuse. A recent study found 61% of infants and 41% of older children in out-of-home care had a caregiver who reported active alcohol or drug abuse.  Whether parents experienced the traumatic events during childhood or adulthood, these events can affect their ability to engage in healthy and positive parent-child interactions, protect their children from harm, and help their children recover from traumatic events. 

Assess the parent’s trauma history. 

A parent’s trauma and substance abuse history may not only increase the child’s risk for maltreatment, but can also impact the parent’s ability to mitigate the impact of a trauma on the child. How a child responds and fares after a traumatic experience depends partly on the caregiver’s ability to manage his own emotions related to the trauma, the caregiver’s own trauma history, and the caregiver’s ability to respond to the child and re-establish safety.  A parent with an unresolved trauma history is less likely to be able to manage her own emotional reaction and, therefore, less likely to be able to support the child. In fact, it is common for a child’s traumas to trigger a parent’s own traumatic memories, which can interfere with the parent’s ability to protect and support the child and could lead the parents to engage in maladaptive coping mechanisms, such as substance abuse.

Understand how caregiver functioning affects child functioning. 

Child welfare system interventions, such as removing children from their parents, can be highly distressing for parents and can serve as reminders of parents’ past traumatic memories and further impede parent functioning. Across multiple studies,  caregiver functioning has been found to be a major predictor of child functioning following the child’s exposure to traumatic experiences. Thus, a trauma-informed child welfare system needs to support the caregivers and provide intervention for the caregivers’ symptoms if it hopes to improve child outcomes. Failure to understand and address parent trauma can lead to the following: 

  • Failure to engage in treatment services
  • An increase in symptoms
  • An increase in management problems
  • Re-traumatization
  • An increase in relapse
  • Withdrawal from service relationship
  • Poor treatment outcomes
  • Identify and address parents’ trauma-related needs. 

As court professionals, you can empower parents by ensuring efforts to identify and address their trauma-related needs and involving them in decisions:

  • Ask what services they think might be helpful, recognizing that they may not know.
     
  • Identify mental health services, especially trauma-informed services the parent has already received and the response to those services.
  • Ensure there is a trauma-informed assessment conducted on each parent that includes their relationship with each child.
  • Let parents know you understand the significance of their past trauma, while still holding them accountable for the abuse and/or neglect that led to system involvement.

Conclusion

Court-involved children and adolescents have often experienced many traumatic events that may impact their behaviors, ability to regulate their emotions, and capacity to develop positive and stable relationships. Court professionals play a critical role understanding how a child’s trauma history may be impacting their behaviors and ability to cope with the situation, but also in providing necessary supports to assist them in the court process. These supports include encouraging a child’s strengths and resilience, empathizing with a child’s challenges while providing them with corrective language and healthy coping strategies, and encouraging the child to sustain important relationships in their lives. 

Further, court professionals can work with other professionals by supporting the mental health needs of children and their families involved in the dependency system and understanding the core components of effective trauma treatment. Recognizing trauma symptoms through screening and assessment is the first step, followed by efforts to secure mental health supports and evidence-based treatments. Finally, court professionals can support the entire family by understanding that many parents have their own history of trauma and would benefit from their own trauma screening and referral for mental health services as needed.

Lisa Conradi, PsyD is a clinical psychologist at the Chadwick Center for Children and Families at Rady Children’s Hospital, San Diego.  Currently, she is serving as the Project co-director for both the SAMHSA-funded “Chadwick Trauma-Informed Systems Dissemination and Implementation Project” (CTISP-DI), a Category II Center within the National Child Traumatic Stress Network (NCTSN), and the ACYF-funded “California Screening, Assessment, and Treatment Initiative” (CASAT).  Her areas of focus include trauma screening and assessment practices, creating trauma-informed systems and innovative practices designed to improve the service delivery system for children who have experienced trauma.  

This article is one in a series produced under a grant from the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice.

The opinions, findings, and conclusions or recommendations expressed in this article those of the contributors and do not necessarily represent the official position or policies of the U.S Department of Justice or ABA.

Endnotes

1 Klain, E.J. “Understanding Trauma and Its Impact on Child Clients.” ABA Child Law Practice 33(9), 2014, 181-186.

2 Van der Kolk B.A. “Clinical Implications of Neuroscience Research in PTSD.” Annals of the New York Academy of Sciences 1071, 2005, 1077-1093.

3  Masten, A.S. “Ordinary Magic: Resilience Processes in Development.” American Psychologist 56, 2001, 227-238; Marrow, M. et al. Think Trauma: A Training for Staff in Juvenile Justice Residential Settings. Los Angeles, CA and Durham, NC: National Center for Child Traumatic Stress, 2012.

4  Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.

5  Wulczyn, F., M. Ernst, P. Fisher. Who are the Infants in Out-of-Home Care? An Epidemiological and Developmental Snapshot. Chicago: Chapin Hall at the University of Chicago, 2011.

6  Ghosh Ippen, C., A.F. Lieberman. “Infancy and Early Childhood. In Reyes, G., J. Elhai & J. Ford (Eds.), Encyclopedia of Psychological Trauma.  New York, NY: Wiley & Sons, 2008, 345-353.

7  Lieberman, AF, P. Van Horn, E.J. Ozer. “Preschooler Witnesses of Marital Violence: Predictors and Mediators of Child Behavior Problems.” Developmental Psychopathology 17(2), 2005, 385-396; Linares, L.O., et al. “A Mediational Model for the Impact of Exposure to Community Violence on Early Child Behavior Problems.” Child Development 72, 2001, 639–652.

8  Oben E., N. Finkelstein & V. Brown. “Early Implementation Community, Special Topic: Trauma-Informed Services.” Children and Family Futures Webinar 2011. Available from www.cffutures.org/webinars/early-implementation-community-special-topic-trauma-informed-services.

Sidebar 1: Developmental Stages and  Effects of Trauma

Young Children (0-5)

  • Express their distress through strong physiological and sensory reactions (e.g., changes in eating, sleeping, activity level, responding to touch and transitions)
  • Become passive, quiet, and easily alarmed
  • Become fearful, especially regarding separations and new situations
  • Experience confusion about assessing threats and finding protection, especially in cases where a parent or caretaker is the aggressor
  • Engage in regressive behaviors (e.g., baby talk, bedwetting, crying)
  • Experience strong startle reactions, night terrors, or 
  • aggressive outbursts
  • Blame themselves due to poor understanding of cause and effect and/or magical thinking
  • Have difficulty forming and maintaining attachment relationships or, conversely, attaching quickly and indiscriminately to others leaving them vulnerable for further abuse.

School-Age Children (6-12)

  • Experience unwanted and intrusive thoughts and images
  • Become preoccupied with frightening moments from the traumatic experience
  • Replay the traumatic event in their minds in order to figure out what could have been prevented or how it could have been different
  • Develop intense, specific new fears linking back to the original danger
  • Alternate between shy/withdrawn behavior and unusually aggressive behavior
  • Become so fearful of recurrence that they avoid previously enjoyable activities
  • Have thoughts of revenge
  • Experience sleep disturbances that may interfere with daytime concentration and attention, which may mimic the behaviors associated with ADHD

Adolescents (13-21)

  • Aggressive or disruptive behavior
  • Sleep disturbances masked by late-night studying, television watching, or partying
  • Drug and alcohol use as a coping mechanism to deal with stress
  • Self-harm (e.g., cutting)
  • Over- or underestimation of danger 
  • Expectations of maltreatment or abandonment
  • Difficulties with trust 
  • Increased risk of revictimization, especially if the adolescent has lived with chronic or complex trauma

Sidebar 2: Strategies for Managing the Needs of Special Education Students with Early Trauma Histories

Sidebar 3: Screening, Assessment and Evaluation

Screening refers to a brief measure, test, instrument or tool that is universally administered to children by individuals working directly with children (i.e., child welfare workers, attorneys, educators, etc.). Screening tools focused on trauma typically detect exposure to potentially traumatic events/experiences and/or endorsement of possible traumatic stress symptoms/reactions, although they are not diagnostic. Information from a trauma screening tool is used to determine if a child needs to be referred for a trauma-informed mental health assessment. 

A trauma-informed mental health assessment is a comprehensive process conducted by a trained mental health provider/clinician. It examines multiple domains, including trauma and developmental history, traumatic stress symptoms, broader mental health symptoms, caregiver/family needs or difficulties, environmental/systems issues, and resources and strengths (for child, caregiver, family, and community). It typically includes several forms of data collection, including clinical interviews with the child/caregivers/and others, administration of tests, and behavioral observations. 

Psychological evaluation refers to a comprehensive diagnostic evaluation of all domains of functioning, including an assessment of the child’s cognitive (both intellectual and achievement), developmental, social/emotional and personality. It is completed by a licensed psychologist and is typically conducted in response to a specific referral question. 

The type and number of tools administered in an evaluation often varies depending on the reason for referral. However, use of a standard battery of tests is not uncommon. A psychological evaluation may contain components of a trauma assessment but depending on the referral question this may not be indicated. A psychological evaluation may be warranted under several circumstances, including if there is confusion between the child’s self-report and the parent report, if a question related to the onset and duration of symptoms is unclear, or if there is question regarding defensive/coping processes or personality structure.

Sidebar 4: Core Components of Evidence-Based Trauma Treatments

  • Building a strong therapeutic relationship between the child and therapist.
  • Providing psychoeducation to children and their caregivers about the traumatic event experienced and common responses to trauma. 
  • Parent support, joint parent-child therapy (when the parent and child meet together with a therapist), or parent training.
  • Emotional expression and regulation skills that increase children’s abilities to identify various feelings and develop coping skills to manage feelings such as anger, sadness, or anxiety.
  • Anxiety management and relaxation skills to help the child develop relaxation skills to cope with trauma-related distress. 
  • Trauma processing and integration in which the therapist will help the child find a way to gradually express her traumatic experience and process related feelings about how the trauma has impacted the child’s life. 
  • Personal safety training and other empowerment activities.
  • Resilience and closure: At termination of treatment, the therapist focuses on helping the child identify strengths and areas of resilience to cope with future adversity. 

Sidebar 5: Evidence-Based Trauma Treatment Programs for Children and Adolescents

The California Evidence-Based Clearinghouse for Child Welfare (CEBC, www.cebc4cw.org) reviews published, peer-reviewed research for programs related to child welfare. The following trauma treatment programs for children and adolescents have been rated by the CEBC into the following scientific rating categories. Their target populations from the website are included below:

Well-Supported Research Evidence

Eye Movement Desensitization and Reprocessing (EMDR)—Target Population: Children and adults who have experienced trauma. Research has been conducted on posttraumatic stress disorder (PTSD), posttraumatic stress, phobias, and other mental health disorders.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)—Target Population: Children with a known trauma history who are experiencing significant PTSD symptoms, whether or not they meet full diagnostic criteria. In addition, children with depression, anxiety, and/or shame related to their traumatic exposure. Children experiencing childhood traumatic grief can also benefit from the treatment.

Supported Research Evidence

Child-Parent Psychotherapy (CPP) —Target Population: Children age 0-5 who have experienced a trauma, and their caregivers.

Prolonged Exposure Therapy for Adolescents (PE-A)—Target Population: Adolescents who have experienced a trauma (e.g., sexual assault, car accident, violent crimes, etc.). The program has also been used with children 6 to 12 years of age and adults who have experienced a trauma.

Promising Research Evidence

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT)—Target Population: Caregivers who are aggressive and physically, emotionally, or verbally abuse their children. Children who experience behavioral dysfunction, especially aggression, as a result of the abuse, as well as high-conflict families who are at-risk for physical abuse/aggression.

Child and Family Traumatic Stress Intervention (CFTSI)—Target Population: Children ages 7-18 recently exposed to a potentially traumatic event, or having recently disclosed physical or sexual abuse, and endorsing at least one symptom of posttraumatic stress.

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)—Target Population: 3rd through 8th grade students who screened positive for exposure to a traumatic event and symptoms of post-traumatic stress disorder related to that event, largely focusing on community violence exposure. It has been used in high school settings as well.

Combined Parent-Child Cognitive-Behavioral Therapy (CPC-CBT)—Target Population: Children ages 3-17 and their parents (or caregivers) in families where parents engage in a continuum of coercive parenting strategies.

Fairy Tale Model (Treating Problem Behaviors: A Trauma-Informed Approach)—Target Population: Teens (13 to 18 years of age) with emotional and behavior problems. It is so named because it is taught with the telling of a fairy tale, in which each element of the story corresponds to one of the phases in treatment.

Preschool PTSD Treatment (PPT)—Target Population: 3-6 year-old children with posttraumatic stress disorder (PTSD) symptoms. PPT is a manualized, 12-session cognitive behavioral therapy protocol to treat very young children with posttraumatic stress disorder (PTSD) and trauma-related symptoms.

Sanctuary Model—Target Population: This program is not a client-specific intervention, but a full-system approach that targets the entire organization. The focus is to create a trauma-informed and trauma-sensitive environment in which specific trauma-focused interventions can be effectively implemented.

Seeking Safety for Adolescents—Target Population: Adolescents with a history of trauma and/or substance abuse. Seeking Safety for Adolescents is a present-focused, coping skills therapy to help people attain safety from trauma and/or substance abuse. The treatment may be conducted in group or individual format for adolescents (both females, and males) in various settings.

SITCAP-ART—Target Population: At-risk and adjudicated youth, ages 12-17, with a history of trauma and/or loss. SITCAP-ART is designed for at-risk and adjudicated youth. SITCAP-ART integrates cognitive strategies with sensory/implicit strategies.

Trauma Affect Regulation: Guide for Education and Therapy for Adolescents (TARGET)—Target Population: Youth ages 10-18 with posttraumatic stress disorder (PTSD). TARGET provides practical skills that can be used by trauma survivors and family members to de-escalate and regulate extreme emotional states, manage intrusive trauma memories in daily life, and restore the capacity for information processing and autobiographical memory. 

Trauma-Focused Coping (TFC)— Target Population: Children and adolescents in schools who have suffered a traumatic exposure (e.g., disaster, violence, murder, suicide, fire, accidents). TFC targets the internalizing effects of exposure to trauma in children and adolescents, with an emphasis on treating posttraumatic stress disorder (PTSD) and the collateral symptoms of depression, anxiety, anger, and an external locus of control (i.e., tendency to attribute one’s experiences to fate, chance, or luck).