Winter 2016: Trauma-Informed Practice

by Jessica L. Griffin, Psy.D.

Youth across the Commonwealth of Massachusetts are experiencing childhood trauma at alarming rates.  Research indicates that childhood trauma is a pervasive, global, healthcare crisis, with epidemiologic studies demonstrating a majority (68%) of children have experienced exposure to traumatic events (Copeland, Keeler, Angold, & Costello, 2007) .  Traumatic events can have deleterious effects including short- and long-term impacts (Copeland et al., 2007) , with the number of traumas experienced directly related to the risk for adverse outcomes (Felitti et al., 1998) , including mental health issues, health risk behaviors, disease, and early death.  Unfortunately, childhood trauma and adversity is one of the largest healthcare crises facing our nation.  Estimated costs for untreated child maltreatment are approximately $104 billion per year, just in this country alone. 

Youth who have multiple exposures to violence or victimization are at higher risk for mental health problems, behavioral problems, substance abuse, and delinquent behaviors, often resulting in their involvement with the court system (Ford, Chapman, Hawke, & Albert, 2007; Ford, Elhai, Connor, & Frueh, 2010; Saunders, Williams, Smith, & Hanson, 2005; Tuell, 2008) .  The majority of youth in juvenile detention or at risk of criminal activity have been exposed to community and family violence as well as been the victim of interpersonal violence (Abram et al., 2004; Wiig, Widom, & Tuell, 2003) . In fact, as many as 93% of youth entering the juvenile justice system have a history of trauma and over half of these youth have experienced 6 or more types of trauma (Adams, 2010) resulting in 65% to 75% of children in the juvenile justice system having multiple mental health problems and functional impairment (Adams, 2010). Rates of PTSD in these youth are estimated between 3%-50% (Wolfpaw & Ford, 2004) making it comparable to PTSD rates (12%-20%) of soldiers returning from deployment in Iraq (Roehr, 2007).  Untreated childhood victimization can create a pervasive distrust of and disregard for adults and the parameters/rules that adults impose (Cook, Blaustein, Spinazzola, & van der Kolk, 2003; Cook et al., 2005), increasing the risk for juvenile justice involvement and also explaining why youth may have a negative reaction to legal proceedings.

As an Attorney, why should I care about my client’s trauma history? 

The Attorney General’s National Task Force on Children Exposed to Violence recommends that all professionals serving children exposed to violence and psychological trauma increase their knowledge of trauma-informed care and trauma-focused services.  Additionally, a recent American Bar Association policy calls for integrating trauma knowledge into daily legal practice and incorporating trauma awareness and skills in practice and policies.

There are a myriad of ways in which a client’s trauma history can impact their legal case, from explaining behavior and decision-making, to understanding trauma’s developmental impacts across the lifespan, to explaining courtroom behavior and/or a client’s inability or unwillingness to work with counsel.  Trauma, often relational, can have a detrimental impact on how youth and adults may act or react in relationships, including relationships with their attorneys.  Growing up in homes and environments in which the prevailing message is, “People who love me, leave me” or “People who are supposed to protect me, hurt me” it is not surprising that youth have difficulty in forming connections or trusting relationships with others, including counsel.  Many court-involved youth have complex trauma histories (e.g., multiple traumas occurring over a period of time, typically starting at an early age and involving caregivers) and a complex trauma impact (e.g., affects children across multiple domains of functioning, beyond Posttraumatic Stress Disorder).  For court-involved youth and their families, there are countless trauma “triggers” or trauma reminders as part of the legal process (e.g., a sense of lack of control, authority figures, powerlessness, feeling their voices are “silenced”). 

Potential Signs that Your Client has been "Triggered"

  • Lashing out verbally or physically
  • Client becomes defiant, disrespectful, or even aggressive (fight response meant to deter perceived threats)
  • Suddenly tries to leave situation (flight response)
  • Client shuts down, stops talking (freeze response or avoidance)
  • Difficulty focusing or tracking the attorney’s questions
  • Becomes jumpy, fidgety, starts pacing
  • Sudden, dramatic shifts in mood
  • Zones out, gets lost in conversation, or appears to have "gone somewhere else"
  • Responds to you as if they were responding to someone else
  • Speech grows louder, faster
  • Regressive behaviors (thumb sucking, rocking)

Having increased knowledge about your client’s trauma history, can greatly assist in improving your ability to explain their behavior and functioning as well as yield suggestions as to how to strengthen the attorney-client relationship.   Additionally, for youth whose parents are separating or divorcing, attorneys should consider how exposure to domestic violence between caregivers and/or ongoing exposure to high conflict parents can have a traumatic impact on children and ensure that they are asking youth and caregivers about their client’s ongoing exposure to high conflict or family violence.  Attorneys should also consider the intergenerational transmission of trauma and abuse.  When youth have trauma histories, it is not uncommon to see trauma and child abuse inherent in their family tree – parents and caregivers have their own trauma histories and subsequent impact that can also interfere with or impact the legal process.

Over the last two decades, cutting edge research is revealing the multitude of ways in which trauma (even childhood sexual abuse and exposure to violence) has negative effects on brain and physiological chemistry and actual brain structure (e.g., shrinking the corpus collosum, etc.) (Teicher et al., 2003).  We are now increasing our understanding with regard to how a trauma history affects biology and physiology and subsequently, so many areas of our client’s lives – from health habits, their ability to learn effectively, relate to others, to even being able to understand the consequences of their actions.  This increased knowledge of trauma’s impact underscores the need for effective trauma-focused therapy that can ameliorate and/or protect against these negative effects. 

What can I do as an Attorney when working with youth who have experienced trauma?

Attorneys can do a number of “trauma-informed” activities in order to advocate for their trauma-exposed client.  1) Be clear about your role and the roles of others involved in legal proceedings.  Transparency is critical in forming a connection with youth who have experienced trauma; don’t overpromise, don’t overstate.  For example, if you cannot meet with your client weekly, do not say that you can. 2) Ask about their safety.   Are they feeling safe now, both physically and psychologically?  What would help them to feel safer?  Has anyone developed a trauma-informed safety plan with them?  3) Ask about their trauma history or ensure sure that they have been asked.  If not asked about their trauma and abuse histories, most children and adolescents will not readily offer this information.  Attorneys do not need to be trained mental health providers to ask basic questions, such as “Has anything really bad, sad, or scary happened to you or to someone you love?”  “Has anyone ever tried to hurt you or touch you in a way you did not want to be touched or in a way that made you feel uncomfortable?”  Attorneys can explain that you ask these questions of all youth, not to upset them, but so that you can better understand them in order to provide the best care for them in their legal case.  It is also helpful if attorneys can normalize this for youth.  For example, explain that “Unfortunately, so many kids I work with report that they have experienced these things too and it’s much more common than you might think.”  If you are not comfortable even asking these basic questions, garner assistance from someone in your practice who is, such as a social services advocate.  There are also screening tools available that can be utilized.  4)  Refer for trauma assessment or evaluation.  If your client reports that they do have a trauma history, ask if they have ever disclosed this to anyone and consider referring them to a mental health provider trained in trauma-focused treatment who can then provide further assessment.   Attorneys can also request a trauma evaluation of their client, which should be done only by an experienced mental health professional trained in trauma evaluations. Elements of a trauma evaluation should include a review of records, clinical interviews, standardized assessment instruments that ask about both trauma experiences and trauma-related symptoms as well as psychological testing instruments that assess broader domains of functioning. 5)  Provide information to the Court related to childhood trauma, when appropriate.  The Judge’s Bench Card for the Trauma Informed Judge http://www.nctsn.org/sites/default/files/assets/pdfs/judge_bench_cards_final.pdf and Ten Things Every Juvenile Court Judge Should Know about Trauma and Delinquency http://www.nctsn.org/sites/default/files/assets/pdfs/trauma_20bulletin.pdf  are excellent resources.   6)  Communicate with other collaterals.  A key principle of Trauma-Informed Practice is collaboration and coordination among service providers and systems. As such, it is important for Attorneys to both collect and share relevant information to support their client. By sharing information, we can prevent our clients from having to repeat their trauma histories to multiple people and can also ensure that everyone involved has a clear understanding with how trauma has impacted the client so that recommendations/services can be appropriately made. 7)  Refer for treatment.  If clients have a trauma history and are symptomatic, attorneys can advocate that they receive effective, evidence-based, trauma-focused treatment  (For a list of treatments see: http://www.nctsn.org/resources/topics/treatments-that-work/promising-practices).  Without proper treatment, youth’s symptoms and functioning are likely to worsen.  The most widely disseminated and most scientifically supported treatment for traumatized children is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT, Cohen, Mannarino, & Deblinger, 2006), a components-based, time-limited treatment. Hundreds of providers have been trained across Massachusetts in this particular treatment (www.tfcbt.org).  Additionally, with the advent of the Massachusetts Child Trauma Project www.machildtraumaproject.org, an additional 500+ providers have been trained in three evidence-based or evidence-informed practices. 

Resources for Attorneys

The University of Massachusetts Medical School’s Child Trauma Training Center (CTTC) was established on October 1, 2012 through a federal grant received from the Substance and Mental Health Services Administration (SAMHSA) and the National Child Traumatic Stress Network (NCTSN).  The mission of the CTTC is to improve the standard of care for children who have experienced trauma in our region by: reducing wait times for treatment for youth and their families; increasing the number of professionals trained in trauma-informed care, trauma-sensitive practices, and trauma-focused treatment; strengthening family engagement and participation in treatment; and most importantly, improving psychosocial outcomes for youth and families.  The current priority population of focus for our program has been court-involved youth between the ages 6-18 who have experienced trauma, including underserved populations.  Initially, our catchment area included Central and Western, Massachusetts; however, we recently received generous funding from the Lookout Foundation to expand our referral services to the Boston and Northern Massachusetts regions. The CTTC has been utilizing wide dissemination of trauma-informed, trauma-sensitive training for professionals (probation officers, pediatricians, law enforcement, courts, public schools, etc.) to assist in identification, screening, and/or assessment of trauma and trauma-related symptoms. To date, we have trained over 5200 professionals in trauma-informed care and trauma-sensitive practices, helping professionals be able to better identify and respond to traumatized youth.  As a result of these training efforts, over 102,000 youth have been impacted with trauma-sensitive care and trauma-informed practices.  Once trauma symptoms are identified in children and adolescents, timely referrals are critical to a faster recovery.  As such, a cornerstone of our mission in improving the standard of care for traumatized youth in our region is the Centralized Referral System (CRS, 1-855-LINK-KID). 

If you have a youth in your practice who has experienced trauma and is in need of evidence-based treatment, call 1-855-LINK KID and we can assist the youth and family in making this referral in a timely fashion.

Historically, across our state, despite multiple wide-scale dissemination efforts to train up the workforce in evidence-based trauma-focused treatment, children who have experienced trauma have had to sit on waiting lists until services were available, with average waiting times as long as 4 to 6 months for a first appointment for treatment.  Given these challenges, the CTTC created a neutral Centralized Referral System (CRS/LINK-KID) that is not linked to any single provider agency, but includes a network of mental health agencies and providers (currently 627 providers) who have been trained in evidence-based trauma treatments.  The CTTC’s CRS/LINK-KID has a toll-free number 1-855-LINK-KID, which parents, caregivers, and child-serving professionals can contact to make a referral for traumatized children who are in need of evidence-based, trauma-focused treatment. Out of a need to better serve children and in response to notable failures in our mental health system, we have created a state-of-the-art and trauma-informed solution to access and care issues facing traumatized youth and their families – an innovative strategy which has, to date, yet to be developed elsewhere in the country. To date, we have dramatically reduced wait times for youth and families and improved the access to and quality of care for approximately 570 youth to date.  Through our training efforts, we have impacted approximately .  

Additional Resources and Contact Information:

The NCTSN has developed innumerous materials for professionals working with youth who have experienced trauma (www.nctsn.org) and a project to create resources specifically designed for attorneys is currently underway.   Additional resources that may be useful include www.sesamestreet.org  (for divorce, military families, or parental incarceration). 

For additional questions, please contact Dr. Griffin at Jessica.griffin@umassmed.edu or (508) 856-8829.  For questions related to the UMMS Child Trauma Training Center, please contact Genevieve Kane-Howse, LMHC, Project Director for CTTC. 

https://www.facebook.com/ChildTraumaTrainingCenter

www.umassmed.edu/cttc

Twitter:  @CTTCUmassmed  

References:

Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. L., McClelland, G. M., & Dulcan, M. K. (2004). Posttraumatic stress disorder and trauma in youth in juvenile detention. 

Adams, E. J. (2010). Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense: Justice Policy Institute.

American Bar Association, Policy on Trauma-Informed Advocacy for Children and Youth, adopted Feb. 10, 2014 by the ABA House of Delegates. Available at www.americanbar.org/content/dam/aba/administrative/child_law/ABA%20Policy%20on%20Trauma-Informed%20Advocacy.authcheckdam.pdf.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: The Guilford Press.

Cook, A., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2003). Complex Trauma in Children and Adolescents: National Child Traumatic Stress Network Complex Trauma Task Force.

Cook, A., Spinazzola, J., Ford, J. D., Lanktree, C., Blaustein, M., Cloitre, M., . . . van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annual, 35(5), 390-398.

Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. [Comparative Study

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. [Research Support, U.S. Gov't, P.H.S.]. Am J Prev Med, 14(4), 245-258.

Ford, J. D., Chapman, J. F., Hawke, J., & Albert, D. (2007). Trauma Among Youth in the Juvenile Justice System: Critical Issues and New Directions: National Center for Mental Health and Juvenile Justice.

Ford, J. D., Elhai, J. D., Connor, D. F., & Frueh, B. C. (2010). Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and involvement in delinquency in a national sample of adolescents. J Adolesc Health, 46(6), 545-552. doi: 10.1016/j.jadohealth.2009.11.212

National Task Force on Children Exposed to Violence, U.S. Department of Justice. Report of the Attorney General’s National Task Force on Children Exposed to Violence, 2012.  Available at www.justice.gov/defendingchildhood/cev-rpt-full.pdf.

Roehr, B. (2007). High rate of PTSD in returning Iraq war veterans  Retrieved May 31, 2012, from http://www.medscape.com/viewarticle/565407

Saunders, B. E., Williams, L. M., Smith, D. W., & Hanson, R. F. (2005). The Navy's Future: Issues Related to Children Living in Families Reported to the Family Advocacy Program: Department of the Navy Family Advocacy Program.

Teicher, M., Andersen, S., Polcari, A., Anderson, C., Navalta, C., & Kim, D. (2003).  The neurobiological consequences of early stress and childhood maltreatmentNeuroscience & Biobehavioral Reviews, 27 (1), 33-44.

Wiig, J., Widom, C. S., & Tuell, J. A. (2003). Understanding Child Maltreatment and Juvenile Delinquency: From Research to Effective Program Practice and Systemic Solutions. Washington, DC: Child Welfare League of America.

Wolfpaw, J. M., & Ford, J. D. (2004). Assessing Exposure to Psychological Trauma and Post-Traumatic Stress in the Juvenile Justice Population: National Child Traumatic Stress Network Juvenile Justice Working Group.

Jessica L. Griffin, Psy.D. is an Assistant Professor of Psychiatry and Pediatrics at the University of Massachusetts’ Medical School (UMMS), where she has been a faculty member since 2006.  Dr. Griffin is a clinical and forensic psychologist with a specialty in forensic assessment of children and families, particularly with regard to childhood trauma.  She has expertise in childhood maltreatment and trauma, psychological assessment, high conflict relationships and divorce matters, working within court systems for over 15 years.  Dr. Griffin is a nationally recognized expert in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and is the only nationally-approved TF-CBT trainer in Massachusetts.  Dr. Griffin provides training and consultation in TF-CBT for providers across New England.  Since joining the faculty at UMMS, Dr. Griffin has trained and provided consultation for over a thousand clinicians across the northeast United States including Massachusetts, Connecticut, New York, Rhode Island, Maine as well as California.   In 2012, as Principal Investigator, Dr. Griffin was awarded a 4-year, $1.6 million National Child Traumatic Stress Network (NCTSN) grant by the Substance Abuse Mental Health Services Administration (SAMHSA) to develop the UMMS Child Trauma Training Center, with a focus on training, treatment, and resolving access issues for court-involved youth who have experienced trauma.  Additionally, Dr. Griffin is a partner on the Massachusetts Child Trauma Project, a statewide initiative targeted at improving outcomes for youth with complex trauma within child welfare systems.  Dr. Griffin also partners with Baystate Medical Center’s, Therapy Housecalls (SAMHSA/NCTSN) project, applying TF-CBT in home-based settings.

In her private practice, Dr. Griffin provides consultation, therapy and assessment/evaluation services for individuals, couples, and families.  She serves as a Guardian ad Litem and provides expert witness testimony for the juvenile and family courts.  Dr. Griffin has been featured on national television programming including NPR, Fox News, and more recently, is a television expert on the (A&E) FYI Channel’s relationship docuseries, the “Seven Year Switch.”   She presents regularly at local, national and international levels.