Early Childhood Trauma-Informed Practices: Building a Common

Framework for Community Providers

H. Jane Sites, LSW, Ed. D.Cincinnati Children’s Hospital Medical Center

Jane.Sites@cchmc.org513-636-8390

Barbara W. Boat, Ph.D.Cincinnati Children’s Hospital Medical Center

and University of Cincinnatibarbara.boat@uc.edu

513-558-9007

• Trauma informed practices for children: Seeing the world through the eyes of the child

• Helping the child make sense out of what has happened to them. ADHD might be chronic dissociative or PTSD symptoms

• Must be geared to helping the caseworker, parent, teacher, therapist to understand the emotional meaning of a child’s behavior, and then help the child have a sense of where their lives have been and can go in the future

Alicia Liberman/Patricia Van Horn: 2008

• Use of supportive strategies to appropriately respond to the child’s behavior that at first, might seem rejecting, vulgar, and unmanageable

• Behaviors are really the child’s awkward self-protective effort to guard against their fears that you might be unreliable, punitive, rejecting, like caregivers in the past

Goal of treatment

Provide child with attachment relationships and emotional experiences that will create new memories that will counter balance the child’s anxiety about abandonment and pain generated by their past maltreatment

• Less technical and negative language needed• Build a common language among providers• Few resources to pay for training• Too many child victims going without treatment• Theory doesn’t not tell us what to fix for the child

www.sanctuaryweb.com: S.E.L.F.: S. Bloom, M. D.• Demystify confusing psychological terminology

We Need an Easier Common Language

Easier Framework for Common Trauma-Informed Goals:

SELF

• Safety: attaining safety in feelings about yourself, relationships, environment and beliefs

• Emotional Management: learning how to identify and control your emotions in response to memories, persons, and events

• Losses: overwhelming feelings of grief, and sorrow over personal losses, confronting resistance to changing those thoughts

• Future: a paralyzed ability to plan for, or even imagine a different future

Shared Screening Ideas for Addressing Trauma Needs of a community

• “It takes a village [to help a parent] to raise a child”

• Most agencies in the village do not screen for trauma and violence prior to admission to services

• If you don’t ask – they won’t tell

• High, costly prevalence of trauma in USA

• Embedding trauma screening and intervention in existing service agencies would result in a $3-$7 savings on every $1 currently spent [Putnam, 2010]

Cost Estimates of Child Maltreatment• Alabama1 – in 2005 dollars

– Direct costs - $392 Million– Indirect costs - $129 Million– Total annual costs - $521 Million

• Ohio2 – in 2007 dollars– Direct costs - $290 Million– Indirect costs - $2.1 Billion– Total annual costs – $3 Billion

• US3 – in 2007 dollars– Direct costs - $33 Billion– Indirect costs - $71 Billion– Total annual costs - $104 Billion

1 – Center for Business & Economic Research, Univ of Alabama, 20072 – Preventing Family Violence, Anthem Foundation of Ohio, 2007 3 – Wang & Holton – Economic Impact Study, Prevent Child Abuse America, 2007

OhioCanDo4Kids.Org

1010

The Importance of Linking Research and Intervention to Outcome

Measures for the Child and Family: Sustaining programs in bad

economic times

An Integrated, Community Model For Treating Early Childhood Abuse

Cincinnati Children’s HospitalTherapeutic Interagency Preschool

ProgramTIP

Necessary integrated approach and agreements for

Community Stakeholders:• Stakeholders [educators, M H, children’s services, parents, foster care

staff] receive detailed information about child’s social and trauma history when the child is referred to them.

• Children’s Services work with stakeholders to assess and treat the child’s well-being- not just permanency of placement and child safety

• Clinicians need to be made aware of child’s trauma history and what the courts are doing to help the child handle their fears and uncertainty-so they can move forward

• Children are helped to get a sense of why things have happened and then structure memories into a coherent narrative they can share with chosen others [teacher, caseworker, foster parent, etc.]

• These interagency agreements [M.O.U] act as a tool to help integrate stakeholders’ work and they become allies in assisting the clients

TIP Quality Assurance Service Guidelines

• Monthly reports and documentation of client observations and contacts shared with all participating agencies with guardian’s consent

• Access to and communication with, all current community service providers to the parent/child with the use of a universal release form for all community agencies.

• Minimum of monthly treatment plan reviews and reports on family/child (staff, community professionals, parents as appropriate)

• Program credibility and visibility in the community: frequent contact and sharing of data with community service providers; well trained staff, court appearances as requested.

TIP Quality Assurance Service Guidelines

• Referral of preschool aged children and their families by Children Services Agency on issues of 1) developmental, 2) behavioral, or 3) placement instability concerns

• Interagency Participation/Agreements: Preschools, Children’s Services, EI, Mental Health for Collaborative Program Development and Funding

• Low number of children to staff ratio (recommended 4:1) with a classroom no more than 12 children

• Full Year program Operation (with seasonal and Holiday breaks)

N = 58N = 58* p < .05; ** p < .01; *** p < .001 (two-tailed)* p < .05; ** p < .01; *** p < .001 (two-tailed)Note: Data confined to Cincinnati TIP program from Summer 2001 to Summer 2003Note: Data confined to Cincinnati TIP program from Summer 2001 to Summer 2003

Change in Galileo Individual Development Scores Over 1 Year Children in Cincinnati TIP

1515

0

2

4

6

8

10

12

All Children Sexual Abuse Physical Abuse WitnessedFamily Abuse

Neglect

Mea

n C

DC

Sco

re

TIP Baseline TIP 1 Year Follow-Up Typical Head Start Children

Comparing Change in Average Child Dissociative Checklist Score Over 1 Year Among TIP Children by Exposure to Typical Early

Education Children

N = 5N = 5 N = 9N = 9 N = 29N = 29N = 140N = 140

TIPTIP

EEEE

N = 40N = 40 N = 76N = 76 N = 134N = 134 N = 112N = 112N = 203N = 203

1616

1717

Improvements in Various Social Skills Over 1 Year among Children in TIP Programs

4

6

8

10

12

14

Cooperation Assertion Responsibility Self-Control Total Score

Social Skill Dimensions

Ave

rag

e S

core

Baseline 1 Year Follow-Up

******

****** ******

******

N = 204N = 204* p < .05; ** p < .01; *** p < .001 (two-tailed)* p < .05; ** p < .01; *** p < .001 (two-tailed)

****

1818

Reductions in Dimensions of Parental Stress Over 1 Year among Primary Caregivers with Children in

TIP Programs

40

50

60

70

80

Total Stress Parental Distress Difficult Child Parent-ChildDysfunctional

Interaction

Ave

rage

Sco

re

Baseline 1 Year Follow-Up

**

*

+

N = 194N = 194+ p < .10; * p < .05; ** p < .01; *** p < .001 (two-tailed)+ p < .10; * p < .05; ** p < .01; *** p < .001 (two-tailed)

*

Building a Trauma Informed Early Childhood trauma informed Safety Net:

Southwest Ohio Early Childhood Emotional and Social Wellbeing Pilot Study

2006

Study Rationale • Early childhood education professionals are seeing an

increasingly higher prevalence of difficult behavior among children.

• More and more children are having difficulty adjusting to the classroom environment.

• ODMH estimates 7% to 20% of preschool/early school-aged children have severe enough disruptive behaviors to qualify for mental illness diagnosis

• Desire to understand the underlying reasons and potential causes for the increase in these behaviors in early childhood

Doing the ground work: Importance of Data Collection

• Pilot study to assess feasibility

• Target sample of 50 children per county (200 total)

• Random selection of children from eligible schools in each county

• Data collected in April/May, 2006

• Data provided by preschool teachers and telephone interview of parents

Study Design: Content

• Content Decided upon by Southwest Ohio Counties Early Childhood Education Stakeholders (in collaboration with The Childhood Trust and the Division of Psychiatry, CCHMC)

• Main Content Areas:– Exposure to Traumatic Life Events and

Victimization– Emotional and Behavioral Development– Family socio-demographic information

• Parent/Guardian Report– Childhood Trust Events Survey (CTES)

• The CTES is a 16-item event inventory that was adapted from the Traumatic Stress Survey (TSS) originally developed by Rieg, Foa, & Miller (1993, unpublished manuscript). The format and questions were developed and first used in a study by Baker, Boat, Grinvalsky, & Geraciotti, (1998).

Measures: Traumatic Life Events and Victimization

• Parent/Guardian Report– Child Dissociative Checklist (CDC)

• The CDC is a 20-item, parent/observer-rated measure of dissociation in children. The CDC differentiates subjects with clinically diagnosed dissociative disorders (Putnam et al., 1993; Kisiel & Lyons, 2001, Macfie et al., 2001; Hornstein & Putnam, 1992). The CDC has shown good sensitivity to treatment and has been used repeatedly in several child studies (Putnam et al., 1993).

Measures: Dissociation

Outcomes:Exposure to Traumatic Life Events and

Victimization:

Head Start Children’s Exposure to Trauma

Prevalence of Child Exposure to Traumatic Life Events and Victimization as Reported by Parent/Guardian

8.1

22.9

77.1

49.2

32.8

19.212.1

0

20

40

60

80

100

None 1 or MoreEvents

2 or MoreEvents

3 or MoreEvents

4 or MoreEvents

5 or MoreEvents

6 or MoreEvents

Pe

rce

nt

Responding N = 140 (99.3%) Total N = 141

= 100%

Prevalence of Child Victimization as Reported by Parent/Guardian

28.4

6.4

15.6

20.6

3.5

0

10

20

30

AnyVictimization

WitnessedFamily Abuse

EmotionalMaltreatment

PhysicalAbuse

Sexual Abuse

Pe

rce

nt

Responding N = 141 (100.0%) Total N = 141

Impact of Traumatic Life Events and Victimization on Children in Early

Childhood

The Burden of Victimization for the Child

8.3

5.71

9.2

2.653.15 3.13 3.47

0

2

4

6

8

10

None 1 Event 2 Events 3 Events 4 Events 5 Events 6 or moreEvents

Me

an

CD

C S

co

re

Responding N = 140 (99.3%) Total N = 141

Average Child Dissociative Checklist Score among Children in Early Education by Cumulative Exposure to

Victimization and Traumatic Life Events

Sub-Clinical Threshold

Average Child Dissociative Checklist Score among Children in Early Education by Type of Child

Victimization

0

2

4

6

8

10

12

Sexual Abuse Physical Abuse Witnessed FamilyAbuse

EmotionalMaltreatment

Mea

n C

DC

Sco

re

Exposure No Exposure

* p < .05; ** p < .01; *** p < .001 (two-tailed)* p < .05; ** p < .01; *** p < .001 (two-tailed)

N =

5N

= 5

N =

9N

= 9

**

****

Sub-Clinical Threshold

N =

13

6N

= 1

36

N =

132

N =

132

N =

29

N =

29

N =

112

N =

112

N =

22

N =

22

N =

119

N =

119

Summary

• Children in Early Education programs had a high level of exposure (28.4%) to child victimization.

• Increased level of dissociation with accumulative exposure to traumatic life events

• Significantly higher level of dissociation among children exposed to specific types of victimization

Integrated Knowledge Outcomes:

• Results highlighted the behavioral issues parents, teachers, caseworkers need help in understanding and treating: affect regulation, anxiety, depression, oppositional defiance, somatic complaints, aggression, and dissociation

Instruments

• Instruments chosen for the study were found to be effective as behavioral health screens, culturally sensitive, and research based

Highlighted needs

• The need for the infusion of mental health and child welfare services in early childhood, family friendly, natural community settings where children spend considerable time each day

Integrated and Sustained County Outcomes:

• All four Counties have significantly increased the presence of on-site mental health services in schools and child care settings. Where no such services were present in 2006, 1-4 full time therapists per county Head Start program exists today seeing children during school hours.

• More collaboration with Child Welfare Staff and mental health in Educational Planning for the children