Basically the focus of my talk this afternoon was going to

file:///centervideo.forest.usf.edu/video2$/center/2017abuseneglectconf/chlddvlp/chlddvlp.txt[2/23/2021 14:40:44]

Basically the focus of my talk this afternoon was going to

be to review for us the intersection between Child Development

and understanding of Child Development and how we care for

maltreated children.

So the there's a lot of information in the slide that I'm

going to go through pretty quickly, but it's available for

you. And if you have any questions or any of the instruments

that eyesight and the slides if you're having problems getting

them then Can email me and I'll be happy to send them to

you. Let me give you my email address because I don't think

I put it on my slides.

It is C.

L-- I ll y at Health hea, lth dot u s f dot edu, so you can

go ahead and email if any of the if you're having problems

finding any of the instruments that I talked about today.

Okay.

I don't have any disclosures and part of our goal today really

is to think about how we approach child maltreatment from

the developmental lens.

Then basically requires us to go through a series of thinking

which in turn and in terms of our Assessment informs not

only whether injury might have occurred or what a safety

plan is for a child, but also helps us to incorporate our

Theory into practice in terms of intervention.

So it's very important for us to recognize the impact both

of maltreatment on development.

But also the impact of development on our response to maltreatment


when we're children.

So in this case, I'd like you guys to be thinking in the

framework of risk assessment and how How when we first approached

cases, like let's say we talked about a kid that gets referred

to you who's a three-year-old who has been hit because he

pooped his pants right or he's been burned because he pooped

his pants.

So what's the real issue there with that caregiver?

The issue is not only do they have a poor impulse control

and couldn't control their response to that incident but

there's a disconnect in all of these cases between what the

caregiver expects from the child and what the child is able

to do, right?

So in all Examples examples where a baby is had because they're

crying weren't eight-year-old gets hit because they got to

see on the report card where you know a child with ADHD gets,

you know beat up because they can't finish their work or

because they're not paying attention all those things involve

some sort of caregiver expectation.

That doesn't match the child.

Right?

And so part of our assessment is to note that the other piece

of it is for CPT in particular is to note whether injury

interpretation as dr.

Knox so wonderfully showed us.

Matches certain characteristics given the history and one

of the characteristics that we must ask is what the child's


development capabilities are right.

So we want to know if the child's mobile wonder what language

they have because that helps inform us regarding how we're

going to evaluate injury and then the last to involve us

being able to interpret what child's children say to us when

they're abused how many times have you been in court where

somebody has said to you?

How do you know the child's not lying the child has autism

they can't they don't speak normally so they can't beat.

Possibly telling the truth.

I've had that said to me a couple times in court and so you

have to be able to refute those kinds of statements by having

an understanding of Child Development.

And then the last thing is to try to understand Trauma from

a developmental lens in terms of how children respond to

it and how we can potentially recommend intervention.

Okay.

So this is the definition of development.

I won't, you know belabor this point, but basically it is

a neurological process, but it's heavily explore influenced

by our experiences.

And so we Have to have both of those things.

The brain is an organ just like any other part of the body,

but it when it comes out of the box.

It's not always ready for prime time.

Right?

So so we have you know, the kid there he's got his little


CD his hand but nobody knows how to play it because he doesn't

have a CD player right now.

So we got to figure out how to teach this child.

And sometimes you have what happens on the right here on

your I think it would be your right hand side where you have

a little bit of a steak and the kids get into something and

you got to clean up after him and other times it's pretty

Nice, so the key concept to understand is that while biology

and neurology wires the brain for learning the brain is has

plasticity so that term means that the brain can change as

a result of experiences and is Randy has so carefully talked

about earlier positive early experiences are essential to

brain development and children.

He would relationships of the building blocks of those positive

experiences, and you can alter the course in early childhood

by both in Effective parenting but also by effective intervention.

So it's very important to recognize how important early childhood

is child functioning is shaped by the child the environment

by factors that compound each other like risk factors within

the environment and then these risk factors can just generate

secondary stresses or secondary responses that are maladaptive

within me which then makes it a cycle.

So you have the child who's got poor prefrontal cortex function,

so they're in a tentative and they're aggressive.

And they get in trouble at school and then they get reinforced

to be you know, again to be negative and angry and so the

cycle is really hard to break until you sort of find a way


to get past some of that likely the likelihood of psychiatric

and physical disorders.

You guys know already from the aces study increases with

the number of risk factors.

All right.

So environmentally we know that many factors influence child

maltreatment. And in fact influence development negatively.

These should be very familiar to you.

You but one of the key things is that the reason these impact

us. So intently is that the brain is not developed when you're

born. It's go it goes through developmental stages because

it has to learn from experience.

So it develops with the experiences that you have.

So you have a basic foundation and then the experiences guide

you through how you're going to end up by the time you're

an adult so during pregnancy.

The brain is formed you're hardwired but to a significant

extent. And the route the remaining formation of the connections

between the synapses happens because of our environment and

what we're experiencing.

So to use language as an example most children all children

are born with the capacity if they don't have any brain injury

to learn all languages, so when a baby is born if they're

if I'm you know, Carol Lily and I'm born from two parents

that are into speaking parents, but I'm born in Japan because

my dad Was in the Air Force and I'm raised by a Japanese

made. Okay, just give me an example.


Then.

I'm going to learn to speak Japanese pretty quickly and pretty

easily right so we know that young children can learn multiple

languages actually early on if they're exposed to them in

early infancy and early childhood.

We also know that when once they get to a point, usually

somewhere between 12 months and three years, they start to

have a difficulty assimilating The Sounds what we call the

phonemic awareness and and Language Concepts in terms of

how we use idioms that starts to become difficult to already

for them because they're so used to hearing how their caregivers

speak in their environment.

And so it's very important to recognize that when we have

kids that have a race for instance in bilingual households.

That's actually a strength for them if they're raised from

early infancy.

But if you put somebody who's a non-english speaker into

a school classroom that is not supported and there are non-english

speaker there.

Going to really struggle because they didn't necessarily

learn English when they were during period of early language

development and and then basically Randy has already talked

about Live Language and how much words so he talks about

children who live in poverty have what about 13 million less

words that they've been exposed to than kids who are in stable

environments? Okay now synapses are important because they're

the way the brain communicates right?


So the greatest density we have Synapses is somewhere around

three years of age.

But those synapses get proved with our experiences gradually

until we reach early adulthood.

So the brain is changing throughout childhood and early adulthood.

So in the old days we used to say, oh gee your MRI are being

your scan shows that your brain is not growing anymore.

Your CT looks like it looks like the brain is the same size

and it didn't really we didn't really realize that it wasn't

just size that matters.

It's actually if the content so it's how the brain cells

are myelinated.

It's how they connect that's the most important thing.

So when we talk about the pattern of synapse formation, there's

a plateau period and then a period of pruning or what's called

elimination based on experience.

We it does anybody remember the study where they used to

talk about Vision where kids were not exposed to visual appropriate

visual stimuli by the time they were probably 8 to Lots of

age they will be functionally blind even if their eyes worked

so you ever heard that so in the old days we used to think

that this period was always in early infancy and it was of

the same for each developmental skill Well turns out that's

not really true turns out that actually the plateau period

happens differently for different skills that you learn.

So Vision might be different from hearing might be different

from your ability to attend and organize and use your executive


function skills that might be different from your social

emotional development.

So it's important to recognize that throughout childhood.

There are frequent periods of plateau and pruning that occur

all the way up into 16 to 25 years of age.

And so the child is not done until they're done.

So one of the reasons that we talked about, you know, not

not really assuming that things are finished with children

who have had horrible abuse is because there's always a period

where you might be able to interrupt what's happening to

them before all that pruning and everything has taken place.

So nutrition also plays a huge part.

Early malnutrition I think talked a little bit about this

yesterday can really impact cognitive and behavioral development

children who are malnourished during mid pregnancy up to

two years of age have poor physical and mental growth.

Their brains are physically smaller and they often have difficulties

with fine motor language and poor school performance the

studies on IQR variable.

Some of the studies showed their 325 points in general lower.

But as you know, I IQ is sort of a population-based concept.

So the number for any individual kid isn't as important as

what they're able to do functionally.

So iron deficiency also has been linked to cognitive deficits

and often goes hand in hand, especially in in areas where

kids are being fed only milk or they're not being fed a healthy

wide diet.


Alright, so the myelin is the substance which covers the

neuron and not only provides nutrition, but it also is necessary

to transmit the signal.

This is important because Milan forms around the nerve cell

during infancy.

It's not there when babies are born.

So there's two reasons that's important one is that in abusive

head trauma literature when we talk about the brain, we frequently

talk about the baby's brain being different than adult brain

and part of the reason is structurally it is not developed

yet and it's important to make that point when you're talking

about that with everybody that might be possibly dealing

with a case of abusive head trauma.

The other piece that's important is to recognize is that

as my landforms it actually changes the way the brain looks

on on functional MRI and it becomes it goes from more gray

matter which is sort of the non thinking part of the brain

to the to the white matter part of the brain, which is more

where we're things are sort of being communicated between

the different brain cells and that's important because that

really that process isn't really complete and so well beyond

the age of five or six years and in fact this still Inning

in adolescence and that and the reason that we say that's

important is because again, there's still some plasticity

within the cognitive and prefrontal cortex even as late as

12 or to 16 years of age.

So, why do we care about this?


Well, it's important to understand that developmental screening

and knowing development from an early age helps us to plan

and intervene when kids are at risk or have problems and

when it's been evaluated.

Screening has been found to find not only find kids early

but it has been shown to get kids into services and to improve

developmental outcomes.

And that's based on the national early intervention longitudinal

study. And there's a couple of other Studies by Guevara that

showed that.

Okay.

So this is just some when we think about development we think

about the fun parts of the developing brain.

It's wonderful to watch a kid growin developed, but there's

also the more, you know difficult parts of development, right?

So when when toddler Those are at a certain stage in development.

They were all self-focused.

Right?

So this is my one of my favorite spots because this is how

all the titles in my family were probably how I was too.

So basically the whole world revolves around them basically,

so but when people get pregnant or have children, they don't

often think that like that right?

So how many people have you seen in the course of your practice

where there was all the gooey?

I do.

I'm really proud.


I'm pregnant.

It's my first baby and everybody's really excited.

Well, that's great.

I mean, I'm not picking on that.

That's all good.

But but but a lot of people are quite taken aback by what

the reality is.

And the reality is a mixture.

The reality is you got the kids fighting over the toy the

the kids.

I love the kid in the corner swallowing the Frog you see

that up in the left-hand corner, you know, the girls screaming

that was me, you know, and then you have the kid drawing

and crayon all over the bathroom wall the baby crying, but

then you have the cute little kids who are kind of sitting

there reading and everything and the little boy doing homework

with Mommy.

And the boy coming home from school and hugging his mom.

So then you have those moments to write so it's like a bounce

it's not like all good and it's not all bad.

But a lot of people are prepared for the bad and that's part

of what we deal with when we're in our system.

Right?

We have parents who are just not prepared for what they're

going to have.

Okay.

So what what I wanted to talk about next before we get too


much into how development affects the child's developing

brain is what we mean when we say traumatic stress because

there are Different kinds of exposure and traumatic stress,

but basically it's not always a prolonged exposure as this

slide says, it's not only one exposure.

It can be both so you can have a severe traumatic event,

right? You can have a loss of a parent for instance or you

can have a repetitive or severe event like a chronic illness

child abuse and neglect and we should not forget neglect

because it's probably the most common form of maltreatment.

Well it is there's no question about that and it causes I

think the most ERM two children, but when they break out

trauma categories, they generally talk more about external

trauma such as oh my I lost my house from the from the from

the tornado or the or the school got you know heard in the

flood and then there's the personal intimate stuff like that

involves what I call a betrayal of some sort where it disrupts

the fundamental sense of trust attachment and it's usually

perceived by the person as intentional even though it may

not be As kids get older and they perceive that the way they're

being treated is like that on purpose.

Okay.

So this is sort of the stress Continuum that they talked

about was I said a single traumatic event multiple events

exposure chronic trauma, and then there's there's one that

they talked about which is system induced trauma.

We just all have to understand that when we we are doing


what we believe to be best.

Sometimes we remove kids from their environment, right, but

it's not a it's not an age.

Traumatic event they feel if they're old enough.

They feel the pain of loss from their family members no matter

what happens.

So we as a system need to work on making sure that that is

as as organized and as supported as we can be knowing that

we're going to be causing trauma to the child and we have

to weigh that and in our decision-making so what kind of

situations that you see can be traumatic in families.

Give me some examples of things that you've seen.

and whether their abuse or not Divorce yep.

What else take it death?

Yeah the death of a family member.

Yep.

Job loss.

Say again.

Yep.

Moving is a big stress.

Actually.

It's really intense.

I just did it.

I'm Talia actually to the three years ago, and I'm still

having freckles and I just got my last bedroom cleaned out

of the boxes.

So I'm really proud of myself.


All right, so moving can be stressful but a lot of the people

that experience stress either experienced some acute horrible

event or Experience some chronic sort of stress.

So with an acute event kit people go through a variety of

feelings and thoughts and physical reactions and depending

on how that event overwhelms their capacity.

They may be able to bounce back from that are but they may

not be able to okay.

So chronic trauma is multiple events, they're often cumulative.

So this is a very important concept right?

So it's just as risky as cumulative traumatic chronic trauma

is cumulative.

T''v and then complex trauma describes exposure not only

to Chronic trauma, but it usually involves the fact that

there's a betrayal by the person that's supposed to be caring

for you and it causes a severe impact on the child and the

child at become sort of a cycle because the child's Behavioral

or developmental impact from the trauma.

Alright, so we're not going to go through all of these but

I didn't want to talk about neglect a little bit.

So basic needs are important.

But when you don't get fed, you don't get your diapers changed.

You don't get picked up when you're going to cry when you're

crying. You're the pork baby that died.

And dr.

Knox's, you know, hyperthermia scenario that kids sat there

for all those hours while her their parents ignored them.


Right?

So if that cat had kid had lived there most certainly would

have been some trauma.

The kitchen was certainly old enough to perceive not be taken

care of by their parents and it opens the door.

Or to other traumatic events because you start to perceive

differently start to act differently as a child.

And as if it keeps happening, it's harder to recover.

Okay, one of the things I wanted to talk about in addition

to traumatic grief was medical stress really quick you guys

on how many people here have done cases where he had to do

medical neglect?

Okay, and how many people felt that the caregiver was still

grieving? The loss of their normal child when they were doing

those cases, I think that we forget that like, I we just

we've had an explosion of medical neglect to my area.

So we're kind of going through cases rapid fire on some of

these kids are horrendously complex and I think it's really

important for us to recognize how this affects the caregivers

thinking. They thought they were going to have this normal

baby and they'd lost the baby.

I have one baby right now where the twin died in the hospital

the same hospital at the parents have to take the baby back

to Mississippi.

Back, you know, so even though they have an openly stated

they blame the hospital still brings up memories for them

when they go into the unit and all that kind of stuff.


So these kinds of things we tend to forget that when we're

taking care of people and I think we should try as much as

we can to incorporate that into our family plans.

So one of the things that I think it's important to recognize

with medical traumas that can also affect older kids.

So how many people have had the medical neglect on the diabetes

kid who's 14 and refuses to do Eric.

Great.

So the diabetes 14 year old or the asthma fourteen-year-old

or the pick the chronic disease your choice 14 year old is

really hard because the kids have had this chronic illness

for their whole life.

They know they're not normal.

They know they're starting to understand very carefully and

feel the peer pressure of being different from their peers.

And so you're dealing with that and then you're dealing with

the parents being like kind of over it, you know, reminding

so-and-so to take your insulin and all that kind of stuff

and it can be a real challenge to address when you have kids

that age because the That's child refusal versus parent not

really following through can be very difficult to tell right?

All right, so children foster care.

Also another group that I think are very important to recognize

so kids could get put into foster care.

But how many what percentage do you think of kids in foster

care? Either have some medical or physical or developmental

need that requires Extra Care, right?


It's at least 50 to 60 percent.

I would argue probably higher, right?

So a lot of the kids going into foster care.

Not only are damaged by their prior episodes of neglect or

abuse, but they're sick on top of it and they have to deal

with that and their foster parents have to deal with that.

So we forget some of those things.

Sometimes we tend to kind of blow through and make recommendations

and hope that people follow through but this can be quite

quite impactful for the child and and then other sources

of stress.

I think we all know that these are sort of the community

piece has the poverty discrimination frequent moves as somebody

Brought up.

I think some of our families our kids that have moved five

or six times in a one or two-year period they don't have

a stable place to live.

They don't know what home is, you know, and then you know,

we have we have a group of immigrants that come in that are

not only stressed out by the loss of their Homeland or because

they had to leave family.

But by how they might be being treated when they come.

All right.

So other things that I think we need to recognize then is

that when we see kids With trauma, they frequently get get

diagnosed with other problems as they get older.

Right?


So if I have a dime for every child that has ADHD diagnosis

and an OD D diagnosis when I see those kids.

So the first thing in your head should be is that diagnosis,

correct? The second thing in your head should be is that

diagnosis, correct?

The third thing in your head should be is that something

else is correct?

Because nine times out of ten I'm telling you right now.

It's not easy.

It's either incorrect or it's not fully accurate.

You know, I'm sure they many of these kids have Frontal cortex

damage they have problems with executive function that is

definitely true.

But what is also true is that they have grief mood moodiness

fear and loss and so if we don't address those things it's

very hard to sort of just address their prefrontal cortex

issues. Okay, and so the other piece that I think is important

to recognize is that kids sometimes have learned the behaviors

they've learned to survive.

The reason they act the way they do is because It's the only

way they knew how to get get by.

Okay, so we have to understand their behaviors in the context

of where they come from.

And then one of the big pieces that I see is that especially

with some of the kids as they hit between three and five

years of age.

They really start don't trust their environment that so they


stay remain dysregulated.

It's hard to get them to engage and as they get older and

they get a little bit smarter.

They get a little bit more difficult to manage because they

just don't have a In a trust anybody in their minds, they

also have problems with personal safety.

They don't really understand risk the same way other people

do and so they're more likely to be picked on in the future.

All right.

So the impact of trauma on children is dependent upon a lot

of things age and developmental stages 1 the perception of

the danger face.

So one person might think that going to the hospital And

getting your IV and getting your you know medicine is like

oh I got my V look.

My here's my here's my thing.

It's my battle scar and other kids.

It might just be a horrifying event for them.

So a lot of it is individual response and in our ability

to recognize that is very important because we can't just

assume it's a one-size-fits-all and then for me the biggest

piece involves whether the child is a victim or witness and

what their relationship to the victim or perpetrator is because

Does the force of betrayal cannot be understated?

You know, if you're supposed to be careful by somebody and

they don't do it.

You can't really put it into words when you're a six-year-old,


but you have the feeling of it.

Okay, and then the one of the biggest things that we talked

about is as people that can help afterwards.

All right, so trauma threshold is the idea of when you're

kind of crack under trauma.

So remember Randy talked about kind of what I guess when

he called good stress and then there's sort of the The toxic

stress. That's really that's the point at which you just

can't really cope anymore.

And so everybody has a different threshold and that's dependent

upon individual characteristics.

And also what you've been taught so when we're dealing with

trauma, I'm not going to spend a lot of time on the system

of care, but this is what a system should be and if I were

doing it right at our CPT, we'd be doing trauma-informed

screening on most of the verbal kids and a lot of the families

that come to see us and I think we do some of that That in

our specialized interviews, right?

We try to get at how people are perceiving things and the

stressors for the family, but I'm not totally convinced that

we're as organized as we should be about how we articulated

a particularly when it comes to intervention planning.

And so I think it's important for us to try to continue to

improve our knowledge and how we use this in a more planful

way, which is why I bring about I bring up some of the screening

things later in the talk here.

So this is I think a very compelling statement which is that


Moving a child from a dangerous environment does not undo

the serious consequences to reverse the impacts of early

fear learning.

There is no doubt that children In Harm's Way should be removed

from a dangerous situation.

But simply moving the child out of meeting danger doesn't

in itself reverse or eliminate the way they learn to be fearful.

So I think it's really important recognize that removals

the first step but it is the first step and there's many

steps after that.

Okay.

So why do we need trauma-informed care?

Well, we know that when kids aged out.

Order them will be incarcerated within two years of Aging

out Children experiencing abuse and neglect are 59 percent

more likely to be arrested as a juvenile and 30% more likely

to commit a violent crime depending on what kind of abuse

or neglect they experienced and more than 20% will become

homeless and I think it's way more than 20% in some areas

fifty-eight percent graduate high school.

So the rest of them don't and they don't go to college so

they don't get the secondary education.

And then we look in early steps 40% of the infants Toddlers

and fifty percent of preschoolers have serious developmental

behavioral problems.

And we did a study in Florida.

It was 2012 where we looked at early intervention and more


than 35 percent of the kids in the early intervention system

at the time had some sort of a family support plan in early

intervention that were had previously been abused or neglected.

So a lot of the kids in the EI system have Prior history

of abuse or neglect and then when we look at adults a large

percentage of women and men have experienced rape physical

violence or stalking and eighty percent of female founders

of the mental illness report prior physical or sexual abuse.

So these things shouldn't be really a strange to you, but

it's just kind of strikes us as how frequent this is.

So I just wanted to basically quickly go through through

the principles of a trauma informed system.

The first thing to recognize is that a trauma informed system

is intended to impaired children during the developmental

period to mitigate the effects of whatever trauma they experienced

the system can either mitigated or can inadvertently cause

new ones based on how you approach the child.

Right?

So many people remember when the little boy from Cuba was

removed from his house, right?

That's the picture at all.

Come to my mind when I think about we should really be careful

about this right because there's guns it's scary and I get

that it you know, maybe that kind of stuff has to happen.

But there's no question that that causes trauma to the child

when it happens.

And so I think that it's very important to try to make it


from the first responder all the way up into everybody who's

deep in the system doing intervention that we try to look

at how we can decrease the vicarious trauma for children.

Trauma also impacts families and we forget sometimes about

family. So I think in our planning when we're planning for

families, we tend to offer them counselling I'm not totally

convinced that our counseling right now is as effective as

it should be I think in some areas, there's good trauma-informed

care how many people have a system in their County or they

can refer somebody for trauma-informed care for both individual

or family counseling?

Okay.

So there's a few that's good to hear.

Okay, I think.

Last year the year before when I did this, I think only one

or two hands went up.

So I'm hoping that the state will continue to improve with

regards to that and then vicarious trauma I think affects

us. So we're the were the workforce that gets traumatized

because we see this stuff all the time and we have to take

care of ourselves.

This is called hot docs relaxation CD and it is a progressive

relaxation exercise that you guys can do.

So it is free on YouTube.

And so it basically teaches you how to take deep breaths

and how to breathe and then How to relax yourself from head

to toe it's a 10-minute exercise.


It can be done at the office.

So you guys can Musa and try to find your happy place.

Okay.

I do find it to be effective.

We started using it in our behavioral program with parents.

We start teaching parents how to do it.

And what's really cute as you can teach kids as young as

four or five how to start to try to do the breathing.

It's really funny put their hands on their stomach.

You tell make your stock go out they do all the stuff with

her stomach and but they're very cute and they do learn how

to do it.

And so a lot of kids can learn how to self calm and learn

how to do.

Rest of relaxation.

So that's just for you guys.

Have you searched hot docs relaxation CD English YouTube.

It is free and you will find it.

All right.

So and then the other piece is that we because we're affected

by what we see.

I think we sometimes I know I have to stop myself from being

jaded. So I think it's important to always try to remember

and step back and try to think of all the other setting events

or what else is happening that might be explaining what your

families are experiencing or what the a child is experiencing

because I think sometimes it shapes our world in terms of


how we view things just like it shapes the world of the kids

that experience and families that experience trauma.

Okay.

Alright, so I'm not going to go too much into this but some

of the most important elements of of trauma informed system

involved not only maximizing safety in terms of getting the

child away from from abuse or neglect or other trauma, but

Adding that the behaviors or or or things that we see that

that the children experience or that they're acting out are

not good or bad but the behavior is reflective of their experience.

So we already talked about the challenging behaviors may

be a way to survive and so it's important for us to recognize

that and I don't think we support our foster families enough

as I think adoption assistance would be with long-term supports

because I don't think it off while I know it's not so I think

that both foster care and adoptive families.

Are not prepared and I would include kinship stuff in there

as well when we put families with relatives.

It's I don't think they get the support they need either

so it's not because we don't try it's because it's very hard

to get the support funded.

All right.

So the other piece we talked about it is how we practice

and how we can promote a feeling of security in practice.

So when we're dealing with families always informing them

about what's next.

What are we going to do next?


What's the plan down the road?

Because it helps to kind of calm things down giving children

some control.

So even as little as saying, you know, do you want to sit

this way on the table or that one on the table?

Do you want to use this blanket or that blanket?

Give them some kind of control during the assessment process.

I always talk about a safety message, which is teaching them

what to do.

If something happens again, where do you call who do you

go to?

What's your plan is going to be and then there are hot spots

that kids experience.

Science all kids not just children who experience stress

have difficulties with daily routines, right?

Because that's our job as parents right is to get kids through

get em up and get em breakfast again.

I'm dressed get him to school get it home get them to do

their homework get them through dinner, right so going through

the day for the how many people are parents.

Let's just raise the hand sir.

We got quite a few.

Okay.

Alright, so getting them through their day can be a real

challenge, right?

So but in particular kids who are dysregulated or have not

had that kind of routine can really be challenged in the


so Get making sure the caregivers recognize that food and

mealtimes might be difficult because they didn't really have

organized meals before or that was the time when Mom and

Dad always fought or whatever it is.

Okay sleep in bed time often very disrupted the most and

not in our hot docs class which is our parenting behavioral

class the routine that people complain about the most is

trying to get the kids to sleep.

It's so hard because not only are they still wound up and

it's hard for them to shut down the, you know, sort of the

feelings in their head, but there the room is dark, you know,

they're in bed by themselves.

So there's a lot of fears that come up and so it's very important

to recognize the sleeper teams and try to come up with activities

to try to help them transition to sleep.

And then what I call Comfort objects or things that they

can do to self calm.

I I do use Progressive relaxation before bed and a lot of

the kids that we see in child development and then physical

boundaries. Some of these kids don't have a sense of boundaries

right there either like out there.

They don't want to contact anybody and they're sort of angry

or their little younger kids are all over your right there

in your face.

They're touching your clothes there.

Have you ever had the little kid in clinic that's grabbing.

You're certain.


You're bright and you're like, okay, so they don't have a

sense of boundaries.

And so teaching the foster parents.

Look sometimes this happens and it's okay.

You don't get upset.

The child is not automatically going to be a perpetrator

take a deep breath and just teach them the boundaries because

that's our job as a teacher.

Um, you know, you can do this and leave this alone.

Neck out thing.

Okay.

All right, and then and then this is this is mostly centering

on Mental Health, which is we're going to talk a little bit

more about trauma-informed care in a second and then family

well-being. I think that we need to include parents and counseling

and again as you settle adoptive and foster parents as well

because I think families get confront these behaviors and

they really are struggling with how to deal with them.

And then I think one of the big important things is Well,

we're trying to develop our systems.

We don't always ask kids.

What would have helped them?

And I mean, we just don't I think we should when they get

older we should talk to them about.

You know, what made it really hard for you.

What would have made it better?

What did you think what worked for you?


That kind of thing?

I don't think we ever really get their impression.

I'm not aware of very much out there where we really got

their opinion.

I think there's some like when Sharon Cooper talks about

talking to the victims of trafficking where they came back

and serve talked about how they were treated.

And when they're in the assessment process or during the

legal process, but I think we don't do that enough.

Okay.

Alright.

So basically the goal of trauma-informed care is to look

through a lens which understands that trauma has affected

the person and basically want to understand how it affects

them psychologically and physically and incorporate our practices

to address that from the minute.

We touch the kid or the family from the minute they hit the

door and so the whole idea is to change our This from what's

wrong with you, which is a medical promise.

Right?

Why did you come to my clinic today?

I know you're hurt.

Sorry.

I'll give you some amoxicillin for infection, right?

So to what happened and have them narrate as much as you

can what happened if they're old enough, right?

Alright.


So before we go into too much further than that, the last

part of the the lecture is going to really talk about the

developmental impact of trauma exposure based on age, but

I really wanted to talk a little bit.

About and I'm going to avoid the Asus stuff because Randy

already did this so you guys don't need to hear that again,

but I really want to talk about the developmental impact

of how children present when they've had a traumatic experience

or multiple traumatic experiences.

First of all response to trauma is not only based on the

the number or severity of episodes, but also on the extent

to which the disruption hurt their support system, so it's

one thing to you know, Get involved and have a traumatic

event. But if your caregiver or your parent or somebody that

you know is still there that can be a mitigating Factor.

But if everybody, you know is taken away from you that can

be really harmful or cause a lot of pain to the children.

And then again we talked about whether they were a victim

of witness.

One of the other pieces that I think is important is the

presence of adults who can offer help and protection and

how we interact with them as First Responders.

And so I think those things are mitigating factors.

That we can help them from the minute.

They hit the system.

All right, so when kids experience PTSD, they can't always

tell you when they're younger that they're really experiencing


an event.

But no, there's no question that they are probably experiencing

trauma and that certain things remind them of the trauma.

So key symptoms involve some behaviors which indicate that

they might be experiencing a traumatic event or the or the

overall trauma and the kids tend to have both Behavioral

and physiological reactions to q's and so this is the kid

who hears something that sounds like either mother's voice

or dad yelling or The Gunshot or whatever and it reminds

them of the event, even though they can't articulate that

avoidance of thoughts and feelings that are associated with

the trauma.

So these are the kids that when you when they don't want

to go a certain place that I want to be or do certain activities.

It's because it reminds them of the event negative changes

in thoughts and moods so they can't recall the Trauma, they're

fearful guilty sad and then increased arousal.

This is the fight-or-flight, you know that they are there

constantly kind of on guard and if this happens chronically

as Grand as already said that prefrontal cortex is programmed

to be fight or flight and after a time that becomes permanent.

All right, so briefly I wanted to talk about the impact on

brain development.

We used to sort of talk about this back in the day when I

was younger.

And maybe a little lighter we used to talk about this being

a psychiatric issue, but we didn't do a good job of linking


it to the actual brain and the body and the neurology, but

we've become much more careful about making sure people understand

how many people have gone to court and try to present the

impact of child neglect or abuse to the legal system.

How many people who are lawyers lawyers raise your hands.

I love you.

All right.

So how many people have tried to get?

At this past like a judge or a jury where you're trying to

explain that.

There are there are psychological effects and it's not just

you know, some thing that's nebulous like, you know, my beliefs

or my religious spirituality.

It's actually based on how the brain is built.

So this is where I think we could continue to refine our

message to folks about it affects.

The hippocampus is smaller.

The prefrontal cortex is smaller and poorly developed.

The corpus callosum is small Poorly developed the syrup cerebellum

is smaller and part poorly developed and all those things

impact the child's memory their ability to attend and organize

and solve problems their ability to for the brain to communicate

across both sides the corpus callosum and higher cognition.

That's that comes with that and their ability to Executive

plan motor activity.

So these are the kids that are motor-driven.

They look like ADHD, right?


So a lot of these kids but their One was hurt by what happened

that it's not about something.

That's nebulous.

It's the brain.

It's like it's like your heart having chest pain because

your arteries are closing up, but this is the brain.

Okay.

All right.

So cortisol directly damages the brain.

It causes a number of symptoms including increased depression

and anxiety and when we talk about trauma and its impact

on memory, we talk about implicit and explicit memory implicit

is what I was talking about with the baby retaining unconscious.

Memories, but it clearly affects them.

So they hear something or smell something that sounds like

their mother's voice or smells like something that they smelled

at home or explicit memory which are actually conscious memories

which began to be created somewhere around Age Two and are

tied to language development.

When words can explain things the big guy the scary black

gun that kind of thing when they can say those kinds of things.

Okay, so they may kids with early trauma retain implicit

memories of abuse.

And so that's why it affects their behavior and development.

The sensitive period for attachment is the first two years

of life and all development that we have occurs within the

context of how we attach to our caregivers because what we


decide to focus on as babies and children depends on how

we develop and so basically if we're with a caregiver who's

coaching us and giving us a lot of words and who's giving

us positive praise then our attachment to that caregiver

helps to forward our If the attachment is avoidant where

the child doesn't feel accepted or the caregiver thinks the

child should be able to do more than they're capable of and

doesn't give them affectionate nurturing than that changes

the way the child views the world and they don't learn the

same way.

All right, so critical periods for attachment or in the first

year of life and disruptions and that attachment May threaten

secure attachment where the child never really learns to

trust that the caregiver will protect them.

So again, this is not a given where it's going to happen

to every child but it's important to recognize that probably

happens to some level and every child and Our obligation

is to do what we can to mitigate this when we're dealing

with children.

All right disorganized attachment occur when the pattern

of caregiver interaction is Inconsistent, so this is where

one minute the parents really loving and and happy and playing

with you in the next one of the pair cable parent is mad

angry. There are mad at you about something that makes no

sense stuff that that sets them off as minor.

So common signs of disorganized attachment include fearful

or disoriented behaviors or the kids might engage in repetitive


behavior and withdraw and then many of these kids.

Exhibit poor impulse control cognitive impairments and they

have a higher risk for psychopathy including not only depression

and anxiety, but sort of significant mood disturbances and

aggression. So the clinical signs of attachment problems

in young and younger maltreated children include developmental

delays poor feeding trouble soothing poured social poor social

emotional functioning and appropriate aggression and inappropriate

modeling. So when we talk about this, I think Porter recognize

that these this can look like a lot of other developmental

disorders, right?

So I've had kids in our office that were I could have sworn.

They were autistic.

I'm not even kidding.

I could have sworn their autistic and they get moved and

they they're devout development Behavior completely changes

when they get attention and so I think it's really important

when we're seeing kids with developmental behavioral issues

to routinely screened for trauma because I think it's a pretty

a pretty hidden.

Cause of some of the behavioral developmental problems that

we're seeing that we don't really want to talk about when

we're in primary care when we're in mental health.

All right, so let's talk about The effect of influence of

trauma on developmental stage.

The first thing I wanted to say is that trauma chronic trauma

did rails development kids think it's always dangerous time.


They're quick to react to threats.

Sometimes things that are not even really threatening to

other people and they continue to produce a lot of stress

hormones. The there's a chain reaction that starts early.

If you're pregnant.

There's Direct effects of of trauma if Mom is stressed out

the court, Mom's, you know the in Mom's body affects the

baby the baby feels stressed out there hypothalamic pituitary

axis changes and then as the kids are born you have impact

on Maternal Child interactions because their stress and continued

neglect in the household and then as they get older it impacts

their executive functioning.

Okay.

Alright, so young infants, obviously, you can't identify

specifics because they Aunt tell you right so but they can

remember through implicit memory things that have happened.

So again, it smells and sights it sounds they have problems

with emotional regulation they become easily overwhelmed

when they're not verbal, they're more irritable and they

have a hard time engaging when they are a little bit more

verbal, they look inattentive there or they're clingy or

aggressive. So these are the kids that are walking around

whacking people or the kids who are sitting They're refusing

to leave the person that they like or the thing that they

like they don't want to transition from one thing to the

other because it's too scary for them preschoolers are more

independent, but they still require caregivers to help them


because they learn how to cope with stress from their caregivers.

So this is the age where you teach kids take a deep breath

and calm down.

Let's all go take a take a quiet time right now, like right

we met you know in kindergarten.

What are we do?

We spend our whole time teaching between three and five years

of age teaching kids.

All skills, you know walk away be nice to your brother use

your hands for playing Not For Hitting all that kind of stuff.

Right?

So if that stuff isn't happening, these guys are really dysregulated

and they have they either become much more immature after

a traumatic event has occurred or much more clingy or they

get really rigid.

They don't want to change from one place to the other.

So getting from eating to sleeping is an impossible task

and this is the age where you might start to see my tummy

hurts my head hurts.

Time but you can't really find anything wrong with them and

they're more fussy irritable that kind of stuff as kids get

a little bit older in the elementary age.

This is where you start to see between maybe three to seven

years of age.

They might start to have magical thinking or reenactment

of trauma themes and play.

So you might see them doing things like pretending to shoot


somebody or pretending to or the hitting might be actually

a reenactment of what's going on.

Have you ever seen kids do that?

With their dolls how many people have done forensic interviews

where they've seen kids like attacked their dolls or like,

you know scratch at their dialogues or do things like that

like that?

They're just re-enacting some of the things that they've

seen at home and then the elementary age kids.

They're starting to get a little more where they not only

can remember but they're starting to internalize their symptoms

a little bit so they often have a lot of somatic symptoms.

They start to feel depression and anxiety which may look

like withdrawal.

Or it may look like them being irritable or inattentive.

So it's going to be hard to read and they often have other

symptoms like poor eating bedwetting.

And these are the kids were occasionally.

You'll see a kid who's written a picture that looks like

somebody shot somebody or a picture where somebody takes

a baseball bat and hit somebody over the head or that kind

of thing.

So sometimes these kids will reenact whatever happened to

them could be a picture and then adolescence as they go through

this they have they might have more somatic complaints but

really they're starting to really get involved with their

peers and they rebelled against Authority and so they start


to have this they kind of go overboard and have these delinquents

self-destructive behaviors, but they also feel they're still

that you know, how you're an adolescent and basically everything

is you, you know, you're not quite out there yet to recognize

that there's a world around you you think that you're the

cause of everything or you are the one who's responsible.

They have extreme guilt.

They feel like they should have done something.

They should have stopped it.

There's a lot of self-incrimination which is why they don't

discuss their emotions.

It's why they frequently deny or refuse to discuss what happened

because they feel like it was their fault and they take the

whole onus upon themselves.

They do have flashbacks suicidal thoughts and it can affect

their peer relationships.

Okay.

So these are just the rates of developmental delay and kids

in out-of-home care.

I think it's closer to see if you add behavioral mental health

issues is closer to 60% and I just want to bring up that

there's a higher risk in kids with developmental delays mostly

because they're harder to take care of right and they don't

have the same coping skills.

So where I you know might take more to overcome somebody

who's cognitively normal and who has normal adaptive skills

that trauma might you might require relatively more trauma


to overtake them a kid who's got developmental delays and

or delays and social emotional cognitive functioning might

be more easily overwhelmed by the situation or circumstance

at hand, depending On the nature of their delays or they

may not understand the situation and this is where I get

into. I talked a little bit about this before with the ADHD,

but the mental health diagnostic accuracy is really a problem

in part because our system is so fractured, right?

So we have a situation where the child presents this time

and goes to this agency and gets an assessment but never

really gets care and then they present the next time and

they may go to the same agency and see a different person

or they may go to a different agency.

They get this diagnosis and then they met start some care

and then they don't finish it.

So by the time you've seen them how many people had CPT of

seeing kids where they're on six or seven different medications.

They've got five six seven eight different diagnoses.

So when you get Beyond three diagnoses in my book for mental

health, that's where I say, you know what you're talking

about. We need to reassess the situation because the bottom

line is that that what that means basically is that they're

going off of what either caregivers are reporting or what

they're seeing at the time, but we're not getting enough

collateral stuff about how the child's functioning across

the Which is hard, I'm not saying anybody's at fault because

if you're a system, I did Child Development for a lot of


years at USF.

It's very hard to get that collateral information.

I mean, we used to have to fight to get the schools to give

us stuff.

You know, we used to have to really work hard to get collateral

information from other family members so it can be a challenge

but actually you guys at CPT and DCF might be in a better

position than anybody when you're in the middle of an investigation

because you can do specialized interviews of family members

you can get collaterals from school.

All that often somebody that's a psychiatrist and a practice,

you know, like try to get something from the school and they've

been waiting three months for it.

So, I think that that's something that we should keep in

mind and I will say that as I've said before that I think

that there is overlap between trauma symptoms and some of

the developmental disorders and tweezing that out in the

best of hands as hard.

So I just think we need to keep that in the back of our mind.

So a tiered approach to trauma would require that we screen

and then If the screening is positive assess, so I aim this

at pediatricians or primary care or people who are First

Responders that we really should be screening much more effectively.

And then most of the kids are many of the kids.

I should say not most it that we see our families at the

Child Protection Team.

If we really were doing things properly.


We would end up doing a full assessment for trauma symptoms.

How many people here at cpt's do the full sort of Psychosocial?

Assessments when they're seeing kids few and how many people

have a psychologist on their team?

Good?

Okay, that's good to see.

Okay.

So the reason I bring that up is that you see kids a lot

where you feel like they need a full comprehensive assessment

of the child and the family.

I'm not sure that all of us have that capacity in our team,

but I think it's really critical to doing the best job that

we can here's what I talk to when I talk with primary care

doctors. So any child who's experienced early and repeated

exposure to overwhelming of Adverse Events should be referred

at the very least for a screening and children with difficulty

of controlling regulating their behavior.

And in my opinion kids with mental health diagnosis.

I think if you present now this day and age knowing what's

out there there should be some screening for some kind of

trauma, you know, I thought the sea questionnaire is not

great for primary care because it misses a few things but

it's better than nothing and I believe we had somebody that

came in and talked to us about some other good ways to do

screening and I really think that's I think that's what we're

going to have to try to do to kind of get at this mental

health Mountain that we've created for ourselves here.


And then as I said before multiple mental health diagnosis

without anyone diagnosis to explain the problem should be

a red flag.

It should immediately trigger people to go away.

We should really rethink this.

Okay.

All right, so it's important when you're doing the diagnostic

evaluation to get a bead on the developmental ability the

child. So if you're assessing a child for trauma, you really

got to get in the Understanding of their language and there's

some things you can actually do at the CPT to assess what

their capabilities are.

There's a couple of really quick tests.

What one of them is called the swills SW ILS and it's for

kids 6 and above and it's a basic literacy assessment and

its really fast.

Look it's got a bunch of words on a page and you ask the

child to identify the words and say what they mean and there's

an age Norm for what they should be able to do.

So That's one quick one we use ages and stages right how

many people their teams have the ages and stages?

Okay, what's the risk of the ages and stages?

Where do you usually get the information to put it that way?

From the caregiver or parent?

Right?

And so one of the things with ages and stages that I find

a bit Troublesome is that you have to also observe and so


when the child's there and your playroom and your waiting

room it might be beneficial to sort of familiarize yourself

with it enough that you can sort of say that I see them do

this and I see them to that does that makes sense?

Right?

And so the more you practice the better you get but I really

think it's important to routinely screen.

Okay.

The other thing is ask ask the school.

How's the kid doing?

I think collateral School are really crucial.

Are they misbehaving are they having problems?

Are they failing do they were learning disability?

These are all things that are important to recognize before

we decide what intervention we're going to put in place and

if we do send them for counseling, I think it's important

for the counselor to know that it's important to know if

they have a learning disability or reading disability or

they have significant delays because they're going to adjust

their counseling based on or they should okay.

All right.

So I make the case that all kids have been exposed to trauma

events should have some sort of screening.

But I also make the case that all children would have Behavior

emotional or social emotional developmental problems should

be screened for trauma.

So this is where I certainly at cpt's I think we should be


thinking about this but I would really like to see this happening

and pre schools daycares and pediatricians offices.

So the to the goal the goal of screening is to get an idea

if the ACT if the trauma has Are there symptoms present and

basically the goal of screening is to determine whether the

child needs further comprehensive assessment and so there's

a number of screening instruments.

One of them is the seek which is what we use in primary care

that was comes out of Maryland and IT addresses basically

addresses basically domains involving some safety stuff,

like other adverse experiences not just child abuse intimate

partner violence.

I think there's a question on There it's something that's

delivered in primary care.

So it's hopefully in a setting where parents are not going

to be too upset about it.

It's been studied and parents didn't seem too upset about

it. And so essentially this can be implemented within primary

care, but it's somewhat difficult to get primary care offices

to do it.

I make the case that if the child has behavior problems you

definitely should do it and then the trauma symptom checklist

for kids is a checklist that basically asked people to list

the particular stressor.

That they've experienced and then basically do they the kids

show certain behaviors or certain emotions or modes.

And again, if that's screen is positive then you would refer


for further and then they also look for relational or act

peer relation or family relational a Admiral - okay.

You can also do this with parents.

There's a life events struck the strut a checklist and a

trauma recovery scale that you can use.

I don't want to spend The whole time doing it, but I think

these are things that could be done at the CPT or by the

psychologist. If you have one to help us how trauma is impacting

or has impacted parents.

I think we should try to do this if we can especially on

some cases where it's pretty complex because it can help

inform recommendations for intervention and for further assessment.

These are some other assessment tools.

I'm not going to get into them the child behavior checklist

requires that you have a scoring formats.

So I don't usually do it unless you have a somebody a mental

health wise on your team and some of these other ones you

can find on the national child traumatic stress Network.

Okay.

Alright, so my recommendations are that we embed trauma screening

into the already existing system and that we don't be afraid

to ask people if they need further training related to it

in our area.

I actually asked our crisis center person.

So he goes and does training for case management and is willing

to do so again, and I asked her if she would actually do

another training.


So I think if you find who your crisis center people are

and if they have some training and trauma-informed care,

you can try to engage them and then similarly I don't want

to forget foster parents.

I think that in our systems we can be advocates for better

after care when kids get placed in foster care that that

not only goes with the you know, the how many people here

are DCF CPI?

Dinosaur so you have that little thing that you have to do

right where you have to do the thing where they went and

got a physical if they get placed in foster care, right?

And so where that happens is pretty crucial in my mind how

that happens is pretty crucial in my mind and I think systematically

there are some studies in Philadelphia and other areas that

show that you can actually organize that evaluation across

a network to try to mobilize resources better for kids and

families. And so I think that something is a state that I'd

like to see us working more on.

maybe developing these networks of primary care docs that

are may be willing to do a little bit more for this complex

group of children and then I think we talked a little bit

about this.

This is when we talk about trauma-informed practice.

These are the things that a good trauma-informed counselor

will focus on so again, when you're talking to families and

you're making a referral for trauma-informed care, these

are the kinds of things they should be empowered to expect


from their counselor.

Okay, so I tell them that there should be focused on teaching

them about basic things like how to manage the child's Behavior

basic skills relaxation techniques and coping for Them and

the child how to teach the child to talk about what happened

to them or them to talk about what happened to the family

Mastery of what to do when the child has reminders or appears

to be remind being reminded of a bad event and then working

together to sort of enhance the safety and to cope together

as a caregiver in the child together.

This model assumes that the caregiver has to participate

and so how many people here think that a lot of the kids

that go.

Go have the carapace caregiver participate in the care.

How many how many people think that that's more likely the

child gets put in counseling and then the carrier gets sold

something upward.

So again, this is something that I think we need to keep

reinforcing as a community and as advocates for kids.

Okay, so I'm going to open it up for questions or comments.

Rock and roll, it's Friday.

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Basically the focus of my talk this afternoon was going to

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